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Tudball J, Reddel HK, Laba TL, Jan S, Flynn A, Goldman M, Lembke K, Roughead E, Marks GB, Zwar N. General practitioners' views on the influence of cost on the prescribing of asthma preventer medicines: a qualitative study. AUST HEALTH REV 2020; 43:246-253. [PMID: 29754592 DOI: 10.1071/ah17030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 01/19/2018] [Indexed: 12/25/2022]
Abstract
Objective Out-of-pocket costs strongly affect patient adherence with medicines. For asthma, guidelines recommend that most patients should be prescribed regular low-dose inhaled corticosteroids (ICS) alone, but in Australia most are prescribed combination ICS-long-acting β2-agonists (LABA), which cost more to patients and government. The present qualitative study among general practitioners (GPs) explored the acceptability, and likely effect on prescribing, of lower patient copayments for ICS alone. Methods Semistructured telephone interviews were conducted with 15 GPs from the greater Sydney area; the interviews were transcribed and thematically analysed. Results GPs reported that their main criteria for selecting medicines were appropriateness and effectiveness. They did not usually discuss costs with patients, had low awareness of out-of-pocket costs and considered that these were seldom prohibitive for asthma patients. GPs strongly believed that patient care should not be compromised to reduce cost to government. They favoured ICS-LABA combinations over ICS alone because they perceived that ICS-LABA combinations enhanced adherence and reduced costs for patients. GPs did not consider that lower patient copayments for ICS alone would affect their prescribing. Conclusion The results suggest that financial incentives, such as lower patient copayments, would be unlikely to encourage GPs to preferentially prescribe ICS alone, unless accompanied by other strategies, including evidence for clinical effectiveness. GPs should be encouraged to discuss cost barriers to treatment with patients when considering treatment choices. What is known about the topic? Australian guidelines recommend that most patients with asthma should be treated with low-dose ICS alone to minimise symptom burden and risk of flare ups. However, most patients in Australian general practice are instead prescribed combination ICS-LABA preventers, which are indicated if asthma remains uncontrolled despite treatment with ICS alone. It is not known whether GPs are aware that the combination preventers have a higher patient copayment and a higher cost to government. What does this paper add? This qualitative study found that GPs favoured combination ICS-LABA inhalers over ICS alone because they perceived ICS-LABA combinations to have greater effectiveness and promote patient adherence. This aligned with GPs' views that their primary responsibility was patient care rather than generating cost savings for government. However, it emerged that GPs rarely discussed medicine costs with patients, had low knowledge of medicine costs to patients and the health system and reported that patients rarely volunteered cost concerns. GPs believed that lower patient copayments for asthma preventer medicines would have little effect on their prescribing practices. What are the implications for practitioners? This study suggests that, when considering asthma treatment choices, GPs should empathically explore with the patient whether cost-related medication underuse is an issue, and should be aware of the option of lower out-of-pocket costs with guideline-recommended ICS alone treatment. Policy makers must be aware that differential patient copayments for ICS preventer medicines are unlikely to act as an incentive for GPs to preferentially prescribe ICS alone preventers, unless the position of these preventers in guidelines and evidence for their clinical effectiveness are also reiterated.
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Affiliation(s)
| | - Helen K Reddel
- Woolcock Institute of Medical Research, University of Sydney, 431 Glebe Point Rd, Glebe, NSW 2037, Australia. Email
| | - Tracey-Lea Laba
- The George Institute for Global Health, University of New South Wales, Sydney, Level 5, 1 King Street, Newtown NSW 2042, Australia.
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, Level 5, 1 King Street, Newtown NSW 2042, Australia.
| | - Anthony Flynn
- Asthma Australia Ltd, Level 13, 799 Pacific Hwy, Chatswood NSW 2067, Australia.
| | - Michele Goldman
- Asthma Australia Ltd, Level 13, 799 Pacific Hwy, Chatswood NSW 2067, Australia.
| | - Kirsty Lembke
- NPS MedicineWise, PO Box 1147 Strawberry Hills NSW 2012. Email
| | - Elizabeth Roughead
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, CEA-19, University of South Australia, GPO Box 2471, Adelaide, SA 5001, Australia. Email
| | - Guy B Marks
- Woolcock Institute of Medical Research, University of Sydney, 431 Glebe Point Rd, Glebe, NSW 2037, Australia. Email
| | - Nick Zwar
- School of Public Health and Community Medicine, University of New South Wales Sydney, NSW 2052, Australia
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2
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Laba TL, Reddel HK, Zwar NJ, Marks GB, Roughead E, Flynn A, Goldman M, Heaney A, Lembke K, Jan S. Does a Patient-Directed Financial Incentive Affect Patient Choices About Controller Medicines for Asthma? A Discrete Choice Experiment and Financial Impact Analysis. PHARMACOECONOMICS 2019; 37:227-238. [PMID: 30367400 DOI: 10.1007/s40273-018-0731-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND In Australia, many patients who are initiated on asthma controller inhalers receive combination inhaled corticosteroid/long-acting beta2-agonist (ICS/LABA) despite having asthma of sufficiently low severity that ICS-alone would be equally effective and less costly for the government. METHODS We conducted a discrete choice experiment (DCE) in a nationally representative sample of adults (n = 792) and parents of children (n = 609) with asthma. Mixed multinomial models were estimated and calibrated to reflect the estimated market shares of ICS-alone, ICS/LABA and no controller. We then simulated the impact of varying patient co-payment on demand and the financial impact on government pharmaceutical expenditure. RESULTS Preference for inhaler decreased with increasing costs to the patient or government, increasing chance of a repeat visit to the doctor, and if fewer symptoms were present. Adults preferred high-strength controllers, but parents preferred low-strength inhalers for children (general beneficiaries only). The DCE predicted a higher proportion choosing controller treatment (89%) compared to current levels (57%) at the current co-payment level, with proportionately higher uptake of ICS-alone and a lower average cost per patient [32.73 Australian dollars (AU$) c.f. AU$38.54]. Reducing the co-payment on ICS-alone by 50% would increase its market share to 50%, whilst completely removing the co-payment would only have a small marginal impact on market share, but increased average cost of treatment to the government to AU$41.04 per person. CONCLUSIONS Patient-directed financial incentives are unlikely to encourage much switching of medicines, and current levels of under-treatment are not explained by patient preferences. Interventions directed at prescribers are more likely to promote better use of asthma medicines.
