Annual costs of chronic obstructive pulmonary disease in Finland during 1996–2006 and a prediction model for 2007–2030

ARTICLE OPEN Annual cos s o ch onic obs uc i e pulmona y disease in Finland du ing 1996–2006 and a p edic ion model o 2007–2030 F ed ik He se 1 , Toni Kiljande 2 and Lau i Leh imäki 3,4 BACKGROUND: Ch onic obs uc i e pulmona y disease (COPD) is a majo bu den o he heal h ca e sys em, bu he exac cos s a e di ficul o es ima e and he e a e insu ficien da a a ailable on pas and u u e ime ends o COPD- ela ed cos s. AIMS: The aim o he s udy was o calcula e COPD- ela ed cos s in Finland du ing he yea s 1996–2006 and es ima e u u e cos s o he yea s 2007–2030. METHODS: COPD- ela ed di ec and indi ec cos s in he public heal h ca e sec o o he whole o Finland du ing he yea s 1996–2006 we e e ie ed om na ional egis e s. In addi ion, we made a ma hema ical p edic ion model on COPD cos s o he yea s 2007–2030 on he basis o popula ion p ojec ion and changes in smoking habi s. RESULTS: The o al annual COPD- ela ed cos s amoun ed o abou 100–110 million Eu os in 1996–2006, wi h no ob ious change, bu he e was a sligh dec ease in di ec cos s and an inc ease in indi ec cos s du ing hese yea s. The es ima ion model p edic ed a 60% inc ease up o 166 million Eu os in COPD- ela ed annual cos s by he yea 2030. This is caused almos en i ely by an inc ease in di ec heal h ca e cos s ha eflec he p edic ed ageing o he Finnish popula ion, as olde age is a significan ac o ha inc eases he need o hospi alisa ion. CONCLUSIONS: The o al annual COPD- ela ed cos s in Finland ha e been s able du ing he yea s 1996–2006, bu i managemen s a egies a e no changed a significan inc ease in di ec cos s is expec ed by he yea 2030 due o ageing o he popula ion. npj P ima y Ca e Respi a o y Medicine (2015) 25, 15015; doi:10.1038/npjpc m.2015.15; published online 26 Ma ch 2015 INTRODUCTION Ch onic obs uc i e pulmona y disease (COPD) is highly p e alen wo ldwide, and i is es ima ed o become he hi d mos common cause o dea h globally by he yea 2020. 1 The p e alence o COPD in he Finnish adul popula ion is abou 4–10% depending on he defini ion used. 2–4 In wo ecen popula ion-based s udies, he p e alence o COPD, as defined by pos -b onchodila o a io o o ced expi a o y olume in 1 s o o ced i al capaci y o0.7, was 9.4% among 21–70-yea -old subjec s in No he n Finland 2 and 5.9% among 26–74-yea -old subjec s in Helsinki. 4 O he la e popula ion, 0.6% had se e e, 3.0% had mode a e and 2.2% had mild COPD. These figu es a e oughly in line wi h hose published in e na ionally, 5 bu e en highe figu es ha e been epo ed in, e.g., No he n Sweden 6 and Denma k. 7 Al hough he age-adjus ed p e alence o COPD has no changed du ing he las ew decades in Finland, 3 he o e all incidence and p e alence o COPD may inc ease due o ageing o he popula ion. COPD is a majo disease in economic e ms as well. The di ec annual heal h ca e cos s o COPD in he Eu opean Union a e es ima ed o be abou 23.3 billion Eu os. 8 A la ge sha e o his is hough o be caused by hospi alisa ions due o acu e exace ba- ions o COPD. Como bidi ies ela ed o COPD u he inc ease he o al cos s, bu hei e ec s a e di ficul o es ima e. As COPD- ela ed heal h ca e cos s a e associa ed wi h he se e i y o he disease, ea ly diagnosis and smoking cessa ion is ad oca ed o hinde he disease p og ession 1 and he eby hope ully also dec ease heal h ca e cos s. New