Nurse or physician-led care for patients suffering from asthma ?
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Koen Van den Heede
Asthma is a common chronic condition that affects both children and adults. Symptoms such as breathlessness, coughing, wheezing and chest tightness manifest themselves on an intermittent basis. To get these symptoms properly under control, asthma sufferers require regular, professional follow-up. During these follow-up consultations, aspects such as the prescription of medication, self-management education (e.g. the use of inhalers, recognising and following up symptoms) need to be discussed, a treatment plan drawn up and medical check-ups scheduled. Traditionally, this follow-up care was ensured by physicians (mostly by general practitioners - GPs or paediatricians). Since the 90s however, some Western countries have been deploying specialist nursing staff (e.g. asthma nurses, nurse practitioners) to ease the overwhelming workload on physicians caused by the ever increasing numbers of asthma patients and the growing shortage of physicians.
In February 2013, the Cochrane Collaboration published an overview of randomised clinical studies on nurse versus physician-led care for patients suffering from asthma.1 The review dealt with the following research question:
- Is specialised nurse-led care in asthma equivalent and not inferior to care delivered by a physician?
Only randomised clinical trials with control group were considered for this particular study. In the end, five studies were retained, three of which on adults and two on children. All in all, 588 patients were included, 154 of whom with uncontrolled asthma and 434 with controlled asthma. The primary outcomes were: frequency of exacerbations, severity of the asthma and healthcare costs. Other outcome parameters, such as quality of life, were also examined. The duration of follow-up ranged between 6 months and 2 years.
There was no difference in the number of asthma exacerbations, asthma severity or quality of life between patients being followed up by nurses and patients being followed up by physicians. In terms of healthcare costs, no differences were established either (based on one single study).
Frequency of exacerbations
Exacerbation frequency formed the object of 4 studies (2 on adults and 2 on children). The results were analysed separately as the various studies did not define exacerbations in a uniform manner. Yet, the conclusions of the 4 studies were similar: in terms of the number of exacerbations, no statistically significant difference was found between the intervention and control group (follow-up period between 6 and 24 months).
One study included 154 patients whom had recently suffered an asthma exacerbation. 78 patients, 31 of whom had suffered an exacerbation during their follow-up period, received nurse-led care. 32 of the 76 patients being followed by physicians also suffered an exacerbation. Statistically speaking, there is no difference between these results: odds ratio (OR) 0.86; 95 % credibility interval (CrI) 0.44 to 1.71.
In two studies, which included children with controlled asthma, the incidence of exacerbations was very low. No differencebetween the intervention and control group was found.
A study conducted in primary care did not bring any difference between both groups to light either.
Severity of the asthma
Asthma severity formed the object of one study (n=107) only. Two years on, no difference was found between children with asthma who were being followed up by their general practitioner (p=0.18) or paediatrician (p=0.28) as against children who received nurse-led care.
Total healthcare costs
No difference (p=0.62) was established in overall healthcare costs between patients being followed up by nurses (€ 343) and patients being followed up by physicians (€ 357).
Quality of life
Disease-specific quality of life was reported on in 3 studies that included 380 patients in total. On the basis of these studies, no difference in the quality of life between the intervention and control group could be established.
Conclusion of the Cochrane review
“No significant difference was found between nurse-led care for patients with asthma compared to physician-led care for the outcomes assessed. Based on the relatively small number of studies (n=5) in this review, nurse-led care may be appropriate in patients with well-controlled asthma. More studies in varied settings and among people with varying levels of asthma control are needed with data on adverse events and healthcare costs.”1
1. Kuethe MC, Vaessen-Verberne AA, Elbers RG, Van Aalderen WM. Nurse versus physician-led care for the management of asthma. Cochrane Database Syst Rev. 2013;2:CD009296.