Asthma Control and Cost in Latin America

The use of systemic corticosteroids in asthma management in Latin American countries

The stepwise treatment approach recommended by the Global Initiative for Asthma (GINA) includes systemic corticosteroids (SCS) suggested as a final step if asthma is severe and/or difficult to treat. Yet, despite the effectiveness of SCS, they are also associated with potentially irreversible adverse outcomes such as type 2 diabetes, adrenal suppression, and cardiovascular disease. Based on recent data indicating that the risk of developing these conditions can increase after as few as 4 short-term (burst) courses of SCS, even patients with mild asthma who receive SCS occasionally for exacerbations are also at risk of these events. As a result, recent updates by GINA and the Latin American Thoracic Society recommend decreasing SCS use by optimizing administration of non-SCS therapies and/or increasing the use of alternatives, such as biologic agents. Recent and ongoing studies characterizing treatment patterns among patients with asthma have revealed alarming trends suggesting the widespread overuse of SCS around the world. In Latin America, asthma prevalence is approximately 17%, and data suggest that the majority of patients have uncontrolled disease. In this review, we summarize currently available data on asthma treatment patterns in Latin America, which indicate that SCS are prescribed to 20-40% of patients with asthma considered to be well controlled and over 50% of patients with uncontrolled disease. We also offer potential strategies to help reduce SCS use for asthma in everyday clinical practice.

Over-prescription of short-acting β2-agonists is associated with poor asthma outcomes: results from the Latin American cohort of the SABINA III study

OBJECTIVE

Short-acting β₂-agonist (SABA) over-reliance is associated with poor asthma outcomes. As part of the SABA Use IN Asthma (SABINA) III study, we assessed SABA prescriptions and clinical outcomes in patients from six Latin American countries.

METHODS

In this cross-sectional study, data on disease characteristics/asthma treatments were collected using electronic case report forms. Patients (aged ≥12 years) were classified by investigator-defined asthma severity (guided by the 2017 Global Initiative for Asthma) and practice type (primary/specialist care). Multivariable regression models analyzed the associations between SABA prescriptions and clinical outcomes.

RESULTS

Data from 1096 patients (mean age, 52.0 years) were analyzed. Most patients were female (70%), had moderate-to-severe asthma (79.4%), and were treated by specialists (87.6%). Asthma was partly controlled/uncontrolled in 61.5% of patients; 47.4% experienced ≥1 severe exacerbation in the previous 12 months. Overall, 39.8% of patients were prescribed ≥3 SABA canisters in the preceding 12 months (considered over-prescription). SABA canisters were purchased over the counter (OTC) by 17.2% of patients, of whom 38.8% purchased ≥3 canisters in the 12 months prior. Of patients who purchased SABA OTC, 73.5% were prescribed ≥3 SABA canisters. Higher SABA prescriptions (vs. 1 - 2 canisters) were associated with an increased incidence rate of severe exacerbations (ranging from 1.31 to 3.08) and lower odds ratios of having at least partly controlled asthma (ranging from 0.63 to 0.15).

CONCLUSIONS

SABA over-prescription was common in Latin America, highlighting the need for urgent collaboration between healthcare providers and policymakers to align clinical practices with the latest evidence-based recommendations to address this public health concern.

Toward a better understanding of severe asthma phenotypes in Latin America: results from the PREPARE study

OBJECTIVE

Data on severe asthma phenotypes in Latin America are lacking. The PREPARE study describes the prevalence of certain determinants of severe asthma among patients in 5 Latin American countries with blood eosinophil counts (BEC) ≥300 cells/mm³ and serum immunoglobulin E (IgE) concentrations >100 IU/mL.

METHODS

In this cross-sectional study, information on demographics, disease characteristics, and asthma treatments were extracted from the existing medical records of patients aged ≥12 years attending centers specialized in severe asthma management. Medical record data were transcribed onto electronic case report forms. Blood eosinophil counts and IgE concentrations were assayed from specimens obtained at study visit. Data were analyzed with descriptive statistics.

RESULTS

Data from 461 patients with severe asthma (mean age, 50.5 years) were analyzed. Most patients were female (73%), had a body mass index of ≥25 kg/m² (77%), and received full healthcare reimbursement (63%). In the previous 12 months, 52% of patients experienced ≥1 severe exacerbation and 44% received oral corticosteroid burst therapy. Blood eosinophil counts ≥300 cells/mm³ and ≥150 cells/mm³ were reported in 44% and 76% of patients, respectively. In 58% of patients, serum IgE concentrations exceeded 100 IU/mL. Uncontrolled asthma was documented in 50% (n = 230) of patients.

