A Closer Look At Asthma

A CLOSER LOOK

Asthma results in approximately 5,000 deaths annually in the United States and accounts for nearly half a million hospitalizations, 1.6 million emergency room visits, and over 10 million physician office visits.

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JOINT PROJECT BETWEEN T H E A S T H M A A N D A L L E R G Y F O U N DAT I O N O F A M E R I C A A N D T H E N AT I O N A L P H A R M AC E U T I C A L C O U N C I L

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sthma is a chronic, potentially fatal disease caused by inflamed airways that restrict airflow. Disease characteristics are shortness of breath, wheezing, chest tightness and coughing.1 In 1996, asthma affected an estimated 14.5 million people in the United States, an estimated 10.5 million of whom were under the age of 45.2 During the past two decades, the number of asthma cases and asthmarelated deaths has increased, particularly among economically disadvantaged, urban, and minority groups.3,4 Asthma is also increasing in prevalence among children. The death rate due to asthma for children 19 years of age and younger increased by 78 percent between 1980 and 1993.5 There are about 470,000 hospitalizations and more than 5,000 deaths each year from asthma, and it is the third leading cause of preventable hospitalizations in the United States.6 Asthma is recognized as an important public health issue in the U.S. although it remains under diagnosed and under treated, possibly because signs and symptoms vary widely from patient to patient as well as within each patient over time.7 Managing asthma requires a long-term, multi-faceted approach, including patient education, frequent medical follow-up, behavior changes, drug therapy, and avoidance of asthma triggers such as irritants, viruses, and inhaled allergens to which the patient is sensitive. About one of every five adults and children suffer from allergies, including allergic asthma.5 Effective therapies are available to treat and manage asthma. Asthma therapies improve respiratory function, thus reducing coughing, wheezing, and tightness in the chest, and improve the patient’s functional activity and quality of life. However, data shows an increase in prevalence and complications of asthma despite available effective therapies. In 1991, in response to this data, the

National Asthma Education and Prevention Program (NAEPP) of the National Institutes of Health released guidelines as the first step toward attempting to reduce 7, 8 incidences of death and disability due to asthma. The guidelines were distributed to more than 300,000 practitioners to enhance physician understanding of effective asthma management. In 1997, the guidelines were updated.1 They recommend long-term control with daily use of inhalers for those with moderate to severe asthma.1, 9 Although not new, inhalers containing anti-inflammatory medicines have emerged as the primary treatment for asthma.10 New drugs have recently been introduced that offer longer lasting effects for patients who require regular, frequent treatments, and offer oral dosage forms that are particularly useful to children who may not be able to properly use inhalers. Although appropriate care and management does reduce the use of asthma-related health care services, overall compliance with national guidelines is low.11 The NAEPP guidelines also emphasize the importance of educating patients about the proper use of inhalers to manage asthma and recommend a written action plan for patients with moderate to severe persistent asthma or a history of severe asthma. However, studies from two major metropolitan areas of adults hospitalized with asthma found that only 28 percent of the adult patients hospitalized had written action plans that explained how to manage their asthma.7 Multiple efforts to prevent and appropriately treat asthma are being undertaken. The Center for Disease Control (CDC) is working with state and local partners to implement and evaluate comprehensive asthma prevention programs and is funding selected state and city health agencies in their efforts to assess their asthma programs. As these efforts become increasingly successful, it is likely that pharmaceutical spending will continue to increase. However, this increased use of asthma medications not only improves the quality of care for asthma patients, but also reduces the use of other costly medical resources.

