Self-management education and regular practitioner review for adults with asthma

Statewide evaluation of measuring physician delivery of self-management support in chronic disease care

BACKGROUND

Self-management support is an important component of improving chronic care delivery.

OBJECTIVE

To validate a new measure of self-management support and to characterize performance, including comparisons across chronic conditions.

DESIGN, SETTING, PARTICIPANTS

We incorporated a new question module for self-management support within an existing annual statewide patient survey process in 2007.

MEASUREMENTS

The survey identified 80,597 patients with a chronic illness on whom the new measure could be evaluated and compared with patients' experiences on four existing measures (quality of clinical interactions, coordination of care, organizational access, and office staff). We calculated Spearman correlation coefficients for self-management support scores for individual chronic conditions within each medical group. We fit multivariable logistic regression models to identify predictors of more favorable performance on self-management support.

RESULTS

Composite scores of patient care experiences, including quality of clinical interactions (89.2), coordination of care (77.6), organizational access (76.3), and office staff (85.8) were higher than for the self-management support composite score (69.9). Self-management support scores were highest for patients with cancer (73.0) and lowest for patients with hypertension (67.5). The minimum sample size required for medical groups to provide a reliable estimate of self-management support was 199. There was no consistent correlation between self-management support scores for individual chronic conditions within medical groups. Increased involvement of additional members of the healthcare team was associated with higher self-management support scores across all chronic conditions.

CONCLUSION

Measurement of self-management support is feasible and can identify gaps in care not currently included in standard measures of patient care experiences.

Home use of albuterol for asthma exacerbations

BACKGROUND

To reduce symptoms and emergency department (ED) visits, the National Asthma Education and Prevention Program (NAEPP) guidelines recommend early treatment of acute asthma symptoms with albuterol and oral corticosteroids. Yet, ED visits for asthma are frequent and often occur several days after onset of increased symptoms, particularly for children from low-income, urban neighborhoods.

OBJECTIVES

To describe home use of albuterol and identify factors associated with appropriate albuterol use.

METHODS

A total of 114 caregivers in the intervention group of a randomized trial to reduce emergent care for low-income, urban children completed a structured telephone interview with an asthma nurse to evaluate home management of their child's acute asthma symptoms. Interviews lasted approximately 20 minutes and were conducted from November 5, 2003, through September 30, 2005. Albuterol use as reported by caregivers was categorized as appropriate or inappropriate based on NAEPP recommendations.

RESULTS

Albuterol use for worsening asthma symptoms was categorized as appropriate for only 68% of caregivers and was more likely if the children had an ED visit or hospitalization for asthma in the prior year. The remaining 32% of caregivers used albuterol inappropriately (overtreatment or undertreatment). Appropriate albuterol use was not associated with caregiver report of having an asthma action plan (AAP) or a recent primary care physician visit to discuss asthma maintenance care.

CONCLUSIONS

Caregivers reported that they would use albuterol to treat their child's worsening asthma symptoms, but many described inappropriate use. Detailed evaluation of proper albuterol use at home may provide insight into how health care professionals can better educate and support parents in their management of acute exacerbations and more effective use of AAPs.

Single-inhaler combination therapy for maintenance and relief of asthma: a new strategy in disease management

When an adequate standard of asthma control is not achieved with maintenance treatment of inhaled corticosteroids, the addition of a long-acting beta(2)-adrenergic receptor agonist (LABA) bronchodilator is recommended. Using a combination product, salmeterol/fluticasone propionate (Seretide or Advair) or budesonide/formoterol (Symbicort) is preferred for convenience and avoids any risk that LABA might be used as monotherapy. As formoterol has a rapid onset of bronchodilator effect, the budesonide/formoterol combination can be used for both the maintenance and reliever components of asthma treatment (Symbicort SMART) and this is endorsed as an effective treatment by the Global Initiative for Asthma. The efficacy of this approach has been evaluated in a series of well conducted, controlled studies. Current control of asthma symptoms is improved or achieved with reduced total dose administration with Symbicort SMART compared with any reasonable alternate option. In every study, the risk of severe exacerbations was lower with Symbicort SMART than comparator treatment. Patients who benefit to the greatest extent are those with evidence of more severe asthma and greater exacerbation risk. When initiated in suitable patients in conjunction with appropriate education, Symbicort SMART is dominant in pharmacoeconomic terms. Symbicort SMART delivers improved asthma outcomes with lower treatment and social costs than any alternative.

Interventions for educating children who are at risk of asthma-related emergency department attendance

BACKGROUND

Asthma is the most common chronic childhood illness and is a leading cause for paediatric admission to hospital. Asthma management for children results in substantial costs. There is evidence to suggest that hospital admissions could be reduced with effective education for parents and children about asthma and its management.

OBJECTIVES

To conduct a systematic review of the literature and update the previous review as to whether asthma education leads to improved health outcomes in children who have attended the emergency room for asthma.

SEARCH STRATEGY

We searched the Cochrane Airways Group Trials Register, including the MEDLINE, EMBASE and CINAHL databases, and reference lists of trials and review articles (last search May 2008).

SELECTION CRITERIA

We included randomised controlled trials of asthma education for children who had attended the emergency department for asthma, with or without hospitalisation, within the previous 12 months.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We pooled dichotomous data with a fixed-effect risk ratio. We used a random-effects risk ratio for sensitivity analysis of heterogenous data.

MAIN RESULTS

A total of 38 studies involving 7843 children were included. Following educational intervention delivered to children, their parents or both, there was a significantly reduced risk of subsequent emergency department visits (RR 0.73, 95% CI 0.65 to 0.81, N = 3008) and hospital admissions (RR 0.79, 95% CI 0.69 to 0.92, N = 4019) compared with control. There were also fewer unscheduled doctor visits (RR 0.68, 95% CI 0.57 to 0.81, N = 1009). Very few data were available for other outcomes (FEV1, PEF, rescue medication use, quality of life or symptoms) and there was no statistically significant difference between education and control.

AUTHORS' CONCLUSIONS

Asthma education aimed at children and their carers who present to the emergency department for acute exacerbations can result in lower risk of future emergency department presentation and hospital admission. There remains uncertainty as to the long-term effect of education on other markers of asthma morbidity such as quality of life, symptoms and lung function. It remains unclear as to what type, duration and intensity of educational packages are the most effective in reducing acute care utilisation.

Individualized asthma self-management improves medication adherence and markers of asthma control

BACKGROUND

Adherence to inhaled anti-inflammatory therapy and self-management skills are essential parts of the asthma treatment plan to improve asthma control and prevent exacerbations. Whether self-management education improves long-term medication adherence is less clear.

OBJECTIVE

A 24-week prospective, randomized controlled trial was performed to study the effect of self-management education on long-term adherence to inhaled corticosteroid (ICS) therapy and markers of asthma control.

METHODS

After stabilization on ICS medication during a run-in phase, 95 adults with moderate-to-severe asthma were recruited from a large metropolitan community, and 84 were randomized to individualized self-management education, including self-monitoring of symptoms and peak flow or usual care with self-monitoring alone. The key components of the 30-minute intervention were asthma information, assessment, and correction of inhaler technique; an individualized action plan based on self-monitoring data; and environmental control strategies for relevant allergen and irritant exposures. The intervention was personalized based on pulmonary function, allergen skin test reactivity, and inhaler technique and reinforced at 2-week intervals.

RESULTS

Participants randomized to the self-management intervention maintained consistently higher ICS adherence levels and showed a 9-fold greater odds of more than 60% adherence to the prescribed dose compared with control subjects at the end of the intervention (P = .02) and maintained a 3-fold greater odds of higher than 60% adherence at the end of the study. Perceived control of asthma improved (P = .006), nighttime awakenings decreased (P = .03), and inhaled beta-agonist use decreased (P = .01) in intervention participants compared with control subjects.

CONCLUSION

Our results show that individualized asthma self-management education attenuates the usual decrease in medication adherence and improves clinical markers of asthma control.

Telephone peer-delivered intervention for diabetes motivation and support: the telecare exploratory RCT

OBJECTIVE

To test trial design issues related to measuring the effectiveness of a peer telephone intervention to enhance self-efficacy in type 2 diabetes; evaluate the impact on self-efficacy and clinical outcome; and describe patient and peer experience.

METHODS

Eligible patients had raised HbA1c (initial threshold >8%, reduced to >7.4% mid-way through trial). Patients were recruited from 40 general practices and randomised (40:40:20 ratio) to receive routine care alone or, in addition, motivational telephone support from a peer supporter or a diabetes specialist nurse (9 peers and 12 DSNs) for a period of up to 6 months. The primary outcome measure was self-efficacy score, and secondary outcome measures included HbA1c. Patient and telecare supporter satisfaction and experience were evaluated.

