Self-management education and regular practitioner review for adults with asthma

Effects of self-management intervention on health outcomes of patients with heart failure: a systematic review of randomized controlled trials

Background

Heart failure is the most common cause of hospitalization among adults over 65. Over 60% of patients die within 10 years of first onset of symptoms. The objective of this study is to determine the effectiveness of self-management interventions on hospital readmission rates, mortality, and health-related quality of life in patients diagnosed with heart failure.

Methods

The study is a systematic review of randomized controlled trials. The following data sources were used: MEDLINE (1966-11/2005), EMBASE (1980-11/2005), CINAHL (1982-11/2005), the ACP Journal Club database (to 11/2005), the Cochrane Central Trial Registry and the Cochrane Database of Systematic Reviews (to 11/2005); article reference lists; and experts in the field. We included randomized controlled trials of self-management interventions that enrolled patients 18 years of age or older who were diagnosed with heart failure. The primary outcomes of interest were all-cause hospital readmissions, hospital readmissions due to heart failure, and mortality. Secondary outcomes were compliance with treatment and quality of life scores. Three reviewers independently assessed the quality of each study and abstracted the results. For each included study, we computed the pooled odds ratios (OR) for all-cause hospital readmission, hospital readmission due to heart failure, and death. We used a fixed effects model to quantitatively synthesize results. We were not able to pool effects on health-related quality of life and measures of compliance with treatment, but we summarized the findings from the relevant studies. We also summarized the reported cost savings.

Results

From 671 citations that were identified, 6 randomized trials with 857 patients were included in the review. Self-management decreased all-cause hospital readmissions (OR 0.59; 95% confidence interval (CI) 0.44 to 0.80, P = 0.001) and heart failure readmissions (OR 0.44; 95% CI 0.27 to 0.71, P = 0.001). The effect on mortality was not significant (OR = 0.93; 95% CI 0.57 to 1.51, P = 0.76). Adherence to prescribed medical advice improved, but there was no significant difference in functional capabilities, symptom status and quality of life. The reported savings ranged from $1300 to $7515 per patient per year.

Conclusion

Self-management programs targeted for patients with heart failure decrease overall hospital readmissions and readmissions for heart failure.

[Bronchial asthma. Update 2006]

Bronchial asthma, with a prevalence in Germany of 5% among adults and 10% among children, remains a frequent disease. Newer cell biological data show a separate regulation of the allergy (interleukin 4, IL-4, pathway) and of the eosinophilic inflammation in asthma (IL-5 pathway). Both conditions require a therapeutic approach. To prevent irreversible bronchial remodeling, early diagnosis and targeted therapy are decisive. Bronchial asthma is regarded as evident when the paroxysmal character of the disease is confirmed and an-at least intermittent-obstructive ventilation disorder is apparent which responds well to short-acting beta2-adrenergic agents. Current asthma treatment has been assured in many studies (evidence level A) and is based on therapy in stages which classifies therapeutic measures depending on four grades of severity. Accordingly, most patients are largely without complaints, and nocturnal attacks are now rare. New medications are intended to overcome any remaining therapeutic weak points. Antileukotrienes and anti-IgE antibodies can contribute to reducing the necessary corticosteroids. Pharmaceutical agents that intervene in the IL-4 or IL-5 regulation or prevent remodeling are being developed.

A randomized clinical trial of peak flow versus symptom monitoring in older adults with asthma

OBJECTIVE

To determine whether peak flow monitoring has value above and beyond symptom monitoring when used as part of an asthma management plan.

METHODS

From a large managed-care organization, 296 adults, aged 50-92 yr, were recruited and randomly assigned in equal numbers to either use of symptoms or peak flow rate (twice daily or "as needed") for asthma monitoring, and monitored every 6 mo for 2 yr. Interventions were delivered in four 90-min small-group classes and included a personalized action plan and coaching in proper use of asthma inhalers.

RESULTS

We found no significant differences between peak flow rate and symptom monitoring, or between twice-daily and as-needed peak flow monitoring in the primary or secondary study outcomes: health care utilization (acute, nonacute, or total asthma visits), Asthma Quality-of-Life Questionnaire (AQLQ) scores, and lung function. AQLQ scores and prebronchodilator FEV1 increased significantly for both groups between baseline and 6 mo (AQLQ: mean, 0.4 units; 95% confidence interval, 0.3, 0.5; p < 0.0001; FEV1% predicted: mean, 4%). Inhaler technique improved substantially in both groups.

CONCLUSIONS

Peak flow monitoring has no advantage over symptom monitoring as an asthma management strategy for older adults with moderate-severe asthma when used in a comprehensive asthma management program. Improved outcomes in both groups suggest that understanding proper medication use, regular monitoring of asthma status, and understanding how to respond to changes are of primary importance.

Understanding reasons for asthma outpatient (non)-attendance and exploring the role of telephone and e-consulting in facilitating access to care: exploratory qualitative study

OBJECTIVE

To understand factors influencing patients' decisions to attend for outpatient follow up consultations for asthma and to explore patients' attitudes to telephone and email consultations in facilitating access to asthma care.

DESIGN

Exploratory qualitative study using in depth interviews.

SETTING

Hospital outpatient clinic in West London.

PARTICIPANTS

Nineteen patients with moderate to severe asthma (12 "attenders" and 7 "non-attenders").

RESULTS

Patients' main reasons for attending were the wish to improve control over asthma symptoms and a concern not to jeopardise the valued relationship with their doctor. Memory lapses, poor health, and disillusionment with the structure of outpatient care were important factors implicated in non-attendance. The patients were generally sceptical about the suggestion that greater opportunity for telephone consulting might improve access to care. They expressed concerns about the difficulties in effectively communicating through non-face to face media and were worried that clinicians would not be in a position to perform an adequate physical examination over the telephone. Email and text messaging were viewed as potentially useful for sending appointment reminders and sharing clinical information but were not considered to be acceptable alternatives to the face to face clinic encounter.

CONCLUSIONS

Memory lapses, impaired mobility due to poor health, and frustration with outpatient clinic organisation resulting in long waiting times and discontinuity of care are factors that deter patients from attending for hospital asthma assessments. The idea of telephone review assessments was viewed with scepticism by most study subjects. Particular attention should be given to explaining to patients the benefits of telephone consultations, and to seeking their views as to whether they would like to try them out before replacing face to face consultations with them. Email and text messaging may have a role in issuing reminders about imminent appointments.

