Impact of asthma controller medications on medical and economic resource utilization in adult asthma patients

Impact of Guideline-Based Asthma Treatment on Health Services Use in Singapore Before and During COVID-19 Outbreak

Introduction

To date, the role of standard asthma care in reducing asthma-related health services use (HSU) during the COVID-19 pandemic remains unclear. This study examined the impact of guideline-based asthma treatment on the use of asthma-related emergency department (ED) visits, polyclinic visits (total visits and urgent visits characterized by nebuliser use) before and during the pandemic.

Methods

Data from April 2017 to October 2020 was obtained from the National University Health System, one of the three healthcare clusters in Singapore. Using generalized linear models, we estimated the joint effects of the ratio of preventer to reliever dispensations (PRR) and COVID-19 on asthma-related ED visits per hospital per month, total asthma-related polyclinic visits and asthma-related urgent polyclinic visits per clinic per month.

Results

Findings show that before the onset of COVID-19, for every 0.5 unit increase in PRR, the number of asthma-related ED visits and urgent polyclinic visits decreased by 12.9% (95% CI: -13.0% to -12.9%) and 6.8% (95% CI: -6.9% to -6.7%), respectively, whereas total asthma-related polyclinic visits increased by 1.0% (95% CI: 0.9% to 1.0%). During the pandemic, a 0.5 unit increase of PRR decreased the number of asthma-related ED visits, urgent and total polyclinic visits by 16.9% (95% CI: -17.0% to - 16.9%), 9.3% (95% CI: -9.5% to -9.2%) and 0.7% (95% CI: -0.8% to -0.7%), respectively.

Discussion

These findings suggest that regardless of the COVID-19 pandemic, an increase in PRR consistently reduced the frequency of asthma-related urgent and emergent care, although it barely influenced routine asthma follow-up visits.

Association between asthma control and healthcare costs: Results from a German linked data study

Background: This study aimed to evaluate differences in healthcare resource utilization and cost among patients with controlled and uncontrolled asthma.Methods: Claims data from a German sickness fund was linked to patient survey data. Outpatient physicians enrolled patients and assessed asthma control using the ACT^TM questionnaire. All-cause and asthma-specific healthcare resource use (HCRU)/costs were compared descriptively and based on multivariable models using a continuous ACT^TM score.Results: Overall, 492 asthma patients were included (mean age: 53.8, 73.8% female). The mean/median ACT^TM score was 19.9/20.7, with 183 patients (37.2%) classified as having uncontrolled asthma (mean ACT^TM score<20) Patients with uncontrolled asthma had significantly more hospitalizations (p = .035) and medication prescriptions (p < .001), which resulted in higher total healthcare costs for asthma-related (€1785 vs. €1615; p = .004) and all-cause care (€4695 vs. €4117; p = .009). While controlling for baseline characteristics, multivariable models confirmed a negative association between asthma control and total all-cause healthcare costs (p = .008), total asthma-related costs (p = .008), and costs of medication prescriptions (p = .001). However, no significant association was found for all-cause (p = .062) and asthma-related hospitalization costs (p = .576).Conclusion: Considering continuous patient care, improving asthma control is not only desirable from a clinical perspective, but could also be an effective approach to reduce asthma-related HCRU and cost burden.

Overuse of reliever inhalers and associated healthcare utilization of asthma patients

