Annual Scientific Meeting 2023

Lee B¹, Turner S², Borland M³ *, Csonka P⁴*, Grigg J⁵*,  Guilbert T⁶*, Jartti T^7,8,9*, Oommen A¹⁰*, Lewis S¹¹, Cunningham S¹². * listed in alphabetical order by surname.  

¹Asthma UK Centre for Applied Research, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK. ²Royal Aberdeen Children’s Hospital, NHS Grampian, Aberdeen, UK . ³Divisions of Paediatrics and Emergency Medicine, School of Medicine, University of Western Australia, Australia. ⁴Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland. ⁵Centre for Genomics and Child Health, Queen Mary University of London, UK. ⁶Division of Pulmonology Medicine, Cincinnati Children's Hospital & Medical Center, USA. ⁷Department of Pediatrics, Turku University Hospital and University of Turku, Turku, Finland. ⁸PEDEGO, Research Unit, University of Oulu, Oulu, Finland. ⁹Department of Pediatrics, Oulu University Hospital, Oulu, Finland. ¹⁰Department of Paediatrics, Milton Keynes University Hospital NHS Trust, United Kingdom. ¹¹Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK. ¹²Asthma UK Centre for Applied Research, NHS Lothian, Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK. 

Introduction. Our systematic review (SR) of the effects of oral corticosteroids (OCS) on preschool wheeze found inconclusive effects due to high heterogeneity between RCTs. We conducted an Individual Participant Data (IPD) meta-analysis from RCTs to evaluate the efficacy of OCS for preschool wheeze treatment.  Methods. IPD were obtained from seven trials identified from our SR (n=2172). We analysed the following outcomes in children aged 12-71 months (n= 1823): change in wheezing severity score (WSS); length of hospital stay (LOS); and revisit to GP/emergency department (ED) or hospital.  Two-stage meta-analysis using a random-effects model was used. Results. Compared to the placebo group, the change in WSS at 4 hours in the OCS group showed a mean difference (MD) of -0.31 (95% CI= -0.38 to -0.24, I2= 0.0%) in the two studies where data were available after adjusting for age (months), allergies and parental allergies. For change in WSS at 12 hours, the MD in three studies was 0.09 (95% CI: -0.69 to 0.87, I2= 0.0%). In five studies, OCS treatment was associated with an MD in LOS of -3.18 hours (95% CI= -4.43 to -1.93, I2= 0.0%). For revisit to GP/ED and rehospitalisation, the pooled ORs in seven studies were respectively 1.11 (95% CI= 0. 86 to 1.43, I2= 0.0%) and 0.94 (95% CI= 0.38 to 2.32, I2= 20.3%). There was no evidence of a subgroup in whom OCS had a preferential benefit. Conclusions. OCS could be beneficial for short-term outcomes for acute wheeze in preschool children, but does not appear to have long-term benefits. 

Lewis G^1,2, Milnes L^1,2, Adams A*^2,3, Schwarze J*^2,4, Duff A^1,2,3  *Listed alphabetically

¹School of Healthcare, Faculty of Medicine and Health, University of Leeds, Leeds, United Kingdom. ² Asthma UK Centre for Applied Research, USHER Institute, University of Edinburgh, Edinburgh, United Kingdom. ³ Paediatric Respiratory Unit, Leeds Children’s Hospital, Clarendon Wing, Leeds General Infirmary, Leeds, United Kingdom, ⁴ Child Life and Health, Centre for Inflammation Research, The University of Edinburgh, Edinburgh, United Kingdom

Background. Families of children and young people (CYP) with asthma are tasked with asthma trigger and indoor allergen avoidance as part of supported self-management.  However, multiple triggers exist, and CYP are often poly-sensitised to allergens, complicating identification of asthma triggers and decisions regarding remediation.  A scoping review identified very limited evidence explaining what influences family uptake of trigger and allergen remediations. Aim. To understand influences on trigger and allergen avoidance from the perspectives of CYP with asthma and allergic sensitisation to indoor environmental allergens and their parents, to provide insight for future interventions to increase avoidance uptake. Methods. In-depth qualitative interviews with CYP aged 11–15-years, with severe/sub-optimally controlled asthma and allergic sensitisation to pets and/or house dust mites, and CYP’s parents were conducted.   Grounded theory methodology guided study design and analyses.  Patient and public involvement was included throughout. Findings. 21 individuals (11 mothers and 10 CYP) participated.  Multiple factors affect families’ decisions about trigger and allergen avoidance, including perceived asthma severity, observable responses to exposures, and the acceptability of remediation methods.  Families value discussion of individualised needs and barriers to avoidance uptake with health professionals.  Findings suggest families with sensitised children will employ allergen remediations in response to repeated attacks and hospitalisations, but many do not employ methods with the greatest evidence base.  Moreover, avoidance uptake was often many years after initial advice was given following allergen testing.  Families also struggled to understand the mechanisms linking allergen exposure and asthma control. Conclusions. Families may benefit from educational interventions to enhance understanding of the mechanisms linking allergen and trigger exposures with asthma control.  Interventions could aim to explain which allergen reduction methods currently show effectiveness for CYP with asthma.   Additionally, interventions addressing the delayed uptake of avoidance could aid self-management.

Funding: [This work is funded by Asthma + Lung UK as part of Asthma UK Centre for Applied Research AUK-AC-2018-01]

Gudziunaite S^1, Mackintosh KA^1, Jordan KA^1, Davies GA²​​​,​ Lewis PD³​​​​, Griffiths CJ⁴ and McNarry MA¹. 

¹Applied Sports, Technology, Exercise and Medicine (A-STEM) Research Centre, Swansea University, Swansea, UK. ²Swansea University Medical School, Swansea University, Swansea, UK. ³Vindico, Llanelli, UK. ⁴Blizard Institute, Queen Mary University of London, London, UK.

Background. Children are more susceptible to air pollution due, at least in part, to their less developed respiratory systems and higher respiratory rates. Whilst the health benefits associated with physical activity are indisputable, there is considerable debate regarding whether the increased exposure to, and deeper inhalation of, air pollution while being physically active negates such health benefits. Objectives. The purpose of this review was to explore the relationship between air pollution and lung function, and the role of asthma status and physical activity in this relationship, in children and adolescents. Methods. In accordance with PRISMA guidelines, the following databases were searched (March 2022) with no date restrictions: PubMed, Web of Science, MEDLINE, EMBASE, SPORTDiscus and Cochrane Central Register of Controlled Trials (CENTRAL). Studies were included if they: (1) studied children (5 – 16 years); (2) were peer-reviewed; (3) available in the English language; and (4) recorded data using pre-determined validated-tools. Interim results. 11,262 references were retrieved of which 3,857 papers were duplicates and a further 7,392 were excluded due to not meeting inclusion criteria. From this, 13 studies were included in this review. An increased exposure to various air pollutants, particularly during times of outdoor physical activity resulted in lung function deficits, with little variation according to the type of pollutant, this was especially concerning for children with pre-established respiratory conditions. Discussion. Children with respiratory conditions, appeared more sensitive to variations in pollution and therefore might benefit from individualised physical activity plans/frequent asthma management re-evaluations from family doctors. It is yet to be fully elucidated how early-years exposure to air pollution contributes to the development of asthma and to what extent it does so. However, local-Governments and local authorities must continue to reduce air pollution levels and bring about change at a population level through reducing air pollution levels. 

Registration – CRD42022307206 Funding – This work is funded by Asthma + Lung UK through the Asthma UK Centre for Applied Research [AUK-AC-2012-01 and AUK-AC-2018-01]. 

Easton S^1,2, Ainsworth B², Thomas M²​, Latter S²,Knibb R³, Cook A¹, Wilding S¹, Bahrami-Hessari M¹, Kennington E⁴, Gibson D¹, Wilkins H¹, Yardley L², Roberts G^1,2

¹University Hospital Southampton. ²University of Southampton. ³University of Aston. ⁴Asthma + Lung UK.

Background. Many adolescents with asthma co-present with dysfunctional breathing and have poor quality of life. Breathing retraining is recommended to encourage patients to manage symptoms and increase breathing efficiency. Digital interventions are a potential self-management tool to provide breathing retraining at low-cost and have already successfully demonstrated improvements in the quality of life in an existing adult study (BREATHE). Aim. The current pilot study aimed to explore the acceptability and feasibility of conducting a definitive trial to evaluate the effectiveness and cost-effectiveness of a breathing retraining intervention for adolescents with asthma (Breathe4T). Methods. Adolescents with asthma (n=64) were recruited via primary and secondary care within the UK to take part in a 6-month trial. Adolescents (aged 12-17 years) with physician diagnosed asthma and impaired quality of life were recruited and randomised into two, parallel groups. The intervention group accessed the website for 6 months (n=32) and a usual care group received access at the end of the trial period (n=32). Both groups were followed up after 2 and 6 months. Intervention usage data was collected, in addition to 13 interviews to explore participant’s experiences of using the intervention. Results. Adolescents were successfully recruited from primary and secondary care, despite challenges relating to the Covid-19 pandemic. The results indicated that a future trial would need ~20 secondary care sites and 61 general practice mail-outs to recruit 500 participants across a year. Follow-up rates at 2 months were low (30%), however a more active follow-up approach increased success at 6 months (71.4%). Adolescents perceived the intervention to be useful and described benefits of using breathing exercises. Conclusions. A self-guided breathing retraining intervention for adolescents with asthma has been demonstrated to be acceptable and feasible. A definitive Phase 3 trial now needs to be conducted to explore the (cost)effectiveness of the intervention.

