We report a Phase IV study of breathing retraining for adults with asthma who are uncontrolled on their current treatment, which has shown improved outcomes and reduced costs of a breathing retraining programme delivered by DVD. On the basis of this evidence, we feel that this intervention is potentially of benefit to the majority of adults with asthma in the community and can be delivered to them as a low-cost, and logistically viable, self-guided programme that has the potential to reduce NHS costs as well as benefit patients. We therefore feel that implementation studies are now needed, to optimise delivery and to assess the effects of providing the intervention in a wide and community-based programme. This has implications for service delivery.
Specific research issues that should be addressed include assessing the effectiveness of the programme delivered though internet-based and smartphone-based platforms. We are currently in the process of carrying out the technical work necessary for this. Comparisons of the acceptability and effectiveness of different delivery methods are needed. We would hope to make these comparisons and are in discussion with our charity partner, Asthma UK, on how to structure and deliver the intervention most effectively.
Given the effectiveness of the intervention in an adult population, we feel that there is a need for research to be carried out in a paediatric population, among whom there is great interest in such interventions. It is not justifiable to automatically extrapolate the results of asthma trials in older age groups to children, although this has frequently been carried out, often inappropriately. In addition, the framing of the intervention and the language and directions provided will need to be adapted for younger people. As mentioned earlier, there is also a need to frame and translate the intervention for specific groups, such as ethnic minorities, those with health literacy problems and those with learning disabilities.
DOI: 10.3310/hta21530 HEALTH TECHNOLOGY ASSESSMENT 2017 VOL. 21 NO. 53
© Queen’s Printer and Controller of HMSO 2017. This work was produced by Thomas et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.
Chapter 8 Conclusions
T
he majority of adults with asthma have impaired QoL, despite the wide availability of effective pharmacotherapy. Breathing retraining exercises have a good evidence base as adjuvant treatment to improve QoL for people with asthma when taught by a physiotherapist in a face-to-face programme. However, although recommended in national and international guidelines, such programmes are under-used because suitably trained specialist therapists are not available to most people who could benefit. We created a self-guided intervention (DVD plus supporting booklet), involving a multidisciplinary professional team, with extensive patient input, and using a qualitative, iterative methodology. Our aim was to transfer the content of a physiotherapy breathing retraining programme to an attractive and accessible format suitable for patients to use at home, at a time convenient to them. We performed a 12-month, three-armed, parallel-group, observer-blinded RCT involving consenting adults with asthma treated in the community in a primary care setting to compare the effects of the new self-guidedintervention with the effects of a three-session face-to-face physiotherapy breathing retraining programme plus the booklet and usual care. Asthma-related QoL was the primary outcome. The study was powered to show the superiority of both breathing retraining programmes over usual care and the equivalence of the self-guided and face-to-face physiotherapy programmes and succeeded in doing so. The improvement in QoL was similar to that reported in a meta-analysis of the effects on QoL of add-on pharmacological interventions for uncontrolled patients. There was no significant change in lung function or airway inflammation associated with breathing retraining by either route, implying that the interventions did not alter the underlying biological pathophysiology of asthma. Consistent (but statistically non-significant) trends in improvement in other patient-reported outcome measures (including symptom scores and anxiety and depression scores) and in asthma attacks, GP consultations and rescue medication use were observed with the active interventions compared with usual care. Both active programmes were well received, acted on and accepted by patients and there was no evidence of adverse effects. Asthma-related health-care costs were lower in both of the active arms than in the usual-care arm, with the self-guided intervention having the lowest costs and a> 80% probability of being the ‘dominant’ health economic strategy, that is, the strategy with better outcomes at lower costs.
Physiotherapy breathing retraining exercises are therefore acceptable, clinically effective and cost-effective for adults with asthma and may be delivered by a simple self-guided intervention (our DVD plus our theory-based behaviour change booklet). There is now a need for research on effectively implementing this intervention within usual care and to investigate the effects of similar interventions adapted for other patient groups not studied during this project.
DOI: 10.3310/hta21530 HEALTH TECHNOLOGY ASSESSMENT 2017 VOL. 21 NO. 53
© Queen’s Printer and Controller of HMSO 2017. This work was produced by Thomas et al. under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.
Acknowledgements
T
he authors would like to acknowledge the key role played by the following: all patients volunteering for the study; those providing PPI input, in particular Mark Stafford-Watson; all practices hosting the study; Asthma UK; the CRN research nurses; Darren Taylor, Lisa McDermott and Mark Stafford-Watson, who were the patients on the DVD; Denise Gibson, the physiotherapist advisor for intervention development; Dr Mark Porter, the presenter on the DVD; Nick Das, Mike Radford and Sarah Benge of the SCTU; NIHR Research Design Service South Central; Ruth DeVos, the face-to-face intervention physiotherapist; Solent NHS trust, which provided non-research costs for the face-to-face physiotherapy; and Tim O’Riordan from Zemedia.Funding
The authors acknowledge funding from the UK NIHR HTA Board and the NIHR CRN and support from the NIHR CRN.
Sponsor
University of Southampton.