COPD Index
Overview
The Copenhagen Institute for Futures Studies, with the support of an independent, expert steering committee, has developed the COPD Index, a unique data tool for assessing both country health systems’ approach to preventing and managing COPD, as well as other related factors that may impact COPD severity and control. Building on the approach and vision of the previously released Severe Asthma Index, the COPD Index evaluates 34 countries’ approaches to COPD across a range of parameters linked to health policy, access to and quality of care, clinical indicators, population health indicators, and environmental factors. The Index marks a robust attempt to bring together various sources of data to support a comprehensive, multinational analysis of approaches to COPD care and prevention. By providing such an overview, it aims to motivate the creation and implementation of more robust policies and strategies related to COPD, support improved access to and quality of care, and assist health system stakeholders in identifying, sharing, adapting, and implementing best practices.
COPD
300 to 400 million
Chronic obstructive pulmonary disease (COPD) affects between 300 and 400 million people globally, making it the third leading cause of death worldwide.
COPD
45% of the public
45% of the public could not correctly identify COPD as a lung disease despite the fact that it is the third leading cause of death worldwide and kills more people yearly than lung and breast cancer combined.
COPD
€38.6 billion
COPD contributes 56% (€38.6 billion) of the total costs associated with respiratory conditions in the EU, yet spending to address the burden of COPD is only 0.1% of the 2021-2027 EU4Health programme budget allocated to chronic respiratory diseases.
Where Does Your Country Rank?
Following normalisation, country scores for each indicator category were averaged and then multiplied by 10 to give a score out of 100 points.
Ranking
P
A
H
D
E
SCORE
1
Australia
23
6
11
20
9
74
2
Chile
20
29
8
10
11
74
3
Colombia
6
19
36
6
25
74
4
United Kingdom
18
2
35
34
8
72
5
Finland
13
15
14
28
5
71
6
Costa Rica
5
40
26
4
16
69
7
Estonia
19
28
18
13
22
69
8
Slovakia
1
14
22
12
29
69
9
Lithuania
21
34
25
5
38
69
10
Spain
15
13
5
45
24
68
11
Greece
34
24
2
31
18
68
12
New Zealand
8
5
39
35
2
68
13
Romania
2
31
12
1
43
68
14
Switzerland
16
22
9
19
15
67
15
Ireland
17
4
41
29
6
67
16
Denmark
14
3
37
43
7
67
17
Canada
7
25
24
23
14
66
18
Netherlands
4
26
38
22
4
66
19
Austria
31
10
13
25
20
66
20
Japan
41
32
20
21
23
66
21
Sweden
25
18
19
37
3
66
22
Italy
43
21
3
30
32
65
23
France
26
8
7
27
13
65
24
South Korea
27
36
4
16
36
65
25
Israel
37
17
15
9
10
64
26
Poland
10
20
1
26
28
64
27
Brazil
38
35
27
8
31
63
28
Hungary
28
11
21
44
35
63
29
Argentina
12
33
33
11
12
63
30
Mexico
40
9
23
39
21
63
31
Germany
3
16
28
41
26
63
32
Cyprus
35
1
31
17
1
62
33
United Arab Emirates
45
23
6
7
42
61
34
Czechia
22
7
42
38
34
61
35
Portugal
11
12
40
36
39
61
36
Norway
42
43
34
2
41
60
37
Latvia
32
27
16
24
30
59
38
Slovenia
24
30
32
15
33
59
39
Peru
44
37
29
14
37
57
40
Belgium
30
39
10
33
19
57
41
Saudi Arabia
39
42
30
18
27
56
42
Egypt
36
41
44
3
40
54
43
China
9
44
17
42
45
54
44
South Africa
29
45
45
40
17
53
45
India
33
38
43
32
44
50
COPD Calls to Action
Discover the gold standard in COPD management, encapsulating the latest advances in treatment protocols and patient care pathways to optimize respiratory health outcomes.
Unite for COPD
Prevent COPD
Recognise COPD
Understand COPD
Empower COPD patients
COPD Key Aims
The Respiratory Health Initiative aims to
Improve
Improve health care decision making and prioritisation of chronic respiratory disease through the use of a broad set of data and insights
Identify
Identify good practices in respiratory health care and support the development of resilient, learning health systems
Provide
Provide stakeholders with a unified platform for accessing, exploring, and sharing insights
COPD Data Takeaways
What we found from our study into COPD
Policy Context
A lack of national COPD strategies: Only 16 out of 34 countries have a dedicated national strategy for COPD, with insufficient knowledge about the societal impacts of COPD being prevalent, in both medical staff and general population
Access and Care Coverage
Varying access to care: COPD care access and coverage varies significantly between countries, with a general need for better diagnostic conditions and stronger care referral pathways
Health System Characteristics
Specialists Needed: Relatively Low Respiratory Specialist Density in Countries. There is a significant relationship between higher respiratory specialist density and lower COPD hospitalisations.
