National trends in ambulatory asthma treatment, 1997-2009

Association of Asthma Exacerbation Risk and Physician Time Expenditure With Provision of Asthma Action Plans and Education for Pediatric Patients

OBJECTIVE

To provide information about factors underlying provision of asthma action plans (AAPs) to a minority of pediatric patients with asthma, assess whether risk of exacerbation acts on provision of AAP and asthma education directly, suggesting targeting to highest-risk patients, or indirectly by influencing physician-patient interaction time.

METHODS

This study was a retrospective cross-sectional analysis of a nationally representative sample of physician office visits that consisted of patients aged 2 to 18 years with asthma. Exacerbation risk comprised proxy indicators of control and severity. Direct and time-mediated effects of exacerbation risk on provision of AAP and education were calculated from logistic regression models.

RESULTS

Asthma action plans were provided in 14.3% of visits, education in 23.9%. Total direct effects of exacerbation risk (ORs = 3.88-4.69) far exceeded indirect, time-mediated effects (both ORs = 1.03) on AAPs. Direct effects on education were similar but smaller. After adjusting for risk, physician time expenditure of ≥30 minutes was associated with nearly doubled odds of providing AAP or education (ORs = 1.90-1.99). Visits that included allied health professionals alongside physician care were significantly associated with all 4 outcomes in multivariate analyses (ORs = 3.06-5.28).

CONCLUSIONS

Exacerbation risk has a strong, direct association with AAP provision in pediatric asthma, even controlling for physician time expenditure. Provision of AAP and education to pediatric patients with asthma may be facilitated by increasing available time for office visits and involving allied health professionals.

Ambulatory noninsulin treatment of type 2 diabetes mellitus in the United States, 2015 to 2019

OBJECTIVE

To examine trends in the noninsulin drug treatment of type 2 diabetes, including first- and second-line therapies on top of metformin, from 2015 to 2019.

PARTICIPANTS AND METHODS

We conducted a descriptive analysis of cross-sectional data using the IQVIA National Disease and Therapeutic Index, a nationally representative audit of ambulatory physician practices in the United States. We focused on the use of noninsulin pharmacological treatments for type 2 diabetes among individuals aged 35 years and older between January 1, 2015 and December 31, 2019. The main outcome was type 2 diabetes visits where a prescription drug was used ("treatment visit").

RESULTS

Ambulatory diabetes visits decreased from 30.1 million treatment visits in 2015 to 29.5 million treatment visits in 2019. Among treatment visits where a single drug was prescribed, the use of metformin declined from 57.0% of monotherapy in 2015 to 46.0% of monotherapy in 2019, while during the same period the share of monotherapy accounted for by glucagon-like peptide-1 (GLP-1) receptor agonists increased from 4.3% to 8.5% and the share accounted for by sodium-glucose cotransporter-2 (SGLT2) inhibitors increased from 7.3% to 19.5%. Among treatment visits where metformin plus another drug was prescribed, the share of second-line therapy accounted for by dipeptidyl peptidase-4 (DPP-4) inhibitors decreased from 21.9% of treatment visits in 2015 to 20.8% of treatment visits in 2019; sulphonylurea use declined from 45.2% to 32.7%, use of SGLT2 inhibitors increased from 14.5% to 21.2% and use of GLP-1 receptor agonists increased from 9.8% to 18.2%.

CONCLUSIONS

Significant changes in the landscape of ambulatory care for diabetes have taken place during the past 6 years, including moderate declines in metformin monotherapy, moderate declines in second-line sulphonylurea use, and large increases in SGLT2 use. These changes underscore the dynamic nature of drug utilization for diabetes in the United States, and reflect the effects of emerging evidence, evolving clinical guidelines and evolving regulatory and payment policies.

Changes in Short-term, Long-term, and Preventive Care Delivery in US Office-Based and Telemedicine Visits During the COVID-19 Pandemic

Question

Has the COVID-19 pandemic been associated with any changes in the clinical content of ambulatory care in the US?

Findings

In this cross-sectional study of serial data from the IQVIA National Disease and Therapeutic Index, there was a moderate rebound in office-based care during the second half of 2020, while telemedicine accounted for 23.9% of care observed. Office-based care during the pandemic (quarters 2-4 of 2020) involved 58.0% long-term, 23.0% short-term, and 25.6% preventive diagnoses, while telemedicine care involved substantially greater long-term (77.2%), modestly greater short-term (26.8%), and almost no preventive (2.7%) diagnoses.

Meaning

In contrast to office-based care, telemedicine was more commonly used for established patients and substantially greater delivery of psychiatric or behavioral treatments than preventive care.

Importance

While the COVID-19 pandemic has been associated with some substitution of telemedicine for office-based care in the US, to our knowledge, little is known regarding the pandemic’s association with the clinical content of ambulatory care.

Objective

To characterize changes in the clinical content of ambulatory care among office-based vs telemedicine encounters in the US before vs during the COVID-19 pandemic.

Design, Settings, and Participants

This analysis of serial cross-sectional data from the IQVIA National Disease and Therapeutic Index was a 2-stage, stratified nationally representative audit of outpatient care in the US from January 1, 2018, through December 31, 2020. The National Disease and Therapeutic Index generates approximately 33 617 quarterly visits that are projected to 306.7 million national visits based on the survey design.

Main Outcomes and Measures

(1) Prevalence of common diagnoses and (2) mix of long-term, short-term, and preventive care.

Results

The mean (SD) number of projected quarterly, in-person, office-based visits was 282.1 (1.4) million in 2018 and 284.7 (10.3) in 2019 before declining to 250.8 million in quarter 1 of 2020 and 147.8 million in quarter 2 of 2020 and then increasing moderately to 181.5 million in quarter 3 of 2020 and 180.2 million in quarter 4 of 2020. The mean (SD) number of telemedicine visits was 2.8 (0.4) million in 2018 and 3.0 (0.1) million in 2019 before increasing to 8.6 million in quarter 1 of 2020 and 72.2 million in quarter 2 of 2020 and then declining notably to 43.8 million in quarter 3 of 2020 and 44.2 million in quarter 4 of 2020. Office-based care during the second through fourth quarters of 2020 involved 58.0% long-term, 23.0% short-term, and 25.6% preventive care. In contrast to office-based care, 4 of the top 10 diagnoses that were treated by telemedicine during 2020 were for psychiatric or behavioral conditions: depression, attention deficit/hyperactivity, anxiety, and bipolar disorders. Throughout this period, approximately half of office-based visits and nearly two-thirds of telemedicine visits were for established rather than new patients.

