Low prevalence of diagnosed asthma in Greenland – a call for increased focus on diagnosing

ABSTRACT

The aim of this study was to estimate prevalence of patients with asthma in Greenland according to age, gender and residence and to investigate the associated quality of care. The study was performed as a cross-sectional study with data extracted from the Greenlandic electronical medical record. A total of 870 patients aged 12 years or above were diagnosed with asthma at the end of 2022, corresponding to a prevalence of 1.9%. In 2020, the total prevalence was 0.2%. The prevalence of patients aged 12 years or above with asthma was highest among patients in Nuuk (3.3%) compared with patients in the remaining parts of Greenland (1.1%). More women than men were diagnosed with asthma, and the prevalence increased with age from 20 to 59 years. The prevalence of current smokers was high among the asthma population. The quality of care was significantly higher among patients living in Nuuk for all process indicators compared with patients from the remaining parts of Greenland. The prevalence of asthma in Greenland is low compared to other comparable populations and might be underestimated. Initiatives supporting increased focus on diagnosing asthma are thus warranted.

KEYWORDS:

• Asthma
• prevalence
• quality of care
• Greenland
• Inuit

Introduction

Asthma is one of the most common chronic diseases affecting more than 300 million people worldwide [1,2]. The prevalence of asthma has increased over the past few decades, and the incidence and prevalence of asthma is higher in the earliest stages of life, especially in the paediatric population [1]. Morbidity and mortality associated with the disease have been reduced with improved management and disease understanding [2]. However, asthma remains a major public health issue with high societal and individual costs. Asthma is defined as a history of respiratory symptoms such as wheezing, coughing and chest tightness [3], which affects the lungs by causing inflammation and swelling of the airways [4]. People with obesity have increased risk for developing asthma, and obese adults with asthma often have more symptoms compared to lean asthmatics [5].

Smoking increases inflammation in the lungs and is associated with an exacerbation of asthma symptoms [6]. In Greenland, smoking is a major public health issue, with more than half of the population smoking on a daily basis [7]. In adulthood, more women than men are diagnosed with asthma [8]. According to the Global Initiative for Asthma (GINA), the asthma diagnosis is made on the basis of history of characteristic symptoms and evidence of variable expiratory airflow limitations, which should be documented from bronchodilator reversibility or other tests [3]. In a study from 2004 of Inuit in Greenland, Backer et al. found different factors to be important for the presence of asthmatic symptoms like climate, living conditions or areas, diet, tobacco use, and atopy [9]. In addition, they reported that 9% of a selected study population living in towns (n = 1,766) had asthma compared with 6% living in smaller settlements (n = 263) based on self-reported asthma, use of asthma medication or cough on exertion in a questionnaire. In Denmark, the prevalence of asthma is estimated to be 7.0% [10]. In 2012, a study from Canada reported a prevalence of asthma of 9.7% among Inuit aged 15–64 years [11]. In 2021, a study from Greenland found the prevalence of patients using medication for obstructive lung disease (asthma or chronic obstructive pulmonary disease (COPD)) to be 7.5% (2,855/38,164) [12]. Of those, only 101 patients were registered with a medical diagnosis code for asthma in the electronic medical record (EMR), while 152 patients were registered with a medical diagnosis code for COPD. No information was available to substantiate whether the remaining patients suffered from asthma, COPD, other lung diseases or were treated without having lung disease. Since 2019, the health care system in Greenland has worked on improving diagnostics by adding more medical diagnosis codes in the EMR. In 2020, it became mandatory for doctors in the primary sector of Nuuk to add to medical diagnostic codes in the EMR. Furthermore, the health care system in Greenland has focused on active case finding among patients aged 40 years or above in treatment with pulmonary medicine.

Therefore, the aim of this study was to estimate the prevalence of patients diagnosed with asthma in Greenland according to age, gender and residency and, furthermore, to investigate the associated quality of care.

Material and methods

Study design

The study was carried out as a cross-sectional study based on data obtained from the EMR in Greenland.

