Systematic meta-review of supported self-management for asthma: a healthcare perspective

Optimizing adherence to medication to improve outcomes in asthma

PURPOSE OF REVIEW

Adherence to medication is essential for asthma control and reducing the risk of exacerbations. Research has accumulated in recent years on causes and consequences of adherence and effective interventions. This review highlights current advances in adherence research and their potential for clinical practice.

FINDINGS

Optimizing adherence to medication can be achieved through interventions that identify individual barriers and train the care team in offering tailored support. Digital technologies that facilitate remote monitoring, patient-provider communication and care coordination are increasingly being integrated into asthma care.

SUMMARY

Adherence determinants reported cover individual, social and health service-related factors. Age and attitudes toward adherence are crucial determinants. Patients' and caregivers' mental health is relevant for adherence and clinical outcomes, highlighting the importance of integrating this aspect into holistic asthma management. Single-site care arrangements are beneficial for adherence. Tailoring adherence interventions to individual needs, using brief questionnaires to assess barriers and recommending evidence-based strategies to address them, have been found useful and feasible across care settings. Digital technologies such as smart inhaler systems and telemedicine-enhanced care have been shown to be effective in randomized controlled trials, yet implementation research highlights challenges to sustaining support on the long-term.

Development and validation of a machine learning risk prediction model for asthma attacks in adults in primary care

Primary care consultations provide an opportunity for patients and clinicians to assess asthma attack risk. Using a data-driven risk prediction tool with routinely collected health records may be an efficient way to aid promotion of effective self-management, and support clinical decision making. Longitudinal Scottish primary care data for 21,250 asthma patients were used to predict the risk of asthma attacks in the following year. A selection of machine learning algorithms (i.e., Naïve Bayes Classifier, Logistic Regression, Random Forests, and Extreme Gradient Boosting), hyperparameters, training data enrichment methods were explored, and validated in a random unseen data partition. Our final Logistic Regression model achieved the best performance when no training data enrichment was applied. Around 1 in 3 (36.2%) predicted high-risk patients had an attack within one year of consultation, compared to approximately 1 in 16 in the predicted low-risk group (6.7%). The model was well calibrated, with a calibration slope of 1.02 and an intercept of 0.004, and the Area under the Curve was 0.75. This model has the potential to increase the efficiency of routine asthma care by creating new personalized care pathways mapped to predicted risk of asthma attacks, such as priority ranking patients for scheduled consultations and interventions. Furthermore, it could be used to educate patients about their individual risk and risk factors, and promote healthier lifestyle changes, use of self-management plans, and early emergency care seeking following rapid symptom deterioration.

Are acute asthma presentations to the emergency department an opportunity for optimising long-term management? A qualitative study on beliefs and behaviours of healthcare professionals

BACKGROUND

Guidelines recommend Emergency Department (ED) healthcare professionals (HCPs) ensure patients have a supply of inhaled corticosteroid on discharge after an acute asthma presentation. By optimising medication, acute asthma presentations to EDs are a potentially reachable moment to improve long-term asthma management as well as treating the acute exacerbation. Optimising medication for long-term asthma management requires behavioural changes from HCPs, which may be considered unacceptable or unfeasible. Understanding health beliefs and attitudes of HCPs who provide asthma treatment in emergency care is a critical step in determining whether interventions could be developed to address this.

AIMS

To explore the health beliefs, attitudes and behaviours of HCPs involved in the care of adult patients presenting to the ED with asthma.

METHODS

UK HCPs, purposively sampled for profession, experience and work setting, were invited to participate in a semi-structured face-to-face or online interview. These were conducted between November 2021 and June 2022. Eligible participants had experience of caring for patients with asthma in either the ED or primary care setting. Interviews were analysed with reflective thematic analysis.

RESULTS

19 HCPs were interviewed. Four themes were identified, constructed around the beliefs and behaviours of HCPs: (1) Compassionate understanding, that is, recognising the accessibility of ED, patients' self-management and the emotional aspects of exacerbations, (2) Doing what is right for the patient, that is, maximising a reachable moment, (3) Tensions of capacity in the system, that is, acknowledging workload within ED and (4) ED as providers of preventative care.

CONCLUSION

This study found HCPs recognise both the accessibility of the ED as a place for patients to seek help and that there are potential opportunities to optimise asthma control, but there are barriers to overcome. ED professionals may be willing to make changes in the best interests of the patients if they can follow guidelines and receive training.

Effectiveness of an online asthma education program in adults with asthma in general practice: Results from a cluster randomised controlled trial

BACKGROUND

Asthma education programs (AEPs) are crucial to improving patient outcomes, but few patients participate. Therefore, an online asthma education program (electronic AEP, eAEP) has been developed. We aimed to investigate the effectiveness of the eAEP in adults with asthma in terms of asthma knowledge, symptom control and emergency treatments.

METHODS

In a cluster randomised controlled trial, general practitioner (GP) practices were randomly assigned to either access to the intervention (eAEP), or usual care (UC) control. Outcomes were assessed at baseline, two weeks, three and six months. Primary endpoint was the difference in Asthma Knowledge Test (AKT) scores after completion of the eAEP/UC. Secondary outcomes included symptom control (Asthma Control Test, ACT) and emergency treatments.

FINDINGS

62 patients from 10 intervention practices and 46 patients from 11 control practices were analysed. The intervention group had significantly greater improvements in mean AKT scores (between-group adjusted mean difference (AMD), 9.3 (95 % CI 6.3-12.3), p < 0.001) at the primary endpoint. Differences remained relatively stable during the six-month follow-up. Between-group AMD in the ACT was 1.4 (95 % CI -0.1-2.8, p < 0.062) three months after the eAEP/UC and 1.6 (95 % CI 0.2-2.9, p < 0.023) at study end. More intervention group patients demonstrated the inhalation technique correctly (98 % vs. 79 %, p = 0.007), received peak expiratory flow instructions (94 % vs. 32 %, p < 0.001) and an asthma action plan (96 % vs. 50 %, p < 0.001).

INTERPRETATION

The eAEP was effective in improving knowledge over six months and showed beneficial effects on symptom control. The eAEP may contribute to improved asthma care in GP settings.

Piloting co-developed behaviour change interventions to reduce exposure to air pollution and improve self-reported asthma-related health

BACKGROUND

Exposure to air pollution can exacerbate asthma with immediate and long-term health consequences. Behaviour changes can reduce exposure to air pollution, yet its 'invisible' nature often leaves individuals unaware of their exposure, complicating the identification of appropriate behaviour modifications. Moreover, making health behaviour changes can be challenging, necessitating additional support from healthcare professionals.

OBJECTIVE

This pilot study used personal exposure monitoring, data feedback, and co-developed behaviour change interventions with individuals with asthma, with the goal of reducing personal exposure to PM2.5 and subsequently improving asthma-related health.

METHODS

Twenty-eight participants conducted baseline exposure monitoring for one-week, simultaneously keeping asthma symptom and medication diaries (previously published in McCarron et al., 2023). Participants were then randomised into control (n = 8) or intervention (n = 9) groups. Intervention participants received PM2.5 exposure feedback and worked with researchers to co-develop behaviour change interventions based on a health behaviour change programme which they implemented during the follow-up monitoring week. Control group participants received no feedback or intervention during the study.

RESULTS

All interventions focused on the home environment. Intervention group participants reduced their at-home exposure by an average of 5.7 µg/m³ over the monitoring week (-23.0 to +3.2 µg/m³), whereas the control group had a reduction of 4.7 µg/m³ (-15.6 to +0.4 µg/m³). Furthermore, intervention group participants experienced a 4.6% decrease in participant-hours with reported asthma symptoms, while the control group saw a 0.5% increase. Similarly, the intervention group's asthma-related quality of life improved compared to the control group.

IMPACT STATEMENT

This pilot study investigated a novel behaviour change intervention, utilising personal exposure monitoring, data feedback, and co-developed interventions guided by a health behaviour change programme. The study aimed to reduce personal exposure to fine particulate matter (PM2.5) and improve self-reported asthma-related health. Conducting a randomised controlled trial with 28 participants, co-developed intervention successfully targeted exposure peaks within participants' home microenvironments, resulting in a reduction in at-home personal exposure to PM2.5 and improving self-reported asthma-related health. The study contributes valuable insights into the environmental exposure-health relationship and highlights the potential of the intervention for individual-level decision-making to protect human health.

Prevalence and predictors of annual asthma reviews in Scottish primary care data: an observational study

BACKGROUND

People with asthma are recommended to have regular reviews in primary care, with assessment of symptoms, adjustment of treatment and self-management processes, and the delivery of a written action plan for emergencies.

AIM

To investigate the incidence and factors associated with attendance of annual asthma reviews.

DESIGN & SETTING

This observational study used electronic health records for 49 307 patients in Scotland with asthma between 1 January 2000 and 31 March 2017. The analysis population of 13 726 patients had at least five asthma-related encounters between 2008 and 2016.

METHOD

Multivariable logistic regression was employed, using linked primary care prescription data and primary care registration demographic data.

RESULTS

There was a median of 381 days between subsequent reviews. Reviews in the index year were strongly associated with reviews in the following year (odds ratio [OR] 1.76, 95% confidence interval [CI] 1.68 to 1.84). In contrast, asthma consultations (excluding reviews) in the index year were associated with lower odds of having a review in the following year (OR 0.48, 95% CI = 0.46 to 0.51). Those aged 18-35 years in the index year or those with missing addresses in the practice registration data were the least likely groups to have an asthma review in the following year.

CONCLUSION

Reviewing the delivery of asthma care identifies patients who may be slipping through the gaps by receiving only reactive asthma care rather than the structured, preventive care that can be delivered through annual reviews. Understanding the risk factors for not receiving an annual review can be leveraged to create more effective review invitations, such as explaining the specific content of reviews, introducing new contact methods to improve health equity, and reviewing the algorithm used to determine who is invited.

Home use of short-acting beta agonists by children with asthma: a multicentre digital prospective study

OBJECTIVE

To investigate real-life salbutamol use by children with asthma at home and compare it with their written asthma action plans (WAAPs).

DESIGN

Multicentre, observational prospective study.

SETTING

Five tertiary care hospitals in France.

PATIENTS

120 children aged 3-11 years with asthma.

INTERVENTIONS

Parents used a smartphone application connected to a smart inhaler via Bluetooth to record salbutamol use and answer questionnaires about their child's asthma symptoms over 6 months.

