Assessing Physician Agreement in Biologic Therapy Initiation and Selection in Patients with Severe Asthma

Considerable variability exists in the management of severe asthma, particularly with the increasing availability of biologic therapies targeting different inflammatory pathways. This study aimed to assess intra- and inter-person variability among experienced specialists in the initiation and selection of biologic treatment for severe asthma.

Four asthma specialists, each with more than 10 years of experience prescribing biologic therapies, independently evaluated 50 hypothetical clinical cases of severe asthma. For each case, clinicians determined whether to initiate biologic therapy and, if so, selected the mechanism of action and specific biologic agent. After one month, all cases were re-evaluated to assess intra-person consistency. Agreement was quantified using kappa (κ) statistics.

Intra-person agreement for the decision to initiate biologic therapy was almost perfect (κ = 0.825), while agreement for selecting the mechanism of action and specific biologic agent was moderate to substantial (κ = 0.597 and κ = 0.582, respectively). Inter-person agreement was moderate for initiating biologic therapy (κ = 0.515) but only fair for selecting the mechanism of action (κ = 0.238) and the specific biologic agent (κ = 0.230).

Despite high internal consistency among individual clinicians, substantial variability exists between experts in the selection of biologic therapies for severe asthma. These findings underscore the need for comparative, head-to-head clinical trials to better guide biologic selection in patients eligible for multiple therapies.