Parental education and guided self-management of asthma and wheezing in the pre-school child: a randomised controlled trial

European Respiratory Society statement on preschool wheezing disorders: updated definitions, knowledge gaps and proposed future research directions

Since the publication of the European Respiratory Society (ERS) task force reports on the management of preschool wheezing in 2008 and 2014, a large body of evidence has accumulated suggesting that the clinical phenotypes that were proposed (episodic (viral) wheezing and multiple-trigger wheezing) do not relate to underlying airway pathology and may not help determine response to treatment. Specifically, using clinical phenotypes alone may no longer be appropriate, and new approaches that can be used to inform clinical care are needed for future research. This ERS task force reviewed the literature published after 2008 related to preschool wheezing and has suggested that the criteria used to define wheezing disorders in preschool children should include age of diagnosis (0 to <6 years), confirmation of wheezing on at least one occasion, and more than one episode of wheezing ever. Furthermore, diagnosis and management may be improved by identifying treatable traits, including inflammatory biomarkers (blood eosinophils, aeroallergen sensitisation) associated with type-2 immunity and differential response to inhaled corticosteroids, lung function parameters and airway infection. However, more comprehensive use of biomarkers/treatable traits in predicting the response to treatment requires prospective validation. There is evidence that specific genetic traits may help guide management, but these must be adequately tested. In addition, the task force identified an absence of caregiver-reported outcomes, caregiver/self-management options and features that should prompt specialist referral for this age group. Priorities for future research include a focus on identifying 1) mechanisms driving preschool wheezing; 2) biomarkers of treatable traits and efficacy of interventions in those without allergic sensitisation/eosinophilia; 3) the need to include both objective outcomes and caregiver-reported outcomes in clinical trials; 4) the need for a suitable action plan for children with preschool wheezing; and 5) a definition of severe/difficult-to-treat preschool wheezing.

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

INTRODUCTION

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

AREAS COVERED

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

EXPERT OPINION

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

Impact in the quality of life of parents of children with chronic diseases using psychoeducational interventions - A systematic review with meta-analysis

OBJECTIVE

This study aimed to identify psychoeducational interventions applied to parents of children with chronic diseases and evaluate their impact on their quality of life (QoL).

METHODS

It was conducted in six databases, complemented by references from the included studies and other reviews, manual search, and contact with experts. We included primary studies on parents of children with chronic diseases that studied psychoeducational interventions versus standard care.

RESULTS

We screened 6604 titles and abstracts, reviewed the full text of 60 records, and included 37 primary studies. Half of the studies were on Asthma. We found three intervention formats: one-to-one (43%), groups (49%), and combined approach with individual and group settings (8%). More than 60% of the included studies found statistically significant differences between the intervention and the control group (p < 0.05).

CONCLUSION

Several interventions have shown efficacy in improving parental QoL. Despite that, there is insufficient evidence of interventions' implementation.

PRACTICE IMPLICATIONS

A holistic approach encompassing the patient and the family's biopsychosocial dimensions is fundamental in successfully managing chronic disease in children. It is vital to design and implement interventions accommodating the common issues experienced by children, parents, and families that deal with chronic childhood conditions. Systematic review registration number PROSPERO 2018 CRD42018092135.

Interactive Inpatient Asthma Education: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

Inpatient asthma education interventions provide benefit compared with usual care, but evaluation of the most effective educational model is needed. We compared the impact of interactive versus didactic inpatient pediatric asthma education on subsequent emergency department (ED) visits and hospitalizations.

METHODS

Children (aged 2‒16) with asthma admitted to a tertiary care children's hospital with an asthma exacerbation between October 2016 and June 2017 were randomly assigned to interactive or didactic (control) asthma education. The primary outcome was asthma ED visits at 6 and 12 months; secondary outcomes included hospitalizations (6 and 12 months), inhaler technique, asthma knowledge, symptoms, quality of life, and parental management skills at baseline, discharge, and/or 12 months.

RESULTS

One hundred forty participants (69 interactive, 71 control) completed the study. There were no differences in ED visits at 6 or 12 months. Compared to controls, the interactive group had fewer hospitalizations (10.1% vs 22.5%; P = .04) at 6 months. Inhaler technique in the interactive group improved at discharge (mean change 4.07 [95% confidence interval (CI): 3.21-4.94]) and remained increased at 12 months (P = .03). Patient-reported asthma symptoms and quality of life were similar in both groups at baseline (19.9 vs 20.62, best possible score 8) and significantly improved in the interactive group at 12 months (least square mean change, 3.52 vs -1.75; P < .01).

CONCLUSIONS

There were no differences in ED visits; however, the interactive education reduced asthma hospitalizations over a 6-month period. These findings demonstrate that educational delivery methods can play a role in improving clinical outcomes for asthma.

Sociodemographic Differences in Asthma Self-Management Knowledge of Parents Seeking Asthma Care for their Children in Pediatric Emergency Departments

To effectively support asthma self-management among children most at risk for poor outcomes, it is important to examine potential disparities in parents' asthma-related knowledge. This study draws on baseline data collected from a randomized controlled trial to analyze how knowledge of asthma self-management varies by sociodemographic characteristics in a racially and economically diverse sample of Medicaid-insured children seeking emergency asthma care (N=221). Multivariable linear regression revealed that parent race/ethnicity, preferred language, and education were independently associated with scores on the Asthma Self Management Knowledge Questionnaire, and there was a significant interaction between parent race/ethnicity and education. In analyses stratified by parent education level, Latinx race/ethnicity was associated with lower-self-management knowledge among parents with higher education level, but not among those with a lower level of education. Our findings call for further research to understand and address the unique barriers to improving asthma self-management knowledge among Latinx parents and parents with limited English proficiency.

Reducing asthma hospitalisations in at-risk children: A systematic review

AIM

To identify interventions that reduce hospitalisations and improve related outcomes in children at risk of asthma hospital admissions.

METHODS

Medline, Embase, Pubmed and Cochrane Library search from January 2002 to April 2020.

INCLUSION CRITERIA

randomised controlled trials of any intervention for children with asthma who are at risk of hospitalisations.

OUTCOMES

hospitalisation (primary outcome), rescue oral corticosteroid use, school absences, quality of life and cost-effectiveness.

RESULTS

Twelve randomised controlled trials were conducted with 2719 participants. Due to heterogeneity of interventions and reporting of outcomes, a meta-analysis was not conducted. Multi-modal interventions comprising caregiver education, reduction of home environmental allergens and regular follow-up reduced hospitalisations, rescue corticosteroid use and improved quality of life. Cost-effectiveness was not reported. Three studies scored an overall low risk of bias, and nine had some concerns.

CONCLUSION

Multi-modal interventions can be effective in reducing hospitalisations, rescue oral corticosteroid use and quality of life but cost-effectiveness is unknown.

