Specialist nurse intervention to reduce unscheduled asthma care in a deprived multiethnic area: the east London randomised controlled trial
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《英国医生杂志》
1 Centre for General Practice and Primary Care, Institute of Community Health Sciences, Barts and the London, Medical Sciences, Queen Mary's School of Medicine and Dentistry, Queen Mary, University of London E1 4NS, 2 Department of Respiratory Medicine, London Chest Hospital, London E2 9JX, 3 Gill Street Health Centre, London E14 8HQ, 4 Amersham Health, Little Chalfont, Bucks HP7 9NA, 5 Royal London Hospital, London E1 1BB
Correspondence to: C Griffiths c.j.griffiths@qmul.ac.uk
Abstract
The numbers and roles of specialist nurses are increasing, but uncertainty remains about their effects on the costs and use of health care.1 Two types of intervention involving asthma specialist nurses have been evaluated: educating patients after hospital attendance with acute asthma and outreach to educate and support general practitioners and practice nurses. Evaluations show inconsistent benefits on unscheduled care for the first,2-6 and no benefit for the second.7
We tested a liaison model of specialist nursing, which combined the education of patients after discharge with educational outreach and clinical support for primary care clinicians. This model may be particularly appropriate in deprived areas, where general practices vary in their capacity to manage chronic illness.8
Improving asthma outcomes for ethnic minority groups remains a global challenge. Morbidity due to asthma is higher for minority or disadvantaged groups.9 10 In the United Kingdom, hospital admission rates for South Asian patients have been double those of white patients and high for black patients.11 12 South Asian patients may benefit less from asthma education than white patients and have poorer access to care during attacks.13 14 Although evaluations of asthma specialist nurses have been in socioeconomically deprived areas, none has included large populations of ethnic minority groups.2 5 Whether asthma specialist nurses can reduce morbidity in multiethnic inner city populations is unknown.
Two important questions remain for specialist nurses, particularly those dealing with asthma. Can they reduce health service use, and can they improve outcomes equally across ethnic groups? We tested the effectiveness of asthma specialist nurses using a liaison model of care across a single health district comprising one of the most ethnically diverse and deprived areas in the United Kingdom. We focused on patients attending hospital with acute asthma, because they have the highest morbidity and health service use and costs. We compared this intervention group with practices receiving outreach visits promoting standard asthma guidelines, since this itself modestly improves care.15 We used a pragmatic cluster randomised controlled design, as an important element of the intervention addressed clinicians in general practice. We hypothesised that asthma specialist nurses would reduce unscheduled care for asthma.
Methods
Practices in the intervention and control groups were well matched for stratifying factors (table 1). Figure 1 shows the flow of participants and practices through the trial. Practices contributed a mean of eight (range 2-28) participants. The characteristics of participants were similar between groups (table 2). Overall, 50% (164/324) of the participants were South Asian, 34% (108) were white, and 16% (52) were from 12 other ethnic groups, predominantly black African, Afro-Caribbean, and black British. Fourteen different first languages were spoken; 45% (146) of participants spoke English. Eighty nine per cent (269) lived in rented accommodation and 55% (177) were unemployed. Overall, 63% (204) of participants were recruited prospectively after attendance with acute asthma. The remainder met eligibility criteria over the previous years.
Fig 1 Flow of practices and participants through study
Table 2 Characteristics of participants allocated to nurse led intervention for acute asthma or standard guidelines for asthma. Values are numbers (percentages) unless stated otherwise
Primary outcome: unscheduled asthma care
Primary outcome data were gathered for 98% (319/324) of participants. The specialist nurse intervention delayed first attendance for unscheduled asthma care in the year after intervention (fig 2, adjusted hazard ratio for reattendance 0.73, 95% confidence interval 0.54 to 1.00) and reduced the percentage of participants attending for unscheduled care over the following year (58% (101/174) for intervention v 68% (99/145) for control, adjusted odds ratio with clustering 0.61, 0.38 to 0.99, without clustering 0.62, 0.38 to 1.01; table 3). Mean rates of hospital admission, attendance at accident and emergency, and attendance at general practice for exacerbations were all non-significantly lower in the intervention group than in the control group (data not shown). The overall rates of yearly attendance for unscheduled care for each participant were 1.98 for the intervention group and 2.36 for the control group (adjusted incidence rate ratio 0.91, 0.66 to 1.26).
