In recent years, China has undergone rapid economic growth and industrialization, with non-communicable diseases (NCDs) now being the main health burden in China. In 2009, the four major NCDs (cancer, cerebrovascular diseases, heart disease, and respiratory diseases) accounted for approximately 80% of all deaths in urban and rural areas of China, and the prevalence of NCDs is expected to increase significantly between 2010 and 2030. Addressing the public health challenge of NCDs in China is imperative, and will likely improve outcomes for patients and result in social and economic benefits.
Previous surveys in China have shown that the prevalence of allergic rhinitis (AR) and asthma has increased in the past decade, which might be associated with China's increased urbanization and poorer air quality.[2,3] Two large scale cross-sectional surveys conducted in all regions of mainland China found high levels of uncontrolled asthma in patients with coexistent AR and that AR was an independent risk factor for uncontrolled asthma.[4,5] As these two conditions frequently coexist,[6–10] accurate diagnosis and treatment of both diseases are of paramount importance, as highlighted in the Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines. ARIA stipulates that patients with one condition, AR or asthma, should routinely be evaluated for the presence of the other, and recommends a combination of intranasal (INS) and inhaled corticosteroids (ICSs) for treating the upper and lower airways in patients with diagnosed coexistent asthma-AR. While a recent cross-sectional survey of physicians in China showed a high understanding of the burden of asthma-AR, there was evidence that ARIA treatment guidelines were not fully understood and applied in clinical practice.
The Asia-Pacific Survey of Physicians on Asthma and Allergic Rhinitis (ASPAIR) aimed to assess physicians’ knowledge, beliefs, and treatment patterns of coexistent asthma-AR in six countries. This paper described the results for the physician population sampled in China.
The survey protocol and consent procedure were reviewed by an Institutional Review Board of GSK and was granted an exemption as the criteria for exemption were met under 45 CFR 46.101.(b)(2) of the US Code of Federal Regulations.
Study design and participants
Details of the study design, methods, and results for the total physician sample in the ASPAIR study have been reported elsewhere, with study aspects unique to China highlighted as follows.
This was a cross-sectional survey of general physicians (ie, general practitioner/family doctor/internal medicine physicians) and pediatricians, conducted in six countries in Asia (China, India, Malaysia, the Philippines, Thailand, and Vietnam; GSK Study No. 206753). In China, the sampled general physicians and pediatricians were hospital-based physicians, as all levels of care, including primary care, are provided in hospital/clinic settings. Respiratory and non-respiratory specialists were excluded. All participating physicians were required to routinely treat at least ten asthma patients per month (adult and/or children).
A probability-based sampling methodology was used to select a representative sample of approximately 200 physicians per country. In China, a sample of hospitals was drawn from five cities (Beijing, Chengdu, Guangzhou, Shanghai, and Wuhan). The five cities fall within the ten largest metro areas of China and are representative of the largest cities in each region of China (north, south, east, west, south central). Within each city, the sampling approach was allocated by hospital tier as follows: community level: 15%; district level: 35%; and provincial or city: 50%. Tier 1 hospitals are tasked with providing preventive care, minimal health care, and rehabilitation services. Tier 2 hospitals tend to be located in a medium size city/county/district and are responsible for providing comprehensive health services, medical education as well as regional research initiatives. Tier 3 hospitals are the largest, most comprehensive hospitals, comprised of general hospitals found in large cities. A random number generator was used to select a sample of physicians (typically at a ratio of 4:1, ie, from 16 potential physicians, four completed interviews would be obtained), with every effort made to contact selected physicians via two callback attempts and contact by letter. In addition, the number of physicians interviewed per facility was restricted to four.
All physicians were interviewed using a structured questionnaire in Mandarin or Cantonese and was administered face-to-face by an interviewer using Computer-Assisted-Personal-Interviewing tablets or laptops [Supplementary material 1 for details of full questionnaire, http://links.lww.com/CM9/A35].
The questionnaire covered beliefs and treatment practices in relation to the separate conditions, as well as coexistent asthma-AR, and understanding and application of the Global Initiative for Asthma report (GINA) and ARIA guidelines. In China, the mean interview length was 30 min and the response rate was 57%, similar to average results across the six participating countries.
Physician responses are summarized descriptively and presented as unadjusted means, medians, frequencies and/or proportions. Physician responses are presented as unadjusted statistics to reflect the full sampled population. Physician sample data were not weighted as standardized and reliable estimates of the key demographic parameters of physicians were not readily available for all of the countries in the survey.
The majority of the physicians interviewed in China were aged 35 to 54 years (78%), two thirds were female (66%), and on average physicians had been in clinical practice for 20 years [Table 1]. Compared with the total sample, fewer of the physicians interviewed in China were <35 years (11% vs. 27%), more were female (66% vs. 53%) and, on average, they had been in clinical practice for longer (median of 20 years vs. 14 years). Most physicians interviewed in China had received some form of additional training in the management of asthma and AR, similar to the total sample.