Disease Burden
Varying societal cost: Large discrepancy in COPD societal cost can be explained by difference in prevalence, disease burden, and death rate between countries
Environmental Factors
Impact of indoor and outdoor environmental factors: Indoor air quality, in terms of housing conditions, and particulate matter levels may significantly affect COPD outcomes
COPD Steering Committee
The committee includes eight global COPD and health policy experts. The members were selected in order to balance clinical knowledge in COPD, patient organisation leadership, and expertise in health policy development and implementation.
Sir David Behan
Chair Health Education England, NHS, UK
Dr MeiLan Han, MD, MS
Professor of Medicine and Chief, Division of Pulmonary and Critical Care, University of Michigan Health Member of the GOLD Science Committee (2023)
Prof Dr Chen Rongchang
Deputy Director, Guangzhou Institute of Respiratory Health Guangzhou Medical University, China
Eric Sutherland
Senior Health Economist, OECD
Susanna Palkonen
Director, EFA; EU
Dr Ioanna Tsiligianni
Associate Professor in General Practice and Public Health, Faculty of Medicine, University of Crete Director, Clinic of Social and Family Medicine, University of Crete Chair, International Primary Care Respiratory Group COPD Right Care Strategy Team
Siân Williams
Chief Executive Officer, International Primary Care Respiratory Group
Tonya Winders
President, Global Allergy and Airways Patient Platform
Data scoring and normalisation
Country selection
Country selection in the COPD Index was informed by the importance of broad geographic representation, as well as the inclusion of countries able to represent the extent of the global COPD burden. A key inclusion criterion was the existence of a de jure or de facto universal health coverage scheme or statutory requirement for health insurance coverage for the national population. Notably, the United States was excluded for this reason.Data availability also determined the inclusion of countries in order to ensure as complete a dataset as possible. Specifically, we selected countries that regularly publicly report data that has been validated by recognised international or supranational institutions. The number of countries included ensured that the size of the dataset was neither too small (which would not be sufficient to identify trends) nor too large (which would present challenges such as heterogenous availability of data and increased complexity of analysis/results).
Empanelling of steering committee
A Steering Committee was established to validate the data and to lead decision-making regarding the design and content of the COPD Index. The committee includes eight global COPD and health policy experts. The members were selected in order to balance clinical knowledge in COPD, patient organisation leadership, and expertise in health policy development and implementation.
Preliminary literature review and desktop research
CIFS conducted a preliminary review of the literature regarding COPD to:
- Develop a robust understanding of the condition, including its varying definitions,reports on disease incidence and prevalence, risk factors, comorbidities, and overallimpact on individuals, societies, and health systems
- Identify usual clinical practice including diagnosis, standard of care, and stratification
- Identify health policies addressing COPD and associated risk factors
These insights then informed the identification of potentially relevant and viable indicators to be included in the Index, as well as potential sources of data.
Indicator proposal
Insights from the literature review supported the identification of indicators, i.e., qualitative and quantitative variables both directly and indirectly linked to patient health outcomes or impacting the ability of country health systems to manage and prevent COPD among country populations. We identified over 70 potential indicators that were broadly grouped into five categories:
- Policy Context
- Access and Care Coverage
- Health System Characteristics
- Disease Burden
- Environmental Factors
The indicator categories were structured to facilitate a multifaceted analysis of health system performance concerning COPD. As a result, COPD was examined not only as a clinical issue, but also as a disease impacted by public policy, health system design, comorbidities, and environmental factors.
Indicator validation
The draft indicators were prioritised and validated by the COPD Index Steering Committee through two rounds of review. Review of the indicator list first took place in a group workshop with the Steering Committee and then through individual written feedback.The process resulted in a final list of 45 indicators across the five indicator categories (see Appendix II for the list of indicators and category assignments). The exclusion and addition of indicators was based on an assessment of conceptual goodness of fit, data availability, and convertibility, i.e., whether the raw indicator data could be feasibly and meaningfully quantified in the index data model.
Data collection
Data collection commenced upon receiving validation of the prioritised list of indicators.Data collection took place between February and July 2024, and was conducted in several ways:
Desktop research
The research team identified and collected relevant data points from credible, publicly available sources such as the OECD, WHO, World Bank, and Eurostat databases as well as from peer-reviewed articles and reports and other official documents authored or approved by relevant public authorities in each country included in the index.
