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Grigg J, Nibber A, Paton JY, Chisholm A, Guilbert TW, Kaplan A, Turner S, Roche N, Hillyer EV, Price DB. Matched cohort study of therapeutic strategies to prevent preschool wheezing/asthma attacks. J Asthma Allergy 2018; 11:309-321. [PMID: 30588038 PMCID: PMC6294169 DOI: 10.2147/jaa.s178531] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background An inhaled corticosteroid (ICS) or leukotriene receptor antagonist (LTRA) may prevent wheezing/asthma attacks in preschoolers with recurrent wheeze when added to short-acting β-agonist (SABA). Objective The aim of this historical matched cohort study was to assess the effectiveness of these treatments for preventing wheezing/asthma attacks. Methods Electronic medical records from the Optimum Patient Care Research Database were used to characterize a UK preschool population (1–5 years old) with two or more episodes of wheezing during 1 baseline year before first prescription (index date) of ICS or LTRA, or repeat prescription of SABA. Children initiating ICS or LTRA on the index date were matched 1:4 to those prescribed only SABA for age, sex, year of index prescription, mean baseline SABA dose, baseline attacks, baseline antibiotic prescriptions, and eczema diagnosis. Wheezing/asthma attacks (defined as asthma-related emergency attendance, hospital admission, or acute oral corticosteroid prescription) during 1 outcome year were compared using conditional logistic regression. Results Matched ICS and SABA cohorts included 990 and 3,960 children, respectively (61% male; mean [SD] age 3.2 [1.3] years), and matched LTRA and SABA cohorts included 259 and 1,036 children, respectively (65% male; mean [SD] age 2.6 [1.2] years). We observed no significant difference between matched cohorts in the odds of a wheezing/asthma attack: ICS vs SABA, OR (95% CI) 1.01 (0.85–1.19) and LTRA vs SABA, OR (95% CI) 1.28 (0.96–1.72). Conclusion We found no evidence that initiation of ICS or LTRA therapy is associated with fewer attacks during 1 outcome year than SABA alone for a heterogeneous group of preschool children with recurrent wheeze in the real-life clinical setting.
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Affiliation(s)
- Jonathan Grigg
- Blizard Institute, Queen Mary University of London, London, UK,
| | | | - James Y Paton
- School of Medicine, College of Medical, Veterinary, and Life Sciences, University of Glasgow, Glasgow, UK
| | | | - Theresa W Guilbert
- Pulmonary Division, Cincinnati Children's Hospital Medical Center, and Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Alan Kaplan
- Family Physician Airways Group of Canada, University of Toronto, Toronto, ON, Canada
| | - Steve Turner
- Department of Child Health, Royal Aberdeen Children's Hospital, University of Aberdeen, Aberdeen, UK
| | - Nicolas Roche
- Respiratory Medicine, Cochin Hospital Group, AP-HP, University of Paris Descartes (EA2511), Paris, France
| | - Elizabeth V Hillyer
- Observational and Pragmatic Research Institute Pte Ltd, Singapore, Singapore
| | - David B Price
- Observational and Pragmatic Research Institute Pte Ltd, Singapore, Singapore.,Academic Primary Care, University of Aberdeen, Aberdeen, UK
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Hillyer EV, Price DB, Chrystyn H, Martin RJ, Israel E, van Aalderen WM, Papi A, Usmani OS, Roche N. Harmonizing the Nomenclature for Therapeutic Aerosol Particle Size: A Proposal. J Aerosol Med Pulm Drug Deliv 2018; 31:111-113. [DOI: 10.1089/jamp.2017.1396] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Elizabeth V. Hillyer
- Observational and Pragmatic Research Institute, Pte., Ltd., Singapore, Singapore
| | - David B. Price
- Observational and Pragmatic Research Institute, Pte., Ltd., Singapore, Singapore
- Academic Primary Care, University of Aberdeen, Aberdeen, United Kingdom
| | - Henry Chrystyn
- Observational and Pragmatic Research Institute, Pte., Ltd., Singapore, Singapore
- Inhalation Consultancy, Ltd., Leeds, United Kingdom
| | - Richard J. Martin
- Department of Medicine, National Jewish Health and University of Colorado Denver, Denver, Colorado
| | - Elliot Israel
- Pulmonary and Critical Care Division, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Willem M.C. van Aalderen
- Department of Pediatric Respiratory Medicine and Allergy, Emma Children's Hospital AMC, Amsterdam, The Netherlands
| | - Alberto Papi
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Omar S. Usmani
- Airway Disease Section, National Heart and Lung Institute, Imperial College London, and Royal Brompton Hospital, London, United Kingdom
| | - Nicolas Roche
- University Paris Descartes (EA2511), Cochin Hospital Group (AP-HP), Paris, France
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3
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Kerkhof M, Hillyer EV, Price DB. The effect of smoking on exacerbation risk in eosinophilic patients with COPD. Eur Respir J 2017; 50:50/6/1702086. [PMID: 29269585 DOI: 10.1183/13993003.02086-2017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 10/10/2017] [Indexed: 11/05/2022]
Affiliation(s)
- Marjan Kerkhof
- Observational and Pragmatic Research Institute (OPRI), Singapore
| | | | - David B Price
- Observational and Pragmatic Research Institute (OPRI), Singapore
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Kerkhof M, Tran TN, Soriano JB, Golam S, Gibson D, Hillyer EV, Price DB. Healthcare resource use and costs of severe, uncontrolled eosinophilic asthma in the UK general population. Thorax 2017; 73:116-124. [PMID: 28918400 PMCID: PMC5801646 DOI: 10.1136/thoraxjnl-2017-210531] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Revised: 08/08/2017] [Accepted: 08/14/2017] [Indexed: 11/28/2022]
Abstract
Background Little is known about the prevalence of severe, uncontrolled eosinophilic asthma (SUEA) and associated costs. Aims We sought to determine the prevalence of SUEA and compare asthma-related healthcare resource use (HCRU) and associated costs with overall means for a general asthma population. Methods This cohort study evaluated anonymised medical record data (December 1989 through June 2015) from the Clinical Practice Research Datalink and the Optimum Patient Care Research Database to study UK patients with active asthma (diagnostic code and one or more drug prescriptions in the baseline year), aged 5 years and older, without concomitant COPD, and with recorded eosinophil count. SUEA was defined as two or more asthma attacks during 1 baseline year preceding a high blood eosinophil count (≥0.3×109/L) for patients prescribed long-acting β2-agonist (LABA) and high-dosage inhaled corticosteroids (ICS) during baseline plus 1 follow-up year. We compared asthma-related HCRU and associated direct costs (2015 pounds sterling, £) during the follow-up year for SUEA versus the general asthma population. Results Of 363 558 patients with active asthma and recorded eosinophil count, 64% were women, mean (SD) age was 49 (21) years; 43% had high eosinophil counts, 7% had two or more attacks in the baseline year and 10% were prescribed high-dosage ICS/LABA for 2 study years. Overall, 2940 (0.81%; 95% CI 0.78% to 0.84%) patients had SUEA. Total mean per-patient HCRU and associated costs were four times greater for SUEA versus all patients (HCRU and cost ratios 3.9; 95% CI 3.7 to 4.1). Conclusions Less than 1% of patients in a general asthma population had SUEA. These patients accounted for substantially greater asthma-related HCRU and costs than average patients with asthma.
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Affiliation(s)
- Marjan Kerkhof
- Observational and Pragmatic Research Institute Pte Ltd, Singapore, Singapore
| | - Trung N Tran
- Medical Evidence and Observational Research, AstraZeneca, Gaithersburg, Maryland, USA
| | - Joan B Soriano
- Instituto de Investigación Hospital Universitario de la Princesa (IISP), Universidad Autónoma de Madrid, Madrid, Spain
| | - Sarowar Golam
- Global Payer Evidence and Pricing, AstraZeneca, Gothenburg, Sweden
| | | | - Elizabeth V Hillyer
- Observational and Pragmatic Research Institute Pte Ltd, Singapore, Singapore
| | - David B Price
- Observational and Pragmatic Research Institute Pte Ltd, Singapore, Singapore.,Academic Primary Care, University of Aberdeen, Aberdeen, UK
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Kerkhof M, Sonnappa S, Postma DS, Brusselle G, Agustí A, Anzueto A, Jones R, Papi A, Pavord I, Pizzichini E, Popov T, Roche N, Ryan D, Thomas M, Vogelmeier C, Chisholm A, Freeman D, Bafadhel M, Hillyer EV, Price DB. Blood eosinophil count and exacerbation risk in patients with COPD. Eur Respir J 2017; 50:50/1/1700761. [PMID: 28729477 DOI: 10.1183/13993003.00761-2017] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 04/22/2017] [Indexed: 11/05/2022]
Affiliation(s)
- Marjan Kerkhof
- Observational and Pragmatic Research Institute (OPRI), Singapore, Singapore
| | - Samatha Sonnappa
- Observational and Pragmatic Research Institute (OPRI), Singapore, Singapore
| | - Dirkje S Postma
- Dept of Pulmonology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Guy Brusselle
- Dept of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium.,Dept of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands.,Dept of Respiratory Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Alvar Agustí
- Respiratory Institute, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), University of Barcelona, Barcelona, Spain.,Centro de Investigación Biomédica en red Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Antonio Anzueto
- Division of Pulmonary Diseases and Critical Care Medicine, School of Medicine, The University of Texas Health Science Center, San Antonio, TX, USA.,Audie L. Murphy Memorial VA Hospital, South Texas Veterans Health Care System, San Antonio, TX, USA
| | - Rupert Jones
- Plymouth University Peninsula Schools of Medicine and Dentistry (PU PSMD), Plymouth University, Plymouth, UK
| | - Alberto Papi
- Dept of Medicine, University of Ferrara, Ferrara, Italy
| | - Ian Pavord
- Respiratory Medicine Unit, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | - Emilio Pizzichini
- Asthma Research Centre (NUPAIVA), University Hospital, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Todor Popov
- Clinic of Allergy and Asthma, Medical University Sofia, Sofia, Bulgaria
| | - Nicolas Roche
- Unit EA2511 (Cystic Fibrosis and Chronic bronchopathy), Faculté de Médecine, Université Paris Descartes, Paris, France.,Hôpital Cochin, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Dermot Ryan
- Allergy and Respiratory Research Group, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Mike Thomas
- Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Southampton, UK.,NIHR Southampton Respiratory Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Claus Vogelmeier
- Dept of Medicine (Pulmonary and Critical Care Medicine), University Medical Center Giessen and Marburg, Philipps-University Marburg, Marburg, Germany.,German Center for Lung Research (DZL), Marburg, Germany
| | - Alison Chisholm
- On behalf of the Respiratory Effectiveness Group, Cambridge, UK
| | | | - Mona Bafadhel
- Respiratory Medicine Unit, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
| | | | - David B Price
- Observational and Pragmatic Research Institute (OPRI), Singapore, Singapore .,On behalf of the Respiratory Effectiveness Group, Cambridge, UK.,Institute of Applied Health Sciences (Academic Primary Care), University of Aberdeen, Aberdeen, UK
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Burden A, Roche N, Miglio C, Hillyer EV, Postma DS, Herings RM, Overbeek JA, Khalid JM, van Eickels D, Price DB. An evaluation of exact matching and propensity score methods as applied in a comparative effectiveness study of inhaled corticosteroids in asthma. Pragmat Obs Res 2017; 8:15-30. [PMID: 28356782 PMCID: PMC5367458 DOI: 10.2147/por.s122563] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Cohort matching and regression modeling are used in observational studies to control for confounding factors when estimating treatment effects. Our objective was to evaluate exact matching and propensity score methods by applying them in a 1-year pre–post historical database study to investigate asthma-related outcomes by treatment. Methods We drew on longitudinal medical record data in the PHARMO database for asthma patients prescribed the treatments to be compared (ciclesonide and fine-particle inhaled corticosteroid [ICS]). Propensity score methods that we evaluated were propensity score matching (PSM) using two different algorithms, the inverse probability of treatment weighting (IPTW), covariate adjustment using the propensity score, and propensity score stratification. We defined balance, using standardized differences, as differences of <10% between cohorts. Results Of 4064 eligible patients, 1382 (34%) were prescribed ciclesonide and 2682 (66%) fine-particle ICS. The IPTW and propensity score-based methods retained more patients (96%–100%) than exact matching (90%); exact matching selected less severe patients. Standardized differences were >10% for four variables in the exact-matched dataset and <10% for both PSM algorithms and the weighted pseudo-dataset used in the IPTW method. With all methods, ciclesonide was associated with better 1-year asthma-related outcomes, at one-third the prescribed dose, than fine-particle ICS; results varied slightly by method, but direction and statistical significance remained the same. Conclusion We found that each method has its particular strengths, and we recommend at least two methods be applied for each matched cohort study to evaluate the robustness of the findings. Balance diagnostics should be applied with all methods to check the balance of confounders between treatment cohorts. If exact matching is used, the calculation of a propensity score could be useful to identify variables that require balancing, thereby informing the choice of matching criteria together with clinical considerations.
