Managers failing on complaints
diagnosis and management in children
Our practice is in a converted bingo hall in a deprived area. There is lots of traffic congestion, most parents smoke and the psychosocial factors that contribute to asthma are highly prevalent.
About one in three children has asthma in our practice. It is difficult to diagnose asthma in young children as peak flow measurement is not yet an option and asthma presents in different ways in different children.
The result of not getting the diagnosis right is that asthma goes untreated and becomes uncontrolled. A lot of parents present with a recurrent need for antibiotics for their children (taking up a number of consultations), saying the antibiotics haven't cleared up the infection. So we then issue an inhaler and then a preventer even though the diagnosis sometimes remains uncertain.
What we did
I am a founder of a new patient and practitioner support group called Respiratory Excellence Across Care in the Community and Hospitals (REACH). Two years ago we developed a symptom diary (see below) in light of the British Thoracic Society's 2003 asthma guidelines, which urged GPs to look for asthma in children with wheeze and in terms of how they respond to treatment and ongoing assessment. This computer-generated diary was created to allow parents to tick the applicable response. We also asked parents to record:
· their fears around their child's breathing
· the frequency of inhaler use
· the recording of any unusual events, eg attending casualty, having antibiotics, having oral steroids etc
· the exposure of their child to a smoky environment.
The diary was printed out on A5 paper and given to parents.
Parents were encouraged to complete this every day over a six-week period, after which they were invited to come in for a follow-up discussion to look at their results. Obviously if they had concerns during the six-week period they could still make an appointment to see a nurse or GP.
Over the past two years we've issued the diary to about 200 parents and between 60-70 per cent have completed them.
Recurrent symptoms of cough and wheeze responding to inhalers were evidence of possible asthma, although careful consideration was made of other possible diagnoses.
The diaries could be scanned on to the patient's records to provide a permanent record of symptoms, interventions and their success.
The diary page also had a column for the GP to make notes or indicate problems highlighted by the diary.
What we achieved as a result
·More accurate diagnosis Between 60-70 per cent of parents (approximately 130) completed the diary for the six-week period. Only about 50 per cent of these children had consistent symptoms and responded to inhalers in a way that suggested they had asthma, and of these about 50 per cent have continued to still need inhalers two years later and so have established asthma.
·Less prescribing and consultations Our antibiotic prescribing for respiratory infections has halved and I'm certain the number of consultations for respiratory complaints in children has gone down as parents know they have a scheduled date in the future to discuss their child's asthma.
·Greater parent confidence Parents reported more confidence in using reliever inhalers as and when required. The GP could also review the frequency of inhaler use so inappropriate use could be identified and challenged. Also triggers could be identified smoking, colds.
Some cases, especially where relief was minimal and concerns still high, were referred to a paediatrician for further clarification.
The improvement in the doctor-parent relationship should not be underestimated either. Before, we had parents with children on antibiotics saying 'Are you sure the diagnosis is right, doctor?' or 'Why is he still coughing even though he's taking the medicine?'.
Similarly, given the negative connotations asthma still unfortunately has, the
diary has been a useful tool to help parents accept their child has asthma, feel less anxious and be more enabled to control it.
·Awareness of smoking asthma link Particularly satisfying has been the connection parents now make between their smoking and their child's asthma symptoms. Some have inquired about the smoking cessation services and others now talk about giving up (which they never did before).