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Project steps

Step 1

Invite all patients without evidence of variability currently on the asthma register (gathered in part one).

Step 2

Perform a test to support the patient's asthma diagnosis or continue investigations and code appropriately.
[/vc_column_text][/vc_column_inner][/vc_row_inner][/vc_column][/vc_row][vc_row el_class="qitaskouterrow"][vc_column][vc_row_inner el_class="qigrey"][vc_column_inner][vc_column_text]Step 1 - Invite patients for a diagnostic review Ensure you have completed the first QI project in this series 'Fixing the Asthma register'. From this first project, you should have a list of patients who need a review of their Asthma diagnosis:
  • Those who have no record of diagnostic testing
  • Those who have inconclusive test results to support the diagnosis of Asthma
[/vc_column_text][/vc_column_inner][/vc_row_inner][/vc_column][/vc_row][vc_row el_class="qitaskouterrow"][vc_column][vc_row_inner el_class="qigrey"][vc_column_inner][vc_column_text]Step 2 - Perform a test to support the patient's diagnosis Start by undertaking a structured clinical assessment to assess the probability of asthma. This should be based on:
  • a history of recurrent episodes (attacks) of symptoms, ideally corroborated by variable peak flows when symptomatic and asymptomatic
  • symptoms of wheeze, cough, breathlessness and chest tightness that vary over time
  • recorded observation of wheeze heard by a healthcare professional
  • personal/family history of other atopic conditions (in particular, atopic eczema/ dermatitis, allergic rhinitis)
  • no symptoms/signs to suggest alternative diagnoses
The next step is to ask the patient to complete a two week Peak Flow Diary, taking one measurement in the morning and one measurement in the evening, and recording the results. This record can be a paper diary, or you can advise your patient to download the Asthmahub or Asthmahub for parents app, with an in-built peak flow diary. Once the patient returns the PEF diary, record these results in the patient's notes with the correct code for a peak flow diary:
  • Read Code: 66YY
  • Or SNOMED code: 401011001
Check the Peak Flow Diary for evidence of "dips"; if there are "dips" in the peak flow measurement of more than 20%, the diagnosis of Asthma has been confirmed. Make sure the diagnostic code reflects this:
  • Read Code: H33
  • SNOMED Code: 195967001
For those patients who did not experience significant "dips" in their Peak Flow measurement, try an alternative diagnostic test:
  • Spirometry
  • Spirometry with reversibility
  • Peak flow with reversibility
  • Fractional exhaled nitric oxide
Of course, some patients will be stable on their medication and will not show evidence of objective variability for this reason. Click through the scenarios below for more details.[/vc_column_text][/vc_column_inner][/vc_row_inner][/vc_column][/vc_row][vc_row][vc_column][vc_tta_accordion active_section="0" collapsible_all="true"][vc_tta_section title="Scenario 1: High probability supported by tests" tab_id="1614005719562-799eea7b-bf9e"][vc_column_text]If you there is a high probability of Asthma following a structured clinical review and the patient demonstrates variable airflow obstruction, you have confirmed the diagnosis of Asthma and should continue managing their asthma. Make sure the diagnostic code reflects this:
  • Read Code: H33
  • SNOMED Code: 195967001
[/vc_column_text][/vc_tta_section][vc_tta_section title="Scenario 2: High probability, but tests are inconclusive" tab_id="1614007801075-37b13c21-2c13"][vc_column_text]If you there is a high probability of Asthma following a structured clinical review but the patient does not demonstrate variable airflow obstruction, continue managing the patient according to the Asthma Management Plan. Remember, tests influence the probability of asthma but do not prove a diagnosis.[/vc_column_text][/vc_tta_section][vc_tta_section title="Scenario 3: Low probability, and tests are inconclusive" tab_id="1614076453942-02e7bfd7-93f1"][vc_column_text]If there is a low probability of asthma and/or an alternative diagnosis is more likely, investigate for the alternative diagnosis, reconsidering asthma if the clinical picture changes or an alternative diagnosis is not confirmed. If reconsidering asthma, undertake or refer for further tests to investigate for a diagnosis of asthma.[/vc_column_text][/vc_tta_section][/vc_tta_accordion][/vc_column][/vc_row][vc_row el_class="qitaskouterrow"][vc_column][vc_row_inner el_class="qiaqua"][vc_column_inner][vc_column_text]

Recording your progress

For every patient whose record you change, whether that's changing a patient's code to reflect their Peak Flow Diary results, or performing a spirometry with reversibility test, be sure to record this in the 'Progress' section of the QI platform.
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Related Resources

COPD Diagnosis and Management Guideline

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