Risk Factors and Predictive Clinical Scores for Asthma Exacerbations in Childhood

doi:10.1378/chest.09-2426

Chest

Volume 138, Issue 5, November 2010, Pages 1156-1165

https://doi.org/10.1378/chest.09-2426 Get rights and content

Background

Asthma is a major public health problem that affects millions of children worldwide, and exacerbations account for most of its morbidity and costs. Primary-care providers lack efficient tools to identify children at high risk for exacerbations. We aimed to construct a clinical score to help providers to identify such children.

Methods

Our main outcome was severe asthma exacerbation, which was defined as any hospitalization, urgent visit, or systemic steroid course for asthma in the previous year, in children. A clinical score, consisting of a checklist questionnaire made up of 17 yes-no questions regarding asthma symptoms, use of medications and health-care services, and history, was built and validated in a cross-sectional study of Costa Rican children with asthma. It was then evaluated using data from the Childhood Asthma Management Program (CAMP), a longitudinal trial cohort of North American children.

Results

Compared with children at average risk for an exacerbation in the Costa Rican validation set, the odds of an exacerbation among children in the low-risk (OR, 0.2; 95% CI, 0.1–0.4) and high-risk (OR, 5.4; 95% CI, 1.5–19.2) score categories were significantly reduced and increased, respectively. In CAMP, the hazard ratios for an exacerbation after 1-year follow-up in the low-risk and high-risk groups were 0.6 (95% CI, 0.5–0.7) and 1.9 (95% CI, 1.4–2.4), respectively, with similar results at 2 years.

Conclusions

The proposed Asthma Exacerbation Clinical Score is simple to use and effective at identifying children at high and low risk for asthma exacerbations. The tool can easily be used in primary-care settings.

Section snippets

Study Population

A detailed description of the study methods is provided in the e-Appendix 1 and e-Table 1. Children who participated in this study were index cases for a family-based study of the genetics of asthma in Costa Rica. Subject recruitment and study procedures have been described in detail elsewhere.6, 7 The study was approved by the Institutional Review Boards of the Hospital Nacional de Niños (San José, Costa Rica) and Brigham and Women's Hospital (Boston, MA).

Questionnaires and Laboratory Testing

Parents of the study participants

Costa Rican Cohort

A total of 615 children with asthma enrolled in the study had information on exacerbations. There were no significant differences between the exploratory and validation data sets (e-Table 2). The baseline characteristics of the 465 children in the exploratory data set are shown in Table 1. The age of participants ranged from 6 to 14 years. Physician-diagnosed hay fever, parental history of asthma and hay fever, and skin test reactivity (STR) to one or more allergens were all common; mean total

Discussion

To our knowledge, this study is the first to examine risk factors for asthma exacerbations in a well-characterized cohort of Hispanic children. We constructed a checklist-type clinical score to identify Costa Rican children at low and high risk for asthma exacerbations. This score performed well in the exploratory and validation sets, indicating good reproducibility. In Costa Rica, compared with children at average risk for exacerbations, children at low risk had 0.2 times lower odds for

Acknowledgments

Author contributions: Dr Forno: contributed to the data analysis and was primarily responsible for writing the manuscript.

Dr Fuhlbrigge: contributed to the data analysis and the drafting of the manuscript and review of its final version.

Dr Soto-Quirós: contributed to the data collection and the drafting of the manuscript and review of its final version.

Dr Avila: contributed to the data collection and the drafting of the manuscript and review of its final version.

Dr Raby: contributed to the data

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Cited by (62)

