National trends in hospital admissions for asthma exacerbations among pediatric and young adult population in Spain (2002-2010)

Trends in hospital admissions among children with asthma in Spain (2011-2020)

The purpose of this study is to describe and assess changes in incidence, clinical conditions, use of mechanical ventilation, length of hospital stay (LOHS), and in-hospital mortality (IHM) among children hospitalized with asthma in Spain from 2011 to 2020. We analyzed children aged 0 to 15 years hospitalized with an ICD code for asthma included in the Spanish National Hospital Discharge Database (SNHDD). The analysis was conducted for asthma as the primary diagnosis and with asthma in any diagnosis position. Joinpoint regression was used to assess time trends in incidence. We included a total of 85,664 children hospitalized with asthma; of these, 46,727 (54.55%) had asthma coded as the primary diagnosis. The number of boys was higher than the number of girls, irrespective of age group or diagnostic position. The frequency of asthma as primary diagnosis decreased from 55.7% in 2011 to 43.96% in 2020 (p < 0.001). The incidence of hospitalizations because of asthma decreased significantly from 2011 to 2020, with a faster decrease from 2018 onwards. Over time, the proportion of older children increased. In the year 2020, only 55 children had codes for asthma and COVID-19 in their discharge report, and this infection had no effect on hospitalizations this year. A significant increase in the use of non-invasive ventilation (NIV) was observed over time. Irrespective of the diagnostic position, LOHS and IHM remained stable over time, with the IHM under 0.1%.  Conclusion: Our results show a decrease in the incidence of hospital admissions with asthma either as the primary diagnosis or in any position. The age of children hospitalized seems to be increasing as the use of NIV. Better management of the disease from primary care and the emergency department as is the use of NIV could explain the reduction in incidence. What is Known: • Asthma is the most common chronic respiratory in childhood in high income countries. • The incidence of hospital admissions with asthma and associated factors is one of the best sources of information on morbidity trends and prognosis. What is New: • The incidence of hospital admissions for asthma in Spain decreased in children between 2011 and 2020 with a more frequent use of non-invasive mechanical ventilation and low mortality rates. • COVID-19 did not cause an increase in admissions with asthma in the year 2020.

Paediatric asthma hospitalisations continue to decrease in Finland and Sweden between 2015 and 2020

We previously reported a decreasing incidence of paediatric asthma hospitalisations in Finland, but a rather stable trend in Sweden, between 2005 and 2014. We now aimed to investigate the incidence of paediatric asthma hospitalisations in these countries between 2015 and 2020, using Finland's National Hospital Discharge Register and Sweden's National Patient Register, which cover all hospitalisations in the respective countries. From 2015 to 2019, the incidence of paediatric asthma hospitalisations decreased by 36.7% in Finland and by 39.9% in Sweden and are increasingly approaching parity. In 2020, despite differences in COVID-19-related restrictions, asthma hospitalisations decreased by over 40%, thus warranting future research on the subject.

Mechanical Ventilation and Survival in Patients With Advanced Dementia in Medicare Advantage

CONTEXT

Medicare Advantage (MA) cares for an increasing proportion of traditional Medicare (TM) patients although, the association of MA on low-value care among hospitalized patients is uncertain.

OBJECTIVES

We sought to determine whether invasive mechanical ventilation (IMV) use or mortality differs among hospitalized patients with advanced dementia (AD) enrolled in MA vs. TM and the influence of hospital MA concentration.

METHODS

Retrospective cohort of hospitalized Medicare patients from 2016 to 2017 who were ≥66 years old with AD (n=147,153) and had a hospitalization with an assessment completed during a nursing home stay ≤120 days prior to that hospitalization indicating AD and severe cognitive/functional impairment. MA enrollment was ascertained at hospitalization; IMV use and 30- and 365-day mortality were determined via Medicare data. Multivariable logistic regression models clustered by hospital were used.

RESULTS

Among hospitalized Medicare patients with AD, 27,253 (19%) were enrolled in MA, mean age was 84 (95% CI: 83.9-84.0) and 92,736 (63%) were female. Enrollment in MA was associated with increased IMV use (Adjusted Odds Ratio(AOR)=1.11, 95% CI: 1.04-1.18), 30- (Adjusted Hazard Ratio(AHR)=1.09, 95% CI: 1.05-1.12) and 365-day mortality (AHR=1.12, 95% CI: 1.08-1.16) compared to TM. Use of IMV was not different based on concentration of MA at the hospital level.

