PROACTIVE ASTHMA CARE IN CHILDHOOD: GENERAL PRACTICE-BASED, RANDOMIZED, CONTROLLED TRIAL

Abstract

Glasgow NJ, Ponsonby AL, Yates R, Beilby J, Dugdale P. BMJ. 2003;327:659–665To assess the feasibility and effectiveness of a general practice-based, proactive system of asthma care among children.A total of 174 children with moderate/severe asthma who were cared for by 24 general practitioners in the Australian Capital Territory were studied.The study was a randomized, controlled trial with cluster sampling according to general practice. The intervention involved a system of structured asthma care called the 3+visit plan, which included families being reminded to visit the general practitioner. Visit 1 was a baseline visit in which the concept of a “contract” for care was discussed. Visit 2 was used to assess asthma status, history, drug treatment, and management. Education and review of medications were performed. Visit 3 occurred 2 weeks later and included spirometric evaluation and a review of patient and peak flow records. An asthma action plan was completed. Allergen skin testing or radioallergosorbent testing was used to identify triggers. Visit 4 occurred 4 weeks later; progress was assessed and the asthma action plan was reviewed. Allergy test results were discussed and education was reinforced. Main outcome measures were rates of asthma consultations with the general practitioner, written asthma plans, completion of the 3+visit plan, lung function test results, emergency department visits for treatment of asthma, days absent from school, asthma symptoms, and medication use.The intervention group had more asthma consultations (odds ratio [OR] for >3 asthma consultations: 3.8; 95% confidence interval [CI]: 1.9–7.6; P < .01), asthma action plans (OR: 2.2; 95% CI: 1.2–4.1; P = .01), and 3+visit plans (OR: 24.2; 95% CI: 5.7–103.2; P < .01) than did the control group. The intervention group experienced less reduction in forced expiratory volume in 1 second after cold air challenge (2.6%; range: 1.7–3.5%; P < .01) than did the control group. The intervention group experienced less speech-limiting wheeze (OR: 0.2; 95% CI: 0.1–0.4; P < .01) and was more likely to use spacers (OR: 2.8; 95% CI: 1.6–4.7; P < .01), compared with the control group. No differences in days absent from school or symptom-free days were observed.Proactive care with active recall for children with moderate/severe asthma is feasible in general practice and seems to be beneficial.Delivering optimal health care for chronic illnesses such as asthma requires health systems to move from a reactive approach to a proactive approach. The study nicely evaluates the role of a general practice-based, proactive approach to pediatric asthma care. Studies such as this are often quite difficult to conduct and interpret in a controlled manner; however, this study represents 1 step in evaluating proactive primary care strategies. Reinforcement of education through frequent follow-up visits and encouragement of active recall appear to be feasible and beneficial in a general practice setting.