title: Step-up care improves impairment in uncontrolled asthma: an administrative data study.
abstract: OBJECTIVE
  To determine whether step-up care recommended by national asthma guidelines improves asthma control in a large managed care organization.
  
  
  METHODS
  Cohort analysis.
  
  
  METHODS
  A cohort with uncontrolled asthma, defined as impairment or risk in a 1-year consecutive period, was identified using electronic medical records among continuously enrolled patients with asthma aged 12 to 56 years. Guideline-based step level of care was determined 3 months before and 3 months after the index event of uncontrolled asthma according to an algorithm of asthma medication dispensing using electronic pharmacy data. Impairment based on short-acting β-agonist canisters dispensed and risk based on asthma emergency or hospital care were compared during the following year in patients with vs without step-up care, adjusting for demographics, prior utilizations, asthma risk, and comorbidities.
  
  
  RESULTS
  Uncontrolled asthma was identified in 7694 eligible patients (mean [SD] age, 35.7 [14.4] years; 54.0% female). Step-up care during the 3-month period after the uncontrolled asthma event was seen in 2160 of 7177 patients (30.1%) with classifiable step care. Step-up care was associated with significant reductions in impairment, with adjusted relative risks of 0.78 (95% confidence interval [CI], 0.73-0.85) during the first 6 months and 0.84 (95% CI, 0.78-0.90) during the full 12-month follow-up period. Emergency or hospital care was unaffected by step-up care. Subgroups with uncontrolled asthma defined by impairment only and risk only showed outcomes generally similar to those of the entire cohort.
  
  
  CONCLUSIONS
  Guideline-based step-up care in uncontrolled asthma was determined by administrative data and was shown to be associated with significant and clinically meaningful improvements in asthma impairment but not risk.
authors.affiliation: Department of Allergy, Kaiser Permanente Medical Center, 7060 Clairemont Mesa Blvd, San Diego, CA 92111, USA. robert.s.zeiger@kp.org
authors.forename: Robert S
authors.initials: RS
authors.lastname: Zeiger
authors.forename: Michael
authors.initials: M
authors.lastname: Schatz
authors.forename: Qiaowu
authors.initials: Q
authors.lastname: Li
authors.forename: Feng
authors.initials: F
authors.lastname: Zhang
authors.forename: Anna S
authors.initials: AS
authors.lastname: Purdum
authors.forename: Wansu
authors.initials: W
authors.lastname: Chen
mesh_terms: D000293:Adolescent; D000318:Adrenergic beta-Agonists / Q000627:therapeutic use*; D000328:Adult; D000465:Algorithms; D018927:Anti-Asthmatic Agents / Q000627:therapeutic use*; D001249:Asthma / Q000188:drug therapy*; D002648:Child; D015331:Cohort Studies; D005260:Female; D006279:Health Maintenance Organizations; D006801:Humans; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D017410:Practice Guidelines as Topic; D011787:Quality of Health Care; D012189:Retrospective Studies; D017211:Treatment Failure; D014481:United States; D055815:Young Adult
chemical_list: D000318:Adrenergic beta-Agonists; D018927:Anti-Asthmatic Agents