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Timely referral of asthmatic children could save families expenses

02 Aug 2021

  • Researchers recommend patients timely referral to local clinics 
  •  Health edu/counselling for parents spending on vitamin based medications
By Ruwan Laknath Jayakody As a significant sum is spent by families with children having asthma on travelling to Colombo, and staying overnight to attend regular clinics in tertiary care centres, in addition to the considerable expenses borne for both medicine and related equipment, it has been observed that the timely referral of patients to local clinics could minimise such expenditures. This observation was made by K.N.H. Thalagahage (attached to the Postgraduate Institute of Medicine in Colombo), R. Ediriweera [attached to the Lady Ridgeway Hospital for Children (LRH)], and E.P. Ranasinghe (attached to the Office of the Regional Director of Health Services in Colombo), in a research article on “Chronic asthma in childhood and its economic impact on the family” which was published in the Anuradhapura Medical Journal 14 (1) on 4 December 2020. Asthma, which is a chronic obstructive respiratory disorder of the bronchial tree, as defined by the National Heart, Lung, and Blood Institute, is an inflammatory condition that leads to reversible bronchial constriction and narrowing of the airways, especially in the lower respiratory tract. Chronic asthma can cause airway swelling, cough, shortness of breath, and tightness in the chest due in part to airway sensitivity to a variety of stimuli; it is treated with bronchodilators, corticosteroids, and other relevant anti-inflammatory drugs. Thalagahage et al., whilst noting that it is a non-communicable disease, cited data to the effect that 13-25% patients suffering from bronchial asthma are children between the ages of five to 11 years, noting also that persons with a strong family history for the same, or children who are more exposed to dust, pollen or cigarette smoke, including passive smoking, are more prone to develop the disease. Asthma, as noted by E.J. O’Connell in “The burden of atopy (genetic tendency to develop allergic diseases) and asthma in children”, and W.R. Taylor and P.W. Newacheck’s “Impact of childhood asthma on health” causes a significant socio-economic burden on families in the developing world in low income countries, whereas in middle income countries, this results in the spending of one fourth of the affected family’s income. This expenditure could be reduced through the adequate and proper management of asthma, as noted by R. Franco, H.F. Nascimento, A.A. Cruz, A.C. Santos, C. Souza-Machado, E.V. Ponte, A. Souza-Machado, L.C. Rodrigues, and M.L. Barreto in “The economic impact of severe asthma to low income families”. In this regard, C.A. Stevens, D. Turner, C.E. Kuehni, J.M. Couriel, and M. Silverman’s “The economic impact of preschool asthma and wheeze” recommended taking primary preventive measures. Additionally, an Australian study on the burden of asthma by L.M. Poulos, B.G. Toelle, and G.B. Marks found that over one third of asthmatic children experienced sleep disturbance, while the majority (60%) suffered limitations in terms of the activities they engaged in, such as missing school. In Sri Lanka, K.W. Karunasekera, A.D. Fernando, and C.Y. Jayasinghe’s “Impact of corticosteroid therapy on lifestyles in asthmatic children from Sri Lanka” found that parents of affected children were forced to limit their children’s activities such as bathing, food, and play. Also in Sri Lanka, B.J. Perera’s “Efficacy and cost effectiveness of inhaled steroids in asthma in a developing country” found, that prior to starting treatment for the management of asthma in the form of the use of steroid inhalers, it had cost the family a significantly high amount compared to the cost post-treatment, not to mention the subsequent effect and outcome, which Perera observed indicated the need to properly deliver knowledge and proper management strategies, to help improve the disease condition as well as the cost effectiveness factor.  G.W.K. Wong, N. Kwon, J.G. Hong, J.Y. Hsu, and K.D. Gunasekera mention in “Paediatric asthma control in Asia: Phase 2 of the Asthma Insights and Reality in Asia-Pacific survey”, that tests such as the Asthma Control Test (ACT) and the Childhood ACT (C-ACT) could help practitioners assess the asthma disease status and adjust medication accordingly. Hence, Thalagahage et al., conducted a study at the LRH from April-September 2020, where data was obtained from 388 parents and/or caregivers of children who attended the Hospital's paediatric clinic. Children with bronchial asthma for less than one year, children aged less than five years or more than 15 years, and children with diagnosed respiratory diseases other than asthma, were excluded from the study. A consecutive, non probability, sampling method was used. A structured, interviewer administered questionnaire was used as the study instrument, where the questionnaire also looked into the expenses incurred for medical treatments and investigations (e.g. investigations done outside the LRH, and drugs and equipment bought outside the LRH), along with expenses incurred for visits to the clinic (e.g. travel, meals, lodging, and special food supplements).  In terms of the demographic information of the children, age wise, the minimum age of the children was five years while the maximum age was 15 years with a mean age of 9.24 years, while when it came to biological sex, the majority (52.5%) were female, and the rest (47.5%) were male. The breakdown in terms of the ethnic and religious composition pointed to the majority being Sinhalese (77.6%), followed by Tamils (11.1%), Muslims (10.7%), and others (0.8%), and Buddhists (69.1%), Catholics (13.5%), Islamists (11.1%), Hindus (5.4%), and others (1%), respectively. With regard to the parents, the minimum age of the mothers was 20 years while the maximum age was 55 years with a mean age of 36.9 years, and among the fathers, the minimum age was 26 years, the maximum age was 66 years and the mean age was 40.28 years. Concerning the parents’ education level, with regard to the mothers, the majority (45.4%) had studied up to the GCE Ordinary Level, followed by 35.3% up to GCE Advanced Level, primary 15.2%, graduate 2.6% and no schooling 1.5%. The same pattern was seen among the fathers, up to GCE O/L 59.4%, up to GCE A/L 22.7%, primary 14.9%, graduate 2.6% and no schooling 0.3%.    