Parental knowledge and attitudes regarding asthma in their children: Impact of an educational intervention in an Indian population

INTRODUCTION AND OBJECTIVES

Research shows positive effects of asthma education in improving parental knowledge, self-management skills, and reducing healthcare costs. Such studies are lacking in resource-limited countries. We studied the effectiveness of educational intervention in improving the knowledge and attitudes of parents/caregivers of asthmatic children.

METHODS

The study was conducted in the pediatric chest clinic of tertiary hospital (India) over 21 months after ethics committee approval. Recruited parents were randomized into the interventional group (A) receiving education module and control group (B). Parents' asthma knowledge and attitudes were assessed at baseline and 5 months postenrollment using 25-item questionnaire. Detailed demographic data, clinical data, and exacerbations during study were noted.

RESULTS

A total of 75 parents/guardians fulfilling inclusion criteria were analyzed (cases/group A: 37 and controls/group B: 38). 8.3 percent of parents/caregivers were illiterate. Around 36.9% of patients had a family history of allergy/asthma. Mean knowledge scores at follow-up were 12.24 and 9.89 for groups A and B, respectively (P < .05). Parents did better on knowledge items related to chronicity, family history, chronic cough, home administration of steroids in acute severe asthma, and maintaining records of clinical/medications for good control. Intervention group (A) showed significant improvement in most attitude-based questions postintervention as compared with the nonintervention group (B). There was no statistically significant difference in asthma severity and control between the two groups at follow-up.

CONCLUSIONS

Small group education on asthma in parents/caregivers improves their knowledge and attitudes. Healthcare plans should invest in pediatric asthma education and identify key personnel/opportunities to impart the same in routine care.

Inhaled corticosteroid-phobia and childhood asthma: Current understanding and management implications

Asthma is the most prevalent chronic disease in children. Inhaled corticosteroids (ICS) is the first-line controller therapy for children with persistent asthma, however, suboptimal compliance to ICS therapy remains as a major obstacle in paediatric asthma management. Steroid-phobia, the fear of side-effects and subsequent aversion of ICS, has been widely reported in parents of asthmatic children. The reported prevalence of steroid-phobia varies widely from 19% to 67% in different populations. The concerns about ICS frequently raised by parents include growth suppression, weight gain, bone weakness, addiction and psychiatric disturbances. Outside of growth suppression, which is statistically significant yet mild in clinical studies, the other concerns are not evidence-based and are misconceptions. Conflicting results have been reported regarding the impact of steroid-phobia on ICS compliance. In contrast, steroid-phobia has consistent and negative effects on asthma control in children. While asthma educational programmes have demonstrable benefits in general paediatric populations, the generalisability of such programmes to steroid-phobic parents remains undetermined. There is a paucity of data on specific educational programmes to clear misconceptions and reduce steroid-phobia. Given the continually raising prevalence of paediatric asthma, high-quality studies are warranted to investigate the prevalence and impact of steroid-phobia, with an ultimate goal of developing effective strategies to tackle steroid-phobia and improve asthma care in children.

Asthma in the Preschool Age Child

Wheeze in preschool children (5 years of age and younger) is common. The majority of severe episodes are triggered by viral colds. Unlike atopic asthma in adults and young people, the underlying pathology of this condition is poorly understood, and the label of “preschool wheeze” should therefore not be regarded as a diagnosis but a description of symptoms. It is important to consider other causes of wheeze, but, for the most part, serious conditions such as cystic fibrosis and foreign body aspiration are associated with atypical features on careful history and examination. There remain significant uncertainties about the optimal management of children with this condition. Short-acting bronchodilators are indicated for the acute treatment of wheeze, and current evidence suggests that daily inhaled corticosteroid therapy is an effective preventive therapy, at least in a subgroup of children. Some trials suggest that preemptive therapy with inhaled corticosteroids may be as effective as regular inhaled corticosteroids. Since wheeze is intermittent for the majority of children, preemptive therapy is a logical approach. However, more studies are needed to confirm whether preemptive inhaled corticosteroids are as, or more, effective than regular preventer therapy.

Caseworker-assigned discharge plans to prevent hospital readmission for acute exacerbations in children with chronic respiratory illness

BACKGROUND

Chronic respiratory conditions are major causes of mortality and morbidity. Children with chronic health conditions have increased morbidity associated with their physical, emotional, and general well-being. Acute respiratory exacerbations (AREs) are common in children with chronic respiratory disease, often requiring admission to hospital. Reducing the frequency of AREs and recurrent hospitalisations is therefore an important goal in the individual and public health management of chronic respiratory illnesses in children. Discharge planning is used to decide what a person needs for transition from one level of care to another and is usually considered in the context of discharge from hospital to the home. Discharge planning from hospital for ongoing management of an illness has historically been referral to a general practitioner or allied health professional or self management by the individual and their family with limited communication between the hospital and patient once discharged. Effective discharge planning can decrease the risk of recurrent AREs requiring medical care. An individual caseworker-assigned discharge plan may further decrease exacerbations.

OBJECTIVES

To evaluate the efficacy of individual caseworker-assigned discharge plans, as compared to non-caseworker-assigned plans, in preventing hospitalisation for AREs in children with chronic lung diseases such as asthma and bronchiectasis.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register of Trials, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, trials registries, and reference lists of articles. The latest searches were undertaken in November 2017.

SELECTION CRITERIA

All randomised controlled trials comparing individual caseworker-assigned discharge planning compared to traditional discharge-planning approaches (including self management), and their effectiveness in reducing the subsequent need for emergency care for AREs (hospital admissions, emergency department visits, and/or unscheduled general practitioner visits) in children hospitalised with an acute exacerbation of chronic respiratory disease. We excluded studies that included children with cystic fibrosis.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane Review methodological approaches. Relevant studies were independently selected in duplicate. Two review authors independently assessed trial quality and extracted data. We contacted the authors of one study for further information.

MAIN RESULTS

We included four studies involving a total of 773 randomised participants aged between 14 months and 16 years. All four studies involved children with asthma, with the case-planning undertaken by a trained nurse educator. However, the discharge planning/education differed among the studies. We could include data from only two studies (361 children) in the meta-analysis. Two further studies enrolled children in both inpatient and outpatient settings, and one of these studies also included children with acute wheezing illness (no previous asthma diagnosis); the data specific to this review could not be obtained. For the primary outcome of exacerbations requiring hospitalisation, those in the intervention group were significantly less likely to be rehospitalised (odds ratio (OR) 0.29, 95% confidence interval (CI) 0.16 to 0.50) compared to controls. This equates to 189 (95% CI 124 to 236) fewer admissions per 1000 children. No adverse events were reported in any study. In the context of substantial statistical heterogeneity between the two studies, there were no statistically significant effects on emergency department (OR 0.37, 95% CI 0.04 to 3.05) or general practitioner (OR 0.87, 95% CI 0.22 to 3.44) presentations. There were no data on cost-effectiveness, length of stay of subsequent hospitalisations, or adherence to medications. One study reported quality of life, with no significant differences observed between the intervention and control groups.We considered three of the studies to have an unclear risk of bias, primarily due to inadequate description of the blinding of participants and investigators. The fourth study was assessed as at high risk of bias as a single unblinded investigator was used. Using the GRADE system, we assessed the quality of the evidence as moderate for the outcome of hospitalisation and low for the outcomes of emergency department visits and general practitioner consultations.

