Personalised management and supporting individuals to live with their asthma in a primary care setting

Figures & data

Table 1. Phenotypes of asthma [2].

Phenotype	Characteristics	Response to inhaled steroids (ICS)
Allergic asthma	Commences in childhood. Associated with personal and/or family history of atopy. Eosinophilic airway inflammation	Usually respond well to ICS
Non-allergic asthma	Cellular profile of sputum may be neutrophilic, eosinophilic or a paucity of inflammatory cells	Less likely to respond to ICS
Adult-onset asthma	Often female, onset in adulthood, tend to be non-allergic. (Excluding occupational asthma)	Non-responsive, or requires high doses of ICS.
Persistent airflow obstruction	Persistent/irreversible airway obstruction due to airway remodelling	Reduced potential for response
Obesity	Prominent symptoms, little eosinophilic airway inflammation	Poorly responsive to ICS

Table 2. Clarifying the terminology used in this review.

Terminology	Definition	Comment
Precision medicine (often used synonymously with ‘personalized medicine’)	An approach to tailoring disease prevention and treatment that takes into account differences in people’s genes, environments, and lifestyles [5].	Despite the breadth implied by ‘environment’ and ‘lifestyles’, this term typically focusses on targeting drug treatments (‘medicines’). For example, the example on the FDA website is gene-sequencing the individual’s tumor [5].
Treatable Traits	A strategy where patients are individually assessed for a specified set of treatable problems, and an individualized treatment programme is developed and implemented based on this multidimensional assessment [4].	Described as including pulmonary, extra-pulmonary and behavioral treatable traits [4], although the focus is often on mechanisms of disease. For example, in the context of asthma, adherence/social behaviors are acknowledged as important but dismissed as ‘difficult to modify’ [1].
Personalised management	The term ‘management’ overcomes the narrow focus on drug treatments by encompassing ‘non-pharmacological management’ [2,6].	In ambulatory care, where patients are responsible for day-to-day decisions on coping with their asthma this merges with self-management [6].
Personalised care	‘Care’ describes the health (and social) care services determined by the needs, circumstances and preferences of the individual receiving care [7].	Care should be ‘personalized’, ‘co-ordinated’ and ‘enabling’ affording people ‘dignity, compassion and respect’ [7].
Person-centered care	Health and social care professionals work collaboratively with people who use services [7]. Person-centered care supports people to develop the knowledge, skills and confidence they need to manage and make informed and effective decisions about their own health and health care. It is coordinated and tailored to the individual’s needs.	The most holistic of the definitions which explicitly merges physician management and self-management in agreeing tailored strategies to support people to live with their condition. This aligns with the values of primary care and thus underpins this article [3].

Note: Many of these concepts are new and evolving. The aim in this table is to clarify how we have used the terms in this review. Other definitions exist, and will be modified as the concepts mature.

Table 3. The PRISMS taxonomy of supported self-management with suggestions for personalization and potential digital support (Adapted from [17]).

Component of self-management support	Potential personalization for individuals with asthma	Potential digital support
Information about asthma/management	Information tailored to individual clinical, social characteristics and preferences	Links to on-line sources of information – selected to be relevant to the individual.
Information about available resources	Access to national patient charities and local support groups.	‘Intelligent’ highlighting of local resources relevant to the individual’s asthma, personal and social context.
Provision of specific clinical action plans and/or rescue medication	A personalized action plan that: Reflects the individual’s asthma status and the treatment that they are using. Provides advice about avoidance of triggers relevant to the individual. Includes advice about co-morbidities (specifically including allergic rhinitis) Is adapted to the individual’s preferences, health literacy and confidence in managing their asthma.	Digital action plan, underpinned by a rule-based algorithm agreed with a clinician. In the future AI-based plans are likely to be available.Enhancing accessibility (such as audio plans for visually impaired, pictorial versions to overcome literacy and language problems) Enhancing accessibility (such as audio plans for visually impaired, pictorial versions to overcome literacy and language problems)
Regular clinical review	Regular reviews arranged at a frequency appropriate to the clinical condition and the preferences of the individual.	Remote modes of consultation according to preference and asthma status. Facilitating remote reviews by sharing data.
Monitoring with feedback	Symptom scores, and/or peak flow monitoring according to preference.	Logs of symptoms or peak flows; facility to share with healthcare professional.
Practical support with adherence	Individually relevant strategies to address non/intentional poor adherence.	Smart inhalers, apps/SMS with reminders, Repeat prescription reminders.
Provision of equipment	Individual preference for monitoring peak flow, oximetry for severe asthma.	Digital peak flow meters; smart inhalers, devices that monitor technique
Easy access to advice/support when needed	Flexible mode of reviews according to preference and clinical status.	Facilitation of remote consulting; alert facility for people with severe asthma
Communication with professionals	Information on ‘what to expect at a review’ with suggested questions to ask.	Transmission of monitoring logs to support discussion.
Training/rehearsal for everyday activities	Reminders/reviews linked to seasonal events known to trigger individual’s symptoms	Links to environmental smart city sensors and alerts on allergens/pollution.
Training for practical self-management tasks	Training on inhaler device, and (according to preference) using peak flows	Smart inhalers and digital sensors that assess and feedback on technique.
Psychological strategies	Access to psychological therapies and/or breathing retraining as relevant	Links to on-line talking therapies for those with co-morbid depression/anxiety
Social support	Reference to local support groups	Links to social forums for information and peer support
Lifestyle advice and support	Smoking cessation; weight loss; exercise support according to need and preference	Choice of lifestyle ‘apps’ to support behavioral change

