Factors associated with concordance between parental-reported use and dispensed asthma drugs in adolescents: findings from the BAMSE birth cohort

Living with Food Hypersensitivity as an Adolescent Impairs Health Related Quality of Life Irrespective of Disease Severity: Results from a Population-Based Birth Cohort

Food hypersensitivity (FHS) refers to food-related symptoms, with or without concurrent Immunoglobulin E (IgE) antibodies related to food(s). It remains unclear how different FHS phenotypes affect health-related quality of life (HRQoL). We examined self-reported HRQoL (with the generic instrument EQ-5D (dimensions and a Visual Analogue Scale (VAS), range 0–100) in association with phenotypes of FHS, and food-specific symptoms among adolescents (n = 2990) from a population-based birth cohort. Overall, 22% of the adolescents had FHS. Compared to adolescents without FHS, those with FHS reported more problems in the dimensions of pain/discomfort (p < 0.001), and anxiety/depression (p = 0.007). Females with FHS reported more problems than males in these dimensions (p < 0.001). Different FHS phenotypes (IgE-sensitization, allergic co-morbidity, and severity of symptoms) were not associated with differences in HRQoL. EQ-VAS scores were lowest for adolescents with symptoms for wheat vs. no wheat, median 80 vs. 89, p = 0.04) and milk vs. no milk (median 85 vs. 90, p = 0.03). Physician-diagnosed lactose intolerance median EQ-VAS was 80 vs. 90, p = 0.03 and also associated with more problems in the dimension of anxious/depression. In conclusion, FHS is associated with lower HRQoL in adolescence, irrespective of phenotypes, but differentially affects females vs. males, and those with vs. without symptoms for milk or wheat.

Sibship and dispensing patterns of asthma medication in young children-a population-based study

PURPOSE

Our aim was to study the association between sibship and dispensing patterns of asthma medication in young children, focusing on incidence and persistence, and taking sibship status, asthma diagnoses, and siblings' medication into account.

METHODS

A register-based cohort study including all children (n = 50 546) born in Stockholm, Sweden 2006 to 2007, followed up during 2006 to 2014. Exposure was sibling status; outcome was incidence of dispensed asthma medication and persistence over time. A Cox model was used to study the association between sibship and asthma medication. Persistence was defined using two different time windows (4 and 18 months) in a refill sequence model including siblings' and unrelated control children's medication.

RESULTS

After 1 year of age, the adjusted hazard ratio of dispensed asthma medication was 0.85 (95% CI 0.80-0.90) among children with siblings compared with singletons. The estimated proportion of children with persistent controller medication was 7.2% (4-month model) and 64.5% (18-month model). When including the siblings' controller medication, the estimated proportion was 8.8% (4 months) and 7.8% for control children (relative risk (RR) 0.89, 95% CI 0.81-0.98). The persistence was lower for those with siblings compared with singletons (adj. RR 0.72, 95% CI 0.62-0.85 for 4 months) with similar estimates for older, younger, and full siblings and regardless of asthma diagnoses.

CONCLUSIONS

Siblings have different dispensing patterns of asthma medications compared with singletons regardless of asthma diagnoses. After including the siblings' asthma medication and compared with control children, the proportion of children with persistent medication increased which may indicate that siblings share asthma medications.

Eliminated patient fee and changes in dispensing patterns of asthma medication in children-An interrupted time series analysis

In 2016, all prescription drugs included in the reimbursement system in Sweden were made available for children (age 0-17 years) without any patient fees. Our aim was to estimate the association between this intervention and the dispensing patterns of asthma medications among children. Dispensing data on asthma medications for all children living in Stockholm County during 2014-2017 were selected to include two years before (January 2014-December 2015) and after (January 2016-December 2017) the intervention. In an uncontrolled before and after study, the measures of utilization were as follows: the proportion of children with at least one dispensed asthma medication (prevalence); the number of children initiated on treatment after an 18-month drug-free period (incidence); the number of defined daily doses (DDDs) dispensed per child; and the number of children with at least two prescriptions with controller medication (inhaled corticosteroid or leukotriene receptor antagonist) dispensed during 18 months (persistence). In an interrupted time series (ITS) analysis, all measures were included except for persistence. Socio-economic status was defined using Mosaic data. The prevalence increased after the intervention (from 11.9% to 13.0%). However, the ITS analysis showed a positive trend already before the intervention, and consequently, the increase was not attributable to the intervention. For incidence, similar patterns were observed. There was an increase in dispensed volumes related to the intervention, 46.3 DDDs/child/month before and 51.1 after the intervention (P-value 0.01). The proportion of children with persistent asthma medication increased from 46.0% to 51.9% in children with low socio-economic status. In conclusion, the intervention was only modestly associated with changes in the dispensing patterns of asthma medication, with the volume dispensed per child increasing slightly, particularly in children with low socio-economic status.

