Asthma Management Handbook

Reviewing asthma during visits for respiratory symptoms

Recommendations

When a person presents with respiratory symptoms, assess the cause, considering causes other than asthma.

How this recommendation was developed

Consensus

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

If current symptoms are probably due to asthma, assess:

  • level of recent asthma symptom control including symptoms and reliever use
  • flare-ups during the previous 12 months
  • lung function (if possible)
  • other risk factors (e.g. smoking, exposure to other triggers) or comorbid conditions
  • current treatment, including adherence to preventer if prescribed. Do not assume the person is taking the dose most recently prescribed. Ask which asthma medicines the person is using, in a non-judgmental, empathic manner.
  • inhaler technique. Watch the person use their inhaler.
  • whether the person has a written asthma action plan. If so, ask if they have followed it and whether it has helped.

Table. Definition of levels of recent asthma symptom control in adults and adolescents (regardless of current treatment regimen)

Good control

Partial control

Poor control

All of:

  • Daytime symptoms ≤2 days per week
  • Need for reliever ≤2 days per week
  • No limitation of activities
  • No symptoms during night or on waking

One or two of:

  • Daytime symptoms >2 days per week
  • Need for reliever >2 days per week
  • Any limitation of activities
  • Any symptoms during night or on waking

Three or more of:

  • Daytime symptoms >2 days per week
  • Need for reliever >2 days per week
  • Any limitation of activities
  • Any symptoms during night or on waking

† Not including SABA taken prophylactically before exercise. (Record this separately and take into account when assessing management.)

Note: Recent asthma symptom control is based on symptoms over the previous 4 weeks.

Adapted from:

Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. GINA, 2012. Available from: http://www.ginasthma.org/

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Table. Risk factors for adverse asthma outcomes in adults and adolescents Opens in a new window Please view and print this figure separately: https://www.asthmahandbook.org.au/table/show/40

Table. Management of risk factors for adverse asthma outcomes in adults

Risk factor

Clinical action †

Any risk factor for flare-ups

Check patient has an appropriate action plan

Carefully check inhaler technique and adherence, and identify any barriers to good adherence

Review frequently (e.g. every 3 months)

Hospitalisation or ED visit for asthma or any asthma flare-up during the previous 12 months

Ask about triggers for flare-ups, and lead time

History of intubation or intensive care unit admission for asthma

Ensure action plan recommends early medical review when asthma worsens

Hospitalisation or ED visit for asthma in the past month

Emphasise importance of maintaining regular ICS use after symptoms improve

Confirm that patient has resumed using SABA only when needed for symptoms

High SABA use (>2 canisters per month)

Check lung function

If SABA use appears to be habitual, investigate causes and consider alternative strategies, e.g. short-term substitution of ipratropium for SABA

Long-term high-dose ICS

Consider gradual reduction of ICS dose if symptoms stable

Monitor regularly (e.g. assessment of bone density, regular eye examinations)

For local side-effects, ensure inhaler technique is appropriate

Poor lung function (even if few symptoms)

Consider 3-month trial of higher ICS dose, then recheck lung function

Consider referral for detailed specialist investigation

Sensitivity to unavoidable allergens (e.g. Alternaria species of common moulds)

Refer for further investigation and management

Exposure to cigarette smoke (smoking or environmental exposure)

Emphasise the importance of avoiding smoke

Provide quitting strategies

Consider increasing ICS dose (higher dose of ICS likely to be necessary to control asthma)

Refer for assessment of asthma–COPD overlap

Difficulty perceiving airflow limitation or the severity of exacerbations

Regular PEF monitoring

Action plan should recommend early review and measurement of lung function

No current written asthma action plan

Provide and explain written asthma action plan

† In addition to actions applicable to all risk factors

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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

Ongoing monitoring of asthma in adults

Asthma monitoring includes both self-monitoring by patients and periodic assessments by the clinician.

