A controlled retrospective pilot study of an 'at-risk asthma register' in primary care.

BACKGROUND: There are few reports of primary care initiatives designed to improve management of asthma patients who are at risk of adverse outcomes. AIM: To assess the impact on emergency treatments, service use, and costs, of introducing an at-risk asthma register in a general practice surgery. METHODS: Asthma patients demonstrating characteristics associated with adverse outcomes were added to an at-risk register. Tags were placed in patients' records and practice staff were trained to ensure their appropriate recognition and management. Data were retrospectively extracted from the notes of 26 identified at-risk patients, as well as 26 age-, sex-, and treatment-matched controls with asthma, for one year before and after the introduction of the register. Implementation and service use costs were estimated. RESULTS: Before introduction of the register, more 'at-risk' than control patients were hospitalised (3 vs. 0), attended the accident and emergency (A&E) department (1 vs. 0), and were nebulised (4 vs. 0), for asthma. Significantly higher numbers also used out-of-hours services, received oral steroids, attended their general practitioner (GP), and failed to attend scheduled clinics for asthma (all p<0.025). After introduction of the register, no at-risk patients were admitted or attended A&E. Although differences in the numbers receiving oral steroids remained (p = 0.05), other differences disappeared. There were notably greater reductions in overall numbers of admissions, out-of-hours attendances, GP attendances, courses of steroids, and total costs associated with service use, amongst 'at-risk' as compared to control patients. CONCLUSIONS: An at-risk asthma register is a low cost initiative warranting further evaluation, since it may facilitate appropriate service use in a vulnerable and costly patient group.     

High-dose inhaled corticosteroids and add-on therapy use in adults with asthma in the UK in 2003: an observational study.

AIMS: To quantify use of high dose inhaled corticosteroids (ICS) and add-on therapy in adults, and children aged 12 and over, in the community. METHODS: Cross-sectional observational survey of UK general practice prescribing records from July 2002 to June 2003 utilising the Doctors Independent Network clinical database. RESULTS: 30,895 patients aged 12 and over were treated for asthma with inhaled corticosteroids, with a quantifiable daily dose recommendation in 22,027 cases. Twenty-seven percent (95% Confidence Intervals 26-28%) were prescribed 'high-dose' ICS (>800 mcg/day beclomethasone or equivalent). Of these, 32% (31-33%) were not currently prescribed add-on therapy (long acting B2 agonists, leukotriene antagonists, theophylines), and most of these (84%, 82-86%) had never received a prior trial of add-on therapy. CONCLUSIONS: High dose ICS therapy was commonly prescribed to people with asthma, frequently without co-prescribed add-on therapy. Many adults with more severe asthma may be receiving treatment that does not accord with current evidence of best practice.     

Auricall. A new device for a non-invasive, wireless, continuous monitoring of oxygen saturation and heart rate in patients with heart failure

Sleep apnoea syndrome is frequent in patients with heart failure and associated with a worse prognosis. We evaluated a new device (Auricall®) for non-invasive, continuous recording of oxygen saturation (SpO₂) and heart rate (HR) in patients with heart failure. We studied 20 patients (mean age 48.43 ± 14.4 years, NYHA class II–III). All patients were requested to carry the device for at least 36 h and to write a diary during the recording time. Satisfactory recording of SpO₂ and HR was possible to obtain in 18 of 20 patients. Indeed 9 out of 18 patients showed significant periodic changes in SpO₂ during sleep. Therefore, Auricall® is a useful tool to non-invasively monitor SpO₂ and HR in patients with heart failure and to detect breathing disorders in these patients.     

