Pain relief and associated factors: a cross-sectional observational web-based study in a Quebec cohort of persons living with chronic pain.

Objectives: Randomized clinical trials are used to evaluate the efficacy of various pain treatments individually, while a limited number of observational studies have portrayed the overall relief experienced by persons living with chronic pain. This study aimed to describe pain relief in real-world clinical settings and to identify associated factors. Methods: This exploratory web-based cross-sectional study used data from 1,419 persons recruited in the community. Overall pain relief brought by treatments used by participants was assessed using a 0%-100% scale (10-unit increments). Results: A total of 18.2% of participants reported minimal pain relief (0%-20%), 60.0% moderate to substantial pain relief (30%-60%), and 21.8% extensive pain relief (70%-100%). Multivariable multinomial regression analysis revealed factors significantly associated with greater pain relief, including reporting a stressful event as circumstances surrounding the onset of pain, living with pain for ≥10 years, milder pain intensity, less catastrophic thinking, use of prescribed pain medications, use of nonpharmacological pain treatments, access to a trusted healthcare professional, higher general health scores, and polypharmacy. Factors associated with lower pain relief included surgery as circumstances surrounding pain onset, use of over-the-counter pain medications, and severe psychological distress. Discussion: In this community sample of persons living with chronic pain, 8 out of 10 persons reported experiencing at least moderate relief with their treatment. The analysis has enabled us to explore potential modifiable factors as opportunities for improving the well-being of persons living with chronic pain.

Where we live matters: a comparison of chronic pain treatment between remote and non-remote regions of Quebec, Canada.

Objective: Where a person lives is a recognized socioeconomic determinant of health and influences healthcare access. This study aimed to compare the pain treatment profile of persons with chronic pain (CP) living in remote regions to those living in non-remote regions (near or in major urban centers). Methods: A cross-sectional study was performed among persons living with CP across Quebec. In a web-based questionnaire, participants were asked to report in which of the 17 administrative regions they were living (six considered "remote"). Pain treatment profile was drawn up using seven variables: use of prescribed pain medications, over-the-counter pain medications, non-pharmacological pain treatments, multimodal approach, access to a trusted healthcare professional for pain management, excessive polypharmacy (≥10 medications), and use of cannabis for pain. Results: 1,399 participants completed the questionnaire (women: 83.4%, mean age: 50 years, living in remote regions: 23.8%). As compared to persons living in remote regions, those living in non-remote regions were more likely to report using prescribed pain medications (83.8% vs. 67.4%), a multimodal approach (81.5% vs. 75.5%), experience excessive polypharmacy (28.1% vs. 19.1%), and report using cannabis for pain (33.1% vs. 20.7%) (bivariable p < 0.05). Only the use of prescribed medications as well as cannabis remained significantly associated with the region of residence in the multivariable models. Discussion: There are differences in treatment profiles of persons with CP depending on the region they live. Our results highlight the importance of considering remoteness, and not only rurality, when it comes to better understanding the determinants of pain management.

Changing society, changing research: integrating gender to better understand physical and psychological treatments use in chronic pain management.

ABSTRACT: Treatment of chronic pain should be multimodal and include pharmacological, physical, and psychological treatments. However, because various barriers to physical and psychological treatments (PPTs) exist, a better understanding of biopsychosocial factors leading to their use is relevant. This study aimed to explore the association between gender identity, gender-stereotyped personality traits, and the use of PPTs in chronic pain management. The ChrOnic Pain trEatment cohort, a self-reported data infrastructure resulting from a web-based recruitment of 1935 people living with chronic pain (Quebec, Canada) was analyzed. Gender identity was operationalized as women, men, and nonbinary. Gender-stereotyped personality traits were measured using the Bem Sex-Role Inventory (feminine, masculine, androgynous, undifferentiated). A checklist of 31 types of PPTs that can be used for chronic pain management was presented to participants (yes/no). From the 1433 participants, 85.5% reported using at least one PPT. Hot-cold therapies (43.4%), exercise (41.9%), and meditation (35.2%) were the most frequently used PPTs, but most popular PPTs were not the same among women and men. Women reported a significantly higher use of PPTs in general (87.2% vs 77.2%; P < 0.001). Multivariable and interaction analyses showed that identifying as a man decreased the odds of reporting the use of PPTs (odds ratio: 0.32, 95% confidence interval: 0.11-0.92) but only among participants who scored high on both masculine and feminine personality traits (those classified as androgynous). The high prevalence of PPTs use found in our study is positive. Our results are relevant for a more personalized promotion of PPTs for chronic pain management.

