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

Comparative Efficacy of Strategies to Support Self-Management in Patients with Asthma: A Systematic Review and Network Meta-Analysis

BACKGROUND

There is limited evidence about which composite feature of asthma self-management strategies is the best and should be adopted into practice.

OBJECTIVE

To compare the efficacy of different strategies to support self-management, based on the newly developed framework, in patients with asthma.

METHODS

We searched PubMed, EMBASE, CENTRAL, CINAHL, and PsycInfo from 1993 to December 2019. We identified randomized controlled trials that explored effects of strategies to support self-management in adult patients with asthma. We conducted network meta-analyses using a random effects model with usual care as the common comparator. Surface under the cumulative ranking curve methods were used to rank different support strategies.

RESULTS

Thirty-five trials (5195 patients) were included and classified on the basis of our newly created TIP framework: Theme, Intensity, and Provider/Platform. We identified 6 features from the included trials, each represented by 1 element of the TIP framework: (1) behavioral support more than once a month by e-Health; (2) behavioral support more than once a month by health care personnel (HCP); (3) behavioral support less often than or equal to once a month by HCP; (4) education support less often than or equal to once a month by e-Health; (5) education support less often than or equal to once a month by HCP; and (6) psychosocial support less often than or equal to once a month by HCP. Behavioral support more than once a month by e-Health showed significant improvement in asthma control when compared with the other 2 support strategies, which was confirmed by the highest surface under the cumulative ranking of 97.6%. However, the surface under the cumulative ranking for behavioral support less often than or equal to once a month by HCP suggested that it has the potential to be the best intervention to reduce the risk of hospitalization (89.1%) and emergency department visit (84.2%).

CONCLUSIONS

Different features of asthma self-management support strategies work best on unique outcomes.

Patient education for children with interstitial lung diseases and their caregivers: A pilot study

OBJECTIVE

Patient education in children with rare chronic diseases like children's interstitial lung disease (chILD) remains a challenge.

AIMS

To develop and evaluate a component-based educational program for individual counselling and to improve patients' and caregivers' self-efficacy and treatment satisfaction. Furthermore, to create chILD-specific educational material and assess physicians' satisfaction with the intervention as well as patients' health-related quality of life (HrQoL).

METHODS

The study was conducted in two German centers for pediatric pulmonology, as a single-group intervention with pre-post-follow-up design.

RESULTS

Participants (N = 107, age: M = 7.67, SD = 5.90) showed significant improvement of self-efficacy (self-report: t = 2.89, p < 0.01; proxy-report: t = 3.03, p < 0.01), and satisfaction (patients: t = 3.56, p = 0.001; parents t = 6.38, p < 0.001) with the medical consultations. There were no pre-post differences in HrQoL. Participants were highly satisfied with the material and the physicians with the program.

CONCLUSIONS

The chILD education-program is a promising strategy to improve patients' and their parents' self-efficacy and treatment-satisfaction. Specific effects of the intervention need to be determined in a randomized controlled trial.

PRACTICE IMPLICATION

Healthcare providers managing pediatric patients with chILD, may choose to use a patient education-program specifically tailored to the needs of chILD patients and their families, such as the program described here, which is the first of its kind.

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.

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.

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.

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.

Impact of patient characteristics, education and knowledge on emergency room visits in patients with asthma and COPD: a descriptive and correlative study

Background

Asthma and COPD are major health problems and an extensive burden for the patient and the health care system. Patient education has been recommended, but the influence on knowledge and health outcomes is not fully examined. Our aims were to compare patient characteristics, education and knowledge in patients who had an emergency room (ER) visit, to explore factors related to disease knowledge, and to investigate patient characteristics, patient education and knowledge in relation to further ER visits over a 12 month period.

Methods

Eighty-four patients with asthma and 52 with COPD, who had had an ER visit, were included. They were interviewed by telephone 4 to 6 weeks after the ER visit and followed for a year.

Results

Patients with COPD were older, more sedentary, had had more ER visits the previous year, and had more co morbidity than patients with asthma. About 80% of the patients had received information from health professionals or participated in education/rehabilitation, but a minority (< 20%) reported that their knowledge about how to handle the disease was good. Patients with "good knowledge" were younger, were more likely to have asthma diagnose, and had a higher educational background (p < 0.05). Sixty-seven percent of the patients with COPD had repeated ER visits during the following year versus 42% in asthma (p < 0.05) (adjusted HRR: 1.73 (1.03-2.90)). Patients who had had ER visits the year before inclusion had a higher risk of ER visits the following year (adjusted HRR: 3.83 (1.99-7.38)). There were no significant differences regarding patient education and knowledge between the group with and without further ER visits after adjusting for sex, diagnose, age, and educational background.