Global Initiative for Asthma 2019 guidelines recommend to avoid strengthening patients’ reliance on relievers since they increase exacerbation risk. Our aim was to examine the association between reliever inhalers overuse and all-cause healthcare utilization (HCU). A retrospective study among Clalit Health Services (CHS) adult enrollees (n = 977) for 2012–2017. Reliever inhalers overuse was defined as consistent prescription refills of ≥ 3 canisters annually. Adherence to controllers was calculated using the proportion of days covered. HCU included: hospitalizations, diagnostic and surgical procedures, medications, emergency room (ER) visits, and clinic visits. 27% of the study population (n = 264) consistently refilled ≥ 3 relievers prescriptions annually, and had higher adherence to controllers (0.38 vs. 0.24, p < 0.001). Their total 6-year HCU costs were not higher than that of others ($5,550 vs. $5,562, p = 0.107). Most HCU components [including hospitalization (p = 0.405) and ER visits (p = 0.884)] were comparable; however, medication costs were higher ($1734 vs. $1504, p < 0.001). A multivariable ordered-logit model revealed that frequent and regular use of relievers was not associated with higher HCU costs (OR = 0.82, 95% CI 0.62–1.09, p = 0.175). Higher adherence to maintenance and reliever therapy (OR = 2.18, 95% CI 1.44–3.28, p < 0.001), other controllers (OR = 3.30, 95% CI 2.11–5.16, p < 0.001), and nebulized SABAs and SAMAs (OR = 1.08, 95% CI 1.02–1.14, p = 0.007) was associated with higher costs. Overuse of reliever inhalers was prevalent and associated with higher adherence to controllers, yet not associated with higher all-cause HCU. This highlights the need to examine the sources of elevated usage in order to develop intervention strategies to optimize pharmaceutical therapy of asthma patients.

Suboptimal compliance to aerosol therapy in pediatric asthma: A prospective cohort study from Eastern India

Background:

Suboptimal compliance to aerosol medication is common in pediatric asthma. Accordingly, the objective of this study is to assess noncompliance to aerosol therapy in childhood asthma and determine contributory factors.

Materials and Methods:

A prospective cohort study was conducted among pediatric patients attending asthma clinic. Patients (n = 215) having “mild” and “moderate” asthma severity rating were included. The total study duration was 12 months (June 2016–June 2017), with an active recruitment phase of 6 months. The minimum period for follow-up was 90 days. Caregivers were instructed to maintain an “asthma diary” for daily dosages of inhalers. At follow-up, the diary entries were corroborated with the amount of inhaler medication unused. Subsequently, medication compliance ratio (CR) was calculated according to the following formula: CR = number of medication doses taken/number of medication doses prescribed. CR% >80 was considered as “good compliance”.

Results:

A total of 169 patients (78.6%) returned for follow-up. The mean compliance to asthma medication was suboptimal (75.3%). The children were primarily prescribed inhaled corticosteroids and short-acting beta-agonist (SABA)-based regimens on index visit. Leukotriene receptor antagonist was added in select cases (67.9%). Nearly 45.6% of the patients had “good compliance.” CR correlated with the sociodemographic profile and disease severity. Higher socioeconomic status and proper inhaler technique reflected better symptom control. Fear of side effects, behavioral difficulties, and economic restrictions were the identified causes of medication default.

Conclusion:

In the Eastern part of India, compliance to aerosol therapy in pediatric asthma is suboptimal. Sociodemographics, disease severity, and inhaler technique are important determinants.

Economic Burden Associated with Receiving Inhaled Corticosteroids with Leukotriene Receptor Antagonists or Long-Acting Beta Agonists as Combination Therapy in Older Adults

BACKGROUND

There is a paucity of literature on the health care expenditures associated with different pharmacologic treatments in older adults with asthma that is not well controlled on inhaled corticosteroids (ICS).

OBJECTIVE

To compare asthma-related and all-cause health care expenditures associated with leukotriene receptor antagonists (LTRA) versus long-acting beta agonists (LABA) when added to ICS in older adults with asthma.

