The National Sustainable Asthma Care Roadmap - Roundtable Report

Stakeholder recommendations:\n Goal 1:\nEstablish a data dashboard to display the national indicators of high-quality asthma care and decarbonisation trends – to monitor and evaluate progress towards improved asthma care quality and reduced associated greenhouse gas emissions.\nA comprehensive assessment of Australia’s total asthma care footprint is required. Recommendations include developing an agreed set of indicators and enhancing the collection of multi-source inhaler prescription and sales data, including privately and Pharmaceutical Benefits Scheme (PBS)-prescribed, hospital-dispensed, and over-the-counter asthma medications; stratifying prescription and sales data by inhaler type (to estimate the overall emissions burden of propellant inhalers); and integrating these new metrics with the clinical asthma outcomes currently reported as the National Asthma Indicators.\n\n Goal 2:\nEstablish processes and resources to support annual/regular updating of the national asthma guidelines and for harmonising secondary recommendations and clinical tools in consultation with peak asthma bodies – to inform and facilitate a national implementation strategy.\nSupporting regular updating of the Australian Asthma Handbook, published by the National Asthma Council Australia, is critical to ensuring that the clinical practice recommendations are based on the highest quality and most recent evidence. Consistency between the AAH, other asthma guidelines available in Australia and secondary clinical resources will be essential to fostering knowledge translation, minimising confusion and improving care for people with asthma. Recommendations include developing and/or supporting mechanisms to review new evidence annually/regularly to support knowledge translation across different contexts (for example, primary care versus hospital care) and to different cohorts (for example, young children, adults with frailty) and to highlight low-carbon inhaler options.\n\n Goal 3:\nIncrease clinician education and digital enablement to implement evidence-based guideline- concordant, low-carbon asthma care, particularly the use of AIR regimens – to increase clinician knowledge and adoption of best practice in asthma care and sustainability; enabled\nby digital clinical decision-making, management and prescribing tools, in order to avoid SABA overuse, increase the use of ICS-containing medications, and reduce asthma exacerbations reduce asthma exacerbations.\nRecommendations include launching a comprehensive national educational initiative for healthcare providers, focusing on evidence-based guideline-concordant care from the time of diagnosis, with the use of combination ICS–formoterol for anti inflammatory reliever (AIR-only), and maintenance and reliever therapy (MART) regimens, instead of SABA-based regimens; prescribing of low-carbon inhaler options where they are available for relevant medications and suitable for patient abilities; ensuring appropriate discharge planning after emergency department or hospital admission; designing and implementing integrated digital health tools such as asthma action plan templates and associated consumer information; and embedding these tools in practice management and electronic medical record software for primary, secondary and tertiary care.\n\n Goal 4:\nInform people with asthma about how to improve their asthma control and options to reduce greenhouse gas emissions from inhalers where suitable devices are available – to increase patient/consumer knowledge, empowerment and shared decision-making.\nRecommendations include launching a research-informed, multimodal national public awareness campaign targeting people with asthma and the options for them to encourage their prescribers to transition to low-carbon alternatives where available and appropriate. This campaign would be augmented by the Therapeutic Goods Administration and other regulators setting requirements for environmental product declarations and standards for careful device labelling regarding the carbon footprint of inhalers.\n\n\n Goal 5: \nReduce the imbalance between cost and ease of access to SABA compared with safer and more effective medications – to support the implementation of evidence-based guidelines and thereby improve safety and disease control.\nThis is a priority as there is evidence that using more than two SABA inhalers in a year is a marker of poor control, and the risk of asthma exacerbations and mortality escalates as usage of SABA increases. While Goals 2, 3 and 4 recommend reducing SABA use by transitioning to guideline- concordant asthma care, stakeholders described the need for regulatory and supply mechanisms to support this.\nRecommendations include reducing the quantity and number of repeats on SABA prescriptions (currently up to 2 inhalers per dispensing episode and 12 per prescription, with no annual limit)\nfor safety reasons because this level of SABA use is associated with a marked increase in asthma mortality; prompts for medical review if the frequency of SABA use indicates asthma control is suboptimal; and considering monitoring and limiting the purchasing of over-the-counter SABA (while retaining emergency access). Other recommendations include re-evaluating consumer costs and PBS prescribing criteria of guideline-concordant medications (particularly ICS–formoterol) to ensure equitable access.\n\nGoal 6: \nSupport research to implement and evaluate high-quality sustainable asthma care – to inform a national implementation of evidence-based, guideline-concordant, low-carbon asthma care, with continuous improvement in asthma care delivery and environmental sustainability.\nRecommendations include supporting mixed-methods research, such as qualitative studies and nationally representative surveys on patient and healthcare professional experiences, to produce recommendations for improving models of care; and supplementing this research with quantitative data monitoring to track progress towards co-benefit aims (as per Goal 1).\n\nGoal 7:\nReduce greenhouse gas emissions by minimising residual hydrofluorocarbon leakage from discarded asthma inhalers – specifically targeting propellant leakage from pMDIs disposed of in household waste.\nRecommendations include involving other key stakeholders to develop and establish an effective nationwide program for collecting and appropriately disposing of pMDIs with the destruction\nof unused propellants; exploring funding options (such as a levy on high-GWP pMDI sales); and considering incentives for consumer participation.\n\nGoal8:\nSupport governments in developing a ‘health in all policies’ approach to reducing the modifiable inducers and triggers of asthma – to improve air quality and reduce asthma triggers while also improving respiratory health for all.\nRecommendations include establishing a working group with key stakeholders to consider a cross- sectoral, systems-oriented approach to reducing asthma triggers related to air quality and climate change, informed by evidence and health economic analyses; delivering education campaigns on common asthma triggers; and incentivising households to transition from gas to electric heating and cooking.