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Kligler SK, Vargas-Torres C, Abbott EE, Lin M. Inhaled Corticosteroids Rarely Prescribed at Emergency Department Discharge Despite Low Rates of Follow-Up Care. J Emerg Med 2023; 64:555-563. [PMID: 37041095 PMCID: PMC10192099 DOI: 10.1016/j.jemermed.2023.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 01/31/2023] [Accepted: 02/17/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND Guidelines recommend an inhaled corticosteroid (ICS) prescription on emergency department (ED) discharge after acute asthma exacerbations. OBJECTIVE We sought to identify rates and predictors of ICS prescription at ED discharge. Secondary outcomes included ICS prescription rates in a high-risk subgroup, outpatient follow-up rates within 30 days, and variation in ICS prescriptions among attending emergency physicians. METHODS This was a retrospective cohort study of adult asthma ED discharges for acute asthma exacerbation across 5 urban academic hospitals. We used multivariable logistic regression to evaluate predictors of ICS prescription after adjusting for patient characteristics and hospital-level clustering. RESULTS Among 3948 adult ED visits, an ICS was prescribed in 6% (n = 238) of visits. Only 14% (n = 552) completed an outpatient visit within 30 days. Among patients with 2 or more ED visits in 12 months, the ICS prescription rate was 6.7%. ICS administration in the ED (odds ratio [OR] 9.91; 95% CI 7.99-12.28) and prescribing a β-agonist on discharge (OR 2.67; 95% CI 2.08-3.44) were associated with higher odds of ICS prescription. Decreased odds of ICS prescription were associated with Hispanic ethnicity (OR 0.71; 95% CI 0.51-0.99) relative to Black race, and private (OR 0.75; 95% CI 0.62-0.91) or no insurance (OR 0.54; 95% CI 0.35-0.84) relative to Medicaid. One-third (36%, n = 66) of ED attendings prescribed 0 ICS prescriptions during the study period. CONCLUSIONS An ICS is infrequently prescribed on ED asthma discharge, and most patients do not have an outpatient follow-up within 30 days. Future studies should examine the extent to which ED ICS prescriptions improve outcomes for patients with barriers to accessing primary care.
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Affiliation(s)
- Sophie Karwoska Kligler
- Icahn School of Medicine at Mount Sinai, Department of Emergency Medicine, 1 Gustave L. Levy Place, New York, NY 10029
| | - Carmen Vargas-Torres
- Icahn School of Medicine at Mount Sinai, Department of Emergency Medicine, 1 Gustave L. Levy Place, New York, NY 10029
| | - Ethan E Abbott
- Icahn School of Medicine at Mount Sinai, Department of Emergency Medicine, 1 Gustave L. Levy Place, New York, NY 10029
| | - Michelle Lin
- Icahn School of Medicine at Mount Sinai, Department of Emergency Medicine, 1 Gustave L. Levy Place, New York, NY 10029
- Icahn School of Medicine at Mount Sinai, Department of Population Health Science and Policy, 1 Gustave L. Levy Place, New York, NY 10029
- Icahn School of Medicine at Mount Sinai, Institute for Health Equity Research, 1 Gustave L. Levy Place, New York, NY 10029
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Jacob C, Haas JS, Bechtel B, Kardos P, Braun S. Assessing asthma severity based on claims data: a systematic review. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2017; 18:227-241. [PMID: 26931557 PMCID: PMC5313583 DOI: 10.1007/s10198-016-0769-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/22/2014] [Accepted: 02/04/2016] [Indexed: 06/05/2023]
Abstract
INTRODUCTION Asthma is one of the most common chronic diseases in Germany. Substantial economic evaluation of asthma cost requires knowledge of asthma severity, which is in general not part of claims data. Algorithms need to be defined to use this data source. AIMS AND OBJECTIVES The aim of this study was to systematically review the international literature to identify algorithms for the stratification of asthma patients according to disease severity based on available information in claims data. METHODS A systematic literature review was conducted in September 2015 using the DIMDI SmartSearch, a meta search engine including several databases with a national and international scope, e.g. BIOSIS, MEDLINE, and EMBASE. Claims data based studies that categorize asthma patients according to their disease severity were identified. RESULTS The systematic research yielded 54 publications assessing asthma severity based on claims data. Thirty-nine studies used a standardized algorithm such as HEDIS, Leidy, the GINA based approach or CACQ. Sixteen publications applied a variety of different criteria for the severity categorisation such as asthma diagnoses, asthma-related drug prescriptions, emergency department visits, and hospitalisations. CONCLUSION There is no best practice method for the categorisation of asthma severity with claims data. Rather, a combination of algorithms seems to be a pragmatic approach. A transfer to the German context is not entirely possible without considering particular conditions associated with German claims data.
