Direct costs of asthma in Brazil: a comparison between controlled and uncontrolled asthmatic patients

Asthma in the Brazilian Unified Health Care System: an epidemiological analysis from 2008 to 2021

OBJECTIVE

To analyze the number of hospitalizations, the length of hospital stay, and mortality due to asthma, as well as the costs to the Unified Health Care System in Brazil between 2008 and 2021.

METHODS

This was a cross-sectional epidemiological study using data from the Information Technology Department of the Brazilian Unified Health Care System. Proportional hospitalization and death rates were estimated per 100,000 population by age, microregion, and year.

RESULTS

The number of hospitalizations and deaths due to asthma decreased from 2008 to 2021 (205,392 vs. 55,009 and 822 vs. 327, respectively). In addition, a between-sex difference was observed in asthma-related hospitalizations in 2008, and more men were hospitalized in 2021 (51.8%). Asthma mortality rates were similar for both sexes (50.0% each) in 2008, and a slight increase was observed in women's deaths in 2021 (52.9%). Even so, approximately one death/day and more than 55,000 hospitalizations were observed yearly, with a mean length of hospital stay of three days. Additionally, the Southeast region allocated more financial resources to asthma-related hospitalizations.

CONCLUSIONS

Our results showed that the number of deaths and hospitalizations due to asthma substantially declined during the study period.

Epidemiology of patients with asthma in Korea: Analysis of the NHISS database 2006-2015

Background

There has been a concerning increase in the prevalence and socioeconomic burden of asthma in Korea. Korea's National Health Insurance System (NHIS) covers insurance payment and claims management for all Koreans. Using National Health Insurance Sharing Service (NHISS) claims data. This study aimed to investigate patterns of healthcare utilization and direct cost in patients with asthma over a 10-year period.

Methods

In this retrospective population-based study, we examined NHISS claims records between July 2005 and June 2016 and investigated healthcare utilization among patients with asthma based on age group and severity of disease (non-severe asthma [NSA] and severe asthma [SA]).

Results

From 2006 to 2015, the total number of patients with asthma in Korea steadily increased from 743 968 to 2 286 309, with a corresponding increase in prevalence from 1.62% to 4.74%. The proportion of patients with SA decreased from 3.16% in 2006 to 1.56% in 2015; the proportion was consistently higher in men than in women. In addition, patients with SA had a higher cost per outpatient visit than patients with NSA, and the number of outpatient visits per year increased. The inhaled corticosteroid (ICS) prescription rate among patients with asthma decreased from 22.9% in 2006 to 15.7% in 2015. Furthermore, for a period of 10 years, more than 40% of patients with SA have been prescribed short-acting β-2 agonists (SABAs).

Conclusions

Although patients with SA comprised a small proportion of patients with asthma, they incurred greater medical costs per person. The pharmaceutical prescription pattern indicated a lack of ICS-based prescriptions and frequent SABA prescriptions.

The economic impact of asthma on private healthcare system in Brazil: Economic impact of asthma in Brazil

To assess healthcare resource utilization and costs of patients with asthma in Brazilian Supplementary Healthcare System, focusing on hospitalization data. Retrospective cohort study, using data from an administrative database of a private company (Orizon). Patients aged ≥ 12 years with at least one record of emergency visit/hospitalization in the database with the ICD-10 J45 between January/2010 and June/2015 were included and followed until June/2016, death or inactivation of health plan. Sociodemographic characteristics, emergency visit and hospital admission per patient per year (exacerbation rate), physician visit with a procedure, exams, length of hospitalization (with/without intensive care unit (ICU)), and in-hospital treatments were assessed. A total of 54,568 patients were included in this analysis. Regarding resource utilization, emergency visit and hospital admission rates of 0.34 and 0.04 per person-year were observed, respectively. Mean length of hospital stay were 8.82 (SD = 36.48), 5.24 (SD = 19.06) and 19.53 (63.89) days for hospitalizations in general, without and with ICU, respectively. An exacerbation rate of 0.36 per person year was observed with a mean cost per episode of 3178 Brazilian Real (BRL) (SD = 31,667). Mean cost related to emergency department visits was estimated at 293 BRL (SD = 328). Hospitalization costs were stratified by the need of ICU and values observed were of 9307 BRL (SD = 18,979) without ICU, and 75,252 BRL (SD = 174,248) with ICU need. Asthma exacerbations may cost ~75,000 BRL for an ICU-dependent event in the Supplementary Healthcare System. To improve disease control may reduce disease burden for both healthcare system and patients.

