Dispensing of antibiotics, antitussives and mucolytics to asthma patients: a pharmacy-based observational survey.

BACKGROUND: Antibiotics, antitussives and mucolytics are commonly used in asthma, despite limited evidence for their effectiveness. The correlates of use for these medication classes in asthma were identified. METHODS: Asthma patients aged 18-50 who were regular customers of pharmacies were included in an observational study. Patients completed a questionnaire, which was complemented by computerised pharmacy records of previously dispensed medications. Users of each drug class were compared to non-users in terms of demographics, asthma characteristics and management. RESULTS: Among 886 patients (mean age: 37; 55% females), 63.2%, 55.8% and 27.2%, respectively, were users of antibiotics, mucolytics and antitussives during the previous 12 months. In multivariate analysis, dispensing of >2 units of oral corticosteroids was the major correlate of receiving antibiotics (OR=5.47; 95% CI=[3.00-9.97]), mucolytics (OR=3.93; 95% CI=[2.38-6.50]) and antitussives (OR=1.86; 95% CI=[1.18-2.94]). Compared to well-controlled patients, the probability of receiving antibiotics was significantly higher for poorly controlled patients (OR=2.01; 95% CI=[1.28-3.15]). CONCLUSIONS: Our results suggest that these drugs are mainly used during asthma exacerbations. A better understanding of the use of co-medication in asthma is required.

Home warmth and health status of COPD patients.

BACKGROUND: Home Energy Efficiency guidelines recommend domestic indoor temperatures of 21 degrees C for at least 9 h per day in living areas. Is health status of patients with Chronic Obstructive Pulmonary Disease (COPD) associated with maintaining this level of warmth in their homes? METHODS: In a cross-sectional observational study of patients, living in their own homes, living room (LR) and bedroom (BR) temperatures were measured at 30 min intervals over 1 week using electronic dataloggers. Health status was measured with the St George's Respiratory Questionnaire (SGRQ) and EuroQol: EQ VAS. Outdoor temperatures were provided by Met Office. RESULTS: One hundred and forty eight patients consented to temperature monitoring. Patients' mean age was 69 (SD 8.5) years, 67 (45%) male, mean percentage of predicted Forced Expiratory Volume in one second (FEV(1)) 41.7 (SD 17.4). Fifty-eight (39%) were current smokers. Independent of age, lung function, smoking and outdoor temperatures, poorer respiratory health status was significantly associated (P = 0.01) with fewer days with 9 h of warmth at 21 degrees C in the LR. A sub analysis showed that patients who smoked experienced more health effects than non-smokers (P < 0.01). CONCLUSION: Maintaining the warmth guideline of 21 degrees C in living areas for at least 9 h per day was associated with better health status for COPD patients. Patients who were continuing smokers were more vulnerable to reduction in warmth.

Objective neuropsychological test performance of professional divers reporting a subjective complaint of "forgetfulness or loss of concentration".

OBJECTIVE: This study attempted to determine whether the higher prevalence of reported "forgetfulness or loss of concentration" among professional divers can be confirmed using objective neuropsychological tests. Secondary aims were to qualify the functional nature of the complaints and to ascertain whether reduced performance was linked to diving history. METHODS: In a case-control study, the neuropsychological test performance of divers complaining of moderate or severe "forgetfulness or loss of concentration" was compared with two age-matched control groups reporting no or slight "forgetfulness or loss of concentration" ("nonforgetful" divers and "nonforgetful" nondivers). The group differences were analyzed using a multivariate analysis of co-variance, followed by canonical discriminant function analysis. Altogether 102 divers with a complaint, 100 nonforgetful divers, and 100 nonforgetful nondivers completed the study. RESULTS: The overall neuropsychological performance differed significantly between the groups [Pillai's trace: F(24,484)=2.04, P=0.003]. Verbal memory (Logical Memory and the California Verbal Learning Test), current intelligence (Wechsler Abbreviated Scale of Intelligence), and sustained attention (rapid visual processing) were poorer among the divers with a complaint than among the nonforgetful divers or the nonforgetful nondivers. The tests of memory, but not those of executive function, differentiated the divers with complaints from the two control groups. Mixed gas bounce diving and surface oxygen decompression diving, but not other techniques, were negatively associated with memory performance. CONCLUSIONS: A cognitive complaint of divers was confirmed using objective tests of neuropsychological performance. Memory, rather than executive function, was affected at the group level, but only to a mild degree. The relationships between diving experience and neuropsychological test performance were small and only seen with diving techniques used in the offshore oil and gas industry.

