Trends in the epidemiology of asthma in England: a national study of 333,294 patients

Adherence to Asthma Guidelines in Children, Tweens, and Adults in Primary Care Settings: A Practice-Based Network Assessment

OBJECTIVE

To assess primary care adherence to 2007 US asthma guidelines.

PATIENTS AND METHODS

Patients with persistent asthma aged 5 to 65 years from 22 primary care participating practices provided the data for this analysis of baseline information from the pragmatic randomized clinical trial the Asthma Tools Study. Using a combination of abstracted medical record data and patient-reported demographic information, we assessed the medical record documentation for elements of the 2007 US asthma guidelines. Elements assessed included documentation of (1) assessment of control, (2) factors that affect control (medication adherence evaluation, inhaler technique education, and evaluation for triggers), (3) self-management support (action plan), and (4) asthma medications prescribed (short-acting β-agonists and daily maintenance therapy). The baseline data was collected from March 16, 2009, to May 1, 2014.

RESULTS

In 1176 patients (285 children, 211 tweens, and 680 adults) from 16 family medicine and 6 pediatric practices across the United States, documented guideline adherence was highest for prescription of medications (88.0% for short-acting β-agonists and 70.4% for maintenance medications) and lowest for an asthma action plan (3.1%). Documentation of control (15.0%) and factors that affect control (inhaler technique education, 7.6%; medication adherence assessment, 32.5%; and allergy evaluation, 32.5%) was not common and even less common for adults compared with children. A total of 22.2% of the enrolled patients had no asthma-related visit in the year before enrollment. Adherence to the nonmedication elements were higher in practices located in cities of more than 250,000 people and cities that used electronic medical records. Older patient age was negatively associated with guideline adherence.

CONCLUSION AND RELEVANCE

Adherence to asthma guidelines is poor in primary care practices, leaving many opportunities for improvement.

No further increase in the parent reported prevalence of allergies in Bavarian preschool children: Results from three cross-sectional studies

BACKGROUND

After three decades of an increase in the prevalence of asthma and allergies, new findings show a plateau in the prevalence of industrialized nations. The objective of this study was to determine whether there was a change in the parent reported prevalence of asthma and allergies among Bavarian preschool children since 2004.

METHODS

A parent questionnaire was administered as part of the Bavarian school entrance examination in three cross-sectional studies from 2004/2005, 2006/2007 and 2012/2013. The questionnaire included items on allergy testing history, identified allergens, symptoms (e.g. wheezing, itchy eyes, rash), medically diagnosed asthma, hay fever and atopic dermatitis. Logistic regression was performed to observe time patterns and adjust for risk factors.

RESULTS

Data were available for 6350 (2004/2005), 6483 (2006/2007) and 5052 (2012/2013) individuals. Symptoms and diseases were more frequent in boys, except for allergies which affect the skin. From 2004 to 2012 the parent reported prevalence of asthma (2.6% to 2.8%), hay fever (4.7% to 4.0%) and atopic dermatitis (12.4% to 11.1%) either remained quite stable or decreased not significantly.

CONCLUSIONS

Results from these three cross-sectional surveys of parent reports suggest that the parent reported prevalences of asthma and allergies are quite stable with small fluctuations since 2004 for Bavarian preschool children. Future research is needed to determine if this trend will continue.

Volatile organic compounds and risk of asthma and allergy: a systematic review

Volatile organic compounds (VOCs) are ubiquitous domestic pollutants. Their role in asthma/allergy development and exacerbations is uncertain. This systematic review investigated whether domestic VOC exposure increases the risk of developing and/or exacerbating asthma and allergic disorders. We systematically searched 11 databases and three trial repositories, and contacted an international panel of experts to identify published and unpublished experimental and epidemiological studies. 8455 potentially relevant studies were identified; 852 papers were removed after de-duplication, leaving 7603 unique papers that were screened. Of these, 278 were reviewed in detail and 53 satisfied the inclusion criteria. Critical appraisal of the included studies indicated an overall lack of high-quality evidence and substantial risk of bias in this body of knowledge. Aromatics (i.e. benzenes, toluenes and xylenes) and formaldehyde were the main VOC classes studied, both in relation to the development and exacerbations of asthma and allergy. Approximately equal numbers of studies reported that exposure increased risks and that exposure was not associated with any detrimental effects. The available evidence implicating domestic VOC exposure in the risk of developing and/or exacerbating asthma and allergy is of poor quality and inconsistent. Prospective, preferably experimental studies, investigating the impact of reducing/eliminating exposure to VOC, are now needed in order to generate a more definitive evidence base to inform policy and clinical deliberations in relation to the management of the now substantial sections of the population who are either at risk of developing asthma/allergy or living with established disease.

Lung function in children in relation to ethnicity, physique and socioeconomic factors

Can ethnic differences in spirometry be attributed to differences in physique and socioeconomic factors?Assessments were undertaken in 2171 London primary schoolchildren on two occasions 1 year apart, whenever possible, as part of the Size and Lung function In Children (SLIC) study. Measurements included spirometry, detailed anthropometry, three-dimensional photonic scanning for regional body shape, body composition, information on ethnic ancestry, birth and respiratory history, socioeconomic circumstances, and tobacco smoke exposure.Technically acceptable spirometry was obtained from 1901 children (mean (range) age 8.3 (5.2-11.8) years, 46% boys, 35% White, 29% Black-African origin, 24% South-Asian, 12% Other/mixed) on 2767 test occasions. After adjusting for sex, age and height, forced expiratory volume in 1 s was 1.32, 0.89 and 0.51 z-score units lower in Black-African origin, South-Asian and Other/mixed ethnicity children, respectively, when compared with White children, with similar decrements for forced vital capacity (p<0.001 for all). Although further adjustment for sitting height and chest width reduced differences attributable to ethnicity by up to 16%, significant differences persisted after adjusting for all potential determinants, including socioeconomic circumstances.Ethnic differences in spirometric lung function persist despite adjusting for a wide range of potential determinants, including body physique and socioeconomic circumstances, emphasising the need to use ethnic-specific equations when interpreting results.

Case series: the application of "third wave" cognitive behavioural therapies in difficult to treat asthma

OBJECTIVE

This paper provides for the first time cases of individual psychological therapy undertaken in tertiary, difficult to treat asthma services using "third wave" cognitive behavioural therapy (CBT) approaches.

METHODS

These cases were selected to represent common psychological presentations in difficult to treat asthma clinics, namely denial of severity and over-identification with asthma. Assessment, formulation, intervention and results are outlined.

RESULTS

Case 1 demonstrated change from severe to mild depression and anxiety, reduction in shame and improved well-being. Case 2 demonstrated improvements in well-being and psychological symptoms. Both interventions were experienced by the patients as highly satisfactory.

CONCLUSIONS

It is concluded that a psychological understanding of patients' presentations can open up new avenues for intervention. Further research into the potential utility of third wave cognitive therapies in difficult to treat asthma is warranted.

Cost-effectiveness of asthma therapy: a comprehensive review

BACKGROUND

Asthma has an important impact in terms of both direct and indirect costs. In Europe, the disease costs € 19 000 million a year. Moreover, the cost is greater among patients with severe uncontrolled asthma and is even higher when the work productivity is also taken into account. Improved control of the disease results in cost savings. In this context, cost-effectiveness and cost-utility studies offer important information for clinicians in deciding the best treatment options for asthmatic patients and contribute to ensure an efficient use of the available healthcare resources.

