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 Te Whanake CPD programme requirements
Practice or clinical audits are useful tools for improving clinical practice and credits can be claimed towards the Patient Outcomes (Improving Patient Care and Health Outcomes) learning category of the Te Whanake CPD programme, on a two credit per learning hour basis. A minimum of 12 credits is required in the Patient Outcomes category over a triennium (three years).
Any data driven activity that assesses the outcomes and quality of general practice work can be used to gain credits in the Patient Outcomes learning category. Under the refreshed Te Whanake CPD programme, audits are not compulsory and the RNZCGP also no longer requires that clinical audits are approved prior to use. The college recommends the PDSA format for developing and checking the relevance of a clinical audit.
To claim points go to the RNZCGP website: www.rnzcgp.org.nz
If a clinical audit is completed as part of Te Whanake requirements, the RNZCGP continues to encourage that evidence of participation in the audit be attached to your recorded activity. Evidence can include:
- A summary of the data collected
- An Audit of Medical Practice (CQI) Activity summary sheet (Appendix 1 in this audit or available on the
RNZCGP website).
N.B. Audits can also be completed by other health professionals working in primary care (particularly prescribers), if relevant. Check with your accrediting authority as to documentation requirements.
