Behavioural effect of self-treatment guidelines in a self-management program for adults with asthma

GEMA 5.3. Spanish Guideline on the Management of Asthma

The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).

Acceptance and Dropout Rates of Individuals with Asthma Approached in Self-management Interventions: A Systematic Review and Meta-analysis

Objective

The objectives of this systematic review were to assess the acceptability of self-management interventions for people with asthma and identify contributing factors.

Methods

A systematic literature search was conducted using PubMed, MEDLINE, EMBASE (OVIDWEB), CINAHL and Cochrane databases. Clinical trials design was included if they met specified criteria. A random-effect meta-regression analysis was conducted to estimate the overall acceptance and drop-out rates and to assess the potential factors that may influence the outcomes.

Results

A total of 64 studies were included and 8,092 participants were recruited and participated in the trials. The estimated acceptance rate was 51.1%, while the estimated drop-out rates in the intervention and control groups were 18.2% and 15.6%, respectively. Lack of interest was the main reported reason for refusing to participate and dropping out from the program. Study-related and program-related factors influenced the acceptance and drop-out rates statistically and clinically.

Conclusion

The acceptance rate of self-management programs among asthmatic people was not high and the dropout rate was somewhat low. The review suggests optimizing the design of self-management studies and modifying the implemented self-management programs to increase the acceptance rate and decrease the dropout rate.

Exercise Training Programs Improve Cardiorespiratory and Functional Fitness in Adults With Asthma: A SYSTEMATIC REVIEW AND META-ANALYSIS

PURPOSE

This systematic review aimed to identify the characteristics and determine the effects of exercise interventions on improving health-related physical fitness in adults with asthma.

REVIEW METHODS

A systematic search was completed in MEDLINE, CINAHL, Embase, and SPORTDiscus for peer-reviewed publications of experimental studies that investigated the effects of an exercise training intervention on performance-based health-related physical fitness outcomes in adults with asthma. Two reviewers independently screened studies for inclusion according to predetermined criteria and performed data extraction and quality assessment of included studies.

SUMMARY

Forty-five articles were included, in which results for 39 unique studies were reported. Subjects (n = 2135) were aged 22 ± 4 to 71 ± 11 yr with mild-severe asthma. Most exercise programs used aerobic exercise, either alone or in combination with resistance or breathing/stretching exercises. The most common exercise program characteristics were supervised moderate-to-vigorous intensity aerobic exercise performed for 30-45 min 3 d/wk. Meta-analyses revealed significant improvements in cardiorespiratory fitness (V˙o2peak: unstandardized mean difference [MD] 3.1 mL/kg/min, 95% CI, 1.9-4.3), functional fitness (walking distance: MD 41 m, 95% CI, 27-54), and overall health-related physical fitness (standardized mean difference [SMD] 0.67, 95% CI, 0.46-0.89) in favor of groups who underwent experimental exercise training interventions. Aerobic exercise elicited superior improvements in health-related physical fitness compared with breathing/stretching exercise (SMD 0.47, 95% CI, 0.14-0.81).Supervised exercise training programs, particularly those aerobic in nature, are effective in eliciting clinically meaningful improvements in cardiorespiratory and functional fitness in adults with asthma.PROSPERO registration ID number = CRD42018092828.

Occupational Therapy Practice Guidelines for Adults With Chronic Conditions

IMPORTANCE

Demand is increasing for occupational therapy practitioners to help the growing population of adults with chronic conditions manage their conditions.

OBJECTIVE

This Practice Guideline, which is informed by systematic reviews of the literature on the use of self-management interventions, is meant to guide occupational therapy practitioners' clinical decision making when working with community-dwelling adults with chronic conditions. The chronic conditions included heart disease, chronic lung conditions, diabetes, and kidney disease. The self-management interventions addressed ADLs and sleep and rest; IADLs; education, work, volunteering, leisure, and social participation; and the caregiver role.

METHOD

We reviewed, discussed, and integrated the clinical recommendations developed from four systematic reviews, supporting literature, and expert opinion to provide recommendations for practice.

RESULTS

A total of 102 articles were included in the systematic reviews, which served as the primary basis for the practice recommendations.

CONCLUSIONS AND RECOMMENDATIONS

Strong to moderate evidence supports clinical recommendations for the use of self-management interventions when working with clients with chronic conditions. We recommend the use of a multimodal approach that includes three components-education, goal setting, and problem solving-over an extended period to assist clients in establishing self-management habits and routines. On the basis of emerging evidence and expert opinion, we recommend that occupational therapy practitioners consider using a prevention approach, helping clients establish habits and routines, and emphasizing shared goal setting when addressing clients' self-management of chronic conditions. What This Article Adds: This Practice Guideline provides a summary of strong to moderate evidence that supports clinical recommendations for the use of self-management interventions with clients with chronic conditions. When guided by this evidence, occupational therapy practitioners are better able to help clients meet their occupational challenges.

Perception of oral corticosteroids in adult patients with asthma in France

OBJECTIVE

Oral corticosteroids (OCS) are frequently used as relievers for acute asthma and controllers for severe asthma. However, the relief offered by OCS is counterbalanced by adverse effects. We aimed to describe how patients perceive OCS treatment benefits and risks, and how this could affect their adherence to the treatment.

METHODS

Patients aged ≥18 years with asthma registered with Carenity, an online patient community, were invited to respond to a questionnaire containing 35 closed and 3 open questions to assess their asthma and perceptions of OCS.

RESULTS

268/300 respondents were receiving or had received OCS for asthma (58 for long-term use and 107 for short-term use). The mean age at diagnosis was 21.3 years. 66% had uncontrolled asthma (GINA control score 3 or 4). Although 42% perceived OCS to be efficacious, 46% mentioned adverse effects. Respondents were mostly satisfied with OCS (median = 7.0/10), particularly for efficacy (median = 8.0/10). Respondents reported having strategies to avoid OCS, mainly because of adverse effects. 26% of respondents had previously reduced or stopped OCS; this proportion was 22% for short-term OCS users and 36% for long-term users. 15% of the respondents not receiving long-term OCS would take the treatment without doing anything else if long-term OCS were prescribed; 42% would seek an alternative treatment.

