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General Practice

Randomised comparison of cost effectiveness of guided self management and traditional treatment of asthma in Finland

BMJ 1998; 316 doi: (Published 11 April 1998) Cite this as: BMJ 1998;316:1138
  1. Aarne Lahdensuo, heada (aarne.lahdensuo{at},
  2. Tari Haahtela, directorb,
  3. Jaakko Herrala, consultant physiciana,
  4. Tuomo Kava, headc,
  5. Kirsti Kiviranta, consultant physicianb,
  6. Paula Kuusisto, consultant physiciana,
  7. Markku Pekurinen, directord,
  8. Erkki Perämäki, consultant physicianc,
  9. Seppo Saarelainen, consultant physiciana,
  10. Thore Svahn, clinical research scientiste,
  11. Bengt Liljas, health economistf
  1. a Department of Pulmonary Diseases, Tampere University Hospital, 36280 Pikonlinna, Finland,
  2. b Skin and Allergy Hospital, Helsinki University Central Hospital, 00250 Helsinki, Finland,
  3. c Department of Pulmonary Diseases, Central Hospital of Northern Karelia, 80780 Kontioniemi, Finland,
  4. d Health Services Research, 00150 Helsinki, Finland,
  5. e Suomen Astra Oy, 02430 Masala, Finland,
  6. f Astra Draco AB, 221 00 Lund, Sweden
  1. Correspondence to: Dr Lahdensuo
  • Accepted 8 September 1997

In many countries the cost of caring for patients with asthma is high.1 Guidelines have recommended guided self management for the treatment of asthma. 2 3 We recently compared the efficacy of guided self management with traditional treatment for asthma4 and here report the cost effectiveness of the two treatments.

Patients, methods, and results

One hundred and fifteen patients with mild to moderately severe asthma were randomly allocated guided self management or traditional treatment. The 56 patients allocated guided self management were given personal education and they were taught to measure their peak expiratory flow rate every morning for a year. If the value fell below 85% of their predetermined optimal value on any morning they were instructed to double their dose of inhaled corticosteroid for 2 weeks. If the value fell below 70% of the optimal value on any morning they were to take oral prednisolone (40 mg/day) for 7 days and immediately contact their nurse or doctor. The 59 patients allocated traditional treatment did not have peak flow meters and received no instructions about changing their dosage. Every fourth month all the patients visited their outpatient clinic.

Direct healthcare costs related to asthma included counselling (individual training and instruction in the guided self management group and general information in the other) peak flow meter, drugs, visits to the doctor other than for the study, and admissions. Indirect healthcare costs included absence from work. Total costs were the sum of the direct and indirect costs. Resource use was valued at 1994 prices (currently 8.84 Finnish marks=£1). Effectiveness was measured as the number of healthy days, defined as 365 minus the number of days with any incident caused by asthma, including admission, unscheduled visits to their doctor, outpatient clinic, or casualty department, days off work, and courses of oral antibiotics or prednisolone.

The table shows the average costs per patient over the year. The direct healthcare costs were 649 Finnish marks lower for traditional treatment (P=0.05), but because of the lower indirect costs for guided self management (2412 Finnish marks; P=0.008) the total costs were 1762 Finnish marks lower for guided self management (P=0.09). The mean number of healthy days was 359.2 in the guided self management group and 344.3 in the traditional treatment group. Thus, guided self management was 4.3% (P<0.001) more effective than traditional treatment. One outlier in the guided self management group was excluded from the analysis as the indirect costs were 24 times higher than those for the patient with the next highest indirect costs in that group. The patient who was the outlier had taken extended sick leave to avoid potentially harmful dusts in the workplace, not because of an exacerbation of asthma as in the other cases. Including this outlier would bias the results and not reflect the true expected costs of guided self management. When, however, the outlier (table) was included the differences in indirect costs were reduced to 1607 Finnish marks (P=0.18) and the differences in total costs were reduced to 950 Finnish marks (P=0.47). Both these costs are still higher for traditional treatment. We regard the results without the outlier as the main results.

Mean annual direct, indirect, and total costs (in Finnish marks), and mean annual number of healthy days per patient for guided self management (with and without the outlier) and traditional treatment

View this table:


The guided self management group had more healthy days (P<0.001) and lower total costs (P<0.1) than the traditional treatment group. The inclusion of an outlier in the guided self management group reduced the difference in total costs, but the conclusions remain the same. The short term direct healthcare costs for guided self management were increased because of extensive counselling during the study year. Reduction in the counselling should decrease the difference in the direct healthcare costs long term, while the benefits of healthy days with guided self management should prevail.


Contributors: AL initiated and supervised the study, discussed the core ideas, participated in the design protocol, data analysis, and interpretation, and was the main writer of the paper; he will act as guarantor for the paper. TH initiated the study, discussed the core ideas, participated in the design protocol, data analysis, and interpretation, and contributed to the paper. BL discussed the core ideas, participated in the data analysis, statistical analysis, and interpretation, and was the main contributor of the paper. PK discussed the core ideas, participated in the design protocol, data collection, data analysis, and interpretation, and edited the paper. JH, TK, KK, EP, and SS participated in the data collection and edited the paper. TS participated in the design protocol, data analysis, and interpretation, and quality control and edited the paper; he was the clinical monitor of the study. MP participated in the design and collection of the financial data, data analysis and interpretation, and statistical analysis and edited the paper.

Funding: Suomen Astra Oy.

Conflict of interest: None.


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