METHODS

An English and Spanish literature search using electronic search engines (PubMed and EMBASE) was conducted in peer-review journals, from 2009 to June 2014. In order to perform the search for the most suitable and representative articles, key words were selected ("asthma", "cost-effectiveness", "cost-utility", "QALY", "cost-benefit", "economic impact of asthma" "healthcare cost", "asthma treatment" and "work productivity with asthma").

RESULTS

Two-hundred forty-three titles and abstracts were identified by the primary literature search. The full text of the potentially 76 eligible papers was reviewed, and 22 articles were qualified to be finally included.

CONCLUSIONS

This article provides a comprehensive review on the evidence of cost-effectiveness of asthma treatments derived from the published literature and offers an overall summary of the socioeconomic burden of asthma and its relationship with the degree of disease control. Management alternatives, such as the use of combination therapy with ICS/LABA or omalizumab, when administered according to their current therapeutic indications, have been shown to be cost-effective.

How "healthy" should children be when selecting reference samples for spirometry?

How "healthy" do children need to be when selecting reference samples for spirometry? Anthropometry and spirometry were measured in an unselected, multi-ethnic population of school children aged 5-11 years in London, UK, with follow-up assessments 12 months later. Parents provided information on children's birth data and health status. Forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) were adjusted for sex, age, height and ethnicity using the 2012 Global Lungs Initiative equations, and the effects of potential exclusion criteria on the z-score distributions were examined. After exclusions for current and chronic lung disease, acceptable data were available for 1901 children on 2767 occasions. Healthy children were defined as those without prior asthma or hospitalisation for respiratory problems, who were born at full-term with a birthweight ≥2.5 kg and who were asymptomatic at testing. Mean±sd z-scores for FEV1 and FVC approximated 0±1, indicating the 2012 Global Lungs Initiative equations were appropriate for this healthy population. However, if children born preterm or with low birthweight, children with prior asthma or children mildly symptomatic at testing were included in the reference, overall results were similar to those for healthy children, while increasing the sample size by 25%. With the exception of clear-cut factors, such as current and chronic respiratory disease, paediatric reference samples for spirometry can be relatively inclusive and hence more generalisable to the target population.

Time trends in the incidence, prevalence and age at diagnosis of asthma in children

BACKGROUND

Current knowledge on the prevalence of asthma is mainly based on cross-sectional questionnaire data. Current population-based data on the incidence of asthma in children are scarce.

OBJECTIVE

To study the incidence, prevalence, and age at diagnosis of asthma in children in the Netherlands over the study period 2000-2012.

METHODS

A population-based cohort study was conducted in the Integrated Primary Care Information database. The cohort consisted of 176,516 children (379,536 personyears (PY) of follow-up), aged 5-18 years between 2000 and 2012. All medical records of children with physician diagnosed asthma were validated. Incidence rates, annual percent change (APC), and prevalence for asthma were calculated. Influence of age and gender on incidence rates and change in age at diagnosis were studied.

RESULTS

We identified an asthma cohort of 14,303 children with 35,118 PY. The overall incidence rate was 6.7/1000 PY (95% CI, 6.45-6.97). Until 2008, the incidence rate was significantly increasing (APC 5.79 (95% CI 1.43-10.34); from 2008 onwards, a non-significant decrease was observed (APC -12.16 (95% CI -23.07 to 0.28). Incidence for girls was lower than for boys, this difference decreased with increasing age. (p < 0.001) Overall, the age at diagnosis increased over calendar time and was lower for boys. (linear trend p < 0.001).

CONCLUSION

Our population-based cohort study observed an incidence rate of 6.7 per 1000 PY of physician-diagnosed asthma in children in the Netherlands over 2000-2012. The asthma incidence rate was increasing until 2008. Further studies are needed to confirm the decrease in asthma incidence rate from 2008 onwards.

Multiple sclerosis course and clinical outcomes in patients with comorbid asthma: a survey study

OBJECTIVE

To determine if comorbid asthma is associated with accumulation of multiple sclerosis (MS)-related impairment and disability.

METHOD

We sent a comprehensive questionnaire to a cohort of patients with MS and examined the association between comorbid asthma and reaching Expanded Disability Status Scale (EDSS) scores 4.0 and 6.0. Multiple Sclerosis Impact Scale (MSIS-29) scores were compared between patients with MS with and without comorbid asthma.

RESULTS

680 patients participated in our study of whom 88 (12.9%) had comorbid asthma. There was no difference in the prevalence of asthma between our MS cohort and the England general population (OR: 0.89, 95% CI 0.68 to 1.17). We did not observe a significant association between having asthma and the risk of reaching EDSS scores 4.0 and 6.0 (HR: 1.29, 95% CI 0.93 to 1.77, and HR: 1.33, 95% CI 0.93 to 1.89, respectively) after controlling for confounders. Patients with MS with asthma reported higher level of psychological impairments (coefficient: 2.29, 95% CI 0.1 to 4.49).

CONCLUSIONS

Asthma is a prevalent condition among patients with MS and it may contribute to the psychological impairment in MS. Although we did not observe significant association between comorbid asthma and physical disability in MS, it seems that the two conditions influence one another.

Helicobacter pylori update: gastric cancer, reliable therapy, and possible benefits

Helicobacter pylori infection contributes to the development of diverse gastric and extragastric diseases. The infection is necessary but not sufficient for the development of gastric adenocarcinoma. Its eradication would eliminate a major worldwide cause of cancer death, therefore there is much interest in identifying how, if, and when this can be accomplished. There are several mechanisms by which H pylori contributes to the development of gastric cancer. Gastric adenocarcinoma is one of many cancers associated with inflammation, which is induced by H pylori infection, yet the bacteria also cause genetic and epigenetic changes that lead to genetic instability in gastric epithelial cells. H pylori eradication reduces both. However, many factors must be considered in determining whether treating this bacterial infection will prevent cancer or only reduce its risk-these must be considered in designing reliable and effective eradication therapies. Furthermore, H pylori infection has been proposed to provide some benefits, such as reducing the risks of obesity or childhood asthma. When tested, these hypotheses have not been confirmed and are therefore most likely false.

Diagnosis of asthma: clinical assessment

BACKGROUND

Asthma is a common condition that presents with varied symptomatology and exam findings. The diagnosis of asthma is made through a combination of clinical assessment and diagnostic testing.

METHODS

A literature review was conducted through PubMed, focusing on systematic reviews and practice parameters. The highest-quality studies and those including the highest number of patients were included. References were reviewed for additional relevant articles.

RESULTS

Patients with asthma present with the symptoms of cough, dyspnea, and wheezing. The physical exam can demonstrate hyperinflation, wheezing, and increased work of breathing, but most patients will present with a normal pulmonary exam because they are between episodes. The symptoms and examination of patients with asthma varies greatly from patient to patient and within the same patient over time. The diagnosis of asthma in the pediatric population may be more difficult because the classic symptoms may not be present in many of those patients.

CONCLUSION

The diagnosis of asthma is made in the setting of clinical history, physical exam, and diagnostic testing. The astute physician will rely on all 3 of these factors when making the diagnosis.

Cost-effectiveness of initiating extrafine- or standard size-particle inhaled corticosteroid for asthma in two health-care systems: a retrospective matched cohort study

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.

