Chronic obstructive pulmonary disease (COPD) is a major global cause of mortality, with complications that extend beyond the lungs. Among these, cardiac rhythm disturbances are particularly significant. Atrial fibrillation and ventricular arrhythmias occur more frequently in COPD patients than in the general population. In moderate to severe COPD cases, atrial fibrillation affects between 20% and 30% of individuals, with higher rates during acute flare-ups. Ventricular irregularities, including nonsustained tachycardia, are often seen in those with severe oxygen deficiency or right-sided heart stress. The underlying mechanisms involve chronic low oxygen levels, which heighten sympathetic nervous system activity and disrupt electrical stability in the heart. Pulmonary hypertension and structural changes in the right ventricle contribute to atrial stretching and scarring. Systemic inflammation and autonomic dysfunction further impair normal conduction. Additionally, certain medications used in COPD, such as beta-agonists and theophylline, may worsen these cardiac effects.
Beyond clinical severity, COPD imposes a substantial financial strain on healthcare systems. In the United States, annual costs are estimated at $31 billion and are projected to double by 2029, primarily due to increased use of medical services. However, the additional economic impact of arrhythmias in this population and the benefits of early detection through ambulatory ECG monitoring—such as Holter, event, mobile telemetry, or implantable loop recorders—remain poorly understood. This real-world study aimed to quantify the incremental healthcare resource utilization (HCRU) and costs linked to arrhythmias in COPD patients and evaluate how early detection via continuous cardiac monitoring influences outcomes.
The analysis used data from Merative MarketScan (2006–2024), a claims database covering over 200 million insured individuals across commercial, Medicare, and Medicaid plans. The study included adults aged 18 or older diagnosed with COPD using ICD-9 or ICD-10 codes, who had no prior arrhythmia diagnosis in the 12 months before the index date. Patients with diabetes were excluded to maintain cohort consistency. Three comparison groups were analyzed: COPD patients with arrhythmias versus those without; monitored patients with arrhythmias versus monitored patients without; and monitored versus unmonitored patients both diagnosed with arrhythmias. Monitoring included various ambulatory ECG technologies used for diagnostic purposes.
Each patient’s observation window spanned 24 months—12 months before and after the index date. For arrhythmia patients, the index date was the first confirmed diagnosis; for others, a pseudo-index date was assigned to match the time distribution from COPD diagnosis. Comorbidity burden was assessed using the Elixhauser Comorbidity Index (ECI), and baseline COPD medication regimens were recorded. Entropy balancing was applied to adjust for differences in age, sex, region, insurance type, and ECI across groups.
Outcomes included hospital admissions, 30-day readmissions, emergency room visits, and annual healthcare costs, adjusted to 2024 dollars. Statistical models using Tweedie and negative binomial distributions were employed to analyze cost and utilization data.
From a pool of 1.2 million COPD patients without diabetes, three matched sub-cohort pairs were formed. Results showed that arrhythmia presence was consistently linked to higher healthcare use and costs. In the first comparison, 71,585 arrhythmic COPD patients (mean age 68, 56% female) had 2.15 times the hospitalization rate, 2.32 times the readmission rate, and 1.89 times the ER visit rate per 1,000 patients per year compared to 261,188 non-arrhythmic patients (mean age 59, 61% female). Annual per-patient costs were $39,867 in the arrhythmia group versus $24,867 in the control group, with hospitalization-specific costs at $25,123 versus $17,500. On the day of arrhythmia diagnosis, average costs reached $16,297, compared to $2,186 in those without arrhythmias.
In the second comparison, among monitored patients, those with arrhythmias (n=24,423, mean age 67, 59% female) had 1.82 times the hospitalization rate, 1.87 times the readmission rate, and 1.49 times the ER visit rate compared to monitored patients without arrhythmias (n=16,406, mean age 59, 69% female). Annual costs were $35,504 versus $23,878, and hospitalization costs were $23,081 versus $17,135. Diagnosis-day costs were $13,118 versus $2,261.
