Randomized controlled trial of asthma education after discharge from an emergency department. Can a self-management programme delivered by a community pharmacist improve asthma control? A randomised trial. A pilot study of telephone based asthma management. Telephone based asthma management - financial and individual benefits. Cost-effectiveness of a nurse-led telemonitoring intervention based on peak expiratory flow measurements in asthmatics: results of a randomised controlled trial. Internet-based self-management plus education compared with usual care in asthma: a randomized trial. Daily telemonitoring of exhaled nitric oxide and symptoms in the treatment of childhood asthma. A randomized trial of a self-regulation intervention for women with asthma. The effectiveness of nurse-led telemonitoring of asthma: results of a randomized controlled trial. Process evaluation of a nurse-led telemonitoring programme for patients with asthma. An internet-based interactive telemonitoring system for improving childhood asthma outcomes in Taiwan. Web-based or paper-based self-management tools for asthma--patients' opinions and quality of data in a randomized crossover study. Internet-based monitoring of asthma: a long-term, randomized clinical study of 300 asthmatic subjects. Accessibility, acceptability, and effectiveness in primary care of routine telephone review of asthma: pragmatic, randomised controlled trial. Cost-effectiveness of telephone or surgery asthma reviews: economic analysis of a randomised controlled trial. [Tele-medicine system for high-risk asthmatic patients]. Accessibility, clinical effectiveness, and practice costs of providing a telephone option for routine asthma reviews: phase IV controlled implementation study. Internet-based home monitoring and education of children with asthma is comparable to ideal office-based care: results of a 1-year asthma in-home monitoring trial. Improving asthma control through telemedicine: a study of short-message service. The effect of telepharmacy counseling on metered-dose inhaler technique among adolescents with asthma in rural Arkansas. Use and impact of an automated telephone outreach system for asthma in a managed care setting. Targeted routine asthma care in general practice using telephone triage. [Hospitalization reduction by an asthma tele-medicine system].
To test the hypothesis that reinforcement of the advice given at the time of discharge from the emergency department by telephone consultation would improve asthma outcomes.
                A randomized controlled trial of the parents of 310 children who had been discharged from the emergency department with asthma was undertaken. The parents were randomized to receive either standard care (155 children) or standard care plus education by telephone (155 children) from a trained asthma educator. Symptoms, parental asthma knowledge, parental quality of life and use of asthma action plans and preventer therapy were collected at baseline and 6 months later. The primary measure was days of wheeze in last 3 months; intermediate measures were regular use of preventer medications, possession and use of written asthma action plan, parental asthma knowledge scores and parental quality of life scores.
                A total of 266 parents (136 intervention) completed the follow-up questionnaires after 6 months. Both groups showed similar symptoms and process measures at baseline, apart from more regular use of preventer medication in the control children. At follow up, the intervention group children were significantly more likely than controls to possess (87.5% vs 72.3%; P = 0.002) a written asthma action plan. Possession of action plans increased from baseline in the intervention group but tended to decrease in the control group. Use of action plans was greater in the intervention group but decreased from baseline in both groups. Both intervention and control groups showed significant decreases in asthma symptoms.
                Reinforcement by telephone consultation did not improve the primary outcome of wheeze in the last 3 months. However, it increased the possession and regular use of written asthma action plans in the intervention group. No randomised studies have addressed whether self-management for asthma can be successfully delivered by community pharmacists. Most randomised trials of asthma self-management have recruited participants from secondary care; there is uncertainty regarding its effectiveness in primary care. A randomised controlled study was undertaken to determine whether a community pharmacist could improve asthma control using self-management advice for individuals recruited during attendance at a community pharmacy.
                Twenty four adults attending a community pharmacy in Tower Hamlets, east London for routine asthma medication were randomised into two groups: the intervention group received self-management advice from the pharmacist with weekly telephone follow up for 3 months and the control group received no input from the pharmacist. Participants self-completed the North of England asthma symptom scale at baseline and 3 months later.
