Faculdade de Medicina da Universidade do Porto Introdução à Medicina

Faculdade de Medicina da Universidade do PortoIntrodução à MedicinaFaculdade de Medicina da Universidade do PortoIntrodução à Medicina

ASTHMAASTHMA

Is home monitoring more effectivethan usual care?Is home monitoring more effectivethan usual care?

Class 19

Coordinator: Dr. João Fonseca

INTRODUCTIONINTRODUCTION

ASTHMAASTHMA

chronic inflammatory disorder of the airways1chronic inflammatory disorder of the airways1

chronically inflamed airways arehyperresponsive; they become obstructed andairflow is limited (by bronchoconstriction,mucus plugs, and increased inflammation)when airways are exposed to various riskfactors1chronically inflamed airways arehyperresponsive; they become obstructed andairflow is limited (by bronchoconstriction,mucus plugs, and increased inflammation)when airways are exposed to various riskfactors1

1. “Pocket Guide for Asthma Management and Prevention” www.ginasthma.com

BackgroundBackground

300 million people worldwide now have asthma1300 million people worldwide now have asthma1

His control is possible, but it isn’t accomplished inmost cases:His control is possible, but it isn’t accomplished inmost cases:

- 75% of asthma admissions are avoidable2- 75% of asthma admissions are avoidable2

- 40% of asthma patients don’t react properly when theirsymptoms worsen2- 40% of asthma patients don’t react properly when theirsymptoms worsen2

- 50% of asthma patients admitted with acute asthmahave had alarming symptoms a week before admission2- 50% of asthma patients admitted with acute asthmahave had alarming symptoms a week before admission2

- 60% of asthma patients are poor at judging theirdyspnoea2- 60% of asthma patients are poor at judging theirdyspnoea2

1. Global Burden of Asthma Repor

2. Guided self management of asthma - how to do it. Aarzne Lahdensuo

Rationale behind our aimRationale behind our aim

Monitorization between observations at medicalfacilities may:Monitorization between observations at medicalfacilities may:

–detect early negative events–detect early negative events

–provide a better insight to the variations of the disease–provide a better insight to the variations of the disease

–foster patients participation in their own care.–foster patients participation in their own care.

Insufficiently known methods and patients’characteristics that have better outcomes withhome monitoringInsufficiently known methods and patients’characteristics that have better outcomes withhome monitoring

It is necessary summarize the information of thestudiesIt is necessary summarize the information of thestudies

Systematic reviewSystematic review

–address a specific clinical question 1–address a specific clinical question 1

–require a comprehensive literature search, 1–require a comprehensive literature search, 1

–use explicit selection criteria to identify relevantstudies1–use explicit selection criteria to identify relevantstudies1

–assess the methodologic quality of includedstudies1–assess the methodologic quality of includedstudies1

–explore differences among study results1–explore differences among study results1

1. Montori VM, Swiontkowski MF, Cook DJ. Methodologic issues in systematic reviews andmeta-analyses.

AIMAIM

Primary aim: summarize the available controlledstudies about the clinical benefits of asthmapatients to monitoring their disease outsidemedical facilities (home monitoring / self-monitoring)Primary aim: summarize the available controlledstudies about the clinical benefits of asthmapatients to monitoring their disease outsidemedical facilities (home monitoring / self-monitoring)

Secondary aim: to compare the clinical efficacyof different techniques of home monitoringSecondary aim: to compare the clinical efficacyof different techniques of home monitoring

METHODS

Randomised controlled studiesRandomised controlled studies

Indexed at SCOPUS and MedlineIndexed at SCOPUS and Medline

Assessing the benefits of using homemonitoring in patients with asthmaAssessing the benefits of using homemonitoring in patients with asthma

Literature researchLiterature research

PubmedPubmed

(asthm*[MeSH] OR asthm*[TIAB]) (asthm*[MeSH] OR asthm*[TIAB])