CONCLUSION

MA may reduce hospitalizations, however, once hospitalized, patients with AD enrolled in MA experience higher rates of IMV use and worse 30- and 365-day mortality compared to TM patients. Higher hospital concentration of MA did not reduce use of IMV. MA may not offer significant benefits in reducing low-value care among patients hospitalized with serious illness, questioning the benefits of this care model.

Decline in hospitalization for childhood asthma in different air pollution regions in Taiwan, 2001-2012

This study aimed to investigate the trends in childhood asthma hospitalization in regions with differing levels of air pollution in Taiwan, 2001-2012. Joinpoint regression was used to identify significant trend changes. The hospitalization rate varied according to gender, geographic region, and age. The incidence of childhood asthma hospitalization decreased from 127.99 to 76.67 (/100,000 population), with an average annual percentage change of around -4.1%; in the Yilan region, the average air pollution concentrations were 19.92 μg/m³, 39.47 μg/m³, 25.99 ppb, 2.19 ppb, and 11.23 ppb for PM_2.5, PM₁₀, O₃, SO₂, and NO₂, respectively, which were lower than Taiwan's average values; however, the childhood asthma hospitalization rate was the highest (179.75/100,000 population). The national trend in childhood asthma hospitalization exhibited a significant decrease. The effects of air pollution on childhood asthma were greater in the higher-level air pollution regions, while less association was observed in the lower-level air pollution regions.

Regional differences in pediatric asthma hospital admissions: National data from Israel 1996-2017

BACKGROUND

Asthma is a common chronic childhood illness and frequent cause of hospitalization. A decline in hospital admission rates was noted up to the 1990s, however, trends are not as clear since the turn of the century. This study aimed to assess the rates and regional differences of asthma admissions over more than two decades using the national Ministry of Health database, which registers data from all the hospitals.

METHODS

A retrospective cohort study, analysis of all pediatric asthma admissions, for Patients 1-14 years old, between 1996 and 2017 as recorded by the National Hospital Discharge Registry, was performed. Asthma admission rates were calculated per 1000 age adjusted residents, using the number of admission cases as the numerator, and age specific population size as the denominator.

RESULTS

The annual asthma hospitalization rate decreased in the entire pediatric population from 2.14 in 1996-0.89 in 2017. Children in the 1-4 year age group comprised most of the hospital admissions, and most of the decline was attributable to this age group. Significant differences in hospitalizations were found between different regions as well as differences in the rate of decline in asthma hospitalizations with the lowest admission rate in the Jerusalem district, highest in Haifa, northern and southern Israeli regions and the greatest rate of decline in the Tel-Aviv district.

CONCLUSION

This nationwide study, over more than two decades, shows clear regional differences in the rates of asthma admissions as well as regional differences in the rates of decline.

Dying with dementia in Medicare Advantage, Accountable Care Organizations, or traditional Medicare

BACKGROUND/OBJECTIVE

Medicare Advantage (MA) and Accountable Care Organizations (ACOs) operate under incentives to reduce burdensome and costly care at the end of life. We compared end-of-life care for persons with dementia who are in MA, ACOs, or traditional Medicare (TM).

DESIGN, SETTING, AND PARTICIPANTS

Retrospective study of decedents with dementia enrolled in MA, attributed to an ACO, or in TM. Decedents had a nursing home stay between 91 and 180 days prior to death, two or more functional impairments, and mild to severe cognitive impairment.

MEASUREMENTS

Hospitalization, invasive mechanical ventilation (IMV) use, and in-hospital death in the last 30 days of life reported in Medicare billing.

RESULTS

Among 370,094 persons with dementia, 93,801 (25.4%) were in MA (mean age [SD], 86.9 [7.7], 67.6% female), 39,586 (10.7%) were ACO attributed (mean age [SD], 87.2 [7.6], 67.3% female), and 236,707 (63.9%) were in TM (mean age [SD], 87.0 [7.8], 67.6% female). The proportion hospitalized in the last 30 days of life was higher among TM enrollees (27.9%) and those ACO attributed (28.1%) than among MA enrollees (20.5%, p ≤ 0.001). After adjustment for socio-demographics, cognitive and functional impairments, comorbidities, and Hospital Referral Region, adjusted odds of hospitalization in the 30 days prior to death was 0.72 (95% confidence interval [CI] 0.70-0.74) among MA enrollees and 1.05 (95% CI 1.02-1.09) among those attributed to ACOs relative to TM enrollees. Relative to TM, the adjusted odds of death in the hospital were 0.78 (95% CI 0.75-0.81) among MA enrollees and 1.02 (95% CI 0.96-1.08) for ACO participants. Dementia decedents in MA had a lower likelihood of IMV use (adjusted odds ratio 0.80, 95% CI 0.75-0.85) compared to TM.

