Impact of choice of inhalers for asthma care on global carbon footprint and societal costs: a long-term economic evaluation.

BACKGROUND: While effective asthma control medications reduce the burden of asthma, a significant subgroup of these treatments, namely metered-dose inhalers (MDIs), produce substantial greenhouse gas (GHG) emissions, thus contributing to climate change. This study quantified the global climate impact (i.e. carbon dioxide equivalent [CO2e] emissions) and costs of long-term status quo asthma inhaler use versus alternative scenarios substituting MDIs with propellant-free dry powder inhalers (DPIs). METHODS: Three scenarios were evaluated across 10-year (2020-2030) and 50-year (2020-2070) time horizons: A (status quo inhaler use), B and C (2% and 5% year-over-year substitution of MDIs with DPIs, respectively). Global inhaler volumes and costs at baseline were sourced from IQVIA, then projected using UN and WHO trends in per capita GDP, urbanization, and asthma population growth. Inhaler spending was assumed to fall by 90% following generic entry in 2030. The carbon footprint per inhaler and health damage factors for disability-adjusted life years (DALYs) were derived from literature. The US government's central and high-impact estimates for the social cost of carbon (SCC) were used to calculate emissions costs. RESULTS: Over 50 years, scenario A resulted in 826 million tonnes of CO2e emissions globally, with an associated SCC between 21% and 65% of the projected global spending on asthma inhalers. In comparison, CO2e emissions were reduced by 38% and 58% in Scenarios B and C, respectively, and DALYs improved by 33 and 51%. Depending on SCC estimates, Scenarios B and C increased global costs by 7.3% and 16.5%, respectively (central SCC), or decreased costs by 4.2% and 2.6% (high-impact SCC) versus Scenario A. Over 10 years, Scenario A resulted in 97 million tonnes of CO2e emissions globally, with an associated SCC between 4.4% and 12.2% of projected spending. In comparison, Scenarios B and C were associated with 12% and 24% reductions in CO2e emissions and improvements in DALYs by 11.5% and 22.7%, respectively. CONCLUSIONS: Global efforts by environmental and health-policy decision-makers to substitute currently available MDIs with DPIs for asthma control would result in substantial reductions in GHG emissions with manageable costs, or potential cost savings, depending on the SCC. Policies that decrease use of MDIs warrant global attention.

Carbon footprint and associated costs of asthma exacerbation care among UK adults.

INTRODUCTION: Asthma exacerbations are a primary driver of costs and health impacts from asthma. Despite research suggesting that asthma care has a disproportionate carbon footprint, emissions costs are not considered when evaluating its societal burden. To advance the understanding of greenhouse gas (GHG) emissions associated with asthma, we estimated the carbon footprint and associated costs of asthma exacerbation care by severity level among UK adults. METHODS: Guidelines for asthma exacerbation treatment in UK adults were reviewed by severity level: mild, moderate, and severe/life-threatening. Components of care for each severity were evaluated for GHG emission potential and key drivers were identified. Carbon dioxide equivalent (CO2e) emissions of drivers were sourced from published literature and combined to estimate the carbon footprint per exacerbation, by severity level. Emissions were scaled up to the annual UK adult population based on the annual number of exacerbations at each severity. Costs associated with emissions were estimated using the UK government's 2020 nontraded price of carbon, at £71 per tonne CO2e (tCO2e). RESULTS: Overall, emissions drivers for exacerbations were medical services, including patient-travel, and quick-relief inhalers. The annual number of mild, moderate, and severe/life-threatening asthma exacerbations among UK adults were 118.9 M, 5.5 M, and 2.4 M. Associated annual carbon footprints were estimated to be 83,455 tCO2e, 192,709 tCO2e, and 448,037 tCO2e for mild, moderate, and severe/life-threatening exacerbations, respectively, with a total of 724,201 tCO2e. Total annual emissions costs from exacerbation care were £51.3 M; £5.9 M, £13.6 M, and £31.7 M for mild, moderate, and severe/life-threatening exacerbations, respectively. CONCLUSION: GHG emissions from asthma exacerbation management were the highest for severe/life-threatening events, followed by moderate exacerbations. Treatment to reduce the severity and occurrence of exacerbations, such as effective, long-term control therapy via lower-emission dry powder inhalers (DPIs), can help mitigate asthma care emissions. For mild exacerbations, the use of DPIs can eliminate associated emissions.

