The relationship between asthma, asthma control and economic outcomes in the United States

Impact of sex on severe asthma: a cross-sectional retrospective analysis of UK primary and specialist care

INTRODUCTION

After puberty, females are more likely to develop asthma and in a more severe form than males. The associations between asthma and sex are complex with multiple intrinsic and external factors.

AIM

To evaluate the sex differences in the characteristics and treatment of patients with severe asthma (SA) in a real-world setting.

METHODS

Demographic, clinical and treatment characteristics for patients with SA in the UK Severe Asthma Registry (UKSAR) and Optimum Patient Care Research Database (OPCRD) were retrospectively analysed by sex using univariable and multivariable logistic regression analyses adjusted for year, age and hospital/practice.

RESULTS

3679 (60.9% female) patients from UKSAR and 18 369 patients (67.9% female) from OPCRD with SA were included. Females were more likely to be symptomatic with increased Asthma Control Questionnaire-6 (UKSAR adjusted OR (aOR) 1.14, 95% CI 1.09 to 1.18) and Royal College of Physicians-3 Question scores (OPCRD aOR 1.29, 95% CI 1.13 to 1.47). However, they had a higher forced expiratory volume in 1 second per cent (FEV1%) predicted (UKSAR 68.7% vs 64.8%, p<0.001) with no significant difference in peak expiratory flow. Type 2 biomarkers IgE (UKSAR 129 IU/mL vs 208 IU/mL, p<0.001) and FeNO (UKSAR 36ppb vs 46ppb, p<0.001) were lower in females with no significant difference in blood eosinophils or biological therapy. Females were less likely to be on maintenance oral corticosteroids (UKSAR aOR 0.86, 95% CI 0.75 to 0.99) but more likely to be obese (UKSAR aOR 1.67, 95% CI 145 to 1.93; OPCRD SA aOR 1.46, 95% CI 1.34 to 1.58).

CONCLUSIONS

Females had increased symptoms and were more likely to be obese despite higher FEV1% predicted and lower type 2 biomarkers with consistent and clinically important differences across both datasets.

The economic burden of asthma prior to death: a nationwide descriptive study

Background

In addition to the clinical burden, asthma is responsible for a high economic burden. However, little is known about the economic burden of asthma prior to death.

Objective

We performed an economic analysis to describe the costs during 12 and 24 months prior to asthma death between 2013 and 2017 in France.

Methods

An observational cohort study was established using the French national health insurance database. Direct medical and non-medical costs, as well as costs related to absence from the workplace, were included in the analysis.

Results

In total, 3,829 patients were included in the final analysis. Over 24 and 12 months prior to death, total medical costs per patient were €27,542 [26,545-28,641] and €16,815 [16,164-17,545], respectively. Total medical costs clearly increased over 24 months prior to death. Over 12 months prior to death, costs increased significantly according to age categories, with mean total costs of €8,592, €15,038, and €17,845, respectively, for the categories <18 years old, 18-75 years old, and 75+ years old (p < 0.0001). Over 12 months prior to death, costs were statistically higher in patients with a dispensation of six or more SABA canisters compared to those with a dispensation of five or less canisters (p < 0.0001). In multivariate analysis, comorbidities, hospital as location of death, and dispensation of 12 or more canisters of SABA per year are independent factors of the highest costs.

Conclusion

To conclude, the economic burden of asthma death is high and increases with time, age, and SABA dispensation.

Real-World Study of Single-Inhaler Triple Therapy with Fluticasone Furoate/Umeclidinium/Vilanterol on Asthma Control in the US

Purpose

Real-world asthma control data among patients initiating fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) are limited. This study assessed rescue medication use and asthma-related exacerbations in patients with asthma before and after initiating single-inhaler FF/UMEC/VI using administrative claims data.

Patients and Methods

This retrospective, pre-post cohort study analyzed data from the IQVIA PharMetrics Plus database (September 18, 2016‒March 31, 2020). Patients aged ≥18 years that had ≥1 dispensing of single-inhaler FF/UMEC/VI 100/62.5/25 mcg (first dispensing = index date), ≥12 months of continuous health insurance enrollment prior to (pre-treatment) and following (post-treatment) FF/UMEC/VI initiation and ≥1 diagnosis of asthma during the pre-treatment period or on the index date were included. The primary endpoint was the number of oral corticosteroid (OCS) dispensings per patient per year during pre- and post-treatment periods. Secondary endpoints included asthma-related exacerbation rates and short-acting β2-agonist (SABA) use. Comparisons between pre- and post-treatment periods were made using risk and rate ratios.

Results

Overall, 890 patients with asthma initiating treatment with FF/UMEC/VI were included. The most recently dispensed controller medications prior to FF/UMEC/VI initiation were inhaled corticosteroids/long-acting β2-agonists (33.5%) and leukotriene modifiers (33.0%). Patients had a 29% reduction in the number of OCS dispensings (rate ratio [95% confidence interval (CI)]: 0.71 [0.65, 0.77], P < 0.001) during post-treatment versus pre-treatment, with a 23% reduction in the proportion of patients with ≥1 OCS dispensing post-treatment (risk ratio [95% CI]: 0.77 [0.73, 0.82], P < 0.001). Significant reductions in rates (rate ratio [95% CI]) of asthma-related exacerbations (0.59 [0.52, 0.67], P < 0.001) and SABA use (0.80 [0.74, 0.86], P < 0.001) were also observed.

Conclusion

In this real-world study, patients with asthma had significantly lower OCS use, asthma-related exacerbations, and SABA use following treatment initiation with FF/UMEC/VI compared with their pre-treatment period. These results suggest better asthma control following initiation of FF/UMEC/VI in a routine clinical practice setting.

BALB/c and C57BL/6 mice differ in oxidant and antioxidant responses in innate and adaptive immune cells in an asthma model induced by cockroach allergens

Asthma is a complex and heterogenous disease affected by a multitude of factors. Several phenotypes of asthma exist which are influenced by various molecular mechanisms that include presence of antioxidant and oxidant enzymes in different immune cells such as dendritic cells (DCs), alveolar macrophages (AMs), neutrophils, and T cells. Close interaction between epithelial cells and dendritic cells initiates complex pathogenesis of asthma followed by involvement of other innate and adaptive immune cells. In chronic phase of the disease, these immune cells support each other in amplification of airway inflammation where oxidant-antioxidant balance is known to be an important contributing factor. Genetic variability in antioxidant response may influence the development of airway inflammation, however it has not been studied in mice yet. The two most studied mice strains, i.e. BALB/c and C57BL/6 are reported to have dissimilar airway responses to the same allergens due to their genetic makeup. In this investigation, we explored whether these strains had any differences in pulmonary oxidant-antioxidant system (Nrf2, SOD2, iNOS, HO-1, nitrotyrosine) in different immune cells (DCs, AMs, neutrophils, T cells), airway inflammation (presence of eosinophils and/or neutrophils) and mucus production in response to repeated cockroach allergen extract (CE) mouse model of asthma. Our data show that C57BL/6 mice had better induction of antioxidant system than BALB/c mice. Consequently, iNOS/nitrotyrosine levels were much exaggerated in BALB/c than C57BL/6 mice. As a result, BALB/c mice developed mixed granulocytic airway inflammation, whereas C57BL/6 developed mostly eosinophilic airway inflammation. Our data suggest that an exaggerated oxidant generation along with a weak antioxidant induction in response to a natural allergen on a susceptible genetic background may determine development of severe asthma phenotype such as mixed granulocyte inflammation.

The Association of Medicaid expansion with prescription drug utilization and expenditure among low-income participants with asthma

OBJECTIVE

This study estimated the association between the 2014 Medicaid expansion and asthma-related prescription drug utilization and expenditures among low-income adult participants with asthma, including those with uncontrolled asthma, in the United States.

METHODS

In this national analysis, using a pooled dataset from 2007-2018 Medical Expenditure Panel Surveys (MEPS), regression discontinuity (D-RD) analyses estimated the association between Medicaid expansion and utilization of and expenditures for asthma-related prescription drugs among participants with asthma aged 26-64 with incomes below vs. at/above 138% of the federal poverty level (FPL). A sub-sample analysis was also conducted among participants with uncontrolled asthma. Utilization and expenditure outcomes were estimated using two-part models with logit as the first part and generalized linear models as the second part.

RESULTS

Utilization of and total cost for asthma-related prescription drugs increased by 1.89 fills (p < 0.001) and $306.59 (p < 0.001) among participants with asthma with income below 138% FPL after Medicaid expansion. The utilization and total cost of both short-acting bronchodilators and inhaled corticosteroids (ICSs) increased after Medicaid expansion among participants with asthma with incomes below 138% FPL. Among participants with uncontrolled asthma with incomes below 138% FPL, utilization and expenditures increased after Medicaid expansion for all asthma-related prescription drugs and short-acting bronchodilators.

CONCLUSION

Medicaid expansion was associated with increased utilization of and total expenditures for both quick-relief and preventive asthma medications among all low-income participants with asthma, but not with utilization of preventive medications among those with uncontrolled asthma.

