Using Randomized Controlled Trials to Estimate the Effect of Community Interventions for Childhood Asthma.

INTRODUCTION: The Centers for Disease Control and Prevention's Controlling Childhood Asthma and Reducing Emergencies initiative aims to prevent 500,000 emergency department (ED) visits and hospitalizations within 5 years among children with asthma through implementation of evidence-based interventions and policies. Methods are needed for calculating the anticipated effects of planned asthma programs and the estimated effects of existing asthma programs. We describe and illustrate a method of using results from randomized control trials (RCTs) to estimate changes in rates of adverse asthma events (AAEs) that result from expanding access to asthma interventions. METHODS: We use counterfactual arguments to justify a formula for the expected number of AAEs prevented by a given intervention. This formula employs a current rate of AAEs, a measure of the increase in access to the intervention, and the rate ratio estimated in an RCT. RESULTS: We justified a formula for estimating the effect of expanding access to asthma interventions. For example, if 20% of patients with asthma in a community with 20,540 annual asthma-related ED visits were offered asthma self-management education, ED visits would decrease by an estimated 1,643; and annual hospitalizations would decrease from 2,639 to 617. CONCLUSION: Our method draws on the best available evidence from RCTs to estimate effects on rates of AAEs in the community of interest that result from expanding access to asthma interventions.

Return on investment of self-management education and home visits for children with asthma.

OBJECTIVE: Priorities of the Centers for Disease Control and Prevention's 6|18 Initiative include outpatient asthma self-management education (ASME) and home-based asthma visits (home visit) as interventions for children with poorly-controlled asthma. ASME and home visit intervention programs are currently not widely available. This project was to assess the economic sustainability of these programs for state asthma control programs reimbursed by Medicaid. METHODS: We used a simulation model based on parameters from the literature and Medicaid claims, controlling for regression to the mean. We modeled scenarios under various selection criteria based on healthcare utilization and age to forecast the return on investment (ROI) using data from New York. The resulting tool is available in Excel or Python. RESULTS: Our model projected health improvement and cost savings for all simulated interventions. Compared against home visits alone, the simulated ASME alone intervention had a higher ROI for all healthcare utilization and age scenarios. Savings were primarily highest in simulated program participants who had two or more asthma-related emergency department visits or one inpatient visit compared to those participants who had one or more asthma-related emergency department visits. Segmenting the selection criteria by age did not significantly change the results. CONCLUSIONS: This model forecasts reduced healthcare costs and improved health outcomes as a result of ASME and home visits for children with high urgent healthcare utilization (more than two emergency department visits or one inpatient hospitalization) for asthma. Utilizing specific selection criteria, state based asthma control programs can improve health and reduce healthcare costs.

The Economic Burden of Asthma in the United States, 2008-2013.

RATIONALE: Asthma is a chronic disease that affects quality of life, productivity at work and school, and healthcare use; and it can result in death. Measuring the current economic burden of asthma provides important information on the impact of asthma on society. This information can be used to make informed decisions about allocation of limited public health resources. OBJECTIVES: In this paper, we provide a comprehensive approach to estimating the current prevalence, medical costs, cost of absenteeism (missed work and school days), and mortality attributable to asthma from a national perspective. In addition, we estimate the association of the incremental medical cost of asthma with several important factors, including race/ethnicity, education, poverty, and insurance status. METHODS: The primary source of data was the 2008-2013 household component of the Medical Expenditure Panel Survey. We defined treated asthma as the presence of at least one medical or pharmaceutical encounter or claim associated with asthma. For the main analysis, we applied two-part regression models to estimate asthma-related annual per-person incremental medical costs and negative binomial models to estimate absenteeism associated with asthma. RESULTS: Of 213,994 people in the pooled sample, 10,237 persons had treated asthma (prevalence, 4.8%). The annual per-person incremental medical cost of asthma was $3,266 (in 2015 U.S. dollars), of which $1,830 was attributable to prescription medication, $640 to office visits, $529 to hospitalizations, $176 to hospital-based outpatient visits, and $105 to emergency room visits. For certain groups, the per-person incremental medical cost of asthma differed from that of the population average, namely $2,145 for uninsured persons and $3,581 for those living below the poverty line. During 2008-2013, asthma was responsible for $3 billion in losses due to missed work and school days, $29 billion due to asthma-related mortality, and $50.3 billion in medical costs. All combined, the total cost of asthma in the United States based on the pooled sample amounted to $81.9 billion in 2013. CONCLUSIONS: Asthma places a significant economic burden on the United States, with a total cost of asthma, including costs incurred by absenteeism and mortality, of $81.9 billion in 2013.

