asthma care quality improvement tool instruction guide (tpp

PRIMIS’ development of the Asthma Care quality improvement tool has been funded

by Boehringer Ingelheim. Boehringer Ingelheim has undertaken a medico legal

review but PRIMIS has retained editorial control and intellectual property rights for

this quality improvement tool.

Reviewed by PRIMIS

April 2016

© The University of Nottingham. All rights reserved. UK/RESP-141175b(1)a

Asthma Care Quality Improvement Tool

Asthma Care Quality Improvement Tool

Instruction Guide (TPP SystmOne)

PRIMIS: Quality Improvement Tool Instruction Guide

Asthma_Analysis_TPP_V2.0 20th April 2016

Contents Introduction .............................................................................................. 3

Aim of the asthma care quality improvement tool .......................................... 5

Clinical audit notes and GP revalidation ...................................................... 6

Running the asthma quality improvement tool ............................................ 7

CHART Online ......................................................................................... 7

Asthma Case Finder ................................................................................... 8

View 1 – Summary sheet (classic view) ...................................................... 9

View 2 – Datasheet ............................................................................... 14

Case finder pre-set filters .................................................................... 15

Asthma Care Management ........................................................................ 17

View 1 – Summary sheet ....................................................................... 17

Dashboard view ................................................................................. 18

Classic view ....................................................................................... 18

View 2 – Datasheet ............................................................................... 28

Asthma care pre-set filters .................................................................. 29

Key questions for GP practices ................................................................... 31

Recommended follow-up work ................................................................ 31

References .............................................................................................. 32

Glossary ................................................................................................. 34

Appendices.............................................................................................. 35

1. Columns within the pseudonymised datasheet - case finder ............... 35

2. Columns within the pseudonymised datasheet - asthma care ............. 36

3. Note regarding unusual quantities of prescribed inhalers .................... 39

IMPORTANT NOTE: This instruction guide corresponds with the Asthma Care quality improvement

tool for TPP SystmOne only.

If you are using another GP clinical system, there is an alternate version of this instruction guide available.


Asthma_Analysis_TPP_V2.0 of 39 20th April 2016

Introduction Asthma is a common respiratory condition that is largely managed in primary

care, generating significant work for general practice1. Asthma symptoms are notoriously variable and intermittent and it is the episodic nature of the disease that makes it difficult to define and diagnose.

There is no confirmatory diagnostic test for asthma, meaning diagnosis relies on

clinical interpretation of symptoms and suggestive changes in lung function tests1,2. Consequently, asthma prevalence is a complex area that is open to interpretation. Prevalence in the UK is reportedly amongst the highest in the

world at approximately 9-10% of adults according to a report from the Department of Health3. This is slightly higher than the rates reported by Asthma

UK who state that one in 11 children and one in 12 adults in the UK are currently being treated for asthma:

“5.4 million people in the UK are currently receiving treatment

for asthma: 1.1 million children (1 in 11) and 4.3 million

adults (1 in 12). The UK has among the highest prevalence rates of asthma symptoms in children worldwide.”

Asthma UK: Asthma Facts and FAQs4.

The majority of the workload relating to asthma is generated by poor disease

management, particularly the under use of preventative medicine1. Asthma cannot be cured, but with appropriate management it can be controlled,

enabling good quality of life5. Symptoms can be relieved with short-term medication whilst long-term inhaled steroids are used to limit disease progression. Long-term daily medication can control underlying inflammation

and help to prevent symptoms and reduce the risk of exacerbation5.

Severity of asthma is assessed by the amount of medication needed to control the disease6. The National Review of Asthma Deaths (NRAD) in 2011 defined severe asthma as those patients who receive treatment at the British Thoracic

Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN) steps 4 and 5 or have evidence of hospital admission or asthma attack in the previous year1,6.

Asthma control relates to the presence of related symptoms, such as breathlessness and wheezing. Recurrent asthma symptoms frequently cause

sleeplessness, tiredness, reduced activity levels and absenteeism5. During an asthma attack, the lining of the bronchial tubes swell; this causes the airways to

narrow and reduces the amount of air that can enter the lungs. Asthma attacks can be fatal. The number of (reported) asthma related deaths in the UK is amongst the highest in Europe6.

“Premature mortality from COPD in the UK was almost twice

as high as the European average and premature mortality for asthma was over 1.5 times higher. Around 90% of deaths

from asthma each year could have been prevented.” “There are around 1,000 deaths from asthma a year in the UK,

the majority of which are preventable.”

An Outcomes Strategy for COPD and Asthma: NHS Companion Document3



Medication is the optimum way to control the disease, although, asthma is sometimes referred to as an atopic disease due to the fact that allergen

exposure can produce atopic sensitisation. It has been proposed that prolonged allergen exposure can result in clinical asthma through inflammation of the

airways, bronchial hyper responsiveness and reversible airflow obstruction7. Asthmatic patients should learn to recognise environmental triggers that provoke allergic reactions or irritate the airways in order to avoid them and potentially

provide an extra degree of control3,5.

One of the main aims of asthma care is to achieve freedom of symptoms for patients. The Royal College of Physicians has developed a patient-focused outcome measure to help health professionals assess whether the care they

provide is effective. By asking all asthma patients (regardless of severity) three specific symptom-related questions at every review, it is possible to build a

picture of the overall well-being of asthma patients over time8,9. The fundamental causes of asthma are not completely understood, making it

impossible to prevent the disease from developing3. A combination of exposure to environmental triggers along with a family history of the disease is by far the

strongest risk factor for developing asthma5. Asthma is currently under-diagnosed and under-treated5. The Outcomes Strategy for COPD and Asthma

recommends early accurate diagnosis and assessment of severity to ensure that risks are reduced and effective interventions can begin earlier3. This can be greatly assisted through case finding activity in general practice to identify

patients with asthma who have not yet been diagnosed.

Local Clinical Commissioning Groups (CCGs) and NHS England are under a statutory duty to continuously improve quality of care. In order to help support delivery of the NHS Outcomes Framework (NHS OF), NHS England has

developed the Clinical Commissioning Group Outcomes Indicator Set (CCG OIS). The CCG OIS 2014/15 contains a specific indicator aimed at reducing time spent

in hospital due to asthma10. The Outcomes Strategy for COPD and Asthma and the NICE Quality Standard for asthma11 (QS25) also help to support quality improvement in relation to the NHS Outcomes Framework.

