Advances in prevention and education in lung disease

The effect of a holistic self-management plan on asthma control

The holistic self-management plan includes lifelong actions that enable patients to cope with their disease. The present study was designed to evaluate the effect of a holistic self-management plan on asthma control. A 12-month controlled study was conducted. Adult patients with mild-to-moderate asthma (n = 24) who attended the emergency asthma department were randomized to two groups: One group followed four educational sessions and three personal home sessions (n = 12), while a second group received a short manual with asthma information (n = 12). The main measure was the asthma control test (ACT), while secondary outcomes were self-efficacy (general self-efficacy scale, GSE), end-tidal carbon dioxide (ETCO₂), respiratory rate (RR), breathing hold time (BHT), the Nijmegen Questionnaire (NQ), and spirometry (FEV₁% predicted (forced expiratory volume in 1 second % predicted)) scores. The 2 × 4 ANOVA showed a significant interaction effect between intervention and time in ACT (p = 0.001), GSE (p < 0.001), ETCO₂ (p < 0.001), RR (p < 0.001), BHT (p < 0.001), NQ (p = 0.05), and FEV₁% predicted (p < 0.001). Predictors of asthma control were self-efficacy and ETCO₂. In conclusion, this exploratory study provided support for the effectiveness of holistic self-management in asthma control. Behavioral changes, as indicated by the development of self-efficacy and the reduction of hyperventilation, contributed to the effectiveness of the intervention.

Impact of a short-term educational intervention on adherence to asthma treatment and on asthma control

OBJECTIVE

To evaluate the effect of a short-term individualized education program on adherence to asthma treatment, inhalation techniques, and asthma control.

METHODS

A prospective study involving patients aged 14 years or older, with a confirmed diagnosis of asthma and recruited from the asthma outpatient clinic of a university hospital in the city of Porto Alegre, Brazil. The study was conducted in two phases (before and after the educational intervention). At a routine medical visit, the participants completed a general questionnaire in order to assess the level of asthma control and inhalation techniques. The participants also underwent pulmonary function testing. Subsequently, they participated in an asthma education program, which consisted of one individualized session. The participants were reevaluated after three months.

RESULTS

Of the 174 patients recruited, 115 completed the study. Between the first and second evaluations, there was a significant improvement in the effective use of inhaled corticosteroids (90.4% vs. 93.3%; p = 0.003), the effective use of long-acting β2 agonists (57.4% vs. 63.5%; p < 0.0001), the effective use of a combined regimen with these two medications (57.4% vs. 62.6%; p < 0.0001), and the self-reported adherence to corticosteroid therapy (p = 0.001). There was a significant decrease in the proportion of patients visiting ERs (30.4% vs. 23.5%; p = 0.012). However, the level of asthma control and the inhalation technique did not improve significantly (p = 0.095 and p = 0.512, respectively).

CONCLUSIONS

This short-term asthma education program resulted in an improvement in the use of medications for asthma control and a decrease in the number of ER visits, although it had no significant effect on the inhalation technique.

Disparities in asthma medication dispensing patterns: the case of pediatric asthma in Puerto Rico

BACKGROUND

Disparities exist in asthma medication dispensing between children with public insurance and those with private insurance under a Managed Care Medicaid system in Puerto Rico.

OBJECTIVES

Island-wide medical claims data were used to examine the extent to which differences between the private and public health care sectors affect medication dispensing and health care utilization among asthmatic children.

METHODS

Children 3-18 years old with at least one service claim [outpatient, hospitalization, or emergency department (ED) visit] for asthma or reactive airway disease from 2005 to 2006 were selected. Chi-square analyses compared medication dispensing and health care utilization between the public and private sectors. Negative binomial regression identified factors associated with the mean dispensing rate of prescriptions for anti-inflammatory controller medication (CM).

RESULTS

Private insurance families (n = 28,088) were dispensed significantly more CM (48.3% vs. 12.0%) and quick relief medication (47.4% vs. 44.6%) than public insurance families (n = 13,220). The dispensing of inhaled corticosteroids (24.4% vs. 6.7%) and leukotriene modifiers and cromolyn (31.4% vs. 5.7%) was dramatically higher in the private sector. In contrast, emergency room use was significantly higher among public insurance children (51.7% vs. 13.8%). Multivariate analysis showed that age, number of β-agonists, and type of insurance was associated with CM dispensing; private insurance showed the greatest effect.

CONCLUSION

Asthmatic Puerto Rican children enrolled in public insurance were significantly less likely to be dispensed CM than children with private insurance; suggesting that under-treatment of public insured children may substantially contribute to increased asthma morbidity in this population as evidenced by significantly higher rates of ED visits.

CAPSULE SUMMARY

A disparity exists in asthma medication dispensing between children with public insurance compared with those with private insurance under a Managed Care Medicaid system in Puerto Rico. If asthma disparities in medication dispensing are to be reduced, then a better understanding of the complex ways in which multiple variables related to the health care system policies, socioeconomic factors, family and provider interactions, as well as the relative weight that each one contributes to the observed inequalities is needed.

Designing patient-related interventions in COPD care: empirical test of a theoretical model

OBJECTIVES

The aim of this exploratory study was to test the applicability of a theoretical model to develop patient-related interventions. In this model knowledge, psychosocial mediators, self-efficacy and behaviour are determinants of patient-related interventions.

