1. 6 th May 2014 Dr. James Paton University of Glasgow, Clinical Audit Lead, RCPCH NRAD and Children What the Report Means for Paediatric Care

2. 28 Children and Young People Died of Asthma Age Group <10 yrs10 (5%) 10 – 19 yrs18 (9%) 20 – 44yrs33 (17%) 45 – 64yrs50 (26%) 65 – 74yrs35 (18%) 75 +47 (24%) Age 4 – 19 yrs

3. Many Children Died Before Reaching Hospital 8/10 (80%) children <10 yrs 13/18 (72%) children 10-19 yrs

4. Even Those With Mild/ Moderate Asthma Were At Risk Age Group Asthma Severity<10 years10 - 19yrs Mild00%16% Moderate330%844% Severe660%739% Not Known110%211% Total10100%18100% 12/28 (42%) of children who died were thought to have mild / moderate asthma

5. How Did the Children Die? “Asthma Attacks” Only 4 / 28 (14%) children had a record of being 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

6. Avoidable Factors – Families & Environment Factors Under 10yrs10 - 19yrs One or More Avoidable Factors 9 (90%)17 (94%) Poor Adherence to Medical Advice 9 (90%)13 (72%) - Failure to Take Appropriate Medications 4 (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%) 2 (20%) 7 (39%) 2 (11%) 6 (33%)

7. 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

8. Daily Hospital Admissions for Asthma among Children between 2000 and 2009 in Scotland Mackay et al N Engl J Med 2010; 363:1139-1145

9. Avoidable Factors – Ongoing Medical Care/Supervision Factors <10yrs N (%) 10 - 19yrs N (%) 1ry2ry1ry2ry 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)

10. Asthma Deaths and Time of Year

11. Quality of Care – Panel Conclusions ConclusionAll 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%)

12. Trends in Childhood Asthma Deaths Have Been Downwards

13. But Children with Asthma Are Still Dying 2012 – 17 CF deaths in children <20 yrs 1 2012 – 28 Asthma deaths in children <20yrs 1 UK Cystic Fibrosis Registry Annual data report 2012

14. What Does the Report Mean for Paediatric Care? 1.Always remember – children die of asthma – “Asthma Attacks” can kill 2.Everyone should have an asthma action plan 3.Good adherence can be achieved, and does matter 4.Passive smoking is bad for children with asthma 5.Do not forget psychosocial factors & asthma triggers 6.Meticulous attention to asthma guidelines will save lives

15. Expertise No. Paediatricians (general, respiratory, allergy, intensive care and emergency care) 21 Adult physicians (general, respiratory, allergy, intensive care and emergency 67 General Practitioners34 Pharmacists2 Primary care nurses (specialist asthma and respiratory)25 Secondary care nurses (consultants, paediatric nurses, specialist adult and paediatric asthma and respiratory nurses ) 24 Clinical Lecturers1 Total 174 NRAD Confidential Enquiry Panels

16. Coding Accuracy - Panel vs Coding