Cost of Asthma

In 2023-2024, the expenditure for asthma was an estimated $1.28 billion spent on the treatment and management of asthma (out of $180.4 billion total spending on disease and injury and $98 billion spent on chronic conditions, and $5.77 billion spent on respiratory disease in 2023-2024), making asthma the third most costly respiratory condition (after COPD and upper respiratory conditions).(ref 1)

This is an increase from $1,192 million in 2022-23 and $852 million in 2020-21 (ref 2, 3)

The 1.3 billion spent on asthma represents:(ref 4)

• 0.7% of health system expenditure allocated by disease
• 22% of all respiratory condition expenditure

Asthma expenditure repartition: (ref 4)

• about 20% of asthma expenditure was spent on children under 15 years
• 58% was spent on females , 42% on males, and 0.3% was unattributed to any sex
• spending per case was higher for females vs males ($440 vs $390 per case)
• almost half (43%) of asthma spending was attributed to the PBS ($180 per case), followed by general practitioner services, 16% of asthma spending ($68 per case)

Asthma expenditure in 2023-24 included (ref1):

• $549 million spent on pharmaceuticals
• $210 million spent on GP
• $166 million spent on public hospital admissions
• $146 million spent on public hospital EDs
• $104 million spent on public hospital outpatient services

Asthma spending breakdown (Fig 5, ref 4):

Asthma expenditure was spent as follows: (ref 4)

• 61% ($780.8 million) on Primary healthcare, which is about 2.2 times the primary healthcare proportion average spent for all disease groups: this included 43% spent on PBS benefits, which is 3.6 times higher than the proportion of PBS spending for all diseases groups (12%)
• 33% for Hospital services (1.9 times lower that the 63% hospital proportion average for all disease groups), however the ED proportion was especially large for asthma (11%), 2.2 times higher than the average for all disease groups (5%)
• referred medical services (5.8%) was lower than the average proportion for all disease group (9.0%)

Trends over time (ref 4):

• asthma expenditure has increased from $0.7 billion to $1.3 billion between 2013-14 and 2023-24 (in current prices – unadjusted for inflation)
• after adjusting for inflation, real expenditure on asthma grew $261 million (constant prices) between 2013-14 and 2023-24
• after adjusting for inflation, average health spending on asthma per case remained stable between 2015–16 ($415) and 2023–24 ($420)

Burden of disease summary (Fig 8, ref 1):

Spending on asthma by jurisdictions (ref 1):

• ACT: $25.04 million
• NSW: $402.83 million
• NT: $12.78 million
• QLD: $254.19 million
• SA: $94.56 million
• TAS: $31.84 million
• VIC: $335.08 million
• WA: $126.12 million

Worldwide incidence of asthma readmission is up to 40% (ref 1, intro).

NSW (ref 1,3)

A retrospective longitudinal study looking at 48,217 asthma hospitalisations in children aged 2-17 years reported that over 1 in 5 children hospitalised for asthma in NSW between 2007 and 2022 were readmitted for asthma within a year, costing an average AU$2593 per readmission. (ref 1)

The study included all children born in NSW between 2005 and 2015 who had at least one asthma hospitalisation across NSW between 2007 and 2022.

Findings (ref 1):

• 21.6% of children were readmitted to hospital due to asthma within 12 months
• readmitted children were younger than non-readmitted ones (mean age 3.8 vs 4.37) with 81% of readmitted children being aged 2-4 years (vs 65% of non-readmitted)
• overall incidence rate for the first asthma readmission within the 12 months was 23.8 per 100 person-years (95% CI 22.6 to 25.1)
• the incidence rate of asthma readmission was twice as high in children 2-4 years and went down with age up to the age group (28.7 per 100 person-years for 2-4 yo; 14.7 for 5-9 yo; 11.2 for 10-14 yo) but then increased again in older adolescents (18.0 per 100 person-years in 15-17 yo)
• the readmission incidence rate was highest in the first month following hospitalisation

• readmission incidence rate was higher in the more disadvantaged areas and major cities, implying socioeconomic disparities with higher population density, traffic congestion, and environmental pollution

• First readmission cost on average AU$2593 in direct medical cost per episode,  but increased with age up to 10-14yo: lowest cost in children 2-4 yo (AU$2867 per episode) and highest cost in children 10-14 yo (AU$4392 per episode).
• the medical cost of first asthma readmissions within 12 months was AU$ 15.6million.

