Factors Associated with Asthma Control in Primary Care Patients in Spain: The CHAS study

Does asthma-bronchiectasis overlap syndrome (ABOS) really exist?

OBJECTIVE

To analyze the relationship between asthma and bronchiectasis, as well as the necessary conditions that this connection must meet for this group of patients to be considered a special phenotype.

DATA SOURCES

We performed a PubMed search using the MeSH terms "asthma" and "bronchiectasis." The literature research was limited to clinical trials, meta-analyses, randomized controlled trials, cohort studies, and systematic reviews, involving adult patients, published until November 30th, 2022.

STUDY SELECTIONS

Selected papers were initially evaluated by the Authors, to assess their eligibility in contributing to the statements.

RESULTS

The prevalence of bronchiectasis is higher than expected in patients with asthma, particularly in those with more severe disease, and in some patients, between 1.4% and 7% of them, asthma alone could be the cause of bronchiectasis. Both diseases share etiopathogenic mechanisms, such as neutrophilic and eosinophilic inflammation, altered airway microbiota, mucus hypersecretion, allergen sensitization, immune dysfunction, altered microRNA, dysfunctional neutrophilic activity, and variants of the HLA system. Besides that, they also share comorbidities, such as gastroesophageal reflux disease and psychiatric illnesses. The clinical presentation of asthma is very similar to patients with bronchiectasis, which could cause mistakes with diagnoses and delays in being prescribed the correct treatment. The coexistence of asthma and bronchiectasis also poses difficulties for the therapeutic focus.

CONCLUSIONS

The evidence available seems to support that the asthma-bronchiectasis phenotype really exists although longitudinal studies which consistently demonstrate that asthma is the cause of bronchiectasis are still lacking.

Over-prescription of short-acting β2-agonists is associated with poor asthma outcomes: results from the Latin American cohort of the SABINA III study

OBJECTIVE

Short-acting β₂-agonist (SABA) over-reliance is associated with poor asthma outcomes. As part of the SABA Use IN Asthma (SABINA) III study, we assessed SABA prescriptions and clinical outcomes in patients from six Latin American countries.

METHODS

In this cross-sectional study, data on disease characteristics/asthma treatments were collected using electronic case report forms. Patients (aged ≥12 years) were classified by investigator-defined asthma severity (guided by the 2017 Global Initiative for Asthma) and practice type (primary/specialist care). Multivariable regression models analyzed the associations between SABA prescriptions and clinical outcomes.

RESULTS

Data from 1096 patients (mean age, 52.0 years) were analyzed. Most patients were female (70%), had moderate-to-severe asthma (79.4%), and were treated by specialists (87.6%). Asthma was partly controlled/uncontrolled in 61.5% of patients; 47.4% experienced ≥1 severe exacerbation in the previous 12 months. Overall, 39.8% of patients were prescribed ≥3 SABA canisters in the preceding 12 months (considered over-prescription). SABA canisters were purchased over the counter (OTC) by 17.2% of patients, of whom 38.8% purchased ≥3 canisters in the 12 months prior. Of patients who purchased SABA OTC, 73.5% were prescribed ≥3 SABA canisters. Higher SABA prescriptions (vs. 1 - 2 canisters) were associated with an increased incidence rate of severe exacerbations (ranging from 1.31 to 3.08) and lower odds ratios of having at least partly controlled asthma (ranging from 0.63 to 0.15).

CONCLUSIONS

SABA over-prescription was common in Latin America, highlighting the need for urgent collaboration between healthcare providers and policymakers to align clinical practices with the latest evidence-based recommendations to address this public health concern.

Asthma control and its predictors in Ethiopia: Systematic review and meta-analysis

BACKGROUND

Determining the status of asthma control and identifying risk factors for poor asthma control is a key strategy for curbing the negative health impacts and the financial burden of the disease. Therefore, this review was aimed to determine the rate of asthma control and assess the predictors of uncontrolled asthma in Ethiopia.

METHODS

PubMed, Web of Science, and Google Scholar searches were performed using key terms; "asthma, bronchial asthma, control, controlled, uncontrolled and Ethiopia" up to October 16, 2020. University repositories were also searched to retrieve gray literature. The results were presented as a prevalence rate with a 95% confidence interval (CI). Subgroup analysis and meta-regression were performed to identify the sources of heterogeneity in the outcomes.

