Characterisation of asthma management in the Fallon Community Health Plan from 1988 to 1991

Economic burden of asthma: implications for outcomes and cost-effectiveness analyses

Asthma is a disease of chronic airway inflammation. It is of importance to clinicians and health systems because the hospitalization and death rate due to asthma have increased since 1980. Cost of illness studies have estimated that the total cost of asthma (direct and indirect costs) exceed USD 10 billion annually, in the USA. Since 1985, the proportion of asthma costs in hospitals have decreased and the proportion of costs due to asthma medications have increased. However, approximately half of direct medical costs of asthma are due to hospitalizations. The mean direct cost of asthma per year per patient has been estimated to be approximately USD 1,100. As the implementation of national and international guidelines continues, future costs for asthma will likely come from the treatment and management of the disease. Adequate assessments of treatment and cost-effectiveness analysis are important. Recommendations promoting the use of cost-effective anti-inflammatory medications are crucial to efficiently managing asthma.

[The costs of asthma in France: an economic analysis by a Markov model]

INTRODUCTION

In France about 3.5 million people suffer from asthma, with an estimated annual cost of 1.5 billion euros. Few data on the components of the cost are available. To develop a medico-economic model to identify the mean annual cost of a patient with asthma together with the components of the cost and the consequences of different modalities of management (out-patient and in-patient).

METHODS

A first degree homogeneous Markov model was constructed, based on published data, to identify the different states of health of asthmatic patients, their development and probabilities of change from one to another.

RESULTS

The mean annual cost of asthma is 631 +/- 299 euros; 298 euros for stable patients, 1,052 for those who have at least one acute attack and 3,811 for those hospitalised. Actions leading to better control of the disease in the community (prevention and management of attacks) would produce a larger reduction in mean costs than actions undertaken in patients seen as an emergency or admitted to hospital.

CONCLUSIONS

From the point of view of society better control of asthma in the community is the most effective strategy to reduce expenditure.

Level of control and hospital contacts in persistent asthma

The purpose of this study was to estimate relationships between asthma control and hospital contacts (visits to emergency rooms and hospitalizations) in a group of patients suffering from persistent asthma, after adjustment for prior use of inhaled corticosteroids. A computerized family practice database was used to identify patients (aged 6-50 years) with persistent asthma who received asthma therapy from January 1995. The database provided information on patient demographics and drug therapy. Asthma control was estimated by a survey of patients at the end of a 12-month study period. Frequency of hospital contacts during the study period was related to demographics, asthma control, and prescribed doses of inhaled corticosteroids during a prestudy period. Review of computerized medical files of 497 family practice physicians identified 1,966 patients with persistent asthma who met the study criteria. Of these patients, 1,251 completed the survey (63.6%). Asthma control was assessed in 1,130 patients; it was moderate or poor in 42% of the cases. During the 12-month study period, 14.8% of patients reported at least one hospital contact. The level of asthma control was significantly (p < 0.001) associated with hospital contacts. The odds ratio (OR) for hospital contact for good and poor asthma control was 0.5 (95% confidence interval [CI] 0.2-0.7) and 2.2 (95% CI 1.2-4.4), respectively. Asthma control was related to hospital contacts independently of use of inhaled corticosteroids before the study period. Overall, control of asthma was not optimal in this population. The occurrence of hospital contacts was closely related with the level of control. This association was independent of the dose of inhaled corticosteroids prescribed before the study, suggesting that in asthma, hospital contacts are primarily related to the level of control experienced by the patients.

Cost implications for the use of inhaled anti-inflammatory medications in the treatment of asthma

OBJECTIVE

To compare the expected costs of treating patients with asthma with versus without inhaled anti-inflammatory medications, adjusting for other factors that also influence medical care expenditures.

DESIGN

Nonlinear exponential regression analyses were used to estimate relationships between medical care expenditures and treatment with inhaled corticosteroids, sodium cromoglycate (cromolyn) or nedocromil. The regressions adjusted for differences in patients' demographics, location, plan type and severity of illness.

SETTING

Large, self-insured, corporate-sponsored medical plans represented in MarketScan database.

PATIENTS AND PARTICIPANTS

7466 continuously enrolled patients with asthma.

INTERVENTIONS

Treatment with inhaled corticosteroids, sodium cromoglycate or nedocromil.

MAIN OUTCOME MEASURES

(i) Total inpatient, outpatient and pharmaceutical expenditures; and (ii) asthma-related expenditures in the 1996 calendar year.

RESULTS

If all patients had been treated with inhaled anti-inflammatory drugs, total expenditures would be expected to be about $US944.82 per patient lower, on average, than would be the case if no patients received these drugs. Asthma-related expenditures would be about $US498.74 per patient higher, on average, if all patients were treated with these drugs.

CONCLUSIONS

Using inhaled anti-inflammatory agents would be associated with higher asthma-related expenditures but lower total expenditures. Treatment with inhaled anti-inflammatory drugs may represent an investment in better care that pays off with better health and lower total medical care expenditures.

Direct medical costs of chronic obstructive pulmonary disease: chronic bronchitis and emphysema

In this study we aimed to estimate direct medical costs of Chronic Obstructive Pulmonary Disease (COPD) by disease type; chronic bronchitis and emphysema. This study estimates direct costs in 1996 dollars using a prevalence approach and both aggregate and microcosting. A societal perspective is taken using prevalence, and multiple national, state and local data sources are used to estimate health-care utilization and costs. Chronic bronchitis and emphysema together account for $14.5 billion in annual direct costs. Inpatient costs are greater than outpatient and emergency costs ($8.3 vs. $7.8 billion) and hospital and medication costs account for most resources spent. The high prevalence of chronic bronchitis accounts for its larger total costs ($11.7 billion) compared with emphysema ($2.8 billion). Emphysema, which is more severe, has higher costs per prevalent case ($1341 vs. $816). Hospital stays account for the highest costs, $6.0 billion for chronic bronchitis and $1.9 billion for emphysema. The hospitalization rate, length of stay and average cost per prevalent case are higher for emphysema than for chronic bronchitis. Medication costs are the second highest cost category ($4.4 billion for chronic bronchitis, $0.693 billion for emphysema). The high hospitalization and low home care costs (0.2% of total) suggest underuse of home care and room to shift from acute to preventive care. More attention to healthcare management of chronic bronchitis and emphysema is suggested, and improving inhaler and anti-smoking compliance might be important targets.

A national estimate of the economic costs of asthma

This cost of illness analysis examines national cost and resource utilization by persons with asthma using a single, comprehensive data source, the 1987 National Medical Expenditure Survey. Direct medical expenditures included payments for ambulatory care visits, hospital outpatient services, hospital inpatient stays, emergency department visits, physician and facility payments, and prescribed medicines. Indirect medical costs included costs resulting from missed work or school and days with restricted activity at work. Point estimates and 95% confidence intervals (CI) were calculated and inflated to 1994 dollars. The total estimated cost was $5.8 billion (95% CI, $3.6 to $8 billion). The estimated direct expenditures were $5.1 billion (95% CI, $3.3 to $7.0 billion), and indirect expenditures were valued at $673 million (95% CI, $271 to $1,076 million). Hospitalization accounted for more than half of all expenditures. More than 80% of resources were used by 20% of the population (defined as 'high-cost patients'). The estimated annual per patient cost for those high-cost patients was $2,584, in contrast with $140 for the rest of the sample. Findings from this study indicate that future asthma research and intervention efforts directed at hospitalizations and high-cost patients could help to decrease health care resource use and provide cost savings.