The relationship between health-related quality of life, lung function and daily symptoms in patients with persistent asthma

Targeting Asthma Remission as the Next Therapeutic Step Toward Improving Disease Control

The long-term goal of asthma management is to achieve disease control, comprising the assessment of 2 main domains: (1) symptom control and (2) future risk of adverse outcomes. Decades of progress in asthma management have correlated with increasingly ambitious disease control targets. Moreover, the introduction of precision medicines, such as biologics, has further expanded the limits of what can be achieved in terms of disease control. It is now believed that clinical remission, a term rarely associated with asthma, may be an achievable treatment goal. An expert framework published in 2020 took the first step toward developing a commonly accepted definition of clinical remission in asthma. However, there remains a widespread discussion about the clinical parameters and thresholds that should be included in a standardized definition of clinical remission. This review aims to discuss on-treatment clinical remission as an aspirational outcome in asthma management, drawing on experiences from other chronic diseases where remission has long been a goal. We also highlight the integral role of shared decision-making between patients and health care professionals and the need for a common understanding of the individual patient journey to remission as foundational elements in reducing disease burden and improving outcomes for patients with asthma.

Predictors of change in asthma-related quality of life: a longitudinal real-life study in adult asthmatics

PURPOSE

Asthma negatively impacts health-related quality of life (HRQL). The objective is to investigate the longitudinal relationship between HRQL in asthma and disease control, demographic and clinical objective parameters in an adult population in real-life settings.

METHODS

We conducted a longitudinal study on adult asthmatics recruited from Liege University Hospital Asthma Clinic (Belgium) between 2011 and 2019. We selected those who had two visits and completed two patient-reported outcome measures (PROMs), the asthma control test (ACT) and the mini asthma quality of life questionnaire (AQLQ) (n = 290). AQLQ was the dependent variable. Demographic, functional and inflammatory characteristics, asthma control, and exacerbations were the independent variables. We applied generalized linear mixed models to identify the factors associated with change in AQLQ and its dimensions.

RESULTS

Median (IQR) time interval between the two visits was 7 (5-19) months. Overall, median (IQR) global AQLQ increased from 4.1 (3-5.1) to 4.6 (3.4-5.9) (p < 0.0001). All AQLQ dimensions significantly improved, apart the environmental one. AQLQ improved in patients who had both step-up and step-down pharmacological treatment as well as in patients reporting no change between the two visits. The fitted models indicated that change in ACT was the main predictor of change in AQLQ (p < 0.0001). A rise in 3 units in ACT predicted an improvement of 0.5 AQLQ (AUC-ROC = 0.85; p < 0.0001). Change in BMI inversely impacted global AQLQ (p < 0.01) and its activity dimension (p < 0.0001).

CONCLUSION

Asthma control and BMI are key predictors of asthma quality of life acting in an opposite direction. AQLQ may improve without step-up in the pharmacological treatment.

Comparison of health-related quality of life measures in asthma-COPD overlap

OBJECTIVE

The Asthma Quality of Life Questionnaire (AQLQ) and COPD assessment test (CAT) are used to assess the health status of asthma and chronic obstructive pulmonary disease (COPD), respectively. However, whether these questionnaires are appropriate in patients with asthma-COPD overlap (ACO) has not been reported. This study aimed to evaluate the performance of the AQLQ and CAT in subjects with ACO.

METHODS

Subjects were enrolled from two previously described observational studies in Beijing, China. ACO was defined by a consensus definition from a roundtable discussion. All subjects completed the AQLQ, CAT, St George's Respiratory Questionnaire (SGRQ), pulmonary function tests, and the Asthma Control Questionnaire (ACQ)-5. Cross-sectional construct validity was evaluated by correlating the AQLQ and CAT with SGRQ score and other measures of asthma and COPD severity.

RESULTS

147 subjects with ACO were recruited. There were floor effects on non-respiratory components of the CAT, and ceiling effects on emotion domains of the AQLQ. Both questionnaires were significantly correlated with ACQ-5 score but were not correlated with FEV1% predicted or FVC% predicted. The AQLQ and CAT were strongly correlated with SGRQ score (r = -0.657 and r = 0.623, respectively). Multivariable linear regression analysis showed that the AQLQ (standardized β-coefficient = -0.449, p < .001) had a stronger association with SGRQ score compared with CAT (standardized β-coefficient = 0.211, p = .023).

DISCUSSION

The AQLQ and CAT were both valid for assessing the health-related quality of life in subjects with ACO, but the AQLQ performed better than CAT.

Asthma exacerbations are associated with a decline in lung function: a longitudinal population-based study

RATIONALE

Progressive lung function (LF) decline in patients with asthma contributes to worse outcomes. Asthma exacerbations are thought to contribute to this decline; however, evidence is limited with mixed results.

METHODS

This historical cohort study of a broad asthma patient population in the Optimum Patient Care Research Database, examined asthma patients with 3+eligible post-18th birthday peak expiratory flow rate (PEF) records (primary analysis) or records of forced expiratory flow in 1 s (FEV₁) (sensitivity analysis). Adjusted linear growth models tested the association between mean annual exacerbation rate (AER) and LF trajectory.

RESULTS

We studied 1 09 182 patients with follow-up ranging from 5 to 50 years, of which 75 280 had data for all variables included in the adjusted analyses. For each additional exacerbation, an estimated additional -1.34 L/min PEF per year (95% CI -1.23 to -1.50) were lost. Patients with AERs >2/year and aged 18-24 years at baseline lost an additional -5.95 L/min PEF/year (95% CI -8.63 to -3.28) compared with those with AER 0. These differences in the rate of LF decline between AER groups became progressively smaller as age at baseline increased. The results using FEV₁ were consistent with the above.

CONCLUSION

To our knowledge, this study is the largest nationwide cohort of its kind and demonstrates that asthma exacerbations are associated with faster LF decline. This was more prominent in younger patients but was evident in older patients when it was related to lower starting LF, suggesting a persistent deteriorating phenotype that develops in adulthood over time. Earlier intervention with appropriate management in younger patients with asthma could be of value to prevent excessive LF decline.

Asthma control in Brazil: a systematic review

Objectives: To explore asthma control in patients undergoing pharmacotherapy on studies in the last 20 years in Brazil. Asthma is a chronic airway inflammation disease with a high prevalence worldwide. Even with a variety of drug treatment improvements, attaining asthma control is challenging, since it should have a personalized approach. In Brazil, studies on the prevalence of asthma control are scarce and usually from a small sample size.Data Sources: A systematic review was performed to assess asthma control in Brazilian population. Terms related to "asthma", "asthma control" and "Brazil" were used in the search strategies in PubMed, BVSalud, Embase and Cochrane Library, including Brazilian Journal of Allergy and Immunology as data sources. A narrative synthesis was performed to report key outcome.Study Selections: In total, 23 studies were included. Most of them were conducted in the Southeastern and Northeast regions, in a short duration.Results: Pediatric and non-pediatric population were assessed, with a higher proportion of female. In pediatric population, those with poorly controlled asthma usually had severe or persistent disease. In elderly, an increased asthma severity was found, although proper treatment might be effective. Most studies (70%) also described exacerbations, hospitalizations (48%), quality of life (39%), and emergency visits (30%). Despite heterogeneity of outcomes and population, studies show an important prevalence of uncontrolled asthma even in patients being treated, with better disease control with treatment improvements.Conclusions: Studies in Brazil have shown that asthma control remains a challenge and there is still a need for improvement on disease management.

Use of Health Related Quality of Life in Clinical Trials for Severe Asthma: A Systematic Review

BACKGROUND

Asthma Health Related Quality of Life (HRQoL) is an outcome important to patients with severe asthma and can provide clinicians with additional insight into the benefits of treatment. The aim of this systematic review is to examine the use and reporting of HRQoL questionnaires within randomised controlled trials (RCTs) of biologics, fevipiprant and bronchial thermoplasty.

METHODS

We followed the guidelines on the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) statement. Of the 2380 retrieved articles, 52 studies were identified for inclusion.

RESULTS

Sixty-three percent included an asthma HRQoL questionnaire. It was a secondary outcome in the majority of cases (73%). The proportion of studies including an asthma HRQoL questionnaire did not change significantly over a 20-year period. While the Asthma Quality of Life Questionnaire (AQLQ) was used in 45% of studies, 55% used a variety of 4 questionnaires. Most (70%) of the studies that included a HRQoL questionnaire did not report its subscale scores. Approximately half (52%) of studies that used HRQoL reported this in the abstract of the paper. A higher proportion of studies used an asthma control questionnaire compared to a HRQoL questionnaire (71% vs 63%).

CONCLUSION

In order to increase the use of asthma HRQoL questionnaires in RCTs of severe asthma treatments, the drivers and barriers to their use must first be understood. At present, the patients' perspective is underrepresented in RCTs of biologics, fevipiprant and bronchial thermoplasty for severe asthma.

