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Biomedical subjects

G Hoskins

Publications and source records attributed to G Hoskins.

15 recordsLinked to original sources
PubMed2002

The RCP's 'Three Key Questions' for asthma: review of practical use.

Assessment tools are a vital component of chronic disease management. The Royal College of Physicians has developed a patient-focused outcome measure for the treatment of asthma, the 'Three Key Questions'. However, in a study investigating the goals of people with asthma, several issues related to the tool emerged. Forty-seven adults of a range of ages and asthma severity but with no significant co-morbidity were interviewed. It emerged that the outcome measure may be subject to recall bias. Also, symptom reports may be conflated if daytime symptoms also occur with activity. 'Interference with activity' is a subjective term the interpretation of which varies considerably. Changes in the level of activity undertaken may be reported rather than changes in symptom severity. The 'Three Key Questions' are not fully patient-centred because they assess the presence of symptoms rather than their importance to the individual. The use of the 'Three Key Questions' as an outcome measure may not allow valid comparisons to be made between settings.

Activities of Daily Living↗
PubMed2001

Asthma care by nurse practitioners in the United States.

PURPOSE: To survey nurse practitioners (NPs) in the United States on their level of input to asthma care prior to enrolling in The National Asthma and Respiratory Training Centre (NARTC) specialist asthma education program in the UK. DATA SOURCES: Responses of 134 (66%) of the 202 NPs who self-selected for enrollment in the NARTC program on a preliminary questionnaire. CONCLUSIONS: Nearly all (133 or 99%) currently work with asthmatics and 122 (91%) prescribe asthma drugs. Only 92 (69%) measure peak flow(PF), 84 (63%) check inhaler technique, 76 (57%) teach use of a home PF meter and diary, and 63 (47%) provide written self-management plans on any regular basis. Many have not established follow-up procedures (56 or 42%), or evaluated their asthma management practices (55 or 41%). IMPLICATIONS FOR PRACTICE: Successful asthma management requires correct medication, systematic follow-up, patient education, and self-management. Specialist asthma training should encourage practitioners to combine effective drug usage with a long-term preventative approach.

Asthma↗
PubMed2001

Cross-sectional observations on the natural history of asthma.

BACKGROUND: Asthma is a major health care problem that affects all ages. It is uncertain whether asthma is a single clinical entity or a grouping of separate clinical syndromes that share a common set of treatment guidelines. AIM: To observe the symptoms, treatment step, and health service utilisation of a population of patients throughout the United Kingdom (UK) listed on an asthma register. DESIGN OF STUDY: A cross-sectional study and clinical assessment of asthma patients. SETTING: A total of 12,203 patients from 393 general practices throughout the UK. METHOD: A database was used to observe the symptoms, treatment step, and health service utilisation of the asthma patients. RESULTS: Children aged up to four years had a distinctive profile of symptoms, including night time cough. They also experienced increased health service utilisation including a high hospital admission rate. Symptoms in adults became more common with increasing age. The pattern of symptoms in patients aged 45 years and over suggest many patients on asthma registers may have chronic obstructive pulmonary disease. Patients aged 16 to 30 years showed a different pattern of health service usage to those aged 5 to 15 years and 31 to 45 years, relying more on unscheduled use of health services rather than a review-based management plan. Patients aged 16 to 30 years used less anti-asthma medication than those aged 5 to 15 years and 31 to 45 years. CONCLUSIONS: Databases may be a useful tool with which to study the natural history of asthma, but there are problems with bias. Several clinical subgroups exist within the broad diagnosis label of asthma. Knowledge of how these subgroups of doctor-diagnosed asthma use health services may help clinicians to create individual care plans for groups of patients.

Adolescent↗
PubMed2000

Risk factors and costs associated with an asthma attack.