Development and Validation of the Asthma Exacerbation Risk Score Using Claims Data
2022, Academic Pediatrics
Pediatric asthma is a costly and complex disease with proven interventions to prevent exacerbations. Finding the patients at highest risk of exacerbations is paramount given limited resources. Insurance claims identify all outpatient, inpatient, emergency, pharmacy, and diagnostic services. The objective was to develop a risk score indicating the likelihood of asthma exacerbation within the next year based on prior utilization.
A retrospective analysis of insurance claims for patients 2 to 18 years in a network in Massachusetts with 3 years of continuous enrollment in a commercial plan. Thirty-six potential predictors of exacerbation in the third year were assessed with a stepwise regression. Retained predictors were weighted relative to their contribution to asthma exacerbation risk and summed to create the Asthma Exacerbation Risk (AER) score.
In a cohort of 28,196 patients, there were 10 predictors associated with the outcome of having an asthma exacerbation in the next year that depend on age, meeting the Healthcare Effectiveness Data and Information Set persistent asthma criteria, fill patterns of asthma medications and oral steroids, counts of nonexacerbation outpatient visits, an exacerbation in the last 6 months, and whether spirometry was performed. The AER score is calculated monthly from a claims database to identify potential patients for an asthma home-visiting program.
The AER score assigns a risk of exacerbation within the next 12 months using claims data to identify patients in need of preventive services.
Evaluation of Risk Scores to Predict Pediatric Severe Asthma Exacerbations
2021, Journal of Allergy and Clinical Immunology: In Practice
Citation Excerpt :
A variety of studies have attempted to predict exacerbations, and to date, no single tool has been widely accepted.7 One tool developed by Forno et al32 was intended to be used with children in an outpatient office setting. Two additional studies attempted to predict which children would need hospitalization after exacerbation had already developed and children presented to the ED.33,34
Asthma exacerbations commonly lead to unplanned health care utilization and are costly. Early identification of children at increased risk of asthma exacerbations would allow a proactive management approach.
We evaluated common asthma risk factors to predict the probability of exacerbation for individual children aged 0-21 years using data from the electronic medical record (EMR).
We analyzed longitudinal EMR data for over 3000 participants with asthma seen at Cincinnati Children’s Hospital Medical Center over a 7-year period. The study population was divided into 3 age groups: 0-4, 5-11, and 12-21 years. Each age group was divided into a derivation cohort and a validation cohort, which were used to build a risk score model. We predicted risk of exacerbation in the next 12 months, validated the scores by risk stratum, and developed a clinical tool to determine the risk level based on this model.
Risk model results were confirmed with validation cohorts by calendar year and age groups. Race, allergic sensitization, and smoke exposure were each important risk factors in the 0-4 age group. Abnormal spirometry and obesity were more sensitive predictors of exacerbation in children >12 years. For each age group, a higher expanded score was associated with a higher predicted probability of an asthma exacerbation in the subsequent year.
This asthma exacerbation prediction model, and the associated clinical tool, may assist clinicians in identifying children at high risk for exacerbation that may benefit from more aggressive management and targeted risk mitigation.
Exacerbation-Prone Asthma: A Biological Phenotype or a Social Construct
2021, Journal of Allergy and Clinical Immunology: In Practice
Asthma is a complex syndrome with multiple phenotypes and endotypes. Asthma exacerbations are not only the clearest indictor of the morbidity of asthma and of the risk for mortality due to asthma, but also comprise a significant amount of the cost to care for poorly controlled asthma. There continues to be significant disparity in the prevalence, mortality, and morbidity due to asthma. Patients with asthma who suffer recurrent exacerbations are considered to have exacerbation-prone asthma (EPA). Efforts to characterize patients with frequent exacerbations show that the etiology is likely multifactorial. Research to determine the intrinsic risk factors for EPA include studies of both genetic and inflammatory biomarkers. External factors contributing to exacerbations have been extensively reviewed and include viral infection, environmental exposures, air pollution, and psychosocial and economic barriers to optimizing health. It is likely that EPA occurs when patients who have an increased underlying intrinsic/biological risk are placed in a given exposome (environments with a variety of exposures and triggers including allergens, pollution, stress, barriers, and occupational exposures). It is the social construct combined with underlying biology that frequently drives an EPA phenotype.
Predicting Severe Asthma Exacerbations in Children: Blueprint for Today and Tomorrow
2021, Journal of Allergy and Clinical Immunology: In Practice
Severe asthma exacerbations are the primary cause of morbidity and mortality in children with asthma. Accurate prediction of children at risk for severe exacerbations, defined as those requiring systemic corticosteroids, emergency department visit, and/or hospitalization, would considerably reduce health care utilization and improve symptoms and quality of life. Substantial progress has been made in identifying high-risk exacerbation-prone children. Known risk factors for exacerbations include demographic characteristics (ie, low income, minority race/ethnicity), poor asthma control, environmental exposures (ie, aeroallergen exposure/sensitization, concomitant viral infection), inflammatory biomarkers, genetic polymorphisms, and markers from other “omic” technologies. The strongest risk factor for a future severe exacerbation remains having had one in the previous year. Combining risk factors into composite scores and use of advanced predictive analytic techniques such as machine learning are recent methods used to achieve stronger prediction of severe exacerbations. However, these methods are limited in prediction efficiency and are currently unable to predict children at risk for impending (within days) severe exacerbations. Thus, we provide a commentary on strategies that have potential to allow for accurate and reliable prediction of children at risk for impending exacerbations. These approaches include implementation of passive, real-time monitoring of impending exacerbation predictors, use of population health strategies, prediction of severe exacerbation responders versus nonresponders to conventional exacerbation management, and considerations for preschool-age children who can be especially high risk. Rigorous prediction and prevention of severe asthma exacerbations is needed to advance asthma management and improve the associated morbidity and mortality.
Prediction of Asthma Exacerbations in Children
2024, Journal of Personalized Medicine
Predictors of asthma control differ from predictors of asthma attacks in children: The Swiss Paediatric Airway Cohort
2023, Clinical and Experimental Allergy

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Funding/Support: The Genetics of Asthma in Costa Rica study is supported by National Institutes of Health [Grants HL04370 and HL66289]. The Childhood Asthma Management Program is supported by National Heart, Lung, and Blood Institute [Grants NO1-HR-16044, NO1-HR-16045, NO1-HR-16046, NO1-HR-16047, NO1-HR-16048, NO1-HR-16049, NO1-HR-16050, NO1-HR-16051, and NO1-HR-16052] and General Clinical Research Center [Grants M01RR00051, M01RR0099718-24, M01RR02719-14] and the National Center for Research Resources [Grant RR00036]. This work was conducted at the Channing Laboratory of Brigham and Women's Hospital.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

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Chest

Original ResearchAsthmaRisk Factors and Predictive Clinical Scores for Asthma Exacerbations in Childhood

Background

Methods

Results

Conclusions

Section snippets

Study Population

Questionnaires and Laboratory Testing

Costa Rican Cohort

Discussion

Acknowledgments

Lancet

J Allergy Clin Immunol

Chest

Chest

Ann Allergy Asthma Immunol

Immunol Allergy Clin North Am

Pharmacol Ther

J Emerg Med

Lancet

J Allergy Clin Immunol

J Allergy Clin Immunol

National Surveillance for Asthma—United States, 1980–2004

MMWR Surveill Summ

Expert Panel Report 3 (EPR-3): guidelines for the diagnosis and management of asthma—summary report 2007

J Allergy Clin Immunol

Worldwide trends in the prevalence of asthma symptoms: phase III of the International Study of Asthma and Allergies in Childhood (ISAAC)

Thorax

Collaborative studies on the genetics of asthma–National Heart, Lung and Blood Institute

Clin Exp Allergy

Original Research
Asthma
Risk Factors and Predictive Clinical Scores for Asthma Exacerbations in Childhood