 |
|
Asthma in Older Patients
Factors Associated With Hospitalization
Gregory B. Diette, MD, MHS;
Jerry A. Krishnan, MD;
Francesca Dominici, PhD;
Ed Haponik, MD;
Elizabeth Ann Skinner, MSW;
Donald Steinwachs, PhD;
Albert W. Wu, MD, MPH
Arch Intern Med. 2002;162:1123-1132.
ABSTRACT
| |
Background Although older adults ( 65 years) with asthma have higher rates of
hospitalization and death from asthma than younger adults, the reasons for
this are not known.
Objectives To determine whether patterns of care were less favorable for older
than younger adults with asthma and to assess whether patient characteristics
such as symptom severity and comorbid illnesses explain the higher rate of
hospitalization.
Methods Prospective cohort study of 6590 adults with asthma in 15 managed care
organizations in the United States. Participants completed a survey of demographics,
symptoms, health status, comorbid illnesses, treatment, access to care, self-care
knowledge, physician specialty, and health care use.
Results Among 6590 adults with asthma, 554 (8%) were 65 years or older and 1942
(29%) were aged 18 to 34 years. Older patients were more likely than younger
patients to be men, white, non-Hispanic, and less educated. At baseline, older
patients reported a greater frequency of asthma-related symptoms, such as
daily cough (36% vs 22%, P<.001) and wheezing
(27% vs 22%, P<.002). They were also more likely
to report comorbid conditions, such as sinusitis (50% vs 38%), heartburn (35%
vs 23%), chronic bronchitis (43% vs 16%), emphysema (19% vs 1%), congestive
heart failure (8% vs 1%), and history of smoking (54% vs 34%) (all P<.001). Care appeared to be better for the older patients compared
with the younger, including more frequent use of inhaled corticosteroids,
greater self-management knowledge, and fewer reported barriers to care. In
the follow-up year, older patients were approximately twice as likely to be
hospitalized (14%) than were younger patients (7%) (P<.001).
In multivariate analysis, however, older age was not predictive of future
hospitalization (odds ratio, 1.05; 95% confidence interval, 0.68-1.61), after
adjustment for sex, ethnicity, education, baseline asthma symptoms, health
status, comorbid illnesses, and tobacco use. Factors independently associated
with hospitalization included being female, nonwhite, less educated, and less
physically healthy, and more frequent asthma symptoms.
Conclusions Although the older adults with asthma had greater respiratory symptoms
and more comorbidity than their younger counterparts, chronologic age was
not an independent risk for hospitalization. Appropriate care for older adults
with asthma should address asthma symptoms and other chronic conditions.
INTRODUCTION
ASTHMA IS A major public health problem in the United States, affecting
patients across the age spectrum, from infants to older adults. Although much
research and public attention has focused on children and young adults, there
has been little research on older persons (65 years) with asthma.1-2 Although the prevalence of asthma may
be similar in older and younger adults, ranging from 4% to 9%,3
morbidity and mortality are greater in older patients. The death rate attributable
to asthma is 14 times higher for persons 65 and older compared with those
18 to 35, with 89.8 deaths vs 6.3 deaths per million, respectively.2 Among 5400 deaths from asthma reported in the United
States between 1993 and 1995 for all ages, 2900 (54%) were among people 65
and older.2 Similarly, older adults are hospitalized
at more than twice the rate of younger adults, with a rate of 25.6 hospitalizations
per 10 000 compared with 10.0 per 10 000 for persons aged 15 to
34.2
Older adults shoulder a disproportionate burden of health care use and
mortality, but little is known about how asthma differs in this subset of
the population.4 For some medical illnesses,
studies5-6 have shown that older
patients receive less vigorous management. In some severely ill patients,
chronologic age was not related to outcomes, after accounting for severity
of illness factors.7 These findings suggest
not only that older patients may receive less care or may be sicker but also
that advanced chronologic age may not always be the cause of poorer outcomes.
In the case of asthma, investigators8-9
have suggested that blunted awareness of respiratory discomfort may lead to
delays in seeking treatment and to undertreatment of underlying airways inflammation.
As with other medical conditions, asthma care may be less vigorous in older
patients, or its management could be complicated by greater frequency and
severity of comorbid illnesses and poorer disease-specific or general health
status.