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Affiliation(s)
- Tracey-Lea Laba
- Menzies Centre for Health Policy, Sydney Medical School, School of Public Health, The University of Sydney, Sydney, Australia.
- The George Institute for Global Health, University of New South Wales, Sydney, Australia.
| | - Helen K Reddel
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - Nicholas J Zwar
- School of Public Health and Community Medicine, University of New South Wales, Randwick, Sydney, Australia
- School of Medicine, University of Wollongong, Wollongong, Australia
| | - Guy B Marks
- Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
- South Western Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Elizabeth Roughead
- Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical Sciences, University of South Australia, Adelaide, Australia
| | - Anthony Flynn
- Asthma Foundation Queensland and New South Wales, now part of Asthma Australia Limited, Sydney, Australia
| | - Michele Goldman
- Asthma Foundation Queensland and New South Wales, now part of Asthma Australia Limited, Sydney, Australia
| | | | | | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
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3
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Reddel HK, Beckert L, Moran A, Ingham T, Ampon RD, Peters MJ, Sawyer SM. Is higher population-level use of ICS/LABA combination associated with better asthma outcomes? Cross-sectional surveys of nationally representative populations in New Zealand and Australia. Respirology 2017; 22:1570-1578. [PMID: 28791752 DOI: 10.1111/resp.13123] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Revised: 04/26/2017] [Accepted: 05/26/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE New Zealand (NZ) and Australia (AU) have similarly high asthma prevalence; both have universal public health systems, but different criteria for subsidized medicines. We explored differences in asthma management and asthma-related outcomes between these countries. METHODS A web-based survey was administered in AU (2012) and NZ (2013) to individuals aged ≥16 years with current asthma, drawn randomly from web-based panels, stratified by national population proportions. Symptom control was assessed with the Asthma Control Test (ACT). Healthcare utilization was assessed from reported urgent doctor/hospital visits in the previous year. RESULTS NZ (n = 537) and Australian (n = 2686) participants had similar age and gender distribution. More NZ than Australian participants used inhaled corticosteroid (ICS)-containing medication (68.8% vs 60.9%; P = 0.006) but ICS/long-acting β2 -agonist (LABA) constituted 44.4% of NZ and 81.5% of Australian total ICS use (P < 0.0001). Adherence was higher with ICS/LABA than ICS-alone (P < 0.0001), and higher in NZ than in AU (P < 0.0001). ACT scores were similar (P = 0.41), with symptoms well controlled in 58.6% and 54.4% participants, respectively. More NZ participants reported non-urgent asthma reviews (56.6% vs 50.4%; P = 0.009). Similar proportions had urgent asthma visits (27.9% and 28.6%, respectively, P = 0.75). CONCLUSION This comparison, which included the first nationally representative data for asthma control in NZ, showed that poorly controlled asthma is common in both NZ and AU, despite subsidized ICS-containing medications. The greater use of ICS-alone in NZ relative to ICS/LABA does not appear to have compromised population-level asthma outcomes, perhaps due to better adherence in NZ. Different ICS/LABA subsidy criteria and different patient copayments may also have contributed to these findings.
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Affiliation(s)
- Helen K Reddel
- Woolcock Institute of Medical Research, University of Sydney, Glebe, NSW, Australia
| | - Lutz Beckert
- Department of Medicine, University of Otago, Christchurch, New Zealand.,Respiratory Services, Canterbury District Health Board, Christchurch, New Zealand
| | - Angela Moran
- Respiratory Services, Canterbury District Health Board, Christchurch, New Zealand
| | - Tristram Ingham
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - Rosario D Ampon
- Woolcock Institute of Medical Research, University of Sydney, Glebe, NSW, Australia
| | - Matthew J Peters
- Department of Respiratory Medicine, Concord Hospital and Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - Susan M Sawyer
- Department of Paediatrics, The University of Melbourne and Murdoch Childrens Research Institute, Royal Children's Hospital Centre for Adolescent Health, Melbourne, VIC, Australia
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4
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Fingleton J, Hardy J, Baggott C, Pilcher J, Corin A, Hancox RJ, Harwood M, Holliday M, Reddel HK, Shirtcliffe P, Snively S, Weatherall M, Beasley R. Description of the protocol for the PRACTICAL study: a randomised controlled trial of the efficacy and safety of ICS/LABA reliever therapy in asthma. BMJ Open Respir Res 2017; 4:e000217. [PMID: 29071080 PMCID: PMC5647477 DOI: 10.1136/bmjresp-2017-000217] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2017] [Accepted: 05/30/2017] [Indexed: 12/21/2022] Open
Abstract
Introduction In adult asthma, combination inhaled corticosteroid (ICS)/fast-onset long-acting beta agonist (LABA) used solely as reliever therapy may represent an effective and safe alternative to ICS maintenance and short-acting beta agonist (SABA) reliever therapy. Objective To compare the efficacy and safety of ICS/fast-onset LABA reliever therapy with ICS maintenance and SABA reliever therapy in adults with asthma. Methods and analysis A 52-week, open-label, parallel group, multicentre, phase III randomised controlled trial with 1:1 randomisation to either budesonide/formoterol Turbuhaler 200/6 µg, one actuation as required for symptom relief, or budesonide Turbuhaler 200 µg, one actuation twice daily and terbutaline Turbuhaler 250 µg, two actuations as required for symptom relief. 890 adults aged 18–75 years with asthma for whom maintenance ICS and SABA reliever therapy is indicated by current guidelines will be recruited in New Zealand. The primary outcome variable is the rate of severe exacerbations per patient per year. This study will investigate a novel treatment regimen that might lead to a paradigm shift in asthma management for adults for whom guidelines currently recommend maintenance ICS and SABA reliever therapy. Ethics and dissemination Ethical approval has been granted (15/NTB/178). Study findings will be published according to Iinternational Committee of Medical Journal Editors' recommendations. Trial registration number ACTRN12616000377437; Pre-results.
