Asthma Prescriptions Research Articles

Prescriptions for Asthma and COPD in Germany for the Years 2007, 2010, 2013, 2015 - 2017

Numbers of prescriptions of the most important substances/combinations for the treatment of asthma and COPD have been extracted out of the sum of all prescriptions of a statistically relevant number of family physicians, internal medicine specialists and pneumologists and analysed.Prescriptions of inhalation drugs showed an increase and those of oral drugs a decrease in therapy of asthma and COPD over a period of 10 years.With asthma there was a clear increase in the prescription of anti-inflammatory substances and a decrease in that of short-acting bronchodilators. There was an increase in prescriptions of short-acting beta agonists in relation to prescriptions of short-acting muscarine antagonists and short-acting beta agonists/short-acting muscarine antagonists, which showed a decrease. For the therapy of COPD, there was a clear increase in the prescription of long-acting bronchodilators and a very slight tendency towards a decrease of ICS-containing drugs. This decrease was so slight that we still have to fear extensive overuse of ICS in COPD. Prescriptions of short-acting bronchodilators increased minimally, and whereas there was an increase in prescriptions of short-acting beta-agonists, there was a decrease in short-acting muscarine antagonists and short-acting beta agonists/short-acting muscarine antagonists.

Trends in Asthma Control, Treatment, Health Care Utilization, and Expenditures Among Children in the United States by Place of Residence: 2003-2014

Examining national trends in asthma treatment and control is essential to inform treatment and public health initiatives. Explore national trends in asthma control and treatment over time among children and those residing in poor-urban areas. This was an analysis of trends from 2003 to 2014 among children (aged 1-17 years) in the Medical Expenditure Panel Survey. Indicators of poor control included use of more than 3 canisters of short-acting β-agonists (SABAs) in 3 months, asthma attack, emergency department/inpatient hospitalization, and systemic corticosteroids. Treatment included inhaled corticosteroids, controller medications, SABAs, and greater than or equal to 0.7 ratio of controller-to-total prescriptions. Other measures included the number of asthma medications, outpatient visits, asthma-specific drug, and total expenditures per-patient-per-year. There were 8.4 million children with asthma in the United States in 2014; 11.1% lived in poor-urban areas. There was a statistically significant decrease in the percentage of children using inhaled corticosteroids, controller medications, daily preventive medications, systemic corticosteroids, SABAs, more than 3 canisters of SABAs (in 3 months), overall asthma prescriptions, and outpatient visits. There was a significant increase in the percentage of children reporting having an asthma attack. Trends for children residing in poor-urban areas were compared with all others; however, limited data and variability in annual estimates prevent clear conclusions. Results suggest lack of improvement in treatment and control since 2003 among children with asthma in the United States. There is significant room for improvement in asthma control and disease management among children.

Prescriptive adherence to GINA guidelines and asthma control: An Italian cross sectional study in general practice.

Although general practitioners (GPs) are frequently the first healthcare professionals whom asthma patients refer to for their symptoms, few studies have explored the extent of adherence to guidelines for asthma management based on data provided directly by GPs. Aims of the present study were to assess drug prescriptions for asthma by GPs and to evaluate prescriptive adherence to GINA guidelines (GL) and its relationship with disease control in real life. 995 asthmatic patients (45% males, mean age 43.3 ± 17.7 yrs) were enrolled by 107 Italian GPs distributed throughout the country. Data on diagnosis, disease severity, prescribed anti-asthmatic drugs and control were collected through questionnaires filled out by GPs taking into consideration the 2009 GINA Guidelines. Data on drug use and chronic sinusitis, nasal polyposis, chronic bronchitis, emphysema were reported by patients through a self-administered questionnaire. The large majority of patients were classified by GPs as having intermittent (48.4%) or mild persistent asthma (25.3%); 61% had co-morbid allergic rhinitis (AR). The prevalent therapeutic regimen used by patients was a combination of inhaled corticosteroids (ICS) plus long-acting β2-agonists (LABA) (54.1%), even in the intermittent/mild persistent group. ICS as mono-therapy or in combination with other drugs but LABA, was the second most frequently adopted treatment (14.4%). In general, the GPs adherence to GL treatment indications was 28.8%, with a significant association with a good asthma control (OR 1.85, 95% CI 1.18-2.92). On the other hand, comorbidity (OR 0.52, 95% CI 0.32-0.84), moderate (0.44, 0.28-0.69) and severe (0.06, 0.02-0.20) persistent asthma showed significant negative effects on asthma control. Our results show that over-treatment of intermittent/mild persistent asthma is frequent in the GPs setting while therapeutic regimens are more appropriately applied for moderate/severe asthma. In general, we found low adherence to GINA GL treatment recommendations even if its relevance in asthma control was confirmed.

