Health-Care Utilization After Near-Fatal Asthma

doi:10.1378/chest.107.6.1564

Chest

Volume 107, Issue 6, June 1995, Pages 1564-1569

https://doi.org/10.1378/chest.107.6.1564 Get rights and content

Near-fatal asthma has been repeatedly associated with an increased risk of premature death. Despite a higher risk, death after near-fatal asthma remains infrequent. Few studies have examined the long-term outcome of those who experience a near-fatal event but do not succumb to asthma. We therefore contacted patients who had an episode of near-fatal asthma 5 to 10 years earlier and documented their use of health-care services for asthma. Each index case was compared with two age-matched controls who had been hospitalized for severe but not near-fatal asthma within 2 years of the index case admission. Thirty-seven index cases and 74 control subjects were assessed. Demographics did not distinguish the two groups. Availability of primary care physicians and asthma specialists were similar. There was no difference in the frequency of hospitalizations, emergency room visits, or visits to physicians for asthma between the two groups. ICU admissions were extremely infrequent. Although the mean number of ICU admissions per subject were similar in the year preceding our contact (0.03 ± 0.16 in each group), there was a trend toward ICU admissions occurring more often in the near-fatal group (0.62 ± 1.67 vs 0.31 ± 0.91 admissions/subject). Days away from work were more frequent in the control group (3.5 ± 5.5 vs 1.6 ± 3.3 d/yr) including days away from work in the year preceding our contact (8.9 ± 43 vs 1.8 ± 6.1 d). The data suggests that with regards to characteristics and health-care utilization, it may not be possible to distinguish people with near-fatal asthma from those who are hospitalized without a near-fatal event.

Section snippets

Methods

We examined all medical records from The Toronto Hospital from 1981 to 1986 where patients’ admitting diagnosis was recorded as asthma. A trained research assistant reviewed the entire hospital chart of each patient and excluded the chart from the analysis if (1) there was a second admitting diagnosis, ie, congestive heart failure, (2) the diagnosis of asthma was unclear, or (3) there was a second respiratory diagnosis, ie, pneumonia, COPD. Charts were excluded if the discharge diagnosis did

Patient Characteristics

A total of 101 cases of near-fatal asthma were identified through hospital records using the preset criteria. Thirty-seven patients consented to participate in the study. There was a mean of 6.76 ± 1.4 years between the near-fatal admission and the time of the present study. Forty-six percent of the subjects had been intubated. The mean age of the near-fatal cases intubated and those not intubated was 40.9 ± 17.6 and 38.45 ± 14.3 years respectively. The man to woman ratio was 7:10 for those

Discussion

Near-fatal asthma, as defined by the occurrence of an elevated PaCO₂ of at least 45 mm Hg or intubation, has been associated with an increased risk of death from asthma.5, 6, 9, 10 We sought to examine the long-term use of health-care services by patients who experience near-fatal asthma but do not die from their disorder. Demographic data such as place of birth, level of education, marital status, or occupation did not distinguish patients who survived over a prolonged period after a

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Cited by (16)

