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Cochrane Database of Systematic Reviews

Atención de la bronquiectasia dirigida por personal de enfermería versus dirigido por médicos

Información

DOI:
https://doi.org/10.1002/14651858.CD004359.pub2Copiar DOI
Base de datos:
  1. Cochrane Database of Systematic Reviews
Versión publicada:
  1. 20 junio 2018see what's new
Tipo:
  1. Intervention
Etapa:
  1. Review
Grupo Editorial Cochrane:

  1. Grupo Cochrane de Vías respiratorias

Copyright:
  1. Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Cifras del artículo

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Autores

  • Kathryn Lawton

    Correspondencia a: Respiratory Medicine Unit, The Queen Elizabeth Hospital, Central Adelaide Local Health Network, Adelaide, Australia

    [email protected]

    School of Medicine, The University of Adelaide, Adelaide, Australia

  • Karen Royals

    Respiratory Medicine Unit, The Queen Elizabeth Hospital, Central Adelaide Local Health Network, Adelaide, Australia

    School of Medicine, The University of Adelaide, Adelaide, Australia

  • Kristin V Carson‐Chahhoud

    School of Medicine, The University of Adelaide, Adelaide, Australia

    School of Health Sciences, The University of South Australia, Adelaide, Australia

    School of Health Sciences, University of South Australia, Adelaide, Australia

  • Fiona Campbell

    School of Health and Related Research, The University of Sheffield, Sheffield, UK

  • Brian J Smith

    Respiratory Medicine Unit, The Queen Elizabeth Hospital, Central Adelaide Local Health Network, Adelaide, Australia

    School of Medicine, The University of Adelaide, Adelaide, Australia

Contributions of authors

KL and KR wrote the protocol with additional input from KVC. KL and KR assessed search results. KL and KVC‐C entered data and developed the discussion. FC and BJS contributed comments to the final draft of the manuscript before submission to editorial.

Sources of support

Internal sources

  • The review authors declare that no such funding was received for this systematic review, Other.

External sources

  • The review authors declare that no such funding was received for this systematic review, Other.

Declarations of interest

None known.

Acknowledgements

Mike Greenstone, Emma Dennett, and Rebecca Normansell were the editors for this review and commented critically on the review. Christopher Cates checked and provided guidance for statistical analysis.

We would like to thank all staff at the Cochrane Airways Group for their ongoing help and support. We also wish to thank the peer reviewers for their time and valuable feedback.

We wish to thank the original authors of this review ‐ J. French (French 2003), D. Bilton, and F. Campbell.

The Background and Methods sections of this review are based on a standard template used by Cochrane Airways.

This project was supported by the National Institute for Health Research (NIHR), via Cochrane Infrastructure funding to the Cochrane Airways Group. The views and opinions expressed therein are those of the review authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, NHS, or the Department of Health.

Version history

Published

Title

Stage

Authors

Version

2018 Jun 20

Nurse‐led versus doctor‐led care for bronchiectasis

Review

Kathryn Lawton, Karen Royals, Kristin V Carson‐Chahhoud, Fiona Campbell, Brian J Smith

https://doi.org/10.1002/14651858.CD004359.pub2

2003 Jan 20

Nurse specialist care for bronchiectasis

Review

Jane French, Diana Bilton, Fiona Campbell

https://doi.org/10.1002/14651858.CD004359

Differences between protocol and review

This review includes a new review author team.

Outcome measures include the following.

  1. The new review author team reordered primary and secondary outcomes and included data on patient satisfaction and cost‐effectiveness not previously reported.

  2. Hospital admission was changed to a primary outcome, in addition to exacerbations.

  3. Lung function was changed to a secondary outcome, as it is unlikely to show significant differences in stable bronchiectasis.

New methods include the following.

  1. Since the last review, changes to search methods and standard airways protocol have occurred; these have been included in this update.

  2. Assessment of risk of bias has been updated. Results have been presented in the 'Summary of findings' table.

In the previous review, the first review author and Diana Bilton were involved in the only trial analysed in the review.

