ABSTRACT Systematically assessing asthma during follow-up contacts is important to accomplish comprehensive treatment. No previous long-term studies exist on how comorbidities, lifestyle

factors, and asthma management details are documented in scheduled asthma contacts in primary health care (PHC). We showed comorbidities and lifestyle factors were poorly documented in PHC

in this real-life, 12-year, follow-up study. Documented information on rhinitis was found in 8.9% and BMI, overweight, or obesity in ≤1.5% of the 542 scheduled asthma contacts. Of the 145

patients with scheduled asthma contacts, 6.9% had undergone revision of their inhalation technique; 16.6% had documentation of their asthma action plan. Screening of respiratory symptoms was

HEALTH CARE: A 12-YEAR FOLLOW-UP STUDY Article Open access 21 October 2022 ASTHMA CONTROL AMONG TREATED US ASTHMA PATIENTS IN PRACTICE FUSION’S ELECTRONIC MEDICAL RECORD RESEARCH DATABASE

Article Open access 27 April 2023 SOCIO-DEMOGRAPHIC ENVIRONMENTAL AND CLINICAL FACTORS INFLUENCING ASTHMA CONTROL IN COMMUNITY PHARMACIES OF LAHORE PAKISTAN Article Open access 27 March 2025

INTRODUCTION Asthma is a long-term variable respiratory disease1 with low remission rates if diagnosed at adult age2,3,4. The reasons for poor asthma control are complex and may include

patient-, healthcare-, and therapy-related issues5. Comorbidities such as obesity, allergy, rhinitis, gastroesophageal reflux, psychiatric disorders, obstructive sleep apnea, bronchiectasis,

and sensitivity to non-steroidal anti-inflammatory drugs (NSAIDs) are common in asthmatics6,7,8,9,10,11,12,13. Asthma-related comorbidities may contribute to poor disease control by

aggravating or mimicking symptoms, thus making it more difficult to distinguish true, severe asthma from difficult-to-treat asthma7,9. This, in turn, may lead to overtreatment or

undertreatment with anti-asthma medication or lead to misdiagnosis6,7. The risk of multiple, non-respiratory comorbidities has been shown to be higher in late-onset asthma11,14.

Socioeconomic factors15,16, poor adherence to inhaled corticosteroids (ICS)1,5, problems in inhalation technique1,5 and lifestyle factors such as smoking17 and low physical activity18, are

also, in addition to comorbidities, associated with poorer asthma control. Self-management, including education, personal action plan, and structured follow-up, are strongly recommended as

key components of asthma care and are shown to improve asthma control and reduce patients’ use of health-care resources and costs19,20. The aforementioned aspects underscore why regular

holistic assessment and guidance of asthma patients is important1. Annual follow-up reviews do not, unfortunately, occur often according to guidelines21,22,23,24, even in severe asthma25,26,

that is shown to be underdiagnosed in primary health care (PHC)27. The lack of regular follow-up is not limited only to primary care21,22, when studies with patients from both primary and

specialised care have also suggested that ~50–70% of patients23,24 and over 30% in severe asthma26 had no annual planned contacts. Moreover, adherence to asthma guidelines has been reported

to be suboptimal among health-care practitioners21,28,29,30. Based on those factors, one might assume asthma evaluation is largely carried out, e.g., during visits made for other conditions

or for acute exacerbations. However, in visits where asthma is not the only issue of attention, or if the visit has been made, e.g., due to acute exacerbation, no similar possibility for a

comprehensive asthma assessment exists, arguably, except in planned follow-up contacts. Thus, it can be considered important to discover how systematically asthma assessments are performed

in visits that focus purely on asthma to evaluate how guidelines are implemented in asthma monitoring. The main responsibility for asthma treatment was shifted to PHC within the Finnish

National Asthma Programme31. Important programme goals, were, e.g., active asthma treatment, use of lung function tests as part of control assessment, patient education together with guided

self-management, and possible trigger evaluation31. Our previous long-term study showed that adherence to lung function measurements, especially to spirometry, in assessing asthma control

was high in PHC22. Conversely, the frequency of asthma follow-up contacts was insufficient22, as was smoking data and smoking cessation documentation32. Previous studies, mainly based on

self-reports or short-term follow-ups, have suggested several shortcomings in asthma management in PHC, including asthma control assessment30,33,34, self-care guidance33,34, rhinitis

screening and treatment35,36, inhaler technique review30,34 and physical activity, nutrition and alcohol consumption assessment34. To the best of our knowledge, no previous long-term

real-life studies exist on how comorbidities, lifestyle factors, and asthma management details, such as inhalation technique and medication data, are screened and documented in scheduled

asthma contacts during long-term follow-up in PHC, being the current study’s aim. Our additional aim was to assess whether there are differences according to who encountered the patient at

the follow-up visit (GP, nurse, or both). METHODS SETTING OF THE SAAS STUDY The study was part of the Seinäjoki Adult Asthma Study (SAAS), a real-life, single-centre, 12-year follow-up study

of 203 patients with new-onset asthma diagnosed at adult age (≥15 years). The details of the SAAS study protocol with inclusion, exclusion and specific diagnostic criteria were published

separately (eTable 1)37. The original study cohort comprised 256 patients with new-onset asthma diagnosed between 1999 and 2002 in Seinäjoki Central Hospital’s respiratory department by a

respiratory physician based on typical symptoms and was confirmed by objective lung function measurements. Smokers and patients with concomitant COPD or other comorbidities were also

included37. The patients were treated and monitored by their personal physicians after the diagnosis was confirmed and the medication started, mostly in PHC, according to the Finnish

