Abstract
OBJECTIVES--To evaluate integrated care for asthma in clinical, social, and economic terms. DESIGN--Pragmatic randomised trial. SETTING--Hospital outpatient clinics and general practices throughout the north east of Scotland. PATIENTS--712 adults attending hospital outpatient clinics with a diagnosis of asthma confirmed by a chest physician and pulmonary function reversibility of at least 20%. MAIN OUTCOME MEASURES--Use of bronchodilators and inhaled and oral steroids; number of general practice consultations and hospital admissions for asthma; sleep disturbance and other restrictions on normal activity; psychological aspects of health including perceived asthma control; patient satisfaction; and financial costs. RESULTS--After one year there were no significant overall differences between those patients receiving integrated asthma care and those receiving conventional outpatient care for any clinical or psychosocial outcome. For pulmonary function, forced expiratory volume was 76% of predicted for integrated care patients and 75% for conventional outpatients (95% confidence interval for difference -3.6% to 5.0%). Patients who had experienced integrated care were more likely to select it as their preferred course of future management (75% (251/333) v 62% (207/333) (6% to 20%)); they saved 39.52 pounds a year. This was largely because patients in conventional outpatient care consulted their general practitioner as many times as those in integrated care, who were not also visiting hospital. CONCLUSION--Integrated care for moderately severe asthma patients is clinically as effective as conventional outpatient care, cost effective, and an attractive management option for patients, general practitioners, and hospital consultants.
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Selected References
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- Burney P. G. Asthma mortality in England and Wales: evidence for a further increase, 1974-84. Lancet. 1986 Aug 9;2(8502):323–326. doi: 10.1016/s0140-6736(86)90012-7. [DOI] [PubMed] [Google Scholar]
- Burney P. G., Papacosta A. O., Withey C. H., Colley J. R., Holland W. W. Hospital admission rates and the prevalence of asthma symptoms in 20 local authority districts. Thorax. 1991 Aug;46(8):574–579. doi: 10.1136/thx.46.8.574. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Charlton I., Charlton G., Broomfield J., Mullee M. A. Audit of the effect of a nurse run asthma clinic on workload and patient morbidity in a general practice. Br J Gen Pract. 1991 Jun;41(347):227–231. [PMC free article] [PubMed] [Google Scholar]
- Day J. L., Humphreys H., Alban-Davies H. Problems of comprehensive shared diabetes care. Br Med J (Clin Res Ed) 1987 Jun 20;294(6587):1590–1592. doi: 10.1136/bmj.294.6587.1590. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Fleming D. M., Crombie D. L. Prevalence of asthma and hay fever in England and Wales. Br Med J (Clin Res Ed) 1987 Jan 31;294(6567):279–283. doi: 10.1136/bmj.294.6567.279. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Hayes T. M., Harries J. Randomised controlled trial of routine hospital clinic care versus routine general practice care for type II diabetics. Br Med J (Clin Res Ed) 1984 Sep 22;289(6447):728–730. doi: 10.1136/bmj.289.6447.728. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Hyland M. E. The Living with Asthma Questionnaire. Respir Med. 1991 Sep;85 (Suppl B):13–37. doi: 10.1016/s0954-6111(06)80163-0. [DOI] [PubMed] [Google Scholar]
- Jones K. Asthma care in general practice--time for revolution? Br J Gen Pract. 1991 Jun;41(347):224–226. [PMC free article] [PubMed] [Google Scholar]
- Jones K. Asthma--still a challenge for general practice. J R Coll Gen Pract. 1989 Jun;39(323):254–256. [PMC free article] [PubMed] [Google Scholar]
- Klein R. On the Oregon trail: rationing health care. BMJ. 1991 Jan 5;302(6767):1–2. doi: 10.1136/bmj.302.6767.1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Leitch A. G., Parker S., Currie A., King T., McHardy G. J. Evaluation of the need for follow-up in an out-patient clinic. Respir Med. 1990 Mar;84(2):119–122. doi: 10.1016/s0954-6111(08)80013-3. [DOI] [PubMed] [Google Scholar]
- Mao Y., Semenciw R., Morrison H., MacWilliam L., Davies J., Wigle D. Increased rates of illness and death from asthma in Canada. CMAJ. 1987 Oct 1;137(7):620–624. [PMC free article] [PubMed] [Google Scholar]
- Ninan T. K., Russell G. Respiratory symptoms and atopy in Aberdeen schoolchildren: evidence from two surveys 25 years apart. BMJ. 1992 Apr 4;304(6831):873–875. doi: 10.1136/bmj.304.6831.873. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Osman L. M., Abdalla M. I., Beattie J. A., Ross S. J., Russell I. T., Friend J. A., Legge J. S., Douglas J. G. Reducing hospital admission through computer supported education for asthma patients. Grampian Asthma Study of Integrated Care (GRASSIC). BMJ. 1994 Feb 26;308(6928):568–571. doi: 10.1136/bmj.308.6928.568. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Petrie J. C., Robb O. J., Webster J., Scott A. K., Jeffers T. A., Park M. D. Computer assisted shared care in hypertension. Br Med J (Clin Res Ed) 1985 Jun 29;290(6486):1960–1962. doi: 10.1136/bmj.290.6486.1960. [DOI] [PMC free article] [PubMed] [Google Scholar]
- Schwartz D., Lellouch J. Explanatory and pragmatic attitudes in therapeutical trials. J Chronic Dis. 1967 Aug;20(8):637–648. doi: 10.1016/0021-9681(67)90041-0. [DOI] [PubMed] [Google Scholar]
- Tobin D. L., Wigal J. K., Winder J. A., Holroyd K. A., Creer T. L. The "Asthma Self-Efficacy Scale". Ann Allergy. 1987 Oct;59(4):273–277. [PubMed] [Google Scholar]
- Tuberculous meningitis in children. Br Med J. 1971 Jan 2;1(5739):1–2. [PMC free article] [PubMed] [Google Scholar]
- Van Damme R., Drummond N., Beattie J., Douglas G. Integrated care for patients with asthma: views of general practitioners. Br J Gen Pract. 1994 Jan;44(378):9–13. [PMC free article] [PubMed] [Google Scholar]
- Williams D. R., Munroe C., Hospedales C. J., Greenwood R. H. A three-year evaluation of the quality of diabetes care in the Norwich community care scheme. Diabet Med. 1990 Jan;7(1):74–79. doi: 10.1111/j.1464-5491.1990.tb01312.x. [DOI] [PubMed] [Google Scholar]
- Zigmond A. S., Snaith R. P. The hospital anxiety and depression scale. Acta Psychiatr Scand. 1983 Jun;67(6):361–370. doi: 10.1111/j.1600-0447.1983.tb09716.x. [DOI] [PubMed] [Google Scholar]