Cost-effectiveness of pediatric asthma treatments

Abstract

In a recently published review, Spahn and Szefler1Spahn JD Szefler SJ Childhood asthma: new insights into management.J Allergy Clin Immunol. 2002; 109: 3-13Abstract Full Text Full Text PDF PubMed Scopus (33) Google Scholar summarized progress made during the past 15 years in the management of childhood asthma and discussed the need to recognize asthma early and to identify the most effective and safe treatment for early and long-term asthma control. Several important new classes of medications are currently being used in the treatment of persistent asthma in children, and their placement in the hierarchy of available asthma medications will evolve as data from controlled clinical trials and real-world experience accumulate. Current guidelines recognize inhaled corticosteroids as the cornerstone of asthma therapy. Inhaled corticosteroids provide greater overall asthma control than nonsteroidal controllers, including cromolyn, theophylline, and leukotriene modifiers. For example, a study by Leflein et al2Leflein JG Szefler SJ Murphy KR Fitzpatrick S Cruz-Rivera M Miller CJ et al.Nebulized budesonide inhalation suspension compared with cromolyn sodium nebulizer solution for asthma in young children: results of a randomized outcomes trial.Pediatrics. 2002; 109: 866-872Crossref PubMed Scopus (63) Google Scholar demonstrated that budesonide inhalation suspension was more effective than nebulized cromolyn sodium and was well tolerated in young children with mild to moderate persistent asthma. One important issue not discussed by Spahn and Szefler is the cost-effectiveness of competing asthma treatments. Cost-effectiveness studies are a new and rapidly evolving area of interest to health care providers. In light of the substantial morbidity and economic burden of asthma, the “National Asthma Education and Prevention Program Working Group Report on the Cost Effectiveness of Asthma Care”3Sullivan S Elixhauser A Buist AS Luce BR Eisenberg J Weiss KB National Asthma Education and Prevention Program Working Group report on the cost effectiveness of asthma care.Am J Respir Crit Care Med. 1996; 154: S84-S95Crossref PubMed Google Scholar has emphasized the need for cost-effectiveness studies of asthma treatments. A recent study by Smith et al4Smith MJ Rascati KL Johnsrud MT Costs and utilization patterns associated with persistent asthma: a comparison of Texas Medicaid patients with and without continuous inhaled corticosteroid treatment.J Managed Care Pharm. 2001; 7: 452-459Google Scholar reported that the number of emergency department visits was halved in a group of patients after the start of inhaled corticosteroid treatment, whereas the number of emergency department visits in patients not receiving inhaled corticosteroids nearly doubled. Higher prescription payments for patients using inhaled corticosteroids were offset by reductions in medical visits and other medical costs, resulting in similar Medicaid payments between the groups. Despite the limitations of this study (eg, the retrospective design), it demonstrates the utility of cost analysis to guide treatment decisions. Similarly, a second study reported by Adams et al5Adams RJ Fuhlbrigge A Finkelstein JA Lozano P Livingston JM Weiss KB et al.Impact of inhaled antiinflammatory therapy on hospitalization and emergency department visits for children with asthma.Pediatrics. 2001; 107: 706-711Crossref PubMed Scopus (165) Google Scholar demonstrated a significant protective effect of inhaled antiinflammatory therapy on the risk for hospitalization and emergency department visits in children with asthma. In a Swedish study, Andersson et al6Andersson F Kjellman M Forsberg G Möller C Arheden L Comparison of the cost-effectiveness of budesonide and sodium cromoglycate in the management of childhood asthma in everyday clinical practice.Ann Allergy Asthma Immunol. 2001; 86: 537-543Abstract Full Text PDF PubMed Scopus (24) Google Scholar further demonstrated that budesonide was more cost-effective than sodium cromoglycate (cromolyn sodium) and resulted in fewer drug switches to maintain asthma control. Ideally, cost-effectiveness studies should take into consideration the benefits and risks associated with treatments. Spahn and Szefler explained that the Childhood Asthma Management Program (CAMP) Research Group study7Childhood Asthma Management Program Research Group Long-term effects of budesonide or nedocromil in children with asthma.New Engl J Med. 2000; 343: 1054-1063Crossref PubMed Scopus (1281) Google Scholar was the first prospective, randomized trial specifically demonstrating a reduction in significant asthma exacerbations that lead to hospitalizations, urgent care visits, and prednisone courses. Importantly, safety data from the CAMP study regarding estimated final adult height, bone mineralization, and ocular disorders with budesonide were reassuring. In summary, given the substantial economic burden of asthma, optimal disease management must now take into consideration the efficacy and the safety of competing asthma treatments as well as their cost-effectiveness. Research regarding the relative cost-effectiveness of inhaled corticosteroid use in children will be especially valuable. As new data from CAMP are published, additional insight into factors to be included in such studies can be ascertained.