Asthma management in primary care should include periodic reassessment of (both):1

  • recent asthma symptom control based on symptoms over the previous 4 weeks, with or without lung function testing. In many patients in primary care, symptoms, reliever use and lung function are useful surrogate measures of the degree to which the underlying disease process is controlled.
  • risk factors that predict poor asthma outcomes (e.g. flare-ups, accelerated decline in lung function, or treatment-related adverse effects) independent of the person’s level of recent asthma symptom control.

Planned asthma check-ups should be made at intervals determined by both the individual’s level of recent asthma symptom control and risk factors. The following is a guide:

  • 1–3 months after each adjustment to medications
  • yearly for a person with no flare-up in the past 12 months and good symptom control for at least a year
  • every 6 months for a person who has had a flare-up within the past 12 months or who has other risk factors for flare-ups or life-threatening asthma (e.g. smoking, previous recording of poor lung function on spirometry, history of admission to an intensive care unit for asthma)
  • at least every 3 months for a person with severe asthma, work-exacerbated asthma, poor perception of airflow limitation, frequent rhinosinusitis symptoms, or other comorbid conditions that affect asthma control
  • every 4–6 weeks for pregnant women.

Note: For patients with occupational asthma, management and follow-up by a specialist with experience in occupational asthma is recommended.

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Assessing recent asthma control in adults: symptoms

Questionnaires

Questionnaire-based tools can be used to standardise review of asthma symptoms, e.g.:

  • Primary care Asthma Control Screening tool (also known as Pharmacy Asthma Control Screening tool)2 – a quick screening test to detect poor asthma control, developed and validated for use with Australian patients attending primary care
  • UK Royal College of Physicians ‘3 Questions’3
  • Asthma Score (also known as Asthma Control Test).4
  • Asthma Control Questionnaire (ACQ)

The questionnaires can be completed on paper in the waiting room and scored by the practice nurse. They have also been administered via an application on hand-held personal electronic devices,56 or by telephone.7

Note: Clinicians and researchers should only use the versions of the ACQ and Asthma Score that have been validated for use in the Australian population. The wording and layout of questionnaires must not be changed.
 

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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Table. UK Royal College of Physicians ‘3 Questions’ screening tool

In the last month: Yes No
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 or breathlessness)?
  •  
  •  
Has your asthma interfered with your usual activities (e.g. housework, work/school etc)?
  •  
  •  

Inerpetation:

No to all three questions indicates good control.

Yes to 2 or 3 questions indicates poor control.

Yes to 1 question indicates that more detailed questioning is needed to assess level of asthma control (using another validated questionnaire or by asking about frequency of daytime symptoms, reliever requirement, limitation of activities and symptoms at night or on waking during the previous month).

Note: This test provides a quick and easy way of confirming someone’s asthma control is good, or identifying those who need more assessments.

Sources

Thomas M, Gruffydd-Jones K, Stonham C et al. Assessing asthma control in routine clinical practice: use of the Royal College of Physicians ‘3 Questions’. Prim Care Respir J 2009; 18: 83-8. Available from: http://www.nature.com/articles/pcrj200845

Pinnock H, Burton C, Campbell S et al. Clinical implications of the Royal College of Physicians three questions in routine asthma care: a real-life validation study. Prim Care Respir J 2012; 21: 288-94. Available from: http://www.nature.com/articles/pcrj201252

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Symptom-guided management

Data from one UK study suggest that, for the majority of patients attending primary care, asthma symptoms are concordant with eosinophilic airway inflammation, and that symptoms can therefore be used as a guide to changing anti-inflammatory treatment.8

However, if symptoms do not improve as expected after a change in treatment, or if the person continues to experience flare-ups, it is necessary to measure lung function and consider other possible causes:

  • Respiratory symptoms in a person with asthma may be due to non-asthma factors (e.g. cough due to post-nasal drip, shortness of breath due to obesity). Increasing the preventer treatment in such patients could result in unnecessarily high doses. A careful history (with lung function measurement in some patients) is necessary to confirm that symptoms are due to asthma, before deciding to change a person’s treatment.
  • Patients vary in their ability to perceive airflow limitation, so symptoms may be an unreliable measure of asthma control in some patients. Spirometry can help identify if the person is a poor perceiver of airflow limitation (e.g. person is unable to feel the difference when FEV1 increases or decreases by 15%).
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Assessing asthma control in adults: spirometry

Spirometry is necessary when making the diagnosis of asthma and when establishing the patient’s baseline and personal best status.

