Dear Sirs,

Preventable factors related to asthma deaths have been known for over 50 years.1–3 These relate to clinical management — both acute and chronic and patients' own understanding and care of their condition. With excellent evidence-based UK guidelines (http://www.sign.ac.uk/pdf/sign101.pdf) and an international strategy (http://www.ginasthma.org/) for management of asthma, it is surprising that preventable factors are still identified in asthma deaths in the UK.

The study by Anagnostou et al.4 (published online initially and now in this issue of the PCRJ) has identified factors contributing to asthma death in 20 children between 2001 and 2006 in the Eastern Region of the UK. 35% of the children were taking long acting β-agonist (LABA) treatment without an inhaled corticosteroid (ICS), two of whom had not been prescribed ICS in accordance with prescribing advice. Only 30% of the children had been given a written asthma management plan, and only 25% had peak flow measurement recorded within a year of death. 30% of the children had poorly controlled asthma despite treatment, and follow up was considered inadequate by the authors in 40%.

Asthma seems to have fallen off the radar, and health professionals (as well as health care managers) have perhaps become complacent about the management of asthma. In the UK, the Quality Outcomes Framework (QOF) rewards primary care practices financially for attaining targets; in asthma, over 90% of primary care practices have attained most of the incentive points for asthma (http://www.qof.ic.nhs.uk/). This care includes an annual asthma review, provision of an asthma self-management action plan, an assessment of the patient's ability to use their inhaler, and an assessment of asthma control.

In their linked editorial,5 Stephenson and Shields propose the creation of asthma at-risk registers as a possible solution to reducing preventable asthma deaths. Unfortunately I cannot agree. Many studies on asthma deaths, including the Anagnostou et al. paper in this issue,4 found a high proportion of deaths (nearly 50%) in mild-to-moderate cases. Therefore, I believe that many of the risk factors would not apply and at-risk asthma registers will deny quality care for the most at-risk patients.

In my opinion, what we need is a wake-up call for health professionals to stimulate greater adherence to evidence-based guidelines. A recent paper by the GINA implementation group addresses this issue.6 In the UK, the process outcomes for asthma that determine incentive payments should perhaps be supplemented by outcomes based on evidence of quality of care, and in particular implementation of evidence-based guidelines — for example, evidence that asthma control has been assessed and that steps have been taken by the clinician to improve control in poorly controlled patients. Another example would be evidence that patients have been provided with written asthma action plans detailing the frequency of medication, recognition of danger signs, and what action to take when at risk of an attack.

The UK Department of Health has funded a new landmark National Review of Asthma Deaths (NRAD). This review — which includes in-depth audit, a multidisciplinary confidential inquiry, and interviews of a sample of bereaved families — is investigating all deaths due to asthma in all age-groups in the UK for 12 months from 1st February 2012. The NRAD will investigate the circumstances and management of the fatal attacks, and also the quality of care provided in the preceding 12 months. It will also help us understand why people of all ages die from asthma so that recommendations can be made to prevent deaths from asthma in the future.

Participation in the NRAD offers health professionals working in the UK an opportunity to contribute to our understanding of these deaths as well as to the recommendations we will make. We are particularly keen to hear from interested primary care health professionals. Please contact us at www.rcplondon.ac.uk/nrad.