Tag Archives: asthma

Nothing to see here – General Practice serves our children well

20 Feb


February 19, 2013 UK readers awoke to the headline that NHS is failing the children. Why?

  • Kids with meningococcal disease are turned away rather than sent to hospital to be cured;
  • Children with asthma are not given adequate treatment;
  • Too many children are admitted to paediatric wards with minor illnesses
  • Doctors prescribe too many drugs which have not been tested on children
  • General practitioners do not have proper postgraduate training in child health

At face value such accusations are depressing. The accusations sully the credibility of GPs who are constantly berated for some failing or other every week in the Britain.

Here I hope to show that the accusations are baseless. General practitioners are fantastic physicians who can manage any patient in first contact doctor setting from cradle to grave.

Meningococcal disease in children

This myth perpetuated in the article that children are turned away is based on an article published in 2006 [http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(06)67932-4/abstract, accessed Feb 20, 2013]


Much has changed since that article was published. In any event the study makes no mention of the fate of the fatalities many of whom, one may argue, would have died anyway. Be that as it may, meningococcal disease is less common now Haemophilus influenzae type B (HiB) immunisation is universally available in UK.


Screen clipping taken: 20/02/2013 22:22

Nearly 70% reduction in cases since 2006 is attributable to the immunisation program. Given that millions of GP visits are children, the fact is the chance of any one GP diagnosing a case of meningococcal disease is vanishingly small today. Thus the hazard referred to is scaremongering. The British public deserve better information to make decisions about their kids who develop fevers and blanching rashes. Sadly a reputable charity, The Meningococcal Foundation perpetuates the hazard speculating there are nearly 3,500 cases of meningococcal disease annually in Britain. The figure for 2012 is 443 recorded cases, and many are adults.

Childhood Asthma

Asthma in children is a common condition. General practitioners diagnose the condition regularly. It is a core competency of MRCGP curriculum to diagnose, treat, and manage asthma.

What we cannot do is make parents give the treatment as often as may be needed. We cannot make children and teens take their inhalers regularly. Important risk factor for poor asthma control in youngsters include: parents/carers who smoke, overcrowding, damp, dusty environment. Prematurity is an independent risk factor for bronchial hyperreactivity/asthma. This is important with the upsurge in assisted conception and attendant increase in multiple births which often end in premature delivery of the babies.

Asthma UK does a good job helping people with asthma understand their condition and manage it properly, including an excellent section on inhaler usage.


Screen clipping taken: 20/02/2013 22:36

It is not doctors’ fault that many children have poorly controlled asthma and asthma-like conditions. People with asthma must take more responsibility for the correct management of this long term condition. Wringing of hands that doctors are not treating people with asthma properly perpetuates a State-controlled solution for every ill affecting individuals. This requires better reading comprehension, better education of children to take responsibility for their actions/conditions, and better access to online resources for everyone to improve information flow.

The story about asthma can apply to every long-term condition. There is not space here to enumerate many of the places to look for advice, though NHS Choices and BBC Health deserve wider readership at least in UK.

Minor illness admissions of children

It is a truism that all serious illness begins as minor illness. The trick is to spot which cases may progress. Doctors receive many years of training to learn how to spot the the worrying case. It is an art not a science in this. Suffice to say, like many of my colleagues, I will refer a child to hospital when I fear that worry will stop me sleeping at night about a particular case. This is, I know, not scientific, but when the hairs on the back of my neck stand on end, the child in front of me at that moment will be referred to see a colleague in paediatrics.

If one admits too few patients to hospital, too many unwell children will be taken to Emergency Department out of hours. If one admits too many children, there will be no space for the truly ill child referred by a colleague. All GPs know this. Yes some of us are high referrers while others are not. No-one has discovered what is the ideal referral rate. This is well known to the profession and health economists.

Therefore the accusation in the article is baseless.

