A retrospective randomized study of asthma control in the US: results of the CHARIOT study

Psychological distress and symptom-related burnout in asthma during the COVID-19 pandemic

People with asthma may be particularly vulnerable to pandemic-related psychological distress, and research is needed to understand the impact of the coronavirus disease 19 (COVID-19) pandemic on their health and well-being. We sought to study the well-being of people with asthma relative to non-asthmatic controls during the COVID-19 pandemic. We also investigated asthma symptoms and COVID-19-related anxiety as potential mediators of distress. Participants completed self-report measures of psychological functioning, including anxiety, depression, stress, and burnout. Controlling for potential confounds, multiple-regression analyses examined differences in psychological health between people with and without asthma. Mediator analyses investigated the role of asthma symptoms and COVID-19-related anxiety in this relationship. 234 adults (111 with asthma, 123 without) participated in an online survey from July to November 2020. During this time, people with asthma reported higher levels of anxiety, perceived stress, and burnout symptoms compared to controls. Elevations in burnout symptoms were found beyond general anxiety and depression (sr2 = .03, p < .001). Reported symptoms typical in both asthma and COVID-19 partially mediated this relationship (Pm = .42, p < .05). People with asthma reported unique psychological challenges during the COVID-19 pandemic including elevated burnout symptoms. Experience of asthma symptoms played a key role in vulnerability to emotional exhaustion. Clinical implications include increased attention to asthma symptom burden within the context of heightened environmental stress and restricted healthcare access.

Suboptimally controlled asthma in patients treated with inhaled ICS/LABA: prevalence, risk factors, and outcomes

This observational claims-linked survey study assessed the prevalence of and risk factors for suboptimal asthma control and healthcare utilization in adults with asthma receiving fixed-dose combination (FDC) inhaled corticosteroid/long-acting β₂-agonist (ICS/LABA). Commercially insured adults from the Optum Research Database were invited to complete the Asthma Control Test (ACT) and Asthma Control Questionnaire-6 (ACQ-6). Among participants (N = 428), 36.4% (ACT-assessed) and 55.6% (ACQ-6-assessed) had inadequately controlled asthma. Asthma-related quality of life was worse and asthma-related healthcare resource utilization was higher in poorly controlled asthma. Factors associated with ACT-defined suboptimal asthma control in multivariate analysis included: frequent short-acting β₂-agonist (SABA) use, asthma-related outpatient visits, lower treatment adherence, and lower education levels. During follow-up, factors associated with asthma exacerbations and/or high SABA use included: inadequately controlled asthma (ACT-assessed), body mass index ≥30 kg/m², and high-dose ICS/LABA. Approximately 35-55% of adults with asthma were inadequately controlled despite FDC ICS/LABA; poor control was associated with worse disease outcomes.

Association Between a Type 2 Inflammatory Disease Burden Score and Outcomes Among Patients with Asthma

Background

Although prevalence of co-existing type 2 inflammatory diseases (cT2) in asthma patients has been reported, limited data exist regarding their impact on asthma outcomes.

Objective

To assess the impact of cT2 burden on asthma outcomes and to evaluate patterns of clustering of cT2 in a real-world setting.

Methods

From medical records of 4.5 million enrollees in 650 primary care practices in the UK (January 2010–December 2017), patients with ≥1 diagnosis code for asthma at any time pre-index date (date of most recent asthma-related medical encounter) and ≥2 asthma-related prescriptions during the year before index date were categorized into the Global Initiative of Asthma (GINA) guideline severity steps. A cT2 burden score (range 0–9) was assigned based on the total number of co-existing conditions (allergic conjunctivitis, allergic rhinitis, anaphylaxis, eczema/atopic dermatitis, chronic rhinosinusitis, eosinophilic esophagitis, food allergy, nasal polyps, or urticaria) for which patients received a medical diagnosis. Multivariate regression models evaluated associations between cT2 burden score and asthma exacerbations and asthma control. Factor analysis was performed to assess which cT2 comorbidities were correlated and exhibited patterns of clustering.

