An online survey detected knowledge gaps and cost-saving opportunities in asthma maintenance treatment among allergists, pulmonologists, ENTs and primary care

Abstract

BackgroundIn April 2017 the Mexican Asthma Guidelines (GUIMA) were published. Before the launch, physicians’ knowledge was explored related to key issues of the guideline. MethodsA SurveyMonkey® survey was sent out to board-certified physicians of 5 medical specialties treating asthma. Replies were analyzed per specialty against the GUIMA evidence-based recommendations. We present the treatment part here. ResultsA total of 364 allergists (ALLERG), 161 pulmonologists (PULM), 34 ENTs, 239 pediatricians (PED) and 62 general practitioners (GPs) replied to the survey and 247-83-14-135-37 respectively finished it. Spirometry is not routinely indicated when asthma is very probable by ALLERG 54%, PULM 47%, ENT 39%, PED 65%, GP 64%. A fictitious case proposed to the physicians with intermittent asthma was erroneously treated with ICS by ALLERG 9%, PULM 11%, ENT 28%, PED 10%, GP 11%. The mild persistent case received mistakenly ICS-LABA by ALLERG 25%, PULM 26%, ENT 33%, PED 27%, GP 23%. The first-line option for moderate persistent asthma was ICS(median dose) instead of ICS(low)+LABA for ALLERG 29%, PULM 25%, ENT 17%, PED 27%, GP 23% and in severe asthma maintenance treatment PULM20%, ALLERG-ENT-PED-GP 22-34% failed to indicate LABA. Concerning the guidelines’ recommendation to use one inhaler for maintenance & rescue in moderate-to-severe asthma, PULM45%, ALLERG-ENT-PED-GP 56-80% (p < 0.00001), erroneously indicated ICS-salmeterol could be used, instead of ICS-formoterol. Oral β2 or theophylline are no longer recommended, but PULM 37% and ALLERG-ENT-PED-GP 42-62% (p < 0.01) still indicate their use. In severe asthma 61-73% of physicians consider adding LTRA to the treatment; only PULM38%, OTHERS12-25% consider adding tiotropium (p < 0.001) and 3-17% consider adding omalizumab, both guideline recommended add-ons. As for asthma in pregnancy, most surveyed are not aware budesonide is the 1st line option ICS. Finally, 81-97% of the group-members recognized allergen immunotherapy, as a viable add-on, in line with GINA/GEMA/GUIMA recommendations. ConclusionsAn online survey could detect knowledge-gaps related to asthma treatment. Interestingly, surveyed physicians tended to over-treat the milder asthma cases, thus clearly leaving room for cost-savings. Caution should be taken in the promotion of the SMART (single-maintenance-and-reliever-treatment) approach, which can only be done with ICS-formoterol. Many physicians opt for other combinations not apt for this approach. Among all surveyed specialties there is ample room for improvement in mild and severe asthma management.