Value-based comparison of ambulatory children with respiratory diseases in an emergency department and a walk-in clinic: a retrospective cohort study in Québec, Canada.

OBJECTIVE: To compare health outcomes and costs given in the emergency department (ED) and walk-in clinics for ambulatory children presenting with acute respiratory diseases. DESIGN: A retrospective cohort study. SETTING: This study was conducted from April 2016 to March 2017 in one ED and one walk-in clinic. The ED is a paediatric tertiary care centre, and the clinic has access to lab tests and X-rays. PARTICIPANTS: Inclusion criteria were children: (1) aged from 2 to 17 years old and (2) discharged home with a diagnosis of upper respiratory tract infection (URTI), pneumonia or acute asthma. MAIN OUTCOME MEASURES: The primary outcome measure was the proportion of patients returning to any ED or clinic within 3 and 7 days of the index visit. The secondary outcome measures were the mean cost of care estimated using time-driven activity-based costing and the incidence of antibiotic prescription for URTI patients. RESULTS: We included 532 children seen in the ED and 201 seen in the walk-in clinic. The incidence of return visits at 3 and 7 days was 20.7% and 27.3% in the ED vs 6.5% and 11.4% in the clinic (adjusted relative risk at 3 days (aRR) (95% CI) 3.17 (1.77 to 5.66) and aRR at 7 days 2.24 (1.46 to 3.44)). The mean cost (95% CI) of care (CAD) at the index visit was $C96.68 (92.62 to 100.74) in the ED vs $C48.82 (45.47 to 52.16) in the clinic (mean difference (95% CI): 46.15 (41.29 to 51.02)). Antibiotic prescription for URTI was less common in the ED than in the clinic (1.5% vs 16.4%; aRR 0.10 (95% CI 0.03 to 0.32)). CONCLUSIONS: The incidence of return visits and cost of care were significantly higher in the ED, while antibiotic use for URTI was more frequent in the walk-in clinic. These data may help determine which setting offers the highest value to ambulatory children with acute respiratory conditions.

Development and validation of a claims-based algorithm to identify moderate exacerbations in patients with asthma treated in the US.

INTRODUCTION: Definitions of moderate asthma exacerbation have been inconsistent, making their economic burden difficult to assess. An algorithm to accurately identify moderate exacerbations from claims data is needed. METHODS: A retrospective cohort study of Reliant Medical Group patients aged ≥18 years, with ≥1 prescription claim for inhaled corticosteroid/long-acting ß2-agonist, and ≥1 medical claim with a diagnosis code for asthma was conducted. The objective was to refine current algorithms to identify moderate exacerbations in claims data and assess the refined algorithm's performance. Positive and negative predictive values (PPV and NPV) were assessed via chart review of 150 moderate exacerbations events and 50 patients without exacerbations. Sensitivity analyses assessed alternative algorithms and compared healthcare resource utilization (HRU) between algorithm-identified patients (claims group) and those confirmed by chart review (confirmed group) to have experienced a moderate exacerbation. RESULTS: Algorithm-identified moderate exacerbations were: visit of ≤1 day with an asthma exacerbation diagnosis OR visit of ≤1 day with selected asthma diagnoses AND ≥1 respiratory pharmacy claim, excluding systemic corticosteroids, within 14 days after the first claim. The algorithm's PPV was 42%; the NPV was 78%. HRU was similar for both groups. CONCLUSION: This algorithm identified potential moderate exacerbations from claims data; however, the modest PPV underscores its limitations in identifying moderate exacerbations, although performance was partially due to identification of previously unidentified severe exacerbations. Application of this algorithm in future claims-based studies may help quantify the economic burden of moderate and severe exacerbations in asthma when an algorithm identifying severe exacerbations is applied first.

Frequency and economic burden of exacerbations in inhaled corticosteroid/long-acting beta-agonist-treated patients with asthma: A retrospective US claims study.

INTRODUCTION: Despite adherence to inhaled corticosteroid/long-acting ß2-agonist (ICS/LABA) therapy, many patients with asthma experience moderate exacerbations. Data on the impact of moderate exacerbations on the healthcare system are limited. This study assessed the frequency and economic burden of moderate exacerbations in patients receiving ICS/LABA. METHODS: Retrospective, longitudinal study analyzed data from Optum's de-identified Clinformatics® Data Mart Database recorded between October 1, 2015, and December 31, 2019. Eligibility criteria included patients ≥18 years of age with ≥1 ICS/LABA claim and ≥1 medical claim for asthma in the 12 months pre-index (first ICS/LABA claim). Primary objectives included describing moderate exacerbation frequency, and associated healthcare resource utilization (HRU) and costs. A secondary objective was assessing the relationship between moderate exacerbations and subsequent risk of severe exacerbations. Patients were stratified by moderate exacerbation frequency in the 12 months post index. Moderate exacerbations were identified using a newly developed algorithm. RESULTS: In the first 12 months post index 61.6% of patients experienced ≥1 moderate exacerbation. Mean number of asthma-related visits was 4.1 per person/year and median total asthma-related costs was $3544. HRU and costs increased with increasing exacerbation frequency. Outpatient and inpatient visits accounted for a similar proportion of these costs. Moderate exacerbations were associated with an increased rate and risk of future severe exacerbations (incidence rate ratio, 1.56; hazard ratio, 1.51 [both p < 0.001]). CONCLUSIONS: This study highlighted that a high proportion of patients continue to experience moderate exacerbations despite ICS/LABA therapy and subsequently experience increased economic burden and risk of future severe exacerbations.