Economic implications of unintentional carbon monoxide poisoning in the United States and the cost and benefit of CO detectors.

BACKGROUND: Unintentional non-fire-related (UNFR) carbon monoxide (CO) poisoning has been among the leading causes of poisoning in the United States. Current estimation of its economic burden is important for an optimal allocation of resources for UNFR CO poisoning prevention. OBJECTIVE: This study was to estimate the morbidity costs of UNFR CO poisoning. We also compared the costs and benefits of installing CO detectors in residences. METHODS: We used 2010-2014 charges and cost data from Healthcare Cost and Utilization Project (HCUP), and Truven© Health MarketScan Commercial Claims and Encounters and Medicare Supplemental data. We directly measured the morbidity cost as the summation of costs for different healthcare services. Benefit of installing CO detector was estimated by summing up the avoidable morbidity cost and mortality cost (value of life). Cost of CO detectors was calculated using the average market price of CO detectors. We also calculated the benefit-to-cost ratio by dividing the benefit by its cost. All expenditures were converted into 2013 U.S. dollars. RESULTS: For UNFR CO poisoning, total annual medical cost ranged from $33.6 to $37.7 million. Annual non-health-sector costs varied from $3.7 to almost $4.4 million. The benefit-to-cost ratio can be as high as 7.2 to 1. CONCLUSION: UNFR CO poisoning causes substantial economic burden in the U.S. The benefit of using CO detectors in homes to prevent UNFR CO poisoning can considerably exceed the cost of installation. Public health programs could use these findings to promote broad installation of CO detectors in homes.

Economic Valuation of Selected Illnesses in Environmental Public Health Tracking.

BACKGROUND: In benefit-cost analysis of public health programs, health outcomes need to be assigned monetary values so that different health endpoints can be compared and improvement in health can be compared with cost of the program. There are 2 major approaches for estimating economic value of illnesses: willingness to pay (WTP) and cost of illness (COI). In this study, we compared these 2 approaches and summarized valuation estimates for 3 health endpoints included in the Centers for Disease Control and Prevention's National Environmental Public Health Tracking Network-asthma, carbon monoxide (CO) poisoning, and lead poisoning. METHOD: First, we compared results of WTP and COI estimates reported in the peer-reviewed literature when these 2 methods were applied to the same study participants. Second, we reviewed the availability and summarized valuations using these 2 approaches for 3 health endpoints. RESULT: For the same study participants, WTP estimates in the literature were higher than COI estimates for minor and moderate cases. For more severe cases, with substantial portion of the costs paid by the third party, COI could exceed WTP. Annual medical cost of asthma based on COI approach ranged from $800 to $3300 and indirect costs ranged from $90 to $1700. WTP to have no asthma symptoms ranged from $580 to $4200 annually. We found no studies estimating WTP to avoid CO or lead poisoning. Cost of a CO poisoning hospitalization ranged from $14 000 to $17 000. For patients who sustained long-term cognitive sequela, lifetime earnings and quality-of-life losses can significantly exceed hospitalization costs. For lead poisoning, most studies focused on lead exposure and cognitive ability, and its impact on lifetime earnings. CONCLUSION: For asthma, more WTP studies are needed, particularly studies designed for conditions that involve third-party payers. For CO poisoning and lead poisoning, WTP studies need to be conducted so that more comprehensive economic valuation estimates can be provided. When COI estimates are used alone, it should be clearly stated that COI does not fully capture the nonmarket cost of illness, such as pain and suffering, which highlights the need for WTP estimates.

