Gaylor Hoskins

Risk factors and costs associated with an asthma attack

BACKGROUND A study was undertaken to identify asthma patients at risk of an attack and to assess the economic impact of treatment strategies. METHODS A retrospective cohort analysis of a representative data set of 12 203 patients with asthma in the UK over a one year period was performed. Logistic multiple regression was used to model the probability of an attack occurring using a set of categorised predictor factors. Health service costs were calculated by applying published average unit costs to the patient resource data. The main outcome measures were attack incidence, health service resource use, drug treatment, and cost estimates for most aspects of asthma related health care. RESULTS Children under five years of age accounted for 597 patients (5%), 3362 (28%) were aged 5–15 years, 4315 (35%) 16–44, 3446 (28%) 45–74, and 483 (4%) were aged over 74 years. A total of 9016 patients (74%) were on some form of prophylactic asthma medication; 2653 (22%) experienced an attack in the year data collection occurred. Overall health care expenditure was estimated at £2.04 million. The average cost per patient who had an attack was £381 compared with £108 for those who did not, an increase of more than 3.5 times. In those aged under five and those over 75 years of age there were no significant markers to identify risk, but both groups were small in size. The level of treatment step in the British Thoracic Society (BTS) asthma guidelines was a statistically significant factor for all other age groups. Night time symptoms were significant in the 5–15, 16–44 and 45–74 age groups, exercise induced symptoms were only significant for the 5–15 age group, and poor inhaler technique in the 16–44 age group. CONCLUSIONS Patients at any treatment step of the BTS asthma guidelines are at risk of an asthma attack, the risk increasing as the treatment step increases. Poorly controlled asthma may have a considerable impact on health care costs. Appropriate targeting of preventive measures could therefore reduce overall health care costs and the growing pressures on hospital services associated with asthma management.

Lessons from a randomized controlled trial designed to evaluate computer decision support software to improve the management of asthma.

PRIMARY OBJECTIVE To investigate whether computer decision support software used in the management of patients with asthma improves clinical outcomes. RESEARCH DESIGN Randomized controlled trial with practices each reporting on 30 patients with asthma over a 6 month period. METHODS AND PROCEDURES 447 patients were randomly selected from practice asthma registers managed by 17 general practices from throughout the UK. Intervention practices used the software during consultations with these patients throughout the study while control practices did not. MAIN OUTCOMES AND RESULTS Practice consultations, acute exacerbations of asthma, hospital contacts, symptoms on assessment and medication use. A smaller proportion of patients within the intervention group initiated practice consultations for their asthma: 34 (22%) vs 111 (34%), odds ratio (OR) = 0.59, 95% confidence interval (CI) (0.37-0.95); and suffered acute asthma exacerbations: 12 (8%) vs 57 (17%), OR = 0.43, 95% CI = 0.21-0.85 six months after the introduction of the computer decision support software. There were no discernable differences in reported symptoms, maintenance prescribing or use of hospital services between the two groups. CONCLUSION The use of computer decision support software that implements guidelines during patient consultations may improve clinical outcomes for patients with asthma.Primary objective : To investigate whether computer decision support software used in the management of patients with asthma improves clinical outcomes. Research design : Randomized controlled trial with practices each reporting on 30 patients with asthma over a 6 month period. Methods and procedures : 447 patients were randomly selected from practice asthma registers managed by 17 general practices from throughout the UK. Intervention practices used the software during consultations with these patients throughout the study while control practices did not. Main outcomes and results : Practice consultations, acute exacerbations of asthma, hospital contacts, symptoms on assessment and medication use. A smaller proportion of patients within the intervention group initiated practice consultations for their asthma: 34 (22%) vs 111 (34%), odds ratio (OR)= 0.59, 95% confidence interval (CI) (0.37-0.95); and suffered acute asthma exacerbations: 12 (8%) vs 57 (17%) , OR = 0.43, 95% CI = 0.21- 0.85 six months after the introduction of the computer decision support software. There were no discernable differences in reported symptoms, maintenance prescribing or use of hospital services between the two groups. Conclusion : The use of computer decision support software that implements guidelines during patient consultations may improve clinical outcomes for patients with asthma.

