1
|
Davis SR, Cvetkovski B, Katsoulotos GP, Lee JW, Rimmer J, Smallwood N, Tonga KO, Abbott P, Bosnic-Anticevich SZ. The Path to Diagnosis of Severe Asthma-A Qualitative Exploration. Int J Gen Med 2024; 17:3601-3611. [PMID: 39184910 PMCID: PMC11342952 DOI: 10.2147/ijgm.s435347] [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: 09/08/2023] [Accepted: 05/17/2024] [Indexed: 08/27/2024] Open
Abstract
Purpose Severe asthma poses a significant health burden in those with the disease, therefore a timely diagnosis can ensure patients receive specialist care and appropriate medication management. This study qualitatively explored the patient experience of adult Australians with severe asthma regarding specialist referral, to identify potential opportunities to streamline the process of severe asthma diagnosis and treatment and optimise referral pathways. Patients and Methods Adults currently being treated with medication for severe asthma were invited to participate in this study. Participants were interviewed and asked to describe initial diagnosis of their asthma or severe asthma, and how they came to be referred to secondary care. Interviews were transcribed verbatim, coded by two members of the research team and thematically analysed. Results Thirty-two people completed the study; 72% were female. Mean interview length was 33 minutes. The major themes generated were patient-related factors contributing to seeking a severe asthma diagnosis; perceptions of health care provision; diagnosis of severe asthma and the referral journey. Key findings were that both patient and healthcare provider attitudes contributed to participants' willingness to seek or receive a referral, and referral to respiratory specialists was often delayed. Contributing factors included a mismatch between patient expectations and general practice, lack of continuity of primary care, and a lack of patient understanding of the role of the respiratory specialist. Conclusion Timely severe asthma diagnosis in Australia appears to be hampered by an absence of a clear referral process, lack of general practitioner (GP) knowledge of additional treatment options, underutilisation of pharmacists, and multiple specialists treating patient comorbidities. Directions for future research might include interviewing healthcare providers regarding how well the referral process works for severe asthma patients, and researching the time between referral and when a patient sees the respiratory specialist.
Collapse
Affiliation(s)
- Sharon R Davis
- Woolcock Institute of Medical Research, Macquarie Park, NSW, Australia
| | | | | | - Joy W Lee
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, VIC, Australia
| | - Janet Rimmer
- Department of Respiratory Medicine, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Natasha Smallwood
- Department of Respiratory Medicine, Alfred Hospital, Melbourne, VIC, Australia
| | - Katrina O Tonga
- Respiratory Department, Westmead Hospital, Westmead Clinical School, Faculty of Medicine & Health, University of Sydney, Sydney, NSW, Australia
| | - Penelope Abbott
- School of Medicine, Western Sydney University, Penrith, NSW, Australia
| | - Sinthia Z Bosnic-Anticevich
- Woolcock Institute of Medical Research, Macquarie Park, NSW, Australia
- Macquarie Medical School, Macquarie University, Macquarie Park, NSW, Australia
| |
Collapse
|
2
|
Carr T, Tkacz J, Chung Y, Ambrose CS, Spahn J, Rane P, Wang Y, Lindsley AW, Lewing B, Burnette A. Gaps in Care Among Uncontrolled Severe Asthma Patients in the United States. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1775-1782.e2. [PMID: 38508336 DOI: 10.1016/j.jaip.2024.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 03/08/2024] [Accepted: 03/11/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Understanding the implementation of key guideline recommendations is critical for managing severe asthma (SA) in the treatment of uncontrolled disease. OBJECTIVE To assess specialist visits and medication escalation in US patients with SA after events indicating uncontrolled disease (EUD) and associations with health outcomes and social disparity indicators. METHODS Patients with SA appearing in administrative claims data spanning 2015 to 2020 were indexed hierarchically on asthma-related EUD, including hospitalizations, emergency department visits with systemic corticosteroid treatment, or outpatient visits with systemic corticosteroid treatment. Patients with SA without EUD served as controls. Eligibility included age 12 or greater, 12 months enrollment before and after index, no biologic use, and no other major respiratory disease during the pre-period. Escalation of care in the form of specialist visits and medication escalation, health care resource use, costs, and disease exacerbations were assessed during follow-up. RESULTS We identified 180,736 patients with SA (90,368 uncontrolled and 90,368 controls). Between 35% and 51% of patients with SA with an EUD had no specialist visit or medication escalation. Follow-up exacerbations ranged from 51% to 4% across EUD cohorts, compared with 13% in controls. Among uncontrolled patients with SA who were Black or Hispanic/Latino, 41% and 38%, respectively, had no specialist visit or medication escalation after EUD, compared with 33% of non-Hispanic White patients. CONCLUSIONS A substantial proportion of uncontrolled patients with SA had no evidence of specialist visits or medication escalation after uncontrolled disease, and there was a clear relationship between uncontrolled disease and subsequent health care resource use and exacerbations. Findings highlight the need for improved guideline-based care delivery to patients with SA, particularly for those facing social disparities.
Collapse
Affiliation(s)
- Tara Carr
- Department of Medicine, University of Arizona, Tucson, Ariz
| | | | | | | | | | | | | | | | | | - Autumn Burnette
- Division of Allergy and Immunology, Howard University, Washington, DC
| |
Collapse
|
3
|
Al-Ahmad M, Al Zaabi A, Madkour A, Alqaraghuli HA, Al Hayaan H, Mobayed H, Idrees M, Al Busaidi N, Zeineldine S. Expert consensus on oral corticosteroids stewardship for the treatment of severe asthma in the Middle East and Africa. Respir Med 2024; 228:107674. [PMID: 38782138 DOI: 10.1016/j.rmed.2024.107674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 05/17/2024] [Accepted: 05/18/2024] [Indexed: 05/25/2024]
Abstract
In the Middle East and Africa (MEA) region, overuse of oral corticosteroids (OCS) for asthma management, both as burst and maintenance therapy, poses a significant challenge. Gaps in knowledge regarding the need to taper OCS in patients with severe asthma and the use of OCS in comorbid conditions have been noted. OCS stewardship can help attain optimal and effective OCS tapering along with reducing OCS overuse and over-reliance. In this paper, we discuss current practices regarding the use of OCS in asthma, globally and in the MEA region. Expert recommendations for achieving OCS stewardship in the MEA region have also been presented. Regional experts recommend increasing awareness among patients about the consequences of OCS overuse, engaging community pharmacists, and educating primary healthcare professionals about the benefits of prompt appropriate referral. Innovative local referral tools like ReferID can be utilized to refer patients with asthma to specialist care. The experts also endorse a multidisciplinary team approach and accelerating access to newer medicines like biologics to implement OCS stewardship and optimize asthma care in the MEA region.
Collapse
Affiliation(s)
- Mona Al-Ahmad
- Microbiology Department, College of Medicine, Kuwait University, Kuwait.
| | | | | | | | | | | | - Majdy Idrees
- Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | | | | |
Collapse
|
4
|
Damery S, Jones J, Idris E, Cooper A, Minshall H, Clowes C, Jolly K. Mixed-methods evaluation of an enhanced asthma biologics clinical pathway in the West Midlands UK. NPJ Prim Care Respir Med 2024; 34:7. [PMID: 38693173 PMCID: PMC11063170 DOI: 10.1038/s41533-024-00365-y] [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: 10/27/2023] [Accepted: 04/10/2024] [Indexed: 05/03/2024] Open
Abstract
Biologic treatments can alleviate severe asthma symptoms and reduce health service use. However, service capacity limits and low referral rates from primary care indicate unmet patient need. We report a mixed-methods evaluation of an enhanced severe asthma pathway implemented in Staffordshire and Stoke-on-Trent, UK which aimed to optimise primary care referrals through training/education, and increased capacity in specialist clinics. Quantitative analysis assessed patient wait times between pathway stages, prescribing changes, exacerbations, hospital admissions and asthma control. Interviews with 12 stakeholders evaluated perceptions of the enhanced pathway across settings. In 12 months, 564 patients from 28 general practices were reviewed for biologics eligibility, of whom 125 (22.2%) were referred for specialist assessment. Wait times were significantly lower under the enhanced pathway when compared against historic patients following the standard pathway, and reduced overall from a mean of 76.4 to 26.7 weeks between referral and biologics initiation (p < 0.001). Patients commencing biologics (n = 46) showed significantly reduced reliever inhaler prescribing rates (p = 0.037), 60% lower oral steroid use (p < 0.001), significantly reduced exacerbation rates (p < 0.001) and fewer hospital admissions (p < 0.001) compared with the 12 months pre-treatment. Mean asthma control scores reduced from 3.13 pre-initiation to 1.89 post-initiation (p < 0.001) - a clinically significant improvement. Interviewees viewed the enhanced pathway positively, although ongoing issues related to difficulties engaging primary care amid concerns around increased workloads and pathway capacity. The large number of referrals generated from a comparatively small number of general practices confirms substantial unmet need that an enhanced severe asthma pathway could help address if implemented routinely.
Collapse
Affiliation(s)
- Sarah Damery
- Institute of Applied Health Research, University of Birmingham, Edgbaston, West Midlands, B15 2TT, UK.
| | - Janet Jones
- Institute of Applied Health Research, University of Birmingham, Edgbaston, West Midlands, B15 2TT, UK
| | - Elfatih Idris
- Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Newcastle Road, Staffordshire, ST4 6QG, UK
| | - Angela Cooper
- Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Newcastle Road, Staffordshire, ST4 6QG, UK
| | - Holly Minshall
- Royal Stoke University Hospital, University Hospitals of North Midlands NHS Trust, Newcastle Road, Staffordshire, ST4 6QG, UK
| | - Chris Clowes
- Health Innovation West Midlands, Faraday Wharf, Holt Street, Birmingham, B7 4BB, UK
| | - Kate Jolly
- Institute of Applied Health Research, University of Birmingham, Edgbaston, West Midlands, B15 2TT, UK
| |
Collapse
|
5
|
Kallis C, Morgan A, Fleming L, Quint JK. Prevalence of Poorly Controlled Asthma and Factors Associated with Specialist Referral in Those with Poorly Controlled Asthma in a Paediatric Asthma Population. J Asthma Allergy 2023; 16:1065-1075. [PMID: 37808460 PMCID: PMC10559784 DOI: 10.2147/jaa.s428623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 09/24/2023] [Indexed: 10/10/2023] Open
Abstract
Background Significant morbidity and mortality are associated with poor asthma control. The aim of this study was to determine factors associated with poor control and referral to specialist secondary care services. Methods We used primary care data from the Clinical Practice Research Datalink Aurum (CPRD) linked with Hospital Episode Statistics (HES) records from 1st January 2007 to 31st December 2019. We selected patients aged 6-17 years old. Poor control was defined as six or more prescriptions of short-acting beta-agonist (SABA) inhalers, two or more courses of oral corticosteroids (OCS), an Asthma Control test (ACT) or childhood ACT <20, one hospital admission for asthma, or one visit to Accident & Emergency (A&E) department for asthma-related episodes in the 12 months following asthma diagnosis. Asthma severity was defined following GINA guidelines 2021. Results About 17.6% of children aged between 6 and 17 years with active asthma had poor control. Severe asthma, eczema, food allergies, increased BMI and living in deprived areas were identified as risk factors for poor control. Among those with poor control, referral rates to specialist care were extremely low, only 2% overall. Those with severe asthma were three-times more likely to be referred than those with mild-to-moderate asthma [HRcrude = 4.04 (95% CI, 3.35-4.87); HRadj = 2.72 (95% CI: 2.13-3.49)]. Other factors associated with referral were food allergy and living in a more deprived area. Conclusion Around 1 in 6 children and adolescents with active asthma are not achieving adequate control of their symptoms. Among the subset of 6-17-year olds with poorly controlled asthma, timely referral for specialist advice in secondary care is rare, especially in those with so-called mild asthma who nevertheless are at significant risk for poor asthma outcomes.
Collapse
Affiliation(s)
- Constantinos Kallis
- National Heart and Lung Institute, Imperial College London, London, UK
- School of Public Health, Imperial College London, London, UK
| | - Ann Morgan
- National Heart and Lung Institute, Imperial College London, London, UK
- School of Public Health, Imperial College London, London, UK
| | - Louise Fleming
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Jennifer K Quint
- National Heart and Lung Institute, Imperial College London, London, UK
- School of Public Health, Imperial College London, London, UK
| |
Collapse
|
6
|
Plaza Moral V, Alobid I, Álvarez Rodríguez C, Blanco Aparicio M, Ferreira J, García G, Gómez-Outes A, Garín Escrivá N, Gómez Ruiz F, Hidalgo Requena A, Korta Murua J, Molina París J, Pellegrini Belinchón FJ, Plaza Zamora J, Praena Crespo M, Quirce Gancedo S, Sanz Ortega J, Soto Campos JG. GEMA 5.3. Spanish Guideline on the Management of Asthma. OPEN RESPIRATORY ARCHIVES 2023; 5:100277. [PMID: 37886027 PMCID: PMC10598226 DOI: 10.1016/j.opresp.2023.100277] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).
Collapse
Affiliation(s)
| | - Isam Alobid
- Otorrinolaringología, Hospital Clinic de Barcelona, España
| | | | | | - Jorge Ferreira
- Hospital de São Sebastião – CHEDV, Santa Maria da Feira, Portugal
| | | | - Antonio Gómez-Outes
- Farmacología clínica, Agencia Española de Medicamentos y Productos Sanitarios (AEMPS), Madrid, España
| | - Noé Garín Escrivá
- Farmacia Hospitalaria, Hospital de la Santa Creu i Sant Pau, Barcelona, España
| | | | | | - Javier Korta Murua
- Neumología Pediátrica, Hospital Universitario Donostia, Donostia-San, Sebastián, España
| | - Jesús Molina París
- Medicina de familia, semFYC, Centro de Salud Francia, Fuenlabrada, Dirección Asistencial Oeste, Madrid, España
| | | | - Javier Plaza Zamora
- Farmacia comunitaria, Farmacia Dr, Javier Plaza Zamora, Mazarrón, Murcia, España
| | | | | | - José Sanz Ortega
- Alergología Pediátrica, Hospital Católico Universitario Casa de Salud, Valencia, España
| | | |
Collapse
|
7
|
Dhar R, Rhee CK, Perng DW, Fukunaga K, Ip MSM, Juthong S, Koh MS, Li J, Sharma S, Wiyono WH. The burden of systemic corticosteroid use in asthma management in Asia. Respirology 2023. [PMID: 37301540 DOI: 10.1111/resp.14533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Accepted: 05/03/2023] [Indexed: 06/12/2023]
Abstract
For most patients, asthma can be effectively managed using inhaled medications. However, patients who have severe and/or uncontrolled asthma, or who experience exacerbations, may require systemic corticosteroids (SCSs) to maintain asthma control. Although SCS are highly effective in this regard, even modest exposure to these medications can increase the risk for long-term, adverse health outcomes, such as type 2 diabetes, renal impairment, cardiovascular disease and overall mortality. Clinical and real-world data from studies investigating asthma severity, control and treatment practices around the globe have suggested that SCS are overused in asthma management, adding to the already substantial healthcare burden experienced by patients. Throughout Asia, although data on asthma severity, control and SCS usage are limited and vary widely among countries, available data strongly suggest a pattern of overuse consistent with the broader global trend. Coordinated changes at the patient, provider, institutional and policy levels, such as increasing disease awareness, promoting better adherence to treatment guidelines and increasing availability of safe and effective alternatives to SCS, are likely necessary to reduce the SCS burden for patients with asthma in Asia.
