ORIGINAL ARTICLE
Asthma in Asia: Physician perspectives on control, inhaler use
and patient communications.
Short running header: Physician perspective of asthma in Asia.
Keywords: physician-patient communications, education, inhaler techniques, attitudes
David Price1,2,
Aileen David-Wang3,
Sang-Heon Cho4,
James Chung-Man Ho5,
Jae-Won Jeong6,
Chong-Kin Liam7,
Jiangtao Lin8,
Abdul Razak Muttalif9,
Diahn-Warng Perng10,11,
Tze-Lee Tan12,
Faisal Yunus13
and Glenn Neira14 for the REcognise Asthma and LInk to Symptoms and Experience (REALISE) Asia
Working Group
1
Centre of Academic Primary Care, University of Aberdeen, Aberdeen, UK, 2Research in Real Life,
Singapore; 3Section of Pulmonary Medicine, University of the Philippines-Philippine General Hospital,
Manila, Philippines; 4College of Medicine, Seoul National University, Seoul, Republic of Korea;
5
Department of Medicine, University of Hong Kong, Hong Kong Special Administrative Region of the
People’s Republic of China; 6College of Medicine, Inje University, Goyang, Republic of Korea; 7Faculty
of Medicine, University of Malaya, Kuala Lumpur, Malaysia; 8Respiratory Medicine Department, ChinaJapan Friendship Hospital, Beijing, People’s Republic of China; 9Institute of Respiratory Medicine, Kuala
Lumpur, Malaysia; 10School of Medicine, National Yang-Ming University, 11Department of Chest
Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; 12National University Hospital, Singapore;
13
Persahabatan Hospital, University of Indonesia, Jakarta, Indonesia; 14Medical Affairs Department,
Mundipharma Pte Ltd, Singapore.
Correspondence: A Prof Aileen David-Wang,
Section of Pulmonary Medicine, University of the Philippines-Philippine General Hospital,
Taft Avenue, Manila 1000, Philippines.
Tel: +63-25548400 ext.3157
Fax: +63-25673486
Email: [email protected];
Abstract
Objective
We examined the physician perspectives on asthma management in Asia.
Methods
An online/face-to-face, questionnaire-based survey of respiratory specialists and primary care physicians
from eight Asian countries/region was carried out. The survey explored asthma control, inhaler selection,
technique and use; physician-patient communications and asthma education. Inclusion criteria were >50%
of practice time spent on direct patient care; and treated >30 patients with asthma per month, of which
>60% were aged >12 years.
Results
REALISE Asia (Phase 2) involved 375 physicians with average 15.9(+6.8) years of clinical experience.
89.1% of physicians reporting use of guidelines estimated that 53.2% of their patients have well-controlled
(GINA-defined) asthma. Top consideration for inhaler choice was asthma severity (82.4%) and lowest,
socio-economic status (32.5%). 54.7% of physicians checked their patients’ inhaler techniques during
consultations but 28.2(+19.1)% of patients were using their inhalers incorrectly. 21.1-57.9% of physicians
could spot improper inhaler techniques in video demonstrations. 79.6% of physicians believed combination
inhalers could increase adherence because of convenience (53.7%), efficacy (52.7%) and usability (18.9%).
Initial and follow-up consultations took 16.8(+8.4) and 9.2(+5.3) minutes respectively. Most (85.1%)
physicians used verbal conversations and least (24.5%), video demonstrations of inhaler use. 56.8% agreed
that patient attitudes influenced their treatment approach.
Conclusion
Physicians and patients have different views of ‘well-controlled’ asthma. While physicians informed
patients about asthma and inhaler usage, they overestimated actual usage and patients’ knowledge was suboptimal. Physician-patient interactions can be augmented with understanding of patient attitudes, visual
aids and ancillary support to perform physical demonstrations to improve treatment outcomes.
