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Intermittent Asthma and Risk of Severe Exacerbation in Children
Shahid Sheikh1, Mariah Eisner2, Wheaton Kelin3
1Department of Pediatrics, Ohio State University College of Medicine, Columbus, OH; Division of Pulmonary Medicine, Columbus, OH; Division of Pulmonary Medicine, Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH.
Insights
A subgroup of mild asthma patients has a very low risk of severe exacerbations. Current GINA guidelines may not be necessary or cost-effective for this low-risk group.
Area of Science:
- Pediatric Pulmonology
- Asthma Management
- Public Health
Background:
- Current GINA guidelines recommend against using short-acting beta-agonists (SABA) alone for mild asthma due to severe exacerbation risks.
- It remains unclear if all mild asthma patients share an equal risk for severe exacerbations.
Purpose of the Study:
- To identify if a specific subgroup of mild asthma patients exhibits a very low risk of severe asthma exacerbations.
- To evaluate the cost-effectiveness of current treatment guidelines for this identified low-risk subgroup.
Main Methods:
- A cohort of 2-18 year olds with intermittent asthma was identified from Ohio Medicaid claims data over three years.
- A low-risk group was defined based on SABA canister dispensing in the first two years.
- The third year compared severe asthma exacerbation risks between the low-risk group and the rest of the cohort.
Main Results:
- 13,208 patients met inclusion criteria. The low-risk group (3,935 patients) had significantly lower rates of hospitalization (0.08%) and ED/UC visits (0.97%/0.55%) with 0-2 SABA canisters/year.
- Relative risk of hospitalization was 0.17 (95% CI: 0.06, 0.52) and severe exacerbation was 0.18 (95% CI: 0.13, 0.27) in the low-risk group compared to high-risk patients.
- Preventing one hospitalization in the low-risk cohort required treating 5,535 patients, costing $779,716 per hospitalization prevented with ICS therapy.
Conclusions:
- A subgroup of mild asthma patients exists with a demonstrably lower risk of hospitalization and severe exacerbations.
- Current GINA first-step treatment recommendations may be unnecessary and not cost-effective for this identified low-risk population.
- Further research into personalized asthma management strategies based on risk stratification is warranted.
Background:
Because of risk of severe asthma exacerbations, current Global Initiative for Asthma recommendations advise against use of short-acting beta-agonists (SABAs) alone as the first step in treating mild asthma. It is unclear if everyone with mild asthma carries equal risk for severe asthma exacerbations.
Research Question:
Is there a subgroup of patients with mild asthma with very low risk of severe asthma exacerbations?
Study Design And Methods:
This study cohort used administrative claims data for patients ages 2 to 18 years with intermittent asthma enrolled in Ohio Medicaid Managed Care Plans for 3 consecutive years. A low-risk group was identified for the first 2 years; in the third year, risk of severe asthma exacerbations was compared among the low-risk group and the rest of the cohort.
Results:
A total of 13,208 patients met inclusion criteria. In the third year, among 3,935 low-risk patients, rates of asthma hospitalization, emergency department visits, and urgent care visits for those with 0 to 2 SABA canisters dispensed per year were 3 (0.08%), 37 (0.97%), and 21 (0.55%), respectively, with a relative risk of hospitalization of 0.17 (95% CI, 0.06-0.52) and a relative risk of severe asthma exacerbation of 0.18 (95% CI, 0.13-0.27) compared with high-risk patients. In the low-risk cohort, the number of patients needed to treat to prevent 1 hospitalization was 5,535. The cost to prevent 1 hospitalization using a single inhaler of inhaled corticosteroids per year was $779,716.
Interpretation:
Our results show that among patients with mild asthma, there is a subgroup of low-risk patients with lower risk of hospitalization and severe asthma exacerbation in which current Global Initiative for Asthma recommendations for first-step treatment may neither be needed nor cost-effective.
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