Asthma Insights & Reality in Europe: Executive Summary
Overview and Survey Design
Asthma Insights & Reality in Europe (AIRE) is the largest and most comprehensive multi-national survey of patient knowledge, attitudes and behavior related to asthma in Europe. The survey was conducted in March and April 1999 by the national public opinion research organization, Schulman, Ronca and Bucuvalas, Inc. (SRBI). The AIRE survey was funded by Glaxo Wellcome, a research-based pharmaceutical company. One key objective of the study was to better understand the experience of the full range of persons with asthma in Europe. Most previous studies of asthma patients in Europe involved relatively small samples of patients selected from a limited number of clinical settings. While these samples can be effectively used to test the clinical efficacy of new medications or hypotheses about treatment outcomes, they do not necessarily yield an accurate picture of the knowledge, attitudes, behaviors and health outcomes of the population of asthma sufferers.

The national survey of Asthma in America conducted by SRBI in 1998 for Glaxo Wellcome served as a prototype for the AIRE survey. Survey measures and procedures that had been successfully developed for describing Asthma in America were replicated in the AIRE survey. Using a common set of survey questions and survey procedures, Asthma Insights & Reality in Europe represents national probability samples of asthma sufferers in seven countries: the United Kingdom, France, Germany, the Netherlands, Sweden, Spain and Italy.

In each of the seven countries, a national probability sample of asthma sufferers was selected and interviewed by telephone. Without any national registry of asthma patients, a national sample of asthma patients was identified by systematically screening a national sample of households by telephone. The study design called for approximately 400 interviews with asthma patients in each of the seven countries. In order to accomplish this objective, a total of 73,880 households in Europe were screened by telephone between February 25 and April 21, 1999. In each of these households, an adult informant was asked whether a physician had ever diagnosed any member of the household as having asthma. If a household member had been diagnosed as having asthma, the interviewer asked whether any of these persons take any medication for their asthma or have had asthma symptoms in the past year. One or more current asthma patients were identified in 3,488 households out of the 73,880 in which a screening interview was conducted.

If more than one household member qualified as a current asthma patient, the computer randomly selected one designated respondent. If the selected respondent was 16 years of age or older, then the interview was conducted with the patient. If the selected respondent was less than 16 years-old, then the interview was conducted with the parent or guardian who was most knowledgeable about the child?s asthma condition and treatment. The interview averaged 30 minutes in length. Interviews were completed with 2,862 out of the 3,488 selected asthma patients or parents (82.1%). (Some questions were inadvertently skipped in 59 of these interviews, so this report is based on the 2,803 completed interviews with all questions.) Only 254 qualified respondents out of the 3,488 selected respondents refused to conduct the interview, another 154 terminated the interview before completing it, the remaining 218 eligible non-respondents were awaiting callback for interviews when the field period for the survey ended.

The AIRE patient/parent survey yielded a national probability sample of persons with current asthma in each of the seven European countries in the survey. These seven national samples, when weighted for total population and asthma prevalence of each country, also yield a probability sample of asthma patients in Europe (as represented by the seven AIRE countries). Hence, in this report we will present the survey findings for the total European sample, as well as the seven nations represented in the sample.

We believe the Asthma Insights & Reality in Europe survey will serve as a landmark study in asthma research. The patient survey is one of the largest, if not the largest, cross-national probability survey of both adult and children with asthma. The size of the patient sample (N=2,803) is large enough to yield both precise estimates of the total population of patients in Europe and permit more detailed investigation of important subsets of that population (e.g., children, minorities, urban, severe symptoms). While the 30-minute interview covers a broader range of subjects, in more depth, than any previous large-scale survey of patients. Hence, the AIRE patient survey provides an unparalleled resource for the understanding of the current state of asthma management and treatment in Europe from the patient perspective.

The size, depth and comprehensiveness of the Asthma Insights & Reality in Europe survey parallels earlier baseline studies of the U.S. National Heart, Lung and Blood Institute?s High Blood Pressure Education Program and Cholesterol Education Program. We believe the AIRE Survey will be regarded, like these pioneering efforts in public health education, as a landmark study. The information generated by this study can be a major signpost for future directions in asthma policy, education and research.

