Cost saving of switching to equivalent inhalers and its effect on health outcomes

Relationship between proton pump inhibitor prescription and asthma exacerbation among adult patients: a self-controlled case series study

Proton-pump inhibitors (PPI) are empirically used to treat asthma symptoms such as cough; however, the effectiveness of PPI on asthma exacerbation has not been well studied. We aimed to evaluate the relationship between PPI use and asthma exacerbation using a large administrative claims database in Japan. We conducted a self-controlled case series using the JMDC Claims Database (JMDC, Inc., Tokyo, Japan). The cases included adult patients with asthma who were prescribed PPI and experienced at least one outcome event between January 2015 and December 2019. The primary outcome was the composite outcome of hospital admissions and unscheduled outpatient clinic visits due to asthma exacerbation. We also conducted stratified analyses based on PPI generation, the presence of gastroesophageal reflux disease (GERD), asthma severity, and the number of allergic comorbidities. A total of 7379 eligible patients were included in the study. PPI prescription was associated with a decrease in the composite outcomes (incidence rate ratio, 0.90; 95% confidence interval, 0.87-0.93). However, PPI prescriptions did not affect the outcomes of hospital admissions (incidence rate ratio, 1.34; 95% confidence interval, 0.86-2.10). Stratified analyses based on PPI generation, the presence of GERD, asthma severity (except for severe asthma), and the number of allergic comorbidities yielded consistent results. PPI use was associated with a moderate decrease in asthma exacerbation, regardless of the patient profile. However, this effect was not as strong as the prevention of hospital admissions, and outcome events were not prevented in patients with severe asthma.

Pharmacoequity and Biologics in the Allergy Clinic: Providing the Right Care, at the Right Time, Every Time, to Everyone

Pharmacoequity refers to equity in access to pharmacotherapy for all patients and is an especially large barrier to biologic agents in patients with allergic diseases. Value-based care models can prompt clinicians to address social determinants of health, promoting pharmacoequity. Pharmacoequity is influenced by numerous factors including socioeconomic status, which may be mediated through insurance status, educational attainment, and access to specialist care. In addition to lower socioeconomic status, race and ethnicity, age, locations isolated from care systems, and off-label indications for biologic agents all constitute barriers to pharmacoequity. Whereas pharmaco-inequity is more apparent for expensive biologics, it also affects many other allergy treatments including epinephrine autoinjectors and SMART for asthma. Current programs aimed at alleviating cost barriers are imperfect. Patient assistance programs, manufacturer-sponsored free drug programs, and rebates often increase the complexity of care, with resultant inequity, particularly for patients with lower health literacy. Ultimately, single silver-bullet solutions are elusive. Long-term improvement instead requires a combination of research, advocacy, and creative problem-solving to design more intelligent and efficient systems that provide timely access to necessary care for every patient, every time.

Cost-related medication nonadherence in adults with COPD in the United States 2013-2020

BACKGROUND

Cost-related medication nonadherence (CRN) is associated with poor prognosis among patients with chronic obstructive pulmonary disease (COPD), a population that requires long-term treatment for secondary prevention. In this study, we aimed to estimate the prevalence and sociodemographic characteristics of CRN in individuals with COPD in the US.

METHODS

In a nationally representative survey of US adults in the National Health Interview Survey (2013-2020), we identified individuals aged ≥18 years with a self-reported history of COPD. Cross-sectional study.

RESULTS

Of the 15,928 surveyed individuals, a weighted 18.56% (2.39 million) reported experiencing CRN, including 12.50% (1.61 million) missing doses, 13.30% (1.72 million) taking lower than prescribed doses, and 15.74% (2.03 million) delaying filling prescriptions to save costs. Factors including age < 65 years, female sex, low family income, lack of health insurance, and multimorbidity were associated with CRN.

CONCLUSIONS

In the US, one in six adults with COPD reported CRN. The influencing factors of CRN are multifaceted and necessitating more rigorous research. Targeted interventions based on the identified influencing factors in this study are recommended to enhance medication adherence among COPD patients.

Methods to assess COPD medications adherence in healthcare databases: a systematic review

BACKGROUND

The Global Initiative for Chronic Obstructive Lung Disease 2023 report recommends medication adherence assessment in COPD as an action item. Healthcare databases provide opportunities for objective assessments; however, multiple methods exist. We aimed to systematically review the literature to describe existing methods to assess adherence in COPD in healthcare databases and to evaluate the reporting of influencing variables.