Development of Novel, Value-Based, Digital Endpoints for Clinical Trials: A Structured Approach Toward Fit-for-Purpose Validation

Novel digital endpoints gathered via wearables, small devices, or algorithms hold great promise for clinical trials. However, implementation has been slow because of a lack of guidelines regarding the validation process of these new measurements. In this paper, we propose a pragmatic approach toward selection and fit-for-purpose validation of digital endpoints. Measurements should be value-based, meaning the measurements should directly measure or be associated with meaningful outcomes for patients. Devices should be assessed regarding technological validity. Most importantly, a rigorous clinical validation process should appraise the tolerability, difference between patients and controls, repeatability, detection of clinical events, and correlation with traditional endpoints. When technically and clinically fit-for-purpose, case building in interventional clinical trials starts to generate evidence regarding the response to new or existing health-care interventions. This process may lead to the digital endpoint replacing traditional endpoints, such as clinical rating scales or questionnaires in clinical trials. We recommend initiating more data-sharing collaborations to prevent unnecessary duplication of research and integration of value-based measurements in clinical care to enhance acceptance by health-care professionals. Finally, we invite researchers and regulators to adopt this approach to ensure a timely implementation of digital measurements and value-based thinking in clinical trial design and health care. SIGNIFICANCE STATEMENT: Novel digital endpoints are often cited as promising for the clinical trial of the future. However, clear validation guidelines are lacking in the literature. This paper contains pragmatic criteria for the selection, technical validation, and clinical validation of novel digital endpoints and provides recommendations for future work and collaboration.

Perspectives on decisions for treatment and care in severe asthma

Background

Severe asthma is a subtype of asthma that can be hard to control, resulting in an exceptional impact on an individual's quality of life. The aim of this review article is to explore the misalignment of perceptions of severe asthma among different stakeholders to identify how to reduce burden and improve delivery of care.

Results

The misalignment of perspectives is best reflected in randomised controlled trials (RCTs) in asthma treatments, which are often designed for regulatory approval with a focus on exacerbations with no direct input from the individuals that the treatments are designed for. Based on a literature review and the clinical experience of the authors to overcome this disparity, the goals of people with severe asthma need to be incorporated throughout their care, from study design to the day-to-day management of their condition. Improved education for individuals and their support network will provide them with resources and knowledge so that they can effectively communicate their needs to other stakeholders involved in their care.

Conclusion/recommendation

A collaborative effort from all stakeholders is essential to ensure efficient management of asthma and a reduction in asthma burden on individuals and society.

Fibromyalgia in Iraqi patients with asthma and its impact on asthma severity and control

Background

Fibromyalgia (FM) is common with significant impact on patients quality of life. Limited reports on coexistence of FM with asthma.

Objectives

To assess the prevalence of FM in asthmatic patients and its impact on asthma severity and control.

Patients and methods

This case-control study included 103 patients with asthma and 102 apparently healthy controls matched in age and sex. Sociodemographic and clinical characteristics of FM and controls were recorded. FM was diagnosed according to the 2016 revision of American College of Rheumatology criteria. Asthma diagnosis and severity were performed by the pulmonologist according to Global Initiative for Asthma (GINA) guidelines and asthma control was assessed by Asthma Control Test (ACT) score.

Results

The mean age of asthmatic patients was 41.1 ± 12.7 years and for controls was 39.8 ± 12 years (p = 0.453). Females were more prevalent in asthmatic patients and controls although statistically were not significant (p-value = 0.532). Prevalence of FM was significantly more in asthmatic patients compared to controls [18 (17.6%) vs 7 (6.8%), p = 0.018] and asthmatic patients had three folds risk of having FM (ranging from 1.2 to 7.4 times. FM increased the risk of severe asthma by 4.91 folds (P < 0.005). Also, only FMS and glucocorticoids were significant independent predictor of having poor asthma control. FM was significantly and negatively correlated with low ACT score (β standardized regression coefficient = −0.291, p = 0.005).

Conclusions

fibromyalgia was common in asthmatic patients and was significantly associated with more severe and poorly controlled asthma.

•

Fibromyalgia (FM) was more common in asthmatic patients compared with controls.

•

FM was significantly associated with more severe and poorly controlled asthma.

•

Breathing training programs may be useful management in asthmatic patients with FM.

Biologics for Severe Asthma: Treatment-Specific Effects Are Important in Choosing a Specific Agent

Patients with uncontrolled severe persistent asthma have greater morbidity, greater use of health care resources, and more impairment in health-related quality of life when compared with their peers with well-controlled disease. Fortunately, since the introduction of biological therapeutics, patients with severe eosinophilic asthma now have beneficial treatment options that they did not have just a few years ago. In addition to anti-IgE therapy for allergic asthma, 3 new biological therapeutics targeting IL-5 and 1 targeting IL-4 and IL-13 signaling have recently been approved by the Food and Drug Administration for the treatment of severe eosinophilic asthma, and approval of more biological therapeutics is on the horizon. These medications decrease the frequency of asthma exacerbations, improve lung function, reduce corticosteroid usage, and improve health-related quality of life. This article reviews the mechanisms of action, specific indications, benefits, and side effects of each of the approved biological therapies for asthma. Furthermore, this article reviews how a clinician could use specific patient characteristics to decide which biologic treatment may be optimal for a given patient.

Longitudinal Relationships between Asthma-Specific Quality of Life and Asthma Control in Children; The Influence of Chronic Rhinitis

Managing pediatric asthma includes optimizing both asthma control and asthma-specific quality of life (QoL). However, it is unclear to what extent asthma-specific QoL is related to asthma control or other clinical characteristics over time. The aims of this study were to assess in children longitudinally: (1) the association between asthma control and asthma-specific QoL and (2) the relationship between clinical characteristics and asthma-specific QoL. In a 12-month prospective study, asthma-specific QoL, asthma control, dynamic lung function indices, fractional exhaled nitric oxide, the occurrence of exacerbations, and the use of rescue medication were assessed every 2 months. Associations between the clinical characteristics and asthma-specific QoL were analyzed using linear mixed models. At baseline, the QoL symptom score was worse in children with asthma and concomitant chronic rhinitis compared to asthmatic children without chronic rhinitis. An improvement of asthma control was longitudinally associated with an increase in asthma-specific QoL (p-value < 0.01). An increased use of β₂-agonists, the occurrence of wheezing episodes in the year before the study, the occurrence of an asthma exacerbation in the 2 months prior to a clinical visit, and a deterioration of lung function correlated significantly with a decrease in the Pediatric Asthma Quality of Life Questionnaire (PAQLQ) total score (p-values ≤ 0.01). Chronic rhinitis did not correlate with changes in the PAQLQ score over 1 year. The conclusion was that asthma control and asthma-specific QoL were longitudinally associated, but were not mutually interchangeable. The presence of chronic rhinitis at baseline did influence QoL symptom scores. β₂-agonist use and exacerbations before and during the study were inversely related to the asthma-specific QoL over time.

Effect of pranayama breathing technique on asthma control, pulmonary function, and quality of life: A single-blind, randomized, controlled trial

OBJECTIVE

This study evaluated the effect of pranayama on asthma control, pulmonary function, and quality of life in people with asthma.

METHODS

Pranayama was applied to the pranayama group for 20 min once daily for 1 month, and relaxation was applied to the relaxation group similarly in addition to the standard treatment. The outcome measurement tools used were the Asthma Control Test (ACT), Asthma Quality of Life Questionnaire (AQLQ), pulmonary function test (PFT), and patient observation chart.

RESULTS

The pranayama group had significantly higher ACT score, overall AQLQ score, and subscale scores than the relaxation group (p < 0.05). However, there was no significant difference between the groups in terms of PFT parameters and peak expiratory flow values (p > 0.05).

CONCLUSION

Pranayama improved asthma control and asthma-related quality of life in people with asthma, but it did not show a significant difference in PFT values.

Effect of outdoor particulate air pollution on FEV1 in healthy adults: a systematic review and meta-analysis

The effect of acute and long-term exposures to outdoor particulate air pollution on lung function in healthy adults is not well established. The objective of this study was to conduct a systematic literature review and meta-analysis of studies that assessed the relationship of outdoor particulate air pollution and lung function in healthy adults. Studies that contained data on outdoor air particulate matter levels (PM₁₀ or PM_2.5) and forced expiratory volume in 1 s (FEV₁) in healthy adults were eligible for inclusion. Effect estimates, in relation to long-term and acute exposures, were quantified separately using random effects models. A total of 27 effect estimates from 23 studies were included in this review. Acute exposures were typically assessed with PM_2.5, while long-term exposures were predominantly represented by PM₁₀ A 10 µg/m3 increase in short-term PM_2.5 exposure (days) was associated with a -7.02 mL (95% CI -11.75 to -2.29) change in FEV₁ A 10 µg/m³ difference in long-term PM₁₀ exposure was associated with a -8.72 mL (95% CI -15.39 to -2.07) annual change in FEV₁ and an absolute difference in FEV₁ of -71.36 mL (95% CI -134.47 to -8.24). This study provides evidence that acute and long-term exposure to outdoor particulate air pollution are associated with decreased FEV₁ in healthy adults. Residual confounding from other risk factors, such as smoking, may explain some of the effect for long-term exposures. More studies are required to determine the relationship of long-term exposure to PM_2.5 and short-term exposure to PM₁₀, which may have different biologic mechanisms.

