The primary objective of this study was to assess factors associated with underutilization of ICS among persistent asthma patients under regular follow up at the chest unit of TASH. In the present study, high prevalence of underutilization of ICS was found from patients’ perspective. Significant association was found between underutilization of ICS and patients with monthly income of less than 1200 ETB, comorbidity, and types of ICS prescribed. Commonly cited reasons for underutilization of ICS were increased cost, use only when symptoms appear, patients perception towards ICS and inconsistent availability.
Overall, in this study, underutilization of ICS was found to be 68%. The finding is in agreement with a study done in the US where 65% of the patients were using a dose of ICS below that recommended in the National Heart, Lung, and Blood Institute guideline for asthma diagnosis and management . However, the major difference between these two studies is that in the later study, most of the underutilization appeared to represent physicians’ recommendations. This is not the case in this study where underutilization of ICS was primarily due to primary non-adherence, discontinuation, and suboptimal regimen use.
Generally, it is well understood that cost of medications affects utilization pattern of patients adversely. The problem is critical when it comes to asthma drugs, particularly ICS, which is the mainstay therapy of asthma. In the current study, monthly income of participants was significantly associated with underutilization of ICS. Though it is difficult to compare income pattern of different countries hence its association with underutilization of ICS, our finding is in agreement with studies done in elsewhere [13,14,15].
The present study also showed significant association between underutilization of ICS and comorbidity. Similar finding is reported form Canadian study . Increased odds of underutilization of ICS among patients with one or more comorbidity could be due to different reasons. Patients with comorbidity are more likely to use other medications than ICS which may lead to increased financial burden. Relatedly, taking medications other than asthma medications can result in complicated and burdensome medication regimens often leading to forgetfulness.
In the present study, types of ICS product prescribed, whether corticosteroids were prescribed alone or in combination with LABA, was significantly associated with ICS underutilization. According to the guideline when corticosteroids alone is used, increasing the dose from low to moderate or high is recommended depending on the steps of management or severity of the disease. However, sometimes physicians fail to do so and tend to recommend similar dose across most steps of asthma management . This malpractice could be associated with absence of local clinical guideline for management of asthma as it was mentioned by some of the practitioners in the setting. On the other hand, in spite of having prescription for combination therapy, patients tend to use corticosteroids alone mostly due to increased cost of combination therapy which might be inadequate (in terms of dose and frequency) for the given step of management.
With respect to patients’ reported reasons for underutilization of ICS, unaffordability of ICS was found to have big influence on ICS use (44%). This finding is in line with reports from elsewhere [16,17,18,19,20]. In addition, unavailability of ICS in the study setting was reported from both patients and care providers as one of the factors contributing for underutilization of ICS.
Another frequently stated reason in association with underutilization of ICS was use of ICS when only symptoms appear (21%). Although there was no significant association found between ICS underutilization and knowledge of ICS and asthma, in this study, only 45.5 and 64.1% of the patients had good knowledge of ICS and asthma, respectively. This finding supplements the idea that patients’ tendency to use ICS when symptoms appears is because of lack of understanding about the nature of the disease, and exact role ICS in asthma therapy as well as the necessity for their continuous use as it is indicated in other studies [21, 22].
In this study, about 9% of patients with persistent asthma had not received prescription for ICS which is in consistent with other studies [21, 23]. Aforementioned under prescription could be attributed to different reasons. Firstly, physician may prescribe other drug than ICS intentionally when the patients fail to afford ICS as it was reported by some of the physicians. Secondly, physicians also tend to use drugs from other class for uncontrolled/refractory asthma management which might have contributed for reported under prescribing.
Finally, in this study, absence of local protocol for management of asthma was shown to have negative impact on the proper utilization of ICS from physicians’ side. Although physicians are expected to use international guidelines in this situation, inconsistent prescribing pattern and failure to adhere to such guidelines might occur .