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Bravata DM, Sundaram V, Lewis R, et al. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 5: Asthma Care). Rockville (MD): Agency for Healthcare Research and Quality (US); 2007 Jan. (Technical Reviews, No. 9.5.)
Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 5: Asthma Care).
Show detailsTable 11Summary of self-monitoring or self-management interventions directed at children with asthma
| Reference | Study Purpose | Target population | Study Design | Type of intervention | Results |
|---|---|---|---|---|---|
| Agrawal et al.85 | To evaluate the effects of adding a individualized written asthma home-management plan to standard asthma care. | 60 children aged 5–12 years with moderate persistent asthma in India. | RCT | 32 children completed the self-management program that included an individualized home-management plan (trained to perform PF measurement, use a PF and symptom diary, and given specific instructions for home medication management based on symptoms and PF measurement). 28 children completed the usual care arm. All subjects were followed weekly for 4 weeks then monthly for 3 additional months (7 visits). | 4 months after the intervention, children in the intervention group had fewer acute asthma events (p=0.02), fewer days missed from school (p=0.015), fewer nocturnal awakenings (p=0.001), and fewer symptoms (p=0.0006).85 |
| Bartholomew et al.53 | To evaluate whether a computer-based asthma self-management tool would increase process and clinical outcomes of care for inner-city children with moderate to several asthma in Houston. | 133 children aged 6–17 with asthma. | RCT | 70 children used the Watch, Discover, Think, and Act multimedia CD-ROM program for variable amounts of time after their scheduled office visits. The program presents an “adventure game” in which the player makes choices to manage the game character's asthma (the game's character is matched with the subject on gender and ethnicity). Within the game, children can learn new skills, identify symptoms, reduce environmental triggers, and take preventative actions. 63 children received usual care with telephone reminders before their scheduled office visits. | 7.9 months after enrollment in the intervention, there were no differences between groups in the number of ED visits, hospitalizations, or symptoms.53 |
| Burkhart et al.71 | To determine the effects of interventions that combine education and behavioral techniques in managing asthma at home. | 42 English-speaking children aged 7–11 years with persistent asthma in Kentucky; Nint=21; Ncon=21. | RCT | Patients received asthma education and instructions on how to use an electronic PF meter twice daily and record data in an asthma diary. Patients received three 1-hour individual sessions with a nurse, a contingency management intervention, which consisted of a contingency contract, reinforcement, tailoring, and reminders. The contract outlined requested behaviors (PF monitoring, diary self-reporting) and associated rewards. (We describe the rewards used in the section on financial incentives.) A nurse educator also contacted patients weekly to reinforce teachings. The control group received the teaching sessions but no contingency contract and no follow up calls from nurses. | At 5 weeks, they found no difference in adherence with PF monitoring between the intervention and the usual-care (control group) children.71 |
| Cicutto et al.77 | To evaluate whether an interactive childhood asthma education program improved asthma-related morbidity among elementary school children in Toronto, Canada. | 256 children with asthma in grades 2 to 5 (aged 6–11 years) and their parents. Nint=132, Ncon=124. | RCT | The “Roaring Adventures of Puff (RAP)” consists of 6 sessions of 50–60minutes held once a week for 6 consecutive weeks. Sessions cover use of PF meters, diary monitoring, trigger identification and control, use of inhalers and medications, symptom recognition and action plan use, and managing asthma exacerbations. Parents are invited to the last session in which children showcase their learning and new skills. The strategies utilized included games, puppetry, and model building to teach about trigger identification, medication use, symptom recognition, sharing information with teachers and parents. | 12 months after the intervention, RAP attendees had 32% fewer urgent health visits (p<0.01), less asthma-related school absenteeism (p<0.05), and less activity limitation due to asthma (p<0.01) than control children.77 |
| Dahl et al.86 | To evaluate the effects of a behavioral treatment program when superimposed on medical treatment. | 19 children in Sweden with severe asthma using continual β-agonist therapy. Ncon=10, Nint=9. | RCT | All patients underwent a 4-week baseline period during which a behavioral analysis was made for each child and daily asthma charts were kept. Patients in the intervention group underwent a 4-week intervention period, during which they received four 1-hour individualized behavior therapy treatment sessions in their home or school focusing on discrimination training of asthma signals, self-management techniques for breathlessness, counter-conditioning any learned fear response, contingency management of asthma-related behavior, and compliance training. The control group received usual care. | All data were presented as comparisons of change from baseline. After 4 weeks of follow up, patients in the intervention group had a significantly larger reduction in “as needed” spray doses of β-agonist and a significantly larger reduction in days of school absenteeism compared to patients in the control group. There was no difference between the groups in PF values.86 |