National Asthma Programme31 as described previously22,37. The patients were invited to follow-up visit in the respiratory department after 12 years (mean 12.2, range 10.8–13.9 years). Of the

original study population, 53 patients were lost to follow-up (Supplementary Figure 1) and 203 patients completed a follow-up visit, where asthma status, disease control, comorbidities, and

medication were evaluated using structured questionnaires and lung function was measured37,38. The participants in the follow-up visit gave written informed consent to the study protocol

approved by the Ethics Committee of Tampere University Hospital, Tampere, Finland37. All data of the asthma-related health-care contacts (_n_ = 3639) during the 12-year period were collected

from PHC, occupational health care, private clinics, and hospitals in addition to the data gathered at diagnostic and follow-up visits, as previously described22,37. Each patient, on

average, had 4 [interquartile range (IQR) 1–6] scheduled asthma contacts and, overall, 15 (IQR 9–23) asthma-related health-care contacts during the follow-up period. The SAAS study flowchart

and schematic presentation are shown in the supplementary material (eFig. 1; eFig. 2). The SAAS study is registered at www.ClinicalTrials.gov with identifier number NCT0273301637. STUDY

DESIGN AND POPULATION All asthma-related health-care contacts (_n_ = 3639) of the 203 patients during the 12-year follow-up period were retrospectively assessed in the present study (Fig.

1). The following definitions were used to categorise different asthma contact types: * _Primary health care (PHC) contact_: contact made in primary health care centre or in occupational

health care. * _Secondary care contact_: contact in specialised care in respiratory department. * _Private health care contact_: contact in private health care. * _Doctor/GP contact_:

contact with only GP participating in the asthma assessment. * _Nurse contact_: contact with only nurse participating in the asthma assessment. * _Both doctor/GP and nurse contact_: contact

with both professionals participating in the asthma assessment. * _Scheduled asthma contact_: planned monitoring contact that purely focused on asthma. * _Office-based contact_: patient

encountered the professional face-to-face. * _GP telephone contact_: a doctor phone call to a patient regarding asthma. * _Other than scheduled asthma contact_: includes other asthma-related

health-care contacts, excluding planned asthma contacts. * _Unclear type of contact_: the exact type for the contact could not be determined. * _All asthma-related health-care contacts_:

includes scheduled asthma contacts and contacts made for infection, exacerbation, or for asthma and other reason. We excluded contacts made for infection, exacerbation or for asthma and

other reason of all the asthma-related contacts (_n_ = 3639) (Fig. 1). Of the total 203 patients, 154 had scheduled asthma contacts (_n_ = 607) in PHC, while 20 patients’ follow-up was

arranged in secondary care or in private health care, and 29 patients had no planned follow-up contacts between the diagnostic visit and the 12-year follow-up visit as our previous study

described22. Overall, of all scheduled asthma contacts during the 12-year follow-up, 742 occurred in secondary care, 49 in other locations, and two contacts’ locations were unclear. Our

previous studies described the occurrence of scheduled asthma contacts in PHC and the overall occurrence of asthma follow-up contacts in the SAAS study population22,23. We included all

office-based, scheduled asthma contacts (_n_ = 542) in PHC in this study. GP telephone contacts (_n_ = 65) were excluded because these were often short phone calls, e.g., due to a previously

made medication change, discussion of current test results, or the need for specific medical certificates, and were basically not intended to replace a more comprehensive face-to-face

assessment. Nine patients had only telephone contacts of the total population of 154 patients with scheduled asthma contacts in PHC. Thus, after exclusion of GP telephone contacts, the total

population in this study with office-based, scheduled asthma contacts was 145 (Fig. 1). The data of 145 patients and the data gathered from their office-based, scheduled asthma contacts in

PHC were manually collected and evaluated. EVALUATION OF THE CONTENT OF ASTHMA CONTACTS ACCORDING TO PROFESSIONAL We divided the 542 scheduled contacts into three groups (GP, nurse, or both)

to evaluate whether differences exist in how comorbidities and other asthma-related data were documented. The contacts were evaluated according to who was responsible for the patient in the

office-based asthma follow-up contact: 310 were GP contacts,103 were nurse contacts, and 129 were combined GP and nurse contacts (Fig. 1). Of 129 combined GP and nurse contacts, the patient

first met the nurse and the GP thereafter at the same visit in 83 contacts; the patient met the nurse and the GP was only consulted in 46 contacts. COLLECTION OF DATA ON COMORBIDITIES,

