Lung function in adults and future burden of obstructive lung diseases in a long-term follow-up.

Spirometry is recommended in symptomatic smokers to identify obstructive lung diseases. However, it is unknown whether there are certain characteristics that can be used to identify the individual risk of developing obstructive lung diseases. The aim of this study was to examine the association between lung function in adults and burden of lung diseases throughout 27 years of follow-up. We performed a cohort study among individuals aged 30-49 years at baseline (1991). Spirometry measurements were divided into three groups: (1) FEV1/FVC < 70, (2) FEV1/FVC: 70-75, (3) FEV1/FVC > 75 (reference). Using negative binominal regression, the burden of lung diseases was measured by contacts to general practice, hospitalisations, redeemed respiratory medicine and socioeconomic parameters between 1991 and 2017. A total of 905 citizens were included; mean age of 40.3 years, 47.5% were males and 51.2% were smokers at baseline. The group with an FEV1/FVC: 70-75 received more respiratory medicine (IRR = 3.37 (95% CI: 2.69-4.23)), had lower income (IRR = 0.96 (95% CI: 0.93-0.98)), and had more contacts to general practice (IRR = 1.14 (95% CI: 1.07-1.21)) and hospitals for lung diseases (IRR = 2.39 (95% CI: 1.96-5.85)) compared to the reference group. We found an association between lung function and the future burden of lung diseases throughout 27 years of follow-up. In particular, adults with an FEV1/FVC: 70-75 need extra attention in the case finding.

Impact of changes to reimbursement of fixed combinations of inhaled corticosteroids and long-acting ß2 -agonists in obstructive lung diseases: a population-based, observational study.

BACKGROUND: In 2010, the Icelandic government introduced a new cost-saving policy that limited reimbursement of fixed inhaled corticosteroid/long-acting ß2 -agonist (ICS/LABA) combinations. METHODS: This population-based, retrospective, observational study assessed the effects of this policy change by linking specialist/primary care medical records with data from the Icelandic Pharmaceutical Database. The policy change took effect on 1 January 2010 (index date); data for the year preceding and following this date were analysed in 8241 patients with controlled/partly controlled asthma and/or chronic obstructive pulmonary disease (COPD) who had been dispensed an ICS/LABA during 2009. Oral corticosteroid (OCS) and short-acting ß2 -agonist (SABA) use, and healthcare visits, were assessed pre- and post-index. RESULTS: The ICS/LABA reimbursement policy change led to 47.8% fewer fixed ICS/LABA combinations being dispensed during the post-index period among patients whose asthma and/or COPD was controlled/partly controlled during the pre-index period. Fewer ICS monocomponents were also dispensed. A total of 48.6% of patients were no longer receiving any respiratory medications after the policy change. This was associated with reduced disease control, as demonstrated by more healthcare visits (44.0%), and more OCS (76.3%) and SABA (51.2%) dispensations. CONCLUSIONS: Overall, these findings demonstrate that changes in healthcare policy and medication reimbursement can directly impact medication use and, consequently, clinical outcomes and should, therefore, be made cautiously.

The respiratory pyramid: From symptoms to disease in World Trade Center exposed firefighters.

BACKGROUND: This study utilizes a four-level pyramid framework to understand the relationship between symptom reports and/or abnormal pulmonary function and diagnoses of airway diseases (AD), including asthma, recurrent bronchitis and COPD/emphysema in WTC-exposed firefighters. We compare the distribution of pyramid levels at two time-points: by 9/11/2005 and by 9/11/2010. METHODS: We studied 6,931 WTC-exposed FDNY firefighters who completed a monitoring exam during the early period and at least two additional follow-up exams 9/11/2005-9/11/2010. RESULTS: By 9/11/2005 the pyramid structure was as follows: 4,039 (58.3%) in Level 1, no respiratory evaluation or treatment; 1,608 (23.2%) in Level 2, evaluation or treatment without AD diagnosis; 1,005 (14.5%) in Level 3, a single AD diagnosis (asthma, emphysema/COPD, or recurrent bronchitis); 279 (4.0%) in Level 4, asthma and another AD. By 9/11/2010, the pyramid distribution changed considerably, with Level 1 decreasing to 2,612 (37.7% of the cohort), and Levels 3 (N = 1,530) and 4 (N = 796) increasing to 22.1% and 11.5% of the cohort, respectively. Symptoms, spirometry measurements and healthcare utilization were associated with higher pyramid levels. CONCLUSIONS: Respiratory diagnoses, even four years after a major inhalation event, are not the only drivers of future healthcare utilization. Symptoms and abnormal FEV-1 values must also be considered if clinicians and healthcare administrators are to accurately anticipate future treatment needs, years after initial exposure.

