Implementing Spirometry and Fractional Exhaled Nitric Oxide Testing in Childhood Asthma Management in UK Primary Care: An Observational Study to Examine Training and Implementation Cost and Impact on Patient’s Health Use and Outcome

Abstract

National Asthma Guidelines are important to implement in the primary care setting to provide standardized and improved asthma care. This study was designed to evaluate the implementation and clinical outcomes related to the delivery of spirometry and fractional exhaled nitric oxide (FeNO) testing for children with diagnosed or suspected asthma in the primary care setting.The study included 27 clinical staff from 10 general practices and 612 children with asthma ages 5 to 16 years in a prospective observational cohort in the United Kingdom. Children with asthma were defined as those with the diagnosis of asthma or those suspected to have asthma who were prescribed asthma medications in the last 12 months.Training materials on spirometry and FeNO tests were developed and taught to 27 clinical staff to implement for the study patients. The cost of implementation was estimated based on time, cost of resources, and standard costs of care in the UK-based system. The study then compared this invested cost to the benefits, such as decreased unplanned healthcare utilization and the amount of oral corticosteroids used. Participants were given the 3 questionnaires: Asthma Control Test (ACT), mini Pediatric Asthma Quality of Life Questionnaire (mini PAQLQ), and Child's Health Utility 9D (CHU9D), which measure asthma control, asthmatic quality of life, and general health, respectively, at the time of review and 6 months later to measure the benefits.The overall cost for material development, training time, and purchase of equipment was about £58 317 ($75 171 US dollars). The study equipment included 2 spirometers and 2 FeNO machines that rotated between clinics; however, the spirometry machines were donated and therefore, did not contribute to the total costs. Healthcare utilization was reduced by a total of £26 064 ($33 596) or £43 ($55) per child in the subsequent 6 months after the asthma review. Following the asthma assessments, there was an increase in daily inhaled corticosteroids prescribed, and fewer children required prescribed oral corticosteroids. There was no significant difference in the number of short-acting β-agonist inhalers prescribed. Of the 612 children, only 226 however completed their follow-up surveys at 6 months. ACT scores for ages 5 and up improved significantly. The mini PAQLQ was not statistically significant and the CHU9D decreased significantly at follow-up.Overall, the cost to train the staff and implement spirometry and FeNO measurement practices in the primary care clinic was £95 per child ($123). The potential healthcare dollar savings and benefits demonstrated with improved outcomes are significant and worth consideration and investment.This study from the UK demonstrates how a $150 investment per asthmatic child could lead to fewer emergency department visits, better controller medication compliance, fewer oral steroids, and better healthcare dollar utilization overall. With training and implementation of asthma education using objective asthma data at the primary care provider level, these improved asthma outcomes can be achieved. A similar study based on the most recent EPR-4 guidelines and the American medical system would be beneficial to assess the translation and replication of cost-benefit analysis in the US healthcare system.URL: www.pediatrics.org/cgi/doi/10.1542/peds.10.1136.archdischild-2020-319310