Pragmatic 'real world' study of the effect of audit of asthma on clinical outcome.

AIMS: To test whether participation in clinical audit is associated with improved care of a long-term health condition. METHODS: 'Real world' study comparing 1339 patients of all ages and severity of asthma managed by 77 self-selected highly motivated general practices in Scotland with 9617 patients from 319 practices from a national sample. RESULTS: Patients managed by 'audit' practices had more structured clinical reviews by nurses [817 (61%) versus 4301 (45%) OR 0.52, 95% CI 0.46-0.58] and less acute GP contacts [440 (33%) v 4161 (43%) OR 1.56, CI 1.38-1.56]. Consequently they experienced more checking of inhaler technique, use of peak flow meters and self- management plans. 'Audit' patients had more symptom free days [365 (42%) v 2216 (23%) OR 0.80, CI 0.70-0.91], and fewer asthma attacks [217 (16%) v 1938 (20%) OR 1.30, CI 1.12-1.53]. They made less use of hospital services including A&E [30 (2%) v 326 (3%) OR 1.53, CI 1.03-2.28] and outpatients [42 (3%) v 459 (5%) OR 1.55, CI 1.11-2.16]. CONCLUSIONS: Patients with asthma benefit from being managed by a practice involved in a programme of audit.

What predicts poor collection of medication among children with asthma? A case-control study.

Compliance with asthma medication is recognised to be a problem. Acquisition of medication is the first step towards compliance. Factors predicting poor collection of prophylactic medication were investigated. A case/control study was conducted. Cases were children who had had at least two consultations for poorly controlled asthma in 1 yr and collected prescriptions of prophylactic medication irregularly. Controls were children whose prescriptions were collected as instructed. Levels of knowledge about asthma and asthma medication were high in both groups. Parents of cases were more likely to perceive their child's asthma to be moderate or severe and more likely to report that their child's asthma was not well controlled. They reported more night-time symptoms, exercise symptoms and school absence. Parents of cases were less likely to report that administering inhalers was part of the evening routine. They were less likely to perceive their child's prophylactic medication to be very effective and more reluctant to administer prophylactic medication. Some parents may decide to undertreat their children, although lack of organised routine may contribute to poor compliance. Parents need guidance on interpreting symptoms and support in establishing routines for the administration of medication.

The RCP's 'Three Key Questions' for asthma: review of practical use.

Assessment tools are a vital component of chronic disease management. The Royal College of Physicians has developed a patient-focused outcome measure for the treatment of asthma, the 'Three Key Questions'. However, in a study investigating the goals of people with asthma, several issues related to the tool emerged. Forty-seven adults of a range of ages and asthma severity but with no significant co-morbidity were interviewed. It emerged that the outcome measure may be subject to recall bias. Also, symptom reports may be conflated if daytime symptoms also occur with activity. 'Interference with activity' is a subjective term the interpretation of which varies considerably. Changes in the level of activity undertaken may be reported rather than changes in symptom severity. The 'Three Key Questions' are not fully patient-centred because they assess the presence of symptoms rather than their importance to the individual. The use of the 'Three Key Questions' as an outcome measure may not allow valid comparisons to be made between settings.

Lessons from a randomized controlled trial designed to evaluate computer decision support software to improve the management of asthma.

PRIMARY OBJECTIVE: To investigate whether computer decision support software used in the management of patients with asthma improves clinical outcomes. RESEARCH DESIGN: Randomized controlled trial with practices each reporting on 30 patients with asthma over a 6 month period. METHODS AND PROCEDURES: 447 patients were randomly selected from practice asthma registers managed by 17 general practices from throughout the UK. Intervention practices used the software during consultations with these patients throughout the study while control practices did not. MAIN OUTCOMES AND RESULTS: Practice consultations, acute exacerbations of asthma, hospital contacts, symptoms on assessment and medication use. A smaller proportion of patients within the intervention group initiated practice consultations for their asthma: 34 (22%) vs 111 (34%), odds ratio (OR) = 0.59, 95% confidence interval (CI) (0.37-0.95); and suffered acute asthma exacerbations: 12 (8%) vs 57 (17%), OR = 0.43, 95% CI = 0.21-0.85 six months after the introduction of the computer decision support software. There were no discernable differences in reported symptoms, maintenance prescribing or use of hospital services between the two groups. CONCLUSION: The use of computer decision support software that implements guidelines during patient consultations may improve clinical outcomes for patients with asthma.

