Factors associated with patient visits to the emergency department for asthma therapy

Health-Related Quality of Life of Asthmatic Patients in Al-Baha City, Saudi Arabia

Introduction According to disability-adjusted life years (DALY), bronchial asthma (BA) is rated 28th among the top causes of disease burden globally and among the most significant reasons for years lived with disability. Internationally, 300 million people have asthma, and another 100 million individuals may develop it by 2025. In Al-Baha City, where environmental factors such as dust and pollen levels can exacerbate asthma symptoms, understanding and addressing the health-related quality of life of asthmatic patients is crucial. Understanding the health-related quality of life of asthmatic patients can inform public health policies and initiatives aimed at reducing environmental triggers and promoting better asthma management in the city. Objectives The study aims to assess the impact of asthma regarding physical, emotional, and social activities that affect health-related quality of life.  Subjects and methods A cross-sectional study was conducted from January 2023 to May 2023 at King Fahad Hospital in Al-Baha City, Saudi Arabia. The study used a Mini Asthma Quality of Life Questionnaire that measures physical, emotional, and social activities that affect health-related quality of life.  Results One hundred and fifty-one out of 185 participants responded, yielding a response rate of 81.6%. The average age of the participants was 52, with a standard deviation of 15.4 years. Participants' responses regarding symptoms related to the environment during the last two weeks indicated "all the time" experiencing feeling bothered by or having to avoid cigarette smoke (n=104, 69%) and dust (n=92, 61%) in the environment. Moreover, considering emotion-related symptoms, 54% reported they did not feel afraid of not having their asthma medication available. Similarly, 46% reported never feeling frustrated because of asthma, whereas 3.3% of the participants documented hardly ever feeling frustrated. Regarding social activity limitations, 44 individuals (29%) reported no limits in these activities, while 43 (28%) reported being completely limited. While there were limitations in work-related activities, 42 participants (28%) reported no restrictions, whereas 34 (23%) reported being completely limited.  Conclusion The study findings highlight a concern about suboptimal asthma control and the need to attain more satisfactory levels of asthma management.

The Saudi initiative for asthma - 2024 update: Guidelines for the diagnosis and management of asthma in adults and children

The Saudi Initiative for Asthma 2024 (SINA-2024) is the sixth version of asthma guidelines for the diagnosis and management of asthma for adults and children that was developed by the SINA group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up-to-date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA Panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is aligned for age groups: adults, adolescents, children aged 5-12 years, and children aged <5 years. SINA guidelines have focused more on personalized approaches reflecting a better understanding of disease heterogeneity with the integration of recommendations related to biologic agents, evidence-based updates on treatment, and the role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and the current situation at national and regional levels. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.

Impact of adherence to treatment with inhaled corticosteroids/long-acting β-agonists on asthma outcomes in the United States

BACKGROUND

Suboptimal adherence to maintenance medication has been associated with poor outcomes in asthma. This study examined single-inhaler inhaled corticosteroid (ICS)/long-acting β2 agonist (LABA) adherence and asthma-related outcomes.

METHODS

This retrospective observational study of patients with asthma initiating ICS/LABA used data from IQVIA PharMetrics Plus (1 January 2014-31 March 2019). Patients included were ⩾18 years old and had ⩾12 months continuous eligibility before, and ⩾180 days follow-up after, the index date. Adherence was measured as proportion of days covered ([PDC] adherent ⩾ 0.8; non-adherent <0.8) each quarter, with outcomes measured each subsequent quarter. Endpoints were asthma-related overall and severe (inpatient/emergency department [ED] visit) exacerbations, rescue medication use, and asthma-related healthcare resource utilization and costs. Regression models evaluated associations between adherence and outcomes, controlling for repeated measures and differences in baseline characteristics.

RESULTS

Overall, 50,037 patients were included (mean age 45.3 years; mean follow-up 23.3 months). Adherent patients were less likely to experience asthma-related overall (adjusted odds ratio [aOR] 95% confidence interval [CI]: 0.942 [0.890, 0.998]; p = 0.041), or severe exacerbations (aOR [95% CI]: 0.778 [0.691, 0.877]; p < 0.001) per quarter versus non-adherent patients. Adherent patients had lower severe exacerbation rates (adjusted rate ratio [aRR] [95% CI]: 0.792 [0.702, 0.893]; p < 0.001) but similar overall exacerbation rates (aRR [95% CI]: 0.993 [0.945, 1.044]; p = 0.783) versus non-adherent patients. The odds of rescue medication use were lower per 20% PDC increase (aOR [95% CI] short-acting β2 agonist: 0.991 [0.985, 0.996]; p = 0.001; oral corticosteroid: 0.988 [0.982, 0.995]; p < 0.001). Adherent patients were less likely to visit EDs per quarter (aOR [95% CI]: 0.775 [0.680, 0.883]; p < 0.001) and odds of hospitalization were lower per 20% PDC increase (aOR [95% CI]: 0.930 [0.881, 0.982]; p = 0.009). Across most measures, adherent patients incurred lower costs.