The influence of perceived control of asthma on health outcomes
2006, Chest
Citation Excerpt :
To establish a cohort with more severe asthma,8,910,11,12 we recruited adults after hospitalization for asthma using a previously established algorithm.13 Beginning in April 2000, we attempted to recruit all eligible adults who were admitted to the ICU for asthma and were therefore considered to have more severe asthma.8,1415,16,17 To broaden the spectrum of asthma severity, we also began recruiting a random sample of all eligible adults who were hospitalized for asthma in September 2000; in October 2002, we began recruiting all eligible adults who had been hospitalized for asthma.
Psychosocial factors play an important role in outcomes of asthma. Perceived control, a measure of patients' beliefs about their ability to control their disease, has not been studied in association with asthma health outcomes
We used data from a prospective cohort study of patients who were hospitalized for asthma (n = 865). After hospital discharge, we conducted structured telephone interviews to obtain demographic characteristics, asthma history, and psychological variables. Interviews included administration of the Perceived Control of Asthma Questionnaire (PCAQ). We then prospectively measured emergency department (ED) visits and hospitalizations for asthma over time, with a median follow-up time of 1.9 years
Greater perceived control was associated with better physical health status (mean score increment per 2-point change in PCAQ score, 1.13; 95% confidence interval [CI], 0.79 to 1.47), better asthma-related quality of life (mean score increment, −2.24; 95% CI, −2.6 to −1.83), fewer days of restricted activity due to asthma (mean increment, −1.23; 95% CI, −1.62 to −0.83), and lower asthma severity scores (mean score increment, −0.40; 95% CI, −0.53 to −0.27). In a multivariate model, greater perceived control was associated with a significantly decreased prospective risk of ED visits (hazard ratio [HR], 0.92; 95% CI, 0.86 to 0.98; p = 0.008) and hospitalizations for asthma (HR, 0.84; 95% CI, 0.78 to 0.90; p < 0.0001). There was no association found between perceived control and most aspects of preventive care or self-management
Greater perceived control is associated with improved asthma-related health status as well as with a decreased prospective risk of severe asthma attacks resulting in emergency health-care utilization. This difference does not appear to be mediated by changes in preventive care or asthma self-management practices.
Risk Factors for Work Disability in Severe Adult Asthma
2006, American Journal of Medicine
Citation Excerpt :
A combined clinical approach that includes smoking cessation, a careful occupational history, and optimization of asthma therapy has the potential to prevent work loss, financial deterioration, and negative asthma health outcomes.24-27
We aimed to elucidate the prevalence of and risk factors for work disability in severe adult asthma and to evaluate the impact of work disability on downstream health outcomes.
We used data from a prospective cohort study of 465 adults with severe asthma. Structured telephone interviews ascertained asthma status and employment history. A job exposure matrix (JEM) was used to characterize the likelihood of workplace exposure to “asthmagens.”
The prevalence of asthma-related complete work disability was 14% among working-age adults with severe asthma (95% confidence interval, 11%-18%). Among those who were currently employed, the prevalence of partial work disability was 38% (95% confidence interval, 31%-45%). Sociodemographic (P = .027) and medical factors (P = .020) were related to the risk of complete work disability. Both sociodemographic characteristics (P = .06) and work exposures based on the JEM (P = .012) were related to partial work disability. In additional models, poorer asthma severity, physical health status, and mental health status were all associated with a higher risk of complete and partial work disability.
Work disability is common among adults with severe asthma. There are three sets of risk factors for work disability that are potentially modifiable: smoking, workplace exposures, and asthma severity.
Asthma-related healthcare services utilization by African-Americans enrolled in West Virginia Medicaid
2006, Respiratory Medicine
Over the past 25 years, African–Americans have experienced higher rates of emergency department (ED) visits, hospitalizations, and death due to asthma compared to other ethnic groups in the US. African–Americans of lower socioeconomic groups are particularly vulnerable to asthma morbidity and mortality. Few studies have investigated asthma-related healthcare services use by different age and gender groups within this sub-population.
The objectives of this study are to: (1) report rates of asthma among African–Americans who receive healthcare through a state government Medicaid program that provides medical coverage to low-income citizens; (2) report rates of asthma-related medical services and prescription utilization for these recipients; and (3) report the costs to the Medicaid program for asthma-related care for these recipients.
This was a cross-sectional descriptive analysis. West Virginia (WV) Medicaid administrative fee-for-service claims data from calendar year 2002 were the data source. Medical services claims with a primary diagnosis of asthma for recipients who were African–American less than 65 years of age were extracted. Matching prescription claims for these recipients for medications to treat asthma were extracted. Dollars reimbursed for medical services and prescription medications were from the perspective of WV Medicaid.
