-
Level of asthmutilization in A
Phiean
ReseaSAAustralia,, Mahrck &
Received 17 September 2013; accAvailable online 24 December
201
KEYWORDS
maintenancemedications;
Summary
sia-Pacific region isere associated withong a population of
s from the 2011 Asia-itiative for Asthma
(GINA) guidelines, patients were categorized as having
well-controlled, partly- controlled, or un-controlled asthma.
Chi-square tests were used to assess the relation of degree of
asthma control
ood.controlled, with thehina (2%). Patientscations, more
emer-
gency healthcare visits or hospitalizations for their asthma,
and more interference of their moode to asthma.r utilization rates
ofissing multiple days
ese associations sug-cts on patient well-
being and utilization of healthcare resources. 2013 Elsevier
Ltd. All rights reserved.
* Corresponding author. University of Washington, Box 359455,
Seattle, WA 98195-9455, USA. Tel.: 1 (206) 543 2749; fax: 1 (206)
543 8609.E-mail address: [email protected] (L.S. Gold).
0954-6111/$ - see front matter 2013 Elsevier Ltd. All rights
reserved.http://dx.doi.org/10.1016/j.rmed.2013.12.004
Available online at www.sciencedirect.com
ScienceDirect
j
Respiratory Medicine (2014) 108, 271e277due to asthma. They also
reported significant decreases in productivity duConclusions:
Patients who did not have well-controlled asthma had greateasthma
medications and healthcare services and were more likely to report
mof work/school compared to patients whose asthma was
well-controlled. Thgest that emphasis on improving asthma control
could have dramatic effeOral steroids;Productivity
with utilization of asthma medications, health services,
productivity, and mResults: Overall, 7.6% of the patients surveyed
had asthma that was well-highest proportions in Singapore (14%) and
the lowest in India (0%) and Cwhose asthma was not well-controlled
reported greater use of asthma mediGlobal Initiative forAsthma
(GINA)guidelines;Healthcareutilization;Long term
Background: Data on the impact of asthma in many countries in
the Alimited. This study investigated whether partly- and
uncontrolled asthma wincreased medication use/healthcare
utilization and productivity loss amasthma patients from nine
Asia-Pacific countries.Methods: We used cross-sectional data from
3630 asthma patients12 yearPacific Asthma Insights and Management
(AP-AIM) survey. Using Global InLaura S. Gold a,*,Rab A. Faruqi d,
S
a Pharmaceutical OutcomesWashington, Seattle, WA, Ub Lung
Institute of WesternUniversity of Western AustrcChest Research
FoundationdGlobal Medical Affairs, Mea control and health
caresia-Pacific countries
llip Thompson b, Sundeep Salvi c,D. Sullivan a
rch and Policy Program, School of Pharmacy, University of
alia and Centre for Asthma, Allergy, and Respiratory
Research,Nedlands, Australiaarashtra, IndiaCo., Inc, Whitehouse
Station, NJ, USA
epted 13 December 20133
ournal homepage: www.elsevier .com/locate/rmed
-
272 L.S. Gold et al.Introduction
A World Health Survey conducted in 2002e2003 estimatedthat 3e6%
of the 4.2 billion residents of Asian-Pacificcountries have asthma
and, although data are sparse, theprevalence of asthma in most of
these countries is believedto be increasing [1e3]. Asthma causes
significant morbidityin Asia-Pacific countries. In the 2003 Asthma
Insights andReality in Asia-Pacific (AIRIAP) Study, 44% of the
re-spondents reported at least one unscheduled emergencyhealthcare
visit for treatment of asthma in the previousyear [4].
Additionally, some of the highest mortality ratesfrom asthma are in
Asia-Pacific countries [1]. Althoughaffordable medications that
have been shown to be highlyeffective at managing asthma have been
available since the1990s [5], the majority of patients worldwide,
including inAsia-Pacific countries [6], do not have
well-controlledasthma. The economic burden of asthma in terms of
bothdirect and indirect costs has been shown to be substantial-a
recent U.S. study estimated that the total annual cost ofasthma was
$56 billion [7] and substantial costs have alsobeen attributed to
asthma in Asian-Pacific settings [8,9].Because the economic and
societal impacts of asthma arealmost certainly correlated with
disease severity, we con-ducted these analyses to shed light on the
relationshipbetween degree of asthma control and utilization of
healthservices and reduced productivity.
