Follow-up After an Asthma Hospitalization: Discussion

Follow-up After an Asthma Hospitalization: DiscussionForty-seven intervention patients were randomized to follow-up by one pediatric respirologist, and 48 patients continued to receive regular care from their family physician or pediatrician. Intervention subjects had less school absenteeism than control subjects (mean, 10.7 vs 16.0 days, respectively; p = 0.04), but there were no significant differences in the rates of hospitalizations or emergency department visits during the study year. However, fewer days were spent in the hospital by the intervention patients compared to control patients (mean, 3.7 vs 11.2 days, respectively; p = 0.02). Castro et al reported the results of a nurse specialist intervention program in asthmatic patients with a history of frequent health-care use. The intervention group consisted of 50 patients, and 46 patients who continued their usual care with their private primary care physician were assigned to the control group. canadian health care mall

There were 21 hospital readmissions for asthma in the intervention group compared to 42 readmissions for asthma in the control group (p = 0.04). Significant reductions in lost work or school days and health-care costs were also achieved in the intervention group. Finally, two nonrandomized (alternate assignment) controlled intervention studies have shown a reduced number of emergency department visits in patients who had received prior emergency asthma care and had been followed up by allergists compared to patients followed up by generalists. These data suggest that follow-up by asthma specialist physicians or nurses after an asthma hospitalization or emergency department visit can reduce the frequency of subsequent exacerbations as well as improve other asthma outcomes.
The study by Nathan et al in the current issue of CHEST (see page 51) adds to this body of knowledge regarding follow-up after an asthma hospitalization in order to prevent subsequent exacerbations. These authors report the first direct comparison of specialist nurse vs specialist physician follow-up and conclude that outcomes achieved by a visit with a specially trained nurse practitioner are equivalent to those achieved by a respiratory physician. Although we believe that the data support this conclusion, there are some methodological issues that suggest confirmatory studies are necessary. First, < 50% of eligible subjects were enrolled in the study, suggesting the potential for selection bias. Second, by the authors’ admission and calculations, the final study sample achieved was underpowered to demonstrate actual “equivalence” between the two groups in the primary outcome variable. Finally, although randomization should balance measured and unmeasured confounders, in this relatively small study (n = 6670 per group) confounding by age, sex, history of exacerbations, socioeconomic status, smoking, or hospital discharge pulmonary function cannot be excluded.

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