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Journal ArticleDOI

Primary care based clinics for asthma.

18 Apr 2012-Cochrane Database of Systematic Reviews (John Wiley & Sons, Ltd)-Vol. 2012, Iss: 4
TL;DR: 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.
Abstract: Background Asthma is defined as the presence of variable airflow obstruction with symptoms (more than one of wheeze, breathlessness, chest tightness, cough). It is becoming increasingly common worldwide and this is especially true in higher income countries. In several of these countries there has been a move towards delivery of asthma care via primary care based asthma clinics. Such clinics deliver proactive asthma care sited within primary care, via regular, dedicated sessions which are usually nurse led and doctor supported. They include organised recall of patients on an asthma register and care usually comprises education, symptom review and guideline-based management. Despite the proliferation of such clinics, especially in countries such as the United Kingdom (UK), there is a paucity of evidence to support their use. This review sets out to look at the evidence for the effectiveness of asthma clinics. Objectives To determine the effectiveness of organised asthma care delivered via primary care based asthma clinics. Search methods We searched the Cochrane Airways Group Specialised Register of trials (last search December 2011) and reviewed reference lists of all primary studies for additional references. Selection criteria We included randomised controlled trials of primary care based asthma clinics with a parallel group design, where clinics took place within dedicated time slots and included face-to-face interaction with doctor or nurse and control groups received usual clinical practice care by a general practitioner. Data collection and analysis Two review authors independently assessed the trials for inclusion and conducted all data extraction and analysis. All disagreements were resolved by discussion. Main results A total of three studies involving 466 participants were included. There was no statistically significant difference between the asthma clinic group and the control group for most outcomes (primary outcomes: asthma exacerbations leading to hospitalisation or accident and emergency (AE secondary outcomes: symptoms, time lost from work and withdrawals from the intervention or usual care). However, the confidence intervals were wide for all outcomes and there was substantial heterogeneity between the studies for both AE 95% CI 0.12 to 0.77). There were no studies looking at the secondary outcome of exacerbations requiring oral steroids. Authors' conclusions 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.

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Citations
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Journal ArticleDOI
TL;DR: Behavior change interventions including education, training, and enablement in the context of collaborative team-based approaches are effective to change practice of primary healthcare professionals.
Abstract: There is a plethora of interventions and policies aimed at changing practice habits of primary healthcare professionals, but it is unclear which are the most appropriate, sustainable, and effective. We aimed to evaluate the evidence on behavior change interventions and policies directed at healthcare professionals working in primary healthcare centers. Study design: overview of reviews. Data source: MEDLINE (Ovid), Embase (Ovid), The Cochrane Library (Wiley), CINAHL (EbscoHost), and grey literature (January 2005 to July 2015). Study selection: two reviewers independently, and in duplicate, identified systematic reviews, overviews of reviews, scoping reviews, rapid reviews, and relevant health technology reports published in full-text in the English language. Data extraction and synthesis: two reviewers extracted data pertaining to the types of reviews, study designs, number of studies, demographics of the professionals enrolled, interventions, outcomes, and authors’ conclusions for the included studies. We evaluated the methodological quality of the included studies using the AMSTAR scale. For the comparative evaluation, we classified interventions according to the behavior change wheel (Michie et al.). Of 2771 citations retrieved, we included 138 reviews representing 3502 individual studies. The majority of systematic reviews (91%) investigated behavior and practice changes among family physicians. Interactive and multifaceted continuous medical education programs, training with audit and feedback, and clinical decision support systems were found to be beneficial in improving knowledge, optimizing screening rate and prescriptions, enhancing patient outcomes, and reducing adverse events. Collaborative team-based policies involving primarily family physicians, nurses, and pharmacists were found to be most effective. Available evidence on environmental restructuring and modeling was found to be effective in improving collaboration and adherence to treatment guidelines. Limited evidence on nurse-led care approaches were found to be as effective as general practitioners in patient satisfaction in settings like asthma, cardiovascular, and diabetes clinics, although this needs further evaluation. Evidence does not support the use of financial incentives to family physicians, especially for long-term behavior change. Behavior change interventions including education, training, and enablement in the context of collaborative team-based approaches are effective to change practice of primary healthcare professionals. Environmental restructuring approaches including nurse-led care and modeling need further evaluation. Financial incentives to family physicians do not influence long-term practice change.

