Nearly one in every thirteen children has asthma, making it the most common chronic condition in childhood. For a variety of biological and environmental reasons, the prevalence of childhood asthma has risen dramatically in the past 20 years, with disproportionate effects on lowincome populations, minorities, and children living in inner cities. Much of the morbidity associated with childhood asthma, such as activity restrictions, missed school days, and emergency doctor visits, are preventable through appropriate management strategies. This Issue Brief summarizes evidence on the effectiveness of educational programs to improve self-management in children with asthma, and bolsters existing guidelines to include selfmanagement education in the routine care of these patients

Guevara, James P

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University of PennsylvaniaScholarlyCommonsIssue Briefs Leonard Davis Institute of Health Economics12-16-2003Self-Management Education of Children withAsthma: A Meta-AnalysisJames P. GuevaraFollow this and additional works at: http://repository.upenn.edu/ldi_issuebriefsThis paper is posted at ScholarlyCommons. http://repository.upenn.edu/ldi_issuebriefs/42For more information, please contact repository@pobox.upenn.edu.Guevara, James P.. Self-Management Education of Children with Asthma: A Meta-Analysis. LDI Issue Briefs. 2003; 9 (3).http://ldi.upenn.edu/brief/self-management-education-children-asthma-meta-analysisSelf-Management Education of Children with Asthma: A Meta-AnalysisAbstractNearly one in every thirteen children has asthma, making it the most common chronic condition inchildhood. For a variety of biological and environmental reasons, the prevalence of childhood asthma hasrisen dramatically in the past 20 years, with disproportionate effects on lowincome populations, minorities,and children living in inner cities. Much of the morbidity associated with childhood asthma, such as activityrestrictions, missed school days, and emergency doctor visits, are preventable through appropriatemanagement strategies. This Issue Brief summarizes evidence on the effectiveness of educational programs toimprove self-management in children with asthma, and bolsters existing guidelines to include selfmanagementeducation in the routine care of these patients.LicenseThis work is licensed under a Creative Commons Attribution-No Derivative Works 4.0 License.This brief is available at ScholarlyCommons: http://repository.upenn.edu/ldi_issuebriefs/42Leonard Davis Institute of Health EconomicsLDI Issue BriefVolume 9, Number 3November / December 2003James P. Guevara, MD, MPHLDI Senior Fellow;Assistant Professor of Pediatrics,University of PennsylvaniaChildren’s Hospital ofPhiladelphiaGuidelines encourageeducating patients aboutmanaging their asthma,but effectiveness inchildren is unknownContinued on next page.Self-management education of children withasthma: a meta-analysisEditor’s note:  Nearly one in every thirteen children has asthma, making itthe most common chronic condition in childhood.  For a variety of biologicaland environmental reasons, the prevalence of childhood asthma has risendramatically in the past 20 years, with disproportionate effects on low-income populations, minorities, and children living in inner cities.  Much ofthe morbidity associated with childhood asthma, such as activity restrictions,missed school days, and emergency doctor visits, are preventable throughappropriate management strategies. This Issue Brief summarizes evidence onthe effectiveness of educational programs to improve self-management inchildren with asthma, and bolsters existing guidelines to include self-management education in the routine care of these patients.Despite clinical advances in the understanding of asthma and its treatment,morbidity and mortality from asthma continue to rise.  In response to thisparadox, most experts have emphasized the importance of educatingphysicians on optimal treatment through clinical guidelines, and educatingpatients and families about the management of asthma.• Educational programs aimed at adults with asthma that include self-monitoring, regular medical care, and an asthma action plan have beenshown to improve health outcomes, but the effects of such programs forchildren have been mixed.• Education of children and families by information transfer alone (i.e.,patient handouts) is ineffective.  A previously published review in 1992found that asthma educational programs for children do not affectoutcomes, but the review was based on a small number of studies.• Since the 1992 review, asthma education programs that teach patients skillsin self-management have shown some promise.  These programs arehighly varied.  They can be based in clinics, schools, or the community,or on home visits, and consist of individual or group sessions, single orMeta-analysis of studiesincludes 32 trials and3,706 childrenEducational programs forchildren with asthmaimprove lung function,and reduce number ofschool days missedmultiple sessions, and a variety of educational techniques designed toimprove attack management, disease prevention, or social skillsdevelopment.• Guevara and colleagues attempted to synthesize all existing evidence todate to determine the effectiveness of these educational programs.Meta-analysis is a procedure for combining the results from many differentstudies.  The investigators identified all clinical trials between 1980 and 1998that tested educational interventions in self-management for children aged 2-18.  They identified 45 trials, 32 of which were eligible for the review, basedon adequate comparisons with control groups, and reporting of outcomessuch as pulmonary function tests, morbidity, or health care utilization.• The 32 trials included 3,706 children and adolescents with asthma.  Mostwere relatively small randomized controlled trials and enrolled childrenwith severe asthma.• Fifteen trials enrolled adolescents aged 13-18, and 12 enrolled childrenaged 2-5; no study reported data by age.• The educational programs were diverse and targeted children, parents, orboth.  