NIHR Signal GP letter to improve medication adherence did not reduce unplanned care for children with asthma

Published on 14 March 2017

A one-off GP letter reminding parents of children with asthma to use their medications over the August summer holiday did not prevent a characteristic annual peak in unplanned care on returning to school in September, but did lead to more prescriptions.

Unplanned care represents visits to the GP or accident and emergency that is not part of the child’s asthma care plan. They do not include scheduled medical review or visits for repeat prescriptions.

The letter prompted about a third more parents to collect inhaler prescriptions in August than parents receiving no letter. But this failed to reduce the high proportion of children receiving unplanned care in September (45% of children in the letter group compared to 44% in the control group).

Most of the unplanned care was not for asthma, which may be why the letter had little impact.  It remains unclear why children with asthma are more likely to access unplanned care.

This NIHR-funded trial was large, well-designed and, despite problems with labelling planned and unplanned care, is likely to be reliable.

GP letter to improve medication adherence did not reduce unplanned care for children with asthma

Share your views on the research.

Why was this study needed?

About 25% of children under 12 have had at least one episode of wheeze or have asthma. A previous NIHR study found that children with asthma are twice as likely to access unplanned care when returning to school in September as their non-asthmatic counterparts. 

Researchers noticed unplanned care contacts peaked in September and followed a 25% dip in asthma prescription collections in August.

So they wanted to test a way to encourage parents to pick up prescriptions for their children in the August summer holiday, and to use them in the run-up to returning to school. They hoped this would reduce or remove the September peak.

Their intervention of choice was an inexpensive one-off letter sent to the parents of children with asthma from their family GP.

What did this study do?

This cluster-randomised control trial, called PLEASANT, recruited 12,179 children with asthma in England and Wales. Around half (5,917) were randomly assigned to receive the letter, with the rest (6,262), receiving usual care and no letter.

The letter encouraged parents to check their child’s asthma medication was up-to-date and that they take it for at least two weeks before school started.

Planned and unplanned medical contacts were automatically captured using the Clinical Practice Research DataLink, a research database. This links patients’ medical records to prescriptions collected, attendance at hospital, their GP, or other medical services.

Data analysis spanned August 2013 to August 2014 with the main focus on unplanned care in September 2013.

Database records weren’t always complete or coded accurately, but this is unlikely to have changed the overall conclusions.

What did it find?

  • A higher proportion of parents collected steroid inhaler prescriptions in August 2013 having received the letter than not, 16.5% versus 12.6% (adjusted odds ratio [OR] 1.43, 95% confidence interval [CI] 1.24 to 1.64).
  • The proportion of children accessing at least one unscheduled medical contact in September 2013 was no different in those sent the letter than not, 45.2% compared with 43.7% (adjusted OR 1.09, 95% CI 0.96 to 1.25).
  • Over the full year, September 2013 to August 2014, the number of unscheduled and scheduled medical contacts was slightly lower in those sent the letter, 11.5 contacts per child, compared with no letter, 12.1 contacts per child (adjusted incidence rate ratio [IRR] 0.95 95%CI 0.91 to 0.99).
  • Most of the scheduled and unscheduled visits were not asthma related. Over the year, 88% of visits were for a non-respiratory reason in each group.
  • The letter had the opposite effect than intended for some outcomes. For example, the proportion of children with asthma taking up at least one unscheduled medical contact for asthma-related reasons in September 2013 was actually higher in the letter group, 5.3%, compared with no letter 4.2% (adjusted OR 1.30, 95% CI 1.03 to 1.66).
  • The economic analysis used the full year data to predict the letter was 96.3% likely to be cost saving, at an average cost saved of £36.07 per child. No quality of life benefits were predicted for the children.

What does current guidance say on this issue?

A NICE asthma management guideline covering children under five, young people aged five to sixteen and adults diagnosed with asthma is currently in development. Final publication is expected June 2017 and consultation on a draft closes 16 February 2017.

Current draft recommendations on self-management say:

  • Offer an asthma self-management package, comprising a written personalised action plan with supportive education, to adults, young people and children aged five and over with a diagnosis of asthma (and their families or carers if appropriate).
  • Consider an asthma self-management package, comprising a written personalised action plan with supportive education, for the families or carers of children under five with suspected or confirmed asthma.

Advice from Asthma UK reminds parents to maintain children’s asthma medication over the school summer holidays.

What are the implications?

A one-off letter is unlikely to reduce the September peak in unplanned care.

While asthma management is important in its own right, as only a minority of the unplanned care was asthma related, establishing what is behind the majority appears the better strategy to tackle the September peak.

The current draft NICE guideline doesn’t refer to the PLEASANT trial or its economic analysis but recommends written personalised asthma action plans to promote better self-management of asthma, among other recommendations.

