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Faculdade de Medicina da Universidade do Porto Introdução à Medicina

Faculdade de Medicina da Universidade do Porto Introdução à Medicina. ASTHMA Is self monitoring more effective than usual care?. Class 19 Coordinator: Dr. João Fonseca. INTRODUCTION. ASTHMA. chronic inflammatory disorder of the airways with variable obstruction 1

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Faculdade de Medicina da Universidade do Porto Introdução à Medicina

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  1. Faculdade de Medicina da Universidade do PortoIntrodução à Medicina ASTHMA Is self monitoring more effective than usual care? Class 19 Coordinator: Dr. João Fonseca

  2. INTRODUCTION

  3. ASTHMA • chronic inflammatory disorder of the airways with variable obstruction1 • “ambulatory care sensitive condition”2 • 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]. • 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

  4. Background • 300 million people worldwide now have asthma1 • His control is possible, but it isn’t accomplished in most cases: - 75% of asthma admissions are avoidable2 - 40% of asthma patients don’t react properly when their symptoms worsen2 - 50% of asthma patients admitted with acute asthma have had alarming symptoms a week before admission2 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.

  5. Rationale behind our aim • Self-monitoring of asthma - prevents exacerbations1 - improves care1 - is a cost effective investment1 - reduce - hospitalizations2 - unplanned doctor visits3 - emergency room attendance3 - work absence3 • 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 • Powell H, Gibson PG. Options for self-management education for adults with asthma. Cochrane Database Syst Rev. 2003;(1):CD004107. • 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

  6. Systematic review • address a specific clinical question 1 • require a comprehensive literature search, 1 • use explicit selection criteria to identify relevant studies1 • assess the methodologic quality of included studies1 • explore differences among study results1 1. Montori VM, Swiontkowski MF, Cook DJ. Methodologic issues in systematic reviews and meta-analyses.

  7. AIMS • compare the clinical benefits of children and adults with asthma that performed self-monitoring with those who do not performed self-monitoring • compare the clinical outcomes attained using different monitoring instruments/technologies

  8. METHODS

  9. Study participants • Randomized controlled studies written in English, French, Spanish or Portuguese and published between 1996 and 2005 • Adults and children with asthma using, or not, self-monitoring

  10. Pubmed (asthm*[MeSH] OR asthm*[TIAB]) AND (("self management"[TIAB] OR ("self care"[TIAB] OR “self care”[MeSH]) OR “self-monitoring”[TIAB]) AND ("peak-flow-meter"[TIAB] OR (spirometry[TIAB] OR spirometry[MeSH]) OR telemedicine[TIAB] OR "communication tecnhologies"[TIAB] OR ehealth[TIAB] OR “home automated telemanagement”[TIAB] OR Internet*[TIAB] OR mobile[TIAB])) AND ((clinical[Title/Abstract] AND trial[Title/Abstract]) OR clinical trials[MeSH Terms] OR clinical trial[Publication Type] OR random*[Title/Abstract] OR random allocation[MeSH Terms] OR therapeutic use[MeSH Subheading]))

  11. Scopus I (TITLE-ABS-KEY(asthm*)) AND (TITLE-ABS-KEY("self-management“ OR "self care“ OR "self-monitoring") AND (TITLE-ABS-KEY("peak-flow-meter" OR Spirometry OR telemedicine OR "communication technologies" OR ehealth OR "home automated telemanagement" OR internet OR mobile)) AND (TITLE-ABS-KEY(random* OR trial OR control*))

  12. Scopus II (TITLE-ABS-KEY(asthm*)) AND (TITLE-ABS-KEY(monitor*)) AND (TITLE-ABS-KEY("peak-flow-meter" OR Spirometry OR telemedicine OR "communication technologies" OR ehealth OR "home automated telemanagement" OR internet OR mobile)) AND (TITLE-ABS-KEY(random* OR trial OR control*))

  13. Inclusion criteria One and/or the other: • Articles which compare the clinical outcomes of children and adults with asthma that performed self-monitoring with those who do not performed self-monitoring • Articles that compare clinical efficacy of different techniques of home monitoring

