Asthma economics: focusing on therapies that improve costly outcomes

Respiratory Disability in The Van Region Based on the Medical Board Reports

OBJECTIVES

Respiratory system disorders have an impact on daily living activities of subjects, resulting in disability. Data should be gathered on disability for health services. The present study aimed to review the records of patients with a respiratory disability report from our medical board, and contribute to the national and regional statistics on disability.

MATERIAL AND METHODS

We retrospectively reviewed sociodemographic characteristics, respiratory diseases and disability rates of the patients who were examined by the Chest Diseases Department during the Medical Board evaluations in our hospital between January 1st and July 1st, 2014.

RESULTS

Among 4285 patients whose applications were submitted to the medical board for evaluation, 401 (9.3%) had a respiratory disease. Of these patients, 163 were male, and 238 were female, with a mean age of 64.2 years. The most common diseases associated with disability were chronic obstructive pulmonary disease, asthma and sequelae tuberculosis. The disability rating for respiratory system was 80% in 24.9% of patients, 40% in 34.7% of patients, and 20% in 40.4% of patients. Patients with a respiratory disability report were also considered disabled by the departments of Physical Therapy and Rehabilitation, Cardiology and Eye diseases. There was a positive correlation between disability rating and age, and a negative correlation between forced expiratory volume in first second (FEV1) and oxigen saturation measured by pulse oximeter (SpO2) values (p= 0.002; p< 0.001; p< 0.001, respectively). Furthermore, smokers had a higher disability rating compared to non-smokers (p= 0.02).

CONCLUSION

In Turkey, we have limited number of studies about respiratory disability. We believe that the present study will help determination of the etiology of respiratory disability and contribute to any action on prevention of these disorders in our region.

Unrecognised psychopathology in patients with difficult asthma: major mental and personality disorders

BACKGROUND

Difficult asthma is a severe subgroup of asthma in which the main feature is uncontrollability of symptoms. Psychopathology is suggested to be prominent in patients with difficult asthma and considered important in its treatment; however, the evidence is scarce.

AIMS

To describe psychopathology in difficult asthma, both major mental and personality disorders, based on diagnostic interviews.

METHOD

This study was conducted in a specialised asthma care centre. A total of 51 patients with difficult asthma were diagnosed at the start of the treatment programme using two structured clinical interviews for both major mental (SCID-I) and personality disorders (SCID-II) according to DSM-IV-TR.

RESULTS

About 55% of the patients with difficult asthma had a psychiatric disorder of which 89% was undiagnosed and untreated before being interviewed. About 49% had a minimum of one major mental disorder of which the cluster of anxiety disorders was the most common cluster of major mental disorders, followed by somatoform disorders. About 20% were diagnosed with a personality disorder. Of the 10 patients with a personality disorder, 9 had an obsessive-compulsive personality disorder.

CONCLUSIONS

This study demonstrates that more than half of patients with difficult asthma had a psychiatric disorder of which 89% was unrecognised. This study highlights the importance of offering patients with difficult asthma a psychiatric diagnostic interview and/or a psychiatric consultation as part of their routine medical examination and provision of appropriate psychiatric treatment. Moreover, it highlights the urgency of further research into the role of psychopathology in the development of difficult asthma.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2015. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Asthma in children and adolescents: a comprehensive approach to diagnosis and management

