Modern Innovative SolutionS Improving Outcomes iN Asthma Breathlessness and COPD (MISSION ABC)

The aims of both the initial project and the subsequent knowledge transfer extension align closely to NICE guidelines NG80 and NG115 as detailed below.

The aims of the MISSION ABC project are to:

• Accurately quantify the burden of uncontrolled asthma and COPD in the region.
• Optimise diagnostic certainty by embedding specialists in primary care settings and using enhanced diagnostic tools (FeNO, Oscillometry) (NG80: recommendations 1.3.2, 1.5.1, 1.14.5)
• Identify symptomatic but yet not yet diagnosed adult patients with breathlessness and achieve a definitive diagnosis (NG80: recommendations 1.3.2, 1.5.1 & NG115).
• Review patients with symptomatic COPD and asthma achieving all NICE quality standards (NG80, NG115).
• Optimise treatment through medicines review and guideline-based prescribing (NG80: 1.6, NG115).
• Give all relevant patients streamlined access to specialist diagnostics and therapies (NG80: recommendations 1.3.11, 1.3.20 & NG115)
• Give all patients personalised self-management plans (NG80: recommendations 1.10, 1.11).
• Offer bespoke respiratory mentorship education to all HCPs in primary care attending the MISSION clinics, on assessment, diagnosis including use of diagnostic tools such as FeNO, treatment options management, auditing and evaluation.
• Create and drive strong collaborative partnerships between primary care, secondary care, external NHS organisations, charities and third sector groups.
• Deliver bespoke inhaler technique training to every patient, supported with ongoing written information and assistive devices (NG80: recommendation 1.5.5 & NG115).
• Ensure all patients are offered support to stop smoking (NG115).
• Give every patient targeted education, through face-to-face events and online platforms.
• Spread and disseminate the benefits of research and ensure every patient is offered access where suitable.
• Offer ongoing supported care to those identified as high risk of exacerbation through remote monitoring in collaboration with community providers (NG80: recommendation 1.14).

The aims of the knowledge transfer extension project were to:

• Embed learning gained from the MISSION project into routine practice, particularly focussed on the use of enhanced diagnostics (FeNO measurement) to aid clinical decision making (NG80: recommendations 1.3.2, 1.14.5).
• Reduce the perceived barrier between primary and secondary care through greater collaboration.
• Reduce variation in care across the south eastern Hants region.
• Facilitate greater use of personalised self-management planning.

Asthma and COPD burden: asthma and COPD are major drivers to acute care episodes, and in many areas of Wessex clinical outcomes compare poorly to national comparators. There are more than 5 million people with asthma in the UK, with more than 500,000 suffering from severe or difficult to control asthma. It is these patients with the more severe, exacerbation prone disease that are more likely to be admitted to hospital and account for the most significant health service utilisation - the “missing millions”.

Both asthma and COPD are under-diagnosed with patients presenting frequently with symptoms of breathlessness. There are still many GP practices with a “prevalence gap” between expected and actually diagnosed COPD patients. The prevalence in south eastern Hants is approximately 1.3% of people diagnosed with COPD (nearly 7,000 people) - similar to the Hampshire average and lower than the England average of 1.6%. However, the expected proportion of people with COPD is 2.2% (nearly 12,000 people) - there may be up to 5,000 people yet to be diagnosed.

Experience from prior projects has shown us that misdiagnosis or under-recognition of comorbidity is also prevalent, many of which may in fact be a major contributor to the symptoms felt by the patient.

Since 2014, Portsmouth Hospitals NHS Trust has delivered three highly successful projects improving care and education for people with airways disease and undiagnosed breathlessness; MISSION Asthma, MISSION COPD and NHSIQ Breathlessness. The outcomes demonstrated by these projects have generated considerable interest in the future spread and adoption of the model. Patient and health care professional feedback has highlighted a real need for such projects addressing conditions that often are burdensome to patients and healthcare systems, and can be life-threatening.

Lack of effective integration means that the pathway to specialist care can be long and inefficient and there are genuine inequalities in care due to variation in local knowledge, practice and resources. Patients tend to be high-cost, frequent users of healthcare at all levels: medicines, GP visits, out of hours contacts, ED attendances and hospital admissions; and may lack sufficient understanding, acceptance or engagement with their condition to enable them to feel confident about self-management. In light of these powerful drivers, MISSION ABC was delivered to test and embed the learnings of the prior projects and scale up.

MISSION ABC was launched in March 2016 at a launch event. The event combined education with showcasing of the evidence of improved patient outcomes and cost savings seen in the 3 preceding pilots. The stakeholder event was followed up with visits from the project team to potential practices to allay any nervousness or uncertainty. Ten practices subsequently signed up.