CONCLUSIONS

Among decedents with dementia, MA enrollees but not decedents in ACOs experienced less costly and potentially burdensome care compared with those with TM. Policy changes are needed for ACOs.

Maternal asthma and early fetal growth, the MAESTRO study

BACKGROUND

Several maternal conditions can affect fetal growth, and asthma during pregnancy is known to be associated with lower birth weight and shorter gestational age.

OBJECTIVE

In a new Swedish cohort study on maternal asthma exposure and stress during pregnancy (MAESTRO), we have assessed if there is evidence of early fetal growth restriction in asthmatic women or if a growth restriction might come later during pregnancy.

METHODS

We recruited women from eight antenatal clinics in Stockholm, Sweden. Questionnaires on background factors, asthma status and stress were assessed during pregnancy. The participants were asked to consent to collection of medical records including ultrasound measures during pregnancy, and linkage to national health registers. In women with and without asthma, we studied reduced or increased growth by comparing the second-trimester ultrasound with first-trimester estimation. We defined reduced growth as estimated days below the 10th percentile and increased growth as days above the 90th percentile. At birth, the weight and length of the newborn and the gestational age was compared between women with and without asthma.

RESULTS

We enrolled 1693 participants in early pregnancy and collected data on deliveries and ultrasound scans in 1580 pregnancies, of which 18% of the mothers had asthma. No statistically significant reduced or increased growth between different measurement points were found when women with and without asthma were compared; adjusted odds ratios for reduced growth between first and second trimester 1.11 95% CI (0.63-1.95) and increased growth 1.09 95% CI (0.68-1.77).

CONCLUSION AND CLINICAL RELEVANCE

In conclusion, we could not find evidence supporting an influence of maternal asthma on early fetal growth in the present cohort: Although the relatively small sample size, which may enhance the risk of a type II error, it is concluded that a potential difference is likely to be very small.

Trends in Noninvasive and Invasive Mechanical Ventilation Among Medicare Beneficiaries at the End of Life

IMPORTANCE

End-of-life care is costly, and decedents often experience overtreatment or low-quality care. Noninvasive ventilation (NIV) may be a palliative approach to avoid invasive mechanical ventilation (IMV) among select patients who are hospitalized at the end of life.

OBJECTIVE

To examine the trends in NIV and IMV use among decedents with a hospitalization in the last 30 days of life.

DESIGN, SETTING, AND PARTICIPANTS

This population-based cohort study used a 20% random sample of Medicare fee-for-service beneficiaries who had an acute care hospitalization in the last 30 days of life and died between January 1, 2000, and December 31, 2017. Sociodemographic, diagnosis, and comorbidity data were obtained from Medicare claims data. Data analysis was performed from September 2019 to July 2020.

EXPOSURES

Use of NIV or IMV.

MAIN OUTCOMES AND MEASURES

Validated International Classification of Diseases, Ninth Revision, Clinical Modification or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification procedure codes were reviewed to identify use of NIV, IMV, both NIV and IMV, or none. Four subcohorts of Medicare beneficiaries were identified using primary admitting diagnosis codes (chronic obstructive pulmonary disease [COPD], congested heart failure [CHF], cancer, and dementia). Measures of end-of-life care included in-hospital death (acute care setting), hospice enrollment at death, and hospice enrollment in the last 3 days of life. Random-effects logistic regression examined NIV and IMV use adjusted for sociodemographic characteristics, admitting diagnosis, and comorbidities.