METHODS

A retrospective cohort was constructed using 2009-2010 Medicare fee-for-service medical and pharmacy claims from a 10% random sample of beneficiaries continuously enrolled in Parts A, B, and D in 2009. The sample comprised patients who were aged 65 years and older, diagnosed with asthma, and treated exclusively with ICS + LABA or ICS + LTRA. Outcomes assessed were asthma-related expenditures (medical, pharmacy, and total) and all-cause health care expenditures (medical, pharmacy, and total). Outcomes were measured from the date of the first prescription for the add-on treatment (LABA or LTRA in combination with ICS) after having at least a 4-month "wash-in" period in which patients were receiving no controller, ICS alone, or ICS plus the add-on treatment of the follow-up period. Patients were followed until death, switching to or adding the other add-on treatment, or the end of the study (December 31, 2010). Multivariable regression models with nonparametric bootstrapped standard errors were used to compare all-cause and asthma-related expenditures per patient per month (PPPM) between ICS + LABA and ICS + LTRA users. All models were adjusted for demographics, comorbidities, and county-level health care access variables.

RESULTS

The primary analysis included 14,702 patients, of whom 12,940 were treated with ICS + LABA and 1,762 were treated with ICS + LTRA. The mean (SD) follow-up periods were 12.3 (± 5.7) months for the ICS + LABA group and 15.3 (± 5.1) months for the ICS + LTRA group. Adjusted asthma-related expenditures PPPM were $400 for the ICS + LTRA group compared with $286 for the ICS + LABA group (P < 0.001). However, adjusted total all-cause expenditure PPPM was significantly lower for patients treated with ICS + LTRA ($6,087 for ICS + LTRA compared with $6,975 for ICS + LABA, P = 0.029).

CONCLUSIONS

Older adults with asthma often experience economic burden from asthma and other chronic illnesses. Compared with ICS + LTRA, ICS + LABA was associated with lower asthma-related expenditures but with higher all-cause expenditures in older adults.

DISCLOSURES

Support for this study was provided by the University of Pittsburgh School of Pharmacy and the Pittsburgh Claude D. Pepper Older Americans Independence Center (NIA P30 AGAG024827). C. Thorpe reports grants from the National Institute of Aging during the conduct of this study. The other authors have nothing to disclose.

Motivational interviewing for adherence: post-training attitudes and perceptions of physicians who treat asthma patients

OBJECTIVE

The aim of this study was to evaluate the attitudes and perceptions of health care professionals (HCPs) who have been trained in motivational interviewing (MI) to improve adherence. Another objective of this study was to compare groups of HCPs with different levels of training in adherence (trained vs untrained; previous training in adherence education [AdhE] vs specific training in MI).

METHODS

For this study, a national questionnaire-based survey was conducted among HCPs treating asthma. A total of 360 HCPs were surveyed (allergists: n=110; pulmonologists: n=120; general practitioners: n=130). Of them, 180 physicians had received a training intervention (training in AdhE: n=90; training in MI to promote adherence: n=90).

RESULTS

Of the total surveyed HCPs, 92.8% reported adherence is highly important in asthma control. More professionals trained in MI compared to those trained in AdhE considered that "simplifying treatment as far as possible" (85.6% vs 68.9%, P=0.0077), "involving the patient in treatment plans" (85.6% vs 71.1%, P=0.0187), "giving the patient self-care patterns" (52.2% vs 36.7%, P=0.0357) and "performing MI" (42.2% vs 15.6%, P<0.0001) were the most important interventions to promote adherence. "Empathy between doctor and patient" (93.3% vs 77.8%, P=0.0036) and "concordance of medical and patient treatment goals" (96.7% vs 72.2%, P<0.0001) were the factors perceived as having the greatest influence in improving adherence to asthma treatment by the physicians in the MI group as opposed to those in the AdhE group. The use of MI in asthma consultation was the most highly valued resource to promote adherence to treatment among all the professionals, particularly those who had received specific MI training compared to those who had received any kind of previous training in AdhE (96.7% vs 66.7%, P<0.0001).

CONCLUSION

MI is considered an important tool to promote adherence to asthma treatment among HCPs, especially among those specifically trained in that aspect. MI training interventions seem to influence HCPs' approaches to improve self-care and to engage patients in treatment plans rather than approaches solely centered on AdhE.