Cost-Effectiveness of Once-Daily, Single-Inhaler Indacaterol Acetate/ Glycopyrronium Bromide/ Mometasone Furoate in Patients with Uncontrolled Moderate-to-Severe Asthma in Canada.

PURPOSE: We evaluated the cost-effectiveness of high-dose indacaterol acetate (IND)/glycopyrronium bromide (GLY)/mometasone furoate (MF) (150/50/160 µg, once daily) compared with high-dose salmeterol/fluticasone (SAL/FLU; 50/500 µg, twice daily)+tiotropium (TIO; 5 µg, once daily) (SAL/FLU+TIO) and with high-dose SAL/FLU (50/500 µg, twice daily) for the treatment of inadequately controlled moderate-to-severe asthma. PATIENTS AND METHODS: A Markov model estimated the incremental cost-effectiveness ratio of treatment with high-dose IND/GLY/MF compared with SAL/FLU+TIO and high-dose IND/GLY/MF compared with SAL/FLU. The model included three health states (day-to-day symptoms without exacerbations, day-to-day symptoms with exacerbations, and death) with a 4-week cycle length. A lifetime time horizon was used. Exacerbation rates and utility values were derived from ARGON and IRIDIUM clinical trials. Canadian dollars (CAD$, 2020) were applied. RESULTS: IND/GLY/MF was the less costly and more effective treatment strategy compared with SAL/FLU+TIO and SAL/FLU in the base-case analyses. IND/GLY/MF had lower costs (CAD $33,501 versus CAD $50,907) and higher quality-adjusted life-years (QALYs) (18.37 versus 18.06 QALYs) compared with SAL/FLU+TIO. Compared with SAL/FLU, IND/GLY/MF had lower costs (CAD $33,408 versus CAD $36,577) and higher QALYs (19.33 versus 19.04 QALYs). IND/GLY/MF was the most cost-effective option in all scenarios tested. CONCLUSION: IND/GLY/MF was cost-effective at a willingness-to-pay threshold of CAD $50,000/QALY in patients with uncontrolled, moderate-to-severe asthma versus SAL/FLU+TIO and SAL/FLU in the base case and all scenarios tested.

Physician-Patient Concordance in the Assessment of Asthma Control.

BACKGROUND: Discordance between physicians' and patients' perceptions of asthma control may negatively impact symptom control, treatment, and outcomes. OBJECTIVE: To evaluate concordance between physicians' and patients' perceptions of overall asthma control and the association between perceived overall control and individual components of control. METHODS: U.S. survey data (Dec 2015-Feb 2016; Apr-Aug 2018) from the Respiratory Disease Specific Programme were analyzed. Physicians recorded patient disease characteristics and their perception of patients' asthma control. Patients' perception of control was assessed using the Asthma Control Test; responses were compared with level of symptom control per the Global Initiative for Asthma criteria and Work Productivity and Impairment questionnaire responses. Agreement and association were assessed by weighted kappa (κ) and Spearman rho (ρ), respectively. RESULTS: The study included 1,288 patients. Concordance between physician-perceived and patient-perceived asthma control in the prior 4 weeks was moderate (κ = 0.4951). Association between physicians' overall perception of asthma control and patients' overall Asthma Control Test score was also moderate (ρ = 0.5450). However, 61.5% of patients with self-reported, well-controlled asthma had shortness of breath 1 to 2 times/wk, 45.6% had 1 to 2 night-time awakenings/wk, and patients reported a mean (SD) daily activity impairment of 17.5% (16.2%). Only 21.8% of patients with self-reported, well-controlled asthma were classified as such by Global Initiative for Asthma symptom criteria. CONCLUSIONS: Patients' self-assessment of overall control does not accurately characterize the true level of control; thus, patients and physicians may benefit from working together to assess the individual components of asthma control to achieve better disease management, treatment decisions, and improved outcomes.

