Asthma Review Research Articles

Evaluation of a Telehealth Paediatric Asthma and Allergy Clinic Patient Follow-Up During the COVID-19 Pandemic.

The COVID-19 pandemic created many challenges for health services, particularly during lockdown periods. Asthma is one of the most common childhood conditions, and children with asthma are generally cared for in an outpatient setting. In regional Northwest Tasmania, during the COVID-19 lockdowns, asthma and allergy outpatient clinic services were transferred to a virtual platform in the form of telehealth appointments for routine consultations. This study aims to explore the patient and family perspectives of a telehealth outpatient asthma review service in a regional area. We utilised a mixed-methods approach, interviewing parents and children who attended the clinic via telehealth and collating routine clinical audit data collected during the same period. Sixty-three patient reviews were audited, with a mean age of 9.79 years. Since their last review, 13% visited their GP, 9% presented to the ED, 6% were hospitalised, and 19% had changes in their treatment plan. Interviews highlighted three main themes: (i) telehealth is a convenient strategy for routine asthma and allergy review appointments, (ii) barriers associated with using telehealth are a minor concern for parents of children with asthma and allergy routine appointments, and (iii) shared decision-making between clinicians and parents of children with asthma and allergy around the type of appointment required is valued. We demonstrated that the benefits of telehealth include implementing treatment changes and facilitating access to care for children living in rural and remote areas.

Effectiveness and Acceptability of Asynchronous Digital Health in Asthma Care: Mixed Methods Systematic Review.

Asynchronous digital health (eg, web-based portal, text, and email communication) can overcome practical barriers associated with in-person and remote synchronous (real-time) consultations. However, little is known about the effectiveness and acceptability of asynchronous digital health to support care for individuals with asthma (eg, asthma reviews). We aimed to systematically review the qualitative and quantitative evidence on the role of asynchronous digital health for asthma care. Following Cochrane methodology, we searched 6 databases (January 2001-July 2022; search update: September 2023) for quantitative, qualitative, or mixed methods studies supporting asthma care using asynchronous digital health. Screening and data extraction were duplicated. We assessed the risk of bias in the clinical outcomes of randomized controlled trials included in the meta-analysis using the revised Cochrane risk of bias tool. For the remaining studies, we evaluated the methodological quality using the Downs and Black checklist, critical appraisal skills program, and mixed methods appraisal tool for quantitative, qualitative, and mixed methods studies, respectively. We determined the confidence in the evidence using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) criteria. We conducted a meta-analysis of trial data and a thematic analysis of qualitative data. We included 30 studies (20 quantitative, 6 qualitative, and 4 mixed methods) conducted in 9 countries involving individuals with asthma, their caregivers, and health care professionals. Asynchronous digital consultations linked with other functionalities, compared to usual care, improved asthma control (standardized mean difference 0.32, 95% CI 0.02-0.63; P=.04) and reduced hospitalizations (risk ratio 0.36; 95% CI 0.14-0.94; P=.04). However, there were no significant differences in quality of life (standardized mean difference 0.16; 95% CI -0.12 to 0.43; P=.26) or emergency department visits (risk ratio 0.83; 95% CI 0.33-2.09; P=.69). Patients appreciated the convenience of asynchronous digital health, though health care professionals expressed concerns. Successful implementation necessitated an organizational approach. Integrative synthesis underscored the ease of asking questions, monitoring logs, and medication reminders as key digital functionalities. Despite low confidence in evidence, asynchronous consultation supported by digital functionalities is an effective and convenient option for nonemergency asthma care. This type of consultation, well accepted by individuals with asthma and their caregivers, offers opportunities for those facing challenges with traditional synchronous consultations due to lifestyle or geographic constraints. However, efficient organizational strategies are needed to manage the associated workload. PROSPERO CRD42022344224; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=344224. RR2-10.1371/journal.pone.0281538.

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

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. 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. 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). 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. 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. 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.

