Asthma

Asthma - Rationale for Inclusion of Indicator Set
Asthma is a common condition which responds well to appropriate management and which is principally managed in primary care.

This indicator set was informed by the British Thoracic Society/ SIGN guidelines which are to be published in early 2003. In keeping with the other indicators, not all areas of management are included in the indicator set in an attempt to keep the data collection within manageable proportions.

Asthma Indicator 1
The practice can produce a register of patients with asthma, excluding patients with asthma who have been prescribed no asthma-related drugs in the last twelve months

Asthma 1.1 Rationale
Proactive structured review as opposed to opportunistic or unscheduled review is associated with reduced exacerbation rates and days lost from normal activity. A register of patients who require follow up is a pre-requisite for structured asthma care.

The diagnosis of asthma is a clinical one; there is no confirmatory diagnostic blood test, radiological investigation or histopathological investigation. In most people, the diagnosis can be corroborated by suggestive changes in lung function tests.

One of the main difficulties in asthma is the variable and intermittent nature of asthma.

Adults
Some of the symptoms of asthma are shared with diseases of other systems. Features of an airway disorder in adults such as cough, wheeze and breathlessness should be corroborated where possible by measurement of airflow limitation and reversibility.

Obstructive airways disease produces a decrease in peak expiratory flow (PEF) and forced expiratory volume in one second (FEV1). One or both of these should be measured, but may be normal if the measurement is made between episodes of bronchospasm. If they are repeatedly normal in the presence of symptoms, then a diagnosis of asthma must be in doubt.

Variability of PEF and FEV1, either spontaneously over time or in response to therapy, is a characteristic feature of asthma. Sequential measurement of PEF may be useful in making the diagnosis. A 20% or greater variability in amplitude with a minimum change of 60 l/min, ideally for three days in a week for two weeks seen over a period of time, is highly suggestive of asthma. As with other aspects of the framework, decisions about which patients actually have asthma and should therefore be included on the register are clinical ones which are intended to be made by individual GPs.

Many patients with asthma will demonstrate variability below 20%, making this a reasonably specific but insensitive diagnostic test. Marked variability of peak flow and easily demonstrated reversibility confirm a diagnosis of asthma but smaller changes do not necessarily exclude the diagnosis.

SIGN/BTS British Guideline on the Management of Asthma

Children
A definitive diagnosis of asthma can be difficult to obtain in young children. Asthma should be suspected in any child with wheezing, ideally heard by a health professional on auscultation and distinguished from upper airway noises.

In schoolchildren, bronchodilator responsiveness, PEF variability or tests of bronchial hyperactivity may be used to confirm the diagnosis, with the same reservations as above.

The diagnosis of asthma in children should be based on:
- the presence of key features and careful consideration of alternative diagnoses
- assessing the response to trials of treatment and ongoing assessment
- repeated reassessment of the child, questioning the diagnosis if management is ineffective.

Grade D recommendation: SIGN/BTS British Guideline on the Management of Asthma

It is well recognised that asthma is a variable condition and many patients will have periods when they have minimal symptoms. It is inappropriate to attempt to monitor symptom-free patients on no therapy or very occasional therapy.

This produces a significant challenge for the Quality and Outcomes Framework. It is important that resources in primary care are targeted to patients with greatest need - in this instance patients who will benefit from asthma review rather than insistence that all patients with a diagnostic label of asthma are reviewed on a regular basis.

For this reason it is proposed that the asthma register should be constructed annually by searching for patients with a history of asthma, excluding those who have had no prescription for asthma-related drugs in the last 12 months. This indicator has been constructed in this way as most GP clinical computer systems will be able to identify the defined patient list.

Asthma 1.2 Preferred Coding
Asthma H33%

Asthma 1.3 Reporting and Verification
Asthma 1.3.1 Practices should report the number of patients with active asthma (ie a diagnosis of asthma, excluding those who have had no prescription issued for an asthma-related drug in the last 12 months), and the number of patients with active asthma (ie diagnosis of asthma, excluding those who have had no prescription issued for an asthma-related drug in the last 12 months) as a proportion of their practice list size.