CD200Fc limits dendritic cell and B-cell activation during chronic allergen exposures

Allergic asthma is a chronic inflammatory disease characterized by Th2, conventional dendritic cell, and B-cell activation. In addition to excessive inflammation, asthma pathogenesis includes dysregulation of anti-inflammatory pathways, such as the CD200/CD200R pathway. Thus, we investigated whether a CD200R agonist, CD200Fc, could disrupt the inflammatory cascade in chronic allergic asthma pathogenesis using a mice model of experimental asthma. Mice were exposed to house dust mites for 5 wk, and CD200Fc treatment was initiated after chronic inflammation was established (starting on week 4). We demonstrate that chronic house dust mite exposure altered CD200 and CD200R expression on lung immune cell populations, including upregulation of CD200 on alveolar macrophages and reduced expression of CD200 on conventional dendritic cells. CD200Fc treatment does not change bronchoalveolar cellular infiltration, but it attenuates B-cell activation and skews the circulating immunoglobulin profile toward IgG2a. This is accompanied by reduced activation of conventional dendritic cells, including lower expression of CD40, especially on conventional dendritic cell subset 2 CD200R+. Furthermore, we confirm that CD200Fc can directly modulate conventional dendritic cell activation in vitro using bone marrow-derived dendritic cells. Thus, the CD200/CD200R pathway is dysregulated during chronic asthma pathogenesis, and the CD200R agonist modulates B-cell and dendritic cell activation but, in our chronic model, is not sufficient to alter inflammation measured in bronchoalveolar lavage.

Cost-Effectiveness of Mepolizumab Add-On in the Treatment of Severe Eosinophilic Asthma in Chile

OBJECTIVE

Asthma is one of the 4 leading causes of death worldwide. Severe asthma is associated with poor quality of life, decreased life expectancy, and higher health resources consumption such as the use of oral corticosteroids (OCSs). This study aimed to assess the cost-effectiveness of mepolizumab as an add-on compared with the standard care of the Chilean public health system (combined inhaled corticosteroid therapy and a long-acting beta-agonist, short-acting beta-agonist, and OCS).

MATERIALS AND METHODS

A Markov model was adapted to represent the day-to-day of patients with severe asthma over a lifetime horizon. Deterministic and probabilistic sensitivity analyses were performed to account for the second-order uncertainty of the model. In addition, a risk subgroup analysis was conducted to evaluate the cost-effectiveness of mepolizumab across different risk populations.

RESULTS

Mepolizumab produces more benefits than standard of care alone (1 additional quality-adjusted life-year, a decrease of OCS usage, an approximated 11 avoided exacerbations) but it cannot be considered cost-effective in the light of the Chilean threshold (incremental cost-effectiveness ratio: US dollars [USD] 105 967/quality-adjusted life-year vs USD 14 896). Despite this, cost-effectiveness increases in specific subgroups, with an incremental cost-effectiveness ratio of USD 44 819 in patients with eosinophil count ≥ 300 cell/mcL and exacerbation history of at least 4 exacerbations in the past year.

CONCLUSION

Mepolizumab cannot be considered a cost-effective strategy for the Chilean health system. Nevertheless, price discount in specific subgroups improves its cost-effectiveness profile significantly and may offer opportunities for access to specific subgroups.

Healthcare expenditure and its socio-demographic and clinical predictors in Australians with poorly controlled asthma

INTRODUCTION

Asthma has substantial and increasing health and economic burden worldwide. This study aimed to estimate healthcare expenditure and determine the factors that increase expenditure in Australians with poorly controlled asthma.

METHODS

Individuals ≥18 years of age with poorly controlled asthma, as determined by a score ≥1.5 on the Asthma Control Questionnaire, were included in the study. Healthcare utilization costs from medical services and medications were estimated over an average follow-up of 12 months from administratively linked data: the Medicare Benefits Schedule and Pharmaceutical Benefits Scheme. A generalized linear model with gamma distribution and log link was used to predict participants' key baseline characteristics associated with variations in healthcare costs.

RESULTS

A total of 341 participants recruited through community pharmacies were included. The mean (standard deviation, SD) age of participants was 56.6 (SD 17.6) years, and approximately 71% were females. The adjusted average monthly healthcare expenditure per participant was $AU386 (95% CI: 336, 436). On top of the average monthly costs, an incremental expenditure was found for each year increase in age ($AU4; 95% CI: 0.78, 7), being unemployed ($AU201; 95% CI: 91, 311), one unit change in worsening quality of life ($AU35; 95% CI: 9, 61) and being diagnosed with depression and anxiety ($AU171; 95% CI: 36, 306).

CONCLUSIONS

In a cohort of Australian patients, characterized by poor asthma control and co-morbidities individuals impose substantial economic burden in terms of Medicare funded medical services and medications. Programs addressing strategies to improve the quality of life and manage co-morbid anxiety and depression and encourage asthma patients' engagement in clinically tolerable jobs, may result in significant cost savings to the health system.

The impact of Medicaid expansion on asthma-related health care services utilization and expenditure

OBJECTIVE

The purpose of this study was to examine the effect of Medicaid expansion on asthma-related health care services utilization and expenditures among low-income adult patients with asthma aged 26-64.

METHODS

Using a pooled dataset from 2007 to 2018 Medical Expenditures Panel Surveys (MEPS), we implemented a multivariate difference-in-differences analysis, which compared changes in utilization and expenditures for asthma-related health care services among adult patients with asthma with income below 133% Federal Poverty Level (FPL) vs. above 133%-400% FPL, before and after Medicaid expansion in 2014. We used negative binomial models to analyze utilization outcomes. Expenditures were estimated using two-part models with logit as the first part and generalized linear models as the second part. Estimates were weighted for the complex multi-stage sampling design of MEPS.

RESULTS

Medicaid expansion was associated with increases in both utilization and expenditures for asthma-related prescription drugs among low-income patients with asthma, by 1.8 prescription fills (p < 0.05) and $233 (p < 0.05) per year, respectively. No statistically significant association was detected for other asthma-related health care services.

CONCLUSION

Medicaid expansion led to an increase in accessibility of prescription drugs among low-income asthma patients, but had no effect on other asthma-related health care services.

Adherence and Persistence to Single-Inhaler Versus Multiple-Inhaler Triple Therapy for Asthma Management

BACKGROUND

Treatment guidelines recommend triple therapy for patients with asthma who remain uncontrolled on inhaled corticosteroid/long-acting β₂-agonist therapy. Previously, triple therapy was only available via multiple inhalers. Single-inhaler fluticasone furoate/umeclidinium/vilanterol (FF/UMEC/VI) is approved as maintenance treatment for asthma; however, real-world information on adherence and persistence is limited.

OBJECTIVE

To compare adherence and persistence among adult patients with asthma receiving single-inhaler FF/UMEC/VI versus multiple-inhaler triple therapy (MITT) in the United States.

METHODS

This retrospective cohort study used IQVIA PharMetrics Plus data to evaluate patients with asthma who initiated once-daily FF/UMEC/VI 100/62.5/25 mcg or MITT between September 18, 2017, and September 30, 2019. Inverse probability weighting and multivariable regression adjusted for differences in characteristics between the FF/UMEC/VI and MITT cohorts. Adherence was assessed using proportion of days covered (PDC) and proportion of patients achieving PDC ≥0.8 and PDC ≥0.5. Non-persistence was identified as a >45-day gap between fills.

RESULTS

The study included 1396 FF/UMEC/VI and 5115 MITT initiators. Three months after initiation, FF/UMEC/VI users had significantly higher mean PDC versus MITT users (0.68 vs 0.59; P < .001) and 31% more likely to be adherent (PDC ≥0.8; 40.6% vs 31.3%; adjusted risk ratio [95% confidence interval (CI)]: 1.31 [1.13-1.54]; P < .001). Similar patterns were observed at 6 and 12 months post initiation. In addition, FF/UMEC/VI users were 49% more likely to persist at 12 months than MITT users (25.9% vs 15.1%, adjusted hazard ratio [95% CI]: 1.49 [1.39-1.60]; P < .001).

CONCLUSIONS

Patients with asthma initiating triple therapy with FF/UMEC/VI had significantly better adherence and persistence compared with MITT initiators.

Suboptimal Control of Asthma Among Diverse Patients: A US Mixed Methods Focus Group Study

Purpose

The US National Asthma Education and Prevention Program updates and Global Initiative for Asthma report encourage considering the patient perspective to improve asthma control. The objective of the present study was to collect data about the perceptions, experiences, and concerns of adult patients and caregivers of children with asthma regarding rescue, maintenance, and oral corticosteroid treatments.

Patients and Methods

In-person focus groups were conducted in three cities across the US. Participants also completed patient-reported outcome measures assessing asthma control and experiences.

Results

Focus groups were conducted in demographically and clinically diverse adults with asthma (five groups, n=34), caregivers of children with asthma (five groups, n=35), and adults with a dual diagnosis of asthma and chronic obstructive pulmonary disease (one group, n=5). Only 28% of patients were well-controlled by Asthma Control Test/Asthma Control Test-Caregiver Report and 18% by Asthma Impairment and Risk Questionnaire. Forty-four percent of participants reported not following their prescribed medical plan. Four key themes emerged from the focus groups: (1) asthma symptom control and monitoring are often inadequate; (2) treatments are often used incorrectly; (3) communication between health care professionals and patients or caregivers is often ineffective; and (4) concerns related to treatment and desires to improve treatment.

