Paediatric asthma outpatient care by asthma nurse, paediatrician or general practitioner: randomised controlled trial with two-year follow-up. Use of an 'evidence-based implementation' strategy to implement evidence-based care of asthma into rural district hospital emergency departments. Randomised controlled trial of general practice based asthma clinics. Trial of nurse-run asthma clinics based in general practice versus usual medical care. Effect of computerised evidence based guidelines on management of asthma and angina in adults in primary care: cluster randomised controlled trial. Asthma at the interface: bridging the gap between general practice and a district general hospital. Educational outreach to general practitioners reduces children's asthma symptoms: a cluster randomised controlled trial. Improved asthma outcomes in a high-morbidity pediatric population: results of an emergency department-based randomized clinical trial. Improving care for minority children with asthma: professional education in public health clinics.
For children with stable asthma, to test non-inferiority of care provided by a hospital-based specialised asthma nurse versus a general practitioner (GP) or paediatrician.
                Randomised controlled trial evaluating standard care by a GP, paediatrician or an asthma nurse, with two-year follow-up.
                107 children were recruited, 45 from general practice and 62 from hospital. After two years, no significant differences between groups were found for airway responsiveness, FEV1, asthma control, medication, school absence or parental work absence. In the general practice group there was a significantly lower frequency of regular review visits ('regular' = at least one review per six months) compared to the paediatrician and specialised asthma nurse group, both after one year [45.7% versus 87.9% and 94.3%, respectively, (p<0.0005)] and after two years [26.5% versus 87.9% and 75.8%, respectively, (p<0.0005)]. We found no significant differences in unplanned visits. In most cases the asthma nurse was able to provide care without consultation with the paediatrician.
                The degree of disease control in stable childhood asthma managed by an asthma nurse is not inferior to traditional management by primary or secondary care physicians. The results also suggest that a lower review frequency does not detract from good disease control. To determine if an evidence-based implementation (EBI) could lead to the successful implementation of evidence based care for adult asthma in small rural district hospitals.
                A controlled trial involving eight small rural hospitals (four each in the study and control groups) was conducted. Retrospective pre-intervention audits were conducted at all eight hospitals for 7 months (1 January 2004 to 31 July 2004) and evidence-practice gaps identified. An EBI was then used to implement established guidelines for the management of asthma in the study hospitals. Post-intervention audits were then performed over a period of 7 months (1 October 2004 to 31 April 2005).
                There were 52 presentations of asthma in the study hospitals in the pre-implementation phase and 47 post-implementation. The corresponding numbers for the control hospitals were 46 and 42 respectively. There were no statistically significant differences in the severity between the groups. Following the EBI there were significant improvements at the study hospitals for the documentation of severity (8% to 62%, p <0.001), use of spirometry (12% to 62%, p <0.001) and the use of written short-term asthma plans (9% to 26%, p = 0.05). There was a decrease in use of ipratropium in mild asthma (44% to 30%, p = 0.228), an increase in the use of systemic steroids (61% to 72%, p = 0.255) and no change in prescribing antibiotics for afebrile patients with asthma (21% to 21% p = 0.956). There was no significant change in practice at the control hospitals except for a decrease in the use of systemic steroids (48% to 21%, p = 0.011). For the six clinical indicators aggregate there was a significant increase in compliance with guidelines at the study hospitals (36% to 62%, p < 0.001) but no change at the control hospitals (31% to 31%, p = 0.970).
                The pre-intervention audits demonstrated low levels of compliance with asthma guidelines across six clinical indicators. An EBI significantly improved compliance across these six indicators, and no improvement was noted in the control hospitals. This study demonstrates that an EBI can alter clinical practice in small rural district hospitals. To compare the effects on asthma morbidity of asthma clinics based in general practice with standard general practice care.
                A randomised controlled trial in eight general practices. Patients, general practitioners and outcomes assessors were not blinded to treatment allocation.
                195 patients with asthma aged 5-64 years; 191 completed the trial.
                Three asthma clinic sessions over six months involving nurse counselling, education about asthma management, spirometry and consultation with the general practitioner.
                Patients reporting days lost from work or school, number of days lost, the presence of morning or nocturnal asthma symptoms, use of an action plan, medication use, current smoking, hospitalisation, and emergency visits.
                Asthma clinics were associated with a greater reduction in nocturnal symptoms, an increase in the ownership of peak flow meters and an increase in the number of patients commencing or resuming smoking. Both control and intervention groups showed similar improvement in days lost from work or school, the presence of symptoms, use of an action plan and taking reliever medication.
