Asthma Prescribing Practices of Government and Private Doctors in Malaysia - A Nationwide Questionnaire Survey

Transcription

1 ASIAN PACIFIC JOURNAL OF ALLERGY AND IMMUNOLOGY (2005) 23: 7-17 Asthma Prescribing Practices of and Doctors in Malaysia - A Nationwide Questionnaire Survey Li-Cher Loh and Pei-Se Wong SUMMARY A self-answered, anonymously comleted questionnaire survey was erformed between June 2002 and May 2003 where doctors from government and rivate sectors in Malaysia were invited to articiate by ost or during medical meetings. One hundred and sixteen government doctors and 110 rivate doctors rovided satisfactorily comleted questionnaires (effective resondent rate: 30.1%). The most referred medications for first-line, second-line and third-line treatment were for government doctors: inhaled short-acting β 2 -agonist (SABA) (98%), inhaled corticosteroids (CS) (75%), and leukotriene antagonist (52%); and for rivate doctors: oral SABA (81%), inhaled CS (68%), and oral CS (58%). The first choice inhaler device for most government and rivate doctors were metered dose inhalers, with cost and ersonal references (for rivate doctors), and technical ability (for government doctors) as the key considerations when deciding on the choice of device. This benchmark data on the asthma rescribing ractices of a healthcare delivery system fully dichotomized into government and rivate sector, rovides evidence for ractice differences affected by the nature of the healthcare system, and might have imlications on healthcare systems of other countries that share similarities with that of Malaysia. In recent years, the treatment of asthma has undergone a aradigm shift with increased emhasis in the early use of inhaled corticosteroids (ICS) 1,2 and better recognition of the roles of long-acting β 2 - agonists (LABA) 3,4 and leukotriene recetor antagonist (LTRA). 5,6 These changes are regularly udated in international and national clinical ractice guidelines (CPGs) to enable racticing clinicians and healthcare roviders to kee abreast with the latest recommendations for asthma management. 7,8 In Malaysia, the national CPGs for treating adult and children with asthma are roduced since 1996 and are communicated to healthcare rofessionals in medical talks and conferences organized by the Ministry of Health Malaysia and societies such as the Malaysian Thoracic Society. It is well known that factors influencing the rescribing ractices are comlex and information alone does not always roduce change The issues affecting rescribing ractices are even greater when comaring government with rivate medical healthcare rofessionals where the medical cost and the nature of ractice vary substantially. Such differences are also obviously deendent on the tye of olicies that govern the ractice of government and rivate healthcare in different countries or regions. From the IMU Lung Research, International Medical University, Kuala Lumur and Deartment of Medicine, Clinical School, International Medical University, Negeri Sembilan, Malaysia. Corresondence: Li-Cher Loh E mail: loh@imu.edu.my

2 8 LOH AND WONG Currently, the healthcare delivery in Malaysia is dichotomized into those of government and rivate sectors where government healthcare is being fully financed by the Ministry of Health Malaysia whilst cost of rivate healthcare is entirely borne by atients or rivate medical insurances. Currently, another imortant asect of rivate medical healthcare in Malaysia is that doctors have disensing rights and therefore rofit from drug selling can influence rescribing ractices. While many studies have addressed the rescribing atterns in various doctor grous or doctors in general, none, to our knowledge, had comared the asthma rescribing ractices between government and rivate doctors whether in Malaysia or in other countries. In the face of the current increasing trend in global asthma morbidity and mortality, 7 attemts to understand the rescribing atterns among government and rivate doctors may shed light on the way asthma is being treated by healthcare rofessionals, on whether they are aroriate or showing lack in some asects, and on factors that influences ractices one way or the other. It is hoed that from here, relevant questions can be raised and imortant roblems, if resent, be aroriately addressed. The objectives of our nationwide survey study were two-fold: First, to examine the rescribing atterns among government and rivate doctors in Malaysia; and second, to investigate, as encountered by doctors surveyed, atients ercetion on the use of inhaler and inhaled corticosteroids (CS). The latter is ertinent for this study because of its ossible influence on rescribing references. The survey method SUBJECTS AND