A Pilot Study of Telephone-Based Asthma Management
- SourceAvailable from: ncbi.nlm.nih.gov[Show abstract] [Hide abstract]
ABSTRACT: Improper inhaler technique is a common problem affecting asthma control and healthcare costs. Telephonic asthma management can increase access to care while reducing costs and hospitalizations. However, no reliable method has been established for telephonically evaluating and correcting inhaler technique. The purpose of this study was to pilot test a method for assessing and correcting patient inhaler technique via telephone. Participants (n=30) were adults with asthma using metered-dose inhalers (MDIs) and diskus inhalers. A pharmacist was located in one room and communicated via telephone with a participant in another room. The pharmacist telephonically assessed and taught inhaler technique. Participants were video-recorded, and videos were later examined by a second pharmacist to visually evaluate inhaler technique. Participants were assigned pre- and posteducation inhaler technique scores for the telephonic and video assessments. Scores were based on summated scales for MDI (0-9) and diskus (0-11) inhalers. Paired samples t-tests were used to compare telephone and video assessments. Findings indicated a significant difference between the telephone and video assessments of MDI technique (p<0.05); however, no difference was found for the diskus inhaler. Comparing pre- and posteducation inhaler technique for MDI and diskus, mean scores significantly improved from 5.7 to 7.8 (p<0.05) and from 8.5 to 10.4 (p<0.05), respectively. The telephonic method was able to improve and detect some deficiencies in patients' inhaler technique. However, modifications and further investigation will more clearly determine the role and value of such a telephonic intervention.Telemedicine and e-Health 09/2011; 17(9):734-40. · 1.40 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: Telehealthcare has the potential to provide care for long-term conditions that are increasingly prevalent, such as asthma. We conducted a systematic review of studies of telehealthcare interventions used for the treatment of asthma to determine whether such approaches to care are effective. We searched the Cochrane Airways Group Specialised Register of Trials, which is derived from systematic searches of bibliographic databases including CENTRAL (the Cochrane Central Register of Controlled Trials), MEDLINE, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature) and PsycINFO, as well as other electronic resources. We also searched registers of ongoing and unpublished trials. We were interested in studies that measured the following outcomes: quality of life, number of visits to the emergency department and number of admissions to hospital. Two reviewers identified studies for inclusion in our meta-analysis. We extracted data and used fixedeffect modelling for the meta-analyses. We identified 21 randomized controlled trials for inclusion in our analysis. The methods of telehealthcare intervention these studies investigated were the telephone and video- and Internet-based models of care. Meta-analysis did not show a clinically important improvement in patients' quality of life, and there was no significant change in the number of visits to the emergency department over 12 months. There was a significant reduction in the number of patients admitted to hospital once or more over 12 months (risk ratio 0.25 [95% confidence interval 0.09 to 0.66]). We found no evidence of a clinically important impact on patients' quality of life, but telehealthcare interventions do appear to have the potential to reduce the risk of admission to hospital, particularly for patients with severe asthma. Further research is required to clarify the cost-effectiveness of models of care based on telehealthcare.Canadian Medical Association Journal 08/2011; 183(11):E733-42. · 6.47 Impact Factor
- Iranian Journal of Pediatrics 12/2012; 22(4):575-6. · 0.26 Impact Factor
170 Reprinted from AustRAliAn FAmily PhysiciAn Vol. 37, No. 3, March 2008
Karen J Donald
PhD, is Lecturer, School of Physiotherapy,
La Trobe University, Victoria. k.donald@
PhD, is Associate Professor,
School of Physiotherapy, La Trobe
MBBS(Hons), FRACP, is Director, Department
of Respiratory and Sleep Disorders Medicine,
Western Hospital, Victoria.
MBBS, FRACP, is Director,
Department of Respiratory Medicine,
Royal Melbourne Hospital, Victoria.
Asthma self management – including education, regular
review, provision of peak expiratory flow meter (PEFm) and
preparation of a written asthma action plan (AAP) – is an
important element of optimal asthma management.1 Asthma self
management programs that include most of these components
result in clinically and statistically significant improvements in
asthma health outcomes.2 self management programs have
been particularly recommended for adults recently admitted to
hospital or recently attending emergency departments because
of asthma. this group is not only over-represented in mortality
and morbidity statistics, but are also more likely to be
re-admitted to hospital than any other group of asthmatics,3 and
therefore have most to gain from optimal asthma management.
Telephone based management has been trialled for a number of chronic
conditions such as diabetes,4,5 depression,6 hyperchloesterolaemia,7
and general medical problems,8 with telephone calls used to confirm
adherence to medications and management plans, monitoring, and to
discuss questions and provide advice.
