Models of chronic disease management in primary care for patients with mild‐to‐moderate asthma or COPD: a narrative review

Abstract

Objective: To review the literature for any promising strategies for the primary care management of mild‐to‐moderate asthma and chronic obstructive pulmonary disease (COPD) in adults. Methods: Using “MeSH” terms for COPD, asthma and primary health care, we conducted an extensive literature search for relevant meta‐analyses, systematic reviews, narrative reviews, reports and individual studies. Grey literature was also included. We chose a narrative review approach because of substantial heterogeneity of study designs in the literature. Results: 1119 articles of potential relevance were retained, of which 246 were included in our review. There was insufficient evidence to determine whether general practitioners with a special interest (GPwSI) in respiratory care improved the diagnosis and management of mild‐to‐moderate COPD. An asthma service involving GPwSI increased respiratory drug costs but reduced the costs for less specific drugs. No clear benefit has been shown for practice nurse‐run asthma clinics in primary care compared with usual care in altering asthma morbidity, quality of life, lung function or medication use. Evidence to determine the effectiveness of practice nurse‐run COPD clinics could not be found. Self‐management education, GP review and action plans may produce short‐term benefits for asthma patients, particularly those with moderate‐to‐severe disease, but the evidence for a similar approach to patients with mild‐to‐moderate COPD is equivocal. There has been poor uptake of respiratory clinical guidelines relevant to primary care — partly because most guidelines are based on moderate‐to‐severe disease. Spirometry programs in primary care are useful for differential diagnosis of asthma and COPD. Spirometry may alter the management of mild asthma, but there is a lack of evidence that it alters the management of COPD in primary care. Conclusion: The role of primary health care in management of mild‐to‐moderate asthma and COPD requires further investigation using randomised controlled trials.

Bringing evidence to bear on policy processes: the challenge of the Australian Primary Health Care Research Institute

“… Chronic disease management ( Cranston et al, 6 Dennis et al 7 ); Integration, coordination and multidisciplinary care ( Jackson et al, 8 Mitchell et al, 9 Powell Davies et al 10 ); Innovative models for comprehensive primary health care delivery ( McDonald et al, 11 Naccarella et al, 12 Humphreys et al 13 ); Innovative models for the management of mental health in primary health care settings ( Griffiths and Christensen 14 ); Children and young Australians, health promotion and prevention ( McDonald et al, 15 Hearn et al 16 ); and Workforce (focus on competency‐based training) ( Glasgow et al 17 ). …”

Mortality in Western Australian seniors with chronic respiratory diseases: a cohort study

“…Collectively, these findings illustrate the importance of more actively focusing disease management on mild-to-moderate CRD. This has been emphasized by Cranston et al, who suggest that a more fruitful primary care approach is needed for managing mild-to-moderate CRD in Australia since most guidelines are based on moderate-to-severe disease [44]. Our findings are thus important for primary health care policy because they highlight a need to more actively target services at patients with mild-to-moderate CRD so as to prevent disease progression and subsequent mortality.…”

Models of care for severe asthma: the role of primary care

“…The quality of evidence in this area is probably affected by patients' poor clinic attendance, and practice nurses may not be adequately trained or supported to deliver the necessary self-management education. 38 A GP asthma clinic involving a trained specialist nurse followed by GP consultation was shown to be potentially be cost-effective in the Australian setting if it could translate to broad benefits in reducing ED presentations, unscheduled GP visits, hospitalisations and days off work. 39 However, this proposal was based on a small intervention trial with outdated cost estimates from 2003, and may not reflect the true costs of national implementation.…”