Mixed Age Groups
Asthma Self-management Training Program (India)
Ghosh CS, Ravindran P, Joshi M, Stearns SC. Reductions in hospital use from self management training for chronic asthmatics. Social Science & Medicine 1998;46(8): 1087-1093.
The intervention setting was located at the asthma and allergy clinic in the Department of Respiratory Medicine at the Medical College in Trivandrum, India.
The target population was clinic patients, aged 10 to 45 years, who had chronic asthma. Patients visited the emergency room or hospital at least once in the past year because of their asthma, and they were on drug therapy at least 15 days each month. Patients who had chronic respiratory infections, bronchitis, emphysema, multi-system disorders, and a history of chronic smoking were excluded.
The objective of this study was to assess the effect of asthma self-management training (SMT) on the health status and medical care of patients who had chronic asthma. The purpose of SMT is to maintain function, to slow deterioration, and to minimize impact of the disease and its treatment on the health status of the patients. A social scientist conducted intervention sessions during the first month following the baseline interview. The patients were given precise, written instructions about drug administration. Patients were trained to adjust medications promptly and safely on the basis of their severity and peak expiratory flow rate (PEFR). Role models were used to help the patients develop skills for minimizing antigen exposure. Using focus group discussions and scenario descriptions, patients were trained to identify early symptoms and to take remedial actions to control acute attacks.
The study utilized an individually randomized control design. The two groups were similar at baseline in terms of sex, age, health status, and health care utilization in the month prior to the study. Both groups received usual clinical care for asthma management (including bronchodilator and anti-inflammatory drugs). The intervention group received SMT along with usual care. Patients were monitored for 12 months. Health status data were recorded daily for four one-month periods. The PEFR was used to assess disease severity. The overall mean PEFR for each patient during the follow-up year was used to measure health status. Health service data were used to acquire information on emergency visits and hospitalizations.
The study initially included 153 patients enrolled in the intervention group and 150 in the control group. A total of 276 patients, 140 in the intervention group and 136 in the control group, completed the three follow-up periods.
Outcome Measures and Results:
Outcome measures included daily asthma severity (as measured by PEFR), number and duration of hospitalizations, number of emergency visits, and cost. The intervention group’s mean PEFR improved by 14.5% over the 12-month follow-up. The intervention group had 48.5% fewer productive days lost and had 53.2% fewer days hospitalized compared with the control group. The likelihood that an intervention group participant would be hospitalized was reduced 26%. For patients hospitalized, the average number of days hospitalized during the year was 38 days for the control group and 22 days for the intervention group. The intervention group had a 46.7% reduction in emergency visits overall. The average total medical cost for the intervention group was 22% less than for the control group.
Availability of Protocol and Materials:
The protocol and materials are not available for widespread distribution.
Community Asthma Care Education Centre (AEC) Program
Hopman WM, Owen JG, Gagne E. Assessment of the effect of asthma education on outcomes. Managed Care Interface May 1999;89-93.
Oakville Trafalgar Memorial Hospital in Ontario, Canada
The Oakville program is one of Canada’s Community Asthma Care Centers (CACC) whose objectives include decreasing hospital and ED utilization, assisting patients in achieving the best possible control of their asthma symptoms, eliminating duplication of services, supporting treatment prescribed by referring physicians, and improving consistency of asthma management in the community.
Asthma patients of all ages referred by the emergency department (ED), pediatricians, and family physicians were targeted for the study.
The study objective was to assess the effectiveness of a comprehensive assessment, treatment, and education program for referred patients with asthma. The program varied according to each patient’s needs. At an initial visit, standardized information was collected, and education and information were provided on the basis of patient responses on topics including medications, trigger avoidance, environmental control, self-monitoring skills, delivery systems and techniques, and basic spirometry. After 2 weeks, patients returned to the Asthma Education Centre for reassessment visits to build on the assessment and educational topics and to determine additional needs. Assessment visits continued until the patient’s asthma was under control. A personal action plan was developed, and the physician was contacted to provide information on patient’s condition, use of delivery devices, medications, and dosage. The physician also reviewed the action plan for approval. Patients were then seen at 3- and 6-month intervals.