AUTHORS' CONCLUSIONS

Current evidence suggests that individual caseworker-assigned discharge plans, as compared to non-caseworker-assigned plans, may be beneficial in preventing hospital readmissions for acute exacerbations in children with asthma. There was no clear indication that the intervention reduces emergency department and general practitioner attendances for asthma, and there is an absence of data for children with other chronic respiratory conditions. Given the potential benefit and cost savings to the healthcare sector and families if hospitalisations and outpatient attendances can be reduced, there is a need for further randomised controlled trials encompassing different chronic respiratory illnesses, ethnicity, socio-economic settings, and cost-effectiveness, as well as defining the essential components of a complex intervention.

Hospital-to-Home Interventions, Use, and Satisfaction: A Meta-analysis

CONTEXT

Hospital-to-home transitions are critical opportunities to promote patient safety and high-quality care. However, such transitions are often fraught with difficulties associated with increased health care use and poor patient satisfaction.

OBJECTIVE

In this review, we determine which pediatric hospital discharge interventions affect subsequent health care use or parental satisfaction compared with usual care.

DATA SOURCES

We searched 7 bibliographic databases and 5 pediatric journals.

STUDY SELECTION

Inclusion criteria were: (1) available in English, (2) focused on children <18 years of age, (3) pediatric data reported separately from adult data, (4) not focused on normal newborns or pregnancy, (5) discharge intervention implemented in the inpatient setting, and (6) outcomes of health care use or caregiver satisfaction. Reviews, case studies, and commentaries were excluded.

DATA EXTRACTION

Two reviewers independently abstracted data using modified Cochrane data collection forms and assessed quality using modified Downs and Black checklists.

RESULTS

Seventy one articles met inclusion criteria. Although most interventions improved satisfaction, interventions variably reduced use. Interventions focused on follow-up care, discharge planning, teach back-based parental education, and contingency planning were associated with reduced use across patient groups. Bundled care coordination and family engagement interventions were associated with lower use in patients with chronic illnesses and neonates.

LIMITATIONS

Variability limited findings and reduced generalizability.

CONCLUSIONS

In this review, we highlight the utility of a pediatric discharge bundle in reducing health care use. Coordinating follow-up, discharge planning, teach back-based parental education, and contingency planning are potential foci for future efforts to improve hospital-to-home transitions.

Preschool wheeze, genes and treatment

Preschool wheeze is a common but poorly understood cause of respiratory morbidity that is both distinct from and overlaps with infantile bronchiolitis and school age asthma. Attempts at classification by epidemiology, pathophysiology, therapeutic response and clinical phenotype are imperfect and yet fundamental to both treatment choice and research design. The four main therapeutic classes for preschool wheeze, namely beta₂ agonists, anticholinergics, corticosteroids and leukotriene modifiers are employed with variable and often scanty evidence base, with evidence for a genetic influence on response variations. The article will discuss the pharmacogenetics of the various options, summarise current treatment recommendations, and explore future research directions.

Effects of caregiver-involved interventions on the quality of life of children and adolescents with chronic conditions and their caregivers: a systematic review and meta-analysis

PURPOSE

Childhood chronic conditions have a considerable effect on the quality of life (QoL) of pediatric patients and their caregivers. The purpose of this meta-analysis was to evaluate the effects of caregiver-involved interventions on the QoL of children and adolescents with chronic conditions and their caregivers.

METHODS

The PubMed, EMBASE, Web of Science, Cumulative Index of Nursing and Allied Health Literature, Academic Search Complete, Education Resource Information Center, and PsycINFO databases were searched for published randomized controlled trials from inception to April 2016. Two reviewers (NS and JM) independently screened included studies and assessed study quality. The meta-analyses and meta-regressions using random-effects models were performed with the Comprehensive Meta-analysis software (version 3, Biostat, Englewood, NJ).

RESULTS

Fifty-four studies involving 10075 pediatric patients diagnosed with asthma, diabetes, cancer, hypersensitivity, cerebral palsy, arthritis, or sickle cell diseases and 10015 caregivers were included in our analysis. The interventions mainly involved education about disease, skill training, environment change, psychological intervention, physical exercise, experience sharing, monitoring, or social support. The results demonstrated that caregiver-involved interventions significantly improved the health-related QoL (HRQoL) of caregivers [standardized mean difference (SMD) = 0.26, 95% CI 0.14-0.38, p < 0.001], particularly those delivered through the face-to-face mode (SMD = 0.32, 95% CI 0.21-0.43, p < 0.001). However, no improvements in the QoL (SMD = 0.00, 95% CI - 0.22 to 0.22, p = 1.00) and HRQoL (SMD = 0.06, 95% CI - 0.02 to 0.14, p = 0.16) of children and both caregivers and children (SMD = 0.04, 95% CI - 0.08 to 0.17, p = 0.52) were observed.

CONCLUSIONS

This meta-analysis provides evidence on the positive effects of caregiver-involved interventions on the HRQoL of caregivers. Moreover, face-to-face mode is the delivery approach with a promising effect on the HRQoL of caregivers. Further research on conditions not found in this review is warranted.

Inpatient Quality Improvement Interventions for Asthma: A Meta-analysis

CONTEXT

Despite the availability of evidence-based guidelines for the management of pediatric asthma, health care utilization remains high.

OBJECTIVE

Systematically review the inpatient literature on asthma quality improvement (QI) and synthesize impact on subsequent health care utilization.

DATA SOURCES

Medline and Cumulative Index to Nursing and Allied Health Literature (January 1, 1991-November 16, 2016) and bibliographies of retrieved articles.

STUDY SELECTION

Interventional studies in English of inpatient-initiated asthma QI work.

DATA EXTRACTION

Studies were categorized by intervention type and outcome. Random-effects models were used to generate pooled risk ratios for health care utilization outcomes after inpatient QI interventions.

RESULTS

Thirty articles met inclusion criteria and 12 provided data on health care reutilization outcomes. Risk ratios for emergency department revisits were: 0.97 (95% confidence interval [CI]: 0.06-14.47) <30 days, 1.70 (95% CI: 0.67-4.29) for 30 days to 6 months, and 1.22 (95% CI: 0.52-2.85) for 6 months to 1 year. Risk ratios for readmissions were: 2.02 (95% CI: 0.73-5.61) for <30 days, 1.68 (95% CI: 0.88-3.19) for 30 days to 6 months, and 1.27 (95% CI 0.85-1.90) for 6 months to 1 year. Subanalysis of multimodal interventions suggested lower readmission rates (risk ratio: 1.49 [95% CI: 1.17-1.89] over a period of 30 days to 1 year after the index admission). Subanalysis of education and discharge planning interventions did not show effect.