Influence of contextual factors on quality of primary care in children with asthma

OBJECTIVE

Asthma is a common chronic disease among children, quality assurance is thus important. Adherence to pre-specified quality indicators of practice guidelines could be used to assess the quality of asthma care. The aim was to estimate which contextual factors that had an influence on the primary health care centres (PHCs) adherence to the quality indicators as stated in the practice guidelines.

METHOD

A pragmatic cross-sectional study was performed comprising 14 PHCs in Sweden. Included contextual factors were socio-demographic characteristics, organizational characteristics, and indicators regarding engagement in asthma care. Documentation on adherence to the quality indicators was retrieved from the medical health care records. Quality indicators included documentation of history of allergy and risk factors, diagnostics and patient support performed, and pharmacological treatment. To score adherence, a composite quality indicator (CQI) was computed for each PHC. A multivariable regression analysis was performed by orthogonal projection to latent structures (OPLS). By this analysis, the relationship between the result variable (CQI) and 26 pre-specified contextual factors was assessed.

RESULTS

There was a wide variation of CQI between the PHCs. The OPLS analysis identified that 10 of the contextual factors influenced CQI. The most pronounced influences were found in more time scheduled for asthma care, a lower age-limit for performing spirometry, a lower duty-grade for general practitioners, and a higher activity at asthma educational seminars. We found no influence of socio-demographic contextual factors.

CONCLUSION

We found that some of the contextual factors at the PHCs influenced the quality of performed care. Evidence-based care in paediatric asthma may thus be presumed to be facilitated by allocating time, by improving interprofessional collaboration, and by creating structures and opportunities for commitment to asthma care.

Agreement between asthma questionnaire and health care register data

PURPOSE

Risk factors and consequences of asthma can be studied by using validated questionnaires. The overall objective of this study was to assess the agreement of parental-reported asthma-related questions regarding their children against Swedish health care registers.

METHODS

We linked a population-based twin cohort of 27 055 children aged 9 to 12 years to the Swedish Prescribed Drug Register, National Patient Register, and the primary care register. Parent-reported asthma was obtained from questionnaires, and diagnoses and medication were retrieved from the registers. For the agreement between the questionnaire and the registers, Cohen's kappa was estimated.

RESULTS

The kappa of the "reported ever asthma" against a "register-based ever asthma" was 0.69 and 0.57 between the parental-"reported doctor's diagnosis" and "register-based doctor's diagnosis." The highest agreement between "reported current asthma" and "register-based current asthma" with at least 1 dispensed medication or a diagnosis applied to different time windows was seen for an 18-month window (kappa = 0.70).

CONCLUSIONS

We found that parent-reported asthma-related questions showed on average good agreement with the Swedish health care registers. This implies that in-depth questionnaires with rich information on phenotypes are suitable proxies for asthma in general and can be used for health care research purposes.

Does asthma affect school performance in adolescents? Results from the Swedish population-based birth cohort BAMSE

BACKGROUND

Asthma is common among schoolchildren and may influence quality of life and school attendance. However, it is unclear if asthma affects school performance. The aim of this study was to examine whether different phenotypes of asthma affect school performance during adolescence.

METHODS

The study population consisted of 1715 adolescents from a population-based birth cohort, followed up to age 16 with questionnaires and clinical examinations. Asthma was defined as at least 4 wheeze episodes or at least 1 wheeze episode in combination with inhaled steroids in the last 12 months. School grades were obtained from Statistics Sweden, and logistic regression analysis was performed to investigate the association between the final overall grade from secondary school and asthma phenotypes.

