Long-term economic evaluation of intensive patient education during the first treatment year in newly diagnosed adult asthma

Clinical inertia in asthma

Despite advances in pharmaceutical treatment in recent years, a relatively high proportion of patients with asthma do not have adequate asthma control, causing chronic disability, poor quality of life, and multiple emergency department visits and hospitalizations. A multifaceted approach is needed to overcome the problems with managing asthma, and clinical inertia (CI) is a crucial concept to assist with this approach. It divides clinical inertia into three main categories, which include healthcare provider-related, patient-related, and healthcare system-related CI. The strategies to overcome these CI are complex, and the M-GAP approach, which combines a multidisciplinary approach, dissemination of guidelines, utilization of applications, and development and promotion of low-cost prescriptions, will help clinicians.

Acceptance and Dropout Rates of Individuals with Asthma Approached in Self-management Interventions: A Systematic Review and Meta-analysis

Objective

The objectives of this systematic review were to assess the acceptability of self-management interventions for people with asthma and identify contributing factors.

Methods

A systematic literature search was conducted using PubMed, MEDLINE, EMBASE (OVIDWEB), CINAHL and Cochrane databases. Clinical trials design was included if they met specified criteria. A random-effect meta-regression analysis was conducted to estimate the overall acceptance and drop-out rates and to assess the potential factors that may influence the outcomes.

Results

A total of 64 studies were included and 8,092 participants were recruited and participated in the trials. The estimated acceptance rate was 51.1%, while the estimated drop-out rates in the intervention and control groups were 18.2% and 15.6%, respectively. Lack of interest was the main reported reason for refusing to participate and dropping out from the program. Study-related and program-related factors influenced the acceptance and drop-out rates statistically and clinically.

Conclusion

The acceptance rate of self-management programs among asthmatic people was not high and the dropout rate was somewhat low. The review suggests optimizing the design of self-management studies and modifying the implemented self-management programs to increase the acceptance rate and decrease the dropout rate.

Developing and evaluating ASTHMAXcel adventures: A novel gamified mobile application for pediatric patients with asthma

BACKGROUND

The ASTHMAXcel mobile application has been linked to favorable outcomes among adult patients with asthma.

OBJECTIVE

To assess the impact of ASTHMAXcel Adventures, a gamified, guideline-based, pediatric version on asthma control, knowledge, health care utilization, and patient satisfaction.

METHODS

Pediatric patients with asthma received the ASTHMAXcel Adventures mobile intervention on-site only at baseline (visit 1), 4 months (visit 2), and 6 months (visit 3). The asthma control test, asthma illness representation scale-self-administered, pediatric asthma impact survey, and Client Satisfaction Questionnaire-8 were used to assess asthma control, knowledge, and patient satisfaction. Patients reported the number of asthma-related emergency department (ED) visits, hospitalizations, and oral prednisone use.

RESULTS

A total of 39 patients completed the study. The proportion of controlled asthma increased from visit 1 to visits 2 and 3 (30.8% vs 53.9%, P = .04; 30.8% vs 59.0%, P = .02), and largely seen in boys. The mean asthma illness representation scale-self-administered scores increased from baseline pre- to postintervention, with sustained improvements at visits 2 and 3 (3.55 vs 3.76, P < .001; 3.55 vs 3.80, P = .001; 3.55 vs 3.99, P < .001). The pediatric asthma impact survey scores improved from baseline to visits 2 and 3 (43.33 vs 34.08, P < .001; 43.33 vs 31.74, P < .001). ED visits and prednisone use significantly decreased from baseline to visits 2 and 3 (ED: 0.46 vs 0.13, P = .03; 0.46 vs 0.02, P = .02; prednisone use, 0.49 vs 0.13, P = .02; 0.49 vs 0.03, P = .003. Satisfaction was high with mean client satisfaction questionnaire score of approximately 30 (out of 32) at all visits.

CONCLUSION

ASTHMAXcel Adventures improved asthma control, knowledge, and quality of life, and reduced ED visits and prednisone use with high satisfaction scores.

Developing and pilot testing ASTHMAXcel, a mobile app for adults with asthma

Objective: We sought to compare the impact of ASTHMAXcel, a novel, guideline-based, patient-facing mobile app to human-delivered asthma education.Methods: We conducted a focus group with asthma patients in the Bronx to identify desired mobile app features. ASTHMAXcel was designed based on patient feedback and consistent with NAEPP, BTS/SIGN, and GINA guidelines. The app was reviewed by internists, allergist/immunologists, and pulmonologists specializing in asthma treatment, asthma educators, and a behavioral scientist, and iteratively refined. The refined version of ASTHMAXcel was administered once via tablet at our outpatient Montefiore Asthma Center (MAC). Asthma knowledge was measured through the Asthma Knowledge Questionnaire (AKQ) pre and post-intervention. We also recorded process outcomes including completion time and patient satisfaction. In parallel, human-delivered education was delivered once at MAC. These outcomes were similarly collected.Results: 60 patients were enrolled with 30 in the ASTHMAXcel and 30 in the human-educator group. Mean AKQ in the ASTHMAXcel group vs human-educator group pre-intervention was 9.9 vs 10.5, p = 0.27. Mean AKQ post-intervention in the ASTHMAXcel group vs human-educator group was 12.3 vs 14.4, p = 0.0002. The mean AKQ improvement for both groups were 2.4 vs 3.9, p = 0.007. Patients were highly satisfied in the ASTHMAXcel group scoring on average 27.9 out of 30 maximum points on the satisfaction survey. There was no difference in satisfaction scores or completion times (minutes) of either intervention.Conclusion: ASTHMAXcel was associated with an increase in AKQ, but the human-educator group experienced a greater improvement. ASTHMAXcel demonstrated no differences in process outcomes vs human-delivered education.

Health economic evaluations of patient education interventions a scoping review of the literature

OBJECTIVES

To provide a comprehensive overview of health economic evaluations of patient education interventions for people living with chronic illness.

