Evaluation of two different educational interventions for adult patients consulting with an acute asthma exacerbation

Effectiveness of Rehabilitation Interventions in Adults With Asthma: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of the study is to evaluate the effectiveness of pulmonary rehabilitation programs and other rehabilitation interventions in adults with asthma.

DESIGN

This is a systematic review and meta-analysis.

RESULTS

MEDLINE (PubMed), Embase, Cumulative Index to Nursing & Allied Health Literature, and CENTRAL were searched from inception to 31 May 2023. PROSPERO registration number: CRD42022331440. Thirty-six randomized controlled trials were analyzed, and only 26 were pooled in the meta-analysis because of the heterogeneity of comparisons and outcomes across the studies. Pulmonary rehabilitation, compared with education associated with breathing exercises, may result in little to no difference in the Asthma Quality of Life Questionnaire (mean difference 0.01 score, 95% confidence interval = -0.48 to 0.50, 163 participants, three studies, low certainty).

CONCLUSIONS

Our findings show that pulmonary rehabilitation, compared with education associated with breathing exercises, may result in little to no difference in the impact of asthma on health-related quality of life. Overall, the certainty of evidence was low or very low preventing any firm conclusion on the effects of single or combined rehabilitation interventions.

GEMA 5.3. Spanish Guideline on the Management of Asthma

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

Impact of asthma severity on long-term asthma control

Background: Asthma is a common childhood disease with significant morbidity. Severe asthma accounts for just 4-6% of patients, but this group is more difficult to treat and is responsible for up to 40% of asthma expenses.Objective: The relationship between asthma severity and control is not well characterized. The main objective of this study was to determine impact of asthma severity on asthma control over time.Methods: This was a three year, prospective observational cohort study at a tertiary care children's hospital. Results were compared over time and between patients with severe and non-severe persistent asthma. Intervention included therapy based on severity and control, accompanied by a NAEPP (EPR-3) guidelines based structured asthma education program.Results: The sample included 471 children referred from primary care offices with the diagnosis of persistent asthma, mean age 6.4 ± 2.4 years. Forty-one children (8.7%) had severe persistent asthma and 430 (91.3%) children had non-severe persistent asthma (mild-moderate persistent). Our sample size decreased over the three-year period and the number of patients completing the third year were 176 (38%) and among them 20 (11.4%) had severe asthma. At the initial visit, children with severe persistent asthma had significantly more acute care needs, more daily symptoms, and lower mean Asthma Control Test™ scores compared to children with non-severe persistent asthma. Differences between groups decreased within six months with significant improvements in most indicators persisting throughout three-year follow up in both groups (p < 0.05).Conclusion: Asthma control improves independent of severity if asthma guidelines are followed.

Impact of Group Asthma Education on Asthma Control and Emergency Room Visits in an Underserved New York Community

Objective

Asthma education programs have been shown to be effective in decreasing health care utilization and improving disease control and management. However, there are few studies evaluating the outcomes of group asthma education. The aim of this study was to assess the impact of an outpatient adult group asthma education program in an inner-city-based hospital caring for an underserved population.

Methods

We conducted a pre- and poststudy of all patients with asthma who participated in two structured group asthma education sessions led by a respiratory therapist, clinical pharmacist, and pulmonologist. The study period (January 2016 to April 2018) included the year before group education and the year after education. The primary outcomes were the number of patients requiring emergency room visits and hospital admission. The secondary outcomes included asthma control as assessed by Asthma Control Test scores, use of systemic corticosteroids, and change in test scores postintervention.

Results

Eighty-eight patients received group education during the study period; 82 attended 2/2 sessions, and 6 attended 1/2 sessions. The study population was largely Hispanic (73%) or African American (25%) and had a mean age of 58 years. Most had moderate (57%) or severe (25%) persistent asthma. Significantly, fewer patients required emergency room visits in the postintervention period than in the preintervention period (20 visits vs. 42 visits, p=0.0002). Group education was also associated with increased asthma control (p=0.0043), decreased use of systemic corticosteroids (p=0.0005), and higher postintervention test scores (p=0.0001).

Conclusions

Group asthma education provided by a multidisciplinary team in an inner-city hospital clinic caring for underserved and minority populations is feasible and may decrease utilization of health care resources when patients are educated and empowered to participate in their asthma management.

Impact of non-drug therapies on asthma control: A systematic review of the literature

BACKGROUND

Despite growing access to effective therapies, asthma control still needs improvement. Many non-drug factors, such as allergens, air pollutants and stress also affect asthma control and patient quality of life, but an overview of the effectiveness of non-drug interventions on asthma control was lacking.

OBJECTIVES

To identify non-drug interventions likely to improve asthma control.

METHODS

A systematic review of the available literature in Medline and the Cochrane Library was conducted in March 2017, without any time limit. Initial searching identified 884 potentially relevant clinical trial reports, literature reviews and meta-analyses, which were screened for inclusion using criteria of quality, relevance, and reporting outcomes based on asthma control.

RESULTS

Eighty-two publications met the inclusion criteria. In general, the quality of the studies was low. Patient education programmes (22 studies) significantly improved asthma control. Multifaceted interventions (10 studies), which combined patient education programmes with decreasing exposure to indoor allergens and pollutants, significantly improved asthma control based on clinically relevant outcomes. Renovating homes to reduce exposure to allergens and indoor pollutants improved control (two studies). Air filtration systems (five studies) were effective, especially in children exposed to second-hand smoke. Most measures attempting to reduce exposure to dust mites were ineffective (five studies). Dietary interventions (eight studies) were ineffective. Promoting physical activity (five studies) tended to yield positive results, but the results did not attain significance.

