Lower Respiratory Tract Infections

Pharmacoeconomics 2003; 21 (10): 749-759ORIGINAL RESEARCH ARTICLE 1170-7690/03/0010-0749/$30.00/0

© Adis Data Information BV 2003. All rights reserved.

Lower Respiratory Tract InfectionsImpact on the Workplace

Howard G. Birnbaum,1 Melissa Morley,1 Stephanie Leong,1 Paul Greenberg1 andGene L. Colice2

1 Analysis Group, Boston, Massachusetts, USA2 Washington (DC) Hospital Center, Washington, DC, USA

Background: While there is some literature on the cost of specific respiratoryAbstractinfections, much of the existing research focuses only on direct medical treatmentcosts and does not take into consideration workplace burden due to disability andabsenteeism.Objective: To evaluate the impact of lower respiratory tract infections (LRTIs) onthe workplace, specifically regarding the economic burden from an employer’sperspective.Design: Specific LRTI considered here were acute bronchitis, acute exacerbationsof chronic bronchitis and pneumonia. Data from medical, prescription drug anddisability claims of a large, national company in the US were used. These dataprovide information on both the healthcare and work loss impacts of LRTI on thismajor self-insured employer. The annual per capita expenditures for persons withLRTI were determined for beneficiaries (including employees and dependants) ofthis employer by analysing all claims in 1997. Results were compared with thoseof a 10% random sample of beneficiaries in the employer’s overall beneficiarypopulation.Results: In 1997, total per person expenditures and total medical service utilisa-tion were higher among beneficiaries with LRTI than among beneficiaries in theoverall beneficiary population sample. Annual per capita employer expendituresfor beneficiaries with LRTI totalled $US6116, compared with $US2368 (1997values) for the average beneficiary in the overall beneficiary population sample.Employer payments for lost work time through disability and absenteeismaccounted for 17% of these expenditures amongst beneficiaries with LRTI and for35% amongst employees with LRTI.Conclusions: Annual per capita expenditures for beneficiaries with LRTI werealmost three times that of the average beneficiary. We conclude that it is importantto consider work loss in analyses of the cost of LRTI.

Lower respiratory tract infections (i.e. infections Acute bronchitis is a clinical diagnosis based onbelow the larynx) include infections of the lung the characteristic features of a respiratory tract in-itself (pneumonia) and infections of the trache- fection with cough lasting <3 weeks. In most casesobronchial tree (acute bronchitis and acute exacer- an aetiological agent is not identified and symptomsbations of chronic bronchitis). are self-limited. Specific treatment is only warranted

750 Birnbaum et al.

in two situations. Antibacterials are recommended den associated with these patients is important forin the rare case of pertussis and anti-influenza agents payers demanding cost-effective healthcare.might be considered if influenza is suspected.[1]

The focus of the research reported here is on theAcute exacerbation of chronic bronchitis (AECB) is subset of LRTI including pneumonia, acute bronchi-also a clinical diagnosis, made in patients with tis and acute exacerbations of chronic bronchitis.[9]

chronic bronchitis who present with worseningResearch on the epidemiology and treatment of vari-

dyspnoea, increased sputum purulence and/or in-ous respiratory infections has provided important

creased sputum volume. The usual causes of AECBinsights into prognostic factors for these condi-

are tracheobronchial infections, both viral and bac-tions.[10-12] While past studies have reported on di-

terial, and environmental exposures. Effectiverect costs associated with treating these LRTI, there

bronchodilator therapy is an important basis foris little information regarding the indirect costs of

managing AECB; antibacterials may be effective intreatment and the workplace impacts of treatment.reducing the duration of illness in cases of severe

Several studies have used claims data and healthAECB.[2,3] Pneumonia may be either communityinterview data to calculate the direct costs of treatingacquired (CAP) or hospital acquired (nosocomial).LRTI. For example, Niederman et al.[13] studied theThe diagnosis of pneumonia rests on recognising

respiratory symptoms, especially cough productive cost of treating CAP using incidence data from theof purulent phlegm and a new infiltrate on chest National Health and Nutrition Examination Surveyradiograph. Use of empirically chosen antibacterials III, paid claims data from National Healthcare Costis appropriate for both CAP and nosocomial pneu- and Utilization Project and various national surveys.monia because identifying a causative bacterial The results of this study showed that the total directagent may take days.[4,5] cost, in 1995 dollars, of treating patients with pneu-