Figure 1. Factors which have been associated with poor asthma outcomes.

Figure 2. Elements of the practice level approach used in the ARRISA studies.

Table 4. Phenotypes of pre-school wheeze (data from ALSPAC [82]).

	Phenotype Atopic status (Any skin prick sensitivity)	Prevalence	Proportion of children with physician diagnosed asthma by school-age [%, OR (95% CI)]
Never/infrequent wheeze	No history of wheeze throughout preschool years or sporadic wheeze with declining prevalence over pre-school years. Only 16% are atopic.	59%	Low risk of asthma diagnosis [4%, OR 1 (reference)]
Transient early wheeze	Wheeze in first three years, but not between 4–6 years of age. Only 14% are atopic	16%	Low risk of asthma diagnosis [9%, OR 3 (95% CI 2 to 4)]
Persistent wheeze	Episodes of wheeze throughout first six years of life. 42% are atopic.	7%	Very high risk of asthma [92%, OR 308 (95% CI 186 to 510)]
Late onset wheeze	Onset of wheeze between 4–6 years of age. 56% are atopic.	6%	High risk of asthma [76%, OR 85 (95% CI 56 to 128)]
Intermediate onset wheeze	Low prevalence of wheeze by 18 months, but high prevalence by 42 months. 62% are atopic.	3%	Very high risk of asthma93%, OR 326 (95% CI 138 [to 770)]
Prolonged early wheeze	Peak prevalence of wheeze at 30 months, declining by 69 months. Only 15% are atopic.	9%	Medium risk of asthma [36%, OR 15 (95% CI 11 to 21)]

Abbreviations: OR: Odds ratio; 95%CI: 95% confidence intervals.

Figure 3. The four principles of person-centered care (Reproduced with permission from the Health Foundation [7]).

Table 5. Modes of consultation and features that can personalize their use.

Categorisation	Mode of consultation	Benefits	Disadvantages
Synchronous	Face-to-face, in person consultation	Allows examination and visual assessment of clinical status. Enables observation of inhaler technique. Good rapport and co-completion of an action plan.	May be inconvenient for patient, and require a relative/friend to support travel, cost/time for travel, may increase risk of exposure to infection.
	Telephone consultations	Convenient and can improve access to reviews and reduce barriers to routine care [121]. Can discuss goals and action plans, though co-completion difficult.	Tend to be focussed. Reliance on verbal descriptions and auditory clues (e.g. of breathlessness). Not possible to check/demonstrate inhaler technique.
	Video consultation	Enables visual assessment, and may improve rapport and communication [123,124]. Possible to complete an action plan by sharing the screen [125] and check inhaler technique.	Requires patient and clinician to have technology infrastructure [126] – more complex than a telephone call [127].
Asynchronous	Online questionnaires/e-consultations	May be useful for follow-up, responding to queries, delivering results. Validated questionnaires can assess status and inform risk stratification and priorities for care.	Inappropriate in an acute situation as cannot assess status. Not possible to check inhaler technique, or discuss action plans. Limited potential for developing patient/clinician rapport.
	Text messaging	Useful adjunct to a synchronous consultation for communicating results, providing links to resources. Can be used to transfer images.	Not possible to undertake most of the functions of an asthma review unless used to encourage attendance at a synchronous consultation.

Figure 4. Existing and emerging technologies to support the GINA guideline management cycle for personalized asthma care [2].

Note: The GINA personalized asthma management cycle guides the clinician through the stages of assessing, adjusting and reviewing the individual patient’s needs.

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