A self-management program for adult asthma. Part I: Development and evaluation

doi:10.1016/S0091-6749(95)70315-2

Journal of Allergy and Clinical Immunology

Volume 95, Issue 2, February 1995, Pages 529-540

https://doi.org/10.1016/S0091-6749(95)70315-2 Get rights and content

Abstract

Background: We developed and evaluated a self-management program for adult asthma. In developing the program, we considered questions of format and behavior control. The format we selected included components known to be effective in educational settings. We regulated asthma management behavior through the introduction of environmental cues. Methods: Seventy-six subjects, whose asthma was generally under medical control, were assigned randomly to either a treatment group or a waiting-list control group. Those in the treatment group were exposed to a 7-week program that incorporated proven features of providing effective training and establishing behavioral control. Subsequently, subjects in the control group received the treatment. Short-term evaluation of the treatment was made after the subjects in the experimental group were trained but before the control subjects were trained. Long-term evaluation was conducted after both groups of subjects were trained. Results: Over the short term, self-management training led to fewer asthma symptoms and physician visits and improvement in asthma management skills and cognitive abilities. Over the long term, self-management training was related to lower asthma attack frequency, reduced medication use, improvement in cognitive measures, and increased use of self-management skills. Conclusions: The program improved asthma management in patients whose conditions were already under good medical control. The effects of the program were apparent a year after the conclusion of self-management training. (J A LLERGY CLIN I MMUNOL 1995;95:529-40.)

Section snippets

Subjects

The program was offered to 126 patients with asthma. Of these, 41 declined participation and nine dropped out of the study before its completion. The remaining 76 individuals completed all phases of the study. This group included 49 women and 27 men, who, on average, described their asthma as moderate to severe. At the initiation of the study, the asthma of each patient was controlled adequately by medical treatment. The diagnosis of asthma was confirmed in accordance with standards established

Asthma symptoms

Overall, asthma symptoms improved from the first 2 months to the fifth and sixth months in self-management subjects but not in control subjects. The improvements were reflected as decreased frequency of both morning (p < 0.05) and evening (p < 0.01) asthma attacks, higher morning PEFR scores ( p < 0.05), and reductions in breathing difficulty (p < 0.05). From the first 2 months to the fifth and sixth months of the study, self-management patients exhibited the following reliable changes: (1) a

DISCUSSION

A wide variety of outcome measures related to asthma severity changed as a result of self-management training. This was reflected by: (1) a decrease in asthma symptoms, including fewer asthma attacks, higher peak flow rates, and lower patient ratings of breathlessness; (2) an increase in asthma self-management behaviors; (3) changes in cognitive measures, including increased knowledge of asthma and higher self-efficacy and lower depression scores; and (4) a decrease in the number of physician

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Cited by (115)

Psychological treatment of comorbid asthma and panic disorder in Latino adults: Results from a randomized controlled trial
2016, Behaviour Research and Therapy
Confusion between panic and asthma symptoms can result in serious self-management errors. A cognitive behavior psychophysiological therapy (CBPT) intervention was culturally adapted for Latinos consisting of CBT for panic disorder (PD), asthma education, differentiation between panic and asthma symptoms, and heart rate variability biofeedback. An RCT compared CBPT to music and relaxation therapy (MRT), which included listening to relaxing music and paced breathing at resting respiration rates. Fifty-three Latino (primarily Puerto Rican) adults with asthma and PD were randomly assigned to CBPT or MRT for 8 weekly sessions. Both groups showed improvements in PD severity, asthma control, and several other anxiety and asthma outcome measures from baseline to post-treatment and 3-month follow-up. CBPT showed an advantage over MRT for improvement in adherence to inhaled corticosteroids. Improvements in PD severity were mediated by anxiety sensitivity in CBPT and by depression in MRT, although earlier levels of these mediators did not predict subsequent improvements. Attrition was high (40%) in both groups, albeit comparable to CBT studies targeting anxiety in Latinos. Additional strategies are needed to improve retention in this high-risk population. Both CBPT and MRT may be efficacious interventions for comorbid asthma-PD, and CBPT may offer additional benefits for improving medication adherence.
Economic Evidence for US Asthma Self-Management Education and Home-Based Interventions
2016, Journal of Allergy and Clinical Immunology: In Practice
Citation Excerpt :
Also, programs were stratified by whether a benefit-cost ratio (ie, ROI) was explicitly reported, because it could not be ascertained whether calculations of cost savings without accompanying ROI data consistently included program operating costs. We identified 9 US programs that provided intensive outpatient AS-ME and reported the ROI (Table I).13-32 All but one were reported in peer-reviewed literature.15
The health and economic burden of asthma in the United States is substantial. Asthma self-management education (AS-ME) and home-based interventions for asthma can improve asthma control and prevent asthma exacerbations, and interest in health care-public health collaboration regarding asthma is increasing. However, outpatient AS-ME and home-based asthma intervention programs are not widely available; economic sustainability is a common concern. Thus, we conducted a narrative review of existing literature regarding economic outcomes of outpatient AS-ME and home-based intervention programs for asthma in the United States. We identified 9 outpatient AS-ME programs and 17 home-based intervention programs with return on investment (ROI) data. Most programs were associated with a positive ROI; a few programs observed positive ROIs only among selected populations (eg, higher health care utilization). Interpretation of existing data is limited by heterogeneous ROI calculations. Nevertheless, the literature suggests promise for sustainable opportunities to expand access to outpatient AS-ME and home-based asthma intervention programs in the United States. More definitive knowledge about how to maximize program benefit and sustainability could be gained through more controlled studies of specific populations and increased uniformity in economic assessments.
National standards for asthma self-management education
2015, Annals of Allergy, Asthma and Immunology
Asthma education reimbursement continues to be an issue in the United States. Among the greatest barriers is the lack of a standardized curriculum for asthma self-management education recognized by a physician society, non-physician health care professional society or association, or other appropriate source. The applicable Current Procedural Terminology codes for self-management education and training are 98960 through 98962, stating that “if a practitioner has created a training curriculum for educating patients on management of their medical condition, he or she may employ a non-physician health care professional to provide education using a standardized curriculum for patients with that disease.” Without a standardized curriculum, reimbursement from payers is beyond reach.
Representatives from the Joint Council of Allergy, Asthma, and Immunology; American College of Allergy, Asthma, and Immunology; American Academy of Allergy, Asthma, and Immunology; American Lung Association; American Thoracic Society; National Asthma Educator Certification Board; American College of Chest Physicians; and Association of Asthma Educators gathered to write a standardized curriculum as a guideline for payer reimbursement.
The Task Force began with a review of the American Lung Association and American Thoracic Society's Operational Standards for Asthma Education. Board members of the National Asthma Educator Certification Board incorporated comments, rationale, and references into the document.
This document is the result of final reviews of the standards completed by the Task Force and national health care professional organizations in September 2014.
This document meets the requirements of Current Procedural Terminology codes 98960 through 98962 and establishes the minimum standard for asthma self-management education when teaching patients or caregivers how to effectively manage asthma in conjunction with the professional health care team.
Asthma adherence management for the clinician
2013, Journal of Allergy and Clinical Immunology: In Practice
Citation Excerpt :
Studies of adult self-management programs have shown improved health outcomes: reduced nocturnal asthma, hospitalizations, physician visits, and missed days of school and work.50,51 Superior outcomes were achieved for patients with written asthma action plans who had the ability to adjust their medication.50,51 Similarly, Haynes et al52 reported that the most effective interventions for patients included providing reinforcement for patients' efforts to change health-related behaviors, giving feedback on progress, tailoring the education intervention to the specific needs of the patient, teaching self-management skills, and providing the patient with educational resources.52
