In this Issue June 2002

Poor asthma control costs more

'Flu season hits

"Something in the Air"

World respiratory conference for GPs takes off

GPCE 2002, May, Sydney

Asthma Education

Gearing up for Asthma Clinics

Spirometry - Value-adding in GP asthma care*

Poor asthma control costs more

The increase in medications prices announced in the Federal Budget last month means that people with asthma will pay a little more for their inhalers (puffers) from August. How much more they have to pay can be minimised by a clear understanding that well controlled asthma generally costs less than poorly controlled asthma.

Poorly controlled asthma keeps people away from school, work and other usual activity. Having good control, sticking with prescribed preventer medication, even when feeling well, is a good investment. Here's why.

A person with moderate asthma (symptoms most days without treatment) to severe asthma (symptoms every day without treatment) who is on a preventer inhaler would pay, comparing the old price to the new price, about $45 more per year (or $7 more for concessional cardholders).

However, switching from the preventer to the reliever inhaler would cost about $67 more per year ($40 more for concessional cardholders). The preventer inhaler provides better asthma control with fewer puffs so the inhaler lasts longer.

A person with severe asthma on combination medication can expect an annual increase of about $74 ($12 more for concessional cardholders). If they switch to a reliever inhaler the extra cost will be about $81 ($56 for concessional cardholders). The combination medication provides better asthma control with fewer puffs.

A reliever puffer costs less than a preventer puffer but the value with the preventer puffer is it lasts longer and controls asthma symptoms (coughing, wheezing, breathlessness).

Cost increases for concessional cardholders are much lower and these account for about 60 per cent of patient prescriptions for asthma.

There are both sound health and economic reasons for people with asthma to maintain using their preventer medication.

'Flu season hits

Many work places and schools are experiencing high numbers of people absent with colds and influenza. Even now it is not too late to be vaccinated against 'flu if you are in a high risk category. The influenza vaccine however, takes about 14 days to provide its greatest protection. Talk to your doctor about the value of being vaccinated. People aged 65 and over receive the vaccine free.

Influenza vaccination is currently recommended for all who want it. It is particularly recommended for

• children 6 months and older with severe asthma (frequent asthma attacks or regular hospital admissions) 
• teenagers with severe asthma
• adults with severe asthma pregnant 
• women with severe asthma or women with asthma who anticipate being pregnant through the winter. In this case, it is wise to be vaccinated before the pregnancy.

Tips for the prevention of colds and 'flu. 

In Newsletter Issue No. 2 we presented a number of excellent suggestions about how to cope with the symptoms of colds and 'flu and it is probably a good time to review that information.

Droplets of fluid from your nose or mouth spread cold and influenza viruses to other people. To prevent this transfer:

• keep your hands away from your eyes, nose, and mouth
• use paper tissues to blow your nose and throw them away after use
• wash your hands thoroughly with soap after blowing your nose, after covering your mouth for a cough or sneeze, and before preparing or eating food
• do not share cups or cutlery with other people (especially if they are showing cold of 'flu symptoms)

Managing colds and 'flu

First and most important stick with your written Asthma Action Plan. (If you are a person with asthma and you do not have a written Asthma Action Plan please discuss this with your doctor next time you visit.) Get plenty of rest to help your body's immune system fight off the viruses and 

• drink plenty of fluids to replace fluids lost from your body,
• avoid smoking or exposure to cigarette smoke,
• use medication to relieve aches and pains, and reduce fever,
• inhale steam to clear blocked sinuses and ease chest tightness in adults,
• use saline nasal sprays to help clear mucus,
• a decongestant, in the form of nasal spray, drops, tablets, or mixture, may help dry a runny nose or relieve blocked sinuses,
• suck ice or throat lozenges, or gargle warm, salty water to help soothe a sore throat.

Your doctor can assess the severity of your illness, provide information about its expected duration, and advise you on treatment and help you to better manage your asthma through the illness. 

It is especially important you consult your doctor if symptoms are severe, if they persist, or you develop severe headache, difficulty in waking up, a high fever, or if light hurts your eyes.

