A Decade of Asthma Care in Primary Care in Kuwait: Trends in Utilization, Prescribing, and the Reliever-to-Controller Ratio

A Decade of Asthma Care in Primary Care in Kuwait: Trends in Utilization, Prescribing, and the Reliever-to-Controller Ratio | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article A Decade of Asthma Care in Primary Care in Kuwait: Trends in Utilization, Prescribing, and the Reliever-to-Controller Ratio Maryam Alkhamees, Tasneem Aljarki, Ghassan Alothman, Rima Al-Adsani, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9131161/v2 This work is licensed under a CC BY 4.0 License Status: Posted Version 2 posted You are reading this latest preprint version Show more versions Abstract Background. Kuwait carries one of the highest asthma burdens in the Gulf region, with adult prevalence of 11-15% and childhood prevalence of 18%. Most patients rely on government-funded primary care. In 2014, the primary care clinic serving Yarmouk, Kuwait’s first WHO-designated Healthy City, operated from an outdated asthma protocol with no on-site spirometry, no spacer devices, and a controller formulary limited to beclomethasone and montelukast. Objective. To describe changes in asthma-related primary care activity and prescribing over a decade of cumulative clinical and environmental quality improvement, and to evaluate the reliever-to-controller prescribing ratio (R:C) as a candidate national quality metric derivable from routine electronic health record data. Methods. Retrospective longitudinal analysis of 135 consecutive months (January 2015-March 2026) of aggregate monthly data from the national Primary Care Information (PCI) system at Abdalla Al Abdul Hadi Clinic, Yarmouk. Outcomes were asthma-coded visits (absolute and as a proportion of all clinic visits), the R:C ratio, and ambient air quality indicators. Temporal trends were estimated by linear regression with Newey-West standard errors, a three-segment interrupted time series, and seasonal harmonic adjustment. The significance level was α = 0.05. Results. Asthma’s share of clinic visits fell from 1.81% (2016-2018 mean) to 1.02% (2025), a 44% relative reduction (β = -0.007 percentage points/month, p < 0.001). The R:C ratio declined monotonically from 2.77 (2015) to 0.78 (2025), a 72% reduction, crossing below 1.0 in 2023 (β = -0.015/month, R² = 0.79). The largest single-year drop (-26%) occurred between 2018 and 2019, coinciding with the clinic’s protocol revision and the GINA 2019 recommendation against reliever-only treatment. During the COVID-19 lockdown, the asthma-visit proportion rose rather than fell (β = +0.494, p = 0.007), inconsistent with the hypothesis that reduced ambient pollution explained the simultaneous drop in absolute visit counts. Structured patient education delivery rose 3.4-fold (0.82% to 2.81% of visits; β = +0.026/month, p < 0.001). Hospital referrals declined in absolute terms but not per 100 asthma visits. Conclusions. Over a decade, prescribing at this clinic shifted from reliever- to controller-dominated care, and asthma’s proportional share of primary care activity fell by 44%. No single intervention can be isolated as causal. The R:C ratio is proposed as a simple, PCI-derivable metric for national benchmarking of asthma care quality, and the COVID analysis illustrates why proportional (not absolute) outcomes are essential when interpreting trends from routinely collected data. Health sciences/Diseases Earth and environmental sciences/Environmental sciences Earth and environmental sciences/Environmental social sciences Health sciences/Health care Epidemiology asthma primary care quality improvement routinely collected data prescribing indicators air quality Kuwait global health Figures Figure 1 Figure 2 Figure 3 Full Text Additional Declarations The authors declare no competing interests. Supplementary Files SupplementaryMaterialv12.docx SUPPLEMENTARY MATERIAL Supplemental Table S1. Strategic action schedule: clinical and environmental intervention milestones (2014-2026). Supplemental Table S2. Implementation barriers encountered and adaptations applied, by domain. Supplemental Table S3. Workforce, Capacity, Training and Education Indicators (2015-2025) Supplemental Figure S1. Kaizen/PDCA framework for continuous improvement in asthma services. Supplemental Figure S2. Traffic redesign schematic: 4th Ring Road underpass and traffic redirection. Cite Share Download PDF Status: Posted Version 2 posted You are reading this latest preprint version Show more versions Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9131161","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":628418162,"identity":"2f894c77-00bd-48c7-90bd-24b39a25b0bd","order_by":0,"name":"Maryam Alkhamees","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAArklEQVRIiWNgGAWjYPCCBDkDEMVDihZj0rUkbiBai2772WcSP3PS0rdLJDA+eNtGhBazM+lmkr3bcnJ3zkhgNpxLlJYDaWwSvNsqcjfcSGCT5iVKy/lnbJJ/t1WkG9xIYP9NnJYbaUDDt+UkALWwMROp5Rmztey2NMOdPQ+bJeecI8phaYw3325LljdnTz744U0ZEVqAgEUCQjM2EKceCJg/EK10FIyCUTAKRiYAABPuNgw4QjlOAAAAAElFTkSuQmCC","orcid":"","institution":"Ministry