Improving pediatric asthma care: A partnership between pediatric primary care clinics and a free-standing Children's Hospital

Background: Asthma is a common chronic disease of childhood. Providers’ adherence to asthma guidelines is still less than optimal. Objectives: To determine if an Asthma Education Program aimed at primary care practices can improve asthma care within practices and if the results vary by duration of the program. Methods: Ten practices were randomly assigned to an Early Asthma Education Intervention (EI) group or a Delayed Asthma Education Intervention (DI) group. The EI group received the intervention for 12 months and was monitored for 6 additional months. The DI group was observed without intervention for 12 months, then received the intervention for 6 months, and was monitored for 6 additional months. The program included training of asthma educators in each practice and then monitoring for improvement in medical record documentation of National Asthma Education and Prevention Program (NAEPP) asthma quality indicators by blinded random review of patient charts. Results: In the EI group, 6-, 12-, and 18-month data revealed significant improvement in documentation of asthma severity, education, action plan, night time symptoms, and symptoms with exercise compared to baseline and compared to DI group at baseline and at the 12-month interval. In the DI group, significant improvement in documentation in all of the above endpoints and also in documentation of NAEPP treatment guidelines was noted at 18 and 24 months. In both groups, documentation levels remained relatively stable at 6 months after the intervention, with no significant differences between groups. While improved, guideline adherence was <80% for half of the indicators. Conclusion: In-office training of non-physician asthma providers improves the quality of asthma care.     

Using alcohol screening results and treatment history to assess the severity of at-risk drinking in Veterans Affairs primary care patients

Abstract : Background: Primary care providers need practical methods for managing patients who screen positive for at‐risk drinking. We evaluated whether scores on brief alcohol screening questionnaires and patient reports of prior alcohol treatment reflect the severity of recent problems due to drinking. Methods: Veterans Affairs general medicine outpatients who screened positive for at‐risk drinking were mailed questionnaires that included the Alcohol Use Disorders Identification Test (AUDIT) and a question about prior alcohol treatment or participation in Alcoholics Anonymous (“previously treated”). AUDIT questions 4 through 10 were used to measure past‐year problems due to drinking (PYPD). Cross‐sectional analyses compared the prevalence of PYPD and mean Past‐Year AUDIT Symptom Scores (0–28 points) among at‐risk drinkers with varying scores on the CAGE (0–4) and AUDIT‐C (0–12) and varying treatment histories. Results: Of 7861 male at‐risk drinkers who completed questionnaires, 33.9% reported PYPD. AUDIT‐C scores were more strongly associated with Past‐Year AUDIT Symptom Scores than the CAGE (p < 0.0005). The prevalence of PYPD increased from 33% to 46% over the range of positive CAGE scores but from 29% to 77% over the range of positive AUDIT‐C scores. Among subgroups of at‐risk drinkers with the same screening scores, patients who reported prior treatment were more likely than never‐treated at‐risk drinkers to report PYPD and had higher mean Past‐Year AUDIT Symptom Scores (p < 0.0005). We propose a simple method of risk‐stratifying patients using AUDIT‐C scores and alcohol treatment histories. Conclusions: AUDIT‐C scores combined with one question about prior alcohol treatment can help estimate the severity of PYPD among male Veterans Affairs outpatients.     

Interprofessional Pulmocheck care pathway: An innovative approach to managing pediatric asthma care in the Netherlands

Objectives: Under-diagnosis and suboptimal asthma control in children persists. An innovative care pathway was developed by a hospital department of pediatrics with the aim to detect pulmonary problems in children and provide appropriate treatment possibilities through systematic feedback towards the referring primary care physician. Primary care physicians can use this pathway to refer children with asthma-like symptoms for a one-day assessment. Goals are to measure the usage of the pathway by primary care general practitioners (GPs), the outcomes in terms of new diagnoses of asthma, the reduction in regular referrals, generated recommendations/therapy and the adequacy of asthma follow-up. Methods: We collected all feedback letters sent to the GP concerning children who underwent the Pulmocheck in 2010, 2011 and 2012. Furthermore, all GPs, who had referred a child to the Pulmocheck in this period and that subsequently was diagnosed with asthma and was further managed in primary care, were sent a follow-up questionnaire in 2014. Results: There were 121 referrals from 51 GPs in 3 years to this pathway. In 59.5% of these referrals a new diagnosis of asthma was established. In 90.9% one or more changes in clinical management were advised. The response rate to the follow-up questionnaires was 65.7% of which 4.8% of the children with new established asthma were reviewed four times or more in the follow-up period, 17.4% two times, 65.2% once, and in 8.7% were not followed. Conclusions: The specialty pediatric asthma care pathway revealed a high number of children with newly diagnosed asthma, but was also helpful to exclude this diagnosis. However, the referral rate of GPs to this pathway was low, but in the children, that were referred several changes in the clinical management were advised and the frequency of monitoring of the children with diagnosed asthma was not in accordance with the asthma guidelines.     

