Evaluation and Management Outcomes and Burdens in Patients with Refractory Chronic Cough Referred for Behavioral Cough Suppression Therapy.

PURPOSE: The purpose of this study was to investigate the typical symptoms and medical management characteristics of adult patients with refractory chronic cough (RCC) who are referred to speech-language pathology (SLP) for behavioral cough suppression therapy (BCST) in order to estimate cost-effectiveness and efficiency of current practice patterns for this population. METHODS: One hundred sixty-four (164) patients with RCC referred for BCST were surveyed. Patients completed an initial survey at BCST onset related to symptom pattern and prior treatment, including the Leicester Cough Questionnaire (LCQ). Every four to six weeks patients completed follow-up surveys to assess their response to BCST. RESULTS: Mean age was 58 years (83.5% women). The majority of patients reported their cough began two or more years prior to BCST. Approximately half (49%) reported seeing four or more physicians (including primary care physicians) and being prescribed four or more medications (57%) prior to BCST. Medications targeting post-nasal drip (72%), reflux (70%), asthma (56%), and allergies (56%) were most commonly prescribed. BCST resulted in a clinically significant improvement in 70.1% of participants. The mean change in LCQ for those who improved with BCST was 6.61. Over half (58%) reported they were quite satisfied to completely satisfied with their treatment response. The average time from enrollment to study completion was 64 days. CONCLUSION: The results of this study suggest early intervention with BCST may be a cost-effective and efficient option for patients with RCC.

Diagnoses and management of adult cough: An Indian Environmental Medical Association (EMA) position paper.

BACKGROUND: Cough is a common yet distressing symptom that results in significant health care costs from outpatient visits and related consultations. OBJECTIVE: The understanding of the pathobiology of cough in recent times has undergone an evolution with Cough hypersensitivity syndrome (CHS) being suggested in most cases of dry cough. However, in the case of productive cough, ancillary mechanisms including impaired Mucociliary clearance, in addition to hypermucosecretory bronchospastic conditions of Smoker's cough, asthma-COPD overlap, bronchiectasis, and allergic bronchopulmonary aspergillosis, need to be critically addressed while optimizing patient care with symptomatic therapy in outpatient settings of India. METHODS: In this review, evidence-based graded recommendations on use of antitussives - & protussives as a Position Paper were developed based on the Level and Quality of Scientific evidence as per Agency for Health Care and Quality (AHRQ) criteria listing and Expert opinions offered by a multidisciplinary EMA panel in India. RESULTS: Management of acute or chronic cough involves addressing common issues of environmental exposures and patient concerns before instituting supportive therapy with antitussives or bronchodilatory cough formulations containing mucoactives, anti-inflammatory, or short-acting beta-2 agonist agents. CONCLUSION: The analyses provides a real world approach to the management of acute or chronic cough in various clinical conditions with pro- or antitussive agents while avoiding their misuse in empirical settings.

Upper Respiratory Tract Infection-Associated Acute Cough and the Urge to Cough: New Insights for Clinical Practice.

Upper respiratory tract infection (URTI)-associated acute cough is the most common symptom both in children and adults worldwide and causes economic and social problems with significant implications for the patient, the patient's family, and the health care system. New pathogenic mechanisms in acute cough, including the urge to cough (UTC) mechanisms, have been recently identified. The brainstem neural network, pharyngeal sensory innervation, airway mechanical stimulation, inflammatory mediators, and postnasal drip actively participate in the onset and maintenance of acute cough and the urge to cough phenomenon. However, there is still no effective pharmacological treatment capable of interfering with the pathophysiologic mechanisms involved in URTI-associated acute cough. Moreover, severe adverse events frequently occur in administering such cough medications, mainly in children. New evidence has been provided concerning polysaccharides, resins, and honey as potential cough relievers with high antitussive efficiency, effect on the UTC, and minimal side effects.

Direct costs of illness of patients with chronic cough in rural Malawi-Experiences from Dowa and Ntchisi districts.

