Helping Asthma in Real Patients

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					                               Helping Asthma in Real Patients
                                      The HARP study

                                    Interim Report for IPCRG

Project Outline
AIM:
Promote an integrated approach to asthma management, which focuses on doctor and patient
behaviour and sharing of best practices.

Background:
Asthma management requires an involvement between patient and practioner. Better asthma
management requires an improvement in the communication between physician and patient,
eventually turning every consultation into a more informed consultation. Recent work in the UK and
the Netherlands have shown that improvements in asthma management and cross-border information
exchange can best be achieved by using an assessment tool for each patient that examines current
asthma control, evaluates current management (against safety and outcome), records adherence to
the prescribed treatment and, if applicable, exposes reasons for poor adherence. It also identified
other factors that may be responsible for poor asthma control, such as smoking or untreated rhinitis
(see attached manuscript draft that is currently being reviewed by Respiratory Medicine).

Optimum Patient Care (OPC; www.optimumpatientcare.org) has developed a paper-minimal audit and
review service for asthma and COPD. This service is currently available in the UK. As part of EPPPA
(see attached protocol), and in conjunction with the International Primary Care Research Group, OPC
is currently undertaking a pilot to develop and test the feasibility of a paper-minimal asthma review
service in the Republic of Ireland.

Methods and implementation
A. Evaluation of Practice Management Systems
A feasibility study has been undertaken with 5 GPs from across the Republic of Ireland, to establish
whether any of the practice management systems used are the same as those currently being used in
the UK.

Contributing practices were selected to reflect areas of differing geographical and deprivation states,
(e.g low earners and all persons aged 70 or over). Four practice management systems were identified.
No commonality between practice management systems used in the Republic of Ireland and the UK
were found.

2. Development and implementation of software to enable mail merge, anonymisation and de-
anonymisation of patient questionnaires from patient identifiable data provided on an EXCEL
spreadsheet .
The OPC audit and review service uses link-anonymised anonymisation to ensure patient
confidentiality. An anonymisation algorithm was written to produce an anonymised patient identifier for
each patient. A file containing both the patient identifiable details and the anonymised patient identifier
are stored on the GP practice management system. This file would be used to first assign a patient
identifier to each patient questionnaire, and secondly to de-anonymise patient reports once delivered
to the practice.

Difficulties in identification of patients

In the Republic of Ireland there are no standardized systems as in the UK. This meant that we had to
find a general way of exporting the required data that would fit in with the various different systems.
There are also no uniform disease codes. However prescription data was available for most patients
meaning that we could overcome this by searching for patients by medication prescribed.




HARP_ES_11Jul2008
Reported 11 July 2008

Patients were identified using the GP practice management system. Identifiable details, (First and last
name, Date of Birth, and gender) could be exported from 3 of the 4 practice management systems
identified. [OPC is working with the remaining practice to export the patient details]. Using the mail
merge programme, anonymised patient identifiers were created for each patient and printed onto the
Asthma questionnaires. Questionnaires were sent to patients by their GPs. Anonymised asthma
questionnaires returned (international freepost) from patients directly to OPC will be scanned into the
OPC computer.

Changes to Questionnaire
Based on feedback from GPs participating in the original 5 practice pilot, a question has been added
to the questionnaire to ask patients to indicate whether they have a ‘Medical Card’. As a ‘Medical
Card’ is available to patients receiving welfare payments, in the absence of post codes, this will
provide us with an indication of the patients’ social status.

                         nd
Current Status as of 2        October 2008

Status of original 5 practices
                                                                            th
Three practices were successfully extracted and reported on prior to 11 July 2008. Difficulties
relating to the of export data from the practice management systems at the remaining 2 practices have
now been overcome. These practices have now been mail merged. A total of 1184 patients were sent
questionnaires from the 5 practices.

Status of new 10 practices

Data has been successfully exported and questionnaires mail-merged and sent from seven new
                                                                                                   rd
practices. Data from the remaining 2 practices will be exported and mail merges performed on the 3
October. A total of 2546 patients were sent questionnaires from 10 new practices.

