Qual Life Res
DOI 10.1007/s11136-016-1486-0
Quality of life in adults with asthma treated in allergy
and pneumology subspecialties: relationship
with sociodemographic, clinical and psychological variables
Beatriz González-Freire1,2 • Isabel Vázquez2
Accepted: 15 December 2016
Ó Springer International Publishing Switzerland 2016
Abstract
Purpose Prior studies suggest that specialist care associates
with improved health-related quality of life (HRQL) in
asthmatic patients. However, there are limited studies focused
on differences in HRQL among subspecialties. The aim of
this study was to assess the differences in HRQL between
adult asthmatic patients treated in pneumology or allergy
practices, and to estimate to what extent the differences in
HRQL can be explained by sociodemographic, clinical or
psychological characteristics of patients from each specialty.
Methods We recruited adult asthmatic outpatients from
allergy and pneumology practices. Information on
sociodemographic, clinical and psychological characteris-
tics was collected, and HRQL was assessed with generic
and disease-specific questionnaires. HRQL was compared
between groups adjusting for sociodemographic, clinical
and psychological characteristics.
Results A total of 287 asthmatic patients participated in the
study (105 from pneumology and 182 from allergy).
Patients treated by pneumologists reported significantly
poorer HRQL in physical dimensions of generic ques-
tionnaire and all dimensions of disease-specific question-
naire. Pneumology patients were older (p \ .001) and had
a lower education level (p \ .001); a higher number of
patients were in a non-active employment situation
(p = .003) and had worse pulmonary function (p \ .001),
& Isabel Vázquez
mariaisabel.vazquez@usc.es
1 ferences in health outcomes between allergy and pulmonary
Private Psychological Practice Beatriz González Freire.
Psicóloga, Ourense, Spain
2 and Schatz et al. [4] have shown that asthmatic patients
Department of Clinical Psychology and Psychobiology,
University of Santiago de Compostela,
Santiago de Compostela, Spain
longer duration of disease (p = .020), higher prevalence of
obesity (p \ .001) and uncontrolled asthma (p \ .001), and
a higher rate of previous absenteeism (p = .001). Depres-
sion and the use of cognitive avoidance coping were also
higher among pneumology patients (p = .050 and
p = .022, respectively). There were not significant differ-
ences in HRQL between pneumology and allergy patients
after adjustment for these sociodemographic, clinical and
psychological characteristics.
Conclusions Asthmatic patients treated by pneumologists
reported poorer HRQL than patients treated by allergists,
but this outcome is attributed to differences in several
sociodemographic, clinical and psychological characteris-
tics between the two groups of patients.
Keywords Asthma
Health-related quality of life

