Asthma control, cost and race: results from a national survey

Medication use in uncontrolled pediatric asthma: Results from the SysPharmPediA study

BACKGROUND

Uncontrolled pediatric asthma has a large impact on patients and their caregivers. More insight into determinants of uncontrolled asthma is needed. We aim to compare treatment regimens, inhaler techniques, medication adherence and other characteristics of children with controlled and uncontrolled asthma in the: Systems Pharmacology approach to uncontrolled Paediatric Asthma (SysPharmPediA) study.

MATERIAL AND METHODS

145 children with moderate to severe doctor-diagnosed asthma (91 uncontrolled and 54 controlled) aged 6-17 years were enrolled in this multicountry, (Germany, Slovenia, Spain, and the Netherlands) observational, case-control study. The definition of uncontrolled asthma was based on asthma symptoms and/or exacerbations in the past year. Patient-reported adherence and clinician-reported medication use were assessed, as well as lung function and inhalation technique. A logistic regression model was fitted to assess determinants of uncontrolled pediatric asthma.

RESULTS

Children in higher asthma treatment steps had a higher risk of uncontrolled asthma (OR (95%CI): 3.30 (1.56-7.19)). The risk of uncontrolled asthma was associated with a larger change in FEV₁% predicted post and pre-salbutamol (OR (95%CI): 1.08 (1.02-1.15)). Adherence and inhaler techniques were not associated with risk of uncontrolled asthma in this population.

CONCLUSION

This study showed that children with uncontrolled moderate-to-severe asthma were treated in higher treatment steps compared to their controlled peers, but still showed a higher reversibility response to salbutamol. Self-reported adherence and inhaler technique scores did not differ between controlled and uncontrolled asthmatic children. Other determinants, such as environmental factors and differences in biological profiles, may influence the risk of uncontrolled asthma in this moderate to severe asthmatic population.

Direct Medical Cost of Pediatric Asthma in Jordan: A Cost-of-Illness Retrospective Cohort Study

OBJECTIVES

This study aimed to estimate and analyze the direct medical costs of pediatric patients with asthma in Jordan from the provider's perspective.

METHODS

A retrospective analysis of a cohort of pediatric patients with asthma treated during 3 years in a teaching hospital was conducted. The prevalence-based, bottom-up approach has been used to estimate the cost-of-illness of asthma. The total annual direct medical cost was stratified by control status and the severity of asthma.

RESULTS

The total annual cost for whole the sample (N = 613) in the average of 3 years was Jordanian dinar (JD) 110 874 (US$ 156 382). Pediatrics with uncontrolled asthma had significantly higher annual total direct medical costs than partly controlled and controlled asthma (JD 396 [US$ 558], JD 258 [US$ 364], and JD 150 [US$ 211], respectively) (P < .001). The annual total direct medical cost for severe asthma (JD 455 [US$ 641]) was significantly higher than moderate, mild, and intermittent (JD 176 [US$ 248], JD 35 [US$ 49], and JD 7 [US$ 9.8], respectively) (P < .001). Medications were the most expensive healthcare resource used, accounting for 79.8% of the total cost, followed by outpatient clinic visits and hospitalizations.

CONCLUSIONS

Healthcare sources utilization and direct medical costs of asthma were highly related to disease severity and control status of the disease. Health policies targeting the achievement of better and stricter asthma control will play a crucial role in the reduction of the economic burden of asthma for society and the patient.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Perspective on the Budgetary Impact of FP/FORM pMDI on Treatment and Management of Exacerbation in Moderate-to-Severe Asthma Patients in Singapore

Purpose

Reducing the risk of exacerbation is a long-term goal of managing moderate-to-severe asthma. The use of fluticasone propionate/formoterol fumarate dihydrate (FP/FORM) pressurized metered-dose (pMDI, Flutiform^®), a type of inhaled corticosteroid (ICS) and long-acting β2 agonist (LABA) fixed-dose combination, has been associated with lower oral corticosteroid-requiring exacerbation rates than other ICS/LABA fixed-dose combinations, fluticasone propionate/salmeterol xinafoate (FP/SAL) and budesonide/formoterol fumarate (BUD/FORM). This study presents the first budget impact analysis of drug and exacerbation management cost savings associated with the increased access to FP/FORM compared to the currently available ICS/LABAs for treating moderate-to-severe asthma in Singapore.