ANDAND

(((clinical[Title/Abstract] AND trial[Title/Abstract]) OR clinicaltrials[MeSH Terms] OR clinical trial[Publication Type] ORrandom*[Title/Abstract] OR random allocation[MeSH Terms] ORtherapeutic use[MeSH Subheading]))(((clinical[Title/Abstract] AND trial[Title/Abstract]) OR clinicaltrials[MeSH Terms] OR clinical trial[Publication Type] ORrandom*[Title/Abstract] OR random allocation[MeSH Terms] ORtherapeutic use[MeSH Subheading]))

AND AND

(("self management"[TIAB] OR ("self care"[TIAB] OR “selfcare”[MeSH]) OR “self-monitoring”[TIAB])(("self management"[TIAB] OR ("self care"[TIAB] OR “selfcare”[MeSH]) OR “self-monitoring”[TIAB])

ANDAND

("peak-flow-meter"[TIAB] OR (spirometry[TIAB] ORspirometry[MeSH]) OR telemedicine[TIAB] OR "communicationtecnhologies"[TIAB] OR ehealth[TIAB] OR “home automatedtelemanagement”[TIAB] OR Internet*[TIAB] OR mobile[TIAB]))("peak-flow-meter"[TIAB] OR (spirometry[TIAB] ORspirometry[MeSH]) OR telemedicine[TIAB] OR "communicationtecnhologies"[TIAB] OR ehealth[TIAB] OR “home automatedtelemanagement”[TIAB] OR Internet*[TIAB] OR mobile[TIAB]))

Limits: Publication Date 1996-2005, English, RandomizedControlled Trial, HumansLimits: Publication Date 1996-2005, English, RandomizedControlled Trial, Humans

ScopusScopus

TITLE-ABS-KEY(*asthma)TITLE-ABS-KEY(*asthma)

ANDAND

((TITLE-ABS-KEY("self-management" OR "self care"OR "self-monitoring"))((TITLE-ABS-KEY("self-management" OR "self care"OR "self-monitoring"))

ANDAND

(TITLE-ABS-KEY("peak-flow-meter" OR spirometryOR telemedicine OR "communication technologies"OR ehealth OR "home outomated telemanagement"OR internet OR mobile))(TITLE-ABS-KEY("peak-flow-meter" OR spirometryOR telemedicine OR "communication technologies"OR ehealth OR "home outomated telemanagement"OR internet OR mobile))

AND TITLE-ABS-KEY(random* OR trial OR control*)) AND TITLE-ABS-KEY(random* OR trial OR control*))

Limits: DOCTYPE "ar" AND PUBYEAR 1996-2005Limits: DOCTYPE "ar" AND PUBYEAR 1996-2005

FlowchartFlowchart

FAZER HIPERLIGAÇÂOFAZER HIPERLIGAÇÂO

Inclusion criteriaInclusion criteria

•Articles which describe and evaluate the health care ofpatients outside hospital, with asthma•Articles which describe and evaluate the health care ofpatients outside hospital, with asthma

•Articles which compare the clinical outcomes ofchildren and adults with asthma that performed self-monitoring with those who do not performed self-monitoring•Articles which compare the clinical outcomes ofchildren and adults with asthma that performed self-monitoring with those who do not performed self-monitoring

•Not related with our aim•Not related with our aim

Intervention onlyIntervention only

Pharmacologic treatment;Pharmacologic treatment;

Exclusively turned to education ofpatients and professionalsExclusively turned to education ofpatients and professionals

•No control groups•No control groups

•Non-randomized•Non-randomized

Exclusion criteriaExclusion criteria

Data gatheringData gathering

Article data were registered on tables inRevMan and ExcelArticle data were registered on tables inRevMan and Excel

RESULTSRESULTS

Articles selectionArticles selection

Excluded articlesExcluded articles

Summary of excluded articlesSummary of excluded articles

12 articles – not related with our aim12 articles – not related with our aim

5 articles – not RCT5 articles – not RCT

2 articles – no control group2 articles – no control group

2 articles – full text article not available2 articles – full text article not available

Identification of included articlesIdentification of included articles

ArticleID

Author

Tittle

Date ofpublication

Journal/Book/Source

Rasmussen, L.M.,Phanareth, K., Nolte,H., Backer, V..

