Primary care based clinics for asthma.
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.
Citations
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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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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
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
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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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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TL;DR: The educational model can be used to improve prescribing and the proportion of patients receiving an inhaled corticosteroid increased insignificantly in both study arms, suggesting the model is effective.
65 citations
TL;DR: Proactive care with active recall for children with moderate to severe asthma is feasible in general practice and seems to be beneficial.
Abstract: Objectives To assess the feasibility and effectiveness of a general practice based, proactive system of asthma care in children. Design Randomised controlled trial with cluster sampling by general practice. Setting General practices in the northern region of the Australian Capital Territory. Participants 174 children with moderate to severe asthma who attended 24 general practitioners. Intervention System of structured asthma care (the 3+ visit plan), with participating families reminded to attend the general practitioner. Main outcome measures Process measures: rates for asthma consultations with general practitioner, written asthma plans, completion of the 3+ visit plan; clinical measures: rates for emergency department visits for asthma, days absent from school, symptom-free days, symptoms over the past year, activity limitation over the past year, and asthma drug use over the past year; spirometric lung function measures before and after cold air challenge. Results Intervention group children had significantly more asthma related consultations (odds ratio for three or more asthma related consultations 3.8 (95% confidence interval 1.9 to 7.6; P = 0.0001), written asthma plans (2.2 (1.2 to 4.1); P = 0.01), and completed 3+ visit plans (24.2 (5.7 to 103.2); P = 0.0001) than control children and a mean reduction in measurements of forced expiratory volume in one second after cold air challenge of 2.6% (1.7 to 3.5); P = 0.0001) less than control children. The number needed to treat (benefit) for one additional written asthma action plan was 5 (3 to 41) children. Intervention group children had lower emergency department attendance rates for asthma (odds ratio 0.4 (0.2 to 1.04); P = 0.06) and less speech limiting wheeze (0.2 (0.1 to 0.4); P = 0.0001) than control children and were more likely to use a spacer (2.8 (1.6 to 4.7); P = 0.0001). No differences occurred in number of days absent from school or symptom-free day scores. Conclusions Proactive care with active recall for children with moderate to severe asthma is feasible in general practice and seems to be beneficial.
61 citations
TL;DR: This paper performed a systematic review on educational interventions for asthma delivered in the home to children, caregivers or both, and to determine the effects of such interventions on asthma-related health outcomes, finding inconsistent evidence for home-based asthma educational interventions compared to standard care, education delivered outside of the home or a less intensive educational intervention delivered at home.
Abstract: Background
While guidelines recommend that children with asthma should receive asthma education, it is not known if education delivered in the home is superior to usual care or the same education delivered elsewhere. The home setting allows educators to reach populations (such as the economically disadvantaged) that may experience barriers to care (such as lack of transportation) within a familiar environment.
Objectives
To perform a systematic review on educational interventions for asthma delivered in the home to children, caregivers or both, and to determine the effects of such interventions on asthma-related health outcomes. We also planned to make the education interventions accessible to readers by summarising the content and components.
Search methods
We searched the Cochrane Airways Group Specialised Register of trials, which includes the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED and PsycINFO, and handsearched respiratory journals and meeting abstracts. We also searched the Education Resources Information Center database (ERIC), reference lists of trials and review articles (last search January 2011).
Selection criteria
We included randomised controlled trials of asthma education delivered in the home to children, their caregivers or both. In the first comparison, eligible control groups were provided usual care or the same education delivered outside of the home. For the second comparison, control groups received a less intensive educational intervention delivered in the home.
Data collection and analysis
Two authors independently selected the trials, assessed trial quality and extracted the data. We contacted study authors for additional information. We pooled dichotomous data with fixed-effect odds ratio and continuous data with mean difference (MD) using a fixed-effect where possible.
