Greener inhaler prescribing searches
Primary Care IT has collaborated with Greener
Practice to produce supporting searches for their asthma toolkit.
The searches are freely available to all healthcare
organisations, and are available for both EMIS Web and SystmOne. Once
requested, Primary Care IT will send a zip file of searches a protocols for
installing into EMIS Web.
The Greener Practice searches for EMIS Web are only available for Practices who run on a SNOMED CT system. Regions such as Scotland which are still operating on a Read v2 system are not able to import these searches.
To import 026. Greener Inhaler
Project.xml (included within your zip file) please follow the support
article: Importing searches into EMIS
The screenshot below shows the following folders of searches which mirror the tasks in the asthma toolkit. EMIS sorts these folders alphabetically, but the remainder of this article will follow the order shown in the toolkit.
The projects have been written with a view to
focusing on patients with asthma. These searches take a slightly different
approach by ignoring patients with a COPD diagnosis; we recognised that there
are a significant number of patients who do not have an asthma diagnosis, but
receive prescriptions for inhalers on a regular basis. The reports in each
folder include a column to help distinguish between those who already have an
asthma diagnosis and anybody who has no respiratory diagnosis.
Diagnosis 2: SABA without asthma diagnosis
The details of this project can be found here.
This search has been designed to identify patients who have received SABA prescriptions in the past 12 months, who are not currently diagnosed as asthmatic. The GIP-10 report has been designed to refine the results and pull out additional information which will save time checking various parts of the medical record.
As shown by the header above, details of the most recent SABA issue are displayed, as well as the total number of SABAs issued in the last 12 months. If any patients have previously been diagnosed, it will be seen in the Asthma resolved? column.
We recommend exporting the entire results from this report and use the Sort or Filter options in Excel. This will enable you to prioritise patients who have had multiple SABA issues for review.
Disease Control 4: Identifying poor asthma control
The details of this project can be found here.
This folder contains a number of different searches designed to review asthma control. Patients appearing in this folder do not have a current diagnosis of COPD, but are likely to have a current diagnosis of asthma; patients with no formal diagnosis will also appear.
GIP-20) Coded diagnosis of asthma
This search has been built to include patients who have a coded diagnosis of asthma. Do not expect the number reported from this search to match AST05 (asthma register) for QOF; this search purely looks at codes while QOF also looks for patients on inhaled medication issues in the past 12 months. This search should be larger than AST05 as it will include patients who have not received inhaled medication issues in the past 12 months. A consequence of having patients who retain a current diagnosis of asthma is that a single issue of an inhaler (eg: seasonally for hay fever) will return the patient to the QOF register which in turn will increase the amount of work required to complete various QOF asthma indicators. Resolving the asthma diagnosis will prevent the additional work from being needed.
To simplify the exercise in identifying patients who might no longer be diagnosed as asthmatic, GIP-21) Asthma diagnosis NOT on QOF register provides a list; it does not automatically mean that all patients appearing in this list should have the code 'Asthma resolved' added to their records, but completion of an exercise to review and add 'Asthma resolved' where appropriate will help to ensure that the QOF Asthma register can be stable.
The report displays a lot of relevant data which may become useful to reference in other searches described below.
Having completed this exercise, think about a wider review of patients. GIP-10 above already deals with patients who do not have a diagnosis. Use the GIP-20 report to identify patients who have only had 1 inhaler issued in the past 12 months - these patients may also be worth reviewing as they may not technically be asthmatic.
GIP-22) Fewer than 3 ICS in last 12 months
A low number of issues of an inhaled corticosteroid may suggest suboptimal asthma control. This not quite the same as the population excluded of the PCN DES IIF indicator RESP-01 as it is designed to look for patients who have been issued 1 or 2 ICS inhalers in the past 12 months, regardless of an asthma diagnosis. The RESP-01 indicator also has some exclusion criteria in its denominator which are not found here.
For simplicity of addressing this area of management we recommend referring to the search IIF-RESP01a in the first instance.
GIP-23) 6 or more SABA in last 12 months
A high number of issues of a SABA inhaler may suggest suboptimal asthma control. This search is similar but not the same as the PCN DES IIF indicator RESP-02 as it includes patients with no respiratory diagnosis as well as those with an asthma diagnosis. Where the RESP-02 search cannot strictly identify multiple devices issued on the same prescription, this search has been built to pick up patients who had 3 issues of 2 devices and 2 issues of 3 devices in the last 12 months. This can be distinguished in the report using a combination of the Quantity column and the SABA issues in last 12 months count column.
GIP-24) 2+ courses of oral steroids in last 12 months
This search looks at patients who had 2 or more courses of oral steroids (prednisolone) in the past 12 months. Oral steroid issues in asthma are suggestive of exacerbations. Patients with COPD are not shown in this search as they may also be issued oral steroids in the form of a rescue pack, but patients with no respiratory diagnosis are shown.
