The patient level cost of asthma in adults in south

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Ungar et al, patient indirects 50 du co t total Une maladie plus grave un ge plus. MOD LE Co t prospectif de l valuation de la maladie avanc les habitudes tabagiques l accessibilit un r gime. CONTEXTE Patients non hospitalis s recevant un traitement d assurance m dicaments et le fait d tre retrait taient des. ambulatoire r sidant dans la partie centrale du sud de l Ontario pr dicteurs significatifs du co t Le co t annuel par patient variait. POPULATION TUDI E Neuf cent quarante patients de 1 255 dollars IC 95 1 061 1 485 dollars chez les jeunes. asthmatiques g s de plus de 15 ans tudi s entre mai 1995 et avril non fumeurs ne poss dant pas d assurance m dicaments et atteints. 1996 d asthme l ger 5 032 dollars IC 95 4 347 5 825 dollars. MESURES DES R SULTATS On a calcul les co ts directs tels chez les fumeurs plus g s poss dant une assurance m dicaments et. que les consultations pour troubles respiratoires chez un m decin atteints d asthme grave Des r ductions substantielles de la qualit. g n raliste ou un pneumologue les visites la salle des urgences de vie d int r t m dical survenaient lorsque la maladie. les hospitalisations les preuves de laboratoire les m dicaments s aggravait. d ordonnance les frais de distribution les d penses li es aux CONCLUSIONS Les interventions visant r duire les pertes de. appareils et autres sommes d bours es On a galement valu les productivit les hospitalisations et le co t des m dicaments. co ts indirects tels que l absent isme au travail ou l impossibilit peuvent g n rer une pargne pour la soci t le gouvernement. d exercer les t ches habituelles le temps de transport et d attente provincial et le patient La qualit des d cisions politiques et de. PRINCIPAUX R SULTATS Le co t annuel non corrig tait de l attribution des ressources pourrait tre am lior e par des. 2 550 dollars par patient Les hospitalisations et les m dicaments estimations du co t de la maladie qui sont globales pr cises et qui. repr sentaient respectivement 22 du co t total et les co ts contiennent de multiples perspectives. I n societies faced with rapidly growing health care costs. measuring the economic burden of illness can reveal. which components of health care make the largest contribu. generate a comprehensive estimate of the overall cost of ill. ness in a sample of asthmatic patients A stochastic approach. was taken so that indicators of precision 95 CI could be. tions to total costs Traditionally cost of illness assessments presented alongside point estimates of total costs Analyses. have proceeded in a retrospective fashion using data from ex were undertaken from the perspectives of society the On. isting sources resulting in a population based summary of tario Ministry of Health and the patient. average costs 1 Such an approach is valuable for generat. ing an overall cost for the target population however re PATIENTS AND METHODS. searchers often encounter missing data and need to make as Patient sample Study patients were drawn from registrants. sumptions This reduces the precision of the result and its in the Pharmacy Medication Monitoring Program PMMP. value to health professionals and policy makers Observa Bronchial Inhalers project The PMMP is a community. tional study designs hold promise for economic assessments based prospective medication surveillance program based at. that require accurate measurements of costs and the utiliza St Joseph s Hospital in Hamilton Ontario that targets users. tion of health care resources Data on a full range of eco of specific medication classes The methods used to recruit. nomic variables may be collected along with disease and pharmacies and enroll patients have been published else. demographic information Precision may be assessed where 13 14 The Bronchial Inhalers project received eth. through the application of stochastic methods 2 and the re ics approval from McMaster University Hamilton Ontario. sults may be stratified into clinically meaningful categories and participants provided written informed consent This. Costs can be expressed at the patient level and from multiple study focused on health outcomes and health services use re. perspectives facilitating interpretation and application to ported by adult patients filling prescriptions for bronchial in. decision making Prospective evaluations are hindered by halers in pharmacies across south central Ontario including. cost and the challenge of implementing a sampling strategy pharmacies in St Catharines Hamilton Burlington. that ensures the generalizability of the results to the target Oakville Mississauga Brampton Guelph and Kitchener. population in the region of interest Waterloo Ontario The project recruited 2078 subjects be. The rising prevalence and morbidity of asthma in Canada tween May and October 1995 and 1588 subjects success. 