RESULTS

In all, 231 patients participated. At 6 months there were no statistically significant differences in self-efficacy scores (p=0.68), HbA1c (p=0.87) or other secondary outcome measures. There was evidence of a high level of acceptability, but peer telecare support was less highly valued than that from a DSN. Some patients stated that they would have valued more information and advice.

CONCLUSIONS

Further consideration needs to be given to the targeting of the telecare peer support, its intensity, the training and ongoing supervision of peer supporters, and the extent to which information and advice should be incorporated.

PRACTICE IMPLICATIONS

While some patients with poorly controlled type 2 diabetes value peer telephone support, this approach appears not to suit all patients. Further intervention development and evaluation is required before widespread adoption can be recommended.

A randomized, controlled study to evaluate the role of an in-home asthma disease management program provided by respiratory therapists in improving outcomes and reducing the cost of care

BACKGROUND AND PURPOSE

Asthma management programs (AMP) may reduce costs and improve outcomes in patients with moderate to severe asthma. However, it is not known which personnel are best able to deliver such interventions and what settings are most effective. The purpose of this study was to compare the effects of an in-home AMP provided by respiratory therapists (RTs) to an AMP provided by nurses (RNs) and to usual care (UC) provided in physician offices or clinics.

METHODS

Subjects (age 18-64) who had been admitted to the emergency department (ED) or hospital for acute asthma exacerbation were randomized to three groups: AMP-RT, AMP-RN or UC. The AMP groups received five (5) weekly home visits to provide assessment and instruction; the UC group was instructed to return to their physician for routine follow-up. Outcomes assessed at 6 months included hospitalizations, in patient days, hospitalization cost, ED visits and cost, clinic visits, pulmonary function, symptoms, health related quality of life (HRQOL), asthma episode self-management score (AESM), environmental assessment, and patient satisfaction (PS). Variables were compared using ANOVA with a Neuman-Keuls follow-up for multiple comparisons using an intent-to-treat approach.

RESULTS

Upon enrollment, (n = 159) there were no differences (p > .05) between groups for age, gender, pulmonary function or HRQOL (SF-36 and St. Georges Respiratory Questionnaire - SGRQ). At 6 months, both AMP groups (AMP-RN n = 54; AMP-RT n = 46) had significantly fewer (p < 0.05) hospitalizations and in-patient days, lower hospitalization costs, and greater HRQOL physical component summary change scores (PCS) and PS than UC (n = 59). AMP-RT also had greater PEFR, SGRQ Total and SGRQ Symptoms change scores when compared to UC and significantly better AESM and PS scores as compared to AMP-RN and UC.

CONCLUSIONS

An in-home asthma management program can be effectively delivered by respiratory therapists and may reduce hospitalizations, in-patient days, cost and improve measures of HRQOL and PS in a population prone to asthma exacerbation.

UK self-care support initiatives for older patients with long-term conditions: a review

OBJECTIVES

Supporting self-care for people with long-term conditions is an aim of UK health policy. As many with long-term conditions are older it is of interest to explore which self-care support interventions have positive impacts for this group. This review explores what types of intervention have been reported in the UK and their impact upon older people.

METHODS

Studies were identified using existing reviews, electronic databases and through hand searching journals. After inclusion and exclusion criteria were applied data were extracted from 18 studies. These were summarized in a narrative synthesis supported by summary tables.

RESULTS

All studies described interventions to support self-care, many targeted at people with arthritis. All used patient education, usually delivered to groups by a range of professionals. The majority of studies reported some significant positive outcomes, most frequently changes in physical functioning, illness knowledge and increased self-efficacy. The average age of participants was 60.

DISCUSSION

This review shows that self-care interventions have had positive effects for older participants but it remains unknown how best to support self-care in participants over 75, a group of people with long-term conditions who may have different needs.

Two for one: a self-management plan coupled with a prescription sheet for children with asthma

BACKGROUND

Despite strong recommendations in the asthma guidelines, the use of written self-management plans remains low among asthmatic patients.

OBJECTIVES

To develop a written self-management plan, based on scientific evidence and expert opinions, in a format intended to facilitate its dispensing by health care professionals, and to test the perception of its relevance and clarity by asthmatic children, adolescents and adults.

METHODS

Inspired by previously tested self-management plans, surveys of asthma educators, expert opinions and the 2004 Canadian Asthma Guidelines, the authors simultaneously developed French and English versions of a written self-management plan that coupled with a prescription. The self-management plan was tested in parents and their asthmatic children (aged one to 17 years), and it was revised until 85% clarity and perceived relevance was achieved.

RESULTS

Ninety-seven children and their parents were interviewed. Twenty per cent had a self-management plan. On the final revision, nearly all items were clear and perceived relevant by 85% or more of the interviewees. Two self-management plans were designed for clinics and acute care settings, respectively. The plans are divided into three control zones identified by symptoms with optional peak flow values and symbolized by traffic light colours. They are designed in triplicate format with a prescription slip, a medical chart copy and a patient copy.

CONCLUSION

The written self-management plans, based on available scientific evidence and expert opinions, are clear and perceived to be relevant by children, adolescents and their parents. By incorporating the prescription and chart copies, they were designed to facilitate dispensing by physicians in both clinics and acute care settings.

Identification and management of adults with asthma prone to exacerbations: can we do better?

Exacerbations are a major cause of morbidity in asthma and generate high health costs. Identification and management of adults with asthma who are prone to exacerbations is of considerable importance as by this means it should be possible to reduce the number of patients who currently experience inadequately controlled disease. Exacerbations occur most frequently in individuals with severe disease. Other risk factors include a history of a recent exacerbation, co-morbidities such as a raised body mass index and psychological problems as well as current smoking and lower socio-economic status. A low FEV1, particularly if combined with the additional information from questionnaires helps predict exacerbations. Despite the association between these risk factors and exacerbations it remains difficult to accurately predict in an individual patient with asthma whether they will go on to develop an exacerbation in the future. A major aim of international guidelines on the management of asthma is to prevent future risks of exacerbations, but some patients, particularly those with severe disease, respond poorly to current therapies and continue to experience recurrent exacerbations. There is an unmet need for improved management strategies and drugs targeted at preventing asthma exacerbations. Monitoring induced sputum eosinophil cell counts is helpful in preventing exacerbations in some patient with severe asthma. Future developments are likely to include the identification of better biomarkers to predict exacerbations or the cause of exacerbations, augmentation of the immunological response to viruses at the time of the exacerbation, the use of telemonitoring in patients with severe asthma and the development of improved therapies targeted at reducing exacerbations.

Towards Excellence in Asthma Management: final report of an eight-year program aimed at reducing care gaps in asthma management in Quebec

BACKGROUND AND OBJECTIVES

Asthma care in Canada and around the world persistently falls short of optimal treatment. To optimize care, a systematic approach to identifying such shortfalls or 'care gaps', in which all stakeholders of the health care system (including patients) are involved, was proposed.

METHODS

Several projects of a multipartner, multidisciplinary disease management program, developed to optimize asthma care in Quebec, was conducted in a period of eight years. First, two population maps were produced to identify regional variations in asthma-related morbidity and to prioritize interventions for improving treatment. Second, current care was evaluated in a physician-patient cohort, confirming the many care gaps in asthma management. Third, two series of peer-reviewed outcome studies, targeting high-risk populations and specific asthma care gaps, were conducted. Finally, a process to integrate the best interventions into the health care system and an agenda for further research on optimal asthma management were proposed.

RESULTS

Key observations from these studies included the identification of specific patterns of noncompliance in using inhaled corticosteroids, the failure of increased access to spirometry in asthma education centres to increase the number of education referrals, the transient improvement in educational abilities of nurses involved with an asthma hotline telephone service, and the beneficial effects of practice tools aimed at facilitating the assessment of asthma control and treatment needs by general practitioners.

CONCLUSIONS

Disease management programs such as Towards Excellence in Asthma Management can provide valuable information on optimal strategies for improving treatment of asthma and other chronic diseases by identifying care gaps, improving guidelines implementation and optimizing care.

Cochrane reviews of educational and self-management interventions to guide nursing practice: a review

BACKGROUND

The burden of chronic disease on healthcare services worldwide is growing and the increased development of educational interventions which help patients to better manage their own conditions is evident internationally.

OBJECTIVES

This paper reports on findings of a review of Cochrane systematic reviews of interventions designed to improve patients' knowledge and skills to manage chronic disease, with particular reference to nursing contribution and practice.

METHODS

Thirty Cochrane systematic reviews were identified as meeting the inclusion criteria. Data were extracted and summarised.

FINDINGS

The majority of reviews included in this paper were judged by Cochrane reviewers to provide inadequate evidence (n=18, 60%) of the effectiveness of the interventions reviewed. Information on the professional delivering the interventions was often not available, although 77% (23) of reviews mentioned that nurses were involved in a proportion of studies.

