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(Chest. 2001;119:720-725.)
© 2001 American College of Chest Physicians

Underuse of Inhaled Steroid Therapy in Elderly Patients With Asthma*

Don D. Sin, MD, MPH and Jack V. Tu, MD, PhD

* From the Department of Medicine (Dr. Tu), Sunnybrook and Women’s College Health Science Center, University of Toronto, Toronto, Ontario; and Department of Medicine (Dr. Sin), University of Alberta, Edmonton, Alberta, Canada.

Correspondence to: Don D. Sin, MD, 2E4.39 Walter C. MacKenzie Center, University of Alberta, Edmonton, Alberta, Canada, T6G 2B7; email: don.sin{at}ualberta.ca


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Study objectives: Despite their proven efficacy, inhaled steroids may be underused in the elderly asthmatic population. The objectives of this study were to determine if inhaled steroids are underused in the elderly asthmatic population, who are at a high risk for rehospitalization and mortality, and to identify certain risk factors that predict lower use of inhaled steroids in this group of patients.

Design: Population-based, retrospective, cohort study using linked data from hospital discharge and outpatient drug databases.

Participants: All people >= 65 years old in Ontario, Canada, who survived an acute exacerbation of asthma between April 1992 and March 1997.

Measurements and results: Of the 6,254 patients, 2,495 patients (40%) did not receive inhaled steroid therapy within 90 days of discharge from their initial hospitalization for asthma. Patients > 80 years old were at a greater risk of not receiving inhaled steroid therapy, compared to those 65 to 70 years of age (adjusted odds ratio [OR], 1.23; 95% confidence interval [CI], 1.05 to 1.47). Patients with a Charlson comorbidity index of >= 3 were also at an increased risk of not receiving inhaled steroid therapy, compared to those having no comorbidities (adjusted OR, 3.45; 95% CI, 1.56 to 7.69). Moreover, receipt of care from a primary-care physician was independently associated with an elevated risk of not receiving inhaled steroid therapy, compared to receipt of care from respirologists/allergists (adjusted OR, 1.35; 95% CI, 1.10 to 1.61).

Interpretation: Forty percent of Ontario patients >= 65 years old who experienced a recent acute exacerbation of asthma did not receive inhaled steroid therapy near discharge from their initial hospitalization for asthma. Nonreceipt of inhaled steroid therapy was particularly prominent in the older patients with multiple comorbidities. Moreover, those who received care from primary-care physicians were also less likely to receive inhaled steroid therapy, compared to those who received care from specialists.

Key Words: asthma • comorbidities • elderly • inhaled steroids • underuse


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Despite the improved medical technologies for the management of asthma over the past decade, asthma-related mortality in the elderly population continues to rise. Between 1984 and 1994, for instance, there was a 24% increase in asthma-related mortality for those >= 65 years old; in contrast, the other age groups experienced little or no increase in mortality during the same period of time.1

The reasons for the continued rise in asthma mortality in the elderly population are not well understood. However, one important source may be related to the underuse of inhaled steroid therapy in this population of patients.2 3 Although the use of inhaled steroid therapy has been demonstrated to decrease the rate of hospitalization by approximately 50% and asthma mortality by up to 90%,4 5 previous studies6 7 in the younger population have shown that only about half of eligible patients with asthma receive these medications. The rate of use in the elderly population with asthma, however, is not well known. Moreover, there is a paucity of information concerning the risk factors associated with suboptimal utilization of inhaled steroid therapy in this group of patients.

We therefore conducted a large, population-based study of all patients >= 65 years old in Ontario, Canada, who recently experienced an acute exacerbation of asthma, in order to determine the rate of use of inhaled steroid therapy in this group of patients, and to identify certain subgroups within the elderly population who may be particularly undertreated. We chose this population of patients because they are at a high risk for rehospitalization and mortality from their asthma8 9 ; thus, they require long-term inhaled steroid therapy. Moreover, because many of these patients have comorbidities, we wanted to determine whether the presence of comorbidities was associated with nonreceipt of inhaled steroid therapy in view of a previous study10 that demonstrated that presence of comorbidities leads to an underutilization of efficacious drugs in other disease conditions.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Administrative data from the Canadian Institute of Health Information (CIHI) on hospital discharges in Ontario were used to identify residents of Ontario >= 65 years old who were discharged with a most responsible diagnosis of asthma between April 1, 1992, and March 31, 1997. For each patient, the database includes demographic (birth date, sex, and place of residence) and clinical data (most responsible and up to 15 secondary diagnoses, admission date, discharge date, and length of stay). International Classification of Diseases, ninth revision (ICD-9) codes 493.0. 493.1, and 493.9 were used to identify patients who were discharged from hospital with a most responsible diagnosis of asthma.11 12 For patients with multiple hospital admissions during the study period, only the first hospitalization was used in the analysis. We excluded patients who had died or had a recurrent hospitalization within 30 days of the discharge date, because they may not have had a sufficient window of opportunity to obtain outpatient medications. In addition, we excluded patients who were transferred to another acute-care hospital or a chronic-care institution because outpatient drug information was not available for these patients.