Conclusion

Patients with asthma had a better self reported knowledge of disease management and were less likely to have new exacerbations than patients with COPD. Reported level of knowledge was, however, in it self not a predictor of exacerbations. This indicates that information is not sufficient to reduce the burden of disease. Patient education focused on self-management and behavioral change should be emphasized.

Individualized programme to promote self-care among older adults with asthma: randomized controlled trial

AIM

This paper is a report of a trial to examine the effectiveness of individualized self-care education programmes in older adults with moderate-to-severe asthma.

BACKGROUND

Asthma is a common chronic disease in adults and a major cause of frequent work absences, emergency room visits, and hospitalization. The results of studies of self-care education programmes have been largely supportive and suggest that they have positive outcomes for people with asthma. However, for older people with asthma, the effectiveness of computer-aided, self-learning video programmes has been controversial.

METHODS

Older adult patients with asthma (N = 148) were randomly assigned to one of three groups: usual care, individualized education, or individualized education with peak flow monitoring, and followed for 6 months. Data were collected from January to December 2006. The variables studied included demographic data, asthma self-care competence, asthma self-efficacy, and asthma self-care behaviour. FINDINGS. Patients in both individualized education groups reported higher asthma self-care competence scores (F = 334.06 and 481.37, P < 0.001) and asthma self-care and self-efficacy scores (F = 104.08 and 68.42, P < 0.001) than patients in the usual care group. In addition, patients who received individualized education with peak flow monitoring had statistically significantly higher asthma self-care behaviour and self-efficacy scores (P < 0.001) and asthma control indicators (P = 0.025) than the education alone group. No differences were found among the three groups in unscheduled health service usage.

CONCLUSION

Our results suggest that individualized education helps older people with asthma to enhance their self-care behaviours, manage their disease, and increase their quality of life.

Assessing sleep quality and daytime wakefulness in asthma using wrist actigraphy

This study evaluated the sleep/wake cycle of individuals with asthma in relation to asthma control, daytime sleepiness, and daytime activity. Ten persons with mild to moderate persistent asthma monitored their sleep quality and daytime wakefulness for 7 consecutive days using 24-hours wrist actigraphy. Degree of asthma control strongly correlated with sleep quality. Individuals whose asthma was not well controlled took longer to fall asleep, awoke more often, and spent more time awake during the night compared to those with well controlled asthma. Poor asthma control, use of rescue medications, and asthma symptoms were associated with daytime sleepiness and limitations in physical activity and emotional function. Forty percent of subjects reported clinically significant daytime sleepiness. Evaluating asthma throughout a 24-hour cycle provides valuable information on variations in the sleep/wake cycle associated with asthma control, use of rescue medications, and asthma symptoms.

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.

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

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

Self-management education for patients with chronic obstructive pulmonary disease

BACKGROUND

There is great interest in chronic obstructive pulmonary disease (COPD) and the associated large burden of disease. COPD is characterised by frequent day by day fluctuations, and repetitive clinical exacerbations are typical. Self-management is a term applied to educational programmes aimed at teaching skills needed to carry out medical regimens specific to the disease, guide health behaviour change, and provide emotional support for patients to control their disease and live functional lives. In COPD, the value of self-management education is not yet clear. The first Cochrane review about self-management was published in 2003. It was intended to shed light on the effectiveness of self-management programmes in COPD and the relative efficacy of their constitutive elements. No conclusions about the effectiveness of self-management could be drawn because of the large variation in outcome measures used in the limited number of included studies. This article describes the first update of this review.

OBJECTIVES

The objective of this review was to assess the settings, methods and efficacy of COPD self-management education programmes on health outcomes and use of health care services.

SEARCH STRATEGY

We searched the Cochrane Airways Group trial register, MEDLINE (January 1985 to January 2006), reference lists, and abstracts of medical conferences.

SELECTION CRITERIA

Controlled trials (randomised and non-randomised) of self-management education in patients with COPD. Studies focusing mainly on pulmonary rehabilitation and studies without usual care as a control group were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed study quality and extracted data. Investigators were contacted for additional information.

