J. Mark FitzGerald, MD, and Mohsen Sadatsafavi, MD, PhD on the Burden of Asthma in the United States
The financial and health burdens of uncontrolled asthma in the United States are substantial and will continue to grow over the next 20 years. A new study1 estimates the 20-year direct cost associated with asthma will be $300.6 billion. Including costs due to loss of work productivity, that financial burden increases to $963 billion.
To gain more insight into these findings, Pulmonology Consultant reached out to the lead authors of the study: J. Mark FitzGerald, MD, who is faculty of medicine in the Division of Respiratory Medicine at the University of British Columbia, and Mohsen Sadatsafavi, MD, PhD, who is faculty of pharmaceutical sciences in the Respiratory Evaluation Sciences Program and is also affiliated with the Department of Medicine at the University of British Columbia in Canada.
PULM CON: Your study found that uncontrolled asthma will cost the US economy an estimated $300 billion in the next 20 years. In your opinion, is it too late to ameliorate some of these costs? That is to say, how can health care providers intervene now to reduce the economic burden of asthma?
Mohsen Sadatsafavi: It is never too late to be cost-conscious! These estimates reflect the value/costs forgone by not properly controlling asthma and reflect the “preventable” gap in asthma care. Better adherence to contemporary standards of asthma care, in particular anti-inflammatory therapies, can result in immediate reduction of such costs.
PULM CON: Your study also found that the impact on quality of life is projected to be equal to a loss of 15.5 million years with full health. In your opinion, are current medications effective, or are more sophisticated medications needed?
MS: Current medications, in particular inhaled corticosteroids (ICS), are effective in achieving asthma symptom control and reducing the risk of future exacerbations in at least 85% of patients. We can always strive to find treatments that have even better benefit-harm profiles. However, for the vast majority of asthma patients the care gap can be narrowed with the medications we have. Anywhere between 3% and 15% of adults with asthma will not respond to ICS (or anti-inflammatory treatments in general). The patients with severe or difficult-to-control asthma now benefit from novel new therapies that have become available in recent years.
PULM CON: Pulmonologists (and health care providers in general) know that medication adherence is the key to reducing health care costs and improving quality of life. What questions are on your mental checklist when you follow up with patients with asthma? In other words, how do you ensure your patients are adhering to their medication?
MS: Research has shown that a simple question such as “Are you using your inhalers regularly?” can elucidate if the patient is adherent to their therapies. It is also important to ensure the inhaler use techniques are appropriate. If there is a hint of suboptimal adherence, I would go deeper. Reasons for nonadherence could be varied and include intentional (ie, lack of belief in effect, worries about adverse effects) to unintentional (eg, affordability).
My assessment would also involve objective evaluation of asthma control (preferably using one of the validated tools such as ACT (Asthma Control Test), ACQ (Asthma Control Questionnaire), or the GINA (Global Initiative for Asthma) definition of asthma control. Asthma symptom control is easily measurable during a routine clinical encounter. I would also inquire about recent history of asthma exacerbations. Any red flags on these fronts should also prompt further investigation. If such red flags exist, and if the patient is adherent to medications, then stepping up therapy is warranted. Of course inhaler technique and appropriate treatment of comorbidities is also very important. Patients with uncontrolled asthma, despite being adherent to maximum doses of inhalers, might require other (eg, biologic) therapies and generally should be referred to a specialist, ideally with expertise in severe asthma, for subsequent assessment and management.
JMF: Open-ended, nonconfrontational questions are very important in assessing adherence. I have the benefit of being able to access all of my patients’ prescriptions filled in real time as I talk to them. It often requires a diplomatic conversation to get them to accept that they are not always filling their prescriptions. We know that patient-centered care improves adherence, and the big challenge for a busy clinician is taking the time to adopt this style of practice.
PULM CON: How might your findings impact clinical practice and how asthma is managed in the future?
JMF: Physicians and payers are increasingly aware of the importance of developing cost-effectiveness models to better assess newer treatments. This is especially so with the more-expensive biologics that are now available for the treatment of asthma. The data from our study provide compelling evidence for how the indirect costs of uncontrolled asthma have not been integrated into such assessments in the past, and thus, we underestimate the effect of uncontrolled disease.
PULM CON: What else do pulmonologists need to know about your study?
MS: Pulmonologists need to know that adherence to asthma management guidelines (in particular the use of ICS) is low and that such departure from guidelines are costly for the patient (both monetarily and in terms of quality of life), health providers, and society.
- Yaghoubi M, Adibi A, Safari A, FitzGerald JM, Sadatsafavi M; the Canadian Respiratory Research Network. The projected economic and health burden of uncontrolled asthma in the United States. Am J Respir Crit Care Med. 2019;200(9). https://doi.org/10.1164/rccm.201901-0016OC.