Patients and Methods

A budget impact model showed changes to annual drug and exacerbation costs over 5 years for patients with moderate-to-severe asthma in Singapore, following the inclusion of FP/FORM on a government subsidy list. The eligible patient population was identified based on national statistics data. Different treatment costs pertaining to the population were applied according to the usage data (IQVIA Singapore National Sales Data) for different scenarios. Drug costs were obtained from public-sector hospitals. Exacerbation management costs were obtained from literature searches.

Results

The analysis showed that increased access to FP/FORM as a result of switching from FP/SAL could help achieve drug (S$1,042,289) and exacerbation management (S$223,550) cost savings over 5 years. In the scenario where patients switched from BUD/FORM, greater drug (S$2,572,797) and exacerbation management (S$256,781) cost savings were observed over 5 years.

Conclusion

The analysis provides a perspective that the increased access to FP/FORM could help achieve drug and exacerbation cost savings for the treatment of moderate-to-severe asthma.

The Added Burden of Allergen Sensitization Among Children with Severe or Poorly Controlled Asthma

BACKGROUND

Allergen sensitization (AS) may negatively affect asthma outcomes in children with severe or poorly controlled (SPC) asthma.

OBJECTIVES

To examine the impact of AS on asthma exacerbations, health care use, and costs among children with SPC asthma in private and public insurance settings.

METHODS

This retrospective study analyzed children with SPC asthma aged 6 to 11 years from the MarketScan Commercial (private insurance) and Medicaid databases. Selection of children with SPC asthma was based on medical claims and asthma medication prescription claims. AS status was based on diagnoses of extrinsic asthma and allergic conditions. Children were followed for at least 12 months. Outcomes included asthma exacerbations, days with oral corticosteroids (OCS), and asthma-related health care use and costs. Adjusted generalized linear models were fit to compare outcomes in children with versus those without AS.

RESULTS

Among children with SPC asthma, 34% had AS (private insurance: N = 11,448; Medicaid: N = 10,800), 20% did not have AS (private insurance: N = 7744; Medicaid: N = 6535), and, in the remainder, AS status could not be determined. Claims data were available for ≥3 years on average. Children with AS had significantly higher adjusted rates of asthma exacerbations during follow-up than children without AS, and significantly more days with OCS use. Rates of asthma-related hospitalizations, emergency department visits, and health care costs were significantly higher among children with AS than among children without AS.

CONCLUSIONS

Children with SPC asthma and AS have relatively greater asthma-related health care use and costs compared with children with SPC asthma without AS.

Association Between Socioeconomic Status and Asthma-Related Emergency Department Visits Among World Trade Center Rescue and Recovery Workers and Survivors

IMPORTANCE

Although the association between poor economic or social standing and health is well established, few studies have attempted to examine the mediational pathways that produce adverse outcomes in disadvantaged populations.

OBJECTIVE

To determine whether barriers to care mediate the association between socioeconomic status (SES) and asthma-related emergency department (ED) visits.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study used data from the World Trade Center Health Registry, which comprises rescue and recovery workers and community members who worked, lived, studied or were otherwise present in downtown Manhattan, New York, during or immediately after the September 11, 2001, disaster. Data were matched to an administrative database of ED visits. Those who experienced an asthma-related ED visit and those who did not were compared in bivariate analysis. A mediation analysis was conducted to determine the role of barriers to care in the association between number of ED visits and SES.

EXPOSURES

Education, income, and race/ethnicity, which were collected at first survey in 2003 to 2004.

MAIN OUTCOMES AND MEASURES

Asthma-related ED visits that occurred after survey responses regarding barriers to care were collected (2006-2007) but before 2016, the latest date that data were available.

