Analysis of the Budget Impact of Fractional Exhaled Nitric Oxide Monitoring in the Management of Childhood Asthma: The Colombian National Health System Perspective.

BACKGROUND: Fractional exhaled nitric oxide (FeNO) testing is a simple, noninvasive approach to assessing airway inflammation with minimal discomfort that provides results within a few minutes. For policy makers, the economic impact of this technology is the main concern, especially in developing countries. We evaluated the budget impact of asthma management using FeNO monitoring in patients aged between 4 and 18 years in Colombia. METHODS: A budget impact analysis was performed to evaluate the potential cost of FeNO monitoring. The analysis was based on a 5-year time horizon and performed from the perspective of the Colombian National Health System. The incremental budget impact was calculated by subtracting the cost of the new treatment, in which FeNO is reimbursed, from the cost of conventional treatment without FeNO (management based on clinical symptoms [with or without spirometry/peak flow] or asthma guidelines [or both] for asthma-related cases). Univariate 1-way sensitivity analyses were performed. RESULTS: In the base case analysis the 5-year costs associated with FeNO and non-FeNO were estimated to be €469 904 130 and €480 485 149, respectively, indicating savings for the Colombian National Health System of €10 581 019 if FeNO is adopted for the routine management of patients with persistent asthma. This result proved to be robust in the univariate 1-way sensitivity analysis. CONCLUSION: FeNO monitoring generated cost savings in emergency settings for infants with persistent asthma. This evidence can be used by decision makers in Colombia to improve clinical practice guidelines and should be replicated to validate the results in other middle-income countries.

Predictors for the prescription of albuterol in infants hospitalized for viral bronchiolitis.

INTRODUCTION AND OBJECTIVES: Despite the recommendation against routine use of inhaled bronchodilators in infants with viral bronchiolitis given in the main clinical practice guidelines (CPGs) on viral bronchiolitis, albuterol is widely prescribed to patients with this disease. The aim of this study was to identify predictors of prescription of albuterol in a population of infants hospitalized for viral bronchiolitis. MATERIAL AND METHODS: An analytical cross-sectional study performed during the period from March 2014 to August 2015, in a random sample of patients <2 years old hospitalized in the Fundacion Hospital La Misericordia, a hospital located in Bogota, Colombia. After reviewing the electronic medical records, we collected demographic, clinical, and disease-related information, including prescription of albuterol at any time during the course of hospitalization as the outcome variable. RESULTS: For a total of 1365 study participants, 1042 (76.3%) were prescribed with albuterol therapy. After controlling for potential confounders, it was found that age (OR 1.11; CI 95% 1.08-1.15; p<0.001), and a prolonged length of stay (LOS) (OR 1.93; CI 95% 1.44-2.60; p<0.001) were independent predictors of prescription of albuterol in our sample of patients. By contrast, albuterol prescription was less likely in the post-guideline assessment period (OR 0.41; CI 95% 0.31-0.54; p<0.001), and in infants with RSV isolation (OR 0.71; CI 95% 0.52-0.97; p=0.035). CONCLUSIONS: Albuterol was highly prescribed in our population of inpatients with the disease. The independent predictors of prescription of albuterol in our sample of patients were age, implementation of a CPG on viral bronchiolitis, RSV isolation, and LOS.

Direct medical costs of pediatric asthma exacerbations requiring hospital attendance in a middle-income country.

INTRODUCTION AND OBJECTIVES: With the aim of making informed decisions on resource allocation, there is a critical need for studies that provide accurate information on hospital costs for treating pediatric asthma exacerbations, mainly in middle-income countries (MICs). The aim of the present study was to evaluate the direct medical costs associated with pediatric asthma exacerbations requiring hospital attendance in Bogota, Colombia. PATIENTS AND METHODS: We reviewed the available electronic medical records (EMRs) for all pediatric patients who were admitted to the Fundacion Hospital de La Misericordia with a discharge principal diagnosis pediatric asthma exacerbation over a 24-month period from January 2016 to December 2017. Direct medical costs of pediatric asthma exacerbations were retrospectively collected by dividing the patients into four groups: those admitted to the emergency department (ED) only; those admitted to the pediatric ward (PW); those admitted to the pediatric intermediate care unit (PIMC); and those admitted to the pediatric intensive care unit (PICU). RESULTS: A total of 252 patients with a median (IQR) age of 5.0 (3.0-7.0) years were analyzed, of whom 142 (56.3%) were males. Overall, the median (IQR) cost of patients treated in the ED, PW, PIMC, and PICU was US$38.8 (21.1-64.1) vs. US$260.5 (113.7-567.4) vs. 1212.4 (717.6-1609.6) vs. 2501.8 (1771.6-3405.0), respectively: this difference was statistically significant (p<0.001). CONCLUSIONS: The present study helps to further our understanding of the economic burden of pediatric asthma exacerbations requiring hospital attendance among pediatric patients in a MIC.

