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Roifman I, Chu A, Austin PC, Rashid M, Douglas PS, Wijeysundera HC. Comparing Costs of Noninvasive Cardiac Diagnostic Tests-a Population-Based Study. J Am Soc Echocardiogr 2024; 37:288-299. [PMID: 37972792 DOI: 10.1016/j.echo.2023.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 11/05/2023] [Accepted: 11/06/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Noninvasive cardiac diagnostic tests (NITs) for the diagnosis of coronary artery disease have been estimated to cost >$3 billion annually in the United States alone and have recently undergone scrutiny over concerns of overuse. Consequently, comparing costs of different NIT testing strategies is of urgent importance to health care planning. METHODS We utilized population-based administrative and clinical data from Ontario, Canada, to compare downstream costs between 4 available NIT testing strategies (graded exercise stress testing [GXT], stress echocardiography, cardiac computed tomography angiography [CCTA], and myocardial perfusion imaging [MPI] as well as no testing), among patients evaluated for chest pain. To compare costs among the tested (overall and by testing strategy) and nontested groups, we used a log-gamma generalized linear model to account for the skewed distribution of health care cost data, adjusting for relevant clinical covariates. RESULTS A total of 2,340,699 patients were included in our cohort, of whom 481,170 (21%) patients received 1 of the 4 NITs. Among patients who received a NIT, 254,492 (53%) received a GXT as their initial test, 154,137 (32%) received MPI, 69,160 (14%) received a stress echo, and 3,381 (<1%) received a CCTA. After adjustment for differences in baseline patient characteristics, receipt of any NIT was associated with an approximate 12% reduction in downstream 1-year mean costs (cost ratio = 0.88; 95% CI, 0.87, 0.89) compared with those without any testing. Comparing the different testing strategies with no testing, both GXT (cost ratio = 0.80; 95% CI, 0.79-0.81) and stress echocardiography (cost ratio = 0.82; 95% CI, 0.81-0.83) were associated with the lower downstream costs, while both MPI (cost ratio = 1.26; 95% CI, 1.25, 1.27) and CCTA (cost ratio = 1.29; 95% CI, 1.23, 1.35) were associated with higher downstream costs. CONCLUSIONS In a large population-based cohort consisting of >2 million people evaluated for chest pain, we report that receipt of noninvasive testing was associated with a 12% reduction in downstream costs when compared with no testing. Graded exercise stress testing and stress echocardiography were associated with the least downstream costs, whereas CCTA and MPI were associated with higher costs when compared with no testing. These findings may help inform testing decisions in chest pain patients.
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Affiliation(s)
- Idan Roifman
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada.
| | | | - Peter C Austin
- Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada
| | | | - Pamela S Douglas
- Duke University Medical Centre, Duke University, Durham, North Carolina
| | - Harindra C Wijeysundera
- Schulich Heart Program, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada
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2
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Syamlal G, Dodd KE, Mazurek JM. Asthma, chronic obstructive pulmonary disease, and asthma-COPD overlap among US working adults. J Asthma 2023; 60:718-726. [PMID: 35696621 PMCID: PMC10664241 DOI: 10.1080/02770903.2022.2089997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/06/2022] [Accepted: 06/10/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Asthma-COPD overlap (ACO) is a respiratory condition with more severe respiratory symptoms, poorer quality of life, and increased hospital admissions compared with asthma or COPD alone. OBJECTIVES Estimate asthma, chronic obstructive pulmonary disease (COPD), and ACO prevalence among workers by industry and occupation and assess physical and mental health status, healthcare utilization, among workers with ACO. METHODS The 2014-2018 National Health Interview Survey (NHIS) data for working adults aged ≥18 years employed (sample n = 99,424) in the 12 months prior to the survey were analyzed. Age-adjusted ACO, COPD and asthma prevalence and prevalence ratios adjusted for age, sex, race and smoking status were estimated. RESULTS During 2014-2018, of the estimated 166 million (annual average) US workers, age-adjusted asthma, COPD, and ACO prevalence was 6.9%, 4.0%, and 1.1%, respectively. ACO prevalence was highest among workers aged ≥65 years (2.0%), females (1.6%), current smokers (1.9%), those living below the federal poverty level (2.3%), and workers in the accommodation and food services (1.6%) industry and personal care and service (2.3%) occupations. Workers with ACO had more frequent (p < 0.05) physician office visits, emergency department visits; and were more likely to be in poorer mental health, obese, have more lost workdays, more bed days, and comorbidities compared to workers with asthma alone and workers with COPD alone.Conclusion: Higher ACO prevalence among worker groups and increased healthcare utilization underscores the need for early identification of asthma and COPD, assessment of potential workplace exposures, and implementation of tailored interventions to reduce ACO among working adults.