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

BackgroundGuidelines advise minimising asthma exacerbation risk 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 questionDo guidelines-recommended activities such as asthma reviews, inhaler technique checks and asthma management plans prevent asthma exacerbations Study design and methodsThis is a retrospective chart review using UK primary-care medical records between 2004-2021, linked to hospital records. Children were eligible from asthma diagnosis until aged 16 years. Annual implementation of asthma review, inhaler technique check, management plan was measured. Risk factors for them not being undertaken were determined using multivariable logistic regression. Self-controlled case series (SCCS) was adopted to assess the effectiveness of each activity over 12-months; this was divided into two 6-month periods. Results126,483 children were eligible; 30-45% received each annual activity, 8% received all three together. Risk factors for not receiving activities included younger age, more socioeconomic deprivation, higher or no BMI measurement. Management plans and asthma reviews, as standalone activities, were associated with approximately 15% exacerbation reduction over 12-months and 8% over 6-months, respectively (management plan, N=4,624; 0-6 months (IRR, 95%CI): 0.87, 0.79-0.96; 6-12 months: 0.83, 0.73-0.95; asthma review, N=6,948; 0-6 months: 0.92, 0.85-0.99; 6-12 months: 0.93, 0.83-1.03). Standalone inhaler technique checks were not associated with exacerbations. Provision of all activities together was associated with approximately 30% exacerbation reduction over 12-months (N=3,643, 0-6 months: 0.76, 0.68-0.85; 6-12 months: 0.69, 0.60-0.81). InterpretationMost UK children do not receive the guideline-recommended activities to monitor their asthma. This study suggests, if implemented, they are effective in clinical practice and maximally effective when combined in the same visit.

Effectiveness of paediatric asthma hubs: a clinical pilot study

BackgroundChildren and young people (CYP) with asthma in the UK are at higher risk of poor outcomes compared with other high-income European countries due to factors including poor access to high-quality asthma reviews, diagnostic testing and inconsistent postattack reviews. The Leicester Integrated Care Board funded the first UK pilot asthma hub for CYP, to investigate the feasibility and effectiveness of hubs, in providing postattack reviews along with providing asthma education, the opportunity to carry out diagnostic lung function tests and optimise treatment.MethodsClinical pilot study including CYP aged 4–17 years referred to the hub with uncontrolled asthma or postattack from November 2021 to April 2022. CYP received a structured clinical assessment including National Institute for Health and Care Excellence (NICE) first-line diagnostic investigations for asthma including spirometry, bronchodilator reversibility (BDR) and fraction of exhaled nitric oxide (FeNO).ResultsOf 312 CYP referred (mean age 8.6±3.2 years; 42% women), 266 (85.3%) attended their appointment. Median time from referral to review was 2 days (IQR 1–3). Three CYP (1.1%) were severely unwell at review and required further hospital treatment. In the 231 CYP who completed first-line tests, asthma was confirmed for 73 (31.6%) based on NICE diagnostic criteria for CYP. Twenty-two per cent of children with normal baseline spirometry had ≥12% BDR.ConclusionPaediatric asthma hubs are a feasible model of care to deliver CYP postasthma attack reviews and identify high-risk patients requiring further treatment. Spirometry, BDR and FeNO testing allowed diagnostic confirmation in a significant proportion of CYP.

Prevalence and predictors of annual asthma reviews in Scottish primary care data.

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. Our study aimed to investigate the incidence and factors associated with attendance of annual reviews. electronic health records for approximately 50 000 Scottish asthma patients, between 2008 and 2016. Multivariable logistic regression using linked primary care prescription data and primary care registration demographic data. 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 1.76 [1.68-1.84]). In contrast, asthma consultations (excluding reviews) in the index year were associated with a lower odds of having a review in the following year (0.48 [0.46-0.51]). Those aged 18-35 in the index year, or with missing address in the practice registration data, were the least likely age group to have an asthma review in the following year. 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, preventative care which 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.