monia aged under 65 years in the US was $US3.6Lower respiratory tract infections (LRTI) occurbillion per year.[13] This study also demonstratedoften and are a frequent cause of hospitalisation andthat prescription drug costs accounted for 12.2% ofdeath. While the incidence of respiratory infectionsthe total costs of treatment for patients with CAP. Ais higher among the very young and the very old, thesimilar study was performed for AECB and estimat-rates of infection are significant across all ageed that total treatment costs for the under 65 years ofgroups.[6] The World Health Organization reportedage population in the US in 1995 was $US0.4 bil-that over 3.9 million deaths were attributable tolion, with drug costs accounting for 11.2% of totalacute LRTI in 1996.[7] Of all forms of LRTI, acutecosts per patient.[14] In both studies, costs werebronchitis is probably the most commonly occurringcomputed using the average Medicare cost per hos-and is a frequent reason for ambulatory physicianpital day or physician visit and applying these costsoffice visits.[1] According to data from the 1996to the number of hospital and outpatient visits forNational Health Interview Survey, the incidence ofpatients. McGuire et al.[15] have studied AECB inacute bronchitis was 4.6 per 100 persons.[8] It hasEngland and Wales in patients over the age of 45been estimated that 16 million physician office vis-years using disease prevalence data and healthcareits, 500 000 hospitalisations and 110 000 deaths inresource utilisation from a UK national survey ofthe US each year are related to AECB.[2] It has alsogeneral practice consultations, the General Practicebeen estimated that there are 2 million cases of CAPResearch Database and the national healthcare re-each year in the US, causing perhaps 500 000 hos-source and cost statistics. In addition to estimatingpitalisations and 50 000–100 000 deaths.[2] The inci-the excess cost of AECB, the authors found that adence of nosocomial pneumonia is less than that oflarge portion of the excess cost was attributable toCAP, but the mortality rate is substantially higher.[3]

antibacterial and respiratory prescription med-Given the high rate of LRTI, understanding theication.[15]medical resource allocation and the economic bur-

© Adis Data Information BV 2003. All rights reserved. Pharmacoeconomics 2003; 21 (10)

Workplace Impact of Respiratory Tract Infections 751

Similar studies have been conducted for other Methodsrespiratory conditions both in the US and interna-tionally. A recent study of chronic bronchitis and

Claims Dataemphysema in the US by Wilson et al.[16] found thatthe total direct healthcare costs for these illnesses Medical, prescription drug and disability claims,were $US11.7 billion, in 1996 dollars, with hospital from distinct parts of the corporate benefits systemcare accounting for approximately half of that cost. of a large national US corporation were used. TheThis study, too, relied primarily on survey data from data include administrative claims for all benefi-multiple national, state and local sources, and costs ciaries and includes employees, spouses, dependantsfor hospital and physician visits were derived from and retirees and can be linked at the beneficiarythe Healthcare Cost and Utilization Project and na- level. This self-insured company offers comprehen-tional Medicare physician fee estimates in 1996. sive health insurance and has a predominantlyAnother study of the direct medical costs of chronic unionised workforce, 90% of whom are eligible forobstructive pulmonary disease (COPD) was con- disability benefits. Complete data are available forducted by Ward et al.[17] In this study, the authors over 100 000 beneficiaries (and over 10 000 em-used national surveys and Medicare and Medicaid ployees), distributed across the country, who werereimbursement rates and found that the cost of care enrolled in one of this company’s managed indemni-for COPD in the US is $US6.6 billion annually in ty insurance plans in 1997. Data for those enrolled in1993–1994.[17] Rutten van-Molken and Feenstra health maintenance organisations (HMOs) [who ac-studied asthma and COPD in The Netherlands using counted for approximately 20% of enrollees] are notnational incidence and survey data. The results of available, and these individuals are excluded fromthis study indicate that the total direct medical costs the sample. To ensure completeness of records weof asthma and COPD are $US346 million and have also excluded those over the age of 65 years in

1997, due to their coverage by Medicare.amount to 1.3% of the total healthcare budget in TheNetherlands in 1993.[18] Medical claims, including claims for physician

office visits, and inpatient and outpatient hospital-Other published studies related to LRTI haveisations, provide information on the date of servicefocused on cost-effectiveness issues in the contextand nature of the ailment(s) as described by detailedof specific treatments (e.g. use of alternative anti-diagnosis (International Classification of Diseases,bacterials, switching from parenteral to oral therapy,9th Revision [ICD-9]) and procedure (Current Pro-use of a specific agent from the outset of treat-cedural Terminology [CPT]) codes, by place of ser-ment).[19-23] This research provides information re-vice. Similarly, prescription drug claims includegarding the relative, or marginal, costs of one treat-National Drug Code (NDC) information. Compari-ment approach relative to another, rather than datasons of treatment patterns, and healthcare and work-on direct and indirect costs of illness.place expenditures, are made across beneficiaries

