In this 12-year, real-life, follow-up study we showed that comorbidities, lifestyle factors, inhalation technique, and asthma action plan were poorly documented during scheduled asthma contacts (n = 542) in PHC in Finland. The most frequently recorded asthma details were respiratory symptoms (79%), asthma medication brand names (70%), and the recommendation for the timing of the next follow-up contact (62.5%). All these details were found even more often if the nurse and GP both participated in the contact. Rhinitis was the most-often documented comorbidity, but it was registered only in 8.9% of all contacts. Recorded information on possible lifestyle guidance interventions given to the patients was found in <1% of contacts. Results from this longitudinal study may help to identify potential health-care practice-related causes of uncontrolled and difficult-to-treat asthma, and which areas require more urgent training and attention.

Obesity has been shown to be associated with uncontrolled and severe asthma1,2,3,27,49,50,51, poorer work ability12, lower lung function, more dispensed oral corticosteroids with higher doses, and higher health-care costs50, and it is a risk factor for asthma exacerbations even in patients with few symptoms1. Adult patients with asthma are at a higher risk of developing obesity52. Moreover, obesity has been shown to be a permanent problem in more than 85% of adult patients with asthma in long-term follow-up50. Weigh reduction in obese adults, also after bariatric surgery53, has shown to lead to overall improvement in asthma control, including airway hyper-responsiveness and inflammation54. We showed in this study that professionals rarely documented information about a patient’s BMI, overweight, or obesity. According to documented information, patients received no guidance in relation to obesity-related lifestyle factors during long-term follow-up, even though these factors are also shown to contribute to asthma independently. For example, low physical activity is associated with faster lung function decline18, dietary components are suggested to affect immune pathways in asthma55, and prolonged and heavy alcohol exposure may impair mucociliary clearance and may complicate asthma management56. A previous study based on physicians’ self-reports regarding clinical practice indicated that, overall, very few GPs assessed asthma patients’ lifestyle factors34, which is in line with our results. Overall, based on documented patient data, lifestyle factors were poorly registered; however, nurses mentioned exercise habits in almost every third contact. Lifestyle guidance was more the nurse’s responsibility in previous national and local asthma programmes, which may explain this result.

Allergic rhinitis is known as a predominant comorbid disease in difficult-to-treat asthma36,49. Chronic rhinosinusitis is known to be an independent predictor of asthma exacerbation among patients with difficult asthma9,57. Considering the unity of the upper and lower respiratory tract, the concept called ‘united airways’, screening and treating of rhinitis and other nasal conditions in asthma is important57,58. Thus, evaluating possible nasal symptoms and adherence to nasal medication should be assessed in every asthma contact. Medications treating nasal diseases have also been shown to be useful in improving control of asthma and reducing bronchial hyper-responsiveness58. A recent study showed that approximately 67% of the patients with moderate-severe rhinitis were not using the recommended intranasal corticosteroid therapy36. Aligning with previous studies35,36, our results showed that even though rhinitis is highly prevalent49, its screening and treatment in patients with asthma was suboptimal in PHC. In our study 70% of patients had rhinitis but it was recorded in less than every tenth and, overall, nasal symptoms less than in every fifth contact. The initiation of rhinitis treatment was rare. Based on recorded nasal medication data, over half of the patients with rhinitis may have been undertreated when medication for chronic rhinitis has been available only with a doctor’s prescription. Documentation of reflux symptoms, OSA and intolerance to NSAIDs was similarly underperformed, despite all these conditions being associated with severe asthma, poor symptom control, and more frequent exacerbations and hospitalisations8,10,51,59,60. NSAIDs (including aspirin) may exacerbate asthma symptoms in patients with N-ERD (NSAID-exacerbated respiratory disease), a chronic eosinophilic inflammatory disorder of the respiratory tract occurring in patients with asthma and/or rhinosinusitis with nasal polyps10. A recent study showed that the prevalence of N-ERD was 6.9% among asthmatics60, while the prevalence of gastroesophageal reflux varies between 17–74%7,9 and the prevalence of OSA ~39–50%6,9. Reflux disease and OSA may arguably have been underdiagnosed in our study population, considering a majority have a BMI > 25. OSA was probably not yet well known in PHC during the current study’s time period, and recognition improved after the national sleep apnea programme in Finland (2002–2010)61.

The results in this and our previous studies22,32 suggest that implementation of the Finnish National Asthma Programme’s31 main objectives has been partially successful in PHC, but room still exists for improvement (Fig. 3). We found in this study that screening of asthma symptoms as a part of asthma control assessment has been managed well in PHC. Cloutier et al.’s previous study30 showed that physicians monitor selected symptoms depending on the symptom, from 48.4% to 56.0%. We were unable in this study to assess more precisely the extent of the symptoms’ evaluation and of the patients’ true symptom burden; thus, more research regarding this issue is needed in the future. Patients have been shown to overestimate their asthma control36, which supports assessing asthma control using objective methods such as lung function tests together with symptom questionnaires. ACT documentation was rarely found in our study, similar to previous studies in which validated patient-reported questionnaires were rarely used to monitor asthma control28,30. ACT was not yet in wide use in Finland during the SAAS study period, which probably explains our results to some extent. Pulmonary auscultation was recorded in almost 3 of 4 physicians’ contacts but never in nurses’ contacts, which is explained by the fact that pulmonary auscultation is usually performed only by a doctor in Finland.

