Paediatric asthma outpatient care by asthma nurse, paediatrician or general practitioner: randomised controlled trial with two-year follow-up

Abstract

Aims: For children with stable asthma, to test non-inferiority of care provided by a hospital-based specialised asthma nurse versus a general practitioner (GP) or paediatrician.Methods: Randomised controlled trial evaluating standard care by a GP, paediatrician or an asthma nurse, with two-year follow-up.Results: 107 children were recruited, 45 from general practice and 62 from hospital. After two years, no significant differences between groups were found for airway responsiveness, FEV1, asthma control, medication, school absence or parental work absence. In the general practice group there was a significantly lower frequency of regular review visits ('regular' = at least one review per six months) compared to the paediatrician and specialised asthma nurse group, both after one year [45.7% versus 87.9% and 94.3%, respectively, (p<0.0005)] and after two years [26.5% versus 87.9% and 75.8%, respectively, (p<0.0005)]. We found no significant differences in unplanned visits. In most cases the asthma nurse was able to provide care without consultation with the paediatrician. Conclusion:The degree of disease control in stable childhood asthma managed by an asthma nurse is not inferior to traditional management by primary or secondary care physicians. The results also suggest that a lower review frequency does not detract from good disease control.

Adherence to national guidelines for children with asthma at primary health centres in Sweden: potential for improvement

“…11,13 In addition, a Dutch study showed that care provided by a specialised asthma nurse is as effective in the outpatient management of stable childhood asthma as traditional management by a paediatrician or GP. 43 Furthermore, attention to clinical guidelines can improve evidence-based nursing practice in connection with the non-pharmacological management necessary for optimal treatment of childhood asthma in which specialised asthma nurses are highly skilled. 44 Despite the obvious importance of a planned follow-up visit for asthma control as emphasised in national guidelines, only half of the children had a planned follow-up.…”

Assessing Quality of Care in Pediatric Asthma: Applicability of a Revised Version of the QUOTE-CNSLD Questionnaire

“…Written informed consent was obtained from all parents and from patients 12 years and older. This study was part of a more extended trial about the follow-up in the denominated settings (21,22) (see consort diagram).…”

Who should look after children with asthma?

“…In the UK, credit for facilitating this transfer of management from secondary to primary care can be shared by visionary drivers in the General Practitioners in Asthma Group (now the Primary Care Respiratory Society UK, PCRS-UK), the National Asthma Training Centre (now Education for Health), and the support of some wise, thoughtful and nonthreatened secondary care opinion leaders. 1 In this issue of the Journal, Kuethe et al 2 develop the evidence base for alternative models of health care delivery for the management of chronic asthma in children by clinicians of different crafts -paediatrician, GP or (hospital-based) specialist nurse. The rather technical primary endpoint, airway hyper-responsiveness as measured by methacholine challenge, demonstrated non-inferiority between the groups.…”

“…4 These standards, mandatory in Scotland, call inter alia for systems to identify and manage high risk children and young people with asthma, such as those with frequent visits to emergency centres or out-of-hours contacts, or those who are prescribed or appear to require above-licensed doses of ICS. This 2 Even the most reactionary of clinicians should be reassured by a system for allocating patients to a nurse for follow-up which includes confirmation by a doctor of the diagnosis of asthma (although, of course, this is not by definition infallible; diagnoses of asthma in children should always be questioned and the evidence for making the diagnosis recorded), the exclusion of more severe cases, and an insistence that management guidelines are strictly followed. Equally heartening is that nurses still sought specialist support when necessary.…”

“…The measured or cavalier or forgetful approach resulting in reduced numbers of planned reviews gave no indication of poorer outcomes in Kuethe et al's study. 2 In reality, in the UK at least, many GPs have little involvement in the routine, planned review of people with asthma, which has led to fears of de-skilling. 3 In our harsh economic climate, all those responsible for the delivery of health care have encountered tensions in achieving their objectives.…”