Underuse of inhaled steroid therapy in elderly patients with asthma

Integrating Patients Into Programmes to Address the Allergy Knowledge Practice Gap

There is a wide gap between the first publication of new treatments with efficacy and their successful application in clinical practice. In many respects, the management of allergic diseases is a good exemplar of the knowledge/practice gap. It was assumed that systematic reviews and publication of guidelines would ensure timely delivery of effective care, but this has not proved to be the case. While there are many reasons to explain shortcomings in healthcare delivery, the lack of patient and carer involvement in the planning of research, evidence review, guideline development and guideline implementation is most compelling. To achieve adherence to evidence-based guidelines consistently across all levels of the health service requires the implementation of integrated care with clear pathways through which patients can navigate. Quality improvement methodology could be employed to plan and implement integrated care pathways (ICPs). There is evidence that ICPs achieve improved outcomes for acute hospital-based interventions, but less work has focussed on long-term conditions where more diverse agencies are involved. At all stages, stakeholder representation from the full range of healthcare professionals, patients, their families, social services, education, local government and employers must be involved. In this article we review the step-wise and iterative process by which knowledge is implemented into practice to improve patient experience and outcomes We argue how this process can benefit from the involvement of patients and their carers as equal partners, and we discuss how different initiatives have involved patients with allergic diseases. There currently is a gap in evidence that links patient involvement to improved outcomes. We recommend the use of the Core Outcome Sets (COS) and Patient Reported Experience Measures (PREMS) which have been developed for allergic diseases to monitor the effects of implementation research and the impact of patient and carer involvement on outcomes.

Role of cellular senescence in inflammatory lung diseases

Cellular senescence, a characteristic sign of aging, classically refers to permanent cell proliferation arrest and is a vital contributor to the pathogenesis of cancer and age-related illnesses. A lot of imperative scientific research has shown that senescent cell aggregation and the release of senescence-associated secretory phenotype (SASP) components can cause lung inflammatory diseases as well. In this study, the most recent scientific progress on cellular senescence and phenotypes was reviewed, including their impact on lung inflammation and the contributions of these findings to understanding the underlying mechanisms and clinical relevance of cell and developmental biology. Within a dozen pro-senescent stimuli, the irreparable DNA damage, oxidative stress, and telomere erosion are all crucial in the long-term accumulation of senescent cells, resulting in sustained inflammatory stress activation in the respiratory system. An emerging role for cellular senescence in inflammatory lung diseases was proposed in this review, followed by the identification of the main ambiguities, thus further understanding this event and the potential to control cellular senescence and pro-inflammatory response activation. In addition, novel therapeutic strategies for the modulation of cellular senescence that might help to attenuate inflammatory lung conditions and improve disease outcomes were also presented in this research.

Management of Elderly Asthma: Key Questions and Tentative Answers

The aging lung undergoes structural changes, immunosenescence, and inflammation, rendering the elderly more susceptible to developing obstructive airway disease. Thus, asthma in those of chronological age ≥ 65 years is not rare. Elderly asthma (EA) imposes considerable burdens in terms of mortality and morbidity, and expenditure. However, clinicians lack knowledge of EA and thus often prescribe inappropriate management. In this review, we ask 3 key questions frequently encountered during EA diagnosis and treatment: 1) Is EA different?; 2) How can we appropriately diagnose EA?; 3) Are there management strategies specific to EA? Based on recent studies, we provide tentative answers as follows: 1) late-onset EA differs in clinical features and pathogenetic mechanisms from non-EA, and thus further phenotypic and endotypic characterization of EA is needed; 2) both over- and under-diagnosis of asthma in the elderly can be reduced if the objective diagnostic tests are appropriately performed; 3) cautious prescription of ICS to selected EA patients should be encouraged, and a multifaceted approach which involves increasing medical awareness and inhaler use proficiency and adherence, seeking the assistance of caregivers, and correcting micronutrient deficiencies is required to reduce acute exacerbations in EA patients.

Asthma Care in the Elderly: Practical Guidance and Challenges for Clinical Management - A Framework of 5 "Ps"

Uncontrolled asthma in the elderly is a public health issue recognized in developed countries such as the United States and among the European Union, both from patient safety and economic perspectives. Variations in the cutoff, which defines elderly age, contribute to epidemiological study difficulties. Nonetheless, the relevance of elderly asthma from a socioeconomic perspective is inarguable. The projected growth of the enlarging geriatric population in the United States portends an impending national health burden that may or may not be preventable with pharmacologic and non-pharmacologic treatments. Asthma in the elderly might be a consequence of uncontrolled disease that is carried throughout a lifetime. Or elderly asthmatics could suffer from uncontrolled asthma, which overlaps with other ailments common with advancing ages that merit consideration, eg, COPD, heart disease, OSA, diabetes mellitus, and other comorbidities. Because of the heterogeneity of asthma phenotypes and other conditions that could mimic the symptoms of elderly asthma, further cohort studies are needed to elucidate the elderly asthmatic pathophysiology and management. More studies to characterize elderly asthma can help address these patients' unmet need for evidence-based guidelines. We introduce the 5 "Ps" (phenotypes, partnership, pharmacology, practice in acute exacerbations, and problems or barriers for the elderly asthmatics) that establish a framework approach for clinical practice.

Contributing Factors for Underutilization of Inhaled Corticosteroids Among Asthmatic Patients Attending at Adama Hospital Medical College, Adama, Ethiopia

INTRODUCTION

Inhaled corticosteroids (ICSs) are a cornerstone medicine for preventive therapy of persistent severe asthma. Although ICs are very effective for the treatment of severe persistent asthma, the majority of the prescribers worldwide aren't aware of ICs use for the treatment of severe persistent asthma.

OBJECTIVE

To evaluate factors contributing to underutilization of ICS by asthmatic patients.

METHODS

Patient interview was conducted among asthmatic patients using a cross-sectional study design who were attending at the Adama Hospital Medical College from March 1 to July 25, 2017. The total number of patients involved in the study was 94. Semi-structured questionnaire through patient interview was used for data collection and data from physicians who were working at the chest clinic of AHMC were collected by self-administered semi-structured questionnaire focusing their perspectives and experiences on patients' ICS.

RESULTS

Generally 73.5% of underutilization of ICS was reported from the total number of patients involved in the study according to the patient's perception. Monthly income, comorbid disease, and behaviors of ICS use were the main factors contributing to underutilization of ICS. According to patient's report, some of the reasons for underutilization of ICS were unaffordability, using the drugs only when symptoms appear, inaccessibility, side effects and recommendation by physicians. There were also similar reports by the physicians working in the AHMC.

CONCLUSION

In our study setting, prevalence of underutilization of ICS was high and the contributing factors were increased cost of ICS, inaccessibility of ICS, poor knowledge of the patients on asthma disease and ICS, bad attitude toward ICS, and lack of recently reviewed local guideline for asthma treatment. Thus, concerned experts need to take actions that guarantee accessibility of ICS at a reasonable price and increase awareness of patients about asthma disease and use of ICS.

Asthma over the Adult Life Course: Gender and Hormonal Influences

Asthma is a common disorder that affects genders differently across the life span. Earlier in life, it is more common in boys. At puberty, asthma becomes more common and often more severe in girls and women. The effect of sex hormones on asthma incidence and its severity is difficult to differentiate from other asthma severity risk factors, such as racial background, socioeconomic factors, obesity, atopy, environmental exposure, and, in particular, lung aging. Recognizing gender-associated and age-associated differences is important to understanding the pathobiology of asthma and to providing effective education and personalized care for patients with asthma across the life course.

Adherence barriers to inhaled medicines in Japanese older patients with asthma evaluated using the "Adherence Starts with Knowledge 20" (ASK-20) questionnaire

OBJECTIVE

We investigated adherence barriers to inhaled medicines among older compared to younger adults with asthma in Japan.