CONCLUSION

Twenty-six interventions were effective in asthma control. Simultaneously combining several action plans, each focusing on different aspects of asthma management, seems most likely to be effective.

Implementation of an Asthma Self-Management Education Guideline in the Emergency Department: A Feasibility Study

Patients often present to emergency departments (EDs) for the management of chronic asthma. Because of the nature of ED care, national guideline recommendations for asthma education are generally not initiated in the ED. There is evidence that asthma education can have a positive effect on patient outcomes (; ). This study examines the feasibility of implementing an asthma self-management guideline in a tertiary care center ED. Despite protocol utilization by physicians (87%), nurse practitioners and physician assistants (66.7%), and nurses (41.7%), total compliance with national guideline was accomplished in only 25.93% of cases. Barriers to protocol implementation included staff education, high workload, rapid turnover, and competing initiatives within the department. Linear regression analysis identified high daily census as a predictor of protocol noncompliance (p = 0.033).

Effectiveness of written action plans for acute asthma: A systematic review

OBJECTIVE

Self-management is an essential part of achieving asthma control and improving long-term outcomes. While guidelines recommend the provision of written asthma action plans (AAPs), few patients presenting to emergency departments (ED) have one. This systematic review examined if individualized written AAPs reduce relapses in adults following an ED visit for acute asthma.

DATA SOURCES

Comprehensive searches of seven electronic databases and grey literature were conducted.

STUDY SELECTIONS

Randomized controlled trials (RCTs) examining the effectiveness of individualized written AAPs to reduce relapses after ED visits for acute asthma were included. Study quality was determined using the Cochrane Risk of Bias (RoB) tool; intervention fidelity was assessed.

RESULTS

From 695 potentially relevant studies, three RCTs were included. The RoB was low in two studies and high in one study; description of intervention fidelity varied across studies. The provision of individualized written AAPs in adults following an ED visit for acute asthma did not reduce the risk of relapse after ED discharge (risk ratio [RR] = 0.66; 95% confidence intervals [CI]: 0.36, 1.23; I² = 40%). There was a 49% reduction in the risk of relapse after ED discharge when only studies with low RoB were pooled (RR = 0.51; 95% CI: 0.31, 0.83; I² = 0%).

CONCLUSION

This review did not provide conclusive evidence to support the consideration of individualized written AAPs for the reduction of relapses after an ED visit; however, the low frequency of events, small number of studies and samples, and their methodological quality might play an important role in this overall finding.

The burden of nonadherence among adults with asthma: a role for shared decision-making

A shared approach to decision-making framework has been suggested for chronic disease management especially where multiple treatment options exist. Shared decision-making (SDM) requires that both physician and patients are actively engaged in the decision-making process, including information exchange; expressing treatment preferences; as well as agreement over the final treatment decision. Although SDM appears well supported by patients, practitioners and policymakers alike, the current challenge is to determine how best to make SDM a reality in everyday clinical practice. Within the context of asthma, adherence rates are poor and are linked to outcomes such as reduced asthma control, increased symptoms, healthcare expenditures, and lower patient quality of life. It has been suggested that SDM can improve treatment adherence and that ignoring patients' personal goals and preferences may result in reduced rates of adherence. Furthermore, understanding predictors of poor treatment adherence is a necessary step toward developing effective strategies to improve the patient-reported and clinically important outcomes. Here, we describe why a shared approach to treatment decision-making for asthma has the potential to be an effective tool for improving adherence, with associated clinical and patient-related outcomes. In addition, we explore insights into the reasons why SDM has not been implemented into routine clinical practice.

Personalised asthma action plans for adults with asthma

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Effectiveness of an asthma integrated care program on asthma control and adherence to inhaled corticosteroids

OBJECTIVE

To measure the effectiveness of an integrated care program for individuals with asthma aged 12-45 years, on asthma control and adherence to inhaled corticosteroids (ICS).

METHODS

Researchers used a theoretical model to develop the program and assessed effectiveness at 12 months, using a pragmatic controlled clinical trial design. Forty-two community pharmacists in Quebec, Canada recruited participants with either uncontrolled or mild-to-severe asthma. One group was exposed to the program; another received usual care. Asthma control was measured with the Asthma Control Questionnaire; ICS adherence was assessed with the Morisky medication adherence scale and the medication possession ratio. Program effectiveness was assessed with an intention-to-treat approach using multivariate generalized estimating equation models.

RESULTS

Among 108 exposed and 241 non-exposed, 52.2% had controlled asthma at baseline. At 12-months, asthma control had improved in both groups but the interaction between study groups and time was not significant (p = 0.09). The proportion of participants with good ICS adherence was low at baseline. Exposed participants showed improvement in adherence and the interaction between study groups and time was significant (p = 0.02).

CONCLUSION

An integrated intervention, with healthcare professionals collaborating to optimize asthma control, can improve ICS adherence.

A repeated short educational intervention improves asthma control and quality of life

We assessed the effectiveness of an asthma educational programme based on a repeated short intervention (AEP-RSI) to improve asthma control (symptom control and future risk) and quality of life. A total of 230 adults with mild-to-moderate persistent uncontrolled asthma participated in a 1-year cluster randomised controlled multicentre study. The AEP-RSI was given in four face-to-face sessions at 3-month intervals, and included administration of a written personalised action plan and training on inhaler technique. Centres were randomised to the AEP-RSI (intervention) group or usual clinical practice group. Specialised centres using a standard educational programme were the gold standard group. A significant improvement in the Asthma Control Test score was observed in all three groups (p<0.001), but improvements were higher in the intervention and gold standard groups than in the usual clinical practice group (p=0.042), which also showed fewer exacerbations (mean±sd; 1.20±2.02 and 0.56±1.5 versus 2.04±2.72, respectively) and greater increases in the Mini Asthma Quality of Life Questionnaire scores (0.95±1.04 and 0.89±0.84 versus 0.52±0.97, respectively). The AEP-RSI was effective in improving asthma symptom control, future risk and quality of life.

Adherence to controller asthma medications: 6-month prevalence across a US community pharmacy chain

WHAT IS KNOWN AND OBJECTIVE

Non-adherence to controller asthma medications is an important public health problem. It is estimated to occur in 30-70% of individuals and is a significant risk factor for asthma morbidity and mortality. The aim of this study was to determine the level of adherence, as indicated by refill rates, to controller asthma medications in a community pharmacy setting.

METHODS

Secondary analyses of a community pharmacy dispensing database in 15 locations throughout Utah.

RESULTS AND DISCUSSION

The dispensing records of 2193 patients who received controller medications for asthma in a 12-month period, and had a minimum of 6-month potential coverage (180 days) from the date of their first receipt of a controller medication in that period, were examined. Using standard metrics to gauge adherence, the proportion of days covered (PDC) and the medication possession ratio (MPR), the average coverage for controller asthma medications across a 6-month period (180 days) was poor, averaging less than 50% of days' availability. Standard cut-offs (≥80% medication availability) indicated that only 14-16% of patients had 'satisfactory' adherence over their 6-month follow-on period. Females and older patients had significantly greater satisfactory adherence. Medication adherence was significantly greater with inhaled corticosteroid (ICS)-long-acting β₂ -agonist (LABA) combinations than with ICS alone.

WHAT IS NEW AND CONCLUSION

This study confirms the considerable scope of the asthma therapy non-adherence problem. Therefore, it is imperative to conduct survey-based research linked directly to pharmacy-based dispensing data to derive patient behavioural, attitudinal and environmental factors that may contribute to the issue, and then pilot and evaluate interventions for change.

Chronic disease management programmes for adults with asthma

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Severe asthma in children

Severe asthma in children is characterized by sustained symptoms despite treatment with high doses of inhaled corticosteroids or oral corticosteroids. Children with severe asthma may fall into 2 categories, difficult-to-treat asthma or severe therapy-resistant asthma. Difficult-to-treat asthma is defined as poor control due to an incorrect diagnosis or comorbidities, or poor adherence due to adverse psychological or environmental factors. In contrast, treatment resistant is defined as difficult asthma despite management of these factors. It is increasingly recognized that severe asthma is a highly heterogeneous disorder associated with a number of clinical and inflammatory phenotypes that have been described in children with severe asthma. Guideline-based drug therapy of severe childhood asthma is based primarily on extrapolated data from adult studies. The recommendation is that children with severe asthma be treated with higher-dose inhaled or oral corticosteroids combined with long-acting β-agonists and other add-on therapies, such as antileukotrienes and methylxanthines. It is important to identify and address the influences that make asthma difficult to control, including reviewing the diagnosis and removing causal or aggravating factors. Better definition of the phenotypes and better targeting of therapy based upon individual patient phenotypes is likely to improve asthma treatment in the future.

An example of using a decision making framework designed for non-medical prescribers as a method for enhancing prescribing safety for inhaled corticosteroids (ICS)

Non-medical prescribing is needed especially with the increased demand for health care and the physicians' time constrains. Also, it is not well regulated in Saudi Arabia unlike the United Kingdom. This report aims to demonstrate the urged need for regulations to maintain a safe non-medical prescribing process. It also adapts the single competency framework provided by the United Kingdom national prescribing centre (NPC, 2012) to be utilised by the respiratory therapist for a safe prescribing process for inhaled corticosteroids (ICS) to control adult asthma as an example. The framework is thought to be an effective tool for safe non-medical prescribing and it is highly recommended to develop a national Saudi framework to maintain the patients' safety and utilise resources.

Interventions for enhancing medication adherence

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Use of emergency departments and primary care visits for asthma related conditions in the 3 years following an asthma education program

BACKGROUND

This study examines changes in Primary Care Visits (PCVs) and Emergency Department Visits (EDVs) among 1918 patients with asthma who attended either two visits, one visit or were no-show referrals at the Dr. Patrick Gill Asthma Education Center (AEC) in Charlottetown Prince Edward Island (PEI) between January 1, 2003 and March 31, 2008 compared to 2799 controls selected from a list of PEI asthma patients developed for the Canadian Chronic Disease Surveillance System (CCDSS).

METHODS

Hurdle regression was used to model counts of PCVs and negative binomial models were used to model counts of EDVs at 12 months prior to AEC contact and 0-1, >1 to 2 and >2 to 3 years after AEC contact. The PEI Research Board approved the project.