Results

Overall, 245,893 patients with asthma were included (mean [SD] age 44.8 [22.1] years; 43.8% male). Between 55% (GINA step 1) and 60% (GINA step 5) of asthma patients had a medical diagnosis for ≥1 other type2dx. Patients with increased cT2 burden were significantly more likely to experience asthma exacerbations and less likely to achieve asthma control.

Conclusion

Asthma patients with a higher cumulative cT2 burden score were more likely to experience worse asthma outcomes than those without any cT2 (burden score of 0).

Factors Associated with Suboptimal Control of Asthma among Adult Asthma Patients: A Cross-sectional Study

Introduction:

Asthma is a major public health problem that negatively impacts patients, families, and the community. Identifying risk factors for poor asthma control may greatly enhance the establishment of more effective treatment of asthma. The level of asthma control and risk factors for poor asthma control is relatively unknown in Ethiopia.

Methods:

A cross-sectional study was conducted on 150 adult asthma patients at the Outpatient Department (OPD) chest clinic of Jimma Medical Center (JMC), from February 15 –March 20, 2019. The Statistical Package for Social Science (SPSS) 21.0 was used for data analysis. Multivariate logistic regression was conducted to analyze the potential associated factors of suboptimal control of asthma.

Results and Discussion:

Of 150 adults diagnosed with asthma recruited in this study, 81 [54.0%] of them were females, and the mean age of the patients was 41.1 ± 12.4 years. Inhaled corticosteroid (ICS) plus short-acting beta-agonist (SABA) (64, 42.7%) was the most frequently used anti-asthmatic medication. Over one-fourth (26.0%) (95% CI, 19.2-33.8) of study participants had suboptimal asthma control. On multivariate logistic regression, being an urban dweller (AOR=3.70, p=0.025) and not applying proper inhalation technique (AOR=16.23, p=0.022) were increased the risk of suboptimal asthma control, while non-prescription anti-asthmatic drugs taking habit (AOR=0.25, p=0.010) reduces the odds of having suboptimal asthma control.

Conclusion:

Suboptimal asthma control is high among adult asthma patients. Being an urban dweller and not applying proper inhalation techniques were increased the likelihood of suboptimal asthma control, while non-prescription anti-asthmatic drugs taking habits had lower odds of suboptimal asthma control. The authors recommend large sample size studies on the comparative status of asthma control using prescription versus non-prescription anti-asthmatic medication.

Extrapulmonary symptoms of patients with asthma treated in specialist pulmonary care

OBJECTIVE

Patients seeking treatment for their asthma are most likely motivated by a change in their experience of symptoms, but primary complaints are not always related to the pulmonary system. This study aimed to determine the frequency of such extrapulmonary symptoms in asthma outpatients and their association with psychopathology and asthma outcomes.

METHODS

This cross-sectional study utilized data collected as part of a nationwide, clinical-epidemiological study. The final sample of 572 asthma patients represented all levels of asthma control and severity. Information on demographics and respiratory function was obtained from physicians' documentation. Symptoms were explored using a standardized checklist.

RESULTS

Primary symptoms reported by asthma patients were not necessarily airway-related. Patients reported feeling at least occasionally "tired" (72.1%) and "exhausted" (66.8%) more than any other asthma symptom. Hyperventilation and mood symptoms were experienced by 34.4-42.6% of patients. Anxiety or depression diagnoses indicated higher scores in all symptom domains. Controlling for asthma-related factors and psychopathology, fatigue had a small but significant effect on both asthma-related quality of life (AQLQ) (r_sp² = 0.02, P < .001) and asthma control (r_sp² = 0.01, P = .003). Mood symptoms also showed a small but significant effect on AQLQ (r_sp² = 0.02, P < .001).

CONCLUSION

Findings suggest that extrapulmonary symptoms are endorsed more frequently than previously reported. Symptoms nonspecific to asthma can play a substantial role in clinical presentation and exclusive focus on airway symptoms may miss important information related to patients' well-being. Surveillance of extrapulmonary symptoms alongside pulmonary function is warranted for an integrated medicine approach to asthma management.