Developing novel evidence-based interventions to promote asthma action plan use: a cross-study synthesis of evidence from randomised controlled trials and qualitative studies

BackgroundLong-standing randomised controlled trial (RCT) evidence indicates that asthma action plans can improve patient outcomes. Internationally, however, these plans are seldom issued by professionals or used by patients/carers. To understand how the benefits of such plans might be realised clinically, we previously investigated barriers and facilitators to their implementation in a systematic review of relevant RCTs and synthesised qualitative studies exploring professional and patient/carer views. Our final step was to integrate these two separate studies.MethodsFirst, a theoretical model of action plan implementation was proposed, derived from our synthesis of 19 qualitative studies, identifying elements which, if incorporated into future interventions, could promote their use. Second, 14 RCTs included in the quantitative synthesis were re-analysed to assess the extent to which these elements were present within their interventions (that is, ‘strong’, ‘weak’ or ‘no’ presence) and with what effect. Matrices charted each element’s presence and strength, facilitating analysis of element presence and action plan implementation.ResultsFour elements (professional education, patient/carer education, (patient/carer and professional) partnership working and communication) were identified in our model as likely to promote asthma plan use. Thirteen interventions reporting increased action plan implementation contained all four elements, with two or more strongly present. One intervention reporting no effect on action plan implementation contained only weakly present elements. Intervention effectiveness was reported using a narrow range of criteria which did not fully reflect the four elements. For example, no study assessed whether jointly developed action plans increased use. Whilst important from the professional and patient/carer perspectives, the integral role of these elements in intervention delivery and their effect on study outcomes was under-acknowledged in these RCTs.ConclusionsOur novel approach provides an evidence-base for future action plan interventions. Such interventions need to ensure all elements in our implementation model (patient/carer and professional education to support development of effective partnership working and communication) are strongly present within them and a wider range of criteria better reflecting the realities of clinical practice and living with asthma are used to measure their effectiveness. We now intend to test such a complex intervention using a cluster trial design.

Practice development plans to improve the primary care management of acute asthma: randomised controlled trial

BackgroundOur professional development plan aimed to improve the primary care management of acute asthma, which is known to be suboptimal.MethodsWe invited 59 general practices in Grampian, Scotland to participate. Consenting practices were randomised to early and delayed intervention groups. Practices undertook audits of their management of all acute attacks (excluding children under 5 years) occurring in the 3 months preceding baseline, 6-months and 12-months study time-points. The educational programme [including feedback of audit results, attendance at a multidisciplinary interactive workshop, and formulation of development plan by practice teams] was delivered to the early group at baseline and to the delayed group at 6 months. Primary outcome measure was recording of peak flow compared to best/predicted at 6 months. Analyses are presented both with, and without adjustment for clustering.Results23 consenting practices were randomised: 11 to early intervention. Baseline practice demography was similar. Six early intervention practices withdraw before completing the baseline audit. There was no significant improvement in our primary outcome measure (the proportion with peak flow compared to best/predicted) at either the 6 or 12 month time points after adjustment for baseline and practice effects. However, the between group difference in the adjusted combined assessment score, whilst non-significant at 6 months (Early: 2.48 (SE 0.43) vs. Delayed 2.26 (SE 0.33) p = 0.69) reached significance at 12 m (Early:3.60 (SE 0.35) vs. Delayed 2.30 (SE 0.28) p = 0.02).ConclusionWe demonstrated no significant benefit at the a priori 6-month assessment point, though improvement in the objective assessment of attacks was shown after 12 months. Our practice development programme, incorporating audit, feedback and a workshop, successfully engaged the healthcare team of participating practices, though future randomised trials of educational interventions need to recognise that effecting change in primary care practices takes time. Monitoring of the assessment of acute attacks proved to be a feasible and responsive indicator of quality care.

