Title of Project: NHS Dumfries & Galloway Respiratory Bundle Asthma: Bronchodilator Overuse Review April 2015

Transcription

1 Title of Project: NHS Dumfries & Galloway Respiratory Bundle Asthma: Bronchodilator Overuse Review April Reason for the review Respiratory prescribing is long term and can be costly. Appropriate choice and use of inhaled therapy is key to successful management of asthma. The National Review of Asthma Deaths (May 2014) highlighted four key messages which would have significant impact on asthma mortality, one of which was better monitoring of asthma control; where loss of control is identified, immediate action is required including escalation of responsibility, treatment change and arrangements for follow-up. Using >10-12 puffs per day of a bronchodilator is a marker of poorly controlled asthma that puts patients at risk of fatal or near-fatal asthma (SIGN guidelines, Oct 2014 ) The use of 18 cannisters per 12 month period is equivalent to 10 puffs daily. If a patient are using more than 3 doses of bronchodilator weekly, inhaled corticosteroids should be prescribed at an appropriate level to achieve control. (SIGN guidelines, Oct 2014) This project aims to identify those patients who appear to be over ordering their bronchodilator inhalers and highlight them for review of their overall asthma management. 2 Inclusion Criteria All patients with a diagnosis of asthma. 3 Exclusion Criteria Patients with terminal illness. Any individual patient exclusions deemed necessary by the GP. (e.g. patients who are deemed to be not open to change, as judged by the GP) Co-diagnosis of COPD 4 Preparation and planning Implementation of the audit Team will take place as follows: Protocol to be discussed with all GPs in the practice to ensure that agreement to proceed is reached. Educational intervention - ensure all staff involved with asthma review are familiar with review criteria and importance of maintaining asthma symptom control. Computer search of all patients according to the inclusion/exclusion criteria. Review of patients medical notes and repeat prescribing. o Record number of bronchodilators ordered over previous 12 month period. o Record other indicators of high risk behavior: Less than 4 preventer inhalers in 12, out of hour/a and E attendances, more than 2 steroid

2 courses in 12. This will assist in prioritising those for review. o Patients who are over-ordering SABA (and under-ordering ICS) will be flagged up for review by the GP/nurse. This will be regarded as requesting 12 inhalers or more in 1 year as per SIGN, however this is equivalent to 46 puffs weekly. This figure acknowledges that people like to order extra inhalers for school, handbag, workplace etc. The ACT may be used to assess asthma control, as an aid in decision making to step treatment down or up. This could be used face to face at the annual asthma review, conducted by telephone or posted to the patient prior to the review. List of eligible patients to be checked by GP/GPs/practice nurse. Make appointments for further patient review where necessary, action appropriate changes following review, such as checking compliance, checking inhaler technique, stepping up or down of treatment. Patients who do DNA their review will be followed up by telephone or letter. Inhaled steroids should be considered for adults, children aged 5-12 and children under the age of five with any of the following features: using inhaled β2 agonists three times a week or more; symptomatic three times a week or more; or waking one night a week. In addition, inhaled steroids should be considered in adults and children aged 5-12 who have had an exacerbation of asthma requiring oral corticosteroids in the last two years. In adults, a reasonable starting dose will usually be 400 micrograms BDP per day and in children 200 micrograms BDP per day, and dose would be titrated to the lowest dose at which effective control is established. See other information sources within the Respiratory Bundle which may be of help: NHS D&G Guide to Inhalers NHS D&G Primary Care Guideline on management of asthma 5 Action Information should be given to all identified asthma patients outlining the reasons for the review. See attached ACT and letter to the patient which may accompany this if it is to be used as part of the review process. Collate results and make appropriate review appointment for patient. Where patient does not manage their own medication e.g. Level C or Care Home resident, family member or carer as appropriate to be informed as above. Administration staff in practices to be made aware of any changes of repeat medication Local pharmacies to be informed of review taking place so that they can support counselling of patients (e.g. inhaler technique reinforcement) and are aware of the need to reduce stock levels Patients who DNA their asthma review may be highlighted to local pharmacies to encourage them to make an appointment this may be through a note on the

3 repeat prescription (e.g. RHS) or a list (*Confidentiality issues to be clarified) Community Pharmacists could complete an ACT, go through their management plan and check inhaler technique for patients who are unable to make an asthma review at the GP practice. This information can be recorded and a copy given to the GP practices (*again issues such as confidentiality/practicalities need to be clarified) Report for practices will include number of switches made and projected cost savings as a result of the recommendations. Review to be undertaken by: GP Authorisation: Date:

4 Appendix 1: Patient letter. Patient name Address Dear Mr/Mrs As part of a review of prescribing, NHS Dumfries and Galloway are currently reviewing all patients with asthma. Please can you fill in the enclosed Asthma Control Test and return it to the surgery. This will allow our doctors and nurses to review how well controlled your condition is and ensure that you are taking the right medicines for your asthma. Should have any queries, please contact the Surgery on the number above or, alternatively, you can contact a member of the Prescribing Support Team on Yours sincerely Name Prescribing Support Pharmacist On behalf of the Doctors

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6 Bronchodilator overuse review Data collection sheet Surgery: Date: Undertaken by: Patient name/dob Usual GP No. Bronchodi lators in ICS use in OOH/A &E visits in Steroid courses in Date last asthma review Invite for review Attended Changes actioned Follow up if DNA