Over the past decade, physiological measurements ofasthma
control, such as forced expiratory volume in onesecond (FEV1), have
been replaced with symptom andquality-of-life questionnaires to
define asthma control.The Global Initiative for Asthma (GINA) and
the UnitedStates National Asthma Education Prevention
Program(NAEPP) revised their guidelines to focus on
regulatingasthma symptoms, rather than lung function, in order
tomaintain normal daily activity levels [10,11]. We
recentlyconducted studies on asthma patients in the U.S. and
inLatin America that demonstrated that asthma that is
notwell-controlled according to GINA guidelines is associatedwith
increased rates of adverse outcomes compared toasthma that is
well-controlled [12]. The purpose of thecurrent study was to
investigate whether partly- and un-controlled asthma are associated
with outcomes such asincreased medication use, visits to healthcare
providers,hospital admissions, and decreases in productivity amonga
population of asthma patients from nine Asia-Pacificcountries.
Determining whether uncontrolled asthma isassociated with these
costly health outcomes is animportant step toward lessening the
burden of this diseasein these countries.
Methods
Asia-Pacific Asthma Insights and Management(AP-AIM) survey
Details about theAsia-PacificAsthma Insights
andManagement(AP-AIM) survey have been described previously [6]. In
brief,thecross-sectionalAP-AIM surveywasdesigned
tocomplementtheUnited States AIM (US-AIM) survey andwas conducted
fromFebruaryeJuly 2011. Subjects included in our analyses were3630
asthmapatients12 years old identified froma sampleof57,131
households in Australia, China, Hong Kong, India,Malaysia,
Singapore,SouthKorea,Taiwan,andThailand.Thesecountries were
non-randomly selected based on populationsize, accessibility,
andcost of survey implementation. Patientswere selected by random
digit dialing and interviews wereconducted by telephone in
Australia, China, and Hong Kong.Patients were selected by random
face-to-face interviews atpre-specified locations and were
conducted in person in theremaining countries. Both telephone and
in-person interviewsaveraged 35 min in length. For subjects between
12 and 17years, the survey was completed by a parent or guardian.
Inorder to be included in this study, patients had to haveanswered
that they had been diagnosed with asthma AND thatthey were
currently taking medications for their asthma orthey had had an
asthma attack or asthma symptoms in theprevious 12 months. The 53
questions in this survey weredrafted in English as part of the
US-AIM survey and were thentranslated into local languages. The
questions were designedto assess asthma burden (short- and
long-term symptoms,functional impact, and healthcare utilization
such as providervisits and use of asthma medications) and patient
beliefs onappropriate use of medications for asthma control.
Patientswerealsoasked toassess their (or their childrens)
productivityon a scale of 0e100% on both typical days and on days
whentheir asthma was at its worst. Additionally, demographic
vari-ables, such as gender, age, smoking status, education
level,and diagnosis of nasal allergies, were also queried.
Classification of asthma control
Patients were characterized based on GINA guidelines [10]into
three categories of level of asthma control: well-controlled,
partly- controlled, and uncontrolled (Table 1).The manifestations
of asthma that were used for the catego-rizations included daytime
symptoms, restriction of daily ac-tivities, nighttime symptoms, and
need for reliever/rescuetreatment. We used questions from the
surveys that corre-lated with the GINA-defined asthma
manifestations, with theexception of a lung function
measurement
-
a co
hileat
aly
OR
gh,No Yes
ue
nt,
Asthma in Asia-Pacific countries 273federal regulatory
definition of human subjects researchand hence was exempt from
Human Subjects review by theUniversity of Washington Institutional
Review Board.
Results
Frequencies and results of chi-square tests of
demographicvariables, stratified by GINA-defined level of asthma
control,are presented in Table 2. Few patients in our study
(7.6%)had asthma that was classified as well-controlled.
Youngerpatients were slightly more likely than older patients to
havehad asthma that was classified as well-controlled (13%
ofpatients aged 12e17 had well-controlled asthma, comparedto 5% of
patients aged 51). Australia and Singapore had thehighest
proportion of patients whose asthma was classified
Table 1 Survey questions used to categorize level of asthm
GINA characteristic AP-AIM survey question(s)
Daytime symptoms In the past 4 weeks have you (your chad cough,
wheezing, shortness of bror chest tightness during the day?
Limitation of activities Do you feel your (your childs)
asthmlimits you (your child) a lot, some, ona little or not at all
in sports andrecreation/normal physical exertion/daily
activities?
Nocturnal symptoms/awakening
In the past four weeks, have you(your child) been awakened by a
couor wheezing, or shortness of breath,or chest tightness during
the night?
Need for reliever/rescue treatment
How often do you (does your child)use an inhaler for quick
relief or rescfrom asthma symptoms?
