Ambulatory Use of Inhaled β2-Agonists for the Treatment of Asthma in Quebec: A Population-Based Utilization Review

doi:10.1378/chest.119.5.1316

Chest

Volume 119, Issue 5, May 2001, Pages 1316-1321

https://doi.org/10.1378/chest.119.5.1316 Get rights and content

Study objectives:

To assess whether the utilization of inhaled short-acting β₂-agonists (ISAB) and inhaled long-acting β₂-agonists (ILAB) for the treatment of asthma was appropriate according to the 1996 Canadian Asthma Consensus Conference recommendations.

Design:

Population-based retrospective drug utilization review using pharmacists' billing data of the Prescription Drug Insurance Plan administered by the Quebec health insurance board. However, the database used did not contain complete patient clinical information to accurately assess severity of asthma.

Setting:

Province of Quebec, Canada.

Patients:

Persons who received at least one outpatient prescription of ISAB (age range, 5 to 45 years) or ILAB (age range, 12 to 45 years) for the treatment of asthma between August 1997 and April 1998.

Measurements:

Percentages of patients whose use was appropriate according to three criteria regarding the average daily dose of ISAB (criterion 1), the renewal interval of ILAB (criterion 2), and the concomitant daily use of corticosteroids for the expected length of utilization of ILAB (criterion 3).

Results:

Overall proportions of appropriate use according to criterion 1 were as follows: 75% (without inhaled corticosteroids [ICS]) and 84% and 43% (with one or more than one prescription of ICS, respectively). Appropriateness was slightly higher for female patients, younger patients (5 to 18 years old), and those treated by pediatricians. However, appropriateness was only 9% among patients who received at least two prescriptions of ISAB during the study period. The proportion of appropriate use was 19% according to criterion 2 and 15% according to criterion 3; there were few differences by gender or by age, but the appropriateness according to criterion 2 was somewhat higher for patients of respirologists.

Conclusion:

Compared to the 1996 Canadian asthma consensus conference recommendations, ISAB are overused, ICS are underused, and ILAB are often used improperly. Close collaboration between health professionals and patients is essential to improve the pharmacotherapy of asthma.

Section snippets

Materials and Methods

This study was a retrospective drug utilization review of ISAB and ILAB in Quebec, the second largest Canadian province (population 7.4 million).⁷ Data came from the Prescription Drug Insurance Plan administered by the Régie de l'assurance maladie du Québec (RAMQ), the Quebec health insurance board. The RAMQ plan covers about 3 million people classified into three groups: the elderly (≥ 65 years old), welfare recipients, and those who do not have access to a private group plan.

The study

Results

Results are presented separately for ISAB and ILAB. Table 2shows the demographic characteristics of the study population using ISAB and the proportion of appropriate use according to these characteristics. Most users are adult female patients, and most have had their prescriptions written by general practitioners.

In the group not concurrently taking ICS, the overall proportion of appropriate use was 75%. Appropriateness was higher among female and younger subjects and those treated by

Discussion

The three main findings of this study are that, compared to the recommendations of the Canadian Asthma Consensus Conference, (1) ISAB are overused, (2) ICS seem to be underused, and (3) ILAB are often used improperly. This means that, despite their dissemination among physicians, the Canadian consensus guidelines are far from having been put into practice. Other studies¹³¹⁴¹⁵¹⁶¹⁷¹⁸ also have shown that treatment for asthma was suboptimal. More generally, it has often been demonstrated that

Appendix

In addition to Dr. Blais and Dr. Grégoire, the members of the Comité de revue de l'utilisation des médicaments are Dr. Michelle Lussier-Montplaisir, Mrs. Diane Lamarre, Mr. Élie Assal, Mrs. Danielle Doyon, Dr. Yvon Grand'Maison, Dr. Serge Langlois, and Mr. Pierre Madore. Mrs. Diane Blais, Mrs. Louise Barnard, Mrs. Joelle Mimeault, and Mr. Marc Saindon acted as support staff.

ACKNOWLEDGMENT

The clinicians of the expert panel who worked on the criteria of appropriate use of the study drugs were Dr. Jacques Bouchard, general practitioner; Dr. Louis-Philippe Boulet, respirologist; Dr. André Cartier, respirologist; Dr. Pierre Larivée, respirologist; and Mrs. Rachel Rouleau, pharmacist.