In ongoing asthma management, spirometry is useful in the following clinical situations:

  • During a flare-up, spirometry provides objective evidence about the severity of bronchoconstriction.
  • After a dose adjustment (either an increase or a decrease), change in lung function measured by spirometry provides additional information about the response to treatment.
  • Spirometry can help identify if the person’s symptoms may be due to non-asthma conditions (e.g. for a patient with frequent respiratory symptoms, FEV1 above 80–90% predicted should prompt consideration of an alternative cause).
  • Spirometry can help identify if the person is a poor perceiver of airflow limitation (e.g. person is unable to feel the difference when FEV1 increases or decreases by 15%).
  • Repeating spirometry over time may identify lung function decline that is more rapid than expected decline due to ageing alone, so the person can be referred for specialist review. (Spirometry should be repeated approximately every 1–2 years in most patients but more frequently as indicated by individual needs.)

There are limits to the amount of information that can be gained from spirometry alone:

  • For an individual, spirometry readings are not closely reproducible between visits, so only a change in FEV1 of greater than 0.2 L and 12% from baseline can be considered clinically meaningful in adults.9
  • Older people with long-standing asthma may develop fixed (irreversible or incompletely reversible) airflow limitation. Reliance solely on lung function expressed as percentage predicted value as a guide to adjusting preventer treatment would risk dose-escalation and over-treatment in these patients.
  • At the population level, spirometry correlates poorly with symptom-based measures of asthma control,10 so in individual patients it is not possible to predict lung function from symptoms or vice versa.

To obtain reliable, good-quality readings, the spirometer must be well maintained and correctly calibrated, and the operator must be adequately trained and experienced.

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Assessing risk factors for adverse asthma outcomes in adults

Predicting poor asthma outcomes

As well as assessing recent asthma symptom control, it is necessary to assess each patient’s risk of future asthma events or adverse treatment effects. (Recent asthma symptom control and risk of adverse events are both components of overall asthma control.)

Table. Risk factors for adverse asthma outcomes in adults and adolescents Opens in a new window Please view and print this figure separately: https://www.asthmahandbook.org.au/table/show/40

Table. Management of risk factors for adverse asthma outcomes in adults

Risk factor

Clinical action †

Any risk factor for flare-ups

Check patient has an appropriate action plan

Carefully check inhaler technique and adherence, and identify any barriers to good adherence

Review frequently (e.g. every 3 months)

Hospitalisation or ED visit for asthma or any asthma flare-up during the previous 12 months

Ask about triggers for flare-ups, and lead time

History of intubation or intensive care unit admission for asthma

Ensure action plan recommends early medical review when asthma worsens

Hospitalisation or ED visit for asthma in the past month

Emphasise importance of maintaining regular ICS use after symptoms improve

Confirm that patient has resumed using SABA only when needed for symptoms

High SABA use (>2 canisters per month)

Check lung function

If SABA use appears to be habitual, investigate causes and consider alternative strategies, e.g. short-term substitution of ipratropium for SABA

Long-term high-dose ICS

Consider gradual reduction of ICS dose if symptoms stable

Monitor regularly (e.g. assessment of bone density, regular eye examinations)

For local side-effects, ensure inhaler technique is appropriate

Poor lung function (even if few symptoms)

Consider 3-month trial of higher ICS dose, then recheck lung function

Consider referral for detailed specialist investigation

Sensitivity to unavoidable allergens (e.g. Alternaria species of common moulds)

Refer for further investigation and management

Exposure to cigarette smoke (smoking or environmental exposure)

Emphasise the importance of avoiding smoke

Provide quitting strategies

Consider increasing ICS dose (higher dose of ICS likely to be necessary to control asthma)