LIFESTYLES, SYMPTOMS, AND ASTHMA MANAGEMENT We collected information on the comorbidities associated with asthma, including obesity, nasal conditions, gastroesophageal reflux, obstructive

sleep apnea (OSA) and intolerance to NSAIDs. The evaluated nasal conditions included chronic/allergic rhinitis, sinus infections and nasal polyps. We also collected information on

documentation of obesity-related lifestyle factors (including exercise habits, diet, and alcohol use), asthma symptoms, and patient guidance. All documented medication and data considering

inhalation technique were manually collected from patient records and evaluated. Our previous studies described performance of lung function tests, documentation of smoking data and smoking

cessation activities in scheduled asthma contacts in PHC22,32. ASSESSMENT OF LUNG FUNCTION, ASTHMA CONTROL, SEVERITY, AND OTHER CLINICAL PARAMETERS The lung function measurements were

performed with a spirometer according to international recommendations at the diagnostic visit and at the 12-year follow-up visit37,38. The fraction of exhaled nitric oxide (FeNO) was

measured with a portable rapid-response chemiluminescent analyser according to American Thoracic Society standards39 (flow rate 50 mL·s−1; NIOX System, Aerocrine, Solna, Sweden). Venous

blood was collected, and white blood cell differential counts were determined. Total immunoglobulin (Ig)E levels were measured by using ImmunoCAP (Thermo Scientific, Waltham, USA).

Laboratory assays were performed in an accredited laboratory (SFS-EN ISO15189:2013) of Seinäjoki Central Hospital. Patients completed the Asthma Control Test (ACT) and Airways Questionnaire

20 (AQ20) in the 12-year follow-up visit40,41. An asthma control assessment was performed according to the Global Initiative for Asthma (GINA) 2010 report42. Severe asthma assessment was

performed according to the ERS/ATS severe asthma guideline 201443. Adherence to inhaled corticosteroid (ICS) medication was evaluated by comparing the dispensed doses to the prescribed doses

for the whole 12-year period as our previous studies described44,45. The prescribed dose in each patient was calculated based on medical records, and the dispensed ICS, short-acting

β2-agonist (SABA) and oral corticosteroids were obtained from the Finnish Social Insurance Institution, which records all purchased medication from all Finnish pharmacies44,45. The 12-year

adherence and annual adherence for each patient were calculated using specific formulas previously described, considering aspects from the medication possession ratio (MPR) and proportion of

days covered (PDC)44. Information on alcohol consumption was assessed by detailed structured questionnaires at the 12-year follow-up visit. Heavy alcohol consumption was evaluated by

self-report, GT-CDT index or both. An alcohol consumption assessment was performed according to the US definitions for alcohol consumption by portions/week (portion indicates 14 g

alcohol)46. Serum levels for carbohydrate-deficient transferrin (CDT) were measured by a turbidimetric immunoassay (TIA) after ion exchange chromatography (%CDT, Axis-Shield, Oslo, Norway);

plasma γ-glutamyltransferase (GT) concentration was measured using enzymatic colorimetric assay, as standardised against IFCC (International Federation of Clinical Chemistry and Laboratory

Medicine). More detailed information on GT and CDT measurements and on calculating the GT-CDT index has been previously reported47. THE FINNISH HEALTH-CARE SYSTEM DURING THE STUDY The

production of public health care services was the municipalities’ responsibility during the study follow-up period48. Finland was divided into 21 hospital districts that provided specialised

medical care for the population in their own areas, and approximately 160 health-care centres provided the primary health-care services described previously22. Employers were obligated to

offer occupational health-care services for their employees in addition to the municipal system48. Financial incentive systems affecting what will be recorded were not in use in public or

occupational health care. Primary health-care services could also be sought from private health care mainly financed by the patients’ own expence48. However, the availability of private

health-care services during the study period was very limited in the study region compared to bigger cities. Consequently, most patients could use only public health-care services. Thus, in

this and in our previous studies22,23,32, planned asthma follow-up contacts in health-care centres and in occupational health care were considered scheduled PHC contacts. All health-care

centres in the region had respiratory nurses and a coordinator GP responsible for asthma management in the health-care centre, yet all GPs managed their own asthma patients during the study

period. A common electronic patient record system was not yet used in the region, and professionals could use different and separate software in primary health-care centres, hospitals, and

private health care. Our previous study also discussed the Finnish health-care system22. STATISTICAL ANALYSIS Continuous data are expressed as mean (SD) for variables with normal

distribution and for parameters with skewed distributions medians, and 25–75 percentiles are shown. Group comparisons were performed by using Pearson Chi-square test for categorised

variables. Two-sided _p-_values were used. A _P_-value < 0.05 was regarded as statistically significant. Statistical analyses were performed using SPSS software, version 27.0.1 (IBM SPSS,

