Dr Noel Baxter explains that although the QOF indicators for asthma have not been revised, their interpretation is affected by the updated BTS/SIGN asthma guideline

A first look at the 2011/12 quality and outcomes framework (QOF) changes might suggest business as usual for asthma with no change in the four core indicators since 2006 (see Table 1, below).1 However, we now need to view each indicator within the context of the following information:1

  • 2011 update of the British Thoracic Society and Scottish Intercollegiate Guidelines Network (BTS/SIGN) British guideline on the management of asthma2
  • The recently released strategy from the Department of Health—An outcomes strategy for chronic obstructive pulmonary disease (COPD) and asthma in England3
  • The policies within our new healthcare architecture.

The QIPP (quality, innovation, productivity, and prevention) agenda features in this year’s QOF and this article highlights how better asthma care can help achieve these targets.4

During this year of ‘no change’ we can look beyond the four core QOF indicators and consider the public health and inequality issues that are relevant to asthma, which include smoking and the physical health of people with severe mental health problems. There has been no significant change in the annual death rate of 1000–1200 for some years despite the widely accepted view that 90% are avoidable.5 In February 2012, a national review of asthma deaths5 will commence systematic reviews for every fatality due to asthma in the UK within a 1-year period.

In general practice, we can contribute to the prevention of asthma mortality through recognition and review of ‘near misses’ using the significant event review mechanism that remains incentivised in the 2011/12 QOF.1

Quality of asthma care

Asthma services in general practice remain valued by the GMS contract, with 45 points still available (see Table 1, below).1 In England, 5.9% of people have asthma and the majority of care is delivered in general practice.3 The role of primary care is to ensure that a correct diagnosis is made and to then work proactively with patients and their parents or carers so that they can make choices that result in symptom-free lives. Fulfilling this goal can in return deliver decreased healthcare utilisation and a wider impact on society through less absence from work and education.3 The health outcomes in England are being compared increasingly with other nations. The outcomes strategy highlights that in 2008, the premature mortality for asthma was over 1.5 times higher in England compared with the European average. A key outcome therefore is to have asthma outcomes comparable to that of the lowest in the world.3

Table 1: QOF indicators relating to asthma and ways to achieve them1
No. Indicator Points Payment stages Improvement project
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 preceding 12 months
4
  • Review new BTS/SIGN guidance and align with your practice diagnostic protocol
  • Is the asthma prevalence as expected? Check the APHO practice profiles to compare with your locality, PCT, and England
  • Review patients who have inhalers and no asthma or COPD diagnosis.
ASTHMA 8
The percentage of patients aged 8 years and over diagnosed as having asthma from 1 April 2006 with measures of variability or reversibility
15 40%–80%
  • Check the prevalence of asthma on your COPD register and consider over/under diagnosis
  • What percentage of patients with an ‘intermediate probability of asthma’ have documented obstruction and reversibility?
ASTHMA 3
The percentage of patients with asthma between the ages of 14 and 19 years in whom there is a record of smoking status in the preceding 15 months
6 40%–80%
  • What is the smoking prevalence in your asthma register?
  • How many patients have had smoking cessation advice in the last year that included pharmacotherapy?
  • Do you ask about passive smoke exposure at home/at childminders?
ASTHMA 6
The percentage of patients with asthma who have had an asthma review in the preceding 15 months
20 40%–70%
  • What percentage of children on inhaled steroids have had height measurements included in their last asthma review?
  • Does your practice stratify review according to risk? What processes ensure exacerbations are recorded?
QOF=quality and outcomes framework; BTS=British Thoracic Society; SIGN=Scottish Intercollegiate Guidelines Network; APHO=Association of Public Health Observatories; PCT=primary care trust; COPD=chronic obstructive pulmonary disease

ASTHMA 1: the register

Asthma is a clinical diagnosis made in people with intermittent symptoms that include cough, wheeze, or breathlessness, and is supported by the use of objective measures of airways obstruction. Peak-flow monitoring can be used at initial presentation to compare actual and predicted values, but variability cannot be determined from a single measurement and serial recording is essential in supporting the diagnosis. If quality assured spirometry is available, this should be performed at least initially or until an obstructive picture is demonstrated. Persistently normal airflow tests should, however, trigger a review of diagnosis.2

An accurate register is dependent on primary care clinicians making the right diagnosis and being able to recognise the pattern of symptoms that suggest asthma. Unfortunately, diagnostic inaccuracy is common in asthma due to the cross-over of the primary symptoms with other conditions. The absence of a consistent gold standard test therefore requires adherence to diagnostic algorithms.

The BTS/SIGN guideline has included advice on the diagnosis of asthma in children and adults since 2008 and adherence to this guideline should now be both commonplace and standard practice when making a diagnosis.2 It is possible to use a number of data sources to case find and check whether your practice is diagnosing the expected number of asthma cases.

Practice prevalence
Using an in-practice database, it is possible to look at prescription of inhalers that are not linked to an asthma or COPD diagnosis, which can then trigger a review. Comparison of asthma prevalence with neighbouring surgeries using the 2011 practice profiles from the Association of Public Health Observatories (APHO)6 may also highlight variation that warrants further diagnostic policy review.

ASTHMA 8: measuring variability and reversibility

An incorrect diagnosis will result in poor outcomes and extra cost in cases of both under and over diagnosis of asthma. The BTS/SIGN guideline makes it plain that some cases of asthma are not always clear cut and that depending on the presenting scenario, different measures of reversibility and variability are possible in both children and adults.2 The investigative algorithm in the guideline does require some careful reading by clinicians, but can yield a much better experience for the patient and avoid delayed diagnosis and wasteful therapy.

Patients should be considered as having a high, intermediate, or low probability of asthma when initially assessed using clinical history.2 In general, those with low probability require further investigation or referral, while the other two groups will require tests of airways obstruction and a monitored response to bronchodilators or steroids. In some cases of high probability, it is possible to initiate treatment and assess response, but in general, formal evidence of obstruction with variability is preferable.2 These tests are essential in patients with intermediate probability.

Significant variability in peak flow can be shown using a diary and should demonstrate a change of 20% or greater with a minimum change of at least 60 l/min, ideally for 3 days in a week over 2 weeks of morning and evening readings.1 Reversibility can be demonstrated using peak-flow meter readings, but it is preferable to use a reading of forced expiratory volume in 1 second (FEV1):1

  • 15 minutes after administration of a short-acting bronchodilator
  • after 6 weeks of inhaled steroids
  • after 2 weeks of oral steroids.

You may want to consider patient-specific variability testing by demonstrating significant reductions in FEV1 after exercise or by asking the patient to record peak flow when they next experience their candidate trigger. When using spirometry a significant change in FEV1 is more than 15% and 200 ml change.1

Joint diagnosis of asthma and COPD
It is commonly questioned whether it is possible for people to have both asthma and COPD. A joint diagnosis is possible and is a likely outcome in an individual with asthma who smokes. It would normally be expected in about 15% of patients on a COPD register. The NICE guideline on Management of chronic obstructive pulmonary disease in adults in primary and secondary care recommends that patients with both diagnoses should have a documented >400 ml response in FEV1 to bronchodilators or steroid therapy as smaller volumes can be as a result of expected variability in the test itself.7

Box 1: The Royal College of Physicians' three questions1

In the last month:

  • Have you had difficulty sleeping because of your asthma symptoms (including cough)? (663P)
  • Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)? (663q)
  • Has your asthma interfered with your usual activities (e.g. housework, work/school etc? (663N)

ASTHMA 3: smoking status in teenagers

The context of ASTHMA 3 was a focus of the recent BTS/SIGN update, with new material and advice being presented on adolescents with asthma.2 In general, there are startlingly few studies about how to help people with asthma who smoke, considering that at least as many people with asthma smoke as in the general population. The limited evidence available does suggest that smoking increases both morbidity and mortality and that the usual ‘Step 2’ preventive therapy of 400 ?g beclometasone dipropionate equivalent daily is effectively neutralised by regular smoking.8

The Smoking, drinking and drug use survey of young people in England in 20109 reported that for the 11–15-year-old category, 27% of respondents had smoked tobacco at least once and 8% had smoked cannabis. While it should be an important step to ask about smoking in all people with asthma, it is particularly vital to enquire sensitively about this in teenagers to avoid the increased risk of persisting asthma.2 Although tobacco is the smoking of concern in most cases, cannabis is also a problem in teenagers and while we are as yet unsure about its effects on asthma (as this is also a research-poor area), like tobacco smoking it is an opportunity to provide advice and support to promote general health improvement.

The BTS/SIGN guideline also reflects on under diagnosis in adolescents, the effect of family behaviours, and strategies to engage teenagers at this difficult time of transition to adulthood. Key recommendations include working with teenagers to find the right inhaler for them and allowing teenagers to consult with their GP or nurse without parents.2

ASTHMA 6: asthma review

The current QOF guidance recommends the following essential components for an asthma review:1

  • symptom assessment
  • peak flow measurement
  • inhaler-technique assessment
  • consideration of an asthma action plan.

A concise account of a quality primary care asthma review can be found in Primary Care Respiratory Society-UK (PCRS-UK) opinion sheet no 23.10 A key recommendation from the 2011 BTS/SIGN guideline was the need to ensure that asthma review includes the appropriate use of both closed: ‘How many times have you used your reliever this week?’ as well as open: ‘Is your asthma under control’ questions about symptoms.2 The recommendation for closed questioning aligns with the QOF Advisory Committee advice on new indicators for the 2012/13 QOF. The Committee recommends that ASTHMA 6 is retired and replaced with: ‘The percentage of patients with asthma who have had an asthma review in the preceding 15 months that includes an assessment of asthma control using the 3 RCP questions' (see Box 1, below).11

Peak expiratory flow rate (PEFR) monitoring does not improve control in the same way as symptom monitoring,2 although it may help selected adult patients where they have a reduced perception of airways limitation. It is, however, helpful to have an annual record of FEV1 or PEFR when the patient is stable so that any significant decline can be detected and acted upon.

The BTS/SIGN asthma guideline also recommends recording exacerbations, adherence to preventer therapy, and reliance on relievers.2 In practice, there is an opportunity to monitor prescription issues, but it is important to be mindful that wastage through poor technique or underuse may not be picked up by monitoring what has been prescribed.

Although inhaled steroids are safe, and appropriate use prevents significant morbidity and mortality in children, side-effects are possible and the BTS/SIGN guideline now recommends growth (height and weight centile) monitoring at least annually in children with asthma.2

Annual review is usually adequate for people with controlled asthma as they are unlikely to exacerbate. Practices should consider how they stratify asthma severity in their own register and offer more frequent review for those who frequently exacerbate.2

Other QOF indicators related to asthma

Looking beyond the core asthma indicators, there are opportunities for practices to gain points by aligning asthma improvements to other QOF areas (see Table 2, below).

Has the QOF improved asthma outcomes?

It is difficult to assess whether the QOF has improved outcomes for asthma as the indicators do not measure disease management or outcomes and comparing practices using QOF points is difficult because there is often little variation in scores. The most important outcome in asthma is reduction in deaths, but this has not been achieved since the inception of QOF.5

A study published in April 2011 examined the effect of QOF on reducing health inequality and showed that emergency hospital admissions for asthma were not significantly associated with QOF achievement and that in general, the evidence was equivocal as to whether the QOF was influencing improvements in clinical care.16 A weak association was found between higher achievement on the QOF and lower admission rates for all conditions except asthma. It was also noted that the quality of care for certain non-incentivised activities declined. In asthma and heart disease, quality scores dropped for non-incentivised activities between 2005 and 2007.16 This is a reminder for us to look beyond the QOF, review our local population issues and limitations, and use the available evidence base as presented in this article to provide care that can result in satisfying outcomes for practitioners and patients.

Future QOF indicators

We now have evidence that asthma stands out among the other QOF disease indicators in failing to achieve key outcomes.16 It would therefore seem timely to include a measure of disease management. Incentivisation of evidence-based stop-smoking therapy would reduce the need for higher potency steroids,8 and for emergency healthcare12,17 and improve symptom control. Structured review, while currently incentivised in ASTHMA 6 will benefit from the addition of the RCP questions but could be developed further to deal with the nation’s problem of health inequality. Anxiety and depression is common in asthma, with a prevalence of up to 41%; people with severe and difficult-to-control asthma are particularly affected.3 Screening is currently recommended in other chronic diseases and is likely to benefit those at highest risk of poor outcomes. The review should be co-created with the patient and result in a written self-management plan—an intervention that is well evidenced and strongly recommended by key guidance, but has not been well implemented in primary care and is now overdue for inclusion in the QOF.

The PCRS-UK has recommended a new indicator to support the use of guidelines to improve diagnosis in primary care: ‘The percentage of patients, 5 years and over diagnosed as having asthma in whom the diagnosis of asthma has been made according to the criteria in the current BTS-SIGN guideline and clearly documented in the patient’s medical record within 3 months of the diagnosis having been first recorded, and the proportion of children reaching the age of 5 years after 1 April 2010 with an existing diagnosis of asthma who have had the diagnosis reviewed and criteria recorded within one year of becoming 5 years.’18

Table 2: Incentives for better asthma care in the other QOF indicators1
No. Indicator Points Payment stages Improvement project
SMOKING 3
The practice can produce a register of patients with asthma, excluding patients with asthma who have been prescribed no asthma-related drugs in the preceding 12 months
30
  • Smoking is as common in people who have asthma as in the general population.12 Review smoking status at every asthma review and after every exacerbation and offer NICE recommended evidence-based stop-smoking support that includes pharmacotherapy and regular review
  • A 1% increase in smoking prevalence in a GP surgery population is associated with a 1% increase in admissions for asthma.13
SMOKING 4
The percentage of patients aged 8 years and over diagnosed as having asthma from 1 April 2006 with measures of variability or reversibility
30 40%–80%
EDUCATION 10
The percentage of patients with asthma between the ages of 14 and 19 years in whom there is a record of smoking status in the preceding 15 months
3 40%–80%
  • 90% of asthma deaths are considered to be avoidable.5 An admission to hospital for asthma should trigger an SER as a ‘near-miss’ incident. While these patients may be under specialist care, review of primary care factors such as ongoing support with smoking cessation, adherence to therapy, and inhaler technique should be considered.
Quality and productivity
QP1–QP5
The percentage of patients with asthma who have had an asthma review in the preceding 15 months
28 40%–70%
  • Much of the cost in asthma is due to prescribing and there is scope to reduce wastage and promote prescribing appropriate to disease severity. Around 30%–50% of patients who have their prescriptions dispensed do not take them14
  • Patients stepped up to higher potency medications can be stepped down again once good control has been achieved2
  • Promote self-management, ensuring compliance and good inhaler technique2
  • Stop prescribing enteric-coated prednisolone for exacerbations. Plain white prednisolone is significantly cheaper and does not cause more gastric symptoms.15
Quality and outcomes framework; CHD=coronary heart disease; TIA=transient ischaemic attack; COPD=chronic obstructive pulmonary disease; CKD=chronic kidney disease; RCGP=Royal College of General Practitioners; SER=significant event review

Practical support for GPs

The PCRS-UK19 supports GPs in providing better asthma care through publication of condensed and relevant materials written by GPs and primary care nurses who understand the conflicting priorities and demands of general practice. A brief multiple-choice test on the 2011 BTS/SIGN guideline is available on the PCRS-UK website to help identify the learning needs within your practice.

Conclusion

Respiratory disease, and asthma in particular, is a significant burden in practice. Quality care is good for patients and is cost effective. In 2011/12 there has been ‘no change’ in the QOF for asthma, but within each indicator there are opportunities to improve diagnosis, deal with the causes of poor outcomes, and give patients control over their symptoms and condition.

  • The introduction of QOF has failed to translate into improved outcomes for asthma possibly due to a lack of any outcome measures
  • GP commissioners can audit emergency asthma admissions and benchmark them per practice to look for any marked variation or examine the data on the practice-based commissioning comparators website
  • Public health could be asked to look for any demographic factors that could be associated with variations in admission rates and identify interventions to address these
  • Adherence to medication and proper use of inhalers is crucial so local formularies should include a range of types of inhalers, but identify the costs of each as there are marked variations
  • Targeted and proactive smoking advice for people with asthma will help reduce the healthcare costs of COPD and the burden of morbidity in future years
  • Tariff prices for respiratory outpatient = £232 (first), £109 (follow up).a
  1. British Medical Association. NHS Employers. Quality and outcomes framework guidance for GMS contract 2011/12. London: BMA, NHS Employers, 2011. Available at: www.bma.org.uk/employmentandcontracts/independent_contractors/quality_outcomes_framework/qofguidance2011.jsp
  2. British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. SIGN 101. Edinburgh: SIGN, 2011. Available at: www.brit-thoracic.org.uk/guidelines/asthma-guidelines.aspx
  3. Department of Health. An outcomes strategy for chronic obstructive pulmonary disease (COPD) and asthma in England. London: DH, 2011. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_127974
  4. Department of Health website. Quality, innovation, productivity and prevention (QIPP). www.dh.gov.uk/en/Healthcare/Qualityandproductivity/QIPP/index.htm (accessed 23 August 2011).
  5. Royal College of Physicians website. National review of asthma deaths. www.rcplondon.ac.uk/resources/clinical-resources/national-review-of-asthma-deaths (accessed 23 August 2011).
  6. Association of Public Health Observatories website. APHO general practice profiles. www.apho.org.uk/PRACPROF/ (accessed 23 August 2011).
  7. National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease: management of chronic obstructive pulmonary disease in adults in primary and secondary care. Clinical Guideline 101. London: NICE, 2010. Available at: www.nice.org.uk/CG101
  8. Tomlinson J, McMahon A, Chaudhuri R et al. Efficacy of low and high dose inhaled corticosteroid in smokers versus non-smokers with mild asthma. Thorax 2005; 60 (4): 282–287.
  9. The Information Centre, National Statistics. Smoking, drinking and drug use survey of young people in England in 2010. London: National Centre for Social Research, 2011. Available at: www.ic.nhs.uk/statistics-and-data-collections/health-and-lifestyles-related-surveys/smoking-drinking-and-drug-use-among-young-people-in-england/smoking-drinking-and-drug-use-among-young-people-in-england-in-2010
  10. Primary Care Respiratory Society UK. PCRS-UK opinion no 23: asthma review. PCRS, 2008. Available at: www.pcrs-uk.org/opinions/asthma_review_final.pdf
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  15. UK Medicines Information. Is there any evidence to support the use of enteric coated (EC) over uncoated prednisolone tablets? London and South East Regional Medicines Information Service, 2010. Available at: www.nelm.nhs.uk/en/NeLM-Area/Evidence/Medicines-Q--A/Is-there-any-evidence-to-support-the-use-of-enteric-coated-over-uncoated-prednisolone-tablets/
  16. Dixon A, Khachatryan A, Wallace A et al. The quality and outcomes framework (QOF): does it reduce health inequalities? NIHR Service Delivery and Organisation Programme, 2010. Available at: www.sdo.nihr.ac.uk/files/project/SDO_FR_08-1716-207_V01.pdf
  17. McLeish A, Zvolensky M. Asthma and cigarette smoking: a review of the empirical literature. J Asthma 2010; 47 (4): 345–361.
  18. Primary Care Respiratory Society website. Quality and outcomes framework. www.pcrs-uk.org/policy/qof.php (accessed 23 August 2011).
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