Overview
Initiative type
Model of Care
Status
Deliver
Published
June 2026
Summary
To determine if the treatable traits approach, implemented in a low resource, regional bronchiectasis clinic by a physiotherapist and respiratory nursing team, would improve clinical outcomes and hospital avoidance.
Dates: January 2021 - February 2024
Implementation sites: Rockhampton Hospital
Aim
To evaluate whether a bronchiectasis clinic in a regional setting in Australia, implementing a treatable traits approach, would lead to:
(1) improvements in quality of life (QoL)
(2) reductions in annual exacerbations and hospitalisation
(3) increased pulmonary rehabilitation completion.
Outcomes
- Of 78 eligible patients, 50 participated in the study [mean (SD) age 71 (12) years; Bronchiectasis Severity Index (%) mild (22), moderate (44), severe (34)].
- There was a clinically significant improvement in QoL at three and 12 months from baseline [3 months: QoL-B rs mean difference (95% CI) 10.1 (3.9-16.3), LCQ 1.8 (0.8-2.8); 12 months: QoL-B rs 9.2 (3.2-15.2), LCQ 1.7 (0.6-2.8)].
- Exacerbation frequency decreased compared with baseline [median (IQR) from 1.0 (3.0) to 0.0 (1.0), p<0.05)
- Hospitalisation decreased compared with baseline (18% of participants hospitalised in the year before study enrolment
compared with 0% in the 12 months of study participation) - Pulmonary rehabilitation completion was high (84% participants referred, 74% completed).
Background
Bronchiectasis is a syndrome (1), characterised by permanent dilation of the airways, inflammation and symptoms of chronic cough, sputum production, and recurrent infections. A key challenge for clinicians is the heterogeneity of disease presentation, clinical course and progression (1). Several guidelines for bronchiectasis management have been published (2-4). Current management is focused on: 1) identifying treatable causes of bronchiectasis (2-4); 2) airway clearance therapy; 3) individualised self-management plans (2); 4) antibiotic therapy for the treatment of infection, eradication of Pseudomonas and reduction of inflammation (2-4); 5) pulmonary rehabilitation for those with reduced exercise capacity (2-4); and 7) smoking cessation (2). Annual to biannual review by a specialist respiratory physiotherapist (2, 3) and an annual review by a respiratory service with expertise in bronchiectasis (2) are recommended.
The treatment aims are to halt disease progression, improve quality of life, reduce the number of exacerbations and prevent secondary complications (2). Despite clear guidelines (2-4), evidence demonstrates that patients are not receiving recommended care (5). The Australian Bronchiectasis Registry (ABR-tertiary centres only) reports lower pulmonary rehabilitation referral rates (19.5%) than rates of reduced exercise capacity (68%) (6), and lower rates of regular airway clearance therapy (58%) than identified rates of chronic productive cough (70%) (6). A lack of consistent inclusion of these treatments and recommended clinical review potentially contributes to poorer long-term outcomes and preventable healthcare utilisation in people with bronchiectasis. In Australia, the average length of stay for a principal diagnosis of bronchiectasis is 8.2 days, with 79% of hospitalisations resulting in an overnight stay (7). Hospitalisations and emergency department (ED) presentations for bronchiectasis increase with increasing age and are highest in First Nations Australians (7). Potentially preventable hospitalisation due to bronchiectasis is reported as 21 per 100 000 of overall population (8).
A move towards precision medicine has been proposed, with a focus on individualised care as key to improving outcomes for people with bronchiectasis (1). Patients have highlighted that core components, including airway clearance therapy, must be individualised to be successful (9). One method for targeting care to individual disease characteristics is the treatable traits model of care (10). Treatable traits are clinically-relevant, identifiable, measurable and treatable aspects of respiratory disease (11); traits specific to bronchiectasis have been identified (12-13). 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 (11), regardless of disease severity, 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 (14). 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.
Methods
This was an implementation study conducted according to the Standards for Reporting Implementation Studies (StaRI). 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 bronchiectasis (15) 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 clinic intervention
A structured assessment of pulmonary, extrapulmonary and environmental/lifestyle traits was conducted in collaboration with participants. The traits assessed were within the physiotherapist or nurse’s scope to identify, measure and treat (13) (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. 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-month reviews as a minimum standard. Participants received a follow-up telephone call two weeks
after the initial assessment from the physiotherapist to answer any questions from the Bronchiectasis Action Plan, developed during the initial assessment. 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
(e.g. pulmonary rehabilitation). 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
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. Health utilisation outcomes were evaluated by annual exacerbation frequency and hospitalisation (the proportion of participants spending at least one 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. Pulmonary rehabilitation uptake and completion (attended at least 12 of a possible 16 planned supervised exercise sessions) for participants referred to the program, was audited at three and 12 months from hospital records.
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 three months, which was maintained at 12-months, reduced annual exacerbations and hospitalisation, and achieved high rates of pulmonary rehabilitation for those referred. This was shown in people with predominantly moderate and severe bronchiectasis severity index. Improvements in quality of life and healthcare utilisation was achieved with a pragmatic, low resource approach to clinical care, which focused on the development of personalised self-management strategies with minimal equipment and staffing.
