Ann Allergy Asthma Immunol 113 (2014) 241e243
Contents lists available at ScienceDirect
Guest Editorials
The allergist's role in treating acute asthma: is it time to reenter the hospital? The time when an asthmatic patient arrives at the emergency department (ED) with an acute exacerbation may be the critical moment in which certain interventions may mean the difference between costly inpatient care and rapid clinical turnaround with coordinated outpatient care. A recent meta-analysis by Rodrigo and Castro-Rodriguez1 compared standard care of short-acting b2-agonists with supplemental oxygen with the same short-acting b2agonist with heliox and found that heliox use significantly lowered the rate of hospital admissions (25% incidence in the heliox group vs 36% in the oxygen group). Such results are promising, particularly given the vast clinical and economic burden of this disease. The article not only highlights the need for research directed at acute exacerbations but also reminds us that there is an opportunity for us as asthma specialists to play an important and beneficial role in the acute care of our patients with asthma. Allergists are facing changing health care times, as highlighted in a series of Perspectives published in the Annals regarding the Patient Protection and Affordable Care Act and implementation of accountable care organizations (ACOs), which reinforces the need to expand our role within the medical community.2,3 Heliox, an inert breathing gas composed of a mixture of helium and oxygen, has been used medically since the 1930s. Heliox itself does not have any bronchodilator or anti-inflammatory effects. It is believed to be beneficial in those with obstructive respiratory defects by lowering resistance to gas flow within the airways and permitting deposition of inhaled active particles to the distal airways, thus acting as a driving gas. Although mainly used in cases of upper airway obstruction, anecdotal studies have suggested a potential role for its use in patients with asthma refractory to standard treatment. However, given the lack of robust literature on this topic, its use in asthma is sporadic, and it may very well be underused. To further explore this topic, Rodrigo and Castro-Rodriguez performed a meta-analysis to evaluate the efficacy of heliox vs oxygen in driving b-agonist nebulization in patients with acute asthma. The meta-analysis included randomized clinical trials published before August 2013. Eleven trials from 10 publications met the criteria, with 697 participants. Three of these studies included children. Primary outcomes included change in spirometric measurements and severity composite scores in pediatric studies, and secondary outcomes were hospital admissions and serious adverse events. Using an intent-to-treat analysis of 505 patients, the authors found patients receiving heliox had a 17.2% (95% CI, 5.2%e 29.4%; P ¼ .005; 20 L/min) increase in mean change from baseline
Disclosures: Dr. Oppenheimer has received research funding from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, and Medimmune; and has served as a consultant for GlaxoSmithKline, Myelin, and Sonovion. Dr. Desai has nothing to disclose.
peak expiratory flow (PEF) compared with patients receiving oxygen. Post hoc subgroup analysis revealed that patients with severe and very severe asthma had the most significant improvement in PEF (25% improvement from baseline) compared with those with mild-to-moderate asthma. Their analysis of pediatric studies revealed that b2-agonist heliox-driven nebulization significantly decreased the severity of exacerbations in children. In addition, heliox use significantly lowered the rate of hospital admissions (25% incidence in the heliox group vs 36% in the oxygen group). No significant difference in adverse events was noted in the 2 groups. There are several limitations to the studies that diminish the applicability of the meta-analysis findings, which deserve further comment. Methodologic issues with heliox administration (such as variability in helium to oxygen ratios, delivery method, nebulizer flow rates, and percentage of oxygen used in the control group) may have affected the results. Post hoc subgroup analysis demonstrated that studies that adjusted nebulizer flow rate to ensure delivery of heliox had a statistically significant difference for percentage change in PEF compared with studies that did not. This finding suggests the possibility that some of the studies may have had inadequate delivery of heliox, thereby underestimating its potential benefit. Of great importance, the study found the number needed to treat was 9 (treatment of 9 patients with heliox prevented 1 from undergoing hospitalization). Given the economic burden of asthma care, which is estimated to be $30 billion to $50 billion annually, avoidance of hospitalization and costly inpatient care is a high priority goal.4 There are approximately 2 million ED visits annually with asthma as the primary diagnosis and approximately 400,000 hospitalizations with a mean length of stay of approximately 3.6 days.4 In the face of changing economic times, this presents a large potential source of patient consultations for allergists, who mostly have been involved in outpatient care. In a recent Perspectives article in the Annals, Shulkin2 notes that involvement of allergists in the care of asthmatic patients leads to significant reductions in inpatient hospitalizations and ED visits. Given such findings of improved outcomes and reduced costs, the input of allergists in the ED would likely be welcomed by the hospital. Beyond even the ED, the allergist has a rightful place in the hospital, as discussed by Pillay5 in the article “The Allergist and the Intensivist: Not Such Odd Bedfellows,” which depicts the allergist as a key player in the hospital setting. The allergist can become more involved in the acute care of asthma, anaphylaxis, angioedema, and drug allergy by working side by side with our intensivist colleagues and thereby promoting the longevity of our field. Decreased health care use and cost with improved outcomes are important to the success of ACOs, which have launched since the passage of the Patient Protection and Affordable Care Act in 2010.
http://dx.doi.org/10.1016/j.anai.2014.04.010 1081-1206/Ó 2014 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.
242
Guest Editorials / Ann Allergy Asthma Immunol 113 (2014) 241e243
The emergence of ACOs will likely cast a bright light on cost and quality in health care and may move us toward a “value-based” compensation system.3 As nicely reviewed in the articles by Shulkin2 and Ein and Jefferson,3 the current focus of ACOs is mainly around the primary care physician and the patient; the role of allergists and other specialists within the ACOs is yet unclear. However, as more primary care physicians are aligned with such organizations and more patients are covered under these arrangements, the allergist working in a solo or small group practice would be wise to be aware of such shifts in patient care and anticipate its effects. Expanding our role by contributing to costeffective care for asthmatic patients across various settings of care, including the hospital arena, will bolster our relationships with ACOs through shared goals of low-cost, high-quality care. Documenting the cost-beneficial effect of allergists’ role in specific populations of patients will likely be important to leverage such relationships, particularly given the speculation that such organizations may favor primary care over specialty involvement. The findings of Rodrigo and Castro-Rodriguez are salient and provide additional reassuring data to support the use of heliox in powering b-agonist nebulization in cases of moderate to severe asthma in the ED. Given it was a meta-analysis of a limited number of small studies, larger randomized clinical trials with optimized heliox delivery systems and outcome measures, with a focus on cost-benefit, are needed. This study is part of an evolving literature in our journals regarding the acute care of asthmatic patients. This is exemplified by another article just published in the Annals by Doymaz et al,6 who found that the early administration of intravenous terbutaline in the ED may decrease respiratory failure in severe pediatric asthma exacerbation. This emerging literature is exciting and promising. As asthma specialists who are knowledgeable of this literature, we are well poised to bridge the gap between the outpatient and inpatient realms of asthma care. At this
time most allergists are practicing in solo or small group practices and forgoing involvement in the acute care setting. Recent shifts brought on by the Patient Protection and Affordable Care Act will likely precipitate changes in the dynamics of care provided by allergists. Entering the hospital doors is prudent to increase visibility for our specialty and improve patient outcomes through use of new and evolving treatments and may eventually become necessary given the rapidly changing face of health care. As noted by Dr Ein, “Allergists need to get into hospitals, give grand rounds to speak about anaphylaxis and drug allergy, work on medical committees, and go to lunch in the physicians’ cafeteria to assure their rightful place in the medical community.”3 John J. Oppenheimer, MD Mauli Desai, MD UMDNJ-Rutgers Pulmonary and Allergy Associates Morristown, New Jersey [email protected]
References [1] Rodrigo GJ, Castro-Rodriguez JA. Heliox-driven b2-agonists nebulization for children and adults with acute asthma: a systematic review with meta-analysis. Ann Allergy Asthma Immunol. 2014;112:29e34. [2] Shulkin DJ. The role of allergists in accountable care organizations. Ann Allergy Asthma Immunol. 2013;111:437e438. [3] Ein D, Jefferson A. The Patient Protection and Affordable Care Act: causes and effects. Ann Allergy Asthma Immunol. 2014;112:6e8. [4] Centers for Disease Control and Prevention. National Center for Health Statistics. National Health Interview Survey. http:/www.cdc.gov/asthma/asthmadata. htm. Accessed May 2, 2014. [5] Pillay K, Fung SS, Cohn JR. The allergist and the intensivist: not such odd bedfellows. Ann Allergy Asthma Immunol. 2014;112:94e96. [6] Doymaz S, Schneider J, Sagy M. Early administration of terbutaline in severe pediatric asthma may reduce incidence of acute respiratory failure. Ann Allergy Asthma Immunol. 2014;112:207e210.
