Economic Burden of COVID-19: A Systematic Review

To review and qualitatively synthesize the evidence related to the economic burden of COVID-19, including healthcare resource utilization ... Journals WhyPublishWithUs? EditorialPolicies AuthorGuidelines PeerReviewGuidelines OpenOutlook COVID-19 Podcasts Blog Reprints SubmitNewManuscript Menu About Contact Sustainability Awards PressCenter Testimonials Blog FavoredAuthorProgram Permissions Pre-Submission Reprints Login openaccesstoscientificandmedicalresearch Advancedsearch HomeJournalsWhypublishwithus?EditorialPoliciesAuthorInformationPeerReviewGuidelinesOpenOutlookCOVID-19Podcasts Usage 8770 Monthlydownloads/views AverageArticleStatistics 32Days * Fromsubmissiontofirsteditorialdecision. 9Days * Fromeditorialacceptancetopublication. *Businessdays(Mon-Fri)RejectionRate 53% Theabovepercentageofmanuscriptshavebeenrejectedinthelast12months. 75050 PapersPublished SubmitNewManuscript Logintoviewexistingmanuscriptstatus SignupforJournalalerts AboutDovePress Openaccesspeer-reviewedscientificandmedicaljournals.Learnmore OpenAccess DoveMedicalPressisamemberoftheOAI.Learnmore Reprints Bulkreprintsforthepharmaceuticalindustry.Learnmore FavoredAuthors Weofferrealbenefitstoourauthors,includingfast-trackprocessingofpapers.Learnmore PromotionalArticleMonitoring RegisteryourspecificdetailsandspecificdrugsofinterestandwewillmatchtheinformationyouprovidetoarticlesfromourextensivedatabaseandemailPDFcopiestoyoupromptly.Learnmore SocialMedia       BacktoJournals»ClinicoEconomicsandOutcomesResearch»Volume14 Listen Review EconomicBurdenofCOVID-19:ASystematicReview            FulltextMetricsGetPermissionCitethisarticle AuthorsRichardsF,KodjamanovaP,ChenX,LiN,AtanasovP ,BennettsL,PattersonBJ,YektashenasB,Mesa-FriasM ,TronczynskiK,BuyukkaramikliN,ElKhouryAC Received14October2021 Acceptedforpublication23March2022 Published28April2022 Volume2022:14Pages293—307 DOIhttps://doi.org/10.2147/CEOR.S338225 CheckedforplagiarismYes ReviewbySingleanonymouspeerreview Peerreviewercomments2 Editorwhoapprovedpublication: Prof.Dr.DeanSmith DownloadArticle[PDF]  FayolahRichards,1PetyaKodjamanova,2XueChen,3NicoleLi,4PetarAtanasov,5LigaBennetts,6BrandonJPatterson,1BehinYektashenas,1MarcoMesa-Frias,7KrzysztofTronczynski,8NasuhBuyukkaramikli,9AntoineCElKhoury11JanssenGlobalServices,Raritan,NJ,USA;2HEMAAmaris,Sofia,Bulgaria;3HEMAAmaris,Shanghai,People’sRepublicofChina;4HEMAAmaris,Toronto,Canada;5HEMAAmaris,Barcelona,Spain;6HEMAAmaris,Montréal,Canada;7JanssenScientificAffairsLLC,Titusville,NJ,USA;8EMEAJanssen,Warsaw,Poland;9R&DJanssen,Beerse,BelgiumCorrespondence:FayolahRichards,Email[email protected]Objective:ToreviewandqualitativelysynthesizetheevidencerelatedtotheeconomicburdenofCOVID-19,includinghealthcareresourceutilizationandcosts.Methods:Asystematicreviewofstudiesthatassessedtheeconomicburden[eg,directcosts,productivity,macroeconomicimpactduetonon-pharmaceuticalinterventions(NPIs)andequity]ofCOVID-19wasconductedbysearchesinEMBASE,MEDLINE,MEDLINE-IN-PROCESS,andTheCochraneLibrary,aswellasmanualsearchesofunpublishedresearchfortheperiodbetweenJanuary2020toFebruary2021.Singlereviewerdataextractionwasconfirmedindependentlybyasecondreviewer.Results:Thescreeningprocessresultedinatotalof27studies:25individualpublications,and2systematicliteraturereviews,ofnarrowerscopes,thatfulfilledtheinclusioncriteria.ThepatientsdiagnosedwithmoresevereCOVID-19wereassociatedwithhighercosts.ThemaindriversforhighercostswereconsistentacrosscountriesandincludedICUadmission,in-hospitalresourceusesuchasmechanicalventilation,whichleadtoincreasecostsof$2082.65±345.04to$2990.76±545.98.Themostfrequentlyreportedindirectcostswereduetoproductivitylosses.Onaverage,olderCOVID-19patientsincurredhighercostswhencomparedtoyoungeragegroups.Anestimationofa20%COVID-19infectionratebasedonaMonteCarlosimulationintheUnitedStatesledtoatotaldirectmedicalcostof$163.4billionoverthecourseofthepandemic.Conclusion:TheCOVID-19pandemichasgeneratedaconsiderableeconomicburdenonpatientsandthegeneralpopulation.PreventativemeasuressuchasNPIsonlyhavepartialsuccessinloweringtheeconomiccostsofthepandemic.Implementingadditionalpreventativemeasuressuchaslarge-scalevaccinationisvitalinreducingdirectandindirectmedicalcosts,decreasedproductivity,andGDPlosses.Keywords:covid-19,economicImpact,symptomBurden,healthEconomics,vaccines,costs Introduction Sincelate2019,SevereAcuteRespiratorySyndromeCoronavirus2(SARS-CoV-2)hasinfectedmorethan180millionpeoplegloballyandcausedmorethan3.9milliondeathsworldwideasofJune30th2021.1Thevirusandthemeasurestakentocontrolitsspreadhaveprofoundlyimpactedpeople’slives.SincethestartoftheCoronavirusdisease2019(COVID-19)pandemic,significanteffortshavebeenmadebytheindustryandacademiatodiscoverpromisingtreatmentsandvaccinesthatcanimprovetheclinicaldiseasecourseandpatientoutcomesorpreventinfection,andthereforereducetheburdentopublichealthsystems.QuantifyingtheeconomicburdenofCOVID-19isanessentialconsiderationforevaluatingthevalueoftherapeuticandpreventiveinterventionsagainsttheCOVID-19disease. ThemacroeconomicimpactoftheCOVID-19pandemichasbeenoverwhelming,withdatafromEuropeshowinganaverageof7.4%reductionofGDPin2020,withsignificantvariationsacrosscountries.2,3TheGDPlosseswereshowntobehighlycorrelatedwithdropsinemploymentrates,especiallyinregionsthatrelyontourismindustry.Negativeeconomicgrowthwasjustoneoftheunintendedconsequencesassociatedwiththeadoptionofnon-pharmaceuticalinterventions(NPIs),suchaslockdowns.Governmentsworldwidehaveallstruggledinbalancingthetrade-offsbetweencontrollingthespreadofthevirustolimittheburdenofthediseaseagainsttheunintendedeconomic,socioeconomicandotherhealthconsequencesoftheimposedNPImeasures.4 Itwasestimatedthatwithoutadequatepolicymeasures,thepandemicwouldhavethemostsignificanteconomicimpactonthoseoflowerincome,thereforeincreasingpovertyratesandoverallinequality.2SimilarpredictionshavebeenmadebytheCouncilofEconomicAdviserstotheUSgovernment,whopredictedthatwithouteconomicsupportpolicies,peopleinthelower-incomebracketwouldhavesufferedanaveragereductionofdisposableincomeofmorethan10%duringQ1of2020.5 Aswithanyothernewdisease,initially,thecostingdatarelatedtotheburdenofCOVID-19wasscarce.Duetotheprofoundeconomicburdenofthedisease,severalstudiesrelatedtothemedicalcostsofCOVID-19haverecentlybeenpublishedindifferentregions.Duetothisincreaseinthenumberofstudies,anditsprofoundimpactonhealthcarebudgetsaswellasglobaleconomy,itisessentialtounderstandandsynthesizethisdatatoinformpolicymakersontheoverallburdenofCOVID-19. TheobjectiveofthisstudyistosystematicallyreviewandsynthesizetheevidenceontheeconomicassessmentofburdenofCOVID-19sincethestartofthepandemic. Methods