General practice audit of asthma in childhood

Passive Smoking, Potential Atopy and Asthma in the First Five Years

Evidence of prolonged exposure to cigarette smoke was sought in a group of 86 children aged five years and under with moderately severe asthma, and in 1199 infants from a mixed background population of Armed Service and civilian families. Asthmatics with a normal serum IgE (less than +1 s.d. for age) made up almost half of the cases and, compared with those with an elevated serum IgE (+1 s.d. for age or more), a greater proportion were male, had experienced prolonged exposure to cigarette smoke, were from Service families and already had fixed chest deformity. It is suggested that, in addition to facilitating the expression of asthma in young potential atopics, passive smoking may be an important contributory cause of the more severe disease reported in the socalled ‘intrinsic’ group. Perhaps the burden of illness and the extent of exposure noted in this survey will prompt renewed efforts to be made to discourage smoking in families, particularly two years before and for at least five years after the birth of a child.

Inhaled corticosteroids for non-specific chronic cough in children

BACKGROUND

Cough in isolation of other clinical features is known as non-specific cough, which has been defined as non-productive cough in the absence of identifiable respiratory disease or any known aetiology. In children with non-specific cough the possibility of asthma being the underlying disorder is often raised (so called cough variant asthma). The proponents of cough variant asthma suggest a therapeutic trial of medications usually used to treat asthma.

OBJECTIVES

To determine the efficacy of inhaled corticosteroids in non-specific cough in children over the age of two years.

SEARCH STRATEGY

Searches were conducted on Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE and EMBASE. Searches were current as of March 2004.

SELECTION CRITERIA

All randomised (randomised and quasi-randomised) controlled clinical trials in which an inhaled corticosteroid (beclomethasone (BDP), fluticasone (FP), triamcinalone (TAA) or any other corticosteroid) were given for cough in children over two years of age were included. Two review authors independently assessed articles for inclusion and methodological quality.

DATA COLLECTION AND ANALYSIS

Data from trials was extracted by both review authors and entered into the Cochrane Collaboration software program RevMan Analyses 1.0.2.

MAIN RESULTS

Two trials met the inclusion criteria (123 participants). One compared inhaled beclomethasone dipropionate (400 micrograms per day) with placebo and the other compared fluticasone propionate (2 mg per day for 3 days followed by 1 mg per day for 11 days) with placebo. Both studies used metered dose inhalers via a spacer. With the lower dose of inhaled corticosteroid there was no significant difference between the beclomethasone and placebo groups. With the higher dose there was a significant improvement in nocturnal cough frequency after two weeks in children presenting with persistent nocturnal cough. However, a significant but smaller improvement was also seen with placebo.

AUTHORS' CONCLUSIONS

In one study beclomethasone dipropionate (400 micrograms per day) was no different from placebo in reducing the frequency of cough measured objectively or scored subjectively. There might be a small improvement with very high-dose inhaled corticosteroid but the clinical impact of this is unlikely to beneficial.

Inhaled beta2-agonists for treating non-specific chronic cough in children

BACKGROUND

The pathophysiology of so called 'cough variant asthma' has not received a great deal of research interest and opinion lies divided as to whether it is really asthma or not. The proponents of cough variant asthma suggest a therapeutic trial of medications usually used to treat asthma

OBJECTIVES

To determine the effectiveness of inhaled ss2 agonists in non-specific chronic cough in children over the age of 2 years.

SEARCH STRATEGY

The Cochrane Airways Group database (including MEDLINE, EMBASE and CINAHL) and the Cochrane Controlled Trials Register (CCRT) were searched. Additional searching included hand searching of medical journals through the Cochrane Collaboration, references, references of references listed in primary sources and personal communication with authors. In addition "Grey literature" including theses, internal reports, non-peer reviewed journals were sought.

SELECTION CRITERIA

All randomised (randomised and quasi-randomised) controlled clinical trials in which inhaled ss2 agonists were given for chronic cough in children over 2 years of age were included. Two reviewers independently assessed articles for inclusion and methodological quality.

DATA COLLECTION AND ANALYSIS

Data for trials of salbutamol versus placebo were extracted by both reviewers and entered into the Cochrane Collaboration software program Review Manager, version 4.2

MAIN RESULTS

In children presenting with isolated chronic cough there was no significant difference between salbutamol treated group and placebo group.

AUTHORS' CONCLUSIONS

Salbutamol was no different from placebo in reducing the frequency of cough measured objectively or scored subjectively.

How accurate is diagnosis of asthma in a general practice database? A review of patients' notes and questionnaire-reported symptoms

BACKGROUND

Planned care of patients with chronic diseases in primary care depends on being able to identify them. A recorded label of asthma does not necessarily mean that the patient is currently symptomatic, and failure to record the diagnosis may influence future care.

AIM

To determine the degree of under- and over-reporting of the diagnosis of asthma for patients aged 16-55 years inclusive in one large general practice.