IMPACT OF BASELINE EOSINOPHILS ON FUTURE EXACERBATIONS IN PATIENTS WITH MODERATE-TO-SEVERE ASTHMA

Introduction Elevated eosinophils (EOS) are one marker for Type 2 asthma. We assessed the association between baseline EOS and severe asthma exacerbations. Methods Data from the Clinical Practice Research Datalink identified adult patients with clinical diagnosis codes for asthma and prescription utilization patterns indicative of moderate-to-severe asthma (Step 3–5 per British Thoracic Society 2011 guidelines). Date of first asthma prescription during 01JAN2010–31DEC2012 was the index date. Patients had 12-months pre-index and 36-months post-index data. Patients were stratified by baseline EOS (nearest EOS result ±180 days of index date): Level 1 (L1), 3; L2, 150–299 cells/mm3; L3, 300–499 cells/mm3; L4, ≥500 cells/mm3. Risk of severe exacerbations during the post-index period was reported using hazard ratios (HRs) and incident rate ratios (IRRs). Results Overall, 36,614 patients were identified, of which 12,155 had baseline EOS measurements. There were no significant differences in HRs for time to first exacerbation in L2 and L3 patients compared with L1; however, patients in L4 had a significantly greater risk of exacerbations. Unadjusted exacerbation rates per patient per year by EOS category were: L1 (0.42), L2 (0.41), L3 (0.44), and L4 (0.50). IRRs for exacerbations were similar in L2 and L3 patients compared with L1; however, L4 patients had significantly higher exacerbation rates (see Table). Conclusions Given that severe exacerbation rates were not associated with baseline EOS levels except for EOS ≥500 cells/mm3, baseline EOS may not be a consistent predictor of exacerbations; therefore, other potential predictors of exacerbations should be explored. Table. Severe exacerbation risk over the follow-up period categorized by baseline eosinophil level in patients with moderate-to-severe asthma

IMPACT OF BASELINE LUNG FUNCTION ON FUTURE EXACERBATIONS IN PATIENTS WITH MODERATE-TO-SEVERE ASTHMA

Introduction Although reduced lung function is associated with quality of life impairment and increased mortality risk, limited real-world evidence exists on the impact of forced expiratory volume in one second percent predicted (FEV1pp) on exacerbations among moderate-to-severe asthma patients. Methods Data from the Clinical Practice Research Datalink was used to identify adult patients with clinical diagnosis codes for asthma and having prescription utilization patterns indicative of moderate-to-severe asthma (Step 3–5 per British Thoracic Society 2011 guidelines). The date of first asthma prescription during 01JAN2010–31DEC2012 was the index date. Patients had 12-months pre-index and 36-months post-index date data. Additionally, patients having baseline FEV1pp results were selected to assess the relationship between FEV1pp and follow-up severe asthma exacerbations. Severe asthma exacerbations were identified by asthma-related emergency room visits, inpatient admissions, or acute oral corticosteroid use. Patients were stratified by baseline FEV1pp (nearest FEV1pp result ±180 days of index date): Group 1 (G1), ≥80%; G2, 50–79%; G3, Results Overall, 36,614 patients were identified of which 1,865 had baseline FEV1pp results. Patients with lower baseline FEV1pp (G2 and G3) had a significantly greater risk for and higher incidence of exacerbations compared with G1 (see Table). Conclusions Lower baseline FEV1pp levels are associated with a higher risk of severe exacerbations suggesting that baseline lung function is an important predictor of future asthma exacerbations. Table. Severe exacerbation risk over the follow-up period categorized by baseline FEV1pp group in patients with moderate-to-severe asthma