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Justicia pectoralis, a coumarin medicinal plant have potential for the development of antiasthmatic drugs?
2017, Revista Brasileira de Farmacognosia
Citation Excerpt :
Characterized by airway hyper-responsiveness, bronchospasm and airway inflammation with edema and mucus production, the therapy of asthma is based on the use of β-agonists and other bronchodilators that target bronchospasm, leukotriene antagonists, anti-IgE and corticosteroids that reduce the immune-inflammatory responses (Busse and Lemanske, 2001; Bosnjak et al., 2011; Schäper et al., 2011). However, these anti-asthmatic therapeutics are associated with many adverse effects related mainly the use of corticosteroids (Eggleston et al., 1998; Blais et al., 2001; Wise, 2014). Unwanted side effects of corticosteroids and decreased glucocorticoid responsiveness found in patients with severe asthma have increased the need to develop new anti-asthmatic drugs.
Justicia pectoralis Jacq., Acanthaceae, is a medicinal plant found Central America. In the Northeast of Brazil, it is popularly known as “chambá” being extensively used in homemade preparations for the treatment of cough, bronchitis and asthma. The species is part of a public phytotherapy program in Brazil entitled “Farmácias Vivas”, National Record of Plants of Interest to the National Health System and the National Formulary of Herbal medicines. This paper aims to critically review the available scientific literature regarding the health promoting effects of J. pectoralis var. stenophylla. The traditional uses, phytochemistry, pharmacological activities, toxicology, quality control and potential interactions with conventional drugs were included in the present review. Botanical, chemical and pharmacognostical studies stablished several parameters useful for quality control of plant drug, extracts and phytomedicine from aerial parts of J. pectoralis using as markers two bioactive coumarins. A wide range of evidence have demonstrated the anti-inflammatory, anti-nociceptive, anti-spasmodic, smooth muscle relaxant and anxiolytic effects of J. pectoralis and its chemical constituents. Pilot clinical studies showed the efficacy of a syrup preparation of J. pectoralis in the treatment of mild and moderate asthma. The pharmacological potential make these medicinal plants good candidates for the development of new phytomedicine for the treatment of asthma. However, a strong collaboration to bridge the gap between preclinical and clinical study is still necessary for the development of an effective medicine from J. pectoralis.
Controlling Asthma by Training of Capnometry-Assisted Hypoventilation (CATCH) vs slow breathing: A randomized controlled trial
2014, Chest
Citation Excerpt :
Change in perception of obstruction was based on dyspnea and distress differences between maxima during provocation vs saline. Control variables were prescribed inhaled corticosteroid intake (converted to beclomethasone equivalent),27 leukotriene modifier prescription (0 = none and 1 = any use), reported frequency of corticosteroid and leukotriene intake as an indicator of adherence, and cold and flu symptoms in the week prior to assessment (presence = 1, absence = 0). Adverse events were assessed at each visit.
Hyperventilation has been associated with adverse effects on lung function, symptoms, and well-being in asthma. We examined whether raising end-tidal CO₂levels (ie, Pco₂) compared with slow breathing is associated with improvements in asthma control, including peak flow variability.
One hundred twenty patients with asthma were randomly assigned to capnometry-assisted respiratory training (CART) for raising Pco₂or slow breathing and awareness training (SLOW) for slowing respiratory rate. Patients received five weekly sessions and completed bid homework exercises over 4 weeks. Blinded assessments at baseline, posttreatment, 1- and 6-month follow-up of asthma control, Pco₂, and diurnal peak flow variability were primary outcome measures. Additionally, we measured pulmonary function (spirometry, forced oscillation, exhaled nitric oxide, and methacholine challenge), symptoms, quality of life, and bronchodilator use. Because the control group received active treatment, we expected improvements in asthma control in both groups but more pronounced benefits from CART.
Improvements were seen in 17 of 21 clinical indexes (81.0%) in both interventions, including the primary outcome variables asthma control (d= 0.81), peak flow variability (d= 0.54), quality of life, bronchodilator use, lung function, and airway hyperreactivity. Most improvements were sustained across the 6-month follow-up. Compared with slow breathing, CART showed greater increases in Pco₂(d= 1.45 vs 0.64 for CART vs SLOW, respectively) and greater reductions in respiratory impedance during treatment, less distress during methacholine challenge, and greater reduction in asthma symptoms at follow-up (P< .05).
Brief interventions aimed at raising Pco₂or slowing respiratory rate provide significant, sustained, and clinically meaningful improvements in asthma control. Raising Pco₂was associated with greater benefits in aspects of lung function and long-term symptoms.
TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT00975273; URL:www.clinicaltrials.gov
Impact of prior authorization for asthma medications on the use of emergency health services: A retrospective cohort study among newly diagnosed patients with asthma
2010, Clinical Therapeutics
Background: A prior authorization process to limit the nonoptimal use of medications combining inhaled corticosteroids and long-acting bronchodilators was introduced in the province of Québec, Canada, on October 1, 2003.
Objective: We assessed the impact of this administrative measure on the rate of asthma-related emergency department (ED) visits and hospitalizations.
Methods: A retrospective cohort study was conducted using Régie de l’assurance maladie du Québec administrative databases. We identified all persons aged 6 to 44 years with an incident asthma diagnosis in the 2-year periods preceding (October 1, 2001–September 30, 2003) and following (October 1, 2003–September 30, 2005) the introduction of the process. Children aged ≤5 years at the time of the first encountered diagnosis were excluded because it is difficult to make an objective asthma diagnosis until 6 years of age. People aged ≥45 years at the time of the first encountered diagnosis were also excluded to avoid the inclusion of persons who might also have had chronic obstructive pulmonary disease. Two groups were created based on their prescription drug insurance (private or public). Publicly insured persons were considered exposed to the process while privately insured persons were considered not exposed. Cox proportional hazards regression was used to assess, for each insurance group, the hazard ratio (HR) for an asthma-related first hospitalization or ED visit between the 2 periods. The use of medication, quality of life, and visits to physicians' offices were not considered in the analysis. The interaction between group and period was assessed to test whether the change in risk between the preprocess and postprocess periods differed by insurance group; statistical models were adjusted for sex, age, region, presence of a comorbidity other than asthma, and discipline of diagnosing physician.