The representativeness of a European multi-center network for influenza-like-illness participatory surveillance

Background

The Internet is becoming more commonly used as a tool for disease surveillance. Similarly to other surveillance systems and to studies using online data collection, Internet-based surveillance will have biases in participation, affecting the generalizability of the results. Here we quantify the participation biases of Influenzanet, an ongoing European-wide network of Internet-based participatory surveillance systems for influenza-like-illness.

Methods

In 2011/2012 Influenzanet launched a standardized common framework for data collection applied to seven European countries. Influenzanet participants were compared to the general population of the participating countries to assess the representativeness of the sample in terms of a set of demographic, geographic, socio-economic and health indicators.

Results

More than 30,000 European residents registered to the system in the 2011/2012 season, and a subset of 25,481 participants were selected for this study. All age classes (10 years brackets) were represented in the cohort, including under 10 and over 70 years old. The Influenzanet population was not representative of the general population in terms of age distribution, underrepresenting the youngest and oldest age classes. The gender imbalance differed between countries. A counterbalance between gender-specific information-seeking behavior (more prominent in women) and Internet usage (with higher rates in male populations) may be at the origin of this difference. Once adjusted by demographic indicators, a similar propensity to commute was observed for each country, and the same top three transportation modes were used for six countries out of seven. Smokers were underrepresented in the majority of countries, as were individuals with diabetes; the representativeness of asthma prevalence and vaccination coverage for 65+ individuals in two successive seasons (2010/2011 and 2011/2012) varied between countries.

Conclusions

Existing demographic and national datasets allowed the quantification of the participation biases of a large cohort for influenza-like-illness surveillance in the general population. Significant differences were found between Influenzanet participants and the general population. The quantified biases need to be taken into account in the analysis of Influenzanet epidemiological studies and provide indications on populations groups that should be targeted in recruitment efforts.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2458-14-984) contains supplementary material, which is available to authorized users.

Identifying barriers and facilitators to ambulance service assessment and treatment of acute asthma: a focus group study

Background

Acute asthma is a common reason for patients to seek care from ambulance services. Although better care of acute asthma can prevent avoidable morbidity and deaths, there has been little research into ambulance clinicians’ adherence to national guidelines for asthma assessment and management and how this might be improved. Our research aim was to explore paramedics’ attitudes, perceptions and beliefs about prehospital management of asthma, to identify barriers and facilitators to guideline adherence.

Methods

We conducted three focus group interviews of paramedics in a regional UK ambulance trust. We used framework analysis supported by NVivo 8 to code and analyse the data.

Results

Seventeen participants, including paramedics, advanced paramedics or paramedic operational managers at three geographical sites, contributed to the interviews. Analysis led to five themes: (1) guidelines should be made more relevant to ambulance service care; (2) there were barriers to assessment; (3) the approach needed to address conflicts between clinicians’ and patients’ expectations; (4) the complexity of ambulance service processes and equipment needed to be taken into account; (5) and finally there were opportunities for improved prehospital education, information, communication, support and care pathways for asthma.

Conclusions

This qualitative study provides insight into paramedics’ perceptions of the assessment and management of asthma, including why paramedics may not always follow guidelines for assessment or management of asthma. These findings provide opportunities to strengthen clinical support, patient communication, information transfer between professionals and pathways for prehospital care of patients with asthma.

Trends in the prevalence of asthma

The asthma epidemic of the last few decades may have peaked; studies suggest that the incidence and prevalence of asthma has decreased in some countries in the last few years, although other studies suggest continuing small increases in prevalence. Increasing awareness and changing diagnostic habits make precise evaluation of epidemiologic trends difficult in the absence of a gold-standard test for asthma, and on a global basis uncertainty persists. Trends in prevalence in some populations (eg, immigrants, farming communities) suggest both adverse and beneficial effects of specific environmental factors. Although the effects of indoor allergens, dampness, and mold and of outdoor air pollutants, especially traffic related, have traditionally dominated risk-factor research, more recent epidemiologic and clinical studies have focused on metabolic and nutritional factors, including maternal obesity and vitamin D levels, mode of delivery and its effect on the infant microbiome, fetal and infant growth, the psychosocial environment, and medication use by mother and infant. It is likely that changes in incidence and prevalence are due to multiple factors, each contributing a relatively small effect. Longitudinal studies from pregnancy through childhood to adulthood will yield greater insights into the complex pathways leading to asthma.

Epidemiology of bronchial asthma and asthma control assessment in Henan Province, China

BACKGROUND

Prevalence of bronchial asthma, asthma treatment assessment, and estimation of the control level among asthma patients in Henan Province, China are reported in this paper.

METHODS

We selected 10 among the 109 cities and districts in Henan province using a multistage stratified cluster random sampling method. A total of 500 households from each city and district were chosen. Approximately 20,000 residents from a total of 5,000 households were randomly selected to answer a questionnaire recommended by the China Asthma Alliance. Asthma patients were asked to answer a detailed questionnaire using the symptom-based guidelines to assess the levels of disease control.

RESULTS

The overall prevalence of asthma was 0.73% ± 0.12%. Urban and rural residents had asthma prevalence rates of 1.1% ± 0.23% (88/7,924) and 0.48% ± 0.12% (57/11,792), respectively. Among the asthma patients, only 33.8% (52) received regular medication, 25% (13) used oral glucocorticoids, and 71.1% (37) used oral theophylline. The classified control levels of patients were as follows: 33.1% controlled, 49.7% partially controlled, and 17.2% uncontrolled. A total of 38.5% and 27.5% of regularly and irregularly treated asthma patients reached controlled level, respectively. The two groups significantly differed in asthma control level.

CONCLUSION

Asthma prevalence is low in Henan Province, China. Urban residents have higher prevalence of asthma than rural residents do. Patients with asthma receive insufficient medication, resulting in suboptimal asthma control. Improvement in diagnosis and treatment of asthma patients is urgently needed.

[Prevalence of allergic diseases in Germany: results of the German Health Interview and Examination Survey for Adults (DEGS1)]

In the first wave of the "German Health Interview and Examination Survey for Adults" (DEGS1), up-to-date and representative data regarding allergic diseases of 7988 18- to 79-year-old subjects living in Germany were collected using computer-assisted medical interviews. The study identified a lifetime prevalence of 8.6% for asthma, 14.8% for allergic rhinoconjunctivitis, 3.5% each for atopic dermatitis and urticaria, 8.1% for contact eczema, 4.7% for food allergies and 2.8% for insect venom allergies. Overall, nearly one third of adults in Germany have been diagnosed with at least one of the above mentioned allergies during their lifetime by a physician. Currently, nearly 20% suffer from at least one allergic disease. Generally, women reported an allergic disease more frequently than men and younger subjects more frequently than older ones. Additionally, allergies are more common in the former federal states of West Germany than in the former East German federal states. A high socioeconomic status and living in large cities both increase allergy risk. During the last 10 years, asthma prevalence increased about 3%, whereas the prevalence of urticaria and contact eczema declined. The lifetime prevalence of allergic rhinoconjunctivitis, atopic dermatitis and food allergies appeared unchanged. In total, allergy prevalence has declined from 32.7-28.7% over the past decade. An English full-text version of this article is available at SpringerLink as supplemental.