Much of the previous research related to the with the conditions of interest. Since this study relieseconomic burden of LRTI relies on self-reported on insurance claims data, the findings are subject todata and assigned costs per day and per visit. In the usual limitations of administrative data sets.addition to using actual paid claims data, the results Such limitations include possibly inaccurate diagno-reported here supplement the current direct cost ses and incomplete assembly of claims (e.g. missingliterature by providing estimates of the indirect costs bills, multiple plan coverage).[24]

associated with LRTI. Through the use of adminis-trative claims data from a large national employer, Samplesthis research provides a broader view of the eco-nomic burden of treatment for LRTIs, from an em- The LRTI sample includes all beneficiariesployer’s perspective. (under age 65 years) with at least one claim with a


752 Birnbaum et al.

diagnosis for pneumonia, acute bronchitis or AECB and are reported on an average, per person basisin 1997. These beneficiaries were identified using annually. Costs are reported in 1997 values. Ourthe following ICD-9 codes: pneumonia, 480-486; methods are similar to the approach taken by Burtonacute bronchitis, 466; and AECB, 491.21. Analyses and Conti[25] who used a ‘data warehouse’ to analysewere performed on the full LRTI sample as well as a range of other illnesses and document their effectsseparately on beneficiaries with claims for each of on employee productivity.the three LRTI diagnoses. However, while our data set includes disability

Since the perspective of interest here is the em- claims, it does not include sporadic sick time. Dataployer, we contrasted the average beneficiary with available here on the workplace burden of illness doLRTI to that of the average beneficiary, rather than a not include measures of on-the-job productivity, butmatched control. To characterise the resource they do include periods of disability and daily pay-utilisation profile of a beneficiary with LRTI with ments received by the employee. Data on shorter,that of an average beneficiary, results for benefi- medically related illness absences are not available,ciaries with LRTI were contrasted with those for the but are imputed. Because the disability claims coveroverall beneficiary population (under age 65 years), missed work days due to illness for periods of 6 oras reflected in the claims data of a 10% random more consecutive days for eligible workers, 5 sick-sample of the employer’s overall beneficiary popu- ness days were imputed for employees with disabili-lation (e.g. including employees and dependants). ty claims. In addition, we imputed additional sickConsequently, the comparison is between the mean time based on days when medical care was pro-expenditures of a beneficiary with LRTI and that of vided. If an employee was not on disability whenthe average beneficiary in this employer population. medical care occurred during workdays, these daysSince the average beneficiary is a composite of all are counted as medically related work loss days inbeneficiaries, including those treated for respiratory the case of hospital care or as a half-day in the caseinfections, beneficiaries with LRTI appear in both of physician office visits.populations. Work loss expenditures refer here to employer

payments for disability claims paid by its third-partyStatistical Analysis administrator plus the imputed salary for medically

related absence time. See Barnett et al.[26] for a moreMedical, pharmacy and disability claims werecomplete description of these data.linked at the individual level. This allowed for the

calculations of average medical utilisation and aver-Resultsage expenditures per person. Other descriptive sta-

tistics were also performed on the samples includingThere were 14 315 beneficiaries with at least one

demographics and employment status. Statisticalclaim for one of the three LRTI conditions in 1997.

significance between the beneficiaries with LRTIThe incidence rate of treated LRTI in the beneficiary

and the overall beneficiary population were deter-population was 8%. This rate is consistent with that

mined using t-tests for the difference in means be-for the overall (under age 65 years) US population.[8]

tween the groups, and chi-square tests for the differ-In comparing the demographics of beneficiaries

ence in proportions between groups. Analyses werewith LRTI to those of the overall beneficiary popu-

performed on both beneficiaries with LRTI and onlation sample, we found there was a significantly

employees with LRTI. All statistical analyses werelower percentage of females amongst beneficiaries

performed using SAS statistical software, version 8.with LRTI compared with the overall beneficiarypopulation sample (table I). The mean age wasCost Measuressimilar for the two groups, although there were some

Direct and indirect costs are measured as the small but statistically significant differences in theactual cash payments by this self-insured employer, age distributions (table I).