MEDICATION USE PATTERNS IN ASTHMATIC PATIENTS WITH AND WITHOUT ALLERGIES

Introduction The prevalence of allergic asthma (AA) among patients with asthma is significant. We examined medication use patterns among individuals with asthma with and without comorbid allergies to explore potential differences. Methods Retrospective analysis of survey and pharmacy claims from the Observational Study of Asthma Control and Outcomes. Eligible patients with persistent asthma aged ≥12 years were sent four surveys over 15 months. Allergies were identified by a positive response to survey question about hay fever/seasonal allergies and at least one diagnostic code (ICD-9) for atopic conditions. Outcomes included the number of asthma prescriptions dispensed (NPD) and any use (yes/no). Random-effects (RE) negative binomial regression was used for NPD and RE logistic regression was used for dichotomous outcomes, adjusting for age, gender, race, ethnicity, income, education, smoking status and season. Results There were 2,681 individuals with asthma of whom 971 also had allergies. Patients with asthma and comorbid allergies received significantly more prescriptions than patients without comorbid allergies for the following asthma medications (TABLE 1: incidence rate ratio [IRR]): controller (1.22), ICS (1.16), high-dose ICS (2.50), OCS (2.31) and SABA (1.18). Patients with comorbid allergies had significantly greater odds of chronic (OR 16.15) and short-term OCS (OR 2.34) use. Conclusions Patients with asthma and allergic comorbidity have significantly greater asthma-related medication burden than patients with asthma but no allergies. The greater medication use among patients with allergic comorbidity is consistent with more severe asthma. Patients with asthma and allergies may need more vigilant clinical oversight to ensure adequate control. Medication Use for Asthmatic Patients with Allergies Compared to those Without Allergies

Early inspired oxygen and intermittent hypoxemic events in extremely premature infants are associated with asthma medication use at 2 years of age

Objective:Extremely premature infants are at risk for childhood wheezing. Early respiratory support and intermittent hypoxemia (IH) events may be associated with adverse breathing outcomes.Study Design:A single-center retrospective cohort study of 137 premature infants <28 weeks gestational age characterized the associations of cumulative oxygen, cumulative mean airway pressure, IH, and oxygen saturation (SpO2) on the primary outcome of prescription asthma medication use at 2 year follow-up. Relative risk was calculated by generalized estimating equations.Results:Reported asthma medication use was 46%. At 1–3 days of age, elevated cumulative oxygen exposure, increased daily IH, and lower mean SpO2 (adjusted for gestational age and sex) and increased cumulative mean airway pressure exposure (unadjusted) were associated with asthma medication use.Conclusion:Increased oxygen and frequent IH events during just the first three days of age may help identify extremely premature newborns at risk for symptomatic childhood wheezing requiring prescription asthma medications.

The increased purchase of asthma medication for individuals born preterm seems to wane with age: A register-based longitudinal national cohort study

IntroductionPreterm birth is associated with increased risk of respiratory symptoms in childhood, often treated with asthma medication. We designed a follow-up study to previous research and investigated whether the association of gestational age with purchasing asthma medication diminishes in adulthood.MethodsWe conducted a register-based study of a national cohort of all infants born in Denmark in 1980–2009 evaluating longitudinal data on individually prescribed asthma medication (both inhaled ß-2 receptor agonist and different controller treatment over 2-year periods) available from 1995–2011. We analyzed the effect of gestational age considering age, birth year, and perinatal variables using logistic regression with a Generalized Estimating Equations model. All data were unambiguously linked through the Civil Registration System.ResultsWe included 1,819,743 individuals in our study population. We found an inverse dose-response relationship between gestational age and asthma medication in earlier age-groups with a gradual decrease in odds ratios with increasing age and loss of statistical significance in early adulthood (18–31 years). For our oldest generations, there was a significant effect of gestational age (p-value = 0.04), which became insignificant when adjusting for confounding and mediating factors (p = 0.44). There were significant interactions between gestational age and age (p<0.0001) and gestational age and birth year, but these were most important during childhood (0–11 years) and for our youngest generations (born after 1995).ConclusionThe strong association between gestational age and purchase of prescription asthma medication weakens with age into early adulthood, in consistence with the results from our previous study. The risk for purchasing medication to treat asthma-like symptoms was higher in more recent birth years, but the effect of gestational age was small beyond 11 years of age. Gestational age per se did not seem to be significant for the development of asthma-like symptoms: most of its effect could be explained by other perinatal factors.

