Effect of age on asthma control: results from the National Asthma Survey

Medicare Advantage Population in the United States: Outcomes of Patients with Asthma Treated with ICS/LABA Before and After Initiation with Fluticasone Furoate/Umeclidinium/Vilanterol (FF/UMEC/VI)

INTRODUCTION

The clinical benefits of fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) have been demonstrated in clinical trials. There is limited evidence regarding the effectiveness and economic outcomes associated with FF/UMEC/VI use in US clinical practice. This real-world study assessed asthma-related exacerbations, healthcare resource utilization (HRU), and healthcare costs among a Medicare Advantage-insured population before and after initiation of FF/UMEC/VI in patients with asthma previously treated with an inhaled corticosteroid/long-acting β2-agonist (ICS/LABA).

METHODS

De-identified data were obtained from the Komodo Health database (01/01/2016-12/31/2023) for adults with asthma who received prior ICS/LABA treatment and had ≥ 12 months of continuous Medicare Advantage coverage both pre- and post-FF/UMEC/VI initiation (index date). Rates of asthma-related exacerbations and HRU were compared using rate ratios (RR) from Poisson regressions. Healthcare costs were calculated per patient per year (PPPY) and compared using mean cost differences from generalized linear models.

RESULTS

In total, 2598 Medicare Advantage-insured patients who initiated FF/UMEC/VI for asthma were included. The mean ± SD age was 67.9 ± 12.3 years; 75.5% were female. The rate of overall asthma-related exacerbations was 31% lower in the post- versus pre-initiation period (RR 0.69; 95% CI 0.65, 0.73; p < 0.001) and included a 24% lower rate of inpatient/emergency department (IP/ED)-defined exacerbations (RR 0.76; 95% CI 0.68, 0.85; p < 0.001) and a 34% lower rate of systemic corticosteroid (SCS)-defined exacerbations (RR 0.66; 95% CI 0.61, 0.71; p < 0.001). Asthma-related ED visits (RR 0.69; 95% CI 0.60, 0.80; p < 0.001) and asthma-related outpatient (OP) visits (RR 0.77; 95% CI 0.71, 0.84; p < 0.001) were both lower, and the mean reduction in cost was $411 PPPY (95% CI $575, $248; p < 0.001), after FF/UMEC/VI initiation.

CONCLUSIONS

Initiation of FF/UMEC/VI after ICS/LABA treatment among Medicare Advantage-insured patients with asthma was associated with reduced rates of asthma-related exacerbations, ED and OP visits, and healthcare costs, highlighting the benefits of therapy escalation among this patient population.

Adherence Challenges and Strategies in Specific Groups With Asthma: Adolescents, Pregnancy, and Older Adults

Poor adherence to controller therapies is a universal challenge to asthma control. Several high-risk groups, including adolescents, pregnant women, and older adults, have their own unique challenges to adherence. The rates of asthma controller therapy use are low in each of these populations, but secondary to different causes. Adolescents have increased independence and a transition to new self-management responsibilities; pregnant women may be concerned about adverse effects of medications to the fetus; and older adults may have age-related physical and cognitive challenges to effectively taking medication. Only by understanding the nuances of care in these populations can health care professionals develop strategies to address barriers to adherence. Tailored education focused on empowering patients and dispelling misconceptions can serve as tools to improve adherence and ultimately asthma control.

Impact of Loneliness and Social Support on Acute Health Service Use and Symptom Exacerbation Among Adults with Asthma and COPD

Loneliness and low social support are associated with negative health outcomes among adults with asthma or COPD. Although social support is correlated with loneliness, low social support is neither necessary nor sufficient for the experience of loneliness. This study compares the relative association of loneliness and social support on symptom exacerbation (i.e., acute deteriorations in respiratory health) and acute health service utilization (i.e., hospitalizations, emergency department visits) among 206 adults with asthma and 308 adults with COPD. Separate logistic regression models were used to simultaneously examine the association of loneliness and social support with each outcome. Among adults with asthma, loneliness was associated with greater odds of hospitalization (AOR = 2.81, 95%CI [1.13, 7.02]), while low social support was not (AOR = 1.44, 95%CI [0.78, 2.65]). However, neither loneliness nor social support were associated with any other acute health service use or symptom exacerbation among adults with asthma. Among adults with COPD, loneliness, and greater social support were associated with increased odds of symptom exacerbation (AOR = 1.67, 95%CI [1.03, 2.69]; AOR = 1.36, 95%CI 1.02, 1.83]) and hospitalization (AOR = 3.46, 95%CI [1.65, 7.24]; AOR = 1.92, 95%CI [1.15, 3.22]), but only social support was significantly associated with ED visits (AOR = 1.72, 95%CI 1.12, 2.66]). These findings support prior research demonstrating that loneliness and social support are related but separate determinants of patients' physical symptoms and service utilization.

The Impact of Wildfire Smoke on Asthma Control in California: A Microsimulation Approach

Wildfire smoke exposure leads to poorer health among those with pre-existing conditions such as asthma. Particulate matter in wildfire smoke can worsen asthma control, cause acute exacerbations, and increase health resource utilization (HRU) and costs. Research to date has been retrospective with few opportunities to project changes in underlying asthma control and HRU given exposure to wildfire smoke. Using a microsimulation of 5,000 Californians with asthma, we calculated changes in asthma control distribution, risk of exacerbation, and HRU and cost outcomes in the 16 weeks during and after a wildfire. The model was calibrated against empirical values on asthma control distribution and increased HRU after exposure to wildfire smoke. Without smoke exposure, 48% of the cohort exhibited complete or well control of asthma, and 8% required acute healthcare per cycle. Following two consecutive weeks of wildfire smoke, complete or well control of asthma fell to 27%, with an additional 4% HRU. This corresponds to total additional $601,250 in all-cause medical costs and eight fewer quality-adjusted life years over 16 weeks of model time. Our model found increased asthma health and cost burden due to wildfire smoke that were aligned with empirical evidence from a historic wildfire event. This study establishes a framework for a more nuanced understanding of asthma impacts from wildfire smoke that can help inform the development of public health policies to mitigate harm and promote resilience among asthma patients in the face of climate change.

A cross-sectional study on the self-management of asthma and asthma control among adult asthmatic patients in the Aseer region, KSA

Proper management of asthma is crucial for maintaining control over the disease and has a significant impact on the patient's overall condition. The purpose of this study was to determine the extent of self-management and the level of Asthma control in the patients from the Aseer region of Saudi Arabia, as well as to investigate determinants of illness control. A study was conducted using quantitative cross-sectional methods. Researchers utilised a web-based, self-administered structured questionnaire to gather data. The questionnaire included three sections: a socio-demographic section, an Asthma Self-Management Questionnaire (ASMQ), and Asthma Control Test (ACT). An analysis using the chi-square test was conducted to determine if there was a notable connection between the socio-demographic characteristics of the participants and the level of asthma control. A total of 305 responses were collected. The average score for the Asthma Self-Management Questionnaire was 5.72, which corresponds to 40.9%. Based on the scores from the Asthma Control Test, it was found that 60 patients (20.0%) had asthma that was not under control, 94 (30.0%) had asthma that was partially controlled, and 151 (50.0%) had asthma that was well controlled. Factors such as gender, non-smoking status, and having asthma for over 10 years (p ˂0.05) were found to be strongly correlated with improved disease control. Significant gaps were found in patients' awareness of the most important and critical aspects concerning the condition, medications, and preventative actions that limit asthma aggravation. To address the current situation, hospitals and clinics must make substantial efforts.

