Effect of spirometry and medical review on asthma control in patients in general practice: a randomized controlled trial.

BACKGROUND AND OBJECTIVE: Although guidelines for asthma emphasize the importance of spirometry for continuity and evaluation of care, it is underused in general practice. The objective of this study was to investigate the effect of spirometry and medical review on asthma control in general practice over 12 months. METHODS: Patients were recruited through 31 practices, which were randomly allocated to one of three groups: Group A had 3-monthly spirometry with medical review, Group B spirometry only before and after the trial, and Group C usual care. Asthma control data were analysed by intention to treat using non-parametric tests and logistic regression models fitted to allow for confounders, repeated measures and clustering by practice. RESULTS: The trial was completed by 195 patients (Group A 69, Group B 78, Group C 48). Asthma control improved in all groups during the 12 months trial, most impressively in Group A (odds ratio per 3 months = 1.27, 95% confidence interval: 1.08-1.49, P = 0.004), but the difference between the groups' respective 3-monthly changes was not significant. At 6 months, asthma control in Group A had increased more from baseline than in Groups B + C (P = 0.006). CONCLUSIONS: Regular spirometry with medical review was associated with improved asthma control in general practice patients, while there was less improvement in either the spirometry only or usual care group. The mechanisms of this improvement may include appropriate adjustment of medication and improved compliance.

Do spirometry and regular follow-up improve health outcomes in general practice patients with asthma or COPD? A cluster randomised controlled trial.

OBJECTIVE: To determine whether spirometry with regular medical review improves the quality of life or other health outcomes among patients with asthma or chronic obstructive pulmonary disease (COPD) managed in general practice. DESIGN, SETTING AND PARTICIPANTS: Cluster randomised controlled trial conducted in 31 general practices in Melbourne during 2007-2008. Practices recruited 305 adult patients who had been prescribed inhaled medication in the preceding 6 months. INTERVENTION: Practices were randomly assigned to one of three groups: Group A patients received 3-monthly spirometry performed by a respiratory scientist with results returned to the practice and regular medical review; Group B patients received spirometry only before and after the trial; and Group C patients received usual care. MAIN OUTCOME MEASURES: Quality of life, assessed with the 36-item Short Form (SF-36) Australian (English) Version 2 questionnaire at baseline and 3, 6, 9 and 12 months. Secondary outcomes were assessed with the European Community Respiratory Health Survey at baseline and 12 months. RESULTS: The trial was completed by 253 participants: 79 in Group A, 104 in Group B, and 70 in Group C. Median age was 58 years (range, 18-70 years), and 167 participants (66%) were women. There were no significant changes in SF-36 Physical and Mental Component Summary scores from baseline to 12 months, or significant differences between groups on either scale or any subscale of the SF-36. There were also no significant differences in respiratory symptoms, asthma attacks, written asthma action plans, days lost from usual activities or health care utilisation. CONCLUSION: Three-monthly spirometry and regular medical reviews by general practitioners are not associated with any significant improvement in quality of life or other health outcomes for patients with asthma and/or COPD. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12606000378527.

Using discrete choice experiments to investigate subject preferences for preventive asthma medication.

BACKGROUND AND OBJECTIVE: Long-term adherence to inhaled corticosteroids is poor despite the crucial role of preventer medications in achieving good asthma outcomes. This study was undertaken to explore patient preferences in relation to their current inhaled corticosteroid medication, a hypothetical preventer or no medication. METHODS: A discrete choice experiment was conducted in 57 adults with mild-moderate asthma and airway hyper-responsiveness, who were using inhaled corticosteroid

3. Drug hypersensitivity.

Most drug reactions are pharmacological reactions rather than hypersensitivity reactions. In assessing drug reactions, a detailed clinical history and careful documentation of reactions are most important. Elucidating the nature and time course (first versus subsequent exposure, immediate versus non-immediate) of a reaction can help to distinguish immune from non-immune hypersensitivity, as well as IgE-mediated from T cell-mediated allergy. Skin testing and in-vitro tests are of predictive value for only a limited group of IgE-mediated drug allergic reactions. Drug provocation challenges can be used to eliminate suspicion of a low-probability drug reaction, find a safe alternative to a proven or probable drug reaction, or as a means of desensitisation. If a patient taking an angiotensin-converting enzyme (ACE) inhibitor develops angioedema, the cause must be assumed to be the ACE inhibitor until proven otherwise.

Back for more: a qualitative study of emergency department reattendance for asthma.

OBJECTIVE: To explore the reasons why individuals recurrently present with asthma to hospital emergency departments. DESIGN: A predominantly qualitative study in which participants were interviewed in-depth about their asthma. Data on medication use, respiratory health and asthma knowledge were also collected, and asthma severity was determined from medical records. SETTING: A tertiary teaching hospital and a suburban hospital emergency department (ED) from 1 March to 30 April 2000, and a rural hospital ED from 1 July to 31 August 2000. PARTICIPANTS: The participation rate was 32% of an initial 195 ED attendees (183 of whom were eligible) aged 18-70 years: 32 had presented to an ED for asthma care on more than one occasion over the preceding 12 months (reattendees), and 29 were non-reattendees. RESULTS: Two-thirds (22/32) of reattendees had chronic severe asthma and presentation to ED was deemed appropriate for 18 of these, indicated by recurrent severe asthma attacks despite seeking prior medical intervention. Reasons for re-presentation identified in a third of all reattendees included poor asthma knowledge, and financial and other barriers to medication use. CONCLUSIONS: We identified potentially preventable issues in about a third of patients (most of whom had mild to moderate asthma) who recurrently presented to EDs for treatment. The remainder of the participants sought emergency asthma treatment appropriately after failing to respond to medical care, and this was frequently in accordance with their asthma management plans.

Patients' views of the burden of asthma: a qualitative study.

OBJECTIVES: To explore the burden of asthma on the lives of people presenting to hospital emergency departments for asthma treatment. DESIGN: A qualitative study. Consenting individuals with asthma who presented to emergency departments were interviewed in-depth, and interviews were taped, transcribed and thematically analysed. Questionnaire data on medication use, respiratory health and asthma knowledge were also collected. Asthma severity was determined from the medical records. SETTING: A tertiary teaching hospital and a suburban hospital during March and April 2000, and a rural hospital during July and August 2000. PARTICIPANTS: Sixty-two participants (19 male and 43 female), aged 18-70 years. RESULTS: The burden of asthma was broad, affecting social life, personal relationships, employment and finances. The cost of asthma medication was an issue for nearly two-thirds of participants. Individuals performed their own "cost-benefit analysis" for medication use, weighing up expense, perceived side effects and potential benefits. As a consequence, several participants chose to alter their medication dose, or not to take prescribed medications. For some participants, asthma directly contributed to diminished employment opportunities. CONCLUSIONS: To achieve a therapeutic partnership, doctors need to be aware of the substantial social, personal and financial burden of asthma for their patients. They should also recognise that patients' perceptions of treatment cost may compromise treatment adherence.