RESULTS

Among the adolescents, 20.8% have had ever asthma; 24.2% early transient, 47.2% school-age onset, and 24.2% persistent asthma. At 16 years, 7.8% had asthma; 71.7% multimorbidity and 73.9% allergic asthma. A statistically significant association for performing less well was seen for ever asthma (OR_adj  = 1.43, 95% CI = 1.09-1.88). In analyses of asthma onset, an association was seen for school-age onset (OR_adj  = 1.49, CI = 1.02-2.16) and a tendency for persistent asthma (OR_adj  = 1.61, CI = 0.98-2.66), although with overlapping confidence intervals. Further, adolescents with uncontrolled asthma tended to perform less well (OR_adj  = 2.60, CI = 0.87-7.80) compared to adolescents with partly controlled (OR_adj  = 1.12, CI = 0.68-1.83) and fully controlled (OR_adj  = 1.29, CI = 0.55-3.01) asthma.

CONCLUSIONS

Our results indicate that asthma impairs school performance in adolescence. Moreover, some evidence suggests the adolescents with asthma during school age and with poorer asthma control to be more likely to perform less well.

Findings from an Online Survey Assessing the Burden and Management of Seasonal Allergic Rhinoconjunctivitis in US Patients

BACKGROUND

Seasonal allergic rhinoconjunctivitis (SARC) affects ≥16% of the US population annually. Telephone and in-office surveys have demonstrated negative effects of allergic rhinitis (AR) symptoms on sleep, daily activities, productivity, concentration, and emotions.

OBJECTIVE

The objective of this study was to assess the patient-perceived burden of SARC in relation to newer treatments, increased access to treatments, and changing management protocols.

METHODS

An online survey of symptom experience, impact on daily life, and management was conducted in US respondents who suffer (or whose child suffers) from SARC symptoms.

RESULTS

A total of 1001 surveys were completed: 500 adults (≥18 years old) and 501 children (12-17 years old, documented by their parents). Similar to earlier AR surveys, SARC symptoms negatively affected the patient's (and family's) quality of life, and were most severe in the spring. Before being treated, >50% of respondents reported daily symptoms during their season; 75% to 80% considered their symptoms moderate to severe. Patients saw a variety of health care professionals (including pharmacists) and used over-the-counter and prescription medications for symptoms. Those using prescription medications were generally more satisfied with treatment and less likely to switch or discontinue treatment. Nasal and/or ocular symptoms drove adherence, seeing a health care professional, and reviewing and/or changing treatment.

CONCLUSIONS

The majority of patients with SARC report moderate-to-severe symptoms that significantly impair their quality of life. However, patients appear to be taking more responsibility for their (child's) condition, and patient expectations for therapy are increasingly being met. Continued efforts will be needed to examine the contribution of better information and/or increased access to and availability of medications to control the disease.

Treatment of allergic children - Where is the progress (for the practicing allergist)?

For any kind of therapeutic intervention in allergic diseases such as environmental control, pharmacological, or immunomodulating treatment including educational programs, children are addressed separately from adults. Health authorities like the Food and Drug Administration in the United States of America or the European Medicine Agency in Europe request a specific 'Pediatric investigational plan' with studies addressing dose-response relationship, safety, and efficacy for infants, children, and adolescents. During the last 2 years, promising advances have been reported for the treatment of a variety of allergic and immunologic disorders. This review summarizes the progress in the treatment of pediatric asthma and allergic diseases, based on publications of approximately the last 2.5 years (end of 2013 until May 2016) in and beyond this journal. Meanwhile, it highlights areas with promising novel therapeutic approaches, which are likely to change treatment for allergic children in the near future.

