Longitudinal trends in asthma mortality and uncontrolled asthma, and predictors for asthma-related deaths in children living in England

Supervisors

• Dr David Lo
• Dr Clare Gillies
• Professor Jennifer Quint (Imperial College London)

Project description

The 2014 National Review of Asthma Deaths (NRAD) (1) reported the detailed findings from a review of 195 asthma deaths (28 children and young people ≤ 19 years old) occurring in the UK between February 2012 and January 2013. Overall, asthma care was only deemed to be satisfactory in 16% of those who died, with potentially preventable factors identified in almost two-thirds of the cases reviewed. 
The NRAD report made 19 key recommendations for change, relating to organisation of services, medical and professional care, prescribing and medicines use, patient factors and perception of risk. 

Despite this, asthma related death rates in the UK have continued to rise.  Recent press attention has focused on how death rates from asthma in the UK compare unfavourably to the rest of Europe, with the UK reporting the worst mortality rate in people aged 10–24 years, and the second highest among 15–19 years olds amongst European countries in 2016 (2). 

Perhaps more concerning still, is that a recent independent report by the Healthcare safety investigation branch in England, found that only one of the 19 recommendations made by NRAD has been implemented nationally to date – establishment of the National Asthma and COPD (chronic obstructive pulmonary disease) audit programme. However, we do not know if healthcare professionals have implemented any of the recommendations from NRAD into their own personal practice independently. 

Moreover, we also do not know what impact poverty and ethnicity have on asthma outcomes in the UK setting. This has been highlighted as a research priority in the 2019 British Thoracic Society and Scottish Intercollegiate Guidelines Network Asthma Management guidance.

The purpose of this PhD project is to report the trends in asthma deaths and prevalence of uncontrolled asthma in the community in children over the past 10 years, describe the quality of asthma care benchmarked against recommendations made within the NRAD report, identify risk factors associated with asthma related deaths, and to explore whether there is any evidence of inequalities in care between children from different social and ethnic backgrounds. 

AIMS 

1 – Describe the longitudinal trends in Paediatric asthma deaths and prevalence of uncontrolled asthma over the past 10 years in England stratified by socioeconomic and ethnic groups
2 – Describe and compare the care delivered to Paediatric patients with asthma and those who have died from asthma since 2012 with the findings and recommendations from the National Review of Asthma Deaths
3 – Identify risk factors for asthma-related deaths in children using routinely collected primary care data

METHODOLOGY

1. Systematic Review

Firstly, the student will conduct a systematic review to identify individual potential risk factors reported from previous studies for asthma related morbidity and mortality in children. 

These will inform the variables to be inputted into statistical models built to identify risk factors for asthma related deaths and morbidity using routinely collected general practice and hospital level data.

2. Epidemiological Study using Routine Health Care Data

Using data from the Clinical Practice Research Datalink (CPRD) linked to hospital episodes statistics (HES), Office of National Statistics (ONS) mortality data, and the index of multiple deprivation (IMD), the student will describe the longitudinal trends in incidence of childhood asthma deaths and prevalence of uncontrolled asthma in children living in England over the past 10 years, explore whether there are observable differences between children from different ethnic and socioeconomic backgrounds, and use statistical techniques to identify risk factors for adverse outcomes in children with asthma. 

The student will be embedded within a team of experts in clinical paediatric respiratory medicine, epidemiology, and statistics, and receive training in a broad range of statistical methods used to investigate cross-sectional and longitudinal real-world data. The student will be based within the department of respiratory sciences, but will have close links with the Leicester Real World Evidence Unit with access to linked primary care data through the Clinical Practice Research Datalink (CPRD) dataset. The project objectives will be addressed by using a diversity of epidemiological and statistical methods, and aligns to the aspirations of the NIHR Leicester BRC, consolidating collaboration across the respiratory theme with data innovation and ethnic health. 

References: 

1. RCP. Why Asthma Still Kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry Report. London: Royal College of Physicians; 2014.
2. Shah R., Hagell A., Cheung R. International comparisons of health and wellbeing in adolescence and early adulthood. Nuffield Trust 2019.