Poor adherence to asthma medication is known to be an issue but was not measured in this trial, so still needs attention.

Citation and Funding

Julious SA, Horspool MJ, Davis S, et al. PLEASANT: Preventing and Lessening Exacerbations of Asthma in School-age children Associated with a New Term - a cluster randomised controlled trial and economic evaluation. Health Technol Assess. 2016;20(93):1-154.

This project was funded by the National Institute for Health Research Health Technology Assessment programme (project number 11/01/10).

Bibliography

Asthma UK. Asthma at school and nursery. London: Asthma UK; (undated).

Asthma UK. Your asthma action plan. London: Asthma UK; 2016.

NICE. Asthma management (in development). GID-CGWAVE0743. London: National Institute for Health and Care Excellence; 2017.

NICE. NICE Pathway; Asthma Management. London: National Institute for Health and Care Excellence; 2017.

Why was this study needed?

About 25% of children under 12 have had at least one episode of wheeze or have asthma. A previous NIHR study found that children with asthma are twice as likely to access unplanned care when returning to school in September as their non-asthmatic counterparts. 

Researchers noticed unplanned care contacts peaked in September and followed a 25% dip in asthma prescription collections in August.

So they wanted to test a way to encourage parents to pick up prescriptions for their children in the August summer holiday, and to use them in the run-up to returning to school. They hoped this would reduce or remove the September peak.

Their intervention of choice was an inexpensive one-off letter sent to the parents of children with asthma from their family GP.

What did this study do?

This cluster-randomised control trial, called PLEASANT, recruited 12,179 children with asthma in England and Wales. Around half (5,917) were randomly assigned to receive the letter, with the rest (6,262), receiving usual care and no letter.

The letter encouraged parents to check their child’s asthma medication was up-to-date and that they take it for at least two weeks before school started.

Planned and unplanned medical contacts were automatically captured using the Clinical Practice Research DataLink, a research database. This links patients’ medical records to prescriptions collected, attendance at hospital, their GP, or other medical services.

Data analysis spanned August 2013 to August 2014 with the main focus on unplanned care in September 2013.

Database records weren’t always complete or coded accurately, but this is unlikely to have changed the overall conclusions.

What did it find?

  • A higher proportion of parents collected steroid inhaler prescriptions in August 2013 having received the letter than not, 16.5% versus 12.6% (adjusted odds ratio [OR] 1.43, 95% confidence interval [CI] 1.24 to 1.64).
  • The proportion of children accessing at least one unscheduled medical contact in September 2013 was no different in those sent the letter than not, 45.2% compared with 43.7% (adjusted OR 1.09, 95% CI 0.96 to 1.25).
  • Over the full year, September 2013 to August 2014, the number of unscheduled and scheduled medical contacts was slightly lower in those sent the letter, 11.5 contacts per child, compared with no letter, 12.1 contacts per child (adjusted incidence rate ratio [IRR] 0.95 95%CI 0.91 to 0.99).
  • Most of the scheduled and unscheduled visits were not asthma related. Over the year, 88% of visits were for a non-respiratory reason in each group.
  • The letter had the opposite effect than intended for some outcomes. For example, the proportion of children with asthma taking up at least one unscheduled medical contact for asthma-related reasons in September 2013 was actually higher in the letter group, 5.3%, compared with no letter 4.2% (adjusted OR 1.30, 95% CI 1.03 to 1.66).
  • The economic analysis used the full year data to predict the letter was 96.3% likely to be cost saving, at an average cost saved of £36.07 per child. No quality of life benefits were predicted for the children.

What does current guidance say on this issue?

A NICE asthma management guideline covering children under five, young people aged five to sixteen and adults diagnosed with asthma is currently in development. Final publication is expected June 2017 and consultation on a draft closes 16 February 2017.

Current draft recommendations on self-management say:

  • Offer an asthma self-management package, comprising a written personalised action plan with supportive education, to adults, young people and children aged five and over with a diagnosis of asthma (and their families or carers if appropriate).
  • Consider an asthma self-management package, comprising a written personalised action plan with supportive education, for the families or carers of children under five with suspected or confirmed asthma.

Advice from Asthma UK reminds parents to maintain children’s asthma medication over the school summer holidays.

What are the implications?

A one-off letter is unlikely to reduce the September peak in unplanned care.

While asthma management is important in its own right, as only a minority of the unplanned care was asthma related, establishing what is behind the majority appears the better strategy to tackle the September peak.

The current draft NICE guideline doesn’t refer to the PLEASANT trial or its economic analysis but recommends written personalised asthma action plans to promote better self-management of asthma, among other recommendations.

Poor adherence to asthma medication is known to be an issue but was not measured in this trial, so still needs attention.