[Economic burden assessment for the management of asthma patients at Mexico's National Institute for Respiratory Diseases]. / Evaluación de la carga económica para el tratamiento de pacientes con asma en el Instituto Nacional de Enfermedades Respiratorias de México.

OBJETIVO: Determinar la carga económica anual del asma, desde una perspectiva institucional y con base en la clasificación recomendada por GINA, en una cohorte retrospectiva de adultos atendidos en el Instituto Nacional de Enfermedades Respiratorias (INER) de México. MÉTODOS: Estudio observacional, longitudinal y retrospectivo, llevado a cabo a partir de la información recabada de 247 pacientes femeninas con asma. Se estimaron los costos directos anuales: visitas, pruebas de laboratorio, tratamiento farmacológico y de las crisis o exacerbaciones, para determinar la carga anual de la enfermedad desde una perspectiva institucional, y según la clasificación de la Iniciativa Global para el Asma. RESULTADOS: El costo promedio anual fue de $43,813,92, que aumentó en relación con la necesidad de aumento de dosis de corticoides inhalados y beta-agonistas de acción prolongada. El costo promedio de la consulta médica fue de $2004.57, $982.82 por gestión de crisis y $2645.95 por pruebas de laboratorio. El tratamiento farmacológico representó la principal carga económica, con un costo promedio anual de $38,180.58. CONCLUSIONES: Los resultados resaltan una carga económica del asma estimada en un costo anual por paciente de $43,813.92 MXN (DE=93,348.85), en el contexto del tercer nivel de atención en el sistema de salud público mexicano. La gravedad del asma, los tratamientos y los biológicos fueron los principales factores que aumentaron los costos directos de la atención.

OBJECTIVE: Determine the annual economic burden of the disease from an institutional perspective and based on GINA's recommended classification in a retrospective cohort of adults treated at Instituto Nacional de Enfermedades Respiratorias (INER) of Mexico City. METHODS: A retrospective, longitudinal observational study comprised by data from 247 female asthma patients, annual direct costs were estimated including: visits, laboratory tests, pharmacological treatment and management of crisis or exacerbations, to determine the annual burden of the disease from an institutional perspective and according to Global Initiative for Asthma classification. RESULTS: The average annual cost was $43,813.92, which increased in relation to the need of inhaled corticosteroids and long-acting beta agonists dosage increase. The average doctor's appointment cost was $2,004.57, $982.82 for crisis management and $2,645.95 for laboratory testing. Pharmacological treatment represented the main economic burden with an annual average cost of $38,180.58. CONCLUSIONS: The results highlight an economic burden of asthma estimated at an annual cost per patient of $43,813.92 MXN (SD=93,348.85) in the context of the third level of care in the Mexican public health system. The asthma severity and treatments such as biologics were the main factors that increased direct costs of care.

Cost-Effectiveness and Impact on Health Care Utilization of Interventions to Improve Medication Adherence and Outcomes in Asthma and Chronic Obstructive Pulmonary Disease: A Systematic Literature Review.

BACKGROUND: Poor adherence to asthma and chronic obstructive pulmonary disease maintenance therapies impairs health outcomes. Proven and cost-effective programs to promote adherence and persistence are not yet in regular widespread use. Implementation costs are a potential barrier to uptake of such programs. OBJECTIVE: We undertook a systematic literature review and narrative synthesis of studies investigating the cost-effectiveness of treatment adherence-promoting programs or that determined their impact on health care budget directly or via health care resource use (HCRU). METHODS: We identified relevant publications using Medline and PreMEDLINE (PubMed), Embase (Embase.com, Elsevier), and EconLit for publications between January 2000 and July 2021. We also searched clinical trial databases and selected conference proceedings. RESULTS: Of 1,910 potentially relevant articles, 26 met prespecified inclusion criteria and underwent data extraction. Eleven reported a direct assessment of adherence, 15 included economic evaluations, and 17 described HCRU. None included an analysis of biologic medication use. When they were studied, interventions were often found to be highly cost-effective, with dominant incremental cost-effectiveness ratios in some cases. Reductions in direct costs and HCRU (health care visits, hospital admissions, and/or the use of medications, including add-on/reliever treatment and antibiotics) were frequently reported. Reported use of maintenance treatments improved in some studies. Counseling and/or digitally informed programs were used in all cases in which favorable outcomes were observed. CONCLUSIONS: Adherence-promoting interventions are mostly cost-effective and often result in reduced HCRU and associated costs. Multidisciplinary care involving one-to-one advice and digitally enhanced communications appear to offer the greatest benefit.

