The cost-effectiveness of an inner-city asthma intervention for children

doi:10.1067/mai.2002.128009

Journal of Allergy and Clinical Immunology

Volume 110, Issue 4, October 2002, Pages 576-581

https://doi.org/10.1067/mai.2002.128009 Get rights and content

Abstract

Background: Comprehensive management efforts to reduce asthma morbidity among children in urban areas with high levels of poverty and large minority populations have been inconclusive. The National Cooperative Inner-City Asthma Study (NCICAS) demonstrated improved symptom outcomes but did not evaluate cost-effectiveness in this population. Objective: We sought to examine the incremental cost-effect-iveness of a comprehensive social worker–based education program and environmental control in children with asthma stratified by baseline level of asthma control. Methods: We performed a prospective cost-effectiveness analysis alongside a randomized trial. A total of 1033 children and their families residing in 8 inner-city urban areas in the United States were enrolled in the NCICAS. Outcomes included symptom-free days, cost per symptom-free day gained, and annual costs of asthma morbidity compared by baseline symptom control, previous hospitalization, and previous unscheduled physician visits. Results: The NCICAS intervention significantly reduced asthma symptoms. First-year intervention costs were $245 higher for the intervention children compared with those receiving usual care. There were no additional intervention-related costs during the second year. When compared with usual care, the intervention improved outcomes at an average additional cost of $9.20 per symptom-free day gained (95% CI, −$12.56 to $55.29). The intervention was cost saving in 3 strata of children with increasing asthma severity. Conclusions: A multifaceted asthma intervention program reduced symptom days and was cost-effective for inner-city children with asthma. In children with more severe disease, the intervention was substantially more effective and reduced costs compared with that seen in control children. Organizations serving this population should consider this strategy as part of a comprehensive disease-management program for asthma. (J Allergy Clin Immunol 2002;110:576-81.)

Section snippets

Methods

A cost-effectiveness evaluation of the NCICAS multicenter randomized trial was conducted by using a Medicaid payer perspective because the majority of children in the clinical trial were either recipients or eligible for Medicaid coverage. Outcomes, costs, and cost-effectiveness were analyzed over a 2-year period in accordance with the methodology principles for conducting economic evaluations outlined by the US Public Health Services panel on cost-effect-iveness in health and medicine.¹⁵

The

Results

Baseline characteristics of the children are shown in Table I.

. Comparison of baseline characteristics of the AC intervention and usual care groups

Empty Cell	Usual care group (n = 518)	AC intervention group (n = 515)
Male sex, %	66.0	62.1
Age, y (mean ± SD)	7.6 ± 1.8	7.7 ± 1.9
Race-ethnicity, %
Black	73.1	75.9
Hispanic	17.4	17.1
Other	9.5	7
Had primary care physician, %	79.3	84.7
Household income <$15,000/y, %	66.0	68.9
Maximum symptom days (per 2 wk)	5.1 ± 4.6	5.1 ± 4.5
≥1 hospitalization in past 2 mo, %	3.9	5.0

No between-group

Discussion

Asthma morbidity remains a significant public health concern, especially in children living in the dense, urban areas of the United States. Randomized trials have now shown that educational and self-management efforts targeted toward these high-risk children can be effective. However, the cost-effectiveness of these programs had not previously been evaluated. Despite this, more resources continue to be directed toward families and children living in these settings.

We found that when compared

Acknowledgements

We thank Kristin Marciante, MPH, of the University of Washington for data analysis support.

