Adults—Teach Asthma Self-Management Skills To Promote Asthma Control

The Expert Panel recommends that:

• ▪ Clinicians provide to patients asthma self-management education that includes the following essential items: asthma information and training in asthma management skills (Evidence A), self-monitoring (either symptom– or peak flow–based) (Evidence A), written asthma action plan (Evidence B), and regular assessment by a consistent clinician (Evidence B). (See Evidence Table 3: Asthma Self-Management Education for Adults.)
• ▪ Clinicians involve patients in decisions about the type of self-monitoring of asthma control that they will do (Evidence B)
• ▪ Clinicians provide all patients with a written asthma action plan that includes instructions for (1) daily management, and (2) recognizing and handling worsening asthma, including self-adjustment of medications in response to acute symptoms or changes in PEF measures. Written asthma action plans are particularly recommended for patients who have moderate or severe persistent asthma, a history of severe exacerbations, or poorly controlled asthma (Evidence B).
• ▪ Clinicians involve adult patients in the treatment decisionmaking within the context of a therapeutic partnership (Evidence B).
• ▪ Health professionals and others trained in asthma self-management education be used to implement and teach asthma self-management programs (Evidence B).
• ▪ Because poor attendance at multiple sessions may be a problem in some populations, consider introducing key messages and essential skills of self-management in the first session and adjusting subsequent sessions to the needs of the patients in the groups (Evidence D). Research comparing lengthy versus condensed or shorter sessions is encouraged. (See Evidence Table 3, Asthma Self-Management for Adults.)

Children—Teach Asthma Self-Management Skills To Promote Asthma Control

The Expert Panel recommends that asthma self-management education be incorporated into routine care for children who have asthma (Evidence A). (See Evidence Table 4, Asthma Self-Management Education for Children.)

A meta-analysis of 32 controlled trials of educational interventions for self-management in children and adolescents, involving 3,706 patients, showed significant effects of education in improving the child's self-efficacy and lung function as well as in reducing days with restricted activity, school absences, and ED visits (Guevara et al. 2003). No effects were seen on hospitalizations (Guevara et al. 2003; Wolf et al. 2003). The authors conducted subgroup analyses to determine the effect of peak flow versus symptom-based monitoring strategies, individual versus group format, single versus multiple sessions, and moderate or severe asthma versus mild or moderate asthma, but the small number of studies in each subgroup did not provide sufficient statistical power to detect significant differences.

Several other controlled studies have also shown positive effects for self-management education in children. A multicenter RCT of education delivered by asthma counselors through group sessions, individual meetings, and telephone followup showed that education significantly reduced days with asthma symptoms (Evans et al. 1999a). An RCT of education that combined group sessions, individual meetings, and having the family accompany the patient during doctor visits both decreased frequency of symptoms and activity restriction and increased the families' ability and confidence to self-manage asthma (Bonner et al. 2002). A small RCT (N = 33) with minority families found that group education that emphasized collaborative learning and use of cultural resources increased asthma knowledge and reduced ED visits significantly compared to more didactic group education and to a no-intervention control (La Roche et al. 2006). A trial of training to improve children's technique in using a breath-activated inhalation device showed that individual training provided by nurses in a single visit improved inhalation technique and that instructions to practice at home for 2 weeks resulted in further improvements (Agertoft and Pedersen 1998). These studies provide strong evidence for the benefit of providing structured self-management education to children who have asthma as well as their families in conjunction with ambulatory care for asthma.

Adults

The Expert Panel recommends that:

• ▪ At the time of discharge from the ED, clinicians offer brief and focused asthma education (Evidence D) and provide patients with an ED asthma discharge plan with instructions to the patients and family for how to use it (Evidence B).
• ▪ Before patients are discharged home, assess inhaler techniques for all prescribed medications and reinforce correct technique (Evidence B).
• ▪ At the time of discharge from the ED, patients be referred for followup asthma care appointment (either PCP or asthma specialist) within 1–4 weeks (Evidence B). If appropriate, consider referral to an asthma self-management education program (Evidence B).
• ▪ Before patients are discharged from a hospitalization for asthma exacerbations, give them asthma self-management education (Evidence B).

Children

The Expert Panel recommends that asthma education programs that have been shown to be effective be delivered to children during or following discharge from the ED or the hospital (Evidence B). More research is needed to understand how to make education maximally effective at this point of care.

The Expert Panel recommends that:

• ▪ At the time of discharge from the ED, clinicians offer brief and focused asthma education (Evidence D) and provide patients with an ED asthma discharge plan with instructions to the patients and family for how to use it (Evidence B).
• ▪ Before patients are discharged home, assess inhaler techniques for all prescribed medications and reinforce correct technique (Evidence B).
• ▪ At the time of discharge from the ED, patients be referred for followup asthma care appointment (either PCP or asthma specialist) within 1–4 weeks (Evidence B). If appropriate, consider referral to an asthma self-management education program (Evidence B).
• ▪ Before patients are discharged from a hospitalization for asthma exacerbations, give them asthma self-management education (Evidence B).

A meta-analysis of eight controlled studies of educational interventions for children or adolescents following ED visits or hospital admissions found no significant benefit for health status or readmission and concluded that more research is needed (Haby et al. 2001). The authors of the meta-analysis noted trends toward clinically relevant, yet not statistically significant, decreases in ED visits, unscheduled visits, and hospitalizations. Haby and colleagues recommended more studies with larger sample sizes to assess adequately the effectiveness of educational interventions after use of emergency care. Two successful studies included in this meta-analysis showed very different approaches. An RCT of a nurse-led discharge program (consisting of a 20-minute patient education program and a written asthma action plan) significantly reduced unscheduled doctor visits, ED visits, and readmissions to hospital over 12 months (Wesseldine et al. 1999). In another RCT, a nurse-led training program administered during admission with one outpatient followup visit to the nurse resulted in reduced hospital admissions in the following 14 months (Madge et al. 1997).

