Asthma Care Audit Instructional Guide

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PRIMIS: Audit Tool Instructional Guide

Asthma_Analysis_V1.0 25th September 2014

Introduction

Asthma is a common respiratory condition that is largely managed in primary care, generating significant work for general practice1. Asthma symptoms are notoriously variable and intermittent and it is the episodic nature of the disease that makes it difficult to define and diagnose.

There is no confirmatory diagnostic test for asthma, meaning diagnosis relies on clinical interpretation of symptoms and suggestive changes in lung function tests1,2. Consequently, asthma prevalence is a complex area that is open to interpretation. Prevalence in the UK is reportedly amongst the highest in the world at approximately 9-10% of adults according to a report from the Department of Health3. This is slightly higher than the rates reported by Asthma UK who state that 1 in 11 children and 1 in 12 adults in the UK are currently being treated for asthma:

“5.4 million people in the UK are currently receiving treatment for asthma: 1.1 million children (1 in 11) and 4.3 million adults (1 in 12). The UK has among the highest prevalence rates of asthma symptoms in children worldwide.”

Asthma UK: Asthma Facts and FAQs4_.

The majority of the workload relating to asthma is generated by poor disease

management, particularly the under use of preventative medicine1_{. Asthma cannot}

be cured, but with appropriate management it can be controlled, enabling good quality of life5. Symptoms can be relieved with short-term medication whilst long-term inhaled steroids are used to limit disease progression. Long-long-term daily

medication can control underlying inflammation and help to prevent symptoms and reduce the risk of exacerbation5.

Severity of asthma is assessed by the amount of medication needed to control the disease6. The National Review of Asthma Deaths (NRAD) in 2011 defined severe asthma as those patients who receive treatment at the British Thoracic

Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN) steps 4 and 5 or have evidence of hospital admission or asthma attack in the previous year1,6.

Asthma control relates to the presence of related symptoms, such as breathlessness and wheezing. Recurrent asthma symptoms frequently cause sleeplessness,

tiredness, reduced activity levels and absenteeism5. During an asthma attack, the lining of the bronchial tubes swell; this causes the airways to narrow and reduces the amount of air that can enter the lungs. Asthma attacks can be fatal. The number of (reported) asthma related deaths in the UK is amongst the highest in Europe6.

“Premature mortality from COPD in the UK was almost twice as high as the European average and premature mortality for asthma was over 1.5 times higher. Around 90% of deaths from asthma each year could have been prevented.”

“There are around 1,000 deaths from asthma a year in the UK, the majority of which are preventable.”

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Asthma_Analysis_V1.0 Page 4 of 39 25th September 2014 Medication is the optimum way to control the disease, although, asthma is

sometimes referred to as an atopic disease due to the fact that allergen exposure can produce atopic sensitisation. It has been proposed that prolonged allergen exposure can result in clinical asthma through inflammation of the airways, bronchial hyper responsiveness and reversible airflow obstruction7. Asthmatic patients should learn to recognise environmental triggers that provoke allergic reactions or irritate the airways in order to avoid them and potentially provide an extra degree of control3,5.

One of the main aims of asthma care is to achieve freedom of symptoms for

patients. The Royal College of Physicians has developed a patient-focused outcome measure to help health professionals assess whether the care they provide is

effective. By asking all asthma patients (regardless of severity) three specific symptom-related questions at every review, it is possible to build a picture of the overall well-being of asthma patients over time8,9_.

The fundamental causes of asthma are not completely understood, making it impossible to prevent the disease from developing3. A combination of exposure to environmental triggers along with a family history of the disease is by far the

strongest risk factor for developing asthma5. Asthma is currently under-diagnosed and under-treated5. The Outcomes Strategy for COPD and Asthma recommends early accurate diagnosis and assessment of severity to ensure that risks are reduced and effective interventions can begin earlier3. This can be greatly assisted through case finding activity in general practice to identify patients with asthma who have not yet been diagnosed.

Local Clinical Commissioning Groups (CCGs) and NHS England are under a statutory duty to continuously improve quality of care. In order to help support delivery of the NHS Outcomes Framework (NHS OF), NHS England has developed the Clinical Commissioning Group Outcomes Indicator Set (CCG OIS). The CCG OIS 2014/15 contains a specific indicator aimed at reducing time spent in hospital due to asthma10. The Outcomes Strategy for COPD and Asthma and the NICE Quality Standard for asthma11 (QS25) also help to support quality improvement in relation to the NHS Outcomes Framework.

Related QOF indicators – Year 2014/15

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Aim of the asthma care audit tool

The aim of the asthma care audit tool is twofold; to assist with case finding activity and to report upon the level of care being offered to patients diagnosed with asthma who have received asthma medication in the last year.

Note: For the purposes of this audit, patients who have not been prescribed asthma medication in the last year are excluded.

The main audit cohort will be referred to throughout this document as patients with

active asthma.

The case finder element provides practices with a list of patients who may have asthma but do not have this coded in their record. By undertaking a review of these patients and adding any missing diagnosis codes, practices can improve the quality of their asthma register, establish a more accurate prevalence rate and ensure that patients are monitored regularly and are appropriately managed.

The care management part of the audit tool helps practices identify where they can improve the quality of care they provide to patients with active asthma and reduce their risk of exacerbations.

The asthma care audit tool enables practices to extract and analyse relevant clinical data from their clinical information system. The audit tool works across all clinical information systems and presents data in an easy to use format allowing practices to gain insight and knowledge into their management of patients with asthma.