To examine why older adults with asthma are frequently hospitalized,
this investigation aimed to determine (1) whether quality of care was less
favorable for older adults and (2) whether patient characteristics such as
symptom severity and comorbid illness, which are predictive of hospitalization,
explain the different age-related rates of hospitalization in patients enrolled
in managed care.
PATIENTS AND METHODS
STUDY DESIGN
This study used patient-reported data from baseline and 1-year follow-up
in a cohort study to examine patterns of asthma treatment and the association
of baseline patient factors with future hospitalization.
STUDY POPULATION
The Managed Health Care Association Outcomes Management System Asthma
Project was undertaken by 11 large employers and their managed care partners
to test the feasibility and usefulness of patient-reported information to
improve the quality of patient care.10 Fifteen
managed care organizations participated in a prospective longitudinal study
that included an initial patient baseline survey and 2 annual patient follow-up
surveys.
Study participants were selected from the pool of enrollees in each
managed care organization, using claims data or other central information
sources. Three inclusion criteria were applied: (1) age 18 or older on September
1, 1993; (2) enrollment in the managed care organization at the time of sampling;
and (3) 2 or more medical care encounters (outpatient visits or hospitalizations)
with a diagnosis of asthma (International Classification
of Diseases, Ninth Revision, Clinical Modification code 493 and its
subclassifications) between September 1, 1991, and August 31, 1993. The sampling
pool was divided into 2 strata: (1) those who had at least 1 hospitalization
or emergency department visit during the past 24 months and (2) those who
had all of their asthma contacts in outpatient settings. From each of these
groups, at least 300 patients were selected from each health plan. If fewer
than 300 patients had hospitalizations or emergency department visits, the
outpatient group was expanded so that the total baseline sample numbered at
least 600 patients. Individuals were excluded from the baseline assessment
if they stated that they did not have asthma or had disenrolled or expected
to disenroll from the managed care organization before January 1, 1994.
DATA COLLECTION
During August 1993, 10 539 patients were sampled, of whom 8640
were eligible for the study. Reasons for ineligibility included not having
asthma (844 patients), disenrollment (839 patients), and "other" (216 patients).
From September 1993 through December 1993, data were collected from patients
by mail survey, with telephone follow-up of nonresponders to increase the
response rate. The completion rate for the baseline survey was 76% (6590 patients).
Of the 6590 patients who completed the baseline survey, 4876 (74%) completed
the 1-year follow-up survey. Response rates were higher in older patients:
18 to 34 years (66%), 35 to 44 (73%), 45 to 54 (76%), 55 to 64 (80%), and
65 and older (86%) (P<.001).
VARIABLES
The independent variables collected on the baseline survey included
the following:
Patient Demographics
Demographic variables included sex, age, ethnicity (white, black, or
"other"), education (eighth grade or less, some high school, high school graduate,
some college, college graduate, or any postgraduate work), and employment
status (working full time, working part time, unemployed, keeping house, attending
school, disabled, or retired).
Symptoms
Asthma symptom questions were based on the symptom types and frequencies
used by the National Asthma Education and Prevention Program9
and international11 asthma guidelines and included
cough, sputum production, chest tightness, wheezy or whistling sound in the
chest, and shortness of breath (never, once a week or less, 2-3 times a week,
4-5 times a week, or daily over the past 4 weeks). Patients were asked how
many times in the past 4 weeks asthma had awakened them from sleep (never,
once, 2-4 times, 5-7 times, or 8 times), how frequent asthma attacks were
(not at all, less than once a week, once or twice a week, or 3 times a
week), and how their breathing was in between attacks (no problems, some symptoms
on some days, some symptoms on most days, or symptoms most of the time). Patients
also reported the degree to which in the past 4 weeks asthma caused them to
rearrange or cancel normal activities (not at all, a little bit, some, or
quite a bit) and caused emotional problems (not at all, a little bit, some,
or quite a bit). To avoid problems associated with collinearity in multivariate
analysis used to account for symptom frequency, an asthma symptom index was
created based on the answers to 7 symptom questions (chest tightness, wheezing,
shortness of breath, cough, sputum production, nocturnal symptoms, and persistence
of symptoms between attacks).12 The responses
to each item were summed and divided by the number of nonmissing values. The
range for the asthma symptom index is 1 to 5, with a higher score indicating
more symptoms. A previous study10 found that
the asthma symptom index score was associated with the frequency of inhaled  -agonist
use.
