case study 106 asthma

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• Published: 16 October 2014

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

• Hilary Pinnock 1 ,
• Elisabeth Ehrlich 1 ,
• Gaylor Hoskins 2 &
• Ron Tomlins 3  

npj Primary Care Respiratory Medicine volume  24 , Article number:  14063 ( 2014 ) Cite this article

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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.

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A 35-year-old sales representative attends the practice for an asthma review. Her medical record notes that she has had asthma since childhood, and although for many months of the year her asthma is well controlled (when she often reduces or stops her inhaled steroids), she experiences one or two exacerbations a year requiring oral steroids. These are usually triggered by a viral upper respiratory infection, though last summer when the pollen count was particularly high she became tight chested and wheezy for a couple of weeks.

Her regular prescription is for fluticasone 100 mcg twice a day, and salbutamol as required. She has a young family and a busy lifestyle so does not often manage to find time to attend the asthma clinic. A few weeks previously, an asthma attack had interfered with some important work-related travel, and she has attended the clinic on this occasion to ask about how this can be managed better in the future. There is no record of her having been given an asthma action plan.

What do we know about asthma self-management? The academic perspective

Supported self-management reduces asthma morbidity.

The lady in this case study is struggling to maintain control of her asthma within the context of her busy professional and domestic life. The recent unfortunate experience which triggered this consultation offers a rare opportunity to engage with her and discuss how she can manage her asthma better. It behoves the clinician whom she is seeing (regardless of whether this is in a dedicated asthma clinic or an appointment in a routine general practice surgery) to grasp the opportunity and discuss self-management and provide her with a (written) personalised asthma action plan (PAAP).

The healthcare professional advising the lady is likely to be aware that international and national guidelines emphasise the importance of supporting self-management. 1 – 4 There is an extensive evidence base for asthma self-management: a recent synthesis identified 22 systematic reviews summarising data from 260 randomised controlled trials encompassing a broad range of demographic, clinical and healthcare contexts, which concluded that asthma self-management reduces emergency use of healthcare resources, including emergency department visits, hospital admissions and unscheduled consultations and improves markers of asthma control, including reduced symptoms and days off work, and improves quality of life. 1 , 2 , 5 – 12 Health economic analysis suggests that it is not only clinically effective, but also a cost-effective intervention. 13

Personalised asthma action plans

Key features of effective self-management approaches are:

Self-management education should be reinforced by provision of a (written) PAAP which reminds patients of their regular treatment, how to monitor and recognise that control is deteriorating and the action they should take. 14 – 16 As an adult, our patient can choose whether she wishes to monitor her control with symptoms or by recording peak flows (or a combination of both). 6 , 8 , 9 , 14 Symptom-based monitoring is generally better in children. 15 , 16

Plans should have between two and three action points including emergency doses of reliever medication; increasing low dose (or recommencing) inhaled steroids; or starting a course of oral steroids according to severity of the exacerbation. 14

Personalisation of the action plan is crucial. Focussing specifically on what actions she could take to prevent a repetition of the recent attack is likely to engage her interest. Not all patients will wish to start oral steroids without advice from a healthcare professional, though with her busy lifestyle and travel our patient is likely to be keen to have an emergency supply of prednisolone. Mobile technology has the potential to support self-management, 17 , 18 though a recent systematic review concluded that none of the currently available smart phone ‘apps’ were fit for purpose. 19

Identification and avoidance of her triggers is important. As pollen seems to be a trigger, management of allergic rhinitis needs to be discussed (and included in her action plan): she may benefit from regular use of a nasal steroid spray during the season. 20

Self-management as recommended by guidelines, 1 , 2 focuses narrowly on adherence to medication/monitoring and the early recognition/remediation of exacerbations, summarised in (written) PAAPs. Patients, however, may want to discuss how to reduce the impact of asthma on their life more generally, 21 including non-pharmacological approaches.

Supported self-management

The impact is greater if self-management education is delivered within a comprehensive programme of accessible, proactive asthma care, 22 and needs to be supported by ongoing regular review. 6 With her busy lifestyle, our patient may be reluctant to attend follow-up appointments, and once her asthma is controlled it may be possible to make convenient arrangements for professional review perhaps by telephone, 23 , 24 or e-mail. Flexible access to professional advice (e.g., utilising diverse modes of consultation) is an important component of supporting self-management. 25

The challenge of implementation

Implementation of self-management, however, remains poor in routine clinical practice. A recent Asthma UK web-survey estimated that only 24% of people with asthma in the UK currently have a PAAP, 26 with similar figures from Sweden 27 and Australia. 28 The general practitioner may feel that they do not have time to discuss self-management in a routine surgery appointment, or may not have a supply of paper-based PAAPs readily available. 29 However, as our patient rarely finds time to attend the practice, inviting her to make an appointment for a future clinic is likely to be unsuccessful and the opportunity to provide the help she needs will be missed.

The solution will need a whole systems approach

A systematic meta-review of implementing supported self-management in long-term conditions (including asthma) concluded that effective implementation was multifaceted and multidisciplinary; engaging patients, training and motivating professionals within the context of an organisation which actively supported self-management. 5 This whole systems approach considers that although patient education, professional training and organisational support are all essential components of successful support, they are rarely effective in isolation. 30 A systematic review of interventions that promote provision/use of PAAPs highlighted the importance of organisational systems (e.g., sending blank PAAPs with recall reminders). 31 A patient offers her perspective ( Box 1 ), a healthcare professional considers the clinical challenge, and the challenges are discussed from an organisational perspective.

Box 1: What self-management help should this lady expect from her general practitioner or asthma nurse? The patient’s perspective

The first priority is that the patient is reassured that her condition can be managed successfully both in the short and the long term. A good working relationship with the health professional is essential to achieve this outcome. Developing trust between patient and healthcare professional is more likely to lead to the patient following the PAAP on a long-term basis.

A review of all medication and possible alternative treatments should be discussed. The patient needs to understand why any changes are being made and when she can expect to see improvements in her condition. Be honest, as sometimes it will be necessary to adjust dosages before benefits are experienced. Be positive. ‘There are a number of things we can do to try to reduce the impact of asthma on your daily life’. ‘Preventer treatment can protect against the effect of pollen in the hay fever season’. If possible, the same healthcare professional should see the patient at all follow-up appointments as this builds trust and a feeling of working together to achieve the aim of better self-management.

Is the healthcare professional sure that the patient knows how to take her medication and that it is taken at the same time each day? The patient needs to understand the benefit of such a routine. Medication taken regularly at the same time each day is part of any self-management regime. If the patient is unused to taking medication at the same time each day then keeping a record on paper or with an electronic device could help. Possibly the patient could be encouraged to set up a system of reminders by text or smartphone.

Some people find having a peak flow meter useful. Knowing one's usual reading means that any fall can act as an early warning to put the PAAP into action. Patients need to be proactive here and take responsibility.

Ongoing support is essential for this patient to ensure that she takes her medication appropriately. Someone needs to be available to answer questions and provide encouragement. This could be a doctor or a nurse or a pharmacist. Again, this is an example of the partnership needed to achieve good asthma control.

It would also be useful at a future appointment to discuss the patient’s lifestyle and work with her to reduce her stress. Feeling better would allow her to take simple steps such as taking exercise. It would also be helpful if all members of her family understood how to help her. Even young children can do this.

