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Background: To estimate the direct and indirect costs of severe asthma and the economic impact of its management to low-income families in Salvador, Brazil.
Methods: One hundred and ninety-seven patients with severe asthma and referred to a state-funded asthma center providing free treatment were evaluated. At registration, they were asked about family cost-events in the previous year and had a baseline assessment of lung function, symptoms and quality of life. During the subsequent year, they were reassessed prospectively.
Results: One hundred-eighty patients concluded a 12-month follow-up. Eighty-four percent were female patients, and the median family income was US$ 2955/year. Forty-seven percent of family members had lost their jobs because of asthma. Total cost of asthma management took 29% of family income. After proper treatment, asthma control scores improved by 50% and quality of life by 74%. The income of the families increased by US$ 711/year, as their members went back to work. The total cost of asthma to the families was reduced by a median US$ 789/family/year. Consequently, an annual surplus of US$ 1500/family became available.
Conclusions: Family costs of severe asthma consumed over one-fourth of the family income of the underprivileged population in a middle-income country. Adequate management brings major economic benefit to individuals and families.
The prevalence of asthma has been increasing in many countries and worldwide, the economic burden of asthma is high (1). Most studies addressing this issue focused on direct and indirect costs to the public health system. Only a few reports analyzed the family’s costs incurred on patients with severe asthma (2, 3).
In poor households in low- and middle-income countries, even relatively small expenditures on health can be financially disastrous (4). The situation is more difficult in chronic disabling diseases, like severe asthma. In asthma, family’s costs are directly associated with the severity of the disease (5).
The primary aim of management of persistent asthma is to gain control over symptoms with regular use of inhaled corticosteroids, but studies showed that the proportion of individuals with persistent asthma reporting use of inhaled corticosteroids is only 5% in Brazil, which is as low as what has been described in various other parts of the world (6, 7). Uncontrolled asthma is associated with economic burden to families and health systems, causing loss of productivity and deterioration in quality of life (3). In Salvador, Brazil, the prevalence of wheezing among adolescents estimated in the first International Study of Asthma and Allergies in Childhood survey was 27% (8). The standard available strategy for asthma management in the public health system in Brazil was restricted to treatment of exacerbations with bronchodilators and systemic corticosteroids. The combination of high prevalence rates and the lack of access to free secondary prevention of asthma exacerbations through effective pharmacotherapy in the public health system lead to unacceptable levels of high morbidity and costs for families and the health system (9). In 2003, a program for control of severe asthma started in an outpatient reference clinic at the School of Medicine, Federal University of Bahia, in Salvador. The program included specialized care, patient education and free inhaled medication (bronchodilators and topical corticosteroids) for control of asthma in the public health system (10).
The aim of this study was to estimate the family’s direct and indirect costs with one of the family members suffering from severe asthma, before and after being enrolled in a public reference center for management of severe asthma. In the study, a specific questionnaire was used to measure the impact of asthma on families’ budgets (11).
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- Conflict of interest
This study showed that, in Salvador, Brazil, family costs with severe asthma takes a remarkable proportion of family income, representing an important economic burden. The frequent loss of days of work, by patient or their relatives, contributes to the process of impoverishment of these families. The patients studied had severe asthma for 25 years on average, which may have contributed to aggravate the poverty situation experienced by a major part of them (19). We showed that an intervention to provide free regular specialized care including assistance for medication, can control severe asthma, improve quality of life and markedly benefit the family’s economic stability.
This study shows that when patients with severe asthma had their disease under control, there was a major reduction (89%) in family’s direct cost of asthma, and a significant increase in the overall family income. A remarkable effect of the intervention was noticed in the reduction of the proportion of family income (24%vs 2%) used for the treatment of one of the members with severe asthma.
