The economic value of home asthma interventions.
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ABSTRACT: Although not widely recognized as such, asthma is the single most prevalent cause of childhood disability and has contributed to a substantial rise in the overall prevalence of disability among children during the past 25 years. To provide a national profile of the prevalence, impact, and trends in childhood disability due to asthma. (Disability is a long-term reduction in the ability to participate in children's usual activities, such as attending school or engaging in play, due to a chronic condition.) We derived our primary findings from a cross-sectional, descriptive analysis of 62171 children younger than 18 years who were included in the 1994-1995 National Health Interview Survey. Outcome measures include the presence of disability, degree of disability, restricted activity days, school absence days, and use of hospital and physician services. We also used data from the 1969-1970, 1979-1981, and 1994-1995 National Health Interview Surveys to assess trends in the prevalence of disability due to asthma. A small, but significant, proportion of children, estimated at 1.4% of all US children, experienced some degree of disability due to asthma in 1994-1995. Prevalence of disability due to asthma was higher for adolescents (odds ratio [OR], 1.64), black children (OR, 1.66), males (OR, 1.23), and children from low income (OR, 1.46) and single-parent families (OR, 1.37). Disabling asthma resulted in an annual average of 20 restricted activity days, including 10 days lost from school-almost twice the level of illness burden as experienced by children with disabilities due to other types of chronic conditions. Finally, prevalence of disabling asthma, as reported in the National Health Interview Survey, has increased 232% since 1969, the first year that electronic data are available from the survey. In contrast, prevalence of disability due to all other childhood chronic conditions increased by 113% over the same period. Disabling asthma has profound effects on children. The social costs of asthma are likely to rise in the future if current trends in the prevalence of disabling asthma continue.Archives of Pediatrics and Adolescent Medicine 04/2000; 154(3):287-93. · 4.14 Impact Factor
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ABSTRACT: Although work performance has become an important outcome in cost-of-illness studies, little is known about the comparative effects of different commonly occurring chronic conditions on work impairment in general population samples. Such data are presented here from a large-scale nationally representative general population survey. The data are from the MacArthur Foundation Midlife Development in the United States (MIDUS) survey, a nationally representative telephone-mail survey of 3032 respondents in the age range of 25 to 74 years. The 2074 survey respondents in the age range of 25 to 54 years are the focus of the current report. The data collection included a chronic-conditions checklist and questions about how many days out of the past 30 each respondent was either totally unable to work or perform normal activities because of health problems (work-loss days) or had to cut back on these activities because of health problems (work-cutback days). Regression analysis was used to estimate the effects of conditions on work impairments, controlling for sociodemographics. At least one illness-related work-loss or work-cutback day in the past 30 days was reported by 22.4% of respondents, with a monthly average of 6.7 such days among those with any work impairment. This is equivalent to an annualized national estimate of over 2.5 billion work-impairment days in the age range of the sample. Cancer is associated with by far the highest reported prevalence of any impairment (66.2%) and the highest conditional number of impairment days in the past 30 (16.4 days). Other conditions associated with high odds of any impairment include ulcers, major depression, and panic disorder, whereas other conditions associated with a large conditional number of impairment days include heart disease and high blood pressure. Comorbidities involving combinations of arthritis, ulcers, mental disorders, and substance dependence are associated with higher impairments than expected on the basis of an additive model. The effects of conditions do not differ systematically across subsamples defined on the basis of age, sex, education, or employment status. The enormous magnitude of the work impairment associated with chronic conditions and the economic advantages of interventions for ill workers that reduce work impairments should be factored into employer cost-benefit calculations of expanding health insurance coverage. Given the enormous work impairment associated with cancer and the fact that the vast majority of employed people who are diagnosed with cancer stay in the workforce through at least part of their course of treatment, interventions aimed at reducing the workplace costs of this illness should be a priority.Journal of Occupational and Environmental Medicine 04/2001; 43(3):218-25. · 2.06 Impact Factor
Article: Work dynamics of adults with asthma.[show abstract] [hide abstract]
ABSTRACT: Asthma has been found to be among the most common conditions in the working age population and is among the most common causes of work limitation, but we could find no longitudinal studies of employment among persons with this condition. A panel of 601 persons with a diagnosis of asthma from random samples of northern California pulmonologists and allergy-immunologists were interviewed as many as three times at 18-month intervals by a trained survey worker to report on the severity of disease, demographic characteristics, and the extent of their employment. Their employment was then compared to that of a matched sample from the U.S. Bureau of the Census Current Population Survey. Ninety-two percent of the persons with asthma had worked at some point prior to study enrollment. Among persons with onset during adulthood, only 29% of those who were not employed at disease onset were working at study enrollment, compared to 68% among those who were employed. Among the 420 persons interviewed three times, 75, 81, and 75%, respectively, were employed as of the three interviews. Among these 420, 66% were continuously employed and 15% were continuously not employed. The principal determinants of continuity of employment were demographic and employment characteristics, not medical ones. The employment rate and hours of work per week and per year of the persons with asthma were similar to the matched sample. Asthma has not substantially impeded the employment of the persons with asthma we studied, with the exception that those who were not employed at disease onset continued to have low employment rates.American Journal of Industrial Medicine 06/1999; 35(5):472-80. · 1.63 Impact Factor
The Economic Value of
Home Asthma Interventions
Adam J. Atherly, PhD
asthma can be disabled by their illness, especially during
individuals with asthma can lead a normal life, including
participating in sports and other activities, and high-cost
events, such as visits to the emergency department or
inpatient hospital care can be avoided. The review pre-
sented in this supplement to the American Journal of
Preventive Medicine by Nurmagambetov et al.7shows
that comprehensive home environmental interventions
have the potential to be cost-effective interventions for
children with asthma. This is particularly true if the pro-
grams reduce the use of healthcare resources devoted to
treating acute asthma exacerbations brought on by trig-
gers in the home environments.