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Direct Medical Cost of Pediatric Asthma in Jordan: A Cost-of-Illness Retrospective Cohort Study
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This study aimed to estimate and analyze the direct medical costs of pediatric patients with asthma in Jordan from the provider’s perspective.
A retrospective analysis of a cohort of pediatric patients with asthma treated during 3 years in a teaching hospital was conducted. The prevalence-based, bottom-up approach has been used to estimate the cost-of-illness of asthma. The total annual direct medical cost was stratified by control status and the severity of asthma.
The total annual cost for whole the sample (N = 613) in the average of 3 years was Jordanian dinar (JD) 110 874 (US$ 156 382). Pediatrics with uncontrolled asthma had significantly higher annual total direct medical costs than partly controlled and controlled asthma (JD 396 [US$ 558], JD 258 [US$ 364], and JD 150 [US$ 211], respectively) (P < .001). The annual total direct medical cost for severe asthma (JD 455 [US$ 641]) was significantly higher than moderate, mild, and intermittent (JD 176 [US$ 248], JD 35 [US$ 49], and JD 7 [US$ 9.8], respectively) (P < .001). Medications were the most expensive healthcare resource used, accounting for 79.8% of the total cost, followed by outpatient clinic visits and hospitalizations.
Healthcare sources utilization and direct medical costs of asthma were highly related to disease severity and control status of the disease. Health policies targeting the achievement of better and stricter asthma control will play a crucial role in the reduction of the economic burden of asthma for society and the patient.
Systematic review of economic evaluations of children's social care interventions
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Citation Excerpt :
Thanh et al. (2015) applied an annual discount rate of 5%, referencing the Canadian Agency for Drugs and Technologies in Health guidelines (CADTH, 2006). Sullivan et al. (2002) and Foster and Jones (2007) used discount rates of 3% and 5%, respectively, however they did not reference any guidelines to justify their choice. Two studies with a time horizon greater than one year did not indicate that they had applied a discount rate (Lynch et al., 2014; Wansink et al., 2016); the cost-effectiveness results reported may therefore be inaccurate for both studies.
Children’s social care/child welfare services, are under pressure to maximize the value of resource expenditure in meeting the needs of children and young people exposed to risk factors for care entry or residing in care. Economic evaluations can support the decision to adopt, routinize or discontinue an intervention, informing the allocation of limited resources. There is a paucity of economic evaluations in children’s social care, partly because this is an emerging area, hence topic-specific methods are lacking. Prior to the development and recommendation of methods, it is important to systematically synthesize those adopted to highlight challenges that have arisen and guide future research.
To assess the methods applied and the cost-effectiveness evidence generated by economic evaluations of children’s social care interventions.
Searches of electronic databases and websites were carried out to identify full economic evaluations of children’s social care interventions in journal articles and the grey literature. A narrative synthesis of methods adopted and cost-effectiveness results is presented.
Twenty studies were eligible for inclusion. These covered parenting programs (n = 8), in addition to a diverse range of other interventions. Cost-effectiveness analysis was the most common approach taken (n = 17) and a large number of studies concluded that the intervention was cost-effective (n = 14).
The number of published economic evaluations of children’s social care interventions is limited. The available evidence supports the adoption of several of the interventions evaluated, however, the review highlighted a number of challenges in the use of standard economic evaluations methods in this area.
The impact of housing type on low-income asthmatic children receiving multifaceted home interventions
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Citation Excerpt :
The environmental indices improved as well, suggesting reduced environmental triggers. This is an important finding that supports the work of others that have reported that multifaceted home interventions improve the health of childhood asthmatics.2–8 We found that children in market-rate housing experienced greater reductions in asthma attacks, overnight hospital stays, and greater improvement in physical health than children in assisted housing.
This study sought to evaluate whether government-assisted vs market-rate housing type influences the frequency of asthma symptoms or the quality of life scores among low-income urban children. In addition, the study sought to evaluate whether housing type influenced the success of in-home environmental and educational interventions in improving children's asthma symptoms or quality of life scores.
This was a before-and-after intervention design. Comprehensive health and environmental assessments and subsequent interventions were completed in 176 low-income households with 257 asthmatic children living in government-assisted housing and market-rate housing in Lowell, Massachusetts.
We collected environmental and health data with questionnaires at a baseline and a 12-month follow-up visit using the Children's Health Survey for Asthma and a walk-through environmental checklist. Education, tools to remove asthma triggers from the home, and home repairs and remediation were included in the interventions.
As in other studies of multifaceted home interventions, there were significant improvements in all asthma symptoms, reductions in healthcare utilization related to asthma, and improvements in quality of life domains for children in both housing types. Environmental indices also improved from the baseline to the final assessment for both housing types. However, the housing type was an important factor in predicting a child's asthma status at the start of the study, with children living in government-assisted housing having significantly better physical health scores (76.8 of 100) and family emotional health scores (74.8 of 100) and fewer overnight hospital stays (mean of 0.02 in the previous 4 weeks) than children living in market-rate housing (67.6, 71.6, and 0.06, respectively). Examination of the change in the health status over the 1-year study period found that children living in market-rate housing had significantly larger reductions in the number of asthma attacks (0.43 in the previous 4 weeks versus 0.24 in assisted housing) and overnight hospital stays (0.06 in the previous 4 weeks versus 0.01 in assisted housing) and larger improvements in physical health quality of life scores (54% improved versus 25.5% in assisted housing).
