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Studies in the United Kingdom over the last 50 years have repeat- edly demonstrated that between 60- 90% of asthma deaths are associated with major preventable factors. 1-5 Known asthma risk factors include: previous attacks, past admission to intensive care, excess use of short- acting reliever medication, insuffi- cient use of preventer medication, poor lung function, raised eosino- phil count, pregnancy and poor inhaler technique. 6 The NRAD commission In high income countries world- wide, New Zealand, the United States and the UK have the highest age-standardized mortality rates for asthma in people age 5 to 34 years. 7 Consequently, the Healthcare Quality Improvement Partnership (HQIP) on behalf of the four gov- ernments of the UK (England, Ire- land, Scotland and Wales) commis- sioned the National Review of Asthma Deaths (NRAD). 8 The aim of NRAD, a confidential enquiry, was to learn from UK asthma- related deaths and to take appropri- ate action to prevent future events. Selection of cases With ethical committee approval, details of all 3,544 deaths in the UK with the word "asthma" on death certificates during a 12-month period beginning in February 2012 w e r e o b t a i n e d . T h o s e p e o p l e (n=2,644) whose deaths were either not classified with asthma as the underlying cause of death or who were over age 75 when asthma was recorded in part II of their medical certificate of asthma death were excluded. The remaining 900 peo- ple for whom asthma was classified as the underlying cause of death (ICD-10, J45) 9 were selected for fur- ther consideration, and detailed medical information was requested from the doctors caring for them. After excluding 352 cases (39%) in which people clearly did not die from asthma, and a further 272 cases (30%) in which insufficient data had been returned by the doctors, 276 cases (31%) were considered in detail by panels of clinicians and pharmacists from primary, sec- ondary and tertiary care. On the basis of the medical records, the review panels agreed whether those people had asthma or died from asthma (195 cases) and if so, what lessons could be learned. These details cast serious doubt on the accuracy and validity of the current system for classifying asthma deaths. The UK is planning to introduce a system whereby, in the future, doc- tors will have to provide sufficient clinical evidence to confirm the accuracy of the certified cause of death. Disappointing similar results Considering that the UK has had asthma guidelines since 1990, the results were disappointingly similar to those of the aforementioned stud- ies of the last five decades (references 1-5). Sixty percent of the 195 con- firmed asthma deaths had at least one major preventable factor present across the primary/secondary health- care interface. NRAD findings included problems related to pre- scribing, medical reviews, personal asthma action plans (PAAPs), recog- nition of risk and severity, and a sig- nificant minority of people who were diagnosed in their 30s, as follows. Preventable factors Prescribing: The number of doses (puffs) per week of short-acting bronchodilator (SABA) reliever medication is a marker for current asthma symptom control. 6,10 A per- son using four or fewer puffs per week is considered to have good cur- rent control (i.e., less than two SABA 200-dose inhalers per year). Of the 195 deaths investigated, 39% and 56% of those who died were prescribed more than 6 SABA in- halers and 12 SABA inhalers respec- tively in the year before death. Con- versely, most were prescribed insuf- ficient preventer medication (in- haled corticosteroids). In the 128 patients for whom details were avail- able, prescriptions for a median of o n l y 5 i n h a l e d c o r t i c o s t e r o i d inhalers were given in the final year. Patients prescribed inhalers contain- ing 4 and 12 weeks of medication respectively, would have required 4 or 12 of these devices per year. Medical reviews: An asthma review aims to ascertain the level of control and risk in patients with asthma, including their inhaler technique, which if poor contributes to poor asthma control. 11-13 Less than half of those who died had evidence in their medical record of an asthma review in the year before death. Lessons from UK asthma deaths: Improving asthma care Mark Levy, MBChB, FRCGP Clinical Lead NRAD 2011-2014 and General Practitioner London, United Kingdom continued on page 26 BACK • PAGE 28 JUNE 2016 Inhalation