Estimating the economic consequences of an increased medication adherence due to a potential improvement in the inhaler technique with Spiromax^® compared with Turbuhaler^® in patients with moderate-to-severe chronic obstructive pulmonary disease in Spain

Figures & data

Figure 1 Target population of the study.

Notes: COPD prevalence: in Spain 10.20%, in Andalusia 10.13%, in Catalonia 11.90%, in Galicia 8.20%, in Madrid 11.00%, and in Valencia 7.61%; region-specific percentage of patients who are treated with Rilast^®/Symbicort^® Turbuhaler^®: in Spain 34.99%, in Andalusia 33.85%, in Catalonia 31.53%, in Galicia 34.97%, in Madrid 36.46%, and in Valencia 34.26%; percentage of patients who are treated with a fixed-dose combination (FDC): in Spain 35.85%, in Andalusia 31.23%, in Catalonia 33.42%, in Galicia 42.86%, in Madrid 38.17%, and in Valencia 31.64%.
Abbreviations: DPI, dry powder inhaler; FDC, fixed-dose combination.

Table 1 Errors observed in daily practice

Checklist of inhalation technique errors	Patients using Symbicort^®/Rilast^® Turbuhaler^® (%)	Patients using DuoResp^® Spiromax^® (%)
Failure of loading	17.17	0.83
No breath-holding after inhalation	37.00	36.67
Keep the inhaler inclined no more than 45° from the vertical axis during loading	22.33	5.83
No exhalation prior to inhalation	35.83	28.67
Stop inhaling prematurely	27.67	22.50
Exhaling into the device mouthpiece after inhalation	12.17	8.83

Notes: These percentages were not used for calculation. Sources: Clinical expert panel of pneumologists, allergists, and a general practitioner.

Table 2 Drug cost, medical resource utilization, unit costs, and average cost per patient per year in EUR (€) 2015

	Symbicort^® Turbuhaler^®	Rilast^® Turbuhaler^®	DuoResp^® Spiromax^®	Mean of regional unit costs in € 2015a
Annual resources:
Medical visits
PC	6.80	6.80	5.80	52.62
Specialist physician	2.40	2.40	2.40	75.15
Emergency room visits	0.016	0.016	0.009	173.31
Hospital resource utilization
Number of hospitalizationsb	0.010	0.010	0.010	492.39
Length of hospital stay	7.60	7.60	6.60	–
Other interventions
Spirometry	0.17	0.17	0.17	31.69
Thorax radiography	0.40	0.40	0.40	20.98
Annual drug and medical resources costs per patient:
Drug cost of budesonide/formoterol FDC (€)c	240	240	231	–
Cost of medical visits (€)	541	541	487	–
Cost of hospital resource utilization (€)b	37	37	32	–
Cost of other interventions (€)	14	14	14	–
Cost per patient (€)	832	832	764	–

Notes:

a Mean of unit costs of 12 Spanish regions. Region-specific unit costs of health care resources were used to estimate the economic impact in the 5 regions included.

b The proportions of patients who visited the emergency room and those who are hospitalized due to suboptimal inhaler utilization were 4.92% and 3.26%, respectively. Among patients who visited the emergency room, it was observed that on average the number of events, such as hospitalizations, visits to the emergency room, primary care (PC) visits, and specialist visits, with Turbuhaler were 0.33 and with Spiromax were 0.27, which result in 0.016 times €173.71. The authors performed the same calculations with number of hospitalizations, which resulted in 0.010 times €492.39.

c Differences in drug cost were due to the differences in distributions of doses. However, drug cost was not associated with adherence; therefore, this variation was offset for the calculation of adherence effect. Sources: Clinical expert panel of pneumologists, allergists, and a general practitioner.

Abbreviations: DPI, dry powder inhaler; FDC, fixed-dose combination; PC, primary care.

