Are Environmental and Educational Interventions for Asthma Cost Effective?

Wanda Phipatanakul, MD, MS

Environmental interventions have been a major topic of discussion among allergists, as conflicting clinical trial results and recent trends toward positive efficacy have brought into question whether their use should be more widespread.

But one thing is clear—environmental interventions for the treatment of asthma are a cost-effective strategy to managing this chronic condition.

In a presentation at the 2018 American Academy of Allergy, Asthma, and Immunology (AAAAI)/World Allergy Organization (WAO) Joint Congress in Orlando, Florida, Wanda Phipatanakul, MD, MS, explored their affordability. She stressed that while inhaled corticosteroids work well, allergists should be thinking about utilizing conjunctive environmental interventions to reduce costs.

“Fluticasone/salmeterol—the combinations are about $3300 per year. It gets a little bit lower when you do the medium dose and the low dose, about $2500 versus $2100,” Phipatanakul, a professor of pediatrics at Harvard Medical School and the director of the Asthma Clinical Research Center at Boston Children’s Hospital, said. “That’s about $1500 per year. The [environmental] intervention, even [when it is] multi-faceted, it actually only cost about $1500 annually. [In Morgan’s study in NEJM] that intervention lasted through the year, and even in the year after the intervention.”

Phipatanakul noted that as newer biologics and small-molecule treatments, which are expensive, become more widely used, there will need to be future analysis on the cost-effectiveness of these therapies with environmental intervention.

When comparing environmental intervention costs with those of health care utilization, it seems to be clear that costs are reduced further with environmental intervention. In a study led by Maria P. Fabian, ScD, it was revealed that other than weatherization, environmental interventions—including fan repair, stove replacement, smoke reduction, integrated pest management, and HEPA filters, among others—are successful in reducing yearly costs per asthmatic.

Even just educational intervention can be more cost-effective. In Boston, Massachusetts, community asthma initiative data, published in Pediatrics, for 300 pediatric patients with asthma not only reduced basal emergency department visits and hospitalizations by 46.6% and 43.4% in 12 months, respectively, but also reduced the annual costs per patient by $1621 after the first year compared with a $743 reduction in the comparison group.

Moreover, the savings carried over after the first 12 months for the initiative group. By the end of year 2 in the comparison group, an additional $18 were saved annually, compared to an additional $585 in savings by the end of year 2 in the initiative group.

“It really had a dose-response decline in cost,” Phipatanakul said. “And the return on investment was great. It was 50% above break-even costs. It gained a lot of interest—seeing that something that simple could make such a difference.”

School environmental interventions were another facet Phipatanakul expressed a desire to clinicians to examine. Currently, she is leading a study that is open for enrollment which plans to, as part of its data collection, explore the possible cost reductions per person, per school, and overall.

She emphasized the potential for utilizing environmental interventions, especially in places like schools, where interventions are beneficial for not just the pediatric patient with allergy or asthma but for the population as a whole. There is also the added benefit of keeping children in school.

“Fewer symptom days translated into fewer lost school days, which in turn translates to fewer lost caregiver wages—someone has to stay home and watch the kid,” Phipatanakul said. “From some economic evaluations, we estimate that every 7 symptom days in asthma is associated with 1 lost school day, and if you have a lost school day, it doubles the amount of cost.”

“You could potentially target a community of children, so I’m really excited and I hope that in a few years we will have some objective data to help move this field forward,” Phipatanakul added.

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