North of England Asthma Guideline Development Group. North of England evidence based guidelines development project: summary version of evidence based guideline for the primary care management in adults

How Evidence-Based is our Practice in a Hong Kong Emergency Department?

Objective

To evaluate how evidence-based our daily practice was.

Design

Retrospective study.

Setting

Emergency department of a public district hospital.

Patients and Methods

Between 1st August 2000 to 7th August 2000, 91 patients' records were chosen at random. A chief diagnosis was assigned for each patient. Corresponding treatments were reviewed by searching relevant randomised controlled trials (RCTs), systematic reviews and meta-analyses. Each patient had only one chief diagnosis but could have multiple interventions for that diagnosis.

Results

Out of 91 records, 14 were discarded. All of them had not been given any intervention and 11 required admission. For the remaining 77 records, there were 38 subjects in medical, paediatric, or gynaecological specialties and 39 in surgical or orthopaedic specialties. Intervention(s) given for each subject were then searched electronically through our hospital Knowledge Gateway and the results were expressed as either EBM-positive or EBM-negative. “EBM-positive” interventions denoted a support by RCTs. “EBM-negative” interventions denoted an absence of any supportive RCTs. Each patient might have EBM-positive and/or EBM-negative interventions together if that patient received more than one treatment. There were 52 patients (52/77 = 68%) who had one of their interventions being RCT-supported. The majority were patients with (1) antipyretic use of paracetamol in upper respiratory tract infection, or (2) control of pain by nonsteroidal anti-inflammatory drug, dologesic and paracetamol. There were 25 patients (25/77 = 32%) who did not receive any RCT-supported interventions. Concurrently 53 patients out of 77 (69%) received EBM-negative interventions. The majority were patients with (1) the use of antibiotics, antitussives and antihistamines in upper respiratory tract infection, (2) antispasmodics in gastroenteritis or patients with nonspecific abdominal pain, and (3) the use of analgesic balm in minor orthopaedic complaints.

Conclusion

Sixty-eight percent of patients had EBM-positive interventions. Thirty-two percent of patients did not receive any EBM-positive intervention. It was quite encouraging as compared to studies in other specialties with similar design. Concurrently 69% of patients had also been given EBM-negative interventions. There were areas for improvement if we were to implement EBM practice in the emergency department.

Pharmacy Asthma Care Program (PACP) improves outcomes for patients in the community

BACKGROUND

Despite national disease management plans, optimal asthma management remains a challenge in Australia. Community pharmacists are ideally placed to implement new strategies that aim to ensure asthma care meets current standards of best practice. The impact of the Pharmacy Asthma Care Program (PACP) on asthma control was assessed using a multi-site randomised intervention versus control repeated measures study design.

METHODS

Fifty Australian pharmacies were randomised into two groups: intervention pharmacies implemented the PACP (an ongoing cycle of assessment, goal setting, monitoring and review) to 191 patients over 6 months, while control pharmacies gave their usual care to 205 control patients. Both groups administered questionnaires and conducted spirometric testing at baseline and 6 months later. The main outcome measure was asthma severity/control status.

RESULTS

186 of 205 control patients (91%) and 165 of 191 intervention patients (86%) completed the study. The intervention resulted in improved asthma control: patients receiving the intervention were 2.7 times more likely to improve from "severe" to "not severe" than control patients (OR 2.68, 95% CI 1.64 to 4.37; p<0.001). The intervention also resulted in improved adherence to preventer medication (OR 1.89, 95% CI 1.08 to 3.30; p = 0.03), decreased mean daily dose of reliever medication (difference -149.11 microg, 95% CI -283.87 to -14.36; p=0.03), a shift in medication profile from reliever only to a combination of preventer, reliever with or without long-acting beta agonist (OR 3.80, 95% CI 1.40 to 10.32; p=0.01) and improved scores on risk of non-adherence (difference -0.44, 95% CI -0.69 to -0.18; p=0.04), quality of life (difference -0.23, 95% CI -0.46 to 0.00; p=0.05), asthma knowledge (difference 1.18, 95% CI 0.73 to 1.63; p<0.01) and perceived control of asthma questionnaires (difference -1.39, 95% CI -2.44 to -0.35; p<0.01). No significant change in spirometric measures occurred in either group.

CONCLUSIONS

A pharmacist-delivered asthma care programme based on national guidelines improves asthma control. The sustainability and implementation of the programme within the healthcare system remains to be investigated.

