The economic impact of more frequent
inhaler instructions in asthma and COPD
in the Netherlands
Final Thesis MSc Technology and Operations Management
Author: Jildou Kracht Student number: s3741087
Student email address: j.kracht@student.rug.nl Private email address: jildoukracht@gmail.com Study: Technology and Operations Management
Organisation: University of Groningen First supervisor: E.I. Metting Second supervisor: J. Riezebos
Word count: 11,858
Abstract
In the Netherlands, the total costs related to lung diseases are more than €2.6 billion. Inhaled medication is the cornerstone of treatment for Asthma and COPD patients, however, up to 70% of the patients incorrectly take their inhalation medication. It is unknown what these high failure rates do in terms of costs and what the financial benefits are of more frequent inhaler instructions. This study aims to examine the annual economic impact of more frequent in asthma and COPD patients based on the current treatment costs including the costs of high failure rates. Based on the literature, it is expected that inhaler technique will improve if more frequent instructions are being provided to patients. Consequently, this will result in lower direct and indirect costs.
Within the study, different aspects concerning the treatment process and poor and improved inhalation technique are analysed by using a quantitative model-based approach. Various parameters of the current treatment process, poor and improved inhalation technique are included in the model. The current situation characteristics are collected by using Dutch databases. The impact of poor inhalation technique is examined by using an Italian study and the impact of more frequent instructions is analysed by doing a small literature study.
In the current situation in the Netherlands, an asthma patient costs on average €1,351 per year and a COPD patient costs on average €1,297. The total costs of productivity losses account for 56% of total asthma patient costs and 52% for COPD patients. The study showed that 73% to 81% of the costs of unscheduled health-related events can be assigned patients with poor inhalation technique in the Netherlands. Providing more instructions can save up to €40 million for COPD patients and €51 million for asthma patients, mostly in reductions in lost productivity costs. The study is taken as a total cost approach, the savings can be achieved if the impact on the entire society is taken into account and not only savings achieved in healthcare.
CONTENT
Abstract ... - 2 -
Content ... Fout! Bladwijzer niet gedefinieerd. Acknowledgement ... - 5 -
1. Introduction ... - 6 -
2. Theoretical background ... - 9 -
2.1 The treatment process of asthma and COPD ... - 9 -
2.2 Poor inhalation technique ... - 11 -
2.3 Improving inhalation technique ... - 12 -
2.4 Economic evaluation ... - 13 -
2.5 Research Framework & Research Questions ... - 15 -
3. Methodology ... - 18 -
3.1 Parameters and data collection ... - 18 -
3.1.1 Model population ... - 18 -
3.1.2 Cost aspects of the management of asthma and COPD ... - 18 -
3.2 Part 2: poor inhalation impact examination ... - 19 -
3.3 Effects of improved inhalation technique ... - 20 -
3.4 Sensitivity analysis... - 21 -
3.5 Statistical analyses ... - 22 -
4. Results part 1: the current situation ... - 22 -
4.1 Model population the Netherlands ... - 23 -
4.2 Number of scheduled and unscheduled events ... - 23 -
4.3 Costs per health-related event ... - 24 -
5. Results part 2: Impact of poor inhalation technique ... - 26 -
6. Results part 3: Impact improved inhalation technique ... - 28 -
6.1 Study characteristics ... - 28 -
6.1.1 Intervention costs ... - 30 -
6.2 Impact of improvement in inhaler technique (perspective A) ... - 30 -
6.2.1 Reduction of unscheduled events ... - 31 -
6.2.2 Economic impact improved inhalation technique (perspective A) ... - 32 -
6.2.3 Total cost approach of the reductions achieved ... - 33 -
6.2.4 Sensitivity analysis to the parameter intervention costs ... - 35 -
6.2.5 The situation in the Netherlands ... - 36 -
6.3 Impact of improved inhaler technique (perspective B) ... - 36 -
6.3.1 Economic impact reduction in unscheduled healthcare events (perspective B) ... - 38 -
6.3.2 Total cost approach of the reductions achieved ... - 39 -
6.4 Comparison perspective A and B ... - 42 -
7. Discussion and conclusion ... - 43 -
References ... - 47 -
List of Figures
Figure 1 Research Framework ... - 16 -
Figure 2 Research model [41] ... - 17 -
Figure 3 Sensitivity analysis – Parameters with the highest change in costs related to COPD patients with poor technique ... - 27 -
Figure 4 Sensitivity analysis – Parameters with the highest change in costs related to asthma patients with poor technique ... - 27 -
Figure 5 Impact intervention method on the proportion of patients with correct inhaler technique over a 12-month period ... - 31 -
Figure 6 Yearly costs per COPD patient before and after effect of the intervention presented with the number of provided instructions per study ... - 32 -
Figure 7 Yearly costs per asthma patient before and after effect of the intervention presented with the number of provided instructions per study ... - 33 -
Figure 8 Sensitivity analysis – Effect of parameter intervention costs (COPD) on the total cost savings achieved by providing instructions ... - 35 -
Figure 9 Sensitivity analysis – Effect of parameter intervention costs (asthma) on the total cost savings achieved by providing instructions ... - 35 -
Figure 10 Comparison impact interventions on the number of hospitalizations ... - 37 -
Figure 11 Total yearly costs (treatment costs and intervention costs) after effect intervention (COPD) ... - 38 -
Figure 12 Sensitivity analysis - Study U on the unscheduled event parameters and intervention costs parameter. If parameter was not reported the bar is empty for that parameter ... - 40 -
Figure 13 Sensitivity analysis - Study V on the unscheduled event parameters and intervention costs parameter. If parameter was not reported the bar is empty for that parameter ... - 40 -
Figure 14 Sensitivity analysis - Study W on the unscheduled event parameters and intervention costs parameter. If parameter was not reported the bar is empty for that parameter ... - 40 -
Figure 15 Sensitivity analysis - Study X on the unscheduled event parameters and intervention costs parameter. If parameter was not reported the bar is empty for that parameter ... - 40 -
Figure 16 Sensitivity analysis - Study Y on the unscheduled event parameters and intervention costs parameter. . ... - 41 -
Figure 17 Sensitivity analysis - Study Z on the unscheduled event parameters and intervention costs parameter. If parameter was not reported the bar is empty for that parameter ... - 41 -
List of Tables
Table 1 Reference table economic evaluation types with definitions ... - 14 -Table 2 Direct and indirect costs aspects used in the study ... - 19 -
Table 3 Increased risk per event for patients with poor inhalation technique ... - 20 -
Table 4 Model population the Netherlands 2018 ... - 23 -
Table 5 Costs per event ... - 24 -
Table 6 Current situation in the Netherlands; Total scheduled and unscheduled events and costs and per patient in 2018... - 25 -
Table 7 Impact patients with poor inhalation technique ... - 26 -
Table 8 Reference table included studies ... - 29 -
Table 9 Costs allocated to parties of the COPD disease ... - 34 -
Table 10 Costs allocated to parties of the asthma disease ... - 34 -
Table 11 Reference table, comparison parameters reported in studies ... - 36 -
Table 12 Costs allocated to parties COPD ... - 39 -
Table 13 Cost saving percentage if lost productivity was reported by study ... - 41 -
Acknowledgement
1. Introduction
Within the Netherlands, approximately one million people are diagnosed with a lung disease which plays a large role in 25% of the total deaths. The costs related to patients with a lung disease are more than €2.6 billion [1] every year. Asthma and Chronic Obstructive Pulmonary Disease (COPD), both chronic and obstructive diseases, are the most common lung diseases in the Netherlands [2]. Of the total population older than eighteen years, 6.2% and 5.2% are diagnosed with asthma and COPD1, respectively. Together these diseases account for
approximately 90% of the total Dutch lung patients [3].