RESULTS

No-show referrals had a significant increase in pediatric EDVs and PCVs in the first year after referral. The higher rates of PCVs and EDVs prior to contact with the AEC in patients referred to the AEC were reduced after contact with the AEC, although they remained significantly higher than the CCDSS controls.

CONCLUSIONS

Compared to patients who attended the AEC, referred patients who did not attend the AEC did not achieve similar reductions in pediatric EDVs and PCVs in the first year after referral.

The effectiveness of a pictorial asthma action plan for improving asthma control and the quality of life in illiterate women

BACKGROUND

Written asthma action plans are an important part of asthma management, but cannot be used for illiterate people.

OBJECTIVE

The aim of this study was to establish the effectiveness of a pictorial asthma action plan on asthma control, health-related quality of life (HRQoL), and asthma morbidity in a population of illiterate women with asthma.

METHODS

Forty illiterate women with moderate-severe persistent asthma were assigned alternatively to receive either asthma education alone (control group) or asthma education and a pictorial asthma action plan (study group). Asthma control was assessed using the asthma control test (ACT), HRQoL was assessed using the St George's Respiratory Questionnaire (SGRQ), and the frequency of non-scheduled hospital or emergency visits was monitored.

RESULTS

Thirty-four patients completed the study. The ACT and SGRQ scores of both groups improved at every follow-up time point compared with baseline (p < 0.001). The ACT scores at 1 month (22.44 versus 20.75, p = 0.034) and 2 months (23.28 versus 21.81, p = 0.010) were higher in the study group than in the control group, but this was not maintained at 6 months (24.00 versus 23.25, p = 0.069). The SGRQ scores at 6 months were better in the study group (18.12) than in the control group (23.96, p = 0.033). No hospital admissions were recorded for either group.

CONCLUSION

Education provides a significant improvement in asthma control and HRQoL while managing illiterate asthma patients, additionally the pictorial asthma action plan can be a helpful tool for self-medication.

Effects of an outpatient education program in patients with uncontrolled asthma

OBJECTIVE

To evaluate the effects of an outpatient education program in patients with uncontrolled asthma.

METHODS

This was an uncontrolled study evaluating an educational intervention and involving patients with uncontrolled asthma ≥ 14 years of age. The participants completed a questionnaire designed to assess the level of asthma control, the inhalation technique, and quality of life. All of the patients underwent pulmonary function testing, after which they participated in an education program consisting of one 45-min face-to-face session, followed by phone interviews at two, four, and eight weeks. The participants were reevaluated after three months.

RESULTS

Sixty-three patients completed the study. There was a significant improvement in the level of asthma control (p < 0.001). Of the 63 patients, 28 (44.4%) and 6 (9.5%) were classified as having partially controlled asthma and controlled asthma, respectively. The mean FEV1 was 63.0 ± 20.0% and 68.5 ± 21.2% of the predicted value prior to and after the educational intervention, respectively (p = 0.002), and all of the quality of life scores improved (p < 0.05 for all). The same was true for the proportion of patients prior to and after the educational intervention using the proper inhalation technique when using metered dose inhalers (15.4% vs. 46.2%; p = 0.02) and dry powder inhalers (21.3% vs. 76.6%; p < 0.001). The logistic regression analysis revealed that an incorrect inhalation technique identified during the first evaluation was independently associated with a favorable response to the educational intervention.

CONCLUSIONS

This study suggests that an outpatient education program for asthma patients improves the level of asthma control, lung function parameters, and quality of life. An incorrect inhalation technique identified during the first evaluation was predictive of a favorable response to the educational intervention.

Developing novel evidence-based interventions to promote asthma action plan use: a cross-study synthesis of evidence from randomised controlled trials and qualitative studies

BACKGROUND

Long-standing randomised controlled trial (RCT) evidence indicates that asthma action plans can improve patient outcomes. Internationally, however, these plans are seldom issued by professionals or used by patients/carers. To understand how the benefits of such plans might be realised clinically, we previously investigated barriers and facilitators to their implementation in a systematic review of relevant RCTs and synthesised qualitative studies exploring professional and patient/carer views. Our final step was to integrate these two separate studies.

METHODS

First, a theoretical model of action plan implementation was proposed, derived from our synthesis of 19 qualitative studies, identifying elements which, if incorporated into future interventions, could promote their use. Second, 14 RCTs included in the quantitative synthesis were re-analysed to assess the extent to which these elements were present within their interventions (that is, 'strong', 'weak' or 'no' presence) and with what effect. Matrices charted each element's presence and strength, facilitating analysis of element presence and action plan implementation.

RESULTS

Four elements (professional education, patient/carer education, (patient/carer and professional) partnership working and communication) were identified in our model as likely to promote asthma plan use. Thirteen interventions reporting increased action plan implementation contained all four elements, with two or more strongly present. One intervention reporting no effect on action plan implementation contained only weakly present elements. Intervention effectiveness was reported using a narrow range of criteria which did not fully reflect the four elements. For example, no study assessed whether jointly developed action plans increased use. Whilst important from the professional and patient/carer perspectives, the integral role of these elements in intervention delivery and their effect on study outcomes was under-acknowledged in these RCTs.

