According to the Centers for Disease Control and Prevention (CDC), asthma affects approximately 26 million Americans at an incremental cost of $56 billion annually; while Medicaid spends over $10 billion per year treating asthma. In 2010, asthma resulted in 439,000 hospitalizations, 1.8 million emergency department visits, and 14.2 million asthma-related doctor visits. Asthma severity and morbidity are the key drivers of the clinical and economic burden of asthma, leading to impaired quality of life, work productivity loss, greater mortality risk, and significantly higher health care resource utilization and cost. Therefore, effectiveness and adherence are major factors driving the development of treatment formularies.
Disease Burden on Stakeholders
Many safe and efficacious pharmacologic agents are available for controlling asthma symptoms. The 2007 National Asthma Education and Prevention guidelines for the diagnosis and management of asthma reaffirms that inhaled corticosteroids (ICS) are the most consistently effective, long-term, anti-inflammatory asthma control medications.
Other treatments for patients who have a history of severe exacerbations despite use of ICS asthma medicines include the use of injectables, such as Cinqair (Reslizumab, Teva). Phase III clinical trials found that use of reslizumab was associated with a 59% reduction in exacerbations, as well as significant improvement in lung function, symptoms, and quality of life.
Despite the available guidelines for asthma, managed care organizations (MCOs) are still facing several barriers when it comes to determining the appropriate therapy for this disease state because dosage, duration, and agent selection still remain major therapy hurdles. A recent study in Consultant Live examined asthma disease burden, disease management strategies, and asthma formulary management among MCO and employer decision-makers and found that the greatest challenge in managing member populations with asthma were attributed to health care provider behavior, patient education, patient adherence to medication regimen, and misuse of medication.
The analysis of MCO and employer decision makers found that MCO decision makers reported efficacy/safety, cost-effectiveness/value, and adherence as the the key product attributes driving formulary decision making for an ICS medication. However, cost played a significant role in the tier process for a new ICS medication compared with established ICS drugs.
Adherence to asthma medication is a major concern for all stakeholders. An Express Scripts report that looked at recent drug trends found that 55.2% of patients are nonadherent to their asthma medication. Low adherence to controller therapies is an important contributor to asthma remaining uncontrolled in a large population of patients, even with effective and inexpensive controller therapies available.
A study in the Journal of Allergy and Clinical Immunology, by Zafari and colleagues, attempted to quantify the extent to which the asthma burden can be attributed to low adherence. They created a model to simulate the effect of treatment with controller medications on asthma control and exacerbations over a 10-year period. To be cost-effective, the study found an adherence intervention program that improves adherence by 50% should cost less than $130 per person annually at a willingness to pay threshold of $50,000/quality-adjusted life years.
According to the CDC, improving adherence will require the participation of patients, providers, and payers.
According to a recent study in JAMA Internal Medicine, ineffective antibiotic treatments for asthma attacks may also be contributing to the cost burden associated with treating asthma.
Sebastian L Johnston, PhD, professor of respiratory medicine and allergy at the National Heart and Lung Institute at the Imperial College in London, and colleagues studied the effectiveness of using the antibiotic azithromycin to treat asthma attacks. They screened 4582 study participants from 31 sites.
Dr Johnston and colleagues noted that antibiotic therapy is not part of the standard of care for asthma attacks, yet physicians often still use them in an attempt to treat the condition.
“A remarkable finding of this study was the number of patients excluded because they were already receiving antibiotic therapy for their asthma exacerbation despite treatment guidelines recommending that such therapy not be routinely given,” Dr Johnston and colleagues wrote. “For each patient randomized, more than 10 were excluded for this reason. This important finding has obvious and worrying implications regarding antibiotic stewardship.”
According to the researchers, the study found that using antibiotics to treat asthma attacks provided “no statistically significant or clinically important benefit.”
In an accompanying editorial, Guy G Brusselle, MD, PhD, and Eva Van Braeckel, MD, PhD, of the Ghent University Hospital in Belgium, noted that the prevalence of antibiotic use among asthma patients was worrisome.
“Acute episodes of worsening respiratory symptoms, called acute exacerbations or asthma attacks, can be life-threatening, and induce important costs, encompassing both direct health care expenses and indirect costs,” they wrote. “The most striking finding of the study is the overuse of antibiotics in patients with asthma attacks.”
A CDC initiative is partnering public health officials with health care purchasers, payers, and providers to improve health and control health care costs for six high-burden health conditions including asthma. The initiative provides four evidence-based interventions for asthma control. One intervention is to promote strategies to improve access and adherence to asthma medication and devices.
“Asthma can be managed effectively when children and families receive asthma education, understand medications, live in healthy housing, and have a system of coordinated care in place,” the CDC reported. “Major barriers to health care access in poor communities include lack of adequate health insurance coverage, overwhelmed clinics, shortages of culturally and linguistically competent providers, and low health literacy.”
The agency recommends that payers and providers consider how asthma prescription fill rates affect adherence. They cited a retrospective cohort study of 2023 patients from private health maintenance organization that examined medication adherence and patient ability to fill prescriptions within 30 days of the prescription date. The study showed that the first-fill rate was lower for patients with a copay above the mean of $12 and higher for patients prescribed oral plus inhaled medications (Am Health Drug Benefits. 2009;2(4):174-180). Additionally, the CDC recommends that payers and providers should look for ways to improve adherence for patients who may require longer-term use of asthma medications because these patients may not fill those medications requiring higher copays.