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Affiliation(s)
- James Fingleton
- Asthma Programme, Medical Research Institute of New Zealand, Wellington, New Zealand.,Respiratory Medicine, Capital & Coast District Health Board, Wellington, New Zealand
| | - Jo Hardy
- Asthma Programme, Medical Research Institute of New Zealand, Wellington, New Zealand.,School of Biological Sciences, University of Victoria, Wellington, New Zealand
| | - Christina Baggott
- Asthma Programme, Medical Research Institute of New Zealand, Wellington, New Zealand.,School of Biological Sciences, University of Victoria, Wellington, New Zealand
| | - Janine Pilcher
- Asthma Programme, Medical Research Institute of New Zealand, Wellington, New Zealand.,Respiratory Medicine, Capital & Coast District Health Board, Wellington, New Zealand
| | | | - Robert J Hancox
- Respiratory Medicine, Waikato Hospital, Hamilton, New Zealand
| | | | - Mark Holliday
- Asthma Programme, Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Helen K Reddel
- Woolcock Institute of Medical Research, Sydney, Australia
| | - Philippa Shirtcliffe
- Asthma Programme, Medical Research Institute of New Zealand, Wellington, New Zealand.,Respiratory Medicine, Capital & Coast District Health Board, Wellington, New Zealand
| | - Suzanne Snively
- Asthma Programme, Medical Research Institute of New Zealand, Wellington, New Zealand
| | | | - Richard Beasley
- Asthma Programme, Medical Research Institute of New Zealand, Wellington, New Zealand.,Respiratory Medicine, Capital & Coast District Health Board, Wellington, New Zealand
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Jacob C, Haas JS, Bechtel B, Kardos P, Braun S. Assessing asthma severity based on claims data: a systematic review. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2017; 18:227-241. [PMID: 26931557 PMCID: PMC5313583 DOI: 10.1007/s10198-016-0769-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 02/04/2016] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Asthma is one of the most common chronic diseases in Germany. Substantial economic evaluation of asthma cost requires knowledge of asthma severity, which is in general not part of claims data. Algorithms need to be defined to use this data source. AIMS AND OBJECTIVES The aim of this study was to systematically review the international literature to identify algorithms for the stratification of asthma patients according to disease severity based on available information in claims data. METHODS A systematic literature review was conducted in September 2015 using the DIMDI SmartSearch, a meta search engine including several databases with a national and international scope, e.g. BIOSIS, MEDLINE, and EMBASE. Claims data based studies that categorize asthma patients according to their disease severity were identified. RESULTS The systematic research yielded 54 publications assessing asthma severity based on claims data. Thirty-nine studies used a standardized algorithm such as HEDIS, Leidy, the GINA based approach or CACQ. Sixteen publications applied a variety of different criteria for the severity categorisation such as asthma diagnoses, asthma-related drug prescriptions, emergency department visits, and hospitalisations. CONCLUSION There is no best practice method for the categorisation of asthma severity with claims data. Rather, a combination of algorithms seems to be a pragmatic approach. A transfer to the German context is not entirely possible without considering particular conditions associated with German claims data.
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Affiliation(s)
| | | | | | - Peter Kardos
- Group Practice and Centre for Pneumology, Allergy and Sleep Medicine at Red Cross Maingau Hospital, Frankfurt am Main, Germany
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6
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Use of leukotriene receptor antagonists are associated with a similar risk of asthma exacerbations as inhaled corticosteroids. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 2:607-13. [PMID: 25213056 DOI: 10.1016/j.jaip.2014.05.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/03/2013] [Revised: 05/05/2014] [Accepted: 05/07/2014] [Indexed: 01/31/2023]
Abstract
BACKGROUND Based on results of clinical trials, inhaled corticosteroids (ICS) are the most-effective controller medications for preventing asthma-related exacerbations, yet few studies in real-life populations have evaluated the comparative effectiveness of ICS. OBJECTIVE To determine the likelihood of asthma exacerbations among children with asthma after initiation of controller medications: ICS, leukotriene antagonists (LTRA), and ICS-long-acting β-agonist (LABA) combination therapy. METHODS This was a retrospective cohort study of subjects who were part of the Population-Based Effectiveness in Asthma and Lung Diseases Network. We conducted Cox regression analyses by adjusting for baseline covariates, adherence by using proportion of days covered, and high-dimensional propensity scores. The main outcome measurements were emergency department visits, hospitalizations, or oral corticosteroid use. RESULTS Our population included 15,567 health plan subjects and 10,624 TennCare Medicaid subjects with uncontrolled asthma. Overall adherence to controller medications was low, with no more than 50% of the subjects refilling the medication after the initial fill. For subjects with allergic rhinitis, the subjects in TennCare Medicaid treated with LTRAs were less likely to experience ED visits (hazard ratio 0.44 [95% CI, 0.21-0.93]) compared with the subjects treated with ICS. For all other groups, the subjects treated with LTRA or ICS-LABA were just as likely to experience ED visits or hospitalizations, or need oral corticosteroids as the subjects treated with ICS. CONCLUSION Risks of asthma-related exacerbations did not differ between children who initiated LTRA and ICS. These findings may be explainable by LTRA, which has similar effectiveness as ICS in real-life usage by residual confounding by indication or other unmeasured factors.