138 citations


Cites background from "Primary care based clinics for asth..."

  • ...Advance practice nurse care [136], quality improvement strategies [137, 148–152], case management [138], collaborative care [140], evidencebased medicine practice strategies [144], midwife-led continuity services [145], comprehensive asthma care [146], and patient-centered medical home [125, 147] have all been evaluated....

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Journal ArticleDOI
TL;DR: ABM seems to be a promising, novel treatment for child and/or adolescent anxiety disorders with merits over lengthier, talking based therapies, however, more rigorous research trials are needed to clarify the mechanisms behind ABM and establish effective, standardised treatment protocols.

57 citations

Journal ArticleDOI
TL;DR: In this paper, the authors conducted a rapid review of previous systematic reviews from 2006 to 2013 to answer these questions with a view to informing improvements in care co-ordination programs, and found no evidence that discipline had a direct impact on clinical or service outcomes, although specific expertise gained through training and workforce organisational support for the coordinator was required.
Abstract: Care co-ordination is reported to be an effective component of chronic disease (CD) management within primary care. While nurses often perform this role, it has not been reported if they or other disciplines are best placed to take on this role, and whether the discipline of the co-ordinator has any impact on clinical and health service outcomes. We conducted a rapid review of previous systematic reviews from 2006 to 2013 to answer these questions with a view to informing improvements in care co-ordination programmes. Eighteen systematic reviews from countries with developed health systems comparable to Australia were included. All but one included complex interventions and 12 of the 18 involved a range of multidisciplinary co-ordination strategies. This multi-strategy and multidisciplinarity made it difficult to isolate which were the most effective strategies and disciplines. Nurses required specific training for these roles, but performed co-ordination more often than any other discipline. There was, however, no evidence that discipline had a direct impact on clinical or service outcomes, although specific expertise gained through training and workforce organisational support for the co-ordinator was required. Hence, skill mix is an important consideration when employing care co-ordination, and a sustained consistent approach to workforce change is required if nurses are to be enabled to perform effective care co-ordination in CD management in primary care.

46 citations

Journal ArticleDOI
TL;DR: An integrative review of systematic reviews of non-pharmacological and pharmacological interventions for breathlessness in non-malignant disease was undertaken to identify the current state of clinical understanding of the management of breathlessness and highlight promising interventions that merit further investigation.
Abstract: Background: Breathlessness is a debilitating and distressing symptom in a wide variety of diseases and still a difficult symptom to manage. An integrative review of systematic reviews of non-pharmacological and pharmacological interventions for breathlessness in non-malignant disease was undertaken to identify the current state of clinical understanding of the management of breathlessness and highlight promising interventions that merit further investigation. Methods: Systematic reviews were identified via electronic databases between July 2007 and September 2009. Reviews were included within the study if they reported research on adult participants using either a measure of breathlessness or some other measure of respiratory symptoms. Results: In total 219 systematic reviews were identified and 153 included within the final review, of these 59 addressed non-pharmacological interventions and 94 addressed pharmacological interventions. The reviews covered in excess of 2000 trials. The majority of systematic reviews were conducted on interventions for asthma and COPD, and mainly focussed upon a small number of pharmacological interventions such as corticosteroids and bronchodilators, including beta-agonists. In contrast, other conditions involving breathlessness have received little or no attention and studies continue to focus upon pharmacological approaches. Moreover, although there are a number of non-pharmacological studies that have shown some promise, particularly for COPD, their conclusions are limited by a lack of good quality evidence from RCTs, small sample sizes and limited replication. Conclusions: More research should focus in the future on the management of breathlessness in respiratory diseases other than asthma and COPD. In addition, pharmacological treatments do not completely manage breathlessness and have an added burden of side effects. It is therefore important to focus more research on promising non-pharmacological interventions.

32 citations


Cites background from "Primary care based clinics for asth..."

