Predictors of repeated acute hospital attendance for asthma in children: A systematic review and meta-analysis.

BACKGROUND: Asthma attacks are common and have significant physical, psychological, and financial consequences. Improving the assessment of a child's risk of subsequent asthma attacks could support front-line clinicians' decisions on augmenting chronic treatment or specialist referral. We aimed to identify predictors for emergency department (ED) or hospital readmission for asthma from the published literature. METHODS: We searched MEDLINE, EMBASE, AMED, PsycINFO, and CINAHL with no language, location, or time restrictions. We retrieved observational studies and randomized controlled trials (RCT) assessing factors (personal and family history, and biomarkers) associated with the risk of ED re-attendance or hospital readmission for acute childhood asthma. RESULTS: Three RCTs and 33 observational studies were included, 31 from Anglophone countries and none from Asia or Africa. There was an unclear or high risk of bias in 14 of the studies, including 2 of the RCTs. Previous history of emergency or hospital admissions for asthma, younger age, African-American ethnicity, and low socioeconomic status increased risk of subsequent ED and hospital readmissions for acute asthma. Female sex and concomitant allergic diseases also predicted hospital readmission. CONCLUSION: Despite the global importance of this issue, there are relatively few high quality studies or studies from outside North America. Factors other than symptoms are associated with the risk of emergency re-attendance for acute asthma among children. Further research is required to better quantify the risk of future attacks and to assess the role of commonly used biomarkers

Allergic rhinitis: evidence for impact on asthma

BACKGROUND: This paper reviews the current evidence indicating that comorbid allergic rhinitis may have clinically relevant effects on asthma. DISCUSSION: Allergic rhinitis is very common in patients with asthma, with a reported prevalence of up to 100% in those with allergic asthma. While the temporal relation of allergic rhinitis and asthma diagnoses can be variable, the diagnosis of allergic rhinitis often precedes that of asthma. Rhinitis is an independent risk factor for the subsequent development of asthma in both atopic and nonatopic individuals. Controlled studies have provided conflicting results regarding the benefits for asthma symptoms of treating comorbid allergic rhinitis with intranasal corticosteroids. Effects of other treatments for comorbid allergic rhinitis, including antihistamines, allergen immunotherapy, systemic anti-IgE therapy, and antileukotriene agents, have been examined in a limited number of studies; anti-IgE therapy and antileukotriene agents such as the leukotriene receptor antagonists have benefits for treating both allergic rhinitis and asthma. Results of observational studies indicate that treating comorbid allergic rhinitis results in a lowered risk of asthma-related hospitalizations and emergency visits. Results of several retrospective database studies in the United States and in Europe indicate that, for patients with asthma, the presence of comorbid allergic rhinitis is associated with higher total annual medical costs, greater prescribing frequency of asthma-related medications, as well as increased likelihood of asthma-related hospital admissions and emergency visits. There is therefore evidence suggesting that comorbid allergic rhinitis is a marker for more difficult to control asthma and worsened asthma outcomes. CONCLUSION: These findings highlight the potential for improving asthma outcomes by following a combined therapeutic approach to comorbid allergic rhinitis and asthma rather than targeting each condition separately

Thymic stromal lymphopoietin (TSLP) is associated with allergic rhinitis in children with asthma

<p>Abstract</p> <p>Background</p> <p>Allergic rhinitis (AR) affects up to 80% of children with asthma and increases asthma severity. Thymic stromal lymphopoietin (TSLP) is a key mediator of allergic inflammation. The role of the TSLP gene (<it>TSLP</it>) in the pathogenesis of AR has not been studied.</p> <p>Objective</p> <p>To test for associations between variants in <it>TSLP</it>, <it>TSLP</it>-related genes, and AR in children with asthma.</p> <p>Methods</p> <p>We genotyped 15 single nucleotide polymorphisms (SNPs) in <it>TSLP, OX40L, IL7R</it>, and <it>RXRα </it>in three independent cohorts: 592 asthmatic Costa Rican children and their parents, 422 nuclear families of North American children with asthma, and 239 Swedish children with asthma. We tested for associations between these SNPs and AR. As we previously reported sex-specific effects for <it>TSLP</it>, we performed overall and sex-stratified analyses. We additionally performed secondary analyses for gene-by-gene interactions.</p> <p>Results</p> <p>Across the three cohorts, the T allele of <it>TSLP </it>SNP rs1837253 was undertransmitted in boys with AR and asthma as compared to boys with asthma alone. The SNP was associated with reduced odds for AR (odds ratios ranging from 0.56 to 0.63, with corresponding Fisher's combined P value of 1.2 × 10^-4). Our findings were significant after accounting for multiple comparisons. SNPs in <it>OX40L, IL7R</it>, and <it>RXRα </it>were not consistently associated with AR in children with asthma. There were nominally significant interactions between gene pairs.</p> <p>Conclusions</p> <p><it>TSLP </it>SNP rs1837253 is associated with reduced odds for AR in boys with asthma. Our findings support a role for <it>TSLP </it>in the pathogenesis of AR in children with asthma.</p