In the third comparison, monitored arrhythmic patients (n=24,423) had 0.71 times the hospitalization rate, 0.63 times the readmission rate, and 0.83 times the ER visit rate compared to unmonitored arrhythmic patients (n=47,162, mean age 68, 55% female). Annual costs were lower in the monitored group ($35,504 vs. $42,403), with hospitalization costs at $23,081 versus $26,888. Diagnosis-day costs were $13,118 versus $17,943.
These findings highlight the substantial clinical and economic burden of arrhythmias in COPD. The data support the value of early detection through ambulatory ECG monitoring, which is associated with reduced hospitalizations, emergency visits, and overall costs. This suggests that identifying silent or intermittent arrhythmias before they lead to acute events can improve outcomes and lower financial strain. However, the study’s retrospective design limits access to clinical details like lung function or medication adherence. Also, by excluding patients who died within 12 months, results may underestimate total resource use.
In conclusion, arrhythmias significantly increase healthcare utilization and expenses in COPD patients. Early monitoring appears to mitigate these effects, offering a strategy to enhance care and reduce costs. These insights can guide clinical guidelines and policy decisions. Future prospective research should confirm these results and define optimal monitoring protocols for broader adoption.
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Real world evidence on health care resource utilization and economic burden of arrhythmias in patients with COPD
Introduction n nChronic obstructive pulmonary disease (COPD) is a leading cause of death worldwide, with systemic consequences extending beyond respiratory impairment [1]. Among these, cardiac arrhythmias are the most prevalent and clinically relevant. Atrial fibrillation (AF) and ventricular arrhythmia are more common in patients with COPD than in the general population [2]. Estimates place AF prevalence at 20%–30% in moderate-to-severe COPD, with an increased incidence during acute exacerbations. Ventricular ectopy and nonsustained ventricular tachycardia were observed, particularly in patients with severe hypoxemia or right heart strain. Notably, the pathophysiology of arrhythmias in COPD involves several processes. First, chronic hypoxia increases sympathetic tone and alters electrophysiological stability [3]. Second, pulmonary hypertension and right ventricular remodeling promote atrial stretching and fibrosis, particularly on the right side of the heart [4]. Third, systemic inflammation and autonomic imbalance further destabilize electrical conduction [5]. Finally, medications such as beta-agonists and theophylline may exacerbate these effects [6]. n nIn addition to its clinical consequences, COPD has a substantial economic burden. Furthermore, in recent years, the recognition of risk factors such as arrhythmias has emerged. COPD directly costs the United States healthcare system an estimated $31 billion annually, and is expected to double by 2029, driven mainly by increased healthcare resource utilization (HCRU) [7,8]. However, the incremental economic burden of arrhythmias in patients with COPD and the impact of early detection using ambulatory cardiac monitoring services remain unknown. The need for evidence evaluating the potential benefits of early detection of arrhythmias via diagnostic ambulatory ECG monitoring (e.g. Holter, AEM, LTCM, MCT, ILR) among patients with COPD is critical, as healthcare systems transition towards value-based care and risk-sharing agreements. n nThis real-world analysis aimed to address this gap by quantifying the incremental HCRU and costs associated with arrhythmia in COPD and assessing the impact of early detection through ambulatory electrocardiogram (ECG) monitoring services. These findings have implications for policymakers, payers, and clinical guideline developers regarding risk stratification and policy development. n nMethods n nIn this retrospective observational study, data were sourced from Merative MarketScan (2006–2024), a closed claims dataset covering over 200 million unique patients with data of insured employees and their dependents across commercial, Medicare, and Medicaid insurance plans. This dataset focuses on payers and includes fully adjudicated reimbursed payment information for medical and pharmacy claims. n nAll patients in this study were adults (age ≥18 years) diagnosed with COPD, with at least two claims for COPD identified using clinical codes—ICD-10 code J44 and ICD-9 codes 493.2 and 491.2—and were arrhythmia-naïve at the time of initial COPD