Conclusion

Control of asthma symptoms is suboptimal in the vast majority of patients and both patients and caregivers do not feel sufficiently informed about asthma. Health care providers should be encouraged to engage patients and caregivers in shared decision making for managing asthma and selecting treatments that integrate patient values, preferences, and lifestyles.

FeNO in Asthma

Asthma is a common disease affecting 350 million people worldwide, which is characterized by airways inflammation and hyperreactivity. Historically diagnosis and treatment have been mainly based on symptoms, which have the potential to result in misdiagnosis and inappropriate treatment. Nitric oxide (NO) is exhaled in human breath and is a marker of airways inflammation. Levels of NO are increased in the exhaled breath of patients with type 2 asthma and fractional exhaled nitric oxide (FeNO) provides an objective biomarker of airway inflammation. FeNO testing is an accessible, noninvasive, and easy-to-use test. Cut-off values have been established by the American Thoracic Society (ATS), the Global Initiative for Asthma (GINA), and the National Institute for Health and Care Excellence (NICE) but vary between guidance. FeNO levels have been shown to be predictive of blood and sputum eosinophil levels but should not be used in isolation and current guidance emphasizes the importance of incorporating clinical symptoms and testing when utilizing FeNO results. The inclusion of FeNO testing can increase diagnostic accuracy of asthma, while high levels in asthmatic patients can help predict response to inhaled corticosteroids (ICS) and suppression of levels with ICS to monitor adherence. FeNO levels are also a predictor of asthma risk with increased exacerbation rates and accelerated decline in lung function associated with high levels as well as having an emerging role in predicting response to some biologic therapies in severe asthma. FeNO testing is cost-effective and has been shown, when combined with clinical assessment, to improve asthma management.

Impact of Social Determinants on the Burden of Asthma and Eczema: Results from a US Patient Survey

Introduction

Little is known about how patients with asthma and eczema perceive their medical care and burden of disease. A survey was conducted to evaluate the perceptions among the general patient population with asthma and/or eczema regarding disease and treatment burden and barriers to adequate care.

Methods

An online survey was completed by market research panelists in the USA between March 24, 2020 and April 6, 2020. Eligible participants were at least 18 years of age and endorsed a diagnosis of asthma and/or eczema. Survey responses are described for all participants, by designated racial/ethnic groups, and by income level.

Results

In all, 841 participants completed the survey (asthma, n = 554; eczema, n = 398; both, n = 111; White, n = 421; Black, n = 252; Hispanic, n = 95; low income [less than $15,000/year], n = 99; higher income [at least $15,000/year], n = 713). More Black and Hispanic participants than White participants, and more participants with low income than higher income, endorsed health literacy as a barrier (e.g., filling out official documents, understanding written materials). Participants with low income were less likely than participants with higher income to have an asthma action plan (42% vs 53%, respectively) and to discuss asthma control with their healthcare provider (54% vs 69%). Black and Hispanic participants were more likely than White participants to have an emergency department visit (52% and 49% vs 31%, respectively) or hospitalization (31% and 39% vs 16%) for asthma within the last 12 months. Participants reporting low income indicated that they experienced eczema symptoms more frequently than participants with higher income; 35% of low-income participants vs 15% of higher-income participants reported that they had not tried any eczema treatments. Participants in all racial/ethnic and income-level groups reported that their asthma or eczema impacted their lifestyle and daily activities.

Conclusion

More effective and culturally informed communication and education strategies to improve health information uptake and shared decision-making are needed to reduce the burdens of disease and treatment in highly impacted populations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-02021-0.

Disparities in asthma and eczema outcomes have been described in various populations. However, little is known about how these patient populations perceive their disease management or disease burden. A survey of 841 adults across diverse demographic groups in the USA with asthma and/or eczema was conducted to evaluate overall perceived disease burden and to specifically understand burden experiences by marginalized populations. In general, all participants indicated that asthma and eczema have a negative physical, emotional, and social impact on their lives. Some participants who identified as Black or Hispanic, and those with low income (less than $15,000/year), indicated greater difficulties in filling out paperwork or understanding written materials related to their condition than White participants or those with higher incomes. Black and Hispanic participants tended to receive asthma care in the emergency department or urgent care more than White participants and had more emergency department visits and hospitalizations than White Participants. Participants with low income were less likely to discuss their asthma management with their doctor than those with higher incomes and also indicated potential undertreatment of eczema. These results indicate that Black, Hispanic, or low-income patients may experience barriers to health equity. These barriers include lack of effective communication methods and materials to meet the needs of all patients, as well as the overall lack of quality healthcare access. These challenges must be addressed to overcome social disparities in health.

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.

Artificial Intelligence Approach to the Monitoring of Respiratory Sounds in Asthmatic Patients

Background: Effective and reliable monitoring of asthma at home is a relevant factor that may reduce the need to consult a doctor in person.

Aim: We analyzed the possibility to determine intensities of pathological breath phenomena based on artificial intelligence (AI) analysis of sounds recorded during standard stethoscope auscultation.

Methods: The evaluation set comprising 1,043 auscultation examinations (9,319 recordings) was collected from 899 patients. Examinations were assigned to one of four groups: asthma with and without abnormal sounds (AA and AN, respectively), no-asthma with and without abnormal sounds (NA and NN, respectively). Presence of abnormal sounds was evaluated by a panel of 3 physicians that were blinded to the AI predictions. AI was trained on an independent set of 9,847 recordings to determine intensity scores (indexes) of wheezes, rhonchi, fine and coarse crackles and their combinations: continuous phenomena (wheezes + rhonchi) and all phenomena. The pair-comparison of groups of examinations based on Area Under ROC-Curve (AUC) was used to evaluate the performance of each index in discrimination between groups.

Results: Best performance in separation between AA and AN was observed with Continuous Phenomena Index (AUC 0.94) while for NN and NA. All Phenomena Index (AUC 0.91) showed the best performance. AA showed slightly higher prevalence of wheezes compared to NA.

Conclusions: The results showed a high efficiency of the AI to discriminate between the asthma patients with normal and abnormal sounds, thus this approach has a great potential and can be used to monitor asthma symptoms at home.

Childhood Asthma - The Effect of Asthma Specialist Intervention on Asthma Control: A Retrospective Review

Background

Childhood asthma is the most common chronic disease throughout the western world. Improving asthma control is a leading health management goal.

Purpose

To evaluate the effect of an intervention by a visit to an asthma specialist on asthma control in children.

Materials and Methods

This retrospective study was conducted using the electronic database of Maccabi Health Services. All members ages 5-16 with an asthma diagnosis during 2000-2016, and at least one visit to a specialist were included. Asthma outcomes during the 2 years before and after the visit to the asthma specialist were compared.

Results

A total of 37,066 children were diagnosed with asthma. Among them, 13,533 (36.5%) had at least one visit to an asthma specialist and were included. Children with asthma visited their primary care physician more often in the period before the specialist visit (4.4± 4.4 vs 3.16± 3.9 visits, respectively; p<0.01). After visiting a specialist, average number of visits to emergency departments (0.52± 1.3 vs 0.45±1), all cause hospitalizations (0.13±0.45 vs 0.08±0.4) and hospitalizations due to asthma exacerbations (0.08±0.345 vs 0.05±0.3) decreased (p<0.01 for all comparisons). Prescription of short-acting beta agonists decreased (2.85±3.6 vs 2.2 ±3.7, p<0.01) and inhaled steroid prescriptions increased (1.9±2.9 vs 2.7±3.7, p<0.01), respectively, after the intervention. A substantial reduction in the prescription of corticosteroids (0.81±1.9 vs 0.43±1.4, p<0.01) after specialist visit was also noted.

Conclusion

We found significant positive outcomes after a single consultation with an asthma specialist. Referring pediatric asthma patients to an asthma specialist should be one of the goals of an asthma management plan.

A systematic literature review of burden of illness in adults with uncontrolled moderate/severe asthma

BACKGROUND

There are limited published data on the burden of moderate/severe uncontrolled asthma.

METHODS

We conducted a systematic literature review to better understand the impact of moderate-to-severe asthma in the US, the UK, Germany, France, Italy, Spain, Canada, Japan, and Australia in terms of prevalence, clinical measures, health-related quality of life (HRQoL) and economic burden, for patients whose asthma is uncontrolled despite inhaled corticosteroid/long-acting β₂-agonist (ICS/LABA) therapy.

RESULTS

The prevalence of uncontrolled asthma among patients with moderate/severe disease varied but was as high as 100% in some subgroups. Patients with uncontrolled asthma generally had poor lung function (mean/median pre-bronchodilator forced expiratory volume in 1 second [FEV₁]: 1.69-2.45 L; mean/median pre-bronchodilator percent predicted FEV₁: 57.2-79.7). There was also a substantial but variable exacerbation burden associated with uncontrolled asthma, with the annualised rate of exacerbations ranging from 1.30 to 7.30 when considering various patient subgroups. Furthermore, the annualised rate of severe exacerbations ranged from 1.66 to 3.60. The HRQoL burden measured using disease-specific and generic instruments consistently demonstrated substantial impairment of HRQoL for those with uncontrolled asthma; Asthma Quality of Life Questionnaire scores ranged from 3.00 to 5.20, whilst EurQol-5 Dimensions index scores ranged from 0.53 to 0.59. Direct, indirect and total costs together with consumption of other healthcare resources associated with managing uncontrolled asthma were also substantial in the population studied; no caregiver burden was identified.