CONCLUSION

This real-world study highlights the short-term clinical and economic benefits of ICS/LABA adherence in asthma, particularly in reducing severe exacerbations.

Real-life Cretan asthma registry focused on severe asthma: On behalf of 'The Cretan registry of the use of Biologics in Severe Asthma'

Asthma diagnosis and management remains a challenging task for the medical community. The aim of the present study was to present the functional and inflammatory profiles of patients with difficult-to-treat asthma in a real-life clinical setting referred to the specialized asthma clinic at the University Hospital of Heraklion. The registry included a cohort of 267 patients who were referred to the severe asthma clinic. Patients were assessed with emphasis on the history of allergies, nasal polyposis or other comorbidities. Blood testing for eosinophils counts and total and specific IgE, and pulmonary function tests were performed at baseline. The median age of patients with asthma was 55 years old, 68.5% were women and 58.3% were never smokers. The vast majority presented with late onset asthma (75.7%), whereas eight (3%) patients were on oral corticosteroids. The median number of exacerbations during the last 12 months was 1 (0-3). Furthermore, 50.7% of patients had a positive serum allergy test, the median eosinophil count was 300 (188-508.5) cells/µl of blood and median total IgE level was 117.5 (29.4-360.5) IU/ml. Patients were retrospectively grouped in the following categories: Group 1, mild-moderate asthma; group 2, patients prescribed a step 4 or 5 asthma therapy according to Global Initiative for Asthma; and group 3, patients on biologic agents. Group 1 had significantly higher FEV1% than groups 2 and 3 (93.4 vs. 79.9 and 79.4%, respectively; P<0.001). Finally, the median Asthma Control Questionnaire 7 (ACQ7) score was 1.14, with patients from groups 2 and 3 presenting higher ACQ7 scores compared with group 1 patients as expected (1.1 and 2.1 vs. 0.7, respectively; P<0.001). To the best of our knowledge, this was the first real-life asthma study in Crete that demonstrated that severe asthmatics predominantly have late-onset asthma with airflow obstruction and uncontrolled symptoms.

Uncontrolled Asthma: Unmet Needs in the Management of Patients

The recent scientific research has provided clinicians with the tools for substantially upgrading the standard of care in the field of bronchial asthma. Nevertheless, satisfactory asthma control still remains an unmet need worldwide. Identifying the major determinants of poor control in different asthma severity levels represents the first step towards the improvement of the overall patients' management. The present review aims to provide an overview of the main unmet needs in asthma control and of the potential tools for overcoming the issue. Implementing a personalized medicine approach is essential, not only in terms of pharmacological treatments, biologic drugs or sophisticated biomarkers. In fact, exploring the complex profile of each patient, from his inflammation phenotype to his preferences and expectations, may help in filling the gap between the big potential of currently available treatments and the overall unsatisfactory asthma control. Telemedicine and e-health technologies may provide a strategy to both optimize disease assessment on a regular basis and enhance patients' empowerment in managing their asthma. Increasing patients' awareness as well as the physicians' knowledge about asthma phenotypes and treatment options besides corticosteroid probably represent the key and more difficult goals of all the players involved in asthma management at every level.

Effects of body weight and posture on pulmonary functions in asthmatic children

Background

Asthma is one of the most common chronic illnesses in the world. Pulmonary function tests are important tools in monitoring of asthmatic patients. There is need for investigating if spirometric indices were affected by body weight or posture or not.

Objectives

The aim of this study was to evaluate the spirometric measurements in standing and sitting positions in a group of Egyptian asthmatic children with different body weights.

Methods

Sixty patients were included. They were stable asthmatics and were following up in the allergy clinic. Spirometry was conducted at pulmonary functions laboratory of Pediatric Allergy and Chest Unit of New Children's University Hospital, Cairo. The one-way analysis of variance was used to test the differences between groups. The Duncan multiple comparison test was used to test the significant differences between each pair of groups.

Results

The study found that sitting FEV1/FVC is significantly lower in overweight/obese asthmatic children compared to normal weight asthmatic children (p value=0.046).

Conclusion

There was no effect of weight on standing spirometric data. Weight showed significant negative correlation with asthma control level. We concluded that in overweight/obese asthmatic children, spirometric position might affect the results.

