Asthma self management in adults: a review of current literature

The future of allergic rhinitis management: A partnership between healthcare professionals and patients

Allergic rhinitis (AR) is a chronic respiratory condition that internationally continues to be burdensome and impacts quality of life. Despite availability of medicines and guidelines for healthcare providers for the optimal management of AR, optimisation of its management in the community continues to be elusive. The reasons for this are multi-faceted and include both environmental and healthcare related factors. One factor that we can no longer ignore is that AR management is no longer limited to the domain of healthcare provider and that people with AR make their own choices when choosing how to manage their condition, without seeking advice from a health care provider. We must build a bridge between healthcare provider knowledge and guidelines and patient decision-making. With this commentary, we propose that a shared decision-making approach between healthcare professionals and people with AR be developed and promoted, with a focus on patient health literacy. As custodians of AR knowledge, we have a responsibility to ensure it is accessible to those that matter most-the people with AR.

Living with bronchial asthma: A qualitative study among patients in a hill village in Nepal

INTRODUCTION

Bronchial asthma continues to be a problem in the Himalayan country of Nepal. This study explored the impact of bronchial asthma on patients' lives in a hill village in Syangja district, Nepal, and obtained information about the perceived impact of the illness, knowledge of the disease, self-care behaviors and treatment among patients.

MATERIAL AND METHODS

The study site is the village of Jyamire (located at an elevation between 900 to 1200 m) Syangja district. Individuals suffering from asthma residing in the village aged 18 years or above were included. Semi-structured interviews were conducted face-to-face with the respondents at their homes using an interview guide. The interviews were audio recorded, transcribed in the Nepali language, and then translated into English for further analysis.

RESULTS

Most participants were female, between 18 to 60 years of age, and housewives. Most houses were built of mud and poorly ventilated. Gas was used for cooking though firewood was also used. Most used to get an average of three serious attacks a year both during winter and summer. The themes that emerged were the number and seasonal variation in attacks, the perceived effect of asthma on their lives and social interactions, the knowledge of the interviewee about the disease, the impact of asthma on their socioeconomic status, and treatment and self-care behaviors. Residing in a hill village required them to walk up and down several times a day and the disease seriously impacted their lives. The smoke produced during different ceremonies and during cooking also worsened their asthma.

CONCLUSION

Findings suggest, the existence of multiple factors, a few unique to Nepal contributing to poor asthma control. Though the recent socioeconomic improvement has led to improved prevention and treatment options, asthma seriously affected the patients.

Healthcare providers perception of therapeutic patient education efficacy according to patient and healthcare provider characteristics

OBJECTIVES

Therapeutic patient education improves numerous health and psychological outcomes in patients with chronic diseases. However, little is known about what makes a therapeutic patient education intervention more effective than another one. This study aims to identify in healthcare professionals the perceived determinants of therapeutic patient education efficacy at the individual level.

METHODS

Semi-structured individual interviews have been conducted with healthcare professionals (HCP, n=28, including 20 nurses) involved in therapeutic patient education programs (n=14) covering various chronic conditions (kidney and cardiovascular diseases, chronic pain, diabetes, etc.). A thematic content analysis following an inductive approach was used (Nvivo.11 software).

RESULTS

Five themes were retrieved for patient characteristics: understanding and education, personality, readiness and motivation, social environment, and misinformation and beliefs. Four themes were retrieved for healthcare professionals' characteristics: medical knowledge, appropriate attitude and relational skills, pedagogical skills, and training.

DISCUSSION

Patient personality is rarely discussed in the literature. Patients who are introverted, lack curiosity, or are not compliant might benefit from specific therapeutic patient education practices or formats. All these potential determinants regarding patients and healthcare professionals should be routinely assessed in future studies about therapeutic patient education efficacy to understand precisely what makes an intervention successful.

Investigating the Outcomes of an Asthma Educational Program and Useful Influence in Public Policy

The study was conducted to evaluate the effectiveness of an asthma educational program for asthma control, asthma self-management, asthma knowledge, and patient activation. The study analyzes different demographic variables with the purpose of investigating which asthma patients performed better than others. Based on these demographic characteristics, the study provides several recommendations for various stakeholders. The study is based on a positivist approach since its purpose is to investigate the consequences of an asthma educational program with a view to generalizing the results to a larger population. The study targets public and private hospitals which have applied the asthma educational program in collaboration with the Saudi Initiative for Asthma (SINA). Multiple questionnaires were deployed 263 valid responses were received from patients of public and private hospitals using online and offline data collection method. Several parametric and non-parametric tests were carried out in terms of data analysis. The results reveal that patients in the intervention group obtained high scores and were therefore more knowledgeable and able to control their asthma compared to the control group. Overall, patients in the intervention group performed better in terms of asthma control, asthma self-management and knowledge and awareness. There was a high level of patient activation in this group. In the context of demographic features, it was found that patients who are married and are undergraduate degree holders in employment scored high compared to patients who were young, single, post-graduate degree holders that were mainly self-employed. The results of this study can guide policy makers, SINA authorities, and hospitals as to which demographic category of asthma patients require immediate attention. The significance of asthma educational programmes has increased especially through social media platforms as the number of adult patients continues to increase day by day.

