Adherence to asthma controller medication regimens.

BACKGROUND: Improved adherence to inhaled corticosteroids (ICS) is recognized as an important factor in reduced morbidity, mortality and consumption of health care resources. The present study was designed to replicate previous reports of patient adherence with fluticasone/salmeterol in a single inhaler (FSC), fluticasone and salmeterol in separate inhalers (FP+SAL), fluticasone and montelukast (FP+MON), fluticasone alone (FP) and montelukast alone (MON). METHODS: A 24-month observational retrospective study was conducted using administrative claims data. Subjects were 12 years old with 24 months of continuous enrollment; had 1 asthma claim (ICD-9: 493), 1 short-acting beta(2)-agonist claim, and 1 FSC, FP, SAL, or MON claim. Outcomes included asthma medication refill rates and persistence measured by treatment days. This study was designed with a unique population of patients with asthma from different health plans to validate previous findings. RESULTS: A total of 3,503 subjects were identified based on their index medication: FSC (996), FP+SAL (259), FP+MON (101), FP (1254) and MON (893). Mean number of prescription refills for FSC (3.98) was significantly higher than FP (2.29) and the FP component of FP+SAL (2.36), and FP+MON (2.15), P<0.05. No significant differences were observed between FSC and MON fill rates (4.33). Mean number of treatment days was greater for FSC compared to FP, FP+SAL, and FP+MON (P<0.0001). CONCLUSION: This study confirms a previous report that adherence profiles of fluticasone and salmeterol in a single inhaler are significantly better when compared to the controller regimens of fluticasone and salmeterol in separate inhalers, fluticasone and montelukast, or fluticasone alone and similar to montelukast alone.

Comparison of asthma costs in patients starting fluticasone propionate compared to patients starting montelukast.

An observational study using pharmacy and medical claims was used to determine whether there are differences in asthma care cost between patients that are newly started on montelukast and low-dose fluticasone propionate. Patients were identified who had at least one ICD-9 (493.XX) claim for asthma and were newly prescribed inhaled fluticasone propionate 44 microg (FP) or montelukast 5 or 10 mg (MON). Subjects could not have had a claim for any inhaled corticosteroid or oral leukotriene modifier in 9 months prior to the first prescription claim for either FP or MON. They were subsequently followed for 9 months. Multi-variate regression analysis was used to determine the influence of these single-controller therapies on post-index asthma related costs. Positively skewed cost variables were log-transformed prior to their inclusion into the multi-variate model. Asthma-related costs were adjusted for age, gender, health plan, co-morbidities, pre-index asthma medication use and pre-index asthma care costs. Multivariate regression analysis, adjusting for baseline covariates, indicated that compared to treatment with montelukast, treatment with FP had significantly (P<0.001) lower post-index total asthma related costs. Adjusted least squares mean total asthma care costs for the 9-month post-index period were $US649 for FP 44 microg compared to $US1028 for montelukast.

One-year claims analysis comparing inhaled fluticasone propionate with zafirlukast for the treatment of asthma.

BACKGROUND: Randomized clinical trials have demonstrated that fluticasone propionate (FP) has better objective as well as subjective clinical outcomes than zafirlukast (ZA) in the treatment of asthma. OBJECTIVE: The goal of this study was to determine whether the superiority of FP over ZA observed in clinical trials is supported under actual practice conditions. METHODS: A retrospective cohort analysis of pharmacy and medical claims for asthma was performed. Patients were identified who had at least 1 ICD-9 (493.XX) claim for asthma and were recently prescribed inhaled FP or ZA. Subjects could not have had a claim for any inhaled corticosteroid or oral leukotriene modifier in the 9 months before initiation of FP or ZA. They were subsequently observed for 12 months. RESULTS: A total of 725 persons were new users of FP and 309 of ZA. FP was associated with a 70% reduced risk for hospitalization (P =.0232), a 49% lower risk for an emergency department event (P =.0546), and a 51% reduction in combined emergency department events and hospitalizations (P =.0268) when compared with ZA. Adjusted annual asthma care costs declined significantly for FP and increased for ZA. The adjusted mean difference in annual asthma costs was $215 less per patient for FP (P <.0001). CONCLUSION: Asthma care costs decreased for patients treated with FP and increased for patients treated with ZA. Furthermore, FP-treated patients had significantly lower risks of asthma-related hospitalization than ZA patients. This study supports results seen in clinical trials comparing these two medications.

Cost analysis of the use of inhaled corticosteroids in the treatment of asthma: a 1-year follow-up.