METHODS

The model was tested on 278 patients with mild or moderate chronic obstructive pulmonary disease (COPD), recruited in a primary care setting. Hierarchical regression analyses were applied using data from self-reported questionnaires and clinical data from an electronic data registry.

RESULTS

Knowledge, psychosocial mediators, self-efficacy and behaviour proved to be, to a moderate degree, predictors of outcomes in COPD care. Moreover, physical activity appeared to be a significant predictor for all clinical and functional outcomes.

CONCLUSION

Theoretically expected associations of patient-related interventions are existent in patients with mild or moderate COPD. The application of theoretical models in designing patient-directed interventions in COPD care is therefore feasible.

PRACTICE IMPLICATIONS

More attention should be paid to the patterns of physical activity in patients with mild to moderate COPD. The results of this study are also useful in the development of patient-related interventions. Future interventions should be designed along the lines of theory on behaviour change, such as social cognitive theory.

Serving the underserved: school-based asthma intervention programs

Asthma is a common and costly disease, which disproportionately affects young, ethnic minority, and impoverished individuals. A heightened public awareness has catalyzed a variety of efforts to reduce the impact of childhood asthma in the United States. Despite these efforts, however, at-risk groups continue to suffer excess morbidity. Strategies are required that can specifically address the needs of underserved communities. We review the underlying rationale and progress of school-based programs designed to assist asthmatic children.

Assessment of chronic illness care (ACIC): a practical tool to measure quality improvement

OBJECTIVE

To describe initial testing of the Assessment of Chronic Illness Care (ACIC), a practical quality-improvement tool to help organizations evaluate the strengths and weaknesses of their delivery of care for chronic illness in six areas: community linkages, self-management support, decision support, delivery system design, information systems, and organization of care.

DATA SOURCES

(1) Pre-post, self-report ACIC data from organizational teams enrolled in 13-month quality-improvement collaboratives focused on care for chronic illness; (2) independent faculty ratings of team progress at the end of collaborative.

STUDY DESIGN

Teams completed the ACIC at the beginning and end of the collaborative using a consensus format that produced average ratings of their system's approach to delivering care for the targeted chronic condition. Average ACIC subscale scores (ranging from 0 to 11, with 11 representing optimal care) for teams across all four collaboratives were obtained to indicate how teams rated their care for chronic illness before beginning improvement work. Paired t-tests were used to evaluate the sensitivity. of the ACIC to detect system improvements for teams in two (of four) collaboratives focused on care for diabetes and congestive heart failure (CHF). Pearson correlations between the ACIC subscale scores and a faculty rating of team performance were also obtained.

RESULTS

Average baseline scores across all teams enrolled at the beginning of the collaboratives ranged from 4.36 (information systems) to 6.42 (organization of care), indicating basic to good care for chronic illness. All six ACIC subscale scores were responsive to system improvements diabetes and CHF teams made over the course of the collaboratives. The most substantial improvements were seen in decision support, delivery system design, and information systems. CHF teams had particularly high scores in self-management support at the completion of the collaborative. Pearson correlations between the ACIC subscales and the faculty rating ranged from .28 to .52.

CONCLUSION

These results and feedback from teams suggest that the ACIC is responsive to health care quality-improvement efforts and may be a useful tool to guide quality improvement in chronic illness care and to track progress over time.

Methods and effectiveness of indoor environmental control

LEARNING OBJECTIVES

The purpose of this review is to describe recommended methods of decreasing exposure to indoor allergens.

DATA SOURCES

Data were obtained from published studies and reviews.

STUDY SELECTION

The reviewed studies met these criteria: 1) measurement of environmental allergens; 2) selection of participants with clearly defined allergic airway disease confirmed by detection of allergen-specific immunoglobulin E; and 3) clearly defined clinical and environmental outcomes. The studies were conducted as controlled clinical trials and the results between treated and control groups were compared with appropriate statistics.

RESULTS

The results of these studies show that installing allergen proof encasings and washing bedding frequently reduces house-dust mite exposure by 10-fold or more and significantly improves clinical measures of asthma. Washing pets reduces allergen levels temporarily. Excluding the pet from the bedroom while installing allergen-proof encasings and operating air cleaner reduces airborne allergens although having no significant effect on allergic symptoms. Cockroach populations can be controlled for over 6 months and allergens can be reduced with controlled pesticide application and cleaning, but clinical correlates have not been reported. Methods to improve adherence to environmental control measures have not been tested but effective methods can be recommended from literature on medication adherence.

CONCLUSIONS

For patients allergic to indoor allergens, reasonable recommendations include installation of allergen-impermeable encasings, frequent laundering of bedding, removing furred pets from the home, and controlling of cockroach populations with effective pesticides using the principles of integrated pest management.

The awesome Asthma School Days Program: educating children, inspiring a community

Program planners developed an educational program to improve the health of children with asthma in grades three to five in Milwaukee (Wis.) Public Schools. During 1997-1998, 1,400 students from 74 elementary schools participated in the Awesome Asthma School Days education program. In a cross-sectional survey, about 40% of children reported play interrupted and sleep disturbed by asthma, more than 50% of children reported exposure to smoke in their home, most children lacked asthma self-care tools, and most children with persistent symptoms did not use an anti-inflammatory inhaler. The educational program improved students' expectations about normal play and sleep and improved their understanding of asthma. Leaders in Milwaukee used the survey results to develop a community action plan. The educational program, surveys, community partnerships, and strategic plans can be replicated in other schools.