Adults with Asthma

Hospital Medical Clinics/Physicians' Office

Asthma Patient Education Program

Article Citation:
Gallefoss F, Bakke PS, Kjaersgaard P. Quality of life assessment after patient education in a randomized controlled study on asthma and chronic obstructive pulmonary disease. American Journal of Critical Care Medicine 1999;159:812-817.

Gallefoss F, Bakke PS. How does patient education and self-management among asthmatics and patients with chronic obstructive pulmonary disease affect medication? American Journal of Respiratory Critical Care Medicine 1999;160:2000-2005.

Gallefoss F, Bakke PS. Impact of patient education and self-management on morbidity in asthmatics and patients with chronic obstructive pulmonary disease. Respiratory Medicine 2000;94:279-287.

Intervention Setting:
Out patient chest clinic at Central Hospital of Vest-Agder, Kristiansand, Norway

Target Population:
Adults with bronchial asthma or chronic obstructive pulmonary disease (COPD) aged 18-70 years not suffering from other serious diseases (e.g. unstable coronary heart disease, heart failure, serious hypertension, diabetes mellitus, and kidney or liver failure) were included in the study. Subjects with asthma were to have a forced expiratory volume in one second (FEV1) equal to or higher than 80% of predicted value in stable phase along with a positive reversibility test, a documented 20% spontaneous variability, or a positive metacholine test.

Program Description:
The study objective was to assess the effect of education on patients with asthma and COPD on health-related quality of life (HRqol). The intervention group received a booklet with essential information about asthma medication, compliance, self-care, and a self-management plan. Education consisted of four group sessions with five to eight persons on separate days. The first group session, presented by a physician, focused on airway smooth muscle cramp, inflammatory components of obstruction, and prevention of attacks and exacerbation factors; the danger of smoking was also emphasized. The second group session, presented by a pharmacist, focused on asthma drugs and their use. The third group session, presented by a nurse, focused on recording peak expiratory flow (PEF) and symptoms in a diary and the stepwise treatment plan. The fourth group session, presented by a physiotherapist, was on breathing, exercise, rest positions, and respiration. Patients then had one to two individualized sessions with a nurse and one to two individual sessions with a physiotherapist.

Evaluation Design:
The study was a randomized controlled trial with a 1-year follow-up. Spirometry was performed before randomization and at 12 months follow-up. HRqoL was assessed using the following four approaches:

• Extent of chest trouble in the last year;
• Extent of asthma symptoms during the day in last 2 weeks;
• Extent of asthma symptoms at night; and
• Activity restriction in the past 2 weeks.

Sample Size:
A total of 140 patients participated, 78 of whom had asthma. Participants were randomized to either an intervention group or a control group.

Outcome Measures/Results:
Outcome measures included FEV1 scores and scores on the four HRqoL areas. Statistically significant differences were found in all four areas for asthma. (COPD results are not reported in this summary.) Of the intervention group participants, 84% reported their chest trouble had improved compared with 43% of those in the control group. Only 19% of the intervention group participants reported daily or weekly symptoms, compared with 64% in the control group. Six percent of the intervention group participants and 41% of the control participants reported nightly or weekly nighttime symptoms. After 1 year, 13% of those in the intervention group reported an impact on daily life compared with 38% in the control group. None of the intervention group answered they had deteriorated during the follow-up year; 4 of 5 felt their condition had improved. During the 12-month follow-up, the mean FEV1 increased by 112 among participants receiving the intervention, whereas it fell by 83 in the control group.

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

Case Study:
None

Asthma Self-management Program

Article Citation:
Lucas DO, Zimmer LO, Paul JE, Jones D, Slatko G, Liao W, Lashley J. Two-year results of the Asthma self-management program: long-term impact on health care services, cost, functional status, and productivity. Journal of Asthma 2001;38(4):321-330.

Intervention Setting:
The intervention involved 16 health plans, clinics, and employer groups in a classroom setting.

