Only 70% coverage gives full points for asthma
Asthma is included in the quality marker scheme because it is a common, treatable condition which is almost entirely managed in primary care. Although the performance indicators are influenced by the most recent SIGN and BTS guidelines, the 72 points available for asthma management do not involve producing evidence that the practice is following the stepped management plans advised in the guidelines or demonstrating clinical outcomes such as the achievement of normal peak flow readings or low rates of acute exacerbations.
Maximum points on each indicator can be gained by 70 per cent coverage. This reflects the fact that patients with asthma have long symptom-free periods and often comply poorly with maintenance treatment and follow-up.
· Create an asthma register (seven points). Search on inhaled short- and long-acting ?-2 agonists and inhaled corticosteroids. It is unlikely that any patient on asthma treatment will not be taking one or more of these drugs. Look for repeat prescriptions because including patients who have had a single prescription of salbutamol for viral bronchospasm and do not need follow-up will skew your statistics against you. In patients over 50, exclude those with pure COPD as they fall within a different indicator set.
· Ensure all patients over the age of eight with asthma diagnosed after April 2003 have the diagnosis confirmed by spirometry or serial peak flow measurement (15 points for 70 per cent). One of the difficulties in measuring performance in asthma care is that the diagnosis is predominantly a clinical one and there is no definitive objective test. A measurable response to treatment with a bronchodilator is the closest. Eight has been chosen as the age by which everyone should be able to co-operate with testing, but some younger children will also be able to.
· Perform an annual review in all patients (20 points for 70 per cent). Although structured care is more effective than opportunistic care at reducing morbidity it is less clear which elements of the structured care are responsible for this effect (box 1).
· Record smoking status annually in patients with asthma aged between 14 and 19 (six points for 70 per cent). While it is thought unnecessary to ask repeatedly about smoking in adults who have never smoked, this does not apply to teenagers, who are at high risk of starting to smoke. Even non-smoking teenagers should therefore be asked about their smoking status at each asthma review, and those who smoke should be advised that quitting may make their asthma less severe and persistent.
· Record smoking status annually in patients aged 20 and over with asthma (six points for 70 per cent). People over this age who have never smoked are thought unlikely to start, so a single recording is appropriate. In view of the high rate of recidivism, ex-smokers should continue to have annual recording of their smoking status.
· Record smoking cessation advice and use nicotine replacement therapy, bupropion and referral to specialist smoking cessation services where appropriate (six points for 70 per cent). As every GP and practice nurse instinctively responds to discovering that a patient smokes by offering cessation advice, it would seem appropriate to record smoking cessation advice having been given to every current smoker at each asthma review.
· Ensure maximum coverage of flu immunisation in patients aged 16 or over with asthma (12 points for 70 per cent). There are far more points available for immunising patients with asthma than for immunising patients with cardiovascular disease and stroke, so if vaccine supplies are limited it makes economic sense to make asthmatic patients a priority.
1. Asthma review should include
· Assess symptoms by asking whether, in the last month, the patient has experienced:
·Difficulty sleeping due to asthma
symptoms, including cough
·Cough, wheeze, chest tightness
or breathlessness during the day
·Difficulty performing usual
activities such as work, school
or housework due to asthma
· Measure peak flow
· Assess inhaler technique
· Consider a personalised asthma plan according to BTS/SIGN guidelines
2. Asthma quality markers
Preferred Read codes
Peak flow rate abnormal 3395
Never smoked 1371
Smoking cessation advice 8CAL
Asthma review 66YJ
Flu vaccination given 65E
*The % symbol indicates that any code
in this group may be used