The Economic Burden of Asthma in Greece: A Cross-Sectional Study

The association between fruit and vegetable intake and the odds of asthma among children and adolescents

BACKGROUND

Previous epidemiological studies on the correlation between fruit and vegetable consumption and asthma, the majority of them were conducted in developed countries, have led to conflicting results. This study aimed to examine the relationship between fruit and vegetable intake and the risk of asthma among a large sample of children and adolescents.

METHODS

This cross-sectional study was conducted as part of the Global Asthma Network (GAN) on 7667 Iranian children and adolescents. Asthma and its related outcomes were measured using validated questionnaires. A food frequency method was used to assess the dietary intake. The association between fruit and vegetable intake and asthma and its related symptoms was examined using logistic regression.

RESULTS

After adjustment for all possible confounding variables, no significant association was found between fruit and vegetable intake and the odds of medication use for asthma and asthma confirmed by a doctor. However, an inverse significant trend was found between fruits intake and current asthma. After adjusting for age, sex, BMI, and the use of television and computers, participants who regularly consumed fruit had a 37% lower likelihood of experiencing wheezing in the past 12 months (OR = 0.63; 95% CI: 0.42-0.94, P trend = 0.001) compared to those who never or only occasionally consumed fruit. Additionally, individuals who reported consuming vegetables most or all days had a 38% reduced chance of wheezing in the past 12 months (OR = 0.62; 95% CI: 0.48-0.80, P trend < 0.001) compared to participants with infrequent vegetable intake. Participants with regular fruit and vegetable intake combined (OR = 0.50; 95% CI: 0.31-0.82, P trend < 0.001) had a 50% lower likelihood of wheezing in the past 12 months in comparison with those who never or only occasionally fruits and vegetables combined consumers.

CONCLUSION

Our findings suggest that regular consumption of fruits and vegetables on most or all days has a protective effect against wheezing in the past 12 months. Future longitudinal studies should be conducted to confirm our findings.

Primary healthcare professionals' perceptions, attitudes and ideas regarding asthma management in Greece: A mixed-method study

BACKGROUND

Implementing asthma guideline recommendations is challenging and there is variation between countries, and different healthcare professionals (HCPs). The International Primary Care Respiratory Group (IPCRG) has introduced the Asthma Right Care (ARC) programme implemented in 24 low, middle, and high countries, including Greece. It offers a promising approach drawn from social movements for health to improve asthma care by engaging HCPs in implementing guideline-based asthma care.

OBJECTIVES

To explore HCPs' perspectives on current provision of asthma care and their willingness to improve implementation of recommended guidelines using ARC programme tools in Greece.

METHODS

A mixed methods study conducted from September 2020 to April 2021. A convenience sample of 30 pharmacists, and 10 General Practitioners (GPs), responded to a questionnaire investigating perceptions, and attitudes, towards implementation of asthma guidelines. Then, a qualitative survey followed with semi-structured interviews to evaluate the feedback obtained from HCPs to assess the content, and applicability of the ARC tools. Data were analysed using thematic analysis.

RESULTS

A range of practical challenges in implementing guideline-recommended interventions, improving asthma control and management were described by all HCPs, including lack of time and education, high workload, patients' perceptions, and poor communication contributing to poor management and inadequate follow-up of people with asthma. However, most HCPs were willing to use ARC interventions to improve guideline implementation.

CONCLUSION

HCPs in Greece encounter challenges in implementing asthma guidelines; however, they can overcome these challenges by using ARC interventions and engagement tools to address barriers and implement efficient asthma management strategies.

Identification of mitochondria-related biomarkers in childhood allergic asthma

BACKGROUND

The mechanism of mitochondria-related genes (MRGs) in childhood allergic asthma (CAS) was unclear. The aim of this study was to find new biomarkers related to MRGs in CAS.