Polypharmacy and Excessive Polypharmacy Among Persons Living with Chronic Pain: A Cross-Sectional Study on the Prevalence and Associated Factors.

Purpose: Polypharmacy can be defined as the concomitant use of ≥5 medications and excessive polypharmacy, as the use of ≥10 medications. Objectives were to (1) assess the prevalence of polypharmacy and excessive polypharmacy among persons living with chronic pain, and (2) identify sociodemographic and clinical factors associated with excessive polypharmacy. Patients and Methods: This cross-sectional study used data from 1342 persons from the ChrOnic Pain trEatment (COPE) Cohort (Quebec, Canada). The self-reported number of medications currently used by participants (regardless of whether they were prescribed or taken over-the-counter, or were used for treating pain or other health issues) was categorized to assess polypharmacy and excessive polypharmacy. Results: Participants reported using an average of 6 medications (median: 5). The prevalence of polypharmacy was 71.4% (95% CI: 69.0-73.8) and excessive polypharmacy was 25.9% (95% CI: 23.6-28.3). No significant differences were found across gender identity groups. Multivariable logistic regression revealed that factors associated with greater chances of reporting excessive polypharmacy (vs <10 medications) included being born in Canada, using prescribed pain medications, and reporting greater pain intensity (0-10) or pain relief from currently used pain treatments (0-100%). Factors associated with lower chances of excessive polypharmacy were using physical and psychological pain treatments, reporting better general health/physical functioning, considering pain to be terrible/feeling like it will never get better, and being employed. Conclusion: Polypharmacy is the rule rather than the exception among persons living with chronic pain. Close monitoring and evaluation of the different medications used are important for all persons, especially those with limited access to care.

Trends in Prescription Chronic Pain Medication Use before and during the First Wave of the COVID-19 Pandemic in Québec, Canada: An Interrupted Time Series Analysis.

BACKGROUND: In Canada, a state of health emergency was declared in May 2020 as a result of the COVID-19 pandemic. This study aimed to assess trends in the use of prescription medication for pain management by people living with chronic pain before and during the first wave of the pandemic. METHODS: Participants (n = 177) were adults reporting chronic pain who had completed a web-based questionnaire in 2019 and for whom complete longitudinal private and public insurance prescription claims were available. The monthly prevalence of medication use for nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, and prescribed cannabinoids was assessed. An interrupted time series analysis was then performed to evaluate if the COVID-19 pandemic had had an impact on trends in pain medication use. RESULTS: The beginning of the first wave of the pandemic was associated with the onset of a downward trend in opioid use (p < 0.05); no such association was found regarding NSAIDs. However, point prevalence of opioid use at the beginning (Nov. 2019) and at the end (Mai 2020) of the study period remained somewhat stable (17.0% vs. 16.4%). Regarding prescribed cannabinoids, a gradual increase in use was observed over the entire study period independently from the impact of the first wave of the pandemic (15.3% vs. 22.6%, p < 0.05). CONCLUSION: While the occurrence of the first wave did have an impact on opioid use among people living with chronic pain, access to and use of opioids appear to have returned to normal before the end of the first wave of COVID-19.

Multimorbidity Treatment Burden Questionnaire (MTBQ): Translation, Cultural Adaptation, and Validation in French-Canadian.

Reliable treatment burden measures are needed given the aging population and the associated increase in multimorbidity and polypharmacy. Treatment burden is defined as the effort to care for one's health and the resulting impact on one's daily life. This study aimed to translate the Multimorbidity Treatment Burden Questionnaire (MTBQ) for French-Canadians and assess its reliability and validity. The MTBQ was translated and tested with cognitive debriefing interviews, and the French version (MTBQ-F) was then administered 2 times among 105 participants. Reliability and validity were examined using the intra-class correlation coefficient (ICC), Cronbach's alpha, and Spearman's correlations. The median global MTBQ-F scores were 32.69 (interquartile range [IQR]: 21.15-48.08) and 30.77 (IQR: 21.15-46.15) for the first and second administrations, respectively. Test-retest (ICC: 0.73; 95% CI: 0.63-0.81) and internal consistency reliability (Cronbach's alpha: 0.80) were good. There was a moderate positive correlation between the MTBQ-F score and the number of self-reported conditions (rho: 0.28). This valid instrument could identify patients experiencing a high treatment burden and assess the impact of interventions among them.

Feasibility of implementing a web-based tool built from pharmacy claims data (e-MEDRESP) to monitor adherence to respiratory medications in primary care.

OBJECTIVE: e-MEDRESP is a novel web-based tool that provides easily interpretable information on patient adherence to asthma/chronic obstructive pulmonary disease (COPD) medications, using pharmacy claims data. This study investigated the feasibility of implementing e-MEDRESP in primary care. MATERIAL AND METHODS: In this 16-month prospective cohort study, e-MEDRESP was integrated into electronic medical records. Nineteen family physicians and 346 of their patients were enrolled. Counters embedded in the tool tracked physician use during the follow-up. Patient/physician satisfaction with e-MEDRESP was evaluated though telephone interviews and online questionnaires. The capacity of e-MEDRESP to improve adherence was explored using a pre-post analysis. RESULTS: Overall, 245 patients had at least one medical visit during follow-up. e-MEDRESP was consulted by 15 (79%) physicians for 85 (35%) patients during clinic visits. Seventy-three patients participated in telephone interviews; 84% reported discussing their medication use with their physician; 33% viewed their e-MEDRESP report and indicated that it was easy to interpret. The physicians reported that the tool facilitated their evaluation of their patients' medication adherence (mean ± standard deviation rating: 4.8 ± 0.7, on a 5-point Likert scale). Although the pre-post analysis did not reveal improved adherence in the overall cohort, adherence improved significantly in patients whose adherence level was <80% and who were prescribed inhaled corticosteroids (26.9% [95% CI 14.3-39.3%]) or long-acting muscarinic agents (26.4% [95% CI 12.4-40.2%]). CONCLUSIONS: e-MEDRESP was successfully integrated in clinical practice. It could serve as a useful tool to help physicians monitor their patients' medication adherence.

Development of a community pharmacy-based intervention for patients with uncontrolled asthma.

Background: Achieving asthma control is often difficult, despite the availability of effective medications. Because of their expertise, regular contact with patients, and accessibility, community pharmacists can play an important role in helping patients manage uncontrolled asthma. Objective: To develop a community pharmacy-based intervention for improving asthma control in patients with uncontrolled moderate to severe asthma. Methods: A qualitative study involving two focus groups with six and five community pharmacists, respectively, five individual interviews with community pharmacists, and three individual interviews with asthma patients was conducted using semi-structured interview guides. Focus groups aimed to develop the first prototype of the intervention and the topics included criteria to identify patients with uncontrolled asthma, content of the intervention to manage uncontrolled asthma, and potential logistical issues. Interviews were subsequently conducted with individual pharmacists and asthma patients to evaluate the prototype and finalize the intervention. The interviews and focus group transcripts were analyzed thematically, using an iterative process. Results: In focus groups and interviews, the pharmacists discussed how they screen patients with uncontrolled asthma using prescriptions refills, their needs for a convenient tool to assess asthma control, the necessity to identify causes of uncontrolled asthma to guide asthma management strategies, and the importance of patient follow-up. During interviews, patients shared their interest for the commitment of pharmacists to managing asthma. The final intervention consists of structured face-to-face counselling sessions at community pharmacies, with six steps: screening of patients with potential uncontrolled moderate to severe asthma, assessment of asthma control, identification of the causes of uncontrolled asthma, strategies for controlling asthma, an optional follow-up at the next prescription refill, and a follow-up 3 months after the initial intervention. Conclusions: The patients and community pharmacists reached consensus on the intervention's key elements and provided support for implementing the intervention in community pharmacies.

