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Asthma care: getting with the Programme

Ireland has the fourth-highest prevalence of asthma worldwide, with around 470,000 Irish adults and children suffering from the condition.

Yet despite its prevalence, approximately 60 per cent of Irish patients have uncontrolled asthma and around one person dies every week from asthma. Some 90 per cent of asthma deaths are preventable.

Asthma hospital admissions cost an estimated €11.5 million annually and around 25,000 hospital visits per year are due to asthma.

The statistics make for poor reading and demonstrate the urgent need to improve services and care for asthma patients.

This has been the aim of the HSE National Asthma Programme under the guidance of Prof Pat Manning, Consultant Respiratory Physician, Bon Secours Hospital, Dublin, since its inception in early 2012.

According to Prof Manning, the Programme is seeking to maximise the health and quality of life of people with asthma and to prevent avoidable mortality due to asthma.

“Our vision for the Programme is that every adult and every child with asthma would reach their maximum health and quality of life through prevention and early detection and effective treatment for asthma,” Prof Manning told the Medical Independent (MI).

As part of his work at the HSE, Prof Manning was selected as one of the international recipients of the Global Initiative for Asthma (GINA) Ambassador Award for Asthma 2015 in Amsterdam during the European Respiratory Society Annual Meeting.

The GINA Board of Directors created the Ambassador Award to recognise the contribution of individual physicians and scientists to meeting GINA’s goals for asthma worldwide. The work of the National Asthma Programme was subsequently featured on the GINA website.

Cycle of care

A number of achievements have been made by the Programme to date, one of the most notable being the introduction of a cycle of care for asthma in general practice as part of the roll-out of free GP care to under-sixes last July.

The scheme was cautiously welcomed by GPs as the first step towards a more comprehensive model of asthma care for patients.

Around 22,000 children under the age of six are currently receiving asthma care from over 1,500 GPs under the scheme.

It is expected that the cycle of care will be expanded to older children later this year. The cost of free GP care for the under-sixes, including the asthma cycle of care, is €67 million per year.

Under the scheme, GPs have been contracted to provide three-monthly reviews and an annual review for children aged one year.

 GPs are paid €50 for the patient diagnosis/registration, with additional capitation for three-month reviews and an annual review at a cost of €90 for one-year-olds.

Additional capitation is paid from year two to six and GPs are paid €45 for annual reviews.

A typical review looks at a number of areas including diagnosis, levels of control, exacerbations, triggers, inhaler technique, allergies and smoke exposure, Prof Manning advised.

It is recommended that all patients with asthma have an individualised asthma management plan with information on triggers, treatment and steps to take, in the event of an exacerbation or asthma attack.

Prof Manning described the development as a “great achievement” and said the cycle of care reflects significant elements of the Asthma Model of Care developed by the Programme.

He expressed his hope that the cycle of care would expand to the under 12s population this year and to all asthma patients in the future.

Comprehensive approach

To date, a number of guidelines around asthma — including emergency asthma, emergency paediatric asthma and asthma control in general practice — have been developed by the Programme, along with an education programme for healthcare professionals and information for patients.

The Asthma Model of Care is due to be officially launched later this year. Starting out with very little funding due to the economic recession, the Programme focused on how to develop a comprehensive approach to asthma care in Ireland, according to Prof Manning.

“We looked at what would be needed into the future for a successful programme and we followed what generally worked in places like Finland and other countries that implemented a national asthma programme, Australia, etc. Essentially, we worked on our model of care, which is a document that looks at how asthma is managed across the system, from primary care to secondary care.”

In 2015, funding for the roll-out of two asthma integrated care demonstrator projects was released.

Initial sites with high (Midland Regional Hospital Mullingar) and low (Connolly Hospital, Blanchardstown) admission rates in adult asthma were identified.

“The aim of the project is to improve the diagnosis and management of asthma patients in the primary care setting, with links to specialist adult asthma services in order to improve health outcomes and reduce service demand, with a view to implementing this model across other sites,” Prof Manning outlined.

Two clinical nurse respiratory specialist posts were created to support the project last year and a further six specialist nursing posts linked with the HSE National COPD Programme are to be created in 2016.