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Affiliation(s)
- Anne Burden
- Observational and Pragmatic Research Institute Pte Ltd, Singapore
| | - Nicolas Roche
- University Paris Descartes (EA2511), Cochin Hospital Group (AP-HP), Paris, France
| | - Cristiana Miglio
- Observational and Pragmatic Research Institute Pte Ltd, Singapore
| | | | - Dirkje S Postma
- Department of Pulmonology, University Medical Center Groningen, University of Groningen, Groningen
| | - Ron Mc Herings
- PHARMO Institute for Drug Outcomes Research, Utrech, the Netherlands
| | - Jetty A Overbeek
- PHARMO Institute for Drug Outcomes Research, Utrech, the Netherlands
| | | | | | - David B Price
- Observational and Pragmatic Research Institute Pte Ltd, Singapore; Academic Primary Care, University of Aberdeen, Aberdeen, UK
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7
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Guilbert TW, Colice G, Grigg J, van Aalderen W, Martin RJ, Israel E, Postma DS, Roche N, Phipatanakul W, Hillyer EV, Evans JM, Dolovich MB, Price DB. Real-Life Outcomes for Patients with Asthma Prescribed Spacers for Use with Either Extrafine- or Fine-Particle Inhaled Corticosteroids. J Allergy Clin Immunol Pract 2017; 5:1040-1049.e4. [PMID: 28110057 DOI: 10.1016/j.jaip.2016.11.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Revised: 10/21/2016] [Accepted: 11/11/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Spacers are often used with pressurized metered-dose inhalers (pMDIs) to eliminate the need for coordinating inhalation with actuation. OBJECTIVE To investigate the real-life effectiveness of spacers prescribed for use with either extrafine- or fine-particle inhaled corticosteroids (ICSs). METHODS This historical matched cohort study examined anonymous medical record data over 2 years (1-year baseline, 1-year outcome) for patients with asthma aged 12 to 80 years initiating ICSs by pMDI with or without prescribed spacer. We compared outcomes for spacer versus no-spacer arms, matched for key baseline and asthma-related characteristics, within 2 ICS cohorts: (1) extrafine-particle ICS (beclomethasone) and (2) fine-particle ICS (fluticasone). Effectiveness end points were compared using conditional regression methods. RESULTS Matched spacer and no-spacer arms of the extrafine-particle ICS cohort each included 2090 patients (69% females; median age, 46-47 years) and the 2 arms of the fine-particle ICS cohort each included 444 patients (67% females; median age, 45 years). With extrafine-particle ICS, we observed no significant difference between spacer and no-spacer arms in severe exacerbation rate (primary end point): adjusted rate ratio, 1.01 (95% CI, 0.83-1.23). With fine-particle ICS, the severe exacerbation rate ratio with spacers was 0.77 (0.47-1.25). Oropharyngeal candidiasis incidence was low and similar in spacer and no-spacer arms for both ICS cohorts. CONCLUSIONS We found no evidence that prescribed spacer devices are associated with improved asthma outcomes for extrafine- or fine-particle ICS administered by pMDI. These findings challenge long-standing assumptions that spacers should improve pMDI effectiveness and indicate the need for pragmatic trials of spacers in clinical practice.
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Affiliation(s)
| | - Gene Colice
- Global Medicines Development, AstraZeneca, Gaithersburg, Md
| | - Jonathan Grigg
- Blizard Institute, Queen Mary University London, London, United Kingdom
| | - Wim van Aalderen
- Department of Pediatric Respiratory Medicine and Allergy, Emma Children's Hospital AMC, Amsterdam, the Netherlands
| | - Richard J Martin
- Department of Medicine, National Jewish Health, and University of Colorado Denver, Denver, Colo
| | - Elliot Israel
- Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Dirkje S Postma
- University of Groningen, Department of Pulmonary Medicine and Tuberculosis, University Medical Center Groningen, Groningen, the Netherlands
| | - Nicolas Roche
- Respiratory and Intensive Care Medicine, Cochin Hospital Group, AP-HP, University of Paris Descartes (EA2511), Paris, France
| | | | | | - Jennifer M Evans
- Observational and Pragmatic Research Institute Pte Ltd, Singapore
| | - Myrna B Dolovich
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - David B Price
- Observational and Pragmatic Research Institute Pte Ltd, Singapore; Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom.
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8
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Postma DS, Dekhuijzen R, van der Molen T, Martin RJ, van Aalderen W, Roche N, Guilbert TW, Israel E, van Eickels D, Khalid JM, Herings RMC, Overbeek JA, Miglio C, Thomas V, Hutton C, Hillyer EV, Price DB. Asthma-Related Outcomes in Patients Initiating Extrafine Ciclesonide or Fine-Particle Inhaled Corticosteroids. Allergy Asthma Immunol Res 2017; 9:116-125. [PMID: 28102056 PMCID: PMC5266109 DOI: 10.4168/aair.2017.9.2.116] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 07/04/2016] [Indexed: 11/20/2022]
Abstract
Purpose Extrafine-particle inhaled corticosteroids (ICS) have greater small airway deposition than standard fine-particle ICS. We sought to compare asthma-related outcomes after patients initiated extrafine-particle ciclesonide or fine-particle ICS (fluticasone propionate or non-extrafine beclomethasone). Methods This historical, matched cohort study included patients aged 12-60 years prescribed their first ICS as ciclesonide or fine-particle ICS. The 2 cohorts were matched 1:1 for key demographic and clinical characteristics over the baseline year. Co-primary endpoints were 1-year severe exacerbation rates, risk-domain asthma control, and overall asthma control; secondary endpoints included therapy change. Results Each cohort included 1,244 patients (median age 45 years; 65% women). Patients in the ciclesonide cohort were comparable to those in the fine-particle ICS cohort apart from higher baseline prevalence of hospitalization, gastroesophageal reflux disease, and rhinitis. Median (interquartile range) prescribed doses of ciclesonide and fine-particle ICS were 160 (160-160) µg/day and 500 (250-500) µg/day, respectively (P<0.001). During the outcome year, patients prescribed ciclesonide experienced lower severe exacerbation rates (adjusted rate ratio [95% CI], 0.69 [0.53-0.89]), and higher odds of risk-domain asthma control (adjusted odds ratio [95% CI], 1.62 [1.27-2.06]) and of overall asthma control (2.08 [1.68-2.57]) than those prescribed fine-particle ICS. The odds of therapy change were 0.70 (0.59-0.83) with ciclesonide. Conclusions In this matched cohort analysis, we observed that initiation of ICS with ciclesonide was associated with better 1-year asthma outcomes and fewer changes to therapy, despite data suggesting more difficult-to-control asthma. The median prescribed dose of ciclesonide was one-third that of fine-particle ICS.
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Affiliation(s)
- Dirkje S Postma
- University of Groningen, Department of Pulmonology, University Medical Center Groningen, Groningen, The Netherlands
| | | | - Thys van der Molen
- University of Groningen, Department of Pulmonology, University Medical Center Groningen, Groningen, The Netherlands
| | - Richard J Martin
- Department of Medicine, National Jewish Health, and University of Colorado Denver, Denver, CO, USA
| | | | - Nicolas Roche
- University Paris Descartes (EA2511), Cochin Hospital Group (AP-HP), Paris, France
| | | | - Elliot Israel
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | - Ron M C Herings
- PHARMO Institute for Drug Outcomes Research, The Netherlands
| | | | | | | | | | | | - David B Price
- Research in Real Life, Cambridge, UK.,Academic Primary Care, University of Aberdeen, Aberdeen, UK.
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9
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Blakey JD, Price DB, Pizzichini E, Popov TA, Dimitrov BD, Postma DS, Josephs LK, Kaplan A, Papi A, Kerkhof M, Hillyer EV, Chisholm A, Thomas M. Identifying Risk of Future Asthma Attacks Using UK Medical Record Data: A Respiratory Effectiveness Group Initiative. J Allergy Clin Immunol Pract 2016; 5:1015-1024.e8. [PMID: 28017629 DOI: 10.1016/j.jaip.2016.11.007] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 10/13/2016] [Accepted: 11/04/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Asthma attacks are common, serious, and costly. Individual factors associated with attacks, such as poor symptom control, are not robust predictors. OBJECTIVE We investigated whether the rich data available in UK electronic medical records could identify patients at risk of recurrent attacks. METHODS We analyzed anonymized, longitudinal medical records of 118,981 patients with actively treated asthma (ages 12-80 years) and 3 or more years of data. Potential risk factors during 1 baseline year were evaluated using univariable (simple) logistic regression for outcomes of 2 or more and 4 or more attacks during the following 2-year period. Predictors with significant univariable association (P < .05) were entered into multiple logistic regression analysis with backward stepwise selection of the model including all significant independent predictors. The predictive accuracy of the multivariable models was assessed. RESULTS Independent predictors associated with future attacks included baseline-year markers of attacks (acute oral corticosteroid courses, emergency visits), more frequent reliever use and health care utilization, worse lung function, current smoking, blood eosinophilia, rhinitis, nasal polyps, eczema, gastroesophageal reflux disease, obesity, older age, and being female. The number of oral corticosteroid courses had the strongest association. The final cross-validated models incorporated 19 and 16 risk factors for 2 or more and 4 or more attacks over 2 years, respectively, with areas under the curve of 0.785 (95% CI, 0.780-0.789) and 0.867 (95% CI, 0.860-0.873), respectively. CONCLUSIONS Routinely collected data could be used proactively via automated searches to identify individuals at risk of recurrent asthma attacks. Further research is needed to assess the impact of such knowledge on clinical prognosis.