Oxigenoterapia domiciliar prolongada em crianças e adolescentes: uma análise do uso clínico e de custos de um programa assistencial / Long-term home oxygen therapy in children and adolescents: analysis of clinical use and costs of a home care program

OBJETIVOS: Descrever as características clínicas e laboratoriais dos pacientes em oxigenoterapia domiciliar prolongada acompanhados pelo programa de atendimento domiciliar do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, durante um período de 8 anos, e comparar os grupos com e sem hipertensão pulmonar secundária. Estimar o custo do programa utilizando concentradores versus cilindros de oxigênio arcados pela instituição. MÉTODOS: Estudo descritivo retrospectivo e de coorte dos pacientes em oxigenoterapia domiciliar prolongada, em seguimento no período de 2002 a 2009, na Unidade de Pneumologia do Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo. RESULTADOS: Foram estudados 165 pacientes, 53 por cento do sexo masculino, com as medianas: idade de início da oxigenoterapia - 3,6 anos; tempo de oxigenoterapia - 7 anos; e tempo de sobrevida após início da oxigenoterapia - 3,4 anos. Os principais diagnósticos foram: fibrose cística (22 por cento), displasia broncopulmonar (19 por cento) e bronquiolite obliterante (15 por cento). Dos 33 pacientes que realizaram espirometria, 70 por cento apresentavam distúrbio ventilatório obstrutivo grave. O exame ecocardiográfico foi executado em 134 pacientes; 51 por cento deles tinham hipertensão pulmonar secundária. Houve associação estatisticamente significante entre: presença de hipertensão pulmonar e necessidade de maiores fluxos de oxigênio (qui-quadrado, p = 0,011); e presença de hipertensão pulmonar e maior tempo de oxigenoterapia (Logrank, p = 0,0001). Não houve diferença estatisticamente significante entre tempo de sobrevida após início da oxigenoterapia e presença de hipertensão pulmonar. Os custos médios mensais do programa foram: US$ 7.392,93 para os concentradores e US$ 16.630,92 para cilindros. CONCLUSÕES: A oxigenoterapia domiciliar prolongada foi empregada em distintas doenças crônicas, predominantemente em lactentes e pré-escolares. Houve alta frequência de hipertensão pulmonar associada a maiores períodos de uso e fluxos de oxigênio, sem associação à sobrevida. A substituição dos cilindros por concentradores poderá reduzir custos significativamente.

OBJECTIVES: To describe the clinical and laboratory characteristics of patients on long-term home oxygen therapy followed up by the home care program of Hospital das Clínicas, School of Medicine, Universidade de São Paulo, during a period of 8 years; to compare groups with and without secondary pulmonary hypertension; and to estimate the cost of the program using oxygen concentrators versus oxygen cylinders provided by the hospital. METHODS: A descriptive, retrospective cohort study of patients on long-term home oxygen therapy followed up from 2002 to 2009 at the Unit of Pulmonology, Children's Institute, Hospital das Clínicas, School of Medicine, Universidade de São Paulo. RESULTS: We studied 165 patients, of whom 53 percent were male, with the following medians: age at the beginning of oxygen therapy - 3.6 years; duration of oxygen therapy - 7 years; and survival time after beginning of oxygen therapy - 3.4 years. The main diagnoses were: cystic fibrosis (22 percent), bronchopulmonary dysplasia (19 percent), and bronchiolitis obliterans (15 percent). Of the 33 patients who underwent spirometry, 70 percent had severe obstructive lung disease. Echocardiogram was performed in 134 patients; 51 percent of them had secondary pulmonary hypertension. There was a statistically significant association between pulmonary hypertension and need of higher oxygen flows (chi-square, p = 0.011), and between pulmonary hypertension and longer duration of oxygen therapy (Logrank, p = 0.0001). There was no statistically significant difference between survival time after the beginning of oxygen therapy and pulmonary hypertension. The average monthly costs of the program were US$ 7,392.93 for concentrators and US$ 16,630.92 for cylinders. CONCLUSIONS: Long-term home oxygen therapy was used to treat different chronic diseases, predominantly in infants and preschool children. There was a high frequency of pulmonary hypertension associated with longer periods of oxygen use and greater oxygen flow, without association with survival rate. The use of concentrators instead of cylinders may reduce costs significantly.