RESULTS

The analytic sample included 30 452 enrollees (18 585 [61%] male; median [interquartile range] age, 42.0 [35.0-50.0] years; 20 180 [66%] white, 3834 [13%] African American, and 3961 [13%] Hispanic or Latino [any race]). Approximately half (49%) had less than a bachelor's degree, and 15% had an annual income less than $35 000. Those of lower SES were more likely to experience an asthma-related ED visit. Although number of barriers to care mediated this association, they explained only a small percentage of the overall health disparity (ranging from 3.0% [95% CI, 2.3%-3.9%]) of the differences between African American and white individuals to 9.8% [95% CI, 7.7%-11.9%]) comparing those with less than a high school diploma to those with at least a bachelor's degree. However, the association varied by specific barrier to care. Lack of money, insurance, and transportation mediated up to 11.8% (95% CI, 8.1%-15.9%), 12.5% (95% CI, 8.5%-17.4%), and 4.3% (95% CI, 1.7%-8.4%), respectively, of the association between SES and number of ED visits. Lack of childcare, not knowing where to go for care, and inability to find a health care professional mediated a smaller or no percentage of the association.

CONCLUSIONS AND RELEVANCE

The identification of vulnerable subpopulations is an important goal to reduce the burden of asthma-related hospital care. More research is needed to fully understand all of the pathways that lead disaster survivors of lower SES to disproportionately experience ED visits due to asthma.

Evaluation of a Multidisciplinary Disease Management Program to Achieve Asthma Control in Seven Safety Net Hospitals in Louisiana

The objective was to evaluate a multidisciplinary guideline-driven disease management program focused on achievement of asthma control among sustained patients with confirmed asthma in Louisiana and to assess factors affecting achievement of asthma control. Data were extracted from the electronic health records of 1596 adults with confirmed asthma, sustained care for >1 year in the outpatient setting, and ≥2 recorded Asthma Control Test (ACT) scores. Multivariable logistic regression modeling was used to assess the association of demographic variables, comorbidities, and process measures with the best achieved asthma control as represented by the highest ACT score. Most subjects were female (81.1%) and African American (63.9%). Approximately half of them (48.9%) were able to achieve asthma control (ACT ≥20). The most prevalent comorbidities were hypertension (79.8%), rhinitis (55.3%), and obesity (50.5%). Most patients received pulmonary function testing (PFT) (88.6%), controller medication therapy (85.5%), or written asthma action plans (92.7%). Asthma control was positively associated with presence of PFT (OR = 1.63, 95% CI: 1.13, 2.37) and being a "never" smoker (OR = 1.49, 95% CI: 1.08, 2.04). Asthma control was less likely to be achieved by patients who were African American (OR = 0.68, 95% CI: 0.52, 0.87), had more comorbidities (OR = 0.89, 95% CI: 0.83, 0.96), or were on more medications (OR = 0.79, 95% CI: 0.72, 0.88). Asthma control was achieved in 48.9% of an adult, primarily African American population with the implementation of comprehensive guideline-driven care. Furthermore, this is the first study to observe that the presence of PFT may be associated with asthma control.

Novel Biological Therapies in Severe Asthma: Targeting the Right Trait

Asthma is a heterogeneous disease characterized by chronic airway inflammation that results in a wide spectrum of clinical manifestations. Patients with severe asthma represent a substantial share of consumption of healthcare resources and hospitalization. Moreover, these patients are at risk of increased morbidity and mortality. Recently, several phenotypes and endotypes of asthma have been identified. The identification of specific subtypes of asthma is fundamental for optimizing the clinical benefit of novel treatments. Although in most patients the disease can be controlled by some combination of pharmacologic agents, in some 5-10% of patients the disease remains uncontrolled. Several monoclonal antibodies (mAbs) targeting pathogenetic molecules (e.g., IgE, IL-5, IL- 5Rα, IL-4, IL-13, TSLP) are currently available or under development for the treatment of different forms of severe type 2 asthma. The identification of diagnostic and predictive biomarkers (e.g., IgE, blood eosinophil count, FeNO, periostin, etc.) has revolutioned the field of targeted therapy in severe asthma. Monoclonal antibodies targeting Th2-driven inflammation are generally safe in adult patients with moderate-to-severe asthma. The long-term safety of these biologics is a relevant issue that should be addressed. Unfortunately, little is known about non-type 2 asthma. Further studies are needed to identify biomarkers to guide targeted therapies of different forms of non-type 2 asthma.