A retrospective cohort using pharmacy and medical claims was analysed to determine whether the differences in efficacy of various inhaled corticosteroids demonstrated in clinical trials lead to differences in costs of care observed in clinical practice. Subjects that had an ICD-9 (493.XX) code for asthma and a new pharmacy claim for inhaled fluticasone propionate 44 mcg (FP), beclomethasone dipropionate (BDP), triamcinolone acetonide (TAA), budesonide (BUD) or flunisolide (FLU) were identified and followed for 12 months. Annual asthma care charges (pharmacy and medical) over the 12-month observation period were significantly (P < 0.03) higher in patients treated with BDPTAA, BUD and FLU compared to FP, 24%, 27%, 34% and 45% respectively In addition, patients treated with BDPTAA, and FLU were associated with significantly (P < 0.005) higher total healthcare (asthma + non-asthma) charges compared to patients on FP, 53%, 46% and 39% respectively Asthma care and total healthcare charges remained lower for FP after including FP110 mcg and excluding patients who were extreme cost outliers (+/- 2 SD from the mean) in a univariate sensitivity analysis. This analysis supports recent randomized control trials that FP offers a superior efficacy profile at lower asthma care as well as total healthcare charges compared to other inhaled corticosteroids.

Cost-efficacy comparison of inhaled fluticasone propionate and budesonide in the treatment of asthma.

BACKGROUND: The results of a recent meta-analysis comparing 2 inhaled corticosteroids, fluticasone propionate (FP) and budesonide, demonstrated that FP had an improved efficacy-to-safety ratio compared with budesonide. However, limited data are available on the relative economic benefits of these 2 regimens. OBJECTIVE: This pharmacoeconomic analysis used individual patient data from studies in the meta-analysis to compare the relative cost-efficacy of 2 asthma regimens from the perspective of a US third-party payer. METHODS: This analysis included all 7 studies in the meta-analysis that compared budesonide with FP dosed at approximately half the dose of budesonide and that included measurement of daily morning peak expiratory flow (PEF). RESULTS: The total daily per-person cost of asthma management was higher for patients treated with budesonide than with FP ($3.00 vs $2.25, respectively). Treatment with FP had greater cost-efficacy than treatment with budesonide, based on a range of outcome measures that included improvement in morning PEF, symptom-free days, and episode-free days. The daily cost per effectively treated patient (an increase in PEF of > or = 10%) was $5.62 with FP and $10.05 with budesonide. The cost per symptom-free day was $4.36 with FP, compared with $6.67 with budesonide. The cost per episode-free day was $5.60 with FP and $9.42 with budesonide. The pharmacoeconomic difference continued to favor FP as the criteria for success were made more stringent and the cost of budesonide was lowered. CONCLUSION: Based on data from the 7 randomized, controlled trials, treatment of asthma with FP was more effective and less expensive, using US health care assumptions and costs, than treatment with budesonide.

Economic analysis of asthma practices.

When deciding on treatment for patients with asthma, clinicians should consider the following: basic science that supports the therapeutic agent, randomized clinical trials that demonstrate clinical efficacy, and "real world" economic evidence that confirms the basic science and clinical study findings. When selecting first-line controller therapy for persistent asthma, clinicians should look for the single agent that produces the greatest improvement in lung function and patient outcomes, has minimal adverse effects, and is cost effective. To determine whether there is one first-line controller that achieves all of these goals, physicians should evaluate findings of randomized controlled trials that assess a drug's effect on asthma symptoms, lung function, and albuterol use compared with placebo or a comparator. They should also consider findings from retrospective claims analyses. This combination of data provides a truer picture and more robust evidence of a drug's clinical and economic performance. Similar evaluations need to be undertaken when deciding on the most cost-effective add-on therapy.

Treatment of allergic rhinitis: an evidence-based evaluation of nasal corticosteroids versus nonsedating antihistamines.

Allergic rhinitis is a high-cost, high-prevalence disease. In the 12 months ending March 31, 1997 $3.1 billion was spent in the United States for medications to manage this illness. Allergic rhinitis affects quality of life and interferes with work productivity. Nonsedating antihistamines are the most common and most expensive therapy for this condition. This study reviewed 13 randomized studies in which blinded investigators compared management of allergic rhinitis by means of intranasal steroids to management by means of nonsedating antihistamine. Evidence tables demonstrated that in all studies in which total nasal symptoms and nasal obstruction were recorded, the nasal steroid was statistically superior to the nonsedating antihistamine. For nasal blockage the nonsedating antihistamines did not perform better than placebo. For all other nasal symptoms the intranasal steroid was statistically superior in most reports and equal or numerically better in the remaining papers. When these data are linked to those from cost analysis and quality-of-life studies, the evidence strongly suggests that nasal steroids should be first-line therapy for allergic rhinitis. In four reports on the combination of a nonsedating antihistamine compared to a nasal steroid alone, there was no significant difference between these two treatments. Like asthma, allergic rhinitis is an inflammatory disease and should be managed with anti-inflammatory medication. Making such a change in the management of allergic rhinitis should increase efficacy and decrease costs.

Asthma: benchmarking for quality improvement.

