The winning project in the Asthma category of the 2005 Guidelines in Practice Awards used patient questionnaires to monitor asthma control, as Dr Jackie Roberts explains


 

The aim of our project was to gain useful and useable data on our asthma population with a view to improving their clinical care, implementing the BTS/SIGN guideline, meeting our QOF targets and gaining our aspiration points.

In the first year of the QOF we only aspired to 44.67 points out of a possible 72 because we felt our data would not enable us to do better. It was because of our low expectations of this that we embarked on the asthma project.

As a result of the project we achieved 62.18 points which is 86.36% of the maximum points available. This year (2005/06) we have aspired to the maximum of 72 points and have currently achieved 64.14 which is 89% of the maximum – our failure being flu immunisation at 41% uptake, which is always going to be a problem with a young healthy population (Table 1). We are relieved that the flu indicator for asthma has now been removed from the QOF. This should enable us to gain maximum points for asthma in 2006/07.

The Putneymead Medical Centre is situated in the inner London suburb of Putney. Most of our working age patients commute to work, leaving Putney before we open and returning after we close.

We knew from experience that most patients would refuse to attend designated asthma clinics, and therefore we needed to find a different way of assessing asthma control accurately.

By incorporating the three questions recommended by the RCP guidance1 and the British Thoracic Society (BTS)/Scottish Intercollegiate Guidelines Network (SIGN)2 into a short and easy-to-use questionnaire, we achieved a high level of return as well as accurate up-to-date clinical information.

Table 1: QOF1 asthma indicators
Disease/indicator no
Clinical indicator
Points
Maximum threshold
Asthma 1
The practice can produce a register of patients with asthma excluding patients with asthma who have been prescribed no asthma-related drugs in the past 12 months
7
 
Asthma 2
% patients age 8 years and over diagnosed as having asthma from 1 April 2003 where the diagnosis has been confirmed by spirometry or peak flow measurement
15
70%
Asthma 3
% patients with asthma between the ages of 14 and 19 years in whom smoking status has been recorded in the previous 15 months
6
70%
Asthma 4
% patients age 20 years and over with asthma whose notes record smoking status in the past 15 months, except those who have never smoked where smoking status should be recorded at least once
6
70%
Asthma 5
% patients with asthma who smoke, and whose notes contain a record that smoking cessation advice has been offered within the past 15 months
6
70%
Asthma 6
% patients with asthma who have had an asthma review within the past 15 months
20
70%
Asthma 7
% patients with asthma aged 16 years and over who have had influenza immunisation in the preceding 1 September to 31 March
12
70%

Why the project was started

We decided to implement this particular project, because we were aware that we did not have an accurate asthma register, we were not routinely asking the questions suggested in the BTS/SIGN guideline and we were not consistently using the EMIS GP contract asthma template to record our data when seeing asthma patients. So the statistics that we had available for the quality and outcomes framework were incomplete and unreliable.

We wanted to ensure that the data received was accurately recorded by using a structured approach to data entry and that patients with poor symptom control had the opportunity to be reviewed by a clinician.

The 5-step process

The project began in September 2004. Initially this project was set up and run by a senior partner in the practice. We felt this would enable continuity and follow through.

The first step was to set up an accurate register of our asthma population by performing a computer search for the asthma Read code (H33) along with patients on asthma medication as detailed in the BNF (sections 3.1, 3.2 and 3.3).

These two lists were then compared and amalgamated, and the lead clinician examined each patient's records using the following 5-step process:

1) Check the diagnosis.

2) Code the patient for asthma (H33) if they were not already coded.

3) Attempt to code for date of onset wherever possible. If a true date of onset could not be found, then the date of the first medication issued was used as date of onset.

4) An asthma medication review (without the patient) was then done on each individual, assessing frequency of use of medication by looking at 'Detailed History' for each drug used. It then became clear what medication the patient was using on a regular basis.

5) With the aid of the practice manager, a patient letter and questionnaire were created (Figures 1and 2) and sent to each patient, and the administration code for 'letter sent' (90J4) was added to the summary page.

