Quality improvement for asthma

Asthma is a common, chronic respiratory disease. People with asthma experience episodes of wheezing, breathlessness and chest tightness due to widespread narrowing of the airways.¹ Asthma can be controlled but not cured – the aim of treatment is to relieve symptoms and prevent them from recurring. Symptoms vary over time – sometimes they may be mild or entirely absent, while at others they may be severe and persistent.²

Asthma control should be assessed regularly, including current risk factors for adverse events (eg, flare-ups, life-threatening asthma, accelerated decline in lung function, or adverse effects of treatment).² Validated questionnaires provide a valuable objective framework to assess asthma control.² An asthma flare-up is an increase in symptoms from usual day-to-day symptoms.^2,3

Effective management strategies to prevent asthma flare ups are well known. These strategies include:¹

• ongoing treatment with preventer medicines
• regular medical review including inhaler technique
• develop and agree on an asthma action plan
• support for people with asthma to self-manage their treatment and behaviours.

Effective self-management practices include:¹

• self-monitoring of asthma symptoms and attending medical reviews
• consistent medication adherence and correct inhaler technique
• use of asthma action plans
• an understanding of asthma triggers.

Asthma affects about 2.7 million Australians of all ages. In 2017–18, 1 in 9 (11%) Australians had asthma, based on self-reported data from the 2017–18 Australian Bureau of Statistics (ABS) National Health Survey. In 2017 there were 441 deaths due to asthma in Australia.⁴

Asthma is one of the most common reasons for admission to hospital in childhood. Hospitalisation for asthma occurs as a result of disease exacerbations. Hospitalisations rates were highest in children aged 0–14 (425 per 100,000 population) in 2016–17.⁴

GPs play an important role in the management of asthma in the community. This role includes (comprehensive history taking of symptoms and exposure to irritants) assessment (including assessment of lung function using spirometry), prescription of regular medications, education and review, as well as managing acute exacerbations.⁴ In 2015–16 asthma accounted for almost 4% of the chronic problems managed in Australian general practice.⁵

Improvement measures can be used as part of practice quality improvement to:

1. review the care of those patients who are currently being treated for asthma
2. reflect on whole-of-practice asthma care and identify opportunities to improve policy and procedures for future care.

The improvement measures recommended for asthma are: 

• Proportion of patients aged 6 years or more with asthma who do not have spirometry recorded
• Proportion of patients with asthma who are current smokers or who have no smoking status recorded
• Proportion of patients with asthma who have not had a repeat prescription for a preventer issued in the previous 8 months

Please contact info@nps.org.au with questions or feedback about these measures.

Every practice is different and will have different priorities and ways of working. Determine, in collaboration with the practice team, how the practice wishes to prioritise patients for review and then agree on practice-wide procedures for the diagnosis and management of asthma. Discuss what behaviours may need to change to achieve best practice, (and why they are occurring). Choose quality improvement interventions that address the cause of the behaviours.

For individual patients:

• This may include reminders to GPs in clinical software patient files to check smoking status at next visit or to offer support to quit.
• Discuss recalling patients without current preventer prescriptions or without asthma action plans. Can the practice nurse and the pharmacist run a clinic for these people? The practice nurse (if trained) may perform spirometry and the pharmacist can assess adherence and inhaler technique, and counsel the patient before the patient’s review with the GP

For the practice:

• Discuss as a team at a clinical meeting the role of spirometry, should the practice buy a spirometer, who should perform (in-house or external) and how to consistently record the results.
• Are there any upcoming or recent changes to the guidelines for asthma? How do clinicians intend to implement these and what are the barriers?
• How well is the practice assessing asthma control? Could the nurse or pharmacist perform an assessment with a validated tool before the GP consultation?
• Decide if additional education or clinical update is needed (outreach or in-house), for example, NPS MedicineWise educational visiting.

• National Asthma Council Asthma Action Plans
  Choose the most appropriate plan based on the person’s age, treatment regimen, asthma severity, culture, language, literacy level, and ability to self-manage.²
• Validated questionnaires to assess asthma control
  Provide a valuable objective framework that can be used to assess response to treatment over time.
• Asthma: unlocking inhaler technique
  Most patients do not use their asthma inhaler devices correctly – this online module for health professionals teaches skills to engage patients in conversations about device use and how to demonstrate correct technique.

• Asthma apps
  Be familiar with the range of consumer asthma apps and be able to recommend the most appropriate one for your patient’s needs
• About asthma
  Comprehensive consumer information about all aspects of asthma (Asthma Australia)
• Medicines and devices
  Information and demonstration videos for patients how to use different inhalation devices.
• Asthma (short wind) in children and asthma in adults
  Menzies School of Health Research provides content about asthma management and Indigenous health for Aboriginal and Torres Strait Islander populations.

For GPs

• Educational visit – Paediatric asthma: breathing new life into diagnosis and management (available from March 2020)
• Clinical case study – Asthma: optimising asthma control in children