Fig 2 Time to first unscheduled attendance with acute asthma after intervention for all participants (number of participants without reattendance at 365 days was 73 for intervention and 47 for control)
Table 3 Percentages (numbers) of participants attending for unscheduled asthma care and for review of asthma in year after intervention
Secondary outcomes
Review of asthma care
Overall, 54% (78/145) of participants in the control group were reviewed in secondary or primary care in the year after intervention compared with 65% (113/174) in the intervention group (adjusted odds ratio 1.66, 0.96 to 1.98; table 3); 36% (52/145) of participants in the control group were reviewed in primary care compared with 47% (82/174) in the intervention group (1.40, 0.72 to 2.73). Participants in the intervention group received 1.84 reviews yearly compared with 1.56 of participants in the control group (incidence rate ratio 1.15, 0.85 to 1.57).
Self management behaviour, quality of life, and symptoms
Self management behaviour and scores for quality of life and asthma symptoms showed no differences at two or 12 months follow up (table 4). Oral rescue corticosteroids were used by similar numbers of participants in each group (4% (7/174) intervention, 7% (10/145) control, odds ratio 0.7, 0.28 to 1.68).
Table 4 Self management behaviour during exacerbations of asthma, quality of life (AQ20 questionnaire), and symptom scores (north of England scale) at two and 12 months' follow up for participants allocated to nurse led intervention for acute asthma or standard guidelines for asthma. Values are numbers (percentages) of participants unless stated otherwise
Subgroup analyses
Exploratory hypothesis generating analysis comparing the effect of specialist nurse intervention on time to attendance between white patients, South Asian patients, and other ethnic groups was not statistically significant (white to South Asian hazard ratio 0.76, 0.44 to 1.29; white to other ethnicities 0.64, 0.39 to1.06). It was, however, compatible with a larger effect for white participants (intervention group compared with control group hazard ratio 0.57, 0.38 to 0.85; South Asians 0.72, 0.48 to 1.09; other ethnicities 1.29, 0.51 to 3.22). The effect of the intervention was not significantly different for other subgroup analyses.
Discussion
Hobbs R, Murray ET. Specialist liaison nurses. BMJ 1999;318: 683.
Madge P, McColl J, Paton J. Impact of a nurse-led home management training programme in children admitted to hospital with acute asthma: a randomised controlled study. Thorax 1997;52: 223-8.
Osman LM, Calder C, Godden DJ, Friend JA, McKenzie L, Legge JS, et al. A randomised trial of self-management planning for adult patients admitted to hospital with acute asthma. Thorax 2002;57: 869-74.
Stevens CA, Wesseldine LJ, Couriel JM, Dyer AJ, Osman LM, Silverman M. Parental education and guided self-management of asthma and wheezing in the pre-school child: a randomised controlled trial. Thorax 2002;57: 39-44.
Wesseldine LJ, McCarthy P, Silverman M. Structured discharge procedure for children admitted to hospital with acute asthma: a randomised controlled trial of nursing practice. Arch Dis Child 1999;80: 110-4.
Levy ML, Robb M, Allen J, Doherty C, Bland JM, Winter RJ. A randomized controlled evaluation of specialist nurse education following accident and emergency department attendance for acute asthma. Respir Med 2000;94: 900-8.
Premaratne UN, Sterne JAC, Marks GB, Webb JR, Azima H, Burney PGJ. Clustered randomised trial of an intervention to improve the management of asthma: Greenwich asthma study. BMJ 1999;318: 1251-5.
Griffiths C, Sturdy P, Naish J, Omar R, Dolan S, Feder G. Hospital admissions for asthma in east London: associations with characteristics of local general practices, prescribing, and population. BMJ 1997;314: 482-6.
Ehrlich RI, Bourne DE. Asthma deaths among coloured and white South Africans: 1962 to 1988. Respir Med 1994;88: 195-202.
Ng TP, Tan WC. Temporal trends and ethnic variations in asthma mortality in Singapore, 1976-1995. Thorax 1999;54: 990-4.
Ormerod LP. Adult Asian acute asthma admissions reassessed: Blackburn 1991-1992. Respir Med 1995;89: 415-7.
Gilthorpe MS, Lay-Yee R, Wilson RC, Walters S, Griffiths RK, Bedi R. Variations in hospitalization rates for asthma among black and minority ethnic communities. Respir Med 1998;92: 642-8.
