A Pilot Study of Telephone-Based Asthma Management
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ABSTRACT: A small proportion of patients with asthma account for a disproportionate number of acute health service events. To identify whether factors other than severity and low socioeconomic status were associated with this disproportionate use, a prospective study was undertaken to examine management and psychosocial factors associated with increased risk for admission to hospital with asthma and repeat visits to the emergency department over a 12 month period. A total of 293 patients with moderate or severe asthma managed at least in part at two teaching hospitals completed surveys of clinical status, acute events, sociodemographic, and psychological variables. Twenty three percent had a single admission to hospital and 16% had two or more hospital admissions. Twenty six percent had one emergency department visit and 32% had two or more visits to the emergency department. In a multiple logistic regression model, adjusted for age, sex, education and income, odds ratios (95% CI) for baseline factors associated with hospital admissions over the next 12 months were: moderate severity compared with severe asthma 0.6 (0.2 to 0.9); no hospital admissions in the past 12 months 0.1 (0.01 to 0.2); not possessing a written asthma action plan 4.0 (1.5 to 10.7); less use of an avoidance coping style 0.4 (0.3 to 0.7); lower preferences for autonomy in asthma management decisions 1.4 (0.96 to 2.0). Adjusted odds ratios (95% CI) for repeat emergency department visits were: moderate asthma severity 0.3 (0.1 to 0.8); current regular use of oral corticosteroids 10.0 (3.1 to 32.4); a hospital admission in the past 12 months 2.9 (1.8 to 4.8); not possessing a written asthma action plan 2.2 (1.1 to 5.6); less dislike of asthma medications 0.7 (0.5 to 0.9). In addition to factors relating to severity, not possessing a written asthma action plan, avoidance coping, and attitudes to self-management were related to acute use of health services in this at risk group. Interventions need to address or take these factors into account to reduce asthma morbidity.Thorax 08/2000; 55(7):566-73. · 8.38 Impact Factor
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ABSTRACT: Studies seeking to identify factors predictive of asthma mortality have relied on information obtained from relatives, other close acquaintances, and doctors who cared for the deceased. We wanted to determine whether asthmatics who have suffered a near-fatal asthma attack (NFA) are similar to asthmatics who have died of asthma with respect to important features, because studies of NFA asthmatics may provide a better insight into causes of asthma death. Such studies would avoid the difficulties associated with seeking information secondhand from proxy informants. Two groups were studied: asthmatics who had suffered a near-fatal asthma attack resulting in a visit to the accident and emergency departments of teaching hospitals (n = 154), and asthmatics certified as dying of asthma who, following panel review, were confirmed to have died from this disease (n = 80). For each case in the two groups, an interview questionnaire was administered to a close acquaintance (household or family member) and to the general practitioner. Both groups shared many important characteristics. Similarities related to: frequency of symptoms; frequency of hospital and intensive care unit admissions for asthma; use of asthma crisis plans; compliance with prescribed medications; quality of personal asthma management; and asthma severity. The two groups also showed similar psychiatric profiles, and similar use of asthma medications on a regular basis and with increased symptoms. However, NFA cases tended to be younger, were more likely to be male, and less likely to have concurrent medical conditions.(ABSTRACT TRUNCATED AT 250 WORDS)European Respiratory Journal 04/1994; 7(3):490-7. · 6.36 Impact Factor
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ABSTRACT: To determine whether routine review by telephone of patients with asthma improves access and is a good alternative to face to face reviews in general practices. Pragmatic, randomised controlled trial. Four general practices in England. 278 adults who had not been reviewed in the previous 11 months. Participants were randomised to either telephone review or face to face consultation with the asthma nurse. Primary outcome measures were the proportion of participants who were reviewed within three months of randomisation and disease specific quality of life, as measured by the Juniper mini asthma quality of life questionnaire. Secondary outcome measures included the validated "short Q" asthma morbidity score, nursing care satisfaction questionnaire score, and length of consultation. Of 137 people randomised to telephone consultation, 101 (74%) were reviewed, compared with 68 reviewed (48%) of the 141 people in the surgery group, a difference of 26% (95% confidence interval 14% to 37%; P<0.001; number needed to treat 3.8). Three months after randomisation the two groups did not differ in the Juniper score (risk difference -0.07 (95% confidence interval -0.40 to 0.27) or in satisfaction with the consultation (risk difference -0.07 (-0.27 to 0.13)). Telephone consultations were on average 10 minutes shorter than reviews held in the surgery (mean difference 10.7 minutes (12.6 to 8.8; P<0.001)). Compared with face to face consultations in the surgery, telephone consultations enable more people with asthma to be reviewed, without clinical disadvantage or loss of satisfaction. A shorter duration means that telephone consultations are likely to be an efficient option in primary care for routine review of asthma.BMJ (Clinical research ed.). 03/2003; 326(7387):477-9.
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.
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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
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