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7
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Hernández G, Avila M, Pont A, Garin O, Alonso J, Laforest L, Cates CJ, Ferrer M. Long-acting beta-agonists plus inhaled corticosteroids safety: a systematic review and meta-analysis of non-randomized studies. Respir Res 2014; 15:83. [PMID: 25038591 PMCID: PMC4132190 DOI: 10.1186/1465-9921-15-83] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 07/14/2014] [Indexed: 01/16/2023] Open
Abstract
Background Although several systematic reviews investigated the safety of long-acting beta–agonists (LABAs) in asthma, they mainly addressed randomized clinical trials while evidence from non-randomized studies has been mostly neglected. We aim to assess the risk of serious adverse events in adults and children with asthma treated with LABAs and Inhaled Corticosteroids (ICs), compared to patients treated only with ICs, from published non-randomized studies. Methods The protocol registration number was CRD42012003387 (http://www.crd.york.ac.uk/Prospero). Literature search for articles published since 1990 was performed in MEDLINE and EMBASE. Two authors selected studies independently for inclusion and extracted the data. A third reviewer resolved discrepancies. To assess the risk of serious adverse events, meta-analyses were performed calculating odds ratio summary estimators using random effect models when heterogeneity was found, and fixed effect models otherwise. Results Of 4,415 candidate articles, 1,759 abstracts were reviewed and 220 articles were fully read. Finally, 19 studies met the inclusion criteria. Most of them were retrospective observational cohorts. Sample sizes varied from 50 to 514,216. The meta-analyses performed (69,939-624,303 participants according to the outcome considered) showed that odds ratio of the LABAs and ICs combined treatment when compared with ICs alone was: 0.88 (95% CI 0.69-1.12) for asthma-related hospitalization; 0.75 (95% CI 0.66-0.84) for asthma-related emergency visits; 1.02 (95% CI 0.94-1.10) for systemic corticosteroids; and 0.95 (95% CI 0.9-1.0) for the combined outcome. Conclusions Evidence from observational studies shows that the combined treatment of LABAs and ICs is not associated with a higher risk of serious adverse events, compared to ICs alone. Major gaps identified were prospective design, paediatric population and inclusion of mortality as a primary outcome.
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Affiliation(s)
| | | | | | | | | | | | | | - Montserrat Ferrer
- Health Services Research Group, IMIM (Hospital del Mar Medical Research Institute), Barcelona Biomedical Research Park, office 144, Doctor Aiguader, 88
- 08003, Barcelona, Spain.
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8
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Abstract
There are three major problems with asthma care in the USA and misuse of asthma drug therapy contributes to each. Asthma patients suffer from symptoms regularly partly because healthcare providers do not understand the Expert Panel Report III (EPR3) recommendations on assessing asthma symptoms to determine drug treatment and, consequently, undertreat the disease. Asthma patients experience exacerbations often in part because the EPR3 provides limited guidance on using exacerbation risk to guide asthma treatment, again leading to undertreatment. The EPR3 recommends inhaled corticosteroids as the preferred therapy for mild persistent asthma but American healthcare providers disregard this recommendation based on different perceptions about the risks and benefits of inhaled corticosteroids and choose drug treatments with higher healthcare costs.
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Affiliation(s)
- Gene L Colice
- The George Washington University School of Medicine, Director, Pulmonary, Critical Care and Respiratory Services, Washington Hospital Center, 110 Irving St., NW, Washington, DC 20010, USA.
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9
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Acuña-Izcaray A, Sánchez-Angarita E, Plaza V, Rodrigo G, de Oca MM, Gich I, Bonfill X, Alonso-Coello P. Quality assessment of asthma clinical practice guidelines: a systematic appraisal. Chest 2014; 144:390-397. [PMID: 23450305 DOI: 10.1378/chest.12-2005] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The quality and potential impact of available clinical guidelines for asthma management have not been systematically evaluated. We, therefore, evaluated the quality of clinical practice guidelines (CPGs) for asthma. METHODS We performed a systematic search of scientific literature published between 2000 and 2010 to identify and select CPGs related to asthma management. We searched guideline databases, guideline developers' websites, and the MEDLINE database of the US National Library of Medicine. Four independent reviewers assessed the eligible guidelines using the Appraisal of Guidelines Research & Evaluation (AGREE) II instrument. We calculated the overall agreement among reviewers with the intraclass correlation coefficient (ICC). RESULTS Eighteen CPGs published between the years 2000 and 2010 were selected from a total of 1,005 references. The overall agreement among reviewers was moderate (ICC: 0.78; 95% CI, 0.62-0.90). The mean scores for each AGREE domain were: scope and purpose, 44.1% (range: 10.0%-79.0%); stakeholder involvement, 33.8% (range: 4.0%-66.0%); rigor of development, 32.4% (range: 8.0%-64.0%); clarity and presentation, 52.1% (range: 17.0%-85.0%); applicability, 21.1% (range: 3%-55%); and editorial independence, 25% (range: 0%-58%). None of the appraised guidelines had a score > 60% (recommended). One-half of the appraised guidelines were recommended with modifications (nine of 18) or not recommended (nine of 18) for use in clinical practice. We observed improvement over time in overall quality of the guidelines (P = .01; guidelines published in the period 2001-2006 vs 2007-2009). CONCLUSIONS The quality of guidelines for asthma care is low, although it has improved over time. Greater efforts are needed to provide high-quality guidelines that can be used as reliable tools for clinical decision-making in this field.
