L. Laforest

Persistent asthma: disease control, resource utilisation and direct costs

Despite evidence that adverse outcomes are less frequent when asthma management is optimised, the link between the level of control, disease severity and medical resource utilisation (MRU) is poorly documented. This relationship was investigated in a group of patients suffering from persistent asthma (Global Initiative for Asthma (GINA) ≥2) in France. In 1998 a computerised family practice database was used to identify asthma patients aged 17–50 yrs. Information from the database was complemented by a patient survey to retrospectively assess the level of asthma control and hospital contacts. Costs of MRU over a 12month study period were related to demographics, medical history, asthma control, and doses of inhaled corticosteroids prescribed during the prestudy period. A review of the computerised medical database identified 1,038 adult patients with persistent asthma, who completed the survey questionnaire. Over a 12month period, the mean cost of MRU was 549.8 E for wellcontrolled patients, 746.3 E per patient with moderate control, and 1,451.3 E per patient with poor control. Costs also increased significantly with age, access to free asthma care, comorbid conditions, asthma symptoms in the past year and whether inhaled corticosteroids had been prescribed before the study period. In patients with persistent asthma, large differences were observed in the use of medical resources according to control and severity. Therefore, if patients appropriately use prescribed control therapy, their use of medical resources may be reduced.

Quality of asthma care: results from a community pharmacy based survey

Background:  Optimal control is a major objective of disease management of asthma. The aim of the present study was to provide descriptive data on disease management in asthma patients, including medical resource utilization.

Asthma drug ratios and exacerbations: claims data from universal health coverage systems

In claims data, controller-to-total asthma drug ratios may reflect adequacy of disease management. We verified whether asthma patients with high ratios (≥50%) experienced fewer asthma-related outcomes. Two ratios were studied: that of the inhaled corticosteroids to total asthma drug (ICS/R03) and that of the inhaled corticosteroids plus leukotriene antagonist receptors-to-total asthma drug (ICS+LTRA/R03). Patients aged 13–40 years, with ≥3 respiratory drugs dispensed prescriptions in 2005 were selected from the French national claims data. After excluding null ratios, two groups were defined according to ratio values in 2007: low-ratio group (0%<ratio<50%) and high-ratio group (ratio ≥50%). For both ratios, asthma-related outcomes and medical-resource utilisation were compared between groups. Of 2162 patients (mean age 27 years and 52% female), patients with non-null ratios were 81% and 85% for ICS/R03 and ICS+LTRA/R03 ratios, respectively. Patients with high ratios were less likely to receive oral corticosteroids than those in the low-ratio group (relative risk 0.79, 95% CI 0.72–0.88, and 0.80, 95% CI 0.72–0.88, for ICS/R03 and ICS+LTRA/R03, respectively). High ratio groups also presented fewer asthma-related hospitalisations. Significant negative correlations were also observed for both ratios, when studied quantitatively, according to patients’ dispensed level of oral corticosteroids in 2007. In claims data, both ICS/R03 and ICS+LTRA/R03 ≥50% were related to fewer asthma-related outcomes. Ratios should be explored to identify asthma patients at risk of exacerbations. Low ratios can be considered as risk factors of exacerbation whatever the underlying cause. Asthma patients with therapeutic ratios ≥50% had fewer asthma exacerbation markers, suggesting better control http://ow.ly/tHa59

