Asthma is regarded as a chronic disease and affects 334 million people globally [1]. There is a continuous rise in the epidemiology of asthma globally and the number of patients affected are expected to reach 400 million by 2025 [1]. The burden of asthma is greatest for children 10-14 years and elderly aged 75-79 years. Moreover, 4.5% of young adults have either been diagnosed with asthma and/or taking asthma medication [2]. In addition to the life-threatening consequences, asthma produces a major economic burden on healthcare systems around the world. In the USA, asthma has a significant economic burden with a total cost of USD 81.9 billion in 2013, including those incurred by absenteeism and mortality [3]. Similarly, the cost of treating asthma in Europe is USD 21.65 billion annually [4]. Reducing asthma mortality requires a reduction in treatment variability among asthma patients and emphasis is needed in selecting cost-effective medication that can reduce the cost of asthma treatment.

To homogenize clinical practices with evidence-based medicines, Clinical Practice Guideline (CPG) were developed and implemented in various healthcare settings around the globe [5, 6]. The primary objective of CPG is to improve patients’ condition and provide cost-effective therapeutic plans. Ever since the development and implementation of clinical practice guidelines took place, healthcare practitioners have provided constant feedback to rationalize their use. Studies have indicated that the success of CPG implementation has actually improved patients management [7]. However, treatment outcomes of guideline adhered and non-adhered pharmacotherapy are rarely evaluated in the Malaysian healthcare system [8-11].

Therefore, the current study is aimed to assess physicians’ adherence to GINA guidelines and to evaluate treatment outcomes and cost related to guideline-adhered pharmacotherapy among patients visiting a public healthcare institute in the state of Penang, Malaysia.

Altogether 6 doctors from the respiratory department of Hospital Pulau Penang were included in the current study among them, 4 were 4 (66.6%) male and 2 (33.3%) were female doctors (Mean age 32 SD ± 2.13).The mean asthma guideline adherence score was 23.8 (SD ± 2.3) Table 1. Of the total 180 patients, 143 (78.9%) patients received guideline-adhered pharmacotherapy

Unlike previous studies that assessed doctor guidelines adherence by survey [12, 13] or a questionnaire [14, 15] was often subjected to bias, the current study evaluated doctor guidelines adherence by assessing prescribing practices (prescription analysis) of doctors with CPG (GINA 2011) recommendations. A majority of the patients received pharmacotherapy in recommendations with CPG (GINA 2011). When compared to previously conducted studies elsewhere, the current study indicates better adherence to CPG [16-18].

Translating CPG to clinical practice and assessing treatment outcomes are critical processes that form the basis for the development of future guidelines. Studies demonstrate that a majority of patients with uncontrolled asthma and a wide range of severities can gain guideline-defined treatment and management goals [19]. Our findings indicate that altogether, 158 (87.7%) patients’ treatment outcome was successful and achieved guideline-recommended treatment goals. A total of 158 patients’ treatment outcome was successful that represented both patients with guideline-adhered and non-adhered pharmacotherapy. A study by Stone et al. suggests that patient on GINA Step 4 and 5 treatment plans may require additional pharmacotherapies to manage uncontrolled asthma [20]. An important finding from our study was 34 patients who did not receive guideline-adhered pharmacotherapy, and yet, their treatment outcome was successful. Since the main purpose of this clinical practice guideline is to provide a standardised treatment and to increase quality of life, doctors in clinical practice often face a scenario which makes them deviate from standard guideline protocols and provide additional therapies and treatment plan to treat such patients [21]. In the current study, the doctors used their professional skills and experience to treat 34 asthma patients which resulted in successful treatment outcome. Another important aspect of this scenario is that doctors saved RM 479.84 (RM 14.11 average cost) that makes 4.6% of the total cost of asthma treatment. The current study only evaluates the direct cost associated with asthma treatment. However, if indirect cost is included, the overall expenses could have been much higher. In other words, doctors help save considerable cost per patient.

One of the possible reasons for nineteen (10.8%) patients who received guideline adhered pharmacotherapy but had unsuccessful treatment outcome could be that these patients had hypertension (78.9%), diabetes (84.2%) and COPD (84.2%) as comorbidities, and majority (84.2%) of patients were aged > 46 years. Studies have indicated that co-morbidity affects treatment outcomes [22]. Similarly, 3 (1.6%) patients did not receive adhered pharmacotherapy and their treatment outcome was unsuccessful and their mean age was 66.5 years. Studies indicate that lung function value decreases with age and is a common problem in elderly patients [23, 24], which might have been the reason for these 3 elderly patients to be treated differently. Doctors’ experience in treating such patients can be a factor in determining treatment outcome.

In studying treatment outcome among asthma patients aged >50 years and < 50 years, a study by Stephanie et al. reported that the rate of severe asthma exacerbations in patients aged > 50 years reduced by 68.9% as compared to 75.4% in patients with age <50 years (p 0.001) [25]. Moreover, the reduction in asthma day symptoms and nocturnal awakenings in patients aged > 50 years was 67.8% and 72.6% compared to 79.3% and 82.5% among younger asthma patients respectively [25]. The findings suggest that the younger patients are more responsive to treatment outcomes as compared to older patients. However, findings from the current study suggest that patients with the age group of >46 years had a significant association with treatment outcome. Since 65.5% of our enrolled asthma patients belonged to the age group of >46 years, which might explain a statistical association of age group with treatment outcomes.

The cost of asthma is greatest among patients with uncontrolled asthma. A study assessing a varying degree of asthma severity reported that 5-9% of patients had inadequately-controlled asthma but these patients accounted for 26-33% of the medical cost. Overall, inadequately-controlled asthma patients were 4-5 times more costly than adequately-controlled asthma patients [26, 27]. The cost of asthma treatment in the current study was high (RM 10,635.09). However, the cost of asthma treatment among guideline-adhered and successfully treated patients was less as compared to unsuccessfully treated patients. Moreover, 81% of asthma medication prescribed was a combination medication (β agonist + corticosteroid) which is expensive. Hence, careful selection of therapeutic regimen by doctors can help reduce asthma treatment cost.

One of the major limitations of the current study was the sample size. A multicenter study with a larger sample size would have given us a better picture. Since asthma is a chronic disease and requires constant supervision, thereby, follow up with patients to multiple visits could have provided us with more information.

The high percentage of asthma patients receiving guideline adhered pharmacotherapy, treatment outcomes were successful. During clinical practice, doctors had to deviate from guidelines based and rely on additional medication and strategies based on their clinical judgement and patient condition to treat patients Attention is needed in selecting a cost-effective therapeutic regimen for asthma patients.