Asthma is a chronic disease that has a significant impact on quality of life and is particularly important in children and adolescents, in part due to the higher incidence of allergies in children. The incidence of asthma has increased dramatically during this time period, with the highest increases in the urban areas of developed countries. It seems that the incidence in developing countries may follow this trend as well. While our knowledge of the pathophysiology of asthma and the available of newer, safer medication have both improved, the mortality of the disease has undergone an overall increase in the past 30 years. Asthma treatment goals in children include decreasing mortality and improving quality of life. Specific treatment goals include but are not limited to decreasing inflammation, improving lung function, decreasing clinical symptoms, reducing hospital stays and emergency department visits, reducing work or school absences, and reducing the need for rescue medications. Non-pharmacological management strategies include allergen avoidance, environmental evaluation for allergens and irritants, patient education, allergy testing, regular monitoring of lung function, and the use of asthma management plans, asthma control tests, peak flow meters, and asthma diaries. Achieving asthma treatment goals reduces direct and indirect costs of asthma and is economically cost-effective. Treatment in children presents unique challenges in diagnosis and management. Challenges in diagnosis include consideration of other diseases such as viral respiratory illnesses or vocal cord dysfunction. Challenges in management include evaluation of the child’s ability to use inhalers and peak flow meters and the management of exercise-induced asthma.

Efficacy of theophylline plus salmeterol/fluticasone propionate combination therapy in patients with asthma

OBJECTIVE

To compare the efficacy of theophylline plus salmeterol/fluticasone propionate combination product (SFC) with SFC plus placebo in asthmatic patients.

METHODS

In this randomized, stratified, parallel-group study, 325 patients were randomized to receive either 200 mg theophylline plus 50/250 μg SFC or placebo tablet plus 50/250 μg SFC twice daily for 24 weeks. Outcome variables included the level of asthma control (assessed by the Asthma Control Test) and the number of patients experiencing ≥1 exacerbations during the 24-week treatment period. Testing of lung function as well as measurement of the levels of inflammatory markers in induced sputum was performed.

RESULTS

There were significantly fewer patients with ≥1 asthma exacerbation in the theophylline plus SFC group (29.6%) when compared with the SFC plus placebo group (46.9%) (p = 0.004). Theophylline plus SFC improved the FEF(25-75%) value, which indicates enhanced small airway function, to a greater extent than SFC plus placebo (66.9 ± 18.8% and 57.4 ± 17.6%, respectively; p < 0.001). A significant decrease in eosinophil count and concentration of eosinophil cationic protein in induced sputum was also seen in the theophylline plus SFC group when compared with the SFC plus placebo group (4.1 ± 2.2% and 6.3 ± 2.7%, 63.6 ± 39.5 μg/L and 89.4 ± 45.6 μg/L, respectively; all p < 0.01).

CONCLUSION

The combination of theophylline plus SFC may provide greater protection against asthma exacerbations, and its administration is accompanied by significant improvements in small airway function and airway inflammation.

An Innovative Approach to Partnership in Asthma Care

Control of asthma symptoms is fundamental to asthma management. New asthma guidelines suggest that asthma control, for most patients, can be achieved through education aimed at improving management. This includes providing written asthma management plans from health care providers; instructions on proper inhaler use; education about early signs and symptoms of asthma, and how to respond appropriately; medication regimens that prevent misuse of medications; follow-up medical care for long-term management of asthma after any hospitalization due to asthma; and assistance with assessing and reducing exposure to environmental risk factors in patients’ home, school, and work environments. The Shared Medical Appointment (SMA) is a group appointment model that has the potential to change the management of children with asthma for the better by offering benefits to both the health care provider and the patient. The SMA for children with asthma and their caregivers is an innovative 90-minute medical appointment in which 4 to 9 patients and their parents are seen at the same time in a supportive group setting. In addition to having concerns and questions about asthma addressed, the SMA provides education on medications, monitoring symptoms, and the demonstration and distribution of devices. Supportive materials are provided and discussed and education is emphasized through open group discussion and the participation of both caregiver and child. A brief, focused medical examination is also conducted. In this study, the charts of children with asthma who attended an SMA were reviewed for specific asthma-related clinical outcomes as defined by the National Heart, Lung, and Blood Institute’s, Expert Panel Review-3 (NHLBI-EPR-3) in the 4-month period prior to attending an SMA and during the 4-month period after attending an SMA. The results showed that asthma education provided in an SMA, as compared with a usual appointment, resulted in a significant positive impact on asthma-related outcomes in meeting NHLBI-EPR-3 guidelines for asthma management.

