SAPA5 PCN in Sheffield knew asthma care could be improved, and to get a clearer picture of what was going on, it conducted an audit across GP practices. Here’s what they did and what they found.

Good asthma care and appropriate inhaler prescribing are key components of reducing the environmental impact of general practice. Metered dose inhalers (MDI) contribute to 13% of NHS carbon footprint, with short-acting beta-2 agonist (SABA) inhalers forming a large proportion of these inhalers.

As part of the environmental sustainability plan at SAPA5 PCN in North Sheffield, we decided to look at asthma care to improve patients’ health and reduce the impact on the environment. So, we carried out an audit.

Aims

The new NICE/SIGN/BTS asthma guidance and the asthma guidance in Sheffield is that all those with asthma should be on Inhaled Corticosteroid (ICS) inhalers or combination ICS/formoterol inhalers. Best asthma outcomes are achieved when ICS inhalers are started as soon as possible after diagnosis. ICS inhalers have an additional environmental benefit, as they are available as a dry powder inhaler (DPI), which is better for the environment than metered-dose inhalers.

As every step of the asthma management algorithm in Sheffield has ICS combination inhalers as the treatment plan, all patients with asthma should be offered this as treatment across the SAPA5 PCN.

We wanted to investigate whether this was the case after we identified it as an area of need in our PCN. So, in May/June 2024, we carried out a clinical audit across four of the six GP practices in the PCN.

Method

The SAPA5 PCN is located in north Sheffield and covers a population of around 38,000 people across an urban area. It covers an area of high deprivation with a younger age demographic than the national average. The GP practices are in the most deprived decile on the  (Index of Multiple Deprivation) IMD deprivation scale and suffer from the consequences of health inequalities.

The records of 199 patients were analysed across the four GP practices for a 12-month period from 27 April 2023 to 24 April 2024. The patient lists were generated using searches to identify asthma patients without a diagnosis of COPD, who have SABA inhalers, but no ICS inhalers, on their repeat medication list.

Data was gathered and analysed using excel spreadsheets, and conclusions were made for each practice.

Results

For each practice, we calculated the proportion of asthma patients with no ICS. It ranged from 6.6-10.2% of all their asthma patients not being on the recommended asthma treatment.

Of the 199 patients in the audit, 154 had been issued at least one SABA inhaler in the 12-month period. At one practice, 91% of the patients with no ICS inhalers on their repeats had had at least one SABA inhaler in the time frame.

Those who had not had any inhalers issued were often found to have COPD - or they had been coded as ‘asthma/COPD’ or ‘asthma dormant’. Incorrect coding of patients means they might be contacted about reviews and medications that are not required.

The proportion of the 154 patients who had been issued with three or more SABA inhalers ranged from 25.5-40%. These results indicate poor asthma symptom control in this group of patients. Recent studies have found that those who use three or more SABA inhalers per year have a significant increase in asthma exacerbations and healthcare utilisation. And between a quarter to two-fifths of the patients who do not have regular ICS inhalers fall into this category. This will be having a huge impact on their health and quality of life.

We also found that only 26% (52) of the 199 patients had received an asthma review in the time frame. We could see that it was a challenge to get patients to attend for a review as a number had been contacted but not booked an appointment and this is something for practices to look into.

However, encouragingly, all but three patients who’d had a review had their Asthma Control Test (ACT) scores calculated, which indicated good symptom control. The scores ranged from 13-27, but the average scores at all the practices were above 20, indicating good asthma control.

Future

If each of the 154 patients had two SABA inhalers per year - instead of the 1-17 range that the patients actually received - the total number of inhalers prescribed would have been 308. Instead, in this cohort, it was 544 - an additional 236 SABA inhalers.

As the price of 30 days of treatment is £1.46 for a Salamol inhaler, this would mean a cost saving of £4,134.72 per year. And the carbon footprint of the salamol inhaler is 11kg CO2e - a saving of 2,596kg CO2 per month. This is the equivalent of driving about 12,300 miles in a petrol car or four round-trip flights within Europe. Salamol inhalers are the cheapest and have the smallest carbon footprint so it is likely the cost and environmental savings are far greater than these estimates.

For patients with asthma across four of the GP practices in SAPA5 PCN, there are between 6.5-10% who aren’t on the recommended treatment. The overuse of SABA inhalers in this group indicates that for this cohort, their asthma symptoms are not well controlled, and they are at increased risk of exacerbations and worse respiratory health.

This will lead to the increased financial and environmental costs associated with managing these patients’ asthma. Those costs could be reduced by ensuring that all patients attend their asthma reviews and are managed in accordance with the guidance by being on regular ICS inhalers.

Finally, after sharing these findings and trying to ensure as many of these patients are reviewed as possible, it would be helpful to review the prescribing metrics in 6-12 months to see if they have improved across the PCN. We are hoping to do this when we get some more support from medical students to carry out the re-audit.