, Volume 37, Issue 2, pp 227–238 | Cite as

Does a Patient-Directed Financial Incentive Affect Patient Choices About Controller Medicines for Asthma? A Discrete Choice Experiment and Financial Impact Analysis

  • Tracey-Lea LabaEmail author
  • Helen K. Reddel
  • Nicholas J. Zwar
  • Guy B. Marks
  • Elizabeth Roughead
  • Anthony Flynn
  • Michele Goldman
  • Aine Heaney
  • Kirsty Lembke
  • Stephen Jan
Original Research Article



In Australia, many patients who are initiated on asthma controller inhalers receive combination inhaled corticosteroid/long-acting beta2-agonist (ICS/LABA) despite having asthma of sufficiently low severity that ICS-alone would be equally effective and less costly for the government.


We conducted a discrete choice experiment (DCE) in a nationally representative sample of adults (n = 792) and parents of children (n = 609) with asthma. Mixed multinomial models were estimated and calibrated to reflect the estimated market shares of ICS-alone, ICS/LABA and no controller. We then simulated the impact of varying patient co-payment on demand and the financial impact on government pharmaceutical expenditure.


Preference for inhaler decreased with increasing costs to the patient or government, increasing chance of a repeat visit to the doctor, and if fewer symptoms were present. Adults preferred high-strength controllers, but parents preferred low-strength inhalers for children (general beneficiaries only). The DCE predicted a higher proportion choosing controller treatment (89%) compared to current levels (57%) at the current co-payment level, with proportionately higher uptake of ICS-alone and a lower average cost per patient [32.73 Australian dollars (AU$) c.f. AU$38.54]. Reducing the co-payment on ICS-alone by 50% would increase its market share to 50%, whilst completely removing the co-payment would only have a small marginal impact on market share, but increased average cost of treatment to the government to AU$41.04 per person.


Patient-directed financial incentives are unlikely to encourage much switching of medicines, and current levels of under-treatment are not explained by patient preferences. Interventions directed at prescribers are more likely to promote better use of asthma medicines.



The authors would like to acknowledge the valuable input from advisory group members throughout this project.

Compliance with Ethical Standards

Ethical approval and informed consent

Ethical approval was granted by the University of New South Wales Human Research Advisory Panel Ethics Committee (Approval number # HREAP 2014-7-34). All procedures were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Informed consent was obtained from all individual participants.

Data availability

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.


This study was funded by a National Health and Medical Research Council (NHMRC) partnership grant (GNT1077204) with matching funding (including in-kind in the form of staff time) from Asthma Foundation NSW and Asthma Australia Inc. (both now part of the new merged Asthma Australia Limited) and from NPS MedicineWise. TL is supported by a NHMRC Early Career (Sidney Sax) Fellowship (APP 1110230). SJ is supported by an NHMRC Principal Research Fellowship (APP111943). ER is supported by an NHMRC Senior Principal Research Fellowship (APP1110139).

Conflict of interest

HKR reports receiving independent research grants and study inhalers from GlaxoSmithKline and AstraZeneca, honoraria from AstraZeneca, GlaxoSmithKline, Merck and Novartis for participation on a data safety monitoring board, and honoraria for providing independent medical advice on advisory boards or steering committees from AstraZeneca, GlaxoSmithKline, Novartis and Boehringer Ingelheim, and for providing independent medical education at symposia funded by AstraZeneca, GlaxoSmithKline, Novartis, Teva, Boehringer Ingelheim and Mundipharma. HKR is Chair of the Global Initiative for Asthma (GINA) Scientific Committee and a member of the Australian Asthma Handbook Guidelines Committee. GBM reports non-financial support from GlaxoSmithKline PLC, grants from AstraZeneca, outside the submitted work. MG reports income from multiple pharmaceutical and device manufacturers outside the submitted work, specifically, non-financial support from Bird Healthcare, non-financial support from GSK, non-financial support from Astra Zeneca, grants from GSK, grants from Astra Zeneca, grants from Sanofi, grants from Bayer, and grants from Cipla. TL, NJZ, ER, AF, AH, KL, and SJ have no conflicts of interest related to the contents of this article.

Author contributions

All authors contributed to the conception or design of the work; acquisition, analysis or interpretation of data for the work; drafting or critical revision for intellectual content; final approval of the submitted version; and are accountable for all aspects of the work.