Prevalence of cannabis use for pain management in Quebec: A post-legalization estimate among generations living with chronic pain.

Background: Medical cannabis has been legal in Canada since 2001, and recreational cannabis was legalized in October 2018, which has led to a widespread increase in the accessibility of cannabis products. Aims: This study aimed to estimate the prevalence of cannabis use among adults living with chronic pain (CP) and investigate the relationship between age and cannabis use for CP management. Methods: A cross-sectional analysis of the COPE Cohort data set, a large Quebec sample of 1935 adults living with CP, was conducted. Participants completed a web-based questionnaire in 2019 that contained three yes/no questions about past-year use of cannabis (i.e., for pain management, management of other health-related conditions, recreational purposes). Results: Among the 1344 participants who completed the cannabis use section of the questionnaire, the overall prevalence of cannabis use for pain management was 30.1% (95% confidence interval 27.7-32.7). Differences were found between age groups, with the highest prevalence among participants aged ≤26 years (36.5%) and lowest for those aged ≥74 years (8.8%). A multivariable logistic model revealed that age, region of residence, generalized pain, use of medications or nonpharmacological approaches for pain management, alcohol/drug consumption, and smoking were associated with the likelihood of using cannabis for pain management. Conclusions: Cannabis is a common treatment for the management of CP, especially in younger generations. The high prevalence of use emphasizes the importance of better knowledge translation for people living with CP, rapidly generating evidence regarding the safety and efficacy of cannabis, and clinicians' involvement in supporting people who use cannabis for pain management.

Contexte: Le cannabis médical est légal au Canada depuis 2001 et le cannabis récréatif a été légalisé en octobre 2018, ce qui a conduit à une augmentation généralisée de l'accessibilité des produits du cannabis. Objectifs: Cette étude visait à estimer la prévalence de la consommation de cannabis chez les adultes vivant avec la douleur chronique et à étudier l'association entre l'âge et la consommation de cannabis pour la prise en charge de la douleur chronique. Méthodes: Une analyse transversale de l'ensemble de données de la cohorte COPE, un grand échantillon québécois de 1 935 adultes vivant avec la douleur chronique, a été menée. En 2019, les participants ont rempli un questionnaire en ligne qui contenait trois questions oui/non sur la consommation de cannabis au cours de l'année écoulée (c.-à-d., pour la prise en charge de la douleur, la prise en charge d'autres affections liées à la santé, à des fins récréatives). Résultats: Parmi les 1 344 participants qui ont rempli la section du questionnaire portant sur la consommation de cannabis, la prévalence globale de la consommation de cannabis pour la prise en charge de la douleur était de 30,1 % (intervalle de confiance à 95 %, 27,7-32,7). Des différences ont été constatées entre les groupes d'âge, avec la prévalence la plus élevée chez les participants âgés de ≤ 26 ans (36,5 %) et la plus basse chez les participants âgés de ≥ 74 ans (8,8 %). Un modéle logistique multivariable a révélé que l'âge, la région de résidence, la douleur généralisée, l'utilisation de médicaments ou approches non pharmacologiques pour la prise en charge de la douleur, la consommation d'alcool/de drogue et le tabagisme étaient associés à la probabilité d'utiliser le cannabis pour la prise en charge de la douleur. Conclusions: Le cannabis est un traitement courant pour la prise en charge de la douleur chronique, en particulier chez les jeunes générations. La prévalence élevée de l'utilisation souligne l'importance d'un meilleur transfert des connaissances pour les personnes vivant avec la douleur chronique, en générant rapidement des donnant probantes concernant l'innocuité et l'efficacité du cannabis, ainsi que l'implication des cliniciens dans le soutien aux personnes qui consomment du cannabis pour la prise en charge de la douleur.

Gender Differences in Medication Adverse Effects Experienced by People Living With Chronic Pain.

