The COVID-19 impact on severe uncontrolled asthma costs and biologic use.

Background: Patients with severe uncontrolled asthma (SUA) overwhelmingly contribute to the economic burden of asthma and may require biologic therapy. However, the impact of the CoronaVirus Disease of 2019 (COVID-19) on asthma costs and biologic use has yet to be evaluated. Objective: The objective was to test the hypothesis that SUA costs and biologic use decreased during the pandemic. Methods: We analyzed medical costs and biologic use in patients with SUV from January 2017 to December 2021, by using claims data from a large managed care organization and electronic health record data from Robert Wood Johnson Barnabas Health, according to provider specialty. Results: Of the 3817 managed care organization enrollees within Robert Wood Johnson Barnabas Health with a primary diagnosis of asthma, 348 were identified as having SUA. A nested sample of 151 patients revealed that 50% were managed by primary care physicians (PCP) and specialists, 43% by PCPs only, and 4% by specialists only. The total costs of the claims were $10.8 million over 5 years ($2.2 million per year), with 60% generated from patients seeing PCPs and specialists, 27% from PCPs only, and 15% from specialists only. During the pandemic, total average costs decreased for all care groups (34% PCP-only patients and 45% for both specialist-only and PCP and specialist patients). Inpatient and outpatient costs also decreased and were lowest for patients who saw specialists and highest for patients who saw PCPs and specialists. In contrast, prescription costs increased during the pandemic. Biologic use was steadily increasing until a twofold decrease was observed during the pandemic. Thirteen patients were on biologics: two were managed by PCPs, four by specialists, and seven by both. Conclusion: Inpatient and outpatient costs decreased during the COVID-19 pandemic, but prescription costs increased. Biologic use was increasing among patients with SUA before the pandemic but then drastically decreased and remained lower during the observational interval.

Biomarker underuse contributes to an inability to phenotype patients with severe uncontrolled asthma.

Background: Biomarker measurements improve the phenotyping of patients with severe uncontrolled asthma (SUA) and predict therapeutic responses. The use of biomarkers in asthma, however, remains underused. Objective: To test the hypothesis that biomarker measurements of patients with SUA remain markedly underused and contributes to asthma morbidity and oral corticosteroid use. Methods: Leveraging claims data linked to electronic health record data, we calculated biomarker use by providers treating patients with SUA from January 2017 to August 2020. Results: From 3.6 million clients, 3817 had a primary diagnosis of asthma; most were between 50 and 60 years old. Also, 63.2% were female patients; those under ages 10 years were primarily boys. Of the 728 patients who reported race, 69.9% were white and 21.8% were African American. Of the 840 who reported ethnicity, 14% were Latinx. A predetermined definition of SUA identified 348 patients with SUA. In a nested sample of 151 patients with SUA, 43% were managed by primary care physicians (PCP), 4% by specialists, and 49.7% by both. Of this sample, 61.5% had a measurement of serum eosinophils, 9.9% total immunoglobulin E values, and 9.3% radioallergosorbent skin tests; 38% received no tests, whereas 9.9% had more than one. Specialists ordered a biomarker test 4.6 times more often than did PCPs, whereas PCPs ordered 70% of the prednisone prescriptions for recurrent asthma exacerbations. Conclusion: Specialists were more likely to order biomarkers than were PCPs. Patients managed exclusively by PCPs were more likely prescribed oral prednisone. Real-world evidence shows that biomarkers are infrequently used to characterize patients with SUA, especially among patients exclusively managed by PCPs. Programs that encouraged biomarker use may improve SUA management and oral corticosteroid burden.

The Relationship of Risk to Rules, Values, Virtues, and Moral Complexity: What We can Learn from the Moral Struggles of Military Leaders.

Leaders are faced with ethical and moral dilemmas daily, like those within the military who must span from large-scale combat operations to security cooperation and deterrence. For businesses, these dilemmas can include social and environmental impact such as those in mining; and for governments, the social and economic impact of their decision-making in their response to COVID-19. The move by Western defence forces to align their foundational principles, policies, and "soldier" dispositions with the changing values of the countries they serve are starkly illustrative of challenges faced by all leaders. While admirable, such changes face the apparent contradiction of enhancing individual moral agency within a hierarchical organization that maintain enforceable codes of conduct. Ethical leadership theory provides aspirational goals, but lacks empirically based guidance on how to implement policies that facilitate values-based behavior. Using a discourse theory analysis of a moral dilemma vignette with Royal Australian Air Force personnel, this research identifies important aspects of agency and subject position that must be addressed if such policies are to succeed. These findings show that the potential contradiction can be addressed by acknowledging the contrasting tendency to bureaucratic process by leaders at upper levels, while lower-level leaders address moral issues by incorporating their subjectivity and making a conscious deontological choice between humanity and comrade loyalty.