The Association of Food Insecurity With Asthma Control in Adults During COVID-19

BACKGROUND

Food insecurity has been associated with poorer asthma control in children, but research lacks in adults.

OBJECTIVE

To assess the frequency of food insecurity and its association with asthma control in adults during the coronavirus disease 2019 pandemic.

METHODS

An online cross-sectional survey study was conducted in US adults with asthma. Survey questions included how worried or concerned participants were about food security since the pandemic. Asthma control was assessed using the Asthma Control Test, with uncontrolled asthma defined as Asthma Control Test score less than or equal to 19. Self-report of food insecurity since the pandemic was assessed. Food insecurity variables were dichotomized into high insecurity (≥3) or low insecurity (<3). Descriptive statistics and bivariate analyses were performed.

RESULTS

Of the total participants (N = 866), 82.79% were female; mean age of participants was 44 ± 15.05 years, their mean Asthma Control Test score was 19.25 ± 4.54, and 18.48% had high food insecurity. Participants with high food insecurity were more likely to have uncontrolled asthma (74.38%) compared with those with lower food insecurity (34.99%; P < .01). The relationship between asthma control and food insecurity remained significant after adjusting for age, education, sex, race, anxiety, and living stability concerns due to the pandemic.

CONCLUSIONS

Food insecurity exists in adults with asthma and is associated with uncontrolled asthma. Providers should consider screening their patients for food insecurity when treating individuals with uncontrolled asthma.

Characterization and cluster analyses of elderly asthma in comparison with nonelderly patients with asthma in Japan

BACKGROUND

Asthma is a heterogeneous disease with multiple phenotypes that are useful in precision medicine. As the population ages, the elderly asthma (EA, aged ≥ 65 years) population is growing, and EA is now a major health problem worldwide.

OBJECTIVE

To characterize EA and identify its phenotypes.

METHODS

In adult patients with asthma (aged ≥ 18 years) who had been diagnosed with having asthma at least 1 year before study enrollment, 1925 were included in the NHOM-Asthma (registered in UMIN-CTR; UMIN000027776), and the data were used for this study, JFGE-Asthma (registered in UMIN-CTR; UMIN000036912). Data from EA and non-EA (NEA) groups were compared, and Ward's minimum-variance hierarchical clustering method and principal component analysis were performed.

RESULTS

EA was characterized by older asthma onset, longer asthma duration and smoking history, more comorbidities, lower pulmonary function, less atopic, lower adherence, and more hospital admissions because of asthma. In contrast, the number of eosinophils, total immunoglobulin E level, oral corticosteroid use, and asthma control questionnaire scores were equivalent between EA and NEA. There were 3 distinct phenotypes in EA, which are as follows: EA1: youngest, late onset, short duration, mild; EA2: early onset, long duration, atopic, low lung function, moderate; and EA3: oldest, eosinophilic, overweight, low lung function, most severe. The classification factors of the EA phenotypes included the age of onset and asthma control questionnaire-6. Similarities were observed between EA and NEA phenotypes after principal component analysis.

CONCLUSION

The EA in Japan may be unique because of the population's high longevity. Characterization of EA phenotypes from the present cohort indicated the need for distinct precision medicine for EA.

TRIAL REGISTRATION

JFGE-Asthma registered in UMIN-CTR (https://www.umin.ac.jp/ctr/); UMIN000036912.

Cognition, symptom perception, and medication non-adherence in older adults with asthma

BACKGROUND

Cognitive impairment (CI) is highly prevalent in elderly asthmatics and is associated with worse asthma self-management (SM) and outcomes. CI may also explain why older adults may under-perceive asthma symptoms. We hypothesized that CI would be associated with low medication adherence and asthma symptom under-perception (ASP). We also hypothesized that ASP would mediate the relationship between CI and medication adherence.

METHODS

Participants of this longitudinal cohort study were asthmatics (N = 334) ≥60 years (51% Hispanic, 25% Black). Cognitive measures assessed general cognition, attention, processing speed, executive functioning, memory, and language. Measures of SM were self-reported and electronically measured adherence to controller medications. ASP was assessed for 6 weeks by participants entering estimates of peak expiratory flow (PEF) into a programmable peak flow meter, followed by PEF blows. Participants were blinded to actual PEF values. Percentage of time that participants were in the over-perception zone was calculated as an average.

RESULTS

In regression analyses, those with impairments in memory and general cognition had lower odds ratios (OR) for self-reported non-adherence (OR: 0.96, 95% CI 0.93 - 0.98 & OR: 0.90, 95% CI 0.83 - 0.96, respectively). CI was not associated with electronically measured non-adherence or ASP. In structural equation modeling, while CI was associated with adherence (β = 0.04, SE = 0.021, p = 0.04), ASP did not mediate this relationship.

CONCLUSIONS

While results confirmed the importance of cognition in asthma SM, these findings were not linked to ASP. Future analyses are needed to understand the role of confounding factors.

Depressive Symptoms and Overperception of Airflow Obstruction in Older Adults With Asthma

OBJECTIVE

Older adults are at increased risk for depression and poor asthma outcomes. We examined whether depressive symptoms are associated with overperception of airflow obstruction and a pattern of worse asthma control, but not pulmonary function.

METHODS

We recruited a cohort of adults with asthma 60 years and older in East Harlem and the Bronx, New York. Baseline measures included the Geriatric Depression Scale, Asthma Control Questionnaire, and Mini Asthma Quality of Life Questionnaire. Spirometry was conducted at baseline to assess pulmonary function. Perception of airflow obstruction was assessed for 6 weeks following baseline by participants entering estimates of peak expiratory flow (PEF) into a programmable peak flow meter followed by PEF blows. Participants were blinded to actual PEF values. The percentage of time that participants were in the overperception zone was calculated as an average.

RESULTS

Among the 334 participants (51% Hispanic, 25% Black), depressive symptoms were associated with overperception of airflow obstruction (β = 0.14, p = .029), worse self-reported asthma control (β = 0.17, p = .003), and lower asthma-related quality of life (β = -0.33, p < .001), but not with lung function (β = -0.01, p = .82). Overperception was also associated with worse self-reported asthma control (β = 0.14, p = .021), but not lung function (β = -0.05, p = .41).

CONCLUSIONS

Depressive symptoms were associated with greater perceived impairment from asthma, but not pulmonary function. Overperception of asthma symptoms may play a key role in the relationship between depression and asthma outcomes in older adults.

Small Airway Dysfunction Links Asthma Severity with Physical Activity and Symptom Control

BACKGROUND

Little is known about the role of small airway dysfunction (SAD) and its complex relation with asthma control and physical activity (PA).

OBJECTIVE

To investigate the interrelations among SAD, risk factors for asthma severity, symptom control, and PA.

