Original article
Asthma, lower airway disease
Impact of asthma control on sleep, attendance at work, normal activities, and disease burden

https://doi.org/10.1016/j.anai.2010.05.009Get rights and content

Background

The 2007 Expert Panel Report 3 asthma treatment guidelines place substantial emphasis on understanding the effectiveness of treatment strategies on outcomes such as disease control.

Objective

To assess the impact of asthma control on patient-reported outcomes and disease burden in a real-world setting.

Methods

Patients aged 18 to 64 years with moderate to severe asthma defined by medical and pharmaceutical use were asked to participate in a cross-sectional survey of asthma care, control, and burden. Patients were included if they had an International Classification of Diseases, Ninth Revision, Clinical Modification code for asthma, a prescription for an Expert Panel Report 3–defined controller medication (or combinations), and 24-month pre-index continuous eligibility. Patients with chronic obstructive pulmonary disease were excluded. Survey respondent data were linked to commercial health claims information to create the research database. The Asthma Therapy Assessment Questionnaire (ATAQ) was used as the measure of control. The ATAQ scores range from 0 to 4, with 0 indicating no asthma control problems.

Results

A total of 1,199 patients (73% women) completed the survey and had their claims data linked for analysis. Age, sex, and comorbidity index measures did not differ between respondents and nonrespondents. Only 12.2% of respondents scored 0 on the ATAQ, 77.0% scored 1 or 2, and 10.8% scored 3 or 4. The ATAQ scores were moderately correlated with patient-rated severity. Decreasing levels of asthma control were associated with greater prevalences of sleep problems, depression, functional impairment, and effect on work and regular activities.

Conclusions

Approximately 88% of patients with moderate to severe asthma were not fully controlled despite anti-inflammatory drug treatment. Lack of asthma control is associated with substantial patient burden.

Introduction

The National Asthma Education and Prevention Program released updated diagnosis and management guidelines in 2007 that focused attention on achieving disease control as the primary therapeutic goal.1 In drafting the revised guidelines, National Asthma Education and Prevention Program members understood that asthma control is a multifaceted measure that reflects symptoms, lung function, and patient well-being. Each of these, in turn, can affect patient morbidity and burden. The American Thoracic Society and the European Respiratory Society established a task force of asthma experts to provide standardized definitions of asthma control, severity, and exacerbations.2 Until the recent American Thoracic Society/European Respiratory Society Task Force Report on Asthma Control, a standardized definition of asthma control had not been recognized in the clinical or research community, making it difficult to characterize or report control status and correlates in asthma populations.

Despite the lack of standardized definitions, research from real-world observational studies has shown that asthmatic patients receiving guideline-based asthma treatment achieved control only one-third of the time.3 Furthermore, patients with uncontrolled asthma were found to have significantly higher expenditures compared with asthmatic patients whose symptoms were well controlled ($14,212 vs $6,452).4 More important, in this study population, asthma control could not be sustained during the 2-year study in nearly 85% of patients. These findings from observational studies are in contrast to those of a large, well-controlled clinical trial5 that reports that patients receiving a fixed-dose combination of inhaled corticosteroid and long-acting β-agonist can achieve and maintain a high level of asthma control.

We investigated the relationships among asthma control, morbidity, resource use, productivity, and costs in adults with moderate to severe asthma to more clearly characterize and quantify asthma control in a real-world setting. The 2 main study hypotheses were that (1) asthmatic patients in real-world, nonexperimental settings have substantially lower levels of asthma control, despite the availability of effective treatments, and (2) lower levels of asthma control are positively correlated with measures of morbidity, productivity, and medical resource use. We hope that these data improve our understanding of the implications and burden of poor asthma control in nonexperimental settings, where treatment choices and patient behavior approximate real-world circumstances.

Section snippets

Data Source

Data from survey respondents were linked to health care administrative claims data using the HealthCore Integrated Research Database. At the time that this study was conducted, this database was populated from 10 geographically dispersed US health plans consisting of approximately 22.5 million continuously enrolled patients from January 1, 2000, to August 31, 2006. This research was approved by an independent institutional review board (Quorum Review Inc, Seattle, Washington) and includes a

Results

A total of 24,631 patients meeting the inclusion and exclusion criteria were identified from the administrative claims data. From this group, 1,199 patients (73% women) completed the survey across 2 rounds of telephone-based surveys, with 582 patients (67% women) completing round 1 and 617 (79% women) completing round 2. To assess responder bias, we compared age, sex, and mean Deyo-Charlson Comorbidity Index score10, 11 between patients who completed the survey and those who did not. There were

Discussion

In this study, patients with poorly controlled moderate to severe asthma had higher levels of comorbidity and health care utilization than did well-controlled patients. Asthmatic patients with poor control have a lower quality of life and are more likely to miss work because of their asthma. These findings are consistent with previous research12, 13, 14 and are particularly important in light of the usual care settings in which we interviewed patients.

Furthermore, this study found a greater

Conclusions

Patients with asthma remain severely affected by their disease despite available treatment options. More effective oversight and modification of asthma treatment needs to be targeted to asthmatic patients to improve asthma control and decrease impairment of patients' quality of life and functional capacity.

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    Disclosures: Drs Wertz and Rodgers are full-time employees of HealthCore Inc, which received payment from Novartis Pharmaceuticals Corp for research and consulting services associated with this manuscript. Mr Pollack and Dr Bohn were full-time employees of HealthCore Inc at the time the study was conducted. Mr Pollack is now a full-time employee of AstraZeneca, and Dr Bohn is currently an independent consultant in pharmacoepidemiology. Ms Sacco is a full-time employee of Novartis Pharmaceuticals Corp. Dr Sullivan received consulting fees from Novartis Pharmaceuticals Corp for research design, data interpretation, and manuscript preparation.

    Funding Source: This study was supported by Novartis Pharmaceuticals Corp and Genentech Inc.

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