Disease burden and cost of hidradenitis suppurativa: a retrospective examination of US administrative claims data.

OBJECTIVES: Hidradenitis suppurativa (HS) causes substantial morbidity and quality-of-life impairment. We examined demographic/clinical characteristics of patients with HS and treatment patterns, prevalence and healthcare resource utilisation/expenditures related to HS in the real-world. DESIGN: Retrospective claims data of MarketScan Commercial, Medicare Supplemental and Medicaid databases (2009-2014). SETTING: USA. PARTICIPANTS: Patients aged ≥12 years with ≥3 non-diagnostic outpatient or inpatient claims with an HS diagnosis code and ≥12 months continuous enrolment with medical and pharmacy benefits before (preindex) and after (postindex) the earliest diagnosis of HS (index) were included. RESULTS: There were 11 325 Commercial/Medicare patients (mean age 37.4 years) and 5164 Medicaid patients (mean age 28.3 years). HS was more common in Medicaid than Commercial/Medicare patients (0.301% and 0.098%, respectively, in 2014). Cellulitis and psychiatric disorders were the most common comorbidities and oral antibiotics and narcotics were the most frequently prescribed drugs preindex, with ≥10% increase postindex in both populations. HS-related inpatient costs decreased while outpatient costs increased from preindex to postindex. Medicaid patients had several risk factors that may be associated with poor outcomes (eg, high rates of prescription pain medication use, comorbidities, drug discontinuation/interruption/holiday, emergency department (ED) visits and hospitalisation). CONCLUSIONS: Commercial/Medicare and Medicaid HS beneficiaries experience high comorbidity burden but use different treatment modalities to manage HS. Results suggest a substantial unmet need exists among this patient population, with Medicaid patients experiencing a particularly high burden of disease and expensive healthcare resource utilisation.

Cost-effectiveness of twice-daily indacaterol/glycopyrrolate inhalation powder for the treatment of moderate to severe COPD in the US.

BACKGROUND: Indacaterol 27.5 µg/glycopyrrolate 15.6 µg (IND/GLY 27.5/15.6 µg) inhalation powder, a twice-daily, fixed-dose combination of a long-acting beta2-agonist (LABA) and a long-acting antimuscarinic antagonist (LAMA), is indicated in the US for long-term maintenance treatment of airflow obstruction in patients with COPD. The safety and efficacy of IND/GLY 27.5/15.6 µg have been established, but cost-effectiveness is not yet known. This study compared the cost-effectiveness of IND/GLY 27.5/15.6 µg with other long-acting COPD maintenance therapies. METHODS: A Markov model was constructed from the US payer perspective. Health states were defined as mild (post-bronchodilator FEV1 ≥80% of predicted), moderate (50% ≤FEV1 <80% of predicted), severe (30% ≤FEV1 <50% of predicted), and very severe (FEV1 <30% of predicted) COPD. Patients entering the model transitioned through health states based on placebo-adjusted change from baseline in trough FEV1 for each comparator at week 12. Comparators included other US Food and Drug Administration-approved LABA/LAMA fixed-dose combinations as well as commonly prescribed LAMA and LABA/inhaled corticosteroid agents. One-way and probabilistic sensitivity analyses were conducted to test the model assumptions and the overall robustness of the results. RESULTS: Using the model, IND/GLY 27.5/15.6 µg treatment for 12 weeks resulted in total costs of US $23,375 vs US $9,365 for placebo. Compared with placebo, IND/GLY 27.5/15.6 treatment resulted in the highest improvement in FEV1 across all comparators and the lowest cost per decline in 100 mL FEV1. IND/GLY 27.5/15.6 µg was also among the most cost-effective treatment option as measured by St George's Respiratory Questionnaire response rate, at US $3,518 per additional responder at 12 weeks compared with placebo. In addition, IND/GLY 27.5/15.6 µg had the lowest cost per severe exacerbation avoided vs placebo across all comparators (US $87,686). CONCLUSION: This model, developed from the US payer perspective with a 5-year time horizon, found IND/GLY 27.5/15.6 µg to be a cost-effective treatment option for patients with moderate to severe COPD.