AsystematicliteraturereviewbasedonaprotocolwasconductedutilizingEMBASE,MEDLINE,MEDLINE-IN-PROCESS,andTheCochraneLibraryusingthesearchtermspresentedinAppendix1.ThesearchwasconductedonApril1,2021.Inadditiontothesearchesofelectronicdatabase,manualsearcheswerealsoconductedtocapturedatafromrecentstudiesnotyetpublished.Manualsearchesincludedsearchesofconferenceproceedings(publishedfromJanuary2020onwards)andonlineinformationrepositories,theMedRxivpreprintserver,andhealthtechnologyagenciesfromtheUK,France,Germany,Canada,US,SouthKorea,Taiwan,andAustralia. EligibilityCriteriaandStudySelection ThestudyquestionofthisSystematicLiteratureReview(SLR)wasspecifiedusingthePICOS(Population,Intervention,Comparison,OutcomesandStudydesign)framework.ThepopulationofinterestincludedpatientswithCOVID-19.Peopleindirectlyaffected,includingpopulationswhosufferedfromtheconsequencesofCOVID-19preventionmeasures,caregivers,orcarers,werealsoincluded.Studiesreportingonanypopulationsubgroup(forexample,patientswithadifferentsocioeconomicstatus,differentdemographiccharacteristics)thatmettheinclusioncriteriaofbeingaffectedbyCOVID-19directlyorindirectlywereincludedanddatafromthesestudieswereextracted.AllinterventionsforCOVID-19treatmentandstrategiesforpreventionorcontrolofCOVID-19wereincluded. ThestudytypesofinterestwereobservationalcostingstudiesandassessmentsoftheeconomicimpactofCOVID-19.Systematicreviewswereincludedandextractedseparatelyfromtheindividualstudiesidentifiedinthisreview.IndividualstudiesidentifiedfromthoseSLRswerenotextractedbutarelistedinAppendix2.Randomizedcontrolledtrials(RCT),reviews,casereports,andcaseserieswereexcluded.Nodaterestrictionswereplacedonthesearchstrategiesfortheelectronicdatabases.Forthemanualsearches,thedatewasrestrictedtothelastyear. Thetitlesandabstractsofrecordsidentifiedfromthesearchstrategy,whereavailable,werereviewedaccordingtothepre-specifiedinclusion/exclusioncriteriareportedinAppendix3.Asecondreviewerindependentlyscreenedthetitlesandabstractsoftheidentifiedstudies.Anydiscrepancywasresolvedbydiscussion.Articlesidentifiedaspotentiallyrelevantbasedonscreeningoftitlesandabstractswerethenreviewedinfullandselectedaccordingtothelistofpre-specifiedinclusion/exclusioncriteria.Afterthefull-textreviewwascompleted,alistoftheexcludedstudieswascreatedwiththereasonforexclusion.Thecompletelistofexcludedstudiesduringthefull-textreviewstageispresentedinAppendix4.Meta-analysissynthesiswasnotconductedduetothebroadstudyheterogeneity. Theoutcomesofinterestincludedresourceuserelatedtothediseaseandtheassociatedinterventionandmeasuresofequity.Theseareincludedbutarenotlimitedtohospitaladmission,lengthofstay,physicianvisits,emergencydepartmentvisits,andpharmacycosts.Indirectcostsincluded,butnotlimitedto,weredecreasedproductivity,lostwages,orcaregivercosts.Totalcostsperhealthstateandpatientwerealsoofinterest. Results Atotalof18,621citationswereidentifiedthroughtheelectronicdatabasesearch.Duplicateswereidentifiedandcomparedbasedonanexactmatchforauthor,year,title,andabstract.Afterremovalofduplicates,351uniquecitationswereobtainedandscreened. Afterapplicationofthepre-specifiedselectioncriteriaandtitle,abstract,andfull-textstages,atotalof35individualpublicationsand2systemicliteraturereviews