Objectives: Understanding gender differences in chronic pain (CP) outcome research is essential to optimal treatment delivery. This study explored the associations between gender identity, gender roles, and the number of non-life-threatening pain medication adverse effects reported as severe by people living with CP. Methods: The analyses were conducted using the COPE Cohort, a dataset generated through a web-based recruitment of adults with CP. Participants were asked how they identified themselves (women, men, unknown, unspecified) and gender roles were measured using the Bem Sex-Role Inventory (subgroups were formed applying the median split method). Pain medication adverse effects were assessed using a standardized checklist (none/mild/moderate/severe). A zero-inflated Poisson model was used to assess gender identity, gender roles and their interaction as potential predictors of the number of pain medication adverse effects. Results: A total of 1,343 participants reported using pain medications. Adjusting for potential confounders, both gender identity (men vs. women: ß = -0.32, p = 0.0024) and gender roles (androgynous vs. undifferentiated: ß = 0.26, p = 0.0030) were associated with the number of pain medication adverse effects reported as severe, and they interacted with each other. The stratified analysis by gender roles showed that women reported a greater number of severe adverse effects than men among those classified as masculine and androgynous. Discussion: Although we are unable to confirm whether the associations can be explained by differences in the experience or in the reporting of effects, gender identity and gender roles should both be explored when studying pain medication adverse effects.

Identifying asthma patients at high risk of exacerbation in a routine visit: A machine learning model.

BACKGROUND: Tools capable of predicting the risk of asthma exacerbations can facilitate asthma management in clinical practice. However, existing tools require additional data from patients beyond electronic medical records. OBJECTIVE: To predict asthma exacerbation in an upcoming year using electronically accessible data conditional on past adherence to asthma medications. METHODS: This retrospective cohort study included patients with ≥1 hospitalization or ≥2 medical claims for asthma within 2 consecutive years between 2002 and 2015 in Quebec administrative databases. Cohort entry (CE) was defined as the date of the first asthma-related ambulatory visit on or after meeting the operational definition of asthma. Adherence to each controller medication and use of each rescue medication was measured in the year prior to CE. Elastic-net regularized logistic regression was applied. RESULTS: Among 98,823 patients, the mean age was 55.9 years and 36.2% were men. The area under the curve for prediction was 0.708. In the model, the use of long-acting anticholinergic or long-acting ß2-agonists in the year prior to CE increased the odds of exacerbation by 24% and 21%, respectively. Among patients who received rescue medication, low and high adherence to controller medications increased the odds by 2%-5% compared with patients with medium adherence. Patients with a predicted risk of ≥0.20 were more likely to develop future exacerbation. CONCLUSION: This risk prediction indicated that asthma-related medication use increased the risk of asthma exacerbation. A potential U-shaped relationship between adherence to controller medications and the risk of exacerbation was identified among users of rescue medications.

A potential outcomes approach to defining and estimating gestational age-specific exposure effects during pregnancy.

Many studies seek to evaluate the effects of potentially harmful pregnancy exposures during specific gestational periods. We consider an observational pregnancy cohort where pregnant individuals can initiate medication usage or become exposed to a drug at various times during their pregnancy. An important statistical challenge involves how to define and estimate exposure effects when pregnancy loss or delivery can occur over time. Without proper consideration, the results of standard analysis may be vulnerable to selection bias, immortal time-bias, and time-dependent confounding. In this study, we apply the "target trials" framework of Hernán and Robins in order to define effects based on the counterfactual approach often used in causal inference. This effect is defined relative to a hypothetical randomized trial of timed pregnancy exposures where delivery may precede and thus potentially interrupt exposure initiation. We describe specific implementations of inverse probability weighting, G-computation, and Targeted Maximum Likelihood Estimation to estimate the effects of interest. We demonstrate the performance of all estimators using simulated data and show that a standard implementation of inverse probability weighting is biased. We then apply our proposed methods to a pharmacoepidemiology study to evaluate the potentially time-dependent effect of exposure to inhaled corticosteroids on birthweight in pregnant people with mild asthma.

Doubly robust adaptive LASSO for effect modifier discovery.