Trial registration: Clinical Trials Identifier: NCT05006703 Funding: NIHR RfPB (Research for Patient Benefit)

Hajmohammadi H¹, Pfeffer P², De Simoni A¹, Cole J¹, Griffiths C¹, Hull S¹, Heydecker B³ 

¹Centre for Primary Care, Wolfson Institute of Population Health, Queen Mary University of London, UK. ²Department of Respiratory Medicine, Barts Health NHS Trust, London, UK. ³Centre for Transport Studies (CTS), Department of Civil, Environment and Geomatics Engineering, University College London (UCL), UK.

Background. There is strong interest in the relationship between short-term air pollution exposure and human health. Most studies in this field focus on serious health effects such as death or hospital admission, but air pollution exposure affects many people with less severe impacts such as exacerbations of respiratory conditions. Aim. In this study we aimed to quantify the relationship between daily NOx concentration and asthma exacerbations requiring oral steroids from primary care settings in a study cohort in East London. Methods. We developed a time series regression model to understand the relationship between NOx concentration measurements from 8 available monitoring stations in east London, with daily number of oral steroid courses prescribed for patients with asthma in east London. We adjusted this model with ambient temperature, daily precipitation and relative humidity. Lags of NOx concentrations up to 21 days (3 weeks) were used in the model. Results. Results of the time series modelling showed a significant positive association between NOx concentrations on each day and the number of oral steroid courses prescribed in the following three weeks. We find that an increase of 1 mgm3 in NOx concentration (mean, 95.75 mgm3) associated to increase of about 2.7% in the prescriptions of oral steroid courses per day. There was a negative correlation between ambient temperature and asthma exacerbation, but we did not find any effects of daily precipitation or relative humidity. Conclusions. This study has the advantage of using clinical data to quantify less severe impacts of short-term air pollution exposure on patients with asthma. We found a positive association between air pollution (NOx) and asthma exacerbation, which will help the primary care sector to understand better the short-term effects of air pollution exposure.  

Funding: Barts Charity (refe MGU0419), REAL- Health: REsearch Actionable Learning Health Systems asthma programme. 

Alyami RA^1,2*, Simpson R¹, Oliver P^1,3 and Julious SA¹  

¹School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, United Kingdom. ²Respiratory Therapy Department, Faculty of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia.  

Background. It has been shown that asthma exacerbation rates peak after the return to school following the summer break among school-aged children. Studies show a drop in prescription pickups in August, followed by a rise in unscheduled healthcare provider visits. This was investigated by conducting a cluster randomized controlled trial (PLEASANT). The results of this study indicated a 30% increase in prescription collections in August for parents of asthmatic children who received a letter from a family physician during summer vacation, and a decrease in unscheduled visits between September and December following school return. In addition, this intervention resulted in a cost saving of approximately £36.07 per patient per year. Objective. to conduct a randomised trial in order to determine whether informing general practitioners of an evidence-based intervention will result in its implementation. Design. A pragmatic cluster randomised trial with routine data. This study used Clinical Practice Research Datalink (CPRD) to send the intervention and collect data. Participants. 1389 general practitioner (GP) practices in England, with 694 in the intervention group and 695 in the control group. Control arm. Usual care. Randomisation. General practitioner practices were stratified by their size and assigned randomly to either the intervention arm or the control arm. Main outcome. Proportion of children with asthma who have a prescription for an asthma preventer medication in August and September 2021. Results. (We are analysing the study and by the time of the conference we will present the results with conclusion) 

Funding. This trial has been funded by Saudi Cultural Bureau in the UK (SACB) and Jazan University, Saudi Arabia. Trial registration: ClinicalTrials.gov ID: NCT05226091  

Talaei M¹, Pagoni P², Stergiakouli E², Shaheen SO¹ 

¹ Wolfson Institute of Population Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, UK. ² MRC Integrative Epidemiology Unit, University of Bristol, UK. 

Background. The positive association between asthma and attention deficit hyperactivity disorder (ADHD) has not been adequately explained. Aims. To investigate whether shared early-life risk factors and/or shared genetics explain this association in childhood. Methods. In the Avon Longitudinal Study of Parents and Children, we defined doctor-diagnosed asthma, its endotypes according to atopy defined by skin-prick tests, and ADHD using the Strengths and Difficulties Questionnaire, all at 7 years of age. We explored the impact on the asthma-ADHD association when controlling for 8 previously investigated shared maternal/prenatal risk factors, such as age and smoking in pregnancy, and 6 less investigated ones, such as maternal anxiety and sugar intake in pregnancy. Polygenic risk scores (PRS) for asthma and ADHD were calculated using published genome-wide association studies, across 7 P-value thresholds (<5×10−08 to <0.5). To explore potential causal effects of genetic liability to ADHD on asthma and vice versa, we used bidirectional Two-sample Mendelian Randomization method. Results. Asthma was associated with ADHD (OR 1.34, 95% CI 1.09–1.64) (n=8,025) but the association was largely attenuated after adjusting for 14 potential confounders (1.10, 0.88–1.39). Compared to participants without asthma or atopy, atopic asthma was not associated (1.01, 0.70–1.46) but non-atopic asthma was associated (1.51, 1.09–2.08) with ADHD (n=5,435). However, this association was also largely attenuated after adjusting for shared early-life risk factors (1.16, 0.79–1.71). Asthma PRSs were not associated with ADHD at any threshold. ADHD PRSs were only weakly associated with asthma at a P<5×10−08 threshold (1.08, 1.00–1.17). There was limited evidence to support a causal effect of genetic liability to ADHD on asthma (1.02, 0.87–1.20) or genetic liability to asthma on ADHD (1.00, 0.94–1.06). Conclusions. The association between asthma and ADHD in childhood was largely explained by early-life risk factors. There was limited evidence for a shared genetic background. 

Funding. Barts Charity (MGU0570) 

Smith JR¹, Winder R¹, Poltawski L¹, Musgrave S², Noble M¹, Ashford P², Stirling S², Morgan-Trimmer S¹, Caress AL³, Wilson A²

¹Exeter Collaboration for Academic Primary Care (APEx), University of Exeter Medical School. ²Norwich Medical School, University of East Anglia. ³Department of Nursing & Midwifery, University of Huddersfield

Background. The ARRISA-UK trial evaluated whether a GP practice-wide intervention involving staff training and flagging of electronic records reduces severe attacks amongst ‘at-risk’ asthma patients. A parallel process evaluation explored how the intervention worked. Aim. To assess intervention fidelity and implementation, elucidate mechanisms of impact and identify contextual factors potentially influencing effectiveness. Methods. Using an explanatory mixed-methods approach, we collected quantitative and qualitative data from clinicians, receptionists, dispensing and other staff at intervention group practices before, during and after the ARRISA-UK training and flagging. Using a triangulation protocol, we synthesised the data analysed from study records, online training software, questionnaires and focus groups (at 18 practices) to address the aims. Results. 722 individual staff from 128/139 intervention practices contributed data. Most intervention elements were delivered with high fidelity and all practices met minimum requirements. However, fewer met optimal standards due to, for example, low engagement of reception and dispensing staff. Practice action plans prepared following training were detailed and included multiple actions aimed at improving how staff, particularly receptionists, managed at-risk asthma patients. Dissemination of plans could have been improved (particularly to receptionists and new staff), but there was evidence of their successful implementation at most practices with, for example, reported improvements in access, communication and pro-active and opportunistic asthma care. Various staff- and practice-level mechanisms could explain impacts on patient care, experiences and outcomes reported by some staff. The flag and ensuing receptionist actions appeared instrumental in activating these. Practice characteristics, particularly staff turnover, influenced intervention implementation and sustainability. Conclusions. The ARRISA-UK intervention was successfully delivered and reasonably effectively implemented at most practices, with receptionists playing a key role. Though there were areas for improvement, reports of ensuing individual staff- and practice-level changes had potential to improve patient care and outcomes, which forthcoming analyses of trial data will assess.

Trial registration: ISRCTN95472706

Funding: The ARRISA-UK trial is fully funded by the NIHR Health Technology Assessment (HTA), Grant number 13/34/70. This abstract presents independent research commissioned by the NIHR. The views and opinions expressed by authors are those of the authors and do not necessarily reflect those of the NHS, the NIHR, the NIHR Evaluation, Trials and Studies Coordinating Centre, the HTA programme or the Department of Health.