Self management needs to be time and cost efficient for both the
patient and practitioner. Telephone based sessions reduce the time and
money spent by the patient travelling to appointments.6 Calls can be
scheduled around family and work commitments and can be delivered
more frequently than a consultation at a clinic or hospital.8
Care or follow up delivered by telephone achieved comparable if
not improved outcomes to medication and self monitoring regimens
alone.7 A recent study9 in the United Kingdom examined the use of
telephone based review compared with face-to-face consultation
with a practice nurse and found that telephone based management
offered a well accepted and more time efficient way of delivering
routine asthma reviews.
To date the authors are unaware of any trials in Australia that
examine telephone based intervention for either review or ongoing
Self management programs have been advocated for adults who
have recently been admitted to hospital or have recently attended an
emergency department because of asthma. A new telephone based
approach has already been trialled for the management of a number of
other chronic conditions. This study sought to determine the effect of a
telephone based asthma management program for adults with asthma.
Adults with one or more previous admissions for asthma to either or
both of two tertiary hospitals between 1 May 2001 and 30 November
2003 were invited to participate. All participants received one face-to-
face session with an asthma educator. Participants were randomised
to intervention (six telephone calls over 6 months) or control (usual
care) groups. Measures of health care utilisation and morbidity were
collected weekly for 12 months.
Seventy-one adults (54 females) with a mean age of 36.2 years
were recruited to the study. Twenty hospital re-admissions were
recorded for the control group and one for the intervention group at
12 months. Re-admission was significantly associated with allocation
to control group (p=0.05). The control group was significantly more
likely to report being woken by asthma on more than half the nights
of the week (p=0.03).
Telephone based self management intervention results in clinically
important reductions in hospital re-admission in adults previously
hospitalised with asthma.
A pilot study of telephone based
Reprinted from AustRAliAn FAmily PhysiciAn Vol. 37, No. 3, March 2008 171
PhD, is Professor, Monash Institute
of Health Services Research, Monash
MD, FRACP, is Deputy Director,
Department of Respiratory Medicine,
Royal Melbourne Hospital, Victoria.
BN, is Project Officer, National
Asthma Council Australia, Victoria.
RN, is Clinical Research Nurse, Department
of Respiratory and Sleep Disorders Medicine,
Western Hospital, Victoria.
Adults aged 18–55 years admitted to one or both of two metropolitan
Melbourne (Victoria) teaching hospitals with a primary diagnosis of
asthma during the 30 month period from 1 May 2001 to 30 November
2003 were invited to participate. (The upper age limit was set
to exclude participants for whom a diagnosis of chronic obstructive
airways disease [COPD] and asthma may have been difficult
Adults were excluded if they had a chronic respiratory condition
other than asthma, an unstable medical condition, a cognitive or
intellectual disability, psychiatric illness (not including depression) or
were unable to speak or read English.
Ethics approval was granted by La Trobe University Faculty of Health
Sciences and Melbourne Health Directorate Human Ethics Committees.
All participants gave written consent.
Procedures at recruitment
Participants’ age, gender, smoking history, age at onset of asthma
and previous hospital admissions were recorded at recruitment.
Participants were asked whether they had ever received any
counselling by a psychiatrist, psychologist or trained counsellor, and
whether they owned a current written AAP (no longer than 2 years
since issue) and/or a PEFM.
All participants received an AirZone PEFM and identical instructions
on how to use the PEFM and record their results. This record (kept for
up to 1 week) was used by the asthma nurse educator to determine the
participant’s personal best PEFR.
Face-to-face sessions and follow up
Participants were randomised into control and intervention groups.
All participants attended a face-to-face session with an asthma nurse
educator and received asthma management advice based on their
existing knowledge of the pathophysiology of asthma, medications,
known triggers and asthma self management. Participants were
provided with a written AAP10 or advised to obtain one from
their general practitioner if they did not already have a current or
appropriate AAP. All participants’ GPs were informed about their
patient’s involvement in the study.
Control group participants were encouraged to continue with
asthma self management and usual GP care following the face-to-
face session. The asthma educators made six follow up telephone
calls to all intervention participants: one call each week for the first 4
weeks, another at 3 months, and one more at 6 months. During these
calls, participants were asked about and given advice regarding their
current asthma symptoms and management.
All participants (both control and intervention) were telephoned
weekly by a researcher (blinded to participant allocation) for the
12 month study period and were asked about the frequency of
nocturnal waking, days lost from work or study, unplanned visits to
the GP or emergency department, hospital admissions and use of
oral corticosteroids due to asthma in the week before the call. No
advice regarding asthma management was given during these calls.