RESULTS

From 1,388 patients, based on the Global Initiative for Asthma (GINA) symptom control, the rate of the uncontrolled asthma was 45.0% (95% CI 34.0% - 56.0%) with a considerable heterogeneity between the studies; (I2: 94.55, p< 0.001). About 19.0% (95% CI 10.0% - 29.0%); (I2: 96.04, p< 0.001) of the asthma patients had a well-controlled asthma. Moreover, 36.0% (95% CI 22.0% - 50.0%), (I2: 97.11, p< 0.001) of patients had a partly controlled asthma. Similarly, based on the asthma control test (ACT), the rate of well-controlled asthma was 22.0% (95% CI 3% - 42.0%), with considerable heterogeneity between the studies; (I2: 97.75, p< 0.001). The most frequent predictors of uncontrolled asthma were incorrect inhalation techniques, frequent SABA use, moderate/severe persistent asthma, history of exacerbations, presence of comorbidities, use of oral corticosteroids, and irregular follow-up.

CONCLUSION

The rate of uncontrolled asthma in Ethiopia was high. Several factors are associated with uncontrolled asthma. Comprehensive asthma educations at each follow-up visit should be strengthened to minimize the morbidity and the cost of uncontrolled asthma.

Patient perspectives of the influence of severe and non‐severe asthma on their quality of life: A national survey of asthma patients in Spain

Introduction

Little is known about adult asthma patients' perspective of their disease burden. This study aimed to obtain a comprehensive picture of patient needs, evaluate their knowledge, source of information, and perception of the severity of their asthma, and compare these variables between severe (SA) and non‐severe (NSA) asthma patients.

Methods

We conducted an online cross‐sectional survey in Spain among asthma patients aged ≥18 years. A bespoke questionnaire was used to collect sociodemographic data, asthma characteristics, treatments, disease burden, patient's perception of disease severity, and asthma information sources. Patients were classified as SA and NSA according to GINA 2020 treatment steps recommendations. To compare populations, 600 participants (200 SA and 400 NSA) were randomly selected to complete the survey.

Results

Participants were mostly women, mean age >38 years. SA patients underestimated the severity of their asthma; 52% judged it as mild, and only 2% considered their asthma severe. Overall, 50% of NSA and 96% of SA patients had experienced ≥1 exacerbation the previous year (p < 0.001). Fewer asthma exacerbations (SA) and improved quality of life (QoL) (NSA) were the most frequently expected therapy outcomes. NSA patients believe that asthma impacts their daily life (37%) and worsens QoL (34%) to a lesser degree than SA (67% and 59%, respectively; p < 0.001). Patient‐preferred sources of information were specialists (NSA:42%; SA: 38%) and primary care physicians (NSA: 41%; SA: 33%).

Conclusions

Despite the effective therapies currently available, the results of this study still show a significant emotional burden and QoL impairment in patients with severe asthma.

Monoclonal antibody treatment for severe uncontrolled asthma in Spain: analytical map

BACKGROUND

Monoclonal antibodies (mABs) have become available to treat more efficiently patients with severe uncontrolled asthma (SUA). However, the use of mABs is lower than expected given the prevalence of SUA, with significant disparities in the use of these treatments.

OBJECTIVE

To evaluate the proportion of patients with SUA treated with mABs in Spain, and to analyze some of the factors that could determine these prescription patterns.

METHODS

An analysis was performed on the data provided from the Hospitals National Health System (NHS) 2018 catalogue where Chest Diseases Department and a Hospital Pharmacy were available. Random sampling was performed to determine the sample size, stratifying proportionally by geographic area and hospital level. Characteristics of the participating sites, as well as the prescribing of mABs were collected, which included geographic area, hospital levels, prescribing medical specialities, types of clinics, and mABs prescribed.

RESULTS

Data from 90 hospitals were analyzed (Response rate 64.3%). Level 4 hospitals, the Canary Islands geographical area, and the presence of a high complexity Asthma Healthcare Unit (ACU) were associated with a higher probability that the SUA was treated with mABs.