Prescribing untested drugs to children

This is a specious argument. With the widespread availability of the British National Formulary for Children, there is a sound basis for prescribing for children in UK (and elsewhere). Yet another baseless accusation threatening to undermine the professionalism of the medical profession in its management of children.

Too few GPs have postgraduate child health training

This is baseless accusation too. General practice curriculum described by RCGP includes core competency in child health. Further, nearly 80% GPs have some postgraduate training in paediatrics before they complete general practice training (at least in UK) [personal communication from Doctors.net website].

Conclusion

The British public has a fantastic primary healthcare service which serves our children well. With a little bit of research it is obvious the article which prompted me to write this is full of inaccuracies and unfounded accusations.

JRCPL vol 34; Jan/Feb 2000

29 Nov

JRCPL vol 34; Jan/Feb 2000.

Measuring clinical outcome in asthma

Duncan Keeley

Duncan Keeley MA MRCP FRCGP, General Practitioner, Thame, Oxfordshire
J R Coll Physicians Lond 2000;34:9-11

‘”n the last week/month

  1. Have you had difficulty sleeping because of your asthma symptoms (including cough)?
  2. Have you had your usual symptoms during the day (cough, wheeze, chest tightness, or breathlessness?
  3. Has your asthma interfered with your usual activities (eg housework, work/school etc)?

Each of the above questions should be answerable by a simple yes/no, but there could also be supplementary quantitative grades for answers.”

 

This outwardly undramatic quotation forms the kernel of a recent College publication of potentially enormous importance1. Measuring clinical outcome in asthma: a patient-focused approach, prepared by the Clinical Effectiveness and Evaluation Unit, reports on a seminar held in May 1998. The seminar brought together 14 different groups doing research work on asthma outcomes, to seek consensus on a brief symptom based outcome measure for use in the consultation; and this is what they came up with. The aim is that the three questions above should be asked, and the answers recorded, at every asthma consultation both in primary and secondary care.

Effective medical care depends on a willingness and ability to measure changes in the condition of patients as we try to make them better. Clinicians develop their own more or less reliable ways of doing this in the course of routine practice. However, the development of outcome measures capable of aggregation to measure the effectiveness of care for groups of patients poses formidable problems. Keen to move the NHS on from audit of structure and process to a greater emphasis on outcomes, the Department of Health has invested heavily in seeking answers to these problems. In 1993 it set up the Clinical Health Outcomes Unit, now known as the National Centre for Health Outcomes Development (NCHOD), to identify outcome measures for ten clinical areas. Asthma was an obvious priority; a common chronic disease responsible for an enormous burden in terms of direct and indirect costs, with effective treatments and authoritative consensus on their best use2, and documented failure to achieve the full potential of these treatments for symptom control3,4. The NCHOD report on asthma published earlier this year5 detailed 17 possible indicators, from hospital admission rates to patient satisfaction measures, by which the effects of asthma care might be assessed. Of these possible indicators one in particular – Indicator 15A – was chosen for further investigation and development. Indicator 15A consisted of ‘consultation based patient assessed impact measures’, that is to say, systematically asking patients how they are and recording the answers.
Readers may at this point be thinking that this whole exercise represents the worst sort of oversimplified cookbook medicine, but wait …

First, it is important to realise that these questions do not replace the whole clinical assessment of patients and their situation, which remains a much more subtle art. They simply standardise a small but important part of that assessment – the burden of recent symptoms experienced – for comparison over time for the individual and between groups. They do not replace or obviate the need for appropriate physiological measurements of current, predicted and best lung function, neither do they preclude the use of more detailed standardised outcome measures by researchers or enthusiasts.
Second, it does not matter that answers to the questions will not be entirely ‘objective’ owing to variable recall and to differences of interpretation by health workers and patients as to the exact meaning of the words used. We are measuring ‘patient assessed impact’ and must accept some subjective variation as inevitable.

