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(Chest. 2005;128:78-84.)
© 2005 American College of Chest Physicians

Control of Asthma Under Specialist Care*

Is It Achieved?

Mina Gaga, MD; Niki Papageorgiou, MD; Eleftherios Zervas, MD; Dimitris Gioulekas, MD and Stavros Konstantopoulos, MD

* From the Respiratory Medicine Department (Drs. Gaga and Zervas), Athens University, Athens; Fifth Respiratory Department (Dr. Papageorgiou), Sotiria Hospital, Athens; Respiratory Medicine Department (Dr. Gioulekas), University of Thessaloniki, Thessaloniki; and Respiratory Medicine Department (Dr. Konstantopoulos), University of Ioannina, Ioannina, Greece.

Correspondence to: Mina Gaga, MD, Respiratory Medicine Department, Athens University, Sotiria Hospital, 152 Mesogion Ave, Athens 11527, Greece; e-mail: mgaga{at}med.uoa.gr


   Abstract
TOP
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Background: The goal of asthma treatment is control of asthma and good quality of life for asthmatic patients; however, many asthmatic patients experience symptoms and limitations.

Study objectives: To examine treatment outcome in asthmatic patients under specialist care.

Design: Multicenter, cross-sectional study.

Setting: Four large outpatient asthma clinics in teaching hospitals in three Greek cities.

Patients: Three hundred seventy-eight randomly selected patients with mild or moderate asthma (265 female patients; mean age, 42.3 years).

Interventions: None.

Measurements and results: Patients completed a questionnaire structured with eight domains covering patient characteristics, drug use at baseline and during exacerbations, regular follow-up, emergency visits, asthma control, symptoms, and limitations. Results show that the majority of patients have symptoms and limitations in their physical and social activities and have frequent exacerbations, while > 40% of patients think that their asthma is not well controlled. Most of our patients receive preventive medication (primarily inhaled corticosteroids, but less so long-acting ß2-agonists [LABAs] and leukotriene antagonists), increase their use of medication in case of exacerbations and have regular follow-up. However, the report shows that 48% of patients tried to reduce their medication dose, a fact implying that compliance is not always good.

Conclusions: These data indicate that the goals of asthma treatment are not achieved, even under specialist care. Perhaps more effort should be invested in patient education while an increase in the use of LABAs and leukotriene antagonists, medications that have been shown to prevent exercise-induced bronchoconstriction and improve quality of life, may help better asthma outcomes.

Key Words: asthma • clinical characteristics • control • exacerbations • medication • symptoms


   Introduction
TOP
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 
Asthma is a chronic and common disease that affects not only health but also the quality of life of asthmatic patients. In order to combat the problem of asthma, global guidelines1 have been published to promote standardized methods for the diagnosis and treatment of the disease. These guidelines have been disseminated widely, and there are reports showing that doctors are aware of the recommendations2 and that the quality of life of mild asthmatics is similar to that of the general population.3 However, studies24 also show that although doctors accept the guidelines, their patients are not always treated accordingly, and a multinational survey5 shows that the life of asthma patient is affected by the disease to a great extent. This is supported by a number of studies6789 of patients’ perception of the disease and the handicaps that asthma and asthma medications impose on the lifestyle of these patients. These studies are important because they help define the problem of asthma from the patients’ point of view, allow better understanding, and lead to better treatment of the disease.

Greece is a country with a rather low prevalence of asthma,10 but nevertheless it is estimated that > 500,000 people have the disease. Greek guidelines for asthma treatment were published in Greece in 199411 and were distributed to respiratory physicians by the Hellenic Thoracic Society. The first Global Initiative for Asthma (GINA) guidelines were translated into Greek in 199712 and have been widely disseminated, while the most recent update before the study was translated, published, and disseminated in 2003.13 Furthermore, the Greek National Health System (NHS) is structured in such a way that all patients have easy access to specialist care and all medication classes are available through the NHS and are 90 to 100% refunded. Most of the patients living in urban areas are attended by respiratory physicians either in the outpatient clinics of NHS hospitals or of I.K.A., the national insurance organization.