METHODS

Relevant literature published between 2000 and 2016 has been comprehensively reviewed, with attention paid to variations in study, intervention, and patient characteristics.

RESULTS

Of the 4693 titles identified, 56 articles met the inclusion criteria and were included in this scoping review. Of the studies reviewed, 46 concluded that patient education interventions were beneficial in terms of decreased hospitalization, visits to Emergency Departments or General Practitioners, provide benefits in terms of quality-adjusted life years, and reduce loss of production. Eight studies found no health economic impact of the interventions.

CONCLUSIONS

The results of this review strongly suggest that patient education interventions, regardless of study design and time horizon, are an effective tool to cut costs. This is a relatively new area of research, and there is a great need of more research within this field.

PRACTICE IMPLICATIONS

In bringing this evidence together, our hope is that healthcare providers and managers can use this information within a broad decision-making process, as guidance in discussions of care quality and of how to provide appropriate, cost-effective patient education interventions.

Economic evidence for nonpharmacological asthma management interventions: A systematic review

Asthma management, education and environmental interventions have been reported as cost‐effective in a previous review (Pharm Pract (Granada), 2014;12:493), but methods used to estimate costs and outcomes were not discussed in detail. This review updates the previous review by providing economic evidence on the cost‐effectiveness of studies identified after 2012, and a detailed assessment of the methods used in all identified studies. Twelve databases were searched from 1990 to January 2016, and studies included economic evaluations, asthma subjects and nonpharmacological interventions written in English. Sixty‐four studies were included. Of these, 15 were found in addition to the earlier review; 53% were rated fair in quality and 47% high. Education and self‐management interventions were the most cost‐effective, in line with the earlier review. Self‐reporting was the most common method used to gather resource‐use data, accompanied by bottom‐up approaches to estimate costs. Main outcome measures were asthma‐related hospitalizations (69%), quality of life (41%) and utility (38%), with AQLQ and the EQ‐5D being the most common questionnaires measured prospectively at fixed time points. More rigorous costing methods are needed with a more common quality of life tool to aid greater replicability and comparability amongst asthma studies.

Role of Adult Asthma Education in Improving Asthma Control and Reducing Emergency Room Utilization and Hospital Admissions in an Inner City Hospital

Objective. Asthma education programs have been shown to decrease healthcare utilization and improve disease control and management. The purpose of our study was to evaluate the impact of an outpatient adult asthma education program in an inner city hospital caring for patients with low socioeconomic and educational status. Methods. An asthma education program was implemented in September 2014. Patients who received education from September 2014 to July 2015 were evaluated. Outcomes were compared for the same group of patients before and after education. Primary outcomes were emergency room (ER) visits and hospital admissions. Secondary outcomes were change in Asthma Control Test (ACT) score and number of pulmonary clinic visits. Results. Asthma education significantly decreased number of patients requiring ER visits and hospital admissions (p = 0.0005 and p = 0.0015, resp.). Asthma control as per ACT score ≥ 20 improved with education (p = 0.0001) with an increase in clinic visits (p = 0.0185). Conclusions. Our study suggests that implementation of a structured asthma education program in an inner city community hospital has a positive impact on reduction of ER visits and hospital admissions with improvement in asthma control. Institutional Review Board Clinical Study registration number is 01081507.

The Finnish experience to save asthma costs by improving care in 1987-2013

The Finnish National Asthma Program 1994-2004 markedly improved asthma care in the 1990s. We evaluated the changes in costs during 26 years from 1987 to 2013. Direct and indirect costs were calculated by using data from national registries. Costs from both the societal and patient perspectives were included. The costs were based on patients with persistent, physician-diagnosed asthma verified by lung function measurements. We constructed minimum and maximum scenarios to assess the effect of improved asthma care on total costs. The number of patients with persistent asthma in the national drug reimbursement register increased from 83,000 to 247,583. Improved asthma control reduced health care use and disability, resulting in major cost savings. Despite a 3-fold increase in patients, the total costs decreased by 14%, from €222 million to €191 million. Costs for medication and primary care visits increased, but overall annual costs per patient decreased by 72%, from €2656 to €749. The theoretical total cost savings for 2013, comparing actual with predicted costs, were between €120 and €475 million, depending on the scenario used. The Finnish Asthma Program resulted in significant cost savings at both the societal and patient levels during a 26-year period.

ECONOMIC EVALUATION STUDIES OF SELF-MANAGEMENT INTERVENTIONS IN CHRONIC DISEASES: A SYSTEMATIC REVIEW

Background: To our knowledge, there has been no overall systematic review focusing on the methodological quality of full economic evaluation studies of self-management interventions. Our objective was to systematically review the literature of full economic evaluation studies of self-management interventions in adult chronic patients and to investigate their methodological quality and cost-effectiveness.

Methods: A data extraction form was developed to assess general and randomized controlled trial (RCT) -related characteristics, quality, of the RCTs, economic information and quality of the economic evaluation studies by means of a quality assessment (CHEC-list for trial-based studies, adjusted CHEC-list for model-based studies).

Results: Twenty-three reports were found. Sixteen studies (73 percent) lack information on the control intervention(s). Only one study fulfilled all three criteria for quality of RCTs and five studies (23 percent) did not meet any of these criteria. This review included one model-based study; the other studies were trial-based economic evaluation studies based on a RCT. Eight studies (35 percent) used a societal perspective and 12 (60 percent) synthesized costs and effects. Seven studies were categorized into the highest category (<15 score), nine studies into the “moderate” group (9–14 score), six studies received a “low” score (<8) on the CHEC-list. Eighteen studies found the self-management intervention(s) to be cost-effective compared with other interventions

Conclusions: Self-management interventions for adult chronic patients were heterogeneous and there was no clear, well-considered definition of self-management. Overall, the methodological quality of the full economic evaluation studies was moderate and, therefore, cost-effectiveness results must be interpreted with caution. Future research will benefit from further improvements in methodological quality of both economic study design and analysis, as well as a taxonomy for describing self-management interventions and their contents.

