FormalPara Key Summary Points

Why carry out this study?

Identifying barriers to treatment adherence and discordance between physician-directed goal-based treatment and patient perception-based treatment approaches is essential for achieving well-controlled asthma.

A cross-sectional online survey was conducted across seven countries to investigate the factors influencing treatment selection and comprehend the attitudes and perspectives of patients and physicians regarding asthma management and adherence to asthma treatment.

What was learned from the study?

Physicians managing moderate asthma anticipated high rates of exacerbations, equally prioritised exacerbation reduction and symptom control as treatment goals, and recommended preventive measures such as influenza and pneumococcal vaccines for all patients, possibly postponing them for those with uncontrolled or severe asthma.

Most patients with moderate asthma were treated with regular dosing with the most commonly prescribed regimen of an inhaled corticosteroid/long-acting β2-agonist with an as-needed short-acting β2-agonist as a reliever medication.

Despite exhibiting low Asthma Control Test scores and a high symptom burden, patients had a poor perception of their asthma control and overestimated their asthma control, emphasising the need for better patient-physician communication aimed at understanding patients’ perspectives and aligning expectations regarding asthma treatments and outcomes.

Introduction

Asthma prevalence is increasing worldwide, particularly in urban areas and developing countries [1, 2]. The prevalence of adult asthma in Indonesia, Malaysia, Philippines, Thailand, Vietnam, Saudi Arabia, and the United Arab Emirates (UAE) is approximately 2.4% [3], 4.5% [4], 8.7% [5], 3.0% [6], 4.75% [7], 4.7% [8], and 8.5% [8, 9], respectively.

The long-term goals of asthma management should aim at ensuring effective symptom control while reducing the risk of mortality, persistent airflow limitation, exacerbations, and treatment-related side effects [10]. Global Initiative for Asthma (GINA) publishes strategies that need customisation to be suitable for the local setting, based on healthcare resource availability. This customisation ensures appropriate integration into health systems and clinical practice [10]. Various national treatment guidelines such as those of Saudi Arabia, Thailand, the British Thoracic Society, Spain (Spanish Guideline on the Management of Asthma [GEMA] 5.3), Japan, and Canada are consistent in terms of recommending regular dosing with inhaled corticosteroids (ICS) for the treatment of mild asthma or ICS/long-acting β2-agonists (LABAs) for moderate asthma along with inhaled short-acting β2-agonists (SABAs) as reliever medication [6, 11,12,13,14,15].

It is crucial to comprehend the real-world practices and perceptions of both patients and physicians regarding asthma management in different countries. Although good control of asthma can be achieved in many patients [16], real-world studies have shown that asthma is frequently uncontrolled [17, 18]. It is also essential to identify barriers hindering the use of regular controller medication, which could potentially impair the effective suppression of inflammation necessary to achieve well-controlled asthma [19]. Several studies and surveys have delved into real-world practices and have reported discordance between physicians’ and patients’ perceptions of asthma control, which may negatively impact symptom control, treatments, and outcomes. These studies include the Asthma Insights & Reality (AIR) global patient surveys that included the United States, Europe, Latin America, Africa, Middle East, Gulf, and Asia–Pacific regions [20,21,22,23,24,25,26,27,28,29]; the Asthma Insight and Management (AIM) surveys [30] that covered the United States [31], Canada and Western Europe [32], Asia–Pacific [33], and Latin America [34]; and the Global Asthma Physician Survey (GAPS) that covered six countries (Australia, Canada, China, France, Germany, and Japan) [35]. This has also included the recently conducted Asthma Patients’ and Physicians’ Perspectives on the Burden and Management of Asthma 1 (APPaRENT 1; Australia, Canada, China, and Philippines) [36] and APPaRENT 2 (Argentina, Brazil, France, Italy, and Mexico) [37] studies. It has also been shown that a patient’s individual baseline characteristics and treatment choices affect future risk of exacerbation and reliever use [38]. Understanding patients’ demographic profiles and baseline characteristics [38], treatment patterns [39], comorbid conditions [40, 41], treatment costs [42], and status of asthma control [10] is essential to refine clinical treatment recommendations. These clinical decisions are important for providing optimal bronchoprotection to patients depending on the severity of their asthma [43, 44].