CONCLUSIONS

Our novel approach provides an evidence-base for future action plan interventions. Such interventions need to ensure all elements in our implementation model (patient/carer and professional education to support development of effective partnership working and communication) are strongly present within them and a wider range of criteria better reflecting the realities of clinical practice and living with asthma are used to measure their effectiveness. We now intend to test such a complex intervention using a cluster trial design.

[Asthmatic emergencies: a psychosocial approach to behaviour of asthmatics]

Emergency department admissions for acute asthma often show that patients have failed to manage their disease well. Such admissions may reflect poor asthma control, as defined in the literature, often due to a lack of education and medical follow-up. If patient-centred education has been recognised as effective, what are the best locations and the best moments in the patient's disease history to provide this education? The French Guidelines (HAS) on therapeutic education suggested that education should take place in the emergency department. Moreover, the emergency department is a unique healthcare situation and opportunity for therapeutic education. In the emergency department, a better analysis and understanding of an asthmatic's health orientated behaviour by a psychosocial interview may improve the patient's decision making and lead to an appropriate education programme.

Efficacy of interventions to improve adherence to inhaled corticosteroids in adult asthmatics: impact of using components of the chronic care model

BACKGROUND

Adherence to inhaled corticosteroids (ICS) remains poor among asthmatics, yet little is known about the efficacy of interventions to improve adherence. Implementing the Chronic Care Model (CCM) components among patients with respiratory disorders has been associated with an improvement in outcomes, yet little is known about its effects on ICS adherence in asthmatics.

OBJECTIVE

We conducted a systematic review to assess the efficacy of interventions to improve ICS adherence among adult-asthmatics, and whether the use of CCM components (i.e., teaching self-management skills, providing decision support, delivery system design, and clinical information systems) resulted in greater ICS adherence.

METHODS

All English language articles testing the efficacy of an intervention including ICS medication on outcome from MEDLINE and PsychINFO databases through Aug-2010 were reviewed. Interventions were categorized based on the inclusion of CCM components. We standardized treatment effects to obtain effect-size's (ES's) and we combined the ES's of studies according to the number of CCM components included in their interventions.

RESULTS

Eighteen studies met inclusion criteria. Inclusion of a greater number of CCM components within interventions was associated with stronger effects on ICS adherence outcomes, with interventions featuring one, two, and four CCM components having medium (ES = 0.29; 95%CI, 0.16-0.42), large (0.53; 0.40-0.66), and very-large (0.83; 0.69-0.98) effects respectively.

CONCLUSIONS

Findings provide support for using the CCM as a framework for the design and implementation of interventions to improve adherence among adult-asthmatics.

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.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed study quality and abstracted data.

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

[Adult asthma exacerbations in questions]

In this article a French working party critically review the international literature to revise the definition, pathophysiology, treatment and cost of exacerbations of adult asthma. The various guidelines do not always provide a consistent definition of exacerbations of asthma. An exacerbation can be defined as deterioration of clinical and/or functional parameters lasting more than 24 hours, without return to baseline, requiring a change of treatment. No single clinical or functional criterion can be used as an early marker of an exacerbation. Innate and acquired immune mechanisms, modified by contact with infectious, irritant or allergenic agents, participate in the pathogenesis of exacerbations, which are accompanied by bronchial inflammation. In 2010, mortality is related to progression of exacerbations, often occurring before the patient seeks medical attention. The objective of treatment is to control asthma and prevent exacerbations. However, many factors can trigger exacerbations and often cannot be controlled. The efficacy of inhaled corticosteroids has been demonstrated on reduction of the number of exacerbations and the number of asthma-related deaths. This treatment is cost-effective, especially in terms of reduction of exacerbations.

Inhaled corticosteroids should be initiated before discharge from the emergency department in patients with persistent asthma

National and International Guidelines concur that inhaled corticosteroids (ICS) are the preferred long-term maintenance drug therapy for mild persistent asthma for all ages. For moderate and severe persistent asthma, ICS are essential to optimal management, often concurrent with other key therapies. Despite strong evidence and consensus guidelines, ICS are still underused. While some patients who are treated in the emergency department (ED) have intermittent asthma, most have persistent asthma and need ICS for optimum outcomes. Failure to initiate ICS at this critical juncture often results in subsequent lack of ICS therapy. Along with a short course of oral corticosteroids, ICS should be initiated before discharge from the ED in patients with persistent asthma. Although the NIH/NAEPP Expert Panel Report 3 suggests considering the prescription of ICS on discharge from the ED, The Global Initiative for Asthma (GINA) 2008 guidelines recommend initiation or continuation of ICS before patients are discharged from the ED. The initiation of ICS therapy by ED physicians is also encouraged in the emergency medicine literature over the past decade. Misdiagnosis of intermittent asthma is common; therefore, ICS therapy should be considered for ED patients with this diagnosis with reassessment in follow-up office visits. To help ensure adherence to ICS therapy, patient education regarding both airway inflammation (show airway models/colored pictures) and the strong evidence of efficacy is vital. Teaching ICS inhaler technique, environmental control, and giving a written action plan are essential. Lack of initiation of ICS with appropriate patient education before discharge from the ED in patients with persistent asthma is common but unfortunately associated with continued poor patient outcomes.

Effects of a shortened asthma self-management group program

OBJECTIVE

Asthma self-management programs are effective but often time-consuming.We evaluated the effects of a shortened asthma self-management program on asthma knowledge, morbidity and asthma-related behaviour in a group of moderate to severe adult asthmatics.

