Effective practice management of patients with asthma is one of the 10 clinical domains in the new GMS contract.1 Out of a total 1050 quality points, a practice is able to earn 72 from optimising patient care in asthma, an area in which investment of time and resources is particularly rewarding because of the dividends paid in improving patients’ quality of life.
The domain consists of seven indicators (Table 1, below). For the coming year each point represents £75 and the maximum threshold is the percentage that, if achieved, will obtain maximum payment. Good administrative support and an awareness by all members of the practice team that they have an important role in gathering and recording data as well as in patient management are critical to achieving quality points.
|Table 1: Clinical indicators for asthma|
|Disease/indicator no||Clinical indicator||Points||Maximum threshold|
|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 past 12 months||7|
|Asthma 2||The percentage of patients age 8 years and over diagnosed as having asthma from 1 April 2003 where the diagnosis has been confirmed by spirometry or peak flow measurement||15||70%|
|Asthma 3||The percentage of patients with asthma between the ages of 14 and 19 years in whom smoking status has been recorded in the previous 15 months||6||70%|
|Asthma 4||The percentage of patients age 20 years and over with asthma whose notes record smoking status in the past 15 months, except those who have never smoked where smoking status should be recorded at least once||6||70%|
|Asthma 5||The percentage of patients with asthma who smoke, and whose notes contain a record that smoking cessation advice has been offered within the past 15 months||6||70%|
|Asthma 6||The percentage of patients with asthma review within the past 15 months||20||70%|
|Asthma 7||The percentage of patients with asthma aged 16 years and over who have had influenza immunisation in the preceding 1 September to 31 March||12||70%|
The asthma clinical indicators
Documenting patients’ disease and smoking status is an important element in the domain and much of this information should already be on the practice computer system.
Records – Asthma 1
Repeat prescribing data represent a useful source of information to identify all patients with asthma who are currently receiving or who have recently received treatment.This can be gathered by administrative staff, and recorded on the computer with a Read code.
One problem is that patients identified may have a ‘mixed bag’ of respiratory illnesses and any list generated this way will have to be sorted by a clinician and may need to involve individual patient review.
Initial management – Asthma 2
Making an accurate diagnosis in both children and adults is a key indicator and one on which the other indicators in the domain are built. With children, testing lung function parameters is only one aspect of the diagnosis of asthma, with clinical symptoms such as recurrent cough and wheeze being important.
Testing by peak flow or spirometry is particularly important in adult patients where the diagnosis may be confused with other respiratory illness. Here, the objective will be to hone diagnosis and ‘sort’ patients into disease groups.
The asthma domain refers to spirometry and peak flow measurements, but few practices have a spirometer and those that do find that it is most effective when combined with metacholine challenge,2 a measure many GPs may feel is too intrusive in primary care.
Single peak flow measurements are inaccurate,3 so the best approach with adults and children may be to prescribe peak flow meters and arrange for serial measurements to be performed at home for analysis later at the practice. Spirometry is also specified to confirm diagnosis in the chronic obstructive pulmonary disease domain, so practices that do not already have this equipment may need to consider investing in it.
Ongoing management – Asthma 3, 4, 5
Indicators 3, 4 and 5 are all concerned with the smoking status of patients. The domain, following the British Guideline on the Management of Asthma, identifies smoking as a major risk factor.4
Maternal antenatal smoking and parental smoking are risk factors for childhood asthma, increasing both frequency and severity. The British Guideline on the Management of Asthma highlights the fact that teenage smoking more than doubles the risk of persistent asthma developing. 4 This is in addition to the lifetime risks from smoking-related diseases. The indicators represent a challenge for GPs because teenagers are a notoriously difficult group to reach, let alone advise. Perhaps closer engagement with the school health services would be one way to gather information and give advice.
For adults, stopping smoking may reduce severity of asthma, and there will be benefits to other family members. Many indicators in the new contract provide the opportunity to ascertain patients’ smoking status and offer interventions. A key measure will be smoking cessation advice for adults and teenagers. Partnership with agencies that offer smoking advice will be beneficial and I suspect that prescribing anti-smoking treatment will play a part.
Indicator 3 recognises that teenagers are particularly at risk, not just because they are developing harmful lifetime habits but because of the specific risks from smoking.5 Evidence also backs the focus on adult smoking and advice on cessation.6
Practices need to check and record the smoking status of all patients with asthma from the age of 14 years. Up to 19 years of age this should be done annually (the 15-month period allows a ‘buffer’); after that age, if the patient has been recorded as a nonsmoker no further data on smoking are needed.
For all adult smokers with asthma, smoking status needs to be checked at the same regular intervals throughout life and they should be offered cessation advice, and this fact should be recorded. Some tact may be required when asking younger patients if they smoke as many will attend with a parent and may not be totally open about smoking status.
