Improving management of asthma: closing the loop or progressing along the audit spiral?
(33/13648)
OBJECTIVE: To assess whether the management of asthma has improved from three consecutive surveys. DESIGN: Retrospective case note survey of acute asthma admissions in 1983 and 1989; case notes selected from 1985-6 survey of prospectively identified patients to include only patients with a final discharge code of asthma. SETTING: A large city teaching hospital. Patients--101 patients with acute asthma as the primary diagnosis in 1983; 85 in 1985-6; and 133 in 1989, 14 of whom were subsequently transferred elsewhere. MAIN MEASURES: Conformity with a checklist of important aspects of the process of asthma management including initial assessment, treatment, supervision, and discharge and review arrangements. RESULTS: All patient groups were similar in age, smoking habit, and stay in hospital and, as an objective guide to severity of asthma, had similar initial pulse rates. Major improvements occurred in management: by 1989, 119(90%) patients were treated with oral corticosteroids (69(68%), 67(79%) in 1983, 1985-6 respectively) and 109(82%) with oxygen (62(61%), 51(60%)) (both p < 0.001). 114(86%) had regular recording of peak flow measurements (53(52%), 54(64%); p < 0.001), and 103/119(86%) were discharged taking oral corticosteroids (66(65%), 63(74%); p < 0.01). Significantly fewer patients, however, had their regular inhaled corticosteroid treatment increased on discharge (38/119(32%) v 53(52%), 39(46%); p < 0.01), but more were receiving high dose inhaled treatment on admission. CONCLUSIONS: The management of asthma improved significantly, and the normal practice of doctors has changed in an area of practice with longstanding problems. (+info)
Impact of an interest in asthma on prescribing costs in general practice.
(34/13648)
OBJECTIVE: To examine the effect on total prescribing costs and prescribing costs for respiratory drugs for practices with at least one general practitioner with a special interest in asthma. DESIGN: Postal questionnaire survey. SETTING: General practitioners in England and Wales. SUBJECTS: 269 members of the General Practitioners in Asthma Group, of whom 103 agreed to participate. MAIN MEASURES: Individual practitioners' and their practices' PACT prescribing costs from the winter quarters of 1989-90 compared with average costs for their family health services authority (FHSA) and a notional national average of all FHSAs combined. RESULTS: The response rate was 57%; the average total prescribing costs for the practices of the 59 respondents were significantly lower than those of their respective FHSAs (mean difference 505 pounds per 1000 patients per quarter (95% confidence interval -934.0 to -76.2, p = 0.022) and lower than the national average. The average prescribing costs for respiratory drugs for the practices were significantly greater than those for their FHSA (195 pounds per 1000 patients per quarter (84.4 to 306.0, p = 0.001) and the national average. Both types of costs varied widely. CONCLUSION: An interest in asthma care in general practice is associated with higher average prescribing costs for respiratory drugs but no increase in overall prescribing costs compared with those for respective FHSAs and national averages. IMPLICATIONS: FHSAs and their medical advisors should not examine high prescribing costs for individual doctors or one therapeutic category but in the context of practice total costs. (+info)
Community asthma clinics: 1993 survey of primary care by the National Asthma Task Force.
(35/13648)
OBJECTIVES: To establish a baseline of work done in primary care asthma clinics in the United Kingdom and to assess the degree of clinical delegation to nurses and the appropriateness of their training. DESIGN: Prospective questionnaire survey of asthma care in general practices and a subsidiary survey of all family health services authorities (FHSAs) of the number of asthma clinics in their area. SETTING: All 14,251 general practices in the United Kingdom and 117 FHSAs or health boards (Scotland and Northern Ireland). RESULTS: Questionnaires were returned by 4327 (30.4%) general practices, 54% being completed by practice nurses and 22% by general practitioners; in 24% profession was not stated. In all, 77.2% (3339/4327) of respondents ran an asthma clinic. 60 FHSAs state the number of asthma clinics at the time of the general practice survey (total 3653 clinics); within responding FHSAs 1702 (46.6%) practices running an asthma clinic replied to the general practice survey. Clinics exclusive for patients with asthma mostly occurred in practices with five or more general practitioners (70.2%), compared with single-handed practices (31.7%). The average number of asthma clinics run per practice was five a month; the average duration was 2 hours and 20 minutes. 1131 (48.8%) nurses ran clinics by themselves, 1180 (47.9%) with the doctor, and 39 (1.7%) had no medical input. Comprehensive questioning occurred other than for nasal (872, 26.1%) or oesophageal (335, 10.0%) symptoms and use of aspirin and non-steroidal drugs (1161, 33.4%). Growth in children was measured by only a third of respondents. Of the 1131 nurses who ran clinics alone, 251 (22.2%) did so without formal training entailing assessment. CONCLUSION: Asthma clinics are now common in general practice and much of their work is done by nurses, a significant minority of whom may not have had sufficient training. IMPLICATIONS: As this survey is probably biased toward the more asthma aware practices, greater deficiencies in training and standards may exist in other practices. Further evaluation of the effectiveness of asthma clinics is needed. (+info)
Histamine levels in plasma, blood, and urine in severe asthma, and the effect of corticosteroid treatment.
