Greenway-Crombie A, Conners A, Snell T, Oerlemans M
Collaborative Health, Education & Research Centre, Bendigo, Victoria, Australia.
Rural Remote Health. 2003 Jul-Sep;3(2):149. Epub 2003 Jul 9.
The prevalence of asthma in Australia is increasing and places a significant cost burden on the community as well as reducing individuals' quality of life. In the late 1990s, asthma was the sixth National Health Priority in Australia and the prevalence of asthma in the Loddon Mallee region (LMR) of Victoria was approximately 1% higher than the State average. Four LMR local government areas had close to double the State average hospital admission ratios for asthma.
The aim of this project was to develop a Regional Asthma Management Model (RAMM) and strategies for its implementation throughout the LMR, as a tool to implement a major health priority of both the Victorian State and Australian Commonwealth governments: to improve health outcomes for people with asthma.
A literature review was undertaken to identify best practice in asthma management for use as the basis of questions in workbooks designed to profile and compare current asthma management practice in the LMR. The workbooks were sent to all acute hospitals, community health centres and asthma educators in the LMR. The completed workbooks were returned and respondents elaborated on the workbook data at one of five subregional workshops. A survey was also undertaken to identify the range of asthma management strategies currently used by regional general practitioners (GPs) and to invite their views on ways to improve asthma management in the region. To gain consumer input into the RAMM a semi-structured group interview was held in an urban area and individual interviews were held in two rural areas in the region. A multidisciplinary reference group provided guidance to the project and a documentation design team was convened.
Of the 19 workbooks sent to individual acute hospitals, 15 (78.9%) were completed and returned; 13 of 14 workbooks (92.8%) sent to individual community health centres were completed and returned. Fourteen of 15 asthma educators identified in the LMR were employed in the acute hospitals and community health centres that returned the workbooks; one asthma educator worked privately. Of the 215 GP surveys distributed, 38 surveys (17.6%) were returned. The majority of this small sample of GPs supported developing a uniform regional approach to asthma management based on NAC guidelines. Consumers interviewed suggested treating doctors, and/or EDs provide patients and carers with written instructions regarding acute asthma attacks and advice on management strategies for the ensuing 24-48 hours. A regional profile of asthma management practice was produced and compared with identified best practice. Gaps in practice and services were identified and responsive recommendations formulated. The National Asthma Campaign (NAC) guidelines were used as the basis for RAMM documentation, a package which consisted of a Regional Asthma Clinical Pathway and Emergency Department (ED) Package.
The RAMM developed during the project provides documentation to assist best-practice asthma management by regional EDs and acute hospitals. The methodology and outcomes of the RAMM reflect the geography of the region, with multiple service providers from different locations managing a person with asthma across the primary, secondary and tertiary continuum. The RAMM methodology has the potential to be applied to other diseases and to other rural environments. Although the RAMM was designed for rural areas it could be easily adapted to suit the metropolitan environment. Implementation and evaluation of RAMM documentation is in progress.
澳大利亚哮喘的患病率正在上升，给社区带来了巨大的成本负担，同时也降低了个人的生活质量。在20世纪90年代末，哮喘是澳大利亚第六个国家卫生重点项目，维多利亚州洛登·马勒地区（LMR）的哮喘患病率比该州平均水平高出约1%。LMR的四个地方政府辖区的哮喘住院率几乎是该州平均水平的两倍。
本项目的目的是开发一种区域哮喘管理模式（RAMM）及其在整个LMR实施的策略，作为实施维多利亚州和澳大利亚联邦政府一项主要卫生重点项目的工具：改善哮喘患者的健康状况。
进行了一项文献综述，以确定哮喘管理的最佳实践，作为工作手册中问题的基础，这些工作手册旨在描述和比较LMR目前的哮喘管理实践。工作手册被发送到LMR的所有急症医院、社区卫生中心和哮喘教育工作者手中。完成的工作手册被返还，受访者在五个分区研讨会之一对工作手册数据进行了详细说明。还进行了一项调查，以确定该地区全科医生（GP）目前使用的哮喘管理策略范围，并征求他们对改善该地区哮喘管理方法的意见。为了获得消费者对RAMM的意见，在一个城市地区进行了一次半结构化小组访谈，并在该地区的两个农村地区进行了个人访谈。一个多学科参考小组为该项目提供指导，并召集了一个文件设计团队。
在发送给各急症医院的19份工作手册中，15份（78.9%）完成并返还；发送给各社区卫生中心的14份工作手册中有13份（92.8%）完成并返还。在LMR确定的15名哮喘教育工作者中，有14名受雇于返还工作手册的急症医院和社区卫生中心；一名哮喘教育工作者为私人执业。在分发的215份全科医生调查问卷中，有38份（17.6%）被返还。在这个小样本的全科医生中，大多数人支持根据国家哮喘运动（NAC）指南制定统一的区域哮喘管理方法。接受访谈的消费者建议，治疗医生和/或急诊科为患者及其护理人员提供关于急性哮喘发作以及接下来24至48小时管理策略的书面说明。编制了一份该地区哮喘管理实践概况，并与确定的最佳实践进行了比较。确定了实践和服务方面的差距，并提出了相应的建议。NAC指南被用作RAMM文件的基础，该文件包包括一份区域哮喘临床路径和急诊科文件包。
项目期间开发的RAMM提供了文件，以协助该地区急诊科和急症医院进行最佳实践哮喘管理。RAMM的方法和结果反映了该地区的地理情况，来自不同地点的多个服务提供者在初级医疗、二级医疗和三级医疗连续过程中管理哮喘患者。RAMM方法有可能应用于其他疾病和其他农村环境。虽然RAMM是为农村地区设计的，但它可以很容易地进行调整以适应大都市环境。RAMM文件的实施和评估正在进行中。