The APPaRENT 3 study aimed to explore perspectives of patients with asthma and physicians in real-world clinical settings on (1) attitudes, beliefs, and treatment practices related with controller medication in a regular versus flexible dosing approach, (2) asthma management practices, and (3) factors influencing patients’ asthma management and physicians’ treatment and prevention approaches.

Methods

Study Design and Eligibility Criteria

The APPaRENT 3 study was a cross-sectional, closed online survey of both patients with asthma and physicians in Southeast Asia (Indonesia, Malaysia, Philippines, Thailand, and Vietnam) and the Middle East (Saudi Arabia and UAE). Vietnam was not surveyed for physician responses because of a recent similar survey in the region [45]. Patients and physicians were sampled and recruited from online panels between 4 October and 29 November 2023 [see the Supplementary Material for additional details regarding the study design and Checklist for Reporting Results of Internet E-Surveys (CHERRIES) [46]].

Participants were invited to complete a self-administered web survey or face-to-face survey, as appropriate, in their local language (Arabic, Filipino, Indonesian, Malay, Thai, and Vietnamese), with an option for English. Eligible patients were aged ≥ 18 years, had access to the internet, had a self-reported affirmation of asthma diagnosis by a physician, and had used a prescribed inhaler for asthma for the last ≥ 6 months. Eligible physicians included general practitioners and family medicine, internal medicine, and pulmonary medicine specialists. Physicians were required to have access to the internet, be personally responsible for the treatment and management of patients with asthma, have ≥ 3 years of experience in clinical practice, and have treated an average of ≥ 4 patients with asthma each month. Physicians responsible for drug formulary decisions or employed by a pharmaceutical company at the time of the study were excluded from the study.

Ethical Approval

Patients and physicians in all countries were sampled and recruited through high-quality panel providers certified by the International Organization for Standardization (ISO 20252:2019 Market, Opinion and Social Research, including Insights and Data Analytics—Vocabulary and Service Requirements; ISO 27001 Information Security Management) and fully compliant with country-specific regulations [e.g. General Data Protection Regulation, The British Healthcare Business Intelligence Association (BHBIA) Adverse Event Reporting, and European Union (EU) Safe Harbor] for collecting patient and physician data. Before commencing the study, the Western Copernicus Group Institutional Review Board (WCG IRB; WCG Clinical, Inc; Princeton, USA; registration identifier IRB00000533) reviewed and approved the protocol, informed consent forms, and other relevant documents (such as advertisements). The IRB certified that the project protocol ensured respondent confidentiality and privacy, aligning with Adelphi Real World company policies. Additionally, the IRB determined that the research qualified for a waiver of documentation of consent according to 45 CFR 46.117(c)(1)(ii) [2018 Requirements] and 45 CFR 46.117©)(2) [Pre-2018 Requirements]. IRB details for this study include reference number 1360929 and tracking number 20234154. Prior to participation, respondents provided informed consent, including consent for the publication of findings. The study was conducted in accordance with the protocol and consensus ethical principles derived from international guidelines, including the Declaration of Helsinki.

Statistical Analysis

Sample sizes were based on the APPaRENT 1 and 2 studies and were selected to be sufficient for within-country regression analyses [36, 37]. Additional details are provided in the statistical analysis subsection in supplementary information. Reported p values were determined using the chi-square test for categorical data and analysis of variance (ANOVA) for continuous data. Composite p values are reported for statistically significant differences in variables across the surveyed countries. Cooperation rates were defined as the total number of completed surveys divided by the total number of initial web invitations sent minus the number of cases known to be ineligible. Descriptive statistics are reported for individual countries as well as across all countries combined, i.e., proportions for categorical data and means and standard deviations (SDs) for continuous data. Statistically significant differences among countries are detailed in the figures and tables, while they are only highlighted for variables of interest in the text. Percentages are rounded to zero decimal places in both text and tables, except for specific variables such as Asthma Control Test (ACT) score, which are reported up to one decimal place.

Data Presentation

Patients' and physicians' viewpoints are reported in these focus areas, in the specified order in the Results section: study population and cooperation rates, sociodemographic and health characteristics, asthma status, treatment preferences and goals, treatment patterns, vaccination, and perceptions of asthma control and experiences and barriers in treatment.