BACKGROUND: Linked medical and pharmacy claims can be used to identify patients with asthma and benchmark current practice standards. METHOD: This was a 3-year study of five independent practice association style health maintenance organizations with an annual enrollment of 870,000. More than 28,000 members were identified with claims for asthma. OBJECTIVE: The intent of this study was to benchmark current asthma practice. Before quality improvement projects can be implemented baseline data are required. RESULTS: The prevalence of asthma varied by geographic regions. Specialty care was associated with greater use of anti-inflammatory medications and more refills of these drugs. Refill rates for inhaled corticosteroids for all patients was low. Specialty care of asthmatic members was associated with a lower rate of emergency service events and hospitalizations. CONCLUSIONS: Linked medical and pharmacy claims' databases can be used to benchmark current practice performance and serve as a reference for quality improvement programs. Appropriate use of specialty care may improve asthma outcomes.

Patterns of anti-inflammatory therapy in the post-guidelines era: a retrospective claims analysis of managed care members.

Published and widely disseminated guidelines for the care and management of asthma characterize asthma as a chronic, inflammatory disease and propose specific recommendations for therapy with inhaled anti-inflammatory medications. In a retrospective analysis of medical and pharmacy claims data of approximately 28,000 asthmatic members from five managed care settings, the dominant pattern of pharmacologic therapy that emerged was the use of bronchodilators without inhaled anti-inflammatory drug therapy. In addition, a significant proportion of asthmatic patients received no prescription drug therapy for asthma. Less than one third of asthmatic patients received any anti-inflammatory therapy and the majority of these received one or two prescriptions per year. Specialist physicians were two to three times more likely than non-specialists during a study period of 1 year to prescribe an anti-inflammatory medication, and were half as likely to have their asthmatic patients experience an emergency department or hospital event. This database analysis suggests that greater conformity with guidelines and/or access to specialist physician care for asthmatic members will lead to improved patient outcomes.

Drug utilization evaluation identifies costs associated with high use of beta-adrenergic agonists.

BACKGROUND: Drug utilization evaluation is an effective mechanism to identify individual variability in drug use and to promote interventions that will improve patient outcomes. The present analysis is a novel approach incorporating medical claims information with pharmacy data. METHOD: This analysis was conducted during the 12 months of 1993 in four health maintenance organizations with approximately 673,000 members. Health care costs were identified in asthmatic patients, age 7 years and over, who used high doses of inhaled beta-adrenergic agonists, defined as more than 8 puffs per day. RESULTS: A total of 20,512 asthmatic patients were identified. From these patients, 1093 members or 5.3% received high doses of an inhaled bronchodilator. This second group was then stratified by concurrent use of inhaled anti-inflammatory therapy. Group A, 32% of the members, received > or = 4 puffs per day of an anti-inflammatory medicine; group B, 31% of the members, received <4 puffs per day of these medicines; and group C, 37% of the members, received no anti-inflammatory therapy. Examination of the linked medical claims and pharmacy database demonstrated that members using high doses of inhaled bronchodilators had annual charges for treatment related to their asthma that were 3.0 times higher than the average asthmatic patient ($1,346.52 versus $447.42). The high beta-agonist users had inpatient hospital and emergency department charges that grew proportionally as a percent of total annual expenses. Medication charges were 10% greater as a measure of total annual costs while fees for ambulatory services were down 11% for high users of beta-agonists compared with the average asthmatic patient. In patient hospital costs in group B were 12% higher than group A. CONCLUSION: Patients not following the National and International guidelines appear to be more likely to consume greater amounts of health care resources. This drug utilization evaluation demonstrates that there is a failure by the provider or patient with implementation and maintenance of these recommendations. Noncompliance with guidelines was associated with increased morbidity and cost for asthma related care. Interventions targeting these members may improve clinical outcomes and decrease total cost for the treatment of asthma.

Use of a pharmacy and medical claims database to document cost centers for 1993 annual asthma expenditures.

OBJECTIVE: To demonstrate the utility of a combined pharmacy and medical claims database in the assessment of the incidence and the cost centers of asthma care in a managed health care system. DESIGN: A retrospective observational study to document annual cost for asthma therapy by cost center during 1993. SETTING: Four affiliated health maintenance organizations. PARTICIPANTS: A total of 25,614 asthmatics identified from a population of approximately 673,000 members in the health maintenance organization. INTERVENTIONS: None. MAIN OUTCOME MEASURE: Annual charges by cost center for asthma care analyzed by age and gender. RESULTS: The period prevalence of asthma was 3.8%. Annual direct medical charges for asthma were $467.40 per member. Inpatient hospital and emergency department charges were greater in children than adults. Adolescent girls had increased use of the emergency department and inpatient hospital facilities and lower charges for medications than their male counterparts. Their increased use of acute care facilities was responsible for 25% greater charges for total asthma care. The gender differences in cost centers continued for adults, with increased charges for inpatient hospital and emergency department charges and lower expenses for medications for women. CONCLUSIONS: Charges for acute care were inversely related to the dollars spent on pharmaceuticals. This study demonstrates the ability of a combined medical and pharmacy database to document the charges for care and possibly identify indicators of undertreated populations.