A tool to improve the efficiency and reproducibility of research using electronic health record databases

BackgroundInterrogation of electronic health record databases often involves time-consuming, manual, repetitive work in developing database queries. We developed a tool to automate this process.&#x0D; MethodsWe identified elementary approaches to query primary care data from the Secure Anonymised Information Linkage databank of Wales. We designed a web-based query builder that allows using combinations of these approaches as ‘building blocks’ to query complex variables. We created an R programme to automatically generate and execute the corresponding Structured Query Language queries.&#x0D; ResultsThe tool allows data extraction using combinations of the following methods: event count (e.g., asthma prescriptions); code/date of earliest/latest event; code/date/value of the event of maximum/minimum value; and frequency of temporally constrained events. Query intervals could be fixed, dynamic, or individualised. The tool integrates with a codeset repository. Data extraction procedures and codesets are saved on a web server as versioned, shareable, and citable objects.&#x0D; ConclusionThis versatile tool allows rapid and complex data extraction with minimal to no programming skills, reduces human errors, and improves research transparency and reproducibility.&#x0D; Funding/SupportHealth and Care Research Wales, ABMU Health Board, AUKCAR (AUK-AC-2012-01), Farr Institute of Health Informatics Research (MR/K006525/1-MR/K007017/1).

A retrospective cohort study in severe asthma describing commonly measured biomarkers: Eosinophil count and IgE levels.

Identifying asthma patients suitable for biologic therapy includes the assessment of blood biomarkers (IgE and eosinophils (EOS)). How they relate to each other is unclear. This retrospective, database study used routinely collected clinical data to identify and evaluate an asthma cohort (classification code for asthma; ≥ 18 years; ≥1 prescription for asthma; ≥1 estimation of serum IgE, in 2 years prior to index date). Distribution into high and low IgE and EOS groups (IgE cut-point: > or ≤75 kU/L; EOS cut point: >or ≤400 μ/L), and characteristics by group are described. In patients with severe asthma (British Thoracic Society Step (BTS) ≥4; N=884), using maximum recorded IgE/EOS, 33% had high IgE/high EOS, 28% low IgE/low EOS and approximately a fifth each had high IgE/low EOS or low IgE/high EOS. Proportions were similar when EOS values measured 2 or 4 weeks before an exacerbation were excluded. Using EOS/IgE 'same day' measurements (N=578) only identified half of the high EOS group. Patients in high IgE groups were more likely to be younger males without comorbid COPD; those in high EOS groups were more likely to be on BTS treatment Step 5 vs 4. The low IgE/low EOS group had the lowest incidence of asthma-related hospital attendances, the highest incidence was observed in the high EOS groups. Maximum available EOS measurement irrespective of exacerbations may be relevant when considering therapy. These data showed low IgE/Low EOS to be more benign and high EOS groups at increased risk of frequent, severe exacerbations.

Simulation Study of Interactions Between Two Bioactive Components from Zingiber cassumunar and 5-Lipoxygenase.