Armonk, NY). REPORTING SUMMARY Further information on research design is available in the Nature Research Reporting Summary linked to this article. RESULTS CHARACTERISTICS OF THE STUDY

POPULATION Of the 203 total patients in SAAS study, 145 had scheduled office-based asthma contacts in PHC with a GP, nurse, or both. Most patients with PHC follow-up visits were female

(63.4%). The mean age was 59.3 and BMI 28.4 at 12-year follow-up visit; thus, the study population was characterised with overweight. Half of the patients were ex- or current smokers, 37.4%

were atopic (at least one positive skin prick test of common allergens), 69.7% had rhinitis, 8.3% had treated dyspepsia, and 31.0% of the patients had uncontrolled asthma according to GINA

201042. The total adherence to ICS medication (ug budesonide equivalent dispensed/ug budesonide equivalent prescribed *100) during the 12 years was 81.3% among patients with scheduled

office-based asthma contacts in PHC. Table 1 shows the characteristics of the study population at the 12-year follow-up visit. The Supplementary Material (eTable 2) shows the baseline

characteristics of the 145 patients. DOCUMENTATION OF COMORBIDITIES AND LIFESTYLE FACTORS IN SCHEDULED ASTHMA CONTACTS All documented data was collected and analysed from the full 12-year

follow-up period to evaluate the comorbidities and lifestyle factors assessments in scheduled asthma contacts in PHC. Documentation was seldom done for comorbidities such as obesity,

overweight, rhinitis, sleep apnea, reflux symptoms, and intolerance to NSAIDs in the 542 scheduled asthma contacts in PHC. The occurrence of possible chronic or allergic rhinitis was

documented in 8.9% of contacts and reflux symptoms in 1.1% of contacts (Table 2). Chronic or allergic rhinitis was mentioned in 35 subjects (24.1%) of the 145 patients with scheduled asthma

contacts in PHC (eTable 3). Obesity or overweight were documented only in 0.9% to 1.3% of contacts, and the information on BMI was found in 1.5% of the contacts of the total 542 scheduled,

office-based asthma contacts (Table 2). Recorded information on BMI was found in 8 patients (5.5%) out of 145 patients with scheduled asthma contacts in PHC. Overall, BMI and/or possible

overweight or obesity were mentioned in 15 patients’ (10.3%) health records (eTable 3). Exercise habits were the most-often documented lifestyle factor, in 16.2% of the contacts (Table 2)

and in 49 (33.8%) of the patients at least once (eTable 3). Dietary matters and alcohol consumption were rarely mentioned (Table 2). We evaluated whether differences exist in the

documentation of comorbidities or lifestyle factors according to who is responsible for the patient in the office-based asthma contacts; the GP, nurse, or both. However, no significant

differences were found in recording comorbidities, but out of lifestyle factors, exercise habits were more-often mentioned (from 21.7% to 29.1%) if the nurse participated in the scheduled

contact (Table 2). DOCUMENTATION OF ASTHMA SYMPTOMS, MEDICATION, AND PATIENT GUIDANCE Data on asthma management details (asthma symptoms, including ACT, medication, inhalation technique,

patient guidance, etc.) during the follow-up period were collected and analysed. Figure 2 shows the documentation of collected asthma management details during scheduled asthma contacts

(=542) in PHC. The occurrence of possible respiratory symptoms was recorded in 79.0% of visits and in 86.8% if both nurse and GP took part in the scheduled contact of the 542 scheduled PHC

asthma contacts (Table 3). Nasal symptoms were mentioned in only 15.5% of the contacts (Table 3) and, overall, at least once in 52 patients (35.9%) (eTable 3). Data on the Asthma Control

Test (ACT)40 was seldom found, in only 6.3% of contacts, but it was documented more often if both the nurse and GP participated in the contact (15.5%). Pulmonary auscultation data were

registered in 72.9% of the physicians’ contacts. The brand names of the entire asthma medication were recorded in 70.3% of all contacts (_n_ = 542), while complete dosage of the medication

and inhaler names or types were recorded less often in only 13.5% and 11.4% of all contacts. Overall, asthma medication data were mostly only partially documented and were more frequently

mentioned if both professionals attended in the contact (Table 3). Changes in asthma medication were made in 26.8% of visits and more often during contacts when the GP was involved (36.1%).

The information on inhalation technique revision was documented in only 2.2% of contacts (Table 3) and more by nurse (8.7%), but out of all 145 patients, it was revised in only 10 (6.9%)

patients during 12-year follow-up (eTable 3). Regarding medication for comorbidities, medication for the nose was started or changed 23 times and twice for reflux symptoms in scheduled

asthma contacts during the 12-year follow-up (Table 3). Nasal medication was documented at least once in 46 patients (31.7%) and reflux medication in 8 patients (5.5%) out of 145 patients

(eTable 3). Of all scheduled asthma contacts, the timing for the next scheduled follow-up contact was recommended in 62.5% of contacts and more often when the GP or both professionals were

involved. In contrast, an asthma action plan (AAP) was recorded in only 5.0% of contacts (Table 3), and of all patients, only 24 (16.6%) had an AAP documented during the 12-year follow-up

(eTable 3). Guidance on lifestyles (to lose weight, to increase exercise, or to reduce alcohol intake) was also rarely documented (Table 3). DISCUSSION In this 12-year, real-life, follow-up

study we showed that comorbidities, lifestyle factors, inhalation technique, and asthma action plan were poorly documented during scheduled asthma contacts (_n_ = 542) in PHC in Finland. The

most frequently recorded asthma details were respiratory symptoms (79%), asthma medication brand names (70%), and the recommendation for the timing of the next follow-up contact (62.5%).