CONCLUSIONS

OCS for asthma is perceived efficient but associated with adverse effects. Patients seek alternative treatment.

Personalised asthma action plans for adults with asthma

BACKGROUND

A key aim of asthma care is to empower each person to take control of his or her own condition. A personalised asthma action plan (PAAP), also known as a written action plan, an individualised action plan, or a self-management action plan, contributes to this endeavour. A PAAP includes individualised self-management instructions devised collaboratively with the patient to help maintain asthma control and regain control in the event of an exacerbation. A PAAP includes baseline characteristics (such as lung function), maintenance medication and instructions on how to respond to increasing symptoms and when to seek medical help.

OBJECTIVES

To evaluate the effectiveness of PAAPs used alone or in combination with education, for patient-reported outcomes, resource use and safety among adults with asthma.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register of trials, clinical trial registers, reference lists of included studies and review articles, and relevant manufacturers' websites up to 14 September 2016.

SELECTION CRITERIA

We included parallel randomised controlled trials (RCTs), both blinded and unblinded, that evaluated written PAAPs in adults with asthma. Included studies compared PAAP alone versus no PAAP, and/or PAAP plus education versus education alone.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted study characteristics and outcome data and assessed risk of bias for each included study. Primary outcomes were number of participants reporting at least one exacerbation requiring an emergency department (ED) visit or hospitalisation, asthma symptom scores on a validated scale and adverse events (all causes). Secondary outcomes were quality of life measured on a validated scale, number of participants reporting at least one exacerbation requiring systemic corticosteroids, respiratory function and days lost from work or study. We used a random-effects model for all analyses and standard Cochrane methods throughout.

MAIN RESULTS

We identified 15 studies described in 27 articles that met our inclusion criteria. These 15 included studies randomised a total of 3062 participants (PAAP vs no PAAP: 2602 participants; PAAP plus education vs education alone: 460 participants). Ten studies (eight PAAP vs no PAAP; two PAAP plus education vs education alone) provided outcome data that contributed to quantitative analyses. The overall quality of evidence was rated as low or very low.Fourteen studies lasted six months or longer, and the remaining study lasted for 14 weeks. When reported, mean age ranged from 22 to 49 years and asthma severity ranged from mild to severe/high risk. PAAP alone compared with no PAAPResults showed no clear benefit or harm associated with PAAPs in terms of the number of participants requiring an ED visit or hospitalisation for an exacerbation (odds ratio (OR) 0.75, 95% confidence interval (CI) 0.45 to 1.24; 1385 participants; five studies; low-quality evidence), change from baseline in asthma symptoms (mean difference (MD) -0.16, 95% CI -0.25 to - 0.07; 141 participants; one study; low-quality evidence) or the number of serious adverse events, including death (OR 3.26, 95% CI 0.33 to 32.21; 125 participants; one study; very low-quality evidence). Data revealed a statistically significant improvement in quality of life scores for those receiving PAAP compared with no PAAP (MD 0.18, 95% CI 0.05 to 0.30; 441 participants; three studies; low-quality evidence), but this was below the threshold for a minimum clinically important difference (MCID). Results also showed no clear benefit or harm associated with PAAPs on the number of participants reporting at least one exacerbation requiring oral corticosteroids (OR 1.45, 95% CI 0.84 to 2.48; 1136 participants; three studies; very low-quality evidence) nor on respiratory function (change from baseline forced expiratory volume in one second (FEV1): MD -0.04 L, 95% CI -0.25L to 0.17 L; 392 participants; three studies; low-quality evidence). In one study, PAAPs were associated with significantly fewer days lost from work or study (MD -6.20, 95% CI -7.32 to - 5.08; 74 participants; low-quality evidence). PAAP plus education compared with education aloneResults showed no clear benefit or harm associated with adding a PAAP to education in terms of the number of participants requiring an ED visit or hospitalisation for an exacerbation (OR 1.08, 95% CI 0.27 to 4.32; 70 participants; one study; very low-quality evidence), change from baseline in asthma symptoms (MD -0.10, 95% CI -0.54 to 0.34; 70 participants; one study; low-quality evidence), change in quality of life scores from baseline (MD 0.13, 95% CI -0.13 to 0.39; 174 participants; one study; low-quality evidence) and number of participants requiring oral corticosteroids for an exacerbation (OR 0.28, 95% CI 0.07 to 1.12; 70 participants; one study; very low-quality evidence). No studies reported serious adverse events, respiratory function or days lost from work or study.

AUTHORS' CONCLUSIONS

Analysis of available studies was limited by variable reporting of primary and secondary outcomes; therefore, it is difficult to draw firm conclusions related to the effectiveness of PAAPs in the management of adult asthma. We found no evidence from randomised controlled trials of additional benefit or harm associated with use of PAAP versus no PAAP, or PAAP plus education versus education alone, but we considered the quality of the evidence to be low or very low, meaning that we cannot be confident in the magnitude or direction of reported treatment effects. In the context of this caveat, we found no observable effect on the primary outcomes of hospital attendance with an asthma exacerbation, asthma symptom scores or adverse events. We recommend further research with a particular focus on key patient-relevant outcomes, including exacerbation frequency and quality of life, in a broad spectrum of adults, including those over 60 years of age.

Pulse oximeters to self monitor oxygen saturation levels as part of a personalised asthma action plan for people with asthma

BACKGROUND

We became aware through talking with people with asthma that some are using pulse oximeters to monitor their own blood oxygen levels during an asthma attack. Pulse oximeters are marketed by some suppliers as essential equipment for the home medicine cabinet. We wanted to find out if reliable evidence is available on use of pulse oximeters to self monitor asthma exacerbations at home. We decided to include only trials that used pulse oximeters as part of a personalised asthma action plan because it is important that decisions are made on the basis of symptoms as well as oxygen saturation, and that patients have a clear protocol to follow when their asthma worsens.

