Dr Mark L Levy discusses the importance of assessing asthma control and medication, and ensuring that the patient knows when and how to seek help

Asthma is a common condition with 6% of the UK population currently on treatment.1 Asthma accounts for approximately 1400 potentially preventable deaths each year, about one-quarter of which occur in people under 60 years of age.1 Asthma is responsible for considerable levels of morbidity and uses significant healthcare resources,1,2 despite GPs averaging over 98% in the asthma indicators of the Quality and Outcomes Framework (QOF).3 In fact, while there were early improvements in quality of care for asthma after the QOF was introduced, these were not sustained in the long term.4,5 My personal opinion is that the lack of clear clinical asthma outcome indicators impedes the provision of good quality care.

The aims of asthma care are to:6,7

  • ensure patients are accurately diagnosed, optimally treated, and monitored systematically and at appropriate time intervals
  • provide patients with education aimed at ensuring effective self management through provision of written asthma action plans.

These aims are difficult to achieve in the average primary care consultation of 6–10 minutes.

The new NICE system for deciding on QOF indicators may result in the need for more research in the field of asthma.8 The system is directed at effective implementation of guidelines with more emphasis on clinical outcomes to measure efficacy, rather than the current system that measures processes or practice activity.8

Thresholds and changes

The asthma indicators and the payment thresholds remain unchanged in the 2009/2010 QOF document,9 see Table 1. They have stayed the same despite calls from experts and special interest groups10 to include indicators that reflect the effect of asthma on patients’ quality of life and morbidity.

Table 1: Asthma indicators in the quality and outcomes framework 2009/109
No. Indicator Points Payment stages

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 previous 12 months

4
ASTHMA 8

The percentage of patients aged 8 years and over diagnosed from 1 April 2006 as having asthma with measures of variability or reversibility

15 40–80%
ASTHMA 3

The percentage of patients between the ages of 14 and 19 years with asthma in whom there is a record of smoking status in the previous 15 months

6 40–80%
ASTHMA 6

The percentage of patients with asthma who have had an asthma review in the previous 15 months

20 40–70%
Total points 45

 

ASTHMA 1

Accurate diagnosis is vital to ensure appropriate treatment and facilitate access to educational materials and support networks, such as the UK charity Asthma UK (www.asthma.org.uk)11 However, as there is no single test available to confirm a diagnosis of asthma, one of the biggest challenges faced by healthcare professionals is maintaining an accurate asthma register.

The latest version of the British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN) asthma guideline suggests that an asthma diagnosis is made on high, medium, or low probability based on the patient’s history and clinical findings.7 Box 1 details the clinical features that are indicative of asthma in children and adults. The principles of diagnosis in adults are summarised by the General Practice Airways Group (GPIAG).12–14

Asthma should be considered in any patient with recurrent episodes of respiratory symptoms:

  • cough
  • wheeze
  • shortness of breath.15

The likelihood of asthma is increased if the patient’s symptoms are brought on by exposure to triggers such as pollen, viral infection, fumes, dust, smoke, and/or they are associated with exercise or laughter. A positive personal or family history of atopy or allergy also increases the probability of asthma, and in adults with new onset or resurgence of asthma symptoms, occupational causes should be considered. Occupational asthma is the only form of this disease that can be cured and is often preceded by the onset of occupational rhinitis, which could be misdiagnosed as a different form of allergic rhinitis7,15,16

The diagnosis may take a number of GP consultations to confirm. In those patients who are presumed to have asthma and are prescribed medication, follow-up assessment is essential to confirm or refute the diagnosis.7

Problems with ASTHMA 1

The criteria for defining asthma for this indicator potentially puts patients at risk. By only reviewing those patients prescribed medication in the previous 12 months, patients with uncontrolled asthma who do not adhere to their treatment are missed unless they have an attack and therefore seek medical advice.

