Key Barriers to Optimal Management of Adult Asthma in Australia: Physician and Patient Perspectives

By Heiner, Maurice McDonald

Key words: Asthma – Compliance – Inhaled corticosteroids – Safety patient education ABSTRACT

Objective: Despite recent advances in asthma treatment, its management in many patients remains sub-optimal. The aim of the Global Asthma Physicians and Patient (GAPP) survey was to identify barriers to optimal asthma management and to explore the content and dynamics of physician-patient communications. Here we present the key findings for adults with asthma in Australia.

Research design and methods: Patients with asthma aged >/= 18 years and physicians who treat adults (generalists; specialists) participated in telephone interviews conducted in May-June 2005, using close-end questionnaires. The survey examined physicians’ beliefs and prescribing habits; patients’ experiences with asthma; doctor-patient communication; satisfaction with asthma medications and interest In new asthma treatment.

Results: A total of 101 adults with asthma and 100 physicians treating asthma patients in Australia completed the survey. Overall, key barriers to optimal asthma management included medication side effects, treatment compliance and patient education. These barriers may be exacerbated by poor patient-physician communication that fails to address patients concerns regarding side effects and may lead to poor treatment compliance. Both physicians and patients expressed safety concerns regarding the long-term use of inhaled corticosteroid and both groups would welcome new treatment options with improved safety profiles, efficacy and oncedaily dosing.

Conclusion: From both a physician and patient perspective, the safety profile of asthma medication constitutes a key factor in promoting treatment compliance and, ultimately, treatment outcomes. The results highlight discrepancies in perceived patient-physician communication and a need for improved patient education in asthma management.

Introduction

Asthma is one of the most prevalent diseases in Australia and worldwide, and currently affects around 300 million people worldwide and between 10-12% of Australian adults12. Asthma can have a profound impact on both the physical and psychological well-being of an individual by reducing quality of life3 and work productivity4, as well as increasing emergency room visits, hospitalisations and mortality5,6. The prevalence of asthma is rising globally with a subsequent increase in morbidity, mortality and health-care expenditure7.

Since airway inflammation is a key etiologic feature of asthma8 9, targeting inflammation is a critical factor in asthma therapy. The anti-inflammatory agents, inhaled corticosteroids (ICSs), are the most potent and consistently effective long-term control medications for asthma9. Indeed, current asthma treatment guidelines recommend ICSs as first-line therapy in persistent disease of all severities7, with add-on therapy, such as long acting inhaled beta2- agonists (LABA), in moderatesevere disease. The clinical benefits of ICSs in adults with mild-moderate and severe asthma include reduction in symptom severity and the need for rescue medication10- 13, improved lung function10,11 prevention of exacerbations and death 14 and improved quality of Ufe15.

Asthma guidelines can lead to significant benefits in improving disease management. Goals of asthma therapy relate to minimising symptoms, normalizing lung function, eradicating exacerbations and improving quality of life16. However, despite recent advances in asthma treatment, its management in many patients remains sub- optimal and patients are reliant on shortacting beta2-agonist (SABA) rescue medication owing to the under use of ICSs4,5,8. The recent Asthma Insights and Reality (AIR) surveys assessed whether specific goals of asthma management, based on the Global Initiative for Asthma (GINA) guidelines, were being realised4,5. The results indicated that, in many patients worldwide, asthma is sub-optimally controlled, despite the availability of effective therapies, with long-term management falling far short of the goals set in the GINA guidelines4,5.

The AIR studies4 5 raised several issues that warranted further elucidation; namely, the disconnect between patients and physicians regarding side-effects, treatment regimens and patient education concerning the management of their disease. In order to address some of these issues, NYCOMED Pty. Ltd commissioned the Global Asthma Physician and Patient (GAPP) Survey. This large-scale global survey was conducted with both physicians and patients in order to further develop existing research regarding asthma attitudes and treatment practices. The study aimed to enhance understanding and awareness of likely contributors to suboptimal asthma management and to explore the content and dynamics of physician-patient communications. Here we present the GAPP survey results obtained for adults with asthma in Australia.

Patients and methods

Study design

The GAPP survey advisory board was comprised of the following professional organisations and patient advocacy groups: The World Allergy Organization (WAO) and The American College of Allergy, Asthma and Immunology (ACAAI). NYCOMED Pty. Ltd commissioned Harris Interactive, Rochester, New York, to conduct a 16-country survey among physicians, adults diagnosed with asthma and parents of children with asthma, on behalf of the GAPP Survey global advisory board. The 16 countries participating were South Africa, Japan, Australia, Belgium, France, Germany, Ireland, Italy, The Netherlands, Poland, Spain, Switzerland, the United Kingdom, Brazil, Canada and the United States of America. Each country in the global study aimed to recruit about 1 00 patients and 1 00 physicians; for the US this was 200 in each category.