CONCLUSION

The map of the prescribing of mABs for SUA in Spain shows a significant variation by geographic area, hospital level, type of clinic, and the accreditation level of the ACUs. At the current time, there appears to be significant under-prescribing of these treatments.

Effect of pharmacist-led interventions on medication adherence and inhalation technique in adult patients with asthma or COPD: A systematic review and meta-analysis

OBJECTIVE

In patients with asthma and chronic obstructive pulmonary disease (COPD), disease control is still suboptimal-incorrect inhalation technique and medication non-adherence are two important reasons for this outcome. Pharmacists' interventions have been shown to have a positive effect on the clinical outcomes of asthma and COPD. Quantitative assessment of the efficacy of pharmacist-led interventions, mainly on inhalation techniques and medication adherence, is needed. Evidence for different interventions is not totally conclusive, and no results of theory-based adherence promotion interventions for asthma and COPD have been published. The objective of our study is to evaluate the effect of pharmacist-led interventions on asthma and COPD management, focusing mainly on inhalation technique and medication adherence, and whether the content of interventions (categorized based on Information-Motivation-Behavioural skills (IMB) model) affects the effectiveness and whether the IMB model is worthy of clinical promotion and application in adults with asthma or COPD.

METHODS

The PubMed, EMBASE, The Cochrane Library, Web of Science and ClinicalTrials.gov databases were searched for randomized controlled trials that involved pharmacist-led interventions among patients with asthma or COPD. We used database-specific vocabulary (eg, Medical Subject Headings) and free text terms expanding from 'asthma', 'COPD' and 'pharmacist' to identify relevant articles. Two reviewers independently selected the studies, assessed the risk of bias and extracted the data. The meta-analysis was performed in Review Manager 5.3 provided by the Cochrane Collaboration. PROSPERO registration number: CRD42019144793.

RESULTS AND DISCUSSION

Thirteen studies were eligible for qualitative analysis, and 12 studies were included in the meta-analysis. Pharmacist-led interventions showed a positive effect on medication adherence (1.34 [95% CI 1.18-1.53], P < .0001) and inhalation technique (1.85 [95% CI 1.57-2.17], P < .00001) in COPD and asthma patients. In the subgroup meta-analysis, significant medication adherence improvement was found only in COPD patients (1.41 [1.24-1.61], P < .0001). The subgroup meta-analysis also noted that interventions that included all three Information-Motivation-Behavioural skills (IMB) constructs had a significant improvement in medication adherence (1.41 [1.24-1.61], P < .0001). Subgroup meta-analysis conducted between different diseases, different intervention contents, and different measure tools did not significantly change the heterogeneity.

WHAT IS NEW AND CONCLUSION

Pharmacist-led interventions can improve inhalation technique in adult asthma and COPD patients. Significant improvement in medication adherence was found only in COPD patients. The effect among asthmatic patients requires further study. Interventions based on the IMB model may be worthy of clinical promotion and application. More future research is needed to establish solid evidence base for effective interventions and uniform measurement of medication adherence.

Obesity Does Not Increase the Risk of Asthma Readmissions

The relationship between obesity and asthma exacerbations is still under debate. The aim of our work is to analyse the relationship between obesity and hospital re-admissions in asthmatics. A review was retrospectively performed on all hospital admissions of adult patients due to asthma exacerbation occurring in our hospital for 11 years. All those cases with asthma as the first diagnosis in the discharge report were included, or those with asthma as the second diagnosis provided when the first diagnosis was respiratory infection or respiratory failure. Only the first hospital admission of each patient was included in this study. The Odds Ratios of a higher incidence of early/late readmissions due to asthma exacerbation were calculated using a binary logistic regression, using the body mass index (BMI) as independent variable, adjusted for all the variables included in the study. The study included 809 patients with a mean age of 55.6 years, and 65.2% were female. The majority (71.4%) were obese or overweight. No significant relationship was observed in the univariate or multivariate analyses between overweight or obesity and the early or late hospital readmissions due to asthma. Therefore, obesity does not seem to be a determining factor in the risk of asthma exacerbations.

