Comprehensive Long-Term Management Program for Asthma: Effect on Outcomes in Adult African-Americans

Abstract

To determine if a comprehensive long-term management program, emphasizing inhaled corticosteroids and patient education, would improve outcomes in adult African-American asthmatics a nonrandomized control trial with a 2-year intervention was performed in a university-based clinic. Inclusion criteria consisted of (> or = 5) emergency department (ED) visits or hospitalizations (> or = 2) during the previous 2 years. Intervention patients were volunteers; a comparable control group was identified via chart review at hospitals within the same area and time period as the intervention patients. Individualized doses of beclomethasone with a spacer, inhaled albuterol "as needed," and crisis prednisone were the primary therapies. Environmental control, peak flow monitoring, and a partnership with the patient were emphasized. Detailed patient education was an integral part of management. Control patients received usual care from local physicians. ED visits and hospitalizations for 2 years before and 2 years during the intervention period were compared. Quality of life (QOL) measurements were made at baseline and every 6 months in the intervention group. Study group (n = 21) had a significant reduction in ED visits (2.3 +/- 0.2 pre-intervention versus 0.6 +/- 0.2 post-intervention; P = 0.0001). Control group (n = 18) did not have a significant change in ED visits during the 2-year post-intervention period (2.6 +/- 0.2 pre-intervention versus 2.0 +/- 0.2 post-intervention; P = 0.11). Both groups had significant reductions in hospitalizations, but the study group had a greater reduction. Sixty-two percent of study patients had complete elimination of ED visits and hospitalizations, whereas no control patients had total elimination of the need for institutional acute care. QOL in the study patients revealed significant improvements for most parameters. A comprehensive long-term management program emphasizing inhaled corticosteroids combined with other state-of-the-art management, including intensive patient education, improves outcomes in adult African-American asthmatics.

Does an Asthma Education Program Improve Quality of Life? A Two-Year Randomized Trial

“…Kelso et al (12) and Kauppinen et al (3) demonstrated a QoL improvement lasting for 2 and 5 years, respectively, after an education program. However, the former study was uncontrolled, and in the latter, the same QoL improvement was observed in the control group, suggesting causes other than the education program were responsible.…”

“…Although a positive effect on QoL of education programs lasting for up to 1 year of follow-up has often been reported (4,5,12,14), whether the benefit persists in the long term has seldom been investigated (3,12). Kelso et al (12) and Kauppinen et al (3) demonstrated a QoL improvement lasting for 2 and 5 years, respectively, after an education program.…”

“…The improvement in QoL scores in group B during the 1st year could be attributed to initial patient satisfaction with their care, which decreased as they became used to more attention and time spent with them during their checkups. Information reinforcement, whose importance in ensuring enduring benefits in long-term longitudinal studies was recently suggested (12,14), might have been inadequate. Again, the routine of checkups may have led to loss of motivation and enthusiasm by both patients and physicians, therefore causing ineffective information reinforcement, even though it was given in each year of the follow-up.…”

Munchausen by Proxy Syndrome

“…However, not adequately examined by Lieu was the potential for outcome to be influenced by apparent differences in medical practice among specialists and generalists as suggested in several studies. [2][3][4][5] Despite the high level of acuity described among these patients, only 7% of cases and Ͻ5% of controls were identified as having an asthma specialist.…”

“…The specific nature, timing, and dosage of the intervention makes the difference between success and failure, and specialized programs have been demonstrated to be highly successful at implementing effective early intervention measures. [2][3][4][5] Until generalists regard every episode of emergency care and every episode of hospitalization for asthma as a serious treatment failure and either provide intervention measures shown to be effective 6 or refer to an appropriate subspecialty care program for future management, the current endemic nature of asthma emergency care and hospitalization will continue despite the best intention of comprehensive guidelines. 13 Miles Weinberger, MD Pediatric Allergy and Pulmonary Division University of Iowa College of Medicine Iowa City, IA 55242-1083…”