A recent call from a practice nurse in a large rural GP surgery, enquired about ways to organise the Asthma QOF register and encourage patients to attend their annual asthma reviews. While the practice had created and maintained an asthma register, it had not done as well on its QOF points as it had hoped.
Advice from Asthma UK
We often receive calls regarding the Asthma Quality Outcomes Framework (QOF) register and how to meet the indicators.
It’s important to state that while QOF is a tool recognised to incentivise improved patient care, the asthma indicators by themselves do not form a comprehensive overview of what good asthma care looks like. For example, as the QOF indicators stand they do not include the use of action plans which are a fundamental feature of good asthma care and a central part of the NICE Quality Standard on asthma care.
There are four asthma indicators in the 2013/14 General Medical Services contract
- AST001 which relates to indicator records. The contractor establishes and maintains a register of patients with asthma, excluding patients with asthma who have been prescribed no asthma-related drugs in the preceding 12 months
- AST002 which relates to initial diagnosis The percentage of patients aged 8 or over with asthma (diagnosed on or after 1 April 2006), on the register, with measures of variability or reversibility recorded between 3 months before or anytime after diagnosis
- AST003 which concerns ongoing management of asthma The percentage of patients with asthma, on the register, who have had an asthma review in the preceding 12 months that includes an assessment of asthma control using the 3 RCP questions
- Have you had difficulty sleeping because of your asthma symptoms, including cough?
- Have you had your usual asthma symptoms during the day (cough, wheeze,chest tightness)?
- Has your asthma interfered with your usual activities (work / sex / housework / exercise)?
- AST004 which concerns the smoking status of teenagers/young adults The percentage of patients with asthma aged 14 or over and who have not attained the age of 20, on the register, in whom there is a record of smoking status in the preceding 12 months
Indicator Records - AST001
Often asthma registers can be high in numbers – the average practice of 6,651 patients will have 392 patients with asthma - and it can be difficult to set aside time to review the patients individually. Doing a little often can be invaluable and enable the auditor to see any themes within their practice. Pitfalls could be incorrect coding or work that has been done but not entered into the asthma template. At your practice meeting you might wish to explore whether colleagues are aware of how to use the asthma template and that you are all using the template in the same way.
The practice computer system is often a good starting point in troubleshooting these typical problems.
EMIS software for example can do a population search based on prescribing criteria and so you can do a search based on prescribing to ensure all asthma patients are indeed on your register. So for example, you could search for patients prescribed Clenil in the past 12 months and then cross-reference this with those patients who have an asthma diagnosis. The patients left, who have had a Clenil prescription, but no diagnosis can have their notes reviewed individually. Similarly it can help exclude patients, in line with the indicator, who have been prescribed no asthma-related drugs in the past 12 months.
List cleansing is also important – are patients on the list are still registered at the practice? When was the last time they attended the surgery or requested a prescription, or were recalled? Is there a possibility they’ve moved?
Initial Diagnosis - AST002
The indicator relating to initial diagnosis requires healthcare professionals to make a correct asthma diagnosis. As this is such a large clinical area we are not going to focus on this indicator here but would advise the following links
On-going management - AST003
Non-attendance of the annual review can be due to many reasons:
- the patient with asthma does not understand the importance of the review on a regular basis
- patients cannot access appointments with a clinician at the right time for them. This could be inflexible opening hours or that when the patient is unwell with their asthma they find it difficult to get through/book an appointment.
Its important to make use of every opportunity with a patient to have an asthma review.
For example does your reception ask patients collecting a routine prescription to book in for an asthma review? Or when patients come in to the surgery for a follow up review within 48 hours of an asthma exacerbation- their annual review could be part of this consultation, if the person when booking the appointment was encouraged to book a review length slot.
If you noticed patients with asthma are not attending their appointments when invited, it might be worth reviewing the information you are sending out to ensure the letters include information on the importance of an asthma review and asthma symptoms. You might also like to include the questions from the Asthma Control Test so patients can themselves recognise they are in need of a review.
Timing of the annual review invite is also important. School holidays are often a good time for children to attend or after school appointments. If a large number of your patients work office hours, could you offer evening reviews or offer telephone consultations for a initial review?
Find out also how colleagues in neighbouring surgeries meet this indicator and what systems they have in place. Most areas have local respiratory groups who can help see Association of Respiratory Nurse Specialists and PCRS.
The smoking status of teenagers/young adults - AST004
This indicator only requires the recording of the smoking status at an asthma clinic.
The indicator itself does not require you to give smoking cessation advice. However within the Smoking QOF SMOK003 it is an indicator that smoking cessation is promoted at the point of finding out a person is a smoker and it is good practice to do so. The NHS Choices website is a good resource to refer patients to.
Be aware some under-16s are nervous of having on their record that they are a smoker and many may say they are not, when in fact they are, for fear the information might get back to their parents.
Some teenagers might be accompanied to their asthma reviews by their parents and not wish to say they smoke with mum/dad in the room.
Consider other contacts with these patients to ask this question and record on the indicator. For example, a colleague in a practice doing immunisation boosters asked this to teenagers with asthma while getting their injections ready and the teenagers seemed more relaxed about disclosing this information outside of an asthma consultation.
If you would like to confidentially discuss the points in this article or the procedures in your surgery with one of our Asthma nurse specialists, please feel free to call the Helpline on 0800 1216244.