Factors associated with exacerbations among adults with asthma according to electronic health record data

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Abstract

Background

Asthma is a chronic inflammatory lung disease that affects 18.7 million U.S. adults. Electronic health records (EHRs) are a unique source of information that can be leveraged to understand factors associated with asthma in real-life populations. In this study, we identify demographic factors and comorbidities associated with asthma exacerbations among adults according to EHR-derived data and compare these findings to those of epidemiological studies.

Methods

We obtained University of Pennsylvania Hospital System EHR-derived data for asthma encounters occurring between 2011 and 2014. Regression analyses were performed to model asthma exacerbation frequency as explained by age, sex, race/ethnicity, health insurance type, smoking status, body mass index (BMI) and various comorbidities. We analyzed data from the National Health and Nutrition Examination Survey (NHANES) from 2001 to 2012 to compare findings with those from the EHR-derived data.

Results

Based on data from 9068 adult patients with asthma, 33.37% had at least one exacerbation over the four-year study period. In a proportional odds logistic regression predicting number of exacerbations during the study period (levels: 0, 1–2, 3–4, 5+ exacerbations), after controlling for age, race/ethnicity, sex, health insurance type, and smoking status, the highest odds ratios (ORs) of significantly associated factors were: chronic bronchitis (2.70), sinusitis (1.50), emphysema (1.39), fluid and electrolyte disorders (1.35), class 3 obesity (1.32), and diabetes (1.28). An analysis of NHANES data showed associations for class 3 obesity, anemia and chronic bronchitis with exacerbation frequency in an adjusted model controlling for age, race/ethnicity, sex, financial class and smoking status.

Conclusions

EHR-derived data is helpful to understand exacerbations in real-life asthma patients, facilitating design of detailed studies and interventions tailored for specific populations.

Electronic supplementary material

The online version of this article (10.1186/s40733-019-0048-y) contains supplementary material, which is available to authorized users.

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Most cited references 19

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The clinical features of the overlap between COPD and asthma

Megan Hardin, Edwin K Silverman, R. Barr … (2011)

Background The coexistence of COPD and asthma is widely recognized but has not been well described. This study characterizes clinical features, spirometry, and chest CT scans of smoking subjects with both COPD and asthma. Methods We performed a cross-sectional study comparing subjects with COPD and asthma to subjects with COPD alone in the COPDGene Study. Results 119 (13%) of 915 subjects with COPD reported a history of physician-diagnosed asthma. These subjects were younger (61.3 vs 64.7 years old, p = 0.0001) with lower lifetime smoking intensity (43.7 vs 55.1 pack years, p = 0.0001). More African-Americans reported a history of asthma (33.6% vs 15.6%, p < 0.0001). Subjects with COPD and asthma demonstrated worse disease-related quality of life, were more likely to have had a severe COPD exacerbation in the past year, and were more likely to experience frequent exacerbations (OR 3.55 [2.19, 5.75], p < 0.0001). Subjects with COPD and asthma demonstrated greater gas-trapping on chest CT. There were no differences in spirometry or CT measurements of emphysema or airway wall thickness. Conclusion Subjects with COPD and asthma represent a relevant clinical population, with worse health-related quality of life. They experience more frequent and severe respiratory exacerbations despite younger age and reduced lifetime smoking history. Trial registration ClinicalTrials.gov: NCT00608764

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Risk factors of frequent exacerbations in difficult-to-treat asthma.

Elisabeth Bel, K. F. Rabe, A Brinke … (2005)

Recurrent exacerbations are a major cause of morbidity and medical expenditure in patients with asthma. Various exogenous and endogenous factors are thought to influence the level of asthma control, but systematical data on the involvement of these factors in the recurrence of asthma exacerbations are scarce. In this study, 13 clinical and environmental factors potentially associated with recurrent exacerbations were investigated in 136 patients with difficult-to-treat asthma. Patients with more than three severe exacerbations (n = 39) in the previous year were compared with those with only one exacerbation per year (n = 24). A systematic diagnostic protocol was used to assess 13 potential risk factors. Factors significantly associated with frequent exacerbations included: severe nasal sinus disease (adjusted odds ratio (OR) 3.7); gastro-oesophageal reflux (OR 4.9); recurrent respiratory infections (OR 6.9); psychological dysfunctioning (OR 10.8); and obstructive sleep apnoea (OR 3.4). Severe chronic sinus disease and psychological dysfunctioning were the only independently associated factors (adjusted OR 5.5 and 11.7, respectively). All patients with frequent exacerbations exhibited at least one of these five factors, whilst 52% showed three or more factors. In conclusion, the results show that recurrent exacerbations in asthma are associated with specific co-morbid factors that are easy to detect and that are treatable. Therapeutic interventions aimed at correcting these factors are likely to reduce morbidity and medical expenditure in these patients.