METHODS

We assessed SAD by impulse oscillometry and other sophisticated lung function measures including inert gas washout in adults with asthma (mild to moderate, n = 140; severe, n = 128) and 69 healthy controls from the All Age Asthma Cohort. We evaluated SAD prevalence and its interrelation with risk factors for asthma severity (older age, obesity, and smoking), type 2 inflammation (sputum and blood eosinophils, fractional exhaled nitric oxide), systemic inflammation (high-sensitivity C-reactive protein), asthma control (AC), and PA (accelerometer for 1 week). We applied a clinical model based on structural equation modeling that integrated causal pathways among these clinical variables.

RESULTS

The prevalence of SAD ranged from 75% to 90% in patients with severe asthma and from 53% to 64% in mild to moderate asthma. Severe SAD was associated with poor AC and low PA. Structural equation modeling indicated that age, obesity, obesity-related systemic inflammation, T2 inflammation, and smoking are independent predictors of SAD. Small airway dysfunction was the main determinant factor of AC, which in turn affected PA. Obesity affected AC directly and through its contribution to SAD and low PA. In addition, PA had bidirectional associations with obesity, SAD, and AC. Structural equation modeling also indicated interrelations among distal airflow limitation, air trapping, and ventilation heterogeneity.

CONCLUSIONS

Small airway dysfunction is a highly prevalent key feature of asthma that interrelates a spectrum of distal lung function abnormalities with risk factors for asthma severity, asthma control, and physical activity.

Impact of asthma control on different age groups in five Latin American countries

Background

Asthma is a chronic airway inflammatory condition of the airway and is classified as controlled, partially controlled, and uncontrolled. Patients with uncontrolled asthma are at greater risk for hospitalizations and visits to emergencies, and the condition has greater impact on their daily lives. The aim of this study was to evaluate asthma control, the use of health resources, and asthma's impact on the activities of daily living of patients with different age groups in 5 Latin American countries.

Methods

This was a retrospective analysis of The Latin America Asthma Insights and Management (LA AIM) study carried out in Argentina, Brazil, Mexico, Venezuela, and Puerto Rico. Asthmatics were splited into 3 age groups: 12–17, >17–40 and > 40 years old. An interview face to face was carried out and patients answered a questionnaire of 53 questions related to 5 main domains of asthma: symptoms, impact of asthma on daily living activities, patients' perceptions of asthma control, exacerbations, and treatment/medication.

Results

A total of 2167 asthmatics were interviewed. There was a low percentage of controlled patients (mean 9%) in all 3 groups with no particular difference among the five countries, but Venezuelan patients had a 71% chance of having uncontrolled asthma (p < 0.001).

Conclusion

In the 3 age groups, patients experienced poor asthma control, with no significant differences among the countries. Patients who used control medication had a greater chance of controlling their asthma, and those who had emergency health care visits had a greater chance of having uncontrolled asthma.

A behavioral intervention can decrease asthma exacerbations in older adults

BACKGROUND

Older adults have higher rates of asthma morbidity and mortality compared with younger age groups. Few interventions are tailored to this population.

OBJECTIVE

To evaluate a self-management asthma intervention in older adults.

METHODS

Adults age 55 and older with persistent asthma were enrolled into blinded, randomized controlled trial of a 6-session asthma self-management intervention. This educational intervention was conducted in group sessions and through individual telephone calls. Outcomes including asthma exacerbations (defined as unscheduled office visits, emergency department visits, or hospitalizations for asthma), spirometric values, FeNO, asthma control, asthma quality of life, and asthma self-management were assessed at 3, 6, and 12 months.

RESULTS

One hundred eighty-nine subjects were enrolled, 172 were randomized and received at least 1 treatment dose, and 145 (84%) were analyzed at 12 months. On a modified intent-to-treat analysis, those in the intervention group were less likely to have an asthma exacerbation (26.9% vs 47.1%, P = .01), had a lower asthma exacerbation rate (0.8 vs 1.9, P = .02), had better asthma control (19.9 vs 18.6, P = .08), and had a higher asthma self-management score (8.9 vs 8.4, P = .03). After a mixed-model analysis to control for confounding factors, a decrease in asthma exacerbations (P = .02), as well as a decreased asthma exacerbation rate (P = .04), remained statistically significant, whereas asthma control and self-management did not. No other significant outcome differences were found.

CONCLUSION

A 6-session asthma self-management intervention can successfully decrease asthma exacerbations among older adults.

Effect of a Self-management Support Intervention on Asthma Outcomes in Older Adults: The SAMBA Study Randomized Clinical Trial

IMPORTANCE

Older adults with asthma have worse control and outcomes than younger adults. Interventions to address suboptimal self-management among older adults with asthma are typically not tailored to the specific needs of the patient.

OBJECTIVE

To test the effect of a comprehensive, patient-tailored asthma self-management support intervention for older adults on clinical and self-management outcomes.

DESIGN, SETTING, AND PARTICIPANTS

Three-arm randomized clinical trial conducted between February 2014 and December 2017 at primary care practices and personal residences in New York City. Adults 60 years and older with persistent, uncontrolled asthma were identified from electronic medical records at an academic medical center and a federally qualified health center. Of 1349 patients assessed for eligibility, 406 met eligibility criteria, consented to participate, and were randomized to 1 of 3 groups: home-based intervention, clinic-based intervention, or control (usual care). A total of 391 patients received the allocated treatment.

INTERVENTIONS

Screening for psychosocial, physical, cognitive, and environmental barriers to asthma control and self-management with actions to address identified barriers. The intervention was delivered in the home or primary care practices by asthma care coaches.

MAIN OUTCOMES AND MEASURES

Primary outcomes were the Asthma Control Test, Mini Asthma Quality of Life Questionnaire, Medication Adherence Rating Scale, metered dose inhaler technique, and emergency department visits for asthma care. Primary analyses compared intervention (home or clinic based) with usual care.

RESULTS

Of the 391 patients who received treatment, 58 (15.1%) were men, and the mean (SD) age was 67.8 (7.4) years. After accounting for baseline scores, scores on the asthma control test were better in the intervention groups vs the control group (difference-in-differences at 3 months, 1.2; 95% CI, 0.2-2.2; P = .02; 6 months, 1.0; 95% CI, 0.0-2.1; P = .049; 12 months, 0.6; 95% CI, -0.5 to 1.8; P = .28; and overall, χ2 = 13.4, with 4 degrees of freedom; P = .01). Emergency department visits were lower at 12 months for the intervention groups vs the control group (16 [6.2%] vs 17 [12.7%]; P = .03; adjusted odds ratio, 0.8; 95% CI, 0.6-0.99; P = .03). Statistically significant improvements were observed for the intervention vs control patients in quality of life (overall effect: χ2 = 10.5, with 4 degrees of freedom; P = .01), medication adherence (overall effect: χ2 = 9.5, with 4 degrees of freedom; P = .049), and inhaler technique (metered-dose inhaler technique, correctly completed steps at 12 months, median [range]: 75% [0%-100%] vs 58% [0%-100%]). No significant differences in outcomes were observed between patients receiving the intervention in home vs practice settings.

