People with asthma of any age need a structured review conducted by a health professional with expertise in asthma care at least once a year (British Thoracic Society and Scottish Intercollegiate Guidelines Network (BTS/SIGN), 2019). People who have had a recent hospital admission for asthma also need a review within 48 hours (National Institute for Health and Care Excellence (NICE), 2022).
The period during and after the COVID-19 pandemic has been particularly challenging for primary care and specialist respiratory services. In their 2020 survey, Asthma UK (now Asthma and Lung UK) reported that basic asthma care levels – comprising an annual asthma review, an inhaler technique check and a written asthma action plan – have dropped by nearly 5%, and 40.1% of respondents had uncontrolled asthma.
Targeting care
Primary care nurses, therefore, face a major challenge of addressing a backlog of work created by the pandemic and at the same time ensuring that they meet Quality and Outcome Framework (QOF) requirements (Box 1). NHS England (2022) guidelines remind primary care practitioners of the variability of asthma symptoms and that it is inappropriate to monitor symptom free patients on minimal or no therapy. It advises that the frequency of prescription requests for those people be checked and then a decision can be taken by the practice on whether to remove them from the asthma register. However, patients with uncontrolled asthma who do not adhere to their treatment could be missed and may experience an asthma attack. BTS/SIGN (2019) guidelines advise clinicians to target care at those with poor symptom control and an increased risk of asthma attacks. Good knowledge of the patient population and assessment of social and environmental risks (Box 2), as well as clinical risks, are important.
Box 1.Quality and outcome framework (QOF) requirements 2022/23 (NHS England, 2022)An asthma registerAn objective test on diagnosisAn asthma review in the last 12 months that includes:
- An assessment of asthma control using a validated asthma control questionnaire
- A recording of the number of exacerbations
- An assessment of inhaler technique
- A written personalised action plan
- Smoking/passive smoking status
Box 2.Assessing risk (National Institute for Health and Care Excellence, 2022)In adults:
- Greatly increased risk includes history of previous asthma attacks
- Moderately increased risk includes poor control, inappropriate or excessive use of short-acting beta agonists (SABAs)
- Slightly increased risk includes older age, female, reduced lung function, obesity, smoking and depression.
In children:
- Greatly increased risk includes a history of previous asthma attacks and persistent asthma symptoms
- Moderately increased risk includes sub-optimal drug regimen, comorbid/atopic allergic disease, low income family and vitamin D deficiency
- Slightly increased risk includes younger age, exposure to environmental tobacco smoke, obesity and low parental education
Today, structured annual asthma reviews are increasingly being conducted virtually. This is facilitated using software such as accuRx (accurx.com) that can send out asthma control tests by text message and then, depending on the level of control, be triaged and followed up with telephone, video or in-person consultations.
A structured review takes time. It is important to assess the person's ability to understand and contribute to the review. Practice nurses should prioritise what needs to be dealt with first and make a follow up appointment if necessary. Nurses could consider delegating some tasks, such as teaching inhaler technique, to a community pharmacist colleague.
The ‘ARC’ asthma review
Asthma reviews are an opportunity to assess, review and collaborate (ARC) (Hickman et al, 2020):
- Assess asthma control, severity and risk of exacerbations using a validated or endorsed tool
- Review diagnosis and management
- Collaborate with the patient to develop, maintain and review a personalised self-management/action plan.
Assessing control
The aim of asthma reviews is to improve the quality of life for people with asthma by reducing symptoms and minimising the risk of exacerbations. More than two exacerbations in the last month and the need to use three or more puffs of short acting beta agonist (SABA) normally indicates a need for a review, unless there is a good reason, such as recent exposure to a trigger like a cold or seasonal pollens.
The International Primary Care Respiratory Group (IPCRG) manages a social movement called Asthma Right Care, focusing on eliminating overuse of SABAs and ‘underuse of effective interventions, moving away from episodic symptom relief and acute management, and moving to a chronic disease model’. It has a range of resources to support general practice nurses (IPCRG, 2022).
It is important to always review the prescription record and cross-check usage by asking about the use of SABAs, as families can resort to sharing inhalers, especially if one family member receives their prescriptions free.
