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Asthma clinics in primary care may be a convenient way of delivering care, but there is limited
evidence that they themselves improve outcome. 291 Most practices will provide asthma reviews
as part of routine appointment sessions. It is what happens during the review consultation
that matters. 637-640 Audit that feeds back guidelines recommendations on the management of
individual patients may improve outcomes. 641,642
C General practices should maintain a register of people with asthma.
C Clinical review should be structured and utilise a standard recording system.
B feedback of audit data to clinicians should link guidelines recommendations to
management of individual patients.
The ideal content of an asthma review consultation is uncertain. Discussion and provision of a
written action plan leads to improved outcomes. 643 Other activities likely to be important are
reviewing understanding of medication role and use, checking inhaler technique, recording
lung function. Structured review systems such as the Royal College of Physicians ‘Three Key
Questions’, 109 the Tayside Asthma Stamp, 644 and the modified Jones Morbidity Index 645 improve
the recording of relevant data and may prompt a search for causes of suboptimal asthma control,
such as under-treatment, poor adherence or poor inhaler technique. However, such tools can
lead to a more physician-centred or template-directed consultation. Reviewing patients using
a patient-centred style of consultation can lead to improved outcomes. 625
8.1.3 SHARED CARE
Shared care schemes have been shown to be effective in some healthcare environments. There
are no UK studies directly comparing primary and secondary care management, but international
work suggests there may be little difference: what is done would appear to be more important
than who by or where. 646
Integrated care schemes such as Grampian Asthma Study in Integrated Care (GRASSIC) suggest
that place of care is not directly linked to clinical outcome. 647-650 Shared care had a similar
outcome to outpatient care. Outreach support for primary care by asthma specialist nurses
may reduce unscheduled asthma care but only if targeted around follow-up of patients recently
attending secondary care with exacerbations.
Community pharmacists trained in asthma care and teaching self management skills may improve
asthma control, 651,652 although evidence is sparse and inconsistent. 653
8.1.4 PATIENT SUBGROUPS
Ethnic subgroups have adverse clinical outcomes, including higher hospital admission and
exacerbation rates. 654,655 In some countries ethnic minority groups have higher death rates
due to asthma than do their contemporaries. 656,657 Minority groups describe poorer access to
primary care and acute medical care, 658 and compared with majority groups, have a higher
use of emergency facilities for routine care. 659 Educating primary care clinicians improves
diagnosis, prescribing, education, and continuity of care for minority group children. 659 There
is an established link between poor socioeconomic status and adverse asthma outcome. 660-664
Adolescents and the elderly are particularly vulnerable to the adverse effects of asthma.
Adolescents and young adults make more frequent use of emergency asthma healthcare
services, make less use of structured clinical review services than other age groups, and have
high reliance on bronchodilators. 665,666 Asthma in the elderly is a neglected area of research,
despite high mortality and morbidity. 391,667,668
d healthcare professionals who provide asthma care should have heightened awareness
of the complex needs of ethnic minorities, socially disadvantaged groups, adolescents,
the elderly and those with communication difficulties.
Audit asthma outcomes in relevant subgroups of the population.
8 orGAnisAtion And delivery of CAre, And Audit
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