Conclusions and Relevance

This cross-sectional study’s findings suggest that while telemedicine rapidly increased early during course of the COVID-19 pandemic, its use declined modestly since then. In contrast to office-based care, telemedicine was more commonly used for established patients and substantially greater delivery of psychiatric or behavioral treatments rather than preventive care.

Lower Use of Biologics for the Treatment of Asthma in Publicly Insured Individuals

BACKGROUND

Despite bearing a disproportionate burden of poorly controlled asthma, publicly insured individuals are less likely to receive biologics.

OBJECTIVE

To assess biologic use by payer among individuals with asthma.

METHODS

We used IQVIA's National Disease and Therapeutic Index, a nationally representative, all-payer audit of ambulatory care in the United States, to describe the patterns of use by payer.

RESULTS

Asthma treatment visits in which a biologic product was reported increased from approximately 0.1% of asthma-related visits in 2003 to 1% in 2015 and doubled to 2% by 2019. Omalizumab use initially increased from 2003 to 2006 and plateaued till 2015 when its use declined modestly, coinciding with the release of additional biologic products. In 2019, omalizumab accounted for 37% of biologic treatment visits, mepolizumab 21%, benralizumab 27%, dupilumab 15%, and reslizumab <1%. Biologic treatment visits were higher for privately insured individuals (28.3 per 1000 visits) compared with publicly insured individuals (16.3 per 1000 visits). This difference persisted after accounting for age, sex, and race using nationally representative estimates. Whites accounted for a disproportionate amount of biologic treatment visits among the publicly insured (80%) despite accounting for only 60% of publicly insured asthma treatment visits. No biologic treatment visits were observed for individuals who were uninsured. Half of dupilumab visits were for publicly insured patients, compared with 22% of mepolizumab/benralizumab and 27% of omalizumab visits.

CONCLUSION

Biologics were uncommonly used among patients with asthma, and the basis for disproportionately lower use of biologics among the publicly insured, where the burden of uncontrolled asthma is greatest, merits further investigation.

Management of migraine in the emergency department: Findings from the 2010-2017 National Hospital Ambulatory Medical Care Surveys

OBJECTIVE

The study objective was to describe trends in the medical management of migraine in the emergency department (ED) using the 2010-2017 National Hospital Ambulatory Medical Care Survey (NHAMCS) datasets.

METHODS

Using the 2010-2017 NHAMCS datasets, we analyzed visits with a discharge diagnosis of migraine. Drug prescription frequencies between years were compared with the Rao-Scott chi-squared test. Adjusted odds ratios of opioid administration from 2010 to 2017 were calculated using weighted multivariable logistic regression with sex, age, race/ethnicity, pain-score, primary expected source of payment, and year as predictor variables.

RESULTS

Our analysis captured 1846 ED visits with a diagnosis of migraine from 2010 to 2017, representing a weighted average of 1.2 million US ED visits per year. Parenteral opioids were prescribed in 49% (95% CI: 40, 58) of visits in 2010 and 28% (95% CI: 15, 45) of visits in 2017 (p = 0.03). From 2010 to 2017, there was a 10% yearly decrease in opioid prescriptions. Metoclopramide and ketorolac were prescribed more frequently in years 2015 through 2017 than in 2010. Increased opioid administration was associated with female sex, older age, white race, higher pain score, and having Medicare or private insurance as the primary expected source of payment for all years.

CONCLUSION

Opioid administration for migraine in EDs across the US declined 10% annually between 2010 and 2017, demonstrating improved adherence to migraine guidelines recommending against opioids. We identified several factors associated with opioid administration for migraine, identifying groups at higher risk for unnecessary opioids in the ED setting.

Use and Content of Primary Care Office-Based vs Telemedicine Care Visits During the COVID-19 Pandemic in the US

Importance

Little is known about the association between the coronavirus disease 2019 (COVID-19) pandemic and the level and content of primary care delivery in the US.

Objective

To quantify national changes in the volume, type, and content of primary care delivered during the COVID-19 pandemic, especially with regard to office-based vs telemedicine encounters.

Design, Setting, and Participants

Analysis of serial cross-sectional data from the IQVIA National Disease and Therapeutic Index, a 2-stage, stratified nationally representative audit of outpatient care in the US from the first calendar quarter (Q1) of 2018 to the second calendar quarter (Q2) of 2020.

Main Outcomes and Measures

Visit type (office-based or telemedicine), overall and stratified by patient population and geographic region; assessment of blood pressure or cholesterol measurement; and initiation or continuation of prescription medications.

Results

In the 8 calendar quarters between January 1, 2018, and December 31, 2019, between 122.4 million (95% CI, 117.3-127.5 million) and 130.3 million (95% CI, 124.7-135.9 million) quarterly primary care visits occurred in the US (mean, 125.8 million; 95% CI, 121.7-129.9 million), most of which were office-based (92.9%). In 2020, the total number of encounters decreased to 117.9 million (95% CI, 112.6-123.2 million) in Q1 and 99.3 million (95% CI, 94.9-103.8 million) in Q2, a decrease of 21.4% (27.0 million visits) from the average of Q2 levels during 2018 and 2019. Office-based visits decreased 50.2% (59.1 million visits) in Q2 of 2020 compared with Q2 2018-2019, while telemedicine visits increased from 1.1% of total Q2 2018-2019 visits (1.4 million quarterly visits) to 4.1% in Q1 of 2020 (4.8 million visits) and 35.3% in Q2 of 2020 (35.0 million visits). Decreases occurred in blood pressure level assessment (50.1% decrease, 44.4 million visits) and cholesterol level assessment (36.9% decrease, 10.2 million visits) in Q2 of 2020 compared with Q2 2018-2019 levels, and assessment was less common during telemedicine than during office-based visits (9.6% vs 69.7% for blood pressure; P < .001; 13.5% vs 21.6% for cholesterol; P < .001). New medication visits in Q2 of 2020 decreased by 26.0% (14.1 million visits) from Q2 2018-2019 levels. Telemedicine adoption occurred at similar rates among White individuals and Black individuals (19.3% vs 20.5% of patient visits, respectively, in Q1/Q2 of 2020), varied by region (low of 15.1% of visits [East North Central region], high of 26.8% of visits [Pacific region]), and was not correlated with regional COVID-19 burden.

Conclusions and Relevance

The COVID-19 pandemic has been associated with changes in the structure of primary care delivery, with the content of telemedicine visits differing from that of office-based encounters.

Asthma Medication Prescribing Practices in Pediatric Office Visits

This cross-sectional study examined how asthma control, demographic, and clinical characteristics are associated with the use of asthma medications in pediatric office visits in the United States. Data from the 2012-2015 National Ambulatory Medical Care Survey included patients aged 6 to 17 years, with asthma as a primary diagnosis (International Classification of Diseases, Ninth Revision, Clinical Modification, code 493.xx). Descriptive weighted analysis evaluated asthma medication use. Multivariable logistic regression examined characteristics associated with asthma prescribing practices. An estimated 2.5 million pediatric office visits were made annually for asthma. The majority of asthma visits involved males (59.3%), children aged 6 to 11 years (54.8%), and whites (73.6%). Several clinical and demographic characteristics contributed to the variations in overall asthma medication use as well as specific drug classes. Lack of documentation of asthma control and uncontrolled asthma were associated with oral corticosteroid and inhaled corticosteroid use in pediatric asthma patients, but not with overall asthma medication use.

Extent, trends, and determinants of controller/reliever balance in mild asthma: a 14-year population-based study

BACKGROUND

The majority of patients with asthma have the mild form of the disease. Whether mild asthma patients receive appropriate asthma medications has not received much attention in the literature. We examined the trends in indicators of controller/reliever balance.

METHODS

Using administrative health databases of British Columbia, Canada (2000 to 2013), we created a population-based cohort of adolescents/adults with mild asthma using validated case definition algorithms. Each patient-year of follow-up was assessed based on two markers of inappropriate medication prescription: whether the ratio of controller medications (inhaled corticosteroids [ICS] and leukotriene receptor antagonists [LTRA]) to total asthma-related prescriptions was low (cut-off 0.5 according to previous validation studies), and whether short-acting beta agonists (SABA) were prescribed inappropriately according to previously published criteria that considers SABA in relation to ICS prescriptions. Generalized linear models were used to evaluate trends and to examine the association between patient-, disease-, and healthcare-related factors and medication use.

RESULTS

The final cohort consisted of 195,941 mild asthma patients (59.5% female; mean age at entry 29.6 years) contributing 1.83 million patient-years. In 48.8% of patient-years, controller medications were suboptimally prescribed, while in 7.2%, SABAs were inappropriately prescribed. There was a modest year-over-year decline in inappropriate SABA prescription (relative change - 1.3%/year, P < 0.001) and controller-to-total-medications (relative change - 0.5%/year, P < 0.001). Among the studied factors, the indices of type and quality of healthcare (namely respirologist consultation and receiving pulmonary function test) had the strongest associations with improvement in controller/reliever balance.

CONCLUSIONS

Large number of mild asthma patients continue to be exposed to suboptimal combinations of asthma medications, and it appears there are modifiable factors associated with such phenomenon.

Current Trends of Hypertension Treatment in the United States

BACKGROUND

To examine current patterns of hypertension (HTN) treatment in the United States, including blood pressure (BP) control, prevalence of different antihypertensive agents, and variations in treatment associated with patient and physician characteristics.

METHODS

We used data from the National Disease and Therapeutic Index (NDTI), a nationally representative physician survey produced by QuintilesIMS. We selected patients with a diagnosis of HTN and identified those prescribed antihypertensive therapies. We analyzed the type of antihypertensive agents prescribed. Extent of BP control, and associated patient and physician characteristics. We calculated 95% confidence intervals that accounted for the multistage NDTI sampling design.

RESULTS

Among those treated for HTN in 2014, BP control varied: systolic BP (SBP) ≥160 (15%) vs. SBP 150-159 (9%) vs. SBP 140-149 (19%) vs. SBP 130-139 (26%) vs. SBP <130 (32%). Of those treated for HTN, 29% used of angiotensin-converting enzyme inhibitors (ACEIs); 24%, thiazide-like diuretics; 22%, angiotensin receptor blockers (ARBs), 21%, calcium-channel blockers (CCBs); and 19% beta-blockers. Newer drugs had very limited uptake; no drugs approved after 2002 were used in more than 5% of patients. Selection of agents varied only modestly by patient and physician characteristics.

CONCLUSIONS

The treatment of HTN in 2014 predominantly involved older medications in 5 major classes of drugs: ACEIs, thiazide diuretics, ARBs, CCBs, and beta-blockers. Selection of antihypertensive agents showed limited variation by age, gender, race, and insurance type. Although 58% of treated patients had SBP <140, 24% had poorly controlled HTN with SBP ≥150, indicating the need for improved treatment.

Biomarkers of Airway Type-2 Inflammation and Integrating Complex Phenotypes to Endotypes in Asthma

PURPOSE OF REVIEW

Over the past decade, the most important advance in the field of asthma has been the widespread recognition that asthma is a heterogeneous disease driven by multiple molecular processes.

RECENT FINDINGS

The most well-established molecular mechanism in asthma is increased airway type-2 inflammation, and consequently, non-invasive biomarkers of increased airway type-2 inflammation, such as blood eosinophil counts or blood periostin levels, have proven important in stratifying asthma patients in clinical trials of type-2 cytokine inhibitors. However, it remains ambiguous how well these non-invasive biomarkers represent airway measures of type-2 inflammation in asthma. As a result, the utility of these biomarkers to assist with asthma management or as research tools to better understand asthma pathogenesis remains unclear. This article reviews primary data assessing biomarkers of airway type-2 inflammation in asthma and describes how the use of biomarkers can advance a precision medicine approach to asthma treatment.

