Nurse versus physician-led care for the management of asthma.

BACKGROUND: Asthma is the most common chronic disease in childhood and prevalence is also high in adulthood, thereby placing a considerable burden on healthcare resources. Therefore, effective asthma management is important to reduce morbidity and to optimise utilisation of healthcare facilities. OBJECTIVES: To review the effectiveness of nurse-led asthma care provided by a specialised asthma nurse, a nurse practitioner, a physician assistant or an otherwise specifically trained nursing professional, working relatively independently from a physician, compared to traditional care provided by a physician. Our scope included all outpatient care for asthma, both in primary care and in hospital settings. SEARCH METHODS: We carried out a comprehensive search of databases including The Cochrane Library, MEDLINE and EMBASE to identify trials up to August 2012. Bibliographies of relevant papers were searched, and handsearching of relevant publications was undertaken to identify additional trials. SELECTION CRITERIA: Randomised controlled trials comparing nurse-led care versus physician-led care in asthma for the same aspect of asthma care. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS: Five studies on 588 adults and children were included concerning nurse-led care versus physician-led care. One study included 154 patients with uncontrolled asthma, while the other four studies including 434 patients with controlled or partly controlled asthma. The studies were of good methodological quality (although it is not possible to blind people giving or receiving the intervention to which group they are in). There was no statistically significant difference in the number of asthma exacerbations and asthma severity after treatment (duration of follow-up from six months to two years). Only one study had healthcare costs as an outcome parameter, no statistical differences were found. Although not a primary outcome, quality of life is a patient-important outcome and in the three trials on 380 subjects that reported on this outcome, there was no statistically significant difference (standardised mean difference (SMD) -0.03; 95% confidence interval (CI) -0.23 to 0.17). AUTHORS' CONCLUSIONS: We found no significant difference between nurse-led care for patients with asthma compared to physician-led care for the outcomes assessed. Based on the relatively small number of studies in this review, nurse-led care may be appropriate in patients with well-controlled asthma. More studies in varied settings and among people with varying levels of asthma control are needed with data on adverse events and health-care costs.

Children with asthma on inhaled corticosteroids managed in general practice or by hospital paediatricians: is there a difference?

AIM: To investigate whether there are differences in asthma characteristics between two populations of children with moderate asthma requiring inhaled corticosteroids (ICS) who are treated in general practice or in hospital practice. PATIENTS AND METHODS: 45 children from general practice and 62 from hospital practice, diagnosed with asthma and treated with ICS, were analysed in terms of lung function parameters, asthma control (ACQ), and use of medication. RESULTS: Children in general practice did not differ significantly from those in paediatric practice with respect to mean age, lung function tests, and corrected daily dose of ICS. The median ACQ score was higher (representing poorer control) in the general practice group than in the paediatric practice group (0.67 and 0.33 respectively, p < 0.05). Fewer children (22.7%) from the general practice group than from the paediatric group (98.4%) had planned review visits (p< 0.01). Prescriptions for a combination ICS/long-acting beta2-agonist (LABA) inhaler were 28.9% in the general practice group and 6.5% in the paediatric group (p<0.05). CONCLUSION: The hospital-based group was better controlled with less frequent use of combination therapy. Our observations stress the necessity for regular review visits for children with moderately severe asthma especially in general practice.