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is clearly a subject for future research: determining whether late diagnosis is a risk factor for asthma severity, attacks and death. NRAD's 19 recommenda- tions The NRAD concluded by making 19 recommendations, which are listed in Table 1. Time will tell whether these will have made an impact on asthma care in the UK. Sadly, although the NRAD was com- missioned by the four UK govern- ments, only one of these 19 recom- mendations has been implemented nationally throughout the UK. A national asthma audit has been com- missioned, though it is unclear when the results will be reported. Hopefully it will not take another 50 years! References 1. Cochrane GM, Clark TJH. A survey of asthma mortality in patients between ages 35 and 64 in the Greater London hospitals in 1971. Thorax. 1975; 30(3):300-5. 2. MacDonald JB, MacDonald ET, Seaton A, Williams DA. Asthma deaths in Cardiff 1963 to 1974: 53 deaths in hospital. British Medical Journal. 1976;2(6038):721-3. 3. Hills A, Sommer AR, Adelstein AM. Death from asthma in two regions of England. British Medical Journal. 1982;285(6350):1251-5. 4. Proceedings of the Asthma Mortality Task Force. November 13-16, 1986, Bethesda, Maryland. Journal of Allergy and Clinical Immunology. 1987;80(3 Pt 2):361-514. 5. Anagnostou K, Harrison B, Iles R, Nasser S. Risk factors for childhood asthma deaths from the UK Eastern Region Confidential Enquiry 2001- 2006. Primary Care Respiratory Journal. 2012;21(1):71-7. Available from: http://www.thepcrj.org/journ/view_arti cle.php?article_id=873. 6. The Global Strategy for Asthma Man- agement and Prevention, Global Initia- tive for Asthma (GINA).2015. Available from: http://www.ginasthma.org. 7. Global Asthma Network. The Global Asthma Report 2014. 2014. Available from: http://www.globalasthmareport .org/resources/Global_Asthma_Report _2014.pdf. Personal asthma action plans (PAAPs): There is good evidence that people who have been provided with a PAAP (which gives information on asthma, medication, how to recog- nize attacks and how to respond, are less likely to be admitted to the hos- pital. Yet 77% of those who died from asthma had no evidence in their notes of provision of such a plan. The lack of a PAAP may ex- plain, in part, why about half of those who died did not call for or receive medical help during their final, fatal attack. Recognition of risk and severity: The risk factors for asthma attacks and deaths have been well docu- mented in national and interna- tional guidelines. 6,10 Some of these are detailed above and many were evident in the conclusions drawn by the panels. Two examples of failure to recognize and act on risk evident in the NRAD were 1) 10% of the deaths occurred within 28 days of hospital discharge for attacks; and 2) at least 21% of the asthma deaths occurred in people who had atten- ded emergency departments in the year before they died. These well- known risk factors were not acted upon; very few of these people were reviewed after treatment for their attacks. Asthma severity is defined by the amount of treatment required to gain control 14 and was found by the NRAD to be underestimated. While asthma in 58% of those who died was classified as mild or moder- ate, less than 20% overall had an assessment of their asthma control; therefore the classification in these cases was unreliable. Age when asthma was diagnosed: Seventy percent of those who died from asthma in the NRAD were diagnosed after 15 years of age and the mean age of diagnosis was 37 years. This was a surprise finding and the authors of the review considered three possible explanations: 1) These people may have had true late-onset asthma; 2) their diagnosis may have been delayed or 3) they may have gone into remission temporarily after having had childhood asthma. This 8. Why Asthma Still Kills: The National Review of Asthma Deaths (NRAD) Confidential Enquiry Report, Royal College of Physicians. London, UK; 2014. Available from: http://www. rcplondon.ac.uk/sites/default/files/why- asthma-still-kills-full-report.pdf. 9. The International Classification of Dis- eases (ICD): World Health Organisation; 2013. Available from: http://www.who.int/ classifications/icd/en/. 10. British Guideline on the Manage- ment of Asthma: A National Clinical Guideline: British Thoracic Society/ Scottish Intercollegiate Guidelines Net- work; 2014 [updated October, 2014]. Available from: http://www.sign.ac.uk/ pdf/SIGN141.pdf. 11. Levy ML, Hardwell A, McKnight E, Holmes J. Asthma patients' inability to use a pressurised metered-dose inhaler (pMDI) correctly correlates with poor asthma control as defined by the Global Initiative for Asthma (GINA) strategy: A retrospective analysis. Prim Care Resp J. 2013;22(4):406-11. Available from: http://www.thepcrj.org/journ/view_arti cle.php?article_id=1069. 12. Melani AS, Bonavia M, Cilenti V, Cinti C, Lodi M, Martucci P, et al. Inhaler mishandling remains common in real life and is associated with reduced disease control. Respiratory Medicine. 2011;105(6):930-88. 13. Molimard M, Gros VL. Impact of patient-related factors on asthma con- trol. Journal of Asthma. 2008;45 (2):109-13. 14. Reddel HK, Taylor DR, Bateman ED, Boulet LP, Boushey HA, Busse WW, et al. An official American Tho- racic Society/European Respiratory Soci- ety statement: Asthma control and exac- erbations—Standardizing endpoints for clinical asthma trials and clinical practice. American Journal of Respiratory and Critical Care Medicine. 2009;180 (1):59-99. Mark Levy, MBChB, FRCGP was Clinical Lead NRAD 2011-2014 and is a General Practitioner with a special interest in respiratory diseases. He is based in London, UK at Kenton Bridge Medical Centre, 155-175 Kenton Road, Middlesex, HA3 0YX, UK, marklevy@animalswild.com, www.consultmarklevy.com. continued from page 28 26 JUNE 2016 Inhalation