The efficacy of self-management in asthmatic children: a meta-analysis .

1. Academic Year 2010/2011 Introdução à Medicina II The efficacy of self-management in asthmatic children: a meta-analysis. Advisers: Dr. João Fonseca Dr. Luís Silva Daniela Linhares Regent: Prof. Dr. Altamiro Pereira

2. Table of contents • Introduction: Background and justification • Aim and Research Question • Participants and Methods • Flowchart • Results • Discussion and Conclusion • References

3. Introduction: Background and justification Definition • common chronic inflammatory airway disorder that it is currently considered undertreated [1] Lim, KG, MottramC.The Use of Fraction of Exhaled Nitric in Pulmunary Practice 2008 American College of Chest Physicians [2]Kostikas K, Papaioannou A, Tanou K, Koutsokera A, Papala M, Gourgoulianis K. Portable ExhaledNitricOxide as a Screening ToolfoAsthma in Young Adults During Pollen Season. 2008 American College of Chest Physicians Introduction Keywords Aim/RQ Methods Flowchart Results References Disc&Concl

4. Introduction: Background and justification Self-management • avoidance of triggers; • patient adherence to controller medication; • patient’s ability to recognize asthma symptoms and respond appropriately. Achievedby reduce the impact of asthma on related morbidity, functional ability and mostly on quality of life routine feature in the management of this disease Ultimategoal Liberati A, et al: The PRISMA statement for reporting systematic review sand meta-analyses of studies that evaluate health care interventions explanation and elaboration. PLoS Med 2009, 6(7):e1000100, Epub 2009 Jul Introduction Keywords Aim/RQ Methods Flowchart Results References Disc&Concl

5. Introduction: Background and justification • A lack of systematic reviews about the topic; • New approaches on asthma's treatment to improve quality of life weren’t known; • There is a need to keep information update So our work is important because: Introduction Keywords Aim/RQ Methods Flowchart Results References Disc&Concl

6. Aim • assess the impact of self-management in asthma’s control by comparing the quality of life, using numbers of hospitalizations during the treatment. Introduction Keywords Aim/RQ Methods Flowchart Results References Disc&Concl

7. Research Question • Is self-management a better solution for asthmatic children than standard procedures in order to decrease the number of hospitalizations and increase quality of life? Introduction Keywords Aim/RQ Methods Flowchart Results References Disc&Concl

8. Methods: Explanation Ages 6 to 12 Introduction Keywords Aim/RQ Methods Flowchart Results References Disc&Concl

9. Methods: Explanation • Typeofstudy; • StudyParticipants; • Data collectionmethods; • Study design; • Variabledescriptionandexpectedoutcome. Introduction Keywords Aim/RQ Methods Flowchart Results References Disc&Concl

10. Methods: Explanation Typeofstudy Definition: type of synthesis study in which we use a methodological and explicit way to expose high leveled evidence regarding certain clinical question Systematic Review • Steps: • Formulation of the question (population; intervention; comparison; outcome) • Define the selection criteria (inclusion and exclusion) • Define the search strategies Introduction Keywords Aim/RQ Methods Flowchart Results References Disc&Concl

11. Methods: Explanation We randomly split the class in 5 groups using a service from a website Each group was given a determined number of articles to evaluate Introduction Keywords Aim/RQ Methods Flowchart Results References Disc&Concl

12. Methods: Explanation First form –Title and Abstract selection Introduction Keywords Aim/RQ Methods Flowchart Results References Disc&Concl

13. Flowchart – Study Design First phase – Title and Abstract selection The articles obtained were subjected to a process of critical appraising according to its quality. Introduction Keywords Aim/RQ Methods Flowchart Results References Disc&Concl

14. Methods: Explanation Second form –Full-text selection Introduction Keywords Aim/RQ Methods Flowchart Results References Disc&Concl

15. Methods: Explanation Introduction Keywords Aim/RQ Methods Flowchart Results References Disc&Concl

16. Flowchart – Study Design First phase – Title and Abstract selection Second phase – Full-text selection Introduction Keywords Aim/RQ Methods Flowchart Results References Disc&Concl

