As a nurse practitioner in a primary health care practice, you see many adult patients with asthma. The primary health care team wants to discuss strategies to improve care for these patients. They are particularly interested in whether both regular review by a health practitioner and patient education should be continued or whether giving patients written materials is just as effective. You offer to search the literature on the topic and report back at the next team meeting.
You pose the question, “Is a self-management programme that includes asthma education plus regular review by health professionals, effective in improving health outcomes for adults with asthma?”
Searching Terms and Evidence Source:
[“asthma” OR “wheeze”] AND “patient education” in the Cochrane Library. The Cochrane Library is the most comprehensive source of updated systematic reviews, and this simple search identifies the following review which appears to be very relevant to the question: Gibson PG, Coughlan J, Wilson AJ, et al. Self-management education and regular practitioner review for adults with asthma (Cochrane Review, latest update 29 May 1998). In: The Cochrane Library. Oxford: Update Software.
Read the article and decide:
- Is the evidence from this randomised trial valid?
- If valid, is this evidence important?
- If valid and important, can you apply this evidence in caring for your patient?
Completed Systematic Reviews Worksheet for Evidence-Based Nursing
Gibson PG, Coughlan J, Wilson AJ, et al. Self-management education and regular practitioner review for adults with asthma (Cochrane Review, latest update 29 May 1998). In: The Cochrane Library. Oxford: Update Software.
Are the results of this systematic review of therapy valid?
- Is it a systematic review of randomised trials of the treatment you are interested in?
- Yes. The review covers:
- Asthma education (written, verbal, visual, audio, interactive, non-interactive, structured or unstructured communication of information to improve patient knowledge and understanding of asthma)
- Self-monitoring (regular measurement of either peak expiratory flow or symptoms)
- Regular review (regular consultation with a practitioner to review the patient’s asthma status and medications)
- Written action plan (an individualised plan that helps patients to self-manage medication modifications when asthma worsens and informs them about how to access the health care system when asthma worsens)
- Optimal self-management (regular medical review plus self-monitoring plus an individualised written action plan)
- Does it include a methods section that describes finding and including all the relevant trials?
- Yes. A comprehensive search strategy was described, which covered a number of databases including MEDLINE, CINAHL, and EMBASE. Respiratory journals and meeting abstracts were hand searched and reference lists of articles were scanned. Surprisingly the Cochrane Controlled Trials Register was not mentioned as a source.
- Does it include a methods section that describes assessing their individual validity?
- Yes. Each trial was appraised for validity by 2 independent reviewers using criteria such as allocation concealment, blinding of interventions and outcome assessment, and attrition.
- Were the results consistent from study to study?
- The review looked at a variety of outcomes for a range of variations on self-management education and regular review (see above). There was significant heterogeneity for many of the outcomes assessed, although most results were qualitatively similar (i.e., the direction of effect is consistent). Heterogeneity was largely because of variations in the interventions.
- Are the valid results of this systematic review important?
- Yes. 24 RCTs met the inclusion criteria. Self-management education that included a written action plan, self-monitoring, and regular medical review, led to a reduction in the proportion of patients reporting hospitalisations and emergency department visits for asthma, unscheduled doctor visits for asthma, days lost from work because of asthma, and episodes of nocturnal asthma. The number of patients who would need to receive the self-management education in order to prevent 1 additional hospital admission (NNT) is 25; to prevent 1 additional emergency hospital visit is 17; and to prevent 1 unscheduled doctor visit is 11.
Can you apply this valid, important evidence from a systematic review in caring for your patients?
- Do these results apply to your patients?
- Yes, probably. The population of patients in the trials reviewed was probably heterogeneous in that the review included studies of asthma patients aged over 16 years of age. There was little description of the patients in the individual studies.
- Are your patients so different from those in the systematic review that its results can’t help you?
- Probably not.
- How great would the potential benefit of therapy actually be for your individual patient?
- Compared with usual care, the provision of asthma self-management education that includes self-monitoring, regular medical review, and a written action plan significantly improves health outcomes in adults with asthma.
Are your patient’s values and preferences satisfied by the regimen and its consequences?
- Do your patient and you have a clear assessment of their values and preferences?
- Needs to be assessed in each patient.
- Are they met by this regimen and its consequences?
- Needs to be assessed in each patient.
Asthma in adults: Self-management education and regular review improves health outcomes.
Clinical Bottom Line
Patients with asthma who receive self-management education are less likely to be admitted to hospital, have fewer visits to the emergency department, fewer unscheduled visits to the doctor, fewer days off work or school, and less nocturnal asthma. Reductions are greater when self-management education includes a written action plan, self-monitoring, and regular medical review.
Gibson PG, Coughlan J, Wilson AJ et al. Self-management education and regular practitioner review for adults with asthma (Cochrane Review, latest update 25 May 1998). The Cochrane Library. Oxford: Update Software.
Is a self-management programme that includes asthma education plus regular review by health professionals, effective in improving health outcomes for adults with asthma?
[“asthma” OR “wheeze”] AND “patient education” in the Cochrane Library.
- Data Sources: MEDLINE, EMBASE, CINAHL; hand searches of respiratory journals and conference abstracts; reference lists of articles.
- Study Selection: Systematic review of randomised controlled trials (RCTs) and controlled clinical trials (CCTs) that studied the effects of asthma education and self-management on health outcomes of people with asthma who were over 16 years of age. Studies were eligible if they measured any of the following health outcomes: asthma admissions, emergency department visits, unscheduled doctor visits, days off work or school, lung function, peak expiratory flow, use of rescue beta-agonists, use of oral corticosteroids, symptom scores, or quality of life scores.
- Data Extraction: Data were extracted on study quality, patient and disease characteristics, educational interventions, health outcomes, intermediate outcomes such as knowledge and skills, type of control, and duration of intervention. Interventions were categorised as education, self-monitoring, regular review, written action plan, and optimal self-management.
- Multiple independent reviews of individual reports? yes.
- Tested for heterogeneity? yes.
|Outcome||CER||EER||RRR||OR (95% CI)||ARR||NNT (95% CI)|
|Hospital admissions||0.094||0.053||0.44||0.58 (0.38 to 0.89)||0.041||25 (15-74)|
|Emergency hospital visits||0.286||0.226||0.21||0.71 (0.57 to 0.9)||0.00||17 (10-58)|
|Unscheduled doctor visits||0.374||0.276||0.26||0.57 (0.4-0.82)||0.098||11 (7-35)|
See also Gibson PG, Coughlan J, Wilson AJ et al. The effects of limited (information only) education programs on health outcomes of adults with asthma (Cochrane Review, latest version ). In: The Cochrane Library. Oxford: Update Software.
Nicky Cullum, RN, PhD.