Inhalation medication and technique in asthma and COPD patients
The primary treatment for asthma and COPD is inhaled medication which is administered in so-called inhaler devices. The main benefit of this approach is that the medication goes directly to the lungs which reduces unnecessary side effects. However, using inhaler devices requires proper inhalation technique [4]. Approximately 70% of the patients use their prescribed inhalers incorrectly [4]–[7], mostly because of inappropriate instruction, missing instructions, not enough instructions, or incorrect protocols [8]. For example, patients forget to remove the cap of their inhaler or they forget to shake their device if shaking is necessary. Incorrect use is strongly associated with poor healthcare outcomes as unscheduled healthcare visits [4], and results in extra direct cost; more hospitalizations, healthcare visits, and rescue medication use and indirect costs; more lost productivity [9], [10].
Improvement of inhalation technique
Incorrect inhalation technique can be improved in three ways; personalised device selection and shared decision-making, educational interventions in patients and health care, and technological advances [4]. In literature, various educational interventions are evaluated and many studies showed a significant improvement in inhaler technique [11]. Also, the Lung Alliance in the Netherlands (LAN) defined a care path for patients with lung disease in which providing a proper unambiguous instruction and review appointment should be the standard for every patient [12]. However, the LAN defines that the minimal number of instructions per year is one. Already one instruction, e.g. a 2-minute consult on inhaler technique leads to significant improvement in the proportion of patients with proper inhaler technique [13] and
positive effects on, for example, the number of hospital visits [14]. However, the effectiveness of the longer term is debatable. Providing more instructions annually will improve the effectiveness of the longer term [11], [15]. The study of Hesselink, et al. [15] increased the number of instructions in the first year and showed significantly better inhalation technique after two years, and therefore less unscheduled events per year. On the contrary, more frequent instructions will increase instruction costs. This study contributes to the literature in a way that explores the costs in unscheduled events by converting these costs into an analysis of the total costs for a patient per year and the cost of providing additional instructions. So far, this has not been examined in current literature.
The economic impact of inhaler technique
To evaluate the economic impact of providing more instructions in one year to improve inhaler technique, the cost of the current treatment process, and the impact of poor inhaler technique should be analysed. The article by Lewis et al. [9] addresses the economic burden of asthma and COPD together with the impact of poor inhalation technique in Spain, Sweden, and the United Kingdom. The authors describe the resource use and health care costs by analysing direct costs, indirect costs, and the contribution of poor inhalation technique on the total burden of illness. This research reveals results that may point to differences between countries. Within the Netherlands, an analysis of the economic burden of asthma and COPD is not yet performed. This gap will be analysed throughout this study.
study includes all health-related costs that have an impact on the society, health insurers, and employers.
2. Theoretical background
Examining the patient journey related to the treatment of asthma and COPD, multiple different cost aspects are involved. To provide a clear overview, different aspects are examined. First, a section of the treatment process of asthma and COPD is included, followed by a section with the theory behind poor inhalation technique. Another important aspect consists of the interventions used to improve inhalation technique which is discussed in the third section. In the study itself, the aspects will be brought together by examining the economic impact of these aspects of the treatment of asthma and COPD. In the fourth section, a review of different economic evaluation methods is presented. In the last section, the other four sections are brought together in a research framework that will be used in the study.
2.1 The treatment process of asthma and COPD
In the existing literature, the process of asthma and COPD patients is described in different manners from a more global perspective to a more nationwide perspective. The Global Initiative for Asthma (GINA), a network of individuals, organisations and public health officials described a global strategy for asthma management [17]. The authors divided the process into separate components;
1. Develop a patient-doctor partnership, 2. Identify and reduce exposure to risk factors, 3. Assess, treat and monitor asthma
4. Managing asthma exacerbations 5. Special considerations.
Similarly, the GOLD guidelines [18] represent the components for COPD management; 1. Assess and monitor the disease,
2. Reduce risk factors, 3. Manage stable COPD, 4. Manage exacerbations.
outcome of poor disease control. Although, the frequency is different and the number of inhaler technique errors are comparable between asthma and COPD patients. Based on this information, it is decided to generalize the outcomes of the study for asthma and COPD patients.
The LAN care path for inhalation technique in the Netherlands defines the steps that should be taken to achieve proper management of the disease [12]; diagnose, set up a treatment management plan, provide instructions, and define a follow-up plan. In the management of the disease parties as General Practitioners (GP), hospitals and pharmacists are involved. The Dutch study of Suijkerbuijk, et al. [21] used the same distinction in health providers. The authors also mentioned the increased number of Dutch patients consulting a practicing researcher and that most of the patients are treated in primary care. The scheduled events together with prescribed medication are included in the management of the disease to bring the number of unscheduled health-related events to a minimum. In case the management is not sufficient, e.g. too few instructions are provided, the patient has an increased risk of exacerbation, hospitalization, or lost productivity. The difference between scheduled and unscheduled events is based on the fact that the management of the disease is associated with a standard number of scheduled events. However, if the patient has poor control of the disease, unscheduled events e.g. hospitalizations and lost productivity take place. In this study, the scheduled events are included in the current total yearly treatment burden of asthma and COPD patients and the unscheduled events are the input to evaluate the economic impact of asthma and COPD and providing more frequent instructions.
Costs of asthma and COPD
2.2 Poor inhalation technique
Within the treatment process of asthma and COPD, the preferred pharmaceutical treatment consists of inhaled drugs [23]. To control the disease an appropriate inhalation technique is necessary to achieve the desired effect of the medication. The economic burden of poor inhalation technique is an important part of the study. In this section, the literature about poor inhalation technique in relation to the costs will be reviewed.