METHODS

The effects of the program were evaluated with a one year prospective trial in a group of 55 asthmatics (mean age 45 yrs, 42% males, N=26 in intervention group, N=29 in control group) by administering questionnaires and diary exercises at baseline, immediately, 3 and 12 months after the end of the program.

RESULTS

Asthma-related knowledge and hyperventilation symptoms improved more in the intervention than in the control group and this effect was maintained until 3 months after participation. General asthma symptoms improved significantly, but substantial symptom improvements were also found in the control group. The original effects in the intervention group persisted partly but not significantly 1 year after participation. No significant effects were found on pulmonary function.

CONCLUSIONS

Based on our preliminary results, we conclude that our shortened asthma self-management program had an impact on knowledge and asthma symptoms, especially hyperventilation symptoms, until 3 months after the end of the program. Continuous reinforcement and specifying the program content are essential aspects to obtain more robust and long-lasting effects when administering shortened asthma self-management programs.

Self-management plans for asthma control and predictors of patient compliance

OBJECTIVE

To evaluate the impact of peak flow or symptom-based self-management plans on asthma control and patients' quality of life and to determine the main psychosocial factors that affect compliance with these plans.

METHODS

The study sample consisted of 63 patients with persistent asthma outpatients. Data collection included demographics, pulmonary functions, symptom scores, and asthma control parameters recorded over the previous 2 consecutive years. A standard asthma self-management education program including personal action plans was given to the patients who were randomly divided into peak flow meter (PFM) (n = 31) or symptom-based (n = 32) action plan groups. Patients were then assessed prospectively for various study outcomes including symptoms, drug compliance, psychiatric co-morbidities, quality of life, and asthma control over the next 12 months. Psychiatric co-morbidities were assessed using Rotter's Internal and External Locus of Control Scale (RIELCS), Beck Depression Inventory (BDI), Structured Clinical Interview for DSM-IV (SCID-I), Spielberger State-Trait-Anxiety Inventory (STAI), and Short Form-36 (SF-36).

RESULTS

Of the 63 patients (79% female; mean age 43), 85% of them had moderately or severely persistent asthma. Baseline demographics, clinical parameters, psychiatric diagnosis, and quality of life were not different between groups. Personal asthma plans increased optimal asthma control significantly. Emergency visits, antibiotic treatments, systemic corticosteroid treatments, and unscheduled visits were fewer than the previous year. Control parameters were better in the PFM group. After the self-management education, the quality of life dimensions, i.e., vitality, total mental and general scores of both groups increased. Frequency of psychiatric co-morbidities decreased from 61.9% to 49.2%. However, state anxiety levels were increased in both groups. These increases were statistically significant in the PFM group. Compliance with the action plans was better in the PFM group. Higher BDI scores were associated with worse compliance. No statistically significant association was found between demographic parameters and the compliance. Although the compliance had decreased in both groups after 6 months, this decrease was greater in the symptom group. Higher RIELCS and mental health scores were associated with better compliance.

CONCLUSION

Introduction of self-management plans improved illness control and quality of life in asthma patients. Use of the PFM and the presence of higher RIELCS and lower BDI scores can be used to predict compliance with the action plans.

Control of asthma

Control is the aim of asthma management and clinical trials show that control can be achieved in the majority of patients. However, population surveys show that poorly controlled asthma still imposes a considerable burden. This fact has led to a re-evaluation of the international asthma guidelines and the updated 2006 and 2007 GINA and NAEPP guidelines suggest that the level of control should be used as the key feature for the classification and management of asthma. Furthermore, in the latest guidelines, a clearer definition of control is given and new tools for the assessment and monitoring of control are instituted. In order to achieve asthma control, not only relevant pharmacological treatment but, the establishment of a good patient-doctor relationship, proper education of the asthmatic patient, reduction of exposure to triggers and treatment of co-morbidities are pivotal issues and must be ensured.

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.

Two Pharmacy Interventions to Improve Refill Persistence for Chronic Disease Medications

BACKGROUND

Despite the proven effectiveness of many medications for chronic diseases, many patients do not refill their prescriptions in the required timeframe.

OBJECTIVE

Compare the effectiveness of 3 pharmacist strategies to decrease time to refill of prescriptions for common chronic diseases. RESEARCH DESIGN/SUBJECTS: A randomized, controlled clinical trial with patients as the unit of randomization. Nine pharmacies within a medium-sized grocery store chain in South Carolina were included, representing urban, suburban, and rural areas and patients from a variety of socioeconomic backgrounds. Patients (n = 3048) overdue for refills for selected medications were randomized into 1 of 3 treatment arms: (1) pharmacist contact with the patient via telephone, (2) pharmacist contact with the patient's prescribing physician via facsimile, and (3) usual care.

MEASURES

The primary outcome was the number of days from their recommended refill date until the patient filled a prescription for any medication relevant to his/her chronic disease. Prescription refill data were obtained routinely from the pharmacy district office's centralized database. Patient disposition codes were obtained by pharmacy employees. An intent-to-treat approach was used for all analyses.

RESULTS

There were no significant differences by treatment arm in the study outcomes.

CONCLUSIONS

Neither of the interventions is more effective than usual care at improving persistence of prescription refills for chronic diseases in overdue patients.

