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Understanding the journeys of patients with an asthma exacerbation requiring urgent therapy at a primary care clinic

Background Asthma is a significant health issue in primary care. We examined the journeys of patients with asthma exacerbations requiring urgent therapy at a primary care clinic in Singapore. Methods Face-to-face semi-structured interviews were conducted with patients who received urgent therapy for asthma exacerbation at a primary care clinic. Data collected was used to construct themes. Results Fifteen multi-ethnic adult patients were recruited. Participants cited treatment cost, underuse of preventer medication, difficulties attending routine asthma care due to work, and stigma as barriers to asthma control. Reasons for delay in seeking urgent care for asthma were: inability to access medical care out of hours, competing priorities, perception that an exacerbation was ‘not serious enough’, difficulty recognizing symptoms of asthma exacerbation, and being tired or despondent. Participants were triggered to seek care due to failure of reliever inhalers, duration of symptoms, sleep disturbance, inability to work, or advice from others. During an exacerbation, participants often initiated other self-management measures besides using reliever medication. This included over-the-counter medications and non-pharmacological interventions (e.g. drinking water). Of the 15 patients interviewed, only one stepped up preventer inhaler adequately, according to their Asthma Action Plan (AAP). Conclusions In caring for patients with asthma, primary care providers should address patients’ asthma self-management skills, such as recognizing symptoms of asthma exacerbations and regular preventer use, and provide clear instructions on how to respond to asthma symptoms (AAP). Minimizing direct (medication and consultation fees) and indirect costs (loss of earnings and adverse impact on employment prospects) are also important considerations.


Background
Asthma is the most common chronic respiratory condition in Singapore, affecting up to 5% of adults [1] and 20% of children [2,3]. Asthma-related hospitalization and mortality rates are three times that of other developed countries like the United States [2]. Asthma costs to the individual are high, with average annual costs for the patient ranging from S$214 (US$158) [4] to S$614 (US$454) [5]. There is potential for asthma care to be improved locally.
In Singapore, patients seeking medical attention can choose between publicly-funded primary care clinics (polyclinics), private General Practitioner (GP) clinics, or the Accident and Emergency (A&E) departments of government-subsidized (or restructured) or private hospitals. Consultation fees vary. Polyclinic consultation charges are S$6.90 (US$5.10) to S$13.20 (US$9.80) Open Access *Correspondence: jing_sheng_quek@nhgp.com.sg for Singaporeans, and primary care consultation fees for chronic disease management can be partially offset by MediSave monies (MediSave is a mandatory national medical savings scheme that help individuals set aside part of their income to pay for their personal or approved dependants' healthcare expenses). In contrast, A&E attendance fees are upwards of S$120 (US$89), which are either borne wholly by patients, or may be partially offset by optional private insurance.
An asthma exacerbation is an episode of progressive increase in breathlessness, cough, wheezing or chest tightness, and decrease in lung function [6]. Adherence to inhaled corticosteroids (ICS) reduces the risk of asthma exacerbations [7]. Local guidelines (2008 Ministry of Health asthma clinical practice guideline [8] and 2020 Agency for Care Effectiveness Clinical Guidance [9]) also recommend providing an Asthma Action Plan (AAP) for all patients to aid in asthma self-management. AAPs reduce hospitalization rates, days off from work or school [10], and risk of fatal asthma exacerbations [11].
In Singapore, patients presenting to polyclinics with an acute asthma exacerbation are treated with inhaled bronchodilator therapy: short-acting beta-agonist (SABA), with or without a short-acting muscarinic antagonist (SAMA), administered either via nebulization or metered-dose inhaler with spacer ('dry nebulizer' therapy). For the purposes of this study, both forms of inhaled bronchodilator therapy were considered "nebulization" or "nebulizer therapy". To our knowledge, there has been no local study examining the journeys of patients with an asthma exacerbation to bronchodilator therapy. We conducted this study to explore the factors contributing to poor asthma control and health-seeking behaviors of patients with asthma.

Design
We explored patients' journeys from before the start of their symptoms of asthma exacerbation to needing nebulizer therapy, with an emphasis on the delays and factors influencing their self-care decisions prior to seeking medical attention. A qualitative design was chosen to capture patients' experiences and perspectives.
Ethical approval was obtained from the National Healthcare Group (NHG) Domain Specific Review Board (DSRB). Written informed consent was obtained from all participants.