d ugs, such as long-ac ing b onchodila o s, ha e been in oduced o he ea men o COPD du ing he las wo decades. The use o hese d ugs inc eases he di ec medicinal cos s o COPD. Howe e , as he d ugs imp o e heal h s a us in subjec s wi h COPD, 1 hey migh in u n dec ease he cos s caused by ou pa ien isi s. Mos impo an ly, he d ugs a e also shown o dec ease he isk o acu e exace ba ions and hospi alisa ions, 1 and his migh be an impo an ac o in dec easing he o al COPD- ela ed cos s. Fu he , changes in ea men p o ocols o hospi alised pa ien s owa ds sho e in-hospi al pe iods a e likely o a ec he o al cos s. Un o una ely, i is no well known how hese ac o s ha e changed he COPD- ela ed heal h ca e cos s on a na ionwide basis. The Finnish heal h ca e sys em wi h i s comp ehensi e s a is ics o e s a good oppo uni y o es ima ing COPD- ela ed cos s and he e ec s o he abo e-men ioned pa ame e s on he cos s. The aims o he cu en s udy we e o s udy he change in o al na ional COPD- ela ed cos s in Finland du ing he yea s 1996–2006 and es ima e he u u e annual COPD- ela ed cos s in Finland o he yea s 2007–2030. The s udy was conduc ed by he No dic Heal h Ca e G oup and i was unded by Boeh inge - Ingelheim Finland. 1 No dic Heal hca e G oup, Helsinki, Finland; 2 Depa men o Respi a o y Diseases, Te eys alo Hospi al, Tu ku, Finland; 3 School o Medicine, Uni e si y o Tampe e, Tampe e, Finland and 4 Alle gy Cen e, Tampe e Uni e si y Hospi al, Tampe e, Finland. Co espondence: L Leh imäki (lau i.leh imaki@u a.fi) Recei ed 20 Janua y 2015; accep ed 27 Janua y 2015 www.na u e.com/npjpc m All igh s ese ed 2055-1010/15 © 2015 P ima y Ca e Respi a o y Socie y UK/Macmillan Publishe s Limi ed MATERIALS AND METHODS Annual cos s 1996–2006 The annual cos s o COPD du ing he yea s 1996–2006 we e calcula ed using heal h ca e egis e s and s a is ics co e ing he whole popula ion in Finland (5.1 million people in 1996 and 5.3 million in 2006). The di ec cos s o COPD we e ega ded as cos s caused by hospi alisa ions due o COPD, ou pa ien isi s due o COPD and he cos s o COPD medica ion. The indi ec cos s o COPD included sickness allowances and disabili y pensions due o COPD. In con as o some o he s udies, we did no fi s iden i y a ce ain popula ion o subjec s wi h COPD and hen add up all hei heal h ca e cos s om egis e s using hei pe sonal iden i y codes. Ins ead, we u ilised na ional egis e s o di e en heal h ca e se ices o social benefi s and iden ified all such e en s whe e COPD was labelled as he cause o ha se ice/benefi . Di ec cos s Cos s o hospi alisa ions and ou pa ien isi s: The co e o he Finnish heal h ca e sys em is public heal h ca e, which consis s o p ima y (bo h ou pa ien s and inpa ien s) and seconda y heal h ca e (bo h ou pa ien s and inpa ien s) se ices. All ou pa ien isi s, hospi alisa ions and medical p ocedu es in seconda y public heal h ca e and hospi alisa ions in p ima y heal h ca e a e egis e ed wi h he ela ed ICD-10 diagnosis code by he Na ional Ins i u e o Heal h and Wel a e. 9 The cos s o p i a e heal h ca e o occupa ional heal h ca e sys ems we e excluded, as no egis e da a o COPD pa ien s ea ed in hose sec o s could be ob ained. We included in he analysis all ou pa ien isi s, days in hospi al and medical p ocedu es wi h ICD-10 diagnos ic codes J43 (emphysema) o J44 (COPD) as he p ima y cause. The uni cos s in 2006 o a day in hospi al and o an ou pa ien isi we e ob ained om he Na ional Ins i u e o Heal h and Wel a e 10 and a e gi en in Table 1. The p icing o medical p ocedu es was based on a e age DRG p ices quo ed by hospi als. 10 The uni cos s o o he yea s we e de i ed om hese by using infla ion co ec ions wi h p ice index on public expendi u e p o ided by S a is ics Finland. 