REVIEW Achieving asthma control in practice: Understanding the reasons for poor control John Haughney a,*, David Price a, Alan Kaplan b, Henry Chrystyn c, Rob Horne d, Nick May e, Mandy Moffat a, Jennifer Versnel f, Eamonn R. Shanahan g , Elizabeth V. Hillyer h , Alf Tunsater �� i , Leif Bjermer i a Department of General Practice and Primary Care, University of Aberdeen, Foresterhill Health Centre, Westburn Road, Aberdeen AB25 2AY, Scotland, UK b Chairperson, Family Physician Airways Group of Canada, Family Physician, 17 Bedford Park Avenue, Richmond Hill, Ontario, Canada L4C 2N9 c School of Applied Sciences, University of Huddersfield, Huddersfield, West Yorkshire HD1 3DH, UK d Centre for Behavioural Medicine, Department of Policy & Practice, The School of Pharmacy, University of London, Mezzanine Floor, BMA House, Tavistock Square, London WC1H 9JP, UK e Healthcare Practice Europe, Middle East, Africa, Hill & Knowlton, 20 Soho Square, London W1A 1PR, UK f Research & Policy, Asthma UK, Summit House, 70 Wilson Street, London EC2A 2DB, UK g Farranfore Medical Centre, Farranfore, Killarney, Co. Kerry, Ireland h Respiratory Research Ltd., Unit 8, Beech Avenue, Taverham, Norwich NR8 6HW, UK i Department of Respiratory Medicine & Allergology, University Hospital, 221 85 Lund, Sweden Received 17 July 2008 accepted 8 August 2008 Available online 23 September 2008 KEYWORDS Asthma Nonadherence Poor control Primary care Smoking Tools Summary Achieving asthma control remains an elusive goal for the majority of patients worldwide. Ensuring a correct diagnosis of asthma is the first step in assessing poor symptom control this requires returning to the basics of history taking and physical examination, in conjunction with lung function measurement when appropriate. A number of factors may contribute to sub- optimal asthma control. Concomitant rhinitis, a common co-pathology and contributor to poor control, can often be identified by asking a simple question. Smoking too has been identified as a cause of poor asthma control. Practical barriers such as poor inhaler technique must be ad- dressed. An appreciation of patients��� views and concerns about maintenance asthma therapy can help guide discussion to address perceptual barriers to taking maintenance therapy (doubts about personal necessity and concerns about potential adverse effects). Further study into, and a greater consideration of, factors and patient characteristics that could predict * Corresponding author. Tel.: ��44 1355 261666 fax: ��44 1224 550683. E-mail address: j.haughney@abdn.ac.uk (J. Haughney). 0954-6111/$ - see front matter �� 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.rmed.2008.08.003 available at www.sciencedirect.com journal homepage: www.elsevier.com/locate/rmed Respiratory Medicine (2008) 102, 1681e1693

individual responses to asthma therapies are needed. Finally, more clinical trials that enrol patient populations reflecting the real world diversity of patients seen in clinical practice, including wide age ranges, presence of comorbidities, current smoking, and differing ethnic origins, will contribute to better individual patient management. �� 2008 Elsevier Ltd. All rights reserved. Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1682 Reasons for poor asthma control: the wrong diagnosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1683 Asthma diagnosis: the basics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1683 Diagnosing asthma in adults . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1683 Diagnosing asthma in children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1683 Reasons for poor asthma control: incorrect choice of inhaler, poor technique . . . . . . . . . . . . . . . . . . . . . . . . . 1683 Device choice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1684 Metered-dose inhalers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1684 Dry powder inhalers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1684 Devices to aid inhaler technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1684 Beyond device choicedimproving inhaler technique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1684 Reasons for poor asthma control: smoking . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1684 Reasons for relative corticosteroid resistance among smokers with asthma . . . . . . . . . . . . . . . . . . . . . . 1685 Clinical approach to patients with asthma suspected or known to smoke . . . . . . . . . . . . . . . . . . . . . . . . 1685 Reasons for poor asthma control: co-morbid rhinitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1686 Clinical approach to patients with asthma and concomitant rhinitis . . . . . . . . . . . . . . . . . . . . . . . . . . . 1686 Reasons for poor asthma control: individual variation in response to treatment . . . . . . . . . . . . . . . . . . . . . . . 1686 Limitations of randomised controlled trials . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1686 Clinical study patients versus real-life patients . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1687 Group mean versus individual trial data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1688 Pharmacogenetics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1689 Reasons for poor asthma control: patients��� beliefs and adherence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1689 The perceptual-practical model of nonadherence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1689 Assessing necessity beliefs and concerns: the necessity-concerns framework . . . . . . . . . . . . . . . . 1689 Tools to assess patients��� beliefs and identify adherence behaviour . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1689 Reasons for poor asthma controldsummary and next steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1690 Conflict of interest . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1690 Acknowledgements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1691 Supplementary data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1691 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1691 Introduction Achieving asthma control remains an elusive goal for the majority of patients worldwide.1e3 This troublesome reality persists despite the availability for over two decades of international asthma management guidelines and asthma therapies of proven efficacy, at least for the highly selected patient populations studied in controlled trial settings.4,5 Poor asthma control places a heavy burden on patients and their families, as it manifests in increased rates of hospi- talisations and emergency room and other urgent care visits, in addition to activity limitations, night-time awak- enings, and lost time from work and school.6 Moreover, poor asthma control is expensive, accounting for most of asthma-related health-care costs.7 An international initiative was begun in 2006, under the auspices of the International Primary Care Respiratory Group (IPCRG), to examine the reasons for poor asthma control and arrive at a consensus on how best to improve the delivery of asthma care in the primary care setting, where most patients with asthma are managed. The first discussion centred around understanding the patient���s perspective as a means of improving asthma control.8 A key priority emerging from this discussion was the need to identify and develop validated instruments (tools) to assess asthma control and understand the reasons for poor control for individual patients. Primary care providers work under tight time constraints and often with limited diagnostic facilities. Therefore, tools for use in primary care must be simple and practical. Building on the first discussion, a second meeting was held in September 2007 to examine common reasons for poor asthma control and how these might be identified and addressed in clinical practice. Here we report the discussion of these important issues, including what sort of tools could 1682 J. Haughney et al.