How UK Primary Care physicians deal with asthma

Transcript

Mark: Please give us a little background on yourself, your education, experience and your current responsibilities.

Dermot: My name is Dermot Ryan I qualified at University College Dublin back in 1977 and did my primary care training in Ireland. I travelled around a little bit and eventually ended up in England in a partnership as a General Practitioner in 1984. I developed an interest in asthma around 1985 which has been one of the central things of my professional career. I've always been a General Practitioner, I'm not an academic just a real-life GP or primary care physician or family physician, its name changes from country to country. In the UK, GPs look after people from the minute they are born, to the minute they die. We look after children, adults and the elderly as well. Currently, I retired from General Practice a couple of years ago, but I came back to work because of the COVID epidemic. My work now is in the vaccination centres.

Mark: Why don't you tell us about the Respiratory Effectiveness Group and who makes up this group?

Dermot: This group is a group set up by a bunch of interested permissions who work around the world. It's a global not-for-profit organization. It is a collaboration of Clinicians, Scientists and Epidemiologists working together to identify and fulfil real-life research needs in respiratory medicine and advocating for change to drive and improve patient management. Real life differs from the fantasy world (I use those words advisedly) of guidelines which are drawn from highly controlled clinical trials and the findings may not always be applicable in ordinary everyday practice. They do of course become the foundation of our guidelines and are a very important part of the evidence base. We need to translate the evidence base into the environment in which we work.

Primary care patients are considerably different to those seen in secondary care and very much different from those who are seen by clinicians in tertiary care. Although we will have people from all those groups within primary care. For example, guidelines really meet the needs of people who fall in the middle. If you look at a bell-shaped population curve, they'd meet the needs of the people falling between 45 and 55% of the median. However, the vast majority of people fall outside of that. It's about trying to use the true meaning of evidence-based medicine using the guidelines to meet the needs of the individual patient using your clinical expertise and the resources available to you, as I said there are people from around the world from the States, from Canada, from Asia, from Europe working together to try and achieve this.

We have done some very good stuff. We have identified a core data state for asthma / COPD studies that are known as ‘Torpedo’. We looked at the match plasma childhood real-life comparative studies to the addition of antibiotics. They imagined asthma exacerbations in primary care by looking at the point of care, biomarkers and asset management. Which of course is quite important, particularly in the tertiary care environment. We made a manifesto concerning the use of real-life evidence in guidelines which is published in the European Respiratory Journal a couple of years ago.

Janson: I know that you are part of the International Primary Care Respiratory Group. Can you give me more information about that?

Dermot: With pleasure. The International Primary Care Respiratory Group was founded at the annual scientific meeting of the Primary Care and Respiratory Society in Cambridge in 2000. It held its first international meeting in Amsterdam in 2002. It has a scientific meeting every two years and a research meeting in the years which you take those two years.

It's made up of Primary Care Respiratory interest groups from about 35 nations across the world. From wealthy nations and from lower and middle-income countries. It reaches about 150,000 physicians and it shares its journal with the Primary Care Respiratory Society, the Primary Care Respiratory Medicine is published by MPJ. The MPJ was at the primary care respiratory medicine was founded to publish evidence generated within primary care. This is an area which doesn't necessarily appear very often is in specialist journals like the Blue Journal or the Journal of Allergy and Clinical Immunology or the European Respiratory Journal Thorax. It was very important to have a showcase for the research done within primary care to meet the needs of those patients and doctors who work and who attend primary care.

Janson: What are their goals and how have they effectively improved patient care?

Dermot: The goals are to improve patient care (this is the IPCRG) and there have been some very active programs in low- and middle-income countries to help improve care. Particularly programs looking at reducing domestic smoke within the house. In many countries in the world, fuels are used within the home, for example not used with a hole in the roof or a chimney. Even something as basic as a hole, so mothers and children are not breathing in fumes the whole time, it impairs their respiratory function. It started off in Uganda and is now being rolled out in other countries. We have also looked at ways of trying to improve respiratory function tests in lower-middle countries. We have looked at sourcing less expensive Spirometry. Even some simple things like peak flow meters and try to moderate guidelines as they currently stand to meet the needs of the population. Working in those countries, some people might say is dumbing down but on the other hand, it's better to have something on the ground which makes for a more accurate diagnosis and therefore, more direct treatment than having no guidance or no idea of how to proceed at all.

Janson: What are some of the problems with the diagnosis of asthma within primary care?