The most frequently identified traits were mucus hypersecretion, reduced exercise capacity and the absence of an action plan. The most frequently implemented treatments were airway clearance therapy, referral to pulmonary rehabilitation and development of a bronchiectasis action plan. 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) (14). Importantly, improvements were not previously demonstrated in primary care (14), highlighting the significance of the improvements achieved in this community setting. 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 (16).
For these reasons, reducing the annual rate of exacerbations is an important outcome. Hospitalisation and exacerbations are the major drivers of increasing economic cost, and hence important treatment targets. In Australia, reducing the number of overnight stays and
potentially preventable hospital admissions in bronchiectasis would reduce healthcare utilisation and cost. It is important to demonstrate successful implementation of treatment approaches in regional areas, as 26% of Australians live in regional areas (17), and people with bronchiectasis report reduced access to specialist care and disease-specific education if living outside of metropolitan areas (18). A treatable traits model has the potential to be applied in other chronic diseases, through a standardised assessment of traits and collaborative treatment plan that is patient-centred. Our study has demonstrated that improvements can be achieved in settings where access to medical care is not available in the multidisciplinary team, and through targeting only the traits that are prioritised by patients. Further research is necessary to determine the efficacy and cost of scaling the treatable traits model of care in different geographic locations and chronic diseases, compared to standard care, including the patient experience of this approach.
References
1. Chotirmall SH, Chalmers JD. The precision medicine era of bronchiectasis. American Journal of Respiratory and Critical Care Medicine. 2024;210(1):24-34.
2. Chang AB, Bell SC, Byrnes CA, Dawkins P, Holland AE, Kennedy E, et al. Thoracic Society of Australia and New Zealand (TSANZ) position statement on chronic suppurative lung disease and bronchiectasis in children, adolescents and adults in Australia and New Zealand. Respirology. 2023;28(4):339-49.
3. Hill AT, Sullivan AL, Chalmers JD, De Soyza A, Elborn SJ, Floto AR, et al. British Thoracic Society Guideline for bronchiectasis in adults.
Thorax. 2019;74(Suppl 1):1-69.
4. Chalmers JD, Haworth CS, Flume P, Long MB, Burgel PR, Dimakou K, et al. European Respiratory Society clinical practice guideline for the management of adult bronchiectasis. European Respiratory Journal. 2025:2501126.
5. Visser SK, Bye PTP, Fox GJ, Burr LD, Chang AB, Holmes-Liew CL, et al. Management of Australian Adults with Bronchiectasis in Tertiary Care: Evidence-Based or Access-Driven? Lung. 2019;197(6):803-10.
6. Webb EM, Holland AE, Chang AB, Burr L, Holmes-Liew CL, King PT, et al. Current physiotherapy practice for adults with bronchiectasis: data from the Australian Bronchiectasis Registry. Respiratory Medicine. 2024;233:107777.
7. Australian Institute of Health and Welfare. Bronchiectasis. AIHW, Australian Government; 2026.
8. Australian Institute of Health and Welfare. Potentially preventable hospitalisations in Australia by small geographic areas, 2020–21 to 2021–22. Canberra: AIHW; 2024.
9. Franks LJ, Walsh JR, Hall K, Adsett JA, Morris NR. Patient perspectives of airway clearance techniques in bronchiectasis. Physiotherapy theory and practice. 2022:1-11.
10. McDonald VM, Holland AE. Treatable traits models of care. Respirology. 2024;29(1):24-35.
11. McDonald VM, Fingleton J, Agusti A, Hiles SA, Clark VL, Holland AE, et al. Treatable traits: a new paradigm for 21st century management of chronic airway diseases: treatable traits down under international workshop report. European Respiratory Journal. 2019;53:1802058.
12. Boaventura R, Sibila O, Agusti A, Chalmers JD. Treatable traits in bronchiectasis. European Respiratory Journal. 2018;52(3).
13. Watson KE, Lee AL, Dwyer TJ, McKeough ZJ. Applying the treatable traits approach in bronchiectasis-a scoping review of traits, measurements and treatments implemented by allied health professionals and nurses. Respiratory Medicine. 2024;222:107503.
14. Sarwar MR, McDonald VM, Abramson MJ, McLoughlin RF, Geethadevi GM, George J. Effectiveness of interventions targeting treatable traits for the management of obstructive airway diseases: a systematic review and meta-analysis. Journal of Allergy and Clinical Immunology: In Practice. 2022;10(9):2333-45 e21.
15. Chalmers JD, Sethi S. Raising awareness of bronchiectasis in primary care: overview of diagnosis and management strategies in adults. NPJ Primary Care Respiratory Medicine. 2017;27(1):18.
16. Chalmers JD, Aliberti S, Filonenko A, Shteinberg M, Goeminne PC, Hill AT, et al. Characterization of the "frequent exacerbator phenotype" in bronchiectasis. American Journal of Respiratory and Critical Care Medicine. 2018;197(1
Key contact
Kirsty Krieg
Advanced Allied Health Practitioner- Acute
Rockhampton Hospital
Central Queensland HHS