Keywords

MeSH

Medical Subject Headings (MeSH) Keywords

Medical Subject Headings Check Words

Adult; Child; Humans;

PICO

Population
Intervention
Comparison
Outcome

El uso y la enseñanza del modelo PICO están muy extendidos en el ámbito de la atención sanitaria basada en la evidencia para formular preguntas y estrategias de búsqueda y para caracterizar estudios o metanálisis clínicos. PICO son las siglas en inglés de cuatro posibles componentes de una pregunta de investigación: paciente, población o problema; intervención; comparación; desenlace (outcome).

Para saber más sobre el uso del modelo PICO, puede consultar el Manual Cochrane.

Study flow diagram.
Figuras y tablas -
Figure 1

Study flow diagram.

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Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
Figuras y tablas -
Figure 2

Risk of bias summary: review authors' judgements about each risk of bias item for each included study.

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Comparison 1 Nurse‐led versus physician‐led care, Outcome 1 Infective exacerbations (per patient per year).
Figuras y tablas -
Analysis 1.1

Comparison 1 Nurse‐led versus physician‐led care, Outcome 1 Infective exacerbations (per patient per year).

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Comparison 1 Nurse‐led versus physician‐led care, Outcome 2 Admissions per patient per year.
Figuras y tablas -
Analysis 1.2

Comparison 1 Nurse‐led versus physician‐led care, Outcome 2 Admissions per patient per year.

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Comparison 1 Nurse‐led versus physician‐led care, Outcome 3 SGRQ ‐ symptoms.
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Analysis 1.3

Comparison 1 Nurse‐led versus physician‐led care, Outcome 3 SGRQ ‐ symptoms.

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Comparison 1 Nurse‐led versus physician‐led care, Outcome 4 SGRQ ‐ control.
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Analysis 1.4

Comparison 1 Nurse‐led versus physician‐led care, Outcome 4 SGRQ ‐ control.

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Comparison 1 Nurse‐led versus physician‐led care, Outcome 5 SGRQ ‐ impact.
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Analysis 1.5

Comparison 1 Nurse‐led versus physician‐led care, Outcome 5 SGRQ ‐ impact.

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Comparison 1 Nurse‐led versus physician‐led care, Outcome 6 SGRQ ‐ total scores.
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Analysis 1.6

Comparison 1 Nurse‐led versus physician‐led care, Outcome 6 SGRQ ‐ total scores.

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Comparison 1 Nurse‐led versus physician‐led care, Outcome 7 Exercise capacity: 12‐minute walk distance, metres.
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Analysis 1.7

Comparison 1 Nurse‐led versus physician‐led care, Outcome 7 Exercise capacity: 12‐minute walk distance, metres.

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Comparison 1 Nurse‐led versus physician‐led care, Outcome 8 FEV1 (% predicted).
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Analysis 1.8

Comparison 1 Nurse‐led versus physician‐led care, Outcome 8 FEV1 (% predicted).

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Comparison 1 Nurse‐led versus physician‐led care, Outcome 9 FVC (% predicted).
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Analysis 1.9

Comparison 1 Nurse‐led versus physician‐led care, Outcome 9 FVC (% predicted).

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Summary of findings for the main comparison. Nurse‐led care compared with doctor‐led care for management of bronchiectasis

Nurse‐led care compared with doctor‐led care for management of bronchiectasis

Patient or population: management of bronchiectasis
Setting: outpatient
Intervention: nurse‐led care
Comparison: doctor‐led care

Outcomes

Anticipated absolute effects* (95% CI)

Relative effect
(95% CI)

No. of participants
(studies)

Certainty of the evidence
(GRADE)

Comments

Risk with doctor‐led care

Risk with nurse‐led care

Exacerbations
requiring treatment with antibiotics (per patient per year)

Assessed by clinician identified or participant self‐reported

Follow‐up: 12 months

Mean rate of infective exacerbations was 3.1 per patient per year.

