ERS 2024: Excess SABA Prescribing in Respiratory Patients and Social Deprivation in General Practice: A Study of 4 Million Patients
Speaker: Michael Crooks
The study focuses on the excess prescribing of short-acting beta-agonists (SABA) among respiratory patients and its association with social deprivation in general practice. The analysis encompassed over 4 million patients and explored the relationship between SABA use and deprivation. The use of SABA is well-known to be linked with adverse outcomes, particularly in patients with asthma. Previous literature has established a clear association between excessive SABA use and an increase in exacerbations, as well as asthma-related mortality. Interventions aimed at identifying and addressing SABA overuse have been shown to improve patient outcomes. Although SABA use has been less studied in patients with chronic obstructive pulmonary disease (COPD), similar adverse outcomes have been observed. There is evidence suggesting that reducing reliance on SABA and implementing evidence-based therapies can improve patient outcomes in both asthma and COPD populations.
Respiratory outcomes tend to be worse in socioeconomically deprived communities. The Index of Multiple Deprivation (IMD) is used to assess socioeconomic status, with scores ranging from 1 (most deprived) to 10 (least deprived). The study hypothesized that patients in more deprived areas would exhibit higher rates of SABA use, potentially presenting an opportunity for intervention and improvement of outcomes. The data for this study were derived from the Optimum Patient Care Research Database (OPCRD), encompassing records from over 1,000 general practices and approximately 25 million patient records. Patients included in the study had a SABA prescription between 2004 and 2022, leaving over 4 million patients contributing to the final analysis, which included multiple patient years of data.
Analysis of SABA use by patient year showed that 55% of the data was contributed by females. SABA use was categorized into low use (1-2 canisters) and overuse (≥3 canisters), with overuse being defined as greater than 12 canisters per year according to asthma-based guidelines. The data showed higher SABA use among older age groups. The primary goal of the study was to examine the correlation between deprivation and SABA use. A significant relationship was observed, with the most deprived populations (IMD 1) showing higher SABA use (4.5 canisters/year) compared to the least deprived populations (IMD 10) (3 canisters/year). Additionally, approximately 50% of patient years in the most deprived communities were characterized by SABA overuse, compared to 39% in the least deprived communities.
When examining the diagnostic codes associated with SABA use, a persistent correlation between deprivation and SABA overuse was seen across different respiratory conditions. Patients with asthma accounted for 42% of those prescribed a SABA, yet contributed to 60% of overall SABA prescriptions. Those with COPD or dual diagnoses (asthma and COPD) represented a smaller proportion, but still demonstrated a significant correlation. Notably, 47% of patients receiving SABA prescriptions had no documented diagnosis of airways disease, contributing to 10% of all SABA prescriptions. There were some limitations in the data. Some inhaler prescriptions lacked information on the quantity prescribed, necessitating assumption based on dosing instructions. Additionally, the IMD scores used for deprivation analysis were linked to the general practitioner (GP) practice location rather than the patient's residence.
In conclusion, asthma remains the primary driver for the majority of SABA prescriptions, although patients with COPD have a higher average number of SABA prescriptions per year. Importantly, over 10% of SABA prescriptions are issued to individuals without any documented diagnosis of airways disease, highlighting a significant area for potential clinical intervention. The study confirms a strong correlation between higher SABA use and areas of socioeconomic deprivation, presenting an opportunity for targeted quality improvement initiatives to address these healthcare disparities and improve patient outcomes.
Regarding the question of why some patients exhibit high SABA use, various factors may contribute. Historical practices in some GP communities still prioritize SABA for asthma management, despite newer guidelines advocating for early initiation of combination therapy. Additionally, emergency department clinicians may not be fully aware of the latest recommendations, which emphasize the benefits of anti-inflammatory combination treatments. While this study did not specifically examine comorbidities such as body mass index (BMI) or psychological factors, these could be explored further using the available coded data in primary care records. Factors contributing to SABA overuse are likely multifactorial, including patient behaviors, clinician practices, and underlying uncontrolled symptoms in both asthma and COPD populations. Frequent SABA use typically indicates uncontrolled disease, with patients relying on quick-relief inhalers to manage acute symptoms. This preference for immediate symptom relief can overshadow the longer-term benefits of inhaled corticosteroids (ICS) or anti-inflammatory treatments.
In asthma, quality improvement efforts have been focused on anti-inflammatory reliever-based treatments and Maintenance and Reliever Therapy (MART) regimens to reduce SABA overuse. For COPD, the emphasis shifts to managing uncontrolled breathlessness, with both pharmacological (such as triple therapy) and non-pharmacological approaches available to help reduce reliance on SABA. In summary, addressing SABA overuse requires a multifaceted approach, encompassing patient education, clinician awareness, and the implementation of evidence-based therapeutic strategies.
European Respiratory Society Congress 2024, 7–11 September, Vienna, Austria.
