Internet-based self-management compared with usual care in adolescents with asthma: a randomized controlled trial

The effect of online peer and adult education given to adolescents with allergic asthma on their quality of life, self-efficacy, anxiety, and disease knowledge and management: a randomized controlled study

OBJECTIVE

To examine the effect of interactive online education given by peers or adults on anxiety, self-efficacy, quality of life, disease knowledge and management in adolescents with allergic asthma.

METHODS

This was a randomized controlled trial. The study sample consisted of 84 adolescents divided into experimental groups (peer education group, adult education group) and a control group. Peer and adult groups who received training were also compared with each other. The adolescents in the peer or adult education groups were given online interactive education. Data were collected from the adolescents before and immediately after education, one and three months after education.

RESULTS

The study was completed by 41 adolescents. The anxiety scores of the adolescents in the experimental groups were lower immediately and one month after education than those of the control group (p = .006; p = .012, respectively). The self-efficacy, disease knowledge and management scores of the adolescents in the experimental groups immediately after education and one and three months after education were higher than those in the control group (p < .001; p < .001; p = .015, respectively and p < .001; p < .001; p < .001, respectively). There was no difference between the groups in terms of quality of life (p > .05). No difference was found between the peer and adult groups in terms of anxiety, self-efficacy, quality of life, disease knowledge and management (p > .05).

CONCLUSION

Based on our results, peer or adult education reduced adolescents' anxiety, increased self-efficacy, and disease knowledge and management, but there was no effect on quality of life. There was no difference in measured values between the peer and adult education groups.

Assessing Available Adolescent Self-Reported Measures for Asthma Management: A Systematic Literature Review

Objective: Asthma is a common chronic disease and a substantial public health problem for children, adolescents, and adults. Adolescence, a period of increased independence and striving for autonomy, is an opportune time for youth transitioning to adulthood to assume more responsibility for their own asthma self-management. However, accurate measures of adolescent asthma outcomes are limited. The purpose of this systematic review is to identify self-reported asthma measures currently available in the empirical literature focused on adolescent populations. Methods: Search terms were based on the National Library of Medical Subject Headings and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Databases searched included CINAHL, Nursing Allied Health Prevention, Medline, ProQuest, and PubMed. Included studies were peer reviewed and published in English between 2010 and 2022. All studies reported on asthma measures for adolescents between 10 and 19 years old. Results: Nineteen studies were included, comprising 15 experimental and 4 quasi-experimental. This review revealed the following asthma measure domains: asthma knowledge, self-efficacy, attitudes, self-care, self-regulation, symptom prevention and management, medication adherence, asthma disease control, symptoms, and quality of life (QOL) for evaluating psychosocial, behavioral, clinical, and QOL outcomes. Conclusion: This review revealed the necessity of developing a comprehensive measure to assess the asthma self-management behaviors of adolescents. A comprehensive tool related to adolescent asthma self-management behavior would enhance the assessment and evaluation of adolescent asthma self-management behaviors and extend the science and clinical practice around adolescent self-management. Present measures for asthma self-management behavior for adolescents are limited; therefore, developing a valid and reliable measure is necessary not only to assess adolescents' asthma self-management behavior outcomes but also to identify and evaluate the essential components to include in educational interventions for adolescent self-management.

Personalised management and supporting individuals to live with their asthma in a primary care setting

INTRODUCTION

Complementing recognition of biomedical phenotypes, a primary care approach to asthma care recognizes diversity of disease, health beliefs, and lifestyle at a population and individual level.

AREAS COVERED

We review six aspects of personalized care particularly pertinent to primary care management of asthma: personalizing support for individuals living with asthma; targeting asthma care within populations; managing phenotypes of wheezy pre-school children; personalizing management to the individual; meeting individual preferences for provision of asthma care; optimizing digital approaches to enhance personalized care.

EXPERT OPINION

In a primary care setting, personalized management and supporting individuals to live with asthma extend beyond the contemporary concepts of biological phenotypes and pharmacological 'treatable traits' to encompass evidence-based tailored support for self-management, and delivery of patient-centered care including motivational interviewing. It extends to how we organize clinical practiceand the choices provided in mode of consultation. Diagnostic uncertainty due to recognition of phenotypes of pre-school wheeze remains a challenge for primary care. Digital health can support personalized management, but there are concerns about increasing inequities. This broad approach reflects the traditionally holistic ethos of primary care ('knowing their patients and understanding their communities'), but the core concepts resonate with all healthcare.

Standard patient training versus Vik-Asthme chatbot-guided training: 'AsthmaTrain' - a protocol for a randomised controlled trial for patients with asthma

INTRODUCTION

Therapeutic education for patients with asthma has been shown to reduce asthma morbidity. The high availability of smart phones provides the opportunity to furnish patient training via specifically designed chatbot applications. The goal of this protocol is to perform a first pilot comparison of traditional face to face versus chatbot-guided patient therapeutic education programmes for patients with asthma.

METHODS AND ANALYSIS

Eighty adult patients with a physician-confirmed diagnosis of asthma will be enrolled in a two-parallel-arm, randomised (1:1) controlled pilot trial. A single-Zelen consent procedure is deployed to first enrol all participants in the comparator arm, that is, the standard patient therapeutic education programme at the University Hospitals of Montpellier, France. This means of patient therapeutic education is based on reoccurring interviews and discussion with qualified nursing staff as per usual care. Following baseline data acquisition, randomisation will be performed. Those patients randomised to the comparator arm will not be informed of the second arm. Those patients randomised to the experimental arm will be proposed access to a specifically designed chatbot (Vik-Asthme) as the second tested means of patient training (refusals continue with standard training, though analysed as intention to treat). The primary outcome is change in the total Asthma Quality of Life Questionnaire score at the end of follow-up (6 months). Secondary outcomes cover asthma control, spirometry, general health status, programme adherence and burden for medical staff, exacerbations and medical resource use (medications, consults, emergency visits, hospitalisation and intensive care).

ETHICS AND DISSEMINATION

This study ('AsthmaTrain' protocol version 4-20220330) has been approved by the Committee for the Protection of Persons Ile-de-France VII on 28 March 2022 (reference number 21.03617.000059). Enrolment began on 24 May 2022. Results will be published in international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT05248126.

Digital interventions to improve adherence to maintenance medication in asthma

BACKGROUND

Asthma is the most common chronic lung condition worldwide, affecting 334 million adults and children globally. Despite the availability of effective treatment, such as inhaled corticosteroids (ICS), adherence to maintenance medication remains suboptimal. Poor ICS adherence leads to increased asthma symptoms, exacerbations, hospitalisations, and healthcare utilisation. Importantly, suboptimal use of asthma medication is a key contributor to asthma deaths. The impact of digital interventions on adherence and asthma outcomes is unknown.

OBJECTIVES

To determine the effectiveness of digital interventions for improving adherence to maintenance treatments in asthma.

SEARCH METHODS

We identified trials from the Cochrane Airways Trials Register, which contains studies identified through multiple electronic searches and handsearches of other sources. We also searched trial registries and reference lists of primary studies. We conducted the most recent searches on 1 June 2020, with no restrictions on language of publication. A further search was run in October 2021, but studies were not fully incorporated.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) including cluster- and quasi-randomised trials of any duration in any setting, comparing a digital adherence intervention with a non-digital adherence intervention or usual care. We included adults and children with a clinical diagnosis of asthma, receiving maintenance treatment.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures for data collection. We used GRADE to assess quantitative outcomes where data were available.

