dr mark l levy frcgp general practitioner & respiratory lead harrow clinical lead national...

Dr Mark L Levy FRCGP

• General Practitioner & Respiratory Lead Harrow

• Clinical Lead National Review of Asthma Deaths

• Executive Board Member GINA

[email protected] www.consultmarklevy.com

@bigcatdoc www.animalswild.com

Mark L Levy Clinical Lead, NRAD (2011-2014)

Why asthma still killsNational Review of Asthma Deaths (NRAD) www.rcplondon.ac.uk/NRAD

What are the lessons we’ve learnt?

Case review 1 (from a number of cases - for annonymity)

• Female with late onset asthma• Confirmation of diagnosis delayed - after many months on

therapy with intermittent salbutamol (28% reversibility on spirometry)

• Low dose inhaled corticosteroids (beclometasone 100mcg prescribed• She had a poor attendance record• Asthma review with practice nurse:

• Waking at night; daytime symptoms and asthma limited her lifestyle• Px last 12 months: 16 salbutamol inhalers; 1 beclometasone inhaler

• She was advised by the nurse to make an appointment to see the doctor without any advice or changes in the treatment ; no record of a PAAP

• The patient died 8 weeks later without ever making an appointment to be seen

Case history – from a few cases to preserve confidentiality

• male died age 6 - asthma diagnosed in 3rd year• PICU - life threatening asthma attack • 1X Follow up by paediatrician• – failed 2X OPD - discharged from care (Trust policy)• seen by his GP URTI:

• red and inflamed throat• chest was clear with very little wheeze but cough ++• no record of any vital signs or SaO2 • salbutamol 2 puffs up to 4 times daily prn; Amoxicillin125mg tds, and a

volumatic• Died 10 days later – pre-hospital cardiac arrest - status

asthmaticus on Post Mortem

Case history – from a few cases to preserve confidentiality – 6yr old male

At the time of death : not using asthma medication •His last prescription - 3/12 before death

• Formoterol easyhaler •Previous 12/12:

• Salbutamol – 12 inhalers; Seretide 50/25 – 1 inhaler;• Formoterol – 2 inhalers; Qvar – 1 inhaler and • Montelukast – 2 prescriptions (1 month supply each)

Points:Neither hosp or GP taking the responsibility to follow this child up who had fallen between the hospital and the GP (?? Trust policy)‘At-risk’ status not recognisedFailure to take appropriate medication and attend follow-up appointments asthma review / no personal asthma action plan / ? child protection issues

National Review of Asthma Deaths (NRAD)Key Messages

• Diagnosis (Asthma/COPD)• Failure to call for or get help (45%)

• 77% no PAAP• Failure to recognise danger signals

• Excess relievers/insufficient ICS• Failure to follow up after attacks

• Failure to appreciate that asthma is a chronic illness – assess and optimise!

Overall aim of NRAD

The aim of the NRAD was to understand the circumstances surrounding asthma deaths in the UK, in order to identify avoidable factors and make recommendations for changes to improve asthma care as well as patient self-management

(This was not a prevalence study – did not aim to determine the number of asthma deaths in the UK)

www.rcplondon.ac.uk/nrad

Underlying cause of death On the basis of what is written on the Medical Certificate of the

Cause of Death (MCCD), the Office for National Statistics (ONS), National Records of Scotland (NRS), Northern Ireland Statistics and Research Agency (NISRA) then determine the underlying cause of death. Based on the formula used world wide for this purpose - International Classification of Disease (ICD-10)

So where an MCCD reads:

The underlying cause of death (UCD) is determined to be AsthmaThe underlying cause of death (UCD) is also Asthma

Ia Respiratory Failure Ib Asthma Ic Chest infection

Ia Chest infection II Asthma, IBS, Liver failure, sepsis

OR

NRAD Notification(Section 251 of the NHS Act 2006)


Office for National Statistics (ONS); National Records of Scotland (NRS); Northern Ireland Statistics and Research Agency (NISRA).NRAD Website-Clinicians-Families / Friends-Coroners-Local co-ordinators (374 in 297 Hospitals)

NRAD flow diagram - 1


* MCCD= Medical Certificate of Cause of Death

Clinical information requested for final 2 years (n=900)– ALL CONSULTATIONS– ALL CORRESPONDENCE– ALL PRESCRIPTIONS (ACUTE &

REPEAT)– PM/CORONERS

REPORT/AMBULANCE– COPIES OF ANY LOCAL REVIEWS


NRAD flow diagram - 2


Clinical Lead

& Expert panel

276/900 included for panel discussion

Multidisciplinary confidential enquiry panels

• 37 panel meetings• 174 volunteer assessors• 6 -10 cases per panel• Two assessors per case• Panel assessment form• Consensus agreement

• 195/276 died from asthma• 1000 panel recommendations • Major factors in 60% deaths potentially avoidable


PatientsDuration of asthma (n=104) : 0-62 yrs (Median 11 yrs)

Age at diagnosis (n=102) : 10 mths – 90 yrs (Median 37 yrs)