Sampling and recruitment
Purposive sampling was used to select patients of different gender, age, ethnicity and duration of asthma attending a polyclinic; to provide variation of experiences from which shared aspects could be distilled.
The inclusion criteria were English-speaking patients aged 21 years old and above with physician-diagnosed asthma who received urgent therapy for an asthma exacerbation at the polyclinic from September 2018 to September 2019. The interviews were conducted within two months of their asthma exacerbation to minimize inaccuracies due to recall bias.

Data collection
Face-to-face individual semi-structured interviews, each lasting 45-90 min, were conducted by the lead researcher (JSQ), a family physician trained in qualitative research, together with a second or third interviewer. Interviews were audio-recorded digitally. A narrative approach was adopted to explore patients' experiences, perspectives and concerns without being unnecessarily limited by preset questions. The topic guide included questions about asthma history before exploring details of the recent asthma exacerbation, including initial symptoms, perceptions of severity, self-management, help-seeking behavior, symptom progression, and reasons for seeking help at the polyclinic.

Data analysis
Interview recordings were transcribed verbatim and checked by the lead researcher. Thematic analysis was used. Each transcript was independently coded by at least two researchers, and differences in codes were resolved with the help of a third study team member. NVivo (Version 12) was used to facilitate the coding of transcripts, the analysis of which was undertaken in parallel to identify emerging themes that could be further explored in future interviews. The study team met regularly to discuss coding, identify emerging trends, as well as review and refine the interview topic guide in an iterative process. When 15 individuals had been interviewed, it was agreed that data saturation had been reached with adequate diversity in the participants recruited. This study is reported according to the requirements of the Consolidated Criteria for Reporting Qualitative research (COREQ) checklist [12].

Sociodemographic characteristics
Fifteen participants aged 22 to 62 years old were interviewed. Eight were male, 6 Malay, 5 Chinese, 3 Indian and 1 Eurasian. The time since their initial asthma diagnosis ranged from 2 to 50 years (mean 23.9 years) ( Table 1).

Qualitative findings
The journey to nebulization was complex. Four stages could be recognized in patients' transition from symptom onset to nebulization; the journey often began with poor baseline control, progressing to a trial of self-management, before consideration of when to seek clinical advice and finally the trigger to get medical attention.

Factors contributing to poor baseline control of asthma
Many participants described a baseline of poorly-controlled symptoms, which then developed into an exacerbation needing nebulizer therapy. Participants cited multiple reasons for poor adherence to inhalers, some intentional and others unintentional. The latter, like forgetting to administer inhalers, was in the minority. Intentional non-adherence was found to dominate, due to inhaler side effects (e.g. throat discomfort, weight gain) and finding inhaler use troublesome or time-consuming. A few participants perceived no value in using a preventer. Some were concerned about their side effects (e.g. organ injury), not wanting to 'depend' on preventers, the sick image created by inhaler use, and not wanting to use inhalers in front of colleagues.

Self-management measures
Upon experiencing asthma symptoms, participants engaged in self-management measures as an adjunct to asthma medications before seeking medical attention. They included over-the-counter medications, physical measures and relaxation techniques.
Almost all participants used their reliever medication at the onset of worsening asthma symptoms, but few made adjustments to their preventer regime. Two participants who were previously non-adherent to preventer inhalers started using them (P02 and P07). Two stepped up their preventer (P14 and P15), of which only one made an adequate adjustment by doubling the dosage (P15). Only one participant spontaneously mentioned the AAP (P15). When the others were asked about such management plans, three had heard of it (P03, P04 and P07), but only one knew what it entailed and the need to escalate the preventer during an exacerbation. Despite this knowledge, she chose not to do so as she perceived her regular dose was already high (P07). None of the participants mentioned taking systemic steroids in response to their asthma symptoms.

Considerations about when to seek clinical advice
As symptoms persisted or worsened despite self-management measures, participants would consider whether to seek care. They discussed the triggers to action together with the deterrents.
All participants described some form of delay between incomplete response to self-management and eventually seeking treatment at the polyclinic. This delay lasted anywhere from hours to 2 weeks. Six reasons for such delay were identified.
Firstly, many participants cited the inability to access polyclinic out of hours, but 24-h facilities such as hospital A&E, tended not to be used until there was no alternative.

