Effectiveness of routine self monitoring of peak flow in patients with asthma

Domiciliary Fractional Exhaled Nitric Oxide and Spirometry in Monitoring Asthma Control and Exacerbations

BACKGROUND

Domiciliary measurements of airflow obstruction and inflammation may assist healthcare teams and patients in determining asthma control and facilitate self-management.

OBJECTIVE

To evaluate parameters derived from domiciliary spirometry and fractional exhaled nitric oxide (Feno) in monitoring asthma exacerbations and control.

METHODS

Patients with asthma were provided with hand-held spirometry and Feno devices in addition to their usual asthma care. Patients were instructed to perform twice-daily measurements for 1 month. Daily symptoms and medication change were reported through a mobile health system. The Asthma Control Questionnaire was completed at the end of the monitoring period.

RESULTS

One hundred patients had spirometry, of which 60 were given additional Feno devices. Compliance rates for twice-daily measurements were poor (median [interquartile range], 43% [25%-62%] for spirometry; 30% [3%-48%] for Feno); at least 15% of patients took little or no spirometry measurements and 40% rarely measured Feno. The coefficient of variation (CV) values in FEV1 and Feno were higher, and the mean % personal best FEV1 lower in those who had major exacerbations compared with those without (P < .05). Feno CV and FEV1 CV were associated with asthma exacerbation during the monitoring period (area under the receiver-operating characteristic curve, 0.79 and 0.74, respectively). Higher Feno CV also predicted poorer asthma control (area under the receiver-operating characteristic curve, 0.71) at the end of the monitoring period.

CONCLUSIONS

Compliance with domiciliary spirometry and Feno varied widely among patients even in the setting of a research study. However, despite significant missing data, Feno and FEV1 were associated with asthma exacerbations and control, making these measurements potentially clinically valuable if used.

Asthma action plan for proactive bronchial asthma self-management in adults: a randomized controlled trial

Background

Written personalized asthma action plans are recommended as part of patient education and self-management.

Objectives

To enable asthmatic adults to proactively self-manage bronchial asthma and sustain asthma quiescent status through utilization of the Asthma Action Plan (AAP), and to establish a feasible asthmatic/care taker-health care provider communication.

Design

Randomized controlled trial with cluster sampling by pulmonologists.

Setting and participants

The study comprised 320 chronic asthmatic patients attending the chest department at the main health insurance hospital in Alexandria that were randomly allocated as the intervention group (AAIG; n=160) that received standard care and intervention by the AAP and a control group (AACG; n=160) that received the routine standard of care. Data were collected through an interviewing questionnaire. The study continued over a 6-month period and passed into three phase stations. During the preparatory phase the health care provider managed to explain, fill and simplify the use of the Arabic version of the AAP, to explain the correct utilization of the weekly follow-up form and to emphasize the weekly communication/visit with the health care provider (HCP) to update their weekly follow-up records. Follow-up was done on the 90th and 180th days from the launch of the study, respectively. The study asthmatics were subjected to history-taking of their asthma symptoms, signs and triggers, and a review of their medical/peak expiratory flow records, as well as his/her daily activity and exercise.

Results

The AAIG experienced superiority of the average of the green zone days ('doing well') with significantly more episodes of early asthma flare-up self-management concomitant with prominent fewer emergency department visits, hospitalization, admission at the ICU, private health facility, and days of sickness leaves and absenteeism. A preponderance of the high and medium adherence levels to asthma medications, avoidance of asthma triggers and smoking was achieved by the AAIG.

Conclusions

AAP was the basis for effective patient-health care provider communication and patient real time asthma flare-up self-management to achieve and sustain better asthma control in asthmatic adults.

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.

Data-driven health management: reasoning about personally generated data in diabetes with information technologies

OBJECTIVE

To investigate how individuals with diabetes and diabetes educators reason about data collected through self-monitoring and to draw implications for the design of data-driven self-management technologies.

MATERIALS AND METHODS

Ten individuals with diabetes (six type 1 and four type 2) and 2 experienced diabetes educators were presented with a set of self-monitoring data captured by an individual with type 2 diabetes. The set included digital images of meals and their textual descriptions, and blood glucose (BG) readings captured before and after these meals. The participants were asked to review a set of meals and associated BG readings, explain differences in postprandial BG levels for these meals, and predict postprandial BG levels for the same individual for a different set of meals. Researchers compared conclusions and predictions reached by the participants with those arrived at by quantitative analysis of the collected data.

RESULTS

The participants used both macronutrient composition of meals, most notably the inclusion of carbohydrates, and names of dishes and ingredients to reason about changes in postprandial BG levels. Both individuals with diabetes and diabetes educators reported difficulties in generating predictions of postprandial BG; their predictions varied in their correlations with the actual captured readings from r = 0.008 to r = 0.75.

CONCLUSION

Overall, the study showed that identifying trends in the data collected with self-monitoring is a complex process, and that conclusions reached by both individuals with diabetes and diabetes educators are not always reliable. This suggests the need for new ways to facilitate individuals' reasoning with informatics interventions.

Adopting the sensemaking perspective for chronic disease self-management

BACKGROUND

Self-monitoring is an integral component of many chronic diseases; however few theoretical frameworks address how individuals understand self-monitoring data and use it to guide self-management.

PURPOSE

To articulate a theoretical framework of sensemaking in diabetes self-management that integrates existing scholarship with empirical data.

METHODS

The proposed framework is grounded in theories of sensemaking adopted from organizational behavior, education, and human-computer interaction. To empirically validate the framework the researchers reviewed and analyzed reports on qualitative studies of diabetes self-management practices published in peer-reviewed journals from 2000 to 2015.

RESULTS

The proposed framework distinguishes between sensemaking and habitual modes of self-management and identifies three essential sensemaking activities: perception of new information related to health and wellness, development of inferences that inform selection of actions, and carrying out daily activities in response to new information. The analysis of qualitative findings from 50 published reports provided ample empirical evidence for the proposed framework; however, it also identified a number of barriers to engaging in sensemaking in diabetes self-management.

CONCLUSIONS

The proposed framework suggests new directions for research in diabetes self-management and for design of new informatics interventions for data-driven self-management.

