The Cost and Outcome of Treatment of Patients Admitted with Acute Exacerbation of Chronic Obstructive Pulmonary Disease in Shiraz, Southern Iran

doi:10.21203/rs.3.rs-3109536/v1

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Research Article

The Cost and Outcome of Treatment of Patients Admitted with Acute Exacerbation of Chronic Obstructive Pulmonary Disease in Shiraz, Southern Iran

https://doi.org/10.21203/rs.3.rs-3109536/v1

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Background

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) decreases lung function and quality of life, and is the main driver of the costs of chronic obstructive pulmonary disease (COPD), the treatment of which in hospital is highly expensive. The present study aimed at determining the costs and outcomes of treatment of the patients hospitalized with AECOPD in Shahid Faqihi Hospital in Shiraz in 2021.

Methods

The present cost-outcome analysis was conducted as a descriptive-analytical, retrospective study. The research tool was a researcher-made form prepared and used to extract the patients' demographic and clinical information as well as the outcome and direct and avoidable medical costs, after consultations with some experts. In order to analyze the collected data, descriptive and inferential statistics indicators (t-tests with two independent groups and analysis of variance) were used and the data were analyzed using Excel and SPSS23 statistical software.

Results

Most of the studied patients were male (70.7%), and 81.3% of the patients had comorbidities. Besides, 76% of the patients had experienced disease exacerbation at most twice a year and 69.3% had been hospitalized < 7 times in the last year. The total average direct and avoidable medical costs were $2620 and $754, respectively. The financial burdens of avoidable antibiotics, stay, ICU, and lung CT scan in 2021 were $1,501, $3,244, $869, and $1,856, respectively. Of all the patients, 80.6% were discharged with full recovery, 7.3% were transferred to ICU, and 10.7% died. The number of hospitalization days, the use of other drugs, and AECOPD with brain disease had a significant effect on the patients’ total medical costs (p < 0.01).

Conclusion

Prevention of AECOPD, especially moderate or severe ones, is potentially cost-effective. Given that exacerbations can impose a large financial burden on patients and insurers, they will certainly lead to resource loss and prevent the resources from being allocated to effective interventions. Therefore, the use of effective clinical guidelines seems necessary to prescribe avoidable services to patients with AECOPD.

AECOPD

cost

outcomes

cost-outcome analysis

hospital

Today, chronic obstructive pulmonary disease (COPD) is considered a major public health problem(1) and one of the most important causes of death in the world(2). The disease caused the death of 3.23 million people around the world in 2019 and is known as the third cause of death worldwide, with more than 80% of these deaths occurring in low- and middle-income countries(3). The ever-increasing death rate is due to the increased smoking rate and the higher mean age of the population in many countries(4).

COPD patients are prone to worsening of their respiratory symptoms, known as acute exacerbation of chronic obstructive pulmonary disease (AECOPD)(5). AECOPD is characterized by increased systemic inflammatory activity and severe obstruction of airflow that leads to increased breathing, abnormal gas exchange, and hypoxemia with or without hypercapnia(6). It has a negative effect on the health status and outcome of the patients, so that hypercapnia during respiratory failure, usually associated with severe exacerbations, increases the risk of death(7). In addition, AECOPD is the main driver of poor COPD outcomes (8, 9) and a key indicator of disease progression(10, 11).

The average annual exacerbation rate in COPD groups ranges from 0.85 to 1.30 times(12, 13), and it is estimated that on average, 22–40% of all patients with COPD experience at least one moderate or severe exacerbation each year(14, 15). Approximately, 20% of AECOPDs are severe(16) and 19% require hospitalization(17). Exacerbations are usually clusters and the risk of repeated exacerbations is the highest in the first 2 months after the initial one(18).

Severity and frequency of exacerbations are strongly associated with patient prognosis, especially mortality. However, prevention, early diagnosis, and prompt treatment predict a better prognosis(19, 20). Patients who suffer from frequent exacerbations have worse quality of life(21), and their lung function decline is accelerated(22). They are at risk of future exacerbations, myocardial infarction, cerebrovascular events, and death(23–25). Furthermore, frequent exacerbations are associated with a significant increase in the use of health care resources in the form of emergency visits, urgent care visits, and drug administrations(26–28). In addition, most acute exacerbations are associated with increased hospital admissions, accounting for up to 70% of the economic burden of COPD(29–31).

According to the results of a study in the United States, the mean cost of AECOPD treatment per patient in 2020 was estimated at $6,760, which increased according to the frequency and severity of exacerbations(32). Besides, the average costs for each moderate and severe exacerbation were 888€ and 7091€, respectively(33). In another study, the cost of hospitalization for each patient was 1376$, accounting for 82% of the total average cost of AECOPD(34).

In general, exacerbations seem to be the main cost driver in COPD, and health care costs are directly proportional to the severity of COPD exacerbations(35). Hence, considering the chronic course of the disease, the lack of definitive treatment for it, and the multiple psychological, physical, and economic problems it causes for the individuals and the society, a long-term standardization of the treatment can reduce disease exacerbations, medical costs, and the economic burden on the family and society, and improve lung function(36). Therefore, this study aimed at determining the costs and outcomes of treatment in hospitalized patients with AECOPD referred to Shahid Faqihi Hospital in Shiraz in 2021.

Study Design and Population

The present study was a cost-outcome analysis conducted as a descriptive-analytical, retrospective research. The statistical population consisted of all the patients with AECOPD who had referred to Shahid Faqihi Hospital in Shiraz within 6 months (August 23 to February 19) in 2021. The hospital was purposefully selected because it is a referral center for admitting adult inpatients in Shiraz and Fars province. The research samples were selected based on studies and using Cochran's formula ($n=\frac{N{z}^{2}pq}{N{d}^{2}+{z}^{2}pq})$ in which n was the sample size (n=128), N was the studied population (n=522), z was the normal variable value (1.96), p was the ratio of having the intended feature (0. 50), q was the ratio of not having the intended feature (0.5), and d was the allowed error (0.15). Considering the possibility of sample dropouts and in order to increase the richness of the study, the final sample size was estimated to be 150 people.

Inclusion Criteria

The inclusion criteria included > 40 years of age, having been treated in the center as an inpatient (hospitalization time of > 48 hours), consent to participate in the study, and having been diagnosed with AECOPD based on the Global Initiative for Chronic Obstructive Lung Disease (GOLD).

Data Collection

The research tool was a researcher-made form. The patients’ demographic and clinical data, outcomes, direct medical costs (doctor visits, laboratory tests, imaging services, drugs, consumables, and oxygen), and avoidable costs were collected after necessary consultations with experts.

In order to identify the avoidable costs, first of all, the cases requiring antibiotic administrations (fever of $\ge$ 37.7ºC, the presence of rales in lung examinations, CRP > 30 gr/dl, and WBC > 10,000/mm³, each with symptoms of COPD exacerbation), the cases requiring CT scan prescriptions based on lung X-rays (CXR), and the cases requiring ICU prescriptions and stays based on the opinions of pulmonologist and a series of tests and symptoms were found. Then, the data collection form was used to collect the data on avoidable costs.

To estimate the number of avoidable services, the estimated prescriptions of avoidable antibiotic, stay, ICU, and lung CT scan were multiplied by the total number of antibiotics, stay, ICU, and lung CT scan services provided by Shahid Faqihi Hospital in Shiraz. Finally, the total imposed financial burden was estimated by multiplying without-indications in antibiotic, stay, ICU, and lung CT scan tariffs for the patient and the insurer in 2021.

For converting Iranian Rial to USD exchange rate reported by the central bank of Iran was used (1 USD = 42000 IRR)(37).

An informed consent form was obtained from all participants and their legal guardians (for illiterate patients).

Data Analysis

Following the data collecting step, the collected information was analyzed using descriptive and inferential statistics indicators (t-tests with two independent groups and analysis of variance) as well as the spss23 and excel statistical software.

A total of 150 patients were included in this study. The descriptive results related to the patients based on gender, age, education, employment status, etc. are shown briefly in Table 1. According to this table, 20.6% of the patients were < 55 years old, 32.7% were 55–64, 22.7% were 65–74, and 24% were > 74 years old. Besides, 29.3% of the studied patients were female and 70.7% were male. About 43.7% of the patients were illiterate, 41.7% had primary and secondary education levels, and 14.6% had a high school diploma. 55.33% of the patients were self-employed, 27.19% were housewives, and 17.48% were retired. Furthermore, 98.7% of the patients had health insurance and 1.3% did not. About 56.6% of the patients were covered by other insurances, 18.7% by social security insurance, 18% by Iran Health Insurance, and 6.7% by armed forces insurance. Nearly 64% of the patients were current smokers, 6% had quit smoking, and 30% had no history of smoking.

Table 1

Demographic data of the study group
Variable	Items	Frequency	Percent
Age (years)	Age < 55	31	20.6
	Age 55–64 years	49	32.7
	Age 65–74 years	34	22.7
	Age > 74 years	36	24.0
Gender	Female	44	29.3
Gender	Male	106	70.7
Education level	Illiterate	21	43.7
	Elementary & secondary	20	41.7
	High school diploma	7	14.6
Job	Retired	18	17.48
	Housewife	28	27.19
	Self-employed	57	55.33
Basic insurance status	Insured	148	98.7
Basic insurance status	Not insured	2	1.3
Insurer	Social security organization	28	18.7
	Iran health insurance organization	27	18
	Armed forces insurance organization	10	6.7
	Other insurers	85	56.6
Smoking History	Current smoker	96	64
	Ex-smokers	9	6
	Nonsmoker	45	30

Table 2 shows the clinical characteristics and treatment outcomes of the studied patients, based on which, 81.3% of the patients had comorbidities. Along with the chronic lung disease, 36%, 14.7%, 26.7%, and 6.7% of the patients had high blood pressure, diabetes, heart disease, and brain diseases, respectively. About 26.7%, 17.4%, 8%, and 16% of the patients had used corticosteroids, methylxanthine bronchodilators, antibiotics, and other drugs, respectively. In addition, 76% of the patients experienced disease exacerbation less than twice a year and 69.3% were hospitalized less than 7 times in the previous year. Moreover, 80.6% of the patients were discharged from hospital with full recovery and 8.6% with personal consent. 7.3% of the patients were transferred to the ICU and 10.7% died.

Table 2

Clinical characteristics and treatment outcomes of the patients hospitalized with AECOPD
Clinical characteristics
Variable	Items	Frequency	Percent
Comorbidities	Yes	122	81.3
Comorbidities	No	28	18.7
AECOPD with hypertension	Yes	54	36
AECOPD with hypertension	No	96	64
AECOPD with diabetes	Yes	22	14.7
AECOPD with diabetes	No	128	85.3
AECOPD with heart disease	Yes	40	26.7
AECOPD with heart disease	No	110	73.7
AECOPD with Cerebrovascular disease	Yes	10	6.7
AECOPD with Cerebrovascular disease	No	140	93.4
Use of corticosteroids (inhalation and oral)	Yes	40	26.7
Use of corticosteroids (inhalation and oral)	No	110	73.3
Taking methylxanthine bronchodilators (theophylline or aminophylline)	Yes	26	17.4
	No	124	82.6
Taking antibiotics	Yes	12	8
Taking antibiotics	No	138	92
Number of exacerbations in the past year	Exacerbations < 2	11	76
Number of exacerbations in the past year	Exacerbations ≥ 2	35	24
Number of hospital stay in the past year(day)	Hospitalizations < 7	104	69.3
Number of hospital stay in the past year(day)	Hospitalizations ≥ 7	46	30.7
Hospitalization in ICU	Yes	11	7.4
Hospitalization in ICU	No	139	92.6
Treatment outcomes
Recovery and discharge	Yes	121	80.6
Recovery and discharge	No	29	19.4
Discharge with personal consent	Yes	13	8.6
Discharge with personal consent	No	137	91.4
Transfer to ICU	Yes	11	7.3
Transfer to ICU	No	139	92.7
Death	Yes	16	10.7
Death	No	134	89.3

Table 3 shows the direct and avoidable medical costs of the studied patients. The total mean of direct medical cost was $2620, the highest and lowest shares of which were the average costs of ICU ($1090) and radiology ($8), respectively. In addition, the total avoidable medical cost was $754 on average, with ICU ($558) and antibiotics ($9) accounting for the highest and the lowest mean avoidable medical costs, respectively.

