Dr Christine Bucknall describes how the RCP developed three patient-focused outcomes that would act as a prompt to review treatment
Measuring the outcome of care for a condition that has a definite start and finish and agreed intervention should be relatively simple, although the severity of the condition and the correct timing will always have to be considered. Such issues pale into insignificance, however, when compared with the complexity of assessing the care of patients with a variable and chronic condition such as asthma.
Assessment of care is even more difficult when patient involvement in that care has a considerable role in management. I mention this in order not to ignore it, although no further reference to this element of asthma care will be made.
Once the decision to assess the quality of care has been made, the dilemma of whether to measure processes or outcomes must next be addressed.
Most people probably use some combination of these in order to monitor their patients. Barritt,1 in a market town practice in Shropshire, describes ongoing audit of practice locally, with outcome recorded by patient questionnaires as part of that process.
Jones and colleagues2,3 used the approach of targeting care at patients whose outcome, as measured by a short postal questionnaire, showed them to have regular symptoms.
In hospital ambulatory asthma care, there are many local examples of symptom-based assessment tools.4
The relative merits of these tools as outcome measures was evaluated informally by an Outcomes Working Group convened as part of the work of the DoH's Central Health Outcomes Unit. The findings of this group have recently been published.4
In essence, no symptom-based outcomes were recommended because further assessment of the practicality of implementing these in everyday practice, as opposed to the research setting, was felt to be necessary.
The evaluation of available tools undertaken at that time identified a number of groups whose thinking was moving forwards in parallel, with each group having their own preferred set of questions, which were more or less evidence based.
Sharing data in any meaningful way would be impossible if a consensus could not be reached. It was realised that until there was some agreement no pressure could be brought to bear on producers of GP software to encourage them to add any outcome measures to the standard packages.
Patient-focused outcomes have therefore been evolving in a number of formats as professionals sought tools to assess their patients' condition, usually in order to make inferences about the appropriateness of their existing level of treatment.
The tools that have been subjected to more scientific evaluation are unfortunately generally longer and may not be practical for use in everyday clinical practice. It is, however, the challenge of looking after patients in the hurly-burly of everyday practice that cries out for simple tools for evaluating that care.
A meeting of all the groups known to be active in this area was therefore convened by the Royal College of Physicians to try to produce a consensus view, in order to promote systematic review of outcomes by different groups, who would then be able to compare their results with others.
The ability to compare local findings with other groups is increasingly recognised within medicine, as well as more generally, as a powerful tool for quality improvement.
This group met and considered the work of various groups, as well as the reasons for agreeing a common way forward. The proceedings have been published.7 Summary points from the seminar on Asthma Outcome Indicators are shown in Figure 1.
|Figure 1: Summary points from the seminar on Asthma Outcome Indicators held to establish patient-focused outcome measure*|
|* Reproduced by kind permission of the RCP from: Pearson MG, Bucknall CE (Eds). Measuring Clinical Outcome in Asthma: a patient-focused approach. London: RCP, 1999, p.46|
Although some areas (including the best time frame for assessing responses to these questions) remained undefined, three symptom-based questions which patients should be asked opportunistically were agreed:
- Have you had difficulty sleeping because of your asthma symptoms (including cough)?
- Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)?
- Has your asthma interfered with your usual activities (housework, work/school etc)?
These questions are most likely to contribute to a further improvement in the quality of care for patients with asthma – and there have been major changes over the past decade8 – if patients are asked these specific questions about current asthma control whenever they are being seen in general practice.
This will lessen the likelihood of the unproductive interview in which the GP asks non-specific questions which fail to elicit the patient's true symptoms, and thus fails to recognise the need to escalate treatment along the lines of the guidelines which, at another level, he/she is aware of and keen to use.9
If the questions are used routinely – and having them as a standard element of GP software would provide the prompt to do this (perhaps triggered by the patient having a diagnosis of asthma in their list of active problems) – GPs will be reminded of the possibility of modulating treatment accordingly.
If the responses were collated in a systematic manner once a year, for patients attending outwith an exacerbation, then practices or practitioners could obtain a snapshot of current asthma control of their patients.
This information, taken in conjunction with data on current treatment step (perhaps stratified as BTS treatment steps 1-5), would start to generate interest in levels of symptom control – what proportion of patients at any given treatment step should be expected to have negative responses to all three questions, when stable?