INTRODUCTION: Chronic cough is a distressing symptom and a common reason for people to seek health care services. It is a symptom that can indicate underlying tuberculosis (TB) and/or chronic airways diseases (CAD) including asthma, chronic obstructive pulmonary disease (COPD) and bronchiectasis. In developing countries including Malawi, provision of diagnostic services and clinical management of CAD is rudimentary, so it is thought that patients make costly and unyielding repeated care-seeking visits. There is, however, a lack of information on cost of illness, both direct and indirect, to patients with chronic cough symptom. Such data are needed to inform policy-makers in making decisions on allocating resources for designing and developing the relevant health care services to address universal coverage programmes for CAD. This paper therefore explores health seeking costs associated with chronic cough and explores information on usage of the coping mechanisms which indicate financial hardship, such as borrowing and selling household assets. METHODS: This economic study was nested within a community-based, population-proportional cross-sectional survey of 15,795 individuals aged 15 years and above, in Dowa and Ntchisi districts. The study sought to identify individuals with symptoms of chronic airways disease whose health records documented at least one of the following diagnoses within the previous year: TB, Asthma, COPD, Bronchitis and Lower Respiratory Tract Infection (LRTI). We interviewed these chronic coughers to collect information on socioeconomic and socio-demographic characteristics, health care utilization, and associated costs of care in 2015. We also collected information on how they funded their health seeking costs. RESULTS: We identified 608 chronic coughers who reported costs in relation to their latest confirmed diagnosis in their hand-held health record. The mean care-seeking cost per patient was US$ 3.9 (95% CI: 3.00-5.03); 2.3 times the average per capita expenditure on health of US$ 1.69. The largest costs were due to transport (US$ 1.4), followed by drugs (US$ 1.3). The costs of non-medical inputs (US$ 2.09) was considerable (52.3%). Nearly a quarter (24.4%) of all the patients reportedly borrowed or/and sold assets/property to finance their healthcare. CCs with COPD and LRTI had 85.6% and 62.0% lower chance of incurring any costs compared with the TB patients and any patients with comorbidity had 2.9 times higher chance to incur any costs than the patients with single disease. COPD, Bronchitis and LRTI patients had 123.9%, 211.4% and 87.9% lower costs than the patients with TB. The patients with comorbidity incurred 53.9% higher costs than those with single disease. CONCLUSIONS: The costs of healthcare per chronic cougher was mainly influenced by the transport and drugs costs. Types of diseases and comorbidity led to significantly different chances of incurring costs as well as difference in magnitude of costs. The costs appeared to be unaffordable for many patients.

[Diagnostics in general practice: prognosis has to be the guiding principle]. / Diagnostiek in de huisartsenpraktijk.

We propose that diagnostic tests should only be used when their results could affect treatment and prognosis of the diagnosed condition, taking costs into account. The cost-effectiveness of MRI has been evaluated in a randomised clinical trial in which 356 patients were divided over one group in which MRI was done within two weeks after experiencing trauma and one group that received standard care. No difference in QALYs was found between the groups. The number of referrals did not decrease in the MRI group, whereas costs for treatment increased. The point-of-care CRP-test for dealing with patients with acute cough presenting in daily general practice is one example of the opposite. CRP led to a decrease of antibiotic prescriptions and was found to be cost-effective. We conclude that more experts on diagnostics should be consulted in general practice and that diagnostic tests and procedures should receive attention in the medical curriculum and vocational training for general practice.

The contribution of symptoms and comorbidities to the economic impact of COPD: an analysis of the German COSYCONET cohort.

Background: Although patients with COPD often have various comorbidities and symptoms, limited data are available on the contribution of these aspects to health care costs. This study analyzes the association of frequent comorbidities and common symptoms with the annual direct and indirect costs of patients with COPD. Methods: Self-reported information on 33 potential comorbidities and symptoms (dyspnea, cough, and sputum) of 2,139 participants from the baseline examination of the German COPD cohort COSYCONET was used. Direct and indirect costs were calculated based on self-reported health care utilization, work absence, and retirement. The association of comorbidities, symptoms, and COPD stage with annual direct/indirect costs was assessed by generalized linear regression models. Additional models analyzed possible interactions between COPD stage, the number of comorbidities, and dyspnea. Results: Unadjusted mean annual direct costs were €7,263 per patient. Other than COPD stage, a high level of dyspnea showed the strongest driving effect on direct costs (+33%). Among the comorbidities, osteoporosis (+38%), psychiatric disorders (+36%), heart disease (+25%), cancer (+24%), and sleep apnea (+21%) were associated with the largest increase in direct costs (p<0.01). A sub-additive interaction between advanced COPD stage and a high number of comorbidities reduced the independent cost-driving effects of these factors. For indirect costs, besides dyspnea (+34%), only psychiatric disorders (+32%) and age (+62% per 10 years) were identified as significant drivers of costs (p<0.04). In the subsequent interaction analysis, a high number of comorbidities was found to be a more crucial factor for increased indirect costs than single comorbidities. Conclusion: Detailed knowledge about comorbidities in COPD is useful not only for clinical purposes but also to identify relevant cost factors and their interactions and to establish a ranking of major cost drivers. This could help in focusing therapeutic efforts on both clinically and economically important comorbidities in COPD.