METHODS

Adherence barriers to inhaled medicines were evaluated in 251 Japanese older (n = 138) and younger (n = 113) adults with asthma using the self-reporting "Adherence Starts with Knowledge 20" (ASK-20) questionnaire.

RESULTS

There were fewer older adults with poor adherence to inhaled medicines than younger adults. The ASK-20 questionnaire revealed (odds ratio [95% confidence interval]) item Q11 ("My doctor/nurse and I work together to make decisions"; 2.94 [1.31, 6.61]; p < 0.05) as an independent adherence barrier to inhaled medicines among older adults, whereas younger adults reported item Q3 ("My use of alcohol gets in the way of taking my medicines"; 3.91 [1.02 to 15.1]; p < 0.05) and item Q16 ("Taken a medicine more or less often than prescribed? "; 2.31 [1.32 to 4.06]; p < 0.05) as barriers. Older adults with poor adherence identified item Q1 ("I just forget to take my inhaled medicines some of the time"; 4.43 [1.77, 11.1]; p < 0.05) as a barrier, although the total ASK-20 scores and total barrier counts were significantly higher in older (both, p < 0.05) and younger (both, p < 0.05) adults with poor adherence than in those with good adherence.

CONCLUSION

Older Japanese patients had better adherence to inhaled medicines than younger patients. Barriers were different between older and younger adults. These results will help personalize education for inhaled medicines in Japanese asthmatics.

Asthma Over the Age of 65: All's Well That Ends Well

Asthma in older adults (often classified as those 65 years or older) is relatively common, underdiagnosed, and suboptimally treated. It is an important health problem, as the population of the United States continues to age. Unfortunately, asthma morbidity and mortality rates are highest in this age group. Alterations in the innate and adaptive immune responses occur with aging, and contribute to pathophysiologic differences and subsequent treatment challenges. The symptoms of asthma may differ from those in younger populations, and often include fatigue. There are unique factors that can complicate asthma management among older adults, including comorbidities, menopause, caregiver roles, and depression. Pharmacologic therapies are often not as effective as in younger populations, and may have greater side effects. Spirometry, peak flow measurements, and asthma education are typically underused, and may contribute to delays in diagnosis as well as worse outcomes. There are specific strategies that health care providers can take to improve the care of older adults with asthma.

Asthma in the elderly and late-onset adult asthma

Elderly asthmatics are at a higher risk for morbidity and mortality from their asthma than younger patients. There are important age-related physiologic and immunologic changes that complicate the presentation, diagnosis, and management of asthma in the aged population. Evidence suggests that elderly asthmatics are more likely to be underdiagnosed and undertreated. Additionally, elderly patients with asthma have highest rates of morbidity and mortality from their disease than younger patients. The underlying airway inflammation of asthma in this age group likely differs from younger patients and is felt to be non-type 2 mediated. While elderly patients are underrepresented in clinical trials, subgroup analysis of large clinical trials suggests they may be less likely to respond to traditional asthma therapies (ie, corticosteroids). As the armamentarium of pharmacologic asthma therapies expands, it will be critical to include elderly asthmatics in large clinical trials so that therapy may be better tailored to this at-risk and growing population.

Characteristics and Prevalence of Asthma/Chronic Obstructive Pulmonary Disease Overlap in the United States

RATIONALE

The asthma-chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS) occurs in patients with fixed airway obstruction that defines COPD and with symptoms more typical of asthma. ACOS prevalence and the comorbidities associated with this syndrome have been inadequately characterized.

OBJECTIVES

Because this population is prone to more frequent exacerbations, we hypothesized that comorbidities associated with ACOS are higher than those with COPD, asthma, and control populations in the United States.

METHODS

We examined the self-reported demographics, smoking status, comorbidities, and hospitalization or emergency department (ED) visitation experience among study respondents older than 35 years of age (n = 90,851) in the Behavioral Risk Factor Surveillance System survey and compared participants with ACOS to COPD, asthma, and control groups. We used logistic regression to compare ACOS and COPD populations to model the impact of comorbid conditions and hospitalization/ED visits after adjusting for demographic factors and smoking status to generate odds ratios and confidence intervals.

MEASUREMENTS AND MAIN RESULTS

The U.S. prevalence of ACOS was 3.2%, COPD alone was 6.0%, and both increased with age. Respondents with ACOS were younger (64.0 ± 11.7 yr) than respondents with COPD (67.1 ± 11.8 yr) and older than respondents with asthma (59.0 ± 13.1 yr; P < 0.0001). The prevalence of comorbidities was higher in the group with ACOS and COPD than in asthma or control groups. The ACOS group had a higher body mass index, lower income, and lower education than other groups. The ACOS group was more likely to have at least one comorbidity (90.2 vs. 84%, P < 0.0001), more hospitalization or ED visits (22.0 vs. 13.2%, P < 0.0001), less exercise (50.0 vs. 58.6%, P = 0.0024), and more disability (70.8 vs. 58.6%, P < 0.0001) than the COPD group.

CONCLUSIONS

The patients with a dual diagnosis of asthma and COPD are younger and with more disparities than those diagnosed with COPD alone. ACOS has a higher burden of self-reported comorbidity, disability, and hospitalization or ED visitation than COPD alone.

An Official American Thoracic Society Workshop Report: Evaluation and Management of Asthma in the Elderly

Asthma in the elderly (>65 yr old) is common and associated with higher morbidity and mortality than asthma in younger patients. The poor outcomes in this group are due, in part, to underdiagnosis and undertreatment. There are a variety of factors related to aging itself that affect the presentation of asthma in the elderly and influence diagnosis and management. Structural changes in the aging lung superimposed on structural changes due to asthma itself can worsen the disease and physiologic function. Changes in the aging immune system influence the cellular composition and function in asthmatic airways. These processes and differences from younger individuals with asthma are not well understood. Phenotypes of asthma in the elderly have not been clearly delineated, but it is likely that age of onset and overlap with chronic obstructive pulmonary disease impact disease characteristics. Physiologic tests and biomarkers used to diagnose and follow asthma in the elderly are generally similar to testing in younger individuals; however, whether they should be modified in aging has not been established. Confounding influences, such as comorbidities (increasing the risk of polypharmacy), impaired cognition and motor skills, psychosocial effects of aging, and age-related adverse effects of medications, impact both diagnosis and treatment of asthma in the elderly. Future efforts to understand asthma in the elderly must include geriatric-specific methodology to diagnose, characterize, monitor, and treat their disease.

The Seven Stages of Man: The Role of Developmental Stage on Medication Adherence in Respiratory Diseases

The circumstances and drivers of the decision to initiate, implement, or persist with a medication differ for individuals at each developmental stage. For school-age children with asthma, the social environment of their family's cultural beliefs and the influence of peer networks and school policies are strong determinants of medication adherence. The stage of adolescence can be a particularly challenging time because there is a reduction in parental supervision of asthma management as the young person strives to become more autonomous. To illustrate the importance of such factors, adherence interventions in children and young adults with asthma have used peer-based supports and social supports, particularly social media platforms. In older patients, it is internal rather than external factors and age-related decline that pose challenges to medication adherence. Seniors face the challenges of polypharmacy, reduced social support, increased isolation, and loss of cognitive function. Strategies to promote adherence must be tailored to the developmental stage and respective behavioral determinants of the target group. This review considers the different attitudes toward medication and the different adherence behaviors in young and elderly patients with chronic respiratory conditions, specifically asthma and chronic obstructive pulmonary disease. Opportunities to intervene to optimize adherence are suggested.

Comparative effectiveness of allopurinol versus febuxostat for preventing incident renal disease in older adults: an analysis of Medicare claims data

OBJECTIVE

To assess the comparative effectiveness of allopurinol versus febuxostat for preventing incident renal disease in elderly.

