Specialist multi-disciplinary respiratory clinics housed within the primary care setting are cost-effective and can deliver significant improvements across several outcomes, UK study findings have shown.

Disease activity and healthcare utilisation were among the key outcomes significantly improved through the introduction of the MISSION ABC (Modern Innovative Solutions to Improve Outcomes in Asthma, Breathlessness and COPD; MABC) service, which was delivered in GP practices by a team of primary and secondary healthcare professionals and sat alongside usual care, researchers reported in BMJ Open.

“The findings were extremely positive,” lead researcher Professor Anoop Chauhan,  told the limbic.

“A significant proportion of participants had changes in diagnosis, leading to more personalised treatments. This fine-tuning resulted in a sharp decrease in the need for emergency care, including unplanned doctor visits, emergency department visits, and hospital admissions. Interestingly, cost savings were also seen as the decreased need for urgent healthcare services balanced out the costs of improved medication and the running of the clinics,” said Prof. Chauhan, a consultant respiratory physician at Portsmouth Hospital, UK.

Aside from the benefit to patients and services, this new respiratory care model could also positively impact respiratory physicians’ workload.

“The MISSION ABC initiative is anticipated to change the workload for respiratory physicians, potentially easing the pressure in the long term,” he noted.

“By enhancing care through accurate diagnosis and effective disease management, the MISSION ABC approach could lead to fewer emergency interventions. While it may initially increase work to establish the clinics, it is expected to decrease acute presentations, allowing specialists to concentrate on complex case management and preventative care.

“However, it will be crucial to monitor these changes to ensure that the service integration is sustainable and doesn’t inadvertently increase workload elsewhere,” he stressed.

The model

For the study, MABC clinics – each consisting of two to three respiratory physicians, two secondary care respiratory nurse specialists, a physiotherapist, a respiratory physiologist, one or two healthcare professionals (HCP) from the primary care practice and an administrator – were set up in 11 GP practices.

Adults (n=441) aged 16 years and older with poorly controlled asthma or COPD or undifferentiated breathlessness not under specialist care underwent a range of assessments, including spirometry, oscillometry, FeNO, disease control, comorbidity questionnaires and breathing control and inhaler technique, through a carousel of stations for each.

Before leaving the clinic, patients were given a personalised self-management plan and information on inhaler techniques. Each case was then discussed by an MDT, with subsequent alterations to management plans as required, and patients were either discharged back to the GP, referred to another specialty, referred to an MABC investigation clinic, or booked in for further follow-up.

The monthly MABC investigation clinic also offered a “carousel assessment” of investigations such as echocardiography, CT scan, nasendoscopy and detailed body plethysmography to determine whether patients should be referred to specialist care or discharged to primary care.

The results

After a follow-up of 12 months, the results showed that MABC assessments led to changes in diagnosis for 17% of participants with asthma (n=47) and COPD (n=17) and treatment adjustments for 57%.

The number of exacerbations fell significantly: 54% of participants experienced at least one exacerbation in the six months before MABC clinic attendance compared to 7% in the six months after (p=<0.005), equating to a mean reduction of 0.53 per patient.

Significant reductions were also observed for unscheduled and out-of-hours primary care attendance, emergency department visits and hospital admissions, ranging from 55.3% to 78.6% (all p=<0.005), according to the paper.

“Data at 12-month follow-up was available in 200 participants, and a significant reduction in all unscheduled care use was maintained for all participants, though the magnitude of reductions per participant was even larger in asthma and COPD, and were maintained in the high service users,” the authors noted.

Overall, the service made/identified 44 additional diagnoses and comorbidities, the majority of which (73%) were not related to a respiratory condition, while sinonasal disease, gastro-oesophageal reflux disease and bronchiectasis were picked up in 29% overall.

Crucially, the fall in exacerbations and healthcare utilisation countered the increased medication costs and expenses associated with establishing MABC clinics, the investigators stressed.

No cost burden

The mean cost of delivering the MABC clinics was calculated at £139.10 (A$265) per participant, but data showed the service to be “virtually cost neutral” during the first six months and cost saving (28%) at 12 months in all participants with follow-up data.

Notably, almost all (96%) of participants said they would recommend the service, indicating high satisfaction.

According to the investigators, while there were study limitations, such as potential selection bias, the study showed in a real-world setting that this vertically integrated model of care “improved outcomes in a range of poorly controlled respiratory patients”.

“The study involved many GP practices, and its low resource investment and implementation indicate the model could be extended to other local systems and other types of long-term conditions,” they noted.

According to Professor Chauhan, the study’s findings suggest that rolling out similar multidisciplinary clinics on a national scale could positively impact patient outcomes and healthcare service use.

“However, a nationwide implementation would require careful assessment of local healthcare contexts, sufficient specialist training, and financial backing.  Such an expansion must maintain the high care standards and efficacy shown in the study.

“Therefore, while a countrywide introduction of MABC clinics is a favourable step, it should be executed with robust planning and infrastructure to replicate the successful results observed in the research,” he said.