(36/13648)
Plasma, whole blood, and urinary histamine levels have been determined in 64 normal subjects, in 10 patients with severe asthma, and in 10 control patients with other illnesses. The mean whole blood levels did not differ between the three groups. The mean plasma level in the asthmatics was significantly greater than that of the normal subjects but not of the control patients. The urinary histamine output was lower in the control patients than in the normal subjects but in the asthmatics did not differ from that of the normals. Corticosteroid therapy caused a marked fall, often to barely detectable levels, of the whole blood histamine concentration of the asthmatic patients and restored the plasma levels to normal but did not affect urinary histamine levels. (+info)
Change of serum IgE concentration in asthmatic attack.
(37/13648)
Thirty-two patients with clinical diagnosis of bronchial asthma were evaluated. Serum IgE levels, measured by the Phadebas IgE test, were clearly increased in the patients with asthmatic attack compared with those without asthmatic attack. When the patients were grouped according to the clinical grading of severity of asthmatic attack, the levels showed the significant elevation in proportion to the intensity of asthmatic attack and were higher in the group of severe attack or moderately severe attack than in the group of mild attack. When the serial determination of serum IgE concentration was performed during the clinical course of the patients, a high correlation was observed between the levels and the intensity of asthmatic attack. (+info)
National audit of acute severe asthma in adults admitted to hospital. Standards of Care Committee, British Thoracic Society.
(38/13648)
OBJECTIVE: To ascertain the standard of care for hospital management of acute severe asthma in adults. DESIGN: Questionnaire based retrospective multicentre survey of case records. SETTING: 36 hospitals (12 teaching and 24 district general hospitals) across England, Wales, and Scotland. PATIENTS: All patients admitted with acute severe asthma between 1 August and 30 September 1990 immediately before publication of national guidelines for asthma management. MAIN MEASURES: Main recommendations of guidelines for hospital management of acute severe asthma as performed by respiratory and non-respiratory physicians. RESULTS: 766 patients (median age 41 (range 16-94) years) were studied; 465 (63%) were female and 448 (61%) had had previous admissions for asthma. Deficiencies were evident for each aspect of care studied, and respiratory physicians performed better than non-respiratory physicians. 429 (56%) patients had had their treatment increased in the two weeks preceding the admission but only 237 (31%) were prescribed oral steroids. Initially 661/766 (86%) patients had peak expiratory flow measured and recorded but only 534 (70%) ever had arterial blood gas tensions assessed. 65 (8%) patients received no steroid treatment in the first 24 hours after admission. Variability of peak expiratory flow was measured before discharge in 597/759 (78%) patients, of whom 334 (56%) achieved good control (variability < 25%). 47 (6%) patients were discharged without oral or inhaled steroids; 182/743 (24%) had no planned outpatient follow up and 114 failed to attend, leaving 447 (60%) seen in clinic within two months. Only 57/629 (8%) patients were recorded as having a written management plan. CONCLUSIONS: The hospital management of a significant minority of patients deviates from recommended national standards and some deviations are potentially serious. Overall, respiratory physicians provide significantly better care than non-respiratory physicians. (+info)
Exercise-induced bronchocontriction, skin sensitivity, and serum IgE in children with eczema.
(39/13648)
Forty-two children with eczema were studied for exercise-induced asthma (EIA), skin sensitivity to prick testing, blood eosinophil count, and immunoglobulins. 29 had a fall in peak expiratory flow rate after exercise greater than 20% and of these, 23 had symptoms of wheezing. 13 of the eczematous children showed a fall of less than 20%. The children with EIA showed greater cutaneous sensitivity (p less than 0.001) and a higher total serum IgE (p less than 0.025). 3 of the group with a fall of less than 20% had allergic rhinitis with skin sensitivity to grass pollen. The remaining 10 had no clinical evidence of allergic disease, other than eczema and skin sensitivity, and total IgE fell within the normal range. It is suggested that in a proportion of chilren with eczema there is little evidence of reaginic allergy. (+info)
Organisation of asthma care: what difference does it make? A systematic review of the literature.
(40/13648)
OBJECTIVES: To evaluate the effectiveness of different forms of organisation (delivery) of asthma care. METHODS: A systematic review of the published evidence of effectiveness organisational methods of asthma management. Searches on computerised databases including Medline, CINAHL, and HELMIS, and relevant citations and letters to experts were used to identify relevant studies. RESULTS: 27 studies were identified that evaluated different organisational methods of delivery across both primary and secondary sectors, such as shared care, general practice asthma clinics, outpatient programmes, inpatient admissions policies, and the use of specialists. Only one third of the studies used a randomised controlled trial and many had small sample sizes. No conclusive evidence was found to favour any particular organisational form, although limited evidence would suggest that specialist care is better than general care and that shared care can be as effective as hospital led care. CONCLUSIONS: There is little good published research evaluating different ways of organising the delivery of asthma care. There is need for quality research on organisational methods of delivery of asthma care that could be used to inform policy makers, in particular examining whether patients treated by healthcare professional with expertise and interest in asthma will experience better outcomes. (+info)