METHODS

This research utilized two CAS-related datasets (GSE40888 and GSE40732) and extracted 40 MRGs from the MitoCarta3.0 Database. Initially, differential expression analysis was performed on CAS and control samples in the GSE40888 dataset to obtain the differentially expressed genes (DEGs). Differentially expressed MRGs (DE-MRGs) were obtained by overlapping the DEGs and MRGs. Protein protein interactions (PPI) network of DE-MRGs was created and the top 10 genes in the degree ranking of Maximal Clique Centrality (MCC) algorithm were defined as feature genes. Hub genes were obtained from the intersection genes from the Least absolute shrinkage and selection operator (LASSO) and EXtreme Gradient Boosting (XGBoost) algorithms. Additionally, the expression validation was conducted, functional enrichment analysis, immune infiltration analysis were finished, and transcription factors (TFs)-miRNA-mRNA regulatory network was constructed.

RESULTS

A total of 1505 DEGs were obtained from the GSE40888, and 44 DE-MRGs were obtained. A PPI network based on these 44 DE-MRGs was created and revealed strong interactions between ADCK5 and MFN1, BNIP3 and NBR1. Four hub genes (NDUFAF7, MTIF3, MRPS26, and NDUFAF1) were obtained by taking the intersection of genes from the LASSO and XGBoost algorithms based on 10 signature genes which obtained from PPI. In addition, hub genes-based alignment diagram showed good diagnostic performance. The results of Gene Set Enrichment Analysis (GSEA) suggested that hub genes were closely related to mismatch repair. The B cells naive cells were significantly expressed between CAS and control groups, and MTIF3 was most strongly negatively correlated with B cells naive. In addition, the expression of MTIF3 and MRPS26 may have influenced the inflammatory response in CAS patients by affecting mitochondria-related functions. The quantitative real-time polymerase chain reaction (qRT‒PCR) results showed that four hub genes were all down-regulated in the CAS samples.

CONCLUSION

NDUFAF7, MTIF3, MRPS26, and NDUFAF1 were identified as an MRGs-related biomarkers in CAS, which provides some reference for further research on CAS.

Greenhouse gas emissions associated with suboptimal asthma care in the UK: the SABINA healthCARe-Based envirONmental cost of treatment (CARBON) study

BACKGROUND

Poorly controlled asthma is associated with increased morbidity and healthcare resource utilisation (HCRU). Therefore, to quantify the environmental impact of asthma care, this retrospective, cohort, healthCARe-Based envirONmental cost of treatment (CARBON) study estimated greenhouse gas (GHG) emissions in the UK associated with the management of well-controlled versus poorly controlled asthma.

METHODS

Patients with current asthma (aged ≥12 years) registered with the Clinical Practice Research Datalink (2008‒2019) were included. GHG emissions, measured as carbon dioxide equivalent (CO2e), were estimated for asthma-related medication use, HCRU and exacerbations during follow-up of patients with asthma classified at baseline as well-controlled (<3 short-acting β2-agonist (SABA) canisters/year and no exacerbations) or poorly controlled (≥3 SABA canisters/year or ≥1 exacerbation). Excess GHG emissions due to suboptimal asthma control included ≥3 SABA canister prescriptions/year, exacerbations and any general practitioner and outpatient visits within 10 days of hospitalisation or an emergency department visit.

RESULTS

Of the 236 506 patients analysed, 47.3% had poorly controlled asthma at baseline. Scaled to the national level, the overall carbon footprint of asthma care in the UK was 750 540 tonnes CO2e/year, with poorly controlled asthma contributing excess GHG emissions of 303 874 tonnes CO2e/year, which is equivalent to emissions from >124 000 houses in the UK. Poorly controlled versus well-controlled asthma generated 3.1-fold higher overall and 8.1-fold higher excess per capita carbon footprint, largely SABA-induced, with smaller contributions from HCRU.

CONCLUSIONS

These findings suggest that addressing the high burden of poorly controlled asthma, including curbing high SABA use and its associated risk of exacerbations, may significantly alleviate asthma care-related carbon emissions.

Economic evaluation of biological treatments in patients with severe asthma: a systematic review

BACKGROUND

Asthma is a highly prevalent disease, one of the chronic diseases with the highest economic costs; thus, it imposes a high economic burden on society, the healthcare system, patients, and third-party payers. Contrary to this study, until now, systematic reviews of economic evaluations (EEs) of treatments for severe asthma have not been exclusively focused on biological treatments, and have included a small number of studies and only model-based EEs.

