Global Asthma Physician and Patient (GAPP) Survey

1
Global Asthma Physician and Patient (GAPP) Survey

• Key Global Pediatric Findings

2
GAPP Survey Contents

• Key Global Findings
• Objectives and Overview
• Methodology
• Global Pediatric Findings
• Physician-parent-patient communication gaps
• Factors affecting compliance
• Need for new treatments
• Conclusions and Implications

3
GAPP Survey Global Key Findings
4
GAPP Survey Global Key Findings
Patient compliance and outcomes may be enhanced
by
Better physician/parent/patient communication and
asthma education
New treatment options with lower side effect
profiles
Education
Compliance
Treatment

• Treatment non-compliance decreases quality of
  life and increases resource utilization
• Experience and concern about the potential for
  side effects were patients primary reasons for
  non-compliance
• Parents who report having more discussions with
  their physicians about techniques for successful
  asthma management report greater treatment
  compliance

5
GAPP Survey Overview
6
GAPP Survey Overview

A large-scale global survey was conducted with
physicians and parents of patients with asthma to
build on the existing body of research regarding
asthma attitudes and treatment practices
7
GAPP Survey Objectives

• Enhance understanding and awareness of likely
  contributors to suboptimal asthma management
• Explore content and dynamics of
  physician-parent/patient communications
• Ultimately enhance treatment compliance and
  outcomes

8
The GAPP Survey is Unique

• The GAPP Survey was designed to uncover asthma
  attitudes and treatment practices among
  physicians and parents/patients, with the goal of
  identifying barriers to optimal management
• First-ever global quantitative survey to
• Examine the same themes in parents/patients and
  physicians
• Ask similar questions to both parents and
  physicians

9
GAPP Survey Background
10
The Seriousness of Asthma
Despite advances in asthma management, many
patients still experience

• Asthma exacerbations including acute attacks
• Frequent symptoms
• Unscheduled and increased doctor visits
• Emergency room visits and hospitalizations
• Mortality1,2
• Missed lifestyle and social effects
• Economic burden

1. GINA Asthma Fact Sheet What is Asthma?
Available at http//207.159.65.33/wadsetup/materi
als_04/asthma04.doc. 2. GINA Global Strategy for
Asthma Global Strategy for Asthma Management and
Prevention, 1995. Available at
http//www.iaqoc.com/library/workshop.pdf.
11
Previous Asthma Research

• Asthma Insights and Reality (AIR) studies
  described the current state of patient knowledge,
  attitudes and behavior towards asthma1
• Patients underestimate the severity of their
  disease asthma practice falling short of
  treatment guidelines
• Patients do not understand how asthma is caused
  or how it is treated
• Findings suggested need to
• Improve physician and patient expectations of
  asthma treatment
• Increase awareness of anti-inflammatory agents
• AIR studies raised even more questions about
  patient/physician disconnect regarding
  side-effects, treatment regimens and
  communication

Unanswered Questions from AIR led to Development
of the GAPP Survey
1. Rabe KF, et. al. J Allergy Clin Immunol. 2004
Jul114(1)40-7.
12
GAPP Survey Advisory Board

• Comprised of professional organizations
• The World Allergy Organization (WAO)
• The American College of Allergy, Asthma
  Immunology (ACAAI)

13
GAPP Survey Working Group

• Carlos E. Baena-Cagnani
• Catholic University of Córdoba, Córdoba,
  Argentina, for WAO
• Michael S. Blaiss
• University of Tennessee Health Science Center,
  Memphis, TN, USA, for ACAAI
• G. Walter Canonica
• University of Genova DIMI, Genova, Italy, for WAO
  
• Ronald Dahl
• Aarhus University Hospital, Department of
  Respiratory Diseases, Aarhus, Denmark, for WAO
• Past-President of the European Respiratory
  Society (ERS)
• Michael A. Kaliner
• Institute for Asthma Allergy, Chevy Chase, MD,
  USA, for WAO
• President of the World Allergy Organization
• Erkka J. Valovirta
• Turku Allergy Center, Turku, Finland, for WAO
• Past-President of European Federation of Allergy
  and Airways Diseases Patients Associations (EFA)

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GAPP Survey Methodology
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GAPP Survey Population

• Global adult research

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GAPP Survey Pediatric Survey

• 9 Countries
• Asia Japan
• Europe France, Germany, Italy, Spain,
  Switzerland, the United Kingdom
• North America Canada, the United States of
  America

17
GAPP Survey Methodology

• Harris Interactive conducted the research on
  behalf of the GAPP Survey global advisory board
• A prominent global survey company with a
  specialized healthcare market research department
• Recruiting was accomplished via
• Harris Interactives online panel
• Physician referrals
• Existing sample lists
• 20-minute close-ended questionnaires