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Affiliation(s)
- Agustín Acuña-Izcaray
- Servicio de Neumonología, Centro Médico Docente la Trinidad y Hospital Universitario de Caracas, Facultad de Medicina, Universidad Central de Venezuela, Caracas, Venezuela
| | - Efraín Sánchez-Angarita
- Servicio de Neumonología, Centro Médico Docente la Trinidad y Hospital Universitario de Caracas, Facultad de Medicina, Universidad Central de Venezuela, Caracas, Venezuela
| | - Vicente Plaza
- Servicio de Neumología, Hospital de la Santa Creu i Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Gustavo Rodrigo
- Departamento de Emergencia, Hospital Central de las Fuerzas Armadas, Montevideo, Uruguay
| | - Maria Montes de Oca
- Servicio de Neumonología, Centro Médico Docente la Trinidad y Hospital Universitario de Caracas, Facultad de Medicina, Universidad Central de Venezuela, Caracas, Venezuela
| | - Ignasi Gich
- Iberoamerican Cochrane Centre, Institute of Biomedical Research (IIB Sant Pau), CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Xavier Bonfill
- Iberoamerican Cochrane Centre, Institute of Biomedical Research (IIB Sant Pau), CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain
| | - Pablo Alonso-Coello
- Iberoamerican Cochrane Centre, Institute of Biomedical Research (IIB Sant Pau), CIBER de Epidemiología y Salud Pública (CIBERESP), Barcelona, Spain.
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10
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Zhang T, Smith MA, Camp PG, Carleton BC. High use of health services in patients with suboptimal asthma drug regimens: a population-based assessment in British Columbia, Canada. Pharmacoepidemiol Drug Saf 2013; 22:744-51. [PMID: 23559540 DOI: 10.1002/pds.3444] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Revised: 02/15/2013] [Accepted: 03/06/2013] [Indexed: 01/14/2023]
Abstract
BACKGROUND Despite numerous clinical guidelines on asthma management, patients often receive suboptimal drug therapy. This study identified patients who received suboptimal regimens according to the National Heart, Lung and Blood Institute (NHLBI) Guidelines for the Diagnosis and Management of Asthma in a complete population (residents of British Columbia, Canada) and determined the association between patients' regimens and utilization of healthcare services. METHODS A total of 65,345 asthma patients were identified using provincial health service utilization data (including all respiratory-related prescription medication dispensings, physician and hospital visits) for the 2009 fiscal year. Patient-specific regimens of inhaled short-acting bronchodilators (SABA) with or without inhaled corticosteroids (ICS) were categorized as optimal or suboptimal. Logistic regression models were used to determine the association between regimen optimality and health service utilization, adjusted for socioeconomic status, prior year hospital and emergency department (ED) visits for asthma. RESULTS Patients with suboptimal regimens had significantly greater risk of using health services than patients with optimal regimens of SABA and/or ICS. In particular, adolescents with suboptimal regimens were the most likely to have hospital admissions (odds ratio (OR) 3.8; 95% confidence interval (CI) 1.8-7.8), visit the ED (OR 2.2; 95% CI 1.6-3.1) and be high users of family physician services (OR 5.7; 95% CI 4.0-8.1) compared with patients in other age groups. CONCLUSIONS Suboptimal regimens are associated with significantly high usage of health services. Identifying patients with suboptimal regimens and improving their medication management in accordance with asthma clinical guidelines are likely to result in lower health service utilization.
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Affiliation(s)
- Tingting Zhang
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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11
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Abstract
Control-based asthma management has been incorporated in asthma guidelines for many years. This article reviews the evidence for its utility in adults, describes its strengths and limitations in real life, and proposes areas for further research, particularly about incorporation of future risk and identification of patients for whom phenotype-guided treatment would be effective and efficient. The strengths of control-based management include its simplicity and feasibility for primary care, and its limitations include the nonspecific nature of asthma symptoms, the complex role of β(2)-agonist use, barriers to stepping down treatment, and the underlying assumptions about asthma pathophysiology and treatment responses.
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12
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Abstract
Asthma and chronic obstructive pulmonary disease (COPD) are common diseases which cause patients and society considerable difficulties. These are costly diseases which cause substantial morbidity and death. Health care policy makers have made improving outcomes in asthma and COPD a priority. Application of guideline recommended approaches to asthma and COPD care in the real-life setting has been emphasized but outcomes have not improved. Failure to improve outcomes may not be because of inconsistent applications of guideline recommendations, but rather because there are difficulties implementing the Expert Panel Report III (EPR 3) method for categorizing asthma severity and the Global Initiative for Obstructive Lung Disease (GOLD) method for diagnosing COPD. As these serve as the foundation for treatment recommendations for these diseases, alternative approaches should be considered for categorizing asthma severity and identifying COPD patients. Claims-based algorithms provide an intriguing option for identifying persistent asthma patients and symptomatic COPD patients in administrative databases. These methods could be used as the basis for pragmatic research, both retrospective and prospective, on assessing outcomes of guideline recommended treatment approaches in asthma and COPD. Important questions urgently need to be answered about how guideline recommended approaches regarding use of long-acting inhaled β-agonist/inhaled corticosteroid (LABA/ICS) in asthma and long-acting inhaled anti-muscarinic agent (LAMA) and LABA/ICS in COPD affect outcomes in real-life situations.
