Rob Bevan, Timothy Asibey-Berko, Mark Andrews, Leanne Griffin, Rhys Howell, Gautham Appanna and Keir Lewis
Hywel Dda UHB, ABMU Health Board, Cardiff University, Bevan Commission and Swansea University
Wales has the highest percentage of patients in the UK being treated for asthma (Together for Health, 2015). The National Review of Asthma Deaths recommends that every patient with asthma must have an annual asthma review and a “template should be developed to facilitate a structured thorough asthma review” (Why Asthma Still Kills, 2014). This was tested in a community pharmacy using a structured consultation protocol.
Prudent Principle 1
Achieve health and wellbeing with the public, patients and professionals and as equal partners through co-production.
A structured consultation protocol was developed in conjunction with HCPs (GPs and specialists nurses) in a single general practice; it was piloted with two community pharmacies seeking opinions from 20 patients with asthma. Asthma UK (charity) was also asked to comment. Community pharmacies were chosen because they are easily accessible for patients and asthma medication must be collected regularly.
Prudent Principle 2
Care for those with the greatest health need first, making most effective use of all skills and resources.
Patients with asthma on the GP register without a documented annual review within the last 15 months were prioritised. Patients using more than 12 short acting bronchodilators during 12 months or underusing/irregular use of inhaled corticosteroid (identified by NRAD as providing suboptimal control of asthma) were also targeted. Having undertaken training in Advanced Inhaler Technique, two community pharmacists undertook these asthma reviews using a structured consultation protocol. These reviews did not require any extra resources or incur extra costs since community pharmacists already undertake one to one consultations with patients to assess adherence to medication and check understanding of medication.
Prudent Principle 3
Do only what is needed, no more, no less and do no harm.
The template implements the findings of the National Review of Asthma Deaths (NRAD) and is designed to optimise illness understanding and promote lifestyle changes (e.g. smoking). It encourages prudent prescribing by maximising inhaler technique, which will enable step down in a systematic way (as per BTS guidelines) and reduce risk of asthma exacerbations and deaths.
Prudent Principle 4
Reduce inappropriate variation using evidence based practices consistently and transparently.
The consultation protocol is based on best evidence (3 Royal College of Physicians asthma questions, BTS guidelines, asthma.org guidelines and NRAD report). All patient are also issued with a Personal Asthma Action Plan.
To ensure transparency and consistency of process the intention is that HC professionals carrying out asthma reviews in GP surgeries would also use the same innovative protocol thus implementing the findings of NRAD.
Impacts and future actions
To simultaneously record clinical impact, in particular:
Patient outcomes: asthma control symptoms (e.g. AQL), patient satisfaction questionnaires, short course oral steroid rescue therapy, peak flow readings and inhaler technique.
Pharmacy outcomes: Inhaled Corticosteroid (ICS) dose equivalence, oral steroid rescue medication and associated costs.
Healthcare outcomes: frequency of GP contacts, hospital admissions, death rates.
Part of Cohort Bevan Fellows 2015-16