Introduction
Asthma is a global health problem and affects the society at large: directly from hospitalisation, treatment and
healthcare resources; and indirectly, from time lost from work, absenteeism and premature death. In 2014, it
affected 334 million people worldwide.[1] In Asia, it is more pronounced in the South-east Asia and the Western
Pacific regions where there is an estimated 107 million sufferers.[2, 3] Asthma control has remained poor and the
optimal levels of asthma control achieved in randomised clinical trials have not been replicated in real-life
populations[4] due to the restrictive inclusion criteria and patient care issues of such trials. Patients selected are
required to have high adherence, good inhaler technique, be non-smokers, stable asthma and few co-morbidities
and risks. During trials, the intensity of monitoring of patients is often higher than in usual practice leading to
better outcomes. The complexity of such disease-, patient- and doctor-related factors makes it difficult to achieve
them in real-life.
Real-life studies such as the REcognise Asthma and LInk to Symptoms and Experience (REALISE)[5] which was
one of the largest appraisal of patients with asthma in Europe, revealed that asthma control when assessed
according to international guidelines such as the Global Initiative for Asthma (GINA)[6] was poor and many
respondents did not recognise symptoms or even exacerbations as indicators of poor control. Studies of patients
with asthma in Asia[7-9] have addressed the burden of disease and patient attitudes to exacerbations and they
revealed high rates of poor asthma control and severe asthma exacerbations. In the first phase of our REALISE
Asia study of an adult Asian population with asthma, we reported on their perceptions of asthma control and
attitudes towards the disease and its treatment.[10] It revealed a crisis and symptom-oriented approach to asthma
management with high reliever inhaler and oral corticosteroids use, emergency department visits and
hospitalisations. Our patients perceived ‘asthma control’ as treating their exacerbations and symptoms rather than
preventing them through regular maintenance therapy. As a result, they believed that their asthma was well
controlled despite the presence of symptoms and exacerbations and thus overestimated their level of asthma
control when compared to what their clinical symptoms suggested.
In a study of the causes of failure in asthma control, it was reported that many patients felt least informed about
the meaning of asthma control and this was seen to be associated with the physician’s behaviour during
consultation.[4] Physicians were found lacking in that they failed to explore how the patient perceived asthma,
provide sufficient educational materials, involve the patient in the disease management plan or simply, listen to
the patient. The communication and interpersonal skills of the physician in relating to the patient and eliciting
critical diagnostic and attitudinal information is paramount in helping the patient manage the asthma condition.[11]
Using such information to select the appropriate inhaler to suit the patient can help to improve treatment adherence
as many patients failed to adhere to instructions on inhaler use.[12] Equally important is the need to ensure that
the patient adopt the correct inhaler technique to deliver the medication effectively to the lungs to increase its
clinical efficacy.[13] Current asthma management guidelines such as GINA[6] also do not sufficiently address
inhalation devices and the physician has to step in to fill this void through patient education.[14] In this regard, the
physician has to work within the limits of the consultation visit to arrive at an optimal treatment plan to narrow
the gulf between good asthma control as defined by guidelines and the patient’s attitude towards the asthma
condition. The view of the physician on how the patient saw asthma control, and the approach to treating and
educating the patient play an important role in the successful management of asthma.
In Phase 1 of the REALISE Asia study, we sought the perception and attitudes of patients with asthma in eight
Asian countries, aged 18-50 years who have access to social media, using an online questionnaire survey.[10] This
manuscript reports on the second phase of our REALISE Asia study. We sought the perspectives of asthma control
from physicians who treated patients with asthma in the same Asian countries. We also examined the physician
views on inhaler selection, patient inhaler technique and use, and physician-patient communications; and how the
asthma consultation process can be improved to help patients take better control of their disease.
