Special Article
An Economic Evaluation of Asthma in the United States
N Engl J Med 1992; 326:862-866March 26, 1992
- Abstract
- Abstract
Background.
Asthma is a common chronic illness. Recently, increases in morbidity and mortality due to this disease have been reported. We studied the distribution of health care resources used for asthma in order to lay the groundwork for further policy decisions aimed at reducing the economic burden of this disorder.
Methods.
Estimates of direct medical expenditures and indirect costs (in 1985 dollars) were derived from data available from the National Center for Health Statistics. These cost estimates were projected to 1990 dollars.
Results.
The cost of illness related to asthma in 1990 was estimated to be $6.2 billion. Inpatient hospital services represented the largest single direct medical expenditure for this chronic condition, approaching $1.6 billion. The value of reduced productivity due to loss of school days represented the largest single indirect cost, approaching $1 billion in 1990. Although asthma is often considered to be a mild chronic illness treatable with ambulatory care, we found that 43 percent of its economic impact was associated with emergency room use, hospitalization, and death. Nearly two thirds of the visits for ambulatory care were to physicians in three primary care specialties — pediatrics, family medicine or general practice, and internal medicine.
Conclusions.
Potential reductions in the costs related to asthma in the United States may be identified through a closer examination of the effectiveness of care associated with each category of cost. Future health policy efforts to improve the effectiveness of primary care interventions for asthma in the ambulatory setting may reduce the costs of this common illness. (N Engl J Med 1992; 326:862–6.)
Media in This Article
Table 1
Costs of Asthma in 1985 among Selected Age Groups.Table 2
Distribution of Asthma-Related Visits to Physicians' Offices, According to Specialty.*Article Activity
- Article
ASTHMA is a common illness estimated to affect between 9 and 12 million persons in the United States.1 Most patients with asthma have mild symptoms, easily controlled with outpatient care. Recent increases in morbidity and mortality associated with this condition,2 3 4 however, suggest the need to reexamine each aspect of control and prevention. One important component of the morbidity caused by asthma in the United States is its economic impact. A study of the costs of an illness can provide insight into how health care resources to address a condition are distributed and can lay the groundwork for further policy decisions that can direct financial resources toward this disease more effectively.
The most recent comprehensive study of the economic impact of asthma in the United States was conducted in 1972.5 The current study estimates the costs related to asthma in the U.S. population, compares various important components of direct and indirect costs, and identifies categories of expenditure in which improvement in the effectiveness of dollars spent may lead to substantial reductions in cost.
Methods
Estimates of Use, Morbidity, and Mortality
Information on the use of health care resources, morbidity, and mortality was gathered from the population-based data systems of the National Center for Health Statistics (NCHS). Except for the vital-statistics system, which contains information on the whole U.S. population, the NCHS collects data on samples of the population. Whenever possible, data for a five-year period — 1983 through 1987 — have been aggregated to expand the sample. Asthma was defined as in code 493 of the International Classification of Diseases (ninth revision). Costs were evaluated separately for children (persons under 18 years of age) and adults (persons 18 years of age or older). These age categories were chosen to facilitate the analysis of costs — i.e., the indirect costs of school days lost as compared with work days lost.
The National Hospital Discharge Survey (NHDS), an annual survey, studies selected nonmilitary hospitals with six or more beds and average stays of less than 30 days.6 From a sample of 410 hospitals, approximately 200,000 discharges were studied annually. Hospitalizations for asthma were those in which asthma was the first diagnosis listed at discharge.
The 1985 National Ambulatory Medical Care Survey (NAMCS), conducted from March 1985 through February 1986, studied a sample of nonfederal, office-based physicians, excluding anesthesiologists, pathologists, and radiologists.7 Participating physicians recorded data on the visits of approximately 30 patients during one week, for a total of 71,594 visits. Visits for asthma were those in which asthma was the first diagnosis listed. The information obtained from the NAMCS included whether the visit was a first or a repeat visit, the physician's specialty, and the number and type of medications prescribed.
