Economic burden of asthma in Singapore

Cost-effectiveness analysis of budesonide/formoterol SMART therapy versus salmeterol/fluticasone plus as-needed SABA among patients ≥12 years with moderate asthma from the Chinese societal perspective

Objectives: To evaluate the cost-effectiveness of budesonide/formoterol reliever and maintenance therapy compared with salmeterol/fluticasone plus salbutamol as reliever therapy for asthma patients ≥12 years from the societal perspective in China.Methods: A Markov model was developed with three health states (non-exacerbation, exacerbation, and death) with a lifetime horizon. The exacerbation rates were obtained from a prospective cohort study conducted in Chinese asthma patients. Healthcare resources utilization data were estimated based on current clinical asthma management guidelines. Asthma-related mortality, cost input and utility values were derived from public database and literature. Model robustness was assessed with one-way sensitivity and probabilistic sensitivity analyses.Results: Compared with salmeterol/fluticasone plus salbutamol, budesonide/formoterol reliever and maintenance therapy led to fewer exacerbation events (13.6 vs. 15.9) and 0.0077 quality-adjusted life years (QALY) gain at an additional cost of ¥196.38 over lifetime. The base case incremental cost-effectiveness ratio (ICER) was ¥25,409.98 per QALY gained. The variables that had most impact on the model output included drug costs and medication adherence. At a willingness-to-pay threshold of ¥257,094/QALY (3 times of gross domestic product per capita in China in 2022), the probability of budesonide/formoterol maintenance and reliever therapy being cost-effective versus salmeterol/fluticasone plus as-needed salbutamol was 83.00%.Conclusion: From the societal perspective, budesonide/formoterol reliever and maintenance therapy is likely to be a cost-effective option compared with salmeterol/fluticasone plus as-needed salbutamol for Chinese asthma patients ≥12 years.

SABA prescriptions and asthma management practices in Singapore: results from a cross-sectional, observational SABINA III study

OBJECTIVES

To evaluate asthma characteristics and treatment patterns, including short-acting β2-agonist (SABA) prescriptions, in primary and specialist care in the Singapore cohort of the SABA use IN Asthma (SABINA III) study.

DESIGN

Cross-sectional, observational study.

SETTING

Multicentre study conducted at five sites across Singapore.

METHODS

In patients with asthma (aged ≥12 years), data on demographics, disease characteristics and asthma treatment prescriptions were collected using electronic case report forms. Patients were classified by investigator-defined asthma severity (guided by 2017 Global Initiative for Asthma recommendations) and practice type (primary/specialist care).

RESULTS

Of the 205 patients analysed (mean (SD) age, 53.6 (16.8) years; female, 62%), 55.9% were enrolled by specialists and 44.1% by primary care physicians. Most study patients (80.5%) had moderate-to-severe asthma (86.0% in specialist care and 74.4% in primary care). In the 12 months before study enrolment, 18.0% of patients experienced ≥1 severe exacerbation. Asthma was well or partly controlled in 78.0% of patients. Overall, 17.1% of all patients were overprescribed SABA (≥3 SABA canisters/year) in the preceding 12 months, and overprescription was greater in specialist versus primary care (26.3% vs 5.6%). Only 2.9% of patients were prescribed SABA monotherapy, while 41.0% received SABA in addition to maintenance therapy. Among the latter, 40.5% were overprescribed SABA. Overall, a higher percentage of patients prescribed ≥3 SABA canisters (vs 0-2 SABA canisters) were assessed as having uncontrolled asthma during the study visit (42.9% vs 17.6%). Maintenance therapy in the form of inhaled corticosteroids (ICS) or ICS/long-acting β2 agonist fixed-dose combinations were prescribed to 14.1% and 84.9% of patients, respectively, in the 12 months before enrolment.

CONCLUSIONS

In this Singapore cohort, ~17% of all patients and more than 40% of patients prescribed SABA in addition to maintenance therapy were overprescribed SABA. These findings emphasise the need to align clinical practices with the latest evidence-based treatment recommendations.

TRIAL REGISTRATION

NCT03857178.

Approach to difficult-to-treat asthma in childhood: a narrative review

ABSTRACT

Asthma is a major chronic disease affecting children, and children with difficult-to-treat asthma account for a disproportionate share of resource utilisation and healthcare costs. This review presents a comprehensive and up-to-date overview of the treatment strategies in difficult-to-treat paediatric asthma. Mimickers of asthma must first be ruled out, and the diagnosis confirmed with objective tests whenever possible. The effect of comorbid conditions such as obesity, smoking, other atopic conditions and psychosocial factors on asthma control and severity should be considered. Treatment can then be optimised by implementing personalised strategies, including the use of appropriate drug delivery devices and adherence monitoring. Biologics can be an alternative treatment option for selected patients but should not be a substitute for addressing poor adherence. Many patients with difficult-to-treat asthma may not have severe asthma, and the physician should work with patients and families to achieve good asthma control via an individualised approach.

