Trends in hospital admissions due to asthma in north-west Spain from 1995 to 2007

Will the asthma revolution fostered by biologics also benefit adult ICU patients?

PURPOSE

Asthma exacerbations are inflammatory events that rarely result in full hospitalization following an ER visit. Unfortunately, certain patients require prolonged support, including occasional external lung support through ECMO or ECCOR (with subsequent further exposure to other life-threatening issues), and some die. In parallel, biologics are revolutionizing severe asthma management, mostly in T2 high patients.

METHODS

We extensively reviewed the current unmet needs surrounding ICU-admitted asthma exacerbations, with a focus on currently available drugs and the underlying biological processes involved. We explored whether currently available T2-targeting drugs can reasonably be seen as potential players not only for relapse prevention but also as candidate drugs for a faster resolution of such episodes. The patient's perspective was also sought.

RESULTS

About 30% of asthma exacerbations admitted to the ICU do not resolve within five days. Persistent severe airway obstruction despite massive doses of corticosteroids and maximal pharmacologically induced bronchodilation is the main cause of treatment failure. Previous ICU admission is the main risk factor for such episodes and may eventually be considered as a T2 surrogate marker. Fatal asthma cases are hallmarked by poorly steroid-sensitive T2-inflammation associated with severe mucus plugging. New, fast-acting T2-targeting biologics (already used for preventing asthma exacerbations) have the potential to circumvent steroid sensitivity pathways and decrease mucus plugging. This unmet need was confirmed by patients who reported highly negative, traumatizing experiences.

CONCLUSIONS

There is room for improvement in the management of ICU-admitted severe asthma episodes. Clinical trials assessing how biologics might improve ICU outcomes are direly needed.

Time to Asthma-Related Readmission in Children Admitted to the ICU for Asthma

OBJECTIVES

To compare the time to asthma-related readmissions between children with a previous ICU hospitalization for asthma and those with a non-ICU hospitalization and to explore predictors of time to readmission in children admitted to the ICU.

DESIGN

Retrospective cohort study using a pan-Canadian administrative inpatient database from April 1, 2008, to March 31, 2014.

SETTING

All adult and pediatric Canadian hospitals.

SUBJECTS

Children 2-17 years old with a hospitalization for asthma.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 26,168 children were hospitalized 33,304 times during the study period. The time to readmission was shorter in the ICU group compared with the non-ICU group (median time to readmission 27 mo in ICU vs 35 mo in non-ICU group). Preschool-aged children (hazard ratio, 1.48; 95% CI, 1.02-2.14) and increased length of stay (hazard ratio, 1.63; 95% CI, 1.17-2.27) were associated with a shorter time to readmission.

CONCLUSIONS

Children previously admitted to the ICU for asthma had a shorter time to asthma-related readmission, compared with children who did not require intensive care, underlining the importance of targeted long-term postdischarge follow-up of these children. Children of preschool age and who have a lengthier hospital stay are particularly at risk for future morbidity.

Global Asthma Network survey suggests more national asthma strategies could reduce burden of asthma

BACKGROUND

Several countries or regions within countries have an effective national asthma strategy resulting in a reduction of the large burden of asthma to individuals and society. There has been no systematic appraisal of the extent of national asthma strategies in the world.

METHODS

The Global Asthma Network (GAN) undertook an email survey of 276 Principal Investigators of GAN centres in 120 countries, in 2013-2014. One of the questions was: "Has a national asthma strategy been developed in your country for the next five years? For children? For adults?".

RESULTS

Investigators in 112 (93.3%) countries answered this question. Of these, 26 (23.2%) reported having a national asthma strategy for children and 24 (21.4%) for adults; 22 (19.6%) countries had a strategy for both children and adults; 28 (25%) had a strategy for at least one age group. In countries with a high prevalence of current wheeze, strategies were significantly more common than in low prevalence countries (11/13 (85%) and 7/31 (22.6%) respectively, p<0.001).

INTERPRETATION

In 25% countries a national asthma strategy was reported. A large reduction in the global burden of asthma could be potentially achieved if more countries had an effective asthma strategy.