The National Health Interview Survey (NHIS), an annual homeinterview survey of the noninstitutionalized civilian population, studies 40,000 to 50,000 households per year.8 Information on persons over 19 years of age was reported by the respondents, and proxy respondents were used to report on behalf of persons who were under 19 years of age, absent, or unable to report on their own. People with asthma were defined as persons who reported having asthma during the past 12 months. The information obtained in the NHIS included use of medical care (doctor visits, clinic visits, visits to the emergency room, and hospitalizations) and time lost from either work (defined to include both outside work and housekeeping) or school.
Persons with asthma as their underlying cause of death during 1985 were included in this study.9
The National Medical Care Utilization and Expenditure Survey (NMCUES) was conducted periodically over a 14-month period in 1980 and 1981. It was designed to collect information on health care use and expenditures in the United States.10 Data from the NMCUES were used to estimate the charges for selected types of health care resources.
Cost Estimates
The costs of illness related to asthma include direct expenditures for medical care and indirect costs.11 In this study the direct expenditures for medical care included charges for the following: inpatient hospitalization, hospital outpatient services, emergency room services, physicians' services (both inpatient care and office visits), and medications. Indirect costs arising from morbidity and mortality included the value of time lost from school and work (including both outside employment and housekeeping).
Expenditures for Medical Care
Hospital inpatient care. Expenditures were estimated by multiplying the number of days of hospitalization reported in the NHDS by the adjusted expenses per inpatient day spent in nonfederal, short-term general and other special hospitals, as reported by the American Hospital Association in 1985.12
Emergency room services. The NHIS asked whether a person visited an emergency room for asthma (without an overnight hospitalization). It was assumed that all NHDS hospitalizations for asthma required an initial visit to the emergency room before admission. Therefore, the total number of asthma visits to the emergency room was calculated as the sum of NHDS hospitalizations and emergency room visits as estimated in the NHIS. Emergency room expenditures were estimated by multiplying the total number of visits to the emergency room for asthma by the average charge per visit, obtained from the NMCUES data adjusted to 1985 dollars.
Hospital outpatient care. Total expenditures for outpatient visits to the hospital were estimated by multiplying the number of outpatient visits for asthma by the average charge for such a visit, obtained from the NMCUES data adjusted to 1985 dollars.
Inpatient services of physicians. It was assumed that there was one visit by a physician per NHDS hospitalization day. Expenditures for the inpatient services of physicians were calculated by multiplying the number of visits by the charge per initial or follow-up hospital visit by a physician in 1985 in the national survey of physicians made by the American Medical Association (AMA).13
Visits to physicians' offices. To estimate expenditures for care provided in physicians' offices, the number of visits for asthma in the NAMCS, according to the physician's specialty, was multiplied by the mean fee in 1985 for an office visit with new and established patients, according to physician specialty, from the AMA survey.13
Medications. No national estimates of the costs of antiasthma medications were available. Data on antiasthma medication were derived from NAMCS records. The average annual costs of medication were estimated by multiplying the average wholesale prescription price for each of four classes of drugs (beta-adrenergic agonists, theophylline preparations, corticosteroids, and prophylactic agents, mainly cromolyn sodium) times an average annual dose. The wholesale prescription prices were derived by averaging the wholesale costs for the medications in each class, as obtained from the 1989 Drug Topics Red Book , 14 after deflating the costs to 1985 dollars with the consumer price index for prescription drugs.15 The average annual dose was calculated by multiplying the average daily dose by an average duration of use. There was no reliable information on the duration of use. Some patients with asthma would be expected to require short-term therapy, and others long-term therapy. Therefore, an average duration of use of six months was assumed for the one-year period (1985). The manufacturer's average recommended daily dose16 was adjusted for age in children and adults according to the age distribution of the NAMCS data. Small samples prohibit the reporting of age- or medication-specific estimates. Estimates of the extent of use of immunotherapy and over-the-counter prescriptions to treat asthma were not available.