MAIN RESULTS

The reviewers included 15 group comparisons drawn from 14 trials. They assessed a broad-spectrum of interventions and health outcomes with different follow-up times. Meta-analyses could often not appropriately be performed because of heterogeneity among studies. The studies showed a significant reduction in the probability of at least one hospital admission among patients receiving self-management education compared to those receiving usual care (OR 0.64; 95% CI (0.47 to 0.89)). This translates into a one year NNT ranging from 10 (6 to 35) for patients with a 51% risk of exacerbation, to an NNT of 24 (16 to 80) for patients with a 13% risk of exacerbation. On the disease specific SGRQ, differences reached statistical significance at the 5% level on the total score (WMD -2.58; 95% CI (-5.14 to -0.02)) and impact domain (WMD -2.83; 95% CI (-5.65 to -0.02)), but these difference did not reach the clinically relevant improvement of 4 points. A small but significant reduction was detected in dyspnoea measured with the BORG-scale (WMD -0.53; 95% CI (-0.96 to -0.10)). No significant effects were found either in number of exacerbations, emergency department visits, lung function, exercise capacity, and days lost from work. Inconclusive results were observed in doctor and nurse visits, on symptoms other than dyspnoea, the use of courses of oral corticosteroids and antibiotics, and the use of rescue medication.

AUTHORS' CONCLUSIONS

It is likely that self-management education is associated with a reduction in hospital admissions with no indications for detrimental effects in other outcome parameters. This would in itself already be enough reason for recommending self-management education in COPD. However, because of heterogeneity in interventions, study populations, follow-up time, and outcome measures, data are still insufficient to formulate clear recommendations regarding the form and contents of self-management education programmes in COPD. There is an evident need for more large RCTs with a long-term follow-up, before more conclusions can be drawn.

[Self-management program in treatment of asthma]

INTRODUCTION

Recently published national and international guidelines stress the importance of self-management in asthma. They have recommended that self-management plans should be an essential part of the long-term management of asthmatic patients. These plans essentially focus on the early recognition of unstable or deteoriorating asthma, by monitoring peak flow or symptoms.

OBJECTIVE

The aim of our one-year study was to compare the efficacy of peak-flow based self-management of asthma with traditional treatment.

METHOD

Sixty clinically stable adult patients with mild and moderate persistent asthma were randomly allocated to peak-flow based self-management (Group A, n=30) or to conventional treatment (Group B, n=30), with no significant difference between groups in terms of age, sex distribution and initial lung function. The recorded measurements were: lung function, asthma exacerbations, unscheduled ambulatory care facilities (hospital-based emergency department, consultations with general practitioner or pulmonologist), courses of oral prednisolone, courses of antibiotics, days off work.

RESULTS

There was a significant difference between groups in number of asthma exacerbations (p < 0.05), unscheduled visits to ambulatory care facilities (p < 0.005), days off work (p < 0.0001), courses of oral prednisolone (p < 0.001) and antibiotics (p < 0.05). At the final visit, there was a significant improvement in some measurements of asthma severity in group A (reduced unscheduled visits for ambulatory care, reduced treatment requirements for oral corticosteroids and antibiotics, reduced days off work), but a lack of statistical difference in lung function and the maintenance-inhaled corticosteroid dose. There was no significant change in group B.

CONCLUSION

These results suggest that peak-flow based self-management is more effective than traditonal treatment in mild and moderate persistent asthma.

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.

Interventions to enhance medication adherence

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Self-management interventions for chronic illness

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

Management of stable COPD

Chronic obstructive pulmonary disease (COPD) is a systemic disease with major impact worldwide. In the treatment of COPD a holistic approach should be taken. In order to reach this, an individual treatment plan should be made which includes at least elements of smoking cessation, optimisation of pulmonary status by pharmacotherapy and exercise embedded in a new lifestyle. Furthermore, more research on nutritional and metabolic intervention strategies for COPD patients is needed. With the availability of all these treatment options, a nihilistic attitude toward the patient with COPD is no longer justified.

Written individualised management plans for asthma in children and adults

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed study quality and abstracted data.

MAIN RESULTS

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

REVIEWERS' CONCLUSIONS

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

Self-management education for patients with chronic obstructive pulmonary disease: a systematic review

BACKGROUND

The idea of self-management is to teach patients how to carry out the activities of daily living optimally in the face of their physiological impairment, and to prevent or decrease the severity of exacerbations by means of life style adaptation. In chronic obstructive pulmonary disease (COPD) the value of self-management education is not clear. This review was undertaken to clarify the effectiveness of self-management programmes in COPD.

