Accepted Manuscript Choosing Wisely: Adherence by Physicians to Recommended Use of Spirometry in the Diagnosis and Management of Adult Asthma Kristin C. Sokol, MD MS MPH, Gulshan Sharma, MD MPH, Yu-Li Lin, MS, Randall M. Goldblum, MD PII:

S0002-9343(14)01224-8

DOI:

10.1016/j.amjmed.2014.12.006

Reference:

AJM 12818

To appear in:

The American Journal of Medicine

Received Date: 19 August 2014 Revised Date:

21 October 2014

Accepted Date: 4 December 2014

Please cite this article as: Sokol KC, Sharma G, Lin YL, Goldblum RM, Choosing Wisely: Adherence by Physicians to Recommended Use of Spirometry in the Diagnosis and Management of Adult Asthma, The American Journal of Medicine (2015), doi: 10.1016/j.amjmed.2014.12.006. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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Choosing Wisely: Adherence by Physicians to Recommended Use of Spirometry in the Diagnosis and Management of Adult Asthma

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Corresponding Author: Kristin C. Sokol, MD MS MPH Assistant Professor Division of Pediatric Allergy and Immunology The University of Texas Medical Branch 301 University Blvd. Galveston, TX 77555 [email protected] Office: 409-772-0433 Cell: 832-848-0880 Fax: 409-772-0460

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Authors: Sokol KC, Sharma G, Lin Y, Goldblum RM

Gulshan Sharma, MD MPH Sealy & Smith Distinguished Chair in Internal Medicine Director, Division of Pulmonary Critical Care & Sleep Medicine Associate Chief Medical Officer The University of Texas Medical Branch Galveston, TX

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Yu-Li Lin, MS Biostatistician The Office of Biostatistics The University of Texas Medical Branch Galveston, TX

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Randall M. Goldblum, MD Director, Child Health Research Center Laboratory Professor Departments of Pediatrics and Biochemistry and Molecular Biology The University of Texas Medical Branch Galveston, Texas Funding source: Funding was provided by UT Systems Health IT and Systems Engineering. Conflict of Interest: Dr. Gulshan Sharma serves on advisory board of Sunovion Pharmaceuticals. All authors had access to the data and a role in writing the manuscript Article Type: Clinical Research Study

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Keywords: asthma, choosing wisely, cost, pulmonary function test, spirometry Running Head: Choosing Wisely: Spirometry Use in Adult Asthma Abstract

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Purpose: The National Asthma Education and Prevention Program (NAEPP) and the

American Thoracic Society (ATS) provide guidelines stating that physicians should use spirometry in the diagnosis and management of asthma. The aim of this study was to

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evaluate the trends, over a 10-year period, in the utilization of spirometry in patients

newly diagnosed with asthma. We hypothesized that spirometry use would increase in

guidelines were published.

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physicians who care for asthma patients, especially since 2007, when the revised NAEPP

Methods: This retrospective cohort analysis of spirometry use in subjects newly diagnosed with asthma used a privately insured adult population for the years 2002-2011.

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Our primary outcome of interest was spirometry performed within a year (±365 days) of the initial date of asthma diagnosis. We also examined the type of asthma medications prescribed.

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Results: In all, 134,208 patients were found to have a diagnosis of asthma. Only 47.6% had spirometry performed within one year of diagnosis. Younger patients, males and

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those residing in the Northeast were more likely to receive spirometry. Spirometry use began to decline in 2007. Patients cared for by specialists were more likely to receive spirometry than those cared for by primary care physicians, 80.1% vs. 23.3% respectively. Lastly, even without spirometry, a significant portion of patients (78.3%) was prescribed asthma drugs.

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Conclusions: Our study suggests that spirometry is underutilized in newly diagnosed asthma patients. Moreover, the use of controller medications in those diagnosed with

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asthma without spirometry remains high.

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1. Introduction Asthma is a common chronic respiratory condition affecting approximately 8% of the

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adult population in the United States (US) and utilized $56 billion in medical care in 2007.1 The average cost in the US is about $3,300 per person each year in medical

expenses, missed school and work days, and early deaths. About one-third (33%) of

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adults who had an exacerbation in 20082 missed school or work because of their asthma.

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Asthma is characterized by paroxysmal or persistent respiratory symptoms associated with variable airflow limitation and airway hyperresponsiveness to stimuli. The diagnosis of asthma is based on both symptoms and objective evidence of variable airflow obstruction and/or airway hyperresponsiveness.3 Spirometry plays a vital role in the diagnosis and management of asthma by providing accurate measurements of air volumes

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and flows. Bronchoprovocation testing, another measure of pulmonary function, can also be used in the diagnosis of asthma, especially in patients with cough-variant asthma or

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whose spirometry results are normal despite typical asthma symptoms.

