Establishing the safety and effectiveness of a diagnostic therapeutic trial for asthma in community elderly

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Asthma is a major Australian health priority affecting over 2 million people. It is under-diagnosed and a source of significant morbidity in older people. Previous work by the investigators for the Commonwealth of Australia has shown that in the over 55-year age group approximately 40% of asthma is undiagnosed. In this age group severity is comparable with those diagnosed and worse than those diagnosed under the age of 55 years. Most (80%) of asthma deaths occur in the people aged greater than 55 years. There are clear patient and system factors that contribute to under diagnosis. The patient factors are currently being addressed in a general practice patient pilot study. System issues make the diagnosis of asthma in general practice a difficult task. The study is important, as older people are more likely to access the general practitioner than a specialist for respiratory problems. Spirometry in general practice is not common and is of variable quality. The most common approach to diagnosis by the general practitioner is a diagnostic trial of medication to provide evidence of asthma. This can be broken down into four elements of: entry criteria to a therapeutic trial; choice of drug in a therapeutic trial; length of time for a therapeutic trial, and; assessment criteria in a therapeutic trial. No evidence-based guidelines are available to assist the general practitioner in each of these stages making the therapeutic trial a safety and effectiveness issue of major importance, especially in the older person. The purpose of the study proposed is to conduct a randomised controlled trial in a representative population sample of older people to determine the evidence-based components of a diagnostic therapeutic trial for the guidance of general practitioners. The study will also assess which diagnostic questions and medical tests provide greatest assistance to the general practitioner in diagnosing asthma in the older person.