Low levels of endogenous anabolic androgenic steroids in females with severe asthma taking corticosteroids.

Rationale: Patients with severe asthma are dependent upon treatment with high doses of inhaled corticosteroids (ICS) and often also oral corticosteroids (OCS). The extent of endogenous androgenic anabolic steroid (EAAS) suppression in asthma has not previously been described in detail. The objective of the present study was to measure urinary concentrations of EAAS in relation to exogenous corticosteroid exposure. Methods: Urine collected at baseline in the U-BIOPRED (Unbiased Biomarkers for the Prediction of Respiratory Disease outcomes) study of severe adult asthmatics (SA, n=408) was analysed by quantitative mass spectrometry. Data were compared to that of mild-to-moderate asthmatics (MMA, n=70) and healthy subjects (HC, n=98) from the same study. Measurements and main results: The concentrations of urinary endogenous steroid metabolites were substantially lower in SA than in MMA or HC. These differences were more pronounced in SA patients with detectable urinary OCS metabolites. Their dehydroepiandrosterone sulfate (DHEA-S) concentrations were <5% of those in HC, and cortisol concentrations were below the detection limit in 75% of females and 82% of males. The concentrations of EAAS in OCS-positive patients, as well as patients on high-dose ICS only, were more suppressed in females than males (p<0.05). Low levels of DHEA were associated with features of more severe disease and were more prevalent in females (p<0.05). The association between low EAAS and corticosteroid treatment was replicated in 289 of the SA patients at follow-up after 12-18 months. Conclusion: The pronounced suppression of endogenous anabolic androgens in females might contribute to sex differences regarding the prevalence of severe asthma.

Influence of contextual factors on quality of primary care in children with asthma.

OBJECTIVE: Asthma is a common chronic disease among children, quality assurance is thus important. Adherence to pre-specified quality indicators of practice guidelines could be used to assess the quality of asthma care. The aim was to estimate which contextual factors that had an influence on the primary health care centres (PHCs) adherence to the quality indicators as stated in the practice guidelines. METHOD: A pragmatic cross-sectional study was performed comprising 14 PHCs in Sweden. Included contextual factors were socio-demographic characteristics, organizational characteristics, and indicators regarding engagement in asthma care. Documentation on adherence to the quality indicators was retrieved from the medical health care records. Quality indicators included documentation of history of allergy and risk factors, diagnostics and patient support performed, and pharmacological treatment. To score adherence, a composite quality indicator (CQI) was computed for each PHC. A multivariable regression analysis was performed by orthogonal projection to latent structures (OPLS). By this analysis, the relationship between the result variable (CQI) and 26 pre-specified contextual factors was assessed. RESULTS: There was a wide variation of CQI between the PHCs. The OPLS analysis identified that 10 of the contextual factors influenced CQI. The most pronounced influences were found in more time scheduled for asthma care, a lower age-limit for performing spirometry, a lower duty-grade for general practitioners, and a higher activity at asthma educational seminars. We found no influence of socio-demographic contextual factors. CONCLUSION: We found that some of the contextual factors at the PHCs influenced the quality of performed care. Evidence-based care in paediatric asthma may thus be presumed to be facilitated by allocating time, by improving interprofessional collaboration, and by creating structures and opportunities for commitment to asthma care.

Socioeconomic status and the quality of prescribing asthma drugs in Sweden.

INTRODUCTION: Socioeconomic status (SES) is strongly associated with morbidity as well as with health care utilization and expenditure. The association between SES and quality of prescribing of asthma drugs is less studied. OBJECTIVES: The aim of this study was to examine the association between socioeconomic factors, i.e. education, income and country of birth, and the prevalence, incidence and adherence to guidelines for antiasthmatic drugs. METHODS: This registry study includes all Swedish citizens aged 25-44 years who redeemed at least one prescription of an antiasthmatic drug during 2010. Incidence and prevalence was calculated. The adherence to guidelines was studied using two defined quality indicators. Heavy users were also assessed. RESULTS: Incidence for antiasthmatic drugs was 18.4 per 1000 person-years and the prevalence 50.9 per 1000 inhabitants. Previously untreated patients who redeemed fixed combination ranged from 45% to 49%. Patients who purchase long-acting beta-2-adrenoceptor agonists (LABA) without inhaled corticosteroid ranged from 43% to 59%. Six percent of the population was classified as heavy users. CONCLUSION: The study showed a high incidence and prevalence of asthma drug use with a poor adherence to guidelines for rational drug prescribing. Fixed combination as first line asthma treatment as well as purchasing LABA without concomitant ICS was more common in patients born outside Scandinavia. Heavy users of short-acting bronchodilators were associated with male sex, high age, low income levels and low levels of education.

Asthma severity in primary care asthma patients: a comparative study of four different approaches to severity classification.

AIMS: To explore the factor structure of asthma severity and asthma control and to compare the results of different approaches to asthma severity classification on the distribution of costs of asthma medication. METHODS: Comparison of four different approaches to asthma severity classification and factor analysis of asthma control descriptors. A correlation analysis between costs and the different approaches to severity classification was performed. RESULTS: The factor analysis suggests that asthma control consists of at least two factors. Four approaches to severity classification were explored and all except the 'GINA EXPANDED' classification tended to place patients in the most severe category. The pharmaceutical costs varied between 0 and 75 SEK per day (0 and 5.31 GBP; 0 and 7.68 EURO). CONCLUSIONS: There is a considerable overlap between asthma control and asthma severity. None of the approaches used in this study present a superior satisfactory solution to the classification problem.

Brief questionnaires for patient-reported outcomes in asthma: validation and usefulness in a primary care setting.

UNLABELLED: STUDY OBJECTIVES AND DESIGN: Health-related quality of life (QoL) instruments are generally used for studies of asthma in specialized settings. For primary care use, there is a need for brief and simple questionnaires for structured patient-reported outcomes. We validated the Mini-Asthma Quality of Life Questionnaire (Mini-AQLQ), using the Asthma Quality of Life Questionnaire with standardized activities (AQLQ[S]) as the "gold standard." The Asthma Control Questionnaire (ACQ) was validated against the symptoms domain of the AQLQ(S). Patients were characterized by the Short Form-36 Health Survey (SF-36). SUBJECTS: One hundred eight patients (68 women) with asthma diagnosed by their physicians from 24 primary care centers completed two visits (2 to 3 months apart). Their mean SF-36 scores were lower than the national norm for all domains. RESULTS: The Mini-AQLQ and ACQ correlated well with the AQLQ(S). Reliability, determined in 57 patients with stable AQLQ(S) scores, was good. Both brief questionnaires detected improvement or deterioration of patients at the group level. Global ratings of disease severity by patients or clinicians correlated poorly with disease-specific QoL scores. CONCLUSIONS: The Mini-AQLQ and ACQ instruments are sufficiently simple and robust to be suitable for research and quality of care monitoring in primary care at the group level. They may, after further validation, even be useful in the management of individual patients.