Philip Marcus

The CHOICE survey: high rates of persistent and uncontrolled asthma in the United States

BACKGROUND Surveys have consistently shown that many patients with asthma do not have their disease well controlled. OBJECTIVES The CHOICE (Comprehensive Survey of Healthcare Professionals and Asthma Patients Offering Insight on Current Treatment Gaps and Emerging Device Options) survey was designed to evaluate the current status of inhalation devices used in asthma treatment, but questions also were included about asthma severity and control. METHODS A total of 1,000 patients with asthma were interviewed about their use of inhalation devices and asthma-related burden, medication use, and hospital/emergency care. Based on the responses to these questions, asthma severity and control were categorized using methods established in the Expert Panel Report III (EPR 3). RESULTS Almost half (490) of the patients with asthma participating in the CHOICE survey were not using controller medications. Most of those not using controllers (79%) had persistent asthma; 47% had either mild or moderate persistent asthma. Of those on controllers (510), only 14.3% were well controlled. Acute care utilization was greater for patients with persistent asthma than those with intermittent asthma and for patients with not well and poorly controlled asthma than those with well-controlled asthma. CONCLUSION The CHOICE survey is particularly pertinent clinically, because it demonstrates for the first time, using EPR 3 methods, the current extent of poor asthma control in the United States. This situation falls far short of national asthma management targets.

International Classification of Disease Coding for Obstructive Lung Disease: Does It Reflect Appropriate Clinical Documentation?

International Classification of Disease coding is widely used by physicians, hospitals, health-care payers, and governments to assess the health of populations and as a means of reimbursement for medical care based on diagnosis and severity of illness. The current classification system, International Classification of Diseases, 9th ed (ICD-9), will soon be replaced by International Classification of Diseases, 10th ed (ICD-10). When the codes that relate to COPD and asthma are examined, the clinical relevance of the categories in International Classification of Disease coding must be questioned. In the future, a more simplified terminology that is consistent with clinical usage could improve accuracy and ease of coding. At present, however, clinicians should become familiar with the present ICD-9 and future ICD-10 codes so that their descriptions of illnesses in the medical records more accurately reflect current coding terminology.

Use of nebulized inhaled corticosteroids among older adult patients: an assessment of outcomes

BACKGROUND Inhaled corticosteroids (ICSs) are used by patients of all ages, but older patients may have difficulty with conventional inhalation devices and therefore may benefit from the easy-to-use delivery mechanism of the nebulizer. OBJECTIVE To compare the outcomes, resource use, and health care costs of patients prescribed nebulized ICSs before and after treatment. METHODS All patients 50 years and older prescribed nebulized ICSs were identified from a nationally representative managed care claims database (1999-2003). Patients with 1 year of continuous enrollment were analyzed using a retrospective cohort design; outcomes, resource use, and costs were measured and compared 6 months before and 6 months after the initial nebulized ICS prescription. RESULTS A total of 2,178 patients were identified for participation in the study, of whom 668 were analyzed. Patients were prescribed nebulized ICSs primarily for asthma (57.4%) and chronic obstructive pulmonary disease (52.1%). Nebulized ICSs were prescribed mostly by primary care physicians and pulmonologists. More than 40% of patients used nebulized ICSs persistently (at least 1 refill); persistent users averaged 123.4 days of use during 6 months of follow-up. There was a significant decrease in systemic corticosteroid use among persistent users (48.0% vs 38.8%; odds ratio, 0.7; 95% confidence interval, 0.5-1.0; P = .03). There was an emergency department visit in 20.2% and 15.0% of persistent users before and after the index date, respectively (odds ratio, 0.7; 95% confidence interval, 0.45-1.09; P = .12); 20.5% and 17.5% were hospitalized before and after the index date, respectively (odds ratio, 0.8; 95% confidence interval, 0.54-1.27; P = .38). No significant difference occurred in total health care costs during follow-up compared with baseline. CONCLUSIONS In this retrospective cohort study, older patients who used nebulized ICSs persistently demonstrated fewer emergency department visits and systemic corticosteroid use than before nebulized ICS use. These improved outcomes were not associated with an increase in health care costs.

TOPICS IN PRACTICE MANAGEMENTInternational Classification of Disease Coding for Obstructive Lung Disease: Does It Reflect Appropriate Clinical Documentation?

International Classification of Disease coding is widely used by physicians, hospitals, health-care payers, and governments to assess the health of populations and as a means of reimbursement for medical care based on diagnosis and severity of illness. The current classification system, International Classification of Diseases, 9th ed (ICD-9), will soon be replaced by International Classification of Diseases, 10th ed (ICD-10). When the codes that relate to COPD and asthma are examined, the clinical relevance of the categories in International Classification of Disease coding must be questioned. In the future, a more simplified terminology that is consistent with clinical usage could improve accuracy and ease of coding. At present, however, clinicians should become familiar with the present ICD-9 and future ICD-10 codes so that their descriptions of illnesses in the medical records more accurately reflect current coding terminology.

Development of the asthma control test (ACT)

Abstract Background Asthma guidelines indicate that the goal of treatment should be optimum asthma control. In a busy clinic practice with limited time and resources, there is need for a simple method for assessing asthma control with or without lung function testing. Objectives The objective of this article was to describe the development of the Asthma Control Test (ACT), a patient-based tool for identifying patients with poorly controlled asthma. Methods A 22-item survey was administered to 471 patients with asthma in the offices of asthma specialists. The specialists rating of asthma control after spirometry was also collected. Stepwise regression methods were used to select a subset of items that showed the greatest discriminant validity in relation to the specialists rating of asthma control. Internal consistency reliability was computed, and discriminant validity tests were conducted for ACT scale scores. The performance of ACT was investigated by using logistic regression methods and receiver operating characteristic analyses. Results Five items were selected from regression analyses. The internal consistency reliability of the 5-item ACT scale was 0.84. ACT scale scores discriminated between groups of patients differing in the specialists rating of asthma control (F = 34.5, P P 1 (F = 4.3, P = .0052). As a screening tool, the overall agreement between ACT and the specialists rating ranged from 71% to 78% depending on the cut points used, and the area under the receiver operating characteristic curve was 0.77. Conclusion Results reinforce the usefulness of a brief, easy to administer, patient-based index of asthma control.

Intrapatient symptom variability in adults and children with asthma: results of a survey.

The objective of this survey was to evaluate variability of symptoms in adult and pediatric patients with persistent asthma. Prospective participants from a US database of patients with asthma were invited to complete an Internet-based survey designed to assess the occurrence of asthma symptoms during the past year. A total of 1311 adult patients and 491 caregivers of pediatric patients were surveyed. Adult patients (18%–30%) and pediatric patients (8%–20%) experienced a variety of symptoms on a daily basis. At least 50% of patients receiving treatment experienced variability in 1 or more symptoms during the previous year. The most common treatment recommendation when asthma symptoms were experienced included changing the number of medication (reliever or controller) inhalations (48% and 55% of adult and pediatric patients, respectively) or adding another medication (31% and 39%). This survey indicates that adult patients and caregivers of pediatric patients report variability in asthma symptoms over time, even when asthma medications are taken.