Impact of maternal asthma on perinatal outcomes: a two-stage sampling cohort study.

There are conflicting results concerning the impact of maternal asthma during pregnancy on perinatal outcomes. The present study investigated the associations between maternal asthma during pregnancy and the risk of a small-for-gestational-age (SGA) infant, a low-birth-weight (LBW) infant, and preterm birth. A population-based cohort of 40,788 pregnancies from asthmatic and non-asthmatic women was reconstructed through the linking of three Quebec (Canada) administrative databases between 1990 and 2002. A two-stage sampling cohort design was used to collect additional information by way of a mailed questionnaire. The generalized estimation equation models were used to obtain adjusted odds ratios of SGA, LBW and preterm birth comparing asthmatic and non-asthmatic women. The cohort included 13,007 pregnancies from asthmatic and 27,781 pregnancies from non-asthmatic women. Final estimates showed that the odds of SGA (odds ratio: 1.27, 95% confidence interval: 1.14, 1.41), LBW (1.41: 1.22, 1.63) and preterm delivery (1.64: 1.46, 1.83) were significantly higher among asthmatic than non-asthmatic women. Mothers with asthma during pregnancy are more likely to have SGA, LBW, or preterm birth infants than non-asthmatic women. These results can be more easily generalized to women with lower socio-economic status since the cohort under represents women with high socio-economic status.

Pharmacist-led interventions during transitions of care of older adults admitted to short term geriatric units: Current practices and perceived barriers.

Background: During transitions of care, older adults are at risk of adverse drug events which could lead to avoidable hospital visits. Pharmacists are increasingly involved in care teams at various stages of the continuum of care. The types and frequency of clinical interventions performed by pharmacists in the geriatric practice setting remain poorly documented. Objectives: This study aimed to describe the current integration of pharmacist interventions during transitions of care of older adults admitted in short-term geriatric units (STGUs) and to explore barriers and facilitators to their implementation in clinical practice. The secondary objective was to explore associations between certain patient characteristics and pharmacist-led interventions during transitional care. Methods: A mixed methods study was conducted with pharmacists practicing in STGUs in the Montreal area, Canada. The application of 8 pharmaceutical interventions was assessed using a self-administered questionnaire, along with as a retrospective chart review. Four semi-structured group interviews were conducted in order to identify perceived barriers and facilitators. Results: Thirteen pharmacists participated in the study. In the questionnaire, medication reconciliation on admission and at discharge was reported as being performed at least half the time by 12 (92%) and 7 (54%) pharmacists, respectively. The retrospective chart review revealed that these interventions were documented in 95 (98%) and 25 (26%) files, respectively. While 35% of patients had a documented pharmaceutical care plan on admission, none was documented at discharge. Several barriers to implementing clinical interventions were identified such as lack of time, technical support, communication and standardization. Conclusions: Pharmacists are involved at different periods of transitional care; however, certain barriers should be addressed in order to expand their role in discharge planning. Providing guidelines on what is expected at discharge and post-discharge, and having a practice focused on delegation and collaboration would help pharmacists increase their role throughout the transition of care of older adults.

Impact of pharmacist interventions during transition of care in older adults to reduce the use of healthcare services: A scoping review.