Collapse
Affiliation(s)
- Raja Dhar
- Department of Pulmonology, CK Birla Group of Hospitals, Kolkata, West Bengal, India
| | - Chin Kook Rhee
- Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of South Korea, Seoul, South Korea
| | - Diahn-Warng Perng
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Koichi Fukunaga
- Department of Pulmonary Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Mary Sau-Man Ip
- Department of Medicine, University of Hong Kong, Hong Kong, China
| | - Siwasak Juthong
- Department of Internal Medicine, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Mariko Siyue Koh
- Department of Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore, Singapore
| | - Jing Li
- Allergy and Clinical Immunology Department, State Key Laboratory of Respiratory Disease, The First Affiliated Hospital, Guangzhou Medical University, Guangzhou, China
| | - Shubham Sharma
- Heart and Lung Transplant Unit, Yashoda Hospitals, Secunderabad, India
| | - Wiwien Heru Wiyono
- Department of Pulmonology and Respiratory Medicine Faculty of Medicine, Universitas Indonesia, Persahabatan Hospital, Jakarta, Indonesia
| |
Collapse
|
8
|
Haughney J, Winders T, Holmes S, Chanez P, Menzies-Gow A, Kocks J, Mansur AH, McPherson C, Canonica GW. A Charter to Fundamentally Change the Role of Oral Corticosteroids in the Management of Asthma. Adv Ther 2023; 40:2577-2594. [PMID: 37027115 PMCID: PMC10080509 DOI: 10.1007/s12325-023-02479-0] [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: 11/08/2022] [Accepted: 02/21/2023] [Indexed: 04/08/2023]
Abstract
Asthma affects 339 million people worldwide, with an estimated 5-10% experiencing severe asthma. In emergency settings, oral corticosteroids (OCS) can be lifesaving, but acute and long-term treatment can produce clinically important adverse outcomes and increase the risk of mortality. Therefore, global guidelines recommend limiting the use of OCS. Despite the risks, research indicates that 40-60% of people with severe asthma are receiving or have received long-term OCS treatment. Although often perceived as a low-cost option, long-term OCS use can result in significant health impairments and costs owing to adverse outcomes and increased utilization of healthcare resources. Alternative treatment methods, such as biologics, may produce cost-saving benefits with a better safety profile. A comprehensive and concerted effort is necessary to tackle the continued reliance on OCS. Accordingly, a threshold for OCS use should be established to help identify patients at risk of OCS-related adverse outcomes. Receiving a total dose of more than 500 mg per year should trigger a review and specialist referral. Changes to national and local policies, following examples from other chronic diseases, will be crucial to achieving this goal. Globally, multiple barriers to change still exist, but specific steps have been identified to help clinicians reduce reliance on OCS. Implementing these changes will result in positive health outcomes for patients and social and economic benefits for societies.
Collapse
Affiliation(s)
- John Haughney
- Glasgow Clinical Research Facility, Queen Elizabeth University Hospital, Glasgow, UK.
| | - Tonya Winders
- Allergy and Asthma Network, Vienna, VA, USA
- Global Allergy and Airways Patient Platform, Vienna, Austria
| | | | - Pascal Chanez
- Department of Respiratory CIC Nord INSERM INRAE C2VN, Aix Marseille University, Marseille, France
| | | | - Janwillem Kocks
- General Practitioners Research Institute, Groningen, The Netherlands
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Groningen Research Institute Asthma and COPD (GRIAC), University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Pulmonology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Adel H Mansur
- Respiratory Medicine, Birmingham Heartlands Hospital and University of Birmingham, Birmingham, UK
| | | | - Giorgio Walter Canonica
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Personalized Medicine, Asthma and Allergy, Milan, Italy
| |
Collapse
|
9
|
Montero-Arias F, Garcia JCH, Gallego MP, Antila MA, Schonffeldt P, Mattarucco WJ, Gallegos LFT, Beekman MJHI. Over-prescription of short-acting β 2-agonists is associated with poor asthma outcomes: results from the Latin American cohort of the SABINA III study. J Asthma 2023; 60:574-587. [PMID: 35670783 DOI: 10.1080/02770903.2022.2082305] [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: 10/18/2022]
Abstract
OBJECTIVE Short-acting β2-agonist (SABA) over-reliance is associated with poor asthma outcomes. As part of the SABA Use IN Asthma (SABINA) III study, we assessed SABA prescriptions and clinical outcomes in patients from six Latin American countries. METHODS In this cross-sectional study, data on disease characteristics/asthma treatments were collected using electronic case report forms. Patients (aged ≥12 years) were classified by investigator-defined asthma severity (guided by the 2017 Global Initiative for Asthma) and practice type (primary/specialist care). Multivariable regression models analyzed the associations between SABA prescriptions and clinical outcomes. RESULTS Data from 1096 patients (mean age, 52.0 years) were analyzed. Most patients were female (70%), had moderate-to-severe asthma (79.4%), and were treated by specialists (87.6%). Asthma was partly controlled/uncontrolled in 61.5% of patients; 47.4% experienced ≥1 severe exacerbation in the previous 12 months. Overall, 39.8% of patients were prescribed ≥3 SABA canisters in the preceding 12 months (considered over-prescription). SABA canisters were purchased over the counter (OTC) by 17.2% of patients, of whom 38.8% purchased ≥3 canisters in the 12 months prior. Of patients who purchased SABA OTC, 73.5% were prescribed ≥3 SABA canisters. Higher SABA prescriptions (vs. 1 - 2 canisters) were associated with an increased incidence rate of severe exacerbations (ranging from 1.31 to 3.08) and lower odds ratios of having at least partly controlled asthma (ranging from 0.63 to 0.15). CONCLUSIONS SABA over-prescription was common in Latin America, highlighting the need for urgent collaboration between healthcare providers and policymakers to align clinical practices with the latest evidence-based recommendations to address this public health concern.
Collapse
Affiliation(s)
- Felicia Montero-Arias
- Servicio de Neumología, Hospital México, CCSS y Hospital Clínica Bíblica Santa Ana, San José, Costa Rica
| | - Jose Carlos Herrera Garcia
- Pulmonary Function Unit, Unidad de Funcion Pulmonar, Unidad de investigación Clínica de Puebla, UISP Unidad de Investigación y Salud de Puebla, Puebla, Mexico
| | - Manuel Pacheco Gallego
- Neumología, Unversidad Tecnológica de Pereira Y Fundación Universitaria Visión de las Américas. Respiremos S.A.S-Clinical Comfamiliar, Pereira, Colombia
| | - Martti Anton Antila
- Clinical Research/Allergy, Clínica de Alergia Martti Antila, São Paulo, Brazil
| | - Patricia Schonffeldt
- Especialista Médicina Interna y Enfermedades Respiratorias, Instituto Nacional del Tórax ITMS Telemedicina de Chile, Santiago, Chile
| | | | | | | |
Collapse
|
10
|
The feasibility and impact of implementing a computer-guided consultation to target health inequality in Asthma. NPJ Prim Care Respir Med 2023; 33:6. [PMID: 36750578 PMCID: PMC9903267 DOI: 10.1038/s41533-023-00329-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 01/17/2023] [Indexed: 02/09/2023] Open
Abstract
Greater Manchester has a greater prevalence and worse asthma outcomes than the national average. This study aims to evaluate a digital approach to primary care asthma management and in particular the initial impact of implementing Clinical Decision Support System software in the form of a computer-guided consultation (CGC) in the setting of primary care asthma reviews in deprived areas of Greater Manchester. The CGC (LungHealth Ltd) is an intelligent decision support system ensuring accurate guideline-based staging of asthma and assessment of asthma control with the software subsequently prompting guideline-standard management. Patients on asthma registers in Greater Manchester Primary Care Networks were identified and underwent remote review by nursing staff using the CGC linked directly to the GP clinical system. Three-hundred thirty-eight patients (mean age 59 (SD 17) years; 60% Female) were reviewed. The CGC reported the patient's asthma control to be "Good" in 22%, "Partial" in 6% and "Poor" in 72%. ACT scores were significantly higher in those patients exhibiting "Good" and "Partial" control when compared to those with "Poor" control. The number of steroid courses and hospital admissions in the previous 12 months was significantly lower in those patients exhibiting "Good" and "Partial" control when compared to those with "Poor" control. Nineteen percent were found not to have a personalised asthma management plan during CGC review, which was alerted by the CGC and subsequently, all but 3 patients had this created on review completion (McNemar's test; p < 0.001). 5% were found not to have been prescribed regular inhaled steroid therapy resulting in the operator being alerted by the CGC in all cases. Overall, 44% underwent alteration in asthma therapy following the CGC review with 82% of these representing treatment escalation. An end-to-end digital service solution is feasible for Asthma within primary care and the utilisation of a CGC when conducting primary care asthma reviews increases implementation of guideline-level management thus addressing healthcare inequality while enabling identification of "high risk" asthma patients and guiding appropriate therapy escalation and de-escalation.
Collapse
|
11
|
Martinez A, Thakur N. Structural Racism and the Social Determinants of Health in Asthma. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2023; 1426:101-115. [PMID: 37464118 DOI: 10.1007/978-3-031-32259-4_5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
Asthma prevalence and morbidity are disproportionately higher among minoritized communities in the United States. Racial and ethnic disparities in asthma result from complex interactions across biological, environmental, and social factors. Asthma is considered a complex heterogeneous disease consisting of different phenotypes, some of which may be more common in individuals impacted by the downstream effects of structural racism and lack of access to the social determinants of health. Structural racism across generations has created and reinforced inequitable systems through policies and practices which are embedded in the economic, educational, health care, and justice systems (Bailey et al., N Engl J Med 384(8):768-773, 2021; Bailey et al., Lancet 389:1453-1463, 2017; Williams et al., Annu Rev Public Health 40:105-125, 2019). This manifests in an inequitable distribution of resources and the social determinants of health affecting an individual's physical and social environment (Bailey et al., Lancet 389:1453-1463, 2017; Thakur et al., Am J Respir Crit Care Med 202:943-949, 2020; Martinez et al., J Allergy Clin Immunol 148(5):1112-1120, 2021). In this chapter, we outline how inequity in housing, zoning laws, urban planning, education, employment, healthcare access, and healthcare delivery is linked to higher asthma prevalence and morbidity. We also describe the role that chronic physiologic stress has on asthma by enhancing neuroimmune and immunologic responses to environmental exposures. Interventions aimed at addressing the physical or social environment of an individual or community have been shown to improve asthma outcomes in patients at higher risk of severe disease.
Collapse
Affiliation(s)
- Adali Martinez
- Division of Pulmonary, Allergy, Critical Care and Sleep, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Neeta Thakur
- Division of Pulmonary, Allergy, Critical Care and Sleep, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.
| |
Collapse
|
12
|
Bleecker ER, Al-Ahmad M, Bjermer L, Caminati M, Canonica GW, Kaplan A, Papadopoulos NG, Roche N, Ryan D, Tohda Y, Yáñez A, Price D. Systemic corticosteroids in asthma: A call to action from World Allergy Organization and Respiratory Effectiveness Group. World Allergy Organ J 2022; 15:100726. [PMID: 36582404 PMCID: PMC9761384 DOI: 10.1016/j.waojou.2022.100726] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 11/11/2022] [Accepted: 11/18/2022] [Indexed: 12/14/2022] Open
Abstract
Systemic corticosteroids (SCS) are a highly effective treatment for acute exacerbations and long-term symptom control in asthma. Long-term SCS use is highly prevalent across all asthma severities, occurring in over 20% of patients with severe or uncontrolled disease globally. It is now well known that exposure to both long-term and repeated acute courses of SCS is associated with a high risk of serious adverse effects (AEs), such as osteoporosis, and metabolic and cardiovascular complications, especially when prescribed onto a background of other corticosteroids. The aim of this call-to-action article, endorsed by the World Allergy Organization and the Respiratory Effectiveness Group, is to review the accumulating evidence on the burden of SCS on patients with asthma and provide an overview of potential strategies for implementing SCS Stewardship. Primary prevention of exacerbations and improvement of asthma control is a key first step in achieving SCS Stewardship, by optimizing maintenance asthma medications and addressing modifiable risk factors, such as adherence and inhaler technique. Other key elements of SCS Stewardship include increasing appropriate specialist referrals for multidisciplinary review, assessment of biomarkers, and consideration of oral corticosteroid-sparing add-on therapies (eg, biologics). In cases where SCS use is deemed clinically justified, it should be tapered to the lowest possible dose. In addition, patients receiving long-term SCS or frequent acute courses should be closely monitored for emergence of SCS-related AEs. Because of the extensive data available on the costly and burdensome AEs associated with SCS use, as well as the range of treatment options now available, there is a need for healthcare providers (HCPs) to carefully evaluate whether the benefits of SCS outweigh the potential harms, to adopt SCS-sparing and Stewardship strategies, and to consider alternative therapies where possible. Development of a structured and collaborative SCS Stewardship approach is urgently required to protect patients from the potential harm of SCS use.
Collapse
Affiliation(s)
- Eugene R. Bleecker
- Division of Genetics, Genomics and Precision Medicine, Department of Medicine, University of Arizona, Tucson, AZ, USA
| | - Mona Al-Ahmad
- Microbiology Department, College of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Leif Bjermer
- Department of Respiratory Medicine and Allergology, University Hospital, Lund, Sweden
| | - Marco Caminati
- Department of Medicine, University of Verona, Verona, Italy
| | - Giorgio Walter Canonica
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Center, IRCCS, Rozzano, Italy
| | - Alan Kaplan
- Family Physician Airways Group of Canada, Stouffville, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Nikolaos G. Papadopoulos
- Division of Infection, Immunity & Respiratory Medicine, Royal Manchester Children's Hospital, University of Manchester, Manchester, UK
- Allergy Department, 2nd Pediatric Clinic, Athens General Children's Hospital ‘P&A Kyriakou’, University of Athens, Athens, Greece
| | - Nicolas Roche
- Department of Respiratory Medicine, APHP. Centre Université Paris Cité, Cochin Hospital (AP-HP) and Institute (UMR1016), Paris, France
| | - Dermot Ryan
- Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Yuji Tohda
- Kindai University Hospital, Osaka, Japan
| | - Anahí Yáñez
- Center for Research on Allergies and Respiratory Diseases (InAER), Buenos Aires, Argentina
| | - David Price
- Observational and Pragmatic Research Institute, Singapore
- Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
- Corresponding author. Professor David B Price, Observational and Pragmatic Research Institute, 22 Sin Ming Lane, #06 Midview City, Singapore 573969
| |
Collapse
|
13
|
Demoly P, Liu AH, Rodriguez Del Rio P, Pedersen S, Casale TB, Price D. A Pragmatic Primary Practice Approach to Using Specific IgE in Allergy Testing in Asthma Diagnosis, Management, and Referral. J Asthma Allergy 2022; 15:1069-1080. [PMID: 35996427 PMCID: PMC9392458 DOI: 10.2147/jaa.s362588] [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: 03/10/2022] [Accepted: 05/02/2022] [Indexed: 11/26/2022] Open
Abstract
Asthma afflicts an estimated 339 million people globally and is associated with ill health, disability, and early death. Strong risk factors for developing asthma are genetic predisposition and environmental exposure to inhaled substances that may provoke allergic reactions. Asthma guidelines recommend identifying causal or trigger allergens with specific IgE (sIgE) testing after a diagnosis of asthma has been made. Allergy testing with sIgE targets subpopulations of patients considered at high risk, such as those with frequent exacerbations, emergency visits or hospitalizations, or uncontrolled symptoms. Specific recommendations apply to preschool children, school-age children, patients with persistent or difficult-to-control asthma, patients needing oral corticosteroids or high-dose inhaled steroids, patients seeking understanding and guidance about their disease, and candidates for advanced therapies (biologics, allergen immunotherapy). Allergen skin testing is common in specialized settings but less available in primary care. Blood tests for total and sIgE are accessible and yield quantifiable results for tested allergens, useful for detecting sensitization. Results are interpreted in the context of the patient’s clinical presentation, age, and relevant allergen exposures. Incorporating sIgE testing into asthma management adds objective information to identify specific allergies and can guide personalized treatment plans, which reinforce patient-doctor communication. Test results can also be used to predict exacerbations and response to therapies. Additional diagnostic information can be gleaned from (i) eosinophil count ≥300 μL, which significantly increases the odds of having exacerbations, and emerging eosinophil biomarkers (eg, eosinophil-derived neurotoxin), which can be measured in plasma or serum samples, and (ii) fractional exhaled nitric oxide (FeNO), with values ≥25 ppb regarded as the cutoff for diagnosis, evaluating inhaled corticosteroid response, and of probable response to anti-IgE, anti-IL4 and anti-IL5 receptor biologics. Referral to asthma/allergy specialists is warranted when the initial diagnosis is uncertain, and when asthma symptoms, impairment, or exacerbations are repeated or severe.
