Can we reduce salbutamol overuse in patients with asthma? A Quality Improvement project in east London primary care using a learning health system approach

Problem

In the UK about 1,200 people/year die from asthma. Two thirds of these deaths could be prevented by better management. In east London, hospital admissions for asthma are 14% above the London average. Annual admissions rise from 1.3 to 7.5% as the number of prescribed short acting beta agonist (SABA) inhalers rises from 1–3 to >12/year for those on inhaled corticosteroids. There is evidence that electronic alerts may reduce excessive prescribing of SABA inhalers.

Approach

Drawing on emerging models of Learning Health Systems, we propose to develop a clinical decision support system that identifies risk of hospital admission in people prescribed inappropriate or excessive treatment (data into knowledge) and with the use of an alert, prompts a patient intervention, for example a review of asthma medications, to reduce the risk of future asthma exacerbations (knowledge into practice). Our objectives are:1. To develop electronic tools to support asthma management in practice: a) In-consultation prompts for patients overusing SABA inhalers; b) Tools using real-time prescribing data to produce lists of patients using excessive SABA; c) Educational material (written guidance, patient videos, webpages) to support asthma reviews.2. To use feedback data (e.g. practice dashboards, use of prompts and tools) to engage practitioners and CCGs in the implementation and refinement of the intervention.3. To evaluate the impact of the intervention on prescribing of SABA at CCG level using an interrupted time series design, with two neighboring CCGs as natural controls. 4. To identify the characteristics of patients most likely to respond to the intervention, using a cohort study.

Findings

The clinical decision support system was activated in October 2020 in all 49 practices in the intervention CCG (total population 400,000, 16,091 patients with asthma aged 5-80 years).Baseline prescribing data are consistent with existing evidence on SABA overuse,(6% of children, 11% of adults 18-60, and 25% of older adults >60 were prescribed >12 SABA in the previous 12 months). The in-consultation SABA alert resulted in 9,716 activations (from October 2020 to February 2021). GPs mainly chose to review patient medications, while non-clinical staff mostly invited patients for asthma reviews verbally or by letter.

Consequences

The translational focus of this work will demonstrate new ways to rapidly translate and implement new knowledge into practice. We expect our studies to generate more accurate methods of predicting individual patient risk of hospital admission. Such an approach has the potential to achieve implementation more quickly than traditional knowledge translation, and the potential advantage of rapid scalability, both locally, and nationally. Progress in reducing over-reliance on SABA inhalers would represent a true step change in asthma practice.