Integrated care for asthma: matching care to the patient

Abstract

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. Eur Respir J., 1996, 9, 444-448 In medical systems which have two tiered patient care, (specialist out-patient clinics and general practice (GP) care) it is believed that specialist care allows greater costeffectiveness and the focusing of clinical expertise. However, it can be associated with gaps in communication between the specialist who sees the patient at regular intervals in an out-patient clinic and the GP, who sees the patient irregularly and at times of crisis with little knowledge of what is being provided in the specialist clinic. Shared care is intended to address these problems of communication and to offer patients care in general practice which has the support of specialist expertise. Shared care has been defined as "the joint participation of hospital consultants and general practitioners in the planned delivery of care for patients with ...

Patient weighting of importance of asthma symptoms

“…All patients were or had been in a “shared care” scheme12 between the hospital adult clinic and general practice. These patients are managed by their general practice with one annual review at the specialist clinic.…”

British Guideline on the Management of Asthma

“…646 Integrated care schemes such as Grampian Asthma Study in Integrated Care (GRASSIC) suggest that place of care is not directly linked to clinical outcome. [647][648][649][650] Shared care had a similar outcome to outpatient care. Outreach support for primary care by asthma specialist nurses may reduce unscheduled asthma care but only if targeted around follow-up of patients recently attending secondary care with exacerbations.…”

Content and Outcomes of Dutch Nurse Clinics for Children with Asthma

“…Colland's study (18) also concluded that asthmatic children who followed a behavioral self-management program (consisting of 10 weekly 1-hour education sessions with a group of six to eight children) had a lower health care consumption. Other research also indicated that the implementation of an education program for asthmatic patients, which are mainly informative, resulted in a decline in the use of health care services (13,17,(19)(20)(21)(22). Consequently, on the basis of the current underlying study and other research, it can be concluded that education programs for asthmatics in general and nurse clinics for asthmatic children in particular result in a decline in asthmatic patients' use of health care services.…”