Box 1: Clinical features that indicate a high or low probability of an asthma diagnosis in adults and children7

1) Features that indicate a high probability of asthma in adults

  • Symptoms (cough, wheeze, breathlessness, or chest tightness):
    • worse at night and in the morning
    • in response to exercise, allergen exposure, and cold air
    • after taking aspirin or beta blockers
  • History of atopic disease
  • Family history of asthma or atopic disease
  • Widespread wheeze
  • Evidence of airway narrowing

(NB: Normal spirometry when free of symptoms does not exclude asthma)

2) Features that indicate a low probability of asthma in adults

  • Cough in the absence of wheeze or breathlessness
  • Prominent dizziness, light headedness, peripheral tingling
  • Repeatedly normal clinical examination even when symptomatic
  • No evidence of airway narrowing when symptomatic
  • Voice disturbance
  • Symptoms with colds only
  • Chronic productive cough
  • Significant smoking history (>20 pack years)
  • Cardiac disease

3) Clinical features that indicate a high probability of asthma in children

  • More than one of the following symptoms: wheeze, cough, difficulty breathing, and chest tightness; particularly if these symptoms:
    • are frequent and recurrent
    • are worse at night and in the early morning
    • occur in response to, or are worse after, exercise or other triggers, such as exposure to pets, cold or damp air, or with emotions or laughter
    • occur apart from colds
  • Personal history of atopic disorder
  • Family history of atopic disorder and/or asthma
  • Widespread wheeze heard on auscultation
  • History of improvement in symptoms or lung function in response to adequate therapy

4) Clinical features that indicate a low probability of asthma in children

  • Symptoms with colds only, with no interval symptoms
  • Isolated cough in the absence of wheeze or difficulty breathing
  • History of moist cough
  • Prominent dizziness, light-headedness, peripheral tingling
  • Repeatedly normal physical examination of chest when symptomatic
  • Normal PEF or spirometry when symptomatic
  • No response to a trial of asthma therapy
  • Clinical features pointing to alternative diagnosis
PEF=peak expiratory flow

ASTHMA 8

The new BTS/SIGN guideline advocates the use of spirometry to assess lung function,7 rather than peak expiratory flow (PEF), which is not as accurate and is less reliable. However PEF measurements are more convenient and serial readings are possible.7 The diagnosis of variable airflow obstruction can then be made at a later appointment. Those performing spirometry tests in primary care do, however, need appropriate training and experience.17 Asthma cannot be ruled out when an asymptomatic patient has a normal lung function test and, therefore, repeated tests are needed to confirm or refute the diagnosis.7,9

ASTHMA 3

It is very important to encourage people with asthma to stop smoking. Smoking has been implicated as a causative factor in young children whose parents smoke. Furthermore, exposure (either passive or active) is a trigger that aggravates asthma, and is a cause of the majority of cases of chronic obstructive pulmonary disease. For further information see the GPIAG opinion sheet on smoking cessation (www.gpiag.org/opinions/smokingcessation_final.pdf) and the IMPRESS website (www.impressresp.com).

ASTHMA 6

Asthma is a lifelong chronic condition, and although some people do go into remission, most do not outgrow their disease. It, therefore, seems strange that the QOF only focuses on those patients who have had a prescription in the previous 12 months. An asthma review should include an assessment of the patient’s understanding of their asthma and its treatment, and more importantly, their ability to monitor their asthma control.7,9

The main problem with ASTHMA 6 is the lack of specific clinical targets to monitor. As a result, there is the possibility that the ‘box will be ticked’ without a structured review actually taking place.

A structured asthma review should include:6,7

  • assessment of the patient’s current asthma control
  • assessment of the patient’s medication
    • is the drug/device and frequency appropriate?
    • is the medication being used?
    • can the patient use their inhaler?
  • does the patient understand what to do if their asthma gets out of control and when to call for help (see Asthma UK www.asthma.org.uk for example action plans)?

On the basis of the review, asthma management is then either continued or revised according to the findings.