The increasing burden of asthma acute care in Singapore: an update on 15-year population-level evidence

BACKGROUND

In Singapore, there is currently scarce population-based research informing the recent trends of asthma-related healthcare burdens. In this study, we investigated the past 25-year trends of asthma-related hospitalisations, emergency department (ED) visits and deaths in Singapore and projected the future burdens from 2023 to 2040.

METHODS

We acquired annually-measured data from the Singapore Ministry of Health Clinical and National Disease Registry, containing 25-year asthma-related hospitalisation and death rates as well as 15-year ED visit rates. We conducted change-point analysis and generalised linear modelling to identify time intervals with stable trends and estimate asthma-related healthcare utilisation and mortality rates. To project future asthma-related burdens, we developed a probabilistic model which combined projections of future population size with the estimated rate outcomes from the last stable period.

RESULTS

Our results show that the asthma hospitalisation rate in Singapore had remained at approximately 80 episodes per 100,000 from 2003 to 2019 and are likely to grow by 1.7% each year (95% CI: 0.7, 5.0%), leading to a total of 163,633 episodes from 2023 to 2040 which corresponds to an estimated $103,075,820 based on 2022 USD. Besides, Singapore's asthma-related ED visit rate was 390 per 100,000 in 2019 and is expected to decline by 3.4% each year (95% CI: - 5.8, 0.0%), leading to a total of 208,145 episodes from 2023 to 2040 which corresponds to USD$15,053,795. In contrast, the 2019 asthma-related mortality rate in Singapore was approximately 0.57 per 100,000 and is likely to stay stably low (change per year: -1.3, 95% CI: - 11.0, 4.3%). Between 2023 and 2040, Singapore's estimated total number of asthma-related deaths is 638 episodes.

CONCLUSIONS

Currently, the burden of asthma acute care in Singapore is high; Singapore's asthma-related hospitalisation and ED visit rates are relatively higher than those of other developed economies, and its asthma admission rate is expected to increase significantly over time, possibly indicating excess resource use for asthma. The established national asthma programme in Singapore, together with recent efforts in reinforcing primary care at the national level, provides opportunities to reduce avoidable asthma admissions.

Medical resource utilization and the associated costs of asthma in China: a 1-year retrospective study

BACKGROUND

Despite evidence that severe and poorly controlled asthma are associated with more clinical unmet needs and intensive utilization of healthcare resources, limited data is available on severe asthma expenditure in China. The study aimed to assess Medical Resource Utilization (MRU) costs of asthma and explore the cost drivers in order to better understand the economic burden of the Chinese population suffered from asthma.

METHODS

A retrospective analysis was conducted using Chinese sampled national claim database. Patients aged 6 years and above with primary diagnosis of asthma and asthma-related medical visit/hospitalization during 2015 were included. Medication was used as a proxy per the GINA and China guideline to identify asthma severity (i.e. mild, moderate, and severe). multiple linear regression model was conducted to identify MRU costs drivers.

RESULTS

7,254 patients diagnosed with asthma were included: 4,529 (62.4%), 2,200 (30.3%), and 525 (7.2%) had mild, moderate, and severe asthma, respectively. On average, each severe patient spent 6,782 Chinese Yuan (CNY) on asthma treatment and had 57.0% hospitalization rate during the year, 3.9- and 4.4-fold of the average of overall population (P < 0.001 for both). The proportion of patients experiencing exacerbation significantly higher in the severe asthma population (66.5%; P < 0.001) compared to mild (30.0%) and moderate (16.8%) groups. In subgroup with 1,660 samples had annual consecutive data, severe patients had annual cost of CNY 8,314 and 52.2% hospitalization rate. 13% of severe patients who had frequent severe exacerbation (≥ 2 events) experienced the highest annual average cost CNY 23,037, P < 0.001) whereas children aged from 6 to 14 with a lower annual cost of CNY 1,094.2, 1,660.2 and 3,020.2 for mild, moderate, and severe patients respectively. The multiple model identified degree of severity, control status, complications, age, and live region as independent drivers of MRU costs.

CONCLUSIONS

Chinese asthma patients bear heavy economic burden. Severe asthma associated with higher MRU (mainly from hospitalization) and costs compared with mild to moderate asthma in China. More efforts should be devoted to the control of the disease severity and complication as the main drivers of asthma cost.