The aim of our study was to examine the treatment outcome, ie, whether control of asthma is achieved in asthmatic patients in urban areas in Greece, where most patients are treated by respiratory specialists. This report presents data on symptoms, limitations, medication, and overall control of asthma in patients receiving specialist care.


   Materials and Methods
TOP
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Subjects
Asthmatic patients who participated in the study were a random sample of patients who presented to asthma clinics of four Respiratory Medicine Departments in three large cities in Greece: Athens, Thessaloniki, and Ioannina. The majority of patients reviewed in these clinics come from within and around the above cities where 70% of the Greek population lives, while approximately 10% of the outpatients come from other areas in Greece. All patients (n = 437) who presented to these clinics on randomly selected days for a period of 3 months were asked to complete the questionnaire described below. Inclusion criteria were a diagnosis of asthma by a physician based on history and lung function testing, and a history of asthma prescriptions. All patients had an increase in FEV1 of > 12% (and > 200 mL) after bronchodilation and/or a positive methacholine challenge result, either on the study day or recorded in their medical files. Furthermore, data on prescribed medication and dosing as well as asthma severity classification according to the GINA guidelines were noted from the files and are presented in Table 1 . Spirometry was performed using appropriate equipment (Benchmark Pulmonary Function Testing; P.K. Morgan Ltd; Chatham, UK; Fukuda ST300; Fukuda Sangyo; Chiba, Japan; Spirotrac IV; Vitalograph; Buckingham, UK; or Jaeger Masterscreen; Jaeger, Würzburg, Germany). The spirometers and the procedure for spirometry testing fulfilled American Thoracic Society criteria.14 The study was approved by the ethics committees of all hospitals involved, and patients gave informed consent.


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  		Table 1. Clinical Characteristics

 
Questionnaire
The questionnaire used was developed from previously existing, validated, and extensively used questionnaires (American Thoracic Society, European Community Respiratory Health Survey),1516 which have been shown to be valid for the measurement of asthma symptoms17 and were translated and validated in Greek.18 The questionnaire was structured with eight domains of patient characteristics, drug use at baseline and during exacerbations, regular follow-up, type and frequency of symptoms, emergency visits, patient perception of asthma control, and activity limitations.

Interview
The patients were asked to participate in the study and on consent were administered the questionnaire. The questionnaires were completed anonymously. If there were doubts about the questions, there was minimal help with understanding but no interference from the physicians.

Statistical Analysis
Simple descriptive statistics were used to describe the study population. Statistical comparison was done using {chi}2 analysis (with Fisher exact test where indicated by low expected cell count), and correlations were tested using univariate logistic regression, followed by multivariate logistic regression analysis for variables showing significance. Results were given as odds ratios (ORs) with 95% confidence intervals (CIs); p < 0.05 was considered significant. All analyses were performed using software (Sigma-Stat version 3.0; Systat Software GmbH; Erkrath, Germany).


   Results
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Review of the files and analysis of the questionnaires revealed the following results, which are structured in separate paragraphs. Control of asthma was assessed based on the type and frequency of symptoms, activity limitations, emergency visits, and patients’ perception of control.

Demographics
Four hundred thirty-seven adult patients visited the study outpatient departments on the selected days and were asked to complete the questionnaires. Some patients did not consent to participate in the study (n = 59; response rate, 86.5). The most frequent reason for nonconsent was lack of time. Moreover, 12 patients were foreigners with poor command of the language. A total of 378 patients participated in the study. Review of the files showed that 7.4% of the patients were classified as mild-intermittent, 34.7% as mild-persistent, 47.1% as moderate-persistent, and 10.8% as severe asthmatics, according to the GINA criteria.1 Most of them were receiving inhaled corticosteroids (ICSs), and the mean prescribed dose was 663 µg. Clinical characteristics are given in Table 1. The patients were predominantly female (70%), and 59% had asthma for > 5 years, 34% had asthma for > 10 years, and only 7% had asthma < 1 year.

