Tailored Education May Reduce Health Literacy Disparities in Asthma Self-Management

Paasche‐Orlow, Michael K.; Riekert, Kristin A.; Bilderback, Andrew; Chanmugam, Arjun; Hill, Peter; Rańd, Cynthia S.; Brancati, Fred; Krishnan, Jerry A.

doi:10.1164/rccm.200409-1291oc

Cited by 239 publications

(215 citation statements)

References 58 publications

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“…The TTG technique has been endorsed as a patient safety standard by the National Quality Forum for informed consent, 31 and has been used for heart failure educational interventions, 32 and has been successful among patients hospitalized with asthma and COPD. 15,16 Because TTG uses 'teachback,' (i.e., re-assessment after education), inhaler technique recall may be enhanced for this group.…”

Section: Discussionmentioning

confidence: 99%

“…1) The TTG intervention was chosen based on preliminary results from prior work that demonstrated its success as a hospital-based approach for teaching the use of respiratory inhalers. 15,16 A variety of alternative comparators were considered, including usual care. Because usual care may vary by institution and provider, a standardized but limited educational strategy, dubbed "brief intervention" (BI) was chosen.…”

Section: Interventionmentioning

confidence: 99%

“…13,14 However, studies that we and others have conducted have found that the vast majority of patients hospitalized with asthma or COPD misuse their inhalers. 15,16 Improving patients' ability to use inhalers may help prevent adverse events post-hospital discharge, including hospital readmissions. [17][18][19] Although a handful of randomized trials have demonstrated beneficial effects of hospital-based patient selfmanagement education for asthma, [20][21][22][23] these studies employed multi-faceted, time-intensive interventions that were compared to usual care.…”

Section: Introductionmentioning

confidence: 99%

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Teaching the Use of Respiratory Inhalers to Hospitalized Patients with Asthma or COPD: a Randomized Trial

et al. 2012

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BACKGROUND:Hospitalized patients frequently misuse their respiratory inhalers, yet it is unclear what the most effective hospital-based educational intervention is for this population. OBJECTIVE: To compare two strategies for teaching inhaler use to hospitalized patients with asthma or chronic obstructive pulmonary disease (COPD). DESIGN: A Phase-II randomized controlled clinical trial enrolled hospitalized adults with physician diagnosed asthma or COPD. PARTICIPANTS: Hospitalized adults (age 18 years or older) with asthma or COPD. INTERVENTIONS: Participants were randomized to brief intervention [BI]: single-set of verbal and written step-by-step instructions, or, teach-to-goal [TTG]: BI plus repeated demonstrations of inhaler use and participant comprehension assessments (teach-back). MAIN MEASURES: The primary outcome was metereddose inhaler (MDI) misuse post-intervention (<75% steps correct). Secondary outcomes included Diskus® misuse, self-reported inhaler technique confidence and prevalence of 30-day health-related events. KEY RESULTS: Of 80 eligible participants, fifty (63%) were enrolled (BI n=26, TTG n=24). While the majority of participants reported being confident with their inhaler technique (MDI 70%, Diskus® 94%), most misused their inhalers pre-intervention (MDI 62%, Diskus® 78%). Post-intervention MDI misuse was significantly lower after TTG vs. BI (12.5 vs. 46%, p= 0.01). The results for Diskus® were similar and approached significance (25 vs. 80%, p=0.05). Participants with 30-day acute health-related events were less common in the group receiving TTG vs. BI (1 vs. 8, p=0.02).CONCLUSIONS: TTG appears to be more effective compared with BI. Patients over-estimate their inhaler technique, emphasizing the need for hospital-based interventions to correct inhaler misuse. Although TTG was associated with fewer post-hospitalization healthrelated events, larger, multi-centered studies are needed to evaluate the durability and clinical outcomes associated with this hospital-based education.

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Section: Discussionmentioning

confidence: 99%

Section: Interventionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Teaching the Use of Respiratory Inhalers to Hospitalized Patients with Asthma or COPD: a Randomized Trial

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“…35 The three studies that did not find a reduction in symptoms included Martin's social-work led group educational sessions with community health workers home visits, 24 Galbreath's telephone +/-RT home visits, 29 and Ford's multi-session ED-based intervention. 28 The results for selfmanagement (5/15) were more favorable; 24,26,27,31,33 all but one 24 found improvements in participants' self-management skills. Two pharmacist-based education interventions 26,31 showed absolute improvement of chambers (34 %), 26 PFMs (41 %), 26 and/or medication refills (41 %).…”