All these details were found even more often if the nurse and GP both participated in the contact. Rhinitis was the most-often documented comorbidity, but it was registered only in 8.9% of

all contacts. Recorded information on possible lifestyle guidance interventions given to the patients was found in <1% of contacts. Results from this longitudinal study may help to

identify potential health-care practice-related causes of uncontrolled and difficult-to-treat asthma, and which areas require more urgent training and attention. Obesity has been shown to be

associated with uncontrolled and severe asthma1,2,3,27,49,50,51, poorer work ability12, lower lung function, more dispensed oral corticosteroids with higher doses, and higher health-care

costs50, and it is a risk factor for asthma exacerbations even in patients with few symptoms1. Adult patients with asthma are at a higher risk of developing obesity52. Moreover, obesity has

been shown to be a permanent problem in more than 85% of adult patients with asthma in long-term follow-up50. Weigh reduction in obese adults, also after bariatric surgery53, has shown to

lead to overall improvement in asthma control, including airway hyper-responsiveness and inflammation54. We showed in this study that professionals rarely documented information about a

patient’s BMI, overweight, or obesity. According to documented information, patients received no guidance in relation to obesity-related lifestyle factors during long-term follow-up, even

though these factors are also shown to contribute to asthma independently. For example, low physical activity is associated with faster lung function decline18, dietary components are

suggested to affect immune pathways in asthma55, and prolonged and heavy alcohol exposure may impair mucociliary clearance and may complicate asthma management56. A previous study based on

physicians’ self-reports regarding clinical practice indicated that, overall, very few GPs assessed asthma patients’ lifestyle factors34, which is in line with our results. Overall, based on

documented patient data, lifestyle factors were poorly registered; however, nurses mentioned exercise habits in almost every third contact. Lifestyle guidance was more the nurse’s

responsibility in previous national and local asthma programmes, which may explain this result. Allergic rhinitis is known as a predominant comorbid disease in difficult-to-treat

asthma36,49. Chronic rhinosinusitis is known to be an independent predictor of asthma exacerbation among patients with difficult asthma9,57. Considering the unity of the upper and lower

respiratory tract, the concept called ‘united airways’, screening and treating of rhinitis and other nasal conditions in asthma is important57,58. Thus, evaluating possible nasal symptoms

and adherence to nasal medication should be assessed in every asthma contact. Medications treating nasal diseases have also been shown to be useful in improving control of asthma and

reducing bronchial hyper-responsiveness58. A recent study showed that approximately 67% of the patients with moderate-severe rhinitis were not using the recommended intranasal corticosteroid

therapy36. Aligning with previous studies35,36, our results showed that even though rhinitis is highly prevalent49, its screening and treatment in patients with asthma was suboptimal in

PHC. In our study 70% of patients had rhinitis but it was recorded in less than every tenth and, overall, nasal symptoms less than in every fifth contact. The initiation of rhinitis

treatment was rare. Based on recorded nasal medication data, over half of the patients with rhinitis may have been undertreated when medication for chronic rhinitis has been available only

with a doctor’s prescription. Documentation of reflux symptoms, OSA and intolerance to NSAIDs was similarly underperformed, despite all these conditions being associated with severe asthma,

poor symptom control, and more frequent exacerbations and hospitalisations8,10,51,59,60. NSAIDs (including aspirin) may exacerbate asthma symptoms in patients with N-ERD (NSAID-exacerbated

respiratory disease), a chronic eosinophilic inflammatory disorder of the respiratory tract occurring in patients with asthma and/or rhinosinusitis with nasal polyps10. A recent study showed

that the prevalence of N-ERD was 6.9% among asthmatics60, while the prevalence of gastroesophageal reflux varies between 17–74%7,9 and the prevalence of OSA ~39–50%6,9. Reflux disease and

OSA may arguably have been underdiagnosed in our study population, considering a majority have a BMI > 25. OSA was probably not yet well known in PHC during the current study’s time

period, and recognition improved after the national sleep apnea programme in Finland (2002–2010)61. The results in this and our previous studies22,32 suggest that implementation of the