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Affiliation(s)
| | | | | | - Peter Kardos
- Group Practice and Centre for Pneumology, Allergy and Sleep Medicine at Red Cross Maingau Hospital, Frankfurt am Main, Germany
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Johnson LH, Chambers P, Dexheimer JW. Asthma-related emergency department use: current perspectives. Open Access Emerg Med 2016; 8:47-55. [PMID: 27471415 PMCID: PMC4950546 DOI: 10.2147/oaem.s69973] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Asthma is one of the most common chronic pediatric diseases. Patients with asthma often present to the emergency department for treatment for acute exacerbations. These patients may not have a primary care physician or primary care home, and thus are seeking care in the emergency department. Asthma care in the emergency department is multifaceted to treat asthma patients appropriately and provide quality care. National and international guidelines exist to help drive clinical care. Electronic and paper-based tools exist for both physicians and patients to help improve emergency, home, and preventive care. Treatment of patients with asthma should include the acute exacerbation, long-term management of controller medications, and controlling triggers in the home environment. We will address the current state of asthma research in emergency medicine in the US, and discuss some of the resources being used to help provide a medical home and improve care for patients who suffer from acute asthma exacerbations.
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Affiliation(s)
| | | | - Judith W Dexheimer
- Division of Emergency Medicine; Division of Biomedical Informatics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Ducharme FM, Lamontagne AJ, Blais L, Grad R, Lavoie KL, Bacon SL, McKinney ML, Desplats E, Ernst P. Enablers of Physician Prescription of a Long-Term Asthma Controller in Patients with Persistent Asthma. Can Respir J 2016; 2016:4169010. [PMID: 27445537 PMCID: PMC4925971 DOI: 10.1155/2016/4169010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Accepted: 05/10/2016] [Indexed: 11/18/2022] Open
Abstract
Objective. We aimed to identify key enablers of physician prescription of a long-term controller in patients with persistent asthma. Methods. We conducted a mailed survey of randomly selected Quebec physicians. We sent a 102-item questionnaire, seeking reported management regarding one of 4 clinical vignettes of a poorly controlled adult or child and endorsement of enablers to prescribe long-term controllers. Results. With a 56% participation rate, 421 physicians participated. Most (86%) would prescribe a long-term controller (predominantly inhaled corticosteroids, ICS) to the patient in their clinical vignette. Determinants of intention were the recognition of persistent symptoms (OR 2.67), goal of achieving long-term control (OR 5.31), and high comfort level in initiating long-term ICS (OR 2.33). Decision tools, pharmacy reports, reminders, and specific training were strongly endorsed by ≥60% physicians to support optimal management. Physicians strongly endorsed asthma education, lung function testing, specialist opinion, accessible asthma clinic, and paramedical healthcare professionals to guide patients, as enablers to improve patient adherence to and physicians' comfort with long-term ICS. Interpretation. Tools and training to improve physician knowledge, skills, and perception towards long-term ICS and resources that increase patient adherence and physician comfort to facilitate long-term ICS prescription should be considered as targets for implementation.
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Affiliation(s)
- Francine M. Ducharme
- Department of Pediatrics, University of Montreal, Montreal, QC, Canada H3T 1C5
- Clinical Research and Knowledge Transfer Unit on Childhood Asthma, Research Centre, CHU Sainte-Justine, Montreal, QC, Canada H3T 1C5
- Department of Social and Preventive Medicine, University of Montreal, Montreal, QC, Canada H3C 3J7
| | - Alexandrine J. Lamontagne
- Clinical Research and Knowledge Transfer Unit on Childhood Asthma, Research Centre, CHU Sainte-Justine, Montreal, QC, Canada H3T 1C5
| | - Lucie Blais
- Department of Pharmacology, University of Montreal, Montreal, QC, Canada H3T 1J4
| | - Roland Grad
- Department of Family Medicine, McGill University, Montreal, QC, Canada H3T 1E2
| | - Kim L. Lavoie
- Montreal Behavioural Medicine Centre, Hôpital du Sacré-Cœur de Montreal, Montreal, QC, Canada H4J 1C5
- Department of Psychology, Université du Québec à Montreal, Montreal, QC, Canada H3C 3P8
| | - Simon L. Bacon
- Montreal Behavioural Medicine Centre, Hôpital du Sacré-Cœur de Montreal, Montreal, QC, Canada H4J 1C5
- Department of Exercise Science, Concordia University, Montreal, QC, Canada H4B 1R6
| | - Martha L. McKinney
- Clinical Research and Knowledge Transfer Unit on Childhood Asthma, Research Centre, CHU Sainte-Justine, Montreal, QC, Canada H3T 1C5
| | - Eve Desplats
- Research Centre, CHU Sainte-Justine, Montreal, QC, Canada H3T 1C5
| | - Pierre Ernst
- Divisions of Clinical Epidemiology and of Pulmonary Medicine, Department of Medicine, Jewish General Hospital, Montreal, QC, Canada H3T 1E2
- Department of Medicine, McGill University, Montreal, QC, Canada H4A 3J1