CONCLUSION

Educational programmes have definite benefits for patients suffering from asthma and are promising for interventions in areas such as diabetes mellitus, epilepsy and mental health. However, it still is not clear what the active ingredients of many successful interventions are.

Asthma worsenings: approaches to prevention and management from the Asthma Worsenings Working Group

Most asthma patients prescribed maintenance asthma therapies still experience periods of asthma worsenings characterized by daytime or night-time symptoms, or an increased need for rescue medication. In fact, these episodes are highly prevalent even in patients with well-controlled disease. Published literature suggests that asthma worsenings likely represent a window of opportunity during which patients could intervene early to prevent exacerbations or further deterioration of asthma symptoms. However, current evidence suggests that most patients fail to respond or to self-manage appropriately during these periods.To address the issue of asthma worsenings, an interdisciplinary committee of respirologists, allergists, family physicians, pharmacists and certified asthma educators from across Canada developed a practical definition of asthma worsenings and provided approaches to the prevention and management of these episodes based on current literature. To date, combination inhaled corticosteroid/long-acting beta-agonist therapy, particularly single inhaler maintenance and reliever therapy, appears to be an effective strategy for preventing asthma worsenings and exacerbations. Addressing the potential barriers to appropriate patient self-management of asthma worsenings, such as failure to adequately identify and respond to worsenings, low expectations for controlling asthma, low health literacy and poor patient-health care professional communication, are also critical to the successful prevention and management of these episodes. Finally, an interdisciplinary team approach involving patients and their families, certified asthma educators, primary care physicians, pharmacists and specialists is likely to have the greatest impact on the identification, prevention and management of asthma worsenings.

A prospective multicenter study of written action plans among emergency department patients with acute asthma

BACKGROUND

The prevalence of written "action plans" (APs) among emergency department (ED) patients with acute asthma is unknown.

OBJECTIVE

To determine the prevalence of APs among ED patients, to describe the demographic and clinical profile of patients with and without APs, and to examine the appropriateness of response to an asthma exacerbation scenario.

METHODS

Using a standard protocol, 49 North American EDs performed a prospective cohort study involving interviews of 1,756 patients, ages 2-54, with acute asthma. Among children only, a random sample was contacted two years after the index ED visit to assess current AP status and parents' self-management knowledge.

RESULTS

The overall prevalence of APs was 32% (95% confidence interval [CI], 30%-34%), and was higher among children than adults (34% vs. 26%, respectively; p = 0.001). Patients with APs had worse measures of chronic asthma severity (p < 0.05) and were more likely to be hospitalized (multivariate odds ratio, 1.5; 95%CI, 1.1-2.1). After 2 years, most children with an AP at the index ED visit still had one but only 20% of those without an AP had obtained one; moreover, many of the APs appeared inadequate. Parents of children with a current AP performed slightly better on the asthma scenario, but both groups overestimated their asthma knowledge.

CONCLUSION

The prevalence of APs among ED patients with acute asthma is unacceptably low, and many of these APs appear inadequate. "Confounding by severity" will complicate any non-randomized analysis of the potential impact of APs on asthma outcomes in ED patients.

Illness perceptions about asthma are determinants of outcome

This article reviews an emerging area of research on patients with asthma: namely, illness perceptions and their relationships with various aspects of outcome. The article briefly introduces the Common Sense Model, outlining the relevance of how "lay" patients conceptualize symptoms, illness, and treatment. On the basis of a comprehensive literature search, nine empirical studies illustrating the relationships between illness perceptions and outcomes are discussed. It is concluded that further research should focus on assessing asthma-specific illness and treatment beliefs. Also, given the effects of intervention studies in illness perceptions in other patient categories, it is recommended that serious consideration be given to intervention studies focusing on eliciting and changing illness perceptions in asthma patients, especially in those whose self-management seems to be inadequate.

The effectiveness of nurse-led telemonitoring of asthma: results of a randomized controlled trial

RATIONALE, AIMS AND OBJECTIVES

The aim of the study was to evaluate the effects on, and the relationship between, asthma symptoms, asthma-specific quality of life and medical consumption of a nurse-led telemonitoring intervention compared with regular care in asthma in the Netherlands.

METHODS

One hundred and nine asthmatic outpatients (56 children; 53 adults) were randomly assigned to the treatment arms (12-month follow-up). The control group received regular outpatient care, while the intervention group used an asthma monitor with modem at home with an asthma nurse as the main caregiver. Clinical asthma symptoms and medical consumption were measured by using diaries. Asthma-specific quality of life was measured by the (Paediatric) Asthma Quality of Life Questionnaire.

RESULTS

The study population generally represented mild to moderate asthmatics. The results show improvement in follow-up, but no statistically significant difference between the groups was observed. Moderate to high correlations were found within the outcome parameters, but the most remarkable was the low and statistically significant correlation between asthma-specific quality of life (daily functioning) and the self-reported beta-2 agonists.

CONCLUSION

Overall, the telemonitoring programme evaluated in this study did not significantly decrease asthma symptoms or medical consumption, or improve asthma-specific quality of life. The results showed that a telemonitoring programme on its own is not a guarantee of success. The patients' perception of asthma-specific quality of life (daily functioning) should be a key element in asthma telemonitoring programmes.

Asthma counselling targeted to removal of domestic animals

OBJECTIVES

To create and evaluate the efficacy of a short individualized educational intervention program, based on Prochaska's transtheoretical model, for a six-month period in a population of adult asthma patients living with domestic animals but sensitized to these pets.

METHODS

A randomized, controlled study using a pretested questionnaire was conducted at three different times (pretest, and at three and six months postintervention).

RESULTS

Eleven members (29%) of the intervention group and eight members (21%) of the control group removed their pets within six months (X(2)=3.23; P>0.35). The two groups showed similar improvements in their perception of the benefits of pet removal and in their level of belief that they could do it. The experimental group showed a greater improvement in knowledge acquisition about asthma and allergies than the control group (P<0.05). Both experimental and standard educational interventions were effective in facilitating progression through the stages of behavioural change.

CONCLUSION

Overall, the results do not support the utility of behavioural change educational intervention, tailored to the transtheoretical model stage of the individual, in the context of convincing patients to remove their pets from their homes. However, the decision-making aid appears to be helpful in raising awareness of the problem of asthma and allergy in the patient, and in developing appropriate knowledge.

An interactive workshop plus locally adapted guidelines can improve general practitioners asthma management and knowledge: a cluster randomised trial in the Australian setting

BACKGROUND

A cluster randomised trial was conducted to determine the effectiveness of locally adapted practice guidelines and education about paediatric asthma management, delivered to general practitioners (GPs) in small group interactive workshops.

METHODS

Twenty-nine practices were randomly allocated to one of three study arms. Australian asthma management guidelines were adapted to accommodate characteristics of the local area. GPs in the intervention arm (Group 1, n = 18 GPs) participated in a small group based education program and were provided with the adapted guidelines. One control arm (Group 2, n = 18 GPs) received only the adapted guidelines, while the other control arm (Group 3, n = 15 GPs) received an unrelated education intervention. GPs' knowledge, attitudes and management of paediatric asthma was assessed.

RESULTS

Post intervention, intervention arm GPs were no more likely to provide a written asthma action plan, but were better able to assess the severity of asthma attack (Group 1vs Group 2 p = 0.05 and Group 1 vs Group 3 p = 0.01), better able to identify patients at high risk of severe attack (Group 1vs Group 3 p = 0.06), and tended to score higher on the asthma knowledge questionnaire (Group 1 vs Group 2 p = 0.06 and Group 1 vs Group 3 p = 0.2). Most intervention arm GPs felt more confident than control GPs to manage acute asthma attack and ongoing management of infrequent episodic asthma.

CONCLUSION

Using interactive small group workshops to disseminate locally adapted guidelines was associated with improvement in GP's knowledge and confidence to manage asthma, but did not change GP's self-reported provision of written action plans.

Examining asthma quality of care using a population-based approach

BACKGROUND

Asthma accounts for considerable burden on health care, but in most cases, asthma can be controlled. Quality-of-care indicators would aid in monitoring asthma management. We describe the quality of asthma care using a set of proposed quality indicators.

METHODS

We performed a retrospective cross-sectional study using health databases in Saskatchewan, a Canadian province with a population of about 1 million people. We assessed 6 quality-of-care indicators among people with asthma: admission to hospital because of asthma; poor asthma control (high use of short-acting beta-agonists, admission to hospital because of asthma or death due to asthma); no inhaled corticosteroid use among patients with poor control; at least moderate inhaled corticosteroid use among patients with poor control; high inhaled corticosteroid use and use of another preventer medication among patients with poor control; and any main preventer use among patients with poor control. We calculated crude and adjusted rates with 95% confidence intervals. We tested for differences using the chi2 test for proportions and generalized linear modelling techniques.