Finnish National Asthma Programme’s31 main objectives has been partially successful in PHC, but room still exists for improvement (Fig. 3). We found in this study that screening of asthma

symptoms as a part of asthma control assessment has been managed well in PHC. Cloutier et al.’s previous study30 showed that physicians monitor selected symptoms depending on the symptom,

from 48.4% to 56.0%. We were unable in this study to assess more precisely the extent of the symptoms’ evaluation and of the patients’ true symptom burden; thus, more research regarding this

issue is needed in the future. Patients have been shown to overestimate their asthma control36, which supports assessing asthma control using objective methods such as lung function tests

together with symptom questionnaires. ACT documentation was rarely found in our study, similar to previous studies in which validated patient-reported questionnaires were rarely used to

monitor asthma control28,30. ACT was not yet in wide use in Finland during the SAAS study period, which probably explains our results to some extent. Pulmonary auscultation was recorded in

almost 3 of 4 physicians’ contacts but never in nurses’ contacts, which is explained by the fact that pulmonary auscultation is usually performed only by a doctor in Finland. It is essential

that the complete asthma medication information, including names, doses and inhalers, is documented in patient records for continuity of care, because the professional responsible for

patient care may change. The common electronic patient record system was not yet in use in our region during the SAAS study period, and some patients still had handwritten paper

prescriptions in addition to those that were prescribed through the electronic patient health record system. As a result, the patient health record system did not necessarily have an

up-to-date medication list or information about possible changes to medication made elsewhere, which also advocates for the importance of recording medication information. Asthma medication

brand names were mentioned in 70% of scheduled contacts in our study, but dosage and inhalers were documented in only <14% of contacts. Only doctors had the right to prescribe medicines

during the study period, which explains why medication changes were more common in visits when a GP was involved. This study and our previous studies22,23, show that patients with ≥2

scheduled contacts in PHC had high mean adherence to ICS medication (>80%), and their adherence level was higher compared to patients who had mainly follow-up contacts in secondary care

(82% vs. 52%)23. Higher adherence was associated with non-controlled disease in SAAS-study population, while total adherence <80% was associated with more rapid lung function decline in

not-controlled disease62. Our results suggest that professionals in PHC are good at promoting adherence to asthma medication. We were unable in this study, unfortunately, to assess in more

detail how medication adherence was evaluated and if discussion supporting adherence to treatment, occurred at the contacts. The names of the medications in use were recorded well and

adherence was high, so it can be assumed that treatment compliance in medication was discussed in the follow-up contacts to some extent. It could be speculated that continuity of care may be

one reason for the good adherence when it was also shown that the recommendation for the timing of the next scheduled contact was documented in over 62% of contacts and in almost 70% if

both professionals were attending. Incorrect inhaler technique is common and can lead to poor asthma control1. Previous studies from Sweden and Finland showed that 87–97% of patients

reported that they had received education about inhalation technique24,63. Another study from Australia revealed that patients overestimated the true success of their own inhalation

technique when 73% of patients believed they did well, whereas an objective assessment showed that all patients had at least two errors and over 70% exhibited five or more errors36. In

studies from the U.S. and Australia, 17–30% of PHC clinicians reported assessing inhaler technique30,34, but based on documented and reported patient data, only 1–5% of patients had their

inhaler technique checked21,36, which is in line with our results. Checking the inhalation technique is usually the nurses’ task in the Finnish health care system, but still, according to

recorded patient data, this was performed in approximately only 8% of nurse contacts, which is alarming. AAP is a description of how an individual should manage asthma, including advice for

medication changes, if necessary, and a plan for contact with the health-care system20. Use of written action plans is suggested to be poor both in PCH and in secondary care33 and shown to

vary from 0 to 50%21,28,30,33,34. A previous study from Finland showed that over 78% of adult asthmatics reported having an asthma self-management plan24, but based on our results, AAP was

not assessed or updated during planned contacts according to documented data. Recorded information on AAP was found in only 5% and written action plan in 1% of contacts, which can be

considered surprising when one of the Finnish Asthma Programme’s most important goals was patients’ self-care guidance, including provision of both written and verbal asthma action plans31.

Every patient in the SAAS study population received both verbal and literal asthma guidance, usually immediately upon asthma diagnosis confirmation in the respiratory department. Thus, could

be argued whether the existence of an AAP was considered self-evident in PHC; however, it does not justify the omission of an AAP assessment. Chapman et al. suggested that physicians tend

to rely upon advances in pharmacological intervention to improve the quality of asthma care rather than the non-pharmacological aspects of asthma management28. Our results showing that AAP

and lifestyle interventions were poorly implemented in scheduled follow-ups in PHC support that. A recent UK study showed that many factors, such as poor attendance at asthma clinics, lack

of time, demarcation of roles, limited access to a range of resources and competing agendas in consultations that are often due to multimorbidity, may increase the risk that self-care

guidance is not provided during contacts64. These potential barriers are important to recognise when developing asthma monitoring and treatment guidance in the future. This study’s major

strength is its use of a real-life, unselected, adult-asthma population when patients with smoking or comorbidities were not excluded. Thus, our study population represents a typical PHC

population with asthma37,65. Their asthma diagnosis was originally made by a respiratory physician based on typical symptoms and objective lung function measurements showing reversibility of

airway obstruction37. All scheduled asthma contacts in PHC were evaluated in this study, including both nurse and GP visits, and the overall number of scheduled contacts may be expected to

yield a representative sample of a real-life, adult-asthma population. We acknowledge that the significance of comorbidities in asthma control was perhaps not as well understood in 2002

compared to today. However, all the comorbidities with the exception of OSA, as well as other asthma management details evaluated in this study, have already been discussed in the first