Collapse
Affiliation(s)
- Pascal Demoly
- Division of Allergy, Department of Pulmonology, Hôpital Arnaud de Villeneuve, Montpellier, France.,IDESP Inserm, University, Hospital of Montpellier, Montpellier, France
| | - Andrew H Liu
- Airway Inflammation, Resilience & the Environment (AIRE) Program, Breathing Institute, Section of Pediatric Pulmonary & Sleep Medicine, Children's Hospital Colorado, Professor of Pediatrics, University of Colorado School of Medicine, Adjunct Professor of Pediatrics, National Jewish Health, Denver, CO, USA
| | | | - Soren Pedersen
- GINA Program, Department of Pediatrics, Kolding Hospital, Kolding, Denmark
| | - Thomas B Casale
- Food Allergy Research and Education (FARE), McLean, VA, USA.,Department of Medicine and Pediatrics, University of South Florida, Tampa, FL, USA
| | - David Price
- Observational and Pragmatic Research Institute, Singapore
| |
Collapse
|
14
|
Al Busaidi N, Alweqayyan A, Al Zaabi A, Mahboub B, Al-Huraish F, Hameed M, Al-Ahmad M, Khadadah M, Al Lawati N, Behbehani N, Al Jabri O, Salman R, Al Mubaihsi S, Al Raisi S. Gulf Asthma Diagnosis and Management in Adults: Expert Review and Recommendations. Open Respir Med J 2022. [DOI: 10.2174/18743064-v16-e2205230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The prevalence and incidence of asthma are increasing globally because of genetic and environmental influences. Prevalence of asthma in the Gulf has been reported to range from 4.7% to 32.0% and has a substantial economic burden. In this paper, we summarize current asthma management guidance for adults, present insights, and recommendations by key opinion leaders (KOLs) in the Gulf region, and key performance indicators for guiding clinical practice for asthma diagnosis, management, and treatment in the Gulf. While it is recommended that the Global Initiative for Asthma (GINA) guidelines should be followed wherever possible for the management of asthma, KOLs in the Gulf region have presented additional recommendations based on regional challenges and insights. There is a need for better diagnosis using objective testing, increased efforts in tackling the burden of comorbidities in the region, and greater provision of the necessary tools for phenotyping severe asthma. Furthermore, there is a need for greater education for physicians regarding asthma treatment, including the importance of inhaled-corticosteroid-containing controller medication. Regionally, there is also a need for specialist asthma clinics and asthma educators, which would serve to educate physicians and their patients as well as to improve the management of patients. Finally, the use of asthma registries, digital devices, and electronic templates would be of benefit in the management of asthma patients in the region.
Collapse
|
15
|
Abstract
Severe asthma is a heterogeneous syndrome with several clinical variants and often represents a complex disease requiring a specialized and multidisciplinary approach, as well as the use of multiple drugs. The prevalence of severe asthma varies from one country to another, and it is estimated that 50% of these patients present a poor control of their disease. For the best management of the patient, it is necessary a correct diagnosis, an adequate follow-up and undoubtedly to offer the best available treatment, including biologic treatments with monoclonal antibodies. With this objective, this consensus process was born, which began in its first version in 2018, whose goal is to offer the patient the best possible management of their disease in order to minimize their symptomatology. For this 2020 consensus update, a literature review was conducted by the authors. Subsequently, through a two-round interactive Delphi process, a broad panel of asthma experts from SEPAR and the regional pulmonology societies proposed the recommendations and conclusions contained in this document.
Collapse
|
16
|
Methane Alleviates Lung Injury through the IL-10 Pathway by Increasing T Regulatory Cells in a Mouse Asthma Model. J Immunol Res 2022; 2022:6008376. [PMID: 35812246 PMCID: PMC9262571 DOI: 10.1155/2022/6008376] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 05/31/2022] [Accepted: 06/11/2022] [Indexed: 01/31/2023] Open
Abstract
Allergic asthma is associated with allergen-induced airway hyperresponsiveness and inflammatory cell infiltration. While moderate-to-severe asthma with refractory symptoms is difficult to treat, methane is protective against organ damage. In this study, an asthmatic mouse model was established. Airway resistance under acetylcholine stimulation in asthmatic mice and histology of lung tissue injury were determined. EOS infiltration was determined by flow cytometry. Enzyme-linked immunosorbent assays (ELISAs) were performed for the determination of relevant cytokine levels in asthmatic mice with or without methane treatment. The potential mechanisms of methane under anti-IL-10 antibody intraperitoneal intervention were assessed by ELISA and flow cytometry. Pulmonary T regulatory cells (Tregs) were analyzed by flow cytometry, and anti-CD25 antibody was used to block them. Immunoblot analysis was performed to evaluate if methane played a role in the asthmatic lungs via the NF-κB and MAPKs pathways. The results showed that methane significantly improved airway compliance, relieved asthma-induced lung injury, and reduced EOS accumulation and inflammatory mediators in the lungs of ovalbumin-treated asthmatic mice. Anti-IL-10 treatment diminished the ameliorating effect of methane on asthma. In addition, methane enhanced pulmonary Tregs in asthma, which could be blocked by the anti-CD25 antibody. Further analysis revealed that methane decreased p-p65/p65 and p-p38/p38 expression. In conclusion, methane is a readily available and inexpensive molecule potentially suitable for human use, which can alleviate asthma-induced lung injury and EOS infiltration through the IL-10 pathway by increasing Tregs and decreasing NF-κB and p38 MAPK in a mouse model.
Collapse
|
17
|
Skov IR, Madsen H, Andersen JH, Pottegård A, Davidsen JR. Trends and predictors of specialist assessments in oral corticosteroid treated asthma among young adults. ERJ Open Res 2022; 8:00142-2022. [PMID: 35898811 PMCID: PMC9309342 DOI: 10.1183/23120541.00142-2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 05/25/2022] [Indexed: 11/05/2022] Open
Abstract
BackgroundRepeated oral corticosteroid use indicates uncontrolled disease among asthma patients and referral for asthma specialist assessment is recommended. We aimed to describe trends and predictors associated with specialist contacts among young adults with asthma and repeated oral corticosteroid use.MethodsIndividuals aged 18–45 years with ≥2 dispensed asthma medication prescriptions and two dispended oral corticosteroid prescriptions (including short-term and long-term treatments) within 12 months during 1999–2018 were identified by use of Danish healthcare registers. The frequency of specialist contacts within 1 year of follow-up was assessed among individuals without previous specialist contacts within 5 years of inclusion. Factors associated with specialist contact were identified by logistic regression models. Furthermore, oral corticosteroid prescriber sources were assessed.ResultsFor the 11 223 individuals included, 2444 (22%) had previous specialist contacts care within 5 years prior of inclusion and additionally 926 (8.3%) within 1 year of follow-up. Among those without previous specialist contacts (n 8779), the frequency of incident specialist contacts within 1 year of follow-up increased from 6.3% in 1999 to 18% in 2017. Factors associated with incident specialist contacts included dispensing ≥12 SABA canisters and previous asthma-related emergency department visits and hospitalisations. The majority of oral corticosteroid prescriptions at baseline (71%) were prescribed by general practitioners, though with decreasing proportions from 1999–2018.ConclusionsThe majority (70%) of young adults with asthma and repeated oral corticosteroid use do not seem to receive specialist assessment in Denmark. This highlights a potential room for improvement in the patient referral pathway for at-risk asthma patients.
Collapse
|
18
|
Cook DA, Stephenson CR, Pankratz VS, Wilkinson JM, Maloney S, Prokop LJ, Foo J. Associations Between Physician Continuous Professional Development and Referral Patterns: A Systematic Review and Meta-Analysis. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2022; 97:728-737. [PMID: 34985042 DOI: 10.1097/acm.0000000000004575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
PURPOSE Both overuse and underuse of clinician referrals can compromise high-value health care. The authors sought to systematically identify and synthesize published research examining associations between physician continuous professional development (CPD) and referral patterns. METHOD The authors searched MEDLINE, Embase, PsycInfo, and the Cochrane Database on April 23, 2020, for comparative studies evaluating CPD for practicing physicians and reporting physician referral outcomes. Two reviewers, working independently, screened all articles for inclusion. Two reviewers reviewed all included articles to extract information, including data on participants, educational interventions, study design, and outcomes (referral rate, intended direction of change, appropriateness of referral). Quantitative results were pooled using meta-analysis. RESULTS Of 3,338 articles screened, 31 were included. These studies enrolled at least 14,458 physicians and reported 381,165 referral events. Among studies comparing CPD with no intervention, 17 studies with intent to increase referrals had a pooled risk ratio of 1.91 (95% confidence interval: 1.50, 2.44; P < .001), and 7 studies with intent to decrease referrals had a pooled risk ratio of 0.68 (95% confidence interval: 0.55, 0.83; P < .001). Five studies did not indicate the intended direction of change. Subgroup analyses revealed similarly favorable effects for specific instructional approaches (including lectures, small groups, Internet-based instruction, and audit/feedback) and for activities of varying duration. Four studies reported head-to-head comparisons of alternate CPD approaches, revealing no clear superiority for any approach. Seven studies adjudicated the appropriateness of referral, and 9 studies counted referrals that were actually completed (versus merely requested). CONCLUSIONS Although between-study differences are large, CPD is associated with statistically significant changes in patient referral rates in the intended direction of impact. There are few head-to-head comparisons of alternate CPD interventions using referrals as outcomes.
Collapse
Affiliation(s)
- David A Cook
- D.A. Cook is professor of medicine and medical education, director, Section of Research and Data Analytics, School of Continuous Professional Development, and director of education science, Office of Applied Scholarship and Education Science, Mayo Clinic College of Medicine and Science, and consultant, Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota; ORCID: https://orcid.org/0000-0003-2383-4633
| | - Christopher R Stephenson
- C.R. Stephenson is assistant professor of medicine, Mayo Clinic College of Medicine and Science, associate program director, Mayo-Rochester Internal Medicine Residency Program, and consultant, Division of General Internal Medicine, Mayo Clinic, Rochester, Minnesota; ORCID: https://orcid.org/0000-0001-8537-392X
| | - V Shane Pankratz
- V.S. Pankratz is professor of internal medicine, University of New Mexico Health Sciences Center, Albuquerque, New Mexico; ORCID: https://orcid.org/0000-0002-3742-040X
| | - John M Wilkinson
- J.M. Wilkinson is associate professor of family medicine, Mayo Clinic College of Medicine and Science, and consultant, Department of Family Medicine, Mayo Clinic, Rochester, Minnesota; ORCID: https://orcid.org/0000-0003-1156-8577
| | - Stephen Maloney
- S. Maloney is professor of health professions education and deputy head of school, Primary and Allied Health Care, Monash University, Melbourne, Victoria, Australia; ORCID: https://orcid.org/0000-0003-2612-5162
| | - Larry J Prokop
- L.J. Prokop is a reference librarian, Plummer Library, Mayo Clinic, Rochester, Minnesota; ORCID: https://orcid.org/0000-0002-7197-7260
| | - Jonathan Foo
- J. Foo is a lecturer, School of Primary and Allied Health Care, Monash University, Melbourne, Victoria, Australia; ORCID: https://orcid.org/0000-0003-4533-8307
| |
Collapse
|
19
|
Saxena S, Afolabi-Brown O, Ballester L, Schmucker N, Smith-Whitley K, Allen J, Bhandari A. Benefit of pulmonary subspecialty care for children with sickle cell disease and asthma. Pediatr Pulmonol 2022; 57:885-893. [PMID: 35068085 DOI: 10.1002/ppul.25845] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 12/28/2021] [Accepted: 01/20/2022] [Indexed: 01/19/2023]
Abstract
OBJECTIVE Asthma is a recognized comorbidity in children with sickle cell disease (SCD). It increases the risk of acute chest syndrome (ACS), vaso-occlusive episodes, and early mortality. We aim to determine whether evaluation and management of children with SCD and asthma by a pulmonologist reduce rate of asthma exacerbation and ACS. METHODS The study included 192 patients with SCD (0-21 years) followed at Children's Hospital of Philadelphia Hematology between January 1, 2015, and December 31, 2018, with a diagnosis of asthma, wheeze, or cough. Patients were placed in two groups: those evaluated by a pulmonologist (SCD-A-P) and those not (SCD-A). Rates of emergency department (ED) visits and hospitalizations for asthma exacerbation and ACS were compared between groups and over time. RESULTS SCD-A-P patients (n = 70) were predominantly SCD type SS with lower hemoglobin and hematocrit compared to SCD-A patients (n = 122). SCD-A-P started with a higher average rate of hospital visits for asthma exacerbation and ACS per year (2.69 [1.02-4.37]) compared to SCD-A (0.43 [0.24-0.63]), (p < 0.001). For SCD-A-P patients with at least one hospital visit (n = 48), the average rate decreased from 3.93 (1.57-6.29) to 0.85 (0.48-1.23) following pulmonary consultation (p = 0.014) and was comparable to the SCD-A rate by study end. CONCLUSION SCD-A-P was mainly SCD type SS and had higher ED/hospitalization rates for asthma exacerbation and ACS compared to SCD-A, but the rates significantly decreased following pulmonology consultation. These findings support the pulmonologist's role in the multidisciplinary care of SCD patients and highlight the need for evidence-based asthma guidelines for children with SCD.
