Socioeconomic biases in asthma control and specialist referral of possible severe asthma

Abstract

BackgroundAlthough socioeconomic impact on asthma control has been investigated, little is known about its relation to specialist referral of patients with possible severe asthma, especially in a public healthcare setting. The present study aims to identify socioeconomic patterns in disease control and referral of patients with asthma in a nationwide cohort of adult patients treated with inhaled corticosteroid (ICS).MethodsAsthma patients fulfilling the following: aged 18–45 and redeeming ≥2 prescriptions of ICS during 2014–18 based on data from Danish national registers were included. Possible severe asthma was defined as GINA 2020 Step 4 (with either ≥2 courses of systemic steroids or ≥1 hospitalisation) or Step 5 treatment. Findings presented as odds ratio (OR) (95% confidence intervals).ResultsOf 60 534 patients (median age 34, 55% female), 3275 (5.7%) were deemed as having possible severe asthma, of whom 61% were managed in primary care alone.Odds of specialist management for possible severe asthma decreased with age (OR 0.66 (0.51–0.85)), 36–45 versus 18–25 years), male sex (OR 0.75 (0.64–0.87)), residence outside the Capital Region (OR 0.70 (0.59–0.82)) and with receiving unemployment or disability benefits OR 0.75 (0.59–0.95)).Having completed higher education increased odds of specialist referral (OR 1.28 (1.03–1.59)), when compared to patients with basic education.ConclusionEven in settings with nationally available free access to specialist care, the majority of patients with possible severe asthma are managed in primary care. Referral of at-risk asthma patients differs across socioeconomic parameters, calling for initiatives to identify and actively refer these patients.

High Use of Antidepressant Medication in Both Mild-to-Modelate and Possible Severe Asthma – A Nationwide Cohort Study

“…Patients were included in the REASSESS Danish Asthma cohort if they had redeemed ≥2 ICS inhalers during acalendar year within the study period (2014-2018), as commonly used in Danish asthma cohorts. 2,4,20 To reduce the risk of inclusion of ICS-treated patients with chronic obstructive pulmonary disease, the cohort was limited to individuals aged 18-45 on cohort entry (at 1st ICS redemption). 2 An age-and sex-matched population serving as controls was supplied by Statistics Denmark.…”

“…The use of long-acting bronchodilators (beta 2 -agonists, antimuscarinic, or a combination of both) was more common in patients using antidepressants, 3 P-value for Age < 0.9 between Controls and Asthma patients when not stratified by disease severity. 4 Of patients with asthma only. 3 Prevalence based on the asthma subpopulation (n=60,534).…”

“…exposure during the study period; below low < 200 daily mcg, low 200-599 daily mcg, moderate 600-1200 daily mcg, high >1200 mcg daily. 4 During the study period.…”

“…2 Defined as at least one asthma-related hospitalization. 4 As defined in table header. Abbreviations: 3 CI, confidence interval; OR, odds ratio; PPI, proton-pump inhibitor.…”

“…1 Poor asthma control is the main driver of morbidity and mortality, whereas sufficient treatment with inhaled corticosteroids (ICS) significantly reduces symptoms, exacerbation-and mortality risk. 1 With proper treatment, most asthma patients are without any major day-to-day asthma-related symptoms or limitations, 1 yet sub-optimal -or even poor -asthma control is common [2][3][4] with potential important consequences for the patients as asthma has been linked to major mood disorders (MMD) such as anxiety and depression. 5 Psychiatric comorbidity in asthma influences asthma symptom burden, reduces quality of life (QoL) and increases healthcare resource utilization.…”