LIMITATIONS

Linkages between intervention and outcome are complicated by the multimodal approach to QI in most studies.

CONCLUSIONS

We did not identify any inpatient strategies impacting health care reutilization within 30 days of index hospitalization. Multimodal interventions demonstrated impact over the longer interval.

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

Background

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

Objectives

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

Design

Systematic review with meta-analysis.

Population

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

Intervention

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

Comparator

Usual care.

Outcomes

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

Design

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

Data sources

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

Methods

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

Results

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

Limitations

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

Conclusions

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

Future work

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

Study registration

This study is registered as PROSPERO CRD42014015452.

Funding

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

Does self-management prevent severe exacerbations?

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Supported self-management for asthma

KEY POINTS

Self-management education in asthma is not an optional extra. Healthcare professionals have a responsibility to ensure that everyone with asthma has personalised advice to enable them to optimise how they self-manage their condition.Overviews of the extensive evidence-base conclude that asthma self-management supported by regular professional review, improves asthma control, reduces exacerbations and admissions, and improves quality of life.Self-management education should be reinforced by a written personalised asthma action plan which provides a summary of the regular management strategy, how to recognise deterioration and the action to take.Successful implementation combines education for patients, skills training for professionals in the context of an organisation committed to both the concept and the practice of supported self-management.

EDUCATIONAL AIMS

To summarise the evidence base underpinning supported self-management for asthmaTo provide clinicians with a practical approach to providing supported self-management for asthmaTo suggest an appropriate strategy for implementing supported self-management.

SUMMARY

The evidence in favour of supported self-management for asthma is overwhelming. Self-management including provision of a written asthma action plan and supported by regular medical review, almost halves the risk of hospitalisation, significantly reduces emergency department attendances and unscheduled consultations, and improves markers of asthma control and quality of life. Demographic and cultural tailoring enables effective programmes to be implemented in deprived and/or ethnic communities or within schools. A crucial component of effective asthma self-management interventions is the provision of an agreed, written personalised action plan which advises on using regular medication, recognising deterioration and appropriate action to take. Monitoring can be based on symptoms or on peak flows and should specify thresholds for action including increasing inhaled steroids, commencing oral steroids, and when (and how) to seek professional help. Plans should be personalised to reflect asthma severity and treatment regimes, avoidance of triggers, co-morbid rhinitis and the individual's preferences. Implementation is a challenge. Systematic review evidence suggests that it is possible to implement asthma self-management in routine care, but that to be effective this requires a whole systems approach which considers implementation from the perspective of patient education and resources, professional skills and motivation and organisation priorities and routines.

Pediatric asthma readmission: asthma knowledge is not enough?

OBJECTIVE

To characterize factors associated with readmission for acute asthma exacerbation, particularly around caregiver asthma knowledge, beliefs, and reported adherence to prescribed medication regimens.

STUDY DESIGN

We enrolled 601 children (aged 1-16 years) who had been hospitalized for asthma. Caregivers completed a face-to-face survey regarding their asthma knowledge, beliefs, and medication adherence. Caregivers also reported demographic data, child's asthma severity, exposure to triggers, access to primary care, and financial strains. We prospectively identified asthma readmission events via billing data over a 1-year minimum follow-up period. We examined time to readmission with Cox proportional hazards.

RESULTS

The study cohort's median age was 5 years, 53% were African American, and 57% were covered by Medicaid. At 1 year, 22% had been readmitted for asthma. In the multivariate analysis, a caregiver's demonstration of increased asthma knowledge was associated with increased readmission risk. In addition, children whose caregivers reported less-than-perfect adherence to daily medication regimens had increased readmission risk. Likewise, having previously been admitted for asthma, decreased medical home access, and black race were associated with increased readmission risk.

CONCLUSION

In a multifactorial assessment of risk factors for asthma readmission, greater asthma knowledge and decreased medication adherence were associated with readmission. Inpatient efforts to prevent readmission might best target medication adherence rather than continuing to primarily provide asthma education.

The correlation between parental education and their knowledge of asthma

OBJECTIVE

To evaluate the impact of parental education on the success of Asthma Educational Intervention (AEI).

METHODS

AEI took place after the children's hospitalisation. Parental asthma knowledge was assessed at three time points: before AEI, immediately after, and 12 months later. The Intervention (I) group of parents (N=231) received complete AEI. The Control (C) group of parents (N=71) received instructions for proper use of asthma medications and the handbook.

RESULTS

Asthma knowledge in I group increased immediately after the AEI (p<0.01), and had not changed (p>0.05) 12 months later. There were four subgroups in group I divided based on education level: elementary school, high school, college, and university degrees. Taking into account the parental education level, there were no differences in the baseline and final knowledge of asthma between subgroups (p>0.05). The number of asthma exacerbations decreased after AEI (5.96:2.50, p<0.01), regardless of the parental degree. Knowledge of asthma in group C did not improve during the study (p=0.17). Final asthma knowledge was higher in group I compared to group C (p<0.01).

CONCLUSION

The parental education level did not influence the level of asthma knowledge after the AEI. The motivation and the type of asthma education had the greatest input on the final results.

PRACTICE IMPLICATIONS

All parents should be educated about asthma regardless of their general education.

Pediatric hospital discharge interventions to reduce subsequent utilization: a systematic review

BACKGROUND

Reducing avoidable readmission and posthospitalization emergency department (ED) utilization has become a focus of quality-of-care measures and initiatives. For pediatric patients, no systematic efforts have assessed the evidence for interventions to reduce these events.

PURPOSE

We sought to synthesize existing evidence on pediatric discharge practices and interventions to reduce hospital readmission and posthospitalization ED utilization.

DATA SOURCES

PubMed and the Cumulative Index to Nursing and Allied Health Literature.

STUDY SELECTION

Studies available in English involving pediatric inpatient discharge interventions with at least 1 outcome of interest were included.

DATA EXTRACTION

We utilized a modified Cochrane Good Practice data extraction tool and assessed study quality with the Downs and Black tool.

DATA SYNTHESIS

Our search identified a total of 1296 studies, 14 of which met full inclusion criteria. All included studies examined multifaceted discharge interventions initiated in the inpatient setting. Overall, 2 studies demonstrated statistically significant reductions in both readmissions and subsequent ED visits, 4 studies demonstrated statistically significant reductions in either readmissions or ED visits, and 2 studies found statistically significant increases in subsequent utilization. Several studies were not sufficiently powered to detect changes in either subsequent utilization outcome measure.

CONCLUSIONS

Interventions that demonstrated reductions in subsequent utilization targeted children with specific chronic conditions, providing enhanced inpatient feedback and education reinforced with postdischarge support. Interventions seeking to reduce subsequent utilization should identify an individual or team to assume responsibility for the inpatient-to-outpatient transition and offer ongoing support to the family via telephone or home visitation following discharge.