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Sadatsafavi M, Lynd LD, De Vera MA, Zafari Z, FitzGerald JM. One-year outcomes of inhaled controller therapies added to systemic corticosteroids after asthma-related hospital discharge. Respir Med 2015; 109:320-8. [PMID: 25596136 DOI: 10.1016/j.rmed.2014.12.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 12/06/2014] [Accepted: 12/30/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Much of the evidence on the early use of inhaled controllers after severe asthma exacerbations is about their short-term benefit, leaving a gap in evidence on their longer-term outcomes. METHODS We used administrative health data from British Columbia, Canada (2001-2012) to evaluate readmission rate (primary outcome), adherence to controller medications, and use of reliever medications associated with different inhaled controller treatments as an add-on to systemic corticosteroids (SCS) over one-year following discharge from an asthma-related admission in individuals 12-55 years of age. Exposure was assessed in the 60 days after discharge, and categorized as monotherapy with SCS (SCS-only) versus SCS plus inhaled controller therapy (SCS + inhaler); the latter was further divided into SCS + inhaled corticosteroid (SCS + ICS) and SCS + ICS and long-acting beta agonists (SCS + ICS/LABA). Propensity score-adjusted regression models were used to estimate relative rates (RR) of outcomes across exposure groups. RESULTS The final cohort included 2,272 post-discharge periods (43.0% SCS-only, 26.9% SCS + ICS, and 30.1% SCS + ICS/LABA). Readmission rate was significantly lower in the SCS + inhaler versus SCS-only (RR = 0.74 [95%CI 0.59-0.93]), but similar between SCS + ICS and SCS + ICS/LABA (RR = 0.78 [95%CI 0.59-1.04]). Long-term adherence, defined as medication possession ratio, to controller medications was 83% higher in SCS + inhaler than SCS-only, and 64% higher in SCS + ICS/LABA than in SCS + ICS. The use of reliever medications was similar across exposure groups. CONCLUSION Early initiation of inhaled controllers after discharge from an asthma-related hospitalization was associated with significantly better long-term adherence to controller medications as well as reduced rate of readmissions. Combination therapy with ICS/LABA seems to be at least as effective as mono-therapy with ICS in reducing the risk of readmission, with the added benefit of better long-term adherence.
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Affiliation(s)
- Mohsen Sadatsafavi
- Institute for Heart and Lung Health, Department of Medicine, The University of British Columbia, Vancouver, Canada; Centre for Clinical Epidemiology and Evaluation, The University of British Columbia, Vancouver, Canada.
| | - Larry D Lynd
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, Canada; Centre for Health Evaluation and Outcome Sciences, The University of British Columbia, Vancouver, Canada
| | - Mary A De Vera
- Collaboration for Outcomes Research and Evaluation, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, Canada
| | - Zafar Zafari
- Centre for Health Evaluation and Outcome Sciences, The University of British Columbia, Vancouver, Canada
| | - J Mark FitzGerald
- Institute for Heart and Lung Health, Department of Medicine, The University of British Columbia, Vancouver, Canada; Centre for Clinical Epidemiology and Evaluation, The University of British Columbia, Vancouver, Canada
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Blais L, Firoozi F, Kettani FZ, Ducharme FM, Lemière C, Beauchesne MF, Bérard A. Relationship between changes in inhaled corticosteroid use and markers of uncontrolled asthma during pregnancy. Pharmacotherapy 2012; 32:202-9. [PMID: 22392453 DOI: 10.1002/j.1875-9114.2012.01091.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
STUDY OBJECTIVE To describe changes in inhaled corticosteroid use during pregnancy and markers of uncontrolled asthma, and to evaluate the association between them. DESIGN Population-based, cross-sectional study. DATA SOURCE Three administrative claims databases in Québec, Canada. PATIENTS A cohort of 4434 asthmatic women (4920 pregnancies) who delivered their infants between 1990 and 2002 and who used inhaled corticosteroids before their pregnancy. MEASUREMENTS AND MAIN RESULTS The average daily doses of inhaled corticosteroids during pregnancy and during the 9 months before conception were compared; the change in use was categorized as discontinuation (reduction of ≥75%), reduction (26-75% reduction), no change (±25% change), or increase (increase of ≥25%). The markers of uncontrolled asthma included at least one asthma exacerbation and the use of three or more doses/week of a short-acting β(2) -agonist during pregnancy. Generalized estimating equation models were used for statistical analyses. In nearly 50% of the pregnancies (2388 [48.5%] of 4920), the women either stopped or reduced their doses of corticosteroid during pregnancy, and these doses were already quite low before pregnancy. The proportion of women who had an asthma exacerbation during pregnancy was 8.2% among women who discontinued corticosteroids and greater than 20% in all of the other groups. All of the groups used frequent doses of short-acting β(2) -agonists. Discontinuing inhaled corticosteroid use during pregnancy was associated with a lower risk of exacerbations (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.33-0.54), whereas increasing inhaled corticosteroid use was associated with a higher risk (OR 1.42, 95% CI 1.17-1.72), compared with no change in use. CONCLUSION Because of residual confounding by asthma severity, our study was not able to show that women who stopped inhaled corticosteroids during pregnancy were at increased risk of having an asthma exacerbation. However, women who stopped corticosteroids tended to have a milder form of asthma, which is reassuring and suggests that women can recognize, to a certain extent, the need to continue taking their controller agents if necessary.
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Affiliation(s)
- Lucie Blais
- University of Montréal, Montréal, Québec, Canada.
