Asthma Smart App (Asthma⁺me) used in primary care avoids presentation to Emergency Department for 6 year old with severe asthma

Moira Gibbons¹, Robert Thornton², Nicki Barker¹, Craig Burgess³, Kevin Auton³, Heather Elphick¹.

¹Department of Respiratory Medicine, Sheffield Children’s NHS Foundation Trust, ²Wath Health Centre, Rotherham and ³Aseptika Ltd, Cambridgeshire

Introduction

Paediatric asthma is an NHS 10-year (NHS Long-Term) priority¹ and innovative approaches to managing the increasing number of children with moderate-to-severe asthma are needed. In 2014, a national review found that nine out of ten childhood asthma deaths in the UK could have been prevented². Smart inhalers and Health Apps in a digitally evolving NHS have the potential to support self-management of long-term conditions such as asthma at scale³. This approach would support digital transformation of health services to risk stratify according to need and to provide a personalised approach to care⁴, showing both clinical and economic benefit by reducing emergency admissions and improving patient safety and quality of life⁵.

One proposed solution is Asthma⁺me, a comprehensive CE-marked technology-enabled self-care solution for children and young people with asthma. Core to Asthma⁺me is education, engagement and empowerment for children /young people and their parents. It supports integrated Bluetooth-connected devices for monitoring lung function and medication adherence as well as medication and symptom diaries. A weekly PDF report generated by the app is sent automatically from Asthma⁺me to the electronic patient record. The clinician can review progress remotely or can access the patient-generated data in the event of an emergency consultation.

We report the case of a 6 year old boy with severe asthma in whom the use of data generated by Asthma⁺me gave his GP confidence to monitor the child rather than sending him to the Emergency department at the local hospital.

Case report

The patient is a boy aged 6yrs with a complex medical history including atopy, gastro-oesphageal reflux disease and severe asthma. His asthma is managed by his GP, his consultant paediatrician and the Difficult Asthma service at the tertiary paediatric respiratory centre.  Since September 2015, there have been 21 admissions to the local hospital because of asthma or wheeze.  Typically, the family have presented in the Emergency Department and, on two of these occasions, high dependency care has been required. Consequently, this child has become highly anxious about further hospitalisations.

The parent was trained in the use of the Asthma⁺me App as part of a randomised controlled trial being undertaken by the tertiary centre. The commercial partner, (Aseptika Ltd), was responsible for delivering this training in accordance with a protocol agreed with the clinical team. During this training, the parent reported that the child was experiencing an exacerbation and had been seen by their GP earlier that day. Oral steroids had been prescribed and a review booked for the following week.

The child continued to experience worsening symptoms over the intervening period and the parent administered the reliever inhaler as per the emergency instructions in the care plan.  The child was still unwell when reviewed by the GP six days later. The child’s parent took the opportunity to show their GP the Asthma+me report. The GP used the data from the report (Figure 1) and confirmed an improvement in the PEF/FEV₁ from that morning. No wheeze was present at that time and therefore no further reliever medication was administered. A course of Amoxicillin was prescribed because of a persistent low-grade temperature. The child had an appointment already booked with his respiratory specialist in less than a fortnight.

Based on previous experiences of exacerbations, the parent had expected her child to be admitted to hospital that day via the Emergency Department. The GP agreed that this would have been the usual course of action had the extra clinical data provided by the Asthma⁺me App not been available. Instead, assessing the child in the context of the App data gave the GP the confidence to monitor the child’s progress. The GP stated “If I had just looked at the child, I would have sent him to A&E”.  

Following this event, the child continued to be adherent to their preventer inhaler and the use of the reliever inhaler decreased over the following weeks. The parent continued to record PEF & FEV₁ four times a day during the exacerbation but was sufficiently confident to wait for their scheduled outpatient appointment with the respiratory consultant rather than attend the Emergency Department or make an urgent outpatient appointment at SCH. As the parent’s confidence in the control of the child’s asthma increased, the rate of recording PEF & FEV₁ decreased to only twice daily and the use of reliever decreased steadily.

Discussion

This is the first instance that we are aware of in which data generated by Asthma⁺me was used by an expert parent with a primary care-based clinician to support the avoidance of a visit to the Emergency Department.

The aim of the Asthma⁺me trial is to provide evidence of clinical and economical efficacy. One model for implementation would be a “Hub and spoke” model, in which the tertiary paediatric respiratory centre acts as the “hub” and the GP centre the “spoke”. This practice, at which there is considerable experience in respiratory medicine, could make an excellent “test centre” to drive forward expertise and confidence in the model in primary care, thereby reducing the need for escalation of care to emergency services.   

The parent of the boy described in the case report has given full consent for publication.

Acknowledgments

Support provided by SBRI Healthcare, Innovate UK, Yorkshire & Humber AHSN and NIHR (National Institute for Health Research) Children and Young People MedTech Cooperative. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or of the Department of Health and Social Care.

References

1. https://www.longtermplan.nhs.uk/wp-content/uploads/2019/08/nhs-long-term-plan-version-1.2.pdf
2. Royal College of Physicians. (2014) Why Asthma Still Kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry Report. London: RCP.
3. Marcano Belisario JS, Huckvale K, Greenfield G, Car J, Gunn LH. Smartphone and tablet self management apps for asthma. Cochrane Database of Systematic Reviews 2013, Issue 11. Art. No.: CD010013.
4. Asthma UK (2017) “Smart Asthma” – real-world implementation of connected devices in the UK to reduce asthma attacks.
5. Morton RW, Elphick HE, Rigby AS, Daw WJ, King DA, Smith LJ, et al. (2016) STAAR: a randomised controlled trial of electronic adherence monitoring with reminder alarms and feedback to improve clinical outcomes for children with asthma. Thorax. Published Online First: 04 November 2016.