Health economic considerations

The burden of disease, and how to measure this, is still a topic of debate. There are many aspects to include in a comprehensive appraisal of disease burden, and this complexity might be the origin of why there is no consensus on how to do this. Using descriptive cohorts, with no intervention and the availability of a control group, we chose to calculate the incremental costs. As an option, attributable costs can be calculated, but it has been seen that incremental, or so called excessive costs, are more accurate than attributable costs [101].

As the criticism of COI studies arose, some alternative approaches were developed to deal with the possible shortcomings of COI studies [179]. These include more sophisticated measures of change in health related to disease, like quality-adjusted life-years (QALYs), and the previously mentioned DALYs.

Such measures both consider the change in quality of life and the change in quantity, i.e. the lower life expectancy associated with disease [97]. A further criticism has been that burden of disease studies, are of no value if not reported together with some kind of benefit or efficiency measurement [11]. I.e., there is a need of comparing the burden in a group with a given health care programme to the burden in a group without such a programme, or intervention, to enable decision makers to take informed choices. There are three main study types that consider the costs in relationship to a beneficiary outcome (or an aggravated outcome), namely cost-effectiveness analysis (CEA), cost-utility analysis (CUA), and cost-benefit analysis (CBA).

101 Cost-effectiveness analyses, are mostly used to estimate the effects of a limited range of treatment options to illustrate for decision makers the possible choices they can make within their budget [11]. The effectiveness measures can for instance be cases detected of a certain disease, exacerbation-free intervals of asthma or COPD, or years of life gained. Decision makers then have to make trade-offs when they decide upon which effect/intervention/treatment/screening to spend their limited resources on. Lately, cost-utility analyses have become more popular as the outcome often is measured in QALYs or DALYs that incorporate weighting of the various disease states that are investigated, enhancing comparability. In CUA, several different outcomes can be

investigated together with a final combined outcome stating the costs per e.g.

QALY gained, allowing for comparisons across any different health care programme [11].

In contrast to CEA and CUA, CBA value the programme consequences in monetary units. With this approach, both the costs of a programme and the outcome of the programme, is given in the same monetary unit, making direct comparison of the expenditures to the gains possible. The difference between these two, is the net social benefit, be it negative or positive, clarifying if the programme is worthwhile or not [11]. All in all, comparing health care programmes, be it preventive programmes, or treatment alternatives, data on QALYs or DALYs combined with the effectiveness or benefit of the programme, give a comprehensive evaluation of the burden of disease and possible advantages that can be obtained from different choices in health care.

Both the BOLD study and the EconCOPD study were descriptive observational studies with no intervention. We did not have information in our data sets to make evaluations of the consequences of COPD on reduced quality of life or disability-adjustments. Such analyses could have provided valuable additional insight. From the EconCOPD dataset, we performed a comprehensive cost-of-illness analysis on the data available in our descriptive cohort study, including both direct and indirect incremental costs of COPD in two different samples.

The burden is given in monetary units, and can as such, be compared to similar COI studies on COPD, or on other diseases.

We chose the human capital approach when assigning a monetary value to the lost productivity. The most used alternative way of assigning money value to reduced working capacity, is the friction cost method. As explained in the introduction, this method implies finding the time period when absenteeism from work leads to reduced productivity until someone from the pool of unemployed people start doing the chores of the one absent. In Norway, there has not been a high unemployment rate for many decades [180], and hence, if someone is sick or disabled to work, it can be viewed as a permanent loss of productivity. Additionally, the HCA value human beings independently of their capacity to participate in the work force. I would like to argue that this

viewpoint is more ethical than a perspective where people have no value if not working for an income.

With the intention of accomplishing a COI study that includes total costs to society, we have performed a detailed gathering of data. Albeit, there might be some costs missing to make it complete. Intangible costs are the costs related to pain and suffering both among patients and relatives, and are the ones most difficult to measure. We did not include intangible costs as we did not have the information in our dataset to do so, and this make our results on the burden of COPD even more conservative.

103 5.2 Discussion of the main results

The paper from the BOLD study presented the burden of unemployment associated with CAO. The papers from the EconCOPD study, addressed the burden inflicted by COPD by productivity losses, acute exacerbations, and societal costs. Additionally, all three papers from the EconCOPD study examined the differences between a selected hospital sample and a general population sample.