Collapse
Affiliation(s)
- Shikha Saxena
- Division of Pediatric Allergy, Immunology and Pulmonary Medicine, Monroe Carell Junior Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Olufunke Afolabi-Brown
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Lance Ballester
- Biostatistics and Data Management Core, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Nathaniel Schmucker
- Center for Healthcare Quality and Analytics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kim Smith-Whitley
- Division of Hematology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Julian Allen
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Anita Bhandari
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| |
Collapse
|
20
|
D'Urzo KA, Tamari IE, Chapman KR, Maleki-Yazdi MR, Greiver M, Upshur RE, Biro L, O'Neill B, Moineddin R, Aliarzadeh B, Kulasegaram K, To T, D'Urzo AD. Primary Care Severe Asthma Registry and Education Project (PCSAR-EDU): Phase 1 - an e-Delphi for registry definitions and indices of clinician behaviour. BMJ Open 2022; 12:e055958. [PMID: 35332043 PMCID: PMC8948412 DOI: 10.1136/bmjopen-2021-055958] [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: 11/23/2022] Open
Abstract
INTRODUCTION Although most asthma is mild to moderate, severe asthma accounts for disproportionate personal and societal costs. Poor co-ordination of care between primary care and specialist settings is recognised as a barrier to achieving optimal outcomes. The Primary Care Severe Asthma Registry and Education (PCSAR-EDU) project aims to address these gaps through the interdisciplinary development and evaluation of both a 'real-world' severe asthma registry and an educational programme for primary care providers. This manuscript describes phase 1 of PCSAR-EDU which involves establishing interdisciplinary consensus on criteria for the: (1) definition of severe asthma; (2) generation of a severe asthma registry and (3) definition of an electronic-medical record data-based Clinician Behaviour Index (CBI). METHODS AND ANALYSIS In phase 1, a modified e-Delphi activity will be conducted. Delphi panellists (n≥13) will be invited to complete a 30 min online survey on three separate occasions (i.e., three separate e-Delphi 'rounds') over a 3-month period. Expert opinion will be collected via an open-ended survey ('Open' round 1) and 5-point Likert scale and ranking surveys ('Closed' round 2 and 3). A fourth and final Delphi round will occur via synchronous meeting, whereby panellists approve a finalised ideal 'core criteria list', CBI and corresponding item weighting. ETHICS AND DISSEMINATION Ethical approval has been obtained for the activities involved in phase 1 from the University of Toronto's Human Research Ethics Programme (approval number 39695). Future ethics approvals will depend on information gathered in the proceeding phase; thus, ethical approval for phase 2 and 3 of this study will be sought sequentially. Findings will be disseminated through conference presentations, peer-reviewed publications and knowledge translation tools.
Collapse
Affiliation(s)
- Katrina A D'Urzo
- School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
| | | | - Kenneth R Chapman
- University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | | | - Michelle Greiver
- University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
- Department of Family and Community Medicine, North York General Hospital, Toronto, Ontario, Canada
| | - Ross Eg Upshur
- University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
- University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Lana Biro
- The Lung Health Foundation, Toronto, Ontario, Canada
| | - Braden O'Neill
- University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
- Department of Family and Community Medicine, St Michael's Hospital, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Rahim Moineddin
- University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Babak Aliarzadeh
- University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | | | - Teresa To
- University of Toronto Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Anthony D D'Urzo
- University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| |
Collapse
|
21
|
Håkansson KEJ, Backer V, Ulrik CS. Socioeconomic status is associated with healthcare seeking behaviour and disease burden in young adults with asthma - A nationwide cohort study. Chron Respir Dis 2022; 19:14799731221117297. [PMID: 35938497 PMCID: PMC9364195 DOI: 10.1177/14799731221117297] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction Specialist management of asthma has been shown to associate with
socioeconomic status (SES). However, little is known about the influence of
SES on care burden in universal healthcare settings. Methods Patients aged 18–45 years using inhaled corticosteroids (ICS) were followed
in national databases. Impact of asthma was investigated using negative
binomial regression adjusted for age, sex, comorbidity, and GINA 2020 Step.
Uncontrolled asthma was defined as >600 annual SABA puffs, ≥2
prednisolone courses and/or ≥1 hospitalization. Results A total of 60,534 (55% female, median age 33 (IQR 25–39)) patients were
followed for 10.1 years (IQR 5.2–14.3)). Uncontrolled asthma resulted in 6.5
and 0.51 additional annual contacts to primary care and pulmonologists,
respectively. Unscheduled and primary care burden was dependent on SES, increasing with
rural residence, lower education, income and receiving welfare. Differences
in planned respiratory care were slight, only seen among divorced, low
income- or welfare recipients. Lower SES was consistently associated with an
increased utilization of SABA and prednisolone. No dose–response
relationship between ICS use and SES could be identified. Conclusion Lower SES in asthma is a risk factor for a predominance of unscheduled care
and adverse outcomes, warranting further attention to patients’ background
when assessing asthma care.
Collapse
Affiliation(s)
| | - Vibeke Backer
- Department of Otorhinolaryngology, Copenhagen University Hospital - Rigshospitalet, Denmark
| | - Charlotte Suppli Ulrik
- Department of Respiratory Medicine, Copenhagen University Hospital - Hvidovre, Denmark.,Institute of Clinical Medicine, 4321University of Copenhagen, Denmark
| |
Collapse
|
22
|
Menzies-Gow A, Jackson DJ, Al-Ahmad M, Bleecker ER, Cosio Piqueras FDBG, Brunton S, Canonica GW, Chan CKN, Haughney J, Holmes S, Kocks J, Winders T. A Renewed Charter: Key Principles to Improve Patient Care in Severe Asthma. Adv Ther 2022; 39:5307-5326. [PMID: 36251167 PMCID: PMC9573814 DOI: 10.1007/s12325-022-02340-w] [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: 08/25/2022] [Accepted: 09/26/2022] [Indexed: 01/30/2023]
Abstract
Asthma is a heterogenous respiratory disease, usually associated with chronic airway inflammation and hyper-responsiveness, which affects an estimated 339 million people worldwide. Severe asthma affects approximately 5-10% of patients with asthma, approximately 17-34 million people globally, more than half of whom have uncontrolled disease. Severe asthma carries a substantial burden of disease, including unpredictable symptoms and potentially life-threatening flare-ups. Furthermore, severe asthma has a substantial burden on health care systems and economies worldwide. In 2018, a group of experts from the clinical community, patient support groups, and professional organisations joined together to develop the Severe Asthma Patient Charter, which set out six principles to define what patients should expect for the management of their severe asthma and what should constitute a basic standard of care. Since the publication of that original Charter in 2018, several important changes have occurred, including an improved understanding of asthma and effective asthma management; several new therapies have become available; and finally, the COVID-19 pandemic has placed a spotlight on respiratory conditions, the workforces that treat them, and the fundamental importance of health care system resilience. With those developments in mind, we, representatives of the academic, clinical, and patient advocacy group communities, have updated the Charter to Improve Patient Care in Severe Asthma with a focus on six principles: (1) I deserve a timely, comprehensive assessment of my asthma and its severity; (2) I deserve a timely, straightforward referral to an appropriate specialist for my asthma when it is not well controlled; (3) I deserve to understand what makes my asthma worse; (4) I deserve access to treatment and care that reduces the impact of asthma on my daily life; (5) I deserve not to be reliant on systemic corticosteroids; (6) I deserve to be involved in decisions about my treatment and care.
Collapse
Affiliation(s)
- Andrew Menzies-Gow
- Royal Brompton and Harefield Hospitals, School of Immunology and Microbial Sciences, King’s College, London, UK ,Department of Respiratory Medicine, Royal Brompton Hospital, Sydney Street, London, SW3 6NP UK
| | - David J. Jackson
- Guy’s Severe Asthma Centre, School of Immunology and Microbial Sciences, King’s College, London, UK
| | - Mona Al-Ahmad
- Microbiology Department, College of Medicine, Kuwait University, Kuwait City, Kuwait
| | - Eugene R. Bleecker
- Department of Medicine, University of Arizona College of Medicine, Tucson, AZ USA
| | | | | | - Giorgio Walter Canonica
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy ,Personalized Medicine, Asthma and Allergy, Humanitas Clinical and Research Centre IRCCS, Rozzano, Milan Italy
| | | | - John Haughney
- Glasgow Clinical Research Facility, Queen Elizabeth University Hospital, Glasgow, UK
| | | | - Janwillem Kocks
- General Practitioners Research Institute, Groningen, The Netherlands ,Groningen Research Institute Asthma and COPD, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands ,Department of Pulmonology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Tonya Winders
- Allergy and Asthma Network, Vienna, VA USA ,Global Allergy and Airways Patient Platform, Vienna, Austria
| |
Collapse
|
23
|
Correia-DE-Sousa J, Vicente C, Brito D, Tsiligianni I, Kocks JW, Román-Rodriguez M, Baxter N, Maricoto T, Williams S. Managing asthma in primary healthcare. Minerva Med 2021; 112:582-604. [PMID: 34814633 DOI: 10.23736/s0026-4806.21.07277-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Asthma brings considerable challenges for family doctors because of its variety of shapes, different levels of severity, a wide age range, and the fact that in the last decades clinicians are able to offer much better treatment options with a better level of disease control and a higher quality of life. The objectives of the current review article are to provide an up-to-date review by primary care respiratory leaders from different countries of the most significant challenges regarding asthma diagnosis and management, the importance of team work and the problems in recognizing and dealing with difficult-to-manage and severe asthma in primary care. The article provides a short review of the main challenges faced by family physicians and other primary health care professionals in supporting their patients in the management of asthma, such as asthma diagnosis, promoting access to spirometry, the importance of a multiprofessional team for the management of asthma, how to organize an asthma review, the promotion of patient autonomy and shared decision-making, improving the use of inhalers, the importance of the personalized asthma action plan, dealing with difficult-to-manage and severe asthma in primary care and choosing when, where and how to refer patients with severe asthma. The article also discusses the development of an integrated approach to asthma care in the community and the promotion of Asthma Right Care.
Collapse
Affiliation(s)
- Jaime Correia-DE-Sousa
- ICVS/3B's Associate Laboratory, Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal -
| | | | - Dinis Brito
- ICVS/3B's Associate Laboratory, Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal.,.7 Fontes Family Health Unit, ACES Cávado I - ARS Norte, Braga, Portugal
| | - Ioanna Tsiligianni
- International Primary Care Respiratory Group, Edinburgh, UK.,Health Planning Unit, Department of Social Medicine, Faculty of Medicine, University of Crete, Heraklion, Greece
| | - Janwillem W Kocks
- International Primary Care Respiratory Group, Edinburgh, UK.,General Practitioners Research Institute, Groningen, the Netherlands.,GRIAC Research Institute, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.,Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Miguel Román-Rodriguez
- Primary Care Respiratory Research Unit, Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain
| | - Noel Baxter
- International Primary Care Respiratory Group, Edinburgh, UK
| | - Tiago Maricoto
- Aveiro-Aradas Family Health Unit, Aveiro Health Center, Aveiro, Portugal.,Faculty of Health Sciences, University of Beira Interior, Covilhã, Portugal
| | - Siân Williams
- International Primary Care Respiratory Group, Edinburgh, UK
| |
Collapse
|
24
|
Rosman Y, Gabay L, Landau T, Confino-Cohen R. Childhood Asthma - The Effect of Asthma Specialist Intervention on Asthma Control: A Retrospective Review. J Asthma Allergy 2021; 14:1367-1373. [PMID: 34785910 PMCID: PMC8591108 DOI: 10.2147/jaa.s334560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 10/14/2021] [Indexed: 11/23/2022] Open
Abstract
Background Childhood asthma is the most common chronic disease throughout the western world. Improving asthma control is a leading health management goal. Purpose To evaluate the effect of an intervention by a visit to an asthma specialist on asthma control in children. Materials and Methods This retrospective study was conducted using the electronic database of Maccabi Health Services. All members ages 5-16 with an asthma diagnosis during 2000-2016, and at least one visit to a specialist were included. Asthma outcomes during the 2 years before and after the visit to the asthma specialist were compared. Results A total of 37,066 children were diagnosed with asthma. Among them, 13,533 (36.5%) had at least one visit to an asthma specialist and were included. Children with asthma visited their primary care physician more often in the period before the specialist visit (4.4± 4.4 vs 3.16± 3.9 visits, respectively; p<0.01). After visiting a specialist, average number of visits to emergency departments (0.52± 1.3 vs 0.45±1), all cause hospitalizations (0.13±0.45 vs 0.08±0.4) and hospitalizations due to asthma exacerbations (0.08±0.345 vs 0.05±0.3) decreased (p<0.01 for all comparisons). Prescription of short-acting beta agonists decreased (2.85±3.6 vs 2.2 ±3.7, p<0.01) and inhaled steroid prescriptions increased (1.9±2.9 vs 2.7±3.7, p<0.01), respectively, after the intervention. A substantial reduction in the prescription of corticosteroids (0.81±1.9 vs 0.43±1.4, p<0.01) after specialist visit was also noted. Conclusion We found significant positive outcomes after a single consultation with an asthma specialist. Referring pediatric asthma patients to an asthma specialist should be one of the goals of an asthma management plan.
Collapse
Affiliation(s)
- Yossi Rosman
- Allergy and Clinical Immunology Unit, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | - Linoy Gabay
- Maccabitech Institute for Research and Innovation, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Tami Landau
- Maccabitech Institute for Research and Innovation, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Ronit Confino-Cohen
- Allergy and Clinical Immunology Unit, Meir Medical Center, Kfar Saba, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| |
Collapse
|
25
|
Keeping Pace with Adolescent Asthma: A Practical Approach to Optimizing Care. Pulm Ther 2021; 8:123-137. [PMID: 34743311 PMCID: PMC8571974 DOI: 10.1007/s41030-021-00177-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 10/25/2021] [Indexed: 10/30/2022] Open
Abstract
Known for their pre-occupation with body image, self-identity creation, peer acceptance, and risk-taking behaviors, adolescents with asthma face unique challenges. Asthma is a heterogeneous disease and accurate diagnosis requires assessment through detailed clinical history, examination, and objective tests. Diagnostic challenges exist as many adolescents can present with asthma-like symptoms but do not respond to asthma treatment and risk being mis-diagnosed. Under-recognition of asthma symptoms and denial of disease severity must also be addressed. The over-reliance on short-acting beta-agonists in the absence of anti-inflammatory therapy for asthma is now deemed unsafe. Adolescents with mild asthma benefit from symptom-driven treatment with combination inhaled corticosteroids (ICS) and long-acting beta-agonist (LABA) on an as-required basis. For those with moderate-to-persistent asthma requiring daily controller therapy, maintenance and reliever therapy using the same ICS-LABA controller simplifies treatment regimes, while serving to reduce exacerbation risk. A developmentally staged approach based on factors affecting asthma control in early, middle, and late adolescence enables better understanding of the individual's therapeutic needs. Biological, psychological, and social factors help formulate a risk assessment profile in adolescents with difficult-to-treat and severe asthma. Smoking increases risks of developing asthma symptoms, lung function deterioration, and asthma exacerbations. Morbidity associated with e-cigarettes or vaping calls for robust efforts towards smoking and vaping cessation and abstinence. As adolescents progress from child-centered to adult-oriented care, coordination and planning are required to improve their self-efficacy to ready them for transition. Frequent flare-ups of asthma can delay academic attainment and adversely affect social and physical development. In tandem with healthcare providers, community and schools can link up to help shoulder this burden, optimizing care for adolescents with asthma.
