Make asthma SIMPLE for your patients
This week saw the publication of the first national study of asthma deaths in the UK. Its findings provide some powerful statements for pharmacy. Anna Murphy explains.
In the UK more than three people die from asthma every day, reflecting both a failure of care and a failure to access medical help promptly enough during severe episodes.1 In 2012, the Royal College of Physicians (RCP) was commissioned to review UK asthma deaths by the Healthcare Quality Improvement Partnership.
The result is the first national investigation of asthma deaths in the UK, and the largest study, world wide, of this kind to date. The primary aim was to understand the circumstances surrounding the deaths, in order to identify avoidable factors and make recommendations to improve asthma care.
Over 12 months from February 2012 to January 2013, 3,544 people in the UK had the word “asthma” on their death certificate. Of those, 276 cases were reviewed by confidential enquiry multidisciplinary panels. The panels concluded that, of these, 195 people had died because of their asthma and were included in the report. Over half of the people who died from asthma were over 40 years old, 84 per cent were white, 5 per cent mixed race, 7 per cent Asian and 0.5 per cent black. Most people died at home (41 per cent), with a further 23 per cent dying on the way to hospital. Forty-five per cent of cases died before medical assistance could be provided, with 33 per cent of those dying without seeking any assistance. The review concluded that asthma care was less than satisfactory in a quarter of the people who died, with deficiencies in both routine care and in the treatment of exacerbations.
What good care looks like
Asthma is seen as a common condition and is often perceived as “not serious” by patients. Sometimes even healthcare professionals’ attitudes is “it’s only asthma” because most patients have mild or moderate disease. But, as the findings of the National Review of Asthma Deaths (NRAD) reveal, there is a real need to get people with asthma interested in their health and how they can stay as healthy as possible.
Good asthma care includes regular reviews of a person’s asthma. This should include:
- An assessment of asthma control
- Identification of risk factors
- Checking the person’s ability to use an inhaler device
- Optimisation of medicines
- Provision of an agreed personalised asthma action plan that the person understands and will use
But good care also includes other factors, such as supporting smoking cessation and education.
What pharmacists can do and how
If patients with asthma control their symptoms with the appropriate use of medicines they can usually lead a normal, healthy life. Pharmacists have a crucial role in supporting patients to get the best outcomes from their medicines. They are the healthcare professional that patients see regularly as they pick up their medicines. This is an opportunity to engage those with asthma, provide advice on their medicines and to ensure optimum inhaler technique.
SIMPLE provides a useful acronym to support asthma consultations or targeted asthma medicines use reviews by a pharmacist. It highlights the main components of effective asthma management. The acronym stands for: Stop smoking, Inhaler technique, Monitoring, Pharmacotherapy, Lifestyle and Education.2
The NRAD found that one in five of the people who died from asthma were recorded as active smokers, and a further 16 (8 per cent), many children, were exposed to second-hand smoke at home. Exposure to smoke is known to increase the risk of dying from asthma.
There is also evidence that smokers respond less to asthma treatment, often requiring higher doses of inhaled corticosteroids (ICSs) to maintain asthma control.3 Pharmacists and pharmacy staff should, therefore, offer stop smoking advice at every opportunity and provide ongoing support to people trying to quit. A number of resources are available:
- Pharmacists can direct patients to a number of support tools from Smokefree NHS, including “quit kits”, a mobile app and texts. (https://quitnow.smokefree.nhs.uk)
- National Institute for Health and Care Excellence quality standards “Smoking cessation — supporting people to stop smoking”.
- A Centre for Pharmacy Postgraduate Education e-learning guide, “Learning about stop smoking support”, for pharmacists and pharmacy technicians who want to learn how to provide high quality support for people who want to stop smoking.
According to the NRAD report, only 49 per cent of the people reviewed in primary care had had their inhaler technique checked in the year before they died. Furthermore, 17 per cent of people admitted to hospital (n=83) did not have documented evidence that their inhaler technique had been checked during their admission.
Pharmacists can really make a difference in this area by ensuring that any person prescribed an inhaler for the first time knows how to use the device correctly, but they should also recognise that people can pick up bad habits and ongoing technique should be confirmed at every opportunity. Asking patients to demonstrate their inhaler technique should be part of an annual asthma review. If poor inhaler technique persists despite clear instruction, then a different inhaler that the person can use should be recommended, prescribed and demonstrated.
