Global strategy for asthma management and prevention

Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma

ContextDevelopers of health care software have attributed improvements in patient
care to these applications. As with any health care intervention, such claims
require confirmation in clinical trials.ObjectivesTo review controlled trials assessing the effects of computerized clinical
decision support systems (CDSSs) and to identify study characteristics predicting
benefit.Data SourcesWe updated our earlier reviews by searching the MEDLINE, EMBASE, Cochrane
Library, Inspec, and ISI databases and consulting reference lists through
September 2004. Authors of 64 primary studies confirmed data or provided additional
information.Study SelectionWe included randomized and nonrandomized controlled trials that evaluated
the effect of a CDSS compared with care provided without a CDSS on practitioner
performance or patient outcomes.Data ExtractionTeams of 2 reviewers independently abstracted data on methods, setting,
CDSS and patient characteristics, and outcomes.Data SynthesisOne hundred studies met our inclusion criteria. The number and methodologic
quality of studies improved over time. The CDSS improved practitioner performance
in 62 (64%) of the 97 studies assessing this outcome, including 4 (40%) of
10 diagnostic systems, 16 (76%) of 21 reminder systems, 23 (62%) of 37 disease
management systems, and 19 (66%) of 29 drug-dosing or prescribing systems.
Fifty-two trials assessed 1 or more patient outcomes, of which 7 trials (13%)
reported improvements. Improved practitioner performance was associated with
CDSSs that automatically prompted users compared with requiring users to activate
the system (success in 73% of trials vs 47%; P = .02)
and studies in which the authors also developed the CDSS software compared
with studies in which the authors were not the developers (74% success vs
28%; respectively, P = .001).ConclusionsMany CDSSs improve practitioner performance. To date, the effects on
patient outcomes remain understudied and, when studied, inconsistent.

Effects of computerized clinical decision support systems on practitioner performance and patient outcomes: a systematic review.

Self-management approaches for people with chronic conditions: a review.

The PedsQL 4.0 as a pediatric population health measure: feasibility, reliability, and validity.

Primary objective : To investigate whether computer decision support software used in the management of patients with asthma improves clinical outcomes. Research design : Randomized controlled trial with practices each reporting on 30 patients with asthma over a 6 month period. Methods and procedures : 447 patients were randomly selected from practice asthma registers managed by 17 general practices from throughout the UK. Intervention practices used the software during consultations with these patients throughout the study while control practices did not. Main outcomes and results : Practice consultations, acute exacerbations of asthma, hospital contacts, symptoms on assessment and medication use. A smaller proportion of patients within the intervention group initiated practice consultations for their asthma: 34 (22%) vs 111 (34%), odds ratio (OR)= 0.59, 95% confidence interval (CI) (0.37-0.95); and suffered acute asthma exacerbations: 12 (8%) vs 57 (17%) , OR = 0.43, 95% CI = 0.21- 0.85 six months after...

Lessons from a randomized controlled trial designed to evaluate computer decision support software to improve the management of asthma.

OBJECTIVE--To describe the frequency and characteristics of asthma attacks in the United Kingdom and to compare actual management with recommended guidelines for the management of attacks. DESIGN--Correspondence survey. SETTING--218 general practices in the United Kingdom. SUBJECTS--1775 patients of all ages who had a total of 1805 asthma attacks over three months. MAIN OUTCOME MEASURES--Patient characteristics, place of management of attacks, comparison of actual management with recommended guidelines. RESULTS--Of the 1805 attacks, 300 occurred in boys aged 0-9, 144 in girls aged 0-9, and 118 in women aged 20-29. The estimated frequency of attacks in the community was 14.3 per 1000 patients per year. 1546 (86%) patients with attacks were managed within general practice, 225 (12%) were admitted to hospital, and 34 (2%) were discharged from an accident and emergency department. Two patients died. On initial presentation, 248 (14%) patients were "not breathless," 900 (50%) were "moderately breathless," 535 (30%) were "breathless and distressed," 68 (4%) were "too breathless to talk," and 2 were "moribund." Recording of clinical data was variable. Underuse of nebulised bronchodilators and systemic steroid was apparent in all grades of clinical severity. Contrary to current guidelines for asthma management, "step up" in maintenance therapy after an attack was often not practised. CONCLUSION--Reported management was at variance with recommended guidelines. This has major implications for the design and distribution of future guidelines.

https://www.bmj.com/content/bmj/306/6877/559.full.pdf

National asthma attack audit 1991-2. General Practitioners in Asthma Group.