Setting

Greenland is the largest island in the world covering an area of two million km². Despite the large area, only 56,000 people inhabit Greenland. The population is distributed in towns and small settlements along the coastline. Ninety percent of the population are ethnic Greenlanders (Inuit) [13]. Inuit in Greenland are genetically related to Inuit from Alaska and Canada. The health care system in Greenland is divided into five health care regions. One regional hospital is placed in the largest town in each health care region. In the remaining towns and small settlements, health care centres and smaller health care units, respectively, are placed. Medication, hospital treatment and the health care service in general, are free of charge for all permanent residents in Greenland [14]. The treatment of asthma takes place in health care regions at the regional hospital or at the health care centre. Advanced cases of asthma are directed to the Department of Internal Medicine at Queen Ingrid’s Hospital (QIH) in the capital Nuuk [14]. Actually, no specialist in lung medicine is permanently employed in Greenland, but specialists in lung medicine are available for shorter periods at the Department of Internal Medicine at QIH. In Greenland, diagnosis of asthma in the primary sector is based on the presence of symptoms and a positive finding of reversibility in the form of increased variability in peak flow monitoring and/or proven reversibility in spirometry (short with salbutamol or long with steroid inhalation). Access to provocation testing is currently extremely limited in Greenland, and in some cases, the diagnosis must be made pragmatically on the basis of classic symptoms and treatment response. The Greenlandic guideline includes children aged 12 years or above, which is why only this group is included. Currently, there is no specific guidance for diagnosing childhood asthma.

Study population and variables

The study population consists of Greenlandic residents aged 12 years or above diagnosed with asthma as of August 2022. Patient data from all parts of Greenland was extracted from the EMR, except the town, Tasiilaq, in which the EMR is not yet fully implemented. The study population was divided into two groups: patients from the capital Nuuk and patients from the remaining parts of Greenland. Inclusion criteria were registration of medical diagnosis code for asthma in the EMR; ICPC-2 code; R96 and/or ICD10 codes; DJ45, DJ450, DJ451, DJ458, DJ459. Information extracted from the EMR included age, weight, and height. Furthermore, Forced Vital Capacity (FVC), Forced Expiratory Volume in first second (FEV1) and FEV1/FVC in litres were extracted as well as FVC% and FEV1% (percent of predicted values based on European reference). BMI was calculated. Data on quality of care was extracted from the EMR. The quality of care was described according to guidelines from the health care system in Greenland and Danish quality-of-care indicators [15]. Accordingly, process and proximal outcome indicators were evaluated as the percentage of patients in whom smoking status, spirometry and BMI was evaluated/conducted within the previous two years, as well as the percentage of patients who were current smokers, respectively.

When calculating prevalence, the background population was the Greenlandic population aged 12 years or above without Tasiilaq by 1^st of July 2022, and data of the background population were extracted from the online statistic bank by Statistics Greenland [16].

Statistical analysis

Prevalence estimates were calculated with 95% confidence intervals (CI) using the background population as denominator. When calculating the age- and sex-specific prevalence of patients with asthma, patients were divided into age groups of 10 years. Chi-square tests were used to compare frequencies. P-values below 0.05 were considered significant. Normally distributed parameters were described using mean and standard deviation (SD). Check for normality was done using histograms and means were compared using t-test. Statistical analysis was performed in R version 4.1.2.

The study was approved by The Science Ethics Committee in Greenland (reference no. 2016–09) and by The Agency for Health and Prevention in Greenland. All data was handled anonymously.

Results

In total, 870 patients (619 women and 251 men) with a mean age of 48 years were diagnosed with asthma. Table 1 presents the basic characteristics of the study population and shows that 71% were women, 62% of the patients lived in the capital Nuuk, while the residual 38% lived in the remaining parts of Greenland. Men were significantly taller, weighed more and had lower FEV1/FVC compared to women (p<0.001). No difference in BMI was observed among men and women.

Table 1. Basic characteristics of patients in Nuuk vs. from the remaining parts of Greenland.

