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Internet-Based Self-management Plus Education Compared With Usual Care in Asthma: A Randomized Trial

Victor van der Meer, MD; Moira J. Bakker, RN; Wilbert B. van den Hout, PhD; Klaus F. Rabe, MD, PhD; Peter J. Sterk, MD, PhD; Job Kievit, MD, PhD; Willem J.J. Assendelft, MD, PhD; Jacob K. Sont, PhD, SMASHING (Self-Management in Asthma Supported by Hospitals, ICT, Nurses and General Practitioners) Study Group
[+] Article and Author Information

International Standard Randomized Controlled Trial number: ISRCTN79864465.


From Leiden University Medical Center, Leiden, and University of Amsterdam, Amsterdam, the Netherlands.


Acknowledgment: The authors thank Professor E.F. Juniper for the permission to use a Web-based version of the Asthma Control Questionnaire. The SMASHING (Self-Management of Asthma Supported by Hospitals, ICT, Nurses and General Practitioners) Study Group consists of W.J.J. Assendelft, H.A. Thiadens, M.J. Bakker, W.B. van den Hout, J. Kievit, V. van der Meer, J.K. Sont, A.A. Kaptein, E.R.V.M. Rikkers-Mutsaerts, K.F. Rabe, E.H.D. Bel, P.J. Sterk, S.B. Detmar, W. Otten, H.F. van Stel, A.C. Roldaan, J.C. de Jongste, and P.J. Toussaint.

Grant Support: By the Netherlands Organization for Health Research and Development (ZonMw grants 945-04-061 and 920-03-354) and Netherlands Asthma Foundation (grant 3.4.03.45).

Potential Financial Conflicts of Interest:Grants received: V. van der Meer (Netherlands Organization for Health Research and Development), W.B. van den Hout (Netherlands Asthma Foundation, Netherlands Organization for Health Research and Development), J.K. Sont (Netherlands Asthma Foundation, Netherlands Organization for Health Research and Development). Grants pending: W.B. van den Hout (Netherlands Asthma Foundation, Netherlands Organization for Health Research and Development), J.K. Sont (Netherlands Asthma Foundation, Netherlands Organization for Health Research and Development).

Reproducible Research Statement:Study protocol: Available from Dr. van der Meer (e-mail, v.van_der_meer@lumc.nl). Statistical code and data set: Available through written agreements with Dr. van der Meer (e-mail, v.van_der_meer@lumc.nl).

Requests for Single Reprints: Victor van der Meer, MD, Leiden University Medical Center, Postzone J-10-s, Room J-10-87, Albinusdreef 2, PO Box 9600, 2300 RC Leiden, the Netherlands; e-mail, v.van_der_meer@lumc.nl.

Current Author Addresses: Drs. van der Meer, van den Hout, Kievit, and Sont and Ms. Bakker: Department of Medical Decision Making, Postzone J-10-S, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, the Netherlands.

Dr. Rabe: Department of Pulmonology, Postzone C-3-P, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, the Netherlands.

Dr. Sterk: Department of Respiratory Medicine, Postbus 22660, 1100 DD, Amsterdam, the Netherlands.

Dr. Assendelft: Department of Public Health and Primary Care, Postzone V-0-P, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, the Netherlands.

Author Contributions: Conception and design: V. van der Meer, W.B. van den Hout, K.F. Rabe, P.J. Sterk, J. Kievit, W.J.J. Assendelft, J.K. Sont.

Analysis and interpretation of the data: V. van der Meer, W.B. van den Hout, J. Kievit, J.K. Sont.

Drafting of the article: V. van der Meer,W.B. van den Hout, J. Kievit, J.K. Sont.

Critical revision of the article for important intellectual content: V. van der Meer, M.J. Bakker, W.B. van den Hout, K.F. Rabe, P.J. Sterk, J. Kievit, W.J.J. Assendelft, J.K. Sont.

Final approval of the article: V. van der Meer, M.J. Bakker, W.B. van den Hout, K.F. Rabe, P.J. Sterk, W.J.J. Assendelft, J.K. Sont.

Provision of study materials or patients: V. van der Meer, M.J. Bakker, J. Kievit, J.K. Sont.

Statistical expertise: V. van der Meer, W.B. van den Hout, J.K. Sont.

Obtaining of funding: V. van der Meer, J.K. Sont.

Administrative, technical, or logistic support: V. van der Meer, M.J. Bakker, J.K. Sont.

Collection and assembly of data: V. van der Meer, M.J. Bakker, W.J.J. Assendelft, J.K. Sont.


