National audit of acute severe asthma in adults admitted to hospital. Standards of Care Committee, British Thoracic Society

GEMA 5.3. Spanish Guideline on the Management of Asthma

The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).

Generalist vs specialist acute medical admissions - What is the impact of moving towards acute medical subspecialty admissions on efficacy of care provision?

INTRODUCTION

The discussion surrounding generalist versus specialist acute medical admissions continues to stimulate debate and patients with certain conditions benefit from specialist care.

AIM

To determine whether a specialty medical admission program would reduce inpatient length of stay (LOS), mortality and readmission rates.

DESIGN/METHODS

A prospective cohort study of inpatients admitted under a general internal medicine (GIM) service before and after introduction of a specialty-directing programme. We hypothesized that early transfer of patient care to a specialty suited to their presenting complaint would reduce LOS and a specialty-directing early redistribution of care programme was introduced. Seven of the ten clinical teams participating in the GIM roster adopted the programme. On the morning following a specialty-directing team being on call for all new GIM admissions during a 24-hour period, specialty-directing teams were allocated one patient appropriate to their specialty.

RESULTS

5,144 patient-care episodes were analysed over the two-year study period. LOS increased by greater than 15%, one year after introducing the specialty-directing programme (8.5±8.4 vs 7.3±7.5 days, p < 0.001). LOS did not differ between teams that participated and those who did not (8.4±8.1 vs 8.1±7.9 days, p = 0.298). No differences were found in the proportion of patients who were discharged home, died while an inpatient or re-admitted within 30 days of discharge. The proportion of patients aged greater than 80 years increased significantly also - from 24.7% in 2017 to 27.9% in 2019(p == 0.009).

CONCLUSION

Widespread adoption of specialist care may not be beneficial for all medical inpatients and physicians should continue to undergo dual specialist and GIM training.

Impact of Blood Eosinophil Variability in Asthma: A Real-Life Population Study

RATIONALE

Blood eosinophil count predicts response to inhaled corticosteroids and specific biologic therapies in selected asthma patients. Despite this important role, fundamental aspects of eosinophil behavior in asthma have not been studied. Objectives To investigate the behavior of blood eosinophils in a population comparing their distribution with the general population and studying their intra-individual variability over time in relation to hospital episodes (emergency department visits and hospitalizations) in clinical practice.

METHODS

The distribution and variability of 35,703 eosinophil determinations in 10,059 stable asthma patients were investigated in the Majorca Real-Life Investigation in COPD and Asthma cohort (MAJORICA). Eosinophil distribution in the asthma population was compared with a control sample from the general population of 8,557 individuals. Eosinophil variability and hospital episodes were analyzed using correlations, ROC curves and multiple regression analysis. We defined the Eosinophil Variability Index (EVI) as (Eosmax-Eosmin/Eosmax) x 100%. The findings of the asthma population were re-tested in an external well-characterized asthma cohort.

RESULTS

The eosinophil count values and variability were higher in the asthma population than in the general population (p-value<0.001). Variability data showed a better association with hospital episodes than the counting values. An EVI≥50% was more strongly associated with hospital episodes than any of the absolute counting values. These results were validated in the external cohort.

CONCLUSION

The eosinophil variability in asthma patients better identifies the risk of any hospital episode than the absolute counting values currently used to target specific treatments.

Schistosoma mansoni Tegument (Smteg) Induces IL-10 and Modulates Experimental Airway Inflammation

BACKGROUND

Previous studies have demonstrated that S. mansoni infection and inoculation of the parasite eggs and antigens are able to modulate airways inflammation induced by OVA in mice. This modulation was associated to an enhanced production of interleukin-10 and to an increased number of regulatory T cells. The S. mansoni schistosomulum is the first stage to come into contact with the host immune system and its tegument represents the host-parasite interface. The schistosomula tegument (Smteg) has never been studied in the context of modulation of inflammatory disorders, although immune evasion mechanisms take place in this phase of infection to guarantee the persistence of the parasite in the host.