17. Flowchart – Study Design First phase – Title and Abstract selection Second phase – Full-text selection Third phase – Data Extraction Introduction Keywords Aim/RQ Methods Flowchart Results References Disc&Concl

18. Methods: Explanation How to extract data? • List of characteristics and measures to extract (variables); • Specific formulary for the extraction of data; • Trial Study to evaluate methods and formulary; • Extraction by two revisionists; • Definition of ways to work out divergences and evaluate the reproducibility of the process. Introduction Keywords Aim/RQ Methods Flowchart Results References Disc&Concl

19. Methods: Explanation VariableDescription • Type of study • Quality of life – measured in PA-QOL and PC-QOL questionnaires • Sample size • Type of comparison – Control vs Education or 2 different types of education • Sessions – frequency, duration and number • Type of education – topics addressed in intervention • Severity of asthma • Social economical status • Age group • Urgent physician visits for asthma prior and after education • Emergency room visits prior and after education • Numberofhospitalizationsprior and after education • FEV1 - Lung function reported as changes in absolute • forced expiratory volume in one second • Other comparison Introduction Keywords Aim/RQ Methods Flowchart Results References Disc&Concl

20. Methods: Explanation Quality of life – measured in PA-QOL and PC-QOL questionnaires Introduction Keywords Aim/RQ Methods Flowchart Results References Disc&Concl

21. Methods: Explanation Third form –Data Extraction Introduction Keywords Aim/RQ Methods Flowchart Results References Disc&Concl

22. Methods: Explanation Third form –Data Extraction Introduction Keywords Aim/RQ Methods Flowchart Results References Disc&Concl

23. Methods: Explanation Searchresult 264 1st Phase Title and abstract selection Included 58 Excluded 206 2nd Phase Full-text selection Excluded 45 Included 13 Introduction Keywords Aim/RQ Methods Flowchart Results References Disc&Concl

24. Results ISI Web of knowledge Pubmed 77 187 76 *Final count for articles with free full-text • a - Articles not regarding asthma • b-Education programs that aren´t about children, ages 6 to 12 • c -Articles about efficacy of educational school programs in the treatment of asthma and its costs • d- Articles containing secondary information (systematic reviews , meta-analisys ) • e- Articles not concerning quality of life and amount of times children are admitted to hospital • f – Other exclusion criteria (Abstracts without study details , Any intervention except self-management) Results Disc&Concl Introduction Keywords Aim/RQ Methods Flowchart References

25. Results Results Disc&Concl Introduction Keywords Aim/RQ Methods Flowchart References

26. Results Results Disc&Concl Introduction Keywords Aim/RQ Methods Flowchart References

27. Results Variableextraction Results Disc&Concl Introduction Keywords Aim/RQ Methods Flowchart References

28. Results Meta-analysis Results Disc&Concl Introduction Keywords Aim/RQ Methods Flowchart References

29. Results ForestPlots Effect of educational programmes in self management of asthma on number of visits to an emergency department. Visits refers to hospital emergency departments, reported as mean number of visits for a year Results Disc&Concl Introduction Keywords Aim/RQ Methods Flowchart References

30. Results Effect of educational programmes in self management of asthma on lung function. Lung function was reported as changes in absolute forced expiratory volume in one second or peak expiratory flow rate Results Disc&Concl Introduction Keywords Aim/RQ Methods Flowchart References

31. Results Effect of educational programmes in self management of asthma on number of hospitalizations, reported as mean number of hospitalizations for a year. Results Disc&Concl Introduction Keywords Aim/RQ Methods Flowchart References

32. Results PA-QOLQ Effect of educational programmes in self management of asthma on quality of life measures. Quality of life was reported on a PaediatricAsthma Quality of Life Questionnaire Results Disc&Concl Introduction Keywords Aim/RQ Methods Flowchart References

33. Results PC-QOLQ Effect of educational programmes in self management of asthma on quality of life measures. Quality of life was reported on a PaediatricAsthma Caregiver’sQuality of Life Questionnaire Results Disc&Concl Introduction Keywords Aim/RQ Methods Flowchart References