The target sample size globally, and in Australia, was reached.

For the Australian adult survey, telephone interviews were conducted from 18 May to 21 June 2005 using close-ended questionnaires and took an average of 20 minutes to complete. The survey examined the following themes: (1) physicians’ beliefs and prescribing habits; (2) patients’ experiences with asthma; (3) doctor-patient communication; (4) satisfaction with asthma medications (both physician and patient); and (5) interest in new asthma treatment (both physician and patient).

Participants

Two groups of respondents participated in the adult survey: (1) patients aged >/= 18 years, diagnosed with asthma, who were recruited and screened via physician referrals and existing sample lists that included details of 2000 patients; and (2) physicians who treat adults with asthma (generalists [general practitioners] and specialists [including allergists and respirologists]) who were recruited and screened from existing national databases. These national databases included details of 5000 general practitioners (about 90% of Australian GPs) and 500 specialists. Qualifying criteria for physicians included currently practicing medicine for 3- 30 years, seeing Pounds 3 adult patients with asthma per week and writing Pounds 1 prescription for asthma medications per week. This methodology represents patients that are representative of the Australian population and physicians treating patients with asthma. State quotas were implemented to approximately match populations in each state.

Results

Overall, a total of 1726 patients with asthma aged S 18 years and 1733 physicians (916 generalists and 817 specialists) who treated adults with asthma participated in the adult global study. Key data from the global adult patient and physician survey are available at http://www.gappsurvey.org17.

Patient demographics and characteristics of Australian survey participants

For the Australian adult survey, 101 patients with asthma aged >/ = 18 years and 100 physicians who treat adults (50 generalists [general practitioners] and 50 specialists [including allergists and respirologists]) participated in the survey. Questionnaires were completed for physicians and patients during a telephone interview.

Patients’ age, gender, disease duration and selfreported severity of disease are shown in Table 1 . Slightly more females participated in the survey and the average age of patients was 41 years; the majority of patients considered themselves to have mild-moderate disease (Table 1). The majority of physicians were male (76%), with a mean total of 19.4 years in clinical practice. Fifty per cent of physicians were general practitioners, 43% were respirologists and 7% were allergists. The majority of physicians (59%) were located in urban settings and almost half (49%) treated more than 100 patients per week. Twenty-eight per cent of physicians saw between 61 and 100 patients per week, while 17% saw 31-60 and 6% saw between one and 30 patients per week. The mean number of adult asthma patients seen per week was 18.2 with a mean number of 17.7 adult asthma prescriptions written per week.

Current asthma treatment patterns

Physicians’ perspective

The majority (98%) of physicians agreed with the statement that reducing inflammation decreases bronchoconstriction, and 92% of physicians agreed that ICSs are the ‘gold-standard’ treatment for asthma. Physicians’ first-line choice of therapy for mild persistent asthma was ICS monotherapy (Figure 1A); and for both moderate and severe persistent asthma, the treatment of choice was ICS in combination with LABA (Figures 1B and 1C). Regarding current overall asthma treatment options, out of a maximum score of 10 (extremely satisfied), physicians expressed the most satisfaction with ICS + LABA (mean score 8.6), followed by LABA (mean score 7.4), SABA (mean score 7.2) and ICSs (mean score 6.6) as monotherapy. With regard to the key attributes of ICSs, physicians were most satisfied with their efficacy (mean score 8.4), their availability in combination with LABA (mean score 8.3), frequency of dosing and convenience (means scores 7.8 each). Local and systemic First-line medication prescribed by all responding physicians for (A) mild, (B) moderate or (C) severe persistent asthma. All physicians were asked ‘Which medication or medications do you prescribe as firstline treatment for mild (A), moderate (B) or severe (C) persistent asthma?’ Table 1. Patient demographics and characteristics of Australian survey participants

Figure 1. First-line medication prescribed by responding physicians for persistent asthma

side effects were considered the least satisfactory attributes (mean scores 5.7 and 6.4, respectively).

