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Selberg S, Hedman L, Jansson SA, Backman H, Stridsman C. Asthma control and acute healthcare visits among young adults with asthma-A population-based study. J Adv Nurs 2019; 75:3525-3534. [PMID: 31441107 DOI: 10.1111/jan.14174] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 07/04/2019] [Accepted: 08/06/2019] [Indexed: 11/30/2022]
Abstract
AIMS To study asthma control and acute healthcare visits among young adults with asthma. BACKGROUND Despite the access to effective treatment and nursing interventions, poor asthma control is still common among individuals with asthma. However, studies describing clinical characteristics among young adults with asthma are rare. DESIGN A population-based cohort study. METHODS In 2015, as a part of the OLIN paediatric cohort I (recruited in 1996 at age 7-8 years), N = 2,291 young adults (27-28 years) completed a postal questionnaire survey including questions on asthma and respiratory symptoms. Of these, N = 280 (12%) were identified as having current asthma and were further studied. RESULTS Of those with current asthma, women reported respiratory symptoms and smoking to a greater extent than men. Approximately one-fourth had uncontrolled asthma and acute healthcare visits due to asthma was reported by 15% of women and 8% of men. Uncontrolled asthma was associated with smoking, lower educational level, use of reliever treatment most days, and acute healthcare visits. Acute healthcare visits due to asthma were associated with periodic use of regular controller treatment also after adjustment for uncontrolled asthma. CONCLUSION The result indicate poor adherence to asthma treatment which may lead to decreased asthma control and acute healthcare visits. IMPACT Most young adults with asthma are diagnosed and treated in primary care, ideally in a team with a nurse. The main findings highlight the need for evidenced-based nursing interventions, contributing to a more efficient asthma management in primary care.
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Affiliation(s)
- Stina Selberg
- The OLIN Studies, Norrbotten County Council, Luleå, Sweden
| | - Linnea Hedman
- The OLIN Studies, Norrbotten County Council, Luleå, Sweden.,The OLIN Unit, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine, Umeå University, Umeå, Sweden.,Department of Health Sciences, Luleå University of Technology, Luleå, Sweden
| | - Sven-Arne Jansson
- The OLIN Studies, Norrbotten County Council, Luleå, Sweden.,The OLIN Unit, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine, Umeå University, Umeå, Sweden
| | - Helena Backman
- The OLIN Studies, Norrbotten County Council, Luleå, Sweden.,The OLIN Unit, Department of Public Health and Clinical Medicine, Occupational and Environmental Medicine, Umeå University, Umeå, Sweden
| | - Caroline Stridsman
- The OLIN Studies, Norrbotten County Council, Luleå, Sweden.,Department of Health Sciences, Luleå University of Technology, Luleå, Sweden
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Stukus DR, Farooqui N, Strothman K, Ryan K, Zhao S, Stevens JH, Cohen DM. Real-world evaluation of a mobile health application in children with asthma. Ann Allergy Asthma Immunol 2018; 120:395-400.e1. [PMID: 29452259 DOI: 10.1016/j.anai.2018.02.006] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 01/25/2018] [Accepted: 02/02/2018] [Indexed: 12/27/2022]
Abstract
BACKGROUND Mobile health applications for asthma are increasingly being developed. However, there are no published randomized controlled trials evaluating efficacy in decreasing exacerbations. OBJECTIVE To evaluate the impact of a mobile asthma application for asthma-related urgent health care usage. METHODS We conducted a 6-month prospective randomized controlled trial for patients (6 months-21 years old) with persistent asthma presenting with an asthma exacerbation to the emergency department of a pediatric academic medical center. Participants were randomized to AsthmaCare (application providing medication and trigger reminders and treatment plan) or the control (online asthma information). Primary outcome measures were comparison of emergency department and urgent care visits and hospitalizations 6 months before and after randomization. RESULTS AsthmaCare participants (n = 98) were slightly older (7.84 vs 6.24 years; P = .02) than controls (n = 95) but similar for sex (55% vs 62% boys), race (83% vs 77% African American), and insurer (89% vs 98% Medicaid). The 2 groups were similar in having more than 2 comorbidities (34% vs 32%) and receiving National Heart, Lung, and Blood Institute step 3 treatment or higher (69% vs 57%). There was no significant decrease in emergency department or urgent care visits or hospitalizations between the intervention and control groups. AsthmaCare participants were more likely to report improvement in asthma management 6 months after study enrollment (79% vs 64%; P = .06). CONCLUSION This randomized controlled trial did not demonstrate a significant decrease in asthma-related emergency department visits or hospitalizations among children who used a mobile health application. TRIAL REGISTRATION ClinicalTrials.gov, Identifier NCT02333630.
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Affiliation(s)
- David R Stukus
- Division of Allergy and Immunology, Nationwide Children's Hospital, Columbus, Ohio.
| | | | - Kasey Strothman
- Division of Allergy and Immunology, Nationwide Children's Hospital, Columbus, Ohio
| | - Kelsey Ryan
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Songzhu Zhao
- Center for Biostatistics at The Ohio State University, Nationwide Children's Hospital, Columbus, Ohio
| | - Jack H Stevens
- Center for Biobehavioral Health, Nationwide Children's Hospital, Columbus, Ohio
| | - Daniel M Cohen
- Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, Ohio
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3
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McCallum GB, Morris PS, Brown N, Chang AB. Culture-specific programs for children and adults from minority groups who have asthma. Cochrane Database Syst Rev 2017; 8:CD006580. [PMID: 28828760 PMCID: PMC6483708 DOI: 10.1002/14651858.cd006580.pub5] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND People with asthma who come from minority groups often have poorer asthma outcomes, including more acute asthma-related doctor visits for flare-ups. Various programmes used to educate and empower people with asthma have previously been shown to improve certain asthma outcomes (e.g. adherence outcomes, asthma knowledge scores in children and parents, and cost-effectiveness). Models of care for chronic diseases in minority groups usually include a focus of the cultural context of the individual, and not just the symptoms of the disease. Therefore, questions about whether tailoring asthma education programmes that are culturally specific for people from minority groups are effective at improving asthma-related outcomes, that are feasible and cost-effective need to be answered. OBJECTIVES To determine whether culture-specific asthma education programmes, in comparison to generic asthma education programmes or usual care, improve asthma-related outcomes in children and adults with asthma who belong to minority groups. SEARCH METHODS We searched the Cochrane Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register, MEDLINE, Embase, review articles and reference lists of relevant articles. The latest search fully incorporated into the review was performed in June 2016. SELECTION CRITERIA Randomised controlled trials (RCTs) comparing the use of culture-specific asthma education programmes with generic asthma education programmes, or usual care, in adults or children from minority groups with asthma. DATA COLLECTION AND ANALYSIS Two review authors independently selected, extracted and assessed the data for inclusion. We contacted study authors for further information if required. MAIN RESULTS In this review update, an additional three studies and 220 participants were added. A total of seven RCTs (two in adults, four in children, one in both children and adults) with 837 participants (aged from one to 63 years) with asthma from ethnic minority groups were eligible for inclusion in this review. The methodological quality of studies ranged from very low to low. For our primary outcome (asthma exacerbations during follow-up), the quality of evidence was low for all outcomes. In adults, use of a culture-specific programme, compared to generic programmes or usual care did not significantly reduce the number of participants from two studies with 294 participants for: exacerbations with one or more exacerbations during follow-up (odds ratio (OR) 0.80, 95% confidence interval (CI) 0.50 to 1.26), hospitalisations over 12 months (OR 0.83, 95% CI 0.31 to 2.22) and exacerbations requiring oral corticosteroids (OR 0.97, 95% CI 0.55 to 1.73). However, use of a culture-specific programme, improved asthma quality of life scores in 280 adults from two studies (mean difference (MD) 0.26, 95% CI 0.17 to 0.36) (although the MD was less then the minimal important difference for the score). In children, use of a culture-specific programme was superior to generic programmes or usual care in reducing severe asthma exacerbations requiring hospitalisation in two studies with 305 children (rate ratio 0.48, 95% CI 0.24 to 0.95), asthma control in one study with 62 children and QoL in three studies with 213 children, but not for the number of exacerbations during follow-up (OR 1.55, 95% CI 0.66 to 3.66) or the number of exacerbations (MD 0.18, 95% CI -0.25 to 0.62) among 100 children from two studies. AUTHORS' CONCLUSIONS The available evidence showed that culture-specific education programmes for adults and children from minority groups are likely effective in improving asthma-related outcomes. This review was limited by few studies and evidence of very low to low quality. Not all asthma-related outcomes improved with culture-specific programs for both adults and children. Nevertheless, while modified culture-specific education programs are usually more time intensive, the findings of this review suggest using culture-specific asthma education programmes for children and adults from minority groups. However, more robust RCTs are needed to further strengthen the quality of evidence and determine the cost-effectiveness of culture-specific programs.
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Affiliation(s)
- Gabrielle B McCallum
- Menzies School of Health Research, Charles Darwin UniversityChild Health DivisionDarwinNorthern TerritoryAustralia0810
| | - Peter S Morris
- Menzies School of Health Research, Charles Darwin UniversityChild Health DivisionDarwinNorthern TerritoryAustralia0810
| | - Ngiare Brown
- Ngaoara ‐ Child and Adolescent WellbeingAustinmerAustralia
| | - Anne B Chang
- Menzies School of Health Research, Charles Darwin UniversityChild Health DivisionDarwinNorthern TerritoryAustralia0810
- Queensland University of TechnologyInstitute of Health and Biomedical InnovationBrisbaneAustralia
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Rangachari P. A framework for measuring self-management effectiveness and health care use among pediatric asthma patients and families. J Asthma Allergy 2017; 10:111-122. [PMID: 28442924 PMCID: PMC5396924 DOI: 10.2147/jaa.s133481] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Asthma is associated with substantial health care expenditures, including an estimated US$56 billion per year in direct costs. A recurring theme in the asthma management literature is that costly asthma symptoms, including hospitalizations and multiple emergency department (ED)/outpatient visits, can often be prevented through patient/family adherence to the national (National Institutes of Health Expert Panel Report-3) guidelines for effective self-management of asthma, specifically 1) medication adherence and 2) environmental trigger avoidance, as outlined in the patient's personalized Asthma-Action Plan. It is important to note however that while effective self-management of asthma is known to reduce ED visits and hospitalizations, the relationship between asthma self-management effectiveness and outpatient visit frequency remains ambiguous, reflecting a gap in the literature. For instance, do patients/families who self-manage effectively visit outpatient clinics more frequently for asthma care (compared to those who do not self-manage effectively), after accounting for differences in asthma severity, demographic characteristics, and risk factors? Do patients/families who visit outpatient clinics more frequently for asthma care, in turn have fewer ED and inpatient encounters for asthma? On the other hand, do patients/families who do not revisit outpatient clinics regularly have higher ED visits and hospitalizations? It is important to address these gaps, in order to reduce the costs and public health burden of asthma. This paper provides a foundation for addressing these gaps, by conducting an integrative review of the asthma management literature, to develop a conceptual framework for measuring self-management effectiveness and health care use among pediatric asthma patients/families. In doing so, the paper lays the groundwork for future research seeking to explicate the relationship between asthma self-management effectiveness and health care use, which in turn has potential to engage asthma providers in promoting ideal self-management and optimal health care use for pediatric asthma, in accordance with national evidence-based guidelines for asthma management.
