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

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 In 2014, the primary care clinic serving Yarmouk, Kuwait’s first WHO-designated Healthy City, operated from an outdated asthma protocol with no on-site spirometry, no spacer devices, and a controller formulary limited to beclomethasone and montelukast.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.