Determinants of uncontrolled asthma among adult asthmatic patients on follow-up at chest clinic of Jimma medical center: unmatched case-control study

OBJECTIVE

To identify the determinants of uncontrolled asthma among asthmatic patients on follow-up at Jimma Medical Center.

METHODS

Institution-based case-control study was conducted on asthmatic patients who were on follow-up at the chest clinic of Jimma University Medical (JMC) from March to May 2020. A total of 59 cases and 118 controls (1: 2 ratio) were included in the study. Cases and controls were defined based on asthma control test (ACT) scores where those who had scores of ≤19 and above 19 were defined to be cases and controls, respectively.

RESULTS

Age of the patients [AOR: 2.78; 95% CI: 1.14, 6.81], age of the cases' residential houses [AOR: 3.65; 95% CI: 1.30, 10.28], presence of pets within the houses [AOR: 2.78; 95% CI: 1.29, 5.96], having rhinitis [AOR: 3.34; 95% CI: 1.17, 9.52], past asthma exacerbation [AOR: 2.38, 95% CI: 1.05, 5.40], non-adherence to treatment [AOR: 2.81; 95% CI: 1.30, 6.08] and smoking [AOR: 7.09; 95% CI: 1.84, 27.33] were found to be determinants of uncontrolled asthma.

CONCLUSIONS

Uncontrolled asthma results from multiple sociodemographic, environmental, clinical, and behavioral factors. Therefore, patients should be counseled on avoiding pets, maintenance of houses, adherence to treatment, quitting smoking, and early treatment-seeking for rhinitis and asthma exacerbation to improve asthma control comprehensively.

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.

Cost-benefit impact of free asthma medication provision for the pediatric population

BACKGROUND

Asthma is a common chronic disease in childhood, resulting in high costs for health care systems and society. As of June 2011, the Brazilian Unified Health System (SUS) provides free asthma medications for the population. This study evaluated the impact of this program on asthma admissions in the population aged 1-19 years. In addition, a cost-benefit analysis compared data before and after the introduction of the program.

METHODS

This descriptive study was based on information from SUS Information Technology Department (DATASUS). Admission rates and costs of patients aged 1-19 years with diagnosed asthma were compared before (2008-2010) and after (2012-2017) the provision of free inhaled corticosteroid.

RESULTS

The asthma admission rate reduced by 28.4% when comparing the two periods (OR 0.71; 95% CI 0.64-0.79). Children aged 1-4 years had a 27.3% reduction in asthma admissions (OR 0.72; 95% CI 0.63-0.82), while those aged 15-19 years had a 39.65% decrease (OR 0.59; 95% CI 0.37-0.95). Asthma admission costs decreased when comparing the two periods (OR 0.68; 95% CI 0.62-0.74). After the introduction of the program, mean cost savings reached US $27,865,905.08 in children aged 1-4 years and US $21,350,660.63 in those aged 5-19 years.

CONCLUSION

The economic burden of pediatric asthma on Brazil's public health care system is significant. From 2012 to 2015, free provision of inhaled corticosteroid was cost-effective in all age groups. In 2017, no cost-benefit effect was observed in this population, but asthma admission rate decreased.

Distance Education to Improve the Quality of Asthma Treatment in Primary Health Care

Objective: The mere dissemination of standard care recommendations has been insufficient to improve clinical results in patients with asthma. The objective of the present study was to evaluate the clinical effectiveness of a multifaceted asthma distance education for primary care providers. Methods: Cluster randomized controlled trial. Full primary care teams were included if they had access to telehealth support and free basic asthma treatment. Before randomization, selected teams indicated asthma patients between 5-45 years old for inclusion. The intervention group received three interactive online sessions, printed educational material, reminders, booklet for patients, and frequent stimulus to use consulting services. The control group received no intervention. Symptomfree days per two weeks was the primary result. Controlled asthma, unscheduled asthma doctor visits, and preventive inhaled corticosteroid use were the secondary results. Six months after intervention, the results were compared with baseline data using generalized estimating equations for repeated measures and clustering effect. Results: Were enrolled 71 primary care teams and 443 individuals. Most patients (60.3%) were female, and 44% were younger than 12 years old. The attendance of interactive sessions by the teams was 50%. The odds ratio (OR) for additional symptom-free day was 1.31 (95%CI 0.61-2.82; p=0.49). For the secondary results, the results were: controlled asthma OR 1.29 (95%CI 0.89-1.87; p=0.18); unscheduled asthma doctor visits OR 0.81 (95%CI 0.60-1.10; p=0.17); and preventive inhaled corticosteroid use OR 1.02 (95%CI 0.71-1.47; p=0.91). Conclusions: Multifaceted distance education in asthma care for primary care providers was not effective to improve patients’ results. Telemedicine needs to deal with significant obstacles in professional education. ClinicalTrials.gov registry: NCT01595971. 

