Year of Publication



Martin School of Public Policy and Administration

Degree Name

Master of Public Administration

Executive Summary


Asthma is a chronic pulmonary disease that occurs in approximately 10 percent of the population worldwide and is associated with a significant increase in direct medical expenditures. Levalbuterol and racemic albuterol are two short-acting β2-agonists (SABA) prescribed for the treatment of asthma. Racemic albuterol has been used for more than 40 years but is associated with several side effects including tremor. When levalbuterol was approved in 2005 its manufacturer and several studies suggested that using levalbuterol results in better respiratory parameters, fewer hospitalizations, less adverse effects and therefore, lower overall treatment costs and hence less need for β-adrenergic agonist treatment. However, this pattern of results is not universal and some studies suggest no significant difference in clinical endpoints. With these conflicting data it is difficult to agree over the choice of which SABA; levalbuterol or racemic albuterol that should be used. The purpose of this study therefore is to compare asthma-related health care expenditures and treatment outcomes after initiation of maintenance treatment with levalbuterol or albuterol.

Research Strategy:

This was a retrospective cohort study of pharmacy and medical claims from the Kentucky Medicaid MMIS database consisting of patients with asthma who received treatment with a short acting beta agonist (SABA); albuterol or levalbuterol between January 1, 2000 and December 31, 2008. Descriptive statistics were used to characterize the study group. Difference over time analyses were used to generate an estimate of the impact of using levalbuterol on asthma-related and total healthcare expenditure. Multiple linear regression analyses were used to obtain a more precise measure of the financial impact of using levalbuterol.

Major Findings:

The baseline characteristics for the two patient populations were significantly different. The levalbuterol group was much younger with an average age of 11 years whereas the racemic albuterol group had an average age of 25 years. The levalbuterol group on average spent $US281 less on asthma related healthcare costs than the racemic albuterol group (p <0.001). The levalbuterol group had an adjusted savings of $US1317 per patient for total healthcare expenditures (p <0.001) compared with the racemic albuterol group. This was mainly due to a large and statistically significant reduction in hospital visits costs of $US788 (p <0.001). The number of emergency department visits, physician visits, and hospitalizations increased statistically for both groups and there was a general shift from less severe to more severe asthma for both groups over time.


This study showed that the added cost of using levalbuterol was more than offset by reductions in other types of healthcare expenditures. Levalbuterol should therefore become the drug of choice for exacerbation of asthma in the Kentucky Medicaid population. Randomized double-blind studies need to be done to verify these results and to determine whether the difference in total costs is due to fewer adverse effects, better adherence or better long-term efficacy.