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In their letter commenting on Lahdensuo’s review of self management of asthma Fay and Jones are judging the evidence of a Cochrane review as an insufficient basis for a widespread application to general practice1. Fay’s and Jones’ arguments are based on limitations in the different trials which served as a basis for the meta-analysis of the Cochrane review on self management education and regular practitioner review for adults with asthma2. Their comments are important and are calling for some general thoughts on the respective role of efficacy and effectiveness research as evidence for making changes in clinical practice and in the organization of health care.
Both efficacy and effectiveness research, the latter often being called outcomes research3 4, should contribute to evidence based medicine. Unfortunately, effectiveness research entails more practical5 and methodological6 difficulties to carry out than research on efficacy. The relative absence of effectiveness research may explain why most proponents of evidence based medicine are only referring to research on efficacy when discussing the characteristics of research evidence. Haynes and Haines are proposing the following steps from research evidence to clinical practice : synthesing the evidence, creating evidence based clinical policies and applying evidence based policy in practice. The practical realities of the healthcare and clinical settings, which are determining the effectiveness of health care interventions, should balance the synthesis of evidence when formulating clinical policies7.
In Canada, self management of asthma has become part of clinical policy as shown by the recent update of the Canadian guidelines8. Contrary to the position of Fay and Jones, the absence of effectiveness studies on self management programs has thus not been perceived as an obstacle to the inclusion of self management programs into guidelines for clinical practice.
The Conseil d’évaluation des technologies de la santé du Québec (CÉTS) is currently preparing a technical brief on the effectiveness of self management programs for obstructive pulmonary disease. The report will address explicitly the effectiveness of this approach by including research evidence on possible pathways by which self management programs are reducing the morbidity associated with asthma.
For example, self management programs have shown to lead to a therapeutic optimisation by increasing the use of inhaled corticosteroids. The optimisation is the result of increasing the prescriptions of this type of medication by physicians9-11 and by increasing the compliance of patients12 13. In a randomized controlled trial with three treatment arms (no formal education, education and action plan based on peak-flow monitoring , education and action plan based on monitoring of asthma symptoms) the optimisation of medication turned out to be the most important determinant of reduced morbidity14.
Using models of pathways between self management programs and morbidity it becomes possible to make some statements of the expected effectiveness in a specific population. Knowing, for example, the important gap between the therapeutic recommandations of asthma guidelines and the current practice of prescribing asthma medication in Quebec15, the widespread implementation of self management programs has good chances of being effective in this specific context by optimizing drug use, one of the probable pathways of action. Combining the evidence on efficacy with population based data are a feasible way of supporting decision making in the absence of effectiveness studies.
Fay and Jones are asking for more research on the patient’s perspective of self managment programs before implementing these plans in general practice. Effectiveness research is undoubtedly needed and should include the acceptance of this approach by patients in a real world clinical practice. While waiting for these contributions to the evidence base of asthma care, the recent Canadian guidelines on asthma and our work on the effectiveness of self management programs16 will hopefully contribute to lower some of the barriers for a more widespread use of self managements programs for asthma.
1. Lahdensuo A. Guided self management of asthma - how to do it. BMJ 1999;319::759-760.
2. Gibson P, Coughlan J, Wilson A, Abramson M, Bauman A, Hensley M, et al. Self-management education and regular practitioner review for adults with asthma. The Cochrane Library. Oxford: Update Software, 1999.
3. Slater CH. What is outcomes research and what can it tell us? Eval Health Prof 1997;20(3):243-64.
4. Petitti DB. Epidemiological Issues in Outcomes Research. In: Brownson RC, Petitti DB, editors. Applied epidemiology : theory to practice. New York: Oxford University Press, 1998:249-275.
5. Haynes B. Can it work? Does it work? Is it worth it? The testing of healthcare interventions is evolving [editorial; comment]. Bmj 1999;319(7211):652-3.
6. Sturm R, Unutzer J, Katon W. Effectiveness research and implications for study design: sample size and statistical power. Gen Hosp Psychiatry 1999;21(4):274-83.