Section: 35mentioning

confidence: 97%

“…31 Similarly, two inpatient interventions that used repeated rounds of inhaler technique instruction demonstrated 100 % mastery after two or three rounds. 27,33 The only study that did not demonstrate improvements in self-management was Martin's community-based intervention. 24 Again, few CTE studies evaluated symptoms and self-management; 24,26 therefore conclusions based on the effectiveness of cultural tailoring on improving patient self-care or symptoms cannot be made.…”

Section: 35mentioning

confidence: 99%

Interventions to Improve Outcomes for Minority Adults with Asthma: A Systematic Review

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OBJECTIVES:To systematically review the literature to characterize interventions with potential to improve outcomes for minority patients with asthma. DATA SOURCES: Medline, PsycINFO, CINAHL, Cochrane Trial Databases, expert review, reference review, meeting abstracts. STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTEVENTIONS: Medical Subject Heading (MeSH) terms related to asthma were combined with terms to identify intervention studies focused on minority populations. Inclusion criteria: adult population; intervention studies with majority of non-White participants. STUDY APPRAISAL AND SYNTHESIS OF METHODS:Study quality was assessed using Downs and Black (DB) checklists. We examined heterogeneity of studies through comparing study population, study design, intervention characteristics, and outcomes. RESULTS: Twenty-four articles met inclusion criteria. Mean quality score was 21.0. Study populations targeted primarily African American (n=14), followed by Latino/a (n=4), Asian Americans (n=1), or a combination of the above (n=5). The most commonly reported post-intervention outcome was use of health care resources, followed by symptom control and self-management skills. The most common intervention-type studied was patient education. Although less-than half were culturally tailored, language-appropriate education appeared particularly successful. Several system-level interventions focused on specialty clinics with promising findings, although health disparities collaboratives did not have similarly promising results. LIMITATIONS: Publication bias may limit our findings; we were unable to perform a meta-analysis limiting the review's quantitative evaluation. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS:Overall, education delivered by health care professionals appeared effective in improving outcomes for minority patients with asthma. Few were culturally tailored and one included a comparison group, limiting the conclusions that can be drawn from cultural tailoring. Systemredesign showed great promise, particularly the use of team-based specialty clinics and long-term follow-up after acute care visits. Future research should evaluate the role of tailoring educational strategies, focus on patient-centered education, and incorporate outpatient follow-up and/or a team-based approach.

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So Much to Do, So Little Time

Fiscella¹,

Epstein²

2008

Arch Intern Med

153

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There is much to do in primary care and little time to do it. Currently, primary care delivery is organized around visits, often 15 minutes or less, during which much is expected of clinicians. This includes establishing partnerships with patient and families; addressing acute and chronic biomedical and psychosocial problems; prevention, care coordination; and ensuring informed decision-making that respects patients' needs and preferences. Visit-based care discriminates against socially disadvantaged patients, who often require more time due to complex health care needs and the challenge of establishing partnerships and communicating across chasms of race, ethnicity, education, language, and culture. Rushed visits exacerbate disparities in health car due to competing demands, miscommunications and activation of unconscious physician stereotypes. Addressing health care disparities requires radical transformation in the structure and financing of primary care and the roles of the health care team members and patients. One such innovation, the patient-centered medical home, organizes care around patients' needs, not visits. Thus, face-to-face visits and physician-centered care are supplanted by team-based care that relies on multiple communication modalities, expanded health information technology, population management, culturally-sensitive outreach and follow-up, and coaching patients to assume more active roles in care. Implementation requires payment reform that allocates resources based on the true costs of providing high quality care to socially disadvantaged patients. Ensuring success will require physician leadership and training in new care models, transformation in primary care culture, and redesign of care around the needs of patients, particularly those needing care the most.There is so much to do in primary care and so little time to do it. During 15-minute visits, 1 physicians are expected to form partnerships with patients and families, address complex acute and chronic biomedical and psychosocial problems, provide preventive care, coordinate care with specialists, and ensure informed decision-making that respects patients' needs and preferences. While this is a challenging task in straightforward visits, it is nearly impossible when caring for socially disadvantaged patients with complex biomedical and psychosocial problems and multiple barriers to care. Consider the following scenario.Mrs S is a 52-year old female housekeeper with poorly controlled diabetes, hypertension and obesity who missed her last two visits due to job conflicts. She hasn't reached her annual

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Tailored Education May Reduce Health Literacy Disparities in Asthma Self-Management

Cited by 239 publications

References 58 publications

Teaching the Use of Respiratory Inhalers to Hospitalized Patients with Asthma or COPD: a Randomized Trial

Teaching the Use of Respiratory Inhalers to Hospitalized Patients with Asthma or COPD: a Randomized Trial

Interventions to Improve Outcomes for Minority Adults with Asthma: A Systematic Review

So Much to Do, So Little Time

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