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Andrews AL, Teufel RJ, Basco WT. Low rates of controller medication initiation and outpatient follow-up after emergency department visits for asthma. J Pediatr 2012; 160:325-30. [PMID: 21885062 DOI: 10.1016/j.jpeds.2011.07.037] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Revised: 06/13/2011] [Accepted: 07/22/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To determine what proportion of patients who are seen in an emergency department (ED) for asthma receive inhaled corticosteroids or attend follow-up appointments. STUDY DESIGN This was a retrospective cohort study of 2007-2009 South Carolina Medicaid data. Enrollees aged 2-18 years who had an ED visit for asthma were included. Patients admitted for asthma or with an inhaled corticosteroid claim in the 2 months before the month of the ED visit were excluded. Covariates were sex, race, age, rural residence, and asthma severity. Outcome measures were a prescription for an inhaled corticosteroid filled within the 2 months after the ED visit and attendance at a follow-up appointment within the 2 months after the ED visit. RESULTS A total of 3435 patients were included. Out of the study cohort, 57% were male, 76% were of a minority race/ethnicity, 69% lived in an urban areas, 18% had inhaled corticosteroid use, and 12% completed follow-up. Multivariate analyses demonstrated that patients with severe asthma were more likely to receive an inhaled corticosteroid (OR, 2.9; 95% CI, 2.3-3.7) and attend a follow-up appointment (OR, 2.0; 95% CI, 1.5-2.6). Patients aged 2-6 years and those aged >12 years were less likely to attend follow-up (OR, 0.71; 95% CI, 0.56-0.90 and OR, 0.62; 95% CI, 0.47-0.83, respectively) (all models P < .0001). CONCLUSION Children with asthma seen in the ED have low rates of inhaled corticosteroid use and outpatient follow-up. This indicates a need for further interventions to increase the use of inhaled corticosteroids in response to ED visits.
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Affiliation(s)
- Annie Lintzenich Andrews
- Division of General Pediatrics, Medical University of South Carolina, Charleston, SC 29425, USA.
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Inhaled corticosteroids vs. leukotriene-receptor antagonists and asthma exacerbations in children. Respir Med 2010; 105:846-55. [PMID: 21196105 DOI: 10.1016/j.rmed.2010.12.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2010] [Revised: 12/07/2010] [Accepted: 12/08/2010] [Indexed: 11/24/2022]
Abstract
BACKGROUND Compared to inhaled corticosteroids (ICS), better use of leukotriene-receptor antagonists (LTRA) may lead to a greater reduction in exacerbations among asthmatic children in real-life settings. METHODS To test this hypothesis, we used the Quebec administrative databases and identified a cohort of 27,355 asthmatic children aged 5-15 years in whom ICS or LTRA monotherapy was initiated in 1998-2005. The primary outcome was the rate of moderate-or-severe asthma exacerbations (emergency department visit or hospitalization for asthma or a dispensed prescription of oral corticosteroids) over the subsequent year. The adjusted rate ratios (RR) of asthma exacerbations were estimated with Poisson regression models. To minimize confounding by indication, all analyses were stratified by the presence or not of an asthma exacerbation in the year before treatment initiation. We also measured the proportion of days with supply prescribed and patient's adherence with the Proportion of Prescribed Days Covered (PPDC). RESULTS The risk of exacerbations was significantly higher in the ICS than the LTRA group among children with no previous exacerbation (RR = 2.3; 95% CI:1.3-4.0), but not in those with ≥1 exacerbations (RR = 1.6; 0.8-3.1). The PPDC was similar between the groups (66%) but the proportion of days with supply prescribed was significantly higher in the LTRA than the ICS group (52% vs. 34%), resulting in higher use. CONCLUSIONS While confounding by indication cannot be firmly ruled out, ICS appears to be more frequently prescribed as an intermittent than a daily controller therapy resulting in less use, which may contribute to the apparent lower effectiveness compared to LTRA.
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Causes and mechanisms of intrauterine hypoxia and its impact on the fetal cardiovascular system: a review. Int J Pediatr 2010; 2010:401323. [PMID: 20981293 PMCID: PMC2963133 DOI: 10.1155/2010/401323] [Citation(s) in RCA: 170] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2010] [Revised: 08/04/2010] [Accepted: 09/16/2010] [Indexed: 11/17/2022] Open
Abstract
Until today the role of oxygen in the development of the fetus remains controversially discussed. It is still believed that lack of oxygen in utero might be responsible for some of the known congenital cardiovascular malformations. Over the last two decades detailed research has given us new insights and a better understanding of embryogenesis and fetal growth. But most importantly it has repeatedly demonstrated that oxygen only plays a minor role in the early intrauterine development. After organogenesis has taken place hypoxia becomes more important during the second and third trimester of pregnancy when fetal growth occurs. This review will briefly adress causes and mechanisms leading to intrauterine hypoxia and their impact on the fetal cardiovascular system.