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Affiliation(s)
- John D Blakey
- Clinical Sciences, Liverpool School of Tropical Medicine, and Respiratory Medicine, Royal Liverpool Hospital, Liverpool, United Kingdom.
| | - David B Price
- Academic Primary Care, University of Aberdeen, Aberdeen, United Kingdom; Observational and Pragmatic Research Institute Pte Ltd, Singapore
| | - Emilio Pizzichini
- NUPAIVA (Asthma Research Centre), University Hospital, Federal University of Santa Catarina, Florianуpolis, Santa Catarina, Brazil
| | | | - Borislav D Dimitrov
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; NIHR Southampton Respiratory Biomedical Research Unit, Southampton, United Kingdom
| | - Dirkje S Postma
- Department of Pulmonology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Lynn K Josephs
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Alan Kaplan
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - Alberto Papi
- Department of Medicine, University of Ferrara, Ferrara, Italy
| | - Marjan Kerkhof
- Observational and Pragmatic Research Institute Pte Ltd, Singapore
| | | | | | - Mike Thomas
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom; NIHR Southampton Respiratory Biomedical Research Unit, Southampton, United Kingdom
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10
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van Aalderen WMC, Grigg J, Guilbert TW, Roche N, Colice G, Postma DS, Hillyer EV, Price DB. Reply. J Allergy Clin Immunol Pract 2016; 4:372-3. [PMID: 26968965 DOI: 10.1016/j.jaip.2015.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 12/04/2015] [Indexed: 11/15/2022]
Affiliation(s)
- Willem M C van Aalderen
- Department of Pediatric Respiratory Medicine and Allergy, Emma Children's Hospital AMC, Amsterdam, The Netherlands
| | - Jonathan Grigg
- Blizard Institute, Queen Mary University London, London, United Kingdom
| | | | - Nicolas Roche
- Cochin Hospital Group, AP-HP, University of Paris Descartes (EA2511), Paris, France
| | - Gene Colice
- Global Medicines Development, AstraZeneca, Gaithersburg, Md
| | - Dirkje S Postma
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | - David B Price
- Research in Real Life, Ltd, Cambridge, United Kingdom; Academic Primary Care, University of Aberdeen, Aberdeen, United Kingdom.
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11
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van der Molen T, Postma DS, Martin RJ, Herings RMC, Overbeek JA, Thomas V, Miglio C, Dekhuijzen R, Roche N, Guilbert T, Israel E, van Aalderen W, Hillyer EV, van Rysewyk S, Price DB. Erratum to: Effectiveness of initiating extrafine-particle versus fine-particle inhaled corticosteroids as asthma therapy in the Netherlands. BMC Pulm Med 2016; 16:105. [PMID: 27450521 PMCID: PMC4958282 DOI: 10.1186/s12890-016-0270-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 07/19/2016] [Indexed: 11/17/2022] Open
Affiliation(s)
- Thys van der Molen
- Department of General Practice, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Dirkje S Postma
- University of Groningen, University Medical Center Groningen, Department Pulmonary Medicine and Tuberculosis, Groningen, The Netherlands
| | - Richard J Martin
- National Jewish Health and the University of Colorado, Denver, USA
| | - Ron M C Herings
- PHARMO Institute for Drugs Outcome Research, Utrecht, The Netherlands
| | - Jetty A Overbeek
- PHARMO Institute for Drugs Outcome Research, Utrecht, The Netherlands
| | | | | | | | - Nicolas Roche
- Groupe Hospitalier Cochin, AP-HP and University Paris Descartes (EA2511), Paris, France
| | - Theresa Guilbert
- Cincinnati Children's Hospital and Medical Center, Cincinnati, USA
| | - Elliot Israel
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Wim van Aalderen
- Emma's Children Hospital, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Simon van Rysewyk
- Observational & Pragmatic Research Institute Pte, Ltd, Singapore, Singapore
| | - David B Price
- Observational & Pragmatic Research Institute Pte, Ltd, Singapore, Singapore. .,Academic Primary Care, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen, AB25 2ZD, UK.
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Turner S, Richardson K, Murray C, Thomas M, Hillyer EV, Burden A, Price DB. AB027. Long-acting beta-agonist in combination or separate inhaler as step-up therapy for children with uncontrolled asthma receiving inhaled corticosteroids. J Thorac Dis 2016. [DOI: 10.21037/jtd.2016.s027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Roche N, Colice G, Israel E, Martin RJ, Dorinsky PM, Postma DS, Guilbert TW, Grigg J, van Aalderen WMC, Barion F, Hillyer EV, Thomas V, Burden A, Brett McQueen R, Price DB. Cost-Effectiveness of Asthma Step-Up Therapy as an Increased Dose of Extrafine-Particle Inhaled Corticosteroid or Add-On Long-Acting Beta2-Agonist. Pulm Ther 2016. [DOI: 10.1007/s41030-016-0014-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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van der Molen T, Postma DS, Martin RJ, Herings RMC, Overbeek JA, Thomas V, Miglio C, Dekhuijzen R, Roche N, Guilbert T, Israel E, van Aalderen W, Hillyer EV, van Rysewyk S, Price DB. Effectiveness of initiating extrafine-particle versus fine-particle inhaled corticosteroids as asthma therapy in the Netherlands. BMC Pulm Med 2016; 16:80. [PMID: 27184175 PMCID: PMC4869182 DOI: 10.1186/s12890-016-0234-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Accepted: 04/27/2016] [Indexed: 11/25/2022] Open
Abstract
Background Most randomised clinical trials typically exclude a significant proportion of asthma patients, including those at higher risk of adverse events, with comorbidities, obesity, poor inhaler technique and adherence, or smokers. However, these patients might differentially benefit from extrafine-particle inhaled corticosteroids (ICS). This matched cohort, database study, compared the effectiveness of extrafine-particle with fine-particle ICS in a real-life population initiating ICS therapy in the Netherlands. Methods Data were from the Pharmo Database Network, comprising pharmacy and hospital discharge records, representative of 20 % of the Dutch population. The study population included patients aged 12 − 60, with a General Practice-recorded diagnosis for asthma (International Classification of Primary Care code R96), when available, ≥2 prescriptions for asthma therapy at any time in their recorded history, and receiving first prescription of ICS therapy as either extrafine-particle (ciclesonide or hydrofluoroalkane beclomethasone dipropionate [BDP]) or fine-particle ICS (fluticasone propionate or non-extrafine-particle-BDP). Patients were matched (1:1) on relevant demographic and clinical characteristics over 1-year baseline. Primary outcomes were severe exacerbation rates, risk domain asthma control and overall asthma control during the year following first ICS prescription. Secondary outcomes, treatment stability and being prescribed higher versus lower category of short-acting β2 agonists (SABA) dose, were compared over a 1-year outcome period using conditional logistic regression models. Results Following matching, 1399 patients were selected in each treatment cohort (median age: 43 years; males: 34 %). Median (interquartile range) initial ICS doses (fluticasone-equivalents in μg) were 160 (160 − 320) for extrafine-particle versus 500 (250 − 500) for fine-particle ICS (p < 0.001). Following adjustment for residual confounders, matched patients prescribed extrafine-particle ICS had significantly lower rates of exacerbations (adjusted rate ratio [95 % CI], 0.59 [0.47–0.73]), and significantly higher odds of achieving asthma control and treatment stability in the year following initiation than those prescribed fine-particle ICS, and this occurred at lower prescribed doses. Patients prescribed extrafine-particle ICS had lower odds of being prescribed higher doses of SABA (0.50 [0.44–0.57]). Conclusion In this historical, matched study, extrafine-particle ICS was associated with better odds of asthma control than fine-particle ICS in patients prescribed their first ICS therapy in the Netherlands. Of importance, this was reached at significantly lower prescribed dose. Electronic supplementary material The online version of this article (doi:10.1186/s12890-016-0234-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thys van der Molen
- Department of General Practice, University of Groningen, University Medical Center, Groningen, The Netherlands
| | - Dirkje S Postma
- Department of Pulmonary Medicine, University of Groningen, University Medical Center, Groningen, The Netherlands
| | | | - Ron M C Herings
- Pharmo Institute for Drugs Outcome Research, Utrecht, The Netherlands
| | - Jetty A Overbeek
- Pharmo Institute for Drugs Outcome Research, Utrecht, The Netherlands
| | | | | | | | - Nicolas Roche
- Groupe Hospitalier Cochin, AP-HP and University Paris Descartes, Paris, France
| | - Theresa Guilbert
- Cincinnati Children's Hospital and Medical Center, Cincinnati, USA
| | - Elliot Israel
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Wim van Aalderen
- Emma's Children Hospital, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Simon van Rysewyk
- Observational & Pragmatic Research Institute Pte, Ltd, Singapore, Singapore
| | - David B Price
- Observational & Pragmatic Research Institute Pte, Ltd, Singapore, Singapore. .,Academic Primary Care, University of Aberdeen, Polwarth Building, Foresterhill, AB25 2ZD, Aberdeen, UK.
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Price DB, Colice G, Israel E, Roche N, Postma DS, Guilbert TW, van Aalderen WM, Grigg J, Hillyer EV, Thomas V, Martin RJ. Add-on LABA in a separate inhaler as asthma step-up therapy versus increased dose of ICS or ICS/LABA combination inhaler. ERJ Open Res 2016; 2:00106-2015. [PMID: 27730200 PMCID: PMC5005184 DOI: 10.1183/23120541.00106-2015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Accepted: 03/09/2016] [Indexed: 01/01/2023] Open
Abstract
Asthma management guidelines recommend adding a long-acting β2-agonist (LABA) or increasing the dose of inhaled corticosteroid (ICS) as step-up therapy for patients with uncontrolled asthma on ICS monotherapy. However, it is uncertain which option works best, which ICS particle size is most effective, and whether LABA should be administered by separate or combination inhalers. This historical, matched cohort study compared asthma-related outcomes for patients (aged 12-80 years) prescribed step-up therapy as a ≥50% extrafine ICS dose increase or add-on LABA, via either a separate inhaler or a fine-particle ICS/LABA fixed-dose combination (FDC) inhaler. Risk-domain asthma control was the primary end-point in comparisons of cohorts matched for asthma severity and control during the baseline year. After 1:2 cohort matching, the increased extrafine ICS versus separate ICS+LABA cohorts included 3232 and 6464 patients, respectively, and the fine-particle ICS/LABA FDC versus separate ICS+LABA cohorts included 7529 and 15 058 patients, respectively (overall mean age 42 years; 61-62% females). Over one outcome year, adjusted OR (95% CI) for achieving asthma control were 1.25 (1.13-1.38) for increased ICS versus separate ICS+LABA and 1.06 (1.05-1.09) for ICS/LABA FDC versus separate ICS+LABA. For patients with asthma, increased dose of extrafine-particle ICS, or add-on LABA via ICS/LABA combination inhaler, is associated with significantly better outcomes than ICS+LABA via separate inhalers.
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Affiliation(s)
- David B. Price
- Academic Primary Care, University of Aberdeen, Aberdeen, UK
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Gene Colice
- Washington Hospital Center and George Washington University School of Medicine, Washington, DC, USA
| | - Elliot Israel
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nicolas Roche
- University Paris Descartes (EA2511), Cochin Hospital Group (AP-HP), Paris, France
| | - Dirkje S. Postma
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | | | - Jonathan Grigg
- Blizard Institute, Queen Mary University of London, London, UK
| | | | - Victoria Thomas
- Observational and Pragmatic Research Institute, Singapore, Singapore
| | - Richard J. Martin
- National Jewish Health and the University of Colorado Denver, Denver, CO, USA
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Price DB, Pavord ID, Thomas M, Corrigan CJ, Wilson AM, Hillyer EV, Kerkhof M. Inhaled corticosteroid dose-response on blood eosinophils in asthma - Authors' reply. Lancet Respir Med 2016; 4:e1-e2. [PMID: 26762664 DOI: 10.1016/s2213-2600(15)00506-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 11/25/2015] [Indexed: 11/26/2022]
Affiliation(s)
- David B Price
- Research in Real-Life, Cambridge, UK; Academic Primary Care, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UK.
| | - Ian D Pavord
- Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Mike Thomas
- Primary Care and Population Sciences, and NIHR Southampton Respiratory Biomedical Research Unit, University of Southampton, Southampton, UK
| | | | - Andrew M Wilson
- Norwich Medical School, University of East Anglia, Norwich, UK
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Price DB, Rigazio A, Campbell JD, Bleecker ER, Corrigan CJ, Thomas M, Wenzel SE, Wilson AM, Small MB, Gopalan G, Ashton VL, Burden A, Hillyer EV, Kerkhof M, Pavord ID. Blood eosinophil count and prospective annual asthma disease burden: a UK cohort study. Lancet Respir Med 2015; 3:849-58. [PMID: 26493938 DOI: 10.1016/s2213-2600(15)00367-7] [Citation(s) in RCA: 375] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 09/04/2015] [Accepted: 09/11/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Elevated sputum eosinophil counts predict asthma exacerbations and responsiveness to inhaled corticosteroids but are impractical to measure in primary care. We investigated the relation between blood eosinophil count and prospective annual asthma outcomes for a large UK cohort. METHODS This historical cohort study used anonymised medical record data to identify primary care patients with asthma aged 12-80 years with 2 years of continuous records, including 1 year before (baseline) and 1 year after (outcome) their most recent eosinophil count. Negative binomial regression was used to compare outcome exacerbation rates and logistic regression to compare odds of asthma control for patients with blood eosinophil counts of 400 cells per μL or less versus greater than 400 cells per μL, adjusting for age, sex, body-mass index, smoking status, and Charlson comorbidity index. The study is registered at ClinicalTrials.gov, number NCT02140541. FINDINGS Overall, 20 929 (16%) of 130 248 patients had blood eosinophil counts greater than 400 cells per μL. During the outcome year, these patients experienced significantly more severe exacerbations (adjusted rate ratio [RR] 1·42, 95% CI 1·36-1·47) and acute respiratory events (RR 1·28, 1·24-1·33) than those with counts of 400 cells per μL or less. They also had significantly lower odds of achieving overall asthma control (OR 0·74, 95% CI 0·72-0·77), defined as limited reliever use and no asthma-related hospital attendance or admission, acute course of oral corticosteroids, or prescription for antibiotics. Exacerbation rates increased progressively with nine ascending categories of blood eosinophil count as compared with a reference category of 200 cells per μL or less. INTERPRETATION Patients with asthma and blood eosinophil counts greater than 400 cells per μL experience more severe exacerbations and have poorer asthma control. Furthermore, a count-response relation exists between blood eosinophil counts and asthma-related outcomes. Blood eosinophil counts could add predictive value to Global Initiative for Asthma control-based risk assessment. FUNDING Teva Pharmaceuticals.
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Affiliation(s)
- David B Price
- Academic Primary Care, University of Aberdeen, Aberdeen, UK; Research in Real-Life, Cambridge, UK.
| | | | - Jonathan D Campbell
- Department of Clinical Pharmacy, Pharmaceutical Outcomes Research, University of Colorado School of Pharmacy, Aurora, CO, USA
| | - Eugene R Bleecker
- Center for Genomics and Personalized Medicine Research, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | | | - Mike Thomas
- Primary Care and Population Sciences, and NIHR Southampton Respiratory Biomedical Research Unit, University of Southampton, Southampton, UK
| | - Sally E Wenzel
- University of Pittsburgh Asthma Institute at UPMC, Division of Pulmonary, Allergy and Critical Care Medicine, Pittsburgh, PA, USA
| | - Andrew M Wilson
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Mary Buatti Small
- Respiratory, Global Medical Affairs, TEVA Pharmaceuticals, Frazer, PA, USA
| | - Gokul Gopalan
- Respiratory, Global Medical Affairs, TEVA Pharmaceuticals, Frazer, PA, USA
| | | | | | | | | | - Ian D Pavord
- Respiratory Medicine Unit, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Roche N, Postma DS, Colice G, Burden A, Guilbert TW, Israel E, Martin RJ, van Aalderen WMC, Grigg J, Hillyer EV, von Ziegenweidt J, Price DB. Differential effects of inhaled corticosteroids in smokers/ex-smokers and nonsmokers with asthma. Am J Respir Crit Care Med 2015; 191:960-4. [PMID: 25876207 DOI: 10.1164/rccm.201411-2116le] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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van Aalderen WMC, Grigg J, Guilbert TW, Roche N, Israel E, Martin RJ, Colice G, Postma DS, Hillyer EV, Burden A, Thomas V, von Ziegenweidt J, Price D. Small-particle Inhaled Corticosteroid as First-line or Step-up Controller Therapy in Childhood Asthma. J Allergy Clin Immunol Pract 2015; 3:721-31.e16. [PMID: 26032474 DOI: 10.1016/j.jaip.2015.04.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Revised: 04/09/2015] [Accepted: 04/23/2015] [Indexed: 12/26/2022]
Abstract
BACKGROUND Because randomized controlled trials of established pediatric asthma therapies are expensive and difficult to perform, observational studies may fill gaps in the evidence base. OBJECTIVES To compare the effectiveness of representative small-particle inhaled corticosteroid (ICS) with that of standard size-particle ICS for children initiating or stepping up ICS therapy for asthma (analysis 1) and to compare the effectiveness of ICS dose step-up using small-particle ICS with adding long-acting β2-agonist (LABA) to the ICS (analysis 2). METHODS These historical matched cohort analyses drew on electronic medical records of children with asthma aged 5 to 11 years. Variables measured during 2 consecutive years (1 baseline year for confounder definition and 1 outcome year) included risk-domain asthma control (no hospital attendance for asthma, acute oral corticosteroids, or lower respiratory tract infection requiring antibiotics) and rate of severe exacerbations (asthma-related emergency, hospitalization, or oral corticosteroids). RESULTS In the initiation population (n = 797 in each cohort), children prescribed small-particle ICS versus standard size-particle ICS experienced greater odds of asthma control (adjusted odds ratio, 1.49; 95% CI, 1.10-2.02) and lower severe exacerbation rate (adjusted rate ratio, 0.56; 95% CI, 0.35-0.88). Step-up outcomes (n = 206 in each cohort) were also significantly better for small-particle ICS, with asthma control adjusted odds ratio of 2.22 (95% CI, 1.23-4.03) and exacerbations adjusted rate ratio of 0.49 (95% CI, 0.27-0.89). The number needed to treat with small-particle ICS to achieve 1 additional child with asthma control was 17 (95% CI, 9-107) for the initiation population and 5 (95% CI, 3-78) for the step-up population. Outcomes were not significantly different for stepped-up small-particle ICS dose versus ICS/LABA combination (n = 185 in each cohort). CONCLUSIONS Initiating or stepping up the ICS dose with small-particle ICS rather than with standard size-particle ICS is more effective and shows similar effectiveness to add-on LABA in childhood asthma.
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Affiliation(s)
- Willem M C van Aalderen
- Department of Pediatric Respiratory Medicine and Allergy, Emma Children's Hospital AMC, Amsterdam, The Netherlands
| | - Jonathan Grigg
- Blizard Institute, Queen Mary University London, London, UK
| | | | - Nicolas Roche
- Cochin Hospital Group, AP-HP, University of Paris Descartes (EA2511), Paris, France
| | - Elliot Israel
- Brigham and Women's Hospital and Harvard Medical School, Boston, Mass
| | - Richard J Martin
- Department of Medicine, National Jewish Health and University of Colorado Denver, Denver, Colo
| | - Gene Colice
- Washington Hospital Center and George Washington University School of Medicine, Washington, DC
| | - Dirkje S Postma
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | | | | | | | - David Price
- Research in Real Life, Ltd, Cambridge, UK; Academic Primary Care, University of Aberdeen, Aberdeen, UK.
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Postma DS, Roche N, Colice G, Israel E, Martin RJ, van Aalderen WM, Grigg J, Burden A, Hillyer EV, von Ziegenweidt J, Gopalan G, Price D. Comparing the effectiveness of small-particle versus large-particle inhaled corticosteroid in COPD. Int J Chron Obstruct Pulmon Dis 2014; 9:1163-86. [PMID: 25378918 PMCID: PMC4207569 DOI: 10.2147/copd.s68289] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Purpose Small airway changes and dysfunction contribute importantly to airway obstruction in chronic obstructive pulmonary disease (COPD), which is currently treated with inhaled corticosteroids (ICS) and long-acting bronchodilators at Global initiative for Obstructive Lung Disease (GOLD) grades 2–4. This retrospective matched cohort analysis compared effectiveness of a representative small-particle ICS (extrafine beclomethasone) and larger-particle ICS (fluticasone) in primary care patients with COPD. Patients and methods Smokers and ex-smokers with COPD ≥40 years old initiating or stepping-up their dose of extrafine beclomethasone or fluticasone were matched 1:1 for demographic characteristics, index prescription year, concomitant therapies, and disease severity during 1 baseline year. During 2 subsequent years, we evaluated treatment change and COPD exacerbations, defined as emergency care/hospitalization for COPD, acute oral corticosteroids, or antibiotics for lower respiratory tract infection. Results Mean patient age was 67 years, 57%–60% being male. For both initiation (n=334:334) and step-up (n=189:189) patients, exacerbation rates were comparable between extrafine beclomethasone and fluticasone cohorts during the 2 year outcome period. Odds of treatment stability (no exacerbation or treatment change) were significantly greater for patients initiating extrafine beclomethasone compared with fluticasone (adjusted odds ratio 2.50; 95% confidence interval, 1.32–4.73). Median ICS dose exposure during 2 outcome years was significantly lower (P<0.001) for extrafine beclomethasone than fluticasone cohorts (315 μg/day versus 436 μg/day for initiation, 438 μg/day versus 534 μg/day for step-up patients). Conclusion We observed that small-particle ICS at significantly lower doses had comparable effects on exacerbation rates as larger-particle ICS at higher doses, whereas initiation of small-particle ICS was associated with better odds of treatment stability during 2-years’ follow-up.
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Affiliation(s)
- Dirkje S Postma
- University of Groningen, Department of Pulmonary Medicine and Tuberculosis, University Medical Center Groningen, Groningen, the Netherlands
| | - Nicolas Roche
- Respiratory and Intensive Care Medicine, Cochin Hospital Group, APHP, Paris-Descartes University (EA2511), Paris, France
| | - Gene Colice
- Pulmonary, Critical Care and Respiratory Services, Washington Hospital Center and George Washington University School of Medicine, Washington DC, USA
| | - Elliot Israel
- Pulmonary and Critical Care Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Willem Mc van Aalderen
- Dept of Pediatric Respiratory Medicine and Allergy, Emma Children's Hospital AMC, Amsterdam, the Netherlands
| | - Jonathan Grigg
- Blizard Institute, Queen Mary University London, London, UK
| | | | | | | | - Gokul Gopalan
- Respiratory, Global Scientific Affairs, Teva Pharmaceuticals, Frazer, PA, USA
| | - David Price
- Research in Real Life, Ltd, Cambridge, UK ; Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
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Martin RJ, Price D, Roche N, Israel E, van Aalderen WMC, Grigg J, Postma DS, Guilbert TW, Hillyer EV, Burden A, von Ziegenweidt J, Colice G. Cost-effectiveness of initiating extrafine- or standard size-particle inhaled corticosteroid for asthma in two health-care systems: a retrospective matched cohort study. NPJ Prim Care Respir Med 2014; 24:14081. [PMID: 25297072 PMCID: PMC4373495 DOI: 10.1038/npjpcrm.2014.81] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 08/13/2014] [Accepted: 08/30/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Real-life studies are needed to determine the cost-effectiveness of asthma therapies in clinical practice. AIM To compare the cost-effectiveness of extrafine-particle inhaled corticosteroid (ICS) with standard size-particle ICS in the United Kingdom (UK) and United States (US). METHODS These retrospective matched cohort analyses used large electronic databases to study asthma-related outcomes for patients in the UK (12-60 years old; n=1730) and US (12-80 years; n=10,312) prescribed extrafine beclomethasone or fluticasone as their first ICS therapy for asthma. Patients were matched on demographic characteristics and asthma severity during 1 baseline year, and asthma control and asthma-related costs were compared during 1 outcome year. RESULTS In both the UK and US, adjusted odds of risk-domain asthma control were similar, whereas the odds of overall control (no hospitalisation or oral steroids for asthma, no antibiotics for lower respiratory infection, limited reliever use) were greater for extrafine ICS in both countries (UK odds ratio, 1.23; 95% confidence interval (CI), 1.01-1.50). Asthma-related annual costs, adjusted for baseline, were significantly lower for extrafine-particle ICS cohorts in both countries (UK difference, -£66 (95% CI,-93 to -37)). Cost-effectiveness analyses using the two measures of asthma control found 92 and 98% probabilities of extrafine-particle ICS being the preferred treatment strategy (less costly and more effective than standard size-particle ICS) in the UK, and 84 and 100% probabilities in the US. CONCLUSIONS Initiating ICS therapy for asthma as extrafine-particle ICS seems the dominant treatment option (less costly and more effective) compared with standard size-particle ICS in both the UK and the US.
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Affiliation(s)
| | - David Price
- Academic Primary Care, University of Aberdeen, Aberdeen, UK
- Research in Real Life, Ltd, Cambridge, UK
| | - Nicolas Roche
- Cochin Hospital Group, AP-HP, University of Paris Descartes, Paris, France
| | - Elliot Israel
- Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Jonathan Grigg
- Blizard Institute, Queen Mary University of London, London, UK
| | - Dirkje S Postma
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | | | | | | | | | - Gene Colice
- Washington Hospital Center and George Washington University School of Medicine, Washington, DC, USA
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Abstract
A new combination inhaler containing fluticasone, a potent inhaled corticosteroid (ICS), and formoterol, a long-acting β-agonist (LABA) with rapid onset and sustained bronchodilator effect, has been approved for treatment of persistent asthma in patients ≥12 years of age requiring combination ICS-LABA therapy. The fluticasone/formoterol combination, delivered via pressurized metered-dose inhaler and available in three dose strengths, has demonstrated a good safety and tolerability profile in trials of up to 1 year. The efficacy of fluticasone/formoterol is greater than that of fluticasone or formoterol alone and noninferior to that of fluticasone/salmeterol and budesonide/formoterol in tightly controlled 8-12-week clinical trials. Advantages of the fluticasone/formoterol combination aerosol include rapid onset of bronchodilation, an attribute preferred by patients, and emission of a high fine-particle fraction that is consistent at different flow rates, which may aid consistency of delivery (given patient variability in inhalation maneuvers) and provide real-life benefits.
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Affiliation(s)
- David Price
- Academic Primary Care, University of Aberdeen, Aberdeen, Scotland
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Price D, Lee AJ, Sims EJ, Kemp L, Hillyer EV, Chisholm A, von Ziegenweidt J, Williams A. Characteristics of patients preferring once-daily controller therapy for asthma and COPD: a retrospective cohort study. Prim Care Respir J 2014; 22:161-8. [PMID: 23460035 PMCID: PMC6442780 DOI: 10.4104/pcrj.2013.00017] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
Background: Patient preference is an important factor when choosing an inhaler device for asthma or chronic obstructive pulmonary disease (COPD). Aims: To identify characteristics of patients with asthma or COPD who prefer a once-daily controller medication regimen. Methods: This retrospective observational study used electronic patient records and linked outcomes from patient-completed questionnaires in a primary care database. We compared the characteristics of patients indicating a preference for once-daily therapy with those who were unsure or indicating no preference. Results: Of 3,731 patients with asthma, 2,174 (58%) were women; the mean age was 46 years (range 2–94). Of 2,138 patients with COPD, 980 (46%) were women; the mean age was 70 years (range 35–98). Approximately half of the patients in each cohort indicated once-daily preference, one-quarter were unsure, and one-quarter did not prefer once-daily therapy. In patients with asthma or COPD, the preference for once-daily controller medication was significantly associated with poor adherence and higher concerns about medication. In asthma, good control and low self-perceived controller medication need were associated with once-daily preference. By contrast, in COPD, a high self-perceived need for controller medication was associated with once-daily preference. There was no significant relationship between once-daily preference and age, sex, disease severity, or exacerbation history. Conclusions: Understanding patient preferences may help prescribers to individualise therapy better for asthma and COPD.
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Affiliation(s)
- David Price
- Academic Centre of Primary Care, University of Aberdeen, UK.
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Price D, Thomas M, Haughney J, Lewis RA, Burden A, von Ziegenweidt J, Chisholm A, Hillyer EV, Corrigan CJ. Real-life comparison of beclometasone dipropionate as an extrafine- or larger-particle formulation for asthma. Respir Med 2013; 107:987-1000. [PMID: 23643486 DOI: 10.1016/j.rmed.2013.03.009] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2012] [Revised: 02/12/2013] [Accepted: 03/16/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND Beclometasone dipropionate is an inhaled corticosteroid (ICS) available in both extrafine and larger-particle hydrofluoroalkane formulations. Extrafine beclometasone has greater small airway distribution and inhalation technique tolerance than larger-particle beclometasone; therefore, its use may be associated with improved asthma outcomes at population levels. The study objective was to compare real-life effectiveness of extrafine and larger-particle beclometasone. METHODS Retrospective matched cohort study including primary care patients with asthma (ages 12-60 and non-smokers 61-80 years) prescribed extrafine or larger-particle beclometasone by metered-dose inhaler. We studied patients receiving their first ICS (initiation population, n = 11,289) or switched from another ICS without dose change (switch population, n = 19,065). The extrafine and larger-particle beclometasone cohorts were matched in each population for demographic and database measures of asthma control during a baseline year; and endpoints assessed during 1 outcome year were adjusted for residual confounding factors. RESULTS The odds of no loss of asthma control (no asthma-related hospital attendance, consultation for lower respiratory tract infection, or oral corticosteroids) were significantly higher in the extrafine beclometasone cohorts of both initiation population (adjusted odds ratio [aOR] 1.12; 95% CI 1.02-1.23) and switch population (aOR 1.10; 95% CI 1.01-1.19). The odds of better adherence to ICS therapy were also significantly higher in both extrafine beclometasone cohorts (initiation population, aOR 1.64; 95% CI 1.52-1.75 and switch population, aOR 1.35; 95% CI 1.27-1.43). CONCLUSIONS These findings are consistent with the hypothesis that delivery of beclometasone in extrafine particle size produces real-life asthma treatment benefits. Clinical trials no. NCT01400217.
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Affiliation(s)
- David Price
- Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Polwarth Building, Foresterhill, Aberdeen AB25 2ZD, UK.
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Colice G, Martin RJ, Israel E, Roche N, Barnes N, Burden A, Polos P, Dorinsky P, Hillyer EV, Lee AJ, Chisholm A, von Ziegenweidt J, Barion F, Price D. Asthma outcomes and costs of therapy with extrafine beclomethasone and fluticasone. J Allergy Clin Immunol 2013; 132:45-54. [PMID: 23591272 DOI: 10.1016/j.jaci.2013.02.008] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2012] [Revised: 02/06/2013] [Accepted: 02/11/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND Characteristics of inhaled corticosteroids (ICSs) differ, but data comparing the real-life effectiveness of various ICSs for asthma are lacking. OBJECTIVE We sought to compare real-life asthma outcomes and costs of extrafine hydrofluoroalkane (HFA)-beclomethasone and fluticasone administered through a pressurized metered-dose inhaler. METHODS This retrospective matched cohort study examined database markers of asthma control from a large US longitudinal health care claims database over 1 baseline and 1 outcome year for 10,312 patients with asthma aged 12 to 80 years receiving their first ICS as HFA-beclomethasone or fluticasone and matched on baseline demographic characteristics and asthma severity. RESULTS Patients started on HFA-beclomethasone had significantly higher odds (adjusted odds ratio, 1.19; 95% CI; 1.08-1.31) of achieving overall control (risk and impairment), which was defined as no hospital attendance for asthma, oral corticosteroids, or antibiotics for lower respiratory tract infection and less than 2 puffs per day of short-acting β-agonist; they also experienced a lower rate of respiratory-related hospitalizations or referrals (adjusted rate ratio, 0.82; 95% CI, 0.73-0.93) than patients started on fluticasone. Other database outcome measures were similar in the 2 cohorts. Prescribed HFA-beclomethasone doses were lower (P < .001) than fluticasone doses (median, 320 μg/d [interquartile range, 160-320 μg/d] vs 440 μg/d [interquartile range, 176-440 μg/d]). Adjusted respiratory-related health care costs were significantly lower for HFA-beclomethasone than fluticasone (mean, $1869 [95% CI, $1727-$2032] vs $2259 [95% CI, $2111-$2404]), representing a mean annual savings of $390 (95% CI, $165-$620) per patient prescribed HFA-beclomethasone rather than fluticasone. CONCLUSIONS Asthma treatment outcomes were similar or better with HFA-beclomethasone prescribed at significantly lower doses and with lower costs than fluticasone.
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Affiliation(s)
- Gene Colice
- Washington Hospital Center and George Washington University School of Medicine, Washington, DC, USA
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Price D, Chrystyn H, Kaplan A, Haughney J, Román-Rodríguez M, Burden A, Chisholm A, Hillyer EV, von Ziegenweidt J, Ali M, van der Molen T. Effectiveness of same versus mixed asthma inhaler devices: a retrospective observational study in primary care. Allergy Asthma Immunol Res 2012; 4:184-91. [PMID: 22754711 PMCID: PMC3378924 DOI: 10.4168/aair.2012.4.4.184] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2011] [Revised: 12/18/2011] [Accepted: 12/27/2011] [Indexed: 11/20/2022]
Abstract
PURPOSE Correct use of inhaler devices is fundamental to effective asthma management but represents an important challenge for patients. The correct inhalation manoeuvre differs markedly for different inhaler types. The objective of this study was to compare outcomes for patients prescribed the same inhaler device versus mixed device types for asthma controller and reliever therapy. METHODS This retrospective observational study identified patients with asthma (ages 4-80 years) in a large primary care database who were prescribed an inhaled corticosteroid (ICS) for the first time. We compared outcomes for patients prescribed the same breath-actuated inhaler (BAI) for ICS controller and salbutamol reliever versus mixed devices (BAI for controller and pressurised metered-dose inhaler [pMDI] for reliever). The 2-year study included 1 baseline year before the ICS prescription (to identify and correct for confounding factors) and 1 outcome year. Endpoints were asthma control (defined as no hospital attendance for asthma, oral corticosteroids, or antibiotics for lower respiratory tract infection) and severe exacerbations (hospitalisation or oral corticosteroids for asthma). RESULTS Patients prescribed the same device (n=3,428) were significantly more likely to achieve asthma control (adjusted odds ratio, 1.15; 95% confidence interval [CI], 1.02-1.28) and recorded significantly lower severe exacerbation rates (adjusted rate ratio, 0.79; 95% CI, 0.68-0.93) than those prescribed mixed devices (n=5,452). CONCLUSIONS These findings suggest that, when possible, the same device should be prescribed for both ICS and reliever therapy when patients are initiating ICS.
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Affiliation(s)
- David Price
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK
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Abstract
Classical randomized controlled trials are the gold standard in medical evidence because of their high internal validity. However, their necessarily strict design can limit their external validity and the ability to extrapolate these data to real world patients. Therefore, alternatively designed studies may play a complementary role in evaluating the comparative effectiveness of therapies in nonidealized patients in more naturalistic, real world settings. Observational studies have high external validity and can evaluate real world outcomes. Their strength lies in hypothesis generation and testing and in identifying areas in which further clinical trials may be required. Pragmatic trials are designed to maximize applicability of trial results to usual care settings by relying on clinically important outcomes and enrolling a wide range of participants. A combination of these approaches is preferable and necessary.
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Affiliation(s)
- David Price
- Academic Centre of Primary Care, University of Aberdeen, Foresterhill Health Centre, UK.
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Barnes N, Price D, Colice G, Chisholm A, Dorinsky P, Hillyer EV, Burden A, Lee AJ, Martin RJ, Roche N, von Ziegenweidt J, Israel E. Asthma control with extrafine-particle hydrofluoroalkane-beclometasone vs. large-particle chlorofluorocarbon-beclometasone: a real-world observational study. Clin Exp Allergy 2011; 41:1521-32. [PMID: 21752116 DOI: 10.1111/j.1365-2222.2011.03820.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND The extrafine-particle formulation of hydrofluoroalkane-beclometasone (EF HFA-BDP; Qvar®) demonstrates improved total and small airway deposition compared with large-particle chlorofluorocarbon (CFC)-BDP. In some short-term studies, EF HFA-BDP provides greater effects on lung function than CFC-BDP, and hence is recommended to be prescribed at a lower dose, but whether there are differences in asthma outcomes during long-term treatment is unknown. OBJECTIVE To compare the effectiveness of EF HFA-BDP vs. CFC-BDP over 1 year. METHODS This retrospective matched cohort study examined outcomes in a large primary care database for patients aged 5-60 years with asthma receiving their first inhaled corticosteroid (ICS) prescription (initiation population) or first ICS dose increase (step-up population) by a pressurized metered-dose inhaler (pMDI) as EF HFA-BDP or CFC-BDP. Patients were matched on baseline demographic and asthma severity measures in EF HFA-BDP:CFC-BDP ratios of 1:3 and 1:2 for initiation and step-up populations, respectively. Step-up patients were matched also on ICS dose during a baseline year. Co-primary endpoints were asthma control (composite measure comprising no recorded hospital attendance for asthma, oral corticosteroids, or antibiotics for lower respiratory infection) and exacerbation rate during the outcome year. RESULTS For the initiation population (EF HFA-BDP n=2882; CFC-BDP n=8646), adjusted odds of achieving asthma control with EF HFA-BDP vs. CFC-BDP was 1.15 (95% CI 1.02-1.28). For the step-up population (n=258 and 516), adjusted odds of asthma control with EF HFA-BDP was 1.72 (95% CI 1.14-2.56). EF HFA-BDP was prescribed at a median dose half that of CFC-BDP. CONCLUSION AND CLINICAL RELEVANCE During 1 year after initiating or stepping up ICS therapy by pMDI, patients who received EF HFA-BDP were more likely to achieve asthma control than those receiving CFC-BDP. These findings suggest that ICS formulation, particle size, and deposition characteristics play important roles in real-life effectiveness of asthma therapy. This study shows that an EF-particle formulation of beclometasone can be used at half the dose of the large-particle formulation with at least as good clinical outcomes.
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Affiliation(s)
- N Barnes
- Department of Respiratory Medicine, London Chest Hospital, Barts and The London NHS Trust, London, UK
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Price D, Roche N, Christian Virchow J, Burden A, Ali M, Chisholm A, Lee AJ, Hillyer EV, von Ziegenweidt J. Device type and real-world effectiveness of asthma combination therapy: an observational study. Respir Med 2011; 105:1457-66. [PMID: 21612903 DOI: 10.1016/j.rmed.2011.04.010] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2010] [Revised: 03/10/2011] [Accepted: 04/18/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Selection of inhaler device type appears to influence real-world effectiveness of inhaled corticosteroids (ICS), but data are lacking on the role of inhaler device in ICS and long-acting β2-agonist (LABA) combination therapy for asthma. METHODS This retrospective matched cohort study compared 1-year asthma outcomes for UK patients initiating fixed-dose combination (FDC) fluticasone-salmeterol delivered by pressurised metered-dose inhaler (pMDI) versus dry powder inhaler (DPI). Patients with asthma aged 4-80 years receiving a first prescription for FDC fluticasone-salmeterol by pMDI or DPI were matched on baseline demographic and asthma severity measures. Co-primary outcomes were asthma control (a composite measure comprising no recorded hospital attendance for asthma, oral corticosteroids, or antibiotics for lower respiratory infection) and exacerbation rate. RESULTS Compared with the DPI cohort (n = 1567), patients in the pMDI cohort (n = 1567) had significantly greater odds of achieving asthma control during the outcome year (odds ratio [OR] 1.19; 95% confidence interval [CI] 1.01 to 1.40). Exacerbation rate was lower but not significantly in the pMDI cohort (adjusted rate ratio for pMDI cohort, 0.82; 95% CI 0.66 to 1.00). The odds of treatment success (defined as no exacerbations and no change in asthma therapy) was significantly greater in the pMDI cohort (OR 1.23; 95% CI, 1.07 to 1.42). CONCLUSIONS For UK primary care patients, pMDIs appear to achieve better asthma control outcomes than DPIs for delivery of FDC fluticasone-salmeterol. Pragmatic trials are needed to further investigate real-world outcomes with different inhaler devices for combination therapy.
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Affiliation(s)
- David Price
- Centre of Academic Primary Care, University of Aberdeen, Foresterhill Health Centre, Westburn Road, Aberdeen, Scotland, UK.
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Price D, Musgrave SD, Shepstone L, Hillyer EV, Sims EJ, Gilbert RFT, Juniper EF, Ayres JG, Kemp L, Blyth A, Wilson ECF, Wolfe S, Freeman D, Mugford HM, Murdoch J, Harvey I. Leukotriene antagonists as first-line or add-on asthma-controller therapy. N Engl J Med 2011; 364:1695-707. [PMID: 21542741 DOI: 10.1056/nejmoa1010846] [Citation(s) in RCA: 192] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Most randomized trials of treatment for asthma study highly selected patients under idealized conditions. METHODS We conducted two parallel, multicenter, pragmatic trials to evaluate the real-world effectiveness of a leukotriene-receptor antagonist (LTRA) as compared with either an inhaled glucocorticoid for first-line asthma-controller therapy or a long-acting beta(2)-agonist (LABA) as add-on therapy in patients already receiving inhaled glucocorticoid therapy. Eligible primary care patients 12 to 80 years of age had impaired asthma-related quality of life (Mini Asthma Quality of Life Questionnaire [MiniAQLQ] score ≤6) or inadequate asthma control (Asthma Control Questionnaire [ACQ] score ≥1). We randomly assigned patients to 2 years of open-label therapy, under the care of their usual physician, with LTRA (148 patients) or an inhaled glucocorticoid (158 patients) in the first-line controller therapy trial and LTRA (170 patients) or LABA (182 patients) added to an inhaled glucocorticoid in the add-on therapy trial. RESULTS Mean MiniAQLQ scores increased by 0.8 to 1.0 point over a period of 2 years in both trials. At 2 months, differences in the MiniAQLQ scores between the two treatment groups met our definition of equivalence (95% confidence interval [CI] for an adjusted mean difference, -0.3 to 0.3). At 2 years, mean MiniAQLQ scores approached equivalence, with an adjusted mean difference between treatment groups of -0.11 (95% CI, -0.35 to 0.13) in the first-line controller therapy trial and of -0.11 (95% CI, -0.32 to 0.11) in the add-on therapy trial. Exacerbation rates and ACQ scores did not differ significantly between the two groups. CONCLUSIONS Study results at 2 months suggest that LTRA was equivalent to an inhaled glucocorticoid as first-line controller therapy and to LABA as add-on therapy for diverse primary care patients. Equivalence was not proved at 2 years. The interpretation of results of pragmatic research may be limited by the crossover between treatment groups and lack of a placebo group. (Funded by the National Coordinating Centre for Health Technology Assessment U.K. and others; Controlled Clinical Trials number, ISRCTN99132811.).
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Affiliation(s)
- David Price
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, United Kingdom.
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Price D, Haughney J, Sims E, Ali M, von Ziegenweidt J, Hillyer EV, Lee AJ, Chisholm A, Barnes N. Effectiveness of inhaler types for real-world asthma management: retrospective observational study using the GPRD. J Asthma Allergy 2011; 4:37-47. [PMID: 21698214 PMCID: PMC3116791 DOI: 10.2147/jaa.s17709] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2011] [Indexed: 12/02/2022] Open
Abstract
PURPOSE Results of randomized controlled trials may not predict effectiveness of inhaled corticosteroids (ICS) in real-world clinical practice, where inhaler technique and device characteristics can influence effectiveness. We compared asthma outcomes for ICS delivered via three different inhaler devices: pressurized metered-dose inhaler (pMDI), breath-actuated MDI (BAI), and dry powder inhaler (DPI). PATIENTS AND METHODS This retrospective database study evaluated 1-year outcomes for primary care patients with asthma aged 5-60 years prescribed their first ICS (initiation population) by pMDI (n = 39,746), BAI (n = 9809), or DPI (n = 6792), or their first ICS dose increase (step-up population) by pMDI (n = 6245), BAI (n = 1388), or DPI (n = 1536). Co-primary outcome measures were composite proxy measures of asthma control (no hospital attendance for asthma, oral corticosteroids, or antibiotics for lower respiratory infection) and severe exacerbations (unscheduled hospital admission, emergency room attendance, or oral corticosteroids). Outcomes were adjusted for potential confounding factors identified during a baseline year. RESULTS In the initiation population, adjusted odds ratios (95% confidence intervals [CI]) for asthma control, as compared with pMDIs, were significantly better for BAIs (1.08 [1.02-1.14]) and DPIs (1.13 [1.06-1.21]), while adjusted exacerbation rate ratios (95% CI) were 1.00 (0.93-1.08) and 0.88 (0.81-0.95), respectively. In the step-up population, adjusted odds of asthma control were 1.21 (1.05-1.39) for BAIs and 1.13 (0.99-1.29) for DPIs; adjusted exacerbation rate ratios were 0.83 (0.71-0.98) for BAIs and 0.85 (0.74-0.98) for DPIs, compared with pMDIs. CONCLUSION Inhaler device selection may have a bearing on clinical outcomes. Differences in real-world effectiveness among these devices require closer evaluation in well-designed prospective trials.
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Affiliation(s)
- David Price
- Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK
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Price D, Martin RJ, Barnes N, Dorinsky P, Israel E, Roche N, Chisholm A, Hillyer EV, Kemp L, Lee AJ, von Ziegenweidt J, Colice G. Reply. J Allergy Clin Immunol 2011. [DOI: 10.1016/j.jaci.2010.10.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Price D, Kemp L, Sims E, von Ziegenweidt J, Navaratnam P, Lee AJ, Chisholm A, Hillyer EV, Gopalan G. Observational study comparing intranasal mometasone furoate with oral antihistamines for rhinitis and asthma. Prim Care Respir J 2011; 19:266-73. [PMID: 20571732 DOI: 10.4104/pcrj.2010.00040] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
AIMS Retrospective database study comparing upper and lower airway-related outcomes for patients with rhinitis and co-morbid asthma receiving mometasone furoate--an intranasal corticosteroid with low systemic bioavailability--or an oral antihistamine. METHODS 395 patients prescribed intranasal mometasone were matched on 10 demographic and respiratory-related criteria in a 1:2 ratio to 790 patients prescribed oral antihistamine. Asthma and rhinitis control were assessed over one year using predefined composite proxy measures. RESULTS Asthma control was achieved by 309/395 (78.2%) versus 580/790 (73.4%; p=0.071) patients in the mometasone and antihistamine cohorts, respectively. Rhinitis control was achieved by 293 (74.2%) versus 539 (68.2%; p=0.035), respectively. The adjusted odds ratios for antihistamines, relative to mometasone, were 0.71 (95% CI, 0.52-0.98) for achieving asthma control and 0.74 (95% CI, 0.56-0.97) for achieving rhinitis control. CONCLUSIONS Patients with rhinitis and co-morbid asthma initiating rhinitis therapy achieved significantly better upper as well as lower airway outcomes with intranasal mometasone than with oral antihistamine.
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Affiliation(s)
- David Price
- Academic Centre of Primary Care, University of Aberdeen, Aberdeen, UK.
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Kemp L, Haughney J, Barnes N, Sims E, von Ziegenweidt J, Hillyer EV, Lee AJ, Chisholm A, Price D. Cost-effectiveness analysis of corticosteroid inhaler devices in primary care asthma management: A real world observational study. Clinicoecon Outcomes Res 2010; 2:75-85. [PMID: 21935316 PMCID: PMC3169968 DOI: 10.2147/ceor.s10835] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Indexed: 11/23/2022] Open
Abstract
PURPOSE To evaluate and compare real world cost-effectiveness of inhaled corticosteroids (ICS) administered by metered dose inhaler (MDI), breath-actuated MDI (BAI), or dry powder inhaler (DPI) in asthma. PATIENTS AND METHODS This retrospective database study analyzed the direct health care costs and proportion of patients (aged 5-60 years) achieving asthma control over 1 year in two population groups: those starting ICS (initiation population) and those receiving a first increase in ICS dose (step-up population). Asthma control was defined as no unplanned asthma visits, oral corticosteroids, or antibiotics for lower respiratory infection; outcomes were adjusted for confounding variables. Cost-effectiveness of BAI and DPI were compared with MDI. RESULTS For the initiation population (n = 56,347), average annual health care costs per person (adjusted results), as compared with MDIs, were £9 higher (95% CI: -1.65 to 19.71) for BAIs and £32 higher (95% CI: 19.51 to 43.66) for DPIs. The probability of BAIs being the dominant strategy (more effective and less costly than MDIs) was 5% and of BAIs being more effective and more costly than MDIs was 94%. DPIs were consistently more effective and more costly than MDIs, with an incremental cost-effectiveness ratio of £1711 (95% CI: 760 to 3,576) per additional controlled patient per year. For the step-up population (n = 9169), mean total health care costs per person, (adjusted) as compared with MDIs, were £1 higher (95% CI: -27.28 to 31.55) for BAIs and £73 higher (95% CI: 44.48 to 103.29) for DPIs. The probability of BAIs being dominant was 48% and of BAIs being more effective but more costly than MDIs was 52%; the probability of DPIs being more effective but more costly than MDIs was 96%. CONCLUSION The real world effectiveness of ICS inhalers may vary, and inhaler device selection for patients with asthma should take into consideration not only initial device cost but also the subsequent health care resource costs.
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Affiliation(s)
- Linda Kemp
- Research in Real Life Ltd, Old Winery Business Park, Cawston, Norwich, UK
| | - John Haughney
- Centre of Academic Primary Care, University of Aberdeen, Foresterhill Health Centre, Westburn Road, Aberdeen, UK
| | - Neil Barnes
- Department of Respiratory Medicine, London Chest Hospital, Bonner Road, London, UK
| | - Erika Sims
- Research in Real Life Ltd, Old Winery Business Park, Cawston, Norwich, UK
| | | | | | - Amanda J Lee
- Medical Statistics Team, Section of Population Health, University of Aberdeen, Foresterhill, Aberdeen, UK
| | - Alison Chisholm
- Research in Real Life Ltd, Old Winery Business Park, Cawston, Norwich, UK
| | - David Price
- Research in Real Life Ltd, Old Winery Business Park, Cawston, Norwich, UK
- Centre of Academic Primary Care, University of Aberdeen, Foresterhill Health Centre, Westburn Road, Aberdeen, UK
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Wilson ECF, Price D, Musgrave SD, Sims EJ, Shepstone L, Murdoch J, Mugford HM, Blyth A, Juniper EF, Ayres JG, Wolfe S, Freeman D, Gilbert RFT, Hillyer EV, Harvey I. Cost effectiveness of leukotriene receptor antagonists versus long-acting beta-2 agonists as add-on therapy to inhaled corticosteroids for asthma: a pragmatic trial. Pharmacoeconomics 2010; 28:597-608. [PMID: 20446755 DOI: 10.2165/11537560-000000000-00000] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
BACKGROUND Information is lacking on the relative effectiveness and cost effectiveness--in a real-life primary-care setting--of leukotriene receptor antagonists (LTRAs) and long-acting beta2 adrenergic receptor agonists (beta2 agonists) as add-on therapy for patients whose asthma symptoms are not controlled on low-dose inhaled corticosteroids (ICS). OBJECTIVE To estimate the cost effectiveness of LTRAs compared with long-acting beta2 agonists as add-on therapy for patients whose asthma symptoms are not controlled on low-dose ICS. METHODS An economic evaluation was conducted alongside a 2-year, pragmatic, randomized controlled trial set in 53 primary-care practices in the UK. Patients aged 12-80 years with asthma insufficiently controlled with ICS (n = 361) were randomly assigned to add-on LTRAs (n = 176) or long-acting beta2 agonists (n = 185). The main outcome measures were the incremental cost per point improvement in the Mini Asthma Quality of Life Questionnaire (MiniAQLQ), per point improvement in the Asthma Control Questionnaire (ACQ) and per QALY gained from perspectives of the UK NHS and society. RESULTS Over 2 years, the societal cost per patient receiving LTRAs was pounds sterling 1157 versus pounds sterling 952 for long-acting beta2 agonists, a (significant, adjusted) increase of pounds sterling 214 (95% CI 2, 411) [year 2005 values]. Patients receiving LTRAs experienced a non-significant incremental gain of 0.009 QALYs (95% CI -0.077, 0.103). The incremental cost per QALY gained from the societal (NHS) perspective was pounds sterling 22,589 (pounds sterling 11,919). Uncertainty around this point estimate suggested that, given a maximum willingness to pay of pounds sterling 30,000 per QALY gained, the probability that LTRAs are a cost-effective alternative to long-acting beta2 agonists as add-on therapy was approximately 52% from both societal and NHS perspectives. CONCLUSIONS On balance, these results marginally favour the repositioning of LTRAs as a cost-effective alternative to long-acting beta2 agonists as add-on therapy to ICS for asthma. However, there is much uncertainty surrounding the incremental cost effectiveness because of similarity of clinical benefit and broad confidence intervals for differences in healthcare costs. TRIAL REGISTRATION UK National Research Register N0547145240; Controlled Clinical Trials ISRCTN99132811.
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Wilson ECF, Sims EJ, Musgrave SD, Shepstone L, Blyth A, Murdoch J, Mugford HM, Juniper EF, Ayres JG, Wolfe S, Freeman D, Gilbert RFT, Harvey I, Hillyer EV, Price D. Cost effectiveness of leukotriene receptor antagonists versus inhaled corticosteroids for initial asthma controller therapy: a pragmatic trial. Pharmacoeconomics 2010; 28:585-595. [PMID: 20550224 DOI: 10.2165/11537550-000000000-00000] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
BACKGROUND Information is lacking on the relative effectiveness and cost effectiveness--in a primary-care setting--of leukotriene receptor antagonists (LTRAs) as an alternative to inhaled corticosteroids (ICS) for initial asthma controller therapy. OBJECTIVE To compare the cost effectiveness of LTRAs versus ICS for patients initiating asthma controller therapy. METHODS An economic evaluation was conducted alongside a 2-year, pragmatic, randomized controlled trial set in 53 primary-care practices in the UK. Patients aged 12-80 years with asthma and symptoms requiring regular anti-inflammatory therapy (n = 326) were randomly assigned to LTRAs (n = 162) or ICS (n = 164). The main outcome measures were the incremental costs per point improvement in the Mini Asthma Quality of Life Questionnaire, per point improvement in the Asthma Control Questionnaire and per QALY gained from the UK NHS and societal perspectives. RESULTS Over 2 years, resource use was similar between the two treatment groups, but the cost to society per patient was significantly higher for the LTRA group, at pounds sterling 711 versus pounds sterling 433 for the ICS group (adjusted difference pounds sterling 204; 95% CI 74, 308) [year 2005 values]. Cost differences were driven primarily by differences in prescription drug costs, particularly study drug costs. There was a nonsignificant (imputed, adjusted) difference between treatment groups, favouring ICS, in QALYs gained at 2 years of -0.073 (95% CI -0.143, 0.010). Therapy with LTRAs was, on average, a dominated strategy, and, at a threshold for willingness to pay of pounds sterling 30,000 per QALY gained, the probability of LTRAs being cost effective compared with ICS was approximately 3% from both societal and NHS perspectives. CONCLUSIONS There is a very low probability of LTRAs being cost effective in the UK, at 2005 values, compared with ICS for initial asthma controller therapy. TRIAL REGISTRATION UK National Research Register N0547145240; Controlled Clinical Trials ISRCTN99132811.