Economic value of home-based, multi-trigger, multicomponent interventions with an environmental focus for reducing asthma morbidity a community guide systematic review

CONTEXT

A recent systematic review of home-based, multi-trigger, multicomponent interventions with an environmental focus showed their effectiveness in reducing asthma morbidity among children and adolescents. These interventions included home visits by trained personnel to assess the level of and reduce adverse effects of indoor environmental pollutants, and educate households with an asthma client to reduce exposure to asthma triggers. The purpose of the present review is to identify economic values of these interventions and present ranges for the main economic outcomes (e.g., program costs, benefit-cost ratios, and incremental cost-effectiveness ratios).

EVIDENCE ACQUISITION

Using methods previously developed for Guide to Community Preventive Services economic reviews, a systematic review was conducted to evaluate the economic efficiency of home-based, multi-trigger, multicomponent interventions with an environmental focus to improve asthma-related morbidity outcomes. A total of 1551 studies were identified in the search period (1950 to June 2008), and 13 studies were included in this review. Program costs are reported for all included studies; cost-benefit results for three; and cost-effectiveness results for another three. Information on program cost was provided with varying degrees of completeness: six of the studies did not provide a list of components included in their program cost description (limited cost information), three studies provided a list of program cost components but not a cost per component (partial cost information), and four studies provided both a list of program cost components and costs per component (satisfactory cost information).

EVIDENCE SYNTHESIS

Program costs per participant per year ranged from $231-$14,858 (in 2007 U.S.$). The major factors affecting program cost, in addition to completeness, were the level of intensity of environmental remediation (minor, moderate, or major), type of educational component (environmental education or self-management), the professional status of the home visitor, and the frequency of visits by the home visitor. Benefit-cost ratios ranged from 5.3-14.0, implying that for every dollar spent on the intervention, the monetary value of the resulting benefits, such as averted medical costs or averted productivity losses, was $5.30-$14.00 (in 2007 U.S.$). The range in incremental cost-effectiveness ratios was $12-$57 (in 2007 U.S.$) per asthma symptom-free day, which means that these interventions achieved each additional symptom-free day for net costs varying from $12-$57.

CONCLUSIONS

The benefits from home-based, multi-trigger, multicomponent interventions with an environmental focus can match or even exceed their program costs. Based on cost-benefit and cost-effectiveness studies, the results of this review show that these programs provide a good value for dollars spent on the interventions.

Physical activity participation among adult Nevadans with self-reported asthma

OBJECTIVE

This study looked at physical activity patterns among adults (≥ 18 years old) with self-reported asthma living in Nevada and investigated how physical inactivity is associated with asthma prevalence.

METHODS

We examined data from the 2009 Nevada Behavioral Risk Factor Surveillance System. Different physical activity measures among individuals were compared by asthma status.

RESULTS

Among 3840 respondents, 13.9% and 9.0% of them self-reported lifetime and current asthma, respectively. Significantly higher proportions of people with lifetime (12.9%) and current (17.7%) asthma did not engage in regular physical activity or exercise than those without lifetime (7.0%) and current (6.8%) asthma (p < .01). Over 30% of the respondents with asthma had no leisure-time physical activity compared with about 23% of those without asthma (p < .05). Moreover, these findings were statistically significant after adjusting for body mass index as well as other common sociodemographic variables. It was also found that asthmatic people spent significantly less time on moderate and vigorous physical activity than their nonasthmatic counterparts (223 minutes/week vs. 283 minutes/week for moderate physical activity; 214 minutes/week vs. 281 minutes/week for vigorous physical activity; p < .001). More than half of the respondents with asthma and close to half of those without asthma did not meet the current physical activity recommendation.

CONCLUSION

A majority of adults with self-reported asthma living in Nevada are physically inactive. It appears that physical inactivity is associated with an increased prevalence of asthma.