METHODS

A search was made of the Cochrane Airways Group trial registers, Medline, reference lists, and abstracts of medical conferences for controlled trials of self-management education in patients with COPD. Two reviewers independently assessed each paper for methodological quality and extracted the data.

RESULTS

The reviewers included 12 articles describing eight randomised controlled trials and one controlled clinical trial in which self-management education was compared with usual care. The studies assessed a broad spectrum of outcome measures with different follow up times so meta-analysis could not be undertaken. Self-management education had no effect on hospital admissions, emergency room visits, days lost from work, and lung function. Inconclusive results were observed on health related quality of life, COPD symptoms, and use of healthcare facilities such as doctor and nurse visits. Self-management education reduced the need for rescue medication and led to increased use of courses of oral steroids and antibiotics for respiratory symptoms.

CONCLUSIONS

Insufficient data were obtained to make recommendations because of the wide variation in outcome measures used and other limitations to generalisations in the current published literature. Further research in this area is needed.

Options for self-management education for adults with asthma

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

REVIEWER'S CONCLUSIONS

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

Self-management education for chronic obstructive pulmonary disease

BACKGROUND

In asthma, self-management programmes have been proven to be effective. In COPD, their value is not clear.

OBJECTIVES

To assess the efficacy of COPD self-management/ education programmes on health outcomes and use of health services

SEARCH STRATEGY

We searched the Cochrane Airways Group trial registers, MEDLINE (January 1985 to October 2001), reference lists, and abstracts of medical conferences. We also contacted research groups in the field for ongoing trials and unpublished material.

SELECTION CRITERIA

Controlled trials (randomised and non-randomised) of self-management education in patients with COPD. Studies focusing mainly on physical pulmonary rehabilitation were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Investigators were contacted for additional information.

MAIN RESULTS

The reviewers included 12 articles describing 8 randomised-controlled trials and 1 controlled clinical trial. Self-management education was compared with usual care in 8 studies. The studies in this review assessed a broad-spectrum of outcome measures with different follow-up times. Synthesis of the results using meta-analysis was always not possible. The studies showed no effect of self-management education on hospital admissions, emergency room visits, days lost from work and lung function. Inconclusive results were observed on health-related quality of life (HRQoL): studies using the disease specific SGRQ showed a better quality of life in the patients in the intervention group, but only in the activity component where there was heterogeneity between the results of the two included studies. A potential reason for the absence of convincing effects on HRQoL is the limited use of COPD-specific instruments. Inconclusive results were observed on COPD-symptoms and use of other health care resources such as doctor and nurse visits. Self-management education reduced the need for rescue medication, and led to an increased use of courses of oral steroids and antibiotics for respiratory symptoms.

REVIEWER'S CONCLUSIONS

The data available for this review are insufficient for forming recommendations. Further research on the effectiveness of self-management programmes should be focussed on behavioural change evaluated in well designed randomised controlled trials with standardised outcomes designed for use in COPD patients, and with long follow-up time so that definite conclusions can be made.

Randomized controlled economic evaluation of asthma self-management in primary health care

In this randomized controlled economic evaluation we compared guided asthma self-management with usual asthma care according to guidelines for Dutch family physicians. Nineteen family practices were randomized, and 193 adults with stable asthma (98 self-management, 95 usual care) were included and monitored for 2 years. We hypothesized that introducing self-management would not compromise asthma control and cost would be equal to or lower than in usual care. Patient-specific cost data were collected, preference-based utilities were assessed, and incremental cost per quality-adjusted life year (QALY) and successfully treated week gained was calculated. Self-management patients gained 0.039 QALY (95% confidence interval [CI], 0.003 to 0.075) and experienced 81 (95% CI, 78 to 84) successfully treated weeks in 2 years' time; the corresponding figures for usual care were 0.024 (95% CI, -0.022 to 0.071) and 75 (95% CI, 72 to 78). Total costs were 1,084 euros(95% CI, 938 to 1,228) for self-management and 1,097 euros (95% CI, 933 to 1,260) for usual care. Self-management patients consumed 1,680 (95% CI, 1,538 to 1,822) puffs of budesonide, usual care patients 1,897 (95% CI, 1,679 to 2,115). Mean productivity cost due to limited activity days was 213 euros lower among self-management patients. When all costs were included, self-management was cost-effective on all outcomes. The probability that self-management was cost-effective relative to usual care in terms of QALYs was 52%. We conclude that guided self-management is a safe and efficient alternative approach compared with asthma treatment usually provided in Dutch primary care.