Abbreviations: AP-AIM, Asia-Pacific Asthma Insights and
Managemeas well-controlled (13% and 14%, respectively) and India
andChina had the lowest (0% and 2.0%, respectively). Patientswho
had a previous diagnosis of rhinitis were more likely tohave had
well-controlled asthma compared to patients whohad not been
diagnosed with rhinitis (9% compared to 6%). Ahigher proportion of
asthma patients who lived in the samehousehold as a smoker had
uncontrolled asthma (32% versus28%). Although the relationship was
not statistically signifi-cant, higher levels of education were
associated with havingasthma that was classified as well-controlled
compared topatients with less education. We did not observe
meaningfuldifferences of level of asthma control by gender, whether
afamily member outside the household had been diagnosedwith asthma,
or whether any pets were in the household.
Associations between past twelve months-use of asthmamedications
and healthcare services, again stratified bylevel of asthma
control, are presented in Table 3.Compared to patients with
well-controlled asthma, greaterproportions of patients with partly-
and uncontrolledasthma used oral steroid, quick relief or rescue
medica-tions, long-term maintenance medications, and had
un-scheduled healthcare visits, hospitalizations, and visits
totheir healthcare providers for asthma. Additionally,patients with
partly- and uncontrolled asthma were morelikely to have missed work
or school compared to patientswith well-controlled asthma.
Effects of asthma on several indicators of mood arepresented in
Table 4. Patients with partly- and uncontrolledasthma were
significantly more likely to report that asthmaoften or sometimes
made them tired, fearful, depressed,embarrassed, and frustrated
compared to patients withwell-controlled asthma. Additionally,
patients with partly-and uncontrolled asthma were significantly
more likely toreport feeling lack of control of their lives,
inadequate inrelation to their peers, and that asthma affected how
theyfelt about themselves compared to patients with well-controlled
asthma.
Finally, Table 5 indicates the impact of asthma on
theproductivity of respondents on typical days and when asthma
1e2 times a weekor less
Daily or 3e6 timesa week
GINA, Global Initiative for Asthma.ntrol as defined by Global
Initiative for Asthma guidelines.
Response:controlled
Response: partly-controlled
Response: notcontrolled
d)h,
Twice or less perweek
Most days orevery day
Three or morefeatures ofpartly- controlledasthma
Not at all Anywas worst. Compared to patients whose asthma was
classi-fied as well-controlled, patients with partly- and
uncon-trolled asthma had significantly lower productivity on
typicaldays and on days that asthma was worst. This table
alsodemonstrates that patients with partly- and uncontrolledasthma
missed significantly more days of work or school inthe previous
year (an average of 3.7 and 7.9 days) comparedto patients with
well-controlled asthma (average of
-
Table 2 Frequencies of descriptive variables of Asia-Pacific
asthma insights and management survey respondents.
Total(n Z 3630)
Well-controlledn Z 276 (7.6%)
Partly controlledn Z 2271 (63%)
Uncontrolledn Z 1083 (30%)
Chi-squarep-Value
Age12e17 442 57 (13%) 279 (63%) 106 (24%)
-
con
P
n
1
wor
duc
Asthma in Asia-Pacific countries 275[13]. We conducted a similar
study on the United Statespopulation [12] and also found that
GINA-defined level ofasthma control was associated with increased
utilizations
Table 4 Odds associations of mood indicators with level of
Well-controlled
n Z 276 (7.6%)
Often/sometimes tired or fatigued 72 (3.2%)Often/sometimes
fearful 40 (3.6%)Often/sometimes depressed 15 (1.6%)Often/sometimes
embarrassed 17 (2.1%)Often/sometimes frustrated 30
(2.4%)Strongly/somewhat agree feel lack ofcontrol due to asthma
30 (2.3%)
Strongly/somewhat agree feelinadequate in relation to peers
dueto asthma
18 (2.0%)
Strongly/somewhat agree asthmaaffects self-image
28 (2.3%)
Table 5 Asthma interference with productivity and missed
Well-controlled(Mean Std. dev.)
Productivity: typical daya 91 15Productivity: asthma at its
worsta 59 30Number of days of missed work/school 0.75
2.4Abbreviation: Std. dev, standard deviation.a Productivity
measured on scale of 0e100% (higher Z more proof healthcare
resources and decreased productivity. Addi-tionally, several
previous studies have used the ACT[13e16] or the National Asthma
Education Prevention Pro-gram (NAEPP) guidelines [17] to classify
level of asthmacontrol in order to examine the relationship
betweenasthma severity and outcomes. Similar to our findings,these
papers found that patients with partly- and uncon-trolled asthma
were at significantly greater risk of usinghealthcare services and
adverse health outcomes.
Although our study included a large population of asthmapatients
that was randomly selected, it also had severallimitations. First,
the nine countries included in this studyare diverse, especially in
terms of healthcare delivery sys-tems and socioeconomic indicators.
Because we did not haveenough patients to conduct these analyses
separately foreach country, it is possible that our results are not
gener-alizable to the general worldwide asthma population.