                Our study does not show that asthma clinics are more effective than standard general practice care in reducing asthma morbidity. It is uncertain how much of the improvement in outcomes was due to the asthma clinic, the influence of the study itself upon patients and practitioners, or other factors, such as the tendency for a patient's asthma management to improve over time. The aim of this study was to assess the ability of nurse-run asthma clinics based in general practice compared with usual medical care to produce at least a moderate improvement in the quality of life of adults with asthma.
                A randomized controlled trial involving 80 asthma clinic and 90 usual medical care asthma participants, aged 18 years and older was conducted in 11 general practices in Adelaide. The main outcome measure was the St George's respiratory questionnaire (SGRQ), from which quality-of-life scores were used to assess therapeutic benefit. Lung function measurements and health services utilization data were also collected.
                One hundred and fifty-three participants (90%) were reviewed at follow up after 6-9 months. There was little difference between groups in baseline measures or for the 6-month follow-up outcomes, including the mean difference in total SGRQ scores (-0.5, 95% confidence interval (CI) -4.0, 2.9) and the mean difference in percentage predicted FEV(1) (2.3%, 95% CI -0.7, 5.3 pre-bronchodilator; 0.4%, 95% CI -5.1, 5.9 post-bronchodilator). Trends in health services utilization were noted.
                Nurse-run asthma clinics based in general practice and usual medical care were similar in their effects on quality of life and lung function in adults. These findings cannot be generalized to hospital outpatients and other clinics that manage more severe asthmatic patients. To evaluate the use of a computerised support system for decision making for implementing evidence based clinical guidelines for the management of asthma and angina in adults in primary care.
                A before and after pragmatic cluster randomised controlled trial utilising a two by two incomplete block design. Setting: 60 general practices in north east England.
                General practitioners and practice nurses in the study practices and their patients aged 18 or over with angina or asthma.
                Adherence to the guidelines, based on review of case notes and patient reported generic and condition specific outcome measures.
                The computerised decision support system had no significant effect on consultation rates, process of care measures (including prescribing), or any patient reported outcomes for either condition. Levels of use of the software were low.
                No effect was found of computerised evidence based guidelines on the management of asthma or angina in adults in primary care. This was probably due to low levels of use of the software, despite the system being optimised as far as was technically possible. Even if the technical problems of producing a system that fully supports the management of chronic disease were solved, there remains the challenge of integrating the systems into clinical encounters where busy practitioners manage patients with complex, multiple conditions. A clinic supervised by a nurse, using principles originally developed in general practice, was established in the paediatric department of a district general hospital. A randomised controlled study was conducted comparing children admitted with asthma or attending outpatients who were given a patient education programme and self management plan (intervention group) with a control group. The study comprised 91 patients aged 3-14 years admitted for asthma or attending a hospital outpatient department from November 1989 to November 1990. Seventy seven patients completed the study and kept diaries for a median of 283 days. Patients in the intervention group had significantly less restriction of activity (95% confidence interval (CI) -0.27 to -0.01) and fewer episodes of peak flow below 30% of best (95% CI 0.03 to 1.17). Patients in the intervention group were more likely to make the correct response to an acute exacerbation of their asthma than the control group (71% v 47%, 95% CI 9.51 to 39.1). The intervention group had fewer school absences and fewer home visits by a general practitioner. There was an increase in the readmission rate for the intervention group. A subgroup of patients who self managed by doubling their use of inhaled steroids during an exacerbation performed better than those patients who only increased their bronchodilator or were managed on salbutamol or sodium cromoglycate alone. Improvements in patient follow up and the structure of the self management plans used, particularly changing the peak flow level at which inhaled steroids are doubled, may further improve the outcome of patients attending the asthma clinic. Childhood asthma is common in Cape Town, a province of South Africa, but is underdiagnosed by general practitioners. Medications are often prescribed inappropriately, and care is episodic. The objective of this study is to assess the impact of educational outreach to general practitioners on asthma symptoms of children in their practice.
