title: Clinical and Economic Burden of Elevated Blood Eosinophils in Patients With and Without Uncontrolled Asthma.
abstract: BACKGROUND
  The European Respiratory Society and American Thoracic Society (ERS/ATS) published guidelines in 2014 for the evaluation and treatment of asthma. These guidelines draw attention to management of patients with asthma that remains uncontrolled despite therapy. One phenotypic characteristic of therapy-resistant asthma is eosinophil elevation. It is important to better understand the burden of care gaps in this patient subgroup in order to support improved treatment strategies in the future.
  
  
  OBJECTIVE
  To quantify the economic burden of asthma patients with and without peripheral blood eosinophil elevation.
  
  
  METHODS
  A retrospective cohort study was conducted using data from patients aged 12 years or older with a diagnosis of asthma using electronic health records of over 2 million patients between 2004-2010. Patients with a diagnosis of chronic obstructive pulmonary disease, Churg Strauss syndrome/Wegener's granulomatosis, eosinophilia, cystic/pulmonary fibrosis, allergic bronchopulmonary aspergillosis, or lung cancer in the 12-month period before the date of asthma diagnosis were excluded. Patients with asthma were followed for 12 months after their initial asthma diagnosis to identify those with controlled versus uncontrolled asthma based on ERS/ATS criteria. Patients with at least 1 peripheral blood eosinophil test result of ≥ 400 cells/µL were classified as those with elevated eosinophils. Total annual paid-claim cost was compared by eosinophil levels within the controlled and uncontrolled asthma subgroups. Costs were adjusted to 2015 U.S. dollars. Patients were stratified by control level, and generalized linear modeling regressions were used to assess the magnitude of increase in cost of the elevated eosinophil group.
  
  
  RESULTS
  A total of 2,701 patients were included in the study, of which 17% had uncontrolled asthma and 21% had elevated eosinophils. The mean total annual cost of patients with uncontrolled asthma was more than 2 times the cost of those with controlled asthma ($18,341 vs. $8,670, P < 0.001). Patients with uncontrolled asthma in the elevated eosinophil group had almost double the total cost ($28,644 vs. $14,188, P = 0.008) compared with those with blood eosinophil levels in a normal range. Similarly, patients classified as those with controlled asthma in the elevated eosinophil group had almost twice the average costs as those without elevated eosinophils ($14,754 vs. $7,203, P < 0.001). Uncontrolled asthma with elevated eosinophils had 4 times greater hospital admissions and over 4 times higher total costs than controlled asthma without elevated eosinophils. Among patients with uncontrolled asthma, patients with elevated eosinophils had a 53% increase in mean cost ($17,723 vs. $11,581, P < 0.001) compared with patients without elevated eosinophils. Among patients with controlled asthma, patients with elevated eosinophils had a 62% increase in mean cost ($8,897 vs. $5,486, P < 0.001) compared with patients without elevated eosinophils.
  
  
  CONCLUSIONS
  Elevated peripheral blood eosinophil level is associated with higher cost irrespective of disease control status.
  
  
  BACKGROUND
  This study was funded by Teva Pharmaceuticals. Dotiwala and Casciano report consulting and writing fees from Teva Pharmaceuticals for work on this study. Sun is an employee and stockholder of Teva Pharmaceuticals. Li reports consulting fees from eMAX Health. All authors contributed to study design. Dotiwala took the lead in data collection, along with the other authors, and data interpretation was performed primarily by Krishnan, Sun, and Li, along with Casciano and Dotiwala. The manuscript was written by Casciano, Dotiwala, and Li, along with Sun and Krishnan, and revised by Casciano, Dotiwala, Sun, and Li, with assistance from Krishnan.
authors.affiliation: 1 eMAX Health, White Plains, New York.
authors.forename: Julian
authors.initials: J
authors.lastname: Casciano
authors.affiliation: 2 University of Illinois Hospital and Health Sciences System, Chicago.
authors.forename: Jerry
authors.initials: J
authors.lastname: Krishnan
authors.affiliation: 1 eMAX Health, White Plains, New York.
authors.forename: Zenobia
authors.initials: Z
authors.lastname: Dotiwala
authors.affiliation: 3 University of Arkansas for Medical Sciences, Little Rock.
authors.forename: Chenghui
authors.initials: C
authors.lastname: Li
authors.affiliation: 4 Teva Pharmaceuticals, Frazer, Pennsylvania.
authors.forename: Shawn X
authors.initials: SX
authors.lastname: Sun
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001249:Asthma / Q000097:blood / Q000191:economics* / Q000473:pathology*; D002648:Child; D004804:Eosinophils / Q000473:pathology*; D005260:Female; D006760:Hospitalization / Q000191:economics; D006801:Humans; D007958:Leukocyte Count / Q000191:economics / Q000379:methods; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D055815:Young Adult