In the United States, chronic obstructive pulmonary disease (COPD), characterized by airflow limitation that is not fully reversible, is the fourth leading cause of death, after heart disease, cancer, and cerebrovascular disease.1,2 An estimated 12 million Americans are currently diagnosed with COPD, but at least an equal number of people are believed to have the disease and have not been diagnosed.3 More than 90% of cases of COPD are caused by smoking,2 and therefore smoking cessation is a crucial strategy in the effort to reduce the incidence of COPD. No cure has yet been found for this disease, and true breakthroughs in treatment are lacking.
The costs associated with COPD are approaching $18 billion in direct costs and $14 billion in indirect costs.2,4 Hospitalizations account for approximately 40% of the direct costs, and prescription drugs for 20%.5 In 2000, 16 million office visits were attributed to COPD-related conditions.5 Despite these disturbing figures, COPD remains largely unrecognized as a public health problem.
Comorbidities associated with COPD include pneumonia, osteoporosis, respiratory infections, myocardial infarction, and depression. Extrapulmonary features contribute to the severity of the disease.
Symptoms of an exacerbation range from increased breathlessness accompanied by cough and sputum production in mild COPD to life-threatening respiratory failure in severe disease. Infection, particularly bacterial, is frequently implicated in exacerbations. Air pollution can also trigger exacerbations, but a cause-andeffect relationship is not always discernible. COPD exacerbations can often be managed at home. Hospital admission may be required, depending on symptom intensity, lack of response to medical management, or a change in mental status.
COPD will remain a significant and growing problem for years to come. Clinicians will need to pay increasing attention to COPD and collaborate with employers, health plan administrators, and regulatory agencies to mitigate the overall burden of this disease.
Pharmacotherapy can relieve symptoms, prevent or minimize exacerbations and complications, improve exercise performance, and decrease mortality. None of the medications available today can alter the progressive deterioration in lung function typical in COPD. Bronchodilators are the mainstay of management, and glucocorticosteroids are recommended for the treatment of severe to very severe disease in patients who have repeated exacerbations.
Rehabilitation programs generally focus on endurance exercise to increase work and exercise capacity. Oxygen therapy is advised for patients with resting hypoxemia. Surgery to reduce lung volume is an expensive, palliative procedure that should be undertaken only in carefully selected patients.
Businesses, providers, and health benefit managers now have much more information on COPD than in the past to help their decisions on how to reduce the workplace-related economic burden and social cost of this disease. COPD within the working population leads to direct and indirect costs to industry because of the progressive nature of this disease. Each industry sector will need to analyze the impact of COPD on its business and determine benefit solutions that will be effective in reducing lost productivity and healthcare costs, while addressing the social and cultural factors that lead to the disease. Communications about COPD must continue to address all stakeholders and emphasize smoking-cessation, accurate diagnosis, reduction of occupational exposures, and guideline-based management as key interventions for this progressive disease.
1. Murray CJ, Lopez AD. Alternative projection of mortality and disability by cause 1990-2020: Global Burden of Disease Study. Lancet. 1997;349: 1498-1504.
2. National Heart, Lung, and Blood Institute. Data Fact Sheet: Chronic Obstructive Pulmonary Disease. National Institutes of Health Publication 03-5229. Bethesda,MD:US Department ofHealth andHuman Services; 2003. www.nhlbi.nih.gov/health/public/lung/other/copd_fact.pdf. Accessed May 5, 2008.
3. National Heart, Lung, and Blood Institute. Morbidity and Mortality: 2007 Chart Book on Cardiovascular, Lung, and Blood Diseases. Bethesda, MD: National Institutes of Health. www.nhlbi.nih.gov/resources/docs/07-chtbk.pdf. Accessed April 30, 2008.
4. Skrepnek GH, Skrepnek SV. Epidemiology, clinical and economic burden, and natural history of chronic obstructive pulmonary disease and asthma. Am J Managed Care. 2004;10(5 suppl):S129-S138.
5. National Heart, Lung, and Blood Institute. Morbidity and Mortality: 2002 Chartbook on Cardiovascular, Lung, and Blood Diseases. Bethesda, MD: US Department of Health and Human Services; 2002.
Barbara Bekiesz assisted in the development of this overview.