The cost of asthma: can it be reduced?

Exposure to 'farming' and objective markers of atopy: a systematic review and meta-analysis

There is growing interest in the 'farm effect' on the spectrum of allergy. Evidence concerning the farm effect on asthma, eczema, and allergic rhinitis has been systematically synthesized, but without a specific focus on objective markers of sensitization. This focus is important, as farm exposures may be related to allergy but not to non-allergic phenotypes of disease. We aimed to systematically review and meta-analyse literature that has investigated associations between farm exposure at any age and objective measures of atopy, that is serum IgE or skin prick tests results. Using predefined inclusion and exclusion criteria, we identified 29 articles for review. IgE levels were measured in either childhood or adulthood by eighteen studies, while skin prick testing was performed in sixteen studies. Newcastle-Ottawa Scale quality assessments indicated that the majority of these studies demonstrated a representative sample of selected participants. Due to significant heterogeneity in study measures and methodology between studies, only few were meta-analysed. This meta-analysis showed a significant protective effect of farm exposure before 1 year of life on allergic sensitization (OR = 0.60 [0.52-0.70]). Farm exposure during childhood was also associated with a reduced risk of sensitization to cat or timothy (OR = 0.60 [0.51-0.70]; OR=0.46 [0.41-0.51]). Studies investigating the effect of farm exposure in adult life could not be meta-analysed, and their results were inconsistent. Insufficient studies investigated food sensitization as an outcome to allow synthesis. The majority of studies included in this review investigated childhood farm exposure, finding evidence to support a protective childhood 'farm effect' against subsequent atopy. There is inconsistent evidence on the association between farm exposure in adulthood and allergic sensitization. Further studies are needed to tease out the exact exposures and timing associated with farming environments that protect against allergic disease.

Concurrent oral and inhalation drug delivery using a dual formulation system: the use of oral theophylline carrier with combined inhalable budesonide and terbutaline

A novel approach to concurrently deliver oral and inhaled drugs as a single formulation is presented. A triple therapy containing theophylline (THEO; orally delivered) with budesonide (BUD) and terbutaline (TERB; as single and co-spray-dried inhaled powders) was prepared as an ordered mix, with THEO acting as a carrier. The aerosolisation performance of THEO formulations containing BUD and TERB alone, physical mix and co-spray-dried powder was evaluated using a next-generation impactor (NGI). Physicochemical properties were investigated using electron microscopy, laser diffraction, dynamic vapour sorption and thermal analysis. NGI analysis indicated that >99 % of the THEO powder was >4.46 μm, with >90 % dissolved within 5 min. Particle size analysis showed TEB and BUD samples were of a suitable size for inhalation. Thermal and moisture analysis suggested powders to be stable at room temperature up to 70 % RH. Aerosol studies indicated a different performance of BUD and TERB depending on the mixing procedure. The co-spray-dried formulation showed the highest performance, with a fine particle fraction (≤4.46 μm) of BUD and TERB of 34.39 ± 3.56 and 33.61 ± 5.67 %, respectively. Such observations suggest that this multicomponent drug delivery system could be developed to concomitantly deliver oral and inhaled drugs, an approach that, to date, does not exist. Ultimately, this technology potentially reduces the requirement for multiple therapies and increases patient compliance.

Cost effectiveness of fluticasone and budesonide in patients with moderate asthma

OBJECTIVE

The objective of this study was to assess the relative cost effectiveness of fluticasone via metered dose inhaler and budesonide via Turbuhaler((R)) in corticosteroid-naive patients with moderate asthma from a third-party payer perspective (German Sickness Funds).

PATIENTS AND METHODS

A retrospective economic assessment of direct medication costs of treatment was performed on data from a prospective, randomised, parallel group, 6-week clinical trial. 457 corticosteroid-naive patients between the ages of 18 and 70 years with moderate asthma were included in the intention-to-treat analysis.

RESULTS

The fluticasone group had a higher proportion of successfully treated patients (those with a peak expiratory flow rate improvement of >/=10%) [47 vs 42%], a higher average proportion of symptom-free days (40 vs 34%) and lower direct healthcare costs [1997 Deutschmarks (DM)] per day (DM4.23 vs DM5.19) than the budesonide group. Therefore, the daily costs per successfully treated patient (DM9.00 vs DM12.36) and the cost per symptom-free day (DM10.58 vs DM15.26) were both lower with fluticasone than with budesonide. Sensitivity analysis demonstrated that these results were relatively robust over a wide range of plausible assumptions.

