Self-management education and regular practitioner review
for adults with asthma (Review)
Gibson PG, Powell H, Coughlan J, Wilson AJ, Abramson M, Haywood P, Bauman A, Hensley
MJ, Walters EH
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2008, Issue 4
http://www.thecochranelibrary.com
1Self-management education and regular practitioner review for adults with asthma (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
T A B L E O F C O N T E N T S
1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW . . . . . . . . . . . . . . . . . .
3SEARCH METHODS FOR IDENTIFICATION OF STUDIES . . . . . . . . . . . . . . . . . . .
3METHODS OF THE REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4DESCRIPTION OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4METHODOLOGICAL QUALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8POTENTIAL CONFLICT OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . .
8ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
13Characteristics of included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
36Characteristics of excluded studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
37Characteristics of ongoing studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
38ANALYSE S . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
38Comparison 01. Self Management versus Usual Care . . . . . . . . . . . . . . . . . . . . . .
38INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
39COVER SHEET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
40GRAPHS AND OTHER TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
40Analysis 01.01. Comparison 01 Self Management versus Usual Care, Outcome 01 Hospitalisations (% subjects
hospitalised) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
41Analysis 01.02. Comparison 01 Self Management versus Usual Care, Outcome 02 Hospitalisations (mean) . . . .
42Analysis 01.03. Comparison 01 Self Management versus Usual Care, Outcome 03 ER Visits (% subjects) . . . .
43Analysis 01.04. Comparison 01 Self Management versus Usual Care, Outcome 04 ER Visits (Mean) . . . . . .
44Analysis 01.05. Comparison 01 Self Management versus Usual Care, Outcome 05 Unscheduled Dr Visits (mean) .
45Analysis 01.06. Comparison 01 Self Management versus Usual Care, Outcome 06 Unscheduled Dr Visits (% subjects)
47Analysis 01.07. Comparison 01 Self Management versus Usual Care, Outcome 07 Days off work (% subjects) . . .
48Analysis 01.08. Comparison 01 Self Management versus Usual Care, Outcome 08 Days off work (mean) . . . .
49Analysis 01.09. Comparison 01 Self Management versus Usual Care, Outcome 09 Nocturnal Asthma (% subjects) .
50Analysis 01.10. Comparison 01 Self Management versus Usual Care, Outcome 10 FEV1 (mean) . . . . . . .
51Analysis 01.11. Comparison 01 Self Management versus Usual Care, Outcome 11 Peak Expiratory Flow (mean) . .
52Analysis 01.12. Comparison 01 Self Management versus Usual Care, Outcome 12 Hospitalisations (mean total days)
53Analysis 01.13. Comparison 01 Self Management versus Usual Care, Outcome 13 Rescue Medication Use (% subjects)
54Analysis 01.14. Comparison 01 Self Management versus Usual Care, Outcome 14 Q uality of Life Total Score (mean)
55Analysis 01.15. Comparison 01 Self Management versus Usual Care, Outcome 15 Q uality of Life Impact (mean) .
55Analysis 01.16. Comparison 01 Self Management versus Usual Care, Outcome 16 Q uality of Life Activity (mean) .
56Analysis 01.17. Comparison 01 Self Management versus Usual Care, Outcome 17 Q uality of Life Symptoms (mean)
57Analysis 01.18. Comparison 01 Self Management versus Usual Care, Outcome 18 Total Direct Costs (mean) . . .
57Analysis 01.19. Comparison 01 Self Management versus Usual Care, Outcome 19 Total Indirect Costs (mean) . .
58Analysis 01.20. Comparison 01 Self Management versus Usual Care, Outcome 20 Total Costs (mean) . . . . .
iSelf-management education and regular practitioner review for adults wit h asthma (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Self-management education and regular practitioner review
for adults with asthma (Review)
Gibson PG, Powell H, Coughlan J, Wilson AJ, Abramson M, Haywood P, Bauman A, Hensley
MJ, Walters EH
This record should be cited as:
Gibson PG, Powell H, Coughlan J, Wilson A J, Abramson M, Haywood P, Bauman A, Hensley MJ, Walters EH. Self-management
education and regular practitioner review for adults with asthma. Cochrane Database of Systematic Reviews 2002, Issue 3. Art. No.:
CD001117. DOI: 10.1002/14651858.CD001117.
This version first p ublished online: 22 July 2002 in Issue 3, 2002.
Date of most recent substantive amendment: 12 March 2002
A B S T R A C T
Background
A key component of many asthma management guidelines is the recommendation for patient education and regular medical review.
A number of controlled trials have been conducted to measure the effectiveness of asthma education programmes. These programmes
improve patient knowledge, but their impact on health outcomes is less well established. This review was conducted to examine the
strength of evidence supporting Step 6 of the Australian Asthma Management Plan: “Educate and Review Regularly”; to test whether
health outcomes are influenced by education and self-management programmes.