Impact of lung function on exacerbations, health care utilization, and costs among patients with COPD.

OBJECTIVE: To evaluate the impact of lung function, measured as forced expiratory volume in 1 second (FEV1) % predicted, on health care resource utilization and costs among patients with COPD in a real-world US managed-care population. METHODS: This observational retrospective cohort study utilized administrative claim data augmented with medical record data. The study population consisted of patients with one or more medical claims for pre- and postbronchodilator spirometry during the intake period (July 1, 2012 to June 30, 2013). The index date was the date of the earliest medical claim for pre- and postbronchodilator spirometry. Spirometry results were abstracted from patients' medical records. Patients were divided into two groups (low FEV1% predicted [,50%] and high FEV1% predicted [≥50%]) based on the 2014 Global Initiative for Chronic Obstructive Lung Disease report. Health care resource utilization and costs were based on the prevalence and number of discrete encounters during the 12-month postindex follow-up period. Costs were adjusted to 2014 US dollars. RESULTS: A total of 754 patients were included (n=297 low FEV1% predicted group, n=457 high FEV1% predicted group). COPD exacerbations were more prevalent in the low FEV1% predicted group compared with the high group during the 12-month pre- (52.5% vs 39.6%) and postindex periods (49.8% vs 36.8%). Mean (standard deviation) follow-up all-cause and COPD-related costs were $27,380 ($38,199) and $15,873 ($29,609) for patients in the low FEV1% predicted group, and $22,075 ($28,108) and $10,174 ($18,521) for patients in the high group. In the multivariable analyses, patients in the low FEV1% predicted group were more likely to have COPD exacerbations and tended to have higher COPD-related costs when compared with patients in the high group. CONCLUSION: Real-world data demonstrate that patients with COPD who have low FEV1% predicted levels use more COPD medications, have more COPD exacerbations, and incur higher COPD-related health care costs than those with high FEV1% predicted levels.

Burden of illness among patients with fragile X syndrome (FXS): a Medicaid perspective.

BACKGROUND: Fragile X syndrome (FXS) is an inherited intellectual disability that imposes a substantial clinical and humanistic burden on patients and caregivers. This study aimed to quantify the incremental burden of illness following FXS diagnosis in Medicaid populations. METHODS: A retrospective matched-cohort study was conducted using FL, NJ, MO, IA, and KS Medicaid claims (1997-2012). Patients with FXS were matched 1:5 to a comparison group without FXS, based on age, gender, state, and continuous Medicaid coverage. Healthcare resource utilization and costs were compared among cohorts over 1 year following first diagnosis. RESULTS: Overall, 697 patients with FXS were matched to 3485 non-FXS patients. Median age was 12.0 years; 82% were male. Newly diagnosed FXS patients were younger (median age: 7.0 years). During the follow-up, patients with FXS had significantly higher medication use, medical procedure use, medical specialist visits, and associated costs than the non-FXS comparison group. One-fourth of FXS patients filled prescriptions for stimulants, antipsychotics, or anticonvulsants; 25% of patients with FXS had speech and language therapy and 39% had physical therapy (versus 9%, 4% and 8%, respectively, for the comparison group). At least 44% of FXS patients visited a neurologist, cardiologist, otolaryngologist, or gastroenterologist; 92% of patients with FXS had an outpatient visit, 35% had an emergency room visit, and 34% used home services (compared to 31%-32%, 64%, 27%, and 10%, respectively, for the comparison group) (all p < 0.05). Patients with FXS had an incremental annual total healthcare cost of $33,409 (2012$) per person relative to the comparison group, while newly diagnosed FXS patients had incremental total annual healthcare costs of $17,617 (2012$) per person. CONCLUSIONS: Both established and newly diagnosed FXS were associated with significantly increased use of multiple medications and medical services, and increased healthcare costs. Treatments that could help reduce this disease burden are urgently needed.