Cost utility of vitamin D supplementation in adults with mild to moderate asthma.

OBJECTIVE: Uncontrolled asthma significantly impairs health-related quality of life and work productivity. Some add-on therapies, such as vitamin D supplements, safely reduce the rate of asthma exacerbation. The purpose of this study was to assess the cost-utility of vitamin D supplementation in adults with mild to moderate persistent asthma in Colombia. METHODS: A Markov model was created to estimate the cost and quality-adjusted life-years (QALYs) of patients with severe asthma in Colombia. Total costs and QALYs of two therapy strategies, vitamin D supplementation plus ICS versus ICS alone, were calculated over a one-year time horizon. Deterministic and probability sensitivity analyses were conducted, and cost-effectiveness was evaluated at a willingness-to-pay value of $5,180 per QALY gained. RESULTS: The base-case analysis showed that compared with no supplementation, vitamin D supplementation was associated with higher costs and higher QALYs. The expected annual cost per patient with vitamin D supplementation was US$1338 and without this supplementation it was US$1095. The QALYs per person estimated with vitamin D supplementation was 0.80, and without this supplementation it was 0.63. The estimated incremental cost-effectiveness ratio (ICER) was US$1583 per QALY. CONCLUSIONS: Add-on vitamin D supplement was cost-effective when added to the usual care in patients with mild to moderate persistent asthma. Our study provides evidence that should be used by decision-makers to improve clinical practice guidelines.

Are we overcoming our inability to have pediatric patients properly use inhaled corticosteroids by inappropriately escalating their therapy?

OBJECTIVE: To perform a narrative review to describe and discuss potential methods and strategies for effectively assessing and dealing with poor adherence and/or misuse of inhalers in difficult-to-treat pediatric asthmatic patients. DATA SOURCES: Articles available in electronic databases, published from inception to April 2021. STUDY SELECTIONS: Relevant articles in the literature that discuss and analyze potential methods and strategies for effectively assessing and dealing with poor adherence and/or misuse of inhalers in difficult-to-treat pediatric asthmatic patients. RESULTS: Validated self-reported questionnaires, weighing inhaler canisters, and pharmacy records might be the most suitable methods for assessing adherence to inhaled controller therapy in clinical practice. Additionally, validated instruments could be used as an objective measurement of the adequacy of inhaler technique. Finally, empathy and a true and strong physician-parent/patient partnership have a more powerful influence on adherence than almost any other factor, and they are probably the most cost-effective methods not only for detecting poor adherence to controller therapy but also for dealing with and improving it. CONCLUSIONS: Failure to detect or effectively handle nonadherence and/or inhaler misuse in a patient with uncontrolled asthma can mislead clinicians into thinking that the patient is nonresponsive to the original less-intensive therapy, resulting in unneeded dosage increases and/or escalation of controller therapy to more costly medications, in some cases reaching the level of biologic therapy.

Use of inhaled corticosteroids on an intermittent or as-needed basis in pediatric asthma: a systematic review of the literature.

OBJECTIVE: To summarize the principal findings of all available studies that have evaluated the use of inhaled corticosteroids (ICS) on an intermittent or as-needed basis as an add-on therapy to short-acting ß2-agonists (SABAs) or fast-acting ß2-agonists (FABAs) in pediatric asthmatic patients. Studies could either include or omit the use of ICS during stable periods of the disease. DATA SOURCES: Electronic databases MEDLINE, EMBASE, CINAHL, SCOPUS, and the Cochrane Database of Systematic Reviews from inception to February 2021. STUDY SELECTIONS: Relevant articles in the literature published by February 2021. RESULTS: Of 294 references identified, 14 studies were included. The use of ICS on an intermittent or as-needed basis (as an add-on therapy to SABAs) has been shown to be more effective than treatment with SABA alone and to be similarly or less effective compared to regular daily ICS administration. Furthermore, strategies involving increasing the dose of ICS only when needed (as an add-on therapy to formoterol, a FABA) and keeping it low during stable stages of the disease (i.e. single maintenance and reliever therapy, SMART) have been shown to be similarly or more effective than comparators. CONCLUSION: The use of ICS on an intermittent or as-needed basis as an add-on therapy to SABAs or FABAs, with or without ICS use during stable periods of the disease in pediatric asthmatic patients, encompasses several effective treatment strategies.