The Diabetes Manual trial protocol - a cluster randomized controlled trial of a self-management intervention for type 2 diabetes [ISRCTN06315411]

BACKGROUND

The Diabetes Manual is a type 2 diabetes self-management programme based upon the clinically effective 'Heart Manual'. The 12 week programme is a complex intervention theoretically underpinned by self-efficacy theory. It is a one to one intervention meeting United Kingdom requirements for structured diabetes-education and is delivered within routine primary care.

METHODS/DESIGN

In a two-group cluster randomized controlled trial, GP practices are allocated by computer minimisation to an intervention group or a six-month deferred intervention group. We aim to recruit 250 participants from 50 practices across central England. Eligibility criteria are adults able to undertake the programme with type 2 diabetes, not taking insulin, with HbA1c over 8% (first 12 months) and following an agreed protocol change over 7% (months 13 to 18). Following randomisation, intervention nurses receive two-day training and delivered the Diabetes Manual programme to participants. Deferred intervention nurses receive the training following six-month follow-up. Primary outcome is HbA1c with total and HDL cholesterol; blood pressure, body mass index; self-efficacy and quality of life as additional outcomes. Primary analysis is between-group HbA1c differences at 6 months powered to give 80% power to detect a difference in HbA1c of 0.6%. A 12 month cohort analysis will assess maintenance of effect and assess relationship between self-efficacy and outcomes, and a qualitative study is running alongside.

DISCUSSION

This trial incorporates educational and psychological diabetes interventions into a single programme and assesses both clinical and psychosocial outcomes. The trial will increase our understanding of intervention transferability between conditions, those diabetes related health behaviours that are more or less susceptible to change through efficacy enhancing mechanisms and how this impacts on clinical outcomes.

Errors in search strategies were identified by type and frequency

OBJECTIVE

Errors in the electronic search strategy of a systematic review may undermine the integrity of the evidence base used in the review. We studied the frequency and types of errors in reviews published by the Cochrane Collaboration.

STUDY DESIGN AND SETTING

Data sources were MEDLINE searches from reviews in the Cochrane Library, Issue 3, 2002. To be eligible, systematic reviews must have been of randomized or quasi-randomized controlled trials, reported included and excluded studies, and used one or more sections of the Cochrane Collaboration's Highly Sensitive Search Strategy. MEDLINE search strategies not reported in enough detail to be assessed or that were duplicates of a search strategy already assessed for the study were excluded. Two librarians assessed eligibility and scored the eligible electronic search strategies for 11 possible errors. Dual review with consensus was used.

RESULTS

Of 105 MEDLINE search strategies examined, 63 were assessed; 31 were excluded because they were inadequately reported, and 11 were duplicates of assessed search strategies. Most (90.5%) of the assessed search strategies contained > or =1 errors (median 2, interquartile range [IQR] 1.0-3.0). Errors that could potentially lower recall of relevant studies were found in 82.5% (median 1, IQR 1.0-2.0) and inconsequential errors (to the evidence base) were found in 60.3% (median 1, IQR 0.0-1.0) of the search strategies. The most common search errors were missed MeSH terms (44.4%), unwarranted explosion of MeSH terms (38.1%), and irrelevant MeSH or free text terms (28.6%). Missed spelling variants, combining MeSH and free text terms in the same line, and failure to tailor the search strategy for other databases occurred with equal frequency (20.6%). Logical operator error occurred in 19.0% of searches.

CONCLUSION

When the MEDLINE search strategy used in a systematic review is reported in enough detail to allow assessment, errors are commonly revealed. Additional peer review steps are needed to ensure search quality and freedom from errors.

Complementary therapy use by patients and parents of children with asthma and the implications for NHS care: a qualitative study

BACKGROUND

Patients are increasingly using complementary therapies, often for chronic conditions. Asthma is the most common chronic condition in the UK. Previous research indicates that some asthma patients experience gaps in their NHS care. However, little attention has been given to how and why patients and parents of children with asthma use complementary therapies and the implications for NHS care.

METHODS

Qualitative study, comprising 50 semi-structured interviews with a purposeful sample of 22 adults and 28 children with asthma (plus a parent), recruited from a range of NHS and non-NHS settings in Bristol, England. Data analysis was thematic, drawing on the principles of constant comparison.

RESULTS

A range of complementary therapies were being used for asthma, most commonly Buteyko breathing and homeopathy. Most use took place outside of the NHS, comprising either self-treatment or consultation with private complementary therapists. Complementary therapies were usually used alongside not instead of conventional asthma treatment. A spectrum of complementary therapy users emerged, including "committed", "pragmatic" and "last resort" users. Motivating factors for complementary therapy use included concerns about conventional NHS care ("push factors") and attractive aspects of complementary therapies ("pull factors"). While participants were often uncertain whether therapies had directly helped their asthma, breathing techniques such as the Buteyko Method were most notably reported to enhance symptom control and enable reduction in medication. Across the range of therapies, the process of seeking and using complementary therapies seemed to help patients in two broad ways: it empowered them to take greater personal control over their condition rather than feel dependant on medication, and enabled exploration of a broader range of possible causes of their asthma than commonly discussed within NHS settings.

CONCLUSION

Complementary therapy use reflects patients' and parents' underlying desire for greater self-care and need of opportunities to address some of their concerns regarding NHS asthma care. Self-management of chronic conditions is increasingly promoted within the NHS but with little attention to complementary therapy use as one strategy being used by patients and parents. With their desire for self-help, complementary therapy users are in many ways adopting the healthcare personas that current policies aim to encourage.

Attitudes and actions of asthma patients on regular maintenance therapy: the INSPIRE study

BACKGROUND

This study examined the attitudes and actions of 3415 physician-recruited adults aged > or = 16 years with asthma in eleven countries who were prescribed regular maintenance therapy with inhaled corticosteroids or inhaled corticosteroids plus long-acting beta2-agonists.

METHODS

Structured interviews were conducted to assess medication use, asthma control, and patients' ability to recognise and self-manage worsening asthma.

RESULTS

Despite being prescribed regular maintenance therapy, 74% of patients used short-acting beta2-agonists daily and 51% were classified by the Asthma Control Questionnaire as having uncontrolled asthma. Even patients with well-controlled asthma reported an average of 6 worsenings/year. The mean period from the onset to the peak symptoms of a worsening was 5.1 days. Although most patients recognised the early signs of worsenings, the most common response was to increase short-acting beta2-agonist use; inhaled corticosteroids were increased to a lesser extent at the peak of a worsening.