Impact of Guideline-Based Asthma Treatment on Health Services Use in Singapore Before and During COVID-19 Outbreak

Introduction

To date, the role of standard asthma care in reducing asthma-related health services use (HSU) during the COVID-19 pandemic remains unclear. This study examined the impact of guideline-based asthma treatment on the use of asthma-related emergency department (ED) visits, polyclinic visits (total visits and urgent visits characterized by nebuliser use) before and during the pandemic.

Methods

Data from April 2017 to October 2020 was obtained from the National University Health System, one of the three healthcare clusters in Singapore. Using generalized linear models, we estimated the joint effects of the ratio of preventer to reliever dispensations (PRR) and COVID-19 on asthma-related ED visits per hospital per month, total asthma-related polyclinic visits and asthma-related urgent polyclinic visits per clinic per month.

Results

Findings show that before the onset of COVID-19, for every 0.5 unit increase in PRR, the number of asthma-related ED visits and urgent polyclinic visits decreased by 12.9% (95% CI: -13.0% to -12.9%) and 6.8% (95% CI: -6.9% to -6.7%), respectively, whereas total asthma-related polyclinic visits increased by 1.0% (95% CI: 0.9% to 1.0%). During the pandemic, a 0.5 unit increase of PRR decreased the number of asthma-related ED visits, urgent and total polyclinic visits by 16.9% (95% CI: -17.0% to - 16.9%), 9.3% (95% CI: -9.5% to -9.2%) and 0.7% (95% CI: -0.8% to -0.7%), respectively.

Discussion

These findings suggest that regardless of the COVID-19 pandemic, an increase in PRR consistently reduced the frequency of asthma-related urgent and emergent care, although it barely influenced routine asthma follow-up visits.

Real-world data to measure and improve quality of asthma care

In this issue of the Annals, the paper “Association of quality-of-care indicators with asthma outcomes: An observational study for asthma care in Singapore” by Lam et al.1 illustrates the use of real-world data to generate real-world evidence in the area of asthma care in Singapore.

Association of quality-of-care indicators with asthma outcomes: A retrospective observational study for asthma care in Singapore

Introduction

Asthma guidelines have advocated for the use of quality-of-care indicators (QCIs) in asthma management. To improve asthma care, it is important to identify effective QCIs that are actionable. This study aimed to evaluate the effect of the presence of 3 QCIs: asthma education, Asthma Control Test (ACT) and spirometry testing on the time to severe exacerbation (TTSE).

Method

Data collected from the SingHealth COPD and Asthma Data Mart (SCDM), including asthma patients managed in 9 SingHealth polyclinics and Singapore General Hospital from January 2015 to December 2020, were analysed. Patients receiving Global Initiative for Asthma (GINA) Steps 3-5 treatment, with at least 1 QCI recorded, and at least 1 severe exacerbation within 1 year before the first QCI record, were included. Data were analysed using multivariate Cox regression and quasi-Poisson regression models.

Results

A total of 3849 patients in the registry fulfilled the criteria. Patients with records of asthma education or ACT assessment have a lower adjusted hazard ratio (HR) for TTSE (adjusted HR=0.88, P=0.023; adjusted HR=0.83, P<0.001). Adjusted HR associated with spirometry is higher (adjusted HR=1.22, P=0.026). No QCI was significantly associated with emergency department (ED)/inpatient visits. Only asthma education and ACT showed a decrease in the number of exacerbations for multivariate analysis (asthma education estimate: -0.181, P<0.001; ACT estimate: -0.169, P<0.001). No QCI was significant for the number of exacerbations associated with ED/inpatient visits.

Conclusion

Our study suggests that the perfor-mance of asthma education and ACT was associated with increased TTSE and decreased number of exacerbations, underscoring the importance of ensuring quality care in clinical practice.

Beyond direct costs: individual and societal financial burden of asthma in young adults in a Danish nationwide study

INTRODUCTION

As a common chronic disease seen across all ages, asthma has the potential to incur high societal and individual costs from both direct healthcare costs and loss of productivity. Most previous studies use smaller, selected populations to assess the cost of asthma, possibly reducing generalisability. We, therefore, aimed to assess the total, nationwide economic burden of asthma by severity from both an individual and a societal perspective.

METHODS

The annual cost of asthma was assessed in a Danish nationwide cohort of patients aged 18-45 during 2014-2016 as excess healthcare costs, loss of income and welfare expenditure compared with controls (matched 1:4) using national registries. Asthma severity was defined as mild-to-moderate (steps 1-3 or step 4 without exacerbations) or severe (step 4 with exacerbations or step 5).