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

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). 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). 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). 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).

Practice list size, workforce composition and performance in English general practice: a latent profile analysis

BackgroundFollowing government calls for General Practices in England to work at scale, some practices have grown in size from traditionally small, General Practitioner (GP)-led organisations to large multidisciplinary enterprises. We assessed the effect of practice list size and workforce composition on practice performance in clinical outcomes and patient experience.MethodsWe linked five practice-level datasets in England to obtain a single dataset of practice workforce, list size, proportion of registered patients ≥ 65 years of age, female-male sex ratio, deprivation, rurality, GP contract type, patient experience of care, and Quality and Outcomes Framework (QOF) and non-QOF clinical processes and outcomes. Latent Profile Analysis (LPA) was used to cluster general practices into groups based on practice list size and workforce composition. Bayesian Information Criterion, Akaike Information Criterion and deliberation within the research team were used to determine the most informative number of groups. One-way ANOVA was used to assess how groups differed on indicator variables and other variables of interest. Linear regression was used to assess the association between practice group and practice performance.ResultsA total of 6024 practices were available for class assignment. We determined that a 3-class grouping provided the most meaningful interpretation; 4494 (74.6%) were classified as ‘Small GP-reliant practices’, 1400 (23.2%) were labelled ‘Medium-size GP-led practices with a multidisciplinary team (MDT) input’ and 131 (2.2%) practices were named ‘Large multidisciplinary practices’. Small GP-reliant practices outperformed larger multidisciplinary practices on all patient-reported indicators except on confidence and trust where medium-size GP-led practices with MDT input appeared to do better. There was no difference in performance between small GP-reliant practices and larger multidisciplinary practices on QOF incentivised indicators except on asthma reviews where medium-size GP-led practices with MDT input performed worse than smaller GP-reliant practices and immunisation coverage where the same group performed better than smaller GP-reliant practices. For non-incentivised indicators, larger multidisciplinary practices had higher cancer detection rates than small GP-reliant practices.ConclusionSmall GP-reliant practices were found to provide better patient reported access, continuity of care, experience and satisfaction with care. Larger multidisciplinary practices appeared to have better cancer detection rates but had no effect on other clinical processes and outcomes. As England moves towards larger multidisciplinary practices efforts should be made to preserve good patient experience.

Patient experiences of their current asthma care and their views toward providing support for patients with asthma in community pharmacy: A Qualitative study

BackgroundAn estimated 300 million people live with asthma globally. In England, a significant percentage live with poorly controlled asthma symptoms. Community pharmacists might be able to play a role in filling gaps in asthma care as they have the expertise and are in regular contact with patients with long term conditions. This study described patients' experiences of the management of their asthma in the general physician (GP) practice and community pharmacy settings and explored patients' views on providing support for them in community pharmacy. MethodThis is a descriptive qualitative study. Thirteen adult asthma patients were recruited from a GP practice in the Northwest of England. Semi-structured qualitative interviews were conducted face-to-face or by telephone. The interviews were recorded, transcribed and analysed using a thematic analysis approach. Ethics approval was obtained before the study commenced and all participants gave informed written consent to participate. ResultsWe identified challenges in the current asthma care provided to patients with asthma including lack of continuity of care, inability to book an appointment and other experienced differences in the quality of asthma care provided to them and/or access to annual asthma reviews across different GP practices. Additionally, there is lack of awareness of services provided in community pharmacy. These challenges along with having comorbidities alongside asthma may negatively affect asthma patients' engagement with their asthma appointments and their behaviour toward their asthma. ConclusionsPatients showed trust in community pharmacists same as other HCPs to support them with their asthma care. Patients thought that being provided with regular asthma care including reviews in community pharmacy might be a suitable approach to respond to patients' needs and preferences in terms of their asthma management because of ease of access to community pharmacy. Pharmacists could be involved in the provision of community pharmacy-based asthma interventions that involve more than inhaler technique education. Further research should focus on developing structured approaches for asthma patient education that can be implemented consistently in the context of community pharmacy in England.