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Ducharme FM, Zemek RL, Chalut D, McGillivray D, Noya FJD, Resendes S, Khomenko L, Rouleau R, Zhang X. Written action plan in pediatric emergency room improves asthma prescribing, adherence, and control. Am J Respir Crit Care Med 2010; 183:195-203. [PMID: 20802165 DOI: 10.1164/rccm.201001-0115oc] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
RATIONALE An acute-care visit for asthma often signals a management failure. Although a written action plan is effective when combined with self-management education and regular medical review, its independent value remains controversial. OBJECTIVES We examined the efficacy of providing a written action plan coupled with a prescription (WAP-P) to improve adherence to medications and other recommendations in a busy emergency department. METHODS We randomized 219 children aged 1-17 years to receive WAP-P (n = 109) or unformatted prescription (UP) (n = 110). All received fluticasone and albuterol inhalers, fitted with dose counters, to use at the discretion of the emergency physician. The main outcome was adherence to fluticasone (use/prescribed × 100%) over 28 days. Secondary outcomes included pharmacy dispensation of oral corticosteroids, β(2)-agonist use, medical follow-up, asthma education, acute-care visits, and control. MEASUREMENTS AND MAIN RESULTS Although both groups showed a similar drop in adherence in the initial 14 days, adherence to fluticasone was significantly higher over Days 15-28 in children receiving WAP-P (mean group difference, 16.13% [2.09, 29.91]). More WAP-P than UP patients filled their oral corticosteroid prescription (relative risk, 1.31 [1.07, 1.60]) and were well-controlled at 28 days (1.39 [1.04, 1.86]). Compared with UP, use of WAP-P increased physicians' prescription of maintenance fluticasone (2.47 [1.53, 3.99]) and recommendation for medical follow-up (1.87 [1.48, 2.35]), without group differences in other outcomes. CONCLUSIONS Provision of a written action plan significantly increased patient adherence to inhaled and oral corticosteroids and asthma control and physicians' recommendation for maintenance fluticasone and medical follow-up, supporting its independent value in the acute-care setting. Clinical trial registered with www.clinicaltrials.gov (NCT 00381355).
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Blais L, Beauchesne MF, Lemière C, Elftouh N. High doses of inhaled corticosteroids during the first trimester of pregnancy and congenital malformations. J Allergy Clin Immunol 2010; 124:1229-1234.e4. [PMID: 19910032 DOI: 10.1016/j.jaci.2009.09.025] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Revised: 09/16/2009] [Accepted: 09/17/2009] [Indexed: 01/22/2023]
Abstract
BACKGROUND Although reassuring data exist on the use of low-to-moderate doses of inhaled corticosteroids (ICSs) during pregnancy, there are inadequate data for women receiving high doses. OBJECTIVE To investigate the association between doses of ICS during the first trimester of pregnancy and the risk of congenital malformations among women with asthma. METHODS We conducted a cohort study of 13,280 pregnancies of women with asthma (1990-2002) by linking 3 administrative databases from Quebec (Canada). By using generalized estimation equation models, we compared women taking >0 to 1000 microg/d ICS (beclomethasone dipropionate-chlorofluorocarbone equivalent) with women taking >1000 microg/d and those not taking ICSs. The main outcome measures were all and major congenital malformations. RESULTS We identified 1257 infants with a congenital malformation (9.5%) and 782 infants with a major malformation (5.9%). We found that women who used >1000 microg/d ICS (n = 154) were significantly more likely (63%) to have a baby with a malformation than the 4392 women who used >0 to 1000 microg/d (adjusted risk ratio, 1.63; 95% CI, 1.02-2.60). On the other hand, women who used >0 to 1000 microg/d were not found to be more at risk than women who did not use ICSs during the first trimester (n = 8734). Nonsignificant trends of similar magnitude were found for major malformations. CONCLUSIONS Our study adds evidence on the safety of low-to-moderate doses of ICS taken during the first trimester but raises concerns about high doses. However, we cannot rule out the possibility of residual confounding by severity in this association.
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Affiliation(s)
- Lucie Blais
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada.
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To T, Wang C, Dell S, Fleming-Carroll B, Parkin P, Scolnik D, Ungar W. Risk factors for repeat adverse asthma events in children after visiting an emergency department. ACTA ACUST UNITED AC 2008; 8:281-7. [PMID: 18922500 PMCID: PMC7110952 DOI: 10.1016/j.ambp.2008.04.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2007] [Revised: 04/23/2008] [Accepted: 04/26/2008] [Indexed: 11/13/2022]
Abstract
Objective The aim of this study was to identify risk factors for long-term adverse outcomes in children with asthma after visiting the emergency department (ED). Methods A prospective observational study was conducted at the ED of a pediatric tertiary hospital in Ontario, Canada. Patient outcomes (ie, acute asthma episodes and ED visits) were measured at baseline and at 1- and 6-months post-ED discharge. Time trends in outcomes were assessed using the generalized estimating equations method. Multiple conditional logistic regressions were used to model outcomes at 6 months and examine the impact of drug insurance coverage while adjusting for confounders. Results Of the 269 children recruited, 81.8% completed both follow-ups. ED use significantly reduced from 39.4% at baseline to 26.8% at 6 months (P < .001), whereas the level of acute asthma episodes remained unchanged. Children with drug insurance coverage were less likely to have acute asthma episodes (adjusted odds ratio [AOR] = 0.36; 95% CI, 0.15–0.85; P < .02) or repeat ED visits (AOR = 0.45; 95% CI, 0.20–0.99; P < .05) at 6 months. Other risk factors for adverse outcomes included previous adverse asthma events and certain asthma triggers (eg, cold/sinus infection). Washing bed linens in hot water weekly was protective against subsequent acute asthma episodes. Conclusions Our study demonstrated significant improvements in long-term outcomes in children seeking acute care for asthma in the ED. Future efforts remain in targeting the sustainability of improved outcomes beyond 6 months. Risk factors identified can help target vulnerable populations for proper interventions, which may include efforts to maximize insurance coverage for asthma medications and strategies to improve asthma self-management through patient and provider education.