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Affiliation(s)
- Gene L Colice
- The George Washington University School of Medicine, Pulmonary, Critical Care and Respiratory Services, Washington Hospital Center, Washington DC, USA
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13
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The CHOICE survey: high rates of persistent and uncontrolled asthma in the United States. Ann Allergy Asthma Immunol 2012; 108:157-62. [DOI: 10.1016/j.anai.2011.12.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Revised: 12/29/2011] [Accepted: 12/29/2011] [Indexed: 11/24/2022]
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Ivanova JI, Bergman R, Birnbaum HG, Colice GL, Silverman RA, McLaurin K. Effect of asthma exacerbations on health care costs among asthmatic patients with moderate and severe persistent asthma. J Allergy Clin Immunol 2012; 129:1229-35. [PMID: 22326484 DOI: 10.1016/j.jaci.2012.01.039] [Citation(s) in RCA: 209] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2011] [Revised: 01/06/2012] [Accepted: 01/09/2012] [Indexed: 11/24/2022]
Abstract
BACKGROUND Health care costs increase in patients with more severe asthma, but the effect of asthma exacerbations on costs among patients with more severe asthma has not been quantified. OBJECTIVE This study compared direct health care costs between patients with moderate/severe persistent asthma with and without exacerbations. METHODS Patients who had an asthma diagnosis (International Classification of Diseases-ninth revision-Clinical Modification code 493.x), were 12 to 64 years old, and were receiving controller therapy were identified from a large administrative claims database. Patients were categorized as having moderate/severe persistent asthma and were further evaluated for exacerbations during a 12-month exacerbation identification period. Patients with 1 or more exacerbations (asthma-related inpatient or emergency department visit or corticosteroid prescription) were matched to patients without exacerbations on demographic characteristics and asthma severity. Total and asthma-related health care costs during the 1-year study period after the exacerbation index date were calculated. RESULTS Patients with exacerbations had significantly higher total health care costs ($9223 vs $5011, P < .0001) and asthma-related costs ($1740 vs $847, P < .0001). The cost differences remained significant after controlling for patient differences by using multivariate models. Patients with exacerbations (n = 3830) had higher rates of sinusitis, allergy-related diagnoses or medications, pneumonia, and mental disorders and higher average Charlson Comorbidity Index scores at baseline. Patients with exacerbations filled their prescriptions for controllers more often and had higher asthma-related drug costs. CONCLUSIONS Patients with moderate/severe persistent asthma who had exacerbations had higher total and asthma-related health care costs than those without exacerbations. Moreover, controller medication use was higher in patients with exacerbations.
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Hirst C, Calingaert B, Stanford R, Castellsague J. Use of long-acting beta-agonists and inhaled steroids in asthma: meta-analysis of observational studies. J Asthma 2010; 47:439-46. [PMID: 20528600 DOI: 10.3109/02770901003605340] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Current asthma guidelines recommend the use of long-acting beta-agonists (LABAs) in combination with inhaled corticosteroids (ICSs) for long-term control and prevention of symptoms in persistent asthma. Data on the risk of asthma exacerbations of LABAs in combination with ICSs, as prescribed in typical clinical practice, are very scarce. METHODS The authors conducted a systematic literature review and meta-analysis of observational studies to examine the risk of asthma exacerbations, measured as asthma-related hospitalization and/or asthma-related emergency room (ER) visits, in adults receiving LABAs plus ICSs in a fixed-dose combination compared with patients receiving ICSs alone. RESULTS Seven studies, all retrospective cohort studies conducted in the United States, representing approximately 96,000 patients, were included in the meta-analysis. The meta-analysis found that the use of ICSs plus LABAs was associated with a lower risk of asthma-related hospitalizations and/or ER visits than ICSs alone (odds ratio: 0.82; 95% confidence interval: 0.72-0.94). Sensitivity analyses to explore heterogeneity of endpoint definition, duration of follow-up, and patient characteristics did not significantly alter the findings. CONCLUSIONS Overall, this systematic meta-analysis suggests that patients in clinical practice treated with a single inhaler containing ICSs plus LABAs experience fewer asthma exacerbations than similar patients treated with ICSs alone.
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Affiliation(s)
- Ceri Hirst
- Department of Epidemiology, RTI Health Solutions, Barcelona, Spain
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O'Byrne PM, Reddel HK, Colice GL. Does the current stepwise approach to asthma pharmacotherapy encourage over-treatment? Respirology 2010; 15:596-602. [PMID: 20384969 DOI: 10.1111/j.1440-1843.2010.01728.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
For the past 20 years, asthma pharmacotherapy has been described in clinical practice guidelines in terms of a stepwise approach, with medications and/or doses increased if asthma is not well-controlled, and reduced once good control is achieved and maintained. Although many patients with asthma are untreated, there are also significant problems with over-treatment once regular controller therapy is commenced. This increases the cost of treatment and exposes patients to unnecessary risks of side-effects. The present pro-con debate addresses the question of whether the stepwise approach itself leads to over-treatment. Two asthma experts discuss factors for and against this proposition, identify issues on which more research is needed, and suggest areas in which guidelines can be changed in order to facilitate more appropriate prescribing of asthma medications. These strategies include better validation of the concepts underlying asthma treatment recommendations, stronger recommendations that every treatment change should be followed up with a scheduled review using evidence-based assessment tools and incorporation of phenotype-specific considerations into treatment recommendations. In addition, the process for development and dissemination of clinical practice guidelines should ensure that recommendations are easily understood, feasible to implement, and relevant to everyday asthma care and the needs and concerns of patients and clinicians.