Asthma reviews: A guide for nurses working in primary care

Heather Henry explains what nurses need to cover when conducting an asthma review

Post-attack asthma reviews

Post-attack asthma reviews

How does community pharmacy support patients living with asthma?

Abstract Introduction Asthma is a chronic respiratory condition that is currently an increasing issue worldwide. Particularly in the United Kingdom, 185 people are admitted to hospital because of an attack and 3 people die daily despite the National Healthcare Service (NHS) spending £1 billion on asthma care.1 Community pharmacies are taking on a more clinical role in the NHS but the extent of their role in primary care, specifically regarding helping patients living with asthma is unknown. Aim This study aimed to identify how community pharmacists reduced the general practitioners (GPs) workload by helping patients living with asthma. Methods The study used a 30-question survey to collect data from community pharmacists in North-East London boroughs (n=206 pharmacies). The survey consisted of both closed and open-ended questions, exploring the asthma interventions pharmacists conducted and the impact this had on patients, as well as the medication or devices that patients were struggling with the most and how confident pharmacists felt about all aspects of asthma. The paper-based survey was handed to each responsible pharmacist for completion. Data was input into SPSS for analysis. The study received ethical approval from Kingston University. Results Participants found the New Medicines Service to be the most helpful service (4.4/5) for patients living with asthma, followed by influenza vaccine (4/5), Community Pharmacy Consultation Service (CPCS) (3.8/5) and inhaler technique checks (3.8/5). The percentage of referrals to the GP that resulted from these services were 0-20% of patients in an average week. The most frequently referred medication was salbutamol (56.5%) due to its overuse or exacerbation of symptoms with Clenil® (15.2%) the second most referred medicine due to side-effects such as a sore throat. The most frequent inhaler device dispensed was the metered dose inhalers (94%), however the most troublesome inhalers were dry powder inhalers (50.8%) due to patient’s poor inhalation capacity, dexterity, inability to load the capsules and poor knowledge. Overall, pharmacists were confident in their ability to help asthma patients, however, younger pharmacists were less likely to check inhaler technique at every dispensing (p=0.016), more likely to check it only upon patient request (p=0.042) and were more likely to refer patients to the GP after consultations. Contrastingly, nearly all participants (93.2%) found their training for asthma and its services to be sufficient, with 62.5% using centre for pharmacy postgraduate education as their training provider. Discussion/Conclusion The results suggest that most of the time pharmacists were well trained, addressed patients concerns adequately and were able to support with adherence and usage of inhalers.2 It was clear that pharmacists do play an active role in the lives of asthma patients through the services they conduct. Their training allows pharmacists to be confident when carrying out these services so that majority of patient’s concerns are addressed within the pharmacy and only a few require GP referral. It may be beneficial to carry out technique checks more frequently, conduct asthma reviews within the pharmacy and provide additional resources to newly qualified pharmacists to aid their confidence in helping asthma patients.

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

BackgroundSupported 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.MethodsThe 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.ResultsThe 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.ConclusionsA 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 registrationISRCTN15448074. Registered on 2nd December 2019.

Post-hospitalisation asthma management in primary care: a retrospective cohort study.

