Implementing spirometry and fractional exhaled nitric oxide testing in childhood asthma management in UK primary care: an observational study to examine training and implementation cost and impact on patient's health use and outcome

OBJECTIVES

Implementation of guidelines into clinical practice is challenging and complex. This study aims to (1) identify the training needs and capacity requirements, and (2) explore the impact on healthcare utilisation and asthma-related quality of life of implementing both spirometry and fraction of exhaled nitric oxide in diagnosis of asthma among children in the UK primary care.

METHODS

Ten UK general practitioner practices and a total of 612 children (5-16 years) with diagnosed or suspected asthma were invited to participate in this prospective observational study. The total times that the trainer and trainee clinical staff spent on developing the training package, providing and receiving, and performing and interpreting the two tests as part of routine child asthma review were collected, and costs were calculated. We compared healthcare utilisation and asthma-related and general health-related quality of life data between the 6 months before and after the asthma review guided by objective tests.

RESULTS

The average training cost for the 27 primary care clinical members was £1395. The average cost to implement and deliver the test-guided asthma review among the 612 included children was £22. In the 6 months following the tests-guided asthma review, both unplanned primary care attendance, and hospital admissions were reduced, and the asthma-related health status increased significantly.

CONCLUSION

This study provides robust cost estimates of the resources needed to implement the National Institute for Health and Care Excellence asthma guideline. It also demonstrates the potential to save healthcare costs and improve health status among asthmatic children by implementing this guideline.

Risk factors for asthma attacks and poor control in children: a prospective observational study in UK primary care

OBJECTIVE

To identify risk factors for asthma attacks and poor asthma control in children aged 5-16 years.

METHODS

Prospective observational cohort study of 460 children with asthma or suspected asthma from 10 UK general practices.Gender, age, ethnicity, body mass index, practice deprivation decile, spirometry and fraction of exhaled nitric oxide (FeNO) were recorded at baseline. Asthma control scores, asthma medication ratio (AMR) and the number of asthma attacks were recorded at baseline and at 6 months.The above independent variables were included in binary multiple logistic regression analyses for the dependent variables of: (1) poor symptom control and (2) asthma attacks during follow-up.

RESULTS

Poor symptom control at baseline predicted poor symptom control at 6 months (OR 4.4, p=0.001), while an increase in deprivation decile (less deprived) was negatively associated with poor symptom control at 6 months (OR 0.79, p=0.003). Higher FeNO levels (OR 1.02, p<0.001) and a recent history of asthma attacks (OR 2.03, p=0.02) predicted asthma attacks during follow-up. Asian ethnicity was associated with a lower OR for a future attack (OR 0.32, p=0.02).A decrease in AMR was also associated with an increased OR for future asthma attacks (OR 2.99, p=0.003) when included as an independent variable.

CONCLUSIONS

We identified risk factors for poor symptom control and asthma attacks in children. Routine assessment of these factors should form part of the asthma review to identify children at an increased risk of adverse asthma-related events.

Lung function and asthma control in school-age children managed in UK primary care: a cohort study

BACKGROUND

Spirometry and fraction of exhaled nitric oxide (FeNO) are commonly used in specialist centres to monitor children with asthma. The National Institute for Health and Care Excellence recommends spirometry for asthma monitoring from 5 years in all healthcare settings. There is little spirometry and FeNO data in children managed for asthma in UK primary care to support their use.

OBJECTIVES

To study the prevalence of abnormal spirometry and FeNO in children with asthma managed in primary care and to explore their relationship with asthma control and unplanned healthcare attendances (UHA).

METHODS

Prospective observational cohort study in children aged 5-16 years with suspected or doctor-diagnosed asthma attending an asthma review in UK general practice. Spirometry, FeNO, asthma control test (ACT) scores and number of UHAs were studied.

RESULTS

Of 612 children from 10 general practices, 23.5% had abnormal spirometry, 36.0% had raised FeNO ≥35 parts per billion and 41.8% reported poor control. Fifty-four per cent of children reporting good asthma control had abnormal spirometry and/or raised FeNO. At follow-up, the mean number of UHAs fell from 0.31/child in the 6 months preceding review to 0.20/child over the 6 months following review (p=0.0004). Median ACT scores improved from 20 to 22 (p=0.032), and children's ACT from 21 to 23 (p<0.0001).

CONCLUSIONS

Abnormal lung function and FeNO are common in children attending for asthma review in primary care and relate poorly to symptom scores. A symptoms-based approach to asthma monitoring without objective testing is likely to miss children at high risk of future severe asthma attacks.

Providing a seamless service for children with life-limiting illness: experiences and recommendations of professional staff at the Diana Princess of Wales Children's Community Service

The Diana Children's Community Teams (DCCTs), a new nurse-led service funded by the Department of Health, were established to provide care in the community as an alternative to hospital for children with life-threatening/life-limiting illnesses and their families. This paper presents selected findings highlighting the professionals' experiences which formed part of the evaluation of the Diana, Princess of Wales Children's Community Service in Leicester, Leicestershire and Rutland. The Diana Service in Leicestershire attempts to encompass both parental empowerment and interagency collaboration. By working in partnership with the children and their families, the team provides an integrated and multiprofessional community-based service. This paper particularly concentrates on the perceptions and recommendations from the Diana team itself. Three independently managed Community Nursing Services existed in Leicestershire prior to the Diana teams; a Paediatric Macmillan Service, a Children's Community Nursing Service and a Respite Service. The Leicestershire DCCT integrated the three nursing services into a single team. This team has moved away from a traditional uniprofessional service structure by encompassing a wider team of multiprofessionals, including a cultural link worker, an occupational therapist, a physiotherapist, a play specialist and a team of trained counsellors, working in partnership to provide a quality service for families. * The evaluation, which used a longitudinal multimethod process analysis based on an action research framework, suggests that children with complex and life-limiting illnesses and their families benefit greatly from an effective seamless service. This paper recommends a framework of care that may be relevant to other teams of children's community services across the country. This service has been judged by the impact it has had on the families who use it and the professionals employed within it.