Katharine Abba, of the Liverpool PCAG, describes how the Mersey Asthma Care Record helped improve asthma management in general practice

The Mersey Asthma Care Record (figure 1) is based on a patient record card first developed at Aintree Chest Centre, Fazakerley Hospital during 1995. Liverpool Primary Care Audit Group worked with the asthma liaison nurses from the Royal Liverpool and Broadgreen University NHS Trust and Aintree Hospitals NHS Trust to adapt it for use in both primary and secondary care across Liverpool. A set of ready reckoner posters (figure 2) was also produced, at the same time as the record card, which allowed healthcare professionals to calculate peak flow levels more easily.

mersey asthma care record

Figure 1: The Mersey Asthma Care Record contains a peak flow/symptom diary, simple educational material, a list of useful contacts, and a template for the patient's personal written management plan. There is space at the back of the card where asthma attacks or treatment changes can be recorded. It is suitable for all asthma patients, over the age of 16, who use both reliever and preventer inhalers.The management plan uses both symptoms and peak flow readings. The advice given at different peak flow/symptom levels is based on the stages used in the 'credit card study' 5.

We decided to carry out an audit on the impact of introducing the card into primary care and provide practices with a means of evaluating their own asthma services. We had hoped that introducing the Mersey Asthma Care Record would have the following benefits:

  • Improve communication – there is considerable evidence that outcomes in the care of asthma patients are influenced by the effectiveness of communication between different groups of professionals and between professionals and patients 1.
  • Promote the use of management plans – British Thoracic Society (BTS) guidelines recommend that patients who use reliever and preventer inhalers for managing their asthma should be issued with a written management plan, and refer to the evidence available which details the benefits to patients 2, 3.
  • Ensure the availability of peak flow/symptom diaries – BTS guidelines recommend home peak flow monitoring for patients who:
  • have been in hospital because of their asthma
  • are on step three or above of the treatment guidelines
  • have brittle or life-threatening asthma
  • are poor perceivers of symptoms. Research has suggested that up to 60% of adults with asthma are poor perceivers of symptoms 4.

The three main audit tools used were:

  • Practice data collection
  • Patient questionnaires
  • Healthcare professional questionnaires

Forty five of the 102 Liverpool practices took part in the year-long project. The audit leads within practices were mainly practice nurses.

Practice managers and receptionists were also involved in the collection of data. A full-time audit assistant was on hand to help practices with data collection and results feedback.

Figure 2: Aintree Chest Centre/Sefton Health Asthma Management Plan 'Ready Reckoner'. Allows easy peak flow calculation.
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Practices completed a data collection sheet on receipt of the record cards and again six months later. The collective results for the 30 practices that were able to return re-audit data by the end of the project are shown in table 1 below.

There was an increase in the percentage of adults with asthma who were: prescribed preventer medication, reviewed in the past 12 months, provided with a management plan and recorded for smoking status (table 1). This is especially true for the number of patients provided with a management plan – perhaps because a management plan template was included in the record card.

Table 1: Baseline and 6 month re-audit data for the population involved in the study
 
Baseline
After 6 months
 
%
Sample Size
%
Sample Size
Patients with recorded asthma (of total list size)
6.9%
152,356
6.8%
156,834
Patients on preventer treatment (of those over the age of 16 and with recorded asthma)
69%
7,285
73%
7,159
Patients receiving an asthma review in the past 12 months (of those over the age of 16 and with recorded asthma)
53%
7,285

55%

7,159
Patients with a written management plan (of those over the age of 16 and with recorded asthma)
20%
7,285
27%
7,159
Patients with their smoking status recorded (of those over the age of 16 and with recorded asthma
80%
7,285
84%
7,159
Patients who are recorded as smokers (of those who over the age of 16, with recorded asthma and with a smoking status recorded)
37%
7,285
35%
7,159
Patients who have a Mersey Asthma Care Record (of those over 16 and with recorded asthma)
4.5%
7,285
11%
7,159

Computers and data recording

Two practices were not computerised and had to rely on paper records. In practices that were computerised, certain data was often not recorded on the system, for example, smoking status and dates of asthma reviews.This information had to be retrieved from the paper records. In many practices, staff did not have the expertise to run computer searches to retrieve the audit information.