Direct medical costs of RSV-related bronchiolitis hospitalizations in a middle-income tropical country.

INTRODUCTION AND OBJECTIVES: With the objective of making informed decisions on resource allocation, there is a critical need for studies that provide accurate information on hospital costs for treating respiratory syncytial virus (RSV)-related bronchiolitis, mainly in middle-income countries (MICs). The aim of the present study was to evaluate the direct medical costs associated with bronchiolitis hospitalizations caused by infection with RSV in Bogota, Colombia. MATERIAL AND METHODS: We reviewed the available electronic medical records (EMRs) for all infants younger than two years of age who were admitted to the Fundacion Hospital de La Misericordia with a discharge principal diagnosis of RSV-related bronchiolitis over a 24-month period from January 2016 to December 2017. Direct medical costs of RSV-related bronchiolitis were retrospectively collected by dividing the infants into three groups: those requiring admission to the pediatric ward (PW) only, those requiring admission to the pediatric intermediate care unit (PIMC), and those requiring to the pediatric intensive care unit (PICU). RESULTS: A total of 89 patients with a median (IQR) age of 7.1 (3.1-12.2) months were analyzed of whom 20 (56.2%) were males. Overall, the median (IQR) cost of infants treated in the PW, in the PIMC, and in the PICU was US$518.0 (217.0-768.9) vs. 1305.2 (1051.4-1492.2) vs. 2749.7 (1372.7-4159.9), respectively, with this difference being statistically significant (p<0.001). CONCLUSIONS: The present study helps to further our understanding of the economic burden of RSV-related bronchiolitis hospitalizations among infants of under two years of age in a middle-income tropical country.

Epidemic activity of respiratory syncytial virus is related to temperature and rainfall in equatorial tropical countries.

Although viral acute lower respiratory infections (ALRIs) are a major public health problem in tropical low- and middle-income countries (LMICs), and there is growing evidence showing their relationship with meteorological parameters, studies performed in these countries are scarce. In an analytical cross-sectional study, we determined which of the main meteorological parameters (temperature, absolute humidity, rainfall, wind speed, and solar radiation) predicted respiratory syncytial virus (RSV) activity in a population of hospitalized children with ALRI during a 5-year period, from January 2009 to December 2013. Out of a total of 4559 children included in the study (mean age 9·2 ± 8·5 months), 2953 (64·8%) presented RSV infection during the 3-month period from March to May. In the multivariate analysis, after controlling for absolute humidity, wind speed, and solar radiation, temperature [incidence rate ratio (IRR) 2·25, 95% confidence interval (CI) 1·11-4·53, P = 0·024], and rainfall (IRR 1·01, 95% CI 1·00-1·02, P = 0·044) were independently associated with the monthly number of RSV infections. In conclusion, in Bogota, the capital of a tropical LMIC lying slightly above the equator, RSV activity peaks in the 3-month period from March to May, the main rainy period of the year in the city. In addition, rainfall and temperature are the two most important meteorological parameters that are independently associated with RSV activity in hospitalized children with ALRI in the city.

Effects of zinc supplementation in the prevention of respiratory tract infections and diarrheal disease in Colombian children: A 12-month randomised controlled trial.

BACKGROUND: Among the preventive strategies for lowering the incidence of upper respiratory tract infections (URTI) and acute diarrhoea episodes, two of the most common diseases in children, zinc supplementation has received special interest. However, there is a need for additional studies that determine the preventive effects of different doses of zinc on URTI and diarrhoeal disease episodes in children. METHODS: In a randomised, triple-blind clinical trial, we evaluated the efficacy of 12 months of daily zinc supplementation in the incidence of URTI and acute diarrhoea in a population of healthy children aged between 6 and 12 months living in Bogota, Colombia. The outcomes analysed were incidence of URTI, acute diarrhoeal disease episodes, and side effects of the interventions. RESULTS: Between 2010 and 2013, a total of 355 children underwent randomisation, with 174 assigned to the zinc supplementation group and 181 to the control group. In the multivariate analyses, having been randomised to the non-supplemented control group (IRR 1.73, 95% CI 1.52-1.97, p<0.001), and nursery attendance (IRR 1.41, 95% CI 1.07-1.87, p=0.016) were independently linked to the number of URTI. Likewise, having been randomised to the non-supplemented group (IRR 1.43, 95% CI 1.20-1.71, p<0.001), and lower socioeconomic status (IRR 1.86, 95% CI 1.11-3.13, p=0.018) were independently associated to the number of diarrhoeal disease episodes. CONCLUSIONS: Daily supplementation of 5mg of zinc during 12 months significantly decreased the incidence of URTI and diarrhoeal disease episodes in a healthy population of children aged between 6 and 12 months.

Relationship between meteorological conditions and respiratory syncytial virus in a tropical country.

This study aimed to determine which meteorological conditions are associated with respiratory syncytial virus (RSV) isolates in a population of children hospitalized with acute lower respiratory infection (ALRI) in Bogota, Colombia. In an analytical cross-sectional study, links were examined between the number of monthly RSV infections and monthly average climatic variation (temperature, relative humidity, rainfall, wind speed, solar radiation) between 1 January 2010 and 30 April 2011 in a population of hospitalized children aged <3 years with ALRI caused by RSV. Out of a total of 1548 children included in the study (mean age 9·2 ± 8·5 months), 1194 (77·1%) presented RSV infection during the 3-month period from March to May. In the multivariate analysis, after controlling for wind speed, relative humidity, and solar radiation, monthly average temperature [incident rate ratio (IRR) 3·14, 95% confidence interval (CI) 1·56-6·30, P = 0·001] and rainfall (IRR 1·008, 95% CI 1·00-1·01, P = 0·048) were independently associated with the monthly number of RSV infections. In conclusion, in Bogota, a tropical Latin American city, average temperature and rainfall are the meteorological variables most strongly associated with RSV isolation in children hospitalized with ALRI in the city.

Allergic rhinitis and associated factors in schoolchildren from Bogota, Colombia.

BACKGROUND: Allergic rhinitis is one of the most frequent chronic diseases among children. The objective of the study was to assess the prevalence of and the factors associated with self-reported allergic rhinitis symptoms in schoolchildren from Bogota, Colombia. METHODOLOGY/PRINCIPAL: We followed the International Study of Asthma and Allergies in Childhood (ISAAC) methodology. Our sample included 3,256 children aged 6 - 7 and 3,830 adolescents aged 13 - 14 years. RESULTS: The prevalence of self-reported allergic rhinitis symptoms was 30.8% among children and 36.6% among adolescents. Factors associated with self-reported allergic rhinitis among children included current asthma and atopic dermatitis symptoms; use of acetaminophen in the first year of life and in the last 12 months; antibiotic use in the first year of life; high- school and university maternal education; smokers at home; and caesarean delivery. Among adolescents, associated factors included current asthma and atopic dermatitis symptoms; current acetaminophen use once per month; frequent fast-food consumption; cat exposure at home; and smoking. CONCLUSION: Further exploration of factors associated with allergic rhinitis symptoms is needed.

Analysis of the Budget Impact of Fractional Exhaled Nitric Oxide Monitoring in the Management of Childhood Asthma: The Colombian National Health System Perspective