METHODS

In a retrospective cohort study using 2006-2012 Medicare claims data, we included patients newly treated with allopurinol or febuxostat (baseline period of 183 days without either medication). We used 5:1 propensity-matched Cox regression analyses to compare the HR of incident renal disease with allopurinol use (and dose) versus febuxostat (reference). Sensitivity analyses included multivariable-adjusted regression models.

RESULTS

There were 31 465 new allopurinol or febuxostat treatment episodes in 26 443 patients; 8570 ended in incident renal disease. Crude rates of incident renal disease per 1000 person-years were 192 with allopurinol versus 338 with febuxostat. Crude rates of incident renal disease per 1000 person-years were lower with higher daily dose: allopurinol <200, 200-299 and ≥300 mg/day with 238, 176 and 155; and febuxostat 40 and 80 mg/day with 341 and 326, respectively. In propensity-matched analyses, compared with febuxostat, allopurinol use was associated with lower HR of incident renal disease, 0.61 (95% CI 0.49 to 0.77). Compared with febuxostat 40 mg/day, allopurinol doses <200, 200-299 and ≥300 mg/day were associated with lower HR of incident renal disease, 0.75 (95% CI 0.65 to 0.86), 0.61 (95% CI 0.52 to 0.73) and 0.48 (95% CI 0.41 to 0.55), respectively. Sensitivity analyses using multivariable-adjusted regression confirmed these findings.

CONCLUSIONS

Allopurinol was associated with a lower risk of incident renal disease in elderly patients than febuxostat. Future studies need to examine the mechanism of this potential renal benefit of allopurinol.

Assessment of inhaled corticosteroids use and associated factors among asthmatic patients attending Tikur Anbessa Specialized Hospital, Ethiopia

Background

Inhaled corticosteroids (ICSs) are cornerstone therapy for persistent asthma. However, underutilization of ICSs is common and little is known about factors contributing toward this undesirable use.

Methods

A cross-sectional study was conducted through interview and chart review among persistent asthmatic patients attending chest clinic of Tikur Anbessa Specialized Hospital from 1 May to 31 September 2014. A total of 131 eligible patients who attended the clinic during study period were included in the study. A multivariate logistic regression was used to examine the association between independent and dependent variables.

Results

Overall, extent of underutilization of ICSs was found to be 68%. Monthly income, comorbidity and types of ICSs products prescribed showed significant association with reported underutilization. Patients’ reported reasons for underutilization includes; unaffordability (44%), using only when symptoms exacerbate (21%), fear of side effects (10%), practitioners’ recommendation (10%) and unavailability of ICSs in the local market (7%). Physicians also stated unaffordability, fear of side effects and dependency, lack of local guideline for asthma management and unavailability of ICSs as the contributing factors.

Conclusion

In this setting, extent of underutilization of ICSs was found to be high and seems the result of complex interaction of various factors. Financial problem combined with inconsistent availability of ICSs in the local market, patients’ poor knowledge of asthma and ICSs, negative attitude toward ICSs, absence of local guidelines for asthma management are found to be essential elements dictating an extent of ICSs use.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-017-2645-2) contains supplementary material, which is available to authorized users.

Identifying inequitable healthcare in older people: systematic review of current research practice

BACKGROUND

There is growing consensus on the importance of identifying age-related inequities in the receipt of public health and healthcare interventions, but concerns regarding conceptual and methodological rigour in this area of research. Establishing age inequity in receipt requires evidence of a difference that is not an artefact of poor measurement of need or receipt; is not warranted on the grounds of patient preference or clinical safety; and is judged to be unfair.

METHOD

A systematic, thematic literature review was undertaken with the objective of characterising recent research approaches. Studies were eligible if the population was in a country within the Organisation for Economic Co-operation and Development and analyses included an explicit focus on age-related patterns of healthcare receipt including those 60 years or older. A structured extraction template was applied. Extracted material was synthesised in thematic memos. A set of categorical codes were then defined and applied to produce summary counts across key dimensions. This process was iterative to allow reconciliation of discrepancies and ensure reliability.

RESULTS

Forty nine studies met the eligibility criteria. A wide variety of concepts, terms and methodologies were used across these studies. Thirty five studies employed multivariable techniques to produce adjusted receipt-need ratios, though few clearly articulated their rationale, indicating the need for great conceptual clarity. Eighteen studies made reference to patient preference as a relevant consideration, but just one incorporated any kind of adjustment for this factor. Twenty five studies discussed effectiveness among older adults, with fourteen raising the possibility of differential effectiveness, and one differential cost-effectiveness, by age. Just three studies made explicit reference to the ethical nature of healthcare resource allocation by age. While many authors presented suitably cautious conclusions, some appeared to over-stretch their findings concluding that observed differences were 'inequitable'. Limitations include possible biases in the retrieved material due to inconsistent database indexing and a focus on OECD country populations and studies with English titles.

CONCLUSIONS

Caution is needed among clinicians and other evidence-users in accepting claims of healthcare 'ageism' in some published papers. Principles for improved research practice are proposed.

Are allopurinol dose and duration of use nephroprotective in the elderly? A Medicare claims study of allopurinol use and incident renal failure

OBJECTIVE

To assess the effect of allopurinol dose/duration on the risk of renal failure in the elderly with allopurinol use.

METHODS

We used the 5% random Medicare claims data from 2006 to 2012. Multivariable-adjusted Cox regression analyses assessed the association of allopurinol dose/duration with subsequent risk of developing incident renal failure or end-stage renal disease (ESRD) (no prior diagnosis in last 183 days) in allopurinol users, controlling for age, sex, race and Charlson-Romano comorbidity index. HRs with 95% CIs were calculated. Sensitivity analyses considered a longer baseline period (365 days), controlled for gout or used more specific codes.

RESULTS

Among the 30 022 allopurinol treatment episodes, 8314 incident renal failure episodes occurred. Compared with 1-199 mg/day, allopurinol dose of 200-299 mg/day (HR 0.81; 95% CI 0.75 to 0.87) and ≥300 mg/day, 0.71 (0.67 to 0.76), had significantly lower hazard of renal failure in multivariable-adjustment model, confirmed in multiple sensitivity analyses. Longer allopurinol use duration was significantly associated with lower hazards in sensitivity analyses (365-day look-back; reference, <0.5 year): 0.5-1 year, 1.00 (0.88, 1.15); >1-2 years, 0.85 (0.73 to 0.99); and >2 years, 0.81 (0.67 to 0.98). Allopurinol ≥300 mg/day was also associated with significantly lower risk of acute renal failure and ESRD with HR of 0.89 (0.83 to 0.94) and 0.57 (0.46 to 0.71), respectively.

CONCLUSIONS

Higher allopurinol dose is independently protective against incident renal failure in the elderly allopurinol users. A longer duration of allopurinol use may be associated with lower risk of incident renal failure. Potential mechanisms of these effects need to be examined.

Asthma in the elderly patient

Asthma affects a significant proportion of elderly patients, but unfortunately, it is responsible for a high asthma-related morbidity and mortality in this population. This may be related not only to the development of a more severe asthma phenotype compared to younger patients, with more marked airway obstruction and a more neutrophilic type of airway inflammation, but also to the presence of many co-morbid conditions. Furthermore, in older patients, asthma is often under-diagnosed, undertreated and poorly managed. Unfortunately, elderly patients have usually been excluded of clinical trials on asthma and there is an urgent need to perform more research on the optimal management of asthma in this population.