A budget impact analysis of budesonide/formoterol in patients with mild asthma in Egypt

Background: The aim of this study is to estimate the budget impact of budesonide/formoterol fixed dose combination (FDC) vs salbutamol, both used as needed, in mild asthma patients, from the perspective of the Health Insurance Organization (HIO). Methods: A static budget impact model was developed to assess the impact of budesonide/formoterol FDC entry on HIO budget over a 3-year period in Egyptian settings. Direct medical costs, including the costs of asthma medications, exacerbations, and management of side-effects, were obtained from HIO cost data. Population data were obtained from the World Bank and supplemented with local studies, and the rates of exacerbations, adverse effects, and number of sick leave days were elicited from the SYGMA 1 trial. Scenario analyses from a societal perspective and deterministic sensitivity analyses were conducted. Results: The total costs (drug and non-drug costs) for managing mild asthma patients from the HIO perspective were estimated to be EGP8.563 billion before budesonide/formoterol entry compared to EGP5.525 billion post-entry, leading to a total budget savings of EGP3.038 billion after 3 years. This total budget saving included an increase in drug costs (EGP104 million) and a decrease in non-drug costs (EGP3.143 billion). Drug costs were higher in the budesonide/formoterol group than in the salbutamol group, but this cost was offset by reductions in non-drug costs, resulting in a reduction in the total costs of healthcare resources. At the societal level, the total budget savings after including the indirect costs was expected to be EGP5.976 billion after 3 years of budesonide/formoterol entry. Conclusion: Budesonide/formoterol in mild asthma instead of salbutamol produces better patient outcomes and decreases total costs, with increases in drug cost offset by reductions in non-drug costs due to fewer exacerbations. Budesonide/formoterol is a budget saving option for guideline-directed treatment, from the economic perspective of the payer and the health perspective of the patient.

Key factors associated with uncontrolled asthma - the Asthma Control in Latin America Study

Objective: This study aimed to estimate asthma control at specialist treatment centers in four Latin American countries and assess factors influencing poor asthma control.Methods: Patients aged ≥12 years with an asthma diagnosis and asthma medication prescription, followed at outpatient specialist centers in Argentina, Chile, Colombia, and Mexico, were included. The study received all applicable ethical approvals. The Asthma Control Test (ACT) was used to classify patients as having controlled (ACT 20-25) or uncontrolled (ACT ≤19) asthma. Frequency and statistical tests were used to assess the association between hospital admissions/exacerbations/emergency department (ED) visits and uncontrolled asthma; multivariate logistic regression was used to assess the association of uncontrolled asthma with clinical/demographic variables.Results: A total of 594 patients were included. Overall controlled-asthma prevalence was 43.4% (95% confidence interval [CI]: 39.0, 47.4). Patients with uncontrolled asthma were more likely to be women (adjusted odds ratio [aOR]: 1.85; p = 0.003), non-white (aOR: 2.14; p < 0.001), obese (aOR: 1.71; p = 0.036), to have a low monthly family income (aOR: 1.75; p = 0.004), to have severe asthma (aOR:1.59; p = 0.26), and, compared with patients with controlled asthma, to have a higher likelihood of asthma exacerbations (34.5% vs. 15.9%; p < 0.001), hospital admissions (6.9% vs. 3.1%; p = 0.042), and ED visits (34.5% vs. 15.9%; p < 0.001) due to asthma.Conclusions: Even in specialist ambulatory services, fewer than half of patients were classified as having controlled asthma. The proportion of uncontrolled patients varied according to clinical and demographic variables.

Asthma exacerbations: factors related to longer hospital stay

BACKGROUND

Hospital admissions account for a significant part of asthma cost, but with significant differences between geographic areas.

AIMS

The aim of our study is to analyse hospital admissions due to asthma, as well as the factors associated with longer hospital stays.

METHODS

A review was retrospectively carried out on all admissions of patients over 18 years old due to exacerbation of asthma occurring in our hospital between the years 2000 and 2010. The personal characteristics of each patient, the asthma personal history, characteristics of every exacerbation, as well as the treatment before admission and after hospital discharge were recorded.

RESULTS

During the study period, there were 2163 hospital admissions in 1316 patients (mean age 62.6 years; mean hospital stay 11.6 days). The admissions mainly occur in winter, in the 56-75-year age group, and in patients with severe asthma. Female sex, higher comorbidity, a greater number of emergencies due to asthma in the previous year, and baseline treatment with theophylline were independently associated to longer hospital stay.