Cross-sectional observations on the natural history of asthma.

BACKGROUND: Asthma is a major health care problem that affects all ages. It is uncertain whether asthma is a single clinical entity or a grouping of separate clinical syndromes that share a common set of treatment guidelines. AIM: To observe the symptoms, treatment step, and health service utilisation of a population of patients throughout the United Kingdom (UK) listed on an asthma register. DESIGN OF STUDY: A cross-sectional study and clinical assessment of asthma patients. SETTING: A total of 12,203 patients from 393 general practices throughout the UK. METHOD: A database was used to observe the symptoms, treatment step, and health service utilisation of the asthma patients. RESULTS: Children aged up to four years had a distinctive profile of symptoms, including night time cough. They also experienced increased health service utilisation including a high hospital admission rate. Symptoms in adults became more common with increasing age. The pattern of symptoms in patients aged 45 years and over suggest many patients on asthma registers may have chronic obstructive pulmonary disease. Patients aged 16 to 30 years showed a different pattern of health service usage to those aged 5 to 15 years and 31 to 45 years, relying more on unscheduled use of health services rather than a review-based management plan. Patients aged 16 to 30 years used less anti-asthma medication than those aged 5 to 15 years and 31 to 45 years. CONCLUSIONS: Databases may be a useful tool with which to study the natural history of asthma, but there are problems with bias. Several clinical subgroups exist within the broad diagnosis label of asthma. Knowledge of how these subgroups of doctor-diagnosed asthma use health services may help clinicians to create individual care plans for groups of patients.

Scottish Asthma Management Initiative.

OBJECTIVES: To describe the development process of a system that links audit, research and patient care and to detail the lessons learned from establishing a Scotland wide asthma management initiative. DESIGN, SETTING AND SUBJECTS: Health Boards and practices throughout Scotland were invited to participate in an initiative which links review of care, guideline implementation, chronic disease management (CDM) approval and post-graduate education for doctors (PGEA) and nurses (PREP). Participating practices were given the materials to review 30 patients randomly selected from their asthma register. Health service resource use and drugs prescribed over a retrospective 12 month period were recorded for each patient using paper or electronic materials. All patients were invited for clinical assessment. RESULTS: A two-tier management system proved effective. Twelve of the 15 Scottish health authorities agreed to recognise the audit for automatic CDM approval although the negotiation process was prolonged; 566 practices from all parts of Scotland have expressed an interest in the initiative. Provision of distance learning material linked to PGEA accreditation is free to general practitioners (GP's) and is a useful incentive for participation. To date 42 GPs have completed the distance learning element. CONCLUSION: The Scottish Asthma Management Initiative has provided the opportunity for all sectors of the health service in Scotland to work together to explore innovative ways to improve the management and care of chronic disease. Participation in an initiative linked to guidelines, education and CDM approval is an excellent way to facilitate health professionals to improve care.

Risk factors and costs associated with an asthma attack.