Air Quality Standards and Extreme Ozone Events in the São Paulo Megacity

Ozone events in South America might be triggered by increasing air temperatures and dry conditions, leading to vulnerable population exposure. The current air quality standards and attention levels in São Paulo state, Brazil, are 40% higher and 25% higher, respectively, than the limits recommended by the World Health Organization (WHO). We simulated an extreme ozone event in the São Paulo megacity using the Weather Research and Forecast/Chemistry model during an extreme event characterized by positive anomalies of air temperature and solar radiation. Results were evaluated using the different air quality limits from São Paulo state and the WHO, also with socioeconomic vulnerability data from the Brazilian census and cost analysis for the public health system from the extreme episode. More than 3 million people in vulnerability conditions, such as low income and families with an above-average percentage of children, live in areas where ozone concentrations exceeded the attention levels of the WHO during the episode, which is ignored by the lenient SP state environmental laws. WHO air quality guidelines must be adopted urgently in developing nations in order to provide a more accurate basis for cost analysis and population exposure, particularly the for vulnerable population groups.

Estimated cost of asthma in outpatient treatment: a real-world study

OBJECTIVE

To estimate the cost of diagnosis and treatment of asthma.

METHODS

We used the perspective of society. We sequentially included for 12 months, in 2011-2012, 117 individuals over five years of age who were treated for asthma in the Pneumology and Allergy-Immunology Services of the Piquet Carneiro Polyclinic, Universidade do Estado do Rio de Janeiro. All of them were interviewed twice with a six-month interval for data collection, covering 12 months. The cost units were identified and valued according to defined methods. We carried out a sensitivity analysis and applied statistical methods with a significance level of 5% for cost comparisons between subgroups.

RESULTS

The study consisted of 108 patients, and 73.8% of them were women. Median age was 49.5 years. Rhinitis was present in 83.3% of the individuals, and more than half were overweight or obese. Mean family income was U$915.90/month (SD = 879.12). Most workers and students had absenteeism related to asthma. Total annual mean cost was U$1,291.20/patient (SD = 1,298.57). The cost related to isolated asthma was U$1,155.43/patient-year (SD = 1,305.58). Obese, severe, and uncontrolled asthmatic patients had higher costs than non-obese, non-severe, and controlled asthmatics, respectively. Severity and control level were independently associated with higher cost (p = 0.001 and 0.000, respectively). The direct cost accounted for 82.3% of the estimated total cost. The cost of medications for asthma accounted for 62.2% of the direct costs of asthma.

CONCLUSIONS

Asthma medications, environmental control measures, and long-term health leaves had the greatest potential impact on total cost variation. The results are an estimate of the cost of treating asthma at a secondary level in the Brazilian Unified Health System, assuming that the treatment used represents the ideal approach to the disease.

Cost-effectiveness of omalizumab add-on to standard-of-care therapy in patients with uncontrolled severe allergic asthma in a Brazilian healthcare setting

OBJECTIVE

Omalizumab add-on to standard-of-care therapy has proven to be efficacious in severe asthma patients for whom exacerbations cannot be controlled otherwise. Moreover, evidence from different healthcare settings suggests reduced healthcare resource utilization with omalizumab. Based on these findings, this study aimed to assess the cost-effectiveness of the addition of omalizumab to standard-of-care therapy in patients with uncontrolled severe allergic asthma in a Brazilian healthcare setting.

METHODS

A previously published Markov model was adapted using Brazil-specific unit costs to compare the costs and outcomes of the addition of omalizumab to standard-of-care therapy vs standard-of-care therapy alone. Model inputs were largely based on the eXpeRience study. Costs and health outcomes were calculated for lifetime-years and were annually discounted at 5%. Both one-way and probabilistic sensitivity analyses were performed.