Related QOF indicators – Year 2016/17 Asthma: AST001, AST002, AST003, AST004.



Aim of the asthma care quality improvement tool The aim of the asthma care quality improvement tool is twofold; to assist with

case finding activity and to report upon the level of care being offered to patients diagnosed with asthma who have received asthma medication in the last year.

Note: For the purposes of this tool, patients who have not

been prescribed asthma medication in the last year are excluded.

The main cohort will be referred to throughout this document as patients with active asthma.

The case finder element provides practices with a list of patients who may have

asthma but do not have this coded in their record. By undertaking a review of these patients and adding any missing diagnosis codes, practices can improve the quality of their asthma register, establish a more accurate prevalence rate

and ensure that patients are monitored regularly and are appropriately managed.

The care management part of the quality improvement tool helps practices identify where they can improve the quality of care they provide to patients with

active asthma and reduce their risk of exacerbations.

The asthma care quality improvement tool enables practices to extract and analyse relevant clinical data from their clinical information system. The quality

improvement tool works across all clinical information systems and presents data in an easy to use format allowing practices to gain insight and knowledge into their management of patients with asthma.

The asthma care quality improvement tool helps practices by:

generating a list of patients with possible asthma and providing relevant

information to help clinicians to confirm or exclude diagnosis

establishing a more accurate prevalence rate for asthma within their practice population

facilitating clinical audit against national standards for all asthmatic patients prescribed asthma medication within the last 12 months

summarising practice achievement of the Royal College of Physicians ‘3

questions’ outcome measure which assesses asthma patient wellbeing

using patients’ medication history to summarise treatment strategies based

upon the British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN) stepwise approach

highlighting patients whose current treatment step may require review

reporting on key factors that are associated with an increased risk of exacerbation



providing the facility to compare data with other practices both locally and nationally and the option to share aggregated data with their CCG via the

CHART Online tool

contributing to the delivery of the Quality and Outcomes Framework, the

NICE quality standards for asthma (QS25), the NHS Outcomes Framework (NHS OF), the Clinical Commissioning Group Outcomes Indicator Set and the Public Health Outcomes Framework (PHOF)12.

As this is a quality improvement tool, it has been designed simply to signpost

GPs to patients who may be of interest or concern and would benefit from review. The tool is not intended to replace clinical decision making. Any action should be as a result of performing a clinical review with patients based upon

individual circumstances.

Clinical audit notes and GP revalidation

This quality improvement tool has been designed to support GP revalidation. GPs can use the various displays within the CHART software to review clinical

data at both patient and practice level, enabling them to maintain an overall picture of how they are managing patients at a population level but at the same time, look in detail at the care of individual patients.

This is a retrospective clinical audit – looking back at clinical practice that has

already taken place.

When conducting clinical audit for GP revalidation, GPs might choose to audit just their own clinical practice. Note that the asthma care audit tool will

report on all patients with active asthma or with factors suggesting possible asthma. Data will therefore be included on the activity of other colleagues

within the practice.

Involve fellow GPs in the clinical audit project. Several GPs who work together as a team can undertake a common audit. This is acceptable for the

purpose of GP revalidation, as long as each GP can demonstrate that they have contributed fully to the clinical audit activity. Alternatively, seek their

permission.

A clinical audit on the care of patients with asthma (or possible asthma for case finder searches) matches the following criteria:

it is of concern for patients and has the potential to improve patient outcomes

it is important and is of interest to you and your colleagues

it is of clinical concern

it is of local or national importance

it is practically viable

there is new research evidence available on the topic

it is supported by good research



Running the asthma quality improvement tool Before running the quality improvement tool you must ensure that the latest version of CHART is installed and you are familiar with how to use the software.

Detailed instructions on CHART installation and using the software can be found on the PRIMIS website: www.nottingham.ac.uk/primis/tools/chart/chart.aspx

There are two MIQUEST query sets contained within the asthma care quality improvement tool: one for the case finder and one for the management of

patients with active asthma.

Once all data has been loaded into CHART software, practices can switch between the ‘Asthma Case Finder’ and the ‘Asthma Main Audit’ by using the ‘Select Response Workbook’ function, as illustrated below:

Both audits search on all patients who are currently registered at the practice. It

is recommended that both audits are run frequently (e.g. quarterly or six monthly) to monitor standards of care.

CHART Online

CHART Online is a secure web enabled tool that helps practices improve performance through comparative data analysis. Using CHART Online, practices can explore and compare the quality of their own data with anonymised data

from other practices, locally or nationally, through interactive graphs. CHART Online helps practices and Primary Care Organisations (PCOs) to improve data

quality and identify ways to enhance patient care. Variations in data management and activity are more visible when compared across a group of GP

practices. Comparative data analysis provides a powerful tool for standardising care across localities and may be of interest to local commissioning groups to facilitate the planning of care pathways.

Aggregated summary data from the asthma care part of the quality

improvement tool can be uploaded to the PRIMIS comparative analysis tool, CHART Online. There is an inbuilt security function that prevents patient identifiable data being uploaded. Only aggregate data compiled from the

pseudonymised responses can be transmitted. Please note that data from the case finder element cannot be uploaded to CHART Online as there is no

corresponding toolkit. Access to the comparative views will be available online in the near future once

sufficient data have been received to generate the graphs. Please upload data in the meantime to allow enough data to be received to produce the graphs.

http://www.nottingham.ac.uk/primis/tools/chart/chart.aspx



Asthma Case Finder It is strongly recommended that practices use the case finder tool before going

on to examine the management of patients with active asthma. Using the case finder as a starting point will ensure that people with symptoms of asthma are diagnosed earlier, receive appropriate treatment and that the practice asthma

register and practice prevalence rate are as accurate as possible.

The asthma case finder helps practices to answer the following questions: Do we have any patients with asthma who do not have the diagnosis coded in

their electronic record?

Are there any patients who would benefit from review for possible inclusion in

the register and relevant treatment?

How accurate is the practice prevalence rate for asthma?

The case finder audit includes all patients who are currently registered at the practice AND have Read coded entries that suggest possible asthma including:

i. asthma medication in the last 12 months

ii. asthma monitoring at any time or

iii. positive asthma spirometry results at any time

It will exclude any patients with an existing diagnosis of asthma or COPD.

Asthma case finder output The asthma case finder tool provides the following views in CHART:

1. Summary sheet including

- a classic tabular view of the data

2. Full patient datasheet Detailed information on each of these data views can be found on the following

pages.



