Association between respiratory prescribing, air pollution and deprivation, in primary health care

The Impact of Australian Bushfires on Asthma Medicine Prescription Dispensing

BACKGROUND

Air pollution can cause numerous health problems and increase the need for medicines to treat and prevent asthma in affected areas. There is limited evidence about the association between airborne particles with a diameter of 2.5 micrometres or smaller (PM2.5) and asthma medicine usage. This study examined the potential association between the levels of PM2.5 and the supply of prescription asthma medicines in the Australian Capital Territory (ACT), Australia, during the severe bushfire season between November 2019-January 2020.

METHODS

Daily data was obtained from an ACT air quality monitoring station from November 2019 to January 2020 (study period) and November 2018 to January 2019 (control period, no bushfire). The number and types of government-funded asthma medicine prescriptions were obtained from the Services Australia (government) website by searching under 'Pharmaceutical Benefits Scheme Item Reports' and using relevant item codes during the study and control periods.

RESULTS

The medians for PM2.5 levels for the study period were significantly higher than those for the control period (p < 0.001). There were increases in the number of dispensed prescriptions of short-acting beta-2 agonists (SABA), inhaled corticosteroids, and long-acting beta-2 agonists combined with inhaled corticosteroids. The greatest difference was seen with the inhaled corticosteroids: a 138% increase.

CONCLUSIONS

The increase in the number of dispensed asthma prescriptions during the bushfire season should be used to inform the stock holdings of these medicines in preparation for future events to ensure access to lifesaving asthma medicines.

Quantitative methods for climate change and mental health research: current trends and future directions

The quantitative literature on climate change and mental health is growing rapidly. However, the methodological quality of the evidence is heterogeneous, and there is scope for methodological improvement and innovation. The first section of this Personal View provides a snapshot of current methodological trends and issues in the quantitative literature on climate change and mental health, drawing on literature collected through a previous scoping review. The second part of this Personal View outlines opportunities for methodological innovation concerning the assessment of the relationship between climate change and mental health. We then highlight possible methodological innovations in intervention research and in the measurement of climate change and mental health-related variables. This section draws upon methods from public mental health, environmental epidemiology, and other fields. The objective is not to provide a detailed description of different methodological techniques, but rather to highlight opportunities to use diverse methods, collaborate across disciplines, and inspire methodological innovation. The reader will be referred to practical guidance on different methods when available. We hope this Personal View will constitute a roadmap and launching pad for methodological innovation for researchers interested in investigating a rapidly growing area of research.

The association of specific industry-related air pollution with occurrence of chronic diseases: A register-based study

Air pollution may contribute to onset and progression of chronic diseases such as cardiovascular and respiratory diseases. Most studies have focused on the contribution of traffic-related exposure to PM₁₀ or PM_2.5. Our aim was to investigate the association of different components of industry-related air pollution on the occurrence of chronic diseases. A register-based repeated cross-sectional study was conducted among 89,714 subjects (2012) with 536,599 annual observations (2012-2017) living in the vicinity of a large industrial area in the Netherlands. Information from the dispensed medication registration was linked with a dispersion model to characterize annual individual-level exposure of all subjects at place of residence. Associations between annual exposure (concentration and duration) to particulate matter (PM₁₀), nitrogen oxides (NO_X), sulphur dioxide (SO₂), and volatile organic compounds (VOC) with annual dispensed medication for cardiovascular diseases, respiratory diseases, diabetes mellitus, and inflammatory conditions were investigated by multivariate logistic regression analysis with generalized estimating equations (GEE) while controlling for confounders. Exposure to PM₁₀ and to NO_X (per μg/m³) were significantly associated with medication for cardiovascular diseases (OR 1.06, 95CI% 1.06-1.06 and OR 1.01, 95%CI 1.01-1.01 respectively). Exposures to PM₁₀ and SO₂ (per μg/m³) were significantly associated with medication for inflammatory conditions (OR 1.05, 95%CI 1.00-1.09 and OR 1.07, 95%CI 1.01-1.14 respectively). Exposure to SO₂ was inversely associated with respiratory diseases (OR 0.91, 95%CI 0.86-0.97). Except for inflammatory conditions, exposure duration (years) was significantly associated with the other three chronic diseases (OR varying from 1.01 to 1.03). This study indicates that specific air pollution components caused by industry may contribute to the occurrence of cardiovascular diseases, respiratory diseases, diabetes mellitus, and inflammatory conditions.

