We found no change in GP registrars’ LTACM prescribing in either the 1–17 years or 1–13 years age groups.

Despite there being no overall increase in LTACMs prescribing, different LTACM classes did see changes in prescribing over time. While an increase was seen in the proportion of paediatric asthma consultations where an ICS-only medication was prescribed, this effect was counteracted by a decrease in prescriptions of ICS-LABA combinations plus some decrease in LTRA.

It was also noted in post hoc analysis that registrars were more likely to generate a learning goal when prescribing an LTACM for paediatric asthma. Registrars were also overall more likely to generate a learning goal when managing asthma than when managing other paediatric problems. Previous ReCEnT data has also demonstrated higher learning goal generation when managing paediatric patients than adults28. This suggests that while prescription rates have not changed, paediatric asthma, and specifically asthma prescribing, does appear to be an acknowledged area of learning need for registrars.

LTACM prescription is highlighted in guidelines as a key aspect of good asthma management. Previous research however, suggests LTACMs are underutilised, plausibly contributing to asthma morbidity and mortality5,6,7,12,13,14. A British study examining asthma management found an increase in ICS prescriptions for paediatric patients between 2006 and 2016, seeing primarily an increase in low-dose ICS and, overall, seeing a decrease in asthma patients who were on no ICS treatment22.

There has not been similar research on prescribing trends within Australia or of GP trainees internationally. The lack of temporal trend seen within this research raises the question of whether there are factors specific to the Australian setting, or factors relating to GP registrars, that influence prescribing.

Factors that doctors have reported as barriers to adhering to asthma management guidelines include lack of familiarity or agreement with guidelines for managing asthma, and medication cost29,30. Medication cost in Australia is influenced by Pharmaceutical Benefits Scheme (PBS) reimbursement. Medicines being included or not included in the PBS (or having limitations to which doctors may prescribe them) may influence prescribing. Parental concern regarding the potential side effects of ICS for management of paediatric asthma has been linked to reduced medication adherence31,32,33. Parental concerns surrounding long-term inhaled corticosteroid use have been demonstrated to influence prescribing by some healthcare professionals30. We think it unlikely that any of these factors would have had substantive effect on the temporal trend in our study – and, if so, to have potentially resulted in a temporal change in prescribing, which we didn’t find.

As highlighted, there are some discrepancies seen between asthma management guidelines in Australia and internationally. International GINA guidelines now recommend against SABA-only treatment in children >5 years and adolescents7. Within Australia, RCH guidelines recommend all adolescent asthma regimens should include an ICS10. The Australian Asthma Handbook and Therapeutic Guidelines recommend most adolescents should be on an inhaled steroid, though some with few asthma symptoms and without risk factors may be treated with SABA alone19,34. In children 6–11 years, RCH, Australian Asthma Handbook, Therapeutic Guidelines and UK NICE guidelines step 1 in asthma management is still SABA-only, with the recommendation to step up to LTACM treatment based on symptom frequency and severity8,11,20,21. This may result in SABA-only treatment being considered the default position in asthma management. GPs early in their training are known to have higher levels of uncertainty and concerns around causing patient harm35. This uncertainty could result in registrars being more hesitant to step up asthma management to include LTACMs, potentially contributing to the lack of temporal increase seen in LTACMs prescribing.

The ReCEnT project has a large sample size and very high response rate36. It has good external validity, including participating registrars from six of Australia’s eight states and territories, and capturing data from a variety of levels of rurality, socioeconomic status, and patient demographics. Findings can be generalised to GP registrars in Australia, and external validity will also be strong to other countries with apprenticeship-like GP training structures.

The large number of study factors collected (together with the large sample size) allows for detailed multivariable analyses to account for potential confounding in analyses.

A limitation of this study is that ReCEnT only collects data regarding medication prescribed at the index consultation, and we therefore do not have data on patients’ full medication regimens. A further potential limitation of this study is that our outcome factor is prescribing, not dispensing or actual use, of LTACMs. However, our study focus is on registrar behaviour and adherence to guidelines, so our focus on prescribing is appropriate. While every effort was made to include all ICPC-2 codes that may represent asthma in the study, it is possible some asthma presentations have not been coded as such and therefore are not represented in data. This study is an observational cross-sectional study, and therefore causality cannot be inferred from the findings.

The COVID-19 pandemic may have had effects on the number of presentations of respiratory viruses and therefore asthma presentations from 2020. Evidence suggests a reduction in asthma presentations including reduced exacerbations, hospital admissions, and asthma medications following onset of the pandemic23,37. However, this study assessed proportion of prescriptions, as opposed to numbers of prescriptions, and there was no significant change in prescribing over this time period.

The lack of increase in prescribing of asthma medications for children comes despite updates in authoritative guidelines and messaging to GPs that there should be an increase in use of these medications to effectively manage paediatric asthma. Though their training includes dedicated educational content, Australian GP registrars learn primarily within an apprenticeship-like model in which they are taught and supervised by accredited GPs, with most learning in the practice setting and significant supervisory influence in shaping registrar prescribing38,39,40. It is therefore likely that registrar trends may reflect wider GP prescribing trends. Given the primacy of the practice environment, the findings may also have relevance to the practice of established Australian GPs (at least those in teaching practices). Further research could assess prescribing patterns of qualified Australian GPs and potential barriers in prescribing particular asthma medications.

Given the lack of changes in temporal prescribing trends despite the documented harms associated with LTACM under-prescription, it is clear there should be reflection on the delivery of messaging that GPs and other health professionals receive regarding asthma management. Variability seen between guidelines for asthma management may result in confusion amongst prescribers, and thus our findings may suggest the need for review and harmonisation of guidelines. Our results raise questions of whether guidelines should be more emphatic about the need for the inclusion of LTACMs in managing the majority of children with asthma.

Medical educators may also reflect on the education being provided to GP registrars regarding asthma management – tailored education could be designed for registrars around LTACMs, when to escalate asthma medication treatment and how to respond to potential parental concerns around steroid medications if they are raised in consultation. GP registrars are at a pivotal stage in their vocation where they are establishing clinical and prescribing practices that may persist throughout their career25,26,27.

Despite strong evidence for the need for increased prescription of LTACMs for management of paediatric asthma, no increase in the proportion of LTACMs prescriptions for paediatric asthma by GP registrars was seen between 2010-2022, highlighting the need for further emphasis on paediatric asthma management within general practice education, as well as reviewing potential barriers to prescribing in the GP landscape.