Skene I¹, Pike K², Griffiths C¹, Pfeffer P^1,3, Steed L¹ 

¹Queen Mary University of London, ²Bristol Royal Hospital for Children, ³Barts Health NHS Trust  

Introduction. ED attendances with acute asthma are a potential opportunity to improve long-term self-management. Understanding the health beliefs and behaviours of these patients is an important step for developing interventions that need to consider and respond to these beliefs, in order to be successful. Aims. To explore the health beliefs and behaviours of adult patients who have presented to the ED with their asthma, and consider attitudes to interventions aimed at improving including long-term asthma control e.g. optimising medications in the ED. Methods. 19 semi-structured face-to-face or online interviews were conducted with patients between November 2021 and June 2022. Eligible participants were patients over age 16 who had attended and were discharged from the ED with an asthma exacerbation. Purposive sampling was undertaken to ensure the participant group reflected a broad range of ages, backgrounds and asthma severity.  Interviews were analysed with reflective thematic analysis. Results. Themes were constructed reflecting the beliefs and behaviours of patients: 1) Me and my asthma i.e the emotional response and self-management during an exacerbation, 2) Discharge dilemma i.e expectations and communication on discharge from ED, 3) Do what’s best for me, 4) Perceptions of inhaled medications – openness to new things. Conclusion. This study has provided insight into the emotions experienced during an asthma exacerbation and the self-management behaviours of patients who attend the ED. There is no expectation for longer-term care to be provided in the ED. However, patients trust in the healthcare professionals to recommend appropriate treatment and are willing to accept a change in long-term medication in the ED if a rationale and education is provided. Communication is impacted by the acute setting, language barriers and time. Provision of information to take home from the ED would aid information retention.

Trial registration: HRA Approval REC Reference 21/LO/0665  

Funding: This work is funded by Asthma+ Lung UK as part of the Asthma UK Centre for Applied Research [AUK-AC-2012-01 and AUK-AC-2018-01]

Daines L¹, Canny A¹, Donaghy E¹, Murray V¹, Pinnock H¹. 

¹Asthma UK Centre for Applied Research, Usher Institute, University of Edinburgh 

Background. Mis-diagnosis of asthma is common. There is uncertainty about how best to diagnose asthma in primary care, and variability in how clinicians weigh up the likelihood of asthma. To address this, we developed a prototype clinical decision support system (CDSS) which integrates with electronic health records in primary care. The CDSS calculates the probability of an asthma diagnosis in children and young people (≤25 years) and suggests the steps needed to confirm or refute a diagnosis. Aim. 1) To evaluate the usage of the CDSS within GP practices during a 6-month feasibility study. 2) To understand the acceptability and usability of the CDSS to clinicians. Methods. General practices were recruited from England and Scotland. Following a training session, the CDSS was installed in each practice and available for use during routine consultations for six months. Usage of the CDSS was analysed. Toward the end of the study, clinicians who had used the CDSS were invited to take part in a qualitative interview which were audio-recorded, transcribed and analysed thematically. Results. Within the 12 practices recruited, the CDSS was used by 76 clinicians and the probability of asthma diagnosis calculated 185 times. 11 clinicians (8 nurses and 3 GPs) from eight practices were interviewed. The CDSS was acceptable to participants who particularly commented on the ease of use, auto-population of information from the patient record, the presentation of the probability score and resources for patients being embedded in the software. Downsides included the inability to record findings directly into the patient notes and a sense that whilst nice, the CDSS would not necessarily lead to a change in their own practice. Conclusions. The CDSS was generally well received by primary care clinicians, yet participants felt it would be most useful for colleagues with less experience and trainees. 

Funding: Asthma + Lung UK / Innovate UK 

Tomini F¹, Nagarajah M², Ravindran S² and Mihaylova B^{1,3 1}Wolfson Institute of Population Health, Queen Mary University of London, London, UK. ²Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK. ³Nuffield Department of Population Health, University of Oxford, Oxford, UK

Background. Previous research has shown that the quality of life (QoL) of parents and caregivers of children with asthma is negatively affected, with spillover effects on social and occupational relations and work productivity. However, findings on the overall effect of QoL across studies are inconclusive, and more is needed to know how parents’ QoL is related to the severity of asthma. Objectives. To systematically review the current literature assessing the QoL of asthma children’s parents vs no-asthma and by asthma severity. Asthma's effect on overall QoL and core domains (functional, emotional, and socio-occupational) were assessed. Methods. Four databases were searched (February 2020; updated April 2022), restricted to year 2000 and limited to English. Cross-sectional studies, cohort studies, case-control studies, and randomised clinical trials reporting on the QOL overall scores between the various degree of asthma severity groups were included. Two reviewers independently selected studies for inclusion, assessed study quality and extracted data. The Newcastle-Ottawa scale was used to assess the selected studies' methodological quality. A meta-analysis was performed to obtain summary estimates on QoL and indexes. Results. The search strategy yielded 2695 references from which 19 studies were included (14 studies reporting on asthma severity and 5 studies including healthy controls). The mean QoL score, measured on a 0-100 standardised score, was 70.59 (95% CI 60.37 - 80.31) for asthma children’s parents vs 74.98 (62.61, 87.34) for healthy children’s parents. For severe asthma, the overall QoL was 63.13 (55.92 – 70.69), which was broken down to 62.23 (52.17, 72.29) for the activity domain, 63.09 (54.49, 71.69) for emotional and 64.15 (53.44, 74.68) for socio-occupational. Conclusion. Asthma in children affects all domains of QoL of parents and carers, and the effect is accentuated by asthma severity. Monitoring all domains of QoL will help define goals for interventions targeting asthma management in children and reliving the psychosocial impact on parents and carers.

Gassasse Z¹, Tomini F¹ Hull S¹, and Mihaylova B^{1,2 1}Wolfson Institute of Population Health, Queen Mary University of London, London, UK. ²Nuffield Department of Population Health, University of Oxford, Oxford, UK

Background. Studies in the UK have shown that asthma outcomes vary by socioeconomic status (SES). However, the relevance of SES to asthma care and outcomes across the care pathway has not been studied. We assess asthma outcomes and their relationship with SES along the UK primary care pathway. Methodology. A retrospective open cohort of patients with active asthma in the period 2010-2019 was established using linked primary care records of the population of three East London Clinical Commissioning Groups. We assessed ‘care outcomes’ (annual asthma review, asthma management plan, inhaler technique, excessive prescriptions of reliever and preventer inhalers) and ‘asthma disease outcomes’ (asthma severity, asthma control (RCP3Q), exacerbations, and A&E visits). Associations between tertiles of SES in the study population and these outcomes were assessed separately among adults (≥18 years old) and children using multivariable multinomial logistic regression (categorical outcome) or mixedeffects logistic regression (binary outcome) models; trend tests across SES were reported. Results. We identified 69,237 individuals with active asthma (74% adults) observed over a mean follow-up of 5 years. Adults in the most deprived tertile, compared to the least deprived tertile, were more likely to have an asthma review (relative risk ratio [RRR]: 1.049, p-value for trend: 0.003) while also having suboptimal asthma control (RRR: 1.181, trend pvalue<0.001) excessively prescribed preventer inhalers (RRR: 1.178, trend p-value= 0.001) and reliever inhalers (RRR: 1.34, trend p-value<0.001). Poorer inhaler technique increased with deprivation in children (RRR: 2.06, trend p-value<0.001) and adults (RRR: 2.12, trend pvalue<0.001). No other statistically significant trends were observed for children or adults. Conclusion Evidence of gradients across SES for several asthma outcomes was observed. While asthma reviews appeared to reach more disadvantaged categories, they did not ‘translate’ into similar abilities to manage and control asthma. Targeting these outcomes among the socio-economically disadvantaged may reduce health inequalities.

Marquette M^1,2, Sethi D^1,2, Calder PC^3,4, Curtis PJ⁵, Wilson AM^1,2 

¹Department of Respiratory Medicine, Norfolk & Norwich University Hospital, Norwich, UK.&nbsp;²Norwich Medical School, University of East Anglia, Norwich, UK. ³School of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK. ⁴NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK. ⁵Department of Nutrition and Preventive Medicine, Norwich Medical School, University of East Anglia, Norwich, UK 

Aim. Evidence suggests a link between asthma and increased cardiovascular disease (CVD). Therefore, this systematic literature review and meta-analysis evaluated whether there are differences in flow-mediated dilatation (FMD) and pulse-wave velocity (PWV), measures of endothelial dysfunction and arterial stiffness, respectively, in people with asthma compared to healthy controls. Methods. Cross-sectional observational, cohort and parallel-design studies, plus randomised controlled trials involving people with asthma and controls, were identified by searching MEDLINE, EMBASE, EMCARE, CINAHL and PsycINFO in June 2022. Results. Eleven studies were identified for inclusion in both qualitative synthesis and meta-analysis. FMD (n=5 studies) was compromised in people with asthma compared to controls (SMD: -1.06, 95% CI = -1.46 to -0.66; I2= 77%, P=<0.00001). Subgroup analysis revealed differences in adults (SMD: -0.77, 95% CI = -1.09 to -0.44; I2 = 43%), children and adolescents (SMD -1.53, 95% CI = -2.31 to -0.75; I2 = 85%), those with mild to moderate asthma (SMD: -0.93, 95% CI = -1.44 to -0.42; I2 = 79%) and severe asthma (SMD: -1.37. 95% CI = -2.07 to -0.67; I2 77%) compared to controls. Likewise,  PWV (n=8 studies) was higher in asthma (SMD: 0.68, 95% CI = 0.44 to 0.91; I2 = 73%, P=<0.00001) with subgroup analysis showing differences in children and adolescents (SMD 0.70, 95% CI = 0.30 to 1.10; I2 = 14%), adults (SMD: 0.67, 95% CI = 0.40 to 0.95; I2 = 78%), those with severe asthma (SMD: 0.81, 95% CI = 0.17 to 1.45; I2 = 73%) and mild to moderate asthma (SMD: 1.02, 95% CI = 0.32 to 1.72; I2  = 81%). Conclusions. Endothelial dysfunction and arterial stiffness are worse in those with asthma, and this is apparent in adults, children and adolescents and in those with severe and mild/moderate asthma. This may contribute to higher CVD risk in asthma. 