Table 3 Distribution of treatments (year [%]): base case analysis and alternative scenario

	2015 (%)	2016 (%)	2017 (%)	2018 (%)
Base case analysis
Symbicort^® Turbuhaler^®	50.00	50.00	50.00	50.00
Rilast^® Turbuhaler^®	50.00	50.00	50.00	50.00
DuoResp^® Spiromax^®	0	0	0	0
Alternative scenario
Symbicort Turbuhaler	44.50	41.00	39.00	37.50
Rilast Turbuhaler	44.50	41.00	39.00	37.50
DuoResp Spiromax	11.00	18.00	22.00	25.00

Note: Data provided courtesy of Teva Pharma, Spain.

Table 4 Target population for COPD treatment

Target population (n)	Year
	2015	2016	2017	2018
Spain
Adult patients with COPD	3,861,722	3,839,410	3,817,682	3,798,002
Adult patients diagnosed and treated with an FDC	373,798	371,634	369,531	367,626
Adult patients treated with budesonide/formoterol delivered by a DPI	130,777	130,020	129,284	128,618
Andalusia
Adult patients with COPD	683,721	683,930	684,130	684,515
Adult patients diagnosed and treated with an FDC	57,648	57,666	57,683	57,715
Adult patients treated with budesonide/formoterol delivered by a DPI	19,514	19,520	19,526	19,537
Catalonia
Adult patients with COPD	703,566	694,779	686,440	678,818
Adult patients diagnosed and treated with an FDC	63,483	62,690	61,938	61,250
Adult patients treated with budesonide/formoterol delivered by a DPI	20,016	19,766	19,529	19,312
Galicia
Adult patients with COPD	192,217	191,148	190,090	189,073
Adult patients diagnosed and treated with an FDC	22,242	22,119	21,996	21,879
Adult patients treated with budesonide/formoterol delivered by a DPI	7,778	7,734	7,692	7,650
Madrid
Adult patients with COPD	566,610	562,572	558,661	555,121
Adult patients diagnosed and treated with an FDC	58,392	57,976	57,573	57,208
Adult patients treated with budesonide/formoterol delivered by a DPI	21,289	21,138	20,991	20,858
Valencia
Adult patients with COPD	305,243	302,566	299,975	297,573
Adult patients diagnosed and treated with an FDC	26,080	25,851	25,630	25,424
Adult patients treated with budesonide/formoterol delivered by a DPI	8,936	8,858	8,782	8,712

Abbreviations: DPI, dry powder inhaler; FDC, fixed-dose combination.

Table 5 Results of the base case budget impact analysis in EUR 2015 (€)