Target Population:
Persons diagnosed with asthma aged 14 years and older were recruited from various health plans, clinics, and employer groups.

Program Description:
The study objective was to assess the effectiveness of the Asthma Self- Management Program (ASMP) as an education and behavioral change instrument. ASMP is an eight-session course of 60–90 minutes each over 8 weeks with instruction on the respiratory system, trigger avoidance, use of monitoring techniques, peak flow meter and metered dose inhaler use, use of an asthma journal to monitor breathing and self-care, and asthma medication. Print materials used were “Asthma: A Patient Guide to Treatment” and a course manual. A characteristic of the intervention was the development and assessment of participant skills. Skill performance was promoted by take-home exercises to allow participants to apply newly learned skills. Repeated performance of self-management behavior allowed for skill mastery and improved confidence in participants’ capacity to take on desired behaviors.

Evaluation Design:
The evaluation was one-group, pre-post design, with a comparison of responses to questionnaire items before and after program participation. Self administered telephone surveys at 3 and 6 months and mailed surveys at 12 and 24 months following the intervention were used to assess asthma control behaviors, daily functioning, quality of life, and utilization of health care services.

Sample Size:
A total of 213 people enrolled in the program. Only 137 participants attended 5 or more of the 8 weekly sessions. Data were provided by 110 individuals at baseline, 1 year, and 2 years, and were included in the analysis.

Outcome Measures/Results:
Outcome measures included asthma knowledge, self-efficacy, functioning, productivity, and health care utilization. Increases in self-efficacy scores after one year were statistically significant over baseline scores. Statistically significant improvements in functioning (e.g., emotional well-being, daily work, social activities, and physical activities) were observed 1 and 2 years after program completion. Nighttime waking because of asthma in the past week decreased from 1.3 to 0.5, work and school days missed in 12 months decreased from 2.9 to 1.5, and the number of days with reduction in productivity at work and school fell from 18.7 to 3.2 after 2 years. From baseline to 2 years, hospitalizations decreased by 64%, emergency department visits decreased by 86%, and urgent-care visits decreased more than 50%. A return on investment was calculated at 254%.

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

Case Study:
None

Hospital Asthma Education Program

Article Citation:
Choy DKL, Tong M, Ko F, Li ST, Ho A, Chan J, Leung R, Lai CK. Evaluation of the efficacy of a hospital-based asthma education programme in patients of low socioeconomic status in Hong Kong. Clinical and Experimental Allergy 1999;29:84-90.

Intervention Setting:
Hong Kong teaching hospital with an associated asthma clinic

Target Population:
Adults with moderate-to-severe asthma from low socioeconomic and education levels attending an asthma clinic were the focus of this intervention.

Program Description:
The objective of this study was to determine if western-style asthma education can have positive results in an Asian population with low socioeconomic and cultural status where the influence of herbal medicine is still widespread. All patients attended a 2-hour education session in groups of 10 run by a trained asthma education nursing staff. The course addressed the nature of asthma, potential triggers, medications available and their use, and proper inhaler techniques. Participants demonstrated their inhaler techniques and were corrected as necessary. Patients were given a credit-card-sized instruction pamphlet regarding self-management steps and information regarding when to seek help based on peak expiratory flow (PEF) rates and daily recording of asthma symptoms. At intervals of 4–12 weeks, the program was reinforced by video sessions during clinic attendance. Inhaler use and PEF were also checked by the same nurses, and the self-management plan was reviewed.

Evaluation Design:
The study utilized a pre-post pilot design. Several characteristics were measured at baseline, 6 months and 1 year post-intervention to assess the program efficacy. PEF and forced expiratory volume at 1 minute (FEV1) were recorded, inhaler technique was assessed by the same specialist, and a 28-item questionnaire was completed to assess knowledge of asthma pathophysiology, medication, self-management, and self-rating of asthma control over the past 6 months, at baseline, and at 1 year. Outcome measures included hospitalizations, visits to family physicians, emergency department (ED) attendance, and days off work or school.

