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randomised controlled trial.
Follow up period:
Barnes-Jewish Hospital, St Louis, Missouri, USA.
96 patients 18–65 years of age (mean age 36 y, 83% women, 82% African-American) who were admitted to hospital with asthma exacerbation, had physician diagnosed asthma for ⩾12 months, forced expiratory volume in 1 second to forced vital capacity ratio <80%, and ⩾1 hospital admission in the previous 12 months.
a 6 month, limited, nurse led intervention (suggestions to the primary physician to simplify or consolidate current regimens; completion of daily Asthma Care flow sheets; asthma education; psychosocial support and screening for counselling; follow up through telephone contact, home visits, and primary physician visits; individualised asthma self management plan; and consultation with social service professionals to facilitate discharge planning) (n = 50) or usual care by a primary care physician (n = 46).
hospital readmissions for asthma within 1 year. Secondary outcomes included cumulative number of days in hospital, emergency department (ED) visits, asthma specific quality of life, and total healthcare costs.
Patient follow up:
100% (intention to treat analysis).
Fewer patients in the intervention group than in the usual care group had ⩾2 readmissions (table⇓). Patients in the intervention group had fewer asthma specific readmissions (21 v 42, p = 0.04) and fewer days in hospital for asthma (53 v 129 d, p = 0.04). The intervention had lower total healthcare costs (US$5726 v $12 188 per patient, p = 0.03). The groups did not differ for ED visits (93 v 64, p = 0.52) or asthma specific quality of life.
A time limited, nurse led intervention reduced asthma readmissions, hospital days, and total healthcare costs more than usual care in patients with asthma and a history of frequent admissions.
See commentary on next page.
There is increasing recognition that minority ethnic groups have higher rates of disease exacerbation and hospital admissions for asthma.1 Studies have shown that about 15% of patients discharged from hospital or emergency facilities are readmitted within 2 weeks.2 Research is limited on specific interventions that reduce unscheduled asthma care, although post-discharge asthma education involving inhaler technique, peak flow recordings, or written symptom based action plans have been shown to reduce morbidity and relapse rates.3
The studies by Castro et al and Griffiths et al assessed the effect of specialist nurse interventions on unscheduled care or hospital emergency admission rates for [mostly] minority group patients with asthma. The studies varied in methodology, but both were prospective, included patients with physician diagnosed asthma who attended the ED, and assessed health care utilisation outcomes and quality of life at 1 year. However, the study populations differed: Castro et al enrolled mainly African-American women 18–65 years of age, whereas Griffiths et al enrolled mostly South Asian, black African, or Afro-Caribbean patients aged 4–60 years. As well, in the US based study by Castro et al, the intervention occurred primarily in hospital, whereas in the UK based study by Griffiths et al, the intervention occurred primarily in general practices and comprised both patient and clinician education and support.
The lack of an economic analysis by Griffiths et al may be important because the study by Castro et al required more intensive intervention. Griffiths et al did not provide the more costly face to face nurse time or telephone contact with patients. Although both studies reduced hospital admissions, only Castro et al found differences in quality of life measures and medication use.
The findings of these 2 studies are relevant to specialist nurses working with asthma patients in primary and secondary care settings. Both studies provide support for the use of specialist nurse interventions to reduce the use of emergency facilities for asthma care and to identify the patients who will use them. The results highlight the increased use of emergency services by minority groups for asthma care. This may indicate that current service provision disadvantages these patients, and their dissatisfaction with current services may require alternative approaches to asthma care. In particular, although the study by Griffiths et al was not powered to measure differences in outcome for different ethnic groups, there was a suggestion that the intervention might provide greater benefits to white patients. Further research is required to determine the varying needs of different ethnic groups in asthma management. Both studies found that identifying patients with repeated use of emergency services and focusing interventions on these patients were beneficial. However, the precise components of the intervention and the patient groups to which they should be targeted are still to be determined.
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