Demonstration project - Bahia (Brazil)

Impact of a public health intervention for management of severe asthma on health resource utilization and costs

Salvador, a city with 2.7 million inhabitants located in the northeastern state of Bahia, has a asthma prevalence of 27.1% among adolescents, one of the highest in the world. The standard strategy for asthma management in the public health system in Brazil was limited to treatment of exacerbation with bronchodilators and systemic corticosteroids. The Programme for Control of Asthma and Allergic Rhinitis (ProAR), a research project of the Federal University of Bahia School of Medicine in collaboration with the State and City departments of public health and supported by the Brazilian Ministry of Health, operates in Salvador to provide care and medication for patients with severe asthma for free. These free sessions are complemented by education sessions to patients and family members as well as capacity building of primary health-care facilities. Four reference centres for severe asthma were established since 2003, all staffed by pulmonary physicians, nurses and pharmacists. By April 2007, 2385 severe asthmatics had entered the programme.

ProAR resulted in a significant reduction in the frequency of hospital admissions (-90%), emergency department visits (-85%), systemic corticosteroid use (-67%) and school and work days lost (-86%). In the year after admission to the programme, patients also had fewer days of hospitalization and fewer visits to emergency/non-scheduled visits. The median family income was US$2,955/year and 45% of the subjects (or close family) had lost a job due to the illness. Direct cost of asthma management took 24% of family income. After proper treatment asthma control scores improved by 50% and quality of life by 74%. The income of the families increased by US$711/year, as patients went back to work. The total cost of asthma was reduced by US$638/family/year. Consequently, a median annual surplus of US$1,349/family became available.

In Salvador, asthma hospital admissions declined by over 80% (1998-2006). A greater proportion of this reduction (74%) happened after 2003. Asthma hospital mortality was 0.09/10,000 in 2003 and was reduced to 0.00 in 2006. Moreover, there is an inverse correlation between provision of inhaled medication for asthma and hospitalization rates and in-hospital mortality rate. It is widely accepted that the public health intervention of ProAR - targeting severe asthma - was associated with a rapid reduction in asthma admissions and a trend for reduced in-hospital mortality in the entire city.

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