Costs of isocyanate-related occupational diseases: A systematic review

Although isocyanates are increasingly used in manufacturing and workplace exposure to isocyanates is widely recognized as one of the most frequent causes for occupational lung and skin diseases, little is known about the economic burden on the affected individual and the society. This study provides an overview on costs of occupational diseases related to isocyanates. We performed a systematic literature search of studies in the electronic databases of the German Institute of Medical Documentation and Information, and the Canadian Centre for Occupational Health and Safety. We extracted the key characteristics of the studies and performed a study quality assessment. We identified eight studies on the costs of illness, of which five focused on occupational lung diseases and three on occupational skin diseases. Further, eight studies calculated loss of income/compensation payments. Out of the 16 identified articles, only two reported costs directly attributable to isocyanate-induced diseases (asthma). Studies were hardly comparable because they differed substantially in their methodological approaches. Moreover, the quality assessment of the studies revealed substantial limitations. While a wide range of isocyanate-related costs was identified, consequences of isocyanate-related occupational diseases were considerable in terms of societal costs and loss of income. In most studies, indirect costs were the main cost driver. There is a need for high-quality cost of illness studies on isocyanate-induced diseases stratified by degree of severity and sex. Such studies provide valuable information to develop preventive strategies and set priorities for measures to lower the burden of professional health risks.

Non-linear increase of respiratory diseases and their costs under severe air pollution

China is experiencing severe and persistent air pollution, with concentrations of fine particulate matters (PM_2.5) reaching unprecedentedly high levels in many cities. Quantifying the detrimental effects on health and their costs derived from high PM_2.5 levels is crucial because of the unsolved challenges to mitigate air pollution in the following decades. Using the daily monitoring data on PM_2.5 concentrations and clinic visits, we found a non-linear increase of respiratory diseases, but not for other diseases (e.g., digestive diseases) under severe air pollution. We found an increase of respiratory diseases by 1% for each 10 μg m^-3 increase in PM_2.5 when the annual average daily PM_2.5 concentration was less than 50 μg m^-3; while this ratio was doubled (around 2%) with the daily PM_2.5 concentration larger than 50 μg m^-3. Under severe air pollution (PM_2.5 concentration >150 μg m^-3), the respiratory diseases increased by over 50% compared to that in clean days. Children are more sensitive to the severe air pollution. The increase of clinic visits, especially for adults, was observed mainly in bigger (>500 beds) hospitals. Re-allocating medical resources (e.g., doctors) from big hospitals to community hospitals can benefit the respiratory patients due to air pollution. The total medical cost of clinic visits of respiratory diseases derived from PM_2.5 pollution was estimated at 17.2-57.0 billion Yuan in 2014 in China, accounting for 0.5-1.6% of national total health expenditure. Because these medical costs only represent a small part of total health cost derived from air pollution, the reduction of associated health costs would be an important co-benefit of implementation of air pollution preventive strategies.

Informing management on the future structure of hospital care: an extrapolation of trends in demand and costs in lung diseases

OBJECTIVE

The planning of health care management benefits from understanding future trends in demand and costs. In the case of lung diseases in the national German hospital market, we therefore analyze the current structure of care, and forecast future trends in key process indicators.

METHODS

We use standardized, patient-level, activity-based costing from a national cost calculation data set of respiratory cases, representing 11.9-14.1 % of all cases in the major diagnostic category "respiratory system" from 2006 to 2012. To forecast hospital admissions, length of stay (LOS), and costs, the best adjusted models out of possible autoregressive integrated moving average models and exponential smoothing models are used.

RESULTS

The number of cases is predicted to increase substantially, from 1.1 million in 2006 to 1.5 million in 2018 (+2.7 % each year). LOS is expected to decrease from 7.9 to 6.1 days, and overall costs to increase from 2.7 to 4.5 billion euros (+4.3 % each year). Except for lung cancer (-2.3 % each year), costs for all respiratory disease areas increase: surgical interventions +9.2 % each year, COPD +3.9 %, bronchitis and asthma +1.7 %, infections +2.0 %, respiratory failure +2.6 %, and other diagnoses +8.5 % each year. The share of costs of surgical interventions in all costs of respiratory cases increases from 17.8 % in 2006 to 30.8 % in 2018.

CONCLUSIONS

Overall costs are expected to increase particularly because of an increasing share of expensive surgical interventions and rare diseases, and because of higher intensive care, operating room, and diagnostics and therapy costs.

Do marginal investments made by NHS healthcare commissioners in the UK produce the outcomes they hope to achieve? Observational study

OBJECTIVE

To investigate the effect of targeted marginal annual investments by local healthcare commissioners on the outcomes they expected to achieve with these investments.

DESIGN

Controlled before and after study.

SETTING

152 commissioning organisations (primary care trusts) in England.

METHODS

National surveys of commissioning managers in 2009 and 2010 to identify: the largest marginal investments made in four key conditions/services (diabetes, coronary heart disease, chronic pulmonary airways disease and emergency and urgent care) in 2008/2009 and 2009/2010; the outcomes commissioners expected to achieve with these investments; and the processes commissioners used to develop these investments. Collation of routinely available data on outcomes commissioners expected from these investments over the period 2007/2008 to 2010/2011.