7. Haynes B, Haines A. Barriers and bridges to evidence based clinical practice. Bmj 1998;317(7153):273-6.
9. Turner MO, Taylor D, Bennett R, Fitzgerald JM. A randomized trial comparing peak expiratory flow and symptom self- management plans for patients with asthma attending a primary care clinic. Am J Respir Crit Care Med 1998;157(2):540-6.
10. Ghosh CS, Ravindran P, Joshi M, Stearns SC. Reductions in hospital use from self management training for chronic asthmatics. Soc Sci Med 1998;46(8):1087-93.
11. D'Souza W, Crane J, Burgess C, Te Karu H, Fox C, Harper M, et al. Community-based asthma care: trial of a "credit card" asthma self- management plan. Eur Respir J 1994;7(7):1260-5.
12. Lahdensuo A, Haahtela T, Herrala J, Kava T, Kiviranta K, Kuusisto P, et al. Randomised comparison of guided self management and traditional treatment of asthma over one year. Bmj 1996;312(7033):748-52.
13. Berg J, Dunbar-Jacob J, Sereika SM. An evaluation of a self-management program for adults with asthma. Clin Nurs Res 1997;6(3):225-38.
14. Coté J, Cartier A, Robichaud P, Boutin H, Malo JL, Rouleau M, et al. Influence on asthma morbidity of asthma education programs based on self-management plans following treatment optimization. Am J Respir Crit Care Med 1997;155(5):1509-14.
15. Comité de revue de l'utilisation des médicaments. Revue de l'utilisation des agonistes ß2 inhalés employés dans le traitement de l'asthme. Québec: Comité de revue de l'utilisation des médicaments1999, to obtain a copy contact: secretariat.crum@ramq.gouv.qc.ca,.
16. Conseil d'évaluation des technologies de la santé. The english version of the report should be available by June 2000 and can be requested from cets@msss.gouv.qc.ca.
Competing interests:
No competing interests
04 February 2000
Reiner Banken
Medical consultant
Conseil d'évaluation des technologies de la santé du Québec
Guided self management for asthma: Efficacy versus Effectiveness
In their letter commenting on Lahdensuo’s review of self management of asthma Fay and Jones are judging the evidence of a Cochrane review as an insufficient basis for a widespread application to general practice1. Fay’s and Jones’ arguments are based on limitations in the different trials which served as a basis for the meta-analysis of the Cochrane review on self management education and regular practitioner review for adults with asthma2. Their comments are important and are calling for some general thoughts on the respective role of efficacy and effectiveness research as evidence for making changes in clinical practice and in the organization of health care.
Both efficacy and effectiveness research, the latter often being called outcomes research3 4, should contribute to evidence based medicine. Unfortunately, effectiveness research entails more practical5 and methodological6 difficulties to carry out than research on efficacy. The relative absence of effectiveness research may explain why most proponents of evidence based medicine are only referring to research on efficacy when discussing the characteristics of research evidence. Haynes and Haines are proposing the following steps from research evidence to clinical practice : synthesing the evidence, creating evidence based clinical policies and applying evidence based policy in practice. The practical realities of the healthcare and clinical settings, which are determining the effectiveness of health care interventions, should balance the synthesis of evidence when formulating clinical policies7.
In Canada, self management of asthma has become part of clinical policy as shown by the recent update of the Canadian guidelines8. Contrary to the position of Fay and Jones, the absence of effectiveness studies on self management programs has thus not been perceived as an obstacle to the inclusion of self management programs into guidelines for clinical practice.
The Conseil d’évaluation des technologies de la santé du Québec (CÉTS) is currently preparing a technical brief on the effectiveness of self management programs for obstructive pulmonary disease. The report will address explicitly the effectiveness of this approach by including research evidence on possible pathways by which self management programs are reducing the morbidity associated with asthma.
For example, self management programs have shown to lead to a therapeutic optimisation by increasing the use of inhaled corticosteroids. The optimisation is the result of increasing the prescriptions of this type of medication by physicians9-11 and by increasing the compliance of patients12 13. In a randomized controlled trial with three treatment arms (no formal education, education and action plan based on peak-flow monitoring , education and action plan based on monitoring of asthma symptoms) the optimisation of medication turned out to be the most important determinant of reduced morbidity14.