Effect modification occurs when the effect of a treatment on an outcome differsaccording to the level of some pre-treatment variable (the effect modifier). Assessing an effect modifier is not a straight-forward task even for a subject matter expert. In this paper, we propose a two-stageprocedure to automatically selecteffect modifying variables in a Marginal Structural Model (MSM) with a single time point exposure based on the two nuisance quantities (the conditionaloutcome expectation and propensity score). We highlight the performance of our proposal in a simulation study. Finally, to illustrate tractability of our proposed methods, we apply them to analyze a set of pregnancy data. We estimate the conditional expected difference in the counterfactual birth weight if all women were exposed to inhaled corticosteroids during pregnancy versus the counterfactual birthweight if all women were not, using data from asthma medications during pregnancy.

Association Between Asthma Control Trajectories in Preschoolers and Long-Term Asthma Control.

BACKGROUND: The potential influence of asthma control in early life on long-term outcomes in childhood remains largely unknown. OBJECTIVE: To examine whether asthma control trajectories in the 2 years after diagnosis in preschoolers are associated with long-term unsatisfactory asthma control. METHODS: We conducted a multicenter population-based retrospective cohort study, including four Canadian provincial birth cohorts derived from administrative databases. We included preschoolers (aged <5 years) with a diagnosis of asthma, defined as having one hospitalization or two physician visits for asthma within 2 years. Asthma control trajectories, ascertained over four 6-month periods after diagnosis using a validated index, were classified as controlled throughout, improving control, fluctuating control, worsening control, and out of control throughout. Long-term unsatisfactory control was defined as four or more short-acting ß2-agonist average doses per week or an exacerbation, measured within 6 months before index ages 6, 8, 10, 12, 14, and 16 years. Average risk ratios for long-term unsatisfactory control across all index ages were estimated using a robust Poisson model by province and meta-analyzed with a random effects model. RESULTS: In 50,188 preschoolers with asthma, the pooled average risk of having unsatisfactory control at any index age was 42% (95% confidence interval, 34.6-49.4). Compared with children who were controlled throughout, incrementally higher average risk ratios (95% confidence interval) of long-term unsatisfactory control were observed in each trajectory: improving control, 1.38 (1.28-1.49); fluctuating control, 1.54 (1.40-1.68); worsening control, 1.70 (1.55-1.86) and out of control throughout, 2.00 (1.80-2.21). CONCLUSIONS: Suboptimal asthma control trajectories shortly after a preschool diagnosis were associated with long-term unsatisfactory asthma control. Early control trajectories appear to be promising for predicting the risk for long-term adverse outcomes.

The validity of diagnostic algorithms to identify asthma patients in healthcare administrative databases: a systematic literature review.

Objectives To review the available evidence supporting the validity of algorithms to identify asthma patients in healthcare administrative databases.Methods A systematic literature search was conducted on multiple databases from inception to March 2020 to identify studies that reported the validity of case-finding asthma algorithms applied to healthcare administrative data. Following an initial screening of abstracts, two investigators independently assessed the full text of studies which met the pre-determined eligibility criteria. Data on study population and algorithm characteristics were extracted. A revised version of the Quality Assessment of Diagnostic Accuracy Studies tool was used to evaluate the risk of bias and generalizability of studies.Results: A total of 20 studies met the eligibility criteria. Algorithms which incorporated ≥1 diagnostic code for asthma over a 1-year period appeared to be valid in both adult and pediatric populations (sensitivity ≥ 85%; specificity ≥ 89%; PPV ≥ 70%). The validity was enhanced when: (1) the time frame to capture asthma cases was increased to two years; (2) ≥2 asthma diagnostic codes were considered; and (3) when diagnoses were recorded by a pulmonologist. Algorithms which integrated pharmacy claims data appeared to correctly identify asthma patients; however, the extent to which asthma medications can improve the validity remains unclear. The quality of several studies was high, although disease progression bias and biases related to self-reported data was observed in some studies.ConclusionsHealthcare administrative databases are adequate sources to identify asthma patients. More restrictive definitions based on both asthma diagnoses and asthma medications may enhance validity, although further research is required to confirm this hypothesis.

Physician's perspective regarding asthma guided self-management: directives or guidance?