	Nuuk					The remaining parts of Greenland					Nuuk		The remaining parts of Greenland
	Women		Men			Women		Men			Total		Total
	Mean (SD)	N	Mean (SD)	N	p	Mean (SD)	N	Mean (SD)	N	p	Mean (SD)	N	Mean (SD)	N	p
Age (years)	49 (15.5)	385	47 (16.8)	155	0.493	49 (17.3)	234	44 (20.8)	96	<0.05	48 (15.9)	540	48 (18.5)	330	0.576
Weight (kg)	77 (18.0)	370	88 (21.7)	137	<0.001	78 (20.0)	206	82 (22.6)	75	0.165	80 (19.7)	507	79 (20.8)	281	0.502
Height (cm)	160 (7.0)	363	174 (10.1)	136	<0.001	158 (6.6)	194	169 (9.6)	75	<0.001	164 (10.0)	499	161 (8.9)	269	<0.001
BMI (kg/m^2)	30 (6.6)	352	30 (5.8)	129	0.337	31 (7.5)	185	29 (6.9)	66	<0.05	30 (6.4)	481	31 (7.4)	251	0.100
FEV1 (L)	2 (0.7)	336	3 (1.0)	132	<0.001	2 (0.7)	160	3 (1.0)	65	<0.001	2.6 (0.9)	468	2.4 (0.9)	225	<0.05
FEV1%*	90 (17.8)	334	86 (21.6)	130	0.057	90 (21.1)	157	87 (19.5)	64	0.287	89 (19.0)	464	89 (20.6)	221	0.845
FVC (L)	3 (0.8)	336	4 (1.2)	132	<0.001	3 (0.7)	159	4 (1.2)	64	<0.001	3.5 (1.1)	468	3.3 (1.1)	223	<0.05
FVC%*	95 (16.0)	336	94 (17.3)	132	0.334	98 (20.3)	157	100 (17.5)	63	0.529	95 (16.3)	468	98 (19.5)	220	<0.05
FEV1/FVC%	75 (9.4)	334	72 (11.6)	129	<0.001	75 (9.99)	159	70 (11.6)	64	<0.01	75 (10.2)	463	73 (10.6)	223	0.158

P values below 0.05 are in bold. * percent of predicted values based on European reference. FVC= Forced Vital Capacity, FEV1=Forced Expiratory Volume in first second.

Prevalence

The prevalence of patients with asthma aged 12 years or above in Greenland was 1.9% (870/45,313). Table 2 shows the estimated age- and gender-specific prevalence of patients with asthma in the capital Nuuk compared to the remaining parts of Greenland.

Table 2. Age-specific prevalence (%) among women and men in Nuuk vs. from the remaining parts of Greenland.

	Nuuk			The remaining parts of Greenland			Nuuk	The remaining parts of Greenland
	Women	Men		Women	Men		Total	Total
	(95% CI) (n/N)	(95% CI) (n/N)	p	(95% CI) (n/N)	(95% CI) (n/N)	p	(95% CI) (n/N)	(95% CI) (n/N)	p
Prevalence (%) among patients ≥ 12 years of age	5.0 (4.49–5.46) (385/7,736)	1.8 (1.51–2.07) (155/8,669)	<0.001	1.6 (1.40–1.81) (234/14,607)	0.7 (0.54–0.82) (96/14,120)	<0.001	3.3 (3.02–3.56) (540/16,405)	1.1 (1.02–1.26) (330/28,908)	<0.001
Prevalence (%) in age groups
12–19 years	1.8 (0.91–2.64) (16/900)	1.5 (0.71–2.24) (14/950)	0.605	0.9 (0.46–1.34) (16/1,777)	1.1 (0.65–1.58) (22/1,967)	0.506	1.6 (1.05–2.20) (30/1,850)	1.0 (0.69–1.34) (38/3,744)	0.051
20–29 years	2.7 (1.88–3.53) (40/1,478)	0.8 (0.35–1.25) (12/1,502)	<0.001	0.9 (0.55–1.30) (23/2,482)	0.4 (0.12–0.58) (9/2,581)	<0.01	1.7 (1.27–2.22) (52/2,980)	0.6 (0.41–0.85) (32/5,063)	<0.001
30–39 years	3.1 (2.32–3.95) (55/1,756)	1.1 (0.65–1.61) (21/1,861)	<0.001	1.0 (0.63–1.44) (25/2,410)	0.4 (0.14–0.61) (10/2,664)	<0.01	2.1 (1.63–2.57) (76/3,617)	0.7 (0.46–0.92) (35/5,074)	<0.001
40–49 years	5.2 (3.93–6.56) (58/1,106)	2.1 (1.35–2.83) (30/1,434)	<0.001	1.5 (0.98–1.97) (34/2,301)	0.9 (0.39–1.40) (12/1,338)	0.131	3.5 (2.75–4.18) (88/2,540)	1.3 (0.90–1.63) (46/3,639)	<0.001
50–59 years	8.5 (7.02–10.04) (112/1,313)	2.7 (1.89–3.53) (41/1,514)	<0.001	3.1 (2.43–3.79) (77/2,476)	0.7 (0.36–1.06) (16/2,257)	<0.001	5.4 (4.58–6.25) (153/2,827)	1.7 (1.37–2.07) (93/5,409)	<0.001
60–69 years	8.7 (6.82–10.55) (76/875)	2.3 (1.36–3.15) (24/1,064)	<0.001	1.7 (1.13–2.32) (32/1,856)	0.7 (0.38–1.05) (17/2,378)	<0.01	5.2 (4.17–6.14) (100/1,939)	1.2 (0.84–1.48) (49/4,234)	<0.001
70–79 years	11.2 (7.19–15.12) (27/242)	4.2 (1.89–6.59) (12/283)	<0.01	2.1 (1.19–2.93) (21/1,019)	1.0 (0.25–1.68) (7/726)	0.072	7.4 (5.19–9.67) (39/525)	1.6 (1.02–2.19) (28/1,745)	<0.001
80+ years	1.5 (−1.43–4.46) (1/66)	1.6 (−1.55–4.83) (1/61)	0.955	2.1 (0.44–3.76) (6/286)	1.4 (−0.18–3.05) (3/209)	0.586	1.6 (0.59–3.74) (2/127)	1.8 (0.64–3.00) (9/495)	0.853

