A cluster randomised controlled trial Comparing paper Letters in addition to Emailed Audit and feedback in Refining Asthma treatment to Improve clinical and environmental Results in primary care – THE CLEAR AIR STUDY (ID 609)
University of Leeds
Abstract
Background and Aim:
Suboptimal use of preventer inhalers and salbutamol reliever over-prescribing are associated with preventable asthma deaths and are a major source of primary care carbon emissions. Audit and feedback involves assessing clinical performance and delivering feedback to encourage improvement. Although feedback is increasingly delivered digitally, clinicians may respond more to additional printed feedback reports. We evaluated whether combined digital and paper feedback was more effective than digital-only feedback in promoting safer and greener asthma prescribing.
Methods:
In this cluster randomised controlled trial, all 273 primary care practices in West Yorkshire were randomly assigned within their primary care network clusters to receive seven bi-monthly reports on asthma prescribing either in ‘digital and paper’ (intervention) or ‘digital-only’ (control) formats. The primary outcome was the proportion of preventer inhalers prescribed in pressurised metered dose devices, which was chosen due to their high carbon footprint. Intervention group allocation was concealed. The intention-to-treat population was analysed and adjusted for both potential confounders and pre-intervention achievement.
Results:
Due to practice mergers within the control group, 270 practices were analysed. There was no significant difference between the intervention groups based on change in the primary outcome (intervention -0.15%; control -0.19%; risk ratio 1.00; 95% confidence interval 0.98 – 1.03), nor any secondary outcome. This was against background trends of mixed impacts on prescribing behaviours following A&F, which ranged from no significant change in the proportion of high-carbon pMDI prescribing to a 1.29% reduction in the proportion of patients using excessive salbutamol inhalers. Considerable scope was found for improving asthma care given that approximately one in five patients with asthma used excessive SABA medication, half used high-carbon preventer devices, and one in ten experienced frequent exacerbations.
Conclusions:
There was no evidence that combined paper and digital feedback was more effective than digital-only feedback, despite an overall background of mixed improvements following feedback. Challenges remain to understand the barriers to influencing the prescribing of preventer inhalers and moving inhaler devices to low-carbon ‘green’ alternatives; however, this study demonstrated the value of an efficient ‘real-world’ trial embedded within an existing quality improvement initiative.
Funding: Dr Owen Thomas is funded by the NIHR for this research project. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR, NHS or the UK Department of Health and Social Care.
Funding from the NIHR Applied Research Collaboration Yorkshire and Humber was also used to support the statistical planning and analysis of this project through the time of Bethan Copsey.
Conflicts of interest: Toby GD Capstick has received sponsorship for virtual of the European Respiratory Society (ERS) congress from GSK and Chiesi. He or his employer has had payment for teaching and consultancy from AZ, Boehringer Ingelheim, Chiesi, GSK, and Insmed. Grant funding received from Chiesi.
Katherine Hickman is the Respiratory Lead for West Yorkshire ICB, Primary Care Clinical Lead for the National Respiratory Audit Programme (NRAP), and Chair of PCRS.
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