Patients’ perspective

The majority of patients (79%) stated that their asthma limits their daily activity, with 31% and 7% reporting moderate or severe limitations, respectively; only 21% of patients with asthma did not consider their condition to affect their daily activities at all. Ninety-five per cent of asthma patients in the Australian survey are currently taking, or have previously taken, asthma medication. Of those currently taking medication to treat asthma, combination therapy (ICS + LABA) is most commonly taken (421Xi), followed by ICS monotherapy (19%) and LABA monotherapy [9%); anticholinergics represent the next largest class of agents used (7%). For existing asthma therapies, the percentage of patients reporting satisfaction with key attributes was highest for efficacy (97%), ease of use (93%), rapid onset of action (91%) and dosing convenience (88%). The potential for side effects and safety were considered the least satisfactory attributes of existing therapy (69% and 83%, respectively); although these values still represent a 'high' level of satisfaction. For those patients who have ever used asthma medication, safety concerns represent one of the key reasons for patients switching asthma medications; while 34% of patients have switched medication because their symptoms abated, many patients have switched medications owing to the actual occurrence of (22%) or fear of potential (14%) side effects. Other reasons patients switched asthma medications included the inconvenience (7%) and expense (6%) associated with a particular medication. Regarding the potential for side-effects of ICSs, patients are most concerned about long-term side effects, while physicians expressed more concern for short-term side effects (Figure 2 A and 2B).

(A) Patient concern regarding inhaled corticosteroid-related side effects. Patient population: all respondents. On a scale of 1-10 where 'I' means 'not at all concerned' and '10' means 'extremely concerned', how concerned have you been with the following potential side effects or, were you not previously aware of these as potential side effects? (B) Physician concern regarding inhaled corticosteroid- related side effects. Physician population: all respondents. On a scale of 1-10 where 'I' means 'not at all concerned' and '10' means 'extremely concerned', how concerned are you with each of the following potential side effects of inhaled corticosteroids?

Impact of side effects, compliance and health outcomes

Of the 95% of patients currently taking, or previously taken asthma medication, almost a quarter (24%) who take ICS medication report having experienced short-term side effects, such as oral thrush, pharyngitis or hoarseness, while 21% reported long-term side effects, such as osteoporosis, cataracts or glaucoma; 4% of patients said they had experienced decreased Cortisol production. In contrast, the incidence of ICS-associated adverse events was much higher when reported by physicians, who prescribe ICS medication; 97%, 65% and 19% of physicians said their patients had experienced short- and long-term side effects and decreased Cortisol production, respectively. In the 95% of patients currently taking, or who had previously taken asthma medication, and who had experienced at least one side effect with asthma medication, 45% had changed their dosage and at least a quarter of patients considered switching (34%) or actually switched (28%) their medication as a result of the occurrence of side effects. Similarly, at least a quarter of patients have considered skipping (25%) or have actually skipped (26%) doses, while 19% of patients had considered ceasing or have actually ceased (16%) taking their medication.

Regarding treatment-compliance, only 50% of patients report being 1 00% compliant with their asthma medication, but only 1% of physicians consider their patients to be 100% treatment-compliant. The reasons leading to non-compliance with asthma medications are shown in Table 2. Both physicians and patients regard symptom cessation, forgetfulness and concerns regarding medication- dependency and potential side effects as key reasons for patient non- compliance with their treatment regimen (Table 2).

For those patients who do not take their medication as instructed, the majority (91%) have experienced worsening asthma symptoms (Table 3). Patients also report limited physical activity, increased nocturnal awakenings and an increased requirement for rescue medication as a consequence of treatment noncompliance.

Patient-physician communication and patient education

Regarding the potential for side effects, physicians prescribing ICS therapy think their patients are more aware of the side effects associated with ICS therapy than they actually are. These physicians believe that the majority (92%) of their patients are aware of the long-term sides effects associated with ICS therapy, while only half of all patients (51%) reported being aware of these long-term effects. A similar discrepancy was observed regarding the potential for short-term side effects - 98% of physicians believe that their patients are aware of the short-term side effects associated with ICS, while only 69% of patients expressed any knowledge of these effects.

Table 2. Reasons cited for patients' non-compliance with currently avaihble asthma medication treatment regimen

A discrepancy exists between physicians and patients regarding the reported frequency of discussions relating to side effects. More than 50% of all patients reported never discussing the short-term (52%) or long-term (59%) side effects of their medication with their physicians. In contrast, the majority (> 80%) of physicians state they sometimes or always discuss side effects with their patients; no physicians reported never discussing short-term side effects with their patients, while 2% acknowledged they never discussed longterm side effects. Over two-thirds (71%) of physicians said they always discussed short-term side effects with their patients, and 3 1 % stated they always discussed long-term side effects associated with ICS therapy.