Health Status
General health status was assessed with questions from a 36-item short-form
(SF-36 Health Survey).13 The 36-item short-form
is a general health status measure that produces 8 subscales, which can be
combined into 2 summary scores. The physical health component summary score
includes physical functioning, physical role functioning, bodily pain, and
general health. The mental health component summary score includes energy
(vitality), social functioning, emotional role functioning, and mental health.
Scores are standardized so that they range from 0 to 100, with a population
mean of 50. Higher scores indicate better health.
Comorbidity
Comorbid conditions were reported by patients as present or absent,
including sinusitis, heartburn, congestive heart failure, chronic bronchitis,
emphysema, and allergies or hay fever. These conditions were selected as potential
causes of worsening asthma or illnesses with symptoms that overlap those of
asthma.
Treatment
Indicators of treatments were based on recommendations of the National
Asthma Education and Prevention Program guidelines.9
Indicators of drug treatment included whether medications of certain classes
were used by patients for asthma. Medication classes included -agonist
inhalers, anticholinergic and cromolyn sodium inhalers, inhaled corticosteroids
(ICSs), oral theophylline, oral corticosteroids, and oral -agonists.
Inhaled corticosteroid use was assessed for days of use per week (none, <1,
1-2, 3-4, 5-6, or 7 days) and daily dose (1-4, 5-8, 9-12, or >12 puffs per
day). Underuse of ICS was considered to be use on 4 or fewer days per week
or 4 or fewer puffs per day of use.10 -Agonist
inhaler use was quantified as puffs per day on days of use (1-4, 5-8, 9-12,
or >12 puffs per day). Overuse of -agonists was considered to be use
of more than 8 puffs per day on days of use.10
We assessed whether a patient possessed a peak flow meter, had been shown
how to use it, had received instructions regarding what to do if the peak
flow fell below a specified level, and frequency of use. Finally, we asked
about prophylactic measures that patients take for worsening of asthma.
Access to Care
Access to care for patients with an acute asthma problem was assessed
by yes or no answers to questions about trouble reaching a physician or nurse
by telephone, getting an appointment to see a physician, or getting medication
for asthma. We also assessed whether patients had drug coverage as a covered
health insurance benefit.
Patient Knowledge
Knowledge was assessed by answers to questions about whether patients
believed they had been given enough information by the physician or nurse
to report knowing "everything you need to know about what to do when you have
a severe flare-up of your asthma," "how to adjust medicine when your asthma
gets worse," and "what things can make your asthma worse and how to avoid
them." Patients also rated their own knowledge about what to do in a severe
asthma attack, on a 5-point scale (from poor to excellent).
Physician Specialty
The patient was asked to name the physician primarily responsible for
managing his or her asthma and to give the physician's specialty. The specialty
was categorized as a generalist (internist or family practitioner), allergist,
or pulmonologist.
Health Care Use
Baseline health care use for asthma was assessed by the number of office
visits in the past 6 months, telephone calls to the physician in the past
6 months, emergency department visits in the past year, and hospital admissions
in the past year.
For the multivariate model, the dependent variable was the patient's
yes or no report of hospitalization for asthma during the year following the
baseline survey.
STATISTICAL ANALYSIS
We tested the hypothesis that greater asthma symptom severity and comorbid
illness explained the higher rate of hospitalization of older adults (65
years) compared with younger adults (18-34 years).
MANAGEMENT OF MISSING DATA FOR INDEPENDENT VARIABLES
The results in this article are presented with substitutions made for
missing values. Approximately one quarter of the respondents had at least
1 missing response. For variables with missing responses from fewer than 10%
of respondents, the missing value was replaced with the median for continuous
or ordinal variables and mode for nominal variables. For variables with at
least 10% of responses missing, we developed a data augmentation algorithm
for imputation of missing data based on multiple conditional imputation.14-15 Each missing value for a subject
was imputed by using data from the responding subjects in the sample having
a similar covariate profile. In this strategy, all independent variables were
imputed using the same method. The imputation was performed by accounting
for the correlation structure of the independent variables, and 5 multiple
imputations were performed to estimate the uncertainty due to the imputation.
Sensitivity of the analyses to missing values was evaluated by comparing the
difference between odds ratios (ORs) using the data set with missing values
and ORs from imputed data sets. The approach used may produce SEs that are
slightly higher or lower than if missing data had been "ignored." Factors
from multivariate models of borderline statistical significance (or nonsignificance)
should be interpreted with caution.