Is there a better way? As practitioners, we are always asking ourselves, “Is there a better way?” In this issue of the Annals of Allergy, Asthma & Immunology, Dillys van Vliet1 et al once again ask this question in relation to asthma: “Can the practitioner improve asthma control in patients through electronic home monitoring vs standard retrospective assessments?” Asthma control is difficult to obtain because of the multiple variables that play a role.2,3 Practitioners have tried to narrow the list to the most effective measures of control, such as the Asthma Control Questionnaire (ACQ), the Asthma Control Test, and the Global Initiative for Asthma guideline questionnaire.4 Do these retrospective surveys give us the most accurate information? This study suggests that there may be a better way. Asthma control is the goal for all asthmatic patients. This control entails monitoring symptoms regularly and adjusting medications to try to avoid or treat flares and for the patient to be adherent. Many clinical studies have focused on addressing more effective asthma management strategies. Currently, asthma treatment is titrated based on the patient’s perception of control.3 Poor control is associated with increase medication use, exacerbations, cost, and ultimately increased mortality and morbidity. In this study, the traditional measures of control used were the ACQ, forced expiratory volume in 1 second (FEV1), peak expiratory flow, and fraction of exhaled nitric oxide. These were compared with daily electronic home monitoring by means of the Global Imitative Disclosures: Authors have nothing to disclose.
for Asthma questionnaire and FEV1.3 Although the ACQ has been validated,5 this study found that agreement between prospective daily electronic home monitoring and retrospective ACQ was low. In 37% of children, prospective monitoring revealed a less optimistic assessment of asthma control, actually 1 or 2 classes lower than the ACQ. In addition, home monitoring revealed more than twice as many cases of partly controlled asthma compared with the ACQ. Although limited by its small sample size, this study concluded that home monitoring may be superior to our current standard assessments of asthma control in the clinic setting. The results of this study may be impressive; however, data on its efficacy are conflicting. The studies by Jan et al6 and Rasmussen et al7 support the use of electronic home monitoring of symptoms and peak expiratory flow in children and adults. A study by Okupa et al8 also found that daily diaries were more sensitive than the Asthma Control Test in assessing differential treatment response with respect to asthma control. Other studies have found that home monitoring was not effective; however, this may be due to small study size or to the absence of electronic symptom scores or FEV1.9e11 If larger prospective studies prove home monitoring offers superior estimates of control, how will this be obtained and is regular home monitoring an achievable goal? The key to this being possible is adherence, a term used frequently in discussions of chronic disease. Are there ways to increase adherence to the point that regular home monitoring could be simple and easy? Daily home monitoring requires significant adherence. This study pointed out
Contents lists available at ScienceDirect
Guest Editorials
The allergist's role in treating acute asthma: is it time to reenter the hospital? The time when an asthmatic patient arrives at the emergency department (ED) with an acute exacerbation may be the critical moment in which certain interventions may mean the difference between costly inpatient care and rapid clinical turnaround with coordinated outpatient care. A recent meta-analysis by Rodrigo and Castro-Rodriguez1 compared standard care of short-acting b2-agonists with supplemental oxygen with the same short-acting b2agonist with heliox and found that heliox use significantly lowered the rate of hospital admissions (25% incidence in the heliox group vs 36% in the oxygen group). Such results are promising, particularly given the vast clinical and economic burden of this disease. The article not only highlights the need for research directed at acute exacerbations but also reminds us that there is an opportunity for us as asthma specialists to play an important and beneficial role in the acute care of our patients with asthma. Allergists are facing changing health care times, as highlighted in a series of Perspectives published in the Annals regarding the Patient Protection and Affordable Care Act and implementation of accountable care organizations (ACOs), which reinforces the need to expand our role within the medical community.2,3 Heliox, an inert breathing gas composed of a mixture of helium and oxygen, has been used medically since the 1930s. Heliox itself does not have any bronchodilator or anti-inflammatory effects. It is believed to be beneficial in those with obstructive respiratory defects by lowering resistance to gas flow within the airways and permitting deposition of inhaled active particles to the distal airways, thus acting as a driving gas. Although mainly used in cases of upper airway obstruction, anecdotal studies have suggested a potential role for its use in patients with asthma refractory to standard treatment. However, given the lack of robust literature on this topic, its use in asthma is sporadic, and it may very well be underused. To further explore this topic, Rodrigo and Castro-Rodriguez performed a meta-analysis to evaluate the efficacy of heliox vs oxygen in driving b-agonist nebulization in patients with acute asthma. The meta-analysis included randomized clinical trials published before August 2013. Eleven trials from 10 publications met the criteria, with 697 participants. Three of these studies included children. Primary outcomes included change in spirometric measurements and severity composite scores in pediatric studies, and secondary outcomes were hospital admissions and serious adverse events. Using an intent-to-treat analysis of 505 patients, the authors found patients receiving heliox had a 17.2% (95% CI, 5.2%e 29.4%; P ¼ .005; 20 L/min) increase in mean change from baseline
Disclosures: Dr. Oppenheimer has received research funding from AstraZeneca, Boehringer Ingelheim, GlaxoSmithKline, and Medimmune; and has served as a consultant for GlaxoSmithKline, Myelin, and Sonovion. Dr. Desai has nothing to disclose.