diagnosis (Figure 1). Patients were classified as arrhythmia naïve if they had no diagnostic or procedure codes for any cardiac arrhythmia in the 12-months prior to the index date. Patients with diabetes (type 1 or 2) were excluded from the study to preserve cohort homogeneity because patients with COPD and diabetes have distinct care patterns that could confound associations between monitoring and downstream utilization and costs. We examined three subcohort pairs of patients with COPD (Table 1), in which patients either had a diagnosed arrhythmia or underwent ambulatory ECG monitoring for arrhythmias, including event (CPT: 93268-93272), Holter monitors (CPT: 93225-93227), cardiac mobile telemetry (CPT: 93229, 93241, 93245), implantable loop recorders (CPT: C1749, G2066, L8686, 0650T, 33285, 33286, 33289, 93229, 93285, 93291, 93298, 93731, 93732, 93724), and long-term continuous monitors (CPT: 0296T-0298T, 93242-93244, 93246-93248). In this study, ambulatory ECG monitoring strategies are used for diagnostic surveillance and while modalities differ in wear time and implant status, they share the same clinical purpose of advancing time-to-detection to inform management. The three pairs comprised: patients with COPD and arrhythmias (target) versus patients with COPD without arrhythmias (control) (Comparison 1); patients with COPD who were monitored and diagnosed with arrhythmias (target) versus patients with COPD who were monitored but never diagnosed with arrhythmias (control) (Comparison 2), subgroups from Comparison 1; and patients with COPD and arrhythmias who underwent monitoring (target) versus patients with COPD and arrhythmias who were never monitored (control), subgroups from Comparison 2. n nThe study period for the cohort spanned January 2006 to August 2024, but was over a 24-month period for each patient during which they were required to have continuous enrollment – 12 months before and after the index date. For patients diagnosed with arrhythmia, the index date was the initial diagnosis (corresponding to the visit or encounter where monitor data were reviewed and diagnosis confirmed). Costs on this date reflect bundled charges for interpretation (e.g. read-fees for extended monitoring or device interrogations), diagnostic follow-up (e.g. echocardiography or technician time for device programming) and immediate management (e.g. initial medication dispensing or device related billing if an ILR is implanted). For those without arrhythmia, the index date was assigned as conditional random value, post-COPD diagnosis, ensuring the distribution of time from COPD diagnosis to the selected dates matched the distribution of time from COPD diagnosis to arrhythmia diagnosis in the corresponding arrhythmia cohort. This approach using a “pseudo-index” date captures similar billing patterns for routine follow-up visits and ensures that the distribution of time from COPD to index date is the same for both patients with an arrhythmia and those without an arrythmia. n nThe comorbidity burden was assessed for each patient using the Elixhauser Comorbidity Index (ECI) and stratified into five categories from negligible to severe [9,10]. Bronchodilator treatment regimen for COPD including combinations of the long acting (LABA, LAMA) and the short acting (SABA, SAMA) was determined for each patient at baseline. n nEntropy balancing (EB) [11] is a statistical technique that employs a mathematical optimization approach to balance the distribution of covariates across different groups or treatments in an observational study. Rather than estimating treatment probabilities as with propensity score methods like inverse proportional treatment weighting (IPTW), EB achieves covariate balance in one step by imposing constraints at different moments (means, variances and skewness) directly through a constrained optimization framework [13-14]. n nIn this study, EB was used to reweight each pair of sub-cohorts on the baseline variables of age, sex, region, insurance type, and ECI, subject to the mean and variance of each covariate. n nThe HCRU in terms of all-cause hospital admissions, readmissions within 30 days, and emergency room (ER) visits were determined over the 24-month study period for each patient, and their reweighted values were compared within each pair and reported in units per 1000 patients per year. The total cost of care for each patient was adjusted for inflation and reported as 2024 dollars paid to the providers. The costs for each sub-cohort were calculated as the total cost per patient per year (PPPY), and were reported overall and by service location. Outcomes were analyzed using generalized linear