True device compliance: the need to consider both competence and contrivance.

Inability to use inhalers effectively is known to adversely affect the delivery of drug. It is assumed that increasing competence to use inhalers will lead to improved drug delivery. However many subjects appear competent (are able to use a device effectively) but contrive to use the device in a sub-optimal way in routine use. This study aimed to explore levels of True device compliance, that is the extent to which devices are used effectively in routine use, and to explore the influences of age and device on this parameter. The ability of 53 asthmatic patients aged 1-88 years to use their corticosteroid inhaler was assessed by a single investigator. In addition information regarding patient behaviour in routine practice was explored in a structured interview. True device compliance was defined to occur when a subject was rated competent and did not report contrivance. Competence was related to device type. All subjects using a holding chamber [pMDI + HC] (N = 21) or breath activated inhaler (N = 5) could demonstrate an adequate technique compared with only 9 (47%) of those prescribed a pMDI. However only 4 (19%) prescribed a pMDI + HC were true device compliant with the majority regularly using the pMDI alone while (42%) of those prescribed a pMDI were True device compliant. Since 82% of patients over 65 were prescribed pMDI alone, and 92% of patients up to 5 years were prescribed pMDI + HC, True device compliance was low among both groups. Only 33% of patients over 65 prescribed pMDIs were able to use them competently. Lack of competence, particularly in the elderly, and contrivance, particularly common amongst those using holding chambers, are two important but independent impediments to effective inhaled therapy.

Wheezy bronchitis in childhood: a distinct clinical entity with lifelong significance?

BACKGROUND: Historically, clinicians have recognized the existence of the clinical syndrome of childhood wheezy bronchitis. In the late 1960s, children with this syndrome were relabeled as having asthma, and the term wheezy bronchitis was abandoned. In a 1989 study of a cohort that originally had been studied in 1964, we reported that those who had childhood wheezy bronchitis had as adults attained lung function similar to that of healthy control subjects and had less significant symptoms than did those who had experienced childhood asthma, in whom lung function was reduced. In this study, we reexamined these subjects 12 years later to determine whether the improved outcome of the wheezy bronchitis group had been maintained. METHODS: In 2001, we followed up the 283 participants of the 1989 study, who were now aged 45 to 50 years. In interviews, respiratory symptoms and smoking status were assessed. Spirometry was measured. RESULTS: One hundred seventy-seven subjects (63%) completed the study. After adjusting for age, height, gender, socioeconomic status, smoking status, and number of pack-years smoked, the current FEV(1) in the childhood asthma group (mean, 2.45 L; 95% confidence interval, 2.29 to 2.62) was significantly lower than the wheezy bronchitis group (2.78 L, 95% confidence interval, 2.64 to 2.91; p < 0.01) and the control group (2.96 L; 95% confidence interval, 2.83 to 3.1; p < 0.01). The difference between the wheezy bronchitis group and the control subjects was not significant (p = 0.06). Between 1989 and 2001, both the childhood wheezy bronchitis group (p < 0.01) and the childhood asthma group (p = 0.01) had greater declines in FEV(1) than did the control group (asthma group decline, - 0.75 L [95% confidence interval, - 0.66 to - 0.84]; wheezy bronchitis group decline, - 0.75 L [95% confidence interval, - 0.68 to - 0.83]; control group decline, - 0.59 L [95% confidence interval, - 0.52 to - 0.67]). In 2001, the asthma group had more symptoms than did the wheezy bronchitis group (p < 0.01), who were more symptomatic than the control group (p < 0.01). CONCLUSION: Those with childhood wheezy bronchitis, having achieved normal lung function in earlier adulthood, now show a more rapid decline in lung function than did control subjects. If this rate of decline persists, these subjects may develop obstructive airways disease in later life.