Burden of coexistent asthma-AR
Interviewed physicians estimated that just under half of their asthma patients also had AR (47%) and that 40% of their patients with AR also had asthma. Nearly all the physicians surveyed in China agreed that patients with coexistent asthma-AR had more burdensome symptoms than patients with one condition alone (≥91%), leading to a greater negative impact on sleep, work, and school [Figure 1]. This was reflected in their beliefs that both conditions should be managed simultaneously (87%). More physicians agreed that patients with coexistent asthma-AR, vs. those with either AR or asthma alone, were more likely to require additional, unplanned healthcare visits (54% vs. 28% vs. 10%, respectively) or be hospitalized (69% vs. 2% vs. 29%, respectively). However, this also highlighted that nearly one third of physicians interviewed thought that unplanned healthcare visits and hospitalizations were more likely in patients with AR only or asthma only, respectively.
Diagnosis and assessment of asthma and coexistent asthma-AR
Approximately 70% of physicians interviewed in China reported routinely evaluating their patients with either asthma or AR for symptoms of the other condition at every clinic visit, though external factors were also an important prompt for physicians to evaluate coexistent disease [Figures 2A and 2B]. For patients with AR, physicians were also driven by local allergen levels (44%) and local pollution levels (33%), and for patients with asthma, patients’ asthma symptoms (66%) and their asthma triggers (33%) were important prompts.
All physicians used the history of asthma symptoms for diagnosing asthma in patients with AR, with a family history and exposure to common asthma triggers also considered important factors (79% and 74% of physicians, respectively) [Figure 3]. Similarly, a history of nasal symptoms and symptoms due to seasonal allergens were most commonly used to diagnose AR in patients with asthma [Figure 3]. The use of objective measures to diagnose either asthma or AR was not done routinely, with 57% of physicians reporting the use of spirometry for the diagnosis of asthma.
When assessing asthma control, the type and frequency of symptoms was the most commonly used criterion reported by physicians reviewing patients with asthma alone and those with coexistent asthma-AR [Figure 4]. Interestingly, the utility of night-time awakenings as an indicator of asthma control was more commonly used by physicians assessing patients with asthma alone (74%), vs. those with coexistent asthma-AR (55%). Differences in the way physicians assessed asthma control in patients with asthma alone vs. those with coexistent disease were also noted with respect to use of lung function (58% vs. 32%, respectively), and the assessment of exercise impairment (57% vs. 43%, respectively). Monitoring the frequency of short-acting β2-agonist (SABA) use was generally infrequent but notably lower for patients with coexistent disease (22% vs. 11%). On the other hand, monitoring a patient's medical history including number of clinic visits, and feedback from the patients and/or their family were given equal importance when assessing control in both groups of patients, and were used by >40% of physicians.
Management and treatment practices for patients with co-existent asthma-AR
Although all of the physicians surveyed in China agreed that treatment guidelines provide sufficient information for treating uncontrolled asthma-AR, and most (>90%) agreed that patients with coexistent disease require additional and different treatment to patients with one condition alone, nearly all physicians (96%) also believed that patients with coexistent asthma-AR were well managed if either condition alone improved. Only 50% of physicians interviewed reported using guidelines to inform their treatment choices for patients with asthma-AR, citing their own personal experience (63%) and patient affordability (55%) as more important factors [Figure 5].
When asked what controller medications they consider for treating their patients with asthma (open ended question), 90% of Chinese physicians interviewed indicated an ICS and 70% indicated an ICS/long-acting beta agonist (LABA). Other notable medications listed by physicians included oral medications ranging from leukotriene receptor antagonists (LTRAs) by 80% of physicians, theophyllines (37%), oral β2-agonists (24%), long-acting anticholinergics (20%), and oral corticosteroids (16%). When asked to choose their preferred treatment for coexistent asthma-AR from a given list, 71% selected a combination of ICS and INS with very few physicians choosing oral medications. This was contrary to the reported patient preference for oral medication by approximately 40% of physicians. Approximately, a third of the physicians interviewed thought that treating coexistent asthma-AR requires too much medication (32%). For the management of coexistent asthma-AR in children, the surveyed physicians in China were of the view that inhaled and intranasal corticosteroids should be delayed (34% and 30% of physicians, respectively).
The ASPAIR survey provided insights into the knowledge, beliefs, and practices of physicians managing patients with asthma-AR in six countries in the Asia-Pacific region. The results from ASPAIR-China showed that the sampled physicians had a very high understanding of the impact of coexistent asthma-AR, recognized the significant health and social burden it imposes on patients, regularly assessing patients for the coexistence of either disease when one is already present, in line with the ARIA and GINA guidelines.[7,13] These results were consistent with the observation that most physicians had received additional training in the management of asthma and AR and that physicians in China reported seeing large numbers of patients with asthma and AR in their clinics each month. An interesting observation in China was that the frequency of assessing coexistent disease in patients with one condition was also driven by external factors such as allergen and pollution levels. This might be expected in view of China's recent and rapid development and urbanization, and highlights physicians’ awareness of the potential impact of these external triggers on both diseases.
