Medication use and asthma control

Analysis of PBS data shows that in 2022-2023:

Preventer use: amongst people aged 50 and under who were dispensed at least one preventer in 12 months (note: people over 50 may have used a preventer for COPD):
– 31% were considered to have good adherence to their preventer (dispensed a preventer 3 or more times in a year)
– adherence increased from 24% in 15-24 yo to 39% in 45-50 yo
– adherence was slightly higher for males (33%) vs females (29%)
The proportion of people with good adherence has slightly dropped since 2017-2018 (33%), apart from spikes in 2019-2020 and 2020-2021 related to bushfires and COVID pandemic.

Biologic use: amongst people aged 50 and under who were dispensed biologics 3 or more times in the year:
– 70% were considered to have good adherence (dispensed a biologic 6 or more times in the year)
– good adherence was more common in females (71%) vs males (67%)
– good adherence was highest in people 45-50 and lowest in people 25-34 years of age.
The proportion of people with good adherence to biologics has remained stable since 2018-2019 (72%) overall, with a small downward trend for people aged 34 and under.
Between 2018-2019 and 2022-2023, the number of people dispensed at least once biologic in the year has more than tripled, from 810 to 2,900 people.

Analysis of PBS data shows that in 2022-2023, 27% of people aged 40 and under (and dispensed at least one reliever during the year) were considered to have poor asthma control based on their use of reliver medication (dispensed reliever medicine 3 or more times in a year) – progress compared to 29% in 2017-2018. It was:
– 31% in people aged 35-40, higher than for all other age groups
– 29% in males vs 26% in females
Rates have remained similar since 2017-2018 apart from spikes in 2019-2020 and 2020-2021 related to bushfires and COVID-19 pandemic.

Note: since previous reporting by AIHW, the scope of reliever medication has expanded to include SABA and also budesonide-formoterol 50-200mcg, resulting in data changes across all years. Budesonide-formoterol can also be used as a preventer.

Analysis of PBS data indicates that:

• 33% of people 50 and under being dispensed a preventer were dispensed at least 3 preventers within 12 months (overuse) in 2021-2022, compared to 36% in 2020-2021, 35% in 2019-2020, 34% in 2018-2019 and 34% in 2017-2018, and has therefore remained quite stable since 2017-2018 despite a spike in 2020-2021 that may be related to COVID-19 panic buying and bushfires in 2019-2020.
• by age groups, the proportion of reliever overuse (3 or more reliever dispensed within a year) in 2021-2022 was: 29.3% in 0-14 yo; 25.3% in 15-24 yo; 30.5% in 25-34 yo, 35.4% in 35-44 yo and 41.0% in 45-50 yo

This indicates that in 2021-2022, at least 2 in 3 people 50 and under using a preventer did not use it regularly.

Fig.12 Proportion of people aged 50 and under dispensed at least one preventer medicine, who were dispensed preventer medicines 3 or more times within 12 months, by age and sex, 2017–2018 to 2021–2022

Analysis of PBS data indicates that:

• 18% of people 40 and under being dispensed a reliever were dispensed at least 3 relievers within 12 months (overuse) in 2021-2022, compared to 19% in 2020-2021, 18% in 2019-2020, 16% in 2018-2019 and 17% in 2017-2018, and has therefore remained quite stable since 2017-2018 despite a spike in 2020-2021 that may be related to COVID-19 panic buying and bushfires in 2019-2020.
• by age groups, the proportion of reliever overuse (3 or more reliever dispensed within a year) in 2021-2022 was: 10.1% in 0-14 yo; 18.3% in 15-24 yo; 22.3% in 25-34 yo and 26.3% in 35-40 yo

Fig.11:Proportion of people aged 40 and under dispensed at least one reliever, who were dispensed relievers 3 or more times within 12 months, by age and sex, 2017–18 to 2021–22

Letter to the Editor, emphasising latest data/findings on childhood asthma in Australia including:
Facts:
– High prevalence (8.5% for children 0-14)
– Leading cause of burden of disease
– Hospital admissions have decreased in the last decade
– About 1 in 10 children dispensed SABA (e.g. Ventolin) through the PBS (as opposed as over the counter) have poor asthma control
– Only one in three (29%) children that have been dispensed a preventer used it regularly
– Overreliance on SABAs (reliever) and underuse of ICS are an enduring problem in childhood asthma, as these indicators have not improved in the last 5 years
– 1 in 3 hospitalised children is readmitted within 12 months for asthma (compared to 1 in 5 a decade ago) — Note: this is from a study looking at children admitted in 2017-18
– only 16.2% of children admitted to the hospital due to asthma were prescribed ICS before admission, and of those who were not on a preventer at the time of admission only 12.2% were commenced during the admission
– only 25.6% of children admitted to the hospital with asthma received asthma education and only one‐third of children had an assessment of their inhaler technique during their admission
– several studies from across Australia highlight guideline‐ discordant care across many settings (including pediatricians), which is a known risk factor for hospital readmission

Barriers:
A lack of standardized management and asthma action plans, inadequate systems to allow for timely follow‐up with GPs, inadequate asthma education for parents/carers, and lack of integrated asthma care between GPs and hospitals7 are some of the barriers to optimal asthma management in Australian children.

What is needed:
Multidimensional interventions have been shown to improve asthma control and reduce hospitalization, including asthma self‐management education, home environmental assessment regarding potential asthma triggers and supporting families to deliver asthma care at home, care coordination between primary and tertiary care, and school involvement to support the administration of asthma medications.

According to the National Health Survey 2022, amongst people with asthma in 2022:
– Just under half (48.7%) of children used asthma medication in the prior 2 weeks, compared to more than 3 in 5 (63.5%) of adults
– 1 in 3 (33.9%) people with asthma used daily medication in the prior 2 weeks
– 2 in 5 (39.1%) did not take medication in the prior two weeks

In 2018-2019, among Aboriginal and Torres Strait Islander people with asthma that had symptoms in the last 12 months:
– 31.6% had an Asthma Action Plan
– 56.1% had used medications in the last 2 weeks

According to the National Health Survey for the 2020-2021 financial year:
– One in three people with asthma (34.9%) used asthma-related medication daily
– Just under half (48.8%) of children under 18 years of age used asthma-related medication in the two weeks prior to the survey
– More than three in five (63.2%) people aged 18 years and over used asthma-related medication in two weeks prior to the survey
– One in three (34.9%) people of all ages used medication to help manage symptoms daily and two in five (39.8%) did not take medication in the two weeks prior to survey.

Note: NHS 2020-21 should not be compared to other years as it was conducted differently (online) due to the Covid pandemic.

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.

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

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!

A survey of 412 people from Oct 2017 to Oct 2018, who bought a SABA inhaler over the counter from a retail pharmacy found that 289 (70%) were overusers, as defined by inhaler use more than twice per week in the past four weeks.

Other issues of concern from the snapshot of asthma inhaler purchasers in NSW community pharmacies in 2017-2018 include the finding that 74% of SABA inhaler users reporting not using a preventer daily.

Self-reported GP visits in 2014-15, or other actions taken.

note: data is percentage (%)

Note: table 7 also contains information on:

• consultation with a specialist or other HCP
• asthma action plan
• time away from school, study or work
• hospital and ED visits
• interference with daily activities
• medication use by medications

Australian evidence shows that asthma preventer medicines are under-used. Only 17% of those dispensed ICS-containing medication fill prescriptions at a frequency consistent with daily use.

Experience of asthma in the Australian health system from first symptoms, diagnosis, treatment and future expectations, a qualitative study 2019:

Mixed method study of 100 people with asthma
Most participants had poorly controlled asthma (74%) (score of between 5 and 19)
Flare ups:
– Frequent flare-ups (n=36, 36.00%): having a flare-up or asthma attacks once a month or more frequently,
– Occasional flare-ups (n=41, 41.00%): those that had a flare-up once a month to once every three months,
– Infrequent flare-ups (n=23, 23.00%): those that had a flare-up once or twice a year,

Report includes sections on: symptoms and diagnosis, decision-making, treatment and health service provision, communication and information, care and support, quality of life and experience in the health system, and expectations.

Refer to section 5 for information on treatment and medications.

A 2012 survey of nearly 2,700 Australians aged 16 years and older with current asthma found:
– Asthma was not well-controlled in 45% of people with current asthma. 34% of these people did not use any preventer, and 23% used it less than 5 days/week.
– Nearly 40% only used a blue reliever puffer, treating their symptoms but not the cause. 1 in 4 of these people needed urgent treatment for their condition in the previous year.
– Only half (50.5%) of the participants saw their general practitioner for a non-urgent asthma review during the previous year
– 29% of participants needed urgent health care (GP or emergency department) for their asthma during the previous year
– preventer adherence was poor: overall, 43% of preventer medication users reported taking it less than 5 days a week, and 31% used it less than weekly.