Medication adherence in patients with asthma using once-daily versus twice-daily ICS/LABAs

OBJECTIVE

This real-world observational study compared medication adherence and persistence among patients with asthma receiving the once-daily inhaled corticosteroid/long-acting β₂-agonist (ICS/LABA) fluticasone furoate/vilanterol (FF/VI) versus the twice-daily ICS/LABAs budesonide/formoterol (B/F) and fluticasone propionate/salmeterol (FP/SAL).

METHODS

This retrospective cohort study conducted using IQVIA^TM Health Plan Claims Data included patients with asthma ≥18 years of age initiating ICS/LABA therapy with FF/VI, B/F, or FP/SAL between January 1, 2014 and June 30, 2016 (index date). Patients had ≥12 months and ≥3 months of continuous eligibility pre- and post-index date, respectively. Patients receiving FF/VI were separately matched 1:1 with patients receiving B/F or FP/SAL using propensity score matching (PSM) and multivariable regression to balance baseline covariates between cohorts. The primary endpoint was medication adherence, measured by proportion of days covered (PDC). Secondary endpoints included proportion of patients achieving PDC ≥ 0.5 and PDC ≥ 0.8 and persistence with index medication, measured by time to discontinuation (>45-day gap in therapy).

RESULTS

After PSM, 3,764 and 3,339 patients receiving FF/VI were matched with patients receiving B/F or FP/SAL, respectively. Mean PDC was significantly higher for FF/VI versus B/F (0.453 vs 0.345; adjusted p < 0.001) and FP/SAL (0.446 vs 0.341; adjusted p < 0.001). The proportion of patients achieving PDC ≥ 0.5 or PDC ≥ 0.8, and treatment persistence were significantly higher for FF/VI versus B/F and FP/SAL (all p < 0.001).

CONCLUSIONS

In this real-world study, patients initiating FF/VI had better adherence and lower risk of discontinuing treatment versus B/F or FP/SAL, suggesting that once-daily ICS/LABA treatment might improve adherence and persistence compared with twice-daily alternatives.

Asthma specialist care preferences among parents of children receiving emergency department care for asthma

Objective: To learn factors associated with desire for asthma specialist care among parents of children seeking emergency department (ED) care for asthma, and if referral was indicated based on national asthma guidelines. Methods: We surveyed parents of children ages 0-18 years seeking pediatric ED asthma care, then comparisons were made according to parental level of interest in asthma specialist care, with regard to socio-demographics, asthma morbidity and care, by chi-squared and logistic regression. Results: Of 149 children, 20% reported specialist care, but 75% met guideline criteria for referral. About 80% of parents not seeing an asthma specialist expressed a desire to see one. Higher rates of prior urgent care visits (48% vs. 22%, p = 0.03), ED visits (82% vs. 35%, p < 0.001) and oral steroid use (53% vs. 22%, p = 0.009) were reported by parents who desired an asthma specialist compared with parents who did not. 87% of parents not seeing a specialist attributed this to a perceived lack of necessity by their primary care provider. An ED visit within the prior 12 months was the most significant predictor in parental desire for specialist care (odds ratio 9.75; 95% CI 3.42-27.76) in adjusted logistic regression models. Conclusion: High rates of parental preference for asthma specialist care suggest that directly querying parents may be an efficient method to identify children appropriate for specialist care in the ED.

Assessment of Adherence and Asthma Medication Ratio for a Once-Daily and Twice-Daily Inhaled Corticosteroid/Long-Acting β-Agonist for Asthma

BACKGROUND

Although efficacy and safety of fluticasone furoate/vilanterol (FF/VI) and budesonide/formoterol (BUD/F) have been demonstrated in clinical studies, real-world comparisons of utilization have not been performed.

OBJECTIVE

To compare similar patients with asthma initiating FF/VI or BUD/F on measures of adherence, persistence, and the asthma medication ratio (AMR).

METHODS

This was a retrospective cohort study of commercial and Medicare Advantage with Part D enrollees initiating FF/VI or BUD/F for asthma. Adult patients (≥18 years) with at least 15-month (12-month preindex and 3-month postindex) continuous enrollment and 1 or more asthma diagnosis code were eligible for the study. Patients with a history of fixed-dose inhaled corticosteroid/long-acting β-agonist and other respiratory disorders (chronic obstructive pulmonary disease, cystic fibrosis, acute respiratory failure) in the baseline period were excluded. Propensity-score matching was used to balance cohorts on baseline characteristics. Logistic regression and Cox-proportional hazard models were used to assess differences.

RESULTS

A total of 9951 patients met all criteria. After propensity-score matching, 1725 patients were matched in each cohort. Subjects who initiated FF/VI had a significantly higher mean proportion of days covered (P < .001), had 86% greater odds of having a proportion of days covered value of greater than or equal to 0.80 (adjusted odds ratio, 1.86; 95% CI, 1.51-2.30), 26% lower risk of discontinuation (adjusted hazard ratio, 0.74; 95% CI, 0.69-0.79), and 36% greater odds of an AMR of greater than or equal to 0.50 (adjusted odds ratio, 1.36; 95% CI, 1.23-1.50) compared with BUD/F.

CONCLUSIONS

Adherence and treatment persistence were low in both cohorts; however, patients initiating once-daily FF/VI were more likely to be adherent, have an AMR of greater than or equal to 0.5, and were less likely to discontinue therapy compared with patients initiating twice-daily BUD/F (GlaxoSmithKline Study HO1617302/206482).

New and Anticipated Therapies for Severe Asthma

Asthma is frequently undertreated, resulting in a relatively high prevalence of patients with uncontrolled disease, characterized by the presence of symptoms and risk of adverse outcomes. Patients with uncontrolled asthma have a higher risk of morbidity and mortality, underscoring the importance of identifying uncontrolled disease and modifying management plans to improve control. Several assessment tools exist to evaluate control with various cutoff points and measures, but these tools do not reliably correlate with physiological measures and should be considered a supplement to physiological tests. When attempting to improve control in patients, nonpharmacological interventions should always be attempted before changing or adding pharmacotherapies. Among patients with severe, uncontrolled asthma, individualized treatment based on asthma phenotype and eosinophil presence should be considered. The efficacy of the anti-IgE antibody omalizumab has been well established for patients with allergic asthma, and novel biologic agents targeting IL-5, IL-13, IL-4, and other allergic pathways have been investigated for patients with allergic or eosinophilic asthma. Fevipiprant (a CRT_H2 [chemokine receptor homologous molecule expressed on Th2 cells] antagonist) and imatinib (a tyrosine kinase inhibition) are examples of nonbiologic therapies that may be useful for patients with severe, uncontrolled asthma. Incorporation of new and emerging treatment into therapeutic strategies for patients with severe asthma may improve outcomes for this patient population.

Care transition interventions for children with asthma in the emergency department

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

Novel monoclonal treatments in severe asthma

AIM

To provide a general overview of the current biological treatments and discuss their potential anti-asthmatic effects.

DATA SOURCES

We reviewed articles in PubMed found using the search words "Asthma/therapy AND antibodies, monoclonal/therapeutic use AND cytokines."

STUDY SELECTIONS

Only articles published in English since 2000 were considered. The search identified 29 studies; 8 additional studies were found by hand search, generating 37 studies.

RESULTS

Of the 37 studies investigating biological treatments of asthma, 5 were on the effects of anti-IgE (omalizumab); 12 on anti-IL-5; 8 on anti-IL-13; 5 on anti-IL-4R-α; 3 on anti-IL-9; one on TNF-α; one on anti-IL-2R-α; one on TSLP (Thymic Stromal Lymphopoietin); and one on OX40L. Sample sizes ranged from 3 to 943 participants. Studies of therapies targeting IgE, IL-2, IL4R-α, IL-5, and IL-13 showed some efficacy, whereas those targeting TSLP, IL-9, and TNF-α lacked convincing effectiveness.

CONCLUSION

Research on the biological treatment of asthma shows promising results. While anti-IgE (omalizumab) has been used in the treatment of asthma for some years, anti-IL-5 has recently been approved for use. The efficacy of results of other large studies with a longer duration is needed to draw a firm conclusion. Such studies should not only focus on clinical outcomes, but also consider asthma-related quality of life. Knowledge on the asthma phenotypes and identification of biomarkers associated with these will be useful for physicians considering the right treatment for the asthma patient.