Long-term home oxygen therapy in children and adolescents: analysis of clinical use and costs of a home care program.

OBJECTIVES: To describe the clinical and laboratory characteristics of patients on long-term home oxygen therapy followed up by the home care program of Hospital das Clínicas, School of Medicine, Universidade de São Paulo, during a period of 8 years; to compare groups with and without secondary pulmonary hypertension; and to estimate the cost of the program using oxygen concentrators vs. oxygen cylinders provided by the hospital. METHODS: A descriptive, retrospective cohort study of patients on long-term home oxygen therapy followed up from 2002 to 2009 at the Unit of Pulmonology, Children's Institute, Hospital das Clínicas, School of Medicine, Universidade de São Paulo. RESULTS: We studied 165 patients, of whom 53% were male, with the following medians: age at the beginning of oxygen therapy--3.6 years; duration of oxygen therapy--7 years; and survival time after beginning of oxygen therapy--3.4 years. The main diagnoses were: cystic fibrosis (22%), bronchopulmonary dysplasia (19%), and bronchiolitis obliterans (15%). Of the 33 patients who underwent spirometry, 70% had severe obstructive lung disease. Echocardiogram was performed in 134 patients; 51% of them had secondary pulmonary hypertension. There was a statistically significant association between pulmonary hypertension and need of higher oxygen flows (chi-square, p = 0.011), and between pulmonary hypertension and longer duration of oxygen therapy (Logrank, p = 0.0001). There was no statistically significant difference between survival time after the beginning of oxygen therapy and pulmonary hypertension. The average monthly costs of the program were US$ 7,392.93 for concentrators and US$ 16,630.92 for cylinders. CONCLUSIONS: Long-term home oxygen therapy was used to treat different chronic diseases, predominantly in infants and preschool children. There was a high frequency of pulmonary hypertension associated with longer periods of oxygen use and greater oxygen flow, without association with survival rate. The use of concentrators instead of cylinders may reduce costs significantly.

Effect of educational and policy interventions on institutional utilization of wet nebulization respiratory drugs and portable inhalers.

BACKGROUND: Asthma and chronic obstructive pulmonary disease treatment guidelines support the preferential use of portable inhalers (PIs) over wet nebulization (WN) respiratory therapy. Hospital- and community-based educational initiatives and a community-based provincial drug program policy change were previously implemented to promote the conversion of WN therapy to PI and spacer device use in Nova Scotia. OBJECTIVE: To examine the effect of these interventions on salbutamol, ipratropium bromide, and spacer device (Aerochamber) use at the Queen Elizabeth II Health Sciences Centre (QEII HSC). METHODS: We conducted a time-series analysis of drug utilization data from August 1998 to July 2005. We used two intervention phases compared to the pre-intervention phase to determine whether the educational and policy interventions were associated with significant changes in monthly drug and spacer device utilization rates at the QEII HSC (1000-bed teaching hospital; Halifax, Nova Scotia). RESULTS: Salbutamol and ipratropium bromide PI use significantly increased in both intervention phases, compared to the pre-intervention phase. Mean (SD) defined daily doses/100 bed-days for salbutamol PI increased from 30.4 (0.4) in the pre-intervention phase to 34.6 (0.9) and 37.0 (0.4) in intervention phases I and II respectively (p<0.001 for both), and ipratropium bromide PI increased from 27.3 (3.5) to 32.8 (2.5) in intervention phase I (p=0.004) and 35.6 (3.5) in intervention phase II (p<0.001). However, a significant corresponding decrease was observed with salbutamol WN only. Mean (SD) Aerochamber units/100 bed-days significantly increased. CONCLUSIONS: Educational and policy interventions had limited effects on converting WN to PI use at the QEII HSC.

Enfermedad pulmonar obstructiva crónica. Impacto y agudizaciones / Chronic obstructive pulmonary disease

La enfermedad pulmonar obstructiva crónica (EPOC) constituye un problema médico y social de primera magnitud. El curso progresivo y crónico de la enfermedad se ve a menudo agravado por periodos de aumento de los síntomas, particularmente de la tos, la disnea y la cantidad y purulencia del esputo. Estos episodios de incremento en la sintomatología son lo que conocemos por agudizaciones. La mayoría de estas agudizaciones están producidas por infecciones bronquiales y tienen un impacto importante en la calidad de vida de los pacientes y su evolución (AU)

Effects of pulmonary rehabilitation on dyspnea, quality of life, and healthcare costs in California.