The Effect of Asthma Clinical Guideline for Adults on Inhaled Corticosteroids PrescriptionTrend: A Quasi-Experimental Study

In order to increase inhaled corticosteroid (ICS) use and to reduce hospitalization, emergency department visits and ultimately the economic burden of asthma, "Korean Asthma Management Guideline for Adults 2007" was developed. To assess the guideline effects on physician's ICS prescription for asthma, we conducted segmented regression and multilevel logistic regression using National Health Insurance claims database of outpatient visits from 2003 to 2010. We set each quarter of a year as a time unit and compared ICS prescription between before and after guideline dissemination. A total of 624,309 quarterly visits for asthma was observed. The ICS prescription rate before and after guideline dissemination was 13.3% and 16.4% respectively (P < 0.001). In the segmented regression, there was no significant guideline effect on overall ICS prescription rate. In multilevel logistic regression analyses, the effect of guideline on overall ICS prescription was not significant (odds ratio, 1.03; 95% CI, 1.00-1.06). In subgroup analysis, ICS prescription increased in secondary care hospitals (odds ratio, 1.15; 95% CI, 1.02-1.30) and in general hospitals (odds ratio, 1.10; 95% CI, 1.04-1.16). However, in primary clinics, which covered 81.7% of asthma cases, there was no significant change (odds ratio, 0.98; 95% CI, 0.94-1.02). From the in-depth interview, we could identify that the reimbursement criteria of the Health Insurance Review and Assessment Service and patient's preference for oral drug were barriers for the ICS prescription. The domestic asthma clinical guideline have no significant effect on ICS prescription, especially in primary clinics.

A systematic review of validated methods to capture acute bronchospasm using administrative or claims data

PURPOSE

To identify and assess billing, procedural, or diagnosis code, or pharmacy claim-based algorithms used to identify acute bronchospasm in administrative and claims databases.

METHODS

We searched the MEDLINE database from 1991 to September 2012 using controlled vocabulary and key terms related to bronchospasm, wheeze and acute asthma. We also searched the reference lists of included studies. Two investigators independently assessed the full text of studies against pre-determined inclusion criteria. Two reviewers independently extracted data regarding participant and algorithm characteristics.

RESULTS

Our searches identified 677 citations of which 38 met our inclusion criteria. In these 38 studies, the most commonly used ICD-9 code was 493.x. Only 3 studies reported any validation methods for the identification of bronchospasm, wheeze or acute asthma in administrative and claims databases; all were among pediatric populations and only 2 offered any validation statistics. Some of the outcome definitions utilized were heterogeneous and included other disease based diagnoses, such as bronchiolitis and pneumonia, which are typically of an infectious etiology. One study offered the validation of algorithms utilizing Emergency Department triage chief complaint codes to diagnose acute asthma exacerbations with ICD-9 786.07 (wheezing) revealing the highest sensitivity (56%), specificity (97%), PPV (93.5%) and NPV (76%).

CONCLUSIONS

There is a paucity of studies reporting rigorous methods to validate algorithms for the identification of bronchospasm in administrative data. The scant validated data available are limited in their generalizability to broad-based populations.

Advances in the diagnosis and management of asthma in older adults

Global estimates on aging predict an increased burden of asthma in the older population. Consequently, its recognition, diagnosis, and management in clinical practice require optimization. This review aims to provide an update for clinicians, highlighting advances in the understanding of the aging process and immunosenescence together with their applicability to asthma from a diagnostic and therapeutic perspective. Aging impacts airway responses and immune function, and influences efficacy of emerging phenotype-specific therapies when applied to the elderly patient. Differentiating eosinophilic and neutrophilic disease accounts for atopic illness and distinguishes long-standing from late-onset asthma. Therapeutic challenges in drug delivery, treatment adherence, and side-effect profiles persist in the older patient, while novel recording devices developed to aid detection of an adequate inhalation evaluate treatment effectiveness and compliance more accurately than previously attainable. Anticytokine therapies improve control of brittle asthma, while bronchial thermoplasty is an option in refractory cases. Multidimensional intervention strategies prove best in the management of asthma in the older adult, which remains a condition that is not rare but rarely diagnosed in this patient population.

[Asthma in the elderly]

Asthma is a common condition in the elderly although often confounded with chronic obstructive pulmonary disease (COPD) in this population. Asthma in the elderly seems to represent a specific phenotype characterized by more severe, but often less perceived, airway obstruction, a neutrophilic or mixed-type of airway inflammation and frequent comorbidities. Patients aged 65 years and over have an increased asthma-related morbidity and mortality compared to younger patients, probably due to difficulties in regard to diagnosis, assessment of the disease severity and treatment. Research is urgently needed to determine the optimal treatment of the aged patient. In this document we will review the state of knowledge on this topic and discuss the challenges of multidisciplinary asthma management in the elderly.

Clinical, economic, and humanistic burden of asthma in Canada: a systematic review

BACKGROUND

Asthma, one of the most common chronic respiratory diseases, affects about 3 million Canadians. The objective of this study is to provide a comprehensive evaluation of the published literature that reports on the clinical, economic, and humanistic burden of asthma in Canada.

METHODS

A search of the PubMed, EMBASE, and EMCare databases was conducted to identify original research published between 2000 and 2011 on the burden of asthma in Canada. Controlled vocabulary with "asthma" as the main search concept was used. Searches were limited to articles written in English, involving human subjects and restricted to Canada. Articles were selected for inclusion based on predefined criteria like appropriate study design, disease state, and outcome measures. Key data elements, including year and type of research, number of study subjects, characteristics of study population, outcomes evaluated, results, and overall conclusions of the study, were abstracted and tabulated.

RESULTS

Thirty-three of the 570 articles identified by the clinical and economic burden literature searches and 14 of the 309 articles identified by the humanistic burden literature searches met the requirements for inclusion in this review. The included studies highlighted the significant clinical burden of asthma and show high rates of healthcare resource utilization among asthma patients (hospitalizations, ED, physician visits, and prescription medication use). The economic burden is also high, with direct costs ranging from an average annual cost of $366 to $647 per patient and a total annual population-level cost ranging from ~ $46 million in British Columbia to ~ $141 million in Ontario. Indirect costs due to time loss from work, productivity loss, and functional impairment increase the overall burden. Although there is limited research on the humanistic burden of asthma, studies show a high (31%-50%) prevalence of psychological distress and diminished QoL among asthma patients relative to subjects without asthma.

CONCLUSIONS

As new therapies for asthma become available, economic evaluations and assessment of clinical and humanistic burden will become increasingly important. This report provides a comprehensive resource for health technology assessment that will assist decision making on asthma treatment selection and management guidelines in Canada.

Physician adherence to asthma treatment guidelines in Japan: focus on inhaled corticosteroids

OBJECTIVES

Asthma treatment guidelines recommend inhaled corticosteroids (ICS) as the first-line therapy. However, ICS are prescribed to lower percentages of asthmatic patients in Japan than in other developed countries. The aim of this study was to reveal factors affecting the prescription of ICS for asthmatic adults.

METHODS

Using insurance claims data in Kyoto Prefecture, Japan, we performed a cross-sectional study. We assessed whether outpatients aged 15 years or older who were diagnosed with asthma had received ICS or not, and conducted logistic regression analyses to identify patients' and facilities' factors associated with ICS use.

RESULTS

We analysed 13,428 asthmatic adults, of which 51% were prescribed ICS. Patients receiving asthma care at facilities with respiratory or allergy specialists were more likely to receive ICS than facilities without specialists (adjusted odds ratio 2.70; 95% confidence interval 2.46-2.97). Those aged 75 years or older were less likely to receive ICS than those aged 15 to 64 (adjusted odds ratio 0.71; 95% confidence interval 0.64-0.78). An examination of the interaction between the presence or absence of specialists and facility training status suggested that whether asthmatic adults received ICS depended on the former factor rather than the latter.

CONCLUSION

The presence of specialists in facilities and the age of patients were strong factors affecting ICS prescription. Increases in ICS therapy for the elderly and ICS prescription by non-specialists would lead to an overall increase in patients receiving ICS and consequently achieving the goal of asthma control.

Asthma prevalence among US elderly by age groups: age still matters

OBJECTIVE

For over three decades, the greatest burden of asthma deaths has occurred among persons aged 65 years and older. This study analyzed the association between increasing age and asthma prevalence among age groups within the US elderly population.

