Patient, practice and organisational influences on asthma control: observational data from a national study on primary care in the United Kingdom

Temporal and geographical variation in low carbon inhaler dispensing in England, 2016 to 2021: an ecological study

OBJECTIVES

In 2019-2020, four national recommendations were published in the United Kingdom to encourage use of low carbon inhalers. This study aimed to investigate whether these were associated with a change in primary care dispensing in England and to explore associations between geographical variation and clinical commissioning group (CCG) characteristics.

DESIGN

Ecological study using aggregated publicly available data.

SETTING

All CCGs in England (March 2016 to February 2021).

PARTICIPANTS

not applicable.

MAIN OUTCOME MEASURES

Percentage of low carbon inhalers dispensed.

RESULTS

The percentage of low carbon inhalers dispensed was 26.3% in 2020-2021 (of 8.8 million inhalers). This decreased over the study period for short-acting beta-agonist (SABA), inhaled corticosteroid (ICS) and ICS+long-acting beta-agonist (LABA) inhalers. The same trend was seen for LABA and ICS+LABA+long-acting muscarinic antagonist inhalers from 2019. The SABA and ICS classes were less often dispensed as low carbon inhalers (⁓6% versus 35-45%). Interrupted time series analyses found slight increases in low carbon inhaler percentage in the SABA, LABA and ICS classes after April 2019, which were soon erased by the long-term trend. There was also geographical variation, with the north-west, Birmingham and London consistently dispensing more low carbon inhalers. The presence of advice on climate change in CCG formularies/guidelines, the prevalence of asthma and population age profile were associated with significant variation in low carbon inhaler percentage for some classes.

CONCLUSIONS

The percentage of low carbon inhalers dispensed in England remains low and continues to decrease. Greater use of low carbon inhalers is achievable, but is more likely with locally implemented initiatives.

Identifying Critical Errors: Addressing Inhaler Technique in the Context of Asthma Management

Medication use has always played a highly significant role in the overall management of asthma, with appropriate use being linked to good asthma control. However, while patients with asthma enjoy the 'luxury' of having medications delivered directly to the lungs via inhaler devices, with that comes the additional challenge of ensuring that inhaler devices are used correctly. Research and practice provides evidence to the challenges associated with inhaler use and the particular steps that patients perform incorrectly. While this problem is well documented, acknowledged and reported, little has changed in 40 years, and the proportion of patients using inhaler devices remains unacceptably high. This review focuses on aspects specific to the errors that patient's make, the significance of these errors, and the important considerations for health care practitioners in supporting patients in correctly using their inhalers. This review highlights the complexities associated with patient's making inhaler technique errors and highlights the opportunities that lie in future technological developments of inhaler devices. Now more than ever, in the era of precision medicine, it is important that we address inhaler technique use once and for all.

Positioning the principles of precision medicine in care pathways for allergic rhinitis and chronic rhinosinusitis - A EUFOREA-ARIA-EPOS-AIRWAYS ICP statement

Precision medicine (PM) is increasingly recognized as the way forward for optimizing patient care. Introduced in the field of oncology, it is now considered of major interest in other medical domains like allergy and chronic airway diseases, which face an urgent need to improve the level of disease control, enhance patient satisfaction and increase effectiveness of preventive interventions. The combination of personalized care, prediction of treatment success, prevention of disease and patient participation in the elaboration of the treatment plan is expected to substantially improve the therapeutic approach for individuals suffering from chronic disabling conditions. Given the emerging data on the impact of patient stratification on treatment outcomes, European and American regulatory bodies support the principles of PM and its potential advantage over current treatment strategies. The aim of the current document was to propose a consensus on the position and gradual implementation of the principles of PM within existing adult treatment algorithms for allergic rhinitis (AR) and chronic rhinosinusitis (CRS). At the time of diagnosis, prediction of success of the initiated treatment and patient participation in the decision of the treatment plan can be implemented. The second-level approach ideally involves strategies to prevent progression of disease, in addition to prediction of success of therapy, and patient participation in the long-term therapeutic strategy. Endotype-driven treatment is part of a personalized approach and should be positioned at the tertiary level of care, given the efforts needed for its implementation and the high cost of molecular diagnosis and biological treatment.

Limited treatment adaptation despite poor asthma control in asthma patients treated with inhaled corticosteroids

OBJECTIVE

Current asthma guidelines recommend use of inhaled corticosteroids (ICS) in patients with persistent disease. This study was designed to investigate (1) the proportion of patients prescribed ICS-containing maintenance treatment who achieve asthma control, (2) determinants of control and (3) how physicians adapt treatment to the level of control.

METHODS

General practitioners (GPs) and chest physicians (CPs) in France recruited patients consulting for asthma and prescribed an ICS. Over a 2-year follow-up period, asthma symptoms in the previous 3 months and treatments prescribed were documented at each visit. Variables independently associated with asthma control were determined by multiple logistic regression.

RESULTS

Data were available for 924 patients recruited by GPs and 455 recruited by CPs. Asthma control was acceptable in only 24% of patients at inclusion, and in 33.6% at the last follow-up visit. Five factors were independently associated with asthma control: age (or time since diagnosis), gender, smoking status, allergic aetiology of asthma and treatment. Most patients (56.3%) were prescribed the same ICS dose regimen at the end of follow-up as at inclusion. The intensity of controller therapy had been increased in only 12.2% of patients unacceptably controlled at inclusion.