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Affiliation(s)
- Pavani Rangachari
- College of Allied Health Sciences, Augusta University, Augusta, GA, USA
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Pinnock H, Parke HL, Panagioti M, Daines L, Pearce G, Epiphaniou E, Bower P, Sheikh A, Griffiths CJ, Taylor SJC. Systematic meta-review of supported self-management for asthma: a healthcare perspective. BMC Med 2017; 15:64. [PMID: 28302126 PMCID: PMC5356253 DOI: 10.1186/s12916-017-0823-7] [Citation(s) in RCA: 180] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 02/20/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Supported self-management has been recommended by asthma guidelines for three decades; improving current suboptimal implementation will require commitment from professionals, patients and healthcare organisations. The Practical Systematic Review of Self-Management Support (PRISMS) meta-review and Reducing Care Utilisation through Self-management Interventions (RECURSIVE) health economic review were commissioned to provide a systematic overview of supported self-management to inform implementation. We sought to investigate if supported asthma self-management reduces use of healthcare resources and improves asthma control; for which target groups it works; and which components and contextual factors contribute to effectiveness. Finally, we investigated the costs to healthcare services of providing supported self-management. METHODS We undertook a meta-review (systematic overview) of systematic reviews updated with randomised controlled trials (RCTs) published since the review search dates, and health economic meta-analysis of RCTs. Twelve electronic databases were searched in 2012 (updated in 2015; pre-publication update January 2017) for systematic reviews reporting RCTs (and update RCTs) evaluating supported asthma self-management. We assessed the quality of included studies and undertook a meta-analysis and narrative synthesis. RESULTS A total of 27 systematic reviews (n = 244 RCTs) and 13 update RCTs revealed that supported self-management can reduce hospitalisations, accident and emergency attendances and unscheduled consultations, and improve markers of control and quality of life for people with asthma across a range of cultural, demographic and healthcare settings. Core components are patient education, provision of an action plan and regular professional review. Self-management is most effective when delivered in the context of proactive long-term condition management. The total cost (n = 24 RCTs) of providing self-management support is offset by a reduction in hospitalisations and accident and emergency visits (standard mean difference 0.13, 95% confidence interval -0.09 to 0.34). CONCLUSIONS Evidence from a total of 270 RCTs confirms that supported self-management for asthma can reduce unscheduled care and improve asthma control, can be delivered effectively for diverse demographic and cultural groups, is applicable in a broad range of clinical settings, and does not significantly increase total healthcare costs. Informed by this comprehensive synthesis of the literature, clinicians, patient-interest groups, policy-makers and providers of healthcare services should prioritise provision of supported self-management for people with asthma as a core component of routine care. SYSTEMATIC REVIEW REGISTRATION RECURSIVE: PROSPERO CRD42012002694 ; PRISMS: PROSPERO does not register meta-reviews.
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Affiliation(s)
- Hilary Pinnock
- Asthma UK Centre for Applied Research, Allergy and Respiratory Research Group, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Doorway 3, Medical School, Teviot Place, Edinburgh, EH8 9AG UK
| | - Hannah L. Parke
- Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Maria Panagioti
- NIHR School for Primary Care Research, Centre for Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Luke Daines
- Asthma UK Centre for Applied Research, Allergy and Respiratory Research Group, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Doorway 3, Medical School, Teviot Place, Edinburgh, EH8 9AG UK
| | - Gemma Pearce
- Centre for Technology Enabled Health Research (CTEHR), Coventry University, Coventry, UK
| | - Eleni Epiphaniou
- Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Peter Bower
- NIHR School for Primary Care Research, Centre for Primary Care, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | - Aziz Sheikh
- Asthma UK Centre for Applied Research, Allergy and Respiratory Research Group, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Doorway 3, Medical School, Teviot Place, Edinburgh, EH8 9AG UK
| | - Chris J. Griffiths
- Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Stephanie J. C. Taylor
- Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
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Hoskins G, Williams B, Abhyankar P, Donnan P, Duncan E, Pinnock H, van der Pol M, Rauchhaus P, Taylor A, Sheikh A. Achieving Good Outcomes for Asthma Living (GOAL): mixed methods feasibility and pilot cluster randomised controlled trial of a practical intervention for eliciting, setting and achieving goals for adults with asthma. Trials 2016; 17:584. [PMID: 27931242 PMCID: PMC5146838 DOI: 10.1186/s13063-016-1684-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 11/05/2016] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Despite being a core component of self-management, goal setting is rarely used in routine care. We piloted a primary care, nurse-led intervention called Achieving Good Outcomes for Asthma Living (GOAL) for adults with asthma. Patients were invited to identify and prioritise their goals in preparation for discussing and negotiating an action/coping plan with the nurse at a routine asthma review. METHODS The 18-month mixed methods feasibility cluster pilot trial stratified and then randomised practices to deliver usual care (UC) or a goal-setting intervention (GOAL). Practice asthma nurses and adult patients with active asthma were invited to participate. The primary outcome was asthma-specific quality of life. Semi-structured interviews with a purposive patient sample (n = 14) and 10 participating nurses explored GOAL perception. The constructs of normalisation process theory (NPT) were used to analyse and interpret data. RESULTS Ten practices participated (five in each arm), exceeding our target of eight. However, only 48 patients (target 80) were recruited (18 in GOAL practices). At 6 months post-intervention, the difference in mean asthma-related quality of life (mAQLQ) between intervention and control was 0.1 (GOAL 6.20: SD 0.76 (CI 5.76-6.65) versus UC 6.1: SD 0.81 (CI 5.63-6.57)), less than the minimal clinically important difference (MCID) of 0.5. However, change from baseline was stronger in the intervention group: at 6 months the change in the emotions sub-score was 0.8 for intervention versus 0.2 for control. Costs were higher in the intervention group by £22.17. Routine review with goal setting was considered more holistic, enhancing rapport and enabling patients to become active rather than passive participants in healthcare. However, time was a major barrier for nurses, who admitted to screening out patient goals they believed were unrelated to asthma. CONCLUSIONS The difference in AQLQ score from baseline is larger in the intervention arm than the control, indicating the intervention may have impact if appropriately strengthened. The GOAL intervention changed the review dynamic and was well received by patients, but necessitated additional time, which was problematic in the confines of the traditional nurse appointment. Modification to recruitment methods and further development of the intervention are needed before proceeding to a definitive cluster randomised controlled trial. TRIAL REGISTRATION ISRCTN18912042 . Registered on 26 June 2012.
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Affiliation(s)
- Gaylor Hoskins
- Nursing, Midwifery and Allied Health Professions Research Unit, School of Health Sciences, University of Stirling, Unit 13 Scion House, Stirling University Innovation Park, Stirling, FK9 4NF Scotland, UK
| | - Brian Williams
- School of Nursing, Midwifery and Social Care, Edinburgh Napier University, 9 Sighthill Court, Edinburgh, EH11 4BN Scotland
| | - Purva Abhyankar
- Faculty of Health Sciences and Sport, University of Stirling, Pathfoot Building, Stirling, FK9 4LA Scotland, UK
| | - Peter Donnan
- Tayside Clinical Trials Unit, Level 10 Ninewells Hospital and Medical School, Dundee, DD1 9SY Scotland, UK
| | - Edward Duncan
- Nursing, Midwifery and Allied Health Professions Research Unit, School of Health Sciences, University of Stirling, Unit 13 Scion House, Stirling University Innovation Park, Stirling, FK9 4NF Scotland, UK
| | - Hilary Pinnock
- Asthma UK Centre for Applied Research, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Medical School Doorway 3, Teviot Place, Edinburgh, EH8 9AG Scotland, UK
| | - Marjon van der Pol
- Health Economics Research Unit, University of Aberdeen, Foresterhill, Aberdeen, AB25 2ZD Scotland, UK
| | - Petra Rauchhaus
- Tayside Clinical Trials Unit, Level 10 Ninewells Hospital and Medical School, Dundee, DD1 9SY Scotland, UK
| | - Anne Taylor
- Faculty of Health Sciences and Sport, University of Stirling, Pathfoot Building, Stirling, FK9 4LA Scotland, UK
| | - Aziz Sheikh
- Asthma UK Centre for Applied Research, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Medical School Doorway 3, Teviot Place, Edinburgh, EH8 9AG Scotland, UK
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McCleary N, Andrews A, Morrow S, Wiener-Ogilvie S, Fletcher M, Steed L, Taylor SJC, Pinnock H. Educating professionals to support self-management in people with asthma or diabetes: protocol for a systematic review and scoping exercise. BMJ Open 2016; 6:e011937. [PMID: 27793836 PMCID: PMC5093360 DOI: 10.1136/bmjopen-2016-011937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Supported self-management for asthma helps people adjust their treatment in response to symptom changes. This improves day-to-day control and reduces the risk of asthma attacks and the need for emergency healthcare. However, implementation remains poor in routine clinical practice. This systematic review is part of a programme of work developing an intervention to help primary care practice teams embed self-management support into routine asthma care. The aim of the review is to synthesise the evidence regarding the effectiveness of educational interventions for professionals supporting self-management in people with asthma or diabetes (type 1 and type 2). These two conditions have the most robust evidence base for the effectiveness of implementing supported self-management. METHODS AND ANALYSIS Electronic searches will be conducted in CENTRAL, MEDLINE, EMBASE, ISI Web of Science, CINAHL, PsycINFO, AMED, Global Health, WHO Global Health Library, ERIC, BNI, RDRB/CME and Google Scholar. Eligible studies are randomised controlled trials or controlled clinical trials published between 1990 and 2016 which evaluated professional education interventions facilitating asthma or diabetes supported self-management. Further relevant work will be identified from trial registries, citation searching and through contact with authors of included studies. This will be supplemented by scoping potentially relevant educational packages described in English language policy literature or health service websites. Screening, data extraction and risk of bias assessment (using the Cochrane Risk of Bias Tool) will be completed by two independent reviewers, with a third reviewer arbitrating where necessary. We plan a theoretically informed narrative synthesis of the aggregated data as heterogeneity is likely to preclude meta-analysis. ETHICS AND DISSEMINATION Ethical approval is not required for this systematic review. The results will be described in a paper submitted for peer-reviewed publication and will inform the development of an implementation intervention. STUDY REGISTRATION NUMBER PROSPERO CRD42016032922.
