Title: Development of an Integrated Pathway for Preschool Asthma/wheeze Management (IP2AM): a mixed methods study
Funder: Department of Health and Social Care

Abstract: Research Question What are the essential components of an integrated care pathway for preschool children with troublesome asthma/wheeze, and is it feasible and acceptable for families and healthcare professionals? Background Wheezing illnesses in preschool children are extremely common, with some children suffering persistent symptoms, multiple emergency healthcare attendances, and poor quality of life. Severe episodes of preschool wheeze are increasing. Three-quarters of hospital admissions for attacks of asthma/wheeze are in children under the age of five years. Regular preventer treatments, such as inhaled corticosteroids, can reduce attacks by up to half. However, healthcare professionals are often uncertain about when, and in which children, to start regular preventer treatments. Similarly, management plans and advice provided to families of children with preschool wheeze often differ, resulting in parental anxiety and confusion. Aims and Objectives The overall aim is to develop and test the feasibility of a novel pragmatic integrated care pathway for preschool children with troublesome asthma/wheeze, to improve patient care and satisfaction, and reduce morbidity. This is addressed through four linked objectives: Understand the influence of socioeconomic, and ethnic differences on the pattern of presentation and treatment in children with preschool wheeze in the UK Identify risk factors for further attacks of wheeze in preschool children following an acute episode of wheeze Engage with key stakeholders to inform the content and design of the integrated care pathway Explore the feasibility and acceptability of the Integrated Pathway for Preschool Asthma/wheeze Management (IP2AM)Methods and Timelines This 5-year fellowship is comprised of four related work packages (WP). Aligned with the development phase of the MRC complex interventions framework, WP1-to-WP3 will constitute the design and refinement stage of the development process and inform the design of the integrated care pathway (IP2AM) to be tested in WP4. WP1: Retrospective cohort study, using linked de-identified routinely collected healthcare data from the Clinical Practice Research Datalink (CPRD). Variations in health seeking behaviour and treatment decisions will be explored by socioeconomic and ethnic categories to identify patient groups most likely to benefit from the intervention (Years 1-2). WP2: Longitudinal study using linked de-identified routinely collected healthcare data from CPRD to identify independent risk factors for subsequent attacks of asthma/wheeze in preschool children (Years 2-3). WP3: Through semi-structured qualitative interviews and Delphi methodology, families of children with preschool wheeze, and clinicians will participate in the design and development of the integrated care pathway (Years 3-4). WP4: Prospective study to explore the feasibility and acceptability of IP2AM in clinical practice (Years 4-5). Anticipated Impact and Dissemination This research will result in the production of a pragmatic intervention to improve the way preschool asthma/wheeze is managed across different care settings. It has the potential to significantly reduce wheeze attacks and improve quality of life for children, and the families of children, with troublesome preschool asthma/wheeze. Findings will be disseminated through patient, clinical, academic and social networks.

Lay abstract: Background Wheezing illnesses are episodes of difficulty in breathing associated with whistling breath sounds. They are extremely common in preschool children under five years old. Most episodes get better on their own, but many children continue to have frequent wheezing illnesses. These can lead to emergency hospital visits, missed preschool, and continuous symptoms that stop them doing the things they enjoy. In the UK, hospital attendance is increasing because of severe wheezing attacks in young children. Three out of four admissions into hospital are due to symptoms of wheezing in children under five years. Regular medications can help. One such medicine type, called 'inhaled corticosteroids', can reduce wheezing attacks by up to half if given regularly. Despite wheeze attacks increasing, there has not been an increase in the use of these medications. This is worrying, and means many children suffering from wheezing illnesses are not on appropriate treatments. There are many reasons for this, including: Some doctors and nurses having less experience caring for children with preschool wheeze Worries about using regular steroids in young children Not recognising the burden of wheezing on the child and their familyFamilies of children who wheeze have reported being told different information. This means they do not know who to believe, report feeling helpless and confused, and are unsure what to do when their child wheezes or what is in their child's best interest. Aim The purpose of this study is to develop a practical care guide for preschool wheeze that is shared by all doctors and nurses. It will include clear and consistent information and practical advice for parents. The benefits include: Making it easier for doctors and nurses to identify children at risk of regular wheeze Allow doctors and nurses to start regular treatments with more confidence Improve communication with families Improve the quality of life in preschool children with wheezeResearch Plan There are four parts to this research: 1. Identify children with the highest burden of wheezeUsing a national database of GP and hospital computer records. The first part of this research will find out which patients are suffering the most from frequent wheezing illnesses. This will let us know which patients to target with the care guide. 2. Identify children who are more likely to have a further wheeze attack Using the same database of GP and hospital computer records. Part two of this research is to find out which patients are likely to have another wheeze attack in the next year. This will tell us which patients should have their treatment adjusted. 3. Understand what families and healthcare professionals want from a care guide Using interviews with patients, doctors, and nurses. I want to find out what we should include in a care guide for preschool wheeze. Families, children and healthcare professionals will also help to design the care guide. 4. Test how this care guide will work in real life The final part of this study will test how this care guide works in real-life. I will collect feedback from patients, doctors, and nurses. This information will let us improve the care guide and prepare to introduce it in more healthcare settings. Patient and Public Involvement Families of children with preschool wheeze have helped to design this study. They will also have continued input during the running of the study. DisseminationThe results of this study will be published in medical journals, and presented at conferences. Summaries of findings will be made available online and on social media. Results will also be posted to patients, and presented to those in charge of funding children's services.

Research activity codes: 7.1 INDIVIDUAL CARE NEEDS
Health categories: RESPIRATORY