Trends in asthma hospital admissions by seasonal period

1. Trendsinasthma hospital admissions byseasonalperiod Dias AS, Soares AS, Rodrigues D, Rosinha I, Vilela M, Pinto M, Dias M, Barbosa N, Rosinha P, Sá T, Cabreira V, Bessa V Turma 11, 1º ano do Mestrado Integrado em Medicina 2010/2011 intromed1011turma11@gmail.com

2. summary • Thedisease, itsprevalence • TobaccoSmoke • Smoke-freeLegislation • Researchquestion • Introduction • Methods • Results • Discussion • Bibliography

3. Thedisease, itsprevalence • The most common chronic pulmonary disease1. • Causing wheezing, breathlessness, chest tightness and coughing2. • Increase of airways reactivity (hyperresponsive) because they become obstructed and airflow is limited1. • Its prevalencehas increasedconsiderably over the past 20 years, especially in children3. Magazine on European Research. The allergy enigma. 2004 1Global Initiative for Asthma, Pocket guide for asthma management and prevention, 2009 2Mallol J, Castro-Rodriguez JA, Cortez E. Int J Chron Obstruct Pulmon Dis 2007 3Arruda LK, Sole D, Baena-Cagnani CE, Naspitz CK. Curr Opin Allergy Clin Immunol 2005

4. TobaccoSmoke • Gene-environmentalinteractionsplay a key role inthedevelpmentof asthma4. • Tobaccosmokeis a major componentofindoorair pollution5. • Secondhandsmokeincreasestheriskofseverity asthma6. • Longitudinal andcase-controlstudieshavedescribedtobaccosmoke, mainstreamorsecondhand, as a risk factor for developing asthma7-9. 4 Baena-Cagnani CE, Gómez RM, Baena-Cagnani R, Canonica GW. Curr Opin Allergy Clin Immunol, 2009 5 Atkinson, Anderson, Sunyer et al. American Journal of Respiratory and Critical Care Medicine, 2001. 6 Rayens MK, Burkhart PV, Zhang M, Lee S, Moser DK, Mannino D, Hahn EJ. J Allergy Clin Immunol.,2008. 7 Plaschke PP, Janson C, Norrman E, et al. Am J Respir Crit Care Med 2000. 8 Genuneit J, Weinmayr G, Radon K, et al. Thorax 2006. 9 Gilliland FD, Islam T, Berhane K, et al. Am J Respir Crit Care Med 2006.

5. Smoke-freeLegislation • Smoke-freelegislationaims to protectnon-smokersfromsecondhandsmoke, butitalsomayreducetheriskamongsmokersbecauseofreduced smoking orincreased smoking cessation. Public Smoking Bans FULL bans (all public places) PARTIAL bans (smoking is allowed in some places) • Smoke-free legislation has a positive effect as it decreases the hospital admissions for asthma and other diseases.

6. Researchquestions • HavetrendsinASTHMA-RELATED HOSPITAL ADMISSIONS byseasonchangedonthepastdecadein Portugal? • Whatistheimpactofsmoke-freelegislationonthenumberof ASTHMA-RELATED HOSPITAL ADMISSIONS in Portugal?

7. summary • Introduction • Methods • Results • Discussion • Bibliography • Data sources • Exclusioncriteria • Definitons • Statisticalanalysis

8. Data sources National Database Hospital Admissions (Portuguese Public Hospitals) [Jan 1, 2000 ----(Jan 1, 2008)---- May 31, 2009]

9. Exclusioncriteria POPULATION: peopleattendingpublichospitals CAUSE:AsthmaCrisis as DischargeDiagnosis (ICD9-Code 493,xx)

10. Definitions • ICD 9 codes: • 493.0 [0-2] – Extrinsic asthma • 493.1 [0-2] – Intrinsic asthma • 493.2 [0-2] – Chronic obstructive asthma • 493.8 – Other forms of asthma • 493.9 [0-2] – Asthma, unspecified

11. Statisticalanalysis • Groupsofparticipants: • Group I  children (1-17 years) • Group II  adults (18 or more years) • Variablesanalised: • Dischargediagnosis(categorical: ICD9) • Age group(categorical: children, adults)

12. Statisticalanalysis • Aproppriatesummarystatistics for thecontinuousvariables • Describecategoricalvariables • Investigate time trendsin hospital admissions 2000 2008 2009 ImplementationofSmoke-freeLegislation

13. Admissions for asthma Total number of records in the database: 11944725 SELECTION CRITERIA: Total number of records analysed: 28765 • Discharge diagnosis • Admission date prior to June 2009 (due to changes in the registry) • Age >= 1 year

14. 28765 (2000 to 2009) Asthma Hospital Admissions • MALE – 12733 (44 %) • FEMALE – 16032 (56%) • CHILDREN – 13678 (48%) • ADULTS – 15087 (52%) AGE • Children • Mean – 5 • Std. Deviation– 4 • Adults • Mean – 55 • Std. Deviation– 19

15. summary • Introduction • Methods • Results • Discussion • Bibliography • Admissions for asthma • Analysisbysubgroups

16. General analysis Introductionofsmoke-freelegislation

17. Analysisbysubgroups • NumberofAsthmarelatedAdmissionsbyMonth 2009 excluded

18. R2=0,961 Analysisbysubgroups Children R2=0,882 R2=0,860 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

19. R2=0,813 Analysisbysubgroups Adults 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 R2=0,932 R2=0,910 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

20. Analysisbysubgroups

21. Analysisbysubgroups Children R2=0,213 2000 2001 2002 2003 2004 2005 2006 2007 2008 R2=0,590 R2=0,286 2000 2001 2002 2003 2004 2005 2006 2007 2008 2000 2001 2002 2003 2004 2005 2006 2007 2008

22. Analysisbysubgroups Adults R2=0,228 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 R2=0,874 R2=0,357 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2000 2001 2002 2003 2004 2005 2006 2007 2008

23. summary • Introduction • Methods • Results • Discussion • Bibliography • Limitations • Conclusion

24. Limitations • Data inconsistence of database and low quality of registry; • Large amount of data (that caused a difficult selection and loading of information); • In 2008 there is no registry of the variable “Hospital” which give us information about the kind of admission’s hospital. Therefore, to analyze the influence of this variable in asthma trends was not possible. • Only the first five months of 2009 have the total cases of admissions in Portugal. All the other cases of this year were not considered.

25. Limitations • Relative to variable “Módulo_origem” that categorizes episodes as “ambulatory” or “admission” • In the case of asthma we assumed that all strings represent admissions; • In all other cases we cannot admit this idea, so we eliminated all strings as well as ambulatory cases. • This assumptions may introduce bias.

26. Conclusions • In a general analysis, thenumberofasthma hospital admissionshasdecreased • Therewas a influenceoftheweather (andconsequentlytheseason) inthenumberofasthmaepisodes • Children are more affectedthanadults • For bothgroups, theperiodfromJanuary to Mayseems to bethemostcriticalone (with a highernumberofadmissions for asthma)

27. Conclusions • Thetrendsinasthma-related hospital admissionshadnotchangeonthepastdecadein Portugal • Thereisnotevidencethattherewas a decreaseinasthmarelated-hospital admissionsaftertheintroductionofthesmoke-freelegislationin Portugal

28. summary • Introduction • Methods • Results • Discussion • Bibliography

29. Bibliography • Pocket guide for asthma management and prevention. Global Initiative for Asthma 2009. • Mallol J, Castro-Rodriguez JA, Cortez E. Effects of active tobacco smoking on the prevalence of asthma-like symptoms in adolescents. Int J Chron Obstruct PulmonDis2007;2:65-9. • Arruda LK, Sole D, Baena-Cagnani CE, Naspitz CK. Risk factors for asthma and atopy. CurrOpin Allergy ClinImmunol2005;5:153-9. • Baena-Cagnani CE, Gomez RM, Baena-Cagnani R, Canonica GW. Impact of environmental tobacco smoke and active tobacco smoking on the development and outcomes of asthma and rhinitis. CurrOpin Allergy ClinImmunol2009;9:136-40. • Atkinson, Anderson, Sunyer, et al. Acute effects of particulate air pollution on respiratory admissions: results from APHEA 2 project. Air Pollution and Health: a European Approach. Am J RespirCrit Care Med 2001;164:1860-6. • Rayens MK, Burkhart PV, Zhang M, Lee S, Moser DK, Mannino D, Hahn EJ. Reduction in asthma-related emergency department visits after implementation of a smoke-free law. J Allergy ClinImmunol.2008;122:537-41. • Plaschke PP, Janson C, Norrman E, et al. Onsetandremissionofallergicrhinitis and asthma and the relationship with atopic sensitization and smoking. Am J RespirCrit Care Med 2000; 162:920–924. • Genuneit J, Weinmayr G, Radon K, et al. Smoking and the incidence of asthma during adolescence: results of a large cohort study in Germany. Thorax 2006; 61:572–578. • Gilliland FD, Islam T, Berhane K, et al. Regular smoking andasthmaincidencein adolescents. Am J RespirCrit Care Med 2006; 174:1094–1100.