CONCLUSION

These results showed that from the perspective of a third-party payer, fluticasone was more cost effective than budesonide over the 6-week study period.

Costs of asthma in Italy: results of the SIRIO (Social Impact of Respiratory Integrated Outcomes) study

Bronchial asthma is a costly disease and the correlated social impact is ever increasing. The aim of the Social Impact of Respiratory Integrated Outcomes (SIRIO) study was to measure the health resources consumption and the costs generated in 1 year by asthmatic patients investigated in a real-life setting. This bottom-up, observational, prospective, multicentric study was based on the collection of demographic, clinical, diagnostic, therapeutic and outcome data of 577 patients with bronchial asthma who reported spontaneously to the pneumology centers involved in the study. Of these, 485 patients (300 f, mean age 49.2 years+/-16.3 S.D.) were eligible for analysis. At the baseline visit, the asthma severity was as follows: 26.2% intermittent, 37.1% mild persistent, 29.5% moderate, and 6.6% severe. In the 12 months prior to enrollment, 243 patients (50.1%) had visited the general practitioner (GP); 349 (72%) consulted a National Health Service (NHS) specialist; 68 (14%) utilized Emergency Care; and 50 (10.3%) had been admitted to hospital on account of asthma, with a total of 2059 work days lost. At the end of the 1-year survey, asthma severity changed as follows: 32.8% intermittent, 38.1% mild persistent, 23.7% moderate, and 4.3% severe, with a substantial drop in corresponding outcomes: 39.6% visited their GP, 51.5% visited an NHS specialist, 5.2% used Emergency Care, and 4.3% were admitted to hospital. Compared to baseline, the total average cost per patient decreased globally by 17.9% (p<0.001) after the 1-year survey. In conclusion, during the study period we observed a significant decline in health resources consumption and thus in asthma cost of illness, even though specific costs for the pharmaceutical treatment of asthma increased substantially. These results are likely due to a more strict control of patients and to their more appropriate clinical management.

An international observational prospective study to determine the cost of asthma exacerbations (COAX)

Asthma is a common chronic condition that places substantial burden on patients and healthcare services. Despite the standards of asthma control that international guidelines recommend should be achieved, many patients continue to suffer sub-optimal control of symptoms and experience exacerbations (acute asthma attacks). In addition to being associated with reduced quality of life, asthma exacerbations are a key cost driver in asthma management. Routine clinical practice for the management of asthma exacerbations varies in different healthcare systems, so healthcare providers require local costs to be able to assess the value of therapies that reduce the frequency and severity of exacerbations. This prospective study, conducted in a total of 15 countries, assessed the local cost of asthma exacerbations managed in either primary or secondary care. Healthcare resources used were costed using actual values appropriate to each country in local currency and in Euros. Results are presented for exacerbations managed in primary care in Brazil, Bulgaria, Croatia, Czech Republic, Hungary, Poland, Russia, Slovakia, Slovenia, Spain and Ukraine, and in secondary care in Croatia, Denmark, Ireland, Latvia, Norway, Poland, Russia, Slovakia, Slovenia and Spain. Multiple regression analysis of the 2052 exacerbations included in the economic analysis showed that the cost of exacerbations was significantly affected by country (P<0.0001). Mean costs were significantly higher in secondary care (euro 1349) than primary care (euro 445, P=0.0003). Age was a significant variable (P=0.0002), though the effect showed an interaction with care type (P<0.0001). As severity of exacerbation increased, so did secondary care costs, though primary care costs remained essentially constant. In conclusion, the study showed that asthma exacerbations are costly to manage, suggesting that therapies able to increase asthma control and reduce the frequency or severity of exacerbations may bring economic benefits, as well as improved quality of life.

Direct medical cost of asthma in Ankara, Turkey

BACKGROUND

There has been no documented data regarding the cost of asthma in our country.

OBJECTIVE

In this 1-year prospective study, we aimed to determine the annual cost of asthma in Ankara, Turkey.

METHODS

Direct medical cost analysis was performed in 118 patients.