Outpatient monitoring of asthma

Monitoring asthma outcomes is an essential step to the successful implementation of national asthma guidelines. Symptoms, airflow obstruction and exacerbations can be monitored by patients with asthma and by physicians. Patients who practise self-monitoring in conjunction with use of a written action plan and regular medical review have significantly fewer hospitalizations, emergency room visits and lost time from work. Additional monitoring tools are under evaluation, and these include measures of airway responsiveness, airway inflammation, and Internet-based monitoring systems.

Self-management education and regular practitioner review for adults with asthma

BACKGROUND

A key component of many asthma management guidelines is the recommendation for patient education and regular medical review. A number of controlled trials have been conducted to measure the effectiveness of asthma education programmes. These programmes improve patient knowledge, but their impact on health outcomes is less well established. This review was conducted to examine the strength of evidence supporting Step 6 of the Australian Asthma Management Plan: "Educate and Review Regularly"; to test whether health outcomes are influenced by education and self-management programmes.

OBJECTIVES

The objective of this review was to assess the effects of asthma self-management programmes, when coupled with regular health practitioner review, on health outcomes in adults with asthma.

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data were extracted independently by two reviewers. Study authors were contacted for confirmation.

MAIN RESULTS

Twenty-five trials were included. Self-management education was compared with usual care in 22 studies. Self-management education reduced hospitalisations (odds ratio 0.57, 95% confidence interval 0.38 to 0.88); emergency room visits (odds ratio 0.71, 95% confidence interval (0.57 to 0.90); unscheduled visits to the doctor (odds ratio 0.57, 95% confidence interval 0.40 to 0.82); days off work or school (odds ratio 0.55, 95% confidence interval 0.38 to 0. 79); and nocturnal asthma (odds ratio 0.53, 95% confidence interval 0.39 to 0.72). Measures of lung function were little changed. Self-management programmes that involved a written action plan showed a greater reduction in hospitalisation than those that did not (odds ratio 0.35, 95% confidence interval 0.18 to 0.68). People who managed their asthma by self-adjustment of their medications using an individualised written plan had better lung function than those whose medications were adjusted by a doctor.

REVIEWER'S CONCLUSIONS

Training in asthma self-management which involves self-monitoring by either peak expiratory flow or symptoms, coupled with regular medical review and a written action plan appears to improve health outcomes for adults with asthma. Training programmes which enable people to adjust their medication using a written action plan appear to be more effective than other forms of asthma self-management.

Limited (information only) patient education programs for adults with asthma

BACKGROUND

A key component of many asthma management guidelines is the recommendation for patient education and regular medical review. A number of controlled trials have been conducted to measure the effectiveness of asthma education programmes. These programmes improve patient knowledge, but their impact on health outcomes is less well established. At its simplest level, education is limited to the transfer of information about asthma, its causes and its treatment. This review focused on the effects of limited asthma education.

OBJECTIVES

The objective of this review was to assess the effects of limited (i.e. information only) asthma education on health outcomes in adults with asthma.

SEARCH STRATEGY

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

SELECTION CRITERIA

Randomised and controlled trials of individual asthma education involving information transfer only in adults over 16 years of age.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data were extracted independently by two reviewers. Study authors were contacted for missing information.

MAIN RESULTS

Eleven trials were included. They were of variable quality. Limited asthma education did not reduce hospitalisation for asthma (weighted mean difference -0.03 average hospitalisations per person per year, 95% confidence interval -0.09 to 0.03). There was no effect on doctor visits, lung function and medication use. The effects on asthma symptoms were variable. There was no reduction in days lost from normal activity, but perceived asthma symptoms did improve after limited asthma education (odds ratio 0.40, 95% confidence interval 0.18 to 0.86). In one study, limited asthma education was associated with reduced emergency department visits (weighted mean difference -2.76 average visits per person per year, 95% confidence interval -4.34 to 1.18).

REVIEWER'S CONCLUSIONS

Use of limited asthma education as it has been practiced does not appear to improve health outcomes in adults with asthma. However the use of information in the emergency department may be effective, but this needs to be confirmed.