Our recent report and roundtable event on emergency hospital admissions for children and young people showed that asthma was consistently among the most common causes for admissions across the ten years of data surveyed. Dr Andrew Whittamore, Asthma UK’s in-house GP and Clinical Lead looks at some of the reasons lying behind this.
Three people die from asthma every day. Mortality rates from Organisation for Economic Co-operation and Development (OECD) nations (2010) show the UK’s asthma mortality rate as being the 3rd highest in Europe after Estonia and Spain. The numbers could be even worse. Every 10 seconds someone has a life-threatening asthma attack – each one perilously close to adding to these damning statistics.
Asthma is the commonest chronic medical condition in UK children (1.1 million) and is characterised by variable levels of inflammation in the airways. The inflammation leads to symptoms which might include cough, wheeze, breathlessness and chest tightness. Standard asthma therapies, if taken regularly and correctly can control the inflammation and symptoms for the overwhelming majority of children. Having well-controlled asthma halves the risk of needing hospital care.
Asthma symptoms are accepted as normal far too often. Too many people have untreated inflammation in their airways increasing their risk of experiencing a life-threatening asthma attack. This leads to unacceptably high rates of acute care episodes and unacceptably high rates of preventable deaths.
By providing better advice and support for people with asthma and their carers, health care professionals can stimulate improvements in health and wellbeing, reducing the risk of asthma attacks, admissions to hospital and death. Better management of asthma will reduce the burden on struggling NHS resources, yet people with asthma and the clinicians trained to look after them are not recognising under-treated asthma.
Acute asthma episodes are preventable
The 2014 National Review of Asthma Deaths (NRAD) revealed that there are preventable factors in 90% of childhood deaths from asthma. These preventable factors can occur at all stages of the patient journey from routine care (attending annual asthma reviews, receiving medication in accordance with guidelines), acute care (appropriate assessment, treatment and follow up of an asthma attack) and importantly self-care. 40% of children aged under 10, and 72% of 10-19 year olds were not taking their asthma therapies as prescribed. Others did not have a written asthma action plan or did not seek medical care when symptomatic – even during their final, fatal, asthma attack. In 80% of the deaths in children aged 10 or under there was a delay or failure to respond to symptoms.
Healthcare professionals need to ensure that people with asthma, and their carers, have enough information and support to understand their asthma, their medications, what they need to do to stay well and what to do when they are experiencing symptoms. People with asthma symptoms need to know that they should access appropriate healthcare support at an earlier stage.
Overuse of reliever inhalers is a clear signal for poorly controlled asthma and was a missed opportunity for 40% of the total asthma deaths in NRAD. IT systems in General Practice can readily identify overuse of reliever medication and underuse of preventer medication. People with overuse of reliever medication should be identified and assessed as a matter of urgency.
Complacency was a recurrent feature of the asthma deaths investigated. Complacency among health care professionals and complacency among people with asthma and their carers. Reliever medications and steroid tablets can create an economy of false wellbeing and increased complacency in many cases. They are both only temporarily efficacious in addressing today’s symptoms and do nothing to reduce the risk of the next attack. When I review children in my surgery after a flare of their asthma, every single case features the same missed opportunities to prevent ill-health mirrored in NRAD. It highlights to me that asthma deaths are the tip of a very big iceberg. For every death there are many near misses.
Acute care choices
A 2016 study looked at barriers to accessing primary care for adults with acute respiratory conditions.
- 8% of patients/carers reported a lack of primary care appointments as the reason for attending A&E.
- 19% did not try primary care due to the sudden onset of the symptoms, 15% because of anxiety of the patient or their carer and 2% owing to a lack of faith in the GP.
47% of people in this study who attended A&E did seek primary care support in the first instance. One third of these were referred by their GP to A&E and half took themselves to A&E as the treatment provided by primary care was deemed by the patient to have failed.
Ambulance conveyance data, obtained through Freedom of Information requests by Asthma UK in 2016, reveal that children aged 0-4 have the highest conveyance rate of all age groups, perhaps reflecting that healthcare professionals also have anxiety regarding leaving symptomatic children in the community.
Quality of acute care
An audit on asthma care in adults and children, performed by the Royal College of Emergency Medicine, was highly critical of the standards of care provided nationally. Only a minority of patients received vital assessments or potentially life-saving treatments in an acceptable timeframe. On discharge, almost half did not receive oral steroids as per guidelines, less than 1 in 10 people had their inhalers checked and only 8% of people were given written discharge advice.
The lack of written advice or follow up is particularly important. NRAD revealed 21% had an asthma-related A&E attendance within the final 12 months prior to death, with 12% having more than one. 10% died within 28 days of discharge from a previous attendance at hospital.
These findings are despite the existence of NICE Quality Standards and an acute care bundle for asthma developed by the British Thoracic Society. Widespread adoption of the bundle and other standardised assessment and treatment protocols can greatly improve outcomes for people with asthma.
Poor routine care
Poor routine care is also a trigger for life-threatening asthma attacks. Data for former PCTs found a 19-fold variation in the number of emergency admissions for asthma in children, and up to a five-fold variation between general practices within CCGs. NRAD revealed that 46% of deaths were not receiving care as per guidelines.
In spite of this, the majority of practices in primary care achieve very high performance according the Quality Outcomes Framework (QoF). Compared with conditions such as diabetes and heart disease, asthma QoF measures are nebulous. It is very hard to assess for the quality of any meaningful intervention as the measures do not link to patient outcomes. Compare this to diabetes where there are definitive, objective measures of blood pressure, cholesterol and HbA1c – a measure of average, recent blood glucose levels that have an evidence base showing reduction in health outcomes. New measures are required that represent meaningful outcomes for people with asthma. This will also lead to better value for a safer NHS.
Improving self-care
People with asthma, and the parents of children with asthma, are managing their own variable symptoms every minute of every day throughout the year. But poor self-treatment is associated with deaths from asthma. In NRAD, more than one quarter of the children that died had failed to attend a review within primary care and one-third were exposed to tobacco smoke. 80% had not received sufficient preventer medication to suggest regular use. Self-care isn’t working well enough.
Healthcare systems need to make accessible, evidence-based education and self-care advice more readily available. There are many ways in which the NHS can embrace technology to improve supported self-management. This needs to be embraced, and quickly, as outcomes suggest that we are failing so far.
What now?
The continuing prevalence of asthma-related emergency admissions for children points to a range of required changes in care provision and quality.
The recommendations of the NRAD report should be adopted across all healthcare providers, while the British Thoracic Society care bundle should be implemented widely and consistently. Care needs to be audited against the NICE Quality Standards.
Healthcare systems need to look at the entire asthma pathway, not just isolated silos. Identifying and addressing poor asthma control should be central to all aspects of asthma care, with management of symptoms and risk a priority for patients, carers and clinicians.
People with asthma, and their carers, need better access to education, advice and support in order to self-manage more successfully and consistently. Every person with asthma should have a written asthma action plan. IT can help the NHS to support people with asthma in a more disease and person-centric manner.
Complacency about asthma cannot continue. More people will require acute care unless preventable factors throughout every patient’s journey are addressed.
For more information on the high quality advice and support available for people with asthma and their carers, visit www.asthma.org.uk/advice and to read about Asthma UK's key areas of work see www.asthma.org.uk/get-involved/campaigns.