National and regional asthma programmes in Europe

This review presents seven national asthma programmes to support the European Asthma Research and Innovation Partnership in developing strategies to reduce asthma mortality and morbidity across Europe. From published data it appears that in order to influence asthma care, national/regional asthma programmes are more effective than conventional treatment guidelines. An asthma programme should start with the universal commitments of stakeholders at all levels and the programme has to be endorsed by political and governmental bodies. When the national problems have been identified, the goals of the programme have to be clearly defined with measures to evaluate progress. An action plan has to be developed, including defined re-allocation of patients and existing resources, if necessary, between primary care and specialised healthcare units or hospital centres. Patients should be involved in guided self-management education and structured follow-up in relation to disease severity. The three evaluated programmes show that, thanks to rigorous efforts, it is possible to improve patients' quality of life and reduce hospitalisation, asthma mortality, sick leave and disability pensions. The direct and indirect costs, both for the individual patient and for society, can be significantly reduced. The results can form the basis for development of further programme activities in Europe.

Increased health service use for asthma, but decreased for COPD: Northumbrian hospital episodes, 2013-2014

The burden of respiratory disease has persisted over the years, for both men and women. The aim of the present study was to investigate the hospital episode rates in respiratory disease and to understand whether and how the use of the health service for respiratory disease might have changed in recent years in the North-East of England. Hospital episode data covering two full calendar years (in 2013–2014) was extracted from the Northumbria Healthcare NHS Foundation Trust, which serves a population of nearly half a million. Hospital episode rates were calculated from admissions divided by annual and small area-specific population size by sex and across age groups, presented with per 100,000 person-years. The use of the health service for influenza and pneumonia, acute lower respiratory infections and chronic obstructive pulmonary disease (COPD) increased with an advancing age, except for acute upper respiratory infections and asthma. Overall, the use of the health service for common respiratory diseases has seemed to be unchanged, except for asthma. There were large increases in young adults aged 20–50 for both men and women and the very old aged 90+ in women. Of note, there were large increases in acute lower respiratory infections for both men and women aged 90+, whereas there was also a large decrease in COPD in women aged 80–90. This is the first study to examine health service use for respiratory diseases by calculating the detailed population size as denominator. Re-diverting funding to improve population health on a yearly basis may serve the changing need in local areas.

A nationwide survey of the severity, comorbidity, and mortality of hospitalized patients with asthma in Taiwan

OBJECTIVE

To clarify the epidemiology of asthma admission in a nationwide survey, we analyze the characteristics of hospitalized patients in Taiwan.

METHODS

Data regarding asthma-associated hospitalizations were obtained from the National Health Insurance Research Database of Taiwan from January 2001 to December 2002. Patient characteristics in terms of severity, mortality, and cost were stratified by age, gender, and presence of comorbidities.

RESULTS

A total of 59,983 hospitalizations with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code 493.xx and asthma-related treatment were included in the current analysis. When stratified by age, the number and duration of hospitalizations were distributed in J-shape distribution, with the nadir located in the range of 8-18 years of age. The severity of asthma was found to increase with age (p < 0.001) and was more severe in men compared with women (p < 0.001). The severity of in-hospital patients was significantly greater in subjects with underlying respiratory disease compared to patients with other comorbidities, such as cardiovascular disease and infectious disease. The mortality rates of all hospitalized asthma patients and pediatric hospitalized asthma patients were 0.77% and 0.02%, respectively. The risk factor for mortality of asthma was older age and male gender in multiple regression.

CONCLUSION

The severity of asthma increased after 18 years of age. Increased comorbidities in elderly patients might contribute to asthma severity. The mortality rate was low in pediatric patients and significantly increased in males and the elderly. The above findings suggest that additional effort is required in the treatment of elderly and male asthmatic patients.

Role of comorbid conditions in asthma hospitalizations in the south of France

BACKGROUND

Reasons for asthma hospitalizations are dynamic and complex. Comorbid conditions are important contributors to most chronic diseases today. We aim to characterize and describe risk factors associated with hospitalizations due to asthma in the Languedoc-Roussillon region (France) in 2009.