3 6 estimated at 2 in 1979 and 6 in 1994 and uncer fully completed their six month interview by March 31 1996. tainty regarding the determinants of this upward trend 7 8 Figure 1 Among the 1588 registrants who completed the. raise concern regarding the availability of appropriate care study 940 patients aged 15 years or older were classified as. and the consequences of reductions in health services The having asthma They were patients who had a prescription. economic burden of asthma has been investigated in several for a bronchial inhaler medication and who reported experi. countries 9 12 and has been estimated at 504 million encing shortness of breath wheeze or recurrent cough in the. 1990 Canadian dollars in Canada 9 However these stud past Patients over age 55 years with a smoking history of 20. ies were constrained by the limitations of retrospective data pack years or more and patients using oxygen were ex. collection Given the changing epidemiology and treatment cluded Before assessing the cost of illness in the 940 adult. of asthma prospective economic assessments are needed to patients the patients were stratified according to disease se. monitor changes in the cost of this disease and its impact on verity based on reported medication use over the six month. patients lives study period Medication use has been recommended as a. The purpose of this study was to develop a prospective method of ascertaining disease severity in the absence of. observational study design relying on patient self reports to clinical information 15 Severity strata were developed. 464 Can Respir J Vol 5 No 6 November December 1998. Adult asthma costs in south central Ontario, Disease severity defined for the study of adult asthma. costs in south central Ontario,severity Definition. Mild Bronchodilator monotherapy inhaled,bronchodilatory use did not exceed four puffs day. over the study period,Moderate Bronchodilator monotherapy exceeded four.
Inhaled anti inflammatory budesonide,beclomethasone flunisolide triamcinolone. fluticasone cromolyn or nedocromil,monotherapy did not exceed the equivalent of. beclomethasone 800 mg day,Treatment with two types of medication neither of. which was an oral corticosteroid If one or both,medications were inhaled anti inflammatory. agents the combined dose did not exceed the,equivalent of beclomethasone 800 mg day.
Figure 1 Patient recruitment in Pharmacy Medication Monitoring Severe Treatment with one or two types of medication. where one was an inhaled anti inflammatory drug, Program Bronchial Inhaler Study St Joseph s Hospital Hamilton. with a dosage greater than the equivalent of,beclomethasone 800 mg day. based on clinical expert opinion and Canadian prescribing Treatment with three types or more types of. guidelines that were available at the time of the study 16 medication where one was an inhaled. anti inflammatory, The criteria used to define asthma and disease severity are or. described in Table 1 Treatment with oral corticosteriods. Data collection Participants underwent telephone inter. views at one three and six months after registration at which. time they reported demographic characteristics as well as. medication consumption use of health services and symp cause the true value of resources opportunity costs are diffi. toms The telephone interview questions were worded and cult to quantify for most services and products prices and. framed to concentrate specifically on respiratory related re fees excluding taxes were used Measurements of heath re. source use and productivity losses Health related quality of source utilization spanned periods that varied from 18. life was measured with the SF 36 questionnaire a generic months to six months depending on the type of health care. health status instrument 17 Health services consisted of resource All utilization rates were adjusted to annual rates. respiratory related visits to general or family practitioners per person. GP specialists or emergency rooms ER not resulting in an In the societal perspective direct medical costs included. admission and hospitalizations At the one month baseline asthma related health services and prescription medications. interview patients recalled their use of health services for the while direct patient costs were out of pocket expenses to ac. previous six months GP visits or the previous 12 months cess asthma related care In the societal