The asthma care audit tool helps practices by:

• generating a list of patients with possible asthma and providing relevant information to help clinicians to confirm or exclude diagnosis

• establishing a more accurate prevalence rate for asthma within their practice population

• facilitating clinical audit against national standards for all asthmatic patients prescribed asthma medication within the last 12 months

• summarising practice achievement of the Royal College of Physicians ‘3 questions’ outcome measure which assesses asthma patient wellbeing

• using patients’ medication history to summarise treatment strategies based upon the British Thoracic Society/Scottish Intercollegiate Guidelines Network

(BTS/SIGN) stepwise approach

• highlighting patients whose current treatment step may require review

• reporting on key factors that are associated with an increased risk of exacerbation

• providing the facility to compare data with other practices both locally and

nationally and the option to share aggregated data with their CCG via the CHART Online tool

• contributing to the delivery of the Quality and Outcomes Framework, the NICE quality standards for asthma (QS25), the NHS Outcomes Framework (NHS OF), the Clinical Commissioning Group Outcomes Indicator Set and the Public Health Outcomes Framework (PHOF)12.

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Asthma_Analysis_V1.0 Page 6 of 39 25th September 2014 As this is an audit tool, it has been designed simply to signpost GPs to patients who maybe of interest or concern and would benefit from review. The tool is not

intended to replace clinical decision making. Any action should be as a result of performing a clinical review with patients based upon individual circumstances. Clinical audit notes and GP revalidation

This audit tool has been designed to support GP revalidation. GPs can use the various displays within the CHART software to review clinical data at both patient and practice level, enabling them to maintain an overall picture of how they are managing patients at a population level but at the same time, look in detail at the care of individual patients.

• This is a retrospective clinical audit – looking back at clinical practice that has already taken place.

• When conducting clinical audit for GP revalidation, GPs might choose to audit just their own clinical practice. Note that the asthma care audit tool will report on all patients with active asthma or with factors suggesting possible asthma. Data will therefore be included on the activity of other colleagues within the practice.

• Involve fellow GPs in the clinical audit project. Several GPs who work together as a team can undertake a common audit. This is acceptable for the purpose of GP revalidation, as long as each GP can demonstrate that they have contributed fully to the clinical audit activity. Alternatively, seek their permission.

• A clinical audit on the care of patients with asthma (or possible asthma for case finder searches) matches the following criteria:

− it is of concern for patients and has the potential to improve patient outcomes

− it is important and is of interest to you and your colleagues

− it is of clinical concern

− it is of local or national importance

− it is practically viable

− there is new research evidence available on the topic

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Running the asthma audit tool

Before running the audit you must ensure that CHART is installed and you are familiar with how to use the software. Detailed instructions on CHART installation and using the software can be found on the PRIMIS website:

www.nottingham.ac.uk/primis/tools/chart/chart.aspx

There are two MIQUEST query sets contained within the asthma care audit tool: one for the case finder and one for the management of patients with active asthma. Once all data has been loaded into CHART software, practices can switch between the ‘Asthma Case Finder’ and the ‘Asthma Main Audit’ by using the ‘Select

Databook’ function as illustrated below:

Both audits search on all patients who are currently registered at the practice. It is recommended that both audits are run frequently (e.g. quarterly or six monthly) to monitor standards of care.

CHART Online

CHART Online is a secure web enabled tool that helps practices improve

performance through comparative data analysis. Using CHART Online, practices can explore and compare the quality of their own data with anonymised data from other practices, locally or nationally, through interactive graphs. CHART Online helps practices and Primary Care Organisations (PCOs) to improve data quality and identify ways to enhance patient care. Variations in data management and activity are more visible when compared across a group of GP practices. Comparative data analysis provides a powerful tool for standardising care across localities and may be of interest to local commissioning groups to facilitate the planning of care pathways. Aggregated summary data from the asthma care part of the audit tool can be

uploaded to the PRIMIS comparative analysis tool, CHART Online. There is an inbuilt security function that prevents patient identifiable data being uploaded. Only aggregate data compiled from the pseudonymised responses can be transmitted. Please note that data from the case finder element cannot be uploaded to CHART Online as there is no corresponding toolkit.

Access to the comparative views will be available online in the near future once sufficient data have been received to generate the graphs. Please upload data in the meantime to allow enough data to be received to produce the graphs.

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Asthma_Analysis_V1.0 Page 8 of 39 25th September 2014

Asthma Case Finder

It is strongly recommended that practices use the case finder tool before going on to examine the management of patients with active asthma. Using the case finder as a starting point will ensure that people with symptoms of asthma are diagnosed earlier, receive appropriate treatment and that the practice asthma register and practice prevalence rate are as accurate as possible.

The asthma case finder helps practices to answer the following questions:

• Do we have any patients with asthma who do not have the diagnosis coded in their electronic record?

• Are there any patients who would benefit from review for possible inclusion in the register and relevant treatment?

• How accurate is the practice prevalence rate for asthma?

The case finder audit includes all patients who are currently registered at the practice AND have Read coded entries that suggest possible asthma including:

i. asthma medication in the last 12 months ii. asthma monitoring at any time or

iii. positive asthma spirometry results at any time

It will exclude any patients with an existing diagnosis of asthma or COPD. Asthma case finder output

The asthma case finder tool provides the following views in CHART: 1. Summary sheet including

‐ a classic tabular view of the data 2. Full patient datasheet

Detailed information on each of these data views can be found on the following pages.

View 1 – Summary sheet (classic view)

The CHART summary sheet provides a synopsis of all the relevant data recorded by the practice and is the best place to start when viewing the results. The classic view presents practice data in tabular format covering medication, monitoring and

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An example practice summary sheet for the asthma case finder is shown below:

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Asthma_Analysis_V1.0 Page 10 of 39 25th September 2014 Key information

The first two rows of data (blue) provide some important pieces of information:

• an up to date count of the registered practice population

• the total number of patients who have Read coded entries related to asthma but do not have an asthma diagnosis coded in their record (patients included in the datasheet)

What to note about this practice

• 506 patients have been identified by the search and are included in the datasheet, meaning they have items in their record related to asthma but do not have an existing asthma diagnosis.