METHODS A self-comleted questionnaire form was first validated with 10 clinicians who regularly treat asthmatic atients (5 hosital-based and 5 communitybased) for clarity and the aroriateness of questions and answers rovided. Coies were then sent (A) by ost to individual doctors randomly selected from a list of doctor names (every first 10 names from every age) registered with the Malaysian Medical Association (n = 350) (For logistic reasons, no attemt was made to re-select hysicians only) and to all doctors registered with the Malaysian Thoracic Society (n = 102); (B) by hand or ost to heads or reresentatives of Resiratory Units in 8 government hositals in Malaysia (Institute of Resiratory Medicine, Hosital Kuala Lumur, University Malaya Medical Centre, Hosital University Kebangsaan Malaysia, Hosital Selayang, Hosital Kuala Terenggaru, Hosital Alor Setar, and Hosital Seremban) (n = 212), and (C) by hand to delegates in two harmaceutical firmsonsored asthma seminars for secialists and general ractitioners (n = 86). A total of 750 coies were distributed with the anticiated one-third resonse rate (250 returned questionnaires), resulting in a final analyzable samle consisting of at least 100 government and 100 rivate doctors. All questionnaires were distributed once with no formal follow-u reminders of any form and they were anonymously self-comleted. Comleted questionnaires were either osted back in rovided stamed enveloes or collected back by hand in asthma talks. The questionnaire survey study was conducted over a one-year eriod from June 2002 to May The questionnaire The four-age questionnaire was divided into 6 sections: background information, asthma day-to-day treatment, doctors choices and atients ercetion on inhaler devices, atients fears and side-effects encountered with inhaled corticosteroids, ercetion on cost of asthma treatment and, familiarity and ercetion towards asthma CPG. The findings of the latter two will be resented in a searate aer, although certain asects of the last item are included in this aer. There were two tyes of questions in the questionnaire: (a) Questions requiring a four-oint scale, e.g. In your ractice, have you encountered atients who are reluctant to use inhalers? Choose one answer: Frequently, Sometimes, Rarely, Never; (b) Questions whose answers are rovided in categories, e.g. In your ractice, what would influence your choice of inhaler device? Tick only one rimary concern. Cost incurred to atients, Ability to technically handle it, Personal references (non-technical), Others (ask to secify). 8

3 ASTHMA PRESCRIBING PRACTICES IN MALAYSIA 9 Data analysis The details of the returned questionnaires were groued according to government and rivate ractices for analysis. In keeing with the rimary objective of the study, no division was made according to whether ractice was in hosital or community, level of seniority (e.g. secialist vs. general ractitioner), locations (e.g. cities or outside major towns), burden of asthma atients seen in ractice and the tye of atients (children, adult, or both). These details are however described for the urose of documenting the nature of the ractices. For a fair comarison of the choices in anti-asthma medications and inhaler devices between government and rivate doctors, only those that were readily accessible to both grous were selected for analysis as listed in the tables and figures (e.g. a fixed combination inhaler, seretide, was available to rivate, but not government doctors at the time of survey). Differences between grous were analyzed using Chi- square tests. All comutation was made using statistical ackage SPSS version 11.5 for Windows (Chicago, Illinois, USA). The significance was defined at the 1% level for all tests in order to avoid occurrence of significance by chance alone due to the large samle size being tested one at a time. Resondent rate RESULTS The resondent rates were 21.7% from Malaysian Medical Association; 18.6% from Malaysian Thoracic Society; 48.6% from the eight government institutions, and 45.3% from delegates attending asthma seminars. The overall resondent rate was 31.6%. However, 11 questionnaires that were not correctly comleted were excluded from the analysis. This resulted in a total number of 226 satisfactorily comletely questionnaires (effective resondent rate of 30.1%) for analysis. One hundred and sixteen were from government and 110 were from rivate doctors. General information on doctors There are significant differences in the ractices between the government and rivate doctors in Table 1 General information on the government and rivate doctors No recorded (n = 110) ** Patient load, n/week > < Patient tye 200 Adults Children Both < Practice location 223 Cities or major towns Outside major towns < Patient insurance cover 226 < 50% % Familiar with asthma CPGs* 226 Yes No * CPGs= Clinical Practice Guidelines (examles quoted in the questionnaire are those of the Global Initiative, British Thoracic Society and Malaysian Thoracic Society) ** value between government and rivate doctors 9