Public assistance for low-income urban housing is associated with better health among children with asthma, and may influence the impact the in-home interventions have on health outcomes because children in market-rate housing have more prospects for improvement in their asthma-related health.
Health economic evaluations of patient education interventions a scoping review of the literature
2018, Patient Education and Counseling
To provide a comprehensive overview of health economic evaluations of patient education interventions for people living with chronic illness.
Relevant literature published between 2000 and 2016 has been comprehensively reviewed, with attention paid to variations in study, intervention, and patient characteristics.
Of the 4693 titles identified, 56 articles met the inclusion criteria and were included in this scoping review. Of the studies reviewed, 46 concluded that patient education interventions were beneficial in terms of decreased hospitalization, visits to Emergency Departments or General Practitioners, provide benefits in terms of quality-adjusted life years, and reduce loss of production. Eight studies found no health economic impact of the interventions.
The results of this review strongly suggest that patient education interventions, regardless of study design and time horizon, are an effective tool to cut costs. This is a relatively new area of research, and there is a great need of more research within this field.
In bringing this evidence together, our hope is that healthcare providers and managers can use this information within a broad decision-making process, as guidance in discussions of care quality and of how to provide appropriate, cost-effective patient education interventions.
Economic Evidence for US Asthma Self-Management Education and Home-Based Interventions
2016, Journal of Allergy and Clinical Immunology: In Practice
Citation Excerpt :
No effect on asthma-related health care utilization was reported for only 1 program.15 Eight of 9 programs were associated with a positive ROI (ie, >$1 return per $1 invested) for all or some participants (Table II); among these, 2 programs achieved positive ROIs only among participants with higher health care utilization for asthma (eg, ≥1 hospitalization or ≥2 unscheduled visits within a certain time frame before program participation).23-25,29-31 Estimated time to achieve ROI ranged from 1 to 3 years.
The health and economic burden of asthma in the United States is substantial. Asthma self-management education (AS-ME) and home-based interventions for asthma can improve asthma control and prevent asthma exacerbations, and interest in health care-public health collaboration regarding asthma is increasing. However, outpatient AS-ME and home-based asthma intervention programs are not widely available; economic sustainability is a common concern. Thus, we conducted a narrative review of existing literature regarding economic outcomes of outpatient AS-ME and home-based intervention programs for asthma in the United States. We identified 9 outpatient AS-ME programs and 17 home-based intervention programs with return on investment (ROI) data. Most programs were associated with a positive ROI; a few programs observed positive ROIs only among selected populations (eg, higher health care utilization). Interpretation of existing data is limited by heterogeneous ROI calculations. Nevertheless, the literature suggests promise for sustainable opportunities to expand access to outpatient AS-ME and home-based asthma intervention programs in the United States. More definitive knowledge about how to maximize program benefit and sustainability could be gained through more controlled studies of specific populations and increased uniformity in economic assessments.
Patient- and family-centered care as an approach to reducing disparities in asthma outcomes in urban African American children: A review of the literature
2015, Journal of the National Medical Association
We thank Cathy Eames (Director, Library Services, Detroit Medical Center) for valuable input and assistance with the search strategy. Funding for this research was supported by a grant from Children’s Hospital of Michigan Research Foundation (Principal Investigator: Terrance L. Albrecht, Ph.D.).
Patient- and family-centered care (PFCC) has the potential to address disparities in access and quality of healthcare for African American pediatric asthma patients by accommodating and responding to the individual needs of patients and families.
To identify and evaluate research on the impact of family-provider interventions that reflect elements of PFCC on reducing disparities in the provision, access, quality, and use of healthcare services for African American pediatric asthma patients.
Electronic searches were conducted using PubMed, CINAHL, and Psyclnfo databases. Inclusion criteria were peer-reviewed, English-language articles on family–provider interventions that (a) reflected one or more elements of PFCC and (b) addressed healthcare disparities in urban African American pediatric asthma patients (≤ 18 years).
Thirteen interventions or programs were identified and reviewed. Designs included randomized clinical trials, controlled clinical trials, pre- and post-interventions, and program evaluations.
Few interventions were identified as explicitly providing PFCC in a pediatric asthma context, possibly because of a lack of consensus on what constitutes PFCC in practice. Some studies have demonstrated that PFCC improves satisfaction and communication during clinical interactions. More empirical research is needed to understand whether PFCC interventions reduce care disparities and improve the provision, access, and quality of asthma healthcare for urban African American children.
PubMed, CINAHL, and Psyclnfo
AA—African American: CCT—Controlled clinical trial; ED—Emergency Department; ETS—Environmental tobacco smoke; FCC— Family Centered Care; PFCC—Patient and Family Centered Care; RCT— Randomized, controlled trial