Development and pretesting of an electronic learning module to train health care professionals on the use of the Pediatric Respiratory Assessment Measure to assess acute asthma severity

BACKGROUND:

Severity-specific guidelines based on the Pediatric Respiratory Assessment Measure (PRAM), a validated clinical score, reduce pediatric asthma hospitalization rates.

OBJECTIVE:

To develop, pretest the educational value of and revise an electronic learning module to train health care professionals on the use of the PRAM.

METHODS:

The respiratory efforts of 32 children with acute asthma were videotaped and pulmonary auscultation was recorded. A pilot module, composed of a tutorial and 18 clinical cases, was developed in French and English. Health care professionals completed the module and provided feedback. The performance of participants, case quality and difficulty, and learning curve were assessed using the Rasch test; quantitative and qualitative feedback served to revise the module.

RESULTS:

Seventy-two participants (19 physicians, 22 nurses, four respiratory therapists and 27 health care trainees) with a balanced distribution across self-declared expertise (26% beginner, 35% competent and 39% expert) were included. The accuracy of experts was superior to beginners (OR 1.79, 1.15 and 2.79, respectively). Overall performance significantly improved between the first and latter half of cases (P<0.001). Participants assessed the module to be clear (96%), relevant (98%), realistic (94%) and useful (99%) to learn the PRAM. The qualitative/quantitative analysis led to the deletion of three cases, modification of remaining cases to further enhance quality and reordering within three levels of difficulty.

DISCUSSION:

Using rigorous educational methods, an electronic module was developed to teach health care professionals on use of the PRAM score. Using the back-translation technique, both French and English versions were developed and validated simultaneously. The pilot module comprised a tutorial and three case-scenario sections, and was tested on a target audience of physicians, nurses, respiratory therapists and medical trainees.

CONCLUSION:

The final electronic learning module met the clarity and quality requirements of a good teaching tool, with a demonstrated learning effect and high appreciation by health care professionals. Available in French and English, it is offered to facilitate implementation of PRAM-based acute pediatric asthma guidelines.     

Development and implementation of an electronic asthma record for primary care: integrating guidelines into practice

Rationale: Evidence-based practice may be enhanced by integrating knowledge translation tools into electronic medical records (EMRs). We examined the feasibility of incorporating an evidence-based asthma care map (ACM) into Primary Care (PC) EMRs, and reporting on performance indicators. Methods: Clinicians and information technology experts selected 69 clinical and administrative variables from the ACM template. Four Ontario PC sites using EMRs were recruited to the study. Certified Asthma Educators used the electronic ACM for patient assessment and management. De-identified data from consecutive asthma patients were automatically transmitted to a secure central server for analysis. Results: Of the four sites recruited, two sites using “stand-alone” EMR systems were able to incorporate the selected ACM variables into an electronic format and participate in the pilot. Data were received on 161 visits by 130 patients aged 36.5?±?26.9 (mean?±?SD) (range 2–93) years. Ninety-four percent (65/69) of the selected ACM variables could be analyzed. Reporting capabilities included: individual patient, individual site and aggregate reports. Reports illustrated the ability to measure performance (e.g. number of patients in control, proportion of asthma diagnoses confirmed by an objective measure of lung function), benchmark and use EMR data for disease surveillance (e.g. number of smokers and the individuals with suspected work-related asthma). Conclusions: Integration of this evidence-based ACM into different EMRs was successful and permitted patient outcomes monitoring. Standardized data definitions and terminology are essential in order for EMR data to be used for performance measurement, benchmarking and disease surveillance.     