Five recent RCTs show mixed results for the effectiveness of education postdischarge from the ED. Walders and colleagues (2006) provided all participants with medical care by a specialist, including written asthma action plans, peak flow meters, and spacer devices. Participants who also received an intervention that included an asthma education session, a session on problem-solving based on an individualized asthma risk profile, and access to an asthma advice telephone service had significantly fewer ED visits at 12-month followup than the controls who received no education (Walders et al. 2006). Teach and coworkers (2006) scheduled a followup visit, within 2 weeks, to a specialized asthma clinic located in the ED, where followup care and education were provided. The intervention group received a written asthma action plan and referrals to ongoing primary care, plus education about asthma self-monitoring and management as well as environmental modification and trigger control. Compared with controls, the intervention group had significantly greater ICS use, fewer ED visits, and improved quality of life in the 6-month followup period (Teach et al. 2006). Sockrider and colleagues (2006) provided children and their families with tailored education, including a customized asthma action plan and an educational summary, before discharge from the ED for an acute episode of asthma. At 2-week followup, intervention families had significantly greater confidence than controls in their ability to manage asthma. At 9-month followup, among participants who had intermittent asthma, children whose families received education had significantly fewer ED visits than controls, but there was no difference between groups for children who had persistent asthma (Sockrider et al. 2006). Two other controlled trials of brief education, by telephone postdischarge from the ED (Khan et al. 2004) and by a combination of computer instruction and interaction with a nurse practitioner (Sundberg et al. 2005), did not improve patients' health status.

Two recent controlled trials to see if telephone reminders after discharge from the ED increased followup appointments with primary care showed positive findings at short-term but not long-term followup. In one study, appointment rates, quality of life, and asthma symptoms improved relative to controls at 6 months, but no difference was found at 12 months (Sin et al. 2004). In the second study, the number of appointments was higher and symptoms were lower at 2 weeks, but these differences had disappeared at 12 months (Smith et al. 2004).

In an RCT (Zorc et al. 2003), followup primary care appointments for children seen in the ED for acute asthma were scheduled by ED staff, but patients had no higher rate of attendance than when visits were simply requested. Furthermore, there was no change in return visits to the ED, missed school, or use of long-term control medications.

Based on these findings, the Expert Panel concludes that asthma education programs that have been shown to be effective should be delivered to children during or following discharge from the ED or the hospital. More research is needed to understand how to make education maximally effective at this point of care.

Asthma Education

It is the opinion of the Expert Panel that, although studies of community-based asthma education do not demonstrate benefits in health status, they do show that asthma education programs delivered by trained community residents are feasible, can result in behavior change and improved quality of life, and deserve further research (Evidence C). (See Evidence Table 5, Asthma Self-Management Education in Community Settings.)

Community-based asthma interventions (those delivered in various community settings) can positively affect large numbers of persons who have asthma, especially in poor, inner-city communities. A controlled trial of asthma outreach and education, delivered by trained community residents in a community center, found no difference in acute care visits between intervention and comparison communities, but the study found reduced numbers of acute care visits for those who had high levels of participation in the program (Fisher et al. 2004). Surprisingly, socially isolated residents were more likely to participate in program activities than those who were socially active. An observational study of education for caregivers of children who had asthma, delivered by trained, community peer educators, found significant increases in asthma knowledge, management behavior, and quality of life; these increases were sustained at 3, 6, and 12 months (Bryant-Stephens and Li 2004). An asthma education program that included the interventions of group and individual education sessions taught by a nurse and a physiotherapist resulted in significantly fewer primary care visits and less absenteeism from work (Gallefoss and Bakke 2001). In an observational study, hospital inpatient asthma education combined with outpatient followup asthma education in the community for children and families improved asthma knowledge (Ochsner et al. 2002). The inclusion of a child-life specialist in community-based and family-support interventions appears to be beneficial in promoting psychological adjustment of children who have chronic health conditions, such as asthma, especially if the child has low self-esteem (Chernoff et al. 2002).

Home-Based Asthma Education for Caregivers

The Expert Panel recommends that asthma education delivered in the homes of caregivers of young children be considered and that this area needs more research (Evidence C).

A controlled trial of a home-based asthma education intervention for caregivers of young children showed that the intervention significantly reduced the amount of reported bother from asthma symptoms and increased symptom-free days and caregiver quality of life for children 1–3 years of age (Brown et al. 2002). The age of the children who had asthma appeared to moderate the intervention effect of home-based asthma education for caregivers in relation to both asthma morbidity and caregivers' quality of life. A single-group study of home-based asthma education intervention for Latino caregivers of children who have asthma (average age, 7 years) showed reductions in bedroom allergens and increases in allergen-control devices (e.g., mattress covers) at followup (Jones et al. 2001). These studies suggest that the home may be a useful point of care for education interventions.

Home-Based Allergen-Control Interventions

The Expert Panel recommends that multifaceted allergen education and control interventions delivered in the home setting and that have been shown to be effective in reducing exposures to cockroach, rodent, and dust-mite allergen and associated asthma morbidity be considered for asthma patients sensitive to those allergens (Evidence A). Further research to evaluate the cost-effectiveness and the feasibility of widespread implementation of those programs will be helpful.

Avoiding allergens is often difficult (Leickly et al. 1998). The home may be a useful point of care for educational interventions to reduce household allergens and to increase the use of allergen-control devices in the home. Eight controlled trials have evaluated allergen-control interventions that combined education for families about implementing allergen-control strategies with provision of tools and supplies needed to carry them out (Carter et al. 2001; Custovic et al. 2000; Eggleston et al. 2005; Klinnert et al. 2005; Krieger et al. 2005; McConnell et al. 2005; Morgan et al. 2004; Woodcock et al. 2003). Some of these studies added professional allergen-reduction services (Carter et al. 2001; Custovic et al. 2000; Eggleston et al. 2005; Morgan et al. 2004), and several provided broader education about asthma management as well (Klinnert et al. 2005; Krieger et al. 2005). Four of the studies delivered allergen-control education through multiple home visits (Eggleston et al. 2005; Klinnert et al. 2005; Krieger et al. 2005; Morgan et al. 2004).