Economic evaluation of enhanced asthma management: a systematic review

OBJECTIVES

To evaluate and compare full economic evaluation studies on the cost-effectiveness of enhanced asthma management (either as an adjunct to usual care or alone) vs. usual care alone.

METHODS

Online databases were searched for published journal articles in English language from year 1990 to 2012, using the search terms '"asthma" AND ("intervene" OR "manage") AND ("pharmacoeconomics" OR "economic evaluation" OR "cost effectiveness" OR "cost benefit" OR "cost utility")'. Hand search was done for local publishing. Only studies with full economic evaluation on enhanced management were included (cost consequences (CC), cost effectiveness (CE), cost benefit (CB), or cost utility (CU) analysis). Data were extracted and assessed for the quality of its economic evaluation design and evidence sources.

RESULTS

A total of 49 studies were included. There were 3 types of intervention for enhanced asthma management: education, environmental control, and self-management. The most cost-effective enhanced management was a mixture of education and self-management by an integrated team of healthcare and allied healthcare professionals. In general, the studies had a fair quality of economic evaluation with a mean QHES score of 73.7 (SD=9.7), and had good quality of evidence sources.

CONCLUSION

Despite the overall fair quality of economic evaluations but good quality of evidence sources for all data components, this review showed that the delivered enhanced asthma managements, whether as single or mixed modes, were overall effective and cost-reducing. Whilst the availability and accessibility are an equally important factor to consider, the sustainability of the cost-effective management has to be further investigated using a longer time horizon especially for chronic diseases such as asthma.

Association of asthma education with asthma control evaluated by asthma control test, FEV1, and fractional exhaled nitric oxide

BACKGROUND

Asthma education is an important adjunct for asthma control although the way asthma education affects asthma outcomes is poorly understood. The asthma control test (ACT), forced expiratory volume in 1 s (FEV(1)), and fractional exhaled nitric oxide (FeNO) have all been used as markers of asthma control. However, the use of FeNO as a surrogate marker remains controversial.

OBJECTIVES

(i) To examine whether asthma education is associated with asthma control; (ii) to compare absolute levels and changes of ACT, FEV(1), and FeNO over a year; and (iii) to evaluate whether FeNO can be used as an additional marker of asthma control.

METHODS

Fifty asthmatics with poor adherence (12 mild, 21 moderate, and 17 severe) received asthma education at study entry. Medications were unchanged for the first 3 months, and ACT, FEV(1), and FeNO measurements were recorded at entry, 3, 6, and 12 months. Asthma control was assessed at each visit and patients were categorized as either "stable" or "unstable" asthmatics according to the global initiative for asthma (GINA) guidelines.

RESULTS

A significant decrease in FeNO and increase in ACT score were noted in the stable asthmatic group at 3 months (p < .001), and this persisted over 12 months. Significant correlations were seen between changes (Δ) in FeNO, ACT, and FEV(1) over time. However, significant correlations between the absolute levels were not maintained over 12 months. A decrease of ≥18.6% in FeNO and a ≥3-point increase in ACT score (sensitivity: 80% and 73.3% and specificity: 83.3% and 87.5%, respectively) were associated with stable asthma control although the absolute levels were not.

CONCLUSIONS

Asthma education may be useful to achieve stable control. In addition, changes rather than absolute levels of FeNO and ACT may be better markers of asthma control.

The effect of an educational programme consisting of group and individual arthritis education for patients with polyarthritis--a randomised controlled trial

OBJECTIVE

The aim of this study was to investigate the effect of an educational programme for patients with polyarthritis compared to usual care.

METHODS

Patients with rheumatoid arthritis, psoriatic arthritis and unspecified polyarthritis were randomised to the intervention (n=71) or usual care (n=70). The intervention consisted of three group educational sessions followed by one individual educational session. The primary outcomes were a patient's global well-being and arthritis self-efficacy. Secondary outcomes were patient activation, physical and psychological health status, educational needs and disease activity.

RESULTS

After four months the intervention group had significantly better global well-being, 95% CI (2.3-14.1), p=0.01, and self-efficacy, 95% CI (0.2-8.1), p=0.04, than the control group. There were also trends for improved disease activity, and a statistically significant improvement in patient activation and pain in the intervention group.

CONCLUSION

This patient educational programme consisting of group sessions and nurse-delivered individual education has statistically significant benefits for global well-being and maintaining a level of self-efficacy in managing other symptoms in patients with polyarthritis.

PRACTICE IMPLICATIONS

This educational programme allows patients to learn from each other in addition to addressing individual educational needs.

Asthma outcomes: quality of life

BACKGROUND

"Asthma-related quality of life" (QOL) refers to the perceived impact that asthma has on the patient's QOL.

OBJECTIVE

National Institutes of Health institutes and other federal agencies convened an expert group to recommend standardized measures of the impact of asthma on QOL for use in future asthma clinical research.

METHODS

We reviewed published documentation regarding the development and psychometric evaluation; clinical research use since 2000; and extent to which the content of each existing QOL instrument provides a unique, reliable, and valid assessment of the intended construct. We classified instruments as core (required in future studies), supplemental (used according to the study's aims and standardized), or emerging (requiring validation and standardization). This work was discussed at an National Institutes of Health-organized workshop convened in March 2010 and finalized in September 2011.

RESULTS

Eleven instruments for adults and 6 for children were identified for review. None qualified as core instruments because they predominantly measured indicators of asthma control (symptoms and/or functional status); failed to provide a distinct, reliable score measuring all key dimensions of the intended construct; and/or lacked adequate psychometric data.

CONCLUSIONS

In the absence of existing instruments that meet the stated criteria, currently available instruments are classified as either supplemental or emerging. Research is strongly recommended to develop and evaluate instruments that provide a distinct, reliable measure of the patient's perception of the impact of asthma on all of the key dimensions of QOL, an important outcome that is not captured in other outcome measures.

