A randomised controlled trial of clinics in secondary schools for adolescents with asthma

Abstract

Aim To test the hypothesis that delivery of a programme of asthma care in nurse‐led clinics in school would improve access to care and health outcomes compared with care in general practice.Methods Pupils at four secondary schools in Bristol, North Somerset and South Gloucestershire, UK, were included in the randomized controlled trial. Another two schools were included to control for any cross‐contamination between school clinic attenders and general practice attenders in the trial schools. Pupils in trial schools were randomly assigned to receive an invitation for an asthma review at school or in general practice. Schools were stratified for deprivation and covered rural, urban and suburban populations. Pupils with asthma were identified using a screening questionnaire and then cross‐referenced with practice prescribing records. Four school nurses with additional specialist asthma training ran the school clinics weekly. Consultations concentrated on the needs and interests of adolescents and followed national guidelines for treatment changes. Reviews were arranged at 1 and 6 months, with an additional 3‐month review if needed. The pupil's GP was kept informed. General practice care was according to the practice's usual treatment protocols.Primary outcomes were the proportion of pupils who had had an asthma review in 6 months, health‐related quality of life and level of symptoms. Secondary outcomes were pupil knowledge and attitude to asthma, inhaler technique, the proportion taking inhaled steroids daily, school absence due to asthma, PEFR and pupil preference for the setting of care.Sample size was calculated to have an 80% chance of showing an increase from 40% to 60% having a review in 6 months and half a standard deviation improvement on the quality of life measure. Analysis was on an intention to treat basis.Results School clinic pupils were more likely to attend (91% vs. 51%). However, symptom control or quality of life were no better. School clinic pupils knew more about asthma, had a more positive attitude and better inhaler technique. Absence and PEFR showed no difference. 63% who attended school clinics preferred this model but, taking both groups together, just over half would prefer to attend their GP for follow‐up. Cost of care (including practice, school clinic, hospital and medication) was £32.10 at school, £19.80 at the trial practices and £18.00 at control practices.Conclusions Previous evaluations of nurse‐led asthma clinics in practice have also failed to show improvements in outcomes, though process measures do improve. This may be due to the need for nurses to refer patients to doctors for changes in medication, rather than doing this themselves. Some weaknesses in study design that may have affected outcome, but the essential conclusion is that nurse‐led asthma clinics in school are not cost effective. The study does suggest that such clinics can reach a high proportion of adolescents, but for asthma at least this does not result in any measurable improvement in outcome.