Practice nurses can calculate the number of inhalers prescribed over 12 months or puffs per week and use the IPCRG ‘slide rule’ (IPCRG, 2022) to calculate whether the person may be over-reliant on relievers.
QOF (NHS England, 2022) explicitly requires:
- An assessment of asthma control using a validated asthma control questionnaire such as the Asthma Control Questionnaire (Qoltech, 2022) or the Asthma Control Test (GSK, 2022)
- A recording of the number of exacerbations – check for unscheduled GP and out of hours visits and for courses of oral steroids
- An assessment of inhaler technique
- A written personalised action plan.
The Royal College of General Practitioner's 3 asthma questions (difficulty sleeping; symptoms in the day; interference with usual activities) are often used to assess control. However, these questions do not constitute a validated control questionnaire (BTS/SIGN, 2019).
It is important to assess the risk of future asthma attacks to identify people at increased risk. These are the ones who need more frequent monitoring (Box 2).
Potential causes of poor control
If asthma appears to be uncontrolled, consider the possible reasons below before adjusting medicines (NICE, 2022):
- Alternative diagnoses
- Smoking (active or passive)
- Poor inhaler technique
- Lack of adherence, which could be connected to the patient/carer's beliefs
- Occupation exposures to triggers, such as poultry or industrial cleaners
- Psychosocial factors, such as poverty and poor housing
- Seasonal triggers, such as pollens, or environmental factors, such as poor air quality
- Concomitant conditions such as rhinitis from nasal polyps or gastric reflux.
Review diagnosis and management
The practice nurse should check the person's notes for evidence that there is a record of an objective test demonstrating variable airflow obstruction (NICE, 2022):
- Peak expiratory flow (PEF) diary:
- A value of more than 20% variability after monitoring at least twice daily for 2–4 weeks
- Spirometry – offer to those 5 years old and over:
- The FEV1/FVC ratio is normally greater than 70%
- A normal spirometry result when the person is asymptomatic does not rule out asthma
- The forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) lower limit of normal (LLN) values can also be used to detect airway obstruction
- It is important to be aware that spirometry may be affected by empirical treatment with inhaled corticosteroids.
- Fractional exhaled nitric oxide (FeNO) testing (available in local centres generally):
- Tests for eosinophilic airway inflammation
- A FeNO level of 40 parts per billion (ppb) in adults and of 35 ppb in children (in those not on steroids) suggests asthma
- One in five people will have either a false negative of false positive result.
- Bronchodilator reversibility (BDR) measures forced expiratory volume (FEV):
- In adults, an improvement in FEV1 of 12% or more, together with an increase in volume of at least 200 ml in response to beta-2 agonists or corticosteroids is regarded as a positive result. An improvement of greater than 400 ml in FEV1 is strongly suggestive of asthma
- In children, an improvement in FEV1 of 12% or more is regarded as a positive result.
Assessment of asthma medication
Medication review is part of a structured asthma review. As well as checking prescription records, consider that only 15% of patients can use their inhalers properly (Giraud and Roche, 2002). Any patient whose asthma is partly controlled or uncontrolled should have their inhaler technique assessed before any medication is changed or added. Around 43% of 16–65-year-olds have difficulty understanding written health material, so videos of inhaler technique may be better than leaflets (Protheroe et al, 2017).
In addition, there is a national move to switch adults to environmentally friendly or ‘green’ inhalers. pMDIs contain propellants known as hydrofluorocarbons (HFCs), which are powerful greenhouse gases (NICE, 2019). An asthma review is an opportunity to discuss a shift towards a dry powder device or softmist inhaler, if appropriate, and teach the person how to use the new device.
Personalised asthma action plans
Everyone with asthma should have a personalised asthma action plan (PAAP) and have it reviewed at least annually and after an exacerbation. These are written plans that explain to the patient the actions to enable self-care and help parents of younger children to support their child at home. Some clinical systems have editable PAAP templates, allowing electronic sharing with the person (see resources section). The PAAP consists of three sections, that are personalised and completed in partnership between the nurse and the person:
- A plan of the routine medication that the patient should take and when in order to stay well
- What to do if asthma symptoms worsen
- What to do in the case of an asthma attack and when to call 999.
