Improving clinician–patient communication in asthma: the HARP project
Authors: J. Haughney, E. Sims, J. Holohan, D. Ryan, D. Price
Journal: Allergy (2010)

Thirty million people, that is 6% of the population, in the European Union have asthma (1). Improving the lives of people with asthma may require developments in policy at national or international level in terms of public health measures, legislative change and both patient and professional education (2). But progress at an individual, patient–clinician level is also necessary. The International Primary Care Respiratory Group (IPCRG) is committed to identifying reasons for poor asthma control in individuals (3, 4). The Helping Asthma in Real People (HARP) initiative, which we describe here, is a practical implementation project (not a formal academic study) which seeks to start to address some of these issues using validated clinical assessment tools in real-life clinical practice. Improvements in asthma management require an assessment of each patient that examines current asthma control, evaluates current management (against safety and outcome), addresses adherence to the prescribed treatment, exposes possible reasons for poor adherence and identifies other factors that may be responsible for poor asthma control, such as smoking or untreated rhinitis. Optimum Patient Care, a social enterprise company based in Norwich, UK, has developed a system which supports such an assessment by collecting and linking data from the patient, in the form of questionnaires, and from the practitioner in the form of extracted routinely collected clinical data from electronic patient records (see Fig. 1). HARP assessment and reporting system. A questionnaire (a composite of validated questions) is sent to people with asthma to obtain information on current asthma control, exacerbations, admissions to hospital, time off work, inhaler use, beliefs and concerns on long-term inhaled therapy use, co-morbidities (rhinitis), life style choices (smoking) and occupation. An on-line, web site based questionnaire is also available at http://www.asthmatrak.org. Useful analysis of routinely held clinical data relies on the consistency of input of this data, preferably coded in a uniform manner. The quality of routine data collection in clinical care is understandably patchy, as is patient engagement in a clinical care initiative, so a degree of innovation and pragmatism is required to achieve the desired outcomes, albeit at some loss of academic purity. In countries that have standardized electronic clinical codes (e.g. ICD9 or 10 or Read [UK primary care]) an assessment can be made solely on analysis of the data held on an electronic patient record. Given a dependable level of quality and consistency of data input, evidence of both poor asthma control and some of the potential reasons for this can be suggested. Similarly, the online questionnaire is available for patients to complete, irrespective of whether or not they have been invited to do so by their clinician. Feedback is given to both patient and clinician in the form of a summarized questionnaire together with electronic data on current treatment, adherence to therapy, level of asthma control, patient reported concerns and beliefs and asthma management considerations, based on guideline recommendations. This should enhance the consultation process between doctor and patient, hopefully leading to improved asthma control. Confidentiality of patient-identifiable data during transfer or analysis is a justifiable concern for patients, their clinicians and health systems. A robust process of linked-anonymization before transfer and de-anonymization (in the doctor’s office) at the report stage is in place. No patient-identifiable data is held outside the clinician’s office. The Republic of Ireland has the fourth highest prevalence of asthma in the world with approximately 470 000 (12%) people affected. Sub-optimal asthma control is reflected in high rates of morbidity, hospital admissions, emergency presentations to Accident & Emergency and health care costs (5). With well-developed primary care contacts, interested clinicians and the prospect of institutional and political support, together with a shared language, Ireland was chosen as IPCRG’s pilot centre for the HARP implementation project. Fifteen practices were enrolled as part of a feasibility study. Both disease codes and prescriptions for short-acting beta agonists were used to identify patients likely to have asthma. Patients with COPD were excluded as were others as designated by the physician. Response rates to the questionnaire were variable as was the substantial level of uncontrolled asthma according to the measures used. Interestingly, a high percentage of respondents cited concerns about the long-term use of inhaled corticosteroids as a reason for poor compliance. This contrasts with UK studies which suggest patients’ impressions of lack of efficacy or lack of necessity drive this behaviour, although possible selection bias cannot be ruled out (6). Both individual patients and practices (in terms of individual and aggregated data) received feedback reports. It is hoped and expected that identification and reflection on factors related to poor asthma control will lead to better appreciation of the issues, the reality of an individual patient’s status, mutual understanding of the problems and thus to dialogue, implementation or revision of an asthma management plan and ultimately better outcomes. It is anticipated that HARP will be rolled out further in Ireland. We also plan to launch this project in another European country and make the resources used available online to others who wish to implement the project. The problems of the consistent recording of high quality data by clinicians, and responses to questionnaires by patients, were as great in this pilot as was expected and will doubtless remain so in the future. These impediments were balanced by the extraordinary enthusiasm of participating clinicians and the Asthma Society of Ireland. The HARP project in Ireland has become a key part of the advocacy programme of the Asthma Society of Ireland; highlighting both sub-optimal control in a high percentage of patients and the importance of capturing standardized data in managing chronic disease in the primary care environment. The interim HARP data, as a component of a wider report on the burden of asthma, has been influential in highlighting the need for a radical review of asthma management in Ireland. The value of ‘real patient’ data in influencing policy in the context of managing chronic disease should not be underestimated. In a joint policy initiative between the Department of Health, the Health Service Executive and the Asthma Society of Ireland, the Irish Government are now looking at the acclaimed asthma programme in Finland with a view to adopting some of the Finnish strategies in their own country (7). In terms of national health strategies, the structure of latest project from Finland, addressing allergic disease, is an exemplar (8). A common consensus, clear goals, tasks, tools and evaluation methods are described. Clinicians, national institutions and patients are involved and an international perspective and support is provided through an association with the Global Alliance against Chronic Respiratory Diseases (GARD). It gives us great pleasure to see government supported ventures offering the possibility of real change, hopefully for the eventual benefit of many people with asthma and allergic disease in Europe.