Asthma Controller Medication Adherence, Risk of Exacerbation, and Use of Rescue Agents Among Texas Medicaid Patients with Persistent Asthma

BACKGROUND

Adherence to asthma long-term controller medications is one of the key drivers to improve asthma management among patients with persistent asthma. While suboptimal use of controller medications has been found to be associated with more frequent use of oral corticosteroids (OCS), few studies exist regarding the relationship between adherence to controller therapy and the use of short-acting beta2-agonists (SABAs). A better understanding of the association between adherence to asthma controller agents and use of reliever medications will help health care providers and decision makers enhance asthma management.

OBJECTIVE

To determine if there is a relationship between asthma controller adherence, risk of exacerbation requiring OCS, and use of asthma rescue agents.

METHODS

Texas Medicaid claims data from January 1, 2008, to August 31, 2011, were retrospectively analyzed. Continuously enrolled patients aged 5-63 years with a primary diagnosis of asthma (ICD-9-CM code 493) and with 4 or more prescription claims for any asthma medication in 1 year (persistent asthma) were included. The index date was the date of the first asthma controller prescription, and patients were followed for 1 year. The primary outcome variables were SABA (dichotomous: less than  6 vs. ≥ 6) and OCS (continuous) use. The primary independent variable was adherence (proportion of days covered [PDC]) to asthma long-term controller medications. Covariates included demographics and nonstudy medication utilization. Multivariate logistic and linear regression analyses were employed to address the study objective.

RESULTS

The study sample (n = 32,172) was aged 15.0 ± 14.5 years, and adherence to controller therapy was 32.2% ± 19.7%. The mean number of SABA claims was 3.7 ± 3.1, with most patients having 1-5 claims (73.2%), whereas 19.4% had ≥ 6 SABA claims. The mean number of OCS claims was 1.0 ± 1.4. Adherent (PDC ≥ 50%) patients were 96.7% (OR = 1.967; 95% CI = 1.826-2.120) more likely to have ≥ 6 SABA claims when compared with nonadherent (PDC  less than  50%) patients (P  less than  0.001). As for OCS use, adherent patients had 0.11 fewer claims compared with nonadherent patients (P  less than  0.001). Importantly, patients with ≥ 6 SABA claims had 0.7 more OCS claims compared with patients with less than  6 claims for SABA (P  less than  0.001). The odds of having ≥ 6 SABA claims were higher for concurrent dual therapy users, older age, males, African Americans and higher number of nonstudy medications (P  less than  0.001). Dual therapy users, younger age, Hispanic ethnicity, and higher number of nonstudy medications were associated with an increase in OCS use (P  less than  0.005).

CONCLUSIONS

Adherence to long-term controller medications was suboptimal among patients with asthma. Adherent patients had fewer OCS claims, indicating that adherence to controller therapy is critical in preventing asthma exacerbations requiring OCS use. Although there was a positive relationship between adherence to long-term controller medication and SABA use, increased SABA use served as a predictor of increased OCS use, which indicates poor asthma control. Health care providers should be aware of OCS and SABA use among patients who are both adherent and nonadherent to asthma controller medications.

Antileukotriene Agents Versus Long-Acting Beta-Agonists in Older Adults with Persistent Asthma: A Comparison of Add-On Therapies

OBJECTIVES

To compare the effectiveness and cardiovascular safety of long-acting beta-agonists (LABAs) with those of leukotriene receptor antagonists (LTRAs) as add-on treatments in older adults with asthma already taking inhaled corticosteroids (ICSs).

DESIGN

Retrospective cohort study.

SETTING

Medicare fee-for-service (FFS) claims (2009-10) for a 10% random sample of beneficiaries continuously enrolled in Parts A, B, and D in 2009.