Characterization of uncontrolled, severe asthma patients with type 2 inflammation (T2): results from a physician survey across countries from Latin American, Eurasian Middle East regions and China

OBJECTIVE

The 2019 GINA guidance incorporates the presence of T2 inflammation in severe asthma patients to determine eligibility for add-on biologic therapy, though little data exists to characterize this population. The objective of this manuscript is to conduct a descriptive analysis to characterize patients with severe asthma in emerging countries based on disease severity, patient exacerbation history, and T2 phenotype.

METHODS

A cross-sectional survey of physicians treating asthma patients ages 12 years and older was conducted in eight countries. Physicians characterized their severe asthma patients and reported data from their patients' medical charts. Medical chart data was selected from the physicians' six most recent asthma patients taking prescription medication.

RESULTS

A total of 550 physicians completed the survey and filled out 3,300 patient record forms. A total of 876 patients have been characterized with uncontrolled severe asthma. Of the 420 patients with available EOS lab data, 40% are indicated with T2 inflammation (EOS ≥150/µL). Ninety-one percent of all patients with available IgE lab data (n = 498) had IgE 30 - 1500 IU/mL indicating allergy-driven asthma. Finally, chronic OCS use (as reported by physicians) was reported in 11% of patients.

CONCLUSION

This research revealed that 65% of patients had at least one of three T2 inflammation comorbidities assessed: allergic rhinitis, chronic rhinosinusitis with nasal polyps, and atopic dermatitis. Discrepancies were observed between patients' treatment regimens and GINA step reported, suggesting there may be room to improve understanding of asthma severity as defined per GINA guidelines as well as asthma control assessment in clinical practice.

The prevalence of sleep disturbance among asthmatic patients in a tertiary care center

Sleep disturbances are commonly reported by patients with asthma. However, the prevalence of sleep disturbance and its association with the level of asthma control is unknown. The primary objective was to determine the prevalence of sleep disturbance among Saudi adult asthmatic patients attending pulmonary clinics at King Abdulaziz Medical City (KAMC). The study also aimed to compare sleep quality between controlled and uncontrolled asthma patients. The study was carried out in the outpatient pulmonary clinics at KAMC and utilized a cross-sectional survey. The survey included five different questionnaires: asthma control test and questionnaires related to the quality of sleep (Pittsburgh sleep quality index [PSQI], Epworth sleepiness scale [ESS], Berlin questionnaire [a measure of obstructive sleep apnea risk], and insomnia severity index [ISI]). Among the 200 asthma patients, 66% suffered from poor sleep quality (PSQI > 5), 43% were at high risk for obstructive sleep apnea, 25% had excessive daytime sleepiness (ESS > 10), and 46.5% had significant clinical insomnia (ISI ≥ 10). Poor sleep quality was less common in patients with well-controlled asthma (37%) compared to those with partially controlled asthma (78%) and uncontrolled asthma (82%) (p < 0.001). Poor sleep quality was common among patients with asthma, particularly those with suboptimal levels of asthma control. Further studies are needed to better understand the interaction between these two conditions.

Evaluation of a Multidisciplinary Disease Management Program to Achieve Asthma Control in Seven Safety Net Hospitals in Louisiana