                The groups were well matched at baseline for demographic characteristics and mean (SD) symptom scores (26.3 (4.8) and 27.8 (3.7) in the intervention and control groups, respectively). Symptom scores improved in the intervention group and marginally worsened in the control group to 20.3 (4.2) and 28.1 (3.5), respectively (p<0.001; difference adjusted for baseline scores=7.0 (95% CI 4.4 to 9.5).
                A self-management programme delivered by a community pharmacist can improve asthma control in individuals recruited at a community pharmacy. Further studies should attempt to confirm these findings using larger samples and a wider range of outcome measures. 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. The authors calculated the cost of delivering telephone based asthma management compared to usual care. Self efficacy and quality of life were measured at recruitment, 6 months and 12 months. Participants were invited to comment on their experience of the telephone based intervention.
                The intervention was well accepted. At 12 months there was a clinically important improvement in mean quality of life in the intervention group not seen in the control group. Telephone based management costs were offset by reductions in the number of readmissions in the intervention group.
                Telephone based asthma management offers a well accepted, low cost yet potentially effective means of delivering asthma care. Asthma is a chronic lung disease in which recurrent asthma symptoms create a substantial burden to individuals and their families. At the same time the economic burden associated with asthma is considerable.
                The cost-effectiveness study was part of a single centre prospective randomised controlled trial comparing a nurse-led telemonitoring programme to usual care in a population of asthmatic outpatients. The study included 109 asthmatic outpatients (56 children; 53 adults). The duration of follow-up was 12 months, and measurements were performed at baseline, 4, 8, and 12 months. Patients were asked to transfer their monitor data at least twice daily and by judging the received data and following a stepwise intervention protocol a nurse was able to act as the main caregiver in the intervention group. In both groups the EQ-5D and the SF-6D were used to obtain estimates of health state utilities. One year health care costs, patient and family costs, and productivity losses were calculated. The mean incremental costs were weighted against the mean incremental effect in terms of QALY.
                The study population generally represented mild to moderate asthmatics. No significant differences were found between the groups with regard to the generic quality of life. Overall, the mean health care costs per patient were higher in the intervention group than in the control group. The intervention costs mainly caused the cost difference between the groups. The intervention costs the society euro 31,035/QALY gained with regard to adults and with regard to children euro 59,071/QALY gained.
                If the outcome is measured by generic quality of life the nurse-led telemonitoring programme is of limited cost-effectiveness in the study population. From the societal perspective the probability of the programme being cost-effective compared to regular care was 85% at a ceiling ratio of euro 80,000/QALY gained among the adults and 68% among the children. A decrease in the price of the asthma monitor will substantial increase the probability of the programme to be cost-effective. The Internet may support patient self-management of chronic conditions, such as asthma.
                To evaluate the effectiveness of Internet-based asthma self-management.
                Randomized, controlled trial.
                37 general practices and 1 academic outpatient department in the Netherlands.
                200 adults with asthma who were treated with inhaled corticosteroids for 3 months or more during the previous year and had access to the Internet.
                Asthma-related quality of life at 12 months (minimal clinically significant difference of 0.5 on the 7-point scale), asthma control, symptom-free days, lung function, and exacerbations.
                Participants were randomly assigned by using a computer-generated permuted block scheme to Internet-based self-management (n = 101) or usual care (n = 99). The Internet-based self-management program included weekly asthma control monitoring and treatment advice, online and group education, and remote Web communications.
                Asthma-related quality of life improved by 0.56 and 0.18 points in the Internet and usual care groups, respectively (adjusted between-group difference, 0.38 [95% CI, 0.20 to 0.56]). An improvement of 0.5 point or more occurred in 54% and 27% of Internet and usual care patients, respectively (adjusted relative risk, 2.00 [CI, 1.38 to 3.04]). Asthma control improved more in the Internet group than in the usual care group (adjusted difference, -0.47 [CI, -0.64 to -0.30]). At 12 months, 63% of Internet patients and 52% of usual care patients reported symptom-free days in the previous 2 weeks (adjusted absolute difference, 10.9% [CI, 0.05% to 21.3%]). Prebronchodilator FEV1 changed with 0.24 L and -0.01 L for Internet and usual care patients, respectively (adjusted difference, 0.25 L [CI, 0.03 to 0.46 L]). Exacerbations did not differ between groups.
