Family ignores warnings about asthma problems
The receptionist alerts you that one of your patients and her two children aged nine and 12 have gone through 42 inhalers in the six months since they joined the practice. They have repeatedly failed to attend the practice asthma clinic and hospital chest clinic. You have written to the family on two occasions once asking them to come in for review, a second time warning of the dangers of uncontrolled asthma but received no response.
Dr Alison Best
'There is really only so much that the practice can do in this case'
One does not have to be up to date with the 2003 British Thoracic Society guidelines to appreciate that their asthma management is less than optimal, but there really is only so much we can do. I am pleased that the receptionist has flagged up this prescribing issue, but review of the records has shown that they have already failed to respond to two letters asking them to come in for review.
In addition, they have repeatedly failed to attend clinics at both the hospital and practice. The patients will have previously attended for a new patient check and our nurses would have discussed their asthma, given relevant written information and explained how our asthma clinic runs.
Do we have the correct address? If we have a current phone number, perhaps a phone call would be an alternative approach. The family has been registered for only six months so it may well be that no clinician has had a chance to build up a relationship yet.
Since asthma care in our practice is very much nurse-led, it may be more appropriate (and effective) for one of the practice nurses to make contact.
If all else fails, then acting opportunistically is our only option. Inevitably, asthmatics who do not comply with preventive medication will have more exacerbations and I suspect it is only a matter of time before we see at least one of them at an emergency appointment. While this is, of course, not ideal, it may have the benefit of demonstrating the effects of poor compliance with preventive treatment. This could be a good opportunity to begin to influence the health beliefs of the family.
Ultimately we must recognise that patients have to take responsibility for their own health, but this scenario is complicated as two of those involved are children.
Dr Peter Harvey
'Is anyone borrowing the inhalers? Asthma is expensive for low-income groups'
This common scenario is well worth dissecting. I would give the mother a ring and see what is going on as there are a number of possible explanations. I would not make false accusations or convey warnings of dire consequences. I'm sure I could convince them to come to the surgery if I explained we just wanted to make sure their treatment was the best available.
Three patients using 42 salbutamol inhalers in six months is about two each per month, which is not a great number, especially as the children may keep spares in various places that may have expired at the same time children are notoriously wasteful and lose them or break them frequently.
'Poor compliance' with the preventer is a relative term and possibly the use of salbutamol at one inhaler per month doesn't justify a preventer, particularly if their need for the reliever is stable and their conditions are predominantly exercise-induced. There's a lot of justifiable concern on the overuse of steroid inhalers. I don't think there is any prima faciae evidence of uncontrolled asthma here.
Once at the surgery I'd ask if any other third party was 'borrowing them', such as an elder brother or working Dad; having asthma is expensive for low-income groups who are not exempt from prescription charges. Maybe they still follow the 'old' advice of regular qds use of salbutamol or don't understand the difference between reliever and preventer. Perhaps they can't get the best use from an MDI due to poor technique or are reordering before old inhalers are empty.
I'd see if they would contemplate using spacers the Clement Clarke model is very good, or choose something easier such as a Turbohaler.
Dr Nick Imm
'The asthma issue might just be the tip of the iceberg'
This is clearly a rather worrying situation and it needs to be addressed. This family is not attending for clinic follow-up and the number of inhalers they have apparently collected is getting ridiculous.
Perhaps their asthma is severe, requiring excessive salbutamol inhaler use, or perhaps they're not using the medication properly. On the other hand, maybe they give spare inhalers to other members of the family or friends. Whatever the true reason, I need to gently investigate and try to sort matters out.
I don't think there's much point in writing any more letters or offering more primary or secondary care appointments until I've established a rapport. I would hope we could then work together on a plan for effective treatment and follow-up.
In the first instance I'd arrange a practice case conference, inviting the practice nurse and health visitor. It's likely this family has other problems as well this asthma issue might well just be the tip of the iceberg. It would be very helpful to get a clearer picture of the whole situation and try to understand their behaviour.
What are their living conditions or transport arrangements like? Are the children attending school regularly? Have they been to A&E with exacerbations of their asthma recently? Is there any clear reason why they don't attend for follow-up? It's often surprising how much helpful information is available from practice staff once you start asking.
I think it would be unethical to ban them from receiving further prescriptions but the current situation has to change. I reckon I'm going to end up paying them a visit, possibly with the health visitor.
In the first instance I'd try to contact them by phone to arrange a convenient time to meet. If that's unsuccessful I'll just have to turn up on the doorstep.