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Affiliation(s)
- Teresa To
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada.
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13
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Vilain A, Otis S, Forget A, Blais L. Agreement between administrative databases and medical charts for pregnancy-related variables among asthmatic women. Pharmacoepidemiol Drug Saf 2008; 17:345-53. [PMID: 18271060 DOI: 10.1002/pds.1558] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
PURPOSE To determine the validity of pregnancy variables recorded in administrative databases of Quebec using patient medical charts as the gold standard among asthmatic pregnant women. METHODS Three administrative databases were linked and provided information on maternal, pregnancy and infant characteristics for 726 pregnant asthmatic women who delivered in 1990-2000. Algorithms were developed to measure variables that were not recorded directly in the databases or to minimize the number of missing values for variables recorded in two or more databases. Medical file data were collected by two trained research nurses in 43 hospitals. The validity of categorical variables was assessed with sensitivity, specificity, predictive positive values (PPVs) and predictive negative values (PNVs), whereas the validity of continuous variables was assessed with Pearson correlation using the medical chart as the gold standard. RESULTS The sensitivity of the sex of the baby, previous live birth and previous pregnancy ranged from 0.97 to 0.99. Corresponding figures were 0.92-0.98 for specificity. We also found high correlation coefficients, ranging from 0.875 to 0.999 for the length of gestation, dates of last menstruation and delivery, maternal age and birth weight. CONCLUSION Pregnancy-related variables recorded in administrative databases or derived from algorithms based on two or more databases were found to be highly valid as compared to the medical chart among asthmatic women.
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Affiliation(s)
- Anne Vilain
- Faculty of Pharmacy, University of Montreal, Montreal, Quebec, Canada
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Blais L, Forget A. Asthma exacerbations during the first trimester of pregnancy and the risk of congenital malformations among asthmatic women. J Allergy Clin Immunol 2008; 121:1379-84, 1384.e1. [PMID: 18410961 DOI: 10.1016/j.jaci.2008.02.038] [Citation(s) in RCA: 98] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2007] [Revised: 02/27/2008] [Accepted: 02/29/2008] [Indexed: 12/24/2022]
Abstract
BACKGROUND Uncontrolled maternal asthma during pregnancy has been hypothesized as a cause of congenital malformation, but literature is scare on this topic. OBJECTIVE The aim of this study was to investigate whether asthmatic women who had an exacerbation during the first trimester of pregnancy were more at risk of having a baby with a congenital malformation. METHODS From the linkage of 3 Canadian administrative databases, we reconstructed a cohort of 4344 pregnancies of asthmatic women. Asthma exacerbations were assessed during the first trimester of pregnancy and were defined as a filled prescription for oral corticosteroids, an emergency department visit, or a hospitalization for asthma. Congenital malformations were assessed at birth and during the first year of life of the newborn by using diagnoses recorded in the databases. Generalized estimating equation models were used to estimate adjusted odds ratios of congenital malformations in association with asthma exacerbations. RESULTS In the cohort we identified 398 (9.2%) babies with at least 1 malformation and 261 (6.0%) with a major malformation. The crude prevalences of malformations were 12.8% and 8.9%, respectively, for women who had and those who did not have an exacerbation. The adjusted odds ratio for all malformations was 1.48 (95% CI, 1.04-2.09) when comparing women who had and those who did not have an exacerbation. The corresponding figures were 1.32 (95% CI, 0.86-2.04) for major malformations. CONCLUSION Asthma exacerbations during the first trimester of pregnancy were found to significantly increase the risk of a congenital malformation.
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Affiliation(s)
- Lucie Blais
- Faculty of Pharmacy, Université de Montréal, Montreal, Quebec, Canada.
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Castro-Rodríguez JA. [Management of acute asthma exacerbations in pediatrics]. An Pediatr (Barc) 2008; 67:390-400. [PMID: 17949652 DOI: 10.1016/s1695-4033(07)70660-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Despite the significant advances that have been produced in the management of asthma in the last few decades, crises, attacks, or asthma exacerbations (acute asthma) continue to be the most common cause of consultation in pediatric emergency units. Visits to these units and hospital admissions due to acute asthma represent three quarters of the direct costs due to this disease. Acute asthma is a medical emergency that should be rapidly diagnosed and treated. Evaluation of children with acute asthma exacerbations should consist of two phases: a static phase (determination of the severity of the crisis on admission) and a dynamic phase (treatment response). The present article provides an in-depth review and analysis of current pharmacological and nonpharmacological treatments (oxygen, bronchodilators, corticosteroids - inhaled and systemic - aminophylline, magnesium sulfate, etc.) of acute asthma exacerbations and proposes management protocols for use in both primary care and emergency units.