It is worrying that a recent paper in Thorax highlighted that only 7 per cent of healthcare professionals could demonstrate all the correct steps for a metered dose inhaler.2 If any health professional should be able to demonstrate correct use, it should be pharmacists and they should make sure they know how to use different inhaler devices correctly and are competent to provide advice to patients. Resources that pharmacists may find helpful include:
- “7 steps to success inhaler device reminder cards”, designed for pharmacists to use with patients, describe how to use each of the most common types of inhaler devices in seven consistent steps. (www.simplestepseducation.co.uk)
- Videos, including podcasts from Greater Manchester Inhaler Technique Improvement Programme (http://wires.wessexhiec/
partnership.org.uk/video-series/inhaler-technique); guides on the Electronic Medicines Compendium website (www.medicines.org.uk/guides/pages/how-to-use-your-inhaler-videos) and two Asthma UK resources (www.asthma.org.uk/
Sites/healthcare-professionals/pages/inhaler-demos and www.asthma.org.uk/
- Refresher courses on inhaler technique from the CPPE
It is concerning that 17 per cent of the people who died had no record of an asthma review in primary care in their last 12 months. The average time since the previous primary care asthma review was 121 days. The RCP also reported that 10 per cent of those who died did so within one month of discharge from hospital following treatment for asthma. Eighty-three people who died were under specialist review in secondary care, but only 34 per cent of those had had a review by their specialist in the year before death.
It is clear that patients should have an annual review that includes all five aspects already described. Pharmacists can play an important role in encouraging people with asthma to attend their medical practice for their review. Moreover, they could liaise with local GP practices to ask which people have not attended for their asthma review because such patients could be targeted for an MUR.
People identified as being at high risk of severe asthma should be closely monitored and pharmacists should be aware of the features that increase the risk of asthma exacerbations and death (such as recent hospital admission).
In addition, anyone who has been admitted to hospital or treated for an asthma exacerbation should be followed-up and reviewed as soon as possible. Community pharmacists in England and Wales can support some of these patients, in particular, through the new medicine service, and hospital pharmacists can link with patients’ community pharmacists as suggested in the NMS guidance. The British Asthma Guideline 2012 contains further information on monitoring.
The NRAD report states that at least five people who died from asthma were prescribed a long-acting beta-2 agonist (LABA; eg, formoterol or salmeterol) with no ICS. The RCP found that an average of 10 canisters of short-acting beta-2 agonists (SABA), were prescribed per a year and, perhaps shockingly, six of those who died from asthma were prescribed more than 50 SABA canisters during the 12 months before they died.
Also disturbing was that 22 per cent of those prescribed ICSs and 4 per cent prescribed a combined ICS/LABA inhaler had only a single prescription for each in the 12 months before death from asthma. Delays in initiating treatment were identified in 22 per cent admitted to secondary care.
Pharmacotherapy is the area in which pharmacists can and should take the lead. All pharmacists working in acute medicine should actively advocate the use of UK (British Thoracic Society/Scottish Intercollegiate Guidelines Network) asthma management algorithms to support appropriate and timely administration of medicines.Where LABAs are prescribed for people with asthma, they should be prescribed with concomitant ICSs, ideally in a single inhaler device, and pharmacists can ensure this. There is evidence to show that the use of a LABA with no ICS has been associated in controlled trials with increased asthma mortality.4
ICSs should be prescribed for all symptomatic people with asthma. MURs should specifically target those patients where poor adherence is identified, for example, for those who are collecting too few preventer or too many reliever inhalers. You could search patient medication records and highlight these people for a targeted MUR.
In terms of resources, the BNF is a good starting point. Chapter 3 contains key information, including a summary of the BTS/SIGN British asthma guideline. The full copy is available at http://www.brit-thoracic.org.uk/. Other useful materials include:
- NICE quality standards QS25 on asthma (2013). The summary page has a useful list of tools and resources that you might want to take a look at.
- Guidelines, reports and other resources from the Global Initiative for Asthma (GINA), which has input from international experts. (www.ginasthma.org)
- Royal Pharmaceutical Society guidance on medicines optimisation and asthma and its new consultation skills framework to help pharmacists across all settings to improve their skills in carrying out consultations with patients.
More asthma facts
- Approximately 5.6 million people in the UK have asthma.5
- Most commonly asthma arises in childhood and may persist into adulthood. In around two-thirds of children with asthma, the disease remits in the early teenage years, only to relapse, in about a third of these cases, in adulthood. Less commonly, the disease begins for the first time in adulthood.6
- Asthma symptoms and exacerbations have been shown to impact significantly on people’s quality of life and activities of daily living, affecting sleep and the ability to go to work or school.1,7
- Patient with more severe disease live with the uncertainty of unplanned emergency visits to hospital or their GP and, for some, a fear of death.1
Allergy was identified as an avoidable factor during the patient’s last year of life in 12 per cent of cases (eg, allergy to animals, food allergy, seasonal allergy), the review found. Drug-induced allergy appeared in 2 per cent of the cohort.
The review also revealed that the body mass index was over 25 in 50 per cent of those who had died.These are both areas to which pharmacists can contribute by identifying and addressing such avoidable factors in every patient and providing support and advice to each person. For example, since obesity is known to increase the risk of people dying from asthma, pharmacists should encourage patients to adopt a healthy lifestyle and support weight reduction.
Pharmacists can refer asthma patients with allergies to Allergy UK, a charity dedicated to supporting allergy sufferers in the UK, (http://www.allergyuk.org/) as well as Asthma UK, which provides information on allergy and asthma (www.asthma.org.uk).