RESULTS

Mean annual direct medical costs of asthma were USD 1,465.7 +/- 111.8 per capita. Medication cost comprised the majority (81%) of the total direct cost. Mean direct medical costs according to the stage of disease were USD 172.5 +/- 51.7, 860.7 +/- 70.2, 1,671.6 +/- 141.8 and 3,491.9 +/- 417.6 for stage 1 (n = 4), 2 (n = 54), 3 (n = 46) and 4 (n = 14) patients, respectively.

CONCLUSIONS

In this first study to document the cost of asthma for our region, direct cost of asthma was found to be increased with the severity of the illness. Considering the fact that medication cost comprises the major fraction of the direct cost, cost-effectiveness trials to determine the effective treatment with optimal cost for different asthma stages should be the next step.

Experience with quantitative IgE antibody analysis in relation to allergic disease within the BAMSE birth cohort--towards an improved diagnostic process

This paper argues that with a certain allergen profile of airborne and food allergens and the use of total IgE-antibody levels, combined with the number of allergens positive at test represent a powerful tool to identify allergic disease in childhood. The allergens featured in such a profile will be dependent on the subject's age and geographical location.

Quantification of IgE antibodies simplifies the classification of allergic diseases in 4-year-old children. A report from the prospective birth cohort study--BAMSE

Allergic diseases are common among small children, but it is still unclear how immunoglobulin E (IgE) antibodies to ambient allergens are distributed in a population-based prospective material of children at 4 years of age. The study is based on 75% (n = 4089) of all eligible children from northern Stockholm, born between 1994 and 1996 in pre-defined geographical areas. Data on exposure and outcome were obtained by parental questionnaires when the child was 3 months and 4 years of age. Of the 92% who responded to the 4 years of age questionnaire, serum was obtained in 88% of these children for analysis of IgE antibodies performed with Pharmacia CAP system (Phadiatop and food mix fx5). An antibody level > or =0.35 kUA/l was considered as positive. A positive Phadiatop or fx5 was found in 24% of the 4 years old children. A rather poor correlation was found between the two tests (r = 0.39). Occurrence of IgE antibodies > or =3.5 kU/l for both Phadiatop and fx5 in combination could predict any suspected allergic disease [asthma, rhinitis, atopic eczema dermatitis syndrome (AEDS) and allergic reaction to food] to 97.4%. However, the presence of > or =3.5 kUA/l of Phadiatop or fx5 used as single tests only, was far less efficient to predict any allergic disease. The two mixes of airborne and food allergens were also associated, not only to the severity of the allergic disease in terms of number of organ involved, but also to the severity of recurrent wheeze, in particular in boys with a positive Phadiatop who exhibited significantly limited peak flows compared to those with a negative test. Already at the age of 4, one child in four is sensitized to an allergen as assessed by Phadiatop or food mix (fx5). The presence of IgE antibodies seems not only to predict allergic diseases in this age group, but also relates to severity of such diseases, in particular to asthma. Notable, there was a poor correlation between Phadiatop and fx5 that needs to be considered when identifying allergic diseases in young children. The study demonstrates that quantification of IgE antibodies in blood may be beneficial, not only to diagnose allergic diseases in young children, but especially to serve as a marker of severity of asthma.

Cost effectiveness of guideline advice for children with asthma: a literature review

Asthma is an important chronic disease among children. This study reviews the cost effectiveness of interventions in the long-term care of asthmatic children and compares these results with treatment advice in four current guidelines. Cost-effectiveness studies were searched for in Medline, Embase, Healthstar, Biosis, and the Office of Health Economics-Health Economic Evaluations Database (OHE-HEED), and the Cochrane Library was searched for meta-analyses of clinical trials. In the four reviewed guidelines, cost effectiveness is not explicitly used as a criterion. The cost-effectiveness studies show sufficient evidence for the cost effectiveness of treatment with inhaled steroids and for self-management programs for severe asthmatic patients. Inclusion of these results in the guidelines would not lead to significant changes in current treatment advice. The effectiveness of various measures for trigger avoidance is not fully proven, and hence neither is their cost effectiveness. Available information on the cost effectiveness of cromolyn could be used to focus the guidelines. Finally, evidence exists that organizational interventions, e.g., the employment of asthma nurses, can result in cost savings, but it is unclear to what extent these results can be generalized. More cost-effectiveness studies are needed, especially on long-acting bronchodilators and self-management programs for mild and moderate asthma, in order to help make the guidelines more informative and reduce the differences between them.

