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I read Punyadasa et al’s1 article with great interest. Partly because asthma is a serious medical condition that still causes excessive mortality,2 and partly because I have never been able to find strong evidence to support guidelines3 that asthma patients should be followed up in primary care within 48 hours of discharge from hospital.
The authors found that ‘more than 85% of asthma patients failed to receive follow- up asthma care within the recommended 48 hours of hospital discharge’.1
But what evidence is this recommendation based on?
The authors write: ‘evidence suggests comprehensive post-hospitalisation asthma care minimises adverse asthma outcomes’,1 and provide two references to support this statement. The first was the National Review of Asthma Deaths, which advised that patients should see their GP within 48 hours post-discharge.2 This recommendation appears to have been on the basis of expert opinion. The second was a 2002 Cochrane review of randomised trials assessing self- management education for asthma.4 This review makes no reference to post-hospital admission in the abstract. The authors also cite two papers from the US demonstrating that patients often do not receive follow-up post-hospital admission, but do not highlight that neither of these studies found a beneficial relationship between the presence of post-discharge follow-up and patient outcomes.5,6
Given that one of the goals of modern medicine is to encourage self-efficacy, do all patients need such paternalistic care in the form of mandatory follow-up or could most patients seek appropriate help if given comprehensive safety-netting advice7 on discharge?
With the current scarcity of resources in the NHS, we need to understand if 48-hour review in primary care impacts on patient outcomes and is it cost-effective? As highlighted by the authors, retrospective cohorts with linked data to emergency department attendances are a valuable starting point to compare rates of hospital readmission for those who did or did not receive primary care follow-up. A follow- on experimental comparison of usual care versus a financially incentivised follow-up scheme such as a Local Enhanced Service may be more powerful at answering these questions. Until then, expect the berating of GPs for failing to hit targets that do not have a clear evidence base behind them to continue.
Notes
Funding
The author’s academic time is funded by
a National Institute for Health and Care Research (NIHR) In-Practice Fellowship (reference: NIHR302692). The views expressed are those of the author and not necessarily those of the NIHR or the Department of Health and Social Care.
- © British Journal of General Practice 2023
REFERENCES
- 1.↵
- 2.↵
(2014) Royal College of Physicians. Why asthma still kills The National Review of Asthma Deaths (NRAD),
- 3.↵
(2019) British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma,
- 4.↵
- 5.↵
- 6.↵
- 7.↵