The objective was to evaluate a multidisciplinary guideline-driven disease management program focused on achievement of asthma control among sustained patients with confirmed asthma in Louisiana and to assess factors affecting achievement of asthma control. Data were extracted from the electronic health records of 1596 adults with confirmed asthma, sustained care for >1 year in the outpatient setting, and ≥2 recorded Asthma Control Test (ACT) scores. Multivariable logistic regression modeling was used to assess the association of demographic variables, comorbidities, and process measures with the best achieved asthma control as represented by the highest ACT score. Most subjects were female (81.1%) and African American (63.9%). Approximately half of them (48.9%) were able to achieve asthma control (ACT ≥20). The most prevalent comorbidities were hypertension (79.8%), rhinitis (55.3%), and obesity (50.5%). Most patients received pulmonary function testing (PFT) (88.6%), controller medication therapy (85.5%), or written asthma action plans (92.7%). Asthma control was positively associated with presence of PFT (OR = 1.63, 95% CI: 1.13, 2.37) and being a "never" smoker (OR = 1.49, 95% CI: 1.08, 2.04). Asthma control was less likely to be achieved by patients who were African American (OR = 0.68, 95% CI: 0.52, 0.87), had more comorbidities (OR = 0.89, 95% CI: 0.83, 0.96), or were on more medications (OR = 0.79, 95% CI: 0.72, 0.88). Asthma control was achieved in 48.9% of an adult, primarily African American population with the implementation of comprehensive guideline-driven care. Furthermore, this is the first study to observe that the presence of PFT may be associated with asthma control.

Associations of Asthma and Asthma Control With Atrial Fibrillation Risk: Results From the Nord-Trøndelag Health Study (HUNT)

Importance

Asthma, a chronic inflammatory airway disease, and atrial fibrillation (AF) share several common pathophysiological mechanisms. Research on the association between asthma and atrial fibrillation is lacking, and to our knowledge, no previous studies have assessed the dose-response association between levels of asthma control and AF.

Objective

To assess the association between asthma, levels of asthma control, and AF.

Design, Setting, and Participants

This prospective population cohort analyzed data on adults from a second and third iteration of the survey-based Nord-Trøndelag Health Study (HUNT) in Norway. All included participants were free from AF at baseline. Atrial fibrillation was ascertained by linking HUNT data with hospital records from the 2 hospitals in Nord-Trøndelag County. Data analysis was completed from May 2017 to November 2017.

Exposures

Self-reported asthma was categorized into 3 groups: those who had ever had asthma, those who self-report being diagnosed with asthma, and those who had active asthma. Asthma control was defined according to Global Initiative for Asthma guidelines and was categorized into controlled, partly controlled, and uncontrolled cases.

Main Outcomes and Measures

Atrial fibrillation.

Results

A total of 54 567 adults were included (of whom 28 821 [52.8%] were women). Of these, 5961 participants (10.9%) reported ever having asthma, 3934 participants (7.2%) reported being diagnosed with asthma, and 2485 participants (4.6%) reported having active asthma. During a mean (SD) follow-up of 15.4 (5.8) years, 2071 participants (3.8%) developed AF. Participants with physician-diagnosed asthma had an estimated 38% higher risk of developing AF (adjusted hazard ratio, 1.38 [95% CI, 1.18-1.61]) compared with participants without asthma. There was a dose-response association between levels of asthma control and risk of AF with the highest risk for AF in participants with uncontrolled asthma (adjusted hazard ratio, 1.74 [95% CI, 1.26-2.42]; P for trend < .001).

Conclusions and Relevance

Asthma and lack of asthma control were associated with moderately increased risks of AF in a dose-response manner. Further studies are needed to explore the underlying mechanisms and clarify causal pathways between asthma and AF.

Discomfort Intolerance in Relation to Asthma Outcomes

Anxiety symptoms and disorders are common among those with asthma and contribute to poorer health outcomes. Building on work examining anxiety-related cognitive-affective risk factors in asthma, the current study sought to explore associations between discomfort intolerance (i.e., the inability to withstand or tolerate unpleasant bodily sensations) in relation to lung function, asthma control, and quality of life. Participants were 61 adults with asthma (61.9% female; 54.8% African American; M age = 34.72, SD = 13.58) who were administered a self-report assessment battery and a lung function assessment. We found that, above and beyond the effects of anxiety sensitivity-physical concerns, greater discomfort intolerance was significantly associated with poorer lung function (9.5% variance), asthma control (9.9% variance), and overall asthma-related quality of life (11.7% variance) as well as the specific quality of life domains of activity limitations (12.6% variance) and asthma symptoms (6.8% variance). Thus, individuals with asthma who are unable to tolerate physical discomfort may be at risk for poor asthma outcomes and interventions to reduce discomfort intolerance could potentially be useful in this population.