BACKGROUND: A study was undertaken to identify asthma patients at risk of an attack and to assess the economic impact of treatment strategies. METHODS: A retrospective cohort analysis of a representative data set of 12 203 patients with asthma in the UK over a one year period was performed. Logistic multiple regression was used to model the probability of an attack occurring using a set of categorised predictor factors. Health service costs were calculated by applying published average unit costs to the patient resource data. The main outcome measures were attack incidence, health service resource use, drug treatment, and cost estimates for most aspects of asthma related health care. RESULTS: Children under five years of age accounted for 597 patients (5%), 3362 (28%) were aged 5-15 years, 4315 (35%) 16-44, 3446 (28%) 45-74, and 483 (4%) were aged over 74 years. A total of 9016 patients (74%) were on some form of prophylactic asthma medication; 2653 (22%) experienced an attack in the year data collection occurred. Overall health care expenditure was estimated at pound2.04 million. The average cost per patient who had an attack was pound381 compared with pound108 for those who did not, an increase of more than 3.5 times. In those aged under five and those over 75 years of age there were no significant markers to identify risk, but both groups were small in size. The level of treatment step in the British Thoracic Society (BTS) asthma guidelines was a statistically significant factor for all other age groups. Night time symptoms were significant in the 5-15, 16-44 and 45-74 age groups, exercise induced symptoms were only significant for the 5-15 age group, and poor inhaler technique in the 16-44 age group. CONCLUSIONS: Patients at any treatment step of the BTS asthma guidelines are at risk of an asthma attack, the risk increasing as the treatment step increases. Poorly controlled asthma may have a considerable impact on health care costs. Appropriate targeting of preventive measures could therefore reduce overall health care costs and the growing pressures on hospital services associated with asthma management.

Adolescent↗
PubMed2000

Scottish Asthma Management Initiative.

OBJECTIVES: To describe the development process of a system that links audit, research and patient care and to detail the lessons learned from establishing a Scotland wide asthma management initiative. DESIGN, SETTING AND SUBJECTS: Health Boards and practices throughout Scotland were invited to participate in an initiative which links review of care, guideline implementation, chronic disease management (CDM) approval and post-graduate education for doctors (PGEA) and nurses (PREP). Participating practices were given the materials to review 30 patients randomly selected from their asthma register. Health service resource use and drugs prescribed over a retrospective 12 month period were recorded for each patient using paper or electronic materials. All patients were invited for clinical assessment. RESULTS: A two-tier management system proved effective. Twelve of the 15 Scottish health authorities agreed to recognise the audit for automatic CDM approval although the negotiation process was prolonged; 566 practices from all parts of Scotland have expressed an interest in the initiative. Provision of distance learning material linked to PGEA accreditation is free to general practitioners (GP's) and is a useful incentive for participation. To date 42 GPs have completed the distance learning element. CONCLUSION: The Scottish Asthma Management Initiative has provided the opportunity for all sectors of the health service in Scotland to work together to explore innovative ways to improve the management and care of chronic disease. Participation in an initiative linked to guidelines, education and CDM approval is an excellent way to facilitate health professionals to improve care.

Asthma↗
PubMed1997

How general practitioners manage acute asthma attacks.

BACKGROUND: The management of asthma attacks by general practitioners in 1992/93 was compared with 1991/92 in relation to recommended guidelines. METHODS: The findings from a postal survey of 299 UK general practitioners who managed 2332 patients with an asthma attack in 1992/93 were compared with those from 218 practitioners who managed 1805 attacks in 1991/92. Management by a subgroup of practitioners from a special interest group was analysed separately. RESULTS: In 1992/93 2031 (87%) of attacks were managed entirely by general practitioners, 251 (11%) were referred for admission to hospital, and 50 (2%) were managed by an accident and emergency department. There was no change in the pattern of management relative to 1991/92. Compared with recommended guidelines there was underuse of systemic steroids and nebulised bronchodilators. Between 1991/92 and 1992/93 use of systemic steroids in acute attacks increased from 56% to 71%, nebulised bronchodilators from 31% to 32%, and an increase in prophylactic medication after an acute attack from 41% to 49%. Contrary to guidelines, antibiotic use increased from 32% to 40% of attacks. Practitioners from a special interest asthma group gave more of their patients systemic steroids and nebulised bronchodilators both in 1991/92 and 1992/93. CONCLUSIONS: Some aspects of the management of asthma attacks by general practitioners has changed in line with guidelines, but there is still a large gap between actual and recommended management.

