Potential Severe Asthma Hidden in UK Primary Care

Dermot Ryan; Heath Heatley; Liam G Heaney; David J Jackson; Paul E Pfeffer; John Busby; Andrew N Menzies-Gow; Rupert Jones; Trung N Tran; Mona Al-Ahmad; Vibeke Backer; Manon Belhassen; Sinthia Bosnic-Anticevich; Arnaud Bourdin; Lakmini Bulathsinhala; Victoria Carter; Isha Chaudhry; Neva Eleangovan; J Mark FitzGerald; Peter G Gibson; Naeimeh Hosseini; Alan Kaplan; Ruth B Murray; Chin Kook Rhee; Eric Van Ganse; David B Price

doi:10.1016/j.jaip.2020.11.053

Potential Severe Asthma Hidden in UK Primary Care

J Allergy Clin Immunol Pract. 2021 Apr;9(4):1612-1623.e9. doi: 10.1016/j.jaip.2020.11.053. Epub 2020 Dec 9.

Authors

Dermot Ryan¹, Heath Heatley², Liam G Heaney³, David J Jackson⁴, Paul E Pfeffer⁵, John Busby³, Andrew N Menzies-Gow⁶, Rupert Jones⁷, Trung N Tran⁸, Mona Al-Ahmad⁹, Vibeke Backer¹⁰, Manon Belhassen¹¹, Sinthia Bosnic-Anticevich¹², Arnaud Bourdin¹³, Lakmini Bulathsinhala¹⁴, Victoria Carter¹⁴, Isha Chaudhry², Neva Eleangovan¹⁴, J Mark FitzGerald¹⁵, Peter G Gibson¹⁶, Naeimeh Hosseini¹⁷, Alan Kaplan¹⁸, Ruth B Murray¹⁷, Chin Kook Rhee¹⁹, Eric Van Ganse¹¹, David B Price²⁰

Affiliations

¹ Usher Institute, University of Edinburgh, United Kingdom.
² Observational and Pragmatic Research Institute, Singapore, Singapore.
³ UK Severe Asthma Network and National Registry, Queen's University Belfast, Belfast, Northern Ireland.
⁴ UK Severe Asthma Network and National Registry, Guy's and St Thomas' NHS Trust and Division of Asthma, Allergy & Lung Biology, King's College London, London, United Kingdom.
⁵ UK Severe Asthma Network, Barts Health NHS Trust and Queen Mary University of London, London, United Kingdom.
⁶ UK Severe Asthma Network and National Registry, Royal Brompton & Harefield NHS Foundation Trust, London, United Kingdom.
⁷ Faculty of Health, University of Plymouth, Plymouth, United Kingdom.
⁸ AstraZeneca, Gaithersburg, MD.
⁹ Al-Rashed Allergy Center, Ministry of Health, Microbiology Department, Faculty of Medicine, Kuwait University, Kuwait.
¹⁰ Department of ENT & Centre for Physical Activity Research, Rigshospitalet and Copenhagen University, Copenhagen, Denmark.
¹¹ PELyon, HESPER 7425, Claude Bernard University, Lyon, France.
¹² Woolcock Institute of Medical Research, University of Sydney and Sydney Local Health District, Glebe, NSW, Australia.
¹³ Department of Respiratory Diseases, Montpellier University Hospitals, Arnaud de Villeneuve Hospital, Montpellier, France.
¹⁴ Observational and Pragmatic Research Institute, Singapore, Singapore; Optimum Patient Care, Cambridge, United Kingdom.
¹⁵ Centre for Lung Health, Vancouver, Canada.
¹⁶ Australian Severe Asthma Network, Priority Research Centre for Healthy Lungs, University of Newcastle, Newcastle, NSW, Australia; Hunter Medical Research Institute, Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton Heights, NSW, Australia.
¹⁷ Optimum Patient Care, Cambridge, United Kingdom.
¹⁸ Family Physician Airways Group of Canada, Stouffville, ON, Canada; University of Toronto, Toronto, ON, Canada.
¹⁹ Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea.
²⁰ Observational and Pragmatic Research Institute, Singapore, Singapore; Optimum Patient Care, Cambridge, United Kingdom; Centre of Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom. Electronic address: dprice@opri.sg.

PMID: 33309935
DOI: 10.1016/j.jaip.2020.11.053

Abstract

Background: Severe asthma may be underrecognized in primary care.

Objective: Identify and quantify patients with potential severe asthma (PSA) in UK primary care, the proportion not referred, and compare primary care patients with PSA with patients with confirmed severe asthma from UK tertiary care.

Methods: This was a historical cohort study including patients from the Optimum Patient Care Research Database (aged ≥16 years, active asthma diagnosis pre-2014) and UK patients in the International Severe Asthma Registry (UK-ISAR aged ≥18 years, confirmed severe asthma in tertiary care). In the OPCRD, PSA was defined as Global INitiative for Asthma 2018 step 4 treatment and 2 or more exacerbations/y or at Global INitiative for Asthma step 5. The proportion of these patients and their referral status in the last year were quantified. Demographic and clinical characteristics of groups were compared.

Results: Of 207,557 Optimum Patient Care Research Database patients with asthma, 16,409 (8%) had PSA. Of these, 72% had no referral/specialist review in the past year. Referred patients with PSA tended to have greater prevalence of inhaled corticosteroid/long-acting β₂-agonist add-ons (54.1 vs 39.8%), and experienced significantly (P < .001) more exacerbations per year (median, 3 vs 2/y), worse asthma control, and worse lung function (% predicted postbronchodilator FEV₁/forced vital capacity, 0.69 vs 0.72) versus nonreferred patients. Confirmed patients with severe asthma (ie, UK patients in the International Severe Asthma Registry) were younger (51 vs 65 years; P < .001), and significantly (P < .001) more likely to have uncontrolled asthma (91.4% vs 62.5%), a higher exacerbation rate (4/y [initial assessment] vs 3/y), use inhaled corticosteroid/long-acting β₂-agonist add-ons (67.7% vs 54.1%), and have nasal polyposis (24.2% vs 6.8) than referred patients with PSA.

Conclusions: Large numbers of patients with PSA in the United Kingdom are underrecognized in primary care. These patients would benefit from a more systematic assessment in primary care and possible specialist referral.

Keywords: International Severe Asthma Registry; Optimum Patient Care Research Database; Potential severe asthma; Referral; Tertiary care.

Publication types

Research Support, Non-U.S. Gov't

MeSH terms

Administration, Inhalation
Adolescent
Adrenal Cortex Hormones / therapeutic use
Adult
Anti-Asthmatic Agents* / therapeutic use
Asthma* / diagnosis
Asthma* / drug therapy
Asthma* / epidemiology
Cohort Studies
Humans
Primary Health Care
United Kingdom / epidemiology

Substances

Adrenal Cortex Hormones
Anti-Asthmatic Agents