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Affiliation(s)
- Nicola McCleary
- Asthma UK Centre for Applied Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | | | - Susan Morrow
- Asthma UK Centre for Applied Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | | | | | - Liz Steed
- Blizard Institute, Queen Mary University of London, London, UK
| | | | - Hilary Pinnock
- Asthma UK Centre for Applied Research, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
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Abstract
Asthma is the most common inflammatory disease of the lungs. The prevalence of asthma is increasing in many parts of the world that have adopted aspects of the Western lifestyle, and the disease poses a substantial global health and economic burden. Asthma involves both the large-conducting and the small-conducting airways, and is characterized by a combination of inflammation and structural remodelling that might begin in utero. Disease progression occurs in the context of a developmental background in which the postnatal acquisition of asthma is strongly linked with allergic sensitization. Most asthma cases follow a variable course, involving viral-induced wheezing and allergen sensitization, that is associated with various underlying mechanisms (or endotypes) that can differ between individuals. Each set of endotypes, in turn, produces specific asthma characteristics that evolve across the lifecourse of the patient. Strong genetic and environmental drivers of asthma interconnect through novel epigenetic mechanisms that operate prenatally and throughout childhood. Asthma can spontaneously remit or begin de novo in adulthood, and the factors that lead to the emergence and regression of asthma, irrespective of age, are poorly understood. Nonetheless, there is mounting evidence that supports a primary role for structural changes in the airways with asthma acquisition, on which altered innate immune mechanisms and microbiota interactions are superimposed. On the basis of the identification of new causative pathways, the subphenotyping of asthma across the lifecourse of patients is paving the way for more-personalized and precise pathway-specific approaches for the prevention and treatment of asthma, creating the real possibility of total prevention and cure for this chronic inflammatory disease.
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Affiliation(s)
- Stephen T. Holgate
- Clinical and Experimental Sciences, Mail Point 810, Level F, Sir Henry Wellcome Building
- Southampton General Hospital, Southampton, SO16 6YD UK
| | - Sally Wenzel
- Subsection Chief of Allergy, Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, Asthma Institute at UPMC/UPSOM, Pittsburgh, Pennsylvania USA
| | - Dirkje S. Postma
- Department of Pulmonology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Scott T. Weiss
- Channing Division of Network Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts USA
| | - Harald Renz
- Institute of Laboratory Medicine and Pathobiochemistry, Molecular Diagnostics, Philipps University Marburg, University Hospital Giessen and Marburg GmbH, Campus Marburg, Marburg, Germany
| | - Peter D. Sly
- Queensland Children's Medical Research Institute and Centre for Child Health Research, University of Queensland, Brisbane, Australia
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Sheares BJ, Mellins RB, Dimango E, Serebrisky D, Zhang Y, Bye MR, Dovey ME, Nachman S, Hutchinson V, Evans D. Do Patients of Subspecialist Physicians Benefit from Written Asthma Action Plans? Am J Respir Crit Care Med 2015; 191:1374-83. [PMID: 25867075 DOI: 10.1164/rccm.201407-1338oc] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Asthma clinical guidelines suggest written asthma action plans are essential for improving self-management and outcomes. OBJECTIVES To assess the efficacy of written instructions in the form of a written asthma action plan provided by subspecialist physicians as part of usual asthma care during office visits. METHODS A total of 407 children and adults with persistent asthma receiving first-time care in pulmonary and allergy practices at 4 urban medical centers were randomized to receive either written instructions (n = 204) or no written instructions other than prescriptions (n = 203) from physicians. MEASUREMENTS AND MAIN RESULTS Using written asthma action plan forms as a vehicle for providing self-management instructions did not have a significant effect on any of the primary outcomes: (1) asthma symptom frequency, (2) emergency visits, or (3) asthma quality of life from baseline to 12-month follow-up. Both groups showed similar and significant reductions in asthma symptom frequency (daytime symptoms [P < 0.0001], nocturnal symptoms [P < 0.0001], β-agonist use [P < 0.0001]). There was also a significant reduction in emergency visits for the intervention (P < 0.0001) and control (P < 0.0006) groups. There was significant improvement in asthma quality-of-life scores for adults (P < 0.0001) and pediatric caregivers (P < 0.0001). CONCLUSIONS Our results suggest that using a written asthma action plan form as a vehicle for providing asthma management instructions to patients with persistent asthma who are receiving subspecialty care for the first time confers no added benefit beyond subspecialty-based medical care and education for asthma. Clinical trial registered with www.clinicaltrials.gov (NCT 00149461).
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Affiliation(s)
| | | | - Emily Dimango
- 2 Department of Medicine, College of Physicians and Surgeons, and
| | | | | | | | - Mark E Dovey
- 5 Weill Cornell Medical College, New York, New York; and
| | | | | | - David Evans
- 1 Department of Pediatrics and.,8 Department of Sociomedical Sciences, Mailman School of Public Health, Columbia University, New York, New York
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Pinnock H, Ehrlich E, Hoskins G, Tomlins R. A woman with asthma: a whole systems approach to supporting self-management. NPJ Prim Care Respir Med 2014; 24:14063. [PMID: 25321880 PMCID: PMC4373456 DOI: 10.1038/npjpcrm.2014.63] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Revised: 07/15/2014] [Accepted: 07/15/2014] [Indexed: 11/30/2022] Open
Abstract
A 35-year-old lady attends for review of her asthma following an acute exacerbation. There is an extensive evidence base for supported self-management for people living with asthma, and international and national guidelines emphasise the importance of providing a written asthma action plan. Effective implementation of this recommendation for the lady in this case study is considered from the perspective of a patient, healthcare professional, and the organisation. The patient emphasises the importance of developing a partnership based on honesty and trust, the need for adherence to monitoring and regular treatment, and involvement of family support. The professional considers the provision of asthma self-management in the context of a structured review, with a focus on a self-management discussion which elicits the patient's goals and preferences. The organisation has a crucial role in promoting, enabling and providing resources to support professionals to provide self-management. The patient's asthma control was assessed and management optimised in two structured reviews. Her goal was to avoid disruption to her work and her personalised action plan focused on achieving that goal.
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Affiliation(s)
- Hilary Pinnock
- Asthma UK Centre for Applied Research, Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK
| | - Elisabeth Ehrlich
- Asthma UK Centre for Applied Research, Centre for Population Health Sciences, The University of Edinburgh, Edinburgh, UK
| | | | - Ron Tomlins
- Discipline of General Practice, University of Sydney, Sydney, NSW, Australia
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Ryan R, Santesso N, Lowe D, Hill S, Grimshaw J, Prictor M, Kaufman C, Cowie G, Taylor M. Interventions to improve safe and effective medicines use by consumers: an overview of systematic reviews. Cochrane Database Syst Rev 2014; 2022:CD007768. [PMID: 24777444 PMCID: PMC6491214 DOI: 10.1002/14651858.cd007768.pub3] [Citation(s) in RCA: 115] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Many systematic reviews exist on interventions to improve safe and effective medicines use by consumers, but research is distributed across diseases, populations and settings. The scope and focus of such reviews also vary widely, creating challenges for decision-makers seeking to inform decisions by using the evidence on consumers' medicines use.This is an update of a 2011 overview of systematic reviews, which synthesises the evidence, irrespective of disease, medicine type, population or setting, on the effectiveness of interventions to improve consumers' medicines use. OBJECTIVES To assess the effects of interventions which target healthcare consumers to promote safe and effective medicines use, by synthesising review-level evidence. METHODS SEARCH METHODS We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching databases from their start dates to March 2012. SELECTION CRITERIA We screened and ranked reviews based on relevance to consumers' medicines use, using criteria developed for this overview. DATA COLLECTION AND ANALYSIS We used standardised forms to extract data, and assessed reviews for methodological quality using the AMSTAR tool. We used standardised language to summarise results within and across reviews; and gave bottom-line statements about intervention effectiveness. Two review authors screened and selected reviews, and extracted and analysed data. We used a taxonomy of interventions to categorise reviews and guide syntheses. MAIN RESULTS We included 75 systematic reviews of varied methodological quality. Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation and skills acquisition. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most frequently-reported outcome, but others such as knowledge, clinical and service-use outcomes were also reported. Adverse events were less commonly identified, while those associated with the interventions themselves, or costs, were rarely reported.Looking across reviews, for most outcomes, medicines self-monitoring and self-management programmes appear generally effective to improve medicines use, adherence, adverse events and clinical outcomes; and to reduce mortality in people self-managing antithrombotic therapy. However, some participants were unable to complete these interventions, suggesting they may not be suitable for everyone.Other promising interventions to improve adherence and other key medicines-use outcomes, which require further investigation to be more certain of their effects, include:· simplified dosing regimens: with positive effects on adherence;· interventions involving pharmacists in medicines management, such as medicines reviews (with positive effects on adherence and use, medicines problems and clinical outcomes) and pharmaceutical care services (consultation between pharmacist and patient to resolve medicines problems, develop a care plan and provide follow-up; with positive effects on adherence and knowledge).Several other strategies showed some positive effects, particularly relating to adherence, and other outcomes, but their effects were less consistent overall and so need further study. These included:· delayed antibiotic prescriptions: effective to decrease antibiotic use but with mixed effects on clinical outcomes, adverse effects and satisfaction;· practical strategies like reminders, cues and/or organisers, reminder packaging and material incentives: with positive, although somewhat mixed effects on adherence;· education delivered with self-management skills training, counselling, support, training or enhanced follow-up; information and counselling delivered together; or education/information as part of pharmacist-delivered packages of care: with positive effects on adherence, medicines use, clinical outcomes and knowledge, but with mixed effects in some studies;· financial incentives: with positive, but mixed, effects on adherence.Several strategies also showed promise in promoting immunisation uptake, but require further study to be more certain of their effects. These included organisational interventions; reminders and recall; financial incentives; home visits; free vaccination; lay health worker interventions; and facilitators working with physicians to promote immunisation uptake. Education and/or information strategies also showed some positive but even less consistent effects on immunisation uptake, and need further assessment of effectiveness and investigation of heterogeneity.There are many different potential pathways through which consumers' use of medicines could be targeted to improve outcomes, and simple interventions may be as effective as complex strategies. However, no single intervention assessed was effective to improve all medicines-use outcomes across all diseases, medicines, populations or settings.Even where interventions showed promise, the assembled evidence often only provided part of the picture: for example, simplified dosing regimens seem effective for improving adherence, but there is not yet sufficient information to identify an optimal regimen.In some instances interventions appear ineffective: for example, the evidence suggests that directly observed therapy may be generally ineffective for improving treatment completion, adherence or clinical outcomes.In other cases, interventions may have variable effects across outcomes. As an example, strategies providing information or education as single interventions appear ineffective to improve medicines adherence or clinical outcomes, but may be effective to improve knowledge; an important outcome for promoting consumers' informed medicines choices.Despite a doubling in the number of reviews included in this updated overview, uncertainty still exists about the effectiveness of many interventions, and the evidence on what works remains sparse for several populations, including children and young people, carers, and people with multimorbidity. AUTHORS' CONCLUSIONS This overview presents evidence from 75 reviews that have synthesised trials and other studies evaluating the effects of interventions to improve consumers' medicines use.Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers' medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.Decision makers faced with implementing interventions to improve consumers' medicines use can use this overview to inform decisions about which interventions may be most promising to improve particular outcomes. The intervention taxonomy may also assist people to consider the strategies available in relation to specific purposes, for example, gaining skills or being involved in decision making. Researchers and funders can use this overview to identify where more research is needed and assess its priority. The limitations of the available literature due to the lack of evidence for important outcomes and important populations, such as people with multimorbidity, should also be considered in practice and policy decisions.