Suggested actions

• As a baseline quality check, assess whether the practice population count appears accurate. An unusually low number may suggest a problem whilst running the queries.

• Review the remaining summary sheet for further information on possible missing diagnoses. There may be patients with asthma who have not yet had this coded. Missing diagnoses will affect the accuracy of the practice disease prevalence rate.

Note: The case finder can only help to find patients who may be missing a diagnosis (potential under recording of asthma) and cannot help to identify patients who may incorrectly have a diagnosis recorded on their record (potential over recording). However, the main asthma care audit datasheet may be able to help identify such patients.

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Asthma medication in the last year

The next table provides a breakdown of the number of patients receiving asthma related medication in the last year despite not having an asthma or COPD

diagnosis*. Patients on multiple therapies will appear in more than one row/category.

Important note: Patients identified within the asthma medication table may be on this medication for other genuine reasons. The reasons for prescribing should be investigated to establish whether they are asthma related.

• 328 patients have been prescribed an inhaled short-acting β2 agonist (SABA)

in the last year.

• 110 patients have been prescribed inhaled corticosteroids in the last year (including combination inhalers).

• No patients have been prescribed an inhaled long-acting β2 agonist (LABA) in

the last year.

• 14 patients have been prescribed Leukotrienes in the last year. Suggested actions

• Try to identify the patients who are genuinely missing a diagnosis of asthma. Use the associated data in the datasheet to gain a picture of the patient’s history and look for indications or symptoms of asthma. Establish when the patient was last reviewed. The patient’s full medical record may need to be examined and/or the patient called for review to confirm or exclude diagnosis.

• Patients may have received more than one prescription for the relevant medication. Consult the relevant columns in the datasheet to determine the number of prescriptions issued in the last year. Relevant datasheet columns are ‘No. of ICS prescriptions L12m’ and ‘No. of SABA prescriptions L12m’.

• Use pre-set filter 1 within the datasheet to list patients who have been prescribed 2 or more asthma related medications within the last year (see page 15 for more information on pre-set filters). Pre-set filter 5 will list

patients who have received 3 or more prescriptions for a SABA inhaler in the last year.

*Patients are included in the case finder if they have a diagnosis of asthma AND have a coded entry of ‘Asthma Resolved’ where asthma resolved is the latest of the two entries.

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Asthma_Analysis_V1.0 Page 12 of 39 25th September 2014 Monitoring/tests

The next table provides a summary of the presence of relevant lung function tests and asthma monitoring codes. Patients with multiple factors will appear in more than one row.

The first category asthma monitoring includes any codes related to asthma such as asthma severity, emergency admissions due to asthma, asthma management plans and asthma limiting activities or disturbing sleep.

PEFR value, predicted PEFR value and FEV1/FVC value simply indicates that patients have a value recorded for these tests (not necessarily a diagnostic value). What to note about this practice

• 27 patients have monitoring codes related to asthma but do not have an existing diagnosis of asthma.

• 2 patients have an FEV1/FVC ratio post bronchodilator value recorded. Suggested actions

• Use pre-set filter 4 to identify patients with positive asthma spirometry results. Use results and associated data in the datasheet to gain a picture of the patient’s history and look for indications or symptoms of asthma. Establish when the patient was last reviewed. The patient’s full medical record may need to be examined and/or the patient called for review to confirm or exclude a diagnosis.

• It is worthwhile reviewing the records of patients with asthma monitoring codes to establish why these codes are present despite there being no asthma diagnosis. Consider whether a diagnosis is missing or whether the monitoring code has been selected in error. It is possible that these patients have been screened for asthma and a diagnosis ruled out but this should be confirmed.

You can easily list the patients with an asthma monitoring code by applying set filter 2 within the datasheet (see page 15 for more information on pre-set filters).

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Respiratory exacerbations

The final table provides useful information regarding respiratory exacerbations by summarising recent oral steroid and chest antibiotic prescriptions for patients.

Important note: Patients identified within this table may be on this medication for genuine reasons other than asthma. This table is provided for information purposes to support clinical decision making.

The datasheet (shown below) includes counts of the number of prescriptions for oral steroids and chest antibiotics issued within the relevant time period.

• 31 patients have received a prescription for oral steroids within the last 12 months. One patient (shown above) has received 12 prescriptions.

• 365 patients have received a prescription for chest antibiotics within the last 3 years. One patient (shown above) has received 27 prescriptions.

• Identify any patients in your practice who have received high numbers of prescriptions for oral steroids within the last 12 months. Establish when the patients were last reviewed. Patients’ may need to be called for review to confirm or exclude a diagnosis of asthma.

• Also, consider reviewing patients who have received a large number of prescriptions for chest antibiotics within the last three years.

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Case finder pre-set filters

There are five pre-set (or pre-loaded) filters provided within the asthma case finder datasheet.

To apply a pre-set filter, click on ‘PRIMIS CHART’, ‘Load Filter’ when viewing the datasheetand select the desired filter. Review the columns containing data items suggestive of asthma to determine the value of reviewing the patients’ full medical records in more detail.

Pre-set filter 3 – Atopy or allergies

Pre-set filter 3 will list any patients who have any of the following as their presence increases the likelihood of asthma:

• Allergic rhinitis

• Eczema

• Food allergy

• Eosinophilia

• Family history of asthma, hayfever or atopy

A combination of environmental exposure to inhaled substances and particles that may provoke allergic reactions or irritate the airways along with a family history are the strongest risk factors for developing asthma1. Genetic predisposition is the most clearly defined risk factor for atopy and asthma in children. The filter works by applying a custom filter to the ‘Count of associated features column’.

