A dummy guide to successfully conducting asthma reviews

Background

As a healthcare professional working in general practice, you will sooner or later find that you have to do asthma reviews. If this is an area in which you are not very confident, a dummy guide to conducting asthma reviews is what you need. That is the purpose of this post.

From a QOF perspective, the asthma domain is worth a massive 45 points across four indicators: AST005 (income protected – 4 points); AST011 (15 points); AST007 (20 points) and AST008 (6 points). As you conduct the asthma review, make sure that you meet the documentation requirements for each relevant indicator.

While we seek to point out, below, where you might need to consider the relevant indicator during an asthma review, we encourage you to make use of the available documentation prompts in your prescribing software, such as the EMIS Web popup box, to guide you in meeting any clinical or quality indicators.

Schedule the Appointment:

• Contact the patient to schedule an asthma review appointment.
• Best practice is to conduct asthma reviews at least once a year for all asthma patients, but more frequent reviews may be necessary for patients with poorly controlled asthma or those with exacerbations.

Preparation:

• Gather the patient’s medical records, including their asthma action plan, medication list, and any recent test results (such as lung function tests or allergy tests).
• If possible, send an Accurx message beforehand with the Asthma Control Test questionnaire (Ardens Template)
• AST011: Confirm that the asthma diagnosis has been confirmed with objective tests such as spirometry and one other objective test (FeNO, bronchodilator reversibility, peak flow variability). In the case of diagnoses after 01/04/2023, this must be between 3 months and 6 months after diagnosis.

Patient Assessment:

• Start the review by assessing the patient’s asthma symptoms since their last review. Ask about any changes in symptoms, such as increased coughing, wheezing, chest tightness, or shortness of breath.
• Inquire about any asthma triggers the patient has encountered and their impact on symptoms.
• Assess the frequency of reliever medication (e.g., short-acting beta agonists) use. Frequent reliever use may indicate poorly controlled asthma.
• Evaluate any limitations asthma symptoms have imposed on the patient’s daily activities, work, or exercise routine.

Assessment of Asthma Control:

• Use validated asthma control assessment tools such as the Asthma Control Test (ACT) or the Royal College of Physicians (RCP) 3 Questions to assess the level of asthma control.
• Discuss the results of the asthma control assessment with the patient and explain what they mean for their asthma management.
• AST007: Ensure that at annual review, you record the asthma control, number of exacerbations, inhaler technique & personalised action plan.

Medication Review:

• Review the patient’s current asthma medications, including inhalers and oral medications. Ensure the patient is using their inhalers correctly and ask about any difficulties or concerns they may have.
• Confirm adherence to prescribed medications and address any issues contributing to non-adherence.
• Consider the need for adjustments to the patient’s medication regimen based on their symptoms and level of asthma control. Note that this means that you can step up or step down treatment as necessary.
• Use your local prescribing guidelines as a guide in making any changes to the treatment based on a change in symptoms. Where possible, and with patient agreement as part of shared decision making, choose greener inhalers with a lower carbon footprint.
• An example of such guidelines is provided below. This one is taken from the PAN Mersey Guidelines:

Review of Asthma Action Plan:

• Review the patient’s asthma action plan and ensure they understand how to use it to manage their asthma symptoms and respond to worsening symptoms or asthma attacks.
• If the patient does not have an asthma action plan, provide one and explain its importance in managing asthma effectively.

Education and Self-Management:

• Provide asthma education tailored to the patient’s needs, including information on asthma triggers, proper inhaler technique, the importance of adherence to medication, and strategies for asthma self-management.
• Empower the patient to recognize worsening symptoms and take appropriate actions, including when to seek medical assistance.

Referral and Follow-Up:

• Consider referral to a specialist asthma clinic or respiratory consultant for patients with severe asthma, poorly controlled asthma, or complex management issues.
• Schedule a follow-up appointment as needed based on the patient’s asthma control and individual circumstances.

Documentation:

• Document the findings of the asthma review, including the assessment of symptoms, medication review, asthma control test assessment, education provided, and any referrals or follow-up plans, in the patient’s medical record.
• AST008: For patients aged ≤19 yrs, record the smoking record or 2nd hand smoke exposure as per your PMR system.

Communication and Collaboration:

• If there are issues requiring further professional input, identified as part of the assessment, communicate these with relevant members of the multidisciplinary team as appropriate, to ensure continuity of care and coordinated management. The may include the GP, asthma nurse, pharmacists in general practice or community pharmacists and team members.
• An example of where this is helpful is a situation in which you have prescribed a new inhaler (or spacer) and you would like the community pharmacy team to demonstrate or check the inhaler technique, perhaps as part of the NHS New Medicines Service.