Cost-effectiveness of Internet-based self-management compared with usual care in asthma

Background

Effectiveness of Internet-based self-management in patients with asthma has been shown, but its cost-effectiveness is unknown. We conducted a cost-effectiveness analysis of Internet-based asthma self-management compared with usual care.

Methodology and Principal Findings

Cost-effectiveness analysis alongside a randomized controlled trial, with 12 months follow-up. Patients were aged 18 to 50 year and had physician diagnosed asthma. The Internet-based self-management program involved weekly on-line monitoring of asthma control with self-treatment advice, remote Web communications, and Internet-based information. We determined quality adjusted life years (QALYs) as measured by the EuroQol-5D and costs for health care use and absenteeism. We performed a detailed cost price analysis for the primary intervention. QALYs did not statistically significantly differ between the Internet group and usual care: difference 0.024 (95% CI, −0.016 to 0.065). Costs of the Internet-based intervention were $254 (95% CI, $243 to $265) during the period of 1 year. From a societal perspective, the cost difference was $641 (95% CI, $−1957 to $3240). From a health care perspective, the cost difference was $37 (95% CI, $−874 to $950). At a willingness-to-pay of $50000 per QALY, the probability that Internet-based self-management was cost-effective compared to usual care was 62% and 82% from a societal and health care perspective, respectively.

Conclusions

Internet-based self-management of asthma can be as effective as current asthma care and costs are similar.

Trial Registration

Current Controlled Trials ISRCTN79864465

Ten-year follow-up of early intensive self-management guidance in newly diagnosed patients with asthma

OBJECTIVE

We assessed the 10-year effectiveness of self-management guidance in a prospective follow-up study of patients with asthma when inhaled corticosteroids were used from the beginning in the treatment.

METHODS

Consecutive newly diagnosed asthmatics (n = 162) were randomized: 80 to an intervention group (IG) and 82 to a control group (CG). Lung function (LF), airway hyperresponsiveness (AHR), and health-related quality of life (HRQoL) were examined at 10 years.

RESULTS

The advantages of intensive education with regards to LF measured by forced expiratory volume in 1 second and forced vital capacity were seen only after the first year. Later, there were no statistically significant differences in any parameters between the groups. However, during 10-year follow-up, peak expiratory flow, AHR, and HRQoL improved significantly in both groups (no differences as regards gender, smoking, or atopy). At 10 years, 68% of the IG and 75% of the CG patients still showed AHR after histamine challenge. Generic HRQoL scores in both groups equaled that of the age-standardized group a general population but only 50% in the IG and 55% in the CG had normal disease-specific HRQoL scores. According to Global Initiative for Asthma (GINA) criteria 23% of patients in the IG and 25% in the CG had asthma under control.

CONCLUSIONS

The effectiveness of intensive self-management education could be shown only in the short term. The groups did not differ significantly in any of the parameters investigated, and showed nearly normal LF and HRQoL. AHR improved only partly and only a minority of the patients had asthma under good control according to GINA criteria. This study showed that evaluation of asthma using LF alone does not show the whole truth about asthma treatment results. HRQoL should be used in conjunction with GINA criteria, to assess asthma treatment outcomes. The value and importance of AHR for the evaluation of treatment remains obscure.

Role of mucolytics in the management of COPD

There is, to date, no medical therapy that modifies the decline in lung function that occurs in COPD. As the disease becomes more severe, exacerbations of COPD become increasingly common, affecting patient quality of life and increasing health care costs. Mucolytic agents, through their actions on inflammatory and oxidative pathways, have potential benefits in COPD. This paper reviews the randomized controlled trial (RCT) evidence for the effectiveness of at least 2 months of daily therapy with oral mucolytics in COPD. Based on evidence from 26 RCTs, mucolytics reduce exacerbations by up to 0.8 exacerbations per year, with a greater effect in patients with more severe COPD. This effect appears to be of a similar magnitude to the reduction in exacerbations seen with tiotropium and inhaled corticosteroids (ICS), but RCTs that compared the agents would be required to confirm this. Mucolytics do not affect the rate of lung function decline, but they do not have any significant adverse effects. Mucolytic treatment should be considered in: patients with more severe COPD who have frequent or prolonged exacerbations; those who are repeatedly admitted to hospital; or in those patients with frequent exacerbations who are unable to take tiotropium or ICS.

Education interventions for adults who attend the emergency room for acute asthma

BACKGROUND

The use of educational and behavioural interventions in the management of chronic asthma have a strong evidence base. There may be a role for educative interventions following presentation in an emergency setting in adults.

OBJECTIVES

To assess the effectiveness of educational interventions administered following an acute exacerbation of asthma leading to presentation in the emergency department.

SEARCH STRATEGY

We searched the Cochrane Airways Group trials register. Study authors were contacted for additional information. Searches are current to November 2006.

SELECTION CRITERIA

Randomised, parallel group trials were eligible if they recruited adults (> 17 years) who had presented at an emergency department with an acute asthma exacerbation. The intervention of interest was any educational intervention (for example, written asthma management plan).

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted data. Study authors were contacted for additional information.

MAIN RESULTS

Twelve studies involving 1954 adults were included. Education significantly reduced subsequent admission to hospital (relative risk 0.50; 95% confidence interval 0.27 to 0.91); however, did not significantly reduce the risk of re-presentation at emergency departments (ED) the study follow up (relative risk 0.69; 95% confidence interval 0.40 to 1.21). The lack of statistically significant differences between asthma education and control groups in terms of peak flow, quality of life, study withdrawal and days lost were hard to interpret given the low number of studies contributing to these outcomes. One study from the early 1990s measured cost and found no difference for total costs and costs related to physician visits and admissions to hospital. If data were restricted to emergency department treatment, education led to lower costs than control.