Skene I¹, Pike K², Griffiths C¹, Pfeffer P^1,3, Steed L¹ 

¹Queen Mary University of London, ²Bristol Royal Hospital for Children, ³Barts Health NHS Trust  

Introduction. Acute asthma presentations to Emergency Departments (EDs) are potentially a ‘reachable moment’ to improve long-term asthma management as well as treating the acute exacerbation.  Understanding the health beliefs and behaviours of the healthcare professionals (HCP) in the ED, and those in primary care who provide continuing long-term asthma care, is an important step in developing interventions successful interventions. Aims. To explore the health beliefs and behaviours of healthcare professionals (HCP) relating to asthma care, and attitudes to optimising long-term management including potentially switching preventer medications, in adult patients who have presented to the ED with their asthma. Methods. 19 semi-structured face-to-face or online interviews were conducted between November 2021 and June 2022 with healthcare professionals of a range of seniority from EDs and primary care. Eligible participants had experience of caring for patients with asthma in either the ED or primary care setting. Interviews were analysed with reflective thematic analysis. Results. Four themes were apparent, constructed around the beliefs and behaviours of healthcare professionals: 1) Compassionate understanding i.e. recognising the accessibility of ED, patients self-management and the emotional aspects of exacebations, 2) Doing what’s right for the patient i.e maximing a reachable moment, 3) Tensions of capacity in the system i.e acknowledging workload within ED, 4) Beliefs and attitudes to switching long term medication in the ED. Conclusion. This study has established that there is a tension between wanting to ‘do what is right for the patient’ which may include switching long term medications, and what is possible within the constraints of the healthcare system.  There were conflicting views across the participants groups, who felt that ED professionals would not have the time or capacity to support longer-term asthma control, whereas others were open to the ideas if supported with guidelines and training.  

Trial registration:N/A - HRA Approval REC Reference 21/LO/0665   

Funding: This work is funded by Asthma+ Lung UK as part of the Asthma UK Centre for Applied Research [AUK-AC-2012-01 and AUK-AC-2018-01] 

Varghese D¹, Ferris K², Lee B¹, Grigg J³, Pinnock H¹, Cunningham S¹ 

¹Asthma UK Centre for Applied Research, Usher Institute University of Edinburgh ​​​​​​ ²Queens University Belfast ³Queen Mary University of London 

Background. Globally, observational studies have demonstrated an increase in emergency department attendances and hospital admissions in children with asthma exacerbations exposed to high levels of air pollution. Inconsistences in reporting severity of asthma attacks makes it challenging to establish the relationship between air pollution and near fatal and fatal asthma attacks. Objective. Systematic review to assess the association between ambient outdoor air pollution and fatal and/or near fatal asthma attacks. Methods. MEDLINE, EMBASE, Web of Science, Scopus and Open Grey electronic databases were searched for asthma attacks related to air pollutants (particulate matter (PM), sulphur dioxide, nitrogen dioxide, black carbon and ozone) in children aged 2 - 18 years. Identified studies were manually screened for fatal and near fatal attacks. Near fatal attacks were defined as requiring intensive care (ICU) management. Results. Two independent reviewers screened 1073 papers in total. 243 studies identified asthma attacks related to air pollution. 7 observational studies described fatal and near fatal events, of which 3 addressed near fatal asthma alone.  PM 2.5 and ozone (22ppb) changes were associated with near fatal attacks by one study (RR 1.26 CI (1.10-1.44)). Black carbon was not shown to have significant effect on ICU admission compared to no ICU admission(p=0.67). PM10 was observed to impact ICU admission in the context of thunderstorm asthma. Studies addressing mortality included children but did not demarcate age within analysis. Conclusions. Ozone and PM 2.5 have been associated with near fatal and fatal asthma attacks in children. Synthesis of existing studies is limited due to heterogeneity. Current studies do not address all relevant pollutants (i.e. NO2). 

Moon Z¹, Kaplan A², Mak V³, Nannini L⁴, Winders T⁵,Horne R¹ 

¹Centre for Behavioural Medicine, School of Pharmacy, University College London, ³Imperial College Healthcare NHS Trust, ⁴Rosario National University, ⁵Allergy & Asthma Network&nbsp;

Background. Over-use and over-reliance on short-acting beta2 agonists (SABA) is associated with poor asthma control and greater risk of exacerbations and death. Identifying and addressing patient beliefs associated with SABA over-reliance is key to reducing over-use.  The Reliever Reliance Test (RRT) is a pragmatic, self-test tool designed to identify and address beliefs which are associated with SABA over-reliance. Aim. To evaluate the RRT in practice and assess the impact of the RRT on perceptions about asthma and intentions to discuss their treatment with their doctor. Methods. Patients with asthma who had completed the RRT in Argentina were invited to an online survey exploring the acceptability of the RRT, its impact on changing perceptions about asthma treatment and its impact on intention to discuss treatment with a doctor. Results. 109 patients completed the questionnaire. The RRT was acceptable to patients. After completing the RRT, 75% of patients at medium-to-high risk of over-reliance intended to visit their doctor to discuss their treatment. The RRT changed the way patients thought about their asthma treatment, with 67% agreeing that the RRT made them think they depend too much on their SABA and 66% questioning their asthma treatment. Conclusions. The RRT is effective at changing perceptions about asthma treatment and motivating people to seek help. More research is needed to explore the extent to which it will change behaviour. However, this data supports the potential usefulness of the RRT as a tool in clinical practice. 

Funding: The development and evaluation of the RRT was supported by Spoonful of Sugar Ltd, a UCL Business Company and IPCRG Right Care, with funding from AstraZeneca. 

Taylor L¹, Moon Z¹, Truscott H¹, Horne R¹  

¹School of Pharmacy, Centre for Behavioural Medicine, University College London, London, United Kingdom  

Background. The GINA guidelines (2019) have recommended a paradigm shift for asthma treatment. For the last 40 years the first line of treatment has been short acting beta2 agonists (SABA) as symptom relief often combined with daily inhaled corticosteroids (ICS) as preventers. New guidelines suggest that SABA is replaced with an ICS based reliever used as needed. This may require a significant behavioural shift for patients. Aim. This study aimed to explore patient perceptions of SABA, and ICS, with a focus of understanding barriers to implementation of the new GINA guidelines. Methods. A qualitative study investigating UK asthma online community forum posts created using keyword searches between July 2021 to December 2022. A sample of seventy adult patients with asthma were identified through the posts (15 female, 9 male, 46 sex not stated, aged 30-75). Interim results. Thematic analysis of 81 posts highlighted that patients felt very attached to their SABA and perceived it to be key element of their treatment. Patients had few concerns about their SABA and some report being unconvinced by warnings around SABA over-use. In contrast, patients reported a range of concerns of ICS and felt they did not provide the immediate relief they associated with SABA, which may act as barriers to adopting GINA guidelines in medical practice. Results also highlight a perceived lack of individualised care from healthcare professionals and a dislike of guideline driven care. Points for discussion. The online forum posts indicated that patient perceptions of SABA and ICS may act as barriers to implementing GINA recommendations, with implications for how guidelines are communicated to patients. 

Funding: This project is funded by the Asthma UK Centre for Applied Research.

Mukherjee M¹, Okusi C², Fletcher M¹, Quint J³, Lusignan S², Sheikh A¹ 

¹The University of Edinburgh, Edinburgh, UK. ²Nuffield Department of Primary Care Health Sciences, University of Oxford, UK. ³National Heart and Lung Institute, Imperial College London, London, UK.

Background. Studies have reported reductions in asthma exacerbations over the course of the COVID-19 pandemic, but the reasons for these reductions remain poorly understood. Aim. We sought to identify changes in modifiable risk factors for asthma exacerbations that might help explain any reductions seen. Methods. We used pseudonymised cross-sectional data from all 783 participating GP practices in the English Primary Care Sentinel Cohort, selecting people registered with clinician-diagnosed asthma for the period Jan 1, 2019 to Dec 31, 2021. Asthma exacerbations were assessed by comparing percentages of people and events of GP-recorded asthma attacks, GP prescriptions of oral corticosteroids, hospital admission including A&E for asthma during the pre-pandemic period (2019) and during the first two years of the pandemic (2020-21). We also compared percentages of people with potentially modifiable risk factors for asthma exacerbations over these same time periods, namely asthma self-management plan ownership, asthma reviews, ICS prescriptions, current smoking, influenza and PPV vaccination and counts of respiratory-tract-infections (RTI) and influenza-like-illnesses. Non-overlapping 95% CI of percentages were considered statistically significant. Interim results. During the pandemic period compared to pre-pandemic rates people who had asthma attacks (4·9%vs3·3%), prednisolone prescriptions (17·6%vs14·4%) and hospitalisations (0·6%vs0·4%) declined. Rate of asthma attacks (6.7%vs4.6%) and hospitalisations (6.5%vs6.0%) declined but prednisolone prescriptions increased (251.9%vs 263.0%). Asthma self-management plan ownership (38·7%vs52·4%), prescriptions of ICS (64·6% vs 69·9%), and influenza vaccinations (54·7% vs 59·9) increased. PPV vaccinations (42·3%vs41·1%), RTIs (19·1%vs10.1% and influenza-like-illnesses (0·6%vs0·3%) declined. Current smokers remained same: 13·9%vs14·1%. Points for discussion. PPI members inputs pre-analyses were measuring exacerbations could be erroneous by prednisolone since sometimes it’s prescribed routinely or if needed in future or might not be prescribed if diabetic; people try to self-manage exacerbations. Second-hand smoking triggers asthma but not reported. 

