Changes in asthma management in Australian general practice

Assessing appropriateness of paediatric asthma management: A population-based sample survey

BACKGROUND AND OBJECTIVE

We conducted a comprehensive assessment of guideline adherence in paediatric asthma care, including inpatient and ambulatory services, in Australia.

METHODS

National and international clinical practice guidelines (CPG) relating to asthma in children were searched and 39 medical record audit indicator questions were developed. Retrospective medical record review was conducted across hospital inpatient admissions, emergency department (ED) presentations, general practice (GP) and paediatrician consultations in three Australian states for children aged ≤15 years receiving care in 2012 and 2013. Eligibility of, and adherence to, indicators was assessed from medical records by nine experienced and purpose-trained paediatric nurses (surveyors).

RESULTS

Surveyors conducted 18 453 asthma indicator assessments across 1600 visits for 881 children in 129 locations. Overall, the adherence for asthma care across the 39 indicators was 58.1%, with 54.4% adherence at GP (95% CI: 46.0-62.5), 77.7% by paediatricians (95% CI: 40.5-97.0), 79.9% in ED (95% CI: 70.6-87.3) and 85.1% for inpatient care (95% CI: 76.7-91.5). For 14 acute asthma indicators, overall adherence was 56.3% (95% CI: 47.6-64.7). Lowest adherences were for recording all four types of vital signs in children aged >2 years presenting with asthma attack (15.1%, 95% CI: 8.7-23.7), and reviewing patients' compliance, inhaler technique and triggers prior to commencing a new drug therapy (20.5%, 95% CI: 10.1-34.8).

CONCLUSION

The study demonstrated differences between existing care and CPG recommendations for paediatric asthma care in Australia. Evidence-based interventions to improve adherence to CPG may help to standardize quality of paediatric asthma care and reduce variation of care.

Outcomes of childhood asthma to the age of 50 years

BACKGROUND

In 1964, The Melbourne Asthma Study was established to describe the spectrum and natural history of childhood asthma.

OBJECTIVE

To describe the clinical and lung function outcome of childhood asthma to the age of 50 years.

METHOD

Subjects were invited to complete an interviewer-administered questionnaire, skin prick testing, and measurement of lung function from the age of 7 years to the age of 50 years at 7-year intervals.

RESULTS

Of 458 survivors (from the original 484 subjects at recruitment), 346 subjects (76%) participated, of whom, 197 completed lung function measurement. Asthma remission at the age of 50 years was 64% in those with wheezy bronchitis, 47% for those with persistent asthma, and 15% for those with severe asthma in childhood. Multivariable analysis identified severe asthma in childhood (odds ratio [OR] 11.9 [95% CI, 3.4-41.8]), female sex (OR 2.0 [95% CI, 1.1-3.6]), and childhood hay fever (OR 2.0 [95% CI, 1.0-4.0]) as risk factors for "current asthma" at age 50 years. There was no evidence of a difference in the rate of decline in FEV1 (mL/y, 95% CI) between the severe asthma group (15 mL/y [95% CI, 9-22 mL/y]) and all the other recruitment groups: control (16 mL/y [95% CI, 12-20 mL/y]), mild wheezy bronchitis (14 mL/y [95% CI, 8-19 mL/y]), wheezy bronchitis (16 mL/y [95% CI, 11-20 mL/y]), and persistent asthma (19 mL/y [95% CI, 13-24 mL/y]).

CONCLUSION

The clinical and lung function outcome in adult life is strongly determined by asthma severity in childhood. The reduced lung function seen in adults is established in childhood and does not appear to decline more rapidly in adult years despite continuing symptoms.

Update in paediatric asthma management: where is evidence challenging current practice?

Extrapolation of management strategies based on results from predominantly adult asthma studies frequently occurs in paediatric asthma despite increasing evidence that paediatric asthma and, in particular, pre-school recurrent wheeze are very different disease entities. Response to medications in paediatric subjects is often different from that seen in their older adolescent and adult counterparts. In this update, we discussed recent studies that have had important implications for future paediatric asthma management. The overuse of combination inhaled steroid and long-acting beta2 agonist inhalers in paediatric asthma despite ongoing safety concerns is an increasing trend in paediatric asthma, and recent evidence has helped clarify how they should be used in children. Other aspects discussed include the role of oral corticosteroids in pre-school viral-induced wheeze and the utility of leukotriene receptor antagonists in exercise-induced asthma.

