Excess medical costs in patients with asthma and the role of comorbidity

The economic burden of asthma prior to death: a nationwide descriptive study

Background

In addition to the clinical burden, asthma is responsible for a high economic burden. However, little is known about the economic burden of asthma prior to death.

Objective

We performed an economic analysis to describe the costs during 12 and 24 months prior to asthma death between 2013 and 2017 in France.

Methods

An observational cohort study was established using the French national health insurance database. Direct medical and non-medical costs, as well as costs related to absence from the workplace, were included in the analysis.

Results

In total, 3,829 patients were included in the final analysis. Over 24 and 12 months prior to death, total medical costs per patient were €27,542 [26,545-28,641] and €16,815 [16,164-17,545], respectively. Total medical costs clearly increased over 24 months prior to death. Over 12 months prior to death, costs increased significantly according to age categories, with mean total costs of €8,592, €15,038, and €17,845, respectively, for the categories <18 years old, 18-75 years old, and 75+ years old (p < 0.0001). Over 12 months prior to death, costs were statistically higher in patients with a dispensation of six or more SABA canisters compared to those with a dispensation of five or less canisters (p < 0.0001). In multivariate analysis, comorbidities, hospital as location of death, and dispensation of 12 or more canisters of SABA per year are independent factors of the highest costs.

Conclusion

To conclude, the economic burden of asthma death is high and increases with time, age, and SABA dispensation.

Comorbidity Burden in Severe and Nonsevere Asthma: A Nationwide Observational Study (FINASTHMA)

BACKGROUND

Asthma, affecting more than 330 million people worldwide, is associated with a high level of morbidity, mortality, and socioeconomic costs.

OBJECTIVE

In this cross-sectional study, we analyzed the comorbidity burden in patients with severe asthma compared with nonsevere asthma and investigated the role of corticosteroid use on the risk of comorbidities.

METHODS

All adults (≥18 y) with a diagnosis of asthma (International Classification of Diseases-10th revision code J45.x) between 2014 and 2017 were identified and data were collected until 2018 from Finnish nationwide registers. Asthma was defined as continuously or transiently severe or nonsevere based on annual dispensed inhaled corticosteroids (ICS), oral corticosteroids (OCS), and hospitalizations.

RESULTS

Of 193,730 adult identified patients diagnosed with asthma, 86.3% had nonsevere, 8.1% transiently severe, and 5.6% continuously severe asthma. Excess prevalence of pneumonia was observed in continuously (22%) and transiently severe (14%) compared with nonsevere patients after adjusting for age and sex. Cataract, osteoporosis, obesity, heart failure, and atrial fibrillation were also more frequent in severe asthma patients. The ICS and/or OCS use contributed to the risk of several comorbidities in a dose-dependent manner, particularly pneumonia, osteoporosis, obesity, heart failure, and atrial fibrillation. High OCS use and the presence of comorbidities were associated with increased health care resource use.

CONCLUSIONS

Patients with severe asthma have a high burden of comorbidities, especially pneumonia. Many of the comorbidities have a strong dose-dependent association with ICS and OCS treatment, suggesting that corticosteroid doses should be carefully evaluated in clinical practice.

Analysis of comorbidities and multimorbidity in adult patients in the International Severe Asthma Registry

BACKGROUND

Investigation for the presence of asthma comorbidities is recommended by the Global Initiative for Asthma because their presence can complicate asthma management.

OBJECTIVE

To understand the prevalence and pattern of comorbidities and multimorbidity in adults with severe asthma and their association with asthma-related outcomes.

METHODS

This was a cross-sectional study using data from the International Severe Asthma Registry from 22 countries. A total of 30 comorbidities were identified and categorized a priori as any of the following: (1) potentially type 2-related comorbidities, (2) potentially oral corticosteroid (OCS)-related comorbidities, or (3) comorbidities mimicking or aggravating asthma. The association between comorbidities and asthma-related outcomes was investigated using multivariable models adjusted for country, age at enrollment, and sex (ie male or female).

RESULTS

Of the 11,821 patients, 69%, 67%, and 55% had at least 1 potentially type 2-related, potentially OCS-related, or mimicking or aggravating comorbidities, respectively; 57% had 3 or more comorbidities, and 33% had comorbidities in all 3 categories. Patients with allergic rhinitis, nasal polyposis, and chronic rhinosinusitis experienced 1.12 (P = .003), 1.16 (P < .001), and 1.29 times (P < .001) more exacerbations per year, respectively, than those without. Patients with nasal polyposis and chronic rhinosinusitis were 40% and 46% more likely (P < .001), respectively, to have received long-term (LT) OCS. All assessed potential OCS-related comorbidities (except obesity) were associated with a greater likelihood of LTOCS use (odds ratios [ORs]: 1.23-2.77) and, except for dyslipidemia, with a greater likelihood of uncontrolled asthma (ORs: 1.29-1.68). All mimicking or aggravating comorbidities assessed were associated with more exacerbations (1.24-1.68 times more), all (except bronchiectasis) with increased likelihood of uncontrolled asthma (ORs: 1.57-1.81), and all (except chronic obstructive pulmonary disease) with increased likelihood of LTOCS use (ORs: 1.37-1.57). A greater number of comorbidities was associated with worse outcomes.

CONCLUSION

In a global study, comorbidity or multimorbidity is reported in most adults with severe asthma and is associated with poorer asthma-related outcomes.

CLINICAL TRIAL REGISTRATION

The International Severe Asthma Registry database has ethical approval from the Anonymous Data Ethics Protocols and Transparency (ADEPT) committee (ADEPT0218) and is registered with the European Union Electronic Register of Post-Authorization Studies (European Network Centres for Pharmacoepidemiology and Pharmacovigilance [ENCEPP]/DSPP/23720). The study was designed, implemented, and reported in compliance with the European Network Centres for Pharmacoepidemiology and Pharmacovigilance (ENCEPP) Code of Conduct (EMA 2014; EUPAS44024) and with all applicable local and international laws and regulations, and registered with ENCEPP (https://www.encepp.eu/encepp/viewResource.htm?id=48848). Governance was provided by ADEPT (registration number: ADEPT1121).