MAIN OUTCOME MEASURES

The primary outcome was the median number of salbutamol puffs used in the first 2 hours after an asthma symptom occurred, depending on symptom type. Secondary outcomes included how families operationalised WAAP instructions and the proportion who administered more or less salbutamol than prescribed.

RESULTS

43 families used the smart inhaler for asthma symptoms, recording 124 episodes of salbutamol use. The median number of puffs used in the first 2 hours was 3 (IQR 2-4, range 1-26), varying between 2 and 4 depending on the initial symptom type. The number of puffs used did not differ significantly between episodes with and without symptom resolution. 18 (42%) families used a number of salbutamol puffs similar to that in their WAAP, while 21 (49%) used fewer and only 4 (9%) used more.

CONCLUSIONS

Families typically use 2-4 puffs of salbutamol in the first 2 hours after an asthma symptom. Adjusting WAAPs to start with 2-4 puffs of salbutamol, to be repeated if necessary, would be more in line with family practice, and effective in most situations.

TRIAL REGISTRATION NUMBER

NCT04810169.

Qualitative insights into planning implementation of FeNO-guided asthma management in primary care

Fractional exhaled nitric oxide (FeNO) testing is used in primary care in some areas of the UK to aid asthma diagnosis but is used less frequently for managing asthma. A randomised controlled trial (RCT) is investigating whether an intervention, including FeNO testing and a clinical algorithm, improves outcomes for patients with asthma. This study was conducted to explore potential for implementation of the intervention. The study aim was to explore views of those with a vested interest in implementing the FeNO intervention into primary care asthma reviews. In-depth, semi-structured interviews were conducted online with individuals, including those with experience in policymaking, healthcare management, National Health Service commissioning, as healthcare professionals (HCPs) with extended roles, and patients and advocates. Inductive thematic analysis was conducted for nineteen interviews. Findings suggest complex interplay of barriers, contextual issues and facilitators. Overall, participants perceived FeNO-informed asthma management would enhance care, if used appropriately and flexibly according to context, for example planning implementation alongside remote reviews. Easier, equitable access to funded FeNO equipment would be needed for national implementation. Participants suggested motivation of all involved in future implementation may be increased by guidelines recommending FeNO, and by use of financial incentives and champions sharing best practice examples. In conclusion, financial obstacles were reiterated as a primary barrier to FeNO use. Despite barriers, facilitating implementation by harnessing prominent cost-benefits could persuade decision makers and clinicians. Findings lay early foundations for development of an implementation strategy.

Knowledge, perceptions, facilitators, and barriers towards asthma self-management among patients: A systematic review of the literature

Background

Asthma self-management is an effective approach that empowers patients with asthma to control their condition and reduce its impact on their daily lives.

Objective

This systematic review aims to synthesize evidence regarding the knowledge, perceptions, facilitators, and barriers related to asthma self-management among patients.

Methods

A systematic literature search was conducted across five databases (PubMed, Science Direct, Scopus, Web of Science, and Google Scholar) using specific key terms. Studies that reported knowledge, perceptions, facilitators and barriers towards asthma self-management were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed to report this review. All the data from included studies were analyzed through narrative synthesis approach.

Results

A total of 17 studies were included in this review. The findings indicated that most patients had inadequate knowledge of asthma self-management, particularly regarding asthma fundamentals, and inhaler techniques. Patients' cultural beliefs, and perceived social stigma influenced their self-management practices. Facilitators of asthma self-management included strong partnerships with healthcare providers, social support, access to medication, and having a written asthma action plan. Conversely, poor communication with healthcare professionals, travel, smoking, and workplace challenges were identified as barriers.

Conclusion

There is a pressing need for education and training programs to enhance understanding of the disease, and inhaler technique in patients with asthma. Healthcare professionals should create tailored asthma action plans according to patients' beliefs and needs. Moreover, healthcare policies should be developed to promote facilitators and address barriers, to ensure effective asthma management.

Evaluating the Impact of a Teaching Program on the Knowledge, Quality of Life, and Symptoms Among Asthmatic Children

Asthma is a prevalent chronic respiratory condition that affects millions of children worldwide, often disrupting their daily activities, academic performance, and overall well-being. Despite its impact, many children, along with their families and caregivers, have limited knowledge about asthma, its triggers, and effective management strategies. Implementing a structured teaching program is crucial to improving asthma awareness, fostering self-management through action plans, minimizing emergency incidents, and empowering children with the confidence and independence needed to manage their condition effectively. The specific objectives were to assess the baseline levels of knowledge, quality of life, and asthma symptoms, and to determine the effect of the teaching program in improving these outcomes. This randomized controlled trial was conducted among 94 participants from an asthma clinic, with 47 subjects in the experimental group and 47 in the control group, using an allocation concealment technique. The study assessed participants' knowledge, quality of life, and asthma symptoms using the Asthma Knowledge Questionnaire, the Mini Pediatric Asthma Quality of Life Questionnaire (MiniPAQLQ), and the Asthma Control Questionnaire (ACQ). After administering a pretest to both groups, the experimental group received structured education on various aspects of asthma management. Post-intervention assessments were conducted four times at four-week intervals using the same questionnaires as the pretest. The collected data were tabulated and analyzed using descriptive and inferential statistics. The findings of the study indicate that the teaching program effectively improved participants' knowledge, quality of life, and asthma symptoms. The effectiveness of the intervention was assessed using repeated measures ANOVA. Posttest results demonstrated a statistically significant improvement in knowledge, quality of life, and asthma symptoms (P < 0.001). The study concludes that an educational program on various aspects of asthma can help children with asthma better understand their condition, reduce anxiety, enhance coping mechanisms, and encourage responsibility in managing their disease. Therefore, alongside routine medical treatment, asthma education plays a crucial role in improving children's knowledge, quality of life, and symptom management.

Low compression smart clothing for respiratory rate monitoring using a bending angle sensor based on double-layer capacitance

In chronic respiratory diseases, continuous self-monitoring of vital signs such as respiratory rate aids in the early detection of exacerbations. In recent years, the development of smart clothing, such as garments equipped with sensors to measure respiratory rate, has been a focus of research. However, the usability and adoption of smart clothing are often compromised owing to the discomfort caused by compression pressure during wear. This study developed smart clothing designed to measure respiratory rate using a low compression pressure. This was achieved by integrating a bending angle sensor, based on double-layer capacitance, into the rib cage and abdomen areas. The accuracy of the respiratory rate measurement was evaluated in 20 healthy male subjects without respiratory diseases. Breathing was measured while the subjects wore the smart clothing and performed breathing exercises in sitting, supine, and lateral postures, following a metronome set between 12 and 30 bpm. To assess accuracy, the respiratory rate measured by the smart clothing was compared with that measured by a spirometer. The recorded compression pressure was 0.77 ± 0.21 kPa, with no subjects reporting discomfort. Correlation coefficients for respiratory rate in the different postures ranged within 0.97-0.99. The mean difference between the smart clothing and spirometer measurements was less than 0.1 bpm. The low mean difference indicated that the proposed low compression pressure wearable respiration sensor, employing a bending angle sensor based on double-layer capacitance, could measure respiratory rate accurately without causing discomfort and within an acceptable error range.

Implementation and Effectiveness of Guideline-Recommended Clinical Activities for Children With Asthma: Population-Based Cohort

BACKGROUND

Guidelines advise minimizing asthma exacerbation risk, which is achieved partially through good clinical practice activities, including scheduled asthma reviews, inhaler technique checks, and asthma management plans. We assessed how frequently these activities are provided and how effective they are in clinical practice.

RESEARCH QUESTION

Do guideline-recommended activities such as asthma reviews, inhaler technique checks, and asthma management plans prevent asthma exacerbations?

STUDY DESIGN AND METHODS

This retrospective chart review used United Kingdom primary care medical records between 2004 and 2021, linked to hospital records. Children were eligible from asthma diagnosis until age 16 years. Annual implementation of asthma review, inhaler technique check, and asthma management plan was measured. Risk factors for these activities not being undertaken were determined by using multivariable logistic regression. Self-controlled case series was adopted to assess the effectiveness of each activity over 12 months; this was divided into two 6-month periods.

RESULTS

A total of 126,483 children were eligible; 30% to 45% received each annual activity, and 8% received all three together. Risk factors for not receiving activities included younger age, more socioeconomic deprivation, and higher or no BMI measurement. Management plans and asthma reviews, as standalone activities, were associated with an approximately 15% exacerbation reduction over 12 months and 8% over 6 months, respectively (asthma management plan, n = 4,624; 0-180 days [incidence rate ratio (95% CI)]: 0.87 [0.79-0.96]; 181-365 days: 0.83 [0.73-0.95]; asthma review, n = 6,948; 0-180 days: 0.92 [0.85-0.99]; 181-365 days: 0.93 [0.83-1.03]). Standalone inhaler technique checks were not associated with exacerbations. Provision of all activities together was associated with an approximately 30% exacerbation reduction over 12 months (n = 3,643; 0-180 days: incidence rate ratio, 0.76 [0.68-0.85]; 181-365 days: incidence rate ratio, 0.69 [95% CI, 0.60-0.81]).

INTERPRETATION

Our results indicate that most children in the United Kingdom do not receive the guideline-recommended activities to monitor their asthma. This study suggests that these activities, if implemented, are effective in clinical practice and maximally effective when combined in the same visit.

Home-based educational interventions for children with asthma

BACKGROUND

Asthma is a chronic airway condition with a global prevalence of 262.4 million people. Asthma education is an essential component of management and includes provision of information on the disease process and self-management skills development such as trigger avoidance. Education may be provided in various settings. The home setting allows educators to reach populations (e.g. financially poor) that may experience barriers to care (e.g. transport limitations) within a familiar environment, and allows for avoidance of attendance at healthcare settings. However, it is unknown if education delivered in the home is superior to usual care or the same education delivered elsewhere. There are large variations in asthma education programmes (e.g. patient-specific content versus broad asthma education, number/frequency/duration of education sessions). This is an update of the 2011 review with 14 new studies added.

OBJECTIVES

To assess the effects of educational interventions for asthma, delivered in the home to children, their caregivers, or both, on asthma-related outcomes.

SEARCH METHODS

We searched Cochrane Airways Group Trials Register, CENTRAL, MEDLINE, two additional databases and two clinical trials registries. We searched reference lists of included trials/review articles (last search October 2022), and contacted authors of included studies.