The study utilized a pre-post-intervention design. Initial data on patient history, symptoms, triggers, medications, environment, and actions taken during an asthma episode were collected via a validated questionnaire used by all CACCs. A one-year follow-up visit was used to collect post-intervention data; a 24-month follow-up also was carried out for a subset of 113 patients.
In both the initial and a one-year follow-up visit, 121 patients were seen. The patient population assessed by age cohorts: 43 patients were aged 0–5 years, (2) 47 were aged 6–16 years, and (3) 31 were aged greater than 16 years.
Outcome measures included the number of nights awakened because of asthma-related symptoms, school or workdays missed in the past four weeks, and the number of ED visits and hospital admissions in the past 6 months (measured at baseline and at 12 and 24 months). Results include a decrease in night awakenings in the previous four weeks in all three age cohorts, a decrease in emergency visits in the previous 6 months in all age cohorts, a decrease in hospitalizations in the previous 6 months in all cohorts, and a decrease in days missed from school or work in the two older age cohorts. Days of work or school missed were not applicable to the youngest age cohort. All of these differences were statistically significant. Specific outcome measures comparing baseline (pre-) and 24-month follow-up (post-) are shown here:
|Variable||Age 0-5||Age 6-16||Age >16|
|Percent with no night awakenings last 4 weeks||5%||66%||16%||71%||19%||68%|
|Mean number of emergency room visits last 6 months||2.04||0.07||2.25||0.16||1.83||0.22|
|Average number hospital admissions last 6 months||0.48||0.04||0.23||0.04||0.38||0.03|
|Average number of days of work/school missed, last 4 weeks||n/a||n/a||2.58||0.16||2.36||0.26|
Availability of Protocol/Materials:
The protocol and materials are not available for widespread distribution.
East London Controlled Trial for High Risk Asthma
Griffiths C, Foster G, Barnes N, Eldridge S, Tate H, Begum S, et al. Specialist nurse intervention to reduce unscheduled asthma care in a deprived multiethnic area: the east London randomised controlled trial for high risk asthma (ELECTRA). Br Med J 2004;328(7432):144–7.
44 general practices in two boroughs of east London, United Kingdom
People with acute asthma, aged 4–60 years, who sought emergency or after-hours treatment.
Patients were eligible for inclusion in the study if they had asthma diagnosed by a doctor, and had been admitted to or attended the emergency department at the Royal London Hospital or a general practitioner out-of-hours (after hours) service for acute asthma. Intervention included patient review in a nurse-led clinic and liaison with general practitioners and practice nurses comprising educational outreach, promotion of guidelines for high-risk asthma, and ongoing clinical support. Specifically, general practices randomized to the intervention group received two 1-hour visits by the specialist nurses at the start of the study to discuss guidelines for managing patients with acute asthma. Specialist nurses at the nurse-run clinic reviewed participants registered with the intervention practices for asthma control and drugs immediately after recruitment. They discussed a self-management plan. Patients with sufficient understanding received a peak flow meter and a written plan containing standard thresholds for peak flow and symptoms. Practices randomized to the control group received a single visit from the nurses to discuss standard guidelines for asthma. Control practice participants were checked for inhaler technique in the nurse-run clinic immediately after recruitment. Drugs were unaltered and participants continued with usual care.
This was a randomized controlled trial. Randomization took place at the general practice level to either intervention or control groups
324 individuals: 164 [51%] South Asian patients, 108 [33%] white patients, and 52 [16%] from other ethnicities, largely African and Afro-Caribbean. Only 45% of participants spoke English; 89% lived in rented housing and 55% were unemployed. Of the total, 63% were recruited prospectively after attendance with acute asthma.
Percentage of participants receiving unscheduled care for acute asthma over 1 year and time to first unscheduled attendance
The specialist nurse intervention delayed time to first attendance with acute asthma (median of 194 days for the intervention group, 126 days median for the control group). The intervention also reduced the percentage of participants attending with acute asthma (58% for the intervention group, 68% for the control group). The overall rates of yearly attendance for unscheduled care for each participant were 1.98 for the intervention group and 2.36 for the control group.
