Prospective community programme versus parent-driven care to prevent respiratory morbidity in children following hospitalisation with severe bronchiolitis or pneumonia.

BACKGROUND: Hospitalisation with severe lower respiratory tract infection (LRTI) in early childhood is associated with ongoing respiratory symptoms and possible later development of bronchiectasis. We aimed to reduce this intermediate respiratory morbidity with a community intervention programme at time of discharge. METHODS: This randomised, controlled, single-blind trial enrolled children aged <2 years hospitalised for severe LRTI to 'intervention' or 'control'. Intervention was three monthly community clinics treating wet cough with prolonged antibiotics referring non-responders. All other health issues were addressed, and health resilience behaviours were encouraged, with referrals for housing or smoking concerns. Controls followed the usual pathway of parent-initiated healthcare access. After 24 months, all children were assessed by a paediatrician blinded to randomisation for primary outcomes of wet cough, abnormal examination (crackles or clubbing) or chest X-ray Brasfield score ≤22. FINDINGS: 400 children (203 intervention, 197 control) were enrolled in 2011-2012; mean age 6.9 months, 230 boys, 87% Maori/Pasifika ethnicity and 83% from the most deprived quintile. Final assessment of 321/400 (80.3%) showed no differences in presence of wet cough (33.9% intervention, 36.5% controls, relative risk (RR) 0.93, 95% CI 0.69 to 1.25), abnormal examination (21.7% intervention, 23.9% controls, RR 0.92, 95% CI 0.61 to 1.38) or Brasfield score ≤22 (32.4% intervention, 37.9% control, RR 0.85, 95% CI 0.63 to 1.17). Twelve (all intervention) were diagnosed with bronchiectasis within this timeframe. INTERPRETATION: We have identified children at high risk of ongoing respiratory disease following hospital admission with severe LRTI in whom this intervention programme did not change outcomes over 2 years. TRIAL REGISTRATION NUMBER: ACTRN12610001095055.

Primary options for acute care: general practitioners using their skills to manage "avoidable admission" patients in the community.

AIM: To enroll 600 primary care "avoidable admission" patients in a programme that utilised general practitioners to manage those patients in the community. METHODS: The Primary Options for Acute Care (POAC) programme ran from 26 February to 31 December 2001. Using networks already established, primary care teams were invited to manage patients using any resources they required, up to a cost of approximately $266 per patient. If needed, a Service Coordinator was available to arrange investigations, care, or treatment. RESULTS: From 26 February to 31 December 2001, 707 patients were enrolled in POAC by 100 GPs. 104 patients (15%) were eventually admitted to hospital. An average of $200.73 per patient per episode was spent (not including administrative costs). A wide variety of patients and diseases were managed. Patients and general practitioners reported high levels of satisfaction with the programme. CONCLUSION: POAC demonstrated the ability and willingness of primary care providers to successfully manage patients who traditionally would be sent to hospital, within a defined budget