Objectives
The objective of this review was to assess the effects of asthma self-management programmes, when coupled with regular health
practitioner review, on health outcomes in adults with asthma.
Search strategy
We searched the Cochrane Airways Group trials register and reference lists of articles.
Selection criteria
Randomised trials of self-management education in adults over 16 years of age with asthma.
Data collection and analysis
Two reviewers assessed trial quality and extracted data independently. We contacted study authors for confirmation.
Main results
We included thirty six trials, which compared se lf-management education with usual care. Self-management education reduced hos-
pitalisations (relative risk (RR) 0.64, 95% confidence interval (CI) 0.50 to 0.82); emergency room visits (RR 0.82, 95% CI 0.73 to
0.94); unscheduled visits to the doctor (RR 0.68, 95% CI 0.56 to 0.81); days off work or school (RR 0.79, 95% CI 0.67 to 0.93);
nocturnal asthma (RR 0.67, 95% CI 0.0.56 to 0.79); and quality of life (standard mean difference 0.29,CI 0.11 to 0.47). Measures of
lung function were little changed.
Authors’ conclusions
Education in asthma self -management which involves self-monitoring by either peak expiratory flow or symptoms, coupled with regular
medical review and a written action plan improves health outcomes for adults with asthma. Training programmes that enable people
to adjust their medication using a written action plan appear to be more effective than other forms of asthma self-management.
P L A I N L A N G U A G E S U M M A R Y
Asthma self management education is of significant benefit to patients.
1Self-management education and regular practitioner review for adults with asthma (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Guidelines for the treatment of asthma recommend that patients be educated about their condition, obtain regular medical review,
monitor their condition at home with either peak flow or symptoms and use a written action plan. The results of trials comparing
asthma self-management education to usual care were combined. These results showed that asthma sufferers who were educated about
their asthma, visited the doctor regularly and who used a written action plan had f ewer visits to the emergency room; less hospital
admissions; better lung function; improvement in peak expiratory flow; fewer symptoms; and used less rescue medication.
B A C K G R O U N D
The burden of illness from asthma is high and increasing (Peat
1994). There are problems with the delivery of care, which include
undertreatment with corticosteroids, limited knowledge, and poor
asthma management skills amongst patients with severe asthma (
Gibson 1993a). Asthma management guidelines have been devel-
oped in many countries to assist in the application of standardised,
high-quality medical care (Woolcock 1989). These guidelines rely
on expert opinion with variable reporting of their evidence base
(Gibson 1993b).
A key component of many asthma management guidelines, in-
cluding Part 1 of the Six-Part Asthma Management Program pro-
posed by the International Consensus Report on diagnosis and
Treatment of Asthma (Anonymous 1992), is the recommenda-
tion for patient e ducation and regular medical review. Education
is considered to be necessary “to help patients gain th e motiva-
tion, skills and confidence to control their asthma” (Anonymous
1996). A narrative review of asthma education has emphasised
the need for asthma education and suggested successful strate-
gies (Clark 1993). A number of controlled trials have been con-
ducted to identify the effectiveness of asthma education and self-
management programmes. Whilst there is general agreement that
these programmes improve patient knowledge, the impact that
this may have on health outcomes is less well acknowledged. For
example, a review of paediatric education programmes failed to
identify a positive benefit on asthma admissions, doctor visits, or
school absenteeism (Bernard-Bonnin 1995). The influence of pro-
gramme characteristics on health outcomes has not been exam-
ined in adults. This review was conducted to address these issues.
Specificall y, it examined the strength of evidence supporting Step 6
of the Australian Asthma Management Plan, “Educate and Review
Regularly” in order to identify whether health outcomes are influ-
enced by asthma education and self-management programmes.
A companion review has dealt with trials of limited (informa-
tion only) education interventions (Gibson 1998) and concluded
that education did not have a significant effect when administered
without an action plan, self-monitoring or regular review.
O B J E C T I V E S
This study aimed to evaluate the literature supporting Step 6 of
the Australian Asthma Management Plan (AAMP), “Educate and
Review Regularly.” The specific questions addressed are:
(1) Do asthma self-management education and regular review (by
doctor or nurse practitioner) lead to improved health outcomes in
asthma?
(2) What are the characteristics of those programmes which lead
to measurable changes in health outcomes?
C R I T E R I A F O R C O N S I D E R I N G
S T U D I E S F O R T H I S R E V I E W
Types of studies
Studies were included if the y were randomised controlled trials
(RCTs) or quasi-randomised controlled trials (CCTs) which stud-
ied the effects of asthma education and self-management on health
outcomes in adults with asthma.
Types of participants
Predominantly adults (> 16 years old) with asthma (defined by
doctor’s diagnosis or objective criteria or according to American
Thoracic Society guidelines).
