Transforming asthma care in the UK: A path forward

The challenge we currently face

As an inflammatory disease,[i] asthma is often overtreated with short-acting β2-agonists (SABA) inhalers, which have no anti-inflammatory qualities.[ii] In 2014, the National Review of Asthma Deaths (NRAD) found that SABA over-use and under-use of inhaled corticosteroids (ICS) were associated with preventable asthma deaths in the UK.[iii] Although nearly 10-years have passed since NRADs publication, recent data shows that the UK now has the highest rate of SABA prescriptions in Western Europe.[ii] Over reliance of SABA inhalers is not only linked to increased risk of exacerbation, hospitalisation and death,[iv] it also has environmental consequences, contributing to over 60 per cent of greenhouse gas emissions from uncontrolled asthma.[v]

The lack of improvement in asthma outcomes associated with over-prescription and reliance of SABA inhalers is highlighted in the recent Medicine Optimisation Strategy.[vi] This NHS call to action emphasises the need to optimise the prescribing of anti-inflammatory treatments, specifically ICS.[vi] By doing so, we can not only enhance outcomes for asthma patients, but also reduce the environmental impact of asthma and its treatment.

The SENTINEL Project

Hull is the fourth most deprived local authority in England and asthma outcomes in the region have historically been poor, with high rates of SABA over-use observed.[vii] Since 2020, clinical teams in Hull have worked to transform asthma care by identifying and addressing SABA over-reliance to improve outcomes for people living with asthma.

The SENTINEL Project aimed to improve outcomes and reduce the environmental impact of asthma and its treatment by identifying and addressing SABA over-reliance,[viii] supporting the adoption of local evidence-based guidelines, aligned to the GINA strategy[ix]. To do this, the SENTINEL Project used an intervention that was co-designed with stakeholders, including primary and secondary care clinicians, asthma service commissioners, and asthma patients.[x]

Outcomes from the first primary care network to take part in the SENTINEL Project showed that of 2,571 registered asthma patients, fewer patients were over-prescribed SABA in the overall asthma population (23.9 per cent 12 months post-implementation compared to 46.2 per cent, 12 months pre-implementation).[viii] Importantly, among those with asthma reviewed throughout the project, the observed change in prescribing practice was associated with 29.8 per cent fewer patients experiencing one or more asthma exacerbation during the year following implementation compared with the year before.[viii]

In addition, the programme has shown environmental benefits with significant reduction in greenhouse gas emissions. In data reported from the six SENTINEL Project PCNs, one-year after the sixth PCN completed the project, 44,275 fewer SABA inhalers were prescribed compared to what would have been expected if prescribing had remained unchanged from pre-implementation levels. [xi] The associated CO² emissions saved are equivalent to around 1,285 transatlantic flights from Leeds to New York.[xii]

Expanding good practice across the UK

SENTINEL has now been scaled and implemented in over 300 Primary Care Networks across the UK, including sites in England, Scotland, and Northern Ireland.[xi]

SENTINEL is one of the best-practice programmes available to Integrated Care Boards[xiii] across the UK. We hope it will help local systems capitalise on the NHS England Medicine Optimisation Opportunities to transform asthma care and achieve better outcomes for patients and the environment.[vi]

 

[i] What is asthma?. Asthma + Lung UK. Available here: https://www.asthmaandlung.org.uk/conditions/asthma/what-asthma#what-is-asthma. Last accessed November 2023

[ii] Janson, C et al. Adv Ther 2020; 37: 1124-1135

[iii] Royal College pf Physicians. National Review of Asthma Deaths. Why asthma still kills? 2014. Available at: https://www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills. Last accessed December 2023

[iv] Bloom CI, Cabrera C, Arnetorp S, et al. Asthma-related health outcomes associated with short-acting β2-agonist inhaler use: an observational UK study as part of the SABINA Global Program. Adv Ther. 2020;37:4190-4208.

[v] AstraZeneca DOF REF-199560;

[vi] NHS England. National Medicines Optimisation Opportunities. 2023. Available at: https://www.england.nhs.uk/long-read/national-medicines-optimisation-opportunities-2023-24/. Last accessed December 2023

[vii] Deprivation and poverty. Hull City Council. Available at: https://www.hulljsna.com/health-and-wellbeing-influences/deprivation/. Last accessed November 2023

[viii] Crooks et al. Improving asthma care through implementation of the SENTINEL program: findings from the pilot site. ERJ Open Res 2023

[ix] Primary Care Respiratory Society. Focus on asthma: The GINA Approach to Managing Asthma. Available at https://www.pcrs-uk.org/resource/focus-asthma-gina-approach-managing-asthma. Last accessed November 2023

[x] Crowther et al. Towards codesign in respiratory care: development of an implementation-ready intervention to improve guideline-adherent adult asthma care across primary and secondary care settings (The SENTINEL Project). BMJ Open Respir Res. 2022 Feb;9(1):e001155. doi: 10.1136/bmjresp-2021-001155.

[xi] AstraZeneca Case Study ‘The Sentinel Project – Collaborating to Improve Asthma Care’. ABPI. Available at: https://www.abpi.org.uk/partnerships/working-with-the-nhs/nhs-industry-partnership-case-studies-library/astrazeneca-february-2021-case-study-22/. Last accessed December 2023

[xii] Flight Carbon Calculator. Clevel. Available at: https://www.clevel.co.uk/flight-carbon-calculator/. Last accessed December 2023

[xiii] NHS. Integrating Care: Next steps to building strong and effective integrated care systems across England. Available at: https://www.england.nhs.uk/wp-content/uploads/2021/01/integrating-care-next-steps-to-building-strong-and-effective-integrated-care-systems.pdf. Last accessed December 2023