Patient-reported outcomes assessment tools for use in psoriasis in Spain: A systematic review

OBJECTIVES

To review the literature on validated tools for measuring patient-reported outcomes (PROs) in psoriasis in Spain. To evaluate the psychometric properties of the tools and describe the results of their practical application.

MATERIAL AND METHODS

Systematic review of studies validating or using instruments for assessing PROs in Spanish patients with psoriasis. Literature searches were performed in international (PubMed/Medline) and Spanish (Medes, Ibecs) databases. We also searched databases of instruments for measuring PROs (BiblioPRO, PROQOLID). The review included studies published in English or Spanish up to January 9, 2017. We also checked the reference lists of the key publications identified. The quality of the questionnaires was evaluated based on their psychometric properties (construct, transcultural adaptation, reliability, validity, feasibility, and sensitivity to change).

RESULTS

Eighteen publications were included. Six articles described the validation of Spanish versions of 5 PROs tools: 4 health-related quality of life (HRQoL) questionnaires specific to psoriasis and dermatologic diseases and 1 questionnaire specific to satisfaction with treatment. Our assessment of the HRQoL tools' psychometric properties showed that the PSO-LIFE questionnaire received the highest scores, although specific properties varied from instrument to instrument. The 12 remaining articles were observational studies that used the validated instruments. In use, these tools detected the high impact of psoriasis on HRQoL, especially in young female patients with severe disease.

CONCLUSIONS

We identified 5 specific instruments validated in Spain for scoring PROs in patients with psoriasis. The tools' psychometric properties vary, and it is essential to understand their strengths and weaknesses when selecting the right one for each situation. In use, these questionnaires are able to detect the high impact of psoriasis on patients' HRQoL. PROs provide useful information to complement routine clinical findings in psoriasis and may contribute to improving disease management.

Acid-Base Disturbances in Patients with Asthma: A Literature Review and Comments on Their Pathophysiology

Asthma is a common illness throughout the world that affects the respiratory system function, i.e., a system whose operational adequacy determines the respiratory gases exchange. It is therefore expected that acute severe asthma will be associated with respiratory acid-base disorders. In addition, the resulting hypoxemia along with the circulatory compromise due to heart–lung interactions can reduce tissue oxygenation, with a particular impact on respiratory muscles that have increased energy needs due to the increased workload. Thus, anaerobic metabolism may ensue, leading to lactic acidosis. Additionally, chronic hypocapnia in asthma can cause a compensatory drop in plasma bicarbonate concentration, resulting in non-anion gap acidosis. Indeed, studies have shown that in acute severe asthma, metabolic acid-base disorders may occur, i.e., high anion gap or non-anion gap metabolic acidosis. This review briefly presents studies that have investigated acid-base disorders in asthma, with comments on their underlying pathophysiology.

EuroQol (EQ-5D-5L) Validity in Assessing the Quality of Life in Adults With Asthma: Cross-Sectional Study

BACKGROUND

The EuroQol-5 Dimension (EQ-5D), developed in 1990, is a most widely used generic tool to measure the health-related quality of life (HRQoL) and considered suitable for patients with asthma. In 2009, the EuroQol Group developed a new EQ-5D version to overcome limitations related to its consistently reported high ceiling effect. To enhance the sensitivity for assessing the HRQoL in further patient populations, the number of responses of EQ-5D was increased from 3 to 5 levels (EQ-5D-5L). Moreover, the availability of well-defined requirements for its Web-based administration allows EQ-5D-5L use to monitor the HRQoL in electronic health (eHealth) programs. No study has evaluated the metric properties of the new EQ-5D-5L in patients with asthma yet.

OBJECTIVE

This study aims to examine the distribution, construct validity, and reliability of the new EQ-5D-5L questionnaire administered online to adults with asthma.

METHODS

We evaluated patients with asthma (age: 18-40 years) from a primary care setting in France and England, who self-completed the EQ-5D-5L questionnaire online. The inclusion criteria were persistent asthma defined as >6 months of prescribed inhaled corticosteroids and long-acting beta-agonists or inhaled corticosteroids alone during the 12 months prior to inclusion. The EQ-5D index was obtained by applying the English preference value set for the new EQ-5D-5L and the French 3L-5L crosswalk value set. Both value sets produced single preference-based indices ranging from 1 (best health state) to negative values (health states valued as worse than death), where 0=death, allowing the calculation of quality-adjusted life years. Responses to dimensions and index distribution, including ceiling and floor effects, were examined. The construct validity was assessed by comparing the means of known groups by analyses of variance and calculation of effect sizes.

RESULTS

Of 312 patients answering the baseline Web-based survey, 290 completed the EQ-5D-5L (93%). The floor effect was null, and the ceiling effect was 26.5% (74/279). The mean EQ-5D-5L index was 0.88 (SD 0.14) with the English value set and 0.83 (SD 0.19) with the French 3L-5L crosswalk value set. In both indices, large effect sizes were observed for known groups defined by the Asthma Control Questionnaire (1.06 and 1.04, P<.001). Differences between extreme groups defined by chronic conditions (P=.002 and P=.003 for the English value set and French 3L-5L crosswalk value set, respectively), short-acting beta-agonists (SABAs) canisters in the last 12 months (P=.02 and P=.03), or SABA use during the previous 4 weeks (P=.03 and P=.01) were of moderate magnitude with effect sizes around 0.5.

CONCLUSIONS

The new EQ-5D-5L questionnaire has an acceptable ceiling effect, a good construct validity based on the discriminant ability for distinguishing among health-related known groups, and high reliability, supporting its adequacy for assessing the HRQoL in patients with asthma. EQ-5D-5L completion by most Web-based respondents supports the feasibility of this administration form.

Evaluating the Impact and Benefits of Fluticasone Furoate/Vilanterol in Individuals with Asthma or COPD: A Mixed-Methods Analysis of Patient Experiences

INTRODUCTION

This study evaluated patients' experiences with fluticasone furoate/vilanterol (FF/VI) combination therapy in UK patients with asthma or chronic obstructive pulmonary disease (COPD).

METHODS

Participants aged ≥ 18 years, with self-reported, physician-diagnosed asthma or COPD (≥ 1 year) who had been receiving FF/VI (≥ 3 months) were recruited from UK primary care. This two-phase, mixed-methods study consisted of a semi-structured, telephone-interview phase (qualitative) and a self-completed online/paper-survey phase (quantitative).

RESULTS

The telephone-interview phase included 50 individuals [asthma, n = 25; COPD, n = 25; mean age (SD) 56.7 years (13.3); 50% female]. Of these, 21 with asthma reported that their condition was stable/well controlled and 13 with COPD felt their condition was manageable. Most participants found FF/VI easy to use (asthma, 25; COPD, 23), easy to integrate into their daily routine (asthma, 25; COPD, 24), and able to control symptoms for ≥ 24 h (asthma, 14; COPD, 16). During the survey phase, 199 individuals were recruited [asthma, n = 100; COPD, n = 99; mean age (SD) 63.6 years (15.1); 59.3% female]. Most participants were satisfied/very satisfied with the efficacy of FF/VI in terms of all-day symptom relief (asthma, 84%; COPD, 75%) and found FF/VI easy/very easy to fit into their daily routine (asthma, 99%; COPD, 96%), easy/very easy to use (asthma, 97%; COPD, 92%), and convenient/very convenient to take as instructed (asthma, 95%; COPD, 93%). Significantly more individuals with asthma (87% versus 46%, P < 0.001) and numerically more individuals with COPD (84% versus 76%, P = 0.055) were satisfied/very satisfied with FF/VI compared with their most recent previous maintenance medication.

CONCLUSION

The majority of individuals in this study had confidence in FF/VI and were satisfied or very satisfied with various key attributes of the treatment.

TRIAL REGISTRATION

GSK study HO-15-15503/204888.

FUNDING

GSK.

Impact of asthma on women and men: Comparison with the general population using the EQ-5D-5L questionnaire

BACKGROUND

The aim was to evaluate the impact of asthma on patients' Health-Related Quality of Life (HRQoL) by comparing asthmatic women and men with reference norms, to examine the factors which contributed to an impaired HRQoL, and to identify groups at higher risk.

METHODS

Cross-sectional evaluation of 222 primary care patients with persistent asthma (18-40 years old). HRQoL impact was estimated with the EuroQol-5 Dimensions (EQ-5D), which allows calculating Quality-Adjusted Life-Years (QALYs) by applying society preferences. Participants self-completed the EQ-5D questionnaire online. Telephonic interviews collected information on medication and adherence, and administered the Asthma Control Questionnaire. Severity markers included asthma-related comorbidity, previous oral corticosteroids course prescription, and inhaled corticosteroids daily dose. After bivariate analyses, multiple linear regression models were constructed to examine the relations between HRQoL asthma impact and socio-demographic and clinical variables, using as dependent variable the deviation from general population-based EQ-5D reference norms.