Has Asthma Medication Use Caught Up With the Evidence?: A 12-Year Population-Based Study of Trends

BACKGROUND

The importance of balance between controller and reliever medications in asthma is recognized. However, to our knowledge, the extent to which real-world practice has caught up with evidence-based guidelines has not been studied.

METHODS

This was a retrospective cohort study of individuals 15 to 67 years of age who satisfied a validated case definition of asthma in the administrative health database of British Columbia, Canada between 2002 and 2013. Each patient-year was assessed for inappropriate and excessive prescription of short-acting beta-agonists (SABAs) and the balance between controller and reliever medications. Trends on three time axes were evaluated: calendar time, time course of asthma, and age. Poisson regression was used to test for a linear trend.

RESULTS

Three hundred fifty-six thousand, one hundred twelve patients (56.5% female sex; mean age, 30.5 years) contributed 2.6 million patient-years. In 7.3% of the patient-years, SABAs were prescribed inappropriately. This proportion dropped by a relative rate of 5.3% per year (P < .001). In the first year of asthma, 6.3% of patients had indicators of inappropriate SABA use, which dropped within the first 3 years but increased thereafter. Excessive prescription of SABAs increased rapidly during the time course of asthma (change of 23.3% per year; P < .001) and by age (change of 5.1% per year; P < .001).

CONCLUSIONS

Despite overwhelming evidence regarding the risks, inappropriate prescription for SABAs was prevalent. Excessive SABA use might explain high asthma mortality in older patients. Inappropriate prescriptions declined over the study period but increased over the time course of asthma. These trends might have contributed to the declining asthma hospitalization rates in British Columbia, but there remain gaps in care and potential for improvement in asthma outcomes.

National Trends in Ambulatory Oral Anticoagulant Use

BACKGROUND

Four direct oral anticoagulants (DOACs) have been brought to market for the treatment of nonvalvular atrial fibrillation and venous thromboembolism. Many forces, including numerous positive trial results, emerging safety concerns, marketing, and promotion, may shape DOAC adoption by providers. However, relatively little is known regarding their ambulatory utilization compared with warfarin, as well as the degree to which they have decreased under-treatment of atrial fibrillation.

METHODS

We used the IMS Health National Disease and Therapeutic Index, a nationally representative audit of outpatient office visits, to estimate the use of warfarin and DOACs between 2009 and 2014.

RESULTS

Overall, visits with anticoagulation use increased from 2.05 (95% confidence interval [CI], 1.82-2.27) to 2.83 (95% CI, 2.49-3.17) million (M) quarterly visits (P < .001). Of these, DOAC use has grown to 4.21M (95% CI, 3.63M-4.79M; 38.2% of total) treatment visits in 2014 since their introduction in 2010. Use of all oral anticoagulants in treatment visits for atrial fibrillation has increased from 0.88M (95% CI, 0.74M-1.02M) to 1.72M (95% CI, 1.47M-1.97M; P < .001), with similar DOAC and warfarin use in 2014. Atrial fibrillation visits with anticoagulant use increased from 51.9% (95% CI, 50.4%-53.8%) to 66.9% (95% CI, 65.0%-69.3%) between 2009 and 2014 (P < .001). In 2014, rivaroxaban was the most commonly prescribed DOAC for atrial fibrillation (47.9% of office visits), followed by apixaban (26.5%) and dabigatran (25.5%).

CONCLUSIONS

Direct oral anticoagulants have been adopted rapidly, matching the use of warfarin, and are associated with increased use of oral anticoagulation for patients with atrial fibrillation.

Effect of Direct-to-Consumer Advertising on Asthma Medication Sales and Healthcare Use

RATIONALE

The United States is one of only two countries that permit direct-to-consumer advertising (DTCA) of prescription drugs, and many questions remain regarding its effects.

OBJECTIVES

To quantify the association between asthma-related DTCA, pharmacy sales, and healthcare use.

METHODS

This was an ecological study from 2005 through 2009 using linked data from Nielsen (DTCA television ratings), the IMS Health National Prescription Audit (pharmacy sales), and the MarketScan Commercial Claims data (healthcare use) for 75 designated market areas in the United States. We used multilevel Poisson regression to model the relationship between DTCA and rates of prescriptions and use within and across designated market areas. Main outcome measures include (1) volume of total, new, and refilled prescriptions for advertised products based on pharmacy sales; (2) prescription claims for asthma medications; and asthma-related (3) emergency department use, (4) hospitalizations, and (5) outpatient encounters among the commercially insured.

MEASUREMENTS AND MAIN RESULTS

Four Food and Drug Administration-approved asthma medicines were advertised during the period examined: (1) fluticasone/salmeterol (Advair), (2) mometasone furoate (Asmanex), (3) montelukast (Singulair), and (4) budesonide/formoterol (Symbicort). After adjustment, each additional televised advertisement was associated with 2% (incident rate ratio, 1.02; 95% confidence interval, 1.01-1.03) higher pharmacy sales rate from 2005 through 2009, although this effect varied across the three consistently advertised therapies examined. Among the commercially insured, DTCA was positively and significantly associated with emergency room visits related to asthma (incident rate ratio, 1.02; 95% confidence interval, 1.01-1.04), but there was no relationship with hospitalizations or outpatient encounters.

CONCLUSIONS

Among this population, DTCA was associated with higher prescription sales and asthma-related emergency department use.

Analysis of prescription pattern and guideline adherence in the management of asthma among medical institutions and physician specialties in Taiwan between 2000 and 2010

PURPOSE

The aim of this study was to evaluate prescription patterns of antiasthmatic medications in ambulatory care, guideline adherence by physician specialties and medical institutions, and the rate of hospitalization and emergency department visits due to asthma exacerbation.

METHODS

The ambulatory visits between 2000 and 2010 from the Taiwan Longitudinal Health Insurance Database 2000 were analyzed for prescription trends. Seven classes of antiasthmatic medications were identified for prescription trend analysis. Prescription patterns of different medical institutions and physician specialties were further evaluated.