Griffiths C, Kaur G, Gantley M, Feder G, Hillier S, Goddard J, et al. Influences on hospital admission for asthma in south Asian and white adults: qualitative interview study. BMJ 2001;323: 962.
Moudgil H, Marshall T, Honeybourne D. Asthma education and quality of life in the community: a randomised controlled study to evaluate the impact on white European and Indian subcontinent ethnic groups from socioeconomically deprived areas in Birmingham, UK. Thorax 2000;55: 177-83.
Feder G, Griffiths C, Highton C, Eldridge S, Spence M, Southgate L. Do clinical guidelines introduced with practice based education improve care of asthmatic and diabetic patients? A randomised controlled trial in general practices in east London. BMJ 1995;311: 1473-8.
Altman DG. Practical statistics for medical research. London: Chapman and Hall, 1991.
Thomson O'Brien MA, Oxman AD, Davis DA, Haynes RB, Freemantle N, Harvey EL. Educational outreach visits: effects on professional practice and health care outcomes (Cochrane Review). In: Cochrane Library, Issue 4. Chichester: John Wiley, 2003.
EuroQol Group. EuroQol: a new facility for measurement of health related quality of life. Health Policy 1990;16: 199-208.
Barley EA, Quirk FH, Jones PW. Asthma health status measurement in clinical practice: validity of a new short and simple instrument. Respir Med 1998;92: 1207-14.
Steen N, Hutchinson A, McColl E, Eccles MP, Hewison J, Meadows KA, et al. Development of a symptom based outcome measure for asthma. BMJ 1994;309: 1065-8.
Griffiths C, Ahmed S, Ahmed S, Nandy S, Abrams C, Meadows KA, et al. Using health-related quality of life measures in minority ethnic groups: an approach to translating measures into Bengali (Sylheti). Eur J Gen Pract 2000;6: 130-4.
Gallefoss F, Bakke P. How does patient education and self-management among asthmatics and patients with chronic obstructive pulmonary disease affect medication? Am J Respir Crit Care Med 1999;160: 2000-5.
Jolly K, Bradley F, Sharp S, Smith H, Thompson S, Kinmonth AL, et al. Randomised controlled trial of follow up care in general practice of patients with myocardial infarction and angina: final results of the Southampton heart integrated care project (SHIP). BMJ 1999;318: 706.
Bonner S, Zimmerman BJ, Evans D, Irigoyen M, Resnick D, Mellins RB. An individualized intervention to improve asthma management among urban Latino and African-American families. J Asthma 2002;39: 167-79.(Chris Griffiths, professo)
Correspondence to: C Griffiths c.j.griffiths@qmul.ac.uk
Abstract
The numbers and roles of specialist nurses are increasing, but uncertainty remains about their effects on the costs and use of health care.1 Two types of intervention involving asthma specialist nurses have been evaluated: educating patients after hospital attendance with acute asthma and outreach to educate and support general practitioners and practice nurses. Evaluations show inconsistent benefits on unscheduled care for the first,2-6 and no benefit for the second.7
We tested a liaison model of specialist nursing, which combined the education of patients after discharge with educational outreach and clinical support for primary care clinicians. This model may be particularly appropriate in deprived areas, where general practices vary in their capacity to manage chronic illness.8
Improving asthma outcomes for ethnic minority groups remains a global challenge. Morbidity due to asthma is higher for minority or disadvantaged groups.9 10 In the United Kingdom, hospital admission rates for South Asian patients have been double those of white patients and high for black patients.11 12 South Asian patients may benefit less from asthma education than white patients and have poorer access to care during attacks.13 14 Although evaluations of asthma specialist nurses have been in socioeconomically deprived areas, none has included large populations of ethnic minority groups.2 5 Whether asthma specialist nurses can reduce morbidity in multiethnic inner city populations is unknown.
Two important questions remain for specialist nurses, particularly those dealing with asthma. Can they reduce health service use, and can they improve outcomes equally across ethnic groups? We tested the effectiveness of asthma specialist nurses using a liaison model of care across a single health district comprising one of the most ethnically diverse and deprived areas in the United Kingdom. We focused on patients attending hospital with acute asthma, because they have the highest morbidity and health service use and costs. We compared this intervention group with practices receiving outreach visits promoting standard asthma guidelines, since this itself modestly improves care.15 We used a pragmatic cluster randomised controlled design, as an important element of the intervention addressed clinicians in general practice. We hypothesised that asthma specialist nurses would reduce unscheduled care for asthma.