of Health","correspondingAuthor":true,"prefix":"","firstName":"Maryam","middleName":"","lastName":"Alkhamees","suffix":""},{"id":628418163,"identity":"9d1b131f-4e79-4b0e-bb04-d0d8ef32a30f","order_by":1,"name":"Tasneem Aljarki","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Tasneem","middleName":"","lastName":"Aljarki","suffix":""},{"id":628418164,"identity":"40871b16-180f-46e0-ab65-7d58f2902831","order_by":2,"name":"Ghassan Alothman","email":"","orcid":"","institution":"Athr Community (NPO)","correspondingAuthor":false,"prefix":"","firstName":"Ghassan","middleName":"","lastName":"Alothman","suffix":""},{"id":628418165,"identity":"74406f2d-d077-485b-be5b-d2befb0f9c1a","order_by":3,"name":"Rima Al-Adsani","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Rima","middleName":"","lastName":"Al-Adsani","suffix":""},{"id":628418166,"identity":"9f289d1b-1821-405c-80b5-d2190293edb3","order_by":4,"name":"Huda Alduwaisan","email":"","orcid":"","institution":"Ministry of Health","correspondingAuthor":false,"prefix":"","firstName":"Huda","middleName":"","lastName":"Alduwaisan","suffix":""}],"badges":[],"createdAt":"2026-03-15 21:23:40","currentVersionCode":2,"declarations":{"humanSubjects":false,"vertebrateSubjects":false,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":false},"doi":"10.21203/rs.3.rs-9131161/v2","doiUrl":"https://doi.org/10.21203/rs.3.rs-9131161/v2","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107869168,"identity":"f3bdea19-6d45-44bb-add2-0972b3f8c103","added_by":"auto","created_at":"2026-04-27 07:36:18","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":145271,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTemporal trends in reliever-to-controller prescribing at Yarmouk Primary Health Center, 2015-2025.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAnnual reliever-to-controller (R:C) prescribing ratio at Yarmouk PHC (2015-2025). Dashed horizontal line marks R:C = 1.0. Annotated arrows indicate key programme milestones and contextual events.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-9131161/v2/292a278bb07a458d380bd4cf.png"},{"id":107750787,"identity":"7e65a1ac-62ea-45c6-8a67-dd8669223312","added_by":"auto","created_at":"2026-04-24 17:10:55","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":280789,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eLongitudinal pattern of asthma-coded healthcare utilization with key system-level disruptions, 2015-2026.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eMonthly asthma-coded visit counts (January 2015-March 2026). Vertical dashed lines: coding transition (Aug 2017), GINA 2019 update, COVID-19 lockdown onset (Mar 2020), real-time air-quality integration (Jan 2022), and 2024 road reconstruction.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-9131161/v2/f8fd2aa1202cfe0db2c2f81a.png"},{"id":107750786,"identity":"1287cc9f-3bb8-4efc-9af4-86da5e27b9ad","added_by":"auto","created_at":"2026-04-24 17:10:54","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":408767,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAmbient particulate matter trends in relation to asthma visit burden.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailable ambient air quality data (PM10, PM2.5) from nearest monitoring stations alongside monthly asthma visit counts. Data gaps indicated; WHO 2021 guideline levels shown as horizontal reference lines.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-9131161/v2/cfde62f9517ed787ac52ee85.png"},{"id":107871715,"identity":"a1c49742-4f08-484c-833a-cf0e5121c2cf","added_by":"auto","created_at":"2026-04-27 07:53:48","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":905069,"visible":true,"origin":"","legend":"","description":"","filename":"YarmoukAsthmaManuscriptv12.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9131161/v2_covered_bdbcb36c-9aa0-48b8-bfde-b337c012f898.pdf"},{"id":107750784,"identity":"d29d61a6-605f-4a35-a37c-33d96c0cd879","added_by":"auto","created_at":"2026-04-24 17:10:54","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":345520,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eSUPPLEMENTARY MATERIAL\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupplemental Table S1.\u003c/strong\u003e Strategic action schedule: clinical and environmental intervention milestones (2014-2026).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupplemental Table S2.\u003c/strong\u003e Implementation barriers encountered and adaptations applied, by domain.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupplemental Table S3.\u003c/strong\u003e Workforce, Capacity, Training and Education Indicators (2015-2025)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupplemental Figure S1.\u003c/strong\u003e Kaizen/PDCA framework for continuous improvement in asthma services.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSupplemental Figure S2.\u003c/strong\u003e Traffic redesign schematic: 4th Ring Road underpass and traffic redirection.