DESIGN

A questionnaire validated for the detection of bronchial hyper-reactivity was sent to all patients recorded as having asthma and their matched controls. Patients with a diagnosis of asthma and symptomatic bronchial hyper-reactivity were considered to have asthma. Evidence of asthma in the written and computer records was sought for two groups: patients with asthma and without symptoms of bronchial hyper-reactivity, and controls with symptoms of bronchial hyper-reactivity.

SETTING

A semi-rural group practice with 14 830 patients.

METHOD

Questionnaires were sent to 833 patients and 831 controls matched by age and sex.

RESULTS

Response rates were 79.1% (659/833)for patients with asthma and 70.6% (587/831) for control patients. Of the patients with asthma who replied, 60.5% (399/659) had symptomatic bronchial hyper-reactivity. Of those with asthma and a negative bronchial hyper-reactivity status (based on the questionnaire), 190/260 (73.1%) were considered to have had asthma when diagnosed, on review of their primary care records. There was no evidence to suggest asthma in 45 (17.3%) of the 260 patients who had a negative bronchial hyper-reactivity status. Of the control patients, 41 (7.0%) of the 587 responders had symptomatic bronchial hyper-reactivity and nine of these may have asthma. By extrapolation, we estimate that there were possibly another 99 patients with symptoms of asthma, who had not been labelled as having asthma, and 362 patients with symptoms of bronchial hyper-reactivity who had not reported them to their doctors or had not had them recognised.

CONCLUSIONS

There is an 89.4% chance that a patient recorded as having asthma has, or has had, asthma.

Childhood asthma: healthcare resource utilisation in those with and without a diagnosis of the condition

AIM

To examine healthcare utilisation and the direct financial costs in providing medical care to a population of children aged 5-15 years with respiratory complaints. Secondarily, to assess whether these costs depended upon having specific asthma diagnosis or not.

METHOD

A postal respiratory questionnaire was sent to the parents or guardians of all children registered with two general practices. A search of the general practice medical records over a 2-year reference period was made for a stratified random sample and results are presented for 488 children aged 5-15 years.

RESULTS

The cost of primary care lower respiratory tract consultations in children with 4-5 symptoms/risk factors was pounds sterling 17.02 per patient per year for those with a previous diagnosis of asthma compared with pounds sterling 6.08 per patient per year for those with the same number of symptoms but no diagnosis (t = -4.446, P<0.001). The cost of primary care lower respiratory consultations in those with no GP diagnosis of asthma and no symptoms/risk factors was pounds sterling 2.25 per patient per year.

CONCLUSIONS

Studies, which fail to include the costs associated with treating children with respiratory symptoms but without a formal diagnosis, will seriously underestimate the costs of treating asthmatic children.

[Chronic cough in children: signs of serious disease and investigations]

Only in some particular cases chronic cough requires special investigations. Respiratory diseases linked to environment are frequent in children. Cough is the most common symptom in child asthma and usually occurs during sleep or exercise. Environmental tobacco smoke exposure may concern up to 30% of families. Questioning should systematically check for parental smoking in children with chronic cough since avoidance is the only effective treatment. The incidence of whooping cough appears to be increasing and the diagnosis may be difficult among already immunized children in whom symptoms are often nonspecific. Nowadays Bordetella pertussis can easily be detected on nasal smears (ELISA, PCR, cultures). Swallowing dysfunction may cause productive cough in toddlers, most often related to functional dyspraxia, yet possibly due to aerodigestive tract malformation. Unrecognized bronchial foreign body is a well-known pitfall particularly between 9 and 36 months of age. Bronchiectasis and cystic fibrosis are responsible for chronic productive cough in toddlers and older children. In teenagers, psychogenic coughing is difficult to manage and usually requires psycho- and speech therapy.

Asthma diagnosis and management in adults: is the risk of underdiagnosis and undertreatment related to patients' education levels?

To determine the relationship between patient education and the risk of underdiagnosis and undertreatment of asthma, a cross-sectional study of 500 (250 males and 250 females) adult attendees between 16 and 44 years of age was undertaken at five primary health care (PHC) centers in Al-Ain, United Arab Emirates. We used an Arabic translation of the European Community Respiratory Health Survey Screening Questionnaire. Asthmatics with higher levels of education had a significantly higher risk of underdiagnosis and undertreatment than asthmatics with less education. Doctors at PHC centers railed to diagnose 34.6% of the asthmatics with lower levels of education and 77.6% of the patients with higher levels of education. Eighty-five percent of the asthmatics with lower levels of education and 46.6% of the asthmatics with higher levels of education recognized that they had asthma. Thirty-eight percent of the asthmatics with lower levels of education and 83% of the asthmatics with higher levels of education were undertreated. It was found that 19% of the asthmatics with lower levels of education and 3% of the asthmatics with higher level of education were on prophylactic medication for asthma. We concluded that education level was related to underdiagnosis and undertreatment of asthma among adults between 16 and 44 years of age. People with higher levels of education have a higher risk of underdiagnosis and undertreatment than do those with lower levels of education. The factors that might be associated with these findings need to be explored in further studies.