SELECTION CRITERIA

We included randomised controlled trials of education delivered in the home to children and adolescents (aged two to 18 years) with asthma, their caregivers or both. We included self-management programmes, delivered face-to-face and aimed at changing behaviour (e.g. medication/inhaler technique education). Eligible control groups were usual care, waiting list or less-intensive education (e.g. shorter, fewer sessions) delivered outside or within the home. We excluded studies with mixed-disease populations and without a face-to-face component (e.g. telephone only).

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, assessed trial quality, extracted data and used GRADE to rate the certainty of the evidence. We contacted study authors for additional information. We pooled continuous data with mean difference (MD) and 95% confidence intervals (CI). We used a random-effects model and performed sensitivity analyses with a fixed-effect model. When combining dichotomous and continuous data, we used generic inverse variance, using a Peto odds ratio (OR) and fixed-effect model. Primary outcomes were exacerbations leading to emergency department visits and exacerbations requiring a course of oral corticosteroids. Six months was the primary time point for outcomes. The summary of findings tables reported on the primary outcomes, and quality of life, daytime symptoms, days missed from school and exacerbations leading to hospitalisations.

MAIN RESULTS

This review includes 26 studies with 5122 participants (14 studies and 2761 participants new to this update). Sixteen studies (3668 participants) were included in meta-analyses. There was substantial clinical diversity. Participants differed in age (range 1 to 18 years old) and asthma severity (mild to severe). The context and content of educational interventions also varied, as did the aims of the studies (e.g. reducing healthcare utilisation, improving quality of life) and there was diversity in control group event rates. Outcomes were measured over various time points specified in the original studies. All studies were at risk of bias due to the nature of the intervention. It is possible that the participants/educators may not have been aware of their allocation, so all studies were judged at unclear risk for performance bias. Home-based education versus usual care, waiting list or less-intensive education programme delivered outside the home Primary outcomes Home-based education may result in little to no difference in exacerbations leading to emergency department visits at six-month follow-up compared to control, but the evidence is very uncertain (Peto OR 1.22, 95% CI 0.50 to 2.94; 5 studies (2 studies with 2 intervention arms), 855 participants; very low-certainty evidence). Home-based education results in little to no difference in exacerbations requiring a course of oral corticosteroids compared to control (mean difference (MD) -0.18, 95% CI -0.63 to 0.26; 1 study (2 intervention arms), 250 participants; low-certainty evidence). Secondary outcomes Home-based education may improve quality-of-life scores compared to control, but the evidence is very uncertain (standardised mean difference (SMD) 0.32, 95% CI 0.08 to 0.56; 4 studies, 987 participants; very low-certainty evidence). The evidence is very uncertain about the effects of home-based education on mean symptom-free days, days missed from school/work and exacerbations leading to hospitalisation compared to control (all very low-certainty evidence). Home-based education versus less-intensive home-based education for children with asthma Primary outcomes A more-intensive home-based education intervention did not reduce exacerbations leading to emergency department visits (Peto OR 1.36, 95% CI 0.35 to 5.30; 4 studies, 729 participants; low-certainty evidence) or exacerbations requiring a course of oral corticosteroids (MD 0.08, 95% CI -0.14 to 0.30; 3 studies, 605 participants; low-certainty evidence), compared to a less-intensive type of home-based education. Secondary outcomes A more-intensive home-based asthma education intervention may reduce hospitalisation due to an asthma exacerbation (Peto OR 0.14, 95% CI 0.04 to 0.55; 4 studies, 689 participants; low-certainty evidence), but not days missed from school (low-certainty evidence), compared with a less-intensive home-based asthma education intervention. A more intensive home-based education intervention had no effect on quality of life and symptom-free days (both very low certainty), compared with a less-intensive home-based asthma education intervention, but the evidence is very uncertain.

AUTHORS' CONCLUSIONS

We found uncertain evidence for home-based asthma educational interventions compared to usual care, education delivered outside the home or a less-intensive educational intervention. Home-based education may improve quality of life compared to control and reduce the odds of hospitalisation compared to less-intensive educational intervention. Although asthma education is recommended in guidelines, the considerable diversity in the studies makes the evidence difficult to interpret about whether home-based education is superior to none, or education delivered in another setting. This review contributes limited information on the fundamental optimum content and setting for educational interventions in children. Further studies should use standard outcomes from this review and design trials to determine what components of an education programme are most important.

Role of the Respiratory Therapist in Asthma Education

The primary goal of asthma management is attainment of the best possible outcomes for symptom control and reduction of exacerbations. This can be accomplished through partnering with patients and families and providing education. Asthma self-management education empowers patients with the knowledge, confidence, and skills necessary to successfully manage their condition. Components of asthma education include basic facts about asthma, inhaled medications, self-monitoring, environmental control, and a written asthma action plan. Repetition, reinforcement, and good clinician communication skills are vital for successful self-management education. Teach back, teach-to-goal, and motivational interviewing are effective strategies that have demonstrated improved outcomes for adults and children with asthma. Respiratory therapists have positively impacted outcomes for patients with asthma through educational interventions. This paper reviews the published literature regarding asthma education and provides guidance for clinicians for effective asthma self-management education.

Delivery of Supported Self-Management in Primary Care Asthma Reviews: Insights From the IMP2ART Programme

BACKGROUND

Supported self-management (SSM) for asthma reduces the risk of asthma attacks and improves asthma control and quality of life. SSM optimally includes patient-centred communication and behaviour change support, however, the extent to which this occurs in routine primary care is unclear. This project was nested within the IMPlementing IMProved Asthma self-management as RouTine (IMP2ART) programme; a UK-wide trial evaluating an implementation strategy (including healthcare professional (HCP) training on behaviour change strategies and patient-centred care) to improve support for asthma self-management.

OBJECTIVE

To provide an understanding of how healthcare professionals deliver SSM in UK clinical practice; through assessing time spent on SSM strategies, how and to what extent patient-centred care and behaviour change discussions are delivered, and to explore whether factors such as mode of review or implementation support influence delivery.

DESIGN, SETTING AND PARTICIPANTS

We conducted an observational study using video-recordings of 12 HCPs delivering routine face-to-face and telephone asthma reviews (n = 64) in a sample of general practices participating in the IMP2ART trial (implementation n = 4; control n = 6). Analytical methods included: ALFA Toolkit Multi-Channel Video Observation (to code and quantify tasks undertaken); the Patient-Centred Observation Form; and The Behaviour Change Counselling Index (to assess patient-centeredness and behaviour change counselling used by HCPs).

RESULTS

HCPs mostly spent time during routine asthma reviews discussing: an individual's asthma condition and management (average of 27.8% of consultation time); collaboratively reviewing and completing a personalised asthma action plan (6.3%) and training for practical self-management activities (5.4%). Areas of patient-centred care delivery and behavioural discussions included: creating and maintaining relationships, discussing asthma action plans and medication reconciliation. Professionals in IMP2ART implementation group practices delivered more SSM strategies. Comparison of face-to-face and remote consultations found no significant differences in HCP delivery of SSM.

CONCLUSIONS

HCPs in UK primary care spent half the time in both face-to-face and remote asthma reviews delivering components of SSM suggesting that either mode of delivery may be acceptable. Reviews carried out in IMP2ART implementation group practices demonstrated more behaviour change and collaborative SSM strategies compared to those in the control group.

PATIENT AND PUBLIC CONTRIBUTION

Asthma UK Centre for Applied Research (AUKCAR) PPI members were involved throughout, including project conception, providing feedback on participant-facing documents, and discussing implications of study findings.

National expert consensus on short-acting beta2-agonist overreliance in asthma care in Malaysia

OBJECTIVE

Inappropriate use of short-acting beta2-agonists (SABA) in asthma has been associated with undesired outcomes. This national expert consensus was developed to increase awareness of SABA overuse and provide recommendations on the ways to eliminate SABA overprescription and overreliance in Malaysia.

DATA SOURCES

This expert consensus was developed by searching the PubMed database, using index terms to identify SABA overuse-related burden and recommendations made in asthma guidelines. Consensus recommendations were made via the Delphi method, involving a Malaysian expert committee comprising 13 healthcare professionals (five pulmonologists, four family medicine specialists, two emergency medicine physicians and two pharmacists).

STUDY SELECTIONS

The articles reviewed include randomized controlled trials, systematic reviews, meta-analyses, observational studies, guidelines, and surveys, with abstracts in English and published up until June 2023. Relevant recommendations were also sourced from verified websites of medical organizations and societies.

RESULTS

Eleven consensus statements were developed, each statement achieving a priori agreement level of at least 70%. The statements reflect SABA overreliance in asthma care, as well as recommendations to eliminate SABA overprescription and overreliance in Malaysia. Supporting evidence in the literature as well as expert committee discussions leading to the development of the finalized statements were elaborated.

CONCLUSION

This national expert consensus discussed the burden of SABA overreliance and made specific recommendations to eliminate SABA overprescription and overreliance in the Malaysian context. This consensus document is anticipated to impart better awareness among Malaysian healthcare providers and contribute to the continuous improvement of asthma care in the country.

Development and psychometric evaluation of the asthma Action plan questionnaire (AAPQ)

OBJECTIVE

To develop a practical and psychometrically sound tool to evaluate caregiver knowledge of their child's asthma action plan (AAP).

METHODS

A pilot study was conducted in a sample of 40 caregivers of children with asthma to assess the content validity, item difficulty, and item discrimination of the Asthma Action Plan Questionnaire (AAPQ). The inter-rater and intra-rater agreement of the AAPQ's scoring rubric were also examined. Subsequently, a large-scale study was conducted in a sample of 80 caregivers of children with asthma and 40 caregivers of children without current asthma and no prior exposure to patients with asthma to evaluate the internal consistency, test-retest reliability, and known-groups validity of the AAPQ.

RESULTS

The 7-item AAPQ demonstrated acceptable content validity (a scale-content validity index of 0.98) and internal consistency (Cronbach's alpha =.63 and mean inter-item correlation coefficient of .20) and very strong test-retest reliability over a two-to-four-week period (r = .88, p < .001). The AAPQ discriminated between caregivers of children with asthma and caregivers of children without asthma (M ± SD 8.3 ± 1.6 vs. 4.3 ± 1.7, p < .001, respectively).

CONCLUSION

The AAPQ is a valid and reliable questionnaire that provides an assessment of caregivers' knowledge of their child's AAP and can guide educational interventions by healthcare providers.