Defining asthma

Defining asthma for the purposes of the audit was difficult. Many practices did not use the diagnosis screens on their computer system, so 'asthma' patients were defined as those who were prescribed regular bronchodilators. Many practices were therefore unable to distinguish between chronic obstructive pulmonary disease (COPD) and asthma for the purposes of the audit. Asthma management plans are not suitable for COPD patients. COPD sufferers do not always respond to inhaled steroids. The inclusion of COPD patients in the study therefore may have influenced the data for patients using management plans and inhaled steroids.

Patient questionnaires

Questionnaires were given to self-selecting patients before and six months after they received the record card. A section was included to assess patients' control and understanding of their asthma; 'before' and 'after' responses were compared to assess any changes. Patients' views and usage of the record cards were also included. Forty patients completed both sections of the questionnaire.

After 6 months

  • 80% (n=32) of patients said the record card was easy to use
  • 43% (n=17) said that their asthma had improved
  • 57% (n=23) said that they understood their asthma better
  • 100% (n=40) said that they would like to carry on using the card

Patients liked the cards and wanted to carry on using them. One patient commented that she was now more confident to go out, as she had not previously realised that she could carry her reliever with her in case of an emergency.

Although the numbers were too small for statistical analysis, the results suggested that using the record card improved patients' understanding and control of their asthma. This reinforced evidence that management plans are effective in reducing morbidity from asthma.

Towards the end of the project, a questionnaire was sent to the healthcare professionals who used the record cards. This was used to evaluate their views on the card's usefulness. Thirty two questionnaires were returned, all from practice nurses.

  • 100% (n=32) said that they thought the record card would benefit patients, the three main reasons given were:
  • helps with patient education (56%)
  • provides a clear management plan (22%)
  • assists with communication and continuity (19%).
  • 84% (n=27) said that the record card had made the care of patients easier for them
  • 56% (n=18) said that they had seen patients who were using the record card in both primary and secondary care.

Most practice nurses considered the record card was of benefit to patients and a valuable aid to patient care and education. More than half had seen patients using the card in both primary and secondary care, indicating that it is working as a communication tool. One in four responders said either that they would not have an alternative to the record card, or that the alternatives would be inferior.

Uptake of the record card was slow. Practice nurses and GPs were not always able to see their asthma patients as often as they wished and did not always have time to fill in a management plan.

Another reason given was the need to educate patients in stages. It may take one visit to teach a patient how to use a peak flow meter, another to teach them to keep a peak flow diary, and then another to introduce a management plan. It is therefore likely that the demand for record cards with management plans will increase as patients become better educated about their asthma and better able to use them.

It was decided that provision of the Mersey Asthma Care Record to primary care should be continued, and that the data items shown in table 1 should be considered as key items of data collection for continued asthma audit in primary care.

  1. Charlton I et al. Asthma at the interface: bridging the gap between general practice and a district general hospital. Arch Dis Child (1994) 70 (4): 313-8
  2. Aarne et al. Randomised comparison of guided self-management and traditional treatment of asthma over one year. Br Med J (1996) 312: 748-52
  3. The British Thoracic Society. British Guidelines on Asthma Management – 1995 Review and Position Statement. Thorax (1997) 52: Supp 1
  4. Kendrick A H et al. Accuracy of perception of severity of asthma: patients treated in general practice. Br Med J (1993) 307: 422-4
  5. D'Souza W et al. Community based medical care: trial of a 'credit card' asthma self-management plan. Eur Respir J (1991) 7: 1260-5

Guidelines in Practice, October 1998, Volume 1
© 1998 MGP Ltd
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