Questionnaires at 6 and 12 months asked participants if they owned
and used a written AAP.
It was calculated that a sample of 100 participants (50 intervention
and 50 control) would provide an 80% chance of correctly identifying
a moderate effect size at α=0.05. SPSS version 11.5 was used for all
analyses. Statistical significance was set at p<0.05.
Pearson’s chi-square test and independent sample t-test were
used to test for differences between the intervention and control
groups in the number of participants reporting and the mean number of
hospital admissions, unplanned GP visits and emergency department
attendance, occasions of oral steroid initiation or increase, days
lost and nights woken in a week. Fischer’s exact test was used
to determine the effect of group allocation on those participants
re-admitted to hospital.
Six hundred and sixty patients were assessed for eligibility: 385 were
not contactable, 154 declined to participate, 31 were excluded and 19
failed to attend the baseline meeting.
Seventy-one participants (54 or 76.1% females) were recruited with
a mean age 36.2 years. Random allocation resulted in a group of 36
intervention (with 31 remaining for final analysis) and 35 controls (29
in final analysis) that were not significantly different from each other in
terms of baseline measures.
hospital admissions at recruitment
A total of 101 admissions to hospital were recorded for the 30 month
pre-intervention period. Seventy-six percent of participants had a
single admission, and although a greater proportion of the control
group reported more than one admission, the difference was not
significant. Eighty percent of all admissions occurred within 1 year of
the patient being invited to participate.
172 Reprinted from AustRAliAn FAmily PhysiciAn Vol. 37, No. 3, March 2008
A pilot study of telephone based asthma management
number of reports of waking on 4–6 nights of the week in the
control compared to the intervention group.
The telephone based intervention took an average of 10 minutes
per call and required few resources. Neither the participants nor the
clinicians had to travel to hospital or to a clinic, and clinicians were
able to service many participants from one location.
The initial face-to-face asthma educator session for both the
intervention and control groups resulted in a doubling of written
AAP ownership with almost all participants reporting using
their plan. This is an important outcome of the asthma educator
session: lack of (or failure to use) a written AAP is associated with
increased risk of hospital admission and emergency department
limitations of the study
The lack of statistically significant differences seen in the primary
outcome was most likely due to a smaller than anticipated sample
size and therefore a high probability of a type 2 statistical error.
The face-to-face session may have ‘pre-optimised’ asthma
management in all participants, reducing the differences between
intervention and control groups. Equally, the weekly calls to collect
morbidity data likely had a treatment effect, which again may have
diminished the differences between the groups.
The recruitment rate and small sample size may limit the
generalisabilty of the results. Only 20% of potential participants
expressed an interest in taking part. As nearly 55% of potential
participants could not be contacted, their reasons for not taking part
cannot be established nor can their characteristics be compared to
the study group to determine the extent of selection bias. However,
the age and gender mix of the recruited group is representative of
adults admitted to hospital with asthma in Australia.13
implications for general practice
Telephone based asthma management provides an effective
alternative to usual care, and is time efficient for both the
practitioner and the patient. It can be used by a nurse practitioner
operating from a particular site to provide asthma management
and regular review to many patients across many locations, or for a
number of general practices.
Written plan and PEFm ownership
Twenty-eight (39%) of participants owned a current AAP
at recruitment; 40 (56%) owned a PEFM. Results from the
questionnaires showed that written AAP ownership had increased
to 77% at 6 months (44 replies) and 82% at 12 months (49 replies).
In addition, 89 and 95% reported using their plan at 6 and 12
Delivery of management sessions
A mean of 66 minutes (total range 60–140 minutes) was spent in
the face-to-face session with all participants. The total mean time
spent delivering six telephone calls to each intervention participant
was 62 minutes, with each call time ranging from 3–22 minutes
(mean 10.33 minutes).
health care utilisation
At 12 months, one intervention participant reported one hospital
re-admission; six controls reported a total of 20 re-admissions.
Allocation to control group was significantly associated with
hospital re-admission (p=0.05).
There were no significant differences in the number of
participants reporting or the mean number of occasions of hospital
re-admissions, unplanned GP visits or emergency department
attendance (Table 1, 2).
Neither the difference in the number of participants reporting nor
the mean number of days lost or occasions when oral steroids were
initiated or increased reached statistical significance at 12 months
(Table 1, 2). Control participants were significantly more likely to
report being woken on more than half (4–6) of week nights. There
were no significant differences in the mean occurrences of 0 nights
woken, 1–3 nights woken, or all nights woken at 12 months.