Risk factors for depression in asthmatic individuals: Findings from NHANES (2005-2018)

BACKGROUND

The risk factors for depression in asthma are still unclear. The objective of this study was to identify the risk factors associated with depression in asthmatic individuals.

METHODS

We used data from the 2005-2018 National Health and Nutrition Examination Survey (NHANES). Univariate analysis and multivariate logistic regression analyses were used to identify risk factors for depression and calculate unadjusted and adjusted odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

A total of 5,379 asthmatic participants were included. Of these subjects, 767 individuals had depression, and 4,612 individuals had no depression. Univariate analysis and multivariate analyses suggested that asthmatic individuals with smoking (OR 1.98, 95% CI 1.19-3.29), hypertension (OR 2.73, 95% CI 1.48-5.04), and arthritis (OR 2.83, 95% CI 1.53-5.22) were more likely to have depression. Asthmatic individuals who had more than a high school education had lower depression risk than those with less than a high school education (OR 0.55, 95% CI 0.30-0.99). Increasing age was also associated with decreased depression risk (OR 0.97, 95% CI 0.95-0.99).

CONCLUSIONS

Depression was more likely in asthmatic individuals with smoking, hypertension, and arthritis and less likely in individuals with higher education and increasing age. These findings could improve the identification of target populations for effective interventions to improve the mental health of asthmatic individuals.

Impact of mepolizumab in patients with high-burden severe asthma within a managed care population

OBJECTIVE

To evaluate the real-world impact of mepolizumab on the incidence of asthma exacerbations, oral corticosteroid (OCS) use and asthma exacerbation-related costs in patients with high-burden severe asthma.

METHODS

This was a retrospective study of the MarketScan Commercial and Medicare Databases in patients with high-burden severe asthma (≥80th percentile of total healthcare expenditure and/or significant comorbidity burden). Patients were ≥12 years of age upon mepolizumab initiation (index date November 1, 2015-December 31, 2018) and had ≥2 mepolizumab administrations during the 6 months post-index. Asthma exacerbation frequency (primary outcome), use of OCS (secondary outcome), and asthma exacerbation-related costs (exploratory outcome) were assessed during the 12 months pre-index (baseline) and post-index (follow-up).

RESULTS

In total, 281 patients were analyzed. Mepolizumab significantly reduced the proportion of patients with any asthma exacerbation (P < 0.001) or exacerbations requiring hospitalization (P = 0.004) in the follow-up versus baseline period. The mean number of exacerbations decreased from 2.5 to 1.5 events/patient/year (relative reduction: 40.0%; P < 0.001). The proportion of patients with ≥1 OCS claim also decreased significantly from 94.0% to 81.9% (relative reduction: 12.9%; P < 0.001), corresponding to a decrease from 6.6 to 4.7 claims/person/year (P < 0.001). Of the 264 patients with ≥1 OCS claim during baseline, 191 (72.3%) showed a decrease in mean daily OCS use by ≥50% in 117 patients (61.3%). Total asthma exacerbation-related costs were significantly lower after mepolizumab was initiated (P < 0.001).

CONCLUSIONS

Mepolizumab reduced exacerbation frequency, OCS use and asthma exacerbation-related costs in patients with high-cost severe asthma. Mepolizumab provides real-world benefits to patients, healthcare systems and payers.

Strength of association between comorbidities and asthma: a meta-analysis

BACKGROUND

The strength of association between comorbidities and asthma has never been ranked in relation to the prevalence of the comorbidity in the nonasthma population. We investigated the strength of association between comorbidities and asthma.

METHODS

A comprehensive literature search was performed for observational studies reporting data on comorbidities in asthma and nonasthma populations. A pairwise meta-analysis was performed and the strength of association calculated by anchoring odds ratios and 95% confidence intervals with the rate of comorbidities in nonasthma populations via Cohen's d method. Cohen's d=0.2, 0.5 and 0.8 were cut-off values for small, medium and large effect sizes, respectively; very large effect size resulted for Cohen's d >0.8. The review was registered in the PROSPERO database; identifier number CRD42022295657.

RESULTS

Data from 5 493 776 subjects were analysed. Allergic rhinitis (OR 4.24, 95% CI 3.82-4.71), allergic conjunctivitis (OR 2.63, 95% CI 2.22-3.11), bronchiectasis (OR 4.89, 95% CI 4.48-5.34), hypertensive cardiomyopathy (OR 4.24, 95% CI 2.06-8.90) and nasal congestion (OR 3.30, 95% CI 2.96-3.67) were strongly associated with asthma (Cohen's d >0.5 and ≤0.8); COPD (OR 6.23, 95% CI 4.43-8.77) and other chronic respiratory diseases (OR 12.85, 95% CI 10.14-16.29) were very strongly associated with asthma (Cohen's d >0.8). Stronger associations were detected between comorbidities and severe asthma. No bias resulted according to funnel plots and Egger's test.

CONCLUSION

This meta-analysis supports the relevance of individualised strategies for disease management that look beyond asthma. A multidimensional approach should be used to assess whether poor symptom control is related to uncontrolled asthma or to uncontrolled underlying comorbidities.

Direct Health Care Costs Associated With Multiple Sclerosis: A Population-Based Cohort Study in British Columbia, Canada, 2001-2020

BACKGROUND AND OBJECTIVES

Multiple sclerosis (MS), a leading cause of nontraumatic neurologic disability in young adults, exerts a substantial economic burden on the health care system. The objective of this study was to quantify the excess health care costs of MS in British Columbia, Canada.