RESULTS

Deviation from the EQ-5D index norms was moderate in most age/gender groups (-0.1, which corresponds to 0.6 standard deviations), while it was large in women aged 18-24 years (-0.18, corresponding to 1.1 standard deviations). In regression models, a poor asthma control was the only factor independently associated to HRQoL impact in both women and men: β -0.18 (p<0.001) and -0.15 (p = 0.01) respectively. Translating these β coefficients to QALYs, they are interpretable as 66 fewer days of full health per year in women with uncontrolled asthma and 55 for men, compared with those with controlled asthma.

CONCLUSION

Persistent asthma has a moderately negative HRQoL impact on patients of both genders, and the youngest women have been identified as a high risk group which merits further research. We identified asthma control as the major contributor to impaired HRQoL in patients, regardless of their gender, suggesting that asthma HRQoL impact could be alleviated by achieving a good control of symptoms.

Speech-guided breathing retraining in asthma: a randomised controlled crossover trial in real-life outpatient settings

Background

Breathing retraining techniques have received increased attention in the management of asthma, because there is growing evidence of the usefulness of such methods in improving quality of life, reducing symptoms and reducing bronchodilator use. Our study investigated the effect of anthroposophic therapeutic speech (ATS), which uses sounds and syllabic rhythm to improve articulation, breathing and cardiorespiratory interaction, in patients with asthma in a real-life outpatient setting.

Methods

In a randomised controlled crossover trial, patients with asthma in three centres in Switzerland and Germany were randomised to either receive 11 ATS sessions or to wait. Subsequently, patients changed either to wait or to receive ATS. Primary outcomes were changes from the beginning to the end of each phase in the Asthma Quality of Life Questionnaire (AQLQ) and spirometry parameters. Secondary outcomes were changes in inhaled glucocorticoids, the Asthma Control Test (ACT), peak flow and asthma exacerbations.

Results

Altogether, 63 patients were randomised, of which 56 were enrolled and 49 completed the study. Statistically significant differences between the ATS groups and waiting control groups were found for the overall AQLQ score (d = 0.86, p = 0.001) and the domain scores for symptoms, activity limitation and emotional function as well as ACT score (d = 0.53, p = 0.048). No significant differences were observed in spirometry parameters, inhaled glucocorticoids, peak flow and days without asthma exacerbation per week. No serious adverse events occurred during ATS sessions.

Conclusions

ATS significantly improves asthma control and quality of life in patients with asthma. Whether ATS may improve lung function remains to be shown.

Trial registration

ClinicalTrials.gov NCT02501824. Retrospectively registered on 8 July 2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2727-z) contains supplementary material, which is available to authorized users.

Psychometric evaluation of a caregiver diary for the assessment of symptoms of respiratory syncytial virus

BACKGROUND

There are no clinical outcome assessment (COA) tools developed in accordance with Food and Drug Administration (FDA) guidance suitable for the evaluation of symptoms associated with respiratory syncytial virus (RSV) infection among infants. The Gilead RSV Caregiver Diary (GRCD) is being developed to fulfill this need; the present research evaluates the GRCD and documents its reliability, validity, and responsiveness among children < 24 months of age with acute RSV infection.

METHODS

A prospective, observational study was conducted in the United States during the 2014-2015 northern hemisphere winter season. Subjects were < 24-month, full-term, previously healthy infants with confirmed RSV infection and ≤5 days of symptoms. The GRCD was completed twice daily for 14 days by caregivers. Additional data were collected during the initial visit, subsequent visits, and end-of-study interview. Test-retest reliability (kappa and intraclass correlation coefficients [ICCs]), construct validity (correlations and factor analyses), discriminating ability (analyses of variance and chi-square), and responsiveness (effect sizes and standardized response means) were evaluated.

RESULTS

A total of 103 subjects were enrolled (mean age 7.4 ± 5.3 months). GRCD items were grouped into different subscales according to question content, which, with the exception of the behavior impact domain (ICC = 0.43), demonstrated internal consistency (alphas = 0.78-0.94) and test-retest reliability (ICCs = 0.77-0.94). Hypothesized correlations with parent global ratings of RSV severity ranged from 0.45 to 0.70 and provided support for construct validity. Support for discriminating ability was limited. Effect sizes ranged from - 1.48 to - 4.40, indicating the GRCD was responsive to change.

CONCLUSIONS

These psychometric analyses support the validity, reliability, and responsiveness of the GRCD for assessing RSV symptoms in children < 24 months of age.

Fibromyalgia as a cause of uncontrolled asthma: a case-control multicenter study

BACKGROUND

Fibromyalgia can affect the control of asthma when both diseases are present in a single patient.

OBJECTIVES

To characterize asthma in patients with concomitant fibromyalgia to assess whether fibromyalgia is an independent factor of asthma severity that influences poor asthma control. We also evaluated how dyspnea is perceived by patients in order to demonstrate that alterations in the perception of airway obstruction may be responsible for poor asthma control.

METHODS

This was a cross-sectional case-control multicenter study, in which 56 patients in the asthma and fibromyalgia group were matched to 36 asthmatics by sex, approximate age, and asthma severity level. All patients were women. Study variables included the Asthma Control Test (ACT), the Mini Asthma Quality of Life Questionnaire (MiniAQLQ), the Nijmegen hyperventilation syndrome questionnaire, the Hospital Anxiety and Depression Scale, and perception of dyspnea after acute bronchoconstriction.

RESULTS

Although patients in both study groups showed similar asthma severity and use of anti-asthmatic drugs, patients in the asthma and fibromyalgia group showed lower scores on the ACT and MiniAQLQ questionnaires, and higher scores of anxiety and depression as well as hyperventilation compared to asthma patients without fibromyalgia. All these differences were statistically significant.

CONCLUSIONS

Fibromyalgia in patients with asthma influences poor control of the respiratory disease and is associated with altered perception of dyspnea, hyperventilation syndrome, high prevalence of depression and anxiety, and impaired quality of life.

CLINICAL IMPLICATIONS

Fibromyalgia may be considered a risk factor for uncontrolled asthma in patients suffering from asthma and fibromyalgia concomitantly.

Inhaled magnesium sulfate in the treatment of acute asthma

BACKGROUND

Asthma exacerbations can be frequent and range in severity from mild to life-threatening. The use of magnesium sulfate (MgSO₄) is one of numerous treatment options available during acute exacerbations. While the efficacy of intravenous MgSO₄ has been demonstrated, the role of inhaled MgSO₄ is less clear.

OBJECTIVES

To determine the efficacy and safety of inhaled MgSO₄ administered in acute asthma.

SPECIFIC AIMS

to quantify the effects of inhaled MgSO₄ I) in addition to combination treatment with inhaled β₂-agonist and ipratropium bromide; ii) in addition to inhaled β₂-agonist; and iii) in comparison to inhaled β₂-agonist.

SEARCH METHODS

We identified randomised controlled trials (RCTs) from the Cochrane Airways Group register of trials and online trials registries in September 2017. We supplemented these with searches of the reference lists of published studies and by contact with trialists.

SELECTION CRITERIA

RCTs including adults or children with acute asthma were eligible for inclusion in the review. We included studies if patients were treated with nebulised MgSO₄ alone or in combination with β₂-agonist or ipratropium bromide or both, and were compared with the same co-intervention alone or inactive control.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial selection, data extraction and risk of bias. We made efforts to collect missing data from authors. We present results, with their 95% confidence intervals (CIs), as mean differences (MDs) or standardised mean differences (SMDs) for pulmonary function, clinical severity scores and vital signs; and risk ratios (RRs) for hospital admission. We used risk differences (RDs) to analyse adverse events because events were rare.

MAIN RESULTS

Twenty-five trials (43 references) of varying methodological quality were eligible; they included 2907 randomised patients (2777 patients completed). Nine of the 25 included studies involved adults; four included adult and paediatric patients; eight studies enrolled paediatric patients; and in the remaining four studies the age of participants was not stated. The design, definitions, intervention and outcomes were different in all 25 studies; this heterogeneity made direct comparisons difficult. The quality of the evidence presented ranged from high to very low, with most outcomes graded as low or very low. This was largely due to concerns about the methodological quality of the included studies and imprecision in the pooled effect estimates. Inhaled magnesium sulfate in addition to inhaled β₂-agonist and ipratropiumWe included seven studies in this comparison. Although some individual studies reported improvement in lung function indices favouring the intervention group, results were inconsistent overall and the largest study reporting this outcome found no between-group difference at 60 minutes (MD -0.3 % predicted peak expiratory flow rate (PEFR), 95% CI -2.71% to 2.11%). Admissions to hospital at initial presentation may be reduced by the addition of inhaled magnesium sulfate (RR 0.95, 95% CI 0.91 to 1.00; participants = 1308; studies = 4; I² = 52%) but no difference was detected for re-admissions or escalation of care to ITU/HDU. Serious adverse events during admission were rare. There was no difference between groups for all adverse events during admission (RD 0.01, 95% CI -0.03 to 0.05; participants = 1197; studies = 2). Inhaled magnesium sulfate in addition to inhaled β₂-agonistWe included 13 studies in this comparison. Although some individual studies reported improvement in lung function indices favouring the intervention group, none of the pooled results showed a conclusive benefit as measured by FEV1 or PEFR. Pooled results for hospital admission showed a point estimate that favoured the combination of MgSO₄ and β₂-agonist, but the confidence interval includes the possibility of admissions increasing in the intervention group (RR 0.78, 95% CI 0.52 to 1.15; participants = 375; studies = 6; I² = 0%). There were no serious adverse events reported by any of the included studies and no between-group difference for all adverse events (RD -0.01, 95% CI -0.05 to 0.03; participants = 694; studies = 5). Inhaled magnesium sulfate versus inhaled β₂-agonistWe included four studies in this comparison. The evidence for the efficacy of β₂-agonists in acute asthma is well-established and therefore this could be considered a historical comparison. Two studies reported a benefit of β₂-agonist over MgSO₄ alone for PEFR and two studies reported no difference; we did not pool these results. Admissions to hospital were only reported by one small study and events were rare, leading to an uncertain result. No serious adverse events were reported in any of the studies in this comparison; one small study reported mild to moderate adverse events but the result is imprecise.

