Johnathan Laird
ASTHMA UK has created a list of tips for general practitioners to use as they attempt to encourage attendance at annual asthma clinic reviews.
The problem of non-attendance is significant, as there are thought to be as many as one million missed appointments every year.
I was pleased to see that my local practice is doing most of them already.
I liked the idea of making any promotional literature about the need to attend for review very positive. Motivational letters may help. Publishing improving attendance rates rather than highlighting the number of ‘did not attends’. A simple text message may also help to remind the patient to come to the appointment.
Sending a copy of the asthma control test with the letter of invitation is also a good idea for a number of reasons. It not only encourages self-care by the patient, but it also potentially saves some time during the review. The use of written asthma plans has also been shown to reduce subsequent GP emergency appointments by asthmatics. Put simply, if by doing the asthma control the patient knows how well their symptoms are controlled, and what to do when things go wrong by using their written asthma plan, then self care is more likely.
As a community pharmacist I’d like to thank Asthma UK and the contributors for these excellent tips, but I do feel that engaging with community pharmacy might help even further. Let me explain why.
All patients with a formal diagnosis of asthma will usually be prescribed a reliever inhaler. Most commonly this will be a short acting beta agonist like salbutamol or terbutaline. The frequency of use of the reliever inhaler can be monitored using the pharmacy dispensing record and is one indicator of the level of control the patient exhibits over their asthma. NRAD 2014 highlighted that many of the patients in the report that died were found to be overusing short acting beta agonist inhalers.
My second important point is that the only place that patients can pick up the reliever inhaler is at the pharmacy. I would suggest that, as with many other drugs, community pharmacists should be actively monitoring the patient use of these inhalers and intervening as appropriate. I have written previously about how much reliever inhaler is too much (Salbutamol…how much is too much?).
Although most pharmacists in the community are not yet prescribers, actually I’m not sure that for this task they need to be. By using the chronic medication service (CMS) in Scotland or a medication use review (MUR) in England, community pharmacists could quite easily flag these over-users during the dispensing process and the make an intervention in the normal way. I would suggest that if a patient has been prescribed more than 7-10 short acting beta agonist inhalers per year, then an intervention could be warranted. Using the asthma control test is an excellent, evidence-based way, to get an immediate feel for how well the asthma in a particular patient is controlled.
The final, and possibly most important point in this simple process, is to communicate with the rest of the multidisciplinary team. I can guarantee that as a community pharmacist if you manage to find as few as 20 poorly controlled asthmatics your local practice teams will be very grateful.
I would suggest that many of these patients who are using too many reliever inhalers are precisely the group that the Asthma UK tips are aimed at finding.
Remember the patient must come to the pharmacy to get a reliever for their deteriorating symptoms, but they have no overt clinical need to visit the nurse or GP for their annual asthma review.
Johnathan Laird is a community pharmacist independent prescriber with a special interest in asthma. He is based in Aberdeen.
Follow Johnathan @JohnathanLaird