Implementation of the treatable traits approach in a regional clinic: Improving health outcomes in adults with bronchiectasis

Abstract

Objectives

Treatable traits are identifiable and treatable features of disease. The primary objective was to evaluate whether a bronchiectasis clinic in a regional setting, implementing a treatable traits approach, would lead to improvements in quality of life. Secondary objectives were to evaluate clinic implementation outcomes, annual exacerbations and hospitalisation.

Methods

An implementation study. Adults with bronchiectasis attending an outpatient clinic in Rockhampton, Australia between 2021 and 2023 were recruited. Clinical care was implemented by a physiotherapist and nurses according to traits identified. Quality of life (QoL-Bronchiectasis respiratory symptom score (QoL-B rs), Leicester Cough Questionnaire (LCQ) total score) was evaluated at baseline, three and 12-months from first attendance. Implementation outcomes were determined by clinic appointment uptake and attendance and pulmonary rehabilitation uptake and completion at 12-months. Exacerbation frequency and hospitalisation for the 12-months before and after enrolment were compared.

Results

50 participants were recruited [mean (SD) age 71 (12) years; Bronchiectasis Severity Index (%) mild (22) moderate (44) severe (34)]. There was a significant improvement in QoL at three and 12-months from baseline (mean difference, 95% CI) [3 months: QoL-B rs 9.2 (3.2-15.2), LCQ 1.7 (0.6-2.8); 12-months: QoL-B rs 10.1 (3.9-16.3), LCQ 1.8 (0.8-2.8)]. Clinic uptake (91%), attendance (97%) and pulmonary rehabilitation uptake (74%) and completion (84%) were high. Exacerbation frequency [median (IQR) 1.0 (3.0) to 0.0 (1.0), p = 0.007], and hospitalisation decreased (18% vs 0%, p = 0.005).

Discussion

A treatable traits approach improved quality of life, was feasible, including the achievement of high pulmonary rehabilitation uptake and completion, and reduced exacerbation frequency and hospitalisation.

Keywords

airway clearance therapy physiotherapy precision medicine pulmonary rehabilitation quality of life respiratory

Introduction

Bronchiectasis is a syndrome,¹ characterised by permanent dilation of the airways, inflammation and symptoms of chronic cough, sputum production, and recurrent infections.² The pathogenesis of bronchiectasis is represented as a complex vortex of structural airway damage, airway dysfunction, inflammation and infection.³ A key challenge for clinicians is the heterogeneity of disease presentation, clinical course and progression.¹

Several guidelines for bronchiectasis management have been published.^4–6 Current management is focused on: 1) identifying treatable causes of bronchiectasis^4–6; 2) airway clearance therapy, including mucoactive agents for those with difficulty clearing sputum^4–6; 3) individualised self-management plans⁴; 4) antibiotic therapy for the treatment of infection, eradication of Pseudomonas and reduction of inflammation^4–6; 5) pulmonary rehabilitation for those with reduced exercise capacity^4–6; and 7) consideration of environmental pollutants and smoking cessation.⁴ Annual to biannual review by a specialist respiratory physiotherapist^4,5 and an annual review by a respiratory service with expertise in bronchiectasis⁴ are recommended. The treatment aims are to halt disease progression, improve quality of life, reduce the number of exacerbations and prevent secondary complications.⁴

Despite clear guidelines,^4–6 evidence demonstrates that patients are not receiving recommended care.^7–10 In Spain, 51.8% of patients in primary care with bronchiectasis received no treatment.¹¹ The Australian Bronchiectasis Registry (ABR-tertiary centres only) reports lower pulmonary rehabilitation referral rates (19.5%) than rates of reduced exercise capacity (68%),¹² and lower rates of regular airway clearance therapy (58%) than identified rates of chronic productive cough (70%),¹² with similar findings in Europe.⁹ In the European Multicentre Bronchiectasis Audit and Research Collaboration (EMBARC) cohort, only 22.7% of participants were reviewed by a specialist physiotherapist during 12-month follow-up visits.⁹ A lack of consistent inclusion of these treatments and recommended clinical review potentially contributes to poorer long-term outcomes in people with bronchiectasis.