RESULTS

51% (77/152) of commissioners agreed to participate in the survey in 2009 and 60% (91/152) in 2010. Around half reported targeted marginal investments in each condition/service each year. Routine data on many of the outcomes they expected to achieve through these investments were not available. Also, commissioners expected some outcomes to be achieved beyond the time scale of our study. Therefore, only a limited number of outcomes of investments were tested. Outcomes included directly standardised emergency admission rates for the four conditions/services, and the percentage of patients with diabetes with glycated haemoglobin <7. There was no evidence that targeted marginal investments reduced emergency admission rates. There was evidence of an improvement in blood glucose management for diabetes for commissioners investing to improve diabetes care but this was compromised by a change in how the outcome was measured in different years. This investment was unlikely to be cost-effective.

CONCLUSIONS

Commissioners made marginal investments in specific health conditions and services with the aim of improving a wide range of outcomes. There was little evidence of impact on the limited number of outcomes measured.

The Scope and Trends of Pediatric Hospitalizations in Texas, 2004-2010

OBJECTIVE

To examine demographics and trends of financial cost and prominent diseases/conditions resulting in inpatient hospitalizations for infants, children, and adolescents in Texas between 2004 and 2010.

METHODS

Longitudinal retrospective cross-sectional study using the Texas Hospital Inpatient Discharge Database, including all pediatric hospitalizations in the state of Texas, 2004 to 2010.

RESULTS

Texas has an average of 591 571 pediatric hospitalizations per year. Birth was the most common reason for hospitalization, representing 64% of all pediatric hospitalization annually in Texas. Respiratory illnesses were the most common discharge diagnosis for hospitalized children ages 1 month to 9 years and demonstrated a 2% decrease over the study period. The rate of hospitalizations for digestive conditions and childbirth also demonstrated a decrease over this time frame: 4.7% and 3.0%, respectively. The rate of mental illness diagnoses increased 2.5% over the time frame and represented the most common discharge diagnosis for children aged 10 to 14. Childbirth was the most common reason for hospitalization for adolescents aged 15 to 17 years. There was no increase in total cost of pediatric hospitalizations over the time period under study.

CONCLUSIONS

After birth, respiratory illnesses represent the most common reason for hospitalization for children (between 1 month and 10 years of age) in Texas. Mental health conditions and childbirth represent the most common reason for hospitalization for young adolescents (10-14 years) and older adolescents (15-17 years), respectively.

[Economic burden and economic risk of five major chronic diseases among Chinese urban residents]

OBJECTIVE

To provide scientific evidence for medical insurance and health policies allocating the limited health resources in China.

METHODS

Based on the data of the national household survey by the State Council Pilot Urban Resident Basic Medical Insurance Evaluation from Nov.2007 to Nov.2011, a two-step model and the human capital method were used to estimate the economic burden of five major chronic diseases among urban residents in China. According to the economic burden, the relative economic risk (relative risk, RR) and adjusted RR were calculated. The five chronic diseases were hypertension, cardiovascular, diabetes, arthritis or rheumatism and chronic lung diseases.

RESULTS

More than 50% of the residents with these five chronic diseases were the over 65-year-old and retired. 90% of the residents with these five chronic diseases had medical insurance except the residents with chronic lung diseases. Average co-pay from the outpatient department and the pharmacy was more than 60%, and about 50% from the inpatient department. Annual total cost per capita was the highest 8 954.29 Yuan among the residents with cardiovascular disease and the second highest 8 914.36 Yuan among the residents with diabetes. The adjusted RR of the residents with cardiovascular and diabetes were greater than 1, respectively 1.36 and 1.15.

CONCLUSION

The retired take up the largest percentage of population with chronic diseases, and the influence of the major five chronic diseases is more serious in north-west China. The main expenditure is from the outpatient department and the pharmacy, in which the availability of drugs reimbursed needs to be improved. The patients with cardiovascular and diabetes experience both higher economic burden and economic risk.

The human health effects of Florida red tide (FRT) blooms: an expanded analysis

Human respiratory and digestive illnesses can be caused by exposures to brevetoxins from blooms of the marine alga Karenia brevis, also known as Florida red tide (FRT). K. brevis requires macro-nutrients to grow; although the sources of these nutrients have not been resolved completely, they are thought to originate both naturally and anthropogenically. The latter sources comprise atmospheric depositions, industrial effluents, land runoffs, or submerged groundwater discharges. To date, there has been only limited research on the extent of human health risks and economic impacts due to FRT. We hypothesized that FRT blooms were associated with increases in the numbers of emergency room visits and hospital inpatient admissions for both respiratory and digestive illnesses. We sought to estimate these relationships and to calculate the costs of associated adverse health impacts. We developed environmental exposure-response models to test the effects of FRT blooms on human health, using data from diverse sources. We estimated the FRT bloom-associated illness costs, using extant data and parameters from the literature. When controlling for resident population, a proxy for tourism, and seasonal and annual effects, we found that increases in respiratory and digestive illnesses can be explained by FRT blooms. Specifically, FRT blooms were associated with human health and economic effects in older cohorts (≥55 years of age) in six southwest Florida counties. Annual costs of illness ranged from $60,000 to $700,000 annually, but these costs could exceed $1.0 million per year for severe, long-lasting FRT blooms, such as the one that occurred during 2005. Assuming that the average annual illness costs of FRT blooms persist into the future, using a discount rate of 3%, the capitalized costs of future illnesses would range between $2 and 24 million.