Collapse
|
26
|
Blackburn J, Sharma P, Liu Y, Morrisey MA, Menachemi N, Sen B, Sanders T, Becker DJ. Characteristics and outcomes associated with two asthma quality of care measures. J Asthma 2021; 59:2283-2291. [PMID: 34669533 DOI: 10.1080/02770903.2021.1996602] [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: 10/20/2022]
Abstract
OBJECTIVE We investigated asthma quality measures to understand patient characteristics associated with non-attainment of quality care and measure the association with asthma-related emergency department (ED) visits or inpatient hospitalizations (IPs). METHODS Using administrative data from ALL Kids, Alabama's Children's Health Insurance Program, from 2013 to 2019 we calculated non-attainment of the Medication Management for Asthma (MMA) and Asthma Medication Ratio (AMR) quality measures. Patient characteristics and asthma-related ED visits and IPs associated with non-attainment of the MMA and AMR measures were assessed using logit regression models and Marginal effects at the mean. RESULTS Among 2528 children with asthma, 53.2% failed to attain the MMA measure and 8.5% the AMR measure. Prior asthma-related ED visits or IP stays increased likelihood of non-attainment by 14.8 percentage points (95% CI 8.6-20.9) for MMA and 7.3 percentage points (95% CI 2.8-11.8) for AMR. Among 868 children (34.3%) with three years of continuous enrollment, AMR non-attainment was associated with a 6.1 percentage point increase in ED or IP utilization (95% CI 1.3-10.9), however MMA non-attainment was not associated with either outcome. Prior ED visit/IP stay was associated with a 17.2 percentage point (95% CI 8.3-26.1) increase in the likelihood of a subsequent ED visit/IP stay among those with non-attainment MMA and a 15.5 percentage point increase (95% CI 6.9-24.2) for non-attainment AMR. CONCLUSIONS Patient characteristics associated with non-attainment of asthma quality measures presents actionable evidence to guide improvement efforts as non-attainment AMR increases the risk of subsequent ED visits and IP stays.
Collapse
Affiliation(s)
- Justin Blackburn
- Department of Health Policy and Management, Richard M. Fairbanks School of Public Health at IUPUI, Indiana University, Indianapolis, IN, USA
| | - Pradeep Sharma
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ye Liu
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Michael A Morrisey
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Nir Menachemi
- Department of Health Policy and Management, Richard M. Fairbanks School of Public Health at IUPUI, Indiana University, Indianapolis, IN, USA
| | - Bisakha Sen
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Teela Sanders
- Children's Health Insurance Program, Alabama Department of Public Health, Montgomery, AL, USA
| | - David J Becker
- Department of Health Care Organization and Policy, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| |
Collapse
|
27
|
Dunning HT, Boy C, Davis NL, Griffing E, Lasso-Pirot A. A hospital-based multidimensional intervention for high risk pediatric patients with asthma. J Asthma 2021; 59:1732-1741. [PMID: 34374617 DOI: 10.1080/02770903.2021.1963764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Objective: To determine the effects of a multi-dimensional intervention (consisting of education, recommendations for medical management, and short-term case management) provided by pulmonology nurse practitioners(NP) on inpatient and post-discharge outcomes for patients admitted with asthma exacerbations to a Pediatric Intensive Care Unit(PICU).Methods: A retrospective cohort study was completed on subjects with an asthma exacerbation admitted to the PICU from 01-01-2015 to 31-12-2018. Records were reviewed for 12-months post-discharge. We compared inpatient and post-discharge outcomes for those who did vs. did not receive NP consultation. The primary outcome evaluated was optimization of discharge medications. Rates of follow up, repeat ED visits and hospitalizations were also reviewed.Results: 222 subjects met inclusion and exclusion criteria; of those, 101(45.5%) patients received NP consultation and 121(54.5%) had PICU management only. Patients with NP consultation were more likely to have controllers initiated (34.6% vs. 15%) or adjusted (55.5% vs. 33.3%) per asthma guidelines (p < 0.001). The consult group were more likely to have an asthma follow-up appointment made prior to discharge (99% vs. 45%, p < 0.001), and were more likely to attend the appointment (51% vs. 21%, p < 0.001). There were no significant differences between groups for ED visits or readmission for asthma 12-months post-discharge.Conclusions: Patients with NP consultation were more likely to have controllers started or adjusted per guidelines and were more likely to attend specialty follow-up appointments post-discharge. No impact was seen on ED visits or readmissions. Implementation of such a program may aid in optimizing asthma management and continuity of care post hospitalization.
Collapse
Affiliation(s)
- Heather T Dunning
- University of Maryland Children's Hospital, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Christine Boy
- University of Maryland Children's Hospital, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Natalie L Davis
- University of Maryland Children's Hospital, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Emily Griffing
- University of Maryland Children's Hospital, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Anayansi Lasso-Pirot
- University of Maryland Children's Hospital, University of Maryland School of Medicine, Baltimore, MD, USA
| |
Collapse
|
28
|
Attitudes of Croatian pulmonologists concerning obstacles to earlier, more appropriate use of biologics in severe asthma: Survey results. PLoS One 2021; 16:e0253468. [PMID: 34185809 PMCID: PMC8241034 DOI: 10.1371/journal.pone.0253468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 06/04/2021] [Indexed: 11/19/2022] Open
Abstract
AIMS Biologics have been proven efficacious for patients with severe asthma (SA). It is essential to diagnose such individuals correctly. This study was designed to survey pulmonologists to identify barriers to early diagnosis and subsequent appropriate use of biologics for SA in Croatia. METHODS A pulmonologist group with expertise in SA developed the initial list of questions, with the final questionnaire created according to a 2-round Delphi method. The resulting survey consisted of 23 items consequently divided into 4 domains: 1) Pulmonologists' demographics and professional experiences; 2) Concerns about asthma management; 3) Attitudes toward SA diagnosis; and 4) Beliefs and attitudes regarding the use of biologics in managing SA. The given answers represented the respondents' estimates. RESULTS Eighty-four surveys were analyzed, with pulmonologists observing that general practitioners often inaccurately diagnose asthma and treat acute exacerbations. Although specialist centers are capably and correctly equipped, the time to diagnose patients with SA is approximately 3.5 months, with initial use of biologics delayed an additional 2 months. The primary indications for prescribing biologics are conventional therapy with oral glucocorticoids (91.7%) and frequent acute exacerbations (82.1%). In addition to improper diagnosis (64.3%), many patients with SA do not receive the indicated biologics owing to strict administrative directives for reimbursement (70.2%) or limited hospital resources (57.1%). LIMITATIONS The limitations of this survey include the subjective nature of the collected data, the relatively small sample size, and the lack of the biologic efficacy evaluation. CONCLUSIONS Croatian pulmonologists observed that a significant number of patients with SA who are eligible for biologics are not prescribed them, largely because of an inaccurate and/or delayed diagnosis, a delayed referral to a specialist center, highly restrictive criteria for reimbursement, and/or institutional budgetary limitations.
Collapse
|
29
|
Kendzerska T, Aaron SD, Meteb M, Gershon AS, To T, Lougheed MD, Tavakoli H, Chen W, Kunkel E, Sadatsafavi M. Specialist Care in Individuals With Asthma Who Required Hospitalization: A Retrospective Population-Based Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:3686-3696. [PMID: 34182160 DOI: 10.1016/j.jaip.2021.06.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/27/2020] [Revised: 05/23/2021] [Accepted: 06/07/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Patients who are at risk for severe asthma exacerbations should receive specialist care. However, the care pattern for such patients in the real world is unclear. OBJECTIVE To describe the pattern of care among individuals with asthma who required hospitalization, and to identify factors associated with receiving asthma specialist care. METHODS This was a retrospective population-based study using health administrative data from two Canadian provinces. Individuals aged 14 to 45 years who were newly diagnosed with asthma between 2006 and 2016 and had at least one hospitalization for asthma at or within 5 years after the initial asthma diagnosis were included. First, we calculated frequencies of primary and specialist care around the asthma diagnosis: 1 year before and 2 years after in a 6-month period. Next, among individuals diagnosed with asthma by a primary care physician, we used multivariable Cox regressions to identify factors associated with receiving specialist care. RESULTS For 1862 individuals included, we found that most (≥71% per time period) were cared for by primary care physicians 1 year before and 2 years after the asthma diagnosis; the percentage of individuals seen at least once by a specialist for asthma and/or asthma-related respiratory conditions during the first 6 months since the diagnosis did not exceed 40%. Among 1411 of 1862 individuals who were under primary care before the asthma diagnosis (76%), controlling for covariates, living in a rural area or a low-income neighborhood was associated with less likelihood of receiving specialist care. CONCLUSIONS Despite recommendations, more than half of individuals with asthma who required hospitalization did not receive specialist care during the first 2 years since the diagnosis. Identified factors associated with receiving asthma specialist care suggested that access is an important barrier to receiving recommended care.
Collapse
Affiliation(s)
- Tetyana Kendzerska
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Medicine, University of Ottawa, Ontario, Canada; ICES, Ontario, Canada.
| | - Shawn D Aaron
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; Department of Medicine, University of Ottawa, Ontario, Canada
| | - Moussa Meteb
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Andrea S Gershon
- ICES, Ontario, Canada; Department of Medicine, University of Toronto, Ontario, Canada; Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Teresa To
- ICES, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Research Institute, The Hospital of Sick Children, Toronto, Ontario, Canada
| | - M Diane Lougheed
- ICES, Ontario, Canada; Kingston General Hospital Research Institute, Kingston, Ontario, Canada; Queen's University, Kingston, Ontario, Canada
| | - Hamid Tavakoli
- Respiratory Evaluation Sciences Program, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Wenjia Chen
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Elizabeth Kunkel
- The Ottawa Hospital Research Institute, Ottawa, Ontario, Canada; ICES, Ontario, Canada
| | - Mohsen Sadatsafavi
- Respiratory Evaluation Sciences Program, Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | | |
Collapse
|
30
|
Håkansson KEJ, Backer V, Suppli Ulrik C. Socioeconomic biases in asthma control and specialist referral of possible severe asthma. Eur Respir J 2021; 58:13993003.00741-2021. [PMID: 33986027 DOI: 10.1183/13993003.00741-2021] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 05/03/2021] [Indexed: 11/05/2022]
Abstract
BACKGROUND Although socioeconomic impact on asthma control has been investigated, little is known about its relation to specialist referral of patients with possible severe asthma, especially in a public healthcare setting. The present study aims to identify socioeconomic patterns in disease control and referral of patients with asthma in a nationwide cohort of adult patients treated with inhaled corticosteroid (ICS). METHODS Asthma patients fulfilling the following: aged 18-45 and redeeming ≥2 prescriptions of ICS during 2014-18 based on data from Danish national registers were included. Possible severe asthma was defined as GINA 2020 Step 4 (with either ≥2 courses of systemic steroids or ≥1 hospitalisation) or Step 5 treatment. Findings presented as odds ratio (OR) (95% confidence intervals). RESULTS Of 60 534 patients (median age 34, 55% female), 3275 (5.7%) were deemed as having possible severe asthma, of whom 61% were managed in primary care alone.Odds of specialist management for possible severe asthma decreased with age (OR 0.66 (0.51-0.85)), 36-45 versus 18-25 years), male sex (OR 0.75 (0.64-0.87)), residence outside the Capital Region (OR 0.70 (0.59-0.82)) and with receiving unemployment or disability benefits OR 0.75 (0.59-0.95)).Having completed higher education increased odds of specialist referral (OR 1.28 (1.03-1.59)), when compared to patients with basic education. CONCLUSION Even in settings with nationally available free access to specialist care, the majority of patients with possible severe asthma are managed in primary care. Referral of at-risk asthma patients differs across socioeconomic parameters, calling for initiatives to identify and actively refer these patients.
Collapse
Affiliation(s)
| | - Vibeke Backer
- Centre for Physical Activity Research (CFAS), Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.,Department of ENT, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Charlotte Suppli Ulrik
- Department of Respiratory Medicine, Copenhagen University Hospital - Hvidovre, Copenhagen, Denmark.,Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| |
Collapse
|
31
|
Sood V, Rogers L, Khurana S. How I Do It: Managing Corticosteroid-Related Comorbidities in Severe Asthma. Chest 2021; 160:1614-1623. [PMID: 34019864 DOI: 10.1016/j.chest.2021.05.021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 05/05/2021] [Accepted: 05/11/2021] [Indexed: 10/21/2022] Open
Abstract
Oral corticosteroid (OCS) use in severe asthma remains all too common despite advances in asthma treatment. Use of OCS is associated with significant toxicity that can have a lasting adverse impact on a patient's overall health. Monoclonal antibodies have been developed that reduce both the rate of occurrence of OCS-treated exacerbations and the OCS requirements in patients with oral corticosteroid-dependent asthma. This article describes strategies to prevent and best manage endocrine complications associated with OCS use and provides guidance on OCS dose management after the introduction of steroid-sparing therapies. (1) We identify OCS-dependent patients and assess for comorbidities including bone health, glycemic control, and adrenal function; (2) we begin attempts at OCS dose optimization before or soon after introducing a steroid-sparing biologic therapy; (3) we taper OCS, using explicit criteria for asthma control; (4) we assess hypothalamic-pituitary-adrenal axis integrity once a physiologic dose of OCS is achieved to guide further the rate of OCS taper; and (5) we manage corticosteroid-related comorbidities as detailed in this article.
Collapse
Affiliation(s)
- Vidushi Sood
- Division of Endocrinology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Linda Rogers
- Division of Pulmonary, Critical Care and Sleep, Mount Sinai-National Jewish Respiratory Institute and Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sandhya Khurana
- Division of Pulmonary and Critical Care Medicine, Mary Parkes Center for Asthma, University of Rochester School of Medicine and Dentistry, Rochester, NY.
| |
Collapse
|
32
|
Paggiaro P, Barbaglia S, Centanni S, Croce D, Desideri E, Giustini S, Micheletto C, Musarra A, Scichilone N, Trama U, Zedda MT, Canonica GW. Overcoming Barriers to the Effective Management of Severe Asthma in Italy. J Asthma Allergy 2021; 14:481-491. [PMID: 34007186 PMCID: PMC8121981 DOI: 10.2147/jaa.s293380] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 04/21/2021] [Indexed: 11/27/2022] Open
Abstract
Introduction People with severe asthma (SA) often have poor disease control and quality of life, and are at high risk of exacerbations, lung function decline and asthma-related death. The present expert opinion article aimed to identify unmet needs in the management of SA in Italy, and propose possible solutions to address these needs. Methods At five multidisciplinary events in Italy, attendees identified factors that interfered with the effective management of SA and suggested how these barriers could be overcome. A core group of 12 Italian experts (pulmonologists, general practitioners, allergists, payers and patients) identified the main issues and proposed possible solutions based on the results from the meetings and relevant articles from the literature. Results and Conclusions We reviewed the gap between real-world practice and guidelines, oral corticosteroid overuse, SA-related mortality, and barriers to effective SA treatment. Common themes were lack of awareness about SA among both patients and clinicians, and lack of networking/information exchange between those involved in the treatment of SA. Participants agreed on the need to implement patient education and create multidisciplinary groups of specialists to improve SA management through multidisciplinary educational initiatives, meetings with local experts, development of a flow chart for referral/connection with local experts and specialized centers. Clinical instruments that might help specialists improve SA management included referral networks, integrated care pathways, phenotyping and treatment algorithms, exacerbation tracking, and examination of electronic medical records for patients with uncontrolled asthma. The following actions need to be implemented in Italy: i) maximize the use of advanced therapies, eg, biologics; ii) increase/improve education for physicians and patients; iii) improve multidisciplinary communication and care coordination; iv) introduce regional and local protocols for SA diagnosis and treatment; and v) change the structure of healthcare services to reduce specialist waiting times and facilitate access to biologic therapies.