Although all physicians sampled in China acknowledged and accepted the international guidelines for managing asthma (GINA) and coexistent asthma-AR (ARIA), there were some areas where their beliefs and clinical practices were not completely consistent with guideline recommendations. This was particularly true regarding treatment choices, where personal experience was the most common driver of treatment decisions. The surveyed population may have influenced this observation, as the sampled physicians in China tended to be older and have spent significant time in clinical practice. The fact that physicians in China saw large volumes of patients, possibly indicating less available time spent per individual patient, may also be a factor in physicians relying on their personal experience for treating patients rather than full implementation of the guidelines. A lack of time has been highlighted previously as a barrier to implementing practice guidelines.
The healthcare system in China may have also influenced observations regarding physicians’ beliefs. The use of spirometry to diagnose asthma was used by approximately 50% of physicians interviewed, and this relatively low use could be due to more symptomatic or severe patients being referred to specialists, which may be driven by patients who tend to believe that the quality of care provided by specialists is superior to general practioners. The frequent evaluation of patients with either asthma or AR for symptoms of the other condition by >70% of physicians interviewed in China may, paradoxically, be related to the hospital/clinic based nature of healthcare delivery in China, that is, if different physicians are evaluating a patient at their clinic reviews each time, then they may be more inclined to check for other symptoms.
Another interesting observation in this data set was in the criteria physicians used to assess asthma control in patients with asthma alone compared with patients with coexistent asthma-AR. Global and local guidelines in China recommend assessing asthma control based on frequency of daytime symptoms, night-time awakenings, reliever medication use, and activity limitation.[13,16] While most physicians monitored the frequency of symptoms for assessing control in both patient types, the other criteria were used less commonly, and noticeably less frequently in patients with coexistent asthma-AR vs. asthma alone. This highlights the need for diligent assessment of asthma control in patients with coexistent disease.
Finally, although most physicians interviewed in China believed that patients with asthma-AR required additional and different treatments to those with one condition only, these views were not supported by their responses to other questions about treatment. Among the surveyed physicians, two in five reported that their patients preferred to take oral medications rather than nasal sprays and inhalers, and the majority of physicians utilized LTRAs in addition to SABA for treating asthma. Very few physicians chose oral LTRA as a preferred treatment for asthma-AR when the physicians were given a specific list of medications to choose from. However, this survey revealed physician concerns over both too much medication and the overall steroid burden of treating patients with both conditions. For patients with coexistent asthma-AR, undertreatment with the appropriate medications was not only seen in China but was also reported by physicians in other countries. Physicians appear to be aware of the guideline-recommended treatments for asthma-AR but may not routinely incorporate the recommendations into their clinical practice.
A limitation of the ASPAIR China survey is that, due to the size of this country, the sampling of five big cities within large metro areas of China, covering each region of China, may not be truly representative of physician views across China, particularly with respect to rural areas. However, within these constraints, a systematic sampling plan was implemented to obtain a representative sample of physicians within tiers and facilities and, reassuringly, demographic characteristics of general physicians in our survey were consistent with those reported in the Global Asthma Physician Survey (conducted in 2015 in Australia, Canada, China, France, Germany, and Japan). Further study of potential differences in physician views on asthma and AR utilizing methods optimal to understand rural vs. urban differences is warranted, as differences have previously been noted in the management of childhood asthma.
In conclusion, ASPAIR study in China demonstrates that surveyed physicians had a broad understanding of coexistent asthma-AR, its impacts on patients and healthcare resource use, and the required treatments. ASPAIR study in China brings forth a need for improved education about coexistent asthma-AR management in real-life clinical practice. Additionally, it conveys the need to establish parameters of achievable control of coexistent asthma-AR with appropriate medications. The discrepancy between the physician knowledge and patient management of coexistent asthma-AR in clinical practice suggested that a holistic approach to patient management with informed decisions regarding patients’ overall treatment would benefit patients who suffer from coexistent disease.
The authors thank the ASPAIR study team who were responsible for the study oversight: Indu Khosla, Krishna Dabholkar, Maria Isabel Atienza, Maria Cristina Balotro-Torres, Pham Le An, Tran Anh Tuan, Hooi Lai Ngoh, and Sudawan Siriaksorn. Editorial support in the form of copyediting, collating author comments, and fact checking was provided by Kate Hollingworth of Continuous Improvement Ltd and was funded by GSK.
This study was supported by a grant from GlaxoSmithKline (No. 206753).