Ann Intern Med. 2009;151(2):110-120. doi:10.7326/0003-4819-151-2-200907210-00008
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We invited the 930 patients who met the selection criteria to participate in the study. Patients who consented to participate (n = 200 [21.5%]) did not differ from nonparticipants in age (mean age, 36.6 years vs. 35.8 years; P = 0.27) or socioeconomic status (living in an underprivileged area, 5.0% vs. 7.1%; P = 0.29), but they did differ in sex (women, 69.5% vs. 59.7%; P = 0.012). Baseline characteristics of the randomization groups were similar (Table 2).

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Figures

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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.

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Appendix Figure 2.
Screen shot of daily lung function and symptom monitoring.
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Appendix Figure 3.
Screen shot of feedback on daily lung function and symptom monitoring.
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Appendix Figure 4.
Screen shot of weekly Asthma Control Questionnaire monitoring.
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Appendix Figure 5.
Screen shot of feedback on Asthma Control Questionnaire, treatment advice according to personalized treatment plan, and results of past 6 months.
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Figure 2.
Changes in mean Asthma Quality of Life Questionnaire score (A), Asthma Control Questionnaire score (B), FEV1 (C), and daily inhaled corticosteroid dose (D) during 1-year follow-up for the Internet and usual care groups.

The minimal important difference for the Asthma Quality of Life Questionnaire is 0.5, with higher scores indicating better quality of life. The minimal important difference for the Asthma Control Questionnaire is 0.5, with lower scores indicating better asthma control. Plotted values are based on complete cases. Error bars indicate 95% CIs. P values are shown for between-group differences in change in scores at 12 months and are from linear mixed-effects models.

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Figure 3.
Distribution of change in scores for Asthma Quality of Life Questionnaire (top) and Asthma Control Questionnaire (bottom).

δ = 12-month score minus baseline score. The minimal important difference for the Asthma Quality of Life Questionnaire is 0.5, with higher scores indicating better quality of life. The minimal important difference for the Asthma Control Questionnaire is 0.5, with lower scores indicating better asthma control.

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Internet access in a metropolitian asthma disease state management program
Posted on December 5, 2009
Glenn R. Singer
Broward Health
Conflict of Interest: None Declared

Internet-Based Self-management Plus Education Compared With Usual Care in Asthma-the Internet Is Not Available to Everyone in 2009

To the Editor: We read with great interest the article by van der Meer and colleagues on Internet-Based Self- management Plus Education Compared With Usual Care in Asthma (1). Certainly, as noted by the authors self management is a key component of asthma care.

Using the internet has the potential to be an important tool for communication and education. We questioned whether this tool would be available with a more diverse population in our Asthma Disease State Management Program at Broward Health, Fort Lauderdale, Florida.

The Asthma Disease State Management Program at Broward Health is responsible for the care and treatment of unfunded patients within a population of 1 .7 million people. We previously demonstrated that intervention using a case manager approach improved quality of life and reduced expenditure in an asthma population (2).

We surveyed 152 asthma patients who are currently in our asthma program. Patients are referred to the program by emergency department and hospital case managers. We asked these patients what means of communication are available for introduction to disease state management and subsequent education. Options were mail, cell or land line telephone, internet and face to face meetings.

Communication Options Table I

MAIL TELEPHONE INTERNET FACE TO FACE Literature sent to all 152 patients Called all 152 patients 1 Patient (0.7%) had internet access Attempts were made to contact all 152 patients for person to person asthma education appointments 30 letters were returned due to wrong address 18 (12%) were non-working numbers 33 (24%) were met in person

35 (23%) were not answered

38 (25%) were answered by patient, parent, or guardian

49 (32%) were left messages on answering service

12 (8%) were answered by relative or friend

These results highlight the challenges to asthma education and follow up in an urban setting. In a culturally diverse disease state management program, case managers may need to employ methodologies other than internet to help with education and appropriate use of controller medications.

References

1. van der Meer, V, Bakker, MJ, van den Rout, WB, Rabe, KF, et al. Internet-Based Self-management Plus Education Compared With Usual Care in Asthma. Ann Intern Med. 2009; 151: 110-120.

2. Singer, GR, Kessler, L, Martinez, RJ, Gonzalez, GE. Improved quality of life and reduced healthcare expenditure in an innercity asthma population. Abstract. ATS International Conference. San Francisco, CA 2007. (No conflicts of interest)

Conflict of Interest:

None declared

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Summary for Patients

Internet-Based Program to Assist Patients in Asthma Care

The summary below is from the full report titled “Internet-Based Self-management Plus Education Compared With Usual Care in Asthma. A Randomized Trial.” It is in the 21 July 2009 issue of Annals of Internal Medicine (volume 151, pages 110-120). The authors are V. van der Meer, M.J. Bakker, W.B. van den Hout, K.F. Rabe, P.J. Sterk, J. Kievit, W.J.J. Assendelft, and J.K. Sont, for the SMASHING (Self-Management in Asthma Supported by Hospitals, ICT, Nurses and General Practitioners) Study Group.

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