Specialist care
Pneumology
Allergy
Introduction
The cornerstone of the management of asthma is the
achievement of an optimal control and the best quality of life
possible [1]. Physicians such as allergists, pneumologists or
general practitioners work to achieve these goals. Prior
studies with adult asthmatic patients have reported that spe-
cialist care (allergy or pneumology) compared to non-spe-
cialist care is associated with improved health outcomes
including a better health-related quality of life (HRQL) [2–7].
However, there are very few studies that have assessed dif-
specialist care and the results were discrepant. Chen et al. [8]
treated in pneumology practices reported poorer HRQL than
asthmatic patients treated in allergy practices, while in the
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study of Blanc et al. [9] being attended by an allergist spe-
cialist was associated with a poorer HRQL.
Asthma management varies between allergists and pneu-
mologists [9–12], and this could affect the quality of life of
the patients. However, when comparing health outcomes for
patients, such as quality of life, the possible differences for
those treated in allergy versus pneumology practices should
be considered. Several studies have shown that allergist-
treated patients differed from pneumologist-treated patients
in some sociodemographic (younger age and higher educa-
tion level and income) [11, 13] and clinical characteristics
(better pulmonary function and lower severity of asthma)
[4, 9, 11, 13, 14]. Little is known about the differences in the
level of asthma control between patients attended in allergy
practices versus pneumology practices. Schatz et al. [4] in a
sample of adult patients with persistent asthma found that the
group treated by allergists reported a better asthma control
than the group attended by pneumologists. Similar results
were found by Chen et al. [11] in the Epidemiology and
Natural History of Asthma: Outcomes and Treatment Regi-
men study with patients with either severe or difficult-to-treat
asthma. This study showed that patients from allergy prac-
tices reported fewer problems with asthma control. To our
knowledge, there is not any study that has been specifically
compared patients treated in allergy and pneumology prac-
tices with respect to psychological characteristics.
The differences in sociodemographic, clinical and
asthma control characteristics as well as the differences in
psychological characteristics between asthmatic patients
who receive their care from allergists or pneumologists
could be related to their differences in HRQL.
The aim of this study was to assess the differences in
sociodemographic, clinical and psychological characteris-
tics and HRQL between adult asthmatic patients treated by
allergists versus pneumologists and to estimate to what
extent the differences in HRQL can be explained by
sociodemographic, clinical or psychological characteristics
of patients from each specialty. We hypothesized that
asthmatic patients attended in pneumology practices would
report poorer HRQL than asthmatic patients attended in
allergy practices and these differences could be attributed to
differences in sociodemographic, clinical and psychological
characteristics between patients from each type of practice.
Methods
Patients
We recruited adult asthmatic patients who attended the
allergy and the pneumology practices of the Complejo
Hospitalario Universitario of Ourense (Spain). Inclusion
criteria were: (1) diagnosis of asthma established by the
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Qual Life Res
specialist; (2) at least a 6 months evolution since the
diagnosis; (3) age between 18 and 75 years; and (4) read-
ing–writing ability. Patients with other physical or psy-
chiatric chronic comorbid illnesses, except rhinitis, were
excluded.
Instruments
1. Sociodemographic and life style data form
Sex, age, education level, employment situation, social
class, marital status, smoking habit and body mass
index (BMI) were collected for each patient
.
2. Clinical data form
Clinical data form was filled by the specialist (allergist
or pneumologist). This included the following infor-
mation: age of asthma diagnosis, percentage of pre-
dicted value of forced expiratory volume in 1 s (%
FEV1) recorded in the last spirometry, current asthma
control level and severity of disease. The asthma
control level was established according to classifica-
tion of Global Initiative for Asthma (GINA, 2006)
[15]. This classification categorizes the level of asthma
control as controlled, partly controlled and uncon-
trolled, taking into account daytime symptoms, limi-
tations of activities, nocturnal symptoms/awakening,
need for reliever/rescue treatment, lung function and
exacerbations. The severity of asthma was estimated
according to GINA (2009) [16] based on the intensity
of treatment required to achieve good asthma control.
There were four levels of asthma severity established:
intermittent (controlled asthma with Step 1 treatment),
mild persistent (controlled asthma with Step 2 treat-
ment), moderate persistent (controlled asthma with
Step 3 treatment) and severe persistent (controlled
asthma with Step 4 or Step 5 treatment). This clinical
data form also included the absenteeism from work due
to asthma during the previous 12 months.
3. Asthma Control Test (ACT) [17]: the ACT assesses the
level of asthma control over the last 4 weeks. It con-
sists of 5 items, and the total score ranges from 5 to 25
with higher scores indicating better asthma control
level. A total score C20 is classified as well-controlled
asthma, scores between 13 and 19 should be inter-
preted as a warning sign to detect patients who require
treatment change or adjustment to improve control,
and a score B12 is indicative of uncontrolled asthma.
The ACT has shown appropriate reliability, validity
and responsiveness [17, 18]. The Spanish version of
the ACT was used in this study. This adapted version
has demonstrated similar psychometric properties to
the original version [19].
Qual Life Res