Finnish asthma guideline in 2000 and also e.g., in the GINA 2002 recommendation66,67. Therefore, it can be estimated that PHC has had opportunities to apply the best evidence-based practices

during the study’s period. This study’s results are valuable because long-term, real-life, follow-up studies of adult-onset asthma in PHC are rare. Our results help to understand the

possible health-care-related causes behind uncontrolled and difficult-to-treat asthma, e.g., which areas in assessing asthma require more specific training and attention. A possible weakness

of our study is that, e.g., comorbidities and other asthma-related details evaluated may have been screened and discussed during scheduled contacts or assessed earlier in other contexts,

but these data have not been recorded. However, according to good clinical practice, the measures taken shall be recorded; otherwise, it can be interpreted that this has not been performed,

or that the existence of the matter and its possible connection has not been considered. Additionally, regarding continuity of care, it is important that patient document entries are done

well. We were unable in this study to assess more precisely either the extent of symptoms’ evaluation or the content of AAP instructions. Other important aspects of asthma care were not

assessed in this study, such as exacerbations and trigger avoidance. More research is needed to evaluate these topics. Another limitation of our study is that our results may not represent

Finland entirely, and it may not reflect the current situation, because the data were collected between 2002–2013. No common national asthma template is in use, and the recording practices

may also differ regionally, e.g., due to different electronic health record systems. The use of ready-made phrase templates has become more common since the SAAS study period, which may have

improved screening and assessment of asthma control-related issues. However, problems with accessibility to PHC have been increasing48,68, and it is very likely that asthma treatment and

follow-up is largely carried out during visits for other conditions or for other reasons. A new, long-term follow-up study from the 2010s to 2020s would be needed to assess the current

situation and whether asthma assessment has improved since the follow-up period in this study. Asthma control was defined according to GINA 2010 criteria at the 12-year follow-up visit, and

asthma severity was classified according to the ERS/ATS 2014 guideline42,43. We consider it correct to use the data as they were collected and evaluated at the clinical visit on asthma

control and as used in the original SAAS study material, even if asthma control and asthma severity criteria have change since then. Regular monitoring is important when adult-onset asthma

is often in non-remission2,3,4. The causes of poor asthma control can be complex1,5, and as shown in this study, based on documented patient data, the systematic assessment of asthma should

be further improved in scheduled asthma contacts. However, our results also suggest that need exists to pay more attention to the quality of patient document entries in PHC in Finland69.

Based on this study, the importance of screening and treating asthma-related comorbidities in PHC should be given more attention, especially those associated with uncontrolled and severe

asthma. Documentation and follow-up of BMI data, together with guidance on healthy lifestyles and weight management, should be emphasised more in asthma guidelines as part of routine

management. Reviewing asthma inhaler technique and patient self-care guidance are also central areas needing improvement. Based on these results, it is obvious that health-care personnel

need continuous training in asthma management. In general, evaluation of lifestyle factors, patient guidance, lung function test performance, and revision of inhalation techniques have

largely been the nurse’s responsibility, while the doctor’s task has been more to assess asthma control, medication, and patients’ personal treatment recommendation. The regular asthma

follow-up could be carried out largely by the nurses, because not every patient needs a doctor’s assessment every year if their asthma is well controlled. Nevertheless, the nurse can gather

information to assess asthma control and consult the doctor if needed. Asthma is one of our most common chronic diseases, but one could speculate whether its assessment is considered as

important as, e.g., cardiovascular diseases, and whether possible multi-morbidities11,14 divert attention from asthma itself. The establishment of 21 well-being services counties to replace

the former hospital districts since the beginning of 2023 in Finland has provided a new basis for developing uniform health-care services covering larger regions. It would be possible in

this context to develop and update uniform asthma treatment chains covering entire regions and even to implement national asthma templates and educate professionals in systematic asthma

assessment. This could improve asthma management. Further promoting the use of structured phrase templates could support asthma assessment in scheduled contacts, because it has been shown

that evidence-based EMR interventions improve the asthma documentation and provision of asthma care70. In addition, shorter and clearly structured guidelines could be easier to implement in

PHC71. Given the complexity of asthma care, sufficient time and resources for asthma assessment must be guaranteed for comprehensive evaluation and patient guidance to be successful. More

research is needed to evaluate the overall asthma care that is currently obtained in all asthma-related contacts in PHC and to guide health-care personnel education regarding asthma

monitoring in the future. In conclusion, we showed in this real-life, 12-year, follow-up study that comorbidities, lifestyle factors, inhalation techniques, and asthma action plans were

poorly documented in scheduled asthma contacts in PHC. Our results, based on documented patient data, suggest that the comprehensive assessment and guidance of asthma patients still needs to

be improved in PHC. DATA AVAILABILITY All data generated or analysed during this study are included in this published article and its Supplementary Information File. According to ethical

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ACKNOWLEDGEMENTS Aino Sepponen, RN, is gratefully acknowledged for her help through all the stages of this work. We also wish to acknowledge Heidi Andersén, MD, PhD, for the idea of the Fig.