MAIN RESULTS

We included 40 parallel randomised controlled trials (RCTs) involving adults and children with asthma (n = 15,207), of which eight are ongoing studies. Of the included studies, 30 contributed data to at least one meta-analysis. The total number of participants ranged from 18 to 8517 (median 339). Intervention length ranged from two to 104 weeks. Most studies (n = 29) reported adherence to maintenance medication as their primary outcome; other outcomes such as asthma control and quality of life were also commonly reported. Studies had low or unclear risk of selection bias but high risk of performance and detection biases due to inability to blind the participants, personnel, or outcome assessors. A quarter of the studies had high risk of attrition bias and selective outcome reporting. We examined the effect of digital interventions using meta-analysis for the following outcomes: adherence (16 studies); asthma control (16 studies); asthma exacerbations (six studies); unscheduled healthcare utilisation (four studies); lung function (seven studies); and quality of life (10 studies). Pooled results showed that patients receiving digital interventions may have increased adherence (mean difference of 14.66 percentage points, 95% confidence interval (CI) 7.74 to 21.57; low-certainty evidence); this is likely to be clinically significant in those with poor baseline medication adherence. Subgroup analysis by type of intervention was significant (P = 0.001), with better adherence shown with electronic monitoring devices (EMDs) (23 percentage points over control, 95% CI 10.84 to 34.16; seven studies), and with short message services (SMS) (12 percentage points over control, 95% CI 6.22 to 18.03; four studies). No significant subgroup differences were seen for interventions having an in-person component versus fully digital interventions, adherence feedback, one or multiple digital components to the intervention, or participant age. Digital interventions were likely to improve asthma control (standardised mean difference (SMD) 0.31 higher, 95% CI 0.17 to 0.44; moderate-certainty evidence) - a small but likely clinically significant effect. They may reduce asthma exacerbations (risk ratio 0.53, 95% CI 0.32 to 0.91; low-certainty evidence). Digital interventions may result in a slight change in unscheduled healthcare utilisation, although some studies reported no or a worsened effect. School or work absence data could not be included for meta-analysis due to the heterogeneity in reporting and the low number of studies. They may result in little or no difference in lung function (forced expiratory volume in one second (FEV₁)): there was an improvement of 3.58% predicted FEV₁, 95% CI 1.00% to 6.17%; moderate-certainty evidence); however, this is unlikely to be clinically significant as the FEV₁ change is below 12%. Digital interventions likely increase quality of life (SMD 0.26 higher, 95% CI 0.07 to 0.45; moderate-certainty evidence); however, this is a small effect that may not be clinically significant. Acceptability data showed positive attitudes towards digital interventions. There were no data on cost-effectiveness or adverse events. Our confidence in the evidence was reduced by risk of bias and inconsistency.

AUTHORS' CONCLUSIONS

Overall, digital interventions may result in a large increase in adherence (low-certainty evidence). There is moderate-certainty evidence that digital adherence interventions likely improve asthma control to a degree that is clinically significant, and likely increase quality of life, but there is little or no improvement in lung function. The review found low-certainty evidence that digital interventions may reduce asthma exacerbations. Subgroup analyses show that EMDs may improve adherence by 23% and SMS interventions by 12%, and interventions with an in-person element and adherence feedback may have greater benefits for asthma control and adherence, respectively. Future studies should include percentage adherence as a routine outcome measure to enable comparison between studies and meta-analysis, and use validated questionnaires to assess adherence and outcomes.

The Role of Education, Monitoring, and Symptom Perception in Internet-Based Self-management Among Adolescents With Asthma: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Internet-based self-management programs improve asthma control and the asthma-related quality of life in adults and adolescents. The components of self-management programs include education and the web-based self-monitoring of symptoms; the latter requires adequate perception in order to timely adjust lifestyle or medication or to contact a care provider.

OBJECTIVE

We aimed to test the hypothesis that adherence to education and web-based monitoring and adequate symptom perception are important determinants for the improvement of asthma control in self-management programs.

METHODS

We conducted a subgroup analysis of the intervention group of a randomized controlled trial, which included adolescents who participated in the internet-based self-management arm. We assessed the impacts that attendance in education sessions, the frequency of web-based monitoring, and the level of perception had on changes in asthma control (Asthma Control Questionnaire [ACQ]) and asthma-related quality of life (Pediatric Asthma Quality of Life Questionnaire) from baseline to 12 months after intervention.

RESULTS

Adolescents who attended education sessions had significant and clinically relevant improvements in asthma control (ACQ score difference: -0.6; P=.03) and exhibited a nonsignificant trend of improvement in asthma-related quality of life (Pediatric Asthma Quality of Life Questionnaire score difference: -0.45; P=.15) when compared to those who did not adhere to education. Frequent monitoring alone did not improve asthma control (P=.07) and quality of life (P=.44) significantly, but its combination with education did result in improved ACQ scores (difference: -0.88; P=.02). There were no significant differences in outcomes between normoperceivers and hypoperceivers.

CONCLUSIONS

Education, especially in combination with frequent web-based monitoring, is an important determinant for the 1-year outcomes of asthma control in internet-based self-management programs for adolescents with partly controlled and uncontrolled asthma; however, we could not establish the effect of symptom perception. This study provides important knowledge on the effects of asthma education and monitoring in daily life.

Digital Health Technology in Asthma: A Comprehensive Scoping Review

BACKGROUND

A variety of digital intervention approaches have been investigated for asthma therapy during the past decade, with different levels of interactivity and personalization and a range of impacts on different outcome measurements.

OBJECTIVE

To assess the effectiveness of digital interventions in asthma with regard to acceptability and outcomes and evaluate the potential of digital initiatives for monitoring or treating patients with asthma.

METHODS

We evaluated digital interventions using a scoping review methodology through a literature search and review. Of 871 articles identified, 121 were evaluated to explore intervention characteristics, the perception and acceptability of digital interventions to patients and physicians, and effects on asthma outcomes. Interventions were categorized by their level of interactivity with the patient.

RESULTS

Interventions featuring non-individualized content sent to patients appeared capable of promoting improved adherence to inhaled corticosteroids, but with no identified improvement in asthma burden; and data-gathering interventions appeared to have little effect on adherence or asthma burden. Evidence of improvement in both adherence and patients' impairment due to asthma were seen only with interactive interventions involving two-way responsive patient communication. Digital interventions were generally positively perceived by patients and physicians. Implementation was considered feasible, with certain preferences for design and features important to drive use.

CONCLUSIONS

Digital health interventions show substantial promise for asthma disease monitoring and personalization of treatment. To be successful, future interventions will need to include both inhaler device and software elements, combining accurate measurement of clinical parameters with careful consideration of ease of use, personalization, and patient engagement aspects.

A Systematic Review and Meta-Analysis of Change in Health-Related Quality of Life for Interactive Telehealth Interventions for Patients With Asthma

OBJECTIVES

Asthma is one of the most common major noncommunicable diseases in the world and affects individuals of all ages. Medication is used to achieve and maintain quality of life (QOL) for people with asthma. Telehealth interventions offer optimized and personalized symptom monitoring with timely treatment adjustment and the potential to increase medication adherence for individuals with asthma. This study examines and synthesizes the available data on the change in the QOL for patients with asthma who use interactive telehealth interventions, and identifies the most effective telehealth modalities used for intervention in this area.

METHODS

Literature searches were conducted in 5 databases in November 2018 for studies measuring a change in QOL for patients with asthma. Study QOL outcomes, where possible, were pooled in a meta-analysis.

RESULTS

Seventeen publications (describing 16 studies) comprising 2015 patients were included. Based on a meta-analysis, interactive telehealth interventions can improve QOL outcomes for people living with asthma, although the improved effects may be small: web portals (0.51, 95% confidence interval [CI] -0.00 to 1.03), interactive smartphone apps (0.30, 95% CI -0.16 to 0.76) and remote monitoring (standardized mean difference 0.20, 95% CI -0.11 to 0.52). Intervention delivery modalities identified include interactive web portals, smartphone apps, and remote monitoring programs.

CONCLUSIONS

The findings provide a comprehensive overview of the available literature on interactive telehealth interventions, including interactive web portals, smartphone apps, and remote monitoring programs. These findings demonstrated that a positive change in QOL can be attributed to these interventions and provide evidence for the implementation of telehealth interventions for individuals with asthma.