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Affiliation(s)
- Girija Syamlal
- Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia, USA
| | - Katelynn E Dodd
- Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia, USA
| | - Jacek M Mazurek
- Respiratory Health Division, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Morgantown, West Virginia, USA
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Brunette MF, Halenar MJ, Edwards KC, Taylor KA, Emond JA, Tanski SE, Woloshin S, Paulin LM, Hyland A, Lauten K, Mahoney M, Blanco C, Borek N, DaSilva LC, Gardner LD, Kimmel HL, Sargent JD. Association between tobacco product use and asthma among US adults from the Population Assessment of Tobacco and Health (PATH) Study waves 2-4. BMJ Open Respir Res 2023; 10:10/1/e001187. [PMID: 36750276 PMCID: PMC9906250 DOI: 10.1136/bmjresp-2021-001187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 12/08/2022] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Research on cigarettes and adult asthma offers mixed findings, perhaps due to overlap with chronic obstructive pulmonary disease (COPD) and inadequate adjustment for other smoke exposures. Associations between other tobacco products, including e-cigarettes, and asthma are also understudied. RESEARCH QUESTION Using Population Assessment of Tobacco and Health Study waves 2-4 (2014/2015-2016/2017) data, we assessed the relation between tobacco product use and asthma in persons unlikely to have COPD. STUDY DESIGN AND METHODS Prospective study of 10 267 adults aged 18-39 years without COPD diagnoses. Past-month tobacco use at wave 2 was modelled first as combustible versus non-combustible use and second as specific product categories (former, cigarettes, e-cigarettes, cigars, hookah, smokeless tobacco). Outcomes included lifetime asthma prevalence at wave 2, incidence (waves 3 and 4) and Asthma Control Test score (lower=worse). Multivariable regressions adjusted for predictors of asthma, including other smoke exposures: cigarette pack-years, secondhand smoke and marijuana use. Sensitivity analyses examined findings when persons >39 years and those with both COPD and asthma were added, and when smoke exposure adjustments were removed. RESULTS No product, including cigarettes and e-cigarettes, was associated with prevalence or incidence of asthma. Among people with asthma at wave 2, combustible tobacco (beta=-0.86, 95% CI (-1.32 to -0.39)) and cigarettes (beta=-1.14, 95% CI (-1.66 to -0.62)) were associated with worse asthma control. No tobacco product was associated with asthma control over time. In sensitivity analyses, tobacco use became associated with incident asthma as adults >39 years and those with asthma+COPD were added, and as adjustments for other smoke exposures were omitted. INTERPRETATION Although cigarette use was associated with worse asthma control, there were no longitudinal associations between combustible tobacco or e-cigarette use and new onset or worsening asthma in these preliminary analyses. Research on tobacco and asthma should exclude COPD and adjust for smoking history and other smoke exposures.
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Affiliation(s)
- Mary F Brunette
- Research Division, Department of Psychiatry, Dartmouth Health, Lebanon, New Hampshire, USA .,Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA.,The C Everette Koop Institute, Dartmouth College, Lebanon, New Hampshire, USA.,The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire, USA
| | - Michael J Halenar
- Behavorial Health and Health Policy Practice, Westat, Rockville, Maryland, USA
| | - Kathryn C Edwards
- Behavorial Health and Health Policy Practice, Westat, Rockville, Maryland, USA
| | - Kristie A Taylor
- Behavorial Health and Health Policy Practice, Westat, Rockville, Maryland, USA
| | - Jennifer A Emond
- Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA,The C Everette Koop Institute, Dartmouth College, Lebanon, New Hampshire, USA
| | - Susanne E Tanski
- Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA,The C Everette Koop Institute, Dartmouth College, Lebanon, New Hampshire, USA
| | - Steven Woloshin
- The C Everette Koop Institute, Dartmouth College, Lebanon, New Hampshire, USA,The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, New Hampshire, USA
| | - Laura M Paulin
- Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA,The C Everette Koop Institute, Dartmouth College, Lebanon, New Hampshire, USA
| | - Andrew Hyland
- Department of Health and Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Kristen Lauten
- Behavorial Health and Health Policy Practice, Westat, Rockville, Maryland, USA
| | - Martin Mahoney
- Department of Health and Behavior, Roswell Park Comprehensive Cancer Center, Buffalo, New York, USA
| | - Carlos Blanco
- Division of Epidemiology, Services and Prevention Research (DESPR), National Institute on Drug Abuse, Bethesda, Maryland, USA
| | - Nicolette Borek
- Office of Science, Center for Tobacco Products, Silver Spring, Maryland, USA
| | | | - Lisa D Gardner
- Office of Science, Center for Tobacco Products, Silver Spring, Maryland, USA
| | - Heather L Kimmel
- Division of Epidemiology, Services and Prevention Research (DESPR), National Institute on Drug Abuse, Bethesda, Maryland, USA
| | - James D Sargent
- Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA,The C Everette Koop Institute, Dartmouth College, Lebanon, New Hampshire, USA
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Asamoah-Boaheng M, Farrell J, Bonsu KO, Oyet A, Midodzi WK. Association Between Medication Adherence and Risk of COPD in Adult Asthma Patients: A Retrospective Cohort Study in Canada. Clin Epidemiol 2022; 14:1241-1254. [PMID: 36325197 PMCID: PMC9621002 DOI: 10.2147/clep.s370623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/13/2022] [Indexed: 11/23/2022] Open
Abstract
Background Poor adherence to prescribed asthma medications and risk of severe asthma exacerbations have been well established. However, the effects of changes in asthma medication compliance levels and subsequent risk of COPD is unknown and yet to be investigated. This study investigated the independent effect of medication adherence (MA) and asthma severity levels on the risk of COPD. Methods We used four linked administrative health databases from the Population data BC to identify asthma patients aged 18 years and older between January 1, 1998 and December 31, 1999 without diagnosis of COPD. The primary event was time-to-COPD diagnosis during the follow-up period (January 1, 2000 to December 31, 2018). The proportion of days covered (PDC) – was used as a surrogate measure for medication adherence (MA) assessed at optimal-level (≥ 0.80), Intermediate-level (0.50–0.79), and low-level (< 0.5) of adherence. A propensity adjusted analysis with Marginal Structural Cox (MSC) model was employed to estimate the adjusted hazard ratios (aHR) and 95% confidence intervals (95% CI) for the effect of medication adherence and asthma severity over time. Results At cohort entry, the sample included 68,211 asthma patients with an overall mean age of 48.2 years. The 18-year incidence of COPD in asthma patients was 9.8 per 1000-persons year. In an inverse weighted propensity adjusted analysis of the MSC model, higher MA levels were significantly associated with decreased risk of COPD as follows: optimal-level (aHR: 0.19, 95% CI: 0.17–0.24); Intermediate-level (aHR: 0.20, 95% CI: 0.18, 0.23) compared to the low-level adherence group. A significant increase in COPD risk was observed in severe asthma patients with low medication adherence (aHR: 1.72, 95% CI: 1.52–1.93), independent of other patient factors. Conclusion Optimal (≥ 0.80) and intermediate adherence (0.5 to 0.79) levels were associated with reduced risk of COPD incidence over time. Interventions aimed at improving adherence to prescribed medications in adult asthma patients should be intensified to reduce their risk of COPD.
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Affiliation(s)
| | - Jamie Farrell
- Faculty of Medicine, Memorial University of Newfoundland, St John’s, NL, Canada
| | - Kwadwo Osei Bonsu
- School of Pharmacy, Memorial University of Newfoundland, St John’s, NL, Canada
| | - Alwell Oyet
- Department of Mathematics and Statistics, Memorial University of Newfoundland, St John’s, NL, Canada
| | - William K Midodzi
- Faculty of Medicine, Memorial University of Newfoundland, St John’s, NL, Canada,Correspondence: William K Midodzi, Faculty of Medicine, Memorial University of Newfoundland, St John’s, NL, Canada, Email
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5
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The Role of Smoking in Asthma and Chronic Obstructive Pulmonary Disease Overlap. Immunol Allergy Clin North Am 2022; 42:615-630. [DOI: 10.1016/j.iac.2022.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Thomson NC, Polosa R, Sin DD. Cigarette Smoking and Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:2783-2797. [PMID: 35533997 DOI: 10.1016/j.jaip.2022.04.034] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/27/2022] [Accepted: 04/29/2022] [Indexed: 11/29/2022]
Abstract
Globally, around half the adult asthma population are current or former cigarette smokers. Cigarette smoking and asthma interact to induce an "asthma-smoking phenotype(s)," which has important implications for diagnosis, pathogenic mechanisms, and management. The lack of progress in understanding the effects of smoking on adults with asthma is due in part to their exclusion from most investigative studies and large clinical trials. In this review, we summarize the adverse clinical outcomes associated with cigarette smoking in asthma, highlight challenges in diagnosing asthma among cigarette smokers with chronic respiratory symptoms, particularly in older individuals with a long-standing smoking history, and review pathogenic mechanisms involving smoking- and asthma-related airway inflammation, tissue remodeling, corticosteroid insensitivity, and low-grade systemic inflammation. We discuss the key components of management including the importance of smoking cessation strategies, evidence for the effectiveness of the Global Initiative for Asthma recommendations on treatment in cigarette smokers, and the role of treatable traits such as type 2 eosinophilic airway inflammation. Lastly, we provide an algorithm to aid clinicians to manage current and former smokers with asthma. In the future, controlled and pragmatic trials in real-world populations should include cigarette smokers with asthma to provide an evidence base for treatment recommendations.
