PreparationPlanning the Asthma Management Quality Improvement Programme (AMQuIP)

The methodology was developed after discussions between the AMQuIP leads and the adult and paediatric leads in the Finnish project.

Informing and engaging GP practices

The AMQuIP was implemented in two English and one Scottish clinical commissioning group (CCGs). All practices in the three CCGs were contacted, provided with information about the programme and invited to join. Where appropriate, practice visits were undertaken. One CCG included asthma in its incentivised quality improvement scheme. A GP Champion was appointed in each CCG to promote the AMQuIP.

Developing the relevant resources

The items developed and included in the AMQuIP Toolkit can be seen in Box 1.

Box 1 List of the items included in the AMQuIP toolkit 1.

Summary of the project for General Practice

2.

General Practice to do list and Optimum Patient Care (OPC) QI sign-up form

3.

PowerPoint presentation about the project

4.

OPC protocol for data extraction, analysis and reporting of the objective assessment

5.

Protocol for the distribution, analysis and reporting of the subjective assessment

6.

Questionnaire to assess training needs and baseline confidence

7.

Diagnostic and management pathway algorithm

8.

Assessment of asthma control (ACT / C-ACT)

9.

Assessment of risk of exacerbation

10.

Patient review and education checklist

11.

Patient information menu

12.

Poster for GP surgery

13.

GP evaluation sheet

Baseline assessmentObjective assessment

An initial anonymised electronic records data extraction was undertaken at each participating GP practice by Optimum Patient Care (OPC) UK (https://optimumpatientcare.org) using a pre-specified search strategy with strict inclusion/exclusion criteria. The data were held with the OPC Research Database (OPCRD). These data identified patients with asthma to whom the questionnaire would be sent and collected data for use in the individual practice reports which summarised their asthma cohort including the numbers of high-risk patients. It also enabled technical issues to be resolved prior to the main data extraction and informed which measure of asthma control would be used as the primary outcome. More details on the criteria of the data extraction are given in the Evaluation section below.

Subjective assessment

A patient questionnaire collecting data on medication, adherence, symptom control (Asthma Control Test [ACT] or Childhood Asthma Control Test [C-ACT]), impact of asthma on daily life, smoking status and confidence in self-managing asthma was agreed to be sent out securely via Doc-mail to the identified asthma cohort after the practice had approved the generated lists.

Training needs

Each practice completed a survey to identify specific training needs.

AMQuIP interventionDelivery of QI report to GP practice

Each practice was provided with an individual report containing their data from the initial extraction. A meeting was held with staff to explain how to use and interpret the reports.

Training of primary care staff

A minimum of one GP and one asthma nurse from each practice was invited to attend a 3-hour training session delivered by local trainers. This focused on accurate diagnosis of asthma, differential/dual diagnoses, assessment of control, the risk of exacerbations, difficult asthma management, referral to specialist services and patient education/self-management. The training was delivered in line with the NHS Outcomes Framework14, NICE Quality Standard for Asthma15, BTS SIGN Guideline9 and the NHS Designing and commissioning services for adults with asthma: A good practice guide16. Prior to delivering these sessions, the trainers attended a one-day train-the-trainers course. The GP and asthma nurse from each practice were provided with training resources and tasked to cascade the training to their colleagues at their practice.

Tailored Intervention for the GP Practice

Based on the risk assessment in the baseline individual practice reports, a plan was developed for each GP practice to try to address the identified risks. If needed, additional visits by the training team were undertaken to address knowledge or training gaps. Practices were then challenged to utilise their training by performing an asthma review during the outcome period on as many of their asthma patients as possible.

GovernanceAsthma advisory group

A group comprising of asthma experts and key stakeholders was set up to provide advice and support during planning, delivery and evaluation.

Local governance

Each CCG had local governance arrangements to ensure the AMQuIP was successfully delivered in a way that reflected local infrastructure, service delivery and available resources. A Local Strategic Group oversaw the delivery in each pilot site. A Local Operations Group planned and co-ordinated the day-to-day delivery of the AMQuIP in each pilot site. A local data team liaised with OPC and included practices to ensure software compatibility and to confirm the extraction was within national and local governance law and guidance. The data team reported to the Operations Group.

Ethical approval

The implementation of the Asthma Management Project was a quality improvement project and as such did not require ethical approval or written informed consent form the participants. The analysis of the anonymised dataset by project by OPC was approved by the Anonymised Data Ethics and Protocol Transparency (ADEPT) Committee (ADEPT protocol reference: PROTOCOL2242, ADDEPT approval reference ADEPT1018, date of approval 21/08/2018) and is therefore covered under NHS HRA Approval 20/EM/0148.

Evaluation of the impact of the AMQuIP on asthma outcomes

Anonymised asthma outcome data was compared for the 12 months pre-intervention (baseline) from 28/11/2012 to 27/11/2013 and the 12 months post-intervention (outcome) from 18/03/2014 to 17/03/2015. Patients were included in the asthma cohort if they were aged 1–89 years, had a Quality and Outcomes Framework (QOF) ‘asthma diagnosis’ code but no ‘COPD diagnosis’ or ‘asthma resolved’ codes, had medical record data in both the baseline and outcome periods and had been prescribed inhaled corticosteroids (ICS) or a short acting beta agonist (SABA) in the baseline or outcome period. The primary outcome was prespecified as asthma control (assessed during the baseline and follow-up periods using the same measure). The research team retrieved data on a range of measures of asthma control including Royal College of Physicians Three Questions (RCP3Q), Asthma Control Test (ACT) and childhood ACT (C-ACT). Secondary outcomes were prescription of SABA, prescription of ICS, adherence with ICS respiratory exacerbations and hospitalisation.

Statistics

Statistical analysis was performed using STATA 13.0 (StataCorp. 2013). As all outcome data were non-parametric, differences between groups were sought using the Wilcoxon Sign Rank test or the Mann–Whitney U test for paired and unpaired data respectively. Tests of proportions were undertaken using the Chi-squared test.

Reporting summary

Further information on research design is available in the Nature Research Reporting Summary linked to this article.