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  2. Management of chronic disease by practitioners and patients: are we teaching the wrong things?
Education And Debate

Management of chronic disease by practitioners and patients: are we teaching the wrong things?

BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7234.572 (Published 26 February 2000) Cite this as: BMJ 2000;320:572

Data supplement

  • Table A

    Table B

    References

    Table A Studies evaluating pediatric education about asthma
     

    Study
    No of patients
    Study design
    Follow up period
    Outcomes
    Jenkinson et alw1
    177
    RCT
    3 and 12 months
    		Significant knowledge increases (P=0.002)

    No other significant change

    Staudenmayer et alw2
    40
    Pre/Post
    6 months
    		Change in direction of fewer school absences (P=0.09)

    Reduced No of emergency physician visits for those with baseline use (P=0.03)

    Reduced No of hospitalisations (P=0.03)

    Fireman et alw3
    26
    RCT
    8-16 months
    		Decreased school absences (P<0.05)

    Reduced ED use (no statistical analysis)

    Reduced hospitalisation time (no statistical analysis)

    Lewis et alw4
    76
    RCT
    1 year
    		Reduced ED visits (P<0.001)

    Reduced No of hospital days (P<0.01)

    Hindi-Alexander and Croppw5
    92
    Pre/Post
    1 year
    		Reduced school absences (P<0.005)

    Reduced ED use but not significant

    No difference in hospitalisations

    McNabb et alw6
    14
    Pre/Post
    1 year
    		Reduced ED use (no statistical analysis)
    LeBaron et alw7
    31
    RCT
    4 months
    		Increased knowledge about cromolyn (no statistical analysis)

    No change in pulmonary function or systems

    Rubin et alw8
    54
    RCT
    1 year
    		No difference in school absences

    Improvement in ED use but not significant

    Clark et alw9
    310
    RCT
    1 year
    		Improved academic performance (P<0.05)

    Increased self management behaviour (parent P=0.0001, child P= 0.05)

    No difference in school absences

    Reduced ED use among those with baseline use (P=0.05)

    Reduced hospitalisations among those with baseline use (P=0.05)

    Mesters et alw10
    67
    RCT
    1 year
    		Higher level of asthma self efficacy (P<0.02)

    Increased self management behaviour (P<0.01)

    Decreased MD visits (P<0.01)

    Wilson and Starr-Schneidkrautw11
    80
    RCT
    1 year
    		Increased symptom free days (P=0.004)

    Fewer nights of parental sleep interruption

    Rakos et alw12
    43
    RCT
    1 year
    		No significant difference in school absences

    No significant differences in ED use or emergency MD visits

    Mitchell et alw13
    368
    RCT
    6 months
    		Differences according to ethnicity of child

    No differences in hospital days

    Hughes et alw14
    95
    RCT
    1 year
    		Reduced school absences (P=0.04)
    McIntosh et alw15
    92
    RCT
    4-6 months
    		More treatment (35%) than control (17%) subjects reported more smoking outside their homes after test (and their children's cotinine levels were lower) but not significant
    Parcel et alw16
    104
    Comparison group
    1 year
    		Improved ED use but not significant

    Higher levels of self efficacy regarding asthma (P=0.018)

    Evans et alw17
    239
    RCT
    1 year
    		Increased self management (P=0.05)

    Increased communication with parent (P=0.002)

    Better academic grades (P=0.05)

    Fewer days with symptoms (P=0.004)

    Robinsonw18
    74
    Pre/Post
    3 years
    		Reduced school absences (no statistical analysis)

    Better MDI technique (P=0.0005)

    Fewer hospital days (P=0.02)

    RCT=randomised controlled trial. ED=emergency department. MD=physician. MDI=metered dose inhaler.
     

    Table B Studies evaluating adult education about asthma
     

    Study
    No of patients
    Study design
    Follow up period
    Outcomes
    Allen et alw19
    116
    RCT
    3, 6, 9, and 12 months
    		Increased knowledge (P<0.0001)

    Increased compliance (P<0.02)

    No difference in morbidity

    Bailey et alw20
    225
    RCT
    1 year
    		Better adherence to treatment regimens (P=0.0001) decreased

    ED visits and hospitalisations, but difference from control group not significant

    Bolton et alw21
    241
    RCT
    4, 8, and 12 months
    		Fewer ED visits (most significant at 4 months P=0.003, but still at 12 months P=0.005)

    Reduction in ED charges by $628

    Charlton et alw22
    115 (69 adults, 46 children)
    Pre/Post
    Every 8 weeks for 1 year
    		Reduced median No of MD visits (from 8.0 to 2.0 in peak flow education group and 4.5 to 1.0 in symptoms only education group)

    Reduced use of oral corticosteroids

    Garrett et alw23
    500 adults and children
    RCT
    9 months
    		Increased ownership of peak flow meters (P=0.0001) and improved technique (children P<0.05, adults P<0.005)

    Increased use of preventive drugs (adults P<0.05)

    Increased self management plans (adults P<0.01)