The effect of family routines on care for inner city children with asthma

This article provides the results of a study utilizing baseline data from the School-Based Asthma Therapy Trial, an ongoing comprehensive school-based intervention for urban children. We examined the effect of family routines as measured by the Asthma Routines Questionnaire on asthma care measures of trigger control and medication adherence, as well as on parental quality of life. We found that families with more asthma routines had better adherence with preventive medications (r = .36) and less exposure to environmental triggers (r = -.22). These findings suggest that assisting families in developing routines around asthma care might improve preventive care for urban youth.

The relationship of household routines to morbidity outcomes in childhood asthma

PURPOSE

The major purpose of this study was to explore the effect of routines on asthma management and morbidity outcomes for children with asthma and their parents.

DESIGN AND METHODS

This study is a secondary data analysis in a sample of 150 children, which was originally used for an intervention study.

RESULTS

Parents who had fewer routines in their homes had lower quality-of-life scores and higher burden of asthma scores when compared to parents in households with more routines. More routines were associated with improved asthma morbidity outcomes as measured by nurse rankings of routines.

PRACTICE IMPLICATIONS

Assisting families to establish routines may result in improved asthma morbidity outcomes.

Targeting airway inflammation in asthma: current and future therapies

Asthma is a chronic inflammatory disease of the airway that requires long-term antiinflammatory therapy. Inhaled corticosteroids (ICSs) are recommended for first-line treatment of persistent disease, but not all patients achieve asthma control even when these agents are used in high doses and in combination with other medications, including a long-acting beta(2)-agonist or a leukotriene modifier. Such patients may require additional therapy. As information about asthma pathophysiology and inflammatory phenotypes continues to increase, and additional antiinflammatory options become available, it may be possible to target antiinflammatory therapy to various aspects of the disease and consequently to improve the treatment of patients with inadequate responses to standard ICS-based therapy. Several novel antiinflammatory therapies are in different stages of clinical development. The most clinically advanced of these is omalizumab, a recombinant humanized monoclonal antibody that specifically targets IgE and is indicated for patients with moderate-to-severe asthma caused by allergies. Omalizumab has demonstrated efficacy in patients with moderate-to-severe asthma and documented evidence of allergen sensitivity. Other key therapy options in clinical development either target proinflammatory cytokines (eg, interleukin-4 and tumor necrosis factor-alpha) or inflammatory cells (eg, T-helper type 2 cells and eosinophils). This review provides an overview of the current and future approaches targeting airway inflammation in patients with asthma.

A Holy Grail of asthma management: toward understanding how long-acting beta(2)-adrenoceptor agonists enhance the clinical efficacy of inhaled corticosteroids

There is unequivocal evidence that the combination of an inhaled corticosteroid (ICS) -- i.e. glucocorticoid -- and an inhaled long-acting beta(2)-adrenoceptor agonist (LABA) is superior to each component administered as a monotherapy alone in the clinical management of asthma. Moreover, Calverley and colleagues (Lancet 2003, 361: 449-456; N Engl J Med 2007, 356: 775-789) reporting for the 'TRial of Inhaled STeroids ANd long-acting beta(2)-agonists (TRISTAN)' and 'TOwards a Revolution in COPD Health (TORCH)' international study groups also demonstrated the superior efficacy of LABA/ICS combination therapies over ICS alone in the clinical management of chronic obstructive pulmonary disease. This finding has been independently confirmed indicating that the therapeutic benefit of LABA/ICS combination therapies is not restricted to asthma and may be extended to other chronic inflammatory diseases of the airways. Despite the unquestionable benefit of LABA/ICS combination therapies, there is a vast gap in our understanding of how these two drugs given together deliver superior clinical efficacy. In this article, we review the history of LABA/ICS combination therapies and critically evaluate how these two classes of drugs might interact at the biochemical level to suppress pro-inflammatory responses. Understanding the molecular basis of this fundamental clinical observation is a Holy Grail of current respiratory diseases research as it could permit the rational exploitation of this effect with the development of new 'optimized' LABA/ICS combination therapies.

