Faculdade de Medicina da Universidade do PortoFaculdade de Medicina da Universidade do PortoIntrodução à MedicinaIntrodução à Medicina

ASTHMAASTHMA

Is self monitoring more Is self monitoring more effective than usual care?effective than usual care?

Class 19

Coordinator: Dr. João Fonseca

INTRODUCTIONINTRODUCTION

ASTHMAASTHMA

chronic inflammatory disorder of the airways with chronic inflammatory disorder of the airways with variable obstructionvariable obstruction11

““ambulatory care sensitive condition”ambulatory care sensitive condition”22

1. Global initiative for asthma. Global Strategy for Asthma Management and Prevention issued January, 1995, and revised 2002.NIH Publication No. 02-3659. Available on http://www.ginasthma.org [accessed in 2005 May 19].

2. Sylvia Guendelman PhD, Improving asthma outcomes and self-management behaviors of inner-city children. A randomized trial of the

health buddy interactive device and an Asthma diary. Arch Pediatr Adolesc Med 2002;156;114-120

BackgroundBackground

300 million people worldwide now have asthma300 million people worldwide now have asthma11 His control is possible, but it isn’t accomplished in His control is possible, but it isn’t accomplished in

most cases:most cases:- 75% of asthma admissions are avoidable- 75% of asthma admissions are avoidable22

- 40% of asthma patients don’t react properly when their - 40% of asthma patients don’t react properly when their symptoms worsensymptoms worsen22

- 50% of asthma patients admitted with acute asthma - 50% of asthma patients admitted with acute asthma have had alarming symptoms a week before admissionhave had alarming symptoms a week before admission22

1. Global Burden of Asthma Report

2. Aarzne Lahdensuo. Guided self management of asthma--how to do it. BMJ. 1999 Sep 18;319(7212):759-60.

Rationale behind our aimRationale behind our aim

Self-monitoring of asthma Self-monitoring of asthma - prevents exacerbations- prevents exacerbations11 - improves care- improves care11

- is a cost effective investment- is a cost effective investment11

- reduce - reduce - - hospitalizationshospitalizations22

- unplanned doctor visits- unplanned doctor visits33

- emergency room attendance- emergency room attendance33

- work absence- work absence33

1. Aarzne Lahdensuo. Guided self management of asthma--how to do it. BMJ. 1999 Sep 18;319(7212):759-60. 2. Options for self-management education for adults with asthma. Powell H; Gibson PG

2. Powell H, Gibson PG. Options for self-management education for adults with asthma. Cochrane Database Syst Rev. 2003;(1):CD004107.

3. Peak Flow Monitoring for Guided Self-management in Childhood Asthma: A Randomized Controlled Trial Diane Wensley and Mike Silverman Department of Child Health and Institute for Lung Health, University of Leicester, Leicester, United Kingdom

Systematic reviewSystematic review

– address a specific clinical question address a specific clinical question 11

– require a comprehensive literature search, require a comprehensive literature search, 11

– use explicit selection criteria to identify relevant use explicit selection criteria to identify relevant studiesstudies11

– assess the methodologic quality of included assess the methodologic quality of included studiesstudies11

– explore differences among study resultsexplore differences among study results11

1. Montori VM, Swiontkowski MF, Cook DJ. Methodologic issues in systematic reviews and meta-analyses.

AIMSAIMS

compare the clinical benefits of children and compare the clinical benefits of children and adults with asthma that performed self-adults with asthma that performed self-monitoring with those who do not performed self-monitoring with those who do not performed self-monitoringmonitoring

compare the clinical outcomes attained using compare the clinical outcomes attained using different monitoring instruments/technologiesdifferent monitoring instruments/technologies

METHODS

Randomized controlled studies written in Randomized controlled studies written in English, French, Spanish or PortugueseEnglish, French, Spanish or Portuguese and and published between 1996 and 2005published between 1996 and 2005

Adults and children with asthma using, or not, Adults and children with asthma using, or not, self-monitoringself-monitoring

Study participantsStudy participants

PubmedPubmed

(asthm*[MeSH] OR asthm*[TIAB]) (asthm*[MeSH] OR asthm*[TIAB]) ANDAND

(("self management"[TIAB] OR ("self care"[TIAB] OR “self (("self management"[TIAB] OR ("self care"[TIAB] OR “self care”[MeSH]) OR “self-monitoring”[TIAB]) care”[MeSH]) OR “self-monitoring”[TIAB])