Annual review of patients with sleep apnea/hypopnea syndrome--a pragmatic randomised trial of nurse home visit versus consultant clinic review.

BACKGROUND: This pragmatic randomised, controlled trial investigated annual review of patients with sleep apnea/hypopnea syndrome (SAHS). Clinical outcomes and costs were compared for consultant clinic review versus specialist nurse home visit. METHOD: One hundred and seventy-four patients were randomised to annual review by consultant clinic appointment or by specialist nurse home visit. SAHS symptoms, Epworth score, hospital anxiety and depression scale (HADS), Short Form-36 (SF-36) and hours of use of constant positive airway pressure (CPAP) were measured before and 3 months after review. The costs and patient preference for review were determined. RESULTS: After review, both groups significantly increased CPAP use (mean (SD) increase: nurse, 0.66 (1.71) h; consultant, 0.45 (1.69) h) and reduced symptom scores (nurse, -2 (7); consultant, -3 (9)), compared to baseline. There were no differences between groups in these improvements, or in HADS or SF-36 scores. Average duration of a nurse home visit, excluding travel time, was 26 (6) min. Total NHS cost per visit was 52.26 UK pounds (49.85) ($83.62 (79.76)), of which 6.57 UK pounds (1.43) ($10.51 (2.29)) reflected time spent with the patient and the remainder was travel cost. Average duration of consultant review was 10 (6) min, total NHS cost 6.21 UK pounds (3.99) ($9.94 (6.38)). However, the cost to the patient of attending the clinic was 23.63 UK pounds (23.21) ($37.81 (37.13)). Patient preference for review was nurse 16%, consultant 19%, and no preference 65%. CONCLUSION: Following annual review, use of CPAP increased and symptoms improved. Outcomes were similar for consultant and nurse led review. Home visits were expensive for the healthcare provider, whereas clinic attendance incurred substantial costs to the patient. The majority of patients would accept nurse review for their sleep apnea management.

GP discussion of prognosis with patients with severe chronic obstructive pulmonary disease: a qualitative study.

BACKGROUND: Recent research shows that health professionals do not communicate about prognosis with patients with chronic obstructive pulmonary disease (COPD) as openly as with patients who have cancer. AIM: To identify strategies that general practitioners (GPs) can use to facilitate discussion of prognosis with patients who have COPD. DESIGN OF STUDY: Telephone interviews of 15 GPs and five respiratory consultants on the topic of discussing prognosis with patients who have severe COPD. SETTING: Participating doctors worked in the Auckland region of New Zealand. METHOD: GPs and consultants were selected purposively to detect unique and shared patterns from diversity in how prognosis is discussed with patients with severe COPD. An interview guide was developed from a literature review and results of our earlier postal survey of GPs. Transcripts of audiotaped interviews were analysed independently and then together by three authors, using a general inductive approach. RESULTS: Seven strategies were identified that GPs had used or could use to facilitate discussion of prognosis with patients with COPD. These were: be aware of implications of diagnosis; use uncertainty to ease discussion; build relationship with patients; be caring and respectful; begin discussion early in disease course; identify and use opportunities to discuss prognosis; and work as a team. CONCLUSION: A number of suggested strategies can be used to facilitate discussion of prognosis with patients who have severe COPD.

Factors affecting adherence to asthma treatment: patient and physician perspectives.

AIMS: To identify important factors affecting treatment adherence of patients with asthma and to summarise this information as a guide for physicians. METHODS: Information from literature and interviews with 12 respiratory physicians (four each from France, Spain and UK) and 46 asthma patients was obtained. Factors affecting adherence to asthma treatment were identified, reviewed and a flow chart developed to indicate the relationship between key factors. RESULTS: Major factors influencing adherence included: the patient-physician relationship; the patient's understanding of the disease and its treatment; the patient's beliefs and perception of the disease and its treatment, and, importantly, the patient's willingness to take an active part in his/her asthma management. CONCLUSION: Patient adherence to asthma can be improved, and the likelihood of treatment success increased, by paying attention to the factors that influence patients' willingness to participate in their treatment.