Systems for the management of respiratory disease in primary care - an international series: United Kingdom

INTRODUCTION The UK National Health Service (NHS) is essentially publicly funded through general taxation. Challenges facing the NHS include the rise in prevalence of long-term conditions and financial pressures. NATIONAL POLICY TRENDS: Political devolution within the UK has led to variations in the way services are organised and delivered between the four nations. PRIMARY CARE RESPIRATORY SERVICES IN THE UK: Primary care is the first point of contact with services. Most respiratory conditions are managed here, including prevention, diagnosis, treatment and palliative care. EPIDEMIOLOGY Respiratory disease accounts for more primary care consultations than any other type of illness, with 24 million consultations annually. ACCESS TO CARE Equitable access to care is an ongoing challenge: telehealthcare is being tried as a possible solution for monitoring of asthma and COPD. REFERRAL AND ACCESS TO SPECIALIST CARE: Referrals for specialist advice are usually to a secondary care respiratory physician, though respiratory General Practitioners with a Special Interest (GPwSIs) are an option in some localities. CONCLUSIONS Prevalence of asthma and COPD is high. Asthma services are predominantly nurse-led. Self-management strategies are widely promoted but poorly implemented. COPD is high on the policy agenda with a shift in focus to preventive lung health and longterm condition management.

The 'vicious cycle' of personalised asthma action plan implementation in primary care: a qualitative study of patients and health professionals' views

BackgroundPersonal asthma action plans (PAAPs) have been guideline recommended for years, but consistently under-issued by health professionals and under-utilised by patients. Previous studies have investigated sub-optimal PAAP implementation but more insight is needed into barriers to their use from the perspective of professionals, patients and primary care teams.MethodsA maximum variation sample of professional and patient participants were recruited from five demographically diverse general practices and another group of primary care professionals in one Scottish region. Interviews were digitally recorded and data thematically analysed using NVivo.ResultsTwenty-nine semi-structured interviews were conducted (11 adults with asthma, seven general practitioners, ten practice nurses, one hospital respiratory nurse). Three over-arching themes emerged: 1) patients generally do not value PAAPs, 2) professionals do not fully value PAAPs and, 3) multiple barriers reduce the value of PAAPs in primary care. Six patients had a PAAP but these were outdated, not reflecting their needs and not used. Patients reported not wanting or needing PAAPs, yet identified circumstances when these could be useful. Fifteen professionals had selectively issued PAAPs with eight having reviewed one. Many professionals did not value PAAPs as they did not see patients using these and lacked awareness of times when patients could have benefited from one. Multi-level compounding barriers emerged. Individual barriers included poor patient awareness and professionals not reinforcing PAAP use. Organisational barriers included professionals having difficulty accessing PAAP templates and fragmented processes including patients not being asked to bring PAAPs to their asthma appointments.ConclusionsPrimary care PAAP implementation is in a vicious cycle. Professionals infrequently review/update PAAPs with patients; patients with out-dated PAAPs do not value or use these; professionals observing patients’ lack of interest in PAAPs do not discuss these. Patients observing this do not refer to their plans and perceive them to be of little value in asthma self-management. Twenty-five years after PAAPs were first recommended, primary care practices are still not ready to support their implementation. Breaking this vicious cycle to create a healthcare context more conducive to PAAP implementation requires a whole systems approach with multi-faceted interventions addressing patient, professional and organisational barriers.

Do the British Guidelines for Asthma Management facilitate concordance

Background  Asthma is an example of a common, chronic illness in which clinicians are encouraged to promote concordance and adhere to guidelines. Some existing research suggests that these aims may be incompatible.