Variables were examined by descriptive frequencies and cross-tabulations.
Age was grouped as 18 to 34, 35 to 44, 45 to 54, 55 to 64, and 65 years and
older. Bivariate analyses were performed using t
tests for continuous variables and  2 tests for categorical
items. Differences were considered statistically significant at P<.05. In the bivariate analyses of variables that used imputation,
if all the P values for multiple imputation were
significant, we reported the highest P value leading
to the most conservative approach. If all the P values
for the multiple imputation were not significant, then the P value was not reported. The P values are
not sensitive to the multiple imputation, and there were no cases in which
some P values were significant and others were not.
A multivariate model to predict future hospitalization was developed in 2
stages. The relationship between patient factors at baseline and subsequent
hospitalization was first examined in bivariate analyses by 2
test (nominal variables), 2 test for trend (ordinal variables),
and Kruskal-Wallis test (continuous variables). Items that were statistically
significant in bivariate analysis or that were considered clinically important
were examined in multivariate models, using logistic regression analysis.
Multivariate models were developed in each sampling stratum (inpatient and
outpatient); because there were no important differences between the two,
a model combining all patients is reported. Results are reported with ORs
and 95% confidence intervals. Pooled ORs and confidence intervals were estimated
by combining the results of the 5 data sets resulting from imputation. Individual
ORs and their statistical variances were obtained by fitting the model to
each imputed data set. We then estimated a pooled OR by averaging the individual
ORs, and estimated the pooled variance by taking the average of the individual
variances plus the variances of the individual ORs. From the pooled variance,
we calculated the pooled confidence interval. Statistical computations were
performed with SAS version 6.12.16
RESULTS
Among 6590 patients who completed the baseline survey, 8% were 65 years
or older, 27% were 18 to 34, and 65% were 35 to 64. A higher proportion of
older patients (65-94 years) were men, white, and non-Hispanic. The older
patients also were significantly less educated (Table 1).
|
|
|
|
Table 1. Characteristics of Patients With Asthma by Age Group*
|
|
|
BIVARIATE ANALYSES
Respiratory Symptoms and Functional Effects of Asthma
As shown in Table 1, the
older patients tended to report significantly greater symptom frequency than
the younger patients, with the greatest differences in daily shortness of
breath, cough, and sputum production. The asthma symptom index score was higher
for the older compared with the younger patients (2.9 vs 2.7, P<.001). The frequency of nocturnal awakenings was slightly less
with older age, and asthma "attacks," although common, were less frequent
among older than younger patients (67% vs 74%, P<.001).
The older patients were more likely to have canceled scheduled activities
because of asthma and to report emotional problems because of their asthma
(54% vs 45%, P<.001).
Comorbid Conditions and Overall Health
Conditions that worsen asthma symptoms or that cause symptoms similar
to those of asthma (Table 1) were
significantly more prevalent in the older patients, including sinusitis, heartburn,
and congestive heart failure. Older patients were more likely to have ever
smoked (54% vs 34%, P<.001) and reported concomitant
lung conditions more frequently, including chronic bronchitis and emphysema.
On the other hand, allergies and hay fever were inversely related to age,
with 86% of the younger group reporting them vs 68% of the older patients
(P<.001). The physical health component summary
score on the 36-item short-form was substantially lower (worse) for the older
patients compared with the younger patients (mean score, 49.6 vs 80.8, P<.001), whereas the mental health component summary
scores were similar.
Patients Who Never Smoked
Because differences in disease characteristics seen between older and
younger adults could reflect misclassification of disease or effects of tobacco
exposure in older patients, we performed analyses confined to patients who
never smoked. The overall patterns of respiratory symptoms and comorbidity
by age were similar in never smokers (Table
2). However, compared with all older patients, the older patients
who never smoked were more likely to be female (75% vs 65%) and less likely
to report a comorbid diagnosis of chronic bronchitis (40% vs 43%) or emphysema
(8% vs 19%). Daily cough and sputum production were reported more frequently
in the older patients who never smoked compared with the entire group of older
patients, but there was less frequent wheezing and shortness of breath, although
these differences were slight. Asthma attacks were less frequent and symptoms
between attacks were also more favorable in the older patients who never smoked.
|
|
|
|
Table 2. Characteristics of Patients With Asthma Who Never Smoked,
by Age Group*
|
|
|
Barriers to Care
Compared with the younger patients, older patients in this study were
less likely to report barriers to care when there was a problem with their
asthma (Table 3). Older patients
were less likely to report difficulty reaching a physician by telephone, difficulty
getting an appointment to see the physician, or a problem in getting medications.