CONCLUSION

Previous studies of this nature have also reported considerable patient morbidity, but in those studies approximately three-quarters of patients were not receiving regular maintenance therapy and not all had a physician-confirmed diagnosis of asthma. This study shows that patients with asthma receiving regular maintenance therapy still have high levels of inadequately controlled asthma. The study also shows that patients recognise deteriorating asthma control and adjust their medication during episodes of worsening. However, they often adjust treatment in an inappropriate manner, which represents a window of missed opportunity.

Overcoming gaps in the management of asthma in older patients: new insights

Asthma is under-recognised and undertreated in older populations. This is not surprising, given that one-third of older people experience significant breathlessness. The differential diagnosis commonly includes asthma, chronic obstructive pulmonary disease (COPD), heart failure, malignancy, aspiration and infections. Because symptoms and signs of several cardiorespiratory diseases are nonspecific in older people and diseases commonly co-exist, investigations are important. A simple strategy for the investigation of breathlessness in older people should include a full blood count, chest radiograph, ECG, peak flow diary and/or spirometry with reversibility as a minimum. If there are major abnormalities on the ECG, an echocardiogram should also be performed. Diurnal variability in peak flow readings >or=20% or >or=15% reversibility in forced expiratory volume in 1 second, spontaneously or with treatment, support a diagnosis of asthma. Distinguishing asthma from COPD is important to allow appropriate management of disease based on aetiology, accurate prediction of treatment response, correct prognosis and appropriate management of the chest condition and co-morbidities. The two conditions are usually readily differentiated by clinical features, particularly age at onset, variability of symptoms and nocturnal symptoms in asthma, supported by the results of reversibility testing. Full lung function tests may not necessarily help in differentiating the two entities, although gas transfer factor is characteristically reduced in COPD and usually normal or high in asthma. Methacholine challenge tests previously mainly used in research are now also used widely and safely to confirm asthma in clinical settings. Interest in exhaled nitric oxide as a biomarker of airways inflammation is increasing as a noninvasive tool in the diagnosis and monitoring of asthma. Regular inhaled corticosteroids (ICS) are the mainstay of treatment of asthma. Even in mild disease in older adults, regular preventive treatment should be considered, given the poor perception of bronchoconstriction by older asthmatic patients. If symptoms persist despite ICS, addition of long-acting beta(2)-adrenoceptor agonists (LABA) should be considered. Addition of LABA to ICS improves asthma control and allows reduction in ICS dose. However, older people have been grossly under-represented in trials of LABA, many trials having excluded those >or=65 years of age. On meta-analysis, beta(2)-adrenoceptor agonists (both short acting and long acting) are associated with increased cardiovascular mortality and morbidity in asthma and COPD. While the evidence for excess cardiovascular mortality is stronger for short-acting beta(2)-adrenoceptor agonists, it would be prudent to exercise particular care in using beta(2)-adrenoceptor agonists (long acting and short acting) in those at risk of adverse cardiovascular outcomes, including older people. Regular review of cardiovascular status (and monitoring of serum potassium concentration) in patients taking beta(2)-adrenoceptor agonists is crucial. The response to LABA should be carefully monitored and alternative 'add-on' therapy such as leukotriene receptor antagonists (LRA) should be considered. LRA have fewer adverse effects and in individual cases may be more effective and appropriate than LABA. Long-term trials evaluating beta(2)-adrenoceptor agonists and other bronchodilator strategies are needed particularly in the elderly and in patients with cardiovascular co-morbidities. There is no evidence that addition of anticholinergics improves control of asthma further, although the role of long-acting anticholinergics in the prevention of disease progression is currently being researched. Older patients need to be taught good inhaler technique to improve delivery of medications to lungs, minimise adverse effects and reduce the need for oral corticosteroids. Nurse-led education programmes that include a written asthma self-management plan have the potential to improve outcomes.

2003 canadian asthma consensus guidelines executive summary

BACKGROUND

Guidelines for the diagnosis and management of asthma have been published over the last 15 years; however, there has been little focus on issues relating to asthma in childhood. Since the last revision of the 1999 Canadian Asthma Consensus Report, important new studies, particularly in children, have highlighted the need to incorporate new information into the asthma guidelines. The objectives of this article are to review the literature on asthma published between January 2000 and June 2003 and to evaluate the influence of new evidence on the recommendations made in the 1999 Canadian Asthma Consensus Report and its 2001 update, with a major focus on pediatric issues.

METHODS

The diagnosis of asthma in young children and prevention strategies, pharmacotherapy, inhalation devices, immunotherapy, and asthma education were selected for review by small expert resource groups. The reviews were discussed in June 2003 at a meeting under the auspices of the Canadian Network For Asthma Care and the Canadian Thoracic Society. Data published through December 2004 were subsequently reviewed by the individual expert resource groups.

RESULTS

This report evaluates early-life prevention strategies and focuses on treatment of asthma in children, emphasizing the importance of early diagnosis and preventive therapy, the benefits of additional therapy, and the essential role of asthma education.

CONCLUSION

We generally support previous recommendations and focus on new issues, particularly those relevant to children and their families. This document is a guide for asthma management based on the best available published data and the opinion of health care professionals, including asthma experts and educators.

Implementing practice guidelines: a workshop on guidelines dissemination and implementation with a focus on asthma and COPD

The present supplement summarizes the proceedings of the symposium "Implementing practice guidelines: A workshop on guidelines dissemination and implementation with a focus on asthma and COPD", which took place in Quebec City, Quebec, from April 14 to 16, 2005. This international symposium was a joint initiative of the Laval University Office of Continuing Medical Education (Bureau de la Formation Médicale Continue), the Canadian Thoracic Society and the Canadian Network for Asthma Care, and was supported by many other organizations and by industrial partners. The objectives of this meeting were to examine the optimal implementation of practice guidelines, review current initiatives for the implementation of asthma and chronic obstructive pulmonary disease (COPD) guidelines in Canada and in the rest of the world, and develop an optimal strategy for future guideline implementation. An impressive group of scientists, physicians and other health care providers, as well as policy makers and representatives of patients' associations, the pharmaceutical industry, research and health networks, and communications specialists, conveyed their perspectives on how to achieve these goals. This important event provided a unique opportunity for all participants to discuss key issues in improving the care of patients with asthma and COPD. These two diseases are responsible for an enormous human and socioeconomic burden around the world. Many reports have indicated that current evidence-based guidelines are underused by physicians and others, and that there are many barriers to an effective translation of recommendations into day-to-day care. There is therefore a need to develop more effective ways to communicate key information to both caregivers and patients, and to promote appropriate health behaviours. This symposium contributed to the initiation of what could become the "Canadian Asthma and COPD Campaign", aimed at improving care and, hence, the quality of life of those suffering from these diseases. It is hoped that this event will be followed by other meetings that focus on how to improve the transfer of key recommendations from evidence-based guidelines into current care, and how to stimulate research to accomplish this.