Results

Study Population and Cooperation Rates

Approximately 400–2000 invitations were sent to patients in each country, with 200 patients completing the survey from each country (1400 patients were included in the survey). The number of patients who were excluded because they did not meet the eligibility criteria or because the per-country quota was reached ranged from 202 in Vietnam to 1634 in Malaysia. Overall, the patient cooperation rate was 77%. For the physician survey, approximately 1300–2600 invitations were sent to physicians in each country (except Vietnam), with 100 completed surveys returned from each country (599 physicians were included in the survey). The number of physicians who were excluded because they did not meet the eligibility criteria or because the per-country quota was reached ranged from 17 in Thailand to 42 in the UAE. Overall, the physician cooperation rate was 6% (Supplementary Material Table S1).

Sociodemographic and Health Characteristics

The mean age of the patients was 34 years (SD, 8.9 years) where 52% were male patients and 48% were female patients. The patients’ age, gender, education, and their location of residence varied significantly (p < 0.05) among two or more of the surveyed countries. Overall, 89% of patients had attained higher education (college/university or postgraduate). Overall, 65% of patients lived in a large city or metropolitan area, while the remaining 35% lived in a suburb, small city, town, rural area, or remote/hard-to-reach location. Overall, 60% of patients reported that at least one person in their household currently smoked or used a vaping product on a daily basis. In the past 12 months, apart from the outpatient visits for asthma exacerbations, patients had a mean of five (SD, 6.2) routine asthma visits to a physician (Table 1).

Table 1 Patient sociodemographic and health characteristics
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The mean age of the physicians was 43 years (SD, 9.4 years) where 53% were male physicians and 47% were female physicians. Overall, 30% of physicians were pulmonologists, 18% were internal medicine physicians, and 52% were general practitioners or family medicine physicians. Also, 32% of physicians practised in government-sponsored hospital facilities, 30% in private clinics or doctors’ offices, 28% in private hospital facilities, and 11% in government-sponsored clinics or doctors’ offices. Overall, 64% of physicians had treatment facilities situated in a large/metropolitan city. The physicians’ area of practice and location of treatment facilities varied significantly among two or more of the surveyed countries (p < 0.0001) (Table 2).

Table 2 Physician sociodemographic characteristics
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Asthma Status

Physicians reported that 75% of their patients were adults, 24% of whom had experienced asthma symptoms, with 31% being new patients and 69% being follow-up patients. Overall, physicians categorised 44% of their patients as having mild asthma, 33% as moderate asthma, 13% as severe asthma, 6% as fluctuating severity, and 4% as unclear severity, with significant variations among two or more of the surveyed countries (mild asthma, p < 0.0001; moderate asthma, p < 0.01; other asthma categories, p < 0.001). Physicians estimated that 30% of their patients with mild asthma, 42% of those with moderate asthma, and 59% of those with severe asthma would experience ≥ 1 exacerbation annually requiring physician intervention, with significant variations among two or more of the surveyed countries (p < 0.0001 for mild and moderate asthma; p < 0.001 for severe asthma) (Table 3a). The use of the GINA questionnaire [47] to assess asthma control (40%) or achieve thresholds on patient-reported questionnaires (42%) was low in all the countries (Supplementary Material Table S2).

Table 3 Patient asthma status: (a) physician responses and (b) patient responses
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Overall, 58% of patients reported their current level of asthma severity as moderate, 34% reported their asthma severity as mild, and 8% reported their asthma severity as severe, with significant variations among two or more of the surveyed countries (p < 0.0001). The mean ACT score was 15.7 (SD, 4.14), suggesting uncontrolled asthma among patients. The mean ACT scores varied significantly among two or more of the surveyed countries (p < 0.0001). Overall, 82% of patients had uncontrolled asthma (ACT score < 20) (Table 3b). A logistic regression analysis was performed, wherein the dependent variable was defined by a dichotomous classification (uncontrolled asthma, ACT score < 20, or controlled asthma, ACT score ≥ 20) aiming to identify patient characteristics linked to uncontrolled asthma. This analysis suggested that age, adherence (based on how often patients reported forgetting to take their inhalers and how often patients reported using their daily controller inhaler), household smoking status, country, asthma severity (mild vs. moderate), and treatment type were significant predictors of uncontrolled asthma (p < 0.05, applicable for all variables listed) (Fig. 1).