METHODS

A retrospective-matched cohort study of patients with MS was conducted using population-based administrative health data from 2001 to 2020. Patients with MS who satisfied a validated case definition were matched to 5 unique controls without MS on sex, age, and cohort entry date. Patients and controls were followed to the end of 2020 or to their last health care resource use, whichever came first. We calculated the direct medical costs for each individual, including outpatient services use, hospital admissions, and dispensed medications. We used generalized linear models with an identity link and normal distribution to estimate the excess cost of MS as the mean cost difference between patients with MS and controls. All costs were reported in 2020 Canadian dollars.

RESULTS

A total of 17,071 patients with MS were matched to 85,355 controls. Overall, 72.4% were female, and the mean age at cohort entry date was 46.1 years. The excess cost of MS was $6,881 (95% CI: $6,713, $7,049) per patient-year. Inpatient, outpatient, and medication costs accounted for 25%, 10%, and 65% of excess costs, respectively. Excess costs were higher in patients with MS with at least one disease-modifying therapy (DMT) prescription ($13,267; 95% CI: $12,992-$13,542) compared with non-DMT users ($3,469; 95% CI: $3,297-$3,641) and even higher among frequent DMT users ($24,835; 95% CI: $24,528-$25,141). Patients with MS with a history of at least one relapse requiring hospitalization had higher excess costs ($10,543; 95% CI: $10,136-$10,950) compared with patients with MS without a relapse; hospitalizations accounted for 51% of the costs in this group. The excess cost of hospitalizations was $1,391 lower among frequent DMT users than non-DMT users.

DISCUSSION

The economic burden of MS is considerable, with medications, particularly DMTs, being the largest cost driver. Future studies should investigate how disease management strategies, including early diagnosis and timely use of DMTs, could offset future and ongoing costs while improving patients' quality of life.

Adverse drug reactions affecting treatment adherence in first-line treatment of asthma: An observational study

BACKGROUND

Asthma is the most common chronic lung disease among children. International guidelines recommend inhaled corticosteroids (ICS) as the first-line daily controller therapy for children with asthma and leukotriene receptor antagonists (LTRA) as the second alternative therapy. Adherence to treatment is the most significant component to optimize the benefits of therapy in asthma.

OBJECTIVE

This study aims to investigate the frequency of drug discontinuation due to adverse drug reactions (ADRs) that affect adherence to treatment in children with asthma or asthma and allergic rhinitis using LTRA or ICS as monotherapy.

METHODS

The subjects aged 4-18 years with asthma or asthma and allergic rhinitis and using montelukast or ICS as monotherapy were included in the study. They were evaluated in terms of ADRs affecting adherence to treatment in the first and third months of treatment.

RESULTS

A total of 468 cases, 356 of whom received montelukast monotherapy and 112 of whom received ICS treatment, with a mean age of 9.10 ± 3.08 (4-17) years, were included in the study. Males constituted 65.6% of the total cases (n = 307). In the first month of follow-up of the cases, it was observed that 4.8% (n = 17) of the patients in the montelukast group could not continue the treatment due to ADR. It was determined that the drug discontinuation rate in the montelukast group in the first month was significantly higher than in the ICS group (P = 0.016), and the risk of drug discontinuation due to ADR in the montelukast group was 1.333 (95% CI, 1.26-1.40) times higher.

CONCLUSIONS

As a result, it was observed that the drug was discontinued due to ADR at a higher rate in children with asthma who received montelukast monotherapy compared to those who received ICS monotherapy.

Paediatric asthma and non-allergic comorbidities: A review of current risk and proposed mechanisms

It is increasingly recognized that children with asthma are at a higher risk of other non-allergic concurrent diseases than the non-asthma population. A plethora of recent research has reported on these comorbidities and progress has been made in understanding the mechanisms for comorbidity. The goal of this review was to assess the most recent evidence (2016-2021) on the extent of common comorbidities (obesity, depression and anxiety, neurodevelopmental disorders, sleep disorders and autoimmune diseases) and the latest mechanistic research, highlighting knowledge gaps requiring further investigation. We found that the majority of recent studies from around the world demonstrate that children with asthma are at an increased risk of having at least one of the studied comorbidities. A range of potential mechanisms were identified including common early life risk factors, common genetic factors, causal relationships, asthma medication and embryologic origins. Studies varied in their selection of population, asthma definition and outcome definitions. Next, steps in future studies should include using objective measures of asthma, such as lung function and immunological data, as well as investigating asthma phenotypes and endotypes. Larger complex genetic analyses are needed, including genome-wide association studies, gene expression-functional as well as pathway analyses or Mendelian randomization techniques; and identification of gene-environment interactions, such as epi-genetic studies or twin analyses, including omics and early life exposure data. Importantly, research should have relevance to clinical and public health translation including clinical practice, asthma management guidelines and intervention studies aimed at reducing comorbidities.

Bayesian comorbidity network and cost analysis for asthma

The evolving disease spectrum poses significant challenges to the asthma management, thus worsening health quality and increased financial burden on patients. However, potential dependency pattern in comorbidity spectrum remains unclear. We built comorbidity networks based on Bayesian networks utilizing 19604 asthma-patient hospitalization data to investigate dependency patterns among asthma comorbidities. We analyze static properties and trajectory behaviors of gender- and age-stratified asthmatic comorbidity networks. Results suggest that chronic obstructive pulmonary disease, respiratory failure, hypertension, atherosclerosis, and gastritis and duodenitis are the hubs of the asthma comorbidity network. They have a strong dependency pattern, while most of the associations among other comorbidities are sparse and weak. The strength of association between comorbidities is higher in female asthmatics than in males. Although the comorbidity network in children with asthma is simple and stable, the onset of common comorbidities as they age will enhance the association between comorbidities and thus increase the risk of developing other comorbidities. Furthermore, the more attributes of comorbidities, the stronger association with each other, and the greater risk of causing high treatment costs. Our study will help to dissect the asthma co-morbidity network and provide a basis for improving asthma management and cost control.