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Thomas M, Kay S, Pike J, Williams A, Rosenzweig JRC, Hillyer EV, Price D. The Asthma Control Test (ACT) as a predictor of GINA guideline-defined asthma control: analysis of a multinational cross-sectional survey. Prim Care Respir J 2009; 18:41-9. [PMID: 19240948 DOI: 10.4104/pcrj.2009.00010] [Citation(s) in RCA: 183] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
AIMS To evaluate whether the Asthma Control Test (ACT) score is predictive of Global Initiative for Asthma (GINA) guideline-defined classification levels of asthma control. The ACT is a validated, 5-item, patient-completed measure of asthma control with a recall period of four weeks. METHODS Cross-sectional survey comparing ACT score and GINA classification of asthma control among 2949 patients attending primary care physicians and specialists in France, Germany, Italy, Spain, the UK, and the USA. RESULTS The area under the receiver operating characteristics curve for ACT score predicting GINA control was 0.84 (95% CI 0.82-0.85). An ACT score of <19 (not well-controlled asthma) correctly predicted GINA-defined partly controlled/uncontrolled asthma 94% of the time, while an ACT score of >20 predicted GINA-defined controlled asthma 51% of the time, with kappa statistic of 0.42, representing moderate agreement. CONCLUSIONS An ACT score <19 is useful for identifying patients with poorly controlled asthma as defined by GINA.
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Affiliation(s)
- Mike Thomas
- Centre of Academic Primary Care, University of Aberdeen, Scotland, UK.
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Haughney J, Price D, Kaplan A, Chrystyn H, Horne R, May N, Moffat M, Versnel J, Shanahan ER, Hillyer EV, Tunsäter A, Bjermer L. Achieving asthma control in practice: understanding the reasons for poor control. Respir Med 2008; 102:1681-93. [PMID: 18815019 DOI: 10.1016/j.rmed.2008.08.003] [Citation(s) in RCA: 150] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2008] [Accepted: 08/08/2008] [Indexed: 11/26/2022]
Abstract
Achieving asthma control remains an elusive goal for the majority of patients worldwide. Ensuring a correct diagnosis of asthma is the first step in assessing poor symptom control; this requires returning to the basics of history taking and physical examination, in conjunction with lung function measurement when appropriate. A number of factors may contribute to sub-optimal asthma control. Concomitant rhinitis, a common co-pathology and contributor to poor control, can often be identified by asking a simple question. Smoking too has been identified as a cause of poor asthma control. Practical barriers such as poor inhaler technique must be addressed. An appreciation of patients' views and concerns about maintenance asthma therapy can help guide discussion to address perceptual barriers to taking maintenance therapy (doubts about personal necessity and concerns about potential adverse effects). Further study into, and a greater consideration of, factors and patient characteristics that could predict individual responses to asthma therapies are needed. Finally, more clinical trials that enrol patient populations reflecting the real world diversity of patients seen in clinical practice, including wide age ranges, presence of comorbidities, current smoking, and differing ethnic origins, will contribute to better individual patient management.
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Affiliation(s)
- John Haughney
- Department of General Practice and Primary Care, University of Aberdeen, Foresterhill Health Centre, Westburn Road, Aberdeen AB25 2AY, Scotland, UK.
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Panettieri RA, Covar R, Grant E, Hillyer EV, Bacharier L. Natural history of asthma: persistence versus progression-does the beginning predict the end? J Allergy Clin Immunol 2008; 121:607-13. [PMID: 18328890 DOI: 10.1016/j.jaci.2008.01.006] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2007] [Revised: 01/07/2008] [Accepted: 01/09/2008] [Indexed: 11/17/2022]
Abstract
Environmental exposures during the early years and airway obstruction that develops during this time, in conjunction with genetic susceptibility, are important factors in the development of persistent asthma in childhood. Established risk factors for childhood asthma include frequent wheezing during the first 3 years, a parental history of asthma, a history of eczema, allergic rhinitis, wheezing apart from colds, and peripheral blood eosinophilia, as well as allergic sensitization to aeroallergens and certain foods. Risk factors for the development of asthma in adulthood remain ill defined. Moreover, reasons for variability in the clinical course of asthma--persistence in some individuals and progression in others--remain an enigma. The distinction between disease persistence and disease progression suggests that these are different entities or phenotypes. There is currently no consensus on whether disease progression requires either airway inflammation or airway remodeling or the combination of the two. For patients with irreversible airway obstruction, inflammation might, in part, be necessary but perhaps not entirely sufficient to induce the irreversible component, some of which could be attributed to alterations in the structure of the bronchial wall. Intervening with intermittent or daily inhaled corticosteroids in high-risk infants and children does not prevent disease progression or impaired lung growth. These findings, however, might not apply to adults, and further study in adults is needed to determine the effect of inhaled corticosteroid therapy on disease progression.
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Affiliation(s)
- Reynold A Panettieri
- Pulmonary, Allergy & Critical Care Division, University of Pennsylvania, Philadelphia, PA 19104-3403, USA.
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Abstract
OBJECTIVE To assess the impact of migraine on work, family, and leisure among young women who were employed full or part time, or as a full-time student. RESEARCH DESIGN AND METHODS This cross-sectional telephone survey with 6-month recall was conducted in Israel and eight European countries (Finland, Germany, Greece, Italy, Norway, Spain, Sweden, and The Netherlands). Random-digit dialing was used to identify study participants: women 18-35 years of age with migraine, who used medication to treat their migraine, and who were employed or full-time students. RESULTS Of 1810 participants, 42% self-reported having a physician diagnosis of migraine. During the prior 6 months, 46% of participants missed at least 1 day of work or school and 74% were prevented from functioning fully at work or school because of migraine. Mean work/school absenteeism due to migraine was 1.9 days over 6 months (range, 0.8 days in Sweden to 2.8 days in Norway). Over half of participants reported one or more occurrences of being unable to spend time with family or friends (62%) or being unable to enjoy recreational or leisure activities (67%) because of migraine. The percentage of study participants using triptans was lowest in southern Europe and highest in the Nordic countries, ranging from 1% in Greece to 50% in Sweden. Country, age, marital status, physician diagnosis of migraine, and number of migraines or severe headaches in the prior year were independent predictors of the mean number of days of migraine-related work loss. Migraine-related work loss was lowest in Sweden and greatest in Greece, Israel, and The Netherlands. Higher work loss was recorded for those 18-24 years of age; those who were separated, widowed, or divorced; those with migraine diagnosed by a physician; and those with more frequent migraines or severe headaches (> or =24/year). The 6-month recall period used when estimating patient-reported work loss, and identifying participants with migraine based on self-reported migraine or severe headache, were the most important limitations of the study. CONCLUSIONS We found substantial migraine-related impairment of productivity at work and school as well as of family and leisure time among young women in Israel and eight European countries.
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Hillyer EV. Adrenal gland tumors in ferrets. J Am Vet Med Assoc 1994; 205:1660-1. [PMID: 7744634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Blanco MC, Fox JG, Rosenthal K, Hillyer EV, Quesenberry KE, Murphy JC. Megaesophagus in nine ferrets. J Am Vet Med Assoc 1994; 205:444-7. [PMID: 7961071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Megaesophagus was diagnosed in 9 adult ferrets. Clinical history of the ferrets included regurgitation, difficulty in swallowing, partial anorexia, and lethargy. Cachexia, dehydration, weakness, and ptyalism were observed on physical examination. Radiography revealed the esophagus of each ferret to be dilated in the thoracic and cervical regions. Of 4 ferrets that had lymphocytopenia, 2 had concurrent leukopenia. Serum biochemical analysis revealed high activity of alanine transaminase (4 ferrets) and aspartate transaminase (3), and hypoglycemia (4). Treatment included administration of fluid, antibiotics, and agents directed against possible primary causes of megaesophagus. Treatments were ineffective, and all of the ferrets died or were euthanatized. All 6 ferrets that were submitted for necropsy had bronchopneumonia, hepatic lipidosis, mild esophagitis, and gastritis. The etiopathogenesis of megaesophagus in the ferrets was not determined.
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Affiliation(s)
- M C Blanco
- Division of Comparative Medicine, MIT, Cambridge 02139
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Abstract
Pet rabbits are becoming more common, and rabbit owners are demanding quality veterinary care. This article provides a broad overview of pet rabbit medicine, which is a relatively new field compared to laboratory and farm rabbit medicine. The most common differential diagnoses for presenting complaints are summarized in table form. Disease conditions are reviewed individually in the text. Sources of further information on veterinary care of rabbits are listed throughout the text, in an appendix, and in the references.
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Quesenberry KE, Hillyer EV. Preface. Vet Clin North Am Small Anim Pract 1994. [DOI: 10.1016/s0195-5616(94)50016-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Rosenthal KL, Peterson ME, Quesenberry KE, Hillyer EV, Beeber NL, Moroff SD, Lothrop CD. Hyperadrenocorticism associated with adrenocortical tumor or nodular hyperplasia of the adrenal gland in ferrets: 50 cases (1987-1991). J Am Vet Med Assoc 1993; 203:271-5. [PMID: 8407489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Adrenocortical adenoma, nodular hyperplasia, or carcinoma was diagnosed in 50 ferrets. Thirty-five (70%) ferrets were female and 15 (30%) were male. The mean age at which clinical signs were first noticed was 3.4 years (range, 1 to 7 years). Clinical signs included large vulva (n = 31; 89% of females), alopecia (n = 43; 86%), pruritus (n = 20; 40%), and increased consumption of water and increased urine output (n = 4; 8%). A mass was palpated at the cranial pole of the kidney during physical examination of 17 (34%) ferrets. Ultrasonography, performed on 39 of 50 ferrets, revealed a unilateral adrenal gland mass in 19 (49%). Four ferrets were anemic, and 2 ferrets were thrombocytopenic. Baseline plasma concentrations of cortisol and corticosterone were within or below the reference range in all 17 ferrets tested, whereas baseline plasma estradiol concentrations were high in 4 of the 11 ferrets (36%) tested. AFter adrenocorticotropic hormone (ACTH) administration, only 1 ferret had a slightly exaggerated response on the basis of plasma cortisol concentrations, and all 17 had normal responses on the basis of plasma corticosterone concentrations. There was little or no increase in plasma estradiol concentrations after ACTH administration. Of the 50 ferrets, 39 were treated by adrenalectomy. Unilateral adrenalectomy was performed in 34 ferrets in which 1 adrenal gland was large, whereas subtotal bilateral adrenalectomy was performed in 5 ferrets with bilateral adrenal disease. Five ferrets died in the immediate postoperative period, and follow-up information was available for the remaining 34, 1 to 34 months after surgery.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- K L Rosenthal
- Department of Medicine, Animal Medical Center, New York, NY 10021
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Hillyer EV, Moroff S, Hoefer H, Quesenberry KE. Bile Duct Carcinoma in Two out of Ten Amazon Parrots with Cloacal Papillomas. ACTA ACUST UNITED AC 1991. [DOI: 10.2307/30133281] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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