Clinical guidelines recommend that patients admitted to hospital for asthma attacks are reviewed in primary care following hospital discharge. To evaluate asthma management in primary care following a hospital admission for asthma and its associations with patient characteristics. A retrospective cohort study using English primary care data from the Clinical Practice Research Datalink Aurum database and linked Hospital Episode Statistics Admitted Patient Care data. Patients with asthma aged ≥5 years who had at least one asthma-related hospital admission from 1 January 2017 to 31 December 2019 were included. The primary outcome was a composite of any of the following delivered in primary care within 28 days from hospital discharge: asthma review, asthma management plan, asthma medication prescriptions, demonstration of inhaler technique, or smoking cessation counselling. The association between patient characteristics and delivery of clinical care was assessed using logistic regression. The study included 17 457 patients. A total of 10 515 (60.2%) patients received the primary outcome within 28 days of hospital discharge. There were 2311 (13.2%) who received an asthma review, 1459 (8.4%) an asthma management plan, 9996 (57.3%) an asthma medication, 1500 (8.6%) a demonstration of inhaler technique, and 52 (1.2% of smokers) had smoking cessation counselling. Patients from Black ethnic minority groups received less of this care (27%-54% lower odds, depending on age). However, short-acting bronchodilator prescriptions in the previous year were associated with an increased likelihood of the primary outcome. A significant proportion of patients do not receive timely follow-up in primary care following asthma-related admissions to hospital, particularly among Black ethnic minority groups.

Development of an Asthma Exacerbation Risk Prediction Model for Conversational Use by Adults in England.

Improving accurate risk assessment of asthma exacerbations, and reduction via relevant behaviour change among people with asthma could save lives and reduce health care costs. We developed a simple personalised risk prediction model for asthma exacerbations using factors collected in routine healthcare data for use in a risk modelling feature for automated conversational systems. We used pseudonymised primary care electronic healthcare records from the Clinical Practice Research Datalink (CPRD) Aurum database in England. We combined variables for prediction of asthma exacerbations using logistic regression including age, gender, ethnicity, Index of Multiple Deprivation, geographical region and clinical variables related to asthma events. We included 1,203,741 patients divided into three cohorts to implement temporal validation: 898,763 (74.7%) in the training sample, 226,754 (18.8%) in the testing sample and 78,224 (6.5%) in the validation sample. The Area under the ROC curve (AUC) for the full model was 0.72 and for the restricted model was 0.71. Using a cut-off point of 0.1, approximately 27 asthma reviews by clinicians per 100 patients would be prevented compared with a strategy that all patients are regarded as high risk. Compared with patients without an exacerbation, patients who exacerbated were older, more likely to be female, prescribed more SABA and ICS in the preceding 12 months, have history of GORD, COPD, anxiety, depression, live in very deprived areas and have more severe disease. Using information available from routinely collected electronic healthcare record data, we developed a model that has moderate ability to separate patients who had an asthma exacerbation within 3 months from their index date from patients who did not. When comparing this model with a simplified model with variables that can easily be self-reported through a WhatsApp chatbot, we have shown that the predictive performance of the model is not substantially different.

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

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

Obesity alters inflammatory response in thepathology of asthma (Review).

Obesity is one of the comorbidities in patients with asthma and obese patients with asthma present with a distinct phenotype with more severe disease outcomes and reduced responsiveness to standard therapies. Although the full mechanisms of obesity‑related asthma are still not completely understood, abnormal immune responses have been demonstrated to have a critical role in asthma pathogenesis. The present review summarizes the data from clinical, epidemiological and animal studies to provide an updated understanding of the immune responses in obesity‑related asthma, as well as the effect of various factors, such as oxidative stress, mitochondrial dysfunction, genetics and epigenetics, on asthmatic inflammation. Further studies on the in‑depth mechanisms are still required to develop novel preventive and therapeutic strategies for patients with asthma combined with obesity.

HSD62 An Analysis of Asthma Care Pathways and Patient Outcomes in an East London Population Cohort: A Longitudinal Analysis Using Routinely Collected Data

Asthma is a global public health issue affecting millions of people in the UK. However, prevalence and outcomes may differ between socio-economic groups because of inequalities in care, non-adherence to medication, socio-economic circumstances, etc. Our research aims to: (i) assess the relationship between asthma outcomes, including asthma severity steps, asthma reviews, inhaler technique, management plan, exacerbations and emergency visits/admission, with deprivation (as a proxy for socioeconomic status), ethnicity or other demographic characteristics and (ii) understand how this relationship evolves across the care pathway.

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

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

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

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