PrAna: an R package to calculate and visualize England NHS primary care prescribing data

Background

The objective of this work to calculate prescribed quantity of an active pharmaceutical ingredient (API) in prescription medications for human use, to facilitate research on the prediction of amount of API released to the environment and create an open-data tool to facilitate spatiotemporal and long-term prescription trends for wider usage.

Design

We have developed an R package, PrAna to calculate the prescribed quantity (in kg) of an APIs by postcode using England’s national level prescription data provided by National Health Service, for the years 2015–2018. Datasets generated using PrAna can be visualized in a real-time interactive web-based tool, PrAnaViz to explore spatiotemporal and long-term trends. The visualisations can be customised by selecting month, year, API, and region.

Results

PrAnaViz’s targeted API approach is demonstrated with the visualisation of prescribed quantities of 14 APIs in the Bath and North East Somerset (BANES) region during 2018. Once the APIs list is loaded, the back end retrieves relevant data and populates the graphs based on user-defined data features in real-time. These plots include the prescribed quantity of APIs over a year, by month, and individual API by month, general practice, postcode, and medicinal form. The non-targeted API approach is demonstrated with the visualisation of clarithromycin prescribed quantities at different postcodes in the BANES region.

Conclusion

PrAna and PrAnaViz enables the analysis of spatio-temporal and long-term trends with prescribed quantities of different APIs by postcode. This can be used as a support tool for policymakers, academics and researchers in public healthcare, and environmental scientist to monitor different group of pharmaceuticals emitted to the environment and for prospective risk assessment of pharmaceuticals in the environment.

Spatio-temporal associations of air pollutant concentrations, GP respiratory consultations and respiratory inhaler prescriptions: a 5-year study of primary care in the borough of Lambeth, South London

BACKGROUND

Although the associations of outdoor air pollution exposure with mortality and hospital admissions are well established, few previous studies have reported on primary care clinical and prescribing data. We assessed the associations of short and long-term pollutant exposures with General Practitioner respiratory consultations and inhaler prescriptions.

METHODS

Daily primary care data, for 2009-2013, were obtained from Lambeth DataNet (LDN), an anonymised dataset containing coded data from all patients (1.2 million) registered at general practices in Lambeth, an inner-city south London borough. Counts of respiratory consultations and inhaler prescriptions by day and Lower Super Output Area (LSOA) of residence were constructed. We developed models for predicting daily PM_2.5, PM₁₀, NO₂ and O₃ per LSOA. We used spatio-temporal mixed effects zero inflated negative binomial models to investigate the simultaneous short- and long-term effects of exposure to pollutants on the number of events.

RESULTS

The mean concentrations of NO₂, PM₁₀, PM_2.5 and O₃ over the study period were 50.7, 21.2, 15.6, and 49.9 μg/m³ respectively, with all pollutants except NO₂ having much larger temporal rather than spatial variability. Following short-term exposure increases to PM₁₀, NO₂ and PM_2.5 the number of consultations and inhaler prescriptions were found to increase, especially for PM₁₀ exposure in children which was associated with increases in daily respiratory consultations of 3.4% and inhaler prescriptions of 0.8%, per PM₁₀ interquartile range (IQR) increase. Associations further increased after adjustment for weekly average exposures, rising to 6.1 and 1.2%, respectively, for weekly average PM₁₀ exposure. In contrast, a short-term increase in O₃ exposure was associated with decreased number of respiratory consultations. No association was found between long-term exposures to PM₁₀, PM_2.5 and NO₂ and number of respiratory consultations. Long-term exposure to NO₂ was associated with an increase (8%) in preventer inhaler prescriptions only.