Overall, 3730 patients have been sent HARP asthma questionnaires.

3. Analysis of questionnaires and reporting to patients.

Questionnaires were analysed against a rules set based on IPCRG, BTS and NICE guidelines (see
Appendix). The results of this analysis was used to generate two sets of reports for each practice:

A summary practice report including data on response rate, asthma population and asthma health
status. This provides a ‘snapshot overview’ of asthma and asthma status across the practice and
identifies the number of patients recommended for review or referral.

Individual patient reports of asthma health status and, if this is poor, potential causes and options to
improve this. This will help to identify those patients who will need no further asthma review for a year,
as well as priority patients for practice review and/or specialist referral. The feedback will also assist in
informing the content of review.

Anonymised reports were uploaded to each of the practices from a secure server. Using the OPC de-
anonymisation software, GPs were able to de-anonymise reports.


Current Project Status

   Initial development of a paper-minimal asthma audit and review service has been completed
   15 practices have been recruited.
   14 practices have been successfully mail merged. 1 practice is ongoing.
   3 practices have had patient and practice reports delivered

HARP_ES_11Jul2008
                Preliminary results of the 3 completed practices were recently reported at IPCRG 2008 (see
                 poster attached.


OPC Tools for HARP have been successfully used with the following practice management systems in
the Republic of Ireland

Health One
GP Dynamic
GP Clinical
Socrates
MedTech

Table of Practice Status

Practice ID                                                 Patient Number                       Response rate to date*
HARP 1                                                            380                                   49%
HARP 2                                                            134                                   52%
HARP 3                                                            212                                 ONGOING
HARP 4                                                            282                                   33%
HARP 5                                                            176                                 ONGOING
HARP 6                                                        ONGOING                                 ONGOING
HARP 7                                                            262                                 ONGOING
HARP 8                                                            248                                 ONGOING
HARP 9                                                            574                                 ONGOING
HARP 10                                                           658                                 ONGOING
HARP 11                                                            75                                 ONGOING
HARP 12                                                           213                                 ONGOING
HARP 13                                                           272                                 ONGOING
HARP 14                                                           144                                 ONGOING
HARP 15                                                           100                                 ONGOING

*To enable sufficient time for patients to respond to questionnaire and for postal services, a 4 week
window is allowed between mail merge and analysis of data.

Summary of Practice Data
Response Rate
                                                                                           Response rate

                                60
    % questionnaires returned




                                50

                                40

                                30

                                20

                                10

                                 0
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                                               Practices
This figure shows the percentage of patients who returned completed questionnaires in proportion of
the total number of patients who were sent questionnaires. To date approximately 30% of patients


HARP_ES_11Jul2008
responded, however we are still receiving questionnaires from Practice 3, and Practices 5 to 15, which
may increase the response rate further.

                         Controlled versus Uncontrolled Respondants
Response Rate by Asthma Control

                                                                                         Controlled                   Uncontrolled
                              100%
  % questionnaires returned




                              80%


                              60%


                              40%


                              20%


                               0%



                                                                                                                                  0


                                                                                                                                            1


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                                                                                                         Practices

Across all practices, respondents were twice as likely to have uncontrolled as controlled asthma.

Smoking


                                                                                               Never              Ex        Active
                              80%
  % questionnaires returned




                              60%


                              40%


                              20%


                              0%
                                                                                                                                  0


                                                                                                                                            1


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                                                                                                         Practices

Across all practices, the majority of respondents had never smoked. However approximately 19% of
respondents are active smokers. This is slightly lower than the reported prevalence of 23.6% (Office of
Tobacco Control, Ireland).




