Points to Quality
In the third in our series on achieving the necessary standards to meet the quality framework Dr Lorna Gold considers the treatment of asthma
Prepare for the unexpected
There are 72 quality points for asthma care, but these are not for providing evidence of annual peak flow recording (although this is recommended as part of the annual review), for achieving target peak flow measurements, or for treating asthma according to the BTS/SIGN guidelines. In theory, a practice could treat asthma using flower remedies or gentian bitters and still earn the full 72 points.
Create an asthma register
Five quality points are available for this. Most practices will have set up an asthma register to earn chronic disease management payments in 1993, but a decade has elapsed and, with other disease areas having taken priority, registers may have fallen into disuse or become chaotic. Search on repeat prescriptions for inhaled steroids, long- and short-acting bronchodilators, leukotriene receptor antagonists, and short courses of high-dose oral steroids. Patients with mixed asthma and COPD should be treated as having asthma.
Don't make your register over-inclusive
The pendulum has swung away from every cough and wheeze being asthma until proven otherwise. Adding patients who do not have chronic asthma and who do not need an annual review to your register will increase workload and reduce income. Patients who wheeze only occasionally in response to exercise or allergen exposure, or who have received a single script for a short-acting bronchodilator to treat postviral bronchospasm, should not be in your asthma register. Patients who have not needed prescribed medication in the last 12 months, even if a definite diagnosis of asthma was made at some time, should also be excluded.
Forget about the different classification systems for asthma
Not from a clinical aspect, of course, but for administrative purposes. Keep the register simple by recording every patient under a single code rather than trying to keep track of different codes for exercise-induced asthma, adult-onset asthma, atopic asthma and the myriad other labels that could be applied.
Ensure you have a nurse trained in asthma care
Nurses are better than most GPs at delivering structured care recommended by BTS/ SIGN guidelines. A nurse with an interest in asthma and a prescribing qualification could manage the entire asthma caseload almost independently.
Organise an annual recall system
Structured asthma care is preferable to opportunistic care. Patients who consult frequently with loss of asthma control can end up having their crises managed without time being set aside for a rational overview of why their condition is so brittle, while patients who have repeat prescriptions but drift from year to year without being seen may be accepting sub-optimal control. Reviewing 70 per cent of patients in a 12-month period will earn the practice 20 points.
Include the following in your annual review protocol:
mHas patient had symptoms of asthma over the previous month what impact have they had on sleep and daytime activities?
mMeasure peak flow. A record of 'best' peak flow provides an objective background against which exacerbations can be assessed.
mAssess inhaler technique.
mRecord smoking status, and that cessation advice has been offered to all smokers. Worth a further 18 points.
Teenagers are different
People who have not started to smoke by 20 are relatively unlikely to do so, but the teenage years are when most smokers adopt the habit, and having asthma is no deterrent to an adolescent whose peer or parental culture predisposes them to smoke. Inquire annually about smoking status in 14- to 19-year-olds even if they have previously been recorded as non-smokers.
It is worth taking time to review defaulters opportunistically
Some patients will not attend routine review appointments and are only seen when they have an exacerbation. Adding a computer prompt to the prescribing records of patients who miss an annual review, and going through the protocol when they attend normal surgery, could make a significant difference to your coverage. Reviewing patients while they are symptomatic may not be perfect but it is clinically and administratively preferable to sending out repeated appointments and then exception-reporting them when they fail to attend.
Confirm diagnosis in new patients over the age of eight from April 1, 2003, using spirometry or a peak-flow reversibility test
Worth 15 points for 70 per cent coverage. Asthma is a clinical diagnosis but lung function tests are a useful adjunct. The diagnostic standard is 20 per cent or greater variability in peak flow when measured on at least three days a week for two weeks. There is scope for clinical judgment, and some patients with asthma will have a lower level of variability or will have normal spirometry when asymptomatic. If peak flow or spirometry are normal when the patient is symptomatic, asthma is unlikely.
Offer influenza immunisation to patients aged 16 or over
It is good practice to immunise asthmatic children annually from the age of six months, but this happens so rarely that the indicator has been set to exclude children. With 12 points available for 70 per cent coverage it is worth immunising under-65s on your asthma register even without an item-of-service fee.