The management of asthma: a case-scenario-based survey of family physicians and pulmonary specialists

Prescribed therapy for asthma: therapeutic ratios and outcomes

Background

Inhaled corticosteroids (ICS) are the cornerstone of asthma therapy. The ICS-to-total-asthma-medication ratios, calculated from claims data, indicate potentially risky disease management in asthma. Our aim was to assess the utility of ICS-to-total-asthma-medication ratios from primary care electronic medical records (EMRs) in detecting patients at risk of asthma exacerbation, as approached by prescription of oral corticosteroids and/or antibiotics.

Methods

Retrospective cohort studies were identified, using the Health Improvement Network general practice database (THIN, United Kingdom) and the Cegedim Longitudinal Patient Data (France). We selected asthma patients aged 16–40 years, with ≥ 4 prescriptions for asthma medications in 2007 and ≥ 1 prescription in 2008. For each country, three groups were defined according to ratio value in 2008: 0% (non-ICS users), <50% (low-ICS-ratio group) and ≥50% (high-ICS-ratio group). Outcomes were marker of asthma exacerbations: systemic corticosteroids and antibiotics. They were compared between groups in each country.

Results

Among 38,637 British and 4,587 French patients, higher numbers of prescriptions per patient of systemic corticosteroids, antibiotics and total asthma medications were observed in the low-ICS-ratio groups compared to other groups (p < 0.0001 for each outcome in both countries). Likewise, low-ICS-ratio patients had more medical contacts (p < 0.0001 in both countries), suggesting poorly controlled asthma. ICS-treated patients had lower risks of receiving systemic corticosteroids in 2008 in the high-ICS-ratio group, compared to the low-ICS-ratio group: RR = 0.54, 95%CI = [0.50-0.57] and RR = 0.78, 95%CI = [0.67-0.91] in the UK and France, respectively.

Conclusions

Patients with high ICS-to-total-asthma-medication ratios presented fewer asthma-related outcomes. The low ICS-to-total-asthma-medication ratio calculated with EMRs data reflects insufficient prescribing of ICS relative to all asthma medications, which may lead to deteriorated asthma control.

Prescription of antibiotics and anxiolytics/hypnotics to asthmatic patients in general practice: a cross-sectional study based on French and Italian prescribing data

Background

Asthma is often poorly controlled and guidelines are often inadequately followed in medical practice. In particular, the prescription of non-asthma-specific drugs can affect the quality of care. The goal of this study was to measure the frequency of the prescription of antibiotics and anxiolytics/hypnotics to asthmatic patients and to look for associations between sex or age and the prescription of these drugs.

Methods

A cross-sectional study was conducted using computerised medical records from French and Italian general practitioners’ networks. Patients were selected according to criteria adapted from the HEDIS (Healthcare Effectiveness Data and Information Set) criteria. The outcome measure was the number of antibiotics or anxiolytics/hypnotics prescriptions per patient in 1 year. Parallel multivariate models were developed.

Results

The final sample included 3,093 French patients (mean age 27.6 years, 49.7% women) and 3,872 Italian patients (mean age 29.1 years, 48.7% women). In the univariate analysis, the French patients were prescribed fewer antibiotics than the Italian patients (37.1% vs. 42.2%, p < 0.00001) but more anxiolytics/hypnotics (17.8% vs. 6.9%, p < 0.0001). In the multivariate models, the female patients were more likely to receive antibiotics (odds ratio: 1.5 [1.3–1.7]) and anxiolytics/hypnotics (odds ratio: 1.8 [1.5–2.1]).

Conclusions

The prescription of antibiotics and anxiolytics/hypnotics to asthmatic patients is frequent, especially in women. Asthma guidelines should address this issue by referring to other guidelines covering the prescription of non-asthma-specific drugs, and alternative non-pharmacological interventions should be considered.