Prescribed therapy for asthma: therapeutic ratios and outcomes

BackgroundInhaled corticosteroids (ICS) are the cornerstone of asthma therapy. The ICS-to-total-asthma-medication ratios, calculated from claims data, indicate potentially risky disease management in asthma. Our aim was to assess the utility of ICS-to-total-asthma-medication ratios from primary care electronic medical records (EMRs) in detecting patients at risk of asthma exacerbation, as approached by prescription of oral corticosteroids and/or antibiotics.MethodsRetrospective cohort studies were identified, using the Health Improvement Network general practice database (THIN, United Kingdom) and the Cegedim Longitudinal Patient Data (France). We selected asthma patients aged 16–40 years, with ≥ 4 prescriptions for asthma medications in 2007 and ≥ 1 prescription in 2008. For each country, three groups were defined according to ratio value in 2008: 0% (non-ICS users), <50% (low-ICS-ratio group) and ≥50% (high-ICS-ratio group). Outcomes were marker of asthma exacerbations: systemic corticosteroids and antibiotics. They were compared between groups in each country.ResultsAmong 38,637 British and 4,587 French patients, higher numbers of prescriptions per patient of systemic corticosteroids, antibiotics and total asthma medications were observed in the low-ICS-ratio groups compared to other groups (p < 0.0001 for each outcome in both countries). Likewise, low-ICS-ratio patients had more medical contacts (p < 0.0001 in both countries), suggesting poorly controlled asthma. ICS-treated patients had lower risks of receiving systemic corticosteroids in 2008 in the high-ICS-ratio group, compared to the low-ICS-ratio group: RR = 0.54, 95%CI = [0.50-0.57] and RR = 0.78, 95%CI = [0.67-0.91] in the UK and France, respectively.ConclusionsPatients with high ICS-to-total-asthma-medication ratios presented fewer asthma-related outcomes. The low ICS-to-total-asthma-medication ratio calculated with EMRs data reflects insufficient prescribing of ICS relative to all asthma medications, which may lead to deteriorated asthma control.

Relative exposure to controller therapy and asthma exacerbations: a validation study in community pharmacies

“Controllers‐to‐total asthma drug” ratios computed from claims data identify asthmatics at risk of exacerbations. Direct link of ratios to data obtained from patients, such as control and recent outcomes, would facilitate their interpretation. We studied the relationship between R1 ratio (inhaled corticosteroids (ICS)/total anti‐asthma drug ratio) and the Asthma Control Test. Comparisons were also conducted for secondary outcomes (asthma‐related hospital contacts, monthly medical contacts, use of oral corticosteroids, and perception of disease burden). Results with R1 ratio were compared with those obtained with a second ratio, “ICS‐plus‐leukotriene receptor antagonist/total asthma drug” (R2 = ICS + leukotriene receptor antagonist/total anti‐asthma drugs).

Defining the natural history of multiple sclerosis : the need for complete data and rigorous definitions. Answer to Dr Tremlett et al

When studying the time from the onset of SPMS to reaching a given disability score on the DSS scale [2,3], patients who have already reached this given DSS score before the onset of SPMS must obviously be excluded from the analysis. This is not questionable. What is questionable is whether to exclude from the survival analysis (and this is true whatever the starting point for the estimates, be it, for instance, onset of MS or onset of secondary progression), the patients who have already reached the given DSS score before the first visit at the clinic.

Impact of vitamin D supplementation on health-care use in a 25-hydroxyvitamin D-tested population in France: a population-based descriptive cohort study

OBJECTIVE Chronic vitamin D deficiency has been associated in some patients with diffuse musculoskeletal pain. These unspecific symptoms may partly explain why vitamin D deficiency is often diagnosed late. Our aim was to analyse health-care claims after vitamin D supplementation in patients likely to have vitamin D deficiency. DESIGN Ambulatory health-care claims were compared before and after a vitamin D supplementation prescribed following a 25-hydroxyvitamin D assay. SETTING Health Insurance Fund (FHIF) database of the Rhône-Alpes area, France. SUBJECTS Among patients reimbursed for a 25-hydroxyvitamin D assay between 1 December 2008 and 31 January 2009, those supplemented with vitamin D after the assay were matched on the date of assay to patients who did not receive vitamin D. RESULTS Among the 3023 patients who had a 25-hydroxyvitamin D assay, 935 were consequently supplemented and matched to 935 patients not supplemented. Their median age was 50·0 and 49·5 years, respectively. Patients supplemented decreased their muscle relaxant consumption whereas no change was observed in the reference group, the difference between the two groups was significant (P=0·03). Second and third Pain Relief Ladder prescriptions decreased in both groups but not significantly differently between groups (P=0·58). There was a decrease in prescriptions of biological examination in both groups with no significant difference. CONCLUSIONS Besides a decrease in muscle relaxant prescriptions in the supplemented group, it was difficult to assess the impact of vitamin D supplementation in patients likely to have vitamin D deficiency. Prospective cohort studies and randomized trials are needed to assess the efficiency of screening and supplementing vitamin D deficiency.