Living with severe asthma: the role of perceived competence and goal achievement

OBJECTIVE

The overall aim of this study was to examine, among individuals living with severe asthma, the role of perceived competence in achieving their goals.

METHODS

Qualitative research methods were used to conduct in-depth semistructured interviews. Interviews were video and/or audio recorded, transcribed and analyzed inductively and deductively, informed by the self-determination theory construct of perceived competence. Thirty-six face-to-face interviews, lasting 1.5-4 h, were conducted across Australia.

RESULTS

Feeling competent to achieve asthma goals played a role in participants' ability to achieve broader goals. Their desire to achieve their broader goals was strongly driven by their perceived ability to master managing their condition, which at times required more than medical strategies. Two main themes were discerned from the analysis: (1) learning how to look after yourself: self-care is important and (2) reaching an agreement with severe asthma: being at one with the illness.

DISCUSSION

This study highlighted the influence of perceived competence on self-management and goal achievement in severe asthma. Healthcare providers could explore patients' perceived competence to set and achieve goals, as a self-management strategy. Future research should consider these findings when developing and implementing patient-driven, self-management interventions for those living with severe asthma.

The Effect of a Theory of Planned Behavior Education Program on Asthma Control and Medication Adherence: A Randomized Controlled Trial

BACKGROUND

Disease management in individuals with asthma is affected by factors such as avoiding triggers that cause attacks and properly using inhaler devices.

OBJECTIVE

To determine the effect of a theory of planned behavior (TPB) education program on asthma control and medication adherence.

METHODS

A randomized controlled trial enrolled 30 participants in the intervention group and 30 in the control group. The educational approach was employed in participants in the intervention group for five home visits over 3 months according to the TPB program.

RESULTS

Before the education program, all participants in the intervention group and 90% of those in the control group had poorly controlled asthma (P > .05). After the program, all individuals in the intervention group and 20% of the control group had well-controlled asthma (P < .001). There was no statistically significant difference between Morisky Medication Adherence Scale-8 pretest scores in the intervention and control groups in terms of medication adherence (2.37 ± 1.75 and 3.13 ± 1.71, respectively; P > .05). Mean Morisky Medication Adherence Scale-8 scores in the intervention group at posttest (7.50 ± 0.78) were significantly higher than those of the control group (3.93 ± 2.03; P < .001.

CONCLUSIONS

This study revealed that asthma control and medication adherence increased in the intervention group after the TPB education program. The program was effective in asthma control and medication adherence for individuals with asthma.

[The role of written action plans in the management of asthma]

The Written Action Plan is a tool designed to help people with asthma to manage their condition when they experience an exacerbation. Asthma guidelines are consistent in their recommendation that action plans are useful for all people with asthma, but implementation is not systematic. The evidence base for such plans is limited because of methodological biases, but does support their effectiveness. The recommended action plan involves different color-coded zones which advise patients to adjust their management, such as increasing the level of daily treatment, or introducing oral corticosteroids based on symptoms and peak expiratory flow measurements. Recommendations are much less clear as to how to encourage patients to adopt and take ownership of their plan, although they all recommend that written action plans be incorporated into therapeutic education programs. The published literature shows that those caring for people with asthma may not support action plans because they are uncomfortable with the necessary educational posture and as a consequence of this they are under-utilized by patients. Patient-centered therapeutic education principles help us understand both how to encourage the patient want to have a written action plan and how to co-create it with them so that it is useful and meaningful in their life in order to make it more than just a disconnected tool.

Efficacy of inspiratory muscle training on inspiratory muscle function, functional capacity, and quality of life in patients with asthma: A randomized controlled trial

OBJECTIVE

To evaluate the efficacy of an inspiratory muscle training protocol on inspiratory muscle function, functional capacity, and quality of life in patients with asthma.

DESIGN

A single-blind, randomized controlled clinical trial.

SETTING

Community-based.

SUBJECTS

Patients with asthma, aged between 20 and 70 years old, non-smokers.