Incremental cost burden among patients with severe uncontrolled asthma in the United States.

BACKGROUND: The economic burden of severe asthma and severe uncontrolled asthma (SUA) is significant. Updated assessments of health care resource utilization (HCRU) and cost are needed given the increase in treatment options and updates to guidelines in recent years. OBJECTIVE: To describe all-cause and asthma-related HCRU and costs among patients with SUA vs patients with nonsevere asthma in the United States using real-world data. METHODS: MarketScan administrative claims databases were used to select adults with persistent asthma for this retrospective analysis between January 1, 2013, and December 31, 2019. Asthma severity status was defined using the Global Initiative for Asthma step 4/5 criteria (index is the earliest date qualifying patients as severe or randomly assigned for nonsevere patients). Patients with SUA were a subset of the severe cohort meeting the following criteria: those who were hospitalized with asthma as the primary diagnosis or had at least 2 emergency department or outpatient visits with an asthma diagnosis and a steroid burst within 7 days. HCRU, costs (allcause and asthma-related defined as medical claims with an asthma diagnosis and pharmacy claims for asthma treatment), work loss, and indirect costs due to absenteeism and short-term disability (STD) were compared between patients with SUA, severe, and nonsevere asthma. Outcomes were reported during a fixed 12-month post-index period using chi-square and t-tests where appropriate. RESULTS: 533,172 patients with persistent asthma were identified (41.9% [223,610]) severe and 58.1% [309,562] nonsevere). Of the severe patients, 17.6% (39,380) had SUA. The mean (SD) all-cause total health care costs were significantly higher in patients with SUA ($23,353 [$40,817]) and severe asthma ($18,554 [$36,147]) compared with those with nonsevere asthma ($16,177 [$37,897], P < 0.001 vs nonsevere asthma). The results were consistent for asthma-related costs. In addition, although patients with severe asthma made up 41.9% of the total study population, they contributed disproportionately higher costs (60.5%) to the total asthma-related direct costs, with the effect more evident among patients with SUA (7.4% of study population contributed 17.7% of the total asthma-related costs). For the subset of patients with asthma with workplace absenteeism, patients with SUA lost more time from work (259.3 vs 236.2 hours lost, P = 0.002; 7.8 vs 5.3 STD days, P < 0.001), and had higher corresponding indirect costs ($5,944 vs $5,415, P = 0.002 for absenteeism related; $856 vs $582, P < 0.001 for STD related) compared with patients with nonsevere asthma. CONCLUSIONS: Patients with SUA have significantly higher asthma-related economic burden compared with patients with nonsevere asthma and contribute a disproportionally higher percentage of asthma-related costs. DISCLOSURES: This study was funded by Amgen and AstraZeneca. The design and analysis for this study was conducted primarily by Merative. Amgen and AstraZeneca provided funding to support protocol development, data analysis, and manuscript development activities associated with this study. Dr Burnette is on the advisory board and a consultant for GSK, a consultant and member of the advisory boards and speakers' bureaus of Sanofi, Genzyme, Regeneron, AstraZeneca, and Amgen Inc. Dr Wang, Dr Rane, Dr Lindsley, and Dr Llanos are employees and shareholders of Amgen Inc. Dr Chung and Dr Ambrose are employees and shareholders of AstraZeneca. Ms Princic and Ms Park are employees of Merative, which received funding from Amgen to conduct this study.

Association of a Housing Mobility Program With Childhood Asthma Symptoms and Exacerbations.