AND AND ("peak-flow-meter"[TIAB] OR (spirometry[TIAB] OR ("peak-flow-meter"[TIAB] OR (spirometry[TIAB] OR

spirometry[MeSH]) OR telemedicine[TIAB] OR "communication spirometry[MeSH]) OR telemedicine[TIAB] OR "communication tecnhologies"[TIAB] OR ehealth[TIAB] OR “home automated tecnhologies"[TIAB] OR ehealth[TIAB] OR “home automated

telemanagement”[TIAB] OR Internet*[TIAB] OR mobile[TIAB])) telemanagement”[TIAB] OR Internet*[TIAB] OR mobile[TIAB])) AND AND

((clinical[Title/Abstract] AND trial[Title/Abstract]) OR clinical ((clinical[Title/Abstract] AND trial[Title/Abstract]) OR clinical trials[MeSH Terms] OR clinical trial[Publication Type] OR trials[MeSH Terms] OR clinical trial[Publication Type] OR

random*[Title/Abstract] OR random allocation[MeSH Terms] OR random*[Title/Abstract] OR random allocation[MeSH Terms] OR therapeutic use[MeSH Subheading]))therapeutic use[MeSH Subheading]))

Scopus IScopus I

(TITLE-ABS-KEY(asthm*)(TITLE-ABS-KEY(asthm*)))

ANDAND

(TITLE-ABS-KEY("self-management“ OR "self care“ (TITLE-ABS-KEY("self-management“ OR "self care“ OR "self-monitoring")OR "self-monitoring")

ANDAND

(TITLE-ABS-KEY("peak-flow-meter" OR Spirometry OR (TITLE-ABS-KEY("peak-flow-meter" OR Spirometry OR telemedicine OR "communication technologies" OR ehealth telemedicine OR "communication technologies" OR ehealth

OR "home automated telemanagement" OR internet OR OR "home automated telemanagement" OR internet OR mobile)mobile)))

ANDAND

(TITLE-ABS-KEY(random* OR trial OR control*))(TITLE-ABS-KEY(random* OR trial OR control*))

Scopus IIScopus II

(TITLE-ABS-KEY(asthm*)(TITLE-ABS-KEY(asthm*)))

ANDAND

(TITLE-ABS-KEY(monitor*)(TITLE-ABS-KEY(monitor*)))

ANDAND

(TITLE-ABS-KEY("peak-flow-meter" OR Spirometry OR (TITLE-ABS-KEY("peak-flow-meter" OR Spirometry OR telemedicine OR "communication technologies" OR ehealth telemedicine OR "communication technologies" OR ehealth

OR "home automated telemanagement" OR internet OR OR "home automated telemanagement" OR internet OR mobile)mobile)))

ANDAND

(TITLE-ABS-KEY(random* OR trial OR control*)(TITLE-ABS-KEY(random* OR trial OR control*)))

Inclusion criteriaInclusion criteria

One and/or the other:One and/or the other: Articles which compare the clinical outcomes of Articles which compare the clinical outcomes of

children and adults with asthma that performed children and adults with asthma that performed self-monitoring with those who do not performed self-monitoring with those who do not performed self-monitoringself-monitoring

Articles that compare clinical efficacy of different Articles that compare clinical efficacy of different techniques of home monitoringtechniques of home monitoring

Exclusion criteriaExclusion criteria

Not related with our aimNot related with our aim- Intervention other than self-monitoringIntervention other than self-monitoring

Not RTCNot RTC

Non-randomizedNon-randomized

Full text article not availableFull text article not available

Other language Other language

FlowchartFlowchartStart

Bibliographic research(made by 2 groups, 3

people each) in PubMed and SCOPUS

Foud articles

N = 84

1st selection (reading of the

titles and abstracts)

Included articles by groups 1, 2 and 3

2nd Selection(reading of

complete article twice – 3 groups, 2 peolpe each)

1st included articlesN = 9

Included articles by groups 4, 5 and 6

Is it agreament between groups?