Green colour describes the performed assessment that were implemented well, yellow colour describes moderate implementation, and the orange describes the measures that are poorly implemented. *Takala et al.22. #Takala et al.32. ǂSelf-care guidance includes patient asthma action plan instructions and lifestyle guidance.

It is essential that the complete asthma medication information, including names, doses and inhalers, is documented in patient records for continuity of care, because the professional responsible for patient care may change. The common electronic patient record system was not yet in use in our region during the SAAS study period, and some patients still had handwritten paper prescriptions in addition to those that were prescribed through the electronic patient health record system. As a result, the patient health record system did not necessarily have an up-to-date medication list or information about possible changes to medication made elsewhere, which also advocates for the importance of recording medication information. Asthma medication brand names were mentioned in 70% of scheduled contacts in our study, but dosage and inhalers were documented in only <14% of contacts. Only doctors had the right to prescribe medicines during the study period, which explains why medication changes were more common in visits when a GP was involved. This study and our previous studies22,23, show that patients with ≥2 scheduled contacts in PHC had high mean adherence to ICS medication (>80%), and their adherence level was higher compared to patients who had mainly follow-up contacts in secondary care (82% vs. 52%)23. Higher adherence was associated with non-controlled disease in SAAS-study population, while total adherence <80% was associated with more rapid lung function decline in not-controlled disease62. Our results suggest that professionals in PHC are good at promoting adherence to asthma medication. We were unable in this study, unfortunately, to assess in more detail how medication adherence was evaluated and if discussion supporting adherence to treatment, occurred at the contacts. The names of the medications in use were recorded well and adherence was high, so it can be assumed that treatment compliance in medication was discussed in the follow-up contacts to some extent. It could be speculated that continuity of care may be one reason for the good adherence when it was also shown that the recommendation for the timing of the next scheduled contact was documented in over 62% of contacts and in almost 70% if both professionals were attending.

Incorrect inhaler technique is common and can lead to poor asthma control1. Previous studies from Sweden and Finland showed that 87–97% of patients reported that they had received education about inhalation technique24,63. Another study from Australia revealed that patients overestimated the true success of their own inhalation technique when 73% of patients believed they did well, whereas an objective assessment showed that all patients had at least two errors and over 70% exhibited five or more errors36. In studies from the U.S. and Australia, 17–30% of PHC clinicians reported assessing inhaler technique30,34, but based on documented and reported patient data, only 1–5% of patients had their inhaler technique checked21,36, which is in line with our results. Checking the inhalation technique is usually the nurses’ task in the Finnish health care system, but still, according to recorded patient data, this was performed in approximately only 8% of nurse contacts, which is alarming.

AAP is a description of how an individual should manage asthma, including advice for medication changes, if necessary, and a plan for contact with the health-care system20. Use of written action plans is suggested to be poor both in PCH and in secondary care33 and shown to vary from 0 to 50%21,28,30,33,34. A previous study from Finland showed that over 78% of adult asthmatics reported having an asthma self-management plan24, but based on our results, AAP was not assessed or updated during planned contacts according to documented data. Recorded information on AAP was found in only 5% and written action plan in 1% of contacts, which can be considered surprising when one of the Finnish Asthma Programme’s most important goals was patients’ self-care guidance, including provision of both written and verbal asthma action plans31. Every patient in the SAAS study population received both verbal and literal asthma guidance, usually immediately upon asthma diagnosis confirmation in the respiratory department. Thus, could be argued whether the existence of an AAP was considered self-evident in PHC; however, it does not justify the omission of an AAP assessment. Chapman et al. suggested that physicians tend to rely upon advances in pharmacological intervention to improve the quality of asthma care rather than the non-pharmacological aspects of asthma management28. Our results showing that AAP and lifestyle interventions were poorly implemented in scheduled follow-ups in PHC support that. A recent UK study showed that many factors, such as poor attendance at asthma clinics, lack of time, demarcation of roles, limited access to a range of resources and competing agendas in consultations that are often due to multimorbidity, may increase the risk that self-care guidance is not provided during contacts64. These potential barriers are important to recognise when developing asthma monitoring and treatment guidance in the future.