The older patients who had not seen an asthma specialist were also less likely
to indicate that they wanted to see one (15% vs 24%, P<.002).
|
|
|
|
Table 3. Process of Care in Patients With Asthma, by Age Group*
|
|
|
Medications
Older patients were more likely to use medications commonly prescribed
for respiratory conditions, including theophylline (51% vs 32%), inhaled ipratropium
bromide (22% vs 6%), oral -agonists (37% vs 23%), and oral corticosteroids
(37% vs 15%) (all P<.001). Although rates of possession
of ICSs and inhaled -agonists were similar across the age groups, older
patients used ICSs more regularly. Overuse of inhaled -agonists was
significantly greater among the older patients.
Information and Knowledge and Self-management
The older patients, more frequently than the younger, reported having
received all they needed to know about how to adjust medications when the
asthma is worse and were slightly more likely to know the triggers that worsen
asthma and how to avoid them (Table 3).
Older patients were more likely to report having been told all they needed
to know about what to do during a severe flare-up (61% vs 49%), but were less
likely to rate this knowledge as excellent (12% vs 23%) (both P<.001). The older patients were also more likely to use a peak
flow meter daily (28% vs 12%, P<.001). Older patients
were less likely to use asthma medications for worsening of symptoms, but
were more likely to take antibiotics, call their physician, or go to an emergency
department.
Risk of Hospitalization
The older patients were approximately twice as likely to be hospitalized
during the follow-up year after baseline as the younger patients (14% vs 7%, P<.001,
Table 4).
Other baseline patient factors that were significantly associated with future
hospitalization included female sex, nonwhite ethnicity, less education, and
active and passive tobacco exposure. Patients with greater baseline asthma
symptom severity, worse overall health status, and the presence of certain
comorbid conditions (heartburn, sinusitis, congestive heart failure, chronic
bronchitis, and emphysema) were also more likely to be hospitalized. Similar
associations with hospitalization were seen in the subset of adults who never
smoked, although a few of these associations were not statistically significant.
|
|
|
|
Table 4. Association of Baseline Characteristics With Future Hospitalization
for Patients With Asthma*
|
|
|
MULTIVARIATE ANALYSIS
In multivariate analysis, older age was no longer significantly associated
with future hospitalization, after controlling for asthma symptom severity,
health status, comorbidity, tobacco exposure, and demographics (Table 5). Being female, nonwhite, less educated, less physically
healthy, and more severe asthma symptoms remained significant predictors of
hospitalization.
|
|
|
|
Table 5. Multivariate Analysis of Predictors of Future Hospitalization
for Asthma
|
|
|
COMMENT
Consistent with previous findings from national data,2
the older patients in this study were at substantially higher risk of hospitalization.
However, chronologic age was not an independent risk factor for being hospitalized.
Instead, older patients in this study had a higher prevalence of other risk
factors that predict hospitalization, including more respiratory symptoms,
worse general health, and limited education. Although the older adults were
more likely to have smoked and to report having concomitant chronic obstructive
pulmonary disease, these factors alone did not account for the different rate
of hospitalization. Favorable findings for the older patients included their
reporting fewer barriers to care when needed and being more likely to receive
many elements of asthma care that are recommended by guidelines. Nevertheless,
there was still substantial room for improvement in care, as it appeared insufficient
to control symptoms and avert hospitalization.
Older patients reported a different pattern of symptoms compared with
the younger patients, suggesting potential differences in expression of asthma
or a blending of symptoms from multiple medical conditions, potentially obscuring
their primary airways disease. The symptom pattern suggests a more stable,
less episodic illness. For example, although several symptoms were more likely
to be reported daily, the relative difference was greatest for cough, sputum
production, and shortness of breath and less for wheezing and chest tightness.
In addition, older adults were less likely to report having symptoms of nocturnal
awakening and asthma attacks, but more likely to report symptoms "most of
the time." Clinicians need to be aware of these clinical presentations in
older patients and to maintain a high index of suspicion of asthma. Other
investigators have found different patterns of symptoms according to age.