Refer for assessment of asthma–COPD overlap

Difficulty perceiving airflow limitation or the severity of exacerbations

Regular PEF monitoring

Action plan should recommend early review and measurement of lung function

No current written asthma action plan

Provide and explain written asthma action plan

† In addition to actions applicable to all risk factors

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Poor clinical control, as indicated by frequent asthma symptoms and frequent reliever use, is a very strong predictor of the risk of flare-ups in the future. Any asthma flare-up during the previous 12 months indicates higher risk of flare-up over the next 12 months. A history  of artificial ventilation due to acute asthma, and admission to an intensive care unit due to acute asthma have been associated with increased risk of near-fatal asthma,11 but there is not enough evidence to indicate how long this risk may persist over a person’s lifetime. Other risk factors indicate increased probability of future flare-ups or accelerated decline in lung function, independent of the person’s level of recent asthma symptom control. 12413

Other factors may increase a person’s risk of treatment-associated adverse effects. The most important of these are prescription of high dose treatment and frequent courses of oral steroids.

People with risk factors need more frequent asthma review, a carefully tailored written asthma action plan, and close attention to adherence and correct inhaler technique.

Inflammatory markers

Inflammatory markers, such as sputum eosinophil percentage or exhaled nitric oxide, are used in research and for managing severe asthma in patients attending secondary or tertiary care. Elevated sputum eosinophil levels and, to a lesser extent, elevated exhaled nitric oxide, are associated with increased risk of flare-ups. At present, treatment based on inflammatory markers is not recommended for routine use in primary care.

The value of inflammatory markers is being evaluated:

  • Adjusting asthma treatment by monitoring exhaled nitric oxide does not reduce the rate of flare-ups or improve asthma control in adults and children, compared with adjusting treatment according to clinical symptoms or spirometry, based on a meta-analysis of randomised controlled clinical trials.14 However, many of the studies were not optimally designed to answer this question,15 and some comparator regimens did not match current recommended treatment options.
  • In some studies, asthma treatment algorithms based on monitoring sputum eosinophil counts reduced flare-ups, compared with control-based management.1, 16 However, most studies assessing treatment guided by sputum eosinophilia have been conducted in selected populations in a few research centres, and therefore may not apply to the general community population. Assessment of sputum inflammatory cells is not generally available at present even in secondary care.
  • Limited evidence8 suggests that patients whose symptoms do not match their degree of eosinophilic inflammation may benefit more from treatment monitoring using sputum eosinophil count than other patients.
  • Monitoring inflammatory markers might enable safer down-titration of maintenance inhaled corticosteroid doses.
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Correct use of inhaler devices

The majority of patients do not use inhaler devices correctly. Australian research studies have reported that only approximately 10% of patients use correct technique.1718

High rates of incorrect inhaler use among children with asthma and adults with asthma or COPD have been reported,19, 20, 21, 22, 23 even among regular users.24 Regardless of the type of inhaler device prescribed, patients are unlikely to use inhalers correctly unless they receive clear instruction, including a physical demonstration, and have their inhaler technique checked regularly.25

Poor inhaler technique has been associated with worse outcomes in asthma and COPD. It can lead to poor asthma symptom control and overuse of relievers and preventers.19, 26, 24, 27, 28 In patients with asthma or COPD, incorrect technique is associated with a 50% increased risk of hospitalisation, increased emergency department visits and increased use of oral corticosteroids due to flare-ups.24

Correcting patients' inhaler technique has been shown to improve asthma control, asthma-related quality of life and lung function.29, 30

Common errors and problems with inhaler technique

Common errors with manually actuated pressurised metered dose inhalers include:25

  • failing to shake the inhaler before actuating
  • holding the inhaler in wrong position
  • failing to exhale fully before actuating the inhaler
  • actuating the inhaler too early or during exhalation (the medicine may be seen escaping from the top of the inhaler)
  • actuating the inhaler too late while inhaling
  • actuating more than once while inhaling
  • inhaling too rapidly (this can be especially difficult for chilren to overcome)
  • multiple actuations without shaking between doses.

