Review: Brief advocacy (asthma schools) for patients with asthma reduces emergency room visits but does not improve clinical outcomes.
GOAL
To assess the impact of a brief explanatory work conducted by employees of medical institutions among patients with bronchial asthma (BA) on the clinical outcomes of asthma.
SOURCES OF INFORMATION
Databases MEDLINE, EMBASE and CINAHL – search by keywords: bronchial asthma, shortness of breath, education, self-medication; selected articles, abstracts of conferences, bibliographic lists in publications on research on relevant topics.
STUDY SELECTION
Randomized controlled trials involving adult patients with asthma in which nurses, pharmacists, health educators or physicians briefly explained to patients what the pathophysiological mechanisms of asthma are, how to influence its triggers and how to take medications, but did not provide intensive education skills of self-treatment or correction of medical treatment of asthma.
DATA SELECTION
Evidence level of the trial, patient characteristics, types of interventions, clinical background, criteria for assessing the clinical outcomes of asthma (frequency of hospitalizations, emergency department visits, unscheduled visits to the doctor, lung function tests, use of oral corticosteroids or emergency medicines, number of absences from school or work, the number of days with limited activity or feeling unwell), the level of knowledge gained about asthma.
MAIN RESULTS
11 studies met the inclusion criteria. A meta-analysis of the results of 3 studies and a routine analysis of 4 of 5 studies in which the results were presented in a descriptive form did not reveal a reduction in the frequency of hospitalizations for complications of asthma. Four studies assessed the frequency of emergency room visits, all of which showed that a brief outreach to patients reduced this rate. A meta-analysis of data from 5 studies found no reduction in unscheduled doctor visits. Lung function was assessed in 2 studies, with no improvement in functional parameters. None of the 4 studies reporting the use of different medications showed any change in treatment after brief explanatory work. Six studies assessed different clinical outcomes of AD. In general, brief explanatory work did not affect the number of days of incapacity for work. In one of these studies, it was shown to reduce the number of days with asthma attacks (from 73 to 52%; p<0.05), 1 study found a decrease in the number of complaints of poor health, 1 study noted an increase in the frequency of absenteeism ( on average from 0.47 to 0.86 missed days per 1 patient; p<0.05). 1 study shows that the annual cost savings from a brief explanatory work is 1913 US dollars per patient. Four out of six studies found an increase in the level of knowledge about AD.
CONCLUSIONS
Brief advocacy for adults with asthma reduces emergency room visits, improves knowledge, but does not reduce hospitalizations or doctor visits, improves lung function, medication use, or symptoms.
COMMENT
Almost all clinical guidelines for the treatment of asthma emphasize the expediency of patient education. Theoretically, it always makes sense to inform patients about their disease. However, when analyzing publications devoted to the problem of AD, PG Gibson et al . found relatively little evidence that patient outreach improves major clinical outcomes of asthma. Does this mean that such work should be stopped?
Before making any decision, it is important to take into account the limited amount of input data. First, when analyzing 11 out of 15 evaluation criteria, the conclusion was made on the basis of only one study. Second, in the analysis of 5 out of 15 evaluation criteria, the total number of patients was small (<60 patients in the intervention group). Thirdly, the impact of explanatory work on the evaluation criteria associated with the clinical manifestations of asthma and disability was quite favorable, although not statistically significant. Thus, the analyzed studies may not have been powerful enough to show a clinically important benefit. The strongest conclusion seems to be that brief advocacy among patients with asthma does not affect the frequency of hospitalizations and doctor visits. The best possible treatment outcome requires the active participation of the patient. It is impossible to change the patient’s role in the treatment process from passive to active without changing the stereotypes of behavior of both the patients themselves and the doctors. From this point of view, conducting a brief explanatory work cannot be successful. The best results are achieved when such clarification is combined with other non-pharmacological interventions, such as helping patients change behavior, learning to cope with various problems associated with having AD, and providing ongoing psychological support. The results of this review do not at all point to the need to stop explanatory work among patients with AD, they only indicate that the doctor should not rely solely on this method. Further research is needed to determine which additional non-pharmacological interventions (including self-care training) will be most effective.