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Asthma_Analysis_V1.0 Page 16 of 39 25th September 2014 Summary of suggested actions for practices

• Review the data presented in the summary sheet. Using the pre-set filters available in the datasheet, access the lists of patients with possible asthma. Examine the associated data within the datasheet (and practice clinical system if required) to help determine whether a diagnosis is missing.

• Based on the findings, enter any missing diagnostic codes to the patient electronic health record or contact patients to arrange any necessary conclusive tests.

• Once you are confident about the accuracy of the practice asthma disease register move on to the next part of the audit tool examining the care of patients with known active asthma.

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Asthma Care Management

It is recommended that practices use the case finder tool before going on to examine the management of patients with known asthma. This will ensure that the practice asthma register and prevalence rate are as accurate as possible.

The asthma care management part of the tool reports upon the level of care being offered to patients diagnosed with asthma who have received asthma medication in the last year. The audit cohort is referred to as patients with active asthma.

Note: For the purposes of this audit, patients who have not been prescribed asthma medication in the last year are excluded. The asthma care management tool helps practices to answer the following questions:

• What is the practice prevalence rate for asthma? How many patients are considered to have active asthma?

• How many patients were asked the three RCP questions in the last year? How many patients scored zero indicating good asthmatic control?

• How many of our patients with asthma are poorly controlled or at risk of exacerbation?

• Which of the BTS/SIGN step categories do our asthma patients fall into? How well is this recorded in the practice?

• How do we highlight patients whose current treatment step may require review?

Asthma care management output

The asthma care management tool provides the following views in CHART: 1. Summary sheet including

‐ a dashboard view of the main audit data ‐ a classic tabular view of the main audit data 2. Full patient datasheet

Detailed information on each of these data views can be found on the following pages.

View 1 – Summary sheet

CHART summary sheets provide a snapshot of all the relevant data recorded by the practice. For asthma care management there are two different summary sheet views available; a dashboard view and a classic tabular view. The dashboard view provides a visual display of the data whereas the classic view presents data in tabular form (see next page for example practice views).

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Asthma_Analysis_V1.0 Page 18 of 39 25th September 2014 Dashboard view

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Population/prevalence

Both the classic view and dashboard view start by providing key statistical

information. This includes an up to date practice population count, a prevalence rate for patients with active asthma and a rate for the number of patients with an asthma diagnosis recorded regardless of date or medication status (asthma ever)*.

Prevalence graph for active asthma population

The dashboard also includes a prevalence graph of patients with active asthma broken down by age band.

Each bar on the graph represents the

percentage of patients in the practice within that age band who have active asthma.

• The prevalence rate of active asthma (those prescribed medication in the last year) in this practice is 5.9%. This is comparable to the 2012/13 Quality and Outcome Framework rate (reported June 2013) of 6% for England13.

• The prevalence rate for asthma ever in this practice is 10.4%. This figure includes all patients in the practice with a diagnosis of asthma regardless of when asthma medication was last prescribed. This is comparable to the Asthma UK reported prevalence of 1 in 11 children and 1 in 12 adults4. Suggested actions

• As a baseline quality check, assess whether the practice population count seems accurate. An unusually low number may suggest a problem whilst running the queries.

• If your practice prevalence rate is inexplicably low compared to the national or local average (averages can also be determined using CHART Online) then consider looking for patients who are potentially missing a diagnosis of asthma. The case finder can help with this task. If your practice prevalence rate seems unusually high, review coding practice in this area or look for evidence of the underlying cause.

*Some patients will have coded entries of both ‘Asthma Resolved’ and an asthma diagnosis. Patients will only be included in the active asthma population if the asthma diagnosis is the latest entry.

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Asthma_Analysis_V1.0 Page 20 of 39 25th September 2014 BTS/SIGN asthma treatment steps

The next table in the classic view provides information regarding patients’ current treatment step (based on the stepwise

approach taken from the BTS/SIGN guideline on the management of asthma1_{). It applies to}

patients aged 13 and over only. BTS/SIGN guidance differs by age group so this section focuses on the guidance for adults.

There is also a corresponding graph on the dashboard (shown above right). Note: This table/graph is populated using medication data and not coded step information from the clinical information system. Patients in both the step 2 and 3 categories are assumed to be on a SABA inhaler even if no prescription has been issued on the clinical system.

It should be noted that patients with comorbid COPD are the most likely not to fit the treatment steps programme. Additionally, a small number of inhaled corticosteroid (ICS) types have not been included due to lack of unit information.

• The majority of patients with active asthma appear within steps 1 and 2 (combined).

• There are a very small number of patients within steps 4 and 5. For some patients it is impossible to calculate their current step (not known).

• Identify patients within the step 2 and step 3 treatment categories who do not have a prescription for a SABA inhaler. It is unusual for patients to be

prescribed inhaled steroids or inhaled long-acting β2 agonist (LABA) without a

short-acting β2 agonist (SABA).

To identify these patients, find the column ‘Count of SABA prescriptions L12m’ and list patients with a value of 0. Then scroll across to the right to see

patients’ ‘Calculated treatment step’.

• Compare patients calculated treatment step (calculated from medication history) with their actual coded step information (manually entered step codes) and look for mismatches. You can do this using the datasheet (see page 28 for detailed information on how to do this).

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Associated features

The third table on the classic view displays information about the number of active asthma patients with co-morbidities such as COPD, obesity and anxiety or

depression. There is a corresponding graph on the dashboard.

Knowledge of co-morbidities and associated features can help when planning a patient’s care pathway particularly in relation to self-management plans.