Asthma Prevalence in Europe
The national patient survey for Asthma Insights & Reality in Europe was constructed by screening a national probability sample of telephone households in each of the seven AIRE countries. The households were selected by random-digit dialing, which gives both listed and unlisted telephone numbers an equal probability for selection. Within each sampled household, an adult informant was asked whether any of the persons living in the household had ever been diagnosed as having asthma. All negative responses were confirmed by interviewers before the household was considered ineligible for the survey. In both eligible and ineligible households, the respondent was asked for the total number of persons living in the household so that a population prevalence for asthma as well as a household prevalence could be estimated.

The survey found that the household prevalence of diagnosed asthma was 8.6% among the 73,617 households reporting in the seven AIRE countries. This means that one or more persons had been diagnosed by a physician as having asthma in nearly one out of 10 households across the seven European countries. In addition, a small proportion (.4%) of households reported asthma that had not been diagnosed by a physician.

The objective of the survey was to interview national samples of persons with current asthma, so physician diagnosis of asthma was a necessary, but not sufficient condition for survey eligibility. Two subsequent questions determined whether any of the persons in the household diagnosed with asthma would be classified as a current asthma patient. First, “Does this person take medication for their asthma?” Second, “Has this person had an asthma attack or asthma symptom in the past 12 months?” The survey found that 26% of persons who have ever been diagnosed as having asthma report that they are not currently taking medication for their asthma and have not had an asthma attack in the past 12 months. These individuals are excluded from the survey population of persons with current asthma.

The survey found that the household prevalence of current asthma in Europe (AIRE countries) was 6.3%. This means that one or more persons in these households had been diagnosed as having asthma by a doctor and had asthma symptoms in the past year or were currently taking medication for their asthma. In addition, persons who had been diagnosed as having asthma, but who reported no past-year symptoms or current medication for their asthma, were found in another 2.3% of households.

The survey found significant variation among the seven countries in the household prevalence of current asthma. At one extreme, the household prevalence of current asthma was 15.2% in the United Kingdom. At the other extreme, the household prevalence of diagnosed asthma was 2.5% in Germany. In four out of the seven European countries, the household prevalence of current asthma fell in the range of 4%-6% of households.

The population prevalence of current asthma can be estimated based on the total number of persons reported in each household and the total number of persons with current asthma in those households. A total of 213,158 persons were reported living in the 73,617 households screened for the survey. The total population prevalence of current asthma was 2.7% for the seven AIRE countries. The population prevalence is substantially lower than the household prevalence because there is an average of 2.9 persons per household in the AIRE countries, but only an average 1.2 persons with current asthma in households with current asthma.

Asthma Symptoms, Perceived Severity and Control among Patient Population
On balance, patients with asthma in Europe feel their asthma is getting better, rather than worse, compared to 10 years ago. Two out of five persons with asthma in AIRE countries (42%) reported that their asthma was better now than it was 10 years ago. By contrast, only 13% reported that their asthma was worse now than it was 10 years ago. The remainder felt their asthma had stayed about the same or had no asthma 10 years ago. However, among those whose condition had changed compared to 10 years ago, there was more than a three-to-one difference in asthma condition improvement to asthma condition deterioration.

The most common reason adult asthma patients gave for improvement in their asthma in the past 10 years was better medicines (37%). The proportion who identify better medicines as the reason their asthma has improved ranges from 32% in the United Kingdom to 50% in Germany. In addition, 25% attributed the improvement in their asthma to better treatment without specifying medicines or drugs. Other leading reasons asthma patients gave for improvement in their asthma over the past 10 years were: better education about how to control it (18%); better control over environmental allergens (16%); and having a better understanding of the disease (13%).

Following current clinical guidelines, the survey included a number of measures for the frequency and severity of asthma symptoms based on a four-week period. The patient survey was conducted from late February to mid-April, outside the seasonal peaks of asthma in early Spring and in the Fall. Hence, the survey estimates of symptom frequency should represent troughs rather than peak levels.

When asked to describe their asthma in the past four weeks, only 6% of persons with asthma in Europe described their asthma symptoms as severe during the past four weeks. Another 22% of asthma sufferers described their symptoms as moderate during the past four weeks. Most asthma sufferers in Europe described their asthma symptoms in the past four weeks as mild (40%) or none (32%).

The majority of all persons with asthma (55%) in the AIRE countries reported that they had a cough, wheezing, shortness of breath or chest tightness during the day in the past four weeks. Nearly two out of five persons with asthma in Europe (37%) reported being awakened at night by a cough, wheezing, shortness of breath or chest tightness during the past four weeks. Persons with asthma were also asked about exertion-related asthma symptoms. Nearly half of persons with asthma in Europe (47%) reported they had experienced asthma symptoms brought on by exercise or exertion in the past 12 months. Indeed, nearly a quarter (24%) of persons with asthma reported they had exertion-related asthma symptoms at least once a week.