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Affiliation(s)
- Rebecca Ryan
- Centre for Health Communication and Participation, School of Public Health and Human Biosciences, La Trobe University, Bundoora, VIC, Australia, 3086
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Effective management of childhood asthma: pediatricians need to go the extra mile! Indian J Pediatr 2013; 80:536-7. [PMID: 23771853 DOI: 10.1007/s12098-013-1105-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 05/22/2013] [Indexed: 10/26/2022]
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A medication assessment tool to evaluate adherence to medication guideline in asthmatic children. Int J Clin Pharm 2013; 35:289-95. [PMID: 23359031 DOI: 10.1007/s11096-012-9702-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Accepted: 09/17/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Asthma is one of the commonest causes of morbidity and mortality in childhood. The goals of the present study were to design a valid medication assessment tool for evaluating the quality of medication use according to recommendations of updated asthma guidelines for children aged from 5 to 12 years, and to quantify adherence to guideline recommendations. SETTING Two primary care settings in Scotland, UK. METHODS Recommendations related to the long-term management of asthmatic children in the British Thoracic Society/Scottish Intercollegiate Guidelines Network and Global Initiative for Asthma guidelines were identified and corresponding criteria were created. These criteria were incorporated to generate an assessment tool named MAT ASTHMA-PAED. Two phases of field-testing were undertaken and the tool was also subject to examination by a focus group of specialist practitioners. Thereafter, MAT ASTHMA-PAED was modified accordingly. MAIN OUTCOME MEASURE Applicability and adherence to each criterion and overall adherence to the MAT ASTHMA-PAED. RESULTS The MAT ASTHMA-PAED field-testing was undertaken in two primary care practices in Scotland, United Kingdom and 77 asthmatic children were recruited. Results of the pilot study field-testing showed a high overall adherence of 70.0 % (95 % CI: 58.7-81.3 %) to the guidelines. Low adherence (<50 %) was seen for 4 criteria, whereas 8 criteria were considered high-adherence criteria (>70 %). The final MAT ASTHMA-PAED comprised of 25 criteria was produced based on the results of field testing and the opinions from the focus group. CONCLUSION Although high utility of MAT ASTHMA-PAED criteria was found, there were gaps in the implementation of certain recommendations, particularly in relation to demonstrated satisfactory technique of inhaler. Moreover, further studies assessing the use of oral steroids and exercise-induced asthma, and wider implementation of MAT ASTHMA-PAED are required.
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Newbould J, Burt J, Bower P, Blakeman T, Kennedy A, Rogers A, Roland M. Experiences of care planning in England: interviews with patients with long term conditions. BMC FAMILY PRACTICE 2012; 13:71. [PMID: 22831570 PMCID: PMC3436749 DOI: 10.1186/1471-2296-13-71] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Accepted: 07/25/2012] [Indexed: 11/15/2022]
Abstract
BACKGROUND The prevalence and impact of long term conditions continues to rise. Care planning for people with long term conditions has been a policy priority in England for chronic disease management. However, it is not clear how care planning is currently understood, translated and implemented in primary care. This study explores experience of care planning in patients with long term conditions in three areas in England. METHODS We conducted semi-structured interviews with 23 predominantly elderly patients with multiple long term conditions. The interviews were designed to explore variations in and emergent experiences of care planning. Qualitative analysis of interview transcripts involved reflexively coding and re-coding data into categories and themes. RESULTS No participants reported experiencing explicit care planning discussions or receiving written documentation setting out a negotiated care plan and they were unfamiliar with the term 'care planning'. However, most described some components of care planning which occurred over a number of contacts with health care professionals which we term "reactive" care planning. Here, key elements of care planning including goal setting and action planning were rare. Additionally, poor continuity and coordination of care, lack of time in consultations, and patient concerns about what was legitimate to discuss with the doctor were described. CONCLUSIONS Amongst this population, elements of care planning were present in their accounts, but a structured, comprehensive process and consequent written record (as outlined in English Department of Health policy) was not evident. Further research needs to explore the advantages and disadvantages of different approaches to care planning for different patient groups.
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Affiliation(s)
- Jenny Newbould
- Cambridge Centre for Health Services Research, University of Cambridge, Cambridge, UK
| | - Jenni Burt
- Cambridge Centre for Health Services Research, University of Cambridge, Cambridge, UK
| | - Peter Bower
- Health Sciences Research Group, University of Manchester, Manchester, UK
| | - Tom Blakeman
- Health Sciences Research Group, University of Manchester, Manchester, UK
| | - Anne Kennedy
- Health Sciences Research Group, University of Manchester, Manchester, UK
| | - Anne Rogers
- Health Sciences Research Group, University of Manchester, Manchester, UK
| | - Martin Roland
- Health Sciences Research Group, University of Manchester, Manchester, UK
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Labre MP, Herman EJ, Dumitru GG, Valenzuela KA, Cechman CL. Public health interventions for asthma: an umbrella review, 1990-2010. Am J Prev Med 2012; 42:403-10. [PMID: 22424254 DOI: 10.1016/j.amepre.2011.11.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2011] [Revised: 11/04/2011] [Accepted: 11/30/2011] [Indexed: 10/28/2022]
Abstract
CONTEXT Asthma is a chronic respiratory disease increasingly prevalent in the U.S., particularly among children and certain minority groups. This umbrella review sought to assess and summarize existing systematic reviews of asthma-related interventions that might be carried out or supported by state or community asthma control programs, and to identify gaps in knowledge. EVIDENCE ACQUISITION Eleven databases were searched through September 2010, using terms related to four concepts: asthma, review, intervention, and NOT medication. Reviews of the effectiveness of medications, medical procedures, complementary and alternative medicine, psychological interventions, family therapy, and nutrients or nutritional supplements were excluded. Two coders screened each record and extracted data from the included reviews. EVIDENCE SYNTHESIS Data analysis was conducted from May to December 2010. Of 42 included reviews, 19 assessed the effectiveness of education and/or self-management, nine the reduction of indoor triggers, nine interventions to improve the provision of health care, and five examined other interventions. Several reviews found consistent evidence of effectiveness for self-management education, and one review determined that comprehensive home-based interventions including the reduction of multiple indoor asthma triggers are effective for children. Other reviews found limited or insufficient evidence because of study limitations. CONCLUSIONS State or community asthma control programs should prioritize (1) implementing interventions for which the present review found evidence of effectiveness and (2) evaluating promising interventions that have not yet been adequately assessed.
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Lougheed MD, Lemiere C, Ducharme FM, Licskai C, Dell SD, Rowe BH, FitzGerald M, Leigh R, Watson W, Boulet LP. Canadian Thoracic Society 2012 guideline update: diagnosis and management of asthma in preschoolers, children and adults. Can Respir J 2012; 19:127-64. [PMID: 22536582 PMCID: PMC3373283 DOI: 10.1155/2012/635624] [Citation(s) in RCA: 209] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND In 2010, the Canadian Thoracic Society (CTS) published a Consensus Summary for the diagnosis and management of asthma in children six years of age and older, and adults, including an updated Asthma Management Continuum. The CTS Asthma Clinical Assembly subsequently began a formal clinical practice guideline update process, focusing, in this first iteration, on topics of controversy and⁄or gaps in the previous guidelines. METHODS Four clinical questions were identified as a focus for the updated guideline: the role of noninvasive measurements of airway inflammation for the adjustment of anti-inflammatory therapy; the initiation of adjunct therapy to inhaled corticosteroids (ICS) for uncontrolled asthma; the role of a single inhaler of an ICS⁄long-acting beta(2)-agonist combination as a reliever, and as a reliever and a controller; and the escalation of controller medication for acute loss of asthma control as part of a self-management action plan. The expert panel followed an adaptation process to identify and appraise existing guidelines on the specified topics. In addition, literature searches were performed to identify relevant systematic reviews and randomized controlled trials. The panel formally assessed and graded the evidence, and made 34 recommendations. RESULTS The updated guideline recommendations outline a role for inclusion of assessment of sputum eosinophils, in addition to standard measures of asthma control, to guide adjustment of controller therapy in adults with moderate to severe asthma. Appraisal of the evidence regarding which adjunct controller therapy to add to ICS and at what ICS dose to begin adjunct therapy in children and adults with poor asthma control supported the 2010 CTS Consensus Summary recommendations. New recommendations for the adjustment of controller medication within written action plans are provided. Finally, priority areas for future research were identified. CONCLUSIONS The present clinical practice guideline is the first update of the CTS Asthma Guidelines following the Canadian Respiratory Guidelines Committee's new guideline development process. Tools and strategies to support guideline implementation will be developed and the CTS will continue to regularly provide updates reflecting new evidence.
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Abstract
Asthma is a common inflammatory condition affecting more than 7 million children in the United States alone, and tens of millions more globally. Despite effective preventive medications, medication nonadherence in children and adolescents is alarmingly high. Nonadherence can result in poor asthma control, which leads to decreased quality of life, lost productivity, increased health care utilization, and even the risk of death. Nonadherence in children and adolescents deserves special attention because they face unique barriers to adherence that change with age. Young children depend on adults for the delivery of asthma care, and their care is strongly influenced by parental motivation and attitudes and the home environment. As these children enter adolescence, they typically assume responsibility for their asthma care at the same time that they are claiming their independence and possibly experimenting with high-risk behaviors. Morbidity and mortality, as well as nonadherence, appear to be greatest among adolescents and minority children. Although no perfect tool for measuring adherence exists, objective methods, such as electronic monitoring, can provide valuable information to health care providers. Beyond asthma self-management and education, no specific resource-heavy adherence interventions have proven consistently helpful. However, large-scale, well-designed studies on this subject are lacking. In light of the fact that nonadherence is a potentially modifiable factor that impacts on morbidity and mortality, it is worth pursuing further research to determine better interventions. It is likely, however, that no one answer exists, and interventions will need to be tailored to specific at-risk populations.
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Mosnaim GS. Do we have evidence that pediatric written asthma action plans really work? Ann Allergy Asthma Immunol 2011; 107:187-8. [PMID: 21875533 DOI: 10.1016/j.anai.2011.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2011] [Revised: 06/27/2011] [Accepted: 07/11/2011] [Indexed: 10/17/2022]
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Silver A, Figge J, Haskin DL, Pryor V, Fuller K, Lemme T, Li N, O'Brien MJ. An asthma and diabetes quality improvement project: enhancing care in clinics and community health centers. J Community Health 2011; 36:180-90. [PMID: 20668924 DOI: 10.1007/s10900-010-9296-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Asthma and diabetes are major chronic conditions in the United States, particularly in the Medicaid population. The majority of care for these diseases occurs at ambulatory practice sites. The New York State Department of Health Office of Health Insurance Programs (OHIP) worked with IPRO, the New York State Medicare quality improvement organization, to develop and implement a quality improvement project (QIP) for these conditions. The approach was based upon the Chronic Care Model and used an iterative academic-detailing methodology. Clinics and community health centers volunteered to participate and used IPRO-collected data with audit and feedback to improve their practices. Several metrics significantly improved for asthma (e.g., use of anti-inflammatory long term controller agents, assessment of asthma severity, use of asthma action plans) and for diabetes (e.g., lipid testing and control, A1c testing). Key organizational elements of success included senior medical leadership commitment and practice site quality improvement team meetings. OHIP has used the QIP experience to begin patient-centered medical home implementation in New York State.