FINDINGS

We studied 4495 patients with newly diagnosed asthma in 2000. Estimates indicated an increased use in fixed-dose combination of inhaled corticosteroids and long-acting β2-agonists (3.6% in 2002 to 28.8% in 2010) with decreased use of inhaled corticosteroids (14.5% in 2001 to 7.3% in 2010). Xanthine was still the most frequently used medication for asthmatic patients (60.2% in 2001 and 45.2% in 2010). Another marked increase was the use of leukotriene receptor antagonists (2.6% in 2001 to 6.0% in 2010). In the studied population, the rate of hospital admission or emergency department visit moderately decreased from 1.42% to 0.59% during 10 years. Physicians in medical centers and regional hospitals, as well as asthma specialists, dominated the increased use of fixed-dose combinations of inhaled corticosteroids and long-acting β2-agonists and leukotriene receptor antagonists.

IMPLICATIONS

Physicians in academic medical centers and asthma specialists achieved better adherence to the core recommendations of the international guidelines for asthma management. The reasons for guideline nonadherence among physicians in district hospitals and primary care clinics deserve health care professionals' attention and require further investigation.

Prescribing of long-acting beta-2-agonists/inhaled corticosteroids after the SMART trial

Background

After the SMART trial evaluating the safety of salmeterol (long-acting beta-2-agonist (LABA)) in asthma patients, regulatory actions were taken to promote a guideline-adherent prescribing of LABA only to patients receiving inhaled corticosteroids (ICS). We aim to analyse LABA- and ICS-related prescription patterns after the SMART trial in Germany.

Methods

Patients documented in the Bavarian Association of Statutory Health Insurance Physicians database (approximately 10.5 million people) were included if they had a diagnosis of asthma and at least one prescription of LABA and/or ICS between 2004 and 2008. Annual period prevalence rates (PPRs) were estimated and Cochrane Armitage tests were used for time trend analyses.

Results

Highest annual PPRs were found for budesonide and the fixed combination of salmeterol/fluticasone. The proportion of “concomitant LABA and ICS users” increased from 52.0 to 57.6% within the study period, whereas for “LABA users without ICS” a slight decrease from 6.5 to 5.4% was found. In 2008, the proportion of patients with at least one quarter with a LABA prescription without concomitant ICS was highest in elderly, male patients (≈20%). In the majority of these patients, a concomitant diagnosis of COPD (i.e. asthma-COPD overlap syndrome [ACOS]) was present.

Conclusions

Between 2004 and 2008, we found a moderate increase in guideline-adherent LABA prescribing in a representative German population. Elderly men received a significant number of LABA prescriptions without concomitant ICS probably due to ACOS.

Electronic supplementary material

The online version of this article (doi:10.1186/s12890-015-0051-x) contains supplementary material, which is available to authorized users.

National trends in the ambulatory treatment of hypertension in the United States, 1997-2012

Importance

Hypertension is common and costly. Over the past decade, new antihypertensive therapies have been developed, several have lost patent protection and additional evidence regarding the safety and effectiveness of these agents has accrued.

Objective

To examine trends in the use of antihypertensive therapies in the United States between 1997 and 2012.

Design, Setting and Participants

We used nationally representative audit data from the IMS Health National Disease and Therapeutic Index to examine the ambulatory pharmacologic treatment of hypertension.

Outcome Measures

Our primary unit of analysis was a visit where hypertension was a reported diagnosis and treated with a pharmacotherapy (treatment visit). We restricted analyses to the use of six therapeutic classes of antihypertensive medications among individuals 18 years or older.

Results

Annual hypertension treatment visits increased from 56.9 million treatment visits (95% confidence intervals [CI], 53.9–59.8) in 1997 to 83.3 million visits (CI 79.2–87.3) in 2008, then declined steadily to 70.9 million visits (CI 66.7–75.0) by 2012. Angiotensin receptor blocker utilization increased substantially from 3% of treatment visits in 1997 to 18% by 2012, whereas calcium channel blocker use decreased from 27% to 18% of visits. Rates of diuretic and beta-blocker use remained stable and represented 24%–30% and 14–16% of visits, respectively. Use of direct renin inhibitor accounted for fewer than 2% of annual visits. The proportion of visits treated using fixed-dose combination therapies increased from 28% to 37% of visits.

Conclusions

Several important changes have occurred in the landscape of antihypertensive treatment in the United States during the past decade. Despite their novel mechanism of action, the adoption rate of direct renin inhibitors remains low.

Time trends of period prevalence rates of patients with inhaled long-acting beta-2-agonists-containing prescriptions: a European comparative database study

BACKGROUND

Inhaled, long-acting beta-2-adrenoceptor agonists (LABA) have well-established roles in asthma and/or COPD treatment. Drug utilisation patterns for LABA have been described, but few studies have directly compared LABA use in different countries. We aimed to compare the prevalence of LABA-containing prescriptions in five European countries using a standardised methodology.

METHODS

A common study protocol was applied to seven European healthcare record databases (Denmark, Germany, Spain, the Netherlands (2), and the UK (2)) to calculate crude and age- and sex-standardised annual period prevalence rates (PPRs) of LABA-containing prescriptions from 2002-2009. Annual PPRs were stratified by sex, age, and indication (asthma, COPD, asthma and COPD).

RESULTS

From 2002-2009, age- and sex-standardised PPRs of patients with LABA-containing medications increased in all databases (58.2%-185.1%). Highest PPRs were found in men ≥ 80 years old and women 70-79 years old. Regarding the three indications, the highest age- and sex-standardised PPRs in all databases were found in patients with "asthma and COPD" but with large inter-country variation. In those with asthma or COPD, lower PPRs and smaller inter-country variations were found. For all three indications, PPRs for LABA-containing prescriptions increased with age.

CONCLUSIONS

Using a standardised protocol that allowed direct inter-country comparisons, we found highest rates of LABA-containing prescriptions in elderly patients and distinct differences in the increased utilisation of LABA-containing prescriptions within the study period throughout the five European countries.

Emergency department visits by adults for psychiatric medication adverse events

IMPORTANCE

In 2011, an estimated 26.8 million US adults used prescription medications for mental illness.

OBJECTIVE

To estimate the numbers and rates of adverse drug event (ADE) emergency department (ED) visits involving psychiatric medications among US adults between January 1, 2009, and December 31, 2011.

DESIGN AND SETTING

Descriptive analyses of active, nationally representative surveillance of ADE ED visits using the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance system and of drug prescribing during outpatient visits using the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey.

