|ASTHMA 1. The practice can produce a register
of patients with asthma, excluding patients with asthma
who have been prescribed no asthma-related drugs in the
last twelve months
|ASTHMA 2. The percentage of patients aged
eight and over diagnosed as having asthma from 1 April
2003 where the diagnosis has been confirmed by spirometry
or peak flow measurement
|ASTHMA 3. The percentage of patients with
asthma between the ages of 14 and 19 in whom there is
a record of smoking status
in the previous 15 months
|ASTHMA 4. The percentage of patients aged
20 and over with asthma whose notes record smoking status
in the past 15 months, except those who have never smoked
where smoking status should be recorded at least once
|ASTHMA 5. The percentage of patients with
asthma who smoke, and whose notes contain a record that
smoking cessation advice or referral to a specialist service,
if available, has been offered within the last 15 months
|ASTHMA 6. The percentage of patients with
asthma who have had an asthma review in the last 15 months
|ASTHMA 7. The percentage of patients aged
16 years and over with asthma who have had influenza immunisation
in the preceding 1 September to 31 March
Asthma - Rationale for Inclusion
of Indicator Set
Asthma is a common condition which responds well to appropriate
management and which is principally managed in primary care.
This indicator set was informed by the British Thoracic Society/
SIGN guidelines which are to be published in early 2003. In
keeping with the other indicators, not all areas of management
are included in the indicator set in an attempt to keep the
data collection within manageable proportions.
Asthma Indicator 1
The practice can produce a register
of patients with asthma, excluding patients with asthma who
have been prescribed no asthma-related drugs in the last twelve
Asthma 1.1 Rationale
Proactive structured review as opposed to opportunistic or
unscheduled review is associated with reduced exacerbation
rates and days lost from normal activity. A register of patients
who require follow up is a pre-requisite for structured asthma
The diagnosis of asthma is a clinical one; there is no confirmatory
diagnostic blood test, radiological investigation or histopathological
investigation. In most people, the diagnosis can be corroborated
by suggestive changes in lung function tests.
One of the main difficulties in asthma is the variable and
intermittent nature of asthma.
Some of the symptoms of asthma are shared with diseases of
other systems. Features of an airway disorder in adults such
as cough, wheeze and breathlessness should be corroborated
where possible by measurement of airflow limitation and reversibility.
Obstructive airways disease produces a decrease in peak expiratory
flow (PEF) and forced expiratory volume in one second (FEV1).
One or both of these should be measured, but may be normal
if the measurement is made between episodes of bronchospasm.
If they are repeatedly normal in the presence of symptoms,
then a diagnosis of asthma must be in doubt.
Variability of PEF and FEV1, either spontaneously over time
or in response to therapy, is a characteristic feature of
asthma. Sequential measurement of PEF may be useful in making
the diagnosis. A 20% or greater variability in amplitude with
a minimum change of 60 l/min, ideally for three days in a
week for two weeks seen over a period of time, is highly suggestive
of asthma. As with other aspects
of the framework, decisions about which patients actually
have asthma and should therefore be included on the register
are clinical ones which are intended to be made by individual
Many patients with asthma will demonstrate variability below
20%, making this a reasonably specific but insensitive diagnostic
test. Marked variability of peak flow and easily demonstrated
reversibility confirm a diagnosis of asthma but smaller changes
do not necessarily exclude the diagnosis.
SIGN/BTS British Guideline on the Management of Asthma
A definitive diagnosis of asthma can be difficult to obtain
in young children. Asthma should be suspected in any child
with wheezing, ideally heard by a health professional on auscultation
and distinguished from upper airway noises.
In schoolchildren, bronchodilator responsiveness, PEF variability
or tests of bronchial hyperactivity may be used to confirm
the diagnosis, with the same reservations as above.
The diagnosis of asthma in children should be based on:
- the presence of key features and careful consideration of
- assessing the response to trials of treatment and ongoing
- repeated reassessment of the child, questioning the diagnosis
if management is ineffective.
Grade D recommendation: SIGN/BTS British Guideline on the
Management of Asthma
It is well recognised that asthma is a variable condition
and many patients will have periods when they have minimal
symptoms. It is inappropriate to attempt to monitor symptom-free
patients on no therapy or very occasional therapy.
This produces a significant challenge for the Quality and
Outcomes Framework. It is important that resources in primary
care are targeted to patients with greatest need - in this
instance patients who will benefit from asthma review rather
than insistence that all patients with a diagnostic label
of asthma are reviewed on a regular basis.