Fig. 1
figure 1

Forest plot showing the odds ratios of uncontrolled asthma (ACT score < 20) versus controlled asthma (ACT score ≥ 20) for various patient-reported variables. N, 729; events, 602; pseudo-R2, 0.2632; 95% CI are shown within parentheses. Since the ACT regression included adherence as a predictor variable, the analysis was restricted to patients receiving controller treatment while those on inhaled reliever only were excluded. Moreover, only patients with mild and moderate asthma were considered in this regression. Since patients with severe asthma in the regression patient base were "uncontrolled" (i.e. ACT < 20), severe asthma became a definitive predictor, leading to the exclusion of deterministic patients from the analysis. Consequently, the regression was conducted without their inclusion. ACT Asthma Control Test, CI confidence interval, MART maintenance and reliever therapy, N total number of physicians included in the analysis, R coefficient of determination, UAE United Arab Emirates

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During the past 4 weeks, only 13% of patients described their asthma as uncontrolled (reported as ‘not controlled at all’ or ‘poorly controlled’), while 56% perceived their asthma to be well-controlled (reported as well-controlled or ‘completely controlled’). Despite having a perception of reasonable control, in the past 4 weeks, 90% of patients reported that they had shortness of breath ≥ 1 time/week, and 61% reported that their asthma symptoms woke them up at night or earlier than usual in the morning ≥ 1 time/week. Furthermore, 67% of patients used an inhaled reliever or nebuliser (≥ 2 times/week) during the past 4 weeks. Overall, 72% of patients indicated that their asthma hindered their productivity at work, school, or home at least some of the time in the past four weeks. All the above components of ACT scores including difficulties in daily life varied significantly among two or more of the surveyed countries (p < 0.0001). In the past 12 months, patients reported approximately five (SD, 8.0) visits to a clinic, doctor’s office, or emergency room due to an urgent need for asthma exacerbations, with approximately three (SD, 3.1) visits resulting in hospitalisation (Table 3b).

Treatment Preferences and Goals

For patients with mild asthma, 46% of physicians considered achieving symptom control as the most important goal, while 28% prioritised exacerbation reduction. For patients with moderate asthma, 39% of physicians emphasised symptom control as the most important goal, while 40% prioritised reducing exacerbations. For patients with severe asthma, 49% of physicians considered exacerbation reduction as the most important goal (Table 4a; Supplementary Material Table S2). Among patients with moderate asthma treated with controller therapy of ICS/LABA, the most significant factors noted by physicians influencing patient outcomes were asthma control (38%), asthma exacerbations (22%), and symptom severity (22%). Overall, 63% of physicians considered asthma control and asthma exacerbations as related outcomes of asthma treatment. Overall, 90% of physicians agreed that preventing future risk of exacerbations is a better strategy than to treat them once they occur (Supplementary Material Table S2).

Table 4 Treatment preferences and goals: (a) physician responses and (b) patient responses
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For moderate asthma, physicians frequently cited several factors for prescribing as-needed inhaled SABA reliever in addition to ICS/LABA as regular controller, including patients expressing a desire for an extra inhaler to feel safer (61%), patient familiarity with SABA (59%), and patient convenience in having an extra inhaler in their car, at work, or while travelling (51%) (Table 4a).

When prescribing therapies based on the maintenance and reliever therapy (MART), 38% of physicians prioritised asthma control as the most crucial factor, followed by asthma exacerbations (24%) and symptom severity (21%). Physicians were asked to identify key patient factors influencing their decision to prescribe inhaled SABA reliever in addition to ICS/formoterol as part of the MART approach. Patient familiarity with SABA was rated highest (64%), followed by patient’s desire for an extra reliever to feel safer (63%) and patients being accustomed to an extra reliever (53%); these categories were not mutually exclusive (Supplementary Material Table S2).

Overall, 41% of patients reported controlling daily symptoms as the most important clinical goal, followed by 22% who prioritised reducing the risk of asthma exacerbations, whereas 51% of patients considered controlling daily symptoms as the most important personal goal in asthma treatment (Table 4b). Overall, 56% of patients reported that their doctor had changed their asthma medications at least once, with major reasons being side effects (42%), asthma exacerbations (36%), and symptom worsening (35%) (Supplementary Material Table S3b).

Inverse Probability of Treatment Weighting Analysis

The inverse probability of treatment weighting (IPTW) analysis was conducted to understand whether the observed differences among countries for key variables remained when controlling for variations in patient characteristics across samples. In the weighted comparisons, significant differences between countries (p < 0.05) were found for all variables except adherence, current use of daily controller inhaler, and whether the patient was prescribed a separate inhaled reliever alongside their daily controller inhaler (Supplementary Material Table S4).

Asthma Treatment Patterns

Physician-Reported Treatment Patterns

For the initial treatment of moderate asthma, physicians reported that 76% of their patients were treated using regular dosing of controller inhaler. Overall, 20% of patients were prescribed with ICS/LABA with inhaled SABA, 15% with low-dose ICS with inhaled SABA, and 14% with ICS/formoterol as MART with inhaled SABA. Significant variations (p < 0.05) among two or more of the surveyed countries were observed for the initial treatment of moderate asthma. Physicians reported that 10% of patients with moderate asthma were treated without ICS-containing medications (inhaled SABA only, 8%; theophylline, 2%) (Fig. 2). When queried about the most preferred treatment for moderate asthma using a regular controller therapy, 50% of physicians selected daily ICS/LABA with or without inhaled SABA, 49% selected daily ICS/formoterol with or without inhaled SABA, and 1% selected other treatments (Fig. 3).

Fig. 2
figure 2

Physician-reported percentage of patients treated with different treatment classes for moderate asthma: a overall and b across countries. a Mean % values across all countries combined are reported; b mean % values of individual countries are reported. p value (determined by ANOVA means test for continuous data) indicated significant differences between countries. ap < 0.0001; bp < 0.01; cp < 0.05. ANOVA analysis of variance, ICS inhaled corticosteroid, LABA long-acting β2-agonist, MART maintenance and reliever therapy, N total number of physicians included in the survey, excluding those who responded ‘don’t know’ or ‘prefer not to say’, SABA short-acting β2-agonist, UAE United Arab Emirates

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Fig. 3
figure 3

Physician-reported preferred controller approach for patients with moderate asthma using regular controller therapy with ICS/LABA: a overall and b across countries. a % proportion values across all countries combined are reported; b % proportion values of individual countries are reported. ICS inhaled corticosteroid, LABA long-acting β2-agonist, N total number of physicians included in the survey, excluding those who responded ‘don’t know’ or ‘prefer not to say’, SABA short-acting β2-agonist, UAE United Arab Emirates

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For the initial treatment of mild asthma, physicians reported that 20% of their patients were treated with low-dose ICS with inhaled SABA, 18% with inhaled SABA only, and 13% with as-needed ICS/formoterol. If patients remained uncontrolled on initial therapy, 56% of physicians prescribed ICS/LABA with inhaled SABA, 38% prescribed low-dose ICS with inhaled SABA, and 38% prescribed as-needed ICS/formoterol as follow-up treatments. Significant variations (p < 0.05) among two or more of the surveyed countries were observed for the initial and follow-up treatments of mild asthma (Supplementary Material Figure S1a). In cases of mild asthma, when symptoms did not improve, 71% of physicians reported switching from one ICS/LABA regimen to another alternative ICS/LABA combination. Of these, 79% said that they switched ‘often’ or ‘sometimes’. In mild asthma, 33% of physicians cited asthma control as the most frequent reason for switching from one ICS/LABA regimen to another, 27% cited symptom worsening, and 25% cited asthma exacerbations (Supplementary Material Table S3a).

For patients with mild asthma, 77% of physicians considered frequency of symptoms as the most important indicator of asthma control when using an as-needed reliever, 67% considered frequency of nighttime awakenings, 63% considered occurrence of exacerbations in the past six months, and 62% considered interference with daily living activities (Supplementary Material Table S2).

