BMJ  2004;328:144 (17 January), doi:10.1136/bmj.37950.784444.EE (published 12 January 2004)

Primary care

Specialist nurse intervention to reduce unscheduled asthma care in a deprived multiethnic area: the east London randomised controlled trial for high risk asthma (ELECTRA)

¹ Centre for General Practice and Primary Care, Institute of Community Health Sciences, Queen Mary's School of Medicine and Dentistry, Barts and the London, Medical Sciences, London E1 4NS, ² Department of Respiratory Medicine, London Chest Hospital, London E2 9JX, ³ Gill Street Health Centre, London E14 8HQ, ⁴ Amersham Health, Little Chalfont, Bucks HP7 9NA, ⁵ Royal London Hospital, London E1 1BB

Abstract

Objective To determine whether asthma specialist nurses, using a liaison model of care, reduce unscheduled care in a deprived multiethnic area.

Design Cluster randomised controlled trial.

Setting 44 general practices in two boroughs in east London.

Participants 324 people aged 4-60 years admitted to or attending hospital or the general practitioner out of hours service with acute asthma; 164 (50%) were South Asian patients, 108 (34%) were white patients, and 52 (16%) were from other, largely African and Afro-Caribbean, ethnicities.

Intervention Patient review in a nurse led clinic and liaison with general practitioners and practice nurses comprising educational outreach, promotion of guidelines for high risk asthma, and ongoing clinical support. Control practices received a visit promoting standard asthma guidelines; control patients were checked for inhaler technique.

Main outcome measures Percentage of participants receiving unscheduled care for acute asthma over one year and time to first unscheduled attendance.

Results Primary outcome data were available for 319 of 324 (98%) participants. Intervention delayed time to first attendance with acute asthma (hazard ratio 0.73, 95% confidence interval 0.54 to 1.00; median 194 days for intervention and 126 days for control) and reduced the percentage of participants attending with acute asthma (58% (101/174) v 68% (99/145); odds ratio 0.62, 0.38 to 1.01). In analyses of prespecified subgroups the difference in effect on ethnic groups was not significant, but results were consistent with greater benefit for white patients than for South Asian patients or those from other ethnic groups.

Conclusion Asthma specialist nurses using a liaison model of care reduced unscheduled care for asthma in a deprived multiethnic health district. Ethnic groups may not benefit equally from specialist nurse intervention.

Introduction

Introduction

The numbers and roles of specialist nurses are increasing, but uncertainty remains about their effects on the costs and use of health care.¹ Two types of intervention involving asthma specialist nurses have been evaluated: educating patients after hospital attendance with acute asthma and outreach to educate and support general practitioners and practice nurses

Improving asthma outcomes for ethnic minority groups remains a global challenge. Morbidity due to asthma is higher for minority or disadvantaged groups.^{2 3} In the United Kingdom, hospital admission rates for South Asian patients have been double those of white patients and high for black patients.^{4 5} South Asian patients may benefit less from asthma education than white patients and have poorer access to care during attacks.^{6 7} Whether asthma specialist nurses can reduce morbidity in multiethnic inner city populations is unknown.

Two important questions remain for specialist nurses, particularly those dealing with asthma. Can they reduce health service use, and can they improve outcomes equally across ethnic groups? We tested the effectiveness of asthma specialist nurses using a liaison model of care across a single health district comprising one of the most ethnically diverse and deprived areas in the United Kingdom.

Methods

We invited to participate in our study all 42 general practices in the London borough of Tower Hamlets and additionally two practices in the neighbouring borough of Newham which served large Bangladeshi populations using the Royal London Hospital, where the specialist nurses were based. All 44 practices consented to take part. We randomised practices to intervention and control groups using a minimisation programme, stratifying by partnership size, training practice status, hospital admission rate for asthma, employment of practice nurse, and whether the practice nurse was trained in asthma care (see bmj.com).

Patients were eligible for inclusion if they had asthma diagnosed by a doctor, were aged 4-60 years, and had been admitted to or attended the accident and emergency department at the Royal London Hospital or the general practitioner out of hours service with acute asthma.

Practices and participants
The two specialist nurses were accredited by the National Respiratory Training Centre. They intervened at the levels of the general practice and the patient (see bmj.com).

