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Nurse versus physician-led care for the management of asthma

  1. Maarten C Kuethe1,*,
  2. Anja A P H Vaessen-Verberne1,
  3. Roy G Elbers2,
  4. Wim MC Van Aalderen3

Editorial Group: Cochrane Airways Group

Published Online: 28 FEB 2013

Assessed as up-to-date: 30 AUG 2012

DOI: 10.1002/14651858.CD009296.pub2


How to Cite

Kuethe MC, Vaessen-Verberne AAPH, Elbers RG, Van Aalderen WMC. Nurse versus physician-led care for the management of asthma. Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD009296. DOI: 10.1002/14651858.CD009296.pub2.

Author Information

  1. 1

    AMPHIA Hospital, Paediatrics, Breda, Netherlands

  2. 2

    Academic Medical Center, Dutch Cochrane Centre, Amsterdam, Netherlands

  3. 3

    Emma Children's Hospital, Academic Medical Center, Department of Paediatric Respiratory Medicine and Allergy, Amsterdam, Netherlands

*Maarten C Kuethe, Paediatrics, AMPHIA Hospital, PO Box 90157, Breda, 4800 RL, Netherlands. kuethe@planet.nl. mkuethe@amphia.nl.

Publication History

  1. Publication Status: New
  2. Published Online: 28 FEB 2013

SEARCH

 

Summary of findings    [Explanations]

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

 
Summary of findings for the main comparison. Nurse-led versus physician-led care for the management of asthma

Nurse-led versus physician-led care for the management of asthma

Patient or population: the management of asthma
Settings: primary care and hospital
Intervention: nurse-led versus physician-led

OutcomesIllustrative comparative risks* (95% CI)Relative effect
(95% CI)
No of participants
(studies)
Quality of the evidence
(GRADE)
Comments

Assumed riskCorresponding risk

ControlNurse led versus Physician led

Frequency of exacerbationsSee commentSee commentNot estimable-See commentDifferent definitions used for exacerbation between studies, meta-analysis not possible

Asthma severity and symptomsSee commentSee commentNot estimable-See commentOnly 1 study reported on asthma severity

Healthcare costs, direct and indirectSee commentSee commentNot estimable-See commentOnly 1 study reported on health care costs

Quality of life at 12 months
Different self-report questionnaires. Scale from: -1 to 1
Follow-up: mean 12 months
See commentThe mean quality of life at 12 months in the intervention groups was
0.03 standard deviations lower
(0.23 lower to 0.17 higher)
SMD -0.03 (-0.23 to 0.17)380
(3 studies)
⊕⊕⊕⊝
moderate1
As studies reported quality of life on different scales, we pooled using SMD. There was no clinically important difference in quality of life between the 2 groups

Hospital admissions
Number of people having 1 or more hospital admission
62 per 100042 per 1000
(2 to 82)
See comment447
(4 studies)
⊕⊕⊕⊝
moderate2
Risks were calculated from pooled risk differences

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; RR: risk ratio; SMD: standardised mean difference.

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

 1 Blinding of participants not possible.
2 Heterogeneity was found in this outcome (I2 = 59%).

 

Background

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

Asthma is the most common chronic disease in childhood, and the high childhood prevalence persists into adulthood (Akinbami 2009; Wenzel 2006), placing a considerable burden on healthcare resources. Thus effective asthma management is important to reduce morbidity and to optimise utilisation of healthcare facilities. This led to the development of (inter)national guidelines for diagnosis and management (GINA 2011; SIGN 2011; de Jongste 2007; Levy 2009). The cornerstone of asthma management is treatment with an inhaled corticosteroid (ICS) (CAMP 2000). Good asthma management is of the utmost importance in achieving control and should include: institution of (inhaled) medication; asthma self-management education including inhaler technique assessment; written asthma plans; self-monitoring of symptoms or airflow, and regular medical review (GINA 2011; Guarnaccia 2007; O'Byrne 2006). Until recently, care was mainly provided by physicians and the role of the asthma nurse supportive in the implementation of these aspects. However, educational interventions, including self-management and self-monitoring by specialised asthma nurses (in nurse-led care) is already widely implemented in many (but not all) general practices and hospitals in high-income countries for more than two decades and have proved to be effective (Gibson 2008 Gibson 2009 Jones 2009; Nathan 2006; Wolf 2008).

The increasing need for asthma management in general and hospital practice emphasises the importance of adequate 'manpower-planning' in primary and secondary care settings (Akinbami 2009). Many general practitioners as well as paediatricians lack sufficient time for such comprehensive care. Several studies suggested that treatment provided in nurse-led care is non-inferior compared to physician-led care (Kamps 2003; Kuethe 2011; Tsai 2005). Furthermore, from a health economic perspective, substitution of workload from physicians to specialised nurses may lead to financial savings. These professionals may be able to work more efficiently than physicians who are often distracted from chronic care tasks by interfering urgent matters.

Taking these factors into account, we formulated the following research question; is nurse-led care in asthma equivalent and not inferior to care delivered by a physician?

 

Why it is important to do this review

Health economics are increasingly important and intelligent use of human resources is an important issue with regards to effective healthcare. Nurse-led outpatient management may be provided at a lower cost than medical care by a physician. For this reason, is it useful to review the literature in order to find support for the assumption that nurse-led care is not inferior. Until now a systematic literature review on this issue has not been performed.

 

Objectives

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

To review the effectiveness of nurse-led asthma care provided by a specialised asthma nurse, a nurse practitioner, a physician assistant or an otherwise specifically trained nursing professional, working relatively independently from a physician, compared to traditional care provided by a physician. Our scope included all outpatient care for asthma, both in primary care and in hospital settings.

 

Methods

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Criteria for considering studies for this review

 

Types of studies

We included randomised controlled trials (RCTs).

 

Types of participants

Adults and children with the clinical diagnosis of asthma, as defined by the authors, reviewed on a regular basis in primary or in hospital care. No restrictions were made for co-morbidities.

 

Types of interventions

 

Intervention

Any aspect of asthma management, on a regular basis in primary or hospital care, led by an allied health professional (i.e. specialised asthma nurse, nurse practitioner, physician assistant or an otherwise specifically trained nursing professional), supervised by a physician (nurse-led care).

 

Control

The same aspect of asthma management provided by a physician.

 

Types of outcome measures

We assessed effects of interventions on three categories of outcomes where available: patient-related, health economic, and objective measures of lung function, airway reactivity and inflammation.

 

Primary outcomes

  • Frequency of exacerbations.
  • Asthma severity and symptoms: measured by validated asthma control questionnaires (e.g. Asthma Control Questionnaire (ACQ) (Juniper 1999; Juniper 2006) or Asthma Control Test (ACT) (Schatz 2006).
  • Healthcare costs; direct and indirect.

 

Secondary outcomes

 
A. Patient-related variables

  • Quality of life: measured by disease specific or generic questionnaires (e.g. Asthma Quality of Life Questionnaire (AQoL) (Juniper 1993).
  • Symptom-free days (as measured in symptom diaries).
  • Patient satisfaction with care.
  • Quality of care, including:
    • patient knowledge of asthma and understanding of disease;
    • use of an action plan;
    • prescription of ICS;
    • verifying of appropriate inhalation technique.
  • Compliance with medication.
  • Use of rescue medication.

 
B. Health-economics

  • Absence from school or work due to asthma.
  • Hospital admissions.
  • Referrals from primary to hospital care.
  • Duration of consultation and consultations with the specialised asthma nurse, nurse practitioner, physician assistant or an otherwise specifically trained nursing professional and the physician.
  • Evidence of stepping down therapy.

 
C. Objective tests: lung function, airway reactivity, airway inflammation

  • Forced expiratory volume in 1 second (FEV1).
  • Peak expiratory flow rate (PEF).
  • Airway hyper-reactivity (including PD/PC20 methacholine/histamine (where PD is the provocative dose and PC20 is the concentration inhaled aerosol of methacholine or histamine leading to a fall in FEV1 of 20%)).

 

Search methods for identification of studies

 

Electronic searches

We identified trials from the Cochrane Airways Group Specialised Register of trials (CAGR), which were derived from systematic searches of bibliographic databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED and PsycINFO, and handsearching of respiratory journals and meeting abstracts (see Appendix 1 for further details). All records in the CAGR coded as 'asthma' were searched using the following terms: nurse* or nursing* or allied*.

Additional searches of MEDLINE, EMBASE, CINAHL, CENTRAL, AMED and prospective trial registers (the World Health Organization (WHO) trial register and other registers listed in the Cochrane Handbook for Systematic Reviews of Interventions (Section 6.2.3.1; Higgins 2011)) using the keywords: nurse or nursing or allied combined with MeSH terms and free-text words for asthma, combined with the sensitive Cochrane RCT filter were conducted. A search of ClinicalTrials.gov was conducted.

We searched all databases from their inception to August 2012 without restriction to language or status of publication.

 

Searching other resources

We checked reference lists of all primary studies included in this systematic review and review articles identified by the search strategy for additional references.   

 

Data collection and analysis

 

Selection of studies

Two review authors (WvA, MCK) independently screened all studies identified by the search strategy on title and abstract for eligibility. Once agreement was obtained on studies to be considered for inclusion, we retrieved full-text articles. Two review authors (WvA, MCK) independently assessed each study for inclusion, based on the pre-defined criteria for study selection. Any disagreement was resolved by discussion.

 

Data extraction and management

A data extraction form was developed and tested before two review authors (WvA, MCK) independently extracted data from the included studies. MCK entered the data in RevMan 2008. In case of missing data, we attempted to contact authors to confirm data for accuracy and completeness. We extracted the following characteristics:

 

Study design

  • Randomisation method.
  • Follow-up procedures and withdrawals.
  • Sample size.
  • Inclusion criteria.
  • Exclusion criteria.

 

Demographic

  • Age.
  • Gender.

 

Clinical

  • Asthma diagnosis.
  • Asthma severity.
  • Other medical diagnosis.

 

Intervention

  • Nurse-led care.

 

Control

  • Physician led care.

 

Outcomes

 

Assessment of risk of bias in included studies

Two review authors (WvA, MCK) independently assessed the risk of bias for each study using the criteria outlined below and judged the risk of bias as high, low or unclear for the criteria listed according to recommendations in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). Since it was not possible to blind nurses, physicians and participating patients in these studies these criteria were all scored as high risk of bias and the potential impact of non-blinding was reflected in the discussion of the results.

The criteria assessed were:

  • adequate sequence generation; 
  • adequate allocation concealment;
  • adequate blinding of assessors;
  • incomplete outcome data adequately assessed;
  • free of suggestion of selective outcome reporting;
  • free of other bias.

 

Measures of treatment effect

We calculated a mean difference (MD) with 95% confidence intervals (CI) for continuous variables measured on identical metrics.

A standardised mean difference (SMD) with 95% CI was used for the same continuous variable measured with different metrics and for dichotomous outcomes, we calculated the risk ratio (RR) and risk difference (RD) with 95% CI.

When incorporating results from cluster randomised studies for continuous and dichotomous variables we extracted direct estimates of effect measures from an analysis that properly accounted for the cluster design and combined results from studies using the generic inverse variance (GIV) method in RevMan 2008.

 

Dealing with missing data

Investigators or study sponsors were contacted in order to verify key study characteristics and obtain missing numerical outcome data where possible.

 

Assessment of heterogeneity

We assessed heterogeneity by comparing clinical characteristics of the included studies such as type of patients, intervention, comparison and outcome measures. We discussed clinical homogeneity in the review team. Based on this discussion we decided whether pooling of results was sensible. We initially investigated statistical heterogeneity by visual inspection of the forest plots. We applied the Chi2 test for homogeneity and calculated the I2 statistic. To increase the power of the test for homogeneity we used a P value less than 0.1 for rejecting the null-hypothesis of homogeneity. Interpretation of statistical heterogeneity was according to the recommendation of Higgins et al. (Higgins 2011), as follows:

  • 0% to 40%: might not be important;
  • 30% to 60%: may represent moderate heterogeneity;
  • 50% to 90%: may represent substantial heterogeneity;
  • 75% to 100%: considerable heterogeneity.

When interpreting the results of the test for heterogeneity and the I2 statistic, we took into account the size of the studies that were included in the meta-analysis. If statistical heterogeneity was observed (Chi2: P value < 0.1 and I2 > 30%), we explored factors, other than the pre-defined subgroups, that can explain heterogeneity such as clinical or methodological characteristics of studies.

 

Assessment of reporting biases

Where we suspected reporting bias, we attempted to contact study authors asking them to provide missing outcome data. Where this was not possible, and the missing data were thought to introduce serious bias, we explored the impact of including such studies in the overall assessment of results using a sensitivity analysis

We planned to explore publication bias using visual inspection of a funnel plot, if 10 or more studies had been incorporated into a meta-analysis.