Risk factors for asthma exacerbation among Hajj pilgrims: a case study from DKI Jakarta, Indonesia

BACKGROUND Hajj pilgrims are prone to asthma exacerbation because of the high transmission rate of respiratory infections, severe environmental factors, and high-intensity activities during the Hajj. Well-controlled asthma status and preventive efforts prior to the Hajj could reduce such exacerbations. This research aimed to determine the risk factors of asthma exacerbation during the Hajj to help establish preventive measures. METHODS Participants were evaluated at community health centers (puskesmas) through history taking, physical examination, and spirometry. The risk factors examined included a history of exacerbation one year before the Hajj, obesity, comorbidities (e.g., diabetes mellitus, hypertension, coronary heart disease), lung function, smoking, fitness level, and influenza vaccination. Asthma exacerbation while in Saudi Arabia was determined through direct observations by authors and physicians assigned to Hajj pilgrim groups and analysis of data obtained from questionnaires distributed to the pilgrims before their departure. Odds ratios (OR) were calculated using logistic regression. RESULTS Among 68 pilgrims with asthma, exacerbation occurred in 27 (40%) pilgrims. Risk of asthma exacerbation was significantly increased in the pilgrims with a history of exacerbation one year before the Hajj (OR = 4.27; 95% confidence interval [CI] = 1.156–15.829; p = 0.029) and obesity grade II (OR = 4.02; 95% CI = 1.151–14.097; p = 0.029). Other factors, including smoking, comorbidities, lung function, fitness level, obesity grade I, and influenza vaccination, were not significantly related to exacerbation. CONCLUSIONS Obesity grade II and history of asthma exacerbation one year before the Hajj are strong factors for asthma exacerbation during Hajj pilgrims.

Improving asthma care with Asthma-COPD Afterhours Respiratory Nurse at Emergency (A-CARE)

BACKGROUND

Emergency departments (ED) are important providers of asthma care, particularly after-hours. We identified gaps for quality improvement such as suboptimal adherence rates to three key recommendations from the Global Initiative for Asthma (GINA) guidelines for discharge management asthma guidelines. These were: the prescription of oral and inhaled corticosteroids (OCS and ICS) and issuance of outpatient follow-up for patients discharged from the ED.

AIM

To achieve an adherence rate of 80% to GINA guidelines for ED discharge management by providing after-hours asthma counselling services.

METHODS

We implemented Asthma-COPD Afterhours Respiratory Nurse at Emergency (A-CARE) according to the Plan-Do-Study-Act (PDSA) framework to provide after-hours asthma counselling and clinical decision support to ED physicians three nights a week. Data on adherence rates to the GINA guidelines were collected and analysed on a run chart.

RESULTS

After 17 months' follow-up, a sustained improvement was observed in patients reviewed by A-CARE in the median adherence rates to OCS prescription (58% vs 86%), ICS initiation (27% vs 67%) and issuance of follow-up (69% vs 92%), respectively. The overall impact was, however, limited by a suboptimal referral rate to A-CARE (16%) in a clinical audit of all ED patients with asthma. Nonetheless, in this audit, attendance rates for patients referred to our respiratory department for follow-up were higher in those receiving asthma counselling compared with those who did not (41.7% vs 15.9%, p=0.0388).

CONCLUSION

Sustained improvements in the adherence rates to guidelines were achieved for patients reviewed by A-CARE but were limited in overall impact due to suboptimal referral rate. We plan to improve the quality of asthma care by implementing further PDSA cycles to increase the referral rates to A-CARE.

Evaluation of four disease management programs: evidence from blue cross blue shield of Louisiana

Aims: Chronic diseases impose a substantial healthcare burden. This study sought to evaluate the clinical and economic impact of new disease management (DM) programs, targeting four major chronic disease groups: diabetes, coronary heart disease (CHD)/hypertension (HTN), asthma/chronic obstructive pulmonary disease (COPD), and congestive heart failure (CHF)/chronic kidney disease (CKD).Materials and methods: Between March 1, 2015, and February 28, 2018, members with Blue Cross Blue Shield of Louisiana insurance were contacted and enrolled in a DM program if they were aged 18 years through 64 years, eligible for a DM program, and had not been previously enrolled in a DM program. Active enrollees of a DM program ("IN" group) were compared to members who were not yet enrolled ("OUT" group). Average per member per month (PMPM) costs were aggregated annually to document any descriptive trends. Multivariable model estimates were used to compare PMPM costs for all IN subjects and all OUT subjects. Total medical savings were evaluated for the following time intervals: 1-12 months, 13-24 months, and 25-36 months.Results: For all four DM programs, average costs PMPM trended upward over time for the OUT cohort, while they remained relatively stable for the IN cohort. Some evidence also showed that DM programs improved clinical outcomes, such as hemoglobin A1c values. A difference in difference analysis showed PMPM savings for all four programs combined of $31.61, $50.45, and $53.72 after 1, 2, and 3 years, respectively. Multivariable modeling results showed total savings after 3 years of $14,460,174 for all DM programs combined.Limitations: Although multivariable models adjusted for several clinical, demographic, and economic characteristics; it is possible that some important confounders were missing due to lack of data.Conclusions: DM programs implemented to control diabetes, CHD/HTN, CHF/CKD, and asthma/COPD are cost-effective and show some evidence of improved clinical outcomes.