PURPOSE: This study evaluated pulmonary rehabilitation as practiced in the general California medical community to determine its effectiveness in improving dyspnea and health-related quality of life and reducing the use of healthcare resources. METHODS: For this study, 10 established pulmonary rehabilitation programs agreed to collect common clinical health outcome data on consecutive patients over 2 years. The following three self-administered questionnaires were obtained before and after rehabilitation, then at 3-, 6-, 12-, and 18-month follow-up assessments: Medical Outcomes Survey Short Form (SF-36), University of California, San Diego Shortness of Breath Questionnaire (SOBQ), and Health Care Utilization in the preceding 3 months. Information also was collected on patient demographics, diagnostic categories, use of supplemental oxygen, and available spirometry and 6-minute walk tests. RESULTS: Nine centers enrolled 647 patients that met prespecified inclusion criteria. Of these, 521 completed the rehabilitation program and both the pre- and the postprogram assessment. At least two of the four follow-up assessments were completed by 415 patients in eight centers. The mean age of the patients was 68 years, and 42% were men. Overall, the forced expiratory volume in 1 second was 44% of the predicted value. There were few significant differences between the centers. The baseline outcome measures demonstrated marked symptoms, as evidenced by the mean SOBQ score (56.8) and the mean impaired quality of life results (SF-36 physical component score, 31.2; SF-36 mental component score, 47.5). These measures also showed high utilization of healthcare services over the preceding 3 months in terms of mean hospital stay (2.4 days), urgent care visits (0.4), physician visits (4.4), and telephone calls (2.7). After rehabilitation, there were significant improvements in symptoms and quality of life in all the centers, as evidence by mean changes of -6.8 for the SOBQ, 7.5 for the physical component score, and 3.9 for the mental component score). Over 18 months, benefits gradually declined, but levels remained above baseline values. There also were significant reductions in all measures of healthcare utilization. CONCLUSIONS: Pulmonary rehabilitation was effective in improving symptoms and quality of life and reducing the utilization of healthcare resources over 18 months. The results were consistent across participating centers despite variations in practice settings, patient referral patterns, and program structure.

Tratamiento farmacológico y costes hospitalarios del GRD 88. Enfermedad pulmonar obstructiva crónica / Pharmacotherapy and costs of DRD 88. Chronic obstructive pulmonary disease in hospital

Fundamentos: El Grupo Relacionado por el Diagnóstico (GRD) 88 -enfermedad pulmonar obstructiva crónica- es uno de los más frecuentes en la casuística hospitalaria y genera considerables costes sanitarios. Nuestro objetivo era conocer el coste y el patrón farmacoterapéutico asociado a este GRD y determinar los posibles factores relacionados. Método: Estudio transversal descriptivo de 288 altas asignadas al GRD 88 entre enero y diciembre de 1997 en un hospital de tercer nivel. De cada paciente, se analizaron las variables edad, género, diagnósticos, tipo de ingreso y alta, estancias y servicio de alta, así como la medicación recibida y su coste. Resultados: Los medicamentos con mayor impacto en el tratamiento fueron los antiinfecciosos, que además representaron el 46 por ciento del coste total, siendo los más utilizados las cefalosporinas . El 67 por ciento de los pacientes fueron tratados con beta-adrenérgicos inhalados y teofilinas. La combinación de beta-adrenérgicos con bromuro de ipratropio fue menos frecuente (n=152). Los corticoides sistémicos se emplearon en 233 pacientes. El patrón terapéutico presentó diferencias en función del servicio de alta, y de algunas variables clínicas, como diagnóstico que causó el ingreso o presencia de infección respiratoria. El coste/episodio fue 166,6 ñ 110,5 e. El coste/estancia fue 13,1 ñ 15,5 e. Coste farmacéutico y duración de estancia se correlacionaron moderadamente (r2 0 , 2 3 3 ) .Conclusiones: El coste viene determinado fundamentalmente por la utilización de antibióticos y la duración de estancia influye en menor medida. El patrón farmacoterapéutico está sujeto a cierta variabilidad que podría atribuirse, tanto a diferencias clínicas de los pacientes, como a distintos hábitos de prescripción. (AU)

Cost-of-illness of lung disease in the TriVeneto Region, Italy: the GOLD Study.

