Aac For RF

The AAC’s Consensus Pathway for Uncontrolled and Severe Asthma

Thursday, June 16, 2022

Respiratory Futures spoke to two of the members of the group behind the development of this pathway, James Rose Head of Clinical Innovation Adoption at the Oxford Academic Health Science Network, and Dr Hitasha Rupani, Consultant Respiratory Physician at the University Southampton NHS Foundation Trust, and chair of the group. The pathway has been published today on the Oxford AHSN website.

Thank you both for speaking to us. Could you tell us why have you embarked in the development of this document?

At present, there is no national guidance dedicated to uncontrolled and severe asthma. The care pathway for people with severe asthma is fragmented- the Severe Asthma Toolkit is focused on tertiary care but what about primary care?

We know there are patients with uncontrolled asthma in primary and secondary care and so we wanted to bring together all these elements of care, offer guidance on best practice and, where appropriate, on timelines.

Who is this document for?

This pathway has been designed to support all those involved in providing, commissioning or supporting asthma care in England whether working in primary, secondary and tertiary care in severe asthma centres. The pathway primarily looks at the identification and management of adult patients with uncontrolled and potentially severe asthma.

The pathway makes it clear that care for people with uncontrolled or severe asthma is a multi-professional effort and only through collaborative joined up approaches can we really provide the level of support that these patients really need. We have tried to make it explicit that there must be an integrated care approach to patient management that links all stages of diagnosis, management, referral and follow-up on this pathway.

What is in the pathway?

Through the AAC Asthma Biologics programme we have produced a consensus pathway based on collective and shared clinical experience and the best available research. In it, we summarise a consensus approach to optimisation of patients in primary care and a set of criteria and timelines for referral to secondary or tertiary care for local consideration.

The pathway recommends a more proactive approach to the identification of uncontrolled asthma patients, looking for signs of uncontrolled asthma in patients at regular intervals, and we feel there is a key role for technology here to support asthma teams to flag high-risk patients from clinical system notes and prescriptions.

A key part of the pathway has been to reassess the role of secondary care in providing care for severe or potentially severe asthma patients. We propose a tiered model of care for secondary care sites based on resource, capabilities, and capacity which we hope will see more centres support initiation and monitoring of biologic therapies.

Finally, the pathway looks at key aspects of tertiary care provision and looks to make recommendations around the key steps and appropriate timeframes to decision points through services again for local service leads to consider.

Importantly this consensus pathway is not a full guideline, but is a tool to inform and raise awareness of consensus best practice and to start conversations locally and regionally about redefining asthma pathways with uncontrolled and severe asthma in mind.

How is this pathway going to change the patient journey?

We hope that the AAC consensus pathway will act to catalyse local service and pathway transformation to ensure patients with uncontrolled and potential severe asthma are identified earlier, referred appropriately to secondary or tertiary services and are able to access life-changing biologics therapies with fewer barriers.

What will be the benefit to the patient?

Improving elements of the uncontrolled and severe asthma patient pathway will have a multitude of patient benefits. We hope that it will see more patients with improved asthma control and suffering fewer exacerbations.

We hope that it will see improved access to severe asthma care and biologic therapies for asthma and in turn, less reliance on oral corticosteroids. We hope that it will see faster progress to key decision points in the pathway to enable accelerated access to appropriate treatments. Finally, we hope that it will mean that patients will be able to access severe asthma care and biologics closer to where they live.

How did you develop the pathway?

This was a key workstream of the AAC Asthma Biologics programme. The group that was tasked to develop the pathway included a core team of clinical leads supported by Oxford AHSN and stakeholders from a large number of organisations involved in asthma care, including patients, to make sure that our pathway connected seamlessly across the patient’s journey and to other important initiatives designed to improve asthma care.

We conducted a number of focussed workshops, and took into account recent research and evaluations including the AAC NICE adoption scoping report, the Academic Health Science Network Severe Asthma Benchmarking exercise, the AAC Asthma UK Patient Journey time audit and the recent Delphi consensus study of best practice for referral and management of Asthma.

Once the overall structure and direction was agreed, individual clinical leaders took responsibility to develop elements of the pathway specific to their area, such as assessment and management of uncontrolled asthma and severe asthma in primary and secondary care.

Is the work finished, or is there more to do for patients with uncontrolled and severe asthma?

Publishing the consensus pathway will be an important step for uncontrolled and severe asthma care in England, however it is only the first step. The priority moving forward will be to support system leaders, local decision makers and those involved in asthma care to improve their regional asthma pathways. There is currently significant regional and local variation in current pathways, resource and outcomes for uncontrolled and severe asthma patients. Local discussion and agreement around how best the AAC consensus pathway and its elements can be implemented will be critical to delivering improvements that will offer significant benefit for asthma patients.

For more information on the wider AAC Asthma Biologics programme and for details of your local AHSN asthma lead supporting this work please visit https://www.oxfordahsn.org/our-work/asthma-biologics-toolkit/asthma-biologics-overview/  

There is also an evidence-based Asthma Structured Medication Review template now available for use with asthma patients. It can be imported free of charge into GP prescribing systems (EMISweb and SystmOne). It guides the user through calculations, potential reasons for non-adherence, techniques to optimise inhaler use and how to minimise the environmental impact of inhalers by choosing the most appropriate device for them. Access the template here.

An aligned educational module on medication adherence is available here.