                The study was unblinded and lasted only 12 months.
                Internet-based self-management resulted in improvements in asthma control and lung function but did not reduce exacerbations, and improvement in asthma-related quality of life was slightly less than clinically significant.
                Netherlands Organization for Health Research and Development, ZonMw, and Netherlands Asthma Foundation. Asthma treatment might improve when inhaled steroids are titrated on airway inflammation. Fractional exhaled nitric oxide (FeNO0.05), a marker of eosinophilic airway inflammation, can be measured at home.
                We assessed daily FeNO0.05 telemonitoring in the management of childhood asthma.
                Children with atopic asthma (n = 151) were randomly assigned to two groups: FeNO0.05 plus symptom monitoring, or monitoring of symptoms only. All patients scored asthma symptoms in an electronic diary over 30 weeks; 77 received a portable nitric oxide (NO) analyzer. Data were transmitted daily to the coordinating centers. Patients were phoned every 3 weeks and their steroid dose was adapted according to FeNO0.05 and symptoms, or according to symptoms. Children were seen at 3, 12, 21, and 30 weeks for examination and lung function testing. The primary end point was the proportion of symptom-free days in the last 12 study weeks.
                Telemonitoring was feasible with reliable FeNO0.05 data for 86% of days, and valid diary entries for 79% of days. Both groups showed an increase in symptom-free days, improvement of FEV1 and quality of life, and a reduction in steroid dose. None of the changes from baseline differed between groups. The difference in symptom-free days over the last 12 weeks was 0.3% (P = 0.95; 95% confidence interval, -10 to 11%). There was a trend for fewer exacerbations in the FeNO0.05 group.
                Thirty weeks of daily FeNO0.05 and symptom telemonitoring was associated with improved asthma control and a lower steroid dose. We found no added value of daily FeNO0.05 monitoring compared with daily symptom monitoring only. Women with asthma have greater mortality and morbidity than men in the United States. To date, there has been no rigorous evaluation of an intervention focused on the particular problems in asthma management faced by women. This study was a randomized clinical trial of a self-regulation, telephone counseling intervention emphasizing women's concerns, and sex and gender role factors in their management of asthma.
                A total of 808 women with diagnosed asthma were randomly assigned to the intervention group or a usual-care control group, including conventional asthma education. Interviews and medical record data were collected to assess psychosocial factors, and the behavioral factors of functioning, quality of life, symptoms, and health-care use at baseline and the subsequent 1 year. Generalized estimating equations, identity link, logit link, and log link were employed to analyze the data.
                Compared to control subjects, the women receiving treatment had greater annual reductions in the average number of nights with asthma symptoms (p = 0.04), days of missed work/school (p = 0.03), emergency department visits (p = 0.04), unscheduled office visits (p = 0.01), and scheduled office visits (p = 0.04). They had greater recognition of asthma symptoms during the menstrual cycle (p = 0.0003), had decreased asthma symptoms with sexual activity (p = 0.008), and had greater improvement in quality of life (p = 0.0005), self-regulation (p = 0.03), and self-confidence to manage asthma (p = 0.001).
                The intervention improved women's clinical status, functioning, quality of life, and health-care use. A program with a focus on asthma management problems particular to women can significantly assist female asthma patients. The aim of the study was to evaluate the effects on, and the relationship between, asthma symptoms, asthma-specific quality of life and medical consumption of a nurse-led telemonitoring intervention compared with regular care in asthma in the Netherlands.