Supplementary material

40273_2018_731_MOESM1_ESM.docx (30 kb)
Supplementary material 1 (DOCX 31 kb)


  1. 1.
    Vos T, Barber RM, Bell B, Bertozzi-Villa A, Biryukov S, Bolliger I, et al. Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015;386(9995):743–800. Scholar
  2. 2.
    Ni Chroinin M, Greenstone I, Lasserson TJ, Ducharme FM. Addition of long‐acting beta2‐agonists to inhaled steroids as first line therapy for persistent asthma in steroid‐naive adults and children. Cochrane Database Syst Rev. 2009;(4):CD005307.
  3. 3.
    Peters SP, Bleecker ER, Canonica GW, Park YB, Ramirez R, Hollis S, et al. Serious asthma events with budesonide plus formoterol vs. budesonide alone. N Engl J Med. 2016;375(9):850–60. Scholar
  4. 4.
    Stempel DA, Raphiou IH, Kral KM, Yeakey AM, Emmett AH, Prazma CM, et al. Serious asthma events with fluticasone plus salmeterol versus fluticasone alone. N Engl J Med. 2016;374(19):1822–30. Scholar
  5. 5.
    Global Initiative for Asthma. Global strategy for asthma management and prevention. Vancouver: GINA2018; 2018.Google Scholar
  6. 6.
    National Asthma Council Australia. Australian asthma handbook, version 1.3. Melbourne: National Asthma Council Australia; 2017.Google Scholar
  7. 7.
    Reddel HK, Beckert L, Moran A, Ingham T, Ampon RD, Peters MJ, et al. Is higher population-level use of ICS/LABA combination associated with better asthma outcomes? Cross-sectional surveys of nationally representative populations in New Zealand and Australia. Respirology (Carlton, VIC). 2017;22(8):1570–8. Scholar
  8. 8.
    Australian Government Department of Health. Pharmaceutical Benefits Scheme (PBS)|About the PBS. Commonwealth of Australia. 2015. Accessed 25 Sept 2018.
  9. 9.
    Gourzoulidis G, Kourlaba GC, Stafylas PC, Giamouzis G, Parissis J, Maniadakis N. Association between copayment, medication adherence and outcomes in the management of patients with diabetes and heart failure. Health Policy. 2017;121(4):363–77.CrossRefGoogle Scholar
  10. 10.
    Tarasiuk A, Reznor G, Greenberg-Dotan S, Reuveni H. Financial incentive increases CPAP acceptance in patients from low socioeconomic background. PLoS ONE. 2012;7(3):e33178-e. Scholar
  11. 11.
    Ampon RD, Reddel HK, Correll PK, Poulos LM, Marks GB. Cost is a major barrier to the use of inhaled corticosteroids for obstructive lung disease. Med J Aust. 2009;191(6):319–23.Google Scholar
  12. 12.
    Hynd A, Roughead EE, Preen DB, Glover J, Bulsara M, Semmens J. The impact of co-payment increases on dispensings of government-subsidised medicines in Australia. Pharmacoepidemiol Drug Saf. 2008;17(11):1091–9. Scholar
  13. 13.
    Colice GL, Yu AP, Ivanova JI, Hsieh M, Birnbaum HG, Lage MJ, et al. Costs and resource use of mild persistent asthma patients initiated on controller therapy. J Asthma Off J Assoc Care Asthma. 2008;45(4):293–9. Scholar
  14. 14.
    Bridges JFP, Hauber AB, Marshall D, Lloyd A, Prosser LA, Regier DA, et al. Conjoint analysis applications in health—a checklist: a report of the ISPOR Good Research Practices for Conjoint Analysis Task Force. Value Health. 2011;14(4):403–13. Scholar
  15. 15.
    Terris-Prestholt F, Quaife M, Vickerman P. Parameterising user uptake in economic evaluations: the role of discrete choice experiments. Health Econ. 2016;25:116–23. Scholar
  16. 16.
    Mulley AG, Trimble C, Elwyn G. Stop the silent misdiagnosis: patients’ preferences matter. BMJ. 2012;345:e6572. Scholar
  17. 17.
    Research Now SSI. Worldwide survey companies. 2018. Accessed 2 Feb 2018.
  18. 18.
    Reddel HK, Sawyer SM, Everett PW, Flood PV, Peters MJ. Asthma control in Australia: a cross-sectional web-based survey in a nationally representative population. Med J Aust. 2015;202(9):492–7.CrossRefGoogle Scholar
  19. 19.
    Hensher DA, Rose J, Greene W. Applied choice analysis: a primer. Cambridge: Cambridge University Press; 2005.CrossRefGoogle Scholar
  20. 20.
    Ducharme FM, Ni Chroinin M, Greenstone I, Lasserson TJ. Addition of long-acting beta2-agonists to inhaled steroids versus higher dose inhaled steroids in adults and children with persistent asthma. Cochrane Database Syst Rev. 2010. Scholar
  21. 21.
    Ghijben P, Lancsar E, Zavarsek S. Preferences for oral anticoagulants in atrial fibrillation: a best-best discrete choice experiment. PharmacoEconomics. 2014;32(11):1115–27. Scholar
  22. 22.
    Lancsar E, Fiebig DG, Hole AR. Discrete choice experiments: a guide to model specification, estimation and software. PharmacoEconomics. 2017;35(7):697–716. Scholar
  23. 23.
    Australian Government Department of Health. Australian Statistics on Medicines 2014. In: The Pharmaceutical Benefits Scheme. Commonwealth of Australia, 2015, Canberra, Australia. 2015. Accessed 08 Jan 2018.
  24. 24.
    Janssen EM, Hauber AB, Bridges JFP. Conducting a discrete-choice experiment study following recommendations for good research practices: an application for eliciting patient preferences for diabetes treatments. Value Health. 2018;21(1):59–68. Scholar
  25. 25.
    Tudball J, Reddel HK, Laba T-L, Jan S, Flynn A, Goldman M, et al. General practitioners’ views on the influence of cost on prescribing of asthma preventer medicines: a qualitative study. Aust Health Rev. 2018. (Epub ahead of print).Google Scholar
  26. 26.
    Lancsar E, Swait J. Reconceptualising the external validity of discrete choice experiments. PharmacoEconomics. 2014;32(10):951–65. Scholar
  27. 27.
    Gagné ME, Légaré F, Moisan J, Boulet L-P, Murray JJ, Nathan RA. Impact of adding a decision aid to patient education in adults with asthma: a randomized clinical trial. PLOS ONE. 2017;12(1):e0170055-e. Scholar
  28. 28.
    Reddel HK, Busse WW, Pedersen S, Tan WC, Chen YZ, Jorup C, et al. Should recommendations about starting inhaled corticosteroid treatment for mild asthma be based on symptom frequency: a post-hoc efficacy analysis of the START study. Lancet (Lond, Engl). 2017;389(10065):157–66. Scholar
  29. 29.
    Hensher DA. Hypothetical bias, choice experiments and willingness to pay. Transp Res Part B Methodol. 2010;44(6):735–52. Scholar
  30. 30.
    Loomis JB. Strategies for overcoming hypothetical bias in stated preference surveys. J Agric Resour Econ. 2014;39(1):34–46. Scholar
  31. 31.
    Sadatsafavi M, Lynd LD, De Vera MA, Zafari Z, FitzGerald JM. One-year outcomes of inhaled controller therapies added to systemic corticosteroids after asthma-related hospital discharge. Respir Med. 2015;109(3):320–8. Scholar
  32. 32.
    Stempel DA, Stoloff SW, Carranza Rosenzweig JR, Stanford RH, Ryskina KL, Legorreta AP. Adherence to asthma controller medication regimens. Respir Med. 2005;99(10):1263–7. Scholar
  33. 33.
    Aaron SD, Vandemheen KL, FitzGerald JM, Ainslie M, Gupta S, Lemière C, et al. Reevaluation of diagnosis in adults with physician-diagnosed asthma. JAMA. 2017;317(3):269. Scholar
  34. 34.
    Madden JM, Graves AJ, Ross-Degnan D, Briesacher BA, Soumerai SB. Cost-related medication nonadherence after implementation of Medicare Part D, 2006–2007. JAMA. 2009;302(16):1755–6. Scholar

