Environmental Interventions Are Effective in Both Cost and Outcomes

Elizabeth Matsui, MD, MHS

There were many themes for therapies presented at the 2018 American Academy of Allergy, Asthma & Immunology (AAAAI) and World Allergy Joint Congress in Orlando, Florida, but few rang as loudly as the call for environmental intervention as an adjunct to medication for patients with asthma and allergies.

In a plenary presentation, Elizabeth Matsui, MD, MHS, a professor of pediatrics at Johns Hopkins Medicine, proposed that while the in-home use of these tactics has been met with skepticism, it may be due to the way the data are interpreted. While there have been conflicting results from clinical trials—Matsui pointed to 6 examinations, half successful, half failures—she noted that clinicians can make sense of these otherwise confounding results.

“We need standardized reporting framework. Interventions may have clinical effects through pathways other than allergen reduction, so interventions should be interpreted in the context of this step,” Matsui said.

While the current guidelines pay little heed to the use of environmental intervention, Matsui noted that in a survey of AAAAI members, 75% reported that they emphasize the importance these interferences with their patients and 66% responded that they provide educational material to patients to aid their practice of it. That majority may be recommending these methods to their patients simply because they are affordable—especially when used in conjunction with inhalants.

“Fluticasone/salmeterol—the combinations are about $3300 per year. It gets a little bit lower when you do the medium dose and the low dose, about $2500 versus $2100,” Wanda Phipatanakul, MD, MS, a professor of pediatrics at Harvard Medical School and the director of the Asthma Clinical Research Center at Boston Children’s Hospital, said during her presentation. “That’s about $1500 per year. The [environmental] intervention, even [when it is] multi-faceted, actually only cost about $1500 annually. [In Morgan’s study in NEJM] that intervention lasted through the year, and even in the year after the intervention.”

Wanda Phipatanakul, MD, MS

Not only are they successful in lowering the amount patients need to spend, simply educating communities on allergens can prove cost-effective. Phipatanakul pointed to a study published in Pediatrics that showed emergency department visits decrease by 46.6% and hospitalizations decrease by 43.4% over the course of a year for 300 pediatric patients with asthma, while also reducing costs by $878 more than the comparator group.

Additionally, those results were carried over the second year, with an additional average savings of $585 in year 2. “It really had a dose-response decline in cost, and the return on investment was great. It was 50% above break-even costs. It gained a lot of interest—seeing that something that simple could make such a difference,” Phipatanakul said.

While simple education for patients about the interventions can be, and have been, successful, David B. Peden, MD, MS, stressed at the AAAAI/WAO Joint Congress that policy interventions for environmental allergens can provide even better clinical outcomes.

Peden held that during the 1996 Olympic Games in Atlanta, Georgia, policies restricting pollutant output during the games greatly impacted the asthmatic population in the state. In that timeframe, data revealed that hospitalizations for asthma were reduced by 19.1%, and the number of emergency care visits and hospitalizations decreased 41.6% per day (4.23 per day at baseline; 2.47 per day during the Olympic period). Additionally, during the Olympic period, pediatric emergency department visits decreased 11.1%.

Peden noted that the answer is simple: Cleaner air means healthier lungs.

“Show up in to these [municipal] meetings a white coat, tell them you're a doctor, and help generate change,” Peden, the Andrews Distinguished Professor of Pediatrics, the senior associate dean for translational research at the University of North Carolina, and the director of UNC’s Center for Environmental Medicine, Asthma, and Lung Biology, said. “Tell them what we know—that air pollution is damaging and, in some cases, is killing people.”

David B. Peden, MD, MS

Matsui somewhat echoed the sentiment, emphasizing the potential of environmental interventions in places like schools, where they can be beneficial for not just the pediatric patient with allergy or asthma, but for the entire population of the school.

All told, she concluded that the next steps are to alter health care delivery and payment reform, to develop population-level and policy-based interventions, and a framework for random clinical trial reporting.

“Interpreting environmental inventions in random clinical trials is challenging because of mediation by allergen reduction, and population heterogeneity,” she said. “But environmental inventions are effective among pediatric populations when the targeted exposure is reduced, and emerging evidence supports single allergen interventions.”