In many countries the cost of caring for patients with asthma is high.1 Guidelines have recommended guided self management for the treatment of asthma.2,3 We recently compared the efficacy of guided self management with traditional treatment for asthma4 and here report the cost effectiveness of the two treatments.
Patients, methods, and results
One hundred and fifteen patients with mild to moderately severe asthma were randomly allocated guided self management or traditional treatment. The 56 patients allocated guided self management were given personal education and they were taught to measure their peak expiratory flow rate every morning for a year. If the value fell below 85% of their predetermined optimal value on any morning they were instructed to double their dose of inhaled corticosteroid for 2 weeks. If the value fell below 70% of the optimal value on any morning they were to take oral prednisolone (40 mg/day) for 7 days and immediately contact their nurse or doctor. The 59 patients allocated traditional treatment did not have peak flow meters and received no instructions about changing their dosage. Every fourth month all the patients visited their outpatient clinic.
Direct healthcare costs related to asthma included counselling (individual training and instruction in the guided self management group and general information in the other) peak flow meter, drugs, visits to the doctor other than for the study, and admissions. Indirect healthcare costs included absence from work. Total costs were the sum of the direct and indirect costs. Resource use was valued at 1994 prices (currently 8.84 Finnish marks=£1). Effectiveness was measured as the number of healthy days, defined as 365 minus the number of days with any incident caused by asthma, including admission, unscheduled visits to their doctor, outpatient clinic, or casualty department, days off work, and courses of oral antibiotics or prednisolone.
The table shows the average costs per patient over the year. The direct healthcare costs were 649 Finnish marks lower for traditional treatment (P=0.05), but because of the lower indirect costs for guided self management (2412 Finnish marks; P=0.008) the total costs were 1762 Finnish marks lower for guided self management (P=0.09). The mean number of healthy days was 359.2 in the guided self management group and 344.3 in the traditional treatment group. Thus, guided self management was 4.3% (P<0.001) more effective than traditional treatment. One outlier in the guided self management group was excluded from the analysis as the indirect costs were 24 times higher than those for the patient with the next highest indirect costs in that group. The patient who was the outlier had taken extended sick leave to avoid potentially harmful dusts in the workplace, not because of an exacerbation of asthma as in the other cases. Including this outlier would bias the results and not reflect the true expected costs of guided self management. When, however, the outlier (table) was included the differences in indirect costs were reduced to 1607 Finnish marks (P=0.18) and the differences in total costs were reduced to 950 Finnish marks (P=0.47). Both these costs are still higher for traditional treatment. We regard the results without the outlier as the main results.
Comment
The guided self management group had more healthy days (P<0.001) and lower total costs (P<0.1) than the traditional treatment group. The inclusion of an outlier in the guided self management group reduced the difference in total costs, but the conclusions remain the same. The short term direct healthcare costs for guided self management were increased because of extensive counselling during the study year. Reduction in the counselling should decrease the difference in the direct healthcare costs long term, while the benefits of healthy days with guided self management should prevail.
Table.
Mean annual direct, indirect, and total costs (in Finnish marks), and mean annual number of healthy days per patient for guided self management (with and without the outlier) and traditional treatment
| Cost items | Guided self management group without outlier (n=55; 95% CI) | Traditional treatment group (n=59; 95% CI) | Difference (95% CI) | P value† | Guided self management group with outlier (n=56; 95% CI) | Difference (95% CI) | P value† |
|---|---|---|---|---|---|---|---|
| Counselling | 1637 (1605 to 1668) | 843 (819 to 867) | 794 (755 to 833) | <0.001 | 1641 (1609 to 1673) | 798 (758 to 838) | <0.001 |
| Peak flow meter | 150 | 0 | 150 | 150 | 150 | ||
| Drugs | 2882 (2600 to 3164) | 2928 (2648 to 3208) | −46 (−435 to 343) | 0.82 | 2871 (2593 to 3149) | −57 (−452 to 338) | 0.776 |
| Visits to doctor | 223 (91 to 355) | 378 (165 to 592) | −155 (−401 to 91) | 0.22 | 239 (105 to 374) | −139 (−391 to 113) | 0.272 |
| Admission to hospital | 153 (0 to 384) | 246 (0 to 543) | −93 (−461 to 275) | 0.62 | 150 (0 to 378) | −96 (−470 to 278) | 0.608 |
| Direct costs | 5045 (4610 to 5479) | 4396 (3899 to 4892) | 649 (3 to 1295) | 0.053 | 5052 (4625 to 5479) | 656 (1 to 1311) | 0.048 |
| Indirect costs | 1149 (411 to 1888) | 3561 (1945 to 5176) | −2412 (−4151 to −673) | 0.008 | 1954 (186 to 3723) | −1607 (−4002 to 788) | 0.181 |
| Total costs | 6194 (5127 to 7262) | 7956 (6204 to 9708) | −1762 (−3770 to 246) | 0.089 | 7006 (5071 to 8942) | −950 (−3561 to 1661) | 0.467 |
| Effectiveness (No of healthy days) | 359.2 (356.5 to 361.8) | 344.3 (338.8 to 349.8) | 14.9 (8.9 to 20.9) | <0.001 | 358.9 (356.3 to 361.6) | 14.6 (8.5 to 20.7) | <0.001 |
Calculated by Student’s t test.
Footnotes
Funding: Suomen Astra Oy.
Conflict of interest: None.
References
- 1.Weiss KB, Gergen PJ, Hodgson TA. An economic evaluation of asthma in the United States. N Engl J Med. 1992;326:862–866. doi: 10.1056/NEJM199203263261304. [DOI] [PubMed] [Google Scholar]
- 2.National Heart, Lung and Blood Institute, National Institutes of Health. International consensus report on diagnosis and management of asthma. Bethesda, MD: National Heart, Lung and Blood Institute, National Institutes of Health; 1992. (Publication No 92.3091.) [Google Scholar]
- 3.British Thoracic Society; British Paediatric Association; Research Unit of the Royal College of Physicians of London; King’s Fund Centre; National Asthma Campaign; Royal College of General Practitioners. Guidelines on the management of asthma. Thorax. 1993;48:S1–24. doi: 10.1136/thx.48.2_suppl.s1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Lahdensuo A, Haahtela T, Herrala J, Kava T, Kiviranta K, Kuusisto P, et al. Randomised comparison of guided self management and traditional treatment of asthma over one year. BMJ. 1996;312:748–752. doi: 10.1136/bmj.312.7033.748. [DOI] [PMC free article] [PubMed] [Google Scholar]