Current issues of ACP Journal Club are published in Annals of Internal Medicine


Therapeutics

Educating patients in how to deal with chronic obstructive pulmonary disease reduced the use of health services and improved patients' knowledge of the disease

ACP J Club. 1993 Sept-Oct;119:42. doi:10.7326/ACPJC-1993-119-2-042


Source Citation

Tougaard L, Krone T, Sorknaes A, Ellegaard H, the PASTMA Group. Economic benefits of teaching patients with chronic obstructive pulmonary disease about their illness. Lancet. 1992 Jun 20;339:1517-20.


Abstract

Objective

To evaluate the effect on health service use of educating patients with chronic obstructive pulmonary disease (COPD) about their illness.

Design

Randomized controlled trial with 1-year follow-up.

Setting

General medical ward in Denmark.

Patients

100 consecutive patients aged > 35 years and hospitalized with COPD (pulmonary disease with symptoms of respiratory obstruction or secretions). Exclusion criteria were previous thoracic surgery, pulmonary tuberculosis, silicosis, asbestosis, lung cancer, terminal diseases, or severe learning difficulties. 82 patients (mean age 70 y) completed the study.

Intervention

50 patients were allocated to receive personalized hospital practice (PHP), which included training in aspects of their disease, and 50 patients were allocated to standard hospital practice. The aim of PHP was to improve patient awareness of their illness and their feelings of self-control. Medical treatment was the same in both groups in the hospital, but PHP patients received about 3 hours more instruction than control patients.

Main outcome measures

Changes in the use of health services, in level of knowledge of the disease, in severity of respiratory disease and dyspnea, and in arterial blood gas and pulmonary function results.

Main results

The PHP group had better knowledge of their disease compared with the control group. Compared with the year before admission, the use of health services after the intervention was on average Kr15 298 {U.S. $2583}* less per patient per year in the PHP group than in the control group (P = 0.048), mainly because of a high rate of readmission in the control group for hospital and respirator treatment. Use of general practitioner services was increased in the control group compared with the PHP group (Kr1346 {U.S. $227}* vs -Kr89 {U.S. $15}*, P = 0.001). A trend toward less dyspnea occurred in PHP patients (P = 0.06). Tests of airflow obstruction showed similar results.

Conclusion

Training patients with chronic pulmonary obstructive disease in how to deal with their disease reduced the use of health services and increased knowledge of the illness.

Source of funding: Not stated.

For article reprint: Dr. L. Tougaard, Department of Internal Medicine, Faaborg Hospital, DK-5600 Faaborg, Denmark. FAX 45-9675-3269.

*Conversion rate used was the average for 1990 (U.S. $1 = Kr5.9231).


Commentary

Small-group and individual asthma education programs improved symptom control and patient's understanding and management of their condition

The studies by Wilson and colleagues and Tougaard and colleagues help to effectively focus adult asthma education in clinical practice. Asthma is responsible for a large burden of illness, which is expensive and increasing. Preventable factors are present in most asthma deaths and in severe asthma exacerbations. The problems of adherence and compliance are particularly important in asthma. Many patients fail to follow a management plan because the plan is either rejected or misunderstood. Patient education can identify barriers to compliance and can reinforce correct instructions. These 2 studies identify the types of intervention that can make a difference in asthma. Most patients (89%) in the study by Tougaard and colleagues had asthma, and their use of the term COPD reflects the European tendency to "lump" rather than "split" airway diseases.

The 2 studies describe the content and process of a successful asthma management program. Knowledge of medications and their effects is required to aid compliance with a treatment regimen that optimizes asthma control. Instruction on the management of exacerbations is of paramount importance. This involves the avoidance of substances or situations that trigger asthma and involves the early recognition of deteriorating asthma by monitoring symptoms or peak expiratory flow or both. If exacerbations occur, the patient is instructed to increase bronchodilator and anti-inflammatory therapy because exacerbations increase bronchoconstriction and airway inflammation. The appropriate use of medical services is reinforced, especially when a patient needs to seek help (1).

The way these instructions are conveyed to the patient is crucial. As the study by Wilson and colleagues describes, the educational content must be delivered personally, either one-to-one or in a group setting, and in addition to a physician's usual care. This is a critical point. To improve the quality of care, it is necessary to spend more time on patient education, either during a consultation or at additional visits. These and other studies however, do justify the added time and expense of asthma education for adults (2). Successful programs improve symptom control and can reduce the use of health services (2). Smoking cessation needs to be addressed in education programs. Smoking is associated with inadequate asthma management (3), and smokers may avoid these programs. (4). However, the cost savings in the study by Tougaard and colleagues were greatest with smokers in the intervention group. The role of exercise and rehabilitation has not been defined in asthma but may be important, particularly in severe disease with complicating chronic airflow obstruction.

Targeting patients with at least moderate-to-severe asthma is sensible. Although not yet proven, it would reduce the cost of intervening, probably maximize the benefit, and make best use of limited resources. Suitable patients can be identified from clinics, or, as the study by Tougaard and colleagues shows, identified after hospitalization for nonrespiratory problems. A simple screening tool can be used to identify patients with more severe diseases (5). Ironically, those patients who could benefit most from asthma education may not comply (45% in Wilson's study). Future studies will need to define strategies for these patients (4, 6).

Asthma education, the personal delivery of asthma knowledge and management skills in addition to usual medical care, should now be routine care for adults with asthma.

Peter G. Gibson, MBBS
John Hunter HospitalNewcastle, Australia


References

1. National Asthma Education and Prevention Program. Guidelines for the diagnosis and management of asthma: expert panel report 2. Bethesda: National Heart, Lung, and Blood Institute, 1997.

2. Gibson PG, Coughlan J, Wilson AJ, et al. The effects of self-management education and regular practitioner review in adults with asthma. (Cochrane Review, latest version 26 Feb 98). In: The Cochrane Library. Oxford: Update Software.

3. Gibson P, Henry D, Francis L, et al. Association between availability of non-prescription beta 2 agonist inhalers and undertreatment of asthma. BMJ. 1993;306:1514-8.

4. Fish L, Wilson SR, Latini DM, Starr NJ. An education program for parents of children with asthma: differences in attendance between smoking and nonsmoking parents. Am J Public Health. 1996;86:246-8.

5. Jones KP, Charlton IH, Middleton M, Preece WJ, Hill AP. Targeting asthma care in general practice using a morbidity index. BMJ. 1992;304:1353-6.

6. Yoon R, McKenzie DK, Miles DA, Bauman A. Characteristics of attenders and nonattenders at an asthma education programme. Thorax. 1991;46:886-90.