CONCLUSIONS

We found increases in the daily number of GP respiratory consultations and inhaler prescriptions following short-term increases in exposure to NO₂, PM₁₀ and PM_2.5. These associations are more pronounced in children and persist for at least a week. The association with long term exposure to NO₂ and preventer inhaler prescriptions indicates likely increased chronic respiratory morbidity.

Demographic and socioeconomic patterns in healthcare-seeking behaviour for respiratory symptoms in England: a comparison with non-respiratory symptoms and between three healthcare services

OBJECTIVE

This study will analyse respiratory contacts to three healthcare services that capture more of the community disease burden than acute data sources, such as hospitalisations. The objective is to explore associations between contacts to these services and the patient's age, gender and deprivation. Results will be compared between healthcare services, and with non-respiratory contacts to explore how contacts differ by service and illness. It is crucial to investigate the sociodemographic patterns in healthcare-seeking behaviour to enable targeted public health interventions.

DESIGN

Ecological study.

SETTING

Surveillance of respiratory contacts to three healthcare services in England: telehealth helpline (NHS111); general practitioner in-hours (GPIH); and general practitioner out of hours unscheduled care (GPOOH).

PARTICIPANTS

13 million respiratory contacts to NHS111, GPIH and GPOOH.

OUTCOME MEASURES

Respiratory contacts to NHS111, GPIH and GPOOH, and non-respiratory contacts to NHS111 and GPOOH.

RESULTS

More respiratory contacts were observed for females, with 1.59, 1.73, and 1.95 times the rate of contacts to NHS111, GPOOH and GPIH, respectively. When compared with 15-44 year olds, there were 37.32, 18.66 and 6.21 times the rate of respiratory contacts to NHS111, GPOOH and GPIH in children <1 year. There were 1.75 and 2.70 times the rate of respiratory contacts in the most deprived areas compared with the least deprived to NHS111 and GPOOH. Elevated respiratory contacts were observed for males <5 years compared with females <5 years. Healthcare-seeking behaviours between respiratory and non-respiratory contacts were similar.

CONCLUSION

When contacts to services that capture more of the disease burden are explored, the demographic patterns are similar to those described in the literature for acute systems. Comparable results were observed between respiratory and non-respiratory contacts suggesting that when a wider spectrum of disease is explored, sociodemographic factors may be the strongest influencers of healthcare-seeking behaviour.

Deprivation and prognosis in patients with pulmonary arterial hypertension: missing the effect of deprivation on a rare disease?

In this journal, Pellino et al. [1] presented a survival analysis to assess how deprivation affects prognosis in patients with pulmonary arterial hypertension (PAH). Their conclusions were that social deprivation is not a significant referral barrier or prognostic factor for idiopathic (I)PAH or heritable (H)PAH in Scotland. This may appear surprising, given the wider context of literature describing outcomes stratified by social deprivation. The authors were thorough on using both the address at time of diagnosis and at time of censoring to assign deprivation scores and compare the two, finding no significant differences between the two approaches. They also compared deprivation assigned to PAH cases to expected deprivation based on Scottish citizenry as a whole, and found that PAH patients are more socially deprived than expected. Finally, they used the same survival univariate analysis adjusting for age and sex to assess how several clinical variables are associated with prognosis.

No association was found between deprivation and mortality for PAH patients in England and Wales. The association found between risk stratification at baseline and deprivation suggests that the issue of deprivation and outcomes in PAH may be more nuanced. https://bit.ly/2y8WgqB

Neighborhood air pollution and household environmental health as it relates to respiratory health and healthcare utilization among elderly persons with asthma

Objective: The study investigated the associations between fine particulate matter (PM_2.5; <2.5 μm in diameter), indoor environment, pulmonary function, and healthcare utilization in a vulnerable group of elderly persons with asthma. We hypothesized that environmental conditions were associated with adverse pulmonary health outcomes. Methods: The study involved elderly (n = 76; mean age 64.6 years; 48 women) vulnerable persons in Detroit, Michigan, USA, with physician-diagnosed asthma. Exposure variables included measured outdoor PM_2.5, self-rated outdoor and household environmental pollutants. Outcome variables were self-rated and measured pulmonary function, and asthma-related healthcare utilization. Results: Mean ambient PM_2.5 concentrations during the study was 14.14 ± (S.D. 6.36) µg/m³ during the summer and 14.20 (6.33) during the winter (p = 0.95). In multiple regression analyses, adjusting for age and gender, mean 6-month concentration of PM_2.5 was related to shortness of breath (SHOB; standardized β = 0.26, p = 0.02) and inversely with self-rated respiratory health (SRRH; β = 0.28, p = 0.02). However, PM_2.5 did not predict lung function (FEV₁% predicted and FEV₁/FVC). However, PM_2.5 was related to use of asthma controller drugs (β = 0.38, p = 0.001). Participants' air pollution ratings predicted total healthcare utilization (β = 0.33, p = 0.01). Conclusions: In elderly persons with asthma, living near heavy industry and busy highways, objective and perceived environmental pollution relate to participants' respiratory health and healthcare utilization. Importantly, air pollution might increase use of asthma controller drugs containing corticosteroids with implication for elderly persons' risk to develop osteoporosis and cardiovascular disease.

Asthma exacerbations and socio-economic status in French adults with persistent asthma: A prospective cohort study

INTRODUCTION

Adults disadvantaged by poor socio-economic status (SES) are more severely affected by asthma compared to those with better SES. We aimed to determine whether the frequency of asthma exacerbations (AEx), as well as aspects related to AEx management, differed based on SES in patients treated with daily treatments.

METHODS

This study, part of the prospective observational cohort ASTRO-LAB, included French adult patients with persistent asthma. Patients were considered as low SES if they benefited from publicly funded special health insurance and/or were perceived as low SES by their general practitioner. AEx was defined as at least one of the following: asthma-related oral corticosteroid course, medical contact, hospitalization, and death. We examined associations between SES and AEx frequency, perceived triggering factors and type of medical contact after AEx.

RESULTS

In our sample of 255 patients, 11.40% were considered as low SES. Patients with low SES did not report significantly more AEx than medium/high SES patients during one-year follow-up (0.79 versus 0.55, p = 0.38). The type of medical contact during AEx differed significantly between the two groups (p = 0.03): patients with medium/high SES consulted their general practitioner more frequently (OR = 2.23, 95% CI = 0.91-5.50, p = 0.08) and were less likely to visit an emergency department or be hospitalized (OR = 0.27, 95% CI = 0.09-0.84, p = 0.02).

CONCLUSIONS

AEx frequency did not differ significantly between low and medium/high SES patients, but differences were found in the management of AEx. Studies are needed to better understand the relation between precariousness and management of asthma.

Modeling Seasonal and Spatiotemporal Variation: The Example of Respiratory Prescribing

Many measures of chronic diseases, including respiratory disease, exhibit seasonal variation together with residual correlation between consecutive time periods and neighboring areas. We demonstrate a strategy for modeling data that exhibit both seasonal trend and spatiotemporal correlation, using an application to respiratory prescribing. We analyzed 55 months (2002-2006) of prescribing data from the northeast of England, in the United Kingdom. We estimated the seasonal pattern of prescribing by fitting a dynamic harmonic regression (DHR) model to salbutamol prescribing in relation to temperature. We compared the output of DHR models to static sinusoidal regression models. We used the DHR-fitted values as an offset in mixed-effects models that aimed to account for the remaining spatiotemporal variation in prescribing rates. As diagnostic checks, we assessed spatial and temporal correlation separately and jointly. Our application of a DHR model resulted in a better fit to the seasonal variation of prescribing than was obtained with a static model. After adjusting for the fitted values from the DHR model, we did not detect any remaining spatiotemporal correlation in the model's residuals. Using a DHR model and temperature data to account for the periodicity of prescribing proved to be an efficient way to capture its seasonal variation. The diagnostic procedures indicated that there was no need to model any remaining correlation explicitly.

Investigating trends in asthma and COPD through multiple data sources: A small area study

This paper investigates trends in asthma and COPD by using multiple data sources to help understanding the relationships between disease prevalence, morbidity and mortality. GP drug prescriptions, hospital admissions, and deaths are analysed at clinical commissioning group (CCG) level in England from August 2010 to March 2011. A Bayesian hierarchical model is used for the analysis, which takes into account the complex space and time dependencies of asthma and COPD, while it is also able to detect unusual areas. Main findings show important discrepancies across the different data sources, reflecting the different groups of patients that are represented. In addition, the detection mechanism that is provided by the model, together with inference on the spatial, and temporal variation, provide a better picture of the respiratory health problem.

Defining and targeting health disparities in chronic obstructive pulmonary disease

The global burden of chronic obstructive pulmonary disease (COPD) continues to grow in part due to better outcomes in other major diseases and in part because a substantial portion of the worldwide population continues to be exposed to inhalant toxins. However, a disproportionate burden of COPD occurs in people of low socioeconomic status (SES) due to differences in health behaviors, sociopolitical factors, and social and structural environmental exposures. Tobacco use, occupations with exposure to inhalant toxins, and indoor biomass fuel (BF) exposure are more common in low SES populations. Not only does SES affect the risk of developing COPD and etiologies, it is also associated with worsened COPD health outcomes. Effective interventions in these people are needed to decrease these disparities. Efforts that may help lessen these health inequities in low SES include 1) better surveillance targeting diagnosed and undiagnosed COPD in disadvantaged people, 2) educating the public and those involved in health care provision about the disease, 3) improving access to cost-effective and affordable health care, and 4) markedly increasing the efforts to prevent disease through smoking cessation, minimizing use and exposure to BF, and decreasing occupational exposures. COPD is considered to be one the most preventable major causes of death from a chronic disease in the world; therefore, effective interventions could have a major impact on reducing the global burden of the disease, especially in socioeconomically disadvantaged populations.

Respiratory medication sales and urban air pollution in Brussels (2005 to 2011)

BACKGROUND

We investigated the associations between daily sales of respiratory medication and air pollutants in the Brussels-Capital Region between 2005 and 2011.

METHODS

We used over-dispersed Poisson Generalized Linear Models to regress daily individual reimbursement data of prescribed asthma and COPD medication from the social security database against each subject's residential exposure to outdoor particulate matter (PM10) or NO2 estimated, by interpolation from monitoring stations. We calculated cumulative risk ratios (RR) and their 95% confidence intervals (CI) for interquartile ranges (IQR) of exposure for different windows of past exposure for the entire population and for seven age groups.

RESULTS

Median daily concentrations of PM10 and NO2 were 25μg/m(3) (IQR=17.1) and 38μg/m(3) (IQR=20.5), respectively. PM10 was associated with daily medication sales among individuals aged 13 to 64y. For NO2, significant associations were observed among all age groups except >84y. The highest RR were observed for NO2, among adolescents, including three weeks lags (RR=1.187 95%CI: 1.097-1.285).

CONCLUSION

The associations found between temporal changes in exposure to air pollutants and daily sales of respiratory medication in Brussels indicate that urban air pollution contributes to asthma and COPD morbidity in the general population.

Eupafolin nanoparticles protect HaCaT keratinocytes from particulate matter-induced inflammation and oxidative stress

Exposure to particulate matter (PM), a major form of air pollution, can induce oxidative stress and inflammation and may lead to many diseases in various organ systems including the skin. Eupafolin, a flavonoid compound derived from Phyla nodiflora, has been previously shown to exhibit various pharmacological activities, including antioxidant and anti-inflammatory effects. Unfortunately, eupafolin is characterized by poor water solubility and skin penetration, which limits its clinical applications. To address these issues, we successfully synthesized a eupafolin nanoparticle delivery system (ENDS). Our findings showed that ENDS could overcome the physicochemical drawbacks of raw eupafolin with respect to water solubility and skin penetration, through reduction of particle size and formation of an amorphous state with hydrogen bonding. Moreover, ENDS was superior to raw eupafolin in attenuating PM-induced oxidative stress and inflammation in HaCaT keratinocytes, by mediating the antioxidant pathway (decreased reactive oxygen species production and nicotinamide adenine dinucleotide phosphate oxidase activity) and anti-inflammation pathway (decreased cyclooxygenase-2 expression and prostaglandin E2 production through downregulation of mitogen-activated protein kinase and nuclear factor-κB signaling). In summary, ENDS shows better antioxidant and anti-inflammatory activities than raw eupafolin through improvement of water solubility and skin penetration. Therefore, ENDS may potentially be used as a medicinal drug and/or cosmeceutical product to prevent PM-induced skin inflammation.