Budget impact analysis of a fixed-dose combination of fluticasone propionate and formoterol fumarate (FP/FORM) in a pressurized metered-dose inhaler (pMDI) for asthma

INTRODUCTION

The economic burden of asthma on the UK National Health Service (NHS) is the largest among allergic diseases. Current asthma guidelines recommend adding a long acting β2-agonist (LABA) to a low-dose inhaled corticosteroid (ICS) in patients who are on ICS monotherapy and have uncontrolled asthma. The fixed-dose combination of fluticasone propionate and salmeterol xinafoate (FP/SAL), available in a pressurized metered-dose inhaler (pMDI) device, is the most commonly prescribed ICS/LABA combination. An additional fixed-dose combination of fluticasone propionate and formoterol fumarate (FP/FORM) in pMDI is now available. In a 12-week non-inferiority study, FP/FORM demonstrated comparable efficacy to FP/SAL. The present analysis estimates the annual budget impact for the UK NHS using FP/FORM as an alternative to FP/SAL.

METHODS

Current pMDI prescribing data were from a real-world UK patient database (Cegedim Strategic Data). Annual costs to the NHS for drug acquisition, administration, and monitoring were estimated for FP/FORM and FP/SAL and used to assess the potential budget impact for the NHS for the use of FP/FORM instead of FP/SAL. Varying rates of uptake, adherence, adverse event-related costs, and resource use associated with switching treatment were assessed in scenario analyses.

RESULTS

Assuming similar levels of ICS use with both regimens, annual drug acquisition costs per person were lower with FP/FORM (£412) than with FP/SAL (£509). The difference in acquisition costs and otherwise comparable input costs between the treatments, results in potential annual savings of £15,110,279 to the NHS, assuming uptake of FP/FORM over FP/SAL in 50% of existing patients. The introduction of FP/FORM results in cost savings for the NHS in all of the assessed scenario analyses.

CONCLUSIONS

The comparable efficacy and lower acquisition costs of FP/FORM compared with FP/SAL make it a cost-saving option for the UK NHS for the treatment of asthma patients requiring combination maintenance therapy using a pMDI.

Ten years of asthma admissions to adult critical care units in England and Wales

OBJECTIVES

To describe the patient demographics, outcomes and trends of admissions with acute severe asthma admitted to adult critical care units in England and Wales.

DESIGN

10-year, retrospective analysis of a national audit database.

SETTING

Secondary care: adult, general critical care units in the UK.

PARTICIPANTS

830 808 admissions to adult, general critical care units.

PRIMARY AND SECONDARY OUTCOME MEASURES

Demographic data including age and sex, whether the patient was invasively ventilated or not, length of stay (LOS; both in the critical care unit and acute hospital), survival (both critical care unit and acute hospital) and time trends across the 10-year period.

RESULTS

Over the 10-year period, there were 11 948 (1.4% of total) admissions with asthma to adult critical care units in England and Wales. Among them 67.5% were female and 32.5% were male (RR F:M 2.1; 95% CI 2.0 to 2.1). Median LOS in the critical care unit was 1.8 days (IQR 0.9-3.8). Median LOS in the acute hospital was 7 days (IQR 4-14). Critical care unit survival rate was 95.5%. Survival at discharge from hospital was 93.3%. There was an increase in admissions to adult critical care units by an average of 4.7% (95% CI 2.8 to 6.7)/year.

CONCLUSIONS

Acute asthma represents a modest burden of work for adult critical care units in England and Wales. Demographic patterns for admission to critical care unit mirror those of severe asthma in the general adult community. The number of critical care admissions with asthma are rising, although we were unable to discern whether this represents a true increase in the incidence of acute asthma or asthma severity.

Goal-setting intervention in patients with active asthma: protocol for a pilot cluster-randomised controlled trial

BACKGROUND

Supporting self-management behaviours is recommended guidance for people with asthma. Preliminary work suggests that a brief, intensive, patient-centred intervention may be successful in supporting people with asthma to participate in life roles and activities they value. We seek to assess the feasibility of undertaking a cluster-randomised controlled trial (cRCT) of a brief, goal-setting intervention delivered in the context of an asthma review consultation.

METHODS/DESIGN

A two armed, single-blinded, multi-centre, cluster-randomised controlled feasibility trial will be conducted in UK primary care. Randomisation will take place at the practice level. We aim to recruit a total of 80 primary care patients with active asthma from at least eight practices across two health boards in Scotland (10 patients per practice resulting in ~40 in each arm). Patients in the intervention arm will be asked to complete a novel goal-setting tool immediately prior to an asthma review consultation. This will be used to underpin a focussed discussion about their goals during the asthma review. A tailored management plan will then be negotiated to facilitate achieving their prioritised goals. Patients in the control arm will receive a usual care guideline-based review of asthma. Data on quality of life, asthma control and patient confidence will be collected from both arms at baseline and 3 and 6 months post-intervention. Data on health services resource use will be collected from all patient records 6 months pre- and post-intervention. Semi-structured interviews will be carried out with healthcare staff and a purposive sample of patients to elicit their views and experiences of the trial. The outcomes of interest in this feasibility trial are the ability to recruit patients and healthcare staff, the optimal method of delivering the intervention within routine clinical practice, and acceptability and perceived utility of the intervention among patients and staff.

TRIAL REGISTRATION

ISRCTN18912042.

Assessing the risk of attack in the management of asthma: a review and proposal for revision of the current control-centred paradigm

Asthma guidelines focus on day-to-day control of symptoms. However, asthma attacks remain common. They continue to cause mortality and considerable morbidity, and are a major financial burden to the UK National Health Service (NHS) and the wider community. Asthma attacks have chronic consequences, being associated with loss of lung function and significant psychological morbidity. In this article we argue that addressing daily symptom control is only one aspect of asthma treatment, and that there should be a more explicit focus on reducing the risk of asthma attacks. Management of future risk by general practitioners is already central to other conditions such as ischaemic heart disease and chronic renal impairment. We therefore propose a revised approach that separately considers the related domains of daily control and future risk of asthma attack. We believe this approach will have advantages over the current 'stepwise' approach to asthma management. It should encourage individualised treatment, including non-pharmacological measures, and thus may lead to more efficacious and less harmful management strategies. We speculate that this type of approach has the potential to reduce morbidity and healthcare costs related to asthma attacks.