The project launch aligned in both time and values with the South Eastern Hants Better Local Care Vanguard project. As such, we were able to gain both funding and peer support through this project. The initial practices were subsequently chosen from a list of vanguard participants which also aided stakeholder buy in. The project was enthusiastically embraced by both local patient groups and the British Lung Foundation based on the success of the prior pilots.

The project capitalised on their involvement by using feedback from them to adapt and evolve the project throughout its delivery. As the research and innovation department at Portsmouth Hospitals NHS Trust was engaged in the design of guideline NG80 we were keen to promote the importance of the new diagnostic and treatment algorithm. This was the key motivator in the design and implementation of the knowledge transfer extension project where FeNO machines were given on loan to participating practices supported by targeted education and ongoing mentorship.

In addition, the MISSION ABC team invited all of the asthma and COPD patients to several evening patient events, run by MISSION ABC and within the surgeries, to provide support and guidance on their illness, through self-management and self-directed learning as well as answering any questions or concerns they had. These events also allowed for the development of peer support relationships between patients attending from the same practice.

Subsequent to the successes of this project, it is being sustained locally through chronic respiratory disease hubs, and nationally through the development of our website and toolkit which will allow other teams to deliver a MISSION clinic to the same exceptional standard. The MISSION ABC project received financial support from the South Eastern Hants Better Local Care project, Wessex Academic Health Science Network and Pfizer. The diagnostic tools NIOX VERO® FeNO testing devices were provided by Circassia Limited. The digital self-management tools such as Message Dynamics and My mHealth were donated by the relevant companies.

The project has completed the initial delivery phase and we are now engaged in data analysis and implementing learnings in the development of local care. Figure 1 (in attached file) illustrates the number of patients undergoing risk stratification and review.

All patients who were eligible for review at a clinic were accommodated. Where they were not suitable, or did not wish to attend, these stages of triage allowed us to highlight patients for review, lifestyle support or medicines optimisation to their GP.

We have been able to provide an early impact assessment using unscheduled care data before and after the MISSION clinics. Two of these measures are illustrated in figures 3 and 4 (attached document), showing notable decreased in unscheduled GP attendances and hospital admissions.

Full financial impact assessment is underway, but we can extrapolate given these positive reductions in healthcare usage that the savings will be similar to a prior project, MISSION COPD, where savings of up to £270 per patient were observed. See final report here.  

The MISSION project embedded education within its clinics and through novel ‘carousels of education’. Feedback from HCP teaching sessions has been very positive:

“Excellent day – I gained more from this morning than all of the other respiratory updates I’ve attended in recent years put together. Thank you.”

 Most importantly, patients have been effusive in their praise of the MISSION ABC project. Our “Friends and Family” test reveals that 100% would recommend attending. We have selected three illustrative quotes below:

• "I feel more confident now that my condition has been fully explained to me. My appointment wasn't rushed and that made me feel important not just a number. All the staff I met were very helpful, nothing was too much trouble for them. Thank you."

• "I feel like I've been listened to today. Over the years I have had various treatments but nothing has improved my condition. Today it seems as if there may be another route to finding out how to better manage my condition"

• “Excellent clinic. All staff extremely helpful and efficient. The concept of this team of experts in the community is absolutely brilliant and so effective. Being taught how to use medications "correctly" and for the first time. Superb. Thank you.”

The MISSION project benefited from three preceding pilots. These pilots were designed using evidence not only from national guidance and reports (NHS Five Year Forward View, National Review of Asthma Deaths, NICE Guidance) but also from local data (Right Care “where to look” packs) and discussion with local patients and charity groups.

Through the delivery of each of these we employed PDSA cycles to adapt the process based on patient and HCP feedback. This resulted in changes to the way the project was communicated to patients, the ordering of the clinic, the content of the education provided and the ordering of the clinic.

Prior to commencing MISSION ABC, we further reviewed both the clinic content and the patient-facing literature with patient representatives and our steering group before finally agreeing on the clinic model. However, we committed as a team, and a wider steering group, to continuous review and improvement. This resulted in further clinical model change and also in the development of the carousel teaching programme. We also had as a team to redress the balance between the need to collect data for analysis and the burden of questions for the patient. By adopting this continuous improvement model we were able to adapt to the very variable settings of individual primary care practices. We had learnt from the prior projects that several scoping meetings at each surgery to investigate the lay out and allay fears were hugely beneficial.

Throughout the MISSION project we developed a portfolio of written material. This includes consultation templates, how-to guides for diagnostics, treatment guidelines, patient-facing literature and self-management plans. Recognising the value of these, and the knowledge gained from our experiences we have developed a website and training programme for other teams who wish to embark on a similar project. This is free to use for all NHS teams and can be found at https://missionabc.uk.