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

Asthma is a very common chronic condition and symptoms are breathlessness, coughing, wheezing and chest tightness. Symptoms may be persistent or intermittent. In order for asthma to be managed well, and symptoms controlled, regular visits to a healthcare professional are needed. During these visits, a number of aspects should be addressed (prescribing of medication, asthma self-management education including inhaler technique assessment, written asthma treatment plans, self-monitoring of symptoms and regular medical review). Consultations such as these, although important, are time-consuming, placing a burden on healthcare resources and the workload of the doctors treating these patients. Since the 1990s, nurse-led care has been introduced to treat people with asthma. We investigated if nurse-led care is as effective as that delivered by a physician.

We reviewed the medical literature to find randomised controlled trials on care delivered by specialised nurse compared to care by a doctor in the management of asthma. We found five studies on 588 adults and children. The studies were of good methodological quality. The number of asthma exacerbations (flare-ups) and the level of asthma severity did not differ at the end of the study period between the intervention and the control group. Only one study reported information about the costs associated with both kinds of care and there was no significant difference between them. There was also no difference in quality of life. We found no difference between nurse-led care and physician-led care. Based on the relatively small number of studies 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.

Authors' conclusions: 

We found no significant difference 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 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 health-care costs.

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Background: 

Asthma is the most common chronic disease in childhood and prevalence is also high in adulthood, thereby placing a considerable burden on healthcare resources. Therefore, effective asthma management is important to reduce morbidity and to optimise utilisation of healthcare facilities.

Objectives: 

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.

Search strategy: 

We carried out a comprehensive search of databases including The Cochrane Library, MEDLINE and EMBASE to identify trials up to August 2012. Bibliographies of relevant papers were searched, and handsearching of relevant publications was undertaken to identify additional trials.

Selection criteria: 

Randomised controlled trials comparing nurse-led care versus physician-led care in asthma for the same aspect of asthma care.

Data collection and analysis: 

We used standard methodological procedures expected by The Cochrane Collaboration.

Main results: 

Five studies on 588 adults and children were included concerning nurse-led care versus physician-led care. One study included 154 patients with uncontrolled asthma, while the other four studies including 434 patients with controlled or partly controlled asthma. The studies were of good methodological quality (although it is not possible to blind people giving or receiving the intervention to which group they are in). There was no statistically significant difference in the number of asthma exacerbations and asthma severity after treatment (duration of follow-up from six months to two years). Only one study had healthcare costs as an outcome parameter, no statistical differences were found. Although not a primary outcome, quality of life is a patient-important outcome and in the three trials on 380 subjects that reported on this outcome, there was no statistically significant difference (standardised mean difference (SMD) -0.03; 95% confidence interval (CI) -0.23 to 0.17).

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