Neuropsychiatric Adverse Events of Montelukast: An Analysis of Real-World Datasets and drug-gene Interaction Network

Montelukast is a selective leukotriene receptor antagonist that is widely used to treat bronchial asthma and nasal allergy. To clarify the association between montelukast and neuropsychiatric adverse events (AEs), we evaluated case reports recorded between January 2004 and December 2018 in the Food and Drug Administration Adverse Event Reporting System (FAERS). Furthermore, we elucidated the potential toxicological mechanisms of montelukast-associated neuropsychiatric AEs through functional enrichment analysis of human genes interacting with montelukast. The reporting odds ratios of suicidal ideation and depression in the system organ class of psychiatric disorders were 21.5 (95% confidence interval (CI): 20.3–22.9) and 8.2 (95% CI: 7.8–8.7), respectively. We explored 1,144 human genes that directly or indirectly interact with montelukast. The molecular complex detection (MCODE) plug-in of Cytoscape detected 14 clusters. Functional analysis indicated that several genes were significantly enriched in the biological processes of “neuroactive ligand–receptor interaction.” “Mood disorders” and “major depressive disorder” were significant disease terms related to montelukast. Our retrospective analysis based on the FAERS demonstrated a significant association between montelukast and neuropsychiatric AEs. Functional enrichment analysis of montelukast-associated genes related to neuropsychiatric symptoms warrant further research on the underlying pharmacological mechanisms.

The relationship between cognitive function and competence in inhaler technique in older adults with airway disease

Cognitive impairment has high prevalence in older adults with airway diseases, and may influence their competence in inhaler use, thereby negatively affecting patient prognosis. We aimed to evaluate the relationship between cognitive function and competence in inhaler technique. We enrolled 108 inhaler naïve older adults (≥60 years) with airway disease in this prospective observational study and performed the Korean version of the Mini-Mental State Examination (K-MMSE). After explaining the inhaler technique, we scored its competence. While the total K-MMSE score was unrelated to the inhaler score, the orientation for place (estimates=0.62, p = 0.009), registration (estimates=0.988, p = 0.037), and recall (estimates=0.161, p = 0.048) were positively associated with the score. Low K-MMSE scores were associated with lower odds ratio for the competence of the "exhale" step (adjusted odds ratio= 0.23, p = 0.018). Thus, a K-MMSE-mediated evaluation of cognitive function in older adults with airway disease can be a useful tool to predict inhaler competence.

Design Comorbidity Portfolios to Improve Treatment Cost Prediction of Asthma Using Machine Learning

Comorbidity is an important factor to consider when trying to predict the cost of treating asthma patients. When an asthmatic patient suffered from comorbidity, the cost of treating such a patient becomes dependent on the nature of the comorbidity. Therefore, lack of recognition of comorbidity on asthmatic patient poses a challenge in predicting the cost of treatment. In this study, we proposed a comorbidity portfolio design that improves the prediction cost of treating asthmatic patients by regrouping frequently occurred comorbidities in different cost groups. In the experiment, predictive models, including logistic regression, random forest, support vector machine, classification regression tree, and backpropagation neural network were trained with real-world data of asthmatic patients from 2012 to 2014 in a large city of China. The 10-fold cross validation and random search algorithm were employed to optimize the hyper-parameters. We recorded significant improvements using our model, which are attributed to comorbidity portfolios in area under curve (AUC) and sensitivity increase of 46.89% (standard deviation: 4.45%) and 101.07% (standard deviation: 44.94%), respectively. In risk analysis of comorbidity on cost, respiratory diseases with a cumulative proportion in the adjusted odds ratio of 36.38% (95%CI: 27.61%, 47.86%) and circulatory diseases with a cumulative proportion in the adjusted odds ratio of 23.83% (95%CI: 15.95%, 35.22%) are the dominant risks of asthmatic patients that affects the treatment cost. It is found that the comorbidity portfolio is robust, and provides a better prediction of the high-cost of treating asthmatic patients. The preliminary characterization of the joint risk of multiple comorbidities posed on cost are also reported. This study will be of great help in improving cost prediction and comorbidity management.

Real-world effectiveness of mepolizumab in patients with severe asthma and associated comorbidities

BACKGROUND

Patients with severe asthma frequently have associated comorbidities, which can compound existing symptoms, complicating asthma management.

OBJECTIVE

To describe the real-world effectiveness of mepolizumab in patients with severe asthma stratified by common overlapping comorbidities.

METHODS

This was a retrospective analysis of patients with asthma from the MarketScan Commercial and Medicare Supplemental Database initiating mepolizumab treatment (index date). Eligible patients had more than or equal to 1 claim (excluding claims for diagnostic tests) with a diagnosis code for more than or equal to 1 of 7 comorbidities (atopic disease, nasal polyps, chronic sinusitis, obesity, respiratory infections, chronic obstructive pulmonary disease, and depression/anxiety) during the 12-month preindex baseline period; these were used to stratify patients into 7 nonmutually exclusive subgroups. Outcomes included asthma exacerbations and exacerbation-related health care resource utilization during the 12-month baseline and follow-up periods. Each patient acted as their own control.

RESULTS

Of the 639 patients included, the most common comorbidities were atopic diseases (73.2%), respiratory infections (55.6%), and chronic sinusitis (45.1%). Across all 7 comorbidity subgroups, there were significant (P < .05) reductions of 38% to 55% and 57% to 83% in exacerbations and exacerbations requiring hospitalization, respectively, during the follow-up vs baseline period, except for exacerbations requiring hospitalization in the nasal polyp subgroup, owing to the small subgroup sample size. During the follow-up vs baseline periods, mean number of oral corticosteroids claims was significantly (P < .001) reduced by 29% to 38%; 39% to 47% of patients achieved greater than or equal to 50% oral corticosteroids dose reduction. Significant reductions in exacerbation-related health care resource utilization were also observed.