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

BACKGROUND Achieving asthma control is central to optimising patient quality of life and clinical outcome. Contemporary models of chronic disease management across a variety of countries point to the importance of micro, meso and macro level influences on patient care and outcome. However, asthma outcomes research has almost invariably concentrated on identifying and addressing patient predictors. Little is known about higher level organisational influences. OBJECTIVE This paper explores the contribution of organisational factors on poor asthma control, allowing for patient factors, at three organisational levels: the individual patient, local service deliverers, and strategic regional providers. DESIGN, SETTING AND PARTICIPANTS Prospective cross-sectional observational cohort study of 64,929 people with asthma from 1205 primary care practices spread throughout the United Kingdom (UK). Patient clinical data were recorded during a routine asthma review. METHOD Data were analysed using simple descriptive, multiple regression and complex multi-level modelling techniques, accounting for practice clustering of patients. RESULTS Poor asthma control was associated with areas of higher deprivation [regression coefficient 0.026 (95% confidence intervals 0.006; 0.046)] and urban practice [-0.155 (-0.275; -0.035)] but not all local and regional variation was explained by the data. In contrast, patient level predictors of poor control were: short acting bronchodilator overuse [2.129 (2.091; 2.164)], days-off due to asthma [1.203 (1.148; 1.258)], PEFR<80 [0.76 (0.666; 0.854)], non-use of a self-management plan (SMP) [0.554 (0.515; 0.593)], poor inhaler technique [0.53 (0.475; 0.585)], poor medication compliance [0.385 (-0.007; 0.777)], and gender [0.314 (0.281; 0.347)]. Pattern of medication use, smoking history, age, body mass index (BMI), and health service resource use were also significant factors for predicting control. CONCLUSIONS Targeting of health service resource requires knowledge of the factors associated with poor control of asthma symptoms. In the UK the contribution of local and regional structures appears minimal in explaining variation in asthma outcomes. However, unexplained variation in the data suggests other unrecorded factors may play a part. While patient personal characteristics (including self-management plan use, inhaler technique, medication compliance) appear to be the predominant influence the complex nature of the disease means that some, perhaps more subtle, influences are affecting the variability at all levels and this variance needs to be explored. Further research in other international contexts is required to identify the likely applicability of these findings to other health care systems.

Goal-setting intervention in patients with active asthma: protocol for a pilot cluster-randomised controlled trial

BackgroundSupporting self-management behaviours is recommended guidance for people with asthma. Preliminary work suggests that a brief, intensive, patient-centred intervention may be successful in supporting people with asthma to participate in life roles and activities they value. We seek to assess the feasibility of undertaking a cluster-randomised controlled trial (cRCT) of a brief, goal-setting intervention delivered in the context of an asthma review consultation.Methods/designA two armed, single-blinded, multi-centre, cluster-randomised controlled feasibility trial will be conducted in UK primary care. Randomisation will take place at the practice level. We aim to recruit a total of 80 primary care patients with active asthma from at least eight practices across two health boards in Scotland (10 patients per practice resulting in ~40 in each arm). Patients in the intervention arm will be asked to complete a novel goal-setting tool immediately prior to an asthma review consultation. This will be used to underpin a focussed discussion about their goals during the asthma review. A tailored management plan will then be negotiated to facilitate achieving their prioritised goals. Patients in the control arm will receive a usual care guideline-based review of asthma. Data on quality of life, asthma control and patient confidence will be collected from both arms at baseline and 3 and 6 months post-intervention. Data on health services resource use will be collected from all patient records 6 months pre- and post-intervention. Semi-structured interviews will be carried out with healthcare staff and a purposive sample of patients to elicit their views and experiences of the trial. The outcomes of interest in this feasibility trial are the ability to recruit patients and healthcare staff, the optimal method of delivering the intervention within routine clinical practice, and acceptability and perceived utility of the intervention among patients and staff.Trial registrationISRCTN18912042

A woman with asthma: a whole systems approach to supporting self-management.

A 35-year-old lady attends for review of her asthma following an acute exacerbation. There is an extensive evidence base for supported self-management for people living with asthma, and international and national guidelines emphasise the importance of providing a written asthma action plan. Effective implementation of this recommendation for the lady in this case study is considered from the perspective of a patient, healthcare professional, and the organisation. The patient emphasises the importance of developing a partnership based on honesty and trust, the need for adherence to monitoring and regular treatment, and involvement of family support. The professional considers the provision of asthma self-management in the context of a structured review, with a focus on a self-management discussion which elicits the patient’s goals and preferences. The organisation has a crucial role in promoting, enabling and providing resources to support professionals to provide self-management. The patient’s asthma control was assessed and management optimised in two structured reviews. Her goal was to avoid disruption to her work and her personalised action plan focused on achieving that goal.