Table 3

Direct and avoidable medical costs per hospitalized patient with AECOPD
variable	Mean ($)	SD
Direct medical costs
Tests	78	124
ICU	1090	951
Radiology	8	11
visits	143	200
sonography	41	35
CT of the lungs	32	11
other CT	32	22
Surgery	254	127
consumables	132	325
Hoteling	434	1631
Drugs	216	538
other costs	160	281
Total	2620	4256
Avoidable medical costs
Antibiotics	9	13
Hoteling	159	146
ICU	558	314
CT of the lungs	28	11
Total	754	484

Table 4 shows the financial burden and frequency of avoidable and unavoidable services. According to the results, the financial burdens caused by antibiotics, stays, ICUs, and avoidable lung CT scans in 2021 were $1501, $3244, $869, and $1856, respectively. In addition, of all prescribed antibiotics, 5.68% was avoidable and 94.32% was not; of the total length of stay, 17.34% was avoidable and 82.66% was not; of the total number of ICUs, 27.28% was avoidable and 72.72% was not; and of all lung CTs performed, 40.68% was avoidable and 59.32% was not.

Table 4

Financial burden and frequency of avoidable and unavoidable services provided in Shahid Faqihi Hospital of Shiraz, 2021
variable	Frequency of avoidable services (%)	Frequency of unavoidable services (%)	tariff ($)	total cost of avoidable services ($)
Antibiotics	8(5.68)	133(94.32)	188	1504
Hoteling	26(17.34)	124(82.66)	125	3250
ICU	3(27.28)	8(72.72)	290	870
CT of the lungs	24(40.68)	35(59.32)	77	1848

As shown in Table 5, the number of hospitalization days, the use of other drugs, and AECOPD along with brain diseases had a significant effect on the total medical costs of the AECOPD patients referred to Shahid Faqihi Hospital in Shiraz (p < 0.05). In contrast, comorbidities, the use of corticosteroids, taking bronchodilators, taking antibiotics, AECOPD along with heart diseases, blood pressure and diabetes, gender, and having health insurance did not have a significant effect on the medical costs of the AECOPD patients referred to Shahid Faqihi Hospital in Shiraz (p > 0.05).

Table 5

The impact of variables on medical costs of AECOPD patients
Variables	Items	Number	Mean($)	SD	P value
Comorbidities	Yes	120	1319	3179	0.183
Comorbidities	No	30	537	588	0.183
hospitalization days	≤ 7	105	461	302	0.001
hospitalization days	> 7	45	2798	4875	0.001
Use of corticosteroids	Yes	43	1815	5006	0.077
Use of corticosteroids	No	107	900	1185	0.077
Taking bronchodilators	Yes	29	715	580	0.351
Taking bronchodilators	No	14	1270	3176	0.351
Taking antibiotics	Yes	136	1590	3720	0.560
Taking antibiotics	No	26	1119	2782	0.560
Taking other drugs	Yes	124	945	1156	0.042
Taking other drugs	No	26	2199	6416	0.042
AECOPD with heart disease	Yes	42	1347	1674	0.626
AECOPD with heart disease	No	108	1091	3221	0.626
AECOPD with hypertension	Yes	52	950	838	0.511
AECOPD with hypertension	No	98	1275	3499	0.511
AECOPD with diabetes	Yes	24	883	676	0.604
AECOPD with diabetes	No	126	1216	3117	0.604
AECOPD with Cerebrovascular disease	Yes	14	3185	7968	0.005
AECOPD with Cerebrovascular disease	No	136	954	1584	0.005
effect of gender (male)	Yes	106	1295	3371	0.383
effect of gender (male)	No	44	844	806	0.383
impact of health insurance	Yes	148	1171	2888	0.754
impact of health insurance	No	2	527	111	0.754