4 10 LOH AND WONG terms of atient load, tye, and ractice locations (Table 1). A comarable roortion of government and rivate doctors surveyed claimed familiarity with asthma CPGs. Prescribing atterns The referred first-line treatment (i.e. for mild asthma) among most government doctors was inhaled short-acting β 2 -agonist (SABA) and among rivate doctors was oral SABA. Also statistically significantly different between government and rivate doctors were the choices in inhaled long-acting β 2 - agonist (LABA) and theohylline (Table 2). For second-line treatment was defined as treatment rescribed when the first-line treatment was not enough to control symtoms (i.e. moderate Table 2 Prescribing atterns among Malaysian doctors (n = 110) ** 1 st line treatment* Inhaled SABA <0.001 Inhaled corticosteroids Inhaled LABA Inhaled anticholinergic Inhaled Na cromoglycate Oral SABA <0.001 Oral corticosteroids Oral theohylline <0.001 Oral LTRA nd line treatment* Inhaled SABA Inhaled corticosteroids Inhaled LABA Inhaled anticholinergic Inhaled Na cromoglycate Oral SABA Oral corticosteroids Oral theohylline Oral LTRA rd line treatment* Inhaled SABA Inhaled corticosteroids Inhaled LABA Inhaled anticholinergic Inhaled Na cromoglycate Oral SABA Oral corticosteroids Oral theohylline Oral LTRA *1 st line treatment: defined for mild or newly diagnosed asthmatics 2 nd line treatment: defined as when 1 st line treatment is not enough to control symtoms 3 rd line treatment: defined as when 2 nd line treatment is not enough to control symtoms ** value between government and rivate doctors SABA, short-acting β 2 -agonist; LABA, long-acting β 2 -agonist; LTRA, leukotriene recetor antagonist; Na cromoglycate, sodium cromoglycate. 10

5 ASTHMA PRESCRIBING PRACTICES IN MALAYSIA 11 asthma). The referred treatment for most government and rivate doctors were inhaled CS. There was significantly more government than rivate doctors who referred inhaled LABA (Table 2). For third-line treatment defined in the context of a worsening condition in site of the second-line treatment (i.e. severe asthma), the choices of various treatments were closer to one another. In government doctors, most referred leukotriene antagonist (LTRA) followed by oral CS. In rivate ractice, most referred oral CS, followed by LTRA (Table 2). rimary concerns with the rivate doctors (Table 3). On reference to rescribe oral SABA to inhaled SABA, there was a significant trend towards rescribing oral rearation in rivate doctors, as MDI MDi Sacer Rotahaler A About inhaler devices Over half the government and rivate doctors oted for Metered-dose inhalers (MDI) as their first choice device (Fig. 1A). MDI lus sacer ranked second in government doctors (24.1%) whilst among rivate doctors, three tyes of inhaler devices (MDI lus sacer, turbohaler, and nebulizer) ranked second (14.2% in each). Regarding the second choice inhaler device, government doctors ranked first the MDI lus sacer (39.8%), followed by turbohaler (27.3%), nebulizer (18.2%) and others (Fig. 1B). Among the rivate doctors, nebulizer ranked first as the second choice inhaler delivery device (34.4%), followed by turbohaler (18.8%), MDI lus sacer (17.7%) and others. The rimary concerns for choosing inhaler devices were significantly different between the two grous. The majority of government doctors quoted technical ability as their rimary concern while cost and ersonal references ranked equally as main Fig. 1 Turbohaler Easyhaler Nebuliser MDI MDi Sacer Rotahaler Turbohaler Easyhaler Nebuliser B government rivate government rivate Choices of inhaler devices in government (n=112) and rivate doctors. (A) Reresents the first choices and (B) the second choices. Table 3 Primary concerns in choosing the tye of inhaler devices by doctors* (n = 159) (n = 84) (n = 75) Cost Technical ability Personal references Others** < *This section was filled only if doctor s answers to the earlier question regarding the frequency of encountering atients reluctant to use inhalers were either always or sometimes. **Included: whether the tye of inhalers was easily available; unclear on efficacy of some devices. In some, they were unsecified. 11