METHODOLOGY AND PRINCIPAL FINDINGS

The aim of this study was to evaluate the Smteg ability to modulate inflammation in an experimental airway inflammation model induced by OVA and to characterize the immune factors involved in this modulation. To achieve the objective, BALB/c mice were sensitized with ovalbumin (OVA) and then challenged with OVA aerosol after Smteg intraperitoneal inoculation. Protein extravasation and inflammatory cells were assessed in bronchoalveolar lavage and IgE levels were measured in serum. Additionally, lungs were excised for histopathological analyses, cytokine measurement and characterization of the cell populations. Inoculation with Smteg led to a reduction in the protein levels in bronchoalveolar lavage (BAL) and eosinophils in both BAL and lung tissue. In the lung tissue there was a reduction in inflammatory cells and collagen deposition as well as in IL-5, IL-13, IL-25 and CCL11 levels. Additionally, a decrease in specific anti-OVA IgE levels was observed. The reduction observed in these inflammatory parameters was associated with increased levels of IL-10 in lung tissues. Furthermore, Smteg/asthma mice showed high percentage of CD11b+F4/80+IL-10+ and CD11c+CD11b+IL-10+ cells in lungs.

CONCLUSION

Taken together, these findings demonstrate that S. mansoni schistosomula tegument can modulates experimental airway inflammation.

Diagnosis of MS: a comparison of three different clinical settings

In order to compare a newly established diagnostic clinic with two existing clinical settings in the management of the diagnostic phase of multiple sclerosis (MS), a retrospective audit was performed over a 12-month period comparing the length of time, adherence to recently published standards and price charged in diagnosing MS in three different clinical diagnostic settings operating within the same hospital: a specifically designed demyelinating disease diagnostic clinic (DDC), a general neurology clinic (GNC) and an inpatient investigation unit (IIU). A n audit tool was created to measure the standards advocated by the UK MS Society on management of the diagnostic phase of MS. The costing tool was the price charged to health authorities. A randomized retrospective case note and referral letter review method was used. The entry criterion was a confirmed diagnosis of MS documented in the medical notes following investigation during the period A pril 1999-A pril 2001. The time between referral and first appointment favoured the DDC with a mean time of 5.9 weeks, compared to 7.7 weeks for the G NC and 10.0 weeks for the IIU. The mean times between the first appointment and receipt of results were 4.7 weeks (DDC), 18.8 weeks (GNC) and 21.2 weeks (IIU). Prices ranged from £395-£790 (DDC), £95-£380 (GNC) and £1940-£2700 (IIU). This study suggests that the UK MS Society standards are achievable in most areas without excessive additional costs and provides evidence that the DDC offers a better service than other existing models.

Clinical audit: management of acute severe asthma in west Glasgow

BACKGROUND

The U.K. has 75,000 hospital admissions and over 1500 deaths from asthma annually. The British Thoracic Society (BTS) guidelines represent the recognised standard for acute asthma management. We assessed the degree of conformity with these guidelines in an acute medical unit.

METHODOLOGY

Data from consecutive admissions were collected prospectively. Practice was audited in October December 2005 and October 2006 - January 2007. Between cycles an educational programme was instigated,

RESULTS

Fifty-eight patients were included. Clinical parameters were well recorded in both cycles. Peak expiratory flow was consistently under-recorded (72% at admission; 67% in monitoring). in monitoring). Severity assessment was documented at 55% and 66% in cycle one and two respectively. Of these, the assessment was incorrect in 33% in cycle one and 21% in cycle two. All misclassifications of severity were underestimates. All life-threatening attacks were not identified. No improvement occurred between cycles. Overall, 60% of patients were inappropriately treated according to BTS guidelines, 40% due to under-treatment. Under-treatment occurred more frequently in cycle two compared with cycle one (57% vs. 24%, p = 0.007), predominantly due to inadequate treatment of life-threatening asthma.

