International asthma guidelines agree that optimal management should be based on a shared and coordinated approach from a multi-disciplinary team (MDT) and propose specific referral criteria between primary and secondary care.
12092022 
05 min read 
English A recently published consensus document involving family physicians, pulmonologists and nurses offered clear guidance when referring primary care patients in the asthma management pathway:1
- Diagnostic confirmation is needed where inconclusive diagnostic tests have been performed, or due to poor test quality, or because tests are not available in the primary care setting
- Patients considered as having severe (GINA step 5) or poorly controlled asthma, following optimisation of inhaler technique and investigation into treatable traits of poor control e.g., poor compliance, presence of comorbidities and asthma triggers
- In special circumstances e.g., suspected occupational asthma, allergic asthma and aspirin exacerbated respiratory disease (AERD)
Additionally, the consensus recommended that details of all diagnostic tests performed and any previous and/or recommended treatments are recorded in both the primary care referral and secondary care feedback record. Telemedicine follow-up with selected patients could support improved coordination of these data records.1
Unmet Need: Although referral criteria are clearly identified and recommended in asthma guidelines, there is currently a lack of inter-level coordination, especially in severe asthma.
A Delphi process completed in the UK looked at the most valued items among guideline referral criteria and shared management recommendations and concluded:2
- Patients requiring 2 or more courses of oral corticosteroids (OCS), or a hospitalisation, in the last 12 months should be stratified and prioritised within national targets for referral to specialist centres
- Patients should be referred directly into a severe asthma network (or service) by primary or secondary care teams based on agreed criteria being met
- Every patient with suspected severe asthma should be seen within 8 weeks of referral to an appropriate specialist severe asthma service
- Once a patient has been approved by the severe asthma service MDT, or equivalent, for an advanced therapy, initiation of treatment should not be delayed for more than 4 weeks
Real-World Data:
According to a real-life observational study conducted on a Danish community population, most patients with possible severe asthma (61%) were managed exclusively in primary care.3 Although having 2 or more moderate exacerbations or a hospital admission increased the chances of being seen by the pulmonologist, approximately half of the patients admitted for asthma were treated exclusively by primary care without being followed up in secondary care.3
Socio-economic influences:
The authors also identified several socioeconomic variables associated to the likelihood of severe asthma patients being managed in secondary care.
Access to specialist management decreased with age, male gender, residence outside the capital region and with receiving unemployment or disability benefits. Whereas access increased for patients with completed higher education, when compared to those with basic education.3
Key takeaways:
- Despite guidelines recommendations and consensus referral criteria, population studies highlight a reluctance to refer possibly severe or uncontrolled asthma patients for specialist follow up from primary care, especially in those from rural or socially disadvantaged areas with lower levels of education.3
- Health services should endeavour to improve inter-level coordination to optimise this situation and improve systematic evaluation and correct pharmacological treatment of both asthma and its comorbidities at different health care levels.3
ABBREVIATION:
GINA, Global Initiative for Asthma.
REFERENCES:
- Delgado R J, et al. Referral Criteria for Asthma and the Pandemic: New Challenges, New Responses. J Investig Allergol Clin Immunol. 2021 Dec 21;31(6):530-532. doi: 10.18176/jiaci.0747. Epub 2021 Sep 7. PMID: 34489222.
- Jackson D J, et al. Recommendations following a modified UK-Delphi consensus study on best practice for referral and management of severe asthma. BMJ Open Respir Res. 2021;8(1):e001057. doi: 10.1136/bmjresp-2021-001057.
- Håkansson K E J, et al. Socioeconomic biases in asthma control and specialist referral of possible severe asthma. Eur Respir J. 2021;58(6):2100741. Published 2021 Dec 16. doi: 10.1183/13993003.00741-2021.
Dr Sara Núñez Palomo
Dr Miguel Román-Rodríguez
Dr Sara Núñez Palomo
Dr Miguel Román-Rodríguez
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