Table I. Demographic characteristics of beneficiaries and employees with lower respiratory tract infections (LRTIs) in 1997

Beneficiariesa,b Employees

beneficiaries with LRTIs overall beneficiary sample employees with LRTIs overall employee sample

Sample size 14 315 10% of beneficiariesc 5017 10% of employeesd

Gender: percent female 51.4 49.7 23.8b,e 16.1b,e

Individual status

Percent employees 39.5 32.5 100 100

Percent retired 5.4 7.5 0 0

Percent spouses/ 55.2 60.1 0 0dependants

Age (years)

Mean 37.2 37.1 45.4 45.8

Median 43.0 42.0 47.0 47.0

Mode 51.0 51.0 50.0 51.0

<6 (%) 9.3 4.9 NA NA

6–17 (%) 13.0 17.5 NA NA

18–35 (%) 15.4 17.7 18.3 17.2

36–45 (%) 17.4 16.6 26.7 25.6

46–55 (%) 27.6 25.7 38.7 40.6

56–64 (%) 17.4 17.7 16.2 16.5

a All differences between overall beneficiary sample and beneficiaries with LRTIs significant at p < 0.05, with the exceptions of mean,median, and mode of age (p = 0.6751) and ages 56–64 (p = 0.4412).

b p values derived from t tests and χ2 tests for proportions.

c 10% sample of over 100 000 beneficiaries.

d 10% sample of over 10 000 employees.

e Difference between percent female in the overall employee sample and employees with LRTIs significant at p < 0.01.

NA = not applicable.

Treatment Patterns 15.9 and 27.0 claims per person, respectively (p <0.05 versus AECB). The overall beneficiary popula-

Beneficiaries with LRTI had on average over two tion sample had 7.6 claims per person. There wastimes more medical claims than did the average also considerable overlap of beneficiaries betweenbeneficiary (18.4 vs 7.6; p < 0.0001; figure 1a). One the three LRTI. For example, 21% of beneficiariesreason for this is that beneficiaries with LRTI were with a pneumonia diagnosis also had a claim foridentified based on the fact they had submitted at acute bronchitis and 15% had a claim for AECB.least one claim for LRTI, unlike those in the overallbeneficiary population sample who may not have Cost Measuressubmitted any medical claim (figure 1b). The aver-age number of claims for beneficiaries with LRTI Total employer expenditures measured as pay-was more than 50% greater than for comparable ments for healthcare, disability and absenteeismusers in the overall beneficiary population sample were $US6116 per beneficiary with treated LRTI in(18.4 claims vs 10.9 claims, p < 0.0001; figure 1c). 1997 (figure 2). Total employer expenditures were

Because LRTIs vary widely in their severity, $US8209 per employee with an LRTI. These permedical care utilisation also varies among the three capita expenditures are more than twice those of theLRTI conditions. Beneficiaries with AECB had the overall beneficiary population sample and the over-highest number of claims per person (36.3). In con- all employee population sample (i.e. $US2368 andtrast, beneficiaries with acute bronchitis and pneu- $US3815, respectively; p < 0.0001). The differencemonia, who were more numerous, averaged only between expenditures for beneficiaries and employ-


754 Birnbaum et al.

35% of total expenditures for employees with LRTI,compared with 17% for beneficiaries with LRTIs.Of the total expenditures of beneficiaries with LRTI,12% were for prescription drugs.

There was variation by type of LRTI. For exam-ple, in both the beneficiary and the employee sam-ples, patients with an AECB diagnosis had higherper person expenditures than those with a diagnosisfor acute bronchitis or pneumonia. The average ex-penditure per beneficiary with an AECB diagnosiswas $US15 839, compared with $US11 544 for ben-eficiaries with pneumonia and $US4219 for benefi-ciaries with acute bronchitis. A similar pattern isalso seen in the employee sample. One explanationfor the higher expenditures for patients with AECBis that, on average, this population is older and morelikely to use inpatient hospital care compared withpatients with other LRTIs. For example, the averageage for beneficiaries with AECB was 51 years com-pared with 37 years for beneficiaries with any of thespecified LRTIs. Fifty-six percent of beneficiarieswith AECB had at least one inpatient hospital claimin 1997 compared with just 20% of beneficiarieswith any LRTI and 8% of the overall beneficiarypopulation sample. Inpatient care is the primarydriver of the expenditures associated with LRTI.Inpatient care accounted for 54% ($US8569) of totalexpenditures for beneficiaries with AECB, and 55%and 26% ($US6316 and $US1114) for pneumoniaand acute bronchitis, respectively.