CONCLUSIONS AND RELEVANCE

An intervention directed by patients' needs and barriers improved asthma outcomes and self-management behaviors among older adults.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02316223.

Economic Burden Associated with Receiving Inhaled Corticosteroids with Leukotriene Receptor Antagonists or Long-Acting Beta Agonists as Combination Therapy in Older Adults

BACKGROUND

There is a paucity of literature on the health care expenditures associated with different pharmacologic treatments in older adults with asthma that is not well controlled on inhaled corticosteroids (ICS).

OBJECTIVE

To compare asthma-related and all-cause health care expenditures associated with leukotriene receptor antagonists (LTRA) versus long-acting beta agonists (LABA) when added to ICS in older adults with asthma.

METHODS

A retrospective cohort was constructed using 2009-2010 Medicare fee-for-service medical and pharmacy claims from a 10% random sample of beneficiaries continuously enrolled in Parts A, B, and D in 2009. The sample comprised patients who were aged 65 years and older, diagnosed with asthma, and treated exclusively with ICS + LABA or ICS + LTRA. Outcomes assessed were asthma-related expenditures (medical, pharmacy, and total) and all-cause health care expenditures (medical, pharmacy, and total). Outcomes were measured from the date of the first prescription for the add-on treatment (LABA or LTRA in combination with ICS) after having at least a 4-month "wash-in" period in which patients were receiving no controller, ICS alone, or ICS plus the add-on treatment of the follow-up period. Patients were followed until death, switching to or adding the other add-on treatment, or the end of the study (December 31, 2010). Multivariable regression models with nonparametric bootstrapped standard errors were used to compare all-cause and asthma-related expenditures per patient per month (PPPM) between ICS + LABA and ICS + LTRA users. All models were adjusted for demographics, comorbidities, and county-level health care access variables.

RESULTS

The primary analysis included 14,702 patients, of whom 12,940 were treated with ICS + LABA and 1,762 were treated with ICS + LTRA. The mean (SD) follow-up periods were 12.3 (± 5.7) months for the ICS + LABA group and 15.3 (± 5.1) months for the ICS + LTRA group. Adjusted asthma-related expenditures PPPM were $400 for the ICS + LTRA group compared with $286 for the ICS + LABA group (P < 0.001). However, adjusted total all-cause expenditure PPPM was significantly lower for patients treated with ICS + LTRA ($6,087 for ICS + LTRA compared with $6,975 for ICS + LABA, P = 0.029).

CONCLUSIONS

Older adults with asthma often experience economic burden from asthma and other chronic illnesses. Compared with ICS + LTRA, ICS + LABA was associated with lower asthma-related expenditures but with higher all-cause expenditures in older adults.

DISCLOSURES

Support for this study was provided by the University of Pittsburgh School of Pharmacy and the Pittsburgh Claude D. Pepper Older Americans Independence Center (NIA P30 AGAG024827). C. Thorpe reports grants from the National Institute of Aging during the conduct of this study. The other authors have nothing to disclose.

Distinct Asthma Phenotypes Among Older Adults with Asthma

BACKGROUND

Older adults have high rates of asthma morbidity and mortality. Asthma is now recognized as a heterogeneous disease, yet the distinct phenotypes among older adults are unknown.

OBJECTIVE

The objective of this study was to identify asthma phenotypes in a diverse population of elderly patients with asthma.

METHODS

Using cluster analysis, 180 older adults with persistent asthma were analyzed. Subjects completed detailed questionnaires, skin prick testing, and spirometry with reversibility. Twenty-four core variables were analyzed.

RESULTS

Four groups were identified. Subjects in cluster 1 (n = 69) typically had asthma diagnosed after the age of 40 and the shortest duration of asthma. Cluster 2 (n = 40) had the mildest asthma defined by spirometry, Asthma Control test (ACT), and Asthma Quality of Life Questionnaire (AQLQ). They also had the lowest body mass index (BMI), lowest depression score, and least number of comorbidities. Cluster 3 (n = 46) had the longest duration of asthma (56 years) and the highest atopic skin test sensitization (74%). Cluster 4 (n = 25) had the most severe asthma, with extremely low FEV1% predicted (37.8%), lowest ACT, and lowest AQLQ scores. They were more likely to be black and had the highest comorbidities. Using BMI, posttreatment FEV1% predicted, and duration of asthma, 95.6% of subjects were able to be correctly classified.

CONCLUSIONS

In older adults with asthma, distinct phenotypes vary on key features that are more pronounced among the elderly, including comorbidities, fixed airway obstruction, and duration of asthma ≥40 years. Further work is required to determine the clinical and therapeutic implications for different asthma phenotypes in older adults.

Predictors of asthma control in elderly patients

PURPOSE OF REVIEW

We are in the era of rapid aging of the global population. Elderly asthmatic patients have an increased frequency of hospitalization and a high mortality rate. In this review, we focus on comorbidities and treatment issues in terms of the predictors of asthma control in the elderly.

RECENT FINDINGS

Some frequent comorbidities, such as chronic obstructive pulmonary disease, chronic sinusitis, obesity, and depression, are associated with uncontrolled asthma in elderly asthmatic patients. Smoking status in elderly asthmatic patients was associated with more frequent exacerbations. Management of comorbidities should be taken into account when we treat elderly asthmatic patients. Low treatment adherence, which is common in elderly asthmatic patients, predicts poor asthma control status. A poor knowledge about asthma, cognitive function impairment, and inappropriate inhaler technique result in low treatment adherence. Polypharmacy is associated with low treatment adherence, adverse drug reactions, and drug-drug interactions, and it is supposed to be a predictor of asthma control.

SUMMARY

Multifactorial assessments, including comorbidities, treatment adherence, and polypharmacy, are important for better asthma control in elderly asthmatic patients. Further studies on the strategy for the management of elderly asthmatic patients in a real-world setting are warranted.

Economic Burden of Illness Among Patients with Severe Asthma in a Managed Care Setting

BACKGROUND

Despite intensive pharmacotherapy, a considerable number of patients with severe asthma have inadequate disease control. Patients with severe asthma who experience exacerbations consume significant health care resources.

OBJECTIVE

To assess health care resource utilization and associated costs among patients with persistent severe asthma who experienced exacerbations compared with patients with persistent but nonsevere asthma.

METHODS

This retrospective analysis of a national administrative claims database identified patients aged ≥ 12 years who had at least 1 medical claim with an asthma diagnosis in 2012 and had continuous medical and pharmacy coverage under a commercial or Medicare Advantage plan from January 1, 2012, to December 31, 2013. Patients were assigned to 1 of 2 mutually exclusive cohorts-persistent asthma (PA) or severe asthma (SA)-according to an established algorithm based on asthma-related health care resource use and pharmacy claims for controller medication. SA patients were required to meet PA criteria and also have evidence of ≥2 asthma exacerbations in 2012. Asthma-related health care resource utilization and costs were computed from asthma medication use (rescue and controller therapy) and medical claims with an asthma diagnosis in the primary position in 2012 and 2013. Adherence to controller therapy was assessed over 365 days by using the proportion of days covered (PDC), starting with the first claim for controller therapy in 2012. Differences between the PA and SA cohorts were analyzed by t-test for continuous variables and chi-square test for categorical variables. Asthma-related costs in 2013 were also analyzed using a generalized linear model with a gamma distribution and log link, adjusted for patient demographics (age, gender, region, and insurance type) and Quan-Charlson comorbidity score.

