An audit to review high risk asthma patients with over-use of short-acting beta-agonist inhalers
Authors: Yahya F , Huckerby C , Nifel M , Singh G 
Published: November 2022

Abstract

Introduction
The UK National Review of Asthma deaths (NRAD)1 has shown that the over-prescribing of Short Acting Beta Agonist’s (SABA) inhalers is a risk factor for exacerbation and death in asthmatic patients. A quality improvement audit was identified as a priority to review practice performance in line with national guidelines.2,3

Aim
The aim was to identify patients on the asthma register who were prescribed 12 or more SABA inhalers within the preceding 12 months and investigate any reasons for overuse. Additionally, patients were highlighted for review to optimise management in line with national recommendations2,3.

Methods
A search run in a GP practice highlighted high-risk patients on the asthma register prescribed 12 or more SABAs in the preceding 12 months. Audit criteria were defined to assess if 100% of patients had a completed annual asthma review. Patients who were not asthmatics or undergoing investigations for a potential diagnosis of chronic obstructive pulmonary disease (COPD) were excluded. Phase 1 of the audit was notes-based data-collection on recent asthma reviews and reasons for potential overuse. In Phase 2, patients were contacted prioritising those overdue a review. During contact, the Asthma Control Test, checking inhaler technique, discussing any reasons for SABA over-use and patient education on their inhalers were all discussed. Patients requiring treatment optimisation or a follow-up review were highlighted for referral to various members of the multidisciplinary team. This audit did not require ethical approval.

Results
42 out of 988 patients with asthma were identified as being issued more than 12 SABA’s in the preceding 12 months. 1 patient was excluded due to having a diagnosis of COPD. Out of the remaining 41 patients, 16 patients had already had an up to date annual asthma review prior to the search. 13 patients were contacted and referred to the pharmacist or asthma nurse for a review. As a result of the audit, a total of 29 patients had an asthma review conducted. 12 patients were unable to be contacted and follow-up remains outstanding. A number of themes were highlighted during the audit such as patients using the incorrect dose or inhaler, lack of understanding on how the inhaler worked, requests for spare inhalers, absence/lack of using an inhaled corticosteroid (ICS) and worsening asthma.

Discussion/Conclusion
The audit successfully identified reasons for SABA overuse and using the multidisciplinary team to educate patients and optimise medication where needed. Following this audit, the practice has reviewed cohorts of patients that are at high risk of exacerbations and implemented quarterly safety searches to highlight these for review on a regular basis. Two further audits were also identified to improve practice in line with updated national guidance; patients prescribed a SABA alone without an ICS and patients prescribed a Long-acting beta-agonist (LABA) alone without an ICS.

References
1. Royal College of Physicians. Why asthma still kills: the National Review of Asthma Deaths (NRAD) Confidential Enquiry report.2014. [cited 2022 Jul 15] Available from: http://www.rcplondon.ac.uk/sites/default/files/why-asthma-still-kills-full-report.pdf .
2. National Institute for Health and Care Excellence. Asthma: diagnosis, monitoring and chronic asthma management [internet]. [London] NICE; 2017 [updated 2021 Nov; cited 2022 Jul 15]. NICE Guideline 80 [NG80] Available from: https://www.nice.org.uk/guidance/ng80/chapter/Recommendations-for-research
3. British Thoracic Society, Scottish Intercollegiate Guideline Network. SIGN 158 - The British Guideline on the Management of Asthma. 2019. [Internet]. [London] [cited 2022 July 15]. Available from: https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma.