Review: Limited asthma education reduces emergency department visits but does not improve patient outcomes
ACP J Club. 1998 Jul-Aug;129:14. doi:10.7326/ACPJC-1998-129-1-014
Gibson PG, Coughlan J, Wilson AJ, et al. The effects of limited (information only) patient education programs on the health outcomes of adults with asthma. In: The Cochrane Library, Issue 1, 1998. Oxford: Update Software.
In adults with asthma, does limited education (information only) by health care professionals improve patient outcomes?
The MEDLINE, EMBASE, and CINAHL databases were searched by using the terms asthma or wheeze combined with the terms education or self management. Selected journals, abstracts of meetings, and bibliographies of relevant studies were also hand searched.
Randomized controlled trials of adults with asthma were selected if education was provided by a nurse, pharmacist, health educator, or medical personnel; if the education included information on pathophysiology of asthma, management of trigger factors, and medications; and if the education did not include intensive skill training or medication modification.
Data were extracted on study quality, patient characteristics, intervention program components, settings, and outcomes (hospitalization, emergency department visits, unscheduled physician visits, lung function, use of oral corticosteroids or rescue medications, absences from school or work, restricted-activity days, perceived disability, and knowledge).
11 studies met the inclusion criteria. Meta-analysis of 3 studies, as well as 4 of the 5 trials with narrative results, showed no reductions in hospitalization because of asthma complications. 4 of 4 studies showed a reduction in emergency department visits after limited education. Meta-analysis of 5 studies did not show a reduction in the number of unscheduled physician visits. 2 studies assessing lung function did not show improvement. 4 studies assessed medication use, and none showed differences after education. 6 studies assessed multiple symptoms and outcomes. Absences from school and work did not differ. 1 study showed a reduced rate of symptomatic days (52% vs 73%, P < 0.05), 1 study showed decreased perceived disability, and 1 study showed increased absences from work (0.86 vs 0.47 mean absences per person, P < 0.05). 1 study found annual cost savings of U.S. $1913/patient for those who received limited asthma education. 4 of 6 studies showed an increase in asthma-based knowledge.
Limited asthma education for adults reduces emergency department visits and improves knowledge but does not reduce hospitalization or physician visits. Education does not improve lung function, decrease medication use, or improve symptoms.
Source of funding: Hunter Area Health Service, NSW Health Australia.
For correspondence: Dr. P.G. Gibson, Respiratory Medicine, John Hunter Hospital, Locked Bag 1, Hunter Mail Centre, New South Wales 2310, Australia. FAX 61-2-4921-3537.
Providing education to patients with asthma is commonly recommended in practice guidelines. In theory, provision of education makes sense; it is hard to argue that we should not teach patients about their condition. Gibson and colleagues found relatively weak support in the literature for the notion that patient education improves important clinical outcomes. Does this mean we should abandon the effort?
Before deciding, it is important to note limitations in the original data. First, for 11 of the 15 outcomes measures, only 1 study contributed to the conclusion. Second, for 5 of the 15 outcomes, the total number of patients studied was small (≤ 60 in the intervention group). Third, the effects on outcome measures dealing with symptoms and disability, although generally not statistically significant, seem favorable. Thus, these studies may have had insufficient power to detect clinically important benefits. The conclusion most strongly supported by the data from these randomized trials is that limited education makes no difference in the number of hospitalizations or physician visits.
Although these results are disappointing, they are hardly surprising. Asthma is a chronic illness that probably requires patients' active participation in management to achieve the best possible outcomes. Changing patients' participation from passive to active management requires a substantial change in behavior. What we have learned about changing patient or physician behavior in health care is that limited education is not likely to be successful. The best results are achieved when education is combined with other interventions, such as behavior change skills, coping skills, and continued reinforcement. The results of this review do not indicate that we should stop educating patients with asthma about their illness but that we should not rely solely on this intervention. We need more research to determine which additional interventions, including self-management education, will produce the best results.
Paul G. Shekelle, MD, PhD
RANDSanta Monica, California, USA