Possible reasons:

• Hospital discharge without proper disease management, guideline-discordant asthma care, lack of education including reviewing inhaler technique and adequate counselling during discharge have been demonstrated to influence the risk of asthma readmission within the first few months of index hospitalisation
• Causal factors for higher readmission rate in younger children may include the high incidence of respiratory infections, particularly viral infections, environmental triggers such as environmental tobacco smoke, secondary smoking at home, traffic-related air pollution, moulds at home, dust-mite allergens, food allergens and inhalant allergens are causal risk factors for asthma readmissions among young children.

The same study/data was used to identify risk factors for these asthma readmissions (ref 3).

This second publication reported: (ref 3)

• 22% were readmitted within a year: 18% of these readmitted within 30 days (early readmission) and 82% readmitted after 30 days (late readmission)
• Most readmitted children were aged between 2 and 4 (77% of early readmissions, 81.5% of late readmissions)

Risk factors for early readmissions:(ref 3)

• children’s age 2–4 years (adjusted Relative Risk (adjusted risk ratio 1.71)
• No older siblings (1.26)
• Length of stay ≥ 2 days (1.42)
• Intensive care unit admission (2.27)
• Underlying chronic comorbidities and/or congenital anomalies (1.27)
• Admissions related to allergies or eczema (1.54)

Risk factors for late readmissions:(ref 3)

• Children’s age 2–4 years (1.93) – nearly twice as likely!
• No older siblings (1.09)
• Residence in the most socio‐economically disadvantaged areas (1.16)
• Residence in major cities (1.20)
• Index admission during spring (1.16) or summer (1.10)
• Length of stay ≥ 2 days (1.21)
• Admissions related to allergies or eczema (1.40)

VIC (ref 2)

A smaller study was conducted in VIC across 3 hospitals for 767 children 3-18 years hospitalised for asthma between 2017 and 2018. The study found that 34.3% of children were radmitted within 12 months, 69% of them being aged 3-5 yo.(ref 2)

note: the NSW data is stronger evidence as it is a population-based large study in NSW and included longer follow-up.

In 2022-2023, the expenditure for asthma was an estimated $1,192 million spent on the treatment and management of asthma (out of $172 billion total health expenditure in 2022-2023), making asthma the third most costly respiratory disease after COPD and Upper respiratory conditions.

Asthma expenditure included:
– $378M in hospital expenditure (public ED, admitted and outpatient + private hospital services) with $150M spent on public hospital admissions and $125M spent on public hospital ED
– $742M in primary care (incl. allied health and other services, dental expenditure, GP, and PBS expenditure), making asthma the most costly respiratory disease for primary health care: this includes $186M for GP services and $534M in PBS/medication expenditure, ranking first respiratory disease for both
– $72M in referred medical services, ranking second most costly respiratory disease: $48M was spent on Specialist services.

In 2020-2021, the expenditure for asthma was an estimated $852 million, coming third for respiratory diseases after other respiratory diseases and upper respiratory diseases.
Asthma was the respiratory condition with the highest expenditure in primary care, with $631 million spent in 2020-2021, the fourth respiratory condition for expenditure in hospitals ($180M), and the thrid respiratory condition for expenditure in Referred medical services ($41M).

Expenditure for asthma is also available by age and sex on Figure 9:

In 2020-2021, the expenditure for asthma was an estimated $852 million was spent on the treatment and management of asthma, representing 0.6% of total health system expenditure and 19% of expenditure for all respiratory conditions. Specifically:
– Primary care represented 74% of asthma expenditure, about 2.7 times the average portion of primary care for other conditions, and with PBS expenditure in asthma representing more than half (53%) of asthma expenditure (4.7 times the proportion for other conditions)
– hospital services accounted for 21% of asthma expenditure (3 times lower than other conditions), with ED representing 6.23% of asthma expenditure (1.5 times higher proportion than other conditions)
– referred services accounted for 4.8% of asthma expenditure, with Specialist referrals representing 3.4% of asthma expenditure
Asthma accounted for 2.6% of the total (all-cause) PBS expenditure, 1.4% of total GP expenditure, 0.9% of public hospital ED expenditure, 0.5% of specialist services and 0.5% of public hospital outpatient services

A study conducted between July 2018 and February 2020 estimated that the cost of poorly controlled asthma to the healthcare system was over $AU4,600 per person per year.
Specifically, a study by the Woolcock Institute and George Institute, based on 341 participants 18 years old or older with poorly controlled asthma (ACQ score of at least 1.5) recruited through community pharmacies in NSW, Tasmania and WA, looked at real data from Medicare and PBS to calculate the actual yearly cost of asthma to the health system. The study found $AU386 adjusted monthly healthcare expenditure per participant ($4,632 per year), increasing by:
– $4 for each year increase in age
– $201 for being unemployed
– $35 per one unit change in worsening quality of life
– $171 for being diagnosed with depression and anxiety