The study results showed that older patients experienced a higher rate of acute exacerbation episodes, possibly because lung function declines over time and due to the cumulative effect of risk factors such as smoking. In males, the disease exacerbation occurs more frequently due to their habit of smoking(38). Ngo et al. (2018) in Vietnam showed that the majority of the 57 patients (93.0%) were male, the mean age of the patients was 67 years, and 15.8% of the patients were currently smokers(39). Örnek et al. (2012) in Turkey indicated that the studied patients were quite old (mean age of 70.35 ± 10.65 years) and male(40). In other studies, the mean age of the patients was 68–75 years and the majority of the studied patients were male(36, 41–43), which is consistent with the findings of this study. In contrast, the results of various studies in Australia showed that there was no difference between the people with and without clinical diagnoses of AECOPD in terms of age and smoking, and women were more likely to suffer from AECOPD than men (62.8% vs. 37.2%) (44, 45). This is inconsistent with the findings of the present study.

The results of this study showed that 7.3% of the patients were transferred to ICU and 10.7% of them died. Unfortunately, death was not an uncommon outcome for hospitalized AECOPD patients, because most of the AECOPD patients were old(46) and aging was often associated with concurrent diseases and respiratory gas exchange disorders(46). In addition, peripheral blood lymphocytes might decrease in the elderly, and a decrease in the number of lymphocytes (as a biological marker of inflammation) could increase the risk of infection and death from AECOPD(47). The mortality rate of AECOPD in different groups varied from 4–14% in the Asia-Pacific region (41, 48–50), and it was up to 25% for patients who needed hospitalization in ICU(51). The results of the study by Cao et al. (2021) in China showed that 44 of the 384 patients with AECOPD (11.5%) died in hospital and 340 ones (88.5%) were discharged(52).

According to the results of the present research, 81.3% of the patients had comorbidities. Along with the chronic lung disease, 36% of the patients had hypertension, 14.7% had diabetes, 26.7% were suffering from heart disease, and 6.7% had brain diseases. As stated by Cao et al (2021) in China, the most common comorbidity in the AECOPD patients was respiratory failure (76.6%), followed by high blood pressure (55.7%), coronary artery disease (29.9%), and chronic heart failure (19.8%)(52). Exton et al. (2019) in Australia indicated that a significant number of the participants (31.4%) in the AECOPD group had chronic heart failure(44). The results of other studies also showed that most patients had comorbidities; the most common ones observed were high blood pressure, stroke, and heart diseases(39–41, 53). There were pathophysiological mechanisms that could justify the interaction between AECOPD and cardiovascular disease. As AECOPD progressed, increased pulmonary vascular resistance led to pulmonary hypertension and right ventricular dysfunction. Furthermore, both hypoxia and acidosis could reduce myocardial diastolic and systolic dysfunction(54, 55).

the results of this study, the mean frequency of disease exacerbation was 5 times a year and 76% of the patients had experienced disease exacerbation at most twice a year. In addition, the average number of hospitalization days was 6.5 days, with 69.3% of the patients having been hospitalized < 7 times in the previous year. Örnek et al. (2012) in Turkey showed that the average length of hospitalization of the studied patients was 11.38 ± 6.94 days. Besides, 71.1% of the patients had a history of 1 or more hospitalizations in the last year (40). In their study, Maleki-Yazdi et al. (2010) in Canada showed that one-third (34%) of the patients had experienced at least one AECOPD and the mean length of hospital stay for an AECOPD patient was 8 days(34). Various studies reported several factors affecting the duration of patient hospitalization, the most important of which were the types of comorbidities, the severity of the disease, the age of the patient, and the type of insurance(56, 57).