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Affiliation(s)
- Paul M O'Byrne
- Firestone Institute for Respiratory Health, St. Joseph's Healthcare, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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17
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Wilson ECF, Sims EJ, Musgrave SD, Shepstone L, Blyth A, Murdoch J, Mugford HM, Juniper EF, Ayres JG, Wolfe S, Freeman D, Gilbert RFT, Harvey I, Hillyer EV, Price D. Cost effectiveness of leukotriene receptor antagonists versus inhaled corticosteroids for initial asthma controller therapy: a pragmatic trial. PHARMACOECONOMICS 2010; 28:585-595. [PMID: 20550224 DOI: 10.2165/11537550-000000000-00000] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
BACKGROUND Information is lacking on the relative effectiveness and cost effectiveness--in a primary-care setting--of leukotriene receptor antagonists (LTRAs) as an alternative to inhaled corticosteroids (ICS) for initial asthma controller therapy. OBJECTIVE To compare the cost effectiveness of LTRAs versus ICS for patients initiating asthma controller therapy. METHODS An economic evaluation was conducted alongside a 2-year, pragmatic, randomized controlled trial set in 53 primary-care practices in the UK. Patients aged 12-80 years with asthma and symptoms requiring regular anti-inflammatory therapy (n = 326) were randomly assigned to LTRAs (n = 162) or ICS (n = 164). The main outcome measures were the incremental costs per point improvement in the Mini Asthma Quality of Life Questionnaire, per point improvement in the Asthma Control Questionnaire and per QALY gained from the UK NHS and societal perspectives. RESULTS Over 2 years, resource use was similar between the two treatment groups, but the cost to society per patient was significantly higher for the LTRA group, at pounds sterling 711 versus pounds sterling 433 for the ICS group (adjusted difference pounds sterling 204; 95% CI 74, 308) [year 2005 values]. Cost differences were driven primarily by differences in prescription drug costs, particularly study drug costs. There was a nonsignificant (imputed, adjusted) difference between treatment groups, favouring ICS, in QALYs gained at 2 years of -0.073 (95% CI -0.143, 0.010). Therapy with LTRAs was, on average, a dominated strategy, and, at a threshold for willingness to pay of pounds sterling 30,000 per QALY gained, the probability of LTRAs being cost effective compared with ICS was approximately 3% from both societal and NHS perspectives. CONCLUSIONS There is a very low probability of LTRAs being cost effective in the UK, at 2005 values, compared with ICS for initial asthma controller therapy. TRIAL REGISTRATION UK National Research Register N0547145240; Controlled Clinical Trials ISRCTN99132811.
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Navaratnam P, Friedman HS, Urdaneta E. Mometasone furoate vs fluticasone propionate with salmeterol: multivariate analysis of resource use and asthma-related charges. Curr Med Res Opin 2009; 25:2895-901. [PMID: 19821655 DOI: 10.1185/03007990903336515] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Although current National Asthma Education and Prevention Program (NAEPP) guidelines indicate low-dose inhaled corticosteroid (ICS) monotherapy as the preferred treatment for patients with mild persistent asthma, many patients receive ICS and long-acting beta(2)-agonist (LABA) combinations. The objective of the current study was to evaluate asthma-related charges in patients with mild asthma who began treatment with mometasone furoate (MF) versus those who began treatment with a fluticasone propionate/salmeterol (FPS) combination. RESEARCH DESIGN AND METHODS This retrospective administrative claims database analysis collected data from the 365-day periods before (preindex period) and after (postindex period) the study index date from patients with mild asthma aged 12 to 65 years who began treatment with MF or FPS. Asthma-related inpatient, outpatient, pharmaceutical, and total charges; exacerbations; short-acting beta(2)-agonist (SABA) canister claims; and adherence to therapy were assessed. Matched cohorts of MF and FPS patients were compared using multivariate generalized linear regression models. RESULTS Among matched MF (n = 4094) and FPS (n = 4094) cohorts, MF patients had significantly lower postindex asthma-related total charges ($2136 vs $2315, respectively; P = 0.0003), lower pharmaceutical charges ($727 vs $925, respectively; P < 0.0001), fewer exacerbations (0.14 vs 0.16, respectively; P = 0.0306), fewer SABA canister claims (0.9 vs 1.0, respectively; P < 0.0001), and greater adherence measured by prescription fills (3.0 vs 2.8, respectively; P < 0.0001). Asthma-related inpatient charges, outpatient charges, and adherence measured by percent of days covered were not significantly different between treatment cohorts. Limitations included a lack of additional ICS and ICS/LABA therapies, a lack of pediatric patients, and the general limitations associated with retrospective database analyses (e.g., no patient records). CONCLUSIONS These data suggest that MF may be more cost-effective than FPS for the treatment of mild asthma. To effectively and efficiently manage asthma, it is important for clinicians to follow current NAEPP guidelines, which indicate ICS monotherapy as preferred treatment for mild persistent asthma.
