Only as combination therapy. GP, general practitioner; ICS, inhaled corticosteroids; LABA, long-acting beta agonists; *n*/*N* (%), number (percentage) of patients; OCS, oral corticosteroids; SABA, short-acting beta agonists; SD, standard deviation

> Based on the patients' completed questionnaires, 86.1% of patients reported regular administration of their asthma medication. Reliever medication was used by 79.7% of patients for symptom relief only and 19.2% also used it to prevent asthma symptoms. Maintenance medication was used daily to prevent asthma symptoms by 81.3% of those using this type of medication, with 17.9% of the patients reporting the use of their maintenance medication only when experiencing asthma symptoms. Per severity groups, the use of maintenance therapy only when having asthma symptoms was reported by 10 patients (12.2%) with mild asthma, 45 patients (18.1%) with moderate asthma and 18 patients (23.4%) with severe asthma (*p* = 0.390).

#### *3.4. Valuation of Treatment Goals*

The most important treatment goals frequently identified by patients were: participation in all activities of daily living, prevention of asthma exacerbations and prevention of chronic symptoms that interfere with daily living. The most important treatment goals most frequently identified by physicians were preventing asthma exacerbations, allowing the person to participate in all activities of daily living and preventing asthma mortality. Valuation was different between pulmonologists and allergists and between patients with severe asthma and those with mild and moderate forms (Figure 1).

#### *3.5. Patients Attitudes toward Asthma*

The patients in the survey had similar attitudes on the effectiveness of the therapy and the ease of use of any medication irrespective of their asthma severity. However, patients with severe asthma had greater concerns about their therapy and the burden of asthma medication; thus, they scored higher in questions related to worries on having breathing difficulties, the use of medication when feeling well and self-adjustment of medication (Supplementary Table S2).

forms (Figure 1).

**Figure 1.** Valuation of treatment goals in physicians according to their specialty (**a**), in patients according to asthma severity (**b**) and in physicians as compared to patients (**c**). "Reduction in asthma mortality" was not a treatment goal in patient questionnaire due to cultural reasons. **Figure 1.** Valuation of treatment goals in physicians according to their specialty (**a**), in patients according to asthma severity (**b**) and in physicians as compared to patients (**c**). "Reduction in asthma mortality" was not a treatment goal in patient questionnaire due to cultural reasons.

prevention of chronic symptoms that interfere with daily living. The most important treatment goals most frequently identified by physicians were preventing asthma exacerbations, allowing the person to participate in all activities of daily living and preventing asthma mortality. Valuation was different between pulmonologists and allergists and between patients with severe asthma and those with mild and moderate

*3.5. Patients Attitudes toward Asthma*  The patients in the survey had similar attitudes on the effectiveness of the therapy and the ease of use of any medication irrespective of their asthma severity. However, patients with severe asthma had greater concerns about their therapy and the burden of Three attitude clusters were identified based on patients' responses to questions on attitudes towards asthma and its therapy (Supplementary Table S3): empowered savvy (36.5% of the patients), pessimistic non-compliers (43.2% of patients), and anxious strugglers (20.3% of the patients).

asthma medication; thus, they scored higher in questions related to worries on having breathing difficulties, the use of medication when feeling well and self-adjustment of medication (Supplementary Table S2). Three attitude clusters were identified based on patients' responses to questions on attitudes towards asthma and its therapy (Supplementary Table S3): empowered savvy (36.5% of the patients), pessimistic non-compliers (43.2% of patients), and anxious strugglers (20.3% of the patients). "Empowered savvy" patients were aware and knowledgeable of their condition and felt in control even when the worsening of their symptoms occur. Compared to the other clusters, the patients in this cluster generally had a higher level of education, were less likely to be smokers and had the lowest mean number of exacerbations and hospitalizations during the previous 12 months. Furthermore, they more frequently reported administering their asthma medication, the use of reliever therapy when coughing or having breathing difficulties and daily use of maintenance therapy to prevent asthma symptoms (Table 4).