Revision by a group of 3 people

Agreament between 2 people

Final included articles N = 5

NO

NOYESNO

YES

Data extraction

Revision of the references

Quality avaliation

Are there suficient data for metanalyses?

included articles for

metanalysesN = 0

End

YES NO

YES

included articles for a sistematic

review

N = 5

Full text article available

YES

NO

Excluded articles N= 79

· Not related with our aim (n=62)o Intervention other

than self-monitoring

· No RTC (n=13)

· Full text article not available (n=2)

· Other language (n=2)

RESULTS RESULTS ANDAND

DISCUSSIONDISCUSSION

Articles selectionArticles selection

1515

6969

1010

8484

1313550

10

20

30

40

50

60

70

80

90

Medline Scopus Both inMedline and

Scopus

Total 1º selection- nº articles

included

2º selection- nº articles

included

Nº

arti

cles

1515

6969

1010

8484

9955

Excluded articlesExcluded articles

6262

441111

22

not randomizednot RCTfull text article not available

not related with our aim

exclusion reason

60

40

20

0

Co

un

t

Identification of included articlesIdentification of included articlesArticle

IDAuthor Tittle Date of

publication

Journal/Book/Source

A Rasmussen, L.M., Phanareth, K., Nolte,

H., Backer, V..

Internet-based monitoring of asthma: A long-term, randomized clinical study of 300

asthmatic subjects.

2005 Journal of Allergy and Clinical Immunology

B Ostojic, V., Cvoriscec, B., Ostojic,

S.B., Reznikoff, D., Stipic-Markovic, A.,

Tudjman, Z..

Improving asthma control through telemedicine: A study of short-message

service.

2005 Telemedicine Journal and e-health

C Wensley, D., Silverman, M..

Peak flow monitoring for guided self-mamagement in childhood asthma: A

randomized controlled trial

2004 American Journal of Respiratory and Critical Care Medicine

D 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 clinical.

1998, Feb

AM J Respir Crit Care Med

E Adams, R.J., Beath, K., Homan, S.,

Campbell, D.A., Ruffin, R.E..

A randomized trial of peak-flow and symptom-based action plans in adults with

moderate-to-severe asthma

2001 Respirology

Quality evaluationQuality evaluation

Questions to evaluate the quality of the articlesQuestions to evaluate the quality of the articles1,21,2

1.1.Was study described as randomized (this includes the use of words such as randomly, Was study described as randomized (this includes the use of words such as randomly, random, and randomization)?random, and randomization)?

2.2.Was there a description of withdrawals and dropouts?Was there a description of withdrawals and dropouts?

3.3.Was the treatment allocation concealed?Was the treatment allocation concealed?

4.4.Were details of the interventions administered to each group made available?Were details of the interventions administered to each group made available?

5.5.Was participant (i.e., patients) adherence assessed quantitatively?Was participant (i.e., patients) adherence assessed quantitatively?

6.6.Was the follow-up schedule the same in each group?Was the follow-up schedule the same in each group?

7.7.Were the main outcomes analyzed according to the intention-to-treat principle?Were the main outcomes analyzed according to the intention-to-treat principle?

1. Boutron, I (2005) A checklist to evaluate a report of a nonpharmacological trial (CLEAR NPT) was developed using consensus, Journal of clinical 1. Boutron, I (2005) A checklist to evaluate a report of a nonpharmacological trial (CLEAR NPT) was developed using consensus, Journal of clinical Epidemiology 1233-1240Epidemiology 1233-1240

2. Jadad, A.R (1996) Assessing the Quality of reports of randomized clinical trials: is blinding necessary?, Elsevier Science Inc. 1-122. Jadad, A.R (1996) Assessing the Quality of reports of randomized clinical trials: is blinding necessary?, Elsevier Science Inc. 1-12

Quality evaluationQuality evaluation

Nº of articles 5

Mean 4.60

Std. Deviation

1.140

Minimum 3

Maximum 6

Score: 0-6Score: 0-6

5 Adams,

RJ 2001

4 Turner, MO

1998

3 Wensley, D.

2004

2 Ostojic, V.

2005

1 Rasmussen,LM

2005

article identification

6

5

4

3

2

1

0

Mea

n s

core

ParticipantsParticipants

Number of participants:Number of participants:- 16 (minimum), 91, 92 (median), 134 and 300 (maximum)16 (minimum), 91, 92 (median), 134 and 300 (maximum)

Age of participants:Age of participants:- Children – 1 articleChildren – 1 article- Adults – 2 articleAdults – 2 article- Children and Adults – 2 articleChildren and Adults – 2 article

Number of dropouts:Number of dropouts:- no dropouts – 2 articlesno dropouts – 2 articles- less than 80% - 2 articlesless than 80% - 2 articles- more than 80% - 1 articlemore than 80% - 1 article