CONCLUSIONS

Asthma was unacceptably controlled in most patients receiving ICS-containing maintenance treatment and remained so during follow-up. Despite this, treatment adaptations by GPs and CPs were very infrequent. This unsatisfactory situation may be improved by adopting a more dynamic approach to tailoring controller therapy to the needs of the patient.

An exploration of how nurse prescribing is being used for patients with respiratory conditions across the east of England

BACKGROUND

There is a need to reduce symptoms, exacerbations and improve quality of life for patients with respiratory diseases. Across the world, increasing numbers of nurses are adopting the prescribing role and can potentially enhance service provision. Evidence suggests improved quality of care and efficiencies occur when nurses adopt the prescribing role. No evidence is available on the views of nurse prescribers who care for respiratory patients. The aim was to explore how nurse prescribing is being used for patients with respiratory conditions in different care settings across one strategic health authority, and whether this has benefited patients, healthcare professionals and the National Health Service.

METHODS

A qualitative study involving semi-structured interviews with a purposive sample of 40 nurses who prescribed for respiratory patients across the six counties in the East of England Strategic Health Authority. Data were collected in 2011 and subject to thematic analysis.

RESULTS

Disease management, including treatment and prevention of exacerbations, emergency episodes and minor illness, optimising and co-ordinating care were key aspects of care provided. Findings are reported under three themes: access, adherence and risk management and impact on nurses. Prescribing enabled nurses overcome existing problems in service provision to improve access, efficiency and patient convenience, reducing hospital admissions and length of stay. It also enabled patient centered consultations, which encouraged self-management, improved adherence, helped manage expectations, and reduced inappropriate service use. While participants experienced increased job satisfaction, knowledge and confidence, concerns were raised about increased responsibility, support, governance and future commissioning of services in line with planned major changes to the National Health Service.

CONCLUSIONS

This study provides new knowledge about how nurse prescribers provide care to patients with respiratory diseases. Despite a lack of consensus over the most effective model of respiratory care, prescribing was reported to have improved and extended points of access to treatment, and supported management of complex patients, particularly vulnerable groups. Given the high burden of chronic respiratory disease to patients and families this has important implications that need to be considered by those responsible for commissioning services in the United Kingdom and other countries.

Metrics of salbutamol use as predictors of future adverse outcomes in asthma

BACKGROUND

Beta-agonist overuse is associated with adverse outcomes in asthma, however, the relationships between different metrics of salbutamol use and future risk are uncertain.

OBJECTIVE

To investigate the relationship between metrics of salbutamol use and adverse outcome.

METHODS

In a 24-week randomized controlled trial of 303 asthma patients at risk of severe exacerbations which compared the efficacy and safety of combination budesonide/formoterol inhaler according to a single inhaler regimen (SMART) with a fixed-dose regimen with salbutamol as reliever ('Standard'), actual medication use was measured by electronic monitoring (Australian New Zealand Clinical Trials Registry Number ACTRN12610000515099). A nested cohort study explored the relationship between metrics of baseline salbutamol use over 2 weeks and future severe asthma exacerbations, poor asthma control (ACQ-5 ≥ 1.5) or 'extreme' salbutamol overuse (> 32 salbutamol actuations/24-h period).

RESULTS

Higher mean daily salbutamol use (per two actuations/day) [Odds ratio (OR) (95% CI) 1.24 (1.06-1.46)], higher days of salbutamol use (per 2 days in 2 weeks) [OR 1.15 (1.00-1.31)] and higher maximal 24-h use (per two actuations/day) [OR 1.09 (1.02-1.16)] were associated with future severe exacerbations. Higher mean daily salbutamol use was associated with future poor asthma control [OR 1.13 (1.02-1.26)]. Higher mean daily salbutamol use [OR 2.73 (1.84-4.07)], number of days of use [OR 1.46 (1.24-1.71)], and maximal daily use [OR 1.57 (1.31-1.89)] were associated with an increased risk of future extreme salbutamol overuse.

CONCLUSION AND CLINICAL RELEVANCE

Electronically recorded frequency of current salbutamol use is a strong predictor of risk of future adverse outcomes in asthma, with average daily use performing the best. These findings provide new information for clinicians considering metrics of salbutamol as predictors of future adverse outcomes in asthma.

Uncontrolled allergic rhinitis and chronic rhinosinusitis: where do we stand today?

State-of-the-art documents like ARIA and EPOS provide clinicians with evidence-based treatment algorithms for allergic rhinitis (AR) and chronic rhinosinusitis (CRS), respectively. The currently available medications can alleviate symptoms associated with AR and RS. In real life, a significant percentage of patients with AR and CRS continue to experience bothersome symptoms despite adequate treatment. This group with so-called severe chronic upper airway disease (SCUAD) represents a therapeutic challenge. The concept of control of disease has only recently been introduced in the field of AR and CRS. In case of poor control of symptoms despite guideline-directed pharmacotherapy, one needs to consider the presence of SCUAD but also treatment-related, diagnosis-related and/or patient-related factors. Treatment-related issues of uncontrolled upper airway disease are linked with the correct choice of treatment and route of administration, symptom-oriented treatment and the evaluation of the need for immunotherapy in allergic patients. The diagnosis of AR and CRS should be reconsidered in case of uncontrolled disease, excluding concomitant anatomic nasal deformities, global airway dysfunction and systemic diseases. Patient-related issues responsible for the lack of control in chronic upper airway inflammation are often but not always linked with adherence to the prescribed medication and education. This review is an initiative taken by the ENT section of the EAACI in conjunction with ARIA and EPOS experts who felt the need to provide a comprehensive overview of the current state of the art of control in upper airway inflammation and stressing the unmet needs in this domain.