Joanne Rummens led the winning initiative in the Asthma category of the 2006 Guidelines in Practice Awards, which enabled an improvement in treatment procedures


P revious research has categorised asthma treatment into 'asthma treatment steps'.1 This approach to care is promoted in the British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN) asthma guideline.2

For mild intermittent asthma, a short-acting beta 2 agonist (SAB2A) is the only treatment that is needed. The guideline recommends the introduction of steroid inhaler use if a SAB2A is used three times a week or more, and this highlights increased use of a SAB2A as a potential marker for identifying patients whose asthma may not be optimally controlled.

Objectives of the audit

The aims of the audit were to identify patients over 12 years of age who were overusing their prescribed reliever medication, and who might benefit from the introduction of an inhaled steroid to:

  • reduce morbidity and improve quality of life
  • reach and maintain the goals of asthma management
  • evaluate and improve care, in line with the BTS/SIGN recommendations.

BTS/SIGN guideline recommendations

The BTS/SIGN guideline recommends that all asthmatic patients over 12 years of age, who required four or more prescriptions for SAB2A in the previous year, should have an annual asthma review. In addition, inhaled corticosteroid treatment should be initiated in all those in with poor asthma control.

Audit population

The audit population was identified by a computer search of practice records for:

  • patients with a known diagnosis of asthma
  • patients >12 years of age
  • patients who had been prescribed four or more SAB2A inhalers in the previous 12 months
  • chronic obstructive pulmonary disease (COPD) Read Code excluded.

The audit population comprised 22 patients who were invited to attend for an initial assessment with follow-up review 1 month later.

Assessment and management

The Tayside Scoring System (see Table 1) was used to assess the patients' asthma control.3 Those assessed as having poorly controlled asthma were prescribed an inhaled steroid to be used regularly over the month. Data points were taken from consultations at the beginning and end of the audit period. These data comprised patient scores using the Tayside Scoring System, peak expiratory flow readings, and patient use of a SAB2A at a rate >3 times per week. Consultations were used as an opportunity to reinforce and extend patients' knowledge, in order to promote effective self-management.

Of the 22 patients in the audit population, 21 of them attended for assessment. At the follow-up review, four patients failed to attend, despite several requests, and one was reviewed by telephone. The BTS/SIGN guideline recognises that not all patients wish to have a regular review,2 or are willing to attend a pre-arranged appointment.4

Table 1: Tayside Scoring System

Night/day symptom score
Activity symptom score
0 = Never
0 = Rarely
1 = 1–2/month
1 = On exercise
2 = 1–2/week
2 = Hills/stairs
3 = Daily
3 = Walking on flat
   

Audit results

Inadequate control found in most patients

It was found that 19 patients had inadequate control over their asthma. Of these, 17 (90%) were prescribed a steroid inhaler at the assessment, 10% below the practice target of 100%. However, the results were skewed by the concurrent presence of COPD in one patient. This patient was transferred from the asthma to the COPD register for more appropriate management.

The BTS/SIGN guideline does not cover patients with mixed asthma/COPD, where higher levels of SAB2A usage are appropriate.

Poor inhaler technique identified

Four of the patients (18%) needed advice on how best to use their inhaler, and one patient was prescribed a different inhaler device. Although cost may influence the selection of inhaler, this is a false economy if the patient cannot use it effectively as they may take more doses, resulting in increased prescriptions.5 Inhaler devices should be selected to suit a patient's needs and ability.

Reluctance to use steroid inhalers

At the initial assessment, it was found that steroid inhalers had been prescribed to two (9%) of the patients, but they had stopped using them, preferring their reliever medication. Fear of unwanted side-effects plays a large part in patients' reluctance to use preventive steroid inhalers.6 Cost can also be a factor, in cases where asthmatic patients pay for their prescriptions. Some patients may only request their SAB2A medication, believing that to be the one that works best.7

Excessive prescriptions requested

Three (14%) patients were found to be receiving excessive prescriptions, even though their asthma seemed well controlled, and it appears that some patients take their reliever medication out of habit. Patients should be encouraged to take the SAB2A only if they are symptomatic; the frequency of SAB2A use can then be identified as a marker of control (see Table 2).

Poor compliance highlighted

It can be difficult to understand why patients fail to adhere to logical treatment regimens, despite the best efforts of doctors and nurses. However, in this study, seven (32%) patients were assessed as complying poorly with medical advice, of whom three were symptomatic and had suffered an acute exacerbation in the previous year.

Smoking and asthma medication

The audit identified six patients (27%) who smoked. Smoking can be a factor in increased medication use. Spirometry should be considered for older patients who smoke, in order to determine the presence of COPD.8

Reduction in symptoms

Fourteen patients attended for a follow-up review. All had improved peak flow rates and reported a reduction in symptoms and in their use of SAB2A.

Table 2: Recommendations

 
Perfect control
Good control
Poor control
Night score
0
0 or 1
2 or 3
Day score
0
0 or 1
2 or 3
Activity
0
0
1, 2 or 3
SAB2A
<1–2/week
<2–3/week
>3/week
SAB2A=short-acting beta 2 agonist

Recommendations

The recommendations based on the results of the audit are presented in Box 1.

Box 1: Recommendations for GPs

  • Present report to practice team and discuss ongoing audit/review
  • Maintain accurate asthma register; exclude COPD patients as appropriate
  • Conduct an annual re-audit
  • Identify and review patients from this audit who still have symptom scores of 2 or 3 according to the Tayside Scoring System
  • Continue to improve recall system and follow-up of non-attenders
  • Devise computer-generated warning for overuse of bronchodilator
  • Increase use of personalised written asthma plans Introduce spirometry for older smokers

Personalised plans

Written personalised asthma action plans have been identified as an extremely effective non-therapeutic intervention.9 An example of an asthma action plan is available in the Asthma UK's 'Be in control' materials, which are available on its website.10 This has been endorsed by SIGN.2

Conclusions

Clinical governance provides a framework to enhance quality in practice through the implementation of widely accepted national guidelines.

These are available for the management of asthma,2 providing comprehensive evidence-based recommendations for treatment and management. However, the BTS/SIGN guideline recognises that implementing current guidance alone does not guarantee long-term improvement in clinical practice. Feedback based on audit is necessary for ongoing longer-term improvement to be maintained.2

Clinical effectiveness and cost effectiveness of health interventions need to be monitored, by auditing, so that standards can be maintained and improved, and any deficiencies can be highlighted and remedied.

The audit presented here demonstrates that, unless invited to attend for review, some patients accept daily symptoms of asthma and rely excessively on reliever medication. In addition, unless the frequency of repeat prescriptions is monitored, patients may inappropriately self-treat.

Written personalised asthma action plans are strongly recommended for all asthma patients.2

New ways of monitoring and reviewing asthma treatment need to be explored, and telephone consultations may be one way forward. An active recall system is essential for effective asthma management. The GMS contract gives practices financial incentives to initiate regular review,11and the study detailed here underlines the clinical need.

Asthma patients can be helped to achieve as normal a life as possible, without compromising their lifestyle and health. Evaluation of practice through audit can greatly facilitate this goal.

Summary

  • The BTS/SIGN guideline recommends that inhaled corticosteroid treatment should be initiated in all those patients with poor asthma control
  • The aim of the audit was to find those patients over 12 years of age who might benefit from an inhaled steroid
  • The audit population comprised 22 patients
  • The audit identified:
      • that the majority of patients had inadequate asthma control (90%)
      • those patients with poor inhaler technique (18%)
      • poor compliance (32%)
  • All 14 patients attending the follow-up review had improved peak flow rates and reported a reduction in symptoms and their use of SAB2A
 
BTS/SIGN=British Thoracic Society/Scottish Intercollegiate Guidelines Network

 

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  10. www.asthma.org.uk
  11. British Medical Association. Revisions to the GMS Contract, 2006/07. Delivering Investment in General Practice. London: BMA, 2006.G