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Review: regular medical review is equivalent to written self management plans for optimising asthma control in adults
  1. Tasnim Sinuff, MD FRCPC
  1. McMaster University, Hamilton, Ontario, Canada

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 QUESTIONS: In adult asthmatic patients using inhaled corticosteroids: (i) is regular medical review (RMR) equivalent to written self management plans for optimising asthma control? (ii) are written self management plans based on peak expiratory flow self management (PFSM) equivalent to those based on symptom self monitoring (SSM)?

    Data sources

    Studies were identified by searching the Cochrane Airways Group's Special Register of Controlled Trials derived from Medline, EMBASE/Excerpta Medica, and CINAHL and by reviewing bibliographies of relevant articles.

    Study selection

    Studies were selected if they were randomised controlled trials (RCTs) of ≥2 self management asthma education interventions in patients with asthma who were >16 years of age and which reported relevant health outcomes.

    Data extraction

    2 reviewers independently extracted data on sample size, demographic characteristics of the patients, details of the intervention, study setting, study quality, and outcomes. Outcomes included forced expiratory volume in 1 second (FEV1), peak expiratory flow, hospital admissions, emergency room visits, unscheduled doctor visits, days lost from work or school, and use of “rescue” medications.

    Main results

    15 RCTs (2460 patients) met the selection criteria. Meta-analyses were done using a fixed effects model. Primary comparisons included optimal self management with RMR (6 RCTs) comparing 2 interventions which optimised asthma control using dose adjustment of inhaled corticosteroids either by active RMR or an individualised written self management plan where dose adjustment was based on PFSM or SSM. Meta-analysis of 3 RCTs (n=707) showed that the groups did not differ in their FEV1 or peak expiratory volume (table). The groups also did not differ for hospital admissions for asthma (4 RCTs), emergency room visits (1 RCT), unscheduled doctor visits (3 RCTs), days off work or school (2 RCTs), nocturnal asthma (3 RCTs), and disrupted days (1 RCT). The other primary comparison was PFSM with SSM (6 RCTs). Meta-analysis showed that the groups did not differ for hospital admissions (4 RCTs, n=412) and emergency room visits (5 RCTs, n=512) (table), and unscheduled doctor visits, days lost from work, and oral corticosteroid use.

    Conclusions

    In adult asthmatic patients using inhaled corticosteroids, (i) regular medical review is equivalent to written self management plans, and (ii) self management plans based on peak expiratory flow are equivalent to those based on symptom self monitoring.

    Commentary

    Asthma education is one of the actions recommended as part of national guidelines for asthma management.1 But systematic reviews of the evidence supporting this recommendation have been lacking until now. The reviews by Powell and Gibson, and Wolf et al presented in this issue systematically summarised the literature to determine whether asthma education reduces clinically important morbidity.

    Both reviews used extensive literature searches and duplicate and independent data abstraction, and assessed the methodological quality of the individual studies. Important limitations of the studies included in the review by Powell and Gibson reduce the strength of the inferences. Substantial statistical heterogeneity was detected in some of the pooled results, but was reduced or eliminated with the use of standardised mean differences (SMDs). Some of the SMDs were calculated using imputed standard deviations, but the assumed transciption error was not corroborated by the authors of the original trials in question. A random effects model provides a more conservative estimate of the effect size when there is substantial heterogeneity, and may be more appropriate. None of the studies measured all of the outcomes, and a limited number of studies measured certain outcomes such as quality of life. Importantly, a single study in this review showed that less intense education increased unscheduled doctors’ visits.2

    The review on educational interventions for asthma in children by Wolf et al was more rigorous. They used correspondence with the authors to verify data, subgroup analyses, and comparison of random and fixed effects models. Important limitations of the review included lack of quality of life as an outcome measure, statistical heterogeneity, and a limited number of studies for some important outcomes. The use of SMDs may introduce small sample bias, since the SMD is overestimated with very small sample sizes (usually <10).3 The benefits of self management programmes were manifest at 7–12 months following education initiation, after initial physiological improvements. Behaviour modification is delayed, and patients must first learn methods to control their asthma and prevent exacerbations.

    Despite these caveats, self management programmes seem to be useful for managing asthma optimally. According to Powell and Gibson, just providing one—and intensively—seems to be the key, rather than the type of programme. Self management may provide patients with a sense of control over their asthma, reducing dependence on the healthcare professional and system. In particular, the use of a peak flow meter reduces school absenteeism, nocturnal symptoms, healthcare use, and admissions to hospital compared with symptom based strategies in children but not adults. Perhaps children are especially poor at estimating their bronchoconstriction until they learn to associate what they measure with their symptoms. The efficacy of self management programmes on quality of life remains uncertain.

    References

    Peak expiratory flow self management (PFSM) v regular medical review (RMR) or symptoms self monitoring (SSM) at ≥6 months*

    
 
 QUESTIONS: In adult asthmatic patients using inhaled corticosteroids: (i) is regular medical review (RMR) equivalent to written self management plans for optimising asthma control? (ii) are written self management plans based on peak expiratory flow self management (PFSM) equivalent to those based on symptom self monitoring (SSM)?

    View Abstract

    Footnotes

    • Source of funding: Cooperative Research Centre for Asthma Australia.

    • For correspondence: Dr P Gibson, John Hunter Hospital, NSW, Australia.mdpgg{at}mail.newcastle.edu.au

    • A modified version of this abstract appears in Evidence Based Nursing.

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