Definitions of severity and outcome measures

AbstractOutcome measurement is still a difficult area in general, and in asthma in particular, with further research needed. (Attributable) outcomes of health care are the only sort of outcome measure which are of direct use as a contracting tool. However, less well-researched and understood outcomes are useful as quality improvement tools, and within more open-ended discussions involving purchasers and providers. In terms of hospital care of acute asthma, there is no well-defined outcome measure which reflects the quality of hospital care; re-admission rates show promise as an outcome measure which relate to the quality of discharge planning and merit further study. In terms of ambulatory care, there is an urgent need to develop and evaluate a symptom-based outcome measure which would be usable in routine practice and could be recommended for widespread use. As a physiological outcome measure, percentage of best function is one which corrects for the degree of irreversible air flow obstruction and is independent of treatment step. It is valuable for individual patients by providing a realistic gold standard and, if best function is assessed in a standard manner, it also allows results of groups of patients to be compared in a meaningful manner. Severity scores, which might allow categorization of patients on the basis of characteristics other than current symptoms or therapy, are currently being evaluated

Contrasts in asthma care

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Hospital asthma management - a comparison between general medical units with and without a respiratory input

Full details including admitting ward were available for 77% (150) of all asthma admissions in a prospective audit of hospital asthma management. Cases could be subdivided into 64 admitted to general wards with a respiratory input (A) and 86 to similar wards without such specialist interest (B). Cases in A and B were similar in terms of age, previous severity of asthma, previous treatment and initial pulse rate. Fewer cases in B were treated with oral corticosteroids (A 83 %, B 67%; p = 0.04), had regular peak flow recordings made (A 73%, B 42%; p<0.005) or review planned (A 92%, B 56%; p<0.005) and fewer had their regular inhaled therapy increased after discharge (A 55%, B 28%; p<0.005). These differences in management were associated with more cases from B reporting sleep disturbances (A 23 %, B 41 %; p = 0.03), morning chest tightness (A 37%, B 55%; p=0.03) or wheeze on one flight of stairs (A 34%, B 58%; p<0.005) at interview 13 days later. In addition 20% of cases first admitted to B were readmitted within the year compared with 2% for A. The better outcome in cases admitted to A shows that the more intensive management practised in these wards is worthwhile

Hospital management of asthmatic-patients compared with those given a diagnostic label of chronic obstructive airways disease

This meeting abstract discusses hospital management of asthmatic-patients compared with those given a diagnostic label of chronic obstructive airways disease

Differences in hospital asthma management

Asthma management was audited prospectively for one year in a large teaching hospital. Full details were available on 77% of all patients admitted, or readmitted, with asthma during that year (150 of 195 admissions). 64 patients were admitted to general wards with a special interest in respiratory medicine, and 86 to general wards without this specialist interest. Cases in the two groups were similar in terms of age, previous severity of asthma, previous treatment, and initial pulse rate. Fewer cases in the non-specialist group were treated with oral corticosteroids (67%, vs 83%), had regular peak flow recordings (42%, vs 73%), or were given return appointments (56%, vs 92%); and fewer had their regular inhaled therapy increased after discharge (28%, vs 55%). At interview 13 days later, more patients from the non-specialist group reported sleep disturbance (41%, vs 23%), morning chest tightness (55%, vs 37%), or wheeze on 1 flight of stairs (58%, vs 34%). 20% of first admissions in the non-specialist group were readmitted within the year, compared to 2% of the group treated on wards with a specialist interest in respiratory medicine. These data suggest that the intensive management of asthmatic patients, practised in respiratory units, prevents much unnecessary morbidity

Management of asthma in hospital - a prospective audit

In a prospective study of management of asthma in hospital patients with acute asthma admitted to a single hospital over a calendar year were surveyed. Altogether 157 out of 194 admissions (81%) were studied. The patients (16 of whom had been admitted twice and one three times) were interviewed at home about two weeks after discharge, and their hospital records were reviewed. When interviewed an appreciable proportion of patients said that their asthma had been poorly controlled after their discharge from the hospital: 54 reported regular sleep disturbance due to wheeze, 78 tightness of the chest in the morning, and 77 wheeze after climbing one flight of stairs. Patients had been described on admission as having had symptoms of deteriorating asthma for a median of three days. Closer questioning of 71 patients, however, elicited that 50 had had regular symptoms indicating poor control for weeks or months. Most patients did not know how their drugs worked, and many did not have an appropriate plan of action in the event of a further attack. In all the cases studied 114 patients were treated with oral corticosteroids, only 70 had had their previous maintenance treatment increased at the time of discharge, and 107 had a follow up appointment booked for an average of three and a half weeks after discharge. These findings show that undersupervision and undertreatment of patients with asthma are common and not confined to those dying of the condition

Glasgow audit of surgical deaths - 1992

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