• Tae Yoon Lee, David Price, Chandra Prakash Yadav, Rupsa Roy, Laura Huey Mien Lim, Eileen Wang, Michael E Wechsler, David J Jackson, John Busby, Liam G Heaney, Paul E Pfeffer, Bassam Mahboub, Diahn-Warng Perng Steve, Borja G Cosio, Luis Perez-de-Llano, Riyad Al-Lehebi, Désirée Larenas-Linnemann, Mona Al-Ahmad, Chin Kook Rhee, Takashi Iwanaga, Enrico Heffler, Giorgio Walter Canonica, Richard Costello, Nikolaos G Papadopoulos, Andriana I Papaioannou, Celeste M Porsbjerg, Carlos A Torres-Duque, George C Christoff, Todor A Popov, Mark Hew, Matthew Peters, Peter G Gibson, Jorge Maspero, Celine Bergeron, Saraid Cerda, Elvia Angelica Contreras-Contreras, Wenjia Chen, and Mohsen Sadatsafavi.
• Saw Swee Hock School of Public Health, National University of Singapore, Singapore; Respiratory Evaluation Sciences Program, Faculty of Pharmaceutical Sciences, University of British Columbia, Canada.
• Chest. 2024 Jul 1; 166 (1): 283828-38.

BackgroundExacerbation frequency strongly influences treatment choices in patients with severe asthma.Research QuestionWhat is the extent of the variability of exacerbation rate across countries and its implications in disease management?Study Design And MethodsWe retrieved data from the International Severe Asthma Registry, an international observational cohort of patients with a clinical diagnosis of severe asthma. We identified patients aged ≥ 18 years who did not initiate any biologics prior to baseline visit. A severe exacerbation was defined as the use of oral corticosteroids for ≥ 3 days or asthma-related hospitalization/ED visit. A series of negative binomial models were applied to estimate country-specific severe exacerbation rates during 365 days of follow-up, starting from a naive model with country as the only variable to an adjusted model with country as a random-effect term and patient and disease characteristics as independent variables.ResultsThe final sample included 7,510 patients from 17 countries (56% from the United States), contributing to 1,939 severe exacerbations (0.27/person-year). There was large between-country variation in observed severe exacerbation rate (minimum, 0.04 [Argentina]; maximum, 0.88 [Saudi Arabia]; interquartile range, 0.13-0.54), which remained substantial after adjusting for patient characteristics and sampling variability (interquartile range, 0.16-0.39).InterpretationIndividuals with similar patient characteristics but coming from different jurisdictions have varied severe exacerbation risks, even after controlling for patient and disease characteristics. This suggests unknown patient factors or system-level variations at play. Disease management guidelines should recognize such between-country variability. Risk prediction models that are calibrated for each jurisdiction will be needed to optimize treatment strategies.Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.

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