[Review of reimbursement for instrumental techniques used for assisted coughing and thoracic expansion. A French National Health Authority assessment (HAS)]. / Avis sur le remboursement de techniques instrumentales d'aide à la toux et à la mobilisation thoracique. Une évaluation de la Haute Autorité de santé (HAS).

INTRODUCTION: In France, children with neuromuscular diseases and patients with traumatic spinal cord injuries receive reimbursement for home use of intermittent positive-pressure breathing and mechanical in-exsufflators devices. The aim of the study was to update the indications for reimbursement for these both devices. METHODS: A literature review was conducted with several bibliographic databases using the main keywords: intermittent positive-pressure breathing, mechanical insufflation, mechanically-assisted cough, airway clearance. Nine health professionals were interviewed during two meetings. One health professional was interviewed via a questionnaire. An estimation of the population treated with in-exsufflators or intermittent positive-pressure breathing was undertaken from consumer data available for all beneficiaries of the health insurance system. STATE OF THE ART: The review identified 111 references which included 14 clinical practice guidelines, two systematic reviews and one randomized controlled trial. Some clinical data were available. Clinical practice guidelines were in favor of using intermittent positive-pressure breathing and in-exsufflators in patients with neuromuscular disease and spinal cord injuries. The healthcare professionals emphasized the need to reimburse the patient for home use of intermittent positive-pressure breathing and in-exsufflators. The patient population treated in the identified clinical situations was estimated at 3100 per year. CONCLUSIONS: Despite the low level of evidence and after interviewing healthcare professionals, the Haute Autorité de santé (HAS) recommended reimbursement of the costs of in-exsufflators (assisted coughing) and intermittent positive-pressure breathing (thoracic expansion) devices in adults and children with neurological and neuromuscular disease, including spinal cord injury.

The respiratory health of urban indigenous children aged less than 5 years: study protocol for a prospective cohort study.

BACKGROUND: Despite the burden of acute respiratory illnesses (ARI) among Aboriginal and Torres Strait Islander children being a substantial cause of childhood morbidity and associated costs to families, communities and the health system, data on disease burden in urban children are lacking. Consequently evidence-based decision-making, data management guidelines, health resourcing for primary health care services and prevention strategies are lacking. This study aims to comprehensively describe the epidemiology, impact and outcomes of ARI in urban Aboriginal and Torres Strait Islander children (hereafter referred to as Indigenous) in the greater Brisbane area. METHODS/DESIGN: An ongoing prospective cohort study of Indigenous children aged less than five years registered with a primary health care service in Northern Brisbane, Queensland, Australia. Children are recruited at time of presentation to the service for any reason. Demographic, epidemiological, risk factor, microbiological, economic and clinical data are collected at enrolment. Enrolled children are followed for 12 months during which time ARI events, changes in child characteristics over time and monthly nasal swabs are collected. Children who develop an ARI with cough as a symptom during the study period are more intensely followed-up for 28 (±3) days including weekly nasal swabs and parent completed cough diary cards. Children with persistent cough at day 28 post-ARI are reviewed by a paediatrician. DISCUSSION: Our study will be one of the first to comprehensively evaluate the natural history, epidemiology, aetiology, economic impact and outcomes of ARIs in this population. The results will inform studies for the development of evidence-based guidelines to improve the early detection, prevention and management of chronic cough and setting of priorities in children during and after ARI. TRIAL REGISTRATION: Australia New Zealand Clinical Trial Registry Registration Number: 12614001214628 . Registered 18 November 2014.