6 12 LOH AND WONG reflected by roortionately more rivate than government doctors would always rescribe oral SABA (Table 4). The commonest causes for rivate doctors to rescribe oral rearation were cost and atient reluctance to use inhaler device. In contrast, inability to correctly handle inhaler device was the most quoted reason for government doctors. However, these differences were not statistically significant (Table 5). There was clearly a significant trend that doctors in rivate ractice encountered more atients who were reluctant to use inhaler devices (Table 6) as reflected by roortionately more rivate than government doctors always encountering such atients. As to the main reasons why atients were reluctant to use inhaler, the commonest reason quoted to government doctors was that they considered inhalers difficult to use or troublesome (43.6%), while Table 4 Preference by doctors on rescribing oral SABA to inhaled SABA* (n = 110) Always Sometimes Rarely Never < *SABA= short-acting β 2 -agonist Table 5 Main reasons of doctors referring oral SABA to inhaled SABA* (n = 105) (n = 30) (n = 75) Cost Inability to handle Patients reluctance Others** *This section was filled only if a doctor s answer to the earlier question of referring oral SABA to inhaled SABA was either always or sometimes. *Included: asthma eisodes too infrequent ; regnancy ; too oorly controlled ; atient already well controlled on oral SABA ; symtoms nocturnal only. Table 6 Frequency of encounters with atients who are reluctant to use inhalers as reorted by doctors (n = 110) Always Sometimes Rarely Never <

7 ASTHMA PRESCRIBING PRACTICES IN MALAYSIA 13 to rivate doctors, was that their asthma was thought to be more serious by taking inhaler, than if they were to take oral treatment (51%) (Fig. 2). Regarding the comliance with inhaler devices by the atients, both grous of doctors resonded similar in that the majority considered this as being average only (Table 7). About inhaled CS Although the majority of doctors rarely encountered side-effects from inhaled CS as reorted by the atients to them, there was a significant trend in that government comared to rivate doctors faced more of this roblem (Table 8). A similar significant trend was obvious in encountering atients who exressed fear of using inhaled CS in that roortionately more rivate than government doctors always encountered this roblem. With regards to the nature of fear, both grous were similar. Table 7 Degree of comliance with the rescribing of inhaler devices, as reorted by doctors (n =110) Always (i.e. excellent comliance) Sometimes (i.e. average comliance) Rarely (i.e. oor comliance) Never (i.e. total non-comliance) Taking inhalers indicates that asthma is more serious Inhalers are not as effective as oral treatment Finds inhalers difficult to use or troublesome Simly doesn't like inhalers Others** government rivate % doctors *Answers rovided only by doctors who always or sometimes encounter such atients **Others included: cost issue, inhalers cause addiction, risks of being discontinued by comany. Fig. 2 Main reasons for atients reluctance to use inhaler, as quoted to government (n = 78) and rivate doctors (n = 98). 13

8 14 LOH AND WONG Table 8 Doctors exeriences with the use of inhaled corticosteroids (ICS) as reorted by atients (n = 110) Encounters with atients who reorted side-effects from ICS Always Sometimes Rarely Never Encounters with atients who exress fear of using ICS Always Sometimes Rarely Never < Nature of fear Real Unfounded DISCUSSION This was the first study, to our knowledge, that comared the rescribing ractices among the government and rivate doctors in Malaysia. This fact-finding study rovided benchmark data of rescribing ractices and highlighted the wide differences in rescribing between the two grous of doctors in some asects. We achieved our target analyzable samles although the overall resondent rate was slightly lower than anticiated. The low return rates from the members of the two Medical Societies were balanced by the high resondent rates of the government institutions and from asthma talks. This was understandable since in the latter, there was suort from individuals including deartmental heads and seakers. This is likely to introduce some bias to how well the study samle reresented the oulation of doctors at large. This is somewhat unavoidable and inherent with any questionnaire survey study that selects out some section of the target oulation. Nevertheless the findings reorted here were consistent with many anecdotal reorts of rescribing ractices we know of, thus lending confidence that the findings were not too distant away from the reality. Another imortant methodology consideration is our decision not to discriminate between secialist and generalist (e.g. family doctors) and between adult hysician, ediatrician and family doctors, in the analysis. This was mainly due to roblems with definitions on secialist and generalist, and inequality in their distributions among the surveyed oulation. As such, subgrou analysis of these grouings can be misleading. We also areciate that some interretation of our findings may be inaroriate because of not making a distinction between those treating adults and those treating children since some asects of rescribing between these two grous of atients can be very different. This is somewhat avoidable since we anticiated that a substantial number of doctors surveyed would be treating both adult and ediatric atients and that having a questionnaire with searate questions on adult and 14