For example, a study17 of older (65 years)
and younger (<40 years) asthmatics showed that mild symptoms and symptom-free
periods were less likely in older patients. The reasons for these varying
observations are unclear. In our investigation, the high prevalence of reports
that symptoms are triggered by certain environmental exposures (pets, food,
and dust) and concurrent reports of hay fever suggest that this difference
is not simply misclassification of illness. Rather, it seems that this reflects
a different constellation of asthma symptoms in older adults, or that symptoms
are modified by concomitant illnesses.
The high prevalence of comorbid medical conditions in our study is consistent
with other reports and is relevant to the presentation, recognition, and management
of older patients with asthma. Reporting results of the Cardiovascular Health
Study (a study of patients aged 65 years), Enright and colleagues18 showed that many patients with "definite" asthma
had high frequencies of hay fever (60%), chronic bronchitis (28%), and emphysema
(12%). A study19 using interview and medical
chart review data from older asthmatics also revealed a high prevalence of
chronic obstructive pulmonary disease and sinusitis. Coupled with the present
study findings (Table 2), the
high frequency of comorbid conditions underscores the importance of recognizing
and treating other conditions likely to coexist in the older asthmatic. The
high prevalence of reported allergy triggers (62%) is a reminder that older
patients, too, may benefit from environmental measures to control their asthma.
Indeed, management of comorbid conditions may affect nearly all older patients
with asthma, as 91% of our study patients reported at least 1 comorbid condition.
The finding that older patients who never smoked reported emphysema (8%) and
chronic bronchitis (40%) is interesting, as it may suggest that physicians
label older patients with respiratory symptoms as having chronic obstructive
pulmonary disease when primarily they may have asthma.
Although we hypothesized that unfavorable differences in care between
older and younger adults might explain increased hospitalization, we were
encouraged to see that older patients reported more favorable care across
a broad array of care indicators. Care appeared more appropriate in the use
of some medications, including regular use of ICSs, periodic assessment of
disease, avoidance and prophylaxis measures, self-knowledge, and use of specialists.
Indeed, the older patients were less likely to report problems with access
to providers, although they may experience difficulty paying for expensive
medications, as they were less likely to have insurance coverage for medications.
Although some clinicians may assume that older patients with asthma may be
less receptive to using comprehensive asthma care programs, these older patients
often reported more favorable approaches to the use of medications, fewer
barriers to care, and more knowledge and self-management of their disease.
We believe this observation is important and supports an optimistic view that
clinicians' efforts expended in education of older patients with asthma will
prove worthwhile.
On the other hand, although care appeared to be better for older than
younger patients, there were still marked opportunities for improvement. For
example, 37% of the older adults reported recent use of oral corticosteroids,
raising concerns about long-term consequences of this medication, including
loss of bone density, adrenal suppression, and other serious adverse effects.
It is interesting that theophylline was used by half of these older patients
and oral -agonists by 37%, despite the untoward effects in older patients.
Limited or infrequent use of ICSs was reported by nearly half of the older
patients, and more than 40% of the older patients reported not knowing everything
they needed to know to manage flare-ups, adjust medications, or avoid asthma
triggers. Most patients did not have a peak flow meter, and of those who did
have one, 29% did not know what to do in the case of a low reading.
There are limitations to interpretation of our study results. Misclassification
of disease status is possible in this study, with some patients reporting
a physician's diagnosis of asthma that should have been chronic bronchitis
or emphysema. We believe that the analyses limited to never smokers, however,
show that such misclassification is unlikely to be the major explanation for
our findings. In addition, we have used a definition of asthma that is consistent
with that used by the Centers for Disease Control and Prevention2
in establishing asthma prevalence rates in the United States and for documenting
a greater morbidity of asthma in older adults. Factors that affect the quality
of survey data include less education, impaired cognitive status, and worse
physical and mental health, all of which tend to be more frequent in older
patients.20 Multiple studies21-23
have shown, however, that health status information can be reliably obtained
by survey from older adults, including those with comorbid health conditions.
When the reliability of health status reports has been examined in different
age groups, some measures are affected slightly by older age.24
Older adults have been shown to have a "rosy" response bias, with a tendency
to report in a socially desirable direction.25
Because memory problems tend to increase with age, there may have been a bias
toward underreporting of symptoms and comorbid illness in the older patients.