Importance: Structural racism has been implicated in the disproportionally high asthma morbidity experienced by children living in disadvantaged, urban neighborhoods. Current approaches designed to reduce asthma triggers have modest impact. Objective: To examine whether participation in a housing mobility program that provided housing vouchers and assistance moving to low-poverty neighborhoods was associated with reduced asthma morbidity among children and to explore potential mediating factors. Design, Setting, and Participants: Cohort study of 123 children aged 5 to 17 years with persistent asthma whose families participated in the Baltimore Regional Housing Partnership housing mobility program from 2016 to 2020. Children were matched to 115 children enrolled in the Urban Environment and Childhood Asthma (URECA) birth cohort using propensity scores. Exposure: Moving to a low-poverty neighborhood. Main Outcomes: Caregiver-reported asthma exacerbations and symptoms. Results: Among 123 children enrolled in the program, median age was 8.4 years, 58 (47.2%) were female, and 120 (97.6%) were Black. Prior to moving, 89 of 110 children (81%) lived in a high-poverty census tract (>20% of families below the poverty line); after moving, only 1 of 106 children with after-move data (0.9%) lived in a high-poverty tract. Among this cohort, 15.1% (SD, 35.8) had at least 1 exacerbation per 3-month period prior to moving vs 8.5% (SD, 28.0) after moving, an adjusted difference of -6.8 percentage points (95% CI, -11.9% to -1.7%; P = .009). Maximum symptom days in the past 2 weeks were 5.1 (SD, 5.0) before moving and 2.7 (SD, 3.8) after moving, an adjusted difference of -2.37 days (95% CI, -3.14 to -1.59; P < .001). Results remained significant in propensity score-matched analyses with URECA data. Measures of stress, including social cohesion, neighborhood safety, and urban stress, all improved with moving and were estimated to mediate between 29% and 35% of the association between moving and asthma exacerbations. Conclusions and Relevance: Children with asthma whose families participated in a program that helped them move into low-poverty neighborhoods experienced significant improvements in asthma symptom days and exacerbations. This study adds to the limited evidence suggesting that programs to counter housing discrimination can reduce childhood asthma morbidity.

Association of Family Income With Morbidity and Mortality Among US Lower-Income Children and Adolescents.

Importance: Family income is known to be associated with children's health; the association may be particularly pronounced among lower-income children in the US, who tend to have more limited access to health resources than their higher-income peers. Objective: To investigate the association of family income with claims-based measures of morbidity and mortality among children and adolescents in lower-income families in the US enrolled in Medicaid or the Children's Health Insurance Program. Design, Setting, and Participants: This cross-sectional analysis included 795 000 participants aged 5 to 17 years enrolled in Medicaid (Medicaid Analytic eXtract claims, 2011-2012) living in families with income below 200% of the federal poverty threshold (American Community Survey, 2008-2013). Follow-up ended in December 2021. Exposures: Family income relative to the federal poverty threshold. Main Outcomes and Measures: Record of International Classification of Diseases, Ninth Revision codes for an infection, mental health disorder, injury, asthma, anemia, or substance use disorder and death record within 10 years of observation (Social Security Administration death records through 2021). Results: Among 795 000 individuals in the sample (all statistics weighted: mean [SD] income-to-poverty ratio, 90% [53%]; mean [SD] age, 10.6 [3.9] years; 56% aged 10 to 17 years), 33% had a diagnosed infection, 13% had a mental health disorder, 6% had an injury, 5% had asthma, 2% had anemia, 1% had a substance use disorder, and 0.6% died between 2011 and 2021, with the mean (SD) age at death of 19.8 (4.2) years. For those aged 5 to 9 years, higher family income was associated with lower adjusted prevalence of all outcomes, except mortality: children in families with an additional 100% income relative to the federal poverty threshold had 2.3 (95% CI, 1.8-2.9) percentage points fewer infections, 1.9 (95% CI, 1.5-2.2) percentage points fewer mental health diagnoses, 0.7 (95% CI, 0.5-0.8) percentage points fewer injuries, 0.3 (95% CI, 0.09-0.5) percentage points less asthma, 0.2 (95% CI, 0.08-0.3) percentage points less anemia, and 0.06 (95% CI, 0.03-0.09) percentage points fewer substance use disorder diagnoses. Except for injury and anemia, the associations were more pronounced among those aged 10 to 17 years than those 5 to 9 years (P for interaction <.05). For those aged 10 to 17 years, an additional 100% income relative to the federal poverty threshold was associated with a lower 10-year mortality rate by 0.18 (95% CI, 0.12-0.25) percentage points. Conclusions and Relevance: Among children and adolescents in the US aged 5 to 17 years with family income under 200% of the federal poverty threshold who accessed health care through Medicaid or the Children's Health Insurance Program, higher family income was significantly associated with a lower prevalence of diagnosed infections, mental health disorders, injury, asthma, anemia, and substance use disorders and lower 10-year mortality. Further research is needed to understand whether these associations are causal.

Direct healthcare costs associated with management of asthma: comparison of two treatment regimens in Indonesia, Thailand and Vietnam.