Third, widespread use of such a measure has the potential to improve the outcome of asthma care. The easily measurable ‘hard’ outcomes of asthma care, ie deaths and hospital admissions, are rare occurrences in the overall population of asthma sufferers, the majority of whose care takes place in general practice. The three questions in the measure check for the common troublesome symptoms of poorly controlled asthma, symptoms which can almost always be improved by good treatment; they precede and predict the more serious outcomes, and are often not mentioned by patients when asked in non-specific terms ‘how is your asthma?’. Patients for whom frequent night waking is normal may consider their asthma to be fine. They may prefer the quick issue of a repeat prescription for more blue inhalers to the clinic attendance, education and inhaled steroids that will be suggested if they reveal how much asthma is interfering with their life. The discovery of these symptoms is a necessary, though not sufficient, condition for appropriate therapeutic intervention. Repeated negative answers to these questions might indicate the possibility of stepping down regular treatment, or even taking a careful look at the validity of the original diagnosis of asthma. The strength of an outcome measure of this kind lies in its immediate value in prompting better care of each individual patient, regardless of whether the data collected are, or are capable of being, meaningfully analysed to compare the care of groups of patients. The mere fact of collecting the answers to these questions would be a far more valuable process measure to include in the data requirement for the asthma Chronic Disease Management payments to GPs than the current requirement to record a single peak flow reading.

Is widespread use of the outcome measure feasible?

Eminently so. An absolute requirement for the widespread adoption of any such measure is that it should be sufficiently quick and easy to obtain and record, and sufficiently useful in the care of the individual for its routine use to make sense for every busy doctor and nurse and patient. The proposed measure meets these requirements. The majority of GPs, and a gradually increasing number of hospital doctors, work with computers on their desks. The questions could be incorporated in standard format for easy recording at the beginning of the computer asthma follow-up protocols used by doctors and nurses, which can then be made as simple or as ornate as one likes. For those who still enjoy the many advantages of paper records, a simple standard abbreviated format for recording the answers on paper needs to be agreed. It could be as simple as S0 D0 A0 (no sleep disturbance, no daytime symptoms, no activity interference). These doctors will enter their data slightly quicker than their computerised colleagues, but will have a harder job if they wish to analyse the data for groups.

Can the outcome measure be used to assess the quality of asthma care for groups?
The answer to this question is much less straightforward. The interpretation of aggregated results for groups of patients requires great care. Any crass or punitive use of the data collected is likely to result in massage of data at entry which would, in turn, invalidate the entire exercise. Distinction needs to be made between data collected at visits for exacerbations and for routine follow-up, allowing for the fact that it is difficult to give a tight definition of an ‘exacerbation’. Allowance will have to be attempted for case mix, and for social class, ethnic origin and smoking status of practice populations. Care has to be taken over the fact that the population of asthmatics in different practices will vary greatly, given the variable diagnostic labelling that goes on at the overlap between asthma and chronic obstructive pulmonary disease (COPD) (in adults), and recurrent viral associated wheezing (in children, vide infra). These considerations will make comparison between different units difficult. Perhaps, as with school league tables, a better approach would be to look at value added over time within groups, but the overall level of symptomaticity of the asthmatic patients attending a practice or hospital unit must be one factor worthy of study as we try to improve the care we provide.

Where do we go from here?

The College report represents a major step forward in the move towards routine meaningful outcome assessment in asthma care. What more is needed to make it happen?
First, agreement is needed on two unresolved issues: the time period used in the questions, and the quantification or otherwise of the answers. As for the time period, there can be no perfect answer. The shorter period of a week makes accurate recall more likely but is less likely to incorporate disturbance by intermittent symptoms. As for quantification, simple yes/no answers are easier to record but much less sensitive to change than quantified answers. The methods of quantification usually proposed involve mapping the answers to some sort of 3 or 5 point scoring system. The problem is that such methods are not immediately intuitive and therefore less likely to be used properly, or at all, by the majority of doctors and nurses. In the opinion of this writer, the answer to these two unresolved issues should be to base the questions on the last week and quantify the answers 0-7, but definitive answers are needed before any widespread implementation can take place. A swift, efficient and entirely appropriate method to decide what should be done would be to convene a one day meeting. The meeting should consist of one representative for each of the Royal Colleges of Physicians and General Practitioners, the British Thoracic Society, the GPs in Asthma Group, the National Asthma and Respiratory Training Centre, the National Asthma Campaign (as the representative of patients), and the Department of Health. A wider and longer consultation, which is what will probably happen, will take a great deal longer and almost certainly come up with a virtually identical result.