		Year
		2015	2016	2017	2018	Present value
Spain	Current scenario
	Symbicort^® Turbuhaler^®	54,382,762	55,221,607	57,307,803	60,867,158	217,716,147
	Rilast^® Turbuhaler^®	54,382,762	55,221,607	57,307,803	60,867,158	217,716,147
	Total cost	108,765,525	110,443,214	114,615,607	121,734,316	435,432,295
	Alternative scenario
	Symbicort Turbuhaler	48,400,658	45,281,717	44,700,087	45,650,368	176,274,165
	Rilast Turbuhaler	48,400,658	45,281,717	44,700,087	45,650,368	176,274,165
	DuoResp^® Spiromax^®	11,118,937	18,463,363	23,389,224	28,177,600	76,877,616
	Total cost	107,920,255	109,026,799	112,789,398	119,478,338	429,425,947
	Budget impact savings	−845,270	−1,416,415	−1,826,209	−2,255,979	−6,006,348
Andalusia	Current scenario
	Symbicort Turbuhaler	8,106,166	8,281,603	8,645,751	9,235,267	32,747,585
	Rilast Turbuhaler	8,106,166	8,281,603	8,645,751	9,235,267	32,747,585
	Total cost	16,212,332	16,563,206	17,291,503	18,470,535	65,495,171
	Alternative scenario
	Symbicort Turbuhaler	7,214,488	6,790,914	6,743,686	6,926,450	26,502,863
	Rilast Turbuhaler	7,214,488	6,790,914	6,743,686	6,926,450	26,502,863
	DuoResp Spiromax	1,657,789	2,769,674	3,529,544	4,276,478	11,587,311
	Total cost	16,086,765	16,351,502	17,016,917	18,129,380	64,593,038
	Budget impact savings	−125,567	−211,703	−274,586	−341,155	−902,133
Catalonia	Current scenario
	Symbicort Turbuhaler	7,036,367	7,085,759	7,284,274	7,656,351	27,788,519
	Rilast Turbuhaler	7,036,367	7,085,759	7,284,274	7,656,351	27,788,519
	Total cost	14,072,734	14,171,518	14,568,549	15,312,703	55,577,039
	Alternative scenario
	Symbicort Turbuhaler	6,262,367	5,810,322	5,681,734	5,742,263	22,514,021
	Rilast Turbuhaler	6,262,367	5,810,322	5,681,734	5,742,263	22,514,021
	DuoResp Spiromax	1,442,542	2,375,347	2,980,215	3,552,053	9,808,476
	Total cost	13,967,276	13,995,992	14,343,684	15,036,581	54,836,519
	Budget impact savings	−105,459	−175,526	−224,865	−276,122	−740,520
Galicia	Current scenario
	Symbicort Turbuhaler	3,790,274	3,854,414	4,010,272	4,273,525	15,223,372
	Rilast Turbuhaler	3,790,274	3,854,414	4,010,272	4,273,525	15,223,372
	Total cost	7,580,548	7,708,829	8,020,545	8,547,050	30,446,745
	Alternative scenario
	Symbicort Turbuhaler	3,373,344	3,160,620	3,128,012	3,205,144	12,323,520
	Rilast Turbuhaler	3,373,344	3,160,620	3,128,012	3,205,144	12,323,520
	DuoResp Spiromax	768,535	1,278,100	1,623,336	1,962,387	5,335,423
	Total cost	7,515,223	7,599,340	7,879,362	8,372,675	29,982,463
	Budget impact savings	−65,324	−109,489	−141,184	−174,375	−464,281
Madrid	Current scenario
	Symbicort Turbuhaler	7,940,250	8,044,041	8,321,122	8,802,898	31,649,353
	Rilast Turbuhaler	7,940,250	8,044,041	8,321,122	8,802,898	31,649,353
	Total cost	15,880,500	16,088,082	16,642,244	17,605,796	63,298,706
	Alternative scenario
	Symbicort Turbuhaler	7,066,822	6,596,113	6,490,475	6,602,173	25,630,636
	Rilast Turbuhaler	7,066,822	6,596,113	6,490,475	6,602,173	25,630,636
	DuoResp Spiromax	1,641,197	2,719,043	3,433,623	4,120,535	11,288,438
	Total cost	15,774,843	15,911,270	16,414,574	17,324,882	62,549,711
	Budget impact savings	−105,657	−176,812	−227,670	−280,914	−748,996
Valencia	Current scenario
	Symbicort Turbuhaler	4,123,785	4,178,338	4,330,637	4,597,319	16,469,664
	Rilast Turbuhaler	4,123,785	4,178,338	4,330,637	4,597,319	16,469,664
	Total cost	8,247,571	8,356,675	8,661,274	9,194,639	32,939,328
	Alternative scenario
	Symbicort Turbuhaler	3,670,169	3,426,237	3,377,897	3,447,989	13,336,004
	Rilast Turbuhaler	3,670,169	3,426,237	3,377,897	3,447,989	13,336,004
	DuoResp Spiromax	837,079	1,386,998	1,754,809	2,113,064	5,771,508
	Total cost	8,177,417	8,239,472	8,510,603	9,009,044	32,443,516
	Budget impact savings	−70,154	−117,203	−150,671	−185,595	−495,812

Table 6 Specific results: savings due to reduction of health care resource utilization in EUR 2015 (€)

