Reducing disability caused by chronic airflow limitation
ACP J Club. 1992 May-June;116:70. doi:10.7326/ACPJC-1992-116-3-070
Littlejohns P, Baveystock CM, Parnell H, Jones PW. Randomised controlled trial of the effectiveness of a respiratory health worker in reducing impairment, disability, and handicap due to chronic airflow limitation. Thorax. 1991 Aug;46:559-64.
To measure the effect of care provided by a respiratory health worker on disability and respiratory impairment in chronic airflow limitation.
Randomized, controlled trial.
A health district in London, England.
Patients aged 30 to 75 years attending hospital respiratory outpatient clinics who had previously documented, stable chronic airflow limitation, a prebronchodilator forced expiratory volume in 1 second (FEV1) < 60% of predicted, and no other major diseases were included.
Patients received usual care provided by the chest clinic (n = 74) or usual care and respiratory health worker services (n = 71). The latter consisted of health education for the patient and primary care team, symptom and compliance monitoring to detect any worsening of the patients' condition, and liaison between health care providers.
Main outcome measures
All measurements were obtained at baseline and after 1 year, including FEV1, forced vital capacity, peak expiratory flow, 6-minute walking distance, paced-step test, and quality of life as assessed by 4 questionnaires. A diary card was used to record drug prescriptions, physician contacts, and hospitalizations.
3 (4%) intervention-group and 9 (12%) usual-care patients died during the study (relative risk [RR] 2.9; 95% CI, 0.8 to 10.2). The groups did not differ with respect to deterioration in lung function, disability as measured by the 6-minute walking distance and step test, and mood state as measured by the Hospital Anxiety and Depression Scale. The physical score of the Sickness Impact Profile showed greater improvement in the intervention group (P < 0.01), but the psychosocial and total scores were similar. Patients in the intervention group were prescribed antibiotics, nebulized salbutamol, and ipratropium more frequently (all P ≤ 0.02) and were seen more often by their general practitioner (P = 0.03). The 2 groups were similar in the number of outpatient visits and hospitalizations, and in the level of satisfaction with their care.
Patients with chronic airflow limitation receiving additional care provided by a respiratory health worker had similar disability after 1 year compared with patients receiving usual care, although there was a trend to decreased mortality.
Sources of funding: In part, by King's Fund.
Address for article reprint: Dr. P. Littlejohns, Department of Public Health Sciences, St. George's Hospital Medical School, London SW17 0RE, United Kingdom.
Randomized trials provide a scientific basis for clinical practice in the management of chronic airflow obstruction (CAO). These techniques include the long-term administration of supplemental oxygen to reverse arterial hypoxemia (1) and the use of antibiotics for acute exacerbations of bronchitis associated with CAO (2). However, well-designed studies that evaluate the effectiveness of respiratory health workers in the management of CAO are not available. Thus, the study by Littlejohns and colleagues contributes new knowledge to the literature.
The major observation of the study was a reduction in the 1-year mortality of patients with CAO who were attended by the respiratory health worker. Deaths were more likely for older patients with more severe reductions of FEV1. Because the study enrolled patients who were less severely obstructed than those of some previous trials (1, 2), one wonders whether the effect of respiratory health workers would have been greater for a group of more severely obstructed patients.
For the clinician, the major question is what did the health care worker do? In this study the worker provided education and monitoring of treatment (e.g., demonstration of correct inhalation techniques, supervision of home O2, and monitoring for symptoms that suggest acute infectious exacerbations). This service resulted in increased prescribing of antibiotics and bronchodilators and in more physician visits. Until additional data from longer term studies are available, clinicians whose practice pattern does not permit frequent detailed evaluations of patients with advanced CAO may wish to incorporate respiratory workers into the management of selected patients, as has already been done in some centers.
C. Gregory Elliott, MD
LDS Hospital Salt Lake City, Utah