View 1 – Summary sheet (classic view) The CHART summary sheet provides a synopsis of all the relevant data recorded by the practice and is the best place to start when viewing the results. The

classic view presents practice data in tabular format covering medication, monitoring and exacerbation information.

An example practice summary sheet for the asthma case finder is shown below:



Key information

The first two rows of data (blue) provide some important pieces of information:

an up to date count of the registered practice population

the total number of patients who have Read coded entries related to asthma but do not have an asthma diagnosis coded in their record (patients included

in the datasheet)

What to note about this practice

506 patients have been identified by the search and are included in the

datasheet, meaning they have items in their record related to asthma but do not have an existing asthma diagnosis.

Suggested actions

As a baseline quality check, assess whether the practice population count appears accurate. An unusually low number may suggest a problem whilst

running the queries.

Review the remaining summary sheet for further information on possible

missing diagnoses. There may be patients with asthma who have not yet had this coded. Missing diagnoses will affect the accuracy of the practice disease prevalence rate.

Note: The case finder can only help to find patients who may be missing a

diagnosis (potential under recording of asthma) and cannot help to identify patients who may incorrectly have a diagnosis recorded on their record (potential over recording). However, the main asthma care audit datasheet may

be able to help identify such patients.



Asthma medication in the last year

The next table provides a breakdown of the number of patients receiving asthma related medication in the last year despite not having an asthma or COPD

diagnosis*. Patients on multiple therapies will appear in more than one row/category.

Important note: Patients identified within the asthma medication table may be on this medication for other genuine reasons. The reasons for prescribing

should be investigated to establish whether they are asthma related. What to note about this practice

328 patients have been prescribed an inhaled short-acting β2 agonist (SABA)

in the last year.

110 patients have been prescribed inhaled corticosteroids in the last year (including combination inhalers).

No patients have been prescribed an inhaled long-acting β2 agonist (LABA) in the last year.

14 patients have been prescribed Leukotrienes in the last year.

Suggested actions Try to identify the patients who are genuinely missing a diagnosis of asthma.

Use the associated data in the datasheet to gain a picture of the patient’s history and look for indications or symptoms of asthma. Establish when the

patient was last reviewed. The patient’s full medical record may need to be examined and/or the patient called for review to confirm or exclude diagnosis.

Patients may have received more than one prescription for the relevant medication. Consult the relevant columns in the datasheet to determine the

number of prescriptions issued in the last year. Relevant datasheet columns are ‘No. of ICS prescriptions L12m’ and ‘No. of SABA prescriptions L12m’.

Use pre-set filter 1 within the datasheet to list patients who have been

prescribed two or more asthma related medications within the last year (see page 15 for more information on pre-set filters). Pre-set filter 5 will list

patients who have received three or more prescriptions for a SABA inhaler in the last year.

*Patients are included in the case finder if they have a diagnosis of asthma AND have a

coded entry of ‘Asthma Resolved’ where asthma resolved is the latest of the two entries.



Monitoring/tests

The next table provides a summary of the presence of relevant lung function tests and asthma monitoring codes. Patients with multiple factors will appear in

more than one row:

The first category asthma monitoring includes any codes related to asthma such as asthma severity, emergency admissions due to asthma, asthma management

plans and asthma limiting activities or disturbing sleep. PEFR value, predicted PEFR value and FEV1/FVC value simply indicates that

patients have a value recorded for these tests (not necessarily a diagnostic value).


27 patients have monitoring codes related to asthma but do not have an existing diagnosis of asthma.

Two patients have an FEV1/FVC ratio post bronchodilator value recorded.

Suggested actions Use pre-set filter 4 to identify patients with positive asthma spirometry

results. Use results and associated data in the datasheet to gain a picture of the patient’s history and look for indications or symptoms of asthma.

Establish when the patient was last reviewed. The patient’s full medical record may need to be examined and/or the patient called for review to confirm or exclude a diagnosis.

It is worthwhile reviewing the records of patients with asthma monitoring codes to establish why these codes are present despite there being no

asthma diagnosis. Consider whether a diagnosis is missing or whether the monitoring code has been selected in error. It is possible that these patients have been screened for asthma and a diagnosis ruled out but this should be

confirmed.

You can easily list the patients with an asthma monitoring code by applying

pre-set filter 2 within the datasheet (see page 15 for more information on pre-set filters).



Respiratory exacerbations

The final table provides useful information regarding respiratory exacerbations by summarising recent oral steroid and chest antibiotic prescriptions for

patients.

Important note: Patients identified within this table may be on this medication for genuine reasons other than asthma. This table is provided for information

purposes to support clinical decision making.

The datasheet (shown below) includes counts of the number of prescriptions for oral steroids and chest antibiotics issued within the relevant time period:


31 patients have received a prescription for oral steroids within the last 12 months. One patient (shown above) has received 12 prescriptions.

365 patients have received a prescription for chest antibiotics within the last

three years. One patient (shown above) has received 27 prescriptions.

Suggested actions

Identify any patients in your practice who have received high numbers of prescriptions for oral steroids within the last 12 months. Establish when the patients were last reviewed. Patients may need to be called for review to

confirm or exclude a diagnosis of asthma.

Also, consider reviewing patients who have received a large number of

prescriptions for chest antibiotics within the last three years.



View 2 – Datasheet

The datasheet (accessible via this icon from the toolbar) is perhaps the most

valuable part of the asthma case finder. It allows you to access patient level data, providing relevant information in one place to help you confirm or exclude

a diagnosis of asthma. The datasheet can be filtered as desired, to produce bespoke lists of patients.

When preparing the queries to run on the clinical system, you must decide whether to run a pseudonymised set, which uses a patient reference number (as

shown above) or a patient identifiable set, that will return named patient information. The patient identifiable set is the most useful for case finding

activity. The CHART datasheet contains many columns of

relevant data. The datasheet columns can be filtered as desired. A full list of available columns is included

in the appendices of this document. As an example, there is a column titled ‘Latest asthma symptoms’

(shown right in Excel 2003) which lists the patient’s latest entry of an asthma related symptom such as wheezing or breathlessness and the date it was

entered.

