The management of severe and difficult asthma in general practice : a qualitative study
Aim: The aim of this research project is to explore healthcare professionals' experiences of managing severe and difficult asthma in general practice. The project seeks to: establish the definitions given to severe and difficult asthma; examine use of guidelines, self management plans and clinics in the management of asthma; identify organisational and patient issues related to managing severe and difficult asthma; analyse the relationship between patients' and professionals' issues; explore and identify possible solutions to recognised issues. Methods: This is a qualitative study using 47 semi-structured interviews and five focus groups. The total number of participants in the study was 68. Participants consisted of: General Practitioners (n=37); Practice Nurses (n=16); a Health Visitor; Hospital Consultants (n=3); Patients with asthma (n=14). Sampling of healthcare professionals (HCPs) was stratified based on practice location and size, gender, special interest in asthma and experience. Sampling of patients was initially through the HCP participants and then later through a volunteer database. Data collection and analysis was guided by a grounded theory approach. The data were analysed using the constant comparative method and framework approach. Data were also analysed for underlying, emerging and additional interesting themes. Results: Definitions of severe and difficult asthma varied between healthcare professionals. Not all of the definitions elicited in this study matched published definitions. Control issues were commonly mentioned in definitions of both severe and difficult asthma. - Although HCPs had mainly positive attitudes towards guidelines, self-management and asthma clinics, they used these only when they deemed them suitable. Suitability was established according to individual patient issues (e.g. psychosocial factors) and HCP issues (e.g. ease of use, time available, job roles). - Patient issues were viewed as impacting on asthma control. HCPs reported that they lacked suitable communication skills specifically for dealing with difficult patient issues. Patient with difficult asthma were more likely to report negative experiences and poor communication with their HCPs than those with well-controlled asthma. This seemed particularly notable when treatment for exacerbations was required. - HCP roles, training and skills, teamwork and communication, together with practical issues e.g. access to spirometry, were perceived as impacting on asthma management. - Communication skills training was identified as being the most fruitful way forward. Smaller, specific solutions were also identified for specific issues. Conclusion: Eliciting definitions of severe asthma and difficult asthma from this group of primary care health professionals highlighted disease control issues and variance from published definitions.