9 ASTHMA PRESCRIBING PRACTICES IN MALAYSIA 15 children atients might rove too much for some rosective resondents. We have shown that for mild asthmatic atients, oral salbutamol was still a oular choice among doctors from both grous, although rivate doctors contributed more in this asect. Another imortant finding was that theohylline was still referred by many rivate doctors as first-line treatment. This is interesting because two studies, an audit of a Malaysian district hosital outatient clinic 16 and another questionnaire survey among all doctors in Singaore, 13 showed the same reference for oral SABA over 10 years ago. More recently, another questionnaire survey study focusing on childhood asthma 12 also showed a reference of oral theray for relief medication among rivate general ractitioners in Malaysia. Consistent with our findings, it is likely that lower cost of oral rearations and atients reluctance to use inhaler device are imortant factors in the ersistence in such rescribing ractices in rivate settings. On second-line treatment, inhaled CS became the choice theray for the majority from both grous of doctors. This reference is highly aroriate in keeing with the current emhasis to treat the underlying inflammation in asthma 1 and that low-dose inhaled CS can revent asthma death. 2 By far, the most effective anti-inflammatory theray is CS delivered by inhaling, as recommended by the asthma CPGs. 7,8 This reresents a marked imrovement from over 10 years ago in Malaysia where Lim et al. 16 showed that none of their asthmatic atients from hosital medical outatient clinics were on inhaled or oral CS. With regards to the third-line treatment, the referred treatments were closer to one another in that most doctors, whether government or rivate, favored oral CS, LTRA and inhaled LABA. Currently asthma CPGs 7,8 discourage the chronic use of oral CS until all other otions of treatment have been roerly exlored. Clearly, inhaled LABA 4 and more recently LTRA 6 have emerged to be highly effective treatments when combined with inhaled CS. As such, they should be referred to oral CS when asthma control has worsened. Such a rescribing ractice was not reflected in a significant number of government and rivate doctors. While cost should not be an issue among the government doctors, it may be the reason why oral CS is referred to inhaled LABA and LTRA in rivate ractices. MDI remained the first choice inhaler device among all doctors. MDI lus sacer and other breathactuated dry-owder devices such as turbohaler were the logical follow-on choices. This still holds true today in most countries. 17 We recently showed that desite MDI being resent in Malaysia for over 20 years, nearly half of our adult atients treated in our teaching hosital did not handled the device correctly. 18 It seems sensible that the many newer, more efficient delivery devices, such as dry-owder device, can be considered as first choice inhalers, as long as cost is not rohibitive. In fact, there is evidence to show that in terms of cost-effectiveness, MDI and breath-actuated devices for SABA were not different from each other. 19 When having the younger children in mind, the obvious choice is MDI lus sacer, since all others excet nebulizer, are not technically friendly for them. However, the finding of nebulizer as an imortant choice for rivate doctors was surrising. Although they are efficient, they are cumbersome to carry, unfriendly to use and otentially hazardous in that they can cause delay in receiving hosital care during a life-threatening attack The reason for this is oen to seculations. It is ossible that many doctors consider that a nebulizer is the obvious choice for a atient who could not correctly handle the MDI. Our findings also showed that more rivate doctors, than government, encountered atients who feared the use of inhaled CS, while more government doctors, than rivate, observed genuine side effects of inhaled CS. This may be a reflection of the differ- We have shown that more rivate than government doctors, encountered atients who were reluctant to use inhalers. They are likely to influence the rescribing of inhalers since cost and ersonal references are listed as the rimary concerns of the doctors. The main reasons for reluctance among atients revealed some serious misconcetions in the community like thinking that inhaler theray reresents a more serious disease and that oral theray is a more effective treatment than inhaling. It is ossible that many of these misconcetions may have arisen from conflicts with the traditional medical beliefs that still have strong influences in the community. 22,23 15