BACKGROUND: Current literature has shown increasing risk of error in transition of care between different healthcare settings, especially in the older population. Moreover, drug-related hospital readmission has been reported due to lack of appropriate communication. However, the literature is not clear about the impact of pharmacist interventions during transition of care of older adults on the reduction in use of healthcare services. OBJECTIVE: The goal of the scoping review was to describe the impact of pharmacist interventions during transitions of care for older adults on the use of healthcare services. METHODS: MEDLINE was searched for randomized controlled trials and controlled studies that analyzed pharmacist interventions during transition of care of older adults with regard to use of healthcare services. Four reviewers, grouped in pairs, independently screened all references published from 1990 to 2019 and extracted and analyzed the data. A pharmaceutical model of 8 pharmacist-led interventions was adapted from literature to compare the included studies. RESULTS: There were 1527 publications screened, 17 of which met inclusion criteria. Pharmacist-led interventions decreased the use of healthcare services in 11 of these studies. The majority of studies were of very good or good quality based on Mixed Methods Appraisal Tool. Pharmacist were implicated at all times during the transition of care process (i.e. admission/during stay, discharge and post-discharge) in 4 of the effective studies, whereas none did in the not effective studies. More interventions were accomplished by pharmacists in studies with positive outcomes. CONCLUSION: By diversifying their interventions at different moments throughout transition of care, pharmacists can reduce the use of healthcare services for older adults during transition of care. This scoping review also shows the need to better understand key components of post-discharge interventions and to have a dynamic pharmaceutical model accepted by the scientific community.

Relationship between changes in inhaled corticosteroid use and markers of uncontrolled asthma during pregnancy.

STUDY OBJECTIVE: To describe changes in inhaled corticosteroid use during pregnancy and markers of uncontrolled asthma, and to evaluate the association between them. DESIGN: Population-based, cross-sectional study. DATA SOURCE: Three administrative claims databases in Québec, Canada. PATIENTS: A cohort of 4434 asthmatic women (4920 pregnancies) who delivered their infants between 1990 and 2002 and who used inhaled corticosteroids before their pregnancy. MEASUREMENTS AND MAIN RESULTS: The average daily doses of inhaled corticosteroids during pregnancy and during the 9 months before conception were compared; the change in use was categorized as discontinuation (reduction of ≥75%), reduction (26-75% reduction), no change (±25% change), or increase (increase of ≥25%). The markers of uncontrolled asthma included at least one asthma exacerbation and the use of three or more doses/week of a short-acting ß(2) -agonist during pregnancy. Generalized estimating equation models were used for statistical analyses. In nearly 50% of the pregnancies (2388 [48.5%] of 4920), the women either stopped or reduced their doses of corticosteroid during pregnancy, and these doses were already quite low before pregnancy. The proportion of women who had an asthma exacerbation during pregnancy was 8.2% among women who discontinued corticosteroids and greater than 20% in all of the other groups. All of the groups used frequent doses of short-acting ß(2) -agonists. Discontinuing inhaled corticosteroid use during pregnancy was associated with a lower risk of exacerbations (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.33-0.54), whereas increasing inhaled corticosteroid use was associated with a higher risk (OR 1.42, 95% CI 1.17-1.72), compared with no change in use. CONCLUSION: Because of residual confounding by asthma severity, our study was not able to show that women who stopped inhaled corticosteroids during pregnancy were at increased risk of having an asthma exacerbation. However, women who stopped corticosteroids tended to have a milder form of asthma, which is reassuring and suggests that women can recognize, to a certain extent, the need to continue taking their controller agents if necessary.

Effect of maternal moderate to severe asthma on perinatal outcomes.

BACKGROUND/OBJECTIVES: It has been reported that adverse fetal outcomes are more prevalent in pregnant women with asthma than they are in women without asthma. In our study, we investigated the effect that the severity of asthma during pregnancy has on the risk of a small for gestational age (SGA) infant, low birth weight (LBW), and preterm birth. METHODS: A population-based cohort of 13,007 pregnancies from asthmatic women was reconstructed through the linking of three of Quebec's (Canada) administrative databases covering the period between 1990 and 2002. A two-stage sampling cohort design was used to collect additional information on the selected women's life-style habits via a mailed questionnaire. Asthma severity during pregnancy was measured with a validated database index. A logistic regression model was used to obtain the adjusted odds ratios of SGA, LBW and preterm birth as a function of the level of asthma severity. RESULTS: The proportions of women with mild, moderate and severe asthma were 82.5%, 12.5% and 5.0%, respectively. We sent 3,168 questionnaires to selected women, with a 40.2% (n=1274) response rate. Final estimates showed that the risk of SGA was significantly higher among severe (OR:1.48, 95%CI: 1.15-1.91) and moderate asthmatic women (OR: 1.30, 95%CI:1.10-1.55) than mild asthmatic women. No significant associations were found between asthma severity, preterm birth and LBW. CONCLUSIONS: Mothers with severe and moderate asthma during pregnancy have a higher risk of SGA babies than those with mild asthma.