Prevention of sensitization to house dust mite by allergen avoidance in school age children: a randomized controlled study

BACKGROUND

Sensitization to dust mites predisposes to asthma and allergic rhinitis, and prevention of this sensitization might reduce the rising prevalence of these disorders.

OBJECTIVE

To test the effectiveness of dust mite avoidance measures on the development of sensitization to dust mites in children.

METHODS

As part of a multicentre study (Study of Prevention of Allergy in Children of Europe), 242 children, aged 5-7 years, in three European countries (United Kingdom, Greece and Lithuania), were randomized to prophylactic group (n = 127) and control group (n = 115). At randomization these children were required to have a family history of atopy and positive skin test to an aeroallergen but not to house dust mite. Children in the prophylactic group were provided with dust mite impermeable mattress covers and advice on environmental measures to reduce exposure to dust-mite allergen. Control group children were given non-specific advice. After 12 months a standardized questionnaire was completed and skin prick tests were performed.

RESULTS

Ten children in the prophylactic group and 19 in the control group were lost to follow-up. Three of 117 (2.56%) children in the prophylactic group and nine of 96 (9.38%) in the control group developed sensitization to dust mites. Logistic regression analysis confirmed an independent effect of prophylactic measures (adjusted odds ratio (OR): 0.14, 95% confidence interval (CI): 0.03-0.79, P = 0.03). Fifteen children need to be treated to prevent sensitization in one child.

CONCLUSION

Dust mite sensitization can be reduced in school age children with simple mite avoidance measures.

Understanding and use of inhaler medication by asthmatics in specialty care in Trinidad: a study following development of Caribbean guidelines for asthma management and prevention

STUDY OBJECTIVES

Following the development of the Caribbean Guidelines for Asthma Care, we examined the utilization of inhaled medications in asthmatic patients in Trinidad, West Indies.

SETTING

Chest Clinic, Ministry of Health, Trinidad.

PARTICIPANTS

Physician-diagnosed asthmatic patients who attended the Chest Clinic between July 1998 and August 2000.

MEASUREMENTS AND RESULTS

A consecutive sample of patients who were > 7 years of age (n = 402) was interviewed about compliance with, understanding of, and use of inhaler medication. The inhaler technique of these patients was directly observed. Inhaled steroid therapy was prescribed in 83% of patients but were prescribed the least in elderly patients (63%) and children (62%). Salbutamol was prescribed in 98% of patients, and ipratropium and sodium cromoglycate were selectively prescribed in elderly men and children, respectively. Only 33% of patients used the inhaler correctly, and children and the elderly were the least efficient in its use. The use of a spacer device was advised in 19% of patients, including only 6% of the elderly patients. Explanations for different inhaler therapies were given to 62% of patients, and 53% of patients could describe these reasons. The reported 40% noncompliance rate among patients in the sample was primarily a result of long waiting periods at the pharmacy (58%) and the personal cost incurred on purchasing the medication (52%).

CONCLUSIONS

Educating patients, with a focus on children and the elderly, in inhaler techniques and reinforcing understanding of asthma medications can improve asthma management in Trinidad. Asthma caregivers in the Caribbean should ensure the appropriate dissemination of the guidelines and should outline strategies for their implementation.

Asthma nurse practice improves outcomes and reduces costs in primary health care

OBJECTIVE

The aim of this study was to elucidate the care of patients with asthma in primary health care from medical, patient self-management, health, quality of life, and health economic perspectives.

METHODS

Asthma nurse practice (ANP), an alternative asthma self-management strategy, was compared with traditional asthma care in primary health care in southern Sweden regarding medical history, lifestyle, self-management, symptoms caused by asthma, effects on sick leave, state of health, quality of life and health care costs. The first part of the investigation comprised a retrospective study of a randomly selected sample of patient records of asthmatics (n=152). The second part, lasting 3 months, was prospective and included consecutive patients visits (n=347).

