BACKGROUND: Some individuals with moderate/severe persistent asthma develop irreversible airway obstruction. These individuals present with dyspnoea, exercise intolerance and impaired quality of life (QOL), all of which could potentially be alleviated with exercise training.
OBJECTIVE: To investigate whether exercise training improves functional exercise capacity and QOL in middle-aged and older adults with fixed airway obstruction asthma (FAOA).
METHODS: 35 subjects aged 67.8 ± 10.6 years, with FEV(1) 59 ± 16% of predicted, were randomised to a 6-week 'intervention' period of supervised exercise training (n = 20) or usual care (n = 15). This period was preceded by a 3-week run-in period during which asthma control was assessed weekly. Functional exercise capacity (6-min walk distance, 6MWD) and QOL (Asthma QOL Questionnaire, AQLQ) were measured before, immediately following and 3 months after the intervention period.
RESULTS: 34 subjects (exercise group, n = 19, and control group, n = 15) completed the intervention period. Relative to the control group, the exercise group had greater improvements immediately following and 3 months after the intervention in the AQLQ symptom domain (0.61, p = 0.001, and 0.57 points per item, p = 0.005) and AQLQ activity limitation domain (0.43, p = 0.04, and 0.55 points per item, p = 0.04). 6MWD increased (36 ± 37 m, p < 0.01) in the exercise group immediately following training and remained elevated (34 ± 45 m, p < 0.01) at the 3-month follow-up. The magnitude of change in 6MWD between groups was not significant, despite no change in the control group.
CONCLUSIONS: Supervised exercise training improves symptoms and QOL in adults with FAOA.
STATEMENT OF PROBLEM: Despite the availability of improved healthcare access, self-management programs, disease management protocols, and advances in pharmacologic and immunotherapy therapy, the prevalence of asthma in the urban inner city remains one of the major health disparities in the United States. Additionally, sustainability of effective intervention programs after the funding has ended remains a significant issue for asthma programs.
OBJECTIVE: This study examines the effectiveness of a longitudinal intervention program that was designed with the assumption that improved literacy plays a role in improving asthma-related health outcomes among high-risk children with the most severe forms of asthma.
METHODS: A longitudinal intervention over 6 months prospectively addressed the literacy and asthma self-management skills of 110 minority children in South Los Angeles utilizing weekly Saturday-school format.
RESULTS: The results demonstrated that there was a statistically significant decrease in both hospitalization and emergency department (ED) visits during the intervention. In addition, all the children showed significant improvement in their reading level and self-efficacy. Multivariate logistic analysis demonstrated that enhanced self-efficacy was directly related to decreased hospitalizations and ED visits.
CONCLUSION: This intervention demonstrated that literacy enhancement is an important factor in improving self-efficacy and impacting asthma-related outcomes. Improved literacy is a sustainable factor that will not only improve asthma outcomes but will enhance the potential for educational success.
OBJECTIVES: To determine whether well trained lay people could deliver asthma self-management education with comparable outcomes to that achieved by primary care based practice nurses.
DESIGN: Randomised equivalence trial.
SETTING: 39 general practices in West London and North West England.
PARTICIPANTS: 567 patients with asthma who were on regular maintenance therapy. 15 lay educators were recruited and trained to deliver asthma self-management education.
INTERVENTION: An initial consultation of up to 45 min offered either by a lay educator or a practice based primary care nurse, followed by a second shorter face to face consultation and telephone follow-up for 1 year.
MAIN OUTCOME MEASURES: Unscheduled need for healthcare.
SECONDARY OUTCOME MEASURES: Patient satisfaction and need for courses of oral steroids.
RESULTS: 567 patients were randomised to care by a nurse (n = 287) or a lay educator (n = 280) and 146 and 171, respectively, attended the first face to face educational session. During the first two consultations, management changes were made in 35/146 patients seen by a practice nurse (24.0%) and in 56/171 patients (32.7%) seen by a lay educator. For 418/567 patients (73.7%), we have 1 year data on use of unscheduled healthcare. Under an intention to treat approach, 61/205 patients (29.8%) in the nurse led group required unscheduled care compared with 65/213 (30.5%) in the lay led group (90% CI for difference -8.1% to 6.6%; 95% CI for difference -9.5% to 8.0%). The 90% CI contained the predetermined equivalence region (-5% to +5%) giving an inconclusive result regarding the equivalence of the two approaches. Despite the fact that all patients had been prescribed regular maintenance therapy, 122/418 patients (29.2%) required courses of steroid tablets during the course of 1 year. Patient satisfaction following the initial face to face consultation was similar in both groups.
