title: A Structured Approach to Specialist-referred Difficult Asthma Patients Improves Control of Comorbidities and Enhances Asthma Outcomes.
abstract: BACKGROUND
  Systematic evaluation is advocated for difficult asthma, but how best to deliver such care is unclear and outcome data are scarce.
  
  
  OBJECTIVE
  We describe our institution's structured approach to difficult asthma management and report on the outcomes of such an approach.
  
  
  METHODS
  Eighty-two consecutive patients with difficult asthma referred to our clinic from respiratory specialists were evaluated in 3 key areas: diagnostic confirmation, comorbidity detection, and inflammatory phenotyping. We then optimized treatment including relevant comorbidity interventions. The outpatient protocol was supported by comorbidity questionnaires, an electronic clinic template, and standardized panel discussion. Asthma outcomes were assessed at 6 months.
  
  
  RESULTS
  Sixty-eight patients completed follow-up. Asthma diagnosis was refuted in 3 patients and the remaining 65 patients were included in the study analysis. There was no overall escalation of inhaled or oral corticosteroids. Patients had a median of 3 comorbidities, and a median of 3 comorbidity interventions. Control of chronic rhinosinusitis and dysfunctional breathing improved among patients with these diagnoses (22-item Sino-Nasal Outcome Test score from 47 ± 20 to 37 ± 22, P = .017; Nijmegen score from 32 ± 6 to 25 ± 9, P = .003). There were overall improvements in the Asthma Control Test score (from 14 ± 5 to 16 ± 6, P < .001), the Asthma Quality of Life Questionnaire (from 4.29 ± 1.4 to 4.65 ± 1.5, P = .073), and the frequency of exacerbations over 6 months (from 2 [interquartile range, 0-4] to 0 [interquartile range, 0-2], P < .001).
  
  
  CONCLUSIONS
  In patients referred with difficult asthma from respiratory specialists, a structured approach coupled with targeted comorbidity interventions improved control of key comorbidities and enhanced asthma outcomes.
authors.affiliation: Allergy, Asthma and Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia. Electronic address: tunn_ren_tay@cgh.com.sg.
authors.forename: Tunn Ren
authors.initials: TR
authors.lastname: Tay
authors.affiliation: Allergy, Asthma and Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia.
authors.forename: Joy
authors.initials: J
authors.lastname: Lee
authors.affiliation: Allergy, Asthma and Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia.
authors.forename: Naghmeh
authors.initials: N
authors.lastname: Radhakrishna
authors.affiliation: Allergy, Asthma and Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia.
authors.forename: Fiona
authors.initials: F
authors.lastname: Hore-Lacy
authors.affiliation: Allergy, Asthma and Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Medicine, Monash University, Melbourne, Victoria, Australia.
authors.forename: Robert
authors.initials: R
authors.lastname: Stirling
authors.affiliation: Allergy, Asthma and Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
authors.forename: Ryan
authors.initials: R
authors.lastname: Hoy
authors.affiliation: Allergy, Asthma and Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Medicine, Monash University, Melbourne, Victoria, Australia.
authors.forename: Eli
authors.initials: E
authors.lastname: Dabscheck
authors.affiliation: Allergy, Asthma and Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Medicine, Monash University, Melbourne, Victoria, Australia.
authors.forename: Robyn
authors.initials: R
authors.lastname: O'Hehir
authors.affiliation: Allergy, Asthma and Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
authors.forename: Mark
authors.initials: M
authors.lastname: Hew
mesh_terms: D000305:Adrenal Cortex Hormones / Q000627:therapeutic use; D000328:Adult; D000368:Aged; D018927:Anti-Asthmatic Agents / Q000627:therapeutic use; D001249:Asthma / Q000175:diagnosis / Q000188:drug therapy / Q000453:epidemiology; D015897:Comorbidity; D005260:Female; D005764:Gastroesophageal Reflux / Q000453:epidemiology; D006801:Humans; D008297:Male; D008875:Middle Aged; D009765:Obesity / Q000453:epidemiology; D010254:Paranasal Sinus Diseases / Q000453:epidemiology; D010641:Phenotype; D012120:Respiration Disorders / Q000453:epidemiology; D013038:Specialization; D016896:Treatment Outcome
chemical_list: D000305:Adrenal Cortex Hormones; D018927:Anti-Asthmatic Agents
keywords: Asthma; Comorbidity; Difficult; Severe; Systematic assessment