AUTHORS' CONCLUSIONS

Treatment with nebulised MgSO₄ may result in modest additional benefits for lung function and hospital admission when added to inhaled β₂-agonists and ipratropium bromide, but our confidence in the evidence is low and there remains substantial uncertainty. The recent large, well-designed trials have generally not demonstrated clinically important benefits. Nebulised MgSO₄ does not appear to be associated with an increase in serious adverse events. Individual studies suggest that those with more severe attacks and attacks of shorter duration may experience a greater benefit but further research into subgroups is warranted.Despite including 24 trials in this review update we were unable to pool data for all outcomes of interest and this has limited the strength of the conclusions reached. A core outcomes set for studies in acute asthma is needed. This is particularly important in paediatric studies where measuring lung function at the time of an exacerbation may not be possible. Placebo-controlled trials in patients not responding to standard maximal treatment, including inhaled β₂-agonists and ipratropium bromide and systemic steroids, may help establish if nebulised MgSO₄ has a role in acute asthma. However, the accumulating evidence suggests that a substantial benefit may be unlikely.

Psychometric Properties of the German Version of the Health Regulatory Focus Scale

The Health Regulatory Focus Scale (HRFS) is a short scale which measures an individual's prevention and promotion focus in a health-specific context. The main objective of this study was to examine the psychometric properties of the newly translated German version of the HRFS. Reliability and item characteristics were found to be satisfactory. Validity of both subscales toward other psychological constructs including behavioral approach and avoidance, core self-evaluations, optimism, pessimism, neuroticism, as well as several measures of physical and mental health was shown. In addition, invariance of the measure across age and gender groups was shown. Exploratory as well as confirmatory factor analyses clearly indicated a two-factorial structure with a moderate correlation between the two latent constructs. Differences in health promotion and prevention focus between socio-demographic groups are discussed. The HRFS is found to be a valid and reliable instrument for the assessment of regulatory focus in health-related environments.

Estimating asthma control questionnaire (ACQ) scores from claims data

BACKGROUND

Asthma control is the main focus of treatment guidelines. Valid instruments such as the Asthma Control Questionnaire (ACQ) require prospective survey. These surveys may be challenging for large population health applications.

OBJECTIVE

To develop an algorithm for estimating ACQ-5 scores from commonly available claims data.

METHODS

Data was derived from four prospective surveys including the ACQ-5 combined with retrospective claims of Kaiser Permanente of Colorado (KPCO) patients. The statistical approach consisted of derivation and validation of a prediction algorithm including medical and pharmacy claims data using stepwise regression elimination. Validation was conducted by estimating mean squared error (MSE) and mean absolute error (MAE) in one hundred split-sample iterations. Ordinary least squares (OLS), Tobit and Median regression were used.

RESULTS

There were 2,657 individuals with valid ACQ-5 scores, claims and eligibility at baseline. The following had statistically significant associations with ACQ-5 scores: gender, use of oral corticosteroids and short-acting beta agonists, the number of asthma drug classes, and emergency and outpatient visits. Average MSE and MAE were similar for the estimation and validation samples.

CONCLUSION

This research provides preliminary results of the feasibility of predicting ACQ-5 scores using commonly available medical and pharmacy claims data. The resulting algorithm may facilitate public health and population level analyses of asthma control. Future studies in different populations will be important to validate the algorithm.

Asthma Cost-Effectiveness Analyses: Are We Using the Recommended Outcomes in Estimating Value?

BACKGROUND

Asthma medication cost-effectiveness analyses (CEAs) lack the qualitative assessment regarding whether they capture the National Institutes for Health (NIH) 2012 recommended outcomes necessary to allow robust cross-study comparisons.

OBJECTIVE

We aimed to assess the current asthma outcomes used in CEAs and recommend a direction for improvement.

METHODS

We performed a systematic search using electronic databases including PubMed, EMBASE, Tufts CEA registry, Cochrane, and NHSEED from January 2010 through December 2015. Key words included (1) cost-effectiveness, cost-utility, economic evaluation, health economics, or cost-benefit AND (2) asthma. All CEA studies evaluating 1 or more asthma medication were included. Authors assessed each CEA study with respect to asthma-specific NIH outcome recommendations including core (hospitalizations, emergency department visits, outpatient visits, medication, interventions costs), supplemental (visit categories and work/school absence), and emerging (academic/job-related) asthma outcomes. Besides outcomes of each CEA, issues that could prevent robust cross-study comparison were identified and thematically summarized.

RESULTS

A total of 12 pre-NIH and 14 post-NIH recommendation CEAs were included. Eleven (91.7%) and 14 (100%) of the pre-/post-NIH studies included at least 1 core outcome, respectively. Of the 26 total studies, 7 (26.9%) included asthma-specific outpatient visit categories, 6 (23.1%) included asthma school or work absences, 5 (19.2%) included respiratory health care use, and none of the studies included emerging outcomes. Other issues that hamper cross-study comparison include lack of standardized cost data, time frames, quality-of-life measures, and incorporation of adherence.

CONCLUSIONS

Although the use of NIH-recommended asthma core outcomes has improved, there is still room for improvement in using supplemental and emerging outcomes. To allow robust cross-study comparisons, future work should focus on further standardizing of data sources and methods.

Preliminary validation of the Claudication Symptom Instrument (CSI)

This article describes the development of the Claudication Symptom Instrument (CSI) and its measurement properties for evaluating the symptom experience of patients diagnosed with intermittent claudication (IC). We conducted semi-structured qualitative interviews with IC patients for item development and cognitive interviews in which patient comprehension of items was tested. We evaluated measurement properties using data collected and analyzed in the context of an observational comparative effectiveness study of IC treatments. Items measuring five symptom important to patients were developed and cognitively tested: Pain, Numbness, Heaviness, Cramping, and Tingling. Item means (higher means worse) ranged from 1.1 (Tingling) to 2.3 (Pain) (range: 0 'none' to 4 'extreme'). Rasch analysis yielded support for an overall score (χ²=26.5, df=20, p=0.15). The total CSI score differed by clinician-rated severity of mild versus moderate ( p<0.05), but not moderate versus severe. Re-administration of the CSI 5-10 days after baseline yielded an intra-class correlation coefficient of 0.86. Changes in CSI total score and VASCUQOL total score between baseline and 6 months post-treatment were correlated at -0.52 ( p<0.05). The CSI preliminarily meets accepted measurement standards for content validity, internal consistency and test-retest reliability, construct validity, and sensitivity for detecting change. Because of its high test-retest reliability, it may also be useful in clinical care with individual patients. It takes approximately 3 minutes to complete.

Longitudinal co-variations between inflammatory cytokines, lung function and patient reported outcomes in patients with asthma

Background

Asthma is a chronic inflammatory respiratory disorder associated with reduced lung function and poor quality of life. The condition is also associated with poor self-rated health, a major predictor of objective health trajectories. Of biological correlates to self-rated health, evidence suggests a role for inflammatory cytokines and related sickness behaviours. However, this is mainly based on cross-sectional data, and the relation has not been investigated in patients with chronic inflammatory conditions.

Objective

To investigate inflammatory cytokines, lung function, sickness behaviour and asthma-related quality of life as determinants of self-rated health in patients with asthma, and to investigate if these variables co-vary over time.

Methods

Plasma cytokines (IL-5, IL-6), lung function (FEV1), sickness behaviour, asthma-related quality of life and self-rated health were assessed in 181 patients with allergic asthma aged 18–64 years in a one-year longitudinal study. Mixed effect regression models and Spearman’s correlation were performed to analyse the associations between repeated measurements.

Results

More sickness behaviour and poorer asthma-related quality of life were associated with poorer self-rated health (p’s<0.001). In men, both low and high levels of interleukin (IL)-6 and poorer lung function were related with poorer self-rated health (p’s<0.05). Over the year, improved asthma-related quality of life was associated with better self-rated health (Spearman’s rho = -0.34 women,-0.36 men, p’s<0.01). Further, if sickness behaviour decreased, self-rated health improved, but only in women (Rho = -0.21, p<0.05). Increased FEV1 in men was associated with an increase in IL-6 (Rho = 0.24, p<0.05) as well as improved self-rated health (Rho = -0.21, p<0.05) and asthma-related quality of life (Rho = 0.29, p<0.01) over the year.

Conclusion

The study highlights the importance of subjectively perceived sickness behaviour and asthma-related quality of life together with lung function as determinants of self-rated health in asthmatic patients. The importance of inflammatory activation for patient reported outcomes in chronic inflammatory conditions need further investigation.

Life Impact and Treatment Preferences of Individuals with Asthma and Chronic Obstructive Pulmonary Disease: Results from Qualitative Interviews and Focus Groups

INTRODUCTION

The impact of asthma and chronic obstructive pulmonary disease (COPD) on individuals' lives may be substantial, yet clinical practice often focuses only on symptoms. We aimed to better understand the perspective of asthma or COPD patients and to identify condition-related burden, life impact, priorities, unmet needs, and treatment goals.

METHODS

Individuals aged at least 18 years with asthma or COPD were identified by a recruitment panel via clinical referrals, support groups, consumer networks, and a patient database. Interviews were carried out individually (by telephone) or in focus groups (with no more than five participants per group). A semi-structured interview guide was used with prespecified topics, informed by a literature review, that were considered impactful in asthma or COPD (symptoms and daily-life impact, satisfaction with current treatment, important aspects of treatment, adherence, and ideal treatment).

RESULTS

Overall, 72 people participated in focus groups/individual interviews (asthma n = 18/n = 21; COPD n = 15/n = 18). "Shortness of breath" was the most frequently reported symptom; however, participants discussed the life impact of their condition more than symptoms alone. Reported physical impacts included the inability to sleep and socialize, while emotional impacts included "embarrassment, stigma, and/or self-consciousness", "fear and/or panic", and "sadness, anxiety, and/or depression". Coping mechanisms for normal activities included continuing at reduced pace and avoidance. Treatment preferences centered on resolving impacts; improved sleep, "speed of action", and "length of relief" were the most frequently reported ideal treatment factors.

CONCLUSION

Patients with asthma or COPD experience substantial quality of life limitations and tend to focus on these in their expressions of concern, rather than symptoms per se. Life impacts of these conditions may have implications beyond those commonly appreciated in routine practice; these considerations will be applied to a future discrete choice experiment survey.

FUNDING

GSK funded study (H0-15-15502/204821).

Mastery of pMDI technique, asthma control and quality-of-life of children with asthma: A randomized controlled study comparing two inhaler technique training approaches

OBJECTIVE

Verbal counselling (VC) is the clinical standard for training patients on correct inhaler use. Patients fail to recall their VC with time. Ethical approval was obtained to compare the pressurized metered dose inhaler (pMDI) VC with Trainhaler (TH), a novel pMDI inhalation flow and technique training device, in children with asthma.

METHODS

At visit 1, 7-17 year-old children with a pMDI hand-lung coordination problem including a fast peak inhalation flow (PIF) through pMDI >60 L/min were randomized into either VC group that received verbal pMDI training; or into TH group that were trained on- and given TH to practice at home. Whereas, children with correct pMDI use formed the control group (CT). Overall pMDI technique, PIF through inhaler, asthma control (AC) and quality of life (QoL) were evaluated. Participants were re-evaluated 6-8 weeks later (visit 2).

RESULTS

Of 105 enrolled children; 76 completed the study (VC = 21, TH = 25 and CT = 30). VC decreased non-significantly (p > 0.05) the mean PIF from 104.0 L/min at visit 1 to 84.8 at visit 2. Whilst, the TH did significantly (p < 0.05) reduce the PIF from 113.5 to 71.4 L/min. The two approaches similarly and significantly (p < 0.05) improved the inhaler technique, AC and QoL scores.

CONCLUSIONS

The TH improved the inhalation flow through the pMDI close to the ideal needed for adequate lung deposition. Both methods equally enhanced the children's mastery of pMDI use. This was reflected on better AC and QoL. Accessibility to TH might help maintaining the good inhaler use and decreasing regular VC.

The Danish National Database for Asthma: establishing clinical quality indicators

Asthma is one of the most common chronic diseases worldwide affecting more than 300 million people. Symptoms are often non-specific and include coughing, wheezing, chest tightness, and shortness of breath. Asthma may be highly variable within the same individual over time. Although asthma results in death only in extreme cases, the disease is associated with significant morbidity, reduced quality of life, increased absenteeism, and large costs for society. Asthma can be diagnosed based on report of characteristic symptoms and/or the use of several different diagnostic tests. However, there is currently no gold standard for making a diagnosis, and some degree of misclassification and inter-observer variation can be expected. This may lead to local and regional differences in the treatment, monitoring, and follow-up of the patients. The Danish National Database for Asthma (DNDA) is slated to be established with the overall aim of collecting data on all patients treated for asthma in Denmark and systematically monitoring the treatment quality and disease management in both primary and secondary care facilities across the country. The DNDA links information from population-based disease registers in Denmark, including the National Patient Register, the National Prescription Registry, and the National Health Insurance Services register, and potentially includes all asthma patients in Denmark. The following quality indicators have been selected to monitor trends: first, conduction of annual asthma control visits, appropriate pharmacological treatment, measurement of lung function, and asthma challenge testing; second, tools used for diagnosis in new cases; and third, annual assessment of smoking status, height, and weight measurements, and the proportion of patients with acute hospital treatment. The DNDA will be launched in 2016 and will initially include patients treated in secondary care facilities in Denmark. In the nearby future, the database aims to include asthma diagnosis codes and clinical data registered by general practitioners and specialised practitioners as well.

Measurement of utility in asthma: evidence indicating that generic instruments may miss clinically important changes

BACKGROUND

Accurate assessment of preference-based health-related quality of life is important in determining the value of asthma interventions.

OBJECTIVE

To examine the sensitivity and responsiveness of the EQ-5D and the AQL-5D to differences in asthma control measured by the Asthma Control Questionnaire (ACQ-5).

METHODS

The Observational Study of Asthma Control and Outcomes was a prospective survey of persistent asthma patients ≥12 years old in Kaiser Colorado. Patients received a survey three times in 1 year, including the ACQ-5, AQL-5D and EQ-5D-3L (including VAS). Censored Least Absolute Deviations (CLAD) and logistic regression were used, controlling for sociodemographics and smoking.

RESULTS

There were 6666 completed surveys (1799 individuals completed all three survey waves). After controlling for covariates, each one-point increase in ACQ-5 was associated with a decrease of 0.066, 0.058, 0.074 and 6.12 in EQ-5D(US), EQ-5D(UK), AQL-5D and VAS scores. Uncontrolled asthma (ACQ-5 > 1.5) was associated with a decrease of 0.15, 0.17, 0.11 and 10, respectively (vs. ACQ ≤ 1.5). AQL-5D scores were statistically significantly different across categories of ACQ-5 scores of 0.5 (the minimum clinically important difference [MCID]), while EQ-5D scores were not significant across most categories. The AQL-5D appeared more robust to changes in control over time (responsiveness) compared to EQ-5D-3L.

CONCLUSION

The AQL-5D appears more responsive to changes in asthma control over time and more sensitive to detecting differences corresponding to the ACQ-5 MCID than the EQ-5D-3L. Using the EQ-5D-3L without an asthma-specific measure such as the AQL-5D may miss clinically important changes in asthma control.

Measuring the cost of poor asthma control and exacerbations

BACKGROUND

Previous studies have shown an association between cost and poor asthma control. However, longitudinal studies of general populations are lacking.

OBJECTIVE

To examine the cost of poor asthma control and exacerbations across a broad spectrum of asthma patients.

METHODS

The Observational Study of Asthma Control and Outcomes (OSACO) was a prospective survey of persistent asthma patients in Kaiser Colorado in 2011-2012. Patients received a survey 3 times in one year, which included the Asthma Control Questionnaire (ACQ) and questions on exacerbations. Self-reported exacerbations were compared to actual oral corticosteroid (OCS) use. Regression analyses examined the association of control (ACQ-5 scores) and exacerbations with healthcare expenditures, controlling for sociodemographics and smoking. Analyses of expenditures used Generalized Linear Models (GLM) with log-link.

RESULTS

2681 individuals completed at least one survey; 1799 completed all three. ACQ-5 scores were associated with higher all-cause and asthma-specific expenditures across all categories of costs (medical, outpatient, ER, pharmacy) except for inpatient expenditures. Each 1-point increase in the ACQ-5 score (i.e., worse control) was associated with a corresponding increase in all-cause annual healthcare and asthma-specific expenditures of $1443 and $927 ($US 2013). Asthma exacerbations with documented OCS use were associated with an increase of $3014 and $1626 over 4 months, while self-reported exacerbations were $713 and $506.

CONCLUSION

Results demonstrate that poor asthma control and exacerbations are strongly associated with higher healthcare expenditures. Results also confirm that collection of validated measures of control such as the ACQ-5 may provide valuable information toward improving clinical and economic outcomes.

