Risk factors for asthma-related hospital and intensive care admissions in children, adolescents, and adults: a cohort study using primary and secondary care data

Abstract

Objectives To assess the association between demographic and clinical risk factors and asthma-related hospital and intensive care admissions in children, adolescents, and adults, and to estimate the proportion of hospital admissions attributable to modifiable risk factors. Design Cohort study using routinely collected primary and secondary care data. Setting A large UK-based primary care database, the Clinical Practice Research Datalink (CPRD) Aurum, and linked Hospital Episode Statistics Admitted Patient Care (HES APC) data. Participants Patients were eligible for the study if they were aged five years and older and had an asthma diagnosis with linked data to the HES APC database. This included 90,989 children aged 5-11 years, 114,927 adolescents aged 12-17 years, and 1,179,410 adults aged 18 years or older. Primary and secondary outcome measures Primary outcome: asthma-related hospital admissions recorded from 1st January 2017 to 31st December 2019. Secondary outcome: asthma-related intensive care unit (ICU) admissions. Incidence rate ratios (IRR) adjusted for demographic and clinical risk factors were estimated using negative binomial models. Population attributable fraction (PAF) amongst those with asthma was estimated for modifiable risk factors that were statistically significantly associated with the primary outcome. Results In children, the risk factors for asthma-related hospital admission were belonging to an ethnic minority group, increasing socioeconomic deprivation, allergies (PAF 11.4%, 95% CI 6.8 to 15.8), and atopic eczema (6.8%, 3.6 to 9.9). In adolescents, the risk factors were being female, belonging to an ethnic minority group, increasing socioeconomic deprivation, former smoking (PAF 6.8%, 0.9 to 12.3), and allergic rhinitis. In adults, the risk factors were younger age, being female, belong to an ethnic minority group, increasing socioeconomic deprivation, being underweight, overweight or obese (PAF 23.3%, 95% CI 20.5 to 26.1 for obesity), current smoking (4.3%, 3.0 to 5.7), depression (11.1%, 9.1 to 13.1), allergies (6.2%, 4.4 to 8.0), gastro-oesophageal reflux disease (2.3%, 1.2 to 3.4), anxiety (2.0%, 0.5 to 3.6), and chronic rhinosinusitis (0.8%, 0.3 to 1.3%). In all age groups, increasing medication burden was associated with an increased risk in the primary outcome. Risk factors for asthma-related ICU admissions in children were black or mixed ethnicity and high levels of socioeconomic deprivation; in adolescents, they were female sex and black ethnicity; and in adults, they were younger age, female sex, black, mixed, or Asian ethnicity, and depression. In all age groups, increasing medication burden was associated with an increased risk in the secondary outcome. Conclusions There are significant sociodemographic inequalities in the rates of asthma-related hospital and ICU admissions. Treating atopic conditions in all age groups should be considered an integral part of asthma management. Adults have a wide range of potentially treatable risk factors that contribute substantially to asthma-related hospital admissions, including obesity, smoking, depression, anxiety and gastro-oesophageal reflux disease. Treating these risk factors could significantly reduce the rate of avoidable hospital admissions. Overall asthma medication burden is an important reflection of disease severity and prognostic marker of asthma outcomes, which should be monitored in all patients.

Competing Interest Statement

SH reports receiving funding from NIHR and UKRI. KN has been awarded research grants from NIHR, UKRI/MRC, Kennedy Trust for Rheumatology Research, Health Data Research UK, Wellcome Trust, European Regional Development Fund, Institute for Global Innovation, Boehringer Ingelheim, Action Against Macular Degeneration Charity, Midlands Neuroscience Teaching and Development Funds, South Asian Health Foundation, Vifor Pharma, College of Police, and CSL Behring, with all payments made to his academic institution; KN received consulting fees from BI, Sanofi, CEGEDIM, MSD and holds a leadership/fiduciary role with NICST, a charity and OpenClinical, a Social Enterprise. AHM received personal and institution funds for talks, consultancy fees, education or research grants from GSK, AZ, Sanofi, Teva, BI, Novartis, Chiesi. NJA reports receiving funding from NIHR outside the submitted work. PN reports receiving grants from NIHR and fees for educational talks and consultancy from Novartis, GSK and Astrazaneca. All other authors declare no competing interests.

Funding Statement

This research was funded by the National Institute for Health and Research Clinical Research Network West Midlands Improvement and Innovation Strategic Funding, grant number: 1002281. The researchers were independent from the funders and all authors had access to the study data and take responsibility for the integrity of the analyses.

Author Declarations

I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.

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I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.

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I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).

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Data Availability

Access to anonymised patient data from CPRD is subject to a data sharing agreement containing detailed terms and conditions of use following protocol approval from the MHRA Independent Scientific Advisory Committee. This study-specific analysable dataset is therefore not publicly available but can be requested from the corresponding author subject to research data governance approvals. Details about Independent Scientific Advisory Committee applications and data costs are available on the CPRD website (cprd.com).

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