General practices randomised to the intervention group received two one hour visits by the specialist nurses at the start of the study to discuss guidelines for managing patients with acute asthma. We used a behaviour change model, incorporating discussion of relevant research evidence.⁸

Participants registered with the intervention practices were reviewed for asthma control and drugs by the specialist nurses at the nurse run clinic immediately after recruitment. They discussed a self management plan. Patients with sufficient understanding were provided with a peak flow meter and a written plan, which contained standard thresholds for peak flow and symptoms (see bmj.com). Most of the South Asian patients were Bangladeshis speaking Sylheti—a dialect with no written form; they received a plan written in English, explained through a bilingual advocate. Nurses reinforced advice with a face to face or telephone consultation.

Practices randomised to the control group received a single visit from the nurses to discuss standard guidelines for asthma. Participants registered with control practices were checked for inhaler technique in the nurse run clinic immediately after recruitment. Drugs were unaltered. Participants otherwise continued with usual care.

Outcome measures and data collection
Primary outcomes were the percentage of participants attending for unscheduled asthma care and the time to first attendance for unscheduled asthma care in the year after intervention. Secondary outcomes were attendance for unscheduled care and review, self management behaviour, and quality of life.^9-12

Researchers blinded to the randomisation status of the general practice extracted data from written and computerised general practice records. Two researchers blinded to randomisation status interviewed participants in person at baseline and by telephone at two, six, nine, and 12 months after recruitment. Participants self identified their ethnicity.

Statistical analyses
Before breaking the coded allocation of practices, we carried out main and prespecified subgroup analyses. Analyses for primary outcomes were by ethnicity (South Asian (Bangladeshi, Indian, Pakistani), white, other), after exclusion of patients with both asthma and chronic obstructive pulmonary disease noted in the medical records, those recruited retrospectively and prospectively, and children and adults. For secondary outcomes we carried out the main and subgroup analyses by ethnicity.

For unscheduled care, review, and quality of life, we fitted generalised estimating equations to individual level data, taking account of the clustering by practice. For time to unscheduled care and time to review we fitted proportional hazards models. Analyses were by intention to treat.

Results

Practices contributed a mean of eight (range 2-28) participants. The characteristics of participants were similar between groups (table 1). Overall, 50% (164/324) of the participants were South Asian, 34% (108) were white, and 16% (52) were from 12 other ethnic groups, predominantly black African, Afro-Caribbean, and black British. Fourteen different first languages were spoken; 45% (146) of participants spoke English. Eighty nine per cent (269) lived in rented accommodation and 55% (177) were unemployed. Overall, 63% (204) of participants were recruited prospectively after attendance with acute asthma. The remainder met eligibility criteria over the previous year.

View this table: [in this window] [in a new window]   Table 1 Characteristics of participants allocated to nurse led intervention for acute asthma or standard guidelines for asthma. Values are numbers (percentages) unless stated otherwise

 

Primary outcome: unscheduled asthma care
Primary outcome data were gathered for 98% (319/324) of participants. The specialist nurse intervention delayed first attendance for unscheduled asthma care in the year after intervention (adjusted hazard ratio for reattendance 0.73, 95% confidence interval 0.54 to 1.00; figure) and reduced the percentage of participants attending for unscheduled care over the following year (table 2). Mean rates of hospital admission, attendance at accident and emergency, and attendance at general practice for exacerbations were all non-significantly lower in the intervention group than in the control group. The overall rates of yearly attendance for unscheduled care for each participant were 1.98 for the intervention group and 2.36 for the control group (adjusted incidence rate ratio 0.91, 0.66 to 1.26).

View larger version (28K): [in this window] [in a new window]   Time to first unscheduled attendance with acute asthma after intervention for all participants (number of participants without reattendance at 365 days was 73 for intervention and 47 for control)

 

View this table: [in this window] [in a new window]   Table 2 Percentages (numbers) of participants attending for unscheduled asthma care and for review of asthma in year after intervention

 

Secondary outcomes
Review of asthma care
Overall, 54% (78/145) of participants in the control group were reviewed in secondary or primary care in the year after intervention compared with 65% (113/174) in the intervention group (adjusted odds ratio 1.66, 0.96 to 1.98; table 2); 36% (52/145) of participants in the control group were reviewed in primary care only compared with 47% (82/174) in the intervention group (1.40, 0.72 to 2.73). Participants in the intervention group received 1.84 reviews yearly compared with 1.56 of participants in the control group (incidence rate ratio 1.15, 0.85 to 1.57).