This analysis highlights the variation in employerpayments among types of LRTI. For example, al-though the incidence of AECB in this population isrelatively uncommon, it is an extremely expensivecondition, and per capita expenditures are approxi-mately four times that for beneficiaries with acutebronchitis. Similarly, for certain conditions, espe-cially AECB and pneumonia, the major expenseitem is inpatient services. While AECB expendi-tures per beneficiary are greater than for benefi-

4.2

7.6

0.73.1

5.1

9.6

0.6

18.4

2.30.3

02468

1012141618202224262830

Ave

rage

num

ber

ofcl

aim

s pe

r be

nefic

iary

Overall beneficiary sampleBeneficiaries with LRTI (n = 14 315)

a

20%

8%

100%

69%67%

41%

14%7%

94%

62%

0

20

40

60

80

100

Per

cent

age

of b

enef

icia

ries

with

at l

east

one

cla

ima

b

5.67.7

4.43.6

15.8

9.4

18.4

10.9

6.8

10.2

02468

1012141618202224262830

Inpatient Outpatient Office Other Total

Ave

rage

num

ber

of c

laim

spe

r us

er o

f a s

peci

fic s

ervi

ce

c

Fig. 1. 1997 medical claims per beneficiary by type of service. Datafor beneficiaries with treated lower respiratory tract infections(LRTIs; n = 14 315) are compared with a 10% random sample ofthe employer’s overall beneficiary population. Differences betweenthe overall beneficiary population sample and the beneficiaries withLRTIs are all p < 0.0001; p values derived from t tests and χ2 testsfor proportions. a Note that percentages are not cumulative.

ciaries with other LRTIs, because acute bronchitisand pneumonia are more common conditions, theyees was largely due to higher payments for disabilityaccount for more of the economic burden in terms ofand absenteeism among employees. Overall, workaggregate employer expenditures (table II).loss due to disability and absenteeism accounted for



Healthcarea

Disability Absenteeism

0

2000

4000

6000

8000

10 000

12 000

14 000

16 000

18 000

Ann

ual a

vera

ge p

aym

ents

per

per

son

($U

S)

Overallbeneficiary

10% random sample

$US2368

81%

8%11%

LRTIsn = 14 315

$US6116

83%

7%10%

Acuteexacerbations

of chronicbronchitisn = 515

$US15 839

87%

4%

9%

Pneumonian = 4036

$US11 544

9%

87%

4%

Acutebronchitis n = 10 852

$US4219

78%

11%11%

Overallemployee

10% random sample

$US3815

15%

60%

25%

LRTIs n = 5017

$US8209

21%

65%

14%

Acuteexacerbations

of chronicbronchitis

n = 226

$US16 073

Pneumonian = 1362

$US14 837

21%

20%

70%

71%

9%

9%

Acutebronchitis n = 3841

$US6075

59%

19%

22%

Beneficiaries Employees

Fig. 2. 1997 employer payments: cost component data for beneficiaries with treated lower respiratory tract infections (LRTIs; n = 14 315)are compared with a 10% random sample of the employer’s overall beneficiary population and cost component data for the company’semployees with treated LRTIs (n = 5017) are compared with a 10% random sample of the company’s overall employee population.Differences between the overall beneficiary or employee population samples and the groups with LRTIs (both for beneficiary and employeesubgroups) are all p < 0.0001 with the exception of ‘other’ claims for employees where p = 0.0002; p values derived from t tests. aHealthcare includes both medical care costs and prescription drug costs.

Expenses among the LRTI population are con- $US10 000 per patient for approximately 25% of thebeneficiaries with pneumonia in 1997, similar ex-centrated among a relatively small group of benefi-penditures were incurred for only 14% of benefi-ciaries who were disproportionately hospitalised.ciaries with any of the specified LRTIs and an evenFor example, among beneficiaries with pneumonia,smaller percentage (5%) of the overall beneficiarythe most expensive 10% (99% of whom were hos-population sample.pitalised) accounted for 59% of the total expendi-

tures of the entire beneficiary population with pneu- While this data set is for a single employer, it ismonia. While 59% of beneficiaries with AECB and possible to provide an order of magnitude of the36% of beneficiaries with pneumonia had at least expenditures of patients with LRTI in the US, from aone inpatient hospital claim, only 20% of all benefi- self-insured employer’s perspective. To the extentciaries with LRTI had an inpatient hospital claim in that the employed population in the nation is gener-1997 due to the low resource use of the beneficiaries ally similar to the study population (which reflects awith acute bronchitis. While the employer paid over broad range of socioeconomic groups employed by