INTERVENTIONS

Participants were randomized into two groups: inspiratory muscle training group performed inspiratory muscle training 5 days a week for 8 weeks, consisting of six sets of 30 breaths per day with a training load ⩾50% of maximal inspiratory pressure, plus an educational program; the control group only received the educational program.

MAIN MEASUREMENTS

Maximal inspiratory pressure, inspiratory muscle endurance, and the distance performed on the incremental shuttle walking test were assessed pre-intervention, post-intervention and at follow-up (3 months after the end of the intervention). The asthma quality of life questionnaire was applied pre and post-intervention.

RESULTS

Data from 39 participants were analyzed. Maximal inspiratory pressure in percentage of predicted and endurance test duration were significantly higher post-intervention in the inspiratory muscle training group (∆ post-pre: 50.8% vs 7.3% of predicted - P < 0.001 and ∆ post-pre: 207.9 seconds vs 2.7 seconds - P < 0.001, respectively). There was no significant difference in the incremental shuttle walking distance between groups (∆ post-pre: 30.9 m vs -8.1 m, P = 0.165). Quality of life was perceived as significantly better, without a difference between groups (P > 0.05).

CONCLUSIONS

About 8 weeks of inspiratory muscle training in patients with controlled asthma significantly increased inspiratory muscle strength and endurance.

Does an mHealth system reduce health service use for asthma?

Background

Breathe is a mobile health (mHealth) application developed for the self-management of asthma in adults. There is evidence to suggest that mHealth interventions can be used for asthma control; however, their effects on the use of health services remain poorly understood. We sought to determine whether Breathe reduces health services use amongst asthma patients who used the app compared to controls who did not.

Methods

The impact of Breathe on health services use was estimated using a quasi-experimental approach. Two groups of subjects who had participated in a previous randomised clinical trial were included: an intervention group of asthma patients who used the app for 12 months, and a group of controls who did not use the app but received equivalent quality asthma care. A third, external control group of asthma patients were matched to the intervention participants. Generalised linear mixed models were used to determine relative changes in rates of asthma hospitalisations, emergency department (ED) visits, outpatient physician visits and completion of pulmonary function tests (PFTs) over time.

Results

A total of 677 individuals with asthma were included in the study: 132 in the intervention group, and 149 and 396 in the internal and external control groups, respectively. There were no statistically significant differences in the change of asthma hospitalisations, ED visits, physician office visits or completion of PFTs between the intervention group and either control group.

Conclusions

Use of the Breathe app is not associated with changes in health services use in adults with asthma.

Use of a mobile health application designed for asthma self-management was not associated with changes in asthma health services use or completion of pulmonary function testing in adults with asthma who use the application compared to those who did nothttps://bit.ly/2YojkeE

Self-management support provided by trained asthma educators result in improved quality of life and asthma control compared to usual care: A systematic review and meta-analysis

OBJECTIVES

We sought to describe training activities on self-management support (SMS) for asthma educators and the effects of SMS provided by trained educators on asthma patient outcomes.

METHODS

We conducted a systematic review of six medical databases and sought for trials assessing SMS provided for adults with asthma by trained educators. Two reviewers independently selected and extracted data on asthma educators' training activities and patient outcomes. We performed meta-analyses for asthma-related quality of life (QoL) and asthma control.

RESULTS

We screened 3217 records and included 16 trials. Learning activities and assessments were reported in 8/16 and 4/16 trials, respectively. Compared to usual care, trained asthma educators provided SMS that resulted in clinically important improvements in QoL (pooled mean difference [MD] = 0.52; 95% confidence interval [95%CI]: 0.19 to 0.83) and asthma control (pooled MD= -0.68; 95%CI: -0.99 to -0.38).

CONCLUSION

Although asthma-specific SMS provided by trained educators had a beneficial effect over the current care, our results highlight the need to better describe training activities for asthma educators.

PRACTICE IMPLICATIONS

This systematic review provides key elements of efficient training activities for asthma educators and reaffirms the importance of training educators to provide SMS in order to improve asthma patients' QoL and asthma control.

Managing Allergic Rhinitis in the Pharmacy: An ARIA Guide for Implementation in Practice

The paradigm of how we manage allergic rhinitis is shifting with a growing understanding that it is a complex process, requiring a coordinated effort from healthcare providers and patients. Pharmacists are key members of these integrated care pathways resolving medication-related problems, optimizing regimens, improving adherence and recommending therapies while establishing liaisons between patients and physicians. Community pharmacists are the most accessible healthcare professionals to the public and allergic rhinitis is one of the most common diseases managed by pharmacists. Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines developed over the past 20 years have improved the care of allergic rhinitis patients through an evidence-based, integrated care approach. In this paper, we propose an integrated approach to allergic rhinitis management in community pharmacy following the 2019 ARIA in the pharmacy guidelines.