Poor inhaler technique leads to increasing health-related events and hence increasing costs
Examining the literature of poor inhalation technique, a common topic is inhalation errors, one of the critical aspects of the treatment process. These errors have multiple characteristics and different factors causing errors. Due to various errors, up to 70% of the asthma patients do not use their inhalers correctly [4] and the study of Lavorini, et al. [24] even showed that up to 94% of the COPD patients make at least one error in taking their medication. Those errors lead to more exacerbations [4]. In general, poor inhalation technique leads to poor control of asthma or COPD [25]–[27] causing costs related to increased use of healthcare resources. Melani, et al. [27] concluded that poor inhaler technique especially leads to higher unscheduled healthcare resource use, e.g. hospital visits and Emergency Department (ED) visits. The aim of the study of Roggeri, et al. [26] was to examine the economic impact of this increased use of healthcare resources stated by Melani, et al. [27]. The authors conclude that the increased resource consumption of Italian asthma and COPD patients with poor technique accounts for €234 per COPD patient and €441 per asthma patient every year. Similarly, the economic impact of poor inhaler technique in the Netherlands is not evaluated before. Lewis, et al. [9] showed sensitive results pointing to differences between countries. Therefore, this study covers this specific gap.
Preventive interventions to reduce poor inhalation technique
professionals have their thoughts about how and when to provide instructions [29]. Similarly, the Dutch report of Mullenders et al. [30] states that the demanded instructions to manage the disease and the provided instruction standard for COPD patients is not equal. Therefore, it could be likely that the standard appointment after three months defined by the LAN does not take place in all cases. Further elaboration on the topic of inhalation interventions can be found in the next section
2.3 Improving inhalation technique
As mentioned in the previous section most inhaler technique interventions lead to improved inhaler technique. In this section, an overview of these interventions is provided.
Frequency of inhaler technique interventions
In the previously mentioned studies, mostly the effect of one instruction was evaluated. However, as concluded by various studies [11], [15] these types of studies show effectiveness in the short term. In the long term, more frequent instructions are required, since inhaler technique decays over time [16], [33]. The study of Klijn et al. [11] evaluated the effectiveness of inhaler technique interventions in a systematic review. Their results showed that one instruction can already provide a significant improvement that can be achieved. The same conclusion was drawn by the Dutch study of Hesselink et al. [15]. In their study, the intervention group received up to four instructions in the first year and usual care in the second year. Their inhaler technique was significantly better after the follow-up period of two years than the patients in the control group which received only usual care. Therefore, the effect of various face-to-face instructions in a follow-up period of at least three months is compared in this study. The current most common frequency of inhaler instruction in the Netherlands is 1-year or less.
Improved inhaler technique will lead to increased medication adherence which will improve the quality of life for asthma or COPD patients. Additionally, it will also lead to a reduced economic burden of asthma and COPD i.e. lower unscheduled and scheduled health-related events and costs [14], [34]. For example, a reduction in the routine GP visits [35] or emergency department attendances [36]. Within the existing research, there is a lack of studies that examine the economic impact of more frequent instructions even though it can provide useful insights for health authorities and health insurers.
2.4 Economic evaluation
Table 1 Reference table economic evaluation types with definitions Palmer, et
al. 1999 Koopmanschap, et al. 2008 Drummond, et al. 2015 Definition
Cost-minimization analysis
x “involves measuring costs and evaluate
possibilities to minimize these costs”
Cost-effectiveness
analysis
x x x “Measures health benefits in natural units
such as life-years saved or improvements in functional status” [37]
Cost-utility
analysis x x x “Measures an intervention’s effect on both the quantitative and qualitative aspects of health (morbidity and mortality) using a utility-based measure such as quality-adjusted life years (QALYs)” [37]
Cost-benefit
analysis x x x “Involves measuring costs and benefits in commensurate terms, usually monetary”. [37]
Multi-criteria
analysis x “Cost method on the cost side combined with health effects for patients and carers on the effect side” [38]
Based on this information, a cost-benefit analysis fits the best in this study.
Cost-benefit analysis
A cost-benefit analysis fits the best in this study because all health-related direct and indirect costs of asthma and COPD patients are included. Aspects as mortality, quality-adjusted life years, and health effect of the patient itself are less present in this study. Therefore, cost-effectiveness, cost-utility, and multi-criteria analysis do not fit. The study analyses the impact of face-to-face intervention methods in different frequencies based on cost reductions in direct and indirect costs i.e. monetary benefits. Direct cost reductions, e.g. fewer hospitalizations, result in benefits for the healthcare, and less lost productivity days, indirect costs, result in benefits for an employer. Especially, taking into account different parties and the costs and benefits for them fits better in a cost-benefit analysis than a cost-minimization analysis. Therefore, we look into the net excess of monetary benefits over costs which “represents the
gain in welfare by the total society” [37], or in other words; a total cost approach of the costs
2.5 Research Framework & Research Questions
Based on the theoretical background, it is expected that poor inhalation technique has a significant effect on the treatment costs for asthma and COPD patients. It is unclear how strong this effect is in the Netherlands. Depending on the costs of extra unscheduled health-related events, and indirect costs as a result of poor inhalation technique, the reduced costs of unscheduled health-related events by improvement in inhalation technique can be examined by constructing a cost-benefit analysis. Built on existing literature, it is expected that instructions can significantly contribute to improved inhalation technique. This can provide useful insights into the cost aspects of the management of asthma and COPD patients e.g. for the society in general, health authorities, and employers.
The main question that should be answered with the study is:
“What are the costs and benefits of more than one inhaler instruction annually compared to current practice (once every 12 months) in Dutch asthma and COPD patients?”
In order to answer the main question, three sub-questions are specified:
• What are the annual cost aspects of the current treatment process of asthma and COPD in the Netherlands?
• What is the impact of patients with poor inhalation technique on the total annual costs per asthma and COPD patient?
• What are the costs and benefits of various instruction frequencies in inhalation technique annually?
Figure 1 Research Framework; study in three parts
Part 1 of the study will be executed by investigating data from asthma and COPD patients in the Netherlands. Only databases that contain actual data will be used. Generalizations can be made based on available data. For part 2, one study is used and for part 3 a literature review of studies with various instructions with a direct patient-professional interaction is included.
Hypothesis
Based on the literature about poor inhalation technique in various countries, it is expected that patients with poor technique have a significant economic effect in the Netherlands too. The costs of more frequent instructions in one year are expected to be lower than the costs of extra unscheduled events per year, e.g. hospitalization or lost productivity day. Therefore, it can be hypothesized that the yearly costs of the total treatment process with better inhalation technique will be lower. Besides yearly monetary benefits, asthma or COPD patients gain benefits in terms of better control of their disease.
Conceptualization of the research question
The research question is divided into three sub-questions that match the parts of the study. Those parts are analysed and converged into one model. The research method used to conduct the study is a quantitative model-based approach. A quantitative model-based is a widely used method within operations management research and can be easily adopted in the healthcare study setting.