 

Data synthesis

If studies were sufficiently comparable in relation to subjects, interventions and outcome variables, we combined data in a meta-analysis. For continuous outcome variables we calculated a weighted MD or a weighted SMD with 95% CI using the GIV method. For dichotomous outcomes, we estimated a pooled RR or RD using the Mantel-Haenszel method. We hypothesised that the individual studies that evaluated the effect of asthma management provided by an allied health professional may contain different, but related, real values per study for the effect; therefore we combined the results using a random-effects model.

 

Subgroup analysis and investigation of heterogeneity

We planned to carry out the following subgroup analyses:

  • adults versus children;
  • disease severity (using hospital admissions as a surrogate marker for disease severity);
  • doctor-led clinics versus nurse-led clinics versus nurse/doctor shared clinics;
  • duration of intervention.

 

Sensitivity analysis

We planned sensitivity analyses to test the robustness of the results based on the risk of bias assessment. We excluded studies according to the following categories: high risk of bias for allocation concealment, high risk of bias for assessor blinding or high risk of bias for incomplete follow-up. If a limited number of studies (≤ four) were included in a meta-analysis, the random-effects model was tested for its robustness using a fixed-effect model. Dichotomous outcomes (RD) were tested for robustness using the Peto odds ratio (OR).

 

'Summary of findings' table

The quality of the body of evidence was evaluated according to the GRADE system (Higgins 2011), using GRADE pro software (Grade Working Group 2004) to generate a 'Summary of findings' table. We used the most relevant outcomes (number of exacerbations, asthma severity and symptoms, healthcare costs, quality of life, hospital admissions).

Results of RCTs were considered initially as 'high level' evidence. The level of evidence was decreased (downgraded) based on potential risk of bias of the included studies, indirectness of evidence, unexplained heterogeneity or inconsistency in results, imprecision of results or high probability of publication bias (Higgins 2011). The necessity to apply downgrading was evaluated according to previously published criteria (Grade Working Group 2004; Higgins 2011).

 

Results

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies.

 

Results of the search

The search yielded 360 records; 358 records were found by the search strategy and two studies were identified by handsearching (see Figure 1). Of these records, 154 studies did not address the issue of nurse-led care at all and 181 studies did address the issue of interventions by means of nurse-led care in general but were not related to follow-up. Twenty-five studies were assessed in full text of which five (seven articles) were included.

 FigureFigure 1. Flow diagram.

 

Included studies

The characteristics of included studies are summarised in the Characteristics of included studies table. Five studies (Kamps 2003; Kuethe 2011; Nathan 2006; Pilotto 2004; van Son 2004) were included. The results of two of these studies were each presented in two separate publications (Kamps 2003 and Kuethe 2011).

 

Setting

Two studies were executed in primary care (Pilotto 2004; van Son 2004). One of these studies was performed in two academic primary care centres (van Son 2004). Two studies were executed in general hospitals (Kamps 2003; Nathan 2006) and one study combined primary- and hospital care (Kuethe 2011).

 

Type of patients

Three studies included adult patients (Nathan 2006; Pilotto 2004; van Son 2004). One of these studies (van Son 2004) also included nurse-led care for patients with another chronic condition (diabetes rather than asthma); however, these patients were analysed separately in a subgroup and therefore we were able to exclude the diabetic patients from our analysis. Two studies included children (Kamps 2003; Kuethe 2011).

 

Years of publication and countries of origin

All included studies were published after 2000. Three studies originated from the Netherlands (Kamps 2003; Kuethe 2011; van Son 2004). One study (van Son 2004) was published in Dutch. One study was performed in the UK (Nathan 2006) and one study in Australia (Pilotto 2004).

 

Aspects of intervention

In two studies, the asthma nurse worked strictly according to an algorithm derived from guidelines, whereas the physician in the control group had to work according to same guideline (Kamps 2003; Kuethe 2011). In two studies the intervention group as well as the control group received a similar co-intervention at the beginning of the study (Kamps 2003; Nathan 2006). In the two studies there were co-interventions at the beginning of a follow-up period, without an apparently similar co-intervention in the control group (Pilotto 2004; van Son 2004). 

 

Asthma severity

In four studies (Kamps 2003; Kuethe 2011; Pilotto 2004; van Son 2004) the patients had stable asthma and were treated in an outpatient clinic setting in either primary or secondary care. One study included patients who were recently admitted for an asthma exacerbation. These patients were apparently not well controlled (Nathan 2006).

 

Excluded studies

Eighteen studies were excluded after reading the full text and reasons of exclusion are summarised in the Characteristics of excluded studies table. Of these 18 studies, nine did not cover the subject of the review but concerned "added care" to usual care by means of nurse-led care (Alexander 1988; Castro 2003; Catrambone 2000; Charlton 1994; Grieneder 1999; Griffiths 2004; Hughes 1991; Kernick 2002; Levy 2000). Nine studies did compare nurse led care versus physician led care but were either "pre/post" studies (Cave 2001; Charlton 1991; Dickinson 1997; Jones 1995; Lindberg 2002; Weng 2007), were abstracts presented too concise to extract data (Webb 1997) or had co-interventions distracting from our objective or had no clear diagnosis of asthma (Lenz 2004; Mundinger 2000).

 

Risk of bias in included studies

Most of the included studies were well designed and scored on most items low risk of bias. The results of the risk of bias assessment are summarised in Figure 2 and full details can be found in the Characteristics of included studies tables.

 FigureFigure 2. Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

 

Allocation

One study did not describe the randomisation procedure in detail (van Son 2004) and in one study randomisation per participating centre took place, this procedure was computer generated and statistical analyses were adjusted for clustering (Pilotto 2004). Two studies did not clearly describe allocation concealment (Kamps 2003; van Son 2004). It was unclear whether this resulted in selection bias.

 

Blinding

Blinding of participants was not possible as a consequence of the subject involved. None of the studies clearly reported whether the outcome assessor was blinded for allocation. Regarding the objective character of the outcome measures we did not expect a high risk of bias.

 

Incomplete outcome data

In two studies drop-out was very low and unlikely to lead to attrition bias (Kamps 2003; Kuethe 2011). The reasons for drop-out were described in the text and were not related to the intervention. In two studies there was moderate drop-out or partly incomplete outcomes (Pilotto 2004; van Son 2004). The drop-outs in the intervention group and in the control group were about the same and the reason for drop-out was not described, therefore the risk of attrition bias was scored unclear.

 

Selective reporting

No selective reporting bias was detected, in all studies the pre-defined outcomes were presented.

 

Other potential sources of bias

No major forms of other bias were found.

 

Effects of interventions

See:  Summary of findings for the main comparison Nurse-led versus physician-led care for the management of asthma

 

Primary outcomes: frequency of exacerbations

One study on 154 patients who had recently suffered from an exacerbation were randomised to receive either nurse-led or physician-led care (Nathan 2006). This study reported the number of exacerbations as a primary endpoint. Altogether 98 exacerbations occurred in the nurse-led group and 76 in the physician-led group (rate ratio 1.23; 95% CI 0.91 to 1.66; P = 0.368). Thirty-one patients (45.6%) in the nurse-led group and 32 patients (49.2%) in the physician-led group had one or more exacerbations over the six-month follow-up period. The difference between groups was not statistically significant (OR 0.86; 95% CI 0.44 to 1.71; P = 0.674) (Nathan 2006). The definition for an exacerbation was well described in this study, as a drop in PEF of at least 30% accompanied by increased ICS, emergency nebuliser treatment or a course of oral corticosteroids. In one study in a stable paediatric asthma population (Kuethe 2011), there were no differences between groups regarding the number of exacerbations as expressed by the number of prednisolone courses. In the groups as a whole, few exacerbations occurred (two in general practice group, two in paediatric group and three in nurse-led group). The same applies for the other study in a group of children with stable asthma (Kamps 2003) (median of zero in both groups; P = 0.37); however, no definition of an exacerbation was given. A study in a primary care population (van Son 2004) used exacerbations as the outcome parameter, though they were not well defined in the text. The difference between the intervention and the control groups was also not statistically significant (P = 0.68). It was not possible to pool the data for exacerbations for two reasons. First, in two studies (Kamps 2003; van Son 2004) exacerbations were not defined, and the definitions of exacerbation used in the other two studies (Kuethe 2011; Nathan 2006) were not the same. Second, the raw data (standard deviations (SD)) of these studies could not be retrieved after contacting the authors.

 

Primary outcomes: asthma severity and symptoms

One study investigated asthma control (Kuethe 2011) making use of the ACQ (Juniper 1999; Juniper 2006). This paediatric study had three arms; general practitioner-led care, paediatrician-led care and asthma nurse-led care. The median ACQ scores after two years in both the general practitioner-led group and the paediatrician-led group did not significantly differ from the nurse-led group (P = 0.18 and 0.28, respectively), demonstrating non-inferiority for the asthma control in the nurse-led group (Kuethe 2011).

 

Primary outcomes: healthcare costs, direct and indirect

One trial addressed the issue of healthcare costs in nurse- versus physician-led care (Kamps 2003). The costs of outpatient visits was statistically significant lower in the nurse-led group (outpatient visits costs per patient per year; €156 in the nurse-led group versus €189 in the physician-led group; P < 0.001). This difference led to a lower total costs in the healthcare sector, though not statistically significantly (total health costs €343 in nurse led group versus €357 in physician-led group; P = 0.62).

 

Secondary outcomes: patient-related variables

 

Quality of life

Three studies had various forms of quality of life scores as outcome parameter. One study (Kamps 2003) used the Dutch version of the Paediatric Asthma Quality of Life Questionnaire (PAQoL) (Juniper 1993; Juniper 1996a; Juniper 1996b). Two studies (Nathan 2006; Pilotto 2004) used the St George's Respiratory Questionnaire (SGRQ; Barley 1998; Jones 1991). In these studies, quality of life improved from baseline over time, but in none of these studies there was a statistically significant difference between the nurse-led groups and the physician-led groups. After meta-analysis no effect was found (SMD -0.03; 95% CI -0.23 to 0.17; Figure 3). Sensitivity analysis using a fixed-effect model yielded the same results (SMD -0.03; 95% CI -0.23 to 0.17). Kamps 2003 also used two other instruments relating to quality of life; the 'Functional health status FS II score' and the 'RAND general health rating index' (Post 1998a; Post 1998b; Stein 1990). The MD in FSII score between the two treatment groups at the end of the study was 10.1 (95% CI -0.3 to 19.8). The MD in RAND score between both groups at the end of the study was 0.1 (95% CI 22.8 to 2.7).

 FigureFigure 3. Forest plot of comparison: 1 Nurse-led versus physician-led, outcome: 1.1 Quality of life at 12 months.

 

Symptom-free days

One study had symptom-free days as the primary outcome parameter (defined as symptom score and use of rescue medication in a diary for the two weeks preceding a follow-up visit) (Kamps 2003). The mean percentage of symptom-free days throughout the study was comparable between the two treatment groups (70.5% in the paediatrician-led group and 68% in the nurse-led group; P = 0.54).

 

Patient satisfaction with care

One study (van Son 2004) presented data relating to "patient satisfaction with care". However, this study made use of a Dutch scoring system (van Weel 1990) that is derived from an instrument constructed by the "Dartmouth Primary Care Cooperative Project" and is mainly meant to score "ability to perform daily life activities" instead of "patient satisfaction with care" (Nelson 1990).

 

Quality of care

One study briefly addressed the issue of knowledge of asthma and understanding of disease, but the way of scoring was only vaguely described and seemed to favour nurse-led care (van Son 2004). Two studies in children described explicitly the use of ICS and the prescribed dose (Kamps 2003; Kuethe 2011). In none of these studies did the prescribed dose differ significantly between the nurse-led group and the physician-led group at the end of the study period. The use of an "action plan" and "checking of appropriate inhalation technique" was not presented as an outcome measure in any of the studies.

Kuethe 2011 assessed quality of care and patient satisfaction in a paediatric population with asthma using a revised version of the QUality Of care Through the patient's Eyes-Chronic Non Specific Lung Disease (QUOTE-CNSLD) questionnaire (van Campen 1997), containing a process-, structure- and asthma-specific domain plus a simple five-item child-specific scale; in three arms; general practitioner-led care, paediatrician-led care and nurse-led care. After one year for process and structure quality no statistical differences were found between groups. For asthma-specific and child-specific quality the ratings for the paediatrician-led care and nurse-led were higher than for the general practitioner-led care (P < 0.05).

 

Compliance with medication

None of the included studies presented data about compliance as an outcome measure.

 

Use of rescue medication

One study in paediatric patients with stable asthma presented the percentage of "rescue medication free days" (Kamps 2003) without a statistically significant difference at the end of the study period (75.8% in nurse-led group versus 76.8% in physician-led group; P = 0.40).