RESULTS

A total of 65,359 patients were included: 63,597 (97.3%) PA patients and 1,762 SA patients (2.7%). Compared with the PA cohort, the SA cohort was older (mean age = 50.8 years vs. 46.5 years, P < 0.001) and had higher mean comorbidity score (1.47 vs. 1.31, P< 0.001). The mean count of all asthma medications fills was 2.2-fold (2012) and 2.1-fold (2013) higher in the SA cohort, compared with the PA cohort (P< 0.001). Mean PDC for all oral and inhaled controller therapy was also higher in the SA cohort compared with the PA cohort (0.80 vs. 0.65, P< 0.001). SA patients had a significantly greater mean count of asthma-related hospitalizations, emergency room visits, and ambulatory visits in 2012 and 2013 (P< 0.001). Unadjusted mean annual asthma-related costs in the SA versus PA cohorts were $6,496 versus $2,739 (P < 0.001) in 2012 and $5,174 versus $1,775 (P< 0.001) in 2013. Higher asthma-related costs were driven by greater mean annual asthma medication costs in 2012 ($4,545 vs. $1,738, P< 0.001) and 2013 ($4,068 vs. $1,348, P< 0.001). Adjusted mean annual asthma-related costs in 2013 were $3,336 greater (cost ratio=2.878, P< 0.001) in the SA cohort, and adjusted mean annual asthma medication costs were $2,672 higher (cost ratio=2.982, P< 0.001) in the SA cohort.

CONCLUSIONS

Patients with SA who experienced 2 or more exacerbations had 2.1-fold greater use of controller medications across both study years and were more adherent to controller therapy than patients with PA. Despite more intensive pharmacotherapy, SA patients incurred 2.9-fold higher adjusted asthma-related costs and 3-fold higher adjusted asthma medication costs than PA patients. Patients with SA consistently demonstrated a higher rate of health care utilization.

DISCLOSURES

Funding for this study (HO-14-14443) was provided by GlaxoSmithKline (GSK). All listed authors meet the criteria for authorship set forth by the International Committee for Medical Journal Editors. Albers, Forshag, and Yancey are employees of GSK and hold stock in GSK. Dalal, Nagar, and Ortega were employees of GSK at the time this research was conducted. Chastek and Korrer are employees of Optum, which received consulting fees from GSK for research related to this study. Study concept and design were contributed by Chastek, Nagar, and Dalal. Korrer took the lead in data collection, along with Chastek, and data interpretation was performed by Chastek, Ortega, Forshag, and Dalal. The manuscript was written by Chastek and Dalal and revised by Albers and Yancy, assisted by the other authors.

Impact of online patient reminders to improve asthma care: A randomized controlled trial

Importance

Asthma is one of the most burdensome chronic illnesses in the US. Despite widespread dissemination of evidence-based guidelines, more than half of the adults with asthma have uncontrolled symptoms.

Objective

To examine the efficacy of an online tool designed to improve asthma control.

Design

12-month single blind randomized controlled trial of the online tool (Intervention condition, IC) versus an active control tool (CC).

Setting

Patients enrolled in an insurance plan.

Participants

Participants were 408 adults (21–60 years of age) with persistent asthma.

Intervention

At least once each month and before provider visits, participants in the IC answered questions online about their asthma symptoms, asthma medications and asthma care received from providers, such as an asthma management plan. The tool then provided tailored feedback to remind patients 1) to ask health care providers specific questions that may improve asthma control (e.g., additional controller medications) and 2) to consistently perform specific self-care behaviors (e.g., proper inhaler technique). Participants in the CC received similar questions and feedback, yet focused instead on preventive services unrelated to asthma control (e.g., cancer screening).

Main outcome measures

The main outcome measure was asthma control, as assessed by the 5-question Asthma Control Test (ACT). Secondary outcomes included quality of life, medication use and healthcare utilization (e.g., emergency department visits).

Results

After 12 months, 323 participants completed follow-up measures (79.2%). Participants in the IC reported a greater mean improvement in the ACT score than participants in the CC (2.3 vs. 1.2; p = 0.02) and 9 of 11 individual asthma control survey items showed non-significant improvements favoring the IC. No differences were observed in medication adherence, number of asthma controller medications or health care utilization.

Conclusion and relevance

Simple and brief online patient reminders improved asthma control among insured patients. Although future studies are needed to understand the mechanism of the improvement, the magnitude of the effect on asthma control was similar to the addition of an additional controller medication. Given the widespread use of the Internet, simple tools such as this may be useful for improving the control of other chronic diseases as well.

Trial registration

This study is registered at clinicaltrials.gov, NCT00921401, “Improving the Quality of Asthma Care Using the Internet”

Antileukotriene Agents Versus Long-Acting Beta-Agonists in Older Adults with Persistent Asthma: A Comparison of Add-On Therapies

OBJECTIVES

To compare the effectiveness and cardiovascular safety of long-acting beta-agonists (LABAs) with those of leukotriene receptor antagonists (LTRAs) as add-on treatments in older adults with asthma already taking inhaled corticosteroids (ICSs).

DESIGN

Retrospective cohort study.

SETTING

Medicare fee-for-service (FFS) claims (2009-10) for a 10% random sample of beneficiaries continuously enrolled in Parts A, B, and D in 2009.

PARTICIPANTS

Medicare beneficiaries aged 66 and older continuously enrolled in FFS Medicare with Part D coverage with a diagnosis of asthma before 2009 treated exclusively with ICSs plus LABAs or ICSs plus LTRAs (N = 14,702).

MEASUREMENTS

The augmented inverse propensity-weighted estimator was used to compare the effect of LABA add-on therapy with that of LTRA add-on therapy on asthma exacerbations requiring inpatient, emergency, or outpatient care and on cardiovascular (CV) events, adjusting for demographic characteristics, comorbidities, and county-level healthcare-access variables.

RESULTS

The primary analysis showed that LTRA add-on treatment was associated with greater odds of asthma-related hospitalizations or emergency department visits (odds ratio (OR) = 1.4, P < .001), as well as outpatient exacerbations requiring oral corticosteroids or antibiotics (OR = 1.41, P < .001) than LABA treatment. LTRA add-on therapy was also less effective in controlling acute symptoms, as indicated by greater use of short-acting beta agonists (rate ratio = 1.58, P < .001). LTRA add-on treatment was associated with lower odds of experiencing a CV event than LABA treatment (OR = 0.86, P = .006).

CONCLUSION

This study provides new evidence specific to older adults to help healthcare providers weigh the risks and benefits of these add-on treatments. Further subgroup analysis is needed to personalize asthma treatments in this high-risk population.

Effects of older age and age of asthma onset on clinical and inflammatory variables in severe refractory asthma

BACKGROUND

Asthma in the elderly as well as asthma of adult-onset has been associated with increased morbidity, but little is known specifically about the effects of age on clinical and inflammatory outcomes in severe refractory asthma. The aims of the study were to examine the effects of age [<65 versus ≥65 years] and age of onset of asthma [childhood-onset, <18 versus adult-onset, ≥18 years] on clinical and inflammatory variables in patients with severe asthma.