HARP_ES_11Jul2008
     Smoking in controlled (left figure) and uncontrolled respondents (right figure)


                                                                                                       Smoking Controlled                                                                                                               Smoking Uncontrolled

                                                                                                       Never      Ex     Active                                                                                                          Never     Ex      Active
                             100%                                                                                                                                                                            100%




                                                                                                                                                                             % questionnaires returned
% questionnaires returned




                                   75%                                                                                                                                                                       75%



                                   50%                                                                                                                                                                       50%



                                   25%                                                                                                                                                                       25%




                                         0%                                                                                                                                                                   0%




                                                                                                                                                                                                                    P1


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                                                                                                             Practices                                                                                                                         Practices




     The prevalence of smoking is higher in respondents with uncontrolled asthma compare to controlled
     asthma. There is no difference is the proportion of ex-smokers between respondents with controlled
     and uncontrolled asthma.


     Rhinitis


                                                                                                                No Rhinitis                    Mild Rhinitis                                                  Significant Rhinitis
                                                                          80%
                            % questionnaires returned




                                                                          60%




                                                                          40%




                                                                          20%




                                                                                    0%
                                                                                                                                                                                                                0


                                                                                                                                                                                                                          1


                                                                                                                                                                                                                                    2


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                                                                                                                                                           Practices
     Over 50% of respondents reported symptoms of mild rhinitis with a further 20% reporting symptoms of
     significant rhinitis.


     Rhinitis in controlled (left figure) and uncontrolled respondents (right figure)
                                                                                                                 Asthma Controlled                                                                                                      Asthma Uncontrolled

                                                                                              No Rhinitis       Mild Rhinitis       Significant Rhinitis                                                                No Rhinitis     Mild Rhinitis      Significant Rhinitis
                                                                                    100%                                                                                                                 100%
                                                        % questionnaires returned




                                                                                                                                                                         % questionnaires returned




                                                                                     75%                                                                                                                     75%



                                                                                     50%                                                                                                                     50%



                                                                                     25%                                                                                                                     25%



                                                                                     0%                                                                                                                       0%
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                                                                                                                        Practices                                                                                                              Practices

     HARP_ES_11Jul2008
Respondents with uncontrolled asthma (above right figure) were more likely to significant rhinitis
(25%), and less likely to not have symptoms of rhinitis (12%) than respondents with controlled asthma
(15% and 27% respectively).


Indicators of poor control in asthma

Over 60% of all patients used their reliever inhaler at least once a day. 25% of all patients had
received at least one course of corticosteroids more than 20% of patients has had at least one day off
work because of asthma.

SABA use per day


                                                                               SABA use (puffs per day)

                                                                                       controlled     uncontrolled
                              4
  % questionnaires returned




                              3




                              2




                              1




                              0
                                          P1


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                                                                                             Practices


Respondents with uncontrolled asthma had SABA higher use compared to patients with controlled
asthma.




HARP_ES_11Jul2008
Days off work


                                                                                             Days off work

                                                                                        controlled        Uncontrolled
                              50%
  % questionnaires returned




                              40%



                              30%



                              20%



                              10%



                              0%
                                              P1


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                                                                                                                                                                H
                                                                                                 Practices


Almost 30% of respondents with uncontrolled asthma had at least 1 day off work in the 12 months
prior to the audit compared to less than 5% of respondents with controlled asthma.


The following figures ONLY relate to patients with uncontrolled asthma as defined by:
1 or more days/week in which asthma has interfered with normal activities, and/or
1 or more nights/week in which asthma symptoms have affected sleep, and/or
3 or more days/week in which symptoms have been experienced.


                                      Proportion of uncontrolled patients using reliever at least once a day


                              100%
  % questionnaires returned




                              75%




                              50%




                              25%




                               0%
                                         P1


                                         P2


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                                                                               AR


                                                                                        AR


                                                                                                 AR


                                                                                                          AR

                                                                                                                   AR


                                                                                                                             AR


                                                                                                                                       AR


                                                                                                                                                 AR


                                                                                                                                                           AR


                                                                                                                                                                  AR
                                    H


                                    H


                                                            H


                                                                      H


                                                                               H


                                                                                        H


                                                                                                 H


                                                                                                          H

                                                                                                                   H


                                                                                                                             H


                                                                                                                                       H


                                                                                                                                                 H


                                                                                                                                                       H


                                                                                                                                                                H




                                                                                                 Practices


HARP_ES_11Jul2008
This figure shows the proportion of uncontrolled patients using their reliever at least once a day. >75%
of patients used their reliever inhaler at least once a day.