11 Medica ion cos s: In Finland, all d ugs bough om pha macies a e egis e ed wi h he buye s' iden i y o he Finnish S a is ics on Medicines, 12 bu his egis e does no include he diagnos ic codes. Howe e , pa ien s wi h se e e enough as hma o COPD gain a special eimbu semen o hei medica ion. I a pe son en i led o such a eimbu semen buys medica ion, da a on his can be e ie ed om he egis e s. Subjec s wi h as hma and COPD a e no sepa a ed in his egis e bu a e conside ed a single g oup o pa ien s wi h obs uc i e pulmona y diseases. To a oid including medica ion used o ea as hma, we defined COPD- ela ed d ugs as d ugs o he ea men o espi a o y diseases bough by pe sons who we e en i led o a special eimbu semen o obs uc i e pulmona y diseases and who also used inhaled an icholine gics ( hese we e only seldom used o ea as hma in Finland du ing 1996–2006). The cos s o hese COPD- ela ed d ugs we e gained om he Finnish S a is ics on Medicines. 12 Indi ec cos s. Indi ec cos s o COPD, i.e., he loss o p oduc i i y due o illness, we e calcula ed on he basis o sickness allowances and disabili y pensions due o COPD. In Finland, all sickness allowances wi h he ICD-10 code o he cause a e egis e ed by he Social Insu ance Ins i u ion, 13 and disabili y pensions wi h he ICD-10 code o he cause a e egis e ed by he Finnish Cen e o Pensions. 14 The da a we e ie ed om he egis e s included he numbe o days on sickness allowance and he numbe o subjec s on disabili y pension due o COPD (J33 o J44). These we e hen ans o med in o los man-yea s, and he cos s o hese we e calcula ed using he uni cos , quo ed by he Na ional Ins i u e o Heal h and Wel a e, o 24,600€pe yea in 2006. 10 Mo ali y caused by COPD was no included in he calcula ions o loss o p oduc i i y, as mos COPD- ela ed dea hs occu a olde age when he subjec has al eady e i ed. We excluded also he ollowing indi ec cos s ha a e di ficul o define and calcula e: impai ed p oduc i i y a wo k while s ill p esen (p esen eism), 15 wo k ou side o paid wo k, ca e-gi ing by amily membe s and imma e ial cos s, he loss o p oduc i i y o dec ease in e i emen pensions due o mo ali y caused by COPD. Es ima ed annual cos s o 2007–2030 The es ima ion model was buil on an assump ion ha smoking his o y, age and sex a e he majo ac o s de e mining ( he isk o COPD and) COPD- ela ed cos s. In his model, we did no y o es ima e he ac ual numbe o subjec s wi h COPD, bu ou model assumes ha he ac ions o ac i e smoke s and ecen qui e s ha ha e COPD and cause COPD- ela ed cos s emain he same in he u u e. Fi s , we assessed he o al COPD- ela ed cos s in 2006, as desc ibed in he fi s pa o he manusc ip , sepa a ely in each age g oup (5-yea in e als) in bo h sexes. Second, we e ie ed he pe cen ages o ac i e smoke s and ecen qui e s (du ing he p e ious 10 yea s) sepa a ely in each co esponding age g oup and bo h sexes om he Tobacco S a is ics in Finland. 