Having comparable data to the practice next door, with similar patients, and, perhaps even more interesting, to other practices with a different socioeconomic mix of patients, is liable to generate even more questions, but the ensuing discussion and scrutiny of standards of care is unlikely to have an adverse effect on patients' quality of care.
The literature on the use of guidelines to improve the quality of care is quite definite that guidelines alone are of little value10 – we all know this from the guidelines we have in our filing cabinets or pinned on the wall.
Patient-specific prompts remind us to ask the right questions and apply the guidelines usefully. Individuals with an interest have been developing their own patient-specific prompts.
The breakthrough that was achieved by producing a consensus on the questions to ask opens up a whole new vista in terms of sharing data and learning from comparisons between different patient groups – either over time, within one's own practice, or between practice populations.
The main threat is probably lack of time, although anecdotally practitioners who become interested in asthma care report that as their patients' symptoms come under better control, the number of emergency visits and nebulisations diminishes. Routine workload may be increased; Price11 has, however, shown a fall in hospital admissions due to asthma.
Having systems that provide automatic prompts may improve the efficiency of the consultation, but are unlikely to save time. It may be that providing good care will take a little more time; it is to be hoped there will be gains in professional competency and sense of fulfilment to balance against the threat of further encroachments on our time.
Agreement on three patient-focused outcomes that reflect current asthma control and therefore the effectiveness of therapy is a major breakthrough, in that it could act as a prompt to review treatment, as well as offering the possibility of sharing information on different patient groups in a meaningful way.
Whether patient care can be influenced depends on the acceptability of this approach to GPs and hospital doctors caring for patients with asthma.
There is recent evidence from confidential inquiries into asthma deaths in Wales12 and Scotland8 that asthma care has improved dramatically since the original BTA study of deaths in 1979, with its headline '79% of deaths preventable'.13
Further improvements will follow if we involve patients more in their care. These questions provide a frame-work for assessing asthma control and effectiveness of existing therapy which can be shared by doctors and nurses in different settings, as well as by patients.
- Measuring Clinical Outcome in Asthma: a patient-focused approach is available from the Publications Department of the Royal College of Physicians on 020 7935 1174, ext 358, price £15 including p&p.
- Barritt PW, Staples EB. Measuring success in asthma care: a repeat audit. Br J Gen Pract 1991; 41: 232-6.
- Jones KP, Bain DJG, Middleton M et al. Correlates of asthma morbidity in primary care. Br Med J 1992; 304: 361-4.
- Jones KP, Charleton IH, Middleton M et al. Targeting asthma care in general practice using a mordbidity index. Br Med J 1992; 304:1353-6.
- Pearson M, Goldacre M, Coles J et al (Eds). Outcome Indicators for Asthma. Report of a working group to the Department of Health, London Royal College of Physicians Research Unit and Oxford Unit of Health Care Epidemiology. London: NHSE, 1999.
- Hyland ME. The Living with Asthma questionnaire. Respir Med 1991; 85(Suppl B): 13-16.
- Steen N, Hutchinson A, McColl E et al. Development of a symptom based, outcome based measure for asthma. Br Med J 1994; 309: 1065-8.
- Pearson MG, Bucknall CE (Eds). Measuring Clinical Outcome in Asthma; a patient-focused approach. London: Royal College of Physicians, 1999.
- Bucknall CE, Slack R, Godley CC et al. Scottish Confidential Inquiry into Asthma Deaths. Thorax 1999; 54: 978-84.
- Modell M, Harding JM, Horder EJ et al. Improving the care of asthmatic patients in general practice. Br Med J 1983; 286: 2027-30.
- Grimshaw JM, Russell IT. Achieving health gain through clinical guidelines II: Ensuring guidelines change medical practice. Q Health Care 1994; 3; 45-52.
- Price DB. Patterns of prescribing of inhaled steroids over a seven-year period in a general practice and its implications. Thorax 1995; 50: 443P.
- Burr ML, Davies BH, Hoare A et al. A confidential inquiry into asthma deaths in Wales. Thorax 1999; 54: 985-9.
- British Thoracic Association. Death from asthma in two regions of England. Br Med J 1982; 285: 1251-5.