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Cost-analysis of four treatment strategies in the management of moderate-to-severe COPD: an application of non-parametric bootstrapTo evaluate and compare direct healthcare costs associated with four alternative treatment strategies in patients with moderate-to-severe chronic obstructive pulmonary disease (COPD) in Italy.Data on resource consumption were collected alongside a 12-month, multinational, randomised, double-blind, placebo-controlled trial that compared four treatment strategies: budesonide/formoterol combination in a single inhaler, budesonide as a single therapy, formoterol as a single therapy and placebo. Economic analysis was conducted on patients from 6 European countries. The prospective was that of the Italian NHS; national charges and prices were used to evaluate resource consumption. Average total cost per patient per year and its confidence intervals were assessed in each group with a bootstrap percentile method. Differences between groups were tested with bootstrap-Z method.Overall sample included 272 patients (mean age=65.27 years) equally distributed in four treatment groups. Patients treated with budesonide/formoterol combination in a single inhaler tended to consume less healthcare resources in terms of hospital days and emergency room visits than patients treated with single drugs. Average total cost per patient per year was € 1,762.70 in the group treated with budesonide/formoterol combination in a single inhaler, € 1,436.10 in the budesonide group and € 2,725.10 in the formoterol group. There was no statistically significant difference among the alternative treatment strategies.Empirical evidence demonstrates superior clinical efficacy of treatment with the budesonide/formoterol combination in a single inhaler as compared with mono-components budesonide or formoterol. Present cost analysis suggests that its introduction in the management of patients with moderate-to-severe chronic obstructive pulmonary disease doesn't increment consumption of healthcare resources in confront of single drug alternatives.