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Raising the asthma care bar

Dr Elango Vijaykumar explains how his CCG has tackled variation in asthma care by finding undiagnosed sufferers and standardising their management

There is something of a perception that asthma is ‘sorted’.

Deaths from asthma have decreased over the past two decades, although national figures show the number is creeping up again. Asthma is not often in the headlines and it is primarily clinically managed in primary care rather than in hospital, with greater emphasis placed on the patient self-managing.
NHS East Surrey CCG, formerly called EsyDoc, was already on the respiratory curve as a result of work done on COPD, which involved working with pharmaceutical company AstraZeneca, for which we drew up a joint working agreement and built excellent relations with our respiratory secondary care colleagues.
This integrated working produced great outcomes for COPD, including reductions in admissions, costs and waiting times.
Our CCG is made up of 18 practices covering 170,000 patients. Emergency admission rates for asthma were low – 84 during 2010/11 – but we acknowledged asthma care was very variable in our CCG.
It was found that many patients were not using, or had not been given, a specific, properly presented management plan. Sometimes a plan was given but not documented in the patient’s notes. The evidence shows that patients provided with a stepwise approach to self-management are more likely to seek advice sooner when they deteriorate – those without are four times as likely to have an asthma attack requiring hospital treatment.
Use of Read codes to document patient care varied between practices, as did prescribing.
At 5.3 per cent, our CCG’s asthma prevalence was lower than the PCT average of 5.9 per cent, which suggested that more than 700 patients in our CCG had asthma but a documented formal diagnosis was not there.
We had a large number of patients who had previously been prescribed inhalers but who didn’t have a firm diagnosis of asthma. Anecdotal evidence suggests this is nationwide; patients present to their GP with a chest infection or go to hospital with a breathing difficulty and are given an inhaler which helps the problem. This carries on into a repeat prescription. 

Creating cohorts 

asthma cohorts pyramid

A central part in painting a picture of what the asthma challenge was for our practices was putting the patients into cohorts.
This was done by a data company and funded by AstraZeneca. All data seen by persons other than a patient’s GP was anonymised.
The cohorts were created using respiratory medication data and the governance was overseen by the South East Quality Observatory, which also evaluated our outcomes.
The four cohorts are shown, below
The largest, cohort 4, contained patients with no respiratory code but who had either >1 SABA, >1 inhaler or >1 LABA/inhaler combination.
The cohorts supported the development of standardised Read codes, local asthma guidelines developed by our medicines management team in line with BTS/SIGN guidelines and a diagnostic spirometry and/or peak flow pathway to use to confirm a diagnosis for cohort 4 patients.
A patient participation group informed the new local asthma guidelines and their experiences helped shape the strategy.

Peer element

The cohorts were broken down to practice level and fed back to practices to show the number of patients in each category. The information was distributed in a dashboard format to allow practices to compare their cohort breakdown with others in the CCG. This highlighted where their biggest challenges were, but we were not prescriptive in how many reviews, etc, they had to do.
If we had told them to review 150 patients this would have cause disengagement, but clinically diagnosing 15 patients supported by clinical testing proved much more manageable.
When they saw patients, we encouraged GPs to apply the new Read codes, ensure patients’ medication was appropriate for their BTS level and gave them one of two self-management plans – a pictorial guide from Professor Martyn Partridge or a more textual explanatory management plan from Asthma UK. 

Standardising care

Our asthma QOF scores were high because practices were looking after the patients that had a diagnosis with medications and an annual review.  But a big part of our work was finding patients who did not have a formal diagnosis. 
We left it up to practices to decide how best to tackle cohort 4, for them to determine why prevalence was low when so many people were being prescribed respiratory medications. Many patients were already in contact with the practices – because they were coming in to get their inhalers. A small number needed spirometry testing and lung function tests.
Engaging practices with management plans and tools did not reduce clinical assessment but enhanced their motivation to improve patient care. They were happy to use those tools and so the standardised, optimal care became the natural way of consulting.
Upskilling practices
Early on in the project, we held an asthma education day for practices, where we invited Professor Martyn Partridge, which was attended by 60 GPs and nurses and received great feedback.
This educational event and the peer element have proved to be the driving forces for change – we have not had to incentivise practices with any payment.
The educational event was very powerful in getting across the need for management plans and for change to happen locally and nationally.
We were keen that care should improve for all the cohorts in the pyramid and AstraZeneca nurses helped train practice nurses in optimal care in an asthma review for patients in cohorts 1 and 2.
The joint working with AstraZeneca was not dependent on prescribing their products. Our prescribing budget has increased by £105,000 but this has been spent across all three manufacturers of respiratory medicines.
My own practice nurse for example sees which inhaler the patient uses the best technique with and makes the prescribing decision based on this.
We also involved the PCT’s pharmacists and representatives of the local prescribing committee (LCP) in the pathway. The former, which were already working closely with the CCG, came into practices and carried out medication reviews and went into care homes to do patient medication reviews. The LCP also rolled out medicine use reviews in pharmacies which involved doing technique assessments before dispensing the medication.
With various elements of the project running in parallel, it was imperative that practices were kept up to date with results or information, so the team developed a monthly newsletter to keep practices engaged throughout the process.

Ensuring secondary care changes

We have taken steps to ensure better communication between primary and secondary care.
The hospital trust has provided identifiable A&E attendance data to allow proactive case management by practices  so they can help patients with poor asthma control.
Consultants have standardised their paperwork to include discharge notes and ensure follow-up.
A discharge summary is sent by the hospital to practices with primary care follow-up within seven days now
regarded as standard.
Before, the patient would have attended hospital, been assessed and received medication, but there was
a lack of documentation to primary care as to what needed to happen next. The information sometimes got to the GP and sometimes didn’t and it was unclear whether the patient had been advised to arrange a follow-up and for what purpose – for example, medication review, clinical examination and so on.
We have also come to an agreement that the appropriate respiratory clinician sees the patient before admission – every admission has minimum tariff value of £600 and we had 84 during 2010/11.

Outcomes

Outcomes validated by the South East Quality Observatory are:
? 154 new asthma diagnoses
? 79 new COPD diagnoses
? 1,330 patients with a BTS step recorded by May 2012, compared with 61 in August 2011
? 254 more patients recorded as having a self management plan (May 2012 vs August 2011)
? 21 per cent fall in emergency admissions (August 2011 to Feb 2012 compared with August 2010 to Feb 2011
? Increase from 24.6 per cent to 73.1 per cent in asthma patients who are aware they have a self-management plan.
There is also some indication that readmissions have fallen, which can be attributed to a more meaningful appointment in primary care.
The CCG’s asthma prevalence has increased to 5.5 per cent. This can be attributed to clinical review of patients identified within the cohort.
This is still a work in progress and we will continue to distribute the dashboard data and improve the skills of general practice to help patients with asthma.
We are aware of high DNA rates for asthma clinics and we are working to capture this information by age and gender so we can explore whether more primary care access might improve this.
We are looking to draw up local guidelines on when it’s appropriate to prescribe inhalers without a clinical diagnosis of COPD or asthma.
But we have already shown that case finding, standardised management and medicines optimisation improve care.

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