Impact of asthma control on different age groups in five Latin American countries

Background

Asthma is a chronic airway inflammatory condition of the airway and is classified as controlled, partially controlled, and uncontrolled. Patients with uncontrolled asthma are at greater risk for hospitalizations and visits to emergencies, and the condition has greater impact on their daily lives. The aim of this study was to evaluate asthma control, the use of health resources, and asthma's impact on the activities of daily living of patients with different age groups in 5 Latin American countries.

Methods

This was a retrospective analysis of The Latin America Asthma Insights and Management (LA AIM) study carried out in Argentina, Brazil, Mexico, Venezuela, and Puerto Rico. Asthmatics were splited into 3 age groups: 12–17, >17–40 and > 40 years old. An interview face to face was carried out and patients answered a questionnaire of 53 questions related to 5 main domains of asthma: symptoms, impact of asthma on daily living activities, patients' perceptions of asthma control, exacerbations, and treatment/medication.

Results

A total of 2167 asthmatics were interviewed. There was a low percentage of controlled patients (mean 9%) in all 3 groups with no particular difference among the five countries, but Venezuelan patients had a 71% chance of having uncontrolled asthma (p < 0.001).

Conclusion

In the 3 age groups, patients experienced poor asthma control, with no significant differences among the countries. Patients who used control medication had a greater chance of controlling their asthma, and those who had emergency health care visits had a greater chance of having uncontrolled asthma.

Reasons for recurrent visits of emergency department by pediatric asthmatic patients in Al-Qassim Region

INTRODUCTION

Bronchial asthma has been the subject of controversy for several decades. The Global Initiative for Asthma (GINA) describes asthma as "a heterogeneous disease, usually characterized by chronic airway inflammation. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness, and cough that vary over time and in intensity, together with variable expiratory airflow limitation." Although not strictly a definition, this description captures the essential features for clinical purposes. Bronchial asthma is defined as a chronic lung disease characterized by airway obstruction, inflammation and hyper-responsiveness that leads to symptoms like wheezing, coughing, chest tightening and shortness of breath especially at night or in the morning. It is one of the most common medical emergency conditions in the pediatrics all over the world. The primary care provider is the cornerstone of this study; his/her awareness about reasons of recurrent visits of emergency department by pediatric asthmatic patients would help to reduce the frequency of ED visits, which lead to minimizing the load on hospitals by addressing patient's concerns, correcting some misconceptions, and improving the patients' and their parents' knowledge and awareness.

AIM

This study aims to identify the predictors associated with frequent visits to the ED among asthmatic children at main governmental hospitals in Al-Qassim Region.

MATERIALS AND METHODS

This is a cross-sectional study conducted at three different emergency departments in Qassim region such as Maternity and Children Hospital in Buraidah, King Saud Hospital in Unayzah, and Alrass General Hospital. A validated interview questionnaire was used which includes general demographic characteristics, whether the caregiver has been educated about asthma as a disease, about the use of medicines and inhalers, about the management of symptoms, reasons for using the ED for asthma care, prescription received during the ED visit, and referral from ED.

RESULTS

Children with less than 3 visits to ED for the last 6 months were 70.3% while those with 3 or more visits were 29.7%. Nearly all patients (88.3%) had already been diagnosed with asthma with their attending physician. The most commonly known medication was beta-agonist (62%) while the most common reason for ED visit was "to obtain oxygen" and "to obtain a bronchodilator." The prevalence of ED referral to PHC was low (9.7%). Based on the adjusted regression model, we observed that medication used (AOR = 1.760, P = 0.046) and referral from ED (AOR = 3.711, P < 0.001) were the significant factors being associated with 3 or more visits to ED.

CONCLUSION

Recurrent ED visitation of children with asthma was moderately low. Furthermore, medication used and referral from ED were identified as the predictors being associated with recurrent visits to ED. Further research is needed in order to validate the predictors being associated with recurrent ED visitation of asthmatic children in our region.

Determinants of poorly controlled asthma among asthmatic patients in Jimma University Medical Center, Southwest Ethiopia: a case control study

OBJECTIVE

The aim of this study was to assess determinants of poorly controlled asthma among asthmatic patients on follow up at Jimma University Medical Center, Southwest Ethiopia. A facility based case control study involving chart review and patient interview was conducted from April 01/2017 to May 30/2017. Consecutive sampling method was used to select 121 cases and 121 controls. Descriptive statistics were used to present socio demographic data and drug prescription pattern while logistic regression was used to identify predictors of poorly controlled asthma.