Underdiagnosis of asthma: is the doctor or the patient to blame? The DIMCA project

BACKGROUND

It is important to diagnose asthma at an early stage as early treatment may improve the prognosis in the long term. However, many patients do not present at an early stage of the condition so the physician may have difficulty with the diagnosis. A study was therefore undertaken to compare the proportion of patients who underpresented their respiratory symptoms with the proportion of underdiagnosed cases of asthma by the general practitioner (GP). A secondary aim was to investigate whether bad perception of dyspnoea by the patient was a determining factor in the underpresentation of asthma symptoms to the GP.

METHODS

A random sample of 1155 adult subjects from the general population in the eastern part of the Netherlands was screened for respiratory symptoms and lung function and the results were compared with the numbers of asthma related consultations registered in the medical files of the GP. In subjects with reduced lung function the ability to perceive dyspnoea was investigated during a histamine provocation test in subjects who did and did not report their symptoms to their GP.

RESULTS

Of the random sample of 1155 subjects 86 (7%) had objective airflow obstruction (forced expiratory volume in one second (FEV(1)) below the reference value corrected for age, length, and sex minus 1.64SD on two occasions) and had symptoms suggestive of asthma. Of these 86 subjects only 29 (34%) consulted the GP, which indicates underpresentation by 66% of patients. Of all subjects with objective airflow obstruction who presented to their GP with respiratory symptoms, 23 (79%) were recorded in the medical files as having asthma, indicating underdiagnosis by the GP in 21% of cases. Of the subjects with objective airflow obstruction who visited the GP with respiratory symptoms 6% had bad perception of dyspnoea compared with 26% of those who did not present to the GP in spite of airflow obstruction (chi(2) = 3.02, p = 0.08).

CONCLUSIONS

Underpresentation to GPs of respiratory symptoms by asthmatic patients contributes significantly to the problem of underdiagnosis of asthma. Underdiagnosis by the GP seems to play a smaller role. Furthermore, there are indications that underpresentation of symptoms by the patient is at least partly explained by a worse perception of dyspnoea.

[Relationship between respiratory syncytial virus bronchiolitis and asthma]

Data of the literature over the last 20 years indicate that infantile asthma, although heterogeneous, often appears following RSV bronchiotitis, especially when sufficiently severe to justify hospitalisation. The risk of developing episodes of wheezing (bronchial obstruction syndrome) over the following 2 to 3 years is higher than 50%, but estimations vary according to the authors. Functional disturbances (pulmonary distension, nonspecific bronchial hypperreactivity, hypoxia), with or without associated clinical symptoms, may be observed several months to several years after hospitalisation for bronchiolitis. On the other hand, mild bronchiolitis, and most of the recurrent expiratory obstructive syndromes with asymptomatic free intervals between episodes do not appear to carry a risk of functional sequelae. Children suffering from severe bronchiolitis usually develop a severe bronchial obstruction syndrome. In asthma, the percentage of IgE-dependent sensitization is less than 20% before the age of 4 years. The presence of positive skin tests and/or specific serum IgE directed against the usual allergens are associated with the persistence of asthma during the childhood. Similarly, the appearance of wheezing after the age of 3 years (or recurrence after this age) is associated with the persistence of asthma. Prospective studies of cohorts followed since birth show that pre-existing functional abnormalities can promote the appearance of bronchiolitis and bronchial obstruction syndrome. Asthma in infants comprises several phenotypes with very different prognoses.

Persistent nocturnal cough: randomised controlled trial of high dose inhaled corticosteroid

OBJECTIVE

To investigate the effect of a short course of inhaled corticosteroid in the treatment of isolated and persistent nocturnal cough in children.

DESIGN

Randomised double blind placebo controlled study.

SETTING

Subjects' homes in east London, England.

SUBJECTS

Consecutively referred children, 1-10 years old, with persistent nocturnal cough.

INTERVENTIONS

Placebo or fluticasone propionate 1 mg twice daily for three nights and 500 microg twice daily for 11 nights. Videotaping of children at night: two nights' baseline, nights 3 and 4 after three days of inhaled corticosteroid, and nights 15 and 16.

MAIN OUTCOME MEASURE

A fall in 75% of coughs from baseline.

RESULTS

50 subjects were recruited. The median number of coughs in the baseline period for the inhaled corticosteroid group and placebo group were 92 and 71, respectively (p = 0.43) and, on nights 15 and 16, 8 and 36, respectively (p < 0. 01). Compared to baseline, both groups of subjects improved significantly by nights 15 and 16 (p < 0.01; p < 0.01). Comparing the inhaled corticosteroid and placebo groups, coughs fell to a median of 22% and 57% of baseline totals on nights 3 and 4, respectively (p = 0.38), and 8% and 35% on nights 15 and 16, respectively (p = 0.02). 17 of 24 subjects on inhaled corticosteroid who completed the study and 8 of 23 on placebo improved by 75% after two weeks (p = 0.03).