RESULTS

A total of 2 470 435 Medicare beneficiaries (1 353 798 women [54.8%]; mean [SD] age, 82.2 [8.2] years) were hospitalized within 30 days of death. Compared with 2000, the adjusted odds ratio (AOR) for the increase in NIV use was 2.63 (95% CI, 2.46-2.82; % receipt: 0.8% vs 2.0%) for 2005 and 11.84 (95% CI, 11.11-12.61; % receipt: 0.8% vs 7.1%) for 2017. Compared with 2000, the AOR for the increase in IMV use was 1.04 (95% CI, 1.02-1.06; % receipt: 15.0% vs 15.2%) for 2005 and 1.63 (95% CI, 1.59-1.66; % receipt: 15.0% vs 18.2%) for 2017. In subanalyses comparing 2017 with 2000, similar trends found increased NIV among patients with CHF (% receipt: 1.4% vs 14.2%; AOR, 14.14 [95% CI, 11.77-16.98]) and COPD (% receipt: 2.7% vs 14.5%; AOR, 8.22 [95% CI, 6.42-10.52]), with reciprocal stabilization in IMV use among patients with CHF (% receipt: 11.1% vs 7.8%; AOR, 1.07 [95% CI, 0.95-1.19]) and COPD (% receipt: 17.4% vs 13.2%; AOR, 1.03 [95% CI, 0.88-1.21]). The AOR for increased NIV use was 10.82 (95% CI, 8.16-14.34; % receipt: 0.4% vs 3.5%) among decedents with cancer and 9.62 (95% CI, 7.61-12.15; % receipt: 0.6% vs 5.2%) among decedents with dementia. The AOR for increased IMV use was 1.40 (95% CI, 1.26-1.55; % receipt: 6.2% vs 7.6%) among decedents with cancer and 1.28 (95% CI, 1.17-1.41; % receipt: 5.7% vs 6.2%) among decedents with dementia. Among decedents with NIV vs IMV use, lower rates of in-hospital death (50.3% [95% CI, 49.3%-51.3%] vs 76.7% [95% CI, 75.9%-77.5%]) and hospice enrollment in the last 3 days of life (57.7% [95% CI, 56.2%-59.3%] vs 63.0% [95% CI, 60.9%-65.1%]) were observed along with higher rates of hospice enrollment (41.3% [95% CI, 40.4%-42.3%] vs 20.0% [95% CI, 19.2%-20.7%]).

CONCLUSIONS AND RELEVANCE

This study found that the use of NIV rapidly increased from 2000 through 2017 among Medicare beneficiaries at the end of life, especially among persons with cancer and dementia. The findings suggest that trials to evaluate the outcomes of NIV are warranted to inform discussions about the goals of this therapy between clinicians and patients and their health care proxies.

Risk of Rehospitalization and Death in Patients Hospitalized Due to Asthma

BACKGROUND

Asthma is a heterogeneous inflammatory airway disease that continues to cause considerable morbidity across the world, with poor asthma control leading to hospitalizations.

OBJECTIVE

The present study investigated the risk of rehospitalization, mortality, and the management of patients with asthma who had been hospitalized because of an asthma exacerbation.

METHODS

National Swedish health registries were linked for patients 6 years or older who were admitted to hospital because of asthma (index date) between January 1, 2006, and December 31, 2015. Exacerbations were defined as asthma-related hospitalization, emergency visits, or collection of oral steroids. Patients were followed for rehospitalizations 12 months after the index date, health care resource utilization and treatment for 36 months, and mortality to study end. Regression models for time-to-event analyses were applied to assess risk factors for rehospitalization and mortality.

RESULTS

A total of 15,691 patients (mean age, 51.5 years; 63% females) were included, of whom 1,892 (12%) were rehospitalized for asthma within 12 months. Rehospitalized patients had a markedly increased risk of subsequent asthma-related mortality (adjusted hazard ratio, 2.80; 95% CI, 1.95-4.01) compared with those not rehospitalized. Two-third of the patients were not followed up by a hospital-based specialist, and 60% did not collect enough inhaled corticosteroid doses to cover daily treatment the year postindex.

CONCLUSIONS

In this study, more than 1 in 10 patients were rehospitalized because of asthma within 12 months, and rehospitalizations were associated with asthma-related mortality. Few patients were seen by a hospital-based specialist, and few used inhaled corticosteroid continuously. Closer monitoring after hospitalization is needed.

Perspective on the Budgetary Impact of FP/FORM pMDI on Treatment and Management of Exacerbation in Moderate-to-Severe Asthma Patients in Singapore

Purpose

Reducing the risk of exacerbation is a long-term goal of managing moderate-to-severe asthma. The use of fluticasone propionate/formoterol fumarate dihydrate (FP/FORM) pressurized metered-dose (pMDI, Flutiform^®), a type of inhaled corticosteroid (ICS) and long-acting β2 agonist (LABA) fixed-dose combination, has been associated with lower oral corticosteroid-requiring exacerbation rates than other ICS/LABA fixed-dose combinations, fluticasone propionate/salmeterol xinafoate (FP/SAL) and budesonide/formoterol fumarate (BUD/FORM). This study presents the first budget impact analysis of drug and exacerbation management cost savings associated with the increased access to FP/FORM compared to the currently available ICS/LABAs for treating moderate-to-severe asthma in Singapore.

Patients and Methods

A budget impact model showed changes to annual drug and exacerbation costs over 5 years for patients with moderate-to-severe asthma in Singapore, following the inclusion of FP/FORM on a government subsidy list. The eligible patient population was identified based on national statistics data. Different treatment costs pertaining to the population were applied according to the usage data (IQVIA Singapore National Sales Data) for different scenarios. Drug costs were obtained from public-sector hospitals. Exacerbation management costs were obtained from literature searches.