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Choosing Wisely, a multi-year effort of the American Board of Internal Medicine (ABIM) Foundation, helps ensure that physicians make appropriate, evidence-based, and cost-effective health care choices.4 As part of the Choosing Wisely 2014 “List of Ten Things Physicians and Patients should Question,” the American Academy of Allergy, Asthma, and Immunology (AAAAI) includes asthma, adding “Don’t diagnose or manage asthma without spirometry.”5 The AAAAI notes that clinicians often rely solely upon symptoms when diagnosing and managing asthma, but these symptoms may be

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misleading and arise from alternate causes. Therefore, spirometry is essential to confirm the diagnosis in those patients who can perform this procedure. Recent guidelines3 highlight spirometry’s value in stratifying disease severity and monitoring control.

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History and physical exam alone may over- or under-estimate asthma control. Beyond the increased costs of care, repercussions of misdiagnosing asthma include delays of

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establishing a correct diagnosis and treatment.2

Spirometry is currently recommended by the leading national task forces:3,6 1) at the time

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of initial assessment, 2) after treatment is initiated and symptoms and peak expiratory flow have stabilized, 3) during periods of progressive or prolonged loss of asthma control, 4) and at least every 1–2 years. Despite these guidelines, prior studies have

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suggested low rates of spirometry use in patients with newly diagnosed asthma.7-10

To date, no population-based study in the United States has evaluated the utilization of spirometry in newly diagnosed adults with asthma. The aim of the current study was to

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evaluate the trends over a 10-year period in the utilization of spirometry in adults newly diagnosed with asthma. We hypothesized that spirometry use would increase in

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physicians who care for asthma patients, especially since 2007, when the most comprehensive evidence-based National Asthma Education and Prevention Program (NAEPP) guidelines were published. We also examined the pattern of medication use in these patients diagnosed with asthma.

2. Methods

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a. Data Source This is a retrospective study using administrative claims data from Clinformatics

prescription claims data from 2001 to 2012.

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b. Study Cohort

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DataMart (CDM). We used the member eligibility data file, medical services data, and

We selected patients with a first encounter diagnosis of asthma between 2002 and 2011

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in our data set. We defined their earliest asthma encounter during the study period as a new diagnosis of asthma. The patients were required to have at least 2 years of continuous enrollment (1 year before and 1 year after the initial diagnosis) (N= 323,800). A patient was considered to have asthma if s/he: had at least two outpatient visits, at least

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30 days apart within one year, with an encounter diagnosis of asthma, identified by the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) code 493.x; or had 1 evaluation and management claim for inpatient care or observation,

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with asthma being the primary diagnosis. Outpatient visits were identified by Current Procedural Terminology (CPT) codes 99201-99205 and 99211-99215, and inpatient care

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or observation was identified by CPT codes 99221-99226 and 99231-99233. We then selected those diagnosed at the ages of 18-64 years (N= 182,389). We excluded those residing in Puerto Rico/US territories and those with the following diagnosis identified by ICD-9 codes in the prior year: chronic obstructive pulmonary disease (490.x), chronic bronchitis (491.x), emphysema (492.x), bronchiectasis (494.x), extrinsic allergic alveolitis (495.x), chronic airway obstruction, not otherwise classified (496), and esophageal reflux (53081). The final cohort included 134,208 subjects

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c. Study Variables

We categorized patients by age, gender, region (Midwest, Northeast, South, and West),

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year of asthma diagnosis and type of care they received during the 2-year study period (1 year before and 1 year after the first asthma diagnosis). The specialties of the providers

were identified using medical services data. When a patient received at least one bill from a given type of provider (primary care, allergy and immunology, or pulmonary

d. Outcome Measures

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medicine), s/he was considered to be cared for by that type of provider.

Our primary outcome of interest was use of spirometry (identified by CPT codes 94010, 94014, 94015, 94016, 94060, 94070, and 94620) performed within a year (± 365 days) of the initial date of asthma diagnosis. A secondary outcome of interest was the pattern of

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asthma medications prescribed, including inhaled short-acting beta-agonist (SABA), inhaled corticosteroid (ICS), combination inhaled corticosteroid with long-acting betaagonist (ICS-LABA), inhaled long-acting beta agonist alone (LABA), inhaled long-

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acting muscarinic antagonist (LAMA), leukotriene receptor antagonist (LTRA), 5-

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lipoxygenase (LO) inhibitor, and theophylline in patients with and without spirometry.

e. Statistical Analysis

The spirometry use rates within 1 year of the initial asthma diagnosis were calculated, then stratified by age, gender, region, year of diagnosis, and type of care. The effect of patient characteristics on the likelihood of having a spirometry test was examined by logistic regression. The Cochran-Armitage trend test was used to examine the trends in

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spirometry use, type of care, and various medication usages by year. All analyses were performed using SAS 9.3 (SAS Institute, Inc., Cary, NC) and p-values

Choosing wisely: adherence by physicians to recommended use of spirometry in the diagnosis and management of adult asthma.

The National Asthma Education and Prevention Program (NAEPP) and the American Thoracic Society provide guidelines stating that physicians should use s...
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