RESULTS

In 2002/03, there were 24 616 people aged 5-54 years with asthma in Saskatchewan, representing a prevalence of 3.8%. Poor symptom control was observed in 18% of patients with asthma. Among those with poor control, 37% were not dispensed any inhaled corticosteroids, and 40% received potentially inadequate doses. Among those with poor control who were dispensed high doses of inhaled corticosteroids, 26% also used another preventer medication. Hospital admissions because of asthma were highest among those aged 6-9 years and females aged 20-44 years. Males and those in adult age groups (predominantly 20-44 years) had worse quality of care for 4 indicators examined.

INTERPRETATION

Suboptimal asthma management would be improved through increased use of inhaled corticosteroids and preventer medications, and reduced reliance on short-acting beta-agonist medications as recommended by consensus guidelines.

Impact of quality circles for improvement of asthma care: results of a randomized controlled trial

RATIONALE AND AIMS

Quality circles (QCs) are well established as a means of aiding doctors. New quality improvement strategies include benchmarking activities. The aim of this paper was to evaluate the efficacy of QCs for asthma care working either with general feedback or with an open benchmark.

METHODS

Twelve QCs, involving 96 general practitioners, were organized in a randomized controlled trial. Six worked with traditional anonymous feedback and six with an open benchmark; both had guided discussion from a trained moderator. Forty-three primary care practices agreed to give out questionnaires to patients to evaluate the efficacy of QCs.

RESULTS

A total of 256 patients participated in the survey, of whom 185 (72.3%) responded to the follow-up 1 year later. Use of inhaled steroids at baseline was high (69%) and self-management low (asthma education 27%, individual emergency plan 8%, and peak flow meter at home 21%). Guideline adherence in drug treatment increased (P = 0.19), and asthma steps improved (P = 0.02). Delivery of individual emergency plans increased (P = 0.008), and unscheduled emergency visits decreased (P = 0.064). There was no change in asthma education and peak flow meter usage. High medication guideline adherence was associated with reduced emergency visits (OR 0.24; 95% CI 0.07-0.89). Use of theophylline was associated with hospitalization (OR 7.1; 95% CI 1.5-34.3) and emergency visits (OR 4.9; 95% CI 1.6-14.7). There was no difference between traditional and benchmarking QCs.

CONCLUSIONS

Quality circles working with individualized feedback are effective at improving asthma care. The trial may have been underpowered to detect specific benchmarking effects. Further research is necessary to evaluate strategies for improving the self-management of asthma patients.

The effects of additional care by a pulmonary nurse for asthma and COPD patients at a respiratory outpatient clinic: results from a double blind, randomized clinical trial

OBJECTIVE

To assess the effects of additional information based nursing care program in the treatment of asthma and COPD patients at a pulmonary outpatient clinic.

METHODS

In a double blind, randomized clinical trial, 191 patients were allocated to an additional care group or control group. Patients in the intervention group received a protocol-based education program on individual basis by a pulmonary nurse on individual basis (average duration 60 min per patient). All patients were masked for the trial objectives. Effectiveness was expressed in terms of knowledge, inhalation technique, self-management, exacerbation rate (primary outcomes), and health-related quality of life and satisfaction with care received (secondary outcomes). The time interval between the initial and final assessments was 6 months.

RESULTS

Ninety-seven patients were randomized into the additional care group and 94 into the control group, of which 157 had a complete dataset. (Un)adjusted analyses did not show differences between treatment groups in terms of knowledge, inhalation technique, self-management, health-related quality of life, and satisfaction with care. Multivariate logistic regression adjusting for baseline covariates showed a significant treatment effect with regard to exacerbation rate (odds ratio=0.35; 95% confidence limits: 0.13/0.94, p=0.04).

CONCLUSION

With the exception of exacerbation rate, we could not demonstrate efficacy of additional nursing care in a broad range of outcome parameters.

PRACTICE IMPLICATIONS

At present we do not recommend to implement our patient-tailored education program in daily practice.

Racial and ethnic disparities in the quality of asthma care

Racial and ethnic disparities in the quality of asthma care have been well documented in the United States. There are multiple factors associated with such disparities in asthma care, including structural barriers (eg, ability to access the health-care system), process-of-care barriers (eg, ability to navigate the health-care system), and process-of-care barriers at the interpersonal level (eg, ability to work effectively with a health-care provider) for equitable, quality asthma care. This article summarizes these issues and identifies specific areas for future investigation. At a health-systems level, further work is needed to understand how medical care financing arrangements may or may not be contributing to racial and ethnic disparities in asthma care, as well as how specific organizational initiatives can address these issues. Research needs at the patient/provider level include defining the content and methods for disseminating issues regarding cultural competency to health-care providers.

Comparison of Canadian versus American emergency department visits for acute asthma

BACKGROUND

Acute asthma is a common emergency department (ED) presentation in both Canada and the United States.

OBJECTIVE

To compare ED asthma management and outcomes between Canada and the United States.

METHODS

A prospective cohort study of 69 American and eight Canadian EDs was conducted. Patients aged two to 54 years who presented with acute asthma underwent a structured ED interview and telephone follow-up two weeks later.

RESULTS

A total of 3031 patients were enrolled. Canadian patients were more likely to be white (89% versus 22%; P<0.001), have health insurance (100% versus 69%; P<0.001) and identify a primary care provider (89% versus 64%; P<0.001) than American patients. In addition, Canadian patients were more likely to be using inhaled corticosteroids (63% versus 44%; P<0.001) and had higher initial peak expiratory flow (61% versus 48%; P<0.001). In the ED, Canadians received fewer beta-agonist (one versus two; P<0.001) and more anticholinergic (two versus one; P<0.001) treatments in the first hour; use of systemic corticosteroids was similar (60% versus 68%; P=0.13). Canadians were less likely to be hospitalized (11% versus 21%; P=0.02). Corticosteroids were prescribed similarly at discharge (60% versus 69%; P=0.13); however, Canadians were discharged more commonly on inhaled corticosteroids (63% versus 11%; P<0.001) and relapses were similar.

CONCLUSIONS

Canadian patients with acute asthma have fewer barriers to primary care and are more likely to be on preventive medications, both before the ED visit and following discharge. Admissions rates are higher in the United States; however, relapse after discharge is similar between countries. These findings highlight the influences of preventive practices and heath care systems on ED visits for asthma.

Novel interactive cell-phone technology for health enhancement

Self-care is essential in chronic disease management; however, adherence to self-care plans is often far from optimal. Advances in technology can facilitate self-management of chronic disease through patient empowerment and timely feedback. The Confidant system is a novel wireless remote patient monitoring and response system, centered around mobile phone technology, that translates scientifically supported knowledge for chronic disease management into action by providing easily followed daily coaching using the patient's own data. Daily provision of interactive, informative messages removes the burdens of recall, record keeping, decision making, scheduling, and data analysis. A pilot-controlled clinical trial evaluated the feasibility and efficacy of the Confidant system in the management of type 2 diabetes in 15 patients utilizing the cell-phone technology and 15 individuals in a control group (standard type 2 diabetes care). The study demonstrated improved levels of glycosylated hemoglobin, positive changes in diabetes management self-efficacy, and diabetes self-care activities among intervention group patients. A larger trial is now in development to demonstrate the clinical benefit of using the Confidant system among type 2 diabetic patients. This article describes the novel technology and applications of the Confidant system.

Features of asthma management: quantifying the patient perspective

BACKGROUND

In the management of asthma, features of care important to patients may not be fully appreciated. This study quantifies the importance of different features of asthma management from the patient perspective. This may assist in the development of personalised management strategies.

METHODS

We used the technique of discrete choice experiment (DCE). Patients over 18 years of age with asthma, prescribed and taking medicine at step 3 of the UK guidelines were recruited from 15 general (family) practices in three areas of the UK. 147 evaluable questionnaires were returned from a total of 348 sent out. The outcome measures were the relative importance to patients of features of asthma management and the impact of changes in asthma management, as measured by utility shift between the features tested.

RESULTS

The largest shift in mean utility values was recorded in "number of inhalers" and "use of inhaled steroid". Use of a personal asthma action plan was ranked next highest.

CONCLUSION

This study suggests that adults with moderate or severe asthma would trade some improvements in symptom relief in favour of, for example, simpler treatment regimens that use as few inhalers as possible and a lower dose of inhaled steroid.

Asthma patients with low perceived burden of illness: a challenge for guideline adherence

RATIONALE AND AIMS

The reason why many patients seem to tolerate suffering from sub-optimal treated asthma remains unclear. The aim was to evaluate the guideline adherence combined with quality of life of patients with moderate to severe asthma.