[Written personalized action plan for atopic dermatitis: a patient education tool]

Atopic dermatitis (AD) is the most frequent children's chronic skin disease. Management of AD can be difficult because local treatments must be adapted to the skin's condition. Between consultations, sudden changes in the state of the disease can make it difficult to manage local treatment. Parents and children need information that will help them adapt their treatment to the course of their disease. Aiming to enable parents to better treat their atopic child by themselves, we have developed a personalized action plan in order to simplify, personalize, and adapt the medical prescription to the state of the disease. The Personalized Written Action Plan for Atopics (PA2P) is based on the model used in the treatment of asthma, with integrated specificities for AD in children. The aim of this study was to assess the feasibility and pertinence of the PA2P for pediatricians to use in private practice. A total of 479 pediatricians answered a questionnaire sent by e-mail. The vast majority of the respondents gave positive reviews of the tool: 99% of the pediatricians declared the tool to be pertinent, qualifying it as clear and logical. The PA2P appeared to be appropriate for the atopic patient because it improves the families' involvement in the application of local treatment by offering personalized care and by simplifying the doctor's prescription. Finally, 72% of doctors responding to the questionnaire were willing to take part in future studies involving parents. More than a gadget, the PA2P could become a useful tool for therapeutic patient education.

Asthma self management in adults: a review of current literature

Self management programs for chronic conditions, such as asthma, have an important place in healthcare delivery. When properly implemented, they can curb the impact of disease and reduce both the high personal costs for individuals and significant financial costs for health care systems. The purpose of this review was to establish an understanding of current published literature on asthma self management programs in adults and to identify any reported attributes or components which serve to either assist or obstruct the uptake of self management strategies. Electronic data sources including Scopus, Proquest 5000, CINAHL, PubMed and Web of Science were accessed and literature searches were conducted using the key terms: asthma, chronic disease, self management, morbidity, quality of life, health outcomes, patient education and best practice. Inclusion criteria for the search included journal articles relating to adults with asthma published in English in peer reviewed journals from 1995 to 2011. Exclusion criteria included research targeting children, parents of children or families; and articles examining Asthma and COPD (or any other co-morbidity). Sixty four articles were included in this review due to their relevance to the major components of asthma self management, as defined by the Australian Asthma Management Handbook. A major conclusion from this review was that the uptake of asthma self management strategies is poor despite global recommendations for over twenty years; and that a likely reason for this is that generic asthma self management advice does not engage the individual with asthma.

Relationship between sensitivity to dyspnea and fluctuating peak expiratory flow rate in the absence of asthma symptoms

BACKGROUND

Exacerbation of asthma has a negative impact on quality of life and increases the risk of fatal asthma. One of the known risk factors for patients with a history of near-fatal asthma is reduced sensitivity to dyspnea.

OBJECTIVE

We aimed to identify patients with such risk before they experienced severe exacerbation of asthma.

METHODS

We analyzed asthma symptoms and peak expiratory flow rate (PEFR) values of 53 patients recorded daily in a diary over a mean period of 274 days. Patients matched their symptoms to one of eight categories ranging in severity from 'absent' to 'severe attack'. We then analyzed the relationship between PEFR and asthma symptoms by dividing the PEFR value by the values of clinical parameters, including asthma symptom level.

RESULTS

Average PEFR was 75.2% (50.5-100%) in the 'absent' symptom category, 64.5% (36.6-92.6%) in 'wheeze', 57.3% (25.0-94.7%) in 'mild attack' and 43.6% (20.4-83.1%) in 'moderate attack', with the personal best reading taken as 100%. Thus, differences in PEFR in patients in the same symptom category varied widely. PEFR in wheeze, mild attack and moderate attack did not correlate significantly with duration of asthma, forced expiratory volume in one second or proportion of personal best to standard predicted PEFR values. These PEFRs showed no significant difference in groups divided by type of regular treatment, but showed a significant negative correlation with the coefficient of variation (CV) of PEFR when asthma symptoms were absent. CV for absent symptoms should be between +4.0 and -4.0% when using regression analysis to measure PEFR if the decreased PEFR is in agreement with guidelines.

CONCLUSION

To determine which patients have reduced sensitivity to dyspnea, CV of PEFR should be considered when asthma symptoms are reported as absent. When patients present with more than 8% fluctuation in PEFR, we should intervene in their treatment, even when they claim to be stable.

Accuracy of the piko-1 pocket spirometer

BACKGROUND

Good asthma control is the main goal of long-term asthma treatment. According to the Global Initiative for Asthma (GINA) guidelines (www.ginasthma.com), medical professionals assess asthma control based on specific questions regarding asthma symptoms and by spirometry measuring forced expiratory volume in 1 second (FEV(1)). Patients trained in early self-detection of asthma exacerbations use a symptom-based questionnaire, such as the Asthma Control Test (ACT) [Nathan RA, Sorkness CA, Kosinski M, et al. Development of the Asthma Control Test. A survey for assessing asthma control. J Allergy Clin Immunol 2004; 113:59-64]. However, some patients may prefer harder indicators, like peak flow values, when considering how to act within their regular asthma self-management plan.

OBJECTIVES

Monitoring of FEV(1) at home could be an even more valuable alternative to recording peak flow values. The inexpensive handheld pocket spirometer "Piko-1®" offers the opportunity to monitor and store consecutive FEV(1) values. This study assesses the accuracy of the Piko-1 device.

METHODS

Twenty volunteers tested 20 Piko-1 devices over five consecutive days. All results were compared to daily FEV(1) values, as measured by a calibrated reference spirometer.

RESULTS

Overall, the accuracy was acceptable, although Piko-1 tended to underestimate FEV(1) in the lower range. Moreover, there was no evidence of major heterogeneity between Piko-1 devices.

CONCLUSION

The Piko-1 FEV(1) measurements are sufficiently accurate to start a clinical trial to compare the detection of asthma exacerbations with this device and based on asthma symptoms alone.

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.

Can a community evidence-based asthma care program improve clinical outcomes?: a longitudinal study

RATIONALE

Asthma is associated with significant morbidity. Previous studies highlight significant variations in asthma management approaches within primary care settings where the adoption of published asthma guidelines is typically suboptimal.