n/N, number of patients/population. P values below 0.05 are in bold.

In Nuuk, the prevalence of patients with asthma aged 12 years or above was 3.3% (540/16,405) compared to 1.1% (330/28,908) in the remaining parts of Greenland. In Nuuk, the prevalence was significantly higher among women aged 20–79 years compared to men (p<0.01). In the remaining parts of Greenland, the prevalence was higher among women aged 20–39 years and 50–69 years compared to men (p<0.01). The prevalence was significantly higher in Nuuk compared to the remaining parts of Greenland for patients aged 20–79 years (p<0.001). The prevalence increased by age from 20 to 59 years among patients in Nuuk and in the remaining parts of Greenland. Among women in Nuuk, the prevalence further increased until the age of 79 years. In Nuuk, the prevalence was highest among patients aged 70–79 years (7.4%), while the highest prevalence in the remaining parts of Greenland was among 80+ years (1.8%).

In 2020, the total prevalence of patients with asthma aged 12 years or above was 0.2% (101/45,410) (data not shown) and in 2021, the prevalence had increased to 1.6% (711/45,698) (data not shown).

Quality of care

Table 3 shows the quality of care for patients with asthma according to gender and place of residence (Nuuk vs. the remaining parts of Greenland). Among patients in Nuuk, no gender-related differences were observed. Among patients in the remaining parts of Greenland, significantly more men had their BMI measured within the last two years (p<0.05) compared to women.

Table 3. Quality of care (%) among women and men in Nuuk vs. from the remaining parts of Greenland.

	Nuuk			The remaining parts of Greenland			Nuuk	The remaining parts of Greenland
	Women	Men		Women	Men		Total	Total
	(95% CI) (n/N)	(95% CI) (n/N)	p	(95% CI) (n/N)	(95% CI) (n/N)	p	(95% CI) (n/N)	(95% CI) (n/N)	p
Process indicators within the previous two years, % (n/N)
- Patients in whom smoking status was assessed - Patients in whom spirometry was performed	84.4 (80.79–88.04) (325/385) 82.6 (78.81–86.38) (318/385)	78.7 (72.27–85.15) (122/155) 80.7 (74.43–86.86) (125/155)	0.112 0.593	63.3 (57.07–69.43) (148/234) 59.4 (53.11–65.69) (139/234)	58.3 (48.47–68.20) (56/96) 60.4 (50.63–70.20) (58/96)	0.404 0.864	82.8 (79.59–85.96) (447/540) 82.0 (78.80–85.27) (443/540)	61.8 (56.58–67.06) (204/330) 59.7 (54.40–64.99) (197/330)	<0.001 <0.001
- Patients in whom BMI was measured	89.4 (86.27–92.43) (344/385)	87.1 (81.82–92.37) (135/155)	0.454	47.0 (40.61–53.40) (110/234)	69.8 (60.61–78.98) (67/96)	0.027	88.7 (86.03–91.37) (479/540)	75.8 (71.13–80.38) (250/330)	<0.001
Proximal outcome indicator within the previous two years, % (n/N)
- Patients who were current smokers	40.6 (35.28–45.95) (132/325)	31.2 (22.93–39.37) (38/122)	0.066	45.3 (37.25–53.29) (67/148)	37.5 (24.82–50.18) (21/56)	0.317	38.0 (33.53–42.53) (170/447)	43.1 (36.34–49.93) (88/204)	0.217

n/N, number of patients/population. P values below 0.05 are in bold.