Results

The analysis showed that increased access to FP/FORM as a result of switching from FP/SAL could help achieve drug (S$1,042,289) and exacerbation management (S$223,550) cost savings over 5 years. In the scenario where patients switched from BUD/FORM, greater drug (S$2,572,797) and exacerbation management (S$256,781) cost savings were observed over 5 years.

Conclusion

The analysis provides a perspective that the increased access to FP/FORM could help achieve drug and exacerbation cost savings for the treatment of moderate-to-severe asthma.

The use of short-acting beta-2 adrenergic receptor agonists for asthma increased among Finnish and Swedish children from 2006 to 2017

AIM

Paediatric asthma hospitalisation has decreased in Finland, but has remained stable in Sweden. The reasons for these intercountry differences are unclear. The aim of this study was to explore the trend of dispensed asthma medication, including inhaled corticosteroids (ICS), among paediatric populations in the two countries.

METHODS

We explored trends in dispensed asthma medication among paediatric populations aged 0-19 in Finland and Sweden from 2006 to 2017. The Finnish Statistics on Reimbursements for Prescription Medicines and The Swedish Prescribed Drug Register provided data on all dispensed asthma prescriptions.

RESULTS

During the study period, the prevalence of dispensed ICS in paediatric populations was fairly stable in Finland and Sweden. Among children aged 0-4, ICS were 1.5 times more commonly dispensed in Sweden than in Finland. The prevalence of children dispensed short-acting beta-2 adrenergic receptor agonists (SABA) increased in both countries, but rose more in Finland (51%) than in Sweden (27%).

CONCLUSION

Inhaled corticosteroids were more commonly dispensed for children aged 0-4 in Sweden than in Finland during the study period. This study showed an increasing prevalence of children dispensed SABA in Finland and Sweden, particularly in Finland. Differences and trends in asthma medication may effect asthma hospitalisation and asthma deaths.

Economic impact of severe asthma exacerbations in Spain: multicentre observational study

Objective: To describe resource use and costs of severe exacerbations in patients with severe asthma.Method: Secondary analysis of an observational, longitudinal, retrospective study that estimated the economic impact of severe asthma. The study was carried out in severe asthma units of the pulmonology and allergy services of 20 public hospitals (inclusion period: June to November 2016). The study included adult patients diagnosed with severe asthma according to the European Respiratory Society/American Thoracic Society consensus in the stable phase (no exacerbation during the last 2 months), and with at least one severe exacerbation during the study period (12 months). Healthcare resource use due to severe exacerbations (emergency visits, hospitalizations and pharmacological treatment) was recorded. The direct health costs associated with severe exacerbations were calculated by multiplying the resources used by the corresponding unit cost (in 2018 euros).Results: 134 patients with ≥1 severe exacerbation were included: 63% were female and the mean age was 54 years. 249 severe exacerbations were registered. There were 1.5 physician visits at primary care, hospital care and/or emergency room per episode, 13% of episodes required hospitalization, with a mean hospital stay of 7.2 days. Systemic corticosteroids were prescribed in 92% of exacerbations. The mean direct cost was €758.7/exacerbation (95% confidence interval: 556.8-1,011.1), of which 82% was due to hospitalizations (€623.3/episode). Considering only episodes requiring hospital admission, the mean cost increased by €4,997/exacerbation.Conclusions: It was estimated that the economic impact of a severe exacerbation in Spanish patients with severe asthma was €758.7/exacerbation.

Trends and determinants of Emergency Room admissions for asthma: A retrospective evaluation in Northeast Italy

Background

Asthma still represents a cause of death and hospital admissions worldwide. Our study aimed at analyzing the trend of Emergency Room (ER) asthma admissions in Northeast Italy in order to investigate the relevance of specific patient-related determinants and environmental triggers (pollens, mold spores, and pollutants).

Methods

Retrospective data from admissions for asthma exacerbations registered between the years 2013 and 2015 in two main ERs in Northeast Italy were collected. Data about patients' age, sex and nationality were recorded. Classification of disease severity followed the current Italian ER triage scoring system (white: no need for emergency treatment; green: need for fast treatment; yellow: severe condition; red: life-threatening condition). Data on pollen/mold spore counts and pollutants were analyzed.

