Outpatient management of childhood asthma by paediatrician or asthma nurse: randomised controlled study with one year follow up. Paediatric asthma outpatient care by asthma nurse, paediatrician or general practitioner: randomised controlled trial with two-year follow-up. Cost-effectiveness of a nurse-led telemonitoring intervention based on peak expiratory flow measurements in asthmatics: results of a randomised controlled trial.
Until now, care provided by asthma nurses has been additional to care provided by paediatricians. A study was undertaken to compare nurse led outpatient management of childhood asthma with follow up by a paediatrician.
                Seventy four children referred because of insufficient control of persistent asthma were randomly allocated to 1 year follow up by a paediatrician or asthma nurse. The main outcome measure was the percentage of symptom-free days. Additional outcome measures were airway hyperresponsiveness, lung function, daily dose of inhaled corticosteroids (ICS), number of exacerbations, number of additional visits to the general practitioner, absence from school, functional health status, and disease specific quality of life.
                There were no significant differences at the end of the 1 year study period between the two treatment groups in percentage of symptom-free days (mean difference 2.5%; 95% CI -8.8 to 13.8), airway hyperresponsiveness (log10 PD20 0.06; -0.19 to 0.32), functional health status (10.1; -0.3 to 19.8), disease specific quality of life of patients (0.08; -0.9 to 0.7), and disease specific quality of life of caregivers (0.09; -0.2 to 0.3), nor in any other outcome parameters. Most outcome parameters improved considerably over the 1 year study period. These improvements were achieved although the daily dose of ICS was reduced by a mean of 26% compared with the dose received by children at referral. All parents were satisfied with the asthma care received.
                After initial assessment in a multidisciplinary clinic, childhood asthma can be successfully managed by an asthma nurse in close cooperation with a paediatrician. During close follow up by paediatrician or asthma nurse, asthma control improved despite a reduction in ICS dose. For children with stable asthma, to test non-inferiority of care provided by a hospital-based specialised asthma nurse versus a general practitioner (GP) or paediatrician.
                Randomised controlled trial evaluating standard care by a GP, paediatrician or an asthma nurse, with two-year follow-up.
                107 children were recruited, 45 from general practice and 62 from hospital. After two years, no significant differences between groups were found for airway responsiveness, FEV1, asthma control, medication, school absence or parental work absence. In the general practice group there was a significantly lower frequency of regular review visits ('regular' = at least one review per six months) compared to the paediatrician and specialised asthma nurse group, both after one year [45.7% versus 87.9% and 94.3%, respectively, (p<0.0005)] and after two years [26.5% versus 87.9% and 75.8%, respectively, (p<0.0005)]. We found no significant differences in unplanned visits. In most cases the asthma nurse was able to provide care without consultation with the paediatrician.
                The degree of disease control in stable childhood asthma managed by an asthma nurse is not inferior to traditional management by primary or secondary care physicians. The results also suggest that a lower review frequency does not detract from good disease control. Asthma is a chronic lung disease in which recurrent asthma symptoms create a substantial burden to individuals and their families. At the same time the economic burden associated with asthma is considerable.
                The cost-effectiveness study was part of a single centre prospective randomised controlled trial comparing a nurse-led telemonitoring programme to usual care in a population of asthmatic outpatients. The study included 109 asthmatic outpatients (56 children; 53 adults). The duration of follow-up was 12 months, and measurements were performed at baseline, 4, 8, and 12 months. Patients were asked to transfer their monitor data at least twice daily and by judging the received data and following a stepwise intervention protocol a nurse was able to act as the main caregiver in the intervention group. In both groups the EQ-5D and the SF-6D were used to obtain estimates of health state utilities. One year health care costs, patient and family costs, and productivity losses were calculated. The mean incremental costs were weighted against the mean incremental effect in terms of QALY.
                The study population generally represented mild to moderate asthmatics. No significant differences were found between the groups with regard to the generic quality of life. Overall, the mean health care costs per patient were higher in the intervention group than in the control group. The intervention costs mainly caused the cost difference between the groups. The intervention costs the society euro 31,035/QALY gained with regard to adults and with regard to children euro 59,071/QALY gained.
                If the outcome is measured by generic quality of life the nurse-led telemonitoring programme is of limited cost-effectiveness in the study population. From the societal perspective the probability of the programme being cost-effective compared to regular care was 85% at a ceiling ratio of euro 80,000/QALY gained among the adults and 68% among the children. A decrease in the price of the asthma monitor will substantial increase the probability of the programme to be cost-effective.
We found no significant difference between nurse-led care for patients with asthma compared to physician-led care for the outcomes assessed. Based on the relatively small number of studies in this review, nurse-led care may be appropriate in patients with well-controlled asthma. More studies in varied settings and among people with varying levels of asthma control are needed with data on adverse events and health-care costs.