Psychological interventions for adults with asthma

BACKGROUND

Many people have asthma, and for some their symptoms may be triggered by psychological factors. In addition compliance with medical therapy may have a psychological dimension. Therefore, psychological interventions aim to reduce the burden of symptoms and improve management of the disease.

OBJECTIVES

To assess the effectiveness of psychological interventions for adults with asthma.

SEARCH STRATEGY

The Cochrane Airways Group Specialised Register and PsycINFO were searched with pre-defined terms up until August 2005.

SELECTION CRITERIA

Randomised controlled trials published in any language assessing the effects of a psychological intervention compared with a form of control in adult participants were included in the review.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed the relevance of abstracts identified by electronic searching and retrieved agreed studies for further scrutiny. The studies that met the inclusion criteria were assembled and data extracted.

MAIN RESULTS

Fourteen studies, involving 617 particpants, were included in the review, however study quality was poor and sample sizes were frequently small. However, some pooled effects were analysed. The use of 'as needed' medications was reduced in two studies, (47 patients), by relaxation therapy (OR 4.47, CI 1.22 to 16.44). There was no significant difference in FEV1 for relaxation therapy in four studies of 150 patients, (SMD -0.01, CI -0.41 to 0.40). Quality of life, measured using the Asthma Quality of Life Questionnaire in two studies, (48 patients), showed a positive effect following CBT (WMD 0.71, CI 0.23 to 1.19). Peak Expiratory Flow outcome data in two studies, (51 patients), indicated a significant difference in favour of bio-feedback therapy (SMD 0.66, CI 0.09 to 1.23). The remainder of the findings between studies were conflicting. This may have been due to the different types of interventions used and the deficiencies in trial design.

AUTHORS' CONCLUSIONS

This review was unable to draw firm conclusions for the role of psychological interventions in asthma due to the absence of an adequate evidence base. Larger, well-conducted and reported randomised trials are required in this area, in order to determine the effects of these techniques in the treatment of asthma in adults.

A model for a regional system of care to promote the health and well-being of people with rare chronic genetic disorders

People with rare, inherited chronic health conditions, such as hemophilia, face added physical, social, emotional, and fiscal challenges beyond those that are common to more prevalent chronic conditions. In 1975, a partnership among clinicians, consumers, and government agencies created a nationwide regional health delivery system that increased access to clinical care, prevention, and research, thereby improving health outcomes for people with hemophilia in the United States. Today, more than 130 Comprehensive Hemophilia Diagnostic and Treatment Centers in 12 regions serve 70%-80% of the nation's hemophilia patients. Health care leaders and advocates for other rare, expensive, chronic disorders may find that regionalization improves survival and reduces disability among affected populations. However, diverse and stable resources are needed to sustain such a model in our profit-oriented US health care arena.

Clinical practice guidelines: medical follow-up of patients with asthma--adults and adolescents

The follow-up of patients with asthma should focus on asthma control (disease course over a number of weeks).

General practitioner views on barriers and facilitators to implementation of the Asthma 3+ Visit Plan

AIM

The Asthma 3+ Visit Plan is an initiative to promote organised asthma care in general practice. This study aimed to identify factors associated with uptake of the plan by general practitioners, and their views on barriers and facilitators to implementation of the plan.

DESIGN

Postal survey sent to a random sample of GPs.

PARTICIPANTS AND SETTING

315 GPs in five Divisions of General Practice in metropolitan Sydney, surveyed sequentially between 1 October 2002 and 31 May 2003.

OUTCOME MEASURES

Awareness and use of the Asthma 3+ Visit Plan; GP and practice factors associated with use of the plan; and GP views on barriers and facilitators to implementing the plan.

RESULTS

The response rate was 55.7%, and 72.1% of participants were male; participants' mean age was 50.5 years. Most GPs (91.2%) were aware of the plan and and 44.9% had used it. GP and practice factors associated with use of the plan were use of the six-step Australian Asthma Management Plan, confidence in aspects of asthma care, practice accreditation, sign-up for asthma incentives, and computerisation. Major barriers to implementing the plan were workload/paperwork and administrative complexities. Patient factors that influenced completion of the plan were their concept of the severity of their asthma, compliance with follow-up, and patient attitudes towards asthma care.

CONCLUSION

The perceived workload and administrative complexity of the asthma incentives are barriers to uptake. Factors relating to the illness rather than social factors are seen as the most important influences on completion of the plan by patients.

Effectiveness of innovations in nurse led chronic disease management for patients with chronic obstructive pulmonary disease: systematic review of evidence

OBJECTIVE

To determine the effectiveness of innovations in management of chronic disease involving nurses for patients with chronic obstructive pulmonary disease (COPD).

DESIGN

Systematic review of randomised controlled trials.

DATA SOURCES

24 electronic databases searched for English or Dutch language studies published between January 1980 and January 2005.

REVIEW METHODS

Included studies described inpatient, outpatient, and community based interventions for chronic disease management that were led, coordinated, or delivered by nurses. Hospital at home and early discharge schemes for acute exacerbations of COPD were excluded.

RESULTS

We identified nine relevant randomised controlled trials, most of which had some potential methodological flaws. All the interventions seemed to be variations on a case management model. The interventions described could be divided into brief (one month) and longer term (around a year) or more intensive interventions. Only two studies examined the effect of brief interventions, these found little evidence of any benefit. Meta-analysis of the long term interventions failed to detect any influence on mortality at 9-12 months' follow-up (Peto odds ratio 0.85, 95% confidence interval 0.58 to 1.26). There was evidence that the long term interventions had not improved patients' health related quality of life, psychological wellbeing, disability, or pulmonary function. The evidence on whether long term interventions reduced readmissions to hospital was equivocal, but the only study exclusively directed at patients on long term oxygen therapy reported a reduction in readmission. We identified several outcomes where little or no evidence was available; these included patients' satisfaction, self management skills, adherence with treatment recommendations, the likelihood of smoking cessation, and the effect of the interventions on carers.

CONCLUSION

There is little evidence to date to support the widespread implementation of nurse led management interventions for COPD, but the data are too sparse to exclude any clinically relevant benefit or harm arising from such interventions.