A 10 year asthma programme in Finland: major change for the better

BACKGROUND

A National Asthma Programme was undertaken in Finland from 1994 to 2004 to improve asthma care and prevent an increase in costs. The main goal was to lessen the burden of asthma to individuals and society.

METHODS

The action programme focused on implementation of new knowledge, especially for primary care. The main premise underpinning the campaign was that asthma is an inflammatory disease and requires anti-inflammatory treatment from the outset. The key for implementation was an effective network of asthma-responsible professionals and development of a post hoc evaluation strategy. In 1997 Finnish pharmacies were included in the Pharmacy Programme and in 2002 a Childhood Asthma mini-Programme was launched.

RESULTS

The incidence of asthma is still increasing, but the burden of asthma has decreased considerably. The number of hospital days has fallen by 54% from 110 000 in 1993 to 51 000 in 2003, 69% in relation to the number of asthmatics (n = 135 363 and 207 757, respectively), with the trend still downwards. In 1993, 7212 patients of working age (9% of 80 133 asthmatics) received a disability pension from the Social Insurance Institution compared with 1741 in 2003 (1.5% of 116 067 asthmatics). The absolute decrease was 76%, and 83% in relation to the number of asthmatics. The increase in the cost of asthma (compensation for disability, drugs, hospital care, and outpatient doctor visits) ended: in 1993 the costs were 218 million euro which had fallen to 213.5 million euro in 2003. Costs per patient per year have decreased 36% (from 1611 euro to 1031 euro).

CONCLUSION

It is possible to reduce the morbidity of asthma and its impact on individuals as well as on society. Improvements would have taken place without the programme, but not of this magnitude.

Signs of reversing trends in prevalence of asthma

Several recent reports have provided evidence that the burden of asthma may have levelled off, after increasing for decades. Implementation of the national and global asthma prevention and management guidelines that have led to earlier detection and improved treatment of asthmatics, is considered to be involved in this apparent change for the better. In addition, environmental influences associated with the modern life may have reached the maximum in inducing symptoms and disease in genetically susceptible individuals in some areas. Available data obtained from Canada and non-English-speaking countries in Europe show that the peak in asthma prevalence has been reached at the level of 8-12%. This review outlines the most recent literature on time trends in asthma prevalence and considers the possible causes of the current trends. Problems and pitfalls in appraising studies on time trends are also discussed.

Clinical efficacy of inhaler devices containing beta(2)-agonist bronchodilators in the treatment of asthma: cochrane systematic review and meta-analysis of more than 100 randomized, controlled trials

BACKGROUND

A number of different inhaler devices are available to deliver beta(2)-adrenoceptor agonist (beta(2)-agonist) bronchodilators in asthma. These include hydrofluoroalkane or chlorofluorocarbon (CFC)-free propelled pressurized metered-dose inhalers (pMDIs), many dry powder inhalers and breath-actuated inhalers.

OBJECTIVE

To determine the clinical efficacy of all available hand-held inhaler devices compared with the standard CFC-containing pMDI for the delivery of short-acting beta(2)-agonist bronchodilators in nonacute asthma in both children and adults.

METHODOLOGY

A systematic review and meta-analysis was carried out of all available randomized, controlled trials (RCTs) using the standard pMDI compared with any other hand-held inhaler device, delivering short-acting beta(2)-agonist bronchodilators in patients with stable asthma.

RESULTS

One hundred and eighteen RCTs were included in this review. No clinical differences were found between the standard CFC-containing pMDI and 12 other hand-held inhaler devices for most outcome measures. We found no evidence of clinical differences between studies using either a 1 : 1 (pMDI: another inhaler) or a 2 : 1 dosing ratio.

CONCLUSIONS

In patients with stable asthma, short-acting beta(2)-agonist bronchodilators in standard CFC-pMDIs are as effective as any other hand-held inhaler device; therefore the cheapest available device that the patient is able to use should always be considered. Pharmaceutical companies should in future submit to regulatory authorities clinical outcome data (as opposed to in vitro data) in support of any dosing schedules greater than 1 : 1 when compared with the standard pMDI. Clinical effectiveness studies that use an intention-to-treat analysis and report more patient-centered outcomes are required.

Practice nurses and clinical guidelines in a changing primary care context: an empirical study

BACKGROUND

Practice Nurses form an increasingly large proportion of the English National Health Service primary care workforce and the delegation to them of clinical work from General Practitioners has attracted some academic attention. Central to this process are clinical guidelines, which provide the interface between the movement towards 'evidence-based practice' and a range of government-driven policy developments in primary care.