CONCLUSIONS

The PREPARE study provides useful insights about the prevalence of eosinophilic and atopic phenotypes in patients with severe asthma in Latin America, thereby paving the way for a more personalized approach to managing severe asthma. Notwithstanding the treatment at specialized medical centers, disease burden remained high in this study population.

A Cross-Sectional Study on Prescription Patterns of Short-Acting β2-Agonists in Patients with Asthma: Results from the SABINA III Colombia Cohort

Purpose

Overuse of short-acting β₂-agonists (SABAs) for asthma is associated with a significant increase in exacerbations and healthcare resource use. However, limited data exist on the extent of SABA overuse outside of Europe and North America. As part of the multi-country SABA use IN Asthma (SABINA) III study, we characterized SABA prescription patterns in Colombia.

Patients and Methods

This observational, cross-sectional cohort study of SABINA III included patients (aged ≥12 years) with asthma recruited from seven sites in Colombia. Demographics, disease characteristics (including investigator-defined asthma severity guided by the 2017 Global Initiative for Asthma report), and asthma treatments prescribed (including SABAs and inhaled corticosteroids [ICS]) in the 12 months preceding the study were recorded using electronic case report forms during a single study visit.

Results

Of 250 patients analyzed, 50.4%, 33.2%, and 16.4% were enrolled by pulmonologists, general medicine practitioners, and allergists, respectively. Most patients were female (74.0%) and had moderate-to-severe asthma (67.6%). Asthma was partly controlled or uncontrolled in 57.6% of patients, with 15.6% experiencing ≥1 severe exacerbation 12 months before the study visit. In total, 4.0% of patients were prescribed SABA monotherapy and 55.6%, SABA in addition to maintenance therapy. Overall, 39.2% of patients were prescribed ≥3 SABA canisters in the 12 months before the study visit; 25.2% were prescribed ≥10 canisters. Additionally, 17.6% of patients purchased SABAs over the counter, of whom 43.2% purchased ≥3 canisters. Maintenance medication in the form of ICS or ICS/long-acting β₂-agonist fixed-dose combination was prescribed to 36.0% and 66.8% of patients, respectively.

Conclusion

Our findings suggest that prescription/purchase of ≥3 SABA canisters were common in Colombia, highlighting a public health concern. There is a need to improve asthma care by aligning clinical practices with the latest evidence-based treatment recommendations to improve asthma management across Colombia.

Direct Medical Cost of Pediatric Asthma in Jordan: A Cost-of-Illness Retrospective Cohort Study

OBJECTIVES

This study aimed to estimate and analyze the direct medical costs of pediatric patients with asthma in Jordan from the provider's perspective.

METHODS

A retrospective analysis of a cohort of pediatric patients with asthma treated during 3 years in a teaching hospital was conducted. The prevalence-based, bottom-up approach has been used to estimate the cost-of-illness of asthma. The total annual direct medical cost was stratified by control status and the severity of asthma.

RESULTS

The total annual cost for whole the sample (N = 613) in the average of 3 years was Jordanian dinar (JD) 110 874 (US$ 156 382). Pediatrics with uncontrolled asthma had significantly higher annual total direct medical costs than partly controlled and controlled asthma (JD 396 [US$ 558], JD 258 [US$ 364], and JD 150 [US$ 211], respectively) (P < .001). The annual total direct medical cost for severe asthma (JD 455 [US$ 641]) was significantly higher than moderate, mild, and intermittent (JD 176 [US$ 248], JD 35 [US$ 49], and JD 7 [US$ 9.8], respectively) (P < .001). Medications were the most expensive healthcare resource used, accounting for 79.8% of the total cost, followed by outpatient clinic visits and hospitalizations.

CONCLUSIONS

Healthcare sources utilization and direct medical costs of asthma were highly related to disease severity and control status of the disease. Health policies targeting the achievement of better and stricter asthma control will play a crucial role in the reduction of the economic burden of asthma for society and the patient.

Prevalence of asthma at a school-based health clinic in Nicaragua

BACKGROUND

Worldwide, it is estimated that 235-334 million people have been diagnosed with asthma. In Nicaragua, the current asthma rate for children 13-14 years of age was 15.2%.

