Barriers and facilitators to practitioner prescribing and patient adoption of anti-inflammatory maintenance and reliever therapy (MART) for adult asthma: a qualitative study.

Abstract

Background: Asthma was traditionally treated with separate corticosteroid (ICS) containing ('preventer') and short-acting beta-agonist (SABA; 'reliever') inhalers. But overuse of SABA-reliever inhalers is common and associated with poor outcomes. Clinical guidelines increasingly recommend using combined ICS and formoterol (ICS-formoterol) as an anti-inflammatory reliever. While ICS-formoterol use as a reliever only, without maintenance doses, has only recently been licenced in the United Kingdom; use as both preventer and reliever (Maintenance and Reliever Therapy; MART) has been recommended for many years. Despite the evidenced benefits of this approach, MART uptake in the UK has been low.

Methods: We studied the barriers and facilitators to primary care practitioners' prescribing and adult asthma patients' adoption of MART. We recruited practitioners and patients from a network of general practices that had participated in the SENTINEL programme to address SABA over-use and support MART adoption. Semi-structured, theoretically underpinned interviews were conducted with both groups. Data analysis involved deductive coding to the theoretical domains framework (a comprehensive framework including all potential determinants of practitioner and health behaviours) followed by inductive coding within domains.

Results: Fourteen themes were identified, with novel findings. Facilitators were practitioner knowledge and skills, and practice prescribing and appointment systems. Practitioner barriers mostly related to available resources, changes to treatment following emergency hospital presentations, and managing patient barriers to MART adoption and maintenance. Patient barriers included: psychological dependence on SABA-relievers and associated fear of discontinuation lack of understanding of the rationale for change to MART; and reluctance to change caused by concerns about difficulty getting an appointment if their asthma control deteriorated. Some practitioner barriers reported by previous studies (e.g., guideline knowledge and asthma management skills) were identified as facilitators in our study, potentially due to SENTINEL Programme participation.

Conclusions: The Global Initiative for Asthma (GINA) endorse ICS-formoterol as the preferred reliever in asthma, making it vital to understand barriers and facilitators to clinician and patient adoption in practice. We identified unique and previously unreported barriers and facilitators for both groups with potential to inform strategies to support practitioner and patient concordance with anti-inflammatory reliever-based asthma treatment and implementation of evidence-based, guideline-recommended care.