The method used in this study was beyond the direct asthma costs and took into account family’s indirect costs, such as loss of income of patients and family members, house renovations and transportation. After the intervention, patients and their families had a 24% increase in their income, decreasing the effect on the family indirect costs. This increase was because of reduction in work absences of patients or family members, as the majority worked in the unorganized sector, where one does not earn when one does not work. The control of asthma had a direct favorable impact on physical performance, leading to the increase of work capability and income.
There have been efforts to define a threshold of family expenditure on health, beyond which a family will slip into deeper poverty. World Health Organization estimates that families who spend 50% or more of their nonfood expenditure fit in this category (4). Other estimates suggest this threshold at 40% of income after subsistence needs have been met or 5–20% of total income (20, 21). In this study, asthma treatment consumed on average 24% of family total income. This proportion goes up to 29% when indirect costs are included. For the low-income families evaluated in Brazil, food expenditures require over half or their total income (22). Therefore, the costs incurred by the families of subjects suffering from severe asthma in the population studied may be considered catastrophic.
A review of the impact of chronic diseases such human immuno deficiency virus (HIV)/acquired immuno deficiency syndrome (AIDS), tuberculosis and malaria on family costs in 12 low-income countries showed that limitations in the health services such as inadequate coverage and quality contribute to increased family costs. The proportion of family income used for the healthcare varied between 2.5% and 10%, and this latter figure was considered catastrophic (23). A study in South Africa showed that families of patients with HIV/AIDS were poorer and had a higher proportion of unemployed members, and that this increased with time (24).
An Australian study estimated the annual family’s costs for treatment of 238 asthmatic children. It found that the mean annual treatment cost per asthmatic child was US$ 164 (2). In this study, the annual family costs (US$ 868) are five times higher. Possibly, this difference is because of the degree of severity asthma in our patients and because, in the method of collection of cost data, indirect costs were also taken into consideration.
The success of asthma treatment in preventing exacerbations seems to be associated with regular control of symptoms. Patients with scores of ACQ <1.5 (cut-off point for clinical trials) are considered to be under control (16). Within 1 year of follow-up, patients treated in ProAR reduced the ACQ mean score from 4 (poorly controlled) to 2, which is very close to adequate control. Lung function measurements (FEV1 and peak flow) were less responsive to changes during the first year of asthma control than ACQ scores. Severe or uncontrolled asthma causes limitation and impact in physical, social and emotional well-being of patients and their families. Its control may result in remarkable change in quality of life (15). After ProAR intervention, patients left a situation of extreme limitation (AQLQ mean score of 2) to enter a mild/moderate limitation zone (AQLQ mean score of 4) during the 1 year of intervention.
A limitation of our study is that information from the year before intervention was collected retrospectively from patient reports (25). It would not be ethical to have a parallel control group of severe asthmatics followed up without access to ProAR, once free preventive inhaled medication was made available. Therefore, the only way we could study patients inside and outside the program was comparing their own profile before and after the intervention. In this study, patients apparently had no difficulty to recall hospitalizations, emergency room visits, income, financial help, medicine prices and transportation expenses. They were able to recall and to present evidence of their recent expenses on medicine, bringing priced medicine boxes or drugstore receipts, and medical reports and prescriptions from hospitalizations and emergency visits as well. In favor of findings of this report, it shall be considered any possible loss of information related with the retrospective period, acts towards decreasing the estimated economic costs during this period. Therefore, the impact of the asthma on the family income can be even greater than that presented here. The presence of an interviewer might have influenced the patient’s answers. However, this was needed as the majority of patients had low educational level and some were illiterate. The interviewer was trained to avoid influencing the answers, and was the same for all patients throughout all the visits (25).
In conclusion, this study conducted among an underprivileged population in a middle-income country showed that, cases of severe asthma constitute a heavy economic burden to families from low socioeconomic strata. Adequate and free care of these patients generate great clinical improvement and major economic benefits to their families, and, as we demonstrated elsewhere, with a great cost-effectiveness ratio (11). The investments in this asthma management program are only a small proportion of the regular public costs of ambulatory and hospital care for the same uncontrolled asthma patients.