METHODS

In 1042 subjects with refractory asthma recruited to the British Thoracic Society Severe Asthma Registry, we compared patient demographics, disease characteristics and biomarkers of inflammation in patients aged <65 years (n = 896) versus ≥65 years (n = 146) and onset at age <18 years (n = 430) versus ≥18 years (n = 526).

RESULTS

Severe asthma patients aged ≥65 years had improved symptom control, better asthma quality of life and in the last year, less emergency visits and rescue oral steroid courses [3 (1-6) versus 5 (2-7), p < 0.001] than severe asthmatics aged <65 years. Blood eosinophils were lower in the elderly group. Patients with severe adult-onset asthma had similar symptom control, lung function and health-care utilization compared to severe childhood-onset asthma. Adult-onset asthmatics had higher blood eosinophils and were less atopic.

CONCLUSIONS

Patients with severe refractory asthma aged ≥65 years exhibit better clinical and health care outcomes and have lower blood eosinophils compared to those aged <65 years. Severe refractory adult-onset asthma is associated with similar levels of asthma control, higher blood eosinophils and less atopy than severe refractory childhood-onset asthma.

A qualitative investigation of the impact of asthma and self-management strategies among older adults

OBJECTIVE

We sought feedback from elderly patients living with asthma to understand their experience with assuming self-management roles for their asthma in order to inform the design and implementation of a primary care-based strategy that could best support their asthma control.

METHODS

We held six focus groups with a total of 31 English- and Spanish-speaking older adults with a current diagnosis of asthma. Focus groups addressed the effect of asthma on patients' lives and self-management strategies. Transcripts were analyzed using constant comparative techniques.

RESULTS

Asthma exerted a consistent effect on patients' physical and psychological well-being. Common barriers to self-care included misuse of controller medications and uncertainty whether shortness of breath, fatigue, and cough were due to their asthma or some other chronic illness. Patients developed coping strategies to continue with daily activities even when experiencing symptoms, but did not recognize attainable asthma quality of life.

CONCLUSIONS

Asthma had a distinct impact on elderly adults' quality of life; due to their longstanding history with this condition, many patients had accepted these symptoms as a "new normal." Developing strategies to reorient patients' perceptions of the possibilities for managing their illness will be critical to the success of asthma self-management support programs specific to older adults.

Challenges in the management of severe allergic asthma in the elderly

Little is known about the features of asthma and allergy in the elderly. A significant number of elderly patients with asthma have uncontrolled and severe asthma. This review aims to provide an analysis of the literature on the assessment and phenotype of severe allergic asthma in the elderly. Gaps and pitfalls in diagnostic and therapeutic approaches, as well as management of severe allergic asthma in the elderly, are also discussed.

Significant predictors of poor quality of life in older asthmatics

BACKGROUND

Morbidity and mortality from asthma are high in older adults and quality of life (QOL) might be lower, although standardized measurements of QOL have not been validated in this population.

OBJECTIVE

To determine predictors of asthma-related QOL in older adults.

METHODS

Allergy and pulmonary outpatients (n = 164) at least 65 years old with an objective diagnosis of asthma completed the Mini-Asthma Quality of Life Questionnaire (mAQLQ). Demographics, medical history, and mean value for daily elemental carbon attributable to traffic, a surrogate for diesel exposure, were obtained. Regression analysis was used to determine predictors of mAQLQ scores.

RESULTS

Total mAQLQ (mean ± SD 5.4 ± 1.1) and symptom, emotional, and activity domain scores were similar to those of younger populations, whereas environmental domain scores (4.4 ± 1.7) appeared lower. Poorer mAQLQ scores were significantly associated with emergency department visits (adjusted β [aβ] = -1.3, where β values indicate the strength and direction of association, P < .0001) and with poorer scores on the Asthma Control Questionnaire (aβ = -0.7, P < .0001). Greater ECAT exposure (aβ = -1.6, P < .02), female sex (aβ = -0.4, P < .006), body mass index of at least 30 kg/m(2) (aβ = -0.4, P < .01), gastroesophageal reflux (aβ = -0.4, P < .01), nonatopic status (aβ = -0.5, P < .002), and asthma onset before 40 years of age (aβ = -0.5, P < .004) were significantly associated with poorer mAQLQ scores.

CONCLUSION

The mAQLQ scores in older adults with stable asthma were similar to those in younger populations and were predictive of other measurements of asthma control, verifying that the mAQLQ is an appropriate tool in older adults with asthma. Traffic pollution exposure was the strongest predictor of poorer asthma-related QOL in older adults with asthma.

Rates and predictors of uncontrolled bronchial asthma in elderly patients from western Romania

Purpose

Bronchial asthma (BA) is a chronic inflammatory disorder of the airways, featuring variable and often reversible airflow limitations. An accurate assessment of BA control is difficult in practice, especially in the elderly, requiring the assessment of several clinical and paraclinical parameters that are influenced not only by asthma, but also by comorbidities. The purpose of this study was to evaluate the predictors of uncontrolled BA in a group of elderly patients from western Romania.

Patients and methods

We retrospectively evaluated 126 elderly patients (aged $ 65 years), who were consecutively evaluated in the Pulmonology Department of Victor Babes Hospital, Timisoara, Romania, between March 2009 and July 2012. We collected demographic data, performed pulmonary function testing and an asthma control test (ACT), and evaluated the level of BA control based on the 2012 Global Initiative for Asthma guidelines. Statistical processing of the data was done using the Epi Info and STATA programs.

Results

In our study group, 36 (29%) patients were men and 90 (71%) were women; their mean age was 74.42±8.32 years (range: 65–85 years). A total of 14.28% of patients were smokers. About 30.15% of patients had an ACT score <19, 54.76% had an ACT score 20–24, and 15.09% had an ACT of 25. Moreover, 59.52% had normal spirometry results. Infectious exacerbations were found in 58.73% of patients. A history of allergies was demonstrated in 48.41% of patients, 34.12% had occupational exposure, and 82.53% of patients were treated with inhaled corticosteroids. Our results showed that 30.15% of patients had uncontrolled BA. We found six predictive factors for uncontrolled BA: infectious exacerbation, occupational exposure, mixed (obstructive and restrictive) ventilatory dysfunction, persistent airway obstruction on spirometry, duration of disease in months, and current smoking status. Infectious exacerbations, persistent airway obstructions, and occupational exposure were the most powerful predictors.

Conclusion

Elderly patients represent an important group that is at risk for developing uncontrolled BA. Predictors may identify those elderly patients with uncontrolled BA and facilitate early medical interventions.

Association between asthma self-management knowledge and asthma control in the elderly

BACKGROUND

Considerable evidence points to the importance of patient education in achieving better asthma control. However, little is known about the effect of older adults' asthma knowledge on asthma control.

OBJECTIVE

To identify the relation between asthma self-management knowledge and short-term asthma control in older adults.