Part 1:
Current yearly treatment burden •Direct and indirect costs
•Unscheduled and scheduled events Part 2:
Yearly impact poor inhalation technique
•Yearly economic impact of patients poor technique on the total unscheduled events
Part 3:
Improvement in inhalation technique by providing more than one instruction per year
The quantitative model-based approach is based on “a set of variables that vary over a specific
domain, while quantitative and causal relationships have been defined between these variables” [40]. The model aims to explain the behaviour of a real-life situation or process
which can help managers in decision-making aspects. Mitroff et al. [41] defined a research model with the different phases faces in this type of research, Figure 2.
Figure 2 Research model [41]
The phases in the model can be linked to the approach used in this study.
1. The first phase is the conceptualization phase, where clear definitions of the problem, the different parameters, and the scope of the model are defined. Different parameters are relevant to investigate the total yearly costs of the treatment of asthma and COPD. The current situation, part 1, is a result of this step.
2. In the modelling phase, the actual model is built by mapping the different relationships between the parameters of the model. In this phase, the data should be collected to build the model and the different relations between the parameters should be adopted in the model. Part 2 and the study collection of part 3 are a result of this step.
3. The third phase is the solving phase where data is analysed and insights about the relevant parameters and their effects should be provided. All the effects can be brought together in a broad cost-benefit analysis and in this way insights about the yearly effect of poor and improved inhalation technique in the Netherlands can be provided. In this step, the different studies are compared, part 3.
3. Methodology
The study examines the economic aspects of inhalation technique for asthma and COPD patients which are present in the Netherlands. The research question is divided into three parts (1) current direct and indirect costs of Dutch asthma and COPD management, (2) the costs related to unscheduled events associated with poor inhalation technique and (3) the costs related to more frequent inhaler instructions and the benefits related to improvement in inhaler technique hence less expected unscheduled events over one year. The quantitative model-based approach as described in section two, helps to answer the research questions. The methods used to collect data and gather information is described below. For the examination of poor, part 2, and improved inhalation technique, part 3, literature is used. The methods used here are described in sections 3.2 and 3.3.
3.1 Parameters and data collection
In part 1 the various parameters are investigated for current practice in the Netherlands. In this section, those parameters are defined and the method for data collection per parameter is described.
3.1.1 Model population
The study is related to the yearly costs in the Netherlands, therefore, a description of the model population of the Netherlands is required. Demographic aspects like education level are not included in the study since, there is a relevant number of studies that show that these aspects do not have a significant effect on poor inhalation outcomes [6], [42]. The Dutch Centre for Big Data Statistics2 provides the characteristics of the model population. For this research, the
statistics of asthma and COPD patients in the Netherlands of eighteen years or older are considered. Also, the working population is included.
3.1.2 Cost aspects of the management of asthma and COPD
Based on the theoretical background various aspects within the treatment process are distinguished. Within the study, scheduled and unscheduled treatment costs of all aspects are collected based on the number of health-related events and the costs per event. The cost guidelines for the Netherlands [43] is used to define the cost per health-related event. The
different health-related events are divided into direct and indirect treatment costs aspects. In Table 2, the cost aspects used in the different parts are presented.
Table 2 Direct and indirect costs aspects used in the study
Used in part 1: current practice Used in Part 2: impact poor technique Used in part 3: impact more frequent instructions Direct costs • Hospitalization Unscheduled X X X • ED visits Unscheduled X X X • Observations Unscheduled X X X
• One day hospital visits Scheduled X
• GP visits Scheduled X
• Specialist visits Scheduled X
• Moderate exacerbations Unscheduled X X X
• Medication Scheduled X
Indirect costs
• Lost productivity days Unscheduled X X X
Different databases as Nivel3, RIVM4, Volksgezondheid en Zorg5, SFK6 are used to collect data
about the number of scheduled and unscheduled events and the number of patients. For the
input of parts 2 and 3, the methods are described below.
3.2 Part 2: poor inhalation impact examination
Part 2 builds upon the results of part 1 and examines the impact of poor inhalation technique on the total treatment burden in the Netherlands by using the study of Melani, et al. [27]. In this Italian study, the increased risk in unscheduled healthcare events in case of poor inhalation technique is provided. The study is also used in the examination of the impact of poor inhalation technique in three other European countries of Lewis, et al. [9]. An overview of the increased risk per unscheduled event can be found in Table 3.
3 https://nivel.nl/nl 4 https://www.rivm.nl/
Table 3 Increased risk per event for patients with poor inhalation technique
Treatment indicator Increased risk of experiencing an event in case of
poor inhalation technique
Asthma COPD Hospitalization 77.6% 17.3% ED visits 29.5% 76.8% Observations 47.5%a
Medication use by exacerbation 15.7% 33.3%
Productivity losses 47.5% a
Note 1 a :not mentioned in the study, assumed to be the lowest average increased risk of an event for asthma and COPD
patients together (increased risk percentage of hospitalizations)
3.3 Effects of improved inhalation technique
To examine the impact of improved inhalation technique by providing more frequent instructions an examination of numerous studies is done. This literature search provides the quantitative effects of more frequent interventions on the total economic burden of asthma and COPD.
Literature search
The studies included were published in English between 2003 and 2016 and included an examination of the effects on asthma patients, COPD patients, or both. Studies were found by using the databases Google Scholar, Pubmed, and Worldcat and using terms as ‘inhaler intervention’, ‘randomized controlled trial’, ‘improved inhaler technique’, ‘inhalation technique instruction’, etc.
Study quality
Studies included were mostly executed in European countries. Three studies were conducted in the countries Canada and Australia, which appear to have a western culture similar to European countries. Additionally, one study was executed in Japan. The year of publication was preferred to be as recently as possible however, studies executed in 2003 at earliest were included as well since inhaler technique has not improved over the past 40 years [44].
Perspective definition of studies found in the literature research
The outcomes of the included studies were reported mostly in two manners; as an improvement in the proportion of patients with improved inhaler technique, or as a reduction of the number of health-related events (in the intervention group). Some studies reported on both outcomes.
used. When a study only reflects on the improved proportion of patients with correct technique, the number of unscheduled events, and therefore, the costs will decrease. However, this is not directly reported in most cases. On the other hand, in studies that report on a reduction in the number of unscheduled events, it is unclear how many patients still have incorrect technique.
The two perspectives defined are:
- Perspective A: The studies that report on an improvement in the proportion of asthma and COPD patients with correct inhaler technique as a result of inhaler technique interventions.
- Perspective B: The studies that report on a reduction in unscheduled events as a result of inhaler technique interventions.
It is assumed that the outcomes achieved in the study account for both asthma and COPD patients. The follow-up period of the intervention studies should be at least three months after an intervention. For perspective A studies, inclusion criteria were both a measured baseline and measured end proportion of patients with proper inhaler technique. Including patients with (100%) correct steps in inhaler technique or correct patients in general. All studies were executed on adults.