It can also help you to understand how unwell patients might become, or complications that might arise. Many of these features are associated with an increased risk of fatality1.

Anxiety and depression

There is a well-recognised link between asthma and psychosocial problems. Prevalence of anxiety, depression or panic disorder is much higher in patients with asthma and is linked with poorer outcomes such as increased symptoms, higher use of healthcare resources and more frequent emergency admission to hospital6. Compliance with preventative treatment is also reduced.

Allergens

It has been proposed that prolonged allergen exposure can result in clinical asthma through inflammation of the airways, bronchial hyper responsiveness and reversible airflow obstruction7_{. Asthmatic patients should learn to recognise environmental}

triggers that provoke allergic reactions or irritate the airways in order to avoid them and potentially provide an extra degree of control3, 5.

• 30.6% of patients with active asthma (in this practice) are obese.

• Many patients with active asthma suffer with allergic rhinitis (19.5%).

• Use the associated information to build a picture of the patient’s disease severity and level of control. Target patients who have not been reviewed recently (ie. over 12 months ago).

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Asthma_Analysis_V1.0 Page 22 of 39 25th September 2014 RCP questions

In order for health professionals to establish that the care they provide is effective they need to measure the outcome of the treatment given. The RCP have published three simple questions that can be applied to all asthma patients regardless of

severity. By asking the same three questions and recording the result in a standard way, it is possible to build a picture of the overall well-being of all asthma patients.

This section of the summary sheet reports on the numbers of patients asked the RCP three questions in the last year and the number that scored zero. An RCP score of zero indicates well controlled asthma.

The RCP ‘3 questions’ are as follows: In the last week (or 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 (e.g. housework, work/school etc)?

It is recommended that an assessment of recent asthma control should be undertaken at every asthma review6. Data are extracted using either the RCP asthma assessment Read codes (Read version 2 - 388t. and 388t0 or CTV3 - XaNKw and XaXa0) or symptom information regarding sleep disturbance, current symptoms and limitation of activities (hover over relevant datasheet column titles for the range of included codes).

• A high proportion of active asthma patients have had their level of control assessed in the last year using the RCP 3 questions (72.4%).

• 37.8% of all patients with active asthma achieved a score of zero. Suggested actions

• If achievement is low in this area, review coding practice and ensure that control is assessed at every patient review. Review symptomatic patients’ current treatment regime.

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Short-Acting β2 Agonist (SABA) use

A table and corresponding graph are provided detailing numbers of SABA

prescription issues over the last year. This information is provided as a guide to help clinicians identify patients worthy of review. A high number of SABA prescriptions are often indicative of poor asthma control6.

Note: Due to data limitations, this section will only count the number of prescriptions issued and not the number of inhalers issued on each prescription. If a patient is issued with multiple inhalers on one prescription it will still only show as one

prescription. Consult the relevant datasheet columns (see below) for dosage/unit information from the last script.

• The majority of asthma patients (64.9%) received between 0 and 3 prescriptions for SABA inhalers in the last year.

• There are 19 patients (4.8%) who received more than 12 prescriptions for SABA inhalers in the last year.

• Urgently review patients who have received more than 12 SABA prescriptions in the last year (pre-set filter 4). Consider ICS where this is not currently prescribed.

Prioritise those prescribed the highest numbers of SABAs. You can do this by filtering the

‘Count of SABA prescriptions L12m’ column

within the datasheet (see image right). In the example shown to the right, one patient has received 30 prescriptions within the last year.

• Use pre-set filter 2 within the datasheet to identify patients who have received more than 6 prescriptions for SABA inhalers in the last year but who have no record of an inhaled corticosteroid prescription.

• Review the columns ‘No. inhalers on last

SABA Rx’ and ‘No. doses on last SABA Rx’ for

dosage/unit information from the last prescription. Patients may have actually received a higher number of inhalers than prescriptions where

multiple units have been issued. See appendix 3 for a note regarding unusual quantities of prescribed inhalers.

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Asthma_Analysis_V1.0 Page 24 of 39 25th September 2014 Inhaled Corticosteroid (ICS) use

A table and corresponding graph are provided detailing numbers of ICS

prescription issues over the last year. This information is provided as a guide to help clinicians identify patients worthy of review. A low number of prescriptions for

preventative medication may be a feature in patients with poor asthma control. Patients who are under medicated may be at risk of exacerbation and should be monitored6.

Note: Due to data limitations, this section will only count the number of prescriptions issued and not the number of inhalers issued on each prescription. If a patient is issued with multiple inhalers on one prescription it will still only show as one prescription. Consult the relevant datasheet columns (see below) for further dosage/unit information.

• There is a fairly even spread of the number of ICS prescriptions in the last year in this practice.

• There are 90 patients without a prescription for ICS in the last year and 88 patients who received just one prescription.

• Review or monitor patients receiving low numbers of prescriptions for ICS.

• Review the columns ‘No. inhalers last ICS or combined Rx’

and ‘No. doses last ICS or combined Rx’ for dosage/unit

information from the last prescription (see right). Patients may have actually received a higher number of inhalers than prescriptions where multiple units have been issued on the same script.

• The availability and quality of dosage/unit information varies across clinical systems. The datasheet will place values <20 into the ‘No. inhalers last ICS or combined Rx’ columnand values >20 into the ‘No. doses last ICS or combined Rx’ column. Look for erroneous entries that do not correlate with either numbers of inhalers or doses and consider correcting these on the patient’s electronic record.

(25)

Secondary care engagement

The next table and corresponding graph provide information regarding contact with secondary care services including referrals, attendances and an indication of the numbers that may benefit from a review by a specialist. Patients with a history of exacerbation in the previous year may be at greater risk of future exacerbation6.

Admitted last 12 months

Looks for Read codes for asthma related hospital admissions (including the code ‘admitted since last appointment’).