CONCLUSION

Management of acute asthma in a large, urban teaching hospital is suboptimal. Educational intervention failed to improve care; more comprehensive strategies are required.

Asthma exacerbations. 5: assessment and management of severe asthma in adults in hospital

It is difficult to understand why there is such a huge discrepancy between the management of severe asthma recommended by evidence-based guidelines and that observed in clinical practice. The recommendations are relatively straightforward and have been widely promoted both in guidelines and reviews. Specialist physicians need to be more proactive in their implementation of such guidelines through the use of locally derived protocols and assessment sheets, reinforced by audit. The common occurrence of severe asthma and its considerable burden to the community would support such an approach.

Outcome evaluation of early discharge after hospitalization for asthma

PURPOSE OF REVIEW

This review is designed to assess the evidence around the criteria used to decide when it is appropriate for an individual with asthma to be discharged from hospital.

RECENT FINDINGS

There has been scanty recent published research on this subject, and no strong evidence-based discharge guidelines exist. The limited data available suggest that clinical outcome in children is similar when the timing of discharge is the need for 3-hourly rather than 4 hourly bronchodilator. In children, the adoption of this policy would shorten the average length of hospital stay by 5-6 h.

SUMMARY

The available data for adults with acute asthma on the appropriate end points for discharge from hospital are inadequate to provide firm conclusions. Children with acute asthma should be considered ready for discharge when clinically stable on 3-hourly bronchodilator.

Management of acute asthma exacerbations by general practitioners: a cross-sectional observational survey

BACKGROUND

General practitioners (GPs) have a central place in the management of asthma, particularly in the context of acute exacerbations.

AIM

To evaluate the management of asthma exacerbations by GPs, and to investigate the ability of risk factors for near fatal asthma to predict the severity of asthma attacks in the community.

DESIGN OF STUDY

A 1-month multicentre cross-sectional survey.

SETTING

One thousand and ninety-four GPs of the French Sentinel Network were contacted; 365 responded.

METHOD

Asthma exacerbations were classified according to severity at presentation. Univariate and multivariate analyses were performed by logistic regression to identify those factors associated with severe exacerbations.

RESULTS

Exacerbations were described in 219 patients with asthma. Over half (54%) of exacerbations were severe. Peak expiratory flow was recorded during the consultation in 55% of patients who were more than 5 years old. beta(2) agonists were prescribed to 93% of patients, systemic corticosteroids to 71%, and antibiotics to 64%. Only 42% of patients had a written action plan for self-management of exacerbations. Risk factors for near fatal asthma, identified in 26% of patients, were not significantly associated with severe asthma exacerbations. Short duration of exacerbation before consultation (<3 hours) was associated with an increase in relative risk of severe exacerbation of 3.38, 95% confidence intervals (CIs) = 1.19 to 9.61, compared with duration of >3 hours.

CONCLUSION

Risk factors for near fatal asthma identified in previous studies were not predictive of a severe exacerbation in general practice, with the exception of short duration of exacerbation before consultation. This suggests that new methods to predict risk in the outpatient settings should be developed.

Accident and emergency departments are still failing to assess asthma severity

OBJECTIVES

To quantify the documentation of vital signs in children attending accident and emergency (A&E) for asthma and to assess whether indicators of severity were used appropriately.

METHODS

Records of all children aged 3 to 14 attending A&E for the treatment of asthma in four London hospitals over a three month period were examined for documentation of heart rate, respiratory rate, peak expiratory flow rate, oxygen saturation, and fraction of inspired oxygen. The relation between severity indicators and whether the child was admitted or not was examined.

RESULTS

There were 255 attendances in 229 children. Heart rate, respiratory rate, and oxygen saturation were recorded on most attendances (94.5%, 85.5%, and 96.8%) but fraction of inspired oxygen and peak flow were recorded in few children (48.6% and 48.5%). Heart rate and respiratory rate were higher and oxygen saturation lower in children who were admitted compared with those who were not.

