The CLEAR AIR study – a cluster randomised controlled trial of audit and feedback formats to improve clinical, environmental, and equitable asthma outcomes

Problem

Preventable factors such as salbutamol overprescribing and limited ‘preventer’ inhaler use are linked to two-thirds of UK asthma deaths. The most deprived regions in England experience more than triple the asthma mortality rate when compared to the least deprived regions. Respiratory inhalers alone account for 13% of all primary care emissions, despite ‘green’ dry powder inhaler alternatives being available. Audit and feedback is an established quality improvement method that has been demonstrated to be particularly effective when targeting prescribing practices with low baseline compliance. However, there is evidence that quality improvement initiatives may sometimes inadvertently widen the health inequality gaps seen in their target populations.The CLEAR AIR study is rigorously evaluating different audit and feedback report formats to determine the most effective methods of driving clinical and environmental improvements in primary care asthma prescribing, whilst clarifying which regional drivers of inequalities modify the impact of asthma prescribing initiatives.

Approach

This cluster randomised controlled trial (IRAS 321442; clinicaltrials.gov NCT05761873) randomised all primary care practices in West Yorkshire (n=273) to receive seven bi-monthly asthma prescribing reports either in ‘digital and post’, or ‘digital-only’ formats from June 2023 to May 2024.Outcome data from electronic health records and OpenPrescribing.net will primarily measure the prescribing rate of ‘green’ inhalers within primary care, alongside a range of secondary prescribing targets including the frequency of prevent inhaler and oral prednisolone prescriptions. Practice-level data on the wider determinants of health will allow comparisons of the effectiveness of the feedback intervention to be made between subgroups, to clarify the intervention’s impact on pre-existing health inequalities.A qualitative process evaluation (IRAS 333034) will use semi-structured interviews to explore how these reports are used within practices, identify barriers preventing reports from facilitating change, and test the acceptability of large-scale quality improvement trials that gain consent at the level of the Integrated Care Board.

Findings

Our baseline results found that on average, per Primary Care Network (PCN), 18% of patients were prescribed six or more salbutamol inhalers per year, with 39% prescribed 3 or less ‘preventer’ inhalers per year, and 9% prescribed 2 or more courses of oral prednisolone per year. On average, only 51% of ‘preventer’ inhalers issued were ‘green’ dry powder inhalers and each PCN produced 47,805 kgCo2e per month from salbutamol inhalers alone. These results highlight the potential of this intervention to improve asthma outcomes, whilst supporting primary care to sustainability meet its NHS net-zero and CORE20PLUS5 commitments.

Consequences

Regardless of this trial’s outcome, the CLEAR AIR study will demonstrate the utility of this cost-efficient, rigorous study design in undertaking high-quality research embedded within NHS improvement programmes, producing a significant impact on the design of future regional quality improvement campaigns.