Asthma care in Europe fails at the list, not the clinic. A four-country typology of the recall gap and why payers should pay for reach, not reviews.
It is twenty to six on a Thursday. A woman in her thirties is collecting her third reliever inhaler since spring. The pharmacist scans the box, prints the label and asks if she needs a bag. The counter could be in Porto, Malmö or Dortmund, and what happens next is the same in all three places. Nothing happens.
The clinic is open. The patient never arrives
Asthma is not a forgotten disease in Europe. In 2019 almost 6% of people aged 15 and over in the EU reported having it, with Finland at 9% and Germany at 8%, according to Eurostat. Guidelines are mature, and most systems have built the room where the review should take place. In Sweden, most vårdcentraler now run a dedicated asthma and COPD clinic, Socialstyrelsen reported in April 2026. Germany's structured programme for asthma, the DMP Asthma bronchiale, was revised by the G-BA with stepped treatment plans and more weight on self-management.
The hospital end of the chain looks calm too. In 2021, EU admissions for asthma and COPD averaged 117 per 100,000 people, and COPD accounted for 84% of them, the OECD reports. That leaves roughly 19 asthma admissions per 100,000 (117 × 0.16). It is a small number. It is also the wrong place to look.
Four ways to lose an asthma patient
Put the national data side by side and a pattern appears. Every system loses asthma patients somewhere between diagnosis and review, but each loses them at a different point. Each also measures mainly what it already does well.
Leak | Where the patient disappears | Clearest case |
|---|---|---|
Unfound | Has asthma, but no record says so | Portugal |
Unenrolled | Diagnosed, but outside the structured programme | Germany |
Uncalled | On file, but nobody sends an invitation | Sweden |
Excused | Invited twice, did not respond, removed from the count | England |
Portugal. The EPI-ASTHMA study estimates that more than 570,000 adults live with asthma and that 23% of them had no previous diagnosis. That is about 131,000 people (570,000 × 0.23) whom no centro de saúde can call, because no record says they should be called. The gap widens where nobody owns the list: 1,563,710 registered users had no family doctor at the end of 2025.
Germany. The DMP builds recall into its design, with documented check-ups every quarter or half-year. But enrolment is voluntary, and the Bundesamt für Soziale Sicherung counted 1,220,202 asthma participations in September 2026. The statutory insurers cover about 74.6 million people, and diagnosed prevalence in 2016 was 5.1% in children and 5.9% in adults. That puts the number of people with a diagnosis at between 3.8 and 4.4 million. The programme therefore reaches roughly three in ten of them (1.22 ÷ 4.4 = 28%; 1.22 ÷ 3.8 = 32%).
Sweden. Sweden has its patients on file and its clinics open. Yet in an IHE survey of 1,365 adults, only 30% had well-controlled asthma, and nearly half said they were not invited to regular follow-up. The survey was web-based and industry-funded, so caution is fair. Socialstyrelsen's own finding that spirometry and patient education are still not delivered widely enough points the same way.
England. England has gone furthest, because the GP contract's Quality and Outcomes Framework pays practices for the review. It also provides the exit: patients who do not respond to two invitations can be removed from the review indicator. In 2024/25 the indicator showed 82% achievement, while the share of patients actually reviewed was 66% and 20% had been removed through personalised care adjustments, according to NICE. For every 100 patients on a practice's asthma register, that comes to 66 reviewed and 20 set aside. On paper the practice has done its job, and the 20 have stopped being its concern.
The question nobody has assigned
The four leaks look different, but they share one root. In each system the money and the oversight follow the patient who turns up. Nobody is answerable for the one who doesn't, so a board, a payer or a ministry should now ask one thing. Who, in each system, is accountable for the asthma patient who does not come?
Pay for reach, not for reviews
In almost every European system, the honest answer is nobody. That will not change while payers reward the review that happened instead of the patient who was reached. The metric money follows should be reach: the share of everyone with a diagnosis who has been actively contacted and assessed in the past year. In that count, a patient who does not respond is a failure. They are not an exception.
There is a precedent. When Finland made asthma a national programme with explicit targets, hospital days fell by 54% between 1993 and 2003, and annual cost per patient fell by 36%, Haahtela and colleagues reported. The cost of not reaching patients also lands on others. IHE puts the average societal cost of asthma in Sweden at just over SEK 52,000 per person a year, most of it lost productivity. Employers and social insurance pay that bill, not the region that sends the letter, or forgets to.
It also matters who stays away. In Scotland, adults aged 18 to 35 were the least likely to have a review. The UK's national review of asthma deaths found evidence of a review in only 23% of fatal attacks.
The strongest objection deserves a straight answer. Adults are free to decline, nurse time is scarce, and many people who skip reviews are well controlled. Chasing all of them would take time from patients who do attend. The objection is fair, but it argues against chasing everyone equally, not against reach. A list ranked by signals the system already holds, such as reliever refills or an emergency visit, costs no more nurse time than an inbox ranked by whoever phones first. It simply forces someone to decide.
What it means for each actor
- Hospital boards: Treat every emergency asthma visit as a referral back to a named owner in primary care, and count it as returned, not merely discharged.
- Primary care leads: Give one person ownership of the whole asthma list, including people who have not been seen in years.
- Payers and Krankenkassen: Pay for contact with and assessment of the full register. Non-response should trigger a different channel, not an exemption.
- Regulators: Publish reach the same way across regions: patients invited and assessed, divided by everyone diagnosed. It is the only figure that can be compared between systems.
The first moves
Start with the full list: everyone with a diagnosis or a maintenance prescription, not only those who attended. Then count reach honestly by putting excluded and unenrolled patients back into the denominator. Finally, name one person who owns the list. The rest is harder, and most attempts fail there: which signals rank the list, how the pharmacy and the emergency department feed it, and what happens after the second unanswered letter.
On another Thursday, the same woman collects the same third inhaler at the same counter. This time the refill puts her name near the top of a list that someone owns. A week earlier a nurse, who began her morning with a ranked list rather than an inbox, called her and asked how she was sleeping. The question came before the night that would have ended in the emergency department, not after it. How to get there without adding an hour to anyone's day is the part this text does not tell. At CW1, that is what we work on every day.
The inhaler is the same. The silence after it is gone.