In 2019-2020, the expenditure for asthma by area of expenditure (allied health, GP, imaging, pathology, medications private hospital, public hospital, specialist services) can be found by downloading the data table, and opening the tab Table 5.
The total expenditure for asthma was about $900 million, and including:
* $219M for hospitals (ranking fourth among respiratory diseases) – hospital admissions (public and private), ED and outpatient clinics (for public only)
* $639M for primary healthcare (ranking first among respiratory diseases) – includes GP, allied health, pharmaceuticals and dental
* $42M for referred medical services (ranking fourth among respiratory diseases) – includes specialists, medical imaging and pathology

specifically:
* 161.6 million in GP services
* 28.2 million in Specialist services
* 455.0 million in medications (PBS)
* 12.8 million in private hospital services
* 67.4 million in public hospital emergency department
* 84.1 million in public hospital admissions
* 54.8 million in public hospital outpatient services

In 2015-2016, asthma cost the health system an estimated $770 million – 19% of disease expenditure for respiratory conditions and 0.7% of total disease expenditure. This expenditure consisted of:
* $204 million for hospitals (27% of total expenditure on asthma)
* $163 million for non-hospital medical services (21%)
* $383 million for pharmaceuticals (50%)

In 2018-2019, the expenditure for asthma by area of expenditure (allied health, GP, imaging, pathology, medications private hospital, public hospital, specialist services) can be found by downloading the data table, and opening the tab Table 5.
The total expenditure for asthma was about 798.6 million, and includes about:
* 148.4 million in GP services
* 28.5 million in Specialist services
* 350.8 million in medications (PBS)
* 13.3 million in private hospital services
* 66.9 million in public hospital emergency department
* 88.3 million in public hospital admissions
* 66.1 million in public hospital outpatient services

In 2018-2019, the Health System spent an estimated $287 per case due to Asthma, less than other respiratory conditions including upper respiratory conditions and COPD.

Severe refractory and difficult-to-treat asthma is responsible for over 50% of asthma health care costs.

Objective: To explore influences on patients’ purchase and use of asthma preventer medicines and the perceived acceptability of financial incentives via reduced patient co-payments.
Methods: Semi-structured telephone or face-to-face interviews were conducted with adults and carers of children with asthma. Interviews were recorded, transcribed verbatim and coded. Data were analysed using thematic analysis via grounded theory.
Results: Twenty-four adults and 20 carers for children aged 3-17 years with asthma were interviewed. For medicines choice, most participants did not consider themselves the primary decision-maker; cost of medicines was an issue for some, but effectiveness was described as more important. For adherence, cost, side-effects, perceived benefit and patient behaviours were important.
Conclusions: Patient barriers to adherence with asthma preventer medicines including cost are ongoing. Healthcare professionals need to encourage empathic discussion with patients about cost issues. Implications for public health: Asthma patients and carers could benefit from greater involvement and respect within shared decision-making. Healthcare professionals should be aware that cost may be a barrier for patient adherence, and provided with information about the relative costs of guideline-recommended asthma medicines. Patients and healthcare professionals need education around the efficacy of ICS-alone treatment and the rationale behind co-payments, for initiatives around quality use of medicines to succeed.

Background: In Australia, many patients who are initiated on asthma controller inhalers receive combination inhaled corticosteroid/long-acting beta2-agonist (ICS/LABA) despite having asthma of sufficiently low severity that ICS-alone would be equally effective and less costly for the government.
Methods: We conducted a discrete choice experiment (DCE) in a nationally representative sample of adults (n = 792) and parents of children (n = 609) with asthma. Mixed multinomial models were estimated and calibrated to reflect the estimated market shares of ICS-alone, ICS/LABA and no controller. We then simulated the impact of varying patient co-payment on demand and the financial impact on government pharmaceutical expenditure.
Results: Preference for inhaler decreased with increasing costs to the patient or government, increasing chance of a repeat visit to the doctor, and if fewer symptoms were present. Adults preferred high-strength controllers, but parents preferred low-strength inhalers for children (general beneficiaries only). The DCE predicted a higher proportion choosing controller treatment (89%) compared to current levels (57%) at the current co-payment level, with proportionately higher uptake of ICS-alone and a lower average cost per patient [32.73 Australian dollars (AU$) c.f. AU$38.54]. Reducing the co-payment on ICS-alone by 50% would increase its market share to 50%, whilst completely removing the co-payment would only have a small marginal impact on market share, but increased average cost of treatment to the government to AU$41.04 per person.
Conclusions: Patient-directed financial incentives are unlikely to encourage much switching of medicines, and current levels of under-treatment are not explained by patient preferences. Interventions directed at prescribers are more likely to promote better use of asthma medicines.