METHODS

This study systematically reviews EEs of biological therapies for severe asthma published until December 2022 using PRISMA guidelines. The review analyzes the cost-effectiveness of biologicals in comparison to SOC, or SOC plus OCS. The quality of the EEs is assessed using Consensus on Health Economics Checklist extended (CHEC-extended).

RESULTS

Thirty-nine studies were eligible: 15 based on a Markov model, and 19 trial-based; eight adopting societal and NHS perspectives, and seven the payer's perspective. The reviewed EEs addressed cost-effectiveness, cost-utility, and incremental costs and outcomes comparison. Their findings were mainly expressed through ICER-incremental cost-effectiveness ratio (24 studies: 13 concluded that biological were cost-effective) and cost comparison analysis (14 studies: 6 concluded that biological were cost-effective), and were sensitive to a wide variety of factors (e.g. medication cost, treatment response, time horizon, utility benefits, mortality, exacerbation rate, discount rate, etc.).

CONCLUSIONS

There has been some ambiguity concerning the EE of biological therapies due to variation in choice of study design and contradictory results. Nevertheless, it can be concluded that biological treatments improve health outcomes, in many contexts at a high cost.

Patient characteristics and eligibility for biologics in severe asthma: Results from the Greek cohort of the RECOGNISE "real world" study

BACKGROUND

Some patients with severe asthma do not achieve sufficient symptom control despite guideline-based treatment, and therefore receive oral (OCS) and systemic corticosteroids (SCS) on regular basis. The side effects of corticosteroid use negatively impact patients' health-related quality of life (HRQoL) and increase the disease burden. Biologics have shown promise in asthma therapy; however, identifying patients who might benefit from biologic therapy is complex due to the heterogeneous pathophysiology of the disease.

METHODS

The European, non-interventional, multicentre RECOGNISE study (NCT03629782) assessed patient characteristics, asthma medication and control, HRQoL as assessed by St. George's Respiratory Questionnaire (SGRQ), and health care resource use in patients with severe asthma, as well as their eligibility for biologic treatment. Here, data from the Greek cohort (N = 97) are reported.

RESULTS

In Greece, patients with severe asthma were more often female (71%) and never smokers (68%). 87% of patients were assessed as eligible for biologic treatment by investigator's judgement (per label criteria: 76%). Most patients had been previously treated with SCS (82% eligible vs 85% non-eligible), with OCS use being more common in non-eligible patients (23.1% vs 11.9%). More eligible patients had poorly controlled asthma (76% vs 54%), and more impaired HRQoL (mean total SGRQ score: 46% vs 39%); symptom burden was significantly higher (mean symptom score: 60% vs. 44%, p: 0.0389).

CONCLUSIONS

A high proportion of Greek patients with severe asthma are eligible for biologic therapy; however, individual risk factors and differences between asthma types must be considered before the introduction of targeted therapy.

Economic Burden of Asthma in Northwest Iran

Background

The economic burden of asthma is a major public health concern. This study estimates the economic burden of asthma in Northwest of Iran.

Methods

A longitudinal study was conducted between 2017 and 2018 in Tabriz (Iran) using the Persian version of the Work Productivity and Activity Impairment (WPAI) questionnaire. Direct and indirect costs associated with asthma were estimated based on the societal perspective, prevalence-based approach, and bottom-up method. Annual indirect costs were estimated using the human capital (HC) method. The structural equation model was used to evaluate the relationship between costs, sex, and asthma severity.

Results

A total of 621 patients with asthma were enrolled in the study. Significant differences were found between female and male patients for the mean cost of radiology (P=0.006), laboratory (P=0.028), and diagnostic (P=0.017) tests at baseline, and for laboratory (P=0.012), and diagnostic (P=0.027) tests at one-year follow-up. The more severe asthma, the more significant the costs for annual physician office visits (P=0.040) and medications (P=0.013). As asthma severity increased, significantly higher expenditures were observed in women for days lost from work at baseline (P=0.009) and one-year follow-up (P=0.001), and in men for productivity loss at work due to impairment at baseline (P=0.045). A significant association between indirect costs and the cost of impairment-related lost productivity at work (β=3.29, P<0.001), and between severe asthma and indirect costs (β=32.36, P<0.001) was observed.