动态血氧饱和度监测在睡眠呼吸暂停低通气综合征诊断中的应用

目的探讨夜间动态血氧饱和度监测对睡眠呼吸暂停低通气综合征(SAHS)的诊断价值。方法对120例疑似SAHS患者进行夜间动态血氧饱和度与多导睡眠图(PSG)监测,根据睡眠呼吸暂停低通气指数(AH I)将测试者分为SAHS组及非SAHS组。非SAHS组(AH I<5次/小时)27例,设为对照组;SAHS组又分为轻度组(AH I 5~20次/小时)26例;中度组(AH I 21~40次/小时)21例;重度组(AH I>40次/小时)46例。对监测结果进行轶和检验和Pearson相关分析,并观察不同的氧减饱和指数(O ID4)值作为诊断SAHS标准的敏感性与特异性。结果夜间动态血氧饱和度监测的O ID4与AH I的相关性良好(r=0.817,P<0.01),它能较好地反映SAHS患者睡眠时呼吸紊乱的频度。以O ID4≥5次/小时诊断SAHS,敏感性为92.4%,对SAHS具有初筛价值,但特异性只有77.8%。若以O ID4≥15次/小时诊断SAHS,特异性可达96.3%,可作为准确诊断SAHS的标准。结论选用适当的O ID4值作为SAHS的初步筛选或准确判断的标准,夜间动态血氧饱和度监测在SAHS的诊断中具有相当的临床价值。     

Complementary and alternative medicine use and asthma: relation to asthma severity and comorbid chronic disease

Objective: To determine (a) the prevalence of complementary and alternative medicine (CAM) use among people with asthma, and (b) if comorbid chronic disease and asthma severity are associated with CAM use. Methods: This cross-sectional study utilized data from n?=?15?276 adults who participated in the 2009 Behavioral Risk Factor Surveillance System (BRFSS) and the 2009 Asthma Callback Survey (ACBS). Binary Logistic regression was used to determine if comorbid disease and asthma severity were associated with CAM use (yes/no). Model covariates were age, sex, income, and education. Results: About 26% of respondents report using at least one form of CAM. The most frequently reported form of CAM use is breathing exercises (19.8%). The results indicate that neither comorbid cardiovascular disease, diabetes, nor stroke are related to CAM use, but individuals with more severe asthma symptoms were more likely to use CAM (OR?=?1.05, 95% CI 1.04, 1.05). Conclusions: CAM remedies most often reported by people with asthma (breathing techniques, vitamins) are unlikely to pose safety risks. Comorbid chronic disease does not motivate people with asthma to seek unconventional remedies. The increase in CAM use with asthma severity prompts questions about factors that might drive this behavior, such as untreated/inadequately treated disease, or medication side effects.     

Limitations of questioning asthma to assess asthma control in general practice

BACKGROUND: The monitoring of children with asthma in primary care is based on the occurrence and frequency of asthma symptoms. We questioned whether the current approach is adequate to identify all children in whom a sufficient level of asthma control is not achieved. AIM: The aim of this study is to illustrate that in some children asthma was incorrectly considered controlled, because the children failed to report current symptoms of asthma. PATIENTS AND METHODS: One hundred and nineteen children were identified with recent wheezing plus moderate or severe airway hyperresponsiveness. We analyzed whether these children reported current symptoms of asthma (as normally questioned during a routine visit). RESULTS: In 20 children (18%) current asthma symptoms were absent despite moderately or severe airway hyperresponsiveness and wheezing in the last year. In addition, the usage of controller medication was very poor. CONCLUSION: We conclude that the general practitioner has insufficient tools to adequately assess asthma control in all children. The assessment of airway hyperresponsiveness as an additional guide to manage asthma in children in general practice is recommended. In this way, better asthma control can be achieved.     

The use of exhaled nitric oxide monitoring in primary care asthma clinics: a pilot study.