CONCLUSIONS

The management of asthma in our population seems improvable. There appears to be a need to optimise both the diagnosis and treatment of the disease, and to identify risk factors as important as tobacco habits. As regards exacerbations, the hospital stay and mortality must be significantly reduced.

Follow-up of patients with uncontrolled asthma: clinical features of asthma patients according to the level of control achieved (the COAS study)

Our aim was to study the asthma control achieved in patients with uncontrolled asthma who had received appropriate treatment according to the Global Initiative for Asthma (GINA) 2010 (valid at the time the study was designed), and to analyse the factors associated with a lack of asthma control.This was a multicentre study in routine clinical practice performed in patients with uncontrolled asthma according to GINA 2010. At visit 1, we recorded demographics, asthma characteristics and spirometry. We assessed asthma control using GINA 2010 criteria and the Asthma Control Test (ACT). Treatment was optimised according to GINA 2010. At visit 2, 3 months later, we reassessed spirometry, asthma control and factors associated with failure to achieve control.We recruited 1299 patients with uncontrolled asthma (mean age 46.5±17.3 years, 60.7% women, 25.8% obese). The mean percentage of predicted forced expiratory volume in 1 s was 76.4±12.8% and the mean post-bronchodilator increase was 14.9±6.8%. We observed poor agreement between ACT and GINA 2010 when evaluating asthma control (kappa = -0.151). At visit 2, asthma in 71.2% of patients was still not fully controlled. Patients whose asthma remained uncontrolled were older, had a higher body mass index, greater disease severity, longer disease evolution and worse lung function.After treatment optimisation, most patients did not achieve optimal control according to GINA 2010. Risk factors for failure to achieve asthma control were time of disease evolution, severity, age, weight and lung function impairment (excluded in the GINA 2014).

Asthma control in elderly asthmatics. An Italian observational study

BACKGROUND

The exponential increase of individuals aged >64 yrs is expected to impact the burden of asthma. We aimed to explore the level of asthma control in elderly subjects, and factors influencing it.

METHODS

A multicenter observational study was performed on consecutive patients >64 years old with a documented physician-diagnosis of asthma. Sixteen Italian centers were involved in this 6-month project.

FINDINGS

A total of 350 patients were enrolled in the study. More than one-third of elderly asthmatic patients, despite receiving GINA step 3-4 antiasthmatic therapy, had an Asthma Control Test score ≤19, with a quarter experiencing at least one severe asthma exacerbation in the previous year. Twenty-nine percent of patients (n = 101) were classified as having Asthma-COPD Overlap Syndrome (ACOS) due to the presence of chronic bronchitis and/or CO lung diffusion impairment. This subgroup of patients had lower mean Asthma Control Test scores and more exacerbations compared to the asthmatic patients (18 ± 4 compared to 20 ± 4, p < 0.01, and 43% compared to 18%, p < 0.01, respectively). Modified Medical Research Council dyspnea mMRC scores and airway obstruction, assessed on the basis of a FEV(1)/FVC ratio below the lower limit of normal, were more severe in ACOS than in asthma, without any difference in responses to salbutamol. In a multivariate analysis, the mMRC dyspnea score, FEV(1)% of predicted and the coexistence of COPD were the only variables to enter the model.

INTERPRETATION

Our results highlight the need to specifically evaluate the coexistence of features of COPD in elderly asthmatics, a factor that worsens asthma control.

Predictors of perceived asthma control among patients managed in primary care clinics

OBJECTIVE

To estimate the extent to which symptom status, physical activity, beliefs about medications, self-efficacy, emotional status, and healthcare utilization predict perceived asthma control over a period of 16 months among a primary care population.

METHODS

The current study is a secondary analysis of data from a longitudinal study that examined health outcomes of asthma among participants recruited from primary care clinics. Path analysis, based on the Wilson and Cleary and International Classification of Functioning, Disability and Health frameworks, was used to estimate the predictors of perceived asthma control.