Second, the conventions need to be agreed for recording the data both on computers and on paper. Computer Read Codes already exist for ‘asthma disturbing sleep’ (663N. 00), ‘asthma not disturbing sleep’ (663O. 00), ‘asthma limiting activities’ (663P. 00) and ‘asthma not limiting activities’ (663Q. 00). The exact text of these codes might want changing, or new codes assigned to the exact questions in the outcome measure. A code for ‘daytime asthma symptoms’ needs to be created, and all three will need to be in a format and Read code chapter that allows for numeric answers if the decision went in favour of quantification. For paper recording, an agreed sequence and format for recording the answers is needed and should then be widely disseminated. Forms allowing for the answers to the three questions to be recorded could be included in inhaler package inserts and printed on prescription side slips.
Third, collection of the three question outcome measure – initially as a simple process measure – should be added to, or preferably substituted for, one or more of the existing data requirements for the asthma Chronic Disease Management payments to GPs, or to whatever may replace this small financial incentive to organised asthma care. This would encourage GP software suppliers to incorporate the questions into their default asthma management protocols in a user-friendly manner.

Fourth, the necessary research and consultation should be initiated to extend the use of the outcome measure to children. Most of the work on which the College report is based was done on adults, and paediatricians were, unfortunately, not involved in the seminar. The Report makes clear that its conclusions are intended to apply to patients over the age of 16 years. But many of a GP’s asthmatic patients are children, and matters are much simplified if a common outcome measure is used. Sleep disturbance by asthma symptoms, daytime asthma symptoms, and interference with normal activities are concepts easily applicable to persons of any age, while the diagnostic difficulties of what is and is not asthma in young children will always be with us and will certainly not be resolved by subtlety in the choice of outcome measures.

Does all this matter?

The nationwide collection of simple standardised outcome data for management of a common chronic disease would be a world first for the British NHS. It has the potential to yield real and measurable improvements in the health of patients with asthma, and to demonstrate to understandably sceptical health workers that medical audit really can be a force for getting patients better. Nothing could be a better reward for the excellent work done by the researchers in this field and by the Clinical Effectiveness and Evaluation Unit of the College in taking this initiative forward. If this model for quick, feasible, patient-centred outcome measurement were successful, for patients and health workers, not just for purchasers and auditors, it would pave the way for similar approaches to improving the care of other patient groups. Let’s go for it.

References

 

  1. Clinical Effectiveness and Evaluation Unit, Pearson M, Bucknall C (eds). Measuring clinical outcome in asthma: a patient focused approach. London: Royal College of Physicians, July 1999.
  2. British Thoracic Society, et al. Guidelines on the management of asthma. Thorax 1993;48:S1-24.
  3. Jones KP, Bain DJG, Middleton M, Mullee MA. Correlates of asthma morbidity in primary care. Br Med J 1992;304:361-4.
  4. Blackburn LA, Denn DJ, Oliver HF, Vieckery PJM, Waldron J. One year’s asthma admissions in Cornwall: still deficiencies in basic care. Thorax 1996;51:A62.
  5. National Centre for Health Outcomes Development. Asthma. Report of a working group to the Department of Health. London: NCHOD, 1999.

 

Measuring clinical outcome in asthma: a patient-focused approach
Copies of the full report can be obtained by sending a cheque for £15.00 (overseas price £17.00) to: The Publications Department, Royal College of Physicians, 11 St Andrews Place, London NW1 4LE.

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