Stakeholder perceptions of an intervention to introduce FeNO-guided asthma management into routine primary care reviews

Introduction: Asthma affects over four million people in the UK and patient outcomes remain sub-optimal. An objective measure of airway inflammation may provide opportunities for better patient care. An intervention to introduce a non-invasive breath test to measure airway inflammation (fractional exhaled nitric oxide/FeNO) and optimise management in primary care asthma reviews, was developed using the Person-Based Approach. The intervention includes a web-based FeNO-guided algorithm, which generates management recommendations for clinicians. We aimed to explore barriers and facilitators to implementation, perceived by key stakeholders. Methods: Charity representatives, policymakers, clinicians, patients, commissioners and others with a stake in how asthma reviews are run were invited for in-depth interviews. Initial purposive, then snowball sampling were employed. Data were analysed inductively following thematic analysis. Results: 19 individuals participated in interviews, including five patient representatives, and 14 clinicians: 10 currently use FeNO. All clinicians held additional roles, for example, in commissioning or policymaking. Participants felt the FeNO-based recommendations would promote engaging discussions between patients and clinicians and would be helpful in addressing uncertainty about stepping-down treatment, when relevant. They stressed sufficient time must be allocated in consultations to include FeNO and clinicians would wish to maintain autonomy in decision-making. Practices without access to FeNO need support for staff time and training and sustained funding for the equipment. Regional practice champions were perceived as helpful in influencing commissioners’ decision-making and for influencing clinicians to adopt FeNO. However, participants identified significant variation in motivation from clinicians to adopt innovation. Discussion: Motivation could be improved by providing hands-on training to allow clinicians to see intervention benefits first-hand, or by peers sharing examples of good practice. Commissioners will need to be persuaded of cost-benefits for implementation of FeNO to progress. Stakeholders felt champions sharing positive experiences would influence clinicians towards implementing the FeNO-guided intervention.