PARTICIPANTS

Medical records from national probability samples of ED and outpatient visits by adults 19 years or older were reviewed and analyzed.

EXPOSURES

Antidepressants, antipsychotics, lithium salts, sedatives and anxiolytics, and stimulants.

MAIN OUTCOMES AND MEASURES

National estimates of ADE ED visits resulting from therapeutic psychiatric medication use and of psychiatric medication ADE ED visits per 10,000 outpatient visits at which psychiatric medications were prescribed.

RESULTS

From 2009 through 2011, there were an estimated 89,094 (95% CI, 68,641-109,548) psychiatric medication ADE ED visits annually, with 19.3% (95% CI, 16.3%-22.2%) resulting in hospitalization and 49.4% (95% CI, 46.5%-52.4%) involving patients aged 19 to 44 years. Sedatives and anxiolytics, antidepressants, antipsychotics, lithium salts, and stimulants were implicated in an estimated 30,707 (95% CI, 23,406-38,008), 25,377 (95% CI, 19,051-31,704), 21,578 (95% CI, 16,599-26,557), 3620 (95% CI, 2311-4928), and 2779 (95% CI, 1764-3794) respective ADE ED visits annually. Antipsychotics and lithium salts were implicated in 11.7 (95% CI, 10.1-13.2) and 16.4 (95% CI, 13.0-19.9) ADE ED visits per 10,000 outpatient prescription visits, respectively, compared with 3.6 (95% CI, 3.2-4.1) for sedatives and anxiolytics, 2.9 (95% CI, 2.3-3.5) for stimulants, and 2.4 (95% CI, 2.1-2.7) for antidepressants. The commonly used sedative zolpidem tartrate was implicated in 11.5% (95% CI, 9.5%-13.4%) of all adult psychiatric medication ADE ED visits and in 21.0% (95% CI, 16.3%-25.7%) of visits involving adults 65 years or older, in both cases significantly more than any other psychiatric medication.

CONCLUSIONS AND RELEVANCE

Psychiatric medications are implicated in many ADEs treated in US EDs. Efforts to reduce ADEs should include adults of all ages but might prioritize medications causing high numbers and rates of ED visits.

Medication exposure in pregnancy risk evaluation program: the prevalence of asthma medication use during pregnancy

Asthma is one of the most common chronic diseases in women of reproductive age, occurring in up to 8 % of pregnancies. The objective of this study is to assess the prevalence of asthma medication use during pregnancy in a large diverse cohort. We identified women aged 15-45 years who delivered a live born infant between 2001 and 2007 across 11 U.S. health plans within the Medication Exposure in Pregnancy Risk Evaluation Program (MEPREP). Using health plans' administrative and claims data, and birth certificate data, we identified deliveries for which women filled asthma medications from 90 days before pregnancy through delivery. Prevalence (%) was calculated for asthma diagnosis and medication dispensing. There were 586,276 infants from 575,632 eligible deliveries in the MEPREP cohort. Asthma prevalence among mothers was 6.7 %, increasing from 5.5 % in 2001 to 7.8 % in 2007. A total of 9.7 % (n = 55,914) of women were dispensed asthma medications during pregnancy. The overall prevalence of maintenance-only medication, rescue-only medication, and combined maintenance and rescue medication was 0.6, 6.7, and 2.4 % respectively. The prevalence of maintenance-only use doubled during the study period from 0.4 to 0.8 %, while rescue-only use decreased from 7.4 to 5.8 %. In this large population-based pregnancy cohort, the prevalence of asthma diagnoses increased over time. The dispensing of maintenance-only medication increased over time, while rescue-only medication dispensing decreased over time.

Hospitalization rate and 30-day mortality among patients with status asthmaticus in Denmark: a 16-year nationwide population-based cohort study

Objective

Current data on hospitalization and prognosis of acute asthma and status asthmaticus are inconclusive. We aim to analyze the rate of first-time hospitalizations for status asthmaticus among patients of all ages, the proportion admitted to intensive care units (ICU), and the 30-day mortality over a 16-year period.

Methods

In this population-based cohort study, we used medical registries to identify all first-time status asthmaticus hospitalizations in Denmark from 1996 through 2011. Data on comorbidities were also obtained. We computed yearly hospitalization rates overall and by gender and age groups, and estimated the proportion requiring ICU admission. We estimated 30-day age- and gender-standardized mortality. We examined potential misclassification from acute exacerbation of chronic obstructive pulmonary disease (COPD) by excluding patients with preexisting or concurrent COPD.

Results

Of the 5,001 patients identified with a first-time status asthmaticus hospitalization, 50.5% were male, 40.3% were <15 years old, and 12.4% had comorbidity. The hospitalization rate increased from 48.0 per 1,000,000 person-years (PY) (95% confidence interval [CI]: 45.1–51.1 PY) during 1996–1999 to 70.1 per 1,000,000 PY (95% CI: 66.7–73.7 PY) during 2008–2011. This may be explained by an increased hospitalization rate of children. The standardized 30-day mortality risk declined from 3.3% (95% CI: 2.5%–4.1%) in 1996–1999 to 1.5% (95% CI: 0.9%–2.1%) in 2008–2011. During 2005–2011, 10.1% of status asthmaticus patients were admitted to the ICU. Hospitalization rates and mortality risk decreased by excluding 939 patients also registered with COPD, but overall temporal changes did not change.

Conclusion

From 1996 to 2011, status asthmaticus hospitalization rate increased but remained below 100 hospitalizations per 1,000,000 PY. Thirty-day mortality risk was halved to less than 2%.

Tribal implementation of a patient-centred medical home model in Alaska accompanied by decreased hospital use

Background

Between 1995 and 1998, tribally owned Southcentral Foundation (SCF) incrementally assumed responsibility from the Indian Health Service (IHS) for primary care services on the Alaska Native Medical Center (ANMC) campus in Anchorage, Alaska. In 1999, SCF began implementing components of a Patient-Centered Medical Home (PCMH) model to improve access and continuity of care.

Objective

To evaluate hospitalisation trends before, during and after PCMH implementation.

Design

Time series analysis of aggregated medical record data.