OBJECTIVES

To determine whether pulse oximeters used as part of a personalised asthma action plan for people with asthma are safer and more effective than a personalised asthma action plan alone.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register (CAGR), which includes reports identified through systematic searches of bibliographic databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Allied and Complementary Medicine Database (AMED) and PsycINFO, and by handsearching. We also searched ClinicalTrials.gov and the World Health Organization (WHO) trials portal.

SELECTION CRITERIA

We planned to include randomised controlled trials (RCTs). Participants would have included adults, children or both with a diagnosis of asthma. We planned to include trials in which investigators compared participants who used pulse oximeters to monitor oxygen levels at home during an asthma exacerbation as part of a personalised asthma action plan (PAAP) versus those who used a PAAP without a pulse oximeter. We planned to include studies involving people receiving any treatment regimen provided that no medicine was included as part of the randomisation schedule.

DATA COLLECTION AND ANALYSIS

We planned to use standard methods as recommended by The Cochrane Collaboration.

MAIN RESULTS

We found no studies and no evidence to support or refute the use of home pulse oximetry in self management of asthma; therefore, we can make no recommendations about use of a pulse oximeter as part of a PAAP.

AUTHORS' CONCLUSIONS

We found no reliable data to support or refute patient use of pulse oximeters to monitor oxygen saturation levels when experiencing an asthma attack. People should not use a pulse oximeter without seeking advice from a qualified healthcare professional.We identified no compelling rationale for home monitoring of oxygen levels in isolation for most people with asthma. Some people have a reduced perception of the severity of their own breathlessness when exposed to hypoxia. If trials on self monitoring of oxygen levels in the blood by pulse oximeter at home by people with asthma are conducted, the pulse oximeter must be given as part of a personalised asthma action plan.

Do Patients of Subspecialist Physicians Benefit from Written Asthma Action Plans?

RATIONALE

Asthma clinical guidelines suggest written asthma action plans are essential for improving self-management and outcomes.

OBJECTIVES

To assess the efficacy of written instructions in the form of a written asthma action plan provided by subspecialist physicians as part of usual asthma care during office visits.

METHODS

A total of 407 children and adults with persistent asthma receiving first-time care in pulmonary and allergy practices at 4 urban medical centers were randomized to receive either written instructions (n = 204) or no written instructions other than prescriptions (n = 203) from physicians.

MEASUREMENTS AND MAIN RESULTS

Using written asthma action plan forms as a vehicle for providing self-management instructions did not have a significant effect on any of the primary outcomes: (1) asthma symptom frequency, (2) emergency visits, or (3) asthma quality of life from baseline to 12-month follow-up. Both groups showed similar and significant reductions in asthma symptom frequency (daytime symptoms [P < 0.0001], nocturnal symptoms [P < 0.0001], β-agonist use [P < 0.0001]). There was also a significant reduction in emergency visits for the intervention (P < 0.0001) and control (P < 0.0006) groups. There was significant improvement in asthma quality-of-life scores for adults (P < 0.0001) and pediatric caregivers (P < 0.0001).

CONCLUSIONS

Our results suggest that using a written asthma action plan form as a vehicle for providing asthma management instructions to patients with persistent asthma who are receiving subspecialty care for the first time confers no added benefit beyond subspecialty-based medical care and education for asthma. Clinical trial registered with www.clinicaltrials.gov (NCT 00149461).

Chronic disease management programmes for adults with asthma

BACKGROUND

The burden of asthma on patients and healthcare systems is substantial. Interventions have been developed to overcome difficulties in asthma management. These include chronic disease management programmes, which are more than simple patient education, encompassing a set of coherent interventions that centre on the patients' needs, encouraging the co-ordination and integration of health services provided by a variety of healthcare professionals, and emphasising patient self-management as well as patient education.

OBJECTIVES

To evaluate the effectiveness of chronic disease management programmes for adults with asthma.

SEARCH METHODS

Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, MEDLINE (MEDLINE In-Process and Other Non-Indexed Citations), EMBASE, CINAHL, and PsycINFO were searched up to June 2014. We also handsearched selected journals from 2000 to 2012 and scanned reference lists of relevant reviews.

SELECTION CRITERIA

We included individual or cluster-randomised controlled trials, non-randomised controlled trials, and controlled before-after studies comparing chronic disease management programmes with usual care in adults over 16 years of age with a diagnosis of asthma. The chronic disease management programmes had to satisfy at least the following five criteria: an organisational component targeting patients; an organisational component targeting healthcare professionals or the healthcare system, or both; patient education or self-management support, or both; active involvement of two or more healthcare professionals in patient care; a minimum duration of three months.

DATA COLLECTION AND ANALYSIS

After an initial screen of the titles, two review authors working independently assessed the studies for eligibility and study quality; they also extracted the data. We contacted authors to obtain missing information and additional data, where necessary. We pooled results using the random-effects model and reported the pooled mean or standardised mean differences (SMDs).

MAIN RESULTS

A total of 20 studies including 81,746 patients (median 129.5) were included in this review, with a follow-up ranging from 3 to more than 12 months. Patients' mean age was 42.5 years, 60% were female, and their asthma was mostly rated as moderate to severe. Overall the studies were of moderate to low methodological quality, because of limitations in their design and the wide confidence intervals for certain results.Compared with usual care, chronic disease management programmes resulted in improvements in asthma-specific quality of life (SMD 0.22, 95% confidence interval (CI) 0.08 to 0.37), asthma severity scores (SMD 0.18, 95% CI 0.05 to 0.30), and lung function tests (SMD 0.19, 95% CI 0.09 to 0.30). The data for improvement in self-efficacy scores were inconclusive (SMD 0.51, 95% CI -0.08 to 1.11). Results on hospitalisations and emergency department or unscheduled visits could not be combined in a meta-analysis because the data were too heterogeneous; results from the individual studies were inconclusive overall. Only a few studies reported results on asthma exacerbations, days off work or school, use of an action plan, and patient satisfaction. Meta-analyses could not be performed for these outcomes.

AUTHORS' CONCLUSIONS

There is moderate to low quality evidence that chronic disease management programmes for adults with asthma can improve asthma-specific quality of life, asthma severity, and lung function tests. Overall, these results provide encouraging evidence of the potential effectiveness of these programmes in adults with asthma when compared with usual care. However, the optimal composition of asthma chronic disease management programmes and their added value, compared with education or self-management alone that is usually offered to patients with asthma, need further investigation.