INTRODUCTION: Asthma guided self-management enhances patients' control of their condition under the guidance of the treating physician. The aim of the present study was to understand how physicians perceive, endorse, uptake, and support asthma guided self-management. METHODS: We conducted a secondary supplementary analysis of data originally collected as part of a multicenter collective case study in which physicians treating patients with asthma were interviewed. Using reflective thematic analysis, we aimed to explore physicians' understanding of guided asthma self-management as related to four ideas, namely: (a) understanding of the disease management and treatment goals; (b) defining medical frame and guidance; (c) describing the importance of patient-physician relationship; and (d) implementing asthma guided self-management. RESULTS: Evidence indicates that physicians perceived optimal guided self-management as related to patients' adherence to physician's instructions and recommendations, supported by the adjustment of prescribed pharmaceutical therapy contingent upon patient's symptoms. Some physicians also perceived behavior change and environmental control along with the medical recommendations. While physicians' perception of asthma and its treatment were aligned with the recommended guidelines-i.e., patient-centered care approach based on guided self-management, the actual guidance offered to patients remained primarily directive and paternalistic. Non-pharmacological approaches, such as exercise, smoking cessation, patient self-monitoring, and self-management supported by education and written self-management plans, were given little consideration in the context of the recommended treatment plan.

Development of an operational definition of treatment escalation in adults with asthma adapted to healthcare administrative databases: A Delphi study.

BACKGROUND: In recent years, there has been growing interest in studying asthma treatment escalation patterns in the real-world setting, particularly with the advent of expensive biologic therapies. Healthcare administrative claims databases can be used to study treatment escalation patterns at a population-level; however, the reported definitions for claims-based asthma treatment escalation are highly variable in the literature. OBJECTIVE: The aim of this study was to develop an operational definition of treatment escalation in adults with asthma that can be applied to healthcare administrative data. METHODS: A mixed-methods research design incorporating the Delphi process was used to establish an expert consensus for this definition. A multi-disciplinary expert panel participated in three iterative rounds of online questionnaires covering treatment escalation criteria inspired by a systematic review, which was conducted as part of this study. The final definition was constructed using criteria for which a 75% level of agreement was achieved among the experts. RESULTS: We developed a claims-based treatment escalation definition that was adapted from the Global Initiative for Asthma (GINA) strategy. The definition comprised seven treatment steps, as well as escalation options for treatments that are not typically included in clinical guidelines. The definition also incorporated methods to identify treatments in severe asthma, such as oral corticosteroid maintenance therapy and chronic azithromycin use. CONCLUSIONS: The operational definition of treatment escalation developed in this study bridges the gap between clinical guidelines and real-world clinical practice and lays the groundwork for future observational studies on treatment escalation patterns among patients with asthma.

Predictors of Asthma Control and Exacerbations: A Real-World Study.

BACKGROUND: Achieving optimal asthma control and minimizing the risk of exacerbation are the main goals of asthma treatment. OBJECTIVE: This study aimed to assess the predictors of poor asthma control and asthma exacerbations within a population of moderate to severe asthmatic patients treated in a tertiary-care center. METHODS: We conducted a cohort study assessing 738 patients enrolled in the Quebec registry in respiratory health (RESP) with a diagnosis of asthma confirmed by a respirologist and treated in a tertiary care center from April 2010 to March 2016. Sociodemographic and clinical data, including Asthma Control Questionnaire score, were collected at enrollment in the registry (ie, cohort entry) and patients were followed for a 2-year period thereafter. The information regarding exacerbations that occurred during follow-up was collected in administrative databases (Régie d l'assurance médicale du Québec [RAMQ], Maintenance et exploitation des données pour l'étude de la clientèle hospitalière [MED-ECHO], and medication data registry [reMed]). RESULTS: We assessed 738 subjects (64% women). Psychological distress (odds ratio [OR] 1.91; 95% confidence interval [95% CI] 1.21-3.02), smoking (OR 3.72; 95% CI 1.72-8.05]), and poor lung function, forced expiratory volume in 1 second less than 50% (OR 4.1; 95% CI 1.48-11.34]) appeared as significant factors associated with uncontrolled asthma. Occurrence of previous asthma exacerbations (hazard ratio [HR] 6.25; 95% CI 4.01-9.75]), poor asthma control (HR 1.60; 95% CI 1.07-2.38]), forced expiratory volume in 1 second between 50% and 80% (HR 2.25; 95% CI 1.58-3.34]), and older age (HR 2.26; 95% CI 1.37-3.74]) were associated with asthma exacerbations. Adherence to asthma treatment was very low in patients with (44.4% ± 34.4%) and without asthma exacerbations (37.5% ± 33.0%). CONCLUSIONS: Psychological distress and current smoking are modifiable factors that need to be addressed in tailored behavioral interventions to improve asthma control. Asthma exacerbations are mostly associated with the intrinsic severity of the disease.

