Joseph Legge

Reducing hospital admission through computer supported education for asthma patients. Grampian Asthma Study of Integrated Care (GRASSIC).

Abstract Objective : To evaluate a personalised computer supported education programme for asthma patients. Design : Pragmatic randomised trial comparing outcomes over 12 months between patients taking part in an enhanced education programme (four personalised booklets, sent by post) and patients receiving conventional oral education at outpatient or surgery visits. Setting : Hospital outpatient clinics and general practices in north east Scotland. Subjects : 801 adults attending hospital outpatient clinics, with a diagnosis of asthma confirmed by a chest physician and pulmonary function reversibility of at least 20%. Main outcome measures : Numbers of hospital admissions, consultations with general practioner for asthma, steroid courses used, bronchodilators and inhaled steroids prescribed, days of restricted activity, and disturbed nights. Results : Patients with asthma judged too severe for randomisation between clinic care and integrated care and thuse retained in clinic care had 54% fewer hospital admissions after receiving enhanced education than did the control group (95% confidence interval 30% to 97%; P<0.05) over the study year. Patients had not all spent a full year as “educated” patients within the study year: when “educated days” were controlled for, annual admission rates for the entire enhanced education group were 49% (31% to 78%) of those in the control group. Among patients with sleep variation, sleep disturbance in the education group in the week before a regular review was 80% (65% to 97%) of that in the control group. There was no significant difference in days of restricted activity, prescription of bronchodilators or inhaled steroids, use of oral steroids, or number of general practioner consultations for asthma, and no significant interaction between ownership of a peak flow meter and education. Conclusions : An asthma education programme based on computerised booklets can reduce hospital admissions and improve morbidity among hospital outpatients.

Effectiveness of routine self monitoring of peak flow in patients with asthma

Abstract Objective : To evaluate the effectiveness of routine self monitoring of peak flow for asthma outpatients. Design : Pragmatic randomised trial. Setting : Hospital outpatient clinics and general practices in north east Scotland. Main outcome measures : Use of bronchodilators and inhaled and oral steroids; number of general practice consultations and hospital admissions for asthma; sleep disturbance and other restrictions on normal activity; psychological aspects of health including perceived control of asthma. Results : After one year there were no significant differences between patients randomised between self monitoring of peak flow and conventional monitoring. However, those given a peak flow meter recorded an increase in general practice consultations that was nearly significant. Among patients whose asthma was judged on entry to be more severe, those allocated to self monitoring used more than twice as many oral steroids (2.2; 95% confidence interval 1.1 to 4.6). Patients who already possessed a peak flow meter at the start of the study recorded higher morbidity over the course of the year than those eligible for randomisation. Conclusion : Prescribing peak flow meters and giving self management guidelines to all asthma patients is unlikely to improve mortality or morbidity.Patients whose asthma is severe may benefit from such an intervention.

Integrated care for asthma: a clinical, social, and economic evaluation

Abstract Objective : To evaluate integrated care for asthma in clinical, social, and economic terms. Design : Pragmatic randomised trial. Setting : Hospital outpatient clinics and general practices throughout the north east of Scotland. Patients : 712 adults attending hospital outpatient clinics with a diagnosis of asthma confirmed by a chest physician and pulmonary function reversibility of at least 20%. Main outcome measures : Use of bronchodilators and inhaled and oral steroids; number of general practice consultations and hospital admissions for asthma; sleep disturbance and other restrictions on normal activity; pyschological aspects of health including perceived asthma control; patient satisfaction; and financial costs. Results : After one year there were no significant overall differences between those patients receiving integrated asthma care and those receiving conventional outpatient care for any clinical or psycho-social outcome. For pulmonary function, forced expiratory volume was 76% of predicted for integrated care patients and 75% for conventional outpatients (95% confidence interval for difference -3.6% to 5.0%). Patients who had experienced integrated care were more likely to select it as their preferred course of future management (75% (251/ 333) v 62% (207/333) (6% to 20%); they saved pounds sterling 39.52 a year. This was largely because patients in conventional outpatient care consulted their general practioner as many times as those in integrated care, who were not also visiting hospital. Conclusion : Integrated care for moderately severe asthma patients is clinically as effective as conventional outpatient care, cost effective, and an attractive management option for patients, general practioners, and hospital consultants.