Potential barriers to healthcare in Malawi for under-five children with cough and fever: a national household survey.

Failure to access healthcare is an important contributor to child mortality in many developing countries. In a national household survey in Malawi, we explored demographic and socioeconomic barriers to healthcare for childhood illnesses and assessed the direct and indirect costs of seeking care. Using a cluster-sample design, we selected 2,697 households and interviewed 1,669 caretakers. The main reason for households not being surveyed was the absence of a primary caretaker in the household. Among 2,077 children aged less than five years, 504 episodes of cough and fever during the previous two weeks were reported. A trained healthcare provider was visited for 48.0% of illness episodes. A multivariate regression model showed that children from the poorest households (p = 0.02) and children aged > 12 months (p = 0.02) were less likely to seek care when ill compared to those living in wealthier households and children of higher age-group respectively. Families from rural households spent more time travelling compared to urban households (68.9 vs 14.1 minutes; p < 0.001). In addition, visiting a trained healthcare provider was associated with longer travel time (p < 0.001) and higher direct costs (p < 0.001) compared to visiting an untrained provider. Thus, several barriers to accessing healthcare in Malawi for childhood illnesses exist. Continued efforts to reduce these barriers are needed to narrow the gap in the health and healthcare equity in Malawi.

High economic burden of caring for patients with suspected extraesophageal reflux.

OBJECTIVES: Extraesophageal symptoms are common manifestations of gastroesophageal reflux disease (GERD). Lack of a definitive diagnostic or treatment standards complicate management, which often leads to multiple specialty consultations, procedures, pharmaceuticals and diagnostic tests. The aim of this study was to determine the economic burden associated with extraesophageal reflux (EER). METHODS: Direct costs of evaluation were estimated for patients referred with symptoms attributed to EER between 2007 and 2011. Medicare payment for evaluation and management and pharmaceutical prices was used to calculate first year and overall costs of evaluating and treating extraesophageal symptoms attributed to reflux. RESULTS: Overall, 281 patients were studied (cough (50%), hoarseness (23%), globus/post-nasal drainage (15%), asthma (9%), and sore throat (3%)). Over a median (interquartile range) of 32 (16-46) months follow-up, patients had a mean (95% confidence interval) of 10.1 (9.4-10.9) consultations with specialists and underwent 6.4 (3-9) diagnostic procedures. Overall, the mean initial year direct cost was $5,438 per patient being evaluated for EER. Medical and non-medical components contributed $5,154 and $283. Of the overall cost, 52% were attributable to the use of proton pump inhibitors. During the initial year, direct costs were 5.6 times higher than those reported for typical GERD ($971). A total of 54% of patients reported improvement of symptoms. Overall cost per improved patient was $13,700. CONCLUSIONS: EER contributes substantially to health-care expenditures. In this cohort, the cost for initial year's evaluation and treatment of EER symptoms was quintuple that of typical GERD. Prescription costs and, in particular, proton pump inhibitors were the single greatest contributor to the cost of EER management.

The cost of persistent asthma in Europe: an international population-based study in adults.

BACKGROUND: This study is aimed at providing a real-world evaluation of the economic cost of persistent asthma among European adults according to the degree of disease control [as defined by the 2006 Global Initiative for Asthma (GINA) guidelines]. METHODS: A prevalence-based cost-of-illness study was carried out on 462 patients aged 30-54 years with persistent asthma (according to the 2002 GINA definition), who were identified in general population samples from 11 European countries and examined in clinical settings in the European Community Respiratory Health Survey II between 1999 and 2002. The cost estimates were computed from the societal perspective following the bottom-up approach on the basis of rates, wages and prices in 2004 (obtained at the national level from official sources), and were then converted to the 2010 values. RESULTS: The mean total cost per patient was EUR 1,583 and was largely driven by indirect costs (i.e. lost working days and days with limited, not work-related activities 62.5%). The expected total cost in the population aged 30-54 years of the 11 European countries was EUR 4.3 billion (EUR 19.3 billion when extended to the whole European population aged from 15 to 64 years). The mean total cost per patient ranged from EUR 509 (controlled asthma) to EUR 2,281 (uncontrolled disease). Chronic cough or phlegm and having a high BMI significantly increased the individual total cost. CONCLUSIONS: Among European adults, the cost of persistent asthma drastically increases as disease control decreases. Therefore, substantial cost savings could be obtained through the proper management of adult patients in Europe.