Using the CIHI database, the specialty of the attending physician was determined and categorized into three groups: family physicians/general practitioners (ie, primary-care physicians), general internists, and respirologists/allergists. This database was also used to determine the presence of the following comorbid conditions for patients in the cohort: previous myocardial infarction (ICD-9 codes 410–410.9, 412), congestive heart failure (ICD-9 code 428), diabetes (ICD-9 code 250), liver disease (ICD-9 codes 571, 572), renal disease (ICD-9 codes 582, 583, 585, 586, 588), cerebral vascular diseases (ICD-9 codes, 344, 342, 430–438), rheumatologic diseases (ICD-9 codes 710.0, 710.1, 710.4, 714, 725), and malignancies (ICD-9 codes 1966–199.1140–172.9, 174–195.8, 200–208.9).

Drug utilization information was obtained from the Ontario Drug Benefit database. The Ontario Drug Benefit program provides free outpatient medications for Ontario residents >= 65 years old. For each patient in the cohort, receipt of inhaled steroid medications (fluticasone propionate, beclomethasone, triamcinolone acetate, and budesonide), inhaled ß2-adrenergic and anticholinergics, as well as oral steroids and theophyllines was determined using this database.

From the Ontario Health Insurance Plan database, we obtained information on emergency department and outpatient physician visits within 1 year before the initial hospitalization, which was used as a surrogate marker for asthma severity. Scrambled unique identifiers for each patient were used to link the three databases together.

Statistical Analysis
In our primary analysis, age was categorized into four levels: 65 to 69 years, 70 to 75 years, 76 to 80 years, and > 80 years. The Charlson index,13 modified for use in computerized databases, was used to calculate comorbidities. Charlson index scores were then classified into four groups: 0, 1, 2, and >= 3. A score of zero indicates no comorbidities. For binary variables, we used the {chi}2 test, and for continuous variables with a normal distribution we used Student’s t test. For variables with a nonparametric distribution, Wilcoxon rank-sum test was used. Multivariate logistic regression was used to identify independent predictors of nonreceipt of inhaled steroid therapy. Crude and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for each predictor variable were calculated using standard methods. To test for linear trends, we inserted the specific exposure as a continuous variable into the final multivariate model. All p values are two sided, and {chi}2 values are based on one degree of freedom, unless otherwise specified. p values <= 0.05 were considered statistically significant. All analyses were conducted using SAS software (version 6.12; SAS Institute; Cary, NC).


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Baseline Characteristics
There were 6,254 patients in our study cohort. The average age of the patients in the cohort was 74.4 ± 6.9 years; 4,261 of the patients (68%) were women. Many patients had significant comorbidities. For instance, 528 patients (8%) had congestive heart failure.

Forty percent (n = 2,495) of the patients did not receive any inhaled steroid therapy within 90 days of the hospital discharge date. Table 1 shows the baseline characteristics of patients who did and did not receive inhaled steroid therapy within 90 days of the index discharge date. Those who did not receive at least one dispensing for inhaled steroid therapy at or near the time of discharge were slightly older, more likely to be women, and to have been under the care of a primary-care physician during their initial hospitalization. However, those not receiving inhaled steroid therapy had fewer visits to the emergency departments and outpatient physician services in the year before their index hospitalization.


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  		Table 1.. Baseline Characteristics of Elderly Asthmatic Patients in Ontario According to Inhaled Steroid Use Within 90 Days of Hospital Discharge*

 
Predictors for Nonreceipt of Inhaled Steroid Therapy
The variables that were independently associated with nonreceipt of inhaled steroid therapy are shown in Table 2 . Those patients with multiple comorbid conditions had a higher risk of not receiving inhaled steroid therapy, compared to those with no comorbidities (p for trend 0.001). For example, patients who had three or more comorbid conditions had a 3.45-fold (95% CI, 1.56 to 7.69) increased risk of not receiving inhaled steroid therapy than those not having any significant comorbidities. Those receiving care from a primary-care physician also had an increased risk of not receiving inhaled steroid therapy, compared to those under the care of respirologists/allergists (adjusted OR, 1.35; 95% CI, 1.14 to 1.61). However, after age and clinical factors were controlled for, women and men had a similar risk of not receiving inhaled steroid therapy (adjusted OR, 1.05; 95% CI, 0.93 to 1.20).