756 Birnbaum et al.

a major industrial firm including management, salesand marketing, engineering, industrial, office, sup-port staff, etc.), in the incidence of LRTI, as well ashealthcare utilisation and payments, the results ofthis study can be used to approximate the expendi-tures of patients with LRTIs to the entire US em-ployed population and their dependants. We ac-knowledge that insurance plans across the US dovary widely, and that these estimates do not reflectthe costs of the uninsured population Also, since thedata exclude the over the age of 65 years populationand those enrolled in an HMO, this aspect of themethodology limits the ability of the data to beextrapolated to other environments. Our estimate iscalculated by multiplying three numbers: (i) an esti-mate of the employed population and their depen-dants in the US; (ii) the incidence of LRTIs; and (iii)the incremental expenditure of LRTIs (i.e. the dif-ference between the average expenditures of theLRTI sample and that of the overall beneficiarypopulation sample). In 1997, there were approxi-mately 154 million employees and their dependants.This estimate is derived by multiplying the numberof families with at least one employee and no retire-ment income (48.3 million)[27] by the average familysize (3.2 members).[28] Multiplying this populationestimate by the incidence rate for the three respira-tory conditions considered here (8%) and the incre-mental expenditure of LRTI ($US3748) [see figure2 for the difference between the expenditures ofbeneficiaries with LRTI and the overall beneficiarypopulation sample], we estimate that the expendi-tures of insured working persons under 65 years ofage with LRTI to employers in 1997 was $US46billion.

Discussion

This work extends our previous research on theeconomic burden of pneumonia.[29] The analysishere demonstrates the significant financial burden ofLRTI to this employer and of variations in expendi-tures among beneficiaries with LRTI. Total employ-er expenditures for beneficiaries with LRTI are overtwice those for beneficiaries in the overall benefici-ary population, on average. For all three types of


Tab

le I

I. E

mpl

oyer

pay

men

ts p

er b

enef

icia

ry b

y ty

pe o

f lo

wer

res

pira

tory

tra

ct in

fect

ion

(LR

TI)

and

agg

rega

te e

mpl

oyer

cos

t in

199

7 ($

US

; 19

97 v

alue

s)

Ben

efic

iarie

s w

ithC

osts

per

ben

efic

iary

Agg

rega

tecl

aim

s by

typ

e of

empl

oyer

cos

tsa

LRT

Ihe

alth

care

cos

tsdi

sabi

lity

cost

sab

sent

eeis

m c

osts

tota

l cos

tsov

eral

l cos

ts

inpa

tient

outp

atie

ntpr

escr

iptio

nof

fice

othe

rb

drug

Acu

te b

ronc

hitis

1114

951

682

441

114

474

443

4219

4578

458

8(n

= 1

085

2)

Pne

umon

ia63

1619

0297

360

424

210

1649

111

544

4659

158

4(n

= 4

036)

Acu

te e

xace

rbat

ions

8569

2268

1583

867

443

1480

629

1583

98

157

085

of c

hron

ic b

ronc

hitis

(n =

515

)

Uni

que

indi

vidu

als

in24

6212

0675

848

014

461

744

961

1687

550

540

LRT

I sa

mpl

e(n

= 1

431

5)

aO

vera

ll co

sts

= t

otal

cos

ts ×

num

ber

of b

enef

icia

ries

with

spe

cific

con

ditio

n.

b‘O

ther

’ inc

lude

s ca

re a

t ben

efic

iary

’s h

ome,

nur

sing

/ext

ende

d ca

re fa

cilit

y, p

sych

iatr

ic d

ay c

are

faci

lity,

sub

stan

ce a

buse

trea

tmen

t fac

ility

and

inde

pend

ent c

linic

al la

bora

torie

s.


LRTI, an important portion of these expenditures population with its higher incidence rate of LRTI.are the amounts paid for disability and absenteeism, Additionally, sick time at home was not fully mea-especially for employees. Additionally, there is a sured; we captured only that part of work loss due tolarge inpatient burden for a subset of beneficiaries illness that was associated with disability or medicalwith AECB and pneumonia. Data provided here on treatment. Respiratory infections of dependantsexpenditures by type of LRTI may provide a basis (both children and elderly adults) can also lead tofor savings strategies (e.g. pneumonia vaccines as a workplace absences for caregivers who miss work tomandatory treatment). Similarly, the share of expen- care for ill dependants. In addition, the actual pay-ditures (12%) accounted for by prescription drugs is ments for disability that are reported here reflectnotable given the current policy interest in the cost only a fraction of the employer’s total opportunityof drugs and the rising proportion of medical spend- cost for workforce disruptions due to disability.ing that is accounted for by prescription drugs. This Other likely workplace costs include reduced on-suggests that economic analyses of new drugs the-job productivity, administrative and training ex-should not just look at the cost of the medications penses for replacement workers, as well as daysitself, but also at how the new treatment might affect missed for sick time.total healthcare costs, disability payments, and work