4. 36-Item Short-Form Health Survey (SF-36) [20]: the
SF-36 is a generic HRQL questionnaire that includes
35 items, which comprise eight health domains:
Physical Functioning, Role Physical, Bodily Pain,
General Health, Vitality, Social Function, Role Emo-
tional and Mental Health. This questionnaire has an
additional item (not scoreable) about self-reported
health transition over a 1-year period. Each domain is
scored between 0 and 100, with higher scores indicat-
ing better health status. The questionnaire also pro-
vides two summary measures: the Physical Component
Summary (PCS) and the Mental Component Summary
(MCS). The SF-36 has shown an excellent reliability
and validity [21, 22]. The Spanish version of the SF-36
was used in this study. This adapted version has
demonstrated the same good psychometric properties
relative to the original version [23].
5. St. George’s Respiratory Questionnaire (SGRQ) [24]:
the SGRQ is a chronic airflow limitation disease-
specific HRQL questionnaire of 50 items organized
into three domains: Symptoms, Activity, and Impact.
Each domain score and the overall score range from 0
to 100, with higher scores indicating worse HRQL.
The SGRQ has shown adequate reliability, validity and
responsiveness [24]. The Spanish version of Ferrer
et al. [25] was used in this study which has been
demonstrated as valid, reliable and responsive to
asthmatic population [26].
6. Hospital Anxiety and Depression Scale (HADS) [27]:
the HADS is a self-assessment measure for detecting
anxiety and depression in non-psychiatric medical
outpatients. The scale contains 14 items, 7 of which
assess anxiety symptoms (anxiety subscale: HADS-A)
and 7 assess depression symptoms (depression sub-
scale: HADS-D). The scores of both subscales range
from 0 to 21 and Zigmond and Snaith [27] established
three cutoffs: B7 (non-cases), 8–10 (doubtful cases)
and C11 (anxiety or depression clinic problem). The
HADS is presented as a reliable and valid measure
[27]. The Spanish version of the HADS was used in
this study. This adapted version has also shown
appropriate reliability and validity [28, 29].
7. Coping Orientations to Problems Experienced Inven-
tory (COPE) [30]: the COPE is a self-report instrument
for evaluating general coping styles with stress. It
contains 60 items grouped into six basic dimensions of
coping: Behavioral Coping of the Problem, Cognitive
Coping of the Problem, Emotion-Focused Coping,
Cognitive Avoidance, Behavioral Avoidance and
Alcohol–Drug Consumption. Each coping dimension
score ranges between 1 and 4, with higher scores
indicating a more frequent use of the assessed coping
strategy. The COPE has shown appropriate reliability
and validity [30]. The Spanish version of the COPE
was used in this study which has similar psychometric
properties to the original version [31].
Procedure
Participants were recruited consecutively from outpatients
who were attending regularly in allergy or pneumology
practices of the Complejo Hospitalario Universitario of
Ourense (Spain). Patients who matched the inclusion cri-
teria received information about the research and were
asked to participate and signed the informed consent. The
specialist physician (allergist or pneumologist) responsible
for the patient’s treatment filled in the clinical data form
and established the asthma control classification according
to GINA (2006) [15] and the asthma severity classification
according to GINA (2009) [16] with the information col-
lected in the patient history case, the spirometry results, as
well as the information obtained the day of consultation. At
the same time, the psychologist collected information
about sociodemographic characteristics and administered
to the patient the questionnaires ACT, SF-36, SGRQ,
HADS and COPE. These questionnaires were applied in a
self-administered format (via paper and pencil), except in
those patients with difficulties to do it by themselves. In
that case, an interview format was used. A total of 83
patients filled in the questionnaires by interview format (37
in allergy practices and 46 in pneumology practices).
Participants took on average 30 min to complete the
questionnaires.
The study was approved by the Galician Ethical
Research Committee with the code 2009/408.
Statistical analysis
For the descriptive analysis, the continuous variables were
presented as mean, standard deviation and range, and the
categorical variables as frequency and percentage (the
percentage of patients in each category were calculated
excluding missing values). Asthma control level and
severity of disease were grouped as one variable with three
categories: (a) Uncontrolled asthma: this category included
patients with uncontrolled asthma (ACT \ 20 and/or
uncontrolled or partly controlled asthma according to
GINA classification of asthma control); (b) Intermittent or
mild persistent contolled asthma: this category included
patients with controlled asthma (ACT C 20 and controlled
asthma according to GINA classification of control) and
Steps 1 or 2 of treatment according to GINA classification
of severity; (c) Moderate or severe persistent controlled
asthma: this category included patients with controlled
asthma (ACT C 20 and controlled asthma according to

