Running an asthma prescribing Quality Improvement (QI) programme during the COVID-19 pandemic: lessons learned

Problem

Two in three of asthma deaths in the UK could be prevented by better management. In East London, hospitalisation with asthma is 14% above the average for London. Hospital admission rises from 1.3 to 7.5% as the number of SABA inhalers prescribed rises from 1–3 to >12/year. There is evidence that electronic alerts may reduce excessive prescribing of Short Acting Beta Agonist (SABA) inhalers.A quality improvement programme to end in September 2022 with the aim of reducing the excessive prescribing of Short Acting Beta Agonist (SABA) inhalers, included: • In-consultation prompts for patients overusing SABA• Lists of asthma patients overusing SABA• Education sessions, guidelines and material for remote asthma reviews• Feedback of performance compared to local peers.The lockdowns associated with COVID 19 were associated with major changes in practice consultation patterns including a shift to online asthma reviews. Changes in patient behaviour led to a significant reduction in primary and secondary care attendance for asthma exacerbations, and a reduction of 36% in emergency admissions for asthma in Scotland and Wales.

Approach

By comparing the pre- and pandemic prescriptions for asthma medications we aimed to quantify the amount of disruption to the programme.We analysed the pattern of prescribing for SABA, ICS and oral steroid prescriptions for the two years prior to the pandemic and for the period from March 2020 to February 22.A predictive model is used to generate the expected pattern of prescribing during the COVID peaks.

Findings

For SABA, ICS and oral steroids we observed the expected seasonal variation in the pre-pandemic years, followed by a spike in spring 2020 and then a fall-off in prescription issues during the first and second lockdown period. The falloff in oral steroid and ICS prescription demand may be a result of reduced exposure to circulating respiratory infections, or reduced contact with health services and use of medications during COVID peaks.

Consequences

The changes in practice and patient behaviour driven by the COVID 19 pandemic may be greater than changes generated by the quality improvement programme.Practices had less capacity to engage with new computerised tools or new material for remote asthma reviews.A successful QI programme requires practice stability to allow for engagement, delivery and effective monitoring.