From personal experience some people know how beneficial it is to feel they are in a partnership with their local practice and pharmacy. Being proactive produces dividends in asthma control.

What are the clinical challenges for the healthcare professional in providing self-management support?

Due to the variable nature of asthma, a long-standing history may mean that the frequency and severity of symptoms, as well as what triggers them, may have changed over time. 32 Exacerbations requiring oral steroids, interrupting periods of ‘stability’, indicate the need for re-assessment of the patient’s clinical as well as educational needs. The patient’s perception of stability may be at odds with the clinical definition 1 , 33 —a check on the number of short-acting bronchodilator inhalers the patient has used over a specific period of time is a good indication of control. 34 Assessment of asthma control should be carried out using objective tools such as the Asthma Control Test or the Royal College of Physicians three questions. 35 , 36 However, it is important to remember that these assessment tools are not an end in themselves but should be a springboard for further discussion on the nature and pattern of symptoms. Balancing work with family can often make it difficult to find the time to attend a review of asthma particularly when the patient feels well. The practice should consider utilising other means of communication to maintain contact with patients, encouraging them to come in when a problem is highlighted. 37 , 38 Asthma guidelines advocate a structured approach to ensure the patient is reviewed regularly and recommend a detailed assessment to enable development of an appropriate patient-centred (self)management strategy. 1 – 4

Although self-management plans have been shown to be successful for reducing the impact of asthma, 21 , 39 the complexity of managing such a fluctuating disease on a day-to-day basis is challenging. During an asthma review, there is an opportunity to work with the patient to try to identify what triggers their symptoms and any actions that may help improve or maintain control. 38 An integral part of personalised self-management education is the written PAAP, which gives the patient the knowledge to respond to the changes in symptoms and ensures they maintain control of their asthma within predetermined parameters. 9 , 40 The PAAP should include details on how to monitor asthma, recognise symptoms, how to alter medication and what to do if the symptoms do not improve. The plan should include details on the treatment to be taken when asthma is well controlled, and how to adjust it when the symptoms are mild, moderate or severe. These action plans need to be developed between the doctor, nurse or asthma educator and the patient during the review and should be frequently reviewed and updated in partnership (see Box 1). Patient preference as well as clinical features such as whether she under- or over-perceives her symptoms should be taken into account when deciding whether the action plan is peak flow or symptom-driven. Our patient has a lot to gain from having an action plan. She has poorly controlled asthma and her lifestyle means that she will probably see different doctors (depending who is available) when she needs help. Being empowered to self-manage could make a big difference to her asthma control and the impact it has on her life.

The practice should have protocols in place, underpinned by specific training to support asthma self-management. As well as ensuring that healthcare professionals have appropriate skills, this should include training for reception staff so that they know what action to take if a patient telephones to say they are having an asthma attack.

However, focusing solely on symptom management strategies (actions) to follow in the presence of deteriorating symptoms fails to incorporate the patients’ wider views of asthma, its management within the context of her/his life, and their personal asthma management strategies. 41 This may result in a failure to use plans to maximise their health potential. 21 , 42 A self-management strategy leading to improved outcomes requires a high level of patient self-efficacy, 43 a meaningful partnership between the patient and the supporting health professional, 42 , 44 and a focused self-management discussion. 14

Central to both the effectiveness and personalisation of action plans, 43 , 45 in particular the likelihood that the plan will lead to changes in patients’ day-to-day self-management behaviours, 45 is the identification of goals. Goals are more likely to be achieved when they are specific, important to patients, collaboratively set and there is a belief that these can be achieved. Success depends on motivation 44 , 46 to engage in a specific behaviour to achieve a valued outcome (goal) and the ability to translate the behavioural intention into action. 47 Action and coping planning increases the likelihood that patient behaviour will actually change. 44 , 46 , 47 Our patient has a goal: she wants to avoid having her work disrupted by her asthma. Her personalised action plan needs to explicitly focus on achieving that goal.

As providers of self-management support, health professionals must work with patients to identify goals (valued outcomes) that are important to patients, that may be achievable and with which they can engage. The identification of specific, personalised goals and associated feasible behaviours is a prerequisite for the creation of asthma self-management plans. Divergent perceptions of asthma and how to manage it, and a mismatch between what patients want/need from these plans and what is provided by professionals are barriers to success. 41 , 42

What are the challenges for the healthcare organisation in providing self-management support?

A number of studies have demonstrated the challenges for primary care physicians in providing ongoing support for people with asthma. 31 , 48 , 49 In some countries, nurses and other allied health professionals have been trained as asthma educators and monitor people with stable asthma. These resources are not always available. In addition, some primary care services are delivered in constrained systems where only a few minutes are available to the practitioner in a consultation, or where only a limited range of asthma medicines are available or affordable. 50

There is recognition that the delivery of quality care depends on the competence of the doctor (and supporting health professionals), the relationship between the care providers and care recipients, and the quality of the environment in which care is delivered. 51 This includes societal expectations, health literacy and financial drivers.

In 2001, the Australian Government adopted a programme developed by the General Practitioner Asthma Group of the National Asthma Council Australia that provided a structured approach to the implementation of asthma management guidelines in a primary care setting. 52 Patients with moderate-to-severe asthma were eligible to participate. The 3+ visit plan required confirmation of asthma diagnosis, spirometry if appropriate, assessment of trigger factors, consideration of medication and patient self-management education including provision of a written PAAP. These elements, including regular medical review, were delivered over three visits. Evaluation demonstrated that the programme was beneficial but that it was difficult to complete the third visit in the programme. 53 – 55 Accordingly, the programme, renamed the Asthma Cycle of Care, was modified to incorporate two visits. 56 Financial incentives are provided to practices for each patient who receives this service each year.

Concurrently, other programmes were implemented which support practice-based care. Since 2002, the National Asthma Council has provided best-practice asthma and respiratory management education to health professionals, 57 and this programme will be continuing to 2017. The general practitioner and allied health professional trainers travel the country to provide asthma and COPD updates to groups of doctors, nurses and community pharmacists. A number of online modules are also provided. The PACE (Physician Asthma Care Education) programme developed by Noreen Clark has also been adapted to the Australian healthcare system. 58 In addition, a pharmacy-based intervention has been trialled and implemented. 59

To support these programmes, the National Asthma Council ( www.nationalasthma.org.au ) has developed resources for use in practices. A strong emphasis has been on the availability of a range of PAAPs (including plans for using adjustable maintenance dosing with ICS/LABA combination inhalers), plans for indigenous Australians, paediatric plans and plans translated into nine languages. PAAPs embedded in practice computer systems are readily available in consultations, and there are easily accessible online paediatric PAAPs ( http://digitalmedia.sahealth.sa.gov.au/public/asthma/ ). A software package, developed in the UK, can be downloaded and used to generate a pictorial PAAP within the consultation. 60

One of the strongest drivers towards the provision of written asthma action plans in Australia has been the Asthma Friendly Schools programme. 61 , 62 Established with Australian Government funding and the co-operation of Education Departments of each state, the Asthma Friendly Schools programme engages schools to address and satisfy a set of criteria that establishes an asthma-friendly environment. As part of accreditation, the school requires that each child with asthma should have a written PAAP prepared by their doctor to assist (trained) staff in managing a child with asthma at school.

The case study continues...