For this reason it is proposed that the asthma register should
be constructed annually by searching for patients with a history
of asthma, excluding those who have had no prescription for
asthma-related drugs in the last 12 months. This indicator
has been constructed in this way as most GP clinical computer
systems will be able to identify the defined patient list.
Asthma 1.2 Preferred Coding
Asthma 1.3 Reporting and Verification
Asthma 1.3.1 Practices should report the number of patients
with active asthma (ie a diagnosis of asthma, excluding those
who have had no prescription issued for an asthma-related
drug in the last 12 months), and the number of patients with
active asthma (ie diagnosis of asthma, excluding those who
have had no prescription issued for an asthma-related drug
in the last 12 months) as a proportion of their practice list
Asthma 1.3.2 Practices should report the number of patients
with inactive asthma (ie those who have a diagnosis of asthma
who have had no asthma-related drug issued in the last 12
months) and the number of patients with inactive asthma (ie
those who have a diagnosis of asthma who have had no asthma-related
drug issued in the last 12 months) as a proportion of their
practice list size.
Verification - PCOs may compare the expected prevalence with
the reported prevalence.
Asthma Indicator 2
The percentage of patients aged eight
and over diagnosed as having asthma from 1 April 2003 where
the diagnosis has been confirmed by spirometry or peak flow
Asthma 2.1 Rationale
The SIGN guideline suggests that confirmation of diagnosis
by spirometry or serial peak flows should be utilised in schoolchildren,
but does not specify an age. The age of eight has been pragmatically
agreed for the indicator although many children aged six and
over will be able to co-operate with PEF measurements or spirometry.
This indicator is introduced for diagnosis with effect from
1 April 2003 as it is recognised that recording to date may
have not been undertaken in a systematic way.
Asthma 2.2 Preferred Coding
Peak flow rate abnormal 3395
Asthma 2.3 Reporting and Verification
The practice should report the percentage of patients aged
eight or over diagnosed as having asthma after 1 April 2003
who have a record of spirometry or peak flow measurement.
Asthma Indicator 3
The percentage of patients with asthma
between the ages of 14 and 19 in whom there is a record of
smoking status in the previous 15 months
Asthma 3.1 Rationale
Two indicators have been included on the recording of smoking
advice (Asthma 3 and Asthma 4). The two indicators, which
relate to different age groups, have been included because
GPs may take a different clinical approach to this issue at
different ages. Many young people start to smoke at an early
age. It is therefore justifiable to ask about smoking on an
annual basis. Patients aged 20 and over fall into two categories:
those who have never smoked, where recurrently asking about
smoking status is inappropriate, and those who are smokers
or ex-smokers where regular recording and offering of smoking
cessation advice is appropriate. The indicators developed
for the two age groups therefore differ: in adults who have
who have a record of never having smoked, regular recording
of smoking status is not recommended (indicator Asthma 4),
whereas annual enquiry is recommended in children (indicator
The number of studies of smoking related to asthma are surprisingly
few in number. Starting smoking as a teenager increases the
risk of persisting asthma. SIGN/BTS were unable to identify
any study which considered the question of whether smoking
affects asthma severity. One controlled cohort study suggested
that exposure to passive smoke at home delayed recovery from
an acute attack.
It is recommended that smoking cessation be encouraged as
it is good for general health and may decrease asthma severity.
Asthma 3.2 Preferred Coding
Never Smoked 1371
Asthma 3.3 Reporting and Verification
Practices should report the percentage of patients on the
asthma register between the ages of 14 and 19 where smoking
status has been recorded in the last 15 months.
Asthma Indicator 4
The percentage of patients aged 20 and
over with asthma whose notes record smoking status in the
past 15 months, except those who have never smoked where smoking
status should be recorded at least once
Asthma 4.1 Rationale
See asthma 3.1
Asthma 4.2 Preferred Coding
Never Smoked 1371
Asthma 4.3 Reporting and Verification
The aim of this indicator is to ensure that the smoking status
of all patients is known in the previous year, making the
assumption that patients who have never smoked will continue
not to smoke (in order to avoid keeping asking them).
The numerator of the indicator is the number of asthma patients
aged 20 and over who have never smoked plus the number who
have been recorded as ex- or current smokers in the past 15
months. The denominator is the total number of asthma patients
age 20 and over. Thus:
|% with smoking status recorded
(among patients with asthma aged 20 and over) =
|[no of never smoked] +
||[no recorded as ex- or current smokers in
past 15 months]
with asthma aged 20 and over]
Asthma Indicator 5
The percentage of patients with asthma
who smoke, and whose notes contain a record that smoking cessation
advice or referral to a specialist service, if available,
has been offered within the last 15 months
Asthma 5.1 Rationale
The evidence for the value of smoking cessation advice is
largely extrapolated from studies in relation to CHD.