CONCLUSIONS

Children with persistent nocturnal cough improve in two weeks after referral on placebo. There is a modest benefit from a two week course of high dose inhaled corticosteroid.

[Factors related with the morbidity of asthma]

To determine the clinical situation, prescribed treatment and compliance in patients with asthma, and to identify the parameters that most influence control of the disease. We studied 335 asthma patients assigned to health centers. All were interviewed and respiratory gases were measured. Disease symptoms were recorded, along with treatment prescribed and inhalation method used. Compliance and inhaler use were assessed on a scale. Treatment appropriateness was evaluated against criteria of international consensus. Multiple regression analysis was used to identify the variables that most influenced control of asthma. Variables considered were age, sex, smoking, treatment appropriateness, inhaler technique, compliance with prescribed treatment and time since diagnosis. Disease was mild in 96 patients (28.7%), moderate in 111 (33.1%) and severe in 128 (38.2%). Treatment was appropriate in 118 (35.2%). Seventy-two (21.5%) used more drugs or higher doses than recommended. Prescribed treatment was inappropriate in 145 (43.3%). The inhalation technique was appropriate in 87 (27.5%) and inappropriate in 229 (72.5%). Ninety-four patients (28.1%) complied well with treatment and 241 (71.9%) were poor compliers. The variables that were significantly related to control of asthma were appropriate treatment and compliance. There is a high rate of morbidity due to asthma in the population studied. The percentage of inappropriate treatment is high, and compliance is low, these factors being the ones that most influence control of the disease.

The facilitator effect: results from a four-year follow-up of children with asthma

BACKGROUND

A long-term evaluation of the process and outcomes of primary and secondary care is required to establish whether audit facilitators can improve the care of childhood asthma.

AIM

To examine the long-term effect of an intervention by an audit facilitator on the management of children with asthma, and to investigate the implications for health service costs.

METHOD

A 4-year follow up was conducted of an intervention and control group totalling 2557 children aged 1-15 years from 12 general practices in the Tayside region. Primary care consultations, prescriptions, hospital contacts and health service costs 1 year before and 3 years after a facilitator visited practices were recorded. The facilitator encouraged the diagnosis and treatment of childhood asthma in the intervention group.

RESULTS

Favourable changes in consultation patterns, prescriptions and reduced hospital admissions seen during the intervention year did not persist in subsequent years. Two and three years after the facilitator visit the process and outcome of care was similar in both groups. The reduction in health service costs seen in the intervention group was equivalent to the cost of employing a facilitator.

CONCLUSION

The effect of a facilitator lasts only for the period of intervention. Enthusiasts will say that improving patient care without increasing health service costs justifies the widespread deployment of facilitators. Others more interested in long-term outcomes may disagree.

Prevalence of allergic diseases in schoolchildren in relation to family history, upper respiratory infections, and residential characteristics

The prevalences of asthma, allergic rhinitis (AR), and eczema were analyzed in relation to retrospective risk factors from birth in a questionnaire study of schoolchildren in two areas covering the whole climatic span of Sweden: the Göteborg area on the southwestern coast (7-year-olds, n = 1649) and Kiruna, a mining town in the northernmost inland mountains (7-9-year-olds, n = 832). The strongest background factor, a family history of the diseases, was more common in children with another strong risk factor, particularly for asthma: high frequency of upper respiratory tract infection (URTI). Other significant risk factors related to high indoor humidity caused an increased prevalence of both allergic diseases and URTI. Active mechanical ventilation of the homes caused a slight reduction of the prevalence of allergic diseases, and repainting or new wallpaper in the bedroom of the child after birth caused a moderately increased risk of allergic disease. This study illustrates the interaction between genetic and environmental risk factors with special emphasis on factors related to an unventilated indoor climate, which may have substantially contributed to the current increase of the diseases in the country.

The use of children's medical records to predict the risk of asthma attack

Using a large data base of respiratory morbidity in children the opportunity arose to explore the link between what was written in general practice case records and the subsequent risk of a child developing an asthma attack or hospital admission due to asthma. Children with five or more consultations in one year for respiratory symptoms had a 33% risk of experiencing an asthma attack or 7.1% risk of admission in the following year. Twenty seven percent of children who received antibiotics for "respiratory infections" subsequently had an asthma attack. The potential exists to review past and present symptoms and thus attempt to predict future morbidity. Childhood asthma is an example where the quality of care offered by general practitioners could be improved if a precise estimate of risk could be used to modify clinical management.

Controlled trial of an audit facilitator in diagnosis and treatment of childhood asthma in general practice

OBJECTIVE

To test whether an audit facilitator could alter the pattern of diagnosis and treatment of childhood asthma.

DESIGN

Randomised stratified controlled trial.

SETTING

12 general practices in Tayside.

SUBJECTS

3373 children aged 1-15 inclusive who had symptoms suggestive of asthma or possible asthma drawn from a systematic review of 10,725 general practice case records.

INTERVENTION

Children were targeted for a clinical review by their general practitioner or practice nurses.

MAIN OUTCOME MEASURES

Asthma related consultations, prescriptions, hospital attendances, and health service costs 12 months before and after study.

RESULTS

Compared with controls (n = 1563) the intervention group (n = 1585) had more practice initiated consultations for asthma (relative risk 2.18 (95% confidence interval 1.74 to 2.73)), new diagnoses of asthma (2.83 (2.26 to 3.54)), and past diagnoses reaffirmed (1.30 (1.08 to 1.58)), and they were more frequently prescribed inhaled cromoglycate (1.52 (1.02 to 2.25)). Hospital inpatient day rates fell from 152 to 122 in the intervention group and rose from 69 to 117 in the control group between the year before and the year after study. Total primary care costs rose from 30,118 pounds to 37,243 pounds in the intervention group and fell from 29,131 pounds to 27,990 pounds in the control group. Hospital care cost fell in the intervention group from 25,406 pounds to 20,727 pounds and rose in the control group from 12,699 pounds to 19,650 pounds.

CONCLUSION

An audit facilitator can favourably influence the pattern of diagnosis and treatment of childhood asthma in general practice. This may have an impact on health service costs.

The Yentl syndrome in childhood asthma: risk factors for undertreatment in Swiss children

Recent prevalence data for childhood asthma in Switzerland suggest a substantial underdiagnosis which seems to be more pronounced in girls. We further analysed our data trying to specify risk factors for underdiagnosis and undertreatment. Our special interest was focused on female sex as there is evidence for a sex-dependent diagnosis and treatment of chronic disease in adults, called the Yentl syndrome. The data are derived from a parent completed questionnaire survey of a stratified cluster sample of schoolchildren aged 7, 12, and 15 years. Besides the 12 months prevalence of asthma symptoms and bronchodilator treatment, the lifetime prevalence of an asthma diagnosis was noted. With a response rate of 97%, a total of 4353 completed questionnaires were analysed. While age was not associated with undertreatment (except for exercise-induced symptoms in adolescents), the lack of a formal diagnosis of asthma and atypical asthma symptoms other than wheeze such as chronic night cough were confirmed as significant risk factors for undertreatment. Of all boys reporting asthma symptoms 31% received bronchodilator treatment compared with only 15% of the symptom-reporting girls (P < 0.001). For all particular asthma-related symptoms (except wheeze), significantly more boys than girls (approximately double) received treatment. The physiological and psychological bases for these findings are discussed and suggest that gender is an important risk factor for underdiagnosis and undertreatment of asthma. Our research indicates that the Yentl syndrome may exist for childhood asthma.

The role of measuring forced expiratory volume in one second in determining therapeutic changes made in an asthma clinic in general practice

In order to determine whether spirometric measurements in a primary care asthma clinic added useful information to symptom assessment and peak flow recordings, a retrospective audit of manual case records was conducted on patients attending an urban general practice asthma clinic. Sixty-three patients were identified in whom 108 increases in treatment at the clinic had been recorded and the associated determinants of these changes were extracted from their case notes. Therapeutic changes associated with the following determinants alone were only found in single instances: presence of or changes in symptoms, inhaler technique deficiency, forced expiratory volume in 1 s (FEV1) less than 75% of the predicted value and peak expiratory flow (PEF) rate less than 75% of the predicted value. In no instance did changes in FEV1 or in PEF alone occur. The addition of spirometric measurements in this sample of patients only made an obvious difference to decision-making in four instances (4%). Therefore, the role of spirometers in the management of asthma in general practice needs further consideration and clarification on a wider scale before limited resources, whether in terms of time or money, are committed to their use.

Bronchial hyperreactivity and history of wheezing in children

The objective of this analysis was to determine the relationship between wheezing at different age groups in children and the prevalence of bronchial hyperreactivity at the age of 10. A population-based cross-sectional study was conducted in Leipzig and the region around Halle in Germany. Of 3105 10-year-old children, 2658 questionnaires (85.6%) were returned. In addition 2279 (73.4%) pulmonary function tests were performed before and after cold air challenge. 658 children (24.8%) had recurrent wheezing during their lifetime. In 579 children the individual time course could be evaluated (46 children with and 533 without a physician-confirmed diagnosis of asthma). Wheezing began most frequently in the 1st year of life (44.1% of all wheezing children) with the highest annual prevalence in the 3rd year (71.0% of all wheezing children). Wheezing which started in the first 2 years of life, had disappeared in most of the children by the age of 10. However, if wheezing began later than the 3rd year it was more persisting. Bronchial hyperreactivity measured after cold air challenge was higher in the group with recurrent wheezing (24.1%) than in the group without wheezing (18.8%, P = 0.004).

CONCLUSION

Wheezing is a very common symptom in childhood and only partly associated with later bronchial hyperreactivity. On the other hand, asthma is often not diagnosed despite bronchial hyperreactivity and many years of wheezing.

Screening for asthma in children

The primary health care team is at the forefront of asthma management and there is evidence of improved delivery of care via nurse run, audited, general practice clinics. However, hospital admissions for asthma continue to rise. Screening for childhood asthma would appear to have advantages for patient care. This review looks critically at the literature that addresses important issues in screening for childhood asthma, including the problem of defining asthma, its prevalence rate and the importance of dealing with asthma as part of a spectrum of illnesses of the upper respiratory tract. The fundamental principles of screening in relation to asthma are addressed, and five screening procedures are described and debated. Questionnaire studies are concluded to be relatively cheap and reliable, and a compilation of validated questions is described. Such questions could be tailored to individual practice needs and used in the early detection of asthma, giving the potential for early intervention and improved quality of life.

Epidemiological study of wheeze, doctor diagnosed asthma, and cough in preschool children in Leicestershire

OBJECTIVE

To determine the cumulative prevalences of wheeze and doctor diagnosed asthma and the point prevalences of recurrent cough and wheeze in children aged 5 years and under.

DESIGN

Questionnaire survey of population based random sample of children registered on regional authority's child health index for immunisation; questionnaire completed by parents.

SETTING

Leicestershire.

SUBJECTS

1650 white children born in 1985-9 who were surveyed in 1990.

MAIN OUTCOME MEASURES

Cumulative prevalences of wheeze and doctor diagnosed asthma and point prevalences of recurrent cough and wheeze by age and sex.

RESULTS

There were 1422 replies (86.2%; 726 for boys, 696 for girls). Overall, 11.0% (95% confidence interval 9.4% to 12.6%) of children had formally been diagnosed as having asthma, the cumulative prevalence in boys (12.7%) being somewhat higher than in girls (9.2%) (age adjusted odds ratio 1.47, p = 0.03). As expected, the cumulative prevalence of asthma increased significantly with age (7.5% (13/173) in children under 1 year, 15.9% (61/383) in children of 4 years and over; p < 0.001). The cumulative prevalence of wheeze overall was 15.6% (13.7% to 17.5%), being higher in boys (17.6%) than in girls (13.5%) (odds ratio 1.38, p = 0.03). The overall prevalence of recurrent cough without colds was 21.8% (19.6% to 23.9%), with a non-significant excess in boys (23.1% v 20.4%). The overall prevalence of wheezing attacks during the previous 12 months was 13.0% (11.3% to 14.8%) with a non-significant excess in boys (14.5% v 11.5%).

CONCLUSIONS

These findings are baseline results and emphasise the importance of studying the age group of interest rather than relying on the recall of parents of school age children.

Management of asthma in pre-school children

The management of asthma in pre-school children often presents physicians with challenging problems. This article addresses the diagnostic criteria by which the diagnosis may be made, discusses the prognosis of untreated asthma and states the principles underlying the treatment of asthma in this age group. The management according to a stepwise protocol is discussed with reference both to maintenance therapy, and the treatment of acute severe asthma. The methods by which appropriate medication may be delivered are also described.

Asthma morbidity in Australia: an epidemiological study

OBJECTIVE

To examine the prevalence and management of asthma in adults and children in a population sample in eastern Australia.

SETTING

A random sample of children from 33 primary schools in Sydney, Melbourne, Brisbane, and the Upper Hunter Valley (New South Wales), and their parents.

DESIGN

A cross-sectional analytic survey of 8753 primary school children aged between 5 and 12 years, and their parents (n = 13,945 adults). Asthma prevalence and management practices were determined by parental responses to a questionnaire, and spirometry was performed in children with "probable asthma".

RESULTS

Of 8753 children whose parents responded, the prevalence of current wheeze was 19.5% and diagnosed asthma was 17.1%. Of the children with "probable asthma", 30% had their lung function measured in the previous year, and 6% possessed both a peak flow meter and an action plan for their asthma. Undertreatment was likely, as preventive asthma medications (inhaled corticosteroids or sodium cromoglycate) were used regularly by only 25.5% of these children and by 44.3% of children who had asthma symptoms more than twice per week. Children with the diagnosis of asthma reported higher rates of preventive medication use and ventilatory function measurement than children with frequent symptoms without the diagnosis. In the 13,945 adults, the reported prevalence of asthma was 7%, of whom 39% were using preventive medications, 34% had their ventilatory function assessed in the previous year, and 7% had both a peak flow meter and an asthma action plan.

CONCLUSIONS

The study illustrated the gap between the current level of asthma management in the community and the standards set by the Thoracic Society of Australia and New Zealand. Undertreatment and suboptimal management of asthma remain important problems in Australia.

Impact of an interest in asthma on prescribing costs in general practice

OBJECTIVE

To examine the effect on total prescribing costs and prescribing costs for respiratory drugs for practices with at least one general practitioner with a special interest in asthma.

DESIGN

Postal questionnaire survey.

SETTING

General practitioners in England and Wales.