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Affiliation(s)
- Alan Silver
- IPRO Health Care Quality Improvement Team, 1979 Marcus Ave., Lake Success, NY 11042, USA.
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Sunshine J, Song L, Krieger J. Written action plan use in inner-city children: is it independently associated with improved asthma outcomes? Ann Allergy Asthma Immunol 2011; 107:207-13. [PMID: 21875538 DOI: 10.1016/j.anai.2011.04.015] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Revised: 04/23/2011] [Accepted: 04/26/2011] [Indexed: 11/29/2022]
Abstract
BACKGROUND Guidelines from the National Asthma Education and Prevention Program stipulate that multicomponent self-management interventions for asthma should include a written action plan (WAP). However the specific, independent effect of WAPs in improving outcomes remains unclear. OBJECTIVE To measure the association between WAP use during the previous year and improved asthma outcomes. METHODS We conducted a longitudinal quasi-experimental study using data from the Healthy Homes II (HH-II) randomized controlled trial in Seattle, WA. Action plan use during the previous year was measured at exit of HH-II. A participant was a WAP user if he used his action plan every day, almost every day, or once per week, and non-user if he did not meet these criteria. Sensitivity analyses explored less stringent criteria for WAP user designation. Prespecified outcomes were baseline-to-exit changes in asthma control in the previous 2 weeks, Pediatric Asthma Caregiver Quality of Life Scale score, and urgent health services utilization. We used robust linear and logistic regression to compare outcomes across groups. RESULTS Two hundred fifty-one patients participated: 112 WAP users; 139 non-users. After adjustment, no significant differences in outcomes were observed between WAP users and non-users. Among a subgroup of participants with recent urgent health services utilization, WAP users had better asthma control than non-users. Changing WAP user criteria to include those who simply owned an action plan, irrespective of use, did not alter our results. CONCLUSION WAP use during the previous year was not associated with improved outcomes compared with non-use. Additional studies are needed to assess the long-term, independent benefit of this universally recommended intervention.
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Affiliation(s)
- Jacob Sunshine
- University of Washington School of Medicine, Seattle, WA 98195-6340, USA.
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Ring N, Pinnock H, Wilson C, Hoskins G, Jepson R, Wyke S, Sheikh A. Understanding what asthma plans mean: a linguistic analysis of terminology used in published texts. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2011; 20:170-7; 4 p following 177. [PMID: 21445536 PMCID: PMC6549815 DOI: 10.4104/pcrj.2011.00012] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2010] [Revised: 05/26/2010] [Accepted: 12/25/2010] [Indexed: 01/01/2023]
Abstract
AIM To identify from the literature what terms are used for 'asthma plans', with what meaning, and in what context(s). METHODS Linguistic analysis of a selected body of asthma literature from 1989-2009. RESULTS A wide range of asthma plan terminology was evident, with terms such as 'action plans', 'self-management plans' and 'treatment plans' being applied inconsistently and synonymously. For individual patients the term 'asthma plan' can describe a clinically-determined list of prescribed medication, an agreed plan to guide self-management of changing symptoms, or a more holistic 'living with asthma' plan. In some contexts the term 'asthma plan' was also used to describe an organisational system of care, which causes further ambiguity. CONCLUSIONS Within the literature, a plethora of terms is used inconsistently and with varied meaning. This is a potential, but previously unrecognised, barrier to asthma plan implementation. A taxonomy of asthma plans and a standardised definitions of terms is required.
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Affiliation(s)
- Nicola Ring
- School of Nursing, Midwifery and Health, University of Stirling, Stirling, UK.
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Ryan R, Santesso N, Hill S, Lowe D, Kaufman C, Grimshaw J. Consumer-oriented interventions for evidence-based prescribing and medicines use: an overview of systematic reviews. Cochrane Database Syst Rev 2011:CD007768. [PMID: 21563160 DOI: 10.1002/14651858.cd007768.pub2] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Numerous systematic reviews exist on interventions to improve consumers' medicines use, but this research is distributed across diseases, populations and settings. The scope and focus of reviews on consumers' medicines use also varies widely. Such differences create challenges for decision makers seeking review-level evidence to inform decisions about medicines use. OBJECTIVES To synthesise the evidence from systematic reviews on the effects of interventions which target healthcare consumers to promote evidence-based prescribing for, and medicines use, by consumers. We sought evidence on the effects on health and other outcomes for healthcare consumers, professionals and services. METHODS We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching both databases from start date to Issue 3 2008. We screened and ranked reviews based on relevance to consumers' medicines use, using criteria developed for this overview. Standardised forms were used to extract data, and reviews were assessed for methodological quality using the AMSTAR instrument. We used standardised language to summarise results within and across reviews; and a further synthesis step was used to give bottom-line statements about intervention effectiveness. Two review authors selected reviews, extracted and analysed data. We used a taxonomy of interventions to categorise reviews. MAIN RESULTS We included 37 reviews (18 Cochrane, 19 non-Cochrane), of varied methodological quality.Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation, skills acquisition and information provision. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most commonly reported outcome, but others such as clinical (health and wellbeing), service use and knowledge outcomes were also reported. Reviews rarely reported adverse events or harms, and the evidence was sparse for several populations, including children and young people, carers, and people with multimorbidity.Promising interventions to improve adherence and other key medicines use outcomes (eg adverse events, knowledge) included self-monitoring and self-management, simplified dosing and interventions directly involving pharmacists. Other strategies showed promise in relation to adherence but their effects were less consistent. These included reminders; education combined with self-management skills training, counselling or support; financial incentives; and lay health worker interventions.No interventions were effective to improve all medicines use outcomes across all diseases, populations or settings. For some interventions, such as information or education provided alone, the evidence suggests ineffectiveness; for many others there is insufficient evidence to determine effects on medicines use outcomes. AUTHORS' CONCLUSIONS Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers' medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.Decision makers faced with implementing interventions to improve consumers' medicines use can use this overview to inform these decisions and also to consider the range of interventions available; while researchers and funders can use this overview to determine where research is needed. However, the limitations of the literature relating to the lack of evidence for important outcomes and specific populations, such as people with multimorbidity, should also be considered.
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Affiliation(s)
- Rebecca Ryan
- Centre for Health Communication and Participation, Australian Institute for Primary Care & Ageing, La Trobe University, Bundoora, VIC, Australia, 3086
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Twelve evidence-based principles for implementing self-management support in primary care. Jt Comm J Qual Patient Saf 2011; 36:561-70. [PMID: 21222358 DOI: 10.1016/s1553-7250(10)36084-3] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Recommendations to improve self-management support and health outcomes for people with chronic conditions in primary care settings are provided on the basis of expert opinion supported by evidence for practices and processes. Practices and processes that could improve self-management support in primary care were identified through a nominal group process. In a targeted search strategy, reviews and meta-analyses were then identifed using terms from a wide range of chronic conditions and behavioral risk factors in combination with Self-Care, Self-Management, and Primary Care. On the basis of these reviews, evidence-based principles for self-management support were developed. FINDINGS The evidence is organized within the framework of the Chronic Care Model. Evidence-based principles in 12 areas were associated with improved patient self-management and/or health outcomes: (1) brief targeted assessment, (2) evidence-based information to guide shared decision-making, (3) use of a nonjudgmental approach, (4) collaborative priority and goal setting, (5) collaborative problem solving, (6) self-management support by diverse providers, (7) self-management interventions delivered by diverse formats, (8) patient self-efficacy, (9) active followup, (10) guideline-based case management for selected patients, (11) linkages to evidence-based community programs, and (12) multifaceted interventions. A framework is provided for implementing these principles in three phases of the primary care visit: enhanced previsit assessment, a focused clinical encounter, and expanded postvisit options. CONCLUSIONS There is a growing evidence base for how self-management support for chronic conditions can be integrated into routine health care.
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Bailey CD, Wagland R, Dabbour R, Caress A, Smith J, Molassiotis A. An integrative review of systematic reviews related to the management of breathlessness in respiratory illnesses. BMC Pulm Med 2010; 10:63. [PMID: 21143887 PMCID: PMC3016307 DOI: 10.1186/1471-2466-10-63] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2010] [Accepted: 12/09/2010] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Breathlessness is a debilitating and distressing symptom in a wide variety of diseases and still a difficult symptom to manage. An integrative review of systematic reviews of non-pharmacological and pharmacological interventions for breathlessness in non-malignant disease was undertaken to identify the current state of clinical understanding of the management of breathlessness and highlight promising interventions that merit further investigation. METHODS Systematic reviews were identified via electronic databases between July 2007 and September 2009. Reviews were included within the study if they reported research on adult participants using either a measure of breathlessness or some other measure of respiratory symptoms. RESULTS In total 219 systematic reviews were identified and 153 included within the final review, of these 59 addressed non-pharmacological interventions and 94 addressed pharmacological interventions. The reviews covered in excess of 2000 trials. The majority of systematic reviews were conducted on interventions for asthma and COPD, and mainly focussed upon a small number of pharmacological interventions such as corticosteroids and bronchodilators, including beta-agonists. In contrast, other conditions involving breathlessness have received little or no attention and studies continue to focus upon pharmacological approaches. Moreover, although there are a number of non-pharmacological studies that have shown some promise, particularly for COPD, their conclusions are limited by a lack of good quality evidence from RCTs, small sample sizes and limited replication. CONCLUSIONS More research should focus in the future on the management of breathlessness in respiratory diseases other than asthma and COPD. In addition, pharmacological treatments do not completely manage breathlessness and have an added burden of side effects. It is therefore important to focus more research on promising non-pharmacological interventions.
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Affiliation(s)
- Chris D Bailey
- Faculty of Health Sciences, University of Southampton, Highfield, Southampton, SO17 1BJ, UK
| | - Richard Wagland
- Faculty of Health Sciences, University of Southampton, Highfield, Southampton, SO17 1BJ, UK
| | - Rasha Dabbour
- School of Nursing, Midwifery & Social Work, University of Manchester, Manchester M13 9PL, UK
| | - Ann Caress
- School of Nursing, Midwifery & Social Work, University of Manchester, Manchester M13 9PL, UK
| | - Jaclyn Smith
- Department of Translational Medicine, University of Manchester, Manchester, UK & Johns Hopkins Asthma and Allergy Center, Boston, USA
| | - Alex Molassiotis
- School of Nursing, Midwifery & Social Work, University of Manchester, Manchester M13 9PL, UK
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Montani D, Cavailles A, Bertoletti L, Botelho A, Cortot A, Taillé C, Marchand-Adam S, Pinot D, Chouaid C, Crestani B, Garcia G, Humbert M, L'huillier JP, Magnan A, Tillie-Leblond I, Chanez P. [Adult asthma exacerbations in questions]. Rev Mal Respir 2010; 27:1175-94. [PMID: 21163396 DOI: 10.1016/j.rmr.2010.10.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2009] [Accepted: 06/16/2010] [Indexed: 11/26/2022]
Abstract
In this article a French working party critically review the international literature to revise the definition, pathophysiology, treatment and cost of exacerbations of adult asthma. The various guidelines do not always provide a consistent definition of exacerbations of asthma. An exacerbation can be defined as deterioration of clinical and/or functional parameters lasting more than 24 hours, without return to baseline, requiring a change of treatment. No single clinical or functional criterion can be used as an early marker of an exacerbation. Innate and acquired immune mechanisms, modified by contact with infectious, irritant or allergenic agents, participate in the pathogenesis of exacerbations, which are accompanied by bronchial inflammation. In 2010, mortality is related to progression of exacerbations, often occurring before the patient seeks medical attention. The objective of treatment is to control asthma and prevent exacerbations. However, many factors can trigger exacerbations and often cannot be controlled. The efficacy of inhaled corticosteroids has been demonstrated on reduction of the number of exacerbations and the number of asthma-related deaths. This treatment is cost-effective, especially in terms of reduction of exacerbations.