wereincludedinthisSLR(Figure1:PRISMAdiagram).Mostofthepublications(n=247)wereexcludedbecausetheydidnothavetheoutcomesofinterest.Furthermore,25publicationswereexcludedbasedonstudytype,33didnotincludethepopulationofinterest,andfourwerepreviouslymissedduplicates.AfulllistofincludedstudiesispresentedinAppendix2. Figure1PRISMAdiagram. Inexploringtheliterature,wefoundanabundanceofliteratureassessingdirectandindirectmedicalcosts.Thestudiesincludedhereevaluatedsomeofthefollowingobjectives:identifyingriskfactorsforclinicalburdenandresourceuse,resourceuseofhospitalizedpatients,determiningtheassociationofCOVID-19severitywithcostsaswellasassessingthedirectimpactofCOVID-19onGDP. Countriesanalyzedintheindividualstudiesincluded12studiesfromUnitedStates,5studiesfromtheUK,3fromGermany,3multinationalstudies,2studiesfromTurkeyandChinaandonestudyfromthefollowingcountries:Italy,France,Greece,SaudiArabia,Japan,Pakistan,IranandBrazil. ObjectivesandkeyfindingsoftheincludedarticlesaresummarizedbelowinTable1EconomicBurdenofPatientsandTable2EconomicburdenoftheGeneralPopulation,extractiontableswithcompletestudycharacteristicsandoutcomesareinAppendix5. Table1EconomicBurdenofPatients Table2EconomicBurdenoftheGeneralPopulation Discussion Atotalof37publicationswereincludedinthisSLR,35individualpublications,and2SLRs.TheSLRsincludedevaluatedage-adjustedriskfactorsassociatedwithmechanicalventilationandracialandethnicdisparitiesinhospitalizationsanddeath.43,44ConsistentlyreportedacrossallstudieswerehighmedicalcostsandresourceusebyCOVID-19patients.Theincreasedresourceuserequiredforthemostseverepatientsinfluencedcostssubstantially.9,11,12,14–19 Acrossmultiplecountriesinthehospital,thecostsforCOVID-19patientsadmittedinanICUwerehigherthanthosenotadmittedinanICU.WithintheICU,mechanicalventilationcontributedtoafurtherincreaseincosts$2082.65±345.04to$2990.76±545.98.9,15–17,19Overall,studiesfromEurope,theUS,andAsiashowedthatmoresevereCOVID-19patientshadhighercostsandresourceusethanmilderCOVID-19cases.Onamacroeconomiclevel,theCOVID-19pandemicwasadirectcauseofGDPlosses,mainlyduetolossinproductivityandimplementationofnon-pharmaceuticalinterventions.1–3 Economicmodelshaveassessedtheprevention,screeningandtreatmentofCOVID-19,Inlonger-termmodels,screeningtestswereconsideredcost-effectiveinalleconomicmodels.Similarly,socialdistancingwasmorecost-effectivethanquarantine,herdimmunity,andhavingnointervention.Antiviraltreatmentsandcurativetreatmentswereconsideredthemostcost-effectiveoptioncomparedwithanyothermeasuresagainstCOVID-19.36,45–48 AneconomicevaluationconductedinSouthAfricaandtheUKevaluatedtheeconomiceffectsofsocialdistancing.26ThemodelresultsshowedthatifstrictlockdownmeasuresweretakenintheUKatthebeginningofthepandemic,thepandemicwouldhaveresolvedin1.5monthswithapproximately21,000deaths.However,theUKdecidedtoimplement4.5monthsofsemi-lockdown,whichresultedin80,000deaths.AsimilartrendwasobservedinSouthAfrica.Thus,themodelresultsshowedthatsocialdistancingshortensthepandemicdurationanddecreasesthenumberofdeathsbydecreasingthenumberofinfectedpeople. Anothereconomicevaluationconcludedthattreatmentwithremdesivirfornon-ventilatedpatientsanddexamethasoneforventilatedpatientswouldmaximizelivessavedandsave$11.5million.27ThemaindriversweretheefficacyofthedrugsandreductionofICU-timerequired. AstochasticcompartmentmodelfromtheUSestimatedhowhospitalizationsandICUadmissionswoulddecreaseifthedurationofinfectiousratewasshorterandwhensymptomaticpatientsweretreated.Whenhighproportions(>50%)ofsymptomaticpatientsweretreated,theresourceusedecreased.Similarly,shorterinfectiousperiodswereassociatedwithreducedresourceuse.28 