Implementation of the QOF indicators encourages more accurate asthma diagnosis and may reduce emergency hospital admissions, comments Dr Kevin Gruffydd-Jones

Asthma is an important condition commonly encountered in general practice, which affects 5.2 million people in the UK, causing 1432 deaths in 2002, and accounting for 4.1 million GP consultations per year in England and Wales.1 It was, therefore, not surprising that asthma was included as one of the key clinical areas in the Quality and Outcomes Framework (QOF) of the General Medical Services (GMS) contract of 2003.2

This article looks at the changes made to the asthma indicators in the 2006/2007 revisions to the GMS contract3 (see Table 1), and speculates on possible future amendments.

Table 1: Clinical indicators for for asthma

Indicator no. Clinical indicator
Points
Payment stages
Min (%)
Max (%)
Records
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 previous 12 months

4
 
 
Initial management
 
 
 
ASTHMA 8 The percentage of patients aged 8 years and over diagnosed from 1 April 2006 as having asthma with measures of variability or reversibility
15
40
80
Ongoing management
 
 
 
ASTHMA 3 The percentage of patients between the ages of 14 and 19 years with asthma in whom there is a record of smoking status in the previous 15 months
6
40
80
ASTHMA 6 The percentage of patients with asthma who have had an asthma review in the previous 15 months
20
40
70
 
Total points
45
   

Indicators removed from the asthma QOF

ASTHMA 4, recording smoking status, and ASTHMA 5, recording smoking cessation advice in patients aged 20 years and over with asthma, have been moved to a new 'Smoking' category in the QOF indicators. ASTHMA 7, recording the influenza immunisation status of patients aged 16 years and over with asthma, has been withdrawn—reimbursement is already made to GPs for giving influenza immunisations to at-risk patients, which includes patients with asthma.4

Payment thresholds

The payment stages for revised QOF indicators have been increased from 25–70% to 40–80% for all categories except ASTHMA 6, which is set at 40–70% in recognition of the significant number of asthma patients who do not attend for review.

Patient register—ASTHMA 1

The production of an asthma register is easy, but it is far more difficult to make it accurate. In younger adults the diagnosis of asthma is relatively straightforward when confirmed by objective lung function testing (see Table 2).

 

However, the accuracy of registers is limited; for example, in pre-school age children, when testing of lung function may be impossible and there is an overlap of different wheezing phenotypes. The main differential diagnosis is viral-associated wheeze, where children, often born to mothers who smoke in pregnancy, have abnormal lung function in infancy and wheeze in response to viral triggers (mainly rhinoviruses). They do not respond to prophylactic inhaled corticosteroids. A diagnosis of asthma should be made when there is a history of recurrent wheeze, in the presence of family/past history of atopy, or where there is symptomatic improvement with a therapeutic trial of anti-inflammatory treatment (usually a 4–8 week course of an inhaled corticosteroid or leukotriene receptor antagonist).5

Registers can also be inaccurate when there is an overlap in elderly patients with chronic obstructive pulmonary disease (COPD). Although asthma and COPD may co-exist in the same patient, it is important to code the patient as one or the other as the treatment goals and regimens are very different (this can usually be done on the basis of a characteristic history and the presence or lack of reversibility on spirometry).

It is vital to carry out an annual review of the asthma register and remove patients who have not received asthma treatment during the past 12 months, recoding them as 'asthma resolved' (read code 212G or 21262).

Measures of variability or reversibility—ASTHMA 8

Accurate diagnosis of asthma is essential in order to avoid untreated symptoms resulting from underdiagnosis and to avoid inappropriate treatment in the case of overdiagnosis. Recurrent pulmonary embolism or tuberculosis, for example, can both present as intermittent breathlessness and result in a misdiagnosis as asthma. The British Thoracic Society (BTS)/Scottish Intercollegiate Guideline Network (SIGN) guideline on the management of asthma emphasises the importance of demonstrating variable lung function when making the diagnosis.6

Isolated spirometric or peak flow readings, as required by ASTHMA 2 in the 2003 QOF indicators, provided little information about the variability of the disease. This resulted in the withdrawal of this category from the GMS contract, and its replacement by this requirement to demonstrate variability or reversibility in lung function testing.