Sample Size:
The study sample included 192 Chinese adults living in Hong Kong, China; 75 were male, and 117 were female. All required the use of inhaled steroids.

Outcome Measures/Results:
Statistically significant improvements were shown in FEV1 (63.6 ± 20.6% of predicted values at baseline to 68.6 ± 22.8% at one year) and PEF (64.6 ± 23.0% of predicted values at baseline to 76.8 ± 24.5%) at 1 year. Statistically significant improvements also occurred in asthma knowledge, inhaler technique, and patients’ self-rating of their asthma. At the 1-year follow-up, hospitalizations decreased from 0.71 at baseline to 0.45, average ED visits decreased from 1.34 to 0.62, physician visits decreased from 7.26 to 2.98, and days off from work or school decreased from 5.07 to 3.05. Courses of steroids also fell from 2.02 at baseline to 1.37 in the same time period.

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

Case Study:
None

Outpatient Asthma Clinic Self-Management Program

Article Citation(s):
Ignacio-Garcia JM, Pinto-Tenorio M, Chocron-Giraldez MJ, Cabello-Rueda F, Lopez-Cozar GA, Ignacio-Garcia JM, de Ramon-Garrido E. Benefits at 3 years of an asthma education programme coupled with regular reinforcement. European Respiratory Journal 2002; 20:1095-101.

Ignacio-Garcia JM, Gonzalez-Santos P. Asthma self-management education program by home monitoring of peak expiratory flow. American Journal of Respiratory Critical Care Medicine 1995;151:353.

Intervention Setting:
An outpatient asthma clinic of a 210-bed hospital in Ronda, Malaga, Spain

Target Population:
Adults with chronic asthma who had experienced at least one asthma exacerbation requiring hospital care in the previous year

Program Description:
The study was designed to asses the impact of an asthma self-management education program previously found to be effective in a controlled trial (Ignacio-Garcia and Gonzalez-Santos paper referenced above) coupled with educational reinforcement, on the outcome of adult asthma patients 3 years after the intervention. The initial assessment included a complete medical history, physical examination, and spirometry. Researchers tailored medical regimens to each patient’s asthma pattern. Written therapeutic schedules were provided to each patient. Emphasis was placed on explaining the inhaler technique and the correct use of devices. Patients received information about general concepts of asthma and its management, triggering factors, and ways to avoid them, and they were taught to measure their peak expiratory flow rate with a peak flow meter. Patients were instructed to measure their peak flow twice a day just before using the inhalers. They also received diary cards to record symptoms and the need for short-acting B2-agonists. During the second visit, 1 month after the initial assessment, the clinician checked inhaler technique, effective use of peak flow meters, compliance with patient’s diary card, need for B2-agonists, and environmental triggers and ways to avoid them. Further education was provided as needed, and modifications to each patient’s regimen were discussed with him/her. Ongoing education was provided as written information about the use and value of drugs and recognition and appropriate management of acute exacerbations. During follow-up visits at 3, 6, 12, 24, and 36 months, the program and the patient’s behavior was reviewed, and drawbacks and decisions regarding treatment were discussed. Educational reinforcement was provided at all visits and written self-action plans were delivered to patients when their treatment was modified.

Evaluation Design:
A pre-post study of consecutive patients was utilized.

Sample Size:
Sixty-three patients aged 14–65 years whose asthma had been diagnosed at least 2 years before acceptance into the program participated in the study.

