The patient-level economic burden of COPD in China: a systematic review of determinants and consequences.

Background: Chronic obstructive pulmonary disease (COPD) imposes a substantial patient-level economic burden in China, including direct medical expenditure, indirect productivity losses, out-of-pocket payments, and catastrophic health expenditure. However, evidence on the magnitude, determinants, and consequences of this burden remains fragmented across regions, healthcare settings, and study designs. Methods: We conducted a systematic review of empirical studies reporting patient-level economic burden related to COPD in China. Searches were conducted in international and Chinese databases from inception to December 31, 2025. Observational and quasi-experimental studies were eligible if they reported direct costs, indirect costs, catastrophic health expenditure, out-of-pocket expenditure, financial hardship, or policy-related economic outcomes. Due to substantial heterogeneity in study designs and outcome measures, findings were synthesized narratively. Results: Twenty-five studies published between 2002 and 2025 were included. Direct medical costs, particularly hospitalization expenditure related to acute exacerbations of COPD (AECOPD), were the most frequently reported component of burden. Severe exacerbations, greater disease severity, longer hospital stay, intensive care use, mechanical ventilation, comorbidities, poor medication adherence, and anxiety/depression were consistently associated with higher healthcare costs. Indirect costs from productivity loss and work impairment frequently equaled or exceeded direct medical expenditure. Socioeconomic inequality was also evident, with lower-income and rural households experiencing disproportionately higher catastrophic health expenditure and out-of-pocket burden. Policy-related studies suggested that integrated payment reform and comprehensive hospital reform were associated with fewer avoidable readmissions and lower patient out-of-pocket costs, although causal interpretation remains limited by study design and potential confounding. Conclusion: COPD imposes a substantial and multidimensional patient-level economic burden in China. The evidence identifies AECOPD-related hospitalization as a major cost driver and highlights the importance of indirect costs, socioeconomic inequality, and healthcare financing structures. Strategies aimed at preventing severe exacerbations, improving long-term disease management, expanding outpatient reimbursement, and strengthening financial protection for vulnerable populations may help mitigate COPD-related economic burden. Further longitudinal and policy-evaluation studies using standardized economic outcome measures are needed. Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251043025.