In general, the aim of these trials was to test multifaceted strategies to reduce the burden of allergens in the homes of asthma patients and to improve health outcomes rather than the efficacy of specific allergen-control techniques by themselves. An innovative trial of home intervention to control allergens included both a placebo control and a "no-visit" control to assess the relative effect of the intervention versus home visits to prompt allergen-control measures by families of children who have asthma (Carter et al. 2001). The intervention and placebo control (permeable mattress covers and instructions to wash bedding in cold water) groups did not differ significantly, but both groups had reduced acute care visits when compared to the no-visit control group, suggesting that the home visit itself resulted in improved asthma control. This study did not provide information about how families in the no-visit control group reduced allergens or improved asthma control.

Another trial evaluated allergen-control measures in the homes of infants who had atopic parents and no pets; measures included using impermeable bedding covers, replacing carpet with vinyl flooring in the infant's room, and asking participants to wash bed linens in hot water. Over the 1-year followup, the intervention group had significantly less wheeze with shortness of breath, less wheeze after vigorous activity, and less medicine prescribed by PCPs for control of wheezy attacks (Custovic et al. 2000). This study suggests that prenatal intervention in high-risk infants can reduce the risk of asthma symptoms during the first year of life.

One large trial relied primarily on repeated home visits to educate the family in allergen-control techniques and to provide them with HEPA-filter vacuum cleaners and mattress covers. The intervention was tailored to the child's allergen-sensitivity profile, and professional pest control was applied for children allergic to cockroach (Morgan et al. 2004). Over the 2-year followup period, significant reductions occurred in cat, dust-mite, and cockroach allergens in the child's bedroom, and these were associated with reductions in daytime and nighttime symptoms, fewer school absences in both years, and reductions in ED visits in the first followup year. This study suggests that education about relevant environmental control in the home, coupled with the provision of tools for allergen control, can enable families to reduce allergen levels and asthma morbidity effectively.

A clinical RCT of home environmental intervention with inner-city children who had mild persistent asthma demonstrated that tailored, multifaceted environmental treatment and education can reduce airborne particulate matter in inner-city homes, resulting in a modest effect on asthma morbidity, with decreased asthma symptoms, but no improvement in lung function (Eggleston et al. 2005). The intervention group received home-based education, cockroach and rodent extermination, allergen-proof mattress and pillow encasings, and HEPA-filter air cleaners. Outcomes were measured by home evaluations at 6 and 12 months, clinic evaluation at 12 months, and multiple telephone interviews.

Three RCTs, assessing the effect of home-based education on allergens and control interventions, used community health workers. One RCT showed that a home-based allergen-control and education intervention (delivered by trained community health workers to families of children who had asthma), focusing on training residents to apply cockroach-control measures themselves during a five-visit period, could successfully reduce the number of cockroaches in the home and cockroach-allergen levels in the children's bedding (McConnell et al. 2005). No measures of health outcomes were reported. A second trial provided allergen-control education, as well as resources and support for behavior change, by trained community heath workers in seven visits (Krieger et al. 2005). This study found reductions in the use of emergency health care services by children who had asthma and improvements in the quality of life of their caregivers. A third trial of allergen control and both allergen-specific and general asthma education with children relied on 15 home visits over a period of 12 months by nurses trained in community outreach (Klinnert et al. 2005). Compared to controls, this intervention significantly reduced cockroach-allergen and children's cotinine levels but had no effect on health outcomes.

In adults, a trial of dust-mite-allergen control that relied on allergen-impermeable bed covers alone, without instructions to wash linens in hot water or any other education, found no significant differences in mattress dust, morning PEF, or percent of patients who were able to control asthma without ICSs (Woodcock et al. 2003). This study, which involved no educational component, suggests that the role of education in maintaining allergen control is important.

Several studies with strong education components were successful in reducing allergen exposures in the home and/or reducing asthma morbidity, whether education was delivered by community workers or research staff. More research is needed to increase our understanding about how the combination of home-based education interventions and the provision of tools for allergen control in high-risk asthma populations can reduce the burden of allergen exposure and affect asthma morbidity. Studies are also needed to evaluate the cost-effectiveness and feasibility of widespread implementation of all allergen-control interventions delivered in patients' homes.

Summary statement on asthma self-management education at points of care outside the health care system:

According to the review of RCTs, asthma education can be delivered at multiple points of care other than clinics, EDs, and hospitals. With the support of clinicians, effective educational interventions should be provided at points of care outside the traditional health care setting, including schools (Butz et al. 2005; Christiansen et al. 1997; Cicutto et al. 2005; Clark et al. 2004; MeGhan [sic] et al. 2003), pharmacies (Cordina et al. 2001; McLean et al. 2003; Saini et al. 2004), and homes. For example, pharmacy-based education directed toward understanding medications and teaching inhaler skills as well as home-based interventions to increase patient and family capacity to control allergen and irritant exposure (Custovic et al. 2000; Eggleston et al. 2005; Klinnert et al. 2005; Krieger et al. 2005; McConnell et al. 2005; Morgan et al. 2004) are strategies that will enhance overall asthma self-management support.

Education for Children Using Computer-Based Technology

The Expert Panel recommends that computer-based programs that are incorporated into asthma care be considered for adolescents and children (Evidence B).

Four controlled trials have tested the ability of interactive computer asthma-education programs to improve children's asthma self-management behavior, health outcomes, and use of emergency health services. Two studies of computer-based asthma-education programs that children completed over a series of clinic visits reported positive results including: reduced symptoms and hospitalizations, and increased clinic followup visits (Bartholomew et al. 2000); reduced symptoms and ED visits, and less use of ICSs (Krishna et al. 2003). In two other trials of computer-based education, no improvements were found in health status or use of emergency health services. One study involved three opportunities to complete the program over three clinic visits (Homer et al. 2000); the other study involved a single 20-minute opportunity to complete the program at home with guidance from a nurse (Huss et al. 2003).