Lung diseases imply a high consumption of healthcare resources representing a burden for patients and their families as well as for the society. The aim of the Global Outcomes in Lung Diseases (GOLD) study was to perform a cost-of-illness analysis of three pathologies affecting the lower respiratory tract: community-acquired pneumonia (CAP), chronic obstructive pulmonary disease (COPD) and bronchial asthma (BA). This observational study was conducted in a large region of northeast Italy, Triveneto, between 1999 and 2000. Patients of both sexes and aged > or = 14 years, were randomly selected from 28 identified centres of pneumology; patients were considered eligible if they had been visited at least twice at the centre during the observational period. Study periods were different for the three pathologies: for BA and COPD the recruitment period lasted 8 weeks and the follow-up period 12 months; for CAP, given the acute nature of the disease, two recruitment periods (May and November) were identified with a follow-up lasting 6 months. After collecting information for each patient (age, sex, risk factors, severity of the disease, occupation), data were recorded by each centre in a dedicated software program and then sent to a central database where final results were analysed. Cost-of-illness analysis was conducted within the framework of the National Healthcare System (NHS). Consumption of medical resources used during the follow-up period was valued according to market prices and published official tariffs. A total number of 1068 patients (596 men and 458 women) were selected: 42.5% were affected by BA, 46.3% by COPD, and 11.2% by CAP. Mean cost per patient/year for patients affected by BA and COPD ranged from Euro 608 to 2457 and from Euro 1500 to 3912, respectively, depending on illness severity. Mean cost per episode of CAP was Euro 1586. This study confirms the findings of other studies published in the international literature, demonstrating that asthma and COPD are often misdiagnosed and mistreated and so their management, especially for the most severe patients, becomes complex and highly expensive. The use of preventive, specialised care could help in achieving early diagnosis and treatment of these patients.

Seretide for obstructive lung disease.

Seretide (Advair [North America], GlaxoSmithKline) is an inhaler combination formulation intended for the maintenance therapy of obstructive airways disease. Seretide was developed and made available initially as three multi-dose, dry powder inhaler formulations delivering 50 microg/puff of the long acting beta(2) agonist salmeterol and either 100, 250 or 500 microg/puff of the inhaled corticosteroid fluticasone propionate. In addition to the initial multi-dose dry powder inhaler system (Diskus or Accuhaler), a chlorofluorocarbon (CFC)-free pressurised aerosol formulation has become available. Studied mostly extensively as a maintenance therapy for patients with persistent asthma, the combination inhaler is at least equivalent to its components administered separately and is superior to monotherapy with salmeterol or inhaled corticosteroid in both paediatric and adult populations. The combination has a logical role in the treatment of moderate-to-severe asthma, offering the advantage of increased convenience and possibly improved compliance. In addition to improvements in lung function, symptom scores and quality of life, the combination therapy reduces exacerbation rates, an outcome that contributes to favourable cost-effectiveness. A role as initial maintenance therapy in all forms of persistent asthma is also plausible but there are fewer data concerning the impact of Seretide in milder forms of persistent asthma. Clinical trials are underway to examine the potential role of Seretide in patients with chronic obstructive pulmonary disease (COPD). Salmeterol has been shown to be an effective first-line bronchodilator in COPD and fluticasone has been shown to reduce the frequency and or severity of exacerbations in COPD patients in two key trials. At a time when the prevalence of both asthma and COPD is increasing, Seretide is a valuable step in the management of these common obstructive lung diseases.

Estudio comparativo de costos anuales en salud entre usuarios de oxígeno domiciliario y pacientes en lista de espera / Comparative study of health care costs for patients using home oxygen therapy or those in waiting lists

Background: Home oxygen therapy is the only intervention that significantly prolongs survival of patients with chronic obstructive pulmonary disease. Since this therapy is expensive, it is imperative to calculate its cost-benefit ratio. Aim: To compare health care costs for patients in a home oxygen therapy program, with those of a similar group of patients in a waiting list for this therapy. Material and methods: A retrospective analysis of 21 patients on home oxygen therapy for 36 months or less and a group of 13 patients in the waiting list during a similar lapse. Medical consultations, drugs delivered and the cost of oxygen therapy were considered among ambulatory costs. Hospitalization costs included the number of days on regular or intermediary care beds, laboratory tests and drugs delivered. Results: The annual health care costs for patients on home oxygen therapy were 709,656 Chilean pesos and the costs for patients in the waiting list were 797,320 Chilean pesos. Conclusions: The overall health care costs of home oxygen therapy are similar to the costs required by patients with chronic obstructive pulmonary disease remaining in waiting lists

A review of population studies from India to estimate national burden of chronic obstructive pulmonary disease and its association with smoking.