Commercial valved spacers versus home-made spacers for delivering bronchodilator therapy in pediatric acute asthma: a cost-effectiveness analysis.

OBJECTIVE: Although valved spacers are the preferred method for administering metered-dose inhaler bronchodilators such as albuterol in pediatric acute asthma, their high cost and their lack of availability have limited their use, especially in low- and middle-income countries (LMICs). Because of this, it is a common practice to use home-made spacers, although a formal analysis evaluating their cost-effectiveness is lacking. Therefore, the objective of this study was to analyze the cost-effectiveness of home-made spacers compared to commercial valved spacers for delivering bronchodilator therapy in pediatric acute asthma. METHODS: A decision-analysis model was used to estimate health outcomes and costs of a simulated cohort of pediatric patients treated for acute asthma. Effectiveness parameters were obtained from a systematic review of the literature. Cost data were obtained from hospital bills and from the national manual of drug prices in Colombia. The study was carried out from the perspective of the national healthcare system in Colombia, a middle-income country (MIC). The main outcome of the model was avoidance of hospital admission. RESULTS: Base-case analysis showed that compared to commercial valved spacers, administering bronchodilators with home-made spacers results in lower overall treatment costs (US$126.75 vs. US$128.59 average cost per patient) without a significant difference in the probability of hospitalization avoided (0.8500 vs. 0.8500). CONCLUSIONS: The present study shows that in Colombia, an MIC, compared with commercial valved spacers, the use of home-made spacers for administering bronchodilator therapy is more cost-effective because it yields a similar probability of hospital admission at lower overall treatment costs.

A comparative analysis of the bronchodilatador response measured by impulse oscillometry and spirometry in asthmatic children living at high altitude.

OBJECTIVE: Although the assessment of a bronchodilator response (BDR) is a routine and important procedure when performing lung function tests, comparisons between spirometric and oscillometric BDRs in asthmatic children living at high altitude have not been previously reported. The aim of the present study was to compare spirometric and oscillometric BDRs in children living at high altitude, and to identify independent predictors of spirometric and oscillometric BDRs. METHODS: Between January and December, 2015, asthmatic children aged between 5 and 17 years old performed impulse oscillometry (IOS) and spirometry during the same visit before and after albuterol administration. The data were analyzed, and children were classified into those positive for oscillometric BDR only, those positive for spirometric BDR only, those positive for both BDRs, and those negative for both BDRs. RESULTS: Ninety-three asthmatic children (56 boys, 37 girls), with a median (IQR) age of 11 (8-13) years, made up the study population. Among the total of 93 participants, 13 (14.0%), 4 (4.3%), 0 (0%), and 76 (81.7%) were positive for spirometric BDR only, positive for oscillometric BDR only, positive for both BDRs, and negative for both BDRs, respectively. Age and baseline lung function were identified as significant predictors of positive spirometric BDR. CONCLUSIONS: The present study shows poor concordance between positive spirometric and oscillometric BDRs, with a greater proportion of patients with a spirometric BDR when compared to those with positive oscillometric BDR. Additionally, age and baseline lung function are useful for predicting spirometric BDR results.

For which infants with viral bronchiolitis could it be deemed appropriate to use albuterol, at least on a therapeutic trial basis?