A move towards precision medicine has been proposed, with a focus on individualised care as key to improving outcomes for people with bronchiectasis.^1,13 Patients have highlighted that core components, including airway clearance therapy, must be individualised to be successful.¹⁴ One method for targeting care to individual disease characteristics is the treatable traits model of care.¹⁵ Treatable traits are clinically-relevant, identifiable, measurable and treatable aspects of respiratory disease¹⁶; traits specific to bronchiectasis have been identified.^13,17,18 This approach recommends access to multidisciplinary care and the structured identification of clinically-relevant traits to develop a management plan in partnership with the patient and their priorities,¹⁶ regardless of disease severity,¹⁹ to ensure early intervention.

Improved health outcomes have been demonstrated in other respiratory diseases following implementation of a treatable traits approach in tertiary settings. A systematic review of people with obstructive airway disease showed improvements in health-related quality of life and reduced hospitalisations.²⁰ In bronchiectasis, the implementation of a treatable traits approach to clinical care has not been evaluated, and an assessment in a low resource non-tertiary community setting with access to a physiotherapist and nurses has not been undertaken.

This study’s primary aim was to evaluate whether a bronchiectasis clinic, in a regional community setting implementing targeted evidence-based interventions with a physiotherapist and nursing team, using a treatable traits approach in adults with bronchiectasis would lead to improvements in quality of life.

The secondary aims were to evaluate

(1) The implementation outcomes of the clinic through the:

(a) Uptake of the initial clinic appointment after referral to the clinic;

(b) Attendance of scheduled appointments;

(c) Number of participants uptaking and completing pulmonary rehabilitation if referred to the pulmonary rehabilitation program.

(2) Health utilisation outcomes of the clinic through the:

(a) Annual frequency of exacerbations of bronchiectasis in the 12-months before and after study enrolment;

(b) Annual number of days hospitalised in the 12-months before and after study enrolment.

Methods

Study design and participants

This was an implementation study conducted according to the Standards for Reporting Implementation Studies (StaRI) (Table S1).²¹ Ethical approval was received from the Central Queensland Hospital and Health Service (CQHHS) Human Research Ethics Committee (HREC/2020/QCQ/61455). All participants provided written informed consent prior to participating.

All people >18 years of age with clinically-significant bronchiectasis²² who were referred to the bronchiectasis community clinic in Rockhampton, Queensland, Australia between January 2021 and January 2023 were invited to participate. Patients were excluded if they had attended a bronchiectasis clinic with the inclusion of a respiratory physician or respiratory nurse practitioner and a physiotherapist in the 12-months prior to study enrolment. The respiratory nursing team were blinded to study participation. The physiotherapist was not blinded, as they were the principal investigator and there was no funding for a blinded assessor.

The clinic intervention

A structured assessment of pulmonary, extrapulmonary and environmental/lifestyle traits was conducted in collaboration with participants (Table 1). The traits assessed were within the physiotherapist or nurse’s scope to identify, measure and treat¹⁸ (i.e. aetiological traits were not assessed). Once traits were identified, priorities for treatment were jointly determined by clinicians and participants through the pragmatic discussion of evidence-based options. Treatments were not implemented if, after shared decision making, the trait was not prioritised by participants. Participants continued their prescribed usual care provided by their referring doctor (respiratory/general medicine physician or general practitioner), but medical care was not available in the clinic.

Table 1.

Trait identification and treatment at the outpatient bronchiectasis clinic.