18
GAPP Survey Methodology
Harris Interactive conducted the survey on behalf
of the GAPP Survey Advisory Board
Conducting the Survey
Criteria
Sample Sizes

• Online, telephone and face-to-face interviews
• 18 May through 24 August 2005

• Each country surveyed about 100 each for parents
  and physicians
• In the U.S., where the sample sizes were about
  200 for each group (only data weighted)

• Physicians currently practicing medicine for 3-30
  years, sees 3 pediatric patients with asthma
  /week and writes 1 prescription for asthma
  medications /week
• Parents of children diagnosed with asthma

19
GAPP Survey Interviews
5482 physician and parent/patient interviews
conducted worldwide
Pediatric GAPP Survey 1017 parents of children diagnosed with asthma 1006 physicians who treat children with asthma 230 generalists (family practitioners, general practitioners and internal medicine practitioners) 776 pediatricians
Adult GAPP Survey 1726 adults with asthma age 18 years 1733 physicians who treat adults 916 generalists (family, general and internal medicine practitioners) 817 specialists (allergists, pulmonologists, respirologists)
20
GAPP Survey Global Pediatric Findings
21
GAPP Survey Pediatric Arm
2023 physician and parents of children with
asthma were interviewed worldwide

• PARENTS
• 1017 parents of children diagnosed with asthma
• Recruiting was accomplished via Harris
  Interactives online panel, physician referrals
  and existing sample lists

• PHYSICIANS
• 1006 physicians who treat children with asthma
• 230 generalists (family, general and internal
  medicine practitioners)
• 776 pediatricians

22
Pediatric Asthma Treated Mostly by Pediatricians
Which type of doctor or healthcare professional
does your child usually see to treat his or her
asthma? Base All Respondents (Parents)
23
A Majority of Parents Perceive their Childs
Asthma as Mild
Overall, based on your childs symptoms, how
would you describe his or her asthma? Base
All Respondents (Parents)
24
Resource Utilization in the Past 12 Months
Indicates Poor Patient Asthma Control
During the past 12 months, have you because of
your asthma? Base All Respondents (Parents)
25
According to ParentsAsthma Limits Patients
Daily Activities
42 have limited daily activities
Overall, how much has your childs asthma limited
his or her ability to do daily activities?
Base All Respondents (Parents)
26
GAPP SurveyDisconnect between parents and
physicians on factors affecting compliance
27
Disconnect Found Between Parent-Reported
Compliance Physician-Perceived Pediatric
Patient Compliance
100 80 60 40 20 0
59
56
Incidence Reported ()
25
14
15
10
9
9
2
0
81-99 of the time
51-80 of the time
100 of the time
1-50 of the time
0 of the time
What percentage of the time do or did your child
take his or her asthma medication according to
his or her doctor or other health care
professionals instructions? Base Currently or
Has Ever Taken Asthma Medications (Parents) What
percentage of the time does your average
pediatric asthma patient take his or her
medication according to your instructions? Base
All Respondents (Pediatric Physicians)
28
Parents and Physicians Disagree on Content of
Education Provided and Received
Correct inhaler technique
82
95
Develop individual management plan
65
85
Monitor peak expiratory flow
51
71
Keep daily symptom/ medication diaries
33
57
Contact patient support organizations
15
36
0
50
100
Incident Reported ()
Does your childs doctor or other healthcare
professional in his or her office discuss any of
the following with you or your child? Base All
Respondents (Parents) Do you regularly discuss
the following with your pediatric asthma patients
or their parents? Base All Respondents
(Pediatric Physicians)
29
Almost Half of Parents are Unaware or do not
Believe that Asthma can be Fatal in Patients with
Mild Asthma
False 24
True 51
49 are unaware
Not sure25
Is the following statement true or false or are
you not sure? Asthma attacks can be fatal in
patients with mild asthma. Base All
Respondents (Parents)
30
Treatment Compliance Increases with Increased
Parent/Patient Education
Parent/Patient Treatment Compliance
lt 51 51-80 81-99 100 compliant compliant
compliant compliant Amount of time spent
on patient education
23 35 36 40
31
Physicians and Patients Disagree on Who Starts
the Discussion on Side Effects
Physicians
Patients
2 do not discuss side effects
41 Doctor Or healthcare provider