AIMS

To identify the attitudes of practice nurses to clinical guidelines; to investigate the impact of guidelines on nurse/physician relationships; and to describe the impact of the changing primary care context on nurses.

METHODS

We interviewed a sample of 29 Practice Nurses three times during a 16-month period to clarify their attitudes towards guidelines, their use of guidelines in practice and their assessment of guidelines' importance. We gathered further data on organizational culture and perceptions of national reforms of primary care structures.

RESULTS

We found that practice nurses are generally supportive of clinical guidelines. Moreover, nurses' role and influence within primary care is in a process of transition to one in which they may undertake responsibility for influencing General Practitioners' clinical behaviour so as to adhere to guidelines. Practice nurses themselves recognize and welcome this, though with some reservations.

CONCLUSIONS

Our findings support the proposal that explicit codification of the scientific basis of the work of lower paid groups may enhance their relative professional status.

Pressurised metered dose inhalers versus all other hand-held inhaler devices to deliver beta-2 agonist bronchodilators for non-acute asthma

BACKGROUND

A number of different inhaler devices are available to deliver beta2-agonist bronchodilators in asthma. These include hydrofluoroalkane (HFA) or chlorofluorocarbon (CFC)-free propelled pressurised metered dose inhalers (pMDIs) and dry powder devices.

OBJECTIVES

To determine the clinical effectiveness of pMDI compared with any other available handheld inhaler device for the delivery of short-acting beta-2 agonist bronchodilators in non-acute asthma in children and adults.

SEARCH STRATEGY

The Cochrane Collaboration Clinical Trials register was searched for studies as well as separate additional searches carried out on MEDLINE, EMBASE, CINAHL and also on the Current Contents Index as well as the Science Citation Index. In addition, 17 individual online respiratory journals and 12 electronically available clinical trial databases were also searched. The UK pharmaceutical companies who manufacture inhaled asthma medication were contacted in order to obtain details of any published or unpublished studies.

SELECTION CRITERIA

- The full texts of all potentially relevant articles were reviewed independently by two reviewers.

DATA COLLECTION AND ANALYSIS

Fixed and random effect models were used. Dichotomous outcomes were assessed using Odds Ratios or Relative Risks (RR) with 95% Confidence Intervals (95%CI).

MAIN RESULTS

Eighty-four randomised controlled trials were included in this review, but few could be combined to assess a specific outcome for a given delivery device comparison. Only two studies required demonstration of adequate pMDI technique as an entry requirement. There were no difference between a standard CFC containing pMDI and any other device for most outcomes. Regular use of HFA-pMDI containing salbutamol reduced the requirement for short courses of oral corticosteroids (3 trials, 519 patients: RR 0.67; 95% CI 0.49, 0.91); however the total number of exacerbations were unchanged (3 trials, 1271 patients: RR 1.0; 95% CI 0.75, 1.33).

REVIEWER'S CONCLUSIONS

In patients with stable asthma, short-acting beta-2 bronchodilators in standard CFC-pMDI's are as effective as any other devices. The effect of HFA-pMDI on requirement for oral corticosteroid courses to treat acute exacerbations should be confirmed. Effectiveness studies that use an intention-to-treat analysis are required.

Evidence-based guideline on the primary care management of asthma

This is an updated version of the first North of England Asthma Guideline (1,2) and summarizes the full guideline. (3) This paper presents all the recommendations within the guideline and, where these are new or substantially altered from the original version, it also presents a summary of the supporting evidence. The aims and methods of development (summarized in Box 1) of this guideline are unchanged from the original version, to which readers are directed for more detail. The research questions raised during the development of this guideline are shown in Box 2.

Clinical guidelines: attitudes, information processes and culture in English primary care

The application to clinical medicine of evidence-based clinical guidelines is an increasingly international policy prescription, yet research on how such guidelines might be implemented has tended to focus on change initiatives without seeking to understand change processes. This paper reports an empirical study of guideline implementation in UK general practice. Most GPs welcome guidelines as a means of improving care, though have reservations about their authority, relevance and effect on professional autonomy. 'Clan' organizational culture predominates and general practices do not generally have well-functioning internal arrangements for the management of clinical evidence and related information. We found no coherent relationships between these variables and practices' actual uptake of guidelines.