From the original report output it will be necessary to refine the patients by removing patients who have Polymyalgia rheumatica and various other conditions which require regular oral steroids. A linked problems column has been included to help identify these but it may be necessary to review records. If you are filtering in Excel, remember to keep in any patients who have an asthma diagnosis. Of course, there may be some patients with both Asthma and PMR who are only prescribed oral steroids for their PMR so this should be taken into account.
When exporting the report, remember to 'Replicate patient details for each item' to avoid problems when filtering or sorting.
GIP-25) A&E attendance or admission in last 12 months
This search looks at A&E attendances or admissions from the past 12 months for patients with a coded diagnosis of asthma. In particular this search is heavily dependent on the extent of coding by the Practice to ensure that all attendances or admissions are recorded from admission/discharge documents received.
Some generic codes such as 'Seen in accident and emergency department' may relate to any reason for attendance so it is important to review each record to determine the reason for attendance or admission.
GIP-26) Asthma exacerbation coded in last 12 months
This search looks at coded asthma exacerbations from the past 12 months. The search has been built as wide as possible and looks at codes with a SNOMED CT attribute of a disorder (eg: Acute asthma exacerbation) as well as the observation attribute of 'Number of asthma exacerbations in past year'. This latter code will have a value corresponding to the number of exacerbations. The caveat to this number of asthma exacerbations in past year is that if this code had been added 360 days ago, a single exacerbation might have actually been nearly 24 months ago.
Use the report to distinguish between those who have a current asthma diagnosis and those who do not. The report also shows how many exacerbations have been recorded and when they occurred.
GIP-27) Asthma and appointment DNA in last 12 months
This search looks at patients with a coded diagnosis of asthma who have also missed an appointment in the last 12 months. This is addressed in two ways:
1) coded data defining an appointment cancelled or missed, or
2) appointments from the EMIS Web Appointment Book where the current slot status is DNA.
Patients who miss appointments may have poor asthma control. Appearance in this search does not immediately suggest poor asthma control but it is worth looking at. There may be many non-asthma related reasons why a patient cancelled or missed an appointment, so each needs to be assessed in turn.
We have not provided a report for this particular search as it may not provide enough quality information.
GIP-28) Asthma without a personalised asthma care plan in last 12 months
This search looks at patients with a coded diagnosis of asthma who have not has an asthma care plan (management plan) documented in the past 12 months. This forms a part of the AST007 asthma review found in QOF; while the number of patients in GIP-28 will not match AST07, they are likely to track along similar lines if complete asthma reviews are carried out in the same consultation.
IIF-RESP01) Asthma with 3 or more ICS issues
This is a copy of Primary Care IT's build of the PCN DES IIF indicator for RESP-01. There is also a denominator search to refine the eligible population to patients with asthma. Use this numerator (the number of patients and the percentage) to understand progress of the indicator. The denominator search can be influenced by Practices where certain codes are added to patients with a low number of ICS issues; coding Mild asthma, as well as the code 'Inhaled corticosteroid not indicated' will remove patients from the denominator and therefore improve the overall achievement of the indicator. The search below IIF-RESP01a should be a first step to identifying patients for coding these exclusions.
IIF-RESP01a) Asthma with low counts of ICS and SABA issues
This search is a refined version of the population excluded of IIF-RESP01. It is not every asthmatic patient who hasn't had at least 3 issues of an ICS. Those with mild asthma are likely to be those who may only occasionally require inhalers, perhaps seasonally. This search takes asthmatic patients who have had 0, 1, or 2 ICS inhalers, who have also only had a maximum of 3 SABA inhaler prescriptions in the past 12 months. This will therefore remove any patient who is perhaps poorly controlled by using many SABA issues. The smaller list of patients may still be quite large, but should at least show patients who are most likely to have mild asthma.
The IIF RESP searches are mildly flawed in that they are designed only look at prescriptions issued but not the number of devices per prescription. This means that double prescribing may pull in patients to the search who may have had 3 SABA prescriptions but really 6 devices, and if all devices have been used equally it may suggest poor control.
The report from IIF-RESP01 could be used in Excel to filter to either find patients who have a low number of issues of both ICS and SABA, or even the inverse of low issues but high SABA to conduct a different exercise - however these patients are likely to be found in the search RESP-02 below.
IIF-RESP02) Asthma with 6 or more SABA issues
This is a copy of Primary Care IT's build of the PCN DES IIF indicator for RESP-02. There is also a denominator search to refine the eligible population to patients with asthma. Use this numerator (the number of patients and the percentage) to understand progress of the indicator. Unfortunately there is no method of reducing the size of the denominator. As described above, the RESP-02 indicator looks at prescriptions issued rather than number of devices per prescription. This doesn't matter too much where 6+ SABA issues has been chosen as the threshold.