Results: There were 47,579 publicly insured persons and 93,177 privately insured persons with incident asthma during the study period. The risk of an asthma-related first hospitalization or ED visit remained unchanged in the 2 periods evaluated among both the publicly insured (adjusted HR, 0.95 [95% CI, 0.88–1.03]) and the privately insured (adjusted HR, 1.03 [95% CI, 0.96–1.03]). The change in risk between the preprocess and postprocess periods was not significantly different between insurance groups.
Conclusions: The prior authorization process introduced to limit the nonoptimal use of combination products (formoterol/budesonide and salmeterol/fluticasone) had no apparent impact on first asthma-related hospitalization or ED visit in these patients newly diagnosed with asthma who were covered by Québec's public prescription drug insurance plan.
Socioeconomic status and medication prescription patterns in pediatric asthma in Canada
2006, Journal of Adolescent Health
To investigate whether the socioeconomic status of children and adolescents with asthma is associated with optimal use of asthma medications in a health care system that provides free access to prescribed medications.
A cohort of 29,018 children (5–12 y) and adolescents (13–17 y) with asthma was reconstructed from the administrative health database of the Régie de l’assurance maladie du Québec in Canada. Adherence to the Canadian Asthma Guidelines was compared between low-income patients (patients living in families receiving social assistance) and higher-income patients (patients living in middle-class families with working parents). Both groups of patients had free, universal access to medical care and prescribed medications. Patients were considered adherent if they had: (1) 10 doses or fewer of a short-acting β₂-agonist (SABA) per week or (2) greater than 10 doses of a SABA per week plus greater than 1,000 μg of beclomethasone chlorofluorocarbon (CFC) per day. A second definition of adherence was used in which the 10 doses of SABA were replaced by 3 doses.
Our cohort comprised 7,454 adolescents and 21,564 children. Within each definition, low-income adolescents had similar rates of adherence as higher-income adolescents (p = .08–.4). Low-income children, however, had lower rates of adherence than higher-income children when the first definition of adherence was used (76% vs. 80%; p < .001).
Our study showed that socioeconomic status had a small influence on the likelihood of receiving treatment in adherence with the Canadian Asthma Guidelines among children, whereas no association was detected among adolescents.
Regular use of corticosteroids and low use of short-acting β<inf>2</inf>-agonists can reduce asthma hospitalization
2005, Chest
Citation Excerpt :
One canister of salbutamol per month is equivalent to 200 inhalations (100 μg per inhalation) per month or approximately 7 inhalations (700 μg) per day; and according to the National Institutes of Health guidelines, more than one canister use per month is considered to be overreliance on ISABA and inappropriate use of ISABA.3 ICS medications were converted to beclomethasone (aerosol) equivalent using the formula suggested by Blais et al.30,31 One milligram of beclomethasone for nebulizer solution was assumed to be equivalent to 0.1 mg of beclomethasone by metered-dose aerosol. One milligram of beclomethasone for disk inhaler was assumed to be equivalent to 2 mg of beclomethasone by metered aerosol.
Inhaled corticosteroids (ICS) and inhaled short-acting β₂-agonists (ISABA) are the most commonly used medications for management of asthma. Increased asthma morbidity and mortality have been reported with excess use of ISABA in several studies. In these studies, authors have used different indicators to control for the potential confounding by asthma severity. The objective of this study was to determine the effect of ICS use on the association between use of ISABA and first hospitalization for asthma after controlling for several indicators of asthma severity
An inceptional cohort study using Saskatchewan Health databases
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Among the subjects with increased asthma severity, indicated by one or more average number of asthma-related physician visits per 3 months during the follow-up, high use of ISABA was a risk factor for hospitalization when no ICS were used (rate ratio [RR], 2.16; 95% confidence interval [CI], 1.51 to 2.95). There was a beneficial effect of ISABA when there was low use of ICS (RR, 0.65; 95% CI, 0.42 to 0.93) or high use of ICS (RR, 0.23; 95% CI, 0.12 to 0.41). Among the subjects with less severe asthma, indicated by less than one asthma-related physician visits per 3 months, on average, during the follow-up, the risk of hospitalization was even greater for high use of ISABA when no ICS were used (RR, 10.06; 95% CI, 6.99 to 14.47). This was reduced but not abolished when there was low use of ICS (RR, 3.24; 95% CI, 2.29 to 4.59) and negated altogether by high use of ICS (RR, 1.10; 95% CI, 0.39 to 3.12)
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Asthma in older children and adolescents seen in an Emergency Room
2002, Revue Francaise d'Allergologie et d'Immunologie Clinique
Au cours de son passage obligé d'une prise en charge parentale à l'autonomie, l'adolescent asthmatique est exposé, du fait de sa maladie, à des risques particuliers tant en terme de mortalité que de morbidité. Ces risques résultent entre autre de la perception de l'affection, perception individuelle et perception au travers des croyances familiales. La morbidité mesurée est importante : absentéisme scolaire, limitation des activités quotidiennes, asthme persistant et inadaptation des thérapeutiques prescrites. L'insatisfaction est fréquente tout spécialement à l'égard des insuffisantes informations délivrées. De nouvelles modalités de prise en charge de cette tranche d'âge sont à explorer.
During the obligatory passage from being his parent's responsibility to assuming his own therapeutic autonomy, the asthmatic adolescent, as a result of his disease, is exposed to specific risks, including both morbidity and mortality. These risks arise from his personal feelings about his asthma and from his family's beliefs as well. The entire range of morbidity is important : school absenteeism, decreased activity, persistent asthma and inadequate drug prescriptions. Dissatisfaction is frequent, especially regarding patient-provider communication and knowledge. New strategies of care and education for this age group have to be explored.