RESULTS

The path analysis identified initial perceived asthma control asthma (β = 0.43, p < 0.0001), symptoms (β = 0.35, p < 0.0001), physical activity (β = 0.27, p < 0.0001), and self-efficacy (β = 0.29, p < 0.0001) as significant predictors of perceived asthma control (total effects, i.e., direct and indirect), while emotional status (β = 0.08, p = 0.03) was a significant indirect predictor through physical activity. The model explained 24 % of the variance of perceived asthma control. Overall, the model fits the data well (χ (2) = 6.65, df = 6, p value = 0.35, root-mean-square error of approximation = 0.02, Comparative Fit Index = 0.999, and weighted root-mean-square residual = 0.27).

CONCLUSION

Initial perceived asthma control, current symptoms status, physical activity, and self-efficacy can be used to identify individuals likely to have good perceived asthma control in the future. Emotional status also has an impact on perceived asthma control mediated through physical activity and should be considered when planning patient management. Identifying these predictors is important to help the care team tailor interventions that will allow individuals to optimally manage their asthma, to prevent exacerbations, to prevent other respiratory-related chronic disease, and to maximize quality of life.

Effect of lifestyle on asthma control in Japanese patients: importance of periodical exercise and raw vegetable diet

Background

The avoidance of inhaled allergens or tobacco smoke has been known to have favorable effects on asthma control. However, it remains unclear whether other lifestyle-related factors are also related to asthma control. Therefore, a comprehensive study to examine the associations between various lifestyle factors and asthma control was conducted in Japanese asthmatic patients.

Methods

The study subjects included 437 stable asthmatic patients recruited from our outpatient clinic over a one-year period. A written, informed consent was obtained from each participant. Asthma control was assessed using the asthma control test (ACT), and a structured questionnaire was administered to obtain information regarding lifestyle factors, including tobacco smoking, alcohol drinking, physical exercise, and diet. Both bivariate and multivariate analyses were conducted.

Results

The proportions of total control (ACT = 25), well controlled (ACT = 20-24), and poorly controlled (ACT < 20) were 27.5%, 48.1%, and 24.5%, respectively. The proportions of patients in the asthma treatment steps as measured by Global Initiative for Asthma 2007 in step 1, step 2, step 3, step 4, and step 5 were 5.5%, 17.4%, 7.6%, 60.2%, and 9.4%, respectively. Body mass index, direct tobacco smoking status and alcohol drinking were not associated with asthma control. On the other hand, younger age (< 65 years old), passive smoking, periodical exercise (> 3 metabolic equivalents-h/week), and raw vegetable intake (> 5 units/week) were significantly associated with good asthma control by bivariate analysis. Younger age, periodical exercise, and raw vegetable intake were significantly associated with good asthma control by multiple linear regression analysis.

Conclusions

Periodical exercise and raw vegetable intake are associated with good asthma control in Japanese patients.

[Relationship between comorbidity and asthma control]

INTRODUCTION

The coexistence of potentially aggravating processes is common in asthmatics, particularly in patients with difficult control. The primary aim of this study is to ascertain whether comorbidity id more common in uncontrolled patients. As a secondary aim, we propose to evaluate the correlation between the asthma control test (ACT) and the fraction of exhaled nitric oxide (FENO).

PATIENT AND METHODS

A prospective, observational study comparing the function and clinical picture of two groups of asthmatics: controlled (ACT≥20) and uncontrolled (ACT<20). They were all assessed for, smoking, rhinosinusitis, obesity, anxiety, depression, vocal cord dysfunction, gastro-oesophageal reflux (GORD), allergic bronchopulmonary aspergillosis (ABPA), COPD and nasal polyps.

RESULTS

A total of 50 patients with controlled asthma and 102 with suboptimal control were included. The patients with an ACT≥20 had better lung function, less variation in PEF, less bronchial hyper-reactivity and lower FENO values. Comorbidities were found in 95% of the controlled asthmatics and in 97% of the uncontrolled. Only the presence of nasal polyps, GORD and ABPA was more frequent in the uncontrolled group. However, the simultaneous presence of 3 or more comorbidity factors was significantly more frequent in patients with sub-optimal control (P=0.01). There was no significant correlation between the FENO and the ACT values (rho=-0.08; P=0.32).

CONCLUSIONS

Aggravating comorbidities are more common in patients with sub-optimal control. There was no correlation between the FENO and the ACT values.