Prescribing patterns for asthma by general practitioners in six European countries

To assess the level of concordance with international consensus on asthma management, we compared primary care prescribing patterns for asthma in different European countries. A prospective study of prescription items with an associated diagnostic label of asthma in patient consultations with a total of 235 general practitioners (GPs) from Belgium, England, Ireland, Italy, Northern Ireland, Portugal, Scotland and Spain was performed. A total of 101,544 consecutive consultations were recorded in autumns 1994 and 1995 of which 3595 (3.5%) were for patients with asthma and 3243 (3.2%) were for patients receiving a prescription for asthma. Overall, asthma consultations varied from 1.8% in Italy to 5.8% in Ireland (mean 3.4%, SD 1.6). Prescribed inhaled medications for children varied from 72% of the total asthma prescriptions in Ireland and Portugal to 82% in Northern Ireland (mean 79%, SD 8.1) and for adults 55% in Italy to 85% in Spain (mean 70%, SD 10). Inhaled corticosteroid usage for adults varied from 14% in Italy to 31% in Northern Ireland (mean 24%, SD 6.4). For children, beta2-agonist use varied from 24% in Italy to 67% in Spain (mean 45%, SD 13). Despite publication of international guidelines for the management of asthma, inter-country prescribing practices vary considerably and could be improved. The frequency of use of asthma as a diagnostic label also varies markedly.

Guidelines in pulmonary medicine: a 25-year profile

OBJECTIVE

We attempted to identify clinical practice guideline and pathway articles in the area of pulmonary medicine published in peer-reviewed journals since 1974.

DESIGN

Review.

DATA SOURCES

MEDLINE, the Cochrane Database, Best Evidence, and Abstracts of Clinical Care Guidelines from January 1974 to December 1998.

STUDY SELECTION

All articles contained relevant search terms for pulmonary topics and were included irrespective of setting (primary or specialty, inpatient or outpatient). Controlled and uncontrolled trials as well as observational studies and consensus opinion/statements were all identified. The articles were stratified by design as well as by pulmonary topic.

DATA EXTRACTION

Limited data on study type, study focus, year of publication, and results of study were abstracted.

RESULTS

Our criteria yielded 271 articles, including 115 consensus statements and expert opinion guidelines; 30 controlled studies, meta-analyses, or systematic reviews; and 126 uncontrolled trials and observational studies. Of these, 82 articles (30.3%) related to asthma, 46 articles (17.0%) related to COPD, and 36 articles (13.3%) related to pneumonia. In addition, we tracked the increasing publication of all guideline-related pulmonary articles; randomized, controlled trials (RCTs); systematic reviews; and consensus statements by year for the past 25 years.

CONCLUSION

Pulmonary guidelines are increasingly published in peer-reviewed journals, but few are tested clinically in RCTs. There is continued reliance on consensus statements and expert opinion. Pulmonary guideline publications have continued to dramatically increase in number and in importance since 1974, both on the local level and internationally.

A model for the development of evidence-based clinical guidelines at local level--the Leicestershire Genital Chlamydia Guidelines Project

Clinical guidelines can be effective in achieving health gain when they are validly developed, disseminated and implemented appropriately. There is, however, a potential conflict between the need for validity through use of expert resources available at a national level, and implementation, which is undertaken at local level and depends on the local relevance of the guideline. This paper presents a model by which valid guidelines for the management of a given disease (genital chlamydial infection) by general practitioners can be developed at local level using the resources available to a district health authority department of public health. The model has three elements. First, a district-wide postal questionnaire survey was used to document current clinical practice. Secondly, a critical review of the evidence relating to the management of genital chlamydial infection as it relates to British general practice was performed. Thirdly, the information gained from the critical review and survey was used by a multidisciplinary group to develop evidence-based guideline recommendations. It is argued that the Leicestershire Genital Chlamydia Guidelines compare favourably with other recently published national guidelines in terms of their development and content. Local guideline development of guidelines for selected topics can be practical and appropriate.

Clinical guidelines: ways ahead

Clinical guidelines are essential in promoting the implementation of evidence-based practice within the NHS. But there are two broad schools of thought about their development and implementation: the first argues that guidelines should be entirely evidence-based and tolerates a degree of complexity which may make the guideline impractical; the second argues that we need simple guidelines, and sacrifices the strength of evidence in favour of ease of application and dissemination. Both arguments have merits and flaws, which are discussed, and ways to integrate the strengths of both are considered.

[Role of corticosteroid therapy in non-malignant diseases]

INTRODUCTION

As short-term corticosteroid therapy is widely used in clinical practice, it is important to determine its precise indications and limits of use.

CURRENT KNOWLEDGE AND KEY POINTS

Duration of short-term corticosteroid therapy is arbitrarily considered to be up to 21 days. Anti-inflammatory, antiproliferative or analgesic actions represent the main pharmacological features of steroids. They are related to the interactions of steroids with cytokines and immune cells. Results of randomized double-blind and uncontrolled clinical studies were included in this review. Furthermore, clearly demonstrated results that were obtained more particularly in neurology, otorhinolaryngology, pneumology, infectious diseases, rheumatologic and traumatic processes are summarized.

