Physicians’ sample characteristics and prescription drivers
Relevant characteristics of the 350 respondents are described in Table 1. With regard to AR caseload, allergologists visited more patients in the last month (a median of 40 patients, 31% of total caseload) than ENTs (21 patients, 21%) (p<0.001), while GPs’ caseload was the lowest (18 patients, 6% of caseload). About half of the patients seen by allergologists (45%) and ENTs (42%) received a new diagnosis of AR, whereas 80% of the AR patients visited by GPs were already diagnosed (p<0.001).
All the prescription drivers presented through the questionnaire (Appendix 1) were rated high by the interviewed clinicians (average scores were >7). Drivers with the highest score were “effective on all AR symptoms” (average score of the whole sample: 9.1±1.1) and “few/no side effects” (9.1±1.0). On the other hand, cost-related aspects were associated with the lowest scores in all the specialty groups and with smaller percentage of physicians endorsing the positive response options (i.e. score >9). For instance, only 36% of allergologists, 17% of ENTs, and 29% of GPs gave a positive answer to the item “refundable”.
Patients’ sample characteristics
Clinical information of 2823 patients suffering from AR were collected; 909 patient records were retrieved by allergologists, 606 by ENTs, and 1308 by GPs (Table 2). Considering the whole sample, mean age of the majority of patients was <44 (1902 patients, 67%) and 1414 patients (50,1 %) were men. Analysis of patient clinical data confirmed that allergologists (327 patients, 36%) and ENTs (206 patients, 34%) visited more patients needing a new diagnosis than GPs (277 patients, 21%).
Pollens were the more frequent cause of AR, followed by dust mites. More specifically, 1313 patients (46,5%) were allergic only to pollens, 439 (15,6%) only to dust, 222 (7,9%) to other causes, 849 (30,1%) to more than one cause. About a quarter of the cases (674 patients, 23,9%) suffered from concomitant asthma and the majority of these patients (605, 89.9%) took a specific drug for asthma treatment. Among asthmatic patients, 213 were only allergic to pollens, 117 only to dust36 only to other causes.
AR clinical characteristics and disease severity according to HCPs
As shown in Table 3, symptoms reported by patients were similar across specialists. The most common symptoms involved upper respiratory tract: 2148 patients (76%) experienced congestion, 1931 (68,4%) sneezing, 1712 (60,6%) itchy nose, and 1677 (59,4%) runny nose. Ocular symptoms were likewise very common: itchy eyes affected 1085 patients (38,4%), red eyes 990 (35%), and watery eyes 983 (34,8%).
From a physicians’ perspective, distribution of AR severity in the patients’ sample was: 1906 (67,5%) patients with moderate/severe AR and 917 (32,4%) patients with mild AR (Table 3). Concerning symptoms-related discomfort, physicians rated with high scores (>7) the majority of their patients (1982 patients, 70,2%). Average scores of symptoms-related discomfort according to AR severity were 7,7±1,3 for the moderate/severe group and 5.7±1.9 for the mild group. Notably, about half of the patients assigned to the mild category were reported to suffer from extremely bothersome symptoms (Figure 1, panel A). ENTs rated these patients with higher scores relative to both allergologists and GPs (6.5±1.3 vs 5.4±1.9 and 5.6±2.1, respectively, p<0.001) (Figure 1, panel B).
Investigation of AR impact on patients’ professional life disclosed that about one-third of patients (1042 patients, 37.0%) reported reduced productivity due to AR (1338 patients with moderate/severe AR and 72 patients with mild, Appendix 7, panel A). The majority of cases (703 patients, 67,7%) had a productivity impact score >7. According to physicians, 551 patients (19,7%) complaints of work absenteeism due to AR, of whom 404 suffered from moderate/severe AR and 15 from mild AR (Appendix 7, panel B).
HCPs’ prescribing behaviour and AR therapy management
Table 4 reports the main prescription drivers based on patients’ characteristics. Overall, data were consistent with the previous analysis shown in Table 1. In fact, the item “effective on all AR symptoms” was the main prescription driver for the majority of patients (1533 patients on average, 54,3%), followed by “quick symptom relief” (1352 patients, 47,8%). On the other hand, “affordable price” and “refundable” were ranked low and were considered as relevant prescription drivers only for 13,4% and 8,7% of patients, respectively. Of note, “increased patient adherence” was the main prescription drivers for about 40% of patients visited by ENTs and GPs (40% and 35% of patients, respectively), while it was considered less significant by allergologists (28% of patients).
Polytherapy was the most common treatment strategy adopted by the interviewed physicians (1653 patients, 59,6%), while monotherapy was used in 41,4% of cases (1170 patients) (Table 4). Allergologists more often recommended polytherapy (606 patients, 66,7%, p<0.001), while GPs adopted a monotherapy-based therapeutic approach for about half of their cases (621 patients, 47,4%, p<0.001).
With regard to prescribed medications, the most recommended classes of drugs were antihistamines and intranasal corticosteroids (2246 and 1549 prescriptions, respectively) followed by fixed-dose combination of intranasal azelastine/fluticasone (Aze/flu) (543 prescriptions) (Figure 2). Compared to allergologists and ENTs, GPs less often recommended corticosteroids and fixed-dose combination of Aze/flu (p<0.001, Figure 2).
Figure 3, panel A shows the use of the different classes of drugs in either monotherapy or polytherapy regimens. Drugs preferentially used in monotherapy varied significantly across clinicians. Antihistamines were the most recommended medications by allergologists and GPs (50% of patients and 77% of patients, respectively), whereas ENTs more often prescribed corticosteroids (42%) and fixed-dose combination of Aze/flu (41%). Concerning polytherapy, loose combinations of antihistamines and intranasal corticosteroids were the most prescribed drugs (57%, 59%, and 64% of patients by allergologists, ENTs, and GPs, respectively). Aze/flu was largely used in monotherapy by ENTs (41%), while allergologists and GPs preferentially prescribed this drug in combination with antihistamines by (36% and 27%, respectively). Figure 3, panel B displays the main prescription drivers adopted by HCPs in monotherapy and polytherapy regimes considering the most prescribed drugs, i.e. antihistamines, corticosteroids, and Aze/Flu.
In a further analysis focused on AR therapy management based on patients’ severity, treatment regimen and main prescription drivers were independently investigated for mild and moderate/severe patients (Appendix 8). All the interviewed clinicians adopted different therapeutic approaches for mild and moderate/severe AR.
HCPs’ opinions about patient adherence to treatment
Physicians believe that the majority of the patients (88% of patients with score>7) has good adherence to treatment, even in the cases of severe AR (Figure 3, panel A). In HCPs’ opinion the main reasons for low patient compliance were “relief from the symptoms” and “treatment cost” (Figure 3, panel B).