In the spotlight
why three- quarters are still preventable
GP asthma management has come under scrutiny following a confidential inquiry into asthma deaths Dr Mark Levy details how GPs can play a part in better prevention of severe asthma
While the incidence of asthma deaths in the UK has decreased over the past 20 years, there is little room for complacency.
The first UK confidential inquiry on asthma deaths in 19821 concluded there were preventable factors in 77 of 90 cases investigated. Since then there have been a number of confidential inquiries investigating the circumstances surrounding asthma deaths, where common themes keep emerging and in July last year a confidential inquiry concluded three-quarters of asthma deaths are preventable.
The 2005 study
Of the 57 asthma deaths reported in the Eastern region confidential inquiry in Norwich and East Anglia between 2001 and 20032 only 19 per cent were sudden.
In the opinion of the authors, preventable factors among the remaining 46 patients included inadequate use of oral steroids (in 33 per cent); inadequate follow-up (33 per cent by GP, 21 per cent by hospital doctors); overall routine care inappropriate (in 67 per cent) and inadequate peak flow monitoring in 17 per cent.
In addition, in 81 per cent of the patients who died there were significant behavioural and/or psychosocial factors such as poor compliance, smoking, denial and depression which contributed to the patients' deaths from asthma.
Furthermore, in two-thirds of these asthma deaths, medical management failed to comply with national guidelines.
Guidelines with a pedigree
National asthma guidelines have been available in the UK since 1987, starting with those developed by the RCGP, and more recently with the updated British asthma guidelines from the BTS/SIGN3.
These have been very clear in detailing
evidence-based principles of management of patients with uncontrolled asthma. In particular, they have stressed the risks of asthma death in patients exhibiting a combination of features of severe asthma and adverse behavioural or psychosocial features (see box below).
This was highlighted as early as 1987 by an International Task Force on Asthma Deaths4 and yet the recent Eastern region study demonstrated a failure to recognise and deal with patients with these features.
The fact that asthma is not on the
national agenda in the UK is really no excuse for complacency and we therefore need to implement measures in general practice to ensure we reduce the number of preventable asthma deaths.
A practical approach
There are a number of measures we can take to improve management of acute asthma in general practice:
i) Improve follow-up of patients after asthma
exacerbations Patients who have had an
exacerbation of asthma, irrespective of the place of treatment (hospital, A&E, GP surgery or out-of-hours service) need to be followed up to ensure, first, the patient is not deteriorating and, second, that the episode clears up.
Re-attendance rates for new or unresolved episodes of asthma, within two months, following treatment may be as high as 17 per cent. Therefore follow-up should be as stated in the UK guidelines3 within a few days after the index attendance.
Another reason for ensuring that patients are followed up is to review the patient's asthma management thoroughly. Reasons for episodes of poor control need to be identified, and these are not always clear at the time patients are treated acutely.
Sometimes this is obvious, such as the situation where the person has run out of medication, or they have been overexposed to a particular allergen. Evaluation includes checking inhaler technique and ensuring patients understand which medication should be taken and when.
Action point: Implement an agreed system for identifying and recalling patients seen for asthma outside and within the practice. These may often include undiagnosed asthma patients therefore recall anyone who has been treated with high-dose bronchodilators or who has an entry stating they were wheezing.
ii) Ensure all patients with asthma are provided with a written action plan There is good evidence that written action plans help patients to recognise when they are going out of control, reduce hospital admissions and improve their quality of life.
An action plan may be as simple as a few written instructions detailing the purpose of each medication and when to use them, or may include an elaborate peak flow-
driven daily chart with clear action levels for adjusting medication and recognising when to call for help.
As a minimum requirement, all patients should know that they should take action if their medication does not provide the usual effect and, in the case of bronchodilators, that this effect should last for at least four hours5.
Action may include adjustment of medication, starting inhaled steroids or simply calling for help. The plan needs to be tailored to the needs and abilities of the individual patient.
Action point: Agree a consistent system in the practice for providing patients with action plans. These could be 'off the shelf' as in the case of the Asthma UK materials (www.asthma.org.uk) or designed specially by the practice. Examples may be found in my book Asthma at your Fingertips5.
iii) Identify those patients at risk and ensure they are seen regularly (see below). There are many calls for at-risk registers for patients with asthma. I personally do not think these are a good idea in general, as many patients who die from asthma may not fall nicely into one of the at-risk categories.
I believe all asthma patients are at risk at some stage of their lives, and danger signs may be missed in patients consulting without an at-risk flag on their record.
As a result, some patients may be neglected in favour of those on the at-risk register. There is, however, one particularly vulnerable group of patients; those with severe features of asthma and also a history of psychosocial or behavioural problems.
These patients do need extra care and should be specifically targeted, both for routine asthma reviews and also opportunistically when they attend for other reasons.
Action point: Ensure the practice has a system for identifying and aggressively managing asthma patients who also have psychosocial or behavioural problems.
iv) Ongoing audit to monitor management of uncontrolled asthma Medical audit offers us a tried and tested method for evaluating, reviewing and modifying our management of patients.
Despite the presence of excellent guidelines there is good evidence of inadequate management of asthma exacerbations in both primary and secondary care.
I have set up a system for ongoing audit of management of asthma exacerbations, based on published guidelines, to include a benchmarking system that enables health care professionals to evaluate and compare their actions with others.
The system was developed as part of a project in Harrow, has been approved by a national ethics committee, and allows for anonymous recording of data.
The system can be seen at www.consultmarklevy.com/unsafe.
Action point: Ensure that a system is set up to enable ongoing audit of management of uncontrolled asthma in the practice.
Mark Levy is a clinical research fellow in the GP section of the division of community health sciences, University of Edinburgh. He is editor-in-chief of the Primary Care Respiratory Journal and medical adviser to the National Asthma and Respiratory Training Centre, Warwick he is a GP in Harrow
Competing interests Dr Levy has received sponsorship from various pharmaceutical companies to attend conferences and speak at educational events
The bottom line
GPs have greatly improved asthma care over the past three decades and asthma deaths are decreasing. However, the confidential inquiry has shown there is still much room for improvement in the management of asthma exacerbations
1 British Thoracic Association. Death from asthma in two regions of England.
2 Harrison B et al. An ongoing confidential inquiry into asthma deaths in the eastern region of the UK, 2001/3. Primary Care Respiratory Journal, (2005). 14(6), 303-13. Retrieved 28 January, 2006, from Scopus database.
3 British guideline on the management of asthma (Revised version 2005). Available at: www.sign.ac.uk/guidelines/fulltext/63/
4 Proceedings of the Asthma Mortality Task Force. 13-16 November, 1986, Bethesda, Maryland. Journal of Allergy and Clinical Immunology Volume 80, Issue 3 Pt 2, September 1987, Pages 361-514
5 Mark Levy et al. Asthma at your fingertips (Fourth Ed). Class Publishing, London 2006