Increasing the use of anti-inflammatory agents for acute asthma in the emergency department: experience with an asthma care map

PURPOSE

Acute asthma is a common emergency department (ED) presentation and variation in its management is well recognized. The present study examined the use of an asthma care map (ACM) in one Canadian ED to improve adherence to acute asthma guidelines, emphasizing the use of systemic corticosteroids (SCSs) and inhaled corticosteroids (ICSs).

METHODS

Three time periods were studied: the 15 months before ACM introduction (PRE), the 15 months following a three-month introduction of the ACM (POST(1)) and the 18 months after POST(1) (POST(2)). Randomly selected patient charts from each period were included from patients who were 18 to 60 years of age and presented with a primary diagnosis of acute asthma. A priori criteria were established to determine the degree of completion and success of the ACM. Primary outcomes included documentation, use of SCSs in the ED, and prescription of SCSs and ICSs at ED discharge.

RESULTS

A total of 387 patient charts were included (PRE, n=150; POST(1), n=150; POST(2), n=87). Patient characteristics in the three groups were similar; however, patients in POST(1) and POST(2) showed higher use of newer agents than those in the PRE group. Overall, more women (n=209; 54%) than men were seen; the mean age was 32.4 years. The care map was used in 67% of cases during POST(1) and 70% during POST(2). The use of peak expiratory flow (PEF) was high during the PRE, POST(1) and POST(2) periods (91%, 89% and 91%, respectively); however, documentation of other markers of severity increased in the POST periods. Use of SCSs occurred earlier (P<0.01) and more often (57% PRE, 68% POST(1) and 75% POST(2); P<0.01) in the POST(1,2) periods than the PRE period. There was a significant increase in use of SCSs on discharge (55% PRE, 66% POST(1) and 69% POST(2); P<0.05), and prescription of ICSs significantly increased (24% PRE, 45% POST(1) and 61% POST(2); P<0.001) in the POST(1,2) periods. Discharge without any corticosteroids decreased over the three periods (32% PRE, 21% POST(1) and 17% POST(2); P<0.05). The length of stay in the ED increased over the study periods (181 min PRE, 209 min POST(1) and 265 min POST(2); P<0.01) and admissions were infrequent (9% PRE, 13% POST(1) and 6% POST(2); P=0.50).

CONCLUSIONS

The present study provides evidence that the standardized ED ACM was widely accepted, improved chart documentation, improved some aspects of ED care and increased prescribing of discharge preventive medications.

Interventions for enhancing medication adherence

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

The effects of a disease management program on self-reported health behaviors and health outcomes: evidence from the "Florida: a healthy state (FAHS)" Medicaid program

Premature morbidity and mortality from chronic diseases account for a major proportion of expenditures for health care cost in the United States. The purpose of this study was to measure the effects of a disease management program on physiological and behavioral health indicators for Medicaid patients in Florida. A two-year prospective study of 15,275 patients with one or more chronic illnesses (congestive heart failure, hypertension, diabetes, or asthma) was undertaken. Control of hypertension improved from baseline to Year 1 (adjusted odds ratio = 1.60, p < .05), with maintenance at Year 2. Adjusted cholesterol declined by 6.41 mg/dl from baseline to Year 1 and by 12.41 mg/dl (p < .01) from baseline to Year 2. Adjusted average medication compliance increased by 0.19 points (p < .01) in Year 1 and 0.29 points (p < .01) in Year 2. Patients in the disease management program benefited in terms of controlling hypertension, asthma symptoms, and cholesterol and blood glucose levels.

The Current State of Cough Research: The Clinician’s Perspective

Cough is one of the most common reasons for medical consultation and it is responsible for a large human and socioeconomic burden. Current guidelines provide a useful framework for cough management and summarize current knowledge of causes and optimal testing sequences and treatments of cough. However, research is needed on the role of noninvasive airway inflammation measurement in assessing etiology; optimal treatment of postinfectious cough or cough due to gastroesophageal reflux disease; protussive treatment; causes of chronic cough in immunocompromised hosts; and characteristics and management of psychogenic cough. The effects of the use or nonuse of evidence-based guidelines should be documented. An empiric, integrative approach to management of chronic cough also needs further validation.

MDI inhalers: do nursing home support staff have correct technique?

Many elderly patients in nursing homes in the United States use metered-dose inhaler (MDI) medications for a variety of lung diseases. We wondered how much the nursing support staff knew about correct MDI inhaler technique. Thirty-eight nursing home support staff were asked to demonstrate correct use of a placebo MDI inhaler on themselves. The staff completed an average of 6.9 steps out of 8 correctly. The most common error demonstrated was the staff did not hold their breath for 10 seconds at full inspiration after inhaling the medication. The results suggest that the support staff have incorrect MDI inhaler technique.

The paradox of adult asthma control: "who's in control anyway?"

Surveys of Canadian patients with asthma and their physicians consistently report satisfaction with asthma management; however, when objective indicators are used, these same surveys also observe very poor levels of asthma control. The reasons for this apparent discrepancy, with an emphasis on the factors influencing adherence to therapy, are explored in the present review. Clues to the identification of patients at risk of dying from asthma and an approach to difficult asthma are discussed.

Education interventions for adults who attend the emergency room for acute asthma

BACKGROUND

The use of educational and behavioural interventions in the management of chronic asthma have a strong evidence base. There may be a role for educative interventions following presentation in an emergency setting in adults.

OBJECTIVES

To assess the effectiveness of educational interventions administered following an acute exacerbation of asthma leading to presentation in the emergency department.

SEARCH STRATEGY

We searched the Cochrane Airways Group trials register. Study authors were contacted for additional information. Searches are current to November 2006.

SELECTION CRITERIA

Randomised, parallel group trials were eligible if they recruited adults (> 17 years) who had presented at an emergency department with an acute asthma exacerbation. The intervention of interest was any educational intervention (for example, written asthma management plan).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

Twelve studies involving 1954 adults were included. Education significantly reduced subsequent admission to hospital (relative risk 0.50; 95% confidence interval 0.27 to 0.91); however, did not significantly reduce the risk of re-presentation at emergency departments (ED) the study follow up (relative risk 0.69; 95% confidence interval 0.40 to 1.21). The lack of statistically significant differences between asthma education and control groups in terms of peak flow, quality of life, study withdrawal and days lost were hard to interpret given the low number of studies contributing to these outcomes. One study from the early 1990s measured cost and found no difference for total costs and costs related to physician visits and admissions to hospital. If data were restricted to emergency department treatment, education led to lower costs than control.

AUTHORS' CONCLUSIONS

This review found that educational interventions applied in the emergency department reduce subsequent asthma admissions to hospital. The interventions did not significantly reduce ED re-presentations; while the trend in effect favours educational interventions, the pooled results were not statistically significant. The impact of educational intervention in this context on longer term outcomes relating to asthma morbidity is unclear. Priorities for additional research in this area include assessment of health-related quality of life, lung function assessment, exploration of the relationship between socio-economic status and asthma morbidity, and better description of the intervention assessed.

Severe asthma in adults: what are the important questions?

The term severe refractory asthma (SRA) in adults applies to patients who remain difficult to control despite extensive re-evaluation of diagnosis and management following an observational period of at least 6 months by a specialist. Factors that influence asthma control should be recognized and adequately addressed prior to confirming the diagnosis of SRA. This report presents statements according to the literature defining SRA in order address the important questions. Phenotyping SRA will improve our understanding of mechanisms, natural history, and prognosis. Female gender, obesity, and smoking are associated with SRA. Atopy is less frequent in SRA, but occupational sensitizers are common inducers of new-onset SRA. Viruses contribute to severe exacerbations and can persist in the airways for long periods. Inflammatory cells are in the airways of the majority of patients with SRA and persist despite steroid therapy. The T(H)2 immune process alone is inadequate to explain SRA. Reduced responsiveness to corticosteroids is common, and epithelial cell and smooth muscle abnormalities are found, contributing to airway narrowing. Large and small airway wall thickening is observed, but parenchymal abnormalities may influence airway limitation. Inhaled corticosteroids and bronchodilators are the mainstay of treatment, but patients with SRA remain uncontrolled, indicating a need for new therapies.

Can access to spirometry in asthma education centres influence the referral rate by primary physicians for education?

BACKGROUND AND OBJECTIVES

Asthma remains uncontrolled in a large number of asthmatic patients. Recent surveys have shown that a minority of asthmatic patients are referred to asthma educators. The objective of the present study was to assess the influence of increased access to spirometry in asthma education centres (AECs) on the rate of patient referrals to these centres by general practitioners.

METHODS

A one-year, prospective, randomized, multicentric, parallel group study was conducted over two consecutive periods of six months each, with added spirometry being offered in the second six-month period to the experimental group. Ten AECs were enrolled in the project. An advertisement describing the AECs' services was sent by mail to a total of 303 general practitioners at the start of each period, inviting them to refer their patients. Measures of the frequency of medical referrals to the AECs were assessed for each period.

RESULTS

The group of AECs randomly selected for spirometry in the second six-month period received 48 medical referrals during the first period and 32 during the second one, following proposed spirometry. AECs that had not offered spirometry received five referrals during the first period and seven during the second period. One AEC withdrew a few weeks after the study began and others encountered administrative problems, reducing their ability to provide interventions.

CONCLUSIONS

Referral to AECs is not yet integrated into the primary care of asthma and offering more rapid access to spirometry in the AECs does not seem to be a significant incentive for such referrals.

Impact of a continuing education activity on the quality of telephone interventions by nurses in an adult asthma client base

The objectives of this study were to evaluate the effect of a continuing education activity on the clinical evaluation and advice provided by nurses working for a telephone triage service with an asthmatic client base, and to measure the number of referrals to Asthma Education Centers (AECs). The results suggest a positive impact on the quality of the telephone intervention in the short term, but this was not sustained over time. Few patients were referred to an AEC.

Asthma self-management education

Asthma self-management education is a fundamental component of asthma management guidelines. Self-management education should include the provision of information, self-monitoring, regular medical review and the provision of a written asthma management plan. Implementing this form of management can be challenging, this paper reviews the evidence supporting self-management education, provides recommendations and tools for delivering asthma education and discusses the challenges and solutions to implementing these recommendations. We have discussed ways to improve communication, develop patient partnerships and tailor management to facilitate behavioural change, adherence and self-management. Health Professionals providing education and guiding self-management require training to acquire and maintain the skills necessary to deliver this form of education. Provision of this training is important and can be achieved through varied methods of achieving competence.