[Deliberate interruptions and changes of dose of inhaled corticosteroids by asthma patients: "a community pharmacy study"]

BACKGROUND

Adherence to inhaled corticosteroids (ICS) remains a major issue for asthma management, even among patients receiving a regular prescription from their doctor. The frequency of deliberate interruption of ICS, and of spontaneous changes of dose, were studied in a population of asthma patients recruited in community pharmacies.

METHODS

Asthma patients (aged 18-50) recruited in community pharmacies reported in self-administered questionnaires their spontaneous interruptions and changes of doses of ICS during the past 3 months. The characteristics of patients who interrupted their therapy or who modified the dose were compared with other patients.

RESULTS

The studied population included 252 patients (mean age 35 year-old, females: 59%), of whom 62% had inadequately controlled asthma. Among these patients, 25% had interrupted ICS therapy during the past 3 months, while 21% spontaneously changed the dose. The most reported reason for interrupting ICS was the cessation of symptoms (50%). In multivariate analysis, interrupting ICS was mainly associated with inadequate asthma control (OR=3.1, 95% CI 1.5-6.4), while the strongest association with changing ICS doses was the patients' perception of asthma as a concern in their lives (OR=3.2, 95% CI 1.2-8.4).

CONCLUSION

These results underline a poor understanding of the purpose of ICS therapy by patients. They also highlight the need of therapeutic education to improve the management of the disease.

Dispensing of antibiotics, antitussives and mucolytics to asthma patients: a pharmacy-based observational survey

BACKGROUND

Antibiotics, antitussives and mucolytics are commonly used in asthma, despite limited evidence for their effectiveness. The correlates of use for these medication classes in asthma were identified.

METHODS

Asthma patients aged 18-50 who were regular customers of pharmacies were included in an observational study. Patients completed a questionnaire, which was complemented by computerised pharmacy records of previously dispensed medications. Users of each drug class were compared to non-users in terms of demographics, asthma characteristics and management.

RESULTS

Among 886 patients (mean age: 37; 55% females), 63.2%, 55.8% and 27.2%, respectively, were users of antibiotics, mucolytics and antitussives during the previous 12 months. In multivariate analysis, dispensing of >2 units of oral corticosteroids was the major correlate of receiving antibiotics (OR=5.47; 95% CI=[3.00-9.97]), mucolytics (OR=3.93; 95% CI=[2.38-6.50]) and antitussives (OR=1.86; 95% CI=[1.18-2.94]). Compared to well-controlled patients, the probability of receiving antibiotics was significantly higher for poorly controlled patients (OR=2.01; 95% CI=[1.28-3.15]).

CONCLUSIONS

Our results suggest that these drugs are mainly used during asthma exacerbations. A better understanding of the use of co-medication in asthma is required.

[Primary care physicians' and patients' degree of satisfaction with a new respiratory medicine health care program]

BACKGROUND

No ideal model for coordinating primary care and specialized respiratory medicine has been established.

OBJECTIVE

To evaluate primary care physicians' and patients' degree of satisfaction with a new program for coordinating respiratory medicine and primary care.

METHOD

A questionnaire survey of the level of satisfaction with a program combining consultation and direct patient care. The study was carried out at a primary care facility whose staff comprised 31 general practitioners. The respiratory medicine staff consisted of one physician and two nurses from the reference hospital. A questionnaire to determine the physicians' and patients' satisfaction with the program asked for a) overall evaluation on a scale of 0 to 10; b) evaluation on a scale naming five levels from "very bad" to "very good", and c) comparison of the new program with previous ones.

RESULTS

One thousand one hundred seventy patients were seen in 12 months; 663 (57%) received a first visit, 400 (34%) received a second visit, and 107 (9%) received emergency care. The level of satisfaction was 7.8 (1.2) among physicians and 8.7 (1.5) among patients (p = 0.030); 97% of the physicians and 94% of the patients described the program as "very good" or "good". According to 100% of the physicians and 64% of the patients, the new program was better than the old one (p = 0.110).

CONCLUSIONS

The coordinated care plan proposed is accepted by most physicians and patients and uses primary respiratory medicine resources more efficiently.