AUTHORS' CONCLUSIONS

This review found that educational interventions applied in the emergency department reduce subsequent asthma admissions to hospital. The interventions did not significantly reduce ED re-presentations; while the trend in effect favours educational interventions, the pooled results were not statistically significant. The impact of educational intervention in this context on longer term outcomes relating to asthma morbidity is unclear. Priorities for additional research in this area include assessment of health-related quality of life, lung function assessment, exploration of the relationship between socio-economic status and asthma morbidity, and better description of the intervention assessed.

Effectiveness of a nurse-led management programme for paediatric asthma in Taiwan

AIM

The aim of this study was to carry out a preliminary analysis of the impact of a government-sponsored disease management programme for paediatric asthma on economic outcomes and patient satisfaction.

METHODS

Of the 398 patients who participated in the programme, 249 (62.56%) who had at least two medical care encounters with an ICD-9 code of 493 were classified as 'already diagnosed cases'; and 129 (34.12%) who had a single or no medical care encounter with an ICD-9 code of 493 were classified as 'newly diagnosed cases'. A retrospective 1:4 (intervention vs. control group) matched cohort study design was conducted, with the control group randomly drawn from 236 637 paediatric asthmatics who were not enrolled the programme. Questionnaires were collected from 105 (26.3%) of the patients.

RESULTS

Comparison results of 1 year pre/post tests of utilisation of health care resources indicated that the intervention group of already diagnosed cases had 77.97% fewer emergency department visits, 80.77% fewer inpatient visits, and 75.65% fewer stays of significant length. For the newly diagnosed group, the intervention group had 35.11% fewer emergency department visits than the control group. The majority of the patients had substantial adherence to physicians' suggestions, more accurate knowledge and better self-care skills concerning asthma.

CONCLUSION

A nurse-led management programme has proved useful in managing paediatric asthma in Taiwan. Simplification of paperwork, some reorganisation of the practitioner's daily responsibilities and provision of a fail-safe information system may make the programme even more beneficial.

[An evaluation of a patient education programme for children with asthma at a French teaching hospital ("l'espace du souffle", Nantes) (2002-2003)]

A program of patient education was set up at the CHU of Nantes, for groups of children with asthma in 1997. The aim of this study is to realize a formative evaluation to corelate with some effects. This study was proposed to 99 families with asthmatic children. A written questionnaire, was administered to the parents and children, exploring their satisfaction with the programme, their general knowledge and know-how, biomedical parameters. The observation focused on skills and day-to-day life with the illness. The study was completed by 21 families. The majority of the children, aged 7 to 11 years old, had asthma that needed treatment. All of the parents and children were satisfied with their visit to "l'espace du souffle". They all declared having increased their general knowledge and know-how and biomedical parameters did better. They did, however, feel that they did not know enough about how to recognise precursory symptoms of an attack, about how to practise a sport or how to use "corticoids". They also could not control their personal fear during an attack. During the oral questionnaire a general feeling of stress and worry was clearly noticeable in the parents feeling, that did not appear in the written questionnaire. This patient education program appears to be beneficial. Furthermore, this evaluation highlights some subjects that pass unseen during current individual consultations.

Does an asthma education program improve quality of life? A two-year randomized trial

Asthma education programs result in clinical improvement. However, most studies involved programs of up to 1 year of follow-up, and their efficacy in improving quality of life (QoL) is still controversial. The aim of this study was to evaluate the effectiveness of a program of patient education in asthmatics over 2 years. Thirty-seven asthmatic patients were randomly allocated to group A (usual treatment) and 32 to group B (usual treatment plus patient education program). The effectiveness of the education program was evaluated by comparing morbidity outcomes at baseline and 12 and 24 months afterwards. At baseline, no intergroup difference emerged in age, sex, smoking, asthma severity, atopy, FEV1, symptom-free days, use of rescue salbutamol, and QoL. One year later, group B subjects had an improvement in the overall QoL (from 5.8 +/- 0.8 to 6.1 +/- 0.7, p < 0.005), and in "Activities" (from 5.3 +/- 0.9 to 5.7 +/- 0.8, p < 0.05) and "Environment" (from 6.4 +/- 1.0 to 6.8 +/- 0.4, p < 0.05) domains. Two years later the "Activities" domain score increased in group B (from 5.3 +/- 0.9 to 5.7 +/- 1.1, p < 0.05). QoL did not vary in group A. The education program was ineffective in all other parameters at both follow-up time-points. In group A, a significant increase in medication expenses and a significant decrease in rescue salbutamol use was found 1 and 2 years after baseline, respectively. In conclusion, this education program improved QoL for 1 year, but the improvement was not sustained in the 2nd year.

Outcomes of American Lung Association-Indiana Lung Centers asthma program

The American Lung Association of Indiana (ALA-I), in conjunction with participating Indiana hospitals, developed the Lung Center concept as a mechanism to provide standardized delivery of lung health education. The goal of this pilot study was to evaluate initial experience with the Lung Center program "Overcoming Your Asthma," a two-session asthma education program, and identify areas needing improvement. A total of 305 participants responded to a 31-item questionnaire at baseline (immediately prior to program exposure) and again at 1 month (n = 75) and 6 months (n = 30) after participation. Overall, delivery of the ALA-I Lung Center asthma education program improved respondents' experience with asthma. At one month after the educational session, the program improved participant knowledge about asthma. This was associated with modest improvements in treatment behaviors, economic outcomes and asthma symptoms such as reduced breathing difficulties, wheezing and asthma exacerbations, and improvement in sleep. Improvements were not uniformly sustained at 6 months. In summary, the Lung Center asthma education program appears to benefit patients with asthma. The results provide preliminary evidence to support continued delivery of asthma education in Lung Centers. Future efforts should emphasize education to improve treatment attitudes and behaviors.