| Evans et al.68 | To evaluate whether a school-based self-management program would increase children's asthma management skills and other process and clinical outcomes for low income 3rd–5th graders in public schools in New York. | 204 low income 3rd–5th graders in public schools in New York, aged 8 to 11 with asthma. | CBA | 93 children attended the Open Airways program's six 1-hour small group sessions (over a 3 week period) in which children learned basic information about asthma, recognizing and responding to symptoms, using medications and when to seek help, keeping physically active, identifying and controlling triggers, and handling problems related to school. 87 control children received no additional self-management training. | 1 year after the program, experimental children reduced the annual frequency (p=0.024) and duration (p=0.007) of asthma episodes, and annual days with symptoms (p=0.004), and they increased their self-management index score compared to controls (p=0.05). There were no differences between the groups in terms of school attendance and number of episodes requiring a physician visit. 68 |
| Fireman et al.81 | To determine whether a nurse teaching self-management skills to children and their caregivers would improve their disease outcomes. | 26 children aged 2–14 with asthma in Pittsburgh | Sequentially assigned (not randomly) controlled trial | 13 children and their caregivers received 4 individualized sessions with a trained nurse on the use of symptom and medication diaries, two 2-hour group sessions for discussion of asthma management, and phone follow up every 3 months by the nurse. 13 children received usual care. | 13 months after enrollment, the intervention group had fewer asthma attacks (1.5 vs. 6 per child) (p<0.01) and less school absenteeism (0.5 vs. 4.6 days per child) (p<0.05). The authors reported fewer hospitalizations and ED visits for the intervention group but no statistical test for the difference between the groups. There was no difference in wheezing days per month.81 |
| Homer et al.54 | To assess the effectiveness of multimedia educational software program about asthma for inner-city children. | Children aged 3 to 12 with asthma living in inner-city Boston. Nint=57; Ncon=49. | RCT | “Asthma Control” is an interactive educational computer game designed to teach children about asthma and its management. The object of the game is to help the main character, Spacer, a superhero with asthma complete all 6 game levels (3 home and 3 outdoor levels). The player uses his or her knowledge of asthma to help Spacer eliminate common indoor allergens and to avoid outdoor allergens. If Spacer's condition worsens, the program producing coughing and wheezing sounds and he may not be about to jump or run. If the player does not eliminate allergens or use preventive medications, Spacer's mother blocks his/her exit from home. Study patients were asked to return to the study site 3 times to use the educational computer program. | During the one year study period, there were no differences between intervention and control children in terms of ED visits, acute office visits, asthma severity, exposure to environmental triggers, use of PF meters, or asthma management behaviors. |
| Note: 40% of children enrolled in the study had exposure to a least one smoker at home.54 | |||||
| LaRoche et al.78 | To evaluate a multifamily asthma group self management program designed to be culturally relevant and encouraged group cohesiveness among the attending families. | 24 African American and Hispanic families living in Boston with children aged 7–13 with asthma. | RCT | The 24 experimental families were randomized to receive three 1-hour sessions that emphasized collaborative asthma management among patients, parents, and physicians and provided training on asthma symptoms and skills for self management. Half of the experimental families received encouragement to work as a group to share experiences and learn from each other. The 11 control families received no intervention. | During the year after the intervention, the experimental children from families that shared group experiences had fewer ED visits (0.7±0.9) than either the experimental children with standard self-management teaching (1.2±1.7) or controls (1.4±2.4) (p=0.04). There were no differences in self-management scores. The intervention program costs were approximately $2,295 (per 11 patients) and the savings from reduced ED visits was $4,675 (per 11 patients).78 |