  14. Exclusion criteria • Not related with our aim • Intervention other than self-monitoring • Not RTC • Non-randomized • Full text article not available • Other language

  15. Flowchart

  16. RESULTS ANDDISCUSSION

  17. 90 84 80 70 69 60 50 Nº articles 40 30 20 10 15 13 10 5 0 Medline Scopus Both in Total 1º selection 2º selection Medline and - nº articles - nº articles Scopus included included Articles selection 84 69 15 9 10 5

  18. Excluded articles 62 60 40 Count 20 11 4 2 0 not related with our aim full text article not not RCT not randomized available exclusion reason

  19. Identification of included articles

  20. Quality evaluation • Questions to evaluate the quality of the articles1,2 1.Was study described as randomized (this includes the use of words such as randomly, random, and randomization)? 2.Was there a description of withdrawals and dropouts? 3.Was the treatment allocation concealed? 4.Were details of the interventions administered to each group made available? 5.Was participant (i.e., patients) adherence assessed quantitatively? 6.Was the follow-up schedule the same in each group? 7.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 Epidemiology 1233-1240 • 2. Jadad, A.R (1996) Assessing the Quality of reports of randomized clinical trials: is blinding necessary?, Elsevier Science Inc. 1-12

  21. 6 5 Mean score 4 3 2 1 0 1 Rasmussen,LM 2005 2 Ostojic, V. 2005 3 Wensley, D. 2004 4 Turner, MO 1998 5 Adams, RJ 2001 article identification Quality evaluation Score: 0-6

  22. Participants • Number of participants: • 16 (minimum), 91, 92 (median), 134 and 300 (maximum) • Age of participants: • Children – 1 article • Adults – 2 article • Children and Adults – 2 article • Number of dropouts: • no dropouts – 2 articles • less than 80% - 2 articles • more than 80% - 1 article

  23. Articles’ analysis • Rasmussen L.M. 2005 • Aim - compare the outcomes of patients how perform home monitoring and usual care • Home monitoring technique • internet based monitoring • Outcomes • asthma symptoms ≠ • quality of life ≠ • lung function ≠ • Final message - when physicians and patients use internet based home monitoring, better asthma control is achieved

  24. Ostojic, V, 2005 • Aim - determine the benefits of GSM and SMS, in relation to usual care • Home monitoring technique • SMS or GSM mobile telephone • Outcomes • Cough and nigth symptoms • forced expiratory flow = • PEF absolute = • daily consumption of inhaled medication = • Final message - SMS as a mean of telemedicine may contribute to better disease control

  25. Wensley, D., 2004 • Aim - compare the use of PEF and symptom self-management plans • Home monitoring technique • PEF • symptom-based management • Outcomes • quality of life = • lung function = • daily symptom score = • Final message - PEF doesn't have a significant advantage in relation to symptom self-management plans of children with asthma

  26. 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 techniques • PEF • symptom self-management • Variables analized • quality of life = • medications = • compliance with self –management plans: 65% - PEF 52% - symptom • Final message - there is no difference in PFM and symptom techniques but both are advantageous when the patients have a proper asthma education

  27. Adams R.J., 2001 • Aim – compare the use of PEF and symptom self-management plans • home monitoring techniques • PEF • symptom self-management • Variables analized • lung function = • compliance with self-management active plans: 76% PEF 78% symptom • Final message - PEF doesn't have a significant advantage when compared with symptom self-management plans of adults with asthma

  28. Summary of results Clinical benefits of asthma patients to monitoring 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 monitoring: • Turner MO, 1998 – no • Wensley, D., 2004 – no • Adams R.J., 2001 – no Methods' table Results’table

  29. This suggests… • different techniques can be used in the management of asthma • it allows health professionals to decide the intervention they provide to adults with asthma, depending on the resources and patient preferences

  30. Conclusion Self monitoring is more effective than usual care No significative differences between the clinical outcomes were attained using different monitoring instruments/technologies So…It becomes necessary to do more research about which instrument/technologies brings more benefits to the patients…

  31. ACKNOWLEDGEMENTS We would like to thank: • Doutor João Fonseca • Professor doutor Altamiro da Costa-Pereira

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