Symptomatic asthma: attendance and prescribing in general practice

AbstractUnder-prescribing and low attendance continue to be cited as reasons for ongoing asthma symptoms in primary care despite marked increases in prescribing and structured care for asthma over the past 10 years. The objective of this study was to determine the relationship between continuing asthma morbidity and the attendance of and prescribing for symptomatic asthmatic patients in primary care. A random sample of 402 subjects from 801 who reported at least one of six symptoms in the previous month on most or every day were identified from responses to a validated morbidity questionnaire. An analysis of their care over a 2-year period (1 year before and 1 year after the questionnaire) was carried out from their general practice case-notes. Data on 308 patients was available for analysis. Ninety-four per cent of these symptomatic asthma patients attended over the 2-year period, with 77% attending for an asthma related consultation. Most patients were managed exclusively in primary care. Inhaled steroids were prescribed for 78% of patients and high dose inhaled steroids (⩾800 mcg of beclomethasone or equivalent per day) were prescribed for 38%. Patients with most symptoms were more likely to be prescribed inhaled steroids. Rescue courses of oral steroids were prescribed for 29% of patients. Changes in asthma medications were recorded for 31% during the study period. Metered dose inhalers (MDI) were prescribed for 86% with more than half prescribed MDIs combined with some other delivery device. Elements of structured care were more frequently recorded in patients who reported most symptoms. In conclusion the asthma management of the majority of patients in this study was active with high levels of steroid prescribing. There appeared to be room to increase prescribing and to improve the structure of care. While patients who were ‘symptomatic on steroids’ should have had their medications, delivery devices and structured care reviewed regularly, many were already on maximal treatment and were therefore likely to remain symptomatic. It is unclear how practitioners could improve morbidity in many of these patients as under-treatment and low attendance seem unlikely to be the principal causes of continuing symptoms