16 We hen calcula ed in each age g oup and sex ‘smoking s anda dised COPD cos s’in 2006 by di iding he ac ual COPD- ela ed cos s in 2006 by he numbe o ac i e smoke s and ecen qui e s wi h he ollowing weighing ac o s: 1 o ac i e smoke s and hose ex-smoke s who had qui 1–3 yea s ago; 0.75 o ex-smoke s who had qui 3–5 yea s ago; and 0.5 o ex-smoke s who had qui 5–10 yea s ago. To calcula e he COPD- ela ed cos s in each age g oup and gende in he yea s 2007–2030, we needed o calcula e he numbe s o smoking subjec s and ecen qui e s in each age g oup and gende in each o he yea s. We began by calcula ing he pe cen ages o ac i e smoke s and ecen qui e s in each age g oup and sex o each yea om 2007 o 2030 by assuming ha he ac ions o ac i e smoke s and ecen qui e s (1–3 yea s ago, 3–5 yea s ago and 5–10 yea s ago) con inue o change a he same a e hey ha e changed du ing he yea s 1996–2006 in Finland based on he Tobacco S a is ics. 16 We hen mul iplied hese pe cen ages o smoke s and ecen qui e s by he es ima ed numbe s o subjec s in each age g oup and sex e ie ed om he popula ion p ojec ion in Finland 17 o ge he ac ual numbe s o smoke s and ecen qui e s in each g oup and yea . Finally, hese numbe s o ac i e smoke s and ecen qui e s in each age g oup, sex and yea we e mul iplied by he ‘smoking s anda dised COPD cos s’in 2006 using he same weighing ac o s o smoke s and qui e s as men ioned abo e. These o al annual COPD- ela ed cos s du ing he yea s 2007–2030 we e hen co ec ed by an assumed annual infla ion ac o o 2%. RESULTS Annual cos s 1996–2006 The numbe s o ou pa ien isi s, days in hospi al, days on sickness allowance and sickness pensions e ie ed om he egis e s a e gi en in Table 2, bo h in absolu e alues and also pe 100,000 inhabi an s. The e was a 17% inc ease in p ima y ca e hospi al Table 1. The uni cos s o heal h ca e se ices and cos o los man-yea s due o sickness allowance o disabili y pension ob ained om he Na ional Ins i u e o Heal h and Wel a e in he yea 2006 Uni cos , € Days in hospi al in p ima y ca e 142 Days in hospi al in seconda y ca e 590 Seconda y ca e ou pa ien isi s 200 Los man-yea due o sickness allowance o disabili y pension 24,600 Table 2. Numbe s o hospi alisa ion days, ou pa ien isi s, days on sickness allowance and subjec s on disabili y pension e ie ed om egis e s in 1996 and 2006 1996 2006 Popula ion in Finland 5,132,320 5,276,955 Days in hospi al in p ima y ca e 58,986 (1,149) 69,021 (1,308) Days in hospi al in seconda y ca e 68,231 (1,329) 32,446 (615) Seconda y ca e ou pa ien isi s 22,179 (432) 20,115 (381) Days on sickness allowance due o COPD 59,104 (1,152) 64,354 (1,220) Subjec s on disabili y pension due o COPD 1,928 (38) 1,844 (35) The numbe s a e in o al alues in Finland and pe 100,000 inhabi an s in pa en hesis. Abb e ia ion: COPD, ch onic obs uc i e pulmona y disease. Cos o COPD on he inc ease in Finland F He se e al 2 npj P ima y Ca e Respi a o y Medicine (2015) 15015 © 2015 P ima y Ca e Respi a o y Socie y UK/Macmillan Publishe s Limi ed days bu a simul aneous 52% dec ease in mo e expensi e seconda y ca e hospi al days. Changes in ou pa ien isi s, days on sickness allowances and pe sons on disabili y pensions we e no ma ked. The ime ends o key COPD- ela ed cos s in he pe iod 1996– 2006 a e p esen ed in Figu e 1, and he exac numbe s in o al and pe 100,000 inhabi an s in he yea s 1996 and 2006 a e gi en in Table 3. The annual o al COPD- ela ed cos s in Finland a ied be ween 101 and 110 million Eu os du ing he pe iod 1996–2006 and he e was no ob ious change (Figu e 1). Howe e , he e was a sligh dec ease in