According to the findings, the total mean of direct medical costs per patient was $2620, the highest shares of which were related to ICU(44, 58) followed by accommodation costs (16.57), surgery (9.68), drugs (8.23), other costs (6.11), visits (5.46), consumables (5.04), tests (2.97), ultrasound (1.55), lung CT scan (1.19), and radiology (0.31). The results of the study by Stanford et al. (2020) in America indicated that the mean cost for each AECOPD patient was 6760 USD (32). Ngo et al. (2018) in Vietnam stated that the mean cost of treating the patients was 18.3 million VND (795.7 USD) and the hospitalization cost was 2.5 million VND, as well. Furthermore, the cost of medicine accounted for the highest ratio of hospitalization costs with 53.9% (39). Örnek et al. (2012) in Turkey showed that the mean cost of a hospitalized patient was $2139 ± 1765, with the mean cost of visits in hospital wards and in the intensive care unit being $889 ± 533 and $2508 ± 2508, respectively(40). The reason for the difference in costs might be the differences between health systems and tariffs in different hospitals and countries. In addition, the differences in drug prices, resources per year, and the cost of various service-providing techniques led to the difficulty in direct comparisons between our results and the findings of other studies(39).

According to the findings, the total mean of avoidable medical costs was $754, with the ICU ($558) and antibiotics ($9) costs accounting for the highest and lowest shares, respectively. Considering the lack of resources and importance of them in the healthcare sector, doctors should be more careful in prescribing services.

In this study, 8 cases 5.68(%) of the antibiotics administered were avoidable and 133 cases 94.32(%) were unavoidable. In addition, the mean cost and financial burden caused by avoidable antibiotics were estimated at $9 and $1501, respectively. Varol et al. (2020) in Turkey indicated that a total of 64% of antibiotic prescriptions were suitable for AECOPD. However, there were 50 patients (36%) with inappropriate antibiotic prescriptions based on the mentioned criteria(59). The GOLD criteria had poor specifications for the diagnosis of exacerbation, and thus, many trials adopted the Anthonisen criteria, which were more specific (60). Nevertheless, they were developed to identify infectious exacerbations(60) and lack of sensitivity to noninfectious exacerbations, not characterized by increased sputum volume or purulence. The previously described modified Anthonisen criteria, including cough, wheezing, nasal discharge, sore throat, and fever, were developed to address this concern(61). However, some doctors prefer to self-administer antibiotics regardless of the Anthonisen criteria(59).

The results of the present study showed that 26 cases (17.34%) of the total stays were avoidable and 124 cases (82.66%) were unavoidable. In addition, the mean cost and financial burden caused by avoidable stays were estimated at $159 and $3244, respectively. Considering that no study had been conducted to evaluate the appropriateness and inappropriateness of AECOPD patients’ stays, the cases of avoidable stays in different studies were compared with the findings of the present research. Arab-Zozani et al. (2020) in Iran reported the ranges of hospitalization and inappropriate stays to be 5.8–41.2 and 3.4–31.5, respectively. The reasons for such different ranges included the types of hospitals studied, different sections, and demographic information such as age, sex, insurance status, and hospitalization periods(62). Sharfeldin et al. (2019) in Egypt reported that there were 18.3% and 18.6% hospitalizations and inappropriate stays in hospitals, respectively(63). The results of the study by Mahfouzpour et al. (2017) in Iran showed that 9.9% of hospitalizations and hospital stays were unnecessary and 20.3% of the patients experienced at least one day of unnecessary hospitalization. Moreover, the direct financial burden caused by unnecessary hospitalization within 3 months was estimated at 2998$, and the financial damage caused by unnecessary hospitalization of a patient per year was 12066$, as well. The main reasons for unnecessary hospitalization of the patients were as follows: waiting to receive the results of clinical tests, delay in timely visits of the attending physician, insurance and settlement issues, and postponing the surgery(64).