View all citing articles on Scopus

: This study was funded by the Comité de revue de l'utilisation des médicaments of the province of Quebec.

^†: A complete list of participants is given in the Appendix

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Chest

Clinical InvestigationsASTHMAAmbulatory Use of Inhaled β2-Agonists for the Treatment of Asthma in Quebec: A Population-Based Utilization Review

Study objectives:

Design:

Setting:

Patients:

Measurements:

Results:

Conclusion:

Section snippets

Materials and Methods

Results

Discussion

Appendix

ACKNOWLEDGMENT

J Clin Epidemiol

Am J Med

Ann Allergy Asthma Immunol

Chest

Direct and indirect costs of asthma in Canada, 1990

Can Med Assoc J

National asthma education program expert panel report: guidelines for the diagnosis and management of asthma

AAOHN J

Canadian Asthma Consensus Conference: summary of recommendations

Can Respir J

Consensus sur le bilan et le traitement de l'asthme

Le Clinicien

Do practice guidelines guide practice? The effect of a consensus statement on the practice of physicians

N Engl J Med

Revue de l'utilisation des agonistes β2 inhalés employés dans le traitement de l'asthme: rapport d'étude

Inhaled glucocorticoids for asthma

N Engl J Med

Compendium of Pharmaceuticals and Specialties

L'aérosolthérapie dans le traitement de l'asthme et des autres bronchopneumopathies obstructives

Info-médicaments

Clinical Investigations
ASTHMA
Ambulatory Use of Inhaled β₂-Agonists for the Treatment of Asthma in Quebec: A Population-Based Utilization Review

Revue de l'utilisation des agonistes β₂ inhalés employés dans le traitement de l'asthme: rapport d'étude