Specialist Referral Is Rare in Children, Teens With Poor Asthma Control, Study Finds

There is a prevalence of poorly controlled asthma and low rates of specialist referral among children and adolescents with asthma, according to the findings of an observational cohort study published in the Journal of Asthma and Allergy.

The study aimed to identify factors associated with poor asthma control and referral to a secondary care specialist, which may contribute to the significant morbidity and mortality associated with poor asthma control and outcomes.

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“We have shown that among the UK pediatric asthma population, a high proportion of children and young people continue to have poor symptom control, especially in the more severe asthma group and that among patients who are at risk for poor asthma outcomes, the referral rates to specialist care are still meagre,” wrote the researchers of the study.

The study obtained data from general practices by the Clinical Practice Research Dataline (CPRD), which, as of October 2020, contained health data on symptoms, clinical diagnoses, and prescriptions for nearly 12 million patients living in the United Kingdom. Patient data was included children and adolescents ages 6 to 17 years with current asthma, who were registered for at least 6 months during the study period between January 1, 2007, to December 31, 2019. Furthermore, the researchers used the CPRD GOLD database against physician reviewed patient notes and was found to have a high positive predictive value (PPV) above 86%.

Patients with a diagnosis of bronchiectasis, cystic fibrosis, primary ciliary dyskinesia, chronic upper airway cough syndrome, or bronchopulmonary dysplasia were excluded from the study.

The researchers also obtained information on these patients’ baseline characteristics and medication history, including asthma control test (ACT) or childhood asthma control test (cACT) scores, short-acting beta antagonists (SABAs), oral corticosteroids (OCS), and other asthma medications listed from primary care records.

Furthermore, the researchers categorized asthma severity using the Global Initiative for Asthma (GINA) report for 2020. Children and adolescents on GINA steps 1 to 3 were defined as having mild-to-moderate asthma, while those on GINA treatment steps 4 or 5 were defined as having severe asthma.

A total of 155,270 children and adolescents were included in the study, of which about 17.6% (n = 27,396) with active asthma had poor asthma control. Identified risk factors for poor asthma control were severe asthma (odds ratio [OR], 1.18; 95% CI, 1.15-1.22; P < .001), eczema (OR, 1.33; 95% CI, 1.30-1.37; P < .001) food allergies, (OR, 1.59; 95% CI, 1.51-1.67; P < .001), being overweight (OR, 1.15; 95% CI, 1.11-1.20; P < .001) or obese (OR, 1.27; 95% CI, 1.20-1.33; P < .001), and living in the most deprived areas (OR, 1.70; 95% CI, 1.63-1.77; P < .001).

Those with poor asthma control only had a 2% referral rate to specialist care, overall. Patients with severe asthma were 3 times more likely (hazard ratio [HR], 4.04; 95% CI, 3.35-4.87) to be referred than those with mild-to-moderate asthma (adjusted HR, 2.72; 95% CI, 2.13-3.49).

Additional factors that may be associated with referral included food allergy and living in a more deprived area.

The researchers acknowledged that their findings were not surprising and they had expected such a low referral rate. They noted that the result "speaks to a continued unmet need for timely referral for those patients who are not achieving adequate control of their asthma."

However, they also note some limitations to the study, including patient recall bias in the ACT control questionnaires, possible missing data, and not including diagnostic uncertainty.

Despite these limitations, the researchers believe the study shows there is a prevalence of children and adolescents who have poorly controlled asthma, in which improved referral efficiency may result in better patient outcomes.

“This group of patients with these risk factors represents the at-risk pediatric population for whom specialist assessment can help to identify potentially modifiable factors leading to improved control and characterize those who might be eligible for novel biological therapies,” wrote the researchers.

Reference

Kallis C, Morgan A, Fleming L, Quint J. Prevalence of poorly controlled asthma and factors associated with specialist referral in those with poorly controlled asthma in a paediatric asthma population. Journal of Asthma and Allergy. 2023;16:1065-1075. doi:10.2147/jaa.s428623