1999-2002: the pulmonologist is the sole responsible for all aspects of the management: diagnosis , therapy, education and follow-up. The primary care physician and the nurse are merely supportive. An educational book and a CD-ROM are made available for patients and families.
2003-2005: a holistic approach is developed with a team of specialists (pulmonologist, resident, nurse, clinical pedagogue, web-engineer working on its own without co-ordination or a shared plan. A diagnostic therapeutic protocol based on the International Guidelines is developed with primary care physicians.
2006-2008: all team members now create a framework following a sheduled diagnostic-therapeutic- clinical pathway (basis: 3 specialist visits at 0, 6-8, 12-16 weeks, followed by 6-monthly visits).
A total of 1140 consecutive children aged 1 to 15 participated in the three periods above mentioned. The average number of patients per year, in the 1999-2002 and 2003- 2005 is 57 and 121; the number of patients in the 2006, 2007 and 2008 are 145, 168, 176 respectively. The mean number of specialist visits was 2.2 and 3.2 in the first and second periods and consequently the mean length of follow-up was 2.3 and 5.85 months. The mean length of follow-up for 2006, 2007 and 2008 was respectively 5.04, 3.63 and 3.85 months.
The drop-out rate was 60.4% and 19.5% in the first 2 periods; in 2006 it was 18.1%, in 2007, 17. 3%, and in 2008, an outstanding 4.5%.
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