Methods
A quantitative, questionnaire-based survey of physicians was conducted either online or through face-to-face
interviews in eight countries/region, namely, the People’s Republic of China (China), Hong Kong Special
Administrative Region (SAR), Indonesia, South Korea, Malaysia, Philippines, Singapore and Taiwan. The
questionnaire was designed to understand how physicians define ‘asthma control’, their perceptions of what their
patients understood by ‘asthma control’, the level of asthma control of patients being treated and the symptoms
they experienced, the frequency and duration of patient visit and steroid use, what they teach their patients about
asthma and their medication (inhaler) and understood about their attitudes to the disease and adherence to inhaler
use; and finally if an attitudinal profiling tool would be useful. (Supplementary materials) In addition, it also
gauged the physician’s knowledge and accuracy in detecting correct and incorrect usage of inhaler devices through
three video demonstrations of their use (metered dose inhaler [MDI], and dry powder inhalers Diskus® and
Turbuhaler® types; Diskus® and Turbuhaler® are registered trademarks of GlaxoSmithKline and AstraZeneca
respectively).
Cognitive interviews were conducted with 4 respondents to pre-test the questionnaire and supporting materials to
evaluate their effectiveness. The results were analysed by a working group consisting of practising physicians
and respiratory specialists, and minor amendments to the questionnaire were made for clarity. The questionnaire
was translated into the local language for the survey.
Survey population
Our respondents were randomly selected from local hospital/clinic registries or online panels of primary care
physicians and specialists who treated adult patients with asthma. For the local registries, the physicians were
randomised and the resulting list was used to screen respondents either by telephone or through face-to-face
contact, to confirm their eligibility for study participation. For the online panels, survey invitations were sent to
the physicians to complete the questionnaire. The respondents were sub-grouped into respiratory specialists
(Specialists), including pulmonologists, clinical immunologists and allergologists; or primary care physicians
(PCPs) including those in primary care practice such as general practitioners, family physicians (family medicine)
and internists (internal medicine). The sample size was based on the number of physicians practising in the core
urban areas in a country/region to ensure a 95% confidence interval of 94%-104% around an estimated mean of
99%. The final sample sizes were proportional to the relative patient populations of the countries/region i.e. bigger
sample sizes for bigger populations in countries such as China and South Korea. The inclusion criteria comprised
(1) more than 50% of the medical practice time was devoted to direct patient care; (2) more than 50 and 30 asthma
patients were treated per month (Specialists and PCPs respectively); (3) more than 60% of asthma patients were
aged 12 years or older; (4) physicians were not employed by or affiliated with a pharmaceutical company other
than for clinical trials; and (5) physicians had not taken part in healthcare-related market research in the 3 months
prior to the survey.
The survey was conducted according to the International Chamber of Commerce/European Society for Opinion
and Market Research (ICC/ESOMAR) International Code on Market and Social Research[15] which describes the
ethical principles for the conduct of market research. As there were no hospital/physician associations or referrals,
approvals from Institutional Review Boards were not required.
Data collection
The survey was conducted between July and September 2014. Physicians in Hong Kong SAR, South Korea and
Taiwan who were selected from online panels and qualified for the survey were given unique links via email to
complete the survey online. Each participant was allowed to answer the questionnaire once only. For the
remaining countries, face-to-face interviews by trained interviewers were carried out. All interviewers were
thoroughly briefed on the recruitment and interviewing protocols to ensure compliance with hospital and market
research codes of conduct[15] prior to the project initiation date. Each interview took an average of 30 minutes to
complete. Responses from the face-to-face interviews were entered into the same online survey database. Rigorous
data quality checks were performed including calling respondents to confirm responses and checking for
inconsistencies in responses by comparing answers for related questions to ensure that the data is logical and
reasonable. Questionnaire responses in the local language were translated into English. The study’s working group
reviewed and approved the translated responses.
Data analysis
Responses to the questionnaire were analysed for the total eligible population and by sub-group i.e. Specialists
and PCPs. The level of asthma control (controlled, partially controlled, uncontrolled) was determined using the
GINA criteria.[6] Descriptive statistics such as mean and standard deviation were used for continuous values such
as duration of practice, monthly caseload, duration of consultation visit and percentage of asthma medication
prescribed; while percentages were used to describe use of guidelines, asthma control, causes of acute asthma
symptoms and steroid use, factors influencing inhaler selection and adherence, frequency of follow-up
consultations and use of information aids/tools. For statements requiring respondents to indicate their degree of
agreement, such as inhaler selection and adherence, a 7-point (1 for ‘strongly disagree’ to 7 for ‘strongly agree’)
scale was provided. Similarly, 4- or 5-point qualitative scales (i.e. always, sometimes, rarely and never) were used
when respondents were asked about the frequency of consultation visits, use of steroids and information aids and
checking of inhaler technique. The frequencies of the selected choices were computed. For comparisons between
sub-groups, normality conditions were assumed and a P-value <0.05 was considered as statistically significant.