PARTICIPANTS

Medicare beneficiaries aged 66 and older continuously enrolled in FFS Medicare with Part D coverage with a diagnosis of asthma before 2009 treated exclusively with ICSs plus LABAs or ICSs plus LTRAs (N = 14,702).

MEASUREMENTS

The augmented inverse propensity-weighted estimator was used to compare the effect of LABA add-on therapy with that of LTRA add-on therapy on asthma exacerbations requiring inpatient, emergency, or outpatient care and on cardiovascular (CV) events, adjusting for demographic characteristics, comorbidities, and county-level healthcare-access variables.

RESULTS

The primary analysis showed that LTRA add-on treatment was associated with greater odds of asthma-related hospitalizations or emergency department visits (odds ratio (OR) = 1.4, P < .001), as well as outpatient exacerbations requiring oral corticosteroids or antibiotics (OR = 1.41, P < .001) than LABA treatment. LTRA add-on therapy was also less effective in controlling acute symptoms, as indicated by greater use of short-acting beta agonists (rate ratio = 1.58, P < .001). LTRA add-on treatment was associated with lower odds of experiencing a CV event than LABA treatment (OR = 0.86, P = .006).

CONCLUSION

This study provides new evidence specific to older adults to help healthcare providers weigh the risks and benefits of these add-on treatments. Further subgroup analysis is needed to personalize asthma treatments in this high-risk population.

Comparison of Health Care Utilization and Costs for Patients with Asthma by Severity and Health Insurance in Thailand

BACKGROUND

To compare health care utilization and cost by asthma severity and type of health insurance in Thailand.

METHODS

A retrospective cohort study using an electronic database was conducted in patients with asthma. Patients who were diagnosed with asthma from 2009 to 2011, had at least two subsequent health care encounters for asthma during the first six months after the first asthma diagnosis, and had at least 90 days of follow-up were included. The primary outcome was direct health care costs of inpatient and outpatient care. We compared outcomes between groups on the basis of a proxy of severity (mild/moderate severe asthma vs. high severe asthma) and type of health insurance using a multivariable generalized linear model. Covariates such as Patients' demographic characteristics, comorbidities, and concurrent medications were included in the model.

RESULTS

Among 1982 patients included, the average age was 40.3 ± 24.0 years, with 60.7% being males. A total of 1936 patients had mild/moderate severe asthma, whereas 46 patients had high severe asthma. There were 1293 patients under the Universal Coverage Scheme, 264 patients under Social Security Insurance, and 626 patients under the Civil Servant Medical Benefit Scheme (CSMBS). The average annual cost per patient was $598 ± $871. In adjusted analyses, the health care cost of patients with high severe asthma was $71 higher than that of patients with mild/moderate severe asthma (95% confidence interval $-131 to $274). The cost of patients under the CSMBS was $110 (95% confidence interval $29-$191) higher than that of patients under Universal Coverage Scheme.

CONCLUSIONS

Health care costs of patients with asthma were substantial and were higher in patients with high severe asthma and patients under the CSMBS.

Incidence of skin and soft tissue infections in ambulatory and inpatient settings, 2005-2010

BACKGROUND

The emergence of community-associated methicillin-resistant S. aureus was associated with dramatically increased skin and soft tissue infection (SSTI) incidence in the first few years of the 21(st) century in the U.S. However, subsequent trends are poorly understood.

METHODS

We examined ambulatory and inpatient data of over 48 million persons years aged 0-64 years from the HealthCore Integrated Research Database (HIRD) between 2005 and 2010. Data were extracted from medical, pharmacy, and eligibility databases. We quantified SSTI incidence, type, and complications and comparative incidence trends for urinary tract infections (UTIs) and pneumonia.