RESULTS

The ANP approach showed better results in most of the evaluated outcomes such as asthma quality documentation and self-management and the number of asthma symptoms was significantly lower. From a health economic perspective the results were encouraging with respect to ANP.

CONCLUSION

This alternative asthma strategy, ANP, improved asthma care in primary health care and resulted in economic advantages in the health care sector. However the result may only be generalized to other practices working with asthma nurses in the same way.

Efficacy of inhaled budesonide and oral theophylline in asthmatic subjects

The aim of present study was to evaluate clinical, functional, and anti-inflammatory effects of inhaled budesonide and oral theophylline treatments in patients with mild to moderate asthma. The study included 38 patients. After a 10-day run-in period, the patients were randomly assigned into two groups. Group 1 received inhaled budesonide (Pulmicort Turbuhaler) 800 microg/day for 4 weeks. Group 2 received oral theophylline (Talotren tablets, 200 mg twice daily) for 4 weeks. Inhaled budesonide therapy was accompanied by a significant decrease in serum interleukin (IL)-5 levels (p < 0.0005) and blood, sputum, and nasal eosinophil counts (p < 0.005). It produced a significant reduction in daytime (p < 0.01) and nighttime (p < 0.005) symptom scores and an increase in morning (p < 0.005) and evening (p < 0.05) peak expiratory flow (PEF) and forced expiratory volume in I sec (FEV1) values (p < 0.01). Theophylline therapy was associated with a significant decrease in blood (p < 0.02) and nasal (p < 0.01) eosinophil counts and serum IL-5 levels (p < 0.01). It resulted in significant improvements in daytime and nighttime symptom scores (p < 0.05), and morning PEF and FEV1 values (p < 0.05). These changes were more significant in group I than in group 2. There was no statistically significant difference between the two groups with respect to post-treatment values. Our results confirm the role of inhaled corticosteroids in the treatment of asthma and are consistent with the recommendation that theophylline exerts an anti-inflammatory effect. Further studies should be conducted to determine long-term benefits of theophylline.

A cost-effectiveness study comparing the as-needed use of formoterol (Oxis) and terbutaline (Bricanyl) in patients with moderate to severe asthma

This study evaluated the economic and health-related consequences of the as-needed use of a long-acting beta2-agonist with fast onset (formoterol, Oxis Turbuhaler 4.5 microg) versus a short-acting beta2-agonist (terbutaline, Bricanyl Turbuhaler 0.5 mg) in patients with moderate to severe asthma. A multi-national (Sweden, Norway, The Netherlands and Greece), multi-centre (35 centres), randomized, double-blind clinical trial was conducted using 362 patients on inhaled steroids during a 12-week period. The effectiveness results were pooled and the total costs included estimates for beta2-agonists, inhaled steroids, oral steroids, physician visits and sick-leave. The 182 patients in the formoterol group had 14,404 days of exposure and 29 severe exacerbations, and the 180 patients in the terbutaline group had 13,655 days of exposure and 48 severe exacerbations. The terbutaline group had 62% more severe exacerbations than the formoterol group (P=0.039), based on exposure time. Per patient, the calculated total costs were SEK 3386 for the formoterol group and SEK 3709 for the terbutaline group over the 12-week period. The conclusion is that the use of Oxis Turbuhaler instead of Bricanyl Turbuhaler for as-needed treatment is a more effective treatment generating cost savings from a societal perspective.

Use of changes in symptoms to predict changes in lung function in assessing the response to asthma therapy

BACKGROUND

The majority of adult patients with asthma are managed by primary care providers. Although there is no generally accepted gold standard for the assessment of asthma severity in general practice, treatment decisions and modifications to therapy are strongly influenced by patients' symptoms and history of asthma medication use.

OBJECTIVES

The primary goal of this study was to determine whether there is a correlation between changes in asthma symptoms during treatment and changes in lung function, as measured by peak expiratory flow (PEF). A secondary goal was to compare the relative efficacy (in terms of improvement in asthma symptoms and lung function) of 3 commonly used asthma treatments: inhaled fluticasone propionate, inhaled salmeterol xinafoate, and oral zafirlukast.