Within the datasheet, columns have been grouped into relevant sections. Some columns are then hidden from the initial view to prevent the datasheet

becoming too cluttered. In order to reveal relevant collapsed columns click on the plus signs towards the top of the datasheet (see image below):



Case finder pre-set filters

There are five pre-set (or pre-loaded) filters provided within the asthma case finder datasheet:

To apply a pre-set filter, click on ‘PRIMIS CHART’, ‘Load Filter’ when viewing the

datasheet and select the desired filter. Review the columns containing data items suggestive of asthma to determine the value of reviewing the patients’ full medical records in more detail.

Pre-set filter 3 – Atopy or allergies

Pre-set filter 3 will list any patients who have any of the following as their presence increases the likelihood of asthma:

Allergic rhinitis

Eczema

Food allergy

Eosinophilia

Family history of asthma, hayfever or atopy

A combination of environmental exposure to inhaled substances and particles

that may provoke allergic reactions or irritate the airways along with a family history are the strongest risk factors for developing asthma1. Genetic

predisposition is the most clearly defined risk factor for atopy and asthma in children. The filter works by applying a custom filter to the ‘Count of associated features column’.



Summary of suggested action for practices

Review the data presented in the summary sheet. Using the pre-set filters available in the datasheet, access the lists of patients with possible asthma.

Examine the associated data within the datasheet (and practice clinical system if required) to help determine whether a diagnosis is missing.

Based on the findings, enter any missing diagnostic codes to the patient

electronic health record or contact patients to arrange any necessary conclusive tests.

Once you are confident about the accuracy of the practice asthma disease register move on to the next part of the quality improvement tool examining the care of patients with known active asthma.



Asthma Care Management It is recommended that practices use the case finder tool before going on to

examine the management of patients with known asthma. This will ensure that the practice asthma register and prevalence rate are as accurate as possible. The asthma care management part of the tool reports upon the level of care

being offered to patients diagnosed with asthma who have received asthma medication in the last year. The audit cohort is referred to as patients with

active asthma.

Note: For the purposes of this tool, patients who have not

been prescribed asthma medication in the last year are

excluded.

The asthma care management tool helps practices to answer the following questions:

What is the practice prevalence rate for asthma? How many patients are considered to have active asthma?

How many patients were asked the ‘3 three RCP questions’ in the last year? How many patients scored zero indicating good asthmatic control?

How many of our patients with asthma are poorly controlled or at risk of

exacerbation?

Which of the BTS/SIGN step categories do our asthma patients fall into? How

well is this recorded in the practice?

How do we highlight patients whose current treatment step may require

review?

Asthma care management output

The asthma care management tool provides the following views in CHART:

1. Summary sheet including

- a dashboard view of the main audit data

- a classic tabular view of the main audit data

2. Full patient datasheet

Detailed information on each of these data views can be found on the following pages.

View 1 – Summary sheet

CHART summary sheets provide a snapshot of all the relevant data recorded by the practice. For asthma care management there are two different summary

sheet views available; a dashboard view and a classic tabular view. The dashboard view provides a visual display of the data whereas the classic view presents data in tabular form (see next page for example practice views).



Dashboard view

Classic view



Population/prevalence

Both the classic view and dashboard view start by providing key statistical information.

This includes an up to date practice population count, a prevalence rate for patients with active asthma and a rate for

the number of patients with an asthma diagnosis recorded regardless of date or

medication status (asthma ever).

Some patients will have coded entries of both ‘Asthma Resolved’ and an asthma

diagnosis. Patients will only be included in the active asthma population if the asthma diagnosis is the latest entry.

Prevalence graph for active asthma population

The dashboard also includes a prevalence graph of patients with active asthma broken

down by age band.

Each bar on the graph represents the percentage of patients in the practice within that age band who have active asthma.


The prevalence rate of active asthma (those prescribed medication in the last

year) in this practice is 5.9%. This is comparable to the 2014/15 Quality and

Outcome Framework rate (reported October 2015) of 6% for England13.

The prevalence rate for asthma ever in this practice is 10.4%. This figure

includes all patients in the practice with a diagnosis of asthma regardless of when asthma medication was last prescribed. This is comparable to the Asthma UK reported prevalence of one in 11 children and one in 12 adults4.

Suggested actions

As a baseline quality check, assess whether the practice population count

seems accurate. An unusually low number may suggest a problem whilst

running the queries.

If your practice prevalence rate is inexplicably low compared to the national

or local average (averages can also be determined using CHART Online) then consider looking for patients who are potentially missing a diagnosis of asthma. The case finder can help with this task. If your practice prevalence

rate seems unusually high, review coding practice in this area or look for evidence of the underlying cause.



BTS/SIGN asthma treatment steps

The next table in the classic view provides information regarding patients’ current

treatment step (based on the stepwise approach taken from the BTS/SIGN guideline

on the management of asthma1). It applies to patients aged 13 and over only. BTS/SIGN guidance differs by age

group so this section focuses on the guidance for adults.

There is also a corresponding graph on the dashboard (shown above right). Important note: This table/graph is populated using medication data and not

coded step information from the clinical information system. Patients in both the step 2 and 3 categories are assumed to be on a SABA inhaler even if no

prescription has been issued on the clinical system. The BTS steps have been calculated using prescription data from the last six

months with the exception of SABA prescriptions which is from the last 12 months. As the calculation is based purely on prescription data with some

inherent technological limitations, medication compliance, along with changes in prescriptions, need to be considered when analysing the results of this audit. The asthma quality improvement tool is designed to signpost GPs and is

not intended to influence clinical decision making. Any subsequent action should be as a result of performing a clinical review with patients based on individual

outcomes.

It should be noted that patients with comorbid COPD are the most likely not to fit the treatment steps programme.


The majority of patients with active asthma appear within steps 1 and 2 (combined).

There are a very small number of patients within steps 4 and 5. For some

patients it is impossible to calculate their current step (not known).

Suggested actions Identify patients within the step 2 and step 3 treatment categories who do

not have a prescription for a SABA inhaler. It is unusual for patients to be prescribed inhaled steroids or inhaled long-acting β2 agonist (LABA) without a

short-acting β2 agonist (SABA).

To identify these patients, find the column ‘Count of SABA prescriptions L12m’ and list patients with a value of 0. Then scroll across to the right to

see patients’ ‘Calculated treatment step’.



Compare patients calculated treatment step (calculated from medication history) with their actual coded step information (manually entered step

codes) and look for mismatches. You can do this using the datasheet (see page 28 for detailed information on how to do this).

Associated features

The third table on the classic view displays information about the number of

active asthma patients with co-morbidities such as COPD, obesity and anxiety or depression. There is a corresponding graph on the dashboard.