RESULTS

From a total of 242 studied asthmatic patients, 52.9% of controls and 44.6% of cases were males. Poor knowledge about asthma [Adjusted odd ratio(AOR) = 7.30; 95% confidence interval (CI) 1.72-30; P = 0.007], negative attitude about asthma [AOR = 5.10; 95% CI 1.40-18.7; P = 0.014], moderate asthma [AOR = 13.47; 95% CI 2.69-47.23; P = 0.002] and non-adherence to inhaled corticosteroid (ICS) [AOR = 8.52%; 95% CI 2.41-13.45; P = 0.001] were determinants of poorly controlled asthma.

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

Background

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

Methods

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

Results

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

Conclusions

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

The Saudi Initiative for Asthma - 2019 Update: Guidelines for the diagnosis and management of asthma in adults and children

This is the fourth version of the updated guidelines for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up to date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is now more aligned for different age groups. The guidelines have focused more on personalized approaches reflecting better understanding of disease heterogeneity with integration of recommendations related to biologic agents, evidence-based updates on treatment, and role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and current situation at national and regional levels. There is also an emphasis on patient–doctor partnership in the management that also includes a self-management plan.

Care transition interventions for children with asthma in the emergency department

The emergency department (ED) is a critical point of identification and treatment for some of the most high-risk children with asthma. This review summarizes the evidence regarding care transition interventions originating in the ED for children with uncontrolled asthma, with a focus on care coordination and self-management education. Although many interventions on care transition for pediatric asthma have been tested, only a few were actually conducted in the ED setting. Most of these targeted both care coordination and self-management education but ultimately did not improve attendance at follow-up appointments with primary care providers, improve asthma control, or reduce health care utilization. Conducting any ED-based intervention in the current environment is challenging because of the many demands on ED providers and staff, poor communication within and outside of the medical sector, and caregiver/patient burden. The evidence to date suggests that ED care transition interventions should consider expanding beyond the ED to bridge the multiple sectors children with asthma navigate, including health care settings, homes, schools, and community spaces. Patient-centered approaches may also be important to ensure adequate intervention design, enrollment, retention, and evaluation of outcomes important to children and their families.

[Asthma control in patients attending primary care in Spain (Actis study)]

Objetivo

Evaluar la prevalencia de asma no controlada (puntuación < 20 en el Asthma Control Test [ACT]) en la práctica clínica habitual en España.

Diseño

Estudio observacional, transversal.

Emplazamiento

Cincuenta y ocho centros de atención primaria de 13 comunidades autónomas.

Participantes

Pacientes asmáticos atendidos por consulta administrativa sin empeoramiento subjetivo (grupo A) o por empeoramiento de sus síntomas (grupo B).

Mediciones principales

Características sociodemográficas (edad, sexo, educación y tabaquismo), nivel de gravedad del asma según el médico, terapia actual para el asma, enfermedades concomitantes, utilización de recursos sanitarios (consultas, hospitalizaciones y urgencias), absentismo laboral y escolar, puntuación ACT y adherencia al tratamiento.

Resultados

Se incluyeron 376 pacientes del grupo A y 262 del grupo B. El 59% eran mujeres, edad media de 45 años, 21% fumadores y tiempo medio de evolución del asma 8,9 años. El 87% usaban agonistas beta-2 de corta duración, el 62% beta-2 de larga duración asociados con corticoides inhalados y el 13,8% corticoides inhalados regularmente. Se observó mal control del asma en el 75,6% del grupo B y en el 23,4% del grupo A; solo el 5,3% del grupo A presentaba control total (ACT = 25). Un peor control del asma se asociaba significativamente con mayor duración de la enfermedad y mayor uso de recursos.

Conclusiones

La prevalencia de asma no controlada en pacientes que acuden a la consulta de atención primaria por empeoramiento de sus síntomas continúa siendo muy elevada. El mal control del asma se asocia con un elevado uso de recursos e impacta significativamente en la carga de la enfermedad.

The Need for a Well-Organized, Video-Assisted Asthma Education Program at Korean Primary Care Clinics

BACKGROUND

The purpose of this study was to assess the effect of our new video-assisted asthma education program on patients' knowledge regarding asthma and asthma control.

METHODS

Adult asthmatics who were diagnosed by primary care physicians and followed for at least 1 year were educated via smart devices and pamphlets. The education sessions were carried out three times at 2-week intervals. Each education period lasted at most 5 minutes. The effectiveness was then evaluated using questionnaires and an asthma control test (ACT).