Asthma 1.3.2 Practices should report the number of patients with inactive asthma (ie those who have a diagnosis of asthma who have had no asthma-related drug issued in the last 12 months) and the number of patients with inactive asthma (ie those who have a diagnosis of asthma who have had no asthma-related drug issued in the last 12 months) as a proportion of their practice list size.

Verification - PCOs may compare the expected prevalence with the reported prevalence.

Asthma Indicator 2
The percentage of patients aged eight and over diagnosed as having asthma from 1 April 2003 where the diagnosis has been confirmed by spirometry or peak flow measurement

Asthma 2.1 Rationale
The SIGN guideline suggests that confirmation of diagnosis by spirometry or serial peak flows should be utilised in schoolchildren, but does not specify an age. The age of eight has been pragmatically agreed for the indicator although many children aged six and over will be able to co-operate with PEF measurements or spirometry.

This indicator is introduced for diagnosis with effect from 1 April 2003 as it is recognised that recording to date may have not been undertaken in a systematic way.

Asthma 2.2 Preferred Coding
Spirometry 33G1
Peak flow rate abnormal 3395

Asthma 2.3 Reporting and Verification
The practice should report the percentage of patients aged eight or over diagnosed as having asthma after 1 April 2003 who have a record of spirometry or peak flow measurement.

Asthma Indicator 3
The percentage of patients with asthma between the ages of 14 and 19 in whom there is a record of smoking status in the previous 15 months

Asthma 3.1 Rationale
Two indicators have been included on the recording of smoking advice (Asthma 3 and Asthma 4). The two indicators, which relate to different age groups, have been included because GPs may take a different clinical approach to this issue at different ages. Many young people start to smoke at an early age. It is therefore justifiable to ask about smoking on an annual basis. Patients aged 20 and over fall into two categories: those who have never smoked, where recurrently asking about smoking status is inappropriate, and those who are smokers or ex-smokers where regular recording and offering of smoking cessation advice is appropriate. The indicators developed for the two age groups therefore differ: in adults who have who have a record of never having smoked, regular recording of smoking status is not recommended (indicator Asthma 4), whereas annual enquiry is recommended in children (indicator Asthma 3).

The number of studies of smoking related to asthma are surprisingly few in number. Starting smoking as a teenager increases the risk of persisting asthma. SIGN/BTS were unable to identify any study which considered the question of whether smoking affects asthma severity. One controlled cohort study suggested that exposure to passive smoke at home delayed recovery from an acute attack.

It is recommended that smoking cessation be encouraged as it is good for general health and may decrease asthma severity.

Asthma 3.2 Preferred Coding
Never Smoked 1371
Ex-Smoker 137L
Smoker 137R

Asthma 3.3 Reporting and Verification
Practices should report the percentage of patients on the asthma register between the ages of 14 and 19 where smoking status has been recorded in the last 15 months.

Asthma Indicator 4
The percentage of patients aged 20 and over with asthma whose notes record smoking status in the past 15 months, except those who have never smoked where smoking status should be recorded at least once

Asthma 4.1 Rationale
See asthma 3.1

Asthma 4.2 Preferred Coding
Never Smoked 1371
Ex-Smoker 137L
Smoker 137R

Asthma 4.3 Reporting and Verification
The aim of this indicator is to ensure that the smoking status of all patients is known in the previous year, making the assumption that patients who have never smoked will continue not to smoke (in order to avoid keeping asking them).

The numerator of the indicator is the number of asthma patients aged 20 and over who have never smoked plus the number who have been recorded as ex- or current smokers in the past 15 months. The denominator is the total number of asthma patients age 20 and over. Thus:

Asthma Indicator 5
The percentage of patients with asthma who smoke, and whose notes contain a record that smoking cessation advice or referral to a specialist service, if available, has been offered within the last 15 months

Asthma 5.1 Rationale
The evidence for the value of smoking cessation advice is largely extrapolated from studies in relation to CHD.