CONCLUSION

Mepolizumab treatment provided real-world clinical benefits in patients.

An expert review on breaking barriers in severe asthma in Brazil: Time to act

Currently, Brazil lacks a national asthma management program and is burdened with nearly 200,000 hospitalizations due to the disease per year and approximately 5 deaths per day. The purpose of this article was to analyze the current issues surrounding severe asthma in Brazil, as the status of diagnosis and treatment is largely unknown, and to provide feasible recommendations to elicit imminent action. A panel of Brazilian medical experts in the field of severe asthma was provided with a series of relevant questions to address prior to a multi-day conference. Within this conference, each narrative was discussed and edited by the entire group. Through numerous rounds of discussion consensus was achieved. In order to overcome barriers to adequate asthma treatment, this panel recommends specific initiatives that can be implemented in the short-term to decrease the burden of severe asthma in Brazil. With increasing healthcare costs and limited resources globally, there is an opportunity to implement these recommendations in other countries in order to achieve adequate asthma care. Severe asthma is a heterogeneous and complex disease with various phenotypes that requires strict attention for diagnosis and management. Although this disease affects only a small proportion of the population with asthma, it poses a great burden to healthcare systems. Thus, barriers to diagnosis, treatment, and management should be overcome as quickly and efficiently as possible.

Greater length of stay and hospital charges for severe asthma in children with depression or anxiety

RATIONALE

Asthma is one of the most common chronic disorders of childhood and is associated with significant healthcare utilization and costs. Comorbid psychiatric illnesses, specifically depression and anxiety, are more prevalent in patients with asthma and associated with worse asthma control, more emergency department visits, and increased hospitalization rates.

OBJECTIVES

We aimed to compare hospital outcomes and charges for children with severe asthma with and without comorbid depression and anxiety, hypothesizing that those with depression and anxiety would have longer hospitalizations and higher charges.

METHODS

Retrospective review of the 2000-2012 Healthcare Cost and Utilization Project's Kids' Inpatient Databases for admissions of patients aged 10-21 years with an ICD-9 code severe asthma (status asthmaticus or any asthma diagnosis with a procedure code for endotracheal intubation). Depression and Anxiety subgroups were created based on ICD-9 codes. Data collected included demographics, hospital outcomes and charges and comparisons made between groups.

RESULTS

There were 52,485 admissions for severe asthma: 45,094 (86%) with No Comorbid Psychiatric Illnesses, 1284 (2.4%) with depression, and 1297 (2.5%) with anxiety. Patients with depression or anxiety were older, had longer hospitalizations, and higher hospital charges (p < .001 for all).

CONCLUSIONS

Comorbid depression or anxiety is associated with significantly longer hospitalizations and higher charges for children with severe asthma. These findings add to prior reports of worse outcomes for children with asthma and comorbid depression or anxiety and suggest that improved screening for and management of these conditions in children with asthma could improve hospital outcomes and reduce costs.

Impact of comorbid conditions on asthmatic adults and children

Comorbid conditions (comorbidities) can complicate the diagnosis and management of asthma. In different age groups, comorbid conditions can present varying challenges, including diagnostic confusion due to mimicking asthma symptoms, exacerbation of asthma symptoms, therapy for comorbid conditions affecting asthma or therapy for asthma affecting these conditions. This review aims to summarise some common comorbid conditions with asthma, such as rhinitis, vocal cord dysfunction, gastro-oesophageal reflux, psychiatric disorders, obesity and obstructive sleep apnoea, and discuss their prevalence, symptoms, diagnosis and treatment, highlighting any differences in how they impact children and adults. Overall, there is a lack of data on the impact of treating comorbid conditions on asthma outcomes and further studies are needed to guide age-appropriate asthma management in the presence of these conditions.

Chronic oral corticosteroids use and persistent eosinophilia in severe asthmatics from the Belgian severe asthma registry

BACKGROUND

Severe asthma (SA) may require frequent courses or chronic use of oral corticosteroids (OCS), inducing many known side effects and complications. Therefore, it is important to identify risk factors of chronic use of OCS in SA, considering the heterogeneity of clinical and inflammatory asthma phenotypes. Another aim of the present analysis is to characterize a subpopulation of severe asthmatics, in whom blood eosinophil counts (BEC) remain elevated despite chronic OCS treatment.

METHODS

In a cross-sectional analysis of 982 SA patients enrolled in the Belgian Severe Asthma Registry (BSAR) between March 2009 and February 2019, we investigated the characteristics of the OCS treated patients with special attention to their inflammatory profile.

RESULTS

At enrollment, 211 (21%) SA patients were taking maintenance OCS (median dose: 8 [IQR: 5-10]) mg prednisone equivalent). BEC was high (> 400/mm3) in 44% of the OCS treated population. Multivariable logistic regression analysis showed that risk factors for chronic use of OCS in SA were late-onset asthma (i.e. age of onset > 40 yr), frequent exacerbations (i.e. ≥2 exacerbations in the previous year) and non-atopic asthma. Late-onset asthma was also a predictor for persistently high BEC in OCS treated SA patients.

CONCLUSION

These data showed a significant association between a persistently high BEC and late-onset asthma in OCS treated SA patients. Whether it is poor compliance to treatment or corticosteroid insensitivity the reasons for this association warrants further investigation.