CONCLUSIONS

Assessment of airways obstruction is inadequate in children but when measured may be used appropriately to guide admission. There is a need for interventions to improve assessment of children attending A&E for asthma.

Spontaneous pneumothorax: use of aspiration and outcomes of management by respiratory and general physicians

BACKGROUND

Spontaneous pneumothorax is a common problem in hospital practice. Despite the publication of guidelines controversy over its initial management still exists, particularly over the use of simple aspiration.

METHODS

The management of spontaneous pneumothorax by respiratory and general physicians at our hospital was analysed by retrospective case note review. Eighty five patients were identified over the study period (36 managed by respiratory and 49 by general physicians).

RESULTS

There was a significantly greater use of simple aspiration by respiratory (81%) than general physicians (47%, p<0.001) and a higher rate of success in this group. As a result those patients managed by respiratory physicians had fewer intercostal drains inserted and significantly shorter length of stays (mean 5.6 (3.8) days respiratory group and 9.5 (6.8) days in general physicians group, p<0.05).

CONCLUSIONS

The greater and more successful use of simple aspiration by respiratory physicians as an initial treatment for spontaneous pneumothorax resulted in improved outcomes and reduced length of hospital stays.

Inhaler devices for asthma: do we follow the guidelines?

BACKGROUND

Despite national guidelines for asthma treatment, many children have troublesome symptoms.

AIM

To assess the extent to which the use of inappropriate inhaler devices contributes to this problem.

METHODS

Of 14 813 questionnaires distributed to schoolchildren, 6996 (47%) were returned identifying 1444 children using asthma inhalers. Inhalers were categorised as age appropriate or inappropriate according to national guidelines and were compared with those used by 75 patients attending a hospital clinic.

RESULTS

A total of 35% of "schools" and 4% of "clinic" children reported using an inappropriate inhaler device. Most were using metered dose inhalers alone. Twenty four per cent of "schools" children < or = 5 years old did not use a spacer. Both children and parents overestimated the child's ability to use their inhaler.

CONCLUSIONS

Large numbers of children are given inhalers they cannot use. To improve asthma care we must ensure that prescriptions reflect the age and ability of the child. Recent recommendations by the Department of Health in England and Wales stress the importance of seamless care between primary and secondary services. As the management of childhood asthma is guided primarily by secondary care providers, it is therefore imperative that general paediatricians know the difficulties and issues which are occurring in the community. This will enable them to lead and support necessary change.

The management of asthma: a case-scenario-based survey of family physicians and pulmonary specialists

This study assessed family physicians' and pulmonary specialists' approaches to the treatment of adult outpatient asthma using a self-administered questionnaire consisting of six asthma scenarios of varying severity levels. One hundred sixty-three randomly selected family physicians and pulmonary specialists completed the questionnaire (response rate of 80%). We observed that, regardless of asthma severity, more than 75% of physicians (regardless of specialty) would not include oral theophylline or nonsteroidal anti-inflammatory preparations in their treatment approach. Pulmonary specialists' and family physicians' approaches to mild asthma were similar (more than 90% recommended an inhaled beta2-agonist). However, considerable differences existed among and between physician groups for the remaining scenarios. For example, with an exacerbation associated with an upper respiratory tract infection, family physicians were more likely to recommend oral antibiotics (p<0.0001) and a same-day outpatient visit (p<0.0001), whereas specialists were more likely to increase the inhaled corticosteroid dosage (p<0.0001). Overall, disagreement was observed almost twice as often among family physicians than among specialists. Our results suggest that physicians vary markedly in their reported use of most interventions available to treat asthma, even when the disease severity is specified.

How can the implementation of guidelines be improved?

Guidelines for a variety of diseases have now been produced. However, implementation of guidelines requires that the medical profession is willing to conform to patterns of diagnostic and treatment behavior set down by others. This may not happen in practice. Early experience in the United Kingdom was gained with the introduction of guidelines for the management of asthma. For a number of years, there have been improvements in practice, but deficiencies still exist. When the introduction of guidelines for the management of COPD was planned, a new approach was taken with a consortium of the British Thoracic Society, pharmaceutical companies, and medical equipment companies being formed to promote their use. Early studies show that COPD care starts from an even lower baseline than asthma; there is poor understanding of objective diagnosis of COPD in both primary and secondary care.