METHOD

We searched MEDLINE, Web of Science and Embase for peer-reviewed articles evaluating adherence to COPD medication in electronic databases, written in English, published up to 11 October 2022 (PROSPERO identifier CRD42022363449). Two reviewers independently conducted screening for inclusion and performed data extraction. Methods to assess initiation (dispensing of medication after prescribing), implementation (extent of use over a specific time period) and/or persistence (time from initiation to discontinuation) were listed descriptively. Each included study was evaluated for reporting variables with an impact on adherence assessment: inpatient stays, drug substitution, dose switching and early refills.

RESULTS

160 studies were included, of which four assessed initiation, 135 implementation and 45 persistence. Overall, one method was used to measure initiation, 43 methods for implementation and seven methods for persistence. Most of the included implementation studies reported medication possession ratio, proportion of days covered and/or an alteration of these methods. Only 11% of the included studies mentioned the potential impact of the evaluated variables.

CONCLUSION

Variations in adherence assessment methods are common. Attention to transparency, reporting of variables with an impact on adherence assessment and rationale for choosing an adherence cut-off or treatment gap is recommended.

The impact of unsupervised and unconsented switch of inhalers in patients with controlled asthma - A targeted literature review

Inhaler combination formulations consisting of an inhaled corticosteroid (ICS) (fluticasone propionate) and a long-acting β2 agonist (salmeterol xinafoate) are indicated as maintenance treatments for patients with asthma and/or for selected patients with chronic obstructive pulmonary disease. The emergence of generic equivalents to branded inhalers is expected to offer economic edge/savings; however, some may argue that cost advantages offered by generic inhalers may be offset by worsening outcomes due to improper inhaler use, reduced adherence, and consequently worse disease control. To understand how unsupervised and unconsented switch of dry-powder inhalers and/or metered-dose inhalers affects clinical and humanistic outcomes in asthma, comprehensive searches of Embase and MEDLINE were conducted to identify research articles published in the English language since 2011. Patients with asthma of any age who underwent an unsupervised and unconsented switch from an ICS/long-acting β2 agonist to another (brand-to-generic or brand-to-brand) for non-medical reasons were the target of this research. Relevant outcomes included asthma control, medication adherence, and healthcare resource utilization. In total, 11 studies were identified for review (ten non-interventional and one post hoc); cohorts ranged from 19 to 42,553 patients. Six studies indicated that unsupervised and unconsented inhaler switch had a negative impact on asthma control; six studies indicated reduced medication adherence post-switching; and five studies reporting healthcare resource utilization showed it was unchanged or increased post-switching. Findings from this targeted review support concerns that unsupervised and unconsented inhaler switch has a largely negative impact on asthma-associated outcomes. Additional studies are warranted to further explore unsupervised and unconsented switch in asthma.

Barriers to green inhaler prescribing: ethical issues in environmentally sustainable clinical practice

The National Health Service (NHS) was the first healthcare system globally to declare ambitions to become net carbon zero. To achieve this, a shift away from metered-dose inhalers which contain powerful greenhouse gases is necessary. Many patients can use dry powder inhalers which do not contain greenhouse gases and are equally effective at managing respiratory disease. This paper discusses the ethical issues that arise as the NHS attempts to mitigate climate change. Two ethical issues that pose a barrier to moving away from metered-dose inhalers are considered: patients who decline an inhaler with a smaller carbon footprint and increased cost. I argue that while a patient is not morally justified in refusing a more environmentally sustainable inhaler due to the expected harms, a doctor may still prescribe a metered-dose inhaler if they believe that switching without consent might undermine trust or substantially worsen the patient's health. Turning to cost, I argue that the imperative to combat climate change means the NHS should accept small increased financial costs for lower carbon inhalers, even though this provides no additional direct benefit for the patient. I then go on to consider the implications of the preceding analysis for policy and practice. I argue for a policy that minimises the impact of inhalers on the climate by advocating for a principle of environmental prescribing and explore decision-making in practice. While the arguments here pertain primarily to inhalers, the discussion has broader implications for debates around healthcare's responsibility to be environmentally sustainable.

Strategies commercially-insured families use to manage the cost of asthma care: a qualitative interview study

OBJECTIVE

Families affected by asthma report difficulty adhering to care regimens because of high medication costs, coupled with increased cost sharing required by some insurance plans. To inform efforts to support adherence, we conducted a qualitative study to explore how families manage asthma care costs.

METHODS

We conducted phone interviews with commercially-insured, US adults (n = 59) who had asthma and/or a child with asthma. Our purposive sample included participants with high- and low/no-deductible health plans. We analyzed data using thematic content analysis to identify strategies for managing asthma care costs and to assess strategies' implications for adherence.

RESULTS

Our analysis identified four overarching strategies for managing asthma care costs. First, participants used prevention strategies to avoid costly acute care by minimizing exposure to asthma triggers and adhering strictly to preventive medication regimens. Second, participants used shopping strategies to reduce costs, including by comparing medication prices across pharmacies, using medication coupons or free samples, and switching to lower-cost medications. Third, budgeting strategies involved putting aside funds, including in tax-exempt health savings accounts, or taking on debt to pay for care. Finally, some participants sought to reduce costs by forgoing recommended care, including by skipping medication doses or replacing prescribed medications with alternative therapies.

CONCLUSION

Commercially-insured families use a wide range of strategies to manage asthma care costs, with both positive and negative implications for adherence. Our typology of asthma cost management strategies can inform insurance redesign and other interventions to help families safely reduce costs and maximize adherence to recommended care.

Real-World Impact of Nonclinical Inhaler Regimen Switches on Asthma or COPD: A Systematic Review

BACKGROUND

Switching inhaler regimens can be driven by poor disease control but also by nonclinical factors, such as cost and environmental impact. The consequences of switching for nonclinical reasons are largely unclear.

OBJECTIVE

To systematically review the real-world consequences of switching inhaler regimens for nonclinical reasons in asthma and/or chronic obstructive pulmonary disease patients.

METHODS

Embase, MEDLINE, EBM Reviews, and EconLit were searched to November 21, 2020. Conference searches and reference checking were also performed. Real-world studies of asthma and/or chronic obstructive pulmonary disease patients undergoing a switch in inhaler regimen for any reason apart from clinical need were included. Two reviewers screened and extracted data. Key outcomes included symptom control, exacerbations, and patient-doctor relationships.

RESULTS

A total of 8,958 records were screened and 21 studies included. Higher-quality (matched comparative) studies were prioritized. Five matched studies (6 datasets) reported on symptom control: 5 datasets (n = 7,530) with unclear patient consent reported improved disease control following switching, and 1 dataset (n = 1,648) with non-consented patients reported significantly worsened disease control. Three matched studies (5 datasets, n = 10,084) reported on exacerbation rate ratios; results were heterogeneous depending on the definition used. Two studies (n = 137) reported that switching inhaler regimens could have a negative impact on the doctor-patient relationship, especially when the switches were non-consented. Study quality was generally low.

CONCLUSIONS

Switching inhaler regimens is a complex issue that can have variable clinical consequences and can harm the patient-doctor relationship. Limited high-quality evidence was identified, and study designs were heterogeneous. A robust framework is needed to guide the personalized switching of inhalers.

[Reduction of greenhouse gas emissions by inhaler choice in the therapy of asthma and COPD patients]

BACKGROUND

The global warming potential of inhaled medication depends on the applied inhaler. Pressurised metered dose inhalers (pMDI) contain green-house gases (GHG) and are associated with a 10 to 40 times higher CO₂-footprint than GHG-free dry-powder inhalers (DPI).

AIM

Feasibility and relevance of prescription conversion from pMDI to DPI were investigated in a pulmonology outpatient clinic regarding the CO₂-footprint and the economic costs under real-world conditions.

METHODS

Based on exemplary therapy regimens of different intensity for three patients, the annual CO₂-footprint and daily therapy costs were investigated. The effect of converting from pMDI to DPI on CO₂-footprint and economic costs were calculated on the basis of prescriptions during the first quarter of 2020 compared to the first quarter of 2021.

RESULTS

Conversion of a pMDI-based inhalative therapy of exemplary asthma and COPD patients to a DPI-based therapy saved between 115 and 480 kg CO₂ equivalents (CO₂e) per year and patient depending on intensity of therapy and GHG used. A total of 184,297 and 164,165 defined daily doses (DDD) were prescribed by the clinic for 2,610 (January-March 2020) and 2,693 (January-March 2021) patients, respectively. The proportion of DPI prescribed increased from 49 to 78% of total inhaler prescriptions. The increase in prescriptions for single-agent inhaled corticosteroids from 19.8 to 74.1% of total inhaler prescriptions was particularly striking. Due to the conversion, emissions were reduced by 35,000 to 40,000 kg CO₂e between January-March 2020 and January-March 2021 in our clinic. During the same period, there was no increase in costs compared to nationwide costs. The relation of prescribed DPI and pMDI in the same period did not change among the pulmonologists in Saxony nor nationwide in Germany. If all ambulant pulmonologists in Germany would prescribe 75% DPI, CO₂-emissions could be reduced by 11,650 tonnes CO₂e per quarter and 46,600 tonnes CO₂e per year, respectively.

CONCLUSION

The type of inhalers can be converted from pMDI to DPI in a real-world setting. Thereby, a significant reduction of GHG emissions is possible without increased costs.

The environmental impact of inhalers for asthma; a green challenge and a golden opportunity

The propellants in metered-dose inhalers (MDIs) are powerful greenhouse gases, which account for approximately 13% of the NHS's carbon footprint related to the delivery of care. Most MDI use is in salbutamol relievers in patients with poorly controlled disease. The UK lags behind Europe in this regard, with greater reliance on salbutamol MDI and correspondingly greater greenhouse gas emissions; roughly treble our European neighbours'. There has been a broad switch towards MDIs in asthma treatment UK over the last 20 years to reduce financial costs, such that the treatment for two-thirds of asthma patients in the UK is dominated by salbutamol MDI. Strategies that replace overuse of reliever MDIs with regimes emphasising inhaled corticosteroids have the potential to improve asthma control alongside significant reductions in greenhouse gas emissions. Real-world evidence shows that once-daily long-acting combination dry-powder inhalers can improve compliance, asthma control and reduce the carbon footprint of care. Similarly, maintenance and reliever therapy (MART) which uses combination reliever and inhaled steroids in one device (usually a dry-powder inhaler) can simplify therapy, improve asthma control, and reduce greenhouse gas emissions. Both treatment strategies are popular with patients, most of whom would be willing to change treatment to reduce their carbon footprint. By focussing on patients who are currently using high amounts of salbutamol MDI, and prioritising inhaled steroids via dry-powder inhalers, there are golden opportunities to make asthma care in the UK more effective, safer, and greener.

Switching to the Dry-Powder Inhaler Easyhaler®: A Narrative Review of the Evidence

Asthma and chronic obstructive pulmonary disease (COPD) are major causes of morbidity and mortality worldwide. Optimal control of these conditions is a constant challenge for both physicians and patients. Poor inhaler practice is widespread and is a substantial contributing factor to the suboptimal clinical control of both conditions. The practicality, dependability, and acceptability of different inhalers influence the overall effectiveness and success of inhalation therapy. In this paper, experts from various European countries (Finland, Germany, Hungary, Italy, Poland, Spain, and Sweden) address inhaler selection with special focus on the Easyhaler^® device, a high- or medium–high resistance dry-powder inhaler (DPI). The evidence examined indicates that use of the Easyhaler is associated with effective control of asthma or COPD, as shown by the generally accepted indicators of treatment success. Moreover, the Easyhaler is widely accepted by patients, is reported to be easy to learn and teach, and is associated with patient adherence. These advantages help patient education regarding correct inhaler use and the rational selection of drugs and devices. We conclude that switching inhaler device to the Easyhaler may improve asthma and COPD control without causing any additional risks. In an era of climate change, switching from pressurized metered-dose inhalers to DPIs is also a cost-effective way to reduce emissions of greenhouse gases.

Improving adherence in chronic airways disease: are we doing it wrongly?

Non-adherence to medicines is a significant clinical and financial burden, but successful strategies to improve it, and thus bring about significant improvements in clinical outcome, remain elusive. Many barriers exist, including a lack of awareness amongst some healthcare professionals as to the extent and impact of non-adherence and a dearth of skills to address it successfully. Patients may not appreciate that they are non-adherent, feel they cannot disclose it or underestimate its impact on their health in the short and longer term. In describing the evidence-based frameworks that identify the causal factors behind medicines taking (or not taking) behaviours, we can start to personalise interventions to enable individuals to make informed decisions about their treatments and thus overcome real and perceived barriers to adherence.

