Expert Panel Report 2: Guidelines for the Diagnosis and Management of Asthma

OBJECTIVE — To systematically review the incidence of posttransplantation diabetes (PTD), risk factors for its development, prognostic implications, and optimal management. RESEARCH DESIGN AND METHODS — We searched databases (MEDLINE, EMBASE, the Cochrane Library, and others) from inception to September 2000, reviewed bibliographies in reports retrieved, contacted transplantation experts, and reviewed specialty journals. Two reviewers independently determined report inclusion (original studies, in all languages, of PTD in adults with no history of diabetes before transplantation), assessed study methods, and extracted data using a standardized form. Meta-regression was used to explain between-study differences in incidence. RESULTS — Nineteen studies with 3,611 patients were included. The 12-month cumulative incidence of PTD is lower (10% in most studies) than it was 3 decades ago. The type of immunosuppression explained 74% of the variability in incidence (P 0.0004). Risk factors were patient age, nonwhite ethnicity, glucocorticoid treatment for rejection, and immunosuppression with high-dose cyclosporine and tacrolimus. PTD was associated with decreased graft and patient survival in earlier studies; later studies showed improved outcomes. Randomized trials of treatment regimens have not been conducted. CONCLUSIONS — Physicians should consider modification of immunosuppressive regimens to decrease the risk of PTD in high-risk transplant recipients. Randomized trials are needed to evaluate the use of oral glucose-lowering agents in transplant recipients, paying particular attention to interactions with immunosuppressive drugs. Diabetes Care 25:583–592, 2002

A systematic review of the literature

The chronic care model is a guide to higher-quality chronic illness management within primary care. The model predicts that improvement in its 6 interrelated components—self-management support, clinical information systems, delivery system redesign, decision support, health care organization, and community resources—can produce system reform in which informed, activated patients interact with prepared, proactive practice teams. Case studies are provided describing how components of the chronic care model have been implemented in the primary care practices of 4 health care organizations.

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Improving Primary Care for Patients With Chronic Illness

This article reviews research evidence showing to what extent the chronic care model can improve the management of chronic conditions (using diabetes as an example) and reduce health care costs. Thirty-two of 39 studies found that interventions based on chronic care model components improved at least 1 process or outcome measure for diabetic patients. Regarding whether chronic care model interventions can reduce costs, 18 of 27 studies concerned with 3 examples of chronic conditions (congestive heart failure, asthma, and diabetes) demonstrated reduced health care costs or lower use of health care services. Even though the chronic care model has the potential to improve care and reduce costs, several obstacles hinder its widespread adoption.

https://jamanetwork.com/journals/jama/articlepdf/195407/JIP21005.pdf

Improving primary care for patients with chronic illness: the chronic care model, Part 2

National Asthma Education and Prevention Program.

Study objective To determine the effect of an outpatient program designed to reduce readmissions for asthma exacerbations among adults with asthma. Design Randomized patient selection with crossover. Setting Bellevue Hospital, New York City, New York. Patients We identified 104 adult asthmatics who had previously required multiple hospitalizations for asthma attacks. Forty-seven patients were randomly assigned to an intensive outpatient treatment clinic and 57 patients continued to receive their previous outpatient care. Nineteen patients from this latter group were then crossed to the intensive outpatient therapy clinic. Interventions Attenders of the intensive outpatient treatment program were treated with a vigorous medical regimen and educational program. Emphasis was placed on teaching patients aggressive self-management strategies in case of marked asthma exacerbation. Measurements and main results The main measurement used to determine efficacy of the study program was readmission rate and hospital days used. Prospective comparison of treated compared with untreated patients indicated that program enrollment resulted in a threefold reduction in readmission rate and a twofold reduction in hospital day use rate (P less than 0.004 and P less than 0.02, respectively). Using retrospective data with patients serving as their own controls, we found a threefold reduction in readmission rate and in hospital day use (P less than 0.003) during a 32-month follow-up period. A similar magnitude of reduction in hospital utilization was found when patients were crossed over to the intensive treatment group (P less than 0.004). Conclusions By using a vigorous medical regimen and intensive educational program, we were able to decrease hospital use among a group of adult asthmatics who had previously required repeated readmissions for acute asthma exacerbations.

J Richman

Papers

Results of a Program to Reduce Admissions for Adult Asthma