Assessment of a therapeutic education programme for asthma patients: "un souffle nouveau"

The aim of this study was to evaluate the impact of a new patient education programme on adults with asthma. This self-management programme included an individual assessment of patient's needs and two educational group sessions. Teaching methods and session content are described as well as caregivers training programme. The training sessions included a written asthma action plan based on symptoms and personal peak expiratory flow. Patients (n = 238) aged from 18 to 60 years were allocated to the intervention (group A) or control group (group B). Patients filled during 1 year a daily diary and questionnaire and they were administered telephone interviews. 127 patients were included in the treatment program and 111 in the control group. There was a significant improvement in the educated group with regard to symptoms free days (P = 0.03), number of awakenings (P = 0.04), consumption of corticosteroids (P = 0.03), consumption of beta2-agonists (P = 0.03), and quality of life score (P = 0.01). In conclusion, this study validates a specific educational approach named "un souffle nouveau".

Is there time for management of patients with chronic diseases in primary care?

PURPOSE

Despite the availability of national practice guidelines, many patients fail to receive recommended chronic disease care. Physician time constraints in primary care are likely one cause.

METHODS

We applied guideline recommendations for 10 common chronic diseases to a panel of 2,500 primary care patients with an age-sex distribution and chronic disease prevalences similar to those of the general population, and estimated the minimum physician time required to deliver high-quality care for these conditions. The result was compared with time available for patient care for the average primary care physician.

RESULTS

Eight hundred twenty-eight hours per year, or 3.5 hours a day, were required to provide care for the top 10 chronic diseases, provided the disease is stable and in good control. We recalculated this estimate based on increased time requirements for uncontrolled disease. Estimated time required increased by a factor of 3. Applying this factor to all 10 diseases, time demands increased to 2,484 hours, or 10.6 hours a day.

CONCLUSIONS

Current practice guidelines for only 10 chronic illnesses require more time than primary care physicians have available for patient care overall. Streamlined guidelines and alternative methods of service delivery are needed to meet recommended standards for quality health care.

Feasibility of collecting diary data from asthma patients through mobile phones and SMS (short message service): response rate analysis and focus group evaluation from a pilot study

Background

Self-management of asthma may improve asthma outcomes. The Internet has been suggested as a tool for the monitoring and self-management of asthma. However, in a recent study we found that a Web interface had some disadvantages and that users stopped using the application after a short while.

Objective

The primary objective of this study was to evaluate, from a user perspective, the feasibility of using short message service (SMS) for asthma diary data collection through mobile phones. The secondary objective was to investigate patient compliance with an SMS diary, as measured by response rates over time.

Methods

The study included quantitative response rate data, based on SMS collection, and qualitative data from a traditional focus group setting. In a period of 2 months, the participants received 4 SMS messages each day, including a medication reminder, a request to enter peak flow, data on sleep loss, and medication dosage. Participants were asked to reply to a minimum of 3 of the messages per day. Diary inputs were collected in a database and the response rate per patient was expressed as the number of diary inputs (SMS replies) divided by diary requests (product of number of days in the study and the number of diary questions per day) for each participant. After the study period, the participants were invited to a focus group interview addressing the participants' attitudes to their disease, their experience with the SMS asthma diary, and their future expectations from the SMS asthma diary.

Results

Twelve patients with asthma (6 males, 6 females) participated in the data collection study. The median age was 38.5 (range: 13 – 57) years. The median response rate per patient was 0.69 (range: 0.03 – 0.98), ie, half the participants reported more than about two thirds of the requested diary data. Furthermore, response rates were relatively steady during the study period with no signs of decreasing usage over time. From the subsequent focus group interview with 9 users we learned that, in general, the participants were enthusiastic about the SMS diary – it became an integrated part of their everyday life. However, the participants wished for a simpler diary with only one SMS message to respond to and a system with a Web interface for system customization and graphical display of diary data history.

Conclusion

This study suggests that SMS collection of asthma diary data is feasible, and that SMS may be a tool for supporting the self-management of asthma (and possibly other chronic diseases) in motivated and self-efficacious patients because mobile phones are a part of people's everyday lives and enable active requests for data wherever the patient is. The combination of SMS data collection and a traditional Web page for data display and system customization may be a better and more usable tool for patients than the use of Web-based asthma diaries which suffer from high attrition rates.

The dose-response relationship of inhaled corticosteroids in asthma

Inhaled corticosteroids are the only class of asthma medication that can reduce symptoms, improve lung function, reduce the frequency of severe exacerbations, including hospital and ICU admissions, and decrease the risk of mortality. The therapeutic dose range for all clinical outcome measures in adults is 100 to 1000 mg/d of beclomethasone dipropionate or budesonide, or 50 to 500 mg/d of fluticasone propionate. Doses in excess of this range are not recommended for routine use because they are likely to increase the risk of systemic side-effects without further major improvement in efficacy. The recommendations are qualified by the recognition that there is considerable individual variability in the response to inhaled corticosteroids in asthma, which would suggest that some patients might obtain greater benefit at higher doses, just as some might obtain maximum benefit at lower doses.

Add-on therapy options in asthma not adequately controlled by inhaled corticosteroids: a comprehensive review

Many patients with persistent asthma can be controlled with inhaled corticosteroids (ICS). However, a considerable proportion of patients remain symptomatic, despite the use of ICS. We present systematically evidence that supports the different treatment options. A literature search was made of Medline/PubMed to identify randomised and blinded trials. To demonstrate the benefit that can be obtained by increasing the dose of ICS, dose-response studies with at least three different ICS doses were identified. To demonstrate whether more benefit can be obtained by adding long-acting beta2-agonist (LABA), leukotriene antagonist (LTRA) or theophylline than by increasing the dose of ICS, studies comparing these options were identified. Thirdly, studies comparing the different "add-on" options were identified. The addition of a LABA is more effective than increasing the dose of ICS in improving asthma control. By increasing the dose of ICS, clinical improvement is likely to be of small magnitude. Addition of a LTRA or theophylline to the treatment regimen appears to be equivalent to doubling the dose of ICS. Addition of a LABA seems to be superior to an LTRA in improving lung function. However, addition of LABA and LTRA may be equal with respect to asthma exacerbations. However, more and longer studies are needed to better clarify the role of LTRAs and theophylline as add-on therapies.