METHODS

Programme de Médicalisation des Systèmes d'Information (PMSI) data records from 2009 were sorted using selected International Classification of Diseases (ICD10) codes eliciting three groups of asthma hospitalizations according to acute severity. All available data including demographics, comorbid conditions, past hospitalizations either related or unrelated to asthma, seasonality and distance to medical facilities were used to compare the subjects within the three groups.

RESULTS

One thousand two hundred and eighty-nine hospitalizations due to asthma exacerbation were found, concerning 1122 patients. We observed significant differences within the groups, using univariate analysis, concerning duration of hospitalizations (mean ± SD, 4.9 ± 5.9 days vs 6.4 ± 6.8 vs 15.8 ± 16.8, P < 0.001), deaths (percentage, 0.03% vs 1.50% vs 9.20%, P < 0.001) and numbers of comorbid conditions (0.80 ± 0.95 vs 0.75 ± 0.97 vs 1.74 ± 1.36, P < 0.001). Recurrent admissions for asthma during the period 2006-2008 were significantly more frequent in the more severe group (1.93 ± 3.91 vs 2.56 ± 4.47 vs 2.81 ± 3.97, P = 0.006). In the multivariate model, age and number of comorbid conditions were independently associated with severe hospitalizations and deaths.

CONCLUSIONS

Asthma hospitalizations can be appropriately assessed using PMSI coding databases. In this study, age and the presence of comorbid conditions are the major risk factors for asthma hospitalizations and deaths.

Trends in asthma-related direct medical costs from 2002 to 2007 in British Columbia, Canada: a population based-cohort study

Background

Asthma-related health resource use and costs may be influenced by increasing asthma prevalence, changes to asthma management guidelines, and new medications over the last decade. The objective of this work was to analyze direct asthma-related medical costs, and trends in total and per-patient costs of hospitalizations, physician visits, and medications.

Methods

A cohort of asthma patients from British Columbia (BC), Canada, was created. Asthma patients were identified using a validated case definition. Costs for hospitalizations, physician visits, and medications were calculated from billing records (in 2008 Canadian dollars). Trends in total and per-patient costs over the study period were analyzed using Generalized Linear Models.

Results

398,235 patients satisfied the asthma case definition (mid-point prevalence 8.0%). Patients consumed $315.9 million (M) in direct asthma-related health resources between 2002 and 2007. Hospitalizations, physician visits, and medication costs accounted for 16.0%, 15.7% and 68.2% of total costs, respectively. Cost of asthma increased from $49.4 M in 2002 to $54.7 M in 2007. Total annual costs attributable to hospitalizations and physician visits decreased (−39.8% and −25.5%, respectively; p<0.001), while medication costs increased (+38.7%; p<0.001).

Interpretation

This population-based analysis shows that the total direct cost of asthma in BC has increased since 2002, mainly due to a rise in asthma prevalence and cost of medication. Combination therapy with inhaled corticosteroids/long-acting beta-agonists has become a significant component of the cost of asthma. Although billing records capture only a fraction of the true burden of asthma, the simultaneous increase in medication costs and reductions in hospitalization and physician visit costs provides valuable insight for policy makers into the shifts in asthma-related resource use.

Photoperiod-driven variation in an allergic response is independent of allergen exposure

Allergy prevalence and severity varies seasonally in humans, presumably due to intra-annual changes in allergen exposure. However, it is possible that seasonality of allergic responses is also influenced by seasonal changes in the immune system. Here, we asked whether extended exposure to different day lengths would alter allergic responses to pentadecylcatechol (PDC), an allergenic component of poison ivy ( Toxicodendron radicans (L.) Kuntze), in Siberian hamsters ( Phodopus sungorus (Pallas, 1773)), a species exhibiting extensive seasonal variation in immune functions. We found that contact dermatitis responses were larger in short day-length (SD) housed animals than in long day-length (LD) housed animals even though sensitization and challenge dosages of allergen were identical. Furthermore, SD animals were smaller and had regressed reproductive tissues compared with LD animals, results typically observed in this species in response to photoperiod. These data suggest that endogenous changes in immune functions, perhaps via melatonin, may underlie some seasonal variation in allergic responses.