Autor : Nannini, Luis J1-2-3
1 Pulmonologist, Hospital E Perón de Granadero Baigorria. 3 Member of the Cochrane Collaboration.
In January 1946, the presidential
candidate at the time, J.D. Perón, popularized one phrase in a campaign
speech in the extremely poor Northern area of the province of Santa Fe: “We
are the enemies of the selfish, who are capable of being indifferent to misery
without any compassion in their hearts, because the only sensitive viscera they
have is their wallet”. In politics, it seems that it is always the
other person the one to carry the blame. Probably you’re wondering what does
this introduction have to do with the work of my colleagues. No need to be
suspicious to know that the authors will use their findings to motivate changes
in health politics. The rhetorical phrase of Perón wouldn’t be
applicable to the anesthetized public funds. Health-related expenditures are
conceived as expenses, but the authors’ intention would be to generate
astonishment in the authorities so that they change certain behaviors. If these
changes in behavior were made, healthcare expenditures would still be in the
credit column, but as a result there would be an improvement in the morbidity
and mortality rates, if scientific breakthroughs were applied.
The Pulmonology Service of the
Hospital Ramos Mejía, in the city of Buenos Aires is of special note,
due to its publications about critical topics of our specialty during the last
decades. One of those topics is related to the costs associated with
hospitalization for respiratory diseases such as asthma and1 COPD.2
During 2018, there were 26 cases
of hospitalization for COPD exacerbation.3 Direct costs were calculated
from the funder’s perspective on 1462 dollars per patient; the cost per patient
who was hospitalized at the ICU is almost seven times higher. Fortunately,
only 3 patients required intensive care. With one simple calculation, we know
that for Argentina there will be an overwhelming amount of 43 million dollars
per year for COPD hospitalizations, since there are around 30.000 annual
hospitalizations in the country for COPD.4 If 11% of admissions to
intensive care were applied on a national level, there would be another extra
33 million dollars.
Is it possible to lower the
mortality and hospitalization rates for COPD in Argentina?
Smoking cessation,
first, with availability of resources.
Another important aspect is that
half of the patients only received SABAs (short-acting beta agonists) as
treatment, despite the fact that there is scientific evidence on the
significant reduction of morbidity and mortality with current treatments.5
Taking into account the profile
of the patients described in this study, they surely fulfilled the criteria of
triple therapy with LABAs (long-acting beta-adrenergic agonists) + LAMA
(long-acting muscarinic antagonists) + ICS (inhaled corticosteroids) belonging
to group D, in accordance with the year of hospitalization (2018), that would
be group E of the GOLD 2023 report update.6 With a dollar rate of $300,
the hospitalization cost (1462 × 300/12 months= $36 550) would easily cover the
best available pharmacological treatment per month. Another way of sensitizing
the public wallet. One LAMA plus the ICS/LABA combination would cost 30,000
pesos per month, and the triple therapy with inhalator would only cost a bit
less. The cost analysis didn’t include indirect costs, such as absenteeism,
alterations in the family environment and rehabilitation. It could be refuted
that we don’t know the exact amount we need to treat to avoid exacerbations,
but in an intelligent editorial, David Halpin and Fernando J. Martínez5 evaluated the
positive impact of the last clinical trials. The triple therapy properly
indicated in patients with 2 or more exacerbations in the last 12 months, or
hospitalization, o eosinophilia of more than 150/dL was able to reduce
mortality in a significant way. Halpin and Martínez say that the
relevance of the absolute reduction of mortality is similar or better than the
data of cardiovascular studies.5 In these
cardiovascular studies, population benefits are clear, though very modest on
the individual level. Still, they have contributed to the global reduction of
cardiovascular mortality.5
The same will happen with COPD. Though not applicable, I
want to express my admiration for Dr. Fernando J. Martínez, who speaks
Spanish as good as English (he was born in Cuba and went to the United States
when he was eight years old), and is the only pulmonologist who participates in
the GOLD and pulmonary fibrosis recommendations.
Smoking cessation, home oxygen
therapy and rehabilitation, as well as the availability of NIV (non-invasive
ventilation) and high flow therapy in the intensive care unit are legitimate
tools with maximum quality of scientific evidence. Furthermore, COPD drugs
reached a high level of efficacy that modified the natural history of the
disease, thus reducing mortality.5 Why is the
Argentinian hospitalized population deprived of resources and drugs which
science has established as highly efficient and beneficial? It is important to
explain that the wallet of the Argentinian population is emaciated and very
sensitive. For that reason, the free provision of treatment has a determining
function in any program.7 Echoing the
words of the authors: “We must use systematic programs of COPD management to
identify patients with risk factors and to educate and allow access to
medication”. “Some will criticize us for wanting to have the best
original drugs for our patients, and that attitude denotes their moral limitations”.
Thisphrase belongs to Dr. José Ingenieros, disciple
of Dr. José María Ramos Mejía.8
In 1999, there were 33
hospitalizations for COPD exacerbation, and in 2018 there were 26. The sales of
drugs for obstructive diseases changed dramatically. In 2000, the
SABAs/ICS+ICS/ LABAs sales ratio was 4.29, and in 2018, 0.91 due to a
significant increase in the sales of ICS/LABA.9
These data that could be interpreted as better prescription and
sales wouldn’t be including the most vulnerable population (50% of hospitalized
patients only treated with SABAs).
With regard to the criteria that
could be considered for the identification of technologies to be given high
evaluation priority, the triple therapy for COPD fulfills them all.10 The National
Commission for the Evaluation of Health Technologies (CONETEC, for its acronym
in Spanish) has defined the valuable dimensions/criteria for the evaluation of
new technologies (CONETEC 2019): quality of the evidence, magnitude of clinical
benefit, economic impact (budgetary impact and cost effectiveness), impact on
equity and public health.10 This topic
easily exceeds the limitations of this editorial and its author.
Judith García Aymerich
published the analysis of two important cardiology studies. She found a 5-year
mortality of 50% if the patients had been hospitalized for COPD exacerbation at
least once.11 Pascansky et
al showed 23% of inpatient mortality. Of the 20 patients who survived, provided
there are no changes, 10 patients will be alive 5 years later. If new
strategies aren’t applied, the life expectancy of COPD will be worse than many
oncological diseases. Maybe this information can help sensitize the
anesthetized and deranged public funds.
Conflict of interest
The author declares that he is a
researcher for Novartis and a speaker for AstraZeneca. He has no conflict of
interest related to the editorial or the commented article.
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