Sponsored by OPRI with partial funding by Circassia and study drugs provided by TEVA.

Background-There have been important changes in the organisation of care for patients with asthma since asthma deaths were studied in the 1980s by the British Thoracic Association (BTA), with greater emphasis on long term control of symptoms and the use of preventive therapy. Recent trends in routine statistics show a decline in population death rates. Methods-A confidential review was undertaken of general practice and hospital records and interviews with general practitioners of patients dying in mainland Scotland between January 1994 and December 1996 with a principal diagnosis of asthma recorded by the Registrar General's OYce. Panel assessment of the cause of death was carried out and a number of possible adverse factors were identified. The data from the 15-64 year age group were compared with similar data from the earlier study by the BTA. Results-Over the three year period 95 deaths of 235 studied (40%) were confirmed as being due to asthma. Taking account of diVerent methods of case ascertainment used in the BTA and this study, a fall in the calculated rate of "deaths assessed as due to asthma" was found from 2.51 (95% CI 2.34 to 2.68) per 100 000 population in 1979 to 1.26 (95% CI 1.19 to 1.33) per 100 000 population in 1994-6. Fewer individual adverse factors were identified in clinical management, with appropriate routine management in 59% and management of the final attack satisfactory in 71%. Patient factors such as poor compliance, lack of peak expiratory flow (PEF) measurements, and overuse of reliever medication without inhaled corticosteroids, and psychosocial problems, notably depression, were confirmed as important contributing factors. Four of five patients under 16 years of age who died were found to have problems with routine management. Conclusions-Thispopulation based study documents important improvements in the standard of asthma care as well as a significant decline in the rate of deaths due to asthma over a period during which the organisation of care has changed and the chronic nature of the disease has been acknowledged. Strategies which might have a further impact include the greater use of PEF recordings, particularly during acute attacks, to document recovery, prescription monitoring of the underuse of inhaled corticosteroids, consideration of the use of combined preparations where persistent overuse of bronchodilators is occurring, and increased input for young patients whose routine management is proving diYcult. (Thorax 1999;54:978-984)

BackgroundFractional exhaled nitric oxide (FeNO) is a surrogate marker of eosinophilic airway inflammation and good predictor of corticosteroid response.AimTo evaluate how FeNO is being used to guide primary care asthma management in the United Kingdom (UK) with a view to devising practical algorithms for the use of FeNO in the diagnosis of steroid-responsive disease and to guide on-going asthma management.MethodsEligible patients (n = 678) were those in the Optimum Patient Care Research Database (OPCRD) aged 4–80 years who, at an index date, had their first FeNO assessment via NIOX MINO® or Flex®. Eligible practices were those using FeNO measurement in at least ten patients during the study period. Patients were characterized over a one-year baseline period immediately before the index date. Outcomes were evaluated in the year immediately following index date for two patient cohorts: (i) those in whom FeNO measurement was being used to identify steroid-responsive disease and (ii) those in whom FeNO monitoring was being used to guide on-going asthma management. Outcomes for cohort (i) were incidence of new ICS initiation at, or within the one-month following, their first FeNO measurement, and ICS dose during the outcome year. Outcomes for cohort (ii) were adherence, change in adherence (from baseline) and ICS dose.OutcomesIn cohort (i) (n = 304) the higher the FeNO category, the higher the percentage of patients that initiated ICS at, or in the one month immediately following, their first FeNO measurement: 82%, 46% and 26% of patients with high, intermediate and low FeNO, respectively. In cohort (ii) (n = 374) high FeNO levels were associated with poorer baseline adherence (p = 0.005) but greater improvement in adherence in the outcome year (p = 0.017). Across both cohorts, patients with high FeNO levels were associated with significantly higher ICS dosing (p < 0.001).ConclusionsIn the UK, FeNO is being used in primary practice to guide ICS initiation and dosing decisions and to identify poor ICS adherence. Simple algorithms to guide clinicians in the practical use of FeNO could improved diagnostic accuracy and better tailored asthma regimens.

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