Two other trials tested computer-based programs to facilitate recording symptoms, communicating with health care providers, and making decisions about treatment. A trial of a device used at home to monitor symptoms and medication use, obtain immediate programmed feedback, and communicate results to health care providers over a telephone link found reductions in days with activity limitation, reports of peak flow in yellow or red zones, and urgent telephone calls to the doctor (Guendelman et al. 2002). A trial that tested an interactive, Internet-based system, allowing specialists to monitor patient diaries of symptoms and peak flow and to adjust therapy quickly, rapidly improved patients' control of symptoms and quality of life (Rasmussen et al. 2005).

An observational study found that asking children and adolescents to videotape their asthma-management practices at home provided detailed evidence of problems with adherence and inhaler technique (Rich et al. 2000). Reviewing these videotape narratives with the patient may help clinicians improve teaching and care of patients.

Taken together, these studies suggest that new technologies, including computer and Internet-based education and communication with physicians, can improve patients' control of asthma. More research is needed in these areas.

Education on Tobacco Avoidance for Women Who Are Pregnant and Members of Households With Infants and Young Children

The Expert Panel recommends that all patients who have asthma and women who are pregnant be advised not to smoke and not to be exposed to ETS (Evidence C). Query patients about their smoking status, and consider specifically referring to smoking cessation programs adults who smoke and have young children who have asthma in the household (Evidence B).

Several studies strongly suggest that maternal smoking during pregnancy results in harmful in utero exposure of the fetus and increases the risk of the child's developing recurrent wheezing and asthma in the first 5 years of life (Agabiti et al. 1999; Gergen et al. 1998; Gilliland et al. 2001). Children exposed in utero to maternal smoking demonstrate persistent deficits in lung function measured by spirometry (Kelso et al. 1995). Children not exposed in utero but exposed postnatally to tobacco smoke in the home also have an increased risk of wheezing and asthma by age 5 (Gergen et al. 1998). Heavy postnatal tobacco smoke markedly increases the risk for persistent asthma in the child (Infante-Rivard et al. 1999). In addition, children 4–16 years of age who were exposed to pre- and postnatal tobacco smoke and had high cotinine levels were found to have increased wheezing, increased school absences, and decreased lung function (Mannino et al. 2001).

It is now well established that exposure to ETS increases the severity of asthma, increases the risk of asthma-related ED visits and hospitalizations, and decreases the quality of life in both children and adults (Eisner 2002; Mannino et al. 2002; Morkjaroenpong et al. 2002). In adult, nonsmoking persons who have asthma, recent secondhand smoke exposure (as directly measured by 7-day nicotine badge) and long-term 3-month exposure (as measured by levels of both nicotine and cotinine in hair) are associated with increased asthma severity and poorer asthma outcomes (Eisner et al. 2005). In terms of public health, these results support efforts to prohibit smoking in public places.

An important RCT (Wilson et al. 2001) used three nurse-led education sessions with parents who were smokers; the sessions incorporated behavior change strategies, asthma education, and repeated feedback of their children's urinary cotinine levels. The intervention significantly reduced medical visits for acute asthma in these tobacco-exposed, low-income, minority children.

Because of the marked impact of tobacco as an irritant for most people who have asthma plus the negative health consequences of smoking to the smoker, the smoking status of all patients should be obtained, and appropriate advice and support should be offered to all patients who smoke.

Case Management for High-Risk Patients

The Expert Panel recommends that case or care management by trained health professionals be considered for patients who have poorly controlled asthma and have recurrent visits to the ED or hospital (Evidence B).

Case or care management is the strategy of using expert guidelines to focus management of patients who have asthma and have high levels of health care service use on specific, stepwise goals to reduce morbidity and costs, as well as the risk of mortality from asthma. Three RCTs (Greineder et al. 1999; Hughes et al. 1991; Kelly et al. 2000) found that case management reduced ED visits, hospitalizations, and health care costs among children who had asthma and were high users of health care resources. In all three trials, the intervention included intensive education of patients combined with case management by nurses. One study (Greineder et al. 1999) found a 39 percent reduction in ED use in the group that received asthma education alone, but the extent to which this was attributable to the education rather than to developmental changes cannot be determined. However, case management with education resulted in a 73 percent decrease in ED visits—a reduction of 34 percentage points compared with education alone (p = 0.0002). Hospitalizations were reduced by 43 percent in the control group and by 84 percent in the case-management group. Total use of services outside the study group health plans was reduced 28 percent in control and 82 percent in case-management groups. All between-group differences were statistically significant. The positive effect of asthma education was significantly enhanced by followup case management, with continued contact with the nurse case manager. Care-management processes are tools to improve the efficiency and quality of primary care delivery. These tools are often used by organizations that provide care for chronic illnesses, such as asthma and diabetes, to low-income populations.

Another study (Delaronde 2002) explored using case management to increase use of ICSs among 249 persons who had asthma, were in a managed care program, were identified as receiving three or more SABA prescriptions for 3 consecutive months, but had no prescription for anti-inflammatory medications. The results of this study and another observational study with more intensive followup (Delaronde et al. 2005) showed that case management may improve medication use by patients who do not use asthma medications as prescribed. Patients who received intensive case-management intervention were four times more likely to be prescribed anti-inflammatory medications.

Taken together, the findings of these studies suggest that case (or care) management can be effective in improving asthma control in selected populations of individuals who have poorly controlled asthma.

The Expert Panel recommends that

• ▪ Clinicians teach patients and families the basic facts about asthma (especially the role of inflammation), medication skills, and self-monitoring techniques (Evidence A).
• ▪ Provide all patients with a written asthma action plan that includes daily management and how to recognize and handle worsening asthma. Written action plans are particularly recommended for patients who have moderate or severe persistent asthma, a history of severe exacerbations, or poorly controlled asthma (Evidence B).
• ▪ Clinicians teach patients environmental control measures (See "Component 3: Control of Environmental Factors and Comorbid Conditions That Affect Asthma" for evidence ranking on different control measures.).

Self-management education should include the following key points, adapted to meet the individual patient's needs:

• ▪ Figure 3-13 illustrates how education can be delivered across initial patient visits and followup visits.
• ▪ Teach basic facts about asthma so that the patient and family understand the rationale for needed actions. Give a brief verbal description of what asthma is, emphasizing the role of inflammation, and the intended role of each medication. Do not overwhelm the patient with too much information all at once, but repeat the important messages at each visit. Ask the patient to bring all medications to each appointment for review.
• ▪ Teach the patient necessary medication skills, such as correct use of the inhaler (See figure 3-14.) and VHC or spacer and knowing when and how to take quick-relief medications.
• ▪ Teach self-monitoring skills: symptom monitoring; peak flow monitoring, as appropriate; and recognizing early signs of deterioration.
• ▪ Identify current level of asthma control, goals for improvement, and teach how to self-manage worsening asthma by adjusting medications to regain asthma control.
• ▪ Teach relevant environmental control/avoidance strategies (See figure 3-15, "How To Control Things That Make Your Asthma Worse."). Teach how environmental allergens and irritants can make the patient's asthma worse at home, school, and work as well as how to recognize both immediate and delayed reactions. Teach patients strategies for removing allergens and irritants to which they are sensitive from their living spaces. If possible, refer them to evaluated, effective, home-based education programs for allergen and irritant control.
• ▪ Advise all patients not to smoke tobacco and to avoid secondhand tobacco smoke. Emphasize the importance of not smoking for women who are pregnant and for parents of small children.

Figure 3-13

DELIVERY OF ASTHMA EDUCATION BY CLINICIANS DURING PATIENT CARE VISITS Sources: Adapted from Guevara et al. 2003; Janson et al. 2003; Powell and Gibson 2003; Wilson et al. 1993.

Figure 3-14

HOW TO USE YOUR METERED-DOSE INHALER

Figure 3-15

HOW TO CONTROL THINGS THAT MAKE YOUR ASTHMA WORSE

Knowledge and Beliefs

People who have asthma have different levels of knowledge about the disease and diverse underlying asthma-related beliefs. African Americans and other minorities who have asthma often accept suboptimal levels of asthma control because they are not aware of the effect that proper asthma management can have on their quality of life. Incorrect underlying beliefs about asthma may constitute a major obstacle to adherence to daily anti-inflammatory therapy and other self-management behavior, and such beliefs thereby may contribute to poor asthma outcomes. Studies have highlighted the lack of appreciation, on the part of people who have asthma and/or their caregivers, of the importance of the use of ICSs on days when the asthma is asymptomatic. This behavior appears to be based on the belief that asthma is absent if overt asthma symptoms are absent, and therefore asthma medications are only necessary when an acute episode occurs (Halm et al. 2006; Riekert et al. 2003). Doubts about the usefulness of anti-inflammatory asthma medications and concerns about the long-term side effects of these medications also contribute to this pattern of behavior (George et al. 2003; Leickly et al. 1998; Mansour et al. 2000; Van Sickle and Wright 2001). Moreover, African Americans are significantly more likely than Caucasians to report distrust of the health care system (George et al. 2003; Halbert et al. 2006).

A recent study demonstrated how underlying beliefs about asthma may serve as an obstacle to adherence with daily anti-inflammatory therapy and other self-management behaviors in high-risk patients who have moderate or severe persistent asthma (Halm et al. 2006). This prospective, longitudinal, observational cohort study assessed disease beliefs and self-management behaviors. In this group of low-income, high-risk, predominantly Latino and African American people, more than half of the persons who had asthma believed they have asthma only when they have symptoms. This "no symptoms, no asthma" belief was associated with one-third lower odds of adherence to ICS use when the asthma was asymptomatic. One study suggested that, if enough time is taken to explain the function and use of ICSs, adherence to therapy might be improved in African American patients who have asthma (Apter et al. 2003).

Another study demonstrated that education focusing on changing behavior, rather than providing information alone, improved quality of life. Perceived control of asthma and asthma-specific quality of life significantly improved after patients who have asthma completed a behavior modification-based asthma education program for adults. The authors concluded that assessment of perceived control of asthma may enable educators to target and tailor educational interventions for individuals who perceive a lack of control over their asthma and to monitor the effectiveness of asthma education (Olajos-Clow et al. 2005). Qualitative research is one important methodology for understanding the health beliefs and attitudes of patients and for formulating hypotheses for improving ICS adherence that can be tested in the future by using quantitative research methods (George et al. 2003).

Health Literacy

Nationally, almost one-quarter of the adult population cannot read and understand basic written material (Kirsh et al. 1993). Traditional patient education relies largely on printed materials that are often written at too high a level for patients who have a low level of literacy to read and adequately comprehend. Inadequate literacy is a barrier to asthma knowledge and self-care (Williams et al. 1998). Asthma education programs may not adequately reach those patients who suffer the greatest morbidity and mortality from asthma. Some asthma education strategies may not reach a large number of patients who have asthma and poor reading skills. Therefore, it is important that health education literature meet the readability standards (of 5th-grade level or lower) recommended by health education experts (Doak et al. 1996). Knowledge of asthma may affect health behaviors and disease outcomes. Patients need to understand proper health behaviors and acquire self-management skills. Correcting knowledge and behavior deficits through asthma instructional programs has been shown to be cost-effective (Neri et al. 1996) and to reduce physician visits and hospitalizations (Kelso et al. 1996; Patel et al. 2004).

Self-management skills and asthma knowledge are poorer among patients who have limited reading ability. In a cross-sectional survey, using multivariate analysis, a patient's reading level was the strongest predictor of asthma knowledge score and the strongest predictor of skills in use of MDI (Williams et al. 1998). A prospective cohort study examined the relationship between inadequate health literacy and the capacity to learn and retain instructions about discharge medications and appropriate MDI technique. Before instruction, inadequate health literacy was associated with lower asthma medication knowledge and worse MDI technique; after instruction, it was demonstrated that inadequate health literacy was not associated with difficulty in learning or retaining instructions. This study demonstrated that tailored education can successfully overcome barriers related to inadequate health literacy and improve asthma self-management skills (Paasche-Orlow et al. 2005).

Overcoming the barrier of inadequate literacy may be facilitated by structuring asthma education programs for low literacy levels and by developing systematic approaches to tailor asthma education to patients. Additional studies are needed to determine whether tailored asthma education provided to vulnerable populations will result in long-term gains in asthma self-management.

Cultural/Ethnic Considerations

Cultural variables may affect patient understanding of and adherence to medical regimens (Kleinman et al. 1978; Pachter and Weller 1993). Moudgil and colleagues (2000) have suggested that using a culturally sensitive patient education approach directed toward altering attitudes and beliefs, as well as toward physical management of the disease is a more successful approach to improving asthma health outcomes. Improved understanding is needed concerning how ethnocultural practices, independent of socioeconomic variables, may influence asthma care and the use of health care services. Open-ended questions such as "In your community, what does having asthma mean?" can elicit informative responses. The culturally sensitive clinician should attempt to find ways to incorporate harmless or potentially beneficial remedies with the pharmacologic plan.

For example, a prevalent ethnocultural belief among the Latino population is that illnesses are either "hot" or "cold" (Pachter et al. 2002; Risser and Mazur 1995). Asthma is viewed as a "cold" illness amenable to "hot" treatment. Suggesting that asthma medications be taken with hot tea or hot water incorporates this belief into the therapeutic regimen and helps build the therapeutic partnership. In a study of Dominican Americans, most of the mothers of persons who had asthma used folk remedies called "zumos" instead of prescription medicines. These folk remedies were derived from their folk beliefs about health and illness. In this study, most of the mothers said that prescribed medications are overused in this country and that physicians hide therapeutic information from them (Bearison et al. 2002). It is important to be aware of potential barriers posed by ethnocultural beliefs within racial/ethnic minority communities about the practice of traditional Western medicine. When harmful home remedies are being used, clinicians should discourage their use by suggesting a culturally acceptable alternative as a replacement or recommending a safer route of administration (Pachter et al. 1995). These and other strategies may be useful in working with ethnic minorities (NHLBI 1995a).

Every effort should be made to discuss asthma care, especially the asthma action plan, in the patient's native language so that educational messages are fully understood. It is the opinion of the Expert Panel that, for some ethnic groups, the word "action" may require additional explanation to patients and their families when used in the context of a medical treatment plan. Research suggests that lack of language concordance between the clinician and the patient affects adherence and appropriate use of health care services (Manson 1988). Language is a significant barrier for Latinos seeking health care for asthma. In a study assessing risk factors for inadequate asthma therapy in children, the risk of receiving inadequate asthma therapy when Spanish was the preferred language was 1.4 times greater than if English was the preferred language (Halterman et al. 2000). In a study of Latinos attending an inner-city pediatric clinic, immigrant parents cited language as the greatest barrier to health care access for their children (Flores et al. 1998). Language barriers also may complicate the assessment of cultural differences. Often, medical interpreters are not used; when used, they sometimes lack formal training in this skill (Baker et al. 1996). If interpreters are used, they should be equally competent in both English and the patient's language as well as knowledgeable about medical terms (Woloshin et al. 1995).

Implementing Guidelines—Recommended Practices

The Expert Panel recommends the use of multifaceted, clinician education programs that reinforce guidelines-based asthma care and are based on interactive learning strategies (Evidence B). (See Evidence Table 7, Methods for Improving Clinician Behaviors.)

In an attempt to improve and standardize the quality of care given to people with asthma, several studies have focused on methods of implementing guideline-based practice. This process of implementation is designed to change the behavior of clinicians. Eight RCTs and one trial's secondary analysis (Baker et al. 2003; Brown et al. 2004; Cabana et al. 2006; Clark et al. 2000; Finkelstein et al. 2005; Kattan et al. 2006; Lagerlov et al. 2000; White et al. 2004) show the variable effects of interventions designed to change clinicians' use of recommended asthma guidelines. Lagerlov and colleagues (2000) provided 199 general practitioners with two evening meetings, 1 week apart, lasting almost 3 hours each. At the first meeting, participants discussed how they diagnosed asthma and the treatment they prescribed. At the second meeting, guidelines were presented, and the group agreed on quality criteria for prescribing based on the guidelines. The educational sessions resulted in a small (6 percent) but statistically significant increase in the mean proportion of acceptably treated patients compared to controls. In peer groups of doctors, combining feedback about prescribing behavior along with guideline recommendations improved the quality of care of their patients who had asthma.

Clark and coworkers (2000) evaluated the long-term impact of an interactive seminar for pediatricians that focused on teaching and communication skills in managing asthma according to published guidelines. Two years after the intervention, physicians who attended the seminar were more likely than controls to deliver asthma education, supply patients with written directions for adjusting medications when symptoms change, and offer more guidance for modifying therapy. Children seen by physicians in the intervention group had fewer hospitalizations and ED visits. Notably, no differences were found between intervention physicians and controls in time they spent with patients at 1-year followup (Clark et al. 1998). In a reanalysis of the trial by Clark and coworkers, Brown and colleagues (2004) found the program was more effective for children in low-income families than children in families with greater income. Cabana and coworkers (2006) replicated the intervention by Clark and colleagues in a large RCT to test whether the seminar could be delivered effectively by local faculty trained by the investigators. One year postintervention, physicians who attended the seminar were more likely than physicians in the control group to ask about patients' concerns about asthma, to encourage patients to be more physically active, and set goals for successful treatment. Compared with patients in the control group, patients of physicians who attended the seminar had greater decreases in ED visits and in days with limited activity at 1-year followup (Cabana et al. 2006).

On the other hand, two trials of methods to increase use of guidelines (Baker et al. 2003; White et al. 2004) had negative results. In an RCT designed to impart techniques for teaching patients about their asthma, White and colleagues (2004) compared a standard didactic lecture for physicians to problem-based learning. Groups did not differ in knowledge gained, but problem-based learning was perceived to have more educational value than the lectures. Baker and coworkers (2003) showed that neither distribution of evidence-based guidelines alone, nor presentation of guidelines in a prioritized format (with or without performance feedback), led to increased implementation of the guideline recommendations.