Results
Demographics and clinical characteristics
A total of 1074 physicians were selected for the survey. Of these, 431 did not respond or declined to participate
in the survey. Another 268 physicians failed to meet the inclusion criteria and were excluded. (Figure 1) The
most common reason for exclusion was they did not manage the requisite number of patients with asthma (57.1%,
n=153). The final analysis set contained 375 physicians (response rate=34.9%), of which 124 (33.0%) were PCPs
and 251 (67.0%) were specialists. The largest participating groups were from China, South Korea and Taiwan
with 60 physicians from each country (16.0%). Table 1 presents the demographic and clinical characteristics of
the study physicians. Overall, our physicians had a mean of 15.9(+6.8) years of clinical practice experience. They
treated a monthly average of 93.7(+77.6) patients with asthma and they constituted 13.1% of the physician’s
caseload. Patients with asthma formed 21.9% of all patients for the Specialists compared to 7.9% of patients for
the PCPs.
Asthma control
Most (81.3%) of the physicians reported that they used the GINA criteria[6] to assess the level of asthma control
in their patients, while 41.3% and 13.1% of them also used the Asthma Control Test[16] (ACT) and other local
guidelines respectively. However, 10.9% of physicians reported that they did not use any guideline recommended
approaches when assessing the asthma control of their patients. A higher proportion of specialists used these
recommended approaches compared to the PCPs (GINA: 95.5% vs 64.9%, P-value<0.05; ACT: 49.3% vs 32.2%,
P-value<0.05). Using the GINA-recommended level of control guidelines, physicians estimated that half (53.2%)
of their patients had well-controlled asthma while 30.7% and 16.2% had partially controlled and uncontrolled
asthma respectively. PCPs reported a higher percentage of patients with controlled asthma compared to the
Specialists (55.6% vs 51.0%, P-value<0.05) but a lower percentage with uncontrolled asthma (13.9% vs 18.2%,
P-value<0.05). Two-thirds (68.5%) of physicians believed that patients’ definition of ‘well-controlled asthma’
were aligned with theirs. In their view, ‘well-controlled’ asthma meant that ‘asthma symptoms are non-existent
or minimal‘ (60.0%) or ‘asthma having minimal impact on patient’s daily life’ (47.7%). (Figure 2) The remaining
third who disagreed felt that there were differences in the way patients viewed asthma control when compared to
the physicians: patients placed more emphasis on managing the symptoms while physicians used medical
assessment standards such as GINA or ACT.
Use of inhalers
About 88.8% of physicians reported that they explained the purpose of different types of inhalers during the initial
consultation. The most common messages the physicians gave to patients were: ‘to use their controller inhalers
daily’ (59.8%) and ‘to use the reliever inhalers only when necessary’ (59.0%). Our physicians estimated that
65.1% of their patients were using their controllers daily. Figure 3 shows the three most common reasons for not
using the controller inhaler from the physician perspective. Most (43.9%) physicians attributed it to a lack of
perceived need by the patient to use it daily, patients were fearful of being dependent (39.0%) or worried about
its side effects (30.7%).