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Affiliation(s)
- Neil C Thomson
- Institute of Infection, Immunity & Inflammation, University of Glasgow, Glasgow, United Kingdom.
| | - Riccardo Polosa
- Department of Clinical & Experimental Medicine, University of Catania, Catania, Italy; Centre for the Prevention and Treatment of Tobacco Addiction (CPCT), Teaching Hospital "Policlinico-V. Emanuele", University of Catania, Catania, Italy; Center of Excellence for the Acceleration of HArm Reduction (CoEHAR), University of Catania, Catania, Italy
| | - Don D Sin
- Division of Respirology, Department of Medicine, Centre for Heart Lung Innovation, St. Paul's Hospital, University of British Columbia, Vancouver, BC, Canada
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Roifman I, Han L, Fang J, Chu A, Austin P, Ko DT, Douglas P, Wijeysundera H. Patient, physician and geographic predictors of cardiac stress testing strategy in Ontario, Canada: a population-based study. BMJ Open 2022; 12:e059199. [PMID: 35273065 PMCID: PMC8915339 DOI: 10.1136/bmjopen-2021-059199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To identify patient, physician and geographic level factors that are associated with variation in initial stress testing strategy in patients evaluated for chest pain. DESIGN Retrospective cohort study. SETTING Population-based study of patients undergoing evaluation for chest pain in Ontario, Canada between 1 January 2011 and 31 March 2018. PARTICIPANTS 103 368 patients who underwent stress testing (graded exercise stress testing (GXT), stress echocardiography (stress echo) or myocardial perfusion imaging (MPI)) following evaluation for chest pain. PRIMARY AND SECONDARY OUTCOME MEASURES To identify the patient, physician and geographic level factors associated with variation in initial test selection, we fit two separate 2-level hierarchical multinomial logistic regression models for which the outcome was initial stress testing strategy (GXT, MPI or stress echo). RESULTS There was significant variability in the initial type of stress test performed, with approximately 50% receiving a GXT compared with approximately 36% who received MPI and 14% who received a stress echo. Physician-level factors were key drivers of this variation, accounting for up to 59.0% of the variation in initial testing. Physicians who graduated medical school >30 years ago were approximately 45% more likely to order an initial stress echo (OR 1.45, 95% CI 1.17 to 1.80) than a GXT. Cardiovascular disease specialists were approximately sevenfold more likely to order an initial MPI (OR 7.35, 95% CI 5.38 to 10.03) than a GXT. Patients aged >70 years were approximately fivefold more likely to receive an MPI (OR 4.74, 95% CI 4.42 to 5.08) and approximately 26% more likely to receive a stress echo (OR 1.26, 95% CI 1.15 to 1.38) than a GXT. CONCLUSIONS We report significant variability in initial stress testing strategy in Ontario. Much of that variability was driven by physician-level factors that could potentially be addressed through educational campaigns geared at reducing this variability and improving guideline adherence.
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Affiliation(s)
- Idan Roifman
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Lu Han
- ICES, Toronto, Ontario, Canada
| | | | | | - Peter Austin
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Dennis T Ko
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Pamela Douglas
- Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Harindra Wijeysundera
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
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Asamoah-Boaheng M, Farrell J, Osei Bonsu K, Midodzi WK. Examining Risk Factors Accelerating Time-to-Chronic Obstructive Pulmonary Disease (COPD) Diagnosis among Asthma Patients. COPD 2022; 19:47-56. [PMID: 35012399 DOI: 10.1080/15412555.2021.2024159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Asthma patients may have an increased risk for diagnosis of chronic obstructive pulmonary disease (COPD). However, risk factors accelerating time-to-COPD diagnosis are unclear. This study aims to estimate risk factors associated with the incidence of COPD diagnosis in asthma patients. Canada's Population Data BC (PopData BC) was used to identify asthma patients without prior COPD diagnosis between January 1, 1998, to December 31, 1999. Patients were assessed for time-to-incidence of COPD diagnosis from January 1, 2000, to December 31, 2018. The study estimated the effects of several risk factors in predicting the incidence of COPD in asthma patients during the 18-year