29 Parent or child
69 Me
59 Me or my child
When you discuss or discussed side effects of
asthma medications with your childs doctor or
other health care professional, who typically
brings up the topic, you or your child, or your
childs doctor or health care provider? Base
Always, Sometimes or Rarely Discusses Short or
Long Term Side Effects (Parents) When you discuss
side effects of asthma medications, who typically
brings up the topic, you or your patient or their
parent or you don't discuss side effects?
Base All Respondents (Pediatric Physicians)
32
Parents Lack Awareness of Potential ICS Side
Effects
Parents and Physicians Differ in Opinion
Decreased production of cortisol
39
21
27
Long-term side effects
8
14
Short-term side effects
5
0
30
50
40
20
10
of Parents Who Were Not Aware of Side Effects
of Physicians Stating Their Patients Were Not
Aware of Side Effects
Such as weight gain, weakening of the bones or
changing bone density, or cataracts Such as
such as fungal infection, sore throat or
hoarseness
On a scale of 1 10 where 1 means not at all
concerned and 10 means extremely concerned,
how concerned have you been with the following
potential side effects or, were you not
previously aware of these as potential side
effects for your child? Base All Respondents
(Parents) On a scale of 1 10 where 1 means
not at all concerned and 10 means extremely
concerned, how concerned are your patients or
their parents with each of the following
potential side effects of inhaled
corticosteroids, or are they not aware of
potential side effects? Base Prescribes
Inhaled Corticosteroids (Pediatric Physicians)
33
Reasons Patients Switched/Discontinued Asthma
Medications
Side Effects Lead to Parents/Patients Switching
or Discontinuing Treatment
50 40 30 20 10 0
39
Incidence Reported ()
18
12
11
6
Inconvenient to use
Symptoms went away or lessened
Concerned about potential side effects
Medication was too expensive
Experienced side effects
Since being diagnosed with asthma, has your child
ever switched from one asthma medication to
another or discontinued an asthma medication
because? Base Currently or Has Ever Used
Asthma Medication (Parents)
34
Significant Numbers of Pediatric Patients with
Asthma Experience Side Effects (SEs)
50 40 30 20 10 0
26
Incidence Reported ()
10
Short-term SEs
Long-term SEs
While taking asthma medications, has your child
ever experienced ? Base Child Currently or
Has Ever Taken Asthma Medication (Parents)
35
Side Effects Contribute to Treatment
Non-Compliance

• Of patients who have experienced side effects,
  SEs have caused them to

50 40 30 20 10 0
33
33
30
28
Incidence Reported ()
15
Consider skipping doses
Skip doses
Consider switch medications
Stop taking medications
Change dosage
Have any of the asthma medication side effects
you experienced since being diagnosed caused you
or your child to? Base Experienced at Least
One Side Effect of Asthma Medications (Parents)
36
Treatment Non-Compliance Decreases Quality of
Life
66
Increased symptoms
48
Limited physical activity
46
Nocturnal waking
More frequent attacks/ exacerbations
40
Increased Bronchodilator use
34
21
Less interaction with family/friends
9
Life-threatening attacks
0
70
60
50
40
30
20
10
Incidence Reported ()
Has your child ever experienced the following if
he or she doesnt or didnt take his or her
asthma medication as instructed? Base Child
Takes or Took Asthma Medication Less Than 100 of
the Time (Parents)
37
Treatment Non-Compliance Increases Resource
Utilization
More physician visits
38
More hospitalizations/ ER visits
14
0
70
60
50
40
30
20
10
Incidence Reported ()
Has your child ever experienced the following if
he or she doesnt or didnt take his or her
asthma medication as instructed? Base Child
Takes or Took Asthma Medication Less Than 100 of
the Time (Parents)
38
Consequences of Non-ComplianceIncreased
Resource Utilization

• The number of disability-adjusted life years
  (DALYs) lost due to asthma worldwide has been
  estimated to be currently about 15 million per
  year
• Asthma was the 25th leading cause of DALYs lost
  worldwide in 20011
• World-wide, the economic costs associated with
  asthma are estimated to exceed those of TB and
  HIV/AIDS combined2

1. GINA Global Burden of Asthma, 2004.
Available at http//www.ginasthma.com/ReportItem
.asp?l12l22intId94. 2. WHO
http//www.who.int/mediacentre/factsheets/fs206/en
/
39
Side Effects Contribute to Diminished Quality of
Life Increased Resource Utilization
40
GAPP SurveyPhysicians and Parents/Patients
Assess Need for New Asthma Treatment Options
41
Physicians Agree Inhaled Corticosteroids are
First-Line Therapy
100 80 60 40 20 0
98
92
53
Strongly Agree
Incidence Reported ()
78
Somewhat Agree
39
20
In treating asthma, if youtreat the
inflammation, youreduce the risk of
broncho-constriction
Inhaled corticosteroids (ICS) are the gold
standardtreatment for asthma
Please indicate whether you agree strongly, agree
somewhat, disagree somewhat or disagree strongly
with the following statements. Base All
Respondents (Pediatric Physicians)
42
First-Line Treatment Used By Physician Not
Following GINA Guidelines
Generalist
Pediatrician
Mild Intermittent
Mild Persistent
Moderate Persistent
Severe Persistent
SABA ICS LABA Combi LTRA
Which medication or medications do you prescribe
as first-line treatment for mild intermittent,
mild persistent, moderate persistent and severe
persistent asthma in your pediatric patients?
Base All Respondents (Pediatric Physicians)
43
Highlight Physicians are not Following GINA
Guidelines for Treatment of Pediatric Patients
with Mild Persistent Asthma
Generalist
Pediatrician
Mild Intermittent
Low-dose inhaled corticosteroid is recommended
Mild Persistent
Moderate Persistent
Severe Persistent
SABA ICS LABA Combi LTRA
Which medication or medications do you prescribe
as first-line treatment for mild intermittent,
mild persistent, moderate persistent and severe
persistent asthma in your pediatric patients?
Base All Respondents (Pediatric Physicians)
44
USA Food and Drug Administration (FDA) and the
UKs Medicines and Healthcare products Regulatory
Agency (MHRA) LABA Warning

