An intervention tailored to patients’ individual needs improved control outcomes and self-management behavior in older patients with asthma, according to findings from a randomized clinical trial.
“Older adults are prone to poor asthma outcomes owing in part to difficulties with self-management, like daily use of inhaled corticosteroids and proper inhaler technique,” Alex D. Fenderman, MD, MPH, of the division of general internal medicine of the Icahn School of Medicine at Mount Sinai, New York, and colleagues wrote. “These difficulties arise because of varied psychosocial, cognitive, physical and mental health issues. ...Published interventions have typically narrowed their scope, emphasizing generalized asthma education and skills training, with limited tailoring to the specific needs of the patient. Yet, a generalized asthma education approach can cognitively overload older patients, distracting them from the information they need most to improve self-care.”
Asthma patient talking with doctor. Source: Getty
Fenderman and colleagues performed a randomized clinical trial of 406 patients aged 60 years and older, all of whom had persistent, uncontrolled asthma. The researchers randomly assigned patients to a clinic-based intervention, home-based intervention, or usual care (control). The Supporting Asthma Self-Management Behaviors In Older Adults (SAMBA) intervention consisted of a three-step process: screening patients to identify which barriers prevented their asthma control, taking targeted action to address those barriers and reinforcing new behaviors over time. Trained asthma control coaches screened patients for barriers to control such as intermittent medication adherence, poor inhaler technique and evidence of a cockroach infestation in patients’ homes.
The coaches then took targeted actions including education focusing on proper inhaler usage, education about the chronic nature of asthma and roles of different medications and, if necessary, a referral to a New York City-sponsored pest control service to address cockroach infestations. Coaches also faxed the relevant information to patients’ primary care doctors. Fenderman and colleagues measured asthma control and quality of life using the Asthma Control Test and the Mini Asthma Quality of Life Questionnaire, and recorded medication adherence using the Medication Adherence Rating Scale. The researchers collected this data at baseline, 3 months, 6 months and 12 months.
Of 391 patients who received treatment, most (84.9%) were women. The mean age was 67.8 years.
Patients assigned to either intervention group had better scores on the asthma control test compared with those assigned to the control group (difference-in-differences at 3 months, 1.2; 95% CI, 0.2-2.2; P = .02; 6 months, 1.0; 95% CI, 0.0-2.1; P = .049; 12 months, 0.6; 95% CI, −0.5 to 1.8; P = .28; and overall, χ2 = 13.4, with 4 degrees of freedom; P = .01).
By 12 months, patients assigned to an intervention group also demonstrated fewer emergency department visits (16 [6.2%] vs. 17 [12.7%]; P = .03; adjusted OR = 0.8; 95% CI, 0.6-0.99; P = .03).
Further, those assigned to an intervention group showed a better medication adherence (overall effect: χ2 = 9.5, with 4 degrees of freedom; P = .049), quality of life (overall effect: χ2 = 10.5, with 4 degrees of freedom; P = .01) and inhaler technique (metered-dose inhaler technique, correctly completed steps at 12 months, median [range]: 75% [0%-100%] vs 58% [0%-100%]).
Fenderman and colleagues reported no significant differences in outcomes between the home and clinic-based intervention groups.
The researchers noted, however, that the final sample consisted of just 80% of their original planned recruitment, and that overall retention in both treatment arms was less than 70%.
“The SAMBA intervention is a promising model of self-management support and disease control for older adults with asthma, and possibly other chronic diseases, though because of lower retention of intervention patients and diminished intervention effects over time, the model should undergo additional refinement and testing before it is widely adopted,” the researchers wrote.
Disclosures: Fenderman reports no relevant financial disclosures. Please see the full study for a complete list of all other authors’ relevant financial disclosures.