RESULTS

The study enrolled 144 patients (mean age, 56.7±16.7 years). Half of the patients had not been taught how to use their inhalers. After participating in the education program, the participants' understanding of asthma improved significantly across all six items of a questionnaire assessing their general knowledge of asthma. The proportion of patients who made errors while manipulating their inhalers was reduced to less than 10%. The ACT score increased from 16.6±4.6 to 20.0±3.9 (p<0.001). The number of asthmatics whose ACT score was at least 20 increased from 45 (33.3%) to 93 (65.3%) (p<0.001). The magnitude of improvement in the ACT score did not differ between patients who received an education session at least three times within 1 year and those who had not. The majority of patients agreed to the need for an education program (95.8%) and showed a willingness to pay an additional cost for the education (81.9%).

CONCLUSION

This study indicated that our newly developed education program would become an effective component of asthma management in primary care clinics.

Asthma quality of life in Saudi Arabia: Gender differences

OBJECTIVES

To explore potential gender differences in the factors associated with asthma-specific quality of life (AQL).

METHODS

A cross-sectional study of consecutive series of adult patients attending primary care centers at three major hospitals in Riyadh, Saudi Arabia, was performed. AQL was measured using a standardized version of the AQL questionnaire (min = 1, max = 7), with higher scores indicating a better AQL. Multiple linear regression analysis was performed.

RESULTS

The mean AQL was 4.3 (standard deviation [SD] = 1.5) for males and 4.0 (SD = 1.3) for females (p = 0.113). With each unit increase in asthma control, the AQL improved by 0.19 points (95% confidence interval [CI] = 0.14-0.23) in men and by 0.21 points (95% CI = 0.16-0.25) in women. Daily tobacco smoking was associated with a 0.72 point (95% CI = 0.14-1.30) decrease in the AQL among males. Women who had a household member who smoked inside the house had a significantly lower AQL (B = -0.59, 95% CI = -1.0 - -0.19). A monthly household income of 25,000 Saudi Riyals or more was associated with a better AQL among men (B = 0.51, 95% CI = 0.01-1.01), whereas being employed exhibited a protective effect in women (B = 0.48, 95% CI = 0.11-0.84). Higher levels of perceived asthma severity were associated with better AQL in women (B = 0.82, 95% CI = 0.36-1.28).

CONCLUSIONS

Our findings revealed gender-specific differences in the correlates of AQL in Saudi Arabia, particularly in tobacco exposure, socio-economic factors and perceived asthma severity.

Impact of Market Competition on Continuity of Care and Hospital Admissions for Asthmatic Children: A Longitudinal Analysis of Nationwide Health Insurance Data 2009-2013

BACKGROUND

Ambulatory care-sensitive conditions, including asthma, can be managed with timely and effective outpatient care, thereby reducing the need for hospitalization.

OBJECTIVE

This study assessed the relationship between market competition, continuity of care (COC), and hospital admissions in asthmatic children according to their health care provider.

METHODS

A longitudinal design was employed with a 5-year follow-up period, between 2009 and 2013, under a Korean universal health insurance program. A total of 253 geographical regions were included in the analysis, according to data from the Korean Statistical Office. Data from 9,997 patients, aged ≤ 12 years, were included. We measured the COC over a 5-year period using the Usual Provider Continuity (UPC) index. Random intercept models were calculated to assess the temporal and multilevel relationship between market competition, COC, and hospital admission rate.

RESULTS

Of the 9,997 patients, 243 (2.4%) were admitted to the hospital in 2009. In the multilevel regression analysis, as the Herfindahl-Hirschman Index increased by 1,000 points (denoting decreased competitiveness), UPC scores also increased (ß = 0.001; p < 0.0001). In multilevel logistic regression analysis, the adjusted odds ratio (OR) for hospital admissions for individuals with lower COC scores (≥ 2 ambulatory visits and a UPC index score of < 1) was 3.61 (95% CI: 2.98-4.38) relative to the reference group (≥ 2 ambulatory visits and a UPC index score of 1).

CONCLUSIONS

Market competition appears to reduce COC; decreased COC was associated with a higher OR for hospital admissions.

Factors associated with patient visits to the emergency department for asthma therapy in Pakistan

BACKGROUND

Acute asthma is a chronic condition affecting people of all ages around the world and hence, is one of the leading causes of emergency department (ED) visits and hospital admissions globally. Most of them are related to poor patient practices and a weak healthcare system. The aim of our study was to assess the reasons for the increased usage of the ED by asthmatic patients in Pakistan.

METHODS

A cross-sectional study was conducted on 600 asthmatic patients reporting to the ED of Civil Hospital Karachi over a 6-month period. The consenting patients were given a questionnaire to fill and the following data was collected: demographic information, duration of the disease, medications prescribed the, frequency of and reasons for outpatient clinic and ED visits for issues related to asthma.