A randomized, comparative, multicentric clinical trial to assess the efficacy and safety of zileuton extended-release tablets with montelukast sodium tablets in patients suffering from chronic persistent asthma

Leukotriene (LT) modifiers are anti-inflammatory drugs that are useful as an add-on therapy with first-line asthma-controller medications. This group includes LT synthesis inhibitors (eg, Zileuton) and receptor antagonists (eg, Montelukast), whose direct comparative clinical data are not available. This study was conducted to assess the comparative efficacy and safety of orally administered Zileuton extended-release (ER) with Montelukast sodium in patients suffering from chronic persistent asthma. Patients of 18-65 years of age with mild to moderate chronic stable asthma were randomized to treatment with Zileuton ER 2400 mg/d or Montelukast 10 mg/d for 12 weeks. Peak expiratory flow rate (PEFR) and asthma symptoms (cough, wheeze, chest tightness, and shortness of breath each on a 4-point scale) were assessed on monthly scheduled out-patient visits. Safety assessments by clinical and laboratory parameters were carried out during the course of the study. Among 210 patients eligible for efficacy assessment, PEFR improved by 64.8 ± 52.8 (95% confidence interval: 54.8-74.7) L/min with Zileuton ER (n = 109) and 40.6 ± 47.5 (31.3-49.9) L/min with Montelukast (n = 101; P < 0.001), whereas percent improvements were 27.0% (22.6%-31.5%) versus 18.4% (14.1%-22.7%), respectively (P = 0.006). Zileuton ER lead to ≥12% PEFR improvements in 74 of 109 [67.9% (59.1%-76.7%)] patients, whereas the same was noted in 52 of 101 [51.5% (41.7%-61.2%)] patients receiving Montelukast (P = 0.015). The reduction in the mean overall symptom intensity score was also significantly better with Zileuton ER [-5.0 ± 2.1 (4.6-5.4) versus -4.2 ± 2.3 (3.8-4.7)] (P = 0.018); however, the same was not observed for the decline in the individual symptom scores. A lesser but not significantly different adverse event rate was reported in the Zileuton ER group than the Montelukast group with the commonest events being headache and gastrointestinal effects in both the groups. Thus, Zileuton ER seems to be more efficacious than Montelukast and well tolerated for the treatment of mild to moderate chronic persistent asthma in adult patient population. Further studies can elucidate the comparative treatment benefits of these LT modifiers in asthma management.

Location of community pharmacies and prevalence of oral conditions in the Western Cape Province

Community pharmacists are approached regularly for oral health advice; most commonly for ulcers which could be indicative of oral cancer, HIV, and various systemic diseases. Community pharmacists should know how to manage these conditions yet they have very limited training to manage these conditions appropriately. The area location and socioeconomic status (SES) of the pharmacy should be considered as it may influence patient management. A study of this nature has not yet been conducted in the Western Cape Province of South Africa. To determine the prevalence and frequency of oral complaints at community pharmacies and if these parameters differ by metropolitan location and SES. A cross-sectional survey of 162 randomly-selected private sector pharmacies was conducted. The sample (n = 121) was stratified by SES and metropolitan location. An open-ended structured questionnaire was faxed to pharmacists. A telephonic interview was conducted a day later. Community pharmacists were asked about the frequency and type of oral health problems they encountered. Most pharmacists (91%) dealt with oral health problems frequently, most commonly for ulcers (55.8%), thrush (49.2%), and toothache (33.3%). The results did not differ by metropolitan location and SES (Chi-squared, Fisher’s Exact, p > 0.05), with the exception of toothache and mouth sores. Community pharmacists are an important part of an interdisciplinary team, and play a definite role in the early detection of oral health conditions, namely, caries, HIV and oral cancer. Training on common oral health conditions should be included in undergraduate pharmacy curricula and continuous professional development courses.Gemeenskapsaptekers word gereeld genader vir advies rakende mondgesondheid, hoofsaaklik mondsere wat ’n aanduiding kan wees van mondkanker, MIV en verskeie sistemiese siektes. Gemeenskapsaptekers moet weet hoe om hierdie kwessies te hanteer. Die ligging van die area en die sosio-ekonomiese status (SES) van die apteek moet in ag geneem word aangesien dit ’n invloed mag hê op die hantering van die pasiënt. ’n Studie van hierdie aard is nog nie in die Wes-Kaap Provinsie van Suid-Afrika onderneem nie. Die doel van hierdie studie is om die voorkoms en herhaling van klagtes oor mondsiektes by gemeenskapsapteke te bepaal en of hierdie parameters verskil na gelang van metropolitaanse ligging en SES. ’n Deursnee-opname van 162 ewekansig geselekteerde privaat sektor-apteke is onderneem. Die steekproef (n = 121) is gestratifiseer ten opsigte van SES en metropolitaanse ligging. ’n Oopeinde gestruktureerde vraelys is aan apteke gefaks. ’n Telefoniese onderhoud is ’n dag later gevoer. Gemeenskapsaptekers is gevra na die herhaling van en die tipe mondgesondheidsprobleme wat hulle teëgekom het. Die meeste aptekers (91%) het dikwels met mondprobleme te doen gekry, meestal mondsere (55.8%), mondsproei (49.2%) en tandpyn (33.3%). Die bevindinge het nie verskil na gelang van metropolitaanse ligging en SES (Chi-kwadraat, Fisher se eksakte toets, p > 0.05) nie, met die uitsondering van tandpyn en mondsere. Gemeenskapsaptekers vorm ’n belangrike deel van ’n interdissiplinêre span, en speel ’n definitiewe rol in die vroeë opsporing van mondgesondheidstoestande, naamlik tandverrotting, MIV en mondkanker. Opleiding in algemene mondgesondheidstoestande behoort deel te vorm van voorgraadse aptekerskurrikulums en voortgesette professionele ontwikkelingskursusse.

Management of asthma in the elderly patient

A significant number of older asthmatics, more often than in previous ages, have poorly controlled asthma, leading to increased morbidity and mortality. On the other hand, current guidelines suggest that most asthmatics can obtain achievement and maintenance of disease control and do not include sections specific to the management of asthma in the elderly so that it is more evident the contrast between poor control of asthma in the elderly and the lack of specific guidance from guidelines on asthma management in older asthmatics. Inhaled corticosteroids are the cornerstone for older asthmatics, eventually with add-on inhaled long-acting beta-agonists; inhaled short acting beta-agonists can be used as rescue medications. Triggers exacerbating asthma are similar for all ages, but inhaled viruses and drug interactions have greater clinical significance in the elderly. Older asthmatics have an increased likelihood of comorbidities and polypharmacy, with possible worsening of asthma control and reduced treatment adherence. Physicians and older asthmatics probably either do not perceive or accept a poor asthma control. We conclude that specific instruments addressed to evaluate asthma control in the elderly with concomitant comorbidities and measurements for improving self-management and adherence could assure better disease control in older asthmatics.

Allergic airway diseases in childhood - marching from epidemiology to novel concepts of prevention

In the past years, a wide range of epidemiological, clinical, and experimental studies have produced remarkable advances in the field of respiratory allergies in childhood. By the recent investigations on epidemiological trends, risk factors, and prevention of asthma and allergic rhinitis, various exiting concepts have been challenged, and novel innovative approaches have been developed. Pediatric Allergy and Immunology (PAI), with a number of highly relevant contributions between 2010 and 2012, has become an important forum in this area. The prevalence of asthma in some developed countries may have reached a plateau, while in developing countries, where the prevalence was previously low, allergic diseases are still on the increase. A wide array of risk and protective factors, including hygiene, infections, outdoor and indoor air pollution, allergen exposure, breast-feeding practices, nutrition, and obesity, play a multifaceted role in shaping the observed worldwide trends of respiratory allergies. Under the guidance of recent research, prediction and prevention strategies in the clinical practice are progressively changing, the focus moving away from avoidance of allergen exposure and toward tolerance induction.