Collapse
Affiliation(s)
- Pierluigi Paggiaro
- Department of Surgery, Medicine, Molecular Biology, and Critical Care, University of Pisa, Pisa, Italy
| | - Simona Barbaglia
- Associazione Nazionale Pazienti "Respiriamo Insieme", Padova, Italy
| | - Stefano Centanni
- Department of Health Sciences, Università degli Studi di Milano, Milan, Italy.,Respiratory Unit, ASST Santi Paolo e Carlo, Milan, Italy
| | - Davide Croce
- Center for Health Economics, Social and Health Care Management, LIUC-Università Cattaneo, Castellanza, Italy
| | | | - Saffi Giustini
- Italian General Practitioners' Association "SIMG", Florence, Italy.,Local Health Unit of Montale, Pistoia, Italy
| | - Claudio Micheletto
- Cardio-Thoracic Department, Respiratory Unit, Integrated University Hospital, Verona, Italy
| | - Antonino Musarra
- Allergy Unit, National Healthcare System, Reggio Calabria, Italy
| | - Nicola Scichilone
- Biomedical Department of Internal and Specialist Medicine, University of Palermo, Palermo, Italy
| | - Ugo Trama
- Dirigente UOD 06 Politica del Farmaco e Dispositivi, Naples, Italy
| | - Maria Teresa Zedda
- Italian General Practitioners' Association "SIMG", Florence, Italy.,General Practice, Cagliari, Italy
| | - Giorgio Walter Canonica
- Personalized Medicine Asthma & Allergy Clinic, Humanitas University and Research Hospital-IRCCS, Milan, Italy
| |
Collapse
|
33
|
Pudasainee-Kapri S. Providers' Adherence to Evidence-Based Asthma Guidelines in Pediatric Primary Care. J Pediatr Nurs 2021; 57:18-24. [PMID: 33212342 DOI: 10.1016/j.pedn.2020.09.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 09/23/2020] [Accepted: 09/24/2020] [Indexed: 01/16/2023]
Abstract
BACKGROUND Regardless of existence of National asthma guidelines, adherence to major elements of guidelines among providers is suboptimal. The nonadherence contributes to poor clinical outcomes and quality of life of asthma patients. PURPOSE This project aims to improve the standard of care of asthma patients with increased providers' adherence to asthma guidelines through provider education, and implementation of practice guidelines and evidence-based resources. METHODS A pre-post implementation retrospective design was adopted along with the provision of provider education sessions and implementation of pediatric asthma management practice guidelines and asthma resources in the pediatric practice in Southern, New Jersey. Data were collected via retrospective chart review among 41 patients four-months pre-implementation and 38 patients three months post-implementation to assess the improvement of providers' adherence to seven elements of asthma guidelines. Descriptive statistics and chi-square tests were computed to evaluate providers' adherence. RESULTS Results showed improvement from pre- to post-implementation in utilization of six of the seven key elements of guidelines among providers that include, the assessment and documentation of asthma control (4.9% to 39.5%), medication adherence (20% to 87.5%), medication delivery technique (7.3% to 18.4%), environmental triggers (14.6% to 44.7%), asthma action plan (4.9% to 28.9%), and follow-up visits (48.8% to 76.3%). In addition, the chi-square test showed a significant association between environmental triggers assessment from baseline to post-implementation, χ2 (1, n = 79) = 4.29, p = .038. CONCLUSION Providing necessary resources and provider-focused education demonstrated a positive change in promoting best practice and facilitating providers' adherence.
Collapse
|
34
|
Winders T, Maspero J, Callan L, Al-Ahmad M. Perspectives on decisions for treatment and care in severe asthma. World Allergy Organ J 2021; 14:100500. [PMID: 33537114 PMCID: PMC7817505 DOI: 10.1016/j.waojou.2020.100500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 11/12/2020] [Accepted: 11/23/2020] [Indexed: 11/30/2022] Open
Abstract
Background Severe asthma is a subtype of asthma that can be hard to control, resulting in an exceptional impact on an individual's quality of life. The aim of this review article is to explore the misalignment of perceptions of severe asthma among different stakeholders to identify how to reduce burden and improve delivery of care. Results The misalignment of perspectives is best reflected in randomised controlled trials (RCTs) in asthma treatments, which are often designed for regulatory approval with a focus on exacerbations with no direct input from the individuals that the treatments are designed for. Based on a literature review and the clinical experience of the authors to overcome this disparity, the goals of people with severe asthma need to be incorporated throughout their care, from study design to the day-to-day management of their condition. Improved education for individuals and their support network will provide them with resources and knowledge so that they can effectively communicate their needs to other stakeholders involved in their care. Conclusion/recommendation A collaborative effort from all stakeholders is essential to ensure efficient management of asthma and a reduction in asthma burden on individuals and society.
Collapse
Affiliation(s)
- Tonya Winders
- Allergy & Asthma Network/Global Allergy & Airways Patient Platform (GAAPP), Vienna, VA, USA
| | - Jorge Maspero
- Allergy and Respiratory Research Unit, Fundación CIDEA, Buenos Aires, Argentina
| | - Luke Callan
- Global Market Access and Pricing, AstraZeneca UK Ltd., Cambridge, UK
| | - Mona Al-Ahmad
- Department of Microbiology, Faculty of Medicine, Kuwait University, Kuwait
| |
Collapse
|
35
|
Sico IP, Oberle A, Thomas SM, Barsanti T, Egbuonu-Davis L, Kennedy DT, Zullig LL, Bosworth HB. Therapeutic Inertia in Prescribing Biologics for Patients with Moderate-to-Severe Asthma: Workshop Summary. Patient Prefer Adherence 2021; 15:705-712. [PMID: 33854304 PMCID: PMC8039536 DOI: 10.2147/ppa.s303841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/19/2021] [Indexed: 01/22/2023] Open
Abstract
Moderate-to-severe asthma represents about a quarter of the nearly 10% of Americans diagnosed with asthma. Many patients with moderate-to-severe asthma have uncontrolled symptoms that lead to exacerbations requiring oral corticosteroids. There are many factors contributing to poor asthma control, including poor adherence to prescribed therapies, the under-prescribing of biologics and therapeutic inertia. We convened an eight-member panel from fields of primary care, pulmonology, immunology, health services and clinical research, behavioral science and pharmaceutical medical affairs, with the goal of identifying contributing factors and solutions to therapeutic inertia with asthma biologics. We used the Capability, Opportunity, and Motivation (COM-B) model to classify patient and provider behavior towards therapeutic inertia. The model incorporates existing behavior theories and is driven by the interaction of capability, opportunity, and motivation. We used a Delphi method to identify and develop six primary solutions: 1) integration of patient-centered outcomes into asthma management practice; 2) provider education about asthma treatment; 3) moderate-to-severe asthma care delivery redesign; 4) harmonized, evidence-based protocol for the management of moderate-to-severe asthma; 5) designated coordinator approach for optimal asthma management; and 6) a case coordination digital support tool. Integration of patient-centered outcomes into asthma management practice and provider education were identified as having the highest potential to impact therapeutic and clinical inertia. The COM-B model is effective in identifying improvement within therapeutic inertia targeting the capabilities, opportunities, and motivations of patients, providers, and payer systems.
Collapse
Affiliation(s)
- Isabelle P Sico
- Department of Population Health Science, Duke University School of Medicine, Durham, NC, USA
| | - Amber Oberle
- Division of Pulmonary, Allergy and Critical Care, Duke University, Durham, NC, USA
| | | | | | | | | | - Leah L Zullig
- Department of Population Health Science, Duke University School of Medicine, Durham, NC, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC, USA
- Division of General Internal Medicine, Duke University, Durham, NC, USA
| | - Hayden B Bosworth
- Department of Population Health Science, Duke University School of Medicine, Durham, NC, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Medical Center, Durham, NC, USA
- Division of General Internal Medicine, Duke University, Durham, NC, USA
- School of Nursing, Duke University, Durham, NC, USA
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC, USA
- Correspondence: Hayden B Bosworth Duke University School of Medicine, 411 West Chapel Hill Street, Suite 600, Durham, NC, 27701, USATel +1 919-286-6936 Email
| |
Collapse
|
36
|
Ryan D, Heatley H, Heaney LG, Jackson DJ, Pfeffer PE, Busby J, Menzies-Gow AN, Jones R, Tran TN, Al-Ahmad M, Backer V, Belhassen M, Bosnic-Anticevich S, Bourdin A, Bulathsinhala L, Carter V, Chaudhry I, Eleangovan N, FitzGerald JM, Gibson PG, Hosseini N, Kaplan A, Murray RB, Rhee CK, Van Ganse E, Price DB. Potential Severe Asthma Hidden in UK Primary Care. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:1612-1623.e9. [PMID: 33309935 DOI: 10.1016/j.jaip.2020.11.053] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Severe asthma may be underrecognized in primary care. OBJECTIVE Identify and quantify patients with potential severe asthma (PSA) in UK primary care, the proportion not referred, and compare primary care patients with PSA with patients with confirmed severe asthma from UK tertiary care. METHODS This was a historical cohort study including patients from the Optimum Patient Care Research Database (aged ≥16 years, active asthma diagnosis pre-2014) and UK patients in the International Severe Asthma Registry (UK-ISAR aged ≥18 years, confirmed severe asthma in tertiary care). In the OPCRD, PSA was defined as Global INitiative for Asthma 2018 step 4 treatment and 2 or more exacerbations/y or at Global INitiative for Asthma step 5. The proportion of these patients and their referral status in the last year were quantified. Demographic and clinical characteristics of groups were compared. RESULTS Of 207,557 Optimum Patient Care Research Database patients with asthma, 16,409 (8%) had PSA. Of these, 72% had no referral/specialist review in the past year. Referred patients with PSA tended to have greater prevalence of inhaled corticosteroid/long-acting β2-agonist add-ons (54.1 vs 39.8%), and experienced significantly (P < .001) more exacerbations per year (median, 3 vs 2/y), worse asthma control, and worse lung function (% predicted postbronchodilator FEV1/forced vital capacity, 0.69 vs 0.72) versus nonreferred patients. Confirmed patients with severe asthma (ie, UK patients in the International Severe Asthma Registry) were younger (51 vs 65 years; P < .001), and significantly (P < .001) more likely to have uncontrolled asthma (91.4% vs 62.5%), a higher exacerbation rate (4/y [initial assessment] vs 3/y), use inhaled corticosteroid/long-acting β2-agonist add-ons (67.7% vs 54.1%), and have nasal polyposis (24.2% vs 6.8) than referred patients with PSA. CONCLUSIONS Large numbers of patients with PSA in the United Kingdom are underrecognized in primary care. These patients would benefit from a more systematic assessment in primary care and possible specialist referral.
Collapse
Affiliation(s)
- Dermot Ryan
- Usher Institute, University of Edinburgh, United Kingdom
| | - Heath Heatley
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Liam G Heaney
- UK Severe Asthma Network and National Registry, Queen's University Belfast, Belfast, Northern Ireland
| | - David J Jackson
- UK Severe Asthma Network and National Registry, Guy's and St Thomas' NHS Trust and Division of Asthma, Allergy & Lung Biology, King's College London, London, United Kingdom
| | - Paul E Pfeffer
- UK Severe Asthma Network, Barts Health NHS Trust and Queen Mary University of London, London, United Kingdom
| | - John Busby
- UK Severe Asthma Network and National Registry, Queen's University Belfast, Belfast, Northern Ireland
| | - Andrew N Menzies-Gow
- UK Severe Asthma Network and National Registry, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom
| | - Rupert Jones
- Faculty of Health, University of Plymouth, Plymouth, United Kingdom
| | | | - Mona Al-Ahmad
- Al-Rashed Allergy Center, Ministry of Health, Microbiology Department, Faculty of Medicine, Kuwait University, Kuwait
| | - Vibeke Backer
- Department of ENT & Centre for Physical Activity Research, Rigshospitalet and Copenhagen University, Copenhagen, Denmark
| | - Manon Belhassen
- PELyon, HESPER 7425, Claude Bernard University, Lyon, France
| | - Sinthia Bosnic-Anticevich
- Woolcock Institute of Medical Research, University of Sydney and Sydney Local Health District, Glebe, NSW, Australia
| | - Arnaud Bourdin
- Department of Respiratory Diseases, Montpellier University Hospitals, Arnaud de Villeneuve Hospital, Montpellier, France
| | - Lakmini Bulathsinhala
- Observational and Pragmatic Research Institute, Singapore, Singapore; Optimum Patient Care, Cambridge, United Kingdom
| | - Victoria Carter
- Observational and Pragmatic Research Institute, Singapore, Singapore; Optimum Patient Care, Cambridge, United Kingdom
| | - Isha Chaudhry
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Neva Eleangovan
- Observational and Pragmatic Research Institute, Singapore, Singapore; Optimum Patient Care, Cambridge, United Kingdom
| | | | - Peter G Gibson
- Australian Severe Asthma Network, Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, NSW, Australia; Hunter Medical Research Institute, Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton Heights, NSW, Australia
| | | | - Alan Kaplan
- Family Physician Airways Group of Canada, Stouffville, ON, Canada; University of Toronto, Toronto, ON, Canada
| | | | - Chin Kook Rhee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Eric Van Ganse
- PELyon, HESPER 7425, Claude Bernard University, Lyon, France
| | - David B Price
- Observational and Pragmatic Research Institute, Singapore, Singapore; Optimum Patient Care, Cambridge, United Kingdom; Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom.
| |
Collapse
|
37
|
Bellanti JA. The role of the allergist/immunologist in the COVID-19 pandemic: A Janus-faced presentation. Allergy Asthma Proc 2020; 41:397-412. [PMID: 32797762 DOI: 10.2500/aap.2020.41.200072] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background: Following its initial description in December 2019 in Wuhan, China, coronavirus-2 (COVID-19) has rapidly progressed into a worldwide pandemic, affecting millions of lives. Although every specialty of medicine has been affected, the field of allergy/immunology holds a special place in the battle against this modern-day plague. Because of the specialized training in allergy and clinical immunology, and the familiarity with comorbid contributing conditions, the allergist/immunologist is uniquely poised to play a major role both in the delivery of specialized therapeutic procedures and practices that can improve the health of patients with COVID-19 as well as in the use of forthcoming vaccines for the prevention of its spread. Objective: The purpose of this report is to examine the current body of evidence supporting the two phases of infection and inflammation that influence the pathogenesis of COVID-19 and to provide a classification of COVID-19 disease presentations and potential therapeutic targets with which the allergist/immunologist has particular expertise. Methods: This article was based on a literature review of articles published in PubMed related to COVID-19 and the immune response, and the author's own research and clinical experiences in the field of immunology. Results: Currently, the management of COVID-19 disease is being directed by a preventive strategy based on social distancing, quarantine, and facemasks to reduce the spread of the virus. Numerous clinical trials are being initiated to identify effective treatments for COVID-19 and are directed toward treatment of the two phases of infection and inflammation that influence the pathogenesis of COVID-19. An important resource for the allergist/immunologist is the COVID-19 Treatment Guidelines Panel (COVID-19 TGP), a National Institutes of Health sponsored panel of U.S. physicians, statisticians, and other experts, which has developed a set of continuously updated treatment guidelines intended for clinicians caring for patients during the rapidly evolving COVID-19 pandemic. Conclusion: COVID-19 is unique among other infectious diseases because, in many cases, the host immune inflammatory response can cause greater harm to the individual who is infected than the pathogen itself. In this report, the pathogenesis of COVID-19 and the influence it has on COVID-19 presentations is reviewed, together with recommended potential therapeutic targets and treatment recommendations.