Although there is increasing evidence showing that infants with viral bronchiolitis exhibit a high degree of heterogeneity, a core uncertainty shared by many clinicians is with regard to understanding which patients are most likely to benefit from bronchodilators such as albuterol. Based on our review, we concluded that older infants with rhinovirus (RV) bronchiolitis, especially those with a nasopharyngeal microbiome dominated by Haemophilus influenzae; those affected during nonpeak months or during non-respiratory syncytial virus (RSV) predominant months; those with wheezing at presentation; those with clinical characteristics such as atopic dermatitis or a family history of asthma in a first-degree relative; and those infants infected with RSV genotypes ON1 and BA, have the greatest likelihood of benefiting from albuterol. Presently, this patient profile could serve as the basis for rational albuterol administration in patients with viral bronchiolitis, at least on a therapeutic trial basis, and it could also be the starting point for future targeted randomized clinical trials (RCTs) on the use of albuterol among a subset of infants with bronchiolitis.

Advantage of inhaled corticosteroids as additional therapy to systemic corticosteroids for pediatric acute asthma exacerbations: a cost-effectiveness analysis.

Objective: Although the efficacy of systemic corticosteroids (SCs) in acute asthma exacerbations is well established, the fact that many children still require admission to hospital and that SCs have a slow onset of action are cause of concern. For this reason, the use of inhaled corticosteroids (ICS) as a therapy added to SCs has been explored, with no clarity about its cost-effectiveness. The aim of the present study was to evaluate the cost-effectiveness of ICS in addition to SCs (ICS + SCs) compared to standard therapy with SCs for treating pediatric asthma exacerbations.Methods: A decision-analysis model was developed to estimate the cost-effectiveness of SCs compared to ICS + SCs for treating pediatric patients with acute asthma exacerbations. Effectiveness parameters were obtained from a systematic review of the literature. Cost data obtained from hospital bills and from the national manual of drug prices. The study was carried out from the perspective of the national healthcare system in Colombia. The main outcome of the model was avoidance of hospital admission.Results: For the base-case analysis, the model showed that compared to SCs, therapy with ICS + SCs was associated with lower total costs (US$88.76 vs.US$97.71 average cost per patient) and a lower probability of hospital admission (0.9060 vs. 0.9000), thus showing dominance.Conclusions: This study shows that compared with standard therapy with SCs, ICS + SCs for treating pediatric patients with acute asthma exacerbations is the preferred strategy because it was associated with a lower probability of hospital admission, at lower total treatment costs.

Predictors of prolonged length of hospital stay or readmissions for acute viral lower respiratory tract infections among infants with a history of bronchopulmonary dysplasia.

Length of hospital stay and readmissions are outcome measures that have been largely overlooked in many studies that have evaluated the clinical evolution of pediatric patients with bronchopulmonary dysplasia (BPD). The aim of the present study was to identify predictors of prolonged hospitalizations or readmissions for acute lower respiratory infections (ALRIs) in infants with BPD. In a prospective cohort study, we determined independent predictors of prolonged hospitalizations or readmissions for ALRIs during the first 2 years of life in a population of infants with BPD living in Bogota, Colombia. Of a total of 138 patients included in the study, 83 (60.1%) had at least one hospitalization for ALRI during the follow-up period. After controlling for potential confounders, we found that independent predictors of prolonged hospitalizations or readmissions for ALRIs included male gender (OR = 3.09; CI 95% 1.27-7.52; P = 0.013), ambulatory oxygen therapy between 90 and 119 days (OR = 3.21; CI 95% 1.00-10.24; P = 0.049), ambulatory oxygen therapy equal to or greater than 120 days (OR = 5.73; CI 95% 2.01-16.32; P = 0.001), gestational age at birth (OR = 1.35; CI 95% 1.03-1.76; P = 0.026), birth weight (OR = 0.997; CI 95% 0.996-0.999; P = 0.010), and duration of breastfeeding equal to or greater than 6 months (OR = 0.39; CI 95% 0.16-0.96; P = 0.039). The factors identified can be taken into account when planning policies to reduce duration of hospital stay and readmissions in infants with BPD.

Systematic review of instruments aimed at evaluating the severity of bronchiolitis.