RESULTS

An additional cost of R$280,400 for 5.20 additional quality-adjusted life-years was estimated with the addition of omalizumab to standard-of-care therapy, resulting in an incremental cost-effectiveness ratio of R$53,890. One-way sensitivity analysis indicated that discount rates, standard-of-care therapy exacerbation rates, and exacerbation-related mortality rates had the largest impact on incremental cost-effectiveness ratios.

LIMITATIONS

Assumptions of lifetime treatment adherence and rate of future exacerbations, independent of previous events, might affect the findings. The lack of Brazilian patients in the eXpeRience study may affect the findings, although sample size and baseline characteristics suggest that the modeled population closely resembles Brazilian severe allergic asthma patients.

CONCLUSION

Results indicate that omalizumab as an add-on therapy is more cost-effective than standard-of-care therapy alone for Brazilian patients with uncontrolled severe allergic asthma, based on the World Health Organization's cost-effectiveness threshold of up to 3-times the gross domestic product.

Pharmacists' perspectives of the current status of pediatric asthma management in the U.S. community pharmacy setting

Objective To explore community pharmacists' continuing education, counseling and communication practices, attitudes and barriers in relation to pediatric asthma management. Setting Community pharmacies in Michigan, United States. Methods Between July and September 2015 a convenience sample of community pharmacists was recruited from southeastern Michigan and asked to complete a structured, self-reported questionnaire. The questionnaire elucidated information on 4 general domains relating to pharmacists' pediatric asthma management including: (1) guidelines and continuing education (CE); (2) counseling and medicines; (3) communication and self-management practices; (4) attitudes and barriers to practice. Regression analyses were conducted to determine predictors towards pharmacists' confidence/frequency of use of communication/counseling strategies. Main outcome measure Confidence in counseling skills around asthma. Results 105 pharmacists completed the study questionnaire. Fifty-four percent of pharmacists reported participating in asthma related CE in the past year. Over 70% of pharmacists reported confidence in general communication skills, while a lower portion reported confidence in engaging in higher order self-management activities that involved tailoring the regimen (58%), decision-making (50%) and setting short-term (47%) and long-term goals (47%) with the patient and caregiver for managing asthma at home. Pharmacists who reported greater use of recommended communication/self-management strategies were more likely to report confidence in implementing these communication/self-management strategies when counseling caregivers and children with asthma [Beta (B) Estimate 0.58 SE (0.08), p < 0.001]. Female pharmacists [B Estimate -2.23 SE (1.01), p < 0.05] and those who reported beliefs around doctors being the sole provider of asthma education [B Estimate -1.00 SE (0.32), p < 0.01] were less likely to report confidence in implementing communication/self-management strategies. Conclusion A pharmacists' confidence may influence their ability to implement recommended self-management counseling strategies. This study showed that community pharmacists are confident in general communication. However pharmacists are reporting lower confidence levels in counseling on higher order self-management strategies with patients. More appropriate and targeted continuing education programs for pharmacists around asthma self-management education are recommended.

Schistosoma mansoni antigens alter activation markers and cytokine profile in lymphocytes of patients with asthma

Asthma is a chronic disease characterized by airway inflammation, obstruction and hyperresponsiveness. Severe asthma affects a small proportion of subjects but results in most of the morbidity, costs and mortality associated with the disease. Studies have suggested that Schistosoma mansoni infection reduces the severity of asthma and prevent atopy.

OBJECTIVE

We evaluated the ability of S. mansoni antigens, Sm29 and Sm29TSP-2 to modulate lymphocyte activation status in response to the allergen of the mite Dermatophagoides pteronyssinus (Der p1) in cell cultures of individuals with asthma.

METHODS

Thirty four patients were enrolled in this study: seventeen patients with severe asthma (SA group), seventeen patients with mild asthma (MA group) and six controls with no asthma. Peripheral blood mononuclear cells (PBMC) were obtained and stimulated with Sm29 and Sm29TSP-2 in the presence or absence of Der p1. The expression of surface markers and cytokines on lymphocytes was evaluated by flow cytometry and the levels of IL-10 in the culture supernatant were determined by ELISA.