The Canadian Multi-site Asthma Education Program
Hopman WM, Garvey N, Olajos-Clow J, White-Markham A, Lougheed MD. Outcomes of asthma education: results of a multi-site evaluation. Can Respir J 2004;11(4):291–7.
Seven sites across Canada, including community asthma care centers (CACCs) in Nova Scotia, Newfoundland, and British Columbia, two from Ontario, plus a community hospital and an academic health sciences center in Ontario.
This study involved teens and adults, 16 years of age and older, with diagnosed asthma who were attending a participating asthma center or clinic. All participants were referred by family physicians, specialists, or emergency departments on the basis of poor asthma control or an exacerbation of asthma.
This study sought to determine the effectiveness of a standardized asthma education program, administered in a variety of settings, in improving a number of outcomes, and the factors associated with a change in outcome. The study hypothesis was that a standardized asthma education program would improve outcomes regardless of geographical site or physical setting.
Referred patients attended an initial visit and a 6-month follow-up visit to the education program. At the initial visit, spirometry was conducted and a detailed patient profile was concluded using a standardized questionnaire and software developed for this purpose. The questionnaire formed the basis of the needs assessment and contained items relating to patient history, contacts with the health care system, symptoms, triggers, medications, environment, action plans, and action taken during an asthma episode. Health-related quality of life was measured at baseline and again at a 6-month followup using the self-administered Medical Outcomes Study. (The Medical Outcomes Study 36-item Short Form 1.0 [SF-36] has been demonstrated to be reliable and valid for asthma. The SF-36 provides scores ranging from 0 [poor] to 100 [excellent] on eight domains; higher scores represent better function and lower pain levels).
The program was based on a model of education implemented in a large community hospital that had previously demonstrated statistically significant improvements in health outcomes. Trained asthma educators with a background in nursing or respiratory therapy provided the education. The program was standardized across the seven sites by means of a training workshop and the use of questionnaires. The education program included three levels of education available to the patient relative to their asthma severity and initial needs assessment. The education is based on the social cognitive theory of learning and behavior change. Curriculum content included trigger avoidance, environmental control, the role of medications, delivery systems, action plans, and self-monitoring skills. The education took about 2 hours to complete. A follow-up visit was scheduled for 2 weeks later to assess control and understanding and the instructional material was reviewed as necessary. A follow-up visit was scheduled for 6 months after the baseline visit, at which time the patients responded to a second standardized questionnaire that referenced the previous 6 months and assessed contact with the health care system, symptoms, triggers, medication, action plan use, and action taken during an episode.
An uncontrolled, prospective, observational, comparative study with a pre-post design
The final sample comprised 252 adults. The patients were predominantly middle-aged (mean average 42.0 years), with a long-standing history of asthma; 75% were female.
Health care use (regular and unscheduled visits to general physicians and specialists, number of emergency room visits and hospitalizations, and length of stay), absenteeism, amount of leisure time missed, and health-related quality of life in a variety of settings.
Statistically significant improvements resulted in all health care use and absenteeism outcomes, except regular specialist visits. The following mean values are based on total number of visits or admissions divided by the sample size. Unscheduled physician visits fell from an average of 2.71 to 0.51. Unscheduled specialist visits fell from 0.14 to 0.06. The mean number of hospital admissions at baseline was 0.48; at followup this number had dropped to 0.13. The mean number of days in the hospital for the 63 patients admitted was 1.72 at baseline compared to 0.92 at follow-up. Mean number of emergency room visits fell over the same time from 0.95 to 0.27. The mean number of missed work or school days also fell, from 5.04 to 3.65. Finally, missed leisure time days fell from 2.14 to 1.81. Six months after asthma education, statistically significant improvements in all health-related quality of life domains had resulted, except for mental health. The change upward in five domains (physical function, role physical, role emotional, bodily pain, and vitality) exceeded 5 points. The developers considered that to be a clinically and socially meaningful change. The change in social function and general health fell just short of 5 points.