Artificial intelligence in respiratory care: perspectives on critical opportunities and challenges

Artificial intelligence (AI) is transforming respiratory healthcare through a wide range of deep learning and generative tools, and is increasingly integrated into both patients' lives and routine respiratory care. The implications of AI in respiratory care are vast and multifaceted, presenting both promises and uncertainties from the perspectives of clinicians, patients and society. Clinicians contemplate whether AI will streamline or complicate their daily tasks, while patients weigh the potential benefits of personalised self-management support against risks such as data privacy concerns and misinformation. The impact of AI on the clinician-patient relationship remains a pivotal consideration, with the potential to either enhance collaborative care or create depersonalised interactions. Societally, there is an imperative to leverage AI in respiratory care to bridge healthcare disparities, while safeguarding against the widening of inequalities. Strategic efforts to promote transparency and prioritise inclusivity and ease of understanding in algorithm co-design will be crucial in shaping future AI to maximise benefits and minimise risks for all stakeholders.

Patient-managed interventions for adults with bronchiectasis: evidence, challenges and prospects

Bronchiectasis is a chronic lung condition which is characterised by recurrent chest infections, chronic sputum production and cough, and limited exercise tolerance. While bronchiectasis may be caused by various aetiologies, these features are shared by most patients with bronchiectasis regardless of the cause. This review consolidates the existing evidence on patient-managed interventions for adults with bronchiectasis, while also outlining areas for future research. Airway clearance techniques and hyperosmolar agents are key components of the bronchiectasis management and consistently recommended for clinical implementation. Questions around their prescription, such as optimal sequence of delivery, are still to be answered. Pulmonary rehabilitation and exercise are also recommended for patients with bronchiectasis. Relatively strong evidence underpins this recommendation during a clinically stable stage of the disease, although the role of pulmonary rehabilitation following an exacerbation is still unclear. Additionally, self-management programmes feature prominently in bronchiectasis treatment, yet the lack of consensus regarding their definition and outcomes presents hurdles to establishing a cohesive evidence base. Moreover, cough, a cardinal symptom of bronchiectasis, warrants closer examination. Although managing cough in bronchiectasis may initially appear risky, further research is necessary to ascertain whether strategies employed in other respiratory conditions can be safely and effectively adapted to bronchiectasis, particularly through identifying patient responder populations and criteria where cough may not enhance airway clearance efficacy and its control is needed. Overall, there is a growing recognition of the importance of patient-managed interventions in the bronchiectasis management. Efforts to improve research methodologies and increase research funding are needed to further advance our understanding of these interventions, and their role in optimising patient care and outcomes.

Developing theoretically underpinned primary care resources for patients with asthma: an exemplar from the IMP2ART trial

AIM

This article reports on the development of patient resources for the IMPlementing IMProved Asthma self-management as RouTine (IMP2ART) programme that aimed to encourage patients to attend asthma reviews (invitation letters), encourage patients to enquire about asthma action plans (posters), and equip patients with the knowledge to manage their asthma (information website).

BACKGROUND

To improve supported asthma self-management in UK primary care, the IMP2ART programme developed a whole-systems approach (patient resources, professional education, and organisational strategies).

METHODS

Linked to behaviour change theory, we developed a range of patient resources for primary care general practices (an information website, invitation letters to invite patients for asthma reviews, and posters to encourage asthma action plan ownership). We elicited qualitative feedback on the resources from people living with asthma in the UK (n = 17). In addition, we conducted an online survey with volunteers in the UK-wide REgister for Asthma researCH (REACH) database to identify where they source asthma information, whether their information needs are met, and what information would be useful (n = 95).

FINDINGS

Following feedback gathered from the interviews and the online survey, we refined our patient resources for the IMP2ART programme. Refinements included highlighting the seriousness of asthma, enhancing trustworthiness, and including social support resources. We also made necessary colour and formatting changes to the resources. In addition, the patient resources were updated following the COVID-19 pandemic. The multi-stage development process enabled us to refine and optimise the patient resources. The IMP2ART strategy is now being tested in a UK-wide cluster RCT (ref: ISRCTN15448074).

Pollen and viruses contribute to spatio-temporal variation in asthma-related emergency department visits

BACKGROUND

Asthma exacerbations are an important cause of emergency department visits but much remains unknown about the role of environmental triggers including viruses and allergenic pollen. A better understanding of spatio-temporal variation in exposure and risk posed by viruses and pollen types could help prioritize public health interventions.

OBJECTIVE

Here we quantify the effects of regionally important Cupressaceae pollen, tree pollen, other pollen types, rhinovirus, seasonal coronavirus, respiratory syncytial virus, and influenza on asthma-related emergency department visits for people living near eight pollen monitoring stations in Texas.

METHODS

We used age stratified Poisson regression analyses to quantify the effects of allergenic pollen and viruses on asthma-related emergency department visits.

RESULTS

Young children (<5 years of age) had high asthma-related emergency department rates (24.1 visits/1,000,000 person-days), which were mainly attributed to viruses (51.2%). School-aged children also had high rates (20.7 visits/1,000,000 person-days), which were attributed to viruses (57.0%), Cupressaceae pollen (0.7%), and tree pollen (2.8%). Adults had lower rates (8.1 visits/1,000,000 person-days) which were attributed to viruses (25.4%), Cupressaceae pollen (0.8%), and tree pollen (2.3%). This risk was spread unevenly across space and time; for example, during peak Cuppressaceae season, this pollen accounted for 8.2% of adult emergency department visits near Austin where these plants are abundant, but 0.4% in cities like Houston where they are not; results for other age groups were similar.

CONCLUSIONS

Although viruses are a major contributor to asthma-related emergency department visits, airborne pollen can explain a meaningful portion of visits during peak pollen season and this risk varies over both time and space because of differences in plant composition.

Effectiveness of pediatric asthma education program in the context of a general hospital in France: A retrospective real-life study

Objective

To assess the feasibility and effectiveness of a pediatric asthma education program delivered in the context of a French suburban general hospital.

Design

Monocentric retrospective study including children with asthma in Melun, Île-de-France, from January to December 2019. Data collected concerned asthma management, symptoms, education, and knowledge.

Results

We included 262 patients with a median age of 4.5 years. Asthma education (AE) was taught to 226 (86 %) children, 36 with minimal education (ME), 155 (69 %) with an unstructured asthma education program (USEP) and 71 (31 %) a structured asthma education program (SEP). Patients with an SEP had better knowledge of the disease and its treatment as compared with those with a USEP or ME (p < 0.05). Lung function was evaluated for 70 % of children with ME, 90 % with a USEP (p = 0.144) and 77 % an SEP (p = 0.455). Allergy testing was assessed for 42 % of children with ME, 69 % a USEP (p = 0.020) and 57 % an SEP (p = 0.185). Almost all children with USEP (93 %) and SEP (94 %) also had a written asthma action plan as compared with 49 % of the children with ME (p < 0.001). Also, 76 % of children with ME did not have an asthma follow-up as compared with 37 % with a USEP and 52 % an SEP. Overall, 69 % of children with ME had at least one hospitalization within the year as compared with 32 % with a USEP (p = 0.001) and 59 % an SEP (p = 0.506).

Conclusions

An asthma education program delivered in a general hospital resulted in increased disease knowledge for children and their caregivers, together with reduced acute interventions.

Cross-cultural adaptation and reliability of patient asthma knowledge questionnaire in the regional Indian language Marathi: a cross-sectional study

Introduction

patient education is the cornerstone of the clinical management of bronchial asthma. The patient asthma knowledge questionnaire is a valid and reliable tool to assess the disease specific knowledge in the patients with bronchial asthma. To the best of our knowledge and literature search, there is no tool available in Marathi language to assess the knowledge of bronchial asthma in patients.

Methods

standard translation guidelines for cross-cultural adaptation were followed. Forward and backward translations were performed by the eligible translators (T1 and T2) as per the guidelines. Synthesis of the translated versions was performed by translators and recording observer (T12). Recommendations by the expert committee were done to develop a pre-final version. The pre-final version was then tested on 30 individuals with bronchial asthma. The reliability of the translated version was assessed by the internal consistency and intra-class correlation coefficient.

Results

thirty (30) bronchial asthma patients were recruited (with a mean age of 63SD±14.36, 16 males and 14 females) to test the pre-final version, and probing of each item was done to test the equivalence. It showed that the patient comprehended the intent behind each inquiry, and that was gauged on the Likert scale. A total of 102 adults (60.8% female and 39.2% male) with a mean age of 41±11 years were included in the study to examine test-retest reliability. Between the total scores obtained from the first and second applications of the questionnaire within a two-week period, there was no discernible variation. The internal consistency reliability (Cronbach´s alpha) was 0.79 and the Intra-class correlation coefficient was 1.000.

Conclusion

Marathi Version of the patient asthma knowledge questionnaire (PAKQ) is cross-culturally adapted and reliable; it will prove to be a beneficial tool to assess the disease-specific knowledge of bronchial asthma.

Children and young people's self-reported experiences of asthma and self-management nursing strategies: An integrative review

AIM

To explore children and young people's (CYP) (5-24 years of age) self-reported experiences of asthma self-management strategies (ASMS) with nursing involvement across various settings.

BACKGROUND

Childhood asthma is an increasingly significant health issue, highlighting the importance of acquiring self-management skills to optimise future health outcomes. Registered nurses play a pivotal role in delivering appropriate, personalized self-management support.

METHODS

This integrative review searched four electronic databases: Cumulated Index to Nursing and Allied Health Literature via Elton B. Stephens Company, Medical Literature Analysis and Retrieval System Online (MEDLINE), Object, View and Interactive Design (OVID), and PubMed, that followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis flowchart. Included studies were critically appraised using the Joanna Briggs Institute critical appraisal tools. Braun and Clarks thematic analysis was used to generate themes, and sub-themes.

FINDINGS

Fifteen studies were included for review. Thematic analysis generated three themes being healthy literacy; health and wellbeing; and tools and working together.

CONCLUSIONS

Asthma continues to have negative physical, psychological, and social implications among CYP. CYP are both willing and capable of engaging in ASMS and learning self-management skills, however, continue to have unmet self-management needs.

IMPLICATIONS TO PRACTICE

Strategies must bolster health literacy, improve physical and psychological health, and harness interactive, youth-centric, and informative tools to facilitate communication and decrease the burden of self-management. Applications pose a promising avenue for self-management support. This age group remains under-explored and future research should enable meaningful engagement with CYP to better understand their perspectives and improve strategy success.