Funding: HDR UK 

Mukherjee M¹, Okusi C², Fletcher M¹, Lusignan S², Sheikh A¹ 

¹The University of Edinburgh, Edinburgh, UK. ²Nuffield Department of Primary Care Health Sciences, University of Oxford, UK 

Background. Asthma is a common condition in the UK, mostly managed in primary care, which has ~100,000 hospital admissions and costs the UK public sector at least £1 billion. Despite pay-per-performance in UK primary care since 2004, asthma morbidity has not changed. Asthma guidelines suggest people with asthma should have annual reviews and asthma self-management plan. Literature on audit and feedback (A&F) indicated that an inter-disciplinary team with motivation, goals and action plans aided with up-to-date information, could help improve health outcomes. Aim. To improve asthma outcomes, our objective was to find if a near-real time asthma dashboard with A&F can be created in primary care with the epidemiology, modifiable risk factors and outcomes for asthma. Methods. Cross-sectional data on asthma from all 783 participating GP practices in Primary Care Sentinel Cohort (PCSC) in England with 7.8M people registered, was used. Data reported are for the week beginning 31/10/2022. A study-practice is compared to PCSC average. Annual asthma prevalence data was compared to Quality Outcomes Framework, 2021-22. Interim results. A web-based, weekly, automated asthma dashboard with electronic-A&F could be created that compared a GP practice to the average in PCSC with key asthma indicators (https://orchid.phc.ox.ac.uk/index.php/asthma-dashboard/). Annual asthma prevalence: study-practice 5.1%, PCSC 4.4%, QoF 6.4%.  Asthma indicators for the study-practice vs PCSC: weekly incidence 0.007%vs0.006%, annual prevalence 5.7%vs6.0%, inhaled relievers to preventer 0.7vs0.7, self-management plan given 40.9%vs57.5%, annual reviews 68.6%vs40.8%, prednisolone prescriptions 5.7%vs7.2%, A&E attendance 0.3%vs0.3%, hospitalisations 0%vs0.1%. Overall study-practice vs PCSC for: flu vaccination 55.7%vs56.0%, PPV vaccination (over 65-year-olds) 10.6%vs7.2% and current smokers 14.4%vs14.2%. Points for discussion. PPI members mentioned i) flare-ups, ii) how many GP practices prescribed steroids to improve a situation that should never have worsened in the first place, iii) people who end up in A&E but don’t go to GPs, not extracted as useful information.  

Funding: HDR UK 

Rodriguez A¹, Lewis SC¹, Jackson T², Eldridge S³, Weir CJ¹ 

¹Edinburgh Clinical Trials Unit (ECTU), Usher Institute, the University of Edinburgh. ²Asthma UK Centre for Applied Research, Usher Institute, the University of Edinburgh. ³Pragmatic Clinical Trials Unit, Blizard Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London.

Background. There are increasing incentives for anonymised datasets from clinical trials to be shared across the scientific community. Some anonymised datasets are now publicly available for secondary research.  However, we do not know if they pose a privacy risk to the patients involved. Aim. We aimed to collect a broad sample of publicly available anonymised clinical trial datasets in order to calculate their re-identification risk scores using El-Emam’s[1] derived risk metrics under the prosecutor (identifying a previously known individual) and the journalist scenarios (identifying any individual using a matching dataset). These methods only generate numeric risk scores, they do not aim to actually re-identify individuals in the datasets. Methods. Step 1.- We located 17 data repositories and drew a random sample of up to 5 datasets from each repository. Step 2.- We contacted the data repositories and requested access to their anonymised datasets following the data holders’ local procedures. Step 3. We are calculating the number of indirect identifiers present in each of the datasets, as described by Hrynaszkiewicz et al. [2]. Step 4.- Re-identification risk scores are being calculated for each dataset. Step 5.- We will investigate what characteristics of the datasets are associated with increased or decreased risk scores, compare the risk score features, their usability, and discuss our findings. Interim Results. We have so far analysed 53 of 86 datasets. We have discovered that, in general, datasets are well-formatted, but specialised knowledge is required to use them. Re-identification risk scores are high and they only reflect the amount of patients’ personal data in the studied datasets. The presence of direct identifiers (such as date of birth) in the anonymised datasets is a recurrent issue.Finally, the presence of several indirect identifier in the datasets has the biggest impact on minority groups. We are continuing the analysis of the remaining 33 datasets. 

Funding: This work is funded by Asthma + Lung UK as part of the Asthma UK Centre for Applied Research (AUKCAR) [AUK-AC-2012-01 and AUK-AC-2018-01]. AR has a scholarship from the University of Edinburgh to undertake a PhD with the support from the AUKCAR.  

Lee B¹, Turner S², Hine J³, McMurray A⁴, Roland D⁵, Borland M⁶*, Csonka P⁷*, Grigg J⁸*, Guilbert T⁹*, Jartti T^10,11,12*, Oommen A¹³*, Lewis S¹⁴, Cunningham S⁴. *listed in alphabetical order by surname. 

¹Asthma UK Centre for Applied Research, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK. ²Royal Aberdeen Children’s Hospital, NHS Grampian, Aberdeen, UK . ³Asthma UK Centre for Applied Research, National Heart and Lung Institute, Imperial College London, UK. ⁴Asthma UK Centre for Applied Research, NHS Lothian, Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK. ⁵SAPPHIRE Group, Health Sciences, University of Leicester, Leicester, UK. ⁶Divisions of Paediatrics and Emergency Medicine, School of Medicine, University of Western Australia, Australia. ⁷Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland. ⁸Centre for Genomics and Child Health, Queen Mary University of London, UK. ⁹Division of Pulmonology Medicine, Cincinnati Children's Hospital & Medical Center, USA.&nbsp;¹⁰Department of Pediatrics, Turku University Hospital and University of Turku, Turku, Finland. ¹¹PEDEGO, Research Unit, University of Oulu, Oulu, Finland. ¹²Department of Pediatrics, Oulu University Hospital, Oulu, Finland. ¹³Department of Paediatrics, Milton Keynes University Hospital NHS Trust, United Kingdom. ¹⁴Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK.

Introduction. Agreement is lacking on priorities for oral corticosteroids (OCS) treatment outcomes for preschool wheeze. Using a nominal group technique, we aimed to reach a consensus on outcome measures of OCS treatment between health professionals (HPs) and parents. Methods. We invited two groups (1) HPs including lead authors of OCS preschool wheeze trials and (2) parents of children who had experience of OCS for acute wheeze in children aged 1-6 years. Participants ranked outcome measures in order of importance. Two rounds of votes took place, with a discussion in between. Friedman’s test was used to test differences between the rankings across all items. Results. 7 HPs and 9 parents participated. In the first vote, length of hospital stay (LOS) and change in wheezing severity score (WSS) were top priority for HPs and parents, respectively. After discussion and second vote both groups agreed by consensus in WSS as primary outcome. Analysis after the second vote showed a statistically significant difference across all rankings (Χ2 (df = 6, N=15) = 45.66, p<0.001). LOS dropped from 2nd to 4th and revisit to GP/emergency department 5th to 2nd post discussion/2nd vote. Whilst LOS was regarded as the most clinically relevant for HPs, parents noted that revisiting the hospital gave them a more substantial psychological/economic burden than longer LOS. Conclusions. Parents and clinicians conclude that WSS is the most favourable outcome measure, which will be used as a primary outcome for our individual participant data meta-analysis. Parent/patient engagement is key to ensuring relevant patient research outcomes.

Ryan D¹, Williams S¹, Kocks J¹, Correia de Sousa J¹ 

¹The International Primary Care Respiratory Group, Edinburgh, UK

Introduction. Asthma remains both under- and over-diagnosed globally.1 Primary care practitioners (PCPs) have identified an educational need for simple tools to diagnose asthma in the absence of a single objective test.2 New teaching and learning tools are required. Aims. To describe the process of defining the format and content of teaching and learning tools to facilitate and improve the quality of asthma diagnosis by PCPs without an asthma interest or specific training using a jigsaw puzzle metaphor. Methods. A half-day “jigsaw“ workshop of primary care academics and clinicians in low, middle and high income countries with an asthma diagnosis interest was convened. Four working groups in two rounds negotiated and prioritised jigsaw pieces describing: reason for presentation, symptoms, predisposing factors and tests/investigations most relevant when building a clinical picture of asthma. In the third round a single comprehensive jigsaw puzzle was formed through debate about relative importance of jigsaw pieces over time (https://youtu.be/jguPHc8XHDE). This process could be repeated and contextualised at national level. Resource content. Building the puzzle begins with establishing the reason/s the person has presented in primary care followed by an exploration of their respiratory symptoms. A personal and family history is important and continuity of care is crucial as more than one encounter is often needed to build the diagnostic puzzle. Objective tests should be considered where available e.g. a simple test of airway reversibility using peak flow pre- and post- administration of a short-acting bronchodilator, serial peak flow monitoring, microspirometry or spirometry. Other tests such as blood eosinophil levels or FeNO may be considered. Conclusions. This project identified a new teaching and learning strategy, the asthma jigsaw puzzle, to create a context-specific development process and a tool enabling PCPs to visualise the clinical picture and decide on the likelihood of an asthma diagnosis before taking action. 

