International variation in severe exacerbation rates in patients with severe asthma

Tae Yoon Lee, David Price, Chandra Prakash Yadav, Rupsa Roy, Laura Lim Huey Mien, Eileen Wang, Michael E Wechsler, David J Jackson, John Busby, Liam G Heaney, Paul E Pfeffer, Bassam Mahboub, Diahn-Warng Perng Steve, Borja G Cosio, Luis Perez-de-Llano, Riyad Al-Lehebi, Désirée Larenas-Linnemann, Mona Al-Ahmad, Chin Kook Rhee, Takashi IwanagaEnrico Heffler, Giorgio Walter Canonica, Richard Costello, Nikolaos G Papadopoulos, Andriana I Papaioannou, Celeste M Porsbjerg, Carlos A Torres-Duque, George C Christoff, Todor A Popov, Mark Hew, Matthew Peters, Peter G Gibson, Jorge Maspero, Celine Bergeron, Saraid Cerda, Elvia Angelica Contreras Contreras, Wenjia Chen, Mohsen Sadatsafavi

Research output: Contribution to journalArticlepeer-review

Abstract

BACKGROUND: Exacerbation frequency strongly influences treatment choices in patients with severe asthma.

RESEARCH QUESTION: What is the extent of the variability of exacerbations rate across countries and its implications in disease management?

STUDY DESIGN AND METHODS: We retrieved data from the International Severe Asthma Registry, an international observational cohort of patients with a clinical diagnosis of severe asthma. We identified patients ≥ 18 years of age who did not initiate any biologics prior to baseline visit. A severe exacerbation was defined as the use of oral corticosteroids for ≥ 3 days or asthma-related hospitalization/ED visit. A series of negative binomial models were applied to estimate country-specific severe exacerbation rates during 365 days of follow-up, starting from a naïve model with country as the only variable to an adjusted model with country as a random-effect term and patient and disease characteristics as independent variables.

RESULTS: The final sample included 7,510 patients from 17 countries (56% from the United States), contributing to 1,939 severe exacerbations (0.27/person-year). There was large between-country variation in observed severe exacerbation rate (minimum, 0.04 [Argentina]; maximum, 0.88 [Saudi Arabia]; interquartile range, 0.13-0.54), which remained substantial after adjusting for patient characteristics and sampling variability (interquartile range, 0.16-0.39).

INTERPRETATION: Individuals with similar patient characteristics but coming from different jurisdictions have varied severe exacerbation risks, even after controlling for patient and disease characteristics. This suggests unknown patient factors or system-level variations at play. Disease management guidelines should recognize such between-country variability. Risk prediction models that are calibrated for each jurisdiction will be needed to optimize treatment strategies.

Original languageEnglish
JournalChest
Early online date21 Feb 2024
DOIs
Publication statusEarly online date - 21 Feb 2024

Bibliographical note

Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.

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