OBJECTIVE: No recent studies have performed a systematic review of all available instruments aimed at evaluating the severity of bronchiolitis. The objective of the present study was to perform a systematic review of instruments aimed at evaluating the severity of bronchiolitis and to evaluate their measurement properties. METHODS: A systematic search of the literature was performed in order to identify studies in which an instrument for evaluating the severity of bronchiolitis was described. Instruments were evaluated based on their reliability, validity, utility, endorsement frequency, restrictions in range, comprehension, and lack of ambiguity. RESULTS: A total of 77 articles, describing a total of 32 different instruments were included in the review. The number of items included in the instruments ranged from 2 to 26. Upon analyzing their content, respiratory rate turned out to be the most frequently used item (in 26/32, 81.3% of the instruments), followed by wheezing (in 25/32, 78.1% of the instruments). In 18 (56.3%) instruments, there was a report of at least one of their measurement properties, mainly reliability and utility. Taking into consideration the information contained in the instruments, as well as their measurement properties, one was considered to be the best one available. CONCLUSIONS: Among the 32 instruments aimed at evaluating the severity of bronchiolitis that were identified and systematically examined, one was considered to be the best one available. However, there is an urgent need to develop better instruments and to validate them in a more comprehensive and proper way.

A cost-effectiveness threshold analysis of a multidisciplinary structured educational intervention in pediatric asthma.

OBJECTIVE: Asthma educational interventions have been shown to improve several clinically and economically important outcomes. However, these interventions are costly in themselves and could lead to even higher disease costs. A cost-effectiveness threshold analysis would be helpful in determining the threshold value of the cost of educational interventions, leading to these interventions being cost-effective. The aim of the present study was to perform a cost-effectiveness threshold analysis to determine the level at which the cost of a pediatric asthma educational intervention would be cost-effective and cost-saving. METHODS: A Markov-type model was developed in order to estimate costs and health outcomes of a simulated cohort of pediatric patients with persistent asthma treated over a 12-month period. Effectiveness parameters were obtained from a single uncontrolled before-and-after study performed with Colombian asthmatic children. Cost data were obtained from official databases provided by the Colombian Ministry of Health. The main outcome was the variable "quality-adjusted life-years" (QALYs). RESULTS: A deterministic threshold sensitivity analysis showed that the asthma educational intervention will be cost-saving to the health system if its cost is under US$513.20. Additionally, the analysis showed that the cost of the intervention would have to be below US$967.40 in order to be cost-effective. CONCLUSIONS: This study identified the level at which the cost of a pediatric asthma educational intervention will be cost-effective and cost-saving for the health system in Colombia. Our findings could be a useful aid for decision makers in efficiently allocating limited resources when planning asthma educational interventions for pediatric patients.

A systematic review of instruments aimed at evaluating metered-dose inhaler administration technique in children.

OBJECTIVE: The objective of the present study was to perform a systematic review of instruments aimed at evaluating pressurized metered-dose inhaler (pMDI) administration technique in children and evaluating the measurement properties of these instruments. METHODS: A systematic search of the literature was performed in order to identify studies in which an instrument (scale, checklist, or questionnaire) for evaluating pMDI administration technique in children was described. Instruments were evaluated based on their reliability, validity, utility, endorsement frequency, restrictions in range, comprehension, lack of ambiguity, and lack of value-laden or offensive content. RESULTS: A total of 24 instruments were identified. The age of the children ranged from 1 month to 18 years, the number of steps or items included in the instruments ranged from 3 to 21, and nearly half of the instruments distinguished between essential and non-essential steps or items. In only 7 of the 24 instruments was there a report of their measurement properties, mainly reliability and utility. Taking into consideration the information contained in the instruments, as well as their measurement properties, we determined four instruments to be the best of the available ones. CONCLUSIONS: Among the 24 instruments for the assessment of pMDI administration technique in children that were identified and systematically examined, four were considered to be the best ones available. However, additional evaluation of their measurement properties should be done before using them in clinical practice and for research purposes.

Cost-utility analysis of once-daily versus twice-daily inhaled corticosteroid dosing for maintenance treatment of asthma in pediatric patients.