3.4 Sensitivity analysis
Specific-sensitivity analyses are performed to test the sensitivity of the outcomes to parameters in the study and to provide insights in the parameters with the highest impact on the outcomes. A default percentage of 20% for the lower and upper bound of the analysis is taken for all parameters. For the impact of poor inhalation technique the following sensitivity analyses were performed on both the total yearly costs of asthma patients and COPD patients with poor technique:
- The proportion of patients with poor inhalation technique - Cost of hospitalization
- Cost of ED visit - Cost of observation
- Cost of lost productivity days - Cost of moderate exacerbations
- Intervention costs
For the economic analysis of the impact of a reduction in the number of health-related events, we tested all the studies included on the percentage of reductions of the parameters the studies report on, since there is a variation in the height of reductions the studies report on. The following parameters are included:
- Percentage of reduced hospitalizations - Percentage of reduced ED visits - Percentage of reduced observations - Percentage of reduced productivity days - Percentage of reduced moderate exacerbations - Intervention costs
The sensitivity analysis is done per part of the study where the analysis applies to and the results are presented in the result section.
3.5 Statistical analyses
For the relationship between the number of interventions in the follow-up period and the study outcomes i.e. the proportion of patients with correct technique and a reduction in number of unscheduled events, a linear regression analysis is conducted. Also, the relationship between the follow-up period in which the interventions are provided and the outcomes of these interventions is analysed. However, too many assumptions that should be checked in a linear regression7 were violated and too less cases were available. The analyses are excluded in the
results and presented in appendix A.
The results of parts 1, 2, and 3 are converged into one model. The model and statistical, and sensitivity analysis are made by using Microsoft Excel and the add-in Data Analysis.
4. Results part 1: the current situation
The result section is divided into three chapters. The entire study is executed based on the baseline characteristics of asthma and COPD patients in the Netherlands. The baseline data of the Netherlands can be found in this chapter. Based on this information the economic impact
of poor inhalation technique in the Netherlands is presented in Chapter 5. In the last results chapter, Chapter 6, the (economic) impact of more frequent instructions is presented.
4.1 Model population the Netherlands
The model for the evaluation of the impact of more frequent instructions in inhaler technique is developed for the Netherlands. Only adults with asthma and COPD are included. The population characteristics are presented in Table 4.
Table 4 Model population the Netherlands 2018
Population 2018
Total population 17,181,084
Total population > 18 13,794,988
Working population 8,774,000
Total number of people diagnosed with asthma > 18 6.2%
Total number of people diagnosed with COPD > 18 5.1%
Percentage working asthma patients 69%
Percentage working COPD patients 28%
Note 2 all values represent the Netherlands in year 2018. Source: cbs.nl
4.2 Number of scheduled and unscheduled events
The number of health-related events per patient is presented in Table 6. In the table, scheduled and unscheduled events are distinguished. An important indicator is the number of
exacerbations. A small part of the exacerbations results in hospitalization, and the other part,
moderate exacerbations, is treated by medication defined as a prescription of H02 medication (corticosteroids for systemic use, H02AB06 and H02AB07) [45]. The average costs for a corticosteroid’s treatment are €8.40 per distribution [46], which excludes the costs of hospitalization or another event as a result of an exacerbation.
The number of ED visits is based on the total number of ED visits in The Netherlands. In the Netherlands, there were approximately 2.3 million ED visits in 2017 and 2018 [47]. Based on the data of the Volksgezondheidenzorg8, 6% of the total visits can be linked to patients with a
respiratory system diagnosis. Of those respiratory patients 90% has asthma or COPD [3] and we assume that of the ED visits for COPD and asthma patients, 60% accounts for COPD patients (74,520 events), 40% for asthma patients (49,680 events).
4.3 Costs per health-related event
The costs per event are based on guidelines for cost guidelines for the Netherlands [43] and can be found in Table 5.
Table 5 Costs per event
Event Costs
Hospitalization [43] € 476.00 per day One day / observation [43] € 276.00 per event
ED visit [43] € 259.00 per event GP visit [43] € 33.00 per event Specialist visit [43] € 91.00 per event
Medication costs a € 190.00 per year
Moderate exacerbations [46] € 8.40 per event
Lost productivity days [43] € 277.92 per day
Note 3 a GIPdatabank.nl
Table 6 Current situation in the Netherlands; Total scheduled and unscheduled events and costs and per patient in 2018.
Baseline data Total
frequency Total costs Frequency per patient Costs per patient
Asthma
Unscheduled events
Number of hospitalizations 7,490a € 16,756,628.00 0.009 € 19.59
Average duration (in days)
4.7a 4.7
ED visits 49,680a € 12,867,120.00 0.0581 € 15.04
Observations 315a € 86,940.00 0.0004 € 0.10
Moderate exacerbations 282,245 € 2,370,861.82 0.33b € 2.77
Lost productivity days 2,364,716 € 657,201,825.14 2.8c € 768.40
Scheduled events
One day hospital visits 6,480a € 1,788,480.00 0.008 € 2.09
GP visits 1,368,463 € 45,159,272.72 1.6d € 52.80
Specialist visits 2,822,455 € 256,843,363.58 3.3e € 300.30
Medication 855,289 € 162,504,958.64 1f € 190.00
Total € 1,155,579,449.89 Total € 1,351.10
COPD
Unscheduled healthcare events
Number of hospitalizations 33,260a € 118,738,200.00 0.047 € 168.77
Average duration (in days)
8a 7.5
ED visits 74,520a € 19,300,680.00 0.106 € 27.43
Observations 460a € 126,960.00 0.001 € 0.18
Moderate exacerbations 773,899 € 6,500,750.15 1.1g € 9.24
Lost productivity days 1,404,740 € 1,695,053,706.71 2.4c € 674.61
Scheduled healthcare events
One day hospital visits 1,035a € 285,660.00 0.001 € 0.41
GP visits 1,336,734 € 44,112,233.13 1.9i € 62.70
Specialist visits 1,266,380 € 115,240,570.75 1.8j € 163.80
Medication 703,544 € 133,673,433.72 1f € 190.00
Total € 912,593,525.63 Total € 1,297.14
Note 4 :a Reported by Volksgezondheidenzorg.nl, b Reported by Bonten [48], c Reported by Longfonds [49]d Reported by
RIVM [50], eReported by Nivel [51], fReported by GIPdatabank.nl, g Reported by, hReported by Foo, et al.[52], i Report by
Nivel [53], j Reported by Longfonds [54]. Lost productivity days in total are based on the working population. Lost
5. Results part 2: Impact of poor inhalation technique
The proportion of the unscheduled events caused by patients with poor inhalation technique lays between 73% - 81% based on the assumption that 70% of asthma and COPD patients have incorrect technique in the Netherlands. The results are presented in Table 7. This proportion is not only caused by poor inhalation technique because other unscheduled events of patients with poor technique apart from the unscheduled events directly linked to poor technique are included.