Self-management of patients with advanced cancer: A systematic review of experiences and attitudes

BACKGROUND

Patients with advanced cancer are increasingly expected to self-manage. Thus far, this topic has received little systematic attention.

AIM

To summarise studies describing self-management strategies of patients with advanced cancer and associated experiences and personal characteristics. Also, to summarise attitudes of relatives and healthcare professionals towards patient self-management.

DESIGN

A systematic review including non-experimental quantitative and qualitative studies. Data were analysed using critical interpretive synthesis. Included studies were appraised on methodological quality and quality of reporting.

DATA SOURCES

MEDLINE, Embase, Cochrane Central, PsycINFO, CINAHL, Web of Science and Google Scholar (until 11 June 2019).

RESULTS

Of 1742 identified articles, 31 moderate-quality articles describing 8 quantitative and 23 qualitative studies were included. Patients with advanced cancer used self-management strategies in seven domains: medicine and pharmacology, lifestyle, mental health, social support, knowledge and information, navigation and coordination and medical decision-making (29 articles). Strategies were highly individual, sometimes ambivalent and dependent on social interactions. Older patients and patients with more depressive symptoms and lower levels of physical functioning, education and self-efficacy might have more difficulties with certain self-management strategies (six articles). Healthcare professionals perceived self-management as desirable and achievable if based on sufficient skills and knowledge and solid patient-professional partnerships (three articles).

CONCLUSION

Self-management of patients with advanced cancer is highly personal and multifaceted. Strategies may be substitutional, additional or even conflicting compared to care provided by healthcare professionals. Self-management support can benefit from an individualised approach embedded in solid partnerships with relatives and healthcare professionals.

[The Disease Management Experience of Patients with Asthma: Grounded Theory Approach]

PURPOSE

The aim of this study was to develop a situation-specific theory to explain the disease management experience of patients with asthma.

METHODS

Twenty participants with asthma were selected using the theoretical sampling method. The data were acquired through in-depth interviews conducted from June to October 2018 and analyzed using the grounded theory approach of Strauss and Corbin.

RESULTS

In total, 69 concepts, 30 subcategories, and 13 categories were generated to explain the disease management experience of patients with asthma. The core category of the disease management experience of patients with asthma was 'management of the disease to prevent aggravation of symptoms over the lifetime'. The disease management process of asthma patients included three steps: the 'cognition phase', the 'adjustment phase', and the 'maintenance phase'. However, some patients remained in the 'stagnation phase' of disease management, which represents the result of the continual pursuit of risky health behavior. There were three types of disease management experiences among patients with asthma: 'self-managing', 'partially self-managing', and 'avoidant'.

CONCLUSION

This study shows that patients with asthma must lead their disease management process to prevent exacerbation of their symptoms. It is imperative to develop nursing strategies and establish policies for effective disease management of patients with asthma based on their individual disease management processes and types.

Living well with severe asthma

Living well with severe asthma can be challenging. People with severe asthma can be refractory to treatment, can experience poor symptom control and are at a heightened risk of death. Patients experience symptoms of shortness of breath, chest tightness, cough and wheeze. These symptoms influence many aspects of an individual's life, resulting in emotional, financial, functional and medication-related burdens that negatively impact quality of life. Quality of life is known to be influenced by individual levels of satisfaction that stem from real-life treatment experiences. This experience is portrayed through the lens of the patient, which is commonly referred to as the patient perspective. The patient perspective is only one element of the patient experience. It influences health status, which, in severe asthma, is commonly assessed using validated health-related quality of life measures. A positive patient perspective may be achieved with implementation of management strategies tailored to individual needs. Management strategies developed in partnership between the patient, the severe asthma multidisciplinary team and the general practitioner may minimise disease-related impairment, allowing patients to live well with severe asthma.

Key points

Despite advances in treatment over the past decade, the experience of living with severe asthma has not significantly improved, with high levels of burden influencing the patient perspective.The impact of severe disease is not only restricted to asthma symptoms and acute attacks. It causes significant emotional, financial, functional and medication-related burdens, leading to impaired health-related quality of life.Clinical outcomes should not be stand-alone measures in severe asthma. Nonclinical measures should also be considered when evaluating health-related quality of life.Disease burden may be minimised and quality of life improved via self-management strategies, including education sessions, written asthma action plans, symptom monitoring, breathing exercises, physical activity and psychotherapeutic interventions.

Educational aims

To demonstrate the importance of the patient perspective in severe asthma.To identify the significant levels of disease burden associated with severe asthma.To discuss quality of life in severe asthma.To outline strategies that increase well-being in severe asthma.

