Patient-Tailored Self Management Support Significantly Improves Asthma Outcomes

By Alexa Josaphouitch, /alert Contributor
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A recent study published in JAMA Internal Medicine found that older adults receiving patient-tailored self-management support intervention for asthma achieved meaningful improvements in asthma control and quality of life, self-management behaviors, and reductions in emergency department visits.

“A generalized asthma education approach can cognitively overload older patients, distracting them from the information they need most to improve self-care,” Alex D. Federman, MD, MPH, Icahn School of Medicine at Mount Sinai, and his colleagues wrote.

Older asthma patient learning about treatment options. Source: Getty

The team created an intervention program to identify barriers to asthma self-management and control, create targeted actions to address the barriers, and use reinforcement over time to achieve goals. To identify the barriers, the team relied on comprehensive screening for 21 domains of psychosocial, cognitive, physical and mental health, and environmental barriers to asthma control and self-management. Specific actions were then taken to address the identified barriers. The invention lasted 12 months.

This three armed randomized clinical trial of home-based intervention, clinic-based intervention, and usual care occurred between February 1, 2014 and December 31, 2017. Adults older than 60 with uncontrolled, moderate or severe persistent asthma were recruited from 3 adult primary care practices of the Mount Sinai Health System and 6 practices of the Institute for Family Health, a federally qualified health center, all in New York City. 

Of 1,349 patients assessed for eligibility, 406 met eligibility criteria, and 391 received the allocated treatment. Retention at 12 months for the home-based intervention was 70.3%; for the clinic-based intervention was 58.9%, and for the usual care was 70.9% (P = .11). Loss to follow-up was similar across study arms, but drop-out varied significantly: home-based arm, 8.6%; clinic-based arm, 14.7%; and usual care, 2.2% (P = .001). The most common reasons for drop-out were lack of interest (27.3%), other health concerns (21.2%), and time commitment (18.1%).

Asthma control and quality of life were measured with the Asthma Control Test (ACT, range 5-25) and the Mini Asthma Quality of Life Questionnaire (mAQLQ, range 1-7). Adherence to asthma controller medications (inhaled corticosteroids or leukotriene inhibitors) was measured by self-report using the Medication Adherence Rating Scale (MARS, range 0-5). Data were collected at baseline, 3, 6, and 12 months.

Intervention and usual care patients had low average ACT scores (mean[SD], 14.6[4.0]). Average mAQLQ scores were also low (mean [SD], 4.4 [1.1]), and 64.9% had poor quality of life (mAQLQ, <4.7).

The intervention group had overall significantly greater improvements in asthma control, asthma-related quality of life, and medication adherence compared to usual care patients. At 3 months, intervention patients ACT scores were mean 16.2 (SD 4.4) compared to usual care ACT scores of mean 14.6 (SD 4.8). At 12 months, the differences in ACT scores were not statistically significant, invention mean 17.1 (SD 4.7) and usual care patients 16.1 (SD 4.3). Similar patterns occurred in the mAQLQ scores.

Medication adherence was greater at all 3 time points, and the proportion of correctly performed steps for the technique with metered-dose inhalers increased by 15% (absolute increase, 95% CI, 7%-22%; P <.001) at 12 months. Fewer intervention patients had an asthma-related emergency department visit than controls (6.2% vs 12.7%, P = .03; adjusted odds ratio, 0.8; 95% CI, 0.6-0.99). 

There were no significant differences in outcomes between home-based and clinic-based interventions at 3, 6, or 12 months, except greater improvement in quality of life for home-based recipients at 6 months. The power to detect a statistically significant difference between the 2 arms at month 12 was 0.13 for the ACT and 0.31 for the mAQLQ.

Since this invention is patient-tailored, Federman and his colleagues believe it “is a promising model of self-management support and disease control for older adults with asthma, and possibly other chronic diseases.”