RESULTS

A total of 2,301,803 SSTIs were identified. Most SSTIs (95 %) were treated in the ambulatory setting and most (60 %) were categorized as abscesses or cellulitis. During the study period, SSTI incidence remained relatively stable from 47.9 (95 % CI: 47.8-48.1) cases/1,000 PY in 2005 to 48.5 cases/1,000 PY (95 % CI: 48.3-48.6) in 2010). Persons aged 45-64 years had the highest incidence of both ambulatory-treated and inpatient-treated SSTIs (51.2 (95 % CI: 51.1-51.3) and 3.87 (95 % CI: 3.84-3.90) cases/1,000 PY, respectively). SSTI complications such as myositis, gangrene, and sepsis occurred in 0.93 % (95 % CI: 0.92-0.94 %) and 16.92 % (95 % CI: 16.87-16.97 %) of ambulatory-treated and inpatient-treated patients, respectively. SSTI incidence was approximately twice that of UTIs and tenfold of that of pneumonia.

CONCLUSIONS

Among our large, diverse population of persons less than 65 years, SSTI incidence 2005 through 2010 has remained relatively constant at approximately 4.8 SSTIs per 100 person years, suggesting that previously observed increases in SSTI incidence remain sustained.

Long-acting beta-agonists plus inhaled corticosteroids safety: a systematic review and meta-analysis of non-randomized studies

Background

Although several systematic reviews investigated the safety of long-acting beta–agonists (LABAs) in asthma, they mainly addressed randomized clinical trials while evidence from non-randomized studies has been mostly neglected. We aim to assess the risk of serious adverse events in adults and children with asthma treated with LABAs and Inhaled Corticosteroids (ICs), compared to patients treated only with ICs, from published non-randomized studies.

Methods

The protocol registration number was CRD42012003387 (http://www.crd.york.ac.uk/Prospero). Literature search for articles published since 1990 was performed in MEDLINE and EMBASE. Two authors selected studies independently for inclusion and extracted the data. A third reviewer resolved discrepancies. To assess the risk of serious adverse events, meta-analyses were performed calculating odds ratio summary estimators using random effect models when heterogeneity was found, and fixed effect models otherwise.

Results

Of 4,415 candidate articles, 1,759 abstracts were reviewed and 220 articles were fully read. Finally, 19 studies met the inclusion criteria. Most of them were retrospective observational cohorts. Sample sizes varied from 50 to 514,216. The meta-analyses performed (69,939-624,303 participants according to the outcome considered) showed that odds ratio of the LABAs and ICs combined treatment when compared with ICs alone was: 0.88 (95% CI 0.69-1.12) for asthma-related hospitalization; 0.75 (95% CI 0.66-0.84) for asthma-related emergency visits; 1.02 (95% CI 0.94-1.10) for systemic corticosteroids; and 0.95 (95% CI 0.9-1.0) for the combined outcome.

Conclusions

Evidence from observational studies shows that the combined treatment of LABAs and ICs is not associated with a higher risk of serious adverse events, compared to ICs alone. Major gaps identified were prospective design, paediatric population and inclusion of mortality as a primary outcome.

The relationship between direct to consumer advertising (DTCA) and asthma-related emergency department use among Medicaid-enrolled children

OBJECTIVE

Asthma is a leading cause of emergency department (ED) visits. There has been much debate on the impact of direct to consumer advertising (DTCA) on healthcare. This study seeks to examine the association between DTCA expenditure and asthma-related ED use.

STUDY DESIGN

In this study, we combined Medicaid administrative data and a national advertising data on asthma medications. The sample size consisted of 180,584 Medicaid-enrolled children between the ages of 5 and 18 years who had an asthma diagnosis. Twenty percent of the Medicaid-enrolled children in the sample had asthma-related ED visits.

RESULTS

We found that DTCA expenditure is associated with a decrease in asthma-related ED visits (OR = 0.75; CI: 0.64-0.89). However, at higher levels of DTCA expenditure, the likelihood of asthma-related ED visits increases (OR = 1.25; CI: 1.05-1.49), indicating a decreased relationship between DTCA and asthma-related ED visits.