\u003c/p\u003e","description":"","filename":"SupplementaryMaterialv12.docx","url":"https://assets-eu.researchsquare.com/files/rs-9131161/v2/baea8e7ca3eaaac89bc6a840.docx"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eA Decade of Asthma Care in Primary Care in Kuwait: Trends in Utilization, Prescribing, and the Reliever-to-Controller Ratio\u003c/strong\u003e\u003c/p\u003e","fulltext":[],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":true,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":true,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"asthma, primary care, quality improvement, routinely collected data, prescribing indicators, air quality, Kuwait, global health","lastPublishedDoi":"10.21203/rs.3.rs-9131161/v2","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9131161/v2","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground. \u003c/strong\u003eKuwait carries one of the highest asthma burdens in the Gulf region, with adult prevalence of 11-15% and childhood prevalence of 18%. Most patients rely on government-funded primary care. In 2014, the primary care clinic serving Yarmouk, Kuwait’s first WHO-designated Healthy City, operated from an outdated asthma protocol with no on-site spirometry, no spacer devices, and a controller formulary limited to beclomethasone and montelukast.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective. \u003c/strong\u003eTo describe changes in asthma-related primary care activity and prescribing over a decade of cumulative clinical and environmental quality improvement, and to evaluate the reliever-to-controller prescribing ratio (R:C) as a candidate national quality metric derivable from routine electronic health record data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods. \u003c/strong\u003eRetrospective longitudinal analysis of 135 consecutive months (January 2015-March 2026) of aggregate monthly data from the national Primary Care Information (PCI) system at Abdalla Al Abdul Hadi Clinic, Yarmouk. Outcomes were asthma-coded visits (absolute and as a proportion of all clinic visits), the R:C ratio, and ambient air quality indicators. Temporal trends were estimated by linear regression with Newey-West standard errors, a three-segment interrupted time series, and seasonal harmonic adjustment. The significance level was α = 0.05.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults. \u003c/strong\u003eAsthma’s share of clinic visits fell from 1.81% (2016-2018 mean) to 1.02% (2025), a 44% relative reduction (β = -0.007 percentage points/month, p \u0026lt; 0.001). The R:C ratio declined monotonically from 2.77 (2015) to 0.78 (2025), a 72% reduction, crossing below 1.0 in 2023 (β = -0.015/month, R² = 0.79). The largest single-year drop (-26%) occurred between 2018 and 2019, coinciding with the clinic’s protocol revision and the GINA 2019 recommendation against reliever-only treatment. During the COVID-19 lockdown, the asthma-visit proportion rose rather than fell (β = +0.494, p = 0.007), inconsistent with the hypothesis that reduced ambient pollution explained the simultaneous drop in absolute visit counts. Structured patient education delivery rose 3.4-fold (0.82% to 2.81% of visits; β = +0.026/month, p \u0026lt; 0.001). Hospital referrals declined in absolute terms but not per 100 asthma visits.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions. \u003c/strong\u003eOver a decade, prescribing at this clinic shifted from reliever- to controller-dominated care, and asthma’s proportional share of primary care activity fell by 44%. No single intervention can be isolated as causal. The R:C ratio is proposed as a simple, PCI-derivable metric for national benchmarking of asthma care quality, and the COVID analysis illustrates why proportional (not absolute) outcomes are essential when interpreting trends from routinely collected data.\u003c/p\u003e","manuscriptTitle":"A Decade of Asthma Care in Primary Care in Kuwait: Trends in Utilization, Prescribing, and the Reliever-to-Controller Ratio","msid":"","msnumber":"","nonDraftVersions":[{"code":2,"date":"2026-04-24 17:10:50","doi":"10.21203/rs.3.rs-9131161/v2","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}},{"code":1,"date":"2026-03-19 15:54:48","doi":"10.21203/rs.3.rs-9131161/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2f8fd2d9-a98d-49e4-9a66-b2526c590fc4","owner":[],"postedDate":"April 24th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":66970267,"name":"Health sciences/Diseases"},{"id":66970268,"name":"Earth and environmental sciences/Environmental sciences"},{"id":66970269,"name":"Earth and environmental sciences/Environmental social sciences"},{"id":66970270,"name":"Health sciences/Health care"},{"id":66970271,"name":"Epidemiology"}],"tags":[],"updatedAt":"2026-03-22T19:24:23+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-24 17:10:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v2","identity":"rs-9131161","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9131161","identity":"rs-9131161","version":["v2"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}