Interventions for enhancing medication adherence

BACKGROUND

People who are prescribed self administered medications typically take only about half their prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications.

OBJECTIVES

The primary objective of this review is to assess the effects of interventions intended to enhance patient adherence to prescribed medications for medical conditions, on both medication adherence and clinical outcomes.

SEARCH METHODS

We updated searches of The Cochrane Library, including CENTRAL (via http://onlinelibrary.wiley.com/cochranelibrary/search/), MEDLINE, EMBASE, PsycINFO (all via Ovid), CINAHL (via EBSCO), and Sociological Abstracts (via ProQuest) on 11 January 2013 with no language restriction. We also reviewed bibliographies in articles on patient adherence, and contacted authors of relevant original and review articles.

SELECTION CRITERIA

We included unconfounded RCTs of interventions to improve adherence with prescribed medications, measuring both medication adherence and clinical outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive findings at earlier time points.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted all data and a third author resolved disagreements. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Pooling results according to one of these characteristics still leaves highly heterogeneous groups, and we could not justify meta-analysis. Instead, we conducted a qualitative analysis with a focus on the RCTs with the lowest risk of bias for study design and the primary clinical outcome.

MAIN RESULTS

The present update included 109 new RCTs published since the previous update in January 2007, bringing the total number of RCTs to 182; we found five RCTs from the previous update to be ineligible and excluded them. Studies were heterogeneous for patients, medical problems, treatment regimens, adherence interventions, and adherence and clinical outcome measurements, and most had high risk of bias. The main changes in comparison with the previous update include that we now: 1) report a lack of convincing evidence also specifically among the studies with the lowest risk of bias; 2) do not try to classify studies according to intervention type any more, due to the large heterogeneity; 3) make our database available for collaboration on sub-analyses, in acknowledgement of the need to make collective advancement in this difficult field of research. Of all 182 RCTs, 17 had the lowest risk of bias for study design features and their primary clinical outcome, 11 from the present update and six from the previous update. The RCTs at lowest risk of bias generally involved complex interventions with multiple components, trying to overcome barriers to adherence by means of tailored ongoing support from allied health professionals such as pharmacists, who often delivered intense education, counseling (including motivational interviewing or cognitive behavioral therapy by professionals) or daily treatment support (or both), and sometimes additional support from family or peers. Only five of these RCTs reported improvements in both adherence and clinical outcomes, and no common intervention characteristics were apparent. Even the most effective interventions did not lead to large improvements in adherence or clinical outcomes.

AUTHORS' CONCLUSIONS

Across the body of evidence, effects were inconsistent from study to study, and only a minority of lowest risk of bias RCTs improved both adherence and clinical outcomes. Current methods of improving medication adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. The research in this field needs advances, including improved design of feasible long-term interventions, objective adherence measures, and sufficient study power to detect improvements in patient-important clinical outcomes. By making our comprehensive database available for sharing we hope to contribute to achieving these advances.

Perceptions and Practices of Adults With Asthma

This article describes a qualitative study that investigated the experiences, attitudes, and opinions of adults with asthma regarding self-managing their disease. Focus groups were conducted with 22 adults living in metropolitan and regional New South Wales, Australia. Key findings were that the perceived stigma of asthma, the need for social support, and the need for “asthma-friendly general practitioners” concerned participants more than formal self-management procedures such as written Asthma Action Plans and medication regimes. Social cognitive theory was used to explain the fluid relationship between persons with asthma, their environment, and their behavior in relation to self-management strategies and in identifying patient-centered approaches. This qualitative research suggests that asthma is viewed as a specific, individualized condition best managed from the perspective of patients’ disease experience and environmental context and not one that is appropriately represented by collective, generic self-management recommendations. The authors’ findings suggest that self-management outcomes can be improved by recognizing the variance in self-efficacy levels between individuals and tailoring environmental and social support strategies around these.

Modifiable factors associated with severe asthma exacerbations in urban patients

BACKGROUND

Rates of asthma morbidity, mortality, and resource use are highest among African American individuals residing in inner-city locations, yet factors associated with adverse outcomes are not well established.

OBJECTIVE

To identify modifiable factors associated with asthma exacerbations.

METHODS

A total of 104 adult patients who presented to an inner-city hospital or emergency department (ED) with an asthma exacerbation from October 1, 2009, through June 31, 2010, completed surveys of clinical status, acute events, sociodemographic characteristics, current asthma knowledge, self-efficacy, attitudes toward asthma self-management, and perceived barriers to asthma care questionnaires. Associations with asthma hospitalizations and ED visits were assessed.

RESULTS

The mean age of the patients was 42 years, 91% were African American, 33% were insured, 57% were taking a controller medication, and 63% had an income level below the federal poverty line. On bivariate analysis, males, years of asthma, history of smoking, self-classification of asthma severity, history of admission to intensive care unit or intubation, use of peak flow meter or asthma action plan, controller medication use, and history of oral corticosteroid bursts were positively associated, whereas self-efficacy was negatively associated with number of ED visits or hospitalizations. No association was found for asthma knowledge, perceived barriers to care, or attitudes toward asthma management. On multivariate analysis, low self-efficacy remained associated with both asthma hospitalizations and ED visits.

CONCLUSION

Short-term use of health services for asthma is negatively associated with asthma self-efficacy. Self-management programs that enhance self-efficacy, rather than those that focus on knowledge or attitudes, may be effective in reducing adverse asthma outcomes for inner-city, predominantly African American populations.

Asthma action plans are highly variable and do not conform to best visual design practices

BACKGROUND

Asthma action plans improve asthma outcomes and are recommended in guidelines. However, delivery by physicians and usage by patients remain low. This may be because of variability in existing plans and a failure to consider visual design and usability factors in plan development.

OBJECTIVE

To characterize the variability in both the content and the format of existing plans, and the extent to which their format conforms to evidence-based visual design recommendations.

