Qualitative Study of Practices and Challenges of Stepping Down Asthma Medication in Primary Care Across the UK

Chloe I Bloom; Helen Ramsey; Marsha Alter; Shivali Lakhani; Ernie Wong; Katharine Hickman; Sarah L Elkin; Azeem Majeed; Austen El-Osta

doi:10.2147/JAA.S274943

Qualitative Study of Practices and Challenges of Stepping Down Asthma Medication in Primary Care Across the UK

J Asthma Allergy. 2020 Oct 6:13:429-437. doi: 10.2147/JAA.S274943. eCollection 2020.

Authors

Chloe I Bloom¹, Helen Ramsey², Marsha Alter³, Shivali Lakhani³, Ernie Wong⁴, Katharine Hickman⁵, Sarah L Elkin⁴, Azeem Majeed^#⁶, Austen El-Osta^#^{6

7}

Affiliations

¹ Airways Disease Section, National Heart and Lung Institute, Imperial College London, London, UK.
² Kent and Medway CCG, Swanscombe and Bean Partnership, Swanscombe Kent, UK.
³ Middlesex Pharmaceutical Group of LPCs & Community Pharmacy Research Champion NIHR NWL CRN, London, UK.
⁴ Department of Respiratory Medicine, Imperial College Healthcare Trust, London, UK.
⁵ West Yorkshire & Harrogate Health and Care Partnership, Low Moor Medical Practice, West Yorkshire, UK.
⁶ Department of Primary Care & Public Health School of Public Health, Imperial College London, London, UK.
⁷ Self-Care Academic Research Unit (SCARU) Department of Primary Care & Public Health School of Public Health, Imperial College London, London, UK.

^# Contributed equally.

Abstract

Background: Guidelines recommend that asthma treatment should be stepped down to the minimally effective dose that achieves symptom control to prevent medication side effects and reduce unnecessary costs. Little is known about the practice of stepping down and the challenges in primary care, where most asthma patients are managed.

Objective: To explore views, experiences, barriers and ideas, of doctors, nurses and pharmacists working in primary care, related to step down of asthma medication.

Methods: Primary care practitioners from across the UK participated in a survey and/or semi-structured interview. Questions explored four main areas: how asthma medication is reviewed, views on asthma guidelines, perceived barriers faced by healthcare workers and facilitators of stepping down. Qualitative content analysis enabled data coding of interview transcripts to identify major themes.

Results: A total of 274 participants responded to the survey, 29 participated in an interview (12 doctors, 9 nurses, and 8 pharmacists), working in GP practices from across the UK. Nearly half of the survey participants infrequently step down asthma medication (doctors=42.7%, nurses=46.3%). Four major themes related to barriers to stepping down were (i) lack of awareness of the need to step down, (ii) inertia to step down, driven by low confidence in ability, fear of consequences, and concern for who is responsible for stepping down, (iii) self-efficacy of ability to step down, influenced by lack of clear, applied guidance and limited training, and (iv) feasibility of step down, driven by a lack of systematic acceptance of stepping down and time. Strategies proposed to reduce overtreatment included education and training, improved gathering of evidence and guidance, and integrating step down into routine asthma care.

Conclusion: Failure to implement this guideline recommendation into everyday asthma management is influenced by several contributing factors. Future directions should include addressing evidence gaps, implementing clear and practical guidance, integration of step-down assessment into the asthma review, and education of professionals and patients.

Keywords: asthma; perceptions; primary care; qualitative; stepping down.

Grants and funding

None received. The research was supported by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) North West London. The views expressed are those of the authors and not necessarily those of the funder, the NHS, the NIHR or the Department of Health.