Workers' compensation for occupational respiratory diseases

The respiratory system is one of the most important body systems particularly from the viewpoint of occupational medicine because it is the major route of occupational exposure. In 2013, there were significant changes in the specific criteria for the recognition of occupational diseases, which were established by the Enforcement Decree of the Industrial Accident Compensation Insurance Act (IACIA). In this article, the authors deal with the former criteria, implications of the revision, and changes in the specific criteria in Korea by focusing on the 2013 amendment to the IACIA. Before the 2013 amendment to the IACIA, occupational respiratory disease was not a category because the previous criteria were based on specific hazardous agents and their health effects. Workers as well as clinicians were not familiar with the agent-based criteria. To improve these criteria, a system-based structure was added. Through these changes, in the current criteria, 33 types of agents and 11 types of respiratory diseases are listed under diseases of the respiratory system. In the current criteria, there are no concrete guidelines for evaluating work-relatedness, such as estimating the exposure level, latent period, and detailed examination methods. The results of further studies can support the formulation of detailed criteria.

[Analysis of state costs of the social security benefits provided to the insured presenting with lung cancer and pulmonary diseases caused by external factors]

Lung cancer and pneumoconioses constitute two serious problems of contemporary medicine and a public health system.

THE AIM

To analyze the costs associated with social security benefits provided to the insured presenting with lung cancer and pulmonary diseases (including pneumoconioses) caused by external factors.

MATERIAL AND METHODS

The analysis was based on the data obtained from the Department of Statistics and Actuarial Forecasts of the Social Insurance Institution (SlI) in Warsaw. Structural diversity of the costs of the separate benefits available within the national health insurance system has been considered. Based on the data available in Poland costs associated with the incidence of lung cancer and pneumoconiosis were assessed taking into account sex and age of the insured as well as the administrative division of Poland. Additionally, mortality rates from the selected pulmonary diseases were analyzed.

RESULTS

Costs of the pensions paid to the insured presenting with lung cancer amount to 81.11% of the total social security costs associated with these diseases, while the sick leave money paid to the insured lung cancer patients equal to 15.5% of the total costs. In the insured women, costs of the pensions paid due to occupational pulmonary diseases (predominantly pneumoconioses) constitute 41.1% and in the insured men--11.5% of the total 'occupational' pensions.

CONCLUSIONS

Although the maximal incidence of lung cancer occurs in both men and women above their retirement ages the costs of the work incapacity pensions paid to lung cancer patients still exceed 81% of the total social security costs associated with these diseases. In the insured women, the cost of pensions paid due to occupational pulmonary diseases, most of which are pneumoconioses, ranks first among the costs of 'occupational' pensions received by these subjects, while in the insured men the respective cost ranks third (after injuries plus intoxications and cardiovascular diseases) among their 'occupational' pensions. Moreover, the results of the performed analyses indicate that data on the social insurance money allow to comprehensively evaluate the health status of the insured men and women as well as their quality of life and therapeutical, rehabilitational and prophylactic needs. These data can and should, therefore, be utilized in both clinical practice and for accomplishment of the public health tasks.

The association of health and income in the elderly: experience from a southern state of Brazil

OBJECTIVES

In high income, developed countries, health status tends to improve as income increases, but primarily through the 50(th)-66(th) percentile of income. It is unclear whether the same limitation holds in middle income countries, and for both general assessments of health and specific conditions.

METHODS

Data were obtained from Brazil, a middle income country. In-person interviews with a representative sample of community residents age ≥ 60 (N=6963), in the southern state of Rio Grande do Sul, obtained information on demographic characteristics including household income and number of persons supported, general health status (self-rated health, functional status), depression, and seven physician-diagnosed, self-reported health conditions. Analyses used household income (adjusted for number supported and economies of scale) together with higher order income terms, and controlled for demographics and comorbidities, to ascertain nonlinearity between income and general and specific health measures.

RESULTS

In fully controlled analyses income was associated with general measures of health (linearly with self-rated health, nonlinearly with functional status). For specific health measures there was a consistent linear association with depression, pulmonary disorders, renal disorders, and sensory impairment. For musculoskeletal, cardiovascular (negative association), and gastrointestinal disorders this association no longer held when comorbidities were controlled. There was no association with diabetes.

CONCLUSION

Contrary to findings in high income countries, the association of household-size-adjusted income with health was generally linear, sometimes negative, and sometimes absent when comorbidities were controlled.

Hospitalization costs of open vs. laparoscopic appendectomy: 5-year experience

BACKGROUND

There is an ongoing debate over certain aspects of laparoscopic appendectomy (LA) over open appendectomy (OA) in regard to hospitalization costs and associated complications.

METHODS

A database was used to obtain the charts for either LA or OA performed during a 5-year period. Variables analyzed were age, gender, hospitalization cost, length of stay and complications.

RESULTS

Of 1792 appendectomies performed, 633 (35.3%) were OA and 1159 (64.6%) were LA. Both groups were statistically similar with regard to gender (p = 0.075) but differed with respect to age, demonstrating an older patient population in the LA group (p <0.0001). Length of stay was significantly higher in the OA group (3.33 vs. 2.52) days, p <0.0001). The overall hospitalization cost of LA was 25% higher than the OA cost (p = 0.0005). The cost of an uncomplicated LA case was 1.7 times higher than in the OA group (p ≤ 0.0001). We found no statistically significant differences between the hospitalization cost of an OA and LA group when both procedures were associated with a complication (p = 0.5319). A higher complication rate was observed in the OA group, 60 cases (9.47%) as compared to the LA group, 46 cases (3.96%), p <0.0001. The increased rate of complications observed was related to cardiovascular, wound and infectious problems.