0.28 per patient per year higher
(95% CI 0.28 lower to 0.97 higher)

1.09 (95% CI 0.91 to 1.30)

80
(1 RCT)

⊕⊕⊝⊝
LOWa,b

Hospital admissions

(per patient per year).
Follow‐up: 12 months

Mean admission per patient per year was 1.02.

1.55 per patient per year higher
(1.06 higher to 2.27 higher)

1.52 (95% CI 1.03 to 2.23)

80
(1 RCT)

⊕⊕⊝⊝
LOWa,b

More admissions in nurse‐led care. All nurse‐led care admissions approved by consultant. Protocol followed by nurse regarding management

Emergency department attendance

See comment.

See comment.

See comment.

See comment.

See comment.

Not reported

Mortality

Two participants died ‐ 1 from each care group ‐ after 12‐month assessment.

See comment.

⊕⊕⊝⊝
LOWa,b

Cost‐effectiveness

Total cost for duration of study and difference in cost for first and second years

Cost scale: £ per participant

Total costs £5428

Cost difference £274 higher in second year

Total costs £8464

Cost difference £1940 lower in second year

⊕⊕⊝⊝
LOWa,b,c

Costs may be reduced over time through a learning effect.

Quality of life, measured with SGRQ ‐ total scores
Lower scores indicating improved respiratory health
Scale from 0 to 100
Follow‐up: 12 months

Unreported

MD 1.7 higher
(4 lower to 0.6 higher)

79
(1 RCT)

⊕⊕⊝⊝
LOWa,b

Participants reported fewer symptoms and less impact on daily life with nurse‐led care, but data show no clinical or statistically significant differences between nurse‐led and doctor‐led care.

Exercise capacity: 12MWT
Assessed with distance, metres
Follow‐up: 12 months

Mean exercise capacity: 12MWT was 746 m.

MD 18 m greater
(13 lower to 49 higher)

80
(1 RCT)

⊕⊕⊝⊝
LOWa,b

No significant differences in distance walked between nurse‐led and doctor‐led care

FEV1
assessed with % predicted
Scale from 0 to 100
Follow‐up: 12 months

Mean FEV1 was 69.5% predicted.

MD 0.2% predicted higher
(1.6% predicted lower to 2% predicted higher)

80
(1 RCT)

⊕⊕⊝⊝
LOWa,b

Nil significant differences in percentage predicted FEV1 between nurse‐led and doctor‐led care

*The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).

12MWT: 12‐minute walk test; CI: confidence interval; FEV1: forced expiratory volume in one second; MD: mean difference; RCT: randomised controlled trial; SGRQ: St. George's Respiratory Questionnaire.

GRADE Working Group grades of evidence.
High certainty: We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate certainty: We are moderately confident in the effect estimate: The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect.
Very low certainty: We have very little confidence in the effect estimate: The true effect is likely to be substantially different from the estimate of effect.

aCannot rule out carryover effects from cross‐over trial. No reported information at first 12‐month time period before cross‐over. May have had a learned effect that resulted in fewer exacerbations and hospitalisations and better quality of life. This may have led to better lung function and exercise capacity. Marked down one point for risk of bias.

bAge of study, small number of participants, and uncertainty, with some results based on wide confidence intervals. Marked down one point for imprecision.

cCannot rule out selective reporting with the decision not to cross‐over 6 participants after first 12 months. No longer considered stable bronchiectasis. Already marked down for risk of bias previously, so not downgraded again based on this reason.