Funding statement: The Asthma Jigsaw Project was jointly funded by GlaxoSmithKline, AstraZeneca and Vitalograph.  IPCRG convened the Steering Group and designed and implemented the development strategy. 

Uzzaman N¹, Hammersley V¹, McClatchey K¹, Sheringham J², Habib GM^1,3, Pinnock H¹ 

¹University of Edinburgh. ²University College Hospital, London. ³Bangladesh Primary Care Respiratory Society 

Background. Asthma places a substantial burden on healthcare systems globally. Reviews using asynchronous digital health interventions may support care to large numbers of patients and reduce avoidable clinic visits. Aim. We aimed to review the qualitative and quantitative evidence of the effectiveness and acceptability of asynchronous digital health interventions for reviewing asthma. Methods. We searched qualitative, quantitative and mixed-methods studies in six databases (Jan-2001 to Jun-2022). The search strategy included patients with asthma or caregivers; asthma reviewed by asynchronous means; views and experiences of patients and healthcare professionals on asynchronous digital interventions. Interim results. Of 11034 records identified in the search, 30 studies (20 quantitative, eight qualitative and two mixed-methods) were eligible for inclusion. These originated from nine countries, 3428 people with asthma and/or caregivers and 140 healthcare professionals (HCPs). Of the studies (n=21) that reported digital functionalities, 71% used web-based portals, and others used mobile applications (19%) and SMS (10%). Only three studies were linked with electronic health records (EHR). Frequently used digital functionalities were monitoring diaries (n=14), asthma control assessments (n=10), action plans (n=7), automated feedback (n=7), and medication reminders (n=4). Online chat (n=12), email (n=12), telephone (n=7), and SMS (n=3) were the commonly reported communication media. Asthma control (n=12) and quality of life (n=8) improved significantly in 50% and 25% of the RCTs respectively when the intervention group was compared with usual care. Most patients and HCPs welcomed technology-based interventions and highlighted the value of two-way communication subject to the user-friendliness of the system. Most HCPs mentioned a lack of integration with EHR, workload and lack of financial reimbursement as barriers to implementing asynchronous reviews. Point for discussion. How should asynchronous consultations be organised in primary care for reviewing asthma? 

PROSPERO registration: CRD42022344224 

Funding: AUKCAR PhD studentship nested in the IMP2ART programme at the University of Edinburgh. 

Budiarto A¹, Sheikh A¹, Wilson A², Price DB^3,4, Shah SA¹ 

¹University of Edinburgh. ²University of East Anglia. ³Observational and Pragmatic Research Institute. ⁴University of Aberdeen 

Background. A data-driven prediction tool has the potential to provide early warning of an asthma attack and improve asthma management and outcomes. Most previous machine learning (ML)-based studies for asthma attack prediction have reported a severe class imbalance, with major implications for model performance.  Aim. We aimed to undertake a systematic comparison of several class imbalance handling techniques in the context of risk prediction models for asthma prognosis. Methods. We used data from 9,835 asthma patients extracted from the Medical Information Mart for Intensive Care (MIMIC) IV database and deployed five class imbalance handling methods based on synthetic minority oversampling technique (SMOTE) and cost function customisation. We then compared their performances in improving two-class classifier models developed using logistic regression (LR) and extreme gradient boosting (XGBoost) for three different prediction tasks with varying severity of class imbalance (proportion of majority class ranging from 90.86% to 98.98%). Interim results (or Progress made). The cost function customisation technique substantially outperformed the SMOTE-based methods in all tasks. XGBoost combined with cost function customisation achieved the highest prediction performance for the outcome with the most extreme class imbalance ratio (AUC = 0.92). Our findings suggest that the cost function customisation-based approach to tackle class imbalance provides substantially better performance compared to oversampling in the context of asthma management. On-going challenges (or Points for discussion). This study underscores the challenge of class imbalance in the context of prediction tools to improve asthma management and provides a methodological solution that addresses the challenge. Future work to improve model performance will involve the use of L1 regularisation for feature selection, and signal processing techniques to extract temporal information from vital sign data recorded during the stay. 

Funding: AUKCAR Studentship Program funded by Chief Scientist Office, NHS Scotland 

Wood HE^1,2, Karampatakis GD^1,2, Li X³, Day B², Mihaylova B^1,2, Bird V¹, Taylor S^1,2, Panzarasa P³, Sastry N⁴, Griffiths CJ^1,2, De Simoni A^1,2 

¹Wolfson Institute of Population Health, Queen Mary University of London. ²Asthma UK Centre for Applied Research. ³School of Business and Management, Queen Mary University of London. ⁴Department of Computer Science, University of Surrey 

Background. Of 4.3 million adults with asthma in the UK, up to one third experience suboptimal control, with significant impacts on patients’ quality of life and healthcare costs. OHCs are increasingly used as a source of health advice, and represent an untapped resource to foster asthma self-management. However, patients and health professionals often raise questions about the safety and effectiveness of advice given (by other patients) in OHCs. Aim. We aim to develop recommendations for the OHC moderators to follow, that will optimise safety and effectiveness of the OHC for users. Methods. In-depth, qualitative interviews with current OHC moderators to identify areas for potential improvement in safety and effectiveness of user engagment. Written recommendations, based on themes emerging from the interviews, will be developed. Moderators will be re-interviewed 6 months after implementation to examine the impact of recommendations on moderation. Semistructured interviews were conducted remotely with 6 moderators by GDK and HEW, using a topic guide. Recordings were transcribed verbatim and are being analysed thematically. Progress made. We interviewed 4 respiratory nurses (from ALUK), a Customer Support Manager (from HealthUnlocked) and an OHC user with a voluntary administrator role, with 1-5 years’ experience as moderators. This sample represents the different possible moderator roles that exist in such forums. Preliminary findings highlight the lack of an automated process to identify inappropriate posts (e.g. language used or advice given), with moderators relying extensively on users to identify and report troublesome/inappropriate posts. Nurses also reported generally not having enough time allocated to the moderator role and worrying that inappropriate posts get missed. In terms of improving effectiveness for users, the need to generate more activity/engagement/discussion was highlighted. On-going challenges. Developing recommendations effective in improving safety and effectiveness; ensuring that the recommendations are adopted; completing follow-up interviews.

Funding: NIHR202037 Programme Grant for Applied Research 

Varghese D¹, McMurray A¹, Cunningham S¹ on behalf of the Near Fatal Asthma study group 

¹Department of Child Life and Health, Centre for Inflammation Research, University of Edinburgh  

Background. Near Fatal Asthma(NFA) is a severe form of asthma attack, that is considered the penultimate level of attack prior to death. It is difficult to prevent or develop novel treatments for NFA attacks as the phenotype and current management are poorly characterised. Addressing NFA may impact the high incidence of asthma death in children and young people (CYP) in the UK. Aim. To determine the frequency, phenotype and management of Near Fatal Asthma events in CYP in the UK and Ireland using British Paediatric Surveillance Unit (BPSU) methodology. Methods. This is an observational surveillance study over 18 months of (e-delphi defined) NFA in CYP aged 5-15 years.  Paediatric General, Critical Care and Emergency Medicine consultants will register cases of NFA via BPSU electronic reporting system.  Baseline, 12 and 24 months data collected via safe haven electronic reporting (HIC, Dundee). Information on pre hospital, inpatient, discharge and follow up care will be submitted by reporting clinicians. Reporting data will include ethnicity, triggers, allergens and smoke exposure. Through safe haven data linkage, full postcode will enable deprivation status, weather, pollen, viral and pollution exposures to determined. Follow up, future risk and patient focus group data will enable a bundle of care to be developed.  Interim results. Case reporting open from October 2022 and will run until April 2024. Challenges encountered/anticipated. Data analysis: Incomplete clinician responses creating data entry gaps, consideration of this impact on data set. Data linkage of full postcode with air pollution data, determine if time stratified case cross over analysis or other will be able to examine effect of air pollution on events.  

Funding: Chief Scientists Office of Scotland 

Karampatakis GD^1,2, Day B², Wood HE^1,2, Li X³, Taylor SJC^1,2, Mihaylova B^1,2, Bird VJ¹, Griffiths CJ^1,2, De Simoni A^1,2.   

¹Wolfson Institute of Population Health, Queen Mary University of London. ²Asthma UK Centre for Applied Research. ³School of Business and Management, Queen Mary University of London.  

