Reducing short-acting beta-agonist overprescribing in asthma: lessons from a quality-improvement prescribing project in East London

Abstract

Background: Excess prescription and use of short-acting beta-agonist (SABA) inhalers is associated with poor asthma control and increased risk of hospital admission. Aim: To quantify the prevalence, and identify the predictors of SABA overprescribing. Design and Setting: Cross-sectional study using anonymised clinical and prescribing data from the primary care records in three contiguous east London boroughs. Methods: Primary care medical record data for patients aged 5 – 80 years, with ‘active’ asthma were extracted in February 2020. Explanatory variables included demography, asthma management, co-morbidities and prescriptions for asthma medications. Results: In the study population of 30,694 people with asthma, 26% were prescribed ≥6 SABA inhalers in the previous year. A ten-fold variation between practices (<6% to 60%) was observed in the proportion of patients on ≥6 SABA inhalers/year. By converting both SABA and ICS to standard units we improved the accuracy of comparisons across different preparations. 25% of those taking ≥6 SABA/year were underusing ICS, this rose to 80% for those prescribed <6 SABA/year. Prescription modality was a strong predictor of SABA overprescribing, with repeat dispensing strongly linked to SABA overprescribing (OR 6.52, (95% CI 4.64 to 9.41)). Increasing severity of asthma and multimorbidity were also independent predictors of SABA overprescribing. Conclusion: In this multi-ethnic population a fifth of practices demonstrate an overprescribing rate of <20% a year. Based on previous data, supporting practices to enable the SABA≥12 group to reduce to 4-12 /year could potentially save up to 70% of asthma admissions a year within that group.

Characteristics of patients with asthma overprescribed short-acting beta-agonist (SABA) reliever inhalers stratified by blood eosinophil count in North East London: a cross-sectional observational study

“…Research and guidelines are now needed on how to manage SABA over-use in patients inappropriately taking excessive doses despite controlled airways inflammation. Radar plots for each Class showing the asthma medication step and number of oral steroids courses in preceding year of highest probability for members of that class (horizontal positive and negative spokes); ratio of (probabilities for) members having SABA on Repeat prescription vs other prescription type, and for an eosinophil count ≥0.3 vs <0.3x10 9…”

“…Patients over-prescribed SABA inhalers in the preceding 12 month period and with a full blood count measured in the last 2 years were selected from our previous evaluation of SABA prescription, using primary care data from over 30 000 patients aged 5-80 with asthma from North East London. 9 Primary care data, including all prescriptions for inhaled asthma medications and courses of oral corticosteroids in the preceding year, was extracted on secure N3 terminals from EMIS Web during October and November 2021. Data extracted on SABA prescriptions included prescribing modality (acute/automatic, repeat dispending, repeat prescribing).…”

“…SABA over-prescription was defined as the prescription of 6 or more salbutamol 200-dose 100µg/dose equivalent inhalers in the preceding 12 months as previously described. 9 Potential selection bias was addressed by including all patients with asthma from all primary care practices in the region. Use of clinical data extracted from regional standard-of-care templates for clinical care addressed potential information bias.…”

“…Medication prescription refill for inhaled corticosteroids was calculated from prescription data as previously described. 9 Co-morbidities data were extracted on 16 conditions that form part of the UK Quality and Outcomes Framework (QOF), 12 using the earliest recorded diagnostic code before the start of the study, supplemented by SNOMED codes (www.snomed.org) for chronic rhinitis and generalised anxiety.…”

SABAs as Reliever Medications in Asthma Management: Evidence-Based Science

“…Ongoing and regular clinical reviews are essential to check a patient’s inhaler technique and adherence to therapy. Primary care teams should work collaboratively to monitor levels of asthma prescriptions and patient adherence—this may involve electronic surveillance to alert physicians and or asthma nurses to inappropriate ICS controller (too few) and SABA reliever (too many) prescribing [ 30 , 60 , 61 ], the use of an asthma inhaler adherence tool (e.g. Test of Adherence to Inhalers questionnaire [ 62 ]) and the involvement of pharmacists to help in patient education, to ensure patients have an action plan to follow and to encourage patient adherence [ 52 , 63 ].…”