Objective: To test whether an audit facilitator could alter the pattern of diagnosis and treatment of childhood asthma. Design: Randomised stratified controlled trial. Setting: 12 general practices in Tayside. Subjects: 3373 children aged 1-15 inclusive who had symptoms suggestive of asthma or possible asthma drawn from a systematic review of 10 725 general practice case records. Intervention: Children were targeted for a clinical review by their general practitioner or practice nurses. Main outcome measures: Asthma related consultations, precriptions, hospital attendances, and health service costs 12 months before and after study. Results: Compared with controls (n=1563) the intervention group (n=1585) had more practice initiated consultations for asthma (relative risk 2.18 (95% confidence interval 1.74 to 2.73)), new diagnoses of asthma (2.83 (2.26 to 3.54)), and past diagnoses reaffirmed (1.30 (1.08 to 1.58)), and they were more frequently prescribed inhaled cromoglycate (1.52 (1.02 to 2.25)). Hospital inpatient day rates fell from 152 to 122 in the intervention group and rose from 69 to 117 in the control group between the year before and the year after study. Total primary care costs rose from pounds sterling30118 to pounds sterling37243 in the intervention group and fell from pounds sterling29131 to pounds sterling27990 in the control group. Hospital care cost fell in the intervention group from pounds sterling25406 to pounds sterling20727 and rose in the control group from pounds sterling12699 to pounds sterling19650. Conclusion: An audit facilitator can favourably influence the pattern of diagnosis and treatment of childhood asthma in general practice. This may have an impact on health service costs. Key messages Key messages Controlled trial of an audit facilitator is feasible in primary care Intervention of an audit facilitator resulted in desirable changes in the diagnosis and treatment of asthma in children in general practice Such intervention may also have had an impact on the use of hospital resources and on health care expenditure

http://europepmc.org/articles/PMC2549220?pdf=render

Controlled trial of an audit facilitator in diagnosis and treatment of childhood asthma in general practice

Objective: To investigate whether asthma or its treatment impairs children9s growth, after allowing for socioeconomic group. Design: 4 year follow up of a cohort of children aged 1-15. Setting: 12 general practices in the Tayside region of Scotland. Subjects: 3347 children with asthma or features suggestive of asthma registered with the general practices. Main outcome measures: Height and weight standard deviation scores. Results: Children who lived in areas of social deprivation (assessed by postcode) had lower height and weight than their contemporaries (mean standard deviation score −0.26 (SD 1.02) and −0.18 (1.15) respectively, P Conclusion: Most children with asthma were of normal height and weight and had normal growth rates. However, children receiving high doses of inhaled steroids and requiring both general practice and hospital services had a significant reduction in their stature. This effect was independent from but smaller than the effect of socioeconomic group on stature. Key messages Social deprivation has an adverse effect on the height and weight of children irrespective of any disease process Neither asthma nor its treatments had any noticeable effect on the height and weight of most of the children in this primary care study Children who received high doses of inhaled corticosteroids and used hospital services for asthma were shorter and lighter than their contemporaries after social deprivation was allowed for Children receiving high doses of inhaled corticosteroids had lower than normal growth rates

https://www.bmj.com/content/bmj/316/7132/668.1.full.pdf

Effect of asthma and its treatment on growth: four year follow up of cohort of children from general practices in Tayside, Scotland

BACKGROUND: The management of asthma attacks by general practitioners in 1992/93 was compared with 1991/92 in relation to recommended guidelines. METHODS: The findings from a postal survey of 299 UK general practitioners who managed 2332 patients with an asthma attack in 1992/93 were compared with those from 218 practitioners who managed 1805 attacks in 1991/92. Management by a subgroup of practitioners from a special interest group was analysed separately. RESULTS: In 1992/93 2031 (87%) of attacks were managed entirely by general practitioners, 251 (11%) were referred for admission to hospital, and 50 (2%) were managed by an accident and emergency department. There was no change in the pattern of management relative to 1991/92. Compared with recommended guidelines there was underuse of systemic steroids and nebulised bronchodilators. Between 1991/92 and 1992/93 use of systemic steroids in acute attacks increased from 56% to 71%, nebulised bronchodilators from 31% to 32%, and an increase in prophylactic medication after an acute attack from 41% to 49%. Contrary to guidelines, antibiotic use increased from 32% to 40% of attacks. Practitioners from a special interest asthma group gave more of their patients systemic steroids and nebulised bronchodilators both in 1991/92 and 1992/93. CONCLUSIONS: Some aspects of the management of asthma attacks by general practitioners has changed in line with guidelines, but there is still a large gap between actual and recommended management.

https://thorax.bmj.com/content/thoraxjnl/52/2/153.full.pdf

R G Neville

Papers

Lessons from a randomized controlled trial designed to evaluate computer decision support software to improve the management of asthma.

National asthma attack audit 1991-2. General Practitioners in Asthma Group.

Controlled trial of an audit facilitator in diagnosis and treatment of childhood asthma in general practice

Effect of asthma and its treatment on growth: four year follow up of cohort of children from general practices in Tayside, Scotland

How general practitioners manage acute asthma attacks.