Understanding asthma-specific quality of life: moving beyond asthma symptoms and severity

This study identifies the unique contributions of asthma severity, symptoms, control and generic measures of quality of life (QoL) to asthma-specific QoL, as measured by the 12-item RAND Negative Impact of Asthma on Quality of Life scale (RAND-IAQL-12).Using a sample of 2032 adults with asthma, we conducted multiple regression analyses that sequentially examined hypothesised predictors of asthma-specific QoL. The change in variance accounted for and total unique variance accounted for is calculated as hypothesised predictors are added in each step.Our results indicate that asthma severity and asthma symptoms are strong predictors of asthma-specific QoL only when not controlling for aspects of asthma control. In regression models that include other aspects of asthma control, the contributions of both asthma symptoms and severity were substantially reduced, with asthma control and aspects of QoL related to social roles and activities emerging as the strongest predictors of asthma-specific QoL.These findings suggest that researchers measuring the impact of asthma on QoL should also consider the importance of asthma control as measured by the RAND Asthma Control Measure (RAND-ACM) and generic QoL scales that measure aspects of daily life that are uniquely affected by asthma.

Symptoms and markers of symptom severity in asthma--content validity of the asthma symptom diary

BACKGROUND AND OBJECTIVES

The American Thoracic Society/European Respiratory Society (ATS/ERS) Task Force acknowledged the multi-faceted nature of asthma in its recent definition of asthma control as a summary term capturing symptoms, reliever use, frequency/severity of exacerbations, lung function, and future risk and the Global Initiative for Asthma (GINA) defines the clinical manifestations (well established markers of asthma severity) of asthma to include symptoms, sleep disturbances, limitations of daily activity, impairment of lung function, and use of rescue medications. The objectives of this qualitative work were to identify symptoms and markers of symptom severity relevant to patients with moderate to severe asthma and to evaluate the content validity of the asthma symptom diary (ASD).

METHODS

A qualitative interview study was conducted using a purposive sample of symptomatic adult and adolescent (≥12 years) subjects with asthma. Concept elicitation (CE) interviews (n = 50) were conducted to identify core asthma symptoms and symptom-related clinical markers, followed by cognitive interviews (n = 24) to ensure patient comprehension of the items, instructions and response options. CE interviews were coded using ATLAS.ti for content analysis.

RESULTS

The study sample had a diverse range of symptom severity, level of symptom control, sociodemographic and socioeconomic status. The most frequently reported symptoms in adults were chest tightness (n = 33/34; 97.1%), wheezing (n = 31; 91.2%), coughing (n = 30; 88.2%), and shortness of breath (n = 25; 73.5%); in adolescents they were wheezing (n = 14/16; 87.5%), coughing (n = 13; 81.3%), and chest tightness (n = 11; 68.8%). Adults identified chest tightness followed by shortness of breath as their most severe symptoms; while adolescents reported coughing and chest tightness as their most severe symptoms. Sleep awakenings and limitations in day-to-day activities were frequent symptom-related clinical markers. Day-to-day variability and differences between daytime and nighttime symptom experiences reported by subjects resulted in the need for the ASD to be administered twice daily. Cognitive interviews indicated that subjects found the revised ASD items clear and easy to understand.

CONCLUSIONS

This study supports the content validity of the revised ASD, showing it to be consistent with patient experiences and ready for further psychometric testing.

Impact of multimorbidity on disability and quality of life in the Spanish older population

Background

Population aging is closely related to high prevalence of chronic conditions in developed countries. In this context, health care policies aim to increase life span cost-effectively while maintaining quality of life and functional ability. There is still, however, a need for further understanding of how chronic conditions affect these health aspects. The aim of this paper is to assess the individual and combined impact of chronic physical and mental conditions on quality of life and disability in Spain, and secondly to show gender trends.

Methods

Cross-sectional data were collected from the COURAGE study. A total of 3,625 participants over 50 years old from Spain were included. Crude and adjusted multiple linear regressions were conducted to detect associations between individual chronic conditions and disability, and between chronic conditions and quality of life. Separate models were used to assess the influence of the number of diseases on the same variables. Additional analogous regressions were performed for males and females.

Results

All chronic conditions except hypertension were statistically associated with poor results in quality of life and disability. Depression, anxiety and stroke were found to have the greatest impact on outcomes. The number of chronic conditions was associated with substantially lower quality of life [β for 4+ diseases: −18.10 (−20.95,−15.25)] and greater disability [β for 4+ diseases: 27.64 (24.99,30.29]. In general, women suffered from higher rates of multimorbidity and poorer results in quality of life and disability.

Conclusions

Chronic conditions impact greatly on quality of life and disability in the older Spanish population, especially when co-occurring diseases are added. Multimorbidity considerations should be a priority in the development of future health policies focused on quality of life and disability. Further studies would benefit from an expanded selection of diseases. Policies should also deal with gender idiosyncrasy in certain cases.

Heterogeneity of phenotypes in severe asthmatics. The Belgian Severe Asthma Registry (BSAR)

The Belgian severe asthma registry is a web-based registry encompassing demographic, clinical, functional and inflammatory data of severe asthmatics (SA), aiming at improving awareness, knowledge on its natural history and subphenotypes, and offering tools to optimize care of this asthma population.

METHODS

The cross-sectional analyses of this registry included 350 SA as defined by the ATS (2000) from 9 Belgian centres, with at least one year follow up.

RESULTS

Mean age was 55 ± 14 yrs. SA were more frequently female (57%) and atopic (70%). Late-onset asthma (≥40 yr) was observed in 31% of SA. Current smokers represented 12% while 31% were ex-smokers. In addition to high doses ICS + LABA, 65% of patients were receiving LTRA, 27% anti-IgE and 24% maintenance oral corticosteroids (8 mg (Interquartile range-IQR:4-8) methylprednisolone). Despite impaired airflow (median FEV1:67%; IQR: 52-81) only 65% had a post-bronchodilator FEV1/FVC ratio <70%. The median blood eosinophil count was 240/mm³. The median FENO was 26 ppb (IQR: 15-43) and 22% of SA had FENO ≥ 50 ppb. Induced sputum was successful in 86 patients. Eosinophilic asthma (sputum Eos ≥ 3%) was the predominant phenotype (55%) while neutrophilic (sputum Neu ≥ 76%) and paucigranulocytic asthma accounted for 22% and 17% respectively. Comorbidities included rhinitis and chronic rhinosinusitis (49%), nasal polyposis (19%), oesophageal reflux (36%), overweight and obesity (47%) and depression (19%). In addition, 8% had aspirin-induced asthma and 3% ABPA. Asthma was not well-controlled in 83% according to ACT < 20 and 77% with ACQ > 1.5.

CONCLUSION

In this cohort of patients with severe asthma, the majority displayed indices of persistent airflow limitation and eosinophilic inflammation despite high-dose corticosteroids, suggesting potential for eosinophil-targeted biotherapies.

The "e" in cost-effectiveness analyses. A case study of omalizumab efficacy and effectiveness for cost-effectiveness analysis evidence

This article is a call for increased use of real-world evidence in health technology assessment and related policy and decision making. There is currently a disconnect between evidence used to guide regulatory approval of therapies and evidence used to inform therapeutic coverage and reimbursement decisions. Public and private payers need to understand not only whether an intervention works but also whether it offers good value compared with licensed alternatives (not placebo) as they are used in the real-world practice and population (not in a controlled trial environment). Addressing such concerns requires evidence to be drawn from a wide range of study designs, but with consideration and weighting given to their relative strengths and weaknesses, as well as their position on the pragmatic-explanatory (i.e., effectiveness-efficacy) continuum. The potential impact of using different types of evidence to inform cost-effectiveness analysis (CEA) is discussed for omalizumab, comparing and contrasting a CEA model informed by an omalizumab efficacy trial to a CEA model drawing primarily on evidence from effectiveness observational studies of omalizumab. There was reasonable agreement between the two omalizumab CEA models, although the incremental cost-effectiveness ratio generated by the effectiveness observational study-driven model was more favorable for omalizumab. Health technology assessment bodies and payers must use their judgment to determine which components of efficacy-based and effectiveness-based CEA evidence are most closely aligned with their goals. For each CEA evidence component, perhaps the two E's form bounds of the truth as well as a fuller picture of the uncertainty surrounding the truth.

Assessing the validity of the RAND negative impact of asthma on quality of life short forms

BACKGROUND

In response to recommendations from the 2010 National Institutes of Health Asthma Outcomes Workshop, we developed a system for measuring the negative impact of asthma on quality of life (QoL), which was referred to as the RAND Negative Impact of Asthma on Quality of Life (RAND-IAQL) item bank. The bank contains 65 items that focus on the patient's perception of the impact or bother of asthma on his or her life.

OBJECTIVE

Evidence for the validity of 2 short forms, the RAND-IAQL 4-item and 12-item Short Forms, from the bank is presented.

METHODS

Using a sample of 2032 adults with asthma, we validated our short forms against the Asthma Quality of Life Questionnaire-Marks (AQLQ-M), the Asthma Control Test, and generic measures of QoL developed by the Patient-reported Outcomes Measurement Information System (PROMIS). Discriminant validity was examined by comparing scores of respondents who differed according to multiple health indicators.