Dermot: I think the biggest problem with making a diagnosis of asthma in primary care is the feeling that you must make a diagnosis straight away. Of course, is not the case. Diagnosis needs to be made over a period of maybe over three or four consultations. Sometimes it's obvious when a patient comes in that the diagnosis is asthma but really the diagnosis needs to be considered a professional diagnosis until you've proved it. One of the problems with asthma is there is no complete picture of what somebody with asthma looks like. If you think about a picture and break it up into little pieces like a jigsaw, then you must put together those pieces of the jigsaw in order to try and get a fair idea of what the big picture is. Central to that is the need to demonstrate in my opinion. Either airway variability or reversibility. One of the big problems is that, oftentimes tests are done on patients when they are asymptomatic or clinically stable. In which case, unless you're doing provocation testing the tests will be negative giving a misleading reassurance there is nothing going on here. We need to look at the picture, we need to look at the actual symptoms the patient has at the time, when they come to see you, how long they've lasted, how they vary, what brings them on and so forth. We need to think about the family history and whether there's anything relevant in that first degree. Relatives with asthma or a personal history of eczema for example; need to think about occupational factors. About 10% of adults have occupational asthma and some people have akin to occupational asthma hobbies that reduce asthma. When you think about what they are doing in their personal life which might be causing these symptoms. We need to think about what medications are taking in case they are causing the problem. We need to think about comorbidities they may have and in particular, rhinitis. Be it allergic or nonallergic rhinitis, because both impact asthma makes it more likely the patient has got asthma. Having rhinitis doesn't mean you're going to have asthma and we need to think about what biomarkers are available to help put together the picture. Having how high a synovial count is not for example a biomarker for asthma. If you have a higher accentual count in the presence of other features suggesting asthma. Then it may very well be helpful. We need to think also in terms of what is found in clinical examination. One of the things which I find very distressing, and I have observed it very frequently, is the number of times a clinician examines a patient with their clothes on. They are listening to the chest through a shirt or through a blouse, which means they're not really listening to the chest. They are pretending to do something. They are going through the motions so the examination which should include pulse rate, which should include respiratory rate, which should include examination of the chest and if possible, at least at peak flow reading needs to be done properly. I think many examinations are not done properly. We know that in primary care spirometry is a problem. Successive studies from the United Kingdom and the Netherlands had demonstrated that only about 30% of primary care clinics do spirometry to a decent standard. As opposed to 60 to 70% of the hospital setting. Even in hospitals spirometry is always of a high standard and that can be very misleading. Whether you talk about asthma or COPD so it's not just about having the equipment it's knowing how to use it. It is knowing how to do the test properly and it's known how to interpret the test when it is done.

Janson: At the very beginning of that portion and you talked about always needing a diagnosis first time meeting with the patient. Here in the States, somebody goes to the doctor because they are sick, and they want to know why, right now. That is just kind of the US eccentric way of life. You need to know the answers right now but as we know in our field it can take weeks of testing just to verify something. Whether it's oncology or whether it's with respiratory, that's why I feel like trending data is fantastic for a patient that is just recently diagnosed with asthma. Your trend that data the next 30, 60, 90 days, how they are doing with their inhaler, which leads me on to you know why is asthma over-diagnosed? That is huge. I think it's one of those big things. The markers check and I can't uncheck them. I'm just going to go ahead and say you have asthma - in your mind why do you think asthma is overdiagnosed?

Dermot : You're quite right in what you say. I think one of the problems with the diagnosis of asthma is it's a symptom diagnosis. The thing about that is when people present with symptoms, as you rightly say, they want an answer. There's a problem with that. You can't diagnose asthma unless the patient is symptomatic at the time of the test. Because otherwise, if you diagnose somebody without symptoms at the time, you're not diagnosing them with asthma. You're diagnosing them as having had asthma at some stage. That is not the same thing. You're diagnosing them with potential asthma but you're not making the diagnosis until the patient is symptomatic at the time of the test. I'm very careful about how I make a diagnosis. I know that there are people out there who are not so careful. Asthma over-diagnosis is a problem because people are diagnosed without proper testing. I always say a diagnosis needs to be based on good history and examination. So history from the patient's perspective, from the clinical perspective, and from the objective perspective. It's based on a good physical examination. It's based on good respiratory function tests. I think the problem we've got is that a lot of the tests that are done are not particularly helpful. As I've said if you do a test when a patient is asymptomatic, you're going to get negative results and that could be falsely reassuring. So you need to be careful about the tests you do and about how you interpret them.

Janson: Would you say that is a US problem as well, or is that kind of more globally?

Dermot: I think it's a global problem. I think particularly, as I mentioned earlier, in low- and middle-income countries. It's quite possible that there's a lot of over-diagnosis going on because there aren't the resources available to do the tests that we can do in wealthier countries.

Janson: Right. Is there any particular test that you would recommend for primary care physicians to better diagnose their patients?

Dermot: The problem is there's no one single test that you can do which will make a diagnosis of asthma. The tests we do, spirometry, and peak flow, look at lung function. They look at a part of the asthma story, but they don't look at the whole of the asthma story. I think probably the most useful test you can do is a six-week trial of inhaled steroids. Because if somebody has got asthma and you give them inhaled steroids, they will get better. Not necessarily cured, but they will improve their symptoms.