Asthma in general practice: action plans or planned actions

There's more than one way to implement effective asthma management in general practice

Peter G Gibson

MJA 1999; 171: 67

Good general practice is integral to effective asthma management. Asthma prevalence and hospitalisations are high, and, although we don't yet know how to reverse the rise in asthma prevalence, we know that severe exacerbations can be reduced by inhaled corticosteroid therapy and by effective education that involves an individualised, written action plan and regular medical review.1 The burden of illness from asthma is concentrated in general practice, but studies of asthma education have mainly been conducted in hospitals. We need to transfer the improvements seen in these randomised trials to Australian general practice. Several approaches have been tried, including public health initiatives conducted by the National Asthma Campaign (NAC), practice audit,2,3 and nurse-run asthma clinics.4 In this issue of the Journal, Abdulwadud et al provide data showing just how different asthma can be in general practice to asthma in a specialist setting.5 Predictably, asthma is less severe in general practice.5 Medication use and understanding about asthma are similar, but fewer general practice patients have a written action plan and understand how to respond to an asthma emergency. Thus, for Australia, where inhaled corticosteroid use is already high, educational interventions in general practice should focus on the early management of exacerbations using written action plans and on smoking cessation. Also in this issue, Heard et al report their trial of a combined nurse educator/general practitioner asthma clinic.6 As part of the intervention, patients attending the asthma clinic received action plans and education about asthma. Patients in the control group also received action plans from their doctors, so that by the end of the study about 70% of patients had a written action plan and 80% were taking inhaled preventer medication. Asthma morbidity was reduced in both groups, and the asthma clinic did not prove to be any better than regular review of asthma by a general practitioner. Presumably outcomes in the control group improved because the participating general practitioners, who were caring for patients in both intervention and control groups, modified their behaviour by appropriately following proven guidelines. This problem is common in studies of asthma education, where blinding is seldom used and participation in the study is enough to improve management. Thus, this article compares asthma clinics to enhanced medical care, and a direct comparison with usual medical practice is lacking. What can we learn from this? Firstly, that the improvements in asthma mordibity that follow education and medical review can be achieved in general practice in Australia, and can be achieved in several ways. Regular review of asthma control and issuing an action plan by a general practitioner can be as effective as a special asthma clinic. General practitioners can now be confident that modifying their practice will improve asthma control. We know that this is needed, as surveys indicate that, although more people use action plans since the NAC, their use is still unacceptably low.7 General practitioners can choose between setting up an asthma clinic or implementing a structured program of regular review in their practices. The NAC and asthma liaison officers within the divisions of general practice are implementing suggested schemes at present. Regular review could turn into complacency, where a general practitioner feels that his or her current practice is satisfactory and that people with asthma are well managed. The best way to avoid this is to conduct regular quality control of asthma management. There are some simple interventions with asthma audit that do reap rewards for patients and doctors alike.2,3 Special asthma clinics also need to conduct regular quality control of their services, as when they provide asthma education without general practitioner consultations and action plans there is no benefit to patients.8 Structured asthma management programs, whether by systematic regular review or a special asthma clinic, will need to be adapted to the organisational structure of the practice. This can be done fairly simply in practices with several doctors. It is more difficult to do so in solo practices, but here it is even more important, as patients from small practices have a higher admission rate for asthma than those from larger practices.9 General practitioners need to adapt the National Asthma Campaign's six-point asthma management plan to their practices and ensure that all patients with asthma understand their disease, have a set of written instructions about when and how to treat exacerbations (all people with asthma are at risk of exacerbations), and are prescribed optimal therapy to control symptoms and exacerbations. Special asthma clinics or a system of regular education and review will suffice, provided that the processes and outcomes are monitored to ensure success. Organising the process of care for asthma in general practice and defining how to do it may be just as important as educating the doctor about what to do. Most general practitioners understand asthma management. Effective implementation is the issue. Peter G Gibson Staff Specialist, Respiratory Medicine John Hunter Hospital, Newcastle, NSW Gibson PG, Wilson AJ, Coughlan J, et al. The effects of self-management asthma education and regular practitioner review in adults with asthma. In: Cates C, DuCharme F, Gibson PG, et al. Airways module. Cochrane database of systematic reviews, issue 4. Oxford, UK: Update Software, 1998. Bryce FP, Neville RG, Crombie IK, et al. Controlled trial of an audit facilitator in diagnosis and treatment of childhood asthma in general practice. BMJ 1995; 310: 838-842. Feder G, Griffiths C, Highton C, et al. Do clinical guidelines introduced with practice based education improve care of asthmatic and diabetic patients? A randomised controlled trial in general practices in east London. BMJ 1995; 311: 1473-1478. Charlton I, Charlton G, Bloomfield J, et al. Audit of the effect of a nurse-run asthma clinic on workload and patient morbidity in general practice. Br J Gen Pract 1991; 41: 227-231. Abdulwadud OA, Abramson MJ, Light L, et al. Comparison of patients with asthma managed in general practice and in a hospital clinic. Med J Aust 1999; 171: 72-75. Heard AR, Richards IJ, Alpers JH, et al. Randomised controlled trial of general practice based asthma clinics. Med J Aust 1999; 171: 68-71. Comino EJ, Mitchell CA, Bauman A, et al. Asthma management in eastern Australia, 1990 and 1993. Med J Aust 1996; 164: 403-406. Premaratne UN, Sterne JAC, Marks GB, et al. Clustered randomised trial of an intervention to improve the management of asthma: Greenwich asthma study. BMJ 1999; 318: 1251-1255. Griffiths C, Sturdy P, Naish J, et al. Hospital admissions for asthma in East London: associations with characteristics of local general practices, prescribing, and population. BMJ 1997; 314: 482-486. ©MJA 1999 Make a comment Home | Issues | MJA shop | Terms of use | MJA Careers | More... | Contact | Topics | Search | RSS  mja.com.au | The Medical Journal of Australia   Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company. Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1999 Medical Journal of Australia. We appreciate your comments.