di ec cos s om 63.6 o 56.3 million Eu os and a simila sligh inc ease in indi ec cos s om 46.5 o 51.4 million Eu os du ing hese yea s (Table 3). The dec ease in di ec cos s was caused by educed numbe o days in hospi al in seconda y ca e causing a ma ked dec ease in cos s o abou 16 million Eu os. Howe e , his was somewha ou weighed by a simul aneous inc ease in medica ion cos s o abou 6 million Eu os and by smalle inc eases in o he di ec cos s. The ise in indi ec cos s was caused mainly by inc ease in uni cos s o los p oduc i i y, as he e we e no ma ked changes in he days on sickness lea e o subjec s on disabili y pension (Table 2). Es ima ed annual cos s o 2007–2030 On he basis o ou calcula ions, he annual COPD- ela ed cos s in Finland will inc ease by abou 60% du ing he yea s 2007–2030 om 107 o 166 million Eu os (Figu e 2). The main eason o his inc ease is he significan ageing o he Finnish popula ion in he yea s o come, as bo h he p e alence o COPD and especially he use o heal h ca e se ices inc ease wi h ageing. E en he dec easing end in he ac ion o smoke s does no seem o balance ou he e ec o ageing. This ageing- ela ed inc ease in o al cos s is caused almos en i ely by inc easing di ec cos s (hospi alisa ions, ou pa ien isi s and medical cos s). The indi ec cos s will no change subs an ially du ing he yea s 2007–2030, as 0 20,000,000 40,000,000 60,000,000 80,000,000 100,000,000 120,000,000 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 Cos s o disabili y pensions Cos s o sickness allowances Cos s o medica ion Inpa ien episode cos s, p ima y heal h Inpa ien episode cos s, seconda y heal h ca e Ou pa ien isi cos s, seconda y heal h ca e Yea Cos s (€) Di ec cos s Indi ec cos s Figu e 1. To al COPD- ela ed cos s in Finland du ing he yea s 1996–2006 e ie ed om na ional egis e s and di ided in o majo componen s. COPD, ch onic obs uc i e pulmona y disease. Table 3. Di ec and indi ec cos s o COPD in he whole popula ion o Finland in he yea s 1996 and 2006, bo h in absolu e alues and pe 100,000 inhabi an s 1996 2006 To al cos s (€) Cos s pe 100,000 inhabi an s (€) To al cos s (€) Cos s pe 100,000 inhabi an s (€) Ou pa ien isi cos s, SHC 3,890,214 75,798 4,023,000 76,237 Hospi alisa ion cos s, SHC 35,321,979 688,226 19,154,939 362,992 Hospi alisa ion cos s, PHC 7,371,664 143,632 9,835,330 186,383 Cos s o medica ion 17,046,441 332,139 23,268,935 440,954 To al di ec cos s 63,630,298 1,239,796 56,282,204 1,066,566 Cos s o sickness allowances 4,897,021 95,415 6,074,400 115,112 Cos s o disabili y pensions 41,592,319 810,400 45,348,966 859,378 To al indi ec cos s 46,489,340 905,815 51,423,366 974,489 To al cos s 110,119,638 2,145,611 107,705,570 2,041,055 Abb e ia ions: COPD, ch onic obs uc i e pulmona y disease; PHC, p ima y heal h ca e; SHC, seconda y heal h ca e. Cos o COPD on he inc ease in Finland F He se e al 3 © 2015 P ima y Ca e Respi a o y Socie y UK/Macmillan Publishe s Limi ed npj P ima y Ca e Respi a o y Medicine (2015) 15015 inc eased mo bidi y a olde age, when al eady e i ed om wo k, does no a ec he p oduc i i y. DISCUSSION Main findings The main findings o he s udy we e ha he o al COPD- ela ed cos s in Finland we e s able a abou 100 million Eu os annually du ing he yea s 1996–2006, bu due o he o hcoming ageing o he popula ion he annual cos s a e es ima ed o inc ease by abou 60% by he yea 2030. In e p e a ion o findings in ela ion o p e