METHODS

We analyzed aggregated data on 54,485 civilian, noninstitutionalized US adults aged 65 years and older from the 2001-2010 National Health Interview Survey (NHIS). We estimated the prevalence of current asthma, lifetime asthma, and chronic obstructive pulmonary disease (COPD) among US elderly by 5-year age groups and age stages ("young elderly" aged 65-84 years and "oldest old" aged ≥85 years). We calculated adjusted odds ratios (AOR) and 95% confidence intervals (CI) to identify asthma prevalence patterns among elderly populations.

RESULTS

From 2001 to 2010, the estimated average annual prevalence of current asthma among US elderly was 7.0%. Estimates of lifetime asthma, COPD, and co-occurring current asthma and COPD were 9.9%, 9.7%, and 3.0%, respectively. Prevalence of asthma decreased with advancing age while prevalence of COPD increased with advancing age. When controlling for study variables and significant interactions (p = .05) with COPD, the odds of reporting current asthma decreased with advancing age: 0.87 (95% CI, 0.76-1.01) for 70- to 74-year-olds; 0.76 (95% CI, 0.66-0.87) for 75- to 79-year-olds; 0.62 (95% CI, 0.51-0.75) for 80- to 84-year-olds; and 0.45 (95% CI, 0.36-0.55) for ≥85-year-olds, as compared to 65- to 69-year-olds.

CONCLUSIONS

Asthma continues to affect a substantial proportion of the US elderly population. Increased diagnosis of COPD may overshadow correct diagnosis and treatment in populations with advancing age. Treatment guidelines should focus on preventable risk behaviors to increase the quality of life within this population.

Asthma in the elderly: Current understanding and future research needs--a report of a National Institute on Aging (NIA) workshop

Asthma in the elderly is underdiagnosed and undertreated, and there is a paucity of knowledge on the subject. The National Institute on Aging convened this workshop to identify what is known and what gaps in knowledge remain and suggest research directions needed to improve the understanding and care of asthma in the elderly. Asthma presenting at an advanced age often has similar clinical and physiologic consequences as seen with younger patients, but comorbid illnesses and the psychosocial effects of aging might affect the diagnosis, clinical presentation, and care of asthma in this population. At least 2 phenotypes exist among elderly patients with asthma; those with longstanding asthma have more severe airflow limitation and less complete reversibility than those with late-onset asthma. Many challenges exist in the recognition and treatment of asthma in the elderly. Furthermore, the pathophysiologic mechanisms of asthma in the elderly are likely to be different from those seen in young asthmatic patients, and these differences might influence the clinical course and outcomes of asthma in this population.

Age-related changes in immune function: effect on airway inflammation

Immunosenescence is defined as changes in the innate and adaptive immune response associated with increased age. The clinical consequences of immunosenescence include increased susceptibility to infection, malignancy and autoimmunity, decreased response to vaccination, and impaired wound healing. However, there are several immune alterations that might facilitate persistence of asthma into late adulthood or development of asthma after the age of 50 to 60 years. Asthma in older patients is not uncommon, and this is a growing population as the average lifespan increases. Specific innate changes that might affect severity of asthma in older patients or be involved in the development of late-onset asthma include impaired mucociliary clearance and changes in airway neutrophil, eosinophil, and mast cell numbers and function. Additionally, age-related altered antigen presentation and decreased specific antibody responses might increase the risk of respiratory tract infections. Respiratory tract infections exacerbate asthma in older patients and possibly play a role in the pathogenesis of late-onset asthma. Furthermore, cytokine profiles might be modified with aging, with some investigators suggesting a trend toward T(H)2 cytokine expression. This review examines specific innate and adaptive immune responses affected by aging that might affect the inflammatory response in older adults with asthma.

Regular primary care lowers hospitalisation risk and mortality in seniors with chronic respiratory diseases

BACKGROUND

Exacerbations in chronic respiratory diseases (CRDs) are sensitive to seasonal variations in exposure to respiratory infectious agents and allergens and patient factors such as non-adherence. Hence, regular general practitioner (GP) contact is likely to be important in order to recognise symptom escalation early and adjust treatment.

OBJECTIVE

To examine the association of regularity of GP visits with all-cause mortality and first CRD hospitalisation overall and within groups of pharmacotherapy level in older CRD patients.

DESIGN

A retrospective cohort design using linked hospital, mortality, Medicare and pharmaceutical data for participant, exposure and outcome ascertainment. GP visit pattern was measured during the first 3 years of the observation period. Patients were then followed for a maximum of 11.5 years for ascertainment of hospitalisations and deaths.

PARTICIPANTS

We studied 108,455 patients aged >or=65 years with CRD in Western Australia (WA) during 1992-2006.

MAIN MEASURES

A GP visit regularity score (range 0-1) was calculated and divided into quintiles. A clinician consensus panel classified levels of pharmacotherapy. Cox proportional hazards models, controlling for multiple factors including GP visit frequency, were used to calculate hazard ratios and confidence intervals.

KEY RESULTS

Differences in survival curves and hospital avoidance pattern between the GP visit regularity quintiles were statistically significant (p = 0.0279 and p < 0.0001, respectively). The protective association between GP visit regularity and death appeared to be confined to the highest pharmacotherapy level group (P for interaction = 0.0001). Higher GP visit regularity protected against first CRD hospitalisation compared with the least regular quintile regardless of pharmacotherapy level (medium regular: HR = 0.84, 95% CI = 0.77-0.92; 2nd most regular: HR = 0.74, 95% CI = 0.67-0.82; most regular HR = 0.77, 95% CI = 0.68-0.86).

CONCLUSIONS

The findings indicate that regular and proactive 'maintenance' primary care, as distinct from 'reactive' care, is beneficial to older CRD patients by reducing their risks of hospitalisation and death.

Mortality in Western Australian seniors with chronic respiratory diseases: a cohort study

Background

Relatively few studies have examined survival by pharmacotherapy level and the effects of patient characteristics on mortality by pharmacotherapy level in older chronic respiratory disease (CRD) patients. This study aimed to investigate these issues in older (≥ 65) CRD patients in Western Australia.

Methods

We identified 108,312 patients ≥ 65 years with CRD during 1992-2006 using linked medical, pharmaceutical, hospital and mortality databases held by the Commonwealth and State governments. Pharmacotherapy classification levels were designed by a clinical consensus panel. Cox regression was used to investigate the study aim.

Results

Patients using only short acting bronchodilators experienced similar, but slightly worse survival than patients in the highest pharmacotherapy level group using high dose inhaled corticosteroids (ICS) ± long acting bronchodilators (LABs) ± oral steroids. Patients using low to medium dose ICS ± LABs experienced relatively better survival. Also, male gender was associated with all-cause mortality in all patients (HR = 1.72, 95% CI 1.65-1.80) and especially in those in the highest pharmacotherapy level group (HR = 1.97, 95%CI = 1.84-2.10). The P-value of interaction between gender and pharmacotherapy level for the effect on all-cause death was significant (0.0003).

Conclusions

Older patients with CRD not using ICS experienced the worst survival in this study and may benefit from an escalation in therapeutic regime. Males had a higher risk of death than females, which was more pronounced in the highest pharmacotherapy level group. Hence, primary health care should more actively direct disease management to mild-to-moderate disease patients.

Growing old with asthma: what are the changes and challenges?

Asthma is a disease that affects approximately 7% of adults residing in the USA; the prevalence is even greater in children and approaches 10%. The CDC has reported that the overall prevalence of lifetime asthma is 10.5%. New-onset asthma is most often seen in children and is associated with atopy; however, the majority of patients will experience a remission during adolescence. Many former asthmatics will have a reoccurrence of their disease in adulthood and asthma may persist thereafter for a lifetime. New-onset asthma may also begin later in life and remission is uncommon. The burden of asthma is therefore high in the geriatric population and healthcare utilization and mortality from asthma is excessive in this age group. There are many differences with asthma occurring in older adults when compared with younger asthmatics. This includes the frequency of medical comorbidities, the presence in many patients of fixed airflow obstruction that resembles chronic obstructive pulmonary disease, and the lack of perception of dyspnea that may delay effective medical care. Despite these and other differences, the pathophysiology and clinical presentation of asthma in the elderly is similar to that in younger asthmatics and attention to the unique features of aging can lead to improved outcomes in this age group.