View all citing articles on Scopus

^☆: *A list of National Cooperative Inner-City Asthma Study, Phase II, investigators can be found in the Appendix.

^☆☆: Supported by the National Institute of Allergy and Infectious Disease grants U01 A1-30751, A1-30752, A1-30756, A1-30772, A1-30773-01, A1-30777, A1-30779, A1-30780, and N01 A1-15105 and a research grant to the University of Washington from GlaxoSmithKline.

^★: This article does not represent the policy of the Agency for Healthcare Research and Quality. The views expressed are those of the authors, and no official endorsement by the Agency for Healthcare Research and Quality or the National Institutes of Health is intended or should be inferred.

^★★: Reprint requests: Sean D. Sullivan, PhD, Departments of Pharmacy and Health Services, Box 357630, University of Washington, Seattle, WA 98195.

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Asthma, Rhinitis, Other Respiratory DiseasesThe cost-effectiveness of an inner-city asthma intervention for children☆,☆☆,★,★★

Abstract

Section snippets

Methods

Results

Discussion

Acknowledgements

The challenge of inner-city asthma

Curr Opin Pulm Med

Trends in the cost of illness of asthma in the United States, 1985-1994

J Allergy Clin Immunol

Action against asthma

A critique of 19 self-management programs for childhood asthma. Part 1. Development and evaluation of the programs

Pediatr Asthma Allergy Immunol

The impact of health education on frequency and cost of health care use by low income children with asthma

J Allergy Clin Immunol

A randomized trial of A.C.T. (asthma care training) for kids

Pediatrics

Improving care for minority children with asthma: professional education in public health clinics

Pediatrics

Facilitated referral to asthma specialist reduces relapses in asthma emergency room visits

J Allergy Clin Immunol

Results of a program to reduce admissions for adult asthma

Ann Intern Med

Asthma in managed care

Pediatr Ann

Characteristics of inner-city children with asthma: the National Cooperative Inner-City Asthma Study

Pediatr Pulmonol

Asthma, Rhinitis, Other Respiratory Diseases
The cost-effectiveness of an inner-city asthma intervention for children☆,☆☆,★,★★