Risk factors and costs associated with an asthma attack

BACKGROUND

A study was undertaken to identify asthma patients at risk of an attack and to assess the economic impact of treatment strategies.

METHODS

A retrospective cohort analysis of a representative data set of 12 203 patients with asthma in the UK over a one year period was performed. Logistic multiple regression was used to model the probability of an attack occurring using a set of categorised predictor factors. Health service costs were calculated by applying published average unit costs to the patient resource data. The main outcome measures were attack incidence, health service resource use, drug treatment, and cost estimates for most aspects of asthma related health care.

RESULTS

Children under five years of age accounted for 597 patients (5%), 3362 (28%) were aged 5-15 years, 4315 (35%) 16-44, 3446 (28%) 45-74, and 483 (4%) were aged over 74 years. A total of 9016 patients (74%) were on some form of prophylactic asthma medication; 2653 (22%) experienced an attack in the year data collection occurred. Overall health care expenditure was estimated at pound2.04 million. The average cost per patient who had an attack was pound381 compared with pound108 for those who did not, an increase of more than 3.5 times. In those aged under five and those over 75 years of age there were no significant markers to identify risk, but both groups were small in size. The level of treatment step in the British Thoracic Society (BTS) asthma guidelines was a statistically significant factor for all other age groups. Night time symptoms were significant in the 5-15, 16-44 and 45-74 age groups, exercise induced symptoms were only significant for the 5-15 age group, and poor inhaler technique in the 16-44 age group.

CONCLUSIONS

Patients at any treatment step of the BTS asthma guidelines are at risk of an asthma attack, the risk increasing as the treatment step increases. Poorly controlled asthma may have a considerable impact on health care costs. Appropriate targeting of preventive measures could therefore reduce overall health care costs and the growing pressures on hospital services associated with asthma management.

Physicians' approaches to providing asthma education to patients and the level of patient involvement in management decisions

The objectives of this study were to describe physicians' self-reported approaches to providing disease-specific education to adults with asthma in an outpatient setting and their opinions about the level of patient involvement in management decisions. A mailed questionnaire was completed by 163 randomly selected physicians, representing an 80% response rate. The educational actions provided most frequently included information about prescribed medications (90%-100% of physicians), general asthma information (87%-98%), and inhaler demonstration (85%-95%). Educational activities provided least frequently were action plans (7%-74%) and referral to a nonprofit community asthma organization for further information (18%-36%). The reported provision of asthma education was related to patients' asthma severity (p < 0.0001) and physician specialty (p < 0.005). Physicians indicated that their patients were less involved in asthma management decisions than they would prefer (p < 0.001). The results suggest that physicians vary markedly in their approaches to providing asthma education to patients. Future descriptive and intervention studies are needed to identify the most effective models for providing education and patient involvement.

Readmission rates are associated with differences in the process of care in acute asthma

OBJECTIVE

To test the hypothesis that sustained differences in readmission rate for acute asthma were associated with variations in clinical practice.

DESIGN

Data were collected by retrospective review of case notes, using the criteria recommended by the British Thoracic Society.

SETTING

Two city National Health Service (NHS) hospitals that had recorded a sustained difference in readmission rate for acute asthma.

SUBJECTS

A random sample of 50 from each hospital, selected from all 16-44 year old patients discharged in 1992 with acute asthma (ninth revision of the international classification of diseases (ICD-9) 493).

RESULTS

Hospital A had a lower readmission rate than hospital B. The sample groups were similar for age, sex, deprivation of area of residence, and severity of episode. Systemic corticosteroids were given early more often (p = 0.02) and oral corticosteroids were prescribed at discharge more often (p = 0.04) in hospital A. When a short course of oral corticosteroids was prescribed the duration stated was longer (p = 0.02) and inhaled corticosteroids were started or the dose increased more often (p = 0.02) in hospital A.