CONCLUSIONS

Our findings suggest that DTCA may be associated with improved health outcomes for Medicaid-enrolled children with asthma.

Economic and health effect of full adherence to controller therapy in adults with uncontrolled asthma: a simulation study

BACKGROUND

Adherence to evidence-based controller treatments for asthma is disappointingly low in many jurisdictions. Quantifying the burden associated with suboptimal adherence in patients with uncontrolled asthma will help establish the priorities for policymakers.

OBJECTIVE

We sought to quantify the benefits in the United States of improving adherence to controller therapies in adults with uncontrolled asthma in terms of health care costs and quality-adjusted life years (QALYs).

METHODS

A Markov model of asthma was created to simulate the effect of treatment with controller medications on asthma control and exacerbations over a 10-year time horizon. Health care costs and QALYs associated with the current level of adherence (status quo) were compared with a hypothetical scenario in which each patient with uncontrolled asthma at baseline will be fully adherent to an evidence-based controller therapy (the full-adherence scenario). We also evaluated the cost-effectiveness of adherence interventions as a function of their costs and improvement in the adherence.

RESULTS

The status quo level of asthma management was associated with $2,786 costs and 7.55 QALYs over 10 years, whereas the corresponding values for the full-adherence scenario were $5,973 and 7.68, respectively. Consequently, the incremental cost-effectiveness ratio of the full-adherence versus the status quo was $24,515/QALY. To be cost-effective, a program that improves adherence by 50% should cost less than $130 ($450) per person annually at a willingness-to-pay value of $50,000/QALY ($100,000/QALY). Inclusion of productivity loss in the analysis resulted in the full-adherence scenario being cost-saving.

CONCLUSION

Considering the extent of suboptimal adherence, our study shows that attempts in improving adherence to evidence-based therapies in patients with uncontrolled asthma can be associated with significant return on investment.

Electronic health record-based assessment of oral corticosteroid use in a population of primary care patients with asthma: an observational study

Background

Oral corticosteroid prescriptions are often used in clinical studies as an indicator of asthma exacerbations. However, there is rarely the ability to link a prescription to its associated diagnosis. The objective of this study was to characterize patterns of oral corticosteroid prescription orders for asthma patients using an electronic health record database, which links each prescription order to the diagnosis assigned at the time the order was placed.

Methods

This was a retrospective cohort study of the electronic health records of asthma patients enrolled in the Geisinger Health System from January 1, 2001 to August 23, 2010. Eligible patients were 12–85 years old, had a primary care physician in the Geisinger Health System, and had asthma. Each oral corticosteroid order was classified as being prescribed for an asthma-related or non-asthma-related condition based on the associated diagnosis. Asthma-related oral corticosteroid use was classified as either chronic or acute. In patient-level analyses, we determined the number of asthma patients with asthma-related and non-asthma-related prescription orders and the number of patients with acute versus chronic use. Prescription-level analyses ascertained the percentages of oral corticosteroid prescription orders that were for asthma-related and non-asthma-related conditions.

Results

Among the 21,199 asthma patients identified in the electronic health record database, 15,017 (70.8%) had an oral corticosteroid prescription order. Many patients (N = 6,827; 45.5%) had prescription orders for both asthma-related and non-asthma-related conditions, but some had prescription orders exclusively for asthma-related (N = 3,450; 23.0%) or non-asthma-related conditions (N = 4,740; 31.6%). Among the patients receiving a prescription order, most (87.5%) could be classified as acute users. A total of 60,355 oral corticosteroid prescription orders were placed for the asthma patients in this study—31,397 (52.0%) for non-asthma-related conditions, 24,487 (40.6%) for asthma-related conditions, and 4,471 (7.4%) for both asthma-related and non-asthma-related conditions.