Background: Fractional exhaled nitric oxide (FeNO) testing is a simple, noninvasive approach to assessing airway inflammation withminimal discomfort that provides results within a few minutes. For policy makers, the economic impact of this technology is the mainconcern, especially in developing countries. We evaluated the budget impact of asthma management using FeNO monitoring in patientsaged between 4 and 18 years in Colombia.Methods: A budget impact analysis was performed to evaluate the potential cost of FeNO monitoring. The analysis was based on a5-year time horizon and performed from the perspective of the Colombian National Health System. The incremental budget impact wascalculated by subtracting the cost of the new treatment, in which FeNO is reimbursed, from the cost of conventional treatment withoutFeNO (management based on clinical symptoms [with or without spirometry/peak flow] or asthma guidelines [or both] for asthma-relatedcases). Univariate 1-way sensitivity analyses were performed.Results: In the base case analysis the 5-year costs associated with FeNO and non-FeNO were estimated to be €469 904 130 and€480 485 149, respectively, indicating savings for the Colombian National Health System of €10 581 019 if FeNO is adopted for theroutine management of patients with persistent asthma. This result proved to be robust in the univariate 1-way sensitivity analysis.Conclusion: FeNO monitoring generated cost savings in emergency settings for infants with persistent asthma. This evidence can be used bydecision makers in Colombia to improve clinical practice guidelines and should be replicated to validate the results in other middle-income countries (AU)

Antecedentes: El óxido nítrico en aire exhalado es una medición simple y no invasiva de la inflamación de las vías respiratorias cuyosresultados están disponibles en pocos minutos. Para los responsables de la formulación de políticas sanitarias, la principal preocupaciónes el impacto económico que implica la adaptación de esta tecnología, muy especialmente en los países en desarrollo. Este estudiotiene como objetivo evaluar el impacto presupuestario, en el sistema Nacional de Salud de Colombia, del manejo del asma mediante lamonitorización de óxido nítrico exhalado en pacientes entre 4 y 18 años.Métodos: Se realizó un análisis de impacto presupuestario para evaluar el posible impacto financiero derivado de la implementación de lamonitorización óxido nítrico exhalado fraccionado en el asma. El análisis consideró un horizonte temporal de 5 años y la perspectiva delSistema Nacional de Salud de Colombia. El impacto presupuestario incremental se calculó restando el coste del nuevo tratamiento, en elque se reembolsa el FeNO, del coste del tratamiento convencional sin FeNO (manejo basado en síntomas clínicos (con o sin espirometría /flujo máximo) o guías de asma (o ambos), para los relacionados con el asma). Se realizaron análisis de sensibilidad univariantes de una vía.Resultados: En el análisis del caso base, los costos a 5 años asociados a FeNO y no FeNO se estimaron en 469.904.130 € y 480.485.149 €respectivamente, lo que indica un ahorro para la Salud Nacional de Colombia de 10.581.019 € si se adopta la monitorización de FeNOen el manejo rutinario de pacientes con asma persistente. La solidez de este resultado fue confirmada en el análisis de sensibilidadunivariante, unidireccional.Conclusión: El óxido nítrico exhalado fraccionado ahorró costos en los entornos de emergencia en población pediátrica con asma persistente.Esta evidencia puede ser utilizada por los tomadores de decisiones en nuestro país para mejorar las guías de práctica clínic

Factors associated to recurrent visits to the emergency department for asthma exacerbations in children: implications for a health education programme.

INTRODUCTION: Recurrent emergency department (ED) visits for asthma exacerbations produce anxiety as well as high costs to the health system and the family. OBJECTIVE: To identify factors associated with recurrent ED visits for asthma exacerbations in children in Bogotá, Colombia. METHODS: Data obtained from a survey of parents of 223 patients with asthma (mean +/- SD: 4.8+/-3.5 years of age) attending an asthma clinic were analysed. Demographic data and a broad asthma knowledge and attitudes questionnaire were completed by the parents. RESULTS: Of the 223 asthmatic patients enrolled, 60 (26.9 %) had 3 or more visits to the ED for asthma in the last 6 months ("recurrent ED visits"). After controlling by age, educational level of the father, and severity of the disease; parents of children with "recurrent ED visits" were more prone to report that they attended ED because the asthma exacerbations were severe enough to go to the primary care physician (OR, 2.45; CI 95 %, 1.13-5.30; p=0.02); that asthma medications should be administered only when the children are symptomatic (OR, 3.26; CI 95 %, 1.45-7.36; p=0.004), and conversely they were less prone to have knowledge that asthma exacerbations can be avoided if medications are administered in the asymptomatic periods (OR, 0.31; CI 95 %, 0.14-0.68; p=0.003). CONCLUSIONS: An educational programme intended to reduce the recurrent ED visits for asthma exacerbations should consider the inclusion of an explanation about the chronic nature of the disease and the importance of long-term therapy.