OBJECTIVE: Daily inhaled corticosteroid (ICS) and long-acting beta-2-agonist (LABA) combinations comprising either regular maintenance therapy with ICS/LABA plus as-needed short-acting beta-2-agonist (SABA) or ICS-formoterol combinations used as maintenance and reliever therapy (MART) are recommended for moderate asthma. This analysis compares the direct costs of twice-daily fluticasone propionate/salmeterol (FP/salm) and budesonide/formoterol MART in three Southeast Asian countries. METHODS: A literature review identified three randomized trials in patients with asthma (≥ 12 years) comparing regular twice-daily FP/salm with as-needed SABA versus MART in moderate asthma: AHEAD (NCT00242775/17 countries/2309 patients), COMPASS (AstraZeneca study SD-039-0735/16 countries/3335 patients), and COSMOS (AstraZeneca study SD-039-0691/16 countries/2143 patients). Economic analyses, conducted from a healthcare sector perspective (medication costs + healthcare utilization costs), applied unit costs from countries where healthcare costs are publicly available: Indonesia, Thailand and Vietnam. Results are expressed in British pound sterling (GBP/patient/year). RESULTS: Annual exacerbation rates were low and differences between treatment strategies were small (range, FP/salm: 0.31-0.38, MART: 0.24-0.25) although statistically significant in favor of MART. Total average (minimum-maximum) direct costs (in GBP/patient/year) across the three studies were £187 (£137-£284), £158 (£125-£190), and £151 (£141-£164) for those who used FP/salm, and £242 (£217-£267), £284 (£237-£340) and £266 (£224-£315) for MART in Indonesia, Thailand and Vietnam, respectively. On average, total direct costs/patient/year with FP/salm were 22.8%, 44.6% and 43.0% lower than with MART for Indonesia, Thailand and Vietnam, respectively. CONCLUSIONS: In the three countries evaluated, total treatment costs with regular twice-daily FP/salm were consistently lower than with budesonide/formoterol MART due to lower direct healthcare costs.

Analysis of the Budget Impact of Fractional Exhaled Nitric Oxide Monitoring in the Management of Childhood Asthma: The Colombian National Health System Perspective

Background: Fractional exhaled nitric oxide (FeNO) testing is a simple, noninvasive approach to assessing airway inflammation withminimal discomfort that provides results within a few minutes. For policy makers, the economic impact of this technology is the mainconcern, especially in developing countries. We evaluated the budget impact of asthma management using FeNO monitoring in patientsaged between 4 and 18 years in Colombia.Methods: A budget impact analysis was performed to evaluate the potential cost of FeNO monitoring. The analysis was based on a5-year time horizon and performed from the perspective of the Colombian National Health System. The incremental budget impact wascalculated by subtracting the cost of the new treatment, in which FeNO is reimbursed, from the cost of conventional treatment withoutFeNO (management based on clinical symptoms [with or without spirometry/peak flow] or asthma guidelines [or both] for asthma-relatedcases). Univariate 1-way sensitivity analyses were performed.Results: In the base case analysis the 5-year costs associated with FeNO and non-FeNO were estimated to be €469 904 130 and€480 485 149, respectively, indicating savings for the Colombian National Health System of €10 581 019 if FeNO is adopted for theroutine management of patients with persistent asthma. This result proved to be robust in the univariate 1-way sensitivity analysis.Conclusion: FeNO monitoring generated cost savings in emergency settings for infants with persistent asthma. This evidence can be used bydecision makers in Colombia to improve clinical practice guidelines and should be replicated to validate the results in other middle-income countries (AU)

Antecedentes: El óxido nítrico en aire exhalado es una medición simple y no invasiva de la inflamación de las vías respiratorias cuyosresultados están disponibles en pocos minutos. Para los responsables de la formulación de políticas sanitarias, la principal preocupaciónes el impacto económico que implica la adaptación de esta tecnología, muy especialmente en los países en desarrollo. Este estudiotiene como objetivo evaluar el impacto presupuestario, en el sistema Nacional de Salud de Colombia, del manejo del asma mediante lamonitorización de óxido nítrico exhalado en pacientes entre 4 y 18 años.Métodos: Se realizó un análisis de impacto presupuestario para evaluar el posible impacto financiero derivado de la implementación de lamonitorización óxido nítrico exhalado fraccionado en el asma. El análisis consideró un horizonte temporal de 5 años y la perspectiva delSistema Nacional de Salud de Colombia. El impacto presupuestario incremental se calculó restando el coste del nuevo tratamiento, en elque se reembolsa el FeNO, del coste del tratamiento convencional sin FeNO (manejo basado en síntomas clínicos (con o sin espirometría /flujo máximo) o guías de asma (o ambos), para los relacionados con el asma). Se realizaron análisis de sensibilidad univariantes de una vía.Resultados: En el análisis del caso base, los costos a 5 años asociados a FeNO y no FeNO se estimaron en 469.904.130 € y 480.485.149 €respectivamente, lo que indica un ahorro para la Salud Nacional de Colombia de 10.581.019 € si se adopta la monitorización de FeNOen el manejo rutinario de pacientes con asma persistente. La solidez de este resultado fue confirmada en el análisis de sensibilidadunivariante, unidireccional.Conclusión: El óxido nítrico exhalado fraccionado ahorró costos en los entornos de emergencia en población pediátrica con asma persistente.Esta evidencia puede ser utilizada por los tomadores de decisiones en nuestro país para mejorar las guías de práctica clínic

Cost-utility of as-needed ICS-formoterol versus to maintenance ICS in mild to moderate persistent asthma.

