Counting up the economic burden of asthma is difficult: It is a disease that is frequently undiagnosed and untreated, yet it is chronic and can affect sufferers throughout their whole lives. Management is often not optimal even in some of the best-resourced health systems. Asthma is also increasing most rapidly in low- and middle- income countries, many of which do not systematically collect data about asthma rates, outcomes or costs. The high cost of essential asthma medicines has been mentioned frequently in this report. However, treating asthma entails vastly more than the cost of medicines. It amounts to billions of dollars in both direct and indirect costs.

Costs to patients, families, employers, communities

When people with asthma experience the symptoms of airway obstruction, such as shortness of breath, wheezing and coughing, they feel unwell and unable to carry out their usual activities, whether at home, at work or in their communities.

If the asthma becomes abruptly severe, such as in an asthma attack, the person will need acute medical treatment, possibly admission to the hospital and sometimes even intensive care. Occasionally people die.

For all of the people described above – from the person who is not well enough to go to work to the one who ends up in hospital, asthma is incurring both direct and indirect costs. The indirect costs of their symptoms may stem from lost time at work or school, resulting in less income and diminished skills and opportunities. Absent workers, students and citizens also affect the success of the workplaces, businesses, schools and communities counting on their participation. For the families of children with asthma, the children’s illness may require them to miss work and other activities, widening the circle of cost. In addition, the regular direct costs of asthma can be considerable, including not only doctor’s fees, medicines, inhalers and hospital charges, but also the cost of transportation to and from health care facilities, ambulances, parking and other related expenses.

Costs to health systems

The costs incurred by health systems also cover a broad spectrum: from the human resources, materials and facilities required to train health professionals about asthma to the time and resources required to treat people with asthma both acutely and long term. Direct costs include preventer and reliever medicines, spacers and other devices; acute ambulatory, emergency and inpatient hospital care; as well as asthma management planning and patient education.

Costs go up when the person with asthma has other respiratory tract symptoms that can cause more asthma-related emergency visits. Although diagnostic tests are not usually needed, in cases of high severity, complications or diagnostic uncertainty, chest radiographs and blood tests may be indicated. Total hospital costs may also be higher in women, older patients, those with greater severity of asthma or significant co-morbidities, and those that require use of the intensive care unit and prolonged hospital stay.

Who pays the bill?

The level to which all of these costs are borne directly by the patients with asthma and/or their families, taxpayers or health insurance companies depends on the national or local approach to funding health care.

What are the actual costs of asthma?

The economic costs of asthma are among the highest for non-communicable diseases (NCDs) because of the substantial health service use, in many cases over a lifetime. The largest direct costs are for inpatient care and pharmaceuticals. The principal indirect costs stem from loss of productivity due to missed work and school.

While the exact cost of asthma worldwide cannot be determined, a 2009 systematic review found 8 national studies which reported total cost, illustrating its substantial impact. Of those with a study duration of one year, the costs reported in 2008 US dollars were all very high, but also varied widely: Canada $654 million; Germany $2,740 million and $4,430 million; Singapore $49.36 million; Switzerland $1,413 million; and USA $7,189 million, $8,256 million and $2,300 million. In 2004, new cases of occupational asthma alone in the United Kingdom cost GB£70– 100 million.

As the proportion of people with asthma in the population rises, all of these costs will become greater. Clearly more population-based research on the economic burden of asthma is needed, especially in low- and middle-income countries where the prevalence of asthma is increasing.

What can be done to reduce costs?

Most asthma can be controlled, such that symptoms and use of reliever medicines become minimal. Asthma symptoms and acute attacks can be reduced by preventive measures: treatment with preventer medicines, such as inhaled corticosteroids, and other non-drug measures, including asthma education and management plans. However studies have repeatedly shown that many asthmatics have poor asthma control, and that this is more costly (directly and indirectly) than good asthma control. In other words, inadequate treatment leads to poor control which leads to higher costs for the patients, communities, health services and countries. Thus, one key way to reduce costs is to achieve good asthma control in more people in the population.

How can adequate preventer treatment be achieved? A person with symptoms of asthma needs to be able to reach a health professional who has the skills to assess the pattern and severity of symptoms and the adequacy of asthma control. The appropriate medicine needs to be prescribed, and, along with that, the patient needs to be educated about how to use the medicine and manage asthma symptoms. The prescribed asthma medicines need to be available and affordable for the patient. Regular follow-up is necessary to assess control, check that the patient is using the medicines correctly, and adjust treatment where necessary.

As straightforward as these simple steps may seem, they are currently unachievable for a large proportion of the people with asthma in the world – and at every stage, money, time and resources are leaking away, and millions of people are suffering unnecessarily.

In sum: Poor treatment costs more than good treatment

The costs of asthma are enormous at country and global levels and will increase as the global prevalence of asthma rises. Cost containment will result from achieving better asthma control in symptomatic people, and this requires affordable medicines and access to education and treatment. Future prevalence surveys should be accompanied by estimates of the costs of asthma, especially in low- and middle-income countries.

-Innes Asher, Karen Bissell, Eamon Ellwood

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