Trait	Trait identification marker	Treatment
Pulmonary
Mucus hypersecretion³⁹	≥25 mls of sputum produced daily	Airway clearance therapy +/− nebulised saline
Mucus hypersecretion³⁹	≥25 mls of sputum produced daily	Education on hydration- target urine colour
Mucus plugging¹⁷	CT scan	Airway clearance therapy +/− nebulised saline
Mucus plugging¹⁷	CT scan	Education on hydration- target urine colour
Dyspnoea³⁹	MMRC dyspnoea score ≥2	Pulmonary rehabilitation, activity pacing/modification, fan therapy, positioning, pursed lip breathing
Cough¹⁷	Daily cough impacting usual activities and/or sleep	Treat underlying cause, e.g. mucus hypersecretion
Cough¹⁷	Leicester Cough Questionnaire⁴⁰	Referral for investigation e.g. clinical features of GORD
Infection¹⁷	Clinical features	Airway clearance therapy
	Sputum characteristics	Education
	Sputum culture	Prompt treatment of exacerbations
Oxygen desaturation³⁹	Resting SpO2 ≤90%	Referral for 6 Minute Walk Test
Airflow obstruction¹⁷	FEV₁/FVC ratio <70%	Bronchodilators
		Optimise inhaler technique
		Smoking cessation
		Airway clearance therapy
Difficulty clearing sputum¹⁸	VAS⁴¹	Airway clearance therapy +/− nebulised saline
Difficulty clearing sputum¹⁸	VAS⁴¹	Hydration
Extrapulmonary
Rhinosinusitis¹⁷	Clinical features of infection or inflammation	Sinus rinse
Rhinosinusitis¹⁷	Clinical features of infection or inflammation	Education regarding nasal steroids, antihistamines, saline sprays
Urinary incontinence¹⁸	Symptoms of incontinence⁴²	Teach the ‘knack’
		Optimise positioning for airway clearance
		Reduce the use of cough
		Referral to pelvic health physiotherapist
Depression/anxiety¹⁷	QoL-B: Emotional functioning domain ²⁹	Referral to counselling, psychology services +/− web resources
Depression/anxiety¹⁷	Clinical features with biopsychosocial assessment
Daytime sleepiness³⁹	Epworth sleep score >8	Referral for sleep study
Overweight¹⁷	BMI ≥25 kg/m²	Referral to Dietitian
Underweight¹⁷	BMI ≤18.5 kg/m²	Referral to Dietitian
Cardiac history¹⁷	History of cardiac conditions	Modify exercise prescription
GORD¹⁷	Diagnosis of GORD, clinical features of GORD	Modified positioning for airway clearance therapy
GORD¹⁷	Diagnosis of GORD, clinical features of GORD	Referral for assessment- GP
Other significant medical history³⁹	Clinical history	Modify interventions as required e.g. exercise
Pain⁴³	VAS	Modify interventions as required
		Postural education
		Exercise
		Physical activity
Environmental/Lifestyle
Reduced exercise capacity¹⁷	MMRC dyspnoea score ≥1	Referral to pulmonary rehabilitation
Reduced exercise capacity¹⁷	MMRC dyspnoea score ≥1	Home exercise program
Absence of action plan³⁹	A Bronchiectasis Action Plan has not been written or is not in use currently	Develop a Bronchiectasis Action Plan²⁵
Poor inhalation technique³⁹	Observed inhaler technique is suboptimal	Practise of inhaler technique
Poor inhalation technique³⁹	Observed inhaler technique is suboptimal	Use of spacer
Fatigue¹⁸	Reported fatigue limiting daily activities and/or quality of life	Treatment of underlying causes
	QoL-B: Vitality domain ²⁹	Treatment of underlying causes
		Referral to pulmonary rehabilitation
		Home exercise program
		Physical activity
		Pacing of activity
Reduced physical activity¹⁸	MVPA ≤150mins/wk	Physical activity education
Sedentarism¹⁸	Sedentary time >7.8 h/day	Break bouts of sedentary time
Sedentarism¹⁸	Sedentary time >7.8 h/day	Increase physical activity
Reduced adherence to management plan¹⁷	Patient feedback	Education- disease specific
Reduced adherence to management plan¹⁷	Patient feedback	Address barriers to adherence
Smoking¹⁷	Current smoker	Smoking cessation education
Smoking¹⁷	Current smoker	Referral to Quitline
Exposure to environmental irritants, including pollution¹⁷	History of exposure to smoke, paint, dust or other environmental pollutants	Education
		Avoidance
		Mask use
Family and social support⁴⁴	Patient feedback	Referral to social work
Family and social support⁴⁴	Patient feedback	Source adequate supports and funding

CT: Computed Tomography; MMRC: Modified Medical Research Council; SpO₂: Oxygen saturation; FEV₁/FVC: ratio of forced expiratory volume in one second to forced vital capacity; VAS: Visual Analogue Scale; QoL-B: Quality of Life-Bronchiectasis questionnaire; BMI: Body Mass Index; GORD; Gastroesophageal Reflux Disease; GP: General Practitioner; MVPA: Moderate to Vigorous Physical Activity.

NB: the treatment plan and clinical symptoms requiring further investigation were communicated with the patient’s respiratory/general medicine physician and/or general medical practitioner to ensure collaborative care. Individualised disease specific education was provided to all participants.

The targeted evidence-based interventions of the clinic depended on participant trait priorities (summarised in Table 1).

Physiotherapy airway clearance therapy followed the stepwise recommendations in the British Thoracic Society Guideline⁵ (Figure S1) which emphasise a physiotherapist with expertise in respiratory disease should lead treatment, with all participants taught active cycle of breathing technique (ACBT) for airway clearance. There is currently no evidence to recommend the use of any one airway clearance technique over another,²³ or that exercise is a standalone method of airway clearance.²⁴ Information regarding physiotherapy interventions is summarised in Supplemental File S1.

All clinic referrals were reviewed by the physiotherapist and nursing team, with appointments offered based on referral details and clinician-determined clinical need. The physiotherapist offered an initial assessment, three and 12-months reviews as a minimum standard. Participants received a follow-up telephone call 2 weeks after the initial assessment from the physiotherapist to answer any questions from the Bronchiectasis Action Plan,²⁵ developed during the initial assessment (Supplemental File S1). The respiratory nursing team scheduled appointments if participants required a medication action plan and/or support with self-management techniques (e.g. use of spacers). The physiotherapist and respiratory nursing team referred to other health professionals and/or services when a need was identified and the participant agreed this was a priority for management. In this way the clinic was low resource, and the only equipment required was access to information systems (e.g. radiology), airway clearance therapy devices (e.g. Aerobika™) and monitoring devices (e.g. pulse oximeter).

Outcome measures

Demographic and clinical information was collected at study enrolment, including age, sex self-reported co-morbidities, lung function, Modified Medical Research Council (MMRC) Dyspnoea score and Bronchiectasis Severity Index (BSI).²⁶ Quality of life was assessed at study enrolment, and following the three and 12-month clinic appointments with the Quality of Life-Bronchiectasis-respiratory symptoms domain (QoL-B rs) and the Leicester Cough Questionnaire (LCQ) total score. If a participant experienced an exacerbation,²⁷ assessment occurred following the completion of antibiotics (if prescribed) and a return to baseline symptoms.

Implementation of the treatable traits approach was evaluated by clinic uptake (the number of adults with bronchiectasis referred to the clinic who accepted an initial appointment), attendance (the number of clinic appointments attended out of the appointments offered in the 12-months of study participation) and pulmonary rehabilitation uptake and completion (attended at least 12 of a possible 16 planned supervised exercise sessions²⁸) for participants referred to the program, audited at three and 12-months from hospital records.

Health utilisation outcomes were evaluated by annual exacerbation frequency and hospitalisation (the proportion of participants spending at least 1 day in hospital for a primary admission of bronchiectasis), which were self-reported and audited from hospital medical records for the 12-months prior to and after study enrolment.

Statistical analysis

Quality of life was evaluated by comparing the mean difference in the QoL-B rs score and LCQ total score at study enrolment, three and 12-months using a one-way repeated measures analysis of variance (ANOVA). Clinic initial uptake, appointment attendance and pulmonary rehabilitation uptake and completion (of those referred) were reported as percentages. Annual exacerbations were compared for the 12-months before and after study enrolment using the Wilcoxon signed rank test. The proportion of participants hospitalised for the 12-months before and after study enrolment were compared with McNemar’s test. Data analysis was performed using SPSS (Version 25 for Windows IBM, USA) with alpha set at 0.05. A sample size of 50 was calculated to detect a minimally important difference (MID) of 8.0 (standard deviation (SD) = 18.7 points) in the QoL-B rs score,²⁹ with 80% power at the 5% significance level and allowing for 10% loss to follow up.