  • ...Treatments assessed within the reviews included: acupuncture [32], breathing exercises/training [30,33,34]; dietary measures [35-39]; Heliox [29,31]; homeopathy [40]; control of allergens [41,42]; humidity control/ionisers [43,44]; education programs [45-47]; manual therapy[48]; primary care clinics [49]; psychological interventions [50,51]; individualised care plans [52]; and non-invasive positive pressure ventilation (NIPPV) [53], which enhances ventilation by compensating for fatigued ventilator muscles....

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  • ...Of those reviews with positive findings, four reported a single study only [35,49,53,54]....

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Journal ArticleDOI
TL;DR: Current studies suggest CPs may reduce the length of hospital stay, but insufficient evidence is available on total costs or readmissions to justify extensive uptake of asthma CPs in paediatric inpatient care.
Abstract: Objective: To evaluate the effectiveness of clinical pathways (CPs) for paediatric asthma on length of hospital stay, additional visits due to asthma exacerbations, hospital cost, manpower and workload required for implementing CPs. Methods: Studies were eligible if they met the following criteria: children (≦18 years) with asthma, hospital or emergency department based, and study designs were (1) randomised controlled trial, (2) controlled clinical trial or (3) controlled before and after study. Two reviewers independently screened references, extracted data and assessed the risk of bias. We resolved disagreement by discussion between authors. Due to an insufficient number of studies and the heterogeneity of interventions and outcomes, we conducted a narrative systematic review with forest plots but did not pool results. Results: About 3155 relevant articles were identified through a literature search, 628 were duplicates removed, 2037 were excluded based on review of titles and abstracts and 117...

27 citations


Cites background from "Primary care based clinics for asth..."

  • ...Introduction Asthma is defined as the presence of reversible airflow obstruction and at least one other symptom such as wheezing, breathlessness, chest tightness or coughing [1]....

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References
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Journal ArticleDOI
TL;DR: A nurse-run asthma clinic in general practice is an effective way to improve symptoms, pulmonary function, and health care utilisation for asthmatic patients over a four-month period.

8 citations

Journal Article
Bramson R1

4 citations

Journal ArticleDOI
22 Jan 2000-BMJ
TL;DR: The evidence cited from a recent Cochrane review showing a reduction in morbidity with the use of self management plans does not convince us of their widespread application to general practice as discussed by the authors.
Abstract: Editor—Lahdensuo writes in favour of guided self management plans in patients with asthma and indicates what skills patients might acquire and who may be suitable.1 However, the evidence cited from a recent Cochrane review showing a reduction in morbidity with the use of such plans2 does not convince us of their widespread application to general practice. The trials in the review were heterogeneous, recruiting patients from hospital clinics after inpatient or emergency room attendance, from general practice, and from advertisements in newspapers and on radio seeking participants. Selection biases may be present—for example, three British trials sought patients from collections of practices (14, 14, and 24 practices in total) and managed to recruit only small numbers of asthma patients (126, 127, and 339 respectively). Many trials had extensive exclusion criteria, at least five trials excluding smokers. Loss to follow up in the original papers varies up to 60.3% and was over 40% in five studies. An American trial offered open access to a special asthma clinic to those in the intervention arm of the study. The reduction in hospital attendance seen may have been balanced in part by patients attending that clinic. Several studies provided free treatment during the trial, but self management plans may have less impact when patients have to buy their drugs. Follow up ranged from 6 to 12 months. What improvements persist over a longer time and whether patients would require or accept further reinforcement of self management plans is not established. None of the trials established what patients think of self management plans, particularly those who do not accept invitations to attend clinics or who do not adhere to treatment. Professional beliefs that patients should be taught and should be supervised are at odds with a shared decision making model. Lahdensuo quotes Partridge as saying that self management of asthma entails the patient making therapeutic, behavioural, and environmental adjustments in accordance with the advice from healthcare professionals, but Partridge has also pointed out that the patient's perspective may not always be the same as that of the doctor.3,4 Lahdensuo has given us a useful aid on how to guide self management of asthma. However, before we implement these plans in general practice more research is needed on the views of patients.

2 citations

Journal ArticleDOI
TL;DR: Asthma liaison nurse intervention did not reduce unscheduled care in a deprived multiethnic population, but did promote earlier review in a parallel qualitative study.

2 citations