Asthma action plans in the adult population: Rediscovering an invaluable tool in today's health care domain

BACKGROUND AND PURPOSE

Asthma in adults remains a leading cause of morbidity, mortality, and increased health care costs. Asthma action plans (AAPs) have demonstrated improved health outcomes in this populace; however, AAPs continue to be underused by providers. This article aims to re-emphasize the importance of AAPs for adults and refresh providers on the effectiveness and methods to use this indispensable tool.

METHODS

A literature search of MEDLINE, PubMed, Google Scholar, and CINAHL was performed, and subsequent findings were reported.

CONCLUSIONS

With proper involvement and inclusion of the patient in the creation of an AAP, adult patients can greatly improve their self-management capabilities through its use.

IMPLICATIONS FOR PRACTICE

By recognizing the importance and success of AAPs for adults, providers can improve their personal practice through increased AAP delivery. Understanding today's available platforms and formats for AAPs will allow providers a widened subject knowledge base and increased adaptation of patient AAP needs for the adult population. Increased provider knowledge can potentially increase AAP use for adults, as well as improve overall patient outcomes.

Guided asthma self-management or patient self-adjustment? Using patients' narratives to better understand adherence to asthma treatment

PURPOSE

The purpose of this study was to better understand patients' perspective of asthma self-management by focusing on the sociocultural and medical context shaping patients' illness representations and individual decisions.

PATIENTS AND METHODS

We conducted a secondary analysis of semi-structured interviews carried out as part of a multicentered collective qualitative case study. In total, 24 patients, aged 2-76 years with a confirmed diagnosis of asthma (or were parents of a child), who renewed the prescription for inhaled corticosteroids in the past year, participated in this study. The thematic analysis focused on asthma-related events and experiences reported by the patients. Consistent with narrative inquiry, similar patterns were grouped together, and three vignettes representing the different realities experienced by the patients were created.

RESULTS

The comparison of experiences and events reported by the patients suggested that patients' perceptions and beliefs regarding asthma and treatment goals influenced their self-management-related behaviors. More specifically, the medical context in which the patients were followed (ie, frame in which the medical encounter takes place, medical recommendations provided) contributed to shape their understanding of the disease and the associated treatment goals. In turn, a patient's perception of the disease and the treatment goals influenced asthma self-management behaviors related to environmental control, lifestyle habits, and medication intake.

CONCLUSION

Current medical recommendations regarding asthma self-management highlight the importance of the physicians' guidance through the provision of a detailed written action plan and asthma education. These data suggest that while physicians contribute to shaping patients' beliefs and perceptions about the disease and treatment goals, patients tend to listen to their own experience and manage the disease accordingly. Thus, a medical encounter between the patient and the physician, aiming at enhancing a meaningful conversation about the disease, may lead the patient to approach the disease in a more effective manner, which goes beyond taking preventative paths to avoid symptoms.

Non-pharmacological management of adult asthma in Australia: cross-sectional analysis of a population-based cohort study

Aim: To identify the level of non-pharmacological care received by middle-aged adults with current asthma in Australia and to identify its association with clinical measures. Methods: The Tasmanian Longitudinal Health Study (TAHS) is a population-based cohort first studied in 1968 (n = 8583). In 2010, when participants were aged 49 years, a stratified sample enriched for asthma and bronchitis underwent clinical assessments including respiratory questionnaires and lung function testing (n = 836). Current asthma was defined as self-reported asthma symptoms and/or healthcare utilization in the last 12 months. Multivariable linear regression and log-binomial models were used to assess the relevant associations. Results: Of the entire TAHS cohort, 15.6% (95% CI 13.4-18.2%) had current asthma. Of these, 37.9% (95% CI 30.5-45.9%) had seen a general practitioner for their asthma and 16.5% (95% CI 11.5-23.1%) had discussed their asthma with a pharmacist in the last 12 months. Written asthma action plans (AAPs) were reported by 17.9% (95% CI 12.9-23.2%), verbal AAPs by 53.8% (95% CI 45.9-61.6%) and doctor-assessments of inhaler technique by 42.7% (95% CI 35.2-50.5%). Adults with asthma of greater severity were more likely to have received verbal AAPs (p-trend =0.02). In contrast, adults with lower spirometry were more likely to have received verbal AAPs (p = 0.04), written AAPs (p = 0.001) and education on inhaler technique (p = 0.04). Conclusion: Despite an established evidence base and recommendations in local and international guidelines, non-pharmacological asthma management remains sub-optimal in the middle-aged adult asthma population.