BACKGROUND: Recent asthma guidelines, such as the Global Initiative for Asthma (GINA), recommend in adult patients as-needed inhaled corticosteroids (ICS)-formoterol as an alternative to maintenance ICS in mild to moderate persistent asthma. The introduction of these recommendations concerns whether using as-needed budesonide-formoterol would be more cost-effective than to maintenance ICS. This study aimed to evaluate the cost-effectiveness of as-needed combination low-dose budesonide-formoterol compared to short-acting ß2-agonist (SABA) reliever therapy in patients with mild asthma. METHODS: A probabilistic Markov model was created to estimate the cost and quality-adjusted life-years (QALYs) of patients with mild asthma in Colombia. Total costs and QALYs of low-dose budesonide-formoterol compared to short-acting ß2-agonist (SABA) were calculated over a lifetime horizon. Multiple sensitivity analyses were conducted. Cost-effectiveness was evaluated at a willingness-to-pay value of $19,000. RESULTS: The model suggests a potential gain of 0.37 QALYs and per patient per year on as-needed ICS-formoterol and a reduction in the discounted cost per person-year, of as-needed ICS-formoterol to maintenance ICS, of US$40. This position of dominance of as-needed ICS-formoterol negates the need to calculate an incremental cost-effectiveness ratio. In the deterministic and probabilistic sensitivity analysis, our base-case results were robust to variations in all assumptions and parameters. CONCLUSION: Low-dose budesonide-formoterol as a reliever was cost-effective when added to usual care in patients with mild asthma. Our study provides evidence that should be used by decision-makers to improve clinical practice guidelines and should be replicated to validate their results in other middle-income countries.

Cost-utility of triple versus dual inhaler therapy in moderate to severe asthma.

BACKGROUND: An important proportion of asthma patients remain uncontrolled despite using inhaled corticosteroids and long-acting beta-agonists. Clinical guidelines recommend, in these patients, using add-on long-acting muscarinic antagonists (triple therapy) to treatment with high doses of inhaled corticosteroids-long-acting beta2-agonist (dual therapy). The purpose of this study was to assess the cost-effectiveness of triple therapy versus dual therapy for patients with severe asthma. METHODS: A probabilistic Markov model was created to estimate the cost and quality-adjusted life-years (QALYs) of patients with severe asthma in Colombia. Total costs and QALYS of dual and triple therapy were calculated over a lifetime horizon. Multiple sensitivity analyses were conducted. Cost-effectiveness was evaluated at a willingness-to-pay value of $19,000. RESULTS: The model suggests a potential gain of 1.55 QALYs per patient per year on triple therapy with respect to dual therapy. We observed a difference of US$304 in discounted cost per person-year on triple therapy with respect to dual therapy. The incremental cost-effectiveness ratio was US$196 in the probabilistic model. In the sensitivity analysis, our base-case results were robust to variations in all assumptions and parameters. CONCLUSION: In conclusion, triple therapy in patients with moderate-severe asthma was cost-effective. Using triple therapy emerges with our results as an alternative before using oral corticosteroids or biologics, especially in resource-limited settings.

Understanding socio-economic inequalities in the prevalence of asthma in India: an evidence from national sample survey 2017-18.

BACKGROUND: Today, over 300 million people reside with asthma worldwide and India alone is home for 6% of children and 2% of adults suffering from this chronic disease. A common notion of disparity persists in terms of health outcomes across the poor and better-off section of the society. Thus, there is a need to explore socio-economic inequality in the contribution of various factors associated with asthma prevalence in India. METHODS: Data for the study were carved out from the 75th round of National Sample Survey (NSS), collected by the National Sample Survey Organization (NSSO) during 2017-18. The sample size for this study was 555,289 individuals, for which data was used for the analysis. Descriptive statistics were used to show the distribution of the study population. Further, bivariate and multivariate analysis was performed to identify the factors associated with Asthma prevalence. The concentration index was used to measure the inequality. Further, we used decomposition analysis to find the contribution of factors responsible for socio-economic status-related inequality in asthma prevalence. RESULTS: The prevalence of asthma was 2 per 1000 in the whole population; however, the prevalence differs by age groups in a significant manner. Age, sex, educational status, place of residence, cooking fuel, source of drinking water, household size and garbage disposal facility were significantly associated with asthma prevalence in India. It was found that asthma was more concentrated among individuals from higher socioeconomic status (concentration index: 0.15; p < 0.05). While exploring socio-economic inequality for asthma, richest wealth status (53.9%) was the most significant contributor in explaining the majority of the inequality followed by the urban place of residence (37.9%) and individual from age group 45-65 years (33.3%). Additionally, individual aged 65 years and above (27.9%) and household size less than four members (14.7%) contributed in explaining socio-economic inequality for asthma. CONCLUSION: Due to the heterogeneous nature of asthma, associations between different socio-economic indicators and asthma can be complex and may point in different directions. Hence, considering the concentration of asthma prevalence in vulnerable populations and its long-term effect on general health, a comprehensive programme to tackle chronic respiratory diseases and asthma, in particular, is urgently needed.