Outcome Measures/Results:
Outcome measures included days lost from work or school, unscheduled general practitioner visits, emergency department visits either to the primary care center or to the acute-care hospital, hospital admissions, and asthma-related sleep disruptions. Morbidity data from the year before enrollment was compared with the results obtained at 1, 2, and 3 years after the program was completed. Comparison of data showed statistically significant decreases in mean number of days off work or school from 38 (year before intervention) to 15 (after 1 year) to 6 (after 2 years) and 4.25 (after 3 years). Primary care visits for the same periods decreased significantly from the mean of 6.78 in the year before to the intervention to 2.44 at 1 year, to 1.49 at 2 years, and 1.29 at 3 years. Emergency visits for primary care over the 4 years fell from a mean of 1.67 before the intervention to 0.43, 0.24, and 0.25 in the succeeding 3 years. Nocturnal wakening over this same 4-year period fell dramatically from a preintervention mean average of 120, to 35, to 20, and 16 over the following 3 years. All patients had inhaled steroids prescribed before and at the end of the study. The percentage of patients using oral steroids decreased significantly at the end of the study from 22% to 11%.

Materials available:
Educational materials and handouts for the educational program are in Spanish. The point of contact is Dr. J.M Ignacio Garcia, JOSEMARIAIGNACIO@teleconica.net

The Self-Management Education Interdisciplinary Program

Article Citation(s):
Tschopp JM, Frey JG, Pernet R, Burrus C, Jordan B, Morin A, Garrone S, Imhof K, Besse F, Marty S, Uldry C, Assal JP. Bronchial asthma and self-management education: Implementation of guidelines by an interdisciplinary program in a health network. Swiss Medical Weekly 2002;132:92-7.

Intervention Setting:
University hospital outpatient clinic in Switzerland

Target Population:
Adults aged 17 years and older whose forced expiratory volume in 1 second, was ⊃3; 50% of predicted value with > 20% reversibility after bronchodilators

Program Description:
The study was undertaken to promote an interdisciplinary approach to asthma treatment combined with a self-management education (SME) program and then measuring the impact. A panel of pneumonologists and nursing staff in conjunction with communication professionals produced an SME booklet in two languages, French and German. The health network team members participating in the study, i.e., primary care physicians, medical specialists, pharmacists, and nursing staff, attended a 12-hour interdisciplinary seminar to prepare them to implement the intervention. Topics included active education strategy, management of an interdisciplinary team, the role of the various players, patient education strategy, knowledge of asthma, and asthma management using current guidelines. The educational intervention for the patients included basic information about asthma physiopathology, precipitating factors and measures for preventing bronchial asthma, basic information about drugs, inhalation techniques, peak flow measurement, use of a personalized plan of action for preventing and managing asthma attacks, and other topics considered necessary by the patient’s medical care provider. Each patient received a personal follow-up diary with written, individualized objectives. After the education, a physician conducted follow-ups with each participant at 3, 6, 9, and 12 months in conjunction with the physiotherapist responsible for data collection.

Evaluation Design:
A pre-post methodology was utilized.

Sample Size:
A total of 66 patients participated in this study.

Outcome Measures/Results:
Outcome measures included asthma-related hospital stays, emergency consultations, and missed workdays over a 1 year. Total days hospitalized decreased from 232 days before the intervention to 68 days in the year after the intervention, and the total number of emergency consultations decreased from 314 to 128 for the corresponding periods. Thirty-nine percent of patients had missed workdays before to the intervention compared with 14% the following year. Total lost workdays decreased from 652 days before the intervention to 126 days after the intervention. Overall, the intervention resulted in a health cost saving of (Swiss francs) CHF 202,510 in terms of missed work and CHF 131,200 in terms of days in the hospital, for a total of CHF 333,710. Costs saved per patient were CHF 5,056 per year.

Information about materials:
The teaching program used in this study was adapted from the Quebec teaching program on asthma. (Boulet LP. L’Asthma: Notions de Base, Education, Intervention. Les Presses de l’Universite Laval 1997, Quebec, Canada: Publisher 1997;289-97)

The SME booklet developed for the asthma education in French is entitled "Mieux Vivre Avec Son Asthma: Approche Interdisciplinaire a l’intention des Patients Asthmatiques."