Conclusions

Oral corticosteroid prescriptions for asthma patients are frequently ordered for conditions unrelated to asthma. A prescription for oral corticosteroids may be an unreliable marker of asthma exacerbations in retrospective studies utilizing administrative claims data. Investigators should consider co-morbid conditions for which oral corticosteroid use may also be indicated and/or different criteria for assessing oral corticosteroid use for asthma.

Skin and soft tissue infections and associated complications among commercially insured patients aged 0-64 years with and without diabetes in the U.S

Introduction

Skin and soft tissue infections (SSTIs) are common infections occurring in ambulatory and inpatient settings. The extent of complications associated with these infections by diabetes status is not well established.

Methods

Using a very large repository database, we examined medical and pharmacy claims of individuals aged 0–64 between 2005 and 2010 enrolled in U.S. health plans. Diabetes, SSTIs, and SSTI-associated complications were identified by ICD-9 codes. SSTIs were stratified by clinical category and setting of initial diagnosis.

Results

We identified 2,227,401 SSTI episodes, 10% of which occurred in diabetic individuals. Most SSTIs were initially diagnosed in ambulatory settings independent from diabetes status. Abscess/cellulitis was the more common SSTI group in diabetic and non-diabetic individuals (66% and 59%, respectively). There were differences in the frequencies of SSTI categories between diabetic and non-diabetic individuals (p<0.01). Among SSTIs diagnosed in ambulatory settings, the SSTI-associated complication rate was over five times higher in people with diabetes than in people without diabetes (4.9% vs. 0.8%, p<0.01) and SSTI-associated hospitalizations were 4.9% and 1.1% in patients with and without diabetes, respectively. Among SSTIs diagnosed in the inpatient setting, bacteremia/endocarditis/septicemia/sepsis was the most common associated complication occurring in 25% and 16% of SSTIs in patients with and without diabetes, respectively (p<0.01).

Conclusions

Among persons with SSTIs, we found SSTI-associated complications were five times higher and SSTI-associated hospitalizations were four times higher, in patients with diabetes compared to those without diabetes. SSTI prevention efforts in individuals with diabetes may have significant impact on morbidity and healthcare resource utilization.

Comparative outcomes of leukotriene receptor antagonists and long-acting β-agonists as add-on therapy in asthmatic patients: a population-based study

BACKGROUND

Recent evidence suggests that the use of leukotriene receptor antagonists (LTRAs) in addition to inhaled corticosteroids (ICSs) in asthmatic patients provides comparable benefits to the addition of long-acting β-agonists (LABAs) to ICSs.

OBJECTIVE

We sought to compare, in a unified framework, adherence, outcomes, and costs associated with ICS+LTRA versus ICS+LABA as step-up therapies for asthma.

METHODS

Using the administrative databases of British Columbia, Canada (years 1997-2007), we created a propensity score-matched sample of asthmatic patients (12-45 years old) receiving ICS+LTRA therapy versus ICS+LABA therapy after a period of monotherapy with an ICS. We compared the outcomes using 2 analyses: an intention-to-treat (ITT) analysis that followed subjects for a fixed period of 2 years and an uninterrupted treatment analysis that followed subjects for as long as they continuously dispensed their index medications.

RESULTS

The matched cohort consisted of 1032 subjects in each group (mean age at entry, 27.4 years; 52.5% female). Adherence, which was defined as the proportion of days covered, was higher in the ICS+LABA group compared with the ICS+LTRA group. In both the ITT and uninterrupted treatment analyses, use of ICS+LTRA therapy was associated with more asthma-related outpatient visits, asthma-related medication dispensations, and dispensation of reliever medications. Dispensation of oral corticosteroids and rate of asthma exacerbations were higher in the ICS+LTRA group in the uninterrupted treatment analysis but not in the ITT analysis.

CONCLUSIONS

In a real-world clinical setting subjects were more adherent to ICS+LABA therapy than ICS+LTRA therapy. ICS+LABA therapy seems to be more effective than ICS+LTRA therapy in the management of asthma, regardless of adherence.