BMJ 1999;318:1251-1255 ( 8 May )

General Practice

Clustered randomised trial of an intervention to improve the management of asthma: Greenwich asthma study

U N Premaratne, specialist registrar, a J A C Sterne, senior lecturer, a G B Marks, research fellow, b J R Webb, consultant physician, c H Azima, assistant statistician, a P G J Burney, professor. a

a Department of Public Health Sciences, King's College London, Capital House, London SE1 3QD, b Institute of Respiratory Medicine, University of Sydney, New South Wales 2006, Australia, c Asthma Resource Centre, Greenwich District Hospital, Greenwich, London SE10 9HE

Correspondence to: Professor Burney Peter.burney{at}kcl.ac.uk

Objectives: To evaluate the effectiveness of an asthma resource centre in improving treatment and quality of life for asthmatic patients.
Design: Community based randomised controlled trial.
Setting: 41 general practices in Greenwich with a practice nurse.
Subjects: All registered patients aged 15-50 years.
Intervention: Nurse specialists in asthma who educated and supported practice nurses, who in turn educated patients in the management of asthma according to the British Thoracic Society's guidelines.
Main outcome measures: Quality of life of asthmatic patients, attendance at accident and emergency departments, admissions to local hospitals, and steroid prescribing by general practitioners.
Results: Of 24 400 patients randomly selected and surveyed in 1993, 12 238 replied; 1621 were asthmatic of whom 1291 were sent a repeat questionnaire in 1996 and 780 replied. Of 24 400 patients newly surveyed in 1996, 10 783 (1616 asthmatic) replied. No evidence was found for an improvement in asthma related quality of life among newly surveyed patients in intervention practices compared with control practices. Neither was there evidence of an improvement in other measures of the quality of asthma care. Weak evidence was found for an improvement in quality of life in intervention practices among asthmatics registered with study practices in 1993 and followed up in 1996. Neither attendances at accident and emergency departments nor admissions for asthma showed any tendency to diverge in intervention and control practices over the study period. Steroid prescribing rates rose steadily during the study period. The average annual increase in steroid prescribing was 3% per year higher in intervention than control practices (95% confidence interval -1% to 6%, P=0.10).
Conclusions: This model of service delivery is not effective in improving the outcome of asthma in the community. Further development is required if cost effective management of asthma is to be introduced.


Key messages

  • Small randomised trials suggest that implementation of management guidelines can improve outcomes for asthmatic patients treated in specialist units

  • Randomised trials also suggest that guidelines can improve the process of care in general practice

  • An intervention in which specialist nurses trained and supported practice nurses in running asthma clinics on the basis of British Thoracic Society guidelines failed to improve asthma outcomes for patients over a 3 year period

  • Factors that may have reduced the potential impact of the measures include the large number of asthmatic patients that need to be cared for in primary care, and the high turnover of practice nurses in inner city areas

  • Further research is required on how best to implement good practice in inner city areas if cost effective interventions are to be devised




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