follow-up period. Patient factors such as Medication Adherence (MA) were assessed by the proportion of days covered (PDC) and the medication possession ratio (MPR). The log-logistic mixed-effects accelerated failure time model was used to estimate the adjusted failure time ratios (aFTR) and 95% Confidence Interval (95% CI) for factors predicting time-to-COPD diagnosis among asthma patients. We identified 68,211 asthma patients with a mean age of 48.2 years included in the analysis. Risk factors accelerating time-to-COPD diagnosis included: male sex (aFTR: 0.62, 95% CI:0.56-0.68), older adults (age > 40 years) [aFTR: 0.03, 95% CI: 0.02-0.04], history of tobacco smoking (aFTR: 0.29, 95% CI: 0.13-0.68), asthma exacerbations (aFTR: 0.81, 95%CI: 0.70, 0.94), frequent emergency admissions (aFTR:0.21, 95% CI: 0.17-0.25), longer hospital stay (aFTR:0.07, 95% CI: 0.06-0.09), patients with increased burden of comorbidities (aFTR:0.28, 95% CI: 0.22-0.34), obese male sex (aFTR:0.38, 95% CI: 0.15-0.99), SABA overuse (aFTR: 0.61, 95% CI: 0.44-0.84), moderate (aFTR:0.23, 95% CI: 0.21-0.26), and severe asthma (aFTR:0.10, 95% CI: 0.08-0.12). After adjustment, MA ≥0.80 was significantly associated with 83% delayed time-to-COPD diagnosis [i.e. aFTR =1.83, 95%CI: 1.54-2.17 for PDC]. However, asthma severity significantly modifies the effect of MA independent of tobacco smoking history. The targeted intervention aimed to mitigate early diagnosis of COPD may prioritize enhancing medication adherence among asthma patients to prevent frequent exacerbation during follow-up.
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Affiliation(s)
- Michael Asamoah-Boaheng
- Faculty of Medicine, Division of Community Health and Humanity, Clinical Epidemiology Unit, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Jamie Farrell
- Faculty of Medicine, Division of Respirology, Memorial University of Newfoundland, St. John's, NL, Canada
| | - Kwadwo Osei Bonsu
- School of Pharmacy, Memorial University of Newfoundland, St. John's, NL, Canada
| | - William K Midodzi
- Faculty of Medicine, Division of Community Health and Humanity, Clinical Epidemiology Unit, Memorial University of Newfoundland, St. John's, NL, Canada
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Narh CT, Der JB, Afetor M, Ofosu A, Blettner M, Wollschlaeger D. Sociodemographic factors associated with time to discharge for hospitalised patients with asthma and asthma exacerbation using the Ghana Health Service District Information Management System 2 (DHIMS-2) database, 2012-2017. BMJ Open Respir Res 2021; 8:8/1/e001034. [PMID: 34815230 PMCID: PMC8611432 DOI: 10.1136/bmjresp-2021-001034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 10/29/2021] [Indexed: 11/14/2022] Open
Abstract
Objective Data on asthma hospitalisations are a useful source of patient morbidity information. In Ghana, the length of stay (LoS) and sociodemographic factors of patients hospitalised for asthma and its exacerbation are understudied. We aimed to investigate the time to discharge and assessed factors associated with length of hospital stays of asthmatics in Ghana. Methods Retrospective analysis of hospitalised patient with asthma records between 2012 and 2017 from the nationwide Ghana Health Service District Health Information Management System 2 database. We calculated the cumulative incidence function for discharge stratified by age group and sex. Multivariable Cox regression was used to investigate the association of sociodemographic characteristics with the LoS. Results Of 19 926 asthma-associated hospitalisations, 730 (3.7%) were due to asthma exacerbation. Overall mean age was 34 years (SD=24.6), in 12 000 (60.2%) hospitalisations, patients were female. There were 224 deaths (1.1%). Median LoS was 2 days (IQR: 1–3) with almost 90% of all patients discharged by the seventh day. Age and region were among the covariates showing significant association with LoS. Age below 10 years (HR: 1.39 (1.11 to 1.78)) was associated with early discharge while comorbidity and health insurance ownership were associated with late discharge (p<0.001). LoS did not vary by sex. Compared with the Greater Accra region, patients in other regions had shorter LoS, especially the Ashanti and Upper West regions (p<0.001). LoS increased annually, but was highest in 2016 (HR: 0.94 (0.90 to 0.98)). Conclusion Disparities in LoS across regions, and an overall increasing annual trend in Ghana call for tailored healthcare resource allocation. Longer LoS implies that patients are often absent from school or work leading to substantial financial and emotional costs to individuals and families.
