The Impact of Exacerbations on the Asthmatic Patient's Preference Scores

The purpose of this study was to examine the effect of exacerbations on mild to moderate asthmatic patients' preference-based, health-related, quality of life scores and also to describe the effect of these exacerbations on daily life. In a survey, 100 mild to moderate asthmatic patients in the United Kingdom were asked to rate three different health marker states on a scale between 0 (death) and 100 (perfect health), defined as: your asthma of today, a mild exacerbation, and a severe exacerbation of asthma. They were also asked to describe their symptoms and what they did when experiencing an exacerbation. During exacerbations the vast majority of asthmatic patients have significant symptoms and consume a considerable amount of health care resources, which often overlap. The health marker state “your asthma of today” was given a mean score of 81.0, a mild exacerbation a score of 62.1, and a severe exacerbation a score of 25.6, indicating a large impact on patients' daily life and their health-related quality of life. In conclusion, asthmatic patients are severely affected in their health and daily living by mild and severe exacerbations. Considerable effort should be made to reduce the number and severity of exacerbations.     

The Impact of Managed Care on Health Care Utilization Among Adults with Asthma

Study Objectives. To compare kinds and amounts of health care used by adults with asthma in managed care and fee-for-service settings. Design. Cross-sectional structured telephone survey of Northern California adults with asthma from random samples of pulmonologists, allergist-immunologists, family practitioners, and from a random sample of the non-institutionalized population. Measurements. Validated measures of kind of health insurance plans, kinds and amounts of services used for asthma and other reasons, demographic characteristics, severity of asthma, comorbidity, and overall health and functional status. Results. Eighty one percent of the 416 adults with asthma studied were in some form of managed care (75% in HMOs and 6% in PPOs). Those in managed care (MC) and fee-for-service (FFS) did not differ substantively in the proportion with a regular source or principal provider of asthma care, with a peak flow meter or action plan, having received instructions in the use of an inhaler, reporting current use of inhaled beta-agonists, home nebulized beta-agonists, or inhaled steroids, or reporting ER visits or flu shots in the year prior to interview. Persons with asthma in MC reported significantly fewer total physician visits (after adjustment, 4.3 MC, 7.1 FFS, difference = 2.8, 95% CI - 5.4, - 0.1), principally because those in MC had many fewer visits to allergist-immunologists (after adjustment 4.9 MC, 21.4 FFS, difference = - 16.5, 95% CI - 27.8-5.3). The two groups did not differ significantly in the proportion with asthma-related or non asthma hospital admissions. Conclusions. Persons with asthma in fee-for-service settings reported a greater number of certain kinds of ambulatory visits, particularly visits to allergist-immunologists, for their asthma than those in managed care, but did not differ in the use of the hospital for their asthma and in non asthma care.     

The Impact of Managed Care on Health Care Utilization Among Adults with Asthma

Study Objectives. To compare kinds and amounts of health care used by adults with asthma in managed care and fee‐for‐service settings. Design. Cross‐sectional structured telephone survey of Northern California adults with asthma from random samples of pulmonologists, allergist‐immunologists, family practitioners, and from a random sample of the non‐institutionalized population. Measurements. Validated measures of kind of health insurance plans, kinds and amounts of services used for asthma and other reasons, demographic characteristics, severity of asthma, comorbidity, and overall health and functional status. Results. Eighty one percent of the 416 adults with asthma studied were in some form of managed care (75% in HMOs and 6% in PPOs). Those in managed care (MC) and fee‐for‐service (FFS) did not differ substantively in the proportion with a regular source or principal provider of asthma care, with a peak flow meter or action plan, having received instructions in the use of an inhaler, reporting current use of inhaled beta‐agonists, home nebulized beta‐agonists, or inhaled steroids, or reporting ER visits or flu shots in the year prior to interview. Persons with asthma in MC reported significantly fewer total physician visits (after adjustment, 4.3 MC, 7.1 FFS, difference = 2.8, 95% CI ? 5.4, ? 0.1), principally because those in MC had many fewer visits to allergist‐immunologists (after adjustment 4.9 MC, 21.4 FFS, difference = ? 16.5, 95% CI ? 27.8–5.3). The two groups did not differ significantly in the proportion with asthma‐related or non asthma hospital admissions. Conclusions. Persons with asthma in fee‐for‐service settings reported a greater number of certain kinds of ambulatory visits, particularly visits to allergist‐immunologists, for their asthma than those in managed care, but did not differ in the use of the hospital for their asthma and in non asthma care.     