Figure 1: Letter sent to asthma patients

Figure 2: Asthma questionnaire

We also enclosed a stamped addressed envelope with each letter to try to increase the percentage of questionnaires returned.

This 5-step process was carried out for each individual on the amalgamated list. Because of the number of patients involved it took a period of several weeks to complete.

Data entry

As the questionnaires were returned, it became clear that the questions could be refined to be more useful when completing the template in the patient's records and also to conform to the BTS/SIGN guideline recommendations. We therefore expanded questions regarding symptoms to include the frequency of the symptoms, e.g. never, 1-2 per month, 1-2 per week, most days.

The results from the questionnaire were coded into the patient's records by the lead clinician. The patient's contact details were confirmed by ensuring the postal address, telephone number and email address were all correct.

The lead clinician then went into the consultation page for each individual patient to enter the data:

  • Under 'problem', the words 'not seen: from asthma questionnaire' were entered
  • The GP contract asthma template was opened on the EMIS GV system and completed from the information returned in the questionnaire
  • At the end of this template an asthma review date was added and recall was set at 1 year.

Results

Overall 406 questionnaires were sent out and 217 (53.4%) were returned (Table 2). Of those returned, 135 patients (62.2%) appeared very well controlled on their medication with no, or minimal symptoms from their asthma. In view of the fact that their asthma medication had already been reviewed (during the above process), no further action was taken on these patients.

Table 2: Statistics from asthma questionnaire*
 
Total no.
%
% of 'returned'
Sent
406
100
 
Returned
217
53.4
 
No review needed
135
 
62.2
 
Review needed
68
 
31.3
 
Unopened
14
3.4
6.5
* up to 3 June 2005
 
 
 

However, 68 patients (31.3%) were experiencing symptoms suggesting inadequate control of their asthma. An additional 14 questionnaires (3.4%) were returned unopened because the patient was no longer known at that address. The majority of these turned out to be students from our branch surgery at the local university.

The results from the questionnaires enabled us to highlight the patients who needed a review of their asthma medication and control.

In the letter sent to patients, we offered them a patient-instigated review, either by a telephone consultation or by making an appointment with one of the practice nurses or the doctors to discuss their asthma. Several patients took up this offer and arranged their own follow up.

There were 68 patients that we had identified as requiring review. These patients were divided equally between the doctors at the practice to arrange reviews. It was the responsibility of each doctor to make contact with those patients and review them in whatever way they felt was clinically appropriate (either on the telephone or in person). The review and medication changes were then recorded on the computer for each individual.

If the clinician failed to make contact with the patient after repeated telephone calls and personalised letters, an alert was placed on the computer to say that their asthma control needed to be reviewed when they were next seen at the practice.

Conclusion

This project resulted in a marked improvement in our recorded data. We have ended up with a cleaned asthma register, which has up-to-date, accurate and coded information on the majority of the patients on it and medication reviews on all of them. This is obviously beneficial to our patients.

All our clinicians (both nurses and doctors) are more aware of the BTS/SIGN recommendations and are consistently using the GP contract asthma template to record data.

We therefore feel that we have improved our clinical care of many of these patients by implementing the BTS/SIGN guideline and have met most of the indicators in the quality and outcomes framework of the new GMS contract.

Overall we were pleased with the 53.4% return and felt that the cost of 812 second class stamps proved to be worthwhile. We are also able to identify patients who did not return their questionnaires and so are able to chase them on an individual basis as time allows.

Continuation of the project

We feel the project was very successful 'in house' and we have rolled it out to another local practice on request. We are also now using patient questionnaires for many of the other QOF indicators, such as epilepsy.

References

  1. Pearson MG, Bucknall CE, editors. Measuring clinical outcome in asthma: a patient-focused approach. London: Royal College of Physicians, 1999.
  2. The British Thoracic Society/Scottish Intercollegiate Guidelines Network. British Guideline on the Management of Asthma.Thorax 2003; 58(S1): i1-83.

Guidelines in Practice, April 2006, Volume 9(4)
© 2006 MGP Ltd
further information | subscribe