Background. 4.3m people have asthma in the UK, with one-third experiencing poor asthma control, which negatively affects healthcare use and patient outcomes. OHCs are increasingly popular amongst patients, with millions accessing information posted by peers (other people with asthma). Integration of online peer support into primary care services to foster self-management is a new concept. Aim. Co-developing with stakeholders a consultation-based intervention by primary care clinicians to promote engagement with an asthma OHC. Methods. Qualitative, semi-structured, focus groups with adults with asthma (in-person), and one-to-one remote interviews with general practitioners (GPs) and nurses, from general practices in North-East London. Patients were recruited via text message sent by their practice. A topic guide is used to prompt discussions about the intervention content, clinician training needs, and recruitment of eligible patients via a survey. Transcripts are analysed thematically. Interim results. We completed four focus groups across two practices, attended by 13 patients, five male and eight female, aged between 16 and 70, with 70% being of a non-White ethnicity and four interviews with two GPs and two nurses. Preliminary findings: patient and public involvement (PPI) was central in co-designing the intervention. A PPI co-investigator facilitated the focus groups, making sure topics were grounded on patients' perspectives. Clinicians' understanding and value given to the OHCs were important elements, as well as proposing the OHC as source of novel, available 24/7 information and support. Highlighting that OHCs are safe and moderated by clinicians and patients can use them when needed were also important elements of the consultation. Suggestions were made of distributing the recruitment survey in electronic format, highlighting data protection, and simplifying the wording of questions. On-going challenges. Complete the study; translate findings into an intervention, a successful recruitment strategy and clinician training modules.   

Funding: NIHR202037 Programme Grant for Applied Research.  

Ferris K¹, McCrossan P², Shields M¹, Paton J³ and O’Donoghue D¹. 

¹Queen’s University Belfast. ²RHC Glasgow. ³University of Glasgow. 

Background. The Asthma UK Annual Asthma Survey 2020 showed that, worryingly only 48.7% of children and young people aged 17 or under were receiving the basics of asthma care. Patient education including empowering patients and their families to actively self-manage their asthma is fundamental to the basics of asthma care. Aim. To compare a novel augmented teaching method (Video directly observed therapy (v-DOT)) with standard training in achieving and sustaining mastery of inhaler and nasal spray technique and the understanding of a personalised asthma action plan (PAAP). Methods. Children with acute wheezing referred to the Safe Asthma Discharge Care Pathway (SADCP) service have been approached for participation. Participants are randomised 1:1 to either receive v-DOT (intervention) or remain in the SADCP (control). The intervention group is immediately commenced on v-DOT and upload twice-daily patient videos. These videos are reviewed daily by the lead researcher who provides feedback. v-DOT continues until the patient has uploaded 3 consecutive days of correct technique. Progress made. To date (February 2023) 19 patients have been recruited -  9 randomised to v-DOT and 10 randomised to the control arm.  There have been 2 patients on v-DOT lost to follow-up.  Of note an e-mail received from one parent once v-DOT was completed: “Thanks again for taking time to mentor us on inhaler technique.” On-going challenges. How to define mastery of inhaler technique in real world asthma practice. Recruitment is ongoing, most common barrier is parental perception of time commitment required to complete v-DOT.  Qualitative interviews will give a richer perspective of patient experience. 

Funding: This work is funded by Asthma + Lung UK as part of the Asthma UK Centre for Applied Research [AUK-AC-2012-01 and AUK-AC-2018-01] and Royal Belfast Hospital for Sick Children charitable funds. 

Wood HE^1,2, Karampatakis GD^1,2, Li X³, Day B², Mihaylova B^1,2, Bird V¹, Taylor S^1,2, Panzarasa P³, Griffiths CJ^1,2, De Simoni A^1,2 

¹Wolfson Institute of Population Health, Queen Mary University of London. ²Asthma UK Centre for Applied Research. ³School of Business and Management, Queen Mary University of London.  

Background. The ALUK Asthma OHC, hosted by HealthUnlocked, has just under 2000 active users. We have previously found that a core of superusers (users in the top 1% in terms of posts) are vital to sustaining activity within the OHC. The OHC is moderated by a team of specialist respiratory nurses at ALUK, a Customer Service Manager at HealthUnlocked, and a volunteer administrator. The aim of the AD HOC Programme is to establish, through a randomised controlled trial, whether an intervention in primary care promoting engagement with the ALUK OHC helps people with poorly-controlled asthma to better control their symptoms. The trial will recruit around 250 patients to the intervention arm. If proving successful, this would inform decisions about rolling out such an intervention to a much larger number of patients.  Aim. We aim to explore how/whether new users recruited via the AD HOC intervention impact current dynamics of the OHC, including users, superusers and moderators. Proposed Methods. Analysis of OHC dataset for the duration of the AD HOC feasibility study (approx. 8 months); social network measures (e.g. centralities, brokerage, effective size, etc), and quantitative analysis of engagement metrics (e.g. number of active users, logins, and new joiners, time spent on pages, number of posts, likes, etc), and qualitative analysis (via thematic and content analysis) of public posts (with participants tagged). Points for discussion. Would users, superusers and moderators interact differently with AD HOC study participants as opposed to new users joining the OHC for their own reasons? Would study participants change any established dynamics? Would they make more work for the moderators and/or impact the effectiveness and/or safety of OHC engagement?  

Funding: Should be possible to include within the scope of the AD HOC research programme, NIHR202037 Programme Grant for Applied Research. An ethics amendment would be required.

Hine J¹, Bush A¹, Judah G¹, DeSimoni A², Griffiths C², Fleming L¹ 

¹Imperial College London. ²Queen Mary University London 

Background. Adherence to inhaled corticosteroids (ICS) for children and young people (CYP) with asthma is poor; however, behaviour change is challenging and longer-term improvements are not often maintained. Financial incentives are a widely used behaviour change technique (BCT) in healthcare, with growing use in CYP. Aim. The aim of this pilot RCT is to assess the effectiveness of a financial incentives intervention to improve medication adherence for CYP with asthma, and to assess the feasibility of the intervention and other study processes. Methods. CYP aged 11-17 years old who present to a London Emergency Department (ED) with a severe asthma exacerbation, are invited to a 24-week programme. All participants have their adherence measured using an electronic monitoring device (EMD) and receive twice-daily reminders. Participants randomised to the intervention receive £1 per AM/£1 per PM inhaler dose (max £2/day) for 12-weeks. Rewards are delivered directly to CYP at monthly intervals as ‘One4All’ e-vouchers. Data collection includes measures of adherence, asthma control, medicine beliefs, illness perceptions, habit and motivation. Focus groups with participants and interviews with parents/guardians will be conducted post-study. Interim results. 22 participants have been enrolled (intervention, n=11) since July 2022; 6/11 have completed the 12-week intervention (reward: £38-168/£168; adherence: 23%-100%) and 9/11 have received the first monthly reward instalment (average reward: £46/£56 and adherence 82%). However, 2 participants have withdrawn, and 6/11 have experienced technical difficulties. Recruitment closes end Feb 2023. On-going challenges. Technological problems and recruitment difficulties has made the implementation of this pilot challenging. Focus groups/interviews will be useful to obtain feedback on study design and key features of the financial incentives intervention. 

Trial registration: US clinical trials registry. ClinicalTrials.gov identifier: NCT05322044. 

Fitzsimmons D¹, Farr A¹, Hammersley V², MCClatchey K², Steed L³, Pinnock H² on behalf of the IMP2ART research team. 

¹Swansea Centre for Health Economics, Swansea University. ²Usher Institute, University of Edinburgh. ³Wolfson Institute of Population Health, Queen Mary University of London. ⁴Centre for Applied Health Research, University College London. 

Background. The IMP2ART Programme has developed and is now evaluating strategies to improve implementation of supported asthma self-management in routine primary care practices. A health economic evaluation has been incorporated into the IMP2ART trial to determine the costs and cost effectiveness of IMP2ART to the NHS. Aim. We report on the work in progress in designing and embedding our data collection and analysis strategy to capture resource use and costs associated with the implementation of IMP2ART, as part of our plan for the Health Economic Evaluation. Methods. We have designed a strategy to capture: Facilitators are a significant component of the intervention assisting practices to successfully implement IMP2ART. Training and time taken to assist practices will be captured, via the chat function. Education modules for health care professionals have been developed by the trial team and made available to practices via the online website management solution Nimble. The opportunity costs of practice staff to undertake the education modules will be logged and job description captured so applicable salary costs can be applied. The costs of Asthma education resources for patients to access will be captured. Delivery of action plans by health care professional will be recorded during the trial, comparing the time spent discussing action plans with patients for the IMP2ART intervention compared to control. Organisational resources such as electronic templates and reports.  Interim results. The collection of data is underway and our Health Economic Analysis Plan is being drafted. On-going challenges. Health Economics has been integral from the outset of the IMP2ART programme working closely with the research team to design the Health Economic  Data Collection and Analysis Plan. 