34. Results Physicianvisits Effect of educational programmes in self management of asthma on number of visits to a physician, reported as mean number of urgent visits for a year. Results Disc&Concl Introduction Keywords Aim/RQ Methods Flowchart References

35. Discussion Association with modest to moderate improvement in many outcome measures: • lung function • self efficacy • absenteeism from school • number of days of restricted activity • number of visits to an emergency department • possibly nights disturbed by asthma • Few children participate on educational programmes, because programmes take to much time and their costs are not supported by the government. Noreen Clark, CR Houle, MR Partridge. Educational Interventions to Improve Asthma Outcomes in Children. JCOM October 2007,Vol. 14, No. 10 Results Disc&Concl Introduction Keywords Aim/RQ Methods Flowchart References

36. Discussion Our study has several limitations There were insufficient studies and a lack of direct comparisons to reliably estimate group variables. • The query may not • have covered all studies Results Disc&Concl Introduction Keywords Aim/RQ Methods Flowchart References

37. Discussion Our study has important implications for practice and research improve outcomes • Future studies should include more opportunities for interaction between educators and children, studies should be conducted over higher periods, and increase the number of sessions. Results Disc&Concl Introduction Keywords Aim/RQ Methods Flowchart References

38. Conclusion • The intervention: • reduces the mean number of hospitalizations, emergency departments visits for asthma and increases quality of life. • education can reduce the morbidity and the cost of the disease and improve the quality of life asthmatic children and their parents. • Educational programmes should be considered a part of the routine care of young people with asthma. Results Disc&Concl Introduction Keywords Aim/RQ Methods Flowchart References

39. References • (1)  Lim, KG, Mottram C.The Use of Fraction of Exhaled Nitric in Pulmunary Practice 2008 American College of Chest Physicians • (2) Kostikas K, Papaioannou A, Tanou K, Koutsokera A, Papala M, Gourgoulianis K. Portable Exhaled Nitric Oxide as a Screening Tool fo Asthma in Young Adults During Pollen Season. 2008 American College of Chest Physicians • (3)Pai M, McCullock M, Gorman JD, Pai N, Enanoria W, Kennedy G, Tharyan P, Colford JM Jr. Systematic reviews and meta-analyses: Na illustrated, step-by-step guide. The National Medical Journal of India 2004; 17(2): 86-95 • (4) Liberati A, et al: The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions explanation and elaboration. PLoS Med 2009, 6(7):e1000100, Epub 2009 Jul • (5) Egger M, Smith GD, Phillips AN. Meta-analysis: principles and procedures. BMJ. 1997;315:1533-1537. • (6) Indinnimeo L, et all. Clinical effects of a Long-term Educational Program for children with asthma - Aironet. A 1-yr randomized controlled trial.2009 Nov;20(7):654-9. Epub 2009 Jun 12. Introduction Keywords Aim/RQ Methods Flowchart Results References Disc&Concl

40. References • Guevara JP, Wolf FM, Grum CM, Clark NM. Effects of educational interventions for self management of asthma in children and adolescents: systematic review and metaanalysis. BMJ 2003; 326: 1308–1309. • E.D. Bateman, etal.Global strategy for asthma management and prevention: GINA executive summary. Eur Respir J 2008; 31: 143–178 • Noreen Clark, CR Houle, MR Partridge.Educational Interventions to Improve Asthma Outcomes in Children.JCOMOctober 2007,Vol. 14, No. 10 • Noreen M. Clark, Herman E. Mitchell and Cynthia S. Rand. Effectiveness of Educational and Behavioral Asthma Interventions.Pediatrics 2009;123;S185-S192 Introduction Keywords Aim/RQ Methods Flowchart Results References Disc&Concl

41. Class 3 Carolina Simas Catarina Ferreira Daniel Teles Diogo Galvão Fernando Mendonça Filipa Sousa Inês Moreira Joana Almeida Pedro Pinto Raquel Araújo Rui Freitas