CONCLUSIONS: It is possible to recruit and train lay educators to deliver a discrete area of respiratory care, with comparable outcomes to those seen by nurses.
CONTEXT: Increasing urban asthma prevalence and severity is found among minority, underserved populations. Improving asthma self-management includes home management of complex medical protocols as well as environmental trigger removal.
OBJECTIVE: To study the effectiveness of a low-cost approach to improve control of asthma symptoms in an urban population through lay educators who promote a generalized approach to asthma trigger avoidance in the bedrooms of children with asthma.
DESIGN AND PATIENTS: Prospective, randomized controlled trial with two arms: historical controls and matched controls for each subject.
SUBJECTS: Two-hundred-eighty-one patients living in an urban environment, randomized to receive home visits only (n = 128) or home visits with environmental remediation (n = 153). One-hundred-fifteen controls matched according to age, gender and ethnicity did not receive any intervention.
INTERVENTIONS: In-home education visits covered asthma physiology, asthma trigger avoidance and asthma management. Environmental remediation was conducted together with the caregiver.
OUTCOMES: Primary outcomes include length of hospital stay, number of emergency visits and number of sick visits. Secondary outcomes are symptom frequency, medication management and trigger reduction.
RESULTS: Both intervention groups experienced reduction of hospitalizations, emergency room visits, sick visits and asthma symptoms. Both groups showed outcomes significantly superior to the matched control group. Intervention effectively reduced the presence of rodents and carpet in home and increased the use of mattress and pillow covers.
CONCLUSIONS: This study shows that low-cost in-home education and environmental remediation improve outcomes for children with asthma. Lay educators can deliver effective asthma-specific education that results in improved asthma control.
BACKGROUND: Island and mainland Puerto Rican children have the highest rates of asthma and asthma morbidity of any ethnic group in the United States. OBJECTIVE: We evaluated the effectiveness of a culturally adapted family asthma management intervention called CALMA (an acronym of the Spanish for "Take Control, Empower Yourself and Achieve Management of Asthma") in reducing asthma morbidity in poor Puerto Rican children with asthma. METHODS: Low-income children with persistent asthma were selected from a national health plan insurance claims database by using a computerized algorithm. After baseline, families were randomly assigned to either the intervention or a control group. RESULTS: No significant differences between control and intervention group were found for the primary outcome of symptom-free days. However, children in the CALMA intervention group had 6.5% more symptom-free nights, were 3 times more likely to have their asthma under control, and were less likely to visit the emergency department and be hospitalized as compared to the control group. Caregivers receiving CALMA were significantly less likely to feel helpless, frustrated, or upset because of their child's asthma and more likely to feel confident to manage their child's asthma. CONCLUSION: A home-based asthma intervention program tailored to the cultural needs of low income Puerto Rican families is a promising intervention for reducing asthma morbidity.
OBJECTIVE: To compare three pediatric asthma interventions for their impact on improving the health status of inner-city asthmatic children and in achieving cost savings.
STUDY DESIGN: A total of 212 children 1 to 16 years of age were randomized into three groups: group 1 (n = 74) received one individualized asthma education session; group 2 (n = 68) received reinforced asthma education; group 3 (n = 70) received reinforced asthma education plus case management. Asthma-related health resource utilization and cost were primary outcomes. The cost-benefit analysis sought to estimate the expected cost savings to the Illinois Department of Healthcare and Family Services (Medicaid administrator) associated with the intervention.
RESULTS: Participants in all three groups used significantly fewer emergency health care services in the follow-up year. Averaged across all three groups, the magnitudes of declines were substantial: 81% for hospitalizations, 69% for hospital days, 64% for emergency department visits, and 58% for clinic visits. Although there were no statistically significant differences between study groups for three of the four main outcome measures, group 3 participants consistently improved to the greatest degree. All three interventions were associated with considerable cost savings ranging from $4,021/child/year for group 1 to $4,503/child/year for group 3.
CONCLUSION: Asthma education with or without case management services enhances the health of children with asthma thereby reducing associated costs.
INTRODUCTION: To investigate the feasibility of improving asthma management - in particular, the implementation of individualised asthma action plans (AAPs) for poorly-controlled adult asthma patients - by providing training in asthma-focused clinical and communication skills for practice nurses who deliver asthma clinics.
METHODS: A pragmatic, cluster randomised trial with an intervention (an interactive seminar) delivered at practice level (n=13 practices; 6=intervention, 7=control). The impact of the intervention was assessed against patient outcomes: routinely available asthma outcome measures (beta2-agonist prescription rate and number of oral steroid courses) for asthma patients identified as being poorly-controlled from practice records; and questionnaire data - Mini Asthma Quality of Life Questionnaire (AQLQ) and the Asthma Control Questionnaire (ACQ) - from a subset of consenting patients. Data was collected at baseline and at 6-month follow-up. ANALYSISs: Routine data was analysed for 629 patients. 236 (37%) of these patients consented to provide questionnaire data at baseline, with 75% returning questionnaires at follow-up. After adjustment for baseline and practice, there was a significant difference at followup between intervention and control practices on the Mini AQLQ only (p=0.03). Estimates for subsequent sample sizes to inform future trials of asthma training were identified.
CONCLUSION: Training designed to support practice nurses in implementing individualised AAPs impacted on one patient outcome only. This disappointing outcome may have been due to many different factors such as outcome measure limitations, data collection problems, and underestimating the complexity of supporting practice nurses in behaviour change.
BACKGROUND: Women with asthma have greater mortality and morbidity than men in the United States. To date, there has been no rigorous evaluation of an intervention focused on the particular problems in asthma management faced by women. This study was a randomized clinical trial of a self-regulation, telephone counseling intervention emphasizing women's concerns, and sex and gender role factors in their management of asthma. METHODS: A total of 808 women with diagnosed asthma were randomly assigned to the intervention group or a usual-care control group, including conventional asthma education. Interviews and medical record data were collected to assess psychosocial factors, and the behavioral factors of functioning, quality of life, symptoms, and health-care use at baseline and the subsequent 1 year. Generalized estimating equations, identity link, logit link, and log link were employed to analyze the data. RESULTS: Compared to control subjects, the women receiving treatment had greater annual reductions in the average number of nights with asthma symptoms (p = 0.04), days of missed work/school (p = 0.03), emergency department visits (p = 0.04), unscheduled office visits (p = 0.01), and scheduled office visits (p = 0.04). They had greater recognition of asthma symptoms during the menstrual cycle (p = 0.0003), had decreased asthma symptoms with sexual activity (p = 0.008), and had greater improvement in quality of life (p = 0.0005), self-regulation (p = 0.03), and self-confidence to manage asthma (p = 0.001). CONCLUSION: The intervention improved women's clinical status, functioning, quality of life, and health-care use. A program with a focus on asthma management problems particular to women can significantly assist female asthma patients.
BACKGROUND: Despite national disease management plans, optimal asthma management remains a challenge in Australia. Community pharmacists are ideally placed to implement new strategies that aim to ensure asthma care meets current standards of best practice. The impact of the Pharmacy Asthma Care Program (PACP) on asthma control was assessed using a multi-site randomised intervention versus control repeated measures study design.
METHODS: Fifty Australian pharmacies were randomised into two groups: intervention pharmacies implemented the PACP (an ongoing cycle of assessment, goal setting, monitoring and review) to 191 patients over 6 months, while control pharmacies gave their usual care to 205 control patients. Both groups administered questionnaires and conducted spirometric testing at baseline and 6 months later. The main outcome measure was asthma severity/control status.