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  		Table 2.. Crude and Adjusted ORs for Nonreceipt of Inhaled Steroid Therapy Among Elderly Patients With Asthma*

 
Initial Receipt and the Risk of Subsequent Receipt of Inhaled Steroid Therapy
To evaluate whether or not patients who had received inhaled steroid therapy within the first 90 days of the index discharge date would be more likely to receive another inhaled steroid dispensing, we examined medication exposure for periods of 91 to 179 days, 180 to 269 days, and 270 to 365 days after discharge from initial hospitalization. Those who received treatment with inhaled steroids within the first 90 days were > 25 times more likely to have received another dispensing of inhaled steroids between 91 to 179 days of discharge date, compared to those without a 90-day exposure to inhaled steroid therapy (95% CI, 23.4 to 27.0). Overall, patients who were initially treated with inhaled steroids were > 14 times more likely to have received one or more additional dispensings of inhaled steroids, compared to those who were not treated with inhaled steroids in the first 90 days (95% CI, 13.5 to 15.2).

Receipt of Oral Steroid Therapy
We evaluated the effect of age, comorbidities, and gender on receipt of oral steroid therapy to determine whether a similar pattern was present as that for inhaled steroids therapy. We found that age was an important predictor of receipt of oral steroid therapy. As with inhaled steroid therapy, those < 70 years of age had the highest likelihood of receiving oral steroid therapy (41.3%) postdischarge, while the oldest age group (> 80 years of age) had the lowest likelihood of receipt (31.3%; p for trend, 0.001). Comorbidity was also an important determinant. Those with no comorbidities (ie, Charlson score of 0) had the highest likelihood of receiving oral steroid therapy (36.0%), while those with the greatest number of comorbidities (ie, Charlson >= 3) had the lowest likelihood of receiving oral steroid therapy (27.3%; p for trend, 0.001). Men received oral steroid therapy more frequently than women (39.6% vs 34.1%; p = 0.001). This pattern is similar to that found with inhaled steroid therapy, suggesting that receipt of oral steroid therapy did not confound the relationship between receipt of inhaled steroid therapy and these predictor variables.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
We found that 40% of Ontario residents >= 65 years old who experienced a recent acute exacerbation of their asthma did not receive inhaled steroid therapy at or near discharge from the hospital, despite the proven efficacy of these medications in reducing asthma-related morbidity and mortality. These findings are disturbing because this study was conducted among patients who were recently hospitalized and were, therefore, at a high risk for future adverse events related to their asthma.8 9 Indeed, a recent study14 demonstrated that failure to receive inhaled steroid therapy at or near discharge resulted in worse short-term symptom control and a twofold higher relapse rate compared to those who received inhaled steroid therapy at discharge. This study emphasizes the need for patients to be started at hospital discharge with a regimen of inhaled steroid therapy even though they may also be concomitantly receiving oral steroid therapy for the next several weeks after discharge.

Initiation and continued treatment with inhaled steroids after hospital discharge is important because there is growing evidence that persistence of airway inflammation predisposes to airway remodeling resulting in airway fibrosis and irreversible airflow obstruction.15 Because this risk increases with duration of asthma and age of patients, adequate treatment with anti-inflammatory medications is particularly germane to the elderly asthmatic population.15

Moreover, although patients reach clinical stability during hospitalization, their airways remain inflamed for several weeks, predisposing them to suffering relapses during this time16 ; the risk of relapse is as high as 45% by 8 weeks after hospital discharge,17 which makes it important that these patients have close follow-ups after discharge. However, a recent study18 indicates that over half of patients with asthma do not have follow-up visits with a primary-care physician after hospital discharge. Because many asthmatics may not have a follow-up after discharge, a hospital setting provides an important window of opportunity (and perhaps the only opportunity for some patients) to educate patients, prescribe the "appropriate" preventive medications, and make the "right" referrals. The importance of hospital and discharge care is stressed by our observation that patients who do not receive inhaled steroid therapy after hospital discharge are likely to remain free of inhaled steroid therapy over the next 12 months.