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Affiliation(s)
- Clement T Narh
- Department of Epidemiology and Biostatistics, University of Health and Allied Sciences, Ho, Ghana .,Biostatistics Department, Institute for Medical Biostatistics, Epidemiology and Informatics, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany
| | - Joyce B Der
- Department of Epidemiology and Biostatistics, University of Health and Allied Sciences, Ho, Ghana
| | - Maxwell Afetor
- Health Information, Ho Polyclinic, Ghana Health Service, Accra, Ghana
| | - Anthony Ofosu
- Center for Health Information Management, Ghana Health Service, Accra, Ghana
| | - Maria Blettner
- Radiation Epidemiology, Institute for Medical Biostatistics, Epidemiology and Informatics, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany
| | - Daniel Wollschlaeger
- Radiation Epidemiology, Institute for Medical Biostatistics, Epidemiology and Informatics, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany
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10
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Leung C, Sin DD. Asthma-COPD Overlap: What Are the Important Questions? Chest 2021; 161:330-344. [PMID: 34626594 DOI: 10.1016/j.chest.2021.09.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/26/2021] [Accepted: 09/29/2021] [Indexed: 01/15/2023] Open
Abstract
Asthma-COPD overlap (ACO) is a heterogeneous condition that describes patients who show persistent airflow limitation with clinical features that support both asthma and COPD. Although no single consensus definition exists to diagnose this entity, common major criteria include a strong bronchodilator reversibility or bronchial hyperreactivity, a physician diagnosis of asthma, and a ≥ 10-pack-year cigarette smoking history. The prevalence of ACO ranges from 0.9% to 11.1% in the general population, depending on the diagnostic definition used. Notably, patients with ACO experience greater symptom burden, worse quality of life, and more frequent and severe respiratory exacerbations than those with asthma or COPD. The underlying pathophysiologic features of ACO have been debated. Although emerging evidence supports the role of environmental and inhalational exposures in its pathogenesis among patients with a pre-existing airway disease, biomarker profiling and genetic analyses suggest that ACO may be a heterogeneous condition, but with definable characteristics. Early-life factors including childhood-onset asthma and cigarette smoking may interact to increase the risk of airflow obstruction later in life. For treatment options, the population with ACO historically has been excluded from therapeutic trials; therefore strong, evidence-based recommendations are lacking beyond first-line inhaler therapies. Advanced therapies in patients with ACO are selected according to disease phenotypes and are based on extrapolated data from asthma and COPD. Research focused on defining biomarkers and evidence-based treatment options for ACO is needed urgently.
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Affiliation(s)
- Clarus Leung
- Centre for Heart Lung Innovation, University of British Columbia, St. Paul's Hospital, Vancouver, BC, Canada
| | - Don D Sin
- Centre for Heart Lung Innovation, University of British Columbia, St. Paul's Hospital, Vancouver, BC, Canada.
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11
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Sivakumaran S, Alsallakh MA, Lyons RA, Quint JK, Davies GA. Identifying COPD in routinely collected electronic health records: a systematic scoping review. ERJ Open Res 2021; 7:00167-2021. [PMID: 34527726 PMCID: PMC8435805 DOI: 10.1183/23120541.00167-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 06/24/2021] [Indexed: 11/23/2022] Open
Abstract
Although routinely collected electronic health records (EHRs) are widely used to examine outcomes related to COPD, consensus regarding the identification of cases from electronic healthcare databases is lacking. We systematically examine and summarise approaches from the recent literature. MEDLINE via EBSCOhost was searched for COPD-related studies using EHRs published from January 1, 2018 to November 30, 2019. Data were extracted relating to the case definition of COPD and determination of COPD severity and phenotypes. From 185 eligible studies, we found widespread variation in the definitions used to identify people with COPD in terms of code sets used (with 20 different code sets in use based on the ICD-10 classification alone) and requirement of additional criteria (relating to age (n=139), medication (n=31), multiplicity of events (n=21), spirometry (n=19) and smoking status (n=9)). Only seven studies used a case definition which had been validated against a reference standard in the same dataset. Various proxies of disease severity were used since spirometry results and patient-reported outcomes were not often available. To enable the research community to draw reliable insights from EHRs and aid comparability between studies, clear reporting and greater consistency of the definitions used to identify COPD and related outcome measures is key.
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Affiliation(s)
| | | | - Ronan A. Lyons
- Population Data Science, Swansea University Medical School, Swansea, UK
| | - Jennifer K. Quint
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Gwyneth A. Davies
- Population Data Science, Swansea University Medical School, Swansea, UK
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Sex and Gender Differences in Lung Disease. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2021; 1304:227-258. [PMID: 34019273 DOI: 10.1007/978-3-030-68748-9_14] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Sex differences in the anatomy and physiology of the respiratory system have been widely reported. These intrinsic sex differences have also been shown to modulate the pathophysiology, incidence, morbidity, and mortality of several lung diseases across the life span. In this chapter, we describe the epidemiology of sex differences in respiratory diseases including neonatal lung disease (respiratory distress syndrome, bronchopulmonary dysplasia) and pediatric and adult disease (including asthma, cystic fibrosis, idiopathic pulmonary fibrosis, chronic obstructive pulmonary disease, lung cancer, lymphangioleiomyomatosis, obstructive sleep apnea, pulmonary arterial hypertension, and respiratory viral infections such as respiratory syncytial virus, influenza, and SARS-CoV-2). We also discuss the current state of research on the mechanisms underlying the observed sex differences in lung disease susceptibility and severity and the importance of considering both sex and gender variables in research studies' design and analysis.