Validity and Reliability of the Assessment Tool for Asthma (ATA) Questionnaire: the ATA Study

OBJECTIVES

A multicenter trial was designed to validate the "Assessment Tools for Asthma (ATA)" questionnaire, a newly developed questionnaire, which evaluates both asthma control and risk factors associated with asthma control with a single instrument.

MATERIALS AND METHODS

This cross-sectional study involved 810 cases from 14 clinics in 9 Turkish cities. The ATA questionnaire and Asthma Control Test (ACT) were administered. The Visual Analog Scale (VAS) was used to evaluate the control status of 100 randomized cases. ATA is an eight-item physician-administered questionnaire. It comprises the following two sections-ATA1, assesses symptomatic control criteria, and the remaining section, queries the flare-up of asthma, control of comorbidities, treatment adherence, and inhaler technique.

RESULTS

The mean scores for ATA1, ATA total, VAS, and ACT were 24.7±14.8, 53.8±19, 7.1±3, and 18.8±5.5, respectively. According to the ATA questionnaire, among all patients, 34.3% had controlled, 18.8% had partly controlled, and 46.9% had uncontrolled asthma. Furthermore, 16.6% patients had flare-ups between visits, 96.4% patients had uncontrolled comorbidity, 17% patients had irregular asthma treatment, and only 8.4% patients used the incorrect inhaler technique. The ATA questionnaire showed internal consistency (Cronbach's alpha coefficient=0.683). ACT, ATA1, and two specialists' evaluations using VAS correlated strongly with the ATA total scores (Spearman correlation coefficient (r) values: 0.776, 0.783, and 0.909, respectively; p-values: p<0.001, p<0.001, and p<0.001, respectively). According to Receiver Operating Characteristic analysis, the cut-off value of ATA was 50 (sensitivity=84.4%, specificity=82.40%).

CONCLUSION

The validated ATA questionnaire may be a practical tool for physicians in asthma management.

Comparison Of Methods To Estimate Disease-Related Cost And Healthcare Resource Utilization For Autoimmune Diseases In Administrative Claims Databases

Background

Establishing disease-related cost and/or healthcare resource utilization (HCRU) is an important aspect of health outcomes research, particularly when considering the cost offset of novel treatments. However, few studies have compared methodologies used to assess disease-related cost/HCRU.

Methods

Data from the United States IBM^® MarketScan^® Research Databases were used to compare four different methods of calculating disease-related cost and HCRU in patients with rheumatoid arthritis (RA). The analysis was repeated, in part, for patients with ulcerative colitis (UC) to explore the generalizability of findings to a second autoimmune disease. Four methods of disease-related cost/HCRU attribution were selected following a literature search for potential methods: Method 1, claim-wide cost/HCRU attribution based on claim-listed diagnosis codes and a predetermined disease-related medication list (pharmacy claims only); Method 2, line-item cost/HCRU attribution based on procedures/medications more likely to occur in disease cases than in matched controls at two likelihood ratio cutoffs (1.5× and 3.5×); Method 3, disease-related cost/HCRU calculated as the difference in total average cost/HCRU between cases and matched controls; Method 4, line-item cost/HCRU attribution based on clinician manual determination of procedures/medications related to the disease.

Results and conclusion

Overall, 24,373 patients with RA and 9665 with UC were included. Average total cost during 2015 was $US28,750 per patient with RA and $US20,480 per patient with UC. Disease-related cost and HCRU for RA calculated using Method 4 were most closely approximated by Methods 1 and 2 (3.5×), with Method 2 (3.5×) the closest approximation. However, in certain research scenarios, the simplest method compared in this analysis, Method 1, may provide an adequate approximation of disease-related cost and HCRU. Although Method 4 was not executed in the UC analysis because of its labor-intensive nature, similar patterns of disease-related cost and HCRU were observed for Methods 1–3 in patients with UC and RA.

Direct costs of overdiagnosed asthma: a longitudinal, population-based cohort study in British Columbia, Canada

OBJECTIVES

A current diagnosis of asthma cannot be objectively confirmed in many patients with physician-diagnosed asthma. Estimates of resource use in overdiagnosed cases of asthma are necessary to measure the burden of overdiagnosis and to evaluate strategies to reduce this burden. We assessed differences in asthma-related healthcare resource use between patients with a confirmed asthma diagnosis and those with asthma ruled out.

DESIGN

Population-based, prospective cohort study.

SETTING

Participants were recruited through random-digit dialling of both landlines and mobile phones in the province of British Columbia, Canada.

PARTICIPANTS

We included 345 individuals ≥12 years of age with a self-reported physician diagnosis of asthma. The diagnosis of asthma was reassessed at the end of 12 months of follow-up using a structured algorithm, which included a bronchodilator reversibility test, methacholine challenge test, and if necessary medication tapering and a second methacholine challenge test.

PRIMARY AND SECONDARY OUTCOME MEASURES

Self-reported annual asthma-related direct healthcare costs (2017 Canadian dollars), outpatient physician visits and medication use from the perspective of the Canadian healthcare system.

RESULTS

Asthma was ruled out in 86 (24.9%) participants. The average annual asthma-related direct healthcare costs for participants with confirmed asthma were $C497.9 (SD $C677.9) and for participants with asthma ruled out, $C307.7 (SD $C424.1). In the adjusted analyses, a confirmed diagnosis was associated with higher direct healthcare costs (relative ratio (RR)=1.60, 95% CI 1.14 to 2.22), increased rate of specialist visits (RR=2.41, 95% CI 1.05 to 5.40) and reliever medication use (RR=1.62, 95% CI 1.09 to 2.35), but not primary care physician visits (p=0.10) or controller medication use (p=0.11).

CONCLUSIONS

A quarter of individuals with a physician diagnosis of asthma did not have asthma after objective re-evaluation. These participants still consumed a significant amount of asthma-related healthcare resources. The population-level economic burden of asthma overdiagnosis could be substantial.