Annual review – Asthma 6
Annual reviews are a requirement of indicator 6, but no particular structure is defined, nor does the indicator specify that reviews should be performed by any particular member of staff. Encouraging patients, particularly younger ones who may often be fairly fit, to attend for check-ups is a significant problem.
In most cases reviews will be delegated to nursing staff, but phlebotomists could be trained to do some of the physiological measurements such as peak flow and spirometry, while reception staff could confirm the basic data. It is important to ensure the right skill mix so that issues are identified and dealt with at the right level.
Structured review either by nurse or doctor offers the most favourable outcomes.7 However, to achieve targets, practices will probably need to combine nurse-led, programmed reviews with opportunistic reviews.
Good practice would involve the use of guideline-led interactions ideally using computer templates, and these are readily available from software suppliers or user groups.
Such parameters as general health, asthma control, use of medication, inhaler technique, and lifestyle factors and weight are important (Box 1, below). Spirometry or a review of peak flow readings should also be carried out.
|Box 1: Essential features of annual review for asthma|
Positive structured review rather than opportunistic interventions is associated with less school or work absence, fewer exacerbations and better symptom control. Recent studies confirm the importance of this, particularly with respect to children.8 Features of effective annual review are listed in the British Guideline on the Management of Asthma,4 and the importance of patient education is highlighted. Useful materials can be obtained from the National Asthma Campaign (www.asthma.org.uk).
Although the domain makes no mention of individual treatment plans, nor a policy of adherence to practice or external guidelines, these are proven quality markers and should be considered. 9
Flu immunisation – Asthma 7
Indicator 7 relates to influenza immunisation. Historically, the NHS and primary care organisations have encouraged GPs to target groups of patients for flu immunisation. These have included those with significant respiratory disease, heart disease, immune disorders or deficiency, diabetes, other chronic disease and older people. There is good evidence for some of this.
With regard to asthma patients, however, the evidence is less clear, particularly for those with mild to moderate symptoms and those in the younger age group. Inclusion of the whole – over 16 years – asthma group within the indicator may not have a firm evidence base.10
Again, as much of the population will be fairly young and usually fit there are likely to be difficulties in encouraging patients to attend for immunisation. Key elements in a successful campaign would include providing suitable educational material, continuing reminders from all practice staff, and vaccination clinics that are convenient and efficient.
I suspect that this is going to be one of the hardest indicators to meet. However, if patients do attend, it may represent a useful opportunity to record treatment and data about the patient.
The indicators in the asthma domain represent a compromise between easily collectable data and markers of quality care. With the possible exception of the influenza indicator, they are relatively uncontentious.
It is interesting that other markers such as hospital admission rates, steroid to bronchodilator prescribing ratios and more advanced markers of patient education are not used. However, these are all more complex and subject to more variability in their interpretation.
Practices need to start preparing now for the new contract by establishing systems and starting data collection.
- Investing in General Practice:The New General Medical Services Contract. http://www.bma.org.uk
- Taylor DR. Making the diagnosis of asthma. Br Med J 1997; 315: 4-5 (editorial).
- Higgins BG, Britton JR, Chinn S et al. The distribution of peak flow variability in a population sample. Am Rev Respir Dis 1989; 140: 1368-72.
- Scottish Intercollegiate Guidelines Network and The British Thoracic Society. British Guideline on the Management of Asthma. Thorax 2003; 58(Suppl 1).
- Rasmussen F, Siersted HC, Lambrechtsen J et al. Impact of airway lability, atopy and tobacco smoking on the development of asthma-like symptoms in asymptomatic teenagers. Chest 2000; 117: 1330-5.
- Eisner MD,Yelin EH, Henke J et al.Environmental tobacco smoke and adult asthma.The impact of changing exposure status on health outcomes. Am J Respir Crit Care Med 1998; 150: 170-5.
- Charlton I, Charlton G, Broomfield J, Mullee MA. Audit of the effect of a nurse run asthma clinic on workload and patient morbidity in a general practice. Br J Gen Pract 1991; 41: 227-31.
- Glasgow NJ, Ponsonby AL, Yates R, Beilby J, Dugdale P. Proactive asthma care in childhood: general practice based randomised controlled trial. Br Med J 2003; 327: 659-63.
- Gibson PG, Powell H, Coughlan J et al. Selfmanagement and regular practitioner review for adults with asthma (Cochrane Review). In: The Cochrane Library Issue 3. Oxford: Update Software, 2001.
- Cates CJ, Jefferson TO, Bara AI, Rowe BH. Vaccines for preventing influenza in people with asthma (Cochrane Review). In: The Cochrane Library Issue 3. Oxford: Update Software, 2001.