Exploring the perspectives of healthcare professionals on providing supported asthma self-management for Bangladeshi and Pakistani people in the UK

BACKGROUND

Self-management support improves asthma outcomes and is widely recommended in guidelines, yet it is poorly implemented in routine practice. There may be additional challenges in the context of ethnic minority groups, where making sense of culture may be necessary. This study aimed to explore the perspectives of healthcare professionals on supporting UK Bangladeshi and Pakistani patients to self-manage their asthma.

METHODS

One-to-one semi-structured interviews with professionals (primary and secondary care; medical and nursing) who routinely provide asthma care to Bangladeshi or Pakistani patients. Topics addressed included perceptions of professionals in supporting patients with asthma self-management and ideas for improving culturally competent care. Data were analysed thematically.

RESULTS

Nine professionals, from a range of ethnic backgrounds, with considerable experience of treating patients from these communities were interviewed. Despite organisational restrictions (language and time/resources) and expressed gaps in cultural knowledge and training, all interviewees reported attempting to tailor support according to culture. They used their perception of the patient's culture (e.g., big families and family involvement), integrated with their perception of patients' ability to self-manage (e.g., degree of responsibility taken for asthma), to formulate theories about how to culturally adapt their approach to supported self-management, e.g., supporting barriers in understanding asthma. There was consensus that gaps in cultural knowledge of professionals needed to be addressed through training or information. Interventions recommended for patients included basic education, group meetings, and culturally relevant action plans.

CONCLUSION

In the absence of formal training and constrained by organisational limitations, self-management support was adapted based on personal and professional perception of culture. These ideas were based on experience and formulated a chain of reasoning. Professionals recognised the limitations of this approach and potential to overgeneralise their perceptions of culture and adaptations of supported self-management. Interventions were desired and need to address professional training in cultural competence and the provision of culturally relevant materials.

Understanding the processes underpinning IMPlementing IMProved Asthma self-management as RouTine (IMP2ART) in primary care: study protocol for a process evaluation within a cluster randomised controlled implementation trial

BACKGROUND

Providing supported self-management for people with asthma can reduce the burden on patients, health services and wider society. Implementation, however, remains poor in routine clinical practice. IMPlementing IMProved Asthma self-management as RouTine (IMP2ART) is a UK-wide cluster randomised implementation trial that aims to test the impact of a whole-systems implementation strategy, embedding supported asthma self-management in primary care compared with usual care. To maximise opportunities for sustainable implementation beyond the trial, it is necessary to understand how and why the IMP2ART trial achieved its clinical and implementation outcomes.

METHODS

A mixed-methods process evaluation nested within the IMP2ART trial will be undertaken to understand how supported self-management was implemented (or not) by primary care practices, to aid interpretation of trial findings and to inform scaling up and sustainability. Data and analysis strategies have been informed by mid-range and programme-level theory. Quantitative data will be collected across all practices to describe practice context, IMP2ART delivery (including fidelity and adaption) and practice response. Case studies undertaken in three to six sites, supplemented by additional interviews with practice staff and stakeholders, will be undertaken to gain an in-depth understanding of the interaction of practice context, delivery, and response. Synthesis, informed by theory, will combine analyses of both qualitative and quantitative data. Finally, implications for the scale up of asthma self-management implementation strategies to other practices in the UK will be explored through workshops with stakeholders.

DISCUSSION

This mixed-methods, theoretically informed, process evaluation seeks to provide insights into the delivery and response to a whole-systems approach to the implementation of supported self-management in asthma care in primary care. It is underway at a time of significant change in primary care in the UK. The methods have, therefore, been developed to be adaptable to this changing context and to capture the impact of these changes on the delivery and response to research and implementation processes.

Patient and public involvement workshop to shape artificial intelligence-supported connected asthma self-management research

Digital interventions with artificial intelligence (AI) can potentially support people with asthma to reduce the risk of exacerbation. Engaging patients throughout the development process is essential to ensure usability of the intervention for the end-users. Using our Connected for Asthma (C4A) intervention as an exemplar, we explore how patient involvement can shape a digital intervention. Seven Patient and Public Involvement (PPI) colleagues from the Asthma UK Centre for Applied Research participated in four advisory workshops to discuss how they would prefer to use/interact with AI to support living with their asthma, the benefit and caveats to use the AI that incorporated asthma monitoring and indoor/outdoor environmental data. Discussion focussed on the three most wanted use cases identified in our previous studies. PPI colleagues wanted AI to support data collection, remind them about self-management tasks, teach them about asthma environmental triggers, identify risk, and empower them to confidently look after their asthma whilst emphasising that AI does not replace clinicians. The discussion informed the key components in the next C4A interventions, including the approach to interacting with AI, the technology features and the research topics. Attendees highlighted the importance of considering health inequities, the presentation of data, and concerns about data accuracy, data privacy, security and ownership. We have demonstrated how patient roles can shift from that of 'user' (the traditional 'tester' of a digital intervention), to a co-design partner who shapes the next iteration of the intervention. Technology innovators should seek practical and feasible strategies to involve PPI colleagues throughout the development cycle of a digital intervention; supporting researchers to explore the barriers, concerns, enablers and advantages of implementing digital healthcare.

The Asthma App as a New Way to Promote Responsible Short-Acting Beta2-Agonist Use in People With Asthma: Results of a Mixed Methods Pilot Study

BACKGROUND

Approximately 262 million people worldwide are affected by asthma, and the overuse of reliever medication-specifically, short-acting beta2-agonist (SABA) overuse-is common. This can lead to adverse health effects. A smartphone app, the Asthma app, was developed via a participatory design to help patients gain more insight into their SABA use through monitoring and psychoeducation.

OBJECTIVE

This pilot study aims to evaluate the feasibility and usability of the app. The preliminary effects of using the app after 3 months on decreasing asthma symptoms and improving quality of life were examined.

METHODS

A mixed methods study design was used. Quantitative data were collected using the app. Asthma symptoms (measured using the Control of Allergic Rhinitis and Asthma Test) and the triggers of these symptoms were collected weekly. Quality of life (36-Item Short-Form Health Survey) was assessed at baseline and after 3, 6, and 12 months. User experience (System Usability Scale) was measured at all time points, except for baseline. Furthermore, objective user data were collected, and qualitative interviews, focusing on feasibility and usability, were organized. The interview protocol was based on the Unified Theory of Acceptance and Use of Technology framework. Qualitative data were analyzed using the Framework Method.

RESULTS

The baseline questionnaire was completed by 373 participants. The majority were female (309/373, 82.8%), with a mean age of 46 (SD 15) years, and used, on average, 10 SABA inhalations per week. App usability was rated as good: 82.3 (SD 13.2; N=44) at 3 months. The Control of Allergic Rhinitis and Asthma Test score significantly improved at 3 months (18.5) compared with baseline (14.8; β=.189; SE 0.048; P<.001); however, the obtained score still indicated uncontrolled asthma. At 3 months, there was no significant difference in the quality of life. Owing to the high dropout rate, insufficient data were collected at 6 and 12 months and were, therefore, not further examined. User data showed that 335 users opened the app (250/335, 74.6%, were returning visitors), with an average session time of 1 minute, and SABA registration was most often used (7506/13,081, 57.38%). Qualitative data (from a total of 4 participants; n=2, 50% female) showed that the participants found the app acceptable and clear. Three participants stated that gaining insight into asthma and its triggers was helpful. Two participants no longer used the app because they perceived their asthma as controlled and, therefore, did not use SABA often or only used it regularly based on the advice of the pulmonologist.

CONCLUSIONS

The initial findings regarding the app's feasibility and usability are encouraging. However, the notable dropout rate underscores the need for a cautious interpretation of the results. Subsequent studies, particularly those focusing on implementation, should explore the potential integration of the app into standard treatment practices.

Altered Symptom Perception in Children With Asthma Is Associated With Poor Childhood Opportunity and Adverse Outcomes

BACKGROUND

Effective asthma self-management requires that children recognize their asthma symptoms when they occur. However, some children have altered symptom perception, which impairs their ability to respond to their asthma symptoms in a timely manner.

OBJECTIVE

To characterize the prevalence and features of altered symptom perception in children aged 5 to 18 years. We hypothesized that children with altered symptom perception would have more features of uncontrolled asthma, more health inequity, and poorer longitudinal asthma outcomes over 12 months.

METHODS

Children (N = 371) completed an outpatient research visit for clinical characterization. Altered symptom perception was defined by discordance between child responses on the 6-item Asthma Control Questionnaire and medical provider-elicited symptoms. Electronic medical records were reviewed for 12 months for the occurrence of an asthma exacerbation treated with systemic corticosteroids and an asthma exacerbation prompting an emergency department visit.

RESULTS

Approximately 15% of children had altered symptom perception and their asthma features were similar to those of children with uncontrolled asthma. Children with altered symptom perception were uniquely distinguished by non-White race and more severe prior exacerbations. These children also resided in ZIP codes with the poorest childhood opportunity (ie, poorest education, health and environmental features, and socioeconomic features). Outcomes of children with altered symptom perception were equally disparate with approximately 2-fold higher odds of a future exacerbation and approximately 3-fold higher odds of an emergency department visit for asthma.

CONCLUSIONS

Altered symptom perception is present in a small but significant number of children with asthma and is related to poorer childhood opportunity and other health inequities that require additional intervention.

Assessing catastrophic health expenditure and impoverishment in adult asthma care: a cross-sectional study of patients attending six public health clinics in Klang District, Malaysia

BACKGROUND

In Malaysia, asthma is a common chronic respiratory illness. Poor asthma control may increase out-of-pocket payment for asthma care, leading to financial hardships Malaysia provides Universal Health Coverage for the population with low user fees in the public health system to reduce financial hardship. We aimed to determine out-of-pocket expenditure on outpatient care for adult patients with asthma visiting government-funded public health clinics. We examined the catastrophic impact and medical impoverishment of these expenses on patients and households in Klang District, Malaysia.

METHODS

This is a cross-sectional face-to-face questionnaire survey carried out in six government-funded public health clinics in Klang District, Malaysia. We collected demographic, socio-economic profile, and outpatient asthma-related out-of-pocket payments from 1003 adult patients between July 2019 and January 2020. Incidence of catastrophic health expenditure was estimated as the proportion of patients whose monthly out-of-pocket payments exceeded 10% of their monthly household income. Incidence of poverty was calculated as the proportion of patients whose monthly household income fell below the poverty line stratified for the population of the Klang District. The incidence of medical impoverishment was estimated by the change in the incidence of poverty after out-of-pocket payments were deducted from household income. Predictors of catastrophic health expenditure were determined using multivariate regression analysis.

