Adults with Asthma

Asthma Education Program

Article Citation:
Cote J, Cartier A, Robichaud P, Boulin H, Malo JL, Rouleau M, Boulet LP. Influence of asthma education on asthma severity, quality of life and environmental control. Canadian Respiratory Journal 2000;7(5):395-400.

Intervention Setting:
Three tertiary-care hospitals in Quebec, Canada

Target Population:
Adults with moderate to severe asthma

Program Description:
The study objective was to assess the influence of education on airway responsiveness, asthma symptoms, patient quality of life, and environmental control. All subjects’ medications were reviewed and adjusted as necessary. Personal best peak expiratory flow rate (PEF) was determined. All subjects received instruction from their respirologists regarding medicine dosage and the influence of allergenic and non-allergenic triggers. All subjects were given a book titled Understand and Control Your Asthma. All subjects received basic education, but patients in the intervention group were also given individual counseling, ongoing education, and an action plan. Intervention patients sensitized to house dust mites (HDMs) were asked to wash bedding, buy special bedding covers, and to remove carpets in their bedroom. Those with pets were encouraged to find alternative homes for them.

Evaluation Design:
The design was an individual randomized control study with parallel groups. Subjects were randomized into three groups: a control group receiving no formal asthma education, a symptom group receiving asthma education based on asthma symptom severity, or PEF group receiving asthma education based on peak expiratory flows. Evaluation included a baseline and 12-month follow-up assessment. All patients measured PEF in the morning and evening for two weeks and scored their asthma symptoms daily using a scale of 0–3. On the second visit, spirometry was performed, and PEF values were checked by a doctor and repeated at two weeks.

Sample Size:
A total of 90 patients were in the intervention group, which was divided into 45 patients in the symptom self-management subgroup and 50 patients in the PEF self-management subgroup. There were 54 patients in the control group. Eligibility criteria included the presence of moderate asthma requiring daily treatment with inhaled corticosteroids.

Outcome Measures and Results:
Outcome measures included symptom severity and frequency, airway responsiveness, and environmental control. The days per month without daily asthma symptoms increased substantially from the start of the intervention to the 12-month visit only in the intervention group. Asthma symptom score decreased substantially and quality of life scores improved substantially only in the intervention group over the same period. After one year, 26 of 37 patients (70%) in the intervention group sensitized to HDMs adopted the specific measure recommended to reduce their exposure to mites. None of the 21 mite-sensitized patients in the control group acted on these recommended measures.

Availability of Protocol/Materials:
The protocol and materials are not available for widespread distribution.

Case Study:
None

Asthma Self-management Program

Article citation:
Bailey WC, Richards JM, Manzella BA, Windsor RA, Brooks CM, Soong SJ. Promoting self-management in adults with asthma: an overview of the UAB program. Health Educ Q Fall 1987;14(3): 345-355.

Bailey WC, Richards JM, Brooks M, Soong SJ, Windsor RA, Manzella BA. A randomized trial to improve self-management practices of adults with asthma. Arch Intern Med Aug 1990;150:1664-1668.

Intervention Setting:
University medical center

Target Population:
Adult asthmatic patients receiving care from eleven UAB pulmonary physicians

Asthma severity ratings ranged from mild to severe. Participants with another pulmonary disease or severely debilitating disease were excluded.

Program Description:
An adult asthma self-management program grounded in theories of social learning and health belief and the PRECEDE-PROCEED model.

The program’s goal is to increase cognitive skills, create positive attitudes, enhance adherence, provide experiences that allow participants to demonstrate success in asthma self-management, and help adults who have asthma develop effective social support systems. The program has three components: a) skill-oriented self-help workbook; b) one-on-one counseling session with a health educator in which participants received and reviewed the workbook and a peak flow meter; c) participation in an asthma support group facilitated by a health educator.

Evaluation Design:
An individual randomized control study with a 1-year repeated measure design.

The measures included baseline and 12-month follow-up assessments. The control group received the usual routine care offered at UAB, which included limited educational information about asthma in the form of pamphlets. Logistic regression was used to detect changes that may be attributable to the intervention.

Sample Size:
225 completed the intervention and the 1-year follow-up visit.

In this study, 101 were part of the control group and received usual care, and 124 were in the experimental group and received the described intervention.

Outcome Measures/Results:
Data were collected on nine outcome measures: inhaler use skills; adherence to medications and inhaler use; overall rating of adherence by researcher; severity of asthma symptoms over the past seven days; extent to which patients were “bothered” by asthma; number of episodes of respiratory problems, missed days from work, school, or other activities; and health care utilization. Participants improved substantially on the indicators of adherence and less so on the functional status measures. At follow-up, self management patients had better adherence than usual-care patients and improved functional status. Hospitalizations and emergency visits decreased in both groups.

Availability of Protocol/Materials:
The protocol and materials are not available for widespread distribution.

