Inhaled Corticosteroid-Containing Treatment Escalation and Outcomes for Patients with Asthma in a US Health Care Organization
Inhaled Corticosteroid-Containing Treatment Escalation and Outcomes for Patients with Asthma in a US Health Care Organization
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DOI：
10.18553/jmcp.2017.23.11.1149
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发表时间：
2017-11-01
影响因子：
2.1
通讯作者：
Buikema, Ami R.
中科院分区：
文献类型：
--
作者：
Bengtson, Lindsay G. S.;Yu, Yanni;Buikema, Ami R.
背景：哮喘是一种常见的疾病，影响约8%的美国人口。治疗指南表明吸入性皮质类固醇（ICS）是主要治疗方法，但接受ICS治疗的患者中哮喘控制不佳的情况很常见。使用治疗递增（ICS剂量增加和其他控制性治疗添加）来管理症状。量化后结果的真实世界研究可能为治疗决策提供信息。要点：（a）描述升级治疗的哮喘患者的特征和治疗模式，（B）评估结果（急性发作、不受控制的哮喘和卫生保健资源利用[HCRU]）。研究队列是通过ICD-9-CM哮喘编码从美国大型行政索赔数据库中确定的2009年1月1日至2014年9月30日期间（≥ 2个日期493.xx）和开始（定义索引日期）长期（>1次填充）含ICS治疗。索引日期前后需要连续入组一年。递增定义为≥以下1项：ICS剂量增加; ICS、长效β-2受体激动剂（LABA）或白三烯调节剂（LTRM）之间转换为不同的ICS、LABA或LTRM;或添加控制性药物（例如，抗体生物学）。审查了升级模式。计算急性发作率（定义为住院、急诊[艾德]就诊或7天内有口服皮质类固醇[OCS]药房报销的门诊就诊）和未控制哮喘的发生率（定义为1年内短效β受体激动剂[SABA]填充>4次、OCS填充>= 1次或哮喘相关艾德就诊或住院>= 1次）。结果：在35，126例开始长期含ICS治疗的患者（平均[SD]年龄38 [16]岁）中，5，044例（14%）患者在索引后136（105）天（即，升级前阶段）。最常见的变化（单独或联合）包括ICS剂量增加（68%）或LABA（27%）或LTRM（25%）添加。递增前，急性加重率为1.60（5.10）PPPY，1，108例（22%）患者发生急性加重。在251.6（138.9）天的定标后期间，急性加重率为0.75（2.9）PPPY，1，038（21%）例患者发生急性加重。大多数（>85%）在递增之前和之后的急性加重与7天内的办公室访视和OCS药房索赔相关。在剂量递增前和剂量递增后，分别有41.5%和41.0%的患者发生哮喘不受控制。门诊治疗访视在治疗前（平均[SD] 24.0 [26.7]全因PPPY和8.5 [13.4]哮喘相关PPPY）和治疗后（19.3 [21.3]全因PPPY和4.6 [8.1]哮喘相关PPPY）很常见。结论：在开始长期含ICS方案的哮喘患者中，约14%在开始治疗后一年内增加治疗。然而，这些患者中有21%发生≥ 1次急性发作，41%的患者在治疗递增后1年内发生不受控制的哮喘。结果表明，在哮喘患者中，增加含ICS治疗的需求未得到满足。版权所有（C）2017，管理护理药房学院. All rights reserved.
BACKGROUND: Asthma is a common disorder that affects approximately 8% of the U.S. population. Treatment guidelines indicate inhaled corticosteroids (ICS) as the mainstay treatment, yet poor asthma control is common among ICS-treated patients. Treatment escalation (ICS dose increase and other controller therapy add-ons) is used to manage symptoms. Real-world studies of postescalation outcomes may inform treatment decisions.OBJECTIVES: To (a) describe characteristics and treatment patterns among asthma patients who escalated treatment and (b) assess outcomes (exacerbations, uncontrolled asthma, and health care resource utilization [HCRU]) after escalation.METHODS: The study cohort was identified from a large U.S. administrative claims database via ICD-9-CM codes for asthma (493.xx on >= 2 dates) and initiation (defining index date) of long-term (>1 fill) ICS-containing treatment between January 1, 2009, and September 30, 2014. One year of continuous enrollment was required before and after the index date. Escalation was defined as >= 1 of the following: ICS dose increase; a switch between ICS, long-acting beta-2 agonists (LABA), or leukotriene modifiers (LTRM) to a different ICS, LABA, or LTRM; or add-on of controller medications (e.g., antibody biologic). Escalation patterns were examined. Rates of exacerbation (defined by inpatient admission, emergency department [ED] visit, or office visit with a pharmacy claim for an oral corticosteroid [OCS] within 7 days) and occurrence of uncontrolled asthma (defined by >4 fills for a short-acting beta agonist [SABA] in a 1-year period, >= 1 OCS fill, or >= 1 asthma-related ED visit or inpatient admission) were calculated. Per-patient-per-year (PPPY) HCRU was estimated.RESULTS: Among 35,126 patients (mean [SD] age 38 [16] years) who initiated long-term ICS-containing treatment, 5,044 (14%) patients escalated their index regimens at 136 (105) days post-index (i.e., pre-escalation period). The most frequent changes, alone or in combination, included ICS dose increase (68%) or LABA (27%) or LTRM (25%) add-ons. Before escalation, the exacerbation rate was 1.60 (5.10) PPPY, and 1,108 (22%) patients experienced exacerbation. During the postescalation period of 251.6 (138.9) days, the exacerbation rate was 0.75 (2.9) PPPY, and 1,038 (21%) patients experienced exacerbation. A majority (>85%) of exacerbations in the periods before and after escalation were associated with an office visit plus an OCS pharmacy claim within 7 days. Uncontrolled asthma was experienced by 41.5% and 41.0% of patients before and after escalation, respectively. Ambulatory care visits were common before (mean [SD] 24.0 [26.7] all-cause and 8.5 [13.4] asthma-related PPPY) and after escalation (19.3 [21.3] all-cause and 4.6 [8.1] asthma-related PPPY).CONCLUSIONS: Among asthma patients who initiated a long-term ICS-containing regimen, approximately 14% escalated therapy within a year of initiation. Yet, 21% of those patients had = 1 exacerbation, and 41% of patients had uncontrolled asthma within 1 year after treatment escalation. The results demonstrate an unmet need among asthma patients who escalated their ICS-containing treatment. Copyright (C) 2017, Academy of Managed Care Pharmacy. All rights reserved.