The trigger to get medical attention
The ultimate trigger to obtain medical attention could be internal (e.g. ineffectiveness of medication, duration of symptoms or impact on everyday life) or an external prompt from someone they knew.
The need for repeated medication with no accompanying improvement prompted some to seek help.

Summary of findings
Participants described a background of poorly-controlled asthma even prior to the exacerbation episode, identifying barriers to optimal day-to-day asthma care like cost, underuse of preventer medications, difficulties attending routine asthma care due to work and stigma limiting healthcare access. During an asthma exacerbation, other than using reliever medication, participants often initiated self-management measures, including over-thecounter medications and non-pharmacological interventions like massage and drinking water. Of the 15 patients interviewed, only one stepped up preventer inhaler adequately, as instructed in their AAP. Six reasons for the delay in seeking urgent medical attention during an exacerbation were identified: inability to access polyclinic after-hours, competing priorities in life, difficulty recognizing symptoms of asthma exacerbation, perception that the exacerbation was 'not serious enough' , being tired or despondent, and a mentality to 'tough it out' . Factors prompting participants to eventually seek care can be intrinsic (e.g. failure of reliever inhalers, duration of symptoms, sleep disturbance, and inability to work) or extrinsic (e.g. advice from others).

Comparison with existing literature Factors contributing to poor baseline control of asthma
Patients with poorly-controlled symptoms are more likely to experience asthma exacerbations [13]. Conversely, good symptom control reduces exacerbation risks [7]. It is unsurprising that in this cohort of participants that presented with exacerbations requiring nebulizer therapy, many reported a baseline of poor asthma control. Barriers to optimal asthma control were similarly brought up in other studies, including cost [14][15][16][17], nonadherence to ICS [18] due to patient concerns over their safety and fears of dependence [19][20][21][22], stigma surrounding inhaler use [23] and inadequate access to healthcare [20,24]. Interestingly, South Asian participants of another study have also cited concerns that acknowledging their asthma diagnosis would hurt their employment prospects [25], a worry not frequently encountered in the published literature in western populations.

Self-management strategies
When asthma symptoms arose, most participants mentioned using non-pharmacological measures like drinking water, resting or lying down, massage, and praying before, or instead of, taking reliever medication, a finding consistent with other studies [15,17,20,26]. Most respondents who had their reliever inhaler on hand reported eventually using it, but it was used acutely to achieve symptom relief rather than as part of their AAP. Disturbingly, most participants were unaware of their AAP and either made no or inadequate changes to their preventer regime despite recognizing symptoms of an asthma exacerbation. While there is no local study explicitly investigating the prevalence of AAP prescription, our findings echo another qualitative study from Singapore, which in 2009 found variable use of AAP among primary care physicians [27].

Reasons for delay in seeking care during an asthma exacerbation
We could not find any published local studies focusing on the reasons for the delay in seeking urgent care for asthma. A few studies conducted in western countries similarly found minimization or uncertainty [28] about asthma symptoms, the desire to 'tough it out alone' [28,29], and prioritization of childcare responsibilities over asthma symptoms [30] as factors contributing to the delay. Our study adds to the literature that locally, inability to access polyclinic after-hours, fear of adverse impact on employment, and being too tired or despondent were also contributing factors. Underlying patients' preference to attend polyclinics over A&E or GP clinics, this study similarly found that important patient considerations were cost [28,31] and wish to avoid emergency departments [28,29,32] and hospitalization. This study additionally found that patients also prize proximity, convenience and availability of asthma care facilities.

Triggers for seeking care
AAPs encourage patients to seek medical attention if they experience severe symptoms, or if repeated reliever use does not result in adequate relief. Our study concurs with previous research that the decision to seek urgent care for asthma is not as simplistic [32]. While lack of response to self-management or reliever [32,33] and prompting by friends or family [32,33] were also cited in other studies, our study found that patients additionally used duration of symptoms, as well as interference with sleep and work as signposts to need for medical attention. This supports previous research findings that patients' motivations to seek asthma care differ from health professionals' , with patients driven by socially-influenced factors like limitation of valued activities while practitioners strive for guideline-based 'control' of asthma [34].