Association between asthma control and asthma cost: Results from a longitudinal study in a primary care setting

BACKGROUND AND OBJECTIVE

Asthma control can be assessed with the Asthma Control Test (ACT) and a score of 20 or higher indicates good asthma control. Patients pay for their consultation and treatment in the fee-for-service primary healthcare system in Singapore. We hypothesized that achieving asthma control would result in lower asthma costs through reduced acute exacerbations, fewer physician consultations and lower lost productivity. The study compared the healthcare costs of patients who achieved asthma control and those with suboptimal asthma control based on ACT scores. Factors influencing asthma control and healthcare expenditure over time were also examined.

METHODS

A total of 736 patients were enrolled into an asthma care programme in two polyclinics during 2008 and 2013. Direct costs of asthma management were derived from the frequency of polyclinic consultations, medication costs and hospitalization. Indirect costs were estimated from lost workdays due to exacerbations. The generalized estimating equation (GEE) approach was used to longitudinally model the factors associated with total healthcare expenditure.

RESULTS

Patients with asthma control spent S$48 (US$36) more per doctor visit on asthma drugs (P < 0.01) but incurred S$65 (US$48) less per doctor visit in total costs (P < 0.01) than those with suboptimal asthma control. The savings from achieving asthma control for obese patients were greater than for normal-weight patients (S$42 or the equivalent of US$31; P < 0.05).

CONCLUSION

Optimal asthma control was associated with reduced healthcare costs. An effective treatment regimen should also consider other modifiable factors such as weight control to achieve asthma control and eventually reduce asthma costs.

Medicaid beneficiaries who continue to use the ED: a focus on the Illinois Medical Home Network

OBJECTIVES

Frequent, nonurgent emergency department use continues to plague the American health care system through ineffective disease management and unnecessary costs. In 2012, the Illinois Medical Home Network (MHN) was implemented to, in part, reduce an overreliance on already stressed emergency departments through better care coordination and access to primary care. The purpose of this study is to characterize MHN patients and compare them with non-MHN patients for a preliminary understanding of MHN patients who visit the emergency department. Variables of interest include (1) frequency of emergency department use during the previous 12 months, (2) demographic characteristics, (3) acuity, (4) disposition, and (5) comorbidities.

METHODS

We performed a retrospective data analysis of all emergency department visits at a large, urban academic medical center in 2013. Binary logistic regression analyses and analysis of variance were used to analyze data.

RESULTS

Medical Home Network patients visited the emergency department more often than did non-MHN patients. Medical Home Network patients were more likely to be African American, Hispanic/Latino, female, and minors when compared with non-MHN patients. Greater proportions of MHN patients visiting the emergency department had asthma diagnoses. Medical Home Network patients possessed higher acuity but were more likely to be discharged from the emergency department compared with non-MHN patients.

CONCLUSIONS

This research may assist with developing and evaluating intervention strategies targeting the reduction of health disparities through decreased use of emergency department services in these traditionally underserved populations.

Asthma control in the Portuguese National Asthma Survey

INTRODUCTION

We aimed (1) to measure asthma control using a structure-questionnaire and patient self-perception of asthma-control in the Portuguese National Asthma Survey (INAsma) and (2) to study the relationship between asthma control and asthma-related quality of life.

METHODS

We analyze data of asthma patients from a cross-sectional, nationwide telephone interview study - INAsma. Controlled asthma was defined as CARAT global score >24 or CARAT lower airways score ≥16. Mini-AQLQ was used to measure quality of life.

RESULTS

Two hundred and seven (56.9% [95%CI: 51.8-62.0]) of the 364 patients had controlled asthma. Most patients with non-controlled asthma (88%) perceived their disease as controlled. Patients with controlled asthma presented higher mini-AQLQ scores (median, P25-P75; 6.6, 6.0-6.9) than those with non-controlled asthma (4.9, 3.7-5.7) (p<0.001) and a significant positive correlation between CARAT and mini-AQLQ scores was observed (r=0.706; p<0.001).