Methods
Practices in the intervention and control groups were well matched for stratifying factors (table 1). Figure 1 shows the flow of participants and practices through the trial. Practices contributed a mean of eight (range 2-28) participants. The characteristics of participants were similar between groups (table 2). Overall, 50% (164/324) of the participants were South Asian, 34% (108) were white, and 16% (52) were from 12 other ethnic groups, predominantly black African, Afro-Caribbean, and black British. Fourteen different first languages were spoken; 45% (146) of participants spoke English. Eighty nine per cent (269) lived in rented accommodation and 55% (177) were unemployed. Overall, 63% (204) of participants were recruited prospectively after attendance with acute asthma. The remainder met eligibility criteria over the previous years.
Fig 1 Flow of practices and participants through study
Table 2 Characteristics of participants allocated to nurse led intervention for acute asthma or standard guidelines for asthma. Values are numbers (percentages) unless stated otherwise
Primary outcome: unscheduled asthma care
Primary outcome data were gathered for 98% (319/324) of participants. The specialist nurse intervention delayed first attendance for unscheduled asthma care in the year after intervention (fig 2, adjusted hazard ratio for reattendance 0.73, 95% confidence interval 0.54 to 1.00) and reduced the percentage of participants attending for unscheduled care over the following year (58% (101/174) for intervention v 68% (99/145) for control, adjusted odds ratio with clustering 0.61, 0.38 to 0.99, without clustering 0.62, 0.38 to 1.01; table 3). Mean rates of hospital admission, attendance at accident and emergency, and attendance at general practice for exacerbations were all non-significantly lower in the intervention group than in the control group (data not shown). The overall rates of yearly attendance for unscheduled care for each participant were 1.98 for the intervention group and 2.36 for the control group (adjusted incidence rate ratio 0.91, 0.66 to 1.26).
Fig 2 Time to first unscheduled attendance with acute asthma after intervention for all participants (number of participants without reattendance at 365 days was 73 for intervention and 47 for control)
Table 3 Percentages (numbers) of participants attending for unscheduled asthma care and for review of asthma in year after intervention
Secondary outcomes
Review of asthma care
Overall, 54% (78/145) of participants in the control group were reviewed in secondary or primary care in the year after intervention compared with 65% (113/174) in the intervention group (adjusted odds ratio 1.66, 0.96 to 1.98; table 3); 36% (52/145) of participants in the control group were reviewed in primary care compared with 47% (82/174) in the intervention group (1.40, 0.72 to 2.73). Participants in the intervention group received 1.84 reviews yearly compared with 1.56 of participants in the control group (incidence rate ratio 1.15, 0.85 to 1.57).
Self management behaviour, quality of life, and symptoms
Self management behaviour and scores for quality of life and asthma symptoms showed no differences at two or 12 months follow up (table 4). Oral rescue corticosteroids were used by similar numbers of participants in each group (4% (7/174) intervention, 7% (10/145) control, odds ratio 0.7, 0.28 to 1.68).
Table 4 Self management behaviour during exacerbations of asthma, quality of life (AQ20 questionnaire), and symptom scores (north of England scale) at two and 12 months' follow up for participants allocated to nurse led intervention for acute asthma or standard guidelines for asthma. Values are numbers (percentages) of participants unless stated otherwise
Subgroup analyses
Exploratory hypothesis generating analysis comparing the effect of specialist nurse intervention on time to attendance between white patients, South Asian patients, and other ethnic groups was not statistically significant (white to South Asian hazard ratio 0.76, 0.44 to 1.29; white to other ethnicities 0.64, 0.39 to1.06). It was, however, compatible with a larger effect for white participants (intervention group compared with control group hazard ratio 0.57, 0.38 to 0.85; South Asians 0.72, 0.48 to 1.09; other ethnicities 1.29, 0.51 to 3.22). The effect of the intervention was not significantly different for other subgroup analyses.
Discussion
Hobbs R, Murray ET. Specialist liaison nurses. BMJ 1999;318: 683.
Madge P, McColl J, Paton J. Impact of a nurse-led home management training programme in children admitted to hospital with acute asthma: a randomised controlled study. Thorax 1997;52: 223-8.
Osman LM, Calder C, Godden DJ, Friend JA, McKenzie L, Legge JS, et al. A randomised trial of self-management planning for adult patients admitted to hospital with acute asthma. Thorax 2002;57: 869-74.
