Virtual asthma and COPD reviews

Virtual asthma and COPD reviews in general practice allow for a more patient-focused consultation, with patients feeling more relaxed and honest with their GP

Asthma and COPD are two conditions which are ideal for virtual consultations. Both conditions have been the subject of many research studies over the last 20 years to address the issues of non-attendance at both primary and secondary care level appointment.

“Every asthma consultation is an opportunity to review, reinforce and extend both the patient’s knowledge and skills. It is important to recognise that education is a process and not a single event” (BTS/SIGN 2019).

Ryan et al 2013 proposed a universal structured approach to a primary care asthma review – ‘SIMPLES’. SIMPLES is an acronym for Smoking, Inhaler technique, Monitoring, Pharmacotherapy, Lifestyle, Education, and Support.

It can be adapted to the current situation where face-to-face in person reviews may not be possible or even necessary for the majority of those with asthma. It allows an increased patient-focused approach whilst gathering the required information.

Anecdotally, healthcare professionals have noticed that patients are more relaxed and more honest during a virtual consultation as they are away from the clinical environment and have not been waiting in a packed waiting room. This article will address the finer points for undertaking virtual asthma and COPD reviews.

It will also provide a number of resources, which can be used throughout the virtual consultation.

Undertaking an effective asthma review

▸ Identify how you will deliver the remote review, eg, will it be through video consultation or telephone?

▸ In preparation for the consultation, briefly gather information from the medical record and prescribing data to assess morbidity and compliance, looking at short-acting bronchodilator use (SABA). You can assess the patient’s reliance on SABA using the Asthma Slide Ruler. This ruler can also be downloaded from: www.pcrs-uk.org/resource/asthma-slide-rule.

▸ At the time of booking the appointment for the virtual asthma review, check if the patient has an Asthma Action Plan and if they are using it. If the patient does not have an Asthma Action Plan, this can be completed by the practice nurse/GP in advance of the appointment and posted to the patient. Inform the patient that you will be referring to it and discussing it during the consultation.

▸ Start off with an introduction and establish if the patient has access to the Internet as this will be useful to signpost them to educational resources and support, both during (where appropriate) and/or after the consultation. Ask how the patient has been since their last review.

▸ Assessing asthma control – use the Asthma Control Test (ACT) and/or the GINA Assessment of Asthma Control to monitor the patient’s asthma. The ACT can be sent to the patient (or text a link to www.asthma.com) beforehand so it can be discussed during the consultation. An ACT score of less than 19 (scored out of 25) indicates uncontrolled or poorly controlled asthma. If the patient has a peak flow metre, you can ask them to carry out the test and you can work out their percentage.

▸ Explore key triggers that make their asthma worse, including where appropriate, smoking, which is a key element. Ask if there are any occupational or seasonal triggers, which impact their asthma control, and whether avoidance or reduction of these is practicable or acceptable to the patient.

▸ Check the patient’s understanding around the role of each medication in helping their asthma including dosing information and when they should be taking their medication. Explore the Asthma Action Plan and assess the patient’s understanding of when they should increase medication. Ask the patient about SABA use – using salbutamol more than twice a week indicates poor asthma control and an over reliance on salbutamol. If the patient is over reliant on salbutamol inform them of the risks of acute asthma attacks and fatal asthma events in the future.

▸ Ask about inhaler use and technique. Use videos to support your discussion where access is available and signpost people. Inhaler technique videos are available on www.asthma.ie/about-asthma/resources/inhaler-technique-videos. If using video for the virtual consultation, you can check the inhaler technique and also demonstrate inhaler technique.

▸ Ask the patient about flare ups, days off work or school and establish what this means for your patient in terms of impact on their lifestyle. Ensure that the patient understands the five step rule.

▸ Discuss vaccinations in line with current recommendations.

▸ Assessment of control will naturally lead to a discussion with the patient about pharmacotherapy. You will need to consider stepping up or down of treatment as per GINA guidelines (2020).

▸Signpost the patient to any additional psychosocial support where appropriate. Advise the patient to use the Asthma Society of Ireland website for further resources (www.asthma.ie). Patients can also message the Beating Breathlessness WhatsApp service on 086 0590132 or phone the Asthma Adviceline on 1800 44 54 64 for further support.

▸ Discuss any follow-up and arrange review date.

▸ Summarise the discussion at the end of the review.

Undertaking an effective COPD review

▸ Identify how you will deliver the remote review, eg, will it be through video consultation or telephone?

▸ In preparation for the consultation, briefly gather information from the medical record and prescribing data to assess morbidity and compliance.

▸At the time of booking the appointment for the virtual COPD review, check if the patient has a COPD Communication Card and if they are using it. If the patient does not have a COPD Communication Card, this can be completed by the practice nurse/GP in advance of the appointment and posted to the patient. Inform the patient that you will be referring to it and discussing it during the consultation.

▸Start off with an introduction and establish if the patient has access to the Internet as this will be useful to signpost them to educational resources and support, both during (where appropriate) and/or after the consultation. Ask how the patient has been since their last review.

▸Assessing COPD – the COPD assessment test (CAT) can be used to assess the impact COPD is having on the patient’s life. It can be downloaded from: www.catestonline.org. The higher the CAT score (scored out of 40), the higher the impact COPD is having on the patient’s quality-of-life. The Medical Research Council Dyspnoea score (MRC) score can be used to assess the level of dyspnoea the patient is experiencing.

▸Ask about exacerbations in the previous 12 months and if they required admission to hospital. Early recognition and treatment of exacerbations of COPD is key to avoiding hospital admission and the complications associated with hospital admission. Assess if the patient is on the right treatment according to the ABCD classification (GOLD, 2020). Refer to GP for further advice if necessary.

▸Check the person’s understanding around the role of each medication in helping their COPD, including dosing information and when they should be taking their medication. Explore the COPD Communication Card and COPD Self-Management Plan (available for download on www.hse.ie) and assess the patient’s understanding of when they should increase medication.

▸Ask about inhaler use and technique. Use videos to support your discussion where access is available and signpost people. Inhaler technique videos are available on www.asthma.ie/about-asthma/resources/inhaler-technique-videos. If using video for the virtual consultation, you can check the inhaler technique and also demonstrate inhaler technique.

▸Ask about smoking cessation and provide brief intervention strategies if appropriate.

▸Discuss vaccinations in line with current recommendations.

▸Signpost the patient to any additional psychosocial support where appropriate. Advise the patient to use the COPD Support Ireland website for further resources (www.COPD.ie). Patients can also message the Beating Breathlessness WhatsApp service on 086 0590132 or phone the COPD Adviceline on 1800 83 21 46 for further support.

▸Discuss any follow-up and arrange review date.

▸Summarise the discussion at the end of the review.

Conclusion

Virtual reviews for chronic disease management have become a regular feature in the day-to-day running of general practice. This article has addressed the components of virtual asthma and COPD reviews. It has signposted the healthcare practitioner to various resources, which will assist in carrying out virtual reviews.