SUBJECTS

269 members of the General Practitioners in Asthma Group, of whom 103 agreed to participate.

MAIN MEASURES

Individual practitioners' and their practices' PACT prescribing costs from the winter quarters of 1989-90 compared with average costs for their family health services authority (FHSA) and a notional national average of all FHSAs combined.

RESULTS

The response rate was 57%; the average total prescribing costs for the practices of the 59 respondents were significantly lower than those of their respective FHSAs (mean difference 505 pounds per 1000 patients per quarter (95% confidence interval -934.0 to -76.2, p = 0.022) and lower than the national average. The average prescribing costs for respiratory drugs for the practices were significantly greater than those for their FHSA (195 pounds per 1000 patients per quarter (84.4 to 306.0, p = 0.001) and the national average. Both types of costs varied widely.

CONCLUSION

An interest in asthma care in general practice is associated with higher average prescribing costs for respiratory drugs but no increase in overall prescribing costs compared with those for respective FHSAs and national averages.

IMPLICATIONS

FHSAs and their medical advisors should not examine high prescribing costs for individual doctors or one therapeutic category but in the context of practice total costs.

Can morbidity associated with untreated asthma in primary school children be reduced?: a controlled intervention study

OBJECTIVE

To determine whether an intervention programme based on existing school and community resources can reduce school absence and improve participation in games lessons and sport in children with unrecognised or undertreated asthma.

DESIGN

Parallel group controlled intervention study.

SETTING

102 primary schools in Nottingham: 49 were randomised to receive the intervention and 53 to be control schools.

SUBJECTS

All children aged 5 to 10 years with parent reported absence from school because of wheezing in the previous year and taking no treatment or beta agonists only.

INTERVENTIONS

Children with asthma were referred to their general practitioner for assessment of symptoms and treatment. Teachers were given education on asthma by the school nurse in 44 of the 49 intervention schools.

MAIN OUTCOME MEASURES

Changes in school absence and missed games and swimming lessons because of wheezing, and schools' policy towards management of asthma in school.

RESULTS

Of 17,432 children screened, 451 met the entry criteria--228 in intervention schools and 223 in control schools. 152 (67%) children in intervention schools visited their general practitioner, of whom 39 (26%) were given a new diagnosis of asthma and 58 (38%) had treatment for asthma increased or changed. Over the next academic year mean (SE) parent reported school absence due to wheezing fell significantly, but to a similar extent, in both intervention and control schools (0.82 (0.11) and 1.09 (0.21) weeks respectively). There was little change in school recorded absence or participation in games lessons and swimming lessons in either group. At the end of the study intervention schools were more likely to have improved aspects of management of asthma in school.

CONCLUSION

The intervention resulted in a majority of children being assessed by their general practitioner and improved teachers' understanding and management of asthma, but it did not result in any appreciable reduction in morbidity.

Two-year follow up of the management of chronic or recurrent cough in children according to an asthma protocol

To test the hypothesis that many children with a chronic or recurring cough have asthma, 106 children with cough were treated according to an asthma protocol. At the end of 16 weeks, all but two of the children who completed this phase of the trial were free of cough. At a two-year follow up 97 children were reviewed: 71 were now diagnosed as having an asthmatic condition, 34 of whom required regular medication. The original histories of those who developed asthma were compared with those who had no further respiratory symptoms. The results suggest that many children with a chronic or recurring cough have a mild form of asthma, known as cough variant asthma, which is responsive to asthma therapy. Many will subsequently develop mild to moderately severe asthma. Those who subsequently develop an asthmatic condition are statistically more likely to have a family history of asthma or a personal history of atopy. The children are also more likely to have exercise-induced cough or nocturnal exacerbation of their cough. Managing a persistent or recurring cough according to an asthma protocol could mean that many asthmatic children will be diagnosed and treated earlier in the natural history of their illness.

Delay in diagnosis of childhood asthma and its influence on respiratory consultation rates

A survey of cases of asthma in two general practices with a special interest in the disease identified 212 asthmatic children aged 0-16 years by the end of January 1989 who had been registered in that practice since birth. Delay in diagnosis, both in terms of time (median 2.95 years) and number of consultations (median 7), was considerable. Annual rates of consultations for respiratory symptoms that were initiated by the patients fell significantly after diagnosis (median before = 1.80, after = 0.95 consultations/year), but the number initiated by the doctors rose significantly (median before = 0, after = 1.01 consultations/year). The overall rates before and after diagnosis were not significantly different (median before = 2.04, after = 2.21 consultations/year). Increased efforts are required to reduce this delay thereby minimising the morbidity of asthma in childhood.