Internet-based monitoring of asthma: Along-term, randomized clinical study of 300asthmatic subjects.

2005

Journal of Allergy and ClinicalImmunology

Ostojic, V., Cvoriscec,B., Ostojic, S.B.,Reznikoff, D., Stipic-Markovic, A.,Tudjman, Z..

Improving asthma control throughtelemedicine: A study of short-messageservice.

2005

Telemedicine Journal and e-health

Wensley, D.,Silverman, M..

Peak flow monitoring for guided self-mamagement in childhood asthma: Arandomized controlled trial

2004

American Journal of Respiratory andCritical Care Medicine

Turner MO, Taylor D,Bennett R, FitzgeraldJM..

A randomized trial comparing peakexpiratory flow and symptom self-management plans for patients with asthmaattending a primary care clinical.

1998,Feb

AM J Respir Crit Care Med

Adams, R.J., Beath,K., Homan, S.,Campbell, D.A.,Ruffin, R.E..

A randomized trial of peak-flow andsymptom-based action plans in adults withmoderate-to-severe asthma

2001

Respirology

General information of included articlesGeneral information of included articles

Study

Design

Participants

Interventions

Outcomes

Study completion

1Rasmussen

L.M., 2005

RCT

300 asthmaticsubjects

-questionaries, -spirometry,-measurement ofairwayresponsiveness-internet basedmonitoring

-symptoms, -quality of life, -lungfunction,-air responsiveness

2 Ostojic, V,

2005

RCT

16 asthmaticsubjects

-office visits-1 hour asthmaeducation sessionwith a specialist atthe clinic-PEF was to bedetermined threetimes per day-asthma monitoringby GSM and SMS

-Events during study period, -Average symptom score, -spirometry,-PEF by time of day (L/min),-PEF variability, -Dailyconsumption of inhaledmedication, Cost ofmonitoring (per week, perpatient) (money and time

3 Wensley,

D., 2004

RCT

90 asthmaticchildren

-spirometry

-quality of life -self-management

Among 90 participants only one withdrawaled

4 Turner

MO, 1998

RCT

92 asthmaticadults

-asthma education-peak expirotoryflow-Symptom self-management plans

-ED visits and/or hospitalization forasthma unscheduled -doctorvisits, -days absent fromschool or work courses ofprednisone and respiratorytract infections

5 Adams

R.J., 2001

RCT

134 asthmaticadults(82femalesand 52males)

-symptom-based actionplans -peakexpiratory flow

-quality of life -self-management

From the original group of one 134 patients, 21(15%)completed between 3 and 5 months of follow-up, 25(19%) between 6 and 11 months and88(66%) completed the 12 months of follow-up. Among those patients who discontinuedthe study prior to 12 months 30 gave up due tolack of interest.

Methods of included articlesMethods of included articles

Results of included articlesResults of included articles

Summary of resultsSummary of results

Clinical benefits of asthma patients tomonitoring their disease outside medicalfacilities:Clinical benefits of asthma patients tomonitoring their disease outside medicalfacilities:

––Turner MO, 1998 – positive

––Rasmussen L.M., 2005 – positive

––Ostojic, V, 2005 - positive

Clinical efficacy of different techniques ofhome monitoring:Clinical efficacy of different techniques ofhome monitoring:

––Turner MO, 1998 – no significative differences

––Wensley, D., 2004 – no significative differences

––Adams R.J., 2001 – no significative differences

ACKNOWLEDGEMENTSACKNOWLEDGEMENTS

We would like to thank:We would like to thank:

 Dr. João Fonseca because he helped usduring our work Dr. João Fonseca because he helped usduring our work

Professor Altamiro da Costa Pereira forshowing us what we should change.Professor Altamiro da Costa Pereira forshowing us what we should change.