Stevens CA, Wesseldine LJ, Couriel JM, Dyer AJ, Osman LM, Silverman M. Parental education and guided self-management of asthma and wheezing in the pre-school child: a randomised controlled trial. Thorax 2002;57: 39-44.
Wesseldine LJ, McCarthy P, Silverman M. Structured discharge procedure for children admitted to hospital with acute asthma: a randomised controlled trial of nursing practice. Arch Dis Child 1999;80: 110-4.
Levy ML, Robb M, Allen J, Doherty C, Bland JM, Winter RJ. A randomized controlled evaluation of specialist nurse education following accident and emergency department attendance for acute asthma. Respir Med 2000;94: 900-8.
Premaratne UN, Sterne JAC, Marks GB, Webb JR, Azima H, Burney PGJ. Clustered randomised trial of an intervention to improve the management of asthma: Greenwich asthma study. BMJ 1999;318: 1251-5.
Griffiths C, Sturdy P, Naish J, Omar R, Dolan S, Feder G. Hospital admissions for asthma in east London: associations with characteristics of local general practices, prescribing, and population. BMJ 1997;314: 482-6.
Ehrlich RI, Bourne DE. Asthma deaths among coloured and white South Africans: 1962 to 1988. Respir Med 1994;88: 195-202.
Ng TP, Tan WC. Temporal trends and ethnic variations in asthma mortality in Singapore, 1976-1995. Thorax 1999;54: 990-4.
Ormerod LP. Adult Asian acute asthma admissions reassessed: Blackburn 1991-1992. Respir Med 1995;89: 415-7.
Gilthorpe MS, Lay-Yee R, Wilson RC, Walters S, Griffiths RK, Bedi R. Variations in hospitalization rates for asthma among black and minority ethnic communities. Respir Med 1998;92: 642-8.
Griffiths C, Kaur G, Gantley M, Feder G, Hillier S, Goddard J, et al. Influences on hospital admission for asthma in south Asian and white adults: qualitative interview study. BMJ 2001;323: 962.
Moudgil H, Marshall T, Honeybourne D. Asthma education and quality of life in the community: a randomised controlled study to evaluate the impact on white European and Indian subcontinent ethnic groups from socioeconomically deprived areas in Birmingham, UK. Thorax 2000;55: 177-83.
Feder G, Griffiths C, Highton C, Eldridge S, Spence M, Southgate L. Do clinical guidelines introduced with practice based education improve care of asthmatic and diabetic patients? A randomised controlled trial in general practices in east London. BMJ 1995;311: 1473-8.
Altman DG. Practical statistics for medical research. London: Chapman and Hall, 1991.
Thomson O'Brien MA, Oxman AD, Davis DA, Haynes RB, Freemantle N, Harvey EL. Educational outreach visits: effects on professional practice and health care outcomes (Cochrane Review). In: Cochrane Library, Issue 4. Chichester: John Wiley, 2003.
EuroQol Group. EuroQol: a new facility for measurement of health related quality of life. Health Policy 1990;16: 199-208.
Barley EA, Quirk FH, Jones PW. Asthma health status measurement in clinical practice: validity of a new short and simple instrument. Respir Med 1998;92: 1207-14.
Steen N, Hutchinson A, McColl E, Eccles MP, Hewison J, Meadows KA, et al. Development of a symptom based outcome measure for asthma. BMJ 1994;309: 1065-8.
Griffiths C, Ahmed S, Ahmed S, Nandy S, Abrams C, Meadows KA, et al. Using health-related quality of life measures in minority ethnic groups: an approach to translating measures into Bengali (Sylheti). Eur J Gen Pract 2000;6: 130-4.
Gallefoss F, Bakke P. How does patient education and self-management among asthmatics and patients with chronic obstructive pulmonary disease affect medication? Am J Respir Crit Care Med 1999;160: 2000-5.
Jolly K, Bradley F, Sharp S, Smith H, Thompson S, Kinmonth AL, et al. Randomised controlled trial of follow up care in general practice of patients with myocardial infarction and angina: final results of the Southampton heart integrated care project (SHIP). BMJ 1999;318: 706.
Bonner S, Zimmerman BJ, Evans D, Irigoyen M, Resnick D, Mellins RB. An individualized intervention to improve asthma management among urban Latino and African-American families. J Asthma 2002;39: 167-79.(Chris Griffiths, professo)