Chronic pain patients' willingness to share personal identifiers on the web for the linkage of medico-administrative claims and patient-reported data: The chronic pain treatment cohort.

PURPOSE: The linkage between patient-reported data and medico-administrative claims is of great interest for epidemiologic research. The goal of this study was to assess the willingness of people living with chronic pain to share personal identifiers on the web for the linkage of medico-administrative and patient-reported data. METHODS: This methodological investigation was achieved in the context of the implementation of the chronic pain treatment (COPE) cohort. A web-based recruitment initiative targeting adults living with chronic pain was conducted in the province of Quebec (Canada). RESULTS: A total of 1935 participants completed the questionnaire (mean age: 49.86 ± 13.27; females: 83.69%), 921 (47.60%) of which agreed to data linkage and shared their personal identifiers (name, date of birth, health insurance number online). The most common reasons for refusal were: (1) concerns regarding data security/privacy (25.71%) and (2) the belief that the requested data were too personal/intrusive (13.52%). Some participants did not understand the relevance of data linkage (11.81%). Participants from the COPE cohort and those from the subsample who agreed to data linkage were comparable to other random samples of chronic pain individuals in terms of age and pain characteristics. CONCLUSIONS: Although approximately half of the participants refused data linkage, our approach allowed for the implementation of a data platform that contains a diverse and substantial sample. This investigation has also led to the formulation of recommendations for web-based data linkage, including placing items designed to assess willingness to share personal identifiers at the end of the questionnaire, adding explanatory videos, and using a mixed-mode questionnaire.

Association between the timing of asthma diagnosis and medication use during pregnancy.

STUDY OBJECTIVE: To assess whether asthma medication use during pregnancy differs in women newly diagnosed with asthma early in pregnancy (first 19 weeks of pregnancy) compared to those newly diagnosed up to 2 years pre-pregnancy. DESIGN: A retrospective population-based cohort study. DATA SOURCE: To conduct this study, we used the Quebec Asthma and Pregnancy Database (QAPD) constructed by linking two administrative health databases from the province of Quebec (Canada): the Régie de l'Assurance Maladie du Québec and Maintenance et Exploitation des Données pour l'Étude de la Clientèle Hospitalière databases. PATIENTS: A cohort comprising pregnant women newly diagnosed with asthma at any time in the 2 years prior to pregnancy or during the first 19 weeks of pregnancy was selected from the QAPD. MEASUREMENTS AND MAIN RESULTS: We assessed the number of filled prescriptions of inhaled corticosteroids (ICS), ICS/long-acting ß2 agonists (LABA), and short-acting ß2 agonists (SABA), as well as the number of days' supply of oral corticosteroid (OCS) from the 20th week of pregnancy until delivery. Poisson regression was used to compare the rates of asthma medication use in women diagnosed pre-pregnancy versus early in pregnancy. The cohort included 1731 women newly diagnosed with asthma pre-pregnancy and 359 women newly diagnosed with asthma early in pregnancy. Women diagnosed early in pregnancy were more likely to use ICS (adjusted rate ratio: 1.9, 95% confidence interval (CI): 1.6-2.3) and SABA (adjusted rate ratio: 2.0, 95% CI: 1.7-2.4) from the 20th week of pregnancy until delivery than those newly diagnosed pre-pregnancy. No significant differences were observed in the use of ICS/LABA [adjusted rate ratio: 0.9, 95% CI: 0.7-1.3] and OCS [adjusted rate ratio: 0.8, 95% CI: 0.6-1.2]. CONCLUSION: The higher use of ICS and SABA observed in women newly diagnosed with asthma early in pregnancy may suggest a more persistent asthma phenotype caused by pregnancy-triggered hormonal changes.