The effectiveness of self-care support interventions for children and young people with long-term conditions: a systematic review

Children's health policy has highlighted the need to develop self-care programmes. However, there is a lack of evidence on which to base the development of such programmes. This paper reviews the published research on the effectiveness of self-care support interventions for children and young people with asthma, cystic fibrosis and diabetes. A systematic search was conducted of a range of electronic databases, supplemented by searching the reference lists of retrieved papers and published reviews. Retrieved studies were assessed against quality and eligibility criteria by two independent reviewers. The results were narratively synthesized to examine the effectiveness of self-care support interventions on health status, psycho-social well-being, condition-related knowledge, health service use and participant satisfaction. The search strategy identified 4261 papers which were screened against the review inclusion criteria. A total of 194 papers were assessed as being potentially eligible for inclusion with 15 papers being judged as adequate to include in the review. There is strong evidence of the effectiveness of interventions that target children/young people; use e-health or group-based methods; that are delivered in community settings. There is no evidence that interventions that focus on parents alone or are delivered only in hospital settings are effective. While there is some evidence to inform the development of self-care support programmes, there is a need for well-designed trials of interventions that are feasible to transfer into real-life settings and which involve parents and children in their development.

Perceptions of effective self-care support for children and young people with long-term conditions

AIMS AND OBJECTIVES

To: (1) Examine children's/young people's, parents' and professionals'/workers' perceptions of the effectiveness of different models of self-care support, (2) identify factors that support and inhibit self-care and (3) explore how different models integrate with self-care support provided by other organisations.

BACKGROUND

Childhood long-term illness has been largely overlooked in government policy and self-care support under-researched when compared with adults. There is a lack of evidence on which are the most appropriate models and methods to engage young people and their parents in self-care.

DESIGN

Case study.

METHODS

Case studies of six different models of self-care support were conducted using multiple methods of data collection in 2009. Semi-structured interviews were conducted with 26 young people, 31 parents and 36 self-care support providers. A sample of self-care support activities was observed and relevant documents reviewed. Data were analysed using the Framework approach.

RESULTS

The effectiveness of self-care support projects was defined in relation to four dimensions - providing a sense of community, promoting independence and confidence, developing knowledge and skills and engaging children/young people. Self-care support provided by schools appeared to be variable with some participants experiencing barriers to self-management and inclusion. Participants self-referred themselves to self-care support projects, and there was a lack of integration between some projects and other forms self-care support.

CONCLUSION

This study adds to knowledge by identifying four dimensions that are perceived to be central to effective self-care support and the contextual factors that appear to influence access and experiences of self-care support.

RELEVANCE TO CLINICAL PRACTICE

Study findings can inform the development of self-care support programmes to meet the needs of individuals, families and communities. In addition, the findings suggest that healthcare professionals need to support schools if young people with long-term conditions are to have the same educational and social opportunities as their peers.

Effective discharge communication in the emergency department

Communication at discharge is an important part of high-quality emergency department (ED) care. This review describes the existing literature on patient understanding and implementation of discharge instructions, discusses previous interventions aimed at improving the discharge process, and recommends best practices and future research. MEDLINE and Cochrane databases were searched, using combinations of key terms. Literature from both the adult and pediatric ED populations was reviewed. Multiple reports have shown deficient comprehension at discharge, with patients or parents frequently unable to report their diagnosis, management plan, or reasons to return. Interventions to improve discharge communication have been, at best, moderately successful. Patients need structured content, presented verbally, with written and visual cues to enhance recall. Written instructions need to be provided in the patient's language and at an appropriate reading level. Understanding should be confirmed before the patient leaves the ED. Further research is needed to describe the optimal content, channel, and timing for the ED discharge process and the relationship between discharge process and outcomes.

Home-based educational interventions for children with asthma

BACKGROUND

While guidelines recommend that children with asthma should receive asthma education, it is not known if education delivered in the home is superior to usual care or the same education delivered elsewhere. The home setting allows educators to reach populations (such as the economically disadvantaged) that may experience barriers to care (such as lack of transportation) within a familiar environment.

OBJECTIVES

To perform a systematic review on educational interventions for asthma delivered in the home to children, caregivers or both, and to determine the effects of such interventions on asthma-related health outcomes. We also planned to make the education interventions accessible to readers by summarising the content and components.

SEARCH STRATEGY

We searched the Cochrane Airways Group Specialised Register of trials, which includes the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED and PsycINFO, and handsearched respiratory journals and meeting abstracts. We also searched the Education Resources Information Center database (ERIC), reference lists of trials and review articles (last search January 2011).

SELECTION CRITERIA

We included randomised controlled trials of asthma education delivered in the home to children, their caregivers or both. In the first comparison, eligible control groups were provided usual care or the same education delivered outside of the home. For the second comparison, control groups received a less intensive educational intervention delivered in the home.

DATA COLLECTION AND ANALYSIS

Two authors independently selected the trials, assessed trial quality and extracted the data. We contacted study authors for additional information. We pooled dichotomous data with fixed-effect odds ratio and continuous data with mean difference (MD) using a fixed-effect where possible.

MAIN RESULTS

A total of 12 studies involving 2342 children were included. Eleven out of 12 trials were conducted in North America, within urban or suburban settings involving vulnerable populations. The studies were overall of good methodological quality. They differed markedly in terms of age, severity of asthma, context and content of the educational intervention leading to substantial clinical heterogeneity. Due to this clinical heterogeneity, we did not pool results for our primary outcome, the number of patients with exacerbations requiring emergency department (ED) visit. The mean number of exacerbations requiring ED visits per person at six months was not significantly different between the home-based intervention and control groups (N = 2 studies; MD 0.04; 95% confidence interval (CI) -0.20 to 0.27). Only one trial contributed to our other primary outcome, exacerbations requiring a course of oral corticosteroids. Hospital admissions also demonstrated wide variation between trials with significant changes in some trials in both directions. Quality of life improved in both education and control groups over time.A table summarising some of the key components of the education programmes is included in the review.

AUTHORS' CONCLUSIONS

We found inconsistent evidence for home-based asthma educational interventions compared to standard care, education delivered outside of the home or a less intensive educational intervention delivered at home. Although education remains a key component of managing asthma in children, advocated in numerous guidelines, this review does not contribute further information on the fundamental content and optimum setting for such educational interventions.

The management of pre-school wheeze

Wheeze, a common symptom in pre-school children, is a continuous high-pitched sound, with a musical quality, emitting from the chest during expiration. A pragmatic clinical classification is episodic (viral) wheeze and multiple-trigger wheeze. Diagnostic difficulties include other conditions that give rise to noisy breathing which could be misinterpreted as wheeze. Most preschool children with wheeze do not need rigorous investigations. Primary prevention is not possible but avoidance of environmental tobacco smoke exposure should be strongly encouraged. Bronchodilators provide symptomatic relief in acute wheezy episodes but the evidence for using oral steroids is conflicting for children presenting to the Emergency Department [ED]. Parent initiated oral steroid courses cannot be recommended. High dose inhaled corticosteroids [ICS] used intermittently are effective in children with frequent episodes of moderately severe episodic (viral) wheeze or multiple-trigger wheeze, but this associated with short term effects on growth and cannot be recommended as a routine. Maintenance treatment with low to moderate continuous ICS in pure episodic (viral) wheeze is ineffective. Whilst low to moderate dose regular ICS work in multi-trigger wheeze, the medication does not modify the natural history of the condition. Even if there is a successful trial of treatment with ICS, a break in treatment should be given to see if the symptoms have resolved or continuous therapy is still required. Maintenance as well as intermittent Montelukast has a role in both episodic and multi trigger wheeze. Good multidisciplinary support and education is essential in managing this common condition.