For more information see 

Asthma & Influenza - The Facts

"Something in the Air" 

The Australian Asthma Conference "Something in the Air" takes place in Hobart from 20 - 23 August 2002 at the Hotel Grand Chancellor. The conference venue is located on the waterfront in the central city and is one of Australia's newest convention centres providing majestic views over the Derwent River, Mount Wellington and the city.

The Australian Asthma Conference will provide:

• up-to-date information on the management of asthma, with a panel of international and national speakers; 
• access to research on all aspects of the management of asthma; 
• the opportunity for delegates to network with their peers and leading asthma researchers and practitioners: and, 
• the opportunity for delegates to access details of products and information from manufacturers, suppliers and companies with an interest in the asthma market.

The Conference Chairman Trevor Ball and Organising Committee, Marie Murray-Arthur and Cathy Beswick from Asthma Tasmania, Julie Milnes - Program Convenor and Anne Wilson - Sponsorship Convenor look forward to your attendance at this exciting meeting.

For registration details and more information please go to the official conference web site

Something in the Air - Australian Asthma Conference

World respiratory conference for GPs takes off

The first world conference for GPs with a special interest in respiratory medicine takes place in Amsterdam in June. The International Primary Care Respiratory Group (IPCRG) was formed in June 2000 at the General Practice Airways Group (GPIAG) meeting in Cambridge and will hold a conference every two years in a different international venue.

The IPCRG now represents 14 national groups of primary care physicians worldwide and is expanding rapidly. Respiratory medicine, including asthma, COPD, lung cancer and infectious lung diseases, is an area of interest and concern worldwide. No country, whether wealthy or developing, is free from these conditions, and many, like asthma, are diseases of affluent countries.

The IPCRG conference aims to bring together primary care physicians, nurses, pharmacists, researchers and educators to present and discuss new developments in respiratory disease research and management. The program includes clinical and scientific issues presented in an atmosphere of friendliness and collaboration. Open dialogue between groups is crucial to identify primary care solutions to primary care problems!

IPCRG 2002, Amsterdam, June 7-9

The National Asthma Council Australia is a member of the IPCRG through its GPs' Asthma Group (GPAG). Five NAC GPs, including GPAG chairman Dr H. John Fardy and NAC chairman Dr Ron Tomlins, are presenting an integrated asthma session focusing on the 3+ Visit Plan for proactive asthma care and Commonwealth GP Initiative.

See the NAC's IPCRG 2002 page for all conference links

IPCRG 2004, Melbourne, February 19-22

At the 2002 conference, chairmanship of the IPCRG will be handed over to Australia and New Zealand. Through the National Asthma Council, Australia and New Zealand will co-host the next IPCRG conference in Melbourne in the summer of 2004. We hope to attract British, European, South East Asian, Pacific and other overseas GPs as well as Australasian GPs to the conference.

The GPAG and the NZ GP asthma group will not be the only local presenters and delegates. We would like to see you there too.

The conference will showcase the latest Antipodean research and management strategies and provide a forum for lively debate. The IPCRG 2004 advance notice will be forwarded to Australian and NZ GPs as soon as possible. For a preview of our advance notice, check out the new website. Further information, the scientific program, a call for abstracts and registration facilities will become available on the site over the coming months.

For more information and updates on this exciting conference please go to

IPCRG Melbourne web site 

GPCE 2002, May, Sydney 

Once again at GPCE (General Practitioner Conference & Exhibition) the NAC again ran a series of 14 workshops over three days. The workshop topics were the 3+ Visit Plan and lung function testing.

The 3+ Visit Plan is a Commonwealth Government funded national GP Asthma Initiative based on the NAC's 3+ Visit Plan for proactive asthma care. The Plan provides a GP-friendly framework for proactive education and review of moderate to severe asthma patients over 3 or more visits. GPCE delegates attending the workshop found out how to use the Plan in a range of general practices, improving the health & quality of life of patients as well as providing a positive impact on GP income.

Objective testing of lung function is a crucial part of asthma management. The presenters highlighted that lung function testing & interpretation in general practice need not be difficult. With spirometers soon to be essential practice equipment delegates learnt techniques and interpretation to make spirometry work effectively. The latest advice on remuneration through MBS for spirometry was discussed as well as how easily it can be incorporated into the 3+ Visit Plan.

