Effectiveness of an education programme by a general practice assistant for asthma and COPD patients: results from a randomised controlled trial

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Abstract

In this study a randomised controlled trial was carried out to investigate the effectiveness of an education programme for patients with asthma or chronic obstructive pulmonary disease (COPD). All asthma and COPD patients using medication and experiencing pulmonary symptoms were randomly assigned to the intervention (n=139) or usual-care group (n=137). The intervention consisted of taylor-made education conducted by a general practice assistant and focussing on a patients’ technical skills and coping with the disease. Measurements took place at baseline, and after 1 and 2 years of follow-up. After 1 and 2 years the inhalation technique was significantly better in the intervention group compared to the usual-care group. No significant differences were observed regarding disease symptoms, health related quality of life, compliance, smoking cessation, self-efficacy, and coping. The results only support the implementation of the intervention regarding the technical skills (inhalation technique). However, given the importance of improvement of patients’ coping and the need for more efficient care, we recommend further exploration of the possibilities of a more structured and intensive education programme.

Introduction

A substantial discrepancy between provided care and guidelines for adequate treatment has been demonstrated in patients with (mild to moderate) asthma or chronic obstructive pulmonary disease (COPD) in primary care [1], [2]. Previous research reported undertreatment, insufficient patient knowledge (about disease, prescribed medication, and triggers provoking exacerbation), poor compliance, and an incorrect inhalation technique [1], [3], [4], [5]. Health education by the general practitioner (GP) usually occurs in the early phase of the disease, or when patients present themselves with an exacerbation [2], [6]. Without sufficient follow-up, information may not be easily understood or retained. The undertreatment of patients with asthma and COPD has also been attributed to the relative complex treatment schedule and the high workload of Dutch GPs, as a result of which disease-specific education may often be neglected [7], [8].

Recent reviews have shown that programmes containing information only, given through a video, booklet or computer, do not improve health outcomes [9]. Extensive self-management programmes overall did lead to an improvement of most health outcomes [10], [11]. However, almost all reviewed programmes were carried out among more severely ill patients, whereas the majority of patients have mild to moderate asthma or COPD and are treated in primary care [10], [11]. More seriously diseased patients are seen by a specialist on a regular basis and are probably more motivated, creating better opportunities to integrate self-management programmes into daily care [12], [13]. Nevertheless, patients in primary care do need extra care, and might benefit from a less extensive programme.

The GP-assistant in The Netherlands gives administrative support to the GP and assists in minor medical interventions. In order to improve care, create easily accessible care for patients, and unburden the GPs, tasks can be delegated to well trained GP-assistants [14]. We developed a brief education programme provided by a GP-assistant, that addresses individual knowledge and skills regarding the disease, medication, compliance, inhalation technique, smoking behaviour and management of disease specific problems which in turn may also positively influence coping and self-efficacy. This paper reports on a randomised controlled trial (RCT) on the effectiveness of this education programme on disease symptoms and HRQoL, by comparing it with usual-care.

Section snippets

Patient selection

Fourteen GPs from 12 general practices in The Netherlands selected patients with asthma or COPD from their practice records using the following inclusion criteria: a clinical diagnosis of asthma, COPD or mixed disease (asthma with persisting airway obstruction) [15], age 16–75 years, treated by the GP, and the absence of other specific pulmonary or terminal diseases. All patients were invited for a baseline assessment between January 1998 and January 1999. Based on this assessment, only

Recruitment

Of the 663 patients selected by the GPs and invited for baseline assessment, 124 could not be contacted, while 63 refused to participate (Fig. 1). Among the non-responders, there were significantly more males and younger patients. Of the 476 patients assessed, 276 (58%) patients met all inclusion criteria and were randomly allocated to either the intervention (n=139) or usual-care group (n=137).

After one year 17% in the intervention group versus 31% in the usual-care group were lost to

Discussion and conclusion

The education programme developed for primary care patients with asthma or COPD resulted in only small and non-significant changes on disease symptoms or HRQoL. Inhalation technique, which is required for good disease control, was significantly better in the intervention than in the usual-care group.

Acknowledgements

The authors thank the patients and general practitioners for their co-operation and the pulmonary function assistants in the WestFries Gasthuis for conducting the measurements. We also thank the general practice assistants, Paula van den Broek and Sylvia Ruiter, for their enormous effort and excellent work in conducting the education programme.

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