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: There is limited evidence of benefit for primary care based asthma clinics, but firm conclusions cannot be formed until more good quality trials have been carried out.
Abstract: BACKGROUND Primary care clinics for asthma have been encouraged and are becoming widespread in some countries, particularly in the UK. OBJECTIVES To determine the effectiveness of organised asthma care via primary care based asthma clinics. SEARCH STRATEGY A search of the Cochrane Airways Group register and Cochrane Controlled Trials Register using the following search strategy: clinic* OR general pract* OR family pract* or primary care. Separate and additional searches were also conducted using MEDLINE, CINAHL and EMBASE databases. SELECTION CRITERIA Trials had to be performed in primary care and be restricted to patients with asthma. Care could be delivered by doctor or nurse. Two reviewers independently ascertained the relevance of trials from titles and abstracts obtained from the searches. Relevant full text articles were retrieved with two reviewers assessing each study for inclusion. DATA COLLECTION AND ANALYSIS Two reviewers independently conducted all data abstraction and analysis and all disagreements were resolved by discussion. For the dichotomous variables, odds ratio (OR) or relative risks (RR) with 95% Confidence Interval (95%CI) were calculated for individual outcomes. MAIN RESULTS Only one trial met the criteria for inclusion in the review. This trial provided 11 outcome measures of which two showed a significant effect of the intervention. More patients in the intervention group had peak flow meters (RR 1.30; 95%CI 1.05,1.61) and fewer patients in the intervention group were likely to wake up at nights due to their asthma (RR 0.30; 95%CI 0.16, 0.81). REVIEWER'S CONCLUSIONS There is limited evidence of benefit for primary care based asthma clinics, but firm conclusions cannot be formed until more good quality trials have been carried out.
43 citations
TL;DR: A randomized, controlled trial involving 270 general practitioners and found a significant decrease in prescriptions for oral relievers, dry powder relievers in the under 6s, mast cell stabilizers and methylxanthines in both control and intervention groups.
Abstract: The aims were to evaluate the effect of the implementation of an asthma clinical pathway on asthma in children in general practice. A randomized controlled trial involving 270 general practitioners. One group of general practitioners implemented the asthma clinical pathway for children (intervention group) and the control group continued with their usual asthma medical care management. The main outcome measures were admissions to hospital for asthma and attendance at the Childrens Emergency Department. Compliance with the guidelines was assessed by examining asthma drug prescriptions. Admissions to hospital for asthma dropped 40% in the intervention group by 33% in the control group and by 22% in general practitioners not participating in the trial. The differences between the intervention and control and between the intervention and non-participating general practitioners were not statistically significant. The decrease in attendance at the Childrens Emergency Department decreased by 25% 30% and 19% respectively but this was not statistically significant. There was a significant decrease in prescriptions for oral relievers dry powder relievers in the under 6s mast cell stabilizers and methylxanthines in both control and intervention groups. However only for oral relievers was there a significant difference between the intervention group and control with the decrease larger in the intervention group (p < 0.001). Admissions to hospital for asthma decreased as did attendance at the Childrens Emergency Department. Prescriptions for asthma medication changed in the direction anticipated with compliance with the asthma clinical pathway. However we found no evidence within the study that implementation of the asthma clinical pathway by general practitioners resulted in lower morbidity than those general practitioners who did not implement the pathway. Possible explanations are that these general practitioners were already providing care according to the recommendations of the pathway or that there was contamination of the control group by the intervention or that the guidelines although based on currently accepted recommendations are ineffective. (authors)
43 citations
TL;DR: 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 is assessed.
Abstract: Objective: 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.
Methodology: 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.
Results: 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 FEV1 (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.
Conclusions: 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.
38 citations
Journal Article•
TL;DR: A 2-year pilot program of asthma education based on National Heart, Lung, and Blood Institute treatment guidelines improved processes of care and outcomes and member's confidence in their ability to manage their disease.
Abstract: OBJECTIVE To report the results of a 2-year pilot program of asthma education based on National Heart, Lung, and Blood Institute treatment guidelines. PATIENTS AND METHODS Asthmatic members (n = 6698) of a managed care organization received education about their condition directly or through their primary care physician. Medical and pharmacy administrative claims data were reviewed to measure acute asthma events and prescribed therapies in the first (the baseline) and second years of the study. The claims data were augmented by member surveys from a stratified random sample of 2734 asthmatic patients who were members (6 years of age or older) in the baseline year. RESULTS Compared with the first year, asthmatic members received fewer inpatient services and the proportion of asthmatic members prescribed oral inhaled corticosteroids increased 30% in the second year. Health-related quality of life, measured with validated general and disease-specific instruments; satisfaction with the quality of care; exposure to patient education; knowledge of the disease; and member's confidence in their ability to manage their disease showed statistically significant improvements during the follow-up year of the program for both adult and child asthmatic members. CONCLUSION For asthmatic members of this health plan, a comprehensive asthma health management program improved processes of care and outcomes.
37 citations
TL;DR: A pilot randomised trial of computerised templates for the management of asthma and diabetes in general practice in six general practices in North London found health professionals were favourably disposed to the use of templates for general clinical care.
Abstract: We conducted a pilot randomised trial of computerised templates for the management of asthma and diabetes in general practice in six general practices in North London. Uptake of the guidelines by general practitioners and practice nurses was assessed using qualitative (semi-structured interviews designed to assess the users' views) and quantitative (change in use of the template during the study period) outcome measures. The practice nurses used the templates frequently but general practitioners rarely used them. Several reasons were offered for non-use of the templates, such as the length of the template and non-involvement in the care of asthma or diabetes. Despite this, however, health professionals were favourably disposed to the use of templates for general clinical care. Pilot investigations of computerised templates are best achieved by observational or quasi-experimental methods rather than a randomised controlled trial. The use of both qualitative and quantitative methods in this study allowed exploration of the barriers to use of computers.
34 citations