Table 7 Impact patients with poor inhalation technique
Unscheduled events Asthma COPD
Frequency Costs Frequency Costs
Hospital visits 7490 € 16.756.628,00 33260 € 118.738.200,00
Caused by patients with poor inhalation technique
6034 € 13.499.118,67 24360 € 86.964.531,28
% caused by poor 81% 73%
Observations 315 € 86.940,00 460 € 126.960,00
Caused by patients with poor inhalation technique
244 € 70.038,76 356 € 92.986,22
% caused by poor 77% 77%
ED visits 49680 € 12.867.120,00 74520 € 19.300.680,00
Caused by patients with poor
inhalation technique 37327 € 9.667.670,35 59980 € 15.534.938,58
% caused by poor 75% 80%
Moderate exacerbations 282245 € 2.370.861,82 773899 € 6.500.750,15 Caused by patients with poor
inhalation technique 205956 € 1.730.030,62 585618 € 4.919.187,38
% caused by poor 73% 76%
Lost productivity days 2364716 € 657,201,825.14 1707740 € 474,615,037.88
Caused by patients with poor
inhalation technique 1830920 € 508.849.268.68 1322245 € 367,478,460.48
% caused by poor 77% 77%
Note 5 The number of unscheduled events is associated with the total number of patients that have incorrect inhaler technique. Those patients have on average a defined percentage increased risk of an event compared to patients with correct technique. The total number of events is distributed among both patient groups on the assumption that 70% of the patients have incorrect technique and 30% have correct technique.
Sensitivity analysis
Figure 3 Sensitivity analysis – Parameters with the highest change in costs related to COPD patients with poor technique
Figure 4 Sensitivity analysis – Parameters with the highest change in costs related to asthma patients with poor technique -24% -15% -4% -1% 0% 0% 21% 15% 4% 1% 0% 0% -30% -25% -20% -15% -10% -5% 0% 5% 10% 15% 20% 25%
Proportion patients with poor inhalation technique ±20% Cost of lost productivity days ±20% Costs of hospitalization ±20% Costs of ED visit ±20% Cost of observations ±20% Cost of moderate exacerbations ±20%
Change in total costs
Sensitivity analyses - Change in total costs for COPD patients with poor technique
6. Results part 3: Impact improved inhalation technique
Many studies show that inhaler interventions can improve inhaler technique or reduce the number of health-related events per year significantly. In the current situation, patients receive instruction when they start with inhaled drugs and the goal of the LAN is to see these patients after three months to evaluate their technique and well-being. However, the LAN standard is not implemented yet. This results in those patients only having one follow-up a year. In this section, the economic impact of different intervention frequencies is compared.
6.1 Study characteristics
An overview of 13 studies is provided in Table 8. Five studies included only asthma patients, six only COPD patients, and two included both asthma and COPD patients.
Intervention characteristics
The intervention characteristics are part of Table 8. Eight studies compared the results of the intervention group with a control group. Four studies tested the effects of the intervention on the entire patient group included in the study and one study [55] had two intervention groups in which one group received three interventions and the other group received four interventions. Studies included on average 235 patients in their study and the intervention groups consisted on average 147 patients and varied from 31 to 363 patients. The interventions of all studies were provided individually except one study in which also two group sessions were provided [56]. The average number of interventions per study was 3.7 and varied from 1 to 18. The average is high because one study [57] had eighteen interventions (telephone calls). If this study was excluded from the average measurement, the average number of interventions per study was 2.5. The follow-up period per study varied from three months to four years, with an average of 10.8 months.
Intervention outcomes
- 29 -
Table 8 Reference table included studies
References Asthma/COP
D Country Sample size IG/CG Follow-up period Number of
interventi ons Individual/ group sessions Type of
intervention Duration Outcome Inhaler technique improvement (ITI) /
Reduction in healthcare events (RIHE)
Armour, et al. 2012 [55]
Asthma Australia 216
(three-visits)/ 182 (four-visits)
12 months 3.5 Individual Pharmacist 15 min* ITI
Boulet, et al. 2015 [58]
Asthma Canada 124/0 12 months 3 Individual General Practitioner 1 hour, 15 min ITI / RIHE Bourbeau, et
al. 2003 [57] COPD Canada 96/95 12 months 18 (calls) Individual Pharmacist (calls) 10 min* RIHE
Dudvarski, et al. 2016 [59]
Asthma/COP D
Serbia 312/0 3 months 3 Individual Medical center 15 min* ITI
Gallefoss, 2004 [56]
COPD Norway 31/31 12 months 4 Individual/
group
Outpatient clinic 2x2 hours, 15 min* RIHE Garcia
Gardenas, et al. 2013[60]
Asthma Spain 186/150 6 months 3 Individual Pharmacist 15 min* ITI
Khdour, et al. 2009 [61]
COPD North Ireland 86/87 12 months 2 Individual Pharmacist 1 hour, 15 min RIHE
Mehuys, et al.
2008 [62] Asthma Belgium 107/94 6 months 3 Individual Pharmacist 15 min* ITI / RIHE
Rootmensen, et al. 2008 [42]
Asthma/COP D
The Netherlands 97/94 6 months 1 Individual Outpatient clinic 1 hour ITI
Schuermans, et al. 2018 [63]
Asthma Belgium 74/75 3 months 1 Individual Outpatient clinic 10 min ITI
Takemura, et
al. 2013 [64] COPD Japan 51/0 48 months 2 Individual Pharmacist 15 min* RIHE
Tommelein, et al. 2014 [65]
COPD Belgium 363/371 3 months 2 Individual Pharmacist 15 - 25 min ITI / RIHE
Wright, et al.
2015 [35] COPD United Kingdom 137/0 6 months 3 Individual Pharmacist 20, 7, and 11 min RIHE
6.1.1 Intervention costs
An important aspect of the analysis is the intervention costs. Only three studies did report the intervention costs [56], [35] and [65] (reported in [66]). For the other studies, an estimation of the costs is made based on the duration and executor. For example, if an intervention is provided in an outpatient clinic, the assumed costs per consult are €91 [43]. A pharmacist intervention is not described in the guidelines however, eight of the thirteen studies included instructions provided by a pharmacist. In the Netherlands, only one instruction of the pharmacist is reimbursed by a health insurer. A general medication dispensing is reimbursed up to approximately €6 and a first medication dispensing up to €12. In the study, the assumption is made that a specific predefined instruction will cost €25 per intervention. The total overview of intervention duration and costs per intervention method can be found in Appendix B.