                                                                                                            Acute Oral Corticosteroids


                                                   70%
  % questionnaires returned




                                                   35%




                                                    0%
                                                                    P1


                                                                              P2


                                                                                        P3


                                                                                                  P4


                                                                                                            P5


                                                                                                                      P7


                                                                                                                                P8


                                                                                                                                          P9


                                                                                                                                                     0


                                                                                                                                                               1


                                                                                                                                                                         2


                                                                                                                                                                                   3


                                                                                                                                                                                             4


                                                                                                                                                                                                       5
                                                          l
                                                          ta




                                                                                                                                                  P1


                                                                                                                                                            P1


                                                                                                                                                                      P1


                                                                                                                                                                                P1


                                                                                                                                                                                          P1


                                                                                                                                                                                                    P1
                                                        To

                                                                AR


                                                                          AR


                                                                                    AR


                                                                                             AR


                                                                                                        AR


                                                                                                                  AR


                                                                                                                              AR


                                                                                                                                        AR

                                                                                                                                               AR


                                                                                                                                                         AR


                                                                                                                                                                   AR


                                                                                                                                                                             AR


                                                                                                                                                                                       AR


                                                                                                                                                                                                 AR
                                                               H


                                                                         H


                                                                                   H


                                                                                             H


                                                                                                       H


                                                                                                                 H


                                                                                                                           H


                                                                                                                                     H

                                                                                                                                              H


                                                                                                                                                        H


                                                                                                                                                                  H


                                                                                                                                                                            H


                                                                                                                                                                                      H


                                                                                                                                                                                                H
                                                                                                                              Practices


This figure shows the percentage of respondents who have received 1 or more courses of oral
corticosteroids in the previous 12 months.>35% of patients received at least one course of oral
corticosteroids in the preceding 12 months.




                                                                                                       Royal College of Physicians score (max 21)
      Royal College of Physicians score (max 21)




                                                   21


                                                   18


                                                   15


                                                   12


                                                    9


                                                    6


                                                    3


                                                    0
                                                                P1


                                                                          P2


                                                                                    P3


                                                                                              P4


                                                                                                         P5


                                                                                                                     P7


                                                                                                                               P8


                                                                                                                                         P9
                                                        l




                                                                                                                                                    0


                                                                                                                                                              1


                                                                                                                                                                        2


                                                                                                                                                                                  3


                                                                                                                                                                                            4


                                                                                                                                                                                                      5
                                                      ta




                                                                                                                                                  P1


                                                                                                                                                            P1


                                                                                                                                                                      P1


                                                                                                                                                                                P1


                                                                                                                                                                                          P1


                                                                                                                                                                                                    P1
                                                    To

                                                               AR


                                                                         AR


                                                                                   AR


                                                                                             AR


                                                                                                       AR


                                                                                                                 AR


                                                                                                                           AR


                                                                                                                                     AR

                                                                                                                                               AR


                                                                                                                                                         AR


                                                                                                                                                                   AR


                                                                                                                                                                             AR


                                                                                                                                                                                       AR


                                                                                                                                                                                                 AR
                                                            H


                                                                     H


                                                                               H


                                                                                         H


                                                                                                   H


                                                                                                              H


                                                                                                                          H


                                                                                                                                    H

                                                                                                                                             H


                                                                                                                                                     H


                                                                                                                                                               H


                                                                                                                                                                         H


                                                                                                                                                                                   H


                                                                                                                                                                                             H




                                                                                                                           Practices




HARP_ES_11Jul2008
This figure shows the average Royal College of Physicians Asthma score per practice. The maximum
score is 21. Average score was 7.




HARP_ES_11Jul2008
This report was generated by Dr Erika J. Sims.



06 October 2008

Optimum Patient Care
Unit 4
The Old Winery Business Park
Chapel Street
Cawston
Norwich
NR10 4FE

Tel: 01603 871500




HARP_ES_11Jul2008

				
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