Diagnosis and management of asthma in older adults

Despite comprehensive guidelines established by the European Global Initiative for Asthma and the U.S. National Asthma Education and Prevention Program on the diagnosis and management of asthma, its mortality in older adults continues to rise. Diagnostic and therapeutic problems contribute to older patients being inadequately treated. The diagnosis of asthma rests on the history and characteristic pulmonary function testing (PFT) with the demonstration of reversible airway obstruction, but there are unique problems in performing this test in older patients and in its interpretation. This review aims to address the difficulties in performing and interpreting PFT in older patients because of the effects of age-related changes in lung function on respiratory physiology. The concept of "airway remodeling" resulting in "fixed obstructive" PFT and the relevance of atopy in older people with asthma are assessed. There are certain therapeutic issues unique to older patients with asthma, including the increased probability of adverse effects in the setting of multiple comorbidities and issues surrounding effective drug delivery. The use of beta 2-agonist, anticholinergic, corticosteroid, and anti-immunoglobulin E treatments are discussed in the context of these therapeutic issues.

Complexities of diagnosis and treatment of allergic respiratory disease in the elderly

Atopic diseases such as rhinitis and asthma are relatively common in children and young adults. However, many patients aged >65 years are also affected by these disorders. Indeed, the literature suggests that between 3-12% and 4-13% of individuals in this age range have allergic rhinitis and asthma, respectively. However, these numbers are most likely underestimates because atopic diseases are frequently not considered in older patients. The diagnosis of both allergic rhinitis and asthma in older patients is more difficult than in younger patients because of a wide differential diagnosis of other diseases that can produce similar symptoms and must be excluded. Furthermore, treatment of these disorders is complicated by the potential for drug interactions, concern about the adverse effects of medications, in particular corticosteroids, and the lack of drug trials specifically targeting treatment of older patients with allergic rhinitis and asthma.

Improving asthma care for the elderly: a randomized controlled trial using a simple telephone intervention

BACKGROUND

Several studies suggest that asthma is undertreated in the elderly population.

OBJECTIVE

To determine if the use of a simple telephone intervention can improve asthma care in the elderly.

METHODS

Fifty-two elderly subjects with asthma who required their rescue inhalers more than twice a week and had at least one emergency department or urgent care visit in the previous year were randomized to an intervention or control group. All subjects received two telephone calls over a 12-month period. The intervention group received an asthma-specific questionnaire and the control group received a general health questionnaire. Medication use and health care utilization were evaluated at the beginning and end of a 12-month period.

RESULTS

The study was completed by 23 control and 25 intervention subjects. Baseline data were similar in both groups. After 12 months, 72% (n = 18) of the intervention group were on an inhaled corticosteroid compared with 40% (n = 10) of the control group (p = 0.08). The intervention group had fewer emergency department visits when compared with the control group (p = 0.21). Sixty-four percent (n = 16) of the intervention group had an asthma action plan compared with 26% (n = 6) in the control group (p = 0.01).

CONCLUSION

This study suggests that asthma care in the elderly can be improved using a simple telephone intervention.

CLINICAL IMPLICATIONS

Clinicians need to recognize that under treatment of asthma in the elderly still exists and to use alternative methods such as a simple telephone questionnaire to improve care in this population.

Asthma in US seniors: part 2. Treatment. Seeing through the glass darkly

BACKGROUND

We sought to identify the best evidence for treatment of asthmatic patients aged 65 years or more.

METHODS

We used computer-assisted searches to identify randomized, controlled trials for asthma in the elderly that were published in English between 1950 and 2008.

RESULTS

Small trials of an inhaled corticosteroid versus a leukotriene antagonist and an oral beta(2)-agonist versus placebo compose the controlled trial data on asthma therapy in seniors. Epidemiologic evidence suggests that the side effects of corticosteroids and beta-agonists may be more common in the elderly than in younger populations.

CONCLUSION

Seniors with asthma or comorbid conditions that are common in the elderly have been systematically excluded from asthma treatment trials. There is no compelling evidence to demonstrate the superiority of any pharmacologic therapy in these asthmatic patients. Evaluation of response to asthma treatment in clinical trials remains primarily symptom-based when symptoms have been shown to underestimate the severity of disease in seniors.

Asthma pharmacotherapy prescribing in the ambulatory population of the United States: evidence of nonadherence to national guidelines and implications for elderly people

OBJECTIVES

To examine the level of physician adherence to the Expert Panel Report 2 (EPR-2) pharmacotherapy guidelines of the asthma population, specifically in the elderly ambulatory patient population of the United States.

DESIGN

Retrospective cross-sectional study using a national survey.

SETTING

National Ambulatory Medical Care Survey data of U.S. elderly patients from 1998 through 2004.

PARTICIPANTS

The weighted population sample size was 82,020,318 patients. There were 1,540 observations in this study (preweighted sample size) and 96 strata, with 446 population sampling units (PSUs). There were 11,868,340 patients that were elderly, and they accounted for 14.5% of the overall population sampled.

MEASUREMENTS

Specific patient demographic variables, physician demographic variables, and information about asthma medications prescribed were extracted from the data set and analyzed. Descriptive statistics for the patient demographic, physician demographic, and asthma pharmacotherapy variables were generated. A series of logistic regression models were created, with the choice of asthma pharmacotherapy agent used as the dependent variable and patient and physician demographic variables as the independent variables.

RESULTS

A major finding was that physicians were not adherent to the National Asthma Education and Prevention Program EPR-2 asthma pharmacotherapy guidelines. Another finding was that, although elderly patients (aged >or=65) were exposed to more-stable patterns of care, they were less likely to be prescribed controller medications, long-acting bronchodilators (LABAs), combinations of inhaled corticosteroids and LABAs, and short-acting beta agonists than patients aged 35 to 64.

CONCLUSION

A more-concerted effort needs to be undertaken to improve physician adherence to the EPR-2 guidelines, especially in prescribing asthma pharmacotherapy to elderly patients.

Presence of Innovation Adoption-Facilitating Elements in Hospitals, and Relationship to Implementation of Clinical Guidelines

Background:

Despite evidence of benefit from implementation of clinical guidelines, numerous studies have found suboptimal guideline compliance among health professionals.

Objective:

To determine the presence in US hospitals of innovation adoptionfacilitating elements (IAE), assess associations between organizational characteristics and presence of IAE, and assess associations between presence of IAE and implementation of specific clinical guidelines.

Methods:

A mail survey of pharmacy directors in a national random sample of 236 general medical and surgical hospitals with more than 25 beds stratified by state was conducted. Key variables were presence of IAE, the leader's openness to change, centralization, formalization, complexity, size, and guideline implementation. Survey items from preexisting scales were revised for this study. Content validity of survey scales was assessed using expert panel ratings. Cognitive interviews were conducted during survey development to confirm that items were interpreted consistently across respondents. A modified Dillman approach was used to survey 236 hospitals.

Results:

The survey response rate was 69.5%. On average, sample hospitals had implemented 66.9% of IAE inquired about in the survey. Openness to change (p < 0.001), participation in decision-making (p < 0.001), and formalization (p < 0.001) were significantly associated with presence of IAE. However, complexity (p = 0.135) and hospital active bed size (p = 0.195) were not associated with presence of IAE. There was a positive association between presence of IAE and guideline implementation based on an overall score (p = 0.045); however, when guidelines were examined individually, only 1 of the 4 had a positive association (p = 0.029).