OBJECTIVE

To determine whether the implementation of an evidence-based asthma care program in community primary care settings leads to improved clinical outcomes in asthma patients. METHODS, MEASUREMENTS, AND MAIN RESULTS: A community-based participatory research project was implemented at 8 primary care practices across Ontario, Canada, consisting of elements based on the Canadian Asthma Consensus Guidelines (asthma care map, program standards, management flow chart and action plan). A total of 1408 patients aged 2-55 years participated. Conditional logistic regression analyses were used to calculate the odds ratios (OR) comparing baseline to follow-up while adjusting for age, gender, socioeconomic status and other covariates. At 12-month follow-up, there were statistically significant reductions in self-reported asthma exacerbations from 77.8% to 54.5% [OR = 0.35; 95% confidence interval (CI): 0.28-0.43]; emergency room visits due to asthma from 9.9% to 5.5% (OR = 0.47; 95% CI: 0.32-0.62); school absenteeism in children from 19.9% to 10.2% (OR = 0.37; 95% CI: 0.25-0.54); productivity loss in adults from 12.0% to 10.3% (OR = 0.49; 95% CI: 0.34-0.71); uncontrolled daytime asthma symptoms from 62.4% to 41.4% (OR = 0.34; 95% CI: 0.27-0.42); and uncontrolled nighttime asthma symptoms from 46.4% to 25.4% (OR = 0.29; 95% CI: 0.23-0.37).

CONCLUSIONS

Development and implementation of a community-based primary care asthma care program led to risk reductions in exacerbations, symptoms, urgent health service use and productivity loss related to asthma.

Peak expiratory flow-guided self-management treatment of asthma in Serbia

The aims of this study were to compare the efficacy of 1-year peak expiratory flow (PEF)-based self-management of asthma against conventional treatment and to analyze the long-term effectiveness of self-management. Eighty adult patients with persistent asthma (group B). After 1 year, significant improvement was noted in markers of asthma severity in group A but there were no changes in group B. After 6 years of the self-management program, asthma morbidity and emergency use of health services were reduced. These results show short-term and long-term effectiveness of a PEF-based self-management program in persistent asthma.

Home monitoring in asthma self-management

Peak flow monitoring of asthma came into vogue with the advent of asthma self-management programs. Because it offered an objective way to gauge asthma severity, it promised improvement in the accuracy of asthma monitoring over that attainable by symptom monitoring. This promise has not been fulfilled. The ensuing years have witnessed a debate concerning the relative merits of symptom and peak flow monitoring. The debate has focused both on the degree to which peak flow and symptom scores are related to one another and on the relative effectiveness of symptom and peak flow monitoring for asthma control. We review research relating to these topics. The work shows that the strength of the relationship between peak flow and symptoms is low to moderate and varies between individuals and that benefits of peak flow monitoring in asthma self-management provide, at best, no more than a small increment in effectiveness beyond that afforded by symptom monitoring.

A randomized clinical trial of peak flow versus symptom monitoring in older adults with asthma

OBJECTIVE

To determine whether peak flow monitoring has value above and beyond symptom monitoring when used as part of an asthma management plan.

METHODS

From a large managed-care organization, 296 adults, aged 50-92 yr, were recruited and randomly assigned in equal numbers to either use of symptoms or peak flow rate (twice daily or "as needed") for asthma monitoring, and monitored every 6 mo for 2 yr. Interventions were delivered in four 90-min small-group classes and included a personalized action plan and coaching in proper use of asthma inhalers.

RESULTS

We found no significant differences between peak flow rate and symptom monitoring, or between twice-daily and as-needed peak flow monitoring in the primary or secondary study outcomes: health care utilization (acute, nonacute, or total asthma visits), Asthma Quality-of-Life Questionnaire (AQLQ) scores, and lung function. AQLQ scores and prebronchodilator FEV1 increased significantly for both groups between baseline and 6 mo (AQLQ: mean, 0.4 units; 95% confidence interval, 0.3, 0.5; p < 0.0001; FEV1% predicted: mean, 4%). Inhaler technique improved substantially in both groups.

CONCLUSIONS

Peak flow monitoring has no advantage over symptom monitoring as an asthma management strategy for older adults with moderate-severe asthma when used in a comprehensive asthma management program. Improved outcomes in both groups suggest that understanding proper medication use, regular monitoring of asthma status, and understanding how to respond to changes are of primary importance.

Written action plans for asthma in children

BACKGROUND

While all asthma consensus statements recommend the use of written action plan (WAP) as a central part of asthma management, a recent systematic review of randomised trials highlighted the paucity of trials where the only difference between groups was the provision or not of a written action plan.

OBJECTIVES

The objectives of this review were firstly to evaluate the independent effect of providing versus not providing a written action plan in children and adolescents with asthma, and secondly to compare the effect of different written action plans.

SEARCH STRATEGY

We searched the Cochrane Airways Group Specialised Register (November 2004), which is derived from searches of CENTRAL, MEDLINE, EMBASE, CINAHL, as well as handsearched respiratory journals, and meeting abstracts. We also searched bibliographies of included studies and identified review articles.

SELECTION CRITERIA

Randomised controlled trials were included if they compared a written action plan with no written action plan, or different written action plans with each other.

DATA COLLECTION AND ANALYSIS

Two authors independently selected the trials, assessed trial quality and extracted the data. Study authors were contacted for additional information.

MAIN RESULTS

Four trials (three RCTs and one quasi-RCT) involving 355 children were included. Children using symptom-based WAPs had lower risk of exacerbations which required an acute care visit (N = 5; RR 0.73; 95% CI 0.55 to 0.99). The number needed to treat to prevent one acute care visit was 9 (95% CI 5 to 138). Symptom monitoring was preferred over peak flow monitoring by children (N = 2; RR 1.21; 95% CI 1.00 to 1.46), but parents showed no preference (N = 2; RR 0.96; 95% CI 0.18 to 2.11). Children assigned to peak flow-based action plans reduced by 1/2 day the number of symptomatic days per week (N = 2; mean difference: 0.45 days/week; 95% CI 0.04 to 0.26). There were no significant group differences in the rate of exacerbation requiring oral steroids or admission, school absenteeism, lung function, symptom score, quality of life, and withdrawals.

AUTHORS' CONCLUSIONS

The evidence suggests that symptom-based WAP are superior to peak flow WAP for preventing acute care visits although there is insufficient data to firmly conclude whether the observed superiority is conferred by greater adherence to the monitoring strategy, earlier identification of onset of deteriorations, higher threshold for presentation to acute care settings, or the specific treatment recommendations.