Treatment, health care utilization and health outcomes among primary care patients with generalized anxiety disorder in the United Kingdom

The purpose of this study was to determine treatment patterns for primary care patients with Generalized Anxiety Disorder (GAD) in the United Kingdom. Associations between drug treatments, demographic characteristics, clinical outcomes, resource utilization and other economic outcomes were examined. A 12-month retrospective study using a sample of GAD patients from the General Practice Research Database during 1997–99 was conducted. 2,678 patients treated with benzodiazepines (38.1%), serotonin reuptake inhibitors (SRIs) (11.5%), tricyclic antidepressants (TCAs) (13.0%), beta-blockers (30.4%), buspirone (3.3%) and thioxanthene (3.3%) were included. Benzodiazepines were more frequently prescribed to women (p \u3c 0.048), older patients (p \u3c 0.0001), patients with GAD history (p \u3c 0.0153) and history of substance abuse (p \u3c 0.0197), and to patients from Wales, Scotland and Northern Ireland compared to England (p \u3c 0.001). Among 2,499 patients treated with benzodiazepines, SRIs, TCAs and beta-blockers, 20.6 percent experienced some treatment failure, defined as treatment switches or augmentations and/or mental disease related referrals, hospitalizations or emergency visits. Treatment success, physician recorded patient improvement, was seen in 5.4 percent of the patients. There were no differences in likelihood of treatment failure or time-to-treatment failure between drug classes after controlling for risk factors including age, gender, region, dose, prior mental or somatic illnesses and health services utilization. Physician recorded improvement was six times more likely in patients treated with SRIs (p \u3c 0.0001) than in those treated with benzodiazepines after adjusting for risk factors. SRIs also had higher improvement rates than TCAs and beta-blockers (both p \u3c 0.01). However, patients treated with beta-blockers received significantly fewer prescriptions and incurred significantly fewer outpatient visits compared to other groups (both p \u3c 0.0001) after adjustment for risk factors. Costs related to GAD drugs and mental-health services use were significantly higher in the SRIs group primarily due to higher drug costs (£168 [£152–£184], p \u3c 0.0001). Likelihood of mental-health related work-loss was significantly higher in patients treated with TCAs (7.7%) compared to those on beta-blockers (3.5%). Mean mental-health related absence among all GAD patients was 2.4 days and 55.7 days among patients with at least one mental-health related work absence. No differences between treatment groups were noted after adjustment for risk factors. Given the results of this study, there is no clear evidence that treatment with any particular drug provides better long-term clinical outcomes among GAD patients although physicians recorded higher improvement following treatment with SRIs. Treatment costs were substantial, and higher in GAD patients treated with SRIs than in any other group. Despite likely incomplete recording of work-absence data, GAD is responsible for significant work-loss

Healthcare Utilisation and Costs Associated with Adding Montelukast to Current Therapy in Patients with Mild to Moderate Asthma and Co-Morbid Allergic Rhinitis: PRAACTICAL Study