Indirect Costs
Loss of school days. The NCHS data do not provide the sex of the primary caretakers of children with asthma. Therefore, the caretakers were assumed to be the mothers. This produced a conservative cost estimate, because if the primary caretakers were men, they would have accrued substantially higher indirect costs because of their higher average annual earnings. The number of school days lost, as reported by the NHIS, was used to represent the number of days lost from work for women with earnings (considered to be the case for 74 percent of women 20 to 49 years of age)17 or from housekeeping for all other mothers. Costs for 1985 were calculated as the value of the time lost from outside employment (the number of school days lost converted to years and multiplied by the average annual earnings) and housekeeping (the number of school days lost converted to years and multiplied by the imputed value of housework).17
Loss of work. Costs for asthma-related loss of work were calculated for persons currently employed — i.e., with "outside employment" — and for women keeping house. In the case of outside employment, the costs were calculated as the age- and sex-specific product of the number of asthma-related years of work lost times the average annual earnings.17 In the case of housekeeping, it was assumed that the number of work days lost equaled the number of asthma-related days spent in bed ("bed-disability days") plus half the number of asthma-related days of restricted activity in excess of the number of bed-disability days. The number of days lost was converted to years and multiplied by the estimated annual value of housekeeping services.17
Mortality losses. The time lost from outside employment and housekeeping as a result of premature death was calculated from the time of death predicted on the basis of the person's life expectancy. Mortality costs were calculated by multiplying the number of deaths by the age- and sex-specific current values of estimated future lifetime earnings, discounted by 4 percent.18 Discounting was a means of accounting for the reduced value of future dollars as compared with current dollars.19
Projecting Economic Costs in 1990 Dollars
The best available data for asthma with regard to the use of health care resources, morbidity, and mortality were the data for 1985. However, we projected costs to 1990 dollars to provide more current estimates.
Expenditures for personal health increased by 9.2 percent each year between 1985 and 1988, with the increase varying according to the type of expenditure.20 Expenditures for asthma in 1990 were estimated by assuming that the annual rates of increase observed for personal health care services between 1985 and 1988 continued through 1990 and by applying the total change from 1985 through 1990 for the appropriate type of medical care to the expenditures for medical care for asthma in 1985.
From 1985 through 1988, median weekly earnings increased at an average annual rate of 3.4 percent for men and 4.4 percent for women.21 Indirect costs related to asthma for 1990 were estimated by assuming that from 1988 through 1990 earnings grew at the same average rate per year as from 1985 through 1988 and by applying the appropriate rates of growth for men and women to the estimated indirect costs for 1985.
Accuracy and Reliability of the Data
Previous studies have reported on the appropriateness of the design and estimation procedures used to obtain the NCHS data.10 , 22 23 24 25 Data on costs and prices were obtained from national estimates that are believed to be the most reliable and that are the most commonly used in this type of economic analysis. Some of the published data, however, provide only point estimates and include no method of determining the standard error. Without measures of standard error for the cost estimates, it is impossible to assess error quantitatively. Therefore, as is the convention in this type of economic analysis, each assumption is explicitly stated to provide the reader with a means of evaluating the quality of the estimates.
Results
Direct Medical Expenditures for Asthma
Hospital-based Expenditures
Inpatient care. During the study period, there were on average 463,500 hospitalizations annually for asthma, 34.6 percent of which involved persons under 18 years old. The length of stay for all patients averaged 5.0 days, for an estimated total of 2.3 million days. Hospital expenditures were estimated at $1 billion. Seventy-six percent of this total was for persons 18 years old or older (Table 1Table 1
Costs of Asthma in 1985 among Selected Age Groups.).Emergency room services. An estimated 1.81 million people required emergency room services for asthma, and 47.8 percent of the visits involved children under 18 years old. These visits cost $200.3 million (Table 1). Nearly half the expenditures for emergency room services for asthma were attributed to the delivery of care for persons under 18 years old.
Outpatient care. There were an estimated 1.5 million hospital outpatient visits to treat asthma. The expenditures for these visits totaled $129.2 million. The majority (71.3 percent) involved persons 18 years old or older.
Expenditures lor Physicians' Services
Expenditures for physicians' services were studied in both the inpatient and the outpatient settings. Inpatient services were estimated to cost $81.3 million, and 75.3 percent were associated with the care of persons 18 years old or older.