iously published wo k Cos -o -illness s udies can be di ided in o wo ypes: op-down s udies, like his one, es ima ing o al cos s on he basis o he egis e da a on a na ional le el, and bo om-up s udies ha ollow indi idual pa ien s eco ding all hei cos s and hen ex apola ing hese o na ional le el by aking in o accoun disease p e alence. Top-down s udies gene ally include a limi ed numbe o di e en cos s and hey exclude unde diagnosing, whe eas bo om-up s udies include cos s o como bidi ies as well, and he p edic ion o o al na ional cos s is dependen on he accu acy o p e alence es ima es. These issues mus be aken in o conside a ion when compa ing di e en s udies. A Swedish op-down s udy 18 es ima ed ha in 1991 he o al COPD- ela ed cos in Sweden was abou 3.2 million Eu os pe 100,000 inhabi an s (2,784 million SEK (Swedish K ona) in o al, 1€≈10 SEK and Sweden’s popula ion was abou 8.6 million in 1991). This es ima e is somewha highe han ou es ima e o o al COPD- ela ed cos s in Finland in he yea 1996 (2.1 million Eu os pe 100,000 inhabi an s). This di e ence may be, in pa , explained by he ac ha he Swedish s udy also es ima ed mo ali y- ela ed cos s and by he ac ha he mean leng h o hospi alisa ion may ha e dec eased al eady be ween 1991 and 1996 in bo h he coun ies. A mo e ecen s udy om Sweden 19 ga e a much highe es ima e o he o al COPD- ela ed cos s, o alling 15.7 million Eu os pe 100,000 inhabi an s (1.46 billion Eu os in o al; Swedish popula ion 9.3 million in 2010), bu his may be explained by he bo om-up design o he s udy. In Denma k in he yea 2002, COPD- ela ed cos s we e es ima ed by a op-down s udy 20 o be 4.7 million Eu os pe 100,000 inhabi an s (256 million Eu os in o al; Danish popula ion 5.4 million in 2002), which is mo e in he same ange wi h ou s udy and he op-down s udy om Sweden. A p e ious s udy in Finland epo ed ha he annual cos s o COPD we e 194 million Eu os. 21 The di e ence om ou esul (abou 100 million) may be explained by he b oade spec um o diagnos ic labels included in he p e ious s udy (also J40–J42 (ch onic b onchi is) and J47 (b onchiec asis)) in e ie ing heal h ca e u ilisa ion da a om he egis e s. Fu he mo e, he p e ious s udy calcula ed hospi al ea men o be caused by COPD e en i COPD was no he p ima y diagnosis, whe eas he cu en s udy included only hose ea men pe iods in which COPD was labelled as he p ima y cause o hospi alisa ion. Including only ea men pe iods wi h COPD as he p ima y diagnosis may unde es ima e he cos s caused by acu e exace ba ions o COPD, as some o hese pe iods may be labelled wi h a diagnosis o acu e b onchi is o pneumonia. On he o he hand, conside ing ha all ea men pe iods a e caused by COPD, whe e COPD is included in he lis o he pa ien ’s diagnoses, su ely causes o e es ima ion o COPD- ela ed cos s, as hese subjec s a e ea ed o o he diseases as well. Such di e ences be ween s udies make i di ficul o compa e he esul s. A p e ious s udy 22 has es ima ed ha COPD- ela ed cos s in Finland ha e dec eased by 88% om 1997 o 2007. Howe e , he cos s a di e en ime poin s we e e ie ed om di e en s udies wi h conside able di e ences in he calcula ion me hods used. This se e ely unde mines he eliabili y o he s a ed huge dec ease in COPD- ela ed cos s. To ou knowledge, he cu en s udy is he fi s using he same me hods consis en ly in assessing he annual COPD- ela ed cos s in Finland du ing a wide ange o yea s. We ound ha