"Empowered savvy" patients were aware and knowledgeable of their condition and felt in control even when the worsening of their symptoms occur. Compared to the other clusters, the patients in this cluster generally had a higher level of education, were less likely to be smokers and had the lowest mean number of exacerbations and The patients in the "pessimistic non-compliers" cluster had a limited understanding of asthma therapies and as a result, they considered the therapy a burden, leading to complaints about price and multiple inhaler usage, and embarrassment related to inhaler usage in public. Lacking the knowledge or understanding about the ways to prevent a worsening of symptoms, these patients felt scared and worried, unable to manage by themselves such situations. Compared to the other clusters, patients in this attitude cluster were older, had a lower level of higher education and reported the lowest frequency of administering their asthma medication (Table 4).


**Table 4.** Patient characteristics for each attitude cluster identified.

\* Only as combination therapy. ICS, inhaled corticosteroids; LABA, long-acting beta agonists; *n*/*N* (%), number (percentage) of patients; OCS, oral corticosteroids; SABA, short-acting beta agonists; SD, standard deviation.

The patients in the "anxious strugglers" cluster reported a good knowledge of asthma therapies and management of symptoms but exhibited worries regarding the efficiency and potential side effects of their medication. They were worried about taking too much medication when feeling well, and therefore they preferred to adjust the doses. The patients in this attitude cluster were more likely to be smokers, with severe asthma and had more exacerbations and hospitalizations during the previous 12 months. They also more frequently reported the use of reliever medication to prevent asthma symptoms and of maintenance therapy only when coughing and having breathing difficulties and less frequently daily (Table 4).

#### **4. Discussion**

SABATINO is the first survey conducted in Romania specifically investigating the adult patients' expectations and attitudes towards asthma and its treatment. It shows that despite advances in asthma therapy, significant unmet needs persist in terms of asthma care, particularly in those with severe disease and points towards a lack of improvement in asthma control.

Asthma symptoms and exacerbations were common in the sample analysed; for almost half of the patients, physicians reported ≥2 exacerbations and for a quarter of them≥2 hospitalizations within 12 months prior to the survey. Moreover, one-third of the patients reported ER visits. The situation was more dramatic when data were analysed according to the asthma severity, with severe asthma patients having more exacerbations and hospitalizations than mild-to-moderate ones. Unsurprisingly, severe asthma patients used significantly more reliever medication (including over-the-counter use) than mildto-moderate patients. These results align with previously published results of surveys performed in patients with asthma, which also showed a persistence of significant exacerbations and low levels of symptom control in other European populations [11,12]. It is known that patients with severe asthma are a category characterized by a high burden of illness due to poor symptom control, experiencing frequent and often life-threatening exacerbations, associated comorbidities, and low quality of life [20–22]. A recent study evaluated the experiences and impact of severe asthma on patient's life and showed significant emotional distress in these patients because of the disease and its therapy [21]. This study identified the neglected needs of patients with severe asthma, such as "empathy and understanding" and "encouragement" (21). It also pointed towards the need for a support service that would improve adherence problems resulting in concerns about medication side effects [21].

The behaviour of SABATINO participants who reported the use of reliever therapy only to prevent exacerbation or of maintenance therapy when experiencing symptoms is not uncommon [13–15]. Previous reports suggested that low adherence to the prescribed therapy probably reflects patients' beliefs about medication and their personality traits [13,23,24]. In our survey, we identified 3 attitude clusters corresponding to different personality traits with distinct clinical characteristics. "Empowered savvy" had the lowest frequency of severe asthma, the highest adherence to maintenance therapy and the highest level of confidence in the effectiveness of asthma medication. The opposite of this attitude cluster is the "anxious strugglers" with more patients with severe asthma, a higher score for worries about asthma therapy (side effects, dose, and appropriateness especially when symptoms were absent) and better knowledge of their treatment as self-reported which was in contradiction with their behaviour, with 25% of them reporting taking maintenance therapy only when having breathing difficulties. The clusters identified in SABATINO show similarities to clusters previously identified in other populations, which reported well-controlled asthma among patients with few concerns about their medications [25,26]. The non-confidence in the effectiveness of asthma medication and negative concerns about therapy were associated with reduced adherence to therapy [16] and uncontrolled disease [26]. These findings suggest that asthma management should not only be tailored for the severity of the disease but

should also consider patients' beliefs and behaviours, specifically targeting medication concerns with the aim to improve treatment adherence [24,27].