CONCLUSIONS

Noncomplicated LA was associated with a higher hospitalization cost. There was no difference with regard to complicated cases. The incidence of complications increased in the OA group.

[Impact of tobacco on bronchopulmonary affections: magnitude of the problem]

BACKGROUND

Tobacco smoking is frequent in the world affecting 20 à 50% of the population but with a decrease in occidental countries due to a huge effort based on sensiblisation and anti-tobacco decisions.

AIM

To review the impact of tobacco on bronchopulmonary affections.

METHODS

A narrative review of literature

RESULTS

In the next future, yearly tobacco-related deaths could increase from 4.2 millions in 2000 to 10 millions in 2025-2030 making smoking as the main evitable cause of deaths by respiratory diseases. Lung cancer is the leading killer cancer. Tobacco is the most frequent cause of respiratory diseases. It is responsible of 80 to 90% of deaths by chronic obstructive pneumobronchopathiy (COPD) and 80 to 85% deaths by bronchopulmonary cancer.

CONCLUSION

Tobacco is a « chronic disease » necessitating management with advices and medical treatment.

Development and validation of a microsimulation economic model to evaluate the disease burden associated with smoking and the cost-effectiveness of tobacco control interventions in Latin America

OBJECTIVE

To describe the development and validation of a health economic model (HEM) to address the tobacco disease burden and the cost-effectiveness of smoking cessation interventions (SCI) in seven Latin American countries.

METHODS

The preparatory stage included the organization of the research network, analysis of availability of epidemiologic data, and a survey to health decision makers to explore country-specific information needs. The development stage involved the harmonization of a methodology to retrieve local relevant parameters and develop the model structure. Calibration and validation was performed using a selected country dataset (Argentina 2005). Predicted event rates were compared to the published rates used as model inputs. External validation was undertaken against epidemiologic studies that were not used to provide input data.

RESULTS

Sixty-eight decision makers were surveyed. A microsimulation HEM was built considering the availability and quality of epidemiologic data and relevant outcomes conceived to suit the identified information needs of decision makers. It considers all tobacco-related diseases (i.e., heart, cerebrovascular and chronic obstructive pulmonary disease, pneumonia/influenza, lung cancer, and nine other neoplasms) and can incorporate individual- and population-level interventions. The calibrated model showed all simulated event rates falling within ± 10% of the sources (-9%-+5%). External validation showed a high correlation between published data and model results.

CONCLUSIONS

This evidence-based, internally and externally valid HEM for the assessment of the effects of smoking and SCIs incorporates a broad spectrum of tobacco related diseases, SCI, and benefit measures. It could be a useful policy-making tool to estimate tobacco burden and cost-effectiveness of SCI.

Healthcare services funded by Counties Manukau District Health Board for people in the last year of life

INTRODUCTION

The last year of life is often associated with a high level of healthcare utilisation and cost. To date, little information is available regarding the healthcare utilisation patterns in the last year of life in New Zealand.

AIM

To describe the healthcare utilisation patterns and costs of the residents of Counties Manukau District Health Board (CMDHB) region in the 1-year period prior to death in 2008.

METHOD

CMDHB residents who died in 2008 were identified from the National Mortality Dataset. The health services utilisation patterns and costs in the last year of life were derived from National Minimum Dataset (NMDS), Pharmaceutical Collection, Laboratory Claims Collection, and National Non-Admitted Patient Collection via encrypted NHI linkage.

RESULTS

Forty percent of all deaths in 2008 in CMDHB occurred in a publicly funded hospital. Just over 80% of people had at least one inpatient hospital stay in the last year of life. More than 75% of the healthcare costs funded by CMDHB in the last year of life were related to inpatient hospitalisations. The average cumulative length of inpatient stay over the year in the people who had an inpatient event was 20.6 days. Outpatient, pharmaceutical, and laboratory services were received by 84%, 91%, and 86% of people respectively in their last year of life.

CONCLUSION

Consistent with the international literature, this study found that CMDHB residents in the last year of life have a high level of health service utilisation. Decisions about the appropriate use of high cost health services in people towards the end of life can be extremely challenging. These decisions are resource allocation decisions as well as clinical decisions and should be based on clinical factors, cost utilities, and patient, family, and society's expectations.

[Economic evaluation of telehomecare in chronic lung diseases]

OBJECTIVES

We attempted to quantify the cost-effectiveness ratio in telemonitoring lung function of patients affected by Cystic Fibrosis (CF).

MATERIALS AND METHODS

We examined the costs of Telehomecare (THC) in the follow-up of CF patients. We considered the failed hospitalizations as incomes. A standardized questionnaire was submitted by e-mail to verify the patient satisfaction and expectation levels. We studied 3 groups of patients: a) 17 CF patients in THC; b) 28 CF patients not followed by THC and c) 28 non-CF patients affected by chronic diseases and not followed by THC. Some parameters with no market value were evaluated using "willingness to pay" (WTP).

RESULTS

An annual saving of €.5241 was calculated for single FC patient followed by THC. The WTP analysis showed that patients affected by chronic diseases expected very much from new technologies.

CONCLUSIONS

The THC use in CF shows several advantages as fewer hospitalization and economical saving in a general trend of limited economical resources. Further studies are needed to confirm our data.