New Concepts and Technological Resources in Patient Education and Asthma Self-Management

Asthma is a chronic disease that is associated with significant morbidity and mortality. In general, the use of technology resources or electronic health (e-health) has been shown to have beneficial effects on patients with asthma. E-health can impact a broad section of patients and can be cost-effective and associated with high patient satisfaction. E-health may enable remote delivery of care, as well as timely access to health care, which are some of the common challenges faced by patients with asthma. Web-based asthma self-management systems have been found to improve quality of life, self-reported asthma symptoms, lung function, reduction in asthma symptoms/exacerbations, and self-reported adherence for adults. Social media is commonly being used as a platform to disseminate information on asthma to increase public awareness. It can facilitate asthma self-management in a patient friendly manner and has shown to improve asthma control test scores as well as self-esteem. Text massages reminders can increase awareness regarding asthma treatment and control, thus potentially can improve adherence to medications and asthma outcome. Mobile health applications can support asthma self-management, improve a patient's quality of life, promote medication adherence, and potentially reduce the overall costs for asthma care. Inhaler trackers have shown to be beneficial to asthma outcome in various populations by improving adherence to asthma medications. Barriers such as physician financial reimbursement as well as licensing for rendering tele-healthcare services are important concerns. Other limitations of using technology resources in health care are related to liability, professionalism, and ethical issues such as breach of patient confidentiality and privacy. Additionally, there may be less face-to-face interaction and care of the patient when e-health is used.

Does an mHealth system reduce health service use for asthma?

Background

Breathe is a mobile health (mHealth) application developed for the self-management of asthma in adults. There is evidence to suggest that mHealth interventions can be used for asthma control; however, their effects on the use of health services remain poorly understood. We sought to determine whether Breathe reduces health services use amongst asthma patients who used the app compared to controls who did not.

Methods

The impact of Breathe on health services use was estimated using a quasi-experimental approach. Two groups of subjects who had participated in a previous randomised clinical trial were included: an intervention group of asthma patients who used the app for 12 months, and a group of controls who did not use the app but received equivalent quality asthma care. A third, external control group of asthma patients were matched to the intervention participants. Generalised linear mixed models were used to determine relative changes in rates of asthma hospitalisations, emergency department (ED) visits, outpatient physician visits and completion of pulmonary function tests (PFTs) over time.

Results

A total of 677 individuals with asthma were included in the study: 132 in the intervention group, and 149 and 396 in the internal and external control groups, respectively. There were no statistically significant differences in the change of asthma hospitalisations, ED visits, physician office visits or completion of PFTs between the intervention group and either control group.

Conclusions

Use of the Breathe app is not associated with changes in health services use in adults with asthma.

Use of a mobile health application designed for asthma self-management was not associated with changes in asthma health services use or completion of pulmonary function testing in adults with asthma who use the application compared to those who did nothttps://bit.ly/2YojkeE

The effectiveness of interventions to improve self-management for adolescents and young adults with allergic conditions: A systematic review

BACKGROUND

This systematic review aimed to review the literature on interventions for improving self-management and well-being in adolescents and young adults (11-25 years) with asthma and allergic conditions.

METHODS

A systematic literature search was undertaken across eight databases. References were checked by two reviewers for inclusion. Study data were extracted, and their quality was assessed in duplicate. A narrative synthesis was undertaken.

RESULTS

A total of 30 papers reporting data from 27 studies were included. Interventions types were psychological (k = 9); e-health (k = 8); educational (k = 4); peer-led (k = 5); breathing re-training (k = 1). All interventions were for asthma. Psychological interventions resulted in significant improvements in the intervention group compared with the control group for self-esteem, quality of life, self-efficacy, coping strategies, mood and asthma symptoms. E-Health interventions reported significant improvements for inhaler technique, adherence and quality of life. General educational interventions demonstrated significantly improved quality of life, management of asthma symptoms, controller medication use, increased use of a written management plan and reduction in symptoms. The peer-led interventions included the Triple A (Adolescent Asthma Action) programme and a peer-led camp based on the Power Breathing Programme. Improvements were found for self-efficacy, school absenteeism and quality of life.

CONCLUSION

Although significant improvements were seen for all intervention types, many were small feasibility or pilot studies, few studies reported effect sizes and no studies for allergic conditions other than asthma met the inclusion criteria. Research using large longitudinal interventional designs across the range of allergic conditions is required to strengthen the evidence base.

Biomedical REAl-Time Health Evaluation (BREATHE): toward an mHealth informatics platform

OBJECTIVE

To describe a configurable mobile health (mHealth) framework for integration of physiologic and environmental sensors to be used in studies focusing on the domain of pediatric asthma.

MATERIALS AND METHODS

The Biomedical REAl-Time Health Evaluation (BREATHE) platform connects different sensors and data streams, contextualizing an individual's symptoms and daily activities over time to understand pediatric asthma's presentation and its management. A smartwatch/smartphone combination serves as a hub for personal/wearable sensing devices collecting data on health (eg, heart rate, spirometry, medications), motion, and personal exposures (eg, particulate matter, ozone); securely transmitting information to BREATHE's servers; and interacting with the user (eg, ecological momentary assessments). Server-side integration of electronic health record data and spatiotemporally correlated information (eg, weather, traffic) elaborates on these observations. An initial panel study involving pediatric asthma patients was conducted to assess BREATHE.

RESULTS

Twenty subjects were enrolled, during which BREATHE accrued seven consecutive days of continuous data per individual. The data were used to confirm knowledge about asthma (use of controller inhalers, time-activity behaviors, personal air pollution exposure), and additional analyses provided insights into within-day associations of environmental triggers and asthma exacerbations. Exit surveys focusing on mHealth usability, while positive, noted several translational challenges.

DISCUSSION

Based on these promising results, a longitudinal panel study to evaluate individual microenvironments and exposures is ongoing. Lessons learned thus far reflect the need to address various usability aspects, including convenience and ongoing engagement.

CONCLUSION

BREATHE enables multi-sensor mHealth studies, capturing new types of information alongside an evolving understanding of personal exposomes.

A systematic review on randomized controlled trials: Coaching elements of digital services to support chronically ill adolescents during transition of care

AIMS

To define digital health services that have been studied among chronically ill adolescents and to describe e-health coaching elements that may have an impact on transition outcomes.

DESIGN

Systematic review without meta-analysis.

DATA SOURCES

MEDLINE (Ovid), Pub Med, Scopus and CINAHL on 28 May 2018.

REVIEW METHODS

Peer-reviewed articles published between January 2008-May 2018 were reviewed following the Cochrane Handbook for Systematic Reviews of Interventions and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement.

RESULTS

Twelve randomized controlled trials were included. The interventions varied significantly in duration and content. E-coaching that included human and social support showed positive impact on transition outcomes. Digital health services incorporated into usual care provide efficient and accessible care.

CONCLUSION

E-coaching elements enable tailoring and personalization and present a tool for supporting and motivating chronically ill adolescents during transition of care. Future research should evaluate the effectiveness of e-coaching elements.

IMPACT

Digital services are considered a means for increasing adolescents' motivation for self-care and for increasing their accessibility to health care. The coaching elements in digital services consist of a theoretical basis, human support, interactive means and social support. Included interventions varied in terms of duration, dose, content and design. Our results may serve the development of digital health services for adolescents in transition. E-coaching can be used to engage and motivate chronically ill adolescents to improve health behaviour and self-management during transition of care.

Electronic Health Interventions for Preventing and Treating Negative Psychological Sequelae Resulting From Pediatric Medical Conditions: Systematic Review

BACKGROUND

Pediatric medical conditions have the potential to result in challenging psychological symptoms (eg, anxiety, depression, and posttraumatic stress symptoms [PTSS]) and impaired health-related quality of life in youth. Thus, effective and accessible interventions are needed to prevent and treat psychological sequelae associated with pediatric medical conditions. Electronic health (eHealth) interventions may help to meet this need, with the capacity to reach more children and families than in-person interventions. Many of these interventions are in their infancy, and we do not yet know what key components contribute to successful eHealth interventions.

