Asthma diagnosis and treatment
Determinants of future long-term asthma control

https://doi.org/10.1016/j.jaci.2006.07.057Get rights and content

Background

Asthma control has been hypothesized to be inversely related to asthma severity, directly related to effective management, and also related to other definable factors, but empiric data to support this construct are few.

Objective

We sought to identify independent prospective determinants of future long-term asthma control among asthma severity, management, demographic, and comorbidity predictors.

Methods

Surveys were completed by a random sample of 2250 health maintenance organization members aged 18 to 56 years with persistent asthma. Linked computerized pharmacy data provided baseline and follow-up year medication dispensings. The outcome was follow-up year long-term asthma control, as assessed by using a previously validated 4-level scale based on the number of short-acting β-agonist canister dispensings.

Results

Oral corticosteroids (odds ratio [OR], 1.9) or unscheduled visits (OR, 1.2) in the prior year, any prior asthma hospitalizations (OR, 1.4), smoking (OR, 2.2), chronic obstructive pulmonary disease (OR, 1.9), male sex (OR, 1.5), black race (OR, 1.3), and lower educational level (OR, 1.1) were independently associated with poorer control in ordinal logistic regression analyses. Regular inhaled corticosteroids (OR, 0.7), long-acting β-agonists (OR, 0.7) and asthma specialist care (OR, 0.6) were independently associated with better control.

Conclusions

Markers of asthma severity and other patient characteristics are inversely related to future asthma control, but effective management strategies are associated with improved asthma control, even after accounting for these high-risk characteristics.

Clinical implications

Inhaled corticosteroids, long-acting β-agonists, and asthma specialist care are associated with improved asthma control, even after accounting for markers of asthma severity.

Section snippets

Patients

Surveys were sent in August 2000 to a random sample of Kaiser-Permanente Medical Care Program adult members aged 18 to 56 years from the Northern California (n = 3072), Northwest (n = 543), and Southern California (n = 3251) regions who were given diagnoses of persistent asthma based on the presence of one or more of the following National Committee for Quality Assurance Health Plan Data and Information Set (HEDIS)15 administrative database criteria (during 1999): (1) 4 or more asthma

Results

The number of patients at each β-agonist long-term control scale level in 2001 was as follows: level 1 (0-2 canisters per year), 668 (29.7%); level 2 (3-6 canisters per year), 539 (24.0%); level 3 (7-12 canisters per year), 520 (23.1%); and level 4 (>12 canisters per year), 523 (23.2%). Long-term asthma control was significantly and inversely related to all severity-related asthma utilization measures tested (Table I). Table I shows both bivariate associations and, in the final column, the

Discussion

Asthma control is the goal of asthma therapy, and thus its relationship to asthma severity and other factors is of great clinical importance. Asthma severity can be defined as the inherent biologic intensity of the disease process11 and can be inferred from the intensity of the management necessary to achieve control.17 Severe exacerbations are also markers of asthma severity.18 Vollmer13 has developed a hypothetic construct of asthma control that suggests it is inversely related to inherent

References (39)

  • C.L.M. Joseph et al.

    Racial differences in emergency department use persist despite allergist visits and prescriptions filled for anti-inflammatory medications

    J Allergy Clin Immunol

    (1998)
  • N.F. Ray et al.

    Race, income, urbanization and asthma hospitalizations in California: a small area study

    Chest

    (1998)
  • M.D. Eisner et al.

    Health-related quality of life and future health care utilization for asthma

    Ann Allergy Asthma Immunol

    (2002)
  • D.J. Gottlieb et al.

    Poverty, race, and medication use are correlates of asthma hospitalization rates

    Chest

    (1995)
  • K. Toren et al.

    Asthma and asthma-like symptoms in adults assessed by questionnaires: a literature review

    Chest

    (1993)
  • D.M. Mannino et al.

    Surveillance for asthma—United States, 1980-1999

    MMWR Morb Mortal Wkly Rep

    (2002)
  • E.D. Bateman et al.

    Can guideline defined asthma control be achieved? The Gaining Optimal Asthma Control Study

    Am J Respir Crit Care Med

    (2004)
  • A.L. Fuhlbrigge et al.

    The burden of asthma in the United States: level and distribution are dependent on interpretation of the national asthma education and prevention program guidelines

    Am J Respir Crit Care Med

    (2002)
  • L.-P. Boulet et al.

    Evaluation of asthma control by physicians and patients: comparison with current guidelines

    Can Respir J

    (2002)
  • Cited by (62)

    • Determinants of asthma control and exacerbations in moderate to severe asthma

      2022, Journal of Allergy and Clinical Immunology: In Practice
    • Predictors of Asthma Control and Exacerbations: A Real-World Study

      2021, Journal of Allergy and Clinical Immunology: In Practice
      Citation Excerpt :

      Although several studies have attempted to identify predictors for poor asthma control5-14 or asthma exacerbations,15-17 these outcomes were studied in separate populations in the vast majority of studies. For example, older age,5,6 lower socioeconomic status,5 low level of education,6,7 multiple comorbidities,5 insurance status,8 smoking,6,8 obesity,6-11 prior hospital admission for asthma,12 low lung function,14 low adherence to treatment,5 and poor baseline asthma control7,13 were associated with poor asthma control in studies that did not assess asthma exacerbations. In contrast, occurrence of previous asthma exacerbations,16,18 low forced expiratory volume in 1 second (FEV1),16 insurance status,18 and high blood eosinophil count17 were associated with asthma exacerbations in studies that did not report asthma control.

    • Inhaled corticosteroids and asthma control in adult-onset asthma: 12-year follow-up study

      2018, Respiratory Medicine
      Citation Excerpt :

      Even though some interventional studies have shown that good asthma control can be achieved by stepping up treatment or by follow-up interventions [19,20], surprisingly large proportion of patients remain uncontrolled after stepping up the therapy [12]. Factors such as smoking and concurrent chronic obstructive disease, obesity, male sex and rhinitis have been reported to associate with an increased risk of uncontrolled asthma [8,21]. This suggests that a poor disease control may result from several events occurring longitudinally.

    View all citing articles on Scopus

    Supported by the Kaiser-Permanente Care Management Institute, Oakland, Calif.

    Disclosure of potential conflict of interest: The authors have declared that they have no conflict of interest.

    View full text