Conclusion

High costs are incurred by Iranian asthma patients, especially because of impairment-related productivity loss at work associated with asthma exacerbation.

Common exacerbation-prone phenotypes across asthma and chronic obstructive pulmonary disease (COPD)

BACKGROUND AND OBJECTIVES

Chronic inflammatory airway diseases, including asthma and chronic obstructive pulmonary disease (COPD), are complex syndromes with diverse clinical symptoms due to multiple pathophysiological conditions. In this study, using common and shared risk factors for the exacerbation of asthma and COPD, we sought to clarify the exacerbation-prone phenotypes beyond disease labels, and to specifically investigate the role of the IL4RA gene polymorphism, which is related to type 2 inflammation, in these exacerbation-prone phenotypes.

METHODS

The study population comprised patients with asthma (n = 117), asthma-COPD overlap (ACO; n = 37) or COPD (n = 48) and a history of exacerbation within the previous year. Cluster analyses were performed using factors associated with both asthma and COPD exacerbation. The association of the IL4RA gene polymorphism rs8832 with each exacerbation-prone phenotype was evaluated by multinomial logistic analyses using non-asthma non-COPD healthy adults as controls (n = 1,529). In addition, the genetic influence of rs8832 was also examined in asthma patients with allergic rhinitis and no history of exacerbation (n = 130).

RESULTS

Two-step cluster analyses identified five clusters that did not necessarily correspond to the diagnostic disease labels. Cluster 1 was characterized by high eosinophil counts, cluster 2 was characterized by smokers with impaired lung function, cluster 3 was characterized by the presence of gastroesophageal reflux, cluster 4 was characterized by non-allergic females, and cluster 5 was characterized by allergic rhinitis and elevated total immunoglobulin E levels. A significant association with rs8832 was observed for cluster 5 (odds ratio, 3.88 (1.34-11.26), p = 0.013) and also for the type 2 exacerbation-prone phenotypes (clusters 1 and 5: odds ratio, 2.73 (1.45-5.15), p = 1.9 × 10-3).

DISCUSSION

Our results indicated that the clinical heterogeneity of disease exacerbation may reflect the presence of common exacerbation-prone endotypes across asthma and COPD, and may support the use of the treatable traits approach for the prevention of exacerbations in patients with chronic inflammatory airway diseases.

Real-life Cretan asthma registry focused on severe asthma: On behalf of 'The Cretan registry of the use of Biologics in Severe Asthma'

Asthma diagnosis and management remains a challenging task for the medical community. The aim of the present study was to present the functional and inflammatory profiles of patients with difficult-to-treat asthma in a real-life clinical setting referred to the specialized asthma clinic at the University Hospital of Heraklion. The registry included a cohort of 267 patients who were referred to the severe asthma clinic. Patients were assessed with emphasis on the history of allergies, nasal polyposis or other comorbidities. Blood testing for eosinophils counts and total and specific IgE, and pulmonary function tests were performed at baseline. The median age of patients with asthma was 55 years old, 68.5% were women and 58.3% were never smokers. The vast majority presented with late onset asthma (75.7%), whereas eight (3%) patients were on oral corticosteroids. The median number of exacerbations during the last 12 months was 1 (0-3). Furthermore, 50.7% of patients had a positive serum allergy test, the median eosinophil count was 300 (188-508.5) cells/µl of blood and median total IgE level was 117.5 (29.4-360.5) IU/ml. Patients were retrospectively grouped in the following categories: Group 1, mild-moderate asthma; group 2, patients prescribed a step 4 or 5 asthma therapy according to Global Initiative for Asthma; and group 3, patients on biologic agents. Group 1 had significantly higher FEV1% than groups 2 and 3 (93.4 vs. 79.9 and 79.4%, respectively; P<0.001). Finally, the median Asthma Control Questionnaire 7 (ACQ7) score was 1.14, with patients from groups 2 and 3 presenting higher ACQ7 scores compared with group 1 patients as expected (1.1 and 2.1 vs. 0.7, respectively; P<0.001). To the best of our knowledge, this was the first real-life asthma study in Crete that demonstrated that severe asthmatics predominantly have late-onset asthma with airflow obstruction and uncontrolled symptoms.

