Internet-Based Self-management Plus Education Compared With Usual Care in Asthma

Context Patient self-management is an essential component of asthma care, and the Internet is a medium to potentially support patients in self-management. Contribution This randomized trial compared Internet-based asthma self-management with usual care and found modest improvements in asthma control and lung function with the Internet intervention, but found no reduction in exacerbations and changes in asthma-related quality of life that were less than clinically significant at 12 months. Implication Although Internet-based self management can improve some asthma outcomes, the improvements were small and the program did not reduce the number of exacerbations. The Editors Asthma is a chronic disorder of the airways that is characterized by recurring respiratory symptoms, variable airflow obstruction, airway hyperresponsiveness, and underlying inflammation (1, 2). Recent clinical guidelines for the management of asthma distinguish 4 essential components of asthma care: assessment and monitoring, patient education, control of environmental and comorbid factors that affect asthma, and drug treatment. With appropriate medical care, well-informed and empowered patients can control their asthma and live full, active lives (1, 2). However, despite the availability of monitoring tools and effective therapy, asthma control is suboptimal in many patients worldwide, and long-term management falls far short of the goals set in the guidelines (3). Self-monitoring, education, and specific medical care are important aspects in improving the lives of patients with asthma (1, 2). However, many patients with mild or moderate persistent asthma do not attend checkups regularly or visit their physician with symptoms of the disease (4). In addition, in practice, both patients and their health care providers are reluctant to use written self-management plans (5). Internet technology is increasingly seen as an appealing tool to support self-management for patients with chronic disease in remote and underserved populations (68). However, to date, studies on Internet-based asthma self-management show only short-term improvements in asthma control, lung function, and quality of life (911). Long-term studies on the effect of Internet-based self-management, including all its essential features, are not available. Therefore, we developed a guided self-management tool for adult patients with asthma that included Internet-based home monitoring and treatment advice (action plan), online education, and remote Web communication with a specialized asthma nurse. The goal of our study was to assess the long-term clinical effectiveness of Internet-based self-management education compared with usual physician-provided care alone. Methods Design Overview We conducted a 12-month, multicenter, nonblinded, randomized, controlled trial. We randomly assigned patients to Internet-based self-management (Internet group) as an adjunct to usual care or to usual physician-provided care alone (usual care group). The Internet-based self-management program included weekly asthma control monitoring and treatment advice, online and group education, and remote Web communications with a specialized asthma nurse. The intervention continued for 12 months after enrollment. The Medical Ethics Committee of the Leiden University Medical Center, Leiden, the Netherlands, approved the study. Setting and Participants We recruited patients from 37 general practices (69 general practitioners) in the Leiden and The Hague area and the Outpatient Clinic of the Department of Pulmonology at the Leiden University Medical Center from September 2005 to September 2006. Inclusion criteria were physician-diagnosed asthma coded according to the International Classification of Primary Care in the electronic medical record (12), age 18 to 50 years, prescription of inhaled corticosteroids for at least 3 months in the previous year, no serious comorbid conditions that interfered with asthma treatment, access to the Internet at home, and mastery of the Dutch language. We excluded patients who were receiving maintenance oral glucocorticosteroid treatment. On the basis of diagnosis, age, prescribed asthma medication, and comorbid conditions, we sent eligible patients an invitation letter followed by 1 reminder letter after 2 to 4 weeks if they did not respond to the first. We continued this process until a total of 200 patients had entered the study (September 2006). All participants gave written consent. Randomization and Intervention In a 2-week baseline period before randomization, we collected data on patient demographic characteristics, asthma-related quality of life, symptom control, lung function, and medication level. We provided basic education about core information on asthma, action of medications, and inhaler technique instructions to all patients. We trained all participants to measure FEV1 daily with a hand-held electronic spirometer (PiKo-1, Ferraris Respiratory, Hertford, United Kingdom) and to report the highest value of 3 measurements in the morning before taking medication (2, 13). They were shown how to report these values on a personal page on a secure Web application by using a login password (or how to report by mobile telephone text message). Patients were also asked to report their nighttime and daytime asthma symptom scores on this Internet page or by text message. We asked all participants to complete the Asthma Control Questionnaire on their personal Internet page each week (14). We did not give any patients feedback about lung function or asthma control. After the 2-week baseline period, we randomly assigned participants to either the Internet group or the usual care group. We stratified according to care provider (primary vs. subspecialty care) and asthma control at baseline (15). We randomly assigned patients to the 2 groups (1:1 ratio) by using a computer-generated, permuted-block scheme. Allocation took place by computer after collection of the baseline data, ensuring concealment of allocation. The Internet-based self-management program consisted of the 4 principal components of asthma self-management and was accessed through the specially designed Web site, which allowed monitoring through the Web site (or text message on a mobile telephone), use of an Internet-based treatment plan, online education, and Web communications with a specialized asthma nurse (16). Patients monitored their asthma weekly by completing an electronic version of the Asthma Control Questionnaire on the Web site and instantly received feedback on the current state of their asthma control along with advice on how to adjust their treatment according to a predefined algorithm and treatment plan (Table 1 and Appendix Figures 1, 2, 3, 4, and 5). Depending on the scores submitted, patients received 4 types of self-treatment advice. When 4 consecutive Asthma Control Questionnaire scores were 0.5 or less, patients were advised to decrease treatment according to treatment plan. When 2 consecutive scores were greater than 0.5 but less than 1.0, patients were advised to increase treatment according to treatment plan. When 1 score was 1.0 or more but less than 1.5, patients were advised to immediately increase treatment according to treatment plan. Finally, when 1 score was 1.5 or more, patients were advised to immediately increase treatment and contact the asthma nurse. Table 1. Treatment Plan Appendix Figure 1. Algorithm based on consecutive ACQ scores to adjust medical treatment. * ACQ = Asthma Control Questionnaire. At entry of the algorithm, the evaluation period is bypassed. The evaluation period starts after treatment was stepped up. The optimal control period starts after 1 ACQ score 0.5 and ends after 1 ACQ score >0.5. Appendix Figure 2. Screen shot of daily lung function and symptom monitoring. Appendix Figure 3. Screen shot of feedback on daily lung function and symptom monitoring. Appendix Figure 4. Screen shot of weekly Asthma Control Questionnaire monitoring. Appendix Figure 5. Screen shot of feedback on Asthma Control Questionnaire, treatment advice according to personalized treatment plan, and results of past 6 months. We advised no medication changes during the 4 weeks after treatment was stepped up (evaluation period). In addition to weekly assessments, patients could optionally report daily symptoms and lung function and were able to contact our asthma nurse though the Web or by telephone. Thus, any acute deterioration warranting a visit to the general practitioner or hospital could be detected (Appendix Figures 2 and 3). We aimed to empower patients to use the Internet-based self-management tool and to develop a patientprovider partnership in asthma care (2). Self-management education consisted of both Web-based and face-to-face, group-based education. Web-based education included asthma information, news, frequently asked questions, and interactive communication with a respiratory nurse specialist. We scheduled 2 group-based education sessions, which lasted 45 to 60 minutes, for patients in the Internet-based self-management group within 6 weeks after entering the trial. Both sessions included exploration of a patient's interests and previous knowledge (negotiating an agenda and patient-centered education), personalized feedback, and empowerment of self-management (self-efficacy and implementing a plan for change) (2, 17). The first educational session also included pathophysiology of asthma, information on the Web-based action plan, and information and review of inhalation technique. The second educational session gave information about the mechanisms and side effects of medication and explained trigger avoidance. Patients in the usual care group received asthma care according to the Dutch general practice guidelines on asthma management in adults, which recommend a medical review and treatment adjustment every 2 to 4 weeks in unstable asthma and medical review once or twice yearly