Asia Pacific Survey of Physicians on Asthma and Allergic Rhinitis (ASPAIR): Data from China
China’s rapid urbanization and industrialization have led to a significant shift in disease burden, with non-communicable diseases (NCDs) now accounting for approximately 80% of all deaths. Among these, respiratory diseases such as asthma and allergic rhinitis (AR) have seen a marked increase in prevalence over the past decade, likely influenced by environmental factors like air pollution and changing lifestyles. The ASPAIR study, conducted across six Asia-Pacific countries, aimed to evaluate physician knowledge, beliefs, and clinical practices related to coexistent asthma and AR. This analysis focuses on data from China, providing insights into the challenges and opportunities in managing these interconnected conditions.
Study Design and Methodology
The ASPAIR study in China employed a cross-sectional design, interviewing 200 hospital-based general physicians and pediatricians across five major cities: Beijing, Chengdu, Guangzhou, Shanghai, and Wuhan. These cities were selected to represent diverse geographic regions (north, south, east, west, south-central) and hospital tiers (Tier 1: community-level, Tier 2: district-level, Tier 3: provincial/city-level). Physicians were required to treat at least ten asthma patients monthly. Interviews, conducted face-to-face in Mandarin or Cantonese, utilized structured questionnaires to assess beliefs, diagnostic practices, treatment patterns, and adherence to guidelines such as the Allergic Rhinitis and Its Impact on Asthma (ARIA) and Global Initiative for Asthma (GINA).
Physician Demographics and Practice Characteristics
The majority of physicians surveyed were aged 35–54 years (78%), with a median clinical experience of 20 years. Female physicians constituted 66% of the sample. Most worked in government hospitals (98%), with 50% affiliated with Tier 3 institutions. Physicians reported managing a median of 80 asthma patients and 60 AR patients monthly, with pediatricians predominantly treating children under 12 years. Nearly 90% had attended continuing medical education on asthma management, and 72% had training in AR management.
Burden of Coexistent Asthma-AR
Physicians estimated that 47% of asthma patients and 40% of AR patients had coexistent disease. Over 90% recognized that coexistent asthma-AR imposed a greater symptom burden than either condition alone, significantly affecting sleep, work, school performance, and quality of life. Notably, 54% of physicians agreed that coexistent disease increased unplanned healthcare visits, while 69% associated it with higher hospitalization rates. Despite this awareness, 96% believed patients were “well managed” if either condition improved, highlighting a potential gap in understanding the need for dual-disease control.
Diagnostic and Assessment Practices
Approximately 70% of physicians routinely evaluated asthma patients for AR symptoms and vice versa during clinic visits [Figure 2A, 2B]. External factors such as local allergen levels (44%) and pollution (33%) prompted evaluations for AR in asthma patients, while asthma triggers (33%) and symptom severity (66%) influenced assessments for asthma in AR patients. Diagnosis relied heavily on clinical history: 100% used asthma symptom history for diagnosing coexistent asthma in AR patients, while 98% relied on nasal symptoms for AR diagnosis in asthma patients [Figure 3]. Objective measures like spirometry (57%) and allergen testing (41%) were less frequently utilized.
Asthma control assessments differed between patients with asthma alone versus coexistent disease. For asthma-only patients, 74% of physicians monitored nighttime awakenings, 58% used lung function tests, and 57% evaluated exercise limitations. In contrast, for coexistent disease, only 55% assessed nighttime symptoms, 32% used lung function, and 43% considered exercise impairment [Figure 4]. Relief medication use (e.g., short-acting beta-agonists) was monitored by 22% for asthma-only patients but dropped to 11% for coexistent cases, suggesting inconsistent application of guideline-recommended metrics.
Treatment Patterns and Guideline Adherence
While 71% of physicians selected inhaled corticosteroids (ICS) combined with intranasal corticosteroids (INS) as the preferred treatment for coexistent asthma-AR—aligned with ARIA guidelines—divergence emerged in real-world practice. Oral leukotriene receptor antagonists (LTRAs) were prescribed by 80% of physicians, and 37% used theophyllines. Patient preferences influenced prescribing: 40% of physicians reported that patients favored oral medications over inhalers or nasal sprays. Additionally, 32% felt that managing coexistent disease required “too much medication,” and 34% delayed ICS use in children due to safety concerns.
Guideline adherence was mixed. Although 96% acknowledged that coexistent disease required additional treatment, only 50% explicitly used guidelines to inform decisions. Instead, 63% relied on personal experience, and 55% considered medication affordability. This disconnect underscores challenges in translating guidelines into practice, particularly in resource-constrained settings.
Discussion and Implications
The ASPAIR-China findings reveal a paradox: high awareness of coexistent asthma-AR burden coexists with suboptimal management practices. Physicians’ reliance on clinical history over objective tests may lead to underdiagnosis or misclassification of disease severity. The infrequent use of spirometry and allergen testing, coupled with inconsistent monitoring of control metrics, suggests gaps in comprehensive care.
Treatment preferences further highlight systemic barriers. Despite guideline endorsement of ICS/INS combination therapy, oral medications remain widely used, driven by patient preferences and misconceptions about corticosteroid safety. These practices may contribute to the high rates of uncontrolled asthma observed in Chinese patients with AR, as reported in prior studies.
The study’s hospital-based sampling limits generalizability to rural areas, where access to specialized care and diagnostic tools may be poorer. Additionally, the predominance of experienced physicians in the sample may skew findings toward established practices rather than emerging guidelines.
Conclusion
The ASPAIR-China study underscores the need for targeted educational initiatives to bridge knowledge-practice gaps. Enhancing physician training on guideline implementation, promoting objective diagnostic tools, and addressing patient misconceptions about treatment safety could improve outcomes. A holistic approach—integrating asthma and AR management—is essential to reduce the dual burden of these conditions in China’s evolving healthcare landscape.
doi.org/10.1097/CM9.0000000000000229
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