The Effects of Nebulized Albuterol on Esophageal Function in Asthmatic Patients

Purpose Albuterol reduces lower esophageal sphincter (LES) pressure in normal volunteers, although the effects of albuterol on esophageal function in asthmatic patients are not known. The aim of this study was to evaluate the effects of nebulized albuterol on lower esophageal function in asthmatic patients. Symptoms and a methacholine challenge test were used to identify asthmatic patients who were then enrolled in a prospective, randomized, placebo-controlled, double-blinded, crossover trial. Changes in esophageal function in response to nebulized albuterol or placebo were evaluated over two sessions spaced 1 week apart. Results Albuterol induced a dose-dependent drop in lower esophageal sphincter basal pressure with a threshold dose as low as 2.5 mg. Albuterol did not affect the amplitude of esophageal contractions. Conclusions Nebulized albuterol induces a dose-dependent reduction in LES basal pressure in asthmatic patients. These effects raise the possibility that gastroesophageal reflux may occur after bronchodilator therapy.     

The Influence of Gastroesophageal Reflux Disease and its Treatment on Asthmatic Cough

Gastroesophageal reflux is known to cause chronic cough and is also implicated in worsening of asthma. We conducted a prospective study to examine the clinical significance of gastroesophageal reflux disease (GERD) in asthmatic patients with chronic cough to analyze the temporal relationship between reflux events and coughing and to assess the effect of esomeprazole treatment on respiratory symptoms and lung function in these patients. Asthmatic patients (126) with chronic dry cough were studied. Diagnosis of GERD was based on typical symptoms and the effectiveness of therapeutic test or on pH monitoring. Patients without GERD (negative pH results) consisted of the control group. The results of pH monitoring showed that 64% of cough episodes were related to acid reflux and in 91% of reflux events preceded coughing. Esomeprazole treatment (40 mg/day for 3 months) not only diminished GERD symptoms but also improved asthma outcome Baseline FEV₁ and PEF values increased significantly together with a decrease in symptom scores and the use of rescue medication. In most patients included in the extended part of the study for another 3 months, the dose of inhaled steroids could be reduced with sustained GERD therapy. Our data showing that reflux events preceded coughing in most cases and that treatment of GERD resulted in an improvement in different outcome measures of asthma suggest that GERD worsens asthma, and its treatment is of clinical importance to effectively manage these patients.     

Resource Use Study In COPD (RUSIC): A prospective study to quantify the effects of COPD exacerbations on health care resource use among COPD patients

BACKGROUND:

There is increasing interest in health care resource use (HRU) in Canada, particularly in resources associated with acute exacerbations of chronic obstructive pulmonary disease (COPD).

OBJECTIVE:

To identify HRU due to exacerbations of COPD.

METHODS:

A 52-week, multicentre, prospective, observational study of HRU due to exacerbations in patients with moderate to severe COPD was performed. Patients were recruited from primary care physicians and respirologists in urban and rural centres in Canada.