METHODS

This was a retrospective comparison employing regression analyses of asthma symptom and lung function data from 2890 male and female adolescent and adult patients with persistent asthma who were enrolled in 8 randomized, double-blind, double-dummy, parallel-group studies. Data on patients' self-rated symptoms, PEF, supplemental albuterol use, nighttime awakenings, and frequency of asthma exacerbations were used to ascertain whether there was a correlation between changes in asthma symptoms and changes in pulmonary function, and to compare treatment effects.

RESULTS

Changes in patients' ratings of asthma symptoms after treatment with study medications showed a strong correlation with changes in lung function. Similarly, changes in lung function were strongly correlated with changes in supplemental beta-agonist use and quality of life. In addition, fluticasone or salmeterol treatment resulted in significantly greater increases in mean morning PEF (P < 0.001), significantly greater decreases in symptom scores (P < or = 0.004), significantly fewer nights with awakenings due to symptoms (P < or = 0.017), and significantly greater reductions in supplemental beta-agonist use (P < 0.001) compared with zafirlukast treatment or placebo. Patients treated with fluticasone or salmeterol also experienced significantly lower rates of asthma exacerbation (3%) during treatment than did those receiving zafirlukast (7%) or placebo (12%) (P < 0.001 and P = 0.015, fluticasone and salmeterol, respectively).

CONCLUSION

These findings support the validity of primary care practitioners' basing asthma-management decisions on patients' symptoms.

Changes in asthma drug therapy costs for patients receiving chronic montelukast therapy in the U.K

The aim of this study was to assess changes in the costs of asthma drug therapy before and during the use of chronic montelukast treatment in the U.K. A retrospective cohort analysis of a primary care database in the U.K. was carried out. Patients with chronic montelukast use (> or = 140 once-daily doses) were selected for analysis. Benchmarking data were obtained for matched patients with chronic inhaled corticosteroid (ICS) use and patients with chronic salmeterol therapy with concomitant ICS use. The main outcome measures were changes in utilization and monthly cost of asthma therapies costs. Asthma patients experienced significant (P<0.05) reductions in the monthly costs of ICS, short-acting beta-agonists and antibiotics following chronic montelukast therapy. Monthly concomitant drug costs were reduced by Pound Sterling 7.49 per month, which offset 27.5% of the additional cost of montelukast, yielding an increase in total drug costs of Pound Sterling 19.78 per month. Meanwhile, increased total drug costs for matched patients with chronic ICS use, and matched patients with chronic salmeterol therapy and concomitant ICS use, increased by Pound Sterling 5.37 per month and Pound Sterling 44.55 per month respectively. Additionally, patients using chronic montelukast therapy experienced a statistically significant (P<0.05) reduction in the use of short acting beta-agonists, and antibiotics, suggesting improvement in asthma control. Chronic use of montelukast therapy is associated with a reduction of concomitant drug therapy costs.

Cost-efficacy comparison of inhaled fluticasone propionate and budesonide in the treatment of asthma

BACKGROUND

The results of a recent meta-analysis comparing 2 inhaled corticosteroids, fluticasone propionate (FP) and budesonide, demonstrated that FP had an improved efficacy-to-safety ratio compared with budesonide. However, limited data are available on the relative economic benefits of these 2 regimens.

OBJECTIVE

This pharmacoeconomic analysis used individual patient data from studies in the meta-analysis to compare the relative cost-efficacy of 2 asthma regimens from the perspective of a US third-party payer.

METHODS

This analysis included all 7 studies in the meta-analysis that compared budesonide with FP dosed at approximately half the dose of budesonide and that included measurement of daily morning peak expiratory flow (PEF).

RESULTS

The total daily per-person cost of asthma management was higher for patients treated with budesonide than with FP ($3.00 vs $2.25, respectively). Treatment with FP had greater cost-efficacy than treatment with budesonide, based on a range of outcome measures that included improvement in morning PEF, symptom-free days, and episode-free days. The daily cost per effectively treated patient (an increase in PEF of > or = 10%) was $5.62 with FP and $10.05 with budesonide. The cost per symptom-free day was $4.36 with FP, compared with $6.67 with budesonide. The cost per episode-free day was $5.60 with FP and $9.42 with budesonide. The pharmacoeconomic difference continued to favor FP as the criteria for success were made more stringent and the cost of budesonide was lowered.