Results

Participant flow and characteristics

A total of 89 people were assessed for eligibility, with 50 people participating in the study (Figure 1). Reasons for declining study participation are included in Table S2. Participant characteristics are summarised in Table 2. Participants were a mean (SD) age of 71 (12) years, primarily female (n = 36, 72%) and none had completed pulmonary rehabilitation in the 12 months prior to enrolment (n = 0, 0%). According to the BSI,²⁶ 22% of participants had mild, 44% moderate, and 34% severe bronchiectasis. The most frequently reported co-morbidities were gastro-oesophageal disease (GORD, 44%) and COPD (36%).

Figure 1.

Flow of participants, clinic uptake and pulmonary rehabilitation completion PR: Pulmonary rehabilitation.

Table 2.

Characteristics of participants attending the bronchiectasis clinic, n=50.

Characteristic
Sex, n (%)
Female	36 (72)
Age, years, mean (SD, range)	71 (12, 31-89)
BMI, kg/m², mean (SD, range)	26.3 (6.1, 15-43)
FEV1, % predicted, mean (SD, range)	68.6 (16.3, 32-100)
mMRC Dyspnoea scale, n (%)
0 Breathless with strenuous exercise	10 (20)
1 Breathless when hurrying on the level or walking up a slight hill	27 (54)
2 Walks slower than contemporaries on flat ground	9 (18)
3 Able to walk <100 yards or a few minutes on the level	3 (6)
4 Breathless with dressing or housebound due to breathlessness	1 (2)
Bronchiectasis Severity Index, n (%)
Mild	11 (22)
Moderate	22 (44)
Severe	17 (34)
Comorbidities, n (%)
GORD	22 (44)
COPD	18 (36)
Sinusitis	14 (28)
Heart disease	10 (20)
Other chronic respiratory disease	7 (14)
Cancer	6 (12)
Other chronic condition	18 (36)
No comorbidities	8 (16)
Annual exacerbations in previous 12 months, median (IQR, range)	1 (0-3, 0-10)
Annual days in hospital in previous 12 months, median (IQR, range)	0 (0-0, 0-38)
Attended pulmonary rehabilitation in previous 12 months, n (%)^*	0 (0)

BMI: Body mass index; COPD: Chronic Obstructive Pulmonary Disease; FEV₁: Forced expiratory volume in 1 s⁴⁵; GORD: Gastro-oesophageal reflux disease; IQR: interquartile range; mMRC: modified Medical Research Council; SD: standard deviation; ^* attendance of at least 12 supervised exercise sessions if referred to a pulmonary rehabilitation program in the 12 months prior to study enrolment.

Effect of the clinic interventions

Quality of life (QOL-B rs and LCQ total score) was significantly higher at 3 months and maintained at 12-months (Table 3), with the mean difference above the MID for both measures at three and 12-months from baseline. Full results for QoL-B and LCQ domains are outlined in Tables S3-S4. The annual frequency of exacerbations and hospitalisation for bronchiectasis reduced over the study period compared with the 12-months prior to enrolment (Table 4).

Table 3.

Change in quality of life.

Time period	QoL-B rs score (MID = 8.0)	LCQ total score (MID = 1.3)
Baseline to 3 months	9.2 (3.2 to 15.2)^*	1.7 (0.6 to 2.8)^*
Baseline to 12 months	10.1 (3.9 to 16.3)^*	1.8 (0.8 to 2.8)^*
3 to 12 months	0.9 (−5.4 to 7.2)	0.1 (−0.9 to 1.1)

Data are mean difference (95% confidence interval); ^* statistically significant difference.

Table 4.

Annual exacerbations and hospitalisation^*.

	12 months prior to study enrolment	12 months after study enrolment	Significance
Annual exacerbations (median, IQR)	1.0 (0.0, 3.0)	0.0 (0.0, 1.0)	p = 0.007
Annual hospitalisation (%)	18	0	p = 0.005

IQR: interquartile range; ^* exacerbations of bronchiectasis²⁷ and hospitalisation primarily for the treatment of bronchiectasis only.