6.2 Impact of improvement in inhaler technique (perspective A)
Figure 5 Impact intervention method on the proportion of patients with correct inhaler technique over a 12-month period
6.2.1 Reduction of unscheduled events
6.2.2 Economic impact improved inhalation technique (perspective A)
Since the number of unscheduled events decreases if inhaler technique improves, the total yearly costs will decrease after the effect of the intervention period. The total yearly costs before and after the intervention period per study are shown in Figures 6 and 7. The intervention costs are included in the total costs after the effect of an intervention and assumed to come back every year since instructions should be repeated. The number of instructions per method used in a study is displayed on the second axis.
Figure 6 Yearly costs per COPD patient before and after effect of the intervention presented with the number of provided instructions per study
€ 1,297.14 € 1,373.49 € 1,318.63 € 1,313.26 € 1,367.84 € 1,302.79 € 1,232.10 € 1,311.28 € 1,297.14 € 1,362.69 € 1,265.82 € 1,275.14 € 1,297.17 € 1,292.96 € 1,239.23 € 1,287.08 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 € 1,150.00 € 1,200.00 € 1,250.00 € 1,300.00 € 1,350.00 € 1,400.00
Current Study A [61] Study B [63] Study C [60] Study D [56] Study E [58] Study F [57] Study G [55]
N u m b er of p rovi d ed in st ru ct ion s p er s tu d y Y ear ly c os ts p er C O P D p at ie n t
Yearly costs (per COPD patient)
Figure 7 Yearly costs per asthma patient before and after effect of the intervention presented with the number of provided instructions per study
For COPD patients, all studies achieved cost-savings after the total intervention period that varied from 1% to 5% based on the costs before the effect of the intervention(s). Study F [59] did not achieve a cost-saving based on the fact that the proportion of patients with correct technique was already high (53%) and therefore, the number of unscheduled events already low. Especially study D [58] did achieve a high cost-saving of 5%. This is related to the fact that their proportion of patients with correct inhalation technique rises from 5% to 65%, respectively. For asthma patients, the total yearly cost-saving after the total intervention period varied from 1% to 5% for the same reasons as described in case of COPD patients.
6.2.3 Total cost approach of the reductions achieved
If we look further into the cost savings achieved, all studies have higher healthcare costs than benefits per COPD patient, since the intervention costs (all interventions are provided in a healthcare setting) are higher than the cost reductions achieved in healthcare events. The employer of COPD patients has the greatest benefit because they do not have to pay for intervention but their costs for lost productivity decrease. The total cost-saving is mostly allocated to lost productivity days. For the cost-savings achieved per asthma patient, all studies have higher healthcare costs than the benefits achieved in healthcare too. The total cost saving only beneficial for employers.
The characteristics of the studies are applied to the population characteristics in the Netherlands in Tables 9 and 10. The tables should be read as: study A reduces the healthcare costs by €15
€ 1,351.10 € 1,428.82 € 1,385.09 € 1,367.51 € 1,423.07 € 1,356.86 € 1,284.89 € 1,365.49 € 1,351.10 € 1,416.19 € 1,317.82 € 1,327.36 € 1,349.34 € 1,345.49 € 1,290.80 € 1,339.28 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 € 1,200.00 € 1,250.00 € 1,300.00 € 1,350.00 € 1,400.00 € 1,450.00
Current Study A [61] Study B [63] Study C [60] Study D [56] Study E [58] Study F [57] Study G [55]
N u m b er of p rovi d ed in st ru ct ion s i n s tu d y Y ear ly c os ts p er as th m a p at ie n t
Yearly costs (per asthma patient)
per year and reduces the costs of lost productivity days by €87 per year by increasing the proportion correct patients from 3% to 39%. The intervention costs that needs to be paid by healthcare are taken into account in the total reduction for healthcare. Therefore, no total reduction of yearly costs is beneficial for healthcare insurers. However, the reduction in lost productivity costs for companies is higher than the cost for healthcare and therefore a cost reduction is achieved for the entire society in NL.
Table 9 Costs allocated to parties of the COPD disease
COPD Reductions in healthcare Reduction on lost productivity Intervention costs Total reduction in healthcare Total reduction for companies
Total reduction for the community Study A € 15.23 € 86.57 € 91.00 € -53,307,533.11 € 60,907,445.76 € 7,599,912.65 Study B € 19.50 € 110.86 € 77.55 € -40,838,706.58 € 77,995,368.04 € 37,156,661.47 Study C € 16.92 € 96.19 € 75.00 € -40,860,266.66 € 67,674,939.74 € 26,814,673.08 Study D € 25.38 € 144.29 € 99.00 € -51,792,550.75 € 101,512,409.60 € 49,719,858.85 Study E € 12.69 € 72.14 € 75.00 € -43,836,657.27 € 50,756,204.80 € 6,919,547.53 Study F € 10.15 € 57.71 € 75.00 € -45,622,491.64 € 40,604,963.84 € -5,017,527.79 Study G € 16.71 € 94.99 € 87.50 € -49,803,391.04 € 66,829,002.99 € 17,025,611.95
Note 7 Total productivity losses are multiplied by the total COPD population since the lost productivity per patient is the average for the working together with not working population in total
Table 10 Costs allocated to parties of the asthma disease
Asthma Reductions in healthcare Reduction on lost productivity Intervention costs Total reduction in healthcare Total reduction for companies
Total reduction for the community Study A € 5.03 € 98.61 € 91.00 € -73,533,434.81 € 84,338,845.85 € 10,805,411.05 Study B € 18.55 € 126.27 € 77.55 € -50,459,821.39 € 108,000,577.61 € 57,540,756.21 Study C € 5.58 € 109.57 € 75.00 € -59,371,263.66 € 93,709,828.73 € 34,338,565.07 Study D € 8.38 € 164.35 € 99.00 € -77,510,490.53 € 140,564,743.09 € 63,054,252.56 Study E € 4.19 € 82.17 € 75.00 € -60,565,121.29 € 70,282,371.54 € 9,717,250.25 Study F € 3.35 € 65.74 € 75.00 € -61,281,435.87 € 56,225,897.24 € -5,055,538.64 Study G € 5.51 € 108.20 € 87.50 € -70,122,072.24 € 92,538,455.87 € 22,416,383.63
Note 8 Total productivity losses are multiplied by the total asthma population since the lost productivity per patient is the average for the working together with not working population in total
6.2.4 Sensitivity analysis to the parameter intervention costs
The sensitivity analysis of the intervention costs compared to the total cost savings achieved per study after the effect of an intervention is shown in Figures 8 and 9.
Figure 8 Sensitivity analysis – Effect of parameter intervention costs (COPD) on the total cost savings achieved by providing instructions
Figure 9 Sensitivity analysis – Effect of parameter intervention costs (asthma) on the total cost savings achieved by providing instructions
The intervention costs are sensitive in the effect for asthma patients and COPD patients. Study F [59] is most sensitive to the parameter intervention costs since their total cost saving is less and not positive if intervention costs increase with 20%. Study A [63] is sensitive to the parameter intervention costs because their intervention costs are higher than the average of all studies.