Knowledge of co-morbidities and

associated features can help when planning a patient’s care pathway

particularly in relation to self-management plans.

It can also help you to understand how unwell patients might become, or

complications that might arise. Many of these features are associated with an increased risk of fatality1.

Anxiety and depression

There is a well-recognised link between asthma and psychosocial problems. Prevalence of anxiety, depression or panic disorder is much higher in patients

with asthma and is linked with poorer outcomes such as increased symptoms, higher use of healthcare resources and more frequent emergency admission to hospital6. Compliance with preventative treatment is also reduced.

Allergens

It has been proposed that prolonged allergen exposure can result in clinical asthma through inflammation of the airways, bronchial hyper responsiveness and reversible airflow obstruction7. Asthmatic patients should learn to recognise

environmental triggers that provoke allergic reactions or irritate the airways in order to avoid them and potentially provide an extra degree of control3, 5.


30.6% of patients with active asthma (in this practice) are obese.

Many patients with active asthma suffer with allergic rhinitis (19.5%).

Suggested actions

Use the associated information to build a picture of the patient’s disease severity and level of control. Target patients who have not been reviewed

recently (i.e. over 12 months ago).



RCP questions

In order for health professionals to establish that the care they provide is effective they need to measure the outcome of the treatment given. The RCP

have published three simple questions that can be applied to all asthma patients regardless of severity. By asking the same three questions and recording the result in a standard way, it is possible to build a picture of the overall well-being

of all asthma patients.

This section of the summary sheet reports on the numbers of patients asked the RCP three questions in the last year and the number that scored zero. An RCP

score of zero indicates well controlled asthma.

The RCP ‘3 questions’ are as follows: In the last week (or 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 (e.g.

housework, work/school etc)? It is recommended that an assessment of recent asthma control should be

undertaken at every asthma review6. Data are extracted using either the RCP asthma assessment Read codes (Read version 2 - 388t. and 388t0 or CTV3 -

XaNKw and XaXa0) or symptom information regarding sleep disturbance, current symptoms and limitation of activities (hover over relevant datasheet column titles for the range of included codes).


A high proportion of active asthma patients have had their level of control

assessed in the last year using the RCP 3 questions (72.4%).

37.8% of all patients with active asthma achieved a score of zero.

Suggested actions If achievement is low in this area, review coding practice and ensure that

control is assessed at every patient review. Review symptomatic patients’ current treatment regime.



Short-Acting β2 Agonist (SABA) use

A table and corresponding graph are provided detailing numbers of SABA prescription issues over the last year. This information is provided as a guide to

help clinicians identify patients worthy of review. A high number of SABA prescriptions are often indicative of poor asthma control6.

Note: Due to data limitations, this section will

only count the number of prescriptions issued and not the number of inhalers issued on each

prescription. If a patient is issued with multiple inhalers on one prescription it will still only show as one prescription. Consult the relevant

datasheet columns (see below) for dosage/unit information from the last script.


The majority of asthma patients (64.9%) received between zero and three

prescriptions for SABA inhalers in the last year.

There are 19 patients (4.8%) who received more than 12 prescriptions for

SABA inhalers in the last year. Suggested actions

Urgently review patients who have received

more than 12 SABA prescriptions in the last year (pre-set filter 4). Consider ICS where this is not currently prescribed.

Prioritise those prescribed the highest numbers of SABAs. You can do this by filtering the

‘Count of SABA prescriptions L12m’ column within the datasheet (see image right). In the example shown to the right, one patient has

received 30 prescriptions within the last year.

Use pre-set filter 2 within the datasheet to

identify patients who have received more than six prescriptions for SABA inhalers in the last year but who have no record of an inhaled

corticosteroid prescription.

Review the columns ‘No. inhalers on last SABA

Rx’ and ‘No. doses on last SABA Rx’ for dosage/unit information from the last prescription. Patients may have actually received a higher number of

inhalers than prescriptions where multiple units have been issued. See appendix 3 for a note regarding unusual quantities of prescribed inhalers.



Inhaled Corticosteroid (ICS) use

A table and corresponding graph are provided detailing numbers of ICS

prescription issues over the last year. This information is provided as a guide to help clinicians identify patients worthy of review.

A low number of prescriptions for

preventative medication may be a feature in patients with poor asthma control. Patients who are under medicated may be

at risk of exacerbation and should be monitored6.

Note: Due to data limitations, this section will only count the number of prescriptions issued and not the number of inhalers issued on each prescription. If a patient is issued with multiple inhalers on one prescription it will still only

show as one prescription. Consult the relevant datasheet columns (see below) for further dosage/unit information.


There is a fairly even spread of the number of ICS prescriptions in the last year in this practice.

There are 90 patients without a prescription for ICS in the last year and 88 patients who received just one prescription.

Suggested actions

Review or monitor patients receiving low numbers of prescriptions for ICS.

Review the columns ‘No. inhalers last ICS or combined Rx’

and ‘No. doses last ICS or combined Rx’ for dosage/unit information from the last prescription (see right).

Patients may have actually received a higher number of inhalers than prescriptions where multiple units have been

issued on the same script.

The availability and quality of dosage/unit information varies across clinical systems. The datasheet will place

values <20 into the ‘No. inhalers last ICS or combined Rx’ column and values >20 into the ‘No. doses last ICS or

combined Rx’ column. Look for erroneous entries that do not correlate with either numbers of inhalers or doses and consider correcting these on the patient’s electronic record.

See appendix 3 for a note regarding unusual quantities of prescribed inhalers.



Secondary care engagement

The next table and corresponding graph provide information regarding contact

with secondary care services including referrals, attendances and an indication of the numbers that may benefit from a review by a specialist. Patients with a

history of exacerbation in the previous year may be at greater risk of future exacerbation6.

Admitted last 12 months

Looks for Read codes for asthma related hospital admissions (including the code

‘admitted since last appointment’). A&E attendance data (asthma related

illness) This relies on practices having entered such

data (where available). As a result, recording levels in this area will vary. It is likely that the majority of recording will only

take place during annual reviews with patients.

Frequent oral steroid use

Patients who have received six or more prescriptions for oral steroids within the last 12 months are included in dashboard graph and summary sheet table. Patients with frequent oral steroid use are likely to be in contact with secondary

care already but if they are not they should be considered for referral.