RESULT

According to our results most of the participants visited the ED to obtain a nebulized bronchodilator (90 %) or oxygen (79.5 %). Moreover, 44.8 % of the people visited the ED to get treatment without any delay and 24.0 % considered that the severity of asthma does not allow the patient to wait for clinic visits. Strikingly, 92.8 % claimed that inhaled corticosteroid therapy treatment should be stopped when patients feel better. Irregular follow ups with clinics, low education about asthma and an education level higher than a Bachelors degree were the most important factors associated with three or more ED visits per year, p values = 0.0289, 0.0110 and 0.0150 respectively.

CONCLUSION

This study identifies several preventable risk factors responsible for recurrent visits to the ED by asthmatic patients in Pakistan.

The Saudi Initiative for Asthma - 2016 update: Guidelines for the diagnosis and management of asthma in adults and children

This is an updated guideline for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of SINA is to have guidelines that are up to date, simple to understand and easy to use by nonasthma specialists, including primary care and general practice physicians. SINA approach is mainly based on symptom control and assessment of risk as it is the ultimate goal of treatment. The new SINA guidelines include updates of acute and chronic asthma management, with more emphasis on the use of asthma control in the management of asthma in adults and children, inclusion of a new medication appendix, and keeping consistency on the management at different age groups. The section on asthma in children is rewritten and expanded where the approach is stratified based on the age. The guidelines are constructed based on the available evidence, local literature, and the current situation in Saudi Arabia. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.

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.

Poor asthma education and medication compliance are associated with increased emergency department visits by asthmatic children

BACKGROUND:

Acute exacerbations of bronchial asthma remain a major cause of frequent Emergency Department (ED) visits by pediatric patients. However, other factors including psychosocial, behavioural and educational, are also reportedly associated with repetitive ED visits. Therefore, it is necessary to determine whether such visits are justifiable.

OBJECTIVE:

The objective of this cross-sectional study was to identify risk factors associated with visits to ED by asthmatic children.

METHODS:

Asthmatic children (n = 297) between 1-17 years old were recruited and information collected at the time of visiting an ED facility at two major hospitals.

RESULTS:

Asthmatic patients visited the ED 3.9 ΁ 3.2 times-per-year, on average. Inadequately controlled asthma was perceived in 60.3% of patients. The majority of patients (56.4%) reported not receiving education about asthma. Patients reflected misconceptions about the ED department, including the belief that more effective treatments are available (40.9%), or that the ED staff is better qualified (27.8%). About half of patients (48.2%) visited the ED because of the convenience of being open 24 hours, or because they are received immediately (38.4%). Uncontrolled asthma was associated with poor education about asthma and/or medication use. Patients educated about asthma, were less likely to stop corticosteroid therapy when their symptoms get better (OR:0.55; 95% CI:0.3-0.9; P = 0.04).

CONCLUSION:

This study reports that most patients had poor knowledge about asthma and were using medications improperly, thus suggesting inefficient application of management action plan. Unnecessary and frequent visits to the ED for asthma care was associated with poor education about asthma and medication use. Potential deficiencies of the health system at directing patients to the proper medical facility were uncovered and underline the necessity to improve education about the disease and medication compliance of patients and their parents/guardians.

Rs37972 and rs37973 single-nucleotide polymorphisms in the glucocorticoid-inducible 1 gene are not associated with asthma risk in a Saudi Arabian population

OBJECTIVE

Rs37972 and rs37973 variants in the glucocorticoid-induced transcript 1 gene have been associated with inhaled glucocorticosteroid responsiveness in asthmatics; however, some discrepancies have been also reported. This study aims to determine whether rs37972 and rs37973 SNPs are associated with asthma risk in Saudi Arabian asthmatics.

METHODS

Two-hundred seventy-one diagnosed asthmatics (3-65 years old) and 387 healthy control subjects of equivalent age were recruited. DNA from peripheral blood was purified, and genotyping of rs37972 and rs37973 SNPs was performed by PCR amplification of segments of interest, followed by Sanger sequencing.

RESULTS

The global frequencies of the minor (risk) alleles were 28% ("T" allele, rs37972) and 30% ("G" allele, rs37973). Yates-corrected Chi-square (χ(2)) tests revealed significant differences between asthmatic and healthy groups, in allele frequencies for rs37973 SNP only (χ(2) = 3.98, Yates' p value = 0.046). Regarding genotype frequencies, a significant difference between asthmatic and healthy groups was observed for variant rs37972 only (χ(2) = 8.19, Yates' p value = 0.016). To determine a possible association of the minor "T" and "G" alleles with asthma, both the recessive and dominant genetic models were tested. For rs37973, none of the genotypes were significantly associated with asthma. Concerning rs37972, the dominant model (C/T + T/T versus C/C) indicated a significant "protective" association with asthma, in which C/T + T/T individuals had lower odds of being asthmatics than C/C individuals (OR = 0.67; 95% CI = 0.48-0.94; p = 0.019*).