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Affiliation(s)
- D Montani
- Service de Pneumologie et de Réanimation Respiratoire, Hôpital Antoine-Béclère, Université Paris-Sud 11, AP-HP, 157 Rue de la Porte-de-Trivaux, 92140 Clamart, France.
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Adams RJ. Improving health outcomes with better patient understanding and education. Risk Manag Healthc Policy 2010; 3:61-72. [PMID: 22312219 PMCID: PMC3270921 DOI: 10.2147/rmhp.s7500] [Citation(s) in RCA: 205] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
A central plank of health care reform is an expanded role for educated consumers interacting with responsive health care teams. However, for individuals to realize the benefits of health education also requires a high level of engagement. Population studies have documented a gap between expectations and the actual performance of behaviours related to participation in health care and prevention. Interventions to improve self-care have shown improvements in self-efficacy, patient satisfaction, coping skills, and perceptions of social support. Significant clinical benefits have been seen from trials of self-management or lifestyle interventions across conditions such as diabetes, coronary heart disease, heart failure and rheumatoid arthritis. However, the focus of many studies has been on short-term outcomes rather that long term effects. There is also some evidence that participation in patient education programs is not spread evenly across socio economic groups. This review considers three other issues that may be important in increasing the public health impact of patient education. The first is health literacy, which is the capacity to seek, understand and act on health information. Although health literacy involves an individual's competencies, the health system has a primary responsibility in setting the parameters of the health interaction and the style, content and mode of information. Secondly, much patient education work has focused on factors such as attitudes and beliefs. That small changes in physical environments can have large effects on behavior and can be utilized in self-management and chronic disease research. Choice architecture involves reconfiguring the context or physical environment in a way that makes it more likely that people will choose certain behaviours. Thirdly, better means of evaluating the impact of programs on public health is needed. The Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework has been promoted as one such potential approach.
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Affiliation(s)
- Robert John Adams
- The Health Observatory, The Queen Elizabeth Hospital Campus, The University of Adelaide, Woodville, South Australia, Australia
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Ducharme FM, Zemek RL, Chalut D, McGillivray D, Noya FJD, Resendes S, Khomenko L, Rouleau R, Zhang X. Written action plan in pediatric emergency room improves asthma prescribing, adherence, and control. Am J Respir Crit Care Med 2010; 183:195-203. [PMID: 20802165 DOI: 10.1164/rccm.201001-0115oc] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
RATIONALE An acute-care visit for asthma often signals a management failure. Although a written action plan is effective when combined with self-management education and regular medical review, its independent value remains controversial. OBJECTIVES We examined the efficacy of providing a written action plan coupled with a prescription (WAP-P) to improve adherence to medications and other recommendations in a busy emergency department. METHODS We randomized 219 children aged 1-17 years to receive WAP-P (n = 109) or unformatted prescription (UP) (n = 110). All received fluticasone and albuterol inhalers, fitted with dose counters, to use at the discretion of the emergency physician. The main outcome was adherence to fluticasone (use/prescribed × 100%) over 28 days. Secondary outcomes included pharmacy dispensation of oral corticosteroids, β(2)-agonist use, medical follow-up, asthma education, acute-care visits, and control. MEASUREMENTS AND MAIN RESULTS Although both groups showed a similar drop in adherence in the initial 14 days, adherence to fluticasone was significantly higher over Days 15-28 in children receiving WAP-P (mean group difference, 16.13% [2.09, 29.91]). More WAP-P than UP patients filled their oral corticosteroid prescription (relative risk, 1.31 [1.07, 1.60]) and were well-controlled at 28 days (1.39 [1.04, 1.86]). Compared with UP, use of WAP-P increased physicians' prescription of maintenance fluticasone (2.47 [1.53, 3.99]) and recommendation for medical follow-up (1.87 [1.48, 2.35]), without group differences in other outcomes. CONCLUSIONS Provision of a written action plan significantly increased patient adherence to inhaled and oral corticosteroids and asthma control and physicians' recommendation for maintenance fluticasone and medical follow-up, supporting its independent value in the acute-care setting. Clinical trial registered with www.clinicaltrials.gov (NCT 00381355).
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Chang AB, Taylor B, Masters IB, Laifoo Y, Brown AD. Indigenous healthcare worker involvement for Indigenous adults and children with asthma. Cochrane Database Syst Rev 2010:CD006344. [PMID: 20464742 DOI: 10.1002/14651858.cd006344.pub3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Asthma education is regarded as an important step in the management of asthma in national guidelines. Racial, ethnicity and socio-economic factors are associated with markers of asthma severity, including recurrent acute presentations to emergency health facilities. Worldwide, indigenous groups are disproportionately represented in the severe end of the asthma spectrum. Appropriate models of care are important in the successful delivery of services, and are likely contributors to improved outcomes for people with asthma. OBJECTIVES To determine whether involvement of an indigenous healthcare worker (IHW) in comparison to absence of an IHW in asthma education programs, improves asthma related outcomes in indigenous children and adults with asthma. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register, MEDLINE and EMBASE databases, review articles and reference lists of relevant articles. The latest search was in January 2010. SELECTION CRITERIA All randomised controlled trials comparing involvement of an indigenous healthcare worker (IHW) in comparison to absence of an IHW in asthma education programs for indigenous people with asthma. DATA COLLECTION AND ANALYSIS Two independent review authors selected data for inclusion, a single author extracted the data. Both review authors independently assessed study quality. We contacted authors for further information. As it was not possible to analyse data as "intention-to-treat", we analysed data as "treatment received". MAIN RESULTS Two studies fulfilled inclusion criteria involving 133 children randomised to an asthma education programme involving an IHW, compared to a similar education programme without an IHW. One study was not strictly Indigenous. 110 of these children completed the trials. Children's asthma knowledge score was significantly better in the group that had IHW education compared with control (mean difference 3.30; 95% CI 1.07 to 5.53), parents' asthma knowledge score (standardised mean difference (SMD) 1.23; 95% CI 0.59 to 1.87), parents' asthma skill score (SMD 0.67; 95% CI 0.28 to 1.06) and days absent from school (100% school-aged children in the intervention group missed <7 days, 21% of controls missed 7-14 days, difference = 21%, 95%CI 5-36%). There was no significant difference in mean number of exacerbations (per year) between groups. There was no difference in quality of life or children's asthma skill score; both were limited to one study only and the direction favoured IHW group. There were no studies in adults. AUTHORS' CONCLUSIONS The involvement of IHW in asthma programs targeted for their own ethnic group in 2 small trials was beneficial in improving most, but not all asthma outcomes in children with asthma. It is very likely that involvement of an IHW is beneficial. However as exacerbation frequency was not significantly different between groups, we cannot be confident of the results in all settings. Nevertheless, given the complexity of health outcomes and culture as well as the importance of self-determination for indigenous peoples, the practice of including IHW in asthma education programs for indigenous children and adults with asthma is justified, but should be subject to further randomised controlled trials.
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Affiliation(s)
- Anne B Chang
- Royal Children's Hospital, Brisbane and Menzies School of Health Research, CDU, Darwin;, Queensland Children's Respiratory Centre and Queensland Children's Medical Research Institute, Herston Road, Herston, Brisbane, Queensland, Australia, 4029
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Curran JA, Osmond MH, Fitzpatrick E, Newton A, Sinclair D, Zee R, Johnson DW. Interventions to improve management and health outcomes for children and adults with asthma who present to the emergency department. Hippokratia 2010. [DOI: 10.1002/14651858.cd008245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Janet A Curran
- IWK Health Centre; Interdisciplinary Research; 5850 University Ave PO Box 9700 Halifax Nova Scotia Canada B3K 6R8
| | - Martin H Osmond
- University of Ottawa; Children's Hospital of Eastern Ontario; 401 Smyth Road Ottawa Ontario Canada K1H 8L1
| | - Eleanor Fitzpatrick
- IWK Health Centre; Emergency Department; 5850 University Ave PO Box 9700 Halifax Nova Scotia Canada B3K 6R8
| | - Amanda Newton
- University of Alberta; Pediatrics; 1048A Research Transition Facility University of Alberta Edmonton AB Canada T6G 2V2
| | - Douglas Sinclair
- IWK Health Centre; Emergency Department; 5850 University Ave PO Box 9700 Halifax Nova Scotia Canada B3K 6R8
| | - Rebekah Zee
- IWK Health Centre; 5850/5980 University Avenue PO Box 9700 Halifax Nova Scotia Canada B3K 6R8
| | - David W Johnson
- Alberta Health Services; Departments of Pediatrics; Alberta Children's Hospital 2888 Shaganappi Trail NW Calgary Alberta Canada T3B 6A8
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30
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Lougheed MD, Lemière C, Dell SD, Ducharme FM, Fitzgerald JM, Leigh R, Licskai C, Rowe BH, Bowie D, Becker A, Boulet LP. Canadian Thoracic Society Asthma Management Continuum--2010 Consensus Summary for children six years of age and over, and adults. Can Respir J 2010; 17:15-24. [PMID: 20186367 PMCID: PMC2866209 DOI: 10.1155/2010/827281] [Citation(s) in RCA: 131] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND/OBJECTIVE To integrate new evidence into the Canadian Asthma Management Continuum diagram, encompassing both pediatric and adult asthma. METHODS The Canadian Thoracic Society Asthma Committee members, comprised of experts in pediatric and adult respirology, allergy and immunology, emergency medicine, general pediatrics, family medicine, pharmacoepidemiology and evidence-based medicine, updated the continuum diagram, based primarily on the 2008 Global Initiative for Asthma guidelines, and performed a focused review of literature pertaining to key aspects of asthma diagnosis and management in children six years of age and over, and adults. RESULTS In patients six years of age and over, management of asthma begins with establishing an accurate diagnosis, typically by supplementing medical history with objective measures of lung function. All patients and caregivers should receive self-management education, including a written action plan. Inhaled corticosteroids (ICS) remain the first-line controller therapy for all ages. When asthma is not controlled with a low dose of ICS, the literature supports the addition of long-acting beta2-agonists in adults, while the preferred approach in children is to increase the dose of ICS. Leukotriene receptor antagonists are acceptable as second-line monotherapy and as an alternative add-on therapy in both age groups. Antiimmunoglobulin E therapy may be of benefit in adults, and in children 12 years of age and over with difficult to control allergic asthma, despite high-dose ICS and at least one other controller. CONCLUSIONS The foundation of asthma management is establishing an accurate diagnosis based on objective measures (eg, spirometry) in individuals six years of age and over. Emphasis is placed on the similarities and differences between pediatric and adult asthma management approaches to achieve asthma control.
