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The editorial content below has been developed solely between Guidelines in Practice and the expert author.

holmes steve

Guest Editor—Dr Steve Holmes

GP, Park Medical Practice, Shepton Mallet 

We are all aware of the difficulties, problems in delivery, and variations in quality of care highlighted by the  National review of asthma deaths.2The audit points below are intended to be quick to perform and address not only the clinical aspects, but also our understanding of the systems that we work in and the people that we work with. I hope you enjoy them!

Although clinicians provide the best service they can, we are all aware of the difficulties, problems in delivery, and variations in quality of care for asthma highlighted by NHS RightCare1 and, in particular, by the UK National review of asthma deaths (NRAD, 2014).2

Practitioners are encouraged as part of their continuing professional development and revalidation to engage in quality improvement activity. This email offers a variety of audit ideas for reviewing and improving asthma care. It is meant to help improve your own care, rather than for you to reflect and advise on others’ care; so consider the points below that are relevant to your own individual working environment.

1. Long-acting beta2‑agonists should be used in combination with an inhaled corticosteroid2,3

The NRAD data found that at least 3% of people who died from asthma were still prescribed a long-acting beta2‑agonist (LABA) without inhaled corticosteroid (ICS).2

Audit action point

Perform a search of all people with a diagnosis of asthma who were prescribed an inhaled LABA within the last year that was not in combination with an ICS.

In an unpublished clinical action in my own area, approximately two patients per 10,000 population were identified as falling into this category. The case notes can be pulled easily and action taken to eradicate this problem.

2. Personalised asthma action plans are important2,3

Personalised asthma action plans (PAAP) are recognised as being important in the care of people with asthma, and national guidance has recommended providing patients with PAAPs, but the NRAD found that in only 23% of the patients who died from asthma was there a record of them having been provided with a PAAP.2,3

Audit action points

In a non-computerised environment audit the next 10 people who have been seen before and are being reviewed: 

  • is there clear documentation that they were given a plan?
  • does the patient remember being given a plan?
  • are your results acceptable?

If the environment is computerised, look at all the patients in the practice to see how many were given a PAAP in the last year: 

  • if some were not, what actions can you and your team take—and when will you need to review these patients?

3. Frequent use of rescue medication is associated with increased risk of death2

Excessive use of short-acting beta2 -agonist (SABA) reliever inhalers is associated with poor asthma control and increased risk of asthma death.2

Audit action point

In a non-computerised environment, get a print-out of all prescriptions from a sample of (say) 10 patients from the GP practice in the last 15 months, to see whether in review the compliance and use of SABAs were clearly identified.

In a computerised environment, review all people who have been prescribed more than 12 SABAs in the last year and see if they have been well reviewed to assess why they are using rescue medication so frequently.

If the results are not good, what changes can you make to your practice and to those of your colleagues to demonstrate improvement—and when are you going to audit again?

4. Admission to hospital or A&E attendance for asthma are risk factors3,4

Admission to hospital or A&E attendance for asthma are risk factors that should trigger specialist review by a member of a specialist respiratory team.3,4

Audit action points

Identify those in your asthma population who have had unscheduled A&E attendance or admission for asthma over the last year. Review them as case-based reviews, i.e. with the team, discussing and documenting your views and actions that can be improved or addressed, considering: 

  • the routine care—review, compliance, concordance, medication usage, recording of peak flow, smoking habits, PAAP, etc
  • the acute event—whether there was contact with your team, quality of review by team, appropriateness of assessment and treatment
  • post event—was the patient invited for review to assess why the acute episode arose and how to prevent it? Have they been for a specialist review?

In a large group practice, 10 cases would provide an adequate sample to indicate how well care is going within your team and locality.

5. More than two courses of prednisolone should result in specialist review2

More than two courses of prednisolone for acute asthma in the previous 12 months should result in specialist review.2

Audit action point

Use a computerised search to identify any patients who have had three or more courses of prednisolone in the last year: 

  • how many of these patients have had specialist review?

The numbers will not be high: are there some who on a case-based review of the notes should be referred for more interventions?

Key findings from the National review of asthma deaths2

  • At least 3% of people who died from asthma were prescribed a LABA without ICS
  • In only 23% of the patients who died from asthma was there a record of them having been provided with a PAAP
  • From prescribing data on 165 people in the year before they died:
    • 39% were prescribed more than 12 SABA inhalers
    • 4% were prescribed more than 50 SABA inhalers
  • In the 12 months before they died:
    • 22% of people failed to attend for asthma reviews
    • poor adherence to medical advice was identified in 48%.

LABA=long-acting beta2-agonist; ICS=inhaled corticosteroid; PAAP=personalised asthma action plan; SABA=short-acting beta2-agonist.

6. Did not attend for review

Many of those who died from asthma (22%) did not attend either their practice or the specialist unit for review of their asthma. Many were smokers; some had coexisting mental health or drug abuse problems, or other physical problems.2

Audit action point

Take a sample of 10 people who have failed to attend for review: 

  • a case review of the notes for issues, and a clinician call to the patient, are often helpful for gaining an insight into why they have not attended—try to understand why a patient does not wish to attend rather than telling them why they must!

7. Use of ICS

Data from the NRAD showed that ICS usage was considered low in many of those people who died from asthma.2

Audit action point

Carry out a detailed review of the next 10 patients: 

  • can they use their inhaler?
  • are they using their inhaled as planned (i.e. with prescriptions provided)?

If the answer is ‘yes’ in all cases, well done. If, like for most of us, the answer is ‘sometimes’, spend time with your patient trying to understand why they do not want to use the treatment regularly. This approach can often help you and others work out the best ways to explain and negotiate with patients about appropriate use.

There are many more audits and quick quality improvement activities that could be done around asthma, but the ones above have a good grounding in the NRAD report and BTS/SIGN asthma guideline.2,3 Just as importantly, the audits should be quick to perform, make a real impact on the safety of patients with asthma, and help to improve the care you and the team already give.

Learning points

  • Long-acting beta2-agonists should be used in combination with an inhaled corticosteroid
  • Personalised asthma action plans are important
  • Frequent use of rescue medication is associated with increased risk of death
  • Admission to hospital or A&E attendance for asthma are risk factors
  • More than two courses of prednisolone should result in specialist review
  • Many of those who died from asthma did not attend for review
  • Use of inhaled corticosteroids was low in many people who died from asthma.

References

  1. NHS RightCare. The NHS atlas of variation in healthcare. Reducing unwarranted variation to increase value and improve quality. NHS, 2011. Available at: www.fingertips.phe.org.uk/profile/atlas-of-variation 
  2. Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) confidential enquiry report.London: RCP, 2014. Available at: www.rcplondon.ac.uk/projects/outputs/why-asthma-still-kills
  3. British Thoracic Society/Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. SIGN 153, updated 2016. Available at: www.brit-thoracic.org.uk/standards-of-care/guidelines/btssign-british-guideline-on-the-management-of-asthma/
  4. NICE. Asthma. Quality Standard 25. NICE, 2013. Available at: www.nice.org.uk/guidance/qs25