OBJECTIVE

The primary objective of this study was to conduct a systematic review to summarize current evidence on the efficacy of eHealth interventions designed to prevent or treat psychological sequelae in youth with medical conditions.

METHODS

MEDLINE (PubMed) and PsycINFO databases were searched for studies published between January 1, 1998, and March 1, 2019, using predefined search terms. A total of 2 authors independently reviewed titles and abstracts of search results to determine which studies were eligible for full-text review. Reference lists of studies meeting eligibility criteria were reviewed. If the title of a reference suggested that it might be relevant for this review, the full manuscript was reviewed for inclusion. Inclusion criteria required that eligible studies (1) had conducted empirical research on the efficacy of a Web-based intervention for youth with a medical condition, (2) had included a randomized trial as part of the study method, (3) had assessed the outcomes of psychological sequelae (ie, PTSS, anxiety, depression, internalizing symptoms, or quality of life) in youth (aged 0-18 years), their caregivers, or both, (4) had included assessments at 2 or more time points, and (5) were available in English language.

RESULTS

A total of 1512 studies were reviewed for inclusion based on their title and abstracts; 39 articles qualified for full-text review. Moreover, 22 studies met inclusion criteria for the systematic review. Of the 22 included studies, 13 reported results indicating that eHealth interventions significantly improved at least one component of psychological sequelae in participants. Common characteristics among interventions that showed an effect included content on problem solving, education, communication, and behavior management. Studies most commonly reported on child and caregiver depression, followed by child PTSS and caregiver anxiety.

CONCLUSIONS

Previous research is mixed but suggests that eHealth interventions may be helpful in alleviating or preventing problematic psychological sequelae in youth with medical conditions and their caregivers. Additional research is needed to advance understanding of the most powerful intervention components and to determine when and how to best disseminate eHealth interventions, with the goal of extending the current reach of psychological interventions.

Ambulatory Management of Childhood Asthma Using a Novel Self-management Application

BACKGROUND AND OBJECTIVES

Pediatric ambulatory asthma control is suboptimal, reducing quality of life (QoL) and causing emergency department (ED) and hospital admissions. We assessed the impact of the electronic-AsthmaTracker (e-AT), a self-monitoring application for children with asthma.

METHODS

Prospective cohort study with matched controls. Participants were enrolled January 2014 to December 2015 in 11 pediatric clinics for weekly e-AT use for 1 year. Analyses included: (1) longitudinal changes for the child (QoL, asthma control, and interrupted and missed school days) and parents (interrupted and missed work days and satisfaction), (2) comparing ED and hospital admissions and oral corticosteroid (OCS) use pre- and postintervention, and (3) comparing ED and hospital admissions and OCS use between e-AT users and matched controls.

RESULTS

A total of 327 children and parents enrolled; e-AT adherence at 12 months was 65%. Compared with baseline, participants had significantly (P < .001) increased QoL, asthma control, and reduced interrupted and missed school and work days at all assessment times. Compared with 1 year preintervention, they had reduced ED and hospital admissions (rate ratio [RR]: 0.68; 95% confidence interval [CI]: 0.49-0.95) and OCS use (RR: 0.74; 95% CI: 0.61-0.91). Parent satisfaction remained high. Compared with matched controls, participants had reduced ED and hospital admissions (RR: 0.41; 95% CI: 0.22-0.75) and OCS use (RR: 0.65; 95% CI: 0.46-0.93).

CONCLUSIONS

e-AT use led to high and sustained participation in self-monitoring and improved asthma outcomes. Dissemination of this care model has potential to broadly improve pediatric ambulatory asthma care.

Evaluation of a Peer-led Asthma Self-management Group Intervention for Urban Adolescents

PURPOSE

This paper describes the acceptability and generalizability of an evidenced-based peer-led asthma self-management program.

DESIGN AND METHODS

Adolescents with persistent asthma (n = 259, ages 12-17 years) from three urban cities participated in a one day camp led by either trained peer leaders (n = 35, ages 16-20 years; intervention group) or healthcare professionals (control group). Participants completed a camp evaluation form, and the peer leader quality survey.

RESULTS

Overall program evaluation showed high acceptability with average score of 4.5 (±0.87) out of 5 and no treatment group differences were found. Campers highly rated peer leaders' qualification, particularly trustworthiness (98%), knowledge (97%), and sense of humor (95%). Participants from low income families (annual income < $30,000) reported higher satisfaction with their camp experience being enjoyable compared to their counterparts from higher income families (X² = 4.23, p ≤ .04).

CONCLUSIONS

This study supports the acceptability and generalizability of a peer-led asthma self-management program across different urban community locations, seasons and venues.

PRACTICE IMPLICATIONS

Trained peers can be as effective as adult educators in teaching adolescents asthma self-management.

[Effectiveness of Telemonitoring Intervention in Children and Adolescents with Asthma: A Systematic Review and Meta-Analysis]

PURPOSE

This review aimed to evaluate the effectiveness of telemonitoring (TM) in the management of children and adolescents with asthma.

METHODS

We searched Ovid-MEDLINE, Ovid-EMBASE, CENTRAL (Cochrane Central Register of Controlled Trials), CINAHL (Cumulative Index to Nursing and Allied Health Literature), and 5 domestic databases to identify randomized controlled trials (RCTs) published through December 2017. Two reviewers independently selected relevant studies, assessed methodological quality and extracted data. We performed a meta-analysis of TM versus usual care and summarized the intervention characteristics of included studies.

RESULTS

Of the 3,095 articles identified, 8 RCTs (9 articles) were included in this review. The type of TM intervention of included studies was varying across studies (transmitted data, transmission frequency, data review, etc.). The pooled asthma control score was not significantly different between TM and usual care (standardized mean difference 0.04, 95% confidence interval (CI) -0.20~0.28). Another pooled analysis demonstrated no statistically significant difference in asthma exacerbation between TM and usual care (odds ratio 0.95, 95% CI 0.43~2.09). Overall, the pooled results from these studies revealed that TM did not lead to clinically significant improvements in health outcomes, but some studies in our analysis suggested that TM increased patient medication adherence and intervention adherence.

CONCLUSION

The current evidence base does not demonstrate any differences between TM intervention and usual care, but TM intervention might be considered a promising strategy for the delivery of self-management support for children and adolescents with asthma. Further well-designed studies are needed to assess the effects on clinical outcomes.

E-Healthcare for Celiac Disease-A Multicenter Randomized Controlled Trial

OBJECTIVE

To evaluate the (cost-)effectiveness of online consultations in follow-up of patients with celiac disease (CD).

STUDY DESIGN

Multicenter randomized, controlled trial involving 304 patients aged ≤25 years with CD for ≥1 year, randomized to an online (n = 156) or outpatient consultation (n = 148). An online consultation included questionnaires for symptom and growth measurement. Antitransglutaminase-type-2 antibodies were determined using a point-of-care (POC) test. Controls had a traditional consultation with antitransglutaminase-type-2 antibodies testing in laboratories. Both groups completed questionnaires concerning CD-specific health-related quality of life (HRQOL), gluten-free diet adherence, and patient satisfaction. Six months later, participants repeated HRQOL and patient satisfaction questionnaires and the POC test. The primary outcome was anti-transglutaminase-type-2 antibodies after 6 months, and the secondary outcomes were health problems, dietary adherence, HRQOL, patient satisfaction, and costs.