Medicines non-adherence is common and associated with significant morbidity and mortality. @GrainnedAn and colleagues outline causal factors behind this behaviour and the appropriate individualised interventions available to support optimal medicines use.https://bit.ly/3ejJNTV

Environmental impact of inhalers for respiratory diseases: decreasing the carbon footprint while preserving patient-tailored treatment

Patients with asthma and Chronic Obstructive Respiratory Disease (COPD) rely on three main device classes for inhalation therapy: metered-dose inhalers (MDIs), dry powder inhalers (DPIs) and soft-mist inhalers (SMIs). The carbon footprint (CF) of these inhalers differs with MDIs having a higher impact than DPIs and SMIs due to the propellant in MDIs. However, the certified CF of specific MDI products may differ significantly. MDIs still represent an essential option for many patients. Consequently, novel approaches shall be considered to balance environmental goals with patient health and well-being while maintaining a diverse range of choices for patients and physicians.

Sustainability in Inhaled Drug Delivery

Asthma and chronic obstructive pulmonary disease (COPD) are amongst the most common chronic diseases worldwide, and are largely preventable by improving the quality of the air we breathe. The most commonly deployed treatment, the metered dose inhaler (MDI), uses hydrofluorocarbon propellants, which are powerful greenhouse gases that contribute disproportionately to the climate crisis. Alternative treatment strategies are required if we are to avoid contributing to the worst effects of climate change. These strategies include promoting non-pharmacological therapies like smoking cessation and pulmonary rehabilitation; empowering patients to gain better disease control through written management plans and encouraging preventer, rather than reliever therapies. Pharmacological strategies include: improving inhaler technique and spacer use; minimising propellant release by using smaller volume MDIs and simpler dosing regimes; dose counters to prevent waste; switching to low global warming potential inhalers; and inhaler recycling. There are also opportunities to improve disease control alongside reduced greenhouse gas emissions, including better matching of patients' devices to inhaler technique rather than defaulting to MDIs, stopping unnecessary inhaled steroids in COPD and maintenance and reliever therapy in asthma. New, lower global warming potential propellants are on the horizon, and their introduction could offer a golden opportunity to enhance MDIs usability and sustainability by making them refillable, integrating whistles to optimise inhalation technique, adding integrated caps, optimising materials for recycling and adding dose counters to all MDIs.

Diagnostic and therapeutic challenges of chronic obstructive pulmonary disease in the elderly

PURPOSE OF REVIEW

Chronic obstructive pulmonary disease (COPD) imposes a large burden on the global population and even more so for the elderly who face significant obstacles in the diagnosis, management, and psychosocial effects of the disease. This review describes the current challenges and key points in the management of COPD in the elderly.

RECENT FINDINGS

Lower limit rather than fixed cut off of the FEV1/FVC ratio can improve the diagnosis and better predict COPD mortality. High relative to standard dose influenza vaccination reduces confirmed cases of influenza overall and reduces hospitalizations in older nursing home residents. Simple interventions that include electronic health record tracking can significantly improve vaccination rates. Although many inhaler and nebulized medications are available for the elderly, the final regimen is usually determined by a combination of expense, issues with proper device use (from difficulty with coordination, hand grip, inspiratory flows or cognitive function) and the side effect profile. Fortunately, the switch to cheaper or better covered alternatives can be well tolerated with improvement in adherence and exacerbations of COPD. Finally, caution should be made against ageism, which may be a factor in the recommendation of rehabilitation or palliative care in the elderly COPD patient, as both are underused despite evidence of benefit.

SUMMARY

Although care for the elderly COPD patient can be difficult, we summarize key points that the physician should be cognizant of to provide comprehensive care.