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GINA classification of control) and Steps 3, 4 or 5 of
treatment according to GINA classification of severity.
Comparisons between allergy and pneumology patients
related to sociodemographic, clinical, asthma control and
severity, psychological and HRQL variables were per-
formed using Chi-square tests for categorical variables and
analysis of variance or Kruskal–Wallis test for continuous
variables (Kolmogorov–Smirnov test was used to assess
normality).
The relationship between the type of specialty and the
HRQL (assessed with SF-36 and SGRQ questionnaires)
was examined using ANCOVA controlling for sociode-
mographic, clinical and psychological characteristics
which showed differences between allergy and pneumol-
ogy patients.
Power calculations revealed that a minimum sample size
of 105 patients in each group detects differences of 4 points
in SF-36 and 8.1 points in SGRQ between asthmatic
patients treated in allergy and pneumology practices, with a
confidence level of 95% and a statistical power of 90%.
In all statistical analyses, an alpha level of .05 was
established. The SPSS 19.00 package for Windows was
used.
Results
A total of 287 asthmatic patients participated in the study;
out of these, 63.4% (n = 182) were recruited in allergy
practices and 36.6% (n = 105) in pneumology practices.
Sociodemographic, clinical and psychological characteris-
tics of the sample are summarized in Table 1.
Patients who received their care from pneumologists
were older (43.49 ± 17.48 vs 32.74 ± 11.32 years,
p \ .001), and this group had a higher number of partici-
pants without education or primary education (50.5 vs
24.7%, p \ .001) and in a non-active employment situation
(58.1 vs 40.1%, p = .003) compared to allergist group.
There was a statistically significant association between the
type of specialty and the BMI, with a higher percentage of
obesity (BMI C 30) in the pneumology group (36.2 vs
8.8%, p \ .001). In relation to clinical characteristics,
patients who received their care from pneumologists were
diagnosed with asthma at a later stage (30.65 ± 16.68 years
vs 22.49 ± 12.37 years, p \ .001), exhibited longer dura-
tion of the disease (15.58 ± 14.55 years vs 10.32 ±
8.84 years, p = .020), and a higher number had a
FEV1 \ 80% (41.3 vs 20.9%, p \ .001) than patients
treated by allergists. In the pneumology group, there was a
higher prevalence of uncontrolled asthma (66.7 vs 45.1%,
p \ .001). With respect to absenteeism, the percentage of
patients with at least 1 day of absenteeism from work due to
asthma during the previous 12 months was higher in the
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Qual Life Res
pneumology group (37.3 vs 16.1%, p = .001) than in the
allergy group.
With regard to psychological characteristics, in the
pneumology group there were a higher prevalence of
depression (HADS-D C 8; 21.6 vs 12.7%, p = .050) and a
more frequent use of cognitive avoidance coping
(1.73 ± .55 vs 1.56 ± .39, p = .022) than in the allergy
group.
The analysis of differences in HRQL showed that asth-
matic patients treated by pneumologists reported poorer
HRQL in all domains than patients treated by allergists.
Significant differences in physical domains were found with
the SF-36: Physical Functioning (71.53 ± 25.27 vs
84.47 ± 17.07, p \ .001), Role Physical (62.01 ± 42.80 vs
81.21 ± 33.84, p \ .001), Bodily Pain (60.13 ± 29.24 vs
71.54 ± 22.96, p = .001), General Health (46.89 ± 22.99
vs 56.19 ± 19.45, p \ .001), and Vitality (54.03 ± 24.26
vs 62.56 ± 18.77, p = .004) and PCS (43.18 ± 10.12 vs
48.61 ± 7.56, p \ .001). The differences between the two
groups were statistically significant in all domains of SGRQ:
Symptoms (46.92 ± 21.26 vs 37.74 ± 18.28, p \ .001),
Activity (48.21 ± 27.16 vs 29.71 ± 24.20, p \ .001) and
Impact (30.81 ± 22.61 vs 18.35 ± 15.14, p \ .001), and
overall score (38.86 ± 21.63 vs 25.02 ± 15.77, p \ .001;
see Table 2).
ANCOVA analyses for each score of SF-36 and SGRQ
in which there were differences between asthmatic patients
attended in allergy or pneumology practices showed that
after adjustment for BMI, sociodemographic (age, educa-
tion level and employment situation), clinical (duration of
the disease, % FEV1 of predicted value, asthma control and
severity of disease, absenteeism) and psychological vari-
ables (depression and cognitive avoidance coping), sig-
nificant differences in HRQL did not exist between the two
groups of patients. The ANCOVA models showed signif-
icant effects for the clinical variables asthma control and
severity and absenteeism due to asthma in Role Physical,
Bodily Pain, General Health, Vitality and PCS of SF-36
(p \ .05) and in Impact and overall score of SGRQ
(p \ .05). Asthma control and severity was related apart
with Physical Functioning of SF-36 (p \ .001) and
Symptoms and Activity of SGRQ (p \ .001). In respect to
psychological variables, depression and cognitive avoid-
ance coping were associated with Physical Functioning and
General Health of SF-36 (p \ .05) and Impact and overall
score of SGRQ (p \ .01). Depression was also related to
Bodily Pain and Vitality of SF-36 (p \ .01), and cognitive
avoidance coping with Role Physical of SF-36 (p = .016)
and Activity of SGRQ (p = .043). There were also sig-
nificant effects for BMI in Physical Functioning of SF-36
(p = .011) and in Activity, Impact and overall score of
SGRQ (p \ .01), for age in Symptoms of SGRQ
(p = .010), for the employment situation in General Health
Qual Life Res

Table 1 Differences in sociodemographic, clinical and psychological characteristics between asthmatic patients treated in pneumology practices
and asthmatic patients treated in allergy practices
Variables Practice v2/(F) p
Pneumology (n = 105) Allergy (n = 182)