RESULTS

The addition of Sm29 and Sm29TSP-2 antigens to PBMC cultures from both groups of subjects with asthma stimulated with Der p1 reduced the frequency of CD4⁺CD25^low cells whereas and increased frequency of CD4⁺CD25^high population was observed compared to unstimulated cultures. Moreover, cultures stimulated with Sm29TSP-2 showed a reduction in the frequency of T cells expressing CD69, IFN-γ, TNF and TGF-β in the MA group and an increase in the frequency of CD4⁺TSLPR⁺ T cells in the SA group. The addition of Sm29 to the cultures reduced the frequency of CD4⁺CD69⁺ and CD4⁺IL-5⁺ T cells in all asthmatic groups, and reduced the frequency of CD4⁺ T cells expressing IL-13 in the MA group. The cultures stimulated with Sm29 and Sm29TSP-2 showed an increase in the level of IL-10 in the supernatants.

CONCLUSION

These results suggest that the addition of Sm29 and Sm29TSP-2 to the cells cultures from subjects with asthma reduced cell activation markers and altered the cytokine production pattern in a way that can potentialy control the inflammatory response associated with asthma.

Particularities of allergy in the Tropics

Allergic diseases are distributed worldwide and their risk factors and triggers vary according to geographical and socioeconomic conditions. Allergies are frequent in the Tropics but aspects of their prevalence, natural history, risk factors, sensitizers and triggers are not well defined and some are expected to be different from those in temperate zone countries. The aim of this review is to investigate if allergic diseases in the Tropics have particularities that deserve special attention for research and clinical practice. Such information will help to form a better understanding of the pathogenesis, diagnosis and management of allergic diseases in the Tropics. As expected, we found particularities in the Tropics that merit further study because they strongly affect the natural history of common allergic diseases; most of them related to climate conditions that favor permanent exposure to mite allergens, helminth infections and stinging insects. In addition, we detected several unmet needs in important areas which should be investigated and solved by collaborative efforts led by the emergent research groups on allergy from tropical countries.

The effect of internalization and other psychologic factors on the remission and severity of wheeze in children

BACKGROUND

Asthma prevalence in Latin America is high and continues to increase. There is evidence that the psychologic characteristics of the child are associated with greater asthma morbidity. This study aimed to investigate the independent effect of internalizing/externalizing problems on two asthma/wheeze outcomes: (i) remission and (ii) progression to severity on Latin American children with mild asthma symptoms at baseline.

METHODS

This was a prospective study in a cohort of 371 asthmatic children living in a poor urban area in Salvador, Brazil. The psychologic characteristics of the child were assessed using the Child Behavior Checklist (CBCL), and wheezing was defined using the ISAAC questionnaire at the start and end of follow-up. A multiple logistic regression model with random effects was used to examine the association between the psychologic components and both outcomes.

RESULTS

Remission of symptoms of wheeze was observed among 229 (61.73%) children. Remission was 56% lower among children with internalizing problems (OR = 0.54, 95% CI 0.33-0.87, p = 0.01). In addition, we found that 19 (8.76%) of the children acquired severe symptoms during follow-up and there was strong evidence of the effect of internalizing problems in increasing the risk of progression to severe wheeze symptoms (OR = 4.03, 95% CI 1.39-11.70, p = 0.01).

CONCLUSIONS

Children with internalizing problems but not externalizing had less remission of wheezing, and a higher risk of acquiring severe symptoms. These results highlight the importance of psychologic care for children with asthma, to improve the prognosis of this condition.

Cost of severe asthma in Brazil-systematic review

INTRODUCTION

Severe asthma is characterized by frequent exacerbations, symptoms limiting daily activities and nocturnal symptoms. It requires the continuous use of medications, at high doses, and, sometimes, continuous use of oral corticosteroids, representing a significant burden to health system and society. This systematic review sought to address economic data related to severe asthma in Brazil.

METHOD

In June 2014, electronic searches were conducted to identify relevant publications. Quality criteria were developed and applied to each selected study. In order to compare results across the selected studies, costs were refined to an annual basis, grouped according to the study perspective, inflated and converted to 2014 USD.

RESULTS

Cost analyses from the Brazilian public health system perspective were derived from two studies and showed an average annual hospital cost per patient of 135 USD and 733 USD, respectively. From the family perspective, average annual direct costs per patient varied from 764 USD to 929 USD.