Significantly more patients in Nuuk had their smoking status assessed (82.8% vs. 61.8%), had a spirometry performed (82.0% vs. 59.7%) and had their BMI measured (88.7% vs. 75.8%) within the last two years (p<0.001), compared to the remaining parts of Greenland. In Nuuk, 38% of the patients were daily smokers compared to 43.1% daily smokers in the remaining parts of Greenland.

Discussion

The total prevalence of patients aged 12 years or above with asthma in Greenland in 2022 was 1.9%. When looking at the capital Nuuk separately, the prevalence of asthma was 3.3%, while the remaining parts of Greenland had an asthma prevalence of 1.1%. The quality of care was significantly improved among patients living in Nuuk than among patients living in the remaining parts of Greenland.

Prevalence

We found a total prevalence of diagnosed asthma of 1.9%. In Nuuk, the prevalence was much higher than in the remaining parts of Greenland. This might be explained by a major focus in Nuuk on adding medical diagnosis codes to all contacts in the healthcare system. It is well known that fewer people receive medical diagnostic codes in Nuuk compared with the remaining parts of Greenland since it has been mandatory to use diagnostic codes in Nuuk since 2020 [17]. Furthermore, the low prevalence in the remaining parts of Greenland suggests an underestimation of asthma prevalence among the population outside Nuuk.

In total, we found 870 patients with diagnosed asthma, which is significantly more than the 102 diagnosed patients with asthma found at the end of 2019 [12]. The very rapid increase seen in the aftermath of a diagnostic intervention also suggests that a proportion of the population has undiagnosed asthma, as not all patients receiving lung medication have been examined yet. On this basis, we believe that the actual prevalence is higher than the prevalence of 1.9% reported in our study, and lower than the 7.5% receiving lung medication reported earlier [12]. The latter proportion, however, includes both asthmatic patients, but also patients treated for other lung diseases than asthma, such as COPD, while others might be treated for respiratory symptoms such as shortness of breath symptoms, triggered by other causes than asthma. This could be obesity, which is very common in Greenland and is seen in more than one-third of all adult women [18]. Only 26.0% of the patients treated with lung medication had had a spirometry performed within the last two years, which is a part of the screening procedure for asthma [12]. Symptoms from the respiratory airways are frequent in a population with a large prevalence of obesity and many smokers, so the respiratory symptoms can also be explained by other conditions than asthma.

We believe that the prevalence of 3.3% in Nuuk is most representative for Greenland, because the diagnostic activity outside Nuuk is sparse. A prevalence of 3.3% is still much lower than the prevalence reported in the questionnaire from 2004 (9% in towns and 6% in smaller settlements) [9] and among Inuit in Canada which also was based on a questionnaire [11].

The observed low prevalence among children compared with adults may result from an increased focus on detecting COPD among people aged 40 years or older. Especially among children and adolescents, we expect many to be undiagnosed. Summarising, the low asthma prevalence may lead to suspicion of underdiagnosing of the disease as known in other populations [19] and missing diagnosis coding in the remaining parts of Greenland.

The increase in prevalence by age from 20 to 59 years is in line with data from the 2018 Global Health Data Exchange, showing an increase in prevalence from 20 to 70 years [20]. In our study, the increase was most intensely illustrated among women in Nuuk, where the prevalence increased by age from 20 to 79 years.

Since 2020, the total prevalence of patients diagnosed with asthma aged 12 years or above has increased from 0.2% in 2020 to 1.6% in 2021 to 1.9% in 2022. This increase is presumably not explained by more people having developed asthma in Greenland over the past two years but is rather attributable to a stronger focus on diagnosing the disease.

In the present study, more women than men were diagnosed with asthma. This is in line with other studies showing that adult women are diagnosed with asthma more often than men [8,20] and that women have a higher likelihood of developing asthma and a more severe form of asthma than men [21]. Further contributing to a higher prevalence among women is that women more frequently are in contact with the health care system than men [22]. Furthermore, more women than men are obese in Greenland [18] and obese subjects are at a higher risk of developing asthma [5].