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Affiliation(s)
- J A Castro-Rodríguez
- Unidad de Neumología Pediátrica, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile.
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Koné P. AJ, Rivard M, Laurier C. Impact of Follow-Up by The Primary Care Or Specialist Physician on Pediatric Asthma Outcomes after An Emergency Department Visit: The Case of Montreal, Canada. ACTA ACUST UNITED AC 2007. [DOI: 10.1089/pai.2006.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Firoozi F, Lemière C, Beauchesne MF, Forget A, Blais L. Development and validation of database indexes of asthma severity and control. Thorax 2007; 62:581-7. [PMID: 17287299 PMCID: PMC2117251 DOI: 10.1136/thx.2006.061572] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND The use of administrative databases to perform epidemiological studies in asthma has increased in recent years. The absence of clinical parameters to measure the level of asthma severity and control is a major limitation of database studies. A study was undertaken to develop and validate two database indexes to measure the control and severity of asthma. METHODS Database indexes of asthma severity and control were derived from definitions in the Canadian Asthma Consensus Guidelines based on dispensed prescriptions and on medical services recorded in two large administrative databases from the Canadian province of Québec (Régie de l'Assurance Maladie du Québec (RAMQ) and MED-ECHO) over 12 months. The database indexes of asthma severity and control were validated against the pulmonary function test results of 71 patients with asthma randomly selected from two asthma clinics, and they were also applied to a cohort of patients with asthma followed up for 139 283 person-years selected from the RAMQ and MED-ECHO databases between 1 January 1997 and 31 December 2004. RESULTS According to the database indexes, 49.3%, 29.6% and 21.1% of patients recruited at the asthma clinics were found to have mild, moderate and severe asthma, respectively, while 53.5% were found to have controlled asthma. The mean predicted value of the forced expiratory volume in 1 s (FEV(1)) ranged from 89.8% for mild asthma to 61.5% for severe asthma (p<0.001), whereas the range from controlled to uncontrolled asthma was 89.5% to 67.3% (p<0.001). The ratio of the FEV(1) to the forced vital capacity (FEV(1)/FVC ratio) measured in 56 patients ranged from 75.8% for mild asthma to 61.8% for severe asthma (p = 0.030), whereas the range from controlled to uncontrolled asthma was 75.3% to 65.7% (p<0.001). CONCLUSION In the absence of clinical data, these database indexes could be used in epidemiological studies to assess the severity and control of asthma.
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Affiliation(s)
- Faranak Firoozi
- Université de Montréal, Faculté de pharmacie, CP 6128, Succursale Centre-ville, Montreal, Québec, Canada H3C 3J7
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Blais L, Beauchesne MF, Rey E, Malo JL, Forget A. Use of inhaled corticosteroids during the first trimester of pregnancy and the risk of congenital malformations among women with asthma. Thorax 2006; 62:320-8. [PMID: 17121872 PMCID: PMC2092465 DOI: 10.1136/thx.2006.062950] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIM To investigate whether the maternal use of different doses of inhaled corticosteroids (ICSs) during the first trimester of pregnancy for the treatment of asthma increases the risk of congenital malformations in the offspring. METHODS From the linkage of three administrative Canadian databases, a cohort of 4561 pregnancies from women with asthma who delivered between 1990 and 2000 was reconstructed. A two-stage sampling cohort design was used to acquire additional data from the woman's medical chart. Cases of congenital malformation were identified from the medical services database or the hospital database. Using refill patterns of medications, the average daily dose of ICSs used during the first trimester was calculated and categorised as follows: 0, 1-500, 500-1000 and >1000 microg/day in beclomethasone-chlorofluorocarbon equivalent. A Generalized Estimation Equation model was used to estimate the adjusted odds ratio of congenital malformation as a function of ICS daily dose. All analyses were performed for all malformations and major malformations separately. RESULTS Within the cohort 418 babies were identified with a congenital malformation (9.2%), 278 of which had a major malformation. About 40% of women used ICSs during the first trimester, but only 5.3% of women used >500 microg/day. The adjusted odds ratio (95% CI) for all malformations associated with the use of ICSs during the first trimester was: 0.77 (0.53 to 1.13) for 1-500, 0.41 (0.19 to 0.92) for 501-1000 and 1.00 (0.42 to 2.36) for >1000 microg/day. The corresponding figures for major malformations were 0.90 (0.64 to 1.24), 0.56 (0.22 to 1.43) and 1.67 (0.56 to 5.03). CONCLUSION This study adds evidence to the safety of ICSs for the treatment of asthma during pregnancy, with regard to the likelihood of congenital malformation.