Main results
A total of 12 studies involving 2342 children were included. Eleven out of 12 trials were conducted in North America, within urban or suburban settings involving vulnerable populations. The studies were overall of good methodological quality. They differed markedly in terms of age, severity of asthma, context and content of the educational intervention leading to substantial clinical heterogeneity. Due to this clinical heterogeneity, we did not pool results for our primary outcome, the number of patients with exacerbations requiring emergency department (ED) visit. The mean number of exacerbations requiring ED visits per person at six months was not significantly different between the home-based intervention and control groups (N = 2 studies; MD 0.04; 95% confidence interval (CI) -0.20 to 0.27). Only one trial contributed to our other primary outcome, exacerbations requiring a course of oral corticosteroids. Hospital admissions also demonstrated wide variation between trials with significant changes in some trials in both directions. Quality of life improved in both education and control groups over time.
A table summarising some of the key components of the education programmes is included in the review.
Authors' conclusions
We found inconsistent evidence for home-based asthma educational interventions compared to standard care, education delivered outside of the home or a less intensive educational intervention delivered at home. Although education remains a key component of managing asthma in children, advocated in numerous guidelines, this review does not contribute further information on the fundamental content and optimum setting for such educational interventions.
61 citations
Journal Article•
TL;DR: It would appear that small group education of general practitioners in the form reported here is not effective in reducing morbidity from chronic asthma.
Abstract: The effectiveness of small group education of general practitioners in the management of asthma was evaluated by randomized controlled trial. The outcome measure was the asthma morbidity of the general practitioners' own patients. Following random selection from the list of one family practitioner committee in suburban London, the 27 participating general practitioners were allocated randomly to one of two educational groups or to a control group. The educational intervention comprised eight meetings at which the management of chronic asthma was discussed and attempts made to devise agreed strategies for care. The two educational groups devised different strategies. Asthma morbidity was assessed by postal questionnaires to patients before the intervention and on five further occasions at six-monthly intervals over two and a half years. Of 454 patients who entered the study 338 completed the sixth and final assessment. The degree of morbidity experienced by the patients and their reported use of asthma specific drugs was considerable and was notably constant over the period of study. There was no difference in morbidity between the three groups at the outset and no effect of the intervention could be demonstrated. In this educational intervention the participating general practitioners were not informed about the morbidity and drug use reported by their patients. This information may be crucial if small groups are to be used to design and implement effective strategies for care. It would appear that small group education of general practitioners in the form reported here is not effective in reducing morbidity from chronic asthma.
53 citations
Journal Article•
TL;DR: Findings from a large UK sample of practices are subject to participant bias and show association rather than causal links, which opens the debate as to whether accreditation should be linked to recent experience of audit, which does appear to be associated with favourable clinical outcomes.
Abstract: BACKGROUND: There is a need to establish whether the structure of asthma care in general practice is associated with measures of process and with primary and secondary care clinical outcomes. Debate about how to resource general practice asthma care is hampered by a lack of observational data from throughout the United Kingdom (UK). AIM: To observe whether the present system of family health services authority (FHSA) accreditation of asthma clinics, based on measures of structure, is associated with measures of process or clinical outcome. METHOD: Two hundred and twenty-five UK practitioners enrolled in a project and recorded details of how they organized asthma care. Data from 6732 patients, concerning general practitioner and nurse consultations, asthma attacks, symptom control, emergency treatments and hospital attendances covering a 12-month period, were also provided. RESULTS: FHSA approval for a chronic disease management (CDM) asthma clinic was associated with favourable patterns of structure and process, but not of clinical outcome. Practice audit and the employment of a nurse with an asthma diploma were associated with favourable patterns of structure, process and clinical outcome. Practices (n = 143) that had recently audited asthma patient care (n = 4259) had fewer patients who had attended an accident and emergency department [121 (3%): 96 (4%), odds ratio 1.38, 95% confidence interval 1.04-1.83] or a hospital outpatients department [247 (6%): 180 (7%), 1.28, 1.04-1.56], or who had respiratory symptoms on assessment [2400 (56%): 1465 (59%), 1.34, 1.18-1.52] or days absent from work or school in the past 12 months [375 (9%): 296 (12%), 1.48, 1.25-1.74] than those that had not (82 practices, 2473 patients). CONCLUSION: Findings from a large UK sample of practices are subject to participant bias and show association rather than causal links. The present FHSA asthma CDM accreditation system, based on structure, is not associated with favourable clinical outcomes. This opens the debate as to whether accreditation should be linked to recent experience of audit, which does appear to be associated with favourable clinical outcomes.
52 citations