Estimation of asthma incidence among low-income children in Texas: a novel approach using Medicaid claims data

Few recent estimates of childhood asthma incidence exist in the literature, although the importance of incidence surveillance for understanding asthma risk factors has been recognized. Asthma prevalence, morbidity, and mortality reports have repeatedly shown that low-income children are disproportionately impacted by the disease. The aim of this study was to demonstrate the utility of Medicaid claims data for providing statewide estimates of asthma incidence. Medicaid analytic extract (MAX) data for Texas children aged 0-17 years enrolled in Medicaid between 2004 and 2007 were used to estimate incidence overall and by age group, gender, race, and county of residence. A ≥13-month period of continuous enrollment was required in order to distinguish incident from prevalent cases identified in the claims data. The age-adjusted incidence of asthma was 4.26/100 person-years during 2005-2007, higher than reported in other populations. Incidence rates decreased with age, were higher for males than females, differed by race, and tended to be higher in rural than urban areas. This study demonstrates the utility of Medicaid analytic extract data for estimating asthma incidence and describes the methodology required for a population with unstable enrollment.

Ten-year trends in prevalence of asthma in adults in southern Brazil: comparison of two population-based studies

There are discrepancies in the literature regarding time trends in the occurrence of asthma in adults. This study compared asthma prevalence in two cross-sectional studies with a ten-year interval in Pelotas, Rio Grande do Sul State, Brazil. The first, in 2000, included 1,968 individuals, and the second, in 2010, 2,466 adults (20-69 years). Prevalence of wheezing and shortness of breath in the prior 12 months remained the same after ten years (6% and 6.1%, respectively). In both studies, asthma was more frequent among females and people with low family income. Physician-diagnosed asthma increased by 35.6%, and lifetime incidence of asthma, by 32.2%. There was no percentage change in current asthma symptoms or current asthma. Local socioeconomic improvement between the two studies was consistent with the increase in medical diagnosis, but did not reflect better management of asthma symptoms, underlining the need for investment regarding other determinants of the disease.

Prevalence of allergic disorders among primary school-aged children in Madinah, Saudi Arabia: two-stage cross-sectional survey

BACKGROUND

There are limited data on the epidemiology of allergic disorders in Saudi Arabia. Such data are needed for, amongst other things, helping to plan service provision at a time when there is considerable investment taking place in national healthcare development. We sought to estimate the prevalence of atopic eczema, allergic rhinitis and asthma in primary school children in Madinah, Saudi Arabia.

METHODS AND FINDINGS

We conducted a two-stage cross-sectional survey of schoolchildren in Madinah. Children were recruited from 38 randomly selected schools. Questionnaires were sent to the parents of all 6,139 6-8 year old children in these schools. These parental-completed questionnaires incorporated questions from the International Study of Asthma and Allergies in Childhood (ISAAC), which had previously been validated for use in Arab populations. We undertook descriptive analyses, using the Generalized Estimating Equation (GEE) to calculate 95% confidence intervals. The overall response rate was 85.9% (n = 5,188), 84.6% for girls and 86.2% for boys, respectively. Overall, parents reported symptoms suggestive of a history of eczema in 10.3% (95%CI 9.4, 11.4), rhinitis in 24.2% (95%CI 22.3, 26.2) and asthma in 23.6% (95%CI 21.3, 26.0) of children. Overall, 41.7% (95%CI 39.1, 44.4) of children had symptoms suggestive of at least one allergic disorder, with a substantial minority manifesting symptoms indicative of co-morbid allergic disease. Comparison of these symptom-based prevalence estimates with reports of clinician-diagnosed disease suggested that the majority of children with eczema and asthma had been diagnosed, but only a minority (17.4%) of children had been diagnosed with rhinitis. International comparisons indicated that children in Madinah have amongst the highest prevalence of allergic problems in the world.

CONCLUSIONS

Symptoms indicative of allergic disease are very common in primary school-aged children in Madinah, Saudi Arabia, with figures comparable to the highest risk regions in the world.

Death rates for asthma in English populations 1979-2007: comparison of underlying cause and all certified causes

OBJECTIVE

To report on trends in mortality for asthma using all certified causes of death mentioned on death certificates (conventionally termed 'mentions'), not just the underlying cause.

STUDY DESIGN

Retrospective analysis using death certificate information and population data.

METHOD

Analysis of mortality records in the Oxford region (mentions available from 1979 to 2007) and English national data (mentions available from 1995 to 2007). The data were considered in periods defined by different national rules for selecting underlying cause of death (1979-1983, 1984-1992, 1993-2000, 2001-2007), and were also analysed as single calendar years.

RESULTS

In Oxford, underlying cause mortality rates per million population in the four periods were 25, 32, 22 and 15, respectively. Rates for mentions were 44, 47, 41 and 29, respectively. Rule changes exaggerated the increase in underlying cause mortality in 1984-1992 (when 67% of asthma deaths were coded as underlying cause). Conversely, the decrease in underlying cause mortality for asthma by 2001-2007 is less than it seems (because just under 50% of asthma deaths in 2001-2007 were coded as underlying cause). Comparisons of trends in asthma and chronic obstructive airways disease (COPD) for individuals aged ≥ 55 years showed a decrease for both asthma and COPD in men; in women, a decrease in asthma and an increase in COPD was seen from the early 1990s.

CONCLUSIONS

Approximately half of all deaths certified for asthma are missed when asthma mortality is analysed using underlying cause alone. The long-term decreasing trend in asthma mortality is real, and is not attributable to a trend in transferring certification from underlying to contributing cause. Nonetheless, caution is needed when comparing asthma deaths using underlying cause alone across periods that include changes to rules for the selection of underlying cause.

Understanding what helps or hinders asthma action plan use: a systematic review and synthesis of the qualitative literature

OBJECTIVE

To understand better what helps and/or hinders asthma action plan use from the professionals and patients/carers perspective.

METHODS

Systematic review and qualitative synthesis (using meta-ethnography).

RESULTS

Nineteen studies (20 papers) were included in an analysis of patients/carers' and professionals' views. Seven main influences on action plan implementation were identified including perceived un-helpfulness and irrelevance of the plans. Translation and synthesis of the original authors' interpretations suggested that action plan promotion and use was influenced by professional and patient/carers' asthma beliefs and attitudes and patient/carer experiences of managing asthma. Action plan use is hindered because professionals and patients/carers have different explanatory models of asthma, its management and their respective roles in the management process. Patients/carers, based on their experiential knowledge of their condition, perceive themselves as capable, effective in managing their asthma, but health professionals do not always share this view.

CONCLUSION

Professionally provided medically focused action plans that do not 'fit' with and incorporate the patients'/carers' views of asthma, and their management strategies, will continue to be under-utilised.

PRACTICE IMPLICATIONS

Professionals need to develop a more patient-centred, partnership-based, approach to the joint development and review of action plans, recognising the experiential asthma knowledge of patients/carers.

Using the community pharmacy to identify patients at risk of poor asthma control and factors which contribute to this poor control

BACKGROUND

Although asthma can be well controlled by appropriate medication delivered in an appropriate way at an appropriate time, there is evidence that management is often suboptimal. This results in poor asthma control, poor quality of life, and significant morbidity.

METHODS

The objective of this study was to describe a population recruited in community pharmacy identified by trained community pharmacists as being at risk for poor asthma outcomes and to identify factors associated with poor asthma control. It used a cross-sectional design in 96 pharmacies in metropolitan and regional New South Wales, Victoria, Queensland, and Australian Capital Territory in Australia. Community pharmacists with specialized asthma training enrolled 570 patients aged ≥18 years with doctor-diagnosed asthma who were considered at risk of poor asthma outcomes and then conducted a comprehensive asthma assessment. In this assessment, asthma control was classified using a symptom and activity tool based on self-reported frequency of symptoms during the previous month and categorized as poor, fair, or good. Asthma history was discussed, and lung function and inhaler technique were also assessed by the pharmacist. Medication use/adherence was recorded from both pharmacy records and the Brief Medication Questionnaire (BMQ).