Smoking cessation
Asthma reviews present an opportunity to check on smoking status and offer very brief advice (VBA). Smoking increases use of healthcare services and reduces the effectiveness of inhaled medicines in asthma.
Currently, around half of all smokers in England try to quit unaided using willpower alone, despite this being the least effective method. Getting support can greatly increase a person's chances of quitting successfully (Public Health England, 2019). Practice nurses should consider becoming trained to deliver VBA and signpost people to smoking cessation services, to increase the likelihood of quitting (see resources section).
Collaborate: Health literacy and health beliefs
There is no correlation between asthma knowledge and adherence to treatment (Ho et al, 2003). What helps is shared decision making (see resources section), in which the patient and the practitioner share relevant information, discuss risks and benefits, express treatment preferences, deliberate the options and agree on treatment. Asthma self-management education, which emphasises self-efficacy, is also essential.
Between 30 and 50% of prescribed medication is not taken as recommended and clinicians have been shown to be poor judges of adherence, identifying non-adherence no better than would be predicted by chance alone (Burgess et al, 2011).
Practice nurses could use empathic questions to reduce the need for desirable answers (Box 3) and supportive consultation techniques such as:
- The ‘teach back’ method (NHS Education for Scotland, 2022): inviting the patient to describe back to you, in their own words, what has been discussed or the plan/treatment instructions
- Chunk and check: break down information into small chunks with breaks to check understanding in between. Short, regular asthma consultations are better than long ones (NHS Education for Scotland, 2022)
- Use the ICE consulting framework: what are their ideas about what might be causing their asthma problems? What are they concerned about? What are they expecting from you?
Box 3.Empathic questions (Global Initiative for Asthma, 2022)
- ‘Many patients don't use their inhalers as prescribed. In the last 4 weeks, how many days a week have you been taking it not at all, 1, 2, 3 or more days a week?’
- ‘Do you find it easier to remember your inhaler in the morning or the evening?’
- ‘How do you think that the inhaler is helping you control your asthma?’
- ‘Are there times when you find that you don't need your inhaler?’
Conclusion
Asthma reviews are a key part of providing good care to people with asthma. Asthma reviews are an opportunity to assess, review and collaborate. The aim of asthma reviews is to improve the quality of life for people with asthma by reducing symptoms and minimising the risk of exacerbations. Shared decision making can improve adherence to treatment and practice nurses can use empathic questions and supportive consultation techniques to improve patient care.
CPD REFLECTIVE PRACTICE:
- How can you ensure you target care at those who most need it? What are the risks involved?
- How can the assess, review and collaborate (ARC) method help to structure asthma reviews? Do you think this approach could work for you and your patients?
- Reflecting on your patients, do all of your patients have a personalised asthma action plan?
KEY POINTS:
- People with asthma of any age need a structured review conducted by a health professional with expertise in asthma care at least once a year
- The aim of asthma reviews is to improve the quality of life for people with asthma by reducing symptoms and minimise the risk of exacerbations
- Any patient whose asthma is partly controlled or uncontrolled should have their inhaler technique assessed before any medication is changed or added
- Everyone with asthma should have a personalised asthma action plans and have it reviewed at least annually and after an exacerbation
Resources
- Asthma UK inhaler training videos and information: www.asthma.org.uk/advice/inhalers-medicines-treatments/using-inhalers/
- Asthma UK information for patients ‘How to get the best from your asthma review’: www.asthma.org.uk/advice/manage-your-asthma/adult-review/
- Asthma UK personalised asthma action plans (PAAPs) available through EMIS: www.asthma.org.uk/8ae395a8/globalassets/for-professionals/emis_asthma_uk_action_plan_guidance_notes_-_updated.pdf
- International Primary Care Respiratory Group. Asthma right care key resources: www.ipcrg.org/asthma-right-care-key-resources
- NHS England. Shared decision making: www.england.nhs.uk/shared-decision-making/
- Primary Care Respiratory Society (2019) Video: How to complete a personalised asthma action plan: respiratoryacademy.co.uk/resources/how-to-complete-a-personalised-asthma-action-plan-clin/
- Primary Care Respiratory Society ‘Become a quit catalyst’: www.pcrs-uk.org/resource/become-quit-catalyst