Overcoming gaps in the management of asthma in older patients: new insights

Asthma is under-recognised and undertreated in older populations. This is not surprising, given that one-third of older people experience significant breathlessness. The differential diagnosis commonly includes asthma, chronic obstructive pulmonary disease (COPD), heart failure, malignancy, aspiration and infections. Because symptoms and signs of several cardiorespiratory diseases are nonspecific in older people and diseases commonly co-exist, investigations are important. A simple strategy for the investigation of breathlessness in older people should include a full blood count, chest radiograph, ECG, peak flow diary and/or spirometry with reversibility as a minimum. If there are major abnormalities on the ECG, an echocardiogram should also be performed. Diurnal variability in peak flow readings >or=20% or >or=15% reversibility in forced expiratory volume in 1 second, spontaneously or with treatment, support a diagnosis of asthma. Distinguishing asthma from COPD is important to allow appropriate management of disease based on aetiology, accurate prediction of treatment response, correct prognosis and appropriate management of the chest condition and co-morbidities. The two conditions are usually readily differentiated by clinical features, particularly age at onset, variability of symptoms and nocturnal symptoms in asthma, supported by the results of reversibility testing. Full lung function tests may not necessarily help in differentiating the two entities, although gas transfer factor is characteristically reduced in COPD and usually normal or high in asthma. Methacholine challenge tests previously mainly used in research are now also used widely and safely to confirm asthma in clinical settings. Interest in exhaled nitric oxide as a biomarker of airways inflammation is increasing as a noninvasive tool in the diagnosis and monitoring of asthma. Regular inhaled corticosteroids (ICS) are the mainstay of treatment of asthma. Even in mild disease in older adults, regular preventive treatment should be considered, given the poor perception of bronchoconstriction by older asthmatic patients. If symptoms persist despite ICS, addition of long-acting beta(2)-adrenoceptor agonists (LABA) should be considered. Addition of LABA to ICS improves asthma control and allows reduction in ICS dose. However, older people have been grossly under-represented in trials of LABA, many trials having excluded those >or=65 years of age. On meta-analysis, beta(2)-adrenoceptor agonists (both short acting and long acting) are associated with increased cardiovascular mortality and morbidity in asthma and COPD. While the evidence for excess cardiovascular mortality is stronger for short-acting beta(2)-adrenoceptor agonists, it would be prudent to exercise particular care in using beta(2)-adrenoceptor agonists (long acting and short acting) in those at risk of adverse cardiovascular outcomes, including older people. Regular review of cardiovascular status (and monitoring of serum potassium concentration) in patients taking beta(2)-adrenoceptor agonists is crucial. The response to LABA should be carefully monitored and alternative 'add-on' therapy such as leukotriene receptor antagonists (LRA) should be considered. LRA have fewer adverse effects and in individual cases may be more effective and appropriate than LABA. Long-term trials evaluating beta(2)-adrenoceptor agonists and other bronchodilator strategies are needed particularly in the elderly and in patients with cardiovascular co-morbidities. There is no evidence that addition of anticholinergics improves control of asthma further, although the role of long-acting anticholinergics in the prevention of disease progression is currently being researched. Older patients need to be taught good inhaler technique to improve delivery of medications to lungs, minimise adverse effects and reduce the need for oral corticosteroids. Nurse-led education programmes that include a written asthma self-management plan have the potential to improve outcomes.

Adequacy of outpatient management of asthma patients admitted to a state hospital in Argentina

OBJECTIVE

The aim of this study was to assess chronic outpatient management of adult patients admitted with asthma.

METHODOLOGY

A cross-sectional survey was conducted of 98 consecutive asthma admissions to a specialized pulmonary State Hospital in Buenos Aires, Argentina, over a 12-month period. Patients were surveyed, within 48 h of admission, with a previously validated questionnaire which deals with chronic outpatient management and measures taken by patients or physicians to treat symptoms during asthma exacerbations.

RESULTS

FEV1% predicted was 30.2 +/- 10.7. Mean admission rate and emergency department (ED) visits in the previous year were 0.7 +/- 1.2 and 4.6 +/- 5.1, respectively. A total of 96, 65 and 9% of the patients had been treated previously in the ED, admitted to hospital or mechanically ventilated, respectively. Only 62% had been prescribed inhaled corticosteroids (IC) by their physician; 38% had been prescribed nebulized beta agonists (Nbeta2) and 68% a metered dose inhaler (MDIbeta2). Inhaled beta2-agonist usage during acute exacerbations over the 24 h prior to admission was 14.4 +/- 7.4 puffs for MDIbeta2 and 8.6 +/- 5.4 occasions for Nbeta2. Only 11% of the patients were able to perform all the steps of the MDI inhalation technique correctly. An action plan had been provided by their physicians to 43% of patients, while 58% changed their medication on their own. Only three patients had a peak flow meter (PFM) prescribed. ED was used by 26% for their routine care. No health insurance coverage was available to 75.5% of the patients.

CONCLUSIONS

Underuse of IC, poor MDI inhalation technique, and low prescription of an action plan was common and a PFM was seldom prescribed. During exacerbations, many patients changed their medication spontaneously and MDIbeta2 underuse was observed.

Clinical practice guidelines: medical follow-up of patients with asthma--adults and adolescents

The follow-up of patients with asthma should focus on asthma control (disease course over a number of weeks).

Revisiting the accuracy of peak flow meters: a double-blind study using formal methods of agreement

BACKGROUND

There is widespread use of peak flow meters in both hospitals and general practice. Previous studies to assess peak flow meter accuracy have shown significant differences in the values obtained from different meters. However, many of these studies did not use human subjects for peak flow measurements and did not compare meters of varying usage. In this study human subjects have been used with meters of varying usage.

METHODS

Participants were tested using two new (meters A and C) and one old peak flow meter (meter B) in random order. The study was double-blinded. Participants were recruited from the university campus.

RESULTS

Four hundred and nine individuals participated. The difference between peak flow means of A and B was -9.93 l/min (95% CI: -12.37 to -7.48, P<0.0001). The difference between peak flow means of B and C was 20.08 l/min (95% CI: 17.85-22.29, P<0.0001). The difference between peak flow means of A and C was 10.15 l/min (95% CI: 7.68-12.61, P<0.0001).

CONCLUSION

There was a significant difference between the values obtained from the new and old peak flow meters and also between the two new peak flow meters. We conclude that there is need for caution in interchangeably using flow meters in clinical practice.