Case Study:
None

Comprehensive Educational Program

Article Citation:
George MR, O’Dowd LC, Martin I, Lindell KO. A comprehensive educational program improves clinical outcomes in inner-city patients with asthma. Arch of Intern Med Aug 1999;159(15):1710.

Intervention Setting:
Hospital

Target Population:
Adult asthma patients between the ages of 18-45 admitted to the hospital with a primary diagnosis of asthma

Patients were excluded if they had a significant co-morbid illness, were pregnant, did not speak English, and/or did not have a telephone in their home.

Program Description:
An adult in-patient asthma education program designed to increase the likelihood inner-city patients would return for follow-up care.

In addition to the education program, patients received bedside spirometry, a telephone call 24-hours after discharge and scheduled follow-up in an outpatient asthma program within one week of discharge. The inpatient education program instructed patients on metered-dose inhaler technique, how to recognize and respond to symptoms, and techniques to promote adherence to medication. The program also worked with patients to identify and eliminate barriers to adequate care such as lack of transportation and coverage for prescriptions. The education program was conducted by an asthma nurse educator.

Evaluation Design:
Patients were randomly assigned to either the intervention or control groups. Patients in the control group received routine care Data were collected primarily by review of medical records. T-tests, Pearson chi square test , Mann-Whitney and Wilcoxon signed rank test were used to analyze the data.

Sample Size:
77 patients; 44 in the intervention group and 33 in the control group

Outcome Measures/Results:
Data were collected for the following outcome measures: hospital length of stay, readmission rates, attendance at subsequent outpatient appointments, frequency of emergency room visits and the number of hospitalizations six months prior to and following enrollment in the study. There was no significant difference in length of stay between the intervention and control groups; however, patients enrolled in the intervention had higher follow-up rates with outpatient appointments (60% vs. 27%). The intervention group also experienced reductions in the number of hospitalizations and emergency room visits.

Availability of Protocol/Materials:
The protocol and materials are not available for widespread distribution.

Case Study:
None

Nurse-Directed Inpatient Asthma Intervention Program

Article Citation(s):
Castro M, Zimmermann NA, Crocker S, Bradley J, Leven C, Schechtman KB. Asthma intervention program prevents readmissions in high healthcare utilizers. American Journal of Respiratory Critical Care Medicine 2003;168:1095-9.

Intervention Setting:
Hospital

Target Population:
This study included adults who:

• were aged 18-65 years,
• were hospitalized with an asthma exacerbation at Barnes-Jewish Hospital in St. Louis, Missouri, during September 1996–July 1999,
• had a history of frequent health-care utilization, and
• had a forced expiratory volume in 1 second (FEV1) to forced vital capacity (FVC) ratio less than 80%.

Program Description:
The study objective was to decrease rate of hospital readmission within 6 months of hospital discharge, reduce costs, and improve health-related quality of life. The study investigated the use of an asthma nurse specialist to provide a multifaceted approach to asthma care for high-risk inpatients who met the study criteria. The intervention consisted of the following:

1. review of the individual treatment plans with the intervention group and suggestions to the primary physician regarding potential changes to the treatment plan to make it consistent with the National Asthma Education Prevention Program Guidelines;
2. while the patient was hospitalized, provision of a daily "Asthma Care" flow sheet for direct communication from the nurse specialist to the physician on the status of the patient;
3. provision of asthma education appropriate to the patient’s education, motivation, and cultural beliefs;
4. provision of psychosocial support and screening patients for professional counseling;
5. development of an individualized written asthma self-management plan
6. consultation with social service professionals to facilitate discharge planning; and
7. provision of outpatient follow-up through telephone contacts.

The usual-care group received the normal care provided by their private primary-care physicians along with asthma education including medication dosing, action, and side effects; inhaler technique; and peak flow monitoring. The usual-care group received written discharge instructions from the hospital nurse describing discharge medications and physician follow-up information but did not receive an asthma management plan.

Evaluation Design:
A randomized controlled study approach was used.

Sample Size:
The study comprised 96 people with diagnosed asthma.

Outcome Measures/Results:
Outcome measures included readmission because of asthma within 1 year, total hospital readmissions, emergency visits, quality of life, direct and indirect health-care costs, lost school or work days, cumulative number of days of hospitalization, and number of refills of asthma medications within 360 days. The study demonstrated a 60% reduction in total hospitalizations – 31 readmissions in the intervention group and 71 in the control group – but no significant change in emergency department visits. Readmissions for asthma decreased by 54%: 21 in the intervention group compared with 42 in the control group. Lost work days or school days decreased markedly; 246 days in the intervention group, compared with 1,040 days in the control group. The intervention resulted in a substantial reduction in direct and indirect health-care costs. The average total health-care costs per patient in the control group was $12,188 ± $9,352 compared with $5,726 ± $5,679 in the intervention group, resulting in an average savings of $6,462 per patient attributable to the intervention. Quality of life measures improved significantly in both the control and intervention groups, with no significant difference in the improvement between the two groups.