For patients with mild asthma, 44% of physicians preferred prescribing pressurised metered-dose inhaler without a spacer as an as-needed inhaled reliever with ICS/formoterol, 20% preferred pressurised metered-dose inhaler with a spacer, 20% preferred dry powder inhaler, and 12% preferred nebuliser, with significant variations among two or more of the surveyed countries (p < 0.0001). Overall, 53% of physicians preferred inhaled SABA alone as the as-needed inhaled reliever with ICS/formoterol, 35% preferred ICS/formoterol, and 11% preferred inhaled SABA with ICS/formoterol. Overall, 48% of physicians reported once a week as the most appropriate amount of reliever use while 31% considered once a day as the most appropriate. Among patients with mild asthma treated with an as-needed ICS/formoterol inhaled reliever, 64% of physicians agreed not to exceed eight puffs within a 24-h period (Supplementary Material Table S5a).

For the initial treatment of moderate, severe, or fluctuating severity asthma, 39% of physicians considered ICS/LABA with as-needed inhaled SABA reliever, 18% considered as-needed ICS/formoterol, and 11% considered low-dose ICS with as-needed inhaled SABA reliever. If patients remained uncontrolled on initial therapy, 52% of physicians considered ICS/LABA with as-needed inhaled SABA reliever and 33% considered ICS/formoterol and as-needed ICS/formoterol (MART) with inhaled SABA as follow-up treatments. Significant variations (p < 0.05) among two or more of the surveyed countries were observed for the initial and follow-up treatments of moderate, severe, or fluctuating severity asthma (Supplementary Material Figure S1b). In moderate-to-severe asthma cases, 77% of physicians reported switching ICS/LABA regimen for non-improving symptoms. Of these, 82% said that they switched ‘often’ or ‘sometimes’. In moderate, severe, or fluctuating severity asthma, 32% of physicians reported symptom worsening as the most common reason for switching from one ICA/LABA to another, 29% reported asthma control, and 27% reported asthma exacerbations (Supplementary Material Table S3a). For patients with moderate or severe asthma, 66% and 74% of physicians prescribed ICS-containing controller medications once daily and twice daily, respectively, with an as-needed inhaled SABA (Supplementary Material Table S5b).

Overall, 87% of physicians demonstrated awareness of MART, where 98% were pulmonologists and 82% were family medicine and/or internal medicine physicians. Overall, 50% of physicians favoured ICS/formoterol, 20% favoured ICS/LABA with inhaled SABA, and 16% favoured ICS/LABA as an initial MART therapy. For patients with moderate or severe asthma, 62% of physicians preferred ICS/formoterol with or without inhaled SABA and 38% preferred ICS/LABA with or without inhaled SABA as the most preferred MART regimens (Supplementary Material Table S5c).

Patient-Reported Treatment Patterns

A regular dosing approach was preferred among 82% of patients at some point in time, with 92% being those with severe asthma. Among patients who had ever been prescribed this approach, 92% had been prescribed a separate inhaled reliever. Currently, 61% of patients were treated using a regular dosing approach involving daily controller inhaler with or without as-needed inhaled reliever and 13% strictly used MART approach. Approximately 39% of patients reported not using daily controller inhaler but using only an as-needed inhaled reliever to relieve symptoms. Of the patients who were prescribed daily controller inhalers, 51% reported using a daily controller inhaler at least once a day and 38% reported using their inhaled reliever at least once a day for quick symptom relief. The current asthma treatment regimens and the frequency of use of controller inhaler and inhaled reliever varied significantly among two or more of the surveyed countries (p < 0.0001). Overall, 88% of patients reported using a daily controller inhaler for quick relief of symptoms instead of an inhaled reliever (Table 5).

Table 5 Current medication regimens and prescribing behaviour—patient responses
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The awareness of MART approach primarily sourced from their doctors in 81% of patients or pharmacists in 14% of patients. Of the 84% patients who were prescribed MART at some point, 93% were prescribed a separate inhaled reliever (e.g. blue inhaler).

Vaccination

In reference to vaccination, 61% of physicians prioritised vaccination in all patients with asthma (irrespective of severity or current medication), while 24% recommended vaccination for patients with well-controlled asthma but may postpone it for those with uncontrolled or severe asthma. Overall, 97% of physicians recommended vaccinating their patients with the influenza (flu) vaccine annually and 79% recommended pneumococcal vaccines. Overall, 84% of patients reported receiving advice from their physicians to undergo vaccination to prevent infection. Within the past year, 9% of patients had received a vaccine other than the coronavirus disease 2019 (COVID-19) vaccine.

