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Assessing Future Need for Acute Care in Adult Asthmatics^*

The Profile of Asthma Risk Study: A Prospective Health Maintenance Organization-Based Study

^* From the Oregon Health and Science University (Drs. Osborne and Buist); Kaiser Permanente Center for Health Research (Ms. Pedula and Dr. Vollmer), Kaiser Permanente Northwest (Drs. Stibolt and Ettinger); and The Allergy Clinic (Dr. O’Hollaren), Portland, OR.

Correspondence to: Molly Osborne, MD, PhD, FCCP, Mail code L102, Oregon Health and Science University, 3181 SW Sam Jackson Park Rd, Portland, OR 97239; e-mail: osbornem{at}ohsu.edu

Abstract

Study objectives: To develop simple clinical tools predictive of acute asthma care and to identify modifiable risk factors.

Design: Prospective cohort study.

Setting: A large health maintenance organization (430,000 members).

Patients/participants: Adult members (18 to 55 years old) with asthma.

Interventions: Data from a questionnaire, skin-prick testing for inhalant allergens, and spirometry were collected at the baseline visit. Acute care utilization data were obtained from administrative databases for a subsequent 30-month period.

Methods: This two-phase study first identified and performed a split-sample validation on three clinical tools to determine their predictive ability by employing data from a questionnaire, questionnaire plus spirometry, and questionnaire plus spirometry and skin-prick testing. Second, it identified modifiable independent risk factors.

Measurements and results: The 554 study participants generated 173 episodes of acute care over 1,258 person-years of follow-up (0.14 episodes per person per year). Of these, 101 participants had at least one episode, and one third of this group had two or more episodes. Clinical scoring into risk groups was done by reverse stepwise regression analyses. Using relative risks (RRs) as a guide, high-risk, moderate-risk, and low-risk groups were identified. The high-risk groups, 13 to 21% of the validation sample, had a 7- to 11-fold increased risk for hospital care compared to the low-risk groups. The moderate-risk groups, 46 to 50% of the validation sample, had a twofold- to fourfold-increased risk. FEV₁ was the most significant predictor (RR, 4.33). Of the four potentially modifiable risk factors identified, current cigarette smoke exposure (RR, 1.6) and ownership and skin-prick test positivity to cat or dog (RR, 1.5) were the most significant.

Conclusions: These models stratify asthma patients at risk for acute care. Patients with lower FEV₁ values are at significantly higher risk, underscoring the importance of spirometry in asthma care.

Key Words: asthma • health-care utilization • health maintenance organization • spirometry • tobacco

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