New treatment options

The majority of adult asthma patients (87%) and physicians (84%) in the Australia arm of the global survey believe there is a need for new asthma medications. Both physicians and patients regard a reduction in long-term and short-term side effects, efficacy and once-daily dosing to be key attributes of new, improved ICS therapies (Table 4). The majority of all physicians (85%) would be likely to prescribe a new ICS with an improved safety profile; 54% reported they would be 'somewhat likely' and 31% said they would be 'very likely' to prescribe a high dose of a new ICS with an improved safety and tolerability profile, instead of combination treatment, to their patients with moderate asthma.

Table 3. Consequences of non-compliance with treatment medication

Table 4. Mean importance of specific attributes of new inhaled corticosteroids

Discussion

Current asthma treatment guidelines recommend ICSs as first-line therapy in persistent disease of all severities7, with add-on therapy, such as LABA, in moderate-severe disease. Inhaled corticosteroids are widely recognised as the most potent and consistently effective longterm control medications for asthma9. Our findings corroborate this with more than 90% of physicians in the survey regarding ICSs as 'gold-standard' treatment for asthma and ICSs most frequently prescribed as first-line treatment for persistent asthma either as monotherapy (mild asthma) or in combination with LABAs (moderate-severe asthma).

Despite recent advances in asthma treatment, its management in many patients remains sub-optimal with patients reliant on rescue medication owing to die under use of ICSs4,5,8. Side effects and fear of side effects can result in patients discontinuing treatment which, in turn, can lead to a deterioration in asthma control18. Among factors that account for the under use of ICSs are concerns regarding systemic side effects at high doses18. Inhaled corticosteroids exhibit dose-related systemic adverse effects, including hypothalamic-pituitaryadrenal (HPA) axis suppression and reduced bone density19, as well as local oropharyngeal side effects such as oral candidiasis20. In accordance with this, our survey findings demonstrate that nearly a quarter of asthma patients who take ICS medication experience shortor long-term side effects. Moreover, it appears that, in reality, die incidence of side effects widi ICS medication is much higher than patients realise; according to physicians, 97% of patients have experienced a shortterm side effect and two diirds (65%) have experienced long-term adverse effects widi ICS medication.

Our findings indicate that, consistent with previous reports18, concerns regarding the potential for side effects with current asthma medication represent a key factor in treatment non- compliance. Furthermore, the majority (> 90%) of non-compliant patients report a worsening of asthma symptoms, some of which include severe or life-threatening asthma attacks. Adequate patient- physician communication regarding asthma medications is a key factor in promoting treatment compliance21 and, ultimately, optimising treatment outcomes18. Our findings highlight a discord between patient-physician communications. For example, patients are far less aware of potential side effects than physicians realise and patients are unlikely to be aware they have even experienced an adverse event. Moreover, perceptions of in-clinic patient education vary between physicians and patients, with 50% of patients reporting they never discuss side-effects with physicians compared with the majority (> 80%) of physicians stating that they regularly discuss potential treatment side-effects. These findings corroborate those from a previous survey, in which two-thirds of asthma patients had never discussed their concerns about ICSs with their health care provider18.

This survey also reveals patient-physician communication gaps regarding compliance; only 1 % of physicians believe their patients are 100% compliant with their medication. Together, our findings highlight a pressing need for clearer channels of communication and improved asthma education between patients and their healthcare providers as recently highlighted in the AIR survey4. Furthermore, pulmologists agree that many patients need convincing about the benefits of ICS therapy, including efficacy and convenience, and that patients were concerned about side effects, particularly long- term effects8.

The degree to which asthma patients will comply with their treatment regimen is influenced by several factors; as well as the safety profile of the drug, frequency of dosing is also important22. Therefore, therapies that address the potential for poor compliance and are effective and well-tolerated could improve the prognosis for long-term treatment of patients with asthma23. As demonstrated in the survey findings, both physicians and patients believe there is room for improvement in existing asthma therapy.

It has been proposed that the ideal ICS would provide effective asthma control via a convenient dosing regimen, with optimal pharmacological properties which would minimise oral and systemic exposure, while providing an optimal safety and efficacy profile6. An ideal ICS would also only be active within the lung and exhibit low systemic exposure, thus limiting systemic adverse effects24.

Second generation ICS, such as ciclesonide and mometasone furoate, have been specifically designed to reduce systemic absorption and, therefore, reduce adverse effects. These newer ICSs have comparable efficacy profiles to first generation ICSs25-28 but offer improved safety profiles613,2729"31. However, despite the improved safety profiles of newer ICSs, long-term ICS therapy continues to be associated with dosedependent adrenal suppression, particularly with more potent compounds such as fluticasone propionate30, high doses (> 800 [mu]g/day) of which have been associated with adrenal suppression30,32. In addition, although the recently FDA-approved mometasone furoate is associated with less HPA axis suppression at low doses (400 [mu]g/day) compared with beclomethasone dipropionate28, adrenal suppression at higher doses (800 and 1600 [mu]g/day) has been reported33,34. Further studies are needed to fully elucidate the effects of these second generation ICSs on adrenal function.