RESULTS

Our sample ranged in age from 18 to 99 years (mean, 43 years), with 14% Hispanic, 11% Asian, 19% African American, and 56% non-Hispanic white race/ethnicity. Men had a significantly worse impact of asthma on QoL than women. The impact of asthma on QoL was greatest in African American and Hispanic subjects compared with that seen in non-Hispanic white subjects. Our measures correlated highly with the AQLQ-M and more strongly with the PROMIS global physical than mental scales. They differentiated between adults with asthma according to their perceived severity, level of control, presence or absence of exacerbations, and physical comorbidity.

CONCLUSION

The RAND-IAQL item bank, measuring the impact of asthma on QoL, will complement other patient-reported outcomes, such as measures of asthma symptoms, functioning, and control.

Asthma Control and Cost in Latin America

OBJECTIVE

Few patients with asthma have disease that is well-controlled, particularly in Latin American countries. The purpose of this study was to investigate whether partly controlled and uncontrolled asthma are associated with increased costs for asthma-related medications and health care utilization compared with well-controlled asthma in five Latin American countries.

METHODS

Using the Global Initiative for Asthma guidelines, we classified respondents from the Latin American Asthma Insights and Management survey into those with well-controlled, partly controlled, and uncontrolled asthma and compared the utilization of health care services and costs among these groups.

RESULTS

Most respondents to our survey (93%) had asthma that was classified as partly controlled or uncontrolled. Across all countries, patients whose asthma was partly controlled or uncontrolled had greater use of asthma-related medications and medical services than did patients whose asthma was well-controlled. After adjusting for age, sex, and country of residence, total costs for asthma-related medications and health care were greater in patients whose asthma was classified as partly controlled and uncontrolled.

CONCLUSIONS

Our findings indicate that patients with asthma that are not well-controlled used more health care resources and had greater medical costs in Latin America.

A study to assess inhaler technique and its potential impact on asthma control in patients attending an asthma clinic

OBJECTIVES

The aim of this study was to evaluate inhaler technique and symptom control in patients with poorly controlled asthma at baseline and at follow-up in a dedicated asthma clinic in a tertiary hospital. We also investigated the impact of asthma on these patients' quality of life.

METHODS

Patients referred to a newly established asthma clinic in Cork University Hospital were prospectively recruited over a 6-month period. Their inhaler technique was assessed by a pulmonary nurse specialist using a validated scoring system. They received instruction on inhaler usage when scores were suboptimal. Patients completed a validated asthma control questionnaire (ACQ) and asthma quality of life questionnaire (AQLQ). At follow-up 3-4 months later, the inhaler technique was reassessed and the ACQ questionnaire repeated.

RESULTS

Forty-six patients were recruited (female = 74%), and 40/46 were followed up. Mean [SD] FEV1 % predicted at baseline = 76.5% [21.5]. About 63% of the patients were classified as incorrectly using their inhaler at their initial assessment. This decreased to 20% at follow-up, indicating an overall significant improvement in inhaler usage post-training (p = 0.003). ACQ scores improved significantly from median [interquartile range] 2.70 [1.66] to 2.00 [1.90] (p = 0.002). Baseline measurement indicated that patients' quality of life was moderately affected by asthma, with a median AQLQ score of 4.75 [1.97].

CONCLUSION

This study demonstrates the importance of educating and formally assessing inhaler technique in patients with asthma as a part of their ongoing clinical review.

Association between maximal aerobic capacity and psychosocial factors in adults with moderate-to-severe asthma

BACKGROUND

The symptoms of asthma impair health-related quality of life (HRQoL), increase anxiety and depression and may keep subjects from engaging in physical exercise. Physical inactivity has been related to poor asthma outcomes; however, the association between physical fitness and psychosocial disorders remains poorly understood.

OBJECTIVE

To verify the association between aerobic capacity, HRQoL, and psychological distress in adults with moderate or severe persistent asthma who were clinically stable.

METHODS

Eighty-eight participants (68 females) with either moderate or severe persistent asthma (age range, 20-60 years) who were under medical treatment for at least 6 months and considered clinically stable were studied. Participants were evaluated on two non-consecutive days. On the first day, the HRQoL, depression and anxiety levels and pulmonary function were assessed. On the second day, subjects underwent cardiopulmonary exercise testing.

RESULTS

Using the agglomerative cluster approach, two clusters were identified: 21 participants (24%) were grouped in Cluster 1, and 67 (76%) were grouped in Cluster 2. Asthmatic subjects from Cluster 1 exhibited increased aerobic capacity, better HRQoL and lower depression levels than did subjects in Cluster 2 (p < .05). No difference was observed between the clusters with respect to gender, age, body mass index (BMI) or pulmonary function (p > .05). The discriminant function model exhibits good accuracy (R(2) = 0.79) and predicted 93% of the case allocations.

CONCLUSION

Our results suggest an association between reduced exercise capacity, low HRQoL and increases in depressive symptoms in clinically stable asthmatic subjects. These results suggest the need to assess physical fitness and psychosocial distress during asthma treatment and the importance of a multidisciplinary approach.

Exploring factors influencing asthma control and asthma-specific health-related quality of life among children

BACKGROUND

Little is known about factors contributing to children's asthma control status and health-related quality of life (HRQoL). The study objectives were to assess the relationship between asthma control and asthma-specific HRQoL in asthmatic children, and to examine the extent to which parental health literacy, perceived self-efficacy with patient-physician interaction, and satisfaction with shared decision-making (SDM) contribute to children's asthma control and asthma-specific HRQoL.

METHODS

This cross-sectional study utilized data collected from a sample of asthmatic children (n = 160) aged 8-17 years and their parents (n = 160) who visited a university medical center. Asthma-specific HRQoL was self-reported by children using the National Institutes of Health's Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Asthma Impact Scale. Satisfaction with SDM, perceived self-efficacy with patient-physician interaction, parental health literacy, and asthma control were reported by parents using standardized measures. Structural equation modeling (SEM) was performed to test the hypothesized pathways.

RESULTS

Path analysis revealed that children with better asthma control reported higher asthma-specific HRQoL (β = 0.4, P < 0.001). Parents with higher health literacy and greater perceived self-efficacy with patient-physician interactions were associated with higher satisfaction with SDM (β = 0.38, P < 0.05; β = 0.58, P < 0.001, respectively). Greater satisfaction with SDM was in turn associated with better asthma control (β = -0.26, P < 0.01).

CONCLUSION

Children's asthma control status influenced their asthma-specific HRQoL. However, parental factors such as perceived self-efficacy with patient-physician interaction and satisfaction with shared decision-making indirectly influenced children's asthma control status and asthma-specific HRQoL.

Effect of diaphragmatic breathing exercise on quality of life in subjects with asthma: A systematic review

The aim of this systematic review was to determine if diaphragmatic breathing exercise improves quality of life (QoL) in asthma. Electronic databases were searched for randomized controlled trials (RCTs). Data were extracted and risk of bias was assessed by two independent reviewers. Three RCTs were eligible for inclusion (254 subjects). Two studies compared diaphragmatic breathing exercise to asthma education, and one compared with asthma medication. Meta-analysis was not possible due to clinical heterogeneity of the studies. All three studies had a low risk of bias. All studies reported short-term effects, and long-term effects of breathing exercise on asthma quality life. There is a moderate evidence of improvement in QoL following diaphragmatic breathing both in short-term and long-term basis.

Associations of patient outcomes with level of asthma control

BACKGROUND

Despite effective medications, asthma remains a significant burden to the US health care system.

OBJECTIVE

To determine whether partly and uncontrolled asthma in respondents to the Asthma Insights and Management (AIM) survey was associated with adverse outcomes (such as visits to health care professionals and medication use) compared with well-controlled asthma.

METHODS

The AIM survey, conducted in 2009, included 2,500 patients with asthma who were 12 years or older. We classified patients into levels of control and compared use of health care services and limitations of activities in patients whose asthma was well controlled vs those with partly and uncontrolled asthma.

RESULTS

Patients who reported lower income and educational status and lacked health insurance were less likely to have had well-controlled asthma. Respondents with uncontrolled asthma were more likely to report ever use of oral steroids (odds ratio [OR], 2.5; 95% confidence interval [CI], 1.9-3.2) and over-the-counter medicine (OR, 2.7; 95% CI, 2.0-3.7) compared with patients whose asthma was well controlled. Respondents with partly and uncontrolled asthma were also significantly more likely to report ever visiting physicians, specialists, or the emergency department or being hospitalized for asthma compared with those whose asthma was well controlled (ORs ranging from 2.1 to 5.6). Finally, respondents whose asthma was uncontrolled had increased odds (ORs ranging from 14 to 34) of reporting that asthma limited their activities compared with respondents whose asthma was well controlled.

CONCLUSION

Patients with partly and uncontrolled asthma defined by international guidelines reported use of significantly more health care resources and greater limitations of their daily activities compared with patients whose asthma was well controlled.