Health expenditures of asthma-COPD overlap in Northern Jordan.

OBJECTIVE: To investigate the characteristics and medical expenditures of patients with Asthma- chronic obstructive pulmonary disease (COPD) overlap (ACO) compared to asthma and COPD patients. METHODS: This was a retrospective cohort study involving patients diagnosed with ACO, asthma or COPD as of January 2016. Medical records for patients attending King Abdullah University Hospital (KAUH), in northern Jordan, during the years 2015-2016 were used to identify eligible patients and all relevant clinical characteristics. Both respiratory and all-cause charges were extracted from KAUH billing system during the year 2016. Total, inpatient, outpatient, and pharmacy charges were described and compared across the three disease categories. Charges were measured in Jordanian Dinar (JOD, equal to 1.41 US Dollar). RESULTS: Of a total of 761, 87 ACO patients, 494 asthmatic patients and 180 COPD patients were identified and included in this study. The average total respiratory-related charges were significantly higher in patients with ACO compared to patients with asthma (601.4 versus 354.3 JODs; P value < 0.001). Average all-cause charges were higher in case of ACO and COPD compared to patients with asthma (1830.8 and 1705.4 versus 1251.7 JODs; P value < 0.001). ACO was a significant predictor of higher respiratory and all-cause related charges. Respiratory charges were also higher in older patients and those with higher disease severity. CONCLUSIONS: ACO is a risk factor for incurring higher health expenditures in Jordan. Higher respiratory expenditures are also associated with older ages and higher disease severity.

Clinical and economic burden of neovascular age-related macular degeneration by disease status: a US claims-based analysis.

BACKGROUND: New treatment alternatives have revolutionized the management of nAMD. However, there is limited evidence on the clinical and economic burden of nAMD in commercially insured US patients. OBJECTIVES: To examine the clinical and economic burden in patients with nAMD by disease status in the commercially insured US patient population and to identify drivers of nAMD-related costs. METHODS: Patients with at least 1 International Classification of Diseases, 10th Revision Clinical Modification (ICD-10-CM) diagnosis for nAMD were identified from the IQVIA PharMetrics Plus database between April 2016 and August 2017 (index period). Patients had continuous enrollment for at least 6 months before and at least 12 months after the index date. Eye-level disease status was reported, along with intravitreal anti-VEGF treatment patterns. Health care resource utilization (HRU) (all-cause and nAMD-related) and direct health care costs were estimated over the 12 month follow-up period. Outcomes associated with falls and fractures were also assessed. Multivariate analysis identified drivers of annual nAMD-related outpatient costs among patients with anti-VEGF therapy. Incident patients (defined as those without an nAMD diagnosis 6 months prior to the index date) with at least 18 months of continuous enrollment after the index date were identified for a subset analysis to evaluate documented changes in disease status. RESULTS: A total of 6,076 patients with nAMD were identified for the prevalent cohort; 60.1%, 17.2%, and 5.9% had active CNV, inactive CNV, and inactive scar disease stage at index, respectively. The nAMD-related outpatient visit costs were roughly 4 and roughly 7 times higher, respectively, for the active CNV group ($8,658 [SD = $11,612]) compared with the inactive CNV ($2,406 [SD = $5,510]) and inactive scar ($1,198 [SD = $3,035]) groups (P < 0.0001). About 10% of prevalent patients had a fall/fracture claim over 12 months of follow-up. A total of 3,623 prevalent patients (59.6%) were eligible for the anti-VEGF treatment patterns analysis (mean [SD] duration of therapy = 7.7 [4.5] months; mean [SD] number of injections = 6.0 [3.7]). Qualified incident cases comprised 17.8% (n = 1,081) of the prevalent cohort. Approximately 20% of incident eyes with active CNV at baseline transitioned to inactive CNV. A total of 427 incident patients (39.5%) qualified for anti-VEGF treatment patterns analysis (mean [SD] duration of therapy = 6.2 [4.7] months, mean [SD] number of injections = 5.2 [3.5]). Significant drivers of total nAMD-related costs were the initial anti-VEGF agent and anti-VEGF injection frequency (P < 0.0001) in both prevalent and incident cohorts. CONCLUSIONS: The clinical and economic burden of nAMD treatment is substantial to the US healthcare system, where economic burden is higher among those with active CNV. Appropriate treatment may increase the duration of inactive disease periods and preserve visual acuity while lowering costs. DISCLOSURES: This study was funded by Allergan, an AbbVie Company. Allergan employees were involved in the study design, interpretation of data, writing of the manuscript, and the decision to submit for publication. Keyloun and Campbell are employees of Allergan. Multani, McGuiness, and Chen are employees of IQVIA, which received funding from Allergan for conducting the analysis. Almony and Shah-Manek have nothing to disclose.