One study in patients with asthma that was not stable, all older than 16 years, totaled the number of "emergency room nebulization's" and the number of "hospital admissions" in both groups without a statistically significant difference between groups (Nathan 2006). Mean number of exacerbations requiring emergency treatment was 0.59 in nurse-led group versus 0.43 in the physician-led group.

 

Secondary outcomes: health economics

 

Absence from school/work due to asthma

Three studies presented data about absence from school or work due to asthma. One study (Kamps 2003) reported a median of zero days school absence in both groups at the end of the study period (median 0 (range 0 to 23) in the nurse-led group, median 0 (range 0 to 21) in the paediatrician-led group (P = 0.80). Another study (Kuethe 2011) also reported no significant difference in school absence between groups. In an adult population. Pilotto and colleagues (Pilotto 2004) reported that 20.6% of patients in the physician-led group had more than one day of absence from work opposed to no patients in the nurse-led group (P = 0.04).

 

Hospital admissions

Four studies presented data about hospital (re)admissions (Kamps 2003; Kuethe 2011; Nathan 2006; Pilotto 2004). The pooled data showed substantial heterogeneity (RD -0.02; 95% CI -0.06 to 0.02; I2= 59%) as shown in Figure 4. Therefore data are also presented in a subgroup analysis. We performed a subgroup analysis by excluding the study with patients who were discharged from hospital after experiencing an exacerbation (Nathan 2006) from the meta-analysis, including only patients with stable asthma: the summary was again not statistically significant, but the heterogeneity disappeared (RD -0.01; 95% CI -0.04 to 0.02; see Figure 5). Sensitivity analyses using a fixed-effect model and the Peto OR yielded comparable results for the patients with stable asthma (RD -0.01; 95% CI -0.04 to 0.02; Peto OR 0.15; 95% CI 0.01 to 2.42).

 FigureFigure 4. Forest plot of comparison: 1 Nurse-led versus physician-led, outcome: 1.2 Hospital admission.
 FigureFigure 5. Forest plot of comparison: 1 Nurse-led versus physician-led, outcome: 1.4 Hospital admission subgroup analysis.

 

Referrals from primary to hospital care

No data presented in any of the included studies.

 

Duration of consultation and consultations with the asthma nurse and the physician

Kamps and colleagues (Kamps 2003) reported the duration of consultation in the nurse-led group. The mean (SD) duration of the first nurse-led follow-up visit was 29.0 (5.2) minutes. The second and third follow-up visits lasted 19.4 (7.2) and 18.3 (6.3) minutes, respectively. Subsequent nurse-led follow-up visits lasted approximately 15 minutes. No data about duration of consultation were presented for the paediatrician-led group.

One study (Kuethe 2011) reported the extra workload for the physician caused by consultation with the paediatrician by the asthma nurse. In 58% of children the professional providing nurse-led care was confident to provide asthma management without support from the paediatrician. In 34% of the children one or two short oral communications with a paediatrician took place to assist the nurse with management. Eight per cent of the children had problems that required more frequent input from the paediatrician.

 

Evidence of stepping down therapy

One study (Kamps 2003) presented data about stepping down of ICS. At the end of the study period there were no statistically significant differences. (See also prescription of inhaled corticosteroids under subheading "quality of care").

 

Objective tests: lung function, airway reactivity, airway inflammation

 

Forced expiratory volume in 1 second (FEV1)

FEV1 was an outcome parameter in three studies (Kamps 2003; Kuethe 2011; Pilotto 2004). None of the studies found a statistically significant difference between the nurse-led group and the physician-led group. The pooled data are presented in Figure 6. No clear difference was found (MD -0.54% predicted; 95% CI -4.20 to 3.12). Sensitivity analysis using a fixed-effect model showed the same results (MD -0.54% predicted; 95% CI -4.20 to 3.12).

 FigureFigure 6. Forest plot of comparison: 1 Nurse-led versus physician-led, outcome: 1.3 FEV1 % predicted.

 

Peak expiratory flow rate (PEF)

Two studies presented change in peak flow over the course of the study. Nathan and colleagues (Nathan 2006) compared the maximal PEF measurement at first hospital visit with the six-month follow-up measurement. In this study there was a decrease of PEF over time. Mean drop was 2.53% (SD 11.5) in the physician-led group and 3.92% (SD 12.4) in the nurse-led group. No significant difference in change in PEF between the two groups (P = 0.122) was observed. One study (van Son 2004) presented the change in PEF over the study period of one year. In this study there was an increase over time (5.3% in the nurse-led group and 3.94% in the physician-led group), but no statistical significant between group differences were found (P = 0.66).

 

Airway hyper-reactivity (including PD/PC20 methacholine/histamine)

One study (Kuethe 2011) presented airway hyper-reactivity as a primary outcome, no statistically significant differences were found between the nurse-led group and the physician-led groups (general practitioner or paediatrician). Another study (Kamps 2003) presented airway hyper-reactivity as log10PD20, which was at the end of the one-year study period (2.4 in nurse-led group and 2.5 in paediatrician-led group; P = 0.63).

 

Discussion

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Summary of main results

The objective was to review the effectiveness of asthma care provided by a specialised asthma nurse, nurse practitioner, physician assistant or an otherwise specifically trained nursing professional, working relatively independently from a physician, compared to traditional care provided by a physician. We found no statistically significant difference between nurse-led care for patients with asthma compared to physician-led care based on the included studies for the outcomes assessed. A small number of parameters favoured nurse-led care over physician-led care, including savings on healthcare costs. Based on the relatively small number of studies in this review, nurse-led care may be appropriate in patients with well-controlled asthma. We included only one study with uncontrolled patients (Nathan 2006). Therefore we cannot be sure whether nurse-led care might be appropriate in patients with uncontrolled asthma.

 

Overall completeness and applicability of evidence

We did not limit the study search for any language, nevertheless a remarkable proportion of the studies originated from the Netherlands. A probable explanation are the different healthcare settings in different countries. This may limit the extent to which these results may be generalised to countries with different organisation of health care.