Objective: To evaluate the healthcare resource use and costs associated with adding montelukast to therapy in patients with mild to moderate persistent asthma and co-morbid seasonal allergic rhinitis whose asthma is inadequately controlled by their current asthma therapy. Methods: A multicentre, pre-post retrospective cohort study was conducted in three European countries (Italy, Poland and Spain). Consecutive patients who were receiving inhaled corticosteroid therapy (monotherapy or combination therapy with long-acting beta2-adrenoceptor agonists) and who started concomitant treatment with montelukast between January 1999 and December 2002 were identified from clinical charts. Asthma/seasonal allergic rhinitis-related concomitant medications and asthma-related outpatient care, ED visits and hospitalisations for the periods 12 months before and 12 months after montelukast initiation were recorded from patient charts and combined with country-specific published unit costs (adjusted to 2004 values). The analysis was performed from a third-party-payer perspective and thus direct healthcare resource utilisation due to asthma/seasonal allergic rhinitis and associated costs for each country were estimated. Results: A total of 98 physicians provided data for 696 asthmatic patients with seasonal allergic rhinitis (Italy: n = 158; Poland: n = 334; and Spain: n = 204). The mean age of patients was 32.7 years, 57.5% were female and patients had asthma that was considered either mild-persistent (54.5%) or moderate-persistent (45.5%) according to the Global Initiative for Asthma classifications. The introduction of montelukast (10 mg/day daily cost range _0.8-1.68) was associated with increases in the total annual mean healthcare cost per patient of 11.9%, 60.4% and 5.5% for Italy, Poland and Spain, respectively. However, mean annual costs for asthma-related outpatient care, ED visits and hospitalisations dropped significantly in all three countries (Italy: from _805.00 to _281.60 [p_Allergic-rhinitis, Asthma, Cost-analysis, Montelukast, Resource-use

Association between asthma control in children and loss of workdays by caregivers

International audienceBACKGROUND: Although the economic burden of pediatric asthma is a significant public health issue, the loss of workdays by caregivers because of their children's asthma remains scarcely investigated. OBJECTIVES: To evaluate asthma-related loss of workdays incurred by caregivers of asthmatic children and its association with the level of asthma control. METHODS: A retrospective observational study was conducted based on a French computerized general practitioners' database and a survey questionnaire. Children aged 6 to 16 years with persistent asthma (Global Initiative for Asthma grade \\textgreater or = 2) were included in the study. Level of children's asthma control was evaluated from recent asthma symptoms. Caregivers reported the number of workdays lost because of their child's asthma during the 12-month study. RESULTS: Nearly 30% of caregivers lost workdays during the study because of their children's asthma. More than 13% of caregivers lost more than 5 days. Caregiver absenteeism significantly correlated with all components of asthma control (use of relievers, nocturnal symptoms, impairment of activities, and asthma crises). A significant 8-fold risk of losing more than 5 workdays by caregivers was observed when the child's asthma was poorly controlled (odds ratio, 8.6; 95% confidence interval, 2.4-30.5); caregivers' absenteeism also increased significantly with the number of episodes of oral corticosteroid use during the study. CONCLUSIONS: Caregivers' loss of workdays owing to their children's asthma is substantial and is highly correlated with the level of asthma control. These findings highlight the necessity of educational programs for children with poor asthma control and their caregivers to prevent severe asthma attacks that lead to caregiver absenteeism

Asthma-related resource use and cost by GINA classification of severity in three European countries

SummaryBackgroundThis study assessed the relationship between asthma burden and asthma severity in France, Italy, and Spain.MethodsAdult asthmatics, 18–55 years of age, completed a questionnaire while visiting a respiratory physician in 1998 and 1999. Asthma severity was categorized by physicians as intermittent, mild persistent, moderate persistent, or severe persistent according to Global Initiative for Asthma (GINA) guidelines.ResultsTotals of 282 patients in France, 500 in Italy, and 296 in Spain entered the study. There were few differences between the three countries in the asthma symptom burden. Most patients with persistent asthma had used inhaled corticosteroids in the previous 14 days. Unexpectedly, 35% (Italy) to 83% (Spain) of patients with intermittent asthma also had used inhaled corticosteroids. In Spain, visits to the emergency department were more frequent (OR 7.0, 95% CI 4.9–10.0 with Italy as reference) and the costs of emergency care in all asthma severity categories were up to 10 times higher than in Italy and France. The frequency of hospitalizations did not differ systematically between the three countries.ConclusionsInadequate control of asthma symptoms among patients with severe persistent asthma could not be entirely explained by under-prescribing of asthma medications. The use of inhaled corticosteroids by patients with intermittent asthma might reflect misclassification of asthma severity, possibly due to difficulty in interpreting the GINA guidelines. The relatively high cost of emergency care in Spain does not appear to be related to greater asthma severity or poorer symptom control, but may be a feature of the Spanish health care system