The prevalence of adult onset wheeze: longitudinal study

In contrast to wheeze in childhood, less is known about the prevalence of and factors associated with wheeze in adulthood. We studied the onset of wheezing in adults who had had no respiratory symptoms as children. A 1964 random community survey in Aberdeen of 2511 children aged 10-14 years identified 121 children with asthma and 167 with wheeze with infection. The outcome at age 34-40 years of these children with wheeze, together with that of 167 children selected from those who were asymptomatic, has been described.1 In 1995 we tried to contact the 2056 individuals (now aged 39-45 years) who had had no childhood wheezing; 1799 subjects were traced. We posted questionnaires about symptoms, smoking, and employment to 1758 surviving subjects, of whom 1542 (87.7%) responded (75.0% of 2056). Attacks of wheezing ever …

Outcome of wheeze in childhood: the influence of atopy

We have previously demonstrated that the adult outcome of childhood asthma differs from that of wheeze occurring only in the presence of infection. This paper examines the role of atopy in relation to outcome. We investigated the atopic status, current symptoms and bronchial reactivity to methacholine of 235 subjects aged 34-40 yrs, originally classified at age 10-15 yrs as having asthma (asthma group), wheeze only in the presence of infection (wheezy group), or no respiratory symptoms (comparison group). Subjects from the original asthma group were more likely to be atopic as defined by skin test reactivity, total serum immunoglobulin E (IgE) measurement or specific IgE radio allergosorbent test (RAST) measurement than those from the wheezy group. The wheezy group differed significantly from the reference group only in RAST results, when other variables were taken into account. In a logistic regression model, the important independent predictors for adult wheezing symptoms were original group, atopy and current smoking. Methacholine responsiveness was independently associated with original group (the asthma group were more likely to respond positively), atopy and female gender. The results suggest that atopy is an important predictor for wheeze and bronchial hyperreactivity in middle age. However, the difference in outcome for children who had asthma compared to those who had wheeze only in the presence of infection cannot be explained by atopy alone.

Integrated care for asthma: matching care to the patient

The purpose of the present study was to investigate whether criteria associated with assignment of asthma patients between general practice (GP) care alone, integrated care (shared between GP care and hospital clinic) or conventional specialist review could be identified, and whether outcomes for these patients differed over the next 12 months. Seven hundred and sixty four patients with a diagnosis of asthma and previously assigned to either integrated care or clinic care were reviewed after 1 year and reassigned. These patients were then followed for another 12 months and clinical data were collected over this time. After 12 months in clinic care or integrated care, assignment to integrated care was predicted by previous participation in integrated care (OR 2.94), patient preference for integrated care (OR 3.7), no admission (OR 1.56), fewer steroid courses during the previous year (OR 0.88) and nonattendance at review (OR 0.43) in the previous 12 months. Patient discharge to GP care was predicted by higher level of forced expiratory volume in one second (FEV1) (OR 1.49), lower number of GP consultations for troublesome asthma (OR 0.78), and nonattendance for review in the preceding year (OR 2.15). In the following 12 months, the three groups of patients differed significantly in hospital admissions (Discharged = 0.008; Integrated = 0.12; Clinic = 0.31), bronchodilators prescribed (Discharged = 8.5; Integrated = 10.2; Clinic = 13.9), GP consultations (Discharged = 1.3; Integrated = 3.0; Clinic = 4.1) and oral steroid courses (Discharged = 0.62; Integrated = 1.7; Clinic = 2.4). Patients assigned to integrated care, clinic care or discharged to general practice care form three distinct patient populations differing retrospectively and prospectively in morbidity and admission risk. In particular, patients assigned to integrated care fall midway in risk and morbidity between those discharged or those retained in clinic care. These results suggest that integrated care provides general practitioners with a system of management for asthma patients, for whom they do not wish frequent specialist review but who they do not believe can safely be discharged to general practice care only.

Asthma trends Causes of wheeze and asthma may differ

EDITOR, - Two papers report the outcome of childhood asthma in Tasmania1 and Melbourne2 in subjects now in their 30s. We reported a 25 year follow up of schoolchildren in Aberdeen3,4 and think that our findings influence the interpretation of these Australian papers. In the 1964 random community survey that provided the baseline for our study, subjects were classified as having asthma, “wheeze in the presence of respiratory infection” (wheezy bronchitis), or no respiratory symptoms (comparison subjects).5 Review after 25 years of subjects from each group showed that 61% of those who had had asthma in childhood continued to wheeze in adult life, compared with 30% of those who had had wheezy bronchitis; 11% of the comparison subjects had developed wheeze since the original study. Of the subjects who had not had symptoms in childhood who were reviewed by Mark A Jenkins and colleagues, 10.6% had developed symptoms by the age of 29-32,1 a similar percentage to that in our study. Of those who had had symptoms in childhood, 25.6% continued to experience symptoms as adults, a much smaller percentage than we had found. The reason for the difference from our results may lie in the ages at the time of the original studies: the Tasmanian children were identified at age 7, while ours were selected at 10 to 15, when a number of wheezy children would have already grown out of their symptoms. Another explanation may lie in the definition of symptoms in adults: Jenkins and colleagues defined them as the “occurrence of an asthma attack within the previous 12 months,” which is a more stringent definition than that used in our study (wheeze in the past 12 months) or the study by Helmut Oswald and colleagues (wheeze in the past three …