Good informational continuity is essential to health care with limited resources. Asthma is a prime example of a chronic disease for which all health care professionals should work according to a common strategy, providing consistent care. Asthma can be managed in primary care settings, but specialist consultation is needed in cases of an unclear diagnosis or unstable asthma. Optimal communication between physicians is necessary for specialists if they are to plan for further investigations and set a time frame with respect to urgency.
The Finnish National Asthma Programme (1994?2004) was published to enhance the early diagnosis of asthma and to re-organize the responsibility for its care. Referral letters offer a practical tool for measuring performance at the interface between primary and secondary care.
The aim of this thesis was to evaluate asthma management at the interface between primary and secondary care during the asthma programme. Medical record audits were used for this purpose. Quality criteria were developed for referral letters by a consensus-seeking expert panel on the basis of evidence from the literature and from the results of a national questionnaire review. The quality criteria for the spirometry curves were based on international guidelines. The main sources of data were adults? non-acute asthma-related referral letters and copies of primary care spirometry report sheets, which were prospectively collected from the referral letters sent to the respiratory departments of three study hospitals during 2001. Referral letters sent to one of the study hospitals in 1994 were also retrospectively collected so that the results of two years with a 7-year interval could be compared. Clinical profiles of the new asthma patients and the use of secondary care resources were also compared between the two years (1994 and 2001).
A high national consensus was reached about the content of an asthma-related referral letter between primary and secondary care physicians: 7 administrative and 14 asthma-specific criteria were selected. The expert panel defined the gradings of the referral letter quality. The referral letters (n=1289) from the three hospitals were of good quality against the administrative criteria in 96% of the cases in 2001. Asthma-specific quality was poor for 45% of the letters and good for 21%. The most frequently missing items were smoking (58%), medication (59%), peak flow follow-up results (53%), and spirometry with the results of a bronchodilation test (69%).
A comparison between the quality of the referral letters in 1994 (n=624) and that of the letters in 2001 (n=452) was made in one study hospital. The proportion of poor letters decreased (63% versus 44%), while that of good letters increased (7% versus 22%). The visually assessed quality of the primary care spirometry curves (n=489) from 2001 was found to be good for 79% of the letters. Clinical data on respiratory medication and patient co-operation were frequently missing from the spirometry report sheets. The profile of the new asthma patients seems to indicate that those with milder asthma with more co-morbidities were referred in 2001 than 7 years earlier. Overall number of visits in secondary care was smaller in 2001 Quality criteria to assess asthma-related referral letters were set on the basis of a high consensus between primary and secondary care physicians. The proportion of poor letters against the asthma-specific criteria was higher than expected, but the quality improved during the first 7 years of the National Asthma Programme. The quality of the primary care spirometry data was good. Secondary care resources were used more efficiently.
As reflected by the referral letters, primary care professionals took a more active role in asthma management during the National Asthma Programme.