Common errors for dry powder inhalers include:25

  • not keeping the device in the correct position while loading the dose (horizontal for Accuhaler and vertical for Turbuhaler)
  • failing to exhale fully before inhaling
  • failing to inhale completely
  • inhaling too slowly and weakly
  • exhaling into the device mouthpiece before or after inhaling
  • failing to close the inhaler after use
  • using past the expiry date or when empty.

Other common problems include:

  • difficulty manipulating device due to problems with dexterity (e.g. osteoarthritis, stroke, muscle weakness)
  • inability to seal the lips firmly around the mouthpiece of an inhaler or spacer
  • inability to generate adequate inspiratory flow for the inhaler type
  • failure to use a spacer when appropriate
  • use of incorrect size mask
  • inappropriate use of a mask with a spacer in older children.

How to improve patients’ inhaler technique

Patients’ inhaler technique can be improved by brief education, including a physical demonstration, from a health professional or other person trained in correct technique.25 The best way to train patients to use their inhalers correctly is one-to-one training by a healthcare professional (e.g. nurse, pharmacist, GP, specialist), that involves both verbal instruction and physical demonstration.31, 19, 32, 33 Patients do not learn to use their inhalers properly just by reading the manufacturer's leaflet.32 An effective method is to assess the individual's technique by comparing with a checklist specific to the type of inhaler, and then, after training in correct technique, to provide written instructions about errors (e.g. a sticker attached to the device).17, 30

The National Asthma Council information paper on inhaler technique includes checklists for correct technique with all common inhaler types used in asthma or COPD.

Inhaler technique must be rechecked and training must be repeated regularly to help children and adults maintain correct technique.29, 19, 20 

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Written asthma action plans for adults

Every person with asthma should have their own written asthma action plan.

When provided with appropriate self-management education, self-monitoring and medical review, individualised written action plans consistently improve asthma health outcomes if they include two to four action points, and provide instructions for use of both inhaled corticosteroid and oral corticosteroids for treatment of flare-ups.34 Written asthma action plans are effective if based on symptoms35 or personal best peak expiratory flow (not on percentage predicted).34

How to develop and review a written asthma action plan

A written asthma action plan should include all the following:

  • a list of the person’s usual medicines (names of medicines, doses, when to take each dose) – including treatment for related conditions such as allergic rhinitis
  • clear instructions on how to change medication (including when and how to start a course of oral corticosteroids) in all the following situations:
    • when asthma is getting worse (e.g. when needing more reliever than usual, waking up with asthma, more symptoms than usual, asthma is interfering with usual activities)
    • when asthma symptoms get substantially worse (e.g. when needing reliever again within 3 hours, experiencing increasing difficulty breathing, waking often at night with asthma symptoms)
    • when peak flow falls below an agreed rate (for those monitoring peak flow each day)
    • during an asthma emergency.
  • instructions on when and how to get medical care (including contact telephone numbers)
  • the name of the person writing the action plan, and the date it was issued.

Table. Options for adjusting medicines in a written asthma action plan for adults Opens in a new window Please view and print this figure separately: https://www.asthmahandbook.org.au/table/show/42

Table. Checklist for reviewing a written asthma action plan

  • Ask if the person (or parent) knows where their written asthma action plan is.
  • Ask if they have used their written asthma action plan because of worsening asthma.
  • Ask if the person (or parent) has had any problems using their written asthma action plan, or has any comments about whether they find it suitable and effective.
  • Check that the medication recommendations are appropriate to the person’s current treatment.
  • Check that all action points are appropriate to the person’s level of recent asthma symptom control.
  • Check that the person (or parent) understands and is satisfied with the action points.
  • If the written asthma action plan has been used because of worsening asthma more than once in the past 12 months: review the person's usual asthma treatment, adherence, inhaler technique, and exposure to avoidable trigger factors.
  • Check that the contact details for medical care and acute care are up to date.