Switching Inhalers: A Practical Approach to Keep on UR RADAR

The choice of an inhaler device is often as important as the medication put in it to achieve optimal outcomes for our patients with asthma and/or COPD. With a multitude of drug–device combinations available, optimization of respiratory treatment could well be established by switching devices rather than changing or even augmenting pharmacological or non-pharmacological therapies. Importantly, while notable between-device differences in release mechanism, particle size, drug deposition and required inspiratory flow exist, a patient uncomfortable with their device is unlikely to use it regularly and certainly will not use it properly. Switching requires a careful process and should not be done without patient consent. Switching devices entails several steps that need to be considered, which can be guided using the UR-RADAR mnemonic. It starts with (i) UncontRolled asthma/COPD (or UnaffoRdable device), followed by RADAR: (ii) review the patient’s condition (e.g. diagnosis, phenotype, co-morbidities) and address reasons for suboptimal control (e.g. triggers, smoking, non-adherence, poor inhaler technique) to be ruled out before switching; (iii) assess patient’s skills related to inhalation (e.g. inspiratory force); (iv) discuss inhaler switch options, patient preferences (e.g. size, daily regimen) and treatment goals; (v) allow patients input and use shared decision-making to decide final treatment choice, acknowledging individual patient skills, preferences and goals; and (vi) re-educate to the new device (at minimum, physical demonstration, verbal explanation and patient repetition, both verbally and physically) and prime the patient for the follow-up (i.e. explain the future patient journey, including multidisciplinary work flows with physicians, nurses and pharmacists).

Health and cost impact of stepping down asthma medication for UK patients, 2001-2017: A population-based observational study

BACKGROUND

Guidelines recommend stepping down asthma treatment to the minimum effective dose to achieve symptom control, prevent adverse side effects, and reduce costs. Limited data exist on asthma prescription patterns in a real-world setting. We aimed to evaluate the appropriateness of doses prescribed to a UK general asthma population and assess whether stepping down medication increased exacerbations or reliever use, as well as its impact on costs.

METHODS AND FINDINGS

We used nationwide UK primary care medical records, 2001-2017, to identify 508,459 adult asthma patients managed with preventer medication. Prescriptions of higher-level medication: medium/high-dose inhaled corticosteroids (ICSs) or ICSs + add-on medication (long-acting β2-agonist [LABA], leukotriene receptor antagonist [LTRA], theophylline, or long-acting muscarinic antagonist [LAMA]) steadily increased over time (2001 = 49.8%, 2017 = 68.3%). Of those prescribed their first preventer, one-third were prescribed a higher-level medication, of whom half had no reliever prescription or exacerbation in the year prior. Of patients first prescribed ICSs + 1 add-on, 70.4% remained on the same medication during a mean follow-up of 6.6 years. Of those prescribed medium/high-dose ICSs as their first preventer, 13.0% already had documented diabetes, cataracts, glaucoma, or osteopenia/osteoporosis. A cohort of 125,341 patients were drawn to assess the impact of stepping down medication: mean age 50.4 years, 39.4% males, 39,881 stepped down. Exposed patients were stepped down by dropping their LABAs or another add-on or by halving their ICS dose (halving their mean-daily dose or their inhaler dose). The primary and secondary outcomes were, respectively, exacerbations and an increase in reliever prescriptions. Multivariable regression was used to assess outcomes and determine the prognostic factors for initiating stepdown. There was no increased exacerbation risk for each possible medication stepdown (adjusted hazard ratio, 95% CI, p-value: ICS inhaler dose = 0.86, 0.77-0.93, p < 0.001; ICS mean daily = 0.80, 0.74-0.87, p < 0.001; LABA = 1.01, 0.92-1.11, p = 0.87, other add-on = 1.00, 0.91-1.09, p = 0.79) and no increase in reliever prescriptions (adjusted odds ratio, 95% CI, p-value: ICS inhaler dose = 0.99, 0.98-1.00, p = 0.59; ICS mean daily = 0.78, 0.76-0.79, p < 0.001; LABA = 0.83, 0.82-0.85, p < 0.001; other add-on = 0.86, 0.85-0.87, p < 0.001). Prognostic factors to initiate stepdown included medication burden, but not medication side effects. National Health Service (NHS) indicative prices were used for cost estimates. Stepping down medication, either LABAs or ICSs, could save annually around £17,000,000 or £8,600,000, respectively. Study limitations include the possibility that prescribed medication may not have been dispensed or adhered to and the reason for stepdown was not documented.

CONCLUSION

In this UK study, we observed that asthma patients were increasingly prescribed higher levels of treatment, often without clear clinical indication for such high doses. Stepping down medication did not adversely affect outcomes and was associated with substantial cost savings.