Conclusions:

There was a modest presence of IAE in the US hospitals reported here and significant positive association of leaders' openness to change, centralization, and formalization with presence of IAE in hospitals. Findings also indicate that presence of IAE within a hospital is associated with higher levels of clinical guideline implementation.

Asthma in older adults

Asthma is underdiagnosed and undertreated in older adults. The classic symptoms, including episodic wheezing, shortness of breath, and chest tightness, are nonspecific in this age group. Older patients may underrate symptoms, and other diseases, such as chronic obstructive pulmonary disease, congestive heart failure, and angina, may have similar presentations. Objective measurements of lung function always should complement the history taking and physical examination. Management of asthma in older adults should include careful monitoring, controlling triggers, optimizing and monitoring pharmacotherapy, and providing appropriate asthma education. Adverse effects to commonly used asthma medications are more common in older adults, and careful monitoring of their use and adverse effects is important.

Optimal management of asthma in elderly patients: strategies to improve adherence to recommended interventions

Adherence to asthma medications presents a problem in all age groups, and older people with chronic illnesses such as asthma also have multiple co-morbidities and consequently complex healthcare needs. It has been suggested that older people are also less likely to adhere to medication and treatment than younger people. Although the prevalence of asthma in older people is similar to that of the general population, over two-thirds of those who die from asthma are >50 years of age and there is strong evidence for under-diagnosis. Clinicians therefore face specific challenges in providing healthcare with respect to both asthma diagnosis and treatment in older age groups. Non-adherence to medication can be defined as either 'intentional' or 'unintentional'. Unintentional non-adherence is more likely to be associated with sociodemographic or physical barriers to the use of medication. Intentional non-adherence results from the balance of individual reasoning of risks versus the benefits of taking medication and acceptance of asthma diagnosis. Intentional non-adherence can be addressed through strategies that influence health beliefs and concerns about the adverse effects of medicine. Unintentional adherence can be addressed by assessing and educating the patient in relation to device use and providing education and clear written instructions about medication requirements. However, some barriers to medication use, such as financial ones, may be systematic. Most studies of medication use, efficacy, adverse effects and adherence in patients with asthma primarily involve younger people. Studies of strategies to improve asthma adherence outcomes specifically in older people are urgently needed.

Asthma in American Indian adults: the Strong Heart Study

BACKGROUND

Despite growing recognition that asthma is an important cause of morbidity among American Indians, there has been no systematic study of this disease in older adults who are likely to be at high risk of complications related to asthma. Characterization of the impact of asthma among American Indian adults is necessary in order to design appropriate clinical and preventive measures.

METHODS

A sample of participants in the third examination of the Strong Heart Study, a multicenter, population-based, prospective study of cardiovascular disease in American Indians, completed a standardized respiratory questionnaire, performed spirometry, and underwent allergen skin testing. Participants were > or = 50 years old.

RESULTS

Of 3,197 participants in the third examination, 6.3% had physician-diagnosed asthma and 4.3% had probable asthma. Women had a higher prevalence of physician-diagnosed asthma than men (8.2% vs 3.2%). Of the 435 participants reported in the asthma substudy, morbidity related to asthma was high: among those with physician-diagnosed asthma: 97% reported trouble breathing and 52% had severe persistent disease. The mean FEV(1) in those with physician-diagnosed asthma was 61.3% of predicted, and 67.2% reported a history of emergency department visits and/or hospitalizations in the last year, yet only 3% were receiving regular inhaled corticosteroids.

CONCLUSIONS

The prevalence of asthma among older American Indians residing in three separate geographic areas of the United States was similar to rates in other ethnic groups. Asthma was associated with low lung function, significant morbidity and health-care utilization, yet medications for pulmonary disease were underutilized by this population.

Two cases of asthma in handicapped elderly persons in which assisted inhalation therapy was effective

BACKGROUND

Chronic airway inflammation is a basic pathology of bronchial asthma and it is important to control the inflammation by anti-inflammatory therapy mainly with steroids. However, in asthma in the elderly, there are cases where physicians hesitate to introduce the inhaled corticosteroid (ICS) therapy based on the diagnosis that the use of inhalants is difficult due to the existence of a functional lesion accompanying asthma.

METHODS & RESULTS

In cases where self-administrated inhalation therapy is difficult to execute due to the accompaniment of a functional lesion and in cases where sufficient curative effects of steroids are not produced in self-inhalation, administration of assisted inhalation resulted in improvement of clinical symptoms and pulmonary function and was proven effective.

CONCLUSIONS

Assisted inhalation therapy is expected to be useful in general and also in terms of expanding the application of ICS in the asthma in the elderly.

Asthma in older adults: observations from the epidemiology and natural history of asthma: outcomes and treatment regimens (TENOR) study

BACKGROUND

The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens (TENOR) was a 3-year, multicenter, observational study of 4,756 patients 6 years or older with severe or difficult-to-treat asthma by physician evaluation. More than 280 pulmonologist and allergist sites across the United States participated.

OBJECTIVE

To compare health care utilization (HCU), medication use, asthma control, and quality of life (QoL) in older (> or =65 years; n = 566) and younger (18-64 years; n = 2,912) adult patients in TENOR.

METHODS

Patients had to be under a physician's care for at least 1 year and have high medication use or HCU in the past year. Heavy smokers (> or =30 pack-years) and patients with cystic fibrosis were excluded.

RESULTS

Although older patients in TENOR had worse lung function as measured by decreased percent predicted forced expiratory volume in 1 second (FEV1) (P < .001), they had significantly lower HCU compared with younger patients. They also had higher use of inhaled corticosteroids and better QoL than younger patients. Older patients reported fewer problems controlling their asthma (P < .001) but reported worse communication with their physicians (P = .02).

CONCLUSIONS

Older patients in TENOR appeared to do better than younger patients, despite having worse lung function. Older patients in TENOR may have received more aggressive care than older asthmatic patients in other studies, based on a higher use of inhaled and oral corticosteroids. Whether differences in treatment or disease influenced other physiologic or inflammatory outcomes that contribute to the disconnect between HCU and FEV1 awaits further study.

Clinical prognosis, pre-existing conditions and the use of reperfusion therapy for patients with ST segment elevation acute myocardial infarction

BACKGROUND

Some evidence-based therapies are underused in patients with a poor prognosis despite the fact that the survival gains would be highest among such patient subgroups. The extent to which this applies for acute, life-saving therapies is unknown. The impact of prognostic characteristics and pre-existing conditions on the use of reperfusion therapy among eligible patients with acute ST segment elevation myocardial infarction is examined.

METHODS

Of 2829 acute myocardial infarction patients prospectively identified in 53 acute care hospitals across Ontario, 987 presented with ST segment elevation within 12 h of symptom onset and without any absolute contraindications to reperfusion therapy. The baseline prognosis for each patient was derived from a validated risk-adjustment model of 30-day mortality. Multiple logistical regression was used to examine the relationships among reperfusion therapy, prognosis and the number of pre-existing chronic conditions after adjusting for factors such as age, sex, time since symptom onset and socioeconomic status.

RESULTS

Of the 987 appropriate candidates, 725 (73.5%) received reperfusion therapy (70.8% fibrinolysis, 2.6% primary angioplasty). The adjusted odds ratio of reperfusion therapy fell 4% with each 1% increase in baseline risk of death (adjusted OR 0.96, 95% CI 0.92 to 1.00, P=0.04) and fell 18% with each additional pre-existing condition (adjusted OR 0.82, 95% CI 0.76 to 0.90, P<0.001). The number rather than the type of pre-existing conditions inversely correlated with the use of reperfusion therapy. While the impact of baseline risk and pre-existing conditions was additive, pre-existing conditions exerted a greater impact on the nonuse of reperfusion therapy than did baseline risk.