BACKGROUND: A study was undertaken to identify asthma patients at risk of an attack and to assess the economic impact of treatment strategies. METHODS: A retrospective cohort analysis of a representative data set of 12 203 patients with asthma in the UK over a one year period was performed. Logistic multiple regression was used to model the probability of an attack occurring using a set of categorised predictor factors. Health service costs were calculated by applying published average unit costs to the patient resource data. The main outcome measures were attack incidence, health service resource use, drug treatment, and cost estimates for most aspects of asthma related health care. RESULTS: Children under five years of age accounted for 597 patients (5%), 3362 (28%) were aged 5-15 years, 4315 (35%) 16-44, 3446 (28%) 45-74, and 483 (4%) were aged over 74 years. A total of 9016 patients (74%) were on some form of prophylactic asthma medication; 2653 (22%) experienced an attack in the year data collection occurred. Overall health care expenditure was estimated at pound2.04 million. The average cost per patient who had an attack was pound381 compared with pound108 for those who did not, an increase of more than 3.5 times. In those aged under five and those over 75 years of age there were no significant markers to identify risk, but both groups were small in size. The level of treatment step in the British Thoracic Society (BTS) asthma guidelines was a statistically significant factor for all other age groups. Night time symptoms were significant in the 5-15, 16-44 and 45-74 age groups, exercise induced symptoms were only significant for the 5-15 age group, and poor inhaler technique in the 16-44 age group. CONCLUSIONS: Patients at any treatment step of the BTS asthma guidelines are at risk of an asthma attack, the risk increasing as the treatment step increases. Poorly controlled asthma may have a considerable impact on health care costs. Appropriate targeting of preventive measures could therefore reduce overall health care costs and the growing pressures on hospital services associated with asthma management.

A cost analysis on the pattern of asthma prescribing in the UK.

There is a need to establish the proportion of adult asthmatics at each step of the recommended asthma management guidelines, the cost of their prescribed treatment, and a revised cost of treatment assuming patients who were suboptimally controlled were moved up a step. Actual prescription and cost figures and a theoretical projection of an ideal scenario was calculated from a sample of general practices in Great Britain from the Doctors Independent Network. They comprised 102 nationally distributed practices and 17,206 adult patients with a diagnosis of, and prescription related to, asthma recorded between October 1993 and March 1994. Ninety-one per cent of patients received treatment within a recognized step of the guidelines. Of these, 80% were at steps 1 and 2. Employing excess inhaled beta-agonist use as a proxy for control of asthma, between 55% and 69% of patients at Steps 1-3 should receive treatment at a higher step. This could lead to an increased expenditure of up to Pound Sterling 4.66 per adult patient per month. This would imply a rise in the annual UK cost of antiasthma prescriptions for adults from Pound Sterling 388m to a possible Pound Sterling 533m. The United Kingdom Government audit commission has suggested that current expenditure on asthma treatment appears to be insufficient. Using an entirely different approach this study has confirmed that a significant increase in asthma prescribing costs is likely to be needed if optimal control of asthma is to be achieved.

Effect of asthma and its treatment on growth: four year follow up of cohort of children from general practices in Tayside, Scotland.

OBJECTIVE: To investigate whether asthma or its treatment impairs children's growth, after allowing for socioeconomic group. DESIGN: 4 year follow up of a cohort of children aged 1-15. SETTING: 12 general practices in the Tayside region of Scotland. SUBJECTS: 3347 children with asthma or features suggestive of asthma registered with the general practices. MAIN OUTCOME MEASURES: Height and weight standard deviation scores. RESULTS: Children who lived in areas of social deprivation (assessed by postcode) had lower height and weight than their contemporaries (mean standard deviation score -0.26 (SD 1.02) and -0.18 (1.15) respectively, P < 0.001 for both). Children who were receiving > or = 400 micrograms daily of inhaled steroids and who were attending both hospital and general practice for asthma care had lower height and weight than average, independent of the effect of deprivation (mean standard deviation score -0.62 (1.01), P = 0.002, for height and -0.58 (0.94), P = 0.005, for weight). Children receiving high doses of inhaled corticosteroids also showed lower growth rates (mean change in standard deviation score -0.19 (0.51), P = 0.003). However, no other children with asthma showed growth impairment. CONCLUSION: Most children with asthma were of normal height and weight and had normal growth rates. However, children receiving high doses of inhaled steroids and requiring both general practice and hospital services had a significant reduction in their stature. This effect was independent from but smaller than the effect of socioeconomic group on stature.

Does participation in distance learning and audit improve the care of patients with acute asthma attacks? The General Practitioners in Asthma Group.