We found that the lowest utilization of inhaled steroid therapy was among patients with advanced age and multiple comorbidities. Although neither the American nor Canadian consensus guideline statements has indicated that the use of inhaled steroid therapy should be modified by age or comorbidities,19 20 our findings are consistent with previous reports that asthma is underdiagnosed and undertreated in the elderly population. In the Cardiovascular Health Study, for instance, only 30% of asthma patients >= 65 years old were prescribed inhaled steroids.3 In another community-based survey,2 only 22% of eligible elderly patients with asthma were receiving inhaled steroids. Paradoxically, however, a majority of asthma-related deaths occurs in the elderly population with multiple comorbidities.1

Although our study was not designed to tell us why this is occurring in the community, several plausible explanations exist. Previous studies21 22 showing the efficacy of inhaled steroid therapy in asthma have excluded elderly patients, which may make clinicians more hesitant in prescribing these medications for older patients. Physicians may also believe that inhaled steroid therapy may be unsafe for elderly asthmatic patients. Furthermore, elderly patients may be undertreated for their asthma because they have multiple comorbidities.10 Whatever the cause, our findings highlight age and comorbidities as important barriers to inhaled steroid therapy in the asthmatic population.

We also found that patients treated by specialists were approximately 50% more likely to have received inhaled steroid therapy, compared to those treated by family physicians/general practitioners. This finding is consistent with a previous report23 that showed that patients receiving their asthma care from specialists were considerably more likely to report using both inhaled steroid therapy and having higher health-related quality of life. These observations have been supported by other studies.24 25 Differences in disease severity of the patients and lack of familiarity of primary-care providers with these medications may partly explain this disparity.26 Primary-care providers also face numerous resource and time constraints that hinder optimal delivery of asthma care.26 27 Although various asthma consensus guidelines have been promulgated widely over the past decade, there remains a substantial gap between recommended and actual practices regarding inhaled steroid therapy, particularly among primary-care physicians. Our findings are consistent with the prevailing paradigm that information dissemination by itself is ineffectual in modifying practice patterns; more research is needed to identify various physician, patient, and structural barriers present within the current health-care system.

Our study did not have patient information on possible adverse reactions to inhaled steroid therapy, which may have contributed to lower utilization rates in certain subgroups of patients. However, there are no absolute contraindications for inhaled steroid treatment and significant interactions with other drugs are very uncommon,28 making it unlikely that our observations could be accounted for by drug interactions or the presence of adverse effects from inhaled steroid therapy. Moreover, because we did not have physiologic data, we could not determine the diagnostic accuracy of asthma in our cohort. The relevance of this to our findings, however, is not certain because our aim was to determine the use of inhaled steroid therapy among elderly patients who have been labeled by their attending physician as having asthma as their primary cause for their hospital admission regardless of the method used for the diagnosis. Nevertheless, it is reassuring that a previous study by Rawson and Malcolm29 suggests that the CIHI database is highly accurate for capturing those with asthma. A distinct advantage of our study was that because we were able to capture data on the entire Ontario population aged >= 65 years, we were able to avoid selection bias, which makes our findings not only valid but enhances their generalizability. Moreover, our health-care setting, which provided inhaled steroid medications free of charge to the patients in the cohort, created a "natural" experiment by removing most of the financial impediments faced by patients for complying with recommended asthma therapies. Even with increased access to prescription medications, we observed that only 60% received inhaled steroid therapy, suggesting that minimizing patients’ financial burden, while clearly important, cannot by itself fully close the gap between recommended and actual asthma care.

The findings of this study suggest that a substantial window of opportunity exists to increase the use of inhaled steroid therapy among elderly asthmatic patients who have been recently hospitalized for their disease. Underutilization of these drugs may be occurring particularly in patients with advanced age and those with multiple comorbid conditions, which may be contributing to the disproportionate rise in morbidity and mortality among these groups. In addition, our findings highlight the need for further research to understand the complex set of physician, patient, and administrative barriers to optimal asthma care present within the current health-care system.


   Footnotes
 
Abbreviations: CI = confidence interval; CIHI = Canadian Institute of Health Information; ICD-9 = International Classification of Diseases, ninth revision; OR = odds ratio

Dr. Sin was supported by a fellowship from the Alberta Heritage Foundation for Medical Research.

Dr. Tu is supported by a Medical Research Council of Canada Scholarship Award.

This work is supported in part by ICES, which is funded by the Ontario Ministry of Health.

Received for publication January 20, 2000. Accepted for publication October 3, 2000.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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