Effectiveness of an education programme by a general practice assistant for asthma and COPD patients: results from a randomised controlled trial

In this study a randomised controlled trial was carried out to investigate the effectiveness of an education programme for patients with asthma or chronic obstructive pulmonary disease (COPD). All asthma and COPD patients using medication and experiencing pulmonary symptoms were randomly assigned to the intervention (n=139) or usual-care group (n=137). The intervention consisted of taylor-made education conducted by a general practice assistant and focussing on a patients' technical skills and coping with the disease. Measurements took place at baseline, and after 1 and 2 years of follow-up. After 1 and 2 years the inhalation technique was significantly better in the intervention group compared to the usual-care group. No significant differences were observed regarding disease symptoms, health related quality of life, compliance, smoking cessation, self-efficacy, and coping. The results only support the implementation of the intervention regarding the technical skills (inhalation technique). However, given the importance of improvement of patients' coping and the need for more efficient care, we recommend further exploration of the possibilities of a more structured and intensive education programme.

Quantitative and qualitative usage data of an Internet-based asthma monitoring tool

BACKGROUND

In May 2000, AstraZeneca launched a Web service for asthma patients and health-care providers called LinkMedica, which includes an asthma diary for monitoring and self-management. In the diary, the patient enters his or her peak flow, number of doses of rescue medication, and if there have been any asthma symptoms during the previous 24 hours. The patient receives an immediate response from LinkMedica, telling him or her if the asthma is under control and what to do if not, eg, increase the dose of inhaled steroid. Health-care providers have access to the patient diary.

OBJECTIVES

The primary objective of the study was to describe patients' and health-care providers' use of LinkMedica. Secondary objectives were to evaluate their perception of the system and how the users' interaction with the system is influenced by their everyday lives.

METHODS

Site statistics regarding number of registered users and diary usage were analyzed. An online survey among users (85 respondents), a mailed questionnaire to health-care providers (131 respondents; response rate 26.8%), as well as in-depth interviews with 10 patients and 5 general practitioners, elicited further quantitative and qualitative data on users' perceptions.

RESULTS

In February 2003, a total of 7653 users had registered. During 2002, the growth in registered users averaged 50 per month. In the same period, the number of unique diary users per month decreased from 307 to 138. Patients usually stopped using the diary after a short time; the doctors were reluctant to introduce the diary to patients because of time constraints. Several user subtypes were identified among patients and their relatives.

CONCLUSION

The self-selected survey responses and in-depth interviews indicated that LinkMedica is generally considered a trustworthy and reliable site by both patients and doctors. However, there was a contrast between users' positive perception of LinkMedica and their unwillingness to use the site for more than short periods. The primary reason for this was that LinkMedica did not fit into their everyday lives because of technical and psychological aspects. A number of recommendations to improve LinkMedica are suggested.

Improving asthma outcomes in harder-to-reach populations: challenges for clinical and community interventions

The burden of asthma differs from country to country and within populations. The factors that influence this variation include asthma prevalence and severity, aspects of healthcare services (such as accessibility, quality and utilisation) and social demographic factors (such as income inequality, cultural and linguistic diversity and indigenous populations). The identification of individuals and populations that are 'harder to reach', 'special' or at greater risk of poor asthma outcomes therefore depends on how the burden of asthma and its management are measured. Meeting the challenge of educating harder-to-reach populations with asthma is the focus of this article. In clinical settings, communication is the mainstay of engaging and building trust to influence behavioural change in individuals; community-based interventions provide valuable opportunities for targeting harder-to-reach populations. However, they require active community consultation and participation and innovative approaches to service delivery, in addition to being theoretically driven and systematically developed.

Adjustable and fixed dosing with budesonide/ formoterol via a single inhaler in asthma patients: the ASSURE study

Patient-guided management of asthma using adjustable dosing of budesonide/formoterol in a single inhaler (Symbicort) was compared with fixed dosing in an open-label, multicentre, randomised study. Patients, uncontrolled on an inhaled corticosteroid (ICS) or controlled on an ICS and a long-acting beta2-agonist, entered a 4-week run-in period and received budesonide/formoterol (80/4.5 or 160/4.5 microg), 2 inhalations b.i.d. Following randomisation, the fixed-dosing group (n = 764) continued this regimen for a further 12 weeks. The adjustable-dosing group (n = 775) could step down to 1 inhalation b.i.d. if symptoms were controlled, and, at early signs of worsening symptoms, promptly step up to 4 inhalations b.i.d. for < or = 2 weeks. During run-in, National Heart, Lung and Blood Institute symptom-severity grading was maintained in 60% and improved in 31% of patients, clinic peak flow increased from 400 to 4191/min (P<0.001), and health-related quality of life (overall MiniAQLQ) improved from 4.6 to 5.4 (P<0.001). Patients effectively used the adjustable-dosing regimen; 79% reduced budesonide/formoterol dosage and, compared with fixed dosing, the number of inhalations were significantly lowered (3.2 vs. 3.8 inhalations/day, P<0.05). Both regimens were well tolerated. In both groups, symptom control was maintained or improved in 85-86% of patients, and 94% experienced no treatment failures. Consistent with current guidelines, adjustable maintenance dosing with budesonide/formoterol in a single inhaler provides effective asthma control at reduced medication doses.

Corticosteroid therapy for acute asthma

Asthma is a chronic inflammatory disease, which is characterised by reversible airflow obstruction in response to a variety of stimuli. Exacerbations in response to airway irritants are part of the natural history of asthma, but often they also represent a failure in chronic treatment. Presentations to emergency departments and other acute care settings are common and frequently lead to hospitalisation and other complications. After treatment, however, most patients are discharged to the care of their primary care physician for further management. This review highlights the role of systemic and inhaled corticosteroids as mainstays of treatment in the acute and sub-acute phase of an exacerbation. These agents form the basis of most current clinical practice guidelines, yet their use is not universal. We will review the evidence for the use of these agents that arises from the Cochrane Collaboration of Systematic Reviews contained in the Cochrane Library.

Health promotion through self-care and community participation: elements of a proposed programme in the developing countries

BACKGROUND

The concepts of health promotion, self-care and community participation emerged during 1970s, primarily out of concerns about the limitation of professional health system. Since then there have been rapid growth in these areas in the developed world, and there is evidence of effectiveness of such interventions. These areas are still in infancy in the developing countries. There is a window of opportunity for promoting self care and community participation for health promotion.

DISCUSSION

A broad outline is proposed for designing a health promotion programme in developing countries, following key strategies of the Ottawa Charter for health promotion and principles of self care and community participation. Supportive policies may be framed. Self care clearinghouses may be set up at provincial level to co-ordinate the programme activities in consultation with district and national teams. Self care may be promoted in the schools and workplaces. For developing personal skills of individuals, self care information, generated through a participatory process, may be disseminated using a wide range of print and audio-visual tools and information technology based tools. One such potential tool may be a personally held self care manual and health record, to be designed jointly by the community and professionals. Its first part may contain basic self care information and the second part may contain outlines of different personally-held health records to be used to record important health and disease related events of an individual. Periodic monitoring and evaluation of the programme may be done. Studies from different parts of the world indicate the effectiveness and cost-effectiveness of self care interventions. The proposed outline has potential for health promotion and cost reduction of health services in the developing countries, and may be adapted in different situations.

