With good long-term management, the burden of asthma can be reduced.

The Global Asthma Report 2014

Asthma management guidelines in countries responding to the Global Asthma Network survey, 2013.

Figure 1: Asthma management guidelines in countries responding to the Global Asthma Network survey, 2013.

Pharmaceutical sponsorship in asthma management guidelines in countries responding to the Global Asthma Network survey, 2013.

Figure 2: Pharmaceutical sponsorship in asthma management guidelines in countries responding to the Global Asthma Network survey, 2013.

Comparison of 2011 and 2013 asthma guideline usage for those 72 countries participating in both surveys.

Table 1: Comparison of 2011 and 2013 asthma guideline usage for those 72 countries participating in both surveys.

Asthma management guidelines are an essential part of successfully managing asthma and promoting the delivery of quality asthma care.

ASTHMA MANAGEMENT GUIDELINES

Asthma management guidelines were first created in the 1980s, with many being commercially sponsored consensus statements. Now, asthma management guidelines are most commonly independent of pharmaceutical industry support and are evidence-based. The Global Asthma Report 2011 undertook the first worldwide survey on the use of National Asthma Management Guidelines and this survey was repeated by the Global Asthma Network (GAN) in 2013. Use of asthma management guidelines is increasing in countries around the world, particularly in low- and middle-income countries, and most of the guidelines in use were developed without financial assistance from the pharmaceutical industry.

The role of guidelines

Asthma management guidelines play an important role in standardising timely and correct assessment of asthma symptoms and severity, and effective case management, thus potentially lessening the burden of asthma. More recently, asthma management guidelines have become evidence-based guidelines initiated by governments or non-profit bodies. In 2012 the World Health Organization (WHO) published guidelines for the management of asthma for children and adults in their report “Prevention and Control of Noncommunicable Diseases: Guidelines for primary health care in low resource settings.”

Key components of asthma guidelines are recommendations about what asthma medicines to use, and when to use them. It follows that the development of guidelines which are free of the influence, and thus potential bias, of the developers and manufacturers of asthma medicines (the pharmaceutical industry) is preferred.

The Global Asthma Report survey 2011

Chapter 8 of the Global Asthma Report 2011 reported a survey of asthma guidelines use in ISAAC centres. Of 92 countries responding (88% response rate), 74 countries (80%) used asthma management guidelines. Of these 74 countries, 67 (73%) had their own national guidelines, 45 (49%) used guidelines developed without support from the pharmaceutical industry, and 31 (34%) had pharmaceutical industry support.

The Global Asthma Network survey 2013

In 2013, 105 GAN centres were asked to undertake a similar survey about asthma guidelines, completed on-line. The survey questions are in Appendix A, Figure 6. The survey was completed by investigators in 96 countries (93%). Asthma management guidelines were used in 89% of the 96 countries (Figure 1). Most (63%) of the responding countries used their own national asthma guidelines.

The use of guidelines prepared with support of the pharmaceutical industry varied around the world (Figure 2). Of the 96 countries that completed the survey, 42% used guidelines sponsored by the pharamaceutical industry. Of the 63% of countries that had their own national guidelines, 15% were sponsored by the pharmaceutical industry, 30% did not provide information about whether pharmaceutical sponsorship was involved or not, and 8% used a combination of pharmaceutical sponsored and non-pharmaceutical sponsored guidelines (see Appendices, Table 2 and Figure 7.).

Type of guideline

40% of countries used their own national guidelines exclusively. The Global Initiative for Asthma (GINA) guidelines (supported by unrestricted educational grants from non pharmaceutical and pharmaceutical companies) were exclusively used in 17% of countries, 7% used other international guidelines, and 25% of countries used several types of guidelines. 11% did not have any guidelines and, of these, 8% said they would use the recently released WHO guidelines and 3% did not intend to use the recently released WHO guidelines (Figure 1).

Use of guidelines in low-, middle-, and high-income countries

There were some different patterns of use of guidelines according to country income. Of the 96 countries, 32 (33%) were high-income countries and 64 (67%) were low- and middle-income countries. Exclusive use of their own national guidelines was greater in high-income countries than in low- and middle-income countries (78% and 55%, respectively). Use of GINA and other international guidelines was higher in low- and middle-income countries; The International Union Against Tuberculosis and Lung Disease (The Union) guideline was used in three of these. Of low- and middle-income countries, 11% intended to use the recently released WHO guidelines while only one high-income country intended to. A similar proportion of low- and middle-income countries and high-income countries had similar figures for use of multiple guidelines, or no guidelines.

Time Trends

Most (72) countries participated in both the 2011 and 2013 surveys. Comparisons for some of the variables are shown in the Table. The proportion of countries using guidelines increased over the two years, as did the number using multiple guidelines. The proportion of guidelines with specified pharmaceutical industry support increased from 36% to 49%. This increase was in part caused by the number of countries using GINA guidelines increasing from 6 to 22 from 2011 to 2013.

Summary of surveys

These surveys fill a global data gap on guideline use by providers within countries. It is encouraging that the majority of countries use management guidelines, and that most of these were developed without financial assistance from the pharmaceutical industry. Between 2011 and 2013, our research suggests that the number of countries using a guideline has increased. More than one guideline was used in one quarter of the countries. This is not surprising given the availability of guidelines through the internet. However guidelines which are not tailored to the health care system in the country where they are used will be more difficult to implement.

Most investigators were not aware of the recently released WHO guidelines, and at the time of the 2013 survey these guidelines were not widely used. They should be considered for primary health care in low-resource settings, especially where national guidelines free of pharmaceutical industry support are unavailable.

Conclusion

National guidelines are an important tool for the management of asthma. International guidelines free of pharmaceutical industry support are freely available, including the WHO guidelines for low-resource settings. They can be used directly or, with permission, as a model for countries to modify for their own national guidelines. Guidelines should promote access for everyone to quality-assured, affordable essential medicines within the countries they are used.

Recommendation

Health authorities in all countries should ensure the availability of nationally appropriate asthma management guidelines, and provide access for everyone to the quality-assured, affordable essential asthma medicines those guidelines recommend.

Philippa Ellwood, Innes Asher, Karen Bissell, Guy Marks, Asma El Sony, Eamon Ellwood

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