Articles’ analysisArticles’ analysis Rasmussen L.M. 2005

Aim - compare the outcomes of patients how perform home monitoring and usual care

Home monitoring techniqueHome monitoring technique • internet based monitoringinternet based monitoring

OutcomesOutcomes • asthma symptoms asthma symptoms ≠ ≠ • quality of life quality of life ≠≠• lung function lung function ≠≠

Final messageFinal message - - when physicians and patients use internet based home monitoring, when physicians and patients use internet based home monitoring, better asthma control is achievedbetter asthma control is achieved

Ostojic, V, 2005

Aim - determine the benefits of GSM and SMS, in relation to usual care

Home monitoring techniqueHome monitoring technique• SMS or GSM mobile telephoneSMS or GSM mobile telephone

OutcomesOutcomes• Cough and nigth symptomsCough and nigth symptoms• forced expiratory flow =forced expiratory flow =• PEF absolute =PEF absolute =• daily consumption of inhaled medication =daily consumption of inhaled medication =

Final messageFinal message - - SMS as a mean of telemedicine may contribute to better disease SMS as a mean of telemedicine may contribute to better disease controlcontrol

Wensley, D., 2004

Aim - compare the use of PEF and symptom self-management plans

Home monitoring techniqueHome monitoring technique

• PEFPEF• symptom-based managementsymptom-based management

OutcomesOutcomes• quality of life =quality of life =• lung function =lung function =• daily symptom score =daily symptom score =

Final messageFinal message - - PEF doesn't have a significant advantage in relation to symptom PEF doesn't have a significant advantage in relation to symptom

self-management plans of children with asthmaself-management plans of children with asthma

Turner MO, 1998

Aim - compare the efficiency of PEF and symptom self-management in patients with asthma

- compare the evolution of asthma in patients with or without self-monitoring

home monitoring techniqueshome monitoring techniques

• PEFPEF• symptom self-management

Variables analizedVariables analized • quality of life = quality of life = • medications =medications =• compliance with self –management plans: 65% - PEF compliance with self –management plans: 65% - PEF

52% - 52% - symptomsymptom

Final messageFinal message - - there is no difference in PFM and symptom techniques but both there is no difference in PFM and symptom techniques but both are advantageous when the patients have a proper asthma educationare advantageous when the patients have a proper asthma education

Adams R.J., 2001

Aim – compare the use of PEF and symptom self-management plans

home monitoring techniqueshome monitoring techniques

• PEFPEF• symptom self-management

Variables analizedVariables analized • lung function =lung function =• compliance with self-management active plans: compliance with self-management active plans: 76% PEF76% PEF

78% symptom78% symptom

Final messageFinal message - - PEF doesn't have a significant advantage when compared with PEF doesn't have a significant advantage when compared with symptom self-management plans of adults with asthmasymptom self-management plans of adults with asthma

Summary of resultsSummary of results

Clinical benefits of asthma patients to monitoring Clinical benefits of asthma patients to monitoring their disease outside medical facilities:their disease outside medical facilities:– Turner MO, 1998 - yes– Rasmussen L.M., 2005 – yes – Ostojic, V, 2005 - yes

Clinical efficacy of different techniques of home Clinical efficacy of different techniques of home monitoring:monitoring:– Turner MO, 1998 – no – Wensley, D., 2004 – no– Adams R.J., 2001 – no

Methods' tableResults’table

This suggests…This suggests…

different techniques candifferent techniques can be used in the management of be used in the management of asthma asthma

it allows health professionals to decide the intervention it allows health professionals to decide the intervention they provide to adults with asthma, depending on the they provide to adults with asthma, depending on the

resources and patient preferencesresources and patient preferences

ConclusionConclusion

Self monitoring is more effective than usual careSelf monitoring is more effective than usual care

No significative differences between the clinical No significative differences between the clinical outcomes were attained using different outcomes were attained using different monitoring instruments/technologiesmonitoring instruments/technologies

So…It becomes necessary to do more research So…It becomes necessary to do more research about which instrument/technologies brings about which instrument/technologies brings more benefits to the patientsmore benefits to the patients……

ACKNOWLEDGEMENTSACKNOWLEDGEMENTS

We would like to thank:We would like to thank:

Doutor João Fonseca Doutor João Fonseca Professor doutor Altamiro da Costa-PereiraProfessor doutor Altamiro da Costa-Pereira