CONCLUSIONS

The minor alleles "T" and "G" of rs37972 and rs37973 SNPs, respectively, were not significantly associated with increased asthma risk in asthma patients from Saudi Arabia.

Frequent attenders to the ED: patients who present with repeated asthma exacerbations

BACKGROUND

Asthma has been reported as one of the main causes of frequent attendance to the emergency department (ED), and many of those visits are potentially preventable. Understanding the characteristics of frequent attender (FA) patients with asthmatic exacerbations will help to identify factors associated with frequent attendance and improve case management. The aim of this study is to describe the characteristics of FA who present multiple times to the ED for asthma exacerbations.

METHODS

This study was a retrospective review of cases presented to Singapore General Hospital ED in 2010. Patients who attended the ED for 4 times or more with at least 1 visit attributable to asthma exacerbations in 2010 were included. They were then categorized as FA with multiple exacerbations (FAME) and those with fewer exacerbations.

RESULTS

Of 105616 ED patients, 155 patients attending the ED in 2010 were identified as FA with asthma, and 26 (17%) of these patients were classified as FAME, resulting in 213 visits (45% of total visits). Compared with FA with fewer exacerbations group, FAME were more likely to be men (P = .002), unemployed (P < .000), bad debtors (P = .045), substance abusers (P = .022), previously known to medical social workers (P = .002), and were found to spend a longer amount of time in the ED (>6 hours) (P = .03).

CONCLUSION

We found that a small number of FAME patients accumulated a large number of ED visits and spent a significantly longer time in the ED. This group tended to be males with social, financial, and addiction problems.

Factors associated with poor asthma control among asthmatic patient visiting emergency department

INTRODUCTION

Bronchial asthma is a common chronic disease that affects people of all ages. Insufficient asthma control may cause frequent emergency department (ED) visit by patients who seek crisis management of their asthma.

OBJECTIVES

This study aims to identify the factors associated with poor asthma control.

METHODS

We enrolled 450 participants who visited (ED) for asthma management. Besides assessing the asthma severity classification, we assess each participant for asthma control over the months preceding ED visit using Asthma Control Test score. We employed an independent t-test and ANOVA to assess if the differences in asthma control scores by demographic and clinical characteristics are statistically significant. The dependence of asthma control scores on demographic and clinical characteristics had been investigated with stepwise regression model.

RESULTS

There are differences in asthma control scores by the number of ED visits and severity of asthma classification (P values = 0.001). It was found that participant age, multiple ED visits, severe persistent, moderate persistent, mild persistent, received education about asthma medication and received education about asthma disease were greatly affected asthma control scores. For instance, the asthma control is predicted to decrease by 10.688 when participant had severe persistent asthma. Similarly, the asthma control is predicted to decrease by 5.647 when the participant had moderate persistent asthma.

CONCLUSIONS

This study identified many factors that may explain insufficient asthma control.

Influence of subcutaneous specific immunotherapy on drug costs in children suffering from allergic asthma

Background

Subcutaneous specific immunotherapy (SCIT) is an effective treatment attenuating the progression of allergic asthma. To date, there is a lack of studies investigating the economic consequences of SCIT on health care expenditures.

Methods

A health-economic piggy-back analysis of SCIT was conducted based on a RCT that enrolled 65 children and adolescents with allergic asthma. Patients were allocated into two groups: A group receiving SCIT with a high-dose hypoallergenic house dust mite preparation plus asthma medication and a control group receiving only asthma medication. For both groups asthma control was achieved before the start of the SCIT treatment and was maintained during the study. Both, costs and cost-effectiveness of SCIT with the high-dose hypoallergenic house dust mite preparation were investigated based on total medication costs, incremental medication costs and treatment effects (measured as lung function), respectively. A bootstrap analysis was performed to validate the results.

Results

A steady decline in medication costs could be observed in the SCIT group one year after treatment start compared to the control group. This cost trend became statistically significant 3 years after SCIT started. The calculated potential savings in the SCIT group correlated with an improved lung function. The distribution of the bootstrap results revealed that the probability of SCIT having a superior effectiveness compared to the control group is around 90%.

Conclusion

SCIT with a high-dose hypoallergenic preparation received by children and adolescents suffering from mite induced allergic asthma reduces the allergic medication intake and has cost-saving effects. Additional costs associated with SCIT may be completely compensated by drug cost savings 4 years after end of SCIT. Additionally, SCIT is superior compared to routine care as measured by the lung function that improved in SCIT-treated patients. Trial registration: (EudraCT no. 2004 – 003892 – 35).