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Templates for written asthma action plans

Templates are available from National Asthma Council Australia:

  • National Asthma Council Australia colour-coded plan, available as a printed handout that folds to wallet size and as the Asthma Buddy mobile site
  • Asthma Cycle of Care asthma action plan
  • A plan designed for patients using budesonide/formoterol combination as maintenance and reliever therapy
  • Remote Indigenous Australian Asthma Action Plan
  • Every Day Asthma Action Plan (designed for remote Indigenous Australians who do not use written English – may also be useful for others for whom written English is inappropriate).

Some written asthma action plans are available in community languages.

Software for developing electronic pictorial asthma action plans3637 is available online.

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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.38 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.38

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):39

  • 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. Taylor DR, Bateman ED, Boulet LP, et al. A new perspective on concepts of asthma severity and control. Eur Respir J. 2008; 32: 545-554. Available from: http://erj.ersjournals.com/content/32/3/545.long
  2. LeMay KS, Armous 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; 23 (1): 79-84. Available from: http://www.nature.com/articles/pcrj201411
  3. British Thoracic Society (BTS), Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma. A national clinical guideline. BTS, SIGN, Edinburgh, 2012. Available from: https://www.brit-thoracic.org.uk/guidelines-and-quality-standards/asthma-guideline/
  4. Thomas M, Kay S, Pike J, et al. The Asthma Control Test (ACT) as a predictor of GINA guideline-defined asthma control: analysis of a multinational cross-sectional survey. Prim Care Respir J. 2009; 18: 41-49. Available from: http://www.nature.com/articles/pcrj200910
  5. Peters SP, Jones CA, Haselkorn T, et al. Real-world Evaluation of Asthma Control and Treatment (REACT): Findings from a national Web-based survey. J Allergy Clin Immunol. 2007; 119: 1454-1461. Available from: http://www.jacionline.org/article/S0091-6749(07)00619-7/fulltext
  6. Juniper EF, Langlands JM, Juniper BA. Patients may respond differently to paper and electronic versions of the same questionnaires. Resp Med. 2009; 103: 932-934. Available from: http://www.resmedjournal.com/article/S0954-6111(08)00385-5/fulltext
  7. Kosinski M, Kite A, Yang M, et al. Comparability of the Asthma Control Test telephone interview administration format with self-administered mail-out mail-back format. Curr Med Res Opin. 2009; 25: 717-727. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19196218
  8. Haldar P, Pavord ID, Shaw DE, et al. Cluster analysis and clinical asthma phenotypes. Am J Respir Crit Care Med. 2008; 178: 218-224. Available from: http://ajrccm.atsjournals.org/content/178/3/218.full
  9. Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. Eur Respir J. 2005; 26: 948-968. Available from: http://erj.ersjournals.com/content/26/5/948
  10. Schatz M, Sorkness CA, Li JT, et al. Asthma Control Test: Reliability, validity, and responsiveness in patients not previously followed by asthma specialists. J Allergy Clin Immunol. 2006; 117: 549-556. Available from: http://www.jacionline.org/article/S0091-6749(06)00174-6/fulltext
  11. Turner MO, Noertjojo K, Vedal S, et al. Risk factors for near-fatal asthma. A case-control study in hospitalized patients with asthma. Am J Respir Crit Care Med. 1998; 157: 1804-9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/9620909
  12. Global Initiative for Asthma (GINA). Global strategy for asthma management and prevention. GINA, 2012. Available from: http://www.ginasthma.org
  13. Osborne ML, Pedula KL, O'Hollaren M, et al. Assessing future need for acute care in adult asthmatics: the Profile of Asthma Risk Study: a prospective health maintenance organization-based study. Chest. 2007; 132: 1151-61. Available from: http://journal.publications.chestnet.org/article.aspx?articleid=1085456
  14. Petsky HL, Cates CJ, Li A, et al. Tailored interventions based on exhaled nitric oxide versus clinical symptoms for asthma in children and adults. Cochrane Database Syst Rev. 2009; Issue 4: CD006340. Available from: http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006340.pub3/full
  15. Gibson PG. Using fractional exhaled nitric oxide to guide asthma therapy: design and methodological issues for asthma treatment algorithm studies. Clin Exp Allergy. 2009; 39: 478-490. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19260871
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