Asthma control, self-management and healthcare access during the COVID-19 pandemic in Beijing
Chun Chang a* M.D., Linlin Zhanga*B.S., Fawu Dong a* B.S., Ying Liang a M.D., Yahong Chen a M.D., Ying Shang a B.S., Mairipaiti Abulikemua B.S., Yongchang Suna# M.D.
aDepartment of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, China.
#, Corresponding to Yongchang Sun:
Department of Respiratory and Critical Care Medicine, Peking University Third Hospital, Beijing, China.
North Garden Rd. 49.
Haidian District, Beijing, 100191, China
Tel: +86 010 139 1097 9132
Fax +86 108 226 6989
E-mail: suny@bjmu.edu.cn
* Chun Chang, Linlin Zhang and Fawu Dong contribute equally to this work;

Abstract

Background Social distancing and restriction measures during the Coronavirus Disease-19 (COVID-19) pandemic may have impacts on asthma control and management in terms of medication availability and healthcare access. We aimed to understand the status of asthma control, exacerbations, self-management and healthcare utilization during the COVID-19 pandemic in Beijing, China.
Methods Patients with asthma, selected randomly from our hospital database, were interviewed by phone call. During the interview, sociodemographic information and clinical data, including status of asthma control, asthma exacerbation, self-management and medication before and during the COVID-19 pandemic (From January 25, 2020 to April 25, 2020), were collected.
Results We contacted 286 patients, of whom 178 (62.2%) responded with valid results. Before the COVID-19 pandemic, 4.5% (8/178) and 6.7% (12/178) of the patients, respectively, had been hospitalized and visited emergency departments due to asthma exacerbations. 20.3% (36/177) of the patients had regularly visited the hospital for follow-up and prescription, and 66.7% (118/177) had received maintenance medication. During the COVID-19 pandemic, the majority (92.1%, 164/178) of the patients felt that their symptoms were similar or improved compared with usual times. The mean asthma control test (ACT) score of the patients was 22.76 ± 3.06 (ranging from 8 to 25). 24.7% (44/178) of patients sought medical care for asthma. 25.6% (45/176) of the patients ever experienced aggravation of asthma symptoms, but mostly managed by themselves. It was also notable that 13.5% (24/178) of the patients had worried about potential shortage of medications and some reduced dosing.
Conclusion During the COVID-19 pandemic, most of the patients interviewed reported controlled asthma and compliance with usual care. Although a quarter of the patients experienced asthma exacerbations, only a few needed emergency visit or hospitalization. It is important for patients to continue taking their prescribed asthma medications as usual and maintain good asthma control during the ongoing pandemic.
Keywords: COVID-19 pandemic; asthma control; asthma medication, self-management, healthcare access

Introduction

The pandemic of COVID-19, caused by the pathogen respiratory syndrome coronavirus (SARS-CoV-2), has now spread around the globe with over 4.0 million individuals affected and over 270,000 deaths internationally. As of May 10, 2020, 84431 cases have been diagnosed and 4643 died in China1, 2. Chronic health conditions such as diabetes, hypertension and heart diseases are major risk factors for developing more severe symptoms of COVID-193.
Asthma is a common chronic airway disease worldwide, affecting 1–18% of the populations of different countries1. A large comprehensive asthma survey in a nationally representative sample of Chinese adults indicated that asthma is a major public health challenge in China that affects 45.7 million adults aged 20 years or older4. Published data from China noted that asthma was not a strong risk factor for severe COVID-19 disease5-8. However, recently, a report from the CDC in the US indicated that adults hospitalized with COVID-19 had a higher rate of a history of asthma (12.9%) than the general population (10%)9.
International societies responded quickly by releasing guidelines/guidance on the management of asthma during the COVID-19 pandemic1, 10, 11, and the recommendation that patients with asthma should remain on their current asthma medications is supported by multiple international organizations, including the Centers for Disease Control and Prevention11, the Global Initiative for Asthma1, and the North American consensus guideline on allergy care during the COVID-19 pandemic12. However, these temporary guidelines were based largely on previous asthma guidelines and expert consensus, because evidence from related studies was lacking.
During the COVID-19 pandemic, governments have implemented restrictions, even city lockdown, to contain transmission of the disease. In Beijing, from late January 2020, the government advised citizens to stay home and keep social distancing. These measures could compound asthma medication or healthcare access, and even negatively impact asthma control and management. However, there has been no study on the real impact of COVID-19 on asthma. Therefore, we conducted a survey of asthma control, medication, self-management and health resource use during the COVID-19 pandemic in Beijing.