The role for N-acetylcysteine in the management of COPD

Oxidative stress has been implicated in the pathogenesis and progression of COPD. Both reactive oxidant species from inhaled cigarette smoke and those endogenously formed by inflammatory cells constitute an increased intrapulmonary oxidant burden. Structural changes to essential components of the lung are caused by oxidative stress, contributing to irreversible damage of both parenchyma and airway walls. The antioxidant N-acetylcysteine (NAC), a glutathione precursor, has been applied in these patients to reduce symptoms, exacerbations, and the accelerated lung function decline. This article reviews the available experimental and clinical data on the antioxidative effects of NAC in COPD, with emphasis on the role of exhaled biomarkers.

Cost-effectiveness of interventions to support self-care: A systematic review

Objectives: Interventions to support patient self-care of their condition aim to improve patient health and reduce health service costs. Consequently, they have attracted considerable policy interest. There is some evidence of clinical effectiveness but less attention has been paid to whether these interventions are cost-effective. This study examines the quality and quantity of existing evidence of the cost-effectiveness.

Methods: A systematic review was carried out to assess the extent and quality of economic evaluations of self-care support interventions. Thirty-nine economic evaluations were assessed against a quality checklist developed to reflect the special features of these interventions.

Results: The majority of the studies claimed that self-care support interventions were cost-effective or cost saving. The overall quality of economic evaluations was poor because of flaws in study designs, especially a narrow definition of relevant costs and short follow-up periods.

Conclusions: The current evidence base does not support any general conclusion that self-care support interventions are cost-effective, but ongoing trials may provide clearer evidence.

Economic effectiveness of disease management programs: a meta-analysis

The economic effectiveness of disease management programs, which are designed to improve the clinical and economic outcomes for chronically ill individuals, has been evaluated extensively. A literature search was performed with MEDLINE and other published sources for the period covering January 1995 to September 2003. The search was limited to empirical articles that measured the direct economic outcomes for asthma, diabetes, and heart disease management programs. Of the 360 articles and presentations evaluated, only 67 met the selection criteria for meta-analysis, which included 32,041 subjects. Although some studies contained multiple measurements of direct economic outcomes, only one average effect size per study was included in the meta-analysis. Based on the studies included in the research, a meta-analysis provided a statistically significant answer to the question of whether disease management programs are economically effective. The magnitude of the observed average effect size for equally weighted studies was 0.311 (95% CI = 0.272-0.350). Statistically significant differences of effect sizes by study design, disease type and intensity of disease management program interventions were not found after a moderating variable, disease severity, was taken into consideration. The results suggest that disease management programs are more effective economically with severely ill enrollees and that chronic disease program interventions are most effective when coordinated with the overall level of disease severity. The findings can be generalized, which may assist health care policy makers and practitioners in addressing the issue of providing economically effective care for the growing number of individuals with chronic illness.

Impacts of a government-sponsored outpatient-based disease management program for patients with asthma: a preliminary analysis of national data from Taiwan

In response to the high prevalence rates, mortality rates, and rising medical cost of asthma, the Bureau of National Health Insurance (BNHI) initiated a Healthcare Quality Improvement Program (HQIP) for people with asthma. The aim of this study was to investigate a preliminary analysis of the impact of a government-sponsored, outpatient-based disease management programs for people with asthma on the economic outcomes, the physician's and the patient's satisfaction. Using a retrospective design, a 1:4 (intervention vs. control group) matched cohort study design was used. Comparison of 1-year pre/post tests of utilizations of healthcare resources were conducted for 854 already diagnosed cases of patients with asthma. Comparison of independent tests between the intervention group and control group were performed for already diagnosed cases (n = 854) and newly-diagnosed cases (n = 231). Valid surveys were received from 212 physicians who participated the program, for a response rate of 46.0%, and 642 patients who enrolled in the program, for a response rate of 27.70%. Results indicated that the intervention group of already diagnosed cases had 39.94% fewer ED visits, 46.31% fewer inpatient visits, and 51.74% shorter length of stay, at a significant level. Though the HQIP program for people with asthma appeared to reduce medical care resource utilization for the intervention group, the control groups showed similar reductions but in different magnitude. For the newly diagnosed group, the intervention group had 197.43% more outpatient visits and 61.19% fewer ED visits of than those of the control group at a significant level. A majority of physicians (70%-85%) had positive opinions toward the HQIP program, but they admitted that the HQIP program prolonged the consultation time in outpatient visits (79.1%), and only 29.7% physicians did not feel interfered with while carrying out the HQIP. More than 80% of the patients showed positive feedback to the HQIP. The majority of the patients substantially adhered to physicians' suggestions, and had more accurate knowledge of and better self-care skills concerning asthma. These results have significance for the design of future programs aimed at improving the care of people with asthma and other chronic diseases in BNHI, Taiwan.

[The costs of asthma in France: an economic analysis by a Markov model]

INTRODUCTION

In France about 3.5 million people suffer from asthma, with an estimated annual cost of 1.5 billion euros. Few data on the components of the cost are available. To develop a medico-economic model to identify the mean annual cost of a patient with asthma together with the components of the cost and the consequences of different modalities of management (out-patient and in-patient).

METHODS

A first degree homogeneous Markov model was constructed, based on published data, to identify the different states of health of asthmatic patients, their development and probabilities of change from one to another.

RESULTS

The mean annual cost of asthma is 631 +/- 299 euros; 298 euros for stable patients, 1,052 for those who have at least one acute attack and 3,811 for those hospitalised. Actions leading to better control of the disease in the community (prevention and management of attacks) would produce a larger reduction in mean costs than actions undertaken in patients seen as an emergency or admitted to hospital.

CONCLUSIONS

From the point of view of society better control of asthma in the community is the most effective strategy to reduce expenditure.

[Outcome evaluation of education in asthmatic children: the Robert-Debré hospital's experience]

INTRODUCTION

Asthma, the most frequent chronic disease in childhood, is often treated by a continuous preventive treatment associated to the treatment of attacks. This therapeutic scheme fits well with educative skills. The Robert Debré's asthma school has been created in December 1999. Two nurses specialized in child asthma education are working in the school, helped by the pediatric pulmonologists. Children 6-year-old or more, that are treated in the hospital for asthma may be sent to the asthma school for education. They receive individual or collective education for cognitive, psycho-affective and sensory-motor targets related to asthma.