Trial registration: ISRCTN15448074 

Funding: National Institute for Health Research (NIHR) under its Programme Grants for Applied Research Programme (Reference Number RP-PG-1016-20008) 

Tibble H¹

¹Asthma UK Centre for Applied Research, University of Edinburgh

There is huge potential to make use of the wealth of data collected from routine care to inform data-driven clinical support, to reduce the need for emergency care, and, in some cases, death.  Prognostic and diagnostic models are being developed in many domains, including asthma, around the world – indeed many of us in AUKCAR are working on this and related problems.  However, currently there are no tools which are endorsed by asthma management guidelines, and none in routine clinical practice. This is a problem seen in many health domains, with state-of-the-art methodological developments often being siloed from intervention and impact evaluation research, and resulting in lack of implementation and use. It is crucial that qualitative research is conducted with key stakeholders to steer risk stratification research towards maximum value and impact. Changes in clinical practice resulting from the implementation of decision support must be rigorously examined to dissect the barriers and facilitators of certain behaviour changes, to guide interventions towards success. There is so much we currently do not understand about what stimulates individual clinicians to react differently to a patient having, for example, a ‘50% chance’ of an asthma exacerbation, such as understanding of the model, or the prediction horizon (in the next month or next year). I aim to create a network of EHR-based risk prediction model implementation researchers, to share case studies and key learnings for high-value implementation work. Currently, this type of research is often siloed between disease specific conferences, or methodology conferences in which the implementation side and the impact is prioritised lower than innovative methods and high performance, even without external validation.

Perikleous A¹, Bush A², Fleming L², Griffiths CJ³, Rosenthal M², Pavord I⁴, Bowen SJ⁵ 

¹Department of Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College, London. ²Department of Paediatric Respirology, National Heart and Lung Institute, Royal Brompton Hospital and Imperial College, London. ³Asthma UK Centre for Applied Research, Barts Institute of Population Health Sciences, Queen Mary University of London, London, UK, ⁴Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Department of Clinical Medicine, University of Oxford; ⁵Paediatric Respiratory Registrar, Oxford Children’s Hospital, John Radcliffe Hospital, Headington, Oxford, UK. 

Background. Preschool wheeze is common condition and leads to repeated hospital admissions. Biomarkers are needed for management since those with eosinophilic airway inflammation are more likely to respond to inhaled corticosteroids (ICS). A retrospective analysis found that allergic sensitisation and blood eosinophil count (BEC) ≥300/μl were the best predictors of response to regular ICS (1). Exhaled nitric oxide (FeNO) is also a potential biomarker but its use in guiding management has not been studied in this population. Hypothesis. Aeroallergen sensitisation, FeNO ≥10 ppb and BEC ≥300 cells/μl, alone or in any combination, are associated with future wheezing exacerbations and fewer asthma control days, and that these tests are acceptable to families. Methods. Finger prick measurement BEC; SPTs to house dust mite, grass and tree pollen, cat and dog hair to determine presence of atopy and FeNO measurement from tidally exhaled air. Progress. 97 participants are enrolled. Baseline BEC median value was 400 cells/μl (range: 0-1400 cells/microlitre) and 47 participants were aeroallergen sensitised. FeNO was obtained in 72 participants and median value was 7 ppb (range: 0-27.5 ppb), while 22 participants were measured with a faulty gas collection bag that did not allow accurate measurement and 3 participants did not provide sample after bag was replaced. A second optional testing occurred 3 months after baseline to assess biomarkers’ stability (excluding atopy). 41 children have completed the second test and there was no statistically significant difference between measurements for both BEC and FeNO (Wilcoxon signed rank exact test; p>0.05). 471 out of 555 follow up questionnaires (85%) and 137 out of 195 3-monthly follow-up MS Teams meetings (70%) have been completed. On-going challenges. Retention of participants in the study for the 12-month follow-up period. 

Trial registration: REC and HRA approval (21/PR/1195). Clinicaltrials.gov: NCT04942483. 

Scales J^1,2, Hajmohammadi H^1,2,  Katsouyanni K^3,4, Mudway I³, Green D³, Griffiths CJ^1,2 

¹Queen Mary, University of London. ²Asthma UK Centre for Applied Research. ³Imperial College London. ⁴University of Athens  

Background. Particles arising from tire and brake wear, as well as resuspension of road dust, now represent a greater proportion of roadside particulate matter by mass than direct tailpipe emissions. These non-tailpipe emissions remain unregulated, and their health impacts under explored in humans. Aim Investigate whether exposure to non-tailpipe pollution impairs lung function in asthmatic adults. Methods. A randomised cross-over study of short-term respiratory impacts on 48 non-smoking adults with moderate asthma during and after exposure to two contrasting, and one comparison, exposure environments in central London, UK: 1. Busy road with stop-go traffic to enhance brake wear emissions. 2. High speed continuous traffic, to enhance tire and road wear emissions. 3. An urban background site away from clear traffic sources. Adults with mild to moderate asthma will be exposed at each site for two-hours using a static bicycle exercise protocol, with enhanced air pollution monitoring to assist in source appointment into tailpipe and non-tailpipe fractions. Acute response endpoints (lung function: FEV1 primary outcome, FeNO) will be examined pre-, during & post-exposures and then related to source appointed PM. Airway inflammatory markers associated with worsening of asthma symptoms will be examined using nasal lavage. Plasma and air pollution filter samples will be banked for secondary analysis. Interim results The study is progressing in line with initial timelines. Notable milestones include: Established study sites and study documentation, Received institutional ethics approval, Seeking NHS ethics approval, Set up Independent Scientific Committee, Setting up a pilot study with healthy participants (results presented in May), Received multiple grants for further analysis. On-going challenges. Uncertainties regarding recruiting participants for time intensive study. Seeking opportunities for analysis of bio-banked plasma samples, and banked filter samples.  

Funding: Health Effects Institute (USA), Environemental and Health theme QMUL, The physiological society.  

Eck S¹, Hapfelmeier A^1,2, Schultz K³, Linde K¹, Schneider A¹ for the Bavarian Practice-Based Research Network (BayFoNet)

¹Institute of General Practice and Health Services Research, TUM School of Medicine, Technical University of Munich, Munich, Germany. ²Institute for AI and Informatics in Medicine, TUM School of Medicine, Technical University of Munich, Munich, Germany, ³Clinic Bad Reichenhall, Center for Rehabilitation, Pneumology and Orthopedics, Bad Reichenhall, Germany.

Background. Although it has been shown that asthma education programs (AEPs) increase quality of life and reduce unscheduled care and hospital admissions, only few patients with asthma attend such programs. We developed an online education program (electronic AEP, eAEP) to facilitate access to asthma education. Aim. This study investigates the effectiveness of the eAEP compared to usual care in terms of asthma knowledge, asthma control and unscheduled care in general practices in Bavaria, Germany. Methods. This cluster randomized controlled trial will include 100 patients with bronchial asthma from 20 general practices in Bavaria, Germany. General practices will be randomly assigned to either the intervention arm providing access to the eAEP, or to usual care control. Outcomes for both groups will be assessed at baseline (t0), after two weeks (t1), three months (t2) and six months (t3). The primary outcome is the comparison of asthma knowledge gain between intervention and control groups after completion of the eAEP and fAEP,respectively. Secondary outcomes include asthma control, frequency of unscheduled care, patient autonomy as well as attitudes towards asthma medication. Progress made. The first general practices started with patient recruitment in June 2022. To date, 20 general practices have been included in the study and 74 patients have been recruited. The last patient out will be expected in November 2023. Points for discussion. Could the eAEP be an important adjunct in the management of asthma patients in primary care? What are the differences in usual care for asthma patients between countries and how might these impact the generalisability of the study results?

Trial registration: German Clinical Trials Register (DRKS), DRKS0 00288 05.

Funding: The study is funded by the German Ministry of Education and Research (01GK1903A-D)

Jordan KA¹, Mackintosh KA¹, Davies GA², Griffiths CJ³, Chastin S⁴, Runacres A⁵ and McNarry MA¹.  

¹Swansea University. ²Swansea University Medical School. ³Queen Mary University of London. ⁴Glasgow Caledonian University. ⁵Manchester Metropolitan University  

Background. The Global Initiative for Asthma (GINA) encourages children diagnosed with asthma to follow the Government guidelines of achieving an average of 60 minutes of moderate-to-vigorous physical activity (PA) a day. However, less than 5% of children aged between 5-18 years in the United Kingdom achieve this. Despite PA being a crucial part of the management of asthma, PA interventions have largely failed to achieve meaningful, or sustained, improvements. This may be related to a lack of consideration for the composition of physical activity, whereby, due to the finite nature of daily behaviours, an increase in one domain must be at the expense of another. This raises important questions regarding the optimal composition of movement behaviours for health. Aim. This study seeks to investigate how PA is accumulated in children with and without asthma, and the interrelated effects that displacing one movement behaviour may have on the others. Methods. Large, population-level datasets (ALSPAC, Millenium Cohort Study, Gateshead Millenium Study; ages 11-18 years) will be combined and analysed  using a compositional data analysis approach. Multiple linear regression will be used to examine the relationship between lung function and movement behaviours. The influence of reallocating time spent in different movement behaviours on lung function will be examined according to asthma status, age and sex. Interim results. Data has been obtained from the three databanks and are currently being harmonised prior to data processing and analyses. On-going challenges. Uncovering the optimal composition of PA in a meaningful and actionable way, whilst undoubtedly challenging, could greatly improve conversations around disease management between clinicians and patients. Ultimately, this would empower indviduals to better understand their PA tolerance, adapt PA behaviours, and improve overall health, alongside identifying optimal windows for future interventions.