Age (years) M ± SD (range) 43.49 ± 17.48 (18–75) 32.74 ± 11.32 (18–72) 22.73 \.001
Sex .06 .804
Female 77 (73.3) 131 (72)
Male 28 (26.7) 51 (28)
Education level 19.64 \.001
Without education/primary 53 (50.5) 45 (24.7)
Secondary/college 52 (49.5) 137 (75.3)
Marital status 1.37 .242
Single/divorced/widowed 41 (39) 84 (46.2)
Married/living with a stable partner 64 (61) 98 (53.8)
Employment situation 8.65 .003
Active 44 (41.9) 109 (59.9)
Non-active 61 (58.1) 73 (40.1)
Social class 4.15 .126
Lower/lower–middle 27 (26) 34 (18.8)
Middle–middle 72 (69.2) 128 (70.7)
Upper–middle/upper 5 (4.8) 19 (10.5)
Smoking habit 2.45 .293
Smoker 14 (13.3) 36 (19.8)
Former 19 (18.1) 25 (13.7)
Non-smoker 72 (68.6) 121 (66.5)
Body mass index 34.24 \.001
18.5–24.99 40 (38.1) 114 (62.6)
25–29.99 27 (25.7) 52 (28.6)
C30 38 (36.2) 16 (8.8)
Age of the patient in the asthma diagnosis (years) M ± SD (range) 30.65 ± 16.68 (1–64) 22.49 ± 12.37 (1–63) 13.75 \.001
Duration of the disease (years) M ± SD (range) 15.58 ± 14.55 (1–67) 10.32 ± 8.84 (1–37) 5.41 .020
% FEV1 of predicted value 13.66 \.001
C80% 61 (58.7) 144 (79.1)
\80% 43 (41.3) 38 (20.9)
Asthma control and severity of disease 28.97 \.001
Uncontrolled asthma 70 (66.7) 82 (45.1)
Intermittent or mild persistent controlled asthma 9 (8.6%) 69 (37.9)
Moderate or severe persistent controlled asthma 26 (24.8) 31 (17)
Absenteeism due to asthma during previous 12 months 11.66 .001
None 42 (62.7) 120 (83.9)
C1 day 25 (37.3) 23 (16.1)
HADS-A .89 .344
Normal 59 (57.3) 114 (63)
Doubtful cases/clinic problem 44 (42.7) 67 (37)
HADS-D 3.83 .050
Normal 80 (78.4) 158 (87.3)
Doubtful cases/clinic problem 22 (21.6) 23 (12.7)
COPE
Behavioral coping of the problem (M ± SD; range) 2.92 ± .44 (1.55–3.91) 2.84 ± .42 (1.91–4.00) (2.16) .143
Cognitive coping of the problem (M ± SD; range) 2.22 ± .43 (1.00–3.33) 2.17 ± .38 (1.33–3.27) (1.19) .277

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 Qual Life Res

Table 1 continued
Variables Practice v2/(F) p
Pneumology (n = 105) Allergy (n = 182)

Behavioral avoidance (M ± SD; range) 2.59 ± .40 (1.00–3.29) 2.62 ± .34 (1.57–3.86) .03 .862
Cognitive avoidance (M ± SD; range) 1.73 ± .55 (1.00–3.64) 1.56 ± .39 (1.00–2.82) 5.24 .022
Emotion-focused coping (M ± SD; range) 2.49 ± .67 (1.08–4.00) 2.46 ± .48 (1.25–3.67) .01 .940
Alcohol–drug consumption (M ± SD; range) 1.03 ± .17 (1.00–2.00) 1.04 ± .20 (1.00–2.50) .35 .55
The data are showed as n (%), except specification
% FEV1 percentage of predicted value of forced expiratory volume in 1 s, HADS-A anxiety subscale of Hospital Anxiety and Depression Scale,
HADS-D depression subscale of Hospital Anxiety and Depression Scale, COPE coping orientations to problems experienced inventory