Asthma patients' self-reported behaviours toward inhaled corticosteroids.

BACKGROUND: Patient adherence to recommended use of ICS is questionable in asthma, with irregular use or interruptions occurring frequently. Factors explaining discontinuation of controller therapy could orientate interventions. The characteristics of patients with interruptions of inhaled corticosteroids (ICSs), intentional or accidental, were investigated. METHODS: Asthma patients regularly prescribed ICS by GPs (Cegedim network) were included. Patients' characteristics and behaviours toward ICS (accidental/intentional interruptions, less frequent use of ICS and change in dosing) were identified from self-report questionnaires, and linked to data prescription database. Interrelations between declared behaviours toward ICS were studied with a Multiple Component Analysis (MCA) and the correlates of ICS interruptions were identified. RESULTS: During the past 3 months, 31.6% of 204 patients (mean age: 53.8 years, females: 59.3%) intentionally interrupted ICS when feeling better, 25.4% forgot ICS and 18.3% deliberately changed the doses. A quarter of patients considered constant use of respiratory medicines as unhealthy. MCA revealed that intentional, accidental interruptions and less frequent use of ICS were closely correlated. Risk of intentional interruption was increased when patients considered constant use of respiratory therapy to be unhealthy (OR=3.36, 95%CI=[1.47-7.66]). Conversely, risk was significantly lower when ICS was associated or combined with another controller (OR=0.24, 95%CI=[0.08-0.73]), compared to ICS in monotherapy. Less frequent interruptions were observed in patients older than 65 (OR=0.35, 95%CI=[0.13-0.89]). CONCLUSIONS: Our study suggests that discontinuation of use of controllers is associated with other inadequate behaviours or beliefs about inhaled controllers. Efforts should be targeted at patients' perceptions and behaviours toward controller therapy.

Factors influencing dispensing of psychotropic medications to patients with asthma: a community pharmacy-based survey.

BACKGROUND: To our knowledge, the use of psychotropic medications (antidepressant, anxiolytic, and hypnotic agents) in patients with asthma has not been extensively explored. OBJECTIVE: To identify factors associated with the use of these medications in patients with asthma. METHODS: Regular customers (aged 18-50 years) of 348 pharmacies in 9 French regions were consecutively recruited from November 2003 to June 2004. Patients with a prescription for an asthma medication were included. Patients completed a questionnaire, complemented by the computerized records of their therapy dispensed in the past 12 months. Asthma control was measured with the Asthma Control Test. RESULTS: Among 886 patients (mean age, 37.4 years; 55.0% female), during the 12 months before the survey, the proportions who received at least 1 U of anxiolytic, antidepressant, and hypnotic agents were 25.6%, 13.7%, and 13.0%, respectively. Higher dispensing levels of antidepressant, anxiolytic, and hypnotic agents were observed with decreasing asthma control (P < .001 for each drug class). Other correlates of receiving any of these classes included older age, female sex, smoking status, and dispensing of antireflux treatment (P < .001 for all). These results were confirmed in multivariate analyses. CONCLUSIONS: Psychotropic drugs were commonly dispensed to patients with asthma, and correlates of receiving these drugs were identified in this population. The high use of psychotropic medication, particularly in patients with poorly controlled asthma, is of concern.

Indoor air quality in homes of patients with chronic obstructive pulmonary disease.

RATIONALE: Outdoor air quality is associated with respiratory morbidity and mortality. Less is known of the relationship of indoor air quality to respiratory health of groups vulnerable to outdoor air, such as those with chronic obstructive pulmonary disease (COPD). OBJECTIVES: To investigate among patients with COPD the association of health status with indoor air quality in their homes. METHODS: Observational study of indoor environmental characteristics of homes of 148 patients with severe COPD in North East Scotland. MEASUREMENTS AND MAIN RESULTS: Airborne living room levels of particulate matter with a diameter of 2.5 microm or less (PM(2.5)) (microg/m(3)) were measured over 8 to 14 hours using DustTrak monitors. Nitrogen dioxide exposure (ppb) in living rooms was measured over 1 week. Endotoxin (EU [endotoxin units]/mg) in living room dust was measured. Health status of participants was assessed by the St. George's Respiratory Health Questionnaire (symptoms, activity limitation, and disease impact). The mean age of participants was 69 years. Approximately 45% were male, 39% were smokers, and 49% lived in smoking households. Average indoor PM(2.5) levels were 18 mug/m(3), nitrogen dioxide was 7.8 ppb, and endotoxin levels were 95.8 EU/mg of dust. PM(2.5) was significantly higher in smoking households (P < 0.001) and was associated with higher levels of endotoxin and NO(2). PM(2.5) was significantly associated with increased symptom burden (P < 0.01), with greater effect for current smokers. Endotoxin and nitrogen dioxide exposure were not related to health status. CONCLUSIONS: Higher levels of PM(2.5) are associated with worse health status of these patients with severe COPD. Indoor levels of PM(2.5) are significantly higher in homes with smokers.

Health status of professional divers and offshore oil industry workers.

AIMS: To compare the health status of UK professional divers and age-matched non-divers and to contrast offshore divers (OSDs) with non-offshore divers (NOSDs). METHODS: A postal survey sent to 2958 male professional divers, registered with the UK Health & Safety Executive (HSE) before 1991, and 2708 men who had worked in the offshore oil industry in 1990-92 (non-divers). The questionnaire addressed lifestyle, occupation and health status. RESULTS: In all, 56% of divers and 51% of non-divers responded. Three per cent of participants reported ill-health retirement or being off-work on sickness benefit with no difference between groups. Divers were less likely to report asthma or hypertension. Health-related quality of life (SF-12) was within normal limits for both groups but the mental component summary was higher in divers who were also less likely to be receiving medical treatment. Divers were more likely than non-divers to report 'forgetfulness or loss of concentration' (18% versus 6%, OR 3.8, 95% CI 2.7-5.3), musculoskeletal symptoms (41% versus 34%, OR 3.8, 95% CI 2.7-5.3) and 'impaired hearing' (16% versus 11%, OR 1.6, 95% CI 1.2-2.0). These differences were attributable to increased symptom reporting in OSDs and were not present for NOSDs, with the exception of cognitive symptomatology which was commoner in both OSDs (22%, OR 4.8, 95% CI 3.4-6.8) and NOSDs (9%, OR 1.9, 95% CI 1.1-3.3) than in non-divers (6%). CONCLUSIONS: There was increased symptom reporting in OSDs. However, there was no evidence to suggest any major impact on long-term health of UK divers who had started their career before 1991.

Asthmatic patients' poor awareness of inadequate disease control: a pharmacy-based survey.

BACKGROUND: Many asthmatic patients fail to perceive their level of disease control. OBJECTIVE: To investigate whether patients' ability to identify asthma control varied with personal characteristics or factors related to disease management. METHODS: Asthmatic patients were consecutively recruited at 348 pharmacies. They completed a questionnaire (regarding personal characteristics and asthma management) linked to pharmacies records of dispensed medications. The Asthma Control Test questionnaire includes 4 dimensions of asthma control (activity limitations, dyspnea, nocturnal awakenings, and rescue medication use) and assesses patients' perception of control ("How would you rate your asthma control during the past 14 days?"). Analyses were restricted to patients with inadequate control. Patients' perception of control was compared across the other dimensions of the questionnaire. The correlates of patients' failure to perceive inadequate asthma control were investigated. RESULTS: Seven hundred eighteen (68.5%) of the 1,048 patients with inadequate asthma control and documented perception of control considered themselves to be "completely" or "well" controlled. Patients' perception of control did not vary with each dimension of inadequate control. High rates of failure to perceive poor control were observed in patients with at least weekly dyspneas (60%) or nocturnal symptoms (60%). Failure to perceive inadequate control was more likely in patients aged 41 to 50 years (odds ratio, 1.51; 95% confidence interval, 1.05-2.15). No significant effect of factors related to asthma management was observed. CONCLUSIONS: Patients with most uncontrolled asthma have difficulty in properly perceiving their level of disease control regardless of their personal characteristics or disease management. The reasons for this poor perception should be investigated. Education programs should be created that focus on knowledge of asthma miscontrol criteria.

