At-Risk Registers Integrated into primary care to Stop Asthma crises in the UK


UK Clinical Trials, clinical research

Primary Trial ID Number


Background and study aims Asthma is a common long-term condition that can cause coughing, wheezing, chest tightness and breathlessness. Many UK asthma patients are admitted to hospital or die every year. Current treatments should allow asthma to be controlled in most patients. However, certain asthma patients are at greater risk of being admitted or dying than others and intensive support of these patients may improve their health. This study will confirm we can improve the care of these patients, cost to the NHS, and the effect on care of other asthma patients. Who can participate? We will recruit 262 GP practices and expect they will identify 9170 patients who are at risk of having severe asthma attacks. What does the study involve? Half of the GP practices will be randomly allocated to have a computerised alert message whenever any of the ‘at risk’ patients make contact with anyone in the practice. Practice staff will be trained on what to do when they see the alert; for example, remind receptionists to book urgent appointments; remind GPs and nurses to advise patients to take their medication and follow their written asthma action plans (personalised documents which advise patients what to do when their asthma gets worse or better); and remind pharmacists to ensure patients take their medicines. Routinely available anonymised data from patients will be collected from participating practices. Practices will be followed up for 12 months, after which we will count visits to Accident and Emergency, hospital admissions, and deaths due to asthma. We will also measure asthma control, medications prescribed, attendance for routine appointments and smoking cessation. We will calculate how much this costs and whether it improves (or interferes with) the care of other patients with asthma in the practices. With informed consent, we will arrange focus groups and interviews for patients and staff, to discuss thoughts about the at-risk registers, the training, and how it worked in practice. Patients at the other GP practices will receive care as usual. What are the possible benefits and risks of participating? There may be no direct benefit to participants in taking part in this research study but their involvement will give them the opportunity to have their say about their experiences of the ARRISA-UK programme and may help improve treatment for patients with asthma. We do not anticipate there being any significant risks to participant health by taking part in the study. Where is the study run from? Norwich Clinical Trial Unit, UEA, Norwich, UK. When is the study starting and how long is it expected to run for? It will run from December 2014 until November 2018. Who is funding the study? The National Institute for Health Research’s Health Technology Assessment Programme (UK). Who is the main contact? Dr Stanley Musgrave Tel: +44 (0)1603 593309
Research Details
The study aims to test the hypothesis that systematically identifying patients at risk of severe exacerbations of asthma, flagging their primary care EHR to provide enduring prompts at the time of all contacts with the practice, training all practice staff about the systematic management of these patients and providing ongoing practice support will reduce crisis asthma events (asthma-related deaths, hospitalisations and A&E attendances) and be clinically acceptable and cost-effective without detriment to the care of non-at-risk asthma patients. More details can be found at
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Study Design
Two-arm cluster randomised controlled multi-centre trial integrating a mixed-methods process evaluation and economic evaluation
Study Type
This is a complex intervention comprising the following four components: 1. Establishment of register of at-risk patients 2. Practice-wide internet-based training 3. Computerised Decision Support System: a computerised alert 4. Practice support: phone call and video reminders The intervention will target all healthcare professionals and reception staff within the whole practice to improve the care of patients with asthma who are at high risk of crisis events related to exacerbations of their disease. The control arm will receive care as usual in the UK.

Intervention Type
Primary Outcome Measures
The primary outcome is the difference in the proportion of at-risk patients (as identified by the initial search) who have an asthma-related crisis event (A&E attendance, hospitalisation or death) in the 12 months from the date the flags go live on the computer system in the intervention practices compared to the control group practices.
Secondary Outcome Measures
1. The time to first asthma-related crisis event for at-risk patients
2. The percentage of all patients with an asthma-related crisis event and the time to first of these events
3. The percentage of all asthma patients with good control – answering no to all of the ‘RCP 3 questions for asthma’ (difficulty sleeping, daytime symptoms, interference with usual activities)
4. The percentage of all patients with asthma with a hospital admission or death for any reason
5. The number of the following (per patient per year) for both at-risk asthma patients and all asthma patients:
5.1. Short-acting bronchodilator prescriptions issued
5.2. Prescriptions of systemic corticosteroids for asthma exacerbations and antibiotic-treated lower respiratory tract infections
5.3. Modifications of the prescription of asthma-related medications to align more closely with current guidelines (e.g. increased use of inhaled corticosteroids)
5.4. Written personalised asthma action plans and patient self-monitoring with peak flow diaries
5.5. Inhaler technique assessments recorded
5.6. Smoking cessation advice or smoking cessation medications
5.7. Flu vaccinations
The rate of the following (per patient per year)
5.8. ‘Did not attend’ at primary and secondary care routine appointments
5.9. Adherence to medication determined from validated computer-based calculations from prescription data

Health economic outcome
The main outcome measure in the economic analysis will be based on the primary outcome for the study. The number of asthma-related crisis events will be estimated for both study arms. The incremental effect will be the estimated mean difference (between arms) in number of asthma crisis events, after taking account of clustering.

Process evaluation outcomes
The outcomes include quantitative and qualitative assessments of the views of healthcare professionals and patients, practice procedures and processes of care, staff behaviours and awareness, and indicators of intervention uptake, implementation and compliance. The process evaluation will also explore how key intermediary and primary and secondary outcomes (e.g. asthma control) are affected by contextual characteristics (e.g. practice characteristics), including identification of factors that will improve effectiveness and sustainability in practice.

Age Range
Who Can Participate
Number of Participants
The target is 262 GP practices. The number of ‘at risk’ asthma patients identified per practice will be determined by the practice and will vary by practice size. It is anticipated that approximately an average of 35 patients might be identified per practice, which would lead to the identification of approximately 9170 at-risk patients
Participant Inclusion Criteria
1. The unit of randomisation is the cluster (or GP practice). The only inclusion criterion for the clusters is that they are General Practices within the UK
2. The individual participants (for the purpose of the primary endpoint) within the clusters are patients with asthma
3. In addition, for the purposes of process evaluation and health economic analysis practice staff will also be included as participants (as we require data from these individuals)
Participant Exclusion Criteria
The unit of randomisation is the cluster (or GP practice). The exclusion criteria for the clusters are:
1. Practices already implementing a formal prospective process of identification of patients with at- risk asthma and practice wide targeting of asthma care on every approach to patient or their record
2. Practices hosting or affected by research which might significantly influence the practice-wide process of care of patients with ‘at-risk’ asthma

The individual participants within the clusters also have exclusion criteria:
1. Patients with recorded refusal for use of anonymous data in research
2. Terminally ill patients receiving palliative care only
In addition for the purposes of the focus groups and interviews we have the following exclusion criteria:
1. Patients less than 16 years of age
2. Patients unable to communicate in English.

Trial Location(s)
Department of Nutrition, Norwich Medical School
Trial Contact(s)
Primary Trial Contact
Dr Stanley Musgrave
+44 (0)1603593309
Other Trial Contacts
Sorry, this information is not available
Countries Recruiting
United Kingdom

Scientific Title
At-Risk Registers Integrated into primary care to Stop Asthma crises in the UK (ARRISA-UK): a pragmatic cluster randomised trial with nested economic and process evaluations examining the effects of integrating at-risk asthma registers into primary care with internet-based training and support
EudraCT Number
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NIHR Health Technology Assessment Programme – HTA (UK)
Other Study ID Numbers
HTA 13/34/70
University of East Anglia

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