Accessibility, acceptability, and effectiveness in primary care of routine telephone review of asthma: pragmatic, randomised controlled trial

Dear Editor

The study by Pinnock et al (March 1st 2003)highlighted that even in
practices that declared themselves as being "asthma interested" there
remained a high proportion of patients receiving prescriptions who had not
been reviewed in the previous 11 months - or for how long? This amounted
to two thirds of those who had received a bronchodilator prescription in
the past 6 months and about one half of those over 18 years of age who
were on the asthma registers of the practices. This suggests that there is
indeed a real need to improve the regular review of patients with asthma.

However, does this study provide a possible solution to this
challenge? There are questions regarding the selection of patients which
have already been raised by other correspondents. In addition I was unable
to see any information regarding other asthma treatments being taken by
the patients in the study or by those excluded from it. Information on the
proportion of patients who were also being prescribed inhaled
corticosteroids and other forms of preventative therapy would have been
most valuable in helping to describe the patients in this study especially
if examined in conjunction with the morbidity indices.

The value of the study was also diminished by the fact that there was
no standardisation of the interviews, whether by telephone or face-to-
face. Indeed, from the topics discussed there appears to have been a
signficant difference between the topics raised in the two situations. To
suggest that both groups had been exposed to "routine asthma reviews" is
perhaps a step too far.

While patient-recorded PEFs can be discussed - but not examined - in
both situations it is impossible either to verify current, admittedly
instantaneous, lung function over the telephone or to actually check the
real ability to use inhaler devices effectively.

While a three month interval for re-evaluation was chosen it would
only be possible to really compare these two forms of review if performed
over a longer time period in a better described group of patients, with
more contacts.

While I believe strongly that there remains more to be done in terms
of the meaningful review of patients with asthma in order to optimise
their quality of life in relation to their asthma I remain to be convinced
that this can be achieved by the type of telephone review described in
this paper. Perhaps planned telephone reviews might be held with patients
who were appropriately "trained" and prepared, in conjunction with a
structured programme of face-to-face reviews to guide longterm self
management?

Yours sincerely

Robert Pearson

Competing interests:  
None declared

EDITOR – Pinnock et al (1) study on telephone review of asthma tries
to find a practical solution to the difficult problem of providing optimal
clinical care to an important group of patients. However, three issues
throw some doubt as to whether or not telephone review should become
routine practice in primary care.

Firstly, the study itself does not seem to compare like with like. In
the methods section we are told that in the intervention group nurses
were “… told to make up to four attempts to contact the patient by phone.”
Yet in the control arm only “… a written intervention…” If the control
group only got one letter, it is certainly possible that the difference in
numbers who the Pinnock et al were able to review may be due purely to
persistent of the intervention group’s nurses as opposed to the method
used for review.

Secondly, the medico-legal issue of telephone consultations must not
be overlooked. The GMC’s guidelines are that “…the use of phone or e-mail
should not diminish the quality of care patients receive.” (2). The
British Thoracic Society has already issues widely accepted guidelines
(3) for patient care in asthma and in these, the peak expiratory flow rate
(PEFR) measurements are an essential part of assessment and review. Though
Pinnock et al do acknowledge that PEFR measurements cannot be done over
the phone, they seem to overlook the significance of this when it comes to
possible future litigation.

Lastly, general practitioners (GP) work in a world where the
recording of certain pieces of information are seen by others as
important. For example, my local Primary Care Trust considers the PEFR to
be an essential part of my practice’s asthma audit. Furthermore, if the
new GP contract is accepted, practices will be financially disadvantaged
if they do not record the PEFR for each and every asthma patients (see
Annex A) (4).

In the future, there maybe a role for routine telephone review of
asthma patients, but until the real world catches up, this will be one
call I will not be answering.

References

1. Pinnock H, Robert Bawden R, Proctor S, Wolfe S, Scullion J, Price
D, Sheikh A. Accessibility, acceptability, and effectiveness in primary
care of routine telephone review of asthma: pragmatic, randomised
controlled trial. BMJ 2003;326:477-9

2. General Medical Council. Providing advice and medical services on-line
or by telephone. London: General Medical Council; 1998

3. British Thoracic Society, National Asthma Campaign, Royal College of
Physicians of London in association with the General Practitioners in
Asthma Group, British Association of Accident and Emergency Medicine,
British Paediatric Society, Royal College of Paediatrics and Child Health.
The British guidelines on asthma management 1995 review and position
statement. Thorax 1997; 52(suppl 1): s1-21

4. NHS Confederation. GMS contract negotiations.
www.nhsconfed.org/gmscontract/ (accessed 3 March 2003).

Competing interests:  
None declared