Expert questionnaire
To supplement desktop research, the research team designed a two-round questionnaire for the collection of a wide range of COPD specific information. The first round of the questionnaire was a mixed e-Delphi study, i.e., several sections exclusively contained questions and statements seeking the expert opinion of respondents to identity whether a degree of consensus existed among the group (e.g., “The burden of COPD in my country will place significantly more strain on my country’s health care system by 2035.”), whereas other questions sought to collect information of a purely factual nature (e.g., “Does your country have an action plan for COPD?”). The second round of the questionnaire focused solely on consensus-seeking questions.
The questionnaire forms were validated by the COPD Index Steering Committee before being submitted to respondents (see Appendix IV for the questionnaire form).The questionnaire was distributed online to over 300 potential respondents. The response period ran from April to August 2024.Respondents were selected based on the following occupational/professional criteria with the intention of maximising the diversity of responses:
- Policy Context
- Access and Care Coverage
- Health System Characteristics
- Disease Burden
- Environmental Factors
96 responses covering 24 COPD Index countries were received. Responses to the factseeking questions in the first round of the e-Delphi were used to support the calculation of selected indicator scores where data from existing sources were assessed as having a low level ofreliability or were unavailable. Qualitative data collected in the first round of the e-Delphi, such as examples of challenges to and opportunities for COPD diagnosis, prevention, and management identified by respondents were not used to calculate indicator or country scores. However, they were used to provide additional context for individual country profiles (See Appendix I)
Data scoring, normalisation, and weighting
Raw data from desktop research and the questionnaire were matched with each of the validated indicators and then organised into the approved indicator categories. To maximise conceptual fit with some indicators, several data points were also combined to create compound variables. Qualitative data points were quantified through the application of scorecards designed by the research team. The scorecards associated different point values with a set of standardised qualitative characteristics, for example, whether a country has a set of national guidelines for COPD care and, if so, what the general level of adherence to the guidelines is among health care professionals. Indicators based on qualitative data have scorecards with different maximum values; these values depend on the characteristics examined in the COPD Index.
Several qualitative indicators are dichotomised in the Index, i.e., 1 point may be assigned if a given condition is fulfilled, while a score of 0 is assigned if the condition is not fulfilled.Following the scoring of the qualitative data, all data points in the Index were normalised on a 0 to 10 scale using the min-max normalisation method. This approach allows for uniform analysis of many different types of data originally recorded on different scales.
On the normalised scale, a score of 10 always indicates a high level of fulfilment of the Index model’s criteria for a given indicator, while a score of 0 always indicates a low level of fulfilment. Minimum values were set at 0 (the theoretical minimum value of the raw dataset for each indicator), while maximum values were set at either the theoretical maximum (for example, 100 for raw data recorded as percentages), three standard deviations above the mean of the raw dataset for each quantitative indicator (in the case of data recorded as absolute values), or the maximum scorecard value for each qualitative indicator. In the case of extreme outliers in the dataset, the maximum value was set at the value of the greatest outlier.Following normalisation, country scores for each indicator category were averaged and then multiplied by 10 to produce a score out of 100 points. The purpose of the conversion to a 100-point scale on the category level is to reflect smaller differences in country scores that would otherwise be expressed as decimals.
Weighting
To produce an overall Index score, both individual indicators and indicator categories were weighted. The budget allocation approach was applied to identify indicator and category weights: Each member of the COPD Index Steering Committee was tasked with individually assigning weights to the components. The results of the individual inputs were shared with the Steering Committee during a group workshop in June 2024. CIFS then provided a proposal for the component weighting based on the group discussion, which was approved by the Steering Committee in June 2024. The following weights were applied to each indicator category when calculating the overall Index score for each country:
Policy Context
21%
Access and Care Coverage
20%
Health System Characteristics
22.5%
Disease Burden
15%
Environmental Factors
5%
Individual indicator weights are listed in the Indicator List in Appendix II.
The weighting approach emphasises elements of the Index that can be directly addressed by decisionmakers and key stakeholder groups. The Policy Context, Access and Care Coverage, Health System Characteristics, and Environmental Factors categories are therefore more heavily weighted in the Index because they include indicators that directly reflect factors which a country’s decisionmakers and stakeholders have control over. The Disease Burden category is less heavily weighted because it is linked to longer term health outcomes and indirect factors impacting COPD management and outcomes.
