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Structured care has been shown to produce benefits for patients with asthma. The recording of morbidity, PEF levels, inhaler technique and current treatment and the promotion of self-management skills are common themes of good structured care. SIGN/BTS proposes a structured system for recording inhaler technique, morbidity, PEF levels, current treatment and asthma action plans.
National and international guidelines recommend the use of standard questions for the monitoring of asthma. “Proactive structured review, as opposed to opportunistic or unscheduled review, is associated with reduced exacerbation rate and days lost from normal activity. See The British Thoracic Society / Scottish Intercollegiate Guideline Network. British guideline on the management of asthma. Thorax 2003; 58 (S1): i1-i94. 2004 update www.brit-thoracic.org.uk and www.sign.ac.uk
The QOF suggests the utilisation of the RCP three questions as an effective way of assessing symptoms:
“In the last month:
Guidelines suggest it should be abnormal in patients with mild to moderate asthma to have any nocturnal waking or activity limitation. Asthma symptoms may be expected on up to three days per week.
If asthma appears to be uncontrolled the following should be examined as part of the asthma review before increasing asthma therapy and treated appropriately:
• smoking behaviour as smoking interferes with asthma control
• poor inhaler technique
• inadequate adherence with regular preventative asthma therapy
• rhinitis.
There is increasing evidence for personalised asthma action plans in adults with persistent asthma. 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 especially during exacerbations. However, it is much more useful if there is a record of patients’ best peak flow, i.e. 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 regularly. National and international guidelines emphasise the importance of assessing ability to use inhalers before prescribing, and regularly reviewing technique, especially if control is inadequate. “Prescribe inhalers only after patients have received training in the use of the device and have demonstrated satisfactory technique.” “Reassess inhaler technique as part of structured clinical review.” The British Thoracic Society / Scottish Intercollegiate Guideline Network. British Guideline on the management of asthma. Thorax 2003; 58 (S1): i1-i94. 2004 update www.brit-thoracic.org.uk and www.sign.ac.uk
Summary of Asthma Review:
• assess symptoms (using RCP 3 questions)
• measure peak flow
• assess inhaler technique
• consider personalised asthma plan.
If asthma appears to be uncontrolled follow steps as outlined above.
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.
Practices should report the percentage of patients on their asthma register who have had an asthma review in the previous 15 months.
Prepared By Jean Keenan