This systematic review has some limitations. First, although we had strict selection criteria for inclusion or exclusion (same co-interventions in both groups, active follow-up the same in both groups) it was difficult to apply these criteria on some of the studies. Second, we were not able to perform a funnel plot because of the limited studies included in the review. This makes it difficult to judge whether our findings are biased by publication status. Third, initially we did not include the frequency of consultations with the asthma nurse and the physician in the nurse-led group as an outcome . However, this is an important factor in determining workload for both nurses and physicians. Therefore we decided, post hoc, to add it as an outcome parameter. Fourth, we did not pre-define factors about safety. None of the included studies reported data on adverse events. One study (Kuethe 2011) addressed this issue and proposed a number of prerequisites to be fulfilled: nurse-led care requires working strictly according to guidelines, there should be a low threshold for consulting with a physician when a patient deteriorates or shows unexpected symptoms, and supervision or revision by a physician should always take place when there is uncertainty about the child's management. Finally, a report by Kuethe 2011 presented clear data about quality of care in the three different settings.

 

Quality of the evidence

The quality of the body of evidence was evaluated according to the GRADE system. For the pooled outcomes moderate level of evidence was found for health-related quality of life and hospital admission. See  Summary of findings for the main comparison.

 

Agreements and disagreements with other studies or reviews

One Cochrane systematic review (Laurant 2005) investigated the efficacy of nurse-led care in primary practice in people with all types of health problems presenting to primary care (excluding accident and emergency departments). They concluded that appropriately trained nurses can produce as high-quality care as primary care doctors. However, their conclusion should be viewed with caution because of different methodological limitations and small sample size of underlying RCTs. One systematic review about the effectiveness of innovations in nurse-led chronic disease management for patients with chronic obstructive pulmonary disease (COPD; Taylor 2005) found little evidence to support the widespread implementation of nurse-led management interventions for COPD, but the data were too sparse to exclude any clinically relevant benefit or harm arising from such interventions. Another review about specialist nurses in diabetes mellitus care (Loveman 2003) concluded in a similar way that the presence of a diabetes specialist nurse/nurse case manager may improve patients' diabetic control over short time periods, but from currently available trials the effects over longer periods of time are not evident. These reviews focused on clinical outcome parameters and did not specifically address the issue of workload reduction for physicians neither the issue of non-inferiority or equivalence of care. In the study concerning healthcare costs (Kamps 2003), the reduction of costs of care in the nurse-led group was surprisingly limited compared to physician-led care. An RCT about healthcare costs of nurse-led care in a bronchiectasis clinic reported that nurse-led care for stable patients within a chronic chest clinic may use more resources (Sharples 2002). In that study, unit cost of the nurse practitioner was under half of that of the consultant. However, patients receiving nurse practitioner led care had more clinic visits per year and, on average, nurse-led clinic visits lasted longer. Combining these factors, almost negated the lower unit cost of the nurse practitioner use indicators.

 

Authors' conclusions

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

 

Implications for practice

No significant difference was found between nurse-led care for patients with asthma compared to physician-led care for outcomes assessed. Based on the relatively small number of studies in this review, nurse-led care may be appropriate in patients with well-controlled asthma. Since only one study with uncontrolled patients was included we cannot be sure whether nurse-led care is appropriate in uncontrolled asthma.

 
Implications for research

The conclusion of this review is based on a small number of studies. Adverse events should be more precisely addressed in future research. Furthermore research on quality of care in different healthcare settings and in different stadia of asthma control is required. Researchers in the future should incorporate outcome parameters fulfilling the following criteria; 1) well-defined and using validated methods where possible; 2) reported in a manner appropriate for meta-analysis; 3) easy to obtain and 4) relevant for carers of, or people with, asthma and people making decisions around healthcare provision. The primary outcome parameters we choose for this review (frequency of exacerbations, asthma severity and symptoms: measured by validated asthma control questionnaires and healthcare costs; direct and indirect) meet these criteria. Exacerbations, and certainly hospital admissions due to exacerbations, are well definable. For asthma severity, there are a number of very well-validated instruments (Juniper 1999; Juniper 2006; Schatz 2006) which can be easily completed by patients. Financing health care is becoming more and more an issue and therefore the importance costs cannot be overstated. From the societal point of view, the indirect costs in term of loss of labour or loss of school education are as relevant as the direct costs. Although speculative rather than based on the evidence presented in this review, extending nurse-led care seems likely to lead to cost reduction. The issue of costs is even more important in countries where the doctors are scarce and where it may be practically or financially prohibitive to access a physician. Therefore research in this field should be specifically encouraged in developing countries.

 

Acknowledgements

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

Elizabeth Stovold; Trial Search Coordinator, Cochrane Airways Group.

Dr Emma Welsh; Managing Editor, Cochrane Airways Group.

 

Data and analyses

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
Download statistical data

 
Comparison 1. Nurse-led versus physician-led care for the management of asthma

Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size

 1 Quality of life at 12 months3380Std. Mean Difference (IV, Random, 95% CI)-0.03 [-0.23, 0.17]

 2 Hospital admission4447Risk Difference (M-H, Random, 95% CI)-0.02 [-0.06, 0.02]

 3 FEV1 % predicted3297Mean Difference (IV, Random, 95% CI)-0.54 [-4.20, 3.12]

 4 Hospital admission subgroup analysis4447Risk Difference (M-H, Random, 95% CI)-0.02 [-0.06, 0.02]

    4.1 Patients with stable asthma
3314Risk Difference (M-H, Random, 95% CI)-0.01 [-0.04, 0.02]

    4.2 Patients after exacerbation
1133Risk Difference (M-H, Random, 95% CI)-0.11 [-0.22, 0.00]

 

Appendices

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Appendix 1. Sources and search methods for the Cochrane Airways Group Specialised Register (CAGR)

 

Electronic searches: core databases


DatabaseFrequency of search

CENTRAL (The Cochrane Library)Monthly

MEDLINE (Ovid)Weekly

EMBASE (Ovid)Weekly

PsycINFO (Ovid)Monthly

CINAHL (EBSCO)Monthly

AMED (EBSCO)Monthly



 

 

Handsearches: core respiratory conference abstracts


ConferenceYears searched

American Academy of Allergy, Asthma and Immunology (AAAAI)2001 onwards

American Thoracic Society (ATS)2001 onwards

Asia Pacific Society of Respirology (APSR)2004 onwards

British Thoracic Society Winter Meeting (BTS)2000 onwards

Chest Meeting2003 onwards

European Respiratory Society (ERS)1992, 1994, 2000 onwards

International Primary Care Respiratory Group Congress (IPCRG)2002 onwards

Thoracic Society of Australia and New Zealand (TSANZ)1999 onwards



 

 

MEDLINE search strategy used to identify trials for the CAGR

 

Asthma search

1. exp Asthma/

2. asthma$.mp.