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Abstract
PURPOSE OF REVIEW Asthma and chronic obstructive pulmonary disease are both commonly encountered respiratory conditions. The term asthma--COPD overlap (ACO) has been used to identify patients presenting with features of both conditions. Controversy exists regarding its definition, approach to diagnosis and management. In this publication, recent evidence has been reviewed that provides insight into diagnosis and management of this condition. RECENT FINDINGS Previously, multiple criteria were used to define Asthma--COPD overlap. In this publication, the most recent guidelines to identify this condition have been reviewed. This publication provides a summary of the recent evidence with regard to the role of various diagnostic modalities including the use of biomarkers, such as exhaled nitric oxide, serum IgE and provides updated evidence on available treatment choices for this condition. SUMMARY ACO is a commonly encountered clinical condition with patients experiencing frequent exacerbations and resulting in increased healthcare resource utilization. Recent interest in ACO has led to development of a framework towards diagnosis and management of this condition. Therapeutic choices for ACO range from bronchodilator therapy to immunomodulatory therapy, highlighting the heterogeneity of this condition. Additional research is required to improve understanding of pathogenesis and improve outcomes in ACO.
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Wang C, Meng X, Meng M, Shi M, Sun W, Li X, Zhang X, Liu R, Fu Y, Song L. Oxidative stress activates the TRPM2-Ca 2+-NLRP3 axis to promote PM 2.5-induced lung injury of mice. Biomed Pharmacother 2020; 130:110481. [PMID: 32674019 DOI: 10.1016/j.biopha.2020.110481] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 06/14/2020] [Accepted: 06/30/2020] [Indexed: 01/22/2023] Open
Abstract
PM2.5, a main particulate air pollutant, poses a serious hazard to human health. The exposure to PM2.5 increases mortality and morbidity of many respiratory diseases such as asthma, chronic obstructive pulmonary diseases and even lung cancer. The contribution of reactive oxygen species (ROS) in the PM2.5-induced acute lung injury process was confirmed in our previous research, but the molecular mechanism based for it remains unclarified. In this research, ROS-induced lung injury after exposure to PM2.5 was explored in vivo and in vitro. The in vivo study indicated that N-acetyl-L-cysteine (NAC) could attenuate the accumulation of inflammatory cells, the thickening of alveolar wall and the degree of lung injury. Furthermore, we found ROS could regulate the intracellular Ca2+ level, expression of the Transient Receptor Potential Melastatin 2 (TRPM2), NLRP3 and its downstream inflammatory factors in vivo. In vitro experiments with A549 cells and primary type II alveolar epithelium cells (SD cells) showed that ROS induced by PM2.5 exposure could mediate intracellular Ca2+ mobilization via TRPM2, with a subsequent activation of NLRP3. In our present study, we demonstrated the contribution of the ROS-TRPM2-Ca2+-NLRP3 pathway in PM2.5-induced acute lung injury and offered a potential therapeutical target valid for related pathology.
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Affiliation(s)
- Chunyuan Wang
- College of Medical Laboratory, Dalian Medical University, Dalian, Liaoning Province, 116044, People's Republic of China
| | - Xianzong Meng
- College of Medical Laboratory, Dalian Medical University, Dalian, Liaoning Province, 116044, People's Republic of China; Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, Netherlands
| | - Meiling Meng
- College of Medical Laboratory, Dalian Medical University, Dalian, Liaoning Province, 116044, People's Republic of China
| | - Min Shi
- College of Medical Laboratory, Dalian Medical University, Dalian, Liaoning Province, 116044, People's Republic of China
| | - Wenping Sun
- College of Medical Laboratory, Dalian Medical University, Dalian, Liaoning Province, 116044, People's Republic of China
| | - Xiaojing Li
- College of Medical Laboratory, Dalian Medical University, Dalian, Liaoning Province, 116044, People's Republic of China
| | - Xiao Zhang
- College of Medical Laboratory, Dalian Medical University, Dalian, Liaoning Province, 116044, People's Republic of China
| | - Ruihao Liu
- College of Medical Laboratory, Dalian Medical University, Dalian, Liaoning Province, 116044, People's Republic of China
| | - Ying Fu
- College of Medical Laboratory, Dalian Medical University, Dalian, Liaoning Province, 116044, People's Republic of China.
| | - Laiyu Song
- College of Medical Laboratory, Dalian Medical University, Dalian, Liaoning Province, 116044, People's Republic of China.
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To T, Zhu J, Stieb D, Gray N, Fong I, Pinault L, Jerrett M, Robichaud A, Ménard R, van Donkelaar A, Martin RV, Hystad P, Brook JR, Dell S. Early life exposure to air pollution and incidence of childhood asthma, allergic rhinitis and eczema. Eur Respir J 2020; 55:13993003.00913-2019. [PMID: 31806712 PMCID: PMC7031706 DOI: 10.1183/13993003.00913-2019] [Citation(s) in RCA: 78] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 11/07/2019] [Indexed: 01/08/2023]
Abstract
Rationale There is growing evidence that air pollution may contribute to the development of childhood asthma and other allergic diseases. In this follow-up of the Toronto Child Health Evaluation Questionnaire (T-CHEQ) study, we examined associations between early life exposures to air pollution and incidence of asthma, allergic rhinitis and eczema from birth through adolescence. Methods 1286 T-CHEQ participants were followed from birth until outcome (March 31, 2016) or loss to follow-up, with a mean of 17 years of follow-up. Concentrations of nitrogen dioxide (NO2), ozone (O3) and particulate matter with a 50% cut-off aerodynamic diameter of 2.5 µm (PM2.5) from January 1, 1999 to December 31, 2012 were assigned to participants based on their postal codes at birth using ground observations, chemical/meteorological models, remote sensing and land-use regression models. Study outcomes included incidence of physician-diagnosed asthma, allergic rhinitis and eczema. Cox proportional hazard regression models were used to estimate hazard ratios per interquartile range of exposures and outcomes, adjusting for potential confounders. Results Hazard ratios of 1.17 (95% CI 1.05–1.31) for asthma and 1.07 (95% CI 0.99–1.15) for eczema were observed for total oxidants (O3 and NO2) at birth. No significant increase in risk was found for PM2.5. Conclusions Exposures to oxidant air pollutants (O3 and NO2) but not PM2.5 were associated with an increased risk of incident asthma and eczema in children. This suggests that improving air quality may contribute to the prevention of asthma and other allergic disease in childhood and adolescence. This study found that exposure to total oxidants at birth increased the risk of developing asthma by 17% and eczema by 7%. Adverse impacts of exposure to air pollutants, particularly ozone and nitrogen dioxide, may have their origins in early life.http://bit.ly/33PClYN
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Affiliation(s)
- Teresa To
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada .,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Jingqin Zhu
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Dave Stieb
- Environmental Health Science and Research Bureau, Health Canada, Ottawa, ON, Canada
| | - Natasha Gray
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Ivy Fong
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada
| | - Lauren Pinault
- Analytical Studies Branch, Statistics Canada, Ottawa, ON, Canada
| | - Michael Jerrett
- Fielding School of Public Health, The University of California, Los Angeles, CA, USA
| | - Alain Robichaud
- Air Quality Research Division, Environment and Climate Change Canada, Dorval, QC, Canada
| | - Richard Ménard
- Air Quality Research Division, Environment and Climate Change Canada, Dorval, QC, Canada
| | - Aaron van Donkelaar
- Dept of Physics and Atmospheric Science, Dalhousie University, Halifax, NS, Canada.,Dept of Energy, Environmental and Chemical Engineering, Washington University in St Louis, St Louis, MO, USA
| | - Randall V Martin
- Dept of Physics and Atmospheric Science, Dalhousie University, Halifax, NS, Canada.,Dept of Energy, Environmental and Chemical Engineering, Washington University in St Louis, St Louis, MO, USA.,Harvard-Smithsonian Center for Astrophysics, Cambridge, MA, USA
| | - Perry Hystad
- College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA
| | - Jeffrey R Brook
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Sharon Dell
- Child Health Evaluative Sciences, Research Institute, The Hospital for Sick Children, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Chronic Asthma and Bronchitis without Persistent Airflow Limitation May Have Been Misclassified as Chronic Obstructive Pulmonary Disease Using Administrative Data. Ann Am Thorac Soc 2019; 15:1496-1497. [PMID: 30216740 DOI: 10.1513/annalsats.201808-569le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Modifiable Risk Factors for Asthma and Chronic Obstructive Pulmonary Disease Overlap: Encouraging Healthy Living. Ann Am Thorac Soc 2019; 15:1275-1276. [PMID: 30382782 DOI: 10.1513/annalsats.201808-584ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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