he e was no ob ious change in o al COPD- ela ed cos s du ing he pe iod 1996–2006. Al hough he o al COPD- ela ed cos s we e s able du ing he yea s 1996–2006, he e was a dec ease in he di ec cos s and a co esponding inc ease in he indi ec cos s. The di ec cos s dec eased mainly due o a dec ease in he numbe o in-hospi al days. This eflec s changes in clinical p ac ice ega ding he ea men o acu e exace ba ions o COPD. The numbe o hospi al ea men pe iods was abou he same in 1996 and 2006, bu he mean leng h o he ea men pe iods dec eased, which also dec eased he o al numbe o ea men days. Ou finding is in line wi h a ecen epo om Sweden 19 in which cos s o hospi alisa ions due o COPD dec eased be ween he yea s 1999 0 20,000,000 40,000,000 60,000,000 80,000,000 100,000,000 120,000,000 140,000,000 160,000,000 180,000,000 200,000,000 Yea Cos s (€) 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 Figu e 2. P edic ed o al COPD- ela ed cos s in Finland du ing he yea s 2007–2030 di ided in o di ec (open ba s) and indi ec (ha ched ba s) cos s. COPD, ch onic obs uc i e pulmona y disease. Cos o COPD on he inc ease in Finland F He se e al 4 npj P ima y Ca e Respi a o y Medicine (2015) 15015 © 2015 P ima y Ca e Respi a o y Socie y UK/Macmillan Publishe s Limi ed and 2010 bu he e was a simul aneous inc ease in medica ion cos s. The e a e no many p edic ion s udies o u u e COPD cos s a ailable in e na ionally, bu a ecen s udy 23 es ima ed a 53% inc ease in na ional COPD cos s in he Uni ed S a es om 32.1 billion dolla s in 2010 o 49 billion dolla s by he yea 2020. This is in line wi h ou es ima e o a 60% inc ease in COPD cos s by he yea 2030 in Finland. S eng hs and limi a ions o his s udy This s udy is based on na ional egis e s co e ing he public heal h ca e sys em in he whole o Finland and gi es a eliable es ima e on he ue cos s o COPD. Howe e , ou es ima e o o al cos s is likely a conse a i e one because o se e al easons. Fi s , he exac eason and p ima y diagnosis o hospi alisa ion o a subjec wi h COPD and many como bidi ies is no always s aigh o wa d, and some exace ba ions o COPD a e ce ainly ea ed unde o he diagnoses, which may lead o unde es ima ion o hospi alisa ion cos s. Second, ou pa ien isi s in p i a e heal h ca e sys ems o in p ima y public heal h ca e could no be included because o lack o eliable egis e s. Howe e , his is p obably no a significan issue, as he cos s o ou pa ien isi s a e small when compa ed wi h hospi alisa ions and indi ec cos s, and he numbe o isi s o elde ly people in p i a e heal h ca e is e y small. Thi d, no all pa ien s wi h mild o mode a e COPD ha e a special eimbu se- men o medica ion, and he medica ion cos s o subjec s wi hou his eimbu semen a e no included in his analysis. As medica ion cos s a e highe in subjec s wi h se e e COPD, his may no be a ma ked flaw bu leads o unde es ima ion in any case. Fu he mo e, he indi ec cos s a e always di ficul o define and calcula e, and we did no include, e.g., he possibili y ha mo ali y due o COPD migh dec ease he expenses o e i emen pensions due o ea lie dea h o subjec s wi h COPD. Ou es ima e o u u e cos s assumes ha he e ec i eness o he heal h ca e sys em and he age-adjus ed need o hospi alisa- ion will be a he cu en le el in he u u e also. Howe e , i new ea men s eme ge ha significan ly dec ease he need o hospi alisa ion o sho en hospi alisa ion pe iods, he inc ease in u u e cos s