L’utilisation des β2-agonistes à longue durée d’action en association aux corticostéroïdes inhalés, est-elle vraiment sans danger dans l’asthme ?

Nous avons lu avec intérêt l’article de nos confrères GrassinDeyle et Girodet concernant la prévention pharmacologique des exacerbations de l’asthme [1]. Cette revue générale précise à juste titre que la monothérapie par 2-agonistes à longue durée d’action ( 2-LDA) induit une augmentation des risques d’exacerbations d’asthme grave, voire de décès et qu’elle est donc contre-indiquée dans le traitement de fond du patient asthmatique (p235). Elle se veut par ailleurs rassurante quant à l’utilisation de 2-LDA en association aux corticostéroïdes inhalés (CSI), références à l’appui (p237) et ce, conformément aux recommandations qui considèrent leur rapport bénéfice/risque favorable. Nous ne partageons pas ce point. Nous pensons que l’innocuité des 2-LDA en association aux CSI n’est pas clairement établie à ce jour. Même si d’autres études comme la Serevent Nationwide Surveillance (SNS) ont soulevé la toxicité des 2-LDA dans l’asthme, les doutes actuels sur ces traitement reposent en grande partie sur l’étude Salmeterol Multicenter Asthma Research Trial (SMART), essai clinique randomisé en doubleinsu contre placebo, le plus puissant à ce jour et publié en 2006, qui avait eu pour but de vérifier la sécurité du salmétérol à la dose de 84 microgrammes par jour dans le traitement de fond dans l’asthme [2]. Il convient donc de bien analyser les résultats de cette étude car c’est essentiellement sur ses résultats (et des méta-analyses incluant l’étude SMART) que se fondent les recommandations de ne pas utiliser les 2-LDA en monothérapie dans l’asthme et que l’association avec les CSI est sans danger. Ce méga essai évaluait chez 26 355 patients suivis pendant six mois les effets cliniques d’une adjonction de salmétérol ou d’un placebo chez des patients âgés de plus de 12 ans, traités ou non par CSI. Le critère de jugement principal (regroupant la mortalité d’origine respiratoire [respiratory-related deaths], ainsi que les évènements respiratoires mettant la vie en danger [life-threatening experiences]) ne fût pas statistiquement significatif : RR = 1,40 ; IC95 % [0,91—2,14]. Mais les p r e

Prise en charge des patients dyslipidémiques dans cinq pays européens : résultats préliminaires de l’étude LIPIDE

© 2019 E Prise en charge des patients dyslipidémiques dans cinq pays européens : résultats préliminaires de l’étude LIPIDE G. Desamericq , L. Laforest , M.-S. Schwalm , P. Moulin , E. Michel , C. Eteve , G. Coffin , C. Ritleng , E. Van Ganse a a Unité de pharmacoépidémiologie, service neurologie, hôpital PierreWertheimer, CHU de Lyon, 69677 Bron, France b Cegedim Strategic Data France, Boulogne, France c Endocrinologie, 69677 Bron, France

Délivrance des antibiotiques dans une population de patients asthmatiques dans la région Rhône-Alpes : résultats de l’étude L777

© 2019 E Au cours du suivi de 6 mois, la majorité des patients (73 %) n’ont pas eu de changement de traitement (même dose), 5 % ont eu une diminution de dose, 6 % une augmentation de dose, 5 % ont arrêté le traitement, 4 % ont eu un changement intraclasse et 4 % un changement interclasse. Les modalités de traitement étaient très légèrement différentes entre les patients traités par des médecins généralistes et ceux traités par des psychiatres. Au cours du temps, les patients français ont vu une amélioration de leur qualité de vie et leurs symptômes de dépression et d’anxiété. Conclusions.– Plus de la moitié des patients français de cette étude ont eu des douleurs associées à la dépression. La majorité des patients ont reçu un inhibiteur sélectif de la recapture de la sérotonine. Au cours du suivi de 6 mois, la plupart des patients ont poursuivi leur traitement par le même antidépresseur à la même dose et des améliorations de leur qualité de vie et de leurs signes cliniques ont été observées.