This study’s major strength is its use of a real-life, unselected, adult-asthma population when patients with smoking or comorbidities were not excluded. Thus, our study population represents a typical PHC population with asthma37,65. Their asthma diagnosis was originally made by a respiratory physician based on typical symptoms and objective lung function measurements showing reversibility of airway obstruction37. All scheduled asthma contacts in PHC were evaluated in this study, including both nurse and GP visits, and the overall number of scheduled contacts may be expected to yield a representative sample of a real-life, adult-asthma population. We acknowledge that the significance of comorbidities in asthma control was perhaps not as well understood in 2002 compared to today. However, all the comorbidities with the exception of OSA, as well as other asthma management details evaluated in this study, have already been discussed in the first Finnish asthma guideline in 2000 and also e.g., in the GINA 2002 recommendation66,67. Therefore, it can be estimated that PHC has had opportunities to apply the best evidence-based practices during the study’s period. This study’s results are valuable because long-term, real-life, follow-up studies of adult-onset asthma in PHC are rare. Our results help to understand the possible health-care-related causes behind uncontrolled and difficult-to-treat asthma, e.g., which areas in assessing asthma require more specific training and attention.

A possible weakness of our study is that, e.g., comorbidities and other asthma-related details evaluated may have been screened and discussed during scheduled contacts or assessed earlier in other contexts, but these data have not been recorded. However, according to good clinical practice, the measures taken shall be recorded; otherwise, it can be interpreted that this has not been performed, or that the existence of the matter and its possible connection has not been considered. Additionally, regarding continuity of care, it is important that patient document entries are done well. We were unable in this study to assess more precisely either the extent of symptoms’ evaluation or the content of AAP instructions. Other important aspects of asthma care were not assessed in this study, such as exacerbations and trigger avoidance. More research is needed to evaluate these topics. Another limitation of our study is that our results may not represent Finland entirely, and it may not reflect the current situation, because the data were collected between 2002–2013. No common national asthma template is in use, and the recording practices may also differ regionally, e.g., due to different electronic health record systems. The use of ready-made phrase templates has become more common since the SAAS study period, which may have improved screening and assessment of asthma control-related issues. However, problems with accessibility to PHC have been increasing48,68, and it is very likely that asthma treatment and follow-up is largely carried out during visits for other conditions or for other reasons. A new, long-term follow-up study from the 2010s to 2020s would be needed to assess the current situation and whether asthma assessment has improved since the follow-up period in this study. Asthma control was defined according to GINA 2010 criteria at the 12-year follow-up visit, and asthma severity was classified according to the ERS/ATS 2014 guideline42,43. We consider it correct to use the data as they were collected and evaluated at the clinical visit on asthma control and as used in the original SAAS study material, even if asthma control and asthma severity criteria have change since then.

Regular monitoring is important when adult-onset asthma is often in non-remission2,3,4. The causes of poor asthma control can be complex1,5, and as shown in this study, based on documented patient data, the systematic assessment of asthma should be further improved in scheduled asthma contacts. However, our results also suggest that need exists to pay more attention to the quality of patient document entries in PHC in Finland69. Based on this study, the importance of screening and treating asthma-related comorbidities in PHC should be given more attention, especially those associated with uncontrolled and severe asthma. Documentation and follow-up of BMI data, together with guidance on healthy lifestyles and weight management, should be emphasised more in asthma guidelines as part of routine management. Reviewing asthma inhaler technique and patient self-care guidance are also central areas needing improvement. Based on these results, it is obvious that health-care personnel need continuous training in asthma management. In general, evaluation of lifestyle factors, patient guidance, lung function test performance, and revision of inhalation techniques have largely been the nurse’s responsibility, while the doctor’s task has been more to assess asthma control, medication, and patients’ personal treatment recommendation. The regular asthma follow-up could be carried out largely by the nurses, because not every patient needs a doctor’s assessment every year if their asthma is well controlled. Nevertheless, the nurse can gather information to assess asthma control and consult the doctor if needed. Asthma is one of our most common chronic diseases, but one could speculate whether its assessment is considered as important as, e.g., cardiovascular diseases, and whether possible multi-morbidities11,14 divert attention from asthma itself. The establishment of 21 well-being services counties to replace the former hospital districts since the beginning of 2023 in Finland has provided a new basis for developing uniform health-care services covering larger regions. It would be possible in this context to develop and update uniform asthma treatment chains covering entire regions and even to implement national asthma templates and educate professionals in systematic asthma assessment. This could improve asthma management. Further promoting the use of structured phrase templates could support asthma assessment in scheduled contacts, because it has been shown that evidence-based EMR interventions improve the asthma documentation and provision of asthma care70. In addition, shorter and clearly structured guidelines could be easier to implement in PHC71. Given the complexity of asthma care, sufficient time and resources for asthma assessment must be guaranteed for comprehensive evaluation and patient guidance to be successful. More research is needed to evaluate the overall asthma care that is currently obtained in all asthma-related contacts in PHC and to guide health-care personnel education regarding asthma monitoring in the future.

In conclusion, we showed in this real-life, 12-year, follow-up study that comorbidities, lifestyle factors, inhalation techniques, and asthma action plans were poorly documented in scheduled asthma contacts in PHC. Our results, based on documented patient data, suggest that the comprehensive assessment and guidance of asthma patients still needs to be improved in PHC.