Table 2 shows the characteristics of asthma and its treatment. The main causes of acute asthma symptoms resulting
in visits to the clinic cited by our physicians were exacerbation (75.7%), respiratory tract infection (45.6%) and
other symptoms such as flu, cold, bronchitis, pneumonia, chest infection, viral infection, sore throat, nasal
congestion, post-nasal drip, phlegm and fever (48.8%). On average, 22.4(+25.6)% of their asthma patients were
given a course of oral corticosteroids or more in a month. This medication was prescribed mostly for exacerbations
(82.6%), and for severe (75.7%) or uncontrolled (63.5%) asthma. PCPs reported prescribing oral corticosteroids
to a greater proportion of their patients compared to Specialists (27.8% vs 17.7%, P-value<0.05).
The main factors that the physicians took into consideration when selecting an inhaler for their patients were the
severity of asthma (82.4%), asthma control status (68.0%) and patients’ inhalation technique (60.3%). Patient
socio-economic status ranked the lowest (32.5%) and both PCPs and Specialists ranked these factors similarly.
At least half (54.7%) of the physicians reported that they checked their patients’ inhaler techniques frequently
during the follow-up consultations. The physicians estimated that 28.2(+19.1)% of patients were using their
inhalers incorrectly.
About half of the physicians who were shown the Diskus® and Turbuhaler® inhaler video demonstrations of
improper use could spot errors (57.9% for Diskus®, 52.3% for Turbuhaler®); and to a lesser extent, 21.1%, of
them spotted the usage errors in the MDI demonstration.
Combination inhalers containing corticosteroids and long-acting β-agonist (LABA) (53.2%) was the most
commonly prescribed long-term medication. The Specialists reported prescribing these inhalers to a greater extent
compared to their PCP peers (58.7% vs 46.9%, P-value<0.05). About 79.6% of physicians believed that
prescribing combination inhalers can increase patient adherence mainly because of their convenience (53.7%),
efficacy in asthma control (52.7%) and ease of use for patients (18.9%). Physicians perceived that 65.1(+20.6)%
of their patients to be adherent to the use of their controller inhalers. They reported assessing their patient’s
adherence to medication mostly from the patient frequency of inhaler use (84.3%) and prescription refills (76.0%),
movement of dose counter (49.6%) and how controller medication is embedded in patient’s daily routine (48.8%).
Physician-patient communications
Table 3 shows the reported characteristics of the asthma consultation visit. Our physicians estimated that the initial
consultation took on average 16.8(+8.4) minutes and the follow-up consultation, 9.2(+5.3) minutes. Most (80.5%)
physicians stated that they reviewed their patients at least once every 3 months. During the initial consultation,
85.1% of physicians reported that they verbally communicated information about asthma without the aid of
materials. Video demonstrations of inhaler use techniques were the least commonly used communication method
(24.5%). About 59.2% of PCPs and 36.3% of the Specialists used pharmaceutical company materials accompanied
with verbal explanation. More PCPs also asked their patients to take them home to read in their own time (58.0%
vs 39.8%, P-value<0.05). Four in ten (40.0%) physicians would inform their patients that asthma is a chronic
condition and is controllable with medication; that it is triggered by allergens (28.3%) and described its symptoms
and exacerbations (26.1%).
More than half (51.1%) of the physicians would identify the attitudes of their patients towards their asthma and
56.8% agreed that their attitudes will influence the way they manage them. About 41.1% of respondents agreed
that a patient profiling tool would be helpful in tailoring their treatment approach while half (53.6%) remained
neutral towards such a tool. A quarter (27.7%) of physicians foresaw barriers to using the tool in practice such as
time constraint (47.1%), the tool not being all encompassing (30.8%) and patients were unwilling to provide
honest answers (26.9%).
Discussion
The present study examined the similarities and differences in perspectives of asthma control and management
between physicians and adult patients in Asia. The results showed that physicians believed that a higher proportion
(52.3%) of their patients have well-controlled asthma as compared to patients who actually achieved GINAdefined controlled asthma (17.8%[10]). The patients also held a similar view: 89.1% reported that their asthma was
controlled during our REALISE Asia phase 1 study.[10] However, there was a difference in their perceptions of
‘well-controlled’ asthma: patients perceived it as managing their exacerbations through medical help (28.2%) or
medication (21.0%); while the physician view of ‘minimal or absence of symptoms’ only drew a low 9.9% of
patient responses in our Phase 1 study. (Figure 2)
Our survey relied on the physician responses to our questionnaire. These responses could not be clinically verified
and some respondents might have inaccurately recalled certain events. For asthma control, we have compared
these results to patient responses in our Phase 1 study. We had found that these patients were younger and
predominantly male; and a higher proportion of them had well-controlled asthma[10] than the populations reported
in other face-to-face studies[7-9]. This is also a limitation of our study as the profiles of these patients may not be
similar to the patients treated by our physicians. Nonetheless, a wide gulf still exists between the physician
perception of the level of asthma control among their patients and real-life achievement.
Our physicians reported that 65.1% of patients used their controllers daily which was higher than the 40-60%
cited in an earlier review of inhaler competence in asthma[12]; and the 13.9% reported by patients in our Phase 1
patient survey[10]. The main reason for non-adherence cited by both patients and physicians was that patients did
not see a need to use them daily, and patients also viewed inhalers as a nuisance or an embarrassment.
Surprisingly, both physicians and patients did not cite the cost of medication as a main reason for non-adherence.
Likewise, the cost of medication was not a key consideration by physicians when selecting the inhaler, as the
patient’s socio-economic status was ranked lowest among the list of factors. In deciding the choice of inhaler, the
physician instead took into account the patient’s asthma severity, level of control and inhalation technique. The
patient preference for the inhaler did not feature in the selection process although patient satisfaction with the
inhaler could have influenced its treatment outcome. There were also few validated studies on patient preferences
for inhalers mainly due to the lack of a reliable instrument to measure inhaler preference.[17] While physicians can
explain the purpose of the different inhalers, our earlier patient study[10] showed that only 19.9% of patients were
able to correctly distinguish between controller and reliever inhalers. The combination inhaler may be a solution
and our physicians believed that prescribing it can improve patient adherence because of its convenience,
treatment efficacy and ease of use.
The average consultation lasted only about 10-15 minutes and the physician-patient communications were mostly
verbal with little use of instructional or visual aids. Instructing the patients on correct inhaler technique, which is
essential for treatment success, in this manner was unlikely to be successful every time. Our physicians reported
that at least a quarter of patients were not using their inhalers correctly despite their frequent checks on their
inhaler techniques. Complicating the situation is the proliferation of inhalers, each requiring its own handling
technique. A patient who is prescribed with mixed devices (i.e. different types of inhalers for asthma control and
relief) would need to learn at least two different inhaler techniques, making the task even more onerous. Poor
inhaler technique has been the cause of uncontrolled asthma as the failure to deliver the medication effectively to
the lungs compromised its clinical efficacy.[13] Proper patient training by healthcare professionals is critical to
resolving this problem[18] and for training to be effective, healthcare professionals must be able to identify and
correct mistakes made by their patients. The results of our video tests showed that our physicians had difficulties
with this task. Depending on the inhaler type, only 21.1-57.9% of them could spot the errors in the inhalation
techniques shown in the demonstration videos. This range is consistent with the 15-69% range for healthcare
professionals found in other studies.[12]
It has been shown that more patients who received verbal counselling with physical demonstrations achieved
optimal inhaler technique compared to those who had only verbal instructions. [19] Training tools for patients are
readily available to support the physical demonstration of inhalation techniques.[20] Such aids should be relevant
and appropriate to the time available during the patient visit at the clinic and where it is not possible to include
them, patients can be directed to online resources.
Our physicians agreed that patients’ attitudes toward their asthma condition would influence their treatment
approach. While they were not adverse to the use of patient profiling to better understand their patients, they were
concerned that the limited consultation time would not enable patients to provide sufficient and accurate
information for the profiling. Patient empowerment and health literacy can often lead to better patient selfmanagement practices.[21] Supporting healthcare professionals such as nurses and pharmacists can be engaged to
demonstrate and correct inhaler techniques, and conduct patient education with informational aids prior to the
consultation to save valuable consultation minutes. Previous studies have shown no difference in outcomes for
nurse-led care compared to physician-led care for asthma patients.[22]
Conclusion
Our study revealed a dichotomy in the definition of asthma control between physicians and patients: a result of
different views of what was meant by ‘well-controlled’ asthma. Asthma management strategies need to evolve
from relief to prevention and move patients away from a crisis-oriented mind-set. Physicians must position
themselves to educate patients that daily and correct use of their controller inhalers is essential to achieving good
asthma control. Understanding the patient attitudes to this disease can assist the physician to tailor the conversation
and treatment approach. As patient health literacy is paramount to empower the patient to manage his/her
condition, the greater use of visual aids and increased support from ancillary healthcare workers to perform
physical demonstrations of inhaler use can overcome the limited consultation time to promote better patient care
and improve treatment outcomes.
Acknowledgements
This study was supported and funded by Mundipharma Pte Ltd. Online survey and statistical analysis were
performed by Pei-Li Teh, Rachel Howard, Tsin-Li Chua and Jie Sun of Research Partnership Pte Ltd.
Medical writing support was provided by Sen-Kwan Tay of Research2Trials Clinical Solutions Pte Ltd.
Author contributions
All authors were involved in conceptualizing the study design, drafting the article or revising it critically for
important intellectual content, and all authors approved the final version to be submitted for publication. All
authors have full access to all the data in the study and take responsibility for the integrity of the data and the
accuracy of the data analysis.
Declaration of Interest
The authors received honoraria from Mundipharma for their participation in the REALISE Asia Working
Group meetings and discussions. Prof Price has Board membership with Mundipharma; and also received
speaker fees, grants and unrestricted funding support from Mundipharma. Profs Liam and Faisal; and A Prof
David-Wang and Tan are members of the Asia-Pacific Advisory Board of Mundipharma. Profs Cho and
Faisal and A Prof David-Wang and Tan received speaker fees from Mundipharma in the past. A Prof Tan
received conference sponsorship from Mundipharma. Dr Neira is an employee of Mundipharma.
Tables.
Table 1: Demographics and clinical characteristics.
Table 2: Asthma and treatment characteristics.
Table 3: Consultation visit characteristics.
Figures.
Figure 1: Survey flowchart.
Figure 2: Definition of well-controlled asthma (Physicians vs Patients).
Figure 3: Top 3 reasons for non-adherence to asthma medication (Physicians vs Patients).
Supplementary Material.
Questionnaire.
Screener.
References (max 60)
1
Global Asthma Network (GAN). The Global Asthma Report 2014. Available from:
http://www.globalasthmareport.org/burden/burden.php. Accessed: 25 Mar 2015.
2
Aahman, E, Begg, S, Black, B, Boschi-Pinto, C, Chatterji, S, Cibulskis, R, Cousens, S, et. al. World
Health Organisation. The global burden of disease: 2004 update 2008. Available from:
http://www.who.int/healthinfo/global_burden_disease/2004_report_update/en/. Accessed: 10 Feb
2015.
3
Lai CK, Beasley R, Crane J, Foliaki S, Shah J, Weiland S, International Study of Asthma Allergies
in Childhood Phase Three Study Group. Global variation in the prevalence and severity of asthma symptoms:
phase three of the International Study of Asthma and Allergies in Childhood (ISAAC). Thorax. 2009; 64:
476-83.
4
Braido F. Failure in asthma control: reasons and consequences. Scientifica. 2013: 549252.
5
Price D, Fletcher M, van der Molen T. Asthma control and management in 8,000 European patients:
the REcognise Asthma and LInk to Symptoms and Experience (REALISE) survey. NPJ primary care
respiratory medicine. 2014; 24: 14009.
6
The Global Initiative for Asthma (GINA) Science Committee. Global Strategy for Asthma
Management and Prevention 2014. Available from: http://www.ginasthma.org/documents/4. Accessed:
12 Jul 2015.
7
Thompson PJ, Salvi S, Lin J, Cho YJ, Eng P, Abdul Manap R, Boonsawat W, Hsu JY, Faruqi RA,
Moreno-Cantu JJ, Fish JE, Ho JC. Insights, attitudes and perceptions about asthma and its treatment: findings
from a multinational survey of patients from 8 Asia-Pacific countries and Hong Kong. Respirology. 2013;
18: 957-67.