Table 2 Differences in health-

Practice v2/(F) p
related quality of life scores
between asthmatic patients Pneumology Allergy
treated in pneumology practices (n = 105) (n = 182)
and asthmatic patients treated in M ± SD M ± SD
allergy practices
SF-36
Physical functioning 71.53 ± 25.27 84.47 ± 17.07 20.39 \.001
Role physical 62.01 ± 42.80 81.21 ± 33.84 15.76 \.001
Bodily pain 60.13 ± 29.24 71.54 ± 22.96 10.48 .001
General health 46.89 ± 22.99 56.19 ± 19.45 (13.20) \.001
Vitality 54.03 ± 24.26 62.56 ± 18.77 8.27 .004
Social function 77.64 ± 28.49 82.66 ± 22.72 1.22 .269
Role emotional 66.34 ± 42.94 74.76 ± 38.91 2.61 .106
Mental health 62.76 ± 25.33 69.50 ± 20.19 3.65 .056
PCS 43.18 ± 10.12 48.61 ± 7.56 19.50 \.001
MCS 44.29 ± 14.65 46.22 ± 12.19 .41 .520
SGRQ
Overall 38.86 ± 21.63 25.02 ± 15.77 27.76 \.001
Symptoms 46.92 ± 21.26 37.74 ± 18.28 (14.83) \.001
Activity 48.21 ± 27.16 29.71 ± 24.20 29.65 \.001
Impact 30.81 ± 22.61 18.35 ± 15.14 21.80 \.001
SF-36 36-Item Short-Form Health Survey, PCS physical component summary, MCS mental component
summary, SGRQ St. George’s respiratory questionnaire

of SF-36 (p = .037) and for the % FEV1 in Activity of
SGRQ (p = .025). The education level and the duration of
the disease were not associated with HRQL. For more
detailed information about multivariate models for scores
of SF-36 and SGRQ, see Tables 3 and 4, respectively.
Discussion
Although asthmatic patients treated in pneumology prac-
tices reported poorer HRQL than asthmatic patients treated
in allergy practices in Physical Functioning, Role Physical,
Bodily Pain, General Health, Vitality and PCS of SF-36 as
well as in all domains (Symptoms, Activity and Impact)
and overall score of SGRQ, these differences can be
attributed to differences in sociodemographic characteris-
tics (age and employment situation), BMI, clinical char-
acteristics (level of asthma control and severity, pulmonary
function and absenteeism) and psychological characteris-
tics (depression and cognitive avoidance coping) between
the two groups of patients.
When considering the differences in HRQL between
asthmatic patients attended in pneumology or allergy
practices, it should be taken into account that there are
some differences in the sociodemographic, clinical and
psychological characteristics of patients treated in each
speciality. In our study, the pneumologist group presented
an older age, lower education level, had a higher percent-
age of patients in non-active employment, higher preva-
lence of obesity, longer duration of the disease, poorer

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Table 3 ANCOVA models to estimate differences in dimensions of SF-36 between FEV1 of predicted value, asthma control and severity of disease, absenteeism) and
asthmatic patients treated in pneumology or allergy practices adjusting for sociodemographic psychological variables (depression and cognitive avoidance coping)
(age, education level and employment situation), BMI, clinical (duration of the disease, %
Effects Physical functioning Role physical Bodily pain General health Vitality Physical component
summary
F p Partial eta F p Partial eta F p Partial eta F p Partial eta F p Partial eta F p Partial eta
squared squared squared squared squared squared

Practice .04 .842 .000 .35 .555 .002 1.16 .284 .007 .03 .874 .000 .06 .810 .000 .32 .572 .002
Covariates
Age 3.58 .060 .022 2.26 .135 .014 .47 .496 .003 .48 .489 .003 .33 .566 .002 1.15 .286 .007
Education level .01 .906 .000 .00 .989 .000 1.08 .301 .007 1.23 .269 .008 .04 .846 .000 .52 .474 .003
Employment 2.28 .133 .014 .73 .393 .005 .33 .565 .002 4.41 .037 .027 1.68 .197 .011 .03 .861 .000
situation
BMI 4.69 .011 .056 .54 .582 .007 1.18 .311 .015 .71 .493 .009 1.43 .242 .018 1.52 .223 .019
Duration of the .17 .685 .001 .23 .630 .001 .05 .829 .000 .00 .980 .000 .01 .946 .000 .67 .416 .004
disease
% FEV1 of predicted .68 .411 .004 2.23 .137 .014 2.38 .125 .015 .51 .475 .003 .58 .447 .004 .93 .336 .006
value
Asthma control and 8.15 <.001 .094 5.24 .006 .062 3.91 .022 .048 9.91 <.001 .111 6.87 .001 .080 8.03 <.001 .093
severity of disease
Absenteeism .14 .708 .001 19.37 <.001 .109 3.91 .050 .024 5.54 .020 .034 5.60 .019 .034 6.77 .010 .042
Depression 11.34 .001 .067 2.70 .102 .017 7.98 .005 .049 3.99 .048 .025 29.09 <.001 .156 3.22 .075 .020
Cognitive avoidance 5.07 .026 .031 5.94 .016 .036 .31 .580 .002 5.16 .024 .032 2.48 .118 .015 .08 .781 .000
coping