RESULTS

The symptom and activity tool identified that 437 (77%) recruited patients had poor asthma control. Of the 570 patients, 117 (21%) smoked, 108 (19%) had an action plan, 372 (69%) used combination of inhaled corticosteroid (ICS)/long-acting β(2)-agonist (LABA) medications, and only 17-28% (depending on device) used their inhaler device correctly. In terms of adherence, 90% had their ICS or ICS/LABA dispensed <6 times in the previous 6 months, which is inconsistent with regular use; this low adherence was confirmed from the BMQ scores. A logistic regression model showed that patients who smoked had incorrect inhaler technique or low adherence (assessed by either dispensing history or BMQ) and were more likely to have poor control.

CONCLUSION

Community pharmacists were able to identify patients with asthma at risk of suboptimal control, and factors that contributed to this were elicited. This poorly controlled group that was identified may not be visible or accessible to other health-care professionals. There is an opportunity within pharmacies to target poorly controlled asthma and provide timely and tailored interventions.

Telehealthcare for asthma: a Cochrane review

BACKGROUND

Telehealthcare has the potential to provide care for long-term conditions that are increasingly prevalent, such as asthma. We conducted a systematic review of studies of telehealthcare interventions used for the treatment of asthma to determine whether such approaches to care are effective.

METHODS

We searched the Cochrane Airways Group Specialised Register of Trials, which is derived from systematic searches of bibliographic databases including CENTRAL (the Cochrane Central Register of Controlled Trials), MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and PsycINFO, as well as other electronic resources. We also searched registers of ongoing and unpublished trials. We were interested in studies that measured the following outcomes: quality of life, number of visits to the emergency department and number of admissions to hospital. Two reviewers identified studies for inclusion in our meta-analysis. We extracted data and used fixedeffect modelling for the meta-analyses.

RESULTS

We identified 21 randomized controlled trials for inclusion in our analysis. The methods of telehealthcare intervention these studies investigated were the telephone and video- and Internet-based models of care. Meta-analysis did not show a clinically important improvement in patients' quality of life, and there was no significant change in the number of visits to the emergency department over 12 months. There was a significant reduction in the number of patients admitted to hospital once or more over 12 months (risk ratio 0.25 [95% confidence interval 0.09 to 0.66]).

INTERPRETATION

We found no evidence of a clinically important impact on patients' quality of life, but telehealthcare interventions do appear to have the potential to reduce the risk of admission to hospital, particularly for patients with severe asthma. Further research is required to clarify the cost-effectiveness of models of care based on telehealthcare.

Systems for the management of respiratory disease in primary care--an international series: United Kingdom

INTRODUCTION

The UK National Health Service (NHS) is essentially publicly funded through general taxation. Challenges facing the NHS include the rise in prevalence of long-term conditions and financial pressures. NATIONAL POLICY TRENDS: Political devolution within the UK has led to variations in the way services are organised and delivered between the four nations. PRIMARY CARE RESPIRATORY SERVICES IN THE UK: Primary care is the first point of contact with services. Most respiratory conditions are managed here, including prevention, diagnosis, treatment and palliative care.

EPIDEMIOLOGY

Respiratory disease accounts for more primary care consultations than any other type of illness, with 24 million consultations annually.

ACCESS TO CARE

Equitable access to care is an ongoing challenge: telehealthcare is being tried as a possible solution for monitoring of asthma and COPD. REFERRAL AND ACCESS TO SPECIALIST CARE: Referrals for specialist advice are usually to a secondary care respiratory physician, though respiratory General Practitioners with a Special Interest (GPwSIs) are an option in some localities.

CONCLUSIONS

Prevalence of asthma and COPD is high. Asthma services are predominantly nurse-led. Self-management strategies are widely promoted but poorly implemented. COPD is high on the policy agenda with a shift in focus to preventive lung health and longterm condition management.

Utilization, spending, and price trends for short- and long-acting Beta-agonists and inhaled corticosteroids in the medicaid program, 1991-2010

BACKGROUND

Asthma is a chronic respiratory disease that afflicts millions of people and accounts for substantial utilization of healthcare resources in most industrialized countries, including in the United States. However, the exact cost and utilization of anti-asthma medications in Medicaid in the past 2 decades have not been well studied. Considering the safety issues surrounding the long-acting beta-agonists, guideline updates, and the increase in asthma prevalence, understanding anti-asthma medication prescribing trends is important to payers and patients.

GOAL

The purpose of this study was to analyze the utilization and spending trends for anti-asthmatic agents in the US Medicaid program over the past 2 decades.

METHODS

This study was based on a retrospective, descriptive analysis of trends in utilization of and spending on anti-asthma medications, including short-acting beta-agonists, inhaled corticosteroids, long-acting beta-agonists, and inhaled corticosteroid/long-acting beta-agonist combinations. Quarterly utilization and expenditure data were obtained from the national Medicaid pharmacy files provided by the Centers for Medicare & Medicaid Services from quarter 1 of 1991 through quarter 2 of 2010. Average reimbursement per prescription was calculated each quarter as a proxy for drug price.

RESULTS

The total number of prescriptions for the studied anti-asthma medications rose from 8.9 million in 1991 to 15.6 million in 2009, peaking at 20.8 million in 2005, the year before Medicare and Medicaid dual-eligible beneficiaries were moved to Medicare Part D. From 1991 to 2009, Medicaid spending on anti-asthma medications overall rose from $180.7 million to $1.3 billion, and spending on inhaled corticosteroid/long-acting beta-agonist combinations rose from $52.8 million in 2001-their first year on the market-to $411.7 million in 2009. The average price per prescription has risen in all the anti-asthma drug classes: overall, spending per prescription has increased 4-fold between 1991 and 2009, significantly faster than the consumer price index (57.5%) over the same period. In quarter 2 of 2010, Medicaid spent more on the combination medication fluticasone-salmeterol-$60 million-than on any other anti-asthma medication.

CONCLUSION

Anti-asthma medications are a major and growing expense for state Medicaid programs and can be expected to be the same for Medicare Part D in the future. Increased disease prevalence has in part contributed to the rise in pharmacotherapy cost. Nevertheless, drug therapy is crucial for managing asthma and asthma exacerbations.

Prevalence of long-term oral glucocorticoid prescriptions in the UK over the past 20 years

OBJECTIVE

To assess trends in long-term (i.e. ≥3 months) oral glucocorticoid (GC) prescriptions over the past 20 years.

METHODS

Data of UK adult patients registered between January 1989 and December 2008 with general practices contributing to The Health Improvement Network (THIN) database were obtained. The annual prevalence of long-term oral GC prescriptions was assessed in the whole population and specifically in people with RA, PMR/GCA, asthma, chronic obstructive pulmonary disease (COPD), Crohn's disease and ulcerative colitis (UC). Trends over the 20-year period were estimated using sex- and age-adjusted Poisson regression models.