Adjustable and fixed dosing with budesonide/ formoterol via a single inhaler in asthma patients: the ASSURE study

Patient-guided management of asthma using adjustable dosing of budesonide/formoterol in a single inhaler (Symbicort) was compared with fixed dosing in an open-label, multicentre, randomised study. Patients, uncontrolled on an inhaled corticosteroid (ICS) or controlled on an ICS and a long-acting beta2-agonist, entered a 4-week run-in period and received budesonide/formoterol (80/4.5 or 160/4.5 microg), 2 inhalations b.i.d. Following randomisation, the fixed-dosing group (n = 764) continued this regimen for a further 12 weeks. The adjustable-dosing group (n = 775) could step down to 1 inhalation b.i.d. if symptoms were controlled, and, at early signs of worsening symptoms, promptly step up to 4 inhalations b.i.d. for < or = 2 weeks. During run-in, National Heart, Lung and Blood Institute symptom-severity grading was maintained in 60% and improved in 31% of patients, clinic peak flow increased from 400 to 4191/min (P<0.001), and health-related quality of life (overall MiniAQLQ) improved from 4.6 to 5.4 (P<0.001). Patients effectively used the adjustable-dosing regimen; 79% reduced budesonide/formoterol dosage and, compared with fixed dosing, the number of inhalations were significantly lowered (3.2 vs. 3.8 inhalations/day, P<0.05). Both regimens were well tolerated. In both groups, symptom control was maintained or improved in 85-86% of patients, and 94% experienced no treatment failures. Consistent with current guidelines, adjustable maintenance dosing with budesonide/formoterol in a single inhaler provides effective asthma control at reduced medication doses.

Peak flow monitoring for guided self-management in childhood asthma: a randomized controlled trial

We asked whether the addition of PEF recordings to a symptom-based self-management plan improved outcome in school children with asthma. In an open-randomized, parallel-group, controlled trial, we studied children aged 7-14 years with moderate asthma. After a 4-week run-in, 90 children were randomized to receive either PEF plus symptom-based management or symptom-based management alone for 12 weeks. Thresholds for action based on PEF were 70% of best (for increasing inhaled steroids) and 50% of best (for commencing prednisolone). Children were asked to perform twice-daily spirometry at home (using an electronic recording spirometer that revealed only PEF to the study group alone) and to record a symptom diary. The mean daily symptom score was the main outcome. There were no differences between groups in mean symptom score or in spirometric lung function, PEF, quality of life score, or reported use of health services over 12 weeks. During acute episodes, children responded to changes in symptoms by increasing their inhaled steroids at a mean value of PEF of greater than 70% of best so that overall PEF did not contribute to this important self-management decision. Knowledge of PEF did not enhance self-management even during acute exacerbations.

The Value of Home Monitoring Kits in Diabetes, Hypertension, Asthma, and Oral Anticoagulation Therapy

Home monitoring devices encourage people to actively participate in their health care management. In addition, access to more data may help to make better decisions, which may ultimately lead to better health outcomes. The primary focus of this article will be on blood glucose, blood pressure, prothrombin time, and peak flow meters. The empirical evidence on the accuracy and usefulness of these home monitoring devices is discussed. Based on the evidence from the literature, erroneous reporting of the readings by the patients is a major concern. Therefore, primary practitioners are encouraged to consult with patients’ log books and their meters (if memory feature is available), instead of relying solely on self-reported values. Patients also need to be educated and trained adequately about the proper measurement technique and relevance and interpretation of the readings. Continuing education is necessary regarding the behavioral and therapeutic changes patients should carry out in accordance with performing regular home monitoring.

A survey of Medicaid recipients with asthma: perceptions of self-management, access, and care

STUDY OBJECTIVES

To understand how Medicaid recipients with asthma view their experience with care.

DESIGN

Survey sent to Medicaid managed care enrollees.

SETTING

A survey designed to assess general health status, access to care, medication-taking behaviors, and overall satisfaction was sent to 25,171 patients with moderate-to-severe asthma.

RESULTS

A total of 92% of patients rated their asthma care as good or excellent, 64% of adults reported their health as fair or poor, while only 27% of children reported their health as being fair or poor. Respondents were well-educated regarding their asthma, with 87% reporting knowing what to do for severe asthma attacks, 78% knowing the early warning signs of an asthma attack, and 77% recognizing aggravating factors. Eighty-nine percent of respondents rated the quality of the information given to them by their provider as very good or good. While 75% of patients reported using inhaled steroids, only 38% of those reported using them on a daily basis. Forty percent of patients reported using inhaled steroids only when they have symptoms. Forty-six percent of adults either smoke cigarettes or are exposed to smoking in the home, while 35% of children are exposed to smoke in the home.

CONCLUSION

Asthmatic patients rated the quality of the information that their physicians provide very highly and reported that that they understand how to treat exacerbations. However, they do not take prescribed inhaled steroids on a daily basis. In addition, many asthmatic patients reside in homes where cigarette smoking is present.

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.

Management of chronic disease by patients

Chronic conditions dominate health care in most parts of the world, including the United States. Management of a disease by the patient is central to control of its effects. A wide range of influences in the person's social and physical environments enhance or impede management efforts. Interventions to improve management by patients can produce positive outcomes including better monitoring of a condition, fewer symptoms, enhanced physical and psychosocial functioning, and reduced health care use. Successful programs have been theory based. Self-regulation is a promising framework for the development of interventions. Nonetheless, serious gaps in understanding and improving disease management by patients remain because of an emphasis on clinical settings for program delivery, neglect of the factors beyond patient behavior that enable or deter effective management, limitations of study designs in much work to date, reliance on short-term rather than long-term assessments, and failure to evaluate the independent contribution of various program components.

The use of reliever medication in asthma: the role of negative mood and symptom reports

The aim of this study was to investigate the relationships between negative mood, the reporting of asthma symptoms, and the use of short-acting bronchodilators (reliever medication). Forty-two adult asthma patients completed a daily questionnaire over 7 consecutive days. The questionnaire measured negative mood and the number of symptoms patients associated with their asthma. The symptoms included those typical of asthma, as well as nonspecific somatic and distress symptoms. Subjects were also asked to record their daily use of reliever medication and their peak flow values. Data analysis demonstrated that even when controlling for lung function, both asthma symptom labeling and negative mood were related to reliever use. A mediation model suggested that negative mood leads patients to associate a wide range of nonspecific symptoms with their asthma, thereby altering the perception of the severity of the asthma, which in turn influences their use of reliever medication. The results of this study are discussed in relation to asthma self-management strategies.

Options for self-management education for adults with asthma

BACKGROUND

Asthma education and self-management are key recommendations of asthma management guidelines because they improve health outcomes. There are several different modalities for the delivery of asthma self-management education.

OBJECTIVES

We evaluated programmes that: 1) Optimised asthma control through inhaled corticosteroid use by regular medical review or optimised asthma control by individualised written action plans 2) Used written self-management plans based on peak expiratory flow self-monitoring compared with symptom self-monitoring 3) Compared different options for the delivery of optimal self-management programmes.

SEARCH STRATEGY

We searched the Cochrane Airways Group trials register and reference lists of articles.