peak expiratory flow (PEF) compared with patients receiving oxygen. Post hoc subgroup analysis revealed that patients with severe and very severe asthma had the most significant improvement in PEF (25% improvement from baseline) compared with those with mild-to-moderate asthma. Their analysis of pediatric studies revealed that b2-agonist heliox-driven nebulization significantly decreased the severity of exacerbations in children. In addition, heliox use significantly lowered the rate of hospital admissions (25% incidence in the heliox group vs 36% in the oxygen group). No significant difference in adverse events was noted in the 2 groups. There are several limitations to the studies that diminish the applicability of the meta-analysis findings, which deserve further comment. Methodologic issues with heliox administration (such as variability in helium to oxygen ratios, delivery method, nebulizer flow rates, and percentage of oxygen used in the control group) may have affected the results. Post hoc subgroup analysis demonstrated that studies that adjusted nebulizer flow rate to ensure delivery of heliox had a statistically significant difference for percentage change in PEF compared with studies that did not. This finding suggests the possibility that some of the studies may have had inadequate delivery of heliox, thereby underestimating its potential benefit. Of great importance, the study found the number needed to treat was 9 (treatment of 9 patients with heliox prevented 1 from undergoing hospitalization). Given the economic burden of asthma care, which is estimated to be $30 billion to $50 billion annually, avoidance of hospitalization and costly inpatient care is a high priority goal.4 There are approximately 2 million ED visits annually with asthma as the primary diagnosis and approximately 400,000 hospitalizations with a mean length of stay of approximately 3.6 days.4 In the face of changing economic times, this presents a large potential source of patient consultations for allergists, who mostly have been involved in outpatient care. In a recent Perspectives article in the Annals, Shulkin2 notes that involvement of allergists in the care of asthmatic patients leads to significant reductions in inpatient hospitalizations and ED visits. Given such findings of improved outcomes and reduced costs, the input of allergists in the ED would likely be welcomed by the hospital. Beyond even the ED, the allergist has a rightful place in the hospital, as discussed by Pillay5 in the article “The Allergist and the Intensivist: Not Such Odd Bedfellows,” which depicts the allergist as a key player in the hospital setting. The allergist can become more involved in the acute care of asthma, anaphylaxis, angioedema, and drug allergy by working side by side with our intensivist colleagues and thereby promoting the longevity of our field. Decreased health care use and cost with improved outcomes are important to the success of ACOs, which have launched since the passage of the Patient Protection and Affordable Care Act in 2010.
http://dx.doi.org/10.1016/j.anai.2014.04.010 1081-1206/Ó 2014 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.
242
Guest Editorials / Ann Allergy Asthma Immunol 113 (2014) 241e243
The emergence of ACOs will likely cast a bright light on cost and quality in health care and may move us toward a “value-based” compensation system.3 As nicely reviewed in the articles by Shulkin2 and Ein and Jefferson,3 the current focus of ACOs is mainly around the primary care physician and the patient; the role of allergists and other specialists within the ACOs is yet unclear. However, as more primary care physicians are aligned with such organizations and more patients are covered under these arrangements, the allergist working in a solo or small group practice would be wise to be aware of such shifts in patient care and anticipate its effects. Expanding our role by contributing to costeffective care for asthmatic patients across various settings of care, including the hospital arena, will bolster our relationships with ACOs through shared goals of low-cost, high-quality care. Documenting the cost-beneficial effect of allergists’ role in specific populations of patients will likely be important to leverage such relationships, particularly given the speculation that such organizations may favor primary care over specialty involvement. The findings of Rodrigo and Castro-Rodriguez are salient and provide additional reassuring data to support the use of heliox in powering b-agonist nebulization in cases of moderate to severe asthma in the ED. Given it was a meta-analysis of a limited number of small studies, larger randomized clinical trials with optimized heliox delivery systems and outcome measures, with a focus on cost-benefit, are needed. This study is part of an evolving literature in our journals regarding the acute care of asthmatic patients. This is exemplified by another article just published in the Annals by Doymaz et al,6 who found that the early administration of intravenous terbutaline in the ED may decrease respiratory failure in severe pediatric asthma exacerbation. This emerging literature is exciting and promising. As asthma specialists who are knowledgeable of this literature, we are well poised to bridge the gap between the outpatient and inpatient realms of asthma care. At this
