Sullivan SD, Buxton M, Andersson LF, et al. J Allergy Clin Immunol. 2003;112:1229–1236
Purpose of the Study.
These investigators analyzed cost-effectiveness of a commonly prescribed inhaled corticosteroid from the perspectives of both direct and indirect costs.
Patients aged 5 to 66 years from 32 countries were enrolled in the Inhaled Steroid as Regular Therapy in Early Asthma (START) study. Patients were eligible if they were diagnosed with asthma within 2 years of randomization and lacked significant comorbidity.
START was a randomized, 3-year controlled trial of budesonide versus usual asthma therapy in early-onset asthma among 7165 subjects. Three age groups (5–10, 11–17, and ≥18 years) were studied separately and collectively. All patients were allowed to receive other asthma treatments including inhaled and oral corticosteroids, according to local practice. The cost-effectiveness evaluation of the START study was conducted primarily from the health care payer perspective (direct costs) and secondarily from the societal perspective (indirect costs). The primary outcome measure for effectiveness was the number of symptom-free days. This parameter was defined as a complete 24-hour period with no asthma symptoms and has been recognized as a clinical outcome with relevance to patients, providers, and other decision-makers. Unit costs in US dollars were based on reimbursed amounts for each of the health care–resource items such as hospital days, emergency department visits, physician and nurse visits, and telephone contacts. These costs were derived from a large medical- and pharmacy-claims database. The costs for school and work losses were estimated by using standard methods.
Compared with usual therapy, patients receiving budesonide had 14.1 more symptom-free days per year, fewer hospital days and emergency department visits, and less school and work absence. Budesonide added $0.41 per day to direct costs. After considering indirect cost offsets related to lower school and work absence, the net expense dropped to $0.14 per day. Early intervention was most effective and cost saving in the youngest age group.
Long-term treatment with budesonide seems to be cost-effective in patients with mild persistent asthma of recent onset.
The health care system in the United States is only now beginning to experiment with methods that will raise awareness of direct health costs for patients/consumers. Although $0.14 per day for better asthma control sounds like a great value, any comments that we currently make to patients or parents regarding cost-effectiveness of a given therapy usually fall on deaf ears. At the present time, we can better appeal to them by touting the improved quality of life associated with fewer days with symptoms, fewer asthma attacks, and lowered hospitalization risk and also by making it clear that the risks of disease far outweigh the risks of usual doses of ICS. This latter fact, so obvious to us, needs continued restating to parents of children with asthma.