UK primary care: are early referrals the key to improving asthma outcomes?
Published online April 1, 2021
Referral of severe asthma patients to specialist care is associated with improved outcomes, but primary care physicians are often reticent to refer them because they are under the impression that all asthma can be managed effectively in primary care and/or are unaware of the benefits of referral. Thus, it is essential to identify patients with potential severe asthma (PSA) who are hidden in primary care and are not referred for specialist assessment, because these patients may benefit from specialist review and treatments.
In a recent article published in The Journal of Allergy and Clinical Immunology: In Practice, Ryan et al. identified patients with PSA managed in UK primary care using data from the Optimum Patient Care Research Database (OPCRD), estimated how many are hidden from specialist care, and compared the demographic and clinical characteristics of patients with PSA with those of patients with a confirmed severe diagnosis using data from UK patients enrolled in the International Severe Asthma Registry (ISAR).
A study based on historic real-world data was conducted using data from the OPCRD and ISAR. OPCRD inclusion criteria required patients to be aged ≥16 years with an active asthma diagnosis pre-2014, have received ≥1 asthma medication during the 1-year follow-up period, and have ≥1 year of data from 2014 onwards while patients with physician-confirmed diagnosis of other respiratory conditions were excluded. ISAR inclusion criteria required patients to be aged ≥18 years with a confirmed severe asthma diagnosis receiving the Global Initiative for Asthma (GINA) (2018) step 5 treatment or have uncontrolled asthma at GINA 2018 step 4. A total of 207,557 patients from OPCRD meeting all study-specific inclusion criteria were included.
Ryan and colleagues reported that 8% (n=16,409/207,557) of OPCRD patients with active asthma (aged ≥16 years) were found to have PSA. An alarming 72% (n=11,741/16,409) of these PSA patients had not been reviewed by, or referred to, a specialist in the past year, with 56% (n=9,113) having no record of specialist referral or review ever during the, on average, 19-year OPCRD look back period.
Patients with PSA in the OPCRD group were more likely to be female, over 60 years of age, overweight/obese with co-morbidities (allergic rhinitis and eczema being the most common) and be current or ex-smokers when compared to UK patients enrolled in ISAR. They are characterized by poor lung function, poor disease control, and multiple exacerbations annually. These clinical characteristics may help primary care physicians recognize those with potential hidden severe asthma in their care. These patients would also benefit from a structured review by their primary care physician, with possible prompt referral to specialist care.
The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.