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Affiliation(s)
- Lucie Blais
- Université de Montréal, Faculté de Pharmacie, CP 6128, Succursale Centre-ville, Montréal, Québec, Canada H3C 3J7.
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Blais L, Lemière C, Menzies D, Berbiche D. Validity of asthma diagnoses recorded in the Medical Services database of Quebec. Pharmacoepidemiol Drug Saf 2006; 15:245-52. [PMID: 16374899 DOI: 10.1002/pds.1202] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The goal of this study was to evaluate the validity of asthma diagnoses recorded in the Medical Services (physician billing) database of the Canadian province of Quebec. The predictive positive value (PPV) and predictive negative value (PNV) of two operational definitions of asthma based on diagnoses recorded in the database were evaluated. Patients 16-80 years old treated by a respiratory or a family physician in 2002 were selected from the database. The diagnosis derived from the Medical Services database was compared to the diagnosis written in the patient's medical chart. The PPV and PNV of the first operational definition based on one asthma diagnosis or more recorded in the database over a 1-year period were found to be 0.75 and 0.96 for respiratory physicians and 0.67 and 0.99 for family physicians, for patients 16-44 years old. The PPV increased to 0.78 for family physicians and to 0.77 for respiratory physicians when the second operational definition based on two diagnoses of asthma or more was used. Results tended to be lower for 45-80 years old patients. We conclude that diagnoses recorded in the Medical Services database of Quebec are valid to identify patients with asthma.
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Behrens T, Ahrens W. [Epidemiological studies in the HTA evaluation process]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2006; 49:264-71. [PMID: 16477457 DOI: 10.1007/s00103-005-1222-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Results of epidemiological studies should be considered as part of the available evidence when evaluating drug treatment benefits in health technology assessment (HTA). Pharmaco-epidemiological databases can provide a broader understanding of the effectiveness of drugs in populations that are frequently underrepresented in clinical trials. Such databases are also useful to investigate drug safety with regard to socio-demographic and medical care-related indicators and hereby contribute to an optimal and targeted pharmacological therapy. Using examples from pharmaco-epidemiological asthma studies, the present article discusses associated difficulties in interpreting database results against the background of various sources of bias and proposes possibilities for integrating observational data into the HTA evaluation process. Researchers are challenged to engage in considerable efforts to develop a standardized inventory of epidemiological methods, e.g. for the pooled analysis of epidemiological data.
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Affiliation(s)
- T Behrens
- Bremer Institut für Präventionsforschung und Sozialmedizin.
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Flores G, Abreu M, Tomany-Korman S, Meurer J. Keeping children with asthma out of hospitals: parents' and physicians' perspectives on how pediatric asthma hospitalizations can be prevented. Pediatrics 2005; 116:957-65. [PMID: 16199708 DOI: 10.1542/peds.2005-0712] [Citation(s) in RCA: 67] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND A total of 196,000 hospitalizations occur each year among the 9 million US children who have been diagnosed with asthma. Not enough is known about how to prevent pediatric asthma hospitalizations. OBJECTIVES To identify the proportion of preventable pediatric asthma hospitalizations and how such hospitalizations might be prevented, according to parents and physicians of hospitalized children with asthma. METHODS A cross-sectional survey was conducted of parents, primary care physicians (PCPs), and inpatient attending physicians (IAPs) of a consecutive series of all children who were admitted for asthma to an urban hospital in a 14-month period. RESULTS The 230 hospitalized children had a median age of 5 years; most were poor (median annual family income: 13,356 dollars), were nonwhite (93%), and had public (74%) or no (14%) health insurance. Compared with children who were hospitalized for other ambulatory care-sensitive conditions, hospitalized children with asthma were significantly more likely to be African American (70% vs 57%), to be older, and not to have made a physician visit or telephone contact before admission (52% vs 41%). Only 26% of parents said that their child's admission was preventable, compared with 38% of PCPs and 43% of IAPs. The proportion of asthma hospitalizations that were assessed as preventable varied according to the source or combination of sources, from 15% for agreement among all 3 sources to 54% as identified by any 1 of the 3 sources. PCPs (83%) and IAPs (67%) significantly more often than parents (44%) cited parent/patient-related reasons for how hospitalizations could have been prevented, including adhering to and refilling medications, better outpatient follow-up, and avoiding known disease triggers. Parents (27%) and IAPs (26%) significantly more often than PCPs (11%) cited physician-related reasons for how hospitalizations could have been avoided, including better education by physicians about the child's condition, and better quality of care. Multivariate analyses revealed that an age > or =11 years and no physician contact before the hospitalization were associated with approximately 2 times the odds of a preventable asthma hospitalization. CONCLUSIONS The proportion of asthma hospitalizations assessed as preventable varies from 15% to 54%, depending on the source. Adolescents and families who fail to contact physicians before hospitalization are at greatest risk for preventable hospitalizations. Many pediatric asthma hospitalizations might be prevented if parents and children were better educated about the child's condition, medications, the need for follow-up care, and the importance of avoiding known disease triggers.
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Affiliation(s)
- Glenn Flores
- Center for the Advancement of Underserved Children, Medical College of Wisconsin, Milwaukee, WI, USA.
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