METHODS

256 asthma patients from 43 primary care practices in Saxony-Anhalt filled in a questionnaire including the Asthma Quality of Life Questionnaire (AQLQ), the Patient Health Questionnaire (PHQ-D) and questions evaluating the asthma severity, medication and self-management.

RESULTS

43.4% suffered from moderate to severe asthma. Drug treatment accorded with guidelines in 36.9%, drug dosage of inhaled steroids was too low in 34.3%, and 21.5% were not treated according to guidelines. A total of 7.3% of the patients received end-of-dose therapy. AQLQ declined and depression rose with asthma severity and guideline non-adherence (P < 0.001). Only 29.1% received asthma education. However, 64.5% of the patients without education did not want to receive education. They had a higher quality of life, lower depression (P < 0.001) and lower use of steroids (P = 0.016). Higher depression scores where related with hospital admission (OR 3.29; 95% CI 1.57-6.87 for each quartile of PHQ-D) and unscheduled home visits or ambulatory care (OR 1.58; 1.07-2.33).

CONCLUSION

There is a large variation of asthma severity which can partly be explained by the guideline adherence of medication and deficits of patients' management. The perceived burden of illness plays a more important role for education and self-management than the real severity of disease. Therefore, target-oriented interventions are needed to identify and motivate patients at risk.

[Economic aspects of severe asthma]

Severe asthma and difficult-to-treat asthma are major issues in public health, given the mortality and morbidity they induce and their detrimental effects on patients' quality of life. The economic consequences should not be overlooked either. Published studies suggest that asthma-related medical resource use increases with the degree of asthma severity. Medical resource use incurred by severe (and/or difficult-to-treat) asthma could be reduced in part by more appropriate treatment, better patient education, improved coordination of disease management and treatment of comorbid diagnoses. The specific difficulties in the management of severe asthma and/or difficult-to-treat asthma must nonetheless be kept in mind. Recent new treatments appear promising, but their costs and indications in actual medical practice require better definition.

Indigenous healthcare worker involvement for Indigenous adults and children with asthma

BACKGROUND

Asthma education is regarded as an important step in the management of asthma in national guidelines. Racial and socio-economic factors are associated with markers of asthma severity, including recurrent acute presentations to emergency health facilities. Worldwide, indigenous groups are disproportionately represented in the severe end of the asthma spectrum. Appropriate models of care are important in the successful delivery of services, and are likely contributors to improved outcomes for people with asthma.

OBJECTIVES

To determine whether involvement of an indigenous healthcare worker (IHW) in comparison to absence of an IHW in asthma education programmes, improves asthma related outcomes in indigenous children and adults with asthma.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register, MEDLINE and EMBASE databases, review articles and reference lists of relevant articles. The latest search was in December 2006.

SELECTION CRITERIA

All randomised controlled trials comparing involvement of an indigenous healthcare worker (IHW) in comparison to absence of an IHW in asthma education programmes for indigenous people with asthma.

DATA COLLECTION AND ANALYSIS

Two independent review authors selected data for inclusion, a single author extracted the data. Both review authors independently assessed study quality. We contacted authors for further information. As it was not possible to analyse data as "intention-to-treat", we analysed data as "treatment received".

MAIN RESULTS

Only a single study was applicable for this review, and included 24 children randomised to an asthma education programme involving an IHW, compared to a similar intervention without an IHW. Twenty two of these children completed the trial. Only one outcome (asthma knowledge in children, mean difference of 3.30 units, 95% CI 1.07 to 5.53) significantly favoured the IHW involvement group. However, although not statistically significant, all the outcomes favoured the group that had IHW involvement in the asthma education program. There were no studies in adults.

AUTHORS' CONCLUSIONS

The involvement of IHW in asthma programs targeted for their own ethnic group in one small trial was beneficial for some but not all asthma outcomes. Thus there is insufficient data to be confident that the involvement of IHW is beneficial in all settings. Nevertheless, given the complexity of health outcomes and culture as well as the importance of self-determination for indigenous peoples, the practice of including IHW in asthma education programs for indigenous children and adults with asthma is justified, but should be subject to further randomised controlled trials.

Self-management education for patients with chronic obstructive pulmonary disease

BACKGROUND

There is great interest in chronic obstructive pulmonary disease (COPD) and the associated large burden of disease. COPD is characterised by frequent day by day fluctuations, and repetitive clinical exacerbations are typical. Self-management is a term applied to educational programmes aimed at teaching skills needed to carry out medical regimens specific to the disease, guide health behaviour change, and provide emotional support for patients to control their disease and live functional lives. In COPD, the value of self-management education is not yet clear. The first Cochrane review about self-management was published in 2003. It was intended to shed light on the effectiveness of self-management programmes in COPD and the relative efficacy of their constitutive elements. No conclusions about the effectiveness of self-management could be drawn because of the large variation in outcome measures used in the limited number of included studies. This article describes the first update of this review.

OBJECTIVES

The objective of this review was to assess the settings, methods and efficacy of COPD self-management education programmes on health outcomes and use of health care services.

SEARCH STRATEGY

We searched the Cochrane Airways Group trial register, MEDLINE (January 1985 to January 2006), reference lists, and abstracts of medical conferences.

SELECTION CRITERIA

Controlled trials (randomised and non-randomised) of self-management education in patients with COPD. Studies focusing mainly on pulmonary rehabilitation and studies without usual care as a control group were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed study quality and extracted data. Investigators were contacted for additional information.

MAIN RESULTS

The reviewers included 15 group comparisons drawn from 14 trials. They assessed a broad-spectrum of interventions and health outcomes with different follow-up times. Meta-analyses could often not appropriately be performed because of heterogeneity among studies. The studies showed a significant reduction in the probability of at least one hospital admission among patients receiving self-management education compared to those receiving usual care (OR 0.64; 95% CI (0.47 to 0.89)). This translates into a one year NNT ranging from 10 (6 to 35) for patients with a 51% risk of exacerbation, to an NNT of 24 (16 to 80) for patients with a 13% risk of exacerbation. On the disease specific SGRQ, differences reached statistical significance at the 5% level on the total score (WMD -2.58; 95% CI (-5.14 to -0.02)) and impact domain (WMD -2.83; 95% CI (-5.65 to -0.02)), but these difference did not reach the clinically relevant improvement of 4 points. A small but significant reduction was detected in dyspnoea measured with the BORG-scale (WMD -0.53; 95% CI (-0.96 to -0.10)). No significant effects were found either in number of exacerbations, emergency department visits, lung function, exercise capacity, and days lost from work. Inconclusive results were observed in doctor and nurse visits, on symptoms other than dyspnoea, the use of courses of oral corticosteroids and antibiotics, and the use of rescue medication.

AUTHORS' CONCLUSIONS

It is likely that self-management education is associated with a reduction in hospital admissions with no indications for detrimental effects in other outcome parameters. This would in itself already be enough reason for recommending self-management education in COPD. However, because of heterogeneity in interventions, study populations, follow-up time, and outcome measures, data are still insufficient to formulate clear recommendations regarding the form and contents of self-management education programmes in COPD. There is an evident need for more large RCTs with a long-term follow-up, before more conclusions can be drawn.

Understanding the potential role of mobile phone-based monitoring on asthma self-management: qualitative study

BACKGROUND

National and international healthcare policy increasingly seeks technological solutions to the challenge of providing care for people with long-term conditions. Novel technologies, however, have the potential to change the dynamics of disease monitoring and self-management. We aimed to explore the opinions and concerns of people with asthma and primary care clinicians on the potential role of mobile phone monitoring technology (transmitting symptoms and peak flows, with immediate feedback of control and reminder of appropriate actions) in supporting asthma self-management.

METHODS

This qualitative study recruited 48 participants (34 adults and teenagers with asthma, 14 asthma nurses and doctors) from primary care in Lothian (Central Scotland) and Kent (South East England). Thirty-nine participated in six focus groups, which included a demonstration of the technology; nine gave in-depth interviews before and after a 4-week trial of the technology.

RESULTS

Participants considered that mobile phone-based monitoring systems can facilitate guided self-management although, paradoxically, may engender dependence on professional/technological support. In the early phases, as patients are learning to accept, understand and control their asthma, this support was seen as providing much-needed confidence. During the maintenance phase, when self-management predominates, patient and professionals were concerned that increased dependence may be unhelpful, although they appreciated that maintaining an on-going record could facilitate consultations.

CONCLUSION

Mobile phone-based monitoring systems have the potential to support guided self-management by aiding transition from clinician-supported early phases to effective self-management during the maintenance phase. Continuing development, adoption and formal evaluation of these systems should take account of the insights provided by our data.