models, and effect estimates were created using Tweedie distributions for costs and negative binomial distributions for hospitalization, readmission, and ER rates. n nResults n nFrom a cohort of 1.2 million adult patients diagnosed with COPD and without diabetes, three matched pairs of sub-cohorts were constructed. Table 1 presents the baseline distribution of all covariates. Table 2 compares the standardized mean differences (SMDs) for each covariate before and after empirical balancing (EB), demonstrating improved covariate balance post-weighting. Table 3 displays baseline utilization patterns of COPD regimens for the first cohort pair. n nAlthough all differences in baseline drug utilization between patients with and without arrhythmia were statistically significant, within-cohort comparisons showed that post-index utilization was either stable or increased relative to pre-index levels. This suggests that, under an intention-to-treat framework, prescribing clinicians did not modify COPD treatment based on the presence of arrhythmia. n nAcross all comparisons, patients with arrhythmia and those who were unmonitored consistently incurred significantly higher rates of hospitalization, readmission, and emergency room visits, as well as greater total and hospitalization-specific costs (Table 4). n nIn the first comparison, a target cohort of 71,585 patients with COPD and arrhythmias (56% female; mean age, 68 years) were compared with a reweighted comparator cohort of 261,188 patients with COPD without arrhythmias (61% female; mean age, 59 years). Patients with COPD and arrhythmias experienced 2.15 (95% CI: 2.13–2.18) times the hospitalization rate, 2.32 (95% CI: 2.25–2.39) times the readmission rate, and 1.89 (95% CI: 1.87–1.90) times the ER visit rate per 1000 patients per year, compared with patients with COPD without arrhythmias. Total annual healthcare costs PPPY were higher among patients with COPD and arrhythmias ($39,867) than among those without arrhythmias ($24,867). Annual hospitalization-related PPPY costs were also higher in the arrhythmia group ($25,123 vs. $17,500). On the day patients with COPD were diagnosed with arrhythmias, the average total healthcare cost per patient was $16,297, compared with $2,186 among patients with COPD without arrhythmias (Figure 2). n nIn the second comparison that included monitored patients with COPD in both the target and comparator cohorts, a similar result was observed between the patients with and without arrhythmia. The 24,423 monitored patients with COPD and arrhythmias (59% female; mean age, 67 years) were compared with 16,406 monitored patients with COPD without arrhythmias (69% female; mean age, 59 years). Patients with COPD and arrhythmias had 1.82 times (95% CI: 1.77–1.88) the hospitalization rate, 1.87 times (95% CI: 1.69–2.06) the readmission rate, and 1.49 times (95% CI: 1.45–1.52) the ER visit rate per 1000 patients per year, compared with patients with COPD without arrhythmias. Total annual healthcare costs PPPY were higher among patients with COPD and arrhythmias ($35,504) than among patients with COPD without arrhythmias ($23,878), as were hospitalization-related costs ($23,081 vs $17,135). On the day patients with COPD were diagnosed with arrhythmias, the average total healthcare cost per patient was $13,118, compared with $2,261 among patients with COPD without arrhythmias (Figure 3). n nIn the third comparison, 24,423 monitored patients with COPD and arrhythmias (59% female; mean age, 67 years) were compared with 47,162 unmonitored patients with COPD and arrhythmias (55% female; mean age, 68 years). Monitored patients with COPD and arrhythmias had 0.71 (95% CI: 0.69–0.72) times the hospitalization rate, 0.63 (95% CI: 0.60–0.67) times the readmission rate, and 0.83 (95% CI: 0.82–0.85) times the ER visit rate per 1000 patients per year, compared with unmonitored patients with COPD and arrhythmias. Total annual healthcare costs PPPY were lower among monitored patients with COPD and arrhythmias ($35,504) than among unmonitored patients with COPD and arrhythmias ($42,403), as were hospitalization-related costs ($23,081 vs $26,888). On the day monitored patients with COPD were diagnosed with arrhythmias, the average total healthcare cost per patient was $13,118, compared with $17,943 among unmonitored patients with COPD and arrhythmias (Figure 4). n nDiscussion n nThis study provides a comprehensive real-world assessment of the clinical and economic burden of arrhythmias in patients with COPD. Using large-scale claims data from the Merative MarketScan database, we analyzed more than 4 million patients to quantify the impact of arrhythmias on HCRU and