Validation of the International Classification of Functioning, Disability and Health Core Set for obstructive pulmonary diseases in the perspective of adults with asthma

Purpose: To validate the Comprehensive and Brief International Classification of Functioning, Disability and Health Core Sets for obstructive pulmonary diseases from the perspective of adults with asthma.Methods: This was a qualitative, cross-sectional study. Individual interviews with questions related to the disease and its impact on the patient's life were performed. The meaning condensation procedure was used for analysis.Results: Thirty-five participants (26 females, 41 ± 13 years old) were interviewed. A total of 405 concepts were identified, and 348 were associated to the components Body Functions (n = 168), Body Structures (n = 22), Activities and Participation (n = 33), Environmental Factors (n = 125). These concepts were linked to 61 categories: second level (n = 25), third level (n = 33), fourth level (n = 3), which confirmed 41% and 77% of those included in the Comprehensive and Brief Core Sets, respectively. Twenty-four additional categories were identified, and 57 concepts could not be linked to the classification.Conclusions: The International Classification of Functioning, Disability and Health Core Sets for obstructive pulmonary diseases were supported by the perspective of adults with asthma. The Brief version seemed the best reference for rehabilitation, reflecting the typical disabilities and impairments of these patients. Unconfirmed and added categories have been reported, and their analysis may assist future document updates.Implications for rehabilitationThe use of the International Classification of Functioning, Disability and Health Core Sets for Obstructive Pulmonary Diseases is relevant to guide patient assessment, treatment and monitoring.The concepts related to the Body functions and Environmental factors were the most relevant according to the perspective of adults with asthma.The Comprehensive and Brief International Classification of Functioning, Disability and Health Core Sets for Obstructive Pulmonary Diseases were supported by adults with asthma.

"This illness diminishes me. What it does is like theft": A qualitative meta-synthesis of people's experiences of living with asthma

BACKGROUND

What matters to people in their everyday experiences of living with asthma is influenced by a diverse range of personal, social, medical and environmental factors. Previous reviews of the asthma literature have largely focused on medical aspects of asthma or specific population groups with particular needs.

OBJECTIVE

To identify, describe and synthesize from the available qualitative literature the views and experiences of adults living with asthma.

METHOD

We systematically searched for qualitative studies reporting on the personal experience of living with asthma. A meta-synthesis approach was used to analyse and interpret the data. Key themes relating to personal perspectives on asthma were identified and grouped into overarching concepts.

RESULTS

We identified 26 studies. There was a paucity of literature on the physical burden of asthma symptoms and the role of social support. Our synthesis generated a central concept of the "work" associated with living with asthma: work was of a personal nature, and at times an intensely emotional experience. Individuals tailored their behaviour in response to demands of the physical and social environment, including interactions with health-care professionals.

CONCLUSION

This is the first systematic review of the qualitative literature reporting on people's own perspectives of living with asthma. Our findings draw attention to the nuances and sensitivities surrounding patient experiences of self-management. Medical care is a central plank of managing chronic conditions, but our health-care systems are now expected to deliver patient-centred care. Considering the broader aspects of asthma management, beyond that of symptoms and treatment, will help to facilitate comprehensive care.

Tell me about your hay fever: a qualitative investigation of allergic rhinitis management from the perspective of the patient

Allergic rhinitis (AR) is sub-optimally managed in the community and is responsible for a significant health and economic burden. Uncontrolled AR increases the risk of poorly controlled asthma and presents an increased susceptibility to thunderstorm asthma. With the availability of treatments over-the-counter, bypassing the health care professional (HCP), the role of the patient is paramount. Research on the role of the patient in AR management in the current environment is limited. This study aims to explore the patient perspective of AR management and understand why it is sub-optimally managed in the community. Patient perspectives of AR management were explored utilizing a qualitative, phenomenological approach. Adults with AR were included in the study and interviewed. Transcripts were analyzed for recurrent themes and emergent concepts. Forty-seven participants with AR were interviewed about their experiences. Patient reports of delayed diagnosis, treatment fatigue and confidence in the ability to manage their AR themselves, heavily influenced their management preferences. Patients also described barriers associated with AR management including financial expense as well as being mistaken for having an infectious disease. Patients described examples of the impact on their quality of life caused by their AR, yet they strongly believed they could manage it themselves. This belief that AR is a condition that should be entirely self-managed, contributes to its burden. It amplifies patients’ separation from HCPs and having access to guidelines aimed at optimizing their AR control.

