Review and Feature Article
Systematic Assessment of Difficult-to-Treat Asthma: Principles and Perspectives

https://doi.org/10.1016/j.jaip.2020.02.036Get rights and content

Difficult-to-treat asthma affects a minority of adults and children with asthma but represents a challenging mix of misdiagnosis, multimorbidity, inadequate self-management, severe airway pathobiology, and treatment complications. Management of these patients extends beyond asthma pharmacotherapy, because multiple other patient-related domains need to be addressed as well. Such complexity can hinder adequate clinical assessment even when performed in specialist practice. Systematic assessment undertaken by specialized multidisciplinary teams brings a broad range of resources to bear on patients with difficult-to-treat asthma. Although the concept of systematic assessment is not new, practices vary considerably and implementation is not universal. Nevertheless, assessment protocols are already in place in several institutions worldwide, and outcomes after such assessments have been highly encouraging. This review discusses the rationale, components, and benefits of systematic assessment, outlining its clinical utility and the available evidence for improved outcomes. It describes a range of service configurations and assessment approaches, drawing examples from severe asthma centers around the world to highlight common essential elements. It also provides a framework for establishing such services and discusses practical considerations for implementation.

Section snippets

The Need for Systematic Assessment (Table I)

Difficult-to-treat asthma is heterogeneous and complex, involving a multitude of potentially targetable pulmonary, extrapulmonary and behavioral traits.9,10 Most patients with difficult-to-treat asthma have modifiable risk factors for poor asthma control,5 and failure to address them may result in poorer outcomes.11,12 Systematic assessment therefore acts as a cognitive tool to ensure that all essential elements are addressed.13,14 This evaluation process cannot be assumed, as many key aspects

Improved processes

The broad range of deficiencies in care outlined above can be overcome with an assessment system that is comprehensive, holistic, and multidisciplinary.

A comprehensive approach with standardized steps for all patients can prevent the important omissions and reduce the variability with which different specialists have been shown to respond to the same case scenario.43

A holistic approach expands the evaluation beyond an airway-centric approach to encompass additional domains of extrapulmonary

Selecting Patients for Systematic Assessment

Systematic assessment of patients with difficult-to-treat asthma is resource-intensive. It should be prioritized for patients with the greatest complexity and disease burden who, according to responder analysis, derive the most benefit.50 Ideally, it should form the concluding stage of an integrated, coordinated approach to asthma that spans primary and secondary care.56

The prevalence of difficult-to-treat asthma in the community is reportedly as high as 17% of all adult asthma.57 The figure

Service configuration

The model by which systematic assessment is delivered is usually tailored to the overall goal. This goal can range from providing assessment only, to providing the totality of care, inclusive of both assessment and treatment (Figure 1).

An “assessment-predominant” model allows completion of the entire diagnostic process in an intensive 1-day visit, leaving treatment recommendations to be implemented by the referring specialist.48 This model relies on the referrer having subsequent access to

Domains of Systematic Assessment

Systematic assessment of difficult-to-treat asthma focuses on 3 broad domains: asthma itself, comorbidities, and patient factors. Within each domain, specific issues are often found to be recurring and important contributors to difficult-to-treat asthma.

Specific Paediatric Considerations

Systematic assessment of difficult-to-treat asthma is just as beneficial in children as in adults,136 but there are key differences between adult and pediatric practice.137 First, the assessment is centered on the family rather than the patient. Psychosocial morbidity, frequently related to parent/carer influence, is common in children with difficult-to-treat asthma, and exploration of these factors through home and school visits can be revealing.138 The child probably cannot modify factors

Conclusion

Systematic assessment for difficult-to-treat asthma is beneficial and necessary to address the needs of this challenging population. Specific components of the assessment and how these are delivered may vary between health care settings, but there is broad consensus on the main domains of assessment. A substantial range of clinical expertise is required to address patient complexity, and delivering multidisciplinary systematic assessment requires specific resource allocation and training for

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    M. Hew was funded by sabbatical leave from Alfred Health. All other authors report no funding for this manuscript.

    Conflicts of interest: M. Hew has received grants-in-aid, speaker fees, and fees for serving on the advisory boards of GlaxoSmithKline, AstraZeneca, Novartis, Teva, Sanofi, and Seqirus, all paid to his institutional employer Alfred Health. A. Menzies-Gow reports attending advisory boards for GlaxoSmithKline, Novartis, AstraZeneca, Boehringer Ingelheim, Teva, and Sanofi; and receiving speaker fees from Novartis, AstraZeneca, Vectura, Boehringer Ingelheim, and Teva. He has participated in research with Astra Zeneca and attended international conferences with Teva. He has consultancy agreements with AstraZeneca, Vectura, and Sanofi. J. H. Hull reports speaking fees for lectures and advisory work from Novartis, Roche, Astra-Zeneca, and Teva. L. Fleming is an Asthma UK Senior Clinical Fellow supported by the Joan Bending, Evelyn Bending, Mervyn Stephens, and Olive Stephens Memorial Fellowship; and has received speaker fees and fees for attending advisory boards from Astra Zeneca, Boehringer-Ingelheim, GSK, Novartis, Respiri, Sanofi, and Teva, paid directly to her institution. C. Porsbjerg reports attending advisory boards for GlaxoSmithKline, Novartis, AstraZeneca, Teva, and Sanofi; and receiving speaker fees from Novartis, AstraZeneca, Sanofi, and Teva. She has participated in research with Astra Zeneca, Novartis, ALK, MSD, Teva, and Sanofi. A. T. Brinke reports research grants and institutional fees for lectures and advisory boards from AstraZeneca, GlaxoSmithKline, Novartis, Sanofi, and Teva. D. Allen has received speaker fees, paid contributions to advisory boards and support to attend conferences from AstraZeneca, Teva, and Napp. R. Gore reports personal fees from GlaxoSmithKline, UK; personal fees and nonfinancial support from Novartis UK; personal fees from Astra Zeneca, outside the submitted work. T. R. Tay declares no relevant conflicts of interest.

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