3. This study was supported by the Tampere Tuberculosis Foundation (Tampere, Finland), the Finnish Anti-Tuberculosis Association Foundation (Helsinki, Finland), the Jarmari and Rauha Ahokas

Foundation (Helsinki, Finland), the Allergy Research Foundation (Helsinki, Finland), the Ida Montini Foundation (Kerava, Finland), the Pihkahovi Foundation (Ylihärmä, Finland), the Finnish

Allergy, Skin and Asthma Federation, the Järviseutu Foundation (Vimpeli, Finland), the General Practitioners in Finland (Helsinki, Finland), the Medical Research Fund of Seinäjoki Central

Hospital (Seinäjoki, Finland) and the Competitive State Research Financing of the Expert Responsibility Area of Tampere University Hospital (VTR, Tampere, Finland). H Kankaanranta is an

asthma and allergy research Professor funded by the Hermann Krefting Foundation and his work is supported by Swedish Heart- and Lung Foundation, Swedish Asthma and Allergy Foundation,

Vetenskapsrådet (Sweden; 2022-01022) and ALF agreement (ALFGBG-966075; grant from the Swedish state under the agreement between the Swedish Government and the county councils., None of the

sponsors had any involvement in the planning, execution, drafting or write-up of this study. AUTHOR INFORMATION AUTHORS AND AFFILIATIONS * Department of Respiratory Medicine, Seinäjoki

Central Hospital, Wellbeing Services County of South Ostrobothnia, Seinäjoki, Finland Jaana Takala, Iida Vähätalo, Leena E. Tuomisto, Pinja Ilmarinen & Hannu Kankaanranta * Seinäjoki

Health Care Centre, Wellbeing Services County of South Ostrobothnia, Seinäjoki, Finland Jaana Takala * Tampere University Respiratory Research Group, Faculty of Medicine and Health

Technology, Tampere University, Tampere, Finland Jaana Takala, Iida Vähätalo, Leena E. Tuomisto, Pinja Ilmarinen & Hannu Kankaanranta * Department of Laboratory Medicine, Seinäjoki

Central Hospital, Wellbeing Services County of South Ostrobothnia, Seinäjoki, Finland Onni Niemelä * Tampere University, Tampere, Finland Onni Niemelä * Krefting Research Center, Department

of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden Hannu Kankaanranta Authors * Jaana Takala View author

publications You can also search for this author inPubMed Google Scholar * Iida Vähätalo View author publications You can also search for this author inPubMed Google Scholar * Leena E.

Tuomisto View author publications You can also search for this author inPubMed Google Scholar * Onni Niemelä View author publications You can also search for this author inPubMed Google

Scholar * Pinja Ilmarinen View author publications You can also search for this author inPubMed Google Scholar * Hannu Kankaanranta View author publications You can also search for this

author inPubMed Google Scholar CONTRIBUTIONS This study is a part of Seinäjoki Adult Asthma Study. J.T. contributed to the study design, analysed, and interpreted the data, draw the pictures

to this article and wrote the manuscript. L.E.T., PI., and H.K. contributed to the study design and guided the work. I.V. contributed to the computation of adherence and SABA use and

provided statistical advice. O.N. contributed to the laboratory analyses. All authors accept full conduct of the study and critically revised the manuscript. All authors have read and

approved the final version of the manuscript. CORRESPONDING AUTHOR Correspondence to Jaana Takala. ETHICS DECLARATIONS COMPETING INTERESTS None of the authors declares any competing

interests concerning this article. J.T. reports personal fees from NovoNordisk, Novartis, AstraZeneca, and Sanofi outside the current work. I.V. reports personal fees from AstraZeneca

outside the current work. L.E.T. reports personal fees from GSK and Boehringer-Ingelheim outside the current work. P.I. is employed by GSK as scientific advisor. H.K. reports fees for

consultancies and lectures from AstraZeneca, Boehringer-Ingelheim, Chiesi Pharma, Covis Pharma, GSK, Medscape, MSD, Novartis, Orion Pharma and SanofiGenzyme outside the current work. O.N.

declares that he has no relevant conflicts of interest. ADDITIONAL INFORMATION PUBLISHER’S NOTE Springer Nature remains neutral with regard to jurisdictional claims in published maps and

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lifestyle factors, and asthma management during primary care scheduled asthma contacts. _npj Prim. Care Respir. Med._ 34, 2 (2024). https://doi.org/10.1038/s41533-024-00360-3 Download

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