METHODS

The study included 82 patients with asthma undergoing usual asthma care who were interviewed by the same trained allergist. At the same time, the authors conducted an asthma knowledge questionnaire, an Asthma Control Test, skin prick testing, spirometry, and evaluation of inhaler device technique. The Turkish version of the asthma knowledge questionnaire was administered to all participants in face-to-face interviews. The relation between asthma knowledge and asthma control was tested by regression analysis.

RESULTS

The education level was below the secondary level in 79% of patients; 59% of patients were obese; and 44% of patients had mild, 41% had moderate, and 5% had severe persistent asthma. The atopy rate was 21%. The most common sensitization was to Dermatophagoides pteronyssinus. Fifty-two percent of patients had uncontrolled asthma; 22 patients showed proper use of the inhaler device. Forty patients (48%) had limited asthma knowledge. The main source of asthma knowledge was from physicians for 81% of patients. There was no significant association between patients' asthma knowledge and asthma control level (P = .991).

CONCLUSION

Knowledge of asthma was very low in elderly patients and usual asthma care was largely insufficient. These findings suggest that asthma education programs should be developed for older adults based on their education level and clinical asthma characteristics.

Alveolar T-helper type-2 immunity in atopic asthma is associated with poor clinical control

Real-world evaluation studies have shown that many patients with asthma remain symptomatic despite treatment with inhaled corticosteroids (ICSs). As conventional ICSs have poor access to the peripheral airways, the aim of the present paper was to study the relationship between peripheral airway inflammation and clinical control in allergic asthma. Consequently, bronchial and transbronchial biopsies were obtained from patients with poorly controlled asthma [n=12, asthma control test (ACT) score<20], patients with well-controlled asthma (n=12, ACT score≥20) and healthy controls (n=8). Tissue sections were immunostained to assess multiple leucocyte populations. To determine the degree of T-helper type-2 (Th2) immunity, the logarithmic value of the ratio between Th2 cells/mm2 and Th1 cells/mm2 was used as a surrogate score for Th2-skewed immunity. In the bronchi, the leucocyte infiltration pattern and the Th2-score were similar between patients with well-controlled asthma and those with poorly controlled asthma. In contrast, in the alveolar parenchyma, the expression of T-helper cells was significantly higher in patients with poorly controlled asthma than in patients with well-controlled asthma (P<0.01). Furthermore, the alveolar Th2-score was significantly higher in patients with poorly controlled asthma (median 0.4) than in the controlled patients (median -0.10, P<0.05). In addition, in contrast with bronchial Th2-score, the alveolar Th2-score correlated significantly with ACT score (rs=-0.62, P<0.01) in the pooled asthma group. Collectively, our data reveal an alveolar Th2-skewed inflammation, specifically in asthmatic patients who are poorly controlled with ICSs, and suggest that pharmacological targeting of the peripheral airways may be beneficial in this large patient category.

Age is not associated with hospital admission or uncontrolled symptoms of asthma if proper treatment is offered

BACKGROUND

Aging modifies immune response and respiratory physiology. Few studies evaluate the effect of age on asthma. The aim of our study was to evaluate whether age is associated with uncontrolled symptoms and hospital admissions due to asthma in a setting where patients were receiving proper treatment.

METHODS

We enrolled 401 patients with uncontrolled asthma who were inhaled corticosteroid-naive. The follow-up period was 1 year. They received medications for asthma, performed spirometry, a symptoms questionnaire, and all emergency room visits and hospital admissions due to asthma were reported. The primary end point was hospital admission during the follow-up period.

RESULTS

Baseline data demonstrated that subjects >55 years of age had a later onset of asthma and a longer duration of symptoms. Adjusted logistic regression models demonstrated that older age at enrollment did not predict asthma control in the follow-up: hospital admission due to asthma [odds ratio (OR) 1.7 and 95% confidence interval (CI) 0.6-4.7], symptoms score (OR 0.6 and 95% CI 0.3-1.1) and emergency room visits due to asthma (OR 0.9 and 95% CI 0.6-1.3). Older age was associated with worse lung function (OR 1.8 and 95% CI 1.1-3.3).

CONCLUSION

This study allows us to conclude that older age is associated with a later onset of asthma and a longer duration of symptoms. Age does not predict hospital admissions or poor control of asthma symptoms if proper treatment is offered. It does, however, predict worse lung function.

Comorbidities in elderly patients with asthma: Association with control of the disease and concomitant treatment

AIM

The incidence of concomitant conditions increases with age. In elderly patients, the presence of comorbidities has been related to the course and severity of asthma. The aim of the present study was to assess the impact of comorbidities and concomitant treatment on asthma control and severity in older adults.

METHODS

A total of 93 elderly (age >65 years) and 78 younger (age 30-50 years) asthmatic patients were randomly selected from a database including 1755 asthmatics. Evaluation consisted of a questionnaire, spirometry and skin prick testing.

RESULTS

In elderly asthmatics, a higher incidence of chronic comorbidities (mean 8.4 vs 4.7; P < 0.001) and a higher number of prescribed medicines (7.4 vs 4.5, P < 0.001) were observed, but the severity of asthma and the intensity of anti-asthma treatment were similar to that seen in younger patients. Asthma control was not strikingly different between the groups. There was no correlation between the presence of comorbid conditions and asthma control, severity or frequency of exacerbations in older patients. Elderly patients treated with statins had a lower risk of asthma exacerbation (OR 0.39, 95% CI 0.18-0.84, P = 0.017), whereas treatment with proton pump inhibitors was associated with a higher risk of exacerbations in older adults (OR 1.84, 95% CI 1.07-3.18, P = 0.029) and higher disease severity in younger patients (OR 2.49, 95% CI 1.1-5.67, P = 0.029).

CONCLUSION

The higher prevalence of comorbidities observed in elderly asthmatics under specialist care do not seem to be associated with worsened asthma control or severity. However, concomitant medications can significantly affect asthma control in both elderly and younger asthmatics.

Self-management behaviors in older adults with asthma: associations with health literacy

OBJECTIVES

To examine self-management behaviors, including medication adherence and inhaler technique, in older adults with asthma and their association with health literacy.

DESIGN

Observational cohort study.

SETTING

Primary care and pulmonary specialty practices in two tertiary academic medical centers and three federally qualified health centers in New York, New York, and Chicago, Illinois.

PARTICIPANTS

Adults with moderate or severe persistent asthma aged 60 and older (N = 433).

MEASUREMENTS

Outcomes were adherence to asthma controller medications, metered dose inhaler (MDI) and dry powder inhaler (DPI) techniques, having a usual asthma physician, and avoidance of four common triggers. Health literacy was assessed using the Short Test of Functional Health Literacy in Adults.

RESULTS

The mean age was 67, and 36% of participants had marginal or low health literacy. Adherence was low (38%) overall and worse in individuals with low health literacy (22%) than in those with adequate literacy (47%, P < .001) and after adjusting for demographic factors and health status (odds ratio (OR) = 0.48, 95% confidence interval (CI) = 0.31-0.73). Similarly, inhaler technique was poor; only 38% and 54% had good MDI and DPI technique, respectively. Technique was worse in those with low health literacy (MDI technique: OR = 0.57, 95% CI = 0.38-0.85; DPI technique: OR = 0.42, 95% CI = 0.25-0.71). Asthma self-monitoring and avoidance of triggers occurred infrequently but were less consistently associated with low health literacy.