10 16 LOH AND WONG ent atient grous that are treated in government and rivate settings. atients are erhas more inquisitive because of the medical cost they bear. The overall frequency of encounters reiterates the safe tolerance of CS when administered via inhalation. 1 Our findings highlighted some obviously different rescribing ractices from the clinical guidelines recommendations. Some of these ractices are clearly inaroriate. Two major factors that have been reviously identified as contributing to inaroriate rescribing were the clinicians level of knowledge and their ractice settings. 11 Since over 70% of surveyed doctors whether in government or rivate settings claimed familiarity with asthma CPGs, ractice settings- for examle, affordability of drugs by the atients, individual and cultural references among atients- were robably more imortant in determining the rescribing ractices of our cohort of surveyed doctors. According to the results of our study, financial incentives in rescribing certain drugs in rivate ractices did not seem to be an imortant influence since more government than rivate doctors referred exensive drugs such as LTRA and inhaled LABA. Another imortant consideration is whether some clinicians found it difficult to change rescribing habits desite knowledge of a better aroach. Changing rescribing habits or behavior is comlex. Passive dissemination of information such as distribution of education materials and didactic lectures has been shown to have the least effect on changing rescribing behaviors, 9,24 while aroaches such as academic detailing where local oinion leaders identified as their eers disseminate information; 25,26 multi-facet interventions involving audit and feedback, reminders, local consensus rocesses, or marketing are the more efficient means. It is clear that from our findings, the rescribing ractices in some Malaysian doctors need to change. More research on this is required in order to clearly define the ways of imroving aroriateness in rescribing in terms of maximizing treatment effectiveness, minimizing drug side-effects and cost, while resecting atients references. The national asthma treatment CPG of Malaysia, endorsed by the Academy of Medicine and the Ministry of Health Malaysia, has recently been udated 8 and is easily accessible from the Academy s website. In addition, there is the international guideline ublished by the Global Initiative for Asthma (GINA) that is well recognized and disseminated among doctors. There is therefore very little excuse for Malaysian doctors not to follow more closely the modern-day treatment recommendations. Our survey findings rovide benchmark data on asthma rescribing ractices of a healthcare delivery system fully dichotomized into government and rivate sectors. To the best of our knowledge, there are no ublished studies comaring the rescribing atterns in a fully subsidized healthcare setting and a setting where rivate atients comletely bear the burden of their medical cost. This is erhas due to the difficulty of getting reliable information because of the sensitive nature in some asects of such a study. Desite the shortcomings of a selfcomleted questionnaire study, our attemt at a nationwide survey yielded some imortant information for the uroses of defining roblems related to rescribing ractices in our own country and lanning of future healthcare olicies and strategies. It rovides evidence for what was intuitively known or not known, and its imlications extend to healthcare systems of other countries that share similarities to ours. ACKNOWLEDGEMENTS The study was funded by the International Medical University s internal research fund. The authors wish to thank the following ersons and societies for their kind assistance in the distribution of the questionnaires: Dr. I Kuusamy, Institute of Resiratory Medicine, Kuala Lumur; Dr. Aziah AM, Deartment of Medicine, Hosital Kuala Lumur; Dr. Norzila MZ, Paediatric Institute, Hosital Kuala Lumur; Professor CK Liam, Dr. CM Wong, Dr. KH Lim, Resiratory Deartment, University Malaya Medical Centre, Kuala Lumur; Associate Professor J De Bruyne, Associate Professor PWK Chan, Pediatric Resiratory Deartment, University Malaya Medical Centre, Kuala Lumur; Associate Professor Roslina AM, Associate Professor Roslan Harun, Resiratory Deartment, National Hosital Malaysia; Dr. A Razak Muttalif, Hosital Kuala Terenggaru; Dr. G Simon, Hosital Alor Setar; Dr. Norrashidah AW, Paediatric Deartment, Selayang Hosital; Dr. Zainudin MZ, Damansara Secialist Hosital, Kuala Lumur; Malaysian Medical Association; Executive 16

