Patients suffering from asthma and doctors sampled in Italy for the APPaRENT2 survey had very divergent opinions on the severity of the disease and its most important manifestations.

The APPaRENT2 study [1] was a multi-country, cross-sectional, online survey of patients with asthma and physicians (primary care and specialists) that aimed to describe the reality of asthma treatment and how it aligned with the recommendations of the Global Initiative for Asthma (GINA) [2] available at the time of the survey in five countries: Argentina, Brazil, France, Mexico, and Italy. All participants were sampled and recruited using panels certified by the International Organization for Standardization between August and November 2021. Based on the methodology used, the samples studied in APPaRENT2 (330 patients and 216 physicians in each country) could be considered reasonably representative of patient and physician populations in the countries participating in the survey. Notably, sampled Italian patients were older, had a lower level of schooling, and were less often living in large urban areas than patients sampled in Latin American countries (Table 1). Similarly, sampled Italian physicians were slightly older, less frequently operating in large urban areas, and much more frequently operating within the national health system. Given these sample characteristics, it seemed relevant to analyse the Italian data in further detail in order to: 1) describe similarities and discrepancies in asthma symptoms, severity, and treatment protocols between Italy and the other countries; and 2) highlight critical issues in the management of patients with asthma in Italy. Since this study was a secondary analysis conducted on an already existing and anonymous database, further submission to the judgment of an ethics committee was not deemed necessary.

The data reported in this study are the result of a descriptive analysis and are presented as proportions for categorical variables and means for continuous variables. The sample sizes reported in Table 1 were used to calculate all means and proportions. No use was made of statistical analysis of differences between means and proportions. The data dispersion ranges among Latin American countries were used to describe the position of the Italian data with respect to the same data collected in those countries characterized by substantially different health care systems.

Contrary to expectations, despite the respondents’ greater age, lower education, and residence outside large urban centres, the Italian data were in general within or very close to the limits of the range of data collected in other countries participating in APPaRENT2 [1]. In brief, the frequency of severe asthma according to the knowledge of patients was quite low (6%), and almost all patients declared their asthma was at least partially controlled. Most patients reported being satisfied with their current treatment, while admitting they frequently forgot to use it despite frequent limitations in everyday life and a substantial number of exacerbations, even among patients with mild disease. According to the physician survey, the frequency of severe asthma among Italian patients was much higher (15%) than the frequency estimated in the survey of patients. According to physicians, the majority of patients had a written action plan for their asthma to which they were adherent in the majority of cases. In particular, the adherence of patients to the pharmacological treatment was quite high, according to the opinion of physicians, but clearly at odds with the last National Drugs Report [10], which estimated high adherence to respiratory therapy in no more than 22% of patients. The physicians’ treatment strategy was mostly based on a regular use of ICS or ICS/LABA with or without SABA as a reliever when needed. ICS/formoterol as needed or according to the MART strategy was prescribed in a minority of cases. However, according to the survey of patients in Italy, a SABA when needed was the only treatment used by 34% of all cases, but only 17% of mild cases and 1% of moderate/severe cases, according to the physician survey. In summary, separate surveys of patients and physicians in Italy produced conflicting results. Satisfactory asthma control was overestimated in patients who simultaneously reported frequent symptoms and limitations in daily activities. Physicians, however, were much less optimistic about the control of asthma in patients, but that evaluation was quite often based on personal opinion and not supported by standardized tools. In all chronic diseases, adherence to treatment is crucial to achieve the best results, but difficult to achieve and monitor in the long term. In this case, however, the level of adherence was extremely overestimated when compared with the drug possession data derived from national registries. Of course, all surveys performed by questionnaires administered online, and without any objective measurement, may be affected by an intrinsic weakness in defining event frequencies in a population using small sample sizes. However, clear and frequent communication between physicians and patients, their sharing of treatment objectives in an alliance relationship, and the measurement of the outcomes obtained using standardized tools are essential for improving the management of any chronic pathology. When a chronic disease has a high prevalence such as asthma, it seems reasonable to approach its treatment within a chronic disease management model conceptual framework [11–13]. This is probably not the case in Italy, where the management of asthma seems not to have improved much since the late 1990s [14, 15]. A result about which there were no substantial discrepancies between patients and physicians was the low frequency of use of the MART strategy for the treatment of asthma. Moreover, the MART strategy was often coupled to the use of a short-acting SABA as a second reliever, thereby completely distorting the logic underlying the MART strategy. It can be hypothesized that the low frequency of use of the MART strategy may be attributed to several causes: poor understanding of the method’s potential benefits, inadequate knowledge of the supporting scientific evidence, and patients’ failure to follow their doctor’s advice. Patients’ habit of having a medication available on demand, different from the maintenance therapy, may be a plausible explanation for the inappropriate prescribing of a SABA associated with the MART strategy. However, since the APPaRENT2 survey was carried out shortly after the clear indication of preference for the MART strategy in the GINA recommendations [2], we attempted to verify whether the low use of the MART strategy in Italy had changed after the survey date. Analysing the prescriptions of inhalers containing the combination of ICS/formoterol, which are the only ones that can be used for the MART strategy, 12 months before and 12 and 24 months after the publication of the GINA 2021 report, we found no relevant increase in their share compared with other ICS/LABA, as highlighted in Figure 1. On this basis, it is possible to hypothesize that the use of the MART strategy in Italy is still infrequent compared to the consolidated proactive regular treatment with ICS/LABA and SABA as a reliever of proven efficacy for the long-term treatment of asthma.

The results of the APPaRENT2 study, as far as the Italian data are concerned, suggest the need for more effective communication between physicians and patients suffering from bronchial asthma. The sharing of results from standardized instruments such as the ACT or ACQ, administered before each visit, could be an essential tool for such communication. In fact, even in the presence of frequent and structured contacts, according to what was declared by the physicians, the patients had an unsatisfactory awareness of the severity of their disease and an optimistic evaluation of their clinical conditions, not aligned with their reporting of symptoms and limitations of daily living. The consolidated proactive regular treatment with ICS/LABA, and SABA when needed, appears to be the preferred strategy in patients with moderate, severe, or fluctuating severity asthma, despite being defined as a second non-preferential choice in GINA documents from 2021 onwards. Furthermore, the frequent co-prescription of the MART therapy with a SABA suggests there is some relevant misunderstanding of reliever strategies in the general practice and the need for a more effective diffusion of the new messages, from the specialist scientific societies to general practitioners, in Italy.