Economic burden of multimorbidity in patients with severe asthma: a 20-year population-based study

BACKGROUND

The economic impact of multimorbidity in severe or difficult-to-treat asthma has not been comprehensively investigated.

AIMS

To estimate the incremental healthcare costs of coexisting chronic conditions (comorbidities) in patients with severe asthma, compared with non-severe asthma and no asthma.

METHODS

Using health administrative data in British Columbia, Canada (1996-2016), we identified, based on the intensity of drug use and occurrence of exacerbations, individuals who experienced severe asthma in an incident year. We also constructed matched cohorts of individuals without an asthma diagnosis and those who had mild/dormant or moderate asthma (non-severe asthma) throughout their follow-up. Health service use records during follow-up were categorised into 16 major disease categories based on the International Classification of Diseases. Incremental costs (in 2016 Canadian Dollars, CAD$1=US$0.75=₤0.56=€0.68) were estimated as the adjusted difference in healthcare costs between individuals with severe asthma compared with those with non-severe asthma and non-asthma.

RESULTS

Relative to no asthma, incremental costs of severe asthma were $2779 per person-year (95% CI 2514 to 3045), with 54% ($1508) being attributed to comorbidities. Relative to non-severe asthma, severe asthma was associated with incremental costs of $1922 per person-year (95% CI 1670 to 2174), with 52% ($1003) being attributed to comorbidities. In both cases, the most costly comorbidity was respiratory conditions other than asthma ($468 (17%) and $451 (23%), respectively).

CONCLUSIONS

Comorbidities accounted for more than half of the incremental medical costs in patients with severe asthma. This highlights the importance of considering the burden of multimorbidity in evidence-informed decision making for patients with severe asthma.

A Systematic Review of Decision-Analytic Models for Evaluating Cost-Effectiveness of Asthma Interventions

OBJECTIVE

To demonstrate the landscape of model-based economic studies in asthma and highlight where there is room for improvement in the design and reporting of studies.

DESIGN

A systematic review of the methodologies of model-based, cost-effectiveness analyses of asthma-related interventions was conducted. Models were evaluated for adherence to best-practice modeling and reporting guidelines and assumptions about the natural history of asthma.

METHODS

A systematic search of English articles was performed in MEDLINE, EMBASE, and citations within reviewed articles. Studies were summarized and evaluated based on their adherence to the Consolidated Health Economic Evaluation Reporting Standards (CHEERS). We also studied the underlying assumptions about disease progression, heterogeneity in disease course, comorbidity, and treatment effects.

RESULTS

Forty-five models of asthma were included (33 Markov models, 10 decision trees, 2 closed-form equations). Novel biological treatments were evaluated in 12 studies. Some of the CHEERS' reporting recommendations were not satisfied, especially for models published in clinical journals. This was particularly the case for the choice of the modeling framework and reporting on heterogeneity. Only 13 studies considered any subgroups, and 2 explicitly considered the impact of comorbidities. Adherence to CHEERS requirements and the quality of models generally improved over time.

CONCLUSION

It would be difficult to replicate the findings of contemporary model-based evaluations of asthma-related interventions given that only a minority of studies reported the essential parameters of their studies. Current asthma models generally lack consideration of disease heterogeneity and do not seem to be ready for evaluation of precision medicine technologies.

Asthma impacts on workplace productivity in employed patients who are symptomatic despite background therapy: a multinational survey

Background: Asthma affects millions of people worldwide, with many patients experiencing symptoms that affect their daily lives despite receiving long-term controller medication.

Purpose: Work is a large part of most people’s lives, hence this study investigated the impact of uncontrolled asthma on work productivity in adults receiving asthma maintenance therapy.

Patients and methods: An online survey was completed by employed adults in Brazil, Canada, Germany, Japan, Spain and the UK. Participants were confirmed as symptomatic using questions from the Royal College of Physicians’ 3 Questions for Asthma tool. The survey contained the Work Productivity and Activity Impairment – Specific Health Problem questionnaire and an open-ended question on the effect of asthma at work.

Results: Of the 2,055 patients on long-term maintenance therapy screened, 1,598 were symptomatic and completed the survey. The average percentage of work hours missed in a single week due to asthma symptoms was 9.3%, ranging from 3.5% (UK) to 17.4% (Brazil). Nearly three-quarters of patients reported an impact on their productivity at work caused by asthma. Overall work productivity loss (both time off and productivity whilst at work) due to asthma was 36%, ranging from 21% (UK) to 59% (Brazil). When asked how asthma made participants feel at work, many respondents highlighted how their respiratory symptoms affect them. Tiredness, weakness and mental strain were also identified as particular challenges, with respondents describing concerns about the perception of colleagues and feelings of inferiority.

Conclusions: This study emphasizes the extent to which work time is adversely affected by asthma in patients despite the use of long-term maintenance medication, and provides unique personal insights. Strategies to improve patients’ lives may include asthma education, optimizing asthma management plans and running workplace well-being programs. Clinicians, employers and occupational health teams should be more aware of the impact of asthma symptoms on employees, and work together to help overcome these challenges.

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Systematic Approach to Asthma of Varying Severity

Asthma is a serious global health issue and asthma guidelines recommend a stepwise approach to management with goals to achieve control and minimize future risk. Prior to escalation of pharmacotherapy, steps to confirm accurate diagnosis as well as address comorbidities and triggers are critical to effective asthma management. This article provides readers with a structured approach to evaluation and management of asthma of varying severity.

The Impact of Care Specialty on Survival-Adjusted Medical Costs of COPD Patients After a Hospitalization: a longitudinal analysis

BACKGROUND

Little is known about the impact of care provider's specialty on the medical costs of COPD patients over time.

OBJECTIVE

To compare the long-term medical costs between newly hospitalized COPD patients whose post-discharge care was initiated by a pulmonary specialist versus by a general practitioner.

