Breaking the vicious circle—the Asthma Referral Identifier (ReferID) tool

ReferID originated from the concept of the Asthma Patient Navigator (hereafter referred to as ReferID+)—a tool designed to facilitate structured, comprehensive asthma consultations—conceived by David Jackson (Guy’s and St. Thomas’ NHS Trust and King’s College London, UK) for use in the UK National Health Service environment, subject to the successful piloting of the tool. The more comprehensive ReferID+ tool was designed to guide structured consultations and ensure that critical elements of the asthma review are covered, treatment is optimised, and patients with uncontrolled and/or potentially severe asthma receive appropriate, timely referrals to specialist clinics in secondary care. This ReferID+ tool will particularly be useful in countries with well-established healthcare systems. The ReferID tool described here was developed specifically for use in low- and middle-income countries and for cases where primary care clinics have substantial resource limitations and simply do not have the means to reassess inhaler technique, adherence, SABA overuse, or many of the other factors that frequently contribute to poor disease control and risks of future sub-optimal outcomes. In these settings, by referring patients for a specialist consultation, the specialist will be able to reassess the patient, optimise treatment, and, in many cases, refer the patient back to the primary care physician with improved asthma management and treatment options. We developed ReferID in collaboration with asthma experts from around the world. Both tools, ReferID+ and ReferID, have been developed in partnership with the PRECISION programme (supported by AstraZeneca), a global initiative to improve the care and outcomes of patients with severe and uncontrolled asthma by increasing access to healthcare and improving both the speed and quality of treatment4. During our initial collaborations on ReferID, key international asthma experts provided region-specific insights on obstacles to treating asthma in primary care settings in low- and middle-income countries and suggested opportunities for how ReferID could help overcome those obstacles (Table 1). During these discussions, common themes appeared across many regions: there is no clear pathway of care; patients are stuck in a vicious circle; and easily accessible guidelines for asthma management are not routinely available in primary care settings around the world.

Table 1 Key insights on issues and opportunities in the Asia Pacific, Latin America and Middle East Regions.

To understand local patient and HCP needs, including the pathway of care, clinic workflows during new or follow-up patient visits, and potential pain points for end-use of ReferID in clinical practice, we spoke remotely with GPs and specialists throughout Asia Pacific, Latin America, and Middle East regions. We consulted with 17 HCPs, including 14 GPs and 3 specialists, from Singapore, Argentina and Kuwait. These HCPs were identified as colleagues of the collaborators who helped develop the pilot ReferID tool and were not selected through a systematic or objective process. Respondents had varying levels of experience and work settings, from public and private practices to urban and non-urban settings. These informal HCP consultations included a card-sorting exercise, a survey about a pilot version of the ReferID tool, and conversations about their asthma consultation experience, daily clinic workflows, and the facilities available within their practice. These informal consultations were designed to gain functional insights on the user experience with the pilot ReferID tool and HCP-perceived challenges in specific regions and practice settings. The consultations were not intended as a formal consensus-gathering exercise and were not designed to assess or validate specific verbiage for questions in the ReferID tool; as such, these consultations were waived for consent and ethics approval. Finally, there are currently no plans to perform a formal consultation process with additional HCPs from these countries.

During the card-sorting exercise, which was used to guide HCP conversations through specific themes, HCPs were asked to rate 20 asthma assessment questions according to priority for identifying uncontrolled or potentially severe asthma. HCPs ranked questions about asthma symptoms and exacerbations as those most helpful for understanding whether a patient has uncontrolled or severe disease, and priority rankings for the five most critical questions were generally consistent across the group (Fig. 2). There was less agreement about the relevance of other potential assessment questions related to patient risk factors (asthma triggers), patient physical characteristics (e.g., age, sex, height and weight), treatment adherence, and inhaler technique (Fig. 2). Following the card-sorting exercises, informal surveys were used to assess HCPs’ opinions about a pilot ReferID, to optimise form and function for the final ReferID tool. Most HCPs (82%) wanted to complete some or all of the assessment questions themselves, and most (82%) preferred a digital format, although some HCPs (18%) wanted the final tool in a paper format as well (Table 2). A majority of HCPs (65%) preferred that patients respond to assessment questions in front of them rather than in the clinic waiting room before the appointment (35%). Feedback from the card-sorting exercises, informal surveys and conversations were synthesised to identify challenges to asthma treatment in the Asia Pacific, Latin America and Middle East regions.