There are only 38 patients with a record of either being admitted to hospital or seen in A&E with asthma related illness in the last 12 months. It is unclear

whether this reflects reality or is a consequence of poor recording in this area.

There are no patients with asthma related referrals to secondary care. This

may be due to poor recording in this area.

There are two patients who have received six or more prescriptions for oral steroids within the last 12 months.

Suggested actions

Use pre-set filter 3 to identify patients who have been issued with three or more prescriptions for oral steroids in the last year. These patients should either be managed according to step 4 or 5 of the BTS/SIGN guidelines or be

referred for specialist assessment6.

Pre-set filter 5 will list patients who have attended A&E and then been

admitted to hospital with asthma related illness. Patients with a history of exacerbation in the last year should be closely monitored. Review quality of coding in relation to exacerbations and hospital attendances due to asthma.



Management

This section of the summary sheet provides key information regarding smoking status, annual reviews and self-management plans.

Annual review looks for a coded ‘asthma annual review’ in the last 12 months.

Current smoker indicates that the patient’s latest smoking status is ‘current

smoker’.

Smokers given advice reports on the number of current smokers given

appropriate advice and/or prescribed any relevant medication (NRT or other) in the last year.

Asthma attack is determined by the number of asthmatic patients who have

received a prescription for oral steroids within the last year.

Self-management plan should be updated and recorded annually. If recording is

low check practice data entry templates and check recording procedures at annual review.

Inhaler technique should be routinely assessed and documented (i.e. at least

annually).


Smoking status (99.2%), smokers given advice (92.7%) and inhaler technique (76.9%) are well recorded in this practice. Suggested actions

Check recording levels where achievement is low. For example, you would expect the figure for annual review (59.1%)

and self-management plans (66.2%) to be slightly higher - see example practice above.



Other data items

This section reports on the number of patients who have coded entries relating to the avoidance of unplanned admissions to hospital.

The codes included in the audit are as follows:

Read Version 2

8CT2. Admission avoidance care ended 8CV4. Admission avoidance care started

8Iae1 Admission avoidance care plan declined

CTV3 XaYD2 Admission avoidance care ended

XaYD1 Admission avoidance care started XabFn Admission avoidance care plan declined



View 2 – Datasheet

The datasheet (accessible via this icon from the toolbar) is perhaps the most

valuable part of the asthma care quality improvement tool. It allows you to access patient level data, providing relevant information in one place to help

clinicians review relevant information regarding asthma care. The datasheet can be filtered as desired to produce bespoke lists of patients.

When preparing the queries to run on the clinical system, practices must decide whether to run a pseudonymised set, which uses a patient reference number (as

shown below) or a patient identifiable set that will return named patient information. The patient identifiable set is the most useful for audit and patient

care but to achieve the benefits of comparative analysis (using CHART Online), only the pseudonymised set can be uploaded in order to keep patient data secure.

The CHART datasheet contains many columns of relevant data. A full list of available columns is included in the appendices of this document. As

an example, you can use the columns in the datasheet to compare patients’ calculated

treatment step with their actual coded step information by comparing the columns ‘Latest recorded therapeutic steps code’ and ‘Calculated

treatment step’ (see right).

Within the datasheet, columns have been grouped into relevant sections. Some columns are then hidden from the initial view to prevent the

datasheet becoming too cluttered. In order to reveal relevant collapsed columns click on the plus

signs towards the top of the datasheet (see image above).



Asthma care pre-set filters

In addition to creating custom filters, there are five pre-set (or pre-loaded) filters provided within the main audit tool. The can be accessed via ‘PRIMIS

CHART’, ‘Load Filter’ when viewing the datasheet:

Load a filter as desired and then review the columns containing data items to

determine the value of reviewing the patients’ full medical records in more detail. This will also assist with prioritising patients for review.

Summary of suggested action for practices

Use the asthma case finder to identify patients who may have a missing diagnosis.

Use pre-set filter 1 to identify patients who have received a prescription for a long-acting β2 agonist (LABA) in the last year, but have not received a prescription for an inhaled corticosteroid (ICS) within that time. In

accordance with step 3 of the BTS/SIGN stepwise approach, a LABA should be issued in addition to inhaled corticosteroid. Consider whether these

patients would be better suited to a combination inhaler which guarantees that the long-acting β2 agonist is not taken without an inhaled steroid.

Use pre-set filter 2 within the datasheet to identify patients who have

received more than six prescriptions for short-acting β2 agonist (SABA) inhalers in the last year but who have no record of an inhaled corticosteroid

prescription. Urgently review patients who have received more than 12 SABA inhalers in the last year. A high number of SABA prescriptions is often indicative of poor asthma control6.

Review any patients who have been identified as having frequent oral steroid courses (pre-set filter 3). Asthmatic patients receiving more than three

courses of oral steroids in the last year should either be managed using BTS step 4 or 5 to achieve control or be referred to a specialist service6.



Assess practice recording levels for A&E attendances and admission to hospital for asthma related illness. Pre-set filter 5 will list any patients who

were admitted to hospital after attending A&E in the last 12 months (for asthma related illness).

Patients receiving low numbers of ICS in the previous year should have their asthma control assessed (or be closely monitored). Low numbers of prescriptions may be indicative of poor preventer therapy compliance.

Use the datasheet to compare patients calculated treatment step (based on prescribing history) with their actual coded step information and look for

mismatches (see page 28).

Upload summary data to CHART Online for benchmarking and comparison with other practices.

Recommended learning Registered members of the Primary Care Respiratory Society UK (PCRS) can

access online training resources designed to help practices, clinical commissioning groups, health boards and other primary care-based groups

deliver high value, patient-centred, respiratory care.

Their EQUIP (Effecting Quality in General Practice) modular tool provides a structured, systematic way of reviewing the respiratory care being delivered and identifies ways in which the standards of care can be optimised within a single

practice or across multiple practices in a given locality. http://www.pcrs-uk.org/equip

http://www.pcrs-uk.org/equip



Key questions for GP practices Do we have any patients with asthma who do not have the diagnosis coded in

their electronic record? How accurate is our practice prevalence rate for asthma?

Do all of our asthma patients have a self-management plan in place in case

of exacerbation?

Do we have a procedure in place to review patients whose current treatment

step appears to be sub-optimal?

What is our strategy for reducing the risk of exacerbations?

Which patients are receiving high numbers of prescriptions for short-acting β2

agonist (SABA) inhalers? Are these patients receiving prescriptions for and utilising inhaled corticosteroids?