One of the hallmarks of uncontrolled asthma is being awakened with breathing problems at night. Nearly two out of five persons with asthma in Europe (37%) reported being awakened at night by a cough, wheezing, shortness of breath or chest tightness during the past four weeks. Six percent of asthma patients said they were awakened by these symptoms every night in the past four weeks. Three out of 10 (30%) reported they were awakened at least once a week with these symptoms in the past four weeks. The prevalence of weekly sleep disruption ranges from a low of 21% in Sweden to a high of 35% in Germany and Italy (36%).

The reported frequency of daytime symptoms, nighttime symptoms, exertion- induced symptoms, severe episodes and total symptom frequency in the past four weeks was used to create a clinical index based upon international guidelines for asthma symptom severity. Severe persistent asthma was indicated by continual daytime symptoms (we have used three or more episodes per day) or nighttime sleep disruption every night or most nights. Moderate persistent asthma was indicated by daytime symptoms every day, but less than three times per day, or nighttime sleep disruption at least twice a week. Mild persistent asthma was indicated by daytime symptoms at least twice a week or nighttime sleep disruption at least twice a month. Mild intermittent asthma was indicated if symptom frequency is less than the criteria for mild persistent asthma. Since multiple indicators were used for these symptoms, the symptom severity was classified by the highest level achieved on any of these indicators.

Using the international guidelines for the combined symptom severity index based on symptom frequency in the past four weeks, 18% of all asthma patients in the total European sample would be classified as having severe persistent asthma. Another 19% of all patients would be classified according to international guidelines as having moderate persistent asthma. Another one in five asthma patients in Europe (19%) would be classified as having mild persistent asthma. More than two in five asthma patients (44%) in Europe would be classified as having mild intermittent asthma.

The distribution of asthma patients by symptom severity is similar across the seven countries in the AIRE study. Sweden (15%) and France (14%) have slightly fewer patients classified as severe persistent asthma than the European norm (18%). By contrast, the Netherlands (23%) and Germany (26%) have somewhat more patients with severe persistent asthma than the European norm. Germany (33%) and the Netherlands (34%) have fewer patients with mild intermittent asthma than the European norm (44%).

Asthma Morbidity and Health Care Utilization
What are the consequences of the symptoms reported by adults and children with asthma? One of the most dramatic consequences is hospitalization. One out of every 14 persons with asthma in Europe (7%) reported having been hospitalized overnight or longer for their asthma in the past year. The rate of past year hospitalization for asthma ranges from a low of 5% in Sweden to a high of 10% in Spain and Germany.

A second major effect of asthma is emergency room visits. When asked whether they had gone to a hospital emergency room for asthma in the past 12 months, one out of 10 persons with asthma (10%) reported one or more asthma emergency room visits. Big variations were found among the European countries in the rate of past-year emergency room visits from asthma. Only 6% of asthma patients in Germany and the Netherlands reported emergency room visits for asthma in the past year. By contrast, 21% of asthma patients in Sweden and 26% in Spain reported visits to the hospital emergency room for asthma in the past 12 months.

In addition to hospital emergency room visits, the international sample of persons with asthma in Europe was asked whether their asthma had caused other unscheduled, emergency visits to a doctor’s office, clinic or somewhere else in the past 12 months. A quarter of asthma patients (25%) reported other urgent care visits for their asthma in the past 12 months. This varies from a low of 13% in Sweden to a high of 37% in (Figure 29).

The three types of health care utilization for asthma -- in-patient hospital care, hospital emergency room treatment and other urgent care -- can be combined to obtain an estimate of total demand for acute care for asthma. In total, nearly a third of asthma patients in Europe (30%) had been hospitalized, had an emergency room visit, or had another type of urgent care visit for their asthma in the past year. The proportion of asthma patients requiring acute care for their asthma in the past year ranged from a low of 27% in the United Kingdom and 30% in Sweden and Italy, to a high of 42% in Spain.

A final measure of morbidity is the loss of work or school days as a result of asthma. Nearly a fifth of all adult asthma patients in the seven European countries (17%) reported their asthma had caused them to miss work, while 43% of children had missed school in the past 12 months. The proportion of asthma patients who have lost work or school days in the past year ranges from a low of 13% of adults and 34% of children in Sweden to a high of 28% of adults and 49% of children in the Netherlands.