Citation and Funding

Julious SA, Horspool MJ, Davis S, et al. PLEASANT: Preventing and Lessening Exacerbations of Asthma in School-age children Associated with a New Term - a cluster randomised controlled trial and economic evaluation. Health Technol Assess. 2016;20(93):1-154.

This project was funded by the National Institute for Health Research Health Technology Assessment programme (project number 11/01/10).

Bibliography

Asthma UK. Asthma at school and nursery. London: Asthma UK; (undated).

Asthma UK. Your asthma action plan. London: Asthma UK; 2016.

NICE. Asthma management (in development). GID-CGWAVE0743. London: National Institute for Health and Care Excellence; 2017.

NICE. NICE Pathway; Asthma Management. London: National Institute for Health and Care Excellence; 2017.

PLEASANT: Preventing and Lessening Exacerbations of Asthma in School-age children Associated with a New Term a cluster randomised controlled trial and economic evaluation

Published on 22 December 2016

Julious SA, Horspool MJ, Davis S, Bradburn M, Norman P, Shephard N

Health Technology Assessment Volume 20 Issue 93 , 2016

Background Asthma episodes and deaths are known to be seasonal. A number of reports have shown peaks in asthma episodes in school-aged children associated with the return to school following the summer vacation. A fall in prescription collection in the month of August has been observed, and was associated with an increase in the number of unscheduled contacts after the return to school in September. Objective The primary objective of the study was to assess whether or not a NHS-delivered public health intervention reduces the September peak in unscheduled medical contacts. Design Cluster randomised trial, with the unit of randomisation being 142 NHS general practices, and trial-based economic evaluation. Setting Primary care. Intervention A letter sent (n = 70 practices) in July from their general practitioner (GP) to parents/carers of school-aged children with asthma to remind them of the importance of taking their medication, and to ensure that they have sufficient medication prior to the start of the new school year in September. The control group received usual care. Main outcome measures The primary outcome measure was the proportion of children aged 5–16 years who had an unscheduled medical contact in September 2013. Supporting end points included the proportion of children who collected prescriptions in August 2013 and unscheduled contacts through the following 12 months. Economic end points were quality-adjusted life-years (QALYs) gained and costs from an NHS and Personal Social Services perspective. Results There is no evidence of effect in terms of unscheduled contacts in September. Among children aged 5–16 years, the odds ratio (OR) was 1.09 [95% confidence interval (CI) 0.96 to 1.25] against the intervention. The intervention did increase the proportion of children collecting a prescription in August (OR 1.43, 95% CI 1.24 to 1.64) as well as scheduled contacts in the same month (OR 1.13, 95% CI 0.84 to 1.52). For the wider time intervals (September–December 2013 and September–August 2014), there is weak evidence of the intervention reducing unscheduled contacts. The intervention did not reduce unscheduled care in September, although it succeeded in increasing the proportion of children collecting prescriptions in August as well as having scheduled contacts in the same month. These unscheduled contacts in September could be a result of the intervention, as GPs may have wanted to see patients before issuing a prescription. The economic analysis estimated a high probability that the intervention was cost-saving, for baseline-adjusted costs, across both base-case and sensitivity analyses. There was no increase in QALYs. Limitation The use of routine data led to uncertainty in the coding of medical contacts. The uncertainty was mitigated by advice from a GP adjudication panel. Conclusions The intervention did not reduce unscheduled care in September, although it succeeded in increasing the proportion of children both collecting prescriptions and having scheduled contacts in August. After September there is weak evidence in favour of the intervention. The intervention had a favourable impact on costs but did not demonstrate any impact on QALYs. The results of the trial indicate that further work is required on assessing and understanding adherence, both in terms of using routine data to make quantitative assessments, and through additional qualitative interviews with key stakeholders such as practice nurses, GPs and a wider group of children with asthma. Funding details This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 93. See the HTA programme website for further project information.

In this study, scheduled visits were defined as any contact that is part of the planned care, for example an asthma review, a medical review, repeat prescription or immunisation.

An unscheduled contact was defined as any contact not part of the care plan, so would include illness or injury. On the advice of a GP Adjudication Panel, ambiguous contacts and those coded as “other” were also included in the unscheduled contacts.

Expert commentary

This is a beautifully simple intervention! A letter was sent to parents in the summer holidays reminding them to maintain or recommence their child’s asthma prevention in readiness for the ‘return-to-school’ peak in viral infections. The letter did not change the primary outcome of unscheduled care in the first month of the new term, but it did engage families in their asthma care. Prescriptions and routine consultations increased, and there was a (non-significant) reduction in acute care later in the year. At a cost per letter of £1.34, there was a 96% chance that the intervention reduced costs overall.

Hilary Pinnock, Professor of Primary Care Respiratory Medicine, University of Edinburgh; General Practitioner, Whitstable Medical Practice

Categories

  •   Child Health, Respiratory disorders