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GMS Contract Guide - Asthma

Asthma is the disease area with one of the largest numbers of patients in the clinical section of the QoF. It is worth 45 points, producing payments of £5,607 in 2007/8 for the practice with average list size and prevalence.

Asthma: Clinical Indicators
Target (%)Points
Records
Register of patients with asthma (excluding patients not prescribed asthma-related drugs in past 12 months)Register4
Initial Management
Patients aged eight and over diagnosed with asthma after 1 April 2006, with measures of variability or reversibility8015
Ongoing management
Smoking status recorded in past 15 months for patients aged 14 to 19806
Asthma review in past 15 months7020
Total 45

ACTION PLAN

Overview

  • National prevalence of asthma was 5.78 per cent in England and Northern Ireland in 2006/7 and 6.6 per cent in Wales and 5.4 per cent in Scotland in 2005/6 (latest available figures).

  • Average exception reporting rates for asthma in 2005/6 were 7.4 per cent in England.

  • Practices providing well-organised asthma care should be able to achieve maximum points. The indicators are based on the British Guideline on the Management of Asthma - SIGN/BTS (see box, page 6). It must be noted that the indicators do not cover all aspects of care for asthma patients.



Step 1: Setting up and updating the register


  • The first step for practices will be to set up an asthma register, if none exists, or update an existing register. The number of points to be earned from setting up an asthma register has been reduced from seven to four, based on the theory that most of the work in setting up the disease registers has been done and less work is needed to keep them updated.

  • The indicator limits the register to patients who have been prescribed asthma-related drugs in the past 12 months. The practice will need an ‘active’ and ‘inactive’ asthma register. Patients on the active register would be on steps one to five of the SIGN/BTS guidelines; patients on the inactive register would be asymptomatic and coded as step 0.

  • It is recommended that as well as using the preferred Read code for diagnosis of asthma (H33%), practices should also use the Read codes for the SIGN/BTS steps and update every time the patient is reviewed. If you are already doing this, you will be able to subdivide the register into active and inactive by identifying those with the code H33 less those with code 8793 (step 0).

  • A search of patients with the code H33 and a prescription for respiratory drugs in the past 12 months will produce an initial register. Finding patients who have had respiratory drugs in the past 12 months, but never been recorded as having asthma, can be done by searching on the relevant drug groups. Review these patients’ notes and divide them into asthma and COPD.

  • There will be many more patients on the practice list who have been diagnosed as asthma sufferers, but who have not been seen by the practice in the past year. These patients’ notes need to be reviewed and sorted into one of the three following groups:

    - Patients who have ‘inactive’ asthma, defined as no prescription or asthma contact in the past year (Read code as asthma step 0, which will put them on the inactive register).

    - Patients who no longer suffer asthma, or where the diagnosis was not established in the past, defined as no asthma prescription or contact in the past five years (Read code as history of asthma).

    - Patients who should have their therapy reviewed and will probably need to be included on the register.

  • The indicator relates to patients who have received asthma-related drugs in the past year, so the register will be constantly updating itself and only completed when the contract year is over.

  • The practice will need to establish a protocol for how new patients are diagnosed with asthma and placed on the register.

  • The original indicator required that all patients aged eight and over should have their diagnosis confirmed by spirometry or peak flow assessment. For patients placed on the register from 1 April 2006, the requirement is that diagnosis is made ‘with measures of variability and reversibility’. Before patients are placed on the register, the diagnosis is expected to be confirmed with serial peak flow measurements, either over time or in response to therapy. Spirometry can still be used to confirm variability, but the guidance states that changes over time may be missed due to the need for surgery-based measurments.

  • The guidance emphasises the importance of making a diagnosis backed up by variability recordings. It says that where a symptomatic patient has repeated normal readings, confirmation of the diagnosis may require further readings, for example, during a subsequent exacerbation. If doubts remain, specialist assessment is indicated.

  • Note that changes to the way the register should be compiled are combined with an increase in the top threshold for patients. The quality framework now requires 80 per cent of patients on the register to have asthma confirmed with serial peak flow measurements or spirometry.

  • Make sure you record the original onset date when new patients with an existing diagnosis of asthma join the practice, or they may be picked up on your system as new diagnoses.

  • There should be some overlap between the COPD and the asthma registers. The guidance states that a proportion of patients with COPD will also have asthma, but evidence suggests that this would not usually be more than 15 per cent.



Step 2: From now onwards


  • Ensure that all possible new diagnoses of asthma are confirmed with serial peak flow measurements or spirometry.

  • Note that 3395 ‘peak flow’ is no longer a valid code, but 339A ‘PEF before bronchodilation’ is.

  • Develop and agree a practice protocol for the diagnosis, treatment and review of asthma.

  • A computer template for the diagnosis and management of asthma, tied in to the new contract indicators and supplying Read codes, makes effective care easier. The General Practice Airways Group (www.gpiag.org) has developed a set of Read codes, incorporating the contract codes.

  • All patients on the register need an annual review. Staff who take the lead on asthma should go on an accredited course, such as the diploma from the National Respiratory Training Centre (www.nrtc.org.uk) or the Respiratory Education and Training Centres (www.respiratoryetc.com).

  • Practices should cover four areas in the review:

    - Assessment of symptoms (using the three Royal College of Physicians questions).

    - Measurement of peak flow.

    - Assessment of inhaler technique.

    - Production of a personalised asthma plan (recommended in SIGN/BTS guidelines).

  • To earn the maximum payment, practices must review 70 per cent of patients who are on the asthma register. This is a lower percentage than required by some other indicators, to account for the fact that a significant number of patients with asthma do not attend for regular review. Consider establishing an ‘expert patient' initiative to help with non-attenders.

  • Note that telephone reviews for this indicator have been ruled unacceptable by the national Implementation Coordination Group for the nGMS.

  • Six points can be gained from recording the smoking status of patients aged 14 to 19 years.



Step 3: From December onwards


  • Run a search on your asthma register to identify patients who have not attended for a review and make sure three invitations for review are sent out by the end of January. Patients who still fail to attend can be exception reported.

  • Your quality cohort will be constantly changing during the year with new asthma diagnoses. Regular searches will be needed to make sure annual reviews are performed and smoking status recorded, where appropriate.

  • Patients on step one of the SIGN/BTS guidelines may be able to restart therapy after more than a year without seeing a GP, just by requesting a prescription. Limit authorised repeats to 12 months. Patients on the inactive register may also return with an exacerbation and indicators need to be updated wherever possible.



References for Asthma

1. British Guideline on the Management of Asthma (Scottish Intercollegiate Guidelines Network/British Thoracic Society)
www.sign.ac.uk/guidelines/fulltext/63/index.html
2. Global Strategy for Asthma Management and Prevention
www.ginasthma.org

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