The Chronic Conditions We’ve Ignored

With 25 million Americans suffering from Asthma, there’s much more that our healthcare system needs to do to help

Respiratory health in the United States has received renewed attention during the COVID-19 pandemic. Leading up to 2020, payors and self-insured employers emphasized almost every other major chronic condition – diabetes, prediabetes, blood pressure, and so on. But Asthma & COPD need to get the attention they deserve. These conditions are just as big and just as costly as the others mentioned.

A critical component of optimizing asthma control is the engagement of patients as active participants in their asthma management. Motivated and well-informed patients can assume a great deal of control over their asthma care, but few have even received basic asthma education. In fact, education on asthma self-management (ASME) is part of the CDC’s 6|18 Initiative, targeting six common and costly health conditions with 18 proven interventions.1,2 Several studies involving diverse cohorts, including Medicaid and Medicare populations, have shown that patient education decreases hospitalizations, minimizes asthma exacerbations, and improves daily function.3,4,5 However, programs requiring frequent, in-person consultations are not scalable and have continuously failed to engage an adequate number of patients to have a broad-based impact.

The annual per-person incremental medical cost of asthma alone was $3,266 (in 2015 U.S. dollars), of which $1,830 was attributable to prescription medication, $640 to office visits, $529 to hospitalizations, $176 to hospital-based outpatient visits, and $105 to emergency room visits.6 The average child with asthma misses an additional 2.3 school days per year, and the average adult misses an additional 1.8 days of work.6 [BEK1] Nightingale reduces the cost of asthma for payors through ASME, a smart wearable device, and dedicated respiratory therapists.

One measurement of asthma severity is the St. George’s Respiratory Questionnaire (SGRQ), which measures overall health, daily life, and perceived well-being. A clinically significant change for the patient is consistently around 4 units.7 For context, mepolizumab (a biologic drug approved in 2015 for a certain phenotype of severe, uncontrolled asthma) accounted for an improvement in SGRQ of -5.3 points and -6.2 points in recent clinical trials.8 Preliminary data from Nightingale users reveals an improvement in SGRQ of -12 points. 

Our virtual care platform, Nightingale, is a Respiratory Therapy clinic that provides patients with daily tips and reminders, one-on-one coaching with respiratory therapists, and an award-winning wearable that measures symptoms of asthma through cardiopulmonary monitoring to help patients and their therapists recognize trends and triggers. In addition, Nightingale provides accommodation for SDOH. In contrast with traditional, in-person consultations, Nightingale provides convenient at-home patient education with repeated, ongoing check-ins.

While clinical trials and Return on Investment (ROI) data for Nightingale are strong and growing, data from other ASME are long-term and clear. Most programs are associated with a positive ROI ranging from $1.90 per $1 invested to $20 per $1 invested. Time to realization ranged from 1-4 years.9 

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1.     Education on Asthma Self-Management. Published online December 1, 2020. https://www.cdc.gov/asthma/exhale/as-me.htm

2.     CDC’s 6|18 Initiative: Accelerating Evidence into Action. Published online October 4, 2018. https://www.cdc.gov/sixeighteen/index.html

3.     Bailey WC, Richards JM, Brooks CM, Soong SJ, Windsor RA, Manzella BA. A randomized trial to improve self-management practices of adults with asthma. Arch Intern Med. 1990;150(8):1664-1668.

4.     Worsnop CJ, McDonald CF. Asthma self-management with regular support reduces health care use and improves QoL at 8 mo. Ann Intern Med. 2020;173(12):JC67. doi:10.7326/ACPJ202012150-067

5.     Castro M, Zimmermann NA, Crocker S, Bradley J, Leven C, Schechtman KB. Asthma intervention program prevents readmissions in high healthcare users. Am J Respir Crit Care Med. 2003;168(9):1095-1099. doi:10.1164/rccm.200208-877OC

6.     Nurmagambetov T, Kuwahara R, Garbe P. The Economic Burden of Asthma in the United States, 2008-2013. Ann Am Thorac Soc. 2018;15(3):348-356. doi:10.1513/AnnalsATS.201703-259OC

7.     Jones PW. Interpreting thresholds for a clinically significant change in health status in asthma and COPD. Eur Respir J. 2002;19(3):398-404. doi:10.1183/09031936.02.00063702

8.     Nelsen LM, Cockle SM, Gunsoy NB, et al. Impact of exacerbations on St George’s Respiratory Questionnaire score in patients with severe asthma: post hoc analyses of two clinical trials and an observational study. J Asthma Off J Assoc Care Asthma. 2020;57(9):1006-1016. doi:10.1080/02770903.2019.1630640

9.     Hsu J, Wilhelm N, Lewis L, Herman E. Economic Evidence for US Asthma Self-Management Education and Home-Based Interventions. J Allergy Clin Immunol Pract. 2016;4(6):1123-1134.e27. doi:10.1016/j.jaip.2016.05.012