The impact asthma has on the lifestyles of persons with asthma comes into sharpest relief when asking about activity limitations. While many asthma patients continue to exercise, more than two out of five of all asthma patients in Europe (42%) said asthma limited them a lot or some in sports and recreation. Nearly one-quarter (23%) said their asthma limited them a lot or some in their choice of jobs or careers. More than a third (35%) said their asthma limited them a lot or some in sleeping. A third (32%) said their asthma limited them a lot or some in normal physical activity. Three out of 10 said their asthma limited them a lot or some in their lifestyle (29%). More than a quarter (27%) said their asthma limited them a lot or some in housekeeping chores. More than a fifth (22%) said their asthma limited them a lot or some in their social activities.

Asthma Control
Despite the number and frequency of asthma symptoms reported in the survey, the acute heath care visits and the activity limitations imposed by their condition, more than three-quarters of asthma patients in the seven European countries (77%) felt their asthma was well or completely controlled. Among persons with asthma, 34% said their asthma had been completely controlled in the past four weeks and another 43% said it had been well controlled in the past four weeks. Most of the rest (17%) of the asthma patients in the European sample said their asthma was only somewhat controlled. Only 5% of patients said their asthma had been poorly or not controlled in the past four weeks (Figure 37).

There is some variation among the countries in the degree of perceived control over their asthma. The proportion of asthma patients who felt their asthma has been completely or well controlled in the past four weeks is lowest in Sweden (70%). Perceived control is highest in France (85%).

However, the survey finds that the patient’s perceived control over his or her asthma matches their reported symptom severity at the same time. Among patients who would be classified as having severe persistent asthma based on their symptoms in the past four weeks, nearly half (49%) said their asthma was completely (14%) or well controlled (35%) during that period. Among those whose symptoms indicate moderate persistent asthma in the past four weeks, more than two-thirds (70%) said their asthma has been completely or well controlled during that same period. By contrast, only 5% of those with mild persistent asthma and 2% of those with mild intermittent asthma in the past four weeks rated their symptom control as poorly controlled or not controlled in that period. Hence, the survey finds serious discrepancies between actual symptom frequency/severity and the degree of asthma control perceived by the patient. Although the discrepancy occurs in both directions, asthma patients are far more likely to overestimate the degree of control over their asthma.

Medical Treatment
There is considerable variation among the seven European countries in the location where asthma patients usually go for their health care. Almost all persons with asthma in the United Kingdom (94%) and Germany (95%) usually go to a doctor’s private surgery for their usual medical care. By contrast, the majority of asthma patients in Sweden (59%) usually go to a public health clinic for their health care. Nearly half (49%) of asthma patients in Spain usually go to a hospital outpatient clinic or emergency room for their usual source of medical care.

Most persons with asthma in Europe see a primary care doctor most often for their asthma. Indeed, 67% said they saw a general practice doctor or a family practice doctor most often for their asthma. Only a small proportion of asthma sufferers in the seven AIRE countries saw an allergist (10%) or a chest or respiratory care specialist (6%) most often for their asthma. The use of specialists for usual asthma care is lowest in the United Kingdom and highest in France, Spain and Italy.

Although one of the goals of asthma management is improved lung function, the majority of persons with asthma in Europe (54%) reported that their doctor has never given them a lung function test. However, there is considerable variation among the seven countries in the use of lung function tests. Only 20% of asthma patients in Germany and the Netherlands said their doctor has never given them a lung function test. By contrast, 69% of asthma patients in the United Kingdom reported their doctor has never given them a lung function test. Overall, only a third of asthma patients in Europe (33%) report having a lung function test in the past year.

Only three out of five asthma patients in Europe (60%) had ever heard of a peak flow meter. The greatest awareness of peak flow meters was found in the United Kingdom (78%). A majority of asthma patients in Sweden (52%) and the Netherlands (50%) had heard of peak flow meters. By contrast, only 22% of asthma patients in Spain reported that they had ever heard of peak flow meters.

Only a fifth of asthma patients in Europe (21%) reported that their doctor had ever developed a written action plan for their asthma treatment. However, there was considerable variation among the seven countries in the use of asthma action plans. Only 9% of asthma patients in the United Kingdom and 13% in Sweden said their doctor had developed a written action plan for their asthma. By contrast, 37% of asthma patients in France, 40% in Italy and 52% in Spain said their doctors had developed a written action plan for their asthma.