Many strategies have been used to help people to stop smoking.
A meta-analysis of controlled trials in patients post myocardial
infarction showed that a combination of individual and group
smoking cessation advice, and assistance reinforced on multiple
occasions - initially during cardiac rehabilitation and reinforced
by primary care teams - gave the highest success rates.
Reference Grade B recommendation SIGN Guidelines 41/51
Further Information: http://www.sign.ac.uk/guidelines/fulltext/51/index.html
Further Information: http://www.sign.ac.uk/guidelines/fulltext/41/index.html
A number of studies have recently shown benefits from the
prescription of nicotine replacement therapy or buproprion
in patients who have indicated a wish to quit smoking. Further
guidance is available from NICE.
Further Information: http://www.nice.org.uk/pdf/NiceNRT39GUIDANCE.pdf
In a significant number of PCOs across the UK specialist smoking
cessation clinics are now available. Referral to such clinics,
where they are available, can be discussed with patients.
This should also be recorded as smoking cessation advice.
Asthma 5.2 Preferred Coding
Smoking Cessation advice 8CAL
Asthma 5.3 Reporting and Verification
Practices should report the percentage of asthmatic patients
who smoke who have been offered smoking cessation advice in
the last 15 months.
Asthma Indicator 6
The percentage of patients with asthma
who have had an asthma review in the last 15 months
Asthma 6.1 Rationale
Structured care has been shown to produce benefits for patients
with asthma. The evidence on the important aspects of structured
care is not good, although the recording of morbidity, PEF
levels, inhaler technique and current treatment and the promotion
of self-management skills are common themes. SIGN/BTS proposes
a structured system for recording inhaler technique, morbidity,
PEF levels, current treatment and asthma action plans.
Reference Grade C Recommendation SIGN/BTS British Guideline
on the Management of Asthma
The Quality and Outcomes Framework suggests the utilisation
of the RCP three questions as an effective way of assessing
"In the last month
- Have you had difficulty sleeping because of your asthma
symptoms (including cough)?
- Have you had your usual asthma symptoms during the day (cough,
wheeze, chest tightness or breathlessness)?
- Has your asthma interfered with your usual activities eg
housework, work/school etc?"
Although there is good evidence on the use of personalised
asthma plans in secondary care, there is very limited evidence
in primary care. Practices may wish to follow the advice of
the BTS/SIGN guideline and offer a personalised asthma action
plan to patients.
Peak flow is a valuable guide to the status of a patient's
asthma. However, it is much more useful if there is a record
of patients' best peak flow, ie their peak flow when they
are well. Many guidelines for exacerbations are based on the
ratio of current to best peak flows. For patients over the
age of 18 there need be no particular time limit on when the
best peak flow was measured although in view of the reduction
of peak flow with age it is recommended that the measurement
be within the preceding five years. For patients aged 18 and
under the peak flow will be changing; therefore it is recommended
that the best peak flow should be re-assessed annually.
Inhaler technique should be reviewed but there is no evidence
to suggest how frequently this should be undertaken.
Summary of Asthma Review:
- Assess symptoms (using RCP 3 questions)
- Measure peak flow
- Assess inhaler technique
- Consider personalised asthma plan
It is recognised that a significant number of patients with
asthma do not regularly attend for review. For this reason
the percentage achievement for the asthma indicators has been
set at a lower level compared to process indicators in some
other chronic disease areas.
Asthma 6.2 Preferred Coding
Asthma Review 66YJ
Asthma 6.3 Reporting and Verification
Practices should report the percentage of patients on their
asthma register who have had an asthma review in the last
Asthma Indicator 7
The percentage of patients with asthma
aged 16 and over who have had influenza immunisation in the
preceding 1 September to 31 March
Asthma 7.1 Rationale
There a current recommendation from the Departments of Health
and the Joint Committee on Vaccination and Immunisation (www.doh.gov.uk/greenbook/)
which suggests that influenza immunisation should not be given
under 6 months of age. While the guidance implies that all
asthmatic children should be immunised annually from the age
of 6 months, this advice is so far from common practice among
GPs that this indicator refers to adults only at present.
Asthma 7.2 Preferred Coding
Flu Vaccination given 65E
Flu vac contra indicated 8I2F
Asthma 7.3 Reporting and Verification
The percentage of patients on the asthma register aged 16
and over who have had an influenza immunisation administered
in the preceding 1 September
to 31 March.