RESULTS

We found the majority (80%) of the public health clinic attendees were from low-income groups, with 41.6% of households living below the poverty line. About two-thirds of the attendees reported personal savings as the main source of health payment. The cost of transportation and complementary-alternative medicine for asthma were the main costs incurred. The incidences of catastrophic expenditure and impoverishment were 1.69% and 0.34% respectively. The only significant predictor of catastrophic health expenditure was household income. Patients in the higher income quintiles (Q2, Q3, Q4) had lower odds of catastrophic risk than the lowest quintile (Q1). Age, gender, ethnicity, and poor asthma control were not significant predictors.

CONCLUSION

The public health system in Malaysia provides financial risk protection for adult patients with asthma. Although patients benefited from the heavily subsidised public health services, this study highlighted those in the lowest income quintile still experienced financial catastrophe and impoverishment, and the risk of financial catastrophe was significantly greater in this group. It is crucial to ensure health equity and protect patients of low socio-economic groups from financial hardship.

Documentation of comorbidities, lifestyle factors, and asthma management during primary care scheduled asthma contacts

Systematically assessing asthma during follow-up contacts is important to accomplish comprehensive treatment. No previous long-term studies exist on how comorbidities, lifestyle factors, and asthma management details are documented in scheduled asthma contacts in primary health care (PHC). We showed comorbidities and lifestyle factors were poorly documented in PHC in this real-life, 12-year, follow-up study. Documented information on rhinitis was found in 8.9% and BMI, overweight, or obesity in ≤1.5% of the 542 scheduled asthma contacts. Of the 145 patients with scheduled asthma contacts, 6.9% had undergone revision of their inhalation technique; 16.6% had documentation of their asthma action plan. Screening of respiratory symptoms was recorded in 79% but nasal symptoms in only 15.5% of contacts. Lifestyle guidance interventions were found in <1% of contacts. These results, based on documented patient data, indicate a need exists to further improve the assessment and guidance of asthma patients in PHC.

Greenhouse gas emissions associated with suboptimal asthma care in the UK: the SABINA healthCARe-Based envirONmental cost of treatment (CARBON) study

BACKGROUND

Poorly controlled asthma is associated with increased morbidity and healthcare resource utilisation (HCRU). Therefore, to quantify the environmental impact of asthma care, this retrospective, cohort, healthCARe-Based envirONmental cost of treatment (CARBON) study estimated greenhouse gas (GHG) emissions in the UK associated with the management of well-controlled versus poorly controlled asthma.

METHODS

Patients with current asthma (aged ≥12 years) registered with the Clinical Practice Research Datalink (2008‒2019) were included. GHG emissions, measured as carbon dioxide equivalent (CO2e), were estimated for asthma-related medication use, HCRU and exacerbations during follow-up of patients with asthma classified at baseline as well-controlled (<3 short-acting β2-agonist (SABA) canisters/year and no exacerbations) or poorly controlled (≥3 SABA canisters/year or ≥1 exacerbation). Excess GHG emissions due to suboptimal asthma control included ≥3 SABA canister prescriptions/year, exacerbations and any general practitioner and outpatient visits within 10 days of hospitalisation or an emergency department visit.

RESULTS

Of the 236 506 patients analysed, 47.3% had poorly controlled asthma at baseline. Scaled to the national level, the overall carbon footprint of asthma care in the UK was 750 540 tonnes CO2e/year, with poorly controlled asthma contributing excess GHG emissions of 303 874 tonnes CO2e/year, which is equivalent to emissions from >124 000 houses in the UK. Poorly controlled versus well-controlled asthma generated 3.1-fold higher overall and 8.1-fold higher excess per capita carbon footprint, largely SABA-induced, with smaller contributions from HCRU.

CONCLUSIONS

These findings suggest that addressing the high burden of poorly controlled asthma, including curbing high SABA use and its associated risk of exacerbations, may significantly alleviate asthma care-related carbon emissions.

Tele-Monitoring Applications in Respiratory Allergy

Respiratory allergic diseases affect over 500 million people globally and pose a substantial burden in terms of morbidity, mortality, and healthcare costs. Restrictive factors such as geographical disparities, infectious pandemics, limitations in resources, and shortages of allergy specialists in underserved areas impede effective management. Telemedicine encompasses real-time visits, store-and-forward option triage, and computer-based technologies for establishing efficient doctor-patient communication. Recent advances in digital technology, including designated applications, informative materials, digital examination devices, wearables, digital inhalers, and integrated platforms, facilitate personalized and evidence-based care delivery. The integration of telemonitoring in respiratory allergy care has shown beneficial effects on disease control, adherence, and quality of life. While the COVID-19 pandemic accelerated the adoption of telemedicine, certain concerns regarding technical requirements, platform quality, safety, reimbursement, and regulatory considerations remain unresolved. The integration of artificial intelligence (AI) in telemonitoring applications holds promise for data analysis, pattern recognition, and personalized treatment plans. Striking the balance between AI-enabled insights and human expertise is crucial for optimizing the benefits of telemonitoring. While telemonitoring exhibits potential for enhancing patient care and healthcare delivery, critical considerations have to be addressed in order to ensure the successful integration of telemonitoring into the healthcare landscape.

Development of theoretically informed audit and feedback: An exemplar from a complex implementation strategy to improve asthma self-management in UK primary care

RATIONALE

Audit and feedback is an evidence-based implementation strategy, but studies reporting the use of theory to guide design elements are limited.

AIMS AND OBJECTIVES

Within the context of a programme of research aiming to improve the implementation of supported asthma self-management in UK primary care (IMPlementing IMProved Asthma self-management as RouTine [IMP2 ART]), we aimed to design and develop theoretically-informed audit and feedback that highlighted supported asthma self-management provision and areas for improvement in primary care general practices.

METHOD

Aligned with the Medical Research Council (MRC) complex intervention framework, the audit and feedback was developed in three phases: (1) Development: literature and theory exploration, and prototype audit and feedback design; (2) Feasibility: eliciting feedback on the audit and feedback from general practice staff (n = 9); (3) Prepiloting: delivering the audit and feedback within the IMP2 ART implementation strategy (incorporating patient and professional resources and an asthma review template) and eliciting clinician feedback (n = 9).

RESULTS

Audit and feedback design was guided by and mapped to existing literature suggestions and theory (e.g., Theoretical Domains Framework, Behaviour Change Technique Taxonomy). Feedback on the prototype audit and feedback confirmed feasibility but identified some refinements (a need to highlight supporting self-management and importance of asthma action plans). Prepiloting informed integration with other IMP2 ART programme strategies (e.g., patient resources and professional education).

CONCLUSION

We conclude that a multistage development process including theory exploration and mapping, contributed to the design and delivery of the audit and feedback. Aligned with the MRC framework, the IMP2 ART strategy (incorporating the audit and feedback) is now being tested in a UK-wide cluster randomised controlled trial.

[Written action plans for asthma control: How are they used by pulmonologists in France?]

INTRODUCTION

Despite evidence of the benefits of the written asthma action plans (WAP) in asthma control, they remain poorly applied. The aim of our study was to assess the practices of French-speaking pulmonologists and paediatricians in their use of WAP for asthma control and to analyse the contents of several WAPs routinely consulted in treatment of asthma patients.

METHODS

Members of three French medical societies (SPLF, G2A, SP2A) were requested to share their WAPs for asthma patients and to participate in an online survey about the possible influence of these documents on their practices.

RESULTS

Most (95%) of the 41 WAPs taken into consideration were symptom-based and 34% included peak expiratory flow measurement. All of these action plans were in full compliance with current guidelines. Among the 110 survey respondents, while 65% systematically provided a WAP to their asthma patients, only 30% often or always supplemented the written document with therapeutic education sessions. In almost every case, it was the doctor who presented the WAP to the patient, generally devoting to less than 10minutes to explanation of what they were handing out.

CONCLUSIONS

In France, WAPs are generally presented to the patient by the physician, which probably limits the time devoted to explanation of their contents. Furthermore, WAPs are rarely reinforced with therapeutic education. The current study suggests ways of improving the utilization of WAPs in asthma care and treatment.

Exploring the feasibility, acceptability, usability and safety of a digitally supported self-management intervention for uncontrolled asthma: A pre-post pilot study in secondary care

Introduction

Asthma control is often suboptimal, which is associated with incorrect medication use and poor asthma management by patients. Astmakompas, a digital self-management intervention, comprises a mobile app for patients, a web portal for healthcare professionals (HCP), and a wireless spirometer. Together, these components are intended to facilitate symptom monitoring, patient-HCP communication and assist in asthma-related self-management.

Objective

The pilot study primarily aims to assess the feasibility, acceptability, usability and safety of Astmakompas from patient and HCP perspectives, and secondarily to explore potential effects on asthma control, medication use, Quality of Life, self-efficacy and (in)direct costs.

Methods

A mixed-method, multi-center, pre-post study design was conducted in two Dutch hospitals, involving patients with uncontrolled asthma and four HCPs. Primary outcomes were assessed post-intervention using questionnaires and in-depth interviews. Secondary outcomes were assessed at baseline and post-intervention using questionnaires, and post-intervention using in-depth interviews.

Results

In general, the data show that Astmakompas was considered feasible, acceptable, usable and safe by both patients (n = 14) and HCPs (n = 4). Furthermore, qualitative data of 11 patients and all HCPs showed the importance of guidance from HCPs and tailoring of Astmakompas to care needs. Astmakompas helped patients recognise symptoms and provided valuable insights into asthma control while being easy to use. Asthma control improved from baseline (M = 2.1, SD = 1.3) to post-intervention (M = 1.3, SD = 1.0, t(13) = 2.61; p = .02).

Conclusion

Astmakompas shows promise for further implementation and research. Future randomized studies with longer evaluation periods are crucial to assess the tool's impact on asthma outcomes and workload. It is important that HCPs guide and tailor interventions to meet the patient's individual needs and circumstances.

Effects of Self-Management Interventions in People With Interstitial Lung Disease

BACKGROUND

People with interstitial lung disease (ILD) want to actively manage their condition; however, the effects of self-management interventions (SMIs) in this population have not been synthesized. This review summarizes the effects of SMIs on health-related quality of life (HRQOL), functional status, psychological and social factors, symptoms, exacerbations, health care utilization, and survival in people with ILD.

METHODS

The protocol of this systematic review was registered (PROSPERO ID: CRD42022329199). Six digital databases were searched in May 2022 with monthly updates until August 2023. Studies implementing SMIs in people with any type of ILD were included. Risk of bias (RoB) and quality of evidence were assessed with the Cochrane tool for RoB assessment and the grading of recommendations, assessment, development, and evaluations. Meta-analysis was used to summarize the results.