Implications for clinical practice
This study has highlighted multiple areas where asthma care can be improved in Singapore.
Firstly, our research has highlighted multiple reasons why patients have poorly-controlled asthma resulting in exacerbations. Recognizing that patients have myriad barriers to asthma control, self-management measures, reasons for delay and triggers to seeking medical attention, clinicians should personalize asthma care and counseling. This includes understanding patients' asthma care goals, or lack thereof [34]. For example, when counseling a patient facing financial constraints, providing him with a breakdown of the respective costs involved in routine asthma care, nebulizer therapy at polyclinics, emergency treatment at A&Es, and intensive care unit (ICU) admission, could help illustrate the cost-effectiveness of adherence to preventer and follow-ups, over allowing exacerbations to occur. This could be done by physicians or asthma nurses, using illustrative cost comparison tables which could also include the various available governmental subsidies and eligibility criteria. While clinic workflows recommend patient reviews one to two weeks after an asthma exacerbation, appointments for these follow-up visits should take into account patients' schedules to minimize disruptions and reduce barriers to care. A multi-disciplinary team involving nurses, pharmacists, social workers, psychologists, and community partners can better address deeper issues that certain patients face. For instance, patients with financial or social issues would benefit from a social worker's assistance.
Secondly, the use of AAPs and patient engagement to improve asthma self-management should be optimized. Our study found low knowledge of AAP among patients. Primary care providers should actively engage patients with asthma on self-management skills, especially in identifying symptoms of an asthma exacerbation, appropriate self-care measures and when to seek urgent medical attention. For instance, physicians could point out that during an exacerbation, the use of SABA via a spacer is preferred over air or oxygen-driven nebulization, as it leads to similar improvement in lung function [35], and is more cost-effective [36].
Thirdly, we must improve access to after-hours care. After-hours care options should be included in AAP counseling. Polyclinics could collaborate with nearby GP clinics which are equipped with asthma care facilities. A collated list of these clinics with their respective addresses, opening hours, and approximate costs of afterhours asthma care can be shared with patients.
Issues like healthcare costs and asthma-related stigma are better addressed by health and employment policies. Reducing both direct costs (of consultation and medications) and indirect costs (including loss of earnings and impact on employment prospects) of asthma would reduce barriers to healthcare. For example, moving towards an accountable care organization model may incentivize healthcare providers to focus efforts on prevention (rather than treatment) of asthma exacerbations, thereby achieving cost savings for the healthcare provider and individual patients.

Strengths and limitations
This paper is unique in examining patients' journeys to nebulizer therapy in a primary care clinic in Singapore. It explores their difficulties, and when and how they respond to worsening asthma symptoms. The individual interviews conducted with an open-ended approach allowed participants to freely share their thoughts and intimate personal details (e.g. spouse's incarceration), giving insight into how various facets of patients' lives contributed to their journeys to nebulizer therapy. This study has highlighted the areas of cost, AAP, after-hours care and holistic management of the patient with asthma, as potential to be addressed to improve asthma care.
This study has several limitations. It was performed on a sample of patients attending a single primary care clinic in Singapore, potentially limiting the generalizability of findings. Although including only English-speaking patients might be a limitation, we managed to recruit a diverse sample comprising all four major ethnicities in Singapore. Given the limitation in accuracy of physiciandiagnosed asthma, future studies should consider including only patients with diagnosis of asthma confirmed by pulmonary function tests. Finally, given the sampling frame, we did not track the journeys of asthma patients who sought emergency care from other healthcare facilities.

Areas for further exploration
This study has identified several areas that require further investigation.
Patients who attend a primary care clinic in need of nebulizer therapy appear reluctant to consider alternatives despite experiencing uncomfortable symptoms. Further study is required to explore these patient preferences and how patients can be empowered to seek care in a timelier fashion.
While many studies, including ours, have highlighted the need for better asthma education to patients and their family and friends involved in their asthma care, the optimal form and method remain unknown. The question of how to promote close ones' positive influences on patients while minimizing negative impact, also remains unanswered.
The lack of awareness of AAP amongst participants raises the questions of how frequently and how effectively physicians discuss AAPs with patients. While there was a previous local study published in 2009 about family physicians' perceptions of AAP [27], it would also be useful to re-examine how sentiments and practices have evolved.
Finally, the interventions proposed in this paper (e.g. a polyclinic-GP collaborative model and asthma cost analysis counseling) could be the subject of further research.

Conclusion
Patients who present to primary care requiring nebulizer therapy for their asthma have complex and unique journeys. A model of care that is responsive to their individual needs via a personalized, multi-disciplinary and collaborative approach holds promise in addressing some of the issues identified. Patients with asthma would further benefit from a broader review of healthcare and employment policies regarding asthma.