Meningococcal disease: avoid diagnosis pitfalls
Standards of GP asthma management are variable poorly organised care is a key part of the problem. GP Dr Mark Levy (below) and PCT respiratory co-ordinator Kay Holt (page 46) offer tips
Preventing symptoms and acute asthma attacks are two of the fundamental aims of managing people with asthma.
As long ago as 1992, research by the General Practice in Airways Group (GPIAG) revealed a lack of adherence to published guidelines for management of uncontrolled asthma1. Sadly, asthma is still not managed ideally. A more recent audit of 12 research practices in the south of England found more than 90 per cent of adults and children with asthma were not formally diagnosed, despite many being on rather large doses of medication2.
Latest research suggests there is still substantial room for improvement. Two 24-hour snapshot audits of uncontrolled asthma episodes were conducted in Harrow, north-west London, in January and July this year, as part of the RAISE initiative to improve standards of asthma care (see box page 46).
As in the 1992 study, we found that, in many cases, exacerbations were not being managed according to national asthma guidelines. We also discovered that patients were not complying with their treatment3 (see box right).
Although I broadly welcomed the inclusion of asthma and COPD in the quality and outcomes framework of the new GMS contract (nGMS), much more will need to be done to iron out variations in the quality of GP asthma care. The requirements for earning quality points for asthma and COPD fall far short of the standards of care stipulated in national guidelines for these diseases4,5. It is possible to attain maximum points without necessarily improving the quality of care we provide to our patients.
The following relatively simple practical strategies aimed at improving the organisation of asthma care could go a long way towards raising standards of asthma management in practices.
Improve diagnosis/coding for asthma
Any patient with recurring respiratory symptoms (cough, wheeze or shortness of breath), or who has been prescribed anti-asthma treatment, should be considered to have asthma until proved otherwise.
Patients with asthma need to be correctly diagnosed and coded (Read H33) as early as possible on the practice computer system. The coding determines whether practices have achieved nGMS points. Coded patients comprise the asthma register, providing a means of identifying and recalling patients for care and advice, including monitoring, education and immunisation.
Where the history is unclear, the use of spirometry will help to differentiate patients with COPD from those with asthma (provided reversibility testing is done of course!).
Occupational asthma, the only potentially curable form of this disease, may be identified early through rigorous scrutiny and occupational history of all patients with 'late onset' or adult onset asthma6. These patients need four-hourly peak flow charts and referral to a physician trained in occupational medicine if the history and PEF chart suggests this diagnosis.
Use computer templates
not just the nGMS ones
Computer templates that guide clinicians through the process of diagnosis and management of asthma may be helpful. These facilitate and enable consistent coding of information, ensuring achievement of quality points as well as providing useable data for future audit. In addition, templates provide guidelines and checklists for those clinicians less experienced in managing patients with the particular disease. There are a number of asthma templates available; for more information, contact me at firstname.lastname@example.org
Systems for recalling patients
Practice protocols should include methods for identifying and recalling patients whose asthma needs review. Triggers could include:
·patients requesting more reliever medication
·those who have failed to attend for follow-up
·patients who have been seen out of hours or admitted to hospital for uncontrolled asthma.
Systems for monitoring and educating people with asthma
Practice protocols should include a checklist of questions and examinations at each visit. These could include:
·using the Read codes to denote the SIGN/BTS step (8793.- 8798.) the patient is on at the start of the consultation
·asking about the effect of asthma on the patient's life (eg the RCP 3 questions4)
·asking about recent exacerbations and frequency of reliever medication use
·checking the patient's PEF diary chart for the previous week
·checking inhaler technique (omitted from the nGMS asthma contract).
I usually use the Read code for the appropriate step (8793.- 8798.) at the end of the consultation and record if I have stepped up or down.
Written self-management plans for asthma are recommended in the BTS/SIGN guidelines and practice protocols should include the use of a uniformly taught self-management plan that is tailored to the needs of the patient. The plan should include information on detecting uncontrolled asthma (such as using PFM charts), action required when this occurs and clear instructions on how to call for help when needed. Asthma UK (www.asthma.org.uk) provides a useful plan that can be downloaded from its website.
Management of acute asthma exacerbations
An agreed protocol for managing exacerbations may be helpful in addressing this area of asthma care. This could include:
·a low threshold for using oral steroids to control the exacerbation
·monitoring with PEF, pulse oximetry and early referral to hospital if indicated, according to the BTS/SIGN guidelines
·particular care/consider referral of people in high-risk groups those with brittle asthma, food allergy causing anaphylaxis, and pregnant women with acute asthma.
In our practice we use a monitoring form that I was involved in developing (available online at www.mombo.demon.co.uk/asthma_prac.htm and published in the book Asthma in Practice, RCGP). This serves as an aide-mémoire, a system for recording the progress of an attack and, if necessary, can be photocopied to accompany a referral to hospital. We scan these forms on to the patient's record as well.
Other areas for improvement
Systems for regular audit, protocols for 'when the nurse should refer patients to the doctor', and dedicated asthma clinic sessions are other possible areas where practices could improve care.
Current gaps in asthma care
Two 24-hour snapshot audits of uncontrolled asthma, conducted in January and July 2004 in Harrow, north west London, found:
·At least 42 exacerbations per 1,000 patients per year; this is higher than published national prevalence
·Under-diagnosis: patients attended with uncontrolled asthma who had not been previously diagnosed
·Under-treatment: patients were not collecting prescriptions
·Symptomatic patients delayed attending to seek assistance
·Health professionals were failing to evaluate patients objectively (PEF, oximetry) both before and after treatment
·Lack of adherence to acute asthma guidelines; not enough ?-agonists or oral steroids were prescribed for patients attending for attacks
·Variable follow-up: appointments ranged from a few days to six months not in keeping with BTS/SIGN national guidelines
1 Neville RG et al. National asthma attack audit 1991/2. GPs in Asthma Group [see comments]. BMJ 1993 306,559-62
2 Dennis SM et al. The management of newly identified asthma in primary care in England. Prim.Care Respir.J.
3 Levy ML, Brereton J. Snapshot Audit: Uncontrolled Asthma. (Submitted Abstract for American Thoracic Society) 2004
4 BTS/SIGN. British guidelines on the management of asthma. Thorax 58[Suppl 1] www.sign.ac.uk, 1-94. 2003
5 National Institute for Clinical Excellence. Chronic obstructive pulmonary disease: management of adults with chronic obstructive pulmonary disease in primary and secondary care. www.nice.org.uk/
6 Levy ML, Nicholson PJ. Occupational asthma case finding: A role for primary care. British Journal of General Practice 2004.54,731-3
Mark Levy is a GP in Harrow, Middlesex,
and research fellow in community health sciences at the University of Edinburgh he is also editor of the Primary Care Respiratory Journal, and chair of
the primary care and general practice scientific group of the European Respiratory Society