[Role of lung biopsy in diagnosis of pulmonary pathology at the prehospital level]

The aim of the work was to assess the value of biopsy techniques for fibrobronchoscopy under local anesthesia in patients with pulmonary pathology at the prehospital level. It included 706 subjects with lobular, segmental or diffuse lesions in the lungs of specific (tuberculosis), non-specific (pneumonia, exogenous alveolitis), and other origin. All known methods of endobronchial biopsy were employed (bronchoalveolar lavage or liquid lung biopsy, tissue biopsy, transbronchial biopsy, brush biopsy, puncture and aspiration biopsy) with subsequent cytomorphological and bacteriological studies of bioptates. Diagnostic efficiency of direct biopsy was estimated at 97%, transbronchial biopsy at 5-90% depending on nosological form of lung disease, brush and puncture biopsy 20-50 and 6% respectively. Reversible complications occurred in 1.4% and were resolved by therapeutic methods. Cost effectiveness of prehospital instrumental examination of patients with pulmonary pathology is 10 times the intrahospital one.

Pulmonary rehabilitation in chronic respiratory diseases--from goals to outcomes

This paper is a review of current approaches on pulmonary rehabilitation (PR) in chronic pulmonary diseases. Pulmonary rehabilitation is the most accepted method of non-pharmacological treatment in patients with chronic obstructive pulmonary disease (COPD), bronchial asthma, bronchiectasis, cystic fibrosis, interstitial lung disease, neuromuscular degenerative disease and post-tuberculosis lung sequelae. Throughout its components, especially oxygen therapy, it is the most important intervention in chronic respiratory failure in order to improve exercise tolerance, lung function and self-management. Enrolling patients in pulmonary rehabilitation programmes is a consistent help to a better control of their illness and a step forward to the international standards of treating COPD and non-COPD chronic respiratory diseases. It is evidence-based that PR is effective in reducing dyspnoea, improving health-related quality of life, reducing the number of hospital days and the utilisation of costly healthcare resources; there are also psychosocial benefits from comprehensive PR programmes in patients with COPD. PR is currently considered as effective in patients with COPD and in some patients with chronic respiratory diseases other than COPD.

[Cost-benefit analysis of the program on early detection of pulmonary diseases]

BACKGROUND

Economic evaluation of costs and effectiveness of the program aimed at early detection of lung diseases was the subject of the study. The scope of the study is related to the European tendency of creating information resources for public resources management.

MATERIAL AND METHODS

The study covered more than 14 000 people divided into three age groups, living in 11 localities in the Lódź region. The program aimed at lung diseases detection was conducted in three steps: first specialist examinations, X-ray examinations, second specialist examinations. Costs and effectiveness of the program were compared by cost/effectiveness and incremental ratios.

RESULTS

The results of the study were formulated in the following areas: costs of the program by age groups and groups with suspected diseases, effects of the program, costs per one detected case and incremental ratios.

DISCUSSION AND CONCLUSIONS

The results of the study show that economic evaluation conducted from ex post perspective could be useful in building decision scenarios. Sensitivity analysis allows for investigating how different assumptions of variables influence the study results. Variables useful for the scenarios of early lung diseases detection programs were identified for further studies.

Nanotechnology in the diagnosis and management of heart, lung and blood diseases

Heart, lung and blood diseases exert an enormous toll, accounting for almost half of the deaths in the USA each year. In addition to the morbidity and mortality resulting from these diseases, there is also a high economic burden, estimated at 560 billion US dollars for 2006. Nanotechnology offers a broad range of opportunities to improve diagnosis and therapy for cardiovascular, pulmonary and hematopoietic diseases, thereby decreasing these burdens. This review will focus on four areas of particular promise for the application of nanotechnology: imaging, diagnostics and biosensors, drug delivery and therapy, and tissue engineering and repair. The goal is to summarize the current state of science and technology in these areas and to look at future directions that the field is likely to move in to enhance the diagnosis and treatment of heart, lung and blood diseases.

Treino de exercício na doença pulmonar crónica

Exercise training has become a cornerstone of Pulmonary Rehabilitation. Since the nineties, the effectiveness in clinically relevant improvements in exercise capacity and health-related quality of life has been proved. Current guidelines (Evidence A) recommend high intensity continuous exercise for lower extremities as the most effective exercise modality, however, for some patients it is often difficult to initiate such an exercise programme due to the limitation of dyspnoea or leg fatigue. In recent years, special relevance has been given to the integration of other modalities of exercise (continuous versus interval, aerobic versus strength, inclusion or not of respiratory muscle training). The authors carry out a review of the current literature concerning exercise training in chronic pulmonary disease and this highlights the role of tailored exercise to break the vicious cycle of dyspnoea and inactivity.

Chronic airflow limitation in developing countries: burden and priorities

Respiratory disease has never received priority in relation to its impact on health. Estimated DALYs lost in 2002 were 12% globally (similar for industrialized and developing countries). Chronic airflow limitation (due mainly to asthma and COPD) alone affects more than 100 million persons in the world and the majority of them live in developing countries. International guidelines for management of asthma (GINA) and COPD (GOLD) have been adopted and their cost-effectiveness demonstrated in industrialized countries. As resources are scarce in developing countries, adaptation of these guidelines using only essential drugs is required. It remains for governments to set priorities. To make these choices, a set of criteria have been proposed. It is vital that the results of scientific investigations are presented in these terms to facilitate their use by decision-makers. To respond to this emerging public health problem in developing countries, WHO has developed 2 initiatives: "Practical Approach to Lung Health (PAL)" and the Global Alliance Against Chronic Respiratory Diseases (GARD)", and the International Union Against Tuberculosis and Lung Diseases (The Union) has launched a new initiative to increase affordability of essential asthma drugs for patients in developing countries termed the "Asthma Drug Facility" (ADF), which could facilitate the care of patients living in these parts of the world.