RESULTS:

In total, 524 subjects (59% men) completed the study. Their mean age was 68.2±9.4 years, with a forced expiratory volume in 1 s of 1.01±0.4 L. Patients had significant comorbidities. There were 691 acute exacerbations of COPD, which occurred in 53% of patients: 119 patients (23%) experienced one acute exacerbation, 70 patients (13%) had two acute exacerbations and 89 patients (17%) had three or more acute exacerbations. Seventy-five patients were admitted to hospital, with an average length of stay of 13.2 days. Fourteen of the patients spent time in an intensive care unit (average length of stay 5.6 days). Factors associated with acute exacerbations of COPD included lower forced expiratory volume in 1 s (P<0.001), high number of respiratory medications prescribed (P=0.037), regular use of oral corticosteroids (OCSs) (P=0.008) and presence of depression (P<0.001). Of the 75 patients hospitalized, only 53 received OCSs, four received referral for rehabilitation and 15 were referred for home care.

CONCLUSIONS:

The present study showed a high prevalence of COPD exacerbations, which likely impacted on HRU. There was evidence of a lack of appropriate management of exacerbations, especially with respect to use of OCSs, and referral for pulmonary rehabilitation and home care.     

The Impact of Severe Asthma on Schoolchildren

Episodic airway obstruction and hypoxia are potentially life-threatening to children with asthma and may account for neuropsychological impairment. Moreover, living with this chronic disease may severely disrupt children's emotional functioning. The general functioning of 25 children with severe asthma aged 10-13 years was tested by a comparison with 25 matched normal controls. Testing included variables with relevance to normal daily functioning: memory, concentration, school performance, physical condition, subjective symptoms after exercise, and negative emotions. The results showed that children with asthma did not significantly deviate from controls. They reported more dyspnea after physical exercise, which could not be attributed to lung function. Differences in school performance were not significant. It was concluded that children may generally adapt well to living with asthma.     

The Impact of Asthma on Health-Related Quality of Life

Although a substantial body of epidemiological and economic literature on asthma exists, relatively little is known about the impact of asthma on health-related quality of life (HRQL). The purpose of this review was to synthesize results from recent studies, profile the factors influencing HRQL in asthmatics, discuss the impact of treatment on HRQL outcomes, and offer recommendations for further research. The results of this review support the premise that asthma can adversely affect the physical, psychological, and social domains of HRQL. Published data suggest that females, those from lower socioeconomic groups, and ethnic minorities experience poorer quality of life as a result of their asthma symptoms. Results of published clinical trials indicate treatment regimens can have a significant impact on HRQL outcomes. Pharmacological interventions appear to effect change primarily in the physical domain and behavioral interventions lead to improvements in both physical and psychosocial domains. Future research should focus on precise a priori delineation of research hypotheses, including the selection of primary and secondary endpoints, the clarification and consistent application of criteria for defining asthma severity, thoughtful selection of HRQL instruments appropriate for the research hypotheses and target population, and careful delineation of clinically meaningful change scores of asthma-specific outcome measures.     

Impact of the Foundations of Clinical Medicine Course on USMLE Scores

BACKGROUND  The synthesis of basic and clinical science knowledge during the clerkship years has failed to meet educational expectations. OBJECTIVES  We hypothesized that a small-group course emphasizing the basic science underpinnings of disease, Foundations of Clinical Medicine (FCM), could be integrated into third year clerkships and would not negatively impact the United States Medical Licensure Examination (USMLE) step 2 scores. DESIGN  In 2001–2002, all third year students met weekly in groups of 8–12 clustered within clerkships to discuss the clinical and basic science aspects of prescribed, discipline-specific cases. PARTICIPANTS  Students completing USMLE step 2 between 1999 and 2004 (n = 743). MEASUREMENTS  Course evaluations were compared with the overall institutional average. Bivariate analyses compared the mean USMLE steps 1 and 2 scores across pre- and post-FCM student cohorts. We used multiple linear regression to assess the association between USMLE step 2 scores and FCM cohort controlling for potential confounders. RESULTS  Students’ average course evaluation score rose from 66 to 77 (2001–2004) compared to an institutional average of 73. The unadjusted mean USMLE step 1 score was higher for the post-FCM cohort (212.9 vs 207.5, respectively, p < .001) and associated with step 2 scores (estimated coefficient = 0.70, p < .001). Post-FCM cohort (2002–2004; n = 361) mean step 2 scores topped pre-FCM (1999–2001; n = 382) scores (215.9 vs 207.7, respectively, p < .001). FCM cohort remained a significant predictor of higher step 2 scores after adjustment for USMLE step 1 and demographic characteristics (estimated coefficient = 4.3, p = .002). CONCLUSIONS  A curriculum integrating clinical and basic sciences during third year clerkships is feasible and associated with improvement in standardized testing. Electronic supplementary material  The online version of this article (doi: ) contains supplementary material, which is available to authorized users.     