The report header seen below shows how the current course of a SABA can be reviewed as well as the number of issues in the past 12 months.
For the purposes of identifying poor asthma control it may be a worthwhile exercise scrutinising the output in Excel. Whilst the number of issues column could be multiplied by the Quantity column to work out the actual number of devices issued, remember that certain patients (in particular schoolchildren) may have been issued multiple devices to be kept at home as well as at their school/workplace.
GIP-29) Children under the age of 6 for RESP-01
The RESP-01 indicator looks at patients of any age with asthma, contrary to the QOF register which only accounts patients over the age of 6 years. This search highlights young children in the RESP-01 cohort who are not part of the QOF asthma register in case you wish to conduct a targeted review of these patients.
Device 3: High carbon footprint inhalers
The details of this project can be found here.
This search has been designed to identify patients who have been issued high carbon footprint inhalers in the past 12 months. The GIP-30 report has been designed to refine the results and pull out additional information which will save time checking various parts of the medical record.
This project contains elements of the ES-01 and ES-02 indicators for the PCN DES IIF, but are not exactly the same.
The report shows patients who have a current diagnosis of asthma - if that particular cell is blank, the patient does not have a current diagnosis. Remember that patients with COPD are not included. Depending on the types of inhaler issued, patients may or may not also appear in the search GIP-10.
The search GIP-31 No longer on highest
carbon footprint inhaler identifies all patients who were on one of these
inhalers, but it has been moved to past and the last issue was in the last 6
months.
Device 4: Fostair pMDI to NEXThaler
The details of this project can be found here.
This search has been designed to identify patients who have Fostair pMDI (pressurised metered dose inhaler) on their current medication list. The idea of the project is to change patients to the NEXThaler DPI (dry powder inhaler) version of Fostair. This is part of the ES-01 indicator for PCN DES IIF.
The GIP-40 report has been designed to refine the results and pull out additional information which will save time checking various parts of the medical record.
This report helps to show the dose instructions for current Fostair pMDI medication. Due to the change of inhaler type from pMDI to DPI, it is likely that inhaler technique will need to be demonstrated to patients who are being switched.
The search GIP-41 No longer on Fostair pMDI identifies
all patients who were on one of these inhalers, but it has been moved to past
and the last issue was in the last 6 months.
Device 5: Ventolin Evohaler to Salamol or Airomir
The details of this project can be found here.
This search has been designed to identify patients who have Ventolin Evohaler on their current medication list. The idea of the project is to change patients to the Salamol or Airomir brands of salbnutamol. This is part of the ES-02 indicator for PCN DES IIF, which focuses on reducing the number of inhalers prescribed which have a high CO2 emissions value per device by switching to a device with a lower CO2 emissions value. Much like ES-02, the generic Salbutamol CFC free inhaler 100 microgram is not recommended as it has a similar CO2 emissions value to the Evohaler.
The GIP-50 report has been designed to refine the results and pull out additional information which will save time checking various parts of the medical record.
This report helps to show the dose instructions for current Ventolin Evohaler medication.
The search GIP-51 No longer on Ventolin
Evohaler identifies all patients who were on one of these inhalers,
but it has been moved to past and the last issue was in the last 6 months.
Disposal 1&2: Empty inhalers and recycling
The details of this project can be found here.
Unlike the previous folders, this folder identifies
all patients with inhaler issues regardless of diagnosis.
Unlike the previous projects the GIP-60 search only takes into account inhaler issues, meaning that patients with asthma or COPD diagnoses are included as well as patients with no coded respiratory diagnosis.
Disposal projects 1&2 focus on informing and educating patients on how to dispose of or recycle their empty inhalers. 
The report will help to list which inhalers each patient has been issued in the past 12 months. Notice the last column for education about inhaler disposal - this is a code selected by Primary Care IT to represent patients who have been given education about disposing of used inhalers. The idea of this code is that Practices can add the code to patients who have either received direct advice during a consultation, or who have been sent a communication to explain how to effectively dispose of inhalers. In EMIS Web it is possible to batch add a code either via a mailshot or a search cohort to document these campaigns.
Version control
Version 2
14/02/2022
Updated IIF-RESP01 to latest business rules (NHS December update)
Updated IIF-RESP02 to latest business rules (NHS December update)
Added search GIP-29 to identify children under the age of 6 appearing in RESP-01
Version 1.2
21/10/2022
Rename folders to reflect order of projects on Greener Practice website.
Amended GIP-01 search: added in rule to mirror QOF (age GTEQ 6 years). Amended search description.
Amended GIP-21 search: added rule to exclude patients younger than 6 years.
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