RESULTS

The performance of the POC test was inferior to laboratory testing (2/156 positive POC tests vs 13/148 positive laboratory tests; P = .003). Health problems were detected significantly more frequently using online consultation. The detection of growth problems and dietary transgressions was similar. HRQOL (from 1 [good] to 5 [poor]) improved after online consultation (from 3.25 to 3.16 [P = .013] vs controls from 3.10 to 3.23; P = .810). Patient satisfaction (from 1 [low] to 10 [high]) was 7.6 (online) vs 8.0 (controls; P = .001); 58% wished to continue online consultations. Mean costs per participant during the studied period were €202 less for the online group (P < .001).

CONCLUSIONS

The primary outcome could not be tested because the POC test was unreliable. Nevertheless, our results indicate that online consultations for children and young adults with CD are cost saving, increase CD-specific HRQOL, and are satisfactory for the majority.

TRIAL REGISTRATION

Trialregister.nl: NTR3688.

Self-care support for children and adolescents with long-term conditions: the REfOCUS evidence synthesis

Background

Self-care support (e.g. education, training, peer/professional support) is intended to enhance the self-care capacities of children and young people, while simultaneously reducing the financial burden facing health-care systems.

Objectives

To determine which models of self-care support for long-term conditions (LTCs) are associated with significant reductions in health utilisation and costs without compromising outcomes for children and young people.

Design

Systematic review with meta-analysis.

Population

Children and young people aged 0–18 years with a long-term physical or mental health condition (e.g. asthma, depression).

Intervention

Self-care support in health, social care, educational or community settings.

Comparator

Usual care.

Outcomes

Generic/health-related quality of life (QoL)/subjective health symptoms and health service utilisation/costs.

Design

Randomised/non-randomised trials, controlled before-and-after studies, and interrupted time series designs.

Data sources

MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, ISI Web of Science, NHS Economic Evaluation Database, The Cochrane Library, Health Technology Assessment database, Paediatric Economic Database Evaluation, IDEAS, reference scanning, targeted author searches and forward citation searching. All databases were searched from inception to March 2015.

Methods

We conducted meta-analyses, simultaneously plotting QoL and health utilisation effects. We conducted subgroup analyses for evidence quality, age, LTC and intervention (setting, target, delivery format, intensity).

Results

Ninety-seven studies reporting 114 interventions were included. Thirty-seven studies reported adequate allocation concealment. Fourteen were UK studies. The vast majority of included studies recruited children and young people with asthma (n = 66, 68%). Four per cent of studies evaluated ‘pure’ self-care support (delivered through health technology without additional contact), 23% evaluated facilitated self-care support (≤ 2 hours’/four sessions’ contact), 65% were intensively facilitated (≥ 2 hours’/four sessions’ contact) and 8% were case management (≥ 2 hours’ support with multidisciplinary input). Self-care support was associated with statistically significant, minimal benefits for QoL [effect size (ES) –0.17, 95% confidence interval (CI) –0.23 to –0.11], but lacked clear benefit for hospital admissions (ES –0.05, 95% CI –0.12 to 0.03). This finding endured across intervention intensities and LTCs. Statistically significant, minimal reductions in emergency use were observed (ES –0.11, 95% CI –0.17 to –0.04). The total cost analysis was limited by the small number of data. Subgroup analyses revealed statistically significant, minimal reductions in emergency use for children aged ≤ 13 years (ES –0.10, 95% CI –0.17 to –0.04), children and young people with asthma (ES –0.12, 95% CI –0.18 to –0.06) and children and young people receiving ≥ 2 hours per four sessions of support (ES –0.10, 95% CI –0.17 to –0.03). Preliminary evidence suggested that interventions that include the child or young person, and deliver some content individually, may optimise QoL effects. Face-to-face delivery may help to maximise emergency department effects. Caution is required in interpreting these findings.

Limitations

Identification of optimal models of self-care support is challenged by the size and nature of evidence available. The emphasis on meta-analysis meant that a minority of studies with incomplete but potentially relevant data were excluded.

Conclusions

Self-care support is associated with positive but minimal effects on children and young people’s QoL, and minimal, but potentially important, reductions in emergency use. On current evidence, we cannot reliably conclude that self-care support significantly reduces health-care costs.

Future work

Research is needed to explore the short- and longer-term effects of self-care support across a wider range of LTCs.

Study registration

This study is registered as PROSPERO CRD42014015452.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

The use of mobile applications to support self-management for people with asthma: a systematic review of controlled studies to identify features associated with clinical effectiveness and adherence

Objectives

Telehealth is promoted as a strategy to support self-management of long-term conditions. The aim of this systematic review is to identify which information and communication technology features implemented in mobile apps to support asthma self-management are associated with adoption, adherence to usage, and clinical effectiveness.

Methods

We systematically searched 9 databases, scanned reference lists, and undertook manual searches (January 2000 to April 2016). We include randomized controlled trials (RCTs) and quasiexperimental studies with adults. All eligible papers were assessed for quality, and we extracted data on the features included, health-related outcomes (asthma control, exacerbation rate), process/intermediate outcomes (adherence to monitoring or treatment, self-efficacy), and level of adoption of and adherence to use of technology. Meta-analysis and narrative synthesis were used.

Results

We included 12 RCTs employing a range of technologies. A meta-analysis (n = 3) showed improved asthma control (mean difference -0.25 [95% CI, -0.37 to -0.12]). Included studies incorporated 10 features grouped into 7 categories (education, monitoring/electronic diary, action plans, medication reminders/prompts, facilitating professional support, raising patient awareness of asthma control, and decision support for professionals). The most successful interventions included multiple features, but effects on health-related outcomes were inconsistent. No studies explicitly reported adoption of and adherence to the technology system.

Conclusion

Meta-analysis of data from 3 trials showed improved asthma control, though overall the clinical effectiveness of apps, typically incorporating multiple features, varied. Further studies are needed to identify the features that are associated with adoption of and adherence to use of the mobile app and those that improve health outcomes.

A virtual asthma clinic for children: fewer routine outpatient visits, same asthma control

eHealth is an appealing medium to improve healthcare and its value (in addition to standard care) has been assessed in previous studies. We aimed to assess whether an eHealth intervention could improve asthma control while reducing 50% of routine outpatient visits.In a multicentre, randomised controlled trial with a 16-month follow-up, asthmatic children (6-16 years) treated in eight Dutch hospitals were randomised to usual care (4-monthly outpatient visits) and online care using a virtual asthma clinic (VAC) (8-monthly outpatient visits with monthly web-based monitoring). Outcome measures were the number of symptom-free days in the last 4 weeks of the study, asthma control, forced expiratory volume in 1 s, exhaled nitric oxide fraction, asthma exacerbations, unscheduled outpatient visits, hospital admissions, daily dose of inhaled corticosteroids and courses of systemic corticosteroids.We included 210 children. After follow-up, symptom-free days differed statistically between the usual care and VAC groups (difference of 1.23 days, 95% CI 0.42-2.04; p=0.003) in favour of the VAC. In terms of asthma control, the Childhood Asthma Control Test improved more in the VAC group (difference of 1.17 points, 95% CI 0.09-2.25; p=0.03). No differences were found for other outcome measures.Routine outpatient visits can partly be replaced by monitoring asthmatic children via eHealth.

Systematic meta-review of supported self-management for asthma: a healthcare perspective

BACKGROUND

Supported self-management has been recommended by asthma guidelines for three decades; improving current suboptimal implementation will require commitment from professionals, patients and healthcare organisations. The Practical Systematic Review of Self-Management Support (PRISMS) meta-review and Reducing Care Utilisation through Self-management Interventions (RECURSIVE) health economic review were commissioned to provide a systematic overview of supported self-management to inform implementation. We sought to investigate if supported asthma self-management reduces use of healthcare resources and improves asthma control; for which target groups it works; and which components and contextual factors contribute to effectiveness. Finally, we investigated the costs to healthcare services of providing supported self-management.