RESULTS

Four studies that examined 217 participants (81% male, 71 y old, 91% idiopathic pulmonary fibrosis) were included. SMIs were highly heterogeneous. Meta-analysis showed no difference in HRQOL (standardized mean difference: 0.08 [95% CI -0.21 to 0.37], P .58) nor in the secondary outcomes. No evidence for the effects of SMIs on functional capacity, exacerbations, and survival was found. The quality of evidence ranged from low to very low.

CONCLUSIONS

There is low to very low-quality evidence that SMIs have no effect in people with ILD. However, this conclusion is limited by high methodological heterogeneity. A consensus definition of SMIs is needed to implement more comparable interventions and strengthen results.

Management of asthma in primary care in the changing context of the COVID-19 pandemic: a qualitative longitudinal study with patients

BACKGROUND

The COVID-19 pandemic dramatically affected asthma monitoring in primary care, but exploration of patients' views and their experiences of managing their asthma and seeking help from primary care during the pandemic has been limited.

AIM

To investigate patients' experiences of asthma management in the community during the COVID-19 pandemic.

DESIGN AND SETTING

A qualitative longitudinal study using semi-structured interviews with patients from four GP practices across diverse regions including Thames Valley, Greater Manchester, Yorkshire, and North West Coast.

METHOD

Interviews were undertaken with patients with asthma, who were usually managed in primary care. The interviews were audiorecorded, transcribed, and analysed using inductive temporal thematic analysis and a trajectory approach.

RESULTS

Forty-six interviews were conducted with 18 patients over an 8-month period that covered contrasting stages of the COVID-19 pandemic. Patients felt less vulnerable as the pandemic subsided, but the process of making sense of risk was dynamic and influenced by multiple factors. Patients relied on self-management strategies, but felt that routine asthma reviews should still have been conducted during the pandemic and highlighted that they had limited opportunities to discuss their asthma with health professionals. Patients with well-controlled symptoms felt that remote reviews were largely satisfactory, but still thought face-to-face reviews were necessary for certain aspects, such as physical examination and patient-led discussions of sensitive or broader issues associated with asthma, including mental health.

CONCLUSION

The dynamic nature of patients' perception of risk throughout the pandemic highlighted the need for greater clarity regarding personal risk. Having an opportunity to discuss their asthma is important to patients, even when access to face-to-face consultations in primary care is more restricted than usual.

IMP2ART: development of a multi-level programme theory integrating the COM-B model and the iPARIHS framework, to enhance implementation of supported self-management of asthma in primary care

BACKGROUND

Supported asthma self-management, incorporating an asthma action plan and annual clinical review, has been recommended by UK/global guidelines for over three decades. However, implementation remains poor, as only around a third of individuals receive basic asthma care, according to the UKs leading respiratory charity Asthma and Lung UK. A systematic review of implementation studies recommended that a whole systems approach targeting patients, healthcare professional education, and organisations is needed to improve implementation of supported asthma self-management in primary care. The IMPlementing IMProved Asthma self-management as RouTine (IMP2ART) is a national Hybrid-II implementation cluster randomised controlled trial that aims to evaluate such an approach. This paper describes the development of the implementation strategy for IMP2ART with particular focus on the integration of multiple level theories.

METHODS

The Medical Research Council design and evaluation of complex interventions framework and the Person-Based Approach to intervention development were used as guidance for stages of strategy development. Specifically, we (i) set up a multidisciplinary team (including practicing and academic clinicians, health psychologists, public health and patient colleagues), (ii) reviewed and integrated evidence and theory, (iii) developed guiding principles, (iv) developed prototype materials, and (v) conducted a pre-pilot study before final refinement.

RESULTS

The implementation strategy included resources for patients, team-based and individual healthcare professional education, practice audit and feedback, and an asthma review template, as well as a facilitator role accessible to primary care practices for 12 months. The synthesis of the integrated Promoting Action on Research Implementation in Health Services (iPARIHS) and Capability, Opportunity, Motivation and Behaviour (COM-B) frameworks led to an evolved framework bringing together important implementation and behaviour change elements which will be used as a basis for the study process evaluation.

CONCLUSIONS

A description of rigorous implementation strategy development for the IMP2ART study is provided along with newly theorised integration of implementation and behaviour change science which may be of benefit to others targeting implementation in primary care.

TRIAL REGISTRATION

ISRCTN15448074. Registered on 2nd December 2019.

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).

Clinical and psychological aspects in a group of allergic asthma patients and the impact on their health status perception

BACKGROUND

The interplay between physical and psychological symptoms frequently affects the health-related quality of life of asthma patients.

PARTICIPANTS AND PROCEDURE

This research aimed at assessing the psychological status of 60 patients attending their first/second doctor visit at which they were diagnosed with allergic asthma. Information on psychological distress was collected through the Symptom Questionnaire (SQ), personality traits were described through Cattell's 16-Personality Factor Questionnaire (16-PF), stress-related behavior was detected through the P Stress Questionnaire (PSQ), and the perceived quality of life was described with the Rhinasthma questionnaire.

RESULTS

The SQ revealed anxiety levels above the clinical cut-off in 71.7% of patients, levels of depression in 46.7%, anger-hostility in 53.3%, and somatic symptoms in 65%. No significant differences were observed after three months. The 16-PF scores were also suggestive of specific personality traits associated with the predisposition towards psychosomatic disorders. However, no stress-related behaviors were observed with the PSQ. Rhinasthma highlighted a certain degree of the perceived quality of life. Additionally, the quality of life correlated with age, all psychological distress scales, a few personality traits, vigor, and stress disorders.

CONCLUSIONS

Allergic asthma patients present a higher-than-average level of psychological distress and impaired perceived quality of life at the time of diagnosis. Therefore, it is important to assess the psychological status in addition to the respiratory function.

Clinical standards for the diagnosis and management of asthma in low- and middle-income countries

BACKGROUND: The aim of these clinical standards is to aid the diagnosis and management of asthma in low-resource settings in low- and middle-income countries (LMICs).METHODS: A panel of 52 experts in the field of asthma in LMICs participated in a two-stage Delphi process to establish and reach a consensus on the clinical standards.RESULTS: Eighteen clinical standards were defined: Standard 1, Every individual with symptoms and signs compatible with asthma should undergo a clinical assessment; Standard 2, In individuals (>6 years) with a clinical assessment supportive of a diagnosis of asthma, a hand-held spirometry measurement should be used to confirm variable expiratory airflow limitation by demonstrating an acute response to a bronchodilator; Standard 3, Pre- and post-bronchodilator spirometry should be performed in individuals (>6 years) to support diagnosis before treatment is commenced if there is diagnostic uncertainty; Standard 4, Individuals with an acute exacerbation of asthma and clinical signs of hypoxaemia or increased work of breathing should be given supplementary oxygen to maintain saturation at 94-98%; Standard 5, Inhaled short-acting beta-2 agonists (SABAs) should be used as an emergency reliever in individuals with asthma via an appropriate spacer device for metered-dose inhalers; Standard 6, Short-course oral corticosteroids should be administered in appropriate doses to individuals having moderate to severe acute asthma exacerbations (minimum 3-5 days); Standard 7, Individuals having a severe asthma exacerbation should receive emergency care, including oxygen therapy, systemic corticosteroids, inhaled bronchodilators (e.g., salbutamol with or without ipratropium bromide) and a single dose of intravenous magnesium sulphate should be considered; Standard 8, All individuals with asthma should receive education about asthma and a personalised action plan; Standard 9, Inhaled medications (excluding dry-powder devices) should be administered via an appropriate spacer device in both adults and children. Children aged 0-3 years will require the spacer to be coupled to a face mask; Standard 10, Children aged <5 years with asthma should receive a SABA as-needed at step 1 and an inhaled corticosteroid (ICS) to cover periods of wheezing due to respiratory viral infections, and SABA as-needed and daily ICS from step 2 upwards; Standard 11, Children aged 6-11 years with asthma should receive an ICS taken whenever an inhaled SABA is used; Standard 12, All adolescents aged 12-18 years and adults with asthma should receive a combination inhaler (ICS and rapid onset of action long-acting beta-agonist [LABA] such as budesonide-formoterol), where available, to be used either as-needed (for mild asthma) or as both maintenance and reliever therapy, for moderate to severe asthma; Standard 13, Inhaled SABA alone for the management of patients aged >12 years is not recommended as it is associated with increased risk of morbidity and mortality. It should only be used where there is no access to ICS.The following standards (14-18) are for settings where there is no access to inhaled medicines. Standard 14, Patients without access to corticosteroids should be provided with a single short course of emergency oral prednisolone; Standard 15, Oral SABA for symptomatic relief should be used only if no inhaled SABA is available. Adjust to the individual's lowest beneficial dose to minimise adverse effects; Standard 16, Oral leukotriene receptor antagonists (LTRA) can be used as a preventive medication and is preferable to the use of long-term oral systemic corticosteroids; Standard 17, In exceptional circumstances, when there is a high risk of mortality from exacerbations, low-dose oral prednisolone daily or on alternate days may be considered on a case-by-case basis; Standard 18. Oral theophylline should be restricted for use in situations where it is the only bronchodilator treatment option available.CONCLUSION: These first consensus-based clinical standards for asthma management in LMICs are intended to help clinicians provide the most effective care for people in resource-limited settings.

Emerging Roles of Malaysian Pharmacists in Asthma Management Amidst the COVID-19 Pandemic: A Narrative Review

The arrival of COVID-19 pandemic in March 2020 adversely affected every aspect of human life, including the management of asthma. The pandemic has forced clinicians to revisit the application of high-risk aerosol-generating procedures in asthma management, including spirometry and nebuliser therapy. The use of commercial spacers with pressurised metered-dose inhalers to replace nebulisation is limited by the high cost and pandemic-induced stock unavailability of these inhalers. The need for social distancing, healthcare reserves reallocation, and scarce personal protective equipment has promote increased telemedicine uptake for patients' asthma control and monitoring. Malaysian pharmacists have been providing long-term care of asthma through the introduction of the respiratory Medication Therapy Adherence Clinic (MTAC) to empower patients' general health literacy, train and regularly evaluate their inhalation technique, and reinforce the importance of medication compliance. To minimise the use of unplanned healthcare resources and avoidable COVID-19 infection exposure, Malaysian pharmacists need to better support asthma self-management via increased uptake of written Asthma Action Plans (AAPs). Pharmacist-led asthma treatment step-down to attain the lowest effective dose of inhaled corticosteroids (ICS) has become increasingly relevant during the pandemic, as its prolonged use carries risk of numerous side effects and possible hospitalisation. Telepharmacy offers a promising model for exploration and an alternative to the traditional service delivery of asthma education. Despite not being authorised as vaccinators, Malaysian pharmacists hold strong positions in COVID-19 immunisation programmes for pharmacovigilance and advocacy. The pandemic demands an increased role for pharmacists within medication management to prevent patients from the stockpiling that can cause adverse effects on pharmaceutical supply chain. This review intends to summarise the impact of COVID-19 on asthma management, with a focus on the transitional roles of Malaysian pharmacists before and after the pandemic era.

