Gaps in clinical care escalation among severe, persistent asthma patients following indicators of uncontrolled asthma

Introduction Approximately 5-10% of patients with asthma have severe asthma (SA). Standard of care recommends escalation of care with uncontrolled disease. To evaluate current gaps in care in the US, this analysis examined care received among SA patients following events indicating uncontrolled disease (EUD). Methods Administrative claims databases for SA patients with Medicare Fee-for-Service, Medicare Advantage, Managed Medicaid, or commercial insurance spanning 2015-2020 were utilized. Severe, persistent asthma patients were indexed hierarchically on asthma-related EUD: ≥1 hospitalization, ≥2 emergency department (ED) visits with systemic corticosteroid treatment (SCS), 1 ED + ≥1 outpatient (OP) visit with SCS, or ≥2 OP visits with SCS. SA patients without any events were matched as controls. All were required to be 12+ years old, have 12 months enrollment pre- and post-index, and have no other major respiratory disease or biologic treatment during the pre-period. Specialist visits and medication escalation were examined during the post-index period. Results 181,548 SA patients were identified (90,774 uncontrolled, 90,774 controlled). Across payer channels, 33-51% of uncontrolled SA patients presented no specialist nor medication escalation intervention (Figure). Patients with 2 ED visits were most likely to present an absence of any intervention. Conclusion Results demonstrate that a substantial portion of uncontrolled SA patients do not have evidence of care escalation following uncontrolled disease, highlighting substantial gaps in care. Guidelines in the US recommend referral to an asthma specialist for systematic assessment or co-management for all SA patients, particularly those with uncontrolled disease. Accelerating subspecialist referrals and/or medication escalation may improve asthma care.