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Bailey EJ, Cates CJ, Kruske SG, Morris PS, Brown N, Chang AB. Culture-specific programs for children and adults from minority groups who have asthma. Cochrane Database Syst Rev 2009:CD006580. [PMID: 19370643 DOI: 10.1002/14651858.cd006580.pub4] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND People with asthma who come from minority groups have poorer asthma outcomes and more asthma related visits to Emergency Departments (ED). Various programmes are used to educate and empower people with asthma and these have previously been shown to improve certain asthma outcomes. Models of care for chronic diseases in minority groups usually include a focus of the cultural context of the individual and not just the symptoms of the disease. Therefore, questions about whether culturally specific asthma education programmes for people from minority groups are effective at improving asthma outcomes, are feasible and are cost-effective need to be answered. OBJECTIVES To determine whether culture-specific asthma programmes, in comparison to generic asthma education programmes or usual care, improve asthma related outcomes in children and adults with asthma who belong to minority groups. SEARCH STRATEGY We searched the Cochrane Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register, MEDLINE, EMBASE, review articles and reference lists of relevant articles. The latest search was performed in May 2008. SELECTION CRITERIA All randomised controlled trials (RCTs) comparing the use of culture-specific asthma education programmes with generic asthma education programmes, or usual care, in adults or children from minority groups who suffer from asthma. DATA COLLECTION AND ANALYSIS Two review authors independently selected, extracted and assessed the data for inclusion. We contacted authors for further information if required. MAIN RESULTS Four studies were eligible for inclusion in the review. A total of 617 patients, aged from 5 to 59 years were included in the meta-analysis of data. Use of a culture-specific programme was superior to generic programmes or usual care, in improving asthma quality of life scores in adults, pooled WMD 0.25 (95% CI 0.09 to 0.41), asthma knowledge scores in children, WMD 3.30 (95% CI 1.07 to 5.53), and in a single study, reducing asthma exacerbation in children (risk ratio for hospitalisations 0.32, 95%CI 0.15, 0.70). AUTHORS' CONCLUSIONS Current limited data show that culture-specific programmes for adults and children from minority groups with asthma, are more effective than generic programmes in improving most (quality of life, asthma knowledge, asthma exacerbations, asthma control) but not all asthma outcomes. This evidence is limited by the small number of included studies and the lack of reported outcomes. Further trials are required to answer this question conclusively.
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Affiliation(s)
- Emily J Bailey
- Child Health Division, Menzies School of Health Research, Darwin, Brisbane, Queensland, Australia.
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33
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Bailey EJ, Cates CJ, Kruske SG, Morris PS, Chang AB, Brown N. Culture-specific programs for children and adults from minority groups who have asthma. Cochrane Database Syst Rev 2009:CD006580. [PMID: 19160290 DOI: 10.1002/14651858.cd006580.pub3] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND People with asthma who come from minority groups have poorer asthma outcomes and more asthma related visits to Emergency Departments (ED). Various programmes are used to educate and empower people with asthma and these have previously been shown to improve certain asthma outcomes. Models of care for chronic diseases in minority groups usually include a focus of the cultural context of the individual and not just the symptoms of the disease. Therefore, questions about whether culturally specific asthma education programmes for people from minority groups are effective at improving asthma outcomes, are feasible and are cost-effective need to be answered. OBJECTIVES To determine whether culture-specific asthma programmes, in comparison to generic asthma education programmes or usual care, improve asthma related outcomes in children and adults with asthma who belong to minority groups. SEARCH STRATEGY We searched the Cochrane Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register, MEDLINE, EMBASE, review articles and reference lists of relevant articles. The latest search was performed in May 2008. SELECTION CRITERIA All randomised controlled trials (RCTs) comparing the use of culture-specific asthma education programmes with generic asthma education programmes, or usual care, in adults or children from minority groups who suffer from asthma. DATA COLLECTION AND ANALYSIS Two review authors independently selected, extracted and assessed the data for inclusion. We contacted authors for further information if required. MAIN RESULTS Four studies were eligible for inclusion in the review. A total of 617 patients, aged from 5 to 59 years were included in the meta-analysis of data. Use of a culture-specific programme was superior to generic programmes or usual care, in improving asthma quality of life scores in adults, pooled WMD 0.25 (95% CI 0.09 to 0.41), asthma knowledge scores in children, WMD 3.30 (95% CI 1.07 to 5.53), and in a single study, reducing asthma exacerbation in children (risk ratio for hospitalisations 0.32, 95%CI 0.15, 0.70). AUTHORS' CONCLUSIONS Current limited data show that culture-specific programmes for adults and children from minority groups with asthma, are more effective than generic programmes in improving most (quality of life, asthma knowledge, asthma exacerbations, asthma control) but not all asthma outcomes. This evidence is limited by the small number of included studies and the lack of reported outcomes. Further trials are required to answer this question conclusively.
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Affiliation(s)
- Emily J Bailey
- Child Health Division, Menzies School of Health Research, Darwin, Brisbane, Queensland, Australia.
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Coster S, Norman I. Cochrane reviews of educational and self-management interventions to guide nursing practice: a review. Int J Nurs Stud 2008; 46:508-28. [PMID: 19012889 DOI: 10.1016/j.ijnurstu.2008.09.009] [Citation(s) in RCA: 166] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2008] [Revised: 09/09/2008] [Accepted: 09/11/2008] [Indexed: 11/18/2022]
Abstract
BACKGROUND The burden of chronic disease on healthcare services worldwide is growing and the increased development of educational interventions which help patients to better manage their own conditions is evident internationally. OBJECTIVES This paper reports on findings of a review of Cochrane systematic reviews of interventions designed to improve patients' knowledge and skills to manage chronic disease, with particular reference to nursing contribution and practice. METHODS Thirty Cochrane systematic reviews were identified as meeting the inclusion criteria. Data were extracted and summarised. FINDINGS The majority of reviews included in this paper were judged by Cochrane reviewers to provide inadequate evidence (n=18, 60%) of the effectiveness of the interventions reviewed. Information on the professional delivering the interventions was often not available, although 77% (23) of reviews mentioned that nurses were involved in a proportion of studies. CONCLUSION Educational programmes have definite benefits for patients suffering from asthma and are promising for interventions in areas such as diabetes mellitus, epilepsy and mental health. However, it still is not clear what the active ingredients of many successful interventions are.
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Affiliation(s)
- Samantha Coster
- Florence Nightingale School of Nursing and Midwifery, Division of Health and Social Care, King's College, London, UK.
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35
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Rank MA, Volcheck GW, Li JTC, Patel AM, Lim KG. Formulating an effective and efficient written asthma action plan. Mayo Clin Proc 2008; 83:1263-70. [PMID: 18990325 DOI: 10.4065/83.11.1263] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Written asthma action plans (WAAPs) are recommended by national and international guidelines to help patients recognize and manage asthma exacerbations. Despite this recommendation, many patients with asthma do not have a WAAP. In addition, WAAPs vary widely in their readability and usability. To promote issuance and patient use, the WAAP should clearly define the decision (action) points, expected response, and expected time of response. The WAAP should also be easily integrated into a physician's busy practice. Herein, we describe the key elements of an effective WAAP, including concise, detailed recommendations regarding asthma exacerbation recognition (patient self-monitoring) and treatment.
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Affiliation(s)
- Matthew A Rank
- Division of Allergic Diseases, Mayo Clinic, Rochester, MN 55905, USA
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Abstract
Cochrane systematic reviews and meta-analyses on education and monitoring of asthmatic children have come to divergent conclusions, mainly because of the heterogeneity of education programmes and patients. There is little doubt that education is useful. However, the useful components of the education programmes remain to be elucidated, not only by randomized controlled trials but also by observational studies performed within distinct asthma phenotypes. Any education and monitoring package needs to contain basic explanation about the disease and its influencing factors, as well as inhalation instructions. There is no good evidence to justify home monitoring of lung function; symptom monitoring suffices. Probably, the crucial part of asthma education programmes is a high level of agreement between patient and doctor regarding the goals of the treatment (patient-doctor partnership). Therefore, further exploration of the patient's needs should be worthwhile.
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Affiliation(s)
- Alwin F J Brouwer
- Princess Amalia Children's Clinic, Isala klinieken, PO Box 10400, 8000 GK Zwolle, The Netherlands.
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Abstract
This article presents our current understanding of the biological heterogeneity of asthma and reviews some of the key features of the latest proposed recommendations of the National Asthma Education and Prevention Program Guidelines. The diagnosis of asthma is based on such clinical features as variable airflow obstruction that is partially if not fully reversible and airway hyperresponsiveness that predisposes to episodic bronchospasm following exposure to a variety of triggers. The underlying inflammation and airway biology of asthma is heterogeneous and is part of the explanation for the variable response to therapy. New biologics that help to characterize patients according to their underlying biology will aid in making better choices for treatment. New asthma guidelines emphasize the importance of regular monitoring.
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Affiliation(s)
- Ronald Balkissoon
- National Jewish Medical and Research Center, The University of Colorado School of Medicine, 1400 Jackson Street, Room J215, Denver, CO 80206, USA.
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38
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Castillo Laita JA, De Benito Fernández J, Escribano Montaner A, Fernández Benítez M, García de la Rubia S, Garde Garde J, García-Marcos L, González Díaz C, Ibero Iborra M, Navarro Merino M, Pardos Martínez C, Pellegrini Belinchon J, Sánchez Jiménez J, Sanz Ortega J, Villa Asensi JR. Consensus statement on the management of paediatric asthma. Update 2007. First Spanish Consensus for the Management of Asthma in Paediatrics. Allergol Immunopathol (Madr) 2008; 36:31-52. [PMID: 18261431 DOI: 10.1157/13115669] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Chang AB, Taylor B, Masters IB, Laifoo Y, Brown ADH. Indigenous healthcare worker involvement for Indigenous adults and children with asthma. Cochrane Database Syst Rev 2007:CD006344. [PMID: 17943904 DOI: 10.1002/14651858.cd006344.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Asthma education is regarded as an important step in the management of asthma in national guidelines. Racial and socio-economic factors are associated with markers of asthma severity, including recurrent acute presentations to emergency health facilities. Worldwide, indigenous groups are disproportionately represented in the severe end of the asthma spectrum. Appropriate models of care are important in the successful delivery of services, and are likely contributors to improved outcomes for people with asthma. OBJECTIVES To determine whether involvement of an indigenous healthcare worker (IHW) in comparison to absence of an IHW in asthma education programmes, improves asthma related outcomes in indigenous children and adults with asthma. SEARCH STRATEGY We searched the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Airways Group Specialised Register, MEDLINE and EMBASE databases, review articles and reference lists of relevant articles. The latest search was in December 2006. SELECTION CRITERIA All randomised controlled trials comparing involvement of an indigenous healthcare worker (IHW) in comparison to absence of an IHW in asthma education programmes for indigenous people with asthma. DATA COLLECTION AND ANALYSIS Two independent review authors selected data for inclusion, a single author extracted the data. Both review authors independently assessed study quality. We contacted authors for further information. As it was not possible to analyse data as "intention-to-treat", we analysed data as "treatment received". MAIN RESULTS Only a single study was applicable for this review, and included 24 children randomised to an asthma education programme involving an IHW, compared to a similar intervention without an IHW. Twenty two of these children completed the trial. Only one outcome (asthma knowledge in children, mean difference of 3.30 units, 95% CI 1.07 to 5.53) significantly favoured the IHW involvement group. However, although not statistically significant, all the outcomes favoured the group that had IHW involvement in the asthma education program. There were no studies in adults. AUTHORS' CONCLUSIONS The involvement of IHW in asthma programs targeted for their own ethnic group in one small trial was beneficial for some but not all asthma outcomes. Thus there is insufficient data to be confident that the involvement of IHW is beneficial in all settings. Nevertheless, given the complexity of health outcomes and culture as well as the importance of self-determination for indigenous peoples, the practice of including IHW in asthma education programs for indigenous children and adults with asthma is justified, but should be subject to further randomised controlled trials.