CONCLUSIONS

Our findings suggest that significant unmet needs exist for patients with uncontrolled asthma despite the availability of ICS/LABA therapy. Novel treatments are needed to help reduce the burden to patients, healthcare systems and society.

New Treatments for Asthma

Asthma is a complex, heterogeneous chronic airway disease with high prevalence of uncontrolled disease. New therapies, including biologics, are now available to treat T2 high asthma. Treatment of T2 low asthma remains a challenge. Asthma guidelines need be to updated to incorporate new therapeutics.

Interaction effects of asthma and rhinitis control on work productivity and activity impairment: A cross-sectional study

Background: Symptomatic asthma and rhinitis negatively impact patients' work productivity and activity. However, little is known about the potential interaction effect of both asthma and rhinitis control on work productivity and activity impairment. Objective: This study aimed to explore whether there are interaction effects of asthma and rhinitis control on work productivity and activity impairment in patients with asthma and with rhinitis. Methods: A total of 206 adult patients were prospectively recruited and were divided into four groups: both poorly controlled (BPC) n = 53), poorly controlled asthma (PCA) with controlled rhinitis (CR) (n = 38), well controlled asthma with uncontrolled rhinitis (n = 43), and both well controlled (BWC) (n = 72) based on the symptom control status of asthma and rhinitis. Work productivity loss and activity impairment, asthma control, and rhinitis control were assessed by using work productivity and activity impairment questionnaire: general health, the asthma control test, and the rhinitis control assessment test, respectively. General linear regression models were used to study the contribution of asthma control, rhinitis control, and the interaction effect on work productivity and activity impairment. Results: Work productivity loss was most frequently reported in patients in the BPC group. Compared with the patients in the BWC group, the patients in the PCA-CR group had significantly higher activity impairment and worse asthma-related quality of life (both p < 0.001). There were significant interaction effects of asthma and rhinitis control, which accounted for the increase in presenteeism, work productivity loss, and activity impairment (all p < 0.001). Although differences in absenteeism were not significant among the groups, there was a significant interaction effect of control levels accounted for absenteeism (p = 0.035). Conclusion: Distinct interaction effects of asthma and rhinitis control reflected a link between upper and lower airways, which indicated that rhinitis control and the interaction effects of asthma and rhinitis control cannot be neglected during asthma management.

Population pharmacokinetic analysis of dupilumab in adult and adolescent patients with asthma

A population pharmacokinetic model was developed using data from healthy subjects and patients with moderate‐to‐severe asthma receiving intravenous or subcutaneous dupilumab doses. A total of nine phase I to phase III studies were pooled (202 healthy subjects and 1912 patients with asthma including 68 adolescents) in the model development. The best model was a two‐compartment model with parallel linear and nonlinear Michaelis–Menten elimination with first order absorption. The PK parameter estimates were distribution volume of central compartment 2.76 L, linear elimination rate 0.0418 1/day, and subcutaneous bioavailability 60.9%. Pharmacokinetics (PK) properties of dupilumab in patients with asthma were determined to be comparable to those of healthy subjects and patients with atopic dermatitis. Only body weight exerts a notable effect explaining between‐subject variability in dupilumab PK, but dose adjustment for weight is not warranted based on results from clinical studies. There is no PK difference between adolescent and adult patients with asthma after correction for body weight.

Clinical and economic burden of severe asthma among US patients treated with biologic therapies

BACKGROUND

Patients with severe asthma may remain uncontrolled despite biologic therapy in addition to standard therapy, but this disease burden has not been quantified.

OBJECTIVE

To estimate the clinical and economic burden in a US national sample.

METHODS

Patients who have severe asthma with indicated biologic treatment (earliest use = index date) were selected from the MarketScan database between January 1, 2013, and June 30, 2018. Inclusion criteria were continuous enrollment for 12 months postindex with a minimum of 2 biologic fills, greater than or equal to 12 years of age, evidence of medium- to high-dose inhaled corticosteroids and long-acting β-agonist combination before the index, and absence of other respiratory diagnoses and malignancies. Disease exacerbations (used to classify asthma control), health care costs, and treatment characteristics were reported during the 12-month postindex period.

RESULTS

The sample included 3262 biologic patients; 88% with anti-immunoglobulin E therapy (omalizumab) and 12% non-anti-immunoglobulin E (reslizumab, mepolizumab, benralizumab). The mean age was 49 (±15) years; 64% were women. Prescriptions included inhaled corticosteroids and long-acting β-agonist (82%), systemic corticosteroids (76%), and leukotriene receptor antagonists (68%). Notably, 63% of patients presented greater than or equal to 1 asthma exacerbation (mean 1.3 per patient/year). Furthermore, 35% of patients were categorized as having controlled asthma, whereas 28% were suboptimally controlled and 29% were uncontrolled. Patients with uncontrolled disease had higher all-cause and asthma-related costs ($69,206 and $45,693, respectively) than patients with suboptimally controlled ($59,407 and $40,793, respectively) or controlled disease ($53,083 and $38,393, respectively). Furthermore, 62% of newly treated patients were persistent with their index biologic.

CONCLUSION

Biologic therapies are effective in reducing exacerbations, but a substantial proportion of patients with severe asthma treated with current biologics continue to experience uncontrolled disease, highlighting a remaining unmet need for patients with severe uncontrolled asthma.

Reported Neighborhood Traffic and the Odds of Asthma/Asthma-Like Symptoms: A Cross-Sectional Analysis of a Multi-Racial Cohort of Children

Asthma in children poses a significant clinical and public health burden. We examined the association between reported neighborhood traffic (a proxy for traffic-related air pollution) and asthma among 855 multi-racial children aged 4-8 years old who participated in the Environmental Influences on Child Health Outcomes (ECHO) cohort. We hypothesized that high neighborhood traffic density would be associated with the prevalence of asthma. Asthma/asthma-like symptoms (defined as current and/or past physician diagnosed asthma, past wheezing, or nighttime cough or wheezing in the past 12 months) was assessed by parental report. The relationship between neighborhood traffic and asthma/asthma-like symptoms was assessed using logistic regression. The prevalence of asthma/asthma-like symptoms among study participants was 23%, and 15% had high neighborhood traffic. Children with significant neighborhood traffic had a higher odds of having asthma/asthma-like symptoms than children without neighborhood traffic [adjusted OR = 2.01 (95% CI: 1.12, 3.62)] after controlling for child's race-ethnicity, age, sex, maternal education, family history of asthma, play equipment in the home environment, public parks, obesity and prescribed asthma medication. Further characterization of neighborhood traffic is needed since many children live near high traffic zones and significant racial/ethnic disparities exist.

Real-world evidence: Patient views on asthma in respiratory specialist clinics in America

BACKGROUND

Approximately 30% to 50% of patients with moderate/severe asthma have inadequately controlled disease despite adherence to inhaled corticosteroid (ICS)/long-acting β₂-agonist (LABA) therapy. Data on prevalence and burden of uncontrolled asthma in specialty settings are lacking.

OBJECTIVE

To evaluate the prevalence and burden of uncontrolled asthma in respiratory specialist clinics in the United States.

METHODS

Adults with physician-diagnosed asthma attending pulmonary and allergy clinics with self-reported ICS use in the previous 4 weeks completed an electronic questionnaire including the Asthma Control Test and St George's Respiratory Questionnaire. Additional information was collected using an electronic case report form.

RESULTS

Of 774 patients attending 12 pulmonary and 12 allergy clinics, 53% were not well controlled (mean [SD] Asthma Control Test, 14.3 [3.6] vs 22.4 [1.6] in well-controlled patients). Among ICS/LABA users, 56% were not well controlled, which increased with increasing ICS dose (low-dose 45.7%; high-dose 59.7%). The not well-controlled group reported more respiratory illnesses, more comorbidities, and poorer health-related quality of life (mean [SD] St George's Respiratory Questionnaire, 46.1 [18.9] vs 19.8 [12.9] in the well-controlled group). These patients also had more asthma exacerbations (≥1 exacerbation, 68.9% vs 43.1%) and increased health care resource utilization (≥1 asthma-related hospitalization, 10.7% vs 2.7%); 27.3% were also receiving systemic corticosteroids. Approximately 40% of the population were eligible for step-up to ICS/LABA/long-acting muscarinic antagonist triple therapy, and 20% were eligible for biologic therapy.

CONCLUSION

Substantial unmet needs exist among patients with inadequately controlled asthma managed in United States specialist settings, which may be addressed by improved patient and physician education, better guideline implementation, and improved adherence.