In summary, patient reports suggest that the current practices of asthma management in Europe fall short of international guidelines. In specific areas of asthma management, some countries appear to do better than other countries. However, all of the seven countries appear to fall short on at least some of the recommended practices for asthma management.

Treatment of Asthma
The national sample of asthma patients in the seven European countries was asked, based on what they know or had heard, what was the underlying condition that causes asthma symptoms. This was asked as an open-ended question with no response categories offered to the respondents. Most commonly, asthma sufferers reported that allergies (44%), irritants (16%) or pollution (14%) were the underlying condition that causes asthma symptoms. One in five asthma sufferers (20%) said they did not know the underlying condition that causes asthma symptoms. Only 8% of asthma patients in Europe volunteered the correct answer: inflammation of the airways causes asthma (Figure 59A). The unaided awareness of airway inflammation as the underlying cause of asthma ranged from 5% in France and Netherlands, to 15% in Germany.

Those who did not volunteer inflammation of the airways as the underlying condition that causes asthma were asked if they had ever heard it was the underlying cause. A majority of the asthma patients in Europe replied to the aided question that they had heard that inflammation was the underlying cause (56%). However, even when combining the aided and unaided recall, only 64% of asthma patients said they had ever heard inflammation of the airways was the underlying condition that causes asthma. The proportion of asthma patients who said they were aware inflammation of the airways is the underlying cause of asthma ranged from 56% in France to 73% in the Netherlands.

The survey provided an even more striking finding about patient expectations concerning the ability of treatment to affect asthma. Only one-third of the persons with asthma in Europe (32%) said the underlying condition for asthma could be treated. The majority (56%) of persons with asthma said only the symptoms could be treated, not the underlying condition. The reminder of asthma patients were unsure whether the underlying condition or only the symptoms could be treated.

In none of the seven countries did a majority of persons with asthma say the underlying condition was treatable. At one extreme, only 19% of asthma patients in the Netherlands said the underlying condition was treatable. At the other extreme, 48% of asthma patients in France said the underlying condition was treatable. Indeed, only in France did a plurality of asthma patients feel that the underlying condition was treatable.

Treatment
All persons with current asthma, regardless of the awareness of airway inflammation as the underlying condition causing asthma symptoms, were asked what kinds of medicines they had used to reduce or prevent airway inflammation in the past four weeks. The majority (60%) reported they had used prescription medicines to give themselves quick relief from asthma symptoms in the past four weeks. Only a handful of asthma patients (5%) reported the use of over-the-counter drugs to get quick relief from asthma symptoms in the past four weeks. The majority of asthma patients said they were not using any prescription medicine to reduce airway inflammation. However, a relatively large minority (41%) of persons with asthma reported they were being treated with a prescription medication to reduce or prevent asthma. A small proportion of asthma patients (12%) reported the use of any other prescription medicines for asthma in the past four weeks.

Those who reported using a prescription medication in the past four weeks were asked the name of the medicines they were using to treat airway inflammation. In order to get an accurate estimate of what medications are used by asthma patients in Europe, the specific medications reported as prescription medication for airway inflammation and other prescription medicine used for asthma in the past four weeks were coded by class of medication. The survey indicated that less than one-quarter (23%) of asthma patients in Europe were taking inhaled corticosteroids for their asthma. Non-steroid anti-inflammatory medicines are rarely used by asthma patients in Europe (1%). Hence, the proportion of asthma patients taking inhaled corticosteroids for their asthma in Europe is virtually equivalent to the proportion taking any anti-inflammatory medicine for their asthma.

There is substantial variation among the European countries in the use of inhaled corticosteroids among asthma patients. The rate of inhaled corticosteroid use is highest in Sweden, where 37% of asthma patients reported using an inhaled corticosteroid for their asthma in the past four weeks. About a quarter of all asthma patients in the United Kingdom (26%), Germany (26%) and the Netherlands (24%) reported current use of inhaled corticosteroids for their asthma. Only about one in seven persons with asthma in France (15%), Spain (15%) and Italy (13%) reported using an inhaled corticosteroid in the past four weeks (Figure 68).

Perhaps more surprisingly, was the relatively small variation in the rate of anti-inflammatories (inhaled corticosteroids and non-steroid anti-inflammatories) by symptom severity. The rate of anti-inflammatory use in the past four weeks was 26% among persons with severe persistent asthma, 26% among persons with moderate persistent asthma and 30% among persons with mild persistent asthma. Overall, 27% of persons with persistent asthma in the seven AIRE countries were taking anti-inflammatories for their asthma, compared to 18% among those with mild intermittent asthma.