Electronic communications and home blood pressure monitoring (e-BP) study: design, delivery, and evaluation framework

BACKGROUND

Randomized controlled trials have provided unequivocal evidence that treatment of hypertension decreases mortality and major disability from cardiovascular disease; however, blood pressure remains inadequately treated in most affected individuals. This large gap continues despite the facts that more than 90% of adults with hypertension have health insurance, and hypertension is the leading cause of visits to the doctor. New approaches are needed to improve hypertension care.

OBJECTIVES

The Electronic Communications and Home Blood Pressure Monitoring (e-BP) study is a three-arm randomized controlled trial designed to determine whether care based on the Chronic Care Model and delivered over the Internet improves hypertension care. The primary study outcomes are systolic, diastolic, and blood pressure control; secondary outcomes are medication adherence, patient self-efficacy, satisfaction and quality of life, and healthcare utilization and costs.

METHODS

Hypertensive patients receiving care at Group Health medical centers are eligible if they have uncontrolled blood pressure on two screening visits and access to the Web and an e-mail address. Study participants are randomly assigned to three intervention groups: (a) usual care; (b) home blood pressure monitoring receipt and proficiency training on its use and the Group Health secure patient website (with secure e-mail access to their healthcare provider, access to a shared medical record, prescription refill and other services); or (c) this plus pharmacist care management (collaborative care management between the patient, the pharmacist, and the patient's physician via a secure patient website and the electronic medical record).

CONCLUSION

We will determine whether a new model of patient-centered care that leverages Web communications, self-monitoring, and collaborative care management improves hypertension control. If this model proves successful and cost-effective, similar interventions could be used to improve the care of large numbers of patients with uncontrolled hypertension.

Cost-effectiveness of a nurse-led telemonitoring intervention based on peak expiratory flow measurements in asthmatics: results of a randomised controlled trial

Background

Asthma is a chronic lung disease in which recurrent asthma symptoms create a substantial burden to individuals and their families. At the same time the economic burden associated with asthma is considerable.

Methods

The cost-effectiveness study was part of a single centre prospective randomised controlled trial comparing a nurse-led telemonitoring programme to usual care in a population of asthmatic outpatients. The study included 109 asthmatic outpatients (56 children; 53 adults). The duration of follow-up was 12 months, and measurements were performed at baseline, 4, 8, and 12 months. Patients were asked to transfer their monitor data at least twice daily and by judging the received data and following a stepwise intervention protocol a nurse was able to act as the main caregiver in the intervention group. In both groups the EQ-5D and the SF-6D were used to obtain estimates of health state utilities. One year health care costs, patient and family costs, and productivity losses were calculated. The mean incremental costs were weighted against the mean incremental effect in terms of QALY.

Results

The study population generally represented mild to moderate asthmatics. No significant differences were found between the groups with regard to the generic quality of life. Overall, the mean health care costs per patient were higher in the intervention group than in the control group. The intervention costs mainly caused the cost difference between the groups. The intervention costs the society € 31,035/QALY gained with regard to adults and with regard to children € 59,071/QALY gained.

Conclusion

If the outcome is measured by generic quality of life the nurse-led telemonitoring programme is of limited cost-effectiveness in the study population. From the societal perspective the probability of the programme being cost-effective compared to regular care was 85% at a ceiling ratio of € 80,000/QALY gained among the adults and 68% among the children. A decrease in the price of the asthma monitor will substantial increase the probability of the programme to be cost-effective.

Trial registration

Number: NCT00411436

Education interventions for adults who attend the emergency room for acute asthma

BACKGROUND

The use of educational and behavioural interventions in the management of chronic asthma have a strong evidence base. There may be a role for educative interventions following presentation in an emergency setting in adults.

OBJECTIVES

To assess the effectiveness of educational interventions administered following an acute exacerbation of asthma leading to presentation in the emergency department.

SEARCH STRATEGY

We searched the Cochrane Airways Group trials register. Study authors were contacted for additional information. Searches are current to November 2006.

SELECTION CRITERIA

Randomised, parallel group trials were eligible if they recruited adults (> 17 years) who had presented at an emergency department with an acute asthma exacerbation. The intervention of interest was any educational intervention (for example, written asthma management plan).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

Twelve studies involving 1954 adults were included. Education significantly reduced subsequent admission to hospital (relative risk 0.50; 95% confidence interval 0.27 to 0.91); however, did not significantly reduce the risk of re-presentation at emergency departments (ED) the study follow up (relative risk 0.69; 95% confidence interval 0.40 to 1.21). The lack of statistically significant differences between asthma education and control groups in terms of peak flow, quality of life, study withdrawal and days lost were hard to interpret given the low number of studies contributing to these outcomes. One study from the early 1990s measured cost and found no difference for total costs and costs related to physician visits and admissions to hospital. If data were restricted to emergency department treatment, education led to lower costs than control.

AUTHORS' CONCLUSIONS

This review found that educational interventions applied in the emergency department reduce subsequent asthma admissions to hospital. The interventions did not significantly reduce ED re-presentations; while the trend in effect favours educational interventions, the pooled results were not statistically significant. The impact of educational intervention in this context on longer term outcomes relating to asthma morbidity is unclear. Priorities for additional research in this area include assessment of health-related quality of life, lung function assessment, exploration of the relationship between socio-economic status and asthma morbidity, and better description of the intervention assessed.

Action plans for the long-term management of anaphylaxis: systematic review of effectiveness

BACKGROUND

Anaphylaxis is a severe, potentially life-threatening allergic reaction. Most reactions occur in the absence of a healthcare professional and there is a considerable risk of recurrence in those with a past history of anaphylaxis. The concept of action plans has been developed to facilitate long-term self-management of chronic disorders with a view to promoting patient empowerment and improving health outcomes. Although increasingly advocated for use in anaphylaxis, the effectiveness of this approach in this context is unknown.

OBJECTIVES

To assess the effectiveness of action plans as part of the long-term self-management of anaphylaxis in improving health outcomes.

METHODS

Standard systematic review techniques were used. We searched CENTRAL, Cochrane, Medline and Embase databases, contacted an international panel of anaphylaxis experts and relevant pharmaceutical companies and searched key web-based databases of trials (http://www.clinicaltrials.gov, http://www.controlledtrials.com and http://www.nrr.nhs.uk) for published, unpublished and on-going randomized or quasi-randomized controlled trials of action plans in anaphylaxis management. There was no restriction used with respect to the language of publication. Searches were completed in summer 2006.

RESULTS

None of the 1026 potentially relevant studies identified fulfilled the inclusion criteria for this review.

CONCLUSIONS

Although there are potential major benefits of routinely issuing anaphylaxis action plans, there is currently no robust evidence to guide clinical practice. Pragmatic randomized-controlled trials of anaphylaxis action plans are urgently needed; in the meantime, national and international guidelines should make clear this major gap in the evidence base.

Telecare motivational interviewing for diabetes patient education and support: a randomised controlled trial based in primary care comparing nurse and peer supporter delivery

BACKGROUND

There is increasing interest in developing peer-led and 'expert patient'-type interventions, particularly to meet the support and informational needs of those with long term conditions, leading to improved clinical outcomes, and pressure relief on mainstream health services. There is also increasing interest in telephone support, due to its greater accessibility and potential availability than face to face provided support. The evidence base for peer telephone interventions is relatively weak, although such services are widely available as support lines provided by user groups and other charitable services.

METHODS/DESIGN

In a 3-arm RCT, participants are allocated to either an intervention group with Telecare service provided by a Diabetes Specialist Nurse (DSN), an intervention group with service provided by a peer supporter (also living with diabetes), or a control group receiving routine care only. All supporters underwent a 2-day training in motivational interviewing, empowerment and active listening skills to provide telephone support over a period of up to 6 months to adults with poorly controlled type 2 diabetes who had been recommended a change in diabetes management (i.e. medication and/or lifestyle changes) by their general practitioner (GP). The primary outcome is self-efficacy; secondary outcomes include HbA1c, total and HDL cholesterol, blood pressure, body mass index, and adherence to treatment. 375 participants (125 in each arm) were sought from GP practices across West Midlands, to detect a difference in self-efficacy scores with an effect size of 0.35, 80% power, and 5% significance level. Adults living with type 2 diabetes, with an HbA1c > 8% and not taking insulin were initially eligible. A protocol change 10 months into the recruitment resulted in a change of eligibility by reducing HbA1c to > 7.4%. Several qualitative studies are being conducted alongside the main RCT to describe patient, telecare supporter and practice nurse experience of the trial. DISCUSSION AND IMPLICATIONS OF THE RESEARCH: With its focus on self-management and telephone peer support, the intervention being trialled has the potential to support improved self-efficacy and patient experience, improved clinical outcomes and a reduction in diabetes-related complications.

TRIAL REGISTRATION

Current Controlled Trials, ISRCTN63151946.