Comparing LAMA with LABA and LTRA as add-on therapies in primary care asthma management

The Global Initiative for Asthma recommends a stepwise approach to adjust asthma treatment to the needs of individual patients; inhaled corticosteroids (ICS) remain the core pharmacological treatment. However, many patients remain poorly controlled, and evidence-based algorithms to decide on the best order and rationale for add-on therapies are lacking. We explore the challenges of asthma management in primary care and review outcomes from randomised controlled trials and meta-analyses comparing the long-acting muscarinic antagonist (LAMA) tiotropium with long-acting β₂-agonists (LABAs) or leukotriene receptor antagonists (LTRAs) as add-on to ICS in patients with asthma. In adults, LAMAs and LABAs provide a greater improvement in lung function than LTRAs as add-on to ICS. In children, results were positive and comparable between therapies, but data are scarce. This information could aid decision-making in primary care, supporting the use of add-on therapy to ICS to help improve lung function, control asthma symptoms and prevent exacerbations.

The Added Burden of Allergen Sensitization Among Children with Severe or Poorly Controlled Asthma

BACKGROUND

Allergen sensitization (AS) may negatively affect asthma outcomes in children with severe or poorly controlled (SPC) asthma.

OBJECTIVES

To examine the impact of AS on asthma exacerbations, health care use, and costs among children with SPC asthma in private and public insurance settings.

METHODS

This retrospective study analyzed children with SPC asthma aged 6 to 11 years from the MarketScan Commercial (private insurance) and Medicaid databases. Selection of children with SPC asthma was based on medical claims and asthma medication prescription claims. AS status was based on diagnoses of extrinsic asthma and allergic conditions. Children were followed for at least 12 months. Outcomes included asthma exacerbations, days with oral corticosteroids (OCS), and asthma-related health care use and costs. Adjusted generalized linear models were fit to compare outcomes in children with versus those without AS.

RESULTS

Among children with SPC asthma, 34% had AS (private insurance: N = 11,448; Medicaid: N = 10,800), 20% did not have AS (private insurance: N = 7744; Medicaid: N = 6535), and, in the remainder, AS status could not be determined. Claims data were available for ≥3 years on average. Children with AS had significantly higher adjusted rates of asthma exacerbations during follow-up than children without AS, and significantly more days with OCS use. Rates of asthma-related hospitalizations, emergency department visits, and health care costs were significantly higher among children with AS than among children without AS.

CONCLUSIONS

Children with SPC asthma and AS have relatively greater asthma-related health care use and costs compared with children with SPC asthma without AS.

Hybrid Deep Learning Algorithm with Open Innovation Perspective: A Prediction Model of Asthmatic Occurrence

Due to recent advancements in industrialization, climate change and overpopulation, air pollution has become an issue of global concern and air quality is being highlighted as a social issue. Public interest and concern over respiratory health are increasing in terms of a high reliability of a healthy life or the social sustainability of human beings. Air pollution can have various adverse or deleterious effects on human health. Respiratory diseases such as asthma, the subject of this study, are especially regarded as ‘directly affected’ by air pollution. Since such pollution is derived from the combined effects of atmospheric pollutants and meteorological environmental factors, and it is not easy to estimate its influence on feasible respiratory diseases in various atmospheric environments. Previous studies have used clinical and cohort data based on relatively a small number of samples to determine how atmospheric pollutants affect diseases such as asthma. This has significant limitations in that each sample of the collections is likely to produce inconsistent results and it is difficult to attempt the experiments and studies other than by those in the medical profession. This study mainly focuses on predicting the actual asthmatic occurrence while utilizing and analyzing the data on both the atmospheric and meteorological environment officially released by the government. We used one of the advanced analytic models, often referred to as the vector autoregressive model (VAR), which traditionally has an advantage in multivariate time-series analysis to verify that each variable has a significant causal effect on the asthmatic occurrence. Next, the VAR model was applied to a deep learning algorithm to find a prediction model optimized for the prediction of asthmatic occurrence. The average error rate of the hybrid deep neural network (DNN) model was numerically verified to be about 8.17%, indicating better performance than other time-series algorithms. The proposed model can help streamline the national health and medical insurance system and health budget management in South Korea much more effectively. It can also provide efficiency in the deployment and management of the supply and demand of medical personnel in hospitals. In addition, it can contribute to the promotion of national health, enabling advance alerts of the risk of outbreaks by the atmospheric environment for chronic asthma patients. Furthermore, the theoretical methodologies, experimental results and implications of this study will be able to contribute to our current issues of global change and development in that the meteorological and environmental data-driven, deep-learning prediction model proposed hereby would put forward a macroscopic directionality which leads to sustainable public health and sustainability science.

Clinical and Economic Outcomes in Patients with Persistent Asthma Who Attain Healthcare Effectiveness and Data Information Set Measures

BACKGROUND

Attainment of asthma-specific US Healthcare Effectiveness Data and Information Set (HEDIS) quality measures may be associated with improved clinical outcomes and reduced economic burden.

OBJECTIVE

We examined the relationship between the attainment of HEDIS measures asthma medication ratio (AMR) and medication management for people with asthma (MMA) on clinical and economic outcomes.

METHODS

This retrospective claims database analysis linked to ambulatory electronic medical records enrolled US patients aged ≥5 years with persistent asthma between May 2015 and April 2017. The attainment of AMR ≥0.5 and MMA ≥75% was determined over a 1-year premeasurement period. Asthma exacerbations and asthma-related health care costs were evaluated during the subsequent 12-month measurement period, comparing patients attaining 1 or both measures with those not attaining either.

RESULTS

In total, 32,748 patients were included, 75.2% of whom attained AMR (n = 24,388) and/or MMA (n = 12,042) during the premeasurement period. Fewer attainers of 1 or more HEDIS measures had ≥1 asthma-related hospitalizations, emergency department visit, corticosteroid burst, or exacerbation (4.9% vs 7.3%; 9.6% vs 18.2%; 43.8% vs 51.6%; 14.3% vs 23.3%, respectively; all P < .001) compared with nonattainers. In adjusted analyses, HEDIS attainment was associated with a lower likelihood of exacerbations (odds ratio: 0.63, [95% confidence interval: 0.60-0.67]; P < .001). The attainment of ≥1 HEDIS measures lowered total and asthma-related costs, and asthma exacerbation-related health care costs per patient relative to nonattainers (cost ratio: 0.87, P < .001; 0.96, P = .02; and 0.59, P < .001, respectively). Overall and asthma-specific costs were lower for patients attaining AMR, but not MMA.

CONCLUSIONS

HEDIS attainment was associated with significantly improved asthma outcomes and lower asthma-specific costs.

Development of the Asthma Impairment and Risk Questionnaire (AIRQ): A Composite Control Measure

BACKGROUND

Asthma exacerbation risk increases with worsening asthma control. Prevailing numerical control tools evaluate only current symptom impairment despite the importance of also assessing risk based on exacerbation history. An easy-to-use questionnaire addressing impairment and risk domains of control is needed.

OBJECTIVE

To validate a composite asthma control tool that includes impairment and risk assessments (Asthma Impairment and Risk Questionnaire [AIRQ]).

METHODS

Four-hundred forty-two patients aged ≥12 years with physician-diagnosed asthma who were followed in specialty practices completed 15 impairment and risk questions with dichotomized yes/no responses. Patients spanned all Global Initiative for Asthma severities and were classified as well-controlled, not well-controlled, or very poorly controlled according to a standard of Asthma Control Test (ACT) score plus prior-year exacerbations. Logistic regression analyses identified questions with the greatest predictive validity to discriminate among patients and determine cut points for these 3 classifications.

RESULTS

The final AIRQ comprises 10 equally weighted yes/no impairment and risk questions. The final 10-item models yielded receiver operating characteristic curves of 0.94 to identify well-controlled versus not well-/very poorly controlled and 0.93 to identify well-/not well-controlled versus very poorly controlled asthma, as reflected by the ACT plus prior-year exacerbations standard. Cut points of 0-1, 2-4, and 5-10 best represented well-, not well-, and very poorly controlled asthma.

CONCLUSIONS

AIRQ is a rigorously validated composite measure designed to identify adults and adolescents with varying degrees of asthma control. Ongoing investigations will determine test-retest reliability, responsiveness to change, and predictive ability for future exacerbations.

Latent Class Analysis of School-Age Children at Risk for Asthma Exacerbation

BACKGROUND

Factors responsible for asthma exacerbations in children are complex and may differ from those that drive asthma severity.

OBJECTIVE

To identify latent classes of children at risk for asthma exacerbation and determine whether latent class assignment is useful in the prediction of future exacerbation.

METHODS

Latent class analysis was performed on 513 children aged 6 to 17 years at risk for asthma exacerbation, with 31 variables encompassing demographics, medical history, treatment, symptoms, lung function, sensitization, and type 2 inflammation. Primary and secondary outcomes included exacerbation occurrence by 12 months and time to first exacerbation, respectively.

RESULTS

Four latent classes were identified with differing demographic features, sensitization and type 2 inflammatory markers, prior exacerbation severity and health care utilization, and lung function. Exacerbations occurred in 22.4% of class 1 ("lesser sensitization with normal lung function"), 27.9% of class 2 ("lesser sensitization with prior severe exacerbation and normal lung function"), 45.3% of class 3 ("multiple sensitization with reversible airflow limitation"), and 64.3% of class 4 ("multiple sensitization with partially reversible airflow limitation") (P < .001). Time to exacerbation also followed similar trends and was shortest in the latent classes with multiple sensitization and airflow limitation (P < .001). Outcomes were driven largely by children with exacerbation-prone asthma (defined as ≥3 exacerbations in the prior year), who were present in each class but most strongly represented in classes 3 and 4.