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pending for asthma-related health care costs was estimated at more than $14.5 billion in the year 2000.12 Some other startling statistics: • Asthma results in approximately 5,000 deaths annually in the United States and accounts for nearly half a million hospitalizations, 1.6 million emergency room visits, and over 10 million physician office visits.13 • An asthma patient experiences an average of 11.7 days of restricted activity yearly and this restricted activity is the single largest reason that children miss school.14 • Costs associated with time adults lost from work because of their own asthma quadrupled over the last ten years. Lost work time costs for caregivers of asthmatics and housekeepers also increased by 88 percent.6

• The costs associated with asthma care increased 54 percent over a ten-year period.6 • In 1994 the estimated total asthma-related expenditure in the U.S. was $7.8 billion. Of this, $5.1 billion was due to direct medical costs for treating asthma and $2.7 billion was in costs due to missed work and restricted activities. Over half of the direct costs were from hospitalizations.15 • Better treatment improves the quality of care for asthmatics and reduces overall health care costs.16, 17

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HE NATIONAL INSTITUTES OF HEALTH HAS RECOGNIZED THE CRITICAL IMPACT OF APPROPRIATE MEDICAL TREATMENT FOR ASTHMA AND HAS ELEVATED ASTHMA TO A NATIONAL PUBLIC HEALTH ISSUE.

ASTHMA

IN THE

AFRICAN-AMERICAN COMMUNITY

• Asthma affects an estimated 14.5 million Americans. Minority communities suffer disproportionately from the chronic disease. • Asthma is 26 percent more prevalent among AfricanAmerican children than among Caucasian children. • African-American children are three to four times more likely than their Caucasian counterparts to be hospitalized with asthma. • African-Americans of all ages are three times as likely as Caucasians to be hospitalized from asthma and three times as likely to die from the disease. • More than 2 million African-Americans in the United States suffer from asthma. • Minority, inner-city families are more likely to be exposed to asthma risk factors, such as high levels of indoor allergens, including those borne by cockroaches, tobacco smoke, and nitrogen dioxide (a respiratory irritant produced by poorly vented stoves and heating appliances). • Minorities have difficulty obtaining sufficient follow-up asthma treatment from a qualified health care provider and gaining access to medications, inhalers or nebulizers and other treatments that can help control asthma.

• Studies have identified several candidate genes for asthma, some of which may be more common in AfricanAmerican populations. • Investigators have identified a genetic change in an immune-signaling molecule involved in asthma and allergic responses that correlates with asthma severity. This change appears to be several-fold more common among African-Americans than among Caucasians. • Asthma is only slightly more prevalent among AfricanAmerican children than among Caucasian children. However, African-American children with asthma experience more severe disability and have more frequent hospitalizations than do Caucasian children. • Although African-Americans represent only 12 percent of the U.S. population, they experience over 21 percent of all asthma deaths. Source: Asthma and Allergy Foundation of America. (1998). Asthma in the African-American community fact sheet. Washington, D.C.: Author.

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STHMA PATIENTS AVERAGE 11.7 DAYS OF RESTRICTED ACTIVITY YEARLY. THIS REPRESENTS THE SINGLE LARGEST REASON THAT CHILDREN MISS SCHOOL. COSTS ASSOCIATED WITH MISSED WORK AND RESTRICTED ACTIVITIES TOTALED $2.7 BILLION IN 1994.

METHODOLOGY This study separately analyzed prescription drug spending growth for two large national claims databases, one representing managed care plan enrollees and the other representing those covered by large employer-provided health benefit plans. The study defined and assessed several factors affecting the price per day of therapy and the volume of therapy — the number of days of therapy received and the number of patients receiving drug therapy. The analysis also examined the effects of price and volume changes for established drugs on the market during the entire period of analysis and for new drugs that were first marketed during this period.

Spending on pharmaceuticals was analyzed for asthma patients enrolled in managed care plans in 1995 and 1998.