The presenters, Dr Amanda Barnard, Dr Chris Hogan, Dr Chris Luttrell, Dr H. John Fardy, Dr Kerry Hancock, and Dr Noela Whitby are all general practitioners and are members of the NAC's GP Asthma Group (GPAG). Each of these presenters were very well received for the practical approach to the workshops with examples and explanations from their own clinical experience. As in previous years, attendance was strong and feedback positive.

The workshop series was sponsored by Merck Sharp and Dohme as part of the Paediatric Asthma Campaign and supported by Micro Medical, which supplied spirometers.

For the first time, the GPCE Organising Committee submitted the asthma program (the 2 NAC workshops, and a paediatric asthma seminar by Prof. Richard Henry) to RACGP for 5 points/hour status. The NAC GPAG members were crucial in assisting GPCE to develop the pre and post-workshop tests for delegates. Around 40 delegates applied for the 5 points/hr status and took part in the three sessions and the testing. Other delegates will receive 2 points/hr.

Asthma Education 

The 3+Visit Plan encourages partnership in proactive asthma care. CARE also represents Contract, Assess, Review, Educate. Indeed education is an important component of "contracting" the patient with asthma and is an area that GPs often do not have as much time as they would like to spend with patients.

For those GPs who would like to call upon the services of an Asthma Educator to assist with reinforcement of their messages, access to qualified educators is assisted through Asthma Educators Association (NSW) Inc and the Victorian Asthma Health Educators Association or your local Asthma Foundation. The express purpose of asthma education is to improve health outcomes for individuals and families affected by asthma.

While Asthma Educators may be health professionals such as nurses, pharmacists, physiotherapists, respiratory scientists, occupational therapists as well as GPs, they all have specific training in communicating complex medical jargon in plain English. Along with the consumer friendly language, the Asthma Educator focuses on patient understanding of written asthma action plans and demonstrating correct device usage. 

For more information about Asthma Educators see

Asthma Educators Association (NSW) Inc

Victorian Asthma Health Educators Association (VAHEA)

Gearing up for Asthma Clinics 

An excellent resource for GPs reviewing the management of patients with asthma and other respiratory conditions is the Lung Health Promotion Centre at the Alfred (LHPC). The LHPC is committed to providing accessible, evidence-based, holistic education and support for health professionals of all disciplines.

It believes this is an essential component of maintaining quality health care delivery. With the recent upgrade of their web site the LHPC is moving toward making some of their excellent programs available on-line as well as through personal attendance.

The LHPC is also able to assist with education and resources on asthma in general practice offering courses and evening seminars on topics such as:

• Understanding and Performing Spirometry
• Nurse Run Asthma Clinics in General Practice
• Update on Management of Asthma in Adults and Children
• Paediatric Respiratory Conditions

The LHPC can also provide courses tailored to specific needs of Divisions of General Practice local basis. For more details go to 

The Lung Health Promotion Centre at the Alfred

Spirometry - Value-adding in GP asthma care*

Dr H John Fardy, Inaugural Director, Illawarra GP Training Unit; NSW; Chairman, National Asthma Council General Practitioners' Asthma Group

Download PDF version of this article

When I first entered general practice, the first line drug of choice for hypertension was a selective beta-blocker. There were no calcium channel blockers or angiotensin converting enzyme agents available for use in Australia.

Some years later, recommendations were made that, in order to adequately manage asthma in general practice, some sort of objective measurement was needed. The recommendation at that time was that a peak expiratory flow rate [PEFR] should be done, compared to predicted values and recorded in the GP's notes.

Just as the medications that we routinely prescribe in general practice have changed over the years, so has the recommendation as to the preferred objective measurement for the diagnosis, management and monitoring of asthma.

Spirometry is what is recommended now and there are good reasons for its use.

This spirometry result, which comes from a patient of mine, is clearly abnormal. Why? Both the FVC and FEV₁ are low. What does this mean? It is a mixed obstructive and restrictive pattern that does not change significantly with bronchodilation. How this interpretation is made will be explained later in this article.