RESULTS: 186 of 205 control patients (91%) and 165 of 191 intervention patients (86%) completed the study. The intervention resulted in improved asthma control: patients receiving the intervention were 2.7 times more likely to improve from "severe" to "not severe" than control patients (OR 2.68, 95% CI 1.64 to 4.37; p<0.001). The intervention also resulted in improved adherence to preventer medication (OR 1.89, 95% CI 1.08 to 3.30; p = 0.03), decreased mean daily dose of reliever medication (difference -149.11 microg, 95% CI -283.87 to -14.36; p=0.03), a shift in medication profile from reliever only to a combination of preventer, reliever with or without long-acting beta agonist (OR 3.80, 95% CI 1.40 to 10.32; p=0.01) and improved scores on risk of non-adherence (difference -0.44, 95% CI -0.69 to -0.18; p=0.04), quality of life (difference -0.23, 95% CI -0.46 to 0.00; p=0.05), asthma knowledge (difference 1.18, 95% CI 0.73 to 1.63; p<0.01) and perceived control of asthma questionnaires (difference -1.39, 95% CI -2.44 to -0.35; p<0.01). No significant change in spirometric measures occurred in either group.
CONCLUSIONS: A pharmacist-delivered asthma care programme based on national guidelines improves asthma control. The sustainability and implementation of the programme within the healthcare system remains to be investigated.
OBJECTIVE: To establish the efficacy in terms of morbidity and quality of life of a group education program on asthma aimed at children and caregivers.
METHODS: An open, randomized, controlled trial was undertaken in 13 primary health care centers in Spain, Cuba, and Uruguay and involved 245 children with active asthma aged 9 to 13 years and their caregivers. The intervention consisted of 3 educational sessions lasting 45 to 60 minutes each and was performed with 3 intervention groups: children alone, caregivers alone, and both children and caregivers. The outcome measures were difference between intervention and control groups in the rate of asthma attacks and hospital admission, as well as the quality of life of children and caregivers in the 6 months following the intervention.
RESULTS: The rate of asthma attacks per patient-year decreased when the intervention was given only to children (mean difference, -1.61; 95% confidence interval [CI], -2.87 to -0.34) or to both children and caregivers (-1.60; 95% CI, -2.88 to -0.31). Hospital admissions per patient-year decreased in the intervention groups children alone (-0.28; 95% CI, -0.51 to -0.05) and both children and caregivers (-0.25; 95% CI, -0.49 to -0.02). Education provided to caregivers alone was not associated with any changes in morbidity. No differences were observed in terms of quality of life between controls and any of the intervention groups.
CONCLUSIONS: Group education on asthma reduces morbidity but does not improve quality of life. The benefits are apparent when education is aimed at children but no additional benefit is obtained if the intervention is also aimed at their caregivers. Finally, group education for adult caregivers alone is not effective.
Some individuals with moderate/severe persistent asthma develop irreversible airway obstruction. These individuals present with dyspnoea, exercise intolerance and impaired quality of life (QOL), all of which could potentially be alleviated with exercise training.
OBJECTIVE:
To investigate whether exercise training improves functional exercise capacity and QOL in middle-aged and older adults with fixed airway obstruction asthma (FAOA).
METHODS:
35 subjects aged 67.8 ± 10.6 years, with FEV(1) 59 ± 16% of predicted, were randomised to a 6-week 'intervention' period of supervised exercise training (n = 20) or usual care (n = 15). This period was preceded by a 3-week run-in period during which asthma control was assessed weekly. Functional exercise capacity (6-min walk distance, 6MWD) and QOL (Asthma QOL Questionnaire, AQLQ) were measured before, immediately following and 3 months after the intervention period.
RESULTS:
34 subjects (exercise group, n = 19, and control group, n = 15) completed the intervention period. Relative to the control group, the exercise group had greater improvements immediately following and 3 months after the intervention in the AQLQ symptom domain (0.61, p = 0.001, and 0.57 points per item, p = 0.005) and AQLQ activity limitation domain (0.43, p = 0.04, and 0.55 points per item, p = 0.04). 6MWD increased (36 ± 37 m, p < 0.01) in the exercise group immediately following training and remained elevated (34 ± 45 m, p < 0.01) at the 3-month follow-up. The magnitude of change in 6MWD between groups was not significant, despite no change in the control group.
CONCLUSIONS:
Supervised exercise training improves symptoms and QOL in adults with FAOA.