Compound D and DMPBD are compounds extracted from Plai or Zingiber cassumunar Roxb., which have antiasthmatic properties. Thai herbal pharmacopoeia have indicated that approximate 50% of Thai prescriptions for asthma contain Plai. However, the inhibition mechanisms of these compounds are not clearly known. In this study, molecular docking and molecular dynamics (MD) simulations have been used to simulate complex systems and analyze molecular interactions between these compounds and protein target, 5-lipoxygenase (5-LO) enzyme, which is an enzyme involved with asthma symptoms. From our MD simulations, Compound D and DMPBD molecules bind at the same binding site of its natural substrate (arachidonic acid) on 5-LO enzyme, which is similar to the binding of commercial asthma drug (Zileuton). Molecular mechanics generalized born surface area binding energy calculations of the 5-LO complex with Compound D and DMPBD are -26.83 and -29.15kcal/mol, respectively. This work indicated that Compound D and DMPBD are competitive inhibitors, which are able to bind at the same 5-LO substrate binding site. This reveals opportunities for using Compound D and DMPBD as novel antiasthmatic drugs.

Emergency Department Asthma Medication Delivery Program: An Initiative to Provide Discharge Prescriptions and Education.

Background:Prescription fill rates for children being discharged from the emergency department (ED) after asthma exacerbations are low, placing the child at risk for additional ED visits or admissions for asthma. This article describes the implementation of an ED asthma prescription delivery service designed to improve pharmacy prescription capture and decrease ED revisit rates.Methods:A core group developed a service to provide asthma prescriptions and education to patients in their ED room before discharge. The project assessed the percent of ED asthma patients who filled ED asthma prescriptions at the hospital outpatient pharmacy, 7-, 14-, and 30-day ED revisit rates, and patient satisfaction.Intervention:Patients/families who chose to participate in the service received asthma prescriptions and education at the ED bedside. Within 1–3 days, ED outreach nurses obtained patient satisfaction survey responses via telephone.Results:There was a statistically significant increase in the number of patients who filled ED asthma prescriptions at the hospital outpatient pharmacy (22.2% versus 33.8%; P < 0.0001). The decrease in 7-, 14-, or 30-day ED revisit rates for patients who received the medication delivery service compared with standard of care was not statistically significant. Patients were satisfied to very satisfied with the service.Conclusion:Postimplementation of a medication delivery program within the ED, there was an increase in the percentage of patients who filled ED asthma medication prescriptions at the hospital outpatient pharmacy. There was no difference in ED revisit rates for patients who enrolled in the prescription delivery service versus standard of care.

Feasibility Of Supervised Aerobic Interval Exercise Training Following Treatment For Breast Cancer

Aerobic interval training (AIT) can be more effective in improving cardiorespiratory fitness, and muscle oxidative capacity than moderate continuous training (MCT) in a variety of healthy and clinical populations. Due to physical deconditioning associated with breast cancer treatment, AIT is of interest in this population. However, the feasibility and safety of AIT among breast cancer patients is unknown. PURPOSE: To assess the feasibility and occurrence of major adverse events (MAE) with AIT among breast cancer patients immediately post completion of adjuvant chemotherapy and radiation. METHODS: Women with early stage breast cancer were enrolled in the Nutrition and Exercise During Adjuvant Treatment trial within the first half of chemotherapy. MCT aerobic exercise was prescribed 3x/week during chemotherapy and radiation (20-30 min at 50-75% Heart Rate Reserve (HRR)). Upon treatment completion, eligible participants were prescribed AIT (4 sets of 4 min at 75-85% VO2R/HRR and 4 min at 40-65% VO2R/HRR) at least 1x/week, with the choice of either MCT or AIT for remaining sessions. AIT eligibility included an absence of angina, dyspnea, uncontrolled hypertension, asthma or current prescription for heart medications. The ACSM’s metabolic equation for treadmill walking was used to prescribe interval speed/grade, while HRR was used for intervals performed on a cycle ergometer or elliptical trainer. RESULTS: 57 women (age 51±11) entered the post-treatment phase of the study, of which 44 (75%) were eligible for AIT. 36 (82%) participants performed at least one AIT session. 66% of the total sessions performed were AIT workouts, indicating a potential preference for AIT vs. MCT. Those performing AIT attended significantly more sessions overall relative to those who were not performing AIT(18±6 vs 13±8, p=0.01). Adherence to AIT intensity was achieved in 68% of all sessions, with no difference between those performed on the treadmill, bike/elliptical, nor relative to MCT sessions. The most common barrier to AIT intensity adherence was the prescription being too difficult (75%). No MAE occurred. CONCLUSIONS: AIT after treatment completion for breast cancer appears to be feasible, potentially preferable to MCT, and may result in greater attendance than MCT alone.