SELECTION CRITERIA

Randomised trials of asthma self-management education interventions in adults over 16 years of age with asthma.

DATA COLLECTION AND ANALYSIS

Fifteen trials met the inclusion criteria. Trial quality was assessed and data were extracted independently by two reviewers. Study authors were contacted for confirmation.

MAIN RESULTS

1) Six studies compared optimal self-management allowing self-adjustment of medications according to an individualised written action plan to adjustment of medications by a doctor. These two styles of asthma management gave equivalent effects for hospitalisation, ER visits, unscheduled doctor visits and nocturnal asthma. 2) Self-management using a written action plan based on PEF was found to be equivalent to self-management using a symptoms based written action plan in the six studies which compared these interventions. 3) Three studies compared self-management options. In one, that provided optimal therapy but tested the omission of regular review, the latter was associated with more health centre visits and sickness days. In another, comparing high and low intensity education, the latter was associated with more unscheduled doctor visits. In a third, no difference in health care utilisation or lung function was reported between verbal instruction and written action plans.

REVIEWER'S CONCLUSIONS

Optimal self-management allowing for optimisation of asthma control by adjustment of medications may be conducted by either self-adjustment with the aid of a written action plan or by regular medical review. Individualised written action plans based on peak expiratory flow are equivalent to action plans based on symptoms. Reducing the intensity of self-management education or level of clinical review may reduce its effectiveness.

Psychological aspects of asthma

Asthma can be affected by stress, anxiety, sadness, and suggestion, as well as by environmental irritants or allergens, exercise, and infection. It also is associated with an elevated prevalence of anxiety and depressive disorders. Asthma and these psychological states and traits may mutually potentiate each other through direct psychophysiological mediation, nonadherence to medical regimen, exposure to asthma triggers, and inaccuracy of asthma symptom perception. Defensiveness is associated with inaccurate perception of airway resistance and stress-related bronchoconstriction. Asthma education programs that teach about the nature of the disease, medications, and trigger avoidance tend to reduce asthma morbidity. Other promising psychological interventions as adjuncts to medical treatment include training in symptom perception, stress management, hypnosis, yoga, and several biofeedback procedures.

Symptom monitoring in childhood asthma: a randomized clinical trial comparing peak expiratory flow rate with symptom monitoring

BACKGROUND

Accurate symptom evaluation is a critical component of asthma management. Limited data are available about the accuracy of symptom evaluation by children with asthma and their parents, or the impact of various symptom-monitoring strategies on asthma morbidity outcomes.

OBJECTIVE

The purpose of this randomized clinical trial was to evaluate the effect of three different intensities of symptom monitoring on asthma morbidity outcomes.

METHODS

One hundred sixty-eight children (ages 6 to 19) of diverse racial, geographic, and socioeconomic backgrounds were randomized to 1 of 3 treatment groups (subjective symptom evaluation, symptom-time peak expiratory flow rate (PEFR) monitoring, daily PEFR monitoring) in this longitudinal, clinical trial. Outcome measures included a summary asthma severity score, forced expiratory volume in 1 second, symptom days, and health care utilization.

RESULTS

Children who used PEFR meters (PFMs) when symptomatic had a lower asthma severity score, fewer symptom days, and less health care utilization than children in the other two treatment groups. Minority and poor children had the greatest amount of improvement using PFMs when symptomatic. Results were much less striking in white families. Thirty percent of families in the PFM treatment groups discontinued use entirely by 1 year postexit, whereas the majority of families who continued use (94%) used them only when symptomatic to inform symptom interpretation and management decisions.

CONCLUSIONS

Not every child with asthma needs a PFM. Children and families facing extra challenges as a result of illness severity, sociodemographic, or health care system characteristics clearly benefited most from PFM use.

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, 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

A search was carried out 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*. Authors of included studies were contacted for any unpublished or on-going studies and bibliographies of all included studies and reviews were searched for further studies.

SELECTION CRITERIA

Only randomised controlled trials (RCTs) in patients with asthma were considered. 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

Study quality was assessed and data abstracted by two reviewers independently.

MAIN RESULTS

Six 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: 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 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.

REVIEWER'S CONCLUSIONS

The available trials are too small and the results too 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 programmes.

Patient self-management of acute asthma: adherence to national guidelines a decade later

BACKGROUND AND OBJECTIVES

Children in the emergency department (ED) with acute asthma were enrolled to assess the impact of asthma on their activities of daily living and evaluate their access to care and preventive strategies, determine the proportion who adhered to the National Heart, Lung, and Blood Institute (NHLBI) guidelines for proper steps to take at home during an acute asthma exacerbation, and compare adherence rates for those with persistent and mild intermittent asthma.

DESIGN AND METHODS

Children 2 to 18 years old who presented to the Children's Hospital of Philadelphia's ED with acute asthma exacerbations were enrolled prospectively. Parents and patients completed the 108-item Asthma Exacerbation Response Questionnaire with a focus on determining the home management steps they took both at the onset of the asthma exacerbation and just before coming to the ED.

RESULTS

Among the 433 children studied, 76% had at least 1 doctor visit, 75% had at least 1 ED visit, and 43% had at least 1 hospitalization for asthma in the preceding 12 months. Overall, 64% had persistent asthma by NHLBI criteria, yet just 4% were cared for by an allergist or pulmonologist, 38% took daily anti-inflammatory therapy, and 18% received a daily inhaled corticosteroid. Also, 48% did not use a holding chamber with their metered-dose inhalers, and 66% did not use their peak flow meters. Regarding exacerbation response, 71% did not have a written action plan, and 89% did not maintain a symptom diary. Both at the onset of wheezing and just before coming to the ED, administration of a beta2-agonist was the only step that the majority of children performed. One-third or fewer followed the other steps recommended by the NHLBI, including using a peak flow meter, beginning oral corticosteroids, calling or going to see the doctor, or going to the ED. Children with persistent asthma were not more adherent to the guidelines than those with mild intermittent disease.

CONCLUSIONS

Asthma has a significant adverse effect on the lives of these children. The NHLBI guidelines, first published a decade ago, were designed to reduce asthma's increasing morbidity and mortality, but this study uncovered a high rate of nonadherence with many aspects of the guidelines, including preventive strategies and home management of an exacerbation.

A randomized trial of peak-flow and symptom-based action plans in adults with moderate-to-severe asthma

OBJECTIVE

Peak flow meters (PFM) continue to be recommended as an important part of asthma self-management plans. It remains unclear if there is an advantage in using PFM in people with moderate-to severe asthma who are not poor perceivers of bronchoconstriction.