CONCLUSIONS

These results support the hypothesis that differences in readmission rates for acute asthma are associated with variations in clinical practice. Sustained variation in readmission rates is an outcome of health care, for acute asthma. The findings also support audit of the process of hospital asthma care as a proxy for outcome.

Comparison of the process of care of acute severe asthma in adults admitted to hospital before and 1 yr after the publication of national guidelines

This study set out to assess the effect of publication of the British Guidelines on Asthma Management on the processes and outcomes of the inpatient care of acute severe asthma in the U.K. A criterion-based audit of all acute asthma admissions during August and September 1990 (immediately before) and in 1991 (1 yr after publication of the Guidelines) using eight criteria of process and outcome was performed. Thirty-six teaching and district general hospitals in England, Scotland and Wales took part. In total, 766 patients admitted in 1990, and 900 patients admitted in 1991, were studied. The 1990 and 1991 cohorts were very similar demographically and had asthma of comparable severity. Respiratory physicians achieved similar high performance rates of between 75 and 91% for seven of the eight criteria for both years. Respiratory physicians were significantly more likely to provide patients with a written management plan in 1991. General physicians' performance was significantly lower in both years, but overall there was a very small, but just significant, improvement in their performance in 1991. Some hospitals performed consistently well in both years. It is concluded that respiratory physicians consistently provide better asthma care than general physicians. Though statistically significant, the small degree of improvement was disappointing. Possible reasons include: insufficient time for the Guidelines to be incorporated into practice; inaccessibility of the Guidelines to general physicians; failure to accept responsibility for implementing the good practice reflected in the Guidelines; and an explicit need for strategies to implement the Guidelines beyond publication in a widely-read general medical journal.

Definitions of severity and outcome measures

Outcome measurement is still a difficult area in general, and in asthma in particular, with further research needed. (Attributable) outcomes of health care are the only sort of outcome measure which are of direct use as a contracting tool. However, less well-researched and understood outcomes are useful as quality improvement tools, and within more open-ended discussions involving purchasers and providers. In terms of hospital care of acute asthma, there is no well-defined outcome measure which reflects the quality of hospital care; re-admission rates show promise as an outcome measure which relate to the quality of discharge planning and merit further study. In terms of ambulatory care, there is an urgent need to develop and evaluate a symptom-based outcome measure which would be usable in routine practice and could be recommended for widespread use. As a physiological outcome measure, percentage of best function is one which corrects for the degree of irreversible air flow obstruction and is independent of treatment step. It is valuable for individual patients by providing a realistic gold standard and if best function is assessed in a standard manner, it also allows results of groups of patients to be compared in a meaningful manner. Severity scores, which might allow categorization of patients on the basis of characteristics other than current symptoms or therapy, are currently being evaluated.

Organisation of asthma care: what difference does it make? A systematic review of the literature

OBJECTIVES

To evaluate the effectiveness of different forms of organisation (delivery) of asthma care.

METHODS

A systematic review of the published evidence of effectiveness organisational methods of asthma management. Searches on computerised databases including Medline, CINAHL, and HELMIS, and relevant citations and letters to experts were used to identify relevant studies.

RESULTS

27 studies were identified that evaluated different organisational methods of delivery across both primary and secondary sectors, such as shared care, general practice asthma clinics, outpatient programmes, inpatient admissions policies, and the use of specialists. Only one third of the studies used a randomised controlled trial and many had small sample sizes. No conclusive evidence was found to favour any particular organisational form, although limited evidence would suggest that specialist care is better than general care and that shared care can be as effective as hospital led care.

CONCLUSIONS

There is little good published research evaluating different ways of organising the delivery of asthma care. There is need for quality research on organisational methods of delivery of asthma care that could be used to inform policy makers, in particular examining whether patients treated by healthcare professional with expertise and interest in asthma will experience better outcomes.