Methods

Study design

This was a single-center, retrospective, cross-sectional survey by telephone call performed in Peking University Third Hospital. Patients were selected for interview by the following inclusion criteria: (1) 18 years of age or older; (2) a history of at least 3 months of diagnosed asthma according to GINA guidelines [GINA, 2016]. During the phone interview, sociodemographic information and clinical data, including the status of asthma control, exacerbation, medication, self-management plan, and the patients’ perceptions of overall asthma control before and during the COVID-19 pandemic (From January 25, 2020 to April 25, 2020) were collected.
The study protocol was approved by the Independent Ethics Committee of the Peking University Third Hospital. (IRB00006761-M2020189)

Telephone interview and data collection

The study was performed via a telephone interview that was communicated in plain language and designed to assess the status of asthma control, exacerbation, self-management, hospital visits, medication availability and the patients’ perceptions of asthma control before and during the COVID-19 pandemic. The interviewing physician would explain the aim and significance of this investigation, the amount of time required, and the confidentiality and user-permissions for the collection of data. Upon getting approval from the patients, the interviewer carried on asking the questions from a questionnaire, which covered the following items.
Demographics
Demographic variables assessed included time of the survey (month/day/year), sex (male vs. female), age, ethnicity, permanent residence, employment (currently working, retired, unemployed vs. other), professions, education, medical insurances, and smoking status.
Asthma control, self-management and medication before the COVID-19 pandemic
Questions concerning asthma control, self-management and medication before the COVID-19 pandemic were asked, including, (1) history of asthma, status of asthma control, hospitalization or emergency department (ED) visits due to asthma exacerbation in the previous year before the COVID-19 pandemic;(2) asthma management: written asthma action plans, peak flow monitoring, attendance to asthma education program, online consultation, regular follow-up; (3) asthma medications: medications used and compliance.
Asthma control, self-management, medication and healthcare utilization during the COVID-19 pandemic
For evaluation of asthma control, self-management, compliance and health resource utilization in the previous 3 months during the COVID-19 pandemic, we asked the following questions: (1) Asthma Control Test (ACT) scores, by which the control level of asthma was classified into well-controlled (20-25), not well-controlled (16-19) and very poorly controlled (5-15) (1). (2)Asthma exacerbations, hospital or ED visits due to asthma exacerbation; (3) Self-management, disease monitoring, rescue drug use; (4) Asthma medications: compliance in maintenance therapy, maintenance medication, prescription refill, follow-up visits to doctors.

Quality control

Prior to the investigation, the physicians involved were required to attend a centralized training session. Any identifier to an individual patient, such as identification number and full name, was not collected. All data were inputted into a programmed database by two people independently for statistical analysis.

Statistical analysis

Statistical analyses were performed using SPSS Statistics 24(The IBM, Chicago, USA). The mean (SD) was used for continuous variables, and frequency distribution, constituent ratios and percentages were used for categorical variable/binary data. Our analyses used all participants for whom the variables of interest were available. We did not impute missing data.

Results

Demographic and clinical characteristics of study participants

We made telephone calls to 286 patients, of whom 178 (62.2%) accepted the interview and responded with valid results, while108 (37.8%) refused. The mean age of the 178 patients was 49.74 ± 17.06 (ranging from 20 to 92) years, with a median duration of disease of 4.00 (ranging from 0.5 to 62) years. There were 100 women (56.2%) and 78 men (43.8%). The majority of them (90.8%) lived in urban Beijing. 11.0% (19/172) of the patients were current smokers and 7.6% (13/172) were former smokers, with an amount of smoking of 21.03 ± 16.76 (ranging from 4 to 57) pack-years. 54.0% (88/163) were employed, and 88.8% (150/169) had medical insurance coverage, including Free Medical Service, Urban Resident Basic Medical Insurance (URBMI)/Urban Employee Basic Medical Insurance (UEBMI), Medical Insurance in Different Places and New Rural Cooperative Medical System (NCMS). The demographic and socioeconomic data are summarized in Table 1.
Table 1. Demographic and socioeconomic data.