Are key data items (such as annual reviews, self-management plans and treatment steps) being recorded routinely and accurately?

Should some of the individual patients identified be added to the practice

Admissions Risk register?

Are we effectively implementing the recommendations made in The National

Review of Asthma Deaths (NRAD)6?

Recommended follow-up work

Upload summative data to the PRIMIS CHART Online data warehouse and compare your practice data to other practices in the locality and nationally.

Improve data recording and accuracy of clinical coding including the review of

data collection/data entry templates.

Access and complete the Primary Care Respiratory Society UK (PCRS) EQUIP

(Effecting Quality in General Practice) modular online tool (PCRS members only).



References

1. British Thoracic Society (BTS)/Scottish Intercollegiate Guidelines Network

(SIGN). British Guideline on the Management of Asthma [updated online October 2014].

Available: http://www.sign.ac.uk/guidelines/fulltext/141/ Last accessed: 20th April 2016

2. Health and Social Care Information Centre. (February 2014) Prevalence:

asthma and prescribed medication. Indicator Specification Document. Available: HSCIC (2014) Prevalence: asthma and prescribed medication.

Last accessed: 20th April 2016

3. Department of Health. (2012) An Outcomes Strategy for COPD and Asthma:

NHS Companion Document. London.

4. Asthma UK. (August 2014). Number of people treated for asthma in the

United Kingdom.

Available: www.asthma.org.uk/asthma-facts-and-statistics. Last accessed: 20th April 2016

5. World Health Organization. (November 2013) Asthma. Fact Sheet No 307.

Available: www.who.int/mediacentre/factsheets/fs307/en/ Last accessed: 20th April 2016

6. Royal College of Physicians. (May 2014) Why asthma still kills: the National

Review of Asthma Deaths (NRAD) Confidential Enquiry report. London.

7. Pearce, N., Pekkanen, J. and Beasley, R. (1999) How much asthma is

really attributable to atopy? Thorax, vol 54, pp.268:272.

8. Pearson MG, Bucknall CE (Eds). (1999) Measuring Clinical Outcome in

Asthma; a patient-focused approach. London: Royal College of Physicians.

9. Bucknall, C. (November 1999) Asking three simple questions will help

improve asthma care. eGuidelines. Guidelines in Practice. Vol 2, Edition

11. Available: www.eguidelines.co.uk/eguidelinesmain/gip/vol_2/nov_99/bucknall_asthma

_nov99.htm?sector=professional#.U_NTBE0g_IU Last accessed: 20th April 2016

10. NHS England (December 2013) CCG Outcomes Indicator Set 2015/16 – at a

glance. Available: https://www.england.nhs.uk/wp-content/uploads/2012/12/ccg-

ois-2015-glance.pdf Last accessed: 20th April 2016

http://www.sign.ac.uk/guidelines/fulltext/141/

https://indicators.ic.nhs.uk/download/NCHOD/Specification/Spec_23C_649PC_13_V1.pdf

http://www.asthma.org.uk/asthma-facts-and-statistics

http://www.who.int/mediacentre/factsheets/fs307/en/

http://www.eguidelines.co.uk/eguidelinesmain/gip/vol_2/nov_99/bucknall_asthma_nov99.htm?sector=professional#.U_NTBE0g_IU

http://www.eguidelines.co.uk/eguidelinesmain/gip/vol_2/nov_99/bucknall_asthma_nov99.htm?sector=professional#.U_NTBE0g_IU

https://www.england.nhs.uk/wp-content/uploads/2012/12/ccg-ois-2015-glance.pdf

https://www.england.nhs.uk/wp-content/uploads/2012/12/ccg-ois-2015-glance.pdf



11. National Institute for Health and Clinical Excellence, (February 2013) NICE

Quality Standards 25. Quality Standard for Asthma. Available: http://www.nice.org.uk/guidance/QS25

Last accessed: 20th April 2016

12. Public Health England. (Updated December 2015) Public Health Outcomes

Framework 2013 to 2016.

Available: www.gov.uk/government/publications/healthy-lives-healthy-people-improving-outcomes-and-supporting-transparency. Last accessed 20th April 2016

13. Health and Social Care Information Centre. (October 2015) Quality and

Outcomes Framework – Prevalence, Achievements and Exceptions Report,

England 2014-15. Available: Quality and Outcomes Framework – Prevalence, Achievements

and Exceptions Report, England 2014-15 Last accessed: 3rd February 2016

http://www.nice.org.uk/guidance/QS25

https://www.gov.uk/government/publications/healthy-lives-healthy-people-improving-outcomes-and-supporting-transparency

https://www.gov.uk/government/publications/healthy-lives-healthy-people-improving-outcomes-and-supporting-transparency

http://www.hscic.gov.uk/catalogue/PUB18887/qof-1415-Report%20v1.1.pdf

http://www.hscic.gov.uk/catalogue/PUB18887/qof-1415-Report%20v1.1.pdf



Glossary

A&E Accident and Emergency department

BTS British Thoracic Society

CCG Clinical Commissioning Group

CCG OIS

Clinical Commissioning Group Outcomes Indicator Set CCG OIS measures are developed from NHS Outcomes

Framework indicators that can be measured at clinical

commissioning group level together with additional indicators

developed by NICE and the Health and Social Care Information

Centre.

CHART PRIMIS data analysis tool (MS Excel based)

CHART Online

PRIMIS comparative data analysis tool (web based)