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Affiliation(s)
- A B Chang
- Royal Children's Hospital, Brisbane and Menzies School of Health Research, CDU, Respiratory Medicine Level 3 Woolworths Bldg, Herston Road, Herston, Brisbane, Queensland, Australia, 4029.
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40
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Marguet C. [Management of acute asthma in infants and children: recommendations from the French Pediatric Society of Pneumology and Allergy]. Rev Mal Respir 2007; 24:427-39. [PMID: 17468701 DOI: 10.1016/s0761-8425(07)91567-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- C Marguet
- Unité de pneumologie allergologie pédiatrique, Départment de Pédiatrie, Hôpital Charles Nicolle, Rouen Cedex.
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Abstract
In this review, we aim to focus attention on the interaction between adolescents with chronic conditions and the health systems that support them. At least 12% of adolescents live with a chronic condition. Some conditions are characterised by increasing incidence (eg, diabetes) or improving survival rates (eg, cystic fibrosis), while others are concerning because of differentially poorer outcomes in adolescents in comparison to both children and adults (eg cancer). Growing evidence suggests that young people with chronic conditions are doubly disadvantaged--engaging in risky behaviours to at least similar if not higher rates as healthy peers, while having the potential for greater adverse health outcomes from these behaviours. In addition to efforts at improving survival, in order to improve their life chances, we need to better understand how the social and emotional outcomes of young people with a chronic disease can be improved, and better support young people's emerging capacity for self-management.
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Affiliation(s)
- Susan M Sawyer
- Centre for Adolescent Health, Royal Children's Hospital, Parkville 3052, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Victoria, Australia; Murdoch Childrens Research Institute, Melbourne, Victoria, Australia.
| | - Sarah Drew
- Centre for Adolescent Health, Royal Children's Hospital, Parkville 3052, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Victoria, Australia
| | - Michele S Yeo
- Centre for Adolescent Health, Royal Children's Hospital, Parkville 3052, Melbourne, Victoria, Australia; Department of Paediatrics, University of Melbourne, Victoria, Australia; Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Maria T Britto
- Cincinnati Children's Hospital Medical Centre, Cincinnati, Ohio, USA
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Wood-Baker R, McGlone S, Venn A, Walters EH. Written action plans in chronic obstructive pulmonary disease increase appropriate treatment for acute exacerbations. Respirology 2007; 11:619-26. [PMID: 16916336 DOI: 10.1111/j.1440-1843.2006.00902.x] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE AND BACKGROUND COPD is a progressive disorder characterized by periodic exacerbations. While comprehensive self-management programmes decrease health-care resource utilization, the essential components are unclear. We performed a study of written action plans in the management of COPD. METHODOLOGY A randomized, controlled, prospective parallel-group study compared written action plans to usual practice. SUBJECTS Recruited from general practices, received an educational intervention with or without an action plan, which usually emphasized prompt treatment with antibiotics and corticosteroids. Subjects were followed up 3-monthly for a year. RESULTS One hundred and thirty-nine participants, mean FEV(1) 45 +/- 16% predicted, were recruited, 81% completing the study. Both groups had a decline in lung function and physical activity, but increase in quality of life over the study period. Exacerbations were common. The intervention group was significantly more likely to have treatment with antibiotics (chi(2) = 3.86; d.f. = 1; P = 0.05) or short course oral corticosteroids (chi(2) = 14.25; d.f. = 1; P < 0.001). No differences were found between the number of general practitioner consultations, attendances at emergency departments or hospitalizations. CONCLUSIONS The use of a written action plan in COPD increased appropriate therapeutic interventions for exacerbations, but this effect was not associated with a decrease in the use of health-care resources.
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Affiliation(s)
- Richard Wood-Baker
- Respiratory Research Group, University of Tasmania, Hobart, Tasmania 7001, Australia.
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Brown MD, Reeves MJ, Meyerson K, Korzeniewski SJ. Randomized trial of a comprehensive asthma education program after an emergency department visit. Ann Allergy Asthma Immunol 2006; 97:44-51. [PMID: 16892780 DOI: 10.1016/s1081-1206(10)61368-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
BACKGROUND Patients with asthma who visit the emergency department (ED) may benefit from education that optimizes self-management and treatment. OBJECTIVE To conduct a randomized trial of asthma education (AE) after an ED visit. METHODS Patients who present with acute asthma and history consistent with moderate to severe persistent asthma or recent ED visits were stratified by age (adult, child) and randomly assigned to intervention or usual care during the ED visit. The intervention was conducted by trained asthma educators and included a facilitated office visit with the primary care physician followed by a home visit. Intention-to-treat analysis was conducted, with time to first asthma relapse (either ED or unscheduled urgent office visit) during the 6-month follow-up period used as the primary outcome. RESULTS Of the 239 patients analyzed, 46% were adults, 46% were male, 30% were African American, and 56% had moderate to severe persistent asthma. Follow-up information was obtained on 191 patients (80%) at 6 months; 23.1% of the intervention group vs 31.1% of the usual care group had an urgent asthma visit (hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.48-1.29). Overall, 39% of the 117 patients assigned to the intervention group did not comply with any of the post-ED activities. Subgroup analysis suggested greater benefit among children (HR, 0.62; 95% CI, 0.33-1.19) than adults (HR, 1.08; 95% CI, 0.50-2.33). CONCLUSIONS Delivery of a comprehensive AE program after an ED visit was ineffective in adult patients; however, it may be effective in children. Further research on alternative AE delivery strategies appears warranted to reduce the burden of asthma visits to the ED.
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Affiliation(s)
- Michael D Brown
- Grand Rapids MERC/Michigan State University Program in Emergency Medicine, Grand Rapids, Michigan, USA
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Abstract
BACKGROUND The National Cooperative Inner-City Asthma Study (NCICAS) tested a model of asthma management in which a master's degree-prepared social worker functioned as an asthma counselor. The NCICAS resulted in decreased symptom days and a trend toward fewer emergency department (ED) visits and hospital admissions in the intervention group compared with the control group. OBJECTIVE To determine whether a real-world implementation would give similar results to the NCICAS. METHODS Children with moderate or severe persistent asthma were enrolled in a 1-year program, the Inner-City Asthma Intervention (ICAI) program, modeled on the NCICAS. Since the program initially was not designed to be research, data were collected retrospectively. ED and hospital visits were compared 1 year before and after the intervention at 2 of the intervention sites, Children's Mercy Hospital (CMH) and Baystate Medical Center, to determine whether there was a significant change. RESULTS Data for 93 children from CMH and 77 from Baystate were evaluated. At CMH annual ED visits were 0.38 before, 0.42 during, and 0.41 after the intervention, whereas at Baystate ED visits were 0.09 before, 0.17 during, and 0.15 after the intervention. Mean hospitalizations at CMH increased from 0.06 before to 0.22 during and then decreased to 0.12 after (P > .05), whereas admissions at Baystate increased from 0.03 before to 0.05 during and 0.04 after the intervention. CONCLUSIONS Asthma self-management interventions can lead to decreases in asthma utilization under controlled circumstances. Further prospective studies are needed to determinewhether the ICAI intervention is effective under real-world conditions.
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Affiliation(s)
- Jay M Portnoy
- Department of Health Management, Children's Mercy Hospitals and Clinics, Kansas City, Missouri 64108, USA.
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Affiliation(s)
- John Rees
- King's College School of Medicine at Guy's, King's College, and St Thomas's Hospitals, Sherman Education Centre, Guy's Hospital, London SE1 9RT.
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Agrawal SK, Singh M, Mathew JL, Malhi P. Efficacy of an individualized written home-management plan in the control of moderate persistent asthma: a randomized, controlled trial. Acta Paediatr 2005; 94:1742-6. [PMID: 16421033 DOI: 10.1111/j.1651-2227.2005.tb01847.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND The management of childhood asthma necessitates a comprehensive approach including pharmacological treatment as well as education about self-evaluation and home management of the condition. AIM To evaluate the efficacy of adding an individualized written home-management plan in the control of moderate persistent asthma. METHODS Children with moderate persistent asthma were randomized to receive either an individualized written home-management plan or no plan, in addition to standard asthma therapy including education. They were followed up with serial measurement of outcome variables. RESULTS Children receiving an individualized written home-management plan had fewer acute asthma events, fewer lost school days, lower symptom score and less nocturnal awakening than those who did not receive a written plan. CONCLUSION The addition of a written individualized home-management plan improves overall control in children with moderate persistent asthma.
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Affiliation(s)
- Sunil K Agrawal
- Department of Paediatrics, Advanced Paediatrics Centre, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Evaluation of a quality improvement collaborative in asthma care: does it improve processes and outcomes of care? Ann Fam Med 2005; 3:200-8. [PMID: 15928222 PMCID: PMC1466878 DOI: 10.1370/afm.269] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We wanted to examine whether a collaborative to improve asthma care influences process and outcomes of care in asthmatic adults. METHOD We undertook a preintervention-postintervention evaluation of 185 patients in 6 intervention clinics and 3 matched control sites that participated in the Institute for Healthcare Improvement Breakthrough Series (BTS) Collaborative for asthma care. The intervention consisted of 3, 2-day educational sessions for teams dispatched by participating sites, which were followed by 3 action periods during the course of a year. RESULTS Overall process of asthma care improved significantly in the intervention compared with the control group (change of 10% vs 1%, P = .003). Patients in the intervention group were more likely to attend educational sessions (20% vs 5%, P = .03). Having a written action plan, setting goals, monitoring peak flow rates, and using long-term asthma medications increased between 2% and 19% (not significant), but asthma-related knowledge was unchanged for the 2 groups. Patients in the BTS Collaborative were significantly more likely to be satisfied with clinician and lay educator communication (62% vs 39%, P = .02). Health-related quality of life, asthma-specific quality of life, number of bed days caused by asthma-related illness, and acute care service use were not significantly different between the 2 groups. CONCLUSIONS The intervention was associated with improved process-of-care measures that have been linked with better outcomes. Patients benefited through increased satisfaction with communication. Follow-up of patients who participated in the intervention may have been too brief to be able to detect significant improvement in health-related outcomes.
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