Upsides and downsides of a telecounselling model of integrated asthma management between general practitioners and specialists

Abstract Background Asthma control, one of the most important goals in the management of asthmatic patients, requires good adherence to guidelines and support at a territorial level, in particular on the part of general practitioners (GPs). A territorial hospital alliance can become a strength in asthma management, where control by GPs can also be carried out through a spirometric examination. Methods The realisation of a telecounselling model management of asthma between GPs and specialists was the aim of this study, to understand how to obtain good asthma control. A specific digital platform, the PneumoApp platform, was used for the insertion of clinical data and flow volume (F‐V) curves, performed in asthmatic patients by GPs, and for the subsequent evaluation of these data by specialists. Results GPs have shown to be able to perform a check‐up of respiratory function well using a portable spirometer, but the analysis of the collected data showed that GP assessment of the severity level of asthma is incorrect in patients with moderate‐severe asthma. Conclusions The effectiveness of a telecounselling collaboration between hospital and territory in the management of asthma patients can be improved by greater diffusion of the use of Global Initiative for Asthma (GINA) guidelines at a local level.

The use of telemedicine and tele-healthcare in the management of asthma, in particular during the COVID-19 pandemic, may become an instrument to realise the monitoring of asthma patients and a multidisciplinary approach, creating a network of collaboration between hospital and community. 16 As reported by Caminati et al. 17 GPs have a crucial role in the first approach with asthmatic patients who need specific assessment by specialists and, therefore, the recognition and sharing of common tools for the management of these patients is fundamental to obtain good asthma control in a multidisciplinary network between hospital and community.
This study aims to evaluate the sustainability of a collaboration project between hospitals and GPs in the management of asthma, based on telecounselling, highlighting how often at the base of the lack of asthma control there is an incorrect assessment of the level of asthma severity, leading to inappropriate therapy, which is not the one necessary to intervene correctly on the inflammatory process affecting the airways typical of asthma.  In light of the F-V curves performed and the clinical data collected, the specialists gave their assessment on each patient on the level of asthma severity, comparing it with that given by the GPs.

| MATERIALS AND METHODS
The collected data were subjected to statistical analysis. In particular, data were reported as number of patients (percentage) for category variables, and as medians (interquartile range) or mean � standard deviation for continuous variables with a non-normal or normal distribution, respectively. Category variables were compared using the X2 test or the Fisher exact test, while continuous variables were assessed with the independent t-test or the non-parametric Mann-Whitney tests, as appropriate. All analyses were performed using IBM SPSS, version 25.0 (IBM Corp.). A p-value of <0.05 was considered statistically significant.

| RESULTS
The total sample of patients composed of 302 asthmatic patients was slightly more represented by females, with a mean age of 56 years.
Lung function data were available for 213 of the patients. Specialists divided the total sample of the patients into two subgroups: the subgroup of patients who did not use OCS and the subgroup of patients who used OCS. For one patient, information on OCS use was missing.
Subsequently, data collected were analysed as reported in Table 1.
Remembering the crucial role of smoking in asthmatic patients, analysing the total sample, as reported in Figure 1, 49% of patients had a no smoking habit, 27% were current smokers and 24% were former smokers. Analysing the groups of patients not using OCS and using OCS, we observed that: � In patients not using OCS, 48% had a no smoking habit, 26% were current smokers and 26% were former smokers.
� In patients using OCS, 54% had a no smoking habit, 29% were current smokers and 17% were former smokers ( Figure 1).
We analysed the F-V curves performed by GPs with asthmatic patients who arrived at their clinics, observing that 75% of lung function tests were technically correct; 20% were technically interpretable; 5% were not technically interpretable ( Figure 6).
An important part of our analysis included the comparison of asthma severity assigned by specialists and the severity level assessed by GPs in the enrolled patients, highlighting a lack of agreement in moderate asthma, and, in particular, severe asthma cases. Indeed, in moderate asthma, in which agreement between specialists and GPs was 47%, 52% was considered by GPs as mild asthma, instead 1% was considered by GPs as severe asthma. In severe asthma, in which agreement between GPs and specialists was 39%, GPs diagnosed 50% of patients as moderate asthma and 11% of patients as mild asthma ( Figure 7).
Agreement between specialists and GPs was analysed also in the two subgroups, reporting a higher level of agreement on patients that used OCS (Figures 8 and 9).

| DISCUSSION
This study reported a good approach from GPs in performing F-V curves but not always a good interpretation of asthma severity level, which is not connected with FEV1 value. Indeed, the finding of normal F-V curves, which is not a sign of good asthma control, could lead to an incorrect assessment of level of asthma severity and consequently to a milder therapeutic approach. Agreement between specialists and GPs was lower, above all in the total sample, regarding patients with moderate-severe asthma. 18 The low use of SABA, pack-year, found in the enrolled patients, may be due to good asthma control and therefore a lower need of SABA or by careful adherence to GINA guidelines according to which, in the case of need, asthmatic patients can use the association ICS/ LABA (long-acting β2-agonist) inhaled therapy, rather than only SABA that in itself does not confer an anti-inflammatory response.
In the light of the higher use of OCS by asthmatic smokers rather than non-smokers, from the study, smoking can be confirmed as a predictive factor of asthma exacerbations. 19,20 Regarding exacerbations/year and hospitalisations/year a significantly lower number of accesses to A&E and/or hospitalisations in the OCS user group suggests a possible preventive role of OCS therapy on hospitalisations but not on exacerbations.
The discrepancy between asthma severity classification between GPs and specialists leads to a consequent imbalanced treatment and to the need for GINA guideline implementation and increased knowledge at a territorial level, as previously reported in other studies. 21 The treatment was evaluated in order to define the GINA stage.
We did not report the specific treatment for each patient, as this is not included in the main aims of the study. However, also the lack of this information may represent another study limitation.
Our study demonstrated that once GPs are properly trained, they can effectively contribute to asthma patients' regular assessment by sharing lung function and clinical data with specialists.
On the other hand, our results highlight the need for an alignment in terms of asthma severity classification, which is significantly discrepant between GPs and specialists, especially when considering severe asthma. It is not negligible in the light of the implications on treatment choices and overall asthma management. A suboptimal knowledge of the international guidelines may account for this.

| CONCLUSIONS
This study highlights how the realisation of integrated management of asthma patients between hospital and the community is essential F I G U R E 8 Evaluation of agreement between specialists and general practitioners (GPs) in patients not using oral corticosteroids (OCS) on asthma severity in mild, moderate and severe asthma F I G U R E 9 Evaluation of agreement between specialists and general practitioners (GPs) in patients using oral corticosteroids (OCS) on asthma severity in mild, moderate and severe asthma