Collapse
Affiliation(s)
- Joseph A. Bellanti
- From the Department of Pediatrics and Microbiology-Immunology; and International Center for Interdisciplinary Studies of Immunology, Georgetown University Medical Center, Washington, D.C
| |
Collapse
|
38
|
Kaplan A, Chang KL. Tiotropium in asthma - perspectives for the primary care physician. Postgrad Med 2020; 133:552-564. [PMID: 32896185 DOI: 10.1080/00325481.2020.1816329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Asthma is a heterogeneous disease characterized by airway inflammation resulting from complex interactions between multiple hosts as well as environmental factors. As a chronic respiratory condition, asthma exerts a significant impact on patients and the healthcare system. Per the Global Initiative for Asthma (GINA), inhaled corticosteroids (ICS) with/without long-acting beta2-agonists (LABAs) should be used as the preferred controllers for the management of asthma. Despite a range of therapeutic options, many patients with asthma remain uncontrolled, resulting in an increased risk of hospitalization and emergency room visits and a worsened quality of life. Tiotropium (Spiriva®, Boehringer Ingelheim Pharmaceuticals, Inc; 1.25 µg, two puffs, once daily), delivered via the Respimat® inhaler (Boehringer Ingelheim Pharmaceuticals, Inc.), was the first long-acting muscarinic antagonist to be approved as an add-on maintenance treatment option for patients with asthma aged ≥6 years at GINA steps 4 and 5. By binding to the muscarinic receptors M1 and M3 in the bronchial airways, tiotropium antagonizes the action of acetylcholine, leading to smooth muscle relaxation and reduced mucus secretion.The efficacy and safety of tiotropium add-on to ICS±LABA maintenance treatment have been evaluated in randomized controlled trials (RCTs) involving patients with a range of asthma severities (mild, moderate, and severe) and across age groups (children, adolescents, and adults). Add-on tiotropium was found to be well tolerated and efficacious in all RCTs. Moreover, the findings from real-world studies complement results from RCTs, showing beneficial effects of tiotropium in reducing exacerbations, hospitalization, emergency room visits, and asthma worsening.In this review article, we discuss the pathophysiology of asthma and the role of tiotropium in the management of asthma from the perspective of a primary care physician.
Collapse
Affiliation(s)
- Alan Kaplan
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
| | - Ku-Lang Chang
- Department of Community Health and Family Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| |
Collapse
|
39
|
Merianos AL, Jandarov RA, Gordon JS, Lyons MS, Mahabee-Gittens EM. Child tobacco smoke exposure and healthcare resource utilization patterns. Pediatr Res 2020; 88:571-579. [PMID: 32505125 PMCID: PMC7529841 DOI: 10.1038/s41390-020-0997-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 04/08/2020] [Accepted: 05/19/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND The objective was to examine the relationship between healthcare resource utilization patterns in tobacco smoke-exposed children (TSE group) compared with unexposed children (non-TSE group). METHODS We matched 380 children in the TSE group with 1140 children in the non-TSE group based on child age, sex, race, and ethnicity using propensity scores. Healthcare resource utilization variables included respiratory-related procedures, diagnostic testing, disposition, and medications. Logistic and linear regression models were built. RESULTS Child mean age was 4.9 (SD = 0.1) years, 50.5% were female, 55.5% black, and 73.2% had public insurance/self-pay. Compared to the non-TSE group, the TSE group was at increased odds to have the following performed/obtained: nasal bulb suctioning, infectious diagnostic tests, laboratory tests, and radiologic tests. The TSE group was more likely to be admitted to the hospital, and more likely to receive steroids and intravenous fluids during their visit. Among asthmatics, the TSE group was more likely to receive steroids, albuterol, or ipratropium alone, or a combination of all three medications during their visit, and be prescribed albuterol alone or steroids and albuterol. CONCLUSION Tobacco smoke-exposed children are more likely to have higher resource utilization patterns, highlighting the importance of screening and providing TSE prevention and remediation interventions. IMPACT Tobacco smoke exposure may affect the healthcare resource utilization patterns of children. Evidence is lacking concerning these associations among the highly vulnerable pediatric emergency department patient population. This study examined the association between tobacco smoke exposure and healthcare resource utilization patterns among pediatric emergency department patients. Tobacco smoke exposure increased the risk of pediatric patients having respiratory-related procedures, respiratory-related and non-respiratory-related testing, medications administered during the pediatric emergency department visit, and medications prescribed for home administration. Tobacco smoke-exposed patients were more likely to be admitted to the hospital compared to unexposed patients.
Collapse
Affiliation(s)
- Ashley L Merianos
- School of Human Services, University of Cincinnati, PO Box 210068, Cincinnati, OH, 45221-0068, USA.
| | - Roman A Jandarov
- Department of Environmental and Public Health Sciences, Division of Biostatistics and Bioinformatics, College of Medicine, University of Cincinnati, 160 Panzeca Way, Cincinnati, OH, 45267-0056, USA
| | - Judith S Gordon
- College of Nursing, The University of Arizona, 1305 N Martin Avenue, PO Box 210203, Tucson, AZ, 85721-0203, USA
| | - Michael S Lyons
- Department of Emergency Medicine, College of Medicine, University of Cincinnati, 231 Albert Sabin Way, ML 0769, Cincinnati, OH, 45267-0769, USA
| | - E Melinda Mahabee-Gittens
- Cincinnati Children's Hospital Medical Center, Division of Emergency Medicine, College of Medicine, University of Cincinnati, 3333 Burnet Avenue, MLC 2008, Cincinnati, OH, 45229, USA
| |
Collapse
|
40
|
Dhar R, Ip M, Kulkarni T, Kim SH, Perng DW, Yao X, Iwanaga T, Siyue Koh M. Challenges faced in managing adult asthma: A perspective from Asian countries. Respirology 2020; 25:1235-1242. [PMID: 32885896 DOI: 10.1111/resp.13935] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 07/31/2020] [Accepted: 08/07/2020] [Indexed: 01/30/2023]
Abstract
Asthma imposes a significant burden on the health system and patients' quality of life. Within Asia, there is large variability in several cultural, social and economic factors ultimately influencing the management of asthma. Differences in risk factors and asthma management practices across Asia make asthma a truly 'mixed-bag' phenomenon. With the advent of biological agents and the consequent emphasis on asthma phenotyping and endotyping, it is more important than ever to understand the diverse nature of asthma as a disease. This is a collaborative review within Asia to highlight the differences in management of adult asthma, and the local modifications that are made to international guidelines. This review paves the way for a future Asian collaborative network in asthma epidemiological research.
Collapse
Affiliation(s)
- Raja Dhar
- Center of Excellence in Lung Care, Fortis Hospital, Kolkata, India
| | - Mary Ip
- Respiratory and Critical Care Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Tarang Kulkarni
- Center of Excellence in Lung Care, Fortis Hospital, Kolkata, India
| | - Sang-Heon Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, South Korea
| | - Diahn-Warng Perng
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Xin Yao
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Nanjing, Medical University, Nanjing, China
| | - Takashi Iwanaga
- Department of Respiratory Medicine and Allergology, Kindai University Faculty of Medicine, Osakasayama, Japan
| | - Mariko Siyue Koh
- Respiratory and Critical Care Medicine, Singapore General Hospital, Singapore
| |
Collapse
|
41
|
Haughney J, Winders TA, Holmes S, Chanez P, Saul H, Menzies-Gow A. Global Quality Standard for Identification and Management of Severe Asthma. Adv Ther 2020; 37:3645-3659. [PMID: 32725419 PMCID: PMC7444397 DOI: 10.1007/s12325-020-01450-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Severe asthma is a debilitating, life-threatening disease associated with substantial global morbidity, mortality, and health care resource utilization. Patients may not receive guideline-directed medical care for severe asthma. Moreover, viable precision-based assessment tools and newer preventive therapies that can reduce the frequency of exacerbations and associated functional impact are underused. As a result, high rates of poorly controlled severe asthma persist, and patient health-related quality of life suffers. METHODS In 2019, the Improve Access to Better Care Task Force of the PRECISION Steering Committee set out to develop a global template on quality standards for severe asthma care to support improved access to and delivery of quality care. This Quality Standard is grounded in the vast body of published evidence available for severe asthma care, published clinical guidelines (i.e., from the Global Initiative for Asthma in 2019 and the European Respiratory Society/American Thoracic Society in 2014), and the 2018 PRECISION-supported Charter to Improve Patient Care in Severe Asthma. RESULTS The Quality Standard developed emphasizes four key elements aimed at optimizing clinical care and outcomes in severe asthma: (1) organization of services, (2) timely identification and referral for suspected severe asthma, (3) specialized assessment and management of severe asthma to optimize outcomes, and (4) patient-centric care and shared decision-making that is reflective of the patient's expectations, priorities, and values. Four key Quality Statements are provided, along with quality metrics and strategies for local adaptation to optimize implementation. CONCLUSION This Global Quality Standard is intended to mobilize policymakers, health care providers, and patient advocacy groups to build consensus on the definition and expectations of quality care in severe asthma, to promote patient-centric care, to identify gaps in care and areas for improvement, and systematically implement improvement measures and outcomes and to reduce the burden of illness for patients with severe asthma.
Collapse
Affiliation(s)
- John Haughney
- Glasgow Clinical Research Facility, Queen Elizabeth University Hospital, Glasgow, UK.
| | | | | | - Pascal Chanez
- Aix Marseille Université, Clinique des bronches, Allergie Et Sommeil/APHM, Marseille C2VN Center INSERM INRA UMR1062, Marseille, France
| | | | | |
Collapse
|
42
|
Winders TA, Wilson AM, Fletcher MJ, McGuinness A, Price DB. A Patient-Centered Description of Severe Asthma: Patient Understanding Leading to Assessment for a Severe Asthma Referral (PULSAR). PATIENT-PATIENT CENTERED OUTCOMES RESEARCH 2020; 12:539-549. [PMID: 31313272 PMCID: PMC6697753 DOI: 10.1007/s40271-019-00371-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Although severe asthma can be life-threatening, many patients are unaware they have this condition. OBJECTIVES Patient Understanding Leading to Assessment for a Severe Asthma Referral (PULSAR) is a novel, multidisciplinary working group aiming to develop and disseminate a global, patient-centered description of severe asthma to improve patient understanding of severe asthma and effect a change in patient behavior whereby patients are encouraged to visit their healthcare professional, when appropriate. METHODS Current definitions from patient organization websites, asthma guidelines, and medication information for key asthma drugs were assessed and informed a multidisciplinary working group, convened to identify common concepts and terminology used to define severe asthma. A patient-centered description of severe asthma and patient checklist were drafted based on working-group discussions and reviewed by an external behavioral scientist for patient understanding and relevance. These were tested using an online US/Canadian survey. RESULTS The patient-centered description of severe asthma and patient checklist were reviewed and re-drafted by the authors. The text was simplified following the behavioral-scientist review. The survey (n = 153) included 105 patients with severe asthma. Of those with severe asthma, 92.2% of patients reported that the description was consistent with their experiences of severe asthma and 92.6% of patients reported that the PULSAR initiative would encourage them to visit their healthcare provider. CONCLUSION A patient-centered description of severe asthma has been developed and tested using patients with severe asthma; this description will allow patients to assess whether they might have severe asthma and prompt them to visit their healthcare provider, if appropriate.
Collapse
Affiliation(s)
- Tonya A Winders
- Global Allergy Asthma Patient Platform (GAAPP), Vienna, Austria.
| | - Andrew M Wilson
- University of East Anglia, Norwich, UK
- Norfolk and Norwich University Hospital, Norwich, UK
- Asthma UK Centre for Applied Research, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Monica J Fletcher
- Asthma UK Centre for Applied Research, Usher Institute, The University of Edinburgh, Edinburgh, UK
- Global Respiratory Franchise, GlaxoSmithKline, Brentford, London, UK
| | | | - David B Price
- Division of Applied Health Sciences, Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK
- Observational and Pragmatic Research Institute, Singapore, Singapore
- Optimum Patient Care Ltd, Oakington, Cambridge, UK
| |
Collapse
|
43
|
The Role of Aeroallergen Sensitization Testing in Asthma Management. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2526-2532. [PMID: 32687905 DOI: 10.1016/j.jaip.2020.07.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/13/2020] [Accepted: 07/13/2020] [Indexed: 12/17/2022]
Abstract
Asthma is a global disease affecting almost 400 million people. Simultaneously, the overall burden of allergies is increasing. Although allergies are frequent and commonly recognized triggers of asthma severity and exacerbations, the majority of patients with asthma are not investigated for their underlying aeroallergen sensitizations, despite the potentially preventable consequences and therapeutic options. This review summarizes the current state of aeroallergen sensitization testing for people with asthma. We describe who should be tested and why, how testing can be used to optimize asthma management, list barriers to implementation of effective asthma management strategies, and make recommendations for improving asthma/allergy management by aeroallergen testing. Establishing a diagnosis of asthma and determining whether there is an allergic component is fundamental to an effective treatment plan. Moreover, moving from severity-based to phenotype-based asthma care can improve the care of asthma and allergic diseases. Timely diagnosis of aeroallergen sensitizations forms the basis for individualized treatment plans, which may include allergen remediation strategies when appropriate, and allergen immunotherapy, the only immunomodulating therapy for allergic asthma. Finally, the advent of biologics will expand the number of patients who can benefit from treatment, with decreased symptoms and disease remission a possibility for the first time.
Collapse
|
44
|
Humbert M, Bourdin A, Papadopoulos NG, Holgate ST, Hanania NA, Halpin DMG, Chapman KR, Gavornikova M, Price DB, Kaplan A, Heaney LG. Reducing the hidden burden of severe asthma: recognition and referrals from primary practice. J Asthma 2020; 58:849-854. [PMID: 32347748 DOI: 10.1080/02770903.2020.1759084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Since their introduction many decades ago, systemic corticosteroids have become a mainstay treatment for asthma. Despite being a highly effective therapy, corticosteroids can cause significant adverse effects in patients. This results in a "double hit" for some patients as they suffer the burden of disease as well as the burden of treatment-induced morbidity.This article aims to raise awareness of the potential, harmful side effects of prolonged or repeated exposure to systemic corticosteroids in asthma. It also highlights the importance of referral of the appropriate patients with asthma from primary care for specialist assessment once other considerations such as adherence, inhaler technique and co-morbidity have been evaluated. We propose a simple decision step that may help busy primary care physicians and general practitioners to identify patients who could benefit from specialist assessment.Our decision step suggests that a patient with asthma should be reviewed at least once by an asthma specialist if he/she (i) has received ≥2 courses of oral corticosteroids in the previous year; asthma remains uncontrolled despite good adherence and inhaler technique; or (ii) has attended an emergency department or was hospitalized for asthma care.Such referral could facilitate wider access to diagnostic tools, in-depth assessment of confounding comorbidities, and non-corticosteroid-based therapies as needed, which may be unavailable in primary practice.