AIM OF THE STUDY

To evaluate the outcome of educative action in childhood asthma and to study hospitalizations costs.

METHODS

SUBJECTS

children who received education for the first time in the year 2000 or 2001 and in whom exhaustive computerized data were available were eligible for the study.

METHODS

retrospective and comparative study one-year-before/one-year-after the first educational intervention, assessed by comparison of the numbers of scheduled medical consultations and hospitalizations (and their cost).

RESULTS

Sixty-six children were studied. We registered a significant increase of scheduled medical consultations (177 vs. 223; P < 0.03), and a very significant decrease of hospitalizations for asthma attacks (32 vs. 11; P < 0.001) without influence of the number of educational interventions and with a 52% decrease in costs (84,788 vs. 40,073 euros; P < 0.03).

CONCLUSION

Asthmatic children education is a useful tool to improve medical follow-up and to decrease hospitalizations number. In a two-year survey, the decrease of cost in a group of 66 children is 44,715 euros.

Self-management interventions for chronic illness

An increasing number of interventions have been developed for patients to better manage their chronic illnesses. They are characterised by substantial responsibility taken by patients, and are commonly referred to as self-management interventions. We examine the background, content, and efficacy of such interventions for type 2 diabetes, arthritis, and asthma. Although the content and intensity of the programmes were affected by the objectives of management of the illness, the interventions differed substantially even within the three illnesses. When comparing across conditions, it is important to recognise the different objectives of the interventions and the complexity of the issues that they are attempting to tackle. For both diabetes and asthma, the objectives are concerned with the underlying control of the condition with clear strategies to achieve the desired outcome. By contrast, strategies to deal with symptoms of pain and the consequences of disability in arthritis can be more complex. The interventions that were efficacious provide some guidance as to the components needed in future programmes to achieve the best results. But to ensure that these results endure over time remains an important issue for self-management interventions.

Self-management education: history, definition, outcomes, and mechanisms

Self-management has become a popular term for behavioral interventions as well as for healthful behaviors. This is especially true for the management of chronic conditions. This article offers a short history of self-management. It presents three self-management tasks--medical management, role management, and emotional management--and six self-management skills--problem solving, decision making, resource utilization, the formation of a patient-provider partnership, action planning, and self-tailoring. In addition, the article presents evidence of the effectiveness of self-management interventions and posits a possible mechanism, self-efficacy, through which these interventions work. In conclusion the article discusses problems and solutions for integrating self-management education into the mainstream health care systems.

The assessment of childhood asthma

The development of independent outcome measures for assessing the severity of asthma seems justified. The various outcomes measures listed by the guidelines (symptoms, nocturnal awakenings, rescue beta2-agonist use, and lung function) and their response to therapy are predictive of severe exacerbations from asthma. They do not necessarily strongly correlate with each other, however. Measures of AHR, particularly methacholine provocation, and the measurement of FeNO are attractive as assessments of ongoing asthma activity in children when lung function and symptoms are normal.

Options for self-management education for adults with asthma

BACKGROUND

Asthma education and self-management are key recommendations of asthma management guidelines because they improve health outcomes. There are several different modalities for the delivery of asthma self-management education.

OBJECTIVES

We evaluated programmes that: 1) Optimised asthma control through inhaled corticosteroid use by regular medical review or optimised asthma control by individualised written action plans 2) Used written self-management plans based on peak expiratory flow self-monitoring compared with symptom self-monitoring 3) Compared different options for the delivery of optimal self-management programmes.

SEARCH STRATEGY

We searched the Cochrane Airways Group trials register and reference lists of articles.

SELECTION CRITERIA

Randomised trials of asthma self-management education interventions in adults over 16 years of age with asthma.

DATA COLLECTION AND ANALYSIS

Fifteen trials met the inclusion criteria. Trial quality was assessed and data were extracted independently by two reviewers. Study authors were contacted for confirmation.

MAIN RESULTS

1) Six studies compared optimal self-management allowing self-adjustment of medications according to an individualised written action plan to adjustment of medications by a doctor. These two styles of asthma management gave equivalent effects for hospitalisation, ER visits, unscheduled doctor visits and nocturnal asthma. 2) Self-management using a written action plan based on PEF was found to be equivalent to self-management using a symptoms based written action plan in the six studies which compared these interventions. 3) Three studies compared self-management options. In one, that provided optimal therapy but tested the omission of regular review, the latter was associated with more health centre visits and sickness days. In another, comparing high and low intensity education, the latter was associated with more unscheduled doctor visits. In a third, no difference in health care utilisation or lung function was reported between verbal instruction and written action plans.

REVIEWER'S CONCLUSIONS

Optimal self-management allowing for optimisation of asthma control by adjustment of medications may be conducted by either self-adjustment with the aid of a written action plan or by regular medical review. Individualised written action plans based on peak expiratory flow are equivalent to action plans based on symptoms. Reducing the intensity of self-management education or level of clinical review may reduce its effectiveness.

Short-term effectiveness of an asthma educational program: results of a randomized controlled trial

Asthma educational programs have been shown to reduce the use of emergency room, frequency of severe asthma attacks and hospitalization. However, its effectiveness in other morbidity parameters and on quality of life has yet to be fully understood. This prospective randomized control trial evaluated the effectiveness of a patient education program in 77 asthmatics according to "Teach Your Patients About Asthma: A Clinicians Guide" (1992). Forty asthmatic patientswere randomly allocated to Group A (usual treatment) and 37 to Group B (usual treatment plus a patient education program). The effectiveness of the educational program was evaluated by comparing morbidity outcomes at baseline and 3 months after initial evaluation. At enrolment, the two groups were not different with regard to age, sex, smoking, asthma severity atopy, FEV1, symptom-free days, use of rescue salbutamol and quality of life. Three months later, subjects in Group B showed a significant improvement in the overall quality of life (p < 0.01) and in the "Symptoms"domain (p < 0.01). None of the other parameters (use of rescue salbutamol, symptom-free days, days absent from work or school, FEV1) showed any significant change. After stratification for asthma severity, only subjects with moderate-to-severe asthma showed a significant improvement inthe overall qualityof life (p < 0.05) and in the "Symptoms" (p < 0.01) and 'Activities" (< 0.05) domains. Moreover, in subjects with moderate-to-severe asthma FEV1 value at the 3rd month of follow-up was higher in Group B than in Group A (p < 0.05). In conclusion, the educational program improved the quality of life in asthratic subjects, mainly in patients with moderate-to-severe asthma.