Age at death (n=193) : 4 yrs – 97 yrs (Median 58 yrs)

Severity of asthma (n=155): (classified by the Clinicians) Mild 14 (9%)

Moderate 76 (49%) Severe 61 (39%)

12/28 (42%) of children/YP were thought to have mild/mod asthma

Definition of severity of asthma:

‘Amount of treatment required to gain control of the asthma’

European respiratory Journal 2008;32(3):545-54

37 (19%) - had assessment of asthma control

www.consultmarklevy.com

www.ginasthma.org

6th May 2014

GINA assessment of symptom control

SymptomsLevel of asthma symptom control

In the past 4 weeks, has the patient had:Well-

controlledPartly

controlledUncontrolled

• Daytime asthma symptoms more than twice/week?

Yes No

None of these

1-2 of these

3-4 of these

• Any night waking due to asthma?

Yes No

• Reliever needed for symptoms* more than twice/week?

Yes No

• Any activity limitation due to asthma?

Yes No GINA 2014, Box 2-2A

*Excludes reliever taken before exercise, because many people take this routinely

GINA 2014, Box 2-2


www.animalswild.com.com

Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability

Giraud, European respiratory Journal. 2002;19(2):246-51

AIS = Asthma Instability Score



Results of the first (before training), and second and third Vitalograph Aerosol Inhalation Monitor

(AIM) tests after training

Levy et al, Prim Care Respir J 2013;22(4):406-411



pMDI technique using the Vitalograph Aerosol Inhalation Monitor (AIM) and

GINA Control




pMDI with and without spacer and GINA Control




GINA control vs BDP pMDI (Clenil and QVAR) vs QVAR Easi-Breathe


© Global Initiative for Asthma

The control-based asthma management cycle

GINA 2014, Box 3-2

NEW!


Excess use of beta-agonists (SABA)


Asthma consultation = opportunity to reduce risk

Sheriff Kelly said that Emma's death might have been avoided if the consultant paediatrician at Yorkhill Hospital in Glasgow and her GP or pharmacist had acted differently.

Review dose inhaled steroids in children

Prescribing

NRAD Recommendation:Electronic surveillance of prescribing in primary care to alert clinicians and pharmacists -excessive Short Acting Beta-Agonist Bronchodilators (SABAs) or too few preventers

Practices (denominator = 138 except where mentioned otherwise)

Median 4 Doctors/practice (n=131); median 9000 patients

Quality Outcomes Framework (QOF) data (n=89) • Full points 74/89 (83%)

Asthma reviews - performed by: •78/136 (57%) GPs• 3 (2%) GP with Special Interest•82 (60%) Nurses with diploma •62 (46%) nurses without asthma diplomas *


Main conclusions for the 276 cases considered by panels

People who died from asthma 195 (71)People who had asthma but did not die from it 36 (13)People who did not have asthma 27 (10)Insufficient information: - To decide whether the person had asthma 14 (5) - To decide whether the person died of asthma 4 (1)

© Global Initiative for Asthma3.

GINA Global Strategy for Asthma Management and Prevention

GOLD Global Strategy for Diagnosis, Management and Prevention of COPD

Diagnosis of asthma, COPD and asthma-COPD overlap syndrome

(ACOS)A joint project of GINA and GOLD

GINA 2014

GINA 2014 © Global Initiative for AsthmaGINA 2014, Box 5-4

Quality of Care – Panel ConclusionsConclusion All ages

(195)0-19(28)

Chronic Management - Adequate 56 (29%) 2 (7%)

Previous Attack Management- Adequate 69 (35%) 8 (29%)

Final Attack Management- Adequate 66 (34%) 13 (46%)

Overall Standard of Asthma Care- Good practice 31 (16%) 1 (4%)

Major factors identified by panels(i.e. contributed significantly to the deaths, where different management

would reasonably be expected to have affected the outcome )


nDid not recognise high-risk status 21Lack of specific asthma expertise 17Did not perform adequate asthma review 16Did not refer to another appropriate team member 16Failure to take appropriate medication in month before death 15Failure to take appropriate medication in year before death 13 Over prescribed short acting beta agonist bronchodilator 13Poor or inadequate implementation of policy/pathway/protocol 13Lack of knowledge of guidelines 12Did not adhere to medical advice 10

Potential avoidable factors identified by panels in recognition of risk status

The panels identified potential avoidable factors related to the assessment of the final attack

NRAD Recommendation:•Every NHS hospital and general practice - clinical lead for asthma services responsible for formal training in acute asthma care

Primary Care (n=38)

n(%)

Secondary Care (n=59)

n(%)

< 10 yrs Sec Care (n=2)n(%)

10-19 yrs Sec Care (n=5)

n(%)

≥ 1 factors 13(34) 20(34) 1(50) 1(20)

The panels identified potential avoidable factors related to the management of the final attack

• Delay or failure : to initiate treatment / to follow guidelines• Use of NIV in acute severe asthma• Failure to recognise risk features (High normal pCO2 levels)