What are the health and socioeconomic impacts of allergic respiratory disease in Tasmania?

Objective The aim of this study was to quantify the direct and indirect costs of asthma and allergic rhinitis (AR) for 2018 in Tasmania. Methods We used publicly available data, and Tasmanian-specific values where available, to estimate direct and indirect costs of both diseases. Direct costs included outcomes such as emergency department (ED) presentations, hospitalisations, general practice visits and medication use. Indirect costs included premature mortality and lost productivity. Results Direct health impacts for both conditions combined included 1454 ED presentations, 682 hospitalisations, 72446 general practice visits and 7122 specialist visits. Indirect health impacts included 13 deaths and between 483000 and 2.8 million days of lost productivity. Total costs ranged between A$126.5 million and A$436.7 million for asthma and between A$65.3 million and A$259.7 million for AR. Per-person annual costs ranged between A$1918 and A$6617 for asthma and between A$597 and A$2374 for AR. Conclusions The main financial burden due to asthma and AR was related to productivity losses from presenteeism and absenteeism. The magnitude of the economic impacts of AR and asthma warrants further analysis to produce a national-level assessment. Such analyses could identify cost-effective interventions that produce highest benefits for the management of these conditions in our community. What is known about the topic? Allergic respiratory diseases, and particularly asthma and AR, pose a significant health burden, with effects including asthma-related hospital admissions, significant pharmaceutical expenditure and lost workforce and school education productivity. Australia, and particularly Tasmania, has a high prevalence of these conditions, but no recent studies have appraised or estimated their health impacts and costs. What does this paper add? This paper proposes a unique and transparent costing model that allows the costs of these conditions to be estimated while accounting for restrictions in data availability. The model is used to provide the first comprehensive costings of asthma and AR in Tasmania, Australia. We identified that the estimated health costs are dominated by productivity losses from presenteeism and absenteeism, and that total per person costs are higher for a person with asthma compared to one with AR. What are the implications for practitioners? This analysis has the potential to guide cost-effective interventions by identifying where the highest benefits may be obtained when managing these conditions in our community.

Financial Burden of Prescribed Medicines Included in Outpatient Benefits Package Schemes: Comparative Analysis of Co-Payments for Reimbursable Medicines in European Countries

OBJECTIVE

The study aimed to analyse the financial burden that co-payments for prescribed and reimbursed medicines pose on patients in European countries.

METHODS

Five medicines used in acute conditions (antibiotic, analgesic) and in chronic care (hypertension, asthma, diabetes) were selected. Co-payments (standard and five defined population groups, e.g. low-income people, patients with high consumption) were surveyed based on information retrieved from national price lists (September 2017) and co-payment regulation in nine countries (Albania, Austria, England, France, Germany, Greece, Hungary, Kyrgyzstan and Sweden). The financial burden of the selected medicines (originator and lowest-priced generic) was described as the percentage of patients' payments for 1 month's therapy or treatment of one episode in comparison to the national minimum monthly wage.

RESULTS

The study showed large variation in co-payments between the countries. Financial burden resulting from co-payments for reimbursed medicines tended to be higher in lower-income countries (Kyrgyzstan: 9% of minimum monthly wage for generic amlodipine; 2-4% for generic and originator salbutamol; Albania: approximately 3% for originator amoxicillin/clavulanic acid and metformin). Most studied countries applied reduction or exemption mechanisms (children were exempt in five countries, no or lower co-payments for low-income people in five countries, exemptions from co-payments upon reaching a threshold of expenses in six countries).

CONCLUSIONS

Co-payments for prescribed medicines can pose a substantial financial burden for outpatients, particularly in lower-income countries. The price of a medicine, availability of lower-priced medicines and the design of co-payments, including exemptions and reductions for specific groups, can considerably impact patients' expenses for medicines.