State-level medical and absenteeism cost of asthma in the United States.

OBJECTIVE: For medically treated asthma, we estimated prevalence, medical and absenteeism costs, and projected medical costs from 2015 to 2020 for the entire population and separately for children in the 50 US states and District of Columbia (DC) using the most recently available data. METHODS: We used multiple data sources, including the Medical Expenditure Panel Survey, U.S. Census Bureau, Kaiser Family Foundation, Medical Statistical Information System, and Current Population Survey. We used a two-part regression model to estimate annual medical costs of asthma and a negative binomial model to estimate annual school and work days missed due to asthma. RESULTS: Per capita medical costs of asthma ranged from $1,860 (Mississippi) to $2,514 (Michigan). Total medical costs of asthma ranged from $60.7 million (Wyoming) to $3.4 billion (California). Medicaid costs ranged from $4.1 million (Wyoming) to $566.8 million (California), Medicare from $5.9 million (DC) to $446.6 million (California), and costs paid by private insurers ranged from $27.2 million (DC) to $1.4 billion (California). Total annual school and work days lost due to asthma ranged from 22.4 thousand (Wyoming) to 1.5 million days (California) and absenteeism costs ranged from $4.4 million (Wyoming) to $345 million (California). Projected increase in medical costs from 2015 to 2020 ranged from 9% (DC) to 34% (Arizona). CONCLUSION: Medical and absenteeism costs of asthma represent a significant economic burden for states and these costs are expected to rise. Our study results emphasize the urgency for strategies to strengthen state level efforts to prevent and control asthma attacks.

Costs of Chronic Diseases at the State Level: The Chronic Disease Cost Calculator.

INTRODUCTION: Many studies have estimated national chronic disease costs, but state-level estimates are limited. The Centers for Disease Control and Prevention developed the Chronic Disease Cost Calculator (CDCC), which estimates state-level costs for arthritis, asthma, cancer, congestive heart failure, coronary heart disease, hypertension, stroke, other heart diseases, depression, and diabetes. METHODS: Using publicly available and restricted secondary data from multiple national data sets from 2004 through 2008, disease-attributable annual per-person medical and absenteeism costs were estimated. Total state medical and absenteeism costs were derived by multiplying per person costs from regressions by the number of people in the state treated for each disease. Medical costs were estimated for all payers and separately for Medicaid, Medicare, and private insurers. Projected medical costs for all payers (2010 through 2020) were calculated using medical costs and projected state population counts. RESULTS: Median state-specific medical costs ranged from $410 million (asthma) to $1.8 billion (diabetes); median absenteeism costs ranged from $5 million (congestive heart failure) to $217 million (arthritis). CONCLUSION: CDCC provides methodologically rigorous chronic disease cost estimates. These estimates highlight possible areas of cost savings achievable through targeted prevention efforts or research into new interventions and treatments.

Economic value of home-based, multi-trigger, multicomponent interventions with an environmental focus for reducing asthma morbidity a community guide systematic review.