An update on the health economics of asthma and allergy

Health economics is receiving more attention as decision-makers--whether purchaser, physician, or patient--are looking for a more comprehensive understanding of the impact of adopting new healthcare strategies. In this article we review the recent advances in the health economics of asthma and allergy. In burden of illness studies, estimates of the economic burden of asthma and allergy were reported from countries and regions not previously detailing these costs. There were economic evaluations comparing medications and those that evaluated disease management programs. The recent studies of pharmaceuticals have focused on evaluating the cost-effectiveness of various controller medications for the treatment of asthma. Although mostly observational, such studies increase the evidence that these medications are relatively cost-effective. A few recent economic evaluations have been published examining disease management and education programs. These studies are generally long-term evaluations and have not shown consistent health economic impact. The field of health economics in asthma and allergy continues to evolve and aims to provide information to aid in decision making.

Outpatient monitoring of asthma

Monitoring asthma outcomes is an essential step to the successful implementation of national asthma guidelines. Symptoms, airflow obstruction and exacerbations can be monitored by patients with asthma and by physicians. Patients who practise self-monitoring in conjunction with use of a written action plan and regular medical review have significantly fewer hospitalizations, emergency room visits and lost time from work. Additional monitoring tools are under evaluation, and these include measures of airway responsiveness, airway inflammation, and Internet-based monitoring systems.

Self-management education and regular practitioner review for adults with asthma

BACKGROUND

A key component of many asthma management guidelines is the recommendation for patient education and regular medical review. A number of controlled trials have been conducted to measure the effectiveness of asthma education programmes. These programmes improve patient knowledge, but their impact on health outcomes is less well established. This review was conducted to examine the strength of evidence supporting Step 6 of the Australian Asthma Management Plan: "Educate and Review Regularly"; to test whether health outcomes are influenced by education and self-management programmes.

OBJECTIVES

The objective of this review was to assess the effects of asthma self-management programmes, when coupled with regular health practitioner review, on health outcomes in adults with asthma.

SEARCH STRATEGY

We searched the Cochrane Airways Group trials register and reference lists of articles.

SELECTION CRITERIA

Randomised trials of self-management education in adults over 16 years of age with asthma.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data were extracted independently by two reviewers. Study authors were contacted for confirmation.

MAIN RESULTS

Twenty-five trials were included. Self-management education was compared with usual care in 22 studies. Self-management education reduced hospitalisations (odds ratio 0.57, 95% confidence interval 0.38 to 0.88); emergency room visits (odds ratio 0.71, 95% confidence interval (0.57 to 0.90); unscheduled visits to the doctor (odds ratio 0.57, 95% confidence interval 0.40 to 0.82); days off work or school (odds ratio 0.55, 95% confidence interval 0.38 to 0. 79); and nocturnal asthma (odds ratio 0.53, 95% confidence interval 0.39 to 0.72). Measures of lung function were little changed. Self-management programmes that involved a written action plan showed a greater reduction in hospitalisation than those that did not (odds ratio 0.35, 95% confidence interval 0.18 to 0.68). People who managed their asthma by self-adjustment of their medications using an individualised written plan had better lung function than those whose medications were adjusted by a doctor.

REVIEWER'S CONCLUSIONS

Training in asthma self-management which involves self-monitoring by either peak expiratory flow or symptoms, coupled with regular medical review and a written action plan appears to improve health outcomes for adults with asthma. Training programmes which enable people to adjust their medication using a written action plan appear to be more effective than other forms of asthma self-management.

Limited (information only) patient education programs for adults with asthma

BACKGROUND

A key component of many asthma management guidelines is the recommendation for patient education and regular medical review. A number of controlled trials have been conducted to measure the effectiveness of asthma education programmes. These programmes improve patient knowledge, but their impact on health outcomes is less well established. At its simplest level, education is limited to the transfer of information about asthma, its causes and its treatment. This review focused on the effects of limited asthma education.

OBJECTIVES

The objective of this review was to assess the effects of limited (i.e. information only) asthma education on health outcomes in adults with asthma.

SEARCH STRATEGY

We searched the Cochrane Airways Group trials register and reference lists of articles.

SELECTION CRITERIA

Randomised and controlled trials of individual asthma education involving information transfer only in adults over 16 years of age.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data were extracted independently by two reviewers. Study authors were contacted for missing information.

MAIN RESULTS

Eleven trials were included. They were of variable quality. Limited asthma education did not reduce hospitalisation for asthma (weighted mean difference -0.03 average hospitalisations per person per year, 95% confidence interval -0.09 to 0.03). There was no effect on doctor visits, lung function and medication use. The effects on asthma symptoms were variable. There was no reduction in days lost from normal activity, but perceived asthma symptoms did improve after limited asthma education (odds ratio 0.40, 95% confidence interval 0.18 to 0.86). In one study, limited asthma education was associated with reduced emergency department visits (weighted mean difference -2.76 average visits per person per year, 95% confidence interval -4.34 to 1.18).

REVIEWER'S CONCLUSIONS

Use of limited asthma education as it has been practiced does not appear to improve health outcomes in adults with asthma. However the use of information in the emergency department may be effective, but this needs to be confirmed.