DESIGN

Retrospective matched cohort study.

PARTICIPANTS

We identified patients with an incident COPD-related hospitalization from the administrative health database (January 1, 1996, to December 31, 2012) of British Columbia, Canada.

MAIN MEASURES

Patients were categorized as receiving specialist care or primary care within the first 90 days after discharge from an incident COPD-related hospitalization. Using propensity scores, we matched each patient who initially received specialist care to a patient who received primary care based on demographics, COPD severity, comorbidity, and admission time. A survival-adjusted, multi-part generalized linear model was used to estimate direct medical costs (in 2015 Canadian dollars, [$], including inpatient, outpatient, pharmacy, and community care costs) as overall and as COPD-specific and comorbidity-related costs over the following 5 years.

KEY RESULTS

The sample included 7710 patients under each group. The initial specialist-care recipients had a modestly higher 5-year survival than the generalist-care recipients (0.564 [95% CI 0.535, 0.634] vs 0.555 [95% CI 0.525, 0.625]; P < .001). Meanwhile, the former incurred $2809 higher all-cause medical costs over 5 years compared to the latter (95% CI $2343, $2913; P < .001), mainly driven by higher medication costs (difference $1782 [95% CI $1658, $1830]; P < .001) particularly related to COPD medications ($1170 [95% CI $1043, $1225]; P < .001). Specialist care recipients also incurred higher costs of COPD-related hospitalization ($1144 [95% CI $650, $1221]; P < .001).

CONCLUSIONS

Compared to generalist care, specialist care following COPD hospitalization is slightly more expensive, mainly driven by medication costs especially COPD-specific medications. Future studies should compare differences in health-related quality of life and COPD functional status.

Moving toward consensus on diagnosis and management of severe asthma in adults

Asthma is a considerable health problem with an increasing global prevalence. The burden of severe asthma is expected to notably increase in the following years. Some misleading concepts that sometimes appear in the literature can drive the physician responsible for a patient's management to make incorrect decisions. Furthermore, some of the concepts that appear in the literature and in the guidelines may not be clear to understand, follow or adapt to regional and local realities. This could again drive the physicians responsible for a patient's management to make incorrect clinical judgments. In this article, we review the definition, prevalence and immunopathology of severe asthma, describe the asthma phenotypes, clinical features and comorbidities, the diagnosis of severe asthma and personalized asthma treatment. At the end, we offer a treatment approach based on literature publications, personalized medicine and marketed biologic treatment options.

Atopic children and use of prescribed medication: A comprehensive study in general practice

PURPOSE

A comprehensive and representative nationwide general practice database was explored to study associations between atopic disorders and prescribed medication in children.

METHOD

All children aged 0-18 years listed in the NIVEL Primary Care Database in 2014 were selected. Atopic children with atopic eczema, asthma and allergic rhinitis (AR) were matched with controls (not diagnosed with any of these disorders) within the same general practice on age and gender. Logistic regression analyses were performed to study the differences in prescribed medication between both groups by calculating odds ratios (OR); 93 different medication groups were studied.

RESULTS

A total of 45,964 children with at least one atopic disorder were identified and matched with controls. Disorder-specific prescriptions seem to reflect evidence-based medicine guidelines for atopic eczema, asthma and AR. However, these disorder-specific prescriptions were also prescribed for children who were not registered as having that specific disorder. For eczema-related medication, about 3.7-8.4% of the children with non-eczematous atopic morbidity received these prescriptions, compared to 1.4-3.5% of the non-atopic children. The same pattern was observed for anti-asthmatics (having non-asthmatic atopic morbidity: 0.8-6.2% vs. controls: 0.3-2.1%) and AR-related medication (having non-AR atopic morbidity: 4.7-12.5% vs. controls: 2.8-3.1%). Also, non-atopic related medication, such as laxatives and antibiotics were more frequently prescribed for atopic children.

CONCLUSIONS

The present study shows that atopic children received more prescriptions, compared to non-atopic children. Non-atopic controls frequently received specific prescriptions for atopic disorders. This indicates that children with atopic disorders need better monitoring by their GP.

Anxiety Contributes to Poorer Asthma Outcomes in Inner-City Black Adolescents

BACKGROUND

The factors associated with poor asthma control, exacerbations, and health care utilization in black adolescents are complex and not well understood. Although psychological comorbidities such as anxiety are common in patients with asthma, these have not been studied in this population.

OBJECTIVE

This study characterized anxiety and associated asthma features in a cohort of black inner-city adolescents with persistent asthma and determined the association between anxiety symptoms, persistent uncontrolled asthma, and prospective health care utilization over 1 year.

METHODS

Eighty-six black adolescents were enrolled, phenotyped, and screened for anxiety symptoms with the Hospital Anxiety and Depression Scale anxiety subscale (HADS-A). Participants were telephoned every 2 months and a second study visit was completed at 1 year. Primary outcomes included persistent uncontrolled asthma, asthma exacerbations requiring systemic corticosteroids, and unscheduled health care utilization during the 1-year study period.

RESULTS

A total of 31% (n = 27) of adolescents had probable anxiety (ie, HADS-A score >7) and 27% (n = 23) had possible anxiety (ie, HADS-A score 5-7) at the baseline visit. Anxiety symptoms were associated with poorer asthma control, more impaired quality of life, and more insomnia symptoms. Adolescents with probable anxiety disorders also had increased odds of persistent uncontrolled asthma and emergency department utilization, with no differences in physician visits or systemic corticosteroid receipt.

CONCLUSIONS

Inner-city black adolescents with persistent asthma have a high prevalence of anxiety symptoms associated with poorer asthma control, impaired quality of life, insomnia, and increased prospective emergency department utilization for asthma. Routine screening for anxiety disorders may be useful in the clinical management of adolescents with asthma.