Effect of atopy on the natural history of symptoms, peak expiratory flow, and bronchial responsiveness in 7- and 8-year-old children with cough and wheeze. A 12-month longitudinal study [published errarum appears in Am Rev Respir Dis 1992 Aug;146(2):540]

Recurrent lower respiratory tract symptoms are common and disabling in childhood, but little is known of their natural history and relationship to asthma. We report a 12-month longitudinal study designed to determine the influence of atopy on respiratory symptoms and bronchial responsiveness in 7- and 8-yr-old children. A postal questionnaire inquiring into the presence of respiratory symptoms was sent to 3,698 children aged 7 and 8 yr. Those reporting either current wheeze (14.8%) or current cough in the absence of wheeze (12.8%) were randomized, and a sample was invited to attend for skin testing. The following groups of symptomatic children entered the longitudinal study: 48 atopic children with cough, 48 atopic children with wheeze, 48 nonatopic children with cough, and 48 nonatopic children with wheeze. All children recorded twice daily the best of three peak expiratory flow (PEF) measurements and completed a 10-point symptom score card, each day for 1 yr. They also recorded all treatment taken and made a note of relevant life events. Each child was seen monthly for general assessment and for measurement of methacholine bronchial responsiveness. Despite the arduous nature of the study 183 of the 192 children (95.3%) successfully completed the 12 months of observation. Symptom groups were compared with regard to FEV1, bronchial responsiveness, symptom chronicity and severity, and diurnal and day-to-day variation in PEF. Atopy was associated with a lower FEV1, increased prevalence of bronchial hyperresponsiveness, greater within-day and between-day variation in PEF, and greater severity of respiratory symptoms compared with the absence of atopy. Wheeze was associated with lower FEV1, increased prevalence of bronchial hyperresponsiveness, greater within-day and between-day variation in PEF1 and greater severity of respiratory symptoms compared with cough [corrected].

Multidisciplinary co-operation in primary care for asthmatic children

In the development of 'education protocols' for the treatment and education about chronic diseases in primary care the involvement of several disciplines of careproviders must often be taken into account. This implies that tasks will have to be divided across several disciplines. An orderly way to do this does not seem to have been suggested in the literature. In this paper a systematic technique is presented to divide educational tasks across disciplines. The basic idea of this method is that one should link up as far as possible with existing task conceptions and knowledge of the disciplines involved. The general description of the technique will be followed by a piece of research in which the technique is applied to protocol development for parents of asthmatic children (0-4 years). The protocol aims at allocating specific asthma education tasks to community nurses, general practitioners, asthma nurses and doctors working at child health centers in the Netherlands. This paper focuses mainly on results for community nurses. Three criteria were considered in assigning tasks to the different careproviders: whether the discipline in question claimed a certain task; whether the other three disciplines agreed with the claim, and whether the discipline in question had appropriate and sufficient knowledge about asthma to perform the task correctly. Community nurses did claim several tasks in asthma care, but knowledge did not always seem to be sufficient. Additional results indicated that nurses who had taken a refresher course did have a higher knowledge level than nurses who had not taken such a course. Regular contact with asthmatic children also tended to be associated with increased knowledge of asthma.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevalence and management of asthma in a London inner city general practice

A study was set up to examine the prevalence and management of asthma symptoms in a London inner city general practice. All case records were examined and evidence of past or currently active asthma or wheezing illness was identified in 1032 out of 11,148 records (9.3%). This gave a cumulative prevalence of asthma or wheezing illness of 7.2% among adults and 19.5% among children aged 15 years or under. These figures are consistent with previous estimates of prevalence in the UK published since the mid 1960s. In 92.5% of cases in which information was available, the initial diagnosis of asthma or decision to prescribe a bronchodilator was made in primary care. Only nine cases (0.9%) had evidence of recurrent wheezing without the benefit of bronchodilator therapy at any time. There was significant delay in diagnosis in children under five years compared with older children or adults. There was a significant association between a formal diagnosis of 'asthma' in the case notes and the inclination of general practitioners to monitor peak expiratory flow or offer inhaled bronchodilator or corticosteroid therapy. Of 111 asthmatics (83 adults and 28 children aged five to 15 years) with previously 'severe' disease who sought medical advice for their asthma over a 12 month period, 91.6% of adults and 92.9% of children received bronchodilator therapy; nevertheless, only 47.0% of adults and 14.3% of children received inhaled corticosteroids and only 12.0% of adults and 28.0% of children received inhaled cromoglycate. Only 59.0% of adults and 46.4% of children had at least one measurement of peak expiratory flow during the 12 months.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of symptom presentation on delay in asthma diagnosis in children in a general practice

Analysis of 187 children diagnosed as having asthma since 1984 in a general practice population is described. Reasons were sought for possible delay in diagnosis so that appropriate steps could subsequently be taken to minimize further delay. Even in an asthma aware practice (original prevalence 8.8%) a delay of approximately 40% of the total age of the child at diagnosis is shown. This delay does not appear to diminish even for children up to 10 years of age. Asthma is more likely to be missed or labelled as 'bronchitis' in children who cough repeatedly, rather than those who wheeze occasionally. As many as 45% of asthmatic children may have had 'bronchitis' diagnosed and treated instead of asthma, so that a diagnosis of repeated 'bronchitis' merely detracts from underlying asthma.