Fig. 2: HCP prioritisation of the five most critical and ten other potential asthma assessment questions (N = 17 HCPs).figure 2

ER emergency room, HCPs healthcare providers, SABA short-acting β2-agonists.

Table 2 HCP survey responses about the ideal ReferID format.

Key challenges in asthma care involve asthma seasonality, patient attitudes, patient education and barriers to care. Asthma burden is seasonal in many countries, and GPs see an influx of patients during certain peak months or seasons, for example, with increased dust flareups in spring and summer in the Middle East, during the winter flu season in South America, and with reductions in air quality in Singapore due to uncontrolled forest fires in neighbouring countries30,31,32,33,34. Concomitant with the seasonal nature of asthma are patients’ attitudes about the disease, which are largely reactive, meaning that patients may wait to visit their HCPs until they have symptoms, or they might skip follow-up appointments if their asthma improves (furthering patients’ misperceptions about the use of asthma preventers versus relievers, for example). Although the pathway of care is unclear in many regions, most HCPs said that primary care plays an important role in diagnosing and treating patients with asthma. HCPs in all regions stressed the significance of upskilling GPs and educating patients about asthma, especially basic asthma awareness, critical aspects of effective asthma management (i.e., inhaler technique and treatment adherence), and the importance of long-term care. In many regions, patients fail to seek consistent treatment for reasons outside their control, such as financial barriers and long wait times for public clinics; GPs and specialists alike suggested these constraints should be considered in the content and design of the final tool.

HCPs also provided region-specific insights on opportunities to improve patient outcomes by optimising specific aspects of the pathway of care, from the initial asthma diagnosis through treatment, follow-up asthma consultations, and potential referrals to a specialist. HCPs felt that the key factors for obtaining an accurate asthma diagnosis were the patient’s medical history, a physical examination, data from peak flow metres, responses to verbal questions, and guideline criteria. HCPs in all regions acknowledged the substantial utility of spirometry tests when making an asthma diagnosis; however, the tools are not always available in GP clinics in resource-limited areas, and respondents were concerned that including spirometry measurements in the ReferID algorithm might prevent widespread adoption of the tool. With respect to optimising treatment, HCPs highlighted the need to educate patients about inhaler technique, treatment adherence, and recommended roles for preventive and reliever medicines (i.e., consistent use of preventers to avoid overuse of short-acting beta2-agonists). Many HCPs reported that follow-up visits are vital to improving asthma treatment, particularly when considering whether to refer the patient to a specialist and for continued care following the specialist visit.

Most of the GPs, specialists, and international experts who were consulted about the pilot ReferID, agreed that the tool should be quick to complete and use the minimum questions necessary to accurately and consistently identify patients with uncontrolled and/or potentially severe asthma. This was particularly true for regions where HCPs may have limited time for patient consultation and lack specialised asthma knowledge. Indeed, beyond the concise assessment questions, HCPs wanted the flexibility to use ReferID for a more in-depth consultation if time allows, with access to patient education resources, referral recommendations from the GINA report, and resources to guide treatment optimisation2. Feedback from informal conversations with HCPs consistently underscored the importance of a format that is conducive to a back-and-forth patient-provider conversation and a shared decision-making process. HCPs recommended phrasing questions in layman’s terms, with local cultural context to support patients’ comprehension, so that HCPs could focus on the patient and effortlessly switch between interacting with the ReferID tool and conversing with the patient. The findings from this informal, user-centric qualitative research provided valuable insight on the ideal form and function of the ReferID tool. These insights are being used to translate and scale ReferID for rollout in countries around the world.

留言 (0)

沒有登入
gif