RESULTS

Across 63 130 patients (mean age 33, 55% female), the annual excess cost of asthma compared with controls was predicted to €4095 (95% CI €3856 to €4334) per patient. Beyond direct costs related to treatment and hospitalisations (€1555 (95% CI €1517 to €1593)), excess indirect costs related to loss of income (€1060 (95% CI €946 to €1171)) and welfare expenditure (eg, sick pay and disability pensions) (€1480 (95% CI €1392 to €1570)) were seen. Crude pooling of excess costs resulted in an annual societal cost of €263 million for all included patients.Severe asthma (4.5%) incurred 4.4 times higher net costs (€15 749 (95% CI 13 928 to €17 638)) compared with mild-to-moderate disease (€3586 (95% CI €3349 to €3824)). Furthermore, patients with severe asthma experienced an annual loss of income of €3695 (95% CI €4106 to €3225) compared with controls.

CONCLUSION

In young adults with asthma, a significant societal and individual financial burden of disease was seen across severities. Expenditure was mainly driven by loss of income and welfare utilisation, rather than direct healthcare costs.

The Impact of Obesity in Saudi Arabia: Healthcare Resource Use and Costs Associated with Obesity-Related Complications

INTRODUCTION

Saudi Arabia has a high prevalence of obesity, which increases the risk of individuals experiencing multiple chronic complications. Only a few publications highlight the healthcare costs of obesity-related complications (ORCs) in Saudi Arabia.

METHODS

A micro-costing approach was used to estimate the healthcare costs associated with 10 ORCs. Experienced clinicians in public and private practice across different geographical regions in Saudi Arabia were asked to estimate healthcare resource use associated with each ORC, and estimated unit costs were obtained from hospital administrators. Estimated overall annual costs per patient were calculated as a weighted average of separate public and private sector costs.

RESULTS

Individuals in Saudi Arabia with any single ORC incurred overall average annual healthcare costs of 2165-7558 US dollars (USD). Heart failure, chronic kidney disease, dyslipidemia, and type 2 diabetes (T2D) were the most costly complications, mainly driven by monitoring and/or pharmacological treatment costs. In contrast, asthma, hypertension, and angina were the least costly complications. Costs in private healthcare were higher than in public healthcare; the largest differences (2359-2793 USD) were noted for dyslipidemia, T2D, and osteoarthritis, mainly explained by differences in pharmacological treatment costs.

CONCLUSIONS

These data suggest that ORCs result in a considerable financial burden to the healthcare system, and highlight the substantial cost savings that could be achieved by preventing or delaying the occurrence of ORCs in Saudi Arabia.

Healthcare utilisation and health-related quality of life of severe asthma patients in Singapore

BackgroundNotwithstanding unequivocal consensus on the disproportionate effect of severe asthma (SA) on asthma morbidity, healthcare utilisation, quality of life, work impairment and socioeconomic burden, the burden of SA patients in Singapore has not been appraised.ObjectivesTo determine the burden of disease and extent of quality of life impairment in SA patients in Singapore.MethodsA cross-sectional analysis of SA patients seen in Singapore General Hospital (2020-2021) to investigate emergency healthcare utilization, oral corticosteroid (OCS) burden and health-related quality of life (HRQoL) with primary endpoint EuroQoL-5 Dimension three-level (EQ-5D-3L) scores. The empirical measurement properties of the EQ-5D utility index in SA were comprehensively assessed through multivariate regression analyses.ResultsA total of 336 SA patients were recruited, 51.2% of SA patients had at least one acute healthcare resource utilization during the previous year, with 25.6% of patients having an emergency healthcare visit to the hospital. Overall mean (SD) EQ-5D-3L and EQ-5D-3L utility scores in SA patients were 6.22 (1.51) and 0.77 (0.30), respectively. EQ-5D utility scores were 0.14 lower in uncontrolled vs controlled asthma and 0.09 lower in the presence of severe exacerbation, whereas barely changed by maintenance OCS dose and airflow limitation.ConclusionSA patients were found to have high disease burden, high healthcare resource utilization and OCS use, low biologics usage, poor HRQoL and utility in comparison with other chronic diseases.

Severe asthma in children: An official statement from Saudi Pediatric Pulmonology Association

In Saudi Arabia, the prevalence of pediatric asthma ranges between 8% and 25%. However, there are no sufficient data regarding severe asthma in childhood in Saudi Arabia. Therefore, a task force has been formed by the Saudi Pediatric Pulmonology Association which is a subsidiary group of the Saudi Thoracic Society and consists of Saudi experts with well-respected academic and clinical backgrounds in the fields of pediatric asthma as well as other respiratory diseases to write a consensus on definitions, phenotypes, and pathophysiology, evaluation, and management. To achieve this, the subject was divided into various sections, each of which was assigned to at least 2 experts. Without a central literature review, the authors searched the literature using their own strategies. To reach an agreement, the entire panel reviewed and voted on proposed findings and recommendations.