Also, although the findings show that there is room to improve care, we do
not have information about whether care patterns reflect provider behavior
or patient preferences for care. The study was performed only in patients
enrolled in managed care, so the findings may not be generalizable to patients
who receive care under other arrangements. Because patient demographics, disease
severity, and the process of care might be expected to differ considerably
in other circumstances, further study focused on asthma in older patients
in other care settings is essential.
Despite these limitations, the present observations have important implications,
not only for individual patients and their health care providers but also
for health care planners. With the progressive aging of the US population,
health care costs attributable to hospitalization for asthma will increase,
even if hospitalization rates for older adults remain stable. A recent study26 of Medicare recipients shows that the number of hospitalizations
for asthma among older persons is rising. Identifying reasons for hospitalization
and adverse consequences of asthma in the older adult and developing interventions
to address these problems should be a priority for researchers and health
care planners. This study demonstrates that older adults with asthma are sicker
than their younger counterparts and that the care they receive may often be
inadequate. Older adults with asthma have more comorbid illnesses than younger
patients, and health care plans and programs that manage asthma need to consider
more than a single disease in the older adults. Coordination of care among
multiple care providers is often necessary and introduces more challenges
in management, but may prove crucial for the optimal care of the older asthmatic.
AUTHOR INFORMATION
Accepted for publication September 26, 2001.
This work was supported by the Managed Health Care Association, Washington,
DC.
Corresponding author and reprints: Gregory B. Diette, MD, MHS, Department
of Medicine, School of Medicine, Johns Hopkins University, Room 301, 1830
E Monument St, Baltimore, MD 21205 (e-mail: gdiette{at}jhmi.edu).
From the Department of Medicine, School of Medicine (Drs Diette, Krishnan,
Haponik, Steinwachs, and Wu), and the Departments of Biostatistics (Dr Dominici),
Epidemiology (Drs Diette and Wu), and Health Policy and Management (Ms Skinner
and Drs Steinwachs and Wu), School of Hygiene and Public Health, The Johns
Hopkins University, Baltimore, Md.
REFERENCES
| |
1. Chan ED, Welsh CH. Geriatric respiratory medicine. Chest. 1998;114:1704-1733.
FREE FULL TEXT
2. Centers for Disease Control and Prevention. Asthma mortality and hospitalization among children and young adults:
United States, 1980-1993. MMWR Morb Mortal Wkly Rep. 1996;45:350-353.
PUBMED
3. Enright PL, Kronmal RA, Higgins MW, Schenker MB, Haponik EF. Prevalence and correlates of respiratory symptoms and disease in the
elderly. Chest. 1994;106:827-834.
FREE FULL TEXT
4. Tuuponen T, Keistinen T, Sirkka-Liisa K. Hospital admissions for asthma in Finland during 1972-86 of adults
aged 65 years and over. Age Ageing. 1993;22:96-102.
5. Gugliano RP, Camargo CA, Lloyd-Jones DM, et al. Elderly patients receive less aggressive medical and invasive management
of unstable angina: potential impact of practice guidelines. Arch Intern Med. 1998;158:1113-1120.
FREE FULL TEXT
6. Borum ML, Lynn J, Zhong Z for the Study to Understand Prognoses and Preferences for Outcomes
and Risks of Treatments. Blood transfusion administration in seriously ill patients: an evaluation
of SUPPORT data. J Am Geriatr Soc. 2000;48(suppl 5):S39-S43.
7. Ely EW, Evans GW, Haponik EF. Mechanical ventilation in a cohort of elderly patients admitted to
an intensive care unit. Ann Intern Med. 1999;131:96-104.
FREE FULL TEXT
8. Connolly MF, Crowley JJ, Charan NB. Reduced subjective awareness of bronchoconstriction provoked by methacholine
in elderly asthmatic and normal subjects as measured on a simple awareness
scale. Thorax. 1992;47:410-413.
FREE FULL TEXT
9. Guidelines for the Diagnosis and Management of Asthma: Expert
Panel Report Number 2. Bethesda, Md: National Heart, Lung, and Blood Institute, National
Institutes of Health; 1997. NIH publication 97-4051.
