Overall, 47.4% of the patients in our study group had an exacerbation in the 6 months of follow-up. This is higher than reported in other studies but may reflect the comprehensive way the details of exacerbations were obtained. The apparently high exacerbation rate may also reflect the fact that our study included patients with more severe asthma, due to the problems of recruiting patients who were discharged quickly (and who may have had milder attacks). However, the high exacerbation rate was not associated with a correspondingly high hospital readmission rate, which is a recognized outcome measure of asthma care. Over the 6-month follow-up period, 12.3% and 7.4% of patients in the doctor-led and nurse-led groups, respectively, were readmitted with an acute asthma attack. This compares favorably with other studies. so
The number of patients recruited to the study was less than planned, and this led to odds ratios for exacerbation rates that were less precise and only a 60% chance of ruling out clinically significant increases in exacerbation rates. Thus, although there were no significant differences between nurse-led and doctor-led care in the main outcomes, some of the CIs included potentially clinically significant effects. We therefore recommend that this practice be audited to ensure that exacerbation rates remain acceptable.
In general practice, specialist nurse asthma clinics have become a major part of asthma care. Although studies have demonstrated increased asthma knowledge, it is unclear whether hospital admission rates are reduced. Differences may also arise depending on ethnicity. Hospital specialist nurse care has been studied with regard to patient education, self-management, and readmission rates. Inpatient, nurse-led education and management programs have been shown to reduce readmissions in chil-dren. Self-management plans initiated in hospital with a specialist nurse have improved asthma knowledge and morbidity in adults.
This has been shown to reduce the need for contacting health professionals but not necessarily a reduction in readmission rates.’ The role of follow-up by the specialist nurse has been studied with regard to hospital and accident and emergency attendance. Both telephone follow-up and outpatient clinics have been shown to reduce attendance at accident and emergency de-partments., Asthma education programs conducted by a specialist nurse have also been shown to be beneficial. It clearly appears that inpatient and outpatient intervention aimed at asthma education and self-management are important in improving asthma care. However, the safety and effectiveness of sole follow-up by a respiratory specialist nurse in patients admitted to hospital with an acute asthma attack have not previously been studied. In patients with bronchiectasis, routine outpatient care delivered by an appropriately trained specialist nurse has been shown to be as safe and effective as doctor-led care.
Our study demonstrates that outpatient care can be safely and effectively delivered by an appropriately trained respiratory specialist nurse, using a structured intervention, similar-length outpatient times, and prescribing independently according to a patient group directive, even in patients not previously assessed by a respiratory doctor. This study has important implications for the role of the respiratory specialist nurse, since we have demonstrated that their role can be extended to outpatient care. This may not only help reduce some of the workload that exists for many respiratory doctors but also ensure that effective outpatient care continues.