A&E attendance data (asthma related illness) This relies on practices having entered such data (where available). As a result, recording levels in this area will vary. It is likely that the majority of recording will only take place during annual reviews with patients.

Frequent oral steroid use

Patients who have received 6 or more prescriptions for oral steroids within the last 12 months are included in dashboard graph and summary sheet table. Patients with frequent oral steroid use are likely to be in contact with secondary care already and if they are not they should be considered for referral to a specialist.

• There are only 38 patients with a record of either being admitted to hospital or seen in A&E with asthma related illness in the last 12 months. It is unclear whether this reflects reality or is a consequence of poor recording in this area.

• There are no patients with asthma related referrals to secondary care. This may be due to poor recording in this area.

• There are 2 patients who have received 6 or more prescriptions for oral steroids within the last 12 months.

• Use pre-set filter 3 to identify patients who have been issued with 3 or more prescriptions for oral steroids in the last year. These patients should either be managed according to step 4 or 5 of the BTS/SIGN guidelines or be referred for specialist assessment6.

• Use pre-set filter 5 to list patients who have either attended A&E or been admitted to hospital with asthma related illness. Patients with a history of exacerbation in the last year should be closely monitored. Review quality of coding in relation to exacerbations and hospital attendances due to asthma.

(26)

Management

This section of the summary sheet provides key information regarding smoking status, annual reviews and self-management plans.

Annual review looks for acoded ‘asthma annual review’ in the last 12 months.

Current smoker indicates thatthe patient’s latest smoking status is ‘current smoker’.

Smokers given advice reports on the number of current smokers given appropriate

adviceand/or prescribed any relevant medication (NRT or other) in the last year.

Asthma attack is determined by the number of asthmatic patients who have received

a prescription for oral steroids within the last year.

Self-management plan should be updated and recorded annually. If recording is low

check practice data entry templates and check recording procedures at annual review.

Inhaler technique should be routinely assessed and documented (ie. at least

annually).

•

Smoking status (99.2%), smokers given advice (92.7%) and inhaler technique (76.9%) are well recorded in this practice.

• Check recording levels where achievement is low. For example, you would expect the figure for annual review (59.1%) and

(27)

Other data items

This section reports on the number of patients who have coded entries relating to the avoidance of unplanned admissions to hospital.

The codes included in the audit are as follows: Read Version 2

8CT2. Admission avoidance care ended

8CV4. Admission avoidance care started

8Iae1 Admission avoidance care plan declined CTV3

XaYD2 Admission avoidance care ended XaYD1 Admission avoidance care started

(28)

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(29)

Asthma care pre-set filters

In addition to creating custom filters, there are five pre-set (or pre-loaded) filters provided within the main audit tool. The can be accessed via ‘PRIMIS CHART’, ‘Load Filter’ when viewing the datasheet.

Load a filter as desired and then review the columns containing data items to determine the value of reviewing the patients’ full medical records in more detail. This will also assist with prioritising patients for review.

Summary of suggested action for practices

• Use the asthma case finder to identify patients who may have a missing diagnosis.

• Use pre-set filter 1 to identify patients who have received a prescription for a long-acting β2 agonist (LABA) in the last year, but have not received a

prescription for an inhaled corticosteroid (ICS) within that time. In accordance with step 3 of the BTS/SIGN stepwise approach, a LABA should be issued in addition to inhaled corticosteroid. Consider whether these patients would be better suited to a combination inhaler which guarantees that the long-acting β2

agonist is not taken without an inhaled steroid.

• Use pre-set filter 2 within the datasheet to identify patients who have received more than 6 prescriptions for short-acting β2 agonist (SABA) inhalers in the

last year but who have no record of an inhaled corticosteroid prescription. Urgently review patients who have received more than 12 SABA inhalers in the last year. A high number of SABA prescriptions is often indicative of poor asthma control6.

• Review any patients who have been identified as having frequent oral steroid courses (pre-set filter 3). Asthmatic patients receiving more than three

courses of oral steroids in the last year should either be managed using BTS step 4 or 5 to achieve control or be referred to a specialist service6.

(30)

• Assess practice recording levels for A&E attendances and admission to hospital for asthma related illness. Use pre-set filter 5 to list any patients admitted to hospital or A&E in the last 12 months (for asthma related illness).

• Patients receiving low numbers of ICS in the previous year should have their asthma control assessed (or be closely monitored). Low numbers of

prescriptions may be indicative of poor preventer therapy compliance.

• Use the datasheet to compare patients calculated treatment step (based on prescribing history) with their actual coded step information and look for mismatches (see page 28).

• Upload summary data to CHART Online for benchmarking and comparison with other practices.

Recommended learning

Registered members of the Primary Care Respiratory Society UK (PCRS) can access online training resources designed to help practices, clinical commissioning groups, health boards and other primary care-based groups deliver high value, patient-centred, respiratory care.

Their EQUIP (Effecting Quality in General Practice) modular tool provides a structured, systematic way of reviewing the respiratory care being delivered and identifies ways in which the standards of care can be optimised within a single practice or across multiple practices in a given locality.

(31)

Key questions for GP practices

• Do we have any patients with asthma who do not have the diagnosis coded in their electronic record? How accurate is our practice prevalence rate for asthma?

• Do all of our asthma patients have a self-management plan in place in case of exacerbation?

• Do we have a procedure in place to review patients whose current treatment step appears to be sub-optimal?

• What is our strategy for reducing the risk of exacerbations?

• Which patients are receiving high numbers of prescriptions for short-acting β2

agonist (SABA) inhalers? Are these patients receiving prescriptions for and utilising inhaled corticosteroids?