Regions and savings in Euros (€)	Year
	2015	2016	2017	2018	Present value
Spain
Savings due to fewer days of hospital stay (€)	−69,700	−116,795	−150,586	−186,024	−495,274
Savings due to fewer emergency room visits (€)	−18,534	−31,057	−40,043	−49,466	−131,699
Savings due to avoided PC visits (€)	−757,037	−1,268,563	−1,635,580	−2,020,488	−5,379,375
Total savings in Spain (€)	−845,270	−1,416,415	−1,826,209	−2,255,979	−6,006,348
Andalusia
Savings due to fewer days of hospital stay (€)	−12,447	−20,984	−27,218	−33,816	−89,421
Savings due to fewer emergency room visits (€)	−2,096	−3,534	−4,584	−5,696	−15,062
Savings due to avoided PC visits (€)	−111,025	−187,184	−242,784	−301,643	−797,650
Total savings in Andalusia (€)	−125,567	−211,703	−274,586	−341,155	−902,133
Catalonia
Savings due to fewer days of hospital stay (€)	−11,656	−19,400	−24,853	−30,518	−81,846
Savings due to fewer emergency room visits (€)	−2,629	−4,375	−5,605	−6,882	−18,457
Savings due to avoided PC visits (€)	−91,174	−151,751	−194,407	−238,722	−640,217
Total savings in Catalonia (€)	−105,459	−175,526	−224,865	−276,122	−740,520
Galicia
Savings due to fewer days of hospital stay (€)	−4,453	−7,464	−9,624	−11,887	−31,649
Savings due to fewer emergency room visits (€)	−1,634	−2,738	−3,531	−4,361	−11,611
Savings due to avoided PC visits (€)	−59,238	−99,287	−128,029	−158,127	−421,021
Total savings in Galicia (€)	−65,324	−109,489	−141,184	−174,375	−464,281
Madrid
Savings due to fewer days of hospital stay (€)	−10,909	−18,256	−23,507	−29,005	−77,334
Savings due to fewer emergency room visits (€)	−3,143	−5,260	−6,773	−8,356	−22,281
Savings due to avoided PC visits (€)	−91,605	−153,296	−197,390	−243,553	−649,381
Total savings in Madrid (€)	−105,657	−176,812	−227,670	−280,914	−748,996
Valencia
Savings due to fewer days of hospital stay (€)	−3,129	−5,227	−6,720	−8,277	−22,113
Savings due to fewer emergency room visits (€)	−1,186	−1,981	−2,547	−3,137	−8,380
Savings due to avoided PC visits (€)	−65,839	−109,995	−141,405	−174,181	−465,319
Total savings in Valencia (€)	−70,154	−117,203	−150,671	−185,595	−495,812

Abbreviation: PC, primary care.

Table 7 Sensitivity analysis results in EUR 2015 (€)

Parameter	Base case value	Sensitivity analysis value	Present value in Spain (€)	Present value in Andalusia (€)	Present value in Catalonia (€)	Present value in Galicia (€)	Present value in Madrid (€)	Present value in Valencia (€)
Base case			−6,006,348	−902,133	−740,520	−464,281	−748,996	−495,812
Patients’ age	≥18 years	≥40 years	−4,079,776	−587,287	−507,477	−332,721	−500,433	−339,417
Adherence rate	40%	20%	−3,139,202	−563,048	−517,304	−201,720	−490,911	−242,940
		60%	−9,417,607	−1,689,143	−1,551,912	−605,159	−1,472,733	−636,616
Market share	Market share provided by	+2% for DuoResp^® Spiromax^®	−6,634,481	−996,307	−818,113	−512,834	−827,355	−547,709
	TEVA Pharma, Spain	−2% for DuoResp Spiromax	−5,378,215	−807,959	−662,926	−415,729	−670,636	−443,914
COPD severity	All COPD severities	Moderate	−2,144,266	−322,062	−264,366	−165,748	−267,391	−177,005
		Severe	−606,641	−91,115	−74,792	−46,892	−75,649	−50,077