Implementation of the clinic

Clinic uptake was high, with 91% of people attending an initial clinic appointment of those referred (Figure 1). Clinic attendance was also high, with 97% of appointments attended that were offered (Figure 2). The most frequently identified traits were mucus hypersecretion, reduced exercise capacity and the absence of an action plan (Table S5). Reduced exercise capacity (n = 11) and underweight (n = 1) were the only traits identified and not prioritised for treatment by participants. Airway clearance therapy, referral to pulmonary rehabilitation and Bronchiectasis Action Plans were the most frequently implemented treatments (Table S5). Airway clearance therapy was the most frequently modified component of the treatment plan in accordance with the BTS stepwise approach (Supplemental File S1).

Figure 2.

Bronchiectasis clinic attendance.

A total of 84% of participants were recommended to attend pulmonary rehabilitation, and 74% of participants accepted the referral. Reasons for declining a referral are included in Table S2. Pulmonary rehabilitation completion was high, with 84% of participants referred having completed at least 12 supervised exercise sessions by 12-months (Figure 1). Most participants (74%) completed pulmonary rehabilitation between three and 12 months (Figure 1).

Discussion

This is the first study to evaluate the implementation of a treatable traits approach to clinical care in people with bronchiectasis, and the first to implement the approach in a low resourced regional setting. This study demonstrated that a bronchiectasis clinic delivered by a physiotherapist and nurses, utilising a treatable traits approach to clinical care, improved quality of life at 3 months, which was maintained at 12-months, achieved high rates of clinic uptake and attendance, including high rates of pulmonary rehabilitation for those referred, and reduced annual exacerbations and hospitalisation. This was shown in people with predominantly moderate severity bronchiectasis and demographic features similar to other Australian³⁰ and European databases.⁸

The evaluation demonstrated clinically-significant improvements in quality of life at 3 months, which were maintained at 12-months. This was achieved with a pragmatic, low resource approach to clinical care, evidenced by the traits identified and treatments delivered, which focused on the development of personalised self-management strategies with minimal equipment and staffing. Previously, improvements in quality of life in severe asthma and COPD have been demonstrated in clinics utilising a treatable traits approach, within tertiary settings and with the inclusion of a physician (respiratory or general practitioner).²⁰ Importantly, improvements were not previously demonstrated in primary care,¹⁵ highlighting the significance of the improvements achieved in this community setting.

Establishing the feasibility of the treatable traits approach is important, to determine if an outpatient treatable traits model is implementable in adults with bronchiectasis. It has been suggested that this approach would be difficult for patients, and unfeasible in the current health care system due to resources required to complete a multidisciplinary assessment and treatment program.³¹ Our study showed that uptake (91%) and attendance (97%) were high. At each appointment, the treatment goals and signs of treatment success were summarised to encourage future attendance. It is possible to both standardise care through routinely assessable traits, and to personalise it through the decision-making that occurs with the patient, giving patients access to care in regions where health professionals and resources may be limited. The referral rate (84%) to pulmonary rehabilitation in our study was also higher than that reported in the ABR (19.5%),¹² although it is noted that 26% of participants who were referred to pulmonary rehabilitation declined the referral.

Annual exacerbations and hospitalisation were reduced at 12-months from initial assessment. Exacerbation frequency is a predictor of future exacerbation, with frequent exacerbation associated with high disease severity, reduced quality of life and increased mortality in bronchiectasis.³² For these reasons, reducing the annual rate of exacerbations is an important outcome. Treatable traits interventions in asthma and COPD,²⁰ along with exercise training in bronchiectasis,³³ have demonstrated similar findings. The annual hospitalisation rate (18%) in our study prior to the clinic interventions is lower than rates published in Europe (26.4%).⁸ The high referral acceptance (74%) and completion rate (84%) for participants referred to pulmonary rehabilitation in our study may have contributed to the reduction in annual exacerbations.²⁸ It has been noted that due to the mucus abnormalities in people with bronchiectasis, airway clearance alone can improve quality of life and symptoms, although for some, symptoms and exacerbations persist despite the effectiveness of treatment prescribed.³⁴ This highlights the importance of the key components of a treatable traits model of care that it is multifaceted, evidence-based and personalised, so that a larger health benefit is realised than would be possible with individual components of care.¹⁵ What is unknown is if these benefits could be sustained beyond 12-months.