Effectiveness of a short training program for community pharmacists to improve knowledge and practice of asthma counselling - A simulated patient study

OBJECTIVE

Community pharmacists can make significant contributions and be an indispensable member in the asthma therapy chain. The present study aimed to investigate the current knowledge level of Vietnamese community pharmacists in asthma counselling and the impact of a short training program on asthma knowledge and practice.

METHOD

300 community pharmacists participated in the study. A knowledge questionnaire about asthma medications and a standardized inhaler checklist were designed to evaluate their knowledge before and after a 4-h training program. Six to eight weeks later, 10 simulated patients were sent to the community pharmacies to evaluate the pharmacists' knowledge and practice.

RESULTS

The training program significantly improved the asthma knowledge score of pharmacists from 5.3 to 17.2 out of a maximum score of 20 (p < 0.001). After the training, the percentage of pharmacists performing correctly inhaler devices increased significantly (0% vs.∼50%, p < 0.001). In the simulated patient study, pharmacists who attended the training demonstrated better asthma knowledge with higher scores (5.4 vs 1.7 out of a maximum score of 7.0, p < 0.001), as well as much better inhaler technique scores (6.1 vs 4.3, out of a maximum score of 8, p < 0.001). These pharmacists achieved higher scores in all aspects encompassing distinguishing controllers and relievers, counselling correctly about adherence, and common side effects.

CONCLUSION

Our results revealed significant knowledge deficiency about asthma among Vietnamese community pharmacists. However, a short training program was effective in upskilling the pharmacists to effectively counsel asthmatic patients about the management of their condition and medications.

Level of asthma control and risk factors for poor asthma control among clinic patients seen at a Referral Hospital in Addis Ababa, Ethiopia

OBJECTIVE

Uncontrolled asthma negatively impacts patients, families, and the community. The level of symptom control among asthmatics in Ethiopia has not been well studied. We investigated the level of asthma control and risk factors for poor asthma control in clinic patients seen in the largest public hospital in Ethiopia.

RESULTS

In this cross-sectional study, we studied all 182 consecutive subjects with a physician diagnosis of asthma who were seen in chest clinic at Tikur Anbessa Specialized Hospital between July and December 2015. Of the 182 subjects, 68.1% were female. The mean age was 52 ± 12 years and the median duration of asthma was 20 ± 12.7 years. One hundred and seventeen subjects (64.3%) had nighttime awakening due to asthma. Fifty-eight (31%) were not using controller medications and 62 (34.6%) had improper inhaler technique. Only 44 (24.2%) subjects had well-controlled asthma. On multivariate analysis, variables associated with uncontrolled asthma included: use of biomass fuel for cooking, longer duration of asthma (> 30 year), incorrect inhalation technique, and asthma exacerbation in the last 12 months. Most asthmatics attending in the largest public hospital in Ethiopia, had uncontrolled asthma. Several risk factors for poor asthma control were identified. Improved asthma control is possible through directed interventions.

Changes in clinical conversations when providers are informed of asthma patients' beliefs about medication use and integrative medical therapies

OBJECTIVES

To explore whether patient's personal beliefs about inhaled corticosteroid (ICS) and integrative medicine (IM) are discussed at routine primary care visits for asthma.

BACKGROUND

Negative medication beliefs and preferences for IM can be salient barriers to effective asthma self-management.

METHOD

A qualitative analysis of transcripts from 33 audio-recorded primary care visits using conventional content analysis techniques.

RESULTS

Four themes emerged when providers had knowledge of patient's beliefs: negative ICS beliefs, IM use for asthma, decision-making and healthy lifestyles. Two themes were identified when providers did not have this knowledge: asthma self-management and healthy lifestyles.

CONCLUSION

When providers had knowledge of their patient's IM endorsement or negative ICS beliefs, they initiated conversations about these modifiable beliefs. Without training in IM and in effective communication techniques, it is unlikely that providers will be able to effectively engage in shared decision-making aimed at improving asthma self-management.

