title: The at-risk registers in severe asthma (ARRISA) study: a cluster-randomised controlled trial examining effectiveness and costs in primary care.
abstract: BACKGROUND
  Patients at risk of severe exacerbations contribute disproportionally to asthma mortality, morbidity and costs. We evaluated the effectiveness and costs of using 'asthma risk registers' for these patients in primary care.
  
  
  METHODS
  In a cluster-randomised trial, 29 primary care practices identified 911 at-risk asthma patients using British asthma guideline criteria (severe asthma plus adverse psychosocial characteristics). Intervention practices added electronic alerts to identified patients' records to flag their at-risk status and received practice-based training about using the alerts to improve patient access and opportunistic management. Control practices continued routine care. Numbers of patients experiencing the primary outcome of a moderate-severe exacerbation (resulting in death, hospitalisation, accident and emergency attendance, out-of-hours contact, or a course/boost in oral prednisolone for asthma), other healthcare and medication usage, and costs over 1 year were derived from practice-based records.
  
  
  RESULTS
  There was no significant effect on exacerbations (control: 46.5%; intervention: 53.6%, OR, 95% CI 1.30, 0.93 to 1.80). However, this composite outcome masked relative reductions in intervention patients experiencing hospitalisations (OR 0.50, 95% CI 0.26 to 0.94), accident and emergency (OR 0.74, 95% CI 0.42 to 1.31) and out-of-hours contacts (OR 0.79, 95% CI 0.45 to 1.37); and a relative increase in prednisolone prescription for exacerbations (OR 1.31, 95% CI 0.92 to 1.85). Furthermore, prescription of nebulised short-acting β-agonists reduced and long-acting β-agonists increased for intervention relative to control patients. The adjusted mean per patient healthcare cost was £138.21 lower (p=0.837) among intervention practices.
  
  
  CONCLUSIONS
  Using asthma risk registers in primary care did not reduce treated exacerbations, but reduced hospitalisations and increased prescriptions of recommended preventative therapies without increasing costs.
authors.affiliation: Norwich Medical School, University of East Anglia, Norwich NR4 7TJ, UK. j.r.smith@uea.ac.uk
authors.forename: Jane Rebecca
authors.initials: JR
authors.lastname: Smith
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Noble
authors.forename: Stanley
authors.initials: S
authors.lastname: Musgrave
authors.forename: Jamie
authors.initials: J
authors.lastname: Murdoch
authors.forename: Gill M
authors.initials: GM
authors.lastname: Price
authors.forename: Garry R
authors.initials: GR
authors.lastname: Barton
authors.forename: Jennifer
authors.initials: J
authors.lastname: Windley
authors.forename: Richard
authors.initials: R
authors.lastname: Holland
authors.forename: Brian Dw
authors.initials: BD
authors.lastname: Harrison
authors.forename: Amanda
authors.initials: A
authors.lastname: Howe
authors.forename: David B
authors.initials: DB
authors.lastname: Price
authors.forename: Ian
authors.initials: I
authors.lastname: Harvey
authors.forename: Andrew M
authors.initials: AM
authors.lastname: Wilson
mesh_terms: D000293:Adolescent; D000328:Adult; D018927:Anti-Asthmatic Agents / Q000191:economics / Q000627:therapeutic use; D001249:Asthma / Q000191:economics* / Q000503:physiopathology / Q000517:prevention & control* / Q000523:psychology; D002648:Child; D016000:Cluster Analysis; D004739:England; D005260:Female; D006760:Hospitalization / Q000191:economics; D006801:Humans; D008297:Male; D016347:Medical Records Systems, Computerized; D008875:Middle Aged; D011320:Primary Health Care / Q000191:economics; D012042:Registries; D018570:Risk Assessment
chemical_list: D018927:Anti-Asthmatic Agents