6th May 2014

Dr. James PatonUniversity of Glasgow, Clinical Audit Lead, RCPCH

NRAD and ChildrenWhat the Report Means for Paediatric Care

28 Children and Young People Died of Asthma

Age Group<10 yrs 10 (5%)10 – 19 yrs 18 (9%)20 – 44yrs 33 (17%)

45 – 64yrs 50 (26%)

65 – 74yrs 35 (18%)

75 + 47 (24%)

Age 4 – 19 yrs

Many Children Died Before Reaching Hospital

8/10 (80%) children <10 yrs

13/18 (72%) children 10-19 yrs

Even Those With Mild/ Moderate Asthma Were At Risk

Age GroupAsthma Severity <10 years 10 - 19yrsMild 0 0% 1 6%Moderate 3 30% 8 44%Severe 6 60% 7 39%Not Known 1 10% 2 11%Total 10 100% 18 100%

12/28 (42%) of children who died were thought to have mild / moderate asthma

How Did the Children Die?

“Asthma Attacks”Only 4 / 28 (14%) children had a record ofbeing provided with an Asthma Action Plan

-How to spot when symptoms are getting worse-What to do when symptoms worsen-What to do in an emergency-When to call for emergency help

Targeting Lung Attacks Fitzgerald Thorax 2011;66: 365-66

Avoidable Factors – Families & Environment

Factors Under 10yrs 10 - 19yrsOne or More Avoidable Factors 9 (90%) 17 (94%)Poor Adherence to Medical Advice 9 (90%) 13 (72%)- Failure to Take Appropriate

Medications4 (40%) 13 (72%)

Psychosocial factors 3 (30%) 4 (22%)Passive smoke exposure 3 (30%) 7 (39%)

Allergy - Animals - Food allergy - Seasonal

2 (20%)0 (0%)0 (0%)

2 (20%)

7 (39%)2 (11%) 2 (11%) 6 (33%)

Adherence Matters!

• ICS Adherence >80% was associated with better asthma control

• Children with persistent mild symptoms had lower ICS adherence rates (p = .028)

ERJ 2014; 43: 783-91

Daily Hospital Admissions for Asthma among Children between 2000 and 2009 in Scotland

Mackay et al N Engl J Med 2010; 363:1139-1145

Avoidable Factors – Ongoing Medical Care/SupervisionFactors <10yrs

N (%)10 - 19yrs

N (%)1ry 2ry 1ry 2ry

One or More Avoidable Factors

8 (80) 4 (57) 16 (89) 4 (44)

- Did Not Check Inhaler Technique

3 (30) 2 (29) 2 (11) 2 (22)

- Did Not Identify Triggers 0 (0) 1 (14) 6 (33) 2 (22)

Asthma Deaths and Time of Year

Quality of Care – Panel ConclusionsConclusion All ages

(195)0-19(28)

Chronic Management - Adequate 56 (29%) 2 (7%)

Previous Attack Management- Adequate 69 (35%) 8 (29%)*

Final Attack Management- Adequate 66 (34%) 13 (46%)*

Overall Standard of Asthma Care- Good practice 31 (16%) 1 (4%)

Trends in Childhood Asthma Deaths Have Been Downwards

But Children with Asthma Are Still Dying

2012 – 17 CF deaths in children <20 yrs1

2012 – 28 Asthma deaths in children <20yrs

1UK Cystic Fibrosis Registry Annual data report 2012

What Does the Report Mean for Paediatric Care?1. Always remember – children die of asthma – “Asthma

Attacks” can kill2. Everyone should have an asthma action plan3. Good adherence can be achieved, and does matter4. Passive smoking is bad for children with asthma5. Do not forget psychosocial factors & asthma triggers6. Meticulous attention to asthma guidelines will save

lives

Expertise No.

Paediatricians (general, respiratory, allergy, intensive care and emergency care)

21

Adult physicians (general, respiratory, allergy, intensive care and emergency

67

General Practitioners 34

Pharmacists 2

Primary care nurses (specialist asthma and respiratory) 25

Secondary care nurses (consultants, paediatric nurses, specialist adult and paediatric asthma and respiratory nurses )

24

Clinical Lecturers 1

Total 174

NRAD Confidential Enquiry Panels

Coding Accuracy - Panel vs Coding