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Severe exacerbations and decline in lung function in asthma.

Søren Pedersen, Neil Tan, C. Lamm … (2009)

To evaluate the association between asthma exacerbations and the decline in lung function, as well as the potential effects of an inhaled corticosteroid, budesonide, on exacerbation-related decline in patients with asthma. To determine whether severe asthma exacerbations are associated with a persistent decline in lung function. The START (inhaled steroid treatment as regular therapy in early asthma) study was a 3-year, randomized, double-blind study of 7,165 patients (5-66 yr) with persistent asthma for less than 2 years, to determine whether early intervention with low-dose inhaled budesonide prevents severe asthma-related events (exacerbations requiring hospitalization or emergency treatment) and decline in lung function. There were 315 patients who experienced at least one severe asthma exacerbation, of which 305 were analyzable, 190 in the placebo group and 115 in the budesonide group. In the placebo group, the change in post-bronchodilator FEV(1) % predicted from baseline to the end of the study, in patients who did or did not experience a severe exacerbation was -6.44% and -2.43%, respectively (P < 0.001). A significant difference was seen in both children and in adults, but not in adolescents. In the budesonide group, the change in the post-bronchodilator FEV(1) % predicted in patients who did or did not experience a severe exacerbation was -2.48% and -1.72%, respectively (P = 0.57). The difference in magnitude of reduction afforded by budesonide, in patients who experienced at least one severe asthma-related event compared with those who did not, was statistically significant (P = 0.042). Severe asthma exacerbations are associated with a more rapid decline in lung function. Treatment with low doses of inhaled corticosteroid is associated with an attenuation of the decline.

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Author and article information

Contributors

Rebecca E. Greenblatt: Rebecca.Greenblatt@pennmedicine.upenn.edu

Edward J. Zhao: zhaoe@uw.edu

Sarah E. Henrickson: HenricksonS@email.chop.edu

Andrea J. Apter: Andrea.Apter@uphs.upenn.edu

Rebecca A. Hubbard: rhubb@pennmedicine.upenn.edu

Blanca E. Himes:

ORCID: http://orcid.org/0000-0002-2868-1333

(215) 573-3282 , bhimes@pennmedicine.upenn.edu

Journal

Journal ID (nlm-ta): Asthma Res Pract

Journal ID (iso-abbrev): Asthma Res Pract

Title: Asthma research and practice

Publisher: BioMed Central (London )

ISSN (Electronic): 2054-7064

Publication date (Electronic): 18 January 2019

Publication date PMC-release: 18 January 2019

Publication date Collection: 2019

Volume: 5

Electronic Location Identifier: 1

Affiliations

[1 ]ISNI 0000 0004 1936 8972, GRID grid.25879.31, Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, , University of Pennsylvania, ; Philadelphia, PA 19104 USA

[2 ]ISNI 0000 0001 0680 8770, GRID grid.239552.a, Division of Allergy-Immunology, , Children’s Hospital of Philadelphia, ; Philadelphia, PA 19104 USA

[3 ]ISNI 0000 0004 1936 8972, GRID grid.25879.31, Institute for Immunology, , University of Pennsylvania, ; Philadelphia, PA 19104 USA

[4 ]ISNI 0000 0004 1936 8972, GRID grid.25879.31, Pulmonary, Allergy and Critical Care Division, , Perelman School of Medicine, University of Pennsylvania, ; Philadelphia, PA 19104 USA

Author information

Blanca E. Himes http://orcid.org/0000-0002-2868-1333

Article

Publisher ID: 48

DOI: 10.1186/s40733-019-0048-y

PMC ID: 6339400

PubMed ID: 30680222

SO-VID: a3153120-a0e5-442b-9c77-703239a34b36

License:

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

History

Date received : 11 September 2018

Date accepted : 10 January 2019

Funding

Funded by: FundRef http://dx.doi.org/10.13039/100000050, National Heart, Lung, and Blood Institute;

Award ID: R01 HL133433

Award ID: R01 HL141992

Award Recipient : Blanca E. Himes

Custom metadata

Keywords: chronic obstructive pulmonary disease,chronic bronchitis,emphysema,obesity,sinusitis

Data availability:

Keywords: chronic obstructive pulmonary disease, chronic bronchitis, emphysema, obesity, sinusitis

Factors associated with exacerbations among adults with asthma according to electronic health record data

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Abstract

Background

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Biomarkers for Inflammatory Lung Disease

Most cited references 19

The clinical features of the overlap between COPD and asthma

Risk factors of frequent exacerbations in difficult-to-treat asthma.

Severe exacerbations and decline in lung function in asthma.

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