Based on the findings, 27.28% of ICU admissions were avoidable and 72.72% were not. Besides, the mean cost and financial burden caused by avoidable ICU were estimated at $558 and $869 in 2021, respectively. Considering that no study had been conducted to evaluate the appropriateness and inappropriateness of ICU admission of AECOPD patients, other ICU admissions in different studies were compared with the findings of this research. The results of the study by Osinaike et al. (2016) in Nigeria showed that 96.9% of the ICU admissions were inappropriate and unnecessary. The most common reasons for inappropriate ICU admissions were the pressure from the superiors (93.7%), the referring physicians (89.1%), and the hospital management (87.5%) (65). In addition, a study conducted in Milan, Italy, on inappropriate admissions and allocation of resources indicated that the pressure of the elderly and referring doctors were important factors causing inappropriate admissions to the ICU(58).

As observed in this study, AECOPD along with brain diseases, use of other drugs, and the number of hospitalization days had a significant effect on the treatment costs of the AECOPD patients. Chen et al. (2017) stated that in COPD patients, the costs of comorbidities were twice as much as the costs of the disease itself (66), the possible reason for which was that the interaction between COPD and the comorbidities might increase the risk and length of hospitalization (67). In addition, the patients with a larger number of comorbidities paid more costs due to taking more drugs, more visits to the hospital, and more laboratory tests(68). According to the studies conducted, hospitalization costs were the main driver for additional costs caused by COPD(66). In their study, Gutiérrez Villegas et al. (2021) found out that hospitalization and drug treatment accounted for the highest costs reported(68). In other studies, longer hospitalization duration was associated with higher treatment costs(36, 39, 40), which is consistent with the findings of the present study. The high average length of stay of hospitalized patients caused irrational occupancy of beds and the increase in the ratio of pharmaceutical and medical consumables. It also caused the filling of the space needed by the patients to be hospitalized and increased equipment depreciation, and ultimately led to an increase in the costs(69).

Strengths and Limitations of the Study

One of the strengths of this study is that it is the first study conducted in Iran and the world that examined the cost of avoidable services and their financial burden in AECOPD patients. The main limitation of the present study was the small number of similar studies on appropriateness of antibiotic prescriptions, hospital stays, ICU, and lung CT scans, and the financial burden caused by avoidable services, which did not make it possible to compart the results. Another major limitation was that in this research, only direct medical, avoidable costs were calculated and indirect medical costs were not taken into account.

Given that exacerbations are the main cost factor in COPD and health care costs are directly proportional to the severity of COPD exacerbations, prevention of them, especially moderate or severe ones, is potentially cost-effective. In addition, considering that exacerbations generally impose a large financial burden on the patient and the insurer, they will certainly waste the resources of the health sector and prevent allocation of resources to effective interventions. Hence, it seems necessary to use effective clinical guidelines to prescribe avoidable services to AECOPD patients.

AECOPD: Acute exacerbation of chronic obstructive pulmonary disease; COPD: chronic obstructive pulmonary disease; GOLD: Global Initiative for Chronic Obstructive Lung Disease; CXR: CT scan prescriptions based on lung X-rays.

Ethics approval and consent to participate

The project was found to be in accordance to the ethical principles and the national norms and standards for conducting medical research. The study protocol was approved by the Ethics Committee of Shiraz University of Medical Sciences under code IR.SUMS.MED.REC.1399.524.

Consent for publication

Not applicable.

Availability of data and materials

The datasets generated and analyzed during the current study are not publicly available due to confidentiality data but are available from the corresponding author on reasonable request.

Competing interests

The authors declared no potential conflicts of interest

Funding

This paper was financially supported by Shiraz University of Medical Sciences with grant number 19338. The funder had no role in the study design, data collection, analysis, and interpretation, and writing of the manuscript.

Authors’ contributions

M.M and KH. K was involved in study idea and design, data analysis and interpretation, manuscript drafting and final review of manuscript. M.T was involved in data interpretation, manuscript drafting and final review of manuscript. ME was involved in data collection, statistical analysis and interpretation, manuscript drafting and final review of manuscript. All authors have read and approved the final manuscript.

Acknowledgments

The authors would like to thank Shiraz University of Medical Sciences.

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No competing interests reported.

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The Cost and Outcome of Treatment of Patients Admitted with Acute Exacerbation of Chronic Obstructive Pulmonary Disease in Shiraz, Southern Iran

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