OBJECTIVE: Suboptimal adherence to inhaled corticosteroids (ICs) is an important cause of poor asthma control in pediatric patients. Among the factors that can be most easily changed for enhancing adherence to ICs is a reduction in the dosing frequency, from twice-daily dosing to once-daily dosing. However, no previous studies have reported an economic evaluation comparing once-daily versus twice-daily IC dosing for pediatric asthma. The aim of this study was to compare the cost-effectiveness of once-daily versus twice-daily IC dosing for maintenance treatment of asthma in pediatric patients. METHODS: A Markov-type model was developed in order to estimate costs and health outcomes of a simulated cohort of pediatric patients with persistent asthma treated over a 12-month period. Effectiveness parameters were obtained from a systematic review of the literature. Cost data were obtained from official databases provided by the Colombian Ministry of Health. The main outcome was the variable "quality-adjusted life-years" (QALYs). RESULTS: For the base-case analysis, the model showed that compared with twice-daily dosing, once-daily dosing strategy involved lower costs (US$1529.3 versus $1709.1 average cost per patient over 12 months) and the greatest gain in QALYs (0.8284 versus 0.8084 QALYs on average per patient over 12 months), resulting in once-daily dosing strategy being considered dominant. CONCLUSIONS: This study shows that compared with twice-daily dosing, once-daily IC dosing for treating pediatric patients with persistent asthma is the dominant strategy because it involves a greater gain in QALYs at lower total treatment cost.

Principal findings of systematic reviews for the management of acute bronchiolitis in children.

Bronchiolitis is the most common cause of hospitalization among infants during the first 12 months of life, with high direct and indirect cost for health system and families. Different treatment approaches co-exist worldwide resulting in many drugs prescribed, without any proven benefit. Twenty systematic reviews of randomized clinical trials (SRCTs) on management of acute bronchiolitis in children were retrieved through 5 databases and their methodological quality was determined using an AMSTAR tool. Epinephrine showed impact only in short-term outcomes among outpatients (reduced admission at day 1 and improved the clinical score in the first 2 hours, compared to placebo) and inpatients (decreased length of stay (LOS) and improved saturation only in the first 2 hours, compared to nebulized salbutamol, but with high heterogeneity). Nebulized 3% saline among inpatients (but not in the emergency department setting) decreased hospital LOS. In small trials, exogenous surfactant among children may decrease the duration of mechanical ventilation and intensive care unit LOS and had favorable effects on oxygenation and CO2 elimination at 24 hrs. Although several SRCTs are currently available, only few treatments show clinically important improvements. Therefore, it is still difficult to prepare a well-established and accepted guideline for the treatment of acute bronchiolitis.

Validation of the Spanish version of the Pediatric Asthma Caregiver Quality of Life Questionnaire (PACQLQ) in a population of Hispanic children.

OBJECTIVE: The Paediatric Asthma Caregiver's Quality of Life Questionnaire (PACQLQ) is intended to measure the impact of children's asthma on their parents/caregiver's QoL. However, there are no formal validation studies of the Spanish version of PACQLQ. METHODS: In a prospective cohort validation study, asthmatic children aged between 7 and 17 years and their parents, attended both a baseline and a follow-up visit 2-6 weeks later. In these two visits, we gathered the necessary data for assessing the criterion validity, construct validity, test-retest reliability, sensitivity to change, internal consistency and usability of the PACQLQ. RESULTS: At baseline, PACQLQ scores were significantly different between patients with controlled, partly controlled and uncontrolled asthma (median [IQR] 78.0 [61.0-85.0], 71.0 [37.0-76.0] and 48.0 [40.7-55.0], respectively, p < 0.001), and also between patients for whom this visit resulted in a step-up versus no change or a step-down in therapy (50.0 [40.0-60.0] versus 78.0 [61.0-85.0]; p < 0.001). PACQLQ scores at baseline were significantly lower than those obtained in the follow-up visit in patients with change for the better in the global rating of change questionnaire (median [IQR] 50.0 [42.5-56.0] versus 80.0 [78.5-85.0]; p < 0.001). The intraclass correlation coefficient of the measurements was 0.839 (95%CI: 0.735-0.902). The Cronbach α was 0.914 for the questionnaire as a whole. CONCLUSIONS: The Spanish version of the PACQLQ has adequate construct validity, adequate sensitivity to change, good internal consistency, excellent test-retest reliability and good usability when employed in children aged between 7 and 17 years with physician-diagnosed asthma.