A community-based strategy for improving asthma management and outcomes for preschoolers

Although almost one in ten (8.6%) preschool children has been diagnosed with asthma, few asthma management programs are designed for parents of preschool children. The Asthma Basics for Children program addressed this need in 2003-2008 by implementing a multi-layered approach that offered educational activities to center staff, parents, and children and PACE training to physicians in 31 Northern Manhattan daycare centers. Following program participation, 85% of parents reported reducing their child's triggers, 89% said it was easier to talk to their child's physician, and 80% were confident in their ability to manage their child's asthma. Children's any daytime symptoms dropped from 78% to 42%, any nighttime symptoms from 81% to 49%, any daycare absences from 56% to 38%, any asthma-related emergency department (ED) visits from 74% to 47%, and any asthma-related hospitalizations from 24% to 11% (p < .001 for all differences). Outcomes varied by level of exposure. In the Center-Only group (no parent participation), the only reduction was from 19% to 10% (McNemar = 3.77, p = .052) in hospitalizations. Children whose parents participated in the program had significant reductions in daycare absences (62% to 38%, McNemar = 11.1, p < .001), ED visits (72% to 43%, McNemar = 19.2, p < .001), and hospitalizations (24% to 11%, McNemar = 5.54, p = .018). Children whose parents and healthcare provider participated had the greatest improvements with asthma-related daycare absences dropping from 62% to 32% (McNemar = 9.8, p = .001), ED visits from 72% to 37% (McNemar = 14.4, p < .001), and hospitalizations from 35% to 15% (McNemar = 8.33, p = .003). This study demonstrates that a multi-layered approach can improve asthma outcomes among preschoolers with a combination of parent and provider education having the greatest impact.

A randomized controlled trial of an interactive voice response telephone system and specialist nurse support for childhood asthma management

OBJECTIVES

To evaluate the effects of an automated interactive voice response system (IVR) and Specialist Nurse Support to reduce health care utilization and improve health-related quality of life in children with asthma.

STUDY DESIGN

A randomized controlled trial in 121 children with doctor-diagnosed asthma and an acute presentation with asthma in the previous 12 months aged between 3 and 16 years. Children were randomized to one of three groups for a 6-month intervention receiving asthma education and management support from a Specialist Nurse by telephone or e-mail (N = 41), from IVR (N = 39), or receiving usual care (control group; N = 41). Outcomes included health care utilization and use of oral steroid rescue. Health-related quality of life (HRQOL) data using the Pediatric Asthma Quality of Life Questionnaire and Pediatric Quality of Life Inventory were collected at baseline and at the end of the study.

RESULTS

There was no statistically significant benefit identified for either the IVR or the Nurse Support interventions for health care utilization, use of oral steroid rescue, or HRQOL compared with controls. Relative to controls, the incremental costs were -A$225.73 (95% confidence interval [CI]: -A$840, A$391) per child for the Nurse Support intervention and -A$451.45 (-A$1075, A$173) per child for IVR. The results were most sensitive to the frequency of admissions to hospital.

CONCLUSION

This study suggested that both IVR and Nurse Support interventions may be cost-saving from a health system perspective, with IVR providing the greatest benefit and this pilot study provides a strong basis for developing larger trials with longer follow-up.

Preschoolers' and parents' asthma education trial (P2AET)--a randomized controlled study

We aimed to evaluate a family-oriented psycho-educational asthma training program for the age group of 2-5 years, involving both parents and children. Children were included after having at least 3 obstructive episodes in their life plus chronic or recurrent wheeze in the 6 months before the start of the study. In the multicenter randomized trial we had (1) a waiting group (WG), (2) an instruction group (IG) trained in a structured way according to the national asthma guideline, and (3) an education group (EG), having a standardized multiprofessional psycho-educational program, according to the national licensed asthma education for the age group of 6-18 years. All were assessed after 6 months. A subgroup analysis was performed on those being on regular inhaled corticosteroids at study entry (74.3%). A total of 338 children were randomized, and 288 (85%) completed the study. In the asthma emergency management, test scores increased most in EG, less in IG, and not in WG. For emergency visits the risk ratio for EG was 0.68 compared to IG: Patients regularly inhaling corticosteroids (74.3%) had an increased risk for emergency visits when having only an instruction (OR 3.99 [1.89-8.40]) or had been waiting (OR 2.5 [1.16-5.37]) when compared to those having an asthma education. We conclude that in the German health system, the family oriented psycho-educational program provided in a standardized manner by a multiprofessional team is effective also in the age group of 2-5 years. It should be made accessible to each asthmatic child.

Current guidelines for the management of asthma in young children

The diagnosis and management of asthma in young children is difficult, since there are many different wheezy phenotypes with varying underlying aetiologies and outcomes. This review discusses the different approaches to managing young children with wheezy illnesses presented in recently published global guidelines. Four major guidelines published since 2007 are considered. Helpful approaches are presented to assist the clinician to decide whether a clinical diagnosis of asthma can, or should be made in a young child with a recurrent wheezy illness and which treatments would be appropriate, dependent on risk factors, age of presentation, response to initial treatment and safety considerations. Each of the guidelines provide useful information for clinicians assessing young children with recurrent wheezy illnesses. There are differences in classification of the disease and treatment protocols. Although a firm diagnosis of asthma may only be made retrospectively in some cases and there are several effective guidelines to initiating treatment. Consistent review of the need for ongoing treatment with a particular pharmacological modality is essential, since many children with recurrent wheezing in infancy go into spontaneous remission. It is probable that newer biomarkers of airway inflammation will assist the clinician as to when to initiate and when to continue pharmacological treatment in the future.

Asthma clinic attendance improves quality of life of Jamaican asthmatic children and their parents

BACKGROUND

With the increasing incidence of paediatric asthma, there has been a corresponding increase in the physical, emotional and financial burden. This has led to a greater interest in determining the impact of asthma and its treatment on many aspects of patient functioning and wellbeing.

AIM

To assess the usefulness of the Asthma Clinic established in Jamaica in 1997 by ascertaining whether there has been improvement in quality of life of children and care-givers who attend the clinic.

METHODS

The quality of life of patients and their parents/care-givers before attending the Asthma Clinic of Bustamante Hospital for Children in Kingston, Jamaica was compared with that of 1 year afterwards. Parents or guardians were interviewed using the Pediatric Asthma Quality of Life Questionnaire which consists of three domains [symptoms (ten questions), emotional (eight questions) and activity (five questions)] and the Pediatric Asthma Caregiver's Quality of life Questionnaire which consist of two domains [emotional (nine questions) and activity (four questions)].