Figuras y tablas -
Summary of findings for the main comparison. Nurse‐led care compared with doctor‐led care for management of bronchiectasis
Ir a la tabla de la revisión
Table 1. Cost‐effectiveness

Resource

Nurse‐led care (mean visits per participant)

Nurse‐led care (mean cost per participant, £)

Doctor‐led care (mean visits per participant)

Doctor‐led care (mean cost per participant, £)

Difference (SD, £)

Nurse‐led clinics

4.61

180

0

0

180 (158)

Doctor‐led clinics

0.45

25

4.48

217

‐192 (199)

Procedures

0.13

61

0.11

54

7 (376)

Imaging

1.14

47

0.76

45

1 (112)

Other tests

24.58

260

18.94

222

37 (257)

Antibiotics (intravenous)

23 (days)

879

16 (days)

523

356 (1452)

Antibiotics (oral)

222 (days)

684

201 (days)

524

161 (695)

Bronchodilators

461 (days)

213

435 (days)

193

20 (179)

Corticosteroids

238 (days)

278

219 (days)

258

20 (181)

Other drugs

212 (days)

180

190 (days)

155

25 (194)

Inpatient

6.46 (days)

1338

2.36 (days)

477

861 (2755)

Day case

0.11

43

0.05

16

27 (170)

GP visits

1.11

20

1.40

26

‐6 (33)

Total

4208

2711

1498

(688 to 2674)

SD: standard deviation.
Figuras y tablas -
Table 1. Cost‐effectiveness
Ir a la tabla de la revisión
Table 2. Participant satisfaction with consultation

Comments

Nurse practitioner better, number, (%)

Doctor better, number (%)

P value

It was sometimes difficult to discuss your problems with the doctor/nurse practitioner.

11/76 (14.5)

1/76 (1.3)

0.006

The doctor/nurse practitioner explained clearly what is wrong.

7/74 (9.5)

0/74 (0)

0.016

The doctor/nurse practitioner examined you thoroughly when necessary.

6/70 (8.6)

0/70 (0)

0.031

The doctor/nurse practitioner should tell you more about your illness/condition and treatment.

7/59 (11.9)

3/59 (5.1)

0.344

The doctor/nurse practitioner made you feel at ease.

2/75 (2.7)

1/75 (1.3)

1.000

There was not enough time to discuss your problems with the doctor/nurse.

10/74 (13.5)

1/74 (1.4)

0.012

You felt confident the doctor/nurse practitioner knew about your medical history and your care.

7/74 (9.5)

1/74 (1.4)

0.070

Sometimes you felt that the doctor/nurse practitioner should listen more to what you said.

5/69 (7.2)

2/69 (2.9)

0.453

The doctor/nurse practitioner gave clear explanation about any tests that you needed.

4/75 (5.3)

1/75 (1.3)

0.375

You often came away from your appointment wishing you'd asked more questions.

13/72 (18.1)

9/72 (12.5)

0.523

You felt you were given a chance to have an active part when discussing your illness/condition.

4/73 (5.5)

0/73 (0.0)

0.125

There were frequent interruptions during your consultation.

6/73 (8.2)

3/73 (4.1)

0.508
Figuras y tablas -
Table 2. Participant satisfaction with consultation
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Comparison 1. Nurse‐led versus physician‐led care

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Infective exacerbations (per patient per year) Show forest plot

1

Rate Ratio (Fixed, 95% CI)

Totals not selected

2 Admissions per patient per year Show forest plot

1

Rate Ratio (Fixed, 95% CI)

Totals not selected

3 SGRQ ‐ symptoms Show forest plot

1

Mean Difference (Fixed, 95% CI)

Totals not selected

4 SGRQ ‐ control Show forest plot

1

Mean Difference (Fixed, 95% CI)

Totals not selected

5 SGRQ ‐ impact Show forest plot

1

Mean Difference (Fixed, 95% CI)

Totals not selected

6 SGRQ ‐ total scores Show forest plot

1

Mean Difference (Fixed, 95% CI)

Totals not selected

7 Exercise capacity: 12‐minute walk distance, metres Show forest plot

1

Mean Difference (Fixed, 95% CI)

Totals not selected

8 FEV1 (% predicted) Show forest plot

1

Mean Difference (Fixed, 95% CI)

Totals not selected

9 FVC (% predicted) Show forest plot

1

Mean Difference (Fixed, 95% CI)

Totals not selected
Figuras y tablas -
Comparison 1. Nurse‐led versus physician‐led care
Ir a la tabla de la revisión