Download Faculdade de Medicina da Universidade do Porto Introdução à

Faculdade de Medicina da Universidade do Porto
Introdução à Medicina
ASTHMA
Is home monitoring more effective
than usual care?
Class 19
Coordinator: Dr. João Fonseca
INTRODUCTION
ASTHMA
 chronic inflammatory disorder of the airways1
 chronically
inflamed
airways
are
hyperresponsive; they become obstructed and
airflow is limited (by bronchoconstriction,
mucus plugs, and increased inflammation)
when airways are exposed to various risk
factors1
1. “Pocket Guide for Asthma Management and Prevention” www.ginasthma.com
Background
 300 million people worldwide now have asthma1
 His control is possible, but it isn’t accomplished in
most cases:
- 75% of asthma admissions are avoidable2
- 40% of asthma patients don’t react properly when their
symptoms worsen2
- 50% of asthma patients admitted with acute asthma
have had alarming symptoms a week before admission2
- 60% of asthma patients are poor at judging their
dyspnoea2
1. Global Burden of Asthma Repor
2. Guided self management of asthma - how to do it. Aarzne Lahdensuo
Rationale behind our aim
Monitorization between observations at medical
facilities may:
– detect early negative events
– provide a better insight to the variations of the disease
– foster patients participation in their own care.
Insufficiently known methods and patients’
characteristics that have better outcomes with
home monitoring
It is necessary summarize the information of the
studies
Systematic review
– address a specific clinical question 1
– require a comprehensive literature search, 1
– use explicit selection criteria to identify relevant
studies1
– assess the methodologic quality of included
studies1
– explore differences among study results1
1. Montori VM, Swiontkowski MF, Cook DJ. Methodologic issues in systematic reviews and
meta-analyses.
AIM
 Primary aim: summarize the available controlled
studies about the clinical benefits of asthma
patients to monitoring their disease outside
medical facilities (home monitoring / selfmonitoring)
 Secondary aim: to compare the clinical efficacy
of different techniques of home monitoring
METHODS
Literature research
 Randomised controlled studies
 Indexed at SCOPUS and Medline
 Assessing the benefits of using home
monitoring in patients with asthma
Pubmed
(asthm*[MeSH] OR asthm*[TIAB])
AND
(((clinical[Title/Abstract] AND trial[Title/Abstract]) OR clinical
trials[MeSH Terms] OR clinical trial[Publication Type] OR
random*[Title/Abstract] OR random allocation[MeSH Terms] OR
therapeutic use[MeSH Subheading]))
AND
(("self management"[TIAB] OR ("self care"[TIAB] OR “self
care”[MeSH]) OR “self-monitoring”[TIAB])
AND
("peak-flow-meter"[TIAB] OR (spirometry[TIAB] OR
spirometry[MeSH]) OR telemedicine[TIAB] OR "communication
tecnhologies"[TIAB] OR ehealth[TIAB] OR “home automated
telemanagement”[TIAB] OR Internet*[TIAB] OR mobile[TIAB]))
Limits: Publication Date
Controlled Trial, Humans
1996-2005,
English,
Randomized
Scopus
TITLE-ABS-KEY(*asthma)
AND
((TITLE-ABS-KEY("self-management" OR "self care"
OR "self-monitoring"))
AND
(TITLE-ABS-KEY("peak-flow-meter" OR spirometry
OR telemedicine OR "communication technologies"
OR ehealth OR "home outomated telemanagement"
OR internet OR mobile))
AND TITLE-ABS-KEY(random* OR trial OR control*))
Limits: DOCTYPE "ar" AND PUBYEAR 1996-2005
Flowchart
FAZER HIPERLIGAÇÂO
Inclusion criteria
• Articles which describe and evaluate the health care of
patients outside hospital, with asthma
• Articles which compare the clinical outcomes of
children and adults with asthma that performed selfmonitoring with those who do not performed selfmonitoring
Exclusion criteria
• Not related with our aim
Intervention only
Pharmacologic treatment;
Exclusively turned to education of
patients and professionals
• No control groups
• Non-randomized
Data gathering
 Article data were registered on tables in
RevMan and Excel
RESULTS
Articles selection
30
Nº artickes
25
20
15
10
5
0
Medline
Scopus
Both in
Medline
and Scopus
Total
1º selection 2º selection
- nº articles - nº articles
included
included
Excluded articles
Summary of excluded articles
 12 articles – not related with our aim
 5 articles – not RCT
 2 articles – no control group
 2 articles – full text article not available
Identification of included articles
Article
ID
Author
Tittle
Date of
publicati
on
Journal/Book/Source
1
Rasmussen, L.M.,
Phanareth, K., Nolte,
H., Backer, V..