                One hundred and nine asthmatic outpatients (56 children; 53 adults) were randomly assigned to the treatment arms (12-month follow-up). The control group received regular outpatient care, while the intervention group used an asthma monitor with modem at home with an asthma nurse as the main caregiver. Clinical asthma symptoms and medical consumption were measured by using diaries. Asthma-specific quality of life was measured by the (Paediatric) Asthma Quality of Life Questionnaire.
                The study population generally represented mild to moderate asthmatics. The results show improvement in follow-up, but no statistically significant difference between the groups was observed. Moderate to high correlations were found within the outcome parameters, but the most remarkable was the low and statistically significant correlation between asthma-specific quality of life (daily functioning) and the self-reported beta-2 agonists.
                Overall, the telemonitoring programme evaluated in this study did not significantly decrease asthma symptoms or medical consumption, or improve asthma-specific quality of life. The results showed that a telemonitoring programme on its own is not a guarantee of success. The patients' perception of asthma-specific quality of life (daily functioning) should be a key element in asthma telemonitoring programmes. We performed a process evaluation of a nurse-led telemonitoring programme for patients with asthma. The indicators used to evaluate the programme were feasibility, consistency of peak expiratory flow (PEF) tests, compliance and patient satisfaction. Patients in the intervention group received a home monitor in which spirometry results and symptoms could be recorded. They were asked to measure PEF in the morning and evening. A nurse studied the home monitoring data and took stepwise actions in accordance with the intervention protocol. During a 12-month study period, 55 patients were allocated to the intervention group (26 adults and 29 children). Although technical and logistical problems did occur, the dropout rate was low. At least 75% of the PEF manoeuvres were valid for two-thirds of the patients. Compliance with the study protocol was high. The average number of recorded PEF tests was 1.5 per day, which was less than the two tests per day that were required by the protocol. Patient satisfaction was high and, after one year, less than 20% of the participants chose to discontinue their participation. The results indicate that nurse-led telemonitoring for a motivated group of patients with mild to moderate asthma is feasible and reliable, and satisfying to patients. A randomized, controlled trial was conducted to assess the effectiveness of Blue Angel for Asthma Kids, an Internet-based interactive asthma educational and monitoring program, used in the management of asthmatic children. One hundred sixty-four (n = 164) pediatric patients with persistent asthma were enrolled and randomized into two study groups for a 12-week controlled trial. The intervention group had 88 participants who were taught to monitor their peak expiratory flows (PEF) and asthma symptoms daily on the Internet. They also received an interactive response consisting of a self-management plan from the Blue Angel monitoring program. The control group had 76 participants who received a traditional asthma care plan consisting of a written asthma diary supplemented with instructions for self-management. Disease control was assessed by weekly averaged PEF values, symptom scores, and asthma control tests. Adherence measures were assessed by therapeutic and diagnostic monitoring. Outcome was assessed by examining quality of life and retention of asthma knowledge. The data were analyzed by comparing results before and after the trial. At the end of trial, the intervention group decreased nighttime (-0.08 +/- 0.33 vs. 0.00 +/- 0.20, p = 0.028) and daytime symptoms (-0.08 +/- 0.33 vs. 0.01 +/- 0.18, p =0.009); improved morning (241.9 +/- 81.4 vs. 223.1 +/- 55.5, p =0.017) and night PEF (255.6 +/- 86.7 vs. 232.5 +/- 55.3, p =0.010); increased adherence rates (p < 0.05); improved well-controlled rates (70.4% vs. 55.3%, p < 0.05); improved knowledge regarding self-management (93.2% vs. 70.3%, p < 0.05); and improved quality of life (6.5 +/- 0.5 vs. 4.3 +/- 1.2 on a 7-point scale, p < 0.05) when compared with conventional management. The Internet-based asthma telemonitoring program increases selfmanagement skills, improves asthma outcomes, and appears to be an effective and well-accepted technology for the care of children with asthma and their caregivers. The use of communication technologies may overcome some of the difficulties of conventional, paper-based, self-management of chronic diseases. This paper aims to describe and evaluate the use