OBJECTIVE: To test whether general practitioners who completed an audit cycle encompassing a data recording exercise, distance learning programme and personalized feedback changed their management of patients with acute asthma attacks. DESIGN, SETTING AND SUBJECTS: Practice and patient details from two national correspondence surveys of the management of acute asthma attacks in the United Kingdom in 1991-92 and 1992-93 were compared. Main outcome measures were use of nebulised bronchodilators, systemic steroids during an asthma attack, and increased use of prophylactic therapy after attacks. RESULTS: Ninety-one general practitioners completed an audit cycle and reported data on 782 patients with asthma attacks in 1991-92 and 669 in 1992-93. There were no significant changes in practice resources during this time. Management changed in line with recommended guidelines and audit feedback suggestions leading to more use of nebulised bronchodilators [272 (35%) before, 268 (40%) after, Odds Ratio (OR) 0.80, 95% Confidence Intervals (CI) 0.64-0.99], systemic steroids [563 (72%) before, 506 (76%) after, OR 0.83, CI 0.65-1.06], and 'step-up' in preventative therapy [402 (51%) before, 382 (57%) after, OR 0.79, CI 0.64-0.98]. CONCLUSION: General Practitioners who completed an audit cycle showed changes in the management of acute asthma attacks in line with guidelines which may have been caused by participation in distance learning and clinical audit. However, general practitioners motivated to change clinical management may be similarly motivated to take part in audit. Audit may be the catalyst for change rather than the cause of change.

The facilitator effect: results from a four-year follow-up of children with asthma.

BACKGROUND: A long-term evaluation of the process and outcomes of primary and secondary care is required to establish whether audit facilitators can improve the care of childhood asthma. AIM: To examine the long-term effect of an intervention by an audit facilitator on the management of children with asthma, and to investigate the implications for health service costs. METHOD: A 4-year follow up was conducted of an intervention and control group totalling 2557 children aged 1-15 years from 12 general practices in the Tayside region. Primary care consultations, prescriptions, hospital contacts and health service costs 1 year before and 3 years after a facilitator visited practices were recorded. The facilitator encouraged the diagnosis and treatment of childhood asthma in the intervention group. RESULTS: Favourable changes in consultation patterns, prescriptions and reduced hospital admissions seen during the intervention year did not persist in subsequent years. Two and three years after the facilitator visit the process and outcome of care was similar in both groups. The reduction in health service costs seen in the intervention group was equivalent to the cost of employing a facilitator. CONCLUSION: The effect of a facilitator lasts only for the period of intervention. Enthusiasts will say that improving patient care without increasing health service costs justifies the widespread deployment of facilitators. Others more interested in long-term outcomes may disagree.

How general practitioners manage acute asthma attacks.

BACKGROUND: The management of asthma attacks by general practitioners in 1992/93 was compared with 1991/92 in relation to recommended guidelines. METHODS: The findings from a postal survey of 299 UK general practitioners who managed 2332 patients with an asthma attack in 1992/93 were compared with those from 218 practitioners who managed 1805 attacks in 1991/92. Management by a subgroup of practitioners from a special interest group was analysed separately. RESULTS: In 1992/93 2031 (87%) of attacks were managed entirely by general practitioners, 251 (11%) were referred for admission to hospital, and 50 (2%) were managed by an accident and emergency department. There was no change in the pattern of management relative to 1991/92. Compared with recommended guidelines there was underuse of systemic steroids and nebulised bronchodilators. Between 1991/92 and 1992/93 use of systemic steroids in acute attacks increased from 56% to 71%, nebulised bronchodilators from 31% to 32%, and an increase in prophylactic medication after an acute attack from 41% to 49%. Contrary to guidelines, antibiotic use increased from 32% to 40% of attacks. Practitioners from a special interest asthma group gave more of their patients systemic steroids and nebulised bronchodilators both in 1991/92 and 1992/93. CONCLUSIONS: Some aspects of the management of asthma attacks by general practitioners has changed in line with guidelines, but there is still a large gap between actual and recommended management.

Observations on the structure, process and clinical outcomes of asthma care in general practice.