The assigned weights aim to reflect the Index’s primary ambition to motivate concerted action among health care stakeholders and the adoption of best practices that stand to improve health outcomes, health system performance, and ultimately address factors affecting prevention, prevalence and severity of COPD among populations. However, all indicator categories are fundamental to supporting a multifaceted analysis of countries’ management and prevention of COPD.
Analysis of results
The results yielded by the Index data model were compared using descriptive statistics on both the aggregate and individual country levels. Correlation between several indicators was also investigated to determine whether significant relationships exist between any variables. Additional relationships between country indicator data and data not used to calculate country scores were also explored to further contextualise country results and identify future potential areas of inquiry regarding COPD prevention, diagnosis, and management.
Important note on scoring in the COPD Index data model
The COPD Index is constructed as an ideal and abstract model for COPD care and management. This means that no country is expected to receive a perfect score in the Index. Crucially, the scoring system should not be understood as an expression of how objectively “good” or “bad” a country health system is at managing and preventing COPD.Rather, the overall Index score and category scores should be understood as indications of how well country health system COPD approaches and performance fit the ideal model proposed by the COPD Index. Scores also highlight best practices that country health systems could learn from and adapt to their local needs as well as demonstrate potential areas for improvement.
Limitations
The COPD Index is a powerful tool for identifying best practices in COPD care and analysing country health system performance against an ideal model for COPD care.However, the index is still bounded by several important limitations that must be kept in mind when exploring its insights and the data on which they are built.
Country selection
Country selection is in part informed by data availability, leading to the exclusion of some countries, primarily in Africa, that reduces the global representativeness of the Index results. Furthermore, the key inclusion criterion, i.e., the existence of a de jure or de facto universal health coverage scheme or statutory requirement for health insurance coverage for the national population in the countries led to the notable exclusion of the United States.
Data availability and accuracy
There are significant limitations on the availability, accessibility, and accuracy of COPD related data. In some cases, differing definitions of COPD and COPD stages may be used, rendering exact comparison between countries difficult and, in some cases, impossible.
Data fragmentation and a lack of harmonised rules for data reporting and access across the Index countries creates barriers to collecting COPD-specific information. In addition, several sources of information may be used to build the dataset for a single indicator. It is also crucial to note that country-reported data may, in some cases, reflect a tendency to underreport or misreport some data or outcomes.
Time lag and time series
The inclusion of various kinds of data in the Index has necessitated the use of data that has been collected at different time points. The Index makes use of the latest data wherever possible, but there is still variance in the time series within and across indicators. Differences in time series in the dataset are always indicated in the COPD Index sources.
Missing data and imputation
The inclusion of various kinds of data in the Index has necessitated the use of data that has been collected at different time points. The Index makes use of the latest datData points for some countries are not reported or non-existent. In such instances, data has been imputed by calculating the average value for the given indicator using the reporting countries’ data. Imputed values are indicated in the Index.a wherever possible, but there is still variance in the time series within and across indicators. Differences in time series in the dataset are always indicated in the COPD Index sources.
Data reliability and inferred data
The reliability of data collected for a small number of indicators is contested. These data points are linked to sources that provide a direct indication of how the country indicator should be scored, but other sources and contextual information indicate that the value may not be accurate. These data points are indicated in the COPD Index data model as having lower reliability. For a small number of selected qualitative indicators, scores have been inferred based on an assessment of identified sources that do not provide direct indications of how a country indicator should be scored but do provide sufficient contextual information. Inferred data points are also explicitly identified in the COPD Index data model.
Proxy indicators and conceptual accuracy
Several proxy indicators have been developed, in part based on input from the Steering Committee, to approximate data that are not currently directly reported. These proxy indicators may, in some cases, be based on a composite of several sources of data. Proxy indicators and their method of calculation are always listed in the Index.
Intra-country differences and generalisation
The whole-country approach of the COPD Index may risk generalising intra-country differences such as urban/rural divides and differences in regional approaches to care, especially in geographically large countries, federalised countries, and countries with highly devolved health care systems.
Policy implementation and lived experience
Nuances related to how countries’ policies and conditions for care access function may not be fully expressed, as the Index framework takes a country-wide approach that assesses reported system characteristics rather than the day-to-day operational environment. It is also crucial to note that the lived experiences of patients and health care providers are not directly assessed, as these are reliant on often highly variable and subjective reports that do not lend themselves to reliable cross-country comparisons in the context of a quantitative index data model.
COVID-19
Several data points may be influenced by the impact of the COVID-19 pandemic on health system capacity, performance, planning, and access, especially those recorded between 2020 and 2022.