Nonadherence to asthma treatment has been related to increased hospital and emergency care, morbidity, and unnecessary costs. Improving patient adherence is a key component to achieving optimal outcomes.
Review barriers, interventions, and communication skills shown to be effective in promoting asthma adherence.
Asthma adherence literature was reviewed.
Sequential management principles to achieve adherence include the following: (1) measuring adherence, (2) identifying barriers that result in nonadherence, (3) using specific strategies to overcome barriers; and (4) using communication skills to enhance the delivery of selected strategies.
Careful attention to adherence management principles may increase adherence, enhance outcomes, and reduce unnecessary morbidity and cost. The case described applies these principles and gives the reader a framework to review.
Is patient reported outcome (PRO) affected by different follow-up regimens in inflammatory bowel disease (IBD)? A one year prospective, longitudinal comparison of nurse-led versus conventional follow-up
2012, Journal of Crohn's and Colitis
Citation Excerpt :
On the other hand, in other chronic conditions — such as asthma, we have seen that the patients are participating more actively in their own treatment. This has shown to reduce morbidity, personal symptoms, treatment regimens and number of hospital stays due to a greater knowledge of the course and management of the disease.11–13 The primary aim of this study was to compare two different follow-up regimens (nurse-led and conventional) on patient reported outcomes (PRO) such as health-related quality of life (HRQoL) and disease-related worries and distress.
Specialist nurses have become increasingly involved in the management of Inflammatory Bowel Disease (IBD). The objectives of this study were to investigate the impact of nurse-led versus conventional follow-up on patient outcomes, such as quality of life, worries and time from relapse to start of treatment.
Patients completed the Short Form 36 (SF-36), Inflammatory Bowel Disease Questionnaire (N-IBDQ) and the Rating Form of IBD Patient Concerns (RFIPC) at baseline and after 1 year. Socio-demographic and clinical variables were obtained at V1 and V2. In addition the amount of e.g., relapses, hospitalisations, time from relapse to start of treatment, sick-leave, unscheduled visits or telephone calls was recorded during the follow-up period.
A total of 140 patients were included; ulcerative colitis (UC) n = 92, Crohn's disease (CD) n = 48, mean age 46.9 and 40.0 years old, respectively. One hundred and thirty three patients attended the follow-up after 1 year. After 1 year there were no differences between the groups in relation to quality of life, worries, amount of relapse, sick-leave, hospitalisations or surgery. Participants in nurse-led follow-up had a significantly (p < 0.05) shorter interval from the start of a relapse to the start of treatment.
Nurse-led follow-up of IBD patients produces PRO results comparable to that of gastroenterologists and may shorten the interval from the beginning of a relapse to the start of treatment.
Individualized asthma self-management improves medication adherence and markers of asthma control
2009, Journal of Allergy and Clinical Immunology
Adherence to inhaled anti-inflammatory therapy and self-management skills are essential parts of the asthma treatment plan to improve asthma control and prevent exacerbations. Whether self-management education improves long-term medication adherence is less clear.
A 24-week prospective, randomized controlled trial was performed to study the effect of self-management education on long-term adherence to inhaled corticosteroid (ICS) therapy and markers of asthma control.
After stabilization on ICS medication during a run-in phase, 95 adults with moderate-to-severe asthma were recruited from a large metropolitan community, and 84 were randomized to individualized self-management education, including self-monitoring of symptoms and peak flow or usual care with self-monitoring alone. The key components of the 30-minute intervention were asthma information, assessment, and correction of inhaler technique; an individualized action plan based on self-monitoring data; and environmental control strategies for relevant allergen and irritant exposures. The intervention was personalized based on pulmonary function, allergen skin test reactivity, and inhaler technique and reinforced at 2-week intervals.
Participants randomized to the self-management intervention maintained consistently higher ICS adherence levels and showed a 9-fold greater odds of more than 60% adherence to the prescribed dose compared with control subjects at the end of the intervention (P = .02) and maintained a 3-fold greater odds of higher than 60% adherence at the end of the study. Perceived control of asthma improved (P = .006), nighttime awakenings decreased (P = .03), and inhaled β-agonist use decreased (P = .01) in intervention participants compared with control subjects.
Our results show that individualized asthma self-management education attenuates the usual decrease in medication adherence and improves clinical markers of asthma control.

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^☆: From ^aOhio University, Athens; and ^bCenter for Allergy and Asthma, Cincinnati.

^☆☆: Supported in part by grant number HL 32538 from the National Heart, Lung, and Blood Institute and by an Academic Challenge Award from the State of Ohio.

^★: Reprint requests: Thomas L. Creer, PhD, Department of Psychology, Ohio University, Athens, OH 45701.

^★★: 0091-6749/95 $3.00 + 0 1/1/60081

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A self-management program for adult asthma. Part I: Development and evaluation☆,☆☆,★,★★

Abstract

Section snippets

Subjects

Asthma symptoms

DISCUSSION

Patient Educ Counsel

J Adolesc Health Care

Br J Dis Chest

J Chronic Dis

A critique of 19 self-management programs for childhood asthma. Part I. The development and evaluation of the programs

Pediatr Asthma Allergy Immunol

Education of adult patients at an “asthma school”: effects on quality of life, knowledge and need for nursing

Eur Respir J

Videotape educational program for adults with asthma

Can Med Assoc J

Development and evaluation of an adult asthma self-management program: Wheezers Anonymous

J Asthma

Education for self-treatment by adult asthmatics

JAMA

The costs and effectiveness of an education program for adults who have asthma

J Gen Intern Med