Advancing Specialised Treatment and Holistic Management in Asthma (ASTHMA+)

Year Submitted: 2025
Published Date: 25 March 2026

Tags: Care Continuum, Chronic Care, Specialist Care, Outpatient Care, Specialist Outpatient Care, Care Process ＆ Redesign, Access To Care, Referral Rate, Clinical Practice Improvement, Value Based Care, Patient Reported Outcome Measures

About this Content

Aims

To set up a Severe Asthma clinic by August 2024 to provide advanced, holistic specialist care for patients with difficult-to-treat asthma; increase the referral rate of known severe asthma patients to this clinic by 50% by August 2025; improve the delivery of guideline-directed, evidence-based care with 100% referral to case manager for education, personalized action plan, inhaler technique and adherence review; access to biologic therapy for at least 20% of patients by August 2025; improve proportion of patients reviewed with good asthma control (ACT20) by 50% and reduce number of healthcare utilisations by 50% from baseline by August 2025.

Background

Prior to August 2024, there was no dedicated access for patients with difficult-to-treat asthma to holistic specialist care for comprehensive multi-dimensional assessment of treatable traits, directed therapies including biologic therapy and tailored, personalised care bundles. Between 2019 and 2023, median total of 2061 asthma patients were seen annually at NTFGH, with 619 (30%) having at least 1 hospitalisation per year and 203 (10%) having 2 hospitalisations per year, reflecting huge healthcare system burden.

Methods

Root cause analysis to identify potential issues, PDSA cycles for testing and implementing incremental changes, establishment of multi-disciplinary Severe Asthma Clinic, driver diagram development, standardised asthma guidelines for ED/hospitalised patients, streamlined referral criteria, comprehensive assessment protocols, asthma case manager referrals, biologic therapy eligibility assessment, and financial assistance coordination with medical social workers.

Results

104 patients referred to clinic (August 2024-August 2025), 23 with severe asthma
8 patients initiated on biologic therapies
Referral rate to asthma case manager increased from 69.60% to 100%
Mean ACT improved from 144 to 213
Proportion with controlled asthma (ACT20) increased from 17.40% to 60.90%
Mean ED visits/year reduced from 2.6 to 0.6
Mean hospitalisations/year reduced from 2.0 to 0.6
Mean exacerbations/year reduced from 5.22.3 to 1.11.0

Lessons Learnt

Multi-disciplinary Severe Asthma Clinic can provide holistic care and contribute to improved patient-reported outcomes and reduced healthcare utilisation. Success requires engaging various stakeholders early and consistently, disseminating positive results to build confidence and promote service utilisation. Sustainability ensured through Daily Management: standardising workflow, visual management for performance metrics feedback, and continuous improvement huddles. Long-term outcome data collection and analysis needed.

Keywords

severe asthma, biologic therapy, specialist clinic, ACT score, healthcare utilisation, case manager

Innovators' Details

Connect with this contributor!

Ronnie Tan - ronnie_tan@nuhs.edu.sg

Project Attachment

Advancing Specialised Treatment and Holistic Management in Asthma (ASTHMA+).pdf