Anna Eleri Livingstone

Specialist nurse intervention to reduce unscheduled asthma care in a deprived multiethnic area: the east London randomised controlled trial for high risk asthma (ELECTRA)

Objective To determine whether asthma specialist nurses, using a liaison model of care, reduce unscheduled care in a deprived multiethnic area. Design Cluster randomised controlled trial. Setting 44 general practices in two boroughs in east London. Participants 324 people aged 4-60 years admitted to or attending hospital or the general practitioner out of hours service with acute asthma; 164 (50%) were South Asian patients, 108 (34%) were white patients, and 52 (16%) were from other, largely African and Afro-Caribbean, ethnicities. Intervention Patient review in a nurse led clinic and liaison with general practitioners and practice nurses comprising educational outreach, promotion of guidelines for high risk asthma, and ongoing clinical support. Control practices received a visit promoting standard asthma guidelines; control patients were checked for inhaler technique. Main outcome measures Percentage of participants receiving unscheduled care for acute asthma over one year and time to first unscheduled attendance. Results Primary outcome data were available for 319 of 324 (98%) participants. Intervention delayed time to first attendance with acute asthma (hazard ratio 0.73, 95% confidence interval 0.54 to 1.00; median 194 days for intervention and 126 days for control) and reduced the percentage of participants attending with acute asthma (58% (101/174) v 68% (99/145); odds ratio 0.62, 0.38 to 1.01). In analyses of prespecified subgroups the difference in effect on ethnic groups was not significant, but results were consistent with greater benefit for white patients than for South Asian patients or those from other ethnic groups. Conclusion Asthma specialist nurses using a liaison model of care reduced unscheduled care for asthma in a deprived multiethnic health district. Ethnic groups may not benefit equally from specialist nurse intervention.

Do people living near inner city main roads have more asthma needing treatment? Case-control study

Hospital admissions for asthma in east London are 80% above the national rates. This may reflect the high incidence of acute asthma. Recent reports of a higher prevalence of wheeze1 2 or hospital admissions in children in association with traffic flow or proximity of residence to roads3 have highlighted concerns about the possible health effects of road traffic in the London Borough of Tower Hamlets. In each of two computerised general practices in Tower Hamlets around 20% of the population have received computer prescriptions for bronchodilators, inhaled steroids, or inhaled anti-inflammatory drugs since 1990. The diagnostic computer coding for asthma showed a prevalence of treated asthma of 9% in one practice and 17% in the other (unpublished observation). We examined whether the proximity of residence to main roads was associated with these high prescribing rates for asthma in the two inner city practices. This case-control study took place in June 1994 in two adjacent general practices located near …

Effect of an Education Programme for SOuth Asians with Asthma and Their Clinicians: A Cluster Randomised Controlled Trial (OEDIPUS)

Background People with asthma from ethnic minority groups experience significant morbidity. Culturally-specific interventions to reduce asthma morbidity are rare. We tested the hypothesis that a culturally-specific education programme, adapted from promising theory-based interventions developed in the USA, would reduce unscheduled care for South Asians with asthma in the UK. Methods A cluster randomised controlled trial, set in two east London boroughs. 105 of 107 eligible general practices were randomised to usual care or the education programme. Participants were south Asians with asthma aged 3 years and older with recent unscheduled care. The programme had two components: the Physician Asthma Care Education (PACE) programme and the Chronic Disease Self Management Programme (CDSMP), targeted at clinicians and patients with asthma respectively. Both were culturally adapted for south Asians with asthma. Specialist nurses, and primary care teams from intervention practices were trained using the PACE programme. South Asian participants attended an outpatient appointment; those registered with intervention practices received self-management training from PACE-trained specialist nurses, a follow-up appointment with PACE-trained primary care practices, and an invitation to attend the CDSMP. Patients from control practices received usual care. Primary outcome was unscheduled care. Findings 375 south Asians with asthma from 84 general practices took part, 183 registered with intervention practices and 192 with control practices. Primary outcome data were available for 358/375 (95.5%) of participants. The intervention had no effect on time to first unscheduled attendance for asthma (Adjusted Hazard Ratio AHR = 1.19 95% CI 0.92 to 1.53). Time to first review in primary care was reduced (AHR = 2.22, (1.67 to 2.95). Asthma-related quality of life and self-efficacy were improved at 3 months (adjusted mean difference -2.56, (-3.89 to -1.24); 0.44, (0.05 to 0.82) respectively. Conclusions A multi-component education programme adapted for south Asians with asthma did not reduce unscheduled care but did improve follow-up in primary care, self-efficacy and quality of life. More effective interventions are needed for south Asians with asthma.

Clinical governance requirements are needed now

My first consultation regarding metal-on-metal hip replacements came last week when a patient expressed concern.1 The type of prosthesis was stated nowhere in the …

Screen more widely

Now that testing for vitamin D is easy, we are overwhelmed by evidence of deficiency.1 In the past two years 10% (1085) …

Coding issues at the coalface

As GPs providing antenatal care in multiethnic inner city Tower Hamlets, we welcome Shakespeare’s editorial on antenatal haemoglobinopathy that promotes general practice screening of the woman and her partner before or during early pregnancy.1 We also welcome the SHIFT …

Perineal repair after spontaneous vaginal birth

the revolution of 1979 are gradually being reduced, such as music being freely played and listened to, although satellite television is still not permitted. I can heartily recommend a working visit. The doctors and other people do feel isolated from other parts of the world, as indeed has been the purpose of the US embargo. I noticed exactly the same in Iraq last year. A visit will be extraordinarily appreciated (I was told I was the first ever foreign visitor to the medical school), and you will undoubtedly make friends. Historically we have much to make amends for and I hope medical organisations here will make contact with their Iranian (and Iraqi) counterparts to enhance relations in their hour of need. Chris Burns-Cox

Health promotion in general practice. Doctors have a duty to the whole community.

Editor,--The Oxcheck Researchers and the Family Heart Study Group doubt whether multifactorial risk ascertainment and counselling of whole populations are worth the effort.1 2 What, however, did they expect from a population approach? Optimistically these studies might lead to a reduction in mortality from ischaemic heart disease of 4-8%. This compares with an annual fall in mortality from this cause currently around 7%. Sustaining change with margins of 1-2% is made easier by realistic expectations. The lower than average risk in the study populations makes …