Trends in Lung Surgery

BACKGROUND

Reports on the temporal evolution in lung resection are limited. To elucidate temporal changes in the demographics of lung resections, we analyzed nationally representative data that were collected for the National Hospital Discharge Survey from 1988 to 2002.

METHODS

Data collected between 1988 and 2002 were analyzed. Patients with International Classification of Diseases, ninth revision, clinical modification, procedure codes for lung resection were included in the sample. Three 5-year time periods were created (1988 to 1992, 1993 to 1997, and 1998 to 2002) to simplify the temporal analysis. Changes in the prevalence of procedures, age, gender, race, length of care, mortality, disposition status, and distribution by hospital size were evaluated. Trends in procedure-related complications were analyzed.

RESULTS

Between 1988 and 2002, a total of 512,758 lung resections were performed. Comparing the earliest to the most recent time period, we found increases in the average age (61.1 years [range, 1 to 89 years] vs 63.2 years [range, 1 to 91 years], respectively), in the proportion of patients who were female (40.1% vs 49.6%, respectively), and in the proportion of Medicare/Medicaid patients (43.8% vs 49%/4.7% vs 6.7%, respectively). Decreases in the average length of stay (12.9 days [range, 1 to 358 days] vs 9.1 days [range, 1 to 175 days], respectively) and in the proportion of patients discharged to their primary residence (86% vs 79.5%, respectively) were seen. The proportion of patients who had undergone lobectomies compared to other types of lung resection increased. Mortality rates were 5% vs 5.4%, respectively, while the frequency of complications decreased.

CONCLUSION

We identified temporal changes in lung resection surgery that may help in the construction of health-care policies to address the changing needs of and financial burdens on the health-care system.

Pulmonary practice profiles: Results of a practice performance survey

OBJECTIVES

Physician productivity, practice expense, resource allocation, facilities, staff, and malpractice are variables in medical practice profitability. The ongoing challenge of collecting reliable and consistent data created an opportunity in 2001 for the American College of Chest Physicians (ACCP) Practice Administration Network (PAN) to develop a practice-based survey that measured the variables most related to the bottom line.

METHODS

The PAN designed a comprehensive practice survey in 2001 that has been distributed to > 2,000 ACCP members each year. The specialty-specific survey differed from those offered in the market, as its aim was to capture information about pulmonary, critical care, and sleep practices. The single-answer survey included practice expense categories and those related to accounts receivable management. An on-line survey vendor (www.surveymonkey.com) was selected as the platform based on broad functionality and a flexible architecture.

RESULTS

The survey was conducted each June for 5 consecutive years. In 2001, survey respondents represented 68 pulmonary physicians. By 2005, 229 practices responded representing 774 individual physicians. Participants included members of ACCP Leadership, ACCP Committees, and related networks, and past survey participants. The data are presented in graphic format as a percentage of total respondents.

CONCLUSION

The survey offered participants a mechanism to contrast and compare specialty-based trends in practice expense, staffing levels, clinical services, malpractice cost, facilities utilization, and financial management strategies of "better performing" practices. It has served as the groundwork for related Practice Management Committee and Practice Management Department initiatives. The ACCP anticipates future survey collaboration with the Medical Group Management Association.

Air Leaks After Lobectomy Increase the Risk of Empyema but Not of Cardiopulmonary Complications

PURPOSE

To assess whether the presence and duration of air leaks after lobectomy are associated with an increased incidence of cardiopulmonary complications.

METHODS

Propensity score analysis was used on 726 patients undergoing pulmonary lobectomy from 1995 through 2004 to form three well-matched pairs of patients: patients with prolonged air leak (PAL) [> 7 days] and without air leak; patients with short air leak (SAL) [< or = 7 days] and without air leak; and patients with SAL and PAL. These matched groups were then compared to assess postoperative hospital stay and early outcome.

RESULTS

Patients with SAL had a longer postoperative hospital stay compared to patients without air leak (8.6 days vs 7.8 days, respectively; p < 0.0001) but had similar morbidity and mortality. Patients with PAL had a longer postoperative hospital stay compared to patients without air leak (16.2 days vs 8.3 days, respectively; p < 0.0001) and with SAL (16.9 days vs 9 days, respectively; p < 0.0001), but similar cardiopulmonary complications were noted between the groups. Patients with PAL had a higher rate of empyema compared to patients without air leak and with SAL (8.2% vs 0%, p = 0.01 and 10.4% vs.1.1%, p = 0.01, respectively).

CONCLUSIONS

The presence of air leak was not associated with an increased incidence of cardiopulmonary morbidity but was associated with an increased risk of empyema. Future prospective studies are needed to confirm safety of fast track in patients with air leak.

Economic Assessment of the General Thoracic Surgery Outpatient Service

BACKGROUND

One aspect of the definition of institutional value for any program is based on the return on investment (ROI) for that program. Program requests for future resource allocations depend, in part, on that information. The purpose of this project was to determine the ROI for initial outpatient visits only for our General Thoracic Surgery (GTS) program.

METHODS

The number of GTS outpatient visits, studies, and requested consultations ordered by GTS surgeons only was determined after review of the hospital database and office records for the calendar year 2003. Only charges associated with the initial outpatient visits (no inpatient or physician charges) were included. Charges were based on hospital finance department data. The ROI for GTS outpatient services was calculated using total hospital costs and hospital collections.