SUMMARY

Self care, community participation and health promotion are emerging but dominant areas in the developed countries. Elements of a programme for health promotion in the developing countries following key principles of self care and community participation are proposed. Demonstration programmes may be initiated to assess the feasibility and effectiveness of this programme before large scale implementation.

Conceptual framework for a new tool for evaluating the quality of diabetes consumer-information Web sites

BACKGROUND

Most existing tools for measuring the quality of Internet health information focus almost exclusively on structural criteria or other proxies for quality of information, rather than evaluating information accuracy and comprehensiveness.

OBJECTIVE

This research sought to build a conceptual framework that could lay the groundwork for a robust performance-measurement system for evaluating the quality of Internet health information.

METHODS

Application of the quality-of-care measurement paradigm to developing a conceptual framework for defining and evaluating the quality of diabetes consumer-information Web sites.

RESULTS

Performance measures related to accuracy and comprehensiveness of information can be added to structural criteria to provide a more-robust approach to Web site evaluation.

CONCLUSIONS

The development and implementation of a reliable and valid method for evaluating the quality of Internet health sites could provide lay people with a tool to identify useful content more easily and distinguish between beneficial and misleading information.

Proactive asthma care in childhood: general practice based randomised controlled trial

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.

Management of asthma in adults: current therapy and future directions

Asthma is increasing in prevalence worldwide and results in significant use of healthcare resources. Although most patients with asthma can be adequately treated with inhaled corticosteroids, an important number of patients require additional therapy and an increasing number of options are available. A further minority of patients develop severe persistent asthma which remains difficult to manage despite current pharmacological therapies. This review discusses the various treatment options currently available for each stage of asthma severity, highlights some of the limitations of current management, and outlines directions which may improve the management of asthma in the future.

Bridging the gap between doctors' and patients' expectations of asthma management

OBJECTIVES

To assess the prevalence of asthma symptoms, their impact on daily activities, and perceptions of disease severity among people with asthma.

METHODS

A telephone survey of 699 people with asthma was conducted in 1999 in metropolitan and nonmetropolitan New South Wales, Victoria, and Queensland, Australia.

RESULTS

Forty-two percent of adults and 26% of children reported experiencing asthma symptoms at least every 2-3 days. Thirty-seven percent of adults and 26% of children reported using a reliever more than four times in the previous week. Of those for whom preventer therapy had been prescribed (61% of respondents), 30% of children and 45% of adults did not use their preventer as instructed. A high proportion of respondents reported avoiding physical and social activities because of their asthma, while 75% said asthma generally made them feel tired. Many respondents attributed frustration (61%), irritability (57%), fear (38%), and worry (43%) to their asthma. Only 50% of respondents had been reviewed by a general practitioner for asthma in the past year. Respondents generally underestimated the severity of their asthma, compared with symptom frequencies reported.

CONCLUSIONS

The Living with Asthma Survey suggests that national asthma management goals are not being achieved in a high proportion of patients, with evidence for both underprescribing and underusage of preventer medication. Achieving closer alignment between medical and patient perspectives is an important goal of asthma education and management in order to help bridge the gap between current concepts of best practice and the reality of persistently poor asthma outcomes.

Gastro-oesophageal reflux disease and motility disorders

Gastro-oesophageal reflux (GOR) is a common phenomenon occurring at any age with a benign prognosis in the majority of cases, but requiring prompt evaluation and treatment when presenting with alarm symptoms or when persisting. Complications of GOR disease (GORD) may be severe. This chapter will discuss the epidemiology, natural course, pathophysiology, clinical presentation, diagnostic and therapeutic approach towards GORD and motility disorders according to different ages. Similarities and differences between infants, children and adults will be highlighted. The superior efficacy and safety of proton pump inhibitors have recently changed the diagnostic and therapeutic recommendations in adults, and possible indications in children are discussed. Only in patients unresponsive to optimal medical treatment are further investigations to exclude other aetiologies for GORD needed (e.g. eosinophilic oesophagitis in infants, scleroderma in adults). Special patient groups such as those with congenital malformations (e.g. oesophageal atresia) are not considered, whereas neurological, respiratory and allergy-affected patients as well as Helicobacter pylori infection are briefly discussed.

Accessibility, acceptability, and effectiveness in primary care of routine telephone review of asthma: pragmatic, randomised controlled trial

OBJECTIVE

To determine whether routine review by telephone of patients with asthma improves access and is a good alternative to face to face reviews in general practices.

DESIGN

Pragmatic, randomised controlled trial.

SETTING

Four general practices in England.

PARTICIPANTS

278 adults who had not been reviewed in the previous 11 months.

INTERVENTION

Participants were randomised to either telephone review or face to face consultation with the asthma nurse.

MAIN OUTCOME MEASURES

Primary outcome measures were the proportion of participants who were reviewed within three months of randomisation and disease specific quality of life, as measured by the Juniper mini asthma quality of life questionnaire. Secondary outcome measures included the validated "short Q" asthma morbidity score, nursing care satisfaction questionnaire score, and length of consultation.

RESULTS

Of 137 people randomised to telephone consultation, 101 (74%) were reviewed, compared with 68 reviewed (48%) of the 141 people in the surgery group, a difference of 26% (95% confidence interval 14% to 37%; P<0.001; number needed to treat 3.8). Three months after randomisation the two groups did not differ in the Juniper score (risk difference -0.07 (95% confidence interval -0.40 to 0.27) or in satisfaction with the consultation (risk difference -0.07 (-0.27 to 0.13)). Telephone consultations were on average 10 minutes shorter than reviews held in the surgery (mean difference 10.7 minutes (12.6 to 8.8; P<0.001)).

CONCLUSIONS

Compared with face to face consultations in the surgery, telephone consultations enable more people with asthma to be reviewed, without clinical disadvantage or loss of satisfaction. A shorter duration means that telephone consultations are likely to be an efficient option in primary care for routine review of asthma.

A qualitative study of action plans for asthma

OBJECTIVES

To investigate the perspectives of patients with asthma on the use of an action plan and the implementation of this plan during an asthma attack that culminated in a visit to an emergency department.