Bold values correspond to significant F, p and partial eta squared

BMI body mass index, FEV1 forced expiratory volume in 1 s

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 Qual Life Res

Table 4 ANCOVA models to estimate differences in dimensions of FEV1 of predicted value, asthma control and severity of disease,
SGRQ between asthmatic patients treated in pneumology or allergy absenteeism) and psychological variables (depression and cognitive
practices adjusting for sociodemographic (age, education level and avoidance coping)
employment situation), BMI, clinical (duration of the disease, %
Effects Symptoms Activity Impact Overall score
F p Partial eta F p Partial eta F p Partial eta F p Partial eta
squared squared squared squared

Practice 3.04 .083 .019 2.59 .110 .016 .01 .923 .000 1.78 .184 .011
Covariates
Age 6.83 .010 .041 .11 .739 .001 2.71 .101 .017 1.91 .169 .012
Education level .33 .568 .002 .16 .688 .001 .02 .878 .000 .03 .859 .000
Employment situation 1.12 .292 .007 .80 .372 .005 1.44 .233 .009 1.55 .215 .010
BMI 1.36 .260 .017 5.25 .006 .063 7.16 .001 .084 6.89 .001 .082
Duration of the disease 2.96 .087 .018 1.13 .290 .007 .06 .810 .000 .99 .320 .006
% FEV1 of predicted .01 .907 .000 5.13 .025 .032 .50 .481 .003 1.03 .312 .007
value
Asthma control and 9.50 <.001 .107 10.03 <.001 .113 22.08 <.001 .221 22.19 <.001 .223
severity of disease
Absenteeism 2.21 .139 .014 2.72 .101 .017 5.37 .022 .033 5.99 .015 .037
Depression 1.86 .175 .012 1.49 .224 .009 14.04 <.001 .083 7.52 .007 .046
Cognitive avoidance .00 .990 .000 4.16 .043 .026 11.93 .001 .071 7.08 .009 .044
coping

Bold values correspond to significant F, p and partial eta squared

BMI body mass index, FEV1 forced expiratory volume in 1 s

pulmonary function, higher prevalence of uncontrolled
asthma and higher rates of previous absenteeism because of
asthma compared to the allergist group. The differences
showed in this study between asthmatic patients attended in
allergy or pneumology practices are consistent with prior
literature, which have also found differences in some
sociodemographic and clinical characteristics between
patients treated in pneumology or in allergy practices from
the US [4, 9, 11, 14] and Spanish healthcare systems [13]
and it would be of interest to determine in future studies if
these differences are also seen in other cultural and health
contexts. With regard to psychological characteristics, we
only found differences between groups in depression and
cognitive avoidance coping. The pneumologist group had a
higher prevalence of depression and a more frequent use of
cognitive avoidance coping than the allergist group. The
higher prevalence of depression in the pneumologist group
could be related to their lower education level and worse
asthma control because both variables have been linked to
higher rates of depression in asthmatic patients [32, 33]. As
far as we know, there are no prior studies which have
assessed coping strategies in asthmatic patients according
to the type of specialist care, so it is possible that the more
frequent use of cognitive avoidance coping in the pneu-
mologist group in this study is related to its poorer asthma
control and poorer pulmonary function than in the allergist
group. In fact, there is evidence that a higher use of
avoidance coping strategies is exhibited by asthmatic
patients with these clinical characteristics [34].
Since sociodemographic and clinical characteristics and
the presence of depression and avoidance coping strategies
have been associated with poorer HRQL in asthmatic
patients [33, 35–41], we controlled these variables when
analyzing the differences in HRQL according to the type of
specialist who treated the asthmatic patient. Results
revealed the absence of differences in HRQL between the
two groups of patients, unlike the work of Schatz et al. [4]
and Chen et al. [8], in which the differences in HRQL
between asthmatic patients attended in pneumology prac-
tices and those dealt with in allergy practices were main-
tained even after monitoring sociodemographic and clinical
variables. These discrepancies might be due to that in the
work of Schatz et al. [4] the potential confounder effect of
the degree of control of asthma was not monitored and the
population of asthmatic patients assessed was limited to
adult patients aged 18–56 years, and in the study of Chen
et al. [8] the sample only included patients with severe or
difficult-to-treat asthma. In addition, in these two works the
effect of the psychological variables was not monitored
unlike in ours, which are important determinants of HRQL
in asthmatic patients [40, 42–44].
Although in this study we did not assess differences in
clinical practices for asthma management between pneu-
mologists and allergists, which were seen in several studies