Perceptions of Asthma Control and Experiences and Barriers in Treatment

Overall, 86% of physicians and 84% of patients agreed or strongly agreed that asthma was well-controlled; 94% of physicians and 85% of patients were satisfied with their prescribed medication; and 82% of physicians and 85% of patients reported that the inhaler devices were easy to use. Overall, 55% of physicians and 62% of patients reported that medication costs were a significant barrier to filling prescriptions and taking medications as prescribed. Overall, 12% of physicians reported experiencing negative side effects associated with asthma medications, compared with 45% of patients perceived so. Similarly, in contrast to 21% of physicians who believed their patients experienced, 42% of patients reported that asthma treatments negatively impacted daily life (Fig. 4, Supplementary Material Table S6).

Fig. 4
figure 4

Experiences and perceptions in asthma treatment. N total number of physicians included in the survey, excluding those who responded ‘don’t know’ or ‘prefer not to say’. Note: Patient responses are on a positive scale

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There were significant differences between patient and physician responses for their ratings of agreement on asthma control, ease of use of inhaler devices, medication costs as barrier to filling prescription and taking medications, experience of negative side effects associated with asthma medications, and asthma treatments’ negative impact on daily life (p = 0.0021 for medication costs and p < 0.0001 for other parameters), except for the question on satisfaction with prescribed medications (Supplementary Material Table S7). In addition, a significant difference (p < 0.05; see Supplementary Material Table S6 for p values for each response) was observed in the responses across countries for all above variables, with the exception of physicians’ response to the question regarding the negative impact of asthma treatment on patients’ daily lives (Supplementary Material Table S6).

Discussion

The findings from the APPaRENT 3 study confirmed that, despite the high symptom burden, patients overestimated their level of asthma control. When managing patients with moderate asthma, physicians focused on exacerbation reduction and symptom control as treatment goals, and most frequently used a regular dosing approach (ICS/LABA with as-needed inhaled SABA reliever).

This study showed that approximately three of every four patients reported having moderate to severe asthma and presence of disease symptoms despite treatment. Approximately three of every four patients in the survey agreed that their asthma was well-controlled, that they were satisfied with their treatment, and that they found their inhaler devices easy to use. Approximately two of every four patients reported experiencing negative side effects with their treatment, which also negatively impacted their daily lives. Similarly, approximately three of every four physicians agreed that their patients believed that their asthma was well-controlled, were satisfied with prescribed medicines, and found inhalers easy to use. However, only 1─2 of every 10 physicians reported that their patients experienced negative side effects with their asthma medications or had a negative impact on daily life due to their medications. This discordance between physician and patient perceptions, which may have a negative impact on actual asthma control, treatment choice, and exacerbation risks, is in line with the findings of previous studies [48,49,50].

Asthma control may be over- and under-estimated by both physicians and patients, as shown previously [22, 24, 32, 36, 37, 49]. Similarly, APPaRENT 3 findings suggest that patients and physicians in these countries tend to overestimate asthma control, tolerating symptoms as being normal. The proportion of patients claiming their asthma to be well-controlled was very high despite the high symptom burden reported by them. The use of validated tools (ACT or Asthma Control Questionnaire) [35] may be useful to assess patients’ degree of asthma control. The current mean ACT score of 15.7 in the APPaRENT 3 sample suggests poor asthma control, with significant variation across participating countries. Owing to the poor ability to correctly identify level of asthma control, physicians should emphasise on regular higher doses of ICS or ICS/LABA to achieve better control, as symptoms may not be a reliable indicator.

In line with previous studies, physicians more commonly reported using regular dosing with ICS/LABA and as-needed inhaled reliever (SABA) as initial therapy for patients with moderate asthma and if patients remained uncontrolled on initial treatment [36, 37]. The national policy for refunding medication, local availability of drugs, and medication costs can determine treatment patterns. Previous studies [22, 24, 51, 52] have shown that patients may accept symptoms, exacerbations, and lifestyle constraints as an inherent part of living with asthma, but may not realise that effective treatments are available, and may believe that their asthma is controlled despite failing to achieve a guideline-expected asthma control. Raising patient expectations by increasing awareness of an enhanced quality of life [51] and reduced morbidity [10] could be a way forward for patients with asthma.