RESULTS

There were 689 initial outpatient GTS visits. The majority were for lung cancer (48%), benign lung diseases (21%), and esophageal diseases (14%). Total outpatient charges were 1.25M dollars and by disease process were lung cancer (644,000 dollars), benign lung disease (90,000 dollars), esophageal disease (159,000 dollars), and other (357,000 dollars). The most significant hospital charges were the following: radiology (850,000 dollars), laboratory studies (82,000 dollars), gastrointestinal medicine studies (59,000 dollars), and cardiology (42,000 dollars). Total operational costs for the GTS clinic were 415,000 dollars and hospital collections were 513,000 dollars, yielding an ROI of 98,000 dollars or an operating margin of 19%.

CONCLUSIONS

An operating margin of 19% for GTS outpatient services is better than most Fortune 500 companies. Acquisition of this type of information by GTS surgeons may be helpful for future program development and institutional resource allocation.

Chest radiography in general practice: indications, diagnostic yield and consequences for patient management

BACKGROUND

Chest radiography (CXR) is frequently performed in Western societies. There is insufficient knowledge of its diagnostic value in terms of changes in patient management decisions in primary care.

AIM

To assess the influence of CXR on patient management in general practice.

DESIGN OF STUDY

Prospective cohort study.

SETTING

Seventy-eight GPs and three general hospitals in the Netherlands.

METHOD

Patients (n = 792) aged > or =18 years referred by their GPs for CXR were included. The main outcome was change in patient management assessed by means of questionnaires filled in by GPs before and after CXR.

RESULTS

Mean age of the patients was 57.3+/-16.2 years and 53% were male. Clinically relevant abnormalities were found in 24% of the CXRs. Patient management changed in 60% of the patients following CXR. Main changes included: fewer referrals to a medical specialist (from 26 to 12%); reduction in initiation or change in therapy (from 24 to 15%); and more frequent reassurance (from 25 to 46%). However, this reassurance was not perceived as such in a quarter of these patients. A change in patient management occurred significantly more frequently in patients with complaints of cough (67%), those who exhibited abnormalities during physical examination (69%), or those with a suspected diagnosis of pneumonia (68%).

CONCLUSION

Patient management by the GP changed in 60% of patients following CXR. CXR substantially reduced the number of referrals and initiation or change in therapy, and more patients were reassured by their GP. Thus, CXR is an important diagnostic tool for GPs and seems a cost-effective diagnostic test.

Use of nebulized inhaled corticosteroids among older adult patients: an assessment of outcomes

BACKGROUND

Inhaled corticosteroids (ICSs) are used by patients of all ages, but older patients may have difficulty with conventional inhalation devices and therefore may benefit from the easy-to-use delivery mechanism of the nebulizer.

OBJECTIVE

To compare the outcomes, resource use, and health care costs of patients prescribed nebulized ICSs before and after treatment.

METHODS

All patients 50 years and older prescribed nebulized ICSs were identified from a nationally representative managed care claims database (1999-2003). Patients with 1 year of continuous enrollment were analyzed using a retrospective cohort design; outcomes, resource use, and costs were measured and compared 6 months before and 6 months after the initial nebulized ICS prescription.

RESULTS

A total of 2,178 patients were identified for participation in the study, of whom 668 were analyzed. Patients were prescribed nebulized ICSs primarily for asthma (57.4%) and chronic obstructive pulmonary disease (52.1%). Nebulized ICSs were prescribed mostly by primary care physicians and pulmonologists. More than 40% of patients used nebulized ICSs persistently (at least 1 refill); persistent users averaged 123.4 days of use during 6 months of follow-up. There was a significant decrease in systemic corticosteroid use among persistent users (48.0% vs 38.8%; odds ratio, 0.7; 95% confidence interval, 0.5-1.0; P = .03). There was an emergency department visit in 20.2% and 15.0% of persistent users before and after the index date, respectively (odds ratio, 0.7; 95% confidence interval, 0.45-1.09; P = .12); 20.5% and 17.5% were hospitalized before and after the index date, respectively (odds ratio, 0.8; 95% confidence interval, 0.54-1.27; P = .38). No significant difference occurred in total health care costs during follow-up compared with baseline.

CONCLUSIONS

In this retrospective cohort study, older patients who used nebulized ICSs persistently demonstrated fewer emergency department visits and systemic corticosteroid use than before nebulized ICS use. These improved outcomes were not associated with an increase in health care costs.

Practical approach to lung health in Nepal: better prescribing and reduction of cost

OBJECTIVES

To assess the impact of Practical Approach to Lung Health (PAL) guidelines on prescription behaviour and the total cost of prescription for patients with asthma, chronic obstructive pulmonary disease and pneumonia.

METHODS

Pre- and post-intervention comparison in a cluster randomized trial of primary care facilities. Seven health posts and 33 subhealth posts in Nepal were stratified by type and randomized into intervention and control groups. Health workers from the intervention facilities received 5 days training on the adapted PAL guidelines and their use. To collect prescription details, we used carbon-copy prescription pads in both groups. To measure the impact of PAL guidelines we used the World Health Organization's rational use of drug indicators and drug cost indicators, in a multivariate regression analysis.