Results

Overall, 1745 ​ER admissions for asthma were registered, with a persistent and significant increase year by year. A slight prevalence of females and patients over 50 years old was observed. Immigrants accounted for 32%, 36% and 26% of admissions respectively in 2013, 2014 and 2015. The prevalence of immigrants' admissions was significantly higher when comparing the relative ratio of immigrant populations/Italian nationals (p ​< ​0.05). The admissions were coded as follows: white, 6.30%; green, 35.36%; yellow, 39.37%; red, 18.97%. People aged ≥50 years were more frequently admitted with a red code, but the trend was not statistically significant (p ​= ​0,0815). By contrast, amongst immigrants there was a higher prevalence of white and green codes observed in comparison with Italian nationals. Grass pollen peak and PM₁₀ high levels represented environmental determinants of ER admissions increase.

Conclusions

The increasing rate of asthma-related ER admissions highlights the need for implementing asthma control strategies. Investigating the traits of patients referring to ER for asthma exacerbations, as well as environmental-related determinants, may help in identifying at-risk individuals and in orienting preventive strategies accordingly. Immigrants represent the most vulnerable sub-population, and their potential difficulties in accessing treatments and health services should be specifically addressed. Overall, implementing patient education in order to improve treatment adherence, as well as providing an asthma action plan to every asthmatic patient, continue to be the most urgent needs.

Very low asthma death incidence among Finnish children from 1999 to 2015

BACKGROUND

The most recent reports concerning asthma fatalities in Finnish children are from 1998. Since that time, asthma care has improved and asthma-related hospitalizations have decreased. Yet, it is unknown whether pediatric asthma deaths have similarly decreased.

OBJECTIVE

To investigate the epidemiology of asthma deaths in the Finnish pediatric population from 1999 onward and to describe the details of fatal asthma exacerbations.

METHODS

We obtained copies of the death certificates from Statistics Finland of all Finnish children aged 0-19 years who died from asthma between 1999 and 2015. After analyzing the death certificates, the medical records of those with possible asthma death were evaluated in detail to confirm the diagnosis. Incidence rates (IR) of asthma deaths were estimated per 1 000 000 person-years by dividing the number of asthma deaths by the total number of person-years.

RESULTS

Between 1999-2015, there were 6845 deaths among 0-19 year-old children, of which 21 were possible asthma deaths. Based on patient records and pathological findings, we identified four convincing asthma deaths: aged 7 months, 1 year, 2.5 years, and 19 years. None had known allergies or regularly used inhaled corticosteroids. No pre-school or school-aged children died from asthma in Finland between 1999 and 2015. The cumulative incidence of pediatric asthma deaths was 0.19 per million person-years.

CONCLUSION

Four Finnish children died from asthma between 1999 and 2015. This corresponds to a total incidence of 0.19 per million person-years. No pre-school or school-aged children died from asthma in Finland during the study period.

Health Services Utilization in Asthma Exacerbations and PM10 Levels in Rural Colorado

RATIONALE

The San Luis Valley in rural Colorado often has elevated levels of ambient particulate matter. To date little is known about the impact of ambient particulate matter levels and medical care utilization due to asthma exacerbation in rural communities.

OBJECTIVES

We investigated the impact of ambient particulate matter concentrations on emergency/urgent visits and hospitalizations for asthma in a rural community.

METHODS

Daily ambient particulate matter concentrations from an air quality monitor in the San Luis Valley (2003-2012) were obtained from the state health department. Deidentified data for emergency/urgent visits with a diagnosis code for asthma were collected from the local health care system organization. A generalized linear model using splines and employing generalized estimating equations for correlated measures over time was used to examine the association between daily counts of emergency/urgent visits for asthma and 3- to 5-day averaged ambient particulate matter concentrations.

RESULTS

For each 15-μg/m3 increase in 3-day averaged ambient particulate matter, there was an associated 3.1% increase in hospital counts for all patients with asthma (95% confidence interval, 0.3-5.9%; P = 0.03). When the 3-day average exceeded 50 μg/m3, asthma hospital visits increased by 16.8% (P = 0.03), and when it exceeded 100 μg/m3, visits increased by 65.8% (P = 0.002). In children, the odds of one asthma event requiring an emergency/urgent care visit increased 5.0% with each 15-μg/m3 increase in 3-day averaged ambient particulate matter (P = 0.22).

CONCLUSIONS

We observed associations between ambient air levels of particulate matter with a diameter less than 10 μm and emergency/urgent care visits and hospitalization counts in a rural U.S. community prone to dust storms and Environmental Protection Agency exceedances.

Trends in asthma hospital admissions and mortality in Kuwait, 2000-2014: a national retrospective observational study

OBJECTIVES

To examine trends in asthma hospitalisation and mortality rates from 2000 to 2014 in Kuwait according to sex, age and nationality.