Self management behaviour, quality of life, and symptoms
Self management behaviour and scores for quality of life and asthma symptoms showed no differences at two or 12 months' follow up (see bmj.com). Oral rescue corticosteroids were used by similar numbers of participants in each group (4% intervention, 7% control; odds ratio 0.7, 0.28 to 1.68).

Subgroup analyses
Exploratory hypothesis generating analysis comparing the effect of specialist nurse intervention on time to attendance between white patients, South Asian patients, and other ethnic groups was not statistically significant (white to South Asian hazard ratio 0.76, 0.44 to 1.29; white to other ethnicities 0.64, 0.39 to1.06). It was, however, compatible with a larger effect for white participants (intervention group compared with control group hazard ratio 0.57, 0.38 to 0.85; South Asians 0.72, 0.48 to 1.09; other ethnicities 1.29, 0.51 to 3.22). The effect of the intervention was not significantly different for other subgroup analyses.

Discussion

Asthma specialist nurses using a liaison model reduced unscheduled care for acute asthma in a deprived multiethnic area. The intervention delayed attendance with acute asthma and reduced the percentage of participants attending with acute asthma over the following year. Rates of hospital admission, attendance at an emergency department, and visits to primary care for acute asthma were all non-significantly lower for participants receiving specialist nurse care, suggesting an impact on healthcare utilisation across both primary and secondary care. These improvements occurred despite comparison with a control group of practices receiving educational outreach for asthma, which itself improves care.¹³

Strengths of our study include completeness of follow up for primary outcome data and a pragmatic design with inclusion of all general practices in one health district, with a representative sample of the local multiethnic population. Use of a control group receiving outreach visits promoting standard asthma guidelines as a comparator for specialist nurse intervention had three benefits: it allowed a comparison against best usual practice, it reduced the impact of any Hawthorne effect (all practices received some education), and it promoted recruitment of a broader range of practices, increasing external validity. Although a secondary aim was to detect differences in effect between ethnic groups, this prespecified subgroup analysis had limited power.

Our liaison model was more effective than the community based approach evaluated in the Greenwich asthma study, with its similar setting in inner London.¹⁴ In that study, specialist nurses educated practice nurses but not patients, and outcomes were assessed in the wider population of patients with milder asthma rather than a high risk group. Our liaison model of specialist nursing is probably as effective as the secondary care model, but provides additional support for patients in the community through patient education and clinical recommendations for general practitioners and practice nurses, and direct clinical support for patients.^{9 15-18} This may be important in inner city areas, where general practices vary in their capacity to manage chronic illness.¹⁹ A liaison model of specialist nursing has previously been evaluated (using a randomised design) only for patients discharged after a coronary event.²⁰ This study showed no benefits from the intervention perhaps because liaison lacked direct clinical involvement in care and was limited to supporting practice nurses.

What is already known on this topic Clinical specialist nurse outreach to primary care has not been shown to improve patient outcomes Education of hospital attenders with acute asthma by asthma specialist nurses has inconsistent effects on unscheduled care People with asthma from ethnic minority groups experience high levels of morbidity What this study adds When asthma specialist nurses educated patients and liaised with primary care clinicians, unscheduled care in a deprived multiethnic area was reduced Ethnic groups may not benefit equally from specialist nurse intervention

Ethnicity
Our study was not powered to detect differences in effect of the intervention between ethnic groups, but our exploratory findings are compatible with potentially important differences in outcome between ethnic groups. This is consistent with other work suggesting that minority ethnic groups derive less benefit than majority groups from asthma education.⁷ No randomised studies of interventions specifically addressing ethnic minority groups have reduced unscheduled asthma care.^{7 21} These observations are important because interventions that have a differential benefit between majority and minority ethnic groups potentially widen inequalities in health.

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The protocol for study groups is on bmj.com

This is the abridged version of an article that was posted on bmj.com on 12 January 2004: http://bmj.com/cgi/doi/10.1136/bmj.37950.784444.EE

We thank the National Asthma Campaign for funding; the participants; Mark Levy for advice on study design; Yvonne Carter, Allen Hutchinson, Keith Meadows, Jeanette Naish, Peter Stables, Ayesha Khanem, Enid Hennessey, Pat Sturdy, Sarah Cotter, Monica Fletcher, and members of the department of general practice for comments and help.

Contributors: See bmj.com

Funding: National Asthma Campaign.

Competing interests: None declared.

Ethical approval: The study was approved by the local research ethics committee.

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(Accepted 11 November 2003)

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