CONCLUSIONS

A treatment-risk paradox is demonstrable even within a cohort of lower risk patients with ST segment elevation myocardial infarction. These findings are consistent with the view that these clinical decisions are more likely to be attributable to concerns about patient frailty or side effects than to a misunderstanding of treatment benefits.

Effects of inhaled corticosteroids on mortality and hospitalisation in elderly asthma and chronic obstructive pulmonary disease patients: appraising the evidence

Asthma and chronic obstructive pulmonary disease (COPD) are common conditions that have substantial effects on daily functioning and medical resource utilisation. In elderly populations, the use of inhaled corticosteroids (ICS) as a mainstay of treatment in asthma has long been accepted whereas the appropriateness and extent of use of ICS in COPD is not as clear. This paper reviews data associated with ICS treatment in the elderly, specifically characteristics of ICS users, rates of adherence, hospitalisation and mortality associated with ICS treatment. Studies examining the use of ICS in asthma and COPD have generally found that ICS may be underused compared with guideline recommendations or that there are substantial differences between patients who receive ICS and those who do not. Among elderly asthma or COPD patients who receive ICS, there are lower rates of hospitalisation among those who adhere to their treatment plan. Among elderly patients with asthma, the combination of ICS plus long-acting beta-adrenoceptor agonists has been shown to be superior in terms of mortality and hospitalisation compared with either treatment alone. There may be an interaction effect between oral corticosteroids and ICS among elderly COPD patients, although important differences may be present in the clinical characteristics of patients who receive one versus both forms of corticosteroids. A dose-response relationship between ICS and both all-cause and pulmonary-specific mortality has been shown among older COPD patients. Several existing studies are subject to selection bias, as they have identified patients who survived for a specified period, for example, long enough to have received a specified number of prescriptions for ICS. This bias must be further explored. Future research should also clearly delineate asthma and COPD populations in order to identify different benefits from ICS. The use of a claims database that also includes clinical metrics would be useful to identify additional possible outcomes of ICS use. Further, symptom diaries or other patient-reported outcomes, such as health-related quality of life and health status, should be included in studies of ICS among the elderly to identify other benefits that should be considered in treatment selection.

Inhaled corticosteroids and survival in COPD patients receiving long-term home oxygen therapy

BACKGROUND

Several observational studies suggest that therapy with inhaled corticosteroids (ICS) is associated with reduced mortality in patients with chronic obstructive pulmonary disease (COPD). However, none of these has reported survival data in COPD patients with respiratory insufficiency who require domiciliary oxygen therapy. The present study was conducted to examine the association between ICS and all-cause mortality in patients with severe COPD and chronic hypoxemia.

PATIENTS AND METHODS

From a tertiary referral clinic, we identified 145 consecutive COPD patients who met the criteria for long-term oxygen therapy between 1996 and 2002. We compared the hazard ratio (HR) for all-cause mortality over 1 year between patients who were (n=55) and were not treated with ICS (n=90).

RESULTS

In a crude analysis, the use of ICS was associated with a HR of 0.38 (95% confidence interval (CI)=0.18-0.79). After adjustments for age, sex, use of oral steroids, and beta2-agonists, PaO2 and PaCO2, the HR was 0.46 (95% CI=0.21-0.98).

CONCLUSIONS

Our findings indicate that ICS may reduce all-cause mortality in patients with severe COPD and chronic hypoxemia, who require long-term domiciliary oxygen therapy. These data suggest that ICS may play an important role in improving clinical outcomes in patients with advanced COPD.

Doubling daily inhaled corticosteroid dose is ineffective in mild to moderately severe attacks of asthma in adults

BACKGROUND

Asthma guidelines recommend increasing or doubling inhaled corticosteroid (ICS) dose to treat mild and moderate exacerbations of asthma in adults.

AIM

To: (i) compare the effectiveness of doubling existing daily ICS dose (fluticasone) with maintaining usual ICS dose and usual daily ICS dose accompanied by oral steroids (OS) (dexamethasone) during mild and moderately severe exacerbations of asthma in adults; (ii) examine determinants of success and failure; and (iii) compare side-effect profiles.

METHODS

A randomized, double-blind, placebo-controlled (double-dummy), triple crossover trial. Participants acted as their own control. Outcome measures included treatment success/failure, peak expiratory flow (PEF) after 7 days therapy or at treatment failure, and side-effects.

RESULTS

From 22 participants (nine males and 13 females), 18 pairs of data were available for maintaining usual ICS versus doubling ICS and doubling ICS versus OS, and 19 for maintaining usual ICS versus OS. Median (fifth-95th percentile) age was 46.5 (32-64) years and forced expiratory volume in one second (FEV(1)) 73% (29-97%) predicted. The outcome after doubling ICS was not superior to maintaining usual ICS, with 11 (61%) failures in both arms (P = 0.66). OS, with only 5 (26%) failures, was superior to maintaining usual ICS with 12 (63%) failures (P = 0.04), and to doubling ICS with 5 (28%) versus 11 (61%) failures (P = 0.07). Median PEF (as percentage of run-in best) at end-points were 90.5% (57.1-177.1) for OS, 78.3% (39.5-103.1) for maintaining usual ICS and 77.9 (27.7-110.3) for doubling ICS. Neither gender nor PEF at exacerbation were predictive of failure. Although doubling ICS was not an effective therapy overall, ICS dose at exacerbation were predictive of success in the doubling ICS arm (P = 0.04). Treatment failures when doubling daily ICS dose were more common if achieved fluticasone dose was less than 2000 microg (three of 11, 73%) compared to 2000 microg or greater (eight of eight, 37.5%). Increasing age and the presence of an upper respiratory tract infection (URTI) were predictive of failure with OS. Side-effects were more commonly reported with OS (52.6%) than doubling ICS (42.1%) or maintaining usual ICS (19.1%) with the most common being mood changes (36.8%), sleep disturbance (31.6%) and changes in appetite (26.3%).

CONCLUSIONS

Doubling daily ICS dose per se is not effective for the treatment of mild to moderately severe exacerbations of asthma in adults. Success may depend on achieved ICS dose. Oral steroids are effective, but side-effects are common. A review of current guidelines may be warranted.

Improving asthma symptom control in rural communities: the design of the Better Respiratory Education and Asthma Treatment in Hinton and Edson study

METHODS

The prevalence of asthma in adults in the United States is approximately 7%, and 9% of asthma patients will require hospitalization each year. Many patients do not seek care, as they do not recognize overuse of beta-agonists as a risk factor for poorly controlled asthma. However, pharmacists are able to identify these patients through refill information on reliever medication prescriptions and potentially initiate community-management opportunities for these patients.

DESIGN

The study is a randomized, controlled trial. Patients are randomized to intervention or usual care.

STUDY POPULATION

Patients are high-risk asthma patients (defined as having an ER visit or hospitalization in the previous year, or using >2 canisters of short-acting beta-agonist in the previous 6 months). They are identified through community pharmacies.

OBJECTIVES

The primary objective is to determine the effect of an education and referral intervention program initiated by community pharmacists, working with high-risk asthma patients, family physicians and respiratory therapists, on asthma control, as measured by the Asthma Control Questionnaire (ACQ). Secondary objectives include determining the effect of this program on ER visits/hospitalizations, inhaled corticosteroid use, courses of oral steroids and FEV(1).

INTERVENTION

The intervention includes patient education, assessment and optimization of drug therapy, and physician referral as needed. Patients are referred to a respiratory therapist within 1 week of randomization for measurement of FEV(1) and reinforcement of education. Patients assigned to usual care receive written asthma information, referral to a respiratory therapist and usual pharmacy and physician care. UNIQUE ASPECTS: The design of the Better Respiratory Education and Asthma Treatment in Hinton and Edson (BREATHE) study is unique, given the multidisciplinary involvement, rural and community based, pharmacist initiated and targets specifically high risk patients. We believe that this study will show that management of asthma patients, involving the major role-players in their asthma care, will improve their asthma control.