RESULTS

Quality of life improved in patients and their parents/care-givers in all domains.

CONCLUSION

Attendance at an asthma clinic in Jamaica improved the quality of life of asthmatic children and their parents/care-givers.

[Non-physician health care providers for the treatment and care of the chronically ill (focusing on DMP diagnoses)]

BACKGROUND

This systematic review will investigate the question of how non-physician health care providers may be involved in the care and treatment of patients with chronic disease and which role they could play within the scope of the German Disease Management Programmes (DMP).

METHODS

This article is limited to the German DMP diagnoses asthma, COPD, coronary heart disease, and type-1 and -2 diabetes mellitus. Several databases were systematically searched to find national and international studies with interventions carried out by non-physician health care providers such as nurses, dieticians, physiotherapists or occupational therapists.

RESULTS

More than 300 studies and reviews were included in this systematic review. Nurses and dieticians were by far the prevailing professional groups performing the largest number of the interventions identified. Transferring. the results of the literature review to the German setting, non-physician health care providers could both undertake certain tasks on their own responsibility and provide other services in support of the medical treatment of the chronically ill. Some interventions are given as examples.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

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.

Preemptive use of high-dose fluticasone for virus-induced wheezing in young children

BACKGROUND

Although virus-induced wheezing is common in preschool-age children, optimal management remains elusive. We examined the efficacy and safety of preemptive treatment with high-dose fluticasone in reducing the severity of recurrent virus-induced wheezing in children.

METHODS

We randomly assigned 129 children who were 1 to 6 years of age to receive 750 microg of fluticasone propionate (ex-valve [manufacturer-measured] dose) or placebo twice daily, beginning at the onset of an upper respiratory tract infection and continuing for a maximum of 10 days, over a period of 6 to 12 months. The primary outcome was rescue oral corticosteroid use. Secondary outcomes included symptoms, use of beta(2)-agonists, acute care visits, hospitalizations, discontinuation of the study drug, change in growth and bone mineral density, basal cortisol level, and adverse events.

RESULTS

Over a median period of 40 weeks, 8% of upper respiratory tract infections in the fluticasone group led to treatment with rescue systemic corticosteroids, as compared with 18% in the placebo group (odds ratio, 0.49; 95% confidence interval [CI], 0.30 to 0.83). Children who were treated with fluticasone, as compared with those who were given placebo, had smaller mean (+/-SD) gains from baseline in height (6.23+/-2.62 cm [unadjusted value]; z score, -0.19 +/-0.42 vs. 6.56+/-2.90 cm [unadjusted value]; z score, 0.00+/-0.48; difference between groups in z score from baseline to end point, -0.24 [95% CI, -0.40 to -0.08]) and in weight (1.53+/-1.17 kg [unadjusted value]; z score, -0.15+/-0.48 vs. 2.17+/-1.79 kg [unadjusted value]; z score, 0.11+/-0.43; difference between groups in z score from baseline to end point, -0.26 [95% CI, -0.41 to -0.09]). There were no significant differences between the groups in basal cortisol level, bone mineral density, or adverse events.

CONCLUSIONS

In preschool-age children with moderate-to-severe virus-induced wheezing, preemptive treatment with high-dose fluticasone as compared with placebo reduced the use of rescue oral corticosteroids. Treatment with fluticasone was associated with a smaller gain in height and weight. Given the potential for overuse, this preventive approach should not be adopted in clinical practice until long-term adverse effects are clarified. (ClinicalTrials.gov number, NCT00238927.)

Asthma education and monitoring: what has been shown to work

Cochrane systematic reviews and meta-analyses on education and monitoring of asthmatic children have come to divergent conclusions, mainly because of the heterogeneity of education programmes and patients. There is little doubt that education is useful. However, the useful components of the education programmes remain to be elucidated, not only by randomized controlled trials but also by observational studies performed within distinct asthma phenotypes. Any education and monitoring package needs to contain basic explanation about the disease and its influencing factors, as well as inhalation instructions. There is no good evidence to justify home monitoring of lung function; symptom monitoring suffices. Probably, the crucial part of asthma education programmes is a high level of agreement between patient and doctor regarding the goals of the treatment (patient-doctor partnership). Therefore, further exploration of the patient's needs should be worthwhile.

Written action plans: potential for improving outcomes in children with atopic dermatitis

Asthma and atopic dermatitis are common childhood diseases requiring long-term treatment. Adherence to treatment is often poor. Written action plans (WAPs) can improve adherence in pediatric asthma. In this article we review the use of WAPs in pediatric asthma and atopic dermatitis as a basis for assessing WAPs for pediatric patients with atopic dermatitis. Results from a PubMed search for WAPs in pediatric asthma and a Cochrane review on this topic were compiled. Results from a PubMed search for education in pediatric atopic dermatitis were also reviewed. The preponderance of evidence indicates that WAPs improve adherence in pediatric asthma. No such intervention was identified for atopic dermatitis. Few controlled trials directly comparing use to non-use of a WAP were found. WAPs show promise in improving adherence in pediatric asthma, and their effect on adherence in pediatric atopic dermatitis is worthy of further investigation.

[Development of a questionnaire to measure asthmatic patients' knowledge of their disease]

OBJECTIVE

To develop a valid, reliable, and sensitive self-administered questionnaire in Spanish to measure the knowledge asthmatic patients have of their disease.

PATIENTS AND METHODS

The face and content validity of the questions was established by consensus among expert pulmonologists. To determine the importance of the questions, they were put to 100 participating asthmatic patients. The number of questions was reduced by consensus taking into account the importance given to each question by these patients. A further 25 patients participated in the assessment of reliability and sensitivity. The questionnaire was administered 5 times: twice before and 3 times after an educational intervention. The direct and indirect external consistency (kappa statistic) and the overall kappa value were determined. Sensitivity was assessed from the number of correct answers before and after the intervention (Wilcoxon test; P< .05) and from the percentage change (>40% was clinically significant).

RESULTS

Fifty-nine questions were drawn up and the final version included 20. The test-retest consistency was between 0.81 and 1 in 76% of the cases before the intervention and in 92% after it. The kappa statistic before the intervention was between 0.41 and 1 in 96% of the cases, and between 0.81 and 1 in 88% afterwards. The overall kappa values before and after the intervention were 0.12 and 0.43, respectively. The median sensitivity, measured as percentage change, was 67% and 10 patients showed an improvement between 81% and 233%.

CONCLUSIONS

The questionnaire is reliable, has face and content validity, and is very sensitive to change. In view of these results, this instrument is useful for measuring the knowledge that asthmatic patients have of their disease in clinical practice and investigation.

Effectiveness of a nurse-led management programme for paediatric asthma in Taiwan

AIM

The aim of this study was to carry out a preliminary analysis of the impact of a government-sponsored disease management programme for paediatric asthma on economic outcomes and patient satisfaction.