Uncovering the Burden of Rhinitis in Patients Purchasing Nonprescription Short-Acting β-Agonist (SABA) in the Community

Asthma and rhinitis are common comorbidities that amplify the burden of each disease. They are both characterized by poor symptom control, low adherence to clinical management guidelines, and high levels of patient self-management. Therefore, this study aims to investigate the prevalence of self-reported rhinitis symptoms in people with asthma purchasing Short-Acting Beta Agonist (SABA) reliever medication from a community pharmacy and compare the medication-related behavioral characteristics among those who self-report rhinitis symptoms and those who do not. Data were analyzed from 333 people with asthma who visited one of eighteen community pharmacies in New South Wales from 2017-2018 to purchase SABA and completed a self-administered questionnaire. Participants who reported rhinitis symptoms (71%), compared to those who did not, were significantly more likely to have coexisting gastroesophageal reflux disease (GERD), overuse SABA, and experience side effects. They may have been prescribed daily preventer medication but forget to take it, and worry about its side effects. They were also more likely to experience moderate-to-severe rhinitis (74.0%), inaccurately perceive their asthma as well-controlled (50.0% self-determined vs. 14.8% clinical-guideline defined), and unlikely to use rhinitis medications (26.2%) or daily preventer medication (26.7%). These findings enhance our understanding of this cohort and allow us to identify interventions to improve patient outcomes.

ERS International Congress 2022: highlights from the Respiratory Clinical Care and Physiology Assembly

It is a challenge to keep abreast of all the clinical and scientific advances in the field of respiratory medicine. This article contains an overview of the laboratory-based science, clinical trials and qualitative research that were presented during the 2022 European Respiratory Society International Congress within the sessions from the five groups of Assembly 1 (Respiratory Clinical Care and Physiology). Selected presentations are summarised from a wide range of topics: clinical problems, rehabilitation and chronic care, general practice and primary care, mobile/electronic health (m-health/e-health), clinical respiratory physiology, exercise and functional imaging.

Personalised management and supporting individuals to live with their asthma in a primary care setting

INTRODUCTION

Complementing recognition of biomedical phenotypes, a primary care approach to asthma care recognizes diversity of disease, health beliefs, and lifestyle at a population and individual level.

AREAS COVERED

We review six aspects of personalized care particularly pertinent to primary care management of asthma: personalizing support for individuals living with asthma; targeting asthma care within populations; managing phenotypes of wheezy pre-school children; personalizing management to the individual; meeting individual preferences for provision of asthma care; optimizing digital approaches to enhance personalized care.

EXPERT OPINION

In a primary care setting, personalized management and supporting individuals to live with asthma extend beyond the contemporary concepts of biological phenotypes and pharmacological 'treatable traits' to encompass evidence-based tailored support for self-management, and delivery of patient-centered care including motivational interviewing. It extends to how we organize clinical practiceand the choices provided in mode of consultation. Diagnostic uncertainty due to recognition of phenotypes of pre-school wheeze remains a challenge for primary care. Digital health can support personalized management, but there are concerns about increasing inequities. This broad approach reflects the traditionally holistic ethos of primary care ('knowing their patients and understanding their communities'), but the core concepts resonate with all healthcare.

Home monitoring with connected mobile devices for asthma attack prediction with machine learning

Monitoring asthma is essential for self-management. However, traditional monitoring methods require high levels of active engagement, and some patients may find this tedious. Passive monitoring with mobile-health devices, especially when combined with machine-learning, provides an avenue to reduce management burden. Data for developing machine-learning algorithms are scarce, and gathering new data is expensive. A few datasets, such as the Asthma Mobile Health Study, are publicly available, but they only consist of self-reported diaries and lack any objective and passively collected data. To fill this gap, we carried out a 2-phase, 7-month AAMOS-00 observational study to monitor asthma using three smart-monitoring devices (smart-peak-flow-meter/smart-inhaler/smartwatch), and daily symptom questionnaires. Combined with localised weather, pollen, and air-quality reports, we collected a rich longitudinal dataset to explore the feasibility of passive monitoring and asthma attack prediction. This valuable anonymised dataset for phase-2 of the study (device monitoring) has been made publicly available. Between June-2021 and June-2022, in the midst of UK's COVID-19 lockdowns, 22 participants across the UK provided 2,054 unique patient-days of data.

Asthma control and care among six public health clinic attenders in Malaysia: A cross-sectional study

Background and Aims

Asthma is common in Malaysia but neglected. Achieving optimal asthma control and care is a challenge in the primary care setting. In this study, we aimed to identify the risk factors for poor asthma control and pattern of care among adults and children (5-17 years old) with asthma attending six public health clinics in Klang District, Malaysia.

Methods

We conducted a cross-sectional study collecting patients' sociodemographic characteristics, asthma control, trigger factors, healthcare use, asthma treatment, and monitoring and use of asthma action plan. Descriptive statistics and stepwise logistic regression were used in data analysis.

Results

A total of 1280 patients were recruited; 85.3% adults and 14.7% children aged 5-17 years old. Only 34.1% of adults had well-controlled asthma, 36.5% had partly controlled asthma, and 29.4% had uncontrolled asthma. In children, 54.3% had well-controlled asthma, 31.9% had partly controlled, and 13.8% had uncontrolled asthma. More than half had experienced one or more exacerbations in the last 1 year, with a mean of six exacerbations in adults and three in children. Main triggers for poor control in adults were haze (odds ratio [OR] 1.51; 95% confidence interval [CI] 1.13-2.01); cold food (OR 1.54; 95% CI 1.15-2.07), extreme emotion (OR 1.90; 95% CI 1.26-2.89); air-conditioning (OR 1.63; 95% CI 1.20-2.22); and physical activity (OR 2.85; 95% CI 2.13-3.82). In children, hot weather (OR 3.14; 95% CI 1.22-8.11), and allergic rhinitis (OR 2.57; 95% CI 1.13-5.82) contributed to poor control. The majority (81.7% of adults and 64.4% of children) were prescribed controller medications, but only 42.4% and 29.8% of the respective groups were compliant with the treatment. The importance of an asthma action plan was reported less emphasized in asthma education.

Conclusion

Asthma control remains suboptimal. Several triggers, compliance to controller medications, and asthma action plan use require attention during asthma reviews for better asthma outcomes.

IMPlementing IMProved Asthma self-management as RouTine (IMP2ART) in primary care: study protocol for a cluster randomised controlled implementation trial

BACKGROUND

Asthma is a common long-term condition and major public health problem. Supported self-management for asthma that includes a written personalised asthma action plan, supported by regular professional review, reduces unscheduled consultations and improves asthma outcomes and quality of life. However, despite unequivocal inter/national guideline recommendations, supported self-management is poorly implemented in practice. The IMPlementing IMProved Asthma self-management as RouTine (IMP2ART) implementation strategy has been developed to address this challenge. The aim of this implementation trial is to determine whether facilitated delivery of the IMP2ART strategy increases the provision of asthma action plans and reduces unscheduled care in the context of routine UK primary care.

METHODS

IMP2ART is a parallel group, cluster randomised controlled hybrid II implementation trial. One hundred forty-four general practices will be randomly assigned to either the IMP2ART implementation strategy or control group. Following a facilitation workshop, implementation group practices will receive organisational resources to help them prioritise supported self-management (including audit and feedback; an IMP2ART asthma review template), training for professionals and resources to support patients to self-manage their asthma. The control group will continue with usual asthma care. The primary clinical outcome is the between-group difference in unscheduled care in the second year after randomisation (i.e. between 12 and 24 months post-randomisation) assessed from routine data. Additionally, a primary implementation outcome of asthma action plan ownership at 12 months will be assessed by questionnaire to a random sub-group of people with asthma. Secondary outcomes include the number of asthma reviews conducted, prescribing outcomes (reliever medication and oral steroids), asthma symptom control, patients' confidence in self-management and professional support and resource use. A health economic analysis will assess cost-effectiveness, and a mixed methods process evaluation will explore implementation, fidelity and adaptation.

DISCUSSION

The evidence for supported asthma self-management is overwhelming. This study will add to the literature regarding strategies that can effectively implement supported self-management in primary care to reduce unscheduled consultations and improve asthma outcomes and quality of life.

TRIAL REGISTRATION

ISRCTN15448074. Registered on 2 December 2019.

Barriers and facilitators of electronic patient portal uptake for asthma management

OBJECTIVE

An active patient-practitioner partnership is a key aspect of asthma management and patient-reported data helps with shared decision making. Technological advances such as the electronic patient portal can facilitate partnership, with the goal of improved asthma outcomes. However, uptake of portals by end-users for asthma management has been low. We studied portal-based asthma interventions to understand barriers and facilitators to its use.

DATA SOURCES

We searched within the PubMed, Web of Science, Scopus, MEDLINE, and Google Scholar databases.

STUDY SELECTIONS

We used the PRISMA extension for scoping reviews to guide our analysis of studies related to asthma and patient portals. We summarized relevant studies in terms of barriers and facilitators as well as study characteristics.

RESULTS

Sixteen studies were included in our final analysis. Common barriers to patient portal use for asthma management were lack of perceived value by the end-user, low end-user technological literacy, and limited resources. Facilitators of portal use included ease of use, personalization, and adequate technical support. Patient portals in these studies were used for a variety of applications related to core asthma management concepts of assessment and monitoring, education for a partnership in asthma care, environmental factors, co-morbidities, and medications.

CONCLUSIONS

Patient portal use for asthma management can be encouraged by ensuring the portal is easy to access and navigate, demonstrates values, as well as has readily available technical support. Involving end-users closely in the design process and implementation may help address barriers. Special attention is needed for groups with technological resource limitations.