METHODS

We collected plans from the internet, Canadian experts and associations, guidelines, and published trials. We inductively developed analytic criteria for format and content analyses.

RESULTS

We collected 69 unique English or French-language adult outpatient plans from around the world. We found large variability in format, and plans fulfilled a mean of only 3.5 out of 8 evidence-based visual design recommendations. Content was also variable, including different descriptions of the baseline clinical state and descriptions and instructions at each "action point" (point recommending a change in treatment).

CONCLUSION

Existing plans vary widely in content and format. Accordingly, studies evaluating the effectiveness of action plans may not be directly comparable. Also, visual design may affect usability, uptake, and effectiveness. Our results suggest that this has not been adequately addressed in most plans, and design evidence and experts should be included in future development.

WITHDRAWN: Written individualised management plans for asthma in children and adults

BACKGROUND

Non-adherence to treatment advice is a common phenomenon in asthma and may account for a significant proportion of the morbidity. Comprehensive care that includes asthma education, a written self-management plan and regular review has been shown to improve asthma outcomes, but the contribution of these components has not been established.

OBJECTIVES

To determine whether the provision of a written asthma self-management plan increases adherence and improves outcome.

SEARCH STRATEGY

We carried out a search on the Cochrane Airways Group trials register. There was no language restriction. The search of the databases used the following terms: action plan OR self OR self-care OR self-manag* OR educ* AND adher* OR comply OR compli*. We contacted authors of included studies for any unpublished or on-going studies and bibliographies of all included studies and reviews were searched for further studies. The most recent search was carried out in June 2004.

SELECTION CRITERIA

We only considered randomised controlled trials (RCTs) in patients with asthma. Participants must have been assigned to receive an individualised written asthma management plan (symptom or peak flow based) about the actions required for regular asthma management and/or the actions to take in the event of an asthma exacerbation.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed study quality and abstracted data.

MAIN RESULTS

Seven trials met the inclusion criteria. The written management plans were either peak flow or symptom based, which were compared against each other or compared to no written management plan. Reported outcomes included: medication adherence, hospitalisation, emergency department visits, oral corticosteroid use, lung function, days lost from school/work, unscheduled doctor visits and respiratory tract infections. There was no consistent evidence that written plans produced better patient outcomes than no written plan. For some outcomes, there appeared to be an advantage of one type of plan over the other, but there was no consistency - one type of plan was not consistently more effective than another.

AUTHORS' CONCLUSIONS

The available trials are too small and the results too few and inconsistent to form any firm conclusions as to the contribution of written self management plans in the known beneficial effects of a comprehensive asthma care programme.

Patient-centered care and its effect on outcomes in the treatment of asthma

Patient-centered care may be pivotal in improving health outcomes for patients with asthma. In addition to increased attention in both research and clinical forums, recent legislation also highlights the importance of patient-centered outcomes research in the Patient Protection and Affordable Care Act. However, whether patient-centered care has been shown to improve outcomes for this population is unclear. To answer this question, we performed a systematic review of the literature that aimed to define current patient-focused management issues, characterize important patient-defined outcomes in asthma control, and identify current and emerging treatments related to patient outcomes and perspectives. We used a parallel search strategy via Medline(®), Cochrane Central Register of Controlled Trials, CINAHL(®) (Cumulative Index to Nursing and Allied Health Literature), and PsycINFO(®), complemented with a reference review of key articles that resulted in a total of 133 articles; 58 were interventions that evaluated the effect on patient-centered outcomes, and 75 were descriptive studies. The majority of intervention studies demonstrated improved patient outcomes (44; "positive" results); none showed true harm (0; "negative"); and the remainder were equivocal (14; "neutral"). Key themes emerged relating to patients' desires for asthma knowledge, preferences for tailored management plans, and simplification of treatment regimens. We also found discordance between physicians and patients regarding patients' needs, beliefs, and expectations about asthma. Although some studies show promise regarding the benefits of patient-focused care, these methods require additional study on feasibility and strategies for implementation in real world settings. Further, it is imperative that future studies must be, themselves, patient-centered (eg, pragmatic comparative effectiveness studies) and applicable to a variety of patient populations and settings. Despite the need for further research, enough evidence exists that supports incorporating a patient-centered approach to asthma management, in order to achieve improved outcomes and patient health.

Understanding what asthma plans mean: a linguistic analysis of terminology used in published texts

AIM

To identify from the literature what terms are used for 'asthma plans', with what meaning, and in what context(s).

METHODS

Linguistic analysis of a selected body of asthma literature from 1989-2009.

RESULTS

A wide range of asthma plan terminology was evident, with terms such as 'action plans', 'self-management plans' and 'treatment plans' being applied inconsistently and synonymously. For individual patients the term 'asthma plan' can describe a clinically-determined list of prescribed medication, an agreed plan to guide self-management of changing symptoms, or a more holistic 'living with asthma' plan. In some contexts the term 'asthma plan' was also used to describe an organisational system of care, which causes further ambiguity.

CONCLUSIONS

Within the literature, a plethora of terms is used inconsistently and with varied meaning. This is a potential, but previously unrecognised, barrier to asthma plan implementation. A taxonomy of asthma plans and a standardised definitions of terms is required.

The effects of the self-efficacy method on adult asthmatic patient self-care behavior

BACKGROUND

The prevalence of asthma and associated mortality is higher among adults than among children, as are associated morbidity and hospital readmission rates. The literature shows that promoting patient self-care behaviors and self-efficacy helps reduce recurrence and hospital readmission rates. Therefore, self-care behaviors and self-efficacy represent critical issues in successful asthma management.

PURPOSE

This study was developed to investigate the effects of a self-efficacy intervention on (a) the self-care behaviors of adult asthma patients and (b) the self-efficacy of adult asthmatic patients. The study used a pretest-posttest experimental design.