Asthma and the Future
The vast majority of persons with asthma in Europe felt that asthma had increased in their country. However, a plurality (41%) said persons with asthma were generally more healthy now than they were 10 years ago. The most common reason asthma patients gave for the perceived improvement in the health of persons with asthma in the past 10 years was better medicines (61%). In addition, 43% attributed the improvement in the health of asthmatics to better treatment without specifying medicines or drugs. Other leading reasons asthma patients gave for improvement in asthma health over the past 10 years were having a better understanding of the disease (30%) and better education about how to control it (20%).

Although most asthma patients said they understood the issues related to the management and treatment of their condition, there is overwhelming sentiment that there was a need for better education of people with asthma about their condition and treatment. Nearly three-quarters of persons with asthma in Europe (73%) felt there was a strong need for better education of people with asthma about their condition and its treatment. Another 22% of asthma patients said there was a moderate need. Only 5% of asthma patients said there was not much need or no need at all for better education of persons with asthma.

Goals of Asthma Management and Treatment
In April 1997, under the auspices of the National Asthma Education and Prevention Program of the National Heart, Lung and Blood Institute, an expert panel published new Guidelines for the Diagnosis and Management of Asthma. The purpose of the report was to present basic recommendations for the diagnosis and management that would help clinicians and patients make appropriate decisions about asthma care. The AIRE Survey provides an opportunity to compare the goals of these guidelines to the state of asthma management, two years later.
The Guidelines provide five general goals of asthma therapy: (1) prevent chronic asthma symptoms during the day and night; (2) maintain normal activity level; (3) have normal or near-normal lung function; (4) be satisfied with asthma care received; and (5) have no or minimal side effects while receiving optimal medications.

The survey findings suggest that asthma patients in the seven AIRE countries are falling far short of the guideline recommendations concerning the prevention of chronic asthma symptoms during the day and night. The guidelines call for no sleep disruption by asthma. By contrast, the survey found that 37% of all asthma patients in Europe had cough, wheezing, shortness of breath or chest tightness during the night within the past four weeks. The guidelines call for no missed school or work days due to asthma. However, the survey found that one in seven adults with asthma (17%) and more than two in five children with asthma (43%) had missed work or school in the past 12 months due to asthma. Finally, the guidelines call for no emergency room visits or hospitalizations due to asthma. Unfortunately, the survey found that 30% of asthma patients had been hospitalized, gone to a hospital emergency room or other emergency visit for their asthma in the past 12 months.

The survey also found that persons with asthma may not be receiving optimal medication for their asthma. The guidelines recommend long-term control asthma medication to achieve and maintain control of persistent asthma. The guidelines identify the most effective long-term-control medicines as those that reduce inflammation. However, the survey found that only 26% of the patients with severe or moderate persistent asthma symptoms were taking an anti-inflammatory medicine for their asthma.

Finally, the guidelines set patient satisfaction with the asthma care received as one of the goals of asthma therapy. The survey found that most asthma patients (84%) rate their doctor’s knowledge of asthma and asthma management as excellent, very good or good.

Hence, the survey found a major discrepancy between patient satisfaction with the management and treatment of their asthma and the actual rates of morbidity found in this population. Despite fairly high rates of hospitalization and emergency room visits, only a very small minority of current asthma patients were taking anti-inflammatory treatments recommended to treat the underlying condition.

The survey suggests several factors that appear to play a role in this problem. First, many asthma patients were unaware that there was any effective treatment for the underlying condition that causes asthma symptoms. Second, perhaps as a result of this, asthma patients tolerated a much higher rate of asthma symptoms as an acceptable degree of asthma control than were recommended by medical professionals. Third, those who believed that the underlying condition could be controlled were generally unaware of what classes of medications were recommended for treatment of airway inflammation. Fourth, many asthma patients believed that the short-relief medications they were currently taking for asthma symptom relief, were also effective treatments for airway inflammation. This lack of information about the degree of asthma control achievable through effective treatment of airway inflammation and how to treat this inflammation effectively, appeared to inhibit recommended treatments for asthma. In the absence of effective treatment, asthma patients continued to report high levels of asthma symptoms, morbidity related to asthma and heavy use of health care facilities and providers to treat their symptoms and complications.

The total number of household screens in the Europe database (73,617) is slightly lower than the number reported in the final disposition.

AIRE: Executive Summary
June 1, 1999