Symptoms
By far, the most common complaint was breathlessness (70% of the patients), while cough was the second most frequent problem in 39.3% of asthmatics. The third most common complaint, reported by 25% of the patients, was a general feeling of being unwell or tired. Although nasal symptoms are quite frequent in asthma, only 5% of the patients reported nasal symptoms as a leading problem.

Frequency of Symptoms
Twenty-nine percent of patients reported breathing difficulties on a daily basis, and a further 32.5% had breathing difficulties at least once a week. Fifty-one percent of patients reported waking up at least once a week, and of these almost 50% reported waking up every night. Cough was present every day in 25% of patients and one to six times a week in a further 27%.

Limitations on Physical and Social Activities
Twenty-three and one-half percent of patients had breathing difficulties daily, when walking on flat road, and another 15.5% reported breathing difficulties at least once a week. Fifty-four percent of patients reported problems when going uphill or up stairs. Sixty percent of patients reported that they always have difficulties when running, and many of them (21%) never attempt to run (Fig 1 ).



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  		Figure 1. Percentage of patients who reported limitations of physical activities because of breathing difficulties on a daily, weekly, monthly, or infrequent basis.

 
Furthermore, when asked whether and how asthma affected their lives, 22% of patients reported that their asthma interfered with daily activities such as housework, shopping, and social activities; 33% complained that they could not exercise and participate in a favorite sport; and 15% reported that asthma interfered with their work. Lastly, only 24.3% of patients replied that they can function as well as their friends, and most of the patients believed that their friends and colleagues who had no respiratory problems could accomplish more than themselves.

Medical Review
Eighty-seven percent of the patients visited the doctor at least once a year, and more than one half of these patients (61.5%) visited their physician at least three times a year. Eighty-seven percent of patients reported that their physicians ask them about daily symptoms and check whether they experience night awakenings (78%) and limitations on their daily activities (73%). Furthermore, 78% of patients reported that their physicians advise them to step-up their medication use in case of an exacerbation. Ninety-one percent reported that their physicians ask them to undergo spirometry and/or chest radiography. The attending physician is a pulmonologist in most cases (78%) and an allergist in 10% of cases. A specialist in internal medicine is also involved in the treatment in 39% of patients, mostly in the form of the insurance organization doctor. (In Greece, a number of patients will only get a refund for medication cost if a doctor employed by their insurance company prescribes the medication). Moreover, for some patients living far away from the cities, a local physician provides medication prescriptions and/or emergency care between visits to the clinic, usually in cooperation with the specialist.

Exacerbations
Thirty-four percent of patients reported an exacerbation requiring an emergency visit to the doctor, or hospitalization in the last 12 months. A slightly higher percentage of patients (40%) reported the use of oral steroids in the past year; of these, more than one half (54%) reported using oral steroids more than three times. Further analysis showed that the percentage of patients reporting an exacerbation is lower (28%) if patients had received appropriate management education information from specialists prior to the asthma exacerbations, and higher (55%) in patients who had not received education. This difference is statistically significant (p < 0.05; OR, 0.7; 95% CI, 0.5 to 0.9).

Use of Medication
Ninety-four percent of the patients received controller treatment daily. In most cases, this treatment included ICSs; thus, 81% of patients received ICSs daily. Furthermore, another 10% of the patients had ICSs prescribed even if they were not currently receiving ICSs. Long-acting ß2-agonists (LABAs) were prescribed for 53% of these patients and are currently used by 42.5% of patients, usually in combination with an ICS. Therefore, the analysis shows that 39% of patients receive both types of medication. Only 5% of the patients received ICSs and LABAs through one device, and a small proportion of our patients (5.5%) received leukotriene antagonists.

Fifty-one percent of patients reported that reliever medications (specifically ß2-agonists) help them most. However, 43.5% of patients found that ICSs are the medications that help them better, while 10% found the combination of ICSs and LABAs preparations more helpful, even when administered separately.

Eighty-nine percent of patients used reliever medications (rapid-acting ß-agonists) for relief when they had symptoms; however, 11% received an ICS as relief medication. Only 36% of the patients always carry their relief inhaler with them, and 17% never do.