| Maslennikova et al.82 | To assess the effects of a adapting a U.S. self-management educational intervention on asthma outcomes for children in Moscow. | 122 children with asthma and their families living in Moscow. Nint=60; Ncon=62. | RCT | The authors adapted “Open Airways” (developed for low literacy children aged 4–7 years) and “Air Power” (developed for average literacy children aged 8–14 years) for similar populations in Moscow. Intervention subjects also received asthma care from clinicians who had been trained “according to the U.S. guidelines for the diagnosis and management of asthma and use of modern asthma medications.” Intervention subjects participated in 4 weekly 1hr sessions. Control subjects received usual care from clinicians who received no additional training. | 1 year after the intervention, the % of children in the education group who were on inhaled anti-inflammatory medications increased by 46% compared to only 8% for the control group (p<0.05). Intervention children's PF measures also improved more than for control children (p<0.05). There was no difference in terms of the change in the percent of children using theophylline or β-agonists or days missed from school. |
| McGhan et al.76 | To determine whether the asthma education program “Roaring Adventures of Puff (RAP),” improved asthma management behaviors and health status in elementary school children in Edmonton, Canada. | 136 children with asthma aged 7–12 years. Nint=65; Ncon=71. | RCT | Parent and teacher asthma awareness events were held within the school setting. The intervention provided recommendations for school asthma guidelines and six educational group sessions for children with asthma described above.77 | 9 months post-intervention, experimental children had “more appropriate use of preventive medication” (p<0.001), improvement in asthma-related limitations in play, (p<0.001) but there were no differences between groups in medication use, possession of an action plan, ED visits, unscheduled doctor visits, asthma symptoms, or days lost from school. 26% of the children had regular smoking in the home.76 |
| McNabb et al.80 | To evaluate whether children with asthma who had not been compliant with standard medical management would benefit from self-management education that could be tailored to their educational and behavioral needs. | 14 children aged 9 to 13 with asthma in northern California. | RCT | Experimental subjects (N=7) received a 30 minute diagnostic interview followed by four 45-minute individually tailored weekly sessions with a nurse educator on asthma self-management. Control subjects (N=7) received usual care. | In the 12 months after the intervention, the experimental group averaged 1.9 emergency treatments compared to 7.4 for the control group (no p value provided). There were no differences in non-emergency visits or drug use between groups. They estimated a program related $507 per child savings on the basis of the reduced emergency visits.80 |
| Morgan et al.,73 Evans et al.,74, and Sullivan et al.75 | To evaluate whether a home-based intervention for inner-city children designed to teach caregivers to reduce environmental asthma triggers specific to that child would result in improvements in asthma-related outcomes. (The National Cooperative Inner-City Asthma Study.) | 1,023 families of children aged 5 to 11 with asthma from 8 major U.S. cities. Nint=515, Ncon=518. | RCT | During the 12 month intervention, 2 research assistants visited each home 5 to 7 times. Each visit was followed by a phone call to address any barriers to implement the plan. Caregivers were taught about the role of allergens in asthma, mattress covers were installed, families were given a vacuum cleaner with HEPA filter and a HEPA air purifier was set up in the child's bedroom. Professional pest control was provided. | Two years after enrollment, intervention children had more symptom free days (565.1 vs. 538.5), fewer asthma symptoms (p<0.001), days lost from school (p<0.009), and allergen levels.73 There were no differences in spirometry or PF measurements or unscheduled visits to the ED, clinic or hospital between the two groups.73–75 The cost of the intervention was $337 per child for 2 years resulting in an estimate incremental cost-effectiveness ration of $9.20 per symptom-free day gained (95% CI: -$12.56 to $55.29 per symptom free day gained).75 |
| Pérez et al.66 | To evaluate the effectiveness of a self-management program based on social learning models and self management programs with demonstrated effectiveness on asthma morbidity. | 29 children with asthma aged 6–14 years in Venezuela. | RCT | 17 children and their parents were randomized to receive asthma education. Parents received two 90 minute sessions on asthma pathophysiology, treatment and psychological factors associated with the disease. Children received six 60-minute self-management training sessions that included modeling, positive reinforcement, group dynamics, behavioral practice, role-playing, and feedback. | 6 months after the intervention, children reported fewer asthma crises, and their physicians reported less severe asthma than control patients (p<0.05).66 |