CONCLUSION

Based on data from the 7 randomized, controlled trials, treatment of asthma with FP was more effective and less expensive, using US health care assumptions and costs, than treatment with budesonide.

Nordic consensus report on asthma management. Nordic Asthma Consensus Group

The work with the Nordic consensus report on asthma management started some years ago. The Nordic countries have common socioeconomic conditions. We acknowledge the international as well as other European guidelines providing valuable recommendations. Nevertheless, we felt the need to combine the common Nordic experiences in order to have a local statement of asthma and asthma care, based upon Nordic clinical science and tradition. The work has been rewarding and we acknowledge many valuable contributions from paediatricians, allergologists and lung physicians in all Nordic countries. The response has so far been positive and we feel that the present material reflects the main opinion of Nordic physicians taking care of asthma patients of all ages. However, the asthma and allergy research field is rapidly developing. Thus, this document should merely be regarded as a time-limited contribution to the continuing scientific discussion of this fascinating field.

Do eosinophil counts correlate differently with asthma severity by symptoms versus peak flow rate?

BACKGROUND

Discrepancy in asthmatic assessment by symptoms and peak flow rate (PFR) is a frequent dilemma. Currently, total peripheral eosinophil count (TPEC) is under study for asthma evaluation.

OBJECTIVES

To explore the correlation between TPEC and asthma severity assessed by symptoms alone versus symptoms and PFR.

METHOD

Adults asthmatics were selected from the Asthma Clinic. Severity assessment was based on two methods: symptoms alone or symptoms and PFR. Expiratory PFR was recorded by a Wright peak flow meter. Severity levels included mild intermittent, mild persistent, moderate persistent, and severe persistent. Total peripheral eosinophil count was performed on a Celldyn-3500 counter. Data was analyzed for statistical significance.

RESULTS

Sixty asthmatics aged 15 to 70 years (mean = 34 years), of which 68.3% were female, were studied. Severity levels differed between the two assessment methods in 45% of the cases and showed a predominance of the moderate persistent type. Total peripheral eosinophil count ranged between 22 and 2470 cells/mm3 (mean = 520 +/- SD = 393) and eosinophilia was found in 50% of the cases. Total peripheral eosinophil count showed a high positive correlation with increased asthma severity level assessed by history alone (r = 0.460, P < .001); more than by history and PFR (r = 0.328, P < .05).

CONCLUSION

The discrepancy between symptoms and PFR is confirmed by these results. A reliable objective parameter in asthma assessment is a continuous challenge. This study advocates the possible supplementation of TPEC as another objective parameter that might help in selecting the appropriate severity level in asthmatics.

How the discrepancy between symptoms and peak expiratory flow rate influences evaluation of asthma severity

BACKGROUND

Recent asthma guidelines recommend the assessment of severity levels based on the most severe symptoms and peak expiratory flow rate (PEFR). Discrepancies are frequently encountered in the use of these variables in determining the severity levels of asthmatics. The objective of this study was to determine the difference in asthma severity levels as assessed by either symptoms alone or by PEFR alone, as compared with the assessment by the asthma guidelines.

PATIENTS AND METHODS

Severity levels that were determined by recent asthma guidelines for 60 asthmatic patients were reassessed, based on symptoms alone and PEFR alone. They were compared for any significant differences to the asthma guidelines.

RESULTS

Asthmatics were aged between 15 and 70 (mean 34) years, and 63.8% were females. Severity levels by symptoms alone were different from the guidelines in 27 cases (45%). Of these, 89% showed a tendency toward higher severity levels. Severity levels by PEFR alone were different in only three cases (5%). In both comparisons, differences of severity levels were significant (P<0.0001), but assessment by symptoms alone showed more deviation (x(2) =162.1) than PEFR alone (x(2) =73.1).

CONCLUSION

The study documented significant discrepancies in asthma severity assessed by symptoms alone and PEFR alone, when compared to the recent asthma guidelines. Severity assessed by symptoms alone showed lower levels, and the use of PEFR tended to categorize some asthmatics into a more severe level.