METHODS

A total of 60 asthma outpatients who visited the chest medicine division of a medical center in Kaohsiung City between March 2, 2009, and January 31, 2010, were assessed. Patients were randomly divided into two groups (experimental and control), with 30 patients assigned to each. Experimental group participants received the self-efficacy intervention program, which included watching a 15- to 20-minute DVD, received a healthcare booklet on self-efficacy for adult asthmatic patients, were asked to share their illness experience with support groups, and received medical follow-ups by telephone. Control group patients received conventional health education administered by the outpatient department. Study instruments included a self-care behavior scale for adult asthmatic patients (content validity index = .95, Cronbach's α = .82) and a self-efficacy scale for adult asthmatic patients (content validity index = .98, Cronbach's α = .82).

RESULTS

The two key findings of this study were as follows: (a)There was a significant improvement in the self-care behaviors of patients who received self-efficacy intervention in terms of medication adherence (p= .008), self-monitoring (p= .000), avoidance of antigens (p = .001), regular follow-up visits (p = .000), and regular exercise (p = .016); and (b) the program improved participant self-efficacy in terms of both asthma attack prevention (p = .030) and management during asthma attacks (p = .017).

CONCLUSIONS

On the basis of these results, self-efficacy intervention has been demonstrated a beneficial addition to adult asthmatic patient self-care regimens.

Educational and behavioral interventions for asthma: who achieves which outcomes? A systematic review

OBJECTIVES

Randomized clinical trial (RCT) data reviewed for outcomes and processes associated with asthma educational and behavioral interventions provided by different types of health professionals.

METHODS

Cochrane Collaboration, MEDLINE, PUBMED, Google Scholar search from 1998 to 2009 identified 1650 articles regarding asthma educational and behavioral interventions resulting in 249 potential studies and following assessment produced a final sample of 50 RCTs.

RESULTS

Approaches, intended outcomes, and program providers vary greatly. No rationale provided in study reports for the selection of specific outcomes, program providers, or program components. Health care utilization and symptom control have been the most common outcomes assessed. Specific providers favor particular teaching approaches. Multidisciplinary teams have been the most frequent providers of asthma interventions. Physician-led interventions were most successful for outcomes related to the use of health care. Multidisciplinary teams were best in achieving symptom reduction and quality of life. Lay persons were best in achieving self-management/self-efficacy outcomes. Components most frequently employed in successful programs are skills to improve patient-clinician communication and education to enhance patient self-management. Fifty percent of interventions achieved reduction in the use of health care and one-third in symptom control. A combination approach including self-management and patient-clinician communication involving multidisciplinary team members may have the greatest effect on most outcomes.

CONCLUSIONS

The extent to which and how different providers achieve asthma outcomes through educational and behavioral interventions is emerging from recent studies. Health care use and symptom control are evolving as the gold standard for intervention outcomes. Development of self-management and clinician-patient communication skills are program components associated with success across outcomes and providers.

Effect of an individualised education programme on asthma control, inhaler use skill, asthma knowledge and health-related quality of life among poorly compliant Korean adult patients with asthma

AIMS AND OBJECTIVES

This study assessed the effect of an individualised education programme on asthma control, inhaler use, asthma knowledge and health-related quality of life among poorly compliant adult Korean patients with asthma.

BACKGROUND

Previous studies show that proper educational strategies are necessary to increase asthma knowledge and skills to improve patients' self-management and health-related quality of life.

DESIGN

A one-group quasi-experimental design with repeated measurements.

METHODS

Adult patients with asthma (n = 101) were recruited from University hospital located in K City, Korea. Three interventions consisting of 30-minute sessions of individualised education were provided by an education team. Peak expiratory flow rate (PEFR), daily record card (DRC) scores, skill scores for use of metered dose inhaler, level of asthma knowledge and health-related quality of life scores were obtained before the intervention and 2-4 and 4-8 weeks after the intervention. One-way repeated measures analysis of variance was used to identify the effect of the education programme on the dependent variables.

RESULTS

Peak expiratory flow rate, DRC scores, inhaler using skill scores and health-related quality of life scores benefitted from intervention, whereas knowledge score did not. The effect on the PEFR and DRC score was sustained, with that of inhaler use skill increased over time from 4-8 weeks. However, the health-related quality of life effect was not sustained for 4-8 weeks after the intervention.

CONCLUSIONS

Repetitive education and innovative education methods may be needed to improve and to maintain pulmonary function, symptom control, asthma knowledge and health-related quality of life of poorly compliant adult Korean patients with asthma.

RELEVANCE TO CLINICAL PRACTICE

This study confirmed the importance of education for patients suffering from asthma in managing their symptoms and promoting their quality of life.

Association of asthma self-efficacy to asthma control and quality of life

BACKGROUND

Achieving optimal asthma control relies upon several behavioral factors (self-monitoring, treatment adherence) that may be influenced by asthma self-efficacy (ASE).

PURPOSE

To assess the extent to which levels of ASE are associated with asthma control and asthma-related quality of life in patients with asthma.

METHODS

A total of 557 adult patients with documented asthma completed a battery of questionnaires (Asthma Self-Efficacy Scale, ASES; Asthma Control Questionnaire, ACQ; Asthma Quality of Life Questionnaire, AQLQ) and standard spirometry. Patients also underwent a sociodemographic, medical history, and psychiatric interview. Partial correlations adjusting for covariates were conducted to assess associations between ASES scores and ACQ and AQLQ scores.

RESULTS

Results indicated that ASES scores were negatively correlated with ACQ total score and individual items scores, indicating that higher levels of ASE were associated with improved asthma control, and positively correlated with AQLQ total and subscale scores, indicating that higher levels of ASE were associated with better asthma-related quality of life. All findings were independent of covariates.

CONCLUSIONS

Findings suggest that being confident in one's ability to control asthma symptoms is associated with better asthma control and quality of life. Future studies should assess the direction of the association between self-efficacy and asthma morbidity in order to determine optimal treatment targets.

The role of written action plans in childhood asthma

PURPOSE OF REVIEW

The aim of this article is to examine the evidence for the effectiveness of a written action plan as an important element of guided self-management and to identify key features associated with its effectiveness in children and adolescents.

