Asthma Hospitalization Risk Dependent on Controller Treatment

For patients with asthma, the choice of controller therapy and treatment adherence influence the risk of a severe exacerbation, which often results in hospital admission. Asthma-related hospital stays account for a considerable proportion of healthcare costs. Determining medication-use patterns before hospital admission for asthma is the key to improving quality of care, preventing severe exacerbations, and reducing costs.

To determine patterns of asthma medication use and their relation to hospital admission, a team of European and Canadian researchers used a random sample of French national claims data to identify asthma patients who were between 6 and 40 years old between 2000 and 2014. From this sample of 17,846 patients, they selected 275 patients subsequently admitted to the hospital for asthma to participate in their study.

On the basis of the controller therapy dispensed in the year before admission, the researchers categorized treatment profiles into clusters by using Ward’s minimum-variance hierarchical clustering method. This procedure identified three distinct clusters:

1. Patients who had few dispensations of any controller medication (<1 unit) (63.6%)

2. Patients who received frequent dispensations of long-acting beta agonists (LABAs) with ICS in fixed-dose combinations (32.4%)

3. Patients who received free combinations that included more dispensations of LABAs than of ICS (4%).

The researchers noted that asthma therapy was obviously inappropriate in the two-thirds of patients in clusters 1 and 3.

According to the researchers, cluster 1 had intermittent asthma and low health literacy that contributed to inappropriate management of their disease. Moreover, because most did not have long-term disease, the high severity of their asthma went unrecognized. This cluster illustrates that underuse of controller therapy, especially ICS, is a major issue in asthma management.

In contrast, cluster 2 included many patients with long-term disease (27%) and more frequent medical visits. Those in this cluster had more severe asthma that was poorly controlled despite regular use of controller therapy, possibly because of poor quality of inhaler use.

Although cluster 3 also included many patients with long-term disease (27%), they had few contacts with specialists and poor quality of care. The researchers noted that this cluster reflects unresolved questions regarding the safety of LABAs when used with ICS in separate canisters.

According to the investigators, their results indicate that better drug therapy could prevent a large proportion of hospital admissions for asthma. To do so, they recommended improving the quality of prescribing and patient education on appropriate use of therapy, including inhalers. They also recommended giving clinicians feedback from claims data on patients’ actual use of controllers.

They advised giving patients written personal action plans describing how to recognize deterioration in their condition and the steps needed to reestablish control. And they suggested that nurses should review patients’ use of therapy and provide training and support to improve it.

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