RISK PYRAMID

1. RISK PYRAMID

2. Risks, Trends, Prevalence, & FUTURE of Asthma locally & globally Dr. Yoga Nathan Senior Lecturer in Public Health GEMS UL

3. Talk Outline • Risks & Trends • Asthma trends in Ireland & Globally • Prevalence • Risk Pyramid

4. Learning Outcomes • Consider ways to measure rates and trends of disease and apply them to asthma management • Estimate the prevalence of asthma in Ireland. • Construct a 'risk pyramid'. .

5. RISK • Risk can be defined as “the threat or probability that an action or event will adversely or beneficiallyaffect an organization's ability to achieve its objectives”. • In simple terms risk is ‘Uncertainty of Outcome’, either from pursuing a future positive opportunity, or an existing negative threat in trying to achieve a current objective.

6. Relative Risk • In statistics and mathematical epidemiology, relative risk (RR) is the risk of an event (or of developing a disease) relative to exposure. • Relative risk is a ratio of the probability of the event occurring in the exposed group versus a non-exposed group.

7. Relative Risk/Risk Ratio • The relative risk is the risk ratio because it is the ratio of the risk in the exposed divided by the risk in the unexposed. In a simple comparison between an experimental group and a control group: • A relative risk of 1 means there is no difference in risk between the two groups. • An RR of < 1 means the event is less likely to occur in the experimental group than in the control group. • An RR of > 1 means the event is more likely to occur in the experimental group than in the control group.

8. Information Sources for Risk • Risks • Published studies e.g. ISAAC (International Study of Asthma and Allergies in Childhood) • and unpublished studies • The effect of prior atopic illness, was largely explained by the strong independent association of incidence of asthma and wheezy bronchitis with atopic disease at the end of each incidence period

9. Influences of Risks • Genetic • Family History • Twin Studies • Environmental • Antenatal/Neonatal • Maternal smoking • ?in utero/post natal nutrition • Neonatal illness

10. Environmental-Childhood • House dust mite exposure • Parental smoking • Lower socioeconomic group • Pets • Air pollutants • Climate • Diet • Hygiene Hypothesis

11. Precipitants of asthma attack • Allergens: animals, house dust mite, mould spores, pollen etc • Infection • Air pollution: Indoor and outdoor • Physical stimuli: cold air • Exercise • Emotional factors • Chemicals: e.g. Tartrazine dye • Drugs: e.g. Aspirin

12. TRENDS • Trend estimation is a statisticaltechnique to aid interpretation of data. • When a series of measurements of a process are treated as a time series, trend estimation can be used to make and justify statements about tendencies in the data

13. Information Sources for Trends • Trends • Incidence data • Prevalence data • Morbidity data • Mortality data • National and International data

14. Trends Estimation • Incidence data • In Ireland no routine collection of this data • Potential sources: • GP databases • Specially collected data • Prevalence data • ISAAC • National studies • Local studies

15. Morbidity data • Hospital In-patient Enquiry (HIPE) • Public Health Information System (PHIS) • Health Atlas Ireland • Central Statistics Office (CSO) • Between 60 and 80 people die in Ireland each year from asthma (30% of these are under 40 years of age • Costs of Asthma in Ireland (Direct and Indirect Costs): • In 2003 asthma cost the State €463m in total

16. ASTHMA in IRELAND

17. Prevalence in Ireland

18. Prevalence in Ireland

19. Mid-West Area

20. Morbidity in Ireland

21. Summary • These studies demonstrates a sizable persisting level of childhood asthma in the Irish population and in addition there has been an overall upward trend for asthma prevalence. • This represents a 42% relative increase in Irish childhood asthma diagnosis from the period 1995 to 2002-3. • There was however, a relative drop in reported wheeze in these children by over 10%.

22. Summary • The cause for these trends is unknown but may reflect better recognition and diagnosis of asthma in clinical practice, reduced childhood asthma admissions to hospital and the drop in reported wheezing rates in the Irish population from 1998 to 2002-3 would be supportive of this. • These changes have coincided with the launch and the wide dissemination of national evidence-based Asthma Management Guidelines.

23. Burden of Asthma in Ireland • Ireland has the 4th highest prevalence of asthma worldwide • Ireland has highest rate (with UK) in EU • About 470,000 Irish population have asthma (1 in 8 of population) • Four (4) fold increase in Childhood asthma from 1984-2003 • Asthma is the most common chronic disease in children and young adults

24. Possible causes for increasedasthma prevalence • Lifestyle changes (indoors) • Increased atopy (influenced by pollution) • Diet changes (reduced breast feeding, lowered antioxidant intake, increased salt) • Reduced exposure to childhood illness

25. ASTHMA GLOBALLY

26. Global trends in asthma Results of WHO surveys: • The existing burden of asthma and other allergic diseases in developing countries was significant. • The prevalence of asthma in developing countries was likely to increase with industrialisation and Westernisation. • Some 235 million people currently suffer from asthma. It is the most common chronic disease among children

27. Global trends 1. Papua New Guinea • 1960s: asthma rare • 1980s: 7.3% adult population 2. Japan • asthma prevalence doubled between 1955 and 1971 • hay fever: none in 1930s, but 33% children by 1986 3. India • Delhi study, 1961: 1.81% • Patna study, 1966: 1.76% 1992-5: 3.5-6% Late 1990s: 15%

28. Global Trends • Big Picture • Increasing prevalence of diagnosed asthma • Decreasing prevalence of asthma symptoms • High prevalence in English speaking world with downward trend • Low prevalence in many developing countries with upward trend • Decreasing hospital discharges for diagnosis of asthma • Decreasing number of MORTALITY from asthma