Methods

Regression analysis with correlated errors was used to estimate trends over time for the percent of customer-owners hospitalised overall and for specific conditions during 4 time periods (March 1996–July 1999: SCF assumes responsibility for primary care; August 1999–July 2000: PCMH implementation starts; August 2000–April 2005: early post-PCMH implementation; May 2005–December 2009: later post-PCMH implementation). Analysis was restricted to individuals residing in Southcentral Alaska and receiving health care at ANMC.

Results

The percent of SCF customer-owners hospitalised per month for any reason was steady before and during PCMH implementation, declined steadily immediately following implementation and subsequently stabilised. The percent hospitalised per month for unintentional injury or poisoning also declined during and after the PCMH implementation. Among adult asthma patients, the percent hospitalised annually for asthma declined prior to and during implementation and remained lower thereafter. The percent of heart failure patients hospitalised annually for heart failure remained relatively constant throughout the study period while the percent of hypertension patients hospitalised for hypertension shifted higher between 1999 and 2002 compared to earlier and later years.

Conclusion

Implementation of PCMH at SCF was accompanied by decreases in the percent of customer-owners hospitalised monthly for any reason and for unintentional injury and in the percent of asthma patients hospitalised annually for asthma. Increased accessibility to empanelled care teams may have contributed to decreased need for hospitalisation.

Inhaled corticosteroid adherence and emergency department utilization among Medicaid-enrolled children with asthma

OBJECTIVES

Asthma is the most prevalent chronic disease among children enrolled in Medicaid. This study measured real-world adherence and outcomes after an initial prescription for inhaled corticosteroid therapy in a multi-state Medicaid population.

METHODS

We conducted a retrospective study among Medicaid-enrolled children aged 5-12 years with asthma in 14 southern states using 2007 Medicaid Analytic eXtract file claims data to assess adherence and outcomes over the 3 months following an initial prescription drug claim for inhaled corticosteroids (ICS-Rx). Adherence was measured by the long-term controller-to-total asthma drug claims ratio.

RESULTS

Only one-third of children (33.4%) with an initial ICS-Rx achieved a controller-to-total drug ratio >0.5 over the next 90 days. Children for whom long-term control drugs represented less than half of their total asthma drug claims had a 21% higher risk of emergency department (ED) visit (adjusted odds ratio (AOR) 1.21 [95% CI 1.14, 1.27]), and a 70% higher risk of hospital admission (AOR 1.70 [95% CI 1.45, 1.98]) than those with a controller-to-total asthma drug ratio >0.5.

CONCLUSION

Real-world adherence to long-term controller medications is quite low in this racially diverse, low-income segment of the population, despite Medicaid coverage of medications. Adherence to long-term controller therapy had a measurable impact on real-world outcomes. Medicaid programs are a potential surveillance system for both medication adherence and ED utilization.

Effects of FDA advisories on the pharmacologic treatment of ADHD, 2004-2008

OBJECTIVE

This study assessed the effect of public health advisories issued between 2005 and 2007 by the U.S. Food and Drug Administration (FDA) on treatments of attention-deficit hyperactivity disorder (ADHD) and physician prescribing practices.

METHODS

Data obtained from the IMS Health National Disease and Therapeutic Index, a nationally representative audit of ambulatory physicians, were used to examine trends in office visits by children and adolescents (under age 18) during which ADHD was treated with Adderall, other psychostimulants, or atomoxetine. Segmented time series regressions were conducted to determine changes in use associated with three advisories issued between 2005 and 2007.

RESULTS

In 2004, before the first FDA advisory, Adderall accounted for 36% of ADHD pharmacotherapy treatment visits. Other stimulants accounted for 46%, and atomoxetine accounted for 19%. Overall pharmacotherapy treatment rates were stable over the study period, but by 2008 the treatment visits accounted for by Adderall (that is, market share) declined to 24%, and the market share for atomoxetine declined to 8%. The market share for substitute therapies-clonidine, guanfacine, and bupropion-was stable over this period, ranging from 5% to 7%. Despite the declines in the use of Adderall and atomoxetine over the study period, results from the regression models suggest that the advisories did not have a statistically significant effect on ADHD medication prescribing.

CONCLUSIONS

FDA advisories regarding potential cardiovascular and other risks of ADHD medications had little discernible incremental effect on the use of these medicines in this nationally representative ambulatory audit.

Association between the commercial characteristics of psychotropic drugs and their off-label use

BACKGROUND

Off-label prescribing, or the use of a medicine for non-Food and Drug Administration (FDA)-approved indications, is especially common for psychotropic therapies and often lacks scientific support. We quantified the association between 4 commercial characteristics of prescription medicines-product age, therapeutic class age, drug volume, and promotional expenditures-and off-label use of antidepressants, antipsychotics, and mood stabilizers from 1998 through 2009.

METHODS

We linked data from the IMS Health National Disease and Therapeutic Index, a nationally representative audit of office-based physicians, with data from FDA@gov and the drug compendium DrugDex, to derive information regarding off-label use. Our primary outcome was the rate (per 1000 uses) with which a drug was prescribed for non-FDA-approved indications during a given calendar year. We used mixed-effects regression models with random intercepts for each drug, adding measures of commercial characteristics as fixed effects within this model.

RESULTS

From 1998 through 2009, the average proportion of all uses that occurred off-label was 23.3% for antidepressants, 60.7% for antipsychotics, and 54.2% for mood stabilizers. There was a positive association between the annual rate of off-label use and drug volume [incidence rate ratio (IRR), 1.41; 95% confidence intervals (CI), 1.32-1.50], although the strength of this association was not uniform across the therapeutic classes examined. There was also a small but statistically significant association between product age (IRR, 0.96; 95% CI, 0.94-0.98) and class age (IRR, 1.03; 95% CI, 1.01-1.06) and the rate of off-label use, also varying across therapeutic class. There was a statistically significant inverse association between promotional expenditures and off-label use (IRR, 0.94; 95% CI, 0.93-0.96) when controlling for our other commercial characteristics. These associations were similar when examining scientifically unsupported rather than all off-label use.