METHODS

For this nationwide, retrospective observational study, data from hospital discharge records and death certificates listing asthma as the primary reason for hospitalisation or mortality were obtained from the National Center for Health Information database using International Classification of Diseases, Tenth Revision codes J45 and J46. Trends in sex-adjusted, age-adjusted and nationality-adjusted hospitalisation and mortality rates were examined. Poisson regression models were applied to test for linear trends overtime and estimate adjusted rate ratios and 95% CI.

RESULTS

During the 15-year study period, a total of 43 652 hospitalisations and 484 deaths due to asthma exacerbations were identified. The average annual adjusted rates of asthma hospitalisation and mortality were estimated to be 134.9 (95% CI 131.8 to 138.1) and 2.1 (95% CI 1.8 to 2.4) per 100 000 population, respectively. Hospitalisation rates decreased by 49.5% in the total population (from 180.8 to 91.3 admissions per 100 000 population between 2000 and 2014, ptrend <0.001) and by 57.9% in the age group of 5-44 years (from 77.3 to 32.5 admissions per 100 000 population, ptrend <0.001). Mortality rates decreased from 4.1 to 0.9 deaths per 100 000 population between 2000 and 2014 in the total population (77.6% decrease, ptrend <0.001) and from 0.6 to 0.2 deaths per 100 000 population among those aged 5-44 years (61.9% reduction, ptrend=0.005). Kuwaiti compared with non-Kuwaiti subjects had higher risk of asthma hospitalisation and mortality. Among children aged ≤19 years, the risk of hospitalisation was higher in boys compared with girls; however, among adults, women experienced more hospitalisations than men.

CONCLUSIONS

Asthma hospitalisation and mortality rates have substantially decreased between 2000 and 2014 in Kuwait, with persisting differences between genders, age groups and citizens versus non-citizens. The observed decreasing trends in Kuwait are in agreement with global trends.

Changing characteristics of hospital admissions but not the children admitted-a whole population study between 2000 and 2013

There are increasing numbers of emergency medical paediatric admissions. Our hypothesis was that characteristics of children and details of their emergency admissions are also changing over time. Details of emergency admissions in Scotland 2000-2013 were analysed. There were 574,403 emergency admissions, median age 2.3 years. The age distribution, proportion of boys and socioeconomic status of children admitted were essentially unchanged. Emergency admissions rose by 49% from 36/1000 children per annum to 54/1000 between 2000 and 2013. Emergency admissions that were discharged on the same day rose by 186% from 8.6/1000 to 24.6/1000. The mean duration of emergency admission fell from 1.7 to 1.0 days. The odds for an emergency admission with upper respiratory infection, "viral infection", tonsillitis, bronchiolitis and lower respiratory tract infection all rose. In contrast the odds for an emergency admission with asthma and gastroenteritis fell.

CONCLUSIONS

The demographics of children with emergency admissions have not changed substantially but characteristics of admissions have changed considerably, in particular admissions which are short stay and due to respiratory infection are much more common. The fall in the absolute number of children with some acute medical diagnoses suggests that the rise in admissions is not necessarily inexorable. What is Known: • Emergency admission prevalence is rising in many countries across Europe. What is New: • Our paper is the first to comprehensively analyse emergency medical paediatric admissions by exploring how characteristics of admissions and the children admitted have changed over time for a whole population. • The "take home message" is that whilst characteristics of emergency admissions have changed (e.g. number, duration of stay, readmissions, diagnoses), the characteristics of the children have not changed.

Trends in paediatric asthma hospitalisations - differences between neighbouring countries

Paediatric asthma hospitalisation trends in Finland and Sweden over the past 10 years are unclear. We investigated the incidence of paediatric asthma hospitalisations in both countries from 2005 to 2014, using Finland's National Hospital Discharge Register and Sweden's National Patient Register which cover all hospitalisations in the respective countries. During the study period, the incidence of paediatric asthma hospitalisations decreased by 51% in Finland, but remained stable in Sweden. In both countries, asthma hospitalisations decreased over time among children aged 0-4 years, with unclear trends for older ages. The reasons for these intercountry differences are unclear, thus warranting future research.

Health Care Utilization and Direct Costs in Mild, Moderate, and Severe Adult Asthma: A Descriptive Study Using the 2014 South Korean Health Insurance Database

PURPOSE

Although asthma exacerbation comprises a large burden of the total asthma-related costs, few studies have examined the frequency and cost of acute exacerbation according to asthma severity. This study investigated asthma-related health care utilization and costs according to the severity of asthma.