• Are key data items (such as annual reviews, self-management plans and treatment steps) being recorded routinely and accurately?

• Should some of the individual patients identified be added to the practice Admissions Risk register?

• Are we effectively implementing the recommendations made in The National Review of Asthma Deaths (NRAD)6?

Recommended follow-up work

• Upload summative data to the PRIMIS CHART Online data warehouse and compare your practice data to other practices in the locality and nationally.

• Improve data recording and accuracy of clinical coding including the review of data collection/data entry templates.

• Access and complete the Primary Care Respiratory Society UK (PCRS) EQUIP (Effecting Quality in General Practice) modular online tool (PCRS members only).

(32)

References

1. British Thoracic Society (BTS)/Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma [updated online 2013]. Thorax 2008;63(suppl 4):iv1–iv121.

Available: www.sign.ac.uk/guidelines/fulltext/101/index.html Last accessed: 3rd September 2014

2. Health and Social Care Information Centre. (February 2014) Prevalence: asthma and prescribed medication. Indicator Specification Document. Available: HSCIC (2014) Prevalence: asthma and prescribed medication. Last accessed: 3rd September 2014

3. Department of Health. (2012) An Outcomes Strategy for COPD and Asthma:

NHS Companion Document. London.

4. Asthma UK. (August 2014). Number of people treated for asthma in the United Kingdom.

Available: www.asthma.org.uk/asthma-facts-and-statistics. Last accessed 3rd September 2014

5. World Health Organization. (November 2013) Asthma. Fact Sheet No 307. Available: www.who.int/mediacentre/factsheets/fs307/en/

Last accessed: 3rd September 2014

6. Royal College of Physicians. (May 2014) Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report. London. 7. Pearce, N., Pekkanen, J. and Beasley, R. (1999) How much asthma is really

attributable to atopy? Thorax, vol 54, pp.268:272.

8. Pearson MG, Bucknall CE (Eds). (1999) Measuring Clinical Outcome in

Asthma; a patient-focused approach. London: Royal College of Physicians.

9. Bucknall, C. (November 1999) Asking three simple questions will help improve asthma care. eGuidelines. Guidelines in Practice. Vol 2, Edition 11.

Available:

www.eguidelines.co.uk/eguidelinesmain/gip/vol_2/nov_99/bucknall_asthma_nov99.htm?sector=profession

al#.U_NTBE0g_IU

Lastaccessed: 3rd September 2014

10. NHS England (December 2013) CCG Outcomes Indicator Set 2014/15 – at a glance.

Available: http://www.england.nhs.uk/wp-content/uploads/2013/12/ccg-ois-1415-at-a-glance.pdf

(33)

11. National Institute for Health and Clinical Excellence, (February 2013) NICE Quality Standards 25. Quality Standard for Asthma.

Available: http://www.nice.org.uk/guidance/QS25 Last accessed: 3rd_{September 2014}

12. Public Health England. (Updated June 2014) Public Health Outcomes Framework 2013 to 2016.

Available:

www.gov.uk/government/publications/healthy-lives-healthy-people-improving-outcomes-and-supporting-transparency.

Last accessed 3rd September 2014

13. Health and Social Care Information Centre. (June 2013) Disease Prevalence. Quality and Outcomes Framework (QOF) for April 2012 – March 2013,

England.

Available: HSCIC (2014) Prevalence: asthma and prescribed medication. Last accessed: 3rd_{September 2014}

(34)

Glossary

A&E Accident and Emergency department BTS British Thoracic Society

CCG Clinical Commissioning Group CCG OIS

Clinical Commissioning Group Outcomes Indicator Set

CCG OIS measures are developed from NHS Outcomes Framework indicators that can be measured at clinical commissioning group level together with additional indicators developed by NICE and the Health and Social Care Information Centre.

CHART PRIMIS data analysis tool (MS Excel based) CHART

Online PRIMIS comparative data analysis tool (web based) COPD Chronic Obstructive Pulmonary Disease

CTV3 Clinical Terms Version 3 DES Directed Enhanced Service

FEV1 Forced Expiratory Volume in 1 minute FVC Forced Vital Capacity

ICS Inhaled Corticosteroid

LABA Long-Acting β2 Agonist

NHS OF NHS Outcomes Framework

NICE National Institute for Health and Care Excellence NRT Nicotine Replacement Therapy

O/E On examination

PCO Primary Care Organisation PEFR Peak Expiratory Flow Rate

QOF Quality and Outcomes Framework RCP Royal College of Physicians SABA Short-Acting β2 Agonist

(35)

Appendices

1. Columns within the pseudonymised datasheet - case finder

Reference Eczema date Predicted PEFR value

Age Food allergy code Predicted PEFR date

Sex Food allergy date Positive airways

reversibility code Latest SABA code Eosinophilia code Positive airways _{reversibility date} Latest SABA date Eosinophilia date % predicted FEV1 pb _value Latest inhaled steroid

code Family history atopy code % predicted FEV1 pb date Latest inhaled steroid

date Family history atopy date FEV1/FVC ratio pb value Inhaled LABA code Count of associated _features FEV1/FVC ratio pb date Inhaled LABA date History of wheeze code Respiratory function test _present Oral B-agonist code History of wheeze date Latest smoking status Oral B-agonist date O/e wheeze code Latest smoking status date Leukotriene code O/e wheeze date Smoking status present Leukotriene date Dyspnoea code Oral steroid Rx code Count of medication

types Dyspnoea date Oral steroid Rx date

No. of SABA

prescriptions L12m

Latest symptoms relating to asthma

No. of oral steroid prescriptions No. of ICS prescriptions

L12m Latest symptoms date Latest chest antibiotic Rx code Allergic rhinitis code Latest asthma resolved

date

Latest chest antibiotic Rx date

Allergic rhinitis date PEFR value No. of AB prescriptions _L3yr

(36)