CONTEXT: A recent systematic review of home-based, multi-trigger, multicomponent interventions with an environmental focus showed their effectiveness in reducing asthma morbidity among children and adolescents. These interventions included home visits by trained personnel to assess the level of and reduce adverse effects of indoor environmental pollutants, and educate households with an asthma client to reduce exposure to asthma triggers. The purpose of the present review is to identify economic values of these interventions and present ranges for the main economic outcomes (e.g., program costs, benefit-cost ratios, and incremental cost-effectiveness ratios). EVIDENCE ACQUISITION: Using methods previously developed for Guide to Community Preventive Services economic reviews, a systematic review was conducted to evaluate the economic efficiency of home-based, multi-trigger, multicomponent interventions with an environmental focus to improve asthma-related morbidity outcomes. A total of 1551 studies were identified in the search period (1950 to June 2008), and 13 studies were included in this review. Program costs are reported for all included studies; cost-benefit results for three; and cost-effectiveness results for another three. Information on program cost was provided with varying degrees of completeness: six of the studies did not provide a list of components included in their program cost description (limited cost information), three studies provided a list of program cost components but not a cost per component (partial cost information), and four studies provided both a list of program cost components and costs per component (satisfactory cost information). EVIDENCE SYNTHESIS: Program costs per participant per year ranged from $231-$14,858 (in 2007 U.S.$). The major factors affecting program cost, in addition to completeness, were the level of intensity of environmental remediation (minor, moderate, or major), type of educational component (environmental education or self-management), the professional status of the home visitor, and the frequency of visits by the home visitor. Benefit-cost ratios ranged from 5.3-14.0, implying that for every dollar spent on the intervention, the monetary value of the resulting benefits, such as averted medical costs or averted productivity losses, was $5.30-$14.00 (in 2007 U.S.$). The range in incremental cost-effectiveness ratios was $12-$57 (in 2007 U.S.$) per asthma symptom-free day, which means that these interventions achieved each additional symptom-free day for net costs varying from $12-$57. CONCLUSIONS: The benefits from home-based, multi-trigger, multicomponent interventions with an environmental focus can match or even exceed their program costs. Based on cost-benefit and cost-effectiveness studies, the results of this review show that these programs provide a good value for dollars spent on the interventions.

Costs of asthma in the United States: 2002-2007.

BACKGROUND: The economic burden of asthma is an important measure of the effect of asthma on society. Although asthma is a costly illness, the total cost of asthma to society has not been estimated in more than a decade. OBJECTIVE: The purpose of this study is to provide the public with current estimates of the incremental direct medical costs and productivity losses due to morbidity and mortality from asthma at both the individual and national levels for the years 2002-2007. METHODS: Data came from the Medical Expenditure Panel Survey. Two-part models were used to estimate the incremental direct costs of asthma. The incremental number of days lost from work and school was estimated by negative binomial regressions and valued following the human capital approach. Published data were used to value lives lost with an underlying cause of asthma. RESULTS: Over the years 2002-2007, the incremental direct cost of asthma was $3,259 (2009 dollars) per person per year. The value of additional days lost attributable to asthma per year was approximately $301 for each worker and $93 for each student. For the most recent year available, 2007, the total incremental cost of asthma to society was $56 billion, with productivity losses due to morbidity accounting for $3.8 billion and productivity losses due to mortality accounting for $2.1 billion. CONCLUSION: The current study finds that the estimated costs of asthma are substantial, which stresses the necessity for research and policy to work toward reducing the economic burden of asthma.

The economic implications of influenza vaccination for adults with asthma.

BACKGROUND: Influenza vaccination is recommended for adults with asthma. PURPOSE: This study estimates the effect of influenza vaccination on utilization of medical services and expenditures for acute and chronic respiratory conditions (ACRC) among adults with asthma. METHODS: The sample was adults aged ≥18 years self-reporting asthma in the 2003 through 2006 Medical Expenditure Panel Survey (MEPS), covering four complete influenza seasons. The dependent variables were indicators for any ACRC claims within service category and ACRC expenditures. The main independent variable was an indicator of influenza vaccination. To control for selection bias in the observational data, a nonlinear instrumental variables approach was used. The instruments were indicators for influenza in the first year of MEPS and vaccination in the year prior to MEPS. Data were analyzed in 2009. RESULTS: Adults with asthma vaccinated for influenza were 4.4 percentage points less likely to have an inpatient stay due to ACRC (95% CI = -10.8, -1.0). Influenza vaccination was associated with a $492 decrease (95% CI = -$1591, -$56) in annual ACRC nonprescription expenditures, a $224 increase (95% CI = $70, $360) in annual ACRC prescription expenditures, and a nonsignificant $216 decrease (95% CI = -$854, $248) in overall annual ACRC expenditures. CONCLUSIONS: Although there was no evidence that vaccination reduced overall ACRC expenditures, the study suggests that efforts to increase the percentage of adults with asthma who are vaccinated may bring substantial benefits in terms of reducing the prevalence and costs of hospitalization although raising prescription medication costs, possibly through improvement in compliance.