On the matter of their individual and collective monthly income, the mothers’ minimum income was Rs. 32,700, the maximum income was Rs. 120,000, and the mean income was Rs. 20,000 while the fathers had a minimum income of Rs. 25,000, a maximum income of Rs. 500,000, and a mean income of Rs. 45,106. Collectively, the total minimum monthly income was Rs. 35,000, the maximum Rs. 570,000, and the mean income was Rs 46,992.    Concerning clinic related visits and related expenses, the number of persons participating during clinic visits in the majority of the cases were two (42.5%), followed by one ( 41.5%), three (10.6%) and four (5.4%). The mode of travel for the majority (45.1%) was car, followed by three wheeler (31.2%), car, three wheeler or bus (13.4%), other (5.7%), and bus (4.6%). The mean clinic travel related expense was Rs. 1,033. In order to attend clinics, only 14 (4.9%) were forced to stay overnight in Colombo. The mean accommodation related expense was Rs. 3,090. In terms of food purchases, the majority (75.5%) purchased food with the mean expense incurred for such being Rs. 472. With regard to asthma related other expenses, in addition to Western medicine, 23 (5.9%) who used Ayurvedic medicine spent a mean of Rs. 5,383 while three (0.8%) used homeopathic remedies. A total of 73 (18.8%) gave specific foods, drinks, and vitamins to relieve asthma, and spent a mean of Rs. 2,465.  The reasons for the loss of work was cited by the majority (70.1% or 70.4%) as the clinic visit, followed by hospitalisation (14.9%), clinic visit, hospitalisation, and private consultation (13.4%) and private consultation (1.5%). On the number of days parents and guardians had not gone to work, as a result of such, the majority (56.4%) had lost one day, followed by 106 (27.3%) losing two days, 31 (8%) less than four days, 26 (6.7%) less than three days, and six (1.5%) losing four days, with the mean monthly allowance loss due to absenteeism being Rs. 4,117.  In terms of the source of finances to make related payments, 30 had obtained a bank loan to treat the child, with mean monthly loan installments of Rs. 11,325, while in the case of 28 (9.8%), the medical insurance had covered it.  With regard to the cost for drugs and equipment, purchased from outside the LRH during the last six months, a mean of Rs. 1,389 (range Rs. 200-8,400) was expended per month for asthma drugs, which included antibiotics (mean Rs. 925), beta agonist inhalers (mean Rs. 875), steroid inhalers (mean Rs. 1,215), steroid nasal spray (mean Rs. 251), leukotriene receptor blockers (mean Rs. 148), antihistamines (mean Rs.353) and other drugs (mean Rs. 1,406), and nebulizer machines and masks (mean Rs. 10,259). The results of the study indicated that the factors that demonstrate a significant relationship with the total expenditure are being male, the religion, the mother’s level of education, the number of persons participating for the clinic visit, having to spend the night in Colombo, spending money on food whilst attending the clinic, expenses incurred for traditional Ayurvedic treatment, the provision of additional nutritional supplements and vitamins for the purpose of relieving asthma, and having medical insurance. As reiterated by Thalagahage et al., the management of childhood asthma involves monetary expenditure (costs of medication, consultation fees, investigations, and the utilisation of health services such as clinic visits and hospital admissions), and yet, despite the significant financial burdens imposed on families (in “The burden of paediatric asthma”, G. Ferrante and S. La Grutta found that direct costs substantially account for 50–80% of the total costs related to asthma) by the disease, it is vital to provide optimal long term medical management in order to maintain the quality of life, including in the context of childhood activities and schooling (“School functioning of United States children with asthma” by M.G. Fowler, M.G. Davenport, and R. Garg, and “Morbidity and school absence caused by asthma and wheezing illness” by H.R. Anderson, P.A. Bailey, J.S. Cooper, J.C. Palmer, and S. West).  Moreover, Thalagahage et al., observe that poor asthma control is associated with higher economic costs owing to asthma, leading also to a poor quality of life and a loss of productivity. Analysing the study findings further, Thalagahage et al. noted, that the expenditure incurred on drugs to treat asthma ranged from 3-18% of an affected family's monthly income, with additional notable expenses for travel, accommodation, and meals during clinic visits. It must also be noted that not every family can afford access to health insurance coverage, which could afford some relief in terms of reducing the extent of the economic burden on families. The instant study also found that being a male child carried higher total expenditures on asthma, which was attributed to the smaller size of the lungs and airways of boys prior to the age of 14 years, which increases the risk to develop asthma (“Economic burden of paediatric asthma: Annual cost of disease in Iran” by L. Sharifi, R. Dashti, Z. Pourpak, M.R. Fazlollahi, M. Movahedi, Z. Chavoshzadeh, H. Soheili, S. Bokaie, A. Kazemnejad, and M. Moin, and “Social and familial factors in the development of early childhood asthma” by L.J. Horwood, D.M. Fergusson, and F.T. Shannon).  As Perera has shown, the total expenditure incurred in this regard has, to a great extent, reduced upon the disease being brought under a degree of control, where it was found that the total cost including the expenses for the drugs, doctors’ consultation related charges, and indirect costs incurred due to the loss of work, had come down from an approximate average of Rs. 2,650 per month to around Rs. 450 per month. Subsequent to the use of medications and sufficient control of the condition, which as Perera further notes “This treatment could control childhood asthma and save money for parents”, constituted a significant saving in terms of the parents’ income that was expended on the management of the disease.  Furthermore, since a considerable amount is spent on vitamin based medications ‒ if this is practised by parents in the belief that vitamins can improve the asthma condition ‒ such families therefore require further health related education and also counselling, Thalagahage et al. suggested in conclusion.


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