Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Small-group and individual asthma education programs improved symptom control and patient's understanding and management of their condition

ACP J Club. 1993 Sept-Oct;119:43. doi:10.7326/ACPJC-1993-119-2-043


Source Citation

Wilson SR, Scamagas P, German DF, et al. A controlled trial of two forms of self-management education for adults with asthma. Amer J Med. 1993 Jun;94:564-76.


Abstract

Objective

To evaluate the effectiveness of self-management education in improving asthma symptoms and in reducing health services use in patients with moderate-to-severe asthma.

Design

Randomized controlled trial with 1-year follow-up.

Setting

5 medical centers in California.

Patients

323 patients aged 18 to 50 years who were members of the Kaiser health care plan for ≥ 1 year and who had a confirmed diagnosis of bronchial asthma without irreversible respiratory disease. Additional inclusion criteria were that patients were considered by their physician to have moderate-to-severe asthma, had ≥ 3 physician visits for asthma during the screening year, and had been taking daily medication for the past year. 277 patients (86%) completed the study.

Intervention

Patients were allocated to 1 of 4 treatment groups: group education, individual education, information control (workbook), or usual control (no supplemental education). The major emphasis in the education treatment groups was the importance of pharmacologic and environmental control measures to prevent asthma symptoms. The education programs ended 3 to 4 months after randomization.

Main outcome measures

Changes in asthma symptoms, use of medical services, knowledge about asthma, metered-dose inhaler technique, and self-management behaviors.

Main results

Patients receiving group and individual education were bothered less by their asthma at 1 year (55% and 50%, respectively) compared with control patients receiving the workbook or no information (38% and 25%, respectively; P = 0.028). Patients receiving self-management education had fewer symptomatic days at 1 year compared with the no-information control group (P = 0.025), and showed better metered-dose inhaler technique at 1 year compared with both control groups (P < 0.0001). Patients receiving either group or individual education showed greater improvements in their bedroom environment at 1 year compared with the control groups (P > 0.05). Patients receiving small-group education showed improvement in physician evaluation of the patients' asthma status and in the patients' level of physical activity. The use of medical care did not differ.

Conclusion

Small-group and individual asthma education programs improved patients' understanding of their condition, control of asthma symptoms, metered-dose inhaler technique, and environmental control practices.

Source of funding: National Heart, Lung, and Blood Institute.

For article reprint: Dr. S.R. Wilson, Palo Alto Medical Foundation Research Institute, 860 Bryant Street, Palo Alto, CA 94301, USA. FAX 650-329-9114.


Commentary

Educating patients in how to deal with chronic obstructive pulmonary disease reduced the use of health services and improved patients' knowledge of the disease

The studies by Wilson and colleagues and Tougaard and colleagues help to effectively focus adult asthma education in clinical practice. Asthma is responsible for a large burden of illness, which is expensive and increasing. Preventable factors are present in most asthma deaths and in severe asthma exacerbations. The problems of adherence and compliance are particularly important in asthma. Many patients fail to follow a management plan because the plan is either rejected or misunderstood. Patient education can identify barriers to compliance and can reinforce correct instructions. These 2 studies identify the types of intervention that can make a difference in asthma. Most patients (89%) in the study by Tougaard and colleagues had asthma, and their use of the term COPD reflects the European tendency to "lump" rather than "split" airway diseases.

The 2 studies describe the content and process of a successful asthma management program. Knowledge of medications and their effects is required to aid compliance with a treatment regimen that optimizes asthma control. Instruction on the management of exacerbations is of paramount importance. This involves the avoidance of substances or situations that trigger asthma and involves the early recognition of deteriorating asthma by monitoring symptoms or peak expiratory flow or both. If exacerbations occur, the patient is instructed to increase bronchodilator and anti-inflammatory therapy because exacerbations increase bronchoconstriction and airway inflammation. The appropriate use of medical services is reinforced, especially when a patient needs to seek help (1).

The way these instructions are conveyed to the patient is crucial. As the study by Wilson and colleagues describes, the educational content must be delivered personally, either one-to-one or in a group setting, and in addition to a physician's usual care. This is a critical point. To improve the quality of care, it is necessary to spend more time on patient education, either during a consultation or at additional visits. These and other studies however, do justify the added time and expense of asthma education for adults (2). Successful programs improve symptom control and can reduce the use of health services (2). Smoking cessation needs to be addressed in education programs. Smoking is associated with inadequate asthma management (3), and smokers may avoid these programs. (4). However, the cost savings in the study by Tougaard and colleagues were greatest with smokers in the intervention group. The role of exercise and rehabilitation has not been defined in asthma but may be important, particularly in severe disease with complicating chronic airflow obstruction.

Targeting patients with at least moderate-to-severe asthma is sensible. Although not yet proven, it would reduce the cost of intervening, probably maximize the benefit, and make best use of limited resources. Suitable patients can be identified from clinics, or, as the study by Tougaard and colleagues shows, identified after hospitalization for nonrespiratory problems. A simple screening tool can be used to identify patients with more severe diseases (5). Ironically, those patients who could benefit most from asthma education may not comply (45% in Wilson's study). Future studies will need to define strategies for these patients (4, 6).

Asthma education, the personal delivery of asthma knowledge and management skills in addition to usual medical care, should now be routine care for adults with asthma.

Peter G. Gibson, MBBS
John Hunter HospitalNewcastle, Australia


References

1. National Asthma Education and Prevention Program. Guidelines for the diagnosis and management of asthma: expert panel report 2. Bethesda: National Heart, Lung, and Blood Institute, 1997.

2. Gibson PG, Coughlan J, Wilson AJ, et al. The effects of self-management education and regular practitioner review in adults with asthma. (Cochrane Review, latest version 26 Feb 98). In: The Cochrane Library. Oxford: Update Software.

3. Gibson P, Henry D, Francis L, et al. Association between availability of non-prescription beta 2 agonist inhalers and undertreatment of asthma. BMJ. 1993;306:1514-8.

4. Fish L, Wilson SR, Latini DM, Starr NJ. An education program for parents of children with asthma: differences in attendance between smoking and nonsmoking parents. Am J Public Health. 1996;86:246-8.

5. Jones KP, Charlton IH, Middleton M, Preece WJ, Hill AP. Targeting asthma care in general practice using a morbidity index. BMJ. 1992;304:1353-6.

6. Yoon R, McKenzie DK, Miles DA, Bauman A. Characteristics of attenders and nonattenders at an asthma education programme. Thorax. 1991;46:886-90.