There were limitations in the study design. This was an uncontrolled study without a comparative control group of usual care. However, our focus was to evaluate quality of life, feasibility of implementation of the treatable traits approach and health utilisation, rather than to demonstrate superiority to other treatment approaches, so we purposefully chose an implementation design.¹⁵ Participants continued to receive their usual medical care during the 12-months study, hence we cannot rule out that some improvements may be attributable to this medical care received. The physiotherapist leading the clinic was also the study’s principal investigator; this may have introduced response bias in the quality of life measures; although the mean improvements in quality of life measures exceeded the MID. We did, however, demonstrate improvements in the objective measures of exacerbation frequency and hospitalisation. The physiotherapist followed a standardised template for identifying and measuring traits, which limited the potential for researcher bias during implementation, and the nurses were blinded to study participation. The results were demonstrated in a single clinic, however study participants were similar in age, sex and BSI to those in the ABR,³⁰ and therefore representative of adults with bronchiectasis in Australia. There was potential for inaccurate recall (either under or over reporting) in the self-report of exacerbations in the 12 months prior to study participation, but evidence in COPD supports that patient recall is sufficiently robust.³⁵

There were also strengths to our study. We achieved high levels of initial clinic appointment uptake, appointment attendance and pulmonary rehabilitation uptake and completion, which is often difficult in patients with respiratory disease. Pulmonary rehabilitation can reduce annual exacerbations in bronchiectasis.²⁸ In our study, the majority of quality of life improvements were achieved by 3 months, before most participants had commenced pulmonary rehabilitation. This suggests that the other treatment modalities (e.g. airway clearance therapy, Bronchiectasis Action Plan implementation) may account for a substantial proportion of the benefits achieved. Attendance at pulmonary rehabilitation may have reinforced the education provided regarding self-management in clinic appointments. The significant improvements in quality of life were achieved with minimal equipment and resources; this suggests the approach could be replicated in non-specialist settings with limited resources. It is important to demonstrate successful implementation of treatment approaches in regional areas, as 26% of Australians live in regional areas,³⁶ and people with bronchiectasis report reduced access to specialist care and disease-specific education if living outside of metropolitan areas.^37,38

In conclusion, this is the first study to provide evidence for the implementation of a treatable traits approach to clinical care in bronchiectasis; and the first conducted in a regional community setting. Significant improvements in quality of life, high rates of clinic uptake, attendance, and pulmonary rehabilitation uptake and completion, along with reductions in exacerbations and hospitalisation, can be achieved in a low-resourced regional setting with care implemented by a physiotherapist and nurses. Further research is necessary to determine the efficacy and cost of scaling the treatable traits model of care in different geographic locations compared to standard care in bronchiectasis. Qualitative analysis would support an assessment of the acceptability and experience of this approach to patients with bronchiectasis.

Supplemental Material

Supplemental Material - Implementation of the treatable traits approach in a regional clinic: Improving health outcomes in adults with bronchiectasis

Supplemental Material for Implementation of the treatable traits approach in a regional clinic: Improving health outcomes in adults with bronchiectasis by Kirsty E. Watson, Annemarie L. Lee, Tiffany J. Dwyer, Zoe J McKeough in Chronic Respiratory Disease

Footnotes

Acknowledgements

The authors thank Suzanne Williams, Respiratory Nurse Practitioner, Central Queensland Hospital and Health Service (CQHHS) for her clinical support of the bronchiectasis clinic and Joanne Wex, Director of Clinical Measurements (CQHHS) for assisting with spirometry measures.

ORCID iDs

Kirsty E. Krieg

Annemarie L. Lee

Tiffany J. Dwyer

Zoe J McKeough

Ethics approval

Ethical approval was received from the Central Queensland Hospital and Health Service (CQHHS) Human Research Ethics Committee (HREC/2020/QCQ/61455) on 14/05/2020. All participants provided written informed consent prior to participating.

Clinical trial

This study was prospectively registered with the Australian and New Zealand Clinical Trials Registry (), ACTRN12620000328976.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.*

Supplemental Material

Supplemental material for this article is available online.

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