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Ye X, Gutierrez B, Zarotsky V, Nelson M, Blanchette CM. Appropriate use of inhaled corticosteroid and long-acting beta(2)-adrenergic agonist combination therapy among asthma patients in a US commercially insured population. Curr Med Res Opin 2009; 25:2251-8. [PMID: 19622006 DOI: 10.1185/03007990903155915] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To examine health care utilization measures indicating which asthma patients are appropriate for inhaled corticosteroid and long-acting beta(2)-adrenergic agonist (ICS/LABA) therapy and determine whether two ICS/LABA therapies were initiated in accordance with guidelines. RESEARCH DESIGN AND METHODS A retrospective cohort study of commercially insured asthma patients aged > or =12 years that initiated fluticasone propionate/salmeterol (FSC) or budesonide/formoterol fumarate dihydrate (BFC) combination therapy in 2007 was conducted. Use was considered appropriate if patients met any of the following during a 1-year period before ICS/LABA initiation: ICS or leukotriene receptor antagonist (LTRA) use; an asthma-related emergency department (ED) visit or hospitalization; > or =2 oral corticosteroids (OCS) courses; or > or =6 short-acting beta(2)-adrenergic agonist (SABA) canisters. Multivariate logistic regression was used to assess factors associated with appropriate ICS/LABA use. Certain limitations inherent to the use of claims data for research apply to this study. RESULTS Of 24,231 patients who initiated ICS/LABA therapy, 993 received BFC and 23,238 received FSC. Among all patients, 37.6% met > or =1 criteria for appropriate use. However, compared with FSC users, BFC users had a significantly higher likelihood of meeting > or =1 of these criteria (odds ratio, 2.01; 95% CI, 1.76-2.30; p < 0.001), and a higher proportion of BFC than FSC patients met 4 of the 5 appropriate use criteria. In total, 58.4% of BFC patients versus 36.7% of FSC patients met > or =1 criteria for appropriate use. Other factors associated with appropriate use included age, region, Charlson comorbidity score, number of medications, and prescriber specialty. CONCLUSION Fewer than half of all patients fulfilled the specified criteria for being appropriate for ICS/LABA therapy. However, a significantly higher proportion of BFC than FSC users met the criteria for appropriate use of ICS/LABA therapy. These results may suggest a need for improved physician awareness of consensus guidelines for the initiation of ICS/LABA therapy.
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Affiliation(s)
- Xin Ye
- i3 Innovus, Eden Prairie, MN, USA
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Outcomes and costs of patients with persistent asthma treated with beclomethasone dipropionate hydrofluoroalkane or fluticasone propionate. Adv Ther 2009; 26:762-75. [PMID: 19669630 DOI: 10.1007/s12325-009-0056-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Examine outcomes and costs of patients with persistent asthma who initiated treatment with beclomethasone dipropionate hydrofluoroalkane (BDP-HFA) or fluticasone propionate (FP). METHODS MedStat's Commercial Claims and Encounters database (July 1, 2002-June 30, 2007) was utilized. Patients (n=13,968) were included if they initiated treatment with BDP-HFA or FP (first use=index date). Patients also met these criteria: (a) no receipt of other study medication in the 1-year post-period; (b) persistent asthma in the 1-year pre-period; (c) age 5-64 years; (d) no diagnosis of chronic obstructive pulmonary disease; and (e) continuous insurance coverage from 1 year pre-period to 1 year post-period. Multivariate regressions examined the probability of an ER visit or hospitalization, probability of reaching alternative adherence thresholds, and costs. RESULTS Receipt of BDP-HFA, compared with FP, was associated with a 17% reduction in the odds of an ER visit (OR=0.834, 95% CI 0.751 to 0.925), a 30% reduction in the odds of an asthma-related ER visit (OR=0.697, 95% CI 0.571 to 0.852), and an increase in the odds of obtaining a medication possession ratio (MPR) of at least 50% (OR=1.324; 95% CI 1.164 to 1.506) or 75% (OR=1.311; 95% CI 1.072 to 1.604). Total medical costs ($5063 vs. $5377, P=0.0042), prescription drug costs ($2336 vs. $2581, P<0.0001), and ER costs ($185 vs. $249, P<0.0001) were significantly lower among the BDP-HFA cohort. Asthma-related outpatient ($191 vs. $224, P<0.0001) and ER costs ($28 vs. $45, P<0.001) were significantly lower in the BDP-HFA group, while asthma-related inpatient ($101 vs. $59, P<0.0001) and drug costs ($451 vs. $540, P<0.0001) were significantly lower in the FP cohort. CONCLUSIONS Results indicate that receipt of BDP-HFA, compared with receipt of FP, is associated with a decreased probability of ER visits or asthma-related ER visits and higher odds of reaching a medical possession ratio threshold of 50% or 75%. Receipt of BDP-HFA was also associated with lower total drug costs and lower total medical costs.
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Birnbaum HG, Ivanova JI, Yu AP, Hsieh M, Seal B, Emani S, Rosiello R, Colice GL. Asthma severity categorization using a claims-based algorithm or pulmonary function testing. J Asthma 2009; 46:67-72. [PMID: 19191141 DOI: 10.1080/02770900802503099] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVES This study was performed to determine whether pulmonary function test results would appreciably alter asthma severity categorization determined by an algorithm using information readily available in administrative databases. METHODS Patients 6 to 64 years of age with asthma diagnosed from 1999-2005, who had at least one pulmonary function test, were identified from a claims database of a medical group practice located in central Massachusetts. Asthma severity for these patients was categorized using information available in an administrative database (claims-based algorithm) and by percent predicted forced expiratory volume in 1 second (FEV(1)) or peak expiratory flow (PEF) abstracted from medical charts (pulmonary function test method). Gamma rank correlation index was used to measure the association between the two severity categorization methods. Total and asthma-related healthcare costs for each severity category were compared between the two different approaches. RESULTS There was a significant ordinal association between severity categorization with the two classification approaches (p = 0.0002). The pulmonary function test method resulted in more frequent mild categorizations and less frequent moderate and severe categorizations than the claims-based algorithm. In only 10.9% of patients did the pulmonary function test method result in a more severe asthma category than the claims-based algorithm. Patients with more severe asthma, determined by both methods, had higher total and asthma-related health care costs. Total and asthma-related health care costs were similar for each asthma severity categorization for the two classification approaches, except for asthma-related costs in the moderate severity categories. CONCLUSION The claims-based algorithm generally categorized patients as having more severe asthma than the approach using pulmonary function test results. Pulmonary function test results would have appreciably changed asthma severity categorization in only a small percent of patients. These findings add further support to the use of administrative database analyses for the evaluation of asthma care in large populations.
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Affiliation(s)
- H G Birnbaum
- Analysis Group, Inc., Boston, Massachusetts, USA
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