Many strategies have been used to help people to stop smoking. A meta-analysis of controlled trials in patients post myocardial infarction showed that a combination of individual and group smoking cessation advice, and assistance reinforced on multiple occasions - initially during cardiac rehabilitation and reinforced by primary care teams - gave the highest success rates.

Reference Grade B recommendation SIGN Guidelines 41/51

Further Information: http://www.sign.ac.uk/guidelines/fulltext/51/index.html
Further Information: http://www.sign.ac.uk/guidelines/fulltext/41/index.html

A number of studies have recently shown benefits from the prescription of nicotine replacement therapy or buproprion in patients who have indicated a wish to quit smoking. Further guidance is available from NICE.

Further Information: http://www.nice.org.uk/pdf/NiceNRT39GUIDANCE.pdf

In a significant number of PCOs across the UK specialist smoking cessation clinics are now available. Referral to such clinics, where they are available, can be discussed with patients. This should also be recorded as smoking cessation advice.

Asthma 5.2 Preferred Coding
Smoking Cessation advice 8CAL

Asthma 5.3 Reporting and Verification
Practices should report the percentage of asthmatic patients who smoke who have been offered smoking cessation advice in the last 15 months.

Asthma Indicator 6
The percentage of patients with asthma who have had an asthma review in the last 15 months

Asthma 6.1 Rationale
Structured care has been shown to produce benefits for patients with asthma. The evidence on the important aspects of structured care is not good, although the recording of morbidity, PEF levels, inhaler technique and current treatment and the promotion of self-management skills are common themes. SIGN/BTS proposes a structured system for recording inhaler technique, morbidity, PEF levels, current treatment and asthma action plans.

Reference Grade C Recommendation SIGN/BTS British Guideline on the Management of Asthma

The Quality and Outcomes Framework suggests the utilisation of the RCP three questions as an effective way of assessing symptoms:

"In the last month
- Have you had difficulty sleeping because of your asthma symptoms (including cough)?
- Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)?
- Has your asthma interfered with your usual activities eg housework, work/school etc?"

Although there is good evidence on the use of personalised asthma plans in secondary care, there is very limited evidence in primary care. Practices may wish to follow the advice of the BTS/SIGN guideline and offer a personalised asthma action plan to patients.

Peak flow is a valuable guide to the status of a patient's asthma. However, it is much more useful if there is a record of patients' best peak flow, ie their peak flow when they are well. Many guidelines for exacerbations are based on the ratio of current to best peak flows. For patients over the age of 18 there need be no particular time limit on when the best peak flow was measured although in view of the reduction of peak flow with age it is recommended that the measurement be within the preceding five years. For patients aged 18 and under the peak flow will be changing; therefore it is recommended that the best peak flow should be re-assessed annually.

Inhaler technique should be reviewed but there is no evidence to suggest how frequently this should be undertaken.

Summary of Asthma Review:

- Assess symptoms (using RCP 3 questions)
- Measure peak flow
- Assess inhaler technique
- Consider personalised asthma plan

It is recognised that a significant number of patients with asthma do not regularly attend for review. For this reason the percentage achievement for the asthma indicators has been set at a lower level compared to process indicators in some other chronic disease areas.

Asthma 6.2 Preferred Coding
Asthma Review 66YJ

Asthma 6.3 Reporting and Verification
Practices should report the percentage of patients on their asthma register who have had an asthma review in the last 15 months.

Asthma Indicator 7
The percentage of patients with asthma aged 16 and over who have had influenza immunisation in the preceding 1 September to 31 March

Asthma 7.1 Rationale
There a current recommendation from the Departments of Health and the Joint Committee on Vaccination and Immunisation (www.doh.gov.uk/greenbook/) which suggests that influenza immunisation should not be given under 6 months of age. While the guidance implies that all asthmatic children should be immunised annually from the age of 6 months, this advice is so far from common practice among GPs that this indicator refers to adults only at present.

Asthma 7.2 Preferred Coding
Flu Vaccination given 65E
Flu vac contra indicated 8I2F

Asthma 7.3 Reporting and Verification
The percentage of patients on the asthma register aged 16 and over who have had an influenza immunisation administered in the preceding 1 September to 31 March.