Prevalence and Impact of Asthma and Allergy on Daily Life,Health Outcomes and Use of Healthcare Services in Children: A Population-Based Study

IntroductionStudies on the prevalence of asthma and allergies often lack representation of the pediatric population, and their impact has not been examined using children without these diseases as a reference group. This study aimed to determine the prevalence of asthma and allergies in children under 14 years old in Spain and their impact on health-related quality of life, activities, healthcare utilization, and environmental and household exposure risk factors.MethodsData came from a Spanish population-based representative survey of children aged <14 years (N = 6297). A sample of controls (1:4) from the same survey was matched using propensity score matching. Logistic regression models and population-attributable fractions were calculated to determine the impact of asthma and allergy.ResultsThe population prevalence of asthma was 5.7% (95% CI: 5.0%, 6.4%), and of allergy was 11.4% (95% CI: 10.5%, 12.4. In children with lower percentiles of health-related quality of life (≤20th), 32.3% (95% CI, 13.6%, 47.0%) was attributed to asthma and 27.7% (95% CI: 13.0%, 40.0%) to allergy. Forty-four percent of restrictions in usual activity were attributed to asthma (OR: 2.0, p-value: <0.001), and 47.9% to allergy (OR: 2.1, p-value: <0.001). 62.3% of all hospital admissions were attributed to asthma (OR: 2.8, p-value: <0.001), and 36.8% (OR: 2.5, p-value: <0.001) of all specialist consults to allergy.ConclusionsThe high prevalence of atopic disease and its impact on daily life and healthcare utilization call for an integrated healthcare system focused on children and caregivers’ needs with continuity of care across education and healthcare settings.     

The impact of follow-up physician visits on emergency readmissions for patients with asthma and chronic obstructive pulmonary disease: a population-based study

PURPOSE: To examine the relation between follow-up office visits after emergency discharge and the risk of emergency readmissions in patients with asthma or chronic obstructive pulmonary disease (COPD). SUBJECTS AND METHODS: We used population-based data to identify all patients in Alberta, Canada, who had at least one emergency visit for asthma or COPD between April 1, 1996, and March 31, 1997 (N = 25 256). A Cox proportional hazards model was used to estimate the adjusted relative risk (RR) of a repeat visit to an emergency department within 90 days of an initial emergency visit in patients who did or did not have an office follow-up within the first 30 days. RESULTS: There were 7829 patients (31%) who had an office visit during the 30 days after their initial emergency encounter. Follow-up visits were associated with a significant reduction in the 90-day risk of an emergency readmission (RR = 0.79; 95% confidence interval [CI]: 0.73 to 0.86). Sensitivity analyses showed that a follow-up visit was inversely associated with a repeat emergency visit after adjusting for age, sex, area of residence, and income. CONCLUSION: Although these data should be interpreted with caution because of missing information on factors such as quality of care, they suggest that follow-up office visits are effective in reducing early relapses in patients who have been recently treated in emergency departments for asthma or COPD.     

Two-Year Results from the Asthma Self-Management Program: Long-Term Impact on Health Care Services,Costs, Functional Status,and Productivity

Participants in a variety of health plans, clinics and employer groups were invited to participate in the Asthma Self-Management Program (ASMP), an education program designed to improve self-management skills and daily functioning in individuals with asthma. The ASMP is an 8-week classroom program that provides information on the respiratory system, trigger avoidance, use of monitoring techniques and asthma medications. After program completion, graduates were contacted at scheduled intervals to reinforce performance of behaviors that are important to asthma self-management and to collect outcomes data. This paper reports the results of 2 years of follow-up with these individuals.     

