Year of Publication

2020

College

Public Health

Degree Name

Master of Public Health (M.P.H.)

Committee Chair

Dr. Richard Ingram

Committee Member

Dr. Martha Riddell

Committee Member

Dr. Clark Kebodeaux

Abstract

Asthma in Scotland: prescribing trends since the National Review of Asthma Deaths (NRAD)

Purpose: Asthma remains prevalent worldwide with implications for morbidity and mortality. In Scotland, 1 in 14 people are currently being treated for asthma. Asthma burden prompted the creation of the National Review of Asthma Deaths (NRAD), which identified contributing factors. Since the NRAD, guidelines have changed and therapeutic indicators have been developed with an increased emphasis on controller medications. Few publications describe how the NRAD study affected prescribing and if inequalities among the asthmatic population exist. This study aimed to determine whether patients were receiving appropriate treatment according to therapeutic guidelines and how prescribing has changed over time.

Methods: Scotland’s Prescribing Information System (PIS) was used to gain access to population-based outpatient prescription drug claims for Short-Acting Beta-Agonists (SABAs), Long-Acting Beta-Agonists (LABAs), and Inhaled Corticosteroids (ICSs), to create a cohort of asthma patients aged 0-39. All ethical approvals necessary were obtained according to the National Health System (NHS) of Scotland’s specified guidelines for de-identified patient data. Patients were stratified by age, gender, socioeconomic status (SES), and medication type to compare rates of prescribing for different populations. Using NRAD and the national therapeutic indicators as metrics, the data was analyzed to assess changes over time. The primary outcomes included whether there was a difference in asthma prescribing from 2014 to 2018; if there were any significant demographics differences among those with uncontrolled asthma; and whether drug claims were consistent with asthma guidelines.

Results: A total of 222,637 patients were analyzed from 2014 and 205,758 from 2018. In 2018, 7.42% of those received more than 12 SABAs per year, 20.77% received more than 6, and 42.39% received more than 3, only slightly lower than in 2014 (8.85%, 21.83%, 43.73% respectively). For the most recent year that data was available (2018) further analyses were completed. Prevalence of receiving more than 12 SABAs was found to be higher among patients who were male, as well as patients aged 30-39, or those with lower SES. Use of greater than 12 SABAs varied almost two-fold between the populations with the highest and lowest SES (lowest SES – 9.0%; highest SES – 4.6%). When looking at measures related to the therapeutic guidelines, only 89% of patients receiving more than 12 SABAs had received an ICS; of those, only 41% received an adequate amount of ICS medications over the year.

Conclusion: Prescribing practices have changed slowly since the NRAD study was published. When looking at the therapeutic guidelines, prescription drug claims show a disconnect with the recommendations. There appears to remain an over-reliance on reliever medications with a deficit in controller medications. This study shows that a large Scottish asthmatic population remains at increased risk of poor outcomes. More studies are needed to further research hospitalization, morbidity, and mortality rates as well as cost analyses, to further characterize change over time and whether new measures are needed to improve outcomes.

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