Costs in the first year
For the six studies with two or more instructions in their study, the follow-up duration with the outcomes in costs are compared. The follow-up duration was three or six months, mostly. If the instructions were provided in three months the effect is earlier measurable than if the instructions were spread over six months. Results are showed in Appendix E. If an intervention method with two or more instructions is spread over three months instead of six months, up to
210% 168% 153% 72% 39% 29% 28% -210% -168% -153% -72% -39% -29% -28% -250% -200% -150% -100% -50% 0% 50% 100% 150% 200% 250% Study F [59] Study A [63] Study E [60] Study G [55] Study C [62] Study B [65] Study D [58]
Change in cost saving
Sensitivity analysis - Change in total costs saving (per COPD patient) due intervention costs ±20% 254% 144% 132% 67% 37% 23% 27% -254% -144% -132% -67% -37% -23% -27% -300% -200% -100% 0% 100% 200% 300% Study F [59] Study A [63] Study E [60] Study G [55] Study C [62] Study B [65] Study D [58]
Change in cost saving
€12 million in total for all COPD patients, and up to €15 million for asthma patients can be reduced in the first year.
6.2.5 The situation in the Netherlands
In the Netherlands, a COPD patient costs on average €1,297 per year. This is based on the number of scheduled and unscheduled events of all patients of which 30% of the patients have correct inhalation technique. Therefore, we assume improvements achieved in the methods used in studies that have a lower baseline percentage of patients with correct technique can have the same impact as the impact of the study. For studies B, C, F, and G a cost-saving between 1% and 4% can be achieved for COPD patients in the Netherlands. This can save up to €40 million per year. For asthma patients, the yearly economic burden is €1351. Based on the situation in the Netherlands, cost savings up to €51 million per year in total can be achieved for all asthma patients.
6.3 Impact of improved inhaler technique (perspective B)
The other perspective highlighted in the analysis consists of the various studies that reported on the reduction in events after one or more interventions, perspective B. The studies within perspective B differ in the type of health-related events they report on. An overview is provided in Table 11.
Table 11 Reference table, comparison parameters reported in studies
As th m a/ C O PD Ho sp it al iz at io n ED vi si ts Ob se rv at io ns Me di ca ti on fo r exa cerb at ion Ge ne ra l exa cerb at io n Pr od uc ti vi ty lo ss es GP vi si ts Ot he r/ Ge ne ra l uns che dul ed ev ent s Khdour, et al. [61] Study V COPD x x x x Bourbeau, et al. [57] Study U COPD x x x Tommelein, et al. [65] Study X COPD x x X (not sig.) Gallefoss, [56] Study Z COPD x x x Takemura, et al. [64] Study W COPD x Wright, et al. [35] Study Y COPD x x x x x x Boulet, et al. [58]
Asthma X (no impact.) X (no impact.) X (not sig.)
X (no impact.) x
Mehuys, et al. [62]
Asthma X (not sig.) X (not sig.)
assumed to be the decreased percentage in hospitalizations [64]. Two studies did not report a significant reduction in hospitalizations over the intervention period [58], [62]. Both of these studies evaluated the impact on asthma patients. At the end of the intervention period, a decrease of 36% to 75% in hospitalizations is achieved.
6.3.1 Economic impact reduction in unscheduled healthcare events (perspective B)
Based on the reported reductions in unscheduled events, the yearly costs per study after an intervention method can be calculated. Only the studies that report the impact on COPD patients are included to measure the reduction in yearly costs for COPD patients. Reductions in scheduled events are excluded in the measurement.
Figure 11 Total yearly costs (treatment costs and intervention costs) after effect intervention (COPD)
The results in Figure 11 are solely based on the unscheduled events on which the studies reported a reduction in the intervention group. Studies U [57] and V [61] only reported a reduction in hospitalizations and ED visits and both did not achieve a positive cost reduction if the costs for the interventions are included. Studies W [64] and X [65] achieved a reduction in the total costs of €33 (3%) and €55 (4%), respectively. The last two studies Y [35] and Z [56] did report a total cost saving of €173 (13%) and €639 (53%), respectively. 52% and 82% of the total saving is caused by the reduction in the lost productivity days.
€ 1,297.14 € 1,218.65 € 1,188.03 € 1,213.92 € 1,164.79 € 1,052.02 € 534.62 € -€ 306.00 € 116.00 € 50.00 € 77.55 € 71.69 € 78.94 € -€ 200.00 € 400.00 € 600.00 € 800.00 € 1,000.00 € 1,200.00 € 1,400.00 € 1,600.00 € 1,800.00
Current situation Study U [57] Study V [61] Study W [64] Study X [65] Study Y [35] Study Z [56]
Yearly costs per COPD patient
Yearly costs after effect intervention (per COPD patient)
6.3.2 Total cost approach of the reductions achieved
Table 12 presents the costs and benefits for health insurers, employers (companies), and the entire society. If we look further into the cost-savings achieved, studies U [57] and V [61] did not achieve any cost-saving because the intervention costs were higher than the cost-savings in healthcare, and productivity losses were not reported. Studies W [64] and X [65] achieved a minimal cost reduction per COPD patient and their savings were higher than the cost of an intervention. Those costs and benefits (cost reductions) can be allocated to healthcare, in most cases health insurance companies. For the employer, no benefits are reported. For studies Y [35] and Z [56], the cost reduction for healthcare is also minimal, however, the costs of providing the interventions (pharmacist and hospital) are still less than the reduced cost for unscheduled health-related events. The greatest benefit is for the employer of working COPD patients. They do not have additional costs for providing instructions and the productivity losses costs are reduced enormously.
Table 12 Costs allocated to parties COPD COPD Reduction s in healthcare Reduction on lost productivity Intervention costs Total reduction in healthcare (if minus no reduction is achieved)
Total reduction for companies
Total reduction for the society Study U [57] € 78.49 € - € 306.00 € -160,062,970.25 € - € -160,062,970.25 Study V [62] € 109.11 € - € 116.00 € -4,847,392.85 € - € -4,847,392.85 Study W [65] € 83.22 € - € 50.00 € 23,368,660.64 € - € 23,368,660.64 Study X [66] € 132.35 € - € 77.55 € 38,552,470.95 € - € 38,552,470.95 Study Y [35] € 83.22 € 161.91 € 71.69 € 8,108,584.23 € 113,907,609.09 € 122,016,193.32 Study Z [56] € 121.52 € 640.88 € 78.94 € 29,953,710.01 € 450,884,285.98 € 480,837,995.99 Sensitivity analysis
