Managing complex respiratory patients in the community: an evaluation of a pilot integrated respiratory care service

Abstract

IntroductionIn the UK, there is significant variation in respiratory care and outcomes. An integrated approach to the management of high-risk respiratory patients, incorporating specialist and primary care teams' expertise, is the basis for new integrated respiratory services designed to reduce this variation; however, this model needs evaluating.MethodsTo evaluate an integrated service managing high-risk respiratory patients, electronic searches for patients with asthma and chronic obstructive pulmonary disease at risk of poor outcomes were performed in two general practitioner (GP) practices in a local service-development initiative. Patients were reviewed at joint clinics by primary and secondary care professionals. GPs also nominated patients for inclusion. Reviews were delivered to best standards of care including assessments of diagnosis, control, spirometry, self-management, education, medication, inhaler technique and smoking cessation support. Follow-up of routine clinical data collected at 9-months postclinic were compared with seasonally matched 9-months prior to integrated review.Results82 patients were identified, 55 attended. 13 (23.6%) had their primary diagnosis changed. In comparison with the seasonally adjusted baseline period, in the 9-month follow-up there was an increase in inhaled corticosteroid prescriptions of 23.3%, a reduction in short-acting β2-agonist prescription of 33.3%, a reduction in acute respiratory exacerbations of 67.6%, in unscheduled GP surgery visits of 53.3% and acute respiratory hospital admissions reduced from 3 to 0. Only 4 patients (7.3%) required referral to secondary care. Health economic evaluation showed respiratory-related costs per patient reduced by £231.86.ConclusionsPatients with respiratory disease in this region at risk of suboptimal outcomes identified proactively and managed by an integrated team improved outcomes without the need for hospital referral.

Implementation of interventions to reduce preventable hospital admissions for cardiovascular or respiratory conditions: an evidence map and realist synthesis

“…Two UK research studies on specialist clinics published from 2010 onwards were identified from the mapping review. 219,220 One of the clinics was for patients with hypertension 219 and one was for high-risk respiratory patients with COPD or asthma. 220 The research studies were both quantitative: one was a RCT 219 and the other was an uncontrolled observational study.…”

“…219,220 One of the clinics was for patients with hypertension 219 and one was for high-risk respiratory patients with COPD or asthma. 220 The research studies were both quantitative: one was a RCT 219 and the other was an uncontrolled observational study. 220 A summary table of the included studies is provided (see Appendix 4, Table 31).…”

“…220 The research studies were both quantitative: one was a RCT 219 and the other was an uncontrolled observational study. 220 A summary table of the included studies is provided (see Appendix 4, Table 31).…”

“…The observational study found a reduction in acute respiratory exacerbations, unscheduled visits to GPs and hospital admissions for acute respiratory exacerbations. 220 Linking to the GP programme theory, PT5, potentially several aspects of the UK RCT 219 had a beneficial effect on patient blood pressure. One aspect was a letter about the clinic and explaining that they had been invited as their last recorded blood pressure reading was higher than recommended levels.…”

Rebuttal From Dr Hitsman et al

“…5 Integrated care models incorporating specialist respiratory and primary care expertise are associated with improved outcomes, including fewer hospital admissions and better attendance for pulmonary rehabilitation. 6,7 These have focused on primary care interventions carried out by medical and nurse practitioner staff in the patient's home or within the clinic setting. Such models could include behavioral health specialists to train and supervise primary health care staff and deliver clinical interventions to more complex patients.…”