Treatment patterns Among adult patients with asthma : Factors associated with Overuse of inhaled β-agonists and underuse of inhaled corticosteroids
TL;DR: Overuse of inhaled beta-agonists may be caused by symptom severity, while underusers of corticosteroids may interrupt use as symptoms abate, demonstrating an important opportunity to improve medication use among patients with asthma.
Abstract: Background Overuse of inhaled β-agonists and underuse of inhaled corticosteroids by patients with asthma may have adverse consequences. This study was performed to identify factors associated with misuse of these types of asthma medication. Methods We examined baseline data from a longitudinal survey of adult patients with asthma. The setting was a consortium of 15 national managed care organizations serving 11 large employers. Baseline surveys were completed by 6612 health plan enrollees at least 18 years old who had had at least 2 visits with a diagnostic code for asthma in the preceding 2 years. The main outcome measures were the overuse of inhaled β-agonists and the underuse of inhaled corticosteroids. Independent variables were patient and process of care factors. Results Among patients with moderate or severe asthma, 16% of users of inhaled β-agonists reported overuse (>8 puffs per day on days of use), and 64% of users of inhaled corticosteroids reported underuse (use on ≤4 days/wk or ≤4 puffs per day). Overuse of inhaled β-agonists was most strongly associated with concomitant treatment with inhaled corticosteroids or anticholinergic agents, increased asthma symptom severity, problems in obtaining asthma medication, and male sex. Underuse of inhaled corticosteroids was associated with nonwhite race, younger age (18 to 34 years), lower use of inhaled β-agonist, lower symptom severity, and not possessing a peak flow meter. Rates of misuse of medication also varied by speciality of the patient's provider (generalist, allergist, or pulmonologist). Conclusions Overuse of inhaled β-agonists may be caused by symptom severity, while underusers of corticosteroids may interrupt use as symptoms abate. This study demonstrated an important opportunity to improve medication use among patients with asthma.
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TL;DR: Severe asthma is characterized by abnormal lung function that is responsive to bronchodilators, a history of sinopulmonary infections, persistent symptoms, and increased health care utilization.
Abstract: Background Severe asthma causes the majority of asthma morbidity. Understanding mechanisms that contribute to the development of severe disease is important. Objective The goal of the Severe Asthma Research Program is to identify and characterize subjects with severe asthma to understand pathophysiologic mechanisms in severe asthma. Methods We performed a comprehensive phenotypic characterization (questionnaires, atopy and pulmonary function testing, phlebotomy, exhaled nitric oxide) in subjects with severe and not severe asthma. Results A total of 438 subjects with asthma were studied (204 severe, 70 moderate, 164 mild). Severe subjects with asthma were older with longer disease duration ( P P ≤ .0001). Lung function was lower in severe asthma with marked bronchodilator reversibility ( P P = .0007), but blood eosinophils, IgE, and exhaled nitric oxide levels did not differentiate disease severity. A reduced FEV 1 , history of pneumonia, and fewer positive skin tests were risk factors for severe disease. Early disease onset (age P P = .002). Later disease onset (age ≥ 12 years) was associated with lower lung function and sinopulmonary infections ( P ≤ .02). Conclusion Severe asthma is characterized by abnormal lung function that is responsive to bronchodilators, a history of sinopulmonary infections, persistent symptoms, and increased health care utilization. Clinical implications Lung function abnormalities in severe asthma are reversible in most patients, and pneumonia is a risk factor for the development of severe disease.
863 citations
TL;DR: Among Medicare beneficiaries enrolled in managed care health plans, blacks received poorer quality of care than whites, and racial disparities were still statistically significant for eye examinations for patients with diabetes, beta-blocker use after myocardial infarction, and follow-up after hospitalization for mental illness.
Abstract: Context Substantial racial disparities in the use of some health services exist; however, much less is known about racial disparities in the quality of care. Objective To assess racial disparities in the quality of care for enrollees in Medicare managed care health plans. Design and Setting Observational study, using the 1998 Health Plan Employer Data and Information Set (HEDIS), which summarized performance in calendar year 1997 for 4 measures of quality of care (breast cancer screening, eye examinations for patients with diabetes, -blocker use after myocardial infarction, and follow-up after hospitalization for mental illness). Participants A total of 305 574 (7.7%) beneficiaries who were enrolled in Medicare managed care health plans had data for at least 1 of the 4 HEDIS measures and were aged 65 years or older. Main Outcome Measures Rates of breast cancer screening, eye examinations for patients with diabetes, -blocker use after myocardial infarction, and follow-up after hospitalization for mental illness. Results Blacks were less likely than whites to receive breast cancer screening (62.9% vs 70.9%; P<.001), eye examinations for patients with diabetes (43.6% vs 50.4%; P = .02), -blocker medication after myocardial infarction (64.1% vs 73.8%; P<.005), and follow-up after hospitalization for mental illness (33.2 vs 54.0%; P<.001). After adjustment for potential confounding factors, racial disparities were still statistically significant for eye examinations for patients with diabetes, -blocker use after myocardial infarction, and follow-up after hospitalization for mental illness. Conclusion Among Medicare beneficiaries enrolled in managed care health plans, blacks received poorer quality of care than whites.
547 citations
TL;DR: Clinicians must be prepared to work in an ongoing partnership with patients to ensure that they are offered a clear rationale as to why ICS are necessary and to address their concerns about potential adverse effects.
