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Non-adherence prompts post-school holiday surge in child asthma episodes

A new study has linked failure by some children with asthma to take their medication over the summer holidays with a spike in demand for unplanned care on return to school.

GPs have been urged to place a particular focus on encouraging children to take medication over the summer months, after failure to get a prescription in August was associated with an increase in unplanned GP consultations, A&E visits and out-of-hours contacts a month later.

It has usually been assumed that increases in asthma episodes when children return to school after the summer break were associated with seasonal changes and increased exposure to allergens and viruses. The new study is the first to suggest low collection of prescriptions in August could be a factor in a September peak in unplanned medical contacts.

The retrospective study investigated 76,924 children aged between five and 16 with asthma. Information on daily medical contacts and prescribing of inhaled steroids from 1999 to 2005 was taken from theUK general practice research database.Researchers found a dip in the number of prescriptions of inhaled steroids in August followed by successive monthly increases from September to December.

In children who received fewer than 13 prescriptions per year, those who got a prescription in August had 0.14 fewer contacts per patient in September. The authors suggested reduced viral and pollen exposure over summer and good symptom control might cause patients to step-down steroids, leaving them more vulnerable to exacerbations on return to school.

The increase in unplanned contacts in Scotland preceded England’s by about 14 days, reflecting the earlier date children in Scotland return to school.

Study author Dr Stephen Bianchi, honorary clinical senior lecturer in respiratory medicine at the Royal Hallamshire Hospital in Sheffield said:‘Particular attention should be paid by GPs to the weeks preceding commencement of the autumn term, encouraging children to medicate themselves appropriately.’

Dr Iain Small, a GP in Aberdeenshire and UK executive chair of the Primary Care Respiratory Society, said: ‘There is a huge tendency for people to increase and decrease dose depending on what they feel like and because inhaled steroids take a period of time to become effective, that just doesn’t work.’

But he added the study did not determine whether the decrease in prescriptions in August was due to people going away on holiday or patients stepping-down medication.

Dr Kevin Gruffydd-Jones, a GP in Wiltshire and clinical respiratory champion for the RCGP, agreed the study could have gone further: ‘It is a shame it wasn’t supported by qualitative work asking parents and children about steroid use.’


Example case-study

Children who received a prescription in August had 0.14 fewer contacts per patient in September:

In a cohort of 200 children with asthma on inhaled corticosteroids, where 100 receive a prescription in August and 100 do not. If the 100 patients with a prescription make 50 unscheduled medical visits then 64 unscheduled medical contacts would be made by those not receiving a prescription – an excess of 14 unscheduled medical contacts per 100 children.


Suggested CPD module – Case-based learning on asthma in adults

Public Health, 2011 Online 28 October.