Internet-based monitoring of asthma: A
long-term, randomized clinical study of 300
asthmatic subjects.
2005
Journal of Allergy and Clinical
Immunology
2
Ostojic, V., Cvoriscec,
B., Ostojic, S.B.,
Reznikoff, D., StipicMarkovic, A.,
Tudjman, Z..
Improving asthma control through
telemedicine: A study of short-message
service.
2005
Telemedicine Journal and e-health
3
Wensley, D.,
Silverman, M..
Peak flow monitoring for guided selfmamagement in childhood asthma: A
randomized controlled trial
2004
American Journal of Respiratory and
Critical Care Medicine
4
Turner MO, Taylor D,
Bennett R, Fitzgerald
JM..
A randomized trial comparing peak
expiratory flow and symptom selfmanagement plans for patients with asthma
attending a primary care clinical.
1998,
Feb
AM J Respir Crit Care Med
5
Adams, R.J., Beath,
K., Homan, S.,
Campbell, D.A.,
Ruffin, R.E..
A randomized trial of peak-flow and
symptom-based action plans in adults with
moderate-to-severe asthma
2001
Respirology
General information of included articles
Study
Design
Participants
Interventions
Outcomes
1Rasmussen
RCT
300 asthmatic
subjects
-questionaries, -spirometry,
-measurement of
airway
responsiveness
-internet based
monitoring
-symptoms, -quality of life, -lung
function,
-air responsiveness
RCT
16 asthmatic
subjects
-office visits
-1 hour asthma
education session
with a specialist at
the clinic
-PEF was to be
determined three
times per day
-asthma monitoring
by GSM and SMS
-Events during study period, Average symptom score, spirometry,
-PEF by time of day (L/min),
-PEF variability, -Daily
consumption of inhaled
medication, Cost of
monitoring (per week, per
patient) (money and time
RCT
90 asthmatic
childre
n
-spirometry
-quality of life -self-management
RCT
92 asthmatic
adults
-asthma education
-peak expirotory
flow
-Symptom selfmanagement plans
-ED visits and/or hospitalization for
asthma unscheduled -doctor
visits, -days absent from
school or work courses of
prednisone and respiratory
tract infections
RCT
134 asthmatic
adults
(82
females
and 52
males)
-symptom-based action
plans -peak
expiratory flow
-quality of life -self-management
L.M., 2005
2 Ostojic, V,
2005
3 Wensley,
D., 2004
4 Turner
MO, 1998
5 Adams
R.J., 2001
Study completion
Among 90 participants only one withdrawaled
From the original group of one 134 patients, 21(15%)
completed between 3 and 5 months of followup, 25(19%) between 6 and 11 months and
88(66%) completed the 12 months of followup. Among those patients who discontinued
the study prior to 12 months 30 gave up due to
lack of interest.
Methods of included articles
Methods table for included articles
ID article participants' selection methods
Participants'selection criteria
1
Letters were posted until 300 asthmatic subjects →subjects aged 18 to 45 years from the catchment
had been enrol ed. The patients were randomized area of H:S Bispebjerg University Hospital of
consecutively by using the sealed enveloped Copenhagen, Denmark
technique, ir espective of computer experience and →asthma was diagnosed on the basis of a
smoking status, to one of the three groups (Internet combination of respiratory symptoms and at least
group, spe
one objective m
2
They were rendomized by computer
3
They were interviewed
→Patients with moderate persistent asthma for at
least 6 months that were being treated with ICS and
LABA.
→None had a history of smoking, chronic
bronchitis, or emphysema.