Identifying Conditions With High Prevalence, Cost, and Variation in Cost in US Children's Hospitals.

Importance: Identifying high priority pediatric conditions is important for setting a research agenda in hospital pediatrics that will benefit families, clinicians, and the health care system. However, the last such prioritization study was conducted more than a decade ago and used International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Objectives: To identify conditions that should be prioritized for comparative effectiveness research based on prevalence, cost, and variation in cost of hospitalizations using contemporary data at US children's hospitals. Design, Setting, and Participants: This retrospective cohort study of children with hospital encounters used data from the Pediatric Health Information System database. Children younger than 18 years with inpatient hospital encounters at 45 tertiary care US children's hospitals between January 1, 2016, and December 31, 2019, were included. Data were analyzed from March 2020 to April 2021. Main Outcomes and Measures: The condition-specific prevalence and total standardized cost, the corresponding prevalence and cost ranks, and the variation in standardized cost per encounter across hospitals were analyzed. The variation in cost was assessed using the number of outlier hospitals and intraclass correlation coefficient. Results: There were 2 882 490 inpatient hospital encounters (median [interquartile range] age, 4 [1-12] years; 1 554 024 [53.9%] boys) included. Among the 50 most prevalent and 50 most costly conditions (total, 74 conditions), 49 (66.2%) were medical, 15 (20.3%) were surgical, and 10 (13.5%) were medical/surgical. The top 10 conditions by cost accounted for $12.4 billion of $33.4 billion total costs (37.4%) and 592 815 encounters (33.8% of all encounters). Of 74 conditions, 4 conditions had an intraclass correlation coefficient (ICC) of 0.30 or higher (ie, major depressive disorder: ICC, 0.49; type 1 diabetes with complications: ICC, 0.36; diabetic ketoacidosis: ICC, 0.33; acute appendicitis without peritonitis: ICC, 0.30), and 9 conditions had an ICC higher than 0.20 (scoliosis: ICC, 0.27; hypertrophy of tonsils and adenoids: ICC, 0.26; supracondylar fracture of humerus: ICC, 0.25; cleft lip and palate: ICC, 0.24; acute appendicitis with peritonitis: ICC, 0.21). Examples of conditions high in prevalence, cost, and variation in cost included major depressive disorder (cost rank, 19; prevalence rank, 10; ICC, 0.49), scoliosis (cost rank, 6; prevalence rank, 38; ICC, 0.27), acute appendicitis with peritonitis (cost rank, 13; prevalence rank, 11; ICC, 0.21), asthma (cost rank, 10; prevalence rank, 2; ICC, 0.17), and dehydration (cost rank, 24; prevalence rank, 8; ICC, 0.18). Conclusions and Relevance: This cohort study found that major depressive disorder, scoliosis, acute appendicitis with peritonitis, asthma, and dehydration were high in prevalence, costs, and variation in cost. These results could help identify where future comparative effectiveness research in hospital pediatrics should be targeted to improve the care and outcomes of hospitalized children.

Cost-effectiveness analysis of anti-IL-5 therapies of severe eosinophilic asthma in Spain.

AIM: To analyse the cost-effectiveness of MEP with standard of care (SoC) versus other anti-IL-5 therapies approved for the treatment of severe eosinophilic asthma (SEA) patients, within the Spanish National Health System (NHS) perspective. METHODS: A Markov model with a 4-week cycle length was used to compare MEP with BEN and RES as therapies added to SoC in the management of SEA, in terms of cost per QALY gained and incremental cost-effectiveness ratio (ICER). Costs (€2019) were obtained from public sources, while utilities and transition probabilities were retrieved from literature, e.g. network meta-analysis. Continuation criteria for biological treatment and reduction of oral corticosteroids (OCS) was set at 50% minimum reduction of exacerbation rate. Adverse events related to chronic OCS use included diabetes, osteoporosis, cataracts, acute myocardial infarct, and peptic ulcer. The analysis was performed over a 5-year time horizon from the National Healthcare System (NHCS) perspective, with a yearly discount rate of 3% applied to both costs and QALYs. Probabilistic sensitivity analysis and univariate deterministic sensitivity analysis were performed to address uncertainty around the cost-effectiveness results. RESULTS: On top of SoC, the model indicates that MEP is dominant (lower cost, higher benefit) compared to BEN and RES: For BEN and RES, respectively, treatment with MEP had a point estimate of 0.076 and 0.075 additional QALYs, and savings of €3,173.47 and €7,772.95 per patient. The findings were robust to variation as estimated using sensitivity analysis. CONCLUSIONS: MEP is a cost-effective treatment in comparison with BEN and RES added to SoC for patients with SEA in the Spanish setting.