Reviewing SABA-only asthma treatment in adolescents and adults

This audit helps health professionals in primary care identify adolescent* and adult patients with asthma who are taking SABA-only treatment to ensure that they are switched to a regimen that includes an inhaled corticosteroid, as recommended by the Asthma and Respiratory Foundation NZ guidelines (2020).

*People aged 12–17 years

Beasley R, Beckert L, Fingleton J, et al. NZ adolescent & adult asthma guidelines. NZMJ 2020;133. Available from: www.nzma.org.nz/journal-articles/asthma-and-respiratory-foundation-nz-adolescent-and-adult-asthma-guidelines-2020-a-quick-reference-guide

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Published: 4 August 2020

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A short-acting beta2-agonist (SABA), used as needed for symptom relief, has been recommended for patients with asthma for decades. However, evidence has now shown that SABA-only treatment is associated with an increased risk of exacerbations due to inflammation, sensitivity to allergens and tachyphylaxis. Consequently, a SABA as the sole treatment without an inhaled corticosteroid (ICS) is no longer recommended for the management of asthma in adolescents* or adults.

All adolescent and adult patients who were previously prescribed a SABA only now need to switch to a regimen that includes an ICS, including those with mild asthma or exercise-induced symptoms. The Asthma and Respiratory Foundation NZ guidelines (2020) recommend budesonide/formoterol first-line for all patients with asthma, which can be used as needed for symptom relief only or as maintenance treatment with additional as needed doses for symptom relief. Use of budesonide/formoterol in this manner is termed “anti-inflammatory reliever” (AIR) therapy. AIR therapy follows a stepwise progression; Step 1 of AIR therapy is appropriate for patients with good control previously taking a SABA alone. The alternative approach, which is to take an ICS every day with SABA as needed, is not as beneficial as AIR therapy and is only appropriate for patients who are likely to be adherent to daily ICS treatment. People with symptoms less than twice a month are often non-adherent to ICS treatment which increases their risk of SABA-related adverse effects due to SABA overuse.

The recently released guidance from the Asthma and Respiratory Foundation NZ, including the recommendation against SABA-only treatment, provides an opportunity to review all adolescent and adult patients with asthma and discuss how the changes in guidance, i.e. switching to AIR therapy, may help to optimise their asthma control. As this will take time, this audit focuses just on those taking SABA alone as they are most at risk of adverse effects and would benefit from being switched to AIR therapy.

* People aged 12–17 years; a SABA reliever without an ICS continues to be recommended in children aged < 12 years.

For further discussion on the changes to asthma management, see: www.bpac.org.nz/2020/asthma.aspx

To review your personalised SABA-only prescribing data, see: www.bpac.org.nz/report/2020/asthma.aspx

We recommend that the article and report are read before completing the clinical audit.

Summary

This audit identifies adolescent* and adult patients with asthma who are taking SABA-only treatment to ensure that they are switched to a regimen that includes an ICS.

*People aged 12–17 years

Recommended audit standards

Ideally, there will be no patients aged ≥ 12 years with asthma who are using a SABA as their only inhaler. However, this recommendation has only recently been published in the Asthma and Respiratory Foundation NZ guidelines (2020). Therefore, the first cycle of this audit will help to identify patients who are taking SABA as their sole treatment and flag them for a treatment review; after the second cycle there will ideally be no patients who are on SABA-only treatment.

Identifying eligible patients

You will need to have a system in place that allows you to identify patients aged ≥ 12 years with asthma who are taking a SABA as their only inhaled medicine. Many practices will be able to do this by running a “query” through their PMS and then reviewing the clinical notes.

Sample size

The number of eligible patients will vary according to your practice demographic. If a large number of results are returned, a sample size of 20–30 patients is sufficient for this audit. However, all eligible patients will need to be reviewed subsequently.

Criteria for a positive outcome

A positive result is any patient with asthma who is not using a SABA as their sole asthma treatment.

Data analysis

Use the sheet provided to record your data. A positive result is any patient with asthma who is not using a SABA alone. The percentage achievement can be calculated by dividing the number of patients with a positive result (i.e. a tick in the ‘NO’ column) by the total number of patients audited.

The first step to improving medical practice is to identify the criteria where gaps exist between expected and actual performance and then to decide how to change practice.

Once a set of priorities for change have been decided on, an action plan should be developed to implement any changes.

Taking action

It may be useful to consider the following points when developing a plan for action (RNZCGP 2002).

Problem solving process

  • What is the problem or underlying problem(s)?
  • Change it to an aim
  • What are the solutions or options?
  • What are the barriers?
  • How can you overcome them?

Overcoming barriers to promote change

  • Identifying barriers can provide a basis for change
  • What is achievable – find out what the external pressures on the practice are and discuss ways of wdealing with them in the practice setting
  • Identify the barriers
  • Develop a priority list
  • Choose one or two achievable goals

Effective interventions

  • No single strategy or intervention is more effective than another, and sometimes a variety of methods are needed to bring about lasting change
  • Interventions should be directed at existing barriers or problems, knowledge, skills and attitudes, as well as performance and behaviour

Monitoring change and progress

It is important to review the action plan developed previously at regular intervals. It may be helpful to review the following questions:

  • Is the process working?
  • Are the goals for improvement being achieved?
  • Are the goals still appropriate?
  • Do you need to develop new tools to achieve the goals you have set?

Following the completion of the first cycle, it is recommended that practitioners complete the first part of the CQI activity summary sheet (Appendix 1).

Undertaking a second cycle

In addition to regular reviews of progress, a second audit cycle should be completed in order to quantify progress on closing the gaps in performance.

It is recommended that the second cycle be completed within 12 months of completing the first cycle. The second cycle should begin at the data collection stage. Following the completion of the second cycle it is recommended that practitioners complete the remainder of the CQI activity summary sheet.

Claiming credits for Continuing Professional Development (CPD)

This audit has been endorsed by the RNZCGP as an Audit of Medical Practice activity (previously known as Continuous Quality Improvement – CQI) for allocation of CPD credits; 10 credits for a first cycle and 10 credits for a second cycle. General practitioners taking part in this audit can claim credits in accordance with the current CPD programme.

To claim points go to the RNZCGP website: www.rnzcgp.org.nz

Record your completion of the audit on the CPD Online Dashboard, under the Audit of Medical Practice section. From the drop down menu select “Approved practice/PHO audit” and record the audit name.

General practitioners are encouraged to discuss the outcomes of the audit with their peer group or practice.

As the RNZCGP frequently audit claims you should retain the following documentation, in order to provide adequate evidence of participation in this audit:

  1. A summary of the data collected
  2. An Audit of Medical Practice (CQI) Activity summary sheet (included as Appendix 1).
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