METHODS

We undertook a meta-review (systematic overview) of systematic reviews updated with randomised controlled trials (RCTs) published since the review search dates, and health economic meta-analysis of RCTs. Twelve electronic databases were searched in 2012 (updated in 2015; pre-publication update January 2017) for systematic reviews reporting RCTs (and update RCTs) evaluating supported asthma self-management. We assessed the quality of included studies and undertook a meta-analysis and narrative synthesis.

RESULTS

A total of 27 systematic reviews (n = 244 RCTs) and 13 update RCTs revealed that supported self-management can reduce hospitalisations, accident and emergency attendances and unscheduled consultations, and improve markers of control and quality of life for people with asthma across a range of cultural, demographic and healthcare settings. Core components are patient education, provision of an action plan and regular professional review. Self-management is most effective when delivered in the context of proactive long-term condition management. The total cost (n = 24 RCTs) of providing self-management support is offset by a reduction in hospitalisations and accident and emergency visits (standard mean difference 0.13, 95% confidence interval -0.09 to 0.34).

CONCLUSIONS

Evidence from a total of 270 RCTs confirms that supported self-management for asthma can reduce unscheduled care and improve asthma control, can be delivered effectively for diverse demographic and cultural groups, is applicable in a broad range of clinical settings, and does not significantly increase total healthcare costs. Informed by this comprehensive synthesis of the literature, clinicians, patient-interest groups, policy-makers and providers of healthcare services should prioritise provision of supported self-management for people with asthma as a core component of routine care.

SYSTEMATIC REVIEW REGISTRATION

RECURSIVE: PROSPERO CRD42012002694 ; PRISMS: PROSPERO does not register meta-reviews.

Home telemonitoring and remote feedback between clinic visits for asthma

BACKGROUND

Asthma is a chronic disease that causes reversible narrowing of the airways due to bronchoconstriction, inflammation and mucus production. Asthma continues to be associated with significant avoidable morbidity and mortality. Self management facilitated by a healthcare professional is important to keep symptoms controlled and to prevent exacerbations.Telephone and Internet technologies can now be used by patients to measure lung function and asthma symptoms at home. Patients can then share this information electronically with their healthcare provider, who can provide feedback between clinic visits. Technology can be used in this manner to improve health outcomes and prevent the need for emergency treatment for people with asthma and other long-term health conditions.

OBJECTIVES

To assess the efficacy and safety of home telemonitoring with healthcare professional feedback between clinic visits, compared with usual care.

SEARCH METHODS

We identified trials from the Cochrane Airways Review Group Specialised Register (CAGR) up to May 2016. We also searched www.clinicaltrials.gov, the World Health Organization (WHO) trials portal and reference lists of other reviews, and we contacted trial authors to ask for additional information.

SELECTION CRITERIA

We included parallel randomised controlled trials (RCTs) of adults or children with asthma in which any form of technology was used to measure and share asthma monitoring data with a healthcare provider between clinic visits, compared with other monitoring or usual care. We excluded trials in which technologies were used for monitoring with no input from a doctor or nurse. We included studies reported as full-text articles, those published as abstracts only and unpublished data.

DATA COLLECTION AND ANALYSIS

Two review authors screened the search and independently extracted risk of bias and numerical data, resolving disagreements by consensus.We analysed dichotomous data as odds ratios (ORs) while using study participants as the unit of analysis, and continuous data as mean differences (MDs) while using random-effects models. We rated evidence for all outcomes using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation Working Group) approach.

MAIN RESULTS

We found 18 studies including 2268 participants: 12 in adults, 5 in children and one in individuals from both age groups. Studies generally recruited people with mild to moderate persistent asthma and followed them for between three and 12 months. People in the intervention group were given one of a variety of technologies to record and share their symptoms (text messaging, Web systems or phone calls), compared with a group of people who received usual care or a control intervention.Evidence from these studies did not show clearly whether asthma telemonitoring with feedback from a healthcare professional increases or decreases the odds of exacerbations that require a course of oral steroids (OR 0.93, 95% confidence Interval (CI) 0.60 to 1.44; 466 participants; four studies), a visit to the emergency department (OR 0.75, 95% CI 0.36 to 1.58; 1018 participants; eight studies) or a stay in hospital (OR 0.56, 95% CI 0.21 to 1.49; 1042 participants; 10 studies) compared with usual care. Our confidence was limited by imprecision in all three primary outcomes. Evidence quality ratings ranged from moderate to very low. None of the studies recorded serious or non-serious adverse events separately from asthma exacerbations.Evidence for measures of asthma control was imprecise and inconsistent, revealing possible benefit over usual care for quality of life (MD 0.23, 95% CI 0.01 to 0.45; 796 participants; six studies; I(2) = 54%), but the effect was small and study results varied. Telemonitoring interventions may provide additional benefit for two measures of lung function.

AUTHORS' CONCLUSIONS

Current evidence does not support the widespread implementation of telemonitoring with healthcare provider feedback between asthma clinic visits. Studies have not yet proven that additional telemonitoring strategies lead to better symptom control or reduced need for oral steroids over usual asthma care, nor have they ruled out unintended harms. Investigators noted small benefits for quality of life, but these are subject to risk of bias, as the studies were unblinded. Similarly, some benefits for lung function are uncertain owing to possible attrition bias.Larger pragmatic studies in children and adults could better determine the real-world benefits of these interventions for preventing exacerbations and avoiding harms; it is difficult to generalise results from this review because benefits may be explained at least in part by the increased attention participants receive by taking part in clinical trials. Qualitative studies could inform future research by focusing on patient and provider preferences, or by identifying subgroups of patients who are more likely to attain benefit from closer monitoring, such as those who have frequent asthma attacks.

Remote versus face-to-face check-ups for asthma

BACKGROUND

Asthma remains a significant cause of avoidable morbidity and mortality. Regular check-ups with a healthcare professional are essential to monitor symptoms and adjust medication.Health services worldwide are considering telephone and internet technologies as a way to manage the rising number of people with asthma and other long-term health conditions. This may serve to improve health and reduce the burden on emergency and inpatient services. Remote check-ups may represent an unobtrusive and efficient way of maintaining contact with patients, but it is uncertain whether conducting check-ups in this way is effective or whether it may have unexpected negative consequences.

OBJECTIVES

To assess the safety and efficacy of conducting asthma check-ups remotely versus usual face-to-face consultations.

SEARCH METHODS

We identified trials from the Cochrane Airways Review Group Specialised Register (CAGR) up to 24 November 2015. We also searched www.clinicaltrials.gov, the World Health Organization (WHO) trials portal, reference lists of other reviews and contacted trial authors for additional information.

SELECTION CRITERIA

We included parallel randomised controlled trials (RCTs) of adults or children with asthma that compared remote check-ups conducted using any form of technology versus standard face-to-face consultations. We excluded studies that used automated telehealth interventions that did not include personalised contact with a health professional. We included studies reported as full-text articles, as abstracts only and unpublished data.

DATA COLLECTION AND ANALYSIS

Two review authors screened the literature search results and independently extracted risk of bias and numerical data. We resolved any disagreements by consensus, and we contacted study authors for missing information.We analysed dichotomous data as odds ratios (ORs) using study participants as the unit of analysis, and continuous data as mean differences using the random-effects models. We rated all outcomes using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

MAIN RESULTS

Six studies including a total of 2100 participants met the inclusion criteria: we pooled four studies including 792 people in the main efficacy analyses, and presented the results of a cluster implementation study (n = 1213) and an oral steroid tapering study (n = 95) separately. Baseline characteristics relating to asthma severity were variable, but studies generally recruited people with asthma taking regular medications and excluded those with COPD or severe asthma. One study compared the two types of check-up for oral steroid tapering in severe refractory asthma and we assessed it as a separate question. The studies could not be blinded and dropout was high in four of the six studies, which may have biased the results.We could not say whether more people who had a remote check-up needed oral corticosteroids for an asthma exacerbation than those who were seen face-to-face because the confidence intervals (CIs) were very wide (OR 1.74, 95% CI 0.41 to 7.44; 278 participants; one study; low quality evidence). In the face-to-face check-up groups, 21 participants out of 1000 had exacerbations that required oral steroids over three months, compared to 36 (95% CI nine to 139) out of 1000 for the remote check-up group. Exacerbations that needed treatment in the Emergency Department (ED), hospital admission or an unscheduled healthcare visit all happened too infrequently to detect whether remote check-ups are a safe alternative to face-to-face consultations. Serious adverse events were not reported separately from the exacerbation outcomes.There was no difference in asthma control measured by the Asthma Control Questionnaire (ACQ) or in quality of life measured on the Asthma Quality of Life Questionnaire (AQLQ) between remote and face-to-face check-ups. We could rule out significant harm of remote check-ups for these outcomes but we were less confident because these outcomes are more prone to bias from lack of blinding.The larger implementation study that compared two general practice populations demonstrated that offering telephone check-ups and proactively phoning participants increased the number of people with asthma who received a review. However, we do not know whether the additional participants who had a telephone check-up subsequently benefited in asthma outcomes.

AUTHORS' CONCLUSIONS

Current randomised evidence does not demonstrate any important differences between face-to-face and remote asthma check-ups in terms of exacerbations, asthma control or quality of life. There is insufficient information to rule out differences in efficacy, or to say whether or not remote asthma check-ups are a safe alternative to being seen face-to-face.

Cost-effectiveness of FENO-based and web-based monitoring in paediatric asthma management: a randomised controlled trial

BACKGROUND

In children with asthma, web-based monitoring and inflammation-driven therapy may lead to improved asthma control and reduction in medications. However, the cost-effectiveness of these monitoring strategies is yet unknown.

OBJECTIVE

We assessed the cost-effectiveness of web-based monthly monitoring and of 4-monthly monitoring of FENO as compared with standard care.

METHODS

An economic evaluation was performed alongside a randomised controlled multicentre trial with a 1-year follow-up. Two hundred and seventy-two children with asthma, aged 4-18 years, were randomised to one of three strategies. In standard care, treatment was adapted according to Asthma Control Test (ACT) at 4-monthly visits, in the web-based strategy also according to web-ACT at 1 month intervals, and in the FENO-based strategy according to ACT and FENO at 4-monthly visits. Outcome measures were patient utilities, healthcare costs, societal costs and incremental cost per quality-adjusted life year (QALY) gained.

RESULTS

No statistically significant differences were found in QALYs and costs between the three strategies. The web-based strategy had 77% chance of being most cost-effective from a healthcare perspective at a willingness to pay a generally accepted €40 000/QALY. The FENO-based strategy had 83% chance of being most cost-effective at €40 000/QALY from a societal perspective.

CONCLUSIONS

Economically, web-based monitoring was preferred from a healthcare perspective, while the FENO-based strategy was preferred from a societal perspective, although in QALYs and costs no statistically significant changes were found as compared with standard care. As clinical outcomes also favoured the web-based and FENO-based strategies, these strategies may be useful additions to standard care.

TRIAL REGISTRATION NUMBER

Netherlands Trial Register (NTR1995).

Update on the current methods for the diagnosis and treatment of severe childhood asthma

The level of asthma control is the key outcome towards which asthma management is evaluated. The majority of children with asthma can obtain adequate control of symptoms through avoidance of triggering factors and/or with the help of low to moderate doses of current available medications. However, there is still a group of children with poor symptom control despite intensive treatment. The current review will provide an overview of a standardized approach to characterize this heterogeneous group of severely sick children. Factors that attenuate the effect of the prescribed treatment and make asthma difficult to treat are discussed. In addition, the usefulness of current methods of assessing asthma severity, pulmonary function, allergy and airway inflammation is also described. Finally, an overview of therapeutic options for children with severe asthma is provided.

Does self-management prevent severe exacerbations?

PURPOSE OF REVIEW

Despite effective therapies, asthma outcomes remain suboptimal. Education in self-management is crucial to maintaining control in a variable condition such as asthma and reducing the risk of severe asthma exacerbations, hospitalizations and deaths. This review considers the evidence for supported self-management.

RECENT FINDINGS

Recent systematic reviews have clarified and confirmed the major benefits from effective self-management education, but have also shown that implementation is rare in routine practice, with consequent avoidable morbidity and mortality. Recent research has focused on the most effective ways of delivering and supporting self-management in different patient groups and has clarified the relative effectiveness of the different components. Self-management support using new digital technologies has been investigated.

SUMMARY

All clinicians treating patients with asthma should be supporting their patients to understand and manage their own condition. Optimal self-management incorporates education, provision of a personalized asthma action plan and is supported by regular professional review. Action plans in a written or digital format should advise on recognizing deterioration and the actions to take, including when to seek professional help, appropriate changes in medication dose or commencing rescue oral steroids. Action plans should be personalized and agreed by the patient, and provided in a culturally tailored form.

Internet-based adherence interventions for treatment of chronic disorders in adolescents

Background

Treatment adherence is a ubiquitous challenge in medicine, particularly in the adolescent population with chronic disorders. Web-based adherence interventions may be particularly useful in adolescents, due to their familiarity with and frequent use of the Internet.

Objective

To review web-based interventions used to improve adherence to medication in adolescent patients with chronic disorders.

Methods

A PubMed search was performed for full-text, English, clinical trials in adolescents using keywords “adherence” or “compliance”, “Internet” or “web”, and “treatment” from inception until November 2014. Articles were selected if they involved using the Internet to provide support to adolescents to help improve their adherence to treatment, excluding those focused on solely providing medical services through the Internet and articles focusing on preventative care, rather than treatment of an illness.

Results

Fourteen studies were found concentrating on chronic adolescent disorders. Interventions included online surveys, physician chat lines, monitoring programs, and interactive programs. All interventions experienced either greater improvement in adherence or another disease control measure or no statistically significant difference compared with the control group (in-clinic visits).

Limitations

Few clinical trials studying web-based interventions to improve adherence in adolescents were found. Due to not having one standard outcome measured in all of the studies, it was also difficult comparing the effectiveness of the interventions.

Conclusion

Web-based interventions play a role in improving adherence in adolescents with chronic disorders by being more time saving and cost effective compared with in-clinic visits. Further research focusing on adherence interventions using the Internet is necessary to determine the ideal ways of utilizing the Internet to improve adherence in adolescents with chronic disorders.

"I just forget to take it": asthma self-management needs and preferences in adolescents

BACKGROUND

Medication adherence rates often decline as children become teenagers. Effective adherence-enhancing interventions for adolescents are lacking. The objective of this study was to assess adolescent asthmatics needs and preferences regarding medication counseling and support, with focus on new media.

METHODS

Three focus groups including 21 asthmatic adolescents recruited from both primary and secondary care were held to explore needs and preferences regarding asthma-self management. Questions concerned adherence behavior and needs and preferences in adherence support with focus on new media (mobile technology, social media, health games).

RESULTS

Forgetting was mentioned as major reason for not using medication as prescribed. Adolescents also mentioned lack of perceived need or beneficial effects. Parents mainly play a role in reminding to take medication and collecting refills. The suggested strategies to support self-management included smartphone applications with a reminder function and easy access to online information. Participants were positive about sharing of experiences with other teenagers.

CONCLUSION

Forgetfulness is a major reason for non-adherence in adolescents. Furthermore, our results suggest use of peer support may be helpful in promoting good medication use. Future interventions should be aimed at providing practical reminders and should be modifiable to individual preferences.

The use of behavior change theory in Internet-based asthma self-management interventions: a systematic review

Background

The high prevalence rate of asthma represents a major societal burden. Advancements in information technology continue to affect the delivery of patient care in all areas of medicine. Internet-based solutions, social media, and mobile technology could address some of the problems associated with increasing asthma prevalence.

Objective

This review evaluates Internet-based asthma interventions that were published between 2004 and October 2014 with respect to the use of behavioral change theoretical frameworks, applied clinical guidelines, and assessment tools.

Methods

The search term (Asthma AND [Online or Internet or Mobile or Application or eHealth or App]) was applied to six bibliographic databases (Ovid MEDLINE, PubMed, BioMed Central, ProQuest Computing, Web of Knowledge, and ACM Digital Library) including only English-language articles published between 2004 and October 2014. In total, 3932 articles matched the priori search terms and were reviewed by the primary reviewer based on their titles, index terms, and abstracts. The matching articles were then screened by the primary reviewer for inclusion or exclusion based on their abstract, study type, and intervention objectives with respect to the full set of priori inclusion and exclusion criteria; 331 duplicates were identified and removed. A total of 85 articles were included for in-depth review and the remaining 3516 articles were excluded. The primary and secondary reviewer independently reviewed the complete content of the 85 included articles to identify the applied behavioral change theories, clinical guidelines, and assessment tools. Findings and any disagreement between reviewers were resolved by in-depth discussion and through a consolidation process for each of the included articles.

Results

The reviewers identified 17 out of 85 interventions (20%) where at least one model, framework, and/or construct of a behavioral change theory were applied. The review identified six clinical guidelines that were applied across 30 of the 85 interventions (35%) as well as a total of 21 assessment tools that were applied across 32 of the 85 interventions (38%).

Conclusions

The findings of this literature review indicate that the majority of published Internet-based interventions do not use any documented behavioral change theory, clinical guidelines, and/or assessment tools to inform their design. Further, it was found that the application of clinical guidelines and assessment tools were more salient across the reviewed interventions. A consequence, as such, is that many Internet-based asthma interventions are designed in an ad hoc manner, without the use of any notable evidence-based theoretical frameworks, clinical guidelines, and/or assessment tools.

Monitoring asthma in children

The goal of asthma treatment is to obtain clinical control and reduce future risks to the patient. To reach this goal in children with asthma, ongoing monitoring is essential. While all components of asthma, such as symptoms, lung function, bronchial hyperresponsiveness and inflammation, may exist in various combinations in different individuals, to date there is limited evidence on how to integrate these for optimal monitoring of children with asthma. The aims of this ERS Task Force were to describe the current practise and give an overview of the best available evidence on how to monitor children with asthma. 22 clinical and research experts reviewed the literature. A modified Delphi method and four Task Force meetings were used to reach a consensus. This statement summarises the literature on monitoring children with asthma. Available tools for monitoring children with asthma, such as clinical tools, lung function, bronchial responsiveness and inflammatory markers, are described as are the ways in which they may be used in children with asthma. Management-related issues, comorbidities and environmental factors are summarised. Despite considerable interest in monitoring asthma in children, for many aspects of monitoring asthma in children there is a substantial lack of evidence.

Personalized medicine in children with asthma

Personalized medicine for children with asthma aims to provide a tailored management of asthma, which leads to faster and better asthma control, has less adverse events and may be cost saving. Several patient characteristics, lung function parameters and biomarkers have been shown useful in predicting treatment response or predicting successful reduction of asthma medication. As treatment response to the main asthma therapies is partly genetically determined, pharmacogenetics may open the way for personalized medicine in children with asthma. However, the number of genes identified for the various asthma drug response phenotypes remains small and randomized controlled trials are lacking. Biomarkers in exhaled breath or breath condensate remain promising but did not find their way from bench to bedside yet, except for the fraction of exhaled nitric oxide. E-health will most likely find its way to clinical practice and most interventions are at least non-inferior to usual care. More studies are needed on which interventions will benefit most individual children.

PELICAN: a cluster-randomized controlled trial in Dutch general practices to assess a self-management support intervention based on individual goals for children with asthma

OBJECTIVE

Insufficient asthma management leads to impaired health-related quality of life (HRQL). The aim of this study is to assess whether individualized self-management (ISM) support will improve HRQL in children with asthma compared to enhanced usual care (EUC) in Dutch general practices.

METHODS

A cluster-randomized controlled trial with 9-month follow-up. ISM is a nurse-led intervention that is optimized to the needs of children, leading to a written action plan. Power calculation demanded inclusion of 170 children (aged 6-11 years) diagnosed with asthma and active medication use.

RESULTS

Outcomes were HRQL of the child (Paediatric Asthma Quality of Life Questionnaire, PAQLQ-s) and several secondary outcomes. Data of 29 children (mean age 8.6 years, SD 1.7) were analyzed; ISM (n = 15) or EUC (n = 14). Logistic regression analysis (minimal clinical important difference; MCID ≥ 0.5) and descriptive analyses were performed. Despite high PAQLQ-s score at baseline (median ISM 6.35, EUC 6.02), a substantial number of subjects from both groups showed MCID of HRQL (ISM 33%, EUC 57%). Treatment differences on HRQL were not significant (OR 0.38, 95% CI 0.08, 1.69). Secondary outcomes did not show significant differences either, with exception of PAQLQ-s symptoms domain score in favor of EUC.

CONCLUSION

Due to recruitment problems and underpowered analyses, no firm conclusions on the effectiveness of ISM support for childhood asthma in primary care could be drawn. Still, this study can be considered a valuable pilot study and in the future, there might be better capacity in general practices to commit to such treatment.

The adolescent with asthma

The adolescent with asthma experiences a period of physical and psychosocial changes that affect their health and well-being. Overall, adolescents with asthma are at increased risk for asthma morbidity and death. Increased rates of depression and anxiety, for the adolescent and their caregivers, can lead to non-adherence to their medical regimens, poor symptom control, and poor treatment outcomes. Contextual factors, such as race, ethnicity, and living situation, affect the prevalence, morbidity, and mortality for the adolescent with asthma. These factors also affect the transition process for adolescents entering adult medical care. An overview is presented of how the adolescent with asthma differs and how healthcare providers can promote effective asthma management and better asthma control.

Adolescent asthma self-management: patient and parent-caregiver perspectives on using social media to improve care

BACKGROUND

Self-management of asthma can now leverage new media technologies. To optimize implementation they must employ a consumer-oriented developmental approach. This study explored benefits of and barriers to improved asthma self-management and identified key elements for the development of a digital media tool to enhance asthma control.

METHODS

Between August 2010 and January 2011, 18 teens with asthma and 18 parent-caregivers participated in semistructured in-depth interviews to identify mechanisms for improving asthma self-management and propose characteristics for developing a digital media tool to aid such efforts.

RESULTS

Teens and caregivers enumerated physician-recommended strategies for asthma management as well as currently employed strategies. Both groups thought of a potential digital media solution as positive, but indicated specific design requirements for such a solution to have utility. Whereas most participants perceived mobile platforms to be viable modes to improve asthma self-management, interest in having social networking capabilities was mixed.

CONCLUSIONS

A digital media product capable of tracking conditions, triggers, and related asthma activities can be a core element of improved asthma control for youth. Improved asthma control will help decrease school absenteeism.

Innovations in technology: social media and mobile technology in the care of adolescents with asthma

This literature review analyzed technological interventions in the adolescent asthmatic population. A PubMed search was performed with terms of asthma, adolescents, social media, Internet, website, mobile phone, text messaging, SMS, Facebook, Twitter, MySpace, and Technology during a 2.5-year period and identified 64 abstracts. Three studies fulfilled the criteria for adolescent intervention using Internet-based sites but did not provide evidence for effectiveness. Two studies focused on mobile technology. One study included text message reminders for controller medication use in asthma patients. Perceived usefulness, satisfaction, and ease of use of text messages were high, but there was no improvement in asthma control. The literature search did not find any studies exploring the use of smartphone applications or social media services. Current studies of technology use in adolescents with asthma do not provide consistent evidence of effectiveness. The positive attitude toward use of social media or mobile technology opens the possibility for future studies to further explore the potential benefits of such interventions.