3. (antiasthma$ or anti-asthma$).mp.

4. Respiratory Sounds/

5. wheez$.mp.

6. Bronchial Spasm/

7. bronchospas$.mp.

8. (bronch$ adj3 spasm$).mp.

9. bronchoconstrict$.mp.

10. exp Bronchoconstriction/

11. (bronch$ adj3 constrict$).mp.

12. Bronchial Hyperreactivity/

13. Respiratory Hypersensitivity/

14. ((bronchial$ or respiratory or airway$ or lung$) adj3 (hypersensitiv$ or hyperreactiv$ or allerg$ or insufficiency)).mp.

15. ((dust or mite$) adj3 (allerg$ or hypersensitiv$)).mp.

16. or/1-15

 

Filter to identify RCTs

1. exp "clinical trial [publication type]"/

2. (randomised or randomised).ab,ti.

3. placebo.ab,ti.

4. dt.fs.

5. randomly.ab,ti.

6. trial.ab,ti.

7. groups.ab,ti.

8. or/1-7

9. Animals/

10. Humans/

11. 9 not (9 and 10)

12. 8 not 11

The MEDLINE strategy and RCT filter are adapted to identify trials in other electronic databases

 

Contributions of authors

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

  • Designing of draft (RE, MCK).
  • Conceptualisation (MCK, WvA, AVV, RE).
  • Writing Draft (MCK).
  • Reviewing draft (RE, AVV, WvA).
  • Reviewing (WvA, MCK).
  • Third assessor (AVV).

 

Declarations of interest

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

  • None known.

 

Sources of support

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Internal sources

  • New Source of support, Not specified.

 

External sources

  • No sources of support supplied

 

Differences between protocol and review

  1. Top of page
  2. Summary of findings    [Explanations]
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

The search has been amended.

* Indicates the major publication for the study

References

References to studies included in this review

  1. Top of page
  2. AbstractRésumé scientifique
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. Additional references
  21. References to other published versions of this review
Kamps 2003 {published data only}
  • Kamps AW, Brand PL, Kimpen JL, Maille AR, Overgoor-van de Groes AW, van Helsdingen-Peek LC, et al. Outpatient management of childhood asthma by paediatrician or asthma nurse: randomised controlled study with one year follow up. Thorax 2003;58(11):968-73.
  • Kamps AW, Roorda RJ, Kimpen JL, Overgoor-van de Groes AW, van Helsdingen LC, Brand PLP. Impact of nurse-led outpatient management of children with asthma on healthcare resource utilisation and costs. European Respiratory Journal 2004;23(2):304-9.
Kuethe 2011 {published data only}
  • Kuethe M, Vaessen-Verberne A, Mulder P, Bindels P, van Aalderen W. Paediatric asthma outpatient care by asthma nurse, paediatrician or general practitioner: randomised controlled trial with two-year follow-up. Primary Care Respiratory Journal 2011;20(1):84-91.
  • Kuethe MC, Sixma HJ, Vaessen-Verberne AAPH, Booij JC, van Aalderen, WMC. Assessing quality of care in pediatric asthma: applicability of a revised version of the QUOTE-CNSLD Questionnaire. Journal of Asthma 2012;Early Online:1-11.
Nathan 2006 {published data only}
  • Laroche C, Pearce L, Sipmson T, Hawkes J, Webb M, Sharples L. A randomised trial of the effectiveness of early follow-up by a respiratory consultant or a respiratory specialist nurse on asthma readmission. European Respiratory Journal 2000;16 Suppl 31:7s-8s.
  • Nathan JA, Pearce L, Field C, Dotesio-Eyres N, Sharples LD, Cafferty F, et al. A randomized controlled trial of follow-up of patients discharged from the hospital following acute asthma: best performed by specialist nurse or doctor?. Chest 2006;130(1):51-7.
Pilotto 2004 {published data only}
van Son 2004 {published data only}
  • van Son L, Vrijhoef H, Crebolder H, Van Hoef L, Beusmans G. Support for the general practitioner. An exploration of the effect of the practice nurse on the care of asthma, COPD and diabetes patients [De huisarts ondersteund. een RCT naar het effect van een praktijkondersteuner bij astma, copd en diabetes]. Huisarts en Wetenschap 2004;47(1):15-21.

References to studies excluded from this review

  1. Top of page
  2. AbstractRésumé scientifique
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. Additional references
  21. References to other published versions of this review
Alexander 1988 {published data only}
  • Alexander JS, Younger RE, Cohen RM, Crawford LV. Effectiveness of a nurse-managed program for children with chronic asthma. Journal of Pediatric Nursing 1988;3(5):312-17.
Castro 2003 {published data only}
  • Castro M, Zimmermann NA, Crocker S, Bradley J, Leven C, Schechtman KB. Asthma intervention program prevents readmissions in high healthcare users. American Journal of Respiratory and Critical Care Medicine 2003;168(9):1095-99.
Catrambone 2000 {published data only}
  • Catrambone CD. Effect of a case management intervention on symptoms of asthma in high risk children [Dissertation]. Rush University, College of Nursing, 2000.
Cave 2001 {published data only}
  • Cave AJ, Wright A, Dorrett J, McErlain M. Evaluation of a nurse-run asthma clinic in general practice. Primary Care Respiratory Journal 2001;10(3):65-8.
Charlton 1991 {published data only}
  • Charlton I, Charlton G, Broomfield J, Mullee MA. Audit of the effect of a nurse run asthma clinic on workload and patient morbidity in a general practice. British Journal of General Practice 1991;41(347):227-31.
Charlton 1994 {published data only}
  • Charlton I, Antoniou AG, Atkinson J, Campbell MJ, Chapman E, Mackintosh T, et al. Asthma at the interface: bridging the gap between general practice and a district general hospital. Archives of Diseases in Childhood 1994;70(4):313-18.
Dickinson 1997 {published data only}
  • Dickinson J, Hutton S, Atkin A, Jones K. Reducing asthma morbidity in the community: the effect of a targeted nurse-run asthma clinic in an English general practice. Respiratory Medicine 1997;91(10):634-40.
Grieneder 1999 {published data only}
Griffiths 2004 {published data only}
  • Griffiths C, Foster G, Barnes N, Eldridge S, Tate H, Begum S, et al. Specialist nurse intervention to reduce unscheduled asthma care in a deprived multiethnic area: the east London randomised controlled trial for high risk asthma (ELECTRA). BMJ 2004;328(7432):144.
Hughes 1991 {published data only}
Jones 1995 {published data only}
  • Jones KP, Mullee MA. Proactive, nurse-run asthma care in general practice reduces asthma morbidity: scientific fact or medical assumption?. British Journal of General Practice 1995;45(389):497-99.
Kernick 2002 {published data only}
  • Kernick D, Powell R, Reinhold D. A pragmatic randomised controlled trial of an asthma nurse in general practice. Primary Care Respiratory Journal 2002;11(1):6-8.
Lenz 2004 {published data only}
  • Lenz ER, Mundinger MO, Kane RL, Hopkins SC, Lin SX. Primary care outcomes in patients treated by nurse practitioners or physicians: two-year follow-up. Medical Care Research and Review 2004;61(3):331-51.
Levy 2000 {published data only}
  • Levy ML, Robb M, Allen J, Doherty C, Bland JM, Winter RJ. A randomized controlled evaluation of specialist nurse education following accident and emergency department attendance for acute asthma. Respiratory Medicine 2000;94(9):900-8.
Lindberg 2002 {published data only}
Mundinger 2000 {published data only}
  • Mundinger MO, Kane RL, Lenz ER, Totten AM, Tsai WY, Cleary PD, et al. Primary care outcomes in patients treated by nurse practitioners or physicians. JAMA 2000;238(1):59-68.
Webb 1997 {published data only}
  • Webb JR, Brooks S, Goddard J, Meighan-Davies J, Hooper F, Oldind A. Asthma Nurse Specialist (ANS) Intervention in the Management of Asthma: the Asthma Resource project (ARC) in Greenwich. Thorax 1997;52(Suppl 6):A46.
Weng 2007 {published data only}