The findings of the current study increase ourproductivity. It also would be useful to investigate

understanding of the workplace burden of treatingthe economic consequences of treatment-resistant

patients with LRTI. However, these findings areLRTIs and newer medications designed to address

limited by the available data. First, because thisthese conditions.study relies on insurance claims data, the findings

This expense includes all of the healthcare pay- are subject to the usual limitations of administrativements for treating patients with LRTI irrespective of data sets. Such limitations include possibly inaccu-the actual condition for which the patients were rate diagnoses and incomplete assembly of claimstreated, as well as the work loss burden to the (e.g. missing bills, multiple plan coverage).[30]

employer. Hence, the expenditures include those of Second, because many beneficiaries in the LRTItreating all of the comorbidities of LRTI claimants, sample had a claim for more than one LRTI or otheras well as that for treatment explicitly for LRTI. respiratory conditions such as streptococcal-infectedConsequently, our findings should not be taken as an throat or influenza, expenditures to the employerestimate of expenditures for treating just LRTI. should also be considered in the context of comorbi-Since our methodology includes the expenditures of dities. Seventy-seven percent of beneficiaries withconditions other than LRTI for which the patients pneumonia had at least one claim for anotherwere treated, this is a possible reason why the esti- respiratory infection in 1997. In addition to comor-mates are so much higher that direct cost estimates bidity with other respiratory infections, it is alsoof other published literature.[13,14] Also, another necessary to consider comorbidity with other non-possible reason is the use of payments rather than respiratory conditions. For example, the risk of de-costs, whereas other authors may have used costs. veloping pneumonia is highest for patients withRather, the estimates here represent the expenditures other serious conditions, such as cancer and HIV/of treating patients with LRTI, not just for the treat- AIDS. Third, information on antibacterial treatmentment of LRTI. for the various LRTIs was not widely available,

limiting our ability to determine how antibacterialThe estimated expenditures of treating patientschoice may have affected outcomes. Finally, it iswith LRTI presented here may underestimate thepossible that a certain percentage of company bene-true burden, particularly regarding indirect costs, forficiaries will be covered by their spouses insurancea variety of reasons. For example, we excludedplan – information about these employees will haveindividuals over the age of 65 years in 1997, therebybeen missed.removing from our beneficiary sample the elderly


758 Birnbaum et al.

D.C.: Centers for Disease Control and Prevention NationalUnravelling the unique costs of LRTI relative toCenter for Health Statistics, 1999 Oct

other comorbid conditions and the benefits of vari- 9. International Conference on Acute Respiratory Infections 1997.Available from URL: http://www.nceph.anu.edu. [Accessedous prescription medications are topics for future2000 Aug 23]research. Similarly, the caregiver burden of lost

10. Georges H, Leroy O, Vandenbussche C, et al. Epidemiologicalwork time due to LRTI of family members is an features and prognosis of severe community-acquired

pneumoccocal respiratory infection. Intensive Care Med 1999important area for future research, as is the impact ofFeb; 25 (2): 198-206influenza vaccination.

11. Sethi S. Infectious etiology of acute exacerbations of chronicbronchitis. Chest 2000 May; 117 (5 Suppl. 2): 380S-5S

12. White CB, Foshee WS. Upper respiratory tract infections inConclusionadolescents. Adolesc Med 2000 Jun; 11 (2): 225-49

13. Niederman MS, McCombs JS, Unger AN, et al. The cost ofWith this claims data set for a self-insured, largetreating community-acquired pneumonia. Clin Ther 1998 Jul-

national employer, we found that annual per capita Aug; 20 (4): 820-37expenditures for beneficiaries with LRTI were al- 14. Niederman MS, McCombs JS, Unger AN, et al. Treatment cost

of acute exacerbations of chronic bronchitis. Clin Ther 1999most three times that of the average beneficiary andMar; 21 (3): 576-91

over twice as much for employees with LRTI as the 15. McGuire A, Irwin DE, Fenn P, et al. The excess cost of acuteexacerbations of chronic bronchitis in patients aged 45 andaverage employee. Work loss due to disability andolder in England and Wales. Value Health 2001 Sep-Oct; 4 (5):absenteeism accounted for one-third of total expen-370-5

ditures for employees with LRTI. We conclude that 16. Wilson L, Devine EB, So K. Direct medical costs of chronicobstructive pulmonary disease: chronic bronchitis and emphy-it is important to consider work loss in analyses ofsema. Respir Med 2000 Mar; 94 (3): 204-13the cost of LRTI.