There were an estimated 6.5 million visits to physicians' offices for ambulatory care for asthma. Such care was most frequently delivered by physicians from the primary care specialties of family medicine or general practice, pediatrics, and internal medicine (27.4 percent, 19.3 percent, and 18.1 percent, respectively) (Table 2Table 2
Distribution of Asthma-Related Visits to Physicians' Offices, According to Specialty.*). Allergists and pulmonary physicians delivered 30.4 percent of the outpatient care for asthma; 84.3 percent of these visits were to allergists. Older persons were more likely to visit allergists or pulmonary physicians than younger persons (36.1 percent vs. 19.9 percent of visits, respectively). Expenditures for office visits to physicians amounted to $193.3 million. One third of these expenditures were for persons under 18 years of age.Expenditures for Medications
Drug therapy was the principal treatment for asthma. Theophylline preparations were the most frequently prescribed, with more than 3.3 million prescriptions. There were 2.99 million and 1.15 million prescriptions for beta-adrenergic agonists and corticosteroid preparations, respectively. Cromolyn sodium was used infrequently. The total estimated cost of these medications was $712.7 million.
Indirect Costs of Asthma
School and Work Days Lost
Among children 5 to 17 years old, asthma accounted for a loss of more than 10 million school days, at a cost of $726.1 million in caretakers' time lost from work, defined to include both outside employment and housekeeping. Asthma accounted for a loss of nearly 3 million work days among persons 18 years old or older. In the case of outside employment, women were twice as likely as men to miss work because of asthma. Among adults 18 years old or older, asthma-related loss of work from outside employment amounted to $284.7 million. The loss among women keeping house constituted an additional $406 million of indirect costs related to asthma.
Income Lost Because of Premature Death
Death from asthma is infrequent, with 3880 patients having died from the disease in the United States in 1985. These deaths accounted for indirect costs of $676.2 million.
Total Economic Impact of Asthma
The total estimated cost of asthma in the United States in 1985 was nearly $4.5 billion (Table 1). Direct medical expenditures approached $2.4 billion, or 53 percent of the total. The largest category of direct medical expenditure was that of inpatient hospitalizations ($1 billion), with prescriptions for medication the second largest category ($713 million). Physicians' charges accounted for $275 million, or nearly 12 percent of the direct expenditures.
In 1985, the indirect costs for asthma were estimated to have exceeded $2 billion. Two thirds of these costs were associated with morbidity, and of these, nearly 35 percent were associated with the care of children who were kept home from school because of asthma. Premature death accounted for almost one third (32.3 percent) of the indirect costs and 15.1 percent of the total costs of asthma.
We projected these 1985 estimates to 1990 dollars (Table 3Table 3
Costs of Athma in 1990.*). The projected increases in direct medical expenditures and indirect costs were 53.1 percent and 22.7 percent, respectively. The total estimated costs of asthma in 1990 were $6.2 billion.Discussion
A principal objective of our health care system is to reduce morbidity and premature mortality. A study of the cost of a given illness can provide insights into the pattern of spending for that disease and the categories of spending that might be modified to reduce expenditures. In the case of asthma, inpatient services make up the largest single component of direct expenditures.
Another way to view the economic effect of asthma is to compare it with that of other diseases. In such a comparison, it is important to note that no single illness accounts for a large proportion of the total costs attributable to illness in the United States. Only when conditions are grouped together do their costs become sizable. For example, on the basis of other cost-of-illness studies with similar methods, all cancers accounted for only 11 percent of the total estimated U.S. costs of illness in 1985.26 In contrast, on the basis of information from 1980 on the costs of other illnesses, adjusted to 1985 dollars to reflect inflation, it is estimated that asthma accounted for nearly 1 percent of all U.S. health care costs. It is more striking, perhaps, that in 1985 asthma accounted for 8 percent of health expenditures and 10 percent of indirect costs for all diseases of the respiratory system.11 Health care expenditures for asthma were the equivalent of two thirds of the dollars spent for all cancers of the lung, bronchus, and trachea.27
When it is well controlled, asthma rarely leads to hospitalization. Studies have associated high rates of hospitalization and mortality due to asthma with poverty.28 29 300 During the past decade, the percentage of hospitalizations for asthma increased among children who either receive Medicaid or have no source of payment.4 Studies are beginning to associate Medicaid as the principal source of third-party payments with high rates of hospitalization for asthma.28 , 30 Other studies have demonstrated that improvements in access to ambulatory care and in the quality of such care can lead to fewer hospitalizations among both medically indigent and nonindigent persons with asthma.31 , 32 Thus, changes in public health policy that would improve ambulatory primary care in these respects for persons with asthma living in poverty might reduce rates of hospitalization and produce a savings in public expenditures for asthma care.
Expenditures for asthma medications approach $1 billion annually. Recent recommendations have suggested a change in drug therapy for asthma, away from theophylline and toward more expensive metered-dose inhalers containing corticosteroids and cromolyn.33 These recommendations are expected to cause a substantial increase in the cost of medications for persons with asthma, but ultimately to reduce overall costs by decreasing morbidity due to asthma. This expectation is entirely untested. It is also uncertain how reimbursement systems, particularly those such as Medicaid that are designed for the poor, will accommodate any increases in the costs of asthma medications.
Any development in health policy affecting asthma care will need to focus on the providers of care. Nearly two thirds of ambulatory care visits for asthma involve physicians from the three primary care specialties of family medicine or general practice, pediatrics, and internal medicine. Any policy directed at improving care and reducing costs for persons with asthma must enlist the participation of these providers and consider their models of care, rather than focusing only on "asthma specialists."
There are, of course, limitations to this type of study, and caution must be exercised in interpreting the data. It can be argued that estimates of the costs per unit of service or of the value of the resources actually used in the treatment of asthma would be more accurate. No such data are available, however. Calculating the costs of an illness requires that information be available on all major direct expenditures and indirect costs. It was impossible to estimate some expenditures: those for diagnostic services (blood tests, diagnostic radiology, pulmonary-function testing, and the like), costs of education about asthma care, costs of equipment (such as peak-flow meters and nebulizer equipment for the home), costs of lost output at work due to a patient's reduced efficiency during an exacerbation of asthma, costs of travel to obtain health care, and costs of certain medications (immunotherapy and over-the-counter drugs). Whenever a choice was necessary, we selected the more conservative alternative in order to produce a lower estimate (e.g., the earnings of women rather than men were used to calculate indirect costs for school days lost). Finally, it has been reported that morbidity and mortality from asthma in the United States are increasing.2 3 4 Since much of the information used in this analysis was obtained from periodic surveys, it was impossible to estimate directly the increases in costs that may be expected with an associated increase in morbidity and mortality.
Although this study emphasized the total annual costs of illness and the major types of economic effect in the U.S. population, it did little to elucidate the costs associated with asthma for an individual patient. Few studies have examined this question. Yet it seems clear that the costs for a person with asthma can amount to a substantial portion of a family's gross annual household income.34
This study demonstrates the potential of effective intervention programs to reduce the costs of asthma greatly. For this purpose, the overall costs (as a percentage of the U.S. total) are not as important as their relative distribution (among categories such as inpatient and outpatient costs). The largest single category of direct costs was inpatient hospital care. Studies have suggested that relatively inexpensive, primary care-based intervention strategies, such as health education, regular follow-up, and preplanned home care, can reduce the number of hospitalizations.31 , 32 , 35
The potential savings from the shift from more expensive hospital care to less expensive ambulatory care is readily apparent from these analyses. Therefore, if the costs of asthma are to be reduced, any future efforts to direct health policy toward improvement in asthma care must emphasize improving the effectiveness of primary care for asthma in the ambulatory setting.
Supported in part by an epidemiology training grant from the Public Health Service and by a grant from the Asthma and Allergy Foundation of America (both grants to Dr. Weiss).
We are indebted to Ms. Ildy Shannon and Ms. Rachel Kramer for their assistance in data processing.
Source Information
From the Departments of Health Care Sciences and Medicine, George Washington University Medical Center, and the Center for Health Policy Research, George Washington University, Washington, D.C. (K.B.W.); the Division of Allergy, Immunology, and Transplantation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Md. (P.J.G.); and the Office of Analysis and Epidemiology, National Center for Health Statistics, Centers for Disease Control, Hyattsville, Md. (T.A.H.). Address reprint requests to Dr. Weiss at the Department of Health Care Sciences, Rm. 2B–401, 2150 Pennsylvania Ave., NW, Washington, DC 20037.
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