Types of intervention
We categorised the interventions according to whether or not they
involved asthma education, self-monitoring of peak expiratory
flow or symptoms, regular medical review and a written action
plan.
INTERVENTION CHARACTERISTICS:
Patient Asthma Education: a programme which transfers infor-
mation about asthma in any of these forms: written, verbal, visual
or audio. It may be interactive or non-interactive, structured or
unstructured. Minimal education is characterised by the provision
of written material alone or the conduct of a short unstr uctured
verbal interaction between a health provider and a patient where
the primary goal is to improve patient knowledge and understand-
ing of asthma. Maximal education is considered to be structured
with the use of both interactive and non-interactive modes of in-
formation transfer. The content of the education must be related
to asthma and its management.
Self-monitoring: consists of the regular measurement of either
peak expiratory flow or symptoms. It is further characterised by
the recording (or not) of those measurements in a diary.
2Self-management education and regular practitioner review for adults with asthma (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Regular Review: conists of regular consultation with a doctor dur-
ing the intervention period for the purpose of reviewing the pa-
tients’ asthma status and medications. This may occur either as
a formal part of the intervention or the patients may be advised
to see th eir own doctor on a regular basis. Interventions are clas-
sified as having “regular review” either inside the programme (if
the patients were seen as a part of the programme) or outside the
programme (if the patients were merely advised to seek regular
medical review).
Written Action Plan: an individualised written plan produced for
the purpose of patient self-management of asthma exacerbations.
The action plan is characterised by being individualised to the
patient’s underlying asthma severity and treatment. It is also a
written plan which informs participants about:
• when and how to modify me dications in response to worsening
asthma; and
• how to access the medical system in response to worsening
asthma.
Types of outcome measures
Any of the f ollowing outcomes: asthma admissions, emergency
room visits, doctor visits, days lost from work or school, lung
function (FEV1), peak expiratory flow (PEF), use of rescue beta-
agonists, courses of oral corticosteroids, symptom scores, quality
of life scores, costs.
S E A R C H M E T H O D S F O R
I D E N T I F I C A T I O N O F S T U D I E S
See: Cochrane Airways Group methods used in reviews.
We identified studies from the following sources:
Cochrane Airways Group trial register derived from MEDLINE,
EMBASE, CINAHL, handsearched respiratory journals and
meeting abstracts. We searched the register using the following
terms: (Asthma OR wheez*) AND (education* OR self
management OR self-management). We obtained the article s,
and handsearched their bibliographic lists for additional articles.
M E T H O D S O F T H E R E V I E W
STUDY ELIGIBILITY
Two reviewers independently coded studies from the above sources
into three categories based upon the abstract/key word/title:
(1) Include: as RCT, adult, asthma, education
(2) Possible RCT but cannot determine from abstract
(3) Exclude: non-RCT or CCT, paediatric age range, doctor
education.
We examined f ul l text versions of the articles or studies in category
(2) in order to define if the study met the inclusion criteria.
To investigators independently categorised study eligibility, study
quality and intervention type. Agreement was examined and
disagreement resolved by consensus.
We included articles if they were: randomised or quasi-randomised
controlled trials; of asthma education delivered to adults (>
16 years) with asthma. We reported relevant health outcomes:
hospitalisations, visits to medical practitioner, visits to emergency
room, use of beta-agonists, lung functions, quality of life,
symptoms score, symptoms or peak expiratory flow diary.
OUTCOMES
We assessed the following health outcomes:
• hospital admissions
• emergency room visits
• unscheduled doctor visits
• days l ost from work or school
• Forced E xpiratory Volume in 1 second (FEV1)
• Peak Expiratory Flow (PEF)
• use of ’rescue’ (or reliever) medications
• quality of life, symptoms scores, symptom/peak flow diary
• economic data, cost, days lost f r om college/work.
ANALYSIS: We analysed outcomes as continuous and/or
dichotomous variables, using standard statistical techniques.
(1) For continuous outcomes, the weighted mean difference
(WMD) or standardised mean difference (SMD) with 95%
confidence intervals (CI) were calculated as appropriate.
(2) For dichotomous outcomes, the relative risk (RR) was
calculated with 95% CI.
We examined heterogeneity using a Chi-squared test and explored
reasons for heterogeneity if appropriate.
Where appropriate, we entered data as negative values to eliminate
differences in scoring scales for quality of life.
PRIMARY COMPARISONS
The primary comparison, based on the treatment of the
intervention and control groups used was:
Self Management versus Usual Care;
Another review comparing different options for optimal self-
management is in progress.
SUB-GROUP ANALYSIS
We further divided study groups by the intensity of their
intervention into one of the following categories:
(1) Optimal Self-Management which involved a written action
plan for sel f-management of medications for exacerbations,
together with sel f-monitoring and regular medical review;
(2) Self Monitoring and Regular Review without a written action
plan;
3Self-management education and regular practitioner review for adults with asthma (Review)
Copyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd