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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 2  |  Issue : 2  |  Page : 173-178

Prescription patterns and cost of illness in asthma and chronic obstructive pulmonary disease patients


1 Department of Pulmonology, Princess Esra Hospital, Hyderabad, India
2 Department of Pharmacy Practice, Deccan School of Pharmacy, Hyderabad, Telangana, India
3 Department of Pharmacology, Apeejay Stya University, Gurgaon, Haryana, India

Date of Submission31-Jan-2016
Date of Acceptance17-Mar-2016
Date of Web Publication28-Dec-2016

Correspondence Address:
Syed Amir Ali
Deccan School of Pharmacy, Darussalam, Aghapura, Nampally, Hyderabad - 500 001, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2455-5568.196874

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  Abstract 


Background: Although economic burden data of chronic obstructive pulmonary disease (COPD) and asthma for various countries are available, data among Indian population are unavailable. Thus, the aim of this study was to measure the prescription pattern and cost of illness (COI) of asthma and COPD patients.
Methods: This prospective, observational, bottom-up study collected economic, diagnostic, and therapeutic data from 150 COPD and asthma patients. The study was carried out for an 8-month period at Princess Esra Hospital, a Unit of Owaisi Group of Hospitals, located at Shalibanda, Hyderabad, Telangana, India.
Results: Societal perspective was used to account for both direct and indirect costs. Asthma and COPD account for Rs. 12,852 and Rs. 16,514 in annual direct costs per patient per year. Inpatient cost was considerably higher than the outpatient cost. Hospitalization costs ranked first in direct costs followed by laboratory examination and medication costs. Average annual total direct cost per patient for COPD (Rs. 5000–25,000) was considerably higher than asthma (Rs. 1000–20,000). Antibiotics, mucolytics, short-acting beta-2 agonists, long-acting beta-2 agonists, long-acting muscarinic antagonists, leukotriene receptor antagonists, corticosteroids, antihistamines, and methylxanthines were the common categories of drugs prescribed for the two disorders.
Conclusion: In summary, we found that COI for asthma and COPD are substantial. Hospitalization and medication costs can be reduced by implementing preventive strategies including but not limited to home care services, rehabilitation therapies, smoking cessation programs, medication assessment, and patient compliance programs. Future researchers should examine the treatment strategies and interventions that may help to reduce the burden of COPD and asthma.
The following core competencies are addressed in this article: Patient care, practice-based learning and improvement, systems-based practice.

Keywords: Asthma, chronic obstructive pulmonary disease, cost of illness, prescription pattern


How to cite this article:
Naveed A, Ali SA, Parveen A, Yousuf S, Ahmed A, Hashmi MA, Gigani Y. Prescription patterns and cost of illness in asthma and chronic obstructive pulmonary disease patients. Int J Acad Med 2016;2:173-8

How to cite this URL:
Naveed A, Ali SA, Parveen A, Yousuf S, Ahmed A, Hashmi MA, Gigani Y. Prescription patterns and cost of illness in asthma and chronic obstructive pulmonary disease patients. Int J Acad Med [serial online] 2016 [cited 2022 Jan 20];2:173-8. Available from: https://www.ijam-web.org/text.asp?2016/2/2/173/196874




  Introduction Top


Chronic obstructive pulmonary disease (COPD), which includes chronic bronchitis and emphysema, is a slow progressive disease characterized by airflow limitation and gradual loss of lung function.[1] Asthma is defined as the chronic inflammatory condition of the airways. COPD and asthma are a major cause of morbidity and mortality, with a substantial societal burden.[2],[3] Recently, the Indian Study on Epidemiology of Asthma, Respiratory Symptoms and Chronic Bronchitis in Adults showed the overall prevalence of chronic bronchitis as 14.84 million and that of asthma as 13 million patients.[4] The estimated economic burden of COPD for India was 350,000 million rupees in 2001–2005 and projected as 480,000 million rupees in next 5 years. This cost; however, assumes that the practice of treating COPD remains what it was when these estimates were made. If, however, the medical community was to adhere to standardized national and international treatment guidelines this cost could have drastically come down to 41 billion in 2011–2012 and up to Rs. 56 billion in 2016.[5]

COPD and asthma treatment includes bronchodilators, corticosteroids, theophylline, phosphodiesterase-4 inhibitors, leukotriene receptor antagonists, and anticholinergic drugs. Co-morbidities associated with COPD are cardiovascular disorders, hypertension, diabetes mellitus, osteoporosis, stroke, lung cancer, skeletal muscle weakness, anemia, depression, and cognitive decline.[6],[7] Given, the rising prevalence of COPD and asthma worldwide, it is urgently necessary to understand its economic burden and to provide more robust evaluations of healthcare interventions designed to reduce its incidence and impact.[8] Thus, the primary objective of this study was to estimate prospectively the economic burden of COPD and asthma. The secondary objective was to study the prescribing patterns and management of COPD and asthma patients in accordance with standard guidelines.


  Methods Top


The study was prospective, observational study performed in inpatients (IPs) and outpatients (OPs) of the Pulmonary Department of Princess Esra Hospital, a Tertiary Care Hospital, located at Shah Ali Banda, Hyderabad. Because of time constraints, only 150 COPD and Asthma patients were included. Patients with COPD and asthma, with or without co-morbid conditions, above 18 years, of both genders and under private or other government health insurance schemes were included in the study. Pregnant and lactating women and those not willing to give or not able to give verbal informed consent were excluded from the study. The study was carried out for 8 months from July 2014 to February 2015.

Ethical approval

The study was approved by the Institutional Ethics Committee of Owaisi Hospital and Research Centre as Princess Esra Hospital comes under Owaisi Group of Hospitals.

Data collection

This observational, prospective study collected demographic, clinical, and economic data of COPD and asthma patients. The study required a minimum of two visits during the 8-month survey. The data were collected from patient's treatment chart/case sheets, laboratory reports, and patient's attendees. All subjects gave informed consent to participate in the study and allowed the use of their personal data for research purposes. Patients were enrolled consecutively, according to the order in which they presented to the pulmonologist for consultation.

Statistical analysis

Descriptive statistics were used to analyze the demographic, clinical, and treatment characteristics of the total study population. Two-way analysis of variance (ANOVA) was used to detect the difference between the different classes of COPD and asthma drugs. The costs were taken into consideration keeping in view the interests of the society, which is the most favored way of analyzing the direct and indirect costs.[9]


  Results Top


Demographic, clinical, and diagnostic data

A total of 150 patients were included in our study. Of which 80, 68, and 2 patients, i.e., 54%, 45%, and 1% were suffering from COPD, asthma, and overlap syndrome of asthma and COPD, respectively. The male to female ratio was 95 (63%):55 (37%), indicating the greater prevalence of both the disorders in males. The incidence of both the disorders increased with age, with the highest number of patients found in the age group of 60 and above. The majority of the patients were smokers and had some allergies [Table 1]. While wheezing, cough and allergy dominated asthma patients, breathlessness, chest tightness, and cough were common among COPD patients. Hypertension and diabetes mellitus topped the list for co-morbidities in asthma and COPD disorders.
Table 1: Sociodemographic and clinical characteristic of patients

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Medication use

Antibiotics, mucolytics, short-acting beta-2 agonists (SABA), long-acting beta-2 agonists (LABA), long-acting muscarinic antagonists (LAMA), leukotriene receptor antagonists, corticosteroids, antihistamines, and methylxanthines were prescribed for the two disorders. Systemic amoxicillin + clavulanic acid and systemic cefoperazone + sulbactam have highest prescription rate in asthma and COPD, respectively. Among the oral antibiotics, amoxicillin + clavulanic acid is most commonly prescribed for asthma and COPD. While theophylline was the highest oral preparation for both asthma and COPD, montelukast was given only for asthma. Use of salbutamol + ipratropium bromide and budesonide as inhalation therapy was significantly high in both the conditions [Table 2],[Table 3], [Table 4].
Table 2: Prescribing pattern of oral antibiotics used in asthma and chronic obstructive pulmonary disease

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Table 3: Prescribing pattern of IV antibiotics used in asthma and chronic obstructive pulmonary disease

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Table 4: Orally prescribed drugs

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Cost of illness

Direct cost for IPs is notably higher than OPs in both asthma and COPD. OPs had high expenses for laboratory examination and medication cost while for IPs it was hospitalization and laboratory examination. Hospitalizations had the highest costs followed by medications, laboratory examinations, oxygen charges, radiology, and consultation [Table 5],[Table 6], [Table 7]. Travel costs, personal costs, and work and nonwork days lost made up indirect costs in asthma and COPD. Loss of income due to work and nonwork days lost had the highest percentage in indirect costs in both the disorders [Table 8]. Average cost incurred by patients with asthma was between Rs. 1000 and 20,000 [Table 9]. Average cost incurred by patients with COPD was between Rs. 5000 and 25,000 [Table 9]. ANOVA revealed a significant difference between different classes of drugs used in asthma and COPD at a P < 0.05.
Table 5: Cost of different class of drugs used in asthma and chronic obstructive pulmonary disease

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Table 6: Total direct cost involved in asthma

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Table 7: Total direct cost involved in chronic obstructive pulmonary disease

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Table 8: Total indirect cost

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Table 9: Cost of illness of asthma and chronic obstructive pulmonary disease

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Sensitivity analysis

Sensitivity analysis was performed on certain cost parameters to account for uncertainties. Minimum and maximum case estimates were calculated using the lowest and the highest range to present the most extreme range. For example, laboratory examination contributed 21% to the total direct cost of asthma. Therefore, we varied laboratory examination costs between 17% and 25% to present the extreme values for laboratory examination costs. Similarly, we varied radiology costs between 9% and 11% to present the extreme values of low case and high case. Similar variations in the costs of hospitalizations, medications, radiology, consultation and oxygen charges were made. From the 8 months total direct costs, we calculated per patient per year total direct costs assuming that the disease severity remains the same for the remaining 4 months of the year. Similarly, we varied the prevalence of the disorders to present extreme ranges of the national economic burden for the two disorders.

For asthma, expected the total direct cost per patient per year was found to be Rs. 12,852, which varied between Rs. 10,421 (low case) and Rs. 15,284 (high case). The national economic burden based on prevalence per year was found to be 167,076 million rupees which varied between 125,052 million rupees (low case) per year and 213,976 million rupees (high case) per year [Table 10].
Table 10: Sensitivity analysis: Total direct costs for asthma

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Similarly for COPD, expected the total direct cost per patient per year was found to be Rs. 16,514, which varied between Rs. 14,220 (low case) and Rs. 18,810 (high case). The national economic burden based on prevalence per year was found to be 245,067.76 million rupees, which varied between 199,080 million rupees (low case) per year and 294,940.8 million rupees (high case) per year [Table 11].
Table 11: Sensitivity analysis: Total direct costs for chronic obstructive pulmonary disease patients

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  Discussion Top


This study demonstrates that COPD and asthma are a significant cost burden to the society. The COI was evaluated, and prescribing pattern was determined. Among 150 patients 63% were males and 36% were females. The mean age was 55.6 years with (mean ± standard deviation = 70.1 and 41.1). Diagnostic tools applied for evaluating principle diagnosis were chest X-ray, electrocardiogram (ECG), arterial blood gases, spirometry, two-dimensional echo, and high-resolution computed tomography. Personal and social history obtained from patients also contributed in the disease diagnosis. Smokers and alcoholics were found to be at a higher risk. Chief complaints presented by the patient were cough, chest tightness, and shortness of breathing. Wheezing and allergy were less significant. On evaluation via ECG, we noted that majority of patients had noncardiac chest pain. Significant co-morbidities found were an acute renal failure, hypertension, and diabetes mellitus.

Cost of illness

Although economic burden associated with asthma and COPD is high, COI studies indicated COPD as relatively expensive. Kirsch et al. in their study observed that in spite of the heterogeneity in methodology and results, medication was identified as the most important component of direct costs and work loss as the most important component of indirect costs.[10] In our study, hospitalization followed by medication and laboratory examination were identified as important components of direct cost and work and nonwork days lost as the significant component of indirect cost. The results of our study and many other studies confirm that patient care for asthma has decreased whereas that of COPD has increased.[11],[12]

Prescribing patterns

Different drugs are used for COPD and asthma patients for their IP and OP visits. The studied therapeutic regimen showed the use of the combination of inhalational therapy, systemic therapy, and oral therapy.

Maazuddin et al. showed that montelukast was the most prescribed drug in the first and second visits, either alone or in combination. The drug used through inhalational route was formoterol in both visits as monotherapy followed by fluticasone + formoterol as combination therapy. The commonly prescribed drugs in our study were antibiotics, SABA + LAMA, steroids, antihistamine, and mucolytics. In conjugation, montelukast and methylxanthines were also used.[13] All the IP subjects were given inhalation and systemic therapy, with cefoperazone + sulbactam and ipratropium bromide + salbutamol, whereas all the OP subjects were prescribed oral therapy with steroids and antihistamines. Overall, the drug utilization study showed that oral montelukast followed by methylxanthines was the drug of choice for asthmatic patients whereas inhaled salbutamol and ipratropium bromide for COPD. A similar study by Shimpi et al. showed methylxanthine as the drug of choice for asthma.[14]

Study limitations

There are several limitations to our study. The study sample used was small. There was a lack of retrospective data for this study. The prevalence of disorders obtained from the prevalence studies may be subject to response bias and various other biases. We did not stratify the sample based on the age, gender, and socioeconomic status. The adjusting factor to account for the influence of co-morbidities on asthma and COPD has not been included. For example, hypertension may exacerbate COPD. We were not able to Grade COPD due to nonavailability of pulmonary function data. Furthermore, we did not have data on pharmacy dispensing or medication compliance. In both cases, there is a risk of overestimation of drug use. Furthermore, this study calculates the national economic burden based on the prevalence data, additional studies that evaluate the comparative national and international economic burden of COPD, and asthma would be of great interest.


  Conclusion Top


In summary, we found that COI for asthma and COPD are substantial and continue to be a great economic burden for the society. Hospitalization and medication costs can be reduced by implementing the preventive strategies including but not limited to home care services, rehabilitation therapies, smoking cessation programs, medication assessment, and patient compliance programs which have been undermined in the recent times. Future researchers should examine the treatment strategies and interventions that may help to reduce the burden of COPD and asthma.

Acknowledgement

We thank Tahmeena Begum, PharmD Intern, for helping us in this project. We also thank the authorities of Princess Esra Hospital for allowing us to this valuable work.

Financial support and sponsorship

The study was not financially supported or sponsored by any individual or company.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease; Updated 2005. Available from: http://www.goldcopd.org. [Last accessed on 2005 Nov 22].  Back to cited text no. 1
    
2.
Global Initiative for Asthma (GINA); 2006. Available from: http://www.ginaasthma.com.[Last accessed on 22nd March 2016]  Back to cited text no. 2
    
3.
Kim J, Rhee CK, Yoo KH, Kim YS, Lee SW, Park YB, et al. The health care burden of high grade chronic obstructive pulmonary disease in Korea: Analysis of the Korean Health Insurance Review and Assessment Service data. Int J Chron Obstruct Pulmon Dis 2013;8:561-8.  Back to cited text no. 3
    
4.
Jindal SK, Aggarwal AN, Gupta D, Agarwal R, Kumar R, Kaur T, et al. Indian study on epidemiology of asthma, respiratory symptoms and chronic bronchitis in adults (INSEARCH). Int J Tuberc Lung Dis 2012;16:1270-7.  Back to cited text no. 4
    
5.
Bhome AB. COPD in India: Iceberg or volcano? J Thorac Dis 2012;4:298-309.  Back to cited text no. 5
    
6.
Vijayan VK. Chronic obstructive pulmonary disease. Indian J Med Res 2013;137:251-69.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.
Kim H, Mazza J. Asthma. Allergy Asthma Clin Immunol 2011;7 Suppl 1:S2.  Back to cited text no. 7
    
8.
Ramsey SD, Sullivan SD. The burden of illness and economic evaluation for COPD. Eur Respir J Suppl 2003;41:29s-35s.  Back to cited text no. 8
    
9.
Gold MR, Siegel JE, Russell LB, Weinstein MC. Cost Effectiveness in Health and Medicine. New York: Oxford University Press; 1996.  Back to cited text no. 9
    
10.
Kirsch F, Teuner CM, Menn P, Leidl R. Costs of illness for asthma and COPD in adults in Germany. Gesundheitswesen 2013;75:413-23.  Back to cited text no. 10
    
11.
Rutten van-Mölken MP, Feenstra TL. The burden of asthma and chronic obstructive pulmonary disease: Data from the Netherlands. Pharmacoeconomics 2001;19 Suppl 2:1-6.  Back to cited text no. 11
    
12.
Oostenbrink JB, Rutten-van Mölken MP, Al MJ, Van Noord JA, Vincken W. One-year cost-effectiveness of tiotropium versus ipratropium to treat chronic obstructive pulmonary disease. Eur Respir J 2004;23:241-9.  Back to cited text no. 12
    
13.
Maazuddin M, Javeedullah M, Nasir Mohiuddin M. Antibiotic utilization in acute exacerbation of asthma and COPD. Int J Pharm Rev Res 2015;5:1-4.  Back to cited text no. 13
    
14.
Shimpi RD, Salunkhe PS, Bavaskar SR, Laddha GP, Kalam AA, Patel K, et al. Drug utilization evaluation and prescription monitoring in asthmatic patients. Int J Pharm Biol Sci 2012;2:117-22.  Back to cited text no. 14
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11]



 

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