Effect of budesonide/formoterol maintenance and reliever therapy on asthma exacerbations

This randomised, double-blind, 6-month study compared budesonide/formoterol for maintenance and relief with salmeterol/fluticasone and a fixed maintenance dose of budesonide/formoterol, both with terbutaline for relief. Following a 2-week run-in, 3335 symptomatic adults and adolescents (mean FEV1 73% predicted, mean inhaled corticosteroid dose 745 microg/day) received budesonide/formoterol 160/4.5 microg one inhalation bid plus additional inhalations as needed, salmeterol/fluticasone 25/125 microg two inhalations bid plus as-needed terbutaline or budesonide/formoterol 320/9 microg one inhalation bid plus as-needed terbutaline. Budesonide/formoterol for maintenance and relief prolonged the time to first severe exacerbation requiring hospitalisation, emergency room treatment or oral steroids (primary variable) vs. fixed-dose salmeterol/fluticasone and budesonide/formoterol (p=0.0034 and p=0.023 respectively; log-rank test). Exacerbation rates were 19, 16 and 12 events/100 patients/6 months for salmeterol/fluticasone, fixed-dose budesonide/formoterol and budesonide/formoterol for maintenance and relief, respectively, [rate reduction vs. fixed-dose salmeterol/fluticasone (0.61; 95% CI 0.49-0.76, p<0.001) and vs. fixed-dose budesonide/formoterol (0.72; 95% CI 0.57-0.90, p=0.0048)]. Budesonide/formoterol maintenance and relief patients used less inhaled corticosteroid vs. salmeterol/fluticasone and fixed-dose budesonide/formoterol patients. All treatments provided similar marked improvements in lung function, asthma control days and asthma-related quality of life. Budesonide/formoterol for maintenance and relief reduces asthma exacerbations and maintains similar daily asthma control at a lower overall drug load compared with fixed-dose salmeterol/fluticasone and budesonide/formoterol.

Self-management education for adults with epilepsy

BACKGROUND

Self-management education has been shown to improve the quality of life of people with chronic illnesses. It has been suggested that self-management education may improve seizure control and other outcomes in people with epilepsy.

OBJECTIVES

To review systematically the research literature on the effectiveness of self-management education in improving health outcomes for adults with epilepsy.

SEARCH STRATEGY

We searched MEDLINE (Ovid) (1966 to April 2005), EMBASE (Ovid) (1980 to April 2005), CINAHL (Dialog) (1980 to April 2005), PsycINFO (Dialog) (1887 to April 2005), and the Cochrane Epilepsy Group's Specialised Register (April 2005). We also handsearched Epilepsia and conference abstracts and proceedings. Experts in the field were contacted to identify any additional trials. We did not impose any language restriction. We re-ran the searches in February 2007 and added the identified references to the 'Studies awaiting assessment' table.

SELECTION CRITERIA

Randomised trials of self-management education programmes for adults with epilepsy.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed the quality of each study and extracted data.

MAIN RESULTS

Two trials evaluated the effect of self-management education for adults with epilepsy, neither of which assessed as being of high quality. In total, 483 adults with epilepsy were randomised. Both trials showed improvements in seizure frequency and other outcomes, such as knowledge. However, we were not able to estimate a summary effect for seizure frequency due to a lack of data.

AUTHORS' CONCLUSIONS

Self-management education programmes, based on increasing understanding through psychosocial methods, may improve knowledge about epilepsy, certain behavioural outcomes, and reduce seizure frequency. It is, however, not clear how effective self-management programmes of epilepsy would be in a more general population of adults with epilepsy, as both trials had higher proportions of people with partial seizures than would be expected in a community sample.

Patient adherence to medical treatment: a review of reviews

BACKGROUND

Patients' non-adherence to medical treatment remains a persistent problem. Many interventions to improve patient adherence are unsuccessful and sound theoretical foundations are lacking. Innovations in theory and practice are badly needed. A new and promising way could be to review the existing reviews of adherence to interventions and identify the underlying theories for effective interventions. That is the aim of our study.

METHODS

The study is a review of 38 systematic reviews of the effectiveness of adherence interventions published between 1990 and 2005. Electronic literature searches were conducted in Medline, Psychinfo, Embase and the Cochrane Library. Explicit inclusion and exclusion criteria were applied. The scope of the study is patient adherence to medical treatment in the cure and care sector.

RESULTS

Significant differences in the effectiveness of adherence interventions were found in 23 of the 38 systematic reviews. Effective interventions were found in each of four theoretical approaches to adherence interventions: technical, behavioural, educational and multi-faceted or complex interventions. Technical solutions, such as a simplification of the regimen, were often found to be effective, although that does not count for every therapeutic regimen.Overall, our results show that, firstly, there are effective adherence interventions without an explicit theoretical explanation of the operating mechanisms, for example technical solutions. Secondly, there are effective adherence interventions, which clearly stem from the behavioural theories, for example incentives and reminders. Thirdly, there are other theoretical models that seem plausible for explaining non-adherence, but not very effective in improving adherence behaviour. Fourthly, effective components within promising theories could not be identified because of the complexity of many adherence interventions and the lack of studies that explicitly compare theoretical components.

CONCLUSION

There is a scarcity of comparative studies explicitly contrasting theoretical models or their components. The relative weight of these theories and the effective components in the interventions designed to improve adherence, need to be assessed in future studies.

[Monitoring of asthma outpatients after adapting treatment to meet international guidelines]

OBJECTIVE

Poor control of asthma treated in outpatient settings has been demonstrated. The aim of this study was to perform a short intervention, readily replicable in everyday practice, to try to improve control of the disease.

PATIENTS AND METHODS

Two primary health care clinics made appointments with asthma patients to administer a questionnaire and adapt their treatment to the guidelines of the Global Initiative for Asthma. Patients also received an explanation of the disease lasting not more than 5 minutes. The protocol was repeated at a second visit 4 months later. Health care parameters were compared with those from the previous visit.

RESULTS

The characteristics of the 180 patients were as follows: 70% were women, 17% were smokers, 8% were illiterate, 46% had only primary education, 45% were in contact with cleaning products, and 63% had extrinsic asthma. The asthma severity was as follows: mild in 73%, moderate in 23%, and severe in 4%. Twenty-two percent had received previous explanations of the disease, 50% had a written treatment plan, 14% had a plan for exacerbations, and 54% were taking inhaled corticosteroids. The second appointment was kept by 110 (61%) of the patients, who showed differences with respect to the previous visit 4 months earlier in the percentage taking inhaled corticosteroids (78%, P< .001), the number of visits to the physician (P< .01), visits to the physician due to exacerbations (P< .001), emergency visits to the outpatient clinic (P< .002), and disease severity (P< .02).

CONCLUSIONS

This minimal clinical intervention reduced the need for visits to health care centers and improved the control of asthma symptoms.

Action plans in asthma

BACKGROUND

Action plans are recommended for most patients with persistent asthma to reduce the morbidity associated with this chronic disease. Unfortunately, despite these recommendations, this tool remains underused.

METHODS

The authors conducted a descriptive study at the asthma clinic of a tertiary care centre to determine the number of asthmatic patients presenting to a respiratory physician (new reference or follow-up visit) who possessed an individualized, written action plan, and to evaluate the patients' level of confidence and perceived efficacy toward their plans. In addition, for all patients in the study, the level of confidence in and the perceived efficacy of three different action plans (two traditional tools versus a simplified tool) were compared.

RESULTS

A total of 92 asthmatic patients were included in the study. Overall, 46% of the patients possessed an action plan. The patients' average level of confidence and perceived efficacy toward their action plans were high (4.1 out of five and 3.3 out of four, respectively). When the three different action plans were compared, the level of confidence in and perceived efficacy of the traditional tools were similar, both being superior to the simplified tool.

CONCLUSION

The number of asthmatic patients who presented to the asthma clinic and who possessed an action plan was higher than the reported Canadian mean of 10%; however, most of the patients were treated by specialized respiratory physicians, which may explain this improvement. Considering that most patients with persistent asthma should have an individualized, written action plan, the present study confirms that this tool is still not used for all asthmatic patients.

Pharmacy Asthma Care Program (PACP) improves outcomes for patients in the community

BACKGROUND

Despite national disease management plans, optimal asthma management remains a challenge in Australia. Community pharmacists are ideally placed to implement new strategies that aim to ensure asthma care meets current standards of best practice. The impact of the Pharmacy Asthma Care Program (PACP) on asthma control was assessed using a multi-site randomised intervention versus control repeated measures study design.

METHODS

Fifty Australian pharmacies were randomised into two groups: intervention pharmacies implemented the PACP (an ongoing cycle of assessment, goal setting, monitoring and review) to 191 patients over 6 months, while control pharmacies gave their usual care to 205 control patients. Both groups administered questionnaires and conducted spirometric testing at baseline and 6 months later. The main outcome measure was asthma severity/control status.