To summarise, the prevalence of asthma in Greenland is low compared to reported in other countries and is most likely attributed underdiagnosed, especially outside Nuuk and among adolescents and children. The actual prevalence of asthma in Greenland is most likely higher than 3.3% based on the fact that not everyone is diagnosed yet, especially among adolescents and children who are not actively tracked yet. We expect the prevalence to be below 7.5% based on the use of medication [12].

Quality of care

We evaluated the quality of care by estimating the registration rates of different process indicators and one proximal outcome indicator.

Men had lower FEV1/FVC than women, which is consistent with findings from a recent Greenlandic study [12]. Another Greenlandic study from 2016 also found a significantly higher proportion of men to have a FEV1/FVC below 70% [23].

The registration rate of all process indicators was highest for patients in Nuuk, where significantly more patients had their smoking status assessed, had a spirometry performed, and had their BMI measured within the past two years. This may be explained by a greater focus at registering and diagnosis coding in the EMR in Nuuk than in the remaining parts of Greenland.

The study population in Nuuk and in the remaining parts of Greenland had a BMI of 30 kg/m² and 31 kg/m², respectively, categorising them as obese. Obesity is often reported as a comorbidity of asthma and is associated with more frequent exacerbations and with poorer asthma control [5,24].

In Nuuk, 38.0% of the patients were daily smokers compared with 43.1% in the remaining parts of Greenland. This indicates that among patients with asthma, fewer are daily smokers than among the general population in Greenland, where more than half of the population smoke on a daily basis [7,18]. However, approximately 40% of current smokers is high for an asthma population, where smoking is known to exacerbate asthmatic symptoms [6,25]. This further underlines the need for an increased focus of management of asthma in Greenland including smoking cessation.

Adding medical diagnosis codes in the EMR and continuous monitoring of quality of care in Greenland has improved quality of care among patients who use antihypertensive medication [26].

Overall, this population could be described as having a high prevalence of daily smokers (39.6%) even though it is lower compared to the general population in Greenland, where more than half of the population smoke on a daily basis [18]. Furthermore, the mean BMI of the population is around 30 and is therefore categorised as obesity, which is associated with asthma [5,24].

Strengths and limitations

A major strength of this study is the use of data from the EMR encompassing data on 95% of the Greenlandic population above 12 years. Since January 2021, it has been mandatory for medical doctors in primary health care in Nuuk to register all contacts in the clinic with an ICPC-2 code in the EMR. This may also explain the relatively large difference in asthma prevalence among patients in Nuuk compared with patients from the remaining parts of Greenland.

A weakness of the study is the fact that only few quality-of-care indicators are included in the study due to limited availability of data such as patient-reported outcomes. The quality of care may be underestimated concerning registration of smoking, spirometry, and BMI performance indicators since these values only are extracted if registered correctly in the lifestyle table in the EMR. If some clinicians have registered spirometry incorrectly (e.g. in text format rather than in the lifestyle table), data on this measurement will not have been extracted and thus not included in this study. Correct registration of both clinical parameters and diagnosis is essential to monitor and evaluate the quality of care at regional and national level, respectively. In Greenland, a high turnover in health care professionals may unfortunately contribute to incorrect registrations because of lack of knowledge concerning guidelines and low quality on other parameters.

It is a limitation that childhood asthma is not included, as there has not been a focus on diagnosing this group yet. Furthermore, no clinical guidance in this area is available in the health care system in Greenland. At this time, we do not have sufficient data to include children under 12 years of age. Once we have sufficient data, we will follow up on this prevalence.

Conclusions

In conclusion, the prevalence of patients aged 12 years or above with asthma in 2022 was 1.9%. The prevalence was higher among patients in the capital Nuuk compared with the remaining parts of Greenland. More women than men were diagnosed with asthma, and the prevalence increased by age from 20 to 59 years. The associated quality of care did not meet all criteria from national guidelines. Initiatives supporting increased focus on registration of patients with asthma are thus warranted. Based on the above, we recommend the implementation of a new asthma strategy in Greenland, including a continuous focus on monitoring prevalence and quality of care, including international acceptable key performance indicators, an implementation of national asthma management guidelines combined with a focus on diagnosing and adding diagnosis codes in the EMR.

Authors contributions

MBB and MLP conceived the study idea. MHN cleaned and analysed the data. MHN drafted the first version of the manuscript. MHN, MBB and MLP reviewed and approved the final draft of the manuscript.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

Steno Diabetes Center Greenland is partly funded by the Novo Nordisk Foundation (NNF20SA0064190).