RESULTS

During the 26 035 154 person-years of follow-up, an average of 0.75% (95% CI 0.74, 0.75) of the study population was prescribed long-term oral GC therapy at any time point. This rose from 0.59% (0.52, 0.67) in 1989 to 0.79% (0.78, 0.80) in 2008. Long-term prescriptions significantly increased in patients with RA [from 10.3% (8.7, 11.9) to 13.6% (12.9, 14.2)] and PMR/GCA [from 57.6% (53.3, 62.0) to 66.5% (65.2, 67.7)], decreased in patients with asthma, COPD and Crohn's disease and remained stable in patients with UC. However, when only incident cases were considered, we found a decreased use of GCs in patients with RA and UC [odds ratio 0.97 (95% CI 0.96, 0.97) and 0.94 (95% CI 0.93, 0.96) per increasing year, respectively].

CONCLUSION

Over the past 20 years, long-term oral GC prescriptions have increased by 34%. Patients newly diagnosed with RA, Crohn's disease or UC are, however, less likely to receive long-term GC prescriptions than patients with a long past medical history of the disease, suggesting changes in physicians' practice.

Children and adolescents' health-related quality of life in relation to eczema, asthma and hay fever: results from a population-based cross-sectional study

PURPOSE

Several studies have looked at the relationship between childhood atopic disease and health-related quality of life (HRQoL), but existing research is limited by selected populations, small samples or lack to consider each of the three atopic conditions simultaneously.

METHODS

Impact of 4-week and 12-month occurrences of the three conditions on HRQoL were analysed by the use of complex sample general linear models alone and adjusted for the other atopic conditions, sociodemographics and mental health in a population-based sample (n = 6,518) of children and adolescents aged 11-17.

RESULTS

In univariate analyses, total HRQoL was significantly impacted by eczema and hay fever but not asthma with stronger effects for 4-week occurrence. In multivariate analyses, 12-month occurrence of hay fever and 4-week occurrence of eczema and hay fever significantly impacted on total HRQoL. Although most of the variance in HRQoL was explained by mental health, independent effects of the atopic conditions remained.

CONCLUSION

Atopic conditions impact HRQoL over and above mental health. When analysing the relationship between atopic conditions and HRQoL, it is important to consider more immediate versus less immediate effects of the conditions. Extent of impairment and the domains affected appear to vary when different time intervals are used.

Incidence, prevalence, and trends of general practitioner-recorded diagnosis of peanut allergy in England, 2001 to 2005

BACKGROUND

Previous descriptions of the epidemiology of peanut allergy have mainly been derived from small cross-sectional studies.

OBJECTIVE

To interrogate a large national research database to provide estimates for the incidence, prevalence, and trends of general practitioner (GP)-recorded diagnosis of peanut allergy in the English population.

METHODS

Version 10 of the QRESEARCH database was used with data from 2,958,366 patients who were registered with 422 United Kingdom general practices in the years 2001 to 2005. The primary outcome was a recording of clinician-diagnosed peanut allergy.

RESULTS

The age-sex standardized incidence rate of peanut allergy in 2005 was 0.08 per 1000 person-years (95% CI, 0.07-0.08), and the prevalence rate was 0.51 per 1000 patients (95% CI, 0.49-0.54). This translated into an estimated 4000 incident cases (95% CI, 3500-4600) and 25,700 prevalent cases (95% CI, 24,400-27,100) of GP-recorded diagnosis of peanut allergy in England in 2005. During the study period, the incidence rate of peanut allergy remained fairly stable, whereas the prevalence rate doubled. In those under 18 years of age, the crude lifetime prevalence rate was higher in males than females. A significant inverse relationship between prevalence and socioeconomic status was found.

CONCLUSION

These data on GP-recorded diagnosis of peanut allergy from a large general practice database suggest a much lower prevalence in peanut allergy than has hitherto been found. This difference may in part be explained by underrecording of peanut allergy in general practice. Further research is needed to assess the true frequency of peanut allergy in the population and whether there has been a true increase in recent years.

Telehealthcare for asthma

BACKGROUND

Healthcare systems internationally need to consider new models of care to cater for the increasing numbers of people with asthma. Telehealthcare interventions are increasingly being seen by policymakers as a potential means of delivering asthma care. We defined telehealthcare as being healthcare delivered from a distance, facilitated electronically and involving the exchange of information through the personalised interaction between a healthcare professional using their skills and judgement and the patient providing information.

OBJECTIVES

To assess the effectiveness of telehealthcare interventions in people with asthma.

SEARCH STRATEGY

We searched in the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED, and PsycINFO; this was supplemented by handsearching of respiratory journals. We also searched registers of ongoing and unpublished trials.

SELECTION CRITERIA

We selected completed randomised controlled trials of telehealthcare initiatives aiming to improve asthma care.

DATA COLLECTION AND ANALYSIS

Two review authors independently appraised studies for inclusion and extracted data and performed meta-analyses. We analysed dichotomous variables to produce an odds ratio (OR) and continuous variables to produce a mean difference.

MAIN RESULTS

We included 21 trials in this review. The 21 included studies investigated a range of technologies aiming to support the provision of care from a distance. These included: telephone (n = 9); video-conferencing (n = 2); Internet (n = 2); other networked communications (n = 6); text Short Messaging Service (n = 1); or a combination of text and Internet (n = 1). Meta-analysis showed that these interventions did not result in clinically important improvements in asthma quality of life (minimum clinically important difference = 0.5): mean difference in Juniper's Asthma Quality of Life Questionnaire (AQLQ) 0.08 (95% CI 0.01 to 0.16). Telehealthcare for asthma resulted in a non-significant increase in the odds of emergency department visits over a 12-month period: OR 1.16 (95% CI 0.52 to 2.58). There was, however, a significant reduction in hospitalisations over a 12-month period: OR 0.21 (95% CI 0.07 to 0.61), the effect being most marked in people with more severe asthma managed predominantly in secondary care settings.

AUTHORS' CONCLUSIONS

Telehealthcare interventions are unlikely to result in clinically relevant improvements in health outcomes in those with relatively mild asthma, but they may have a role in those with more severe disease who are at high risk of hospital admission. Further trials evaluating the effectiveness and cost-effectiveness of a range of telehealthcare interventions are needed.

Trends in asthma prevalence and incidence in Ontario, Canada, 1996-2005: a population study

In the 1980s and early 1990s, asthma prevalence increased significantly in most Westernized countries. In more recent years, asthma trends have been less clear, with some studies suggesting that they are still rising and others suggesting that they have stabilized or decreased. A population-based cohort study was conducted to estimate asthma prevalence and incidence trends in one large Canadian province, Ontario. All individuals with asthma living in Ontario, a province of Canada with a multicultural population of approximately 12 million, were identified in universal, population health administrative databases by using a validated health administrative case definition of asthma. Annual asthma prevalence, incidence, and all-cause mortality rates were estimated from 1996 to 2005. During this time, the prevalence of asthma increased by 70.5%. The age- and sex-standardized asthma prevalence increased from 8.5% in 1996 to 13.3% in 2005, a relative increase of 55.1% (P < 0.0001). Asthma incidence rates increased in children by 30.0% and were relatively stable in adults. Overall all-cause mortality decreased. Asthma prevalence in Ontario, Canada, has increased significantly. This is attributable, in part, to an increase in the incidence of asthma in children. Effective clinical and public health strategies are needed to prevent and manage asthma in the population.