The Coping with Asthma Study: a randomised controlled trial of a home based, nurse led psychoeducational intervention for adults at risk of adverse asthma outcomes.

BACKGROUND: Morbidity and mortality associated with severe asthma might be reduced by interventions that address psychosocial factors contributing to adverse outcomes. A study was undertaken to assess the effectiveness of a 6 month home based psychoeducational intervention delivered by a respiratory nurse specialist for adults at risk of adverse asthma outcomes. METHODS: A pragmatic randomised controlled trial was performed in 92 adults registered with hospital or primary care asthma clinics. All had previous hospital admissions and/or were on British Thoracic Society step 4-5 treatment and had failed to attend clinic appointments or were considered to have poor adherence to other aspects of their agreed management. Patients were visited in their homes for assessment and, where appropriate, intervention. The main outcomes measured were symptom control, asthma specific quality of life, and generic health status. RESULTS: At the 6 month primary time point there were no significant differences between usual care and intervention groups in mean symptom control, physical functioning, or mental health scores (differences (with 95% CI) -0.35 (-1.83 to 1.13), 3.10 (-11.42 to 17.63), 0.42 (-10.22 to 11.07), respectively). Small effects on asthma specific quality of life up to 12 months (e.g. adjusted difference at 12 months 0.13 (95% CI 0.02 to 0.25)) and short term effects on generic health status, which mirrored improvements in aspects of self-care observed at the end of the intensive phase of the intervention, were apparent only from fully adjusted analyses. CONCLUSIONS: A home based intervention provided by a nurse receiving psychological supervision may have effects on quality of life but is overall of limited long term benefit to adults at risk of adverse asthma outcomes.

A confidential enquiry into deaths caused by asthma in an English health region: implications for general practice.

AIM: To determine the factors contributing to death from asthma in patients aged under 65 years in East Anglia in the early 1990s. METHOD: We have performed on ongoing confidential enquiry since January 1992. For the first time a general practitioner was included in the enquiry team. RESULTS: A review of the clinical and pathological data of the 50 patients reported in the first 3 years suggested that 36 of these deaths were attributable to asthma. Thirty-one patients died out of hospital (3 en route to the hospital), 2 in the Accident and Emergency department, and only 3 in hospital. Adverse social factors were found in 25 out of 34 patients, and adverse psychological characteristics in 23 of the 31 patients where these could be assessed. Only 7 appeared to have no adverse psychological or social factors. Routine medical care was considered appropriate in 20 patients, and inappropriate in 14. Twenty-four had received appropriate advice and education. Nine of the 21 patients, where this could be assessed, and half the relatives, failed to respond appropriately to worsening asthma symptoms during the fatal attack. No potentially preventable factors were identified in two women who died of end stage asthma. CONCLUSION: This enquiry has demonstrated that inadequacies in the medical care of asthma continue to occur, although less frequently than in previous asthma-death studies. In addition, 79% of the patients had experienced psychosocial factors which appeared important in contributing to their deaths. Recommendations for identifying and managing such "at risk' patients have been circulated to all general practitioners and chest physicians in the region.