CONCLUSION

Hospitalizations and medications seem to be the most important resources funded by the Brazilian public health system and by patients and their families. Although further studies are necessary, as information on cost of this disease is scarce in Brazil, these findings suggest that there is a potential room for improving severe asthma care among Brazilian patients.

Burden of asthma among inner-city children from Southern Brazil

OBJECTIVE

To assess the impact of asthma in a population of inner-city Brazilian children.

METHODS

In a cross-sectional study, we selected children with asthma and healthy controls from public schools (8-16 years) from a capital city of Southern Brazil. Divided into three phases, questionnaires were administered, assessing lung function, body mass index and allergic sensitization.

RESULTS

From 2500 children initially included in the study (48.4% males; mean age of 11.42 ± 2.32 years), asthma prevalence was detected in 28.6% (715/2500). The disease was not controlled in 42.7% (305/715) of the children, with 7.6% of hospitalization rate. School absenteeism (at least one day of missing school because of asthma) and sedentary behavior were high (57.1 and 67.2%, respectively), with 47.9% of subjects requiring oral steroids in the previous year, and physical well-being significantly lower than controls, directly interfering with quality of life, and therefore in the daily activities of these students. Moreover, 38% of the parents admitted to being non-adherent to treatment with their children and 31.1 and 53.6%, respectively, believed that rescue medication and exercise might be harmful.

CONCLUSIONS

The burden of asthma in Brazilian children seems to be substantial. New international guidelines with a special focus in developing countries settings, with more pragmatic approaches, should be a priority for discussion and implementation actions.

Temporal trends in the prevalence of asthma and rhinoconjunctivitis in adolescents

OBJECTIVE

To analyze the temporal trend of asthma and rhinoconjunctivitis prevalences as well as their symptoms in adolescents.

METHODS

Two cross-sectional studies were conducted using the same methodology and questionnaire as was used for adolescents aged 12 to 14 years in the Brazilian city of Florianopolis, SC, Southern Brazil. Based on the international protocol of the International Study of Asthma and Allergies in Childhood (ISAAC) study, adolescents were evaluated in 2001 and 3,150 in 2012. The schools included in this study were the same as in the 2001 study. These schools were randomly selected after stratification by network (public and private) and geographic location. The total average percentage variation was estimated for the prevalence of asthma and rhinoconjunctivitis and their symptoms.

RESULTS

The prevalence of reported asthma was 10.9% in 2001 and 14.8% in 2012, with an average variation of 2.8% in the period. The highest average variation in the period was observed among female adolescents (4.1%). In parallel a significant increase occurred in reported physician-diagnosed asthma, 7.3% in 2001 and 11,1% in 2012, with an annual variation of 4.5%. The largest increases in reported physician-diagnosed asthma were seen in female (5.9%) and male (4.5%) public school pupils. In addition, a significant increase in reported rhinoconjunctivitis occurred, with the average variation in the period being 5.2%. Reports of severe asthma symptoms remained unchanged during the period, while the annual variation for reported current wheezing (-1.3%) and wheezing during exercise (-1.2%) decreased.

CONCLUSIONS

The results showed a significant increase in the annual average variation for asthma and rhinoconjunctivitis prevalence during the 2001 to 2012 period.

[Clinical evolution and nutritional status in asthmatic children and adolescents enrolled in Primary Health Care]

Objective:

To evaluate the clinical evolution and the association between nutritional status and severity of asthma in children and adolescents enrolled in Primary Health Care.

Methods:

A retrospective cohort study of 219 asthmatic patients (3-17 years old) enrolled in Primary Care Services (PCSs) in Embu das Artes (SP), from 2007 to 2011. Secondary data: gender, age, diagnosis of asthma severity, other atopic diseases, family history of atopy, and body mass index. To evaluate the clinical outcome of asthma, data were collected on number of asthma exacerbations, number of emergency room consultations and doses of inhaled corticosteroids at follow-up visits in the 6th and 12th months. The statistical analysis included chi-square and Kappa agreement index, with 5% set as the significance level.

Results:

50.5% of patients started wheezing before the age of 2 years, 99.5% had allergic rhinitis and 65.2% had a positive family history of atopy. Regarding severity, intermittent asthma was more frequent (51.6%) and, in relation to nutritional status, 65.8% of patients had normal weight. There was no association between nutritional status and asthma severity (p =0.409). After 1 year of follow-up, 25.2% of patients showed reduction in exacerbations and emergency room consultations, and 16.2% reduced the amount of inhaled corticosteroids.

Conclusions:

The monitoring of asthmatic patients in Primary Care Services showed improvement in clinical outcome, with a decreased number of exacerbations, emergency room consultations and doses of inhaled corticosteroids. No association between nutritional status and asthma severity was observed in this study.

Level of asthma control and its impact on activities of daily living in asthma patients in Brazil

OBJECTIVE:

To evaluate the impact of asthma on activities of daily living and on health status in patients with controlled, partially controlled, or uncontrolled asthma in Brazil.

METHODS:

We used data related to 400 patients in four Brazilian cities (São Paulo, Rio de Janeiro, Salvador, and Curitiba), obtained in a survey conducted throughout Latin America in 2011. All study subjects were > 12 years of age and completed a standardized questionnaire in face-to-face interviews. The questions addressed asthma control, hospitalizations, emergency room visits, and school/work absenteeism, as well as the impact of asthma on the quality of life, sleep, and leisure. The level of asthma control was determined in accordance with the Global Initiative for Asthma criteria.

RESULTS:

Among the 400 respondents, asthma was controlled in 37 (9.3%), partially controlled in 226 (56.5%), and uncontrolled in 137 (34.2%). The numbers of patients with uncontrolled or partially controlled asthma who visited the emergency room, who were hospitalized, and who missed school/work were higher than were those of patients with controlled asthma (p = 0.001, p = 0.05, and p = 0.01, respectively). Among those with uncontrolled asthma, the impact of the disease on activities of daily living, sleep, social activities, and normal physical exertion was greater than it was among those with controlled or partially controlled asthma (p < 0.001).

CONCLUSIONS:

In Brazil, asthma treatment should be monitored more closely in order to increase treatment adherence and, consequently, the level of asthma control, which can improve patient quality of life and minimize the negative impact of the disease.

Treatment of asthma exacerbations with the human-powered nebuliser: a randomised parallel-group clinical trial

Background:

Nebulisers aid the treatment of respiratory diseases, including asthma, but they require electricity and are often cost-prohibitive for low- and middle-income countries.

Aims:

The aim of this study was to compare a low-cost, human-powered nebuliser compressor with an electric nebuliser compressor for the treatment of mild to moderate asthma exacerbations in adults and children.

Methods:

This was a non-blinded, parallel-group, equivalence study, with 110 subjects between 6 and 65 years of age, conducted in the emergency department of a district hospital in Ilopango, El Salvador. Participants were assigned by random allocation to receive a 2.5-mg dose of salbutamol from the experimental human-powered nebuliser or the electric nebuliser control. All assigned participants completed treatment and were included in analysis. The study was not blinded as this was clinically unfeasible; however, data analysis was blinded.

Results:

The mean improvement in peak flow of the experimental and control groups was 37.5 (95% confidence interval (CI) 26.7–48.2) l/min and 38.7 (95% CI, 26.1–51.3) l/min, respectively, with a mean difference of 1.3 (95% CI, −15.1 to 17.7) l/min. The mean improvement in percent-expected peak flow for the experimental and control groups was 12.3% (95% CI, 9.1–15.5%) and 13.8% (95% CI, 9.8–17.9%), respectively, with a mean difference of 1.5% (95% CI, −3.6 to 6.6%).

Conclusions:

The human-powered nebuliser compressor is equivalent to a standard nebuliser compressor for the treatment of mild-to-moderate asthma. (Funded by the Opus Dean’s Fund, Marquette University College of Engineering; ClinicalTrials.gov NCT01795742.)

Asthma and the socio-economic reality in Brazil

BACKGROUND

Asthma is a prevalent disease that is considered a health problem worldwide. The aim of this study was to analyze the clinical and socioeconomic characteristics of a cohort of asthmatics receiving specialized outpatient treatment in a tertiary/teaching public hospital in Brazil.

METHODS

Persistent asthmatics older than 5 years old were consecutively included. They received clinical treatment at 3- to 4-month intervals and were interviewed 2 times at 6-month intervals over a 12-month observation period. The data were collected directly from the patients or their parents by 2 researchers who did not participate in their clinical care. The primary variables were age, gender, education level, monthly family income, place of residence, number of lost days of school or work, BMI, the severity and control level of asthma, the number of scheduled and non-scheduled visits and hospitalization days and the best peak-flow measurement.