Paediatric prescribing of asthma drugs in the UK: are we sticking to the guideline?

BACKGROUND

Asthma guidelines should lead to improved, more rational asthma medication prescribing. The aims of this study were to assess trends in paediatric asthma drug prescribing in the UK and to assess the potential impact of the publication of the British Thoracic Society (BTS) asthma guideline.

METHODS

The estimated community paediatric prescribing figures for asthma medications in the UK were studied using data from the NHS Information Centre for Health and Social Care for the years 2000-2006.

RESULTS

The numbers of prescriptions for bronchodilator syrups decreased by 60% from 2000 to 2006. However, this still represents 121,000 prescriptions for bronchodilator syrups in 2006 despite minimal recommendations for their use. The percentage of steroid inhalers prescribed as combination inhalers of a steroid and a long-acting beta agonist increased from 2.6% in 2000 to 20.6% in 2006.

CONCLUSIONS

Steroid-alone inhalers should be the mainstay for the vast majority of patients with asthma who require controller medications. The increase in the number of combination inhalers prescribed is not consistent with the guideline recommendations that combination inhalers should only be introduced in those patients with asthma not controlled on adequate doses of inhaled steroids. Further education of health professionals is required.

Short-course montelukast for intermittent asthma in children: a randomized controlled trial

RATIONALE

In children, intermittent asthma is the most common pattern and is responsible for the majority of exacerbations. Montelukast has a rapid onset of action and may be effective if used intermittently.

OBJECTIVES

To determine whether a short course of montelukast in children with intermittent asthma would modify the severity of an asthma episode.

METHODS

Children, aged 2-14 years with intermittent asthma participated in this multicenter, randomized, double-blind, placebo-controlled clinical trial over a 12-month period. Treatment with montelukast or placebo was initiated by parents at the onset of each upper respiratory tract infection or asthma symptoms and continued for a minimum of 7 days or until symptoms had resolved for 48 hours.

MEASUREMENTS AND MAIN RESULTS

A total of 220 children were randomized, 107 to montelukast and 113 to placebo. There were 681 treated episodes (345 montelukast, 336 placebo) provided by 202 patients. The montelukast group had 163 unscheduled health care resource utilizations for asthma compared with 228 in the placebo group (odds ratio, 0.65; 95% confidence interval, 0.47-0.89). There was a nonsignificant reduction in specialist attendances and hospitalizations, duration of episode, and beta-agonist and prednisolone use. Symptoms were reduced by 14% and nights awakened by 8.6% (p = 0.043), and days off from school or childcare by 37% and parent time off from work by 33% (p < 0.0001 for both).

CONCLUSIONS

A short course of montelukast, introduced at the first signs of an asthma episode, results in a modest reduction in acute health care resource utilization, symptoms, time off from school, and parental time off from work in children with intermittent asthma.

Asthma and older people in general practice

WHAT WE NEED TO KNOW: Why is there undiagnosed and untreated asthma in older people in the community and in general practice? What patient, general practitioner and organisational factors contribute to this? Are current best practice guidelines appropriate for older people with asthma? WHAT WE NEED TO DO: Undertake broad community and general practice screening to identify characteristics of older people with undiagnosed asthma. Analyse GPs' perspectives and decision-making processes for older people with dyspnoea. Undertake targeted research in general practice, trialling decision-making frameworks for older patients with dyspnoea. Undertake appropriate and relevant community and GP awareness campaigns about the prevalence of asthma in older people. Analyse current best practice management of asthma, including self-management and the Asthma 3+ Visit Plan, in older people.

Chronic disease management in Australia: evidence and policy mismatch, with asthma as an example

All Western countries are developing and implementing new models for managing asthma. In Australia, the Asthma 3+ Visit Plan was implemented in 2001-2002, with the aim of establishing a structured approach in general practice for people with moderate and severe asthma, within a fee-for-service system. Evidence is emerging that the uptake across general practice has been poor, with approximately 5% of eligible people being enrolled. The reasons for the poor uptake include such factors as an inability to identify people with asthma, general practitioners being too busy with other clinical priorities, and the lack of interest and understanding of the need for a structured approach for this disease. This mismatch between evidence and policy development needs to be rectified, if sustainable models of chronic disease care are to be firmly established in general practice.