Price

FACTORS INFLUENCING DRUG SPENDING FOR ASTHMA

Volume

Among health plan members, per person asthma-related drug expenditures increased by 94 percent. Volume factors (increased numbers of people with asthma receiving asthma and asthma-related prescriptions, and increased intensity and duration of drug therapy) had a greater impact than did drug price factors. An increase in the proportion of plan members receiving an asthma-related

Factors Influencing Growth in Rx Expenditures: Total Growth in Expenditures Growth Due to Volume Factors

% Positive Impact +82

-19

Changes in the Number of Prescriptions per Person for New Entrants

+63

Changes in Days of Therapy for Established Drugs

+14

Changes in Days of Therapy for New Entrants Growth Due to Price Factors

-0.3 +25 +12

Inflation Changes in Mix of Established Drugs Price of New Entrants Source: Protocare Sciences managed care database

% Negative Impact

+94

Changes in the Number of Prescriptions per Person for Established Drugs

Patients per 1000 Health Plan Enrollees

prescription contributed 27 percent of the total increase in spending per member, due in part to a greater percentage of asthmatics treated for asthma-related conditions and asthma complications. The percentage of asthmatics using asthma drugs increased from 58 percent in 1995 to 76 percent in 1998.

-0.5 +17 -5

ASTHMA RESULTS IN 5,000 DEATHS ANNUALLY IN THE UNITED STATES AND ACCOUNTS FOR NEARLY HALF A MILLION HOSPITALIZATIONS, 1.6 MILLION EMERGENCY ROOM VISITS AND OVER 10 MILLION PHYSICIAN OFFICE VISITS. ASTHMA-RELATED ER AND HOSPITAL USE Emergency room visits fell by 31 visits per 1000 asthma patients and hospitalizations decreased by 35 per 1000 asthma patients between 1995 and 1998. The cost savings from decreased utilization of hospital resources per patient were $399. This offset the increase in drug expenditures of $224.

No. per 1,000 Asthma Patients

500 424 393

400

300 200

16 163

128

100 0 Hospitalizations

ER Visits 1995

1998

Source: Protocare Sciences managed care database

The change in volume of prescriptions for asthma was the key driver in the overall growth in drug expenditures for asthma therapy. More patients received asthma medications for longer periods of time in a manner consistent with national guidelines for asthma care.

The average number of prescriptions per patient per year increased from 13.0 to 17.1. Increases were observed for medications used to treat asthma directly and for those used to treat complications of asthma and asthma-related diseases.

From 1995 to 1998, the percentage of asthmatic patients taking prescription drugs for their asthma and related conditions increased. In addition, the number of different drugs prescribed and the length of therapy increased. A decrease in acute care services was also demonstrated. Thus, increased use of medications according to the standards of asthma care has contributed to favorable outcomes.

For medications used to treat asthma, increases in the rate of use were noted across all drug categories. The percentage of patients using inhalers increased from 24 percent to 39 percent for one category of inhalers and from 41 percent to 59 percent for another category of inhalers between 1995 and 1998. The “profile” of the asthma patient population changed from 1995 to 1998. The average age of asthmatics increased from 37.5 years to 43.3 years and the number of additional medical conditions per patient increased from 8.8 to 9.6.

ABOUT

THIS PUBLICATION: “A Closer Look at Asthma” is a joint publication of the Asthma and Allergy Foundation of America and the National Pharmaceutical Council. The Asthma and Allergy Foundation of America (AAFA) is the premier patient organization dedicated to improving the quality of life for people with asthma and allergies, and their families through education, advocacy and research. AAFA, a not-for-profit organization founded in 1953, provides practical information, community based services, support and referrals through a national network of chapters and educational support groups. AAFA also raises funds for asthma care and research. Since 1953, the National Pharmaceutical Council (NPC) has sponsored and conducted scientific, evidence-based analyses of the appropriate use of pharmaceuticals and the clinical and economic value of pharmaceutical innovation. NPC provides educational resources to a variety of health care stakeholders, including patients, clinicians, payers and policy makers. More than 20 research-based pharmaceutical companies are members of the NPC.