CONCLUSIONS

Children at risk for asthma exacerbation are a heterogeneous group. Sensitization, prior exacerbation severity, and lung function variables may be particularly useful in identifying children at greatest risk for future exacerbation.

New Treatments for Asthma

Asthma is a complex, heterogeneous chronic airway disease with high prevalence of uncontrolled disease. New therapies, including biologics, are now available to treat T2 high asthma. Treatment of T2 low asthma remains a challenge. Asthma guidelines need be to updated to incorporate new therapeutics.

Healthcare resource utilization, expenditures, and productivity in patients with asthma with and without allergies

Objective: To compare healthcare resource utilization (HCRU), healthcare expenditures, and work productivity and activity impairment within a general asthma population with persistent asthma and evidence of allergy (PA-EA) and persistent asthma with no evidence of allergy (PA-NEA).Methods: We conducted a retrospective analysis of survey responses and claims from the Observational Study of Asthma Control and Outcomes (OSACO) study. Eligible patients with persistent asthma aged ≥12 years were sent four surveys over 15 months. Regression models were used to assess the association between: (1) PA-EA (defined as a positive response to a survey question about hay fever/seasonal allergies AND ≥1 diagnostic code for atopic conditions) and HCRU and expenditures; and (2) PA-EA and Work Productivity and Activity Impairment (WPAI)-Asthma questionnaire scores (vs. PA-NEA).Results: Adjusted data showed that, vs. PA-NEA (n = 312), patients with PA-EA (n = 971) incurred 1.34-times more all-cause prescriptions (95% confidence interval [CI], 1.20-1.48), $132.79 higher prescription costs (95% CI, $22.03-243.56), and $926.11 higher all-cause total healthcare costs (95% CI, $279.67-1572.54), per 4-month period. Patients with PA-EA were 4.1% less productive while working (95% CI, 3.75-4.48%) and experienced a 6.5% reduction in all activities (95% CI, 6.11-6.88%) vs. those with PA-NEA.Conclusions: Patients with PA-EA had greater HCRU, healthcare expenditures, and lower productivity compared with those patients with PA-NEA. These results highlight the burden of atopy in patients with persistent asthma and underscore the importance of allergic endotype identification for more vigilant disease management.

Primary care of asthma: new options for severe eosinophilic asthma

Objective: Asthma is a common heterogeneous disease characterized by airway inflammation and bronchoconstriction. Current treatment guidelines provide recommendations for categorizing disease severity, asthma control and management. This paper reviews asthma assessment in primary care and describes the pathophysiology, clinical characteristics and new targeted treatments available for patients with severe eosinophilic asthma. Methods: A non-systematic PubMed literature search was conducted and articles, primarily from the last 5 years, were selected based on relevance to primary care practice, asthma pathophysiology and biologic therapies. Results: Despite optimal therapy including high-dose inhaled corticosteroids (ICS), long-acting β2-agonists and tiotropium, ∼4-10% of all patients with severe asthma continue to have poor asthma control. These patients have impaired quality of life, frequent exacerbations and are exposed to the side effects of repeated courses of oral steroids. Approximately 50% of patients with severe uncontrolled asthma have eosinophilic asthma, with increased airway expression of type 2 cytokines IL-4, IL-5 and IL-13. Eosinophilic asthma is identified in primary care by having eosinophils ≥150-300 cells/μL on a complete blood count with differential. Conclusions: A new class of agents is available for patients with moderate to severe eosinophilic asthma. Four biologic therapies - mepolizumab, reslizumab, benralizumab and dupilumab - that interfere with the regulation and activity of eosinophils have been approved by the FDA for patients with moderate to severe asthma with an eosinophilic phenotype. Primary care physicians should be familiar with these medications to explain part of the rationale for referral to specialist care and manage patient expectations for treatment.

Therapeutic suppression of pulmonary neutrophilia and allergic airway hyperresponsiveness by a RORγt inverse agonist

Airway neutrophilia occurs in approximately 50% of patients with asthma and is associated with particularly severe disease. Unfortunately, this form of asthma is usually refractory to corticosteroid treatment, and there is an unmet need for new therapies. Pulmonary neutrophilic inflammation is associated with Th17 cells, whose differentiation is controlled by the nuclear receptor, RORγt. Here, we tested whether VTP-938, a selective inverse agonist of this receptor, can reduce disease parameters in animal models of neutrophilic asthma. When administered prior to allergic sensitization through the airway, the RORγt inverse agonist blunted allergen-specific Th17 cell development in lung-draining lymph nodes and attenuated allergen-induced production of IL-17. VTP-938 also reduced pulmonary production of IL-17 and airway neutrophilia when given during the allergen challenge of the model. Finally, in an environmentally relevant model of allergic responses to house dust extracts, VTP-938 suppressed production of IL-17 and neutrophilic inflammation, and also markedly diminished airway hyperresponsiveness. Together, these findings suggest that orally available inverse agonists of RORγt might provide an effective therapy to treat glucocorticoid-resistant neutrophilic asthma.

Respiratory tract infection-induced asthma exacerbations in adults with asthma: assessing predictors and outcomes

Objective: To evaluate clinical and economic burden associated with respiratory tract infection (RTI)-induced asthma exacerbations and to identify risk factors associated with these exacerbations. Factors associated with these exacerbations are understudied and little information is available about consequent expenditures. Methods: In this retrospective case-control study, medical records and pharmacy data in King Abdullah University Hospital in Northern Jordan were reviewed for adults with asthma aged 40 years and older, over the period 2013-2016. Cases of RTI-induced asthma exacerbations were identified, and controls were selected randomly from asthmatic adults who did not experience any RTI-induced asthma exacerbation during the same period. Independent-samples t-tests and chi-square tests were conducted to compare patient characteristics of cases and controls. Predictors of RTI-induced asthma exacerbations and the resultant complications were evaluated using multivariable logistic regression. Multivariable regression on log-transformed charges was used to predict expenditures of these exacerbations. Results: A total of 137 cases and 548 controls were identified. Using inhaled corticosteroid + long-acting beta-agonists (ICS + LABA) was significantly associated with lower odds of RTI-induced asthma exacerbations (OR = 0.4; 95% CI, 0.21-0.77; p = 0.006), and lower odds of resultant serious complications (OR = 0.23; 95% CI, 0.07-0.69; p = 0.009), compared to being untreated with any asthma maintenance treatment. Asthma severity and co-morbidities were associated with increased susceptibility to these exacerbations. The average charges of RTI-induced asthma admissions and outpatient exacerbations were 1042.9 JD ($1471.0) and 81.1 JD ($114.4), respectively. Conclusions: ICS + LABA, asthma severity and co-morbidities appeared to affect the clinical and economic burden associated with RTI-induced asthma exacerbations. Efforts to prevent these exacerbations in patients with risk factors are warranted.

A computerized decision support tool to implement asthma guidelines for children and adolescents

BACKGROUND

Multicenter randomized controlled trials (RCTs) for asthma management that incorporate usual-care regimens could benefit from standardized application of evidence-based guidelines.

OBJECTIVE

We sought to evaluate performance of a computerized decision support tool, the Asthma Control Evaluation and Treatment (ACET) Program, to standardize usual-care regimens for asthma management in RCTs.

METHODS

Children and adolescents with persistent uncontrolled asthma living in urban census tracts were recruited into 3 multicenter RCTs (each with a usual-care arm) between 2004 and 2014. A computerized decision support tool scored asthma control and assigned an appropriate treatment step based on published guidelines. Control-level determinants (symptoms, rescue medication use, pulmonary function measure, and adherence estimates) were collected at visits and entered into the ACET Program. Changes in control levels and treatment steps were examined during the trials.

RESULTS

At screening, more than half of the participants were rated as having symptoms that were not controlled or poorly controlled. The proportion of participants who gained good control between screening and randomization increased significantly in all 3 trials. Between 51% and 70% had symptoms that were well controlled by randomization. The proportion of well-controlled participants remained constant or improved slightly from randomization until the last posttreatment visit. Nighttime symptoms were the most common control-level determinant; there were few (<1%) instances of complete overlap of factors. FEV₁ was the driver of control-level assignment in 30% of determinations.

CONCLUSION

The ACET Program decision support tool facilitated standardized asthma assessment and treatment in multicenter RCTs and was associated with attaining and maintaining good asthma control in most participants.

Nationwide use of inhaled corticosteroids by South Korean asthma patients: an examination of the Health Insurance Review and Service database

BACKGROUND

Previous studies have found that the prescription rates of inhaled corticosteroid (ICS) were considerably low although it is recommended as the optimal asthma treatment. The aim of this study was to analyze the current status of ICS prescription for asthma patients in the South Korea.

METHODS

We evaluated quality assessment data based on nationwide Health Insurance Review and Service (HIRA) database from July 2013 to June 2014. ICS prescription rates in asthma patients were analyzed by types and specialty of medical institutions. Also, we graded medical institutions by their ICS prescription rate. In addition, ICS prescription rates were calculated by patient gender, age, and insurance type.