PURPOSE

The purpose of this study was to determine the prevalence of asthma at this school-based health clinic in Managua, Nicaragua, associated symptoms or diseases, determine asthma classification, medications, and hospitalization rates.

METHODS

A retrospective chart review was performed on all pediatric patient's medical records seen in the clinic during a 5-day period (n = 105).

RESULTS

A total of 23 patients (21.9%) had asthma documented in the medical chart and were included in the analysis. Of the 23 patients, 3 (13%) patients were classified with intermittent asthma while the rest of the patients (87%) were not classified. Albuterol was prescribed for 19 (86%) of the patients with two patients who had both albuterol and QVAR® prescribed. Six (26%) patients had a family history of asthma.

DISCUSSION

This study demonstrated the prevalence of asthma in school-aged children in Nicaragua is significant and higher than previously reported. The lack of a classification of asthma prevents patients from potentially being treated appropriately.

Influence of alexithymia on the management of Latin American patients with asthma: A cross-sectional study

Objectives:

In asthmatic patients, studies suggest that alexithymia leads to negative consequences and emotions that can affect physical, psychological, and social aspects of life. We designed this study to determine the frequency of alexithymia in Latin American patients with asthma, as well as to understand how this personality trait and each of its components interact with asthma severity and demographic variables, and their implications on treatment adherence and disease control under such setting.

Methods:

We conducted a cross-sectional study, involving 265 Latin American patients with asthma. Patient demographics and clinical characteristics were reported. The presence of alexithymia, asthma severity, and control, as well as treatment adherence, was analyzed. To assess the presence of alexithymia, the 20-item Toronto Alexithymia Scale was used. For the statistical analyses, we performed Kendall’s tau-b correlation coefficient, chi-square tests for association, and one-way analysis of variance.

Results:

A total of 265 patients participated in the study with a gender distribution of 69.4% female and an average age of 54.7 years. In total, 30.2% of individuals presented alexithymia. There was a statistically significant correlation between educational level and 20-item Toronto Alexithymia Scale categories (p < .001), as well as a higher proportion of severe (35.1%, p = .001) and uncontrolled (50.0%, p = .185) asthma in patients with alexithymia. A higher proportion of patients with some level of non-adherence was seen on those with uncontrolled asthma (68.5%, p = .008).

Conclusion:

Our results suggest that in our sample, 3 in 10 Latin American asthma patients have alexithymia, and such mental condition is more common in those individuals with lower educational levels. Individuals with alexithymia present with severe asthma more frequently than do patients with possible or no alexithymia and are also more likely to have their disease uncontrolled.

Health care costs and resource utilization for different asthma severity stages in Colombia: a claims data analysis

BACKGROUND

Asthma is one of the most common chronic respiratory conditions worldwide. Asthma-related economic burden has been reported in Latin America, but knowledge about its economic impact to the Colombian health care system and the influence of disease severity is lacking. This study estimated direct medical costs and health care resource utilization (HCRU) in patients with asthma according to severity in Colombia.

METHODS

This study identified all-age patients who had at least one medical event linked to an asthma diagnosis (CIE-10: J45-J46) between 2004 and 2014. Patients were selected if they had a continuous enrollment and uninterrupted insurance coverage between January 1-2015 and December 31-2015 and were categorized into 4 different severity levels using a modified algorithm based on Leidy criteria. Healthcare utilization and costs were estimated in a 1-year period after the identification period. A Generalized Linear Model (GLM) with gamma distribution and log link was used to analyze costs adjusting for patient demographics.

RESULTS

A total of 20,410 patients were included: 69.5% had mild intermittent, 18.0% mild persistent, 6.9% moderate persistent and 5.5% severe persistent asthma; with mean costs (SD) of $67 (134), $482 (1506), $1061 (1983), $2235 (3426) respectively (p < 0.001). The mean total direct cost was estimated at $331 (1278) per patient. Medication and hospitalization had the higher proportion in total costs (46% and 31% respectively). General physician visits was the most used service (57.2%) and short-acting β-2 agonists the most used medication (24%).

CONCLUSIONS

Health services utilization and direct costs of asthma were highly related to disease severity. Nationwide health policies aimed at the effective control of asthma are necessary and would play an important role in reducing the associated economic impact.