RESULTS

Of the 117 participants, 108 completed the study. Of the participants, 73.8% were women, and 25.0% lived outside the county. Of those who lived within the county, 60.1% lived in areas far from the health care unit. The majority (83.3%) had associated rhinitis, and more than 50.0% were overweight or obese, in whom the prevalence of severe asthma was greater (p = 0.001). The median monthly income was US$ 536.58 and was greater among the patients with controlled asthma (p = 0.005 and p = 0.01 at the start and the end of the study, respectively). In the initial evaluation, 16 participants had severe asthma, and in the final evaluation, 8 out of 21 patients with uncontrolled asthma had improved. Three-quarters of the students and half of the workers had missed days of school or work, respectively. The asthmatic population in this study had medium to low socioeconomic status in Brazil and socioeconomic status was associated with overweigth/obesity and with poor control of asthma.

CONCLUSION

Asthma has a great impact on absenteeism in Brazil. Lower monthly family income and body weight above the ideal level were associated with greater severity and worse control of asthma.

The Asthma Control Scoring System: translation and cross-cultural adaptation for use in Brazil

OBJECTIVE

The translation and cross-cultural adaptation of a specific scoring instrument for the comprehensive control of asthma, the Asthma Control Scoring System (ACSS), for use in Brazil.

METHODS

The protocol included ten steps: acquisition of written permission from the author of the ACSS; translation of the instrument to Brazilian Portuguese, carried out by three separate translators; analysis and comparison of the three versions by a review committee; literal back-translation to English; review and harmonization of the back-translation; acquisition of the approval of the original author; review of the translation by specialists; cognitive debriefing: test of clarity to, understanding by, and acceptance of the target population (evaluation of the translation by 10 health care workers); second cognitive debriefing: review of the revised version by a second group of health care workers; and reconciliation and preparation of the final version by the review committee.

RESULTS

The Brazilian Portuguese-language version of the ACSS showed clarity, understandability, and acceptability. The instrument was considered to be comprehensive because it includes the clinical manifestations of asthma, as well as the functional and inflammatory aspects of the disease.

CONCLUSIONS

With the use of this careful methodology in the translation and cross-cultural adaptation of the ACSS, we have ensured its cultural adequacy for Brazil. The use of this instrument could facilitate future studies on asthma control.

Perceptions about self-management among people with severe asthma

AIM

The purpose of this study was to explore the perceptions about self-management among people who were being followed up in a severe asthma clinic by asthma specialists for confirmed, overall severe asthma. Such insight informs how best to tailor programs for this difficult to treat patient population.

METHOD

In-depth tape-recorded interviews of eight adults with severe asthma were transcribed and analyzed for salient themes using content analysis.

RESULTS

To self-manage their illness, over time participants sought asthma information from a variety of sources that they often viewed as inadequate due to lack of scope and or plain language. The most valued sources of asthma information were encountered after referral to an asthma specialist and were health professionals and a pulmonary rehabilitation program.

CONCLUSION

There is a need to examine the content of asthma information sources for their relevance to and influence on the behavior of patients with severe asthma.

Evaluation of diagnostic criteria for severe asthma described in a public health directive regulating the free distribution of medications for the maintenance treatment of asthma

OBJECTIVE

To evaluate the capacity of the criteria described in Complementary Directive SAS/MS 12, issued on November 12, 2002, to identify patients with severe asthma, describing and comparing clinical, functional and treatment data of such patients.

METHODS

This was a nested case-control study using a structured database for adult asthma outpatients. We defined cases as asthma patients who met the inclusion criteria described in the directive, defining controls as those who did not. We collected and compared data related to the following: demographic characteristics; history of asthma; medications in use; comorbidities; history of tobacco use; number of exacerbations within the last 12 months, asthma-related hospitalizations and intensive care unit admissions within the last 12 months; spirometry; and sputum cytology.

RESULTS

The case and control groups consisted of 29 and 31 patients, respectively. The number of asthma exacerbations and emergence room visits within the last 12 months, as well as the number of patients that received at least one pulse of oral corticosteroids, was significantly higher in the case group than in the control group. In addition, prebronchodilator FVC was lower among the cases than among the controls. Furthermore, cytology revealed that eosinophil counts were significantly higher in the induced sputum of cases than in that of controls.

CONCLUSIONS

The criteria described in the directive are suited to stratifying patients with severe asthma.