Copyright information

© Springer Nature Switzerland AG 2018

Authors and Affiliations

  • Tracey-Lea Laba
    • 1
    • 2
    Email author
  • Helen K. Reddel
    • 3
  • Nicholas J. Zwar
    • 4
    • 5
  • Guy B. Marks
    • 3
    • 6
  • Elizabeth Roughead
    • 7
  • Anthony Flynn
    • 8
  • Michele Goldman
    • 8
  • Aine Heaney
    • 9
  • Kirsty Lembke
    • 9
  • Stephen Jan
    • 2
  1. 1.Menzies Centre for Health Policy, Sydney Medical School, School of Public HealthThe University of SydneySydneyAustralia
  2. 2.The George Institute for Global HealthUniversity of New South WalesSydneyAustralia
  3. 3.Woolcock Institute of Medical ResearchUniversity of SydneySydneyAustralia
  4. 4.School of Public Health and Community MedicineUniversity of New South WalesSydneyAustralia
  5. 5.School of MedicineUniversity of WollongongWollongongAustralia
  6. 6.South Western Sydney Clinical SchoolUniversity of New South WalesSydneyAustralia
  7. 7.Quality Use of Medicines and Pharmacy Research Centre, School of Pharmacy and Medical SciencesUniversity of South AustraliaAdelaideAustralia
  8. 8.Asthma Foundation Queensland and New South Wales, now part of Asthma Australia LimitedSydneyAustralia
  9. 9.NPS MedicineWiseSydneyAustralia

Personalised recommendations