Validation of the Spanish version of the childhood asthma control test (cACT) in a population of Hispanic children.

BACKGROUND: There is a critical need for additional validation studies of questionnaires designed to assess the level of control of asthma in pediatric patients. OBJECTIVE: To validate the Spanish version of the Childhood Asthma Control Test (cACT) in children aged between 4 and 11 years with physician-diagnosed asthma. METHODS: In a prospective cohort validation study, asthmatic children aged between 4 and 11 years and their parents, attended both a baseline and a follow-up visit 2 to 6 weeks later. In these two visits, they completed the information required to assess the criterion validity, construct validity, test-retest reliability, sensitivity to change, internal consistency and usability of the cACT. RESULTS: At baseline, cACT scores were significantly different between patients with controlled, partly controlled and uncontrolled asthma [24.0 (23.0-26.0), 18.0 (18.0-22.0), and 17.5 (13.0-20.0), respectively, p < 0.001], and also between patients for whom this visit resulted in a step-up, no change or step-down in therapy [18.0 (15.0-21.0), 24.0 (23.0-24.0) and 26.0 (23.5-26.0) respectively, p < 0.001]. The score of the cACT correlated positively and significantly with the score of the Pediatric Asthma Caregivers Quality of life Questionnaire--PACQLQ (Spearman's rho = 0.50, p < 0.001). The intraclass correlation coefficient of the measurements in patients with no change in clinical status was 0.849 (95% CI: 0.752-0.908). There were statistical significant differences between baseline and follow-up cACT scores in patients with an improvement in clinical status [19.0 (18.0-22.0) versus 24.5 (24.0-25.0), p < 0.001]. Cronbach's α was 0.8276 for the questionnaire as a whole. CONCLUSION: The Spanish version of the cACT has adequate criterion validity, adequate construct validity, adequate sensitivity to change, good internal consistency, good test-retest reliability and excellent usability when administered to asthmatic children aged between 4 and 11 years.

Validation of the Spanish version of the Pediatric Asthma Severity Score (PASS) in a population of Hispanic children.

BACKGROUND: The Pediatric Asthma Severity Score (PASS) is one of the most-used clinical scoring systems for assessing the severity of asthma exacerbations in children. The aim of the present study was to validate a Spanish version of the PASS in a population of Hispanic children with asthma exacerbations living in urban Bogota, Colombia. METHODS: In a prospective cohort and a validation study, parents/caregivers of children between 2 and 18 years old attended in the emergency department (ED) with asthma exacerbations who were admitted to the inpatient unit were invited to participate in the study. During the hospitalization period, we gathered the necessary data for assessing the criterion validity (comparing its score with the Pediatric Respiratory Assessment Measure [PRAM]), construct validity, interrater reliability, responsiveness, and internal consistency of the Col-PASS, the Colombian version of the PASS. RESULTS: At baseline, the scores of the Col-PASS correlated positively with the scores of the PRAM score (ρ = 0.588, p < .001). The baseline Col-PASS scores in patients who required admission to a more complex service were significantly higher than those in patients who presented clinical improvement (1.0 (0.0-2.0) vs. 0.0 (0.0-0.0), p < .001). The interrater reliability was found to be κ = 0.897, 95% CI 0.699-1.000, p < .001. Cronbach's α was .701 for the questionnaire as a whole. CONCLUSION: The Col-PASS has excellent construct validity, adequate criterion validity, interrater reliability, responsiveness; and acceptable internal consistency when used in children between 2 and 18 years old with asthma exacerbations.

Cost-utility analysis of the inhaled steroids available in a developing country for the management of pediatric patients with persistent asthma.