Effect of incomplete registration at general practices on the annual prevalence of treated asthma

ABSTRACTBackgroundAnnual prevalence of 'treated asthma' can be estimated using primary care routine data. However, the denominator may include people with incomplete registration at general practices (GP) in the year of estimation. Patients with incomplete registrations who actually take medications but have no recorded prescriptions represent false-negative cases leading to underestimated prevalence.&#x0D; ObjectivesTo estimate the effect of incomplete GP registrations on the annual prevalence of treated asthma in Wales.&#x0D; MethodsUsing the GP dataset of the Secure Anonymised Information Linkage (SAIL) Databank, we created a denominator of people who lived in Wales and registered at Welsh GPs for any period during 2010. For the uncorrected prevalence, the numerator included people who ever had a recorded asthma diagnosis and any current recorded asthma prescriptions. For the corrected prevalence, we estimated the number of false-negatives and added them to the numerator. To do that, we calculated, for asthma patients with incomplete registrations and no recorded prescriptions, the sum of probabilities of having prescriptions if they had complete registrations. We estimated the absolute and relative increases in the prevalence at national and local authority levels as well as for the subpopulation with incomplete registration.&#x0D; ResultsThe denominator included 2,221,967 people, of whom 94.8% had complete GP registration in 2010. Without correction, the numerator included 132,439 patients giving a prevalence of 5.96% [95% CI 5.93-5.99]. By adding estimated 1,801 false-negative cases to the numerator, the adjusted prevalence is 6.04% [95% CI 6.01-6.07] with absolute and relative increases of 0.08% and 1.36%, respectively. At the local authority level, the relative increase ranged from 0.47% for Blaenau Gwent to 3.94% for Monmouthshire. Among the subpopulation with incomplete registration (5.1%), the prevalence increased by 68.0% from 2.32% to 3.91%.&#x0D; ConclusionIn Wales, which has a highly stable population, incomplete GP registration has negligible effect on the prevalence of treated asthma at a national level, although it was more significant for sub-regions with less stable populations. This correction method could be useful for more accurate estimation of asthma burden and the prevalence of active disease in highly dynamic populations.&#x0D; FundingHealth and Care Research Wales and ABMU Health Board. Supported by Asthma UK Centre for Applied Research [AUK-AC-2012-01].

Results from a pragmatic prospective cohort study: Shared decision making improves outcomes for children with asthma

ABSTRACTObjective: Patient/provider shared decision making (SDM) improves asthma control in a pragmatic clinical trial setting. This study evaluated the impact of an evidence-based SDM toolkit on outcomes for patients with asthma implemented by providers in a real world setting. We hypothesized that these patients with asthma would demonstrate improved outcomes such as reduced emergency department (ED) visits, hospitalizations, and oral steroid use in the 12 months following a SDM visit compared to those who did not receive the intervention. Methods: Patients with asthma were identified within six primary care practices that serve vulnerable populations in Charlotte, NC (746 children; 718 adult patients). Propensity scores were used to match 200 children and 206 adults for analysis. The primary outcome variable was asthma exacerbation defined as an ED visit or hospitalization for asthma or outpatient prescription of an oral steroid. Patients were monitored at 3, 6, and 12 months after the intervention date. The outcome variables of ED visits, hospitalizations, and oral steroids were compared between intervention and matched control patients. Results: The proportion of pediatric patients with one or more exacerbations was significantly lower in the SDM intervention group compared to controls during 12 months after exposure to the intervention (33% vs. 47%, p = 0.023). For adults, there was not a strong association between use of the SDM intervention and outcomes improvement. Conclusions: The evidence-based SDM intervention implemented in this study was associated with improved asthma outcomes for pediatric patients but not adult patients in a real world clinical setting.