Acute Disease↗
PubMed1997

Does participation in distance learning and audit improve the care of patients with acute asthma attacks? The General Practitioners in Asthma Group.

OBJECTIVE: To test whether general practitioners who completed an audit cycle encompassing a data recording exercise, distance learning programme and personalized feedback changed their management of patients with acute asthma attacks. DESIGN, SETTING AND SUBJECTS: Practice and patient details from two national correspondence surveys of the management of acute asthma attacks in the United Kingdom in 1991-92 and 1992-93 were compared. Main outcome measures were use of nebulised bronchodilators, systemic steroids during an asthma attack, and increased use of prophylactic therapy after attacks. RESULTS: Ninety-one general practitioners completed an audit cycle and reported data on 782 patients with asthma attacks in 1991-92 and 669 in 1992-93. There were no significant changes in practice resources during this time. Management changed in line with recommended guidelines and audit feedback suggestions leading to more use of nebulised bronchodilators [272 (35%) before, 268 (40%) after, Odds Ratio (OR) 0.80, 95% Confidence Intervals (CI) 0.64-0.99], systemic steroids [563 (72%) before, 506 (76%) after, OR 0.83, CI 0.65-1.06], and 'step-up' in preventative therapy [402 (51%) before, 382 (57%) after, OR 0.79, CI 0.64-0.98]. CONCLUSION: General Practitioners who completed an audit cycle showed changes in the management of acute asthma attacks in line with guidelines which may have been caused by participation in distance learning and clinical audit. However, general practitioners motivated to change clinical management may be similarly motivated to take part in audit. Audit may be the catalyst for change rather than the cause of change.

Acute Disease↗
PubMed1996

Do self-management plans reduce morbidity in patients with asthma?

BACKGROUND: Self-management plans may help patients with asthma intervene when symptoms deteriorate, thus preventing asthma attacks. AIM: A study set out to test whether a self-management plan tailored to the circumstances of the individual reduces morbidity from asthma. METHOD: General practitioners who had participated in a national audit of asthma attacks were randomized into intervention and control groups. Six months after the intervention group had issued self-management plans to patients with asthma, both groups of practitioners completed morbidity questionnaires on patients. Morbidity outcomes were compared for the 6-month periods before and after the issue of the plans. RESULTS: In the 6 months before the study, the 376 patients enrolled by the intervention group experienced higher levels of morbidity than the 530 patients for whom details were recorded by the control group. In the 6 months after the issue of the plans, control group patients showed little change in levels of morbidity, but intervention group patients showed significant reductions in hospital admissions, consultations for asthma symptoms, asthma review consultations, courses of oral steroids and use of emergency nebulized bronchodilators. CONCLUSION: General practitioners appeared to operate enthusiast bias' and issued more self-management plans to patients with uncontrolled asthma. The reduction in morbidity in this group is probably a result of the use of the plans, but the verdict on whether plans reduce morbidity must be deemed 'not proven'.

Asthma↗
PubMed1996

Observations on the structure, process and clinical outcomes of asthma care in general practice.