“I think this will be the beginning of the future of integrated care,” he explained, “particularly if you look at chronic disease, which this is, and with a view to supporting the GP managing chronic diseases in the community. And when there’s a difficulty then referring the patient into specialist care, either for an outpatient assessment or an acute assessment.”

Work on developing a joint asthma and COPD advice line commenced in 2015 and work on the venture is still progressing. The Asthma Society of Ireland and COPD Support Ireland submitted a proposal to the HSE to fund the advice line in 2016.

Separately, development and planning for a National Severe Asthma Network began last year and is continuing, according to Prof Manning.

Engagement with the HSE has been undertaken, with a view to gaining support for which patients could receive high-cost therapies.

The Programme is also working with the Irish Thoracic Society and RCPI with a view to establishing a network of specialist respiratory colleagues that would have an interest in assessing severe asthma patients.

Prof Manning believes that the network, when established, could lead to the development of asthma research networks and clinical trials.

An audit of asthma deaths in Ireland, similar to one undertaken in the UK recently, is also planned and funding has been identified.

Initial discussions with Dr Philip Crowley, HSE Head of Quality Improvement, have taken place.

The project aims to identify and understand preventable factors related to the management and self-management of asthma to improve the care of people with asthma and prevent future deaths, according to Prof Manning.

Community care

A number of other areas of asthma care are being targeted for improvement this year, including the expansion of spirometry testing in the community.

Spirometry testing is currently very haphazard in Ireland, with some GPs providing the service and others not, Prof Manning noted.

“I suppose in terms of its usefulness, generally anybody over eight years old could do it. A spirometry test is a fast-blow test… somebody with asthma will have a reduced test if they’ve got ongoing wheeze,” he explained.

“Accessibility is an issue we’re trying to address. Certainly in some practices they have spirometry but we want to ensure that anybody who is providing spirometry has the training that would be necessary to interpret the results and also to do the study itself. It’s not just doing the test.

“We would hope that we would be able to provide a service to GPs, either from the hospital base going out to GPs, or the GP practice themselves would be trained up to do that; a specialist there to do that for them. So it is an important thing that we would like to develop.”

In the absence of spirometry testing, Prof Manning recommended the use of a peak flow metre in the management of asthma.

Prof Manning did not comment on specific funding allocations to the Programme but stressed that despite the challenges created by the recession, the Programme had made notable achievements, with more progress to be made in the future.

National Asthma Programme objectives

Quality objectives:

  • All patients diagnosed with asthma are enrolled in a structured asthma programme that will address:
  • Education about asthma, personal trigger factors and medication.
  • Assessment of control.
  • Inhaler device and technique.
  • Smoking cessation/exposure to second-hand smoke.

 

Access objectives:

  • Ensure all patients receive guideline concordant care based upon level of control.
  • Maximise the proportion of patients with asthma whose asthma is controlled.
  • Reduce asthma mortality by 90 per cent over a 10-year period (2013-2023).

 

Value objectives:

  • Reduce GP out-of-hours visits due to asthma by 10 per cent (5,000) over three years.
  • Reduce ED visits due to asthma by 10 per cent (2,000) over three years.
  • Reduce asthma inpatient bed days by 10 per cent per year over three years.

Programme priorities for 2016

Priorities for the HSE’s National Asthma Programme in 2016 (in conjunction with the HSE National COPD Programme) include:

  1. Supporting the implementation of further asthma demonstration projects in primary care, plus the establishment of integrated care services for patients with asthma and COPD to allow better diagnosis and management.
  2. Continued work on the National Severe Asthma Network.
  3. Development of the National Acute Paediatric Asthma Guidelines in collaboration with the National Clinical Effectiveness Committee for launch in late 2016.
  4. Supporting the work of implementing the under-sixes cycle of asthma care and to update the general asthma management guidelines with GPs (ICGP) and when required, for possible future roll-out in primary care of this cycle of care and chronic disease management for asthmatics.
  5. In line with the HSE National COPD Programme, overseeing the expansion of spirometry testing services.
  6. Advocating for better care for asthma patients by increasing public awareness of asthma by working with patient representative groups, such as the Asthma Society of Ireland. 

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