Dr Dermot Ryan explains how the NICE quality standard for asthma is an opportunity for improving diagnosis and management

There are around 5.4 million people in the UK with a diagnosis of asthma.1 Historically, the incidence of asthma increased steadily until the turn of the century, but now appears to have levelled off.2 The number of recorded deaths has fallen from around 2000 annually in the early 1990s, to a current level of about 1200.3 Not all deaths recorded as asthma-related are caused by this condition, and this is currently under intensive review in the National review of asthma deaths, which will report at the end of 2013.4 In spite of the fall in asthma-related deaths, there is no room for complacency. Successive surveys demonstrate that the level of asthma control achieved is very poor and that patients experience a considerable degree of morbidity and impairment in quality of life as a result.5

The NICE quality standard for asthma (QS25; see www.nice.org.uk/guidance/qs25) points us in the right direction;1 understanding the statements and being guided by them presents us with an opportunity to deliver a quality service for our patients, and improve outcomes. It is worth commenting briefly on each individual quality statement; although they are numbered 1 to 11 they are interlinked and co-dependent.

Diagnosis

A correct diagnosis of asthma is critical: an incorrect diagnosis is likely to result in the patient receiving medication for a condition they do not have, while being deprived of treatment for a condition that may require intervention. This is a significant problem, as demonstrated by Starren et al in an audit of results from a centralised respiratory diagnostic service for primary care, published in the Primary Care Respiratory Journal.6 This audit showed that only around 30% of individuals with a diagnosis of definite asthma, and 11% of people with a diagnosis of probable asthma, actually had asthma (70% of those in the latter category had no evidence of airways narrowing).6 As mentioned earlier, the quality statements in QS25 are interlinked: so failure to gain control of asthma should initiate a review of the diagnosis.

Occupational asthma

The importance of diagnosing occupational asthma cannot be underestimated: it is the only form of asthma that can potentially be cured, by moving the worker to another environment away from the causative agent.1 The presence of this type of asthma should always be confirmed by a specialist, as treatment may require a change of occupation, invariably leading to economic disadvantage to the patient. A diagnosis of occupational asthma should be suspected if symptoms resolve on holidays or over weekends. Serial
peak-flow readings will assist in confirming a suspected diagnosis.7

Personalised action plans

Written personalised action plans (or self-management plans)7 should act as memory prompts for patients, helping them to remember information provided at the clinic, and allowing them to refer back to it at a later date. The key elements of personalised action plans for patients should include the following:

  • how they should monitor their asthma
  • how to recognise if they have lost control of their asthma, and what they should do in this situation
  • what they should do if the plan is not working (i.e. they are not gaining or maintaining control).

Personalised action plans are usually provided on paper, but it is possible to access them on phones (for example, AsthmaMD is a free app currently available only on iPhones).8 Information held on a mobile phone is usually immediately accessible to the patient, and there is a wealth of evidence demonstrating that this is a very effective way of aiding self-management.9

Inhaler technique

Comprehensive knowledge of a variety of commonly prescribed inhalers on the part of healthcare professionals is essential if effective control of asthma is to be achieved. Each inhaler has its own critical success factors, including taking the cap off. Successive studies demonstrate that most healthcare professionals do not have adequate knowledge of inhaler technique, making it virtually impossible for them to teach their patients or assess their technique.10,11 It is the responsibility of the prescribing clinician to ensure that patients know how to use the devices prescribed correctly, and also when to use them.

Most of what we read about in guidance on asthma relates to medications and their different combinations; scant attention is given to the very important task of getting that medicine into the lungs. Doctors and nurses in both primary and secondary care fail to instruct their patients adequately in how and when to use their inhalers. Each particular inhaler device has its own criteria for successful administration of the medication,12 and the fewer criteria that are met, the greater the instability of asthma control.13

One reason for poor patient compliance with asthma medication is the patient’s perceived lack of effect. This perception leads to an inappropriate increase in the dose, or the addition of another medicine, when all that was needed was an assessment and correction of inhaler technique, or the prescribing of a different device. Inhaler demonstrations (which allow training at home) can be found on the Asthma UK website.14 Another factor that leads to loss of control of asthma is the pervasive practice of switching medication without a face-to-face review.15 This practice should be resisted on the grounds that it is dangerous.

Review

Currently, practices are paid, through the quality and outcomes framework (QOF),16 to review patients with asthma annually. This is adequate for individuals whose condition is well controlled; however, the majority of these patients have uncontrolled asthma, and so more frequent structured reviews are indicated until such time as control is gained. In individuals in whom control is not achieved, a second opinion is advised to check the diagnosis, as discussed previously, or to further characterise the condition (see ‘Difficult asthma’, p. 22).

The author would recommend that review of a patient with asthma should consist of a variety of elements, including:

  • smoking status
  • inhaler technique
  • assessment of current control
    (e.g. Royal College of Physicians [RCP] three questions, current peak flow)
  • compliance with medication
  • patient education and self-monitoring skills
  • pharmacotherapy
  • lifestyle advice
  • triggers
  • co-morbidities
  • support (e.g. access to Asthma UK)
  • a written self-management plan
  • follow up.