The initial presentation some weeks ago was during an exacerbation of asthma, which may not be the best time to educate a patient. It is, however, a splendid time to build on their motivation to feel better. She agreed to return after her asthma had settled to look more closely at her asthma control, and an appointment was made for a routine review.

At this follow-up consultation, the patient’s diagnosis was reviewed and confirmed and her trigger factors discussed. For this lady, respiratory tract infections are the usual trigger but allergic factors during times of high pollen count may also be relevant. Assessment of her nasal airway suggested that she would benefit from better control of allergic rhinitis. Other factors were discussed, as many patients are unaware that changes in air temperature, exercise and pets can also trigger asthma exacerbations. In addition, use of the Asthma Control Test was useful as an objective assessment of control as well as helping her realise what her life could be like! Many people with long-term asthma live their life within the constraints of their illness, accepting that is all that they can do.

After assessing the level of asthma control, a discussion about management options—trigger avoidance, exercise and medicines—led to the development of a written PAAP. Asthma can affect the whole family, and ways were explored that could help her family understand why it is important that she finds time in the busy domestic schedules to take her regular medication. Family and friends can also help by understanding what triggers her asthma so that they can avoid exposing her to perfumes, pollens or pets that risk triggering her symptoms. Information from the national patient organisation was provided to reinforce the messages.

The patient agreed to return in a couple of weeks, and a recall reminder was set up. At the second consultation, the level of control since the last visit will be explored including repeat spirometry, if appropriate. Further education about the pathophysiology of asthma and how to recognise early warning signs of loss of control can be given. Device use will be reassessed and the PAAP reviewed. Our patient’s goal is to avoid disruption to her work and her PAAP will focus on achieving that goal. Finally, agreement will be reached with the patient about future routine reviews, which, now that she has a written PAAP, could be scheduled by telephone if all is well, or face-to-face if a change in her clinical condition necessitates a more comprehensive review.

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Hilary Pinnock & Elisabeth Ehrlich

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Pinnock, H., Ehrlich, E., Hoskins, G. et al. A woman with asthma: a whole systems approach to supporting self-management. npj Prim Care Resp Med 24 , 14063 (2014). https://doi.org/10.1038/npjpcrm.2014.63

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DOI : https://doi.org/10.1038/npjpcrm.2014.63

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Case Study: Managing Severe Asthma in an Adult

—he follows his treatment plan, but this 40-year-old male athlete has asthma that is not well-controlled. what’s the next step.

By Kirstin Bass, MD, PhD Reviewed by Michael E. Wechsler, MD, MMSc

This case presents a patient with poorly controlled asthma that remains refractory to treatment despite use of standard-of-care therapeutic options. For patients such as this, one needs to embark on an extensive work-up to confirm the diagnosis, assess for comorbidities, and finally, to consider different therapeutic options.

Case presentation and patient history

Mr. T is a 40-year-old recreational athlete with a medical history significant for asthma, for which he has been using an albuterol rescue inhaler approximately 3 times per week for the past year. During this time, he has also been waking up with asthma symptoms approximately twice a month, and has had three unscheduled asthma visits for mild flares. Based on the  National Asthma Education and Prevention Program guidelines , Mr. T has asthma that is not well controlled. 1

As a result of these symptoms, spirometry was performed revealing a forced expiratory volume in the first second (FEV1) of 78% predicted. Mr. T then was prescribed treatment with a low-dose corticosteroid, fluticasone 44 mcg at two puffs twice per day. However, he remained symptomatic and continued to use his rescue inhaler 3 times per week. Therefore, he was switched to a combination inhaled steroid and long-acting beta-agonist (LABA) (fluticasone propionate 250 mcg and salmeterol 50 mcg, one puff twice a day) by his primary care doctor.

Initial pulmonary assessment Even with this step up in his medication, Mr. T continued to be symptomatic and require rescue inhaler use. Therefore, he was referred to a pulmonologist, who performed the initial work-up shown here:

• Spirometry, pre-albuterol: FEV1 79%, post-albuterol: 12% improvement
• Methacholine challenge: PC 20 : 1.0 mg/mL
• Chest X-ray: Within normal limits

Continued pulmonary assessment His dose of inhaled corticosteroid (ICS) and LABA was increased to fluticasone 500 mcg/salmeterol 50 mcg, one puff twice daily. However, he continued to have symptoms and returned to the pulmonologist for further work-up, shown here:

• Chest computed tomography (CT): Normal lung parenchyma with no scarring or bronchiectasis
• Sinus CT: Mild mucosal thickening
• Complete blood count (CBC): Within normal limits, white blood cells (WBC) 10.0 K/mcL, 3% eosinophils
• Immunoglobulin E (IgE): 25 IU/mL
• Allergy-skin test: Positive for dust, trees
• Exhaled NO: Fractional exhaled nitric oxide (FeNO) 53 parts per billion (pbb)

Assessment for comorbidities contributing to asthma symptoms After this work-up, tiotropium was added to his medication regimen. However, he remained symptomatic and had two more flares over the next 3 months. He was assessed for comorbid conditions that might be affecting his symptoms, and results showed:

• Esophagram/barium swallow: Negative
• Esophageal manometry: Negative
• Esophageal impedance: Within normal limits
• ECG: Within normal limits
• Genetic testing: Negative for cystic fibrosis, alpha1 anti-trypsin deficiency

The ear, nose, and throat specialist to whom he was referred recommended only nasal inhaled steroids for his mild sinus disease and noted that he had a normal vocal cord evaluation.

Following this extensive work-up that transpired over the course of a year, Mr. T continued to have symptoms. He returned to the pulmonologist to discuss further treatment options for his refractory asthma.

Diagnosis Mr. T has refractory asthma. Work-up for this condition should include consideration of other causes for the symptoms, including allergies, gastroesophageal reflux disease, cardiac disease, sinus disease, vocal cord dysfunction, or genetic diseases, such as cystic fibrosis or alpha1 antitrypsin deficiency, as was performed for Mr. T by his pulmonary team.

Treatment options When a patient has refractory asthma, treatment options to consider include anticholinergics (tiotropium, aclidinium), leukotriene modifiers (montelukast, zafirlukast), theophylline, anti-immunoglobulin E (IgE) antibody therapy with omalizumab, antibiotics, bronchial thermoplasty, or enrollment in a clinical trial evaluating the use of agents that modulate the cell signaling and immunologic responses seen in asthma.

Treatment outcome Mr. T underwent bronchial thermoplasty for his asthma. One year after the procedure, he reports feeling great. He has not taken systemic steroids for the past year, and his asthma remains controlled on a moderate dose of ICS and a LABA. He has also been able to resume exercising on a regular basis.

Approximately 10% to 15% of asthma patients have severe asthma refractory to the commonly available medications. 2  One key aspect of care for this patient population is a careful workup to exclude other comorbidities that could be contributing to their symptoms. Following this, there are several treatment options to consider, as in recent years there have been several advances in the development of asthma therapeutics. 2

Treatment options for refractory asthma There are a number of currently approved therapies for severe, refractory asthma. In addition to therapy with ICS or combination therapies with ICS and LABAs, leukotriene antagonists have good efficacy in asthma, especially in patients with prominent allergic or exercise symptoms. 2  The anticholinergics, such as tiotropium, which was approved for asthma in 2015, enhance bronchodilation and are useful adjuncts to ICS. 3-5  Omalizumab is a monoclonal antibody against IgE recommended for use in severe treatment-refractory allergic asthma in patients with atopy. 2  A nonmedication therapeutic option to consider is bronchial thermoplasty, a bronchoscopic procedure that uses thermal energy to disrupt bronchial smooth muscle. 6,7

Personalizing treatment for each patient It is important to personalize treatment based on individual characteristics or phenotypes that predict the patient's likely response to treatment, as well as the patient's preferences and practical issues, such as adherence and cost. 8

In this case, tiotropium had already been added to Mr. T's medications and his symptoms continued. Although addition of a leukotriene modifier was an option for him, he did not wish to add another medication to his care regimen. Omalizumab was not added partly for this reason, and also because of his low IgE level. As his bronchoscopy was negative, it was determined that a course of antibiotics would not be an effective treatment option for this patient. While vitamin D insufficiency has been associated with adverse outcomes in asthma, T's vitamin D level was tested and found to be sufficient.