MP-AzeFlu is more effective than fluticasone propionate for the treatment of allergic rhinitis in children

The objective was to evaluate the efficacy of MP-AzeFlu (Dymista(®) ) vs fluticasone propionate (FP), (both 1 spray/nostril bid), in children with allergic rhinitis (AR). MP-AzeFlu combines azelastine hydrochloride, FP and a novel formulation in a single spray. Children were randomized in a 3 : 1 ratio to MP-AzeFlu or FP in this open-label, 3-month study. Efficacy was assessed in children aged ≥ 6 to <12 years (MP-AzeFlu: n = 264; FP: n = 89), using a 4-point symptom severity rating scale from 0 to 3 (0 = no symptoms; 3 = severe symptoms). Over the 3-month period, MP-AzeFlu-treated children experienced significantly greater symptom relief than FP-treated children (Diff: -0.14; 95% CI: -0.28, -0.01; P = 0.04), noted from the first day (particularly the first 7 days) and sustained for 90 days. More MP-AzeFlu children achieved symptom-free or mild symptom severity status, and did so up to 16 days faster than FP. MP-AzeFlu provides significantly greater, more rapid and clinically relevant symptom relief than FP in children with AR.

Efficacy of MP-AzeFlu in children with seasonal allergic rhinitis: Importance of paediatric symptom assessment

BACKGROUND

This study aimed to assess the efficacy of MP-AzeFlu (a novel intranasal formulation of azelastine hydrochloride and fluticasone propionate in a single spray) in children with seasonal allergic rhinitis (SAR) and explore the importance of child symptom severity assessment in paediatric allergic rhinitis (AR) trials.

METHODS

A total of 348 children (4-11 years) with moderate/severe SAR were randomized into a double-blind, placebo-controlled, 14-day, parallel-group trial. Efficacy was assessed by changes from baseline in reflective total nasal symptom score (rTNSS), reflective total ocular symptom score (rTOSS) and individual symptom scores over 14 days (children 6-11 years; n = 304), recorded by either children or caregivers. To determine whether a by-proxy effect existed, efficacy outcomes were assessed according to degree of child/caregiver rating. Moreover, total Paediatric Rhinitis Quality of Life Questionnaire (PRQLQ) score was compared between the groups.

RESULTS

A statistically superior, clinically relevant efficacy signal of MP-AzeFlu versus placebo was apparent for PRQLQ overall score (diff: -0.29, 95% CI -0.55, -0.03; p = 0.027), but not for rTNSS (diff: -0.80; 95% CI: -1.75; 0.15; p = 0.099). However, as the extent of children's self-rating increased, so too did the treatment difference between MP-AzeFlu and placebo; MP-AzeFlu provided significantly better relief than placebo for rTNSS (p = 0.002), rTOSS (p = 0.009) and each individual nasal and ocular symptom assessed (except rhinorrhoea; p = 0.064) when children mostly rated their own symptoms.

CONCLUSIONS

MP-AzeFlu is an effective treatment for AR in childhood. Caregivers are less able than children to accurately assess response to treatment with available tools. A simple paediatric-specific tool to assess efficacy in AR trials in children is needed.

Medicine use and disease control among adolescents with asthma

PURPOSE

Pharmacological treatment is a cornerstone in asthma management, but there is limited evidence on how adolescents use their medication and to what extent their asthma is under control. Therefore, the aim of this study was to compare self-reported and register-based medicine use in asthmatic adolescents. Furthermore, we investigated the association between medicine use, patient characteristics, and degree of asthma control.

METHODS

Cross-sectional analyses of 331 adolescents with asthma from a population-based birth cohort linked to data from the Swedish Prescribed Drug Register. Adolescents' asthma medicine use was assessed with three approaches: self-reported medicine use, self-reported use of someone else's medicines, and dispensed medicines from pharmacies during an 18-month period. Medicine use in adolescents with and without asthma control were compared.

RESULTS

In total, 82% reported use of asthma medicines, 10 % reported use of someone else's medicines, and 62% were dispensed asthma medicines from pharmacies. Among adolescents with self-reported medicine use, 22% (n = 60) were neither dispensed medicines nor using someone else's medicines. The majority of those using someone else's medicines had also been dispensed asthma medicine (22 out of 33). Among adolescents with asthma, 176 were fully controlled and 155 were uncontrolled. Also, boys had higher odds of having asthma control than girls.

CONCLUSION

Most adolescents with asthma reported use of asthma medicines, but a considerable proportion were neither dispensed any medicines nor using someone else's medicines. Girls were less likely to achieve asthma control. It is important to combine data sources to understand medicine use among adolescents with asthma.