Asthma Management Handbook

Reviewing asthma opportunistically

Recommendations

At requests for repeat asthma scripts and whenever otherwise appropriate, consider screening for poor asthma control using the Primary care Asthma Control Screening.

Table. Primary care Asthma Control Screening tool (PACS)

Have you experienced any of the following more than once a week in the last month? Yes No
Symptoms of asthma, cough, wheeze, shortness of breath
  •  
  •  
Waking at night because of asthma
  •  
  •  
Chest tightness on waking
  •  
  •  
Difficulty in performing vigorous activity like running, lifting heavy objects, exercise
  •  
  •  
Difficulty in performing moderate activities like vacuuming, climbing flights of stairs
  •  
  •  

Interpretation: ‘Yes’ to any question indicates that the person may have poorly controlled asthma, so more detailed assessment is needed.

Source: LeMay KS, Armour CL, Reddel HK. Performance of a brief asthma control screening tool in community pharmacy: a cross-sectional and prospective longitudinal analysis. Prim Care Respir J; 2014. Available from: http://dx.doi.org/10.4104/pcrj.2014.00011

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If the patient answers ‘yes’ to any question, further assessment is needed.

How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

At requests for repeat asthma scripts, always ask the person which asthma medicines they are using, using a non-judgemental and empathic manner (ask about both reliever and preventer use.)

If the person is not using prescribed preventer, use non-judgemental questions to find out why.

Table. Suggested questions to ask adults and older adolescents when assessing adherence to treatment

  1. Many people don’t take their medication as prescribed. In the last four weeks:
    • how many days a week would you have taken your preventer medication? None at all? One? Two? (etc).
    • ​how many times a day would you take it? Morning only? Evening only? Morning and evening? (or other)
    • each time, how many puffs would you take? One? Two? (etc).
  2. Do you find it easier to remember your medication in the morning, or the evening?

Source: Foster JM, Smith L, Bosnic-Anticevich SZ et al. Identifying patient-specific beliefs and behaviours for conversations about adherence in asthma. Intern Med J 2012; 42: e136-e44. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21627747

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How this recommendation was developed

Consensus

Based on clinical experience and expert opinion (informed by evidence, where available).

More information

Adherence to preventer treatment: adults and adolescents

Most patients do not take their preventer medication as often as prescribed, particularly when symptoms improve, or are mild or infrequent. Whenever asthma control is poor despite apparently adequate treatment, poor adherence, as well as poor inhaler technique, are probable reasons to consider.

Poor adherence may be intentional and/or unintentional. Intentional poor adherence may be due to the person’s belief that the medicine is not necessary, or to perceived or actual adverse effects. Unintentional poor adherence may be due to forgetting or cost barriers.

Common barriers to the correct use of preventers include:

  • being unable to afford the cost of medicines or consultations to adjust the regimen
  • concerns about side effects
  • interference of the regimen with the person’s lifestyle
  • forgetting to take medicines
  • lack of understanding of the reason for taking the medicines
  • inability to use the inhaler device correctly due to physical or cognitive factors
  • health beliefs that are in conflict with the belief that the prescribed medicines are effective, necessary or safe (e.g. a belief that the prescribed preventer dose is ‘too strong’ or only for flare-ups, a belief that asthma can be overcome by psychological effort, a belief that complementary and alternative therapies are more effective or appropriate than prescribed medicines, mistrust of the health professional).

Adherence to preventers is significantly improved when patients are given the opportunity to negotiate the treatment regimen based on their goals and preferences.1

Assessment of adherence requires an open, non-judgemental approach.

Accredited pharmacists who undertake Home Medicines Reviews can assess adherence while conducting a review.

Table. Suggested questions to ask adults and older adolescents when assessing adherence to treatment

  1. Many people don’t take their medication as prescribed. In the last four weeks:
    • how many days a week would you have taken your preventer medication? None at all? One? Two? (etc).
    • ​how many times a day would you take it? Morning only? Evening only? Morning and evening? (or other)
    • each time, how many puffs would you take? One? Two? (etc).
  2. Do you find it easier to remember your medication in the morning, or the evening?

Source: Foster JM, Smith L, Bosnic-Anticevich SZ et al. Identifying patient-specific beliefs and behaviours for conversations about adherence in asthma. Intern Med J 2012; 42: e136-e44. Available from: http://www.ncbi.nlm.nih.gov/pubmed/21627747

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Health system initiatives that support asthma care

Chronic Disease Management Medicare items

Patients with asthma are eligible for Chronic Disease Management Medicare items.2 These include:

  • Preparation of a GP Management Plan (Item 721)
  • Review of a GP Management Plan (Item 732)
  • Coordination of Team Care Arrangements (Item 723) for patients who need ongoing care from a multidisciplinary team of at least three health or care providers
  • Coordination of a Review of Team Care Arrangements (Item 732)
  • Contribution to a multidisciplinary care plan being prepared by another health or care provider (Item 729)
  • Contribution to a multidisciplinary care plan being prepared for a resident of an aged care facility (Item 731).

GPs can be assisted by practice nurses, Aboriginal and Torres Strait Islander health practitioners, Aboriginal health workers and other health professionals.2

Asthma cycle of care

The Asthma cycle of care is an Australian Government initiative to support primary care health professionals (GPs, other medical practitioners and trainees) to provide asthma care. It is implemented through the Practice Incentives Program (PIP) Asthma Incentive and applies to the clinical care of people with moderate-to-severe asthma, generally defined as people with (any of):3

  • symptoms on most days
  • use of preventative medication
  • bronchodilator use at least three times per week
  • hospital attendance or admission following an acute asthma flare-up.

The Asthma cycle of care involves at least two asthma-related consultations within 12 months for a patient with moderate-to-severe asthma, of which at least one visit is a planned asthma review. Each consultation includes:

  • documenting the diagnosis, assessing asthma severity and assessing level of recent asthma symptom control
  • reviewing the patient’s use of and access to asthma medicines and inhaler devices
  • providing a written asthma action plan (or documented alternative, if the patient is unable to use a written action plan)
  • providing asthma self-management education
  • reviewing the written or documented asthma action plan.

The Personally Controlled eHealth Record System

The eHealth record is an electronic record for a patient that contains a summary of their health information. Patients can choose to register for an eHealth record. Authorised healthcare professionals can access a patient’s record and upload information to the record if their healthcare organisation has registered for the eHealth record system.

Health system initiatives for Aboriginal and Torres Strait Islander people

Health system initiatives to support the care of Aboriginal and Torres Strait Islander people include:

  • Health Assessment Medicare items
  • The Indigenous Chronic Disease Package
  • The Asthma Spacer Ordering System.
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References

  1. Wilson SR, Strub P, Buist SA, et al. Shared treatment decision making improves adherence and outcomes in poorly controlled asthma. Am J Respir Crit Care Med. 2010; 181: 566-77. Available from: http://ajrccm.atsjournals.org/content/181/6/566.full
  2. Australian Government Department of Health. Chronic Disease Management (CDM) Medicare Items. Australian Government, Canberra, 2013. Available from: http://www.health.gov.au/internet/main/publishing.nsf/Content/mbsprimarycare-chronicdiseasemanagement
  3. Australian Government Medicare Australia. Practice Incentives Program Asthma Incentives Guidelines – August 2011. Medicare Australia, Canberra, 2011. Available from: http://www.medicareaustralia.gov.au/provider/incentives/pip/forms-guides.jsp#N10068