Results of a national asthma campaign survey of primary care in Scotland.

OBJECTIVE: To identify within primary care in Scotland how far procedures for asthma review and patient education match guideline recommendations. DESIGN AND SETTING: Telephone survey of a one in four stratified random sample of all 1058 general practices in Scotland. PARTICIPANTS: Practice nurses, general practitioners. MAIN OUTCOME MEASURES: Number of practices matching guideline recommendations for asthma review, targeting of care, use of structured asthma records, provision of management plans, education, and regular audit. RESULTS: Of 276 general practices contacted 91% (251) completed the questionnaire; 93% (228) ran an asthma review service; 74% (166) employed a specially trained asthma nurse; 39% (106) had a policy for providing action plans; 63% (155) had carried out an asthma audit in the previous 3 years; 76% (218) used a structured tool in consultations, 46% with use of computer technology, 34% used only a manual stamp. Sixty-six per cent (173) had searched for patients overusing beta2 agonists; 32% (79) had searched for patients on medication treatment step 3 and above. Single- or two-partner practices were less likely to follow guideline recommendations but neither rurality nor deprivation was related to guideline compliance. CONCLUSIONS: Three-quarters of Scottish general practices have trained asthma nurses and offer patients asthma review, but only a minority have proactive care procedures for targeting patients or a policy for providing patients with action plans. Practice systems are underused for identifying 'at-risk' patients. There is a need for proactive procedures and provision of self-management materials to patients. Access to trained asthma nurses needs to be improved.

Implementing asthma education programmes in paediatric respiratory care: settings, timing, people and evaluation.

Randomised controlled trials have shown that asthma education programmes in paediatric care can improve the ability of children and their parents to control their asthma. This paper discusses the implementation of asthma education within pragmatic care. Key times for implementation are suggested: at the initial diagnosis, after acute asthma events such as hospitalisation, at the time of medication change and at regular review. Special issues, such as implementing programmes for teenagers, are discussed. Evaluation is recommended for processes (does the practice have an agreed protocol for education, does it have a key person with responsibility for co-ordinating education within the clinic or practice, does it have agreed outcomes for audit of education?). Evaluation is also recommended for individual outcomes (clinical improvement and increase in perceived asthma control and confidence in management).

Minor illness education for parents of young children.

BACKGROUND: A number of previous studies on minor illness have concentrated on nurse-led clinics and the role of nurse practitioners. This study examines the effect of a minor illness education programme which aimed to increase parents' confidence and knowledge in managing childhood illnesses. AIM: The primary aim of this study was to evaluate the effectiveness of a home visit and booklet in providing education to parents about minor infant illnesses. DESIGN: A randomized controlled trial was conducted. The intervention involved a home visit to discuss parents' concerns and provide advice and information, and a booklet advising parents what to do and when to consult about infant illnesses. METHOD: A total of 120 parents of 6 week old babies were identified over a 6 month period, using health visitors' caseloads, and randomized to an intervention group (60), that received a visit and a booklet, or a control group (60) that received standard care. Groups were compared on entry to the study and at 7 months, in terms of parental knowledge and confidence about childhood illnesses, the intended use of home care activities, intention to consult professionals and actual use of health services. Data were collected by self-completed questionnaire and case note review. FINDINGS: The educational intervention resulted in a reduction in visits to the child health clinic but had little effect on use of other services. Parents in the intervention group showed a general trend towards greater certainty about the home care options they would choose, and a reduction in intention to consult a doctor. However, they also indicated a feeling of reduced confidence and knowledge. CONCLUSION: The trial showed no effect on use of services but did demonstrate reduction in parents' intentions to consult a doctor, which appeared to be because of increased certainty about home care. However, it is of concern that they indicated feeling less confident and knowledgeable. It is not possible to clarify whether this represented anxiety that was constructive, enhancing decision-making or was destructive. Further work into the role of education in parental decision-making, anxiety levels and enhancement of confidence is required.