METHODS

We conducted a descriptive study using the national health insurance claims database between January 1 and December 31, 2014. We included adult patients with asthma (18 years of age and older) who had ≥2 claims with for an asthma diagnosis and were prescribed ≥1 asthma medications. They were classified into 3 asthma severity levels (level 1 = mild, level 2 = moderate, and level 3 = severe), based on individual medication prescriptions. Acute exacerbation was defined as having a corticosteroid burst, an emergency department visit, or hospitalization. Health care utilization, acute exacerbation, and direct costs associated with asthma were compared according to asthma severity levels.

FINDINGS

Of the 36,687 adult asthma patients, level 1 had the largest proportion of patients (81.2%), followed by level 2 (18.2%), and level 3 (0.6%). The average number of asthma-related outpatient visits was 4.5 for level 1, 7.2 for level 2, and 11.9 for level 3 (P < 0.01). The estimated asthma-related direct cost per patient was $174 for level 1, $634 for level 2, and $1635 for level 3 (P < 0.01). The number of patients who experienced acute exacerbation increased as asthma severity increased: level 1, 22.6%; level 2, 26.0%; and level 3, 48.7% (P < 0.01). Direct costs associated with asthma exacerbation dramatically increased and accounted for 15.1% of the total cost in level 1 patients, 19.5% in level 2 patients, and 40.8% in level 3 patients (P < 0.01).

IMPLICATIONS

The direct costs of acute exacerbation increased as asthma severity increased. In patients with severe asthma, acute exacerbation and the relative cost ratio in South Korea were higher than those in other countries. Proper management is required to avoid acute exacerbations and to reduce the burden of asthma, particularly in patients with severe asthma.

Contemporary treatment of children with critical and near-fatal asthma

Asthma is the most common chronic illness in childhood. Although the vast majority of children with acute asthma exacerbations do not require critical care, some fail to respond to standard treatment and require escalation of support. Children with critical or near-fatal asthma require close monitoring for deterioration and may require aggressive treatment strategies. This review examines the available evidence supporting therapies for critical and near-fatal asthma and summarizes the contemporary clinical care of these children. Typical treatment includes parenteral corticosteroids and inhaled or intravenous beta-agonist drugs. For children with an inadequate response to standard therapy, inhaled ipratropium bromide, intravenous magnesium sulfate, methylxanthines, helium-oxygen mixtures, and non-invasive mechanical support can be used. Patients with progressive respiratory failure benefit from mechanical ventilation with a strategy that employs large tidal volumes and low ventilator rates to minimize dynamic hyperinflation, barotrauma, and hypotension. Sedatives, analgesics and a neuromuscular blocker are often necessary in the early phase of treatment to facilitate a state of controlled hypoventilation and permissive hypercapnia. Patients who fail to improve with mechanical ventilation may be considered for less common approaches, such as inhaled anesthetics, bronchoscopy, and extracorporeal life support. This contemporary approach has resulted in extremely low mortality rates, even in children requiring mechanical support.

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.

Decline in admissions for childhood asthma, a 26-year period population-based study

BACKGROUND

The prevalence of childhood asthma has increased, although the rate of hospitalization for asthma seems to decrease. In Norway, the rate of hospital admission for childhood asthma from 1984 to 2000 increased. The aim of this study was to assess further trends in hospital admissions for childhood asthma up to 2010.

METHODS

A population-based study including children 1-13 yrs of age hospitalized for asthma during six periods from 1984/1985 to 2009/2010 in Rogaland, Norway, was performed. Medical records from 1536 admissions (1050 children) were studied; and gender, age, number of admissions, length of hospital stay, medications and symptoms were recorded.

RESULTS

For all age groups, the rate of admissions per 10.000 increased from 20.1 in 1984/85 to 33.7 in 1989/90, but declined to 14.4 in 2009/2010. Rates were highest in boys (OR 1.87; 95% CI: 1.69, 2.09), younger age groups (OR 2.51; 2.38, 2.64) and decreased from 1984 to 2010 (OR 0.92; 0.88, 0.94). The rates of readmissions were higher than for primary admissions (OR 1.33; 1.19, 1.47). From 1984 to 2010, there was an increased use of inhaled corticosteroids prior to admission (6 to 51%) and started at discharge (7 to 37%), and systemic steroids given during admission (19 to 83%).

CONCLUSION

There has been a substantial decline in the rate of hospital admissions for childhood asthma after 1989/1990, with major differences between age groups and genders. The decline could be due to improved care of children with asthma or a real reduction in asthma exacerbations.