DESIGN

Qualitative study.

SETTING

Tertiary teaching hospital, suburban hospital, and rural hospital.

PARTICIPANTS

62 patients aged 18 to 69 years who presented to an emergency department with asthma over a two month period.

RESULTS

29 participants described having action plans given to them by their doctors. Most patients with action plans reinterpreted their plan from the perspective of their own experiences with asthma. 33 patients did not have an action plan, the most common reason being that they had not been given one by their doctor. Some occupational groups were significantly less likely to have been given an action plan by their doctor than others. Most patients with an action plan found them useful for management of their asthma.

CONCLUSIONS

Action plans were viewed positively by patients. Participants modified their prescribed plan according to their experience of asthma. To facilitate the implementation of a prescribed action plan, doctors need to acknowledge and include the patient's personal experience of their disease.

Poor readability of written asthma management plans found in national guidelines

OBJECTIVE

Written asthma management plans (WAMPs) for patients constitute a key component of current national asthma guidelines, but it is not known whether these plans meet the readability standards (of fifth-grade level or lower) recommended by health education experts. The objective of this study was to assess whether WAMPs presented in national guidelines are written at or below a fifth-grade reading level.

METHODS

We used readability software to analyze 10 WAMPs. These included 7 from the national guidelines, 1 from the World Health Organization, and 2 local ones.

RESULTS

The grade levels for the WAMPs ranged from 4.9 to 9.2. None of the national plans achieved a grade level equal to or below the fifth grade. However, the other plans had grade levels of 4.9, 5.7, and 5.9. The mean grade level for the national plans was 8.1, whereas the mean for the other 3 plans was 5.5. The difference between these 2 sets of WAMPs was significant.

CONCLUSION

WAMPs presented as part of the national guidelines are not written at or below a fifth-grade reading level. However, it is clear from this study that it is possible to achieve this level of readability. Increasing the availability and use of plans that meet recognized readability standards may help to improve asthma outcomes, especially in poor populations in which there is both low literacy and the greatest prevalence and severity of asthma.

Changing approaches to asthma management in Australia: effects on asthma morbidity

Asthma is an important public health issue in Australia and is responsible for significant morbidity and mortality in the community. Recognition of the impact of asthma on the health of Australians, and the apparent failure of new medications to reduce mortality and hospital admission rates resulted in a major review by the stakeholders in asthma care. This led to new approaches to asthma management based on strategic use of asthma medications and the development of the Asthma Management Plan (AMP). The AMP drew together current understanding of asthma to develop a simple stepwise approach to management that could be readily applied in patient management. The National Asthma Campaign (NAC), a coalition of the major stakeholders in asthma care, was launched in 1990 to lead the dissemination of the AMP. In association with other organisations interested in asthma care in Australia, the NAC has developed the AMP, and co-ordinated a decade of education and advocacy about asthma that targeted doctors, health professionals and the general public. These activities have been successful in raising awareness about asthma in the community. However, recent research, while demonstrating the continued uptake of written asthma action plans for asthma and decrease in use of inhaled bronchodilator medications, reported a decrease in use of preventive therapy by people with asthma. These activities have had a sustained impact on asthma-related health outcomes with mortality at the lowest level since 1960 and a decline in hospital readmission rates. This is useful information because there is sound evidence that the prevalence and possibly severity of asthma in children has increased. However, review of management in primary care and among people who present to emergency services with acute asthma suggest that many people continue to manage their asthma poorly. Continued education is needed to build on the progress that has been made. There are opportunities to do this through efforts to integrate general practitioners into the wider health system through the formation of Divisions of General Practice. Recognition of asthma as a health priority area at a national level will help to enhance and maintain awareness of the public health importance of asthma and facilitate the further development of the initiatives begun during the last decade or more.

Influences on hospital admission for asthma in south Asian and white adults: qualitative interview study

OBJECTIVE

To explore reasons for increased risk of hospital admission among south Asian patients with asthma.

DESIGN

Qualitative interview study using modified critical incident technique and framework analysis.

SETTING

Newham, east London, a deprived area with a large mixed south Asian population.

PARTICIPANTS

58 south Asian and white adults with asthma (49 admitted to hospital with asthma, 9 not admitted); 17 general practitioners; 5 accident and emergency doctors; 2 out of hours general practitioners; 1 asthma specialist nurse.

MAIN OUTCOME MEASURES

Patients' and health professionals' views on influences on admission, events leading to admission, general practices' organisation and asthma strategies, doctor-patient relationship, and cultural attitudes to asthma.

RESULTS

South Asian and white patients admitted to hospital coped differently with asthma. South Asians described less confidence in controlling their asthma, were unfamiliar with the concept of preventive medication, and often expressed less confidence in their general practitioner. South Asians managed asthma exacerbations with family advocacy, without systematic changes in prophylaxis, and without systemic corticosteroids. Patients describing difficulty accessing primary care during asthma exacerbations were registered with practices with weak strategies for asthma care and were often south Asian. Patients with easy access described care suggesting partnerships with their general practitioner, had better confidence to control asthma, and were registered with practices with well developed asthma strategies that included policies for avoiding hospital admission.

CONCLUSIONS

The different ways of coping with asthma exacerbations and accessing care may partly explain the increased risk of hospital admission in south Asian patients. Interventions that increase confidence to control asthma, confidence in the general practitioner, understanding of preventive treatment, and use of systemic corticosteroids in exacerbations may reduce hospital admissions. Development of more sophisticated asthma strategies by practices with better access and partnerships with patients may also achieve this.

Qualitative study of views of health professionals and patients on guided self management plans for asthma

OBJECTIVES

To explore the views held by general practitioners, practice nurses, and patients about the role of guided self management plans in asthma care.

DESIGN

Qualitative study using nine focus groups that each met on two occasions.

SETTING

South Wales.

SUBJECTS

13 asthma nurses, 11 general practitioners (six with an interest in asthma), and 32 patients (13 adults compliant with treatment, 12 non-compliant adults, and seven teenagers).

RESULTS

Neither health professionals nor patients were enthusiastic about guided self management plans, and, although for different reasons, almost all participants were ambivalent about their usefulness or relevance. Most professionals opposed their use. Few patients reported sustained use, and most felt that plans were largely irrelevant to them. The attitudes associated with these views reflect the gulf between the professionals' concept of the "responsible asthma patient" and the patients' view.

CONCLUSIONS

Attempts to introduce self guided management plans in primary care are unlikely to be successful. A more patient centred, patient negotiated plan is needed for asthma care in the community.