Air pollution is associated with primary health care visits for asthma in Sweden: A case-crossover design with a distributed lag non-linear model

BACKGROUND

Air pollution can increase the symptoms of asthma and has an acute effect on the number of emergency room visits and hospital admissions because of asthma, but little is known about the effect of air pollution on the number of primary health care (PHC) visits for asthma.

OBJECTIVE

To investigate the association between air pollution and the number of PHC visits for asthma in Scania, southern Sweden.

METHODS

Data on daily PHC visits for asthma were obtained from a regional healthcare database in Scania, which covers approximately half a million people. Air pollution data from 2005 to 2010 were obtained from six urban background stations. We used a case-crossover study design and a distributed lag non-linear model in the analysis.

RESULTS

The air pollution levels were generally within the EU air quality guidelines. The mean number of daily PHC visits for asthma was 34. The number of PHC visits increased by 5% (95% confidence interval (CI): 3.91-6.25%) with every 10µg m(-3) increase in daily mean NO2 lag (0-15), suggesting that daily air pollution levels are associated with PHC visits for asthma.

CONCLUSION

Even though the air quality in Scania between 2005 and 2010 was within EU's guidelines, the number of PHC visits for asthma increased with increasing levels of air pollution. This suggests that as well as increasing hospital and emergency room visits, air pollution increases the burden on PHC due to milder symptoms of asthma.

Two-stage Bayesian model to evaluate the effect of air pollution on chronic respiratory diseases using drug prescriptions

Exposure to high levels of air pollutant concentration is known to be associated with respiratory problems which can translate into higher morbidity and mortality rates. The link between air pollution and population health has mainly been assessed considering air quality and hospitalisation or mortality data. However, this approach limits the analysis to individuals characterised by severe conditions. In this paper we evaluate the link between air pollution and respiratory diseases using general practice drug prescriptions for chronic respiratory diseases, which allow to draw conclusions based on the general population. We propose a two-stage statistical approach: in the first stage we specify a space-time model to estimate the monthly NO2 concentration integrating several data sources characterised by different spatio-temporal resolution; in the second stage we link the concentration to the β2-agonists prescribed monthly by general practices in England and we model the prescription rates through a small area approach.

Health care utilization and expenditures in persons receiving social assistance in 2012: evidence from Switzerland

Introduction:

Lower socioeconomic position and measures of social and material deprivation are associated with morbidity and mortality. These inequalities in health among groups of various statuses remain one of the main challenges for public health. The aim of the study was to investigate differences in health care use and costs between recipients of social assistance and non-recipients aged 65 years and younger within the Swiss healthcare system.

Methods:

We analyzed claims data of 13 492 individuals living in Bern, Switzerland of which 391 received social assistance. For the year 2012, we compared the number of physician visits, hospitalizations, prescribed drugs, and total health care costs as covered by mandatory health insurance. Linear and logistic adjusted regression analyses were made to estimate the effect of receipt of social assistance on health service use and costs.

Results:

Multivariate linear regression analysis revealed that health care costs increased on average by 1 666 CHF if individuals received social assistance. Recipients of social assistance had on average 1.2 more ambulatory consultations than non-recipients and got 1.65 more different medications prescribed as compared to non-recipients. The chance for recipients of social assistance to be hospitalized was almost twice that of non-recipients (Odds Ratio 1.96, 95% confidence interval 1.49-2.59).

Conclusions:

Recipients of social assistance demonstrate an exceedingly high use of health services. The need for interventions to alleviate the identified inequalities in health and health care needs is obvious.