Management of chronic disease by practitioners and patients: are we teaching the wrong things? -- Clark and Gong 320 (7234): 572 Data Supplement

Table A

Table A Studies evaluating pediatric education about asthma

Study	No of patients	Study design	Follow up period	Outcomes
Jenkinson et al^w1	177	RCT	3 and 12 months	Significant knowledge increases (P=0.002) No other significant change
Staudenmayer et al^w2	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 al^w3	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 al^w4	76	RCT	1 year	Reduced ED visits (P<0.001) Reduced No of hospital days (P<0.01)
Hindi-Alexander and Cropp^w5	92	Pre/Post	1 year	Reduced school absences (P<0.005) Reduced ED use but not significant No difference in hospitalisations
McNabb et al^w6	14	Pre/Post	1 year	Reduced ED use (no statistical analysis)
LeBaron et al^w7	31	RCT	4 months	Increased knowledge about cromolyn (no statistical analysis) No change in pulmonary function or systems
Rubin et al^w8	54	RCT	1 year	No difference in school absences Improvement in ED use but not significant
Clark et al^w9	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 al^w10	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-Schneidkraut^w11	80	RCT	1 year	Increased symptom free days (P=0.004) Fewer nights of parental sleep interruption
Rakos et al^w12	43	RCT	1 year	No significant difference in school absences No significant differences in ED use or emergency MD visits
Mitchell et al^w13	368	RCT	6 months	Differences according to ethnicity of child No differences in hospital days
Hughes et al^w14	95	RCT	1 year	Reduced school absences (P=0.04)
McIntosh et al^w15	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 al^w16	104	Comparison group	1 year	Improved ED use but not significant Higher levels of self efficacy regarding asthma (P=0.018)
Evans et al^w17	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)
Robinson^w18	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 al^w19	116	RCT	3, 6, 9, and 12 months	Increased knowledge (P<0.0001) Increased compliance (P<0.02) No difference in morbidity
Bailey et al^w20	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 al^w21	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 al^w22	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 al^w23	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 al^w24	339	RCT	1 year	Increased knowledge in maximum intervention group (P<0.05) No difference in self management ability or asthma morbidity
Huss et al^w25	52	Pre/Post	3 months	Greater adherence scores for avoidance measures (P<0.05)
Jenkinson et al^w1	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 al^w26	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 al^w27	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 al^w28	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 al^w29	62	RCT	16 months	No significant retention of knowledge No change in medical status
Osman et al^w30	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 al^w31	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 al^w32	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 al^w33	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 al^w34	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 al^w35	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

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.
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.
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.
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.
Hindi-Alexander MC, Cropp GJA. Evaluation of a family asthma program. J Allergy Clin Immunol 1984;74:505-10.
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.
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.
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.
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.
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.
Wilson SR, Starr-Schneidkraut N. State of the art in asthma education: the US experience. Chest 1994;106(suppl):197-205S.
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.
Mitchell EA, Ferguson V, Norwood M. Asthma education by community child health nurses. Arch Dis Child 1986;61:1184-9.
Hughes DM, McLeod M, Garner B, Goldbloom RB. Controlled trial of a home and ambulatory program for asthmatic children. Pediatrics 1991;87:54-61.
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.
Parcel GS, Nader PR, Tiernan K. A health education program for children with asthma. J Dev Behav Pediatr 1980;1:128-32.
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.
Robinson LD. Evaluation of an asthma summer camp program. Chest 1985;87(suppl):105s.
Allen RM, Jones MP, Oldenburg B: Randomized trial of asthma self-management programme for adults. Thorax 1995;50:731-8.
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.
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.
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.
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.
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.
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.
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.
Maiman LA, Green LW, Gibson G, MacKenzie EJ: Education for self-treatment by adult asthmatics. JAMA 1979;241:1919-22.
Mayo PH, Richman J, Harris HW. Results of a program to reduce admissions for adult asthma. Ann Intern Med 1990;112:864-71.
Moldofsky H, Broder I, Davies G, Leznoff A. Videotape educational program for people with asthma. Can Med Educ J 1979;120:669-72.
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.
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.
Snyder SE, Winder JA, Creer TL. Development and evaluation of an adult asthma self-management program: wheezers anonymous. J Asthma 1987;24:153-8.
Yoon R, McKenzie D, Bauman A, Miles D. Controlled trial evaluation of an asthma education programme for adults. Thorax 1993;48:1110-6.
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.
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.