Doreen Cochrane outlines the winning initiative of the Guidelines in Practice Asthma Award 2007: an audit to identify if ICS dosing is in line with BTS/SIGN guidance
In 2005, healthcare professionals at the Cedar Practice in Hackney, London, undertook an audit of patients with asthma and their understanding of their condition. The practice also reviewed the prescribed medicines, and the appropriateness and safety of these prescriptions in line with the British Thoracic Society (BTS)/Scottish Intercollegiate Guidelines Network (SIGN) guideline1 on the management of asthma. Smoking cessation advice was also offered.
The audit was repeated in 2007 to assess the impact of procedures put into place following the initial review.
The aim of the audit was to improve the outcomes of patients with a diagnosis of asthma by ensuring that their dose of inhaled corticosteroid (ICS) was consistent with recommendations in current national and local guidelines,1 and that patients were managed at the lowest dose required to control their symptoms effectively.
Practice asthma management
Cedar Practice has an asthma prevalence rate of 5% for its patients. A diagnosis of asthma was made for 72 patients under the age of 18 years, which accounts for 24% of patients with asthma in the practice. Given the high percentage of patients who are children or adolescents, improvement of their care was a particular aim. Cedar Practice, like many others, has found it difficult to engage adolescent patients in attending asthma reviews and this was something we wanted to address.
Implementation of the audit
The team responsible for implementing the audit comprised three GPs, the PCT prescribing support pharmacist, and two practice nurses.
The practice has a particular interest in improving the overall treatment and management of patients with respiratory conditions, and in 2004 a practice register of asthma patients was set up. In addition, the two practice nurses and the PCT prescribing support pharmacist were trained in monitoring and treatment of asthma. The patient asthma register was used to recall patients for their annual reviews. All patients included in the audit had been prescribed one or more asthma drugs in the previous 12-month period.
The prescribing lead for the Cedar Practice invited the PCT pharmacist to provide a weekly asthma clinic to review individual patients and also advise on treatment options in line with the BTS/SIGN guideline. The clinical team decided an audit of current prescribing for asthma was needed.
The initial audit was conducted in 2005 using a proforma, which had been developed by the pharmacy adviser at City and Hackney Teaching PCT and members of the practice for use in this audit. It included:
- three questions that were used to monitor the patient’s subjective experience of how well their asthma symptoms were controlled (see below)
- a note of the BTS/SIGN guideline step used in managing their asthma (see below)
- the number of short-acting beta2-agonist inhalers collected in the previous 12 months
- smoking status.
Asthma patients were asked to provide graded responses to the following three questions. In the past week (month):2
- have you had difficulty sleeping because of your asthma?
- have you had your usual asthma symptoms during the day?
- has your asthma interfered with your usual activities (at work/school)?
BTS/SIGN stepped approach
The guideline from BTS/SIGN sets out a stepped approach to management of asthma patients. The steps are:1
- Step 1—mild intermittent asthma
- Step 2—regular preventer therapy
- Step 3—initial add-on therapy
- Step 4—persistent poor control
- Step 5—continuous or frequent use of oral steroids (not for use in children <5 years of age).
The guideline states that patients should begin at the step most appropriate to the initial severity of their asthma. If there is a poor response to treatment, the initial diagnosis should be reassessed.1
Improvements in care: adult asthma patients
The findings of the initial audit conducted in 2005 indicated that medicines used to manage symptoms in 21 of the 230 adult patients were not consistent with the current guideline from BTS/SIGN.1 Specifically, 20 patients who were managed at Step 2 were being prescribed an ICS at a dose of >800 ?g/day beclometasone or equivalent (without additional long-acting beta2-agonist). These patients were invited for review with their usual GP to assess their need to be moved up to Step 3 or to have their dose of ICS adjusted.
When the audit was repeated in January 2007, the results indicated that prescribing for all adult patients at the Cedar Practice was now consistent with the BTS/SIGN guideline.
Improvements in care: children and adolescents
The initial audit identified two adolescent patients who were being managed at high doses of ICS that exceeded the recommendations for their age. In view of the possible development of side-effects in children being treated with an ICS, including adrenal insufficiency, treatment for these patients was immediately reviewed as were recommendations from their specialist paediatrician.
While administration of medicines in children aged 15 years and under may have been appropriate in these cases, the general learning acquired from this process has alerted all practice staff to be aware of safety when prescribing ICS for children, including use of appropriate spacer devices for administration of medicines in patients aged under 15 years. Healthcare staff in the practice are now familiar with the recommendations made by BTS/SIGN for children under 5 years and children aged 5–12 years, and with prescribing of the new chlorofluorocarbon (CFC) -free beclometasone inhalers, which are prescribed by brand. This is in keeping with the recommendations made by the Medicines and Healthcare Products Regulatory Agency, as one of the CFC-free beclometasone inhalers currently available is not dose equivalent to the CFC-containing beclometasone products.
The re-audit in January 2007 indicated that all the children and adolescents receiving asthma medicines were now managed using the doses of ICS recommended in the national guideline.1 By providing a more teenage-friendly environment at the practice and making contact with this group using their mobile telephones, it has been possible to complete their annual reviews and provide them with an opportunity to learn about their health.
The practice has a relatively low prevalence of smoking among patients on the asthma register (22% in both audits), in part because of the younger age of the practice population.
The audit did not indicate poor control of asthma symptoms among patients who were current smokers when compared with patients who had never smoked or who had stopped smoking. Some recent research findings have indicated poorer long-term control of symptoms with ICS among asthma patients who smoke.3
The most recent audit in 2007 indicated that 98% of smokers were given advice about stopping. The audit did not consider ICS use in patients who had previously smoked.
Roll-out of the project
City and Hackney Teaching PCT has supported this initiative by developing local guidelines for the management of asthma in adults. The guidelines were developed in collaboration with the respiratory consultants at the Homerton University Hospital, and include details of how to increase and decrease the dose of ICS, as well as other aspects of monitoring of chronic disease and use of management plans. The results of the audit were presented as part of the launch of the local guidelines.
Other practices in City and Hackney Teaching PCT have learned of the success of the project and have extended invitations to conduct clinics and/or audit their practice. The project has therefore been contributing to the care of young people and adults throughout Hackney.
The results of a recent audit of accident and emergency admission rates among children and adults with asthma indicate they are higher in areas of deprivation, and that City and Hackney Teaching PCT has higher than average admission rates, particularly for children.4 Since the announcement of the Award, the PCT pharmacist has completed training as an Independent Pharmacist Prescriber, and hopes to develop interventions to reduce emergency admissions for children with asthma with a cluster of practices in east London. Clinicians at the Cedar Practice will also be developing their asthma clinics, as funding for the service was withdrawn by the PCT.
Further information on the audit procedures can be obtained by contacting Doreen Cochrane at email@example.com.
Collaboration between the PCT and Cedar Practice allowed for an innovative service development, which has had a positive impact on patient care. The initiative has contributed to safe and effective prescribing for young people and adults with asthma in our community.
- British Thoracic Society and the Scottish Intercollegiate Guidelines Network. British Guideline on the Management of Asthma. Edinburgh: SIGN, 2005.
- Pearson M, Bucknall C (editors). Measuring clinical outcome in asthma: a patient focused approach. London: Royal College of Physicians, 1999.
- Chalmers G, MacLeod K, Little S et al. Influence of cigarette smoking on inhaled corticosteroid treatment in mild asthma. Thorax 2002; 57 (3): 226–230.
- Asthma UK. Wish you were here. London: Asthma UK, 2008.G