CONCLUSION

Adherence to medications and inhaler technique are poor in older adults with asthma and worse in those with low health literacy. Clinicians should routinely assess controller medication adherence and inhaler technique and use low-literacy communication strategies to support self-management in older adults with asthma.

Asthma characteristics among older adults: using the California health interview survey to examine asthma incidence, morbidity and ethnic differences

OBJECTIVE

The purpose of this study was to examine the incidence, characteristics of asthma morbidity and care, and ethnic differences that exist in older adults with asthma in California.

METHODS

Data were from the 2009 California Health Interview Survey (CHIS). Characteristics of older adults (≥65 years) with and without asthma were compared using population-weighted estimates. Asthma-specific variables were compared among different ethnic groups. Multivariate analyses were preformed to determine factors associated with asthma status, asthma episodes/attacks, asthma symptom frequency and emergency department (ED) visits due to asthma.

RESULTS

Asthma was present in 8.1% of older adults, among which, 67.3% reported taking medication daily for asthma. Asthma symptoms were experienced every day by almost 20%, with over 34% of seniors with asthma having symptoms at least once per week. Despite having a lower frequency of asthma symptoms, Hispanics were 5.31 times more likely to visit the ED due to asthma than were Caucasians.

CONCLUSIONS

The findings from the study showed that older adults with asthma had difficulty with asthma control. We recommend a focus on asthma education so that when symptoms do occur, options are available to avoid costly ED visits. Further research should focus on specific asthma management skills and adherence to asthma treatment regimen among ethnic groups.

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.

Age-related differences in asthma outcomes in the United States, 1988-2006

BACKGROUND

Relatively little is known about the effect of age on asthma outcomes in adults, particularly at a national level.

OBJECTIVE

To investigate age-related differences in asthma outcomes in a nationally representative, longitudinal study.

METHODS

We analyzed data from the Third National Health and Nutrition Examination Survey (1988-1994) with linked mortality files through 2006. Adults with physician-diagnosed asthma were identified and were divided into 2 age groups: younger adults (17-54 years of age) and older adults (55 years or older). The outcome measures were both cross-sectional (health care use, comorbidity, and lung function) and longitudinal (all-cause mortality).

RESULTS

There were an estimated 9,566,000 adults with current asthma. Of these, 73% were younger adults and 27% older adults. Compared with younger adults, older adults had more hospitalizations in the past year, more comorbidities, and poorer lung function (eg, lower forced expiratory volume in 1 second) (P < .05 for all). During a median follow-up of 15 years, significant baseline predictors of higher all-cause mortality included older age (≥55 vs <55 years old: adjusted hazard ratio [HR], 6.77; 95% confidence interval [CI], 3.15-14.54), poor health status (fair and poor vs excellent health status: adjusted HR, 10.07; 95% CI, 3.75-27.01), and vitamin D deficiency (vitamin D level <30 vs ≥50 nmol/L: adjusted HR, 2.19; 95% CI, 1.05-4.58), whereas Mexican American ethnicity (adjusted HR, 0.31; 95% CI, 0.14-0.65) was associated with lower mortality. Controlling for age, asthma was not associated with increased all-cause mortality (adjusted HR, 1.28; 95% CI, 0.99-1.65).

CONCLUSION

Older adults with asthma have a substantial burden of morbidity and increased mortality. The ethnic differences in asthma mortality and the vitamin D-mortality link merit further investigation.

Predictors of asthma control: what can we modify?

PURPOSE OF REVIEW

One strategy to improve asthma control is to identify risk factors for uncontrolled asthma in epidemiologic studies and then consider those risk factors as potential targets for intervention. This article reviews predictors of impairment based on validated tools and predictors of severe asthma exacerbations.

RECENT FINDINGS

Indirectly modifiable risk factors for poor asthma control include older age in adults, lower socioeconomic status, and poor perception of dyspnea. Modifiable risk factors for poor asthma control include allergy triggers, low adherence, comorbidities, absence of specialty care, and various aspects of asthma self-management education.

SUMMARY

Intervention strategies are suggested for predictors that are directly or indirectly modifiable. It is hoped that attention to these factors will improve asthma control and reduce the burden of disease.

Age-dependent deterioration of peak inspiratory flow with two kinds of dry powder corticosteroid inhalers (Diskus and Turbuhaler) and relationships with asthma control

BACKGROUND

Inhaled corticosteroid (ICS) therapy has improved the quality of life (QOL) for many asthmatics and reduced mortality rates associated with asthma. However, some patients do not obtain therapeutic benefit despite satisfactory adherence.

OBJECTIVES

To determine whether asthmatic patients were using ICS devices appropriately, and to clarify relationships between these results and QOL.

SUBJECTS AND METHODS

We studied 100 adult asthmatics, divided into two groups: 50 patients consecutively registered as using Diskus (fluticasone; D-group) and 50 consecutively registered as using Turbuhaler (budesonide; T-group). We measured peak inspiratory flows (PIFs) using the In-Check Dial device. Subjects also completed the Asthma Control Test for evaluation of QOL.

RESULTS

In the D-group, no patients showed PIF below the optimal range (30-90 L/min), whereas 52% of patients had PIF≥91 L/min. In the T-group, 6% of patients showed PIF over the optimal range (60-90 L/min), and 44% had PIF≤59 L/min. When patients in the T-group were required to deliberately make a maximal inhalation, 14% still had PIF≤59 L/min. The proportion of patients with poor control was significantly greater in the T-group than in the D-group. According to univariate logistic regression analyses, low PIF tended to be associated with poor asthma control in the T-group. No significant correlation was found between PIF and age in the D-group, but PIF decreased significantly with age in the T-group.

CONCLUSIONS

Appropriate measures for patients in whom PIF has been judged as lower than optimal include adequate education for inhalation and/or changing to a different inhalation device. These measures should be kept in mind for elderly asthma patients in particular, where appropriate selection of a corticosteroid inhalation device in the early stages of therapy would also be important.

Improving asthma outcomes in large populations

This article summarizes our experience using administrative, survey, and telephone information to define asthma severity, impairment, risk, and quality of care in our large Kaiser Permanente population. Our data suggest that the 2-year Healthcare Effectiveness Data and Information Set definition of persistent asthma is a good surrogate for survey-defined persistent asthma, and thus it would be reasonable to direct asthma population management and quality-of-care assessments at patients with Healthcare Effectiveness Data and Information Set-defined persistent asthma for 2 years in a row. For population management, the numbers of short-acting β-agonist (SABA) canisters dispensed and validated tools on mail or telephone surveys have been used to assess asthma impairment. Algorithms based on pharmacy data (SABA canister and oral corticosteroid dispensings and prior emergency hospital care) have been used to assess the risk domain of asthma control. The asthma medication ratio (controllers divided by controllers plus SABAs) has been shown to be related to improved outcomes and is recommended as an asthma quality-of-care marker. It is hoped that outreach to patients and providers based on these indicators will improve asthma outcomes in patients cared for in individual practices, as well as in large health plans.