                This is a cluster randomised trial with general practices as the unit of intervention, randomisation, and analysis. The setting is Mitchells Plain (population 300,000), a dormitory town near Cape Town. Solo general practitioners, without nurse support, operate from storefront practices. Caregiver-reported symptom data were collected for 318 eligible children (2 to 17 years) with moderate to severe asthma, who were attending general practitioners in Mitchells Plain. One year post-intervention follow-up data were collected for 271 (85%) of these children in all 43 practices. Practices randomised to intervention (21) received two 30-minute educational outreach visits by a trained pharmacist who left materials describing key interventions to improve asthma care. Intervention and control practices received the national childhood asthma guideline. Asthma severity was measured in a parent-completed survey administered through schools using a symptom frequency and severity scale. We compared intervention and control group children on the change in score from pre-to one-year post-intervention.
                Symptom scores declined an additional 0.84 points in the intervention vs. control group (on a nine-point scale. p = 0.03). For every 12 children with asthma exposed to a doctor allocated to the intervention, one extra child will have substantially reduced symptoms.
                Educational outreach was accepted by general practitioners and was effective. It could be applied to other health care quality problems in this setting. To determine if an emergency department-based asthma follow-up clinic could improve outcomes within a high-morbidity pediatric population.
                Prospective, randomized clinical trial with 6 months of follow-up.
                Emergency department of an urban pediatric medical center.
                Convenience sample of 488 patients aged 12 months to 17 years, inclusive, with prior physician-diagnosed asthma and 1 or more other unscheduled visits in the previous 6 months and/or 1 or more hospitalizations in the prior 12 months.
                Single follow-up clinic visit focusing on 3 domains: asthma self-monitoring and management, environmental modification and trigger control, and linkages and referrals to ongoing care.
                The primary outcome measure was unscheduled visits for acute asthma care. Secondary outcomes included compliance with a medical plan and asthma quality of life. Analysis was by intention to treat with adjustment for baseline differences.
                Of those randomized to the clinic visit, 172 (70.5%) of 244 attended. The intervention group had significantly fewer mean unscheduled visits for asthma care during follow-up (1.39 vs 2.34; relative risk [RR] = 0.60 [95% confidence interval (CI), 0.46-0.77]). At 6 months, significantly more patients in the intervention group reported use of inhaled corticosteroids in the prior 2 days (49.3% vs 26.5%; RR = 2.03 [95% CI, 1.57-2.62]), no limitation in daytime quality of life (43.8% vs 34.4%; RR = 1.36 [95% CI, 1.06-1.73]), and no functional limitations in quality of life (49.8% vs 40.8%; RR = 1.33 [95% CI, 1.08-1.63]).
                Attendance in the follow-up clinic was high. The intervention decreased subsequent unscheduled health care use while improving compliance and quality of life. Recent studies have shown that lack of continuing primary care for asthma is associated with increased levels of morbidity in low-income minority children. Although effective preventive therapy is available, many African-American and Latino children receive episodic treatment for asthma that does not follow current guidelines for care. To see if access, continuity, and quality of care could be improved in pediatric clinics serving low-income children in New York City, we trained staff in New York City Bureau of Child Health clinics to provide continuing, preventive care for asthma.
                We evaluated the impact of the intervention over a 2-year period in a controlled study of 22 clinics. Training for intervention clinic staff was based on National Asthma Education and Prevention Program guidelines for the diagnosis and management of asthma, and included screening to identify new cases and health education to improve family management. The intervention included strong administrative support by the Bureau of Child Health to promote staff behavior change. We hypothesized that after the intervention, clinics that received the intervention would, compared with control clinics, have increased numbers of children with asthma receiving continuing care in the clinics and increased staff use of new pharmacologic and educational treatment methods.
                In both the first and second follow-up years, the intervention clinics had greater positive changes than control clinics on measures of access, continuity, and quality of care. For second year follow-up data these include: for access, greater rate of new asthma patients (40/1000 vs 16/1000; P < .01); for continuity, greater percentage of asthma patients returning for treatment 2 years in a row (42% vs 12%; P < .001) and greater annual frequency of scheduled visits for asthma per patient (1.85 vs .88; P < .001); and for quality, greater percentage of patients receiving inhaled beta agonists (52% vs 15%; P < .001) and inhaled antiinflammatory drugs (25% vs 2%; P < .001), and greater percentages of parents who reported receiving patient education on 12 topics from Bureau of Child Health physicians (71% vs 58%; P < .01) and nurses (61% vs 44%; P < .05).
                We conclude that the intervention substantially increased the Bureau of Child Health staff's ability to identify children with asthma, involve them in continuing care, and provide them with state-of-the-art care for asthma.
There is limited evidence of efficacy for primary care based asthma clinics, and firm conclusions cannot be formed until more good quality trials have been carried out.