NRAD Recommendation:• Every NHS hospital and general practice - clinical lead for asthma services

responsible for formal training in acute asthma care• The use of patient-held ‘rescue’ medications should be considered for all

patients who have had a life-threatening asthma attack or a near fatal episode

Primary Care (n=38)n(%)

Secondary Care (n=59)n(%)

< 10 sec care(n=2)n(%)

10-19 prim care(n=1)n(%)

10-19 sec care(n=5)n(%)

≥ 1 factors 12(32) 20(34) 1(50) 1(100) 2(40)

The panels identified potential avoidable factors related to follow-up after attacks

• 19/195 (10%) died within 28 days of hospital discharge for asthma attack • In 13/19 (68%) potentially avoidable factors

• discharge into the community • follow-up arrangements

• At least 40 (21%) attended an emergency department (ED) with an asthma attack in the previous year (23 ≥ 2 occasions)

NRAD Recommendations – follow-up and referral:

• Follow-up after every attendance for an asthma attack• Secondary care follow-up - after every hospital admission for asthma,

and after two or more ED visits with an asthma attack in 12 mths• Patients with > 2 courses systemic corticosteroids or on BTS step 4/5

must be referred to a specialist asthma service


Whqt cqn we do?• Change system (? More specialist involvement)• Review Diagnoses (Asthma, COPD & ACOS)• Identification and reduction of risk

• Current control AND future risk • Admissions & ED attendances• Prescriptions (Salbutamol & ICS)

• Educate colleagues and patients • Implement guidelines (& change them)• PAAPs

• Improve quality of death certification

Levy ML, Winter R. Asthma deaths: what now? Thorax Feb 2015Levy ML, The National Review of Asthma Deaths – what did we learn and what needs to change? Breathe, March 2015


Post attack review

Key recommendations 1: Organisation of NHS services

• Every NHS hospital and general practice - clinical lead for asthma services

• Patients with > 2 courses systemic corticosteroids or on BTS step 4/5 must be referred to a specialist asthma service

• Follow-up arrangements :• after every attendance for an asthma attack• Secondary care follow-up - after every hospital admission for asthma,

and after two or more times ED visits with an asthma attack in 12 mths• A standard national asthma template • Electronic surveillance of prescribing in primary care to alert

clinicians (excessive SABAs or too few preventers • A national ongoing audit of asthma

Key recommendations 2: Medical and Professional Care

• All people with asthma -personal asthma action plan (PAAP)• Structured review by a healthcare professional with

specialist training in asthma, at least annually• Factors that trigger or make asthma worse must be elicited

routinely and documented in the medical records and personal asthma action plans (PAAPs)

• Assess asthma control at every asthma review. Where loss of control is identified, immediate action is required including escalation of responsibility, treatment change and arrangements for follow-up

• Aware of the features that increase the risk of asthma attacks and death, including the significance of concurrent psychological and mental health issues

Key recommendations 3: Prescribing and medicines use

• Patients prescribed > 12 SABAs in 12 mths - for urgent review of their asthma control

• An assessment of inhaler technique - routinely undertaken and also checked by the pharmacist

• Monitor non-adherence with preventers• Where long-acting beta agonist bronchodilators are

prescribed for people with asthma - should be in a single combination inhaler

Key recommendations 4: Patient factors and perception of risk

• Patient self-management should be encouraged to reflect their known triggers (increase Rx before the start of the hay fever season, avoiding NSAIDs, early use of oral corticosteroids with viral or allergic-induced exacerbations)

• Smoking and/or exposure to second-hand smoke -documented & offer referral

• Parents and children, and those who care for or teach them, should be educated about managing asthma. This should include emphasis on ‘how’, ‘why’ and ‘when’ they should use their asthma medications, recognising when asthma is not controlled and knowing when and how to seek emergency advice

• Efforts to minimise exposure to allergens and second-hand smoke should be emphasised especially in young people with asthma

Supporting partners

Eastern Region Confidential Enquiry

of Asthma Deaths

AcknowledgementsColleagues on the NRAD Core teamRachael Andrews Programme coordinatorHannah Evans Medical statisticianJenny Gingles Northern IrelandDebora Miller Northern IrelandRosie Houston Programme manager (until February2013)Navin Puri Programme manager (from February 2013)Laura Searle Program Administrator (until October 2013)

Strategic Advisory Group (Robert Winter) ; RCP Rhona Buckingham & Kevin Stewart (CEEU)

Steering Group (Derek Lowe) ; Expert Advisors ; Panel members ; Hospital co-ordinators ; HQIP (Jenny Mooney) ; Hannah Bristow (RCP Press Team)

Craig Bell (Scotland), Jenny Gingles (NI) and Karen Gully (Wales)Writers group – Caia Francis, Shuaib Nasser, Jimmy Paton and Mike ThomasThose who died from asthma & the clinicians who returned data

dr mark l levy frcgp general practitioner & respiratory lead harrow clinical lead national...

Documents

asthma care

asthma medication

number of asthma deaths

followup appointments

personal asthma action

case review

salbutamol inhalers

paap failure