RESULTS

The PAL guidelines led to fewer prescriptions of multiple drugs and to more prescriptions of generic and essential drugs. The guidelines also lowered average prescription cost and wastage by disease except for chronic obstructive pulmonary disease although not to a statistically significant degree. Similarly, the prescription of antibiotics and adherence to guidelines improved, albeit not statistically significant.

CONCLUSION

There is evidence that the implementation of PAL guidelines promotes rational use of drugs for some respiratory diseases. The expected health effects of PAL guidelines should be compared with their implementation costs before continuing training on lung health, and strategies put in place to sustain the effects.

Economic burden of smoking in China, 2000

OBJECTIVE

To assess the health-related economic burden attributable to smoking in China for persons aged 35 and older.

METHODS

A prevalence-based, disease-specific approach was used to estimate the smoking attributable direct costs, indirect morbidity costs, and costs of premature deaths caused by smoking-related diseases. The primary data source was the 1998 China National Health Services Survey, which contains the smoking status, medical utilisation, and expenditures for 216,101 individuals.

RESULTS

The economic costs of smoking in 2000 amounted to $5.0 billion (measured in 2000, USD) in total and $25.43 per smoker (> or = age 35). The share of the economic costs was greater for men than women, and greater in rural areas than in urban areas. Of the $5.0 billion total costs, direct costs were $1.7 billion (34% of the total), indirect morbidity costs were $0.4 billion (8%), and indirect mortality costs were $2.9 billion (58%). The direct costs of smoking accounted for 3.1% of China's national health expenditures in 2000.

CONCLUSION

The adverse health effects of smoking constitute a huge economic burden to the Chinese society. To reduce this burden in the future, effective tobacco control programmes and sustained efforts are needed to curb the tobacco epidemic and economic losses.

[Pulmonary disease in dental laboratory technicians]

INTRODUCTION

The manufacture of dental prostheses exposes the technician to inhalation of various potentially dangerous dusts (silica, hard metals, dental alloys and acrylic resins).

BACKGROUND AND VIEWPOINT

Inhalation of dusts produced by the technician in the work place may lead to several respiratory disorders (pneumoconiosis, hypersensitivity pneumonitis, asthma, lung cancer). The continuous development of new materials leads to further manifestations of these disorders and justifies their notification, even in the absence of an accepted occupational disease. This step is taken inconsistently as many dental technicians are not salaried or insured.

CONCLUSION

The seriousness of some of these disorders and the absence of effective treatment makes it important to develop effective methods of prevention for the protection of individuals and groups, and for early detection.

Cost-effectiveness analysis of prophylactic respiratory physiotherapy in pulmonary lobectomy☆

OBJECTIVE

To evaluate the cost-effectiveness balance of implementing an intensive program of chest physiotherapy in pulmonary lobectomy.

METHODS

DESIGN

cross-sectional study with historical controls. Cases are 119 patients operated on during a 15-month period of time, after implementation of an intensive chest-physiotherapy program. Controls are 520 patients operated on by the same team before the program started. In these patients, only incentive spirometry was indicated besides routine nursing care. In both series, operative selection criteria and anaesthetic management were similar. Population homogeneity was assessed by comparing age, body mass index (BMI) and estimated postoperative FEV1 (ppoFEV1) of the patients in both series. Selected outcomes were as follows: 30-day mortality, prevalence of respiratory morbidity (atelectasis and pneumonia) and hospital stay. Hospital stay was estimated by Cox regression using age, ppoFEV1, BMI, diagnosis and postoperative morbidity as covariates. Costs were calculated adding chest therapists' salaries and acquisition value of specific training and monitoring devices and its consumable items. Savings from avoided hospitalisation days was discounted.

RESULTS

Prevalence of atelectasis and median hospital stay decreased in physiotherapy group. Cost of the program was 48,447.81 (407.12 per treated patient). An estimated total of 151.75 hospital days was saved in the physiotherapy group. Since daily hospitalisation cost is 590.00 in our centre, 89,532.50 savings was estimated from avoided hospitalisation days.

CONCLUSIONS

We have found a significant decrease in the rate of postoperative atelectasis without additional costs. In fact, the program has produced considerable monetary savings.

Diagnosing Occupational Lung Disease: A Practical Guide to the Occupational Pulmonary History for the Primary Care Practitioner

A well-executed occupational pulmonary history should be part of the evaluation of workers presenting with respiratory illnesses or symptoms. In this article, we review the scope of occupational lung disease and detail the essential elements of the occupational pulmonary history.

Cost analysis of video-assisted thoracic surgery versus thoracotomy: critical review

Cost containment has become an important issue in thoracic surgery. Applying the principles of evidence-based medicine a literature search was performed to determine whether video-assisted thoracic surgery (VATS) has an advantage over thoracotomy concerning total cost. Only eight studies specifically looked at cost; all but one were retrospective. Lung biopsy by VATS yielded higher operating room costs compared with limited thoracotomy. The cost of VATS wedge resection of lung nodules was competitive with open techniques. In a prospective study regarding the treatment of pneumothorax by VATS, no advantages were demonstrated compared with axillary minithoracotomy. In two retrospective studies the total economic cost of VATS was lower but not all relevant factors were considered. Lung volume reduction surgery by VATS had a lower total inpatient cost compared with sternotomy but no specific details were provided. Finally, VATS treatment of lung cancer yielded conflicting results regarding total hospital charges. From these studies it is clear that video-assisted thoracic surgery has a higher initial cost. Whether this is offset by a more rapid discharge remains to be proven. There is a definite need for high-quality prospective randomised studies.