There were 635 African–American recipients who had a primary diagnosis of asthma. Children under 21 years of age comprised the majority of the sample. Males under 21 years of age, and females 21 years and older had the highest rates of asthma. Although males 21 years and older accounted for the lowest proportion of age–gender groups, these recipients had the highest rates of hospitalizations and ED visits for asthma. Less than one-third of the recipients had a prescription claim for an inhaled corticosteroid. There were more claims paid by Medicaid for quick-relief medications vs. controller pharmacotherapy for the sample. A majority of the dollars paid by Medicaid for asthma care were for prescriptions and hospitalizations.
Asthma prevalence and asthma-related medical services utilization rates among African–American recipients of Medicaid varied by age and gender groups. These recipients appeared to be underutilizing controller pharmacotherapy for asthma.
Epidemiology of respiratory viruses in patients hospitalized with near-fatal asthma, acute exacerbations of asthma, or chronic obstructive pulmonary disease
2003, American Journal of Medicine
Citation Excerpt :
In addition, patients hospitalized with acute exacerbations of COPD were significantly older than asthmatic patients. It is unclear whether these differences could be due to possible age- and sex-based susceptibilities for viral infection and type of exacerbation, differences in the natural history of the asthmatic attack (21–23), or perhaps differences in hospitalization (24–28) or health care utilization (29). Another limitation is that we combined groups of viruses (picornavirus and adenovirus, and influenza A and B viruses) in the data analysis; these were not prespecified hypotheses.
We compared the prevalence and spectrum of common respiratory viruses among patients with near-fatal asthma, acute exacerbations of asthma, or chronic obstructive pulmonary disease (COPD), and the relation of these findings to acute respiratory symptoms.
We obtained adequate samples of respiratory secretions from 17 patients hospitalized with near-fatal asthma, 29 with acute asthma, and 14 with COPD. We used a polymerase chain reaction–based method to test for six common respiratory viruses in samples from endotracheal tube aspirates from patients with near-fatal asthma, and from induced sputum specimens from patients with acute asthma or COPD. Respiratory symptoms (runny nose, sore throat, fever, chills, malaise, and cough) were recorded. Quiescent-phase induced sputum specimens were examined from patients who were initially virus positive.
Viral nucleic acids were detected in 52% (31/60) of acute-phase specimens and 7% (2/29) of quiescent-phase specimens examined (P <0.001), with similar proportions of virus-positive patients during the acute phase in the three groups: 59% (10/17) of those with near-fatal asthma, 41% (12/29) with acute asthma, and 64% (9/14) with COPD. Picornavirus (47% [n = 8]) and adenovirus (24% [n = 4]) were most commonly identified in near-fatal asthma, whereas influenza virus (36% [n = 5]) predominated in COPD. Virus-positive patients had a significantly increased frequency of runny nose, sore throat, fever, chills, and malaise (odds ratio = 4.1 to 18; P = 0.02 to 0.001).
Respiratory viruses are associated with hospitalizations for near-fatal asthma, acute asthma, and COPD, with some differences in the spectrum of viruses involved in the different groups of patients. Respiratory viruses are a target for the prevention and perhaps the treatment of these conditions.
Near-fatal asthma: A population-based study of risk factors
2002, Chest
Citation Excerpt :
Effective treatment is likely to improve their quality of life and to allow participation in, for example, sports. Given their subsequent use of health-care resources,31 such an approach may reduce costs. However, there is considerable overlap in the risk factors among the three groups.
The study of near-fatal asthma (NFA) may provide a means to further our understanding of fatal asthma. Studies of NFA often are derived from a single ICU rather than from a defined population. We therefore aimed to identify factors distinguishing NFA patients (cases) from those persons treated in an emergency department (ED) [ED control subjects] and in the community (community control subjects [CCs]).
This was a population-based case-control study conducted over 20 months of 45 NFA patients (age range, 5 to 50 years), 197 ED control subjects treated in an ED, and 303 CCs, all of whom were residents of Alberta.
The age distribution was similar between NFA patients and control subjects, with the majority being < 22 years of age (NFA patients, 68.9%; ED control subjects, 71.3%; CCs, 60.7%). Those patients with NFA were significantly more likely to have received a diagnosis before 5 years of age (66.6%), compared to ED control subjects (39.6%) and CCs (28.7%). The NFA group was significantly more likely to report moderate-to-severe disease and more frequent symptoms than the other groups. Therapy with bronchodilators was used most frequently by the NFA group compared to the ED control subjects and CCs (p < 0.001), as was therapy with inhaled steroids (p < 0.001) and oral steroids (p < 0.001). NFA patients had higher scores for vulnerability and were most likely to admit to stress as an asthma trigger. All groups had high exposure to cigarette smoke and pets.
NFA patients have many modifiable risk factors and many similarities to ED control subjects and CCs with asthma. General measures to improve asthma control and awareness of risks are required in all groups.
Potentially fatal asthma and asthma deaths: Knowledge is greater but implementation appears problematic
2000, Annals of Allergy, Asthma and Immunology

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: revision accepted October 14.

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Chest

Clinical Investigations: AsthmaHealth-Care Utilization After Near-Fatal Asthma

Section snippets

Methods

Patient Characteristics

Discussion

Lancet

J Allergy Clin Immunol

Chest

J Allergy Clin Immunol

Mortality from asthma: a new epidemic in New Zealand

BMJ

Increased rates of illness and death from asthma in Canada

Can Med Assoc J

Clinical Investigations: Asthma
Health-Care Utilization After Near-Fatal Asthma