Variation of health-care resource utilization according to GERD-associated complications.

Complications associated with gastroesophageal reflux disease (GERD) can include esophageal stricture, Barrett's esophagus, gastrointestinal hemorrhage, and extraesophageal symptoms. The impact of GERD-associated complications on health-care utilization deserves further evaluation. We identified commercial enrollees 18-75 years old with claims for GERD (International Classification of Diseases, Ninth Revision, Clinical Modification Codes: 530.81 or 530.11) and subsequent usage of proton pump inhibitors from 01/01/05 to 06/30/09. The initial GERD diagnosis date was designated as the index date, and patients were studied for 6 months preindex and postindex. Eligible patients were subsequently stratified based on medical claims for GERD-associated complications as follows: stage A (GERD diagnosis, no other symptoms), stage B (GERD + extraesophageal symptoms), stage C (GERD + Barrett's esophagus), stage D (GERD + esophageal stricture), and stage E (GERD + iron-deficiency anemia or acute upper gastrointestinal hemorrhage). Patient characteristics, health-care utilization, and costs were compared between stage A and each stage with complicated GERD (B-D). Of the 174,597 patients who were eligible for analysis, 74% were classified as stage A, 20% stage B, 1% stage C, 2% stage D, and 3% stage E. Relative to stage A, patients in stages C, D, and E were significantly more likely to visit a gastroenterologist (13% vs. 68%, 71%, and 38%, respectively) and had higher rates of esophageal ulcers (0.3% vs. 8%, 5%, and 3%, respectively) and Nissen fundoplication (0.05% vs. 0.6%, 0.3%, and 0.2%, respectively). Six-month GERD-related costs ranged from $615/patient (stage A) to $1714/patient (stage D); all-cause costs ranged from $4195/patient (stage A) to $11,340/patient (stage E). Compared with stage A, all other cohorts had significantly higher all-cause and GERD-related costs (P < 0.0001 for all comparisons). While patients with more severe GERD represented a relatively small portion of the GERD cohort, they demonstrated significantly greater health-care costs and overall utilization than patients with uncomplicated GERD.

Resource use and costs of treating acute cough/lower respiratory tract infections in 13 European countries: results and challenges.

The objectives of this study were to estimate the resource use and cost of treating acute cough/lower respiratory tract infection (acute cough/LRTI) in 13 European countries, to explore reasons for differences in cost and to document the challenges that researchers face when collecting information on cost alongside multinational studies. Data on resource use and cost were collected alongside an observational study in 14 primary care networks across 13 European countries and a mean cost was generated for each network. The results show that the mean cost (standard deviation) of treating acute cough/LRTI in Europe ranged from euro23.88 (34.67) in Balatonfüred (Hungary) to euro116.47 (34.29) in Jonkoping (Sweden). The observed differences in costs were statistically significant (P < 0.01). Major cost drivers include general practitioner visits and drug costs in all networks, whilst differences in health systems and regional factors could account for differences in cost between networks. The major barrier to conducting multinational cost studies are barriers associated with identifying cost information.

Systematic evaluation and treatment of chronic cough in a community setting.

Chronic cough is a common symptom of patients in the United States. The vast majority of patients with chronic cough are treated by primary- and specialty-care physicians. The Cough Center in Southern California represents the first independent, community-based facility devoted entirely to diagnosing and treating cough. This article details that experience and represents the first ever attempt to evaluate quality-of-life (QOL) improvement, after treatment, in the community setting. Three hundred and ninety patients were evaluated at The Cough Center for chronic cough. Patients were investigated in a systematic fashion and empirically treated. A subjective assessment of treatment success was made using the Leicester QOL questionnaire. An objective assessment was made by documenting frequency and severity of coughing episodes. In the initial assessment of patients with cough, only 37% were identified as having had a systematic and dedicated work up. Using both subjective and objective measurements, it was determined that 73% of patients improved with an empiric course of treatment. Almost 17% demonstrated no improvement and 10% were lost to follow up. By analyzing treatment outcomes in a community setting, insight can be gained. Physicians need to become more diligent in systematic evaluation and treatment. Also, they should not be deterred from seeking resolution of cough just because it has persisted for a lengthy period of time or has several causes. Most importantly, the prevalence of patients having "unexplained cough" could very well be much greater than that reported at university-based, specialty cough clinics.

