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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.