The limitations of severe asthma: the results of a European survey

BACKGROUND

Asthma has a major impact on patients' lives, and severe asthma is a serious health problem. The European Federation of Allergy and Airways Diseases Patients' Associations (EFA) commissioned a telephonic survey to capture the views of people who are living with severe asthma in Europe.

METHODS

A total of 1300 patients from the UK, France, Germany, Spain and Sweden who reported a previous diagnosis of asthma and reported receiving asthma medication took part in the survey.

RESULTS

Most patients reported having limitations to their lifestyles as a consequence of the symptoms of severe asthma. Almost 70% of patients reported that physical activity was restricted, 50% were restricted from having pets, 30% from taking holidays, and many felt their job prospects were limited. In addition, 50% of this population of patients were not convinced that guideline goals were being achieved, although it is not clear as to the cause of this failing. Patients indicated that they want treatments that are fast-acting, long-lasting and have minimal side effects, and they were optimistic for the development of effective therapies over the next 5 years.

CONCLUSIONS

The results of this study provide insight into how greatly patients' lives are affected by severe asthma.

Medication compliance and disease exacerbation in patients with asthma: a retrospective study of managed care data

BACKGROUND

Compliance with asthma medications probably results in improved outcomes, but few studies have examined this relationship.

OBJECTIVE

To examine the association between medication compliance and exacerbation in asthmatic patients.

METHODS

Retrospective analysis of a managed care database. The 97,743 participants (aged 6-99 years; mean age, 32.8 years) had asthma and prescriptions for controller medications. Compliance with the index medication (the first controller medication prescribed) was measured using 2 methods: medication possession ratio (MPR), calculated for 365 days after the index date, and number of prescriptions for each index medication. Exacerbation was defined as 1 or more emergency department visits or hospitalizations within 1 year of the index date. Multivariate models were used to determine the odds of exacerbation based on relative compliance for each definition of compliance.

RESULTS

Based on the median MPR, more-compliant patients were less likely to experience exacerbation than less-compliant patients (odds ratio, 0.94; 95% confidence interval, 0.91-0.97; P < .001). Using the 75th percentile MPR, risk of exacerbation was even smaller (odds ratio, 0.89; 95% confidence interval, 0.86-0.92; P < .001). All the cutoff points for compliance (> or = 2 through > or = 6 prescriptions) demonstrated significantly less exacerbations in more-compliant vs less-compliant patients after adjusting for covariates. As the criteria for compliance became more stringent, more-compliant patients became increasingly less likely to have an exacerbation vs less-compliant patients.

CONCLUSION

More-compliant asthmatic patients were significantly less likely to experience exacerbation than less-compliant asthmatic patients. These findings demonstrate the importance of improving medication compliance among asthmatic patients to impact outcomes.

What are the best estimates of pediatric asthma control?

PURPOSE OF REVIEW

To evaluate asthma outcome measures in the face of the variable nature of asthma. The outcome measures are divided into objective and subjective clinical measures, humanistic measures such as quality of life, and costs of asthma control.

RECENT FINDINGS

Objective measures of asthma include those traditionally used such as spirometry, peak expiratory flow rate, and airway hyperresponsiveness. Recently, more attention has been geared towards markers of inflammation including exhaled nitric oxide and sputum eosinophils. Subjective measures of asthma control include patient-derived parameters such as number of wheezing episodes, nocturnal symptoms, exercise-induced symptoms, short-acting beta-agonist use, steroid bursts, emergency-department visits, and hospitalizations. Asthma-related quality of life is related to asthma morbidity, and patients with better baseline quality of life have improved outcomes. Asthma-related costs include direct costs mostly comprised of hospitalizations and emergency-room visits, and indirect costs including school absenteeism.

SUMMARY

There is no ideal outcome measure for evaluating pediatric asthma control, but each of these outcome measures must be used together to evaluate a patient at each outpatient visit. Patient-centered measures of asthma control must also be further incorporated into office visits for improved asthma management.