An attempt has been made to estimate the gross burden of chronic obstructive pulmonary disease (COPD) and its smoking association by reviewing the population studies available from India. Of the 14 studies which were reviewed, there were 11 conducted in general populations. The median values of different prevalence rates (i.e. 5 percent in male and 2.7 percent in female population) were accepted as the most appropriate figures to calculate the overall estimates. The overall M:F ratio was 1.6:1, i.e. 61.6 percent males. The estimated total number of adult patients aged 30 years and above in 1996 were 8.15 million males and 4.21 million females. The smoker:non-smoker ratio in males was assessed at 82.3 percent with an estimated burden of 6.7 millions. When the prevalence rates of COPD and its smoking associations were assessed in three different time periods (before 1970; between 1971-1990; after 1990), the median rates of 1971-1990, when the maximum number of studies were conducted, were nearly the same as the overall rates. However, the total burden as well as the smoking associated COPD, increased with time due to an increase in the eligible base population. In conclusion, these figures can be used to estimate the burden of COPD and its smoking association in India for different statistical analyses.

The impact of aging and smoking on the future burden of chronic obstructive pulmonary disease: a model analysis in the Netherlands.

Chronic obstructive pulmonary disease (COPD) causes extensive disability, primarily among the elderly. On the World Health Organization ranking list of disability-adjusted life years (DALYs), COPD rises from the twelfth to the fifth place from 1990 to 2020. The purpose of this study is to single out the impact of changes in demography and in smoking behavior on COPD morbidity, mortality, and health care costs. A dynamic multistate life table model was used to compute projections for the Netherlands. Changes in the size and composition of the population cause COPD prevalence to increase from 21/1,000 in 1994 to 33/1,000 in 2015 for men, and from 10/ 1,000 to 23/1,000 for women. Changes in smoking behavior reduce the projected prevalence to 29/1,000 for men, but increase it to 25/ 1,000 for women. Total life years lost increase more than 60%, and DALYs lost increase 75%. Costs rise 90%; smokers cause approximately 90% of these costs. The model demonstrates the unavoidable increase in the burden of COPD, an increase that is larger for women than for men. The major causes of this increase are past smoking behavior and the aging of the population; changes in smoking behavior will have only a small effect in the nearby future.

An economic overview of chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is a major cause of mortality and morbidity. Relatively few pharmacoeconomic studies have been conducted on this disease. This article reviews available information about the utilisation of healthcare resources and cost of care, and the cost or cost effectiveness of therapeutic interventions reported for this disease. Burden-of-illness data indicate that hospital care, medications and oxygen therapy were the major cost drivers in these studies. Mean annual Medicare expenditures in the US were $US11,841 (2000 values) for patients with COPD compared with $US4,901 for all covered patients. Utilisation was skewed; the most expensive 10% of the Medicare beneficiaries accounted for nearly 50% of total expenditures for this disease. Costs are associated with health status, age, physician specialty, geographic location and type of insurance coverage. Six types of interventions were assessed in the literature--pharmacotherapy, oxygen therapy, home care, surgery, exercise and rehabilitation and health education. The studies used different analytic strategies (e.g. cost-minimisation and cost-effectiveness analyses) and even within the realm of cost-effectiveness analyses, no uniformity existed as to how outcome was measured. Patient severity was not always delineated, and the length of the follow-up period, while quite short, varied. Only 11 of the 34 evaluations were based on randomised controlled trials. Cost-minimisation studies generally found no significant difference in the cost of antimicrobial treatment for first-line, second-line and third-line agents. Studies of bronchodilators indicated that ipratropium bromide alone or in combination with salbutamol (albuterol) was the preferred medication. The major area for achieving cost savings is by reducing hospital utilisation. As the annual rate of hospitalisation is relatively low, large patient samples will be required to demonstrate an economic advantage for a new therapy. The major challenges will be financing such a study, and selecting an outcome measure that satisfies both clinical and economic conventions.