Measuring the financial burden of acute cough in pre-school children: a cost of illness study.

CONTEXT: Acute cough is a very common symptom presentation among children in primary care and is usually due to respiratory infection, yet its cost is unknown. An estimate of the cost to healthcare providers and parents would aid budgetary decision-making, and provide an insight into the need for interventions to reduce the burden. PURPOSE: To estimate the cost per child per episode, and the annual population cost in the UK, of acute cough in pre-school children presenting to primary care. DESIGN: Incidence and prevalence-based cost-of-illness study from the perspectives of the UK NHS and of parents and caregivers. SETTING: 11 general practices in Bristol, UK. SUBJECTS: 121 children without known asthma aged 3 to 59 months presenting for the first time with an acute (

Chronic cough: epidemiology.

Chronic cough is perhaps the commonest symptom of medical importance with some 12% of the general population having the symptom on a daily or weekly basis. Chronic cough causes a large degree of morbidity, with both the physical e.g. incontinence, and the psychological e.g. social isolation, domains. The causes of chronic cough are numerous, but fall into two broad categories; that causing an asthma-like syndrome characterized by eosinophilic infiltration of the airways, and oesophageal disease, particularly weakly acid reflux. Failure to make, particularly this latter, diagnosis leads to enormous consequences in terms of loss of employment, healthcare utilisation and a psychosocial morbidity.

Cost-effectiveness of different diagnostic strategies to assess gastro-oesophageal reflux disease in patients with unexplained chronic persistent cough in Italy.

BACKGROUND: Chronic persistent cough is a common and disabling disorder and gastro-oesophageal reflux disease is considered to be the third leading cause, after asthma and postnasal drip. Therefore, patients with unexplained chronic persistent cough usually undergo a stepwise evaluation to establish the existence of a reflux disease. AIM: To identify the most cost-effective diagnostic approach to assess gastro-oesophageal reflux disease in patients with unexplained chronic persistent cough. METHODS: Direct and indirect costs associated with six diagnostic strategies using 24-h oesophageal pH-metry, oesophago-gastroduodenoscopy and the proton pump inhibitors test in different sequences, were evaluated using a decision tree model. If the first test was positive, the diagnostic work-up was stopped, if negative the patient proceeded to the second test, and so on. Clinical data from an observational prospective trial conducted in 51 patients with unexplained chronic persistent cough were used in the economic model. RESULTS: All six strategies had the same clinical effectiveness (78.4%). The diagnostic work-up with the lowest cost was the proton pump inhibitors test followed by pH-metry and then oesophago-gastroduodenoscopy with a total cost of euro 211.08 (direct euro 142.93, indirect euro 68.15). CONCLUSIONS: This study shows that the lowest cost is the strategy where proton pump inhibitors test is performed as first investigation. Implementation of this diagnostic work-up may lead to cost savings in the management of patients with chronic persistent cough.

An economic analysis of persons with prolonged cough in rural northern Vietnam.

SETTING: Epidemiological surveillance in the Bavi district, northern Vietnam. OBJECTIVE: To compare the prevalences of prolonged cough across socio-economic groups defined by income, expenditure and official classification. To investigate inequalities using the Illness Concentration Index. DESIGN: Interviews in 11,547 randomly selected households with 35,832 persons aged 15 years or more. Prolonged cough was identified in 559 persons (1.5%). RESULTS: Differences between cough prevalences were found for all socio-economic indicators, but were less clear for expenditure. Lower economic groups reported higher prevalences than higher groups, and prevalences were higher among the elderly. Male was similar to female prevalence. The illness gap between the poor and rich was wider for men. The Illness Concentration Index confirmed these findings. CONCLUSION: Inequalities were found when using both different socio-economic indicators and different analysis approaches.