METHODOLOGY

Prospective, randomized controlled trial of 134 adults with moderate-to-severe asthma who did not have evidence of poor perception of bronchoconstriction on histamine challenge testing, who were recruited from inpatients and outpatients of a university teaching hospital. Comparison was made over 12 months of the effectiveness of written action plans using either peak flow monitoring or symptoms to guide management. Subjects were contacted at monthly intervals by telephone for reinforcement and evaluation of use of the action plans, and to provide ongoing education. Spirometry and PD20 histamine were measured at 3-monthly intervals. Measures of health care utilization and morbidity (asthma exacerbations; hospitalizations; emergency department (ED) visits; days absent from work or school due to asthma; medication use and a self-rating of asthma severity) were made monthly. A psychosocial questionnaire (attitudes and beliefs, state-trait anxiety, denial) was given at entry and at 12-months or at withdrawal from the study.

RESULTS

There were significant improvements for both groups for hospitalizations, ED visits, days off from school or work, and PD20 histamine, but no between-group differences. Appropriate use of action plans was 85% in the symptoms group and 86% in the PFM group. For all subjects, those who subsequently had an ED visit had significantly higher levels of denial (P=0.04) and lower scores for self-confidence (P=0.04), compared to those who did not have an ED visit.

CONCLUSIONS

Use of written action plans, combined with regular contact to reinforce self-management, improved airway reactivity and reduced health care utilization. However, use of PFM was not superior to symptom-based plans.

The role of the asthma nurse in treatment compliance and self-management following hospital admission

Effective self-management and treatment compliance is important in achieving good symptom control in asthma. The aim of this study was to determine whether asthma nurse intervention during hospital admission could increase knowledge and improve self-management and whether this would influence the number of emergency call-out visits by Genera Practitioners (GPs) and hospital re-admissions. Patients with acute asthma (n=80) were assessed by the asthma nurse within 24 h of admission using a British Thoracic Society (BTS) guideline-based questionnaire. Main outcome measures were: know edge of inhalers, self-management plans, peak flow monitoring, recognition of worsening symptoms and appropriate emergency action, Following randomization, half received nurse intervention during hospitalization. All received a follow-up questionnaire 6 weeks post-discharge and again at 6 months (response rates 86% and 81% respectively). GPs were contacted by postal questionnaire after 4 months. Questionnaire responses indicated an increase in knowledge in the intervention group, along with an ability to identify appropriate action on worsening symptoms. Emergency GP call-outs were more frequent in the control group in the 4 months post-discharge. Hospital re-admission rates were similar in both groups. Asthma nurse intervention appeared to increase knowledge of asthma management, maintained throughout the study period, but had no significant impact on reducing re-admissions to hospital.

Is home peak expiratory flow monitoring effective for controlling asthma symptoms?

A case in which a home peak expiratory flow (PEF) monitoring device was recommended led us to review the evidence examining this intervention. The clinical question to be answered was: should these devices be consistently recommended to all patients with asthma? A comprehensive search revealed eight randomized controlled trials, one review and one consensus report. Four trials provided all subjects with asthma education and compared patient-specific action plans based on symptoms to those based on PEF readings. Four trials compared usual asthma care to peak flow monitoring (PFM) and varied in both their content and intensity of asthma education. Six out of eight studies showed improvement in some selected markers of asthma morbidity with home PFM-based action plans. Improvements were also observed in patients using a symptom-based action plan. These studies did not demonstrate any obvious advantage of PFM compared with symptom-based monitoring but did suggest that a monitoring plan with predetermined actions based on PEF measurements or symptoms can lead to improved asthma control. Although not specifically studied, PFM may be more appropriate and effective for patients who have difficulty identifying worsening of asthma control through symptom monitoring.

Education, self-management and home peak flow monitoring in childhood asthma

Current asthma guidelines focus on self-management by the patient, in which monitoring of peak flow plays an important role. To be able to participate in self-management, the patient must be educated rigorously on pathophysiological mechanisms of the disease, principles of treatment, correct inhalation technique, treatment goals and the action to take when symptoms or peak flow worsen. This is a time-consuming but important and worthwhile task. The pivotal role of home peak flow monitoring in asthma self-management is based on the assumptions that peak flow variation is a useful measure of disease activity and that peak flow diaries are kept reliably by patients. There is now evidence that neither of these assumptions are true. Self-management plans based on education alone are just as effective as those incorporating peak flow monitoring. Education, therefore, is the most important component of asthma self-management, and home peak flow monitoring is not needed in the majority of asthmatic children.

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

To assess the efficacy of self-management programs it is important to know what behavioural changes take place. This paper assesses whether including self-treatment guidelines (action plans) in a self-management program for adult asthmatics, leads to greater behavioural changes than a program without these guidelines. Patients were randomised into a self-treatment group (n=123) or an active control group (n=122). All subjects received self-management training. Discussed topics included the pathophysiology of asthma, medication and side-effects, triggers, symptoms, smoking, physical exercise, and compliance. The only difference was that the self-treatment group received instructions about self-treatment of exacerbations and the control group did not. At 1 year of follow-up asthma-specific self-efficacy expectancies, outcome expectancies, and asthma-specific knowledge improved significantly in all patients. Only self-treatment group patients demonstrated favourable changes in generalised self-efficacy, social support, and self-treatment and self-management behaviour, in case of a hypothetical scenario of a slow-onset exacerbation. We conclude that our self-management program is effective in changing the behavioural variables, and including self-treatment guidelines (action plans) has added benefit.

[Comparison of two models of education for asthmatic patients]

BACKGROUND

The education programs have demonstrated to be an important point in the management of asthmatic patients. The aim of the present study was to assess if an intensive group asthma education program was able to improve a simplified and individual asthma education program, both with a self-management plan included.

PATIENTS AND METHOD

A prospective randomised controlled trial was conducted over 12 months and 73 moderate-severe asthmatic patients were included. Patients were randomly assigned to control or study group. Patients in control group received individual and simplified education with a self-management plan and patients in study group attended an <<asthma school>> in small groups where they received a three hours education program in three weeks.The outcome measures were: number of hospital admissions, observation unit admissions, emergency visits and unscheduled general practice consultations. Knowledge, adherence to treatment, ability with inhaler devices, airway function, environmental control measures and quality of life. They were assessed at the beginning and the end of the study.