RESULTS

This study included 831,613 patients and 16,804 institutions in the analysis. The overall mean ICS prescription rate was 22.58%. Tertiary hospitals had the highest mean prescription rate (84.16%) whereas primary healthcare clinics had the lowest (20.71%). By specialty, internal medicine physicians prescribed ICS more frequently compared to other specialists. Of all, 47.17% of medical institutions prescribed ICS to <10% of asthma patients, while less than 6% of institutions prescribed ICS to >80% of asthma patients. Also, we found that female and patients with age >90 or <20 years exhibited lower ICS prescription rate.

CONCLUSIONS

The ICS prescription rate was found to be inadequate, given the importance of ICS as an asthma treatment. The prescription rates were especially low in primary healthcare clinics, and by specialists in fields other than internal medicine.

Generating evidence to inform an update of asthma clinical practice guidelines: Perspectives from the National Heart, Lung, and Blood Institute

Asthma is the most prevalent chronic respiratory disease worldwide. Its increasing prevalence and evidence of suboptimal control require renewed efforts in the development and widespread implementation of clinical practice guidelines for prevention, treatment, and control. Given the rapidly changing landscape and evolving best practices for guideline development, the National Heart, Lung, and Blood Institute made a commitment to support rigorous systematic evidence reviews that frontline health care providers and stakeholders could use to create new or update existing guidelines. This article describes the protocols, key questions, methodology, and analytic framework to support the update of the 2007 National Asthma Education and Prevention Program Expert Panel Report 3 (EPR-3) on the diagnosis and management of asthma in adults and children. It also describes the expert panel's practical experience in managing asthmatic patients across the age and severity spectrum. The article explains the process for ensuring that the expert panel's deliberations are conducted in accordance with the Institute of Medicine's standards and recommendations for guideline development. The outcome of this ambitious effort will be an update of the EPR-3 asthma guidelines and publication of the key recommendations in the Journal of Allergy and Clinical Immunology. Importantly, several novel approaches will be explored and incorporated as appropriate to accelerate adoption and sustained implementation of the guidelines.

Inhaled Corticosteroid-Containing Treatment Escalation and Outcomes for Patients with Asthma in a U.S. Health Care Organization

BACKGROUND

Asthma is a common disorder that affects approximately 8% of the U.S.

POPULATION

Treatment guidelines indicate inhaled corticosteroids (ICS) as the mainstay treatment, yet poor asthma control is common among ICS-treated patients. Treatment escalation (ICS dose increase and other controller therapy add-ons) is used to manage symptoms. Real-world studies of postescalation outcomes may inform treatment decisions.

OBJECTIVES

To (a) describe characteristics and treatment patterns among asthma patients who escalated treatment and (b) assess outcomes (exacerbations, uncontrolled asthma, and health care resource utilization [HCRU]) after escalation.

METHODS

The study cohort was identified from a large U.S. administrative claims database via ICD-9-CM codes for asthma (493.xx on ≥ 2 dates) and initiation (defining index date) of long-term (> 1 fill) ICS-containing treatment between January 1, 2009, and September 30, 2014. One year of continuous enrollment was required before and after the index date. Escalation was defined as ≥ 1 of the following: ICS dose increase; a switch between ICS, long-acting beta-2 agonists (LABA), or leukotriene modifiers (LTRM) to a different ICS, LABA, or LTRM; or add-on of controller medications (e.g., antibody biologic). Escalation patterns were examined. Rates of exacerbation (defined by inpatient admission, emergency department [ED] visit, or office visit with a pharmacy claim for an oral corticosteroid [OCS] within 7 days) and occurrence of uncontrolled asthma (defined by > 4 fills for a short-acting beta agonist [SABA] in a 1-year period, ≥ 1 OCS fill, or ≥ 1 asthma-related ED visit or inpatient admission) were calculated. Per-patient-per-year (PPPY) HCRU was estimated.

RESULTS

Among 35,126 patients (mean [SD] age 38 [16] years) who initiated long-term ICS-containing treatment, 5,044 (14%) patients escalated their index regimens at 136 (105) days post-index (i.e., pre-escalation period). The most frequent changes, alone or in combination, included ICS dose increase (68%) or LABA (27%) or LTRM (25%) add-ons. Before escalation, the exacerbation rate was 1.60 (5.10) PPPY, and 1,108 (22%) patients experienced exacerbation. During the postescalation period of 251.6 (138.9) days, the exacerbation rate was 0.75 (2.9) PPPY, and 1,038 (21%) patients experienced exacerbation. A majority (> 85%) of exacerbations in the periods before and after escalation were associated with an office visit plus an OCS pharmacy claim within 7 days. Uncontrolled asthma was experienced by 41.5% and 41.0% of patients before and after escalation, respectively. Ambulatory care visits were common before (mean [SD] 24.0 [26.7] all-cause and 8.5 [13.4] asthma-related PPPY) and after escalation (19.3 [21.3] all-cause and 4.6 [8.1] asthma-related PPPY).

CONCLUSIONS

Among asthma patients who initiated a long-term ICS-containing regimen, approximately 14% escalated therapy within a year of initiation. Yet, 21% of those patients had ≥ 1 exacerbation, and 41% of patients had uncontrolled asthma within 1 year after treatment escalation. The results demonstrate an unmet need among asthma patients who escalated their ICS-containing treatment.

DISCLOSURES

This study was sponsored and funded by Boehringer-Ingelheim, which contracted with Optum to conduct the research. The sponsor collaborated with Optum on the preparation, writing, revision, and approval of the manuscript. Bengston, Cao, Hulbert, Wolbeck, Elliott, and Buikema are employees of Optum. Yu and Wang are employed by Boehringer-Ingelheim. Study concept and design were contributed by Bengston, Yu, and Wang. Cao, Hulbert, and Wolbeck collected the data, and data analysis was performed by Bengston, Yu, and Wang. The manuscript was written by Bengston, along with Yu and Wang, and revised by Bengston, Yu, and Wang, along with the other authors.

Health Disparities Among Children with Asthma in the United States by Place of Residence

BACKGROUND

Children residing in poor-urban areas may have greater asthma morbidity. It is unclear whether this is due to individual characteristics such as race and ethnicity or place of residence.

OBJECTIVE

Assess indicators of control and treatment by residence.

METHODS

This was a cross-sectional analysis of children (aged 1-17 years) in the 2000-2014 Medical Expenditure Panel Survey (MEPS). Indicators of poor control included use of more than 3 canisters of short-acting beta agonist (SABA) in 3 months, asthma attack, and emergency department (ED) or inpatient (IP) visit during the year. Treatment measures included use of controller medications and a ratio of controller-to-total prescriptions of 0.7 or more.

RESULTS

There were 15,052 children with asthma in the MEPS 2000-2014 data, reflecting 8.4 million children in 2014. After controlling for covariates, children with asthma residing in poor-urban areas had lower odds of using controller medications (odds ratio [OR] = 0.77), having a controller-to-total ratio of 0.7 or more (OR = 0.75), and reporting an asthma attack (OR = 0.75) and higher odds of having an ED/IP visit (OR = 1.3) compared with those living elsewhere. Black race and Hispanic ethnicity were associated with greater odds of excessive SABA use (OR = 2.11) and ED/IP visits (OR = 2.03) and lower odds of controller-to-total ratio of 0.07 or more (OR = 0.50).

CONCLUSIONS

Poor-urban residence may be independently associated with asthma control and treatment even after controlling for individual characteristics such as race and ethnicity. Future research is needed to understand the sources of these geographic health disparities to more successfully target public health interventions.

Therapeutic Effect of Omalizumab in Severe Asthma: A Real-World Study in Korea

Purpose

Omalizumab, an anti-immunoglobulin E (IgE) monoclonal antibody, has proved to be effective for the treatment of severe asthma. However, there is no direct evidence of effectiveness of omalizumab in Korean patients with severe asthma. We sought to evaluate the real-world effectiveness of omalizumab in Korean adult patients suffering from severe asthma and to identify predictors of favorable response.

Methods

A retrospective analysis of electrical medical records was performed on severe allergic asthmatic patients with omalizumab treatment group (OT group) for more than 6 months between March 2008 and February 2016. Propensity score matching was applied to define the standardized treatment control group (STC group) treated without omalizumab. Asthma-related outcomes were compared between the 2 groups, and analyzed before and after omalizumab use in the OT group. Responders to treatment were defined as patients showing >50% reduction in asthma exacerbations and/or systemic steroid requirement during the outcome period.

Results

One hundred twenty-four patients with severe asthma (62 in the OT group; 62 in the STC group) were enrolled in the study. Proportion of patients having the reduction of asthma exacerbation (53.2% vs 35.5%, P=0.015) and the rate of responders (67.7% vs 41.9%, P=0.007) were significantly higher in the OT group than in the STC group. Significant reductions were noted in asthma exacerbation (P=0.006), hospitalization (P=0.009), hospitalization days (P=0.006), systemic corticosteroid requirements (P=0.027), and sputum eosinophil count (P=0.031) in OT group compared with STC group. There were no significant differences in changes of forced expiratory volume in the 1 second (FEV1) levels between the 2 groups. No predictors of responders were found for omalizumab treatment.

Conclusions

Omalizumab can reduce exacerbations/hospitalization/systemic steroid burst in Korean adult patients with severe asthma.