Conflicts of interest
All authors are GSK employees and all hold GSK shares.
1. Li L, Guo Y, Chen Z, Chen J, Peto R. Epidemiology and the control of disease in China
, with emphasis on the Chinese Biobank Study. Public Health
2012; 126:210–213. doi: 10.1016/j.puhe.2011.11.012.
2. Wang XD, Zheng M, Lou HF, Wang CS, Zhang Y, Bo MY, et al. An increased prevalence of self-reported allergic rhinitis
in major Chinese cities from 2005 to 2011. Allergy
2016; 71:1170–1180. doi: 10.1111/all.12874.
3. Lin J, Wang W, Chen P, Zhou X, Wan H, Yin K, et al. Prevalence and risk factors of asthma
in mainland China
: the CARE study. Respir Med
2018; 137:48–54. doi: 10.1016/j.rmed.2018.02.010.
4. Lin J, Su N, Liu G, Yin K, Zhou X, Shen H, et al. The impact of concomitant allergic rhinitis
control: a cross-sectional nationwide survey in China
. J Asthma
2014; 51:34–43. doi: 10.3109/02770903.2013.840789.
5. Lin J, Gao J, Lai K, Zhou X, He B, Zhou J, et al. The characteristic of asthma
control among nasal diseases population: results from a cross-sectional study. PLoS One
2018; 13:e0191543doi: 10.1371/journal.pone.0191543.
6. Rimmer J, Ruhno JW. Rhinitis and asthma
: united airway disease. Med J Aust
2006; 185:565–571. doi: 10.5694/j.1326-5377.2006.tb00693.x.
7. Bousquet J, Khaltaev N, Cruz AA, Denburg J, Fokkens WJ, Togias A, et al. Allergic rhinitis
and its impact on asthma
(ARIA) 2008. Allergy
2008; 63 (Suppl 86):8–160. doi: 10.1111/j.1398-9995.2007.01620.x.
8. Bjerg A, Eriksson J, Sif Ólafsdóttir I, Middelveld R, Franklin K, Forsberg B, et al. The association between asthma
and rhinitis is stable over time despite diverging trends in prevalence. Respir Med
2015; 109:312–319. doi: 10.1016/j.rmed.2015.01.002.
9. Navarro A, Valero A, Juliá B, Quirce S. Coexistence of asthma
and allergic rhinitis
in adult patients attending allergy clinics: ONEAIR study. J Investig Allergol Clin Immunol
10. Price D. Asthma
and allergic rhinitis
: linked in treatment and outcomes. Ann Thorac Med
2010; 5:63–64. doi: 10.4103/1817-1737.62467.
11. Su N, Lin J, Liu G, Yin K, Zhou X, Shen H, et al. Asthma
with allergic rhinitis
management in China
: a nationwide survey of respiratory specialists at tertiary hospitals. Int Forum Allergy Rhinol
2015; 5:221–232. doi: 10.1002/alr.21449.
12. Aggarwal B, Shantakumar S, Hinds D, Mulgirigama A. Asia Pacific Survey of Physicians on Asthma
and Allergic Rhinitis
): physician beliefs and practices about diagnosis, assessment and treatment of coexistent disease. J Asthma Allergy
2018; 11:293–307. doi: 10.2147/JAA.S180657.
13. Global Initiative for Asthma
(GINA). Global strategy for asthma
management and prevention, 2018. Available at: http://www.ginasthma.com
. Accessed October 20, 2018.
14. Van Hoecke H, Van Cauwenberge P. Critical look at the clinical practice guidelines for allergic rhinitis
. Respir Med
2007; 101:706–714. doi: 10.1016/j.rmed.2006.08.007.
15. Zou Y, Zhang X, Hao Y, Shi L, Hu R. General practitioners versus other physicians in the quality of primary care: a cross-sectional study in Guangdong Province, China
. BMC Family Practice
2015; 16:134doi: 10.1186/s12875-015-0349-z.
Workgroup, Chinese Thoracic Society, Chinese Society of General Practitioners. Chinese guideline for the prevention and management of bronchial asthma
(Primary Health Care Version). J Thorac Dis
2013; 5:667–677. doi: 10.3978/j.issn.2072-1439.2013.10.16.
17. Chapman KR, Hinds D, Piazza P, Raherison C, Gibbs M, Greulich T, et al. Physician perspectives on the burden and management of asthma
in six countries: the Global Asthma
Physician Survey (GAPS). BMC Pulmonary Medicine
2017; 17:153doi: 10.1186/s12890-017-0492-5.
18. Zhu WJ, Ma HX, Cui HY, Lu X, Shao MJ, Li S, et al. Prevalence and treatment of children's asthma
in rural areas compared with urban areas in Beijing. Chin Med J
2015; 128:2273–2277. doi: 10.4103/0366-6999.163381.