Reducing future risk of exacerbations
An effective asthma review should include an assessment of the patient’s current asthma control. Control of asthma is the basis of the latest revision of the international Global Initiative for Asthma (GINA) guideline for asthma,6 and achieving good control is also emphasised in the BTS/SIGN guideline.7 If the patient has poorly controlled asthma, their medication should be optimised by changing the drug/device prescribed, or by increasing or adding new medication. In this way the healthcare professional can reduce the future risk of exacerbations.7

The BTS/SIGN guideline7 and the QOF9 both suggest that the Royal College of Physicians’ three questions should be used to assess the effect of asthma on patients’ lives:18

  • Have you had difficulty sleeping because of your asthma symptoms (including cough)?
  • Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness, or breathlessness)?
  • Has your asthma interfered with your usual activities such as housework, school, etc?

There are a number of alternative methods for assessing asthma control. The one I favour is the GINA control tool (see Figure 1) which has been validated against the asthma control test,:19 and which includes the RCP three questions, plus a measure of lung function, and also the patient’s need for rescue medication (a sign of poor control).

Assessment of asthma medication
An assessment of the patient’s medication is part of the asthma review. Many patients cannot use their inhalers properly—over 60% of people who use pressurised-metered dose inhalers are unable to operate them.20-22 Any patient whose asthma is partly controlled or uncontrolled should have their inhaler technique assessed before any medication is changed or added.21 Strangely, this has not been included in the QOF indicators for asthma. Furthermore, simply checking the prescribing record will help the clinician determine whether patients are collecting their medication or not, and also whether they are collecting excess reliever devices. A patient who collects more than six reliever inhalers in 12 months has probably got poor asthma control and needs a structured review.

Figure 1: Levels of asthma control6
Characteristic Controlled Partly controlled
(any present in any week)
Uncontrolled
Daytime symptoms None (two or less per week) More than twice per week

Three or more features of partly controlled asthma present in any week

Limitations of activities None Any
Nocturnal symptoms/awakening None Any
Need for rescue/‘reliever’ treatment None (two or less per week) More than twice per week
Lung function (PEF or FEV1) Normal <80% predicted or normal best (if known) on any day
Exacerbation None One or more per year One in any week
PEF=peak expiratory flow; FEV1=forced expiratory volume in 1 second
Used with permission from Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. www.ginasthma.org

Conclusion

Achievement of QOF points is not an end in itself. In order to make a difference to the lives of patients with asthma, GPs need to act on findings when performing a structured asthma review. Patients who are unable to use their inhaler device should be prescribed an alternative—one with which effective use has been demonstrated. Furthermore, it is essential that patients who state that their asthma is uncontrolled, in response to review questions, have their management optimised. This might mean a new drug, a new device, and/or a new or revised asthma action plan.

Key Points
  • Attaining QOF points does not necessarily equate with good asthma care
  • A large majority of patients (and healthcare professionals) cannot use inhaler devices properly
  • Assessment of patient inhaler technique is essential at every review
  • Structured asthma reviews take time
  • To prevent future risk of attacks, assess current asthma control
  • Use questionnaires or tools to assess asthma control
  • Take action to optimise self-management in patients with poorly controlled asthma
  • Provide self-management plans to all patients with asthma
  • Review all patients after an unscheduled GP consultation for asthma exacerbations
  • Regular audit is helpful to assess adherence to guidelines (see www.guideline-audit.com)