RESULTS

At the end of the study period the outcome of morbidity had improved in both groups but the number of observation unit admissions (p = 0.028) and unscheduled general practice consultations (p = 0.022) was substantially lower in study group. This group also demonstrated improvement in environmental control measures and better inhaler technique and knowledge (p = 0.007). In adherence, lung function or quality of life there were no differences between groups.

CONCLUSIONS

In patients with asthma better results can be obtained with an intensive group asthma education program than with the individual and simplified program.

Benefit from the inclusion of self-treatment guidelines to a self-management programme for adults with asthma

This study assessed the long-term efficacy of adding self-treatment guidelines to a self-management programme for adults with asthma. In this prospective randomized controlled trial, 245 patients with stable, moderate to severe asthma were included. They were randomized into a self-treatment group (group S) and a control group (group C). Both groups received self-management education. Additionally, group S received self-treatment guidelines based on peak expiratory flow (PEF) and symptoms. Outcome parameters included: asthma symptoms, quality of life, pulmonary function, and exacerbation rate. The 2-yr study was completed by 174 patients. Both groups showed an improvement in the quality of life of 7%. PEF variability decreased by 32% and 29%, and the number of outpatient visits by 25% and 18% in groups S and C, respectively. No significant differences in these parameters were found between the two groups. After 1 yr, patients in both groups perceived better control of asthma and had more self-confidence regarding their asthma. The latter improvements were significantly greater in group S as compared to group C. There were no other differences in outcome parameters between the groups. Individual self-treatment guidelines for exacerbations on top of a general self-management programme does not seem to be of additional benefit in terms of improvements in the clinical outcome of asthma. However, patients in the self-treatment group had better scores in subjective outcome measures such as perceived control of asthma and self-confidence than patients in the control group.

Long-term economic evaluation of intensive patient education during the first treatment year in newly diagnosed adult asthma

The cost-effectiveness of intensive patient education of guided asthma self-management given during the first treatment year was evaluated after 5 years of follow-up. Consecutive, newly-diagnosed asthmatics (n = 162, age 18-76 years) were randomized for intensive (80 patients) vs. conventional patient education. Effectiveness was evaluated in terms of lung functions, airway hyperresponsiveness (PD15), and quality of life as measured by the generic 15D and disease-specific St. George's Respiratory Questionnaire (SGRQ). Total treatment costs were also estimated. All patients had anti-inflammatory treatment from the beginning. Sixty-four intervention group (IG) patients and 70 control group (CG) patients were evaluated after 5 years. Forced expiratory volume in 1 sec (FEV1) improved only in the IG, and only during the first treatment year. However, PD15 improved throughout the follow-up. The unscheduled healthcare costs were significantly higher in the CG than in the IG (P = 0.04) and the relative risk for sickness days due to asthma was lower in the IG than in the CG, odds ratio 0.33 (95% CI 0.28; 0.40). However, because there was no significant difference between the groups in any outcome variable or in total costs at 5 years, the incremental cost-effectiveness ratio could not be calculated. The first year intervention had only a short-term beneficial treatment effect, which the CG could catch up during the two last follow-up years, except in FEV1. The peak expiratory flow (PEF)-based self-management had no advantage over the symptom-based self-management. However, the intervention had a consistent tendency of being less costly in the long-run. It is possible to conclude tentatively that regular effective medical treatment and control visits during the first treatment year is at least as important for the long-term treatment result as intensive patient education.

Influence of peak expiratory flow monitoring on an asthma self-management education programme

We assessed whether peak expiratory flow monitoring added to a self-management education programme reduced morbidity and improved pulmonary function and adherence to treatment in 100 asthma patients (aged 17-65 years) with adequate treatment and regular 1-year follow-up. Patients randomized to the experimental group used peak expiratory flow readings as the basis for their therapeutic plan coupled with educational intervention, whereas patients in the control group received the same educational intervention and used symptoms only to guide self-management. Morbidity parameters, functional status and adherence to medical regimens improved in both groups, although the percentage of patients with satisfactory adherence was significantly better in the group with peak expiratory flow monitoring (83%) than in controls (52%) (P = 0.05). The multivariate analysis showed that severity of asthma (odds ratio 9.28, 95% confidence interval 1.87-45.96, P = 0.006 for moderate asthma) and type of self-management education programme (odds ratio: 6.19; 95% confidence interval: 2.04-18.81; P = 0.001 for the use of peak expiratory flow readings) were the only independent predictors of adherence to treatment. However, a statistically significant association between adherence and use of peak expiratory flow monitoring was only found in patients with moderate asthma (P = 0.0009). We conclude that peak expiratory flow monitorization in optimal conditions (adequate medical regimen, individualized self-management education and regular follow-up) showed a beneficial effect on adherence to prescribed regimens only in patients with moderate asthma.

Evaluation of physician and patient compliance with the use of peak flow meters in commercial insurance and Oregon health plan asthmatic populations

BACKGROUND

Home use of peak expiratory flow (PEF) meters is recommended by NIH management guidelines for patients with moderate to severe asthma.

OBJECTIVE

To evaluate whether differences in physician PEF meter prescription patterns and patient compliance rates with PEF meter use exist between populations of commercially insured and Oregon Health Plan (OHP) patients.

METHODS

A prospective, case-series study was conducted at the Bay Clinic Coos Bay, Oregon. Volunteers responded to a short survey. Patient asthma severity was evaluated by responses to the following questions: (1) frequency of shortness of breath per week, (2) daily and weekly frequency of albuterol rescue inhaler use, and (3) other prescription medications used. Additional questions included: (1) possession of a PEF meter, (2) physician instruction of meter use, (3) patient compliance with instructions, and (4) type of medical insurance. Using NIH asthma stratification guidelines, only respondents with moderate to severe asthma were included in this study. Respondents were age restricted to between 6 and 60 years. Incomplete surveys were not accepted.

RESULTS

Ninety-six surveys were received and 54 accepted. Only 24 (44%) of the 54 respondents with moderate to severe asthma had a PEF meter. Nineteen (79%) used it according to physician instructions. Of the 29 patients reporting to have commercial insurance, 18 (62%) had a PEF meter and 15 (83%) used it as prescribed. Of the 21 asthmatic patients with OHP coverage, only 5 (24%) P = .007 had a peak flow meter and 4 (80%) used it as prescribed.

CONCLUSIONS

We conclude physician prescription compliance of peak flow meters for asthma monitoring falls short of the NIH guidelines. When a PEF meter is prescribed, patients will likely use it regardless of their medical insurance. Significant differences exist in physician compliance with PEF meter prescription between populations of commercially insured and OHP patients. More study is necessary to further understand this divergence in care delivery.