The cost-effectiveness of inhaled fluticasone propionate and budesonide in the treatment of asthma in adults and children

Inhaled corticosteroids form the mainstay of the treatment and management of asthma and the results of a meta-analysis comparing two of the most frequently prescribed inhaled corticosteroids, fluticasone propionate and budesonide, administered in a clinically equivalent 1:2 dose ratio to 1980 patients with asthma, demonstrated that fluticasone propionate had an improved efficacy:safety ratio. However, limited data are available on the relative economic benefits of fluticasone propionate and budesonide. The database for clinically relevant parameters, for which the efficacy:safety meta-analysis had demonstrated statistical significance between the two corticosteroids, was used for this pharmacoeconomic analysis. Treatment with fluticasone propionate was more cost-effective than budesonide with respect to improvement in morning peak expiratory flow rate, successfully treated weeks, symptom-free days, symptom-free 24 h and episode-free days. The costs of treatment for fluticasone propionate and budesonide were 7.78 Pounds per week and 12.33 Pounds per week, respectively. The main contributing factor to the higher costs of budesonide was the higher cost of health care contacts, which were 4.53 Pounds per week for budesonide and 0.57 Pounds per week for fluticasone propionate. The pharmacoeconomic difference increased in favour of fluticasone propionate as the criteria for success were made more stringent. These results demonstrate that, for asthma patients requiring modification of therapy treatment with fluticasone propionate is more effective and also cheaper, in terms of overall health-care costs, than treatment with budesonide.

Reversing the trend: reducing the prevalence of asthma

BACKGROUND

We urgently need to take steps towards reducing the prevalence of asthma in countries where the prevalence has become unacceptably high in recent years. Because we do not have any good information about causes of the increased prevalence, we cannot act directly to reverse the trend. Therefore we need to take an indirect approach and use known information of etiologic factors to try to reduce asthma in the next generation, while acknowledging that we may be dealing with different factors from those responsible for the increased prevalence. Any successful strategies will also help to ensure that developing countries do not attain such high rates of asthma in their children in coming years.

OBJECTIVE

This article summarizes the roles of the risk factors that identify "high-risk" children, that provide insights into mechanisms, or that have potential for primary prevention. The factors with the most potential for primary prevention are allergen exposure, parental smoking, breast-feeding, and dietary fatty acids.

CONCLUSION

In other health models, information about risk factors has been used in successful public health interventions. It is disappointing that the important risk factors for asthma are well documented but that there have been few trials of primary prevention and no changes in public health policies.

Outcomes and cost benefits associated with the introduction of inhaled corticosteroid therapy in a medicaid population of asthmatic patients

A retrospective cohort study was conducted to assess the clinical and economic impact of the introduction of inhaled corticosteroid therapy in the North Carolina Medicaid population of patients with asthma. The case group consisted of 180 patients who were followed for 1 year before and 1 year after the initiation of inhaled corticosteroid therapy. The control group consisted of 233 patients whose asthma was of similar severity to that of the case group and who remained on any therapy other than corticosteroids for a continuous 2-year period. After the initiation of inhaled corticosteroid therapy, the case group had reductions of 50% in hospitalizations, 26% in outpatient visits, and 15% in physician visits. At the end of the second year, the control group had significant increases of 23% in hospitalizations and 36% in outpatient visits. All of the changes were statistically significant. However, after adjusting for potential confounding factors, there was a nearly 24% decrease in total health care costs per asthmatic patient per month as a result of the introduction of inhaled corticosteroid therapy. Overall, we found that there was a cost benefit to Medicaid in the introduction of inhaled corticosteroid therapy and that this therapy brought about dramatic decreases in health care utilization and costs.

Socio-economic burden of asthma, allergy, and other atopic illnesses

Asthma and atopic illness account for a substantial burden of social morbidity. The purpose of this brief report will be to provide an overview of the different dimensions to the socio-economic burden of asthma and other atopic diseases and suggest areas where future research in this area may advance our understanding of the impact of various treatment strategies of these diseases. While there are occasional studies which describe the full dimensions of this social and economic burden, more studies are needed to complete our understanding of this burden especially studies that investigate the relative cost-effectiveness of medical and non-medical interventions. These studies will provide the infrastructure to rationally examine the optimal cost-effective strategies for these illnesses. In particular economic studies are needed to examine how best to balance resource expenditures for preventive versus pharmacologic control. Use of health economic methods will provide insights into the most efficient design and implementation of current disease control, with potentially concomitant reductions in costs and social burden for atopic illnesses, including asthma.