The survey was completed by n = 792 adults (mean age, 47 years, male 47%, concession 60%) and n = 609 parents of children (5-10 years 51%, male 60%, concession 59%) with asthma. Cost-related underuse was reported by 52.9% adults and 34.3% parents, predominantly decreasing or skipping doses to make medicines last longer. Higher odds of cost-related underuse were observed with younger adults, males, having concerns about medicines, less comfortable talking to prescribers about cost or changing medicines, feeling less engaged with prescribers about medicine decisions, and with poorer asthma control; parents, poor control, and requiring specialist or urgent health care visits. Income and concession card status were not associated with cost-related underuse.
Conclusions: Adults and parents of children with asthma indicate high rates of cost-related underuse of asthma medicines, even in the context of national medicines subsidies. Urgent targeting of interventions to promote discussion of medicines and costs between doctor and patients, particularly young adult males, is needed.

This qualitative study (interviewing 15 GPs) found that GPs favoured combination ICS-LABA inhalers over ICS alone because they perceived ICS-LABA combinations to have greater effectiveness and promote patient adherence. This aligned with GPs’ views that their primary responsibility was patient care rather than generating cost savings for government. However, it emerged that GPs rarely discussed medicine costs with patients, had low knowledge of medicine costs to patients and the health system and reported that patients rarely volunteered cost concerns. GPs believed that lower patient copayments for asthma preventer medicines would have little effect on their prescribing practices. What are the implications for practitioners?: This study suggests that, when considering asthma treatment choices, GPs should empathically explore with the patient whether cost-related medication underuse is an issue, and should be aware of the option of lower out-of-pocket costs with guideline-recommended ICS alone treatment. Policy makers must be aware that differential patient copayments for ICS preventer medicines are unlikely to act as an incentive for GPs to preferentially prescribe ICS alone preventers, unless the position of these preventers in guidelines and evidence for their clinical effectiveness are also reiterated.

Note: a bit dated and higher level of evidence would be preferred, if available.

In 2015-2016, there were 31,245 Potentially Preventable Hospitalisations (PPH) for asthma, costing 89,365,433$ or an average 2,860$ per PPH.

Each ED presentation for asthma costs $443 on average, an uncomplicated hospital admission costs approximately $2,591 (approximately 1.5 hospital days) and a complicated admission costs $5,393 (approximately three hospital days).

– Adults with asthma, emphysema and chronic obstructive pulmonary disease (COPD) had 109% higher household out-of-pocket healthcare expenditure than did those with no health condition
– People with a chronic condition were also more likely to forego care because of cost
– People with asthma, emphysema and chronic obstructive pulmonary disease had 6.16 times higher odds of skipping healthcare than people with no health condition.

Prescription volume and costs per medications 2017-2018 FY.
Medications ranked by highest volume prescriptions, highest cost to government etc.

The recent ABS ‘selected living costs index’ indicates that the cost of living increases across the vulnerable population group of ‘pensioner and beneficiary households’ and ‘age pensioner’ is being driven primarily by ‘Health related costs’ which are pharmaceutical products and medical services.

Design and setting: Cross-sectional study of records of all prescriptions for ICS dispensed to general and concessional beneficiaries aged 15 years or over in the period January 2003 to December 2006. Data were obtained from the Pharmaceutical Benefits Scheme, which subsidises medication costs for all Australians.
Results: ICS prescriptions were dispensed to over 1.6 million people during the study period. Concession card holders were dispensed ICS prescriptions at a higher rate than general beneficiaries, both overall (43.7 v 9.1 ICS prescriptions per 100 person-years) and in all population subgroups. After adjusting for age, sex, remoteness category and socioeconomic status, people holding a concession card were dispensed over 2.5 times the number of ICS prescriptions (alone or in combination with a long-acting β2-agonist) compared with general beneficiaries. Similar patterns were seen after adjusting for differences between the two groups in the prevalence of obstructive lung disease.
Conclusions: As the patient copayment for general beneficiaries is over six times higher than for concession card holders, our findings imply that cost is a barrier to the purchase of ICS prescriptions for obstructive lung disease, independent of socioeconomic status.

Note: this is quite dated!

The estimated cost of asthma in Australia in 2015 was $28 billion. This equates to $11,740 per person with asthma and includes;
• $24.7 billion attributed to disability and premature death,
• $1.2 billion on healthcare costs (including medication, hospital and out-of-hospital costs,
• $1.1 billion in loss of productivity,
• $72.9 million in loss of wages for carers, and
• $289.4 million in income support for carers of people with asthma