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Primary Care

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by

Shuna Gould

on 17 February 2016

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Transcript of Primary Care

Optimized care
Primary Care
High-risk patients
Risk of exacerbations
Uncontrolled patients
Which patient, what assessment and by whom?
Professor David Price
All uncontrolled patients?
Patients with diagnostic doubt?
All high risk patients?
Risk of side effects
From the National Review of Asthma Deaths
23%
had a Personalised Asthma Action Plan
43%
had no asthma review in the year before their death
57%
not under specialist care 12 months prior to death
Avoidable death if guidelines applied in 46%
Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report. London: RCP, 2014.
How many patients do doctors say they refer?
BMC Pulmonary Medicine 2006, 6:13
74%
used at least one SABA inhalation every day 7 days prior to the interview
51%
needed unplanned medical care (e.g hospitalisation)
as a result of asthma attack at least once during
the last year
28%
classified as having controlled asthma
ALL OF THE PATIENTS WERE PRESCRIBED ICS
A high proportion also using concomittant LABA
Which patients should be sent for specialist referral?
Patients uncontrolled at Step 3?
Patients uncontrolled at Step 4?
Long-term oral corticosteroids?
Buhl et al Respir Med 2014;108:50–6
a) Question: Would you consider your asthma to be well-controlled?

Price et al EAACI 2015
Percentage of patients suffering severe exacerbations
How many patients with severe asthma are there?
Bel et al J Allergy Clin Immunol. 2015 ;135(4):896-902
Of asthmatic adults, 3.6% qualified for severe refractory asthma
Oral corticosteroid-induced morbidity in asthma patients
Sweeney et al REG summit 2014
Risks of inhaled corticosteroids: side-effects seen in COPD patients
Price et al. Prim Care Respir J 2013;22:92-100.
Which patients should be referred?
Why are people still dying from asthma?
Which patients are at high risk?
What would be the load on the system?
2+ exacerbations during the past year treated with oral steroids

> 500

µg fluticasone / day to maintain control

Hospitalized during the last year

Patients uncontrolled at Step 4 or 5
% of the asthma population (from State of the Union 2015 n = 9367)
What would be the load on the referral system?
Patients for referral
39% severe asthma
49% treated for moderate asthma
9% treated for mild asthma
39%
prescribed more than 12 SABA prescriptions in past year
All uncontrolled patients?
Patients uncontrolled at Step 3?
Patients uncontrolled at Step 4?
Which patients should be sent for specialist referral?
Asthma with prescription for high intensity treatment
<10 pack years AND self reported diagnosis of "asthma" or "COPD"
Difficult to control asthma
High intensity treatment AND uncontrolled (ACQ >1.5, 3+ exacerbations, 1+ hospitalisation OR well controlled with OCS
Severe refractory asthma
Difficult to control asthma AND good adherence AND correct inhalation technique
FROM THE NETHERLANDS
Adults with asthma
n = 370 019
Asthma + high intensity treatment
n = 87 133
Difficult to control asthma
n = 64 529
Severe refractory asthma
n = 13 248
How high should the ICS dose be increased to maintain control?
Risk factors for exacerbations
Price et al ERS 2015
14%
3%
Increasing likelihood of 2+ exacerbations
People in the city of Amsterdam (pop. approx. 1 million)
Assuming 8% of population has asthma...
2400
11 200
Severe asthma patients
Whom should we be targeting for referral and to which type of specialist?
Vote for my discussion topic!
29%
23 200
3200
17% uncontrolled at Step 3+
10% uncontrolled at Step 4+
4%
Price et al EAACI 2015
Price et al EAACI 2015
REG State of the Union
Number of exacerbations
Patients controlled requiring 500 µg fluticasone / day or equivalent?
Patients controlled requiring 1000 µg fluticasone / day or equivalent?
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