Addi-tionally, we did not have data on non-respondents so
theparticipants who agreed to take part in the survey may nothave
been representative of asthma patients in general.While the wording
of the survey questions that we used todivide our population into
those with well-controlled, partly-controlled, and uncontrolled
asthma was similar to that usedin the GINA guidelines (Table 1), it
did not correlateperfectly. Also, our analyses were based on
self-reportedinformation which may have been biased. Finally,
whilethis paper reports associations between poorly
controlledasthma and health outcomes, the data were
cross-sectionaland we were unable to examine issues of cause and
effect.This study suggests over 90% of the population of
asthmapatients in nine Asia-Pacific countries had asthma that
wasclassified as partly- or uncontrolled by international
trol of asthma symptoms.
artly controlled Uncontrolled Chi-Square p-Value
Z 2271 (63%) n Z 1083 (30%)
283 (58%) 866 (39%)
-
Appendix. Survey questions presented inTables 3e5.
Abbreviated question Table Survey question Survey
answerspresented in table
Oral steroid 3 (Have you/has your child) had to take an oral
steroid(pill or liquid) to manage (your/your childs) asthmasymptoms
in the past twelve months?
Yes
Use of quick relief/rescue medicine 3 When was the most recent
time that (you/your child)used medicine for quick relief or rescue
from asthmasymptoms?
Within the past year
Long-term maintenance medicine 3 When was the most recent time
that (you/your child)took a medicine for the control or prevention
of(your/your childs) asthma?
Within the past year
Unscheduled/emergency healthcare visits
3 Has (your/your childs) asthma caused any unscheduledurgent or
emergency visits to a doctors office, hospital,clinic or somewhere
else in the past 12 months?
Yes
Hospitalization 3 (Have you/Has your child) been hospitalized
overnightfor asthma in the past 12 months?
Yes
Visits to health care provider forasthma
3 In the past 12 months (have you/has your child) seena doctor
or other health care provider because ofasthma exacerbations or
worsening symptoms,or sudden, severe asthma episodes?
Yes
Missed work/school 3 Has (your/your childs) asthma caused
(you/your child)to miss work or school in the past year?
Yes
Often/sometimes tired or fatigued 4 As a result of (your/your
childs) asthma, how often(do you/does he or she) feel tired or
fatigued?
Often/sometimes
Often/sometimes fearful 4 As a result of (your/your childs)
asthma, how often(do you/does he or she) feel fearful?
Often/sometimes
Often/sometimes depressed 4 As a result of (your/your childs)
asthma, how often(do you/does he or she) feel depressed?
Often/sometimes
Often/sometimes embarrassed 4 As a result of (your/your childs)
asthma, how often(do you/does he or she) feel embarrassed?
Often/sometimes
Often/sometimes frustrated 4 As a result of (your/your childs)
asthma, how often(do you/does he or she) feel frustrated?
Often/sometimes
Strongly/somewhat agree feellack of control due to asthma
4 Do you strongly agree, somewhat agree, neither agreenor
disagree, somewhat disagree or strongly disagreethat (my/my childs)
asthma makes (me/my child)feel like (I/they) dont have control of
(my/their) life.
Strongly agree/somewhat agree
Strongly/somewhat agree feelinadequate in relation to peersdue
to asthma
4 Do you strongly agree, somewhat agree, neither agreenor
disagree, somewhat disagree or strongly disagreethat (I/my child)
feel(s) inadequate in relation to(my/their) peers due to (my/their)
asthma.
Strongly agree/somewhat agree
Strongly/somewhat agree asthmaaffects self-image
4 Do you strongly agree, somewhat agree, neither agreenor
disagree, somewhat disagree or strongly disagreethat (my/my childs)
asthma affects how (I/my child)feel(s) about
(myself/himself/herself).
Strongly agree/somewhat agree
Productivity: typical day 5 Thinking about productivity on a
scale of 0e100,where 100 means 100% productivity, where would
yourank (your/your childs) productivity on a typical day?
__________%(Range 0e100)
Productivity: asthma at its worst 5 Where would you rank
(your/your childs) productivityon the same scale of 0e100, at times
of the year
ur childs) asthma was at its worst?
__________%(Range 0e100)
k or school days (have you/has youre past year as a result of
asthma?
____ DAYS LOST
276 L.S. Gold et al.when (your/yoNumber of days of
missedwork/school
5 How many worchild) lost in th
-
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Asthma in Asia-Pacific countries 277
Level of asthma control and health care utilization in
Asia-Pacific countriesIntroductionMethodsAsia-Pacific Asthma
Insights and Management (AP-AIM) surveyClassification of asthma
controlStatistical analysis
ResultsDiscussionConflict of interestAcknowledgementsAppendix
Survey questions presented in Tables 35.References