METHODS

Of the 398 patients who participated in the programme, 249 (62.56%) who had at least two medical care encounters with an ICD-9 code of 493 were classified as 'already diagnosed cases'; and 129 (34.12%) who had a single or no medical care encounter with an ICD-9 code of 493 were classified as 'newly diagnosed cases'. A retrospective 1:4 (intervention vs. control group) matched cohort study design was conducted, with the control group randomly drawn from 236 637 paediatric asthmatics who were not enrolled the programme. Questionnaires were collected from 105 (26.3%) of the patients.

RESULTS

Comparison results of 1 year pre/post tests of utilisation of health care resources indicated that the intervention group of already diagnosed cases had 77.97% fewer emergency department visits, 80.77% fewer inpatient visits, and 75.65% fewer stays of significant length. For the newly diagnosed group, the intervention group had 35.11% fewer emergency department visits than the control group. The majority of the patients had substantial adherence to physicians' suggestions, more accurate knowledge and better self-care skills concerning asthma.

CONCLUSION

A nurse-led management programme has proved useful in managing paediatric asthma in Taiwan. Simplification of paperwork, some reorganisation of the practitioner's daily responsibilities and provision of a fail-safe information system may make the programme even more beneficial.

Childhood asthma in the emergency department: trends, challenges, and opportunities

Acute exacerbations of childhood asthma are frequently managed in the emergency department (ED). ED-based surveillance and intervention projects highlight the limitations and challenges of acute and chronic childhood asthma management. Because a significant number of asthmatic children currently receive and will likely continue to seek acute asthma care in the ED, provision of asthma education and initiation of controller medication therapy during the ED visit, although controversial, may contribute to improving asthma outcomes and eventually to reducing the burden of asthma on our overcrowded EDs.

A gender perspective on parents' answers to a questionnaire on children's asthma

BACKGROUND

Is there a difference in the answers of mothers and fathers to the Paediatric Caregiver's Quality of Life Questionnaire (PACQLQ)? If so, does this reflect a perception that has any consequence for the medication and health of the child?

METHODS

We performed a randomised prospective intervention study with extra support and education in the form of group discussions with half of the parents of 60 pre-school children with newly diagnosed asthma. Parents answered separately the PACQLQ at inclusion, and after 6 and 18 months.

RESULTS

There were no major gender differences in indices at any occasion, but mothers were more disturbed at night, felt more helpless and frightened and the child's asthma interfered more with their work at inclusion. After 6 months the mothers in the intervention group showed improvements in all indices. After 18 months the children in the intervention group had better adherence and their exacerbation rate was half that of the control group. In the region where this method now is standard the in-hospital days with asthma are the lowest in the country.

CONCLUSION

There are differences in the answers of fathers and mothers to the PACQLQ. In the intervention group the mothers reported that they were less worried and less restricted in their activities. This equalisation of the parent's roles in handling their child's asthma might be part of the explanation as to why the children in the intervention group had better adherence and were healthier.

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.

Effect of a structured asthma education program on hospitalized asthmatic children: a randomized controlled study

BACKGROUND

The aim of this study was to compare the effectiveness of an intensive asthma education program (group B) with that of a standard asthma education program (group A).

METHODS

A prospective randomized single blinded study was conducted in the pediatric department of a public hospital in Hong Kong. Children aged 2-15 years admitted to the pediatric department with an acute attack of asthma were recruited. A standard asthma education program (group A) or an intensive asthma education program (group B) for children were offered. The main outcome measures include the number of visits to the emergency department and the number of hospitalization for asthma during the 3 month follow-up period.

RESULTS

A total of 45 children were in group A and 55 in group B. Group B had statistically significant reductions in the number of visits to the emergency department and the number of hospitalizations. Drug compliance was also significantly improved in group B. Parents' satisfaction rate was also higher in group B.

CONCLUSION

The intensive asthma education program might be more cost effective than the standard asthma education program in the management of asthmatic children admitted to hospital in Hong Kong.

Intervenções educativas em asma na infância: uma revisão analítica da literatura

Foi realizada uma revisão analítica da literatura visando avaliar as internações educativas para asmáticos de 0 a 18 anos, no período de 1992 a 2002, e identificar características relacionadas com sua eficácia. Foram utilizados diversas bases de dados. Realizou-se também pesquisa manual, entre as referências bibliográficas dos trabalhos selecionados. Foram incluídos 39 trabalhos (27 controlados), tendo sido encontrados resultados variáveis, que, no entanto, permitiram vislumbrar a validade da educação no controle da asma pediátrica. Os parâmetros de avaliação usados pelos estudos foram: variáveis de morbidade, uso de serviços de saúde, qualidade de vida, função pulmonar, conhecimento sobre a doença e habilidades de automanejo. Em 32 estudos (82%), relatou-se benefício sobre uma ou mais variáveis. Entre os 27 estudos controlados, 85,7% produziram melhora nas habilidades de automanejo, 83,3% no conhecimento, 80% nos sintomas diurnos ou noturnos, 71,4% nas visitas médicas não programadas, 66,6% na capacidade para atividades físicas, 54,5% nas hospitalizações, 50% nas visitas à emergência, 50% na função pulmonar, 22,2% no absenteísmo escolar e 20% na qualidade de vida. O número de itens de conteúdo foi a única característica dos programas educativos revisados associada ao nível de eficácia. Técnicas educativas sofisticadas não contribuíram para melhores resultados. A educação de crianças e adolescentes asmáticos produz resultados benéficos, mas são necessários estudos com melhor controle de variáveis confundidoras, para uma avaliação mais precisa da sua eficácia.

Group discussions with parents have long-term positive effects on the management of asthma with good cost-benefit

AIM

To investigate if an intervention with extra information and support in a group setting to parents of preschool children could improve adherence and clinical outcome.

METHODS

This is a controlled, prospective study where the parents of 60 newly diagnosed preschool asthmatic children aged 3 mo-6 y were randomized to either a control group or to an intervention that consisted of four group sessions in close connection with the diagnosis. The basic education on asthma and the written treatment plan were the same in both groups. The outcome measures were questionnaires to the parents and classification of the children according to symptoms and medication. The adherence rate and the burden of asthma were calculated with the help of diaries and weighing of the MDIs used between 12 and 18 mo after inclusion.

RESULTS

The follow-up rate was 85% after 18 mo. The parents' presence in the sessions was around 70%, with no gender difference. The parents' view on adherence issues improved significantly in the intervention group. In the control group, 30% had poor adherence compared to 8% in the intervention group (p=0.015). Both the parents and the paediatricians underestimated the number of children with poor adherence. The children in the intervention group had significantly fewer exacerbation days during the last 6 mo-2.1 compared to 3.9 d/child-although they had lower inhaled steroid doses after 18 mo. An economic calculation showed that the intervention was profitable.

CONCLUSION

This intervention resulted in an improvement in the parents' view on adherence, in the measured adherence rates and in the clinical outcome.