Greenwich asthma study

EDITOR—Premaratne et al's study highlights the difficulties encountered in implementing the British Thoracic Society's guidelines for asthma in Greenwich,1 an inner city area which has a high incidence of urban deprivation with all its attendant problems known to have an impact on asthma and quality of life.2

When this study took place there was an explosion of asthma education for practice nurses, and it would have been useful to compare asthma knowledge and services within the control and intervention groups. The authors acknowledge that an initiative by the area's family health services authority, targeting the underuse of inhaled steroids in general practice, affected general practitioners' prescribing and that an unusually high turnover of practice nurses within the intervention group had an impact on the service provided. In view of these influences it seems unlikely that the control group was untainted, and the study results become difficult to interpret.

Only 26% of registered asthmatic patients were seen by nurses in the intervention practices. The project therefore failed to target a large number of asthmatic patients (74%). We do not know if these patients were being seen by general practitioners, failed to keep appointments, had asthma that was too mild to be a problem, or had more severe or uncontrolled asthma and were more likely to be admitted to hospital or attend accident and emergency departments. Conclusions have been drawn therefore from a relatively small sample of the total number of asthmatic patients available, a group the authors say had relatively mild disease compared with patients in other studies.

Although the intervention was integrated across both primary and secondary care, there is no evidence to show that it was applied anywhere but in the primary sector. There is no mention of any input involving secondary care staff or patients. Previous studies have illustrated that asthmatic patients attending accident and emergency departments in inner city areas are a notoriously difficult target for asthma care and are often poor at attending for follow up.3 No mention is made of how many of those seen in general practice as part of the intervention were repeated attenders at accident and emergency departments, or vice versa.

What this study does illustrate are the difficulties encountered in providing health care within inner city areas, where staff can become demoralised and face tremendous difficulties in targeting care effectively. It poses more questions than it answers and highlights the need for rigorous protocols in such studies, which need to target specific, easily measured outcomes.