11 ASTHMA PRESCRIBING PRACTICES IN MALAYSIA 17 Committee Members, Malaysian Thoracic Society, Malaysia. REFERENCES 1. Barnes PJ, Pedersen S, Busse WW. Efficacy and safety of inhaled corticosteroids. New develoments. Am J Resir Crit Care Med 1998; 157: S Suissa S, Ernst P, Benayoun S, Baltzan M, Cai B. Low-dose inhaled corticosteroids and the revention of death from asthma. N Engl J Med 2000; 343: Stoloff S, Poinsett-Holmes K, Dorinsky PM. Combination theray with inhaled long-acting beta2-agonists and inhaled corticosteroids: a aradigm shift in asthma management. Pharmacotheray 2002; 22: Shrewsbury S, Pyke S, Britton M. Meta-analysis of increased dose of inhaled steroid or addition of salmeterol in symtomatic asthma (MIASMA). BMJ 2000; 320: Riccioni G, Santilli F, D'Orazio N, et al. The role of antileukotrienes in the treatment of asthma. Int J Immunoathol Pharmacol 2002; 15: Wilson AM, Demsey OJ, Sims EJ, Liworth BJ. Evaluation of salmeterol or montelukast as second-line theray for asthma not controlled with inhaled corticosteroids. Chest 2001; 119: Global Initiative for Asthma (GINA). Global strategy of asthma management and revention. National Institutes of Health: National Heart, Lung, and Blood Institute. Bethesda, MD; 2002 (Publication No. NIH-NHLI ). 8. Clinical ractice guidelines for management of adult asthma. Malaysian Thoracic Society, Academy of Medicine of Malaysia, Ministry of Health Malaysia, 2nd Edition Lomas J, Anderson GM, Domnick-Pierre K, Vayda E, Enkin MW, Hannah WJ. Do ractice guidelines guide ractice? The effect of a consensus statement on the ractice of hysicians. N Engl J Med 1989; 321: Greco PJ, Eisenberg JM. Changing hysicians' ractices. N Engl J Med 1993; 329: Lexchin J. Imroving the aroriateness of hysician rescribing. Int J Health Serv 1998; 28: Chan PWK, Norzila MZ. Prescribing atterns for childhood asthma treatment in general ractice. Med J Malaysia 2003; 58: Tan WC, Chia KS, Goh LG. Choices and references in asthma management. Singaore Med J 1992; 33: Jeson G, Butler T, Gregory D, Jones K. Prescribing atterns for asthma by general ractitioners in six Euroean countries. Resir Med 2000; 94: Naish J, Sturdy P, Toon P. Aroriate rescribing in asthma and its related cost in east London. BMJ 1995; 310: Lim TO, Suiah A, Ismail F, Selvan T, Khan NK, Ngah BA. Morbidity associated with asthma and audit of asthma treatment in out-atient clinics. Singaore Med J 1992; 33: Boyd G. The continued need for metered dose inhalers. J Aerosol Med 1995; 8 Sul 1: S Loh LC, Teng CL, Teh PN, Koh CN, Vijayasingham P, Thayaaran T. Metered-dose inhaler technique in asthmatic atients- a revisit of the Malaysian scene. Med J Malaysia 2004; 59: Kelloway JS, Wyatt R. A cost-effectiveness analysis of breath-actuated metered-dose inhalers. Manag Care Interface 1997; 10: Cambell DA, Luke CG, McLennan G, et al. Near-fatal asthma in South Australia: descritive features and medication use. Aust N Z J Med 1996; 26: Fernandes AK, Mallmann F, Steinhorst AM, et al. Characteristics of acute asthma atients attended frequently comared with those attended only occasionally in an emergency deartment. J Asthma 2003; 40: Heggenhougen HK. Bomohs, doctors and sinsehs--medical luralism in Malaysia. Soc Sci Med [Med Anthrool] 1980; 14B: Chen PC. Traditional and modern medicine in Malaysia. Am J Chin Med 1979; 7: Oxman AD, Thomson MA, Davis DA, Haynes RB. No magic bullets: a systematic review of 102 trials of interventions to imrove rofessional ractice. CMAJ 1995; 153: Soumerai SB, Avorn J. Princiles of educational outreach ('academic detailing') to imrove clinical decision making. JAMA 1990; 263: Schaffner W, Ray WA, Federsiel CF, Miller WO. Imroving antibiotic rescribing in office ractice. A controlled trial of three educational methods. JAMA 1983; 250: Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing hysician erformance. A systematic review of the effect of continuing medical education strategies. JAMA 1995; 274: Wensing M, Grol R. Single and combined strategies for imlementing changes in rimary care: a literature review. Int J Qual Health Care 1994; 6: Bero LA, Grilli R, Grimshaw JM, Harvey E, Oxman AD, Thomson MA. Closing the ga between research and ractice: an overview of systematic reviews of interventions to romote the imlementation of research findings. The Cochrane Effective Practice and Organization of Care Review Grou. BMJ 1998; 317: