The British Thoracic Society (BTS) guidelines1 (below) are already well known and widely available, so these tend to be the standards against which we judge our local asthma guidelines. However, work still needs to be done for them to be fully implemented.
|Chart 1 from 'The British Guidelines on Asthma Management: 1995 review and position statement' (reproduced from 'Thorax' 1997; 52: p.S11, by kind permission of the BMJ Publishing Group)|
Part of the problem with a chronic disease is identifying the population.
Many, but not all of us, have clinical computer systems which have disease codes linked to patient records. But as long as we have paper records in addition to the computer system, these will often be incomplete.
Certainly, we faced these problems in my practice when trying to update our own 'asthma register', and to a certain extent there was no substitute for pulling out the notes.
We started by searching for all codes that related to asthma. Thereafter, a search for patients on asthma-related drugs but excluding those recorded as having asthma, yielded another group.
These, however, needed to be checked, as there are other instances where patients might be prescribed these drugs. Some could be excluded or included from personal knowledge, whereas others had to be reviewed with the notes.
Coding problems cause difficulties, especially in separating out the COPD population. In some cases the diagnosis may not even be clear from the records and has to await further consultations.
Having an accurate database gives us better control over call and recall, as well as allowing us to audit our adherence to the guidelines. This is vital if current guidelines are to be followed, but all the more so when new approaches or changes are subsequently introduced.
The chronic disease management inducements help to concentrate the mind on regular asthma audit. I have found this audit process useful not only in encouraging adjustment and improvement of the clinical approach, but also in encouraging better and more comprehensive data collection and recording.
It is amazing how simple and limited the questions need to be if an audit is to be applicable over a district, region or nationally. Good data collection and management seem crucial to improving the quality and usefulness of audit, as well as fostering !etter clinical decision making.
As with all other guidelines, it is impossible to introduce asthma guide-dlines without including fully all of those involved in managing patients with asthma. This includes all of the doctors (partners, assistants, locums, registrars, and preregistration house officers), the nursing staff, and probably the administrative staff who may be calling people into the asthma clinic or producing repeat prescriptions.
Ideally, the introduction of a guideline involves local collaboration with hospital specialists, perhaps a pharmaceutical advisor, and maybe a specialist liaison nurse, as well as GP colleagues.
Often, these days, this may be through the PCG, although a local asthma interest group or cooperative may form an alternative focus for the development.
With the BTS guidelines the steps of treatment are fairly clear-cut, but, at a local practice level, clinicians may wish to select certain drugs and preferred modes of delivery.
The whole practice team needs to be involved in, and committed to, the development of practice guidelines. Not only that, but they also need to follow the guidelines.
It may be helpful to have a reminder to hand during the consultation. We have a colour-coded folder for guidelines and protocols on each desk.
Prodigy is also likely to help in this respect, being even more accessible during the consultation. I have not yet used this, but hope that the slight local variations in emphasis can be programmed into the system, where the evidence allows this.
Many asthma sufferers are willing to carry on with quite severe symptoms and functional limitations. They may happily ask for repeat prescriptions by post or in person, and it is up to us to spot the need for an improvement in their therapy and to offer them that opportunity.
The easiest time to pick up such patients is when they request repeat prescriptions. With a good system, either manual or computer based, this is fairly straightforward.
We take a detailed look at drug usage and look for excessive use of bronchodilators, especially where 'preventers' are being under-used. These patients certainly might benefit from a review of their therapy in light of the current guidelines.
If a practice runs an asthma clinic, such review is potentially even easier. The asthma nurse can work through the register of patients, recalling them as necessary.
In theory, perhaps, the monitoring of repeat prescriptions should pick up the most needy patients and those on regular medication, while those who do not ask for any medication are likely to have the least serious symptoms.
The drawback of any specialist clinic, however, is the deskilling effect that it can have on other practitioners in the practice, and it is important that we are all kept up to date with current trends and developments.
Decisions may well be made locally on first-choice therapies, based on effectiveness and cost. In our practice, for instance, the first-choice inhaled steroid is beclomethasone from an aerosol, via a spacer if necessary.
Many factors may, however, influence decisions on such prescriptions. These include:
- The ability of the patient to use a particular type of device
- A desire to keep the delivery system the same for all the administered medication
- The individual sensitivities or preferences of the patient.
There needs to be flexibility around a basic framework.
A new factor that will affect this area of prescribing over the coming months is replacement of CFCs in aerosols by the new 'ozone friendly' propellants. Some may require smaller doses to achieve the same effect.
Step 3 of the BTS guidelines can be approached by increasing the inhaled steroids or by adding in a long-acting inhaled bronchodilator. Greening et al2 showed that it was more effective to add a long-acting inhaled bronchodilator than to double the dose of the inhaled corticosteroid. This is the approach we have adopted.
The advent of a new group of drugs, the leukotriene receptor antagonists, since the last BTS guidelines leaves us with a dilemma. Have we enough evidence of their effectiveness to add them to an evidence-based management guideline? If we have, then where do we position them?
As yet the randomised controlled trials that are complete only compare with placebo. A recent MeRec Bulletin5 suggests that leukotriene receptor antagonists should only be prescribed 'by those GPs with specialist knowledge in the area of respiratory disease', in accordance with local guidelines, after other proven treatments have been tried.
Various inhaled preparations are available in combined form. This does go against what we were taught in medical school, as it prevents optimisation of doses of medication for the individual patient.
They do, however, have a role in certain situations:
- When medication is stable, their use can reduce the number of inhalers or the volume of nebulizer solution that the patient has to take each day (also reducing the number of prescription items).
- In poor compliers: we all have asthma patients who will not take their 'preventer' while taking far too much bronchodilator and not adequately controlling their symptoms. Here, the use of a combination of steroid and bronchodilator can result in improvement to the satisfaction of both doctor and patient, while decreasing the total use of bronchodilator.
There is evidence3,4 that self- management plans are helpful in the management of asthma, and they are recommended in the BTS guidelines.
We produce these in an individual form, using a mail-merge facility on our EMIS system, which includes recommendations based on various percentages of the patient's target peak flow.
The concept of considering a reduction in the dose of 'preventer' after a prolonged period of good control is as important to the current guidelines as is stepping up as required.
The management of asthma is improving palpably. We have better and better treatments at our disposal with which to help our patients to manage their condition.
The application of asthma management guidelines in practice can result in better control than ever before.
- British Thoracic Society, National Asthma Campaign, Royal College of Physicians of London et al. The British Guidelines on Asthma Management: 1995 Review and Position Statement. Thorax 1997; 52: S1-S21.
- Greening AP, Ind PW, Northfield M, Shaw G, Added salmeterol versus higher-dose corticosteroid in asthma patients with symptoms on existing inhaled corticosteroid. Allen & Hanburys Limited UK Study Group. Lancet 1994; 344 :219-24.
- Neville RG. Patient education and guided self-management plans. Respir Med 1996; 90: 385-6.
- Lahdensuo A, Haahtelon T, Herrala J et al. Randomised comparison of guided self-management and traditional treatment of asthma over one year. Br Med J 1996; 312: 748-52.
- Leukotriene antagonists: new drugs for asthma. MeReC Bull 1999;10(1).