AIM: Although asthma is defined as a chronic inflammatory disease, inflammation is rarely assessed. The fraction of exhaled nitric oxide (FeNO) is a biomarker of airways inflammation. We assessed the feasibility of FeNO monitoring in general practice. METHODS: Prospective observational study of volunteers attending primary care asthma clinics. Consenting subjects were seen at their own surgery for 2-weekly reviews over 12 weeks, with assessment of FeNO, lung function, symptoms and health status. RESULTS: 22 adults and 15 children provided informed consent. Two subjects were unable to perform the FeNO expiratory manoeuvre. In the remaining subjects, measurements conforming to highest ERS/ATS recommendations were made on 211 of 236 occasions, and on 21 further occasions acceptable readings were made. Acceptability was high to subjects and staff. Correlations between FeNO readings and other parameters were weak and non-significant except for statistically significant correlation between longitudinal FeNO changes and changes in lung function (r= -0.33, p<0.001) and health status (r= -0.22, p=0.022). CONCLUSIONS: Exhaled nitric oxide monitoring is technically feasible and acceptable to staff and patients within the context of a primary care asthma clinic.     

Spirometry in primary care: An analysis of spirometry test quality in a regional primary care asthma program

BACKGROUND:

Primary care office spirometry can improve access to testing and concordance between clinical practice and asthma guidelines. Compliance with test quality standards is essential to implementation.

OBJECTIVE:

To evaluate the quality of spirometry performed onsite in a regional primary care asthma program (RAP) by health care professionals with limited training.

METHODS:

Asthma educators were trained to perform spirometry during two 2 h workshops and supervised during up to six patient encounters. Quality was analyzed using American Thoracic Society (ATS) 1994 and ATS/European Respiratory Society (ERS) 2003 (ATS/ERS) standards. These results were compared with two regional reference sites: a primary care group practice (Family Medical Centre [FMC], Windsor, Ontario) and a teaching hospital pulmonary function laboratory (London Health Sciences Centre [LHSC], London, Ontario).

RESULTS:

A total of 12,815 flow-volume loops (FVL) were evaluated: RAP – 1606 FVL in 472 patient sessions; reference sites – FMC 4013 FVL in 573 sessions; and LHSC – 7196 in 1151 sessions. RAP: There were three acceptable FVL in 392 of 472 (83%) sessions, two reproducible FVL according to ATS criteria in 428 of 469 (91%) sessions, and 395 of 469 (84%) according to ATS/ERS criteria. All quality criteria – minimum of three acceptable and two reproducible FVL according to ATS criteria in 361 of 472 (77%) sessions and according to ATS/ERS criteria in 337 of 472 (71%) sessions. RAP met ATS criteria more often than the FMC (388 of 573 [68%]); however, less often than LHSC (1050 of 1151 [91%]; P<0.001).

CONCLUSIONS:

Health care providers with limited training and experience operating within a simple quality program achieved ATS/ERS quality spirometry in the majority of sessions in a primary care setting. The quality performance approached pulmonary function laboratory standards.     

上腔静脉血氧饱和度检测在儿科临床的应用进展

上腔静脉血氧饱和度检测在成人重症监护病房（ ICU）常用来监测危重病人及指导休克复苏,近年应用于儿科危重症的监测,特别是在感染性休克的复苏、重症呼吸道感染以及危重症的预后评估等多个领域中逐渐被接受,它能早期发现病情变化以及指导救治决策。该文就其在儿科的临床应用进展进行综述。     

Increased identification of the primary care provider as the main source of asthma care among urban minority children

Objective: Urban, minority, and disadvantaged youth with asthma frequently use emergency departments (EDs) for episodic asthma care instead of their primary care providers (PCPs). We sought to increase the rate of guardians' identification of the PCP as the source of asthma care for their children through integrated electronic health records and care coordination. Methods: In this prospective cohort study, we implemented an electronic communication process between an asthma specialty clinic and PCPs coupled with short-term care coordination in sample of youth aged 2–12 years with asthma and surveyed their guardians at baseline and 3 and 6 months after the intervention. Results: Guardians of 50 children (median age 5.8 years, 64% male, 98% African American, 94% public insurance) were enrolled. Compared to baseline, at 3 and 6 months after the intervention, significantly more guardians reported that the PCP was their child's primary asthma health care provider [70% at baseline, 85% at 3 months, 83% at 6 months (time averaged adjusted OR 77.4, 95% CI 3.0, 2027.1]. Further, significantly more guardians reported that they took their child to the PCP when the child experienced problems with his/her asthma [16% at baseline, 35% at 3 months, 41% at 6 months (time averaged adjusted odds ratio (OR) 10.6, 95% CI 2.7, 41.7]. Conclusion: Care in a subspecialty asthma clinic augmented by electronic communication with PCPs and short term care coordination was associated with significantly improved identification of PCPs as the primary source of asthma care in a cohort of urban minority youth.     