perspective indirect. specialist visits ER visits and respiratory admissions At costs consisted of productivity losses associated with asthma. subsequent interviews patients reported use that occurred related absences and restricted activity days as well as travel. since the previous interview a duration of two to three and waiting time associated with the use of asthma related. months The reliability of these recall intervals has been dem health services From the Ministry of Health perspective di. onstrated in previous studies 18 20 and in this study 21 rect medical costs paid for by the provincially administered. The interviews included questions on the use of and out of health insurance program were included health services for. pocket payments for privately insured and complementary all ages and medications for persons over 65 years The pa. health care services copayments for drugs and devices tient perspective comprised the patients contributions to. transportation costs absences from work or usual activities asthma related medication and device costs noninsured. restricted days and travel and waiting time 21 health services out of pocket expenses and asthma related. Measurement of costs A cost of illness model was con lost income All costs were expressed in 1995 Canadian dol. structed to evaluate respiratory related direct and indirect lars. costs from the perspectives of society the Ontario Ministry The unit costs and sources for each item are listed in Ta. of Health and the patient Costs were calculated by multiply ble 2 All prices used were those in effect at the time of health. ing asthma related health resources used by the unit cost Be service use Average respiratory admission costs and average. Can Respir J Vol 5 No 6 November December 1998 465. Ungar et al, Average price and volume for each cost of illness item used to calculate the patient level costs of asthma in. south central Ontario, Number of patients Price fee per service Annual utilization.
Item reporting minimum maximum 1995 Cost data source per person reporting. General family practitioner 693 73 7 1st visit 51 40 Ontario Schedule of Benefits 3 9. additional visits 16 25, Respiratory specialist 245 26 1 1st visit 105 40 Ontario Schedule of Benefits 1 9. additional visits 23 10, Emergency room 71 7 6 120 00 Chedoke McMaster Hospital 0 8. Hospital admissions 63 6 7 487 10 per diem Ontario case costing project 0 9. Spirometry 321 34 1 31 9 Ontario Schedule of Benefits 1 3. Dispensing fees 940 100 0 6 11 11 49 ODB formulary Ontario 15 4. College of Pharmacists, Prescription medications 940 100 0 0 30 95 52 ODB formulary 2 2. Drug device wholesaler,Spacer 202 21 5 23 13 Drug device wholesaler 1 0. Peak flow meter 71 7 6 21 73 1 0,Complementary services 39 4 1 22 7.
Out of pocket 3 00 100 00 Patient self report,Insured 9 65 12 20 Ontario Schedule of Benefits. Transportation 144 15 3 0 25 32 00 Patient self report 4 8. Recreation 44 4 7 Annual fee 12 00 1200 00 Patient self report Not available. Absences days 683 72 7 17 66 254 17 Patient self report 23 2. Travel plus waiting time days 659 70 1 17 66 254 17 Patient self report 0 7. All health services are for respiratory related care Utilization is the number of prescriptions per patient Price is the range of prices for a medica. tion ODB Ontario Drug Benefits Program, lengths of stay LOS were obtained for asthma ICD9 CM acupuncturists were calculated by multiplying the re. code 493 00 22 from the Ontario case costing project a ported number of sessions by the reported out of pocket. joint initiative of the Ontario Hospital Association and the expense per session Fees for chiropractors and physio. Ontario Ministry of Health Hospital costs included nursing therapists reimbursed by the provincial health plan were in. services laboratory and diagnostic tests medications social cluded in the Ministry of Health analysis. services and overhead administration housekeeping etc Indirect costs productivity losses were measured as the. The latter was allocated using the simultaneous equation al days lost from productive activities because of asthma the. location method 23 The fee for an in patient specialist con days that patients worked despite asthma symptoms re. The patient level cost of asthma in adults in south central Ontario Wendy J Ungar MSc PhD1 Peter C Coyte PhD1 4 Kenneth R Chapman MD2 Linda MacKeigan PhD3 and the Pharmacy Medication Monitoring Program Advisory Board 1Department of Health Administration and 2Division of Respirology Faculty of Medicine University of Toronto 3Faculty of Pharmacy University of Toronto Toronto

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