To promote use of asthma guidelines, Lozano and colleagues (2004) conducted a 2-year RCT of 422 primary care pediatric practices using two different asthma care improvement strategies. Peer leader education (training one physician per practice in asthma guidelines) was compared to peer leader education combined with nurse-driven organizational change through planned visits focused on assessment, care planning, and self-management support. Children in the planned care approach had significantly reduced symptoms and lower rates of oral steroid bursts, as well as greater adherence to controller medications. The comprehensive approach was an effective model for improving asthma care. A large, 1-year RCT (n = 937) aimed at inner-city PCPs working with 5- to 11-year-old children who had moderate or severe asthma evaluated the benefit of sending timely clinical information regarding the patient's asthma status in a single-page letter to the physicians in the intervention group. The computer-generated letter summarized the results of bimonthly telephone calls to the child's caretaker; provided information on the child's asthma symptoms, health service use, and medication use; and included a corresponding recommendation to step up or step down the child's medication. The letter served as a prompt to the clinician to change treatment. Children who were in the intervention group had significantly more scheduled preventative asthma visits, resulting in appropriate medication changes, and fewer ED visits and fewer school absences as compared with children who were controls (Kattan et al. 2006).

An observational study was conducted to see whether an organized citywide asthma-management program delivered by PCPs would increase adherence to the asthma guidelines (Cloutier et al. 2005). Among the 3,748 children enrolled in the disease-management program, prescriptions for ICS increased by providers' adherence to the guidelines, and overall hospitalization rates and ED visits decreased.

Finkelstein and coworkers (2005) randomized primary care practices to one of two care-improvement strategies—physician peer leaders alone or in combination with asthma education nurses—or to usual care. The primary outcome, prescription of at least one long-term-control medication, improved in all arms of the study, but there were no differences among groups overall except a slight increase in ambulatory visits for asthma.

Observational studies support the value of targeting physicians to participate in workshops. Rossiter and colleagues (2000) conducted a unique study in recruiting physicians to enroll in communication workshops using multimedia and adult learning techniques to improve communication skills. Hands-on workshops that included negotiating treatment plans for asthma were incorporated in the 6-hour sessions. Free continuing medical education, a discount on malpractice insurance, and free patient-education materials were used as incentives. Medicaid claims for ED care for asthma were reduced, with a marked increase in guideline-based asthma prescriptions. Doctors also got feedback reports identifying patients in need of followup because of poor asthma outcomes in terms of emergency room (ER) visits. However, only 33 percent of physicians from the community participated in the intervention.

Reasons for lack of adherence to guidelines were shown in an observational study (Cabana et al. 2001) that is enlightening on the barriers to pediatricians' adherence to asthma guidelines. Lack of time, lack of educational materials, lack of support staff, and lack of reimbursement were cited as major reasons for not adopting guidelines; notably, these are similar to reasons for patients' nonadherence. This study reinforces the need for multifaceted interventions to address characteristic barriers for each guideline component.

Taken together, these findings suggest that multifaceted clinician education programs based on interactive learning strategies (Cabana et al. 2006; Clark et al. 1998, 2000; Kattan et al. 2006; Lagerlov et al. 2000) can improve quality of care and patient outcomes. In the absence of multifaceted tailored interventions, a prioritized guideline format, with or without feedback, is unlikely to promote change in general practice care. However, it is acknowledged that practice-level interventions may have significant effects on subgroups of patients, but these effects are difficult to detect. More research is needed to understand how to increase adherence to guidelines and improved quality of care for asthma. From available evidence, multifaceted clinician education programs based on interactive learning strategies are a promising alternative to noninteractive educational sessions that provide information only.

Communication Techniques

The Expert Panel recommends that:

• ▪ Clinicians consider participating in programs designed to enhance their skills in communicating with patients (Evidence B).
• ▪ Clinicians consider documenting communication and negotiated agreements between patients and clinicians during medical encounters and that the level of asthma control be documented in the medical record of a patient at every visit to facilitate communication with patients during subsequent visits (Evidence C).
• ▪ Communication skills-building programs include strategies to increase competence in caring for multicultural populations (Evidence D).

The RCT reported on by Clark and colleagues (1998, 2000) and Brown and coworkers (2004) demonstrated that a physician education program could improve the communication skills of pediatricians caring for children and adolescents who have asthma and could result in improved patient outcomes. The program involved two educational sessions, each 2.5 hours long, and combined didactic sessions with interactive role playing. Bratton and coworkers (2006) have replicated this study in a population of physicians providing care to Medicaid patients. Data from providers indicate that the intervention improved providers' use of communication skills, efforts to counsel patients in self-management strategies, and provision of written asthma action plans (Bratton et al. 2006). The results among pediatricians suggest that physicians can be taught improved communication skills that enhance patient adherence as well as asthma self-management and control. Love and coworkers (2000) showed that continuity of clinicians' care can improve patient adherence and quality of life but not other outcomes. In qualitative work, Yawn (2003) reported that parents of children who have asthma were frustrated by lack of clear communication with health professionals, especially regarding changes in diagnosis, classification of asthma severity, and methods for asthma management.

In a slightly different variation of patient–health professional communication, Cabana and colleagues (2003, 2005) and Yawn (2004) have shown that the documentation of the content of medical visits for asthma, if not the actual communication that occurs at those visits, frequently lacks information that is necessary to assess either asthma severity or asthma control as well as current adherence to asthma therapy. These studies suggest a need to document patient–clinician communications that occur in the context of asthma care. Such documentation may improve the content of subsequent communication during asthma care visits.

Wondering whether asthma severity was documented in medical records and whether such documentation prompted actions, Cabana and colleagues (2003) conducted an observational review of outpatient pediatric medical records. Only 34 percent of charts showed documentation of asthma severity during the previous 2 years. Documentation of severity, when identified, was associated with use of written asthma action plans and documented asthma education. Documentation of severity appeared to be associated with markers of improved long-term management of asthma.

In a large, prospective cohort 1-year study of 1,663 children receiving Medicaid in five large, nonprofit health plans, Lieu and coworkers (2004) demonstrated that, at sites that promoted cultural competence combined with physician feedback and improved access to care, improved use of long-term control medications and better ratings of care, according to the parents, resulted.

Clinical Pathways

The Expert Panel recommends that clinical pathways be considered for the inpatient setting for patients who are admitted to hospital with asthma exacerbations (Evidence B).

Clinical pathways are tools, ideally based on clinical guidelines, that outline a sequence of evaluations and interventions to be carried out by clinicians for patients who have asthma. These pathways are designed to improve and maintain the quality of care while containing costs. Three studies described below reported the outcomes of implementing clinical pathways to guide patient care either in the ED or in the hospital setting.

In an RCT, Johnson and colleagues (2000) demonstrated that, for children hospitalized for asthma, a clinical pathway directed by nurses can safely and reliably wean children from acute treatments and thereby significantly decrease the length of hospitalizations, the cost associated with the hospital admission, and the overall amount of nebulized beta₂-agonist used.

In another RCT, directed at children 2–18 years of age presenting to the ED with acute asthma, Zorc and coworkers (2003) used a clinical pathway to improve followup with PCPs. They found, however that even when followup appointments with the PCP 3–5 days later were scheduled by the ED staff, there was no effect on ED return visits, missed school days, or use of long-term control medications in the 4 weeks after the initial ED visit. The only positive outcome identified was an increased likelihood that urban children who had asthma would keep their followup appointment with the PCP. However, only 29 percent of children in the intervention group saw their PCP within 5 days after their ED visit, as requested, compared to 23 percent in the control group. Overall, 63 percent in the intervention group saw a PCP within 4 weeks versus 44 percent in the control group. No information was provided about the reasons for missed followup visits. This study illustrates the difficulties in scheduling followup appointments after acute exacerbation as well as the problem of ensuring that patients go to PCPs as requested.

A recent observational study showed that education of general practitioners in an asthma clinical pathway for children who have persistent asthma decreased prescription rates of oral beta₂-agonists compared to rates prescribed by clinicians who were not educated in the pathway (Mitchell et al. 2005). Three other observational studies of pediatric patients show that implementation of an asthma clinical pathway may reduce hospital length of stay and costs without increasing morbidity or rates of readmission (Kelly et al. 2000; McDowell et al. 1998; Wazeka et al. 2001).

These studies show mixed results for the effectiveness of clinical pathways, depending on the outcomes chosen and the setting.

Clinical Decision Supports

The Expert Panel recommends that:

• ▪ Prompts encouraging guideline-based care be integrated into system-based interventions focused on improving the overall quality of care rather than used as a single intervention strategy (Evidence B).
• ▪ System-based interventions that address multiple dimensions of the organization and delivery of care and clinical decision support be considered to improve and maintain quality of care for patients who have asthma (Evidence B and C).

(See Evidence Table 8, Methods for Improving Systems Support.)

Some investigators have studied the use of computer-based prompts to encourage the use of guidelines in asthma management. McCowan and colleagues (2001) conducted an RCT of a software decision-support system to prompt use of asthma guidelines. The system had a positive effect resulting in reduction of exacerbations in patients whose physicians used the system, but the system had no effect on reported symptoms, physicians' prescribing of long-term-control medications, or use of hospital services by patients. In another RCT (Tierney et al. 2005), care suggestions were delivered by computerized prompts to physicians and pharmacists in the intervention group. The prompts did not result in improved medication adherence, quality of life, patient satisfaction with care, ED visits, or hospitalizations. Intervention physicians had higher health care costs for asthma care of their patients, but care suggestions had no effect on the delivery or the outcomes of care. The results of these two trials suggest that, although the use of computerized prompts is intuitively appealing, there is insufficient evidence that prompts result in improved asthma care.

In a retrospective analysis of administrative claims data, Dombkowski and colleagues (2005) found that adherence to national asthma guidelines varied widely among health care plans covering 3,970 children who had persistent asthma and were enrolled in Medicaid. After low-income families who had children who had asthma enrolled in a statewide insurance plan, Szilagyi and coworkers (2006) interviewed parents at baseline and 1 year later. They found improvements in access to care and a decrease in asthma exacerbations and hospitalizations for the enrolled children. Quality of asthma care improved for most general measures. Taken together, these observational studies suggest opportunities for population-based health care plan interventions to improve access and quality of asthma care.

In one RCT, Lozano and colleagues (2004) demonstrated that multidimensional system-based interventions improved patient outcomes. Observational analysis (Patel et al. 2004) of a large database of 3,400 patients who had asthma and were in a medical group practice that initiated a multidisciplinary asthma disease-management program showed that the program worked in several, but not all, areas: documentation of diagnoses and patient education improved, and ED visits and hospitalizations were reduced. A multidimensional approach, utilizing all staff to assist in implementation of the program, was an important part of the intervention. The key to clinicians' ownership of the program included having clinicians lead the design process, using physician champions who had both formal and informal influence, and using rewards and recognition. In a comprehensive program to restructure health care delivery for all patients who had asthma, one large organization serving children instituted a systemwide restructured plan, including a new inpatient unit, standardized treatment protocol, direct admission policies for PCPs with optional specialist consultation, and use of case managers to help families address barriers to care and facilitate adherence (Evans et al. 1999b). The restructured program resulted in significant reductions in ED visits and length of hospital stays, as well as fewer readmissions to the hospital, while maintaining high quality of care and parental satisfaction with care.

Taken together, these system-based interventions for large populations of low-income children and adults who have asthma demonstrate effectiveness in improving quality of care and reducing use of health resources. Compared to provider-dependent strategies, these systemwide interventions may be more likely to result in consistent improved health outcomes for large populations of patients who have asthma.