An economic evaluation of the school-based "power breathing" asthma program.

This study evaluated the cost effectiveness of the "Power Breathing" program for asthma among middle and high school students. Few systematic evaluations of school based interventions--let alone cost-effectiveness programs--have been identified in the literature. Power Breathing was developed by the Asthma and Allergy Foundation of America and is currently available for implementation by school districts. For the overall evaluation, 8 junior high schools and 2 high schools were selected and matched based on grade range, enrollment, income and race/ethnicity. Schools were randomly assigned to the intervention or control group. Surveys were administered at baseline, immediately post-intervention and 3 months' post-intervention. Children in the intervention arm had a significant decrease in the number of days they experienced an asthma attack or had trouble breathing during a 2-week period of 0.18 days per 2 weeks. In contrast, subjects in the control group had an increase in the in the number of days experiencing an asthma attack or having trouble breathing during a 2-week period of 0.102, from 0.696 to 0.793. The program cost approximately $3.9 per asthma attack-free day gained, on par with pharmaceutical interventions, suggesting that Power Breathing may be a cost effective asthma intervention. The results of this study suggest that school-based interventions aimed at asthma, properly implemented and administrated, are an appropriate use of societal resources.

The economic impact of an urban asthma management program.

OBJECTIVES: To examine costs associated with an asthma management program that reduces asthma-related health services utilization and to calculate potential return on investment (ROI) from the Medicaid managed care plan perspective. STUDY DESIGN: Cross-sectional. METHODS: Clinical and economic data were obtained for 3298 ethnically diverse children with asthma (48% with persistent asthma) who resided in a poor urban community (Hartford, Connecticut) and were enrolled in Easy Breathing, an asthma management program for pediatricians. We calculated the cost per participating child with asthma during the first 3 years (July 1998 to June 2001) relative to the difference in costs for participating and nonparticipating children calculated by applying Medicaid reimbursement rates to data on services. RESULTS: Start-up costs were $28.95 per child with asthma in year 1, and operating costs averaged $10.28 in years 2 and 3. The mean reduction in costs was $36.72 per child per year in years 2 and 3. If Medicaid managed care plans had been charged an amount equal to program operating costs after year 1 ($10.28 per child with asthma per year), at-risk health plans could have incurred cost savings of approximately $26.44 per child with asthma per year. The potential ROI for years 2 and 3 was $3.58 per US dollar spent. CONCLUSIONS: Easy Breathing reduced overall costs of care for urban children with asthma of varying severities. If managed care plans held at risk by Medicaid had reimbursed program operating costs for participants in Easy Breathing, they would have experienced a positive ROI.

What is the cost to employers of direct medical care for chronic obstructive pulmonary disease?

Chronic obstructive pulmonary disease (COPD) is a major cause of morbidity and mortality in the United States. In 2000, an estimated 10.5 million people had COPD, of which more than 7.2 million were from the under-age 65 employed population. The prevalence of COPD in the workforce population was substantial with 46.5% of current employment among adults having the disease. However, the cost burden in the employed population is unknown. We examined COPD prevalence and costs in a large employment-based population. Using claims data from 1999 to 2003, we estimated the cost associated with COPD-related hospitalizations, emergency department visits, outpatient services, and prescription drug use. Per patient use of hospital care for COPD decreased during 1999 through 2003, including a decrease in the number of hospital admissions (from 0.10 in 1999 to 0.04 in 2003) and in the length of stay in hospitals (from 0.53 in 1999 to 0.17 in 2003). The number of outpatient visits, however, increased from 3.45 in 1999 to 3.80 in 2003. COPD-related per patient total medical costs decreased from $1460 in 1999 to $1138 in 2003 largely because of a decrease in the cost of hospitalizations for COPD. In contrast, mean per patient expenditures for outpatient services increased over the same period from $243 in 1999 to $295 in 2003. The cost of COPD to employers is high, but the cost could be reduced by programs aimed at preventing new cases of COPD, reducing hospitalizations, and providing more outpatient services to COPD patients.