It is important to know that 23% of the patients never use their inhaled medication in front of other people and another 20% rarely use it when other people are around. Moreover, 16.1% of the patients always reduce their dosage, and a further 31.7% often try to reduce the dose and actually receive a lower dose than the one prescribed. Finally, 26% of patients constantly worry about medication side effects, and a further 23.3% worry sometimes.

Control of Asthma: Patients’ Perception
Only 10.6% of patients believed that their asthma was totally controlled, and 46.2% believed that their asthma was adequately controlled; 32.1% reported that their asthma was not well controlled, and 11.1% believed that their asthma was uncontrolled. Among patients who reported that their asthma was totally controlled or adequately controlled, 16% and 18%, respectively, reported night awakenings more than once weekly while, among patients who reported totally uncontrolled asthma, 20% wake up less than once a month.

Poor perception of asthma control (inadequate or uncontrolled asthma) was associated with longer duration of asthma (> 5 years; OR, 2.5; 95% CI, 1.6 to 3.9), more frequent symptoms and limitations in physical activities (eg, night awakenings; OR, 2.8; 95% CI, 2.1 to 3.8), breathlessness when going uphill/up stairs (OR, 3.1; 95% CI, 2.0 to 4.8), and more exacerbations (OR, 2.0; 95% CI, 1.3 to 3.0). Using multivariate logistic regression analysis, we found that symptoms and limitations in physical activities were independent risk factors for poor perception of asthma control. Adjusted ORs were 4.7 (95% CI, 2.1 to 10.4) for night awakenings and 4.1 (95% CI, 1.8 to 10.9) for breathlessness when going uphill/stairs.


   Discussion
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
This report shows that the majority of asthma patients receiving specialist care experience symptoms and limitations in their physical and social activities and that > 40% of patients think that their asthma is not well controlled. In our group of patients, 94% received preventive medication, 78% are aware that they should step-up their use of medication in case of an exacerbation, and 91% reported having undergone spirometry and chest radiography. These data indicate that the goals of asthma treatment are not achieved, although it seems that physicians treat asthma according to guidelines. However, 48% of the patients tried to reduce their medication dose, and this fact indicates that compliance is not always good.

This study is not an epidemiologic one on the prevalence of asthma or the impact of the disease in randomly selected asthmatics among the general population. This is a descriptive study on the impact of asthma in the lives of asthmatic patients with current asthma, who in the majority of cases are receiving regular follow-up by a respiratory physician and have easy access to pulmonary medicine services and all antiasthma drug classes. It could be argued that these patients under specialist care represent the moderate and severe spectrum of the disease. However, this is not exactly the case: in outpatient asthma clinics in Greece, any patient with asthma can make an appointment without a referral letter and patients representing every severity group attend these clinics, as is shown in the demographic characteristics of our population. In fact, our patient group included more patients with moderate asthma than the general population, but it also included patients with mild asthma in a percentage reaching 40%. Furthermore, the goals of asthma treatment apply to all patients and should be achieved in patients with moderate asthma and severe asthma, although the later group is difficult to treat.17

Our data are similar to those reported by other studies456789192021; however, in our sample, a larger percentage of patients reported nocturnal awakenings and exacerbations. It must be taken into account that a number of the patients included in this study visited the hospital because of an exacerbation. However, the fact remains that 28% of patients reported exacerbations and the need for oral steroid intake despite regular follow-up, proper education, and reported increase of medication in cases of exacerbation. Indeed, a study22 examining the effect of doubling the dose of ICS during exacerbations demonstrated that this measure was not effective in preventing loss of control. Our study further supports these data and shows that, in a group of patients with mild-to-moderate persistent asthma who are receiving specialist care and who increase their ICS dose in the event of an exacerbation, oral steroid intake is often necessary.