CONCLUSIONS

Our findings suggest that drug prescription volume, rather than product age or therapeutic class age, should be scrutinized further to identify settings where the public health impact of unsupported off-label prescribing may be particularly important.

Short-acting β-agonist use and its ability to predict future asthma-related outcomes

BACKGROUND

Short-acting β-agonist (SABA) use is well established in predicting asthma events in adults. However, this predictive ability has yet to be established in a pediatric population together with an assessment of amount of use.

OBJECTIVE

To identify the number of SABA canisters that best predicts future asthma-related exacerbations and the optimal length of time for measurement of SABA use in pediatric and adult asthma patients.

METHODS

Asthma patients were identified from a Medicaid and a commercially insured database (January 1, 2004, through December 31, 2005, and January 1, 2004, through June 30, 2006, respectively). Following the date of first asthma medication, an assessment period (3, 6, or 12 months) was used to measure SABA use. Asthma-related exacerbations were identified in the subsequent 12-month period. Receiver operating characteristic curve analyses and logistic regression were used to select the critical values of SABA use and optimal assessment periods and to conduct incremental analysis, respectively.

RESULTS

A total of 33,793 Medicaid and 101,437 commercial patients met the study criteria. Use of 3 or more SABA canisters during 12 months was identified in both pediatric Medicaid and commercial populations to best predict an increased risk of an asthma-related exacerbation. For adults, use of 2 or more SABA canisters was found as the critical value with shorter optimal assessment periods of 3 and 6 months. Each additional SABA canister resulted in an 8% to 14% and 14% to 18% increase in risk of an asthma-related exacerbation in children and adults, respectively.

CONCLUSION

The study identified critical values of SABA use that predict future asthma events. Each additional SABA canister predicted increases in exacerbation risk in children and adults.

National trends in oral anticoagulant use in the United States, 2007 to 2011

BACKGROUND

Little is known regarding the adoption of direct thrombin inhibitors in clinical practice. We examine trends in oral anticoagulation for the prevention of thromboembolism in the United States.

METHODS AND RESULTS

We used the IMS Health National Disease and Therapeutic Index, a nationally representative audit of office-based providers, to quantify patterns of oral anticoagulant use among all subjects and stratified by clinical indication. We quantified oral anticoagulant expenditures using the IMS Health National Prescription Audit. Between 2007 and 2011, warfarin treatment visits declined from ≈2.1 million (M) quarterly visits to ≈1.6M visits. Dabigatran use increased from 0.062M quarterly visits (2010Q4) to 0.363M visits (2011Q4), reflecting its increasing share of oral anticoagulant visits from 3.1% to 18.9%. In contrast to warfarin, the majority of dabigatran visits have been for atrial fibrillation, though this proportion decreased from 92% (2010Q4) to 63% (2011Q4), with concomitant increases in dabigatran's off-label use. Among atrial fibrillation visits, warfarin use decreased from 55.8% visits (2010Q4) to 44.4% (2011Q4), whereas dabigatran use increased from 4.0% to 16.9%. Of atrial fibrillation visits, the fraction not treated with any oral anticoagulants has remained unchanged at ≈40%. Expenditures related to dabigatran increased rapidly from $16M in 2010Q4 to $166M in 2011Q4, exceeding expenditures on warfarin ($144M) in 2011Q4.

CONCLUSIONS

Dabigatran has been rapidly adopted into ambulatory practice in the United States, primarily for treatment of atrial fibrillation, but increasingly for off-label indications. We did not find evidence that it has increased overall atrial fibrillation treatment rates.

Trends in attention deficit hyperactivity disorder ambulatory diagnosis and medical treatment in the United States, 2000-2010

OBJECTIVES

Because of several recent clinical and regulatory changes regarding attention deficit-hyperactivity disorder (ADHD) in the United States, we quantified changes in the diagnosis of ADHD and its pharmacologic treatment from 2000 through 2010.

METHODS

We used the IMS Health National Disease and Therapeutic Index, a nationally representative audit of office-based providers, to examine aggregate trends among children and adolescents younger than 18 years of age. We also quantified how diagnosis and treatment patterns have evolved on the basis of patient and physician characteristics and the therapeutic classes used.

RESULTS

From 2000 to 2010, the number of physician outpatient visits in which ADHD was diagnosed increased 66% from 6.2 million (95% confidence interval 5.5-6.9M) to 10.4 million visits (95% confidence interval 9.3-11.6 million). Of these visits, psychostimulants have remained the dominant treatment; they were used in 96% of treatment visits in 2000 and 87% of treatment visits in 2010. Atomoxetine use decreased from 15% of treatment visits upon product launch in 2003 to 6% of treatment visits by 2010. The use of potential substitute therapies-clonidine, guanfacine, and bupropion-remained relatively constant (between 5% and 9% of treatment visits) during most of the period examined. During this period, the management of ADHD shifted away from pediatricians and towards psychiatrists (from 24% to 36% of all visits) without large changes in illness severity or the proportion of ADHD treatment visits accounted for by males (73%-77%).

CONCLUSIONS

In 10 years, the ambulatory diagnosis of ADHD increased by two-thirds and is increasingly managed by psychiatrists. The effects of these changing treatment patterns on children's health outcomes and their families are unknown.

Trends in use of second-generation antipsychotics for treatment of bipolar disorder in the United States, 1998-2009

OBJECTIVE

The authors examined trends in the use of second-generation antipsychotics for treatment of bipolar disorder before and after the U.S. Food and Drug Administration's approval in 2000 of olanzapine for use in treating acute manic episodes of bipolar disorder.

METHODS

The IMS Health National Disease and Therapeutic Index was used to derive monthly patient treatment visits between January 1998 and December 2009 by individuals 18 and older with a diagnosis of bipolar disorder who were treated with one or more pharmacotherapies.

RESULTS

The percentage of treatment visits in which a second-generation antipsychotic was prescribed increased from 18% in 1998 to 49% in 2009. Use of mood stabilizers and first-generation antipsychotics declined substantially. In the 12 months after approval of olanzapine for bipolar disorder, its use increased by 92%, and use of other second-generation antipsychotics increased by 42%.

CONCLUSIONS

Second-generation antipsychotics are increasingly used for bipolar disorder, and their effectiveness compared with therapeutic alternatives merits further research.