CONCLUSION

More than half of the Portuguese patients presented controlled asthma and showed significantly better asthma-related quality of life. Almost 9 out of 10 patients with non-controlled disease have poor perception of their asthma control, which may hinder them from seeking better asthma control.

Complex interventions reduce use of urgent healthcare in adults with asthma: systematic review with meta-regression

INTRODUCTION

Asthma accounts for considerable healthcare expenditure, a large proportion of which is attributable to use of expensive urgent healthcare. This review examines the characteristics of complex interventions that reduce urgent healthcare use in adults with asthma.

METHOD

Electronic searches of MEDLINE, EMBASE, PSYCINFO, CINAHL, the British Nursing Library and the Cochrane library, from inception to January 2013 were conducted. Studies were eligible for inclusion if they: i) included adults with asthma ii) assessed the efficacy of a complex intervention using randomised controlled trial design, and iii) included a measure of urgent healthcare utilisation at follow-up. Data on participants recruited, methods, characteristics of complex interventions and the effects of the intervention on urgent healthcare use were extracted.

RESULTS

33 independent studies were identified resulting in 39 comparisons altogether. Pooled effects indicated that interventions were associated with a reduction in urgent healthcare use (OR = 0.79, 95% CI = 0.67, 0.94). When study effects were grouped according to the components of the interventions used, significant effects were seen for interventions that included general education (OR = 0.77, 95% CI = 0.64, 0.91), skills training (OR = 0.64, 95% CI = 0.48, 0.86) and relapse prevention (OR = 0.75, 95% CI = 0.57, 0.98). In multivariate meta-regression analysis, only skills training remained significant.

CONCLUSIONS

Complex interventions reduced the use of urgent healthcare in adults with asthma by 21%. Those complex interventions including skills training, education and relapse prevention may be particularly effective in reducing the use of urgent healthcare in adults with asthma.

Getting control of uncontrolled asthma

Despite various treatment modalities, a large proportion of patients have asthma that remains uncontrolled. These patients remain at an increased risk of developing severe exacerbations, have a poor quality of life, and pose a high economic healthcare burden, with an estimated mean annual cost more than double that of patients with good symptom control. It is therefore important to accurately diagnose asthma and continually assess asthma control. Several validated tools are available to do this, including questionnaires, biomarker analysis, and bronchoscopy. Current guidelines advise physicians to establish a self-management program for the patient to assess and monitor asthma control. A further recommendation is the establishment of an educational action plan to increase treatment adherence and to improve asthma control. National and international guidelines provide long-term management strategies for these patients and recommend a stepwise approach for achieving and maintaining asthma control. Despite availability of a wide range of controller and reliever therapies, uncontrolled asthma remains a challenge and reflects the need for new therapeutic options. This review discusses current global guidelines for the assessment and management of asthma control and summarizes the broad spectrum of novel therapeutic agents currently under development for the treatment of asthma, including anticholinergics, chemoattractant receptor-homologous molecules expressed on T-helper 2 lymphocyte antagonists, and anti-interleukin (IL)-5, anti-IL-13, and anti-IL-4 agents.

Asthma Control and Cost in Latin America

OBJECTIVE

Few patients with asthma have disease that is well-controlled, particularly in Latin American countries. The purpose of this study was to investigate whether partly controlled and uncontrolled asthma are associated with increased costs for asthma-related medications and health care utilization compared with well-controlled asthma in five Latin American countries.

METHODS

Using the Global Initiative for Asthma guidelines, we classified respondents from the Latin American Asthma Insights and Management survey into those with well-controlled, partly controlled, and uncontrolled asthma and compared the utilization of health care services and costs among these groups.

RESULTS

Most respondents to our survey (93%) had asthma that was classified as partly controlled or uncontrolled. Across all countries, patients whose asthma was partly controlled or uncontrolled had greater use of asthma-related medications and medical services than did patients whose asthma was well-controlled. After adjusting for age, sex, and country of residence, total costs for asthma-related medications and health care were greater in patients whose asthma was classified as partly controlled and uncontrolled.

CONCLUSIONS

Our findings indicate that patients with asthma that are not well-controlled used more health care resources and had greater medical costs in Latin America.