Using models of pathways between self management programs and morbidity it becomes possible to make some statements of the expected effectiveness in a specific population. Knowing, for example, the important gap between the therapeutic recommandations of asthma guidelines and the current practice of prescribing asthma medication in Quebec15, the widespread implementation of self management programs has good chances of being effective in this specific context by optimizing drug use, one of the probable pathways of action. Combining the evidence on efficacy with population based data are a feasible way of supporting decision making in the absence of effectiveness studies.
Fay and Jones are asking for more research on the patient’s perspective of self managment programs before implementing these plans in general practice. Effectiveness research is undoubtedly needed and should include the acceptance of this approach by patients in a real world clinical practice. While waiting for these contributions to the evidence base of asthma care, the recent Canadian guidelines on asthma and our work on the effectiveness of self management programs16 will hopefully contribute to lower some of the barriers for a more widespread use of self managements programs for asthma.
1. Lahdensuo A. Guided self management of asthma - how to do it. BMJ 1999;319::759-760.
2. Gibson P, Coughlan J, Wilson A, Abramson M, Bauman A, Hensley M, et al. Self-management education and regular practitioner review for adults with asthma. The Cochrane Library. Oxford: Update Software, 1999.
3. Slater CH. What is outcomes research and what can it tell us? Eval Health Prof 1997;20(3):243-64.
4. Petitti DB. Epidemiological Issues in Outcomes Research. In: Brownson RC, Petitti DB, editors. Applied epidemiology : theory to practice. New York: Oxford University Press, 1998:249-275.
5. Haynes B. Can it work? Does it work? Is it worth it? The testing of healthcare interventions is evolving [editorial; comment]. Bmj 1999;319(7211):652-3.
6. Sturm R, Unutzer J, Katon W. Effectiveness research and implications for study design: sample size and statistical power. Gen Hosp Psychiatry 1999;21(4):274-83.
7. Haynes B, Haines A. Barriers and bridges to evidence based clinical practice. Bmj 1998;317(7153):273-6.
8. Boulet L-P, Becker A, Bérubé D, Beveridge R, Ernst P. Canadian asthma consensus report, 1999. CMAJ 1999;161(11 supplement):S1-S62, disponible à http://www.cma.ca/cmaj/vol-161/issue-11/asthma/consensus.pdf
9. Turner MO, Taylor D, Bennett R, Fitzgerald JM. A randomized trial comparing peak expiratory flow and symptom self- management plans for patients with asthma attending a primary care clinic. Am J Respir Crit Care Med 1998;157(2):540-6.
10. Ghosh CS, Ravindran P, Joshi M, Stearns SC. Reductions in hospital use from self management training for chronic asthmatics. Soc Sci Med 1998;46(8):1087-93.
11. D'Souza W, Crane J, Burgess C, Te Karu H, Fox C, Harper M, et al. Community-based asthma care: trial of a "credit card" asthma self- management plan. Eur Respir J 1994;7(7):1260-5.
12. Lahdensuo A, Haahtela T, Herrala J, Kava T, Kiviranta K, Kuusisto P, et al. Randomised comparison of guided self management and traditional treatment of asthma over one year. Bmj 1996;312(7033):748-52.
13. Berg J, Dunbar-Jacob J, Sereika SM. An evaluation of a self-management program for adults with asthma. Clin Nurs Res 1997;6(3):225-38.
14. Coté J, Cartier A, Robichaud P, Boutin H, Malo JL, Rouleau M, et al. Influence on asthma morbidity of asthma education programs based on self-management plans following treatment optimization. Am J Respir Crit Care Med 1997;155(5):1509-14.
15. Comité de revue de l'utilisation des médicaments. Revue de l'utilisation des agonistes ß2 inhalés employés dans le traitement de l'asthme. Québec: Comité de revue de l'utilisation des médicaments1999, to obtain a copy contact: secretariat.crum@ramq.gouv.qc.ca,.
16. Conseil d'évaluation des technologies de la santé. The english version of the report should be available by June 2000 and can be requested from cets@msss.gouv.qc.ca.
Competing interests: No competing interests