written by Dr David Jenner, NHS Alliance GMS contract/PBC Lead

  • Asthma accounts for 6% of all prescribed drugs
  • The QOF encourages asthma reviews but does not recognise any tangible asthma outcomes
  • Effective templates for structured asthma reviews could help improve asthma management
  • PBC groups could adapt the BTS/SIGN guideline into local care pathways
  • Local incentive schemes could build on these to help improve asthma care
  • Pharmacists could be commissioned to assist in asthma care through targeted medicine use review
  • Tariff prices: respiratory outpatient = £242 (new), £110 (follow up)a
  1. British Thoracic Society. The burden of lung disease. A statistics report from the British Thoracic Society. 2nd Edition. London: BTS, 2006. Available at: www.brit-thoracic.org.uk/LibraryGuidelines/BTSPublications/BurdenofLungDiseaseReports/tabid/164/Default.aspx
  2. Masoli M, Fabian D, Holt S et al; Global Initiative for Asthma Program. The Global Burden of Asthma: executive summary of the GINA Dissemination Committee report. Allergy 2004; 59 (5): 469–478.
  3. The Information Centre. The quality and outcomes framework 2008/09. www.ic.nhs.uk/qof (accessed 13 November 2009).
  4. Campbell S, Reeves D, Kontopantelis E et al. Quality of primary care in England with the introduction of pay for performance. N Engl J Med 2007; 357 (2): 181–190.
  5. Campbell S, Reeves D, Kontopantelis E et al. Effects of pay for performance on the quality of primary care in England. N Engl J Med 2009; 361 (4): 368–378.
  6. Global Initiative for Asthma. The global strategy for asthma management and prevention. GINA, 2008. Available at: www.ginasthma.org
  7. British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. SIGN 101. Edinburgh: SIGN, 2009. Available at: www.brit-thoracic.org.uk.
  8. Lester H, Majeed A. The future of the quality and outcomes framework. BMJ 2008; 337: a3017. Available at: dx.doi.org/doi:10.1136/bmj.a3017
  9. British Medical Association, NHS Employers. Quality and outcomes framework guidance for GMS contract 2009/10. London: BMA, 2009. Available at: www.nhsemployers.org/Aboutus/Publications/Documents/QOF_Guidance_2009_final.pdf
  10. Price D. Asthma, rhinitis and allergy. QOF Expert panel report. National Primary Care Research and Development Centre, 2007.
  11. Asthma UK. www.asthma.org.uk/ (accessed 13 November 2009).
  12. Small I. GPIAG Opinion 30: Diagnosis of asthma in adults. GPIAG, 2009. Available at: www.gpiag.org/opinions/diagnosis_asthma_adults_final.pdf
  13. Levy M, Thomas M, Small I et al. Summary of the 2008 BTS/SIGN British guideline on the management of asthma. Prim Care Respir J 2009; 18 (Suppl 1): S1–S16. Available at: dx.doi.org/10.3132/pcrj.2008.00067
  14. GPIAG. GPIAG summary guidance for primary care. www.gpiag.org/resources/summary_guidance.php (accessed 13 November 2009).
  15. Newman Taylor A, Nicholson P. Guidelines for the prevention, identification and management of occupational asthma: Evidence review and recommendations. London: British Occupational Health Research Foundation, 2004. Available at: www.bohrf.org.uk/downloads/asthevre.pdf
  16. Levy M, Nicholson P. Occupational asthma case finding: A role for primary care. Br J Gen Pract 2004; 54 (507): 731–733.
  17. Levy M, Quanjer P, Booker R et al. Diagnostic spirometry in primary care: Proposed standards for general practice compliant with American Thoracic Society and European Respiratory Society recommendations. Prim Care Respir J 2009; 18 (3): 130–147. Available at: www.thepcrj.org/journ/view_article.php?article_id=653
  18. Royal College of Physicians. Measuring clinical outcome in asthma: A patient focused approach. Pearson M, Bucknall C, editors. London: RCP, 1999.
  19. Thomas M, Kay S, Pike J et al. The Asthma Control Test (ACT) as a predictor of GINA guideline-defined asthma control: analysis of a multinational cross-sectional survey. Prim Care Respir J 2009; 18 (1): 41–49. Available at: dx.doi.org/10.4104/pcrj.2009.00010
  20. Corrigan C, Levy M, Dekhuijzen P, Crompton G, on behalf of the ADMIT Working Group. The ADMIT series—Issues in inhalation therapy. 3) Mild persistent asthma: the case for inhaled corticosteroid therapy. Prim Care Respir J 2009; 18 (3): 148–158. Available at: www.thepcrj.org/journ/view_article.php?article_id=634
  21. Broeders M, Sanchis J, Levy M et al. The ADMIT series—Issues in inhalation therapy. 2) Improving technique and clinical effectiveness. Prim Care Respir J 2009; 18 (2): 76–82. Available at: dx.doi.org/10.4104/pcrj.2009.00025
  22. Crompton G, Barnes P, Broeders M et al. The need to improve inhalation technique in Europe: A report from the Aerosol Drug Management Improvement Team. Respir Med 2006; 100 (9): 1479–1494.G