FUTURE PROSPECTS AND PROJECTS

Indications for short-term corticosteroid therapy are well established. However, further clinical studies are required, as current prescription of corticosteroid is still empirical in the management of most diseases.

Effect of salmeterol treatment on nitric oxide level in exhaled air and dose-response to terbutaline in children with mild asthma

The aim of this study was to investigate whether regular treatment with inhaled salmeterol modifies the dose-response curve to the inhaled short-acting beta2-agonist terbutaline or affects the concentration of nitric oxide (NO) in exhaled air of children with asthma. Twenty-two children aged 7 to 15 years (mean = 11.6 years) with mild asthma were treated with inhaled 50 microg salmeterol twice daily or placebo for 3 weeks in a randomized double-blind cross-over study. These treatments were followed by treatment with inhaled 200 microg budesonide twice daily for 3 weeks. On the last day of each period, NO level was measured in exhaled air and a cumulative dose-response experiment with terbutaline (cumulative dose: 1,475 microg) was performed. Baseline lung functions after salmeterol treatment were significantly higher than baseline after placebo (P + 0.05). Salmeterol treatment flattened out the dose-response curve to terbutaline such that higher doses of terbutaline were required to produce the same degree of bronchodilation (ED50 for FEV1 was increased by an estimated factor of 70 (95% CI: 0.8-6307) and ED50 for FEF25-75 by a factor of 41 (95% CI: 6.7-254); P < 0.05). NO levels were unaffected by salmeterol treatment (12.7 ppb; placebo = 10.7 ppb), but were significantly reduced during budesonide therapy (5.2 ppb; P < 0.001). The corresponding maximal NO levels were 19.5 (placebo), 22.9 (salmeterol), and 9.4 ppb (budesonide). We conclude that 3 weeks treatment with salmeterol does not affect NO levels in exhaled air, but it significantly changes the dose-response curve to terbutaline.

Formoterol. An update of its pharmacological properties and therapeutic efficacy in the management of asthma

Formoterol, a selective beta 2-adrenoceptor agonist, produces effective dose-proportional bronchodilation, which persists for up to 12 hours, in patients with reversible obstructive respiratory disease. Bronchodilation is significant within minutes of inhalation, maximal within 2 hours, and at therapeutic doses is equivalent to that produced by standard doses of traditional beta 2-agonists. In single-dose studies comparing the two long-acting beta 2-agonists formoterol and salmeterol, significant bronchodilation is achieved more rapidly with formoterol than salmeterol. Duration of bronchodilation is similar with both drugs. The therapeutic efficacy of inhaled formoterol has been equal to or greater than that of salbutamol (albuterol), fenoterol and terbutaline in both short and long term clinical trials. Formoterol reduces symptoms of nocturnal asthma and reduces the need for rescue medication compared with salbutamol. Recent studies have shown that the addition of inhaled formoterol 12 or 24 micrograms twice daily to existing inhaled corticosteroid regimens improves lung function and reduces asthma symptoms compared with placebo. In one well designed study, the frequency of severe exacerbations of asthma over 12 months was decreased by adding formoterol to existing regimens of inhaled corticosteroids. Tolerance to the bronchodilator response of formoterol has not been observed in long term clinical trials. Because of its long duration of action, formoterol offers significant therapeutic advantages over shorter-acting beta 2-agonists in the treatment of nocturnal and exercise-induced asthma. Formoterol is effective in preventing exercise-induced asthma in adults and children and confers significantly more protection than salbutamol when administered 3 and 12 hours before exercise. In general, inhaled formoterol is well tolerated. The most commonly reported adverse effects, tremor and palpitations, are those traditionally associated with the use of beta 2-agonists. Oral formoterol and high doses of inhaled formoterol are associated with more adverse events than are the recommended doses of 6 to 24 micrograms. Formoterol is currently recommended for use as an alternative to increasing inhaled steroid dosage in patients whose symptoms are inadequately controlled despite therapy with low to moderate doses of inhaled steroids and intermittent short-acting beta 2-agonists, and results of recent studies support therapeutic guidelines. Long term clinical studies comparing formoterol and salmeterol have not yet been published. Further studies to evaluate the earlier use of formoterol in patients with mild to moderate asthma are needed to determine the role and long term safety of formoterol in the management of asthma.