| Persaud et al.87 | To evaluate the effects of a school-nurse based self management program for school children in Texas. | 36 children aged 8 – 12 years with moderate to severe asthma. | RCT | All children had a visit with a primary care provider at the time of enrollment during which time they were all given written guidelines for medication use, asthma control and prevention, PF meters, and asthma diaries. Intervention children (N=18) also received 8 individualized, weekly, 20 minute sessions with a school nurse to review asthma symptoms and medication and PF meter use. Control children (N=18) visited the school nurse sporadically, on their own initiation. | 20 weeks after enrollment, the percentage of children visiting the ED for asthma was higher in the control group (50%) than in the intervention group (22%, p<0.05); however, there were no differences in number of ED visits per child or days lost from school between groups.87 |
| Rakos et al.83 | To evaluate the effectiveness of a self-administered self-management program for pediatric asthma. | 43 children aged 7–12 years with moderate to severe asthma in Cleveland. | RCT | 20 children and their caregivers received a “Superstuff” kit in the mail. This program, developed by the American Lung Association, includes a Parent's Magazine containing 29 articles on asthma pathophysiology, triggers, relaxation techniques, and personal control and decision making. The Children's Kit includes riddles about asthma facts, “breathe easy” board game, puzzles and dolls with self-care messages, comic strip about relaxation exercises, mystery house to discover allergens, phone book to advise when to call the doctor and record emergency numbers, and asthma-related door signs, posters, stickers, records, and paper cutouts. 23 children received usual care. | 12 months after receiving the intervention, parental reports suggest a significant decrease in “interruptions due to asthma” (p<0.04). No difference in school absenteeism between groups. The cost of the kits was $7.83 |
| Ronchetti et al.72 | To compare the Open Airways program to Living With Asthma program among Italian children with asthma. | 209 children with asthma from 12 centers across Italy. | CBA | 58 children received either the original version of Open Airways or a 4 session abbreviated version, 56 children received either the original version of Living with Asthma or a 4 session abbreviated version (see text for intervention description). 95 children received usual care. | One year after participation, patients in the Open Airways but not the Living With Asthma groups has fewer emergency treatments for asthma than controls (p<0.03).72 |
| Runge et al52 | To evaluate whether an internet-based education program as an add-on to a standard patient education program improved health outcomes and reduced costs of children with asthma in Germany. | 178 children with asthma aged 8–16. | CBA | 48 children in the control group received no education until after the trial. 86 children received the self-management program of five 2hr sessions in which they used role-playing and small group sessions to teach inhaler use, trigger avoidance, medication management, PF monitoring, and decision making. 44 children received this self-management program plus self-selected to also use the interactive internet adventure game incorporating virtual asthma-related situations in need of management and also provides access to online chats with asthma experts, an online PF protocol that can be maintained by the patient, and chat rooms for other users and healthcare providers. | 6 months after enrollment, the self-management plus internet (SMI) education group had a mean of 0 emergency visits compared to 0.2 for the control group (CG) and 0.3 for the self-management (SM) alone group (p=0.03). The SM group had significantly (p<0.05) fewer physician visits (-44%) and emergency treatments (-67%) than CG. PF improved in all groups, no difference among groups. Significant improvements were seen in 3 of 8 QOL domains in both intervention groups but not in the CG. It cost 585€ to deliver the SMI intervention which reduced asthma costs by 461€. Adjusting for benefits in the CG, 0.79€ were saved for every 1€ spent on the SMI intervention during the 1st year. (1 year follow up data available for the two intervention groups but not the CG.)52 |
| Tieffenberg et al.67 | To evaluate a chronic disease self management program based on behavioral change and learning theory directed at increasing autonomy on the part of children. | 188 children with moderate to severe asthma aged 6 to 15 in Argentina. | RCT | 65 children were randomized to receive 5 weekly 2-hour meetings with a reinforcement meeting 2–6 months later. The curriculum included identifying early warning signs and symptoms of an attack, identifying triggers, understanding therapies, and decision making skills through games, drawings, stories, videos, and role-playing. 52 children received usual care. | 12 months after the intervention, experimental subjects had fewer regular visits for asthma (p=0.048), asthma crises (p=0.36), and less school absenteeism (p=0.006 for fall/winter and p=0.029 for spring semesters) but no difference in emergency visits compared to controls.67 |