123
Qual Life Res
[9–12], our results suggest that patient-related factors are
more important determinants of HRQL in asthma than the
type of specialist. In the same way, Blanc et al. [45] found
that physician-related factors, including the type of spe-
cialty and the clinical asthma management strategies
adopted, were not associated with HRQL, but patient-re-
lated factors were associated.
In this study, all asthmatic patients were recruited in a
hospital belonging to the Spanish public healthcare system.
In this healthcare system, patients with mild symptoms or
those that are easier to control mainly visit primary care
centers to be subsequently referred to hospital practices,
where the profile of the asthmatic patient can be much
more serious [13]. Primary care physicians are responsible
for referring an asthmatic patient for assessment or follow-
up to one or other type of specialist care, so it is important
to determine if this procedure allows the best context to be
provided in order to improve HRQL in each patient. The
results of this study highlighted that differences in HRQL
between asthmatic patients treated in allergy and pneu-
mology subspecialties are more likely to be attributed to
patient-related factors than to actual specialist differences.
The data obtained in this study have different clinical
and research implications. On the one hand, the differences
found in HRQL and sociodemographic, clinical and psy-
chological variables between asthmatic patients attended in
pneumology or allergy practices must be taken into account
in the design and interpretation of future epidemiological
studies that assess any of these aspects. Likewise, the
studies that assess HRQL must indicate the type of con-
sultation from which the samples have been recruited, as
data from pneumology and allergy practices are not
directly comparable. In this same line, when they are
considered to be composite samples (asthmatic patients
recruited both in pneumology and allergy practices), it
would be of interest to carry out an analysis by subgroups
of patients to determine potential differences in the results.
On the other hand, the interventions to improve HRQL in
patients should take into account the context of care in
which they are to be implemented and adapt this to the
characteristics of the patients in each practice type. The
data obtained in this study showed that patients treated in
pneumology practices present less asthma control, higher
prevalence of depression and a more frequent use of cog-
nitive avoidance coping as a strategy. Given that all of
these factors are potentially modifiable, it would be con-
venient that pneumologists screen their asthmatic patients
to detect these characteristics and establish an adequate
therapy in those patients where it is necessary. Psycho-
logical interventions focused on depression and coping
strategies might be used in addition to standard medical
treatment in an attempt to improve HRQL in these patients.
The results of this study must be considered taking into
account several limitations. All patients were recruited in
only one hospital and did not have comorbidity, so both
aspects prevent the generalization of our results. We
included a broad age range because we wanted to obtain
results of the overall population of asthmatic adult patients,
without restricting it to specific age subgroups, such as
occurred in the work of Schatz et al. [4] whose sample was
for adults with ages ranging between 18 and 56. However,
to monitor the greater prevalence of comorbidity associated
with age, the presence of other physical or psychiatric ill-
nesses was established as a criterion for exclusion. The
potential confounder effect of sociodemographic variables
related to the age (education level, employment, marital
status and social status) was also monitored in the multi-
variate analysis together with the smoking habit. However,
it would be of interest to future studies to delve deeper into
studying the differences in HRQL in asthmatic patients
depending on the type of specialist by stratifying the
analysis by age groups. Furthermore, it is necessary to
point out that even though the majority of patients filled out
the questionnaires by self-administered format, 29% filled
them out by interview format which could have produced
biases in some answers, especially for sensitive informa-
tion such as mental health. Finally, this study has a cross-
sectional design so longitudinal studies are therefore nee-
ded to analyze if there are differences in the long-term
HRQL of asthmatic patients treated by pneumologists or
allergists.
In conclusion, the results of this study show that asth-
matic patients treated in pneumology practices reported
poorer HRQL than patients treated in allergy practices,
although the differences in HRQL are related to different
sociodemographic, clinical and psychological characteris-
tics of patients from each specialty, so such differences
should be taken into consideration when comparing results
of studies about HRQL with asthmatic populations
recruited in different specialties.
Acknowledgements The authors thank Dr. José Manuel Garcı́a
Pazos, Dr. Pedro Marcos Velázquez, Dr. Carlos Garcı́a de la Cuesta,
Dra. Marı́a Genoveva Álvarez Eire and Dra. Susana Varela for their
support in register the clinic data of the patients. We also thank the
support or nursery staff of allergy and pneumology services.
Funding This study was funded by Marı́a Barbeito Programme of the
Consellerı́a de Innovación e Industria de la Xunta de Galicia.
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