Control of Asthma Under Specialist Care: Materials and Methods

control

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 guidelines 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. However, studies2- also show that although doctors accept the guidelines, their patients are not always treated accordingly, and a multinational survey shows that the life of asthma patient is affected by the disease to a great extent. This is supported by a number of studies 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, 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. 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.

2The 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.

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, Wurzburg, Germany). The spirometers and the procedure for spirometry testing fulfilled American Thoracic Society criteria. The study was approved by the ethics committees of all hospitals involved, and patients gave informed consent.

Questionnaire

3The questionnaire used was developed from previously existing, validated, and extensively used questionnaires (American Thoracic Society, European Community Respiratory Health Survey), which have been shown to be valid for the measurement of asthma symptoms and were translated and validated in Greek. 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 x2 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).

Table 1—Clinical Characteristics

Characteristics No. Ag^yr Male/Female Gender, No. FEVj, % Predicted (Range) Mean ICSDose, mg
All patients 378 42.3 113/265 89.7 (44132) 663
Mild intermittent 28 39.5 10/18 103.4 (88122)
Mild persistent 131 42.4 38/93 96.1 (81132) 350
Moderate 178 44.7 58/120 87.6 (68108) 770
Severe 41 46.8 7/34 77.7 (4484) 1655