BACKGROUND: There is a need to establish whether the structure of asthma care in general practice is associated with measures of process and with primary and secondary care clinical outcomes. Debate about how to resource general practice asthma care is hampered by a lack of observational data from throughout the United Kingdom (UK). AIM: To observe whether the present system of family health services authority (FHSA) accreditation of asthma clinics, based on measures of structure, is associated with measures of process or clinical outcome. METHOD: Two hundred and twenty-five UK practitioners enrolled in a project and recorded details of how they organized asthma care. Data from 6732 patients, concerning general practitioner and nurse consultations, asthma attacks, symptom control, emergency treatments and hospital attendances covering a 12-month period, were also provided. RESULTS: FHSA approval for a chronic disease management (CDM) asthma clinic was associated with favourable patterns of structure and process, but not of clinical outcome. Practice audit and the employment of a nurse with an asthma diploma were associated with favourable patterns of structure, process and clinical outcome. Practices (n = 143) that had recently audited asthma patient care (n = 4259) had fewer patients who had attended an accident and emergency department [121 (3%): 96 (4%), odds ratio 1.38, 95% confidence interval 1.04-1.83] or a hospital outpatients department [247 (6%): 180 (7%), 1.28, 1.04-1.56], or who had respiratory symptoms on assessment [2400 (56%): 1465 (59%), 1.34, 1.18-1.52] or days absent from work or school in the past 12 months [375 (9%): 296 (12%), 1.48, 1.25-1.74] than those that had not (82 practices, 2473 patients). CONCLUSION: Findings from a large UK sample of practices are subject to participant bias and show association rather than causal links. The present FHSA asthma CDM accreditation system, based on structure, is not associated with favourable clinical outcomes. This opens the debate as to whether accreditation should be linked to recent experience of audit, which does appear to be associated with favourable clinical outcomes.

Adolescent↗
PubMed1993

National asthma attack audit 1991-2. General Practitioners in Asthma Group.

OBJECTIVE: To describe the frequency and characteristics of asthma attacks in the United Kingdom and to compare actual management with recommended guidelines for the management of attacks. DESIGN: Correspondence survey. SETTING: 218 general practices in the United Kingdom. SUBJECTS: 1775 patients of all ages who had a total of 1805 asthma attacks over three months. MAIN OUTCOME MEASURES: Patient characteristics, place of management of attacks, comparison of actual management with recommended guidelines. RESULTS: Of the 1805 attacks, 300 occurred in boys aged 0-9, 144 in girls aged 0-9, and 118 in women aged 20-29. The estimated frequency of attacks in the community was 14.3 per 1000 patients per year. 1546 (86%) patients with attacks were managed within general practice, 225 (12%) were admitted to hospital, and 34 (2%) were discharged from an accident and emergency department. Two patients died. On initial presentation, 248 (14%) patients were "not breathless," 900 (50%) were "moderately breathless," 535 (30%) were "breathless and distressed," 68 (4%) were "too breathless to talk," and 2 were "moribund." Recording of clinical data was variable. Underuse of nebulised bronchodilators and systemic steroid was apparent in all grades of clinical severity. Contrary to current guidelines for asthma management, "step up" in maintenance therapy after an attack was often not practised. CONCLUSION: Reported management was at variance with recommended guidelines. This has major implications for the design and distribution of future guidelines.

Acute Disease↗
PubMedDate not supplied

Lessons from a randomized controlled trial designed to evaluate computer decision support software to improve the management of asthma.

PRIMARY OBJECTIVE: To investigate whether computer decision support software used in the management of patients with asthma improves clinical outcomes. RESEARCH DESIGN: Randomized controlled trial with practices each reporting on 30 patients with asthma over a 6 month period. METHODS AND PROCEDURES: 447 patients were randomly selected from practice asthma registers managed by 17 general practices from throughout the UK. Intervention practices used the software during consultations with these patients throughout the study while control practices did not. MAIN OUTCOMES AND RESULTS: Practice consultations, acute exacerbations of asthma, hospital contacts, symptoms on assessment and medication use. A smaller proportion of patients within the intervention group initiated practice consultations for their asthma: 34 (22%) vs 111 (34%), odds ratio (OR) = 0.59, 95% confidence interval (CI) (0.37-0.95); and suffered acute asthma exacerbations: 12 (8%) vs 57 (17%), OR = 0.43, 95% CI = 0.21-0.85 six months after the introduction of the computer decision support software. There were no discernable differences in reported symptoms, maintenance prescribing or use of hospital services between the two groups. CONCLUSION: The use of computer decision support software that implements guidelines during patient consultations may improve clinical outcomes for patients with asthma.

Asthma↗