    Increased knowledge of action plan when symptoms worsened (children P<0.05, adults P<0.005)

    No difference in compliance, hospital admissions, ED use, or days lost from school or work

    Hilton et alw24
    339
    RCT
    1 year
    		Increased knowledge in maximum intervention group (P<0.05)

    No difference in self management ability or asthma morbidity

    Huss et alw25
    52
    Pre/Post
    3 months
    		Greater adherence scores for avoidance measures (P<0.05)
    Jenkinson et alw1
    177
    RCT
    3 and 12 months
    		Increased knowledge of drugs (after 3 months P=0.002, after 12 months P=0.007)

    More significant increase in knowledge of intervention groups given tape than given only book (P=0.007)

    Reduction in perception of disability

    Kotses et alw26
    76
    RCT
    2-12 months
    		Reduced asthma attack frequency (P<0.05)

    Decreased use of drugs (cromolyn sodium P<0.01, 2 agonists P<0.05)

    Fewer asthma related problems (P<0.01)

    Maiman et alw27
    289
    Factorial
    6 months
    		Fewer ED visits (P=0.05 with intervention from asthmatic nurse, self identified or not)

    No significant results from booklet or non-asthmatic nurse plus booklet intervention

    Mayo et alw28
    104
    RCT
    32 months
    		In treated v untreated patients, threefold reduction in readmission rate (P<0.004), twofold reduction in hospital day use (P<0.05)

    In patients serving as their own controls, threefold reduction in readmission rate and hospital day use (P=0.003)

    Moldofsky et alw29
    62
    RCT
    16 months
    		No significant retention of knowledge

    No change in medical status

    Osman et alw30
    801
    Factorial
    1 year
    		Fewer hospital admissions than control, by 54% (P<0.05) in those retained in clinic care and by 49% (95% CI 31% to 78%) in total intervention group

    Less sleep disturbance by 80%

    No significant difference in days of restricted activity, prescription of bronchodilators, inhaled corticosteroids, use of oral corticosteroids, No of MD consultants, or significant interaction between having a peak flow meter and education

    Ringsberg et alw31
    38
    RCT
    5 and 12 months
    		Decreased No of hospital days (P=0.0001)

    Reduced acute visits to hospital by 44%

    Increased knowledge

    No change in spirometric variables

    Snyder et alw32
    79
    RCT
    1, 2, and 3 months
    		Increased knowledge (interaction effect, P<0.05)

    Decreased No of attacks (1.93 v 2.87 weekly, P<0.05)

    Yoon et alw33
    76
    RCT
    5 and 10 months
    		Fewer readmissions (educated group one seventh that of control, P<0.001)

    Decrease in ED visits (P<0.001)

    No difference in spirometric results, average PEF, or mean daily variability of PEF

    Wilson et alw34
    323
    RCT
    5 and 12 months
    		Reduced "bother" due to asthma (P<0.05)

    Increased physical activity (P<0.05)

    Improved asthma, judged by MD (P<0.05)

    Better environment control (P<0.0001)

    Improved MDI technique (P<0.05)

    Windsor et alw35
    267
    Pre/Post
    12 months
    		Improvement in inhaler skills use (95% CI 0.29 to 0.61), inhaler adherence (0.24 to 0.50), drug adherence (0.31 to 0.57), and total adherence (0.28 to 0.56)

    Costs were $32.03/patient 

    Cost effectiveness was $96.09 for intervention group and $243.68 for control group

    RCT=randomised controlled trial. ED=emergency department. MD=physician. MDI=metered dose inhaler.
     