Table 2 shows the BTS/SIGN guideline criteria for objective measurement of reversibility/variability. It should be emphasised that lung function testing should be carried out in the context of a suggestive history of asthma and in the absence of an alternative clinical diagnosis on examination (including arranging a chest X-ray where there is diagnostic doubt).

Table 1: Clinical indicators for for asthma

Method Criteria Comments
Measurement of morning and evening PEFR over two weeks
20% diurnal variation [(maximum-minimum)/maximum ×100] for ?3 days in a week, with at least 60 l/min change
Specific for asthma, but relatively insensitive (high false-negative rate)
     
Reversibility testing:    

20 minutes post-administration of inhaled short-acting ?2 agonist (e.g. 400 µg salbutamol via metered dose inhaler and spacer or 2.5 mg salbutamol via nebuliser)
or
14 days after trial of oral steroids (prednisolone 30 mg/day)
or
10–15 minutes prior to and 10, 20, 30 minutes after 6 minutes of exercise

PEFR: 20% change from baseline and at least 60 l/min
or
FEV1: ?15% change and at least 200 ml
or
?15% decrease in FEV1 after six minutes of exercise (running)

 

It is generally agreed that measurements should be taken 20 minutes after administration of a short-acting ?2 agonist

Exercise should aim to raise pulse rate to 60–80% of maximum (estimated maximum pulse rate = 220-age)

Maximal reduction in lung function usually occurs 10–15 minutes after exercise

PEFR=peak expiratory flow rate; FEV1=forced expiratory volume in 1 second

Smoking status in 14 and 19 year-olds—ASTHMA 3

There has been no change in the content of this indicator (although the upper threshold has risen from 70% to 80%). This can be a difficult group to monitor and they may be more cooperative if they are reviewed by telephone (although this is not currently accepted for QOF points).

Asthma review—ASTHMA 6

The 2006–2007 revision to the GMS contract gives more advice about what constitutes an asthma review.3 The key elements are:

  • assess symptoms [using Royal College of Physicians (RCP) '3 Questions' (see Figure 1)]7
  • measure peak flow
  • assess inhaler technique
  • consider personalised asthma action plans.

Although not stipulated by the revised QOF, medication can also be reassessed at the asthma review.

The inclusion of the RCP questions is a welcome move towards more outcome-driven measures rather than just measuring process. It enables standardised recording of a simple measure of asthma control. The '3 questions' have not been formally validated, although pilot work8 suggests that they correlate well with asthma outcome indicators.

It is questionable whether an isolated peak flow measurement is of value in asthma review. The measurement is highly effort-dependent and for patients with mild to moderate asthma it may not accurately reflect how asthma affects their health status, nor the degree of asthma control. In spite of this, it is useful to have a record of a patient's 'best-ever' peak flow reading as a reference in case he or she presents with an acute exacerbation in the future.

Traditionally, there has been a high non-attendance rate for asthma review (60% in our clinic prior to introduction of the clinical indicators), and there is some evidence that implementation of the QOF indicators has improved these attendance rates. However, there are still many patients who are very reluctant to take part in the review in person and so more innovative methods (such as telephone consultation) can be used to increase the number of patients reviewed.9 At the author's practice, structured telephone review is carried out by the practice asthma nurses.

The provision of personalised asthma action plans has been shown to reduce asthma morbidity, including hospital admissions,910 but nevertheless uptake of plans varies greatly.

Figure 1: The Royal College of Physicians (RCP) ‘3 questions’8

In the last month:

  • 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, e.g. housework, work/school, etc?

Has the implementation of clinical indicators for asthma improved morbidity rates?

There is no direct evidence available to answer this. More accurate diagnosis should minimise the chance of patients with alternative diagnoses (e.g. COPD) being inappropriately and ineffectively treated as asthmatics, thus skewing the morbidity data. Asthma UK recently produced a report showing that there is a wide variation in emergency asthma admissions across England, and there appears to be an inverse correlation with average asthma QOF points achieved in a particular Primary Care Trust area and the number of hospital admissions for asthma from that area.10

Suggested future changes to the asthma QOF indicators

The General Practice Airways Group (GPIAG)11 has suggested two main changes to the Asthma QOF, which are:

  1. That an additional asthma indicator be included for provision of written personal action plans for patients aged 5 years and over with asthma—the updated BTS/SIGN guideline for 2007 will cite Grade A evidence (from meta-analysis, systematic review) for the efficacy of their use.
  2. ASTHMA 6 should be updated to include an altered definition of what constitutes regular review—the recording of responses to the RCP '3 questions' should be essential.

Other proposed changes to the clinical indicators for asthma are as follows:11

  • carrying out an asthma review via the telephone (at present not allowed under the QOF)—telephone triage of asthma patients using the RCP '3 questions' (where only poorly controlled patients are seen face to face) has been shown to be more cost-effective, and allows more patients to be reviewed than trying to review all patients face to face12
  • recording factors that might be contributing to poor control, such as co-existing rhinitis, smoking status, compliance
  • carrying out of the review by a health professional specifically trained in asthma (which is shown to improve control among the population as a whole).

Conclusion

Asthma forms a large part of chronic disease management in primary care. The 2006/2007 QOF encourages more accurate diagnosis and regular structured review of people with asthma. Future QOF indicators should include outcome markers such as the 'RCP 3 questions' so that the effects of this higher quality management may be more accurately assessed in terms of improvement in asthma morbidity.

  • Asthma admissions are inversely related to QOF scores achieved for asthma
  • Asthma admissions can be avoided by good primary care
  • Proactive primary care can help achieve QOF points and save costly admissions
  • Tariff price: for asthma admission = £11661
  • Tariff price: respiratory (thoracic) medicine outpatient = £201 (new), £101 (follow-up)1
  1. Asthma UK. Where do we stand? Asthma in the UK Today. London: Asthma UK, 2004.
  2. British Medical Association. Investing in General Practice. The New General Medical Services Contract. London: BMA, 2003.
  3. British Medical Association. Revisions to the GMS Contract, 2006/07. Delivering Investment in General Practice. London: BMA, 2006.
  4. British Medical Association. Focus on payments for influenza and pneumococcal vaccinations. 2006. http://www.bma.org.uk/ap.nsf/Content/FocusPayInflu0504
  5. Cochran D. Diagnosing and treating chesty infants. A short trial of inhaled corticosteroid is probably the best approach. Br Med J 1998; 316 (7144): 1546–1547.
  6. British Thoracic Society and Scottish Intercollegiate Guidelines Network. British Guideline on the Management of Asthma. Revised edition 2005. BTS/SIGN, 2005.
  7. Pearson M, Bucknall C, editors. Measuring Clinical Outcome in Asthma: A Patient-Focused Approach. London: RCP, 1999.
  8. Thomas M, Gruffydd-Jones K, Stonham C, Ward S. Assessing asthma control: the RCP 3 questions correlated with clinical parameters and exhaled nitric oxide levels. Thorax 2005; 60 (2): 13.
  9. Gibson P, Powell H, Coughlan J et al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Syst Rev 2002; (3): CD001117.
  10. Asthma UK. The Asthma Divide—Inequalities in emergency care for people with asthma in England. London: Asthma UK, 2007.
  11. General Practice Airways Group www.gpiag.org
  12. Gruffydd-Jones K, Hollinghurst S, Ward S, Taylor G. Targeted routine asthma care in general practice using telephone triage. Br J Gen Pract 2005; 55 (521): 918–923.G