We discussed the possibility of Mr. T's enrollment in a clinical trial. However, because this did not guarantee placement within a treatment arm and thus there was the possibility of receiving placebo, he opted to undergo bronchial thermoplasty.

Bronchial thermoplasty  Bronchial thermoplasty is effective for many patients with severe persistent asthma, such as Mr. T. This procedure may provide additional benefits to, but does not replace, standard asthma medications. During the procedure, thermal energy is delivered to the airways via a bronchoscope to reduce excess airway smooth muscle and limit its ability to constrict the airways. It is an outpatient procedure performed over three sessions by a trained physician. 9

The effects of bronchial thermoplasty have been studied in several trials. The first large-scale multicenter randomized controlled study was  the Asthma Intervention Research (AIR) Trial , which enrolled patients with moderate to severe asthma. 10  In this trial, patients who underwent the procedure had a significant improvement in asthma symptoms as measured by symptom-free days and scores on asthma control and quality of life questionnaires, as well as reductions in mild exacerbations and increases in morning peak expiratory flow. 10  Shortly after the AIR trial, the  Research in Severe Asthma (RISA) trial  was conducted to evaluate bronchial thermoplasty in patients with more severe, symptomatic asthma. 11  In this population, bronchial thermoplasty resulted in a transient worsening of asthma symptoms, with a higher rate of hospitalizations during the treatment period. 11  Hospitalization rate equalized between the treatment and control groups in the posttreatment period, however, and the treatment group showed significant improvements in rescue medication use, prebronchodilator forced expiratory volume in the first second (FEV1) % predicted, and asthma control questionnaire scores. 11

The AIR-2  trial followed, which was a multicenter, randomized, double-blind, sham-controlled study of 288 patients with severe asthma. 6  Similar to the RISA trial, patients in the treatment arm of this trial experienced an increase in adverse respiratory effects during the treatment period, the most common being airway irritation (including wheezing, chest discomfort, cough, and chest pain) and upper respiratory tract infections. 6

The majority of adverse effects occurred within 1 day of the procedure and resolved within 7 days. 6  In this study, bronchial thermoplasty was found to significantly improve quality of life, as well as reduce the rate of severe exacerbations by 32%. 6  Patients who underwent the procedure also reported fewer adverse respiratory effects, fewer days lost from work, school, or other activities due to asthma, and an 84% risk reduction in emergency department visits. 6

Long-term (5-year) follow-up studies have been conducted for patients in both  the AIR  and  the AIR-2  trials. In patients who underwent bronchial thermoplasty in either study, the rate of adverse respiratory effects remained stable in years 2 to 5 following the procedure, with no increase in hospitalizations or emergency department visits. 7,12  Additionally, FEV1 remained stable throughout the 5-year follow-up period. 7,12  This finding was maintained in patients enrolled in the AIR-2 trial despite decreased use of daily ICS. 7

Bronchial thermoplasty is an important addition to the asthma treatment armamentarium. 7  This treatment is currently approved for individuals with severe persistent asthma who remain uncontrolled despite the use of an ICS and LABA. Several clinical trials with long-term follow-up have now demonstrated its safety and ability to improve quality of life in patients with severe asthma, such as Mr. T.

Severe asthma can be a challenge to manage. Patients with this condition require an extensive workup, but there are several treatments currently available to help manage these patients, and new treatments are continuing to emerge. Managing severe asthma thus requires knowledge of the options available as well as consideration of a patient's personal situation-both in terms of disease phenotype and individual preference. In this case, the patient expressed a strong desire to not add any additional medications to his asthma regimen, which explained the rationale for choosing to treat with bronchial thermoplasty. Personalized treatment necessitates exploring which of the available or emerging options is best for each individual patient.

Published: April 16, 2018

• 1. National Asthma Education and Prevention Program: Asthma Care Quick Reference.
• 2. Olin JT, Wechsler ME. Asthma: pathogenesis and novel drugs for treatment. BMJ . 2014;349:g5517.
• 3. Boehringer Ingelheim. Asthma: U.S. FDA approves new indication for SPIRIVA Respimat [press release]. September 16, 2015.
• 4. Peters SP, Kunselman SJ, Icitovic N, et al. Tiotropium bromide step-up therapy for adults with uncontrolled asthma. N Engl J Med . 2010;363:1715-1726.
• 5. Kerstjens HA, Engel M, Dahl R. Tiotropium in asthma poorly controlled with standard combination therapy. N Engl J Med . 2012;367:1198-1207.
• 6. Castro M, Rubin AS, Laviolette M, et al. Effectiveness and safety of bronchial thermoplasty in the treatment of severe asthma: a multicenter, randomized, double-blind, sham-controlled clinical trial. Am J Respir Crit Care Med . 2010;181:116-124.
• 7. Wechsler ME, Laviolette M, Rubin AS, et al. Bronchial thermoplasty: long-term safety and effectiveness in patients with severe persistent asthma. J Allergy Clin Immunol . 2013;132:1295-1302.
• 8. Global Initiative for Asthma: Pocket Guide for Asthma Management and Prevention (for Adults and Children Older than 5 Years).
• 10. Cox G, Thomson NC, Rubin AS, et al. Asthma control during the year after bronchial thermoplasty. N Engl J Med . 2007;356:1327-1337.
• 11. Pavord ID, Cox G, Thomson NC, et al. Safety and efficacy of bronchial thermoplasty in symptomatic, severe asthma. Am J Respir Crit Care Med . 2007;176:1185-1191.
• 12. Thomson NC, Rubin AS, Niven RM, et al. Long-term (5 year) safety of bronchial thermoplasty: Asthma Intervention Research (AIR) trial. BMC Pulm Med . 2011;11:8.

More On This Topic

Treatable traits and future exacerbation risk in severe asthma, baker’s asthma, the long-term trajectory of mild asthma, age, gender, & systemic corticosteroid comorbidities, ask the expert: william busse, md, challenges the current definition of the atopic march, considering the curveballs in asthma treatment, do mucus plugs play a bigger role in chronic severe asthma than previously thought, an emerging subtype of copd is associated with early respiratory disease.

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Reviewed By Allergy, Immunology & Inflammation Assembly

Submitted by

Cathy Benninger, RN, MS, CNP

The Ohio State University

Columbus, OH

John Mastronarde, MD

Submit your comments to the author(s).

A 29-year-old man with mild persistent asthma presented to an outpatient office for a follow-up visit.  He was originally referred 6 months ago by his primary care provider after having an asthma exacerbation which required treatment in an emergency room.