INTRODUCTION: The choice among the different treatments available can have a great impact on the costs of asthma, OBJECTIVES: The objective of this study was to estimate the incremental cost-utility ratio of three inhaled corticosteroids (ICs): budesonide (BUD), fluticasone propionate (FP), and ciclesonide, compared to beclomethasone dipropionate (BDP) (the only IC included in the Compulsory Health Insurance Plan of Colombia), METHODS: A Markov-type model was developed to estimate costs and health outcomes of a simulated cohort of patients less than 18 years of age with persistent asthma treated over a 12-month period. Effectiveness parameters were obtained from a systematic review of the literature. Cost data were obtained from a hospital´s bills and from the national manual of drug prices. The study assumed the perspective of the national healthcare in Colombia. The main outcome was the variable "quality-adjusted life years" (QALY), RESULTS: While treatment with BDP was associated with the lowest cost (£106.16 average cost per patient during 12 months), treatment with FP resulted in the greatest gain in QUALYs (0.9325 QALYs). FP was associated with a greater gain in QALYs compared to BUD and ciclesonide (0.9325 vs. 0.8999 and 0.9051 QALYs, respectively) at lower costs (£231.19 vs. £309.27 and £270.15, respectively), thus leading to dominance. The incremental cost-utility ratio of FP compared to BDP was £19,835.28 per QALY, CONCLUSIONS: BDP is the most cost-effective therapy for treating pediatric patients with persistent asthma when willingness to pay (WTP) is less than £21,129.22/QALY, otherwise, FP is the most cost-effective therapy.

Disparities in prevalence and outcomes of respiratory disease in low- and middle-income countries.

OBJECTIVES: To provide a comprehensive overview of disparities in prevalence and outcomes of respiratory diseases and notable challenges for providing optimal treatment to pediatric patients with respiratory diseases living in low- and middle-income countries (LMICs), as an input to help better understand the roots of respiratory health disparities. METHODS: We conducted a narrative review of relevant literature published in electronic databases from inception to February 2023 that present data on disparities in prevalence and outcomes of respiratory disease in LMICs. Additionally, we included studies that describe and discuss challenges for providing optimal treatment to pediatric patients with respiratory diseases living in LMICs. RESULTS: A number of early life exposures have been associated with adverse respiratory outcomes in later life. Several studies have shown marked geographical variations in the prevalence and burden of pediatric asthma, with consistently lower prevalence rates but significantly higher burdens and worse outcomes in LMICs. There is a wide range of challenges that adversely affect the efficient care of children with respiratory diseases that can be classified into three categories: patient-related factors, social/environmental factors, and factors related to healthcare providers or the healthcare system. CONCLUSIONS: Respiratory health disparities in children living in LMICs represent a global public health issue mainly explained by an unequal distribution of preventable and modifiable risk factors for respiratory diseases across different demographic groups.

Composite predictive models for asthma exacerbations or asthma deterioration in pediatric asthmatic patients: A systematic review of the literature.

A variety of factors have shown to be useful in predicting which children are at high risk for future asthma exacerbations, some of them combined into composite predictive models. The objective of the present review was to systematically identify all the available published composite predictive models developed for predicting which children are at high risk for future asthma exacerbations or asthma deterioration. A systematic search of the literature was performed to identify studies in which a composite predictive model developed for predicting which children are at high risk for future asthma exacerbations or asthma deterioration was described. Methodological quality assessment was performed using accepted criteria for prediction rules and prognostic models. A total of 18 articles, describing a total of 17 composite predictive models were identified and included in the review. The number of predictors included in the models ranged from 2-149. Upon analyzing the content of the models, use of healthcare services for asthma and prescribed or dispensed asthma medications were the most frequently used items (in 8/17, 47.0% of the models). Seven (41.2%) models fulfilled all the quality criteria considered in our evaluation. The identified models may help clinicians dealing with asthmatic children to identify which children are at a higher risk for future asthma exacerbations or asthma deterioration, therefore targeting and/or reinforcing specific interventions for these children in an attempt to prevent exacerbations or deterioration of the disease.