time most allergists are practicing in solo or small group practices and forgoing involvement in the acute care setting. Recent shifts brought on by the Patient Protection and Affordable Care Act will likely precipitate changes in the dynamics of care provided by allergists. Entering the hospital doors is prudent to increase visibility for our specialty and improve patient outcomes through use of new and evolving treatments and may eventually become necessary given the rapidly changing face of health care. As noted by Dr Ein, “Allergists need to get into hospitals, give grand rounds to speak about anaphylaxis and drug allergy, work on medical committees, and go to lunch in the physicians’ cafeteria to assure their rightful place in the medical community.”3 John J. Oppenheimer, MD Mauli Desai, MD UMDNJ-Rutgers Pulmonary and Allergy Associates Morristown, New Jersey [email protected]
References [1] Rodrigo GJ, Castro-Rodriguez JA. Heliox-driven b2-agonists nebulization for children and adults with acute asthma: a systematic review with meta-analysis. Ann Allergy Asthma Immunol. 2014;112:29e34. [2] Shulkin DJ. The role of allergists in accountable care organizations. Ann Allergy Asthma Immunol. 2013;111:437e438. [3] Ein D, Jefferson A. The Patient Protection and Affordable Care Act: causes and effects. Ann Allergy Asthma Immunol. 2014;112:6e8. [4] Centers for Disease Control and Prevention. National Center for Health Statistics. National Health Interview Survey. http:/www.cdc.gov/asthma/asthmadata. htm. Accessed May 2, 2014. [5] Pillay K, Fung SS, Cohn JR. The allergist and the intensivist: not such odd bedfellows. Ann Allergy Asthma Immunol. 2014;112:94e96. [6] Doymaz S, Schneider J, Sagy M. Early administration of terbutaline in severe pediatric asthma may reduce incidence of acute respiratory failure. Ann Allergy Asthma Immunol. 2014;112:207e210.
Is there a better way? As practitioners, we are always asking ourselves, “Is there a better way?” In this issue of the Annals of Allergy, Asthma & Immunology, Dillys van Vliet1 et al once again ask this question in relation to asthma: “Can the practitioner improve asthma control in patients through electronic home monitoring vs standard retrospective assessments?” Asthma control is difficult to obtain because of the multiple variables that play a role.2,3 Practitioners have tried to narrow the list to the most effective measures of control, such as the Asthma Control Questionnaire (ACQ), the Asthma Control Test, and the Global Initiative for Asthma guideline questionnaire.4 Do these retrospective surveys give us the most accurate information? This study suggests that there may be a better way. Asthma control is the goal for all asthmatic patients. This control entails monitoring symptoms regularly and adjusting medications to try to avoid or treat flares and for the patient to be adherent. Many clinical studies have focused on addressing more effective asthma management strategies. Currently, asthma treatment is titrated based on the patient’s perception of control.3 Poor control is associated with increase medication use, exacerbations, cost, and ultimately increased mortality and morbidity. In this study, the traditional measures of control used were the ACQ, forced expiratory volume in 1 second (FEV1), peak expiratory flow, and fraction of exhaled nitric oxide. These were compared with daily electronic home monitoring by means of the Global Imitative Disclosures: Authors have nothing to disclose.
for Asthma questionnaire and FEV1.3 Although the ACQ has been validated,5 this study found that agreement between prospective daily electronic home monitoring and retrospective ACQ was low. In 37% of children, prospective monitoring revealed a less optimistic assessment of asthma control, actually 1 or 2 classes lower than the ACQ. In addition, home monitoring revealed more than twice as many cases of partly controlled asthma compared with the ACQ. Although limited by its small sample size, this study concluded that home monitoring may be superior to our current standard assessments of asthma control in the clinic setting. The results of this study may be impressive; however, data on its efficacy are conflicting. The studies by Jan et al6 and Rasmussen et al7 support the use of electronic home monitoring of symptoms and peak expiratory flow in children and adults. A study by Okupa et al8 also found that daily diaries were more sensitive than the Asthma Control Test in assessing differential treatment response with respect to asthma control. Other studies have found that home monitoring was not effective; however, this may be due to small study size or to the absence of electronic symptom scores or FEV1.9e11 If larger prospective studies prove home monitoring offers superior estimates of control, how will this be obtained and is regular home monitoring an achievable goal? The key to this being possible is adherence, a term used frequently in discussions of chronic disease. Are there ways to increase adherence to the point that regular home monitoring could be simple and easy? Daily home monitoring requires significant adherence. This study pointed out