29. Reasons? • Increasing prevalence of diagnosed asthma • ?Real • ? Changing diagnostic criteria • May be related to increased awareness by • GPs • Public • Decreasing prevalence of symptoms • ? Increased numbers being diagnosed may mean more people on adequate treatment

30. Worldwide prevalence of clinical asthma Braman S S Chest 2006;130:4S-12S ©2006 by American College of Chest Physicians

31. Asthma case fatality rates worldwide (deaths/100,000 cases) Braman S S Chest 2006;130:4S-12S ©2006 by American College of Chest Physicians

32. Summary • Despite international consensus on asthma management, patterns of asthma prescribing & asthma diagnosis frequency by GP vary considerably. • If prescribing were more in concordance with published guidelines, one would expect more consistent asthma treatment, minimal antibiotic use and no prescribing of drugs of limited clinical value. • The variation in proportions of patients with asthma suggests that there may well be differences in the labelling of asthma as indicated by other studies

33. Summary • Despite the variation in the number of participating GPs between the countries, similar trends of high prevalence in the U.K. and Ireland and low in the Mediterranean countries have been reported • For antibacterial drugs, higher levels were found to be prescribed for children in Belgium and Ireland and for adults in Scotland followed by Italy. • Antibacterial drug prescribing for asthma is considered to be irrational. • The incidence of asthma attacks diagnosed by GP’s in the UK and Ireland is about 5 times higher than it was 25 years ago.

34. A gap in patient/provider communications. Braman S S Chest 2006;130:4S-12S ©2006 by American College of Chest Physicians

35. Severe asthma is associated with disproportionately high costs in comparison with other degrees of asthma severity Braman S S Chest 2006;130:4S-12S ©2006 by American College of Chest Physicians

36. RISK PYRAMID

37. Individual work

38. Estimate of asthma morbidity and mortality in a primary care organization (n = 330,000) • X people were diagnosed with asthma • X emergency admissions • X people had wheezing during past year • X Deaths • X Registered in primary care organisation • X received GP treatment

39. Estimate of asthma morbidity and mortality in a primary care organization (n = 330,000) in the United Kingdom Deaths 8 Emergency Admissions 439 Received GP Treatment 25,100 Asthma diagnosis 44,900 Wheezing in past year 66,500 Patients in Primary Care System 330,000

40. Information for Asthma risk pyramid • X Wheezing in past year • X Admissions • X Population • X Deaths • X Asthma diagnosis

41. Risk pyramid - ASTHMA Deaths 10 Admissions 2,500 Asthma diagnosis 186,720 Wheezing in past year 230,807 Population 864,449

42. GINA Six-Point Management Plan • Educate patients to develop a partnership in asthma management • Assess and monitor asthma severity with symptom reports and measures of lung function as much as possible • Avoid exposure to risk factors • Establish medication plans for chronic management in children and adults • Establish individual plans for managing exacerbations • Provide regular follow-upcare • http://www.ginasthma.org/

43. Improving Access to Effective Patient Management • Improved communication of outcomes of specialist referrals • Increased involvement of specialist asthma nurses • More use of self-management plans • Financial drivers for primary care, but linked to quality of care

44. Barriers to Reducing the Burden of Asthma • Poverty; inadequate resources • Low public health priority • Poor health-care infrastructure • Difficulties in implementing guidelines developed in wealthier countries • Limited availability of and access to medication

45. Barriers to Reducing the Burden of Asthma • Lack of patient education • Environmental factors • Tobacco • Pollution • Occupational exposure • Poor patient compliance

46. Summary • Despite considerable knowledge with regard to the pathologic basis of asthma, the ongoing increases in asthma prevalence and subsequent increases in morbidity and mortalitycannot yet be explained. • In addition, the GINA goals of asthma management are not being achieved, with considerable under diagnosis and under appropriate or inappropriate treatment. • A significant proportion of patients are receiving only basic care and are not able to benefit from therapeutic advances.

47. Summary • For the majority of the population of the world, asthma is a low public heath priority. • The diversity of health-care systems worldwide and large variations in access to care require that asthma management guidelines to be tailored to local needs. • More cooperation is imperative between health-care officials and primary and secondary care providers in order to develop individualized asthma management programs that will work at a local level

48. FUTURE of ASTHMA in IRELAND • Ireland to lead the way in asthma care (Posted: Fri 10/07/2009 by Joanne McCarthy) • Ireland is set to become one of the leading countries in the EU to tackle asthma in the community with the roll out of a programme that could see asthma-related hospitalisations halved and asthma deaths reduced by 90%.

49. References • http://www.asthmasociety.ie • http://www.asthmacare.ie/ • http://www.irishhealth.com/clin/asthma/index.html • http://www.asthma-uk.co.uk/ • http://www.greenparty.ie/en/policies/asthma_and_allergies/profile_of_allergies_and_asthma_in_ireland • http://www.who.int/respiratory/asthma/en/ • Asher MI MS, Bjorksten B, Lai CKW, Strachan DP, Weiland SK, Williams H, and the ISAAC Phase Three Study Group Worldwide time trends in the prevalence of symptoms of asthma, allergic rhino conjunctivitis, and eczema in childhood: ISAAC Phase One and Three repeat multicountry cross-sectional surveys. Lancet. 2006;368:733-43. • Manning PJ Goodman P O'Sullivan A CL. Rising prevalence of asthma but declining wheeze in teenagers (1995-2003): ISAAC protocol. Irish Medical Journal. 2007;100(10):614-5. • Kelly I. Epidemiology of Asthma in Children and the use of Best Practice Guidelines in Primary care in the management of Children with Asthma in the counties of Laois, Offaly, Westmeath and Longford. Dublin: Royal College of Physicians of Ireland; 2008.