costs. The use of real-world evidence (RWE) from administrative claims data enables inclusion of a diverse, representative patient population and reflects actual national healthcare delivery across different payer types. n nOur findings demonstrate that the presence of arrhythmias in patients with COPD is associated with markedly higher rates of hospitalization, ER visits, readmissions, and total costs of care. These results align with existing literature showing that arrhythmias are common in COPD and contribute to increased morbidity [2]. However, our study extends this knowledge by providing robust cost data and highlighting the potential value of early arrhythmia detection through ambulatory ECG monitoring. n nOne of the most significant contributions of this analysis is the demonstration that ambulatory ECG monitoring is associated with reduced acute-care utilization in patients with COPD and arrhythmias. Monitored patients had fewer hospitalizations and ER visits and incurred lower overall costs than their unmonitored counterparts. These findings support the hypothesis that early identification and management of silent or paroxysmal arrhythmias—many of which remain undetected until a cardiovascular related event (e.g. inpatient admission, 30-day readmission, ED visit) occurs—can improve patient outcomes and reduce the financial burden [8]. n nArrhythmias in COPD complicate clinical management in several ways. They limit the safe use of beta-blockers to those that are specifically cardioselective, create uncertainty about symptom origin (dyspnea from cardiac versus pulmonary causes), and increase the complexity of anticoagulation strategies, particularly in older adult patients with polypharmacy and fall risk [6,14,15]. Arrhythmias can precipitate or worsen heart failure, a frequent and serious comorbidity in this population. n nThe high prevalence of arrhythmias among patients with COPD, combined with rising costs of acute care, underscores the need for proactive monitoring strategies. Our data suggest that ambulatory ECG monitoring may not only reduce clinical deterioration but also generate cost savings by reducing acute healthcare utilization. n nAs a retrospective analysis of claims data, this study has limitations, including the lack of clinical details such as pulmonary function test results or medication adherence. However, the strength of this study lies in its ability to capture large-scale national utilization trends. We included individuals with ≥12 months of continuous post-index enrollment; by excluding those who died earlier, generalizability is limited to people surviving ≥12 months and estimates may underestimate all-cause utilization and costs if early mortality or end-of-life care intensity differs between cohorts. n nConclusions n nThis RWE study reinforces the significant clinical and economic impact of arrhythmias in COPD and identifies early ambulatory ECG monitoring as a potentially effective intervention to reduce this burden. These findings should inform both clinical practice and policy decisions regarding surveillance and management strategies for high-risk patients with COPD. Future prospective studies should validate these observations and define optimal monitoring protocols to support widespread implementation. n nTransparency n nDeclaration of funding n nThis study was sponsored by iRhythm Technologies. n nDeclaration of financial/other interests n nBW, KB, and EH are employees of and receive equity from iRhythm Technologies. The study sponsor as an institution had no role in the conduct of the study. There are no other competing interests to declare. n nPeer reviewers on this manuscript have received an honorarium from JME for their review work but have no other relevant financial relationships to disclose. n nAuthor Contributions. PR, RN, BW, KB, and EH were involved in the conception and design of the study. PR, RN, JP, and HS were involved in the acquisition, analysis, and interpretation of the data. PR drafted the manuscript. RN, JP, HS, BW, KB, EH critically reviewed the manuscript for important intellectual content. All authors approved the final version of the manuscript and agreed to be accountable for all aspects of the work and ensuring accuracy. PR is the guarantor of the work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. n nPrevious presentations n nPart of this study was presented at the 2025 American Thoracic Association’s International Conference in San Francisco, CA, on May 16-21, 2025. n nData availability statement n nThe data that support the findings of this study are available from the corresponding author, PR, upon reasonable request.