The lack of adherence to prescribed therapy and empowerment in asthma selfmanagement may also reflect the discrepancy between treatment goals as seen by patients and physicians and between different asthma severity groups, suggesting different patients' needs. For example, the most important treatment goal reported by the highest percentage of physicians was preventing asthma exacerbations, while for patients it was the participation in activities of daily living. The difference in asthma expectations between patients and physicians when it comes to asthma control is not new, and points toward unmet patient needs [28–30]. Previous studies showed that physicians tend to focus on asthma control while patients are more concerned about long-term health and costs [28–30]. When analysed by the severity of the disease, in our survey, the most important goals identified by the highest percentage of patients was participation in daily-life activities for those with mild and moderate asthma and preventing chronic symptoms that interfere with daily lives in those with severe asthma. These results indicate a different valuation of treatment goals that vary according to the severity of the disease and the need for targeted approaches. The one-size-fit-all approach may not be suitable, and physicians should work with their respiratory patients to define individualized treatment goals through a shared-decision making process.

This survey has several limitations that may limit the generalization of our findings. This was a cross-sectional survey, and the selection bias cannot be precluded. Moreover, the sample size, especially of those with severe asthma was limited. It was not designed to compare patients with different asthma severity, but it would be of interest to observe these differences in future surveys designed for this purpose.

#### **5. Conclusions**

The results of this survey point to suboptimal asthma control in Romania and underlines the significant burden of asthma, and especially of severe asthma, in Romania, with implications for clinical practice and policymakers. The different valuations of the treatment goals observed in patients and physicians, and in different asthma severity groups suggest the need for individualized approaches, more patient-centred. Guidelines recommendations should be adapted, with practical tools more adequate for the Romanian healthcare setting to be provided for the routine use of clinicians, including patient educational programs. The ultimate common goal should be to improve patients' knowledge and self-awareness through a solid therapeutic alliance with the treating physicians, thus enabling optimal symptom control.

**Supplementary Materials:** The following are available online at https://www.mdpi.com/article/ 10.3390/medicina57101089/s1, Supplementary Table S1. Questionnaires used for physicians and patients in the SABATINO survey, Supplementary Table S2. Patients' attitudes toward asthma by severity of asthma, Supplementary Table S3. Patients' attitude toward asthma according to attitude clusters identified

**Author Contributions:** Conceptualization, D.B., C.P. and R.S.B.; methodology, D.B., C.P. and R.S.B.; formal analysis, D.B., C.P. and R.S.B.; writing—original draft preparation, D.B.; writing—review and editing, D.B., C.P. and R.S.B. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was funded by AstraZeneca Romania. The sponsor participated in the survey design and facilitated the overall operational process, including data collection and statistical analyses. The sponsor was also involved in the decision to publish this manuscript.

**Institutional Review Board Statement:** Ethical review and approval were waived for this study, due to the fact it was a market research survey. Data collection was compliant with GDPR. No information allowing patient identification was collected. The information allowing physicians' identification was not transferred from the company performing the data collection to the sponsor of this survey.

**Informed Consent Statement:** Informed consent was obtained from all subjects involved in the study.

**Data Availability Statement:** Research data are not shared.

**Acknowledgments:** Operational support and statistical analysis were provided by ISRA Center (Bucharest, Romania) and medical writing support by MedInteractiv (Bucharest, Romania) on behalf of AstraZeneca Romania.

**Conflicts of Interest:** D Bumbacea reports personal fees from AstraZeneca, personal fees from Chiesi, personal fees from Novartis, grants and personal fees from Sanofi, outside the submitted work; RS Bumbacea reports personal fees from AstraZeneca, personal fees from Chiesi, personal fees from Ewopharma, personal fees from Novartis, outside the submitted work; C Panaitescu has nothing to disclose.

#### **References**