migh be smalle han es ima ed he e. Ou model on he u u e p e alence o COPD also assumed ha he age- adjus ed p opo ion o smoke s in he popula ion will con inue o dec ease a he same a e as i has in p e ious yea s. I he smoking ends de ia e om he assump ion ei he up- o downwa ds, his migh dec ease he liabili y o ou es ima e on he p e alence o COPD. Howe e , he e is a conside able la ency pe iod be ween changes in smoking habi s and changes in COPD p e alence, and ou ime pe iod o he es ima e is only 24 yea s. The e o e, he accu acy in p edic ing u u e smoking habi s is no ha impo an o he ime pe iod o 24 yea s, bu i would be much mo e pi o al o longe ime pe iods. A weakness o he cu en s udy, as wi h all p edic ion models, is ha in p edic ing u u e COPD- ela ed cos s we needed o es ima e se e al pa ame e s on he basis o hei ime ends in he pas . Howe e , while doing his we ied o be as ealis ic, o e en conse a i e, as possible. Implica ions o u u e esea ch, policy and p ac ice In he pas , he p e alence o COPD has been on he ise due o ageing o he popula ion, and he medicine cos s ha e also isen as new d ugs ha e become a ailable. Howe e , hese ac o s inc easing he cos s ha e been balanced ou by inc eased e ficiency o he heal h ca e sys em ha has dec eased he leng h o in-hospi al pe iods. The Finnish popula ion will be ageing much mo e apidly du ing he nex 20 yea s han du ing he yea s 1996–2006. The numbe o pa ien s wi h COPD will inc ease especially in he olde age g oups, in which also he need o hospi al ea men is he g ea es . This is why he e will be ageing- ela ed inc ease in o al COPD- ela ed cos s in he u u e, al hough his did no ake place in he pas . As he olde age g oups ha e al eady e i ed, he highe p e alence o COPD among hese subjec s does no cause an inc ease in indi ec cos s ha a e ela ed o loss o p oduc i i y. The ageing- ela ed inc ease in COPD cos s should be aken in o accoun in Finland when planning he na ional heal h ca e s a egy. The esul s can be expanded o o he wes e n coun ies wi h simila smoking habi s and ageing o he popula ion. As he s eamlining o he heal h ca e sys em in ea ing exace ba ions has al eady aken place, his is likely no a significan op ion in educing he cos s anymo e. Ins ead, ocus should be on smoking policy o dec ease age-adjus ed COPD incidence and on he managemen o s able COPD o dec ease he isk o exace ba ions. Conclusions In conclusion, he annual cos s o COPD in Finland ha e been s able du ing he yea s 1996–2006, bu he cos s a e es ima ed o inc ease by 60% un il he yea 2030 mainly due o ageing o he popula ion. A s ic smoking policy is needed o dec ease COPD- ela ed mo bidi y and he u u e ise in cos s, and possible new ea men op ions need o be assessed in e ms o cos e ec i eness as well. CONTRIBUTIONS All he au ho s ook pa in planning he s udy and w i ing he manusc ip . FH was esponsible o e ie ing he da a om heal h ca e da abases and o analysing he da a. COMPETING INTERESTS The au ho s decla e no conflic o in e es . FUNDING The s udy was unded by Boeh inge -Ingelheim Finland. REFERENCES 1 Global Ini ia i e o Ch onic Obs uc i e Lung Disease (GOLD). Global S a egy o he Diagnosis, Managemen and P e en ion o COPD 2014. A ailable a h p:// www.goldcopd.o g/. 2 Ko aniemi J, So ijä i A, Lundbäck B. Ch onic obs uc i e pulmona y disease in Finland: p e alence and isk ac o s. 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