This study showed that patients and physicians prioritised asthma control and had high rates of inhaled SABA use across the participating countries. Patients most frequently reported using only an as-needed inhaled reliever (without controller inhaler), followed by both a daily controller inhaler and as-needed inhaled reliever. A minority of patients used one inhaler for both daily use and for use as an as-needed inhaled reliever. Approximately 10% of patients with moderate asthma did not use ICS-containing medications, which is key for asthma management. Recent publications [19, 53] have discussed concerns regarding SABA use and evaluated the safety of SABAs to advocate appropriate SABA use. Domingo et al. indicated that SABA overuse is likely to be the result and indicator of poor asthma control rather than the cause [19]. Vähätalo et al. [54] showed that high SABA use (≥ 3 dispensed canisters per year) was infrequent (10%) in patients with adult-onset asthma over a 12-year period. These high SABA users had good ICS adherence, yet experienced more frequent emergency visits, exacerbations, and courses of antibiotics and oral corticosteroids than those using SABA less frequently. Tavakoli et al. [55] showed that patients who received an appropriate amount of ICS had better continuity of care or visited a specialist were less inclined to engage in inappropriate use of SABA in the subsequent year. In APPaRENT 3, the top factor that physicians reported would convince them to prescribe an inhaled SABA in addition to ICS/formoterol as part of MART or ICS/LABA as regular dosing was patient familiarity with inhaled SABA, followed by patients expressing a desire to have an extra reliever. Changing patient habits regarding reliever use can be challenging, with factors such as the availability, access, and cost of relievers needing consideration within the local health system [10]. Increasing access to ICS-based controllers may facilitate improved asthma control, consequently reducing the habit of overusing inhaled SABA [19]. Busse et al. [56] clearly showed that the use of inhaled reliever was higher both before and after exacerbation. Recognising these patterns could prompt patients to implement their action plan and serve as a reminder to adhere to their regular controller therapy. Having real-time access to reliever data might alert clinicians and/or patients to an impending exacerbation.

In APPaRENT 3, the majority of patients (84%) reported having been advised to get vaccinated for preventing infections, with the majority of physicians generally recommending annual influenza vaccination (97%) and pneumococcal vaccines (79%). This was a new insight from this study, as it was not explored in previous APPaRENT studies [36, 37]. Further research including surveys and focus group interviews [57] may be helpful to better understand the knowledge, attitudes, beliefs, and behaviours of adults and healthcare providers related to adult vaccination in patients with asthma.

The unique aspects of the APPaRENT 3 study compared with previous APPaRENT studies [36, 37] were the inclusion of new countries, inclusion of pulmonologists, modified questionnaires with additional ranking questions, and new questions on prevention through vaccination. There were some methodological limitations associated with this survey. The findings may not be fully representative of real-world clinical practice due to specific populations being included in the survey, selection biases (e.g. individuals with higher education levels and those more concerned about asthma control being more likely to participate), and survey biases (e.g. reporting bias). Online panels may skew towards urban areas, thereby affecting rural practice under-representation. Being cross-sectional, this study offers only a snapshot of perceptions and cannot track changes over time. Recall-based reporting introduces respondent bias and limits data interpretability. Additionally, owing to the nature of the survey, responses could not be matched between physicians and patients. The results may not be generalisable across countries because of treatment and healthcare ecosystem variations. Selection bias, influenced by factors such as internet access, medication costs, and insurance coverage, is also a limitation.

Conclusions

The findings from the APPaRENT 3 study confirmed that, despite the high symptom burden, patients overestimated their level of asthma control. The patients prioritised symptom control over exacerbation reduction as their treatment goal. When managing patients with moderate asthma, physicians focused on exacerbation reduction and symptom control as treatment goals, most frequently used a regular dosing approach (ICS/LABA with as-needed inhaled SABA reliever) and anticipated high rates of asthma exacerbations. The findings from this study point to a need for better patient-physician communication, for understanding patient perspectives, aligning greater expectations from asthma treatments and outcomes, ensuring better adherence to ICS-based treatments, and optimising appropriate use of inhaled reliever medications.