To the best of our knowledge, the GAPP survey was the first-ever global quantitative survey to examine identical themes in patients and physicians, with similar questions posed to both patients and physicians. Overall, our findings demonstrate that in adult patients with asthma, and physicians in the Australian arm of the global survey, key barriers to optimal management exist; these include medication side effects, treatment compliance and patient education. These outcomes are similar to the global survey findings17 and corroborate those reported in the AIR surveys which demonstrated that the current long-term management of asthma falls far short of the goals established by GINA4, 5. These findings also highlight discords in patient-physician communication, which are comparable to global survey findings17, and it has been suggested that improvements in physician-patient communication would improve understanding of asthma management, compliance and, ultimately, treatment outcomes818. Despite ICSs’ demonstrated efficacy and widely accepted role as first-line therapy for persistent asthma, both physicians and patients harbour reservations regarding the safety implications of their long-term use. Compared with global findings patients with asthma in the Australian arm of the survey were more likely to believe there is an unmet need in existing asthma medication17. The availability of new treatment options with improved safety profiles could, however, help to reduce the incidence of side effects, improving patient compliance, and ultimately treatment outcomes.

For the Australian findings there are limitations to the survey. These include the small sample size of physicians and patients, and that the survey was also not designed for statistical inferences to be made between the different findings. The Australian data were not weighted; only the US arm of the survey had physician data weighted by speciality, gender years in practice, and patient data weighted by gender, education, age, household income and region. Recruiting physicians that have practiced for 3 to 30 years may not have included the older age group of physicians more resistant to change. While response rates included 463 unsuccessful phone call attempts to obtain information from 101 patients, no details were recorded for physicians. The choice of response options to survey questions reflected an in-depth knowledge of this specific patient population, but may not have provided an exhaustive choice of options to the close ended questions. Other issues that need to be addressed are how reliably long-term side effects, such as cataracts and osteoporosis, can be attributed to ICS therapy.

Conclusion

In conclusion, our results demonstrate that, from both a physician and patient perspective, the safety profile of asthma medication is a crucial factor in promoting treatment compliance and, ultimately, treatment outcomes, and that there is room for improvement in existing asthma therapy. Our survey also highlights discrepancies in perceived patient-physician communication and a role for improved patient education in asthma management.

Acknowledgments

Declaration of interest: The GAPP Survey Advisory Board is comprised of the following professional organizations and patient advocacy groups: The World Allergy Organization (WAO) and The American College of Allergy, Asthma and Immunology (ACAAI).

Dr Heiner has received honoraria and consulting fees for advisory board input from NYCOMED, GlaxoSmithKline, Boehringer Ingelheim and AstraZeneca. Funding for editorial support from Ogilvy Healthworld Medical Education (Asia Pacific), was provided by NYCOMED, Australia.

GAPP survey working group

Carlos E. Baena-Cagnani, Catholic University of Cordoba, Cordoba, Argentina, for WAO; Michael S. Biais, University of Tennessee Health Science Center, Memphis, TN, USA, for ACAAI; G. Walter Canonica, University of Genova DIMI, Genova, Italy, for WAO; Ronald Dahl, Aarhus University Hospital, Department of Respiratory Diseases, Aarhus, Denmark, for WAO; Michael A. Kaliner, Institute for Asthma and Allergy, Chevy Chase, MD, USA, for WAO; Erkka J. Valovirta; Turku Allergy Center, Turku, Finland, for WAO.

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CrossRef links are available in the online published version of this paper: http://www.cmrojournal.com

Paper CMRO-3856_3, Accepted for publication: 01 June 2007

Published Online: 26 June 2007

doi:10.1185/030079907X210714

Maurice McDonald Heiner

Wesley Medical Centre, Auchenflower, Queensland, Australia

Address for correspondence: Dr M. M. Heiner, Second Floor Wesley Medical Centre, Level 2, 40 Chasley Street, Auchenflower, Queensland 4066, Australia. Tel.: +61 7 3870 4468; Fax: +61 7 3371 3677; lyn.sellars@wesley.com.au

Copyright Librapharm Aug 2007

(c) 2007 Current Medical Research and Opinion. Provided by ProQuest Information and Learning. All rights Reserved.