It is also worth considering and addressing co-morbidities, such as rhinitis. Referral is indicated if control of asthma has not been achieved after a number of reviews.

Assessing asthma control

Assessment of control is subsumed within asthma review, and QOF mandates the use of the RCP three questions;16,17 if the patient is waking at night, experiencing daytime symptoms, or if their condition is preventing them from carrying out normal activities, a full review is required. The patient can use the RCP three questions themselves as a means of self-monitoring. If control of asthma is lost, use of the RCP questions may prompt the patient to:

  • remember whether they have taken their medication
  • check whether there is any medication remaining in the inhaler
  • determine whether they have been exposed to any new triggers
    (e.g. pollens or animal dander)
  • follow their self-management plan.

The critical success factors for achieving asthma control include:18

  • patient education
  • use of self-management plans
  • structured review
  • optimal inhaler technique
  • review of diagnosis if appropriate
  • referral if there is failure to achieve control.

Exacerbations of asthma

Assessing severity of asthma is something of a conundrum. There may be patients taking a significant number of medications who are well controlled (dose reduction should be considered in these cases); in contrast, some individuals may have very severe symptoms as they are being undertreated, either because their inhaler technique is incorrect, or because they are non-compliant, exposed to triggers continuously, or have an unusual form of asthma. In essence, anyone who fails to achieve control after a number of iterations of structured review carried out at 4–6 week intervals has asthma severe enough to merit referral to a difficult asthma clinic.

Acute onset asthma attacks always need to be assessed early and treated vigorously. Patients need to be monitored throughout the attack if they are to avoid hospital admission—clear instructions need to be given when treatment is commenced to help patients recognise that their asthma is deteriorating. Patients should be reviewed in person the day after commencing treatment, and when the course of oral steroids is coming to an end.7

Non-response to treatment should precipitate a hospital admission. Where possible this should be direct to a specialist respiratory ward/unit, avoiding accident and emergency and non-specialist wards where care will be suboptimal. Firm commissioning is needed to ensure that this advice becomes a reality.

On discharge from hospital, the patient should be reviewed within 2 working days of treatment. If the individual is a patient with existing asthma, healthcare professionals should enquire about what happened, why the self-management plan did not work, and if there were any unexpected or unusual events that precipitated the attack. This is an opportunity to perform a further structured review, alter treatment or inhaler device, and arrange further follow up within a few weeks. For patients in whom the acute attack was the initial presentation of asthma, there will need to be more frequent reviews until they have achieved control and gained confidence in self-management.

Difficult asthma

Currently, there are only a few difficult asthma clinics set up in the UK and in future these will be commissioned centrally by NHS England. Their purpose is to further characterise patients with severe asthma symptoms who appear to be non-responsive to treatment. A variety of investigations may be used, such as measuring exhaled nitric oxide (a measure of inflammation), bronchoprovocation testing, sputum analysis, high-resolution computed tomography scans, and other modalities within the context of a multidisciplinary team. It is of note that many patients who attend difficult asthma clinics turn out not to have this condition.19 Some individuals, however, have atypical forms of asthma, which may respond to omalizumab or mepolizumab, and others, particularly those with an asthma subtype associated with obesity, will respond to strict dietary regimens.

Summary

Asthma is a common and complex disease affecting a significant number of patients (and their families). By means of structured review and appropriate referrals, the majority of individuals can be managed safely and effectively by appropriate treatment. The benefits to patients from clinicians implementing NICE QS25 will be a better quality of life, fewer exacerbations, and a lower risk of death. These benefits will contribute in turn to achieving the outcomes in domain 2 (enhancing quality of life for people with long-term conditions) and domain 4 (ensuring that people have a positive experience of care) of the Public health outcomes framework for England 2013/2016.20

  • The NICE quality standard for asthma should be considered by CCGs as a standard against which to assess the current provision of asthma services, and then to aspire to
  • To ensure a short, clear, effective pathway to meet this standard, CCGs need to engage with GPs and GP out-of-hours services to increase training in asthma for primary care clinicians, and ensure that people with uncontrolled asthma can be referred directly to a specialist respiratory unit.NHS England, as commissioners of difficult asthma services, need to give priority to those patients most in need of these services
  • CCGs should aim to ensure that patients with asthma attending hospital, out-of-hours or ambulance services, receive a prompt review of their asthma in hospital from a suitably qualified individual, or at their GP practice after discharge: this extra work needs to be paid for
  • Practices are currently incentivised through QOF to undertake asthma reviews. New incentives are needed for GPs to carry out opportunistic reviews of people with asthma who do not attend reviews, to help reduce the number of emergency admissions; these patients often have psycho-social or emotional problems which hinder their asthma management
  • As part of its central role of improving healthcare, the NHS has a responsibility to establish sustainable educational schemes to meet the education and skills requirements of healthcare professionals.

CCG=clinical commissioning group; QOF=quality and outcomes framework

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