Empowering family physicians to impart proper inhaler teaching to patients with chronic obstructive pulmonary disease and asthma

BACKGROUND:

Patients with chronic obstructive pulmonary disease (COPD) and asthma depend on inhalers for management, but critical errors committed during inhaler use can limit drug effectiveness. Outpatient education in inhaler technique remains inconsistent due to limited resources and inadequate provider knowledge.

OBJECTIVE:

To determine whether a simple, two-session inhaler education program can improve physician attitudes toward inhaler teaching in primary care practice.

METHODS:

An inhaler education program with small-group hands-on device training was instituted for family physicians (FP) in British Columbia and Alberta. Sessions were spaced one to three months apart. All critical errors were corrected in the first session. Questionnaires surveying current inhaler teaching practices and attitudes toward inhaler teaching were distributed to physicians before and after the program.

RESULTS:

Forty-one (60%) of a total 68 participating FPs completed both before and after program questionnaires. Before the program, only 20 (49%) reported providing some form of inhaler teaching in their practices, and only four (10%) felt fully competent to teach patients inhaler technique. After the program, 40 (98%) rated their inhaler teaching as good to excellent. Thirty-four (83%) reported providing inhaler teaching in their practices, either by themselves or by an allied health care professional they had personally trained. All stated they could teach inhaler technique within 5 min. Observation of FPs during the second session by certified respiratory educators found that none made critical errors and all had excellent technique.

CONCLUSION:

A physician inhaler education program can improve attitudes toward inhaler teaching and facilitate implementation in clinical practices.     

Referral rates of patients with diabetes to secondary care are inversely related to the prevalence of diabetes in each primary care practice and confidence in treatment,not to HbA1c level

AimsTo determine the factors affecting the referral rates of patients with diabetes from primary care to secondary care.MethodsA study based on 66 GP surgeries in the Cardiff and Vale University Health Board (population: 515,581) was conducted. We included patients who had an established clinical diagnosis of diabetes (type 1 and type 2) from September 2017 to September 2018.HbA1c outcome data of GP surgeries were obtained from the Quality and Outcomes Framework (QOF) database published for 2018. Referral rates were obtained from the electronic referral database of Cardiff and Vale University Health Board over the same period, and this was adjusted according to the number of patients with diabetes in each GP surgery. Confidence level on the treatment of diabetes among GPs was assessed as a sub-study conducted in nine GP surgeries in the same area, using a self-administered questionnaire. Linear regression was undertaken to assess the relationship between adjusted referral rate and key factors which might influence prescribing rate.ResultsThe average adjusted referral rate to secondary care in one year was 4.23% of patients with diabetes in each GP surgery, with a wide variation of 1.24% to 16.28%. The average percentage of patients with diabetes with HbA1c < 59 mmol/mol was 63.17% (range: 43.19–76.23%). The average confidence score of GPs in treating diabetes was 67% and ranged from 50–85% in the sub-study. Referral rates correlated inversely with the numbers of patients with diabetes in each practice β = ?0.32; (95% CI ?0.57, ?0.08) p = 0.01, but there was no significant correlation with the HbA1c outcome β = ?0.13; (95% CI ?0.39, 0.12); p = 0.30. Borderline significant negative correlation was observed between referral rates and overall practice size β = ?0.23; (95% CI ?0.48, 0.02) p = 0.07.ConclusionsReferral rates of patients with diabetes to secondary care are determined by the number of patients with diabetes in each practice and confidence level in treatment, not by the overall practice size or HbA1c level. Ensuring quality training in diabetes care for primary care teams as well as the development of integrated diabetes care may be the best way to optimise the volume and appropriateness of referrals to secondary care.