RESULTS

186 of 205 control patients (91%) and 165 of 191 intervention patients (86%) completed the study. The intervention resulted in improved asthma control: patients receiving the intervention were 2.7 times more likely to improve from "severe" to "not severe" than control patients (OR 2.68, 95% CI 1.64 to 4.37; p<0.001). The intervention also resulted in improved adherence to preventer medication (OR 1.89, 95% CI 1.08 to 3.30; p = 0.03), decreased mean daily dose of reliever medication (difference -149.11 microg, 95% CI -283.87 to -14.36; p=0.03), a shift in medication profile from reliever only to a combination of preventer, reliever with or without long-acting beta agonist (OR 3.80, 95% CI 1.40 to 10.32; p=0.01) and improved scores on risk of non-adherence (difference -0.44, 95% CI -0.69 to -0.18; p=0.04), quality of life (difference -0.23, 95% CI -0.46 to 0.00; p=0.05), asthma knowledge (difference 1.18, 95% CI 0.73 to 1.63; p<0.01) and perceived control of asthma questionnaires (difference -1.39, 95% CI -2.44 to -0.35; p<0.01). No significant change in spirometric measures occurred in either group.

CONCLUSIONS

A pharmacist-delivered asthma care programme based on national guidelines improves asthma control. The sustainability and implementation of the programme within the healthcare system remains to be investigated.

The effect of pharmacist education on asthma treatment plans for simulated patients

OBJECTIVE

To determine if an educational program designed for community pharmacists to help patients self manage their asthma could improve pharmacists abilities to facilitate asthma treatment plans. Setting Hamilton and Toronto, Ontario, Canada.

METHOD

A randomized controlled trial involving volunteer community pharmacists who received either an asthma education program (AEP; intervention group) or a delayed AEP (control group). The AEP consisted of a one-day workshop and two follow-up telephone calls. Teaching methods progressed from a didactic approach to self-directed learning and role playing with simulated patients (SPs). The primary outcome was measured by SPs who conducted unannounced pharmacy visits.

MAIN OUTCOMES MEASURES

The number of appropriate (defined a priori) action plans facilitated by the pharmacist was the primary outcome. Facilitated was defined as the pharmacist recommending a specific plan, taking responsibility for telephoning the physician, or ensuring the patient would take responsibility for contacting the physician.

RESULTS

Thirty-three pharmacists were randomized to the intervention group and 31 pharmacists were randomized to the control group. Pharmacists in the intervention group facilitated an appropriate plan in 44.8% of situations (117 out of a possible 261) compared with 29.3% (79 out of a possible 270) in the control group, (mean difference 15.5% (95% CI: 7.4-23.8%; P = 0.0004)). Intervention group pharmacists were better able to facilitate plans for the 'under use of inhaled corticosteroids,' 'exposure to pet dander as an asthma trigger,' and 'overuse of short-acting beta-agonist' problems. Intervention group pharmacists exhibited better overall communication skills (including empathy, coherence, verbal skills, and nonverbal skills).

CONCLUSION

This AEP produced improvements in pharmacists' abilities to facilitate plans for SPs in a community pharmacy setting.

Perspectives that influence action plans for chronic obstructive pulmonary disease

BACKGROUND

Prompt treatment of acute exacerbations (AEs) in chronic obstructive pulmonary disease (COPD) improves quality of life and reduces the use of health care resources. Although patient self-management through an individualized action plan (AP) can help with early initiation of therapy, its use is critically dependent on the patient recognizing the features of an exacerbation.

OBJECTIVE

To describe COPD patients' experiences with AEs, as well as health care professionals' (HCPs') attitudes toward the provision of an AP as part of self-management education.

METHODS

Thirty-two patients with moderate to severe COPD who recently experienced at least one AE, and 22 HCPs with experience in the management of COPD, were interviewed.

RESULTS

The most common symptoms and signs associated with an AE were difficulty breathing (84%), fatigue (81%), cold symptoms (59%), changes in sputum colour (53%) or amount (47%), and cough (44%). The main precipitants identified were environmental triggers (47%), infective agents (31%), excessive activities (25%), emotional factors (16%) and changes in medications (9%). Strategies for dyspnea relief included increasing medications (72%), resting (56%), avoiding exposure to environmental triggers (41%) and performing breathing exercises (31%). Patients supported the use of an AP and recommended that it be individualized for symptoms and triggers, and that it should also include strategies for addressing anxiety and depression. HCPs also supported the use of an individualized AP and recommended that it be regularly revisited, depending on the patient's disease severity.

CONCLUSIONS

Patients' experiences with AEs do not always conform to a standard medical definition. Therefore, an understanding of their experience is of value in the design of an individualized AP. HCPs support the use of an AP that emphasizes self-management of exacerbations as well as general COPD management.

Asthma control in Canada remains suboptimal: the Reality of Asthma Control (TRAC) study

BACKGROUND

Two Canadian studies showed that 55% of patients with asthma had daily symptoms (in 1996) and that 57% of patients suffered from poorly controlled asthma (in 1999).

OBJECTIVES

To assess the state of asthma control of adult Canadians, and asthma knowledge and practices of Canadian physicians actively involved in the care of patients with asthma.

METHODS

Telephone interviews were conducted with adults 18 to 54 years of age who had been diagnosed with asthma at least six months before the survey, who did not have chronic obstructive pulmonary disease and who had a smoking history of fewer than 20 pack-years. Physicians were surveyed by telephone and mail. The surveys took place between April and August 2004.

RESULTS

Almost all (97%) of the 893 patients believed that they had controlled asthma; however, only 47% had controlled disease according to symptom-based guideline criteria. Just 39% of 463 physicians based their treatment recommendations on the Canadian asthma guidelines most or all of the time, despite having a high awareness of them. Only 11% of patients had written action plans, and one-half of patients with action plans did not use them regularly. Almost three-quarters of patients expressed concerns about taking inhaled corticosteroids.

CONCLUSIONS

Since the last major national survey, guideline implementation has not resulted in significant changes in asthma-related morbidity. Effective means of knowledge transfer should be developed and implemented to improve the translation of guideline recommendations into care.

A psychological approach to providing self-management education for people with type 2 diabetes: the Diabetes Manual

BACKGROUND

The objectives of this study were twofold (i) to develop the Diabetes Manual, a self-management educational intervention aimed at improving biomedical and psychosocial outcomes (ii) to produce early phase evidence relating to validity and clinical feasibility to inform future research and systematic reviews.

METHODS

Using the UK Medical Research Council's complex intervention framework, the Diabetes Manual and associated self management interventions were developed through pre-clinical, and phase I evaluation phases guided by adult-learning and self-efficacy theories, clinical feasibility and health policy protocols. A qualitative needs assessment and an RCT contributed data to the pre-clinical phase. Phase I incorporated intervention development informed by the pre-clinical phase and a feasibility survey.

RESULTS

The pre-clinical and phase I studies resulted in the production in the Diabetes Manual programme for trial evaluation as delivered within routine primary care consultations.

CONCLUSION

This complex intervention shows early feasibility and face validity for both diabetes health professionals and people with diabetes. Randomised trial will determine effectiveness against clinical and psychological outcomes. Further study of some component parts, delivered in alternative combinations, is recommended.

Quality of care in patients with asthma and rhinitis treated by respiratory specialists and primary care physicians: a 3-year randomized and prospective follow-up study

BACKGROUND

Previous studies evaluating asthma care provided by primary care providers and respiratory specialists (RSs) are limited by short observation periods and nonrandomized designs.

OBJECTIVE

To evaluate long-term outcomes in patients with asthma and rhinitis randomly selected to be cared for by RSs or primary care specialists.

METHODS

In a randomized, 3-year, longitudinal study, 472 patients with asthma and allergic rhinitis were cared for by RSs or primary care physicians. Outcome measures, including disease severity, lung function, medication use, compliance, and self-management knowledge, were compared between groups.

RESULTS

Compared with patients followed up by primary care providers, those in the RS group had reduced asthma severity (P = .046), significantly fewer days with asthma symptoms (P < .01), and improved asthma self-management knowledge (P < .01). At baseline, most patients were undertreated. This value was significantly reduced from 74% to 37% in the RS group and from 71% to 57% in the primary care physician group. We found odds ratios of 8.5 (95% confidence interval, 2-43; P < .01) for worsening of asthma and 0.3 (95% confidence interval, 0.1-0.9; P = .04) for asthma improvement when followed up by primary care physicians, which indicates that primary care follow-up increases the risk of worsening of asthma and decreases the chance of improving. Similar results were observed in patients with allergic rhinitis, although the findings were less pronounced.

CONCLUSION

Treatment and follow-up by an RS ensured better quality of care in patients with asthma and rhinitis.