Limited treatment adaptation despite poor asthma control in asthma patients treated with inhaled corticosteroids

OBJECTIVE

Current asthma guidelines recommend use of inhaled corticosteroids (ICS) in patients with persistent disease. This study was designed to investigate (1) the proportion of patients prescribed ICS-containing maintenance treatment who achieve asthma control, (2) determinants of control and (3) how physicians adapt treatment to the level of control.

METHODS

General practitioners (GPs) and chest physicians (CPs) in France recruited patients consulting for asthma and prescribed an ICS. Over a 2-year follow-up period, asthma symptoms in the previous 3 months and treatments prescribed were documented at each visit. Variables independently associated with asthma control were determined by multiple logistic regression.

RESULTS

Data were available for 924 patients recruited by GPs and 455 recruited by CPs. Asthma control was acceptable in only 24% of patients at inclusion, and in 33.6% at the last follow-up visit. Five factors were independently associated with asthma control: age (or time since diagnosis), gender, smoking status, allergic aetiology of asthma and treatment. Most patients (56.3%) were prescribed the same ICS dose regimen at the end of follow-up as at inclusion. The intensity of controller therapy had been increased in only 12.2% of patients unacceptably controlled at inclusion.

CONCLUSIONS

Asthma was unacceptably controlled in most patients receiving ICS-containing maintenance treatment and remained so during follow-up. Despite this, treatment adaptations by GPs and CPs were very infrequent. This unsatisfactory situation may be improved by adopting a more dynamic approach to tailoring controller therapy to the needs of the patient.

Anxiety Sensitivity and Reactivity to Asthma-Like Sensations Among Young Adults With Asthma

Anxiety sensitivity, particularly the physical concerns domain, is associated with more problematic asthma symptoms and greater functional limitations. It has been theorized that anxiety sensitivity fosters greater reactivity to asthma-related physical sensations; however, this theory has yet to be empirically tested. Thus, the present investigation sought to examine the role of anxiety sensitivity-physical concerns in terms of affective and physical reactivity to asthma-like symptoms. Participants were 101 undergraduates with asthma (76.2% female, Mage = 19.69 years, SD = 3.77 years, range = 18-49 years) who completed self-report measures and a straw-breathing task. Results indicated that after controlling for the effects of gender, asthma control (i.e., how well one's asthma symptoms are managed or controlled), and negative affectivity, greater levels of anxiety sensitivity-physical concerns significantly predicted greater anxiety (4.7% unique variance) and asthma symptoms (6.9% unique variance) and lower levels of lung function (4.4% unique variance) after the straw-breathing task. These findings suggest that individuals with asthma who are fearful of physiological arousal are a particularly "at-risk" population for poor asthma outcomes because of this greater reactivity and could benefit from interventions targeting anxiety sensitivity.

Factors associated with poor asthma control in the outpatient clinic setting

BACKGROUND/OBJECTIVES

The goal of the study was to assess asthma control using asthma control test (ACT) and to explore the factors that effects asthma control among participants with bronchial asthma in the outpatient clinic setting.

METHODS

This cross-sectional descriptive study was conducted in the outpatient primary care clinic at King Abdulaziz Medical City in Riyadh. Adult patients who were diagnosed with bronchial asthma by their primary treating physician were recruited over a 6-month period. Patients completed the ACT and questionnaires, which identified factors that affect asthma control.

RESULTS

Four hundred asthmatic patients (n = 400) were enrolled, and 70% of these patients were women. Fifty-four percent of patients inappropriately used the inhaler device. The estimated prevalence of uncontrolled asthma at the time of the study was 39.8%. Inappropriate device use by the patient was more frequently associated with uncontrolled asthma (P-value = 0.001). Active smoking (P-value = 0.007), passive smoking (P-value = 0.019), unsealed mattress (P-value = 0.030), and workplace triggers (P-value = 0.036) were also associated with uncontrolled asthma. However, the extent of asthma control did not appear to be related to the existence of regular follow-ups, bedroom carpets, outpatient clinic visits, age, body mass index (BMI), or duration of asthma.