Most programs used multiple sessions and taught strategies based onself-monitoring of symptoms. Whereas all trials focused on asthmaprevention measures (e.g., identification and avoidance of asthma triggers)and/or management of asthma attacks (e.g., use of an asthma action plan),13 trials incorporated social skills development into the educationalstrategy.• Because studies presented outcomes using a variety of different units, theinvestigators standardized all outcomes in terms of an “effect size.”Significant effects were characterized as modest, moderate, or large.This updated review of the evidence indicates that educational interventionsto improve self-management of asthma are associated with improvements in awide range of outcomes.• Four trials (258 patients) had complete data on measures of lung function.Education was associated with moderate improvement in lung function.• Eighteen trials (1,649 patients) had complete data on measures ofmorbidity. Education was associated with modest reductions in schoolabsences, night disturbances, and days of restricted activity.  The beneficialeffects of education were more pronounced among trials of moderate-severe asthma than among those of mild-moderate asthma.• Nine trials (522 patients) had complete data on patients’ perceptions ofself-control over asthma (self-efficacy).  Education was associated withContinued on back.Results suggest programcharacteristics that workbestPOLICY IMPLICATIONSmoderate improvements in perceived self-control, but had no effect onthe number or types of symptoms reported.• Eighteen trials (1,899 patients) had complete data on health careutilization.  Education was associated with a modest reduction inemergency department visits, but had no effect on the number ofhospitalizations.• Overall, significant effects on lung function were seen within the first sixmonths, but for measures of morbidity and health care utilization, effectswere greater by 12 months.The investigators attempted to assess the characteristics of programs that wereassociated with better outcomes.  However, no studies involved directcomparisons between educational components, and thus the findings remainsuggestive.• Programs that incorporated individual sessions with patients and familieshad the greatest reductions in morbidity measures, whereas programs thatutilized a group format for teaching had the greatest reductions inhospitalizations.• Programs with a single session had the greatest reduction in morbiditymeasures, whereas those with multiple sessions had the greatestimprovement in self-efficacy and the greatest reduction in number of visitsto the emergency department.• Programs that taught self-monitoring using objective measures of lungfunction, such peak-flow diaries, rather than symptom tracking, had thegreatest improvement in lung function and the greatest improvements inmorbidity measures.This systematic review and meta-analysis provides objective evidence tosupport national and professional guidelines on the use of educationalstrategies to enhance self-management in children with asthma.  It shouldalso encourage payers to provide reimbursement for effective asthmaeducation programs in children.• Incorporating educational programs for self management into the routinecare of children with asthma may significantly improve outcomes.Although selection of a program may depend on cost and availability,efforts should be made to incorporate models that are known to work.Priority should be given to patients with severe asthma, and educationshould be provided long term to account for changing needs.This Issue Brief is based on the following articles:  J.P. Guevara, F.M. Wolf, C.M. Grum, N.M. Clark.  Effects of Educational Interventionsfor Self Management of Asthma in Children and Adolescents: Systematic Review and Meta-analysis.  British Medical Journal, June 14,2003, vol. 326, pp. 1308-1312; see also F.M. Wolf, J.P. Guevara, C.M. Grum, N.M.Clark, C.J. Cates. Educational Interventions forAsthma in Children (Cochrane Review). In: The Cochrane Library, Issue 2 2003. Oxford: Update Software.Published by the Leonard Davis Institute of Health Economics, University of Pennsylvania, 3641 Locust Walk, Philadelphia, PA 19104-6218.Janet Weiner, MPH, Associate Director for Health Policy, EditorDavid A. Asch, MD, MBA, Executive DirectorIssue Briefs synthesize the results of research by LDI’s Senior Fellows, a consortium of Penn scholars studying medical, economic, and social andethical issues that influence how health care is organized, financed, managed, and delivered in the United States and internationally. The LDIis a cooperative venture among Penn schools including Dental Medicine, Medicine, Nursing and Wharton, and the Children’s Hospital ofPhiladelphia. For additional information on this or other Issue Briefs, contact Janet Weiner (e-mail: weinerja@mail.med.upenn.edu; 215-573-9374).Nonprofit OrganizationU.S. PostageP  A  I  DPermit No. 2563Philadelphia, PA 19104Issue Brief Published by theLeonard Davis Instituteof Health EconomicsUniversity of Pennsylvania3641 Locust WalkPhiladelphia, PA 19104-6218215.898.5611fax 215.898.0229ADDRESS CORRECTION REQUESTED© 2003 Leonard Davis InstitutePOLICY IMPLICATIONSContinuedVisit us on the web at www.upenn.edu/ldi• Successful programs tend to be conceptually-based and multifaceted.Two of the more well-known programs are “Air Wise,” a jointeducational program targeting parents, children, and providers andutilizing four one-on-one sessions to individualize a care program, and“Asthma Care Training (ACT),” a group program of five sessions forparents and children that teaches asthma knowledge, environmentalcontrol, relaxation skills, and decision-making using a traffic lightanalogy.• Future studies should test alternative components of educationalprograms directly to determine their relative effectiveness.  For example,studies should compare strategies aimed at the individual with thoseaimed at the group, and strategies based on peak flow with those basedon symptoms.• There is not enough evidence to determine the optimal programs at eachdevelopmental stage and age.  More research is needed to identify effective,developmentally appropriate programs.

Self-Management Education of Children with Asthma: A Meta-Analysis

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Self-Management Education of Children with Asthma: A Meta-Analysis

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