The National Asthma Education and Prevention Pro-
gram suggests that optimal management of asthma de-
pends on three crucial elements:8,9
sthma is a common and costly chronic illness
affecting people of every economic level, demo-
graphic category, and age group. People with
● Access to high-quality medical care
● Medication management
● Environmental trigger avoidance.
Environmental trigger avoidance includes taking ap-
propriate measures to modify the environment of a per-
son with asthma to minimize exposure to potential trig-
gers. Because most individuals spend large portions of
their lives in their homes, the home is one of the key
environments that should be modifıed.
All seven of the reviewed RCTs of home interventions
found positive effects of the interventions on asthma
outcomes. This strongly suggests that home environ-
mental interventions can be used to improve health, a
necessary—although not suffıcient—criterion for cost
The reviewed studies do show wide variations in the
studies reporting cost per symptom-free day (SFD)
gained, the interventions that reported the lowest cost
per SFD gained also had the lowest program cost10
—$458 per participant and a cost per SFD gained of $12.
Both the Inner City Asthma study and Healthy Homes
of those interventions were considerably more costly in
terms of program cost, which yielded a higher cost per
SFD gained. Indeed, the highest cost per benefıt was
found for interventions with the highest program cost.
One key factor that determined the cost of the program
was the type of provider used, most obviously due to
offset by higher effectiveness if the more trained person-
nel were more effective. The reviewed studies generally
did not show such an offset.
Overall, the reviewed research indicates that a moder-
ate health impact can be achieved with a relatively low-
cost, low-intensity home environmental intervention.
Such an intervention may have a cost-effectiveness ratio
on par with standard pharmaceutical interventions, such
inhaled steroids have found that the incremental cost
effectiveness of steroids is $11 per SFD gained11(using
the payer perspective, because most of the home inter-
ventions did not value indirect costs)—little different
from the $12 per SFD reported for home environmental
interventions. So, asthma home interventions can com-
pare favorably to standard pharmacologic treatments.
relatively low-intensity intervention. For example, Doli-
nar et al.12provided a single asthma education session
delivered in the patient’s home, and reported improved
parental coping and a higher perceived change in the
child’s asthma. This effect can also be observed in Heal-
thy Homes, where both the high-intensity and the low-
intensity arms showed improvement over baseline. A
similar result is also reported in the Community Asthma
Prevention Program, as well as in other asthma inter-
ventions, such as the use of pharmacists to provide
Although there have been a number of successful ran-
domized clinical trials examining the impact of home
environmental modifıcations, several key research ques-
tions remain unanswered:
From the Department of Health Systems, Management and Policy, Colo-
rado School of Public Health, University of Colorado, Aurora, Colorado
Address correspondence to: Adam J. Atherly, PhD, Department of
Room E3315, Aurora CO 80045. E-mail: email@example.com.
© 2011 American Journal of Preventive Medicine • Published by Elsevier Inc.Am J Prev Med 2011;41(2S1):S59-S61
● What is the persistence of the effect of home environ-
Of the reviewed studies, most have a 6- to 12-month
follow-up. The evidence suggests that the benefıts of the
interventions decline over time, but the long-term extent
of the decline is unclear. For example, the Inner City
or clinic for asthma care declined by 0.35 per child per
year during the fırst year, and by 0.26 days per year per
child during the second year. This suggests that approxi-
mately one quarter of the benefıts were lost during the
second year. The National Cooperative Inner-City
Asthma Study reported that the maximum symptom-
days declined by ?14.3 per child per year during the fırst
year, and by ?13.3 during the second year, suggesting
If the benefıts of home interventions persist over sev-
ditures may be suffıcient for the program to be cost neu-
tral. Alternatively, if the benefıts diminish substantially,
limited follow-up programs may be effective in sustain-
ing the effectiveness of the intervention.
● What type of professional training is most effective?
There is no consensus in the literature on appropri-
ate training for the individuals performing the home
interventions. In the published literature, studies have
used medical doctors,12environmental counselors/
health workers,16registered nurses,17home health
nurses,18pharmacists,14and peer educators.19There is
also the possibility of using respiratory therapists.
All of these different professional backgrounds have
strengths and weaknesses. The key trade-off is between a
superior understanding of the community—found in
community health workers, asthma counselors, and peer
educators—and a superior understanding of health and
asthma, exemplifıed by medical doctors, pharmacists,
and nurses. Particularly for low-income and minority
communities, the ability to communicate successfully
with families may be more important for effectiveness
than a fuller understanding of the illness. The personnel
with less medical training also typically have lower sala-
ries, which may lead to more cost-effective treatment,
even with potentially lower effectiveness.
● What is the effect of home interventions on indirect
Several of the existing studies have not measured indi-
of work missed. Results from studies that have included
such measures, including the Healthy Homes and Dis-
efıts from reduced indirect costs may be substantial. Fur-
ther efforts to quantify and provide a dollar value for
these indirect costs would provide a fuller measure of the
fınancial impact of these interventions.
Although further study is clearly warranted, the scien-
tifıc evidence to date is strong enough to justify the cov-
private third-party payers for children with moderate to
severe asthma. There is little evidence, however, on the
optimal design of these home environmental modifıca-
on such design issues and against any type of regulation
until better evidence is available.
Publication of this article was supported by the Centers for
Disease Control and Prevention through a Cooperative Agree-
ment with the Association for Prevention Teaching and Re-
search award # 07-NCHM-03.
No fınancial disclosures were reported by the author of this
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