Asthma is common in the UK, with an estimated 5.4 million people currently receiving asthma treatment. Sadly, we also have one of the highest death rates from asthma in Europe.
The first UK-wide investigation into asthma deaths was carried out last year by the RCP. Its report Why asthma still kills followed confidential research into 195 deaths attributed to asthma over a 12-month period.
The report suggested that almost half of the deaths could have been avoided with better routine care. It identified several key findings for primary care, including:
- The quality of routine care was assessed as inadequate in 62% of cases, including failing to adhere to British Thoracic Society (BTS) or Scottish Intercollegiate Guidelines Network (SIGN) asthma guidance (59%). This included, for example, not performing adequate review and not giving a Personal Asthma Action Plan (PAAP), significant under-prescribing of preventer inhalers, and over-prescribing of reliever inhalers.
- For patients treated in primary care for the final fatal asthma attack, there were potentially avoidable factors in management in 32% of cases, including delays in initiating appropriate treatment, and failure to give appropriate treatment.
Key recommendations for primary care included:
- every practice should have a lead clinician for asthma, who engages in additional training for this role
- annual reviews and PAAPs for all asthma patients
- proactive methods of identifying and contacting patients who fail to attend for routine asthma appointments
- guidance on triggers for referral and urgent reviews.
NICE published draft guidance on diagnosing and monitoring asthma in January. This aims to 'determine the most clinical and cost-effective way to effectively diagnose [asthma] and...the most effective monitoring strategy to ensure optimum asthma control'. It adds that there is evidence that incorrect diagnosis is a significant problem - as many as one million adults are thought to have been wrongly diagnosed.
For patients treated in primary care for the final fatal asthma attack, there were potentially avoidable factors in management in 32% of cases
Follow the guidance
The GMC requires doctors to be competent in all aspects of their work1, and be familiar with guidelines that affect their work2. You should follow BTS/SIGN guidance for the management of asthma, and the NICE guidance for diagnosis and monitoring. There may also be local guidelines that you should be aware of.
Of course, there may be situations where you may feel it is appropriate to deviate from the guidelines. If you do so, you must be prepared to justify your decision.
Training and qualifications
Many practices train their nursing staff to conduct asthma reviews, and doctors must ensure that the person providing care has the appropriate qualifications, skills and experience to do so3.
It is good practice to have a protocol in place detailing the assessment, management, referral and review of patients with asthma, so that all clinicians are aware of their responsibilities and the standard of care they should provide.
Audit and patient register
Regular audit of asthma care and prescribing is recommended, as well as attendance, referrals and admissions. The practice should have a register of patients diagnosed with asthma, and audit of prescribing may assist in identifying patients who may have asthma but have been missed from the register, or who may have missed vital monitoring appointments. For example, last year more than one million asthma patients missed their annual review appointment, which the charity Asthma UK calls 'the bedrock of asthma care to ensure people get the right medication and know when to use it'.
The RCP report found that patient lifestyle, family and the environment were potential factors in 65% of cases studied. Smoking and passive smoking, not following medical advice and not attending asthma reviews were cited. Among children and young people, poor recognition of an adverse outcome, including death, was an important avoidable factor. The findings have implications for the advice given to patients.
While the findings of the National Review of Asthma Deaths are worrying, they should be seen as an opportunity to improve asthma services, by considering and implementing the recommendations.
Just 'a bad chest'?
A GP called the MDU advice line after receiving a letter from the wife of a patient, raising concerns about the care provided by the practice. The letter stated that the patient, a 33-year old plasterer, had attended the practice twice in recent months with a bad chest, and that he had only been given antibiotics and told to stop smoking. Three weeks after the last attendance, he collapsed at home and died in hospital 24 hours later from acute asthma. The patient's wife was concerned that the GP had wrongly diagnosed a chest infection, and that the asthma attack and patient's death should have been prevented.
The MDU adviser suggested the GP list the case for discussion at the practice significant event meeting, and assisted the doctor with drafting a letter to the wife expressing condolences for her loss, and explaining that on each attendance, the doctor had made a careful assessment of the patient, and made adjustments to his asthma medication, as well as prescribing antibiotics on one occasion for a chest infection.
A few weeks later, the doctor was asked to provide a report for the coroner, and also received a letter from the GMC, following concerns raised by the wife of the patient. The adviser helped the GP draft a report for the coroner and to provide comments on the case to the GMC.
The coroner returned a narrative determination, with no criticism of the medical care.
The GMC instructed an expert to review the GP's care. The expert commented that after consideration of the GP records and additional information provided by the doctor, the GP had made an adequate assessment of the patient on each occasion, and prescribed and arranged follow-up appropriately. The expert had no criticism of the care provided, and the GMC closed its investigation with no further action.