8
Lai CK, Ko FW, Bhome A, TS DEG, Wong GW, Zainudin BM, Nang AN, Boonsawat W, Cho SH,
Gunasekera KD, Hong JG, Hsu JY, Viet NN, Yunus F, Mukhopadhyay A. Relationship between asthma
control status, the Asthma Control Test and urgent health-care utilization in Asia. Respirology. 2011; 16:
688-97.
9
Zainudin BM, Lai CK, Soriano JB, Jia-Horng W, De Guia TS, Asthma Insights Reality in AsiaPacific Steering Committee. Asthma control in adults in Asia-Pacific. Respirology. 2005; 10: 579-86.
10
Price D, David-Wang A, Cho S, Ho JC, Jeong JW, Liam CK, Lin J, Muttalif AR, Perng DW, Tan
TL, Yunus F, Neira G. Time for a new language for asthma control: results from REALISE Asia. J Asthma
Allergy. 2015; 8: 93-103.
11
Cabana MD, Slish KK, Evans D, Mellins RB, Brown RW, Lin X, Kaciroti N, Clark NM. Impact of
Physician Asthma Care Education on patient outcomes. Health Educ Behav. 2014; 41: 509-17.
12
Inhaler Error Steering Committee, Price D, Bosnic-Anticevich S, Briggs A, Chrystyn H, Rand C,
Scheuch G, Bousquet J. Inhaler competence in asthma: common errors, barriers to use and recommended
solutions. Respir Med. 2013; 107: 37-46.
13
Rau JL. The inhalation of drugs: advantages and problems. Respir Care. 2005; 50: 367-82.
14
Dekhuijzen PN, Bjermer L, Lavorini F, Ninane V, Molimard M, Haughney J. Guidance on handheld
inhalers in asthma and COPD guidelines. Respir Med. 2014; 108: 694-700.
15
European Society for Opinion and Market Research (ESOMAR). ICC/ESOMAR International
Code on Market and Social Research 2008. Available from: http://www.esomar.org/knowledge-andstandards/codes-and-guidelines.php. Accessed: 25 Aug 2014.
16
Nathan RA, Sorkness CA, Kosinski M, Schatz M, Li JT, Marcus P, Murray JJ, Pendergraft TB.
Development of the asthma control test: a survey for assessing asthma control. J Allergy Clin Immunol.
2004; 113: 59-65.
17
Anderson P. Patient preference for and satisfaction with inhaler devices. Eur Respir Rev. 2005; 14:
109–16.
18
Melani AS, Bonavia M, Cilenti V, Cinti C, Lodi M, Martucci P, Serra M, Scichilone N, Sestini P,
Aliani M, Neri M, Gruppo Educazionale Associazione Italiana Pneumologi Ospedalieri. Inhaler mishandling
remains common in real life and is associated with reduced disease control. Respir Med. 2011; 105: 930-8.
19
Basheti IA, Reddel HK, Armour CL, Bosnic-Anticevich SZ. Counseling about turbuhaler
technique: needs assessment and effective strategies for community pharmacists. Respir Care. 2005; 50: 61723.
20
Lavorini F, Levy ML, Corrigan C, Crompton G, Admit Working Group. The ADMIT series - issues
in inhalation therapy. 6. Training tools for inhalation devices. Prim Care Respir J. 2010; 19: 335-41.
21
Londono AM, Schulz PJ. Influences of health literacy, judgment skills, and empowerment on
asthma self-management practices. Patient Educ Couns. 2015.
22
Kuethe MC, Vaessen-Verberne AA, Elbers RG, Van Aalderen WM. Nurse versus physician-led
care for the management of asthma. Cochrane Database Syst Rev. 2013; 2: CD009296.