At his initial visit, he reported wheeze and cough 4 days a week and nocturnal symptoms three times a month.   Spirometry revealed forced vital capacity (FVC) 85% predicted, forced expiratory volume in 1 second (FEV 1 ) 75% predicted, FEV 1 /FVC 65%, and an increase in FEV 1 of 220 ml or 14% following an inhaled short-acting bronchodilator.   He was placed on a low-dose inhaled corticosteroid twice a day and a short-acting inhaled beta-agonist as needed.  He returned 4 weeks later improved, but with continued daytime symptoms 2 days a week.  He also had symptoms of rhinitis; therefore he was referred to an allergist for evaluation. Skin testing was positive for trees, ragweed, dust mites, and cats, and he was prescribed a nasal steroid spray and nonsedating oral antihistamine.   He presents today and reports no asthma exacerbations since his last visit.  Furthermore, during the past 4 weeks, he has not been awakened by his asthma, experienced morning breathing symptoms, missed work, had any limitations in activities due to asthma, or required the use of rescue albuterol.  He currently denies shortness of breath or wheezing.  He performs aerobic exercise 4 days a week for 45 minutes per session without symptoms, provided he premedicates with a short-acting inhaled beta-agonist.  His review of symptoms is otherwise unremarkable.  His current medications include low-dose inhaled corticosteroid, 1 puff twice a day ; steroid nasal spray, 2 puffs each nostril daily; a nonsedating antihistamine, 1 tablet daily; and inhaled beta-agonist, 2 puffs as needed.    His past medical history is significant for intermittent asthma diagnosed at age 13 and frequent “colds.”  He has never required hospitalization for an asthma exacerbation .  He works as a hospital microbiologist and does not smoke, drink alcohol, or use illicit drugs.  He recently moved to a pet-free apartment complex and instituted dust mite protective barriers for his bedding .  His family history is noncontributory.

Physical Exam

The goal of asthma therapy is to minimize risk and maintain asthma control with the least amount of medication (1).   In patients with mild persistent asthma, recent studies have demonstrated several options for "step-down therapy."  The American Lung Association Asthma Clinical Research Centers network study found that patients who stepped down from twice daily low-dose fluticasone to once daily combination therapy with fluticasone/salmeterol had equivalent asthma control scores, FEV 1 , and frequency of exacerbations compared with continued therapy with twice daily fluticasone (2).  Once-daily montelukast demonstrated a slightly higher treatment failure compared with either of the regimens containing inhaled steroids.   Despite the slight increase in treatment failure with montelukast, each of the treatment groups had equivalent symptom-free days and rates of clinically significant asthma exacerbations.   Thus, while either regimen would be appropriate, stepping down to once-daily combination therapy with fluticasone/salmeterol appears to be more beneficial.

Recent studies also suggest that those with mild persistent asthma taking inhaled corticosteroids in combination with either a long-acting beta-agonist or a short-acting beta-agonist when symptomatic, had no increase in adverse outcomes compared with those taking scheduled daily inhaled doses.   Boushey et al. (3) compared patients with mild persistent asthma using twice-daily budesonide versus twice-daily zafirlukast verses placebo. All three groups used budesonide as-needed following a symptom-based action plan. The study found that in comparison with patients on a daily controller (budesonide or zafikulast), participants using only as-needed budesonide had no significant difference in morning peak expiratory flow, postbronchodilator FEV 1 , quality of life, or frequency of asthma exacerbations. Results of this study raise the possibility of treating mild persistent asthmatics with as-needed inhaled corticosteroids.   More recently, Papi et al. (4) found as-needed use of an inhaler containing both beclomethasone and albuterol for symptom relief was associated with fewer exacerbations and higher morning peak flow readings than using an inhaler with albuterol alone.   The morning peak flow readings in the as-needed combination beclomethasone/albuterol group was equivalent to those taking scheduled daily doses of beclomethasone alone, or scheduled daily doses of beclomethasone/albuterol combined.   The combination of an inhaled steroid and a short-acting beta-agonist in a single inhaler is not currently available in the United States.

In the mild persistent asthmatic there is now strong evidence to support multiple treatment approaches which provide good asthma control.   Matching the drug regimen with the patient’s preferences, lifestyle, comorbidities, and financial limitations will help ensure drug adherence and maintain asthma control.

When spirometry is used to diagnose or confirm asthma, testing must include pre- and post-bronchodilator readings (1).   A change in FEV 1 of >200 ml and ≥ 12% from the baseline measure following the administration of a short-acting bronchodilator is indicative of significant airway reversibility which has been shown to correlate with airway inflammation (7).  

The Expert Panel (1) classifies asthma severity by FEV 1 , FEV 1 /FVC, short-acting beta-agonist use, or frequency of asthma symptoms.    Parameters are measured at baseline with asthma severity determined by the worse parameter, e.g., daily symptoms with normal FEV 1 is classified as moderate persistent asthma.   Correct identification of asthma severity guides the provider in choosing the appropriate type and amount of therapy.  

Asthma symptoms should be assessed at each office visit to determine asthma control.   Validated self-assessment tools such as the Asthma Control Test (ACT), Asthma Therapy Assessment Questionnaire (ATAQ), or Asthma Control Questionnaire (ACQ) can facilitate consistent measurement and documentation of asthma symptoms during office visits (1, 8).   All asthmatics are at risk for a severe asthma attack regardless of their asthma classification; therefore, providers are encouraged to teach patients to recognize symptoms of inadequate asthma control and provide them with specific instructions for adjusting their medications or seeking medical care (1).  

When studied, only approximately 25% of patients are able to properly demonstrate use of a meter dose inhaler when asked.   The remaining 75% improved with specific instruction and practice which reinforces the need to incorporate proper inhaler use during the office visit (9,10).   The use of a spacer significantly improves accuracy and dose delivery, particularly in patients with poor coordination skills (9,10).

Assessing patient adherence is best approached with a nonjudgmental attitude.   Adherence to inhaled corticosteroids is estimated at < 50% (11).   Causes of nonadherence are multifactorial but may be improved by providing asthma education, encouraging self management through use of an asthma action plan, and facilitating open communication (11).   Financial barriers often transcend all other efforts to improve adherence and must be taken into account when prescribing asthma therapy (11).

Methacholine challenge testing is useful to demonstrate airway hyperresponsiveness in those with normal spirometry and a suspicion of asthma, but is not recommended as a serial procedure.   Biomarkers for inflammation such as eosinophils or nitric oxide are being investigated in clinical trials but currently have no indication in routine asthma care (1).   Peak flow monitoring is useful for long-term home assessment of asthma control and medication response, but is not indicated for regular office assessment or diagnostic purposes (1).