Collapse
Affiliation(s)
- Marc Humbert
- Université Paris-Saclay, Faculté de Médecine, Le Kremlin-Bicetre, France.,Service de Pneumologie, Hôpital Bicêtre, Le Kremlin-Bicêtre, France
| | - Arnaud Bourdin
- Department of Respiratory Diseases, Université de Montpellier, PhyMedExp, INSERM, CNRS, CHU de Montpellier, Montpellier, France
| | - Nikolaos G Papadopoulos
- Division of Infection, Inflammation & Respiratory Medicine, The University of Manchester, Manchester, UK.,The Allergy Department, National & Kapodistrian University of Athens, Athens, Greece
| | | | - Nicola A Hanania
- Section of Pulmonary, Critical Care and Sleep Medicine, Baylor College of Medicine, Houston, Texas, USA
| | | | - Kenneth R Chapman
- Asthma and Airway Centre, University Health Network, and University of Toronto, Toronto, Ontario, Canada
| | | | - David B Price
- Observational and Pragmatic Research Institute, Singapore.,University of Aberdeen, Aberdeen, UK
| | - Alan Kaplan
- Family Physician Airways Group of Canada, University of Toronto, Toronto, Ontario, Canada
| | - Liam G Heaney
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| |
Collapse
|
45
|
Nyenhuis SM, Akkoyun E, Liu L, Schatz M, Casale TB. Real-World Assessment of Asthma Control and Severity in Children, Adolescents, and Adults with Asthma: Relationships to Care Settings and Comorbidities. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2020; 8:989-996.e1. [PMID: 31707065 PMCID: PMC7064399 DOI: 10.1016/j.jaip.2019.10.032] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Revised: 10/17/2019] [Accepted: 10/18/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Little is known about how patient-level factors and care settings relate to asthma outcomes in real-world settings. OBJECTIVE We therefore examined the rates and relative contributions of comorbidities and care settings in terms of asthma severity and control among pediatric and adolescent/adult patients in a large national sample. METHODS We examined deidentified patient data from 28,508 unique encounters documented in the Asthma Specialist Tool to Help Manage Asthma and Improve Quality database, obtaining patient-level factors (demographics, asthma characteristics, comorbidities), care setting (primary care physician [PCP] vs specialist physician [allergist or pulmonologist]), and guideline-defined levels of asthma control/severity. Rates of comorbidities were identified by asthma severity and control and by care setting. We calculated odds ratios for asthma control and severity based on each comorbidity. RESULTS Baseline demographic data indicated that patients seen by specialists versus PCPs were older, and had more severe and poorly controlled asthma (P < .05). Patients cared for by specialists also had more comorbid conditions, including gastroesophageal reflux disease (GERD; P < .01), rhinosinusitis (P < .01), and obstructive sleep apnea (adolescents/adults only: P < .01). GERD, smoke exposure, depression (adolescents/adults), rhinosinusitis (children), and African American race were associated with uncontrolled asthma. Smoke exposure (children), rhinosinusitis, and African American race were associated with severe disease. CONCLUSIONS We identified several demographics and comorbidities that are independently associated with the specialist care setting, persistent asthma, and poor asthma control. Awareness of these relationships may be helpful for clinicians caring for patients with asthma.
Collapse
Affiliation(s)
- Sharmilee M Nyenhuis
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, Ill; Center for Dissemination and Implementation Science, Department of Medicine, University of Illinois at Chicago, Chicago, Ill.
| | - Esra Akkoyun
- Division of Pulmonary, Critical Care, Sleep and Allergy, Department of Medicine, University of Illinois at Chicago, Chicago, Ill
| | - Li Liu
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois at Chicago, Chicago, Ill
| | | | - Thomas B Casale
- Department of Internal Medicine, University of South Florida, Tampa, Fla
| |
Collapse
|
46
|
Kritikos V, Price D, Papi A, Infantino A, Ställberg B, Ryan D, Lavorini F, Chrystyn H, Haughney J, Lisspers K, Gruffydd-Jones K, Román Rodríguez M, Høegh Henrichsen S, van der Molen T, Carter V, Bosnic-Anticevich S. A multinational observational study identifying primary care patients at risk of overestimation of asthma control. NPJ Prim Care Respir Med 2019; 29:43. [PMID: 31804501 PMCID: PMC6895161 DOI: 10.1038/s41533-019-0156-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 11/08/2019] [Indexed: 11/11/2022] Open
Abstract
Factors related to the discrepancy between patient-perceived and actual disease control remain unclear. Identifying patients at risk of overestimation of asthma control remains elusive. This study aimed to (i) investigate the relationship between patient-reported and actual level of asthma control (ii), compare the characteristics between patients who believe their asthma is well controlled that accurately report ‘well-controlled’ asthma with those that do not, and (iii) identify factors associated with inaccurately reported ‘well-controlled’ asthma. A historical, multinational, cross-sectional study using data from the iHARP (initiative Helping Asthma in Real-life Patients) review service for adults with asthma prescribed fixed-dose combination therapy. Data from 4274 patients were analysed. A major discrepancy between patient-reported and Global Initiative for Asthma defined asthma control was detected; 71.1% of patients who reported ‘well-controlled’ asthma were inaccurate in their perception despite receiving regular maintenance therapy. Significant differences were noted in age, gender, body mass index, education level, medication use, side effects, attitudes to preventer inhaler use, inhaler technique review and respiratory specialist review between patients who accurately reported ‘well-controlled’ asthma and those who did not. Independent risk factors associated with inaccurately reported ‘well-controlled’ asthma were: having taken a maximum of 5–12 puffs or more of reliever inhaler on at least one day within the previous 4 weeks; being female; having seen a respiratory specialist more than a year ago (rather than in the previous year); and having required oral corticosteroids for worsening asthma in the previous year. The study highlighted the significant hidden burden associated with under-recognition of poor asthma control, on the part of the patient and the need for targeted interventions designed to address the continuing discrepancy between perceived and actual disease control.
Collapse
Affiliation(s)
- Vicky Kritikos
- Quality Use of Respiratory Medicines Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia. .,Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, NSW, Australia.
| | - David Price
- Optimum Patient Care, Cambridge, UK.,Observational and Pragmatic Research Institute, Southbank, Singapore.,Academic Primary Care, University of Aberdeen, Aberdeen, UK
| | - Alberto Papi
- Respiratory Medicine, University of Ferrara, Ferrara, Italy
| | - Antonio Infantino
- Special Interest Respiratory Area, Italian Interdisciplinary Society for Primary Care, Bari, Italy
| | - Bjorn Ställberg
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | - Dermot Ryan
- Optimum Patient Care, Cambridge, UK.,Allergy and Respiratory Research Group, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Federico Lavorini
- Department Experimental and Clinical Medicine, University of Florence, Firenze, Italy
| | | | | | - Karin Lisspers
- Department of Public Health and Caring Sciences, Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden
| | | | - Miguel Román Rodríguez
- Primary Care Respiratory Research Unit, Instituto de Investigación Sanitaria de Baleares (IdISBa), Palma, Spain
| | - Svein Høegh Henrichsen
- Department of Primary Health Care Services, Norwegian Directorate of Health, Oslo, Norway
| | - Thys van der Molen
- Department of Primary Care, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Victoria Carter
- Optimum Patient Care, Cambridge, UK.,Observational and Pragmatic Research Institute, Southbank, Singapore
| | - Sinthia Bosnic-Anticevich
- Quality Use of Respiratory Medicines Group, Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia.,Sydney Medical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia.,Central Sydney Local Area Health District, Sydney, NSW, Australia
| |
Collapse
|
47
|
Blakey JD, Gayle A, Slater MG, Jones GH, Baldwin M. Observational cohort study to investigate the unmet need and time waiting for referral for specialist opinion in adult asthma in England (UNTWIST asthma). BMJ Open 2019; 9:e031740. [PMID: 31753883 PMCID: PMC6887034 DOI: 10.1136/bmjopen-2019-031740] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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 This study aimed to estimate how many patients with asthma in England met the referral eligibility criteria using national asthma guidelines, identify what proportion were referred and determine the average waiting time to referral. DESIGN This is an observational cohort study. SETTING/DATA SOURCES Routinely collected healthcare data were provided by Clinical Practice Research Datalink records and Hospital Episode Statistics records from January 2007 to December 2015. PARTICIPANTS Patients with asthma aged 18-80 years participated in this study. MAIN OUTCOME MEASURES Eligibility for referral by the British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN) 2016 guidelines, determined after a 3-month pharmacological therapy exposure assessment, was classed by either 'high-dose therapies', 'continuous or frequent use of oral steroids' or 'incident eligibility' during follow-up (continuous oral corticosteroids for more than 3 months, or ≥800 µg/day inhaled corticosteroids/long-acting β2-agonist (or three controllers) and ≥2 asthma attacks/year). RESULTS From the final cohort (n=23293), 19837 patients were eligible for specialist referral during follow-up based on the BTS/SIGN guideline recommendations. Among eligible patients without any previously recorded referral, 4% were referred during follow-up, with a median waiting time of 880 days (IQR=1428 days) between eligibility and referral. CONCLUSIONS A large number of patients with asthma were eligible for specialist referral, of which a small proportion were referred, and many experienced a long waiting time before referral. The results indicate a major unmet need in asthma referral, which is a potential source of preventable harm and are likely to have implications regarding how services are organised to address this unmet need.
Collapse
Affiliation(s)
- John D Blakey
- Respiratory Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
- University of Liverpool Department of Health Services Research, Liverpool, UK
| | - Alicia Gayle
- Market Access, Boehringer Ingelheim Ltd, Bracknell, UK
| | | | - Gareth H Jones
- Department of Respiratory Medicine, Royal Liverpool and Broadgreen Hospitals NHS Trust, Liverpool, UK
| | - Michael Baldwin
- TA Respiratory/Biosimilars, Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
| |
Collapse
|
48
|
Chung LP, Upham JW, Bardin PG, Hew M. Rational oral corticosteroid use in adult severe asthma: A narrative review. Respirology 2019; 25:161-172. [PMID: 31713955 PMCID: PMC7027745 DOI: 10.1111/resp.13730] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 08/05/2019] [Accepted: 10/22/2019] [Indexed: 12/17/2022]
Abstract
OCS play an important role in the management of asthma. However, steroid‐related AE are common and represent a leading cause of morbidity. Limited published studies suggest OCS usage varies across countries and recent registry data indicate that at least 25–60% of patients with severe asthma in developed countries may at some stage be prescribed OCS. Recent evidence indicate that many patients do not receive optimal therapy for asthma and are often prescribed maintenance OCS or repeated steroid bursts to treat exacerbations. Given the recent progress in adult severe asthma and new treatment options, judicious appraisal of steroid use is merited. A number of strategies and add‐on therapies are now available to treat severe asthma. These include increasing specialist referral for multidisciplinary assessments and implementing OCS‐sparing interventions, such as improving guideline adherence and add‐on tiotropium and macrolides. Biologics have recently become available for severe asthma; these agents reduce asthma exacerbations and lower OCS exposure. Further research, collaboration and consensus are necessary to develop a structured stewardship approach including realistic OCS‐weaning programmes for patients with severe asthma on regular OCS; education and public health campaigns to improve timely access to specialized severe asthma services for treatment optimization; and implementing targeted strategies to identify patients who warrant OCS use using objective biomarker‐based strategies.
Collapse
Affiliation(s)
- Li Ping Chung
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - John W Upham
- Department of Respiratory Medicine, Princess Alexandra Hospital and University of Queensland, Brisbane, QLD, Australia
| | - Philip G Bardin
- Department of Respiratory and Sleep Medicine, Monash Medical Centre, Monash University, Melbourne, VIC, Australia
| | - Mark Hew
- Allergy, Asthma and Clinical Immunology, Alfred Hospital, Melbourne, VIC, Australia
| |
Collapse
|
49
|
Hong CH, Joseph M, Kim VHD, Lansang P, Lara-Corrales I. Approach to the Assessment and Management of Pediatric Patients with Atopic Dermatitis: A Consensus Document. Section II: Comorbid Disease in Pediatric Atopic Dermatitis. J Cutan Med Surg 2019; 23:12S-18S. [DOI: 10.1177/1203475419882655] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Pediatric atopic dermatitis (AD) is one of the most common skin conditions encountered by health-care providers caring for infants, children, and adolescents. Pediatric patients with AD may present with other allergic and nonallergic comorbidities that require appropriate treatment and referral. They may also experience a trajectory of allergic diseases known as the atopic march, which depends on a complex interaction between genetic and environmental factors and likely involves early epidermal barrier dysfunction. Here we provide a review and clinical recommendations on the assessment and referral of comorbidities in pediatric AD.
Collapse
Affiliation(s)
- Chih-ho Hong
- Dr. Chih-ho Hong Medical Inc., Surrey, BC, Canada
- Probity Medical Research, Waterloo, ON, Canada
- Department of Dermatology and Skin Science, University of British Columbia, Vancouver, BC, Canada
| | - Marissa Joseph
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Section of Dermatology, Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Division of Dermatology, Women's College Hospital, Toronto, ON, Canada
| | - Vy HD Kim
- Section of Dermatology, Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Division of Immunology & Allergy, Department of Paediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - Perla Lansang
- Section of Dermatology, Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, ON, Canada
- Division of Dermatology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Division of Dermatology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Irene Lara-Corrales
- Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Section of Dermatology, Division of Paediatric Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| |
Collapse
|
50
|
Majellano EC, Clark VL, Winter NA, Gibson PG, McDonald VM. Approaches to the assessment of severe asthma: barriers and strategies. J Asthma Allergy 2019; 12:235-251. [PMID: 31692528 PMCID: PMC6712210 DOI: 10.2147/jaa.s178927] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 07/25/2019] [Indexed: 12/12/2022] Open
Abstract
Asthma is a chronic condition with great variability. It is characterized by intermittent episodes of wheeze, cough, chest tightness, dyspnea and backed by variable airflow limitation, airway inflammation and airway hyper-responsiveness. Asthma severity varies uniquely between individuals and may change over time. Stratification of asthma severity is an integral part of asthma management linking appropriate treatment to establish asthma control. Precision assessment of severe asthma is crucial for monitoring the health of people with this disease. The literature suggests multiple factors that impede the assessment of severe asthma, these can be grouped into health care professional, patient and organizational related barriers. These barriers do not exist in isolation but interact and influence one another. Recognition of these barriers is necessary to promote precision in the assessment and management of severe asthma in the era of targeted therapy. In this review, we discuss the current knowledge of the barriers that impede assessment in severe asthma and recommend potential strategies for overcoming these barriers. We highlight the relevance of multidimensional assessment as an ideal approach to the assessment and management of severe asthma.
Collapse
Affiliation(s)
- Eleanor C Majellano
- Faculty of Health and Medicine, National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and the Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, NSW, Australia
- Faculty of Health and Medicine, School of Nursing and Midwifery, The University of Newcastle, Newcastle, NSW, Australia
| | - Vanessa L Clark
- Faculty of Health and Medicine, National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and the Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, NSW, Australia
- Faculty of Health and Medicine, School of Nursing and Midwifery, The University of Newcastle, Newcastle, NSW, Australia
| | - Natasha A Winter
- Faculty of Health and Medicine, National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and the Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, NSW, Australia
- Faculty of Health and Medicine, School of Medicine and Public Health, The University of Newcastle, Newcastle, NSW, Australia
| | - Peter G Gibson
- Faculty of Health and Medicine, National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and the Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, NSW, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Vanessa M McDonald
- Faculty of Health and Medicine, National Health and Medical Research Council Centre for Research Excellence in Severe Asthma and the Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, NSW, Australia
- Faculty of Health and Medicine, School of Nursing and Midwifery, The University of Newcastle, Newcastle, NSW, Australia
- Department of Respiratory and Sleep Medicine, John Hunter Hospital, Hunter Medical Research Institute, Newcastle, NSW, Australia
| |
Collapse
|