The purpose of this example is to note the post-bronchodilator PEFRs (measured from the spirometry). In post-bronchodilator PEFR No. 2, the patient purposefully manipulated his expiration to give the much higher PEFR - there are a number of ways to do this - but note that the FEV₁ hardly changed at all. It was not as easily manipulated.

The consistency and reproducibility of the FEV₁, as well as the additional information provided by the spirometer, are among the reasons why spirometry is preferred over PEFR in the GP's surgery. The additional information is the FEV₁, FVC, the calculated ratio of FEV₁ / FVC, and the print-out of the flow/volume loop. With practice, the GP can deduce a great deal of information about the state of the lungs from the shape of the flow volume loop.

PEFR still has an important function in asthma management. It is the basis of guided self-management with the written Asthma Action Plan. It assists in the diagnosis of occupational asthma. Recording the PEFR twice a day for ten days can assist in diagnosis and can be a great feedback mechanism for the patient when medication is being introduced or titrated (up or down).

My rule of thumb is: Spirometry is what is done by the GP at the surgery and PEFR is what is done by the patient, away from the surgery.

So why are GPs not doing spirometry? I think that there are three major obstacles.

1) TIME, TIME and TIME

2) Cost of the equipment 

3) Interpretation (a fear of getting it wrong)

Time

 One of the most common complaints is that there isn't time to do all the things recommended in a general practice consultation. How can this barrier be overcome?

As soon as I become aware in a consultation that this visit concerns asthma and that spirometry is appropriate, I do the pre-bronchodilator spirometry even before finishing the history. After completing history-taking, examination and beginning to outline a management plan, enough time has elapsed for a post-bronchodilator spirometry to be done. And the consultation time is not extended by too much.

The time between pre- and post-bronchodilator tests can be used to complete the written asthma action plan, or to provide other asthma education in a Level 'C' consultation. Salbutamol works very quickly but good results are obtained if the interval is 10 minutes; 15 minutes is better.

Other suggestions are: 

• Do the pre-bronchodilator spirometry, history and exam, send the patient out, get the next patient in and when finished with that patient, get the first patient back in to do the post-bronchodilator spirometry and then consider the management plan for the patient. 
• Have your Practice Nurse do a course in performing spirometry. 
• Send the patient away and get them to return specifically for spirometry. 
• Send the patient to the local pathology lab: many pathology providers will do a spirometry test and report. 
• See if the local hospital physiotherapy department or asthma educators are prepared to perform spirometry on request.

Cost

If you purchase an electronic spirometer for $2000 on a business loan of 15%, the monthly repayment is $97 over 2 years. The current rebate for spirometry is $13.60: seven (7) spirometry tests a month [at rebate only] and the equipment is paid for in two years (and this doesn't include depreciation) and, at the same time, you are providing high quality care. 

Interpretation

One of the concerns that GPs have about doing spirometry is the interpretation of the numbers and graphs on the spirometry print-out.

There is a National Asthma Campaign (now National Asthma Council) publication entitled Spirometry: The Measurement and Interpretation of Ventilatory Function in Clinical Practice, which guides you through the correct performance and interpretation of spirometry. This document is available in printable form by clicking here.

The generalist nature of the medicine that GPs practise prevents them from gaining absolute mastery of everything. Spirometry is a tool to assist in the management of their patients. GPs do not need to be expert in its interpretation, just sufficiently aware of the obvious elements of interpretation to assist in diagnosing and monitoring their patients. These obvious elements are included in the following tables.

	Obstructive	Restrictive	Mixed
FEV1		or N
FEVC	or N
FEV1/FVC		N or

So, in summary, the advantages of spirometry are:

1. Its use aids in diagnosing and monitoring an important chronic condition.

2. It can be made part of a series of consultations for asthma.

3. It is cost effective for the GP (i.e. over time the machine can be paid for and a small profit can be made from pre- and post-bronchodilator spirometry).

4. It is not hard to do nor difficult, generally, to interpret.

So start some 'value-adding' in your care of the patient with asthma: spirometry is an excellent way to begin.

References:

Spirometry: The Measurement and Interpretation of Ventilatory Function in Clinical Practice. Pierce R and Johns DP. National Asthma Council, Melbourne, 1995, 2004.

*This article first appeared in the monthly RACGP newspaper, GP Review