542 citations
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TL;DR: A targeted text message programme targeted at changing patients’ illness and medication beliefs would improve adherence in young adult asthma patients and may be useful for other illnesses where adherence is a major issue.
Abstract: Objective. While effective preventative medication is readily available for asthma, adherence is a major problem due to patients’ beliefs about their illness and medication. We investigated whether a text message programme targeted at changing patients’ illness and medication beliefs would improve adherence in young adult asthma patients.
Methods. Two hundred and sixteen patients aged between 16 and 45 on asthma preventer medication were recruited from pamphlets dispensed with medication and e-mails sent to members of a targeted marketing website. Participants were randomized to receive individually tailored text messages based on their illness and medication beliefs over 18 weeks or no text messages. Illness and medication beliefs were assessed at baseline and at 18 weeks. Adherence rates were assessed by phone calls to participants at 6, 12, and 18 weeks and at 6 and 9 months.
Results. At 18 weeks, the intervention group had increased their perceived necessity of preventer medication, increased their belief in the long-term nature of their asthma, and their perceived control over their asthma relative to control group (all p's < .05). The intervention group also significantly improved adherence over the follow-up period compared to the control group with a relative average increase in adherence over the follow-up period of 10% (p < .001). The percentage taking over 80% of prescribed inhaler doses was 23.9% in the control group compared to 37.7% in the intervention group (p < .05).
Conclusion. A targeted text message programme increases adherence to asthma preventer inhaler and may be useful for other illnesses where adherence is a major issue.
307 citations
Cites background from "Treatment patterns Among adult pati..."
...Younger patients in the 14–25 years - age range have been found to report using preventer inhalers less than older patients (Diette et al., 1999; Legorreta et al., 1998)....
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TL;DR: The use ofβ-agonists administered by a metered-dose inhaler was associated with an increased risk of death from asthma and the regular use of β2-agonist bronchodilators.
Abstract: Background. Morbidity and mortality from asthma appear to be increasing, and it has been suggested that medications used to treat asthma are contributing to this trend. We investigated a possible association between death or near death from asthma and the regular use of β2-agonist bronchodilators. Methods. Using linked health insurance data bases from Saskatchewan, Canada, we conducted a matched case–control study of subjects drawn from a cohort of 12,301 patients for whom asthma medications had been prescribed between 1978 and 1987. We matched 129 case patients who had fatal or near-fatal asthma with 655 controls (who had received medications for asthma but had not had fatal or near-fatal events) with respect to region of residence, age, receipt of social assistance, and previous hospitalization for asthma. Results. The use of β-agonists administered by a metered-dose inhaler was associated with an increased risk of death from asthma (odds ratio, 2.6 per canister per month; 95 percent confidence...
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TL;DR: Findings from this study indicate that future asthma research and intervention efforts directed at hospitalizations and high-cost patients could help to decrease health care resource use and provide cost savings.
Abstract: This cost of illness analysis examines national cost and resource utilization by persons with asthma using a single, comprehensive data source, the 1987 National Medical Expenditure Survey. Direct medical expenditures included payments for ambulatory care visits, hospital outpatient services, hospital inpatient stays, emergency department visits, physician and facility payments, and prescribed medicines. Indirect medical costs included costs resulting from missed work or school and days with restricted activity at work. Point estimates and 95% confidence intervals (CI) were calculated and inflated to 1994 dollars. The total estimated cost was $5.8 billion (95% CI, $3.6 to $8 billion). The estimated direct expenditures were $5.1 billion (95% CI, $3.3 to $7.0 billion), and indirect expenditures were valued at $673 million (95% CI, $271 to $1,076 million). Hospitalization accounted for more than half of all expenditures. More than 80% of resources were used by 20% of the population (defined as 'high-cost patients'). The estimated annual per patient cost for those high-cost patients was $2,584, in contrast with $140 for the rest of the sample. Findings from this study indicate that future asthma research and intervention efforts directed at hospitalizations and high-cost patients could help to decrease health care resource use and provide cost savings.
588 citations
"Treatment patterns Among adult pati..." refers background in this paper
...2 million emergency department visits and 445 000 hospitalization days.(1) While the disease has substantial impact on health care costs and patient morbidity, there are effective treatments and interventions to control symptoms of asthma and to prevent acute care visits....
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TL;DR: A general methodology for analysing multivariate failure time data, analogous to that of Liang and Zeger for longitudinal data analysis is presented, which formulates the marginal distributions ofMultivariate failure times with the familiar Cox proportional hazards models while leaving the nature of dependence among related failure times completely unspecified.
Abstract: Multivariate failure time data are commonly encountered in scientific investigations because each study subject may experience multiple events or because there exists clustering of subjects such that failure times within the same cluster are correlated. In this paper, I present a general methodology for analysing such data, which is analogous to that of Liang and Zeger for longitudinal data analysis. This approach formulates the marginal distributions of multivariate failure times with the familiar Cox proportional hazards models while leaving the nature of dependence among related failure times completely unspecified. The baseline hazard functions for the marginal models may be identical or different. Simple estimating equations for the regression parameters are developed which yield consistent and asymptotically normal estimators, and robust variance-covariance estimators are constructed to account for the intra-class correlation. Simulation results demonstrate that the large-sample approximations are adequate for practical use and that ignoring the intra-class correlation could yield rather misleading variance estimators. The proposed methodology has been fully implemented in a simple computer program which also incorporates several alternative approaches. Detailed illustrations with data from four clinical or epidemiologic studies are provided.
581 citations