General practitioner views on barriers and facilitators to implementation of the Asthma 3+ Visit Plan

Australia has a high prevalence of asthma by international standards. The most recent national data are that 14%–16% of children and 10%–12% of adults have a diagnosis of asthma that remains a current problem.1 There has been a focus on asthma care through the six-step Australian Asthma Management Plan, first published more than a decade ago,2 and widely disseminated to general practitioners through the work of the National Asthma Council (NAC). This work has included publishing the Asthma management handbook3 and proformas for written asthma action plans.

Funding was announced in the 2001 federal budget for a general practice asthma initiative through the Practice Incentives Program (PIP) to support improved asthma care and use of the Australian Asthma Management Plan. The funding ($22.7 million over 4 years for general practice aspects) supports GPs implementing the Asthma 3+ Visit Plan developed by the NAC’s General Practitioners Asthma Group.4 The Asthma 3+ Visit Plan introduces a “contract for care” between GPs and patients with asthma, which includes plans for regular review of asthma symptoms and treatment.

The PIP asthma incentive payments are restricted to supporting better management of moderate to severe asthma. Starting from November 2001, the incentives include a sign-on component and a Service Incentive Payment (SIP). For a GP to claim the Asthma 3+ Visit Plan SIP (SIP-asthma), a patient must have at least three asthma-related consultations over 4 weeks to 4 months. These consultations need to cover diagnosis and assessment of severity, review of asthma-related medication, provision of a written asthma action plan, and education of the patient.

Figures from the Health Insurance Commission (HIC) show that in November 2001, around 60% of the PIP-registered general practices in Australia had signed on for the asthma incentive. This had increased to about 90% of practices by November 2004.

The proportion of practices signed up for diabetes and cervical screening incentives has followed a very similar pattern. However, claims for the SIP-asthma have been declining compared with cervical screening and diabetes SIP claims (Box 1).

For the Asthma 3+ Visit Plan to be effective and achieve the desired outcomes, the practitioner, practice and patient all need to participate. We aimed to examine GP and practice factors associated with uptake of the Asthma 3+ Visit Plan, and to examine GPs’ views on the barriers and facilitators to implementing the plan.

A questionnaire for GPs on the Asthma 3+ Visit Plan was developed with input from GP members of the Primary Health Care Research Network (PHReNet). The survey was piloted with 10 GPs who were members of PHReNet, but had not been part of the development group.

GPs were surveyed sequentially in five Divisions of General Practice in metropolitan Sydney (Fairfield, Bankstown, Western Sydney, Liverpool and St George) commencing with Fairfield in October 2002 and concluding with St George in May 2003. The sequential process was necessary to fit in with other activities being conducted by the Divisions. Of the 1341 GPs on the databases held by these Divisions, 315 were randomly selected to be sent the survey. The initial mail-out was followed by three mailed reminders sent at 2-week intervals. Non-respondents were then telephoned by members of the research team and sent the questionnaire by facsimile if they agreed to participate.

Of the 315 GPs selected, 51 were not contactable or not currently in general practice. Of the remaining 264, 147 (55.7%) responded. Respondents were predominately male (106; 72.1%) and their mean age was 50.5 years (range, 30–80 years). Mean duration of experience in general practice was 20.1 years (range, 3–56 years). Most (112; 76.2%) were vocationally registered, but only 48 (32.7%) held a RACGP fellowship. Most respondents (115; 78.2%) worked full-time in the practice at which they were contacted, and 89 (60.5%) were in group practice.

The GPs came from 133 different practices; 95 practices (71.4%) were accredited and 38 (28.6%) employed a practice nurse. Seventy-seven practices (57.9%) had signed on for the asthma incentive. Most practices used a computer system for clinical care (99; 74.4%), but only 39 (29.3%) had a chronic disease register for asthma. One hundred and 10 practices (82.7%) provided educational materials for their patients with asthma, but only 35 (26.3%) had multilingual materials available.

There is evidence that proactive care, combined with written asthma action plans and training in self-management, improves outcomes for adults with asthma.6 The Asthma 3+ Visit Plan has not been the subject of controlled evaluation in adults, but the impact of the plan has been examined in a cluster randomised trial in children.7 This study found an increase in asthma-related consultations, written asthma action plans and completed Asthma 3+ Visit Plans in the intervention group. The study also provided evidence of better asthma control, with smaller reductions in FEV1 (forced expiratory volume in 1 second) after cold air challenge, fewer emergency department attendances for asthma, and less speech-limiting wheeze in the intervention compared with the control group. Furthermore, the study reported that the delivery of interventions was variable, with only 28% of children in the intervention group actually completing the Asthma 3+ Visit Plan and another 20% partially completing it.

Thus, the Asthma 3+ Visit Plan can improve asthma care, but completing the plan is problematic, even in a clinical trial setting. For the plan and the incentives that support it to be effective, there needs to be participation all round, with the practitioner and practice needing to adapt to this organised approach, and patients needing to be willing to complete the contracted visits and make the necessary self-management changes to improve control of their asthma. The HIC data shown in Box 1 suggest that achieving all this is proving difficult, with a lower and declining number of claims for the GP asthma incentive compared with the diabetes and cervical screening incentives.

Our findings shows that there are characteristics of practitioners and practices that are associated with use of the Asthma 3+ Visit Plan. For practitioners, these include use of and confidence in implementing the six-step Australian Asthma Management Plan. This makes sense, as the Asthma 3+ Visit Plan is essentially a way of translating the six-step plan into a series of general practice consultations, and it builds on GPs’ pre-existing knowledge of the six-step plan. The association between uptake and practice accreditation is not surprising, as accreditation is a prerequisite for enrolment in PIP, and thus for access to the incentive payment. Computerisation may be a marker of practices which are more likely to have the organisational capacity to take up incentives such as the Asthma 3+ Visit Plan.

Our study shows that although there is a high level of awareness and a substantial number of GPs have used the Asthma 3+ Visit Plan, the workload and paperwork, and the perceived administrative burden of the incentive are seen as major barriers to implementation. This appears to be an example of where “red tape” associated with an incentive payment is detracting from the value of the program, and raises the question of whether there is a limit to the number of single-condition incentive programs that can be sustained in general practice. The administrative burden of incentive programs has been the subject of debate,8 and our findings provide further evidence that administrative bureaucracy is a barrier to the success of such programs. Simplifying the administrative requirements, and having a more integrated chronic disease incentive program that includes a number of conditions, should be considered.

Our study also shows that GPs believe illness severity and illness behaviour and attitudes are important determinants of whether people with asthma complete the Asthma 3+ Visit Plan. The factors most frequently rated as important or extremely important (by more than 75% of GPs surveyed) were the patient’s concept of the severity of their asthma, adherence to follow-up and medication, and attitude to planned versus episodic care of asthma. Information and education about the Asthma 3+ initiative has been aimed predominantly at health professionals, especially GPs, and through them to people with asthma. Whether this is enough, or whether other strategies (such as more intensive individual education or a marketing campaign for the public) are needed, deserves consideration.

We did not evaluate whether the barriers to uptake can be overcome through education or other support from the NAC or Divisions of General Practice. Nor did we examine whether GPs or patients perceive the Asthma 3+ Visit Plan and the incentive payment as beneficial for asthma care. Further work is needed to answer these questions. However, it is clear that review and modification of the asthma incentive or the Asthma 3+ Visit Plan will be needed if structured care for asthma is to be widely implemented in general practice in Australia.

1 Service Incentive Payment claims made by general practitioners in Australia for Asthma 3+, diabetes and cervical screening from November 2001 to March 2005

Source: Health Insurance Commission online data.5