Patient-reported poor asthma control was associated with markers of inadequate control such as more frequent symptoms, night awakenings, and limitations in physical activities. It was also associated with longer duration of asthma. This could imply either worsening of asthma over time or the patients’ frustration by the chronicity of disease. It should also be noted that a number of patients who reported totally controlled asthma also reported frequent nighttime awakenings. These facts stress the importance of using objective measures to assess the effectiveness of asthma treatment in achieving control.

We did not approach doctors to directly examine dissemination of guidelines. However, questioning the patients regarding prescribed medication and general advice given by their physician as well as review of the patients’ files indicate that guidelines are followed and that the vast majority of patients receive ICSs and other medications at a dosage that complies with the GINA guidelines. Nevertheless, although patients are treated according to guidelines and by a specialist, control of asthma is achieved in < 60% of cases. Results reported in the literature are not very different. In large studies,232425 in which patients received either ICSs and LABAs or ICSs only and were followed up for a year, the number of exacerbations was lower and control of asthma was better in the ICS/LABA treatment group; even so, control was achieved in 71%25 of patients and exacerbations were reported, even in the high-dose treatment group.23 As control of asthma is the objective of treatment, it is very important to understand why this is not achieved.

Compliance is probably a very important element of this failure, as a substantial number of patients reported that they try to reduce their medication and particularly their ICS dose. Therefore, although patients receive ICSs and the mean prescribed dose is high, they may in fact be receiving a suboptimal dose. Another reason for this failure may be that LABAs are used in < 50% of the cases, and leukotriene antagonists are used in a small minority of patients. In our study, LABAs are slightly underprescribed, but more importantly are underused by the patients; a possible explanation is that many patients claim that they experience quicker relief with short-acting ß2-agonists and consider them more effective. As both LABAs and leukotriene antagonists have been shown to increase symptom-free days and the ability to exercise and to achieve better asthma control,23242526272829303132 the underuse of these medications in our population may be a reason for control failure. Furthermore, devices with combined medications (ICSs and LABAs) are used scarcely because, at the time this study was conducted, these combined medications were not under the NHS refund policy. Studies2733 have shown that the use of a single device for combined delivery of ICS and LABA results in better asthma control than the use of separate devices.

Another key element for achieving asthma control is patient education. Our analysis shows that although patients are aware of many of the important elements of the guidelines, there are still some issues. Many patients do not carry their relief medication with them, and a few patients inhale ICSs for rapid relief. What is also important is that patients seem to feel handicapped and embarrassed by their asthma; they feel that their friends and relatives can manage more, and they do not wish to take their medication in front of other people. It seems that there is room for better education and a better approach of the patients’ problems, including their psychological support. Cote et al34 showed that a structured and repeated educational program helps compliance and dramatically reduces the number of exacerbations, and our results are in line with these data. Nevertheless, even in the structured education group, 30% of patients were noncompliant and there were still a substantial number of exacerbations.32 The issue of effective education is very important, whether it is patient education or continuing medical education. A Cochrane review33 reported that no effect is derived from "didactic" teaching and that interactive sessions can result in moderately large changes. Furthermore, in order to render doctors and nurses better able to effectively manage and treat patients, the inclusion of strategies for acquiring educational and managerial skills should probably be added in continuing medical education programs.

In conclusion, control of asthma is not achieved in almost 50% of patients receiving specialist care. This is not a desirable result, and every effort should be made to provide a better outcome for our patients. Research into new classes of medication, the best use of combinations of currently available ones to overcome asthma pathology and symptoms, and the constant update of guidelines is clearly very important. Spending more time with the patients to help education, to know the patient, and tailor advice and treatment to his/her individual needs and tastes are probably the means to help us achieve asthma control and good health status.


   Footnotes
 
Abbreviations: CI = confidence interval; GINA = Global Initiative for Asthma; ICS = inhaled corticosteroid; IKA = Idryma Koinonikon Asfaliseon (Social Insurance Organization); LABA = long-acting ß2-agonist; NHS = National Health System; OR = odds ratio

This study was supported by an unconditional grant from Merck Sharp and Dohme-Vianex Sa, Athens, Greece.

Received for publication September 16, 2004. Accepted for publication December 23, 2004.


   References
TOP
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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