OnekeystrategytopreventtheburdenassociatedwithCOVID-19isvaccination.Currently,theCDCestimatesthatavailablevaccinationssuchastheyearlyinfluenzavaccinetohaveprevented4.4millionillnesses,2.3millionmedicalvisits,and58,000hospitalizationsduringthe2018–2019influenzaseason.49AMarkovcohortmodelwasusedtoestimateCOVID-19relateddirectmedicalcostsanddeathsintheUnitedStates,Withthemostoptimisticprojections,a60%efficaciousCOVID-19vaccinecanprevent31%ofexpectedCOVID-19deathsintheUnitedStatesversusnovaccines.50AsCOVID-19vaccinesenterthemarket,morespecificcost-effectiveevaluationswillbeneeded.AsofJune2021,therearethreeCOVID-19vaccinesapprovedbyEmergencyUseAuthorizationvaccinesintheUS—BNT162b2mRNA(Pfizer-BioNTech),mRNA-1273(Moderna),andAd26.COV2.S(Janssen).51TheEuropeanMedicinesAgencyhasapprovedanadditionalvaccineChAdOx1-SbyAstraZeneca.52Additionally,therearetenothervaccinesapprovedinvariouscountriesglobally.53 Vaccinesmayalsoofferadditionalbenefitsbeyondmitigationcaseburdenalone.EstimatesforherdimmunitythresholdforCOVID-19rangefrom60–90%ofthepopulation.Thiscanbemoreeasilyachievedthroughvaccinationsupplementingnaturalimmunityfrompastexposure.Thereisuncertaintyonwhetheraninitialinfectionleadstolong-lastingimmunityagainstCOVID-19.29,54Furthermore,theemergenceofnewvariantsofconcern,suchasthosefromtheOmicron(B.1.1.529)lineage,wouldrequirethedemonstrationofvaccineeffectiveness. Vaccinationshavemadeanessentialcontributiontothedecreasedincidenceofinfectiousdiseasesandareconsideredtobeacost-effectivepublichealthintervention.Regardingchildhoodvaccination,itwaspredictedthatforeverydollarspent,itsaves$3fortheUSpayer.55Theeradicationofsmallpoxthroughvaccineshasresultedinadirectmedicalcostsavingsof$300millionintheUS.Theeradicationofpolioisexpectedtosavetheworld$1.5billionyearly.56Missedopportunityforthefourmostcommonvaccine-preventablediseasesinadultsover50yearscontributestoanestimatedcostof$26.5billionintheUS(medicalandindirect).57Vaccinesdemonstrateaconsiderablereturnoninvestmentforpayers. Conclusion TheCOVID-19pandemichasanimmenseimpactandcurrenteffortsimplementingNPIsonlyhavepartialsuccessincontrollingthehumanisticandeconomiccostsofthepandemic.VaccinationisastrategyusedtomitigatetheevolvinglandscapeofCOVID-19,andpolicymakingbodieswillconsidertheircost-effectivenessinmakingrecommendationsforroutineuseinthefuture. Acknowledgments Noassistanceinthepreparationofthisarticleistobedeclared. AuthorContributions Allauthorsmadeasignificantcontributiontotheworkreported,whetherthatisintheconception,studydesign,execution,acquisitionofdata,analysisandinterpretation,orinalltheseareas;tookpartindrafting,revisingorcriticallyreviewingthearticle;gavefinalapprovaloftheversiontobepublished;haveagreedonthejournaltowhichthearticlehasbeensubmitted;andagreetobeaccountableforallaspectsofthework. Funding JanssenGlobalServicesLLC. Disclosure FayolahRichards,BrandonJPatterson,BehinYektashenas,andAntoineCElKhouryareemployeesofJanssen,Raritan,NewJerseyUSA.MarcoMesaFriasisanemployeeofJanssenScientificAffairsLLC.PetyaKodjamanova,XueChen,NicoleLi,PetarAtanasov,andLigaBennetsareemployeesofHEMA,AmarisandreportprofessionalfeesfromJanssenforthisstudy.KrzysztofTronczynskiisanemployeeofJanssen,WarsawPoland.NasuhBuyukkaramikliisanemployeeofJanssen,Beerse,Belgium.Theauthorsreportnootherconflictsofinterestinthiswork. 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