Clinically important reductions were noted in both the number of
participants re-admitted and the number of hospital re-admissions
in the intervention compared to control group; this difference almost
reached statistical significance. There were a significantly greater
Table 1. Number of participants reporting and total occasions reported for unplanned GP visits, emergency department attendance, hospital
admissions, starting or increasing steroids and days lost at 12 months in intervention (n=31) and control (n=29) groups
Participants (total occasions) at 12 months
chi-squared (2) test
χ2=3.03, df=3, p=0.39
χ2=0.93, df=3, p=0.82
χ2=5.20, df=3, p=0.16
χ2=4.25, df=4, p=0.37
χ2=2.85, df=4, p=0.58
Unplanned GP visits
Emergency department attendance
Started/increased oral steroids
* 24 intervention group participants worked or studied at 12 months ** 25 control group participants worked or studied at 12 months
Reprinted from AustRAliAn FAmily PhysiciAn Vol. 37, No. 3, March 2008 173
A pilot study of telephone based asthma management
Conflict of interest: none declared.
1. National Heart, Lung, and Blood Institute. Expert panel report 2: guidelines for
the diagnosis and management of asthma. Maryland (US): National Institutes of
2. Gibson PG, Powell H, Coughlan J, et al. Self-management education and
regular practitioner review for adults with asthma. Cochrane Database Syst Rev
3. Miller MK, Lee JH, Miller DP, Wenzel SE; TENOR Study Group. Recent
asthma exacerbations: a key predictor of future exacerbations. Respir Med
4. Boucher JL, Pronk NP, Gehling EM. Telephone-based lifestyle counseling. Diabetes
5. Piette JD, Weinberger M, Kraemer FB, McPhee SJ. Impact of automated calls
with nurse follow-up on diabetes treatment outcomes in a Department of
Veterans Affairs Health Care System: a randomized controlled trial. Diabetes Care
6. Simon GE, VonKorff M, Rutter C, Wagner E. Randomised trial of monitoring, feed-
back, and management of care by telephone to improve treatment of depression
in primary care. BMJ 2000;320:550–4.
Table 2. Difference in mean number of unplanned GP visits, ED attendances, hospital re-admissions, nights woken,
occasions starting/increasing in oral steroid use and days lost from work or study because of asthma between intervention (n=31)
and control (n=29) groups at 12 months
Variable Groupmean sDsEmtdfs-2-tailed mDsED95% ci
Unplanned GP visitsIntervention 2.102.330.42
–0.0758.00 0.95 –0.040.62
ED attendance Intervention 0.420.920.17
Control 0.381.18 0.22
Hospital re-admission*Intervention 0.030.180.03
Control 1.492.16 0.40
Oral steroidsIntervention 1.972.340.42
Days lost from work or
* Statistics adjusted when Levene’s test for equality of variance was significant (p<0.05)
** 24 intervention group participants worked or studied at 12 months
† 25 control group participants worked or studied at 12 months
SD = standard deviation, SEM = standard error mean, S-2-tailed = significance 2 tailed, MD = mean difference, SED = standard error difference
7. Vale MJ, Jelinek MV, Best JD, Santamaria JD. Coaching patients with coronary
heart disease to achieve the target cholesterol: a method to bridge the gap
between evidence-based medicine and the 'real world': randomized controlled
trial. J Clin Epidemiol 2002;55:245–52.
Wasson J, Gaudette C, Whaley F, Sauvigne A, Baribeau P, Welch HG. Telephone
care as a substitute for routine clinic follow-up. JAMA 1992;267:1788–93.
Pinnock H, Bawden R, Proctor S, et al. Accessibility, acceptability, and effec-
tiveness in primary care of routine telephone review of asthma: pragmatic,
randomised controlled trial. BMJ 2003;326:477–9.
10. Australian Government Department of Health and Ageing. The Asthma 3+ Visit
Plan (brochure). Canberra: DoHA, 2002.
11. Kolbe J, Fergusson W, Vamos M, Garrett J. Case-control study of severe life
threatening asthma (SLTA) in adults: demographics, health care, and management
of the acute attack. Thorax 2000;55:1007–15.
12. Adams RJ, Smith BJ, Ruffin RE. Factors associated with hospital admis-
sions and repeat emergency department visits for adults with asthma. Thorax
13. Campbell DA, McLennan G, Coates JR. A comparison of asthma deaths and near-
fatal asthma attacks in South Australia. Eur Respir J 1994;7:490–7.