BACKGROUND: There is a need to establish whether the structure of asthma care in general practice is associated with measures of process and with primary and secondary care clinical outcomes. Debate about how to resource general practice asthma care is hampered by a lack of observational data from throughout the United Kingdom (UK). AIM: To observe whether the present system of family health services authority (FHSA) accreditation of asthma clinics, based on measures of structure, is associated with measures of process or clinical outcome. METHOD: Two hundred and twenty-five UK practitioners enrolled in a project and recorded details of how they organized asthma care. Data from 6732 patients, concerning general practitioner and nurse consultations, asthma attacks, symptom control, emergency treatments and hospital attendances covering a 12-month period, were also provided. RESULTS: FHSA approval for a chronic disease management (CDM) asthma clinic was associated with favourable patterns of structure and process, but not of clinical outcome. Practice audit and the employment of a nurse with an asthma diploma were associated with favourable patterns of structure, process and clinical outcome. Practices (n = 143) that had recently audited asthma patient care (n = 4259) had fewer patients who had attended an accident and emergency department [121 (3%): 96 (4%), odds ratio 1.38, 95% confidence interval 1.04-1.83] or a hospital outpatients department [247 (6%): 180 (7%), 1.28, 1.04-1.56], or who had respiratory symptoms on assessment [2400 (56%): 1465 (59%), 1.34, 1.18-1.52] or days absent from work or school in the past 12 months [375 (9%): 296 (12%), 1.48, 1.25-1.74] than those that had not (82 practices, 2473 patients). CONCLUSION: Findings from a large UK sample of practices are subject to participant bias and show association rather than causal links. The present FHSA asthma CDM accreditation system, based on structure, is not associated with favourable clinical outcomes. This opens the debate as to whether accreditation should be linked to recent experience of audit, which does appear to be associated with favourable clinical outcomes.

Asthma and growth--cause for concern? Asthma & Growth in Tayside Children.

This project aimed to investigate the height and weight of children with asthma in the community. The Tayside Childhood Asthma Project examined medical records of 3143 children drawn from 12 general practices, for details of asthma morbidity and management. Concurrently, but independent from it, the Tayside Growth Study measured heights and weights of children aged 3-5, 5, 7, 9, 11 and 14 years. This paper reports on a cross-sectional analysis of 699 children who were known to be receiving some form of asthma medication during the school years 1990-91 and 1991-92 when a growth measurement was recorded. A standard deviation score (SDS) was calculated from height measurements for this cohort of children and from weight and body mass index (BMI = weight/height2) measurements for 559 of these children. The mean and standard deviation of these SDS values were calculated, and the distribution of the scores plotted. The results showed no difference in height, weight or BMI between the general population and the cohort receiving asthma medication. However, further analysis showed the distribution of height for children with severe asthma receiving high doses of inhaled corticosteroids (mean -0.38, SD 0.95) was significantly different from the general population (mean 0, SD 1). This group of children appeared to be shorter, by as much as 2 cm on average for a 5-year-old boy. In general, children receiving treatment for asthma within the community have a similar distribution of height and weight to normal children. Children receiving high-dose inhaled corticosteroids are shorter than their contemporaries, and deserve long-term follow-up.

School absence--a valid morbidity marker for asthma?

OBJECTIVE: To determine how often children with asthma are absent from school compared to the 'average' child and to assess the validity of school absence as a marker of morbidity for asthma. DESIGN: Case control study. SETTING: Children registered with 12 general practices, attending 98 primary and secondary schools in the Tayside region. SUBJECTS: 773 children with asthma or related symptoms and 773 controls from school registers. MAIN OUTCOME MEASURES: Episodes of school absence and days absent per term, recorded from school registers. RESULTS: Comparing children taking asthma medication against their controls showed a significant difference for both days absent and episodes of absence. This increase in absence was approximately one school day each term. Severity of asthma was not related to increased school absence. Children receiving no asthma medication, but with asthma related symptoms, were absent no more than their age/sex matched controls. Applying a deprivation index to the cases on asthma medication, gave a significant difference in episodes of absence between Primary children classified as highly deprived and other Primary children. CONCLUSION: The increase in school absence of around one day per term for children with asthma is less than previously reported and could be caused by clinic attendance rather than ill health due to asthma. Recorded absence varied according to deprivation index but not asthma severity. The use of school absence as a marker of morbidity in childhood asthma needs to be reassessed.