• Global Initiative for Asthma (GINA) guidelines
  low-dose glucocorticosteroids mono-therapy is the
  recommended medication for children with mild
  persistent asthma
• The SMART trial, addressed emerging safety issues
  concerning salmeterol (LABA). Thirteen patients
  taking salmeterol suffered asthma-related deaths
  compared to the three asthma-related deaths
  involving patients taking the placebo.
• The FDA and the MHRA announced a warning that
  LABA treatments should not be used for first-line
  treatment, and LABAs should be added to the
  asthma treatment plan only if other medicines do
  not control asthma, including the use of
  low-or-medium dose corticosteroids.1, 2
• First-line treatment physicians are using for
  their pediatric mild persistent patients (based
  on GAPP Findings)
• 41 of physicians are prescribing long acting
  beta-agonists (LABA)
• 48 are prescribing fixed combination medications
  (ICS LABA)

1. United States Food and Drug Administration. 
Long Acting Beta Agonists Advisory. November
2005. Available at http//www.fda.gov/cder/drug/i
nfopage/LABA/default.htm. Accessed February 7,
2006. 2. Medicines and Healthcare products
Regulatory Agency. Safety information for long
acting beta agonists. Available at
http//www.mhra.gov.uk/home/idcplg?IdcServiceSS_G
ET_PAGEuseSecondarytruessDocNameCON2022601ssT
argetNodeId221. Accessed February 7, 2006.
45
Physicians and Parents Agree Need for Improved
Asthma Treatment Options
100 80 60 40 20 0
84
80
Reported
Think There is a Need for New Treatments
Physicians who believe there should be more
treatment options are less satisfied with side
effect profiles of existing treatments
Do you think there is a need for new medication
options for children with asthma? Base All
Respondents (Parents) Do you believe there are
still unmet needs in the area of inhaled
corticosteroid therapy? Base All Respondents
(Pediatric Physicians)
46
ICS Key Attributes Physician Are Least
Satisfied with Side Effects
10
Extremelysatisfied
9
8.1
7.9
7.5
7.4
8
7.1
6.8
7
6
5
4
3
2
1
Extremelydissatisfied
Efficacy
Availability in Combination with LABA
Frequency of Dosing
Convenience
Systemic Side Effects
Local Side Effects
On a scale of 1 10 where 1 means extremely
dissatisfied and 10 means extremely
satisfied, how satisfied are you with the
following features of available inhaled
corticosteroids? Base All Respondents
(Pediatric Physicians)
47
Key Attribute of Current Therapies Parents Are
Least Satisfied with Side Effects
100 80 60 40 20 0
92
91
89
85
85
72
Reported Level of Satisfaction ( )
Ease of Use
Potential for Side Effects
Fast Acting
How Many Times a Day
Safety
Effectiveness
Overall, how satisfied or dissatisfied are you
with the following features of your current
asthma medication or medications? Base
Currently Taking Asthma Medication (Patients)
48
Need for a New Treatment

• PHYSICIANS
• 84 of physicians believe there are still unmet
  needs in the area of ICS therapy
• Physicians report that a new ICS therapy with
  comparable efficacy and an improved safety and
  tolerability profile is needed

• PARENTS
• 80 of parents believe there is a need for new
  medication options
• Those who have been more affected by their
  disease, were more likely to believe there is a
  need for a new treatment

49
Conclusions and Implications
Asthma education is insufficient and inadequate
there is a disconnect between physician-parent/pat
ient communication
Side effects and fear of side effects reduce
compliance with treatment, decreasing quality of
life and increasing resource utilization
Parent/patient compliance and outcomes may be
improved by Better physician/patient
communication and asthma education New treatment
options with lower side effect profiles
Parents and physicians are looking for improved
asthma treatments