CONCLUSIONS

The present study identified a high prevalence of uncontrolled asthma in the primary outpatient clinic setting and common risk factors that may contribute to poor asthma control.

Association of gastroesophageal reflux disease with asthma control

Gastroesophageal reflux disease (GERD) may make asthma difficult to control and may be a potential risk factor for frequent asthma exacerbations, but the mechanisms of the relationship between GERD and not well-controlled asthma remain unclear. The aim of this study was to explore the association of GERD with asthma control in adults. Patients with asthma were consecutively recruited, and Asthma Control Test (ACT) and Reflux Diagnostic Questionnaire scores were determined. The patients were categorized into not well-controlled asthma and well-controlled asthma groups according to the ACT score. Univariate and multivariate logistic regression analyses were performed to evaluate the relationship between GERD and not well-controlled asthma. Seven hundred and sixty-eight patients with asthma were enrolled. The mean ACT score was 18.2 ± 3.6, and there were 161 (21.0%) patients with not well-controlled asthma. The Reflux Diagnostic Questionnaire score was 10.5 ± 4.7, and 212 (27.6%) patients were complicated by GERD. Multivariate logistic regression analyses revealed the independent association of GERD with not well-controlled asthma (odds ratio, 3.12; 95% confidence interval, 1.53-4.88) after other established contributors to asthma control were adjusted. In conclusion, there is an association of GERD with not well-controlled asthma, independent of other potential contributors to asthma control.

Drug development for severe asthma: what are the metrics?

Although reversible airway obstruction in part defines asthma, lung function as measured by spirometry alone inadequately predicts the value of new therapeutic agents in the treatment of severe asthma. Our objectives are 1) to review whether pulmonary function and bronchodilator reversibility are endpoints for drug discovery and 2) to identify parameters that predict efficacy in drug development in severe asthma. An English language literature search using MedLine and PubMed was conducted from 1997 to present concerning pathophysiology, diagnosis and therapy of severe asthma using the terms "severe asthma," "irreversible asthma," "difficult asthma," "airway remodeling," "fixed airway obstruction," "reversibility" and "bronchodilator reversibility" as index terms. Eight studies were characterized that encompass 1424 subjects with asthma. Our review identified the limitations of using bronchodilator reversibility as a predictor in drug development for severe asthma. Neither improvement in lung function nor bronchodilator reversibility characterized the benefit of new drugs in the treatment of severe asthma. Newly approved drugs in the treatment of severe asthma show decreased asthma exacerbations and improved quality of life associated with steroid-sparing benefits without altering bronchodilator responsiveness or improving lung function. Although changes in lung function predict asthma control in mild/moderate asthma, lung function alone is inadequate to assess improvement in asthma control in severe asthma manifested by fixed airway obstruction. Endpoints that focus on asthma control, as defined by the Expert Panel Report 3 and GINA guidelines, may predict the value of new therapeutics in the management of severe asthma.

Evaluating the use of a computerized clinical decision support system for asthma by pediatric pulmonologists

PURPOSE

To investigate use of a new guideline-based, computerized clinical decision support (CCDS) system for asthma in a pediatric pulmonology clinic of a large academic medical center.

METHODS

We conducted a qualitative evaluation including review of electronic data, direct observation, and interviews with all nine pediatric pulmonologists in the clinic. Outcome measures included patterns of computer use in relation to patient care, and themes surrounding the relationship between asthma care and computer use.

RESULTS

The pediatric pulmonologists entered enough data to trigger the decision support system in 397/445 (89.2%) of all asthma visits from January 2009 to May 2009. However, interviews and direct observations revealed use of the decision support system was limited to documentation activities after clinic sessions ended. Reasons for delayed use reflected barriers common to general medical care and barriers specific to subspecialty care. Subspecialist-specific barriers included the perceived high complexity of patients, the impact of subject matter expertise on the types of decision support needed, and unique workflow concerns such as the need to create letters to referring physicians.