    References

    1. Jenkinson D, Davidson J, Jones S, Hawtin P. Comparison of effects of a self-management booklet and audiocassette for patients with asthma. BMJ 1988;297:267-70.
    2. Staudenmayer H, Harris PS, Selner JC. Evaluation of a self-help education-exercise program for asthmatic children and their parents: six-month follow-up. J Asthma 1981;18:1-5.
    3. Fireman P, Friday GA, Gira C, Vierthaler WA, Michaels L. Teaching self-management skills to asthmatic children and their parents in an ambulatory care setting. Pediatrics 1981;68:341-8.
    4. Lewis CE, Rachelsfsky G, Lewis MA, de la Sota A, Kaplan M. A randomized trial of A.C.T. (asthma care training) for kids. Pediatrics 1984;74:478-86.
    5. Hindi-Alexander MC, Cropp GJA. Evaluation of a family asthma program. J Allergy Clin Immunol 1984;74:505-10.
    6. McNabb WL, Wilson-Pessano SR, Hughes GW, Scamagas P. Self-management education of children with asthma: AIR WISE. Am J Public Health 1985;75:1219-20.
    7. LeBaron S, Zeltzer LK, Ratner P, Kniker WT. A controlled study of education for improving compliance with cromolyn sodium (Intal): the importance of physician-patient communication. Ann Allergy 1985;55:811-8.
    8. Rubin DH, Leventhal JM, Sadock RT, Letovsky E, Schottland P, Clemente I, et al. Educational intervention by computer in childhood asthma: a randomized clinical trial testing the use of a new teaching intervention in childhood asthma. Pediatrics 1986;77:1-10.
    9. Clark NM, Feldman CH, Evans D, Duzey O, Levison MJ, Wasilewski Y, et al. Managing better: children, parents, and asthma. Patient Educ Counseling 1986;8:27-38.
    10. Mesters I, Meertens R, Kok G, Parcel GS. Effectiveness of a multidisciplinary education protocol in children with asthma (0-4 years) in primary health care. J Asthma 1994;31:347-59.
    11. Wilson SR, Starr-Schneidkraut N. State of the art in asthma education: the US experience. Chest 1994;106(suppl):197-205S.
    12. Rakos RF, Grodek MV, Mack KK. The impact of a self-administered behavioral intervention program on pediatric asthma. J Psychosom Res 1985;29:101-8.
    13. Mitchell EA, Ferguson V, Norwood M. Asthma education by community child health nurses. Arch Dis Child 1986;61:1184-9.
    14. Hughes DM, McLeod M, Garner B, Goldbloom RB. Controlled trial of a home and ambulatory program for asthmatic children. Pediatrics 1991;87:54-61.
    15. McIntosh N, Clark NM, Howatt WF. Reducing tobacco smoke in the environment of the child with asthma: assisted minimal contact intervention. J Asthma 1994;6;453-62.
    16. Parcel GS, Nader PR, Tiernan K. A health education program for children with asthma. J Dev Behav Pediatr 1980;1:128-32.
    17. Evans D, Clark NM, Feldman CH, Rips J, Kaplan D, Levison MJ, et al. A school health education program for children with asthma aged 8-11 years. Health Educ Q 1987;14:367-79.
    18. Robinson LD. Evaluation of an asthma summer camp program. Chest 1985;87(suppl):105s.
    19. Allen RM, Jones MP, Oldenburg B: Randomized trial of asthma self-management programme for adults. Thorax 1995;50:731-8.
    20. Bailey W, Richards JJ, Brooks C, Soong S, Windsor R, Manzella B. A randomized trial to improve self-management practices of adults with asthma. Arch Intern Med 1990;150:1664-8.
    21. Bolton MB, Tilley BC, Kuder J, Reeves T, Schultz LR. The cost and effectiveness of an education program for adults who have asthma. J Gen Intern Med 1991;6:401-7.
    22. Charlton I, Charlton G, Broomfield J, Mullee MA. Clinical trial. randomized controlled trial. Evaluation of peak flow and symptoms only self-management plans for control of asthma in general practice. BMJ 1990;301:1355-9.
    23. Garrett J, Fenwich JM, Taylor G, Mitchell E, Stewart J, Rea H. Prospective controlled evaluation of the effect of a community-based asthma education centre in a multiracial working class neighbourhood. Thorax 1994;49:976-83.
    24. Hilton S, Anderson H, Sibbald B, Freeling P. Survey. Controlled evaluation of the effects of patient education on asthma morbidity in general practice. Lancet 1986;i:26-9.
    25. Huss K, Salerno M, Huss RW. Computer-assisted reinforcement of instruction: effects on adherence in adult atopic asthmatics. Res Nurs Health 1991;14:259-67.
    26. Kotses H. Bernstein I, Bernstein D, Reynolds R, Korbee L, Wigal J, et al. A self-management program for adult asthma. Part I: Development and evaluation. J Allergy Clin Immunol 1995;95:529-40.
    27. Maiman LA, Green LW, Gibson G, MacKenzie EJ: Education for self-treatment by adult asthmatics. JAMA 1979;241:1919-22.
    28. Mayo PH, Richman J, Harris HW. Results of a program to reduce admissions for adult asthma. Ann Intern Med 1990;112:864-71.
    29. Moldofsky H, Broder I, Davies G, Leznoff A. Videotape educational program for people with asthma. Can Med Educ J 1979;120:669-72.
    30. Osman LM, Abdalla MI, Beattie JA, Ross SJ, Russell IT, Friend JA, et al. Reducing hospital admission through computer supported education for asthma patients. Grampian asthma study of integrated cate (GRASSIC). BMJ 1994;308:568-71.
    31. Ringsberg KC, Wiflund I, Wilhelmsen L. Education of adult patients at an "asthma school": Effects on quality of life, knowledge and need for nursing. Eur Respir J 1990;3:33-7.
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    33. Yoon R, McKenzie D, Bauman A, Miles D. Controlled trial evaluation of an asthma education programme for adults. Thorax 1993;48:1110-6.
    34. Wilson SR, Scamagas P, German DF, Hughes GW, Lulla S, Coss S, et al. A controlled trial of two forms of self-management education for adults with asthma. Am J Med 1993; 94:564-76.
    35. Windsor RA, Bailey WC, Richards JM Jr, Manzella B, Soong SJ, Brooks M: Evaluation of the efficacy and cost effectiveness of health education methods to increase medication adherence among adults with asthma. Am J Public Health 1990;80:1519-21.

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