RECENT FINDINGS

Various written action plans are available for use; however, few have been specifically designed or validated for children. Strong, but limited pediatric evidence confirms that the addition of a written action plan to guided self-management education significantly improves outcome. Use of daily controller medication, with no step-up therapy other than as needed inhaled beta2-agonist, best prevents asthma exacerbations. Symptom-based appear superior to peak-flow based written action plans. The paucity of pediatric trials does not permit the identification of other keys features that enhance the dispensing of written action plans by healthcare professionals or uptake of recommendations by children, adolescents and their parents.

SUMMARY

Written action plans are effective tools to facilitate self-management. While step-up therapy is not superior to daily controller medication, symptom-based are superior to peak-flow based action plans for preventing exacerbations, other keys features associated with effectiveness have yet to be identified.

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.

Interventions for enhancing medication adherence

BACKGROUND

People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects.

OBJECTIVES

To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions.

SEARCH STRATEGY

We updated searches of The Cochrane Library, MEDLINE, CINAHL, EMBASE, International Pharmaceutical Abstracts (IPA), PsycINFO (all via OVID) and Sociological Abstracts (via CSA) in January 2007 with no language restriction. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of relevant original and review articles.

SELECTION CRITERIA

Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings.

DATA COLLECTION AND ANALYSIS

Study design features, interventions and controls, and results were extracted by one review author and confirmed by at least one other review author. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed. The studies differed widely according to medical condition, patient population, intervention, measures of adherence, and clinical outcomes. Therefore, we did not feel that quantitative analysis was scientifically justified; rather, we conducted a qualitative analysis.

MAIN RESULTS

For short-term treatments, four of ten interventions reported in nine RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient adherence, but did not enhance the clinical outcome. For long-term treatments, 36 of 81 interventions reported in 69 RCTs were associated with improvements in adherence, but only 25 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes.

AUTHORS' CONCLUSIONS

For short-term treatments several quite simple interventions increased adherence and improved patient outcomes, but the effects were inconsistent from study to study with less than half of studies showing benefits. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.

Development, implementation and evaluation of a new adult asthma self-management program

The purpose of the research was to develop, implement, and evaluate a new adult asthma self-management program with a multidisciplinary perspective. Small groups of adults met for 2 hr for 7 consecutive weekly meetings. Participants were asked to practice asthma specific behaviors (including peak expiratory flow monitoring, avoidance/removal of asthma triggers, and controller medication adherence) and general lifestyle behaviors (including drinking water, practicing relaxation, washing hands, and exercising). Learner-centered teaching techniques such as interactive communication and social support were utilized to help participants practice self-management behaviors including problem-solving and goal-setting. Paired sample t-tests included statistically significant improvements in asthma knowledge, asthma specific quality of life (QOL), asthma specific behaviors such as peak flow monitoring and general life style behaviors such as frequency of daily exercise. These results provide evidence that this new adult asthma self-management program can lead to both knowledge acquisition and behavioral changes.

Patient-centered education: applying learner-centered concepts to asthma education

OBJECTIVE

To review studies of patient-centered asthma education.

METHOD

CINAHL, Medline, Psycinfo, Eric, PsycARTICLES, and web of science databases were searched. RESULTS Asthma education programs are often based on health behavior theories. Many studies lack rigor in the assessment of the program's efficacy and effectiveness. Asthma education that promotes self-management primarily uses a problem-based approach. Few studies have examined the way educators teach and patients learn. Patient-centered approaches to education have mainly focused on communication between the patient and the health professional. Decision making as part of shared responsibility may vary with every patient. Patient-centered care shares similarities with the Self-Determination Theory as a learner-centered approach to education.

CONCLUSIONS

Many asthma education studies have been completed with varying levels of efficacy and effectiveness reported. Most programs focus on changing behavior with few studies examining educator behavior and/or the patient's learning styles. With a patient-centered approach being the preferred model of care, the incorporation of learner-centered approaches to patient education may prove useful in the future.

A pilot study on a cognitive-behavioral asthma self-management program for adults

The purpose of our research was to design, implement and evaluate a cognitive-behavioral asthma self-management program for adults. Seventeen adults with asthma completed an eight-week course (two hours, once a week) that consisted of interactive small group discussions and a behavior change procedure. The group discussions were led by a multi-disciplinary faculty (nurse, respiratory therapist, allergist, social worker, psychologist). Following each weekly discussion, participants would attempt to change a behavior related to the discussion. At the following meeting, participants would share their results and get feedback from the group; subsequently a new topic was introduced for discussion and a new behavioral change goal was added at the end of the meeting. Primary outcome measurements included asthma related quality of life, peak flow rate and frequency of key lifestyle behaviors. Outcome analyses indicated statistically significant improvements in frequency of: 1) peak flow monitoring; 2) practicing relaxation; 3) drinking 64 ounces of water a day (P < 0.05). Outcome analyses also indicated statistically significant improvements in quality-of-life (QOL) and asthma knowledge (P < 0.05). These results provide evidence that a cognitive-behavioral asthma education program that incorporates a behavior change procedure with interactive group discussions can lead to both knowledge acquisition and behavioral changes. Such outcomes are essential for reducing asthma morbidity and asthma mortality.

Interventions to enhance medication adherence

BACKGROUND

People who are prescribed self-administered medications typically take less than half the prescribed doses. Efforts to assist patients with adherence to medications might improve the benefits of prescribed medications, but also might increase their adverse effects.

OBJECTIVES

To update a review summarizing the results of randomized controlled trials (RCTs) of interventions to help patients follow prescriptions for medications for medical problems, including mental disorders but not addictions.

SEARCH STRATEGY

Computerized searches were updated to September 2004 without language restriction in MEDLINE, EMBASE, CINAHL, The Cochrane Library, International Pharmaceutical Abstracts (IPA), PsycINFO and SOCIOFILE. We also reviewed bibliographies in articles on patient adherence and articles in our personal collections, and contacted authors of original and review articles on the topic.

SELECTION CRITERIA

Articles were selected if they reported an unconfounded RCT of an intervention to improve adherence with prescribed medications, measuring both medication adherence and treatment outcome, with at least 80% follow-up of each group studied and, for long-term treatments, at least six months follow-up for studies with positive initial findings.