Two-Year Results from the Asthma Self-Management Program: Long-Term Impact on Health Care Services, Costs, Functional Status, and Productivity

Participants in a variety of health plans, clinics and employer groups were invited to participate in the Asthma Self-Management Program (ASMP), an education program designed to improve self-management skills and daily functioning in individuals with asthma. The ASMP is an 8-week classroom program that provides information on the respiratory system, trigger avoidance, use of monitoring techniques and asthma medications. After program completion, graduates were contacted at scheduled intervals to reinforce performance of behaviors that are important to asthma self-management and to collect outcomes data. This paper reports the results of 2 years of follow-up with these individuals.     

The effects of outdoor air pollution on the respiratory health of Canadian children: A systematic review of epidemiological studies

BACKGROUND:

Outdoor air pollution is a global problem with serious effects on human health, and children are considered to be highly susceptible to the effects of air pollution.

OBJECTIVE:

To conduct a comprehensive and updated systematic review of the literature reporting the effects of outdoor air pollution on the respiratory health of children in Canada.

METHODS:

Searches of four electronic databases between January 2004 and November 2014 were conducted to identify epidemiological studies evaluating the effect of exposure to outdoor air pollutants on respiratory symptoms, lung function measurements and the use of health services due to respiratory conditions in Canadian children. The selection process and quality assessment, using the Newcastle-Ottawa Scale, were conducted independently by two reviewers.

RESULTS:

Twenty-seven studies that were heterogeneous with regard to study design, population, respiratory outcome and air pollution exposure were identified. Overall, the included studies reported adverse effects of outdoor air pollution at concentrations that were below Canadian and United States standards. Heterogeneous effects of air pollutants were reported according to city, sex, socioeconomic status and seasonality. The present review also describes trends in research related to the effect of air pollution on Canadian children over the past 25 years.

CONCLUSION:

The present study reconfirms the adverse effects of outdoor air pollution on the respiratory health of children in Canada. It will help researchers, clinicians and environmental health authorities identify the available evidence of the adverse effect of outdoor air pollution, research gaps and the limitations for further research.     

A Comparison of Two Simple Measures to Evaluate the Health Status of Asthmatics: The Asthma Bother Profile and the Airways Questionnaire 20

Simple and concise measures for health status are desirable in clinical practice. The Asthma Bother Profile (ABP), which consists of 23 items, has been developed to assess how much asthma bothers patients. The Airways Questionnaire 20 (AQ20) is a simple instrument which consists of 20 items. The purpose of this study was to investigate how the ABP and AQ20 evaluate the health status of patients with asthma. A total of 166 patients with chronic asthma (age: 48 ± 16 yr, 77 males) completed pulmonary function testing, measurement of airway hyperresponsiveness, dyspnea rating, assessments of their anxiety and depression (HADS; Hospital Anxiety and Depression Scale), and assessments of their health status. The health status was assessed using the ABP, AQ20, the short-form 36 health survey questionnaire (SF-36), the Living With Asthma Questionnaire (LWAQ) and the Asthma Quality of Life Questionnaire (AQLQ). The Japanese version of the ABP included only 15 'bother' items out of the original 23 items due to cultural differences. The scores on the ABP were widely distributed, whereas the scores on the AQ20 were skewed towards the milder end of the scale. The ABP had a strong correlation with the Avoidance and Distress constructs on the LWAQ, and Anxiety and Depression on the HADS (Rs = 0.56 ∼ 0.79), and its strongest correlation with the General Health (Rs = - 0.64) scale among the 8 subscales on the SF-36. The AQ20 had a less significant correlation with the LWAQ, AQLQ, and SF-36 than the ABP. The ABP and AQ20 were short and simple to complete, and both measures could easily be used in clinical practice. The ABP can evaluate patients more specifically with respect to distress and bother than the AQ20.