→age 7-14 years old;
→Physician diagnosed asthma;
→at least step 2 of the BTSGAM - regular inhaled
corticoesteroid therapy , stable threatment for a
month, no other respiratory problem,
groups and respective intervention
variables analysed
instruments for data collection
→asthma symptoms ─ the severity of symptom was →The patients were examined on entry into the
graded as:
study and after 6 month of treatment
• Very mild: respiratory symptoms less than once →Questionnaires (al subjects fil ed in
a week and nocturnal symptoms not more than questionnaires on asthma quality life, asthma selftwice a month
care, smoking habits, education, salary, sick leave
• Mild: respiratory symptoms 2 to 6 times a week and h
and nocturnal symptoms more than
16 participants divided into 2 groups (1-hour →Events during study period (acute respiratory →office visits,
asthma education session with a specialist at the il ness, office visits, hospital admission, SMS
→PEF was to be
clinic for each patient)
messages, compliance with PEF measurement (%), determined three times per day and the highest
First group: SMS study group → they were PEF values transmit ed (% measurealPEP), changes value recorded,
→symptom
instructed to send via sms th
of medication)
90 divided in 2 groups
→QoL (quality of life)
To QoL: →questionnaires
First group: S group (n=46) → it was the control
→Lung function
To Spirometry: →VITALOGRAPH
group; they had symptom-based management alone →daily symptom score
for 12 months
Second group: IPF gr
with 3 paral el groups and 2 scheduled visits, 6
month
First group: Internet-group (n=100) →They had an
electronic diary, an action plan and a decision
support system for the phys
Statistic Analysis
→Dif erences within and between groups were
analysed by Wilcoxon signed rank test
→On discontinuous variables
it was used the contingency X² (p value<0,05)
→The data were analized with the statistic program
SPSS
→For the continuous variables it was used
ANOVA, fol owed by the 2-simple T-Test to
compare the groups and a Paired T-Test fo
From previous studies, 53 children were needed in
each group to have 80% power to detected a
between-group dif erence in daily symptom score of
1,5. The aim was to recruit 120 children (60 in each
group) to allow for withdrawals. Details of the
statistica
Results of included articles
Article ID Aim
Main Results
Conclusion
Final Message
1
Investigate the outcome of monitoring and
treatment using a physician-managed online
interactive asthma monitoring tool and to access
whether the outcomes differs from that of
monitoring and treatment in an outpatient clinic and
in a primary care
Demonstrates that asthma is better controlled if
patients self-monitoring their symtoms and PEF,
follow an written action plan and attend regular
control visits to their physician's office. An Internetbased management tool had the potencial of
improving
When physicians and
patiens used Internetbased asthma
monitoring, better
asthma control mas
achieved.
2
Have access to the feasibility and reability of GSM
SMS as a tool of asthma monitoring and to
ascertain its impact on control of asthma
asthma symptoms:
→Internet vs specialis: odds ratio of 2.64, p= 0.002;
→Internet vs GP: odds ratio of 3.26, p< 0.001;
quality of life:
→Internet vs specialis: odds ratio of 2.21, p= 0.03;
→Internet vs GP: odds ratio of 2.10, p= 0.04;
lung function:
→I
→There was no significant difference between the groups in
absolute PEF, but PEF variability was significantly smaller in the
study group (16.12 +/- 6.93% vs. 27.24 +/- 10.01%, p = 0.049).
→forced expiratory flow in 1 second (FEV1; % predicted) in the
stu
Despite the limitations and the need for larger
confirmatory studies, this study has established
feasibility and utility of SMS as a mean of
telemedicine of asthma. SMS can contribute to
better disease control, symptomatic improvement,
and the more favora
Compare the efficiency of PEF and symptom selfSymptoms scores:
In children, self-management studies have
management plans in patients with asthma
no significant differences between the PF and S groupsn the
demonstrated varying degrees of sucess and only
mean daily sympton score during the trial period, the mean daily three studies directly compared symptoms and peak
symptom score for symptomatic day
flow-based management, with inconclusive results
at best, during acute exacerbations. During asthma
management tr
Compare the efficiency of peak expiratory flow and →Effect on clinical measurements and quality of life: There was There is a significant improvement within PFM and
symptom self-management in patients with asthma; no diference in symptom scores for both goups(p>0.39); Quality symptom groups for measures of spirometry, airway
Compare the evolution of asthma in patients with or of life scores showed a moderate increase for both groups
responsiveness, symptoms, and QOF(quality of
without self-monitoring
→Effect on medications:There
live). However there was no difference in primary
outcome measures between the groups. The use of
either a sym
SMS as a means of
telemedicine of asthma
may contribute to
better disease control.
3
4
5
Compare the efficiency of PEF and symptom selfmanagement plans in patients with asthma
→Health care utilization: there was no significant differences
between the 2 groups
→Lung function: there was no significant differences between
the 2 groups
The present study indicates that the choice
between using symptom or peak flow-based action
plans will depend on the circumstances and
preferences of the patient or physician, there is little
evidence that the routine use of PFM for asthma
self-managemnet
PEF doesn't have a
significant advantage
in symptom selfmanagement plans of
children with asthma
There is no difference
in PFM and symptom
techiques but both are
advantagous when the
patients have a proper
asthma education.
PEF doesn't have a
significant advantage
in symptom selfmanagement plans of
adults asthma
Summary of results
Clinical benefits of asthma patients to
monitoring their disease outside medical
facilities:
– Turner MO, 1998 – positive
– Rasmussen L.M., 2005 – positive
– Ostojic, V, 2005 - positive
Clinical efficacy of different techniques of
home monitoring:
– Turner MO, 1998 – no significative differences
– Wensley, D., 2004 – no significative differences
– Adams R.J., 2001 – no significative differences
ACKNOWLEDGEMENTS
We would like to thank:
 Dr. João Fonseca because he helped us
during our work
 Professor Altamiro da Costa Pereira for
showing us what we should change.