University and public health system partnership: A real-life intervention to improve asthma management

ABSTRACTObjective: Asthma is under-diagnosed in many parts of the world. We aimed to assess the outcome of a capacitating program on asthma for non-specialist physicians and other healthcare professionals working in the public system in Ribeirão Preto, Brazil. Methods: A group of 16 asthma specialists developed a one-year capacitating program in 11 healthcare clinics in the Northern District of the city, which included lectures on asthma, training on inhalation device use and spirometry, and development of an asthma management protocol. Researchers visited one health unit 2–4 times monthly, working with doctors on patients' care, discussing cases, and delivering lectures. Asthma education was also directed to the general population, focusing on recognition of signs and symptoms and long-term treatment, including production of educational videos available on YouTube. Outcome measures were the records of doctors' prescriptions of individual asthma medications pre- and post-intervention. Results: Prior to the program, 3205 units of inhaled albuterol and 2876 units of inhaled beclomethasone were delivered by the Northern District pharmacy. After the one-year program, there was increase to 4850 units (51.3%) for inhaled albuterol and 3526 units (22.6%) for inhaled beclomethasone. The albuterol increase followed the recommendation given to the non-specialist doctors by the asthma experts, that every patient with asthma should have inhaled albuterol as a rescue medication, by protocol. No increase was observed in other districts where no capacitating program was conducted. Conclusion: A systematic capacitating program was successful in changing asthma prescription profiles among non-specialist doctors, with increased delivery of inhaled albuterol and beclomethasone.

The Impact of Tobacco Smoke Exposure on Childhood Asthma in a Medicaid Managed Care Plan.

Tobacco smoke exposure increases breathing problems of children. Texas Children's Health Plan is a Managed Medicaid and Children's Health Insurance Program (CHIP) managed care provider. The aim of this study is to determine associations among tobacco smoke exposure, asthma prevalence, and asthma health-care utilization. Texas Children's Health Plan conducts an annual survey of members who have a physician visit. Questions were added to the survey in March 2010 about asthma and tobacco smoke exposure. Survey results for children < 18 years of age were matched to health plan claims data for the 12 months following the date of the physician visit. A total of 22,470 parents of unique members/patients from birth to < 18 years of age participated in the survey. More whites than African Americans or Hispanics report that the child's mother is a smoker (19.5% vs 9.1% and vs 2.3%, respectively; P < .001). Compared with children whose mother does not smoke, parent report of asthma diagnosis and claims for dispensing of short-acting beta agonist medication are greater if the mother is a smoker (adjusted OR, 1.20 [95% CI, 1.03-1.40] and 1.24 [95% CI, 1.08-1.42], respectively). In contrast to Medicaid, in which there are no out-of-pocket costs, the CHIP line of business requires copays for ED visits. ED visits are influenced by maternal smoking only in the CHIP line of business (adjusted OR, 4.40; 95% CI, 1.69-11.44). Maternal smoking increases risk for asthma diagnosis and prescription of asthma quick relief medication. Maternal smoking predicted asthma-related ED visits only for the CHIP line of business.

Population health for children with asthma: time to let some fresh air in.

I must confess that as a primary care pediatrician, treating asthma often feels stale: same old medications, same old conversations about the importance of daily controllers, same old preventable emergency department visits and hospitalizations. But in this issue of Pediatrics , Beck et al1 present a novel ecologic analysis that sheds new light on the topic, linking the asthma medication ratio (AMR; the ratio of asthma controller prescriptions filled to all asthma prescriptions filled) measured at the level of individual community pharmacies with pediatric asthma exacerbations within the census tract in which the pharmacy is located. The magnitude of the association was substantial, with a decrease of nearly 10 asthma exacerbations per 1000 children per year for each 0.1 increase in the pharmacy-level AMR. This central finding suggests that a low community-level AMR highlights a “hot spot” in which untoward asthma events are likely to occur at an increased rate relative to other areas with better community AMRs, even after adjustment for known confounders. Although ecologic … Address correspondence to Louis Vernacchio, MD, MSc, Pediatric Physicians’ Organization at Children’s, 77 Pond Ave, Suite 205C, Brookline, MA 02445. E-mail: louis.vernacchio{at}childrens.harvard.edu