Healthcare professionals must engage fully with allergic rhinitis patients to optimize treatment and avoid issues triggered by constant self-care. Allergic rhinitis, or hay fever, can impact hugely on individuals’ health but remains poorly managed, partly because of the multiple medications available that allow people to bypass doctors and treat themselves. Biljana Cvetkovski at the University of Sydney, Australia, and co-workers, interviewed 47 adults with hay fever to analyze perceptions of the condition and its management. Many patients reported disenchantment with professional guidance for hay fever, often citing delayed diagnosis and endless tests leading to long-term ‘treatment fatigue’ and a loss of confidence in healthcare services. Patients often prefer self-treatment with limited medical help, repeatedly switching between medications and opting for ‘quick fixes’ rather than treating the chronic condition, with sometimes serious consequences.

Patient Self-Management of Asthma Using Mobile Health Applications: A Systematic Review of the Functionalities and Effects

Objective The aim of this systematic review was to summarize the evidence regarding the effects of mobile health applications (mHealth apps) for self-management outcomes in patients with asthma and to assess the functionalities of effective interventions. Methods We systematically searched Medline, Scopus, and the Cochrane Central Register of Controlled Trials. We included English-language studies that evaluated the effects of smartphone or tablet computer apps on self-management outcomes in asthmatic patients. The characteristics of these studies, effects of interventions, and features of mHealth apps were extracted. Results A total of 10 studies met all the inclusion criteria. Outcomes that were assessed in the included studies were categorized into three groups (clinical, patient-reported, and economic). mHealth apps improved asthma control (five studies) and lung function (two studies) from the clinical outcomes. From the patient-reported outcomes, quality of life (three studies) was statistically significantly improved, while there was no significant impact on self-efficacy scores (two studies). Effects on economic outcomes were equivocal, so that the number of visits (in two studies) and admission and hospitalization-relevant outcomes (in one study) statistically significantly improved; and in four other studies, these outcomes did not improve significantly. mHealth apps features were categorized into seven categories (inform, instruct, record, display, guide, remind/alert, and communicate). Eight of the 10 mHealth apps included more than one functionality. Nearly all interventions had the functionality of recording user-entered data and half of them had the functionality of providing educational information and reminders to patients. Conclusion Multifunctional mHealth apps have good potential in the control of asthma and in improving the quality of life in such patients compared with traditional interventions. Further studies are needed to identify the effectiveness of these interventions on outcomes related to medication adherence and costs.

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

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.

There is an "app" for that: Designing mobile phone technology to improve asthma action plan use in adolescent patients

PURPOSE

Asthma burden affects mortality, morbidity, quality of life, and the economy. Written asthma action plans are standard of care according to national guidelines, but these plans are often not prescribed. The purpose of this project was to develop an asthma action plan application for smartphones.

DATA SOURCES

A development studio was consulted for support in developing a smartphone application to code the software for the asthma action plan and assist in the design process. During development of the application, a survey was conducted to assist in design of the application and functionality.

CONCLUSIONS

All survey participants agreed that the application was easy to use, could be used without written instruction, and was designed for adolescents with asthma of any severity. Patients and providers mostly agreed that the app would help provide information about what to do in the event of an asthma exacerbation, and the application would be used frequently.

IMPLICATIONS FOR PRACTICE

There was consensus from both patients and providers that this application is not only functional but also helpful in the event of an asthma exacerbation. The project met the goal of designing a mobile phone application that would improve patient access to asthma action plans.

The journey for adolescents and young adults with chronic conditions transitioning to adult care with successful warfarin management

Health transition of youth from a child-centered care model to the adult model has been recognized to be of critical importance due to the increasing numbers of children now surviving chronic conditions. A formalized transition process is required adequately assess the AYA's readiness for transition and to move towards adult care. Indefinite warfarin therapy poses challenges as warfarin is a narrow therapeutic index drug that requires frequent monitoring and attentiveness to warfarin interactions and affects.

OBJECTIVE

The objective of this study was to evaluate transition to adult care for AYAs requiring indefinite warfarin therapy within a structured self-management program.

OUTCOME MEASURES

Results were compared between Phase 1 (enrollment to patient self-management) and Phase 2 (independent warfarin management) 6months following confirmation of transition to adult care. There was no statistical difference between outcome measures except INR testing frequency, and no adverse events.

CONCLUSIONS

This transition process resulted in successful transition as measured by TTR and other clinical end-points from pediatric to adult care. Implementing a formal transition process for young adults with chronic health conditions that considers patient preferences motivates and empowers them over time to develop autonomy with warfarin self-management, results in successful transition and warfarin management.

EMPoWARed: Edmonton pediatric warfarin self-management study

BACKGROUND

Patient self-management (PSM) in adults is safer and more cost effective than conventional management. Warfarin is a narrow therapeutic index drug with individual patient response to changes and frequently a long-term therapy. Children and their families are proposed to be able to effectively manage their child's warfarin therapy. Increased health related quality of life is highly associated with effective therapy in patients with chronic conditions.