Additional references

  1. Top of page
  2. AbstractRésumé scientifique
  3. Summary of findings
  4. Background
  5. Objectives
  6. Methods
  7. Results
  8. Discussion
  9. Authors' conclusions
  10. Acknowledgements
  11. Data and analyses
  12. Appendices
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Characteristics of studies
  18. References to studies included in this review
  19. References to studies excluded from this review
  20. Additional references
  21. References to other published versions of this review
Akinbami 2009
Barley 1998
CAMP 2000
  • The Childhood Asthma Management Program Research Group. Long-term effect of budesonide or nedocromil in children with asthma. New England Journal of Medicine 2000;343(15):1054-63.
de Jongste 2007
  • de Jongste JC, Vrijlandt EL. Pediatric Asthma; Revised Guidelines of the Pediatric Pulmonology Group of the Dutch Society of Pediatricians. Amsterdam: Jurriaans Lindenbaum Grafimedia, 2007. [ISBN/EAN: 978-90-9023508-0]
Gibson 2008
  • Gibson PG, Powell H, Wilson A, Hensley MJ, Abramson MJ, Bauman A, et al. Limited (information only) patient education programs for adults with asthma. Cochrane Database of Systematic Reviews 2002, Issue 1. [DOI: 10.1002/14651858.CD001005]
Gibson 2009
  • Gibson PG, Powell H, Wilson A, Abramson MJ, Haywood P, Bauman A, et al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database of Systematic Reviews 2002, Issue 3. [DOI: 10.1002/14651858.CD001117]
GINA 2011
  • Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention (updated 2011): Global Initiative for asthma (GINA), 2011. www.ginasthma.org. (accessed 13 December 2012).
Grade Working Group 2004
Guarnaccia 2007
  • Guarnaccia S, Lombardi A, Gaffurini A, Chiarini M, Domenighini S, D'Agata E, et al. Application and implementation of the GINA asthma guidelines by specialist and primary care physicians: a longitudinal follow-up study on 264 children. Primary Care Respiratory Journal 2007;16(6):357-62.
Higgins 2011
  • Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane-handbook.org.
Jones 1991
Jones 2009
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Juniper 1993
Juniper 1996a
Juniper 1996b
Juniper 1999
Juniper 2006
Laurant 2005
Levy 2009
  • Levy ML, Thomas M, Small I, Pearce L, Pinnock H, Stephenson P. Summary of the 2008 BTS/SIGN British Guideline on the management of asthma. Primary Care Respiratory Journal 2009;18(Suppl 1):S1-16.
Loveman 2003
Nelson 1990
  • Nelson EC, Landgraf JM, Hays RD, Wasson JH, Kirk JW. The functional status of patient. How can it be measured in physicians' offices. Medical Care 1990;12:1111-26.
O'Byrne 2006
  • O'Byrne PM. Asthma Management Guidelines: the issue of implementation. Primary Care Respiratory Journal 2006;15(1):5-6.
Post 1998a
  • Post MWM, Kuyvenhoven MM, Verheij ThJM, de Melker RA, Hoes AW. The Dutch version of 'Functional Status II(R)': a questionnaire measuring the functional health status of children [De Nederlandse "Functional status II(R); een vragenlijst voor het meten van de functionele gezondheidstoestand van kinderen]. Ned Tijdschr Geneeskunde 1998;5(142):2675-9.
Post 1998b
  • Post MWM, Kuyvenhoven MM, Verheij ThJM, de Melker RA, Hoes AW. The Dutch 'Rand General Health Rating Index for Children': a questionnaire measuring the general health status of children. [De Nederlandse "RAND general health rating index for children"; een meetinstrument voor de algemene gezondheid van kinderen.]. Ned Tijdschr Geneeskunde 1998;5(142):2680-3.
RevMan 2008
  • The Nordic Cochrane Centre, The Cochrane Collaboration. Review Manager (RevMan). 5.0. Copenhagen: The Nordic Cochrane Centre, The Cochrane Collaboration, 2008.
Schatz 2006
  • Schatz M, Sorkness CA, Li JT, Marcus P, Murray JJ, Nathan RA, et al. Asthma Control Test: reliability, validity and responsiveness in patients not previously followed by asthma specialists. Journal of Allergy & Clinical Immunology 2006;117(3):549-56.
Sharples 2002
  • Sharples LD, Edmunds J, Bilton D, Hollingworth W, Caine N, Keogan M, et al. A randomised controlled crossover trial of nurse practitioner versus doctor led outpatient care in a bronchiectasis clinic. Thorax 2002;57:661-66.
SIGN 2011
  • Scottish Intercollegiate Guidelines Network (SIGN). British Guideline on the Management of Asthma, 2011. www.sign.ac.uk/guidelines/fulltext/101/index.html. (accessed 13 December 2012).
Stein 1990
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