• Expert Panel Report 3 (EPR 3). Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: National Institutes of Health; 2007. NIH Publication No. 08-4051.
• The American Lung Association Asthma Clinical Research Centers. Randomized comparison of strategies for reducing treatment in mild persistent asthma. N Engl J Med 2007;356:2027-2039.
• Boushey HA, Sorkness CA, King TS, et al. Daily versus as-needed corticosteroids for mild persistent asthma. N Engl J Med 2005;352:1519-1528.
• Papi A, Giorgio GW, Maestrelli P, et al. Rescue use of beclomethasone and albuterol in a single inhaler for mild asthma. N Engl J Med 2007;356:2040-2052.
• Gibson PG, Powell H. Written action plans for asthma: an evidence-based review of the key components. Thorax 2007;59:94-99.
• Miller MR, Hankinson J, Brusasco V, et al. Series ATS/ERS Task Force: Standardization of lung function testing. Eur Respir J 2005;26:319-338.
• Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. N Engl J Med 2005;26:948-968.
• Global Initiative for Asthma. Pocket guide for asthma management and prevention. Bethesda, Md: National Institutes of Health; 2006.
• Giraud V, Roche N. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. Eur Respir J 2002;19(2):246-251.
• Johnson DH, Robart P. Inhaler technique of outpatients in the home. Respir Care 2000;45(10):1182-1187.
• Elliott RA. Poor adherence to anti-inflammatory medication in asthma reasons, challenges, and strategies for improved disease management. Dis Manage Health Outcomes 2006;14(4):223-233.

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A case study of asthma care in school age children using nurse-coordinated multidisciplinary collaborative practices

Susan procter.

1 Faculty of Society and Health, Buckinghamshire New University, High Wycombe, UK

Fiona Brooks

2 Centre for Research in Primary and Community Care (CRIPACC), University of Hertfordshire, Hatfield, UK

Patricia Wilson

3 Centre for Health Services Studies, University of Kent, Canterbury, UK

Carolyn Crouchman

Sally kendall.

To describe the role of school nursing in leading and coordinating a multidisciplinary networked system of support for children with asthma, and to analyze the strengths and challenges of undertaking and supporting multiagency interprofessional practice.

The growth of networked and interprofessional collaborations arises from the recognition that a number of the most pressing public health problems cannot be addressed by single-discipline or -agency interventions. This paper identifies the potential of school nursing to provide the vision and multiagency leadership required to coordinate multidisciplinary collaboration.

A mixed-method single-case study design using Yin’s approach, including focus groups, interviews, and analysis of policy documents and public health reports.

A model that explains the integrated population approach to managing school-age asthma is described; the role of the lead school nurse coordinator was seen as critical to the development and sustainability of the model.

School nurses can provide strategic multidisciplinary leadership to address pressing public health issues. Health service managers and commissioners need to understand how to support clinicians working across multiagency boundaries and to identify how to develop leadership skills for collaborative interprofessional practice so that the capacity for nursing and other health care professionals to address public health issues does not rely on individual motivation. In England, this will be of particular importance to the commissioning of public health services by local authorities from 2015.

Introduction

This paper presents the findings from a case study which formed one of seven case studies designed to identify the nursing contribution to chronic disease management. 1 All of the case studies were selected using criteria which indicated innovation and nurse leadership. Findings from the other six case studies, reported elsewhere, 2 highlighted considerable fragmentation in the coordination of services. The case study presented here is reported separately because it provides an exemplar of nursing leading integrated whole-system service provision for children with asthma.

The growth of networked and partnership collaborations arises from the recognition that a number of the most pressing public health problems cannot be addressed by single-agency interventions. 3 Childhood asthma falls into this category. Asthma is one of the most common long-term conditions affecting young people. The first UK national review of asthma deaths found that two thirds of deaths could be prevented with better care and that 96% of children who died did not receive care based on good practice. 4 There is evidence that peaks in hospital admission among school-age children coincides with the start of the school year. 5

A range of initiatives have been evaluated drawing on educational and population-based principles to improve asthma management among school age children. These include education initiatives, 6 , 7 asthma clubs, 8 population screening, 9 combined population screening and education, 10 , 11 and the introduction of a consulting physician with a specific remit to reduce school absenteeism. 12

Whilst school nurses have a history of working with children and families, as well as in schools to provide asthma education and support, the role of teachers in supporting parents to manage the health of school children in England is, however, unclear and in some cases contradictory. 13 , 14 The law in England says that teachers receive delegated authority from parents necessary for maintaining the child’s welfare. However, as Crouchman 13 , 14 points out, there is no obligation for teaching staff, including physical education staff, in England to do any first aid training.

Multiagency collaboration to address public health issues such as childhood asthma is increasingly being advocated. 15 There is a growing body of international knowledge about the governance, management and leadership qualities, and behaviors required for managers and clinicians to work effectively in networked or partnership collaborations. 16 – 18 However, detailed case studies have also identified significant barriers to effective teamwork, with research indicating a cautiousness among many professionals to engage in interprofessional collaboration. 18 – 20

This paper describes a nurse-led population health care service for school children with asthma in which multi-professional interagency collaboration featured strongly. Using Yin’s 21 approach to explanatory case study methodology, this case study describes the role of nursing leadership in coordinating collaborative approaches to health problems which require multiagency integration. It describes some of the challenges and tensions between the different parts of the whole system which need to be addressed in order to develop a more integrated approach to care delivery.

To describe the role of school nursing in leading and coordinating a multidisciplinary, networked system of support for children with asthma, and to analyze the strengths and challenges of undertaking and supporting collaborative interprofessional practice.

The findings presented here are taken from one of seven case study sites.

Yin’s 21 case study methodology was drawn upon to direct the fieldwork and the data analysis of the multiple sources of evidence.

Sample/participants

The case study was selected following a systematic mapping of publicly available information on nursing management of long-term conditions from across England and Wales. Leaders of services were invited to present a description of their service at a conference hosted by the research team and attended by service users. Case studies for in-depth analysis were selected by consensus methods involving all conference participants. A fuller account of sampling and case study selection is given by Wilson et al. 22

Data collection

Semistructured audio recorded face-to-face or telephone interviews were used to collect the data. Interviews lasted between 30 minutes and 1 hour and were conducted with eleven practitioners including the asthma coordinator, who was the lead school nurse, and ten school health advisors, all of whom had a school nursing qualification. All interviews were audio-recorded and transcribed verbatim. Secondary data analysis was undertaken of operational and strategic plans as well as annual reports from the Primary Care Trust (PCT) to identify the relationship between the school nursing service and the organizational objectives of the PCT and commissioners. A PCT was the organizational unit within the National Health Service (NHS) for England at the time of the study whereby services for primary care were both provided and commissioned. In 2010, there was organizational change and transition from PCTs to clinical commissioning groups and community service providers.

The researchers were not able to undertake interviews with general practitioners (GPs), although this would have added a further perspective on the strategy and is recognized as a limitation.

Ethical considerations

Informed consent was obtained from all participants who were made aware that their contribution may be published. All participants were given the opportunity to opt out following participation. Ethics and research governance approval was obtained through the NHS prior to data collection.

Data analysis

The interview data from practitioners were open–coded using N-Vivo software. These data were then subjected to thematic analysis. The reliability of the themes identified was checked by the authors who were involved in data collection and analysis.

Validity and rigor

The findings were independently reviewed by two members of the research team and discussed by the team as a whole. Disconfirming statements were searched for. An expert steering group which included patients reviewed drafts of the findings and gave critical feedback.

The case study covered a primary and secondary school-age population of approximately 40,000 children within a mainly urban area of the West Midlands with a total population of approximately 305,000. The area was characterized by a serious shortage of GPs and poor air quality. Yet, despite these problems, the emergency admission rate of children to hospital in this area was 49 compared to the standardized national average in England of 100 (rate of hospital admissions per head of population, standardized to account for regional differences in age and sex, with the average for England assigned a rate of 100).