Only 23 per cent of the people who died in the review period were found to have been provided with an asthma action plan. It is disturbing that 87 (45 per cent) of the 195 people who died did not try to get help or delayed calling for medical assistance during their final attack. Having a plan in place may have helped avoid these situations and pharmacists should ensure that all their patients with asthma have a written personal asthma action plan which they understand and use.
Clear and consistent education should be made available for patients and their families, from all healthcare professionals. Asthma UK’s website is a valuable source of patient education. The organisation also operates an adviceline (tel 0800 121 62 44; available Monday to Friday, 9:00am to 5:00pm). Other sources of good information and support are the British Lung Foundation (whose regional teams offer “Breathe easy” support groups for people with respiratory disease throughout the UK, with disease specific information available to download and print from the website; http://www.lunguk.org/) and NHS choices (www.nhs.uk/conditions/Asthma).
The findings of the NRAD provide both pharmacists and service commissioners with some powerful evidence that action is needed and asthma care needs to improve. A number of projects in which community pharmacists have improved the asthma control and outcomes for people with asthma are also available to refer to. These are described in the Panel below. Although no study was powered to show a reduction in deaths, they all demonstrate how pharmacists can make a direct and meaningful contribution to the management of people with asthma using the services introduced as part of the pharmacy contract.
Services that demonstrate the value of community pharmacy in asthma management
LloydsPharmacy project The LloydsPharmacy Asthma Medicines Support Service (AMSS) identifies people who are experiencing difficulties controlling their asthma. The service combines the use of a short series of questions, the “Asthma control test” (ACT), with a focused medicines use review. The findings from the project show that a patient’s ACT score significantly improves following a medicines use review.
Rowlands and GSK Rowlands Pharmacy, in collaboration with GSK, developed and implemented a national community pharmacist led asthma support service. This aimed to improve the health and optimise the use of medicines in a cohort of patients with asthma. A University College London School of Pharmacy report, (www.rpharms.com/support/map-of-evidence.asp) provides an evaluation of the collaborative programme. The overall results show a positive effect on asthma control due to pharmacist intervention, and are consistent with other community pharmacy based studies in asthma management.
Bristol project A two-year initiative has helped the Bristol area reduce admissions for asthma through a range of medicines optimisation initiatives, including specialist respiratory nurses working with GP practices to target people frequently admitted to hospital, smokers and those not attending for an annual asthma review; community pharmacy MURs for patients not attending GP practices for their regular review; enhanced training for patients and general practice teams; and incentives for GPs to review patients prescribed excessive reliever inhalers and patients who need to be stepped down.
South of England project An analysis of results from a respiratory MUR project in the south of England has demonstrated significant improvements in patient outcomes, with the interventions leading to better asthma control. An inhaler technique improvement project in the south of England saw over 5,100 MURs delivered across 206 pharmacies, with over 800 “secondary intervention”, or follow-up MURs also completed.
There was evidence of improved asthma control between the first and second MURs — at the second MUR there was a 40 per cent relative increase in the number of people achieving a test score representing good asthma control. This increase was statistically significant. Analysis of data on emergency asthma admissions showed a positive association between the introduction of the project and changes in emergency hospital admissions.
SIMPLE approach in Leicester The SIMPLE service uses the community pharmacy as an additional place for people with asthma to access expert advice and receive a structured review of their asthma, working in collaboration with GP practices. The service has been evaluated, demonstrating outcomes over six months.
In total, 125 people were recruited; 63 per cent of patients returned for a follow-up appointment and review of their asthma after three months. Forty per cent of the patients returned for a follow-up at six months. Fifty-six per cent had not had their inhaler technique checked in the past year. Only 19 patients (15 per cent) owned an asthma action plan at baseline.
Significant improvements in asthma control (measured by the ACT questionnaire) was demonstrated (P=0.002). Intention-to-treat analysis confirmed significance (P<0.001). Quality of life improved significantly (measured by mini asthma quality of life questionnaire; P=0.03).
Medication adherence — both self-reported and adherence scores calculated by prescription re-fill data from the pharmacy computer system — showed improvements. The results showed a significant reduction in the collection of prescriptions for short-acting beta-2 agonists and a highly significant increase in the prescription refill of inhaled corticosteroids (P<0.001).
At the end of six months 92 per cent of patients collected at least 80 per cent of their ICS inhalers. There was a 32 per cent reduction in the number of visits to the GP for an asthma-related issue over the study period (P=0.053).
Asthma continues to kill people in the UK. The findings of NRAD help us to understand the circumstances surrounding death from asthma and identify improvements in the care received by patients. Every time a person picks up his or her inhaler or is admitted to hospital with an exacerbation there is an opportunity for pharmacists to support that person and his or her clinicians by helping to detect signs of poor asthma control, identify those who are not using their medicines correctly and to discuss any issues with action plans. Many deaths from asthma could be prevented with improved asthma care in both primary and secondary care.
Citation: The Pharmaceutical Journal DOI: 10.1211/PJ.2014.11138140
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