FOR MORE INFORMATION ABOUT ASTHMA, PLEASE CONTACT: Asthma and Allergy Foundation of America (AAFA) www.aafa.org

1-800-7-ASTHMA American Academy of Allergy, Asthma and Immunology (AAAAI) www.aaaai.org

1-800-822-2762 American College of Allergy, Asthma and Immunology (ACAAI) www.allergy.mcg.edu

1-800-842-7777 National Asthma Education and Prevention Program (NAEPP) National Heart, Lung and Blood Institute www.nhlbi.nih.gov/about/naepp

301-251-1222 National Centers for Disease Control and Prevention (CDC) www.cdc.gov

1-800-CDC-1311 National Institute of Allergy and Infectious Diseases (NIAID) National Institutes of Health/ Office of Communications and Public Liaison www.niaid.nih.gov

301-496-5717 1

Georgitis JW. The 1997 asthma management guidelines and the therapeutic issues relating to the treatment of asthma. Chest. 1999;115;210-217

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Brown CM, Anderson HA, Etzel RA. Asthma: The states’ challenge. Public Health Rep. 1997;112:198-205

www.cdc.gov/nceh/programs/asthma/ataglance/ asthmaag2.htm

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National Center for Health Statistics. Monitoring Health Care in America. Spotlight on lung disease. Quarterly Fact Sheet. December 1996

Centers for Disease Control and Prevention. (1998). CDC’s Asthma Prevention Program, [Online]. Available: http://www.cdc.gov/nceh/asthma/factsheets/ asthma.htm [07/11/01].

Collins JG. Prevalence of selected chronic conditions: United States, 1990-92. National Center for Health Statistics. Vital Health Stat. 10(194).1997

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Weiss, KB, Sullivan, SD, Lyttle, CS (2000). Trends in the cost of illness for asthma in the United States, 19851994. Journal of Allergy and Clinical Immunology, 106, (3), 493-499.

National Institutes of Health, National Heart, Lung, and Blood Institute. (1997). National Asthma Education and Prevention Program, Practical Guide for the Diagnosis and Management of Asthma, 97-4053. 8

Phone: 703-620-6390 Fax: 703-476-0904 www.npcnow.org

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Legorreta AP, Christian-Herman J, O’Connor RD, Hasan MM, Evans R, Leung KW. Compliance with national asthma management guidelines and specialty care. Arch Intern Med. 1998;158:457-464

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The National Pharmaceutical Council 1894 Preston White Drive Reston, VA 20191-5433

McFadden E, Gilbert I, Asthma, New Engl J Med, 1992;327 (27):1928-37

Centers for Disease Control and Prevention National Center for Health Statistics. (2001). Fast Stats A-Z, [Online]. Available: http://www.cdc.gov/nchs/fastats/ asthma.htm [8/2/01].

Homer CJ. Asthma disease management. New Engl J Med. 1997;227(20):1461-1463

For more information about NPC or for additional resources, please contact:

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National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program Expert Panel Report II: guidelines for the diagnosis and management of asthma. Bethesda, MD: U.S. Department of Health and Human Services, 1997. NIH publication no. 97-4051

National Heart, Lung, and Blood Institute. National Asthma Education and Prevention Program Expert Panel Report: Guidelines for the diagnosis and management of asthma. Bethesda, MD: U.S. Department of Health and Human Services, 1991. NIH publication no. 91-3042.

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Smith DH, Malone DC, Lawson KA, Okamoto LI, Battista C, Saunders WB. A national estimate of the economic costs of asthma. Am J Respir Crit Care Med. 1997;156:787-793 Nestor A, Calhoun AC, Dickson M, Kalik CA. Crosssectional analysis of the relationship between national guideline recommended asthma drug therapy and emergency/hospital use within a managed care population. Ann Allergy Asthma Immunol. 1998;81:327-330

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Buchner DA, Butt LT, De Stefano A, Edgren B, Suarez A, Evans RM. Effects of an asthma management program on the asthmatic member: patient-centered results of a 2year study in a managed care organization. Amer J Managed Care. 1998;4(9):1288-1297