COPD Chronic Obstructive Pulmonary Disease

CTV3 Clinical Terms Version 3

DES Directed Enhanced Service

FEV1 Forced Expiratory Volume in 1 second

FVC Forced Vital Capacity

ICS Inhaled Corticosteroid

LABA Long-Acting β2 Agonist

NHS OF NHS Outcomes Framework

NICE National Institute for Health and Care Excellence

NRT Nicotine Replacement Therapy

O/E On examination

PCO Primary Care Organisation

PEFR Peak Expiratory Flow Rate

QOF

Quality and Outcomes Framework

RCP Royal College of Physicians

SABA Short-Acting β2 Agonist

SIGN Scottish Intercollegiate Guidelines Network



Appendices

1. Columns within the pseudonymised datasheet - case finder

Reference Eczema date Predicted PEFR value

Age Food allergy code Predicted PEFR date

Sex Food allergy date Positive airways reversibility code

Latest SABA code Eosinophilia code Positive airways

reversibility date

Latest SABA date Eosinophilia date % predicted FEV1 pb value

Latest inhaled steroid

code Family history atopy code

% predicted FEV1 pb

date

Latest inhaled steroid date

Family history atopy date FEV1/FVC ratio pb value

Inhaled LABA code Count of associated features

FEV1/FVC ratio pb date

Inhaled LABA date History of wheeze code Respiratory function test

present

Oral B-agonist code History of wheeze date Latest smoking status

Oral B-agonist date O/e wheeze code Latest smoking status

date

Leukotriene code O/e wheeze date Smoking status present

Leukotriene date Dyspnoea code Oral steroid Rx code

Count of medication

types Dyspnoea date Oral steroid Rx date

No. of SABA prescriptions L12m

Latest symptoms relating to asthma

No. of oral steroid prescriptions

No. of ICS prescriptions

L12m Latest symptoms date

Latest chest antibiotic Rx

code

Allergic rhinitis code Latest asthma resolved date

Latest chest antibiotic Rx date

Allergic rhinitis date PEFR value No. of AB prescriptions

L3yr

Eczema code PEFR date



2. Columns within the pseudonymised datasheet - asthma care

Reference SABA Rx L12M code LABA Rx L12M date

Age SABA Rx L12M date LABA Rx L6M

Sex No. inhalers on last SABA Rx

Leukotriene Rx L12M code

Latest asthma severity

code

No. doses on last SABA

Rx

Leukotriene Rx L12M

date

Latest asthma severity date

SABA Rx L6M Leukotriene Rx L6M

Latest Asthma

spirometry code

Count of SABA

prescriptions L12M

Theophylline Rx L12M

code

Latest Asthma spirometry date

Latest inhaled steroid Rx L12M

Theophylline Rx L12M date

Earliest asthma Dx code Latest inhaled steroid Rx

L12M date Theophylline Rx L6M

Earliest asthma Dx date Inhaled steroid Rx L6M SAMA Rx L12M code

Depression diagnosis L24M

Earliest inhaled steroid Rx L12M code

SAMA Rx L12M date

Depression diagnosis

date

Earliest inhaled steroid

Rx L12M date SAMA Rx L6M

Anxiety L24M Latest Combined LABA & ICS Rx L12M

LAMA Rx L12M code

Anxiety date Latest Combined LABA &

ICS Rx L12M date LAMA Rx L12M date

Anxiety or depression L24M

Latest LABA & ICS inhaler count

LAMA Rx L6M

Allergic rhinitis code Combined LABA & steroid Rx L6M

Sodium cromoglicate Rx L12M code

Allergic rhinitis date Earliest Combined LABA

& ICS Rx L12M

Sodium cromoglicate Rx

L12M date

Food allergy code Earliest Combined LABA & ICS Rx L12M date

Sodium cromoglicate Rx L6M

Food allergy date No.inhalers last ICS or

combined Rx Ketotifen Rx L12M code

Earliest COPD Dx code No. doses last ICS or combined Rx

Ketotifen Rx L12M date

Earliest COPD Dx date Estimated ICS dose Ketotifen Rx L6M

Latest BMI date Count of ICS or combined scripts L12M

Nedocromil Rx L12M code

Latest BMI value LABA Rx L12M code Nedocromil Rx L12M date



Nedocromil Rx L6M RCP - sleep undisturbed L12M

QOF smoking code

Oral beta-agonist Rx

L12M code

RCP - sleep undisturbed

date QOF smoking date

Oral beta-agonist Rx L12M date

RCP - sleep disturbed Reference 3

Oral beta-agonist Rx

L6M

RCP - sleep disturbed

date

Smoking cessation

referral code

Oral steroid Rx L12M code

RCP - no current symptoms L12M

Smoking cessation referral date

Oral steroid prescribed L12M date

RCP - no current symptoms date

Smoking cessation activity code

Oral steroid Rx L6M RCP - current symptoms

L12M

Smoking cessation

activity date

Count of oral steroids L12M

RCP - current symptoms date

Smoking cessation medication code

Frequent oral steroid

use RCP score value L12M

Smoking cessation

medication date

Respiratory antibiotics prescribed L12M code

RCP score date Smoking status

Respiratory antibiotics prescribed L12M code

Count of RCP questions Self management plan given

Count of respiratory

antibiotics L12M RCP score calculated

Self management plan

given date

Count of Rx types in L6M (SABA 12M)

Inhaler technique shown ever

Annual Review in last year code

Ever prescribed spacer

device code

Inhaler technique shown

date

Annual Review in last

year date

Ever prescribed spacer device date

Inhaler technique checked L12M code

BUTEYKO breathing technique code

Currently using spacer

device code

Inhaler technique

checked L12M date

BUTEYKO breathing

technique date

Currently using spacer device date

Latest PEFR value Admitted to hospital L12M code

Latest recorded therapeutic steps code

Latest PEFR date Admitted to hospital L12M date

Latest recorded

therapeutic steps date

Best ever recorded PEFR

value

Seen in A&E in the L12M

code

Calculated treatment step

Best ever recorded PEFR date

Seen in A&E in the L12M date

RCP - no impact activity

L12M

Latest predicted PEFR

value

Referred to resp medicine

ever code

RCP - no impact activity date

Latest predicted PEFR date

Referred to resp medicine ever date

RCP - limited activity L12M

Latest predicted FEV1 value

Exercise induced asthma code

RCP - limited activity

date

Latest predicted FEV1

date

Exercise induced asthma

date



Referred to occupational health code

Raised eosinophilia Dx code

Admission avoidance risk register

Referred to occupational

health date

Raised eosinophilia Dx

date

Admission avoidance risk

register date

Latest recorded occupation code

Latest eosinophil level Connective tissue disease code

Latest recorded

occupation date

Latest eosinophil level

date

Connective tissue disease

date

Record of occupational asthma code

FHx atopy code

Record of occupational asthma date

FHx atopy date



3. Note regarding unusual quantities of prescribed inhalers NHS prescription services have reported seeing an increase in unusual quantities of certain items ordered on prescription e.g. inhalers prescribed as 200 x 200

doses.

This is likely to be due to the way prescribing software has been set up in a practice. This makes it unclear how many inhalers were actually prescribed. It may impact how a practice is reimbursed and causes problems for clinical audit

in this area.

We advise practices to look for unusual large quantities of prescribed items and review prescribing software set up to prevent recurrence.

asthma care quality improvement tool instruction guide (tpp

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