Asthma_Analysis_V1.0 Page 36 of 39 25th September 2014 2. Columns within the pseudonymised datasheet - asthma care main audit

Reference SABA Rx L12M code LABA Rx L12M date

Age SABA Rx L12M date LABA Rx L6M

Sex No. inhalers on last SABA _Rx Leukotriene Rx L12M _code Latest asthma severity

code

No. doses on last SABA

Rx Leukotriene Rx L12M date

Latest asthma severity

date SABA Rx L6M Leukotriene Rx L6M

Latest Asthma spirometry

code Count of SABA prescriptions L12M Theophylline Rx L12M code Latest Asthma spirometry

date

Latest inhaled steroid Rx L12M

Theophylline Rx L12M date

Earliest asthma Dx code Latest inhaled steroid Rx

L12M date Theophylline Rx L6M

Earliest asthma Dx date Inhaled steroid Rx L6M SAMA Rx L12M code Depression diagnosis

L24M Earliest inhaled steroid Rx L12M code SAMA Rx L12M date Depression diagnosis

date

Earliest inhaled steroid Rx

L12M date SAMA Rx L6M

Anxiety L24M Latest Combined LABA & _{ICS Rx L12M} LAMA Rx L12M code Anxiety date Latest Combined LABA & _{ICS Rx L12M date} LAMA Rx L12M date Anxiety or depression

L24M Latest LABA & ICS inhaler count LAMA Rx L6M Allergic rhinitis code Combined LABA & steroid

Rx L6M

Sodium cromoglicate Rx L12M code

Allergic rhinitis date Earliest Combined LABA _{& ICS Rx L12M} Sodium cromoglicate Rx _{L12M date} Food allergy code Earliest Combined LABA _{& ICS Rx L12M date} Sodium cromoglicate Rx _L6M Food allergy date No.inhalers last ICS or

combined Rx Ketotifen Rx L12M code Earliest COPD Dx code No. doses last ICS or

combined Rx Ketotifen Rx L12M date Earliest COPD Dx date Estimated ICS dose Ketotifen Rx L6M

Latest BMI date Count of ICS or combined _{scripts L12M} Nedocromil Rx L12M code Latest BMI value LABA Rx L12M code Nedocromil Rx L12M date

(37)

Nedocromil Rx L6M RCP - sleep undisturbed _L12M QOF smoking code Oral beta-agonist Rx

L12M code

RCP - sleep undisturbed

date QOF smoking date

Oral beta-agonist Rx

L12M date RCP - sleep disturbed Reference 3

Oral beta-agonist Rx L6M RCP - sleep disturbed _date Smoking cessation referral _code Oral steroid Rx L12M

code RCP - no current symptoms L12M Smoking cessation referral date Oral steroid prescribed

L12M date

RCP - no current symptoms date

Smoking cessation activity code

Oral steroid Rx L6M RCP - current symptoms _L12M Smoking cessation activity _date Count of oral steroids

L12M RCP - current symptoms date Smoking cessation medication code Frequent oral steroid use RCP score value L12M Smoking cessation

medication date Respiratory antibiotics

prescribed L12M code RCP score date Smoking status Respiratory antibiotics

prescribed L12M code Count of RCP questions

Self management plan given

Count of respiratory

antibiotics L12M RCP score calculated Self management plan given date Count of Rx types in L6M

(SABA 12M)

Inhaler technique shown ever

Annual Review in last year code

Ever prescribed spacer device code

Inhaler technique shown date

Annual Review in last year date

Ever prescribed spacer device date

Inhaler technique checked L12M code

BUTEYKO breathing technique code Currently using spacer

device code Inhaler technique checked L12M date BUTEYKO breathing technique date Currently using spacer

device date Latest PEFR value

Admitted to hospital L12M code

Latest recorded

therapeutic steps code Latest PEFR date

Admitted to hospital L12M date

Latest recorded

therapeutic steps date Best ever recorded PEFR value Seen in A&E in the L12M code Calculated treatment step Best ever recorded PEFR

date

Seen in A&E in the L12M date

RCP - no impact activity L12M

Latest predicted PEFR value

Referred to resp medicine ever code

RCP - no impact activity date

Latest predicted PEFR date

Referred to resp medicine ever date

RCP - limited activity

L12M Latest predicted FEV1 value Exercise induced asthma code RCP - limited activity date Latest predicted FEV1

date

Exercise induced asthma date

(38)

Asthma_Analysis_V1.0 Page 38 of 39 25th September 2014 Referred to occupational

health code

Raised eosinophilia Dx code

Admission avoidance risk register

Referred to occupational

health date Raised eosinophilia Dx date Admission avoidance risk register date Latest recorded

occupation code Latest eosinophil level

Connective tissue disease code

Latest recorded occupation date

Latest eosinophil level date

Connective tissue disease date

Record of occupational

asthma code FHx atopy code Record of occupational

(39)

3. Note regarding unusual quantities of prescribed inhalers

NHS prescription services have reported seeing an increase in unusual quantities of certain items ordered on prescription eg. inhalers prescribed as 200 x 200 doses. This is likely to be due to the way prescribing software has been set up in a practice. This makes it unclear how many inhalers were actually prescribed. It may impact how a practice is reimbursed and causes problems for clinical audit in this area. We advise practices to look for unusual large quantities of prescribed items and review prescribing software set up to prevent recurrence.

Asthma Care Audit Instructional Guide

A

I

Asthm

nstru

ma Ca

uction

are A

nal G

Audit

Guide

Contents

Introduction

Asthma Case Finder

Asthma Care Management

•

Key questions for GP practices

Recommended follow-up work

References

Glossary

Appendices