Do self-management plans reduce morbidity in patients with asthma?

BACKGROUND: Self-management plans may help patients with asthma intervene when symptoms deteriorate, thus preventing asthma attacks. AIM: A study set out to test whether a self-management plan tailored to the circumstances of the individual reduces morbidity from asthma. METHOD: General practitioners who had participated in a national audit of asthma attacks were randomized into intervention and control groups. Six months after the intervention group had issued self-management plans to patients with asthma, both groups of practitioners completed morbidity questionnaires on patients. Morbidity outcomes were compared for the 6-month periods before and after the issue of the plans. RESULTS: In the 6 months before the study, the 376 patients enrolled by the intervention group experienced higher levels of morbidity than the 530 patients for whom details were recorded by the control group. In the 6 months after the issue of the plans, control group patients showed little change in levels of morbidity, but intervention group patients showed significant reductions in hospital admissions, consultations for asthma symptoms, asthma review consultations, courses of oral steroids and use of emergency nebulized bronchodilators. CONCLUSION: General practitioners appeared to operate enthusiast bias' and issued more self-management plans to patients with uncontrolled asthma. The reduction in morbidity in this group is probably a result of the use of the plans, but the verdict on whether plans reduce morbidity must be deemed 'not proven'.

The use of children's medical records to predict the risk of asthma attack.

Using a large data base of respiratory morbidity in children the opportunity arose to explore the link between what was written in general practice case records and the subsequent risk of a child developing an asthma attack or hospital admission due to asthma. Children with five or more consultations in one year for respiratory symptoms had a 33% risk of experiencing an asthma attack or 7.1% risk of admission in the following year. Twenty seven percent of children who received antibiotics for "respiratory infections" subsequently had an asthma attack. The potential exists to review past and present symptoms and thus attempt to predict future morbidity. Childhood asthma is an example where the quality of care offered by general practitioners could be improved if a precise estimate of risk could be used to modify clinical management.

Controlled trial of an audit facilitator in diagnosis and treatment of childhood asthma in general practice.

OBJECTIVE: To test whether an audit facilitator could alter the pattern of diagnosis and treatment of childhood asthma. DESIGN: Randomised stratified controlled trial. SETTING: 12 general practices in Tayside. SUBJECTS: 3373 children aged 1-15 inclusive who had symptoms suggestive of asthma or possible asthma drawn from a systematic review of 10,725 general practice case records. INTERVENTION: Children were targeted for a clinical review by their general practitioner or practice nurses. MAIN OUTCOME MEASURES: Asthma related consultations, prescriptions, hospital attendances, and health service costs 12 months before and after study. RESULTS: Compared with controls (n = 1563) the intervention group (n = 1585) had more practice initiated consultations for asthma (relative risk 2.18 (95% confidence interval 1.74 to 2.73)), new diagnoses of asthma (2.83 (2.26 to 3.54)), and past diagnoses reaffirmed (1.30 (1.08 to 1.58)), and they were more frequently prescribed inhaled cromoglycate (1.52 (1.02 to 2.25)). Hospital inpatient day rates fell from 152 to 122 in the intervention group and rose from 69 to 117 in the control group between the year before and the year after study. Total primary care costs rose from 30,118 pounds to 37,243 pounds in the intervention group and fell from 29,131 pounds to 27,990 pounds in the control group. Hospital care cost fell in the intervention group from 25,406 pounds to 20,727 pounds and rose in the control group from 12,699 pounds to 19,650 pounds. CONCLUSION: An audit facilitator can favourably influence the pattern of diagnosis and treatment of childhood asthma in general practice. This may have an impact on health service costs.