17. Ward MM, Javitz HS, Smith WM, et al. Direct medical costs ofchronic obstructive pulmonary disease in USA. Respir Med2000 Nov; 94 (11): 1123-9Acknowledgements

18. Rutten van-Molken MP, Feenstra TL. The burden of asthma andchronic obstructive pulmonary disease: data from The Nether-This research was funded by an unconditional grant fromlands. Pharmacoeconomics 2001; 19 Suppl. 2: 1-6Aventis Pharmaceuticals, Bridgewater, NJ, USA. Dr Colice

19. Garrelts JC, Herrington AM. Cost-effective treatment of lowerserved as a consultant to Aventis Pharmaceuticals in otherrespiratory tract infections. Pharmacoeconomics 1996 Jul; 10capacities. There are no other financial funding arrangements (1): 36-58

or potential conflicts of interest relevant to this research. 20. Plosker GL, Foster RH, Benfield P. Cefotaxime: a pharmaco-economic review of its use in the treatment of infections.Pharmacoeconomics 1998 Jan; 13 (1 Pt 1): 91-106References 21. Grossman R. Cost-effective therapy for acute exacerbations of

1. Snow V, Mottur-Pilson C, Gonzales R, et al. Principles of chronic bronchitis. Semin Respir Infect 2000; 15 (1): 71-81appropriate antibiotic use for treatment of acute bronchitis in

22. Li-McLeod J, Perfetto EM. Workplace costs associated withadults. Ann Intern Med 2001 Mar 20; 134 (6): 518-20acute exacerbation of chronic bronchitis: a comparison of

2. Snow V, Lascher S, Mottur-Pilson C, et al. Evidence base formoxifloxacin and levofloxacin. Manag Care Interface 2001

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pulmonary disease. Ann Intern Med 2001 Apr 3; 134 (7):23. Grossman RF. How do we achieve cost-effective options in595-9

lower respiratory tract infection therapy? Chest 1998 Mar; 1133. Bach PB, Brown C, Gelfand SE, et al. Management of acute(3 Suppl.): 205S-10Sexacerbations of chronic obstructive pulmonary disease. Ann

24. Birnbaum HG, Cremieux PY, Greenberg PE, et al. UsingIntern Med 2001 Apr 3; 134 (7): 600-20healthcare claims data for outcomes research and pharmaco-4. Heffelfinger JD, Dowell SF, Jorgensen JH, et al. Managementeconomic analyses. Pharmacoeconomics 1999 Jul; 16 (1): 1-8of community-acquired pneumonia in the era of pneumococcal

25. Burton WN, Conti DJ. Use of an integrated health data ware-resistance. Arch Intern Med 2000 May 22; 160 (10): 1399-408house to measure the employer cots of five chronic disease5. Kollef M. The prevention of ventilator-associated pneumonia. Nstates. Dis Manag Health Outcomes 1998; 2 (1): 17-26Engl J Med 1999 Feb 25; 340 (8): 627-34

26. Barnett A, Birnbaum HG, Cremieux PY, et al. The costs of6. Macfarlane JT, Colville A, Guion A, et al. Prospective study ofcancer to a major employer in the United States: a case-controlaetiology and outcome of adult lower respiratory tract infec-analysis. Am J Manag Care 2000 Nov; 6 (11): 1243-51tions in the community. Lancet 1993 Feb 27; 341 (8844):

27. Employment characteristics of families in 1997. US Department511-4of Labor Statistics. Available from URL: http://stats.bls.gov/7. Fifty facts from the World Health Organization report 1997newrels.htm [Accessed 2001 Jul 16][online]. Available from URL: http: //www.who.int/whr/1997/

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29. Birnbaum H, Morley M, Greenberg PE, et al. Economic burdenof pneumonia in an employed population. Arch Intern Med

Correspondence and offprints: Dr Howard G. Birnbaum,2001 Dec 10-24; 161 (22): 2725-31Analysis Group, 111 Huntington Avenue, Boston, MA30. Destache CJ. Optimizing economic outcomes in acute exacerba-02199, USA.tions of chronic bronchitis. Pharmacotherapy 2002 Jan; 22 (1

Pt 2): 12S-7S E-mail: [email protected]


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