Public policy influences on local service delivery

The asthma service was developed in response to a number of policy drivers which impacted on different provider organizations across the system:

• The Public Health Report for 2007: this report records the air quality for the local area. Its findings indicate that at the time of the study, nitrogen oxide and small particle emissions were well above the UK mean. Evidence suggests that both these emissions can have a harmful effect on the respiratory system and that nitrogen oxide has a particularly damaging effect on people with asthma, increasing hospital admissions for children. 23 , 24
• The education system: as a result of government policy, 25 all schools in England are subject to specific targets to reduce school absenteeism.
• The publication of the National Service Framework for Children and Maternity Services 26 by the UK Government included a multiagency partnership exemplar pathway for asthma in childhood.
• Every Child Matters 27 provided an integrated framework of objectives for children’s services, which health, education, and social services in England were required to meet in an attempt to create an integrated policy response to the multiple complex needs of children and young people. Specific advice was issued to schools in relation to children with asthma. This advised that children should have access to their reliever inhalers, that all schools should have an asthma policy, and that all teaching staff, but particularly teachers who supervise physical exercise, should have training once a year or be provided with information on how to care for a child with asthma. 27

The origins of the school asthma service

The development of a school asthma service in this case study began pre-2000. Community nurses had recognized the need to work with schools to meet the health needs of school-aged children with asthma. However, it was only following the appointment of the current school nurse asthma coordinator in 2000 that their aspirations were taken forward strategically:

We’ve been trying to set this policy up going back to sort of 1997 … we couldn’t really take it forward … [Asthma coordinator] came along and obviously with this excellent enthusiasm and interest in asthma and sort of really pushed the service forward. [School health advisor 1]

The initial stimulus for the school asthma strategy was the recognition by key stakeholders including health and education services of the need to provide a more integrated, seamless service for managing childhood asthma. The objectives of the service mirrored policy objectives and were designed to empower children and their families to manage asthma with confidence, reduce hospital admission, and reduce absenteeism from school.

The development of the school asthma service was aided by the charity Asthma UK, which provided 12 months’ funding to pump prime the asthma coordinator role. The role was subsequently funded by the local primary care provider. The multiagency strategy was launched by the primary care service in 2003 as described by the asthma coordinator:

The priority when I came into this post was to get 100% of schools, you know of all [town] schools to have an asthma policy. When I came into post we had 76% of schools signed up to the [town] School’s asthma policy, we’ve now got approximately 96% so there are I think three outstanding schools at the moment and that’s just a time issue for me to actually get round individually to those schools and persuade them to come on board … We have the full backing of the local authority on it, it’s a jointly ratified policy between health and education. [Asthma coordinator]

The structure of the school asthma service

The school asthma service is led by the asthma coordinator who is based in primary care. The asthma coordinator is a registered nurse and sick children’s nurse, as well as a school nurse. She coordinates a team of school health advisors, most of whom are registered as school nurses.

The school health advisors are responsible for a number of schools across the town. Each school has identified schools-based asthma support workers who could be teachers, first aid workers, or teaching assistants. The asthma support workers work with their school advisor to implement the school asthma policy. Collectively, support workers and their school health advisor carry a caseload of children with asthma. All advisors and support workers have had specialist training in asthma management and are regularly updated as part of their professional development.

The organization of the school asthma service

All children with asthma admitted to a school in the area are registered on an asthma register:

Any new children coming into school now, the parents will be sent the asthma information form and hopefully they’ll be put on the register. [School health advisor 2]

The school nurses and support workers made frequent reference to the asthma register of school-aged children and reported the register as a valuable tool that enabled them to identify children with asthma. The school nurses also referred to the way in which they used a data system to reconfigure service delivery, in particular with primary care:

I think one of the main issues was obviously parents not taking children to their asthma clinics, and we were actually saying well maybe we could be seeing the children and the parents at school. [School health advisor 2]

As part of the school asthma service, the asthma coordinator had negotiated the availability of emergency asthma medication in each school:

And also within our asthma policy we will provide for any school that wants one, an emergency salbutamol inhaler and spacer device … we do it as safely as we possibly can, we have a robust risk management strategy, we have a consultant community pediatrician who takes responsibility for placing the drug within the school, the drug is only available [to children] whose names are on the school asthma register, whose parents have signed a consent form for the use of the drug. It’s kept in a safe place within the school and it’s monitored, it’s use is monitored. [Asthma coordinator]

At the time the study was conducted, this was an innovative strategy for the management of asthma in schools. In September 2014, the Department of Health for England produced guidance for schools to enable them to use an emergency salbutamol inhaler without prescription. 28

The audit of emergency inhaler use from January 2006 to December 2006 indicated that emergency inhalers were used in schools 106 times. The close monitoring of the use of the emergency inhaler was used to identify and provide additional support for children and families who were having difficulty with asthma management:

So it’s [monitoring the use of the emergency inhaler] actually quite an effective tool in asthma management because if a child is using the school’s emergency device we want to know why. Why are they using it and it’s down to the school nurses to check those records on a monthly basis, why has Johnnie used that inhaler twice in the last month? Why didn’t he have his own inhaler? And that then generates a work load for the school nurse. [Asthma coordinator]

Throughout the year, the record of inhaler use enables the school asthma advisors to identify the children who are regularly attending school without their inhalers. This triggers a follow-up meeting with the child’s family to identify why this is happening and provide additional education and support. The results of the audit are disseminated across the case study area and between schools and GP practices.

The school asthma registers and audit data formed an important tool used by school health advisors to target interventions for asthma management. The development of a local patient record and data system can be at odds with more centralized electronic patient record systems; they also suffer from limitations in technical support and local expertise. However, the sense of ownership the team had developed was creating enhanced understanding of local needs and driving innovations in practice. The asthma coordinator was seen as the champion of much of this work as clearly identified above.

The asthma coordinator role

The asthma coordinator was seen as key to the service. She provided clear strategic leadership relating to policy and practice concerning the management of asthma in young people. This was welcomed by the School Health Advisors who were enabled to undertake their role by being able to access and work with the specialist asthma coordinator. More generic community nurses were also able to access specialist knowledge from the asthma coordinator which enhanced their service. This reflects the work of Brooks et al 29 who describe a whole network of coordinated activities which fall within the responsibility of the “navigator” role. However, in this case, there was little evidence of succession planning for the role of the asthma coordinator; neither was there evidence of service reconfiguration to adopt a more public-health-focused model. Dependence on a key, single individual was therefore a weakness of the current service.

The school asthma strategy described above had to demonstrate both impact and outcomes for the local health economy. It was clear that although there was a willingness to set up a school asthma service across core organizations, the asthma coordinator was actually key to the realization of this aspiration. Without her expert knowledge, vision, problem solving, and ability to develop and get policies and procedures ratified across all partner agencies, the service might not have been implemented.

The actual nurse time involved in developing and implementing the strategy must also be considered. We were unable to collect precise data on this, but the asthma coordinator role was a full time nursing role and the ten school health advisors had varying full time equivalencies, of which only some of their time was concerned with the asthma strategy. Whilst the cost of this nursing input on an annual basis is relatively high, it can be argued that cost savings could also be made through the reduction in hospital admissions reported for the PCT. As with all service evaluation, this may not be a direct consequence of the asthma service, but there were no other initiatives in the area that could have accounted for the relatively low hospital admission rate compared with other similar areas.

The coordination of central government policy directives towards a focus on health outcomes for children provided a rationale for expenditure that could be used by the local team to implement their vision. Without these policy initiatives, this service might not have received the support from local stakeholders required to realize these outcomes.