New onset of asthma and job status change among world trade center responders and workers

BACKGROUND

Despite the high rates, the consequences of new onset asthma among the World Trade Center (WTC) responders in terms of the change in job status have not been studied.

METHODS

This study consists of a cohort of 8132 WTC responders out of the total 25 787 responders who held a full-time job at the baseline visit, and participated in at least one follow-up visit.

RESULTS

Overall, 34% of the study cohort changed their job status from full-time at a follow-up visit. Multivariable models showed that asthmatics were respectively 27% and 47% more likely to have any job status change and get retired, and twice as likely to become disabled as compared to non-asthmatics.

CONCLUSIONS

With asthma incidence from WTC exposure, negative job status change should be considered as a potential long-term consequence of WTC exposure.

Patient Outcomes, Health Care Resource Use, and Costs Associated with High Versus Low HEDIS Asthma Medication Ratio

BACKGROUND

The Healthcare Effectiveness Data and Information Set (HEDIS) quality measures for asthma include the asthma medication ratio (AMR) as a marker of quality of care for patients with asthma. Few data are available to describe the association between health care use and costs in patients with high versus low AMR.

OBJECTIVE

To characterize health care use and costs associated with high versus low AMR in patients participating in commercial health plans.

METHODS

In a commercial claims database, this study retrospectively identified patients aged 5 to 64 years on December 31, 2011, who met the HEDIS definition of asthma in the premeasurement year (January 1, 2010-December 31, 2010) and the measurement year (January 1, 2011-December 31, 2011). Each patient was classified as having either high or low AMR based on the HEDIS definition. AMR was calculated as the ratio of controller to total asthma medications; high AMR was defined as ≥ 0.5. Annual per-patient health care use and costs were compared in patients with high versus low AMR using (a) multivariable linear regression models to estimate mean annual number of office visits, oral corticosteroids (OCS) bursts (≤ 15-day supply), and costs and (b) negative binomial models to estimate mean annual hospitalization and emergency department (ED) visits. All estimates were adjusted for age, sex, region, and Charlson Comorbidity Index score to control for differences between patients with high versus low AMR.

RESULTS

Patients were identified with high (30,575) and low (6,479) AMR. An average patient with high AMR had more all-cause office visits (14.1 vs. 11.0; P < 0.001), fewer all-cause hospitalizations (0.109 vs. 0.215; P < 0.001), fewer all-cause ED visits (0.321 vs. 0.768; P < 0.001), and fewer OCS bursts (0.83 vs. 1.33; P < 0.001) than an average patient with low AMR. An average patient with high AMR had fewer asthma-related hospitalizations (0.024 vs. 0.088; P < 0.001) and ED visits (0.060 vs. 0.304; P < 0.001) than an average patient with low AMR. Numbers of asthma-related annual office visits were similar between the high and low AMR groups (high 2.2 vs. low 2.2; not significant). The rate of poor asthma control events (≥ 6 short-acting beta-agonist dispensing events or ≥ 2 OCS bursts, asthma-related ED visits, or hospitalizations) was greater in patients with low AMR than in patients with high AMR (74.3% vs. 26.9%). An average patient with high AMR had lower annual nonmedication costs than an average patient with low AMR ($5,733 vs. $6,295; P = 0.011). Similar trends emerged for asthma-related costs. A patient with high AMR had higher average total annual health care costs than a patient with low AMR ($9,811 vs. $8,398; P < 0.001). These increased costs primarily resulted from increased medication costs for patients with high versus low AMR ($4,077 vs. $2,103; P < 0.001).

CONCLUSIONS

Although patients with high AMR had more office visits and higher medication (which resulted in higher overall health care) costs, their care was marked by fewer OCS bursts (indicating fewer instances of poor asthma control), fewer ED visits, and fewer hospitalizations and lower non-medication costs than those patients with low AMR. These findings support the use of AMR as a care quality measure for patients with persistent asthma.

DISCLOSURES

This study was funded by Genentech. Luskin has received consulting and lecture fees, research and travel support, and payment for developing educational presentations from Genentech and has received lecture fees from Merck. Raimundo and Solari are employees of Genentech. Antonova was employed by Genentech at the time of this study. Broder and Chang are employees of Partnership for Health Analytic Research, which received funding from Genentech to conduct this research. Study concept and design were contributed by all authors. Broder and Chang conducted analyses. All authors interpreted the data. Antonova wrote the manuscript with assistance from the other authors. All authors participated in manuscript review and revisions.

Estimating asthma control questionnaire (ACQ) scores from claims data

BACKGROUND

Asthma control is the main focus of treatment guidelines. Valid instruments such as the Asthma Control Questionnaire (ACQ) require prospective survey. These surveys may be challenging for large population health applications.

OBJECTIVE

To develop an algorithm for estimating ACQ-5 scores from commonly available claims data.

METHODS

Data was derived from four prospective surveys including the ACQ-5 combined with retrospective claims of Kaiser Permanente of Colorado (KPCO) patients. The statistical approach consisted of derivation and validation of a prediction algorithm including medical and pharmacy claims data using stepwise regression elimination. Validation was conducted by estimating mean squared error (MSE) and mean absolute error (MAE) in one hundred split-sample iterations. Ordinary least squares (OLS), Tobit and Median regression were used.

RESULTS

There were 2,657 individuals with valid ACQ-5 scores, claims and eligibility at baseline. The following had statistically significant associations with ACQ-5 scores: gender, use of oral corticosteroids and short-acting beta agonists, the number of asthma drug classes, and emergency and outpatient visits. Average MSE and MAE were similar for the estimation and validation samples.

CONCLUSION

This research provides preliminary results of the feasibility of predicting ACQ-5 scores using commonly available medical and pharmacy claims data. The resulting algorithm may facilitate public health and population level analyses of asthma control. Future studies in different populations will be important to validate the algorithm.

The national burden of poorly controlled asthma, school absence and parental work loss among school-aged children in the United States

OBJECTIVE

The degree of poorly controlled asthma and its association with missed school days and parental missed work days is not well understood.

METHODS

This was a retrospective analysis of missed school days and missed work days for school-aged children (SAC; aged 6-17) and their caregivers in the nationally representative 2007-2013 Medical Expenditure Panel Survey (MEPS). Indicators of poor asthma control included: exacerbation in previous 12 months; use of >3 canisters of short-acting beta agonist (SABA) in 3 months; and annual asthma-specific (AS) Emergency Department (ED) or inpatient (IP) visits. Negative binomial regression was used for missed school days, and a Heckman two-step selection model was used for missed work days. All analyses controlled for sociodemographics and other covariates.

RESULTS

There were 44,320 SAC in MEPS, of whom 5,890 had asthma. SAC with asthma and an indicator of poor control missed more school days than SAC without asthma: exacerbation (1.8 times more; p < 0.001); >3 canisters SABA (2.7 times more; p < 0.001) and ED/IP visit (3.8 times more; p < 0.001). The parents/caregivers of SAC with asthma and an exacerbation missed 1.2 times more work days (p < 0.05), while those with SAC with asthma and an ED/IP visit missed 1.8 times more work days (p < 0.01) than the parents of SAC without asthma.

CONCLUSIONS

This study provides evidence of the significant national burden of poorly controlled asthma due to missed school and work days in the United States. More effective and creative asthma management strategies, with collaboration across clinical, community and school-based outreach, may help address this burden.

The national cost of asthma among school-aged children in the United States

BACKGROUND

Recent research has quantified the national health care resource use (HCRU) and health care expenditure (HCE) burden associated with adult asthma; however, estimates specific to school-aged children are more than 2 decades old.

OBJECTIVE

To estimate the national HCRU and HCEs attributable to asthma among school-aged children in the United States.

METHODS

This was a cross-sectional retrospective analysis of school-aged children (aged 6-17 years) in the nationally representative 2007-2013 Medical Expenditure Panel Survey. All-cause HCRU and HCEs of school-aged children with asthma were compared with school-aged children without asthma, controlling for sociodemographics and comorbidities. HCRU encounters included emergency department (ED) and outpatient visits, hospitalizations, and prescriptions. Expenditures included total, medical, ED, inpatient, outpatient, and pharmacy. Negative binomial regression analyses were used for HCRU and Heckman selection with logarithmic transformation, and smearing retransformation was used for HCEs.

RESULTS

There were 44,320 school-aged children of whom 5,890 had asthma. Children with asthma incurred a higher rate of all-cause annual ED visits (incidence rate ratio [IRR], 1.5; P < .001), hospitalizations (IRR, 1.4; P < .05), outpatient visits (IRR, 1.4; P < .001), and prescription drugs (IRR, 3.3; P < .001) compared with school-aged children without asthma. They incurred US$847 (2015 dollars) more annually in all-cause expenditures (P < .001). Private insurance and Medicaid paid the largest share of expenditures. Pharmacy and outpatient costs represented the largest proportion of total expenditures. On the basis of the nationally representative Medical Expenditure Panel Survey sample weights from 2013, the total annual HCEs attributable to asthma for school-aged children in the United States was US$5.92 billion (2015 dollars).

CONCLUSION

Childhood asthma continues to represent a prevalent and significant clinical and economic burden in the United States. More aggressive treatment and asthma management programs are needed to address this national financial and resource burden.