OBJECTIVES

The aim of this study is to evaluate the safety and efficacy of PSM over time including HRQOL and variables that may influence PFU success at PSM.

PATIENTS/METHODS

Children and their family units (PFUs) current performing patient self-testing/monitoring for ≥ 3 months were enrolled in this cohort study. PFUs participated in comprehensive education on warfarin testing and management followed by an apprenticeship. Socio-demographic, clinical, and laboratory data were collected to evaluate safety and efficacy and health related quality of life. Outcomes were compared between the first 6 months on PSM (phase 1) and the last 6 months data collected on PSM (phase 2).

RESULTS

Forty-two patients performed PSM for a median of 2.7 years (range: 1.1-6.2 years). Time in therapeutic range was 90% and 92.9% (p=0.30) in phases 1 and 2 respectively. All measures were strongly associated with improved heath related quality of life. PFUs socio-demographic status did not influence success at PSM. All PFUs maintained warfarin knowledge and INR testing competency. Warfarin dosing decision errors median 0 (range: 0-5, p=0.73) and a median 0 (range 0-4, p=0.55) per patient in phases 1 and 2 respectively. There were no adverse hemorrhagic or thrombotic events.

CONCLUSIONS

Empowering PFUs to self-manage warfarin results in increased knowledge and understanding of their health condition, improved commitment to their health care and adherence to medication regimens and is demonstrated to be sustainable over time.

Age at asthma onset and asthma self-management education among adults in the United States

OBJECTIVE

Asthma self-management education improves asthma-related outcomes. We conducted this analysis to evaluate variation in the percentages of adults with active asthma reporting components of asthma self-management education by age at asthma onset.

METHODS

Data from 2011 to 2012 Asthma Call-back Surveys were used to estimate percentages of adults with active asthma reporting six components of asthma self-management education. Components of asthma self-management education include having been taught to what to do during an asthma attack and receiving an asthma action plan. Differences in the percentages of adults reporting each component and the average number of components reported across categories of age at asthma onset were estimated using linear regression, adjusted for age, education, race/ethnicity, sex, smoking status, and years since asthma onset.

RESULTS

Overall, an estimated 76.4% of adults with active asthma were taught what to do during an asthma attack and 28.7% reported receiving an asthma action plan. Percentages reporting each asthma self-management education component declined with increasing age at asthma onset. Compared with the referent group of adults whose asthma onset occurred at 5-14 years of age, the percentage of adults reporting being taught what to do during an asthma attack was 10% lower among those whose asthma onset occurred at 65-93 years of age (95% CI: -18.0, -2.5) and the average number of components reported decreased monotonically across categories of age at asthma onset of 35 years and older.

CONCLUSIONS

Among adults with active asthma, reports of asthma self-management education decline with increasing age at asthma onset.

Impact of an integrated disease management program in reducing exacerbations in patients with severe asthma and COPD

BACKGROUND

Conflicting data exists on the effectiveness of integrated programs in reducing recurrent exacerbations and hospitalizations in patients with Asthma and chronic obstructive lung disease (COPD). We developed a Pulmonologist-led Chronic Lung Disease Program (CLDP) for patients with severe asthma and COPD and analyzed its impact on healthcare utilization and predictors of its effectiveness.

METHODS

CLDP elements included clinical evaluation, onsite pulmonary function testing, health education, and self-management action plan along with close scheduled and on-demand follow-up. Patients with ≥2 asthma or COPD exacerbations requiring emergency room visit or hospitalization within the prior year were enrolled, and followed for respiratory related ER visits (RER) and hospitalizations (RHA) over the year (357 ± 43 days) after CLDP interventions.

RESULTS

A total of 106 patients were enrolled, and 104 patients were subject to analyses. During the year of follow-up after CLDP enrollment, there was a significant decrease in mean RER (0.56 ± 1.48 versus 2.62 ± 2.81, p < 0.0001), mean RHA (0.39 ± 0.08 versus 1.1 ± 1.62, p < 0.0001), and 30 day rehospitalizations (0.05 ± 0.02 versus 0.28 ± 0.07, p < 0.0001). Reduction of healthcare utilization was strongly associated with GERD and sinusitis therapy, and was independent of pulmonary rehabilitation. Direct variable cost analyses estimated annual savings at $1.17 million. Multivariate logistic regression analysis revealed lack of spirometry utilization as an independent risk factor for severe exacerbations.

CONCLUSIONS

A Pulmonologist-led disease management program integrating key elements of care is cost effective and significantly decreases severe exacerbations. Integrated programs should be encouraged for care of frequent exacerbators of asthma and COPD.