Whole system engagement

The school asthma service is based on public health principles of increasing the capacity across the system of support to manage asthma by raising awareness and education of health service staff, school staff, parents, and children, and as described by the asthma coordinator below:

Well another group before me had decided that we needed asthma policies in schools and they were really struggling, with the barriers between health and education really. And I sort of came on board and just ended up leading that project, just pushing it through and we’ve now got a ratified policy, our school asthma policy. [Asthma Coordinator]

The asthma coordinator working with her team of school health advisors and asthma support workers are working towards enabling the child and family to navigate 29 their way through the health and education network. The goal is to provide an integrated service in which the child with asthma can move seamlessly between NHS, school, and home:

So what we’re actually hoping to achieve at the end of this is some sort of framework integrated care pathway, I’m not really sure what it will be called. Some sort of framework, which has basically got the child or young person and their family at the very heart of the document, really in the center of it all. [School health advisor 1]

There was considerable evidence of collaborative working across agencies including health, education, voluntary sector, and the community. Within the health sector, collaboration between emergency departments, GP practices, and hospital inpatient departments was underway. This was supported by the lead for Healthy Schools on the Primary Care Directorate for Children’s Services, who commented that they had been working on:

the concept of healthy schools in [town] since 1994 so it predates the National Healthy Schools Program … And we have all of our schools signed up and committed including our referral units and we also work with the colleges and it’s very much about promoting and developing the concept of health for children within the school setting and associated settings. [Local authority lead nurse for Healthy Schools]

The healthy schools award is a national initiative which involves a formal accreditation process.

Whilst all the schools within the case study area were involved in the whole-system strategy, there was more difficulty integrating GPs and primary care as well as all other parts of the health system into the asthma strategy:

we’ve just set up the Paediatric Respiratory Forum and what that has done has brought together a range of professionals from primary and secondary care, community services, education, safeguarding children, which is another big area. Brought all of these people together and asked them to look at children with asthma in their area, what we can do about it, and how we can bring it all together basically. [Asthma coordinator]

A key performance indicator for primary care in the UK is the Quality Outcomes Framework (QOF). GPs are able to claim additional funding if they can demonstrate that they have met their QOF targets. QOF accounts for approximately 25% of general medical service income. QOF points are awarded for asthma targets, which include minimally keeping an asthma register through to monitoring those diagnosed with asthma and ensuring they receive an annual review. However, QOF targets are not specific to childhood asthma although children are included in them.

There was evidence that primary care is the weakest link in system-of-care delivery:

It’s very difficult to communicate with GP’s isn’t it, because we’re not just actually covering the schools in a certain catchment GP area. Whereas the health visitor would be working with a particular GP and could do that liaison so much better, we’re dealing with so many GP’s, children are coming from all over the borough to certain schools and that is a problem sometimes. [School health advisor 3]

This case study provides a model of how nurses can develop a system of care which reflects the principles of a public health-orientated primary care system. To make this work effectively, political and organizational commitment, networked leadership, and above all a vision of what they are trying to achieve is required. Collectively, this created a local workforce with well-developed teamwork skills and the ability to work across multiple agencies. However, establishing this service was highly dependent on the vision and energy of a single individual, which makes the replication of the service difficult to achieve. In a review of cross-sector partnerships, Andrews and Entwistle 30 found that public–public partnerships were positively associated with public service efficiency, equity, and effectiveness, indicating the potential of these partnerships to effectively address cross-agency population needs. However, as this study demonstrated, actually establishing effective multiagency partnership working requires the organizations involved to develop a shared vision beyond their individual organizational missions. Coordinated central government policies provided incentives for organizations to collaborate.

In reviewing the case study, it is clear that it conforms to many of the attributes identified by Mikkelsen-Lopez et al 16 required to create governance across health systems. These include a long-term strategic vision led by local clinical stewards (in this case the asthma coordinator) based on transparent information translated into transparent policies (the school asthma register and the inhaler policy), rules (about who can use the inhaler and follow-up of those children who do use it), and incentives (eg, to meet government targets to reduce school absenteeism).

The case study demonstrates that adherence to central government policies and a desire to meet centrally imposed targets, combined with an organic practice development methodology, has been instrumental in enabling the development of an effective local, networked asthma service. These factors have also sustained the service through some of the organizational complexity and constraints imposed by constant NHS reorganization.

Problems remain, however: the local data system set up by the service did not interface with more centralized patient and pupil records; engagement with primary care, which was also responding to a different set of government imposed targets, was still a problem; and there was an apparent lack of succession planning for the asthma coordinator. Despite these problems, there was a real sense of innovation and purpose within the network that provides optimism that such barriers can be overcome.

Front-line stewardship of service redesign is seen as a key attribute of all networked systems. 16 , 18 , 20 , 30 This paper illustrates the potential contribution primary care nurses could make to realizing collaborative professional practice within a networked system of provision. 17 The model still, however, reflects a single-disease-orientated approach to service integration; it is not clear if this model could be replicated simultaneously over a number of different long-term children’s illnesses such as diabetes, epilepsy, and sickle cell disease alongside asthma. Further theoretical, conceptual, and pragmatic work is required to address this.

Limitations of the research

This paper presents the evolution of a single service as described by those practitioners involved in the redesign and implementation of the service. Information derived from public health sources on air quality and hospital admission suggest some success in improving outcomes for the population. However, the data were not strong enough to draw any cause-and-effect conclusions. A number of papers 18 , 30 have highlighted the difficulties of undertaking research into the effectiveness of redesigned services, and the need for improved methodologies and more integrated working practices between academic researchers and service redesign is required to evidence the full impact of these changes.

Implications for public sector management

The contribution of this paper lies in its rich description of the translation into practice of features of multiagency professional collaboration that have been described in detail in the theoretical literature. It indicates the potential of nurses to undertake a leading role in initiating and sustaining public health solutions to pressing health care problems. Current literature indicates a cautiousness 19 , 20 among primary health care clinicians in relation to networked collaboration as well as considerable challenges for service managers in establishing governance systems which reflect the population focus of this way of working. 16 , 31

This paper demonstrates that public sector managers and commissioners need to understand how to support clinicians working across multiagency boundaries, including support for succession planning. This requires improved understanding about how to develop and support health professional leadership skills for collaborative interprofessional practice that does not rely on individual motivation. This presents challenges for service managers and commissioners in providing an enabling framework for public health-orientated clinical practices. This will be of increasing importance in England as the commissioning for public health services and the public health outcomes targets are transitioned from the NHS to local authorities during 2015. 32

Acknowledgments

The authors would like to acknowledge Elaine McNeilly, Jo Magnusson, Melissa Chamney, Sally Roberts, and Stephen Abbott who contributed to data collection and analysis at various stages of the PEARLE project. This project was funded by the National Institute for Health Research Health Services and Delivery Research Programme (project number 08/1605/121).

The authors report no conflicts of interest in this work. The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the HS&DR Programme, NIHR, NHS, or the Department of Health.

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Asthma Case Study

Asthma affects about 6.1 million children in the US under 18 years of age, making it one of the most common chronic childhood disorders (American Lung Association, 2021). Asthma occurs as a result of a stimulus which can range from allergens, cigarette smoke, changes in temperature, stress, or exercise. In this case we’ll experience an asthma attack and subsequent treatment with 16-year-old Ben Mason.

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