DATA COLLECTION AND ANALYSIS

Study design features, interventions and controls, and results were extracted by one reviewer and confirmed by at least one other reviewer. We extracted adherence rates and their measures of variance for all methods of measuring adherence in each study, and all outcome rates and their measures of variance for each study group, as well as levels of statistical significance for differences between study groups, consulting authors and verifying or correcting analyses as needed.

MAIN RESULTS

For short-term treatments, four of nine interventions reported in eight RCTs showed an effect on both adherence and at least one clinical outcome, while one intervention reported in one RCT significantly improved patient compliance, but did not enhance the clinical outcome. For long-term treatments, 26 of 58 interventions reported in 49 RCTs were associated with improvements in adherence, but only 18 interventions led to improvement in at least one treatment outcome. Almost all of the interventions that were effective for long-term care were complex, including combinations of more convenient care, information, reminders, self-monitoring, reinforcement, counseling, family therapy, psychological therapy, crisis intervention, manual telephone follow-up, and supportive care. Even the most effective interventions did not lead to large improvements in adherence and treatment outcomes. Six studies showed that telling patients about adverse effects of treatment did not affect their adherence.

AUTHORS' CONCLUSIONS

Improving short-term adherence is relatively successful with a variety of simple interventions. Current methods of improving adherence for chronic health problems are mostly complex and not very effective, so that the full benefits of treatment cannot be realized. High priority should be given to fundamental and applied research concerning innovations to assist patients to follow medication prescriptions for long-term medical disorders.

Poor adherence to self-medication instructions in children with asthma and their parents

This study describes a self-treatment program for parents of children with asthma. The aim was to prevent asthma exacerbations by learning to recognise prodromal signs and acting upon them by increasing inhaled corticosteroids (ICS). The study questions were: (1) can we teach parents and children to recognise prodromal signs? (2) are instructions to increase inhalation medication followed? (3) will frequency and severity of asthma attacks diminish subsequently? Due to physicians' changed attitude towards prescription of ICS, fewer children could be recruited who were "ICS-naive" than expected. Twenty-nine children of the age of 4-11 years with moderate asthma, participated in a one year prospective randomised study. Structured information was given to all patients on asthma, symptoms and medication. The experimental group received additional information on recognising prodromal signs and doubling ICS during one week. Only in 25% of the patients who recognised prodromal signs the dose of ICS was doubled (as prescribed), in 75% inadequately or not at all. Recognition of prodromal signs was poor as well as compliance to increase as-needed medication. No significant decrease of asthma symptoms occurred in the experimental group. Clinical implications are important for self-treatment instructions: an individually tailored and multi-component program should be offered by health care providers in order to help the patient to recognise early alarm symptoms, comply to self-treatment instructions and to make adaptations for continuous self-regulation.

Self-management interventions for chronic illness

An increasing number of interventions have been developed for patients to better manage their chronic illnesses. They are characterised by substantial responsibility taken by patients, and are commonly referred to as self-management interventions. We examine the background, content, and efficacy of such interventions for type 2 diabetes, arthritis, and asthma. Although the content and intensity of the programmes were affected by the objectives of management of the illness, the interventions differed substantially even within the three illnesses. When comparing across conditions, it is important to recognise the different objectives of the interventions and the complexity of the issues that they are attempting to tackle. For both diabetes and asthma, the objectives are concerned with the underlying control of the condition with clear strategies to achieve the desired outcome. By contrast, strategies to deal with symptoms of pain and the consequences of disability in arthritis can be more complex. The interventions that were efficacious provide some guidance as to the components needed in future programmes to achieve the best results. But to ensure that these results endure over time remains an important issue for self-management interventions.

We are the experts: people with asthma talk about their medicine information needs

People with chronic illness are being encouraged to become more involved in their care. For this, they need to be well informed about their medicines, and more written medicines information is becoming available. However, there is little data about its effectiveness and impact. This study examined the patient perspective of medicines information through focus groups of people with asthma. Most participants actively sought medicines information from a variety of professional and lay sources. There were some positive experiences but many examples of partial or total information failure. Individualised information was valued and medicine leaflets were generally seen as less helpful than face-to-face advice. Some felt strongly that patients with long experience should be involved in the development of medicine information leaflets. We conclude that medicine information leaflets do not currently meet the needs of users and that people who take medicines should be involved in their development and testing.

Written individualised management plans for asthma in children and adults

BACKGROUND

Non-adherence to treatment advice is a common phenomenon in asthma and may account for a significant proportion of the morbidity. Comprehensive care that includes asthma education, a written self-management plan and regular review has been shown to improve asthma outcomes, but the contribution of these components has not been established.

OBJECTIVES

To determine whether the provision of a written asthma self-management plan increases adherence and improves outcome.

SEARCH STRATEGY

We carried out a search on the Cochrane Airways Group trials register. There was no language restriction. The search of the databases used the following terms: action plan OR self OR self-care OR self-manag* OR educ* AND adher* OR comply OR compli*. We contacted authors of included studies for any unpublished or on-going studies and bibliographies of all included studies and reviews were searched for further studies. The most recent search was carried out in May 2003.

SELECTION CRITERIA

We only considered randomised controlled trials (RCTs) in patients with asthma. Participants must have been assigned to receive an individualised written asthma management plan (symptom or peak flow based) about the actions required for regular asthma management and/or the actions to take in the event of an asthma exacerbation.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed study quality and abstracted data.

MAIN RESULTS

Seven trials met the inclusion criteria. The written management plans were either peak flow or symptom based, which were compared against each other or compared to no written management plan. Reported outcomes included: medication adherence, hospitalisation, emergency department visits, oral corticosteroid use, lung function, days lost from school/work, unscheduled doctor visits and respiratory tract infections. There was no consistent evidence that written plans produced better patient outcomes than no written plan. For some outcomes, there appeared to be an advantage of one type of plan over the other, but there was no consistency - one type of plan was not consistently more effective than another.

REVIEWERS' CONCLUSIONS

The available trials are too small and the results too few and inconsistent to form any firm conclusions as to the contribution of written self management plans in the known beneficial effects of a comprehensive asthma care programme.