10. Diette GB, Wu AW, Skinner EA, et al. Treatment patterns among adult asthmatics: factors associated with
overuse of inhaled -agonists and underuse of inhaled corticosteroids. Arch Intern Med. 1999;159:2697-2704.
FREE FULL TEXT
11. National Heart, Lung, and Blood Institute, National Institutes of Health. International consensus report on diagnosis and treatment of asthma. Eur Respir J. 1992;5:601-641.
ISI
| PUBMED
12. Steinwachs DM, Wu AW, Skinner EA, Young Y. Outcomes Management System Asthma Final Report: Report
to the Managed Health Care Association. Bethesda, Md: Outcomes Management System Asthma Project; 1996.
13. Ware JE, Kosinski M, Keller SD. The SF-36 Physical and Mental Health Summary Scales:
A User's Manual. Boston, Mass: Health Institute, New England Medical Center; 1994.
14. Rubin DB. Multiple imputation after 18+ years. J Am Stat Assoc. 1996;434:973-989.
15. Rubin DB, Little RJA. Multiple Imputation for Nonresponse in Surveys. New York, NY: John Wiley & Sons Inc; 1987.
16. SAS, Version 6.12. Cary, NC: SAS Institute Inc; 1999.
17. Quadrelli SA, Roncoroni AJ. Is asthma in the elderly really different? Respiration. 1998;65:347-353.
FULL TEXT
|
ISI
| PUBMED
18. Enright PL, McClelland RL, Newman AB, Gottlieb DJ, Lebowitz MD for the Cardiovascular Health Study Research Group. Underdiagnosis and undertreatment of asthma in the elderly. Chest. 1999;116:603-613.
FREE FULL TEXT
19. Bailey WC, Richards JM, Brooks CM, Soong S, Brannen AL. Features of asthma in older adults. J Asthma. 1992;29:21-28.
ISI
| PUBMED
20. Stewart AL, Sherbourne CD, Brod M. Measuring health-related quality of life in older and demented populations. In: Spilker B, ed, Quality of Life and Pharmacoeconomics
in Clinical Trials. Minnetonka, Minn: Lippincott-Raven; 1996:819-830.
21. Gloth FM, Walston J, Meyer J, Pearson J. Reliability and validity of the frail elderly functional assessment
questionnaire. Am J Phys Med Rehabil. 1995;74:45-53.
ISI
| PUBMED
22. Kutner NG, Ory MG, Baker DI, Schechtman KB, Hornbrook MC, Mulrow CD. Measuring the quality of life of the elderly in health promotion intervention
clinical trials. Public Health Rep. 1992;107:530-539.
ISI
| PUBMED
23. Katz JN, Chang LC, Sangha O, Fossel AH, Bates DW. Can comorbidity be measured by questionnaire rather than medical record
review? Med Care. 1996;34:73-84.
FULL TEXT
|
ISI
| PUBMED
24. Sherbourne CD, Meredith LS. Quality of self-report data: a comparison of older and younger chronically
ill patients. J Gerontol. 1992;47(suppl):S204-S211.
25. Carp FM. Maximizing data quality in community studies of older people. In: Lawton MP, Herzog AR, eds. Special Research
Methods for Gerontology. Amityville, NY: Baywood; 1989.
26. Cydulka RK, McFadden ER, Emerman CL, Sivinski LD, Pisanelli W, Rimm AA. Patterns of hospitalization in elderly patients with asthma and chronic
obstructive pulmonary disease. Am J Respir Crit Care Med. 1997;156:1807-1812.
FREE FULL TEXT
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati  Twitter
What's this?
RELATED LETTER
Elderly Asthmatic Patients
Gregory B. Diette and Albert W. Wu
Arch Intern Med. 2003;163(1):122.
EXTRACT
| FULL TEXT
RELATED ARTICLE
Archives of Internal Medicine Reader's Choice: Continuing Medical Education
Arch Intern Med. 2002;162(10):1199-1200.
FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
Tailored Education May Reduce Health Literacy Disparities in Asthma Self-Management
Paasche-Orlow et al.
Am. J. Respir. Crit. Care Med. 2005;172:980-986.
ABSTRACT
| FULL TEXT
Elderly Asthmatic Patients
Satoh and Sekizawa
Arch Intern Med 2003;163:122-122.
FULL TEXT
Elderly Asthmatic Patients
Diette and Wu
Arch Intern Med 2003;163:122-122.
FULL TEXT
|