Effect of fetal gender on maternal asthma exacerbations in pregnant asthmatic women.

Recent studies have found that asthmatic women pregnant with a female fetus reported more symptoms and had slightly lower lung function than women pregnant with a male fetus. In order to further investigate this association, we studied the effect of fetal sex on maternal asthma exacerbations and the use of asthma medications during pregnancy. A large cohort of pregnant asthmatic women and their babies was reconstructed between 1990 and 2002 from the linkage of three administrative databases of the Canadian province of Quebec. Asthma exacerbations were defined as a filled prescription of oral corticosteroids, an emergency department visit, or a hospitalization for asthma. Women pregnant with a female fetus were compared to women with a male fetus with respect to their rate of asthma exacerbation, their weekly doses of inhaled short-acting beta(2)-agonists (SABA), and their daily dose of inhaled corticosteroids (ICS) during pregnancy. Logistic and linear regression models were used to obtain effect measures adjusted for several potential confounders such as asthma severity and control prior to pregnancy. The cohort included 5529 pregnancies with a single female fetus and 5728 pregnancies with a single male fetus. No significant differences were found between mothers of a female and male fetus as to the occurrence of asthma exacerbations (adjusted rate ratio=1.02; 95% CI: 0.92-1.14), the daily dose of ICS (adjusted mean difference (AMD): 2.46 microg; 95% CI: -4.01 to 8.93), and the weekly dose of SABA (AMD: 0.004 dose; 95% CI: -0.23 to 0.24). Based on the results, we conclude that fetal gender is unlikely to affect maternal asthma during pregnancy to the point where acute care and medications are more often required among women pregnant with a female fetus.

Development and validation of database indexes of asthma severity and control.

BACKGROUND: The use of administrative databases to perform epidemiological studies in asthma has increased in recent years. The absence of clinical parameters to measure the level of asthma severity and control is a major limitation of database studies. A study was undertaken to develop and validate two database indexes to measure the control and severity of asthma. METHODS: Database indexes of asthma severity and control were derived from definitions in the Canadian Asthma Consensus Guidelines based on dispensed prescriptions and on medical services recorded in two large administrative databases from the Canadian province of Québec (Régie de l'Assurance Maladie du Québec (RAMQ) and MED-ECHO) over 12 months. The database indexes of asthma severity and control were validated against the pulmonary function test results of 71 patients with asthma randomly selected from two asthma clinics, and they were also applied to a cohort of patients with asthma followed up for 139 283 person-years selected from the RAMQ and MED-ECHO databases between 1 January 1997 and 31 December 2004. RESULTS: According to the database indexes, 49.3%, 29.6% and 21.1% of patients recruited at the asthma clinics were found to have mild, moderate and severe asthma, respectively, while 53.5% were found to have controlled asthma. The mean predicted value of the forced expiratory volume in 1 s (FEV(1)) ranged from 89.8% for mild asthma to 61.5% for severe asthma (p<0.001), whereas the range from controlled to uncontrolled asthma was 89.5% to 67.3% (p<0.001). The ratio of the FEV(1) to the forced vital capacity (FEV(1)/FVC ratio) measured in 56 patients ranged from 75.8% for mild asthma to 61.8% for severe asthma (p = 0.030), whereas the range from controlled to uncontrolled asthma was 75.3% to 65.7% (p<0.001). CONCLUSION: In the absence of clinical data, these database indexes could be used in epidemiological studies to assess the severity and control of asthma.