A Randomized Controlled Trial of Follow-up of Patients Discharged From the Hospital Following Acute Asthma: Change in Peak Flow

A Randomized Controlled Trial of Follow-up of Patients Discharged From the Hospital Following Acute Asthma: Change in Peak FlowWe compared the maximal peak flow measurement at first hospital follow-up with the 6-month measurement (best of actual or predicted). There was a mean drop of 2.53% (SD 11.5) in the doctor group and 3.92% (SD 12.4) in the nurse group. There was no significant difference in change in peak flow between the two groups (mean difference, 1.39%; 95% CI, -3.84 to 6.63; p = 0.122).
Data were available for all 136 patients. The mean number of follow-up clinic appointments arranged was similar in both groups: 3.39 (237 appointments in 70 patients) in the nurse group and 3.32 (219 appointments in 66 patients) in the doctor group (relative risk, 1.02; 95% CI, 0.85 to 1.23). However, patients attended fewer nurse clinics compared to doctor clinics. The mean number of clinics attended was 1.97 (130 clinics in 66 patients) in the nurse group and 2.23 (147 clinics in 66 patients) in the doctor group (relative risk, 0.88; 95% CI, 0.70 to 1.12; p = 0.011). mycanadianfamilypharmacy.net

This appeared to be due to cancellation of clinics by the specialist nurse rather than cancellation or nonattendance by the patient. More clinics were cancelled by the clinical nurse specialist rather than by the doctor. The mean number of clinics cancelled by the nurse was 0.32, compared to 0.08 cancelled by the doctor (relative risk, 4.20; 95% CI, 1.6 to 11.0; p = 0.004). There was a trend toward patients in the nurse group being more likely to cancel the clinic appointment (relative risk, 1.65; 95% CI, 1.30 to 2.08; p = 0.052) but no difference in the number of clinics not attended (relative risk, 0.90; 95% CI, 0.54 to 1.48; p = 0.70).
This study demonstrates that an appropriately trained respiratory specialist nurse, with regard to the follow-up of patients after hospitalization for an acute asthma exacerbation, may provide equivalent asthma care to that of a respiratory physician. This is the first study to directly compare physician-led and nurse-led care in a specialist outpatient setting. The primary outcome, comparing the number of exacerbations between the groups, showed no significant difference between the two groups.

Analysis of subgroups of exacerbation types was pursued to further evaluate whether any subtle differences occurred (Fig 3). The proportions regarding hospital readmission and emergency nebulization appeared different between the groups, but these subgroups were too small for formal statistical analysis. To further compare the groups, we looked at those requiring emergency treatment that included the use of emergency nebulization (in accident and emergency departments, general practice, or ambulances) and hospital readmission. This showed no significant difference between the groups. This is also true when including those who required outpatient treatment with oral corticosteroids. This demonstrates equivalence between the doctor-treated and nurse-treated patients in the number and severity of exacerbations.

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