Outcomes before and after treatment escalation to Global Initiative for Asthma steps 4 and 5 in severe asthma

BackgroundLittle is known about health outcomes in severe asthma reflected by Global Initiative for Asthma steps 4 and 5. ObjectiveTo analyze control, risk, economic, and health resource use (HRU) outcomes associated with treatment escalation to Global Initiative for Asthma steps 4 and 5. MethodsThis was a before-vs-after retrospective cohort study of patients (12–75 years old) with asthma newly initiated to omalizumab, high-intensity corticosteroids (HICS; ≥1,000 μg/day of inhaled fluticasone equivalent or oral prednisone), or high-dose inhaled corticosteroid (HDICS; ≥500 to <1,000 μg/day of fluticasone equivalent) using 2002 to 2011 MarketScan data. Poisson regression was used to model HRU outcomes; Tobit regression was used to model medical expenditures. ResultsOf 19,227 patients, 856 initiated omalizumab, 6,926 initiated HICS, and 11,445 initiated HDICS. Use of β-agonist increased for the HDICS and HICS cohorts and decreased for the omalizumab cohort; acute care visits and oral corticosteroid use decreased during follow-up for the HDICS and omalizumab cohorts. Annual health care expenditures, polypharmacy burden, and outpatient visits were high for all cohorts and increased in the follow-up year (baseline to follow-up; general health care expenditures: omalizumab $14,071 to $34,887, HICS $12,030 to $15,557, HDICS $7,570 to $9,826; annual number of asthma prescriptions: omalizumab 11.74 to 19.46, HICS 7.8 to 12.44, HDICS 5.17 to 9.69; outpatient visits: omalizumab 26.79 to 34.06, HICS 18.78 to 21.37, HDICS 15.06 to 16.64). ConclusionOmalizumab use was associated with improvements in risk and control accompanied by large increases in expenditures per HRU. Patients on HDICS and HICS showed improvements in risk but worsening control and increased expenditures per HRU. Innovations in disease management and available treatment options are needed to more optimally achieve treatment goals.

Pragmatic trial of health care technologies to improve adherence to pediatric asthma treatment: a randomized clinical trial.

Most patients with asthma take fewer than half of prescribed doses of controller medication. Interventions to improve adherence have typically been costly, impractical, and at best only minimally successful. To test a speech recognition (SR) intervention to improve adherence to pediatric asthma controller medication. The Breathe Well study was a 24-month pragmatic randomized clinical trial. The study was conducted within Kaiser Permanente Colorado, a large, group-model health maintenance organization. A total of 1187 children aged 3 to 12 years with a persistent asthma diagnosis and prescription for an inhaled corticosteroid were randomized to the computerized SR intervention or usual care condition and followed up for 24 months between October 2009 and February 2013. Speech recognition telephone calls to parents in the intervention condition were triggered when an inhaled corticosteroid refill was due or overdue. Calls were automatically tailored with medical and demographic information from the electronic health record and from parent answers to questions in the call regarding recent refills or a desire to receive help refilling, learn more about asthma control, or speak with an asthma nurse or pharmacy staff member. Adherence to pediatric asthma controller medication, measured as the medication possession ratio over 24 months. In the intention-to-treat analysis, inhaled corticosteroid adherence was 25.4% higher in the intervention group than in the usual care group (24-month mean [SE] adherence, 44.5% [1.2%] vs 35.5% [1.1%], respectively; P < .001). Asthma-related urgent care events did not differ between the 2 groups. The intervention effect was consistent in subgroups stratified by age, sex, race/ethnicity, body mass index, and disease-related characteristics. The intervention's significant impact on adherence demonstrates strong potential for low-cost SR adherence programs integrated with an electronic health record. The absence of change in urgent care visits may be attributable to the already low number of asthma urgent care visits within Kaiser Permanente Colorado. Application of electronic health record-leveraged SR interventions may reduce health care utilization when applied in a population with less-controlled asthma. clinicaltrials.gov Identifier: NCT00958932.