CONCLUSIONS

Pediatric pulmonologists demonstrated low use of a computerized decision support system for asthma care because of a combination of general and subspecialist-specific factors. Subspecialist-specific factors should not be underestimated when designing guideline-based, computerized decision support systems for the subspecialty setting.

Development of the Asthma Control Composite outcome measure to predict omalizumab response

BACKGROUND

Previous assessments of response to omalizumab were based on diary-based data rather than standard validated instruments. A composite instrument that translates diary-based data into standard validated asthma control measures would characterize patient response to treatment in terms of current asthma control definitions.

OBJECTIVE

To develop the Asthma Control Composite (ACC) tool, using real-time diary-based data to predict treatment response in terms of asthma control.

METHODS

The ACC tool was derived retrospectively using pooled data from two phase 3 studies in patients with moderate to severe allergic asthma. Patients were randomized to receive subcutaneous omalizumab or placebo for 16 weeks plus stable beclomethasone dipropionate therapy, followed by a 3-month corticosteroid reduction period and 5-month double-blind safety extension. Control was assessed as "complete," "good," or "not controlled," based on a composite score of 4 elements: rescue medication (puffs/day), total asthma symptom score, average number of awakening nights/28 days, and activity limitation.

RESULTS

The ACC was mapped to standard validated measures of patient-reported outcomes, with results consistent with clinical outcomes. The proportion of patients with baseline uncontrolled asthma achieving "good" or "complete" asthma control was 48% with omalizumab and 32% with placebo at approximately 4 months. The mean composite score also was improved with omalizumab (3.52) vs placebo (2.56) at approximately 4 months.

CONCLUSIONS

The ACC tool accurately reflects asthma control in moderate to severe asthma patients eligible for biological therapy. Unlike the ACT, which has not been validated in this patient population, the ACC shows promise as an asthma control assessment tool in patients with moderate to severe asthma.

The role of physical activity and body mass index in the health care use of adults with asthma

BACKGROUND

Health care use in patients with asthma is affected by many factors, including sex and ethnicity. The role of physical activity (PA) and body mass index (BMI) (calculated as weight in kilograms divided by height in meters squared) in this relationship is unknown.

OBJECTIVE

To determine the role of PA and BMI in the health care use of patients with asthma.

METHODS

A sample of adults with asthma (n=6,835) and without asthma (n=78,051) from cycle 3.1 of the Canadian Community Health Survey was identified. Health care use was self-reported as overnight hospital stays (yes or no), length of overnight hospital stay (<4 or > or =4 nights), and physician consultations (<3 or > or =3). Self-reported physical activities were used to derive total energy expenditure and to classify participants as active (>3.0 kcal/kg of body weight per day), moderately active (1.5-3.0 kcal/kg of body weight per day), and inactive (<1.5 kcal/kg of body weight per day). The BMI was categorized as normal weight (18.5-24.9), overweight (25.0-29.9), and obese (30.0-59.9).

RESULTS

Adjusted logistic regression models revealed that patients with asthma were more likely to have an overnight hospital stay (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.95-2.60), 4 or more overnight hospital stays (OR, 1.48; 95% CI, 1.12-1.96), and 3 or more physician consultations (OR, 2.43; 95% CI, 2.18-2.71) compared with patients without asthma (OR, 1.00). Inactive patients with asthma were more likely to have an overnight hospital stay (OR, 1.68; 95% CI, 1.31-2.16) and 3 or more physician consultations (OR, 1.23; 95% CI, 1.04-1.46) than active patients with asthma (OR, 1.00). Inactive/obese patients with asthma were 2.35 (95% CI, 1.69-3.27) times more likely to have an overnight hospital stay and 2.76 (95% CI, 2.11-3.60) times more likely to have 3 or more physician consultations than active/normal weight patients with asthma (OR, 1.00).

CONCLUSIONS

Higher PA levels are associated with lower health care use in individuals with and without asthma. In those with asthma, PA was a more important factor in overnight hospital stays than BMI, whereas both BMI and PA were important determinants of physician consultations.