| Toelle et al.88 | To evaluate whether a community-based asthma management program could reduce asthma symptoms and lung function among school children in Sydney, Australia. | 132 school children aged 8 to 11 with asthma and all the adults who influence their care including parents, doctors, pharmacists, community nurses and school teachers. | CBA | Children in the intervention group and their parents (Nint=72) were invited to attend 2 education session each 2 hours, 1 week apart with a curriculum on asthma triggers, medication use, inhalation technique, use of written self-management plan. These children's physicians and pharmacists were invited to attend evening workshops during which asthma management guidelines were reviewed. Community nurses and school teachers in the intervention community received an in-service education session at their workplace. All families, children, physicians, and pharmacists who did not attend the intervention sessions were mailed the materials. 60 children received usual care. | 147 teachers and community nurses, 53 families (74%), 15 pharmacists (21%), and 11 physicians (20%) attended intervention sessions. 6 months after the intervention, both FEV1 and dose-response ratios improved in the intervention group but not the control group (p<0.001). The number of children with wheeze and symptoms that limit activity did not change but night cough decreased significantly in the intervention group (p<0.001). There was no significant difference in physician or ED visits or days absent from school.88 |
| Vazquez and Buceta79, 89 | To evaluate the effects of adding relaxation training to asthma self-management education to improve the care of children with asthma in Spain. | 27 children with “light or moderate” asthma aged 8 to 13 years. | CBA | 9 children in the control group received usual care; 9 children received six 1-hr weekly sessions with their parents on asthma pathophysiology, use of medication, identification of triggers, and breathing exercises; and 9 children received the self-management instruction plus additional training on relaxation techniques at the end of each self-management session. | At 12 months after the intervention, both intervention groups had better scores on the adherence with self-management behaviors scale used by this study compared to the control group but there were no differences among groups in terms of attack frequency or duration, PF, emergency medical consultations or school absenteeism. 79, 89 |
| Velsor-Friedrich et al.69 | To examine the effects of a school-based intervention program on self care abilities, practices and health outcomes of children with asthma. | 102 African American 8–13 year old children with asthma recruited from 8 inner-city public schools in Chicago. | QRCT* | The Open Airways educational program utilized an interactive teaching approach applying group discussions, stories, games and role-playing to promote children's active involvement in the learning process. In six 45-minute sessions offered once a week, small groups of children learned new asthma management skills. Nint=40, Ncon=62. | 5 months after completion of the program, the treatment group had significantly more improvement in PF measurements (7.5% vs. 2.9% improvement, p=0.046), reduction in number of days with symptoms (p=0.047), and number of urgent medical visits (p=0.01). No differences in terms of reported medication use or school absences.69 |
| Webber et al.70 | To evaluated whether the Open Airways program would reduce asthma morbidity and health services utilization among inner-city children with asthma in the Bronx. | 599 3rd to 5th graders in the Bronx with asthma. | CBA | 599 children in schools with school-based health centers were scheduled to attend the Open Airways program (as described in the two prior studies). They were compared with students in schools with school-based health centers that did not offer the Open Airways program (N not specified) and children in control schools without school-based health centers (N not specified). | Approximately 15 months after enrollment, there were declines in office visits for children attending schools with school-based health centers (with and without the Open Airways program) but not for control school children (for whom there was a (9% increase in office visits) (p=0.01). ED use and hospitalizations declined for all children (no difference among groups). 70 |
| Whitman et al.84 | To evaluate the effects of a self-management curriculum on asthma knowledge, skills, and “asthma experiences.” | 38 children aged 6 to 14 in Utah. | RCT | 19 children received eight 90-minute classes for children and caregivers given twice a week for a month included education on breathing control skills, body relaxations skills, bronchial hygiene silks, and physical conditioning. Additionally, intervention subjects received the “Superstuff” kit described in Rakos.83 19 children received no training. | Three months after the intervention, there was no difference in number of asthma episodes or days without asthma between groups. Participants' knowledge (p=0.02) and asthma skills (p<0.01) improved compared to controls.84 |
- *
QRCT=quasi-randomized controlled trials. ED=emergency department. PF=peak flow. QOL=quality of life. CBA=controlled before-after trial.
- Table 11, Summary of self-monitoring or self-management interventions directed a...Table 11, Summary of self-monitoring or self-management interventions directed at children with asthma - Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies (Vol. 5: Asthma Care)
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