of P'ASMA - a web based asthma self-management support tool regarding the opinion of patients and their adherence to monitoring in comparison to standard paper-based tools. System description: P'ASMA allows the collection of asthma monitoring data and provides, to both patient and doctor, immediate feedback about patient's condition. For each patient a set of forms and scheduling options can be chosen. Evaluation methods: Twenty-one adults with previous medical diagnosis of asthma were included in an exploratory randomized crossover study. Patients used P'ASMA or a paper asthma diary and action-plan each during 4 weeks in a random sequence. Results: The number of patients who wrote negative remarks regarding P'ASMA was 2 and regarding paper-tools was 11; positive comments were 6 and 1 respectively for P'ASMA and Paper-based. Twelve patients were very interested to continue to monitor their asthma using P'ASMA whereas only 2 with Paper-based (p=0.002). Of the 19 problems reported with P'ASMA, 9 were related to the Internet connection, 5 to the user interface, 3 to internal system errors and 2 to the questions interpretation. The completeness of paper diary records was better; however, 10 patients reported filling it several days at once which was not allowed in P'ASMA. Conclusions: The intervention was feasible, safe and the problems detected in the web-application can be corrected. With P'ASMA data quality improved as the integrity features increase the reliability of the data. Moreover, patients preferred the web-based application to monitor their asthma. Experience from other fields of internal medicine shows that Internet-based technology can be used to monitor various diseases. The new technology handles complex calculation programs easily, and it is a unique way of communicating. These advantages might be used in optimizing the treatment for asthmatic subjects because undertreatment is a common problem found in European asthmatic subjects.
                We sought to investigate the outcome of monitoring and treatment using a physician-managed online interactive asthma monitoring tool and to assess whether the outcome differs from that of monitoring and treatment in an outpatient respiratory clinic or in primary care.
                Three hundred asthmatic subjects were randomized to 3 parallel groups in a 6-month prospective study: (1) Internet-based monitoring (n = 100); (2) specialist monitoring (n = 100); and (3) general practitioner (GP) monitoring (n = 100). All the patients were examined on entry into the study and after 6 months of treatment.
                The treatment and monitoring with the Internet-based management tool lead to significantly better improvement in the Internet group than in the other 2 groups regarding asthma symptoms (Internet vs specialist: odds ratio of 2.64, P = .002; Internet vs GP: odds ratio of 3.26; P < .001), quality of life (Internet vs specialist: odds ratio of 2.21, P = .03; Internet vs GP: odds ratio of 2.10, P = .04), lung function (Internet vs specialist: odds ratio of 3.26, P = .002; Internet vs GP: odds ratio of 4.86, P < .001), and airway responsiveness (Internet vs GP: odds ratio of 3.06, P = .02).
                When physicians and patients used an interactive Internet-based asthma monitoring tool, better asthma control was achieved. 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. Only about a third of people with asthma attend an annual review. Clinicians need to identify cost-effective ways to improve access and ensure regular review.
                To compare the cost-effectiveness of nurse-led telephone with face-to-face asthma reviews.
                Cost-effectiveness analysis based on a 3-month randomised controlled trial.
                Four general practices in England.
                Adults due an asthma review were randomised to telephone or face-to-face consultations. Trial nurses recorded proportion reviewed, duration of consultation, and abortive calls/missed appointments. Data on use of healthcare resources were extracted from GP records. Cost-effectiveness was assessed from the health service perspective; sensitivity analyses were based on proportion reviewed and duration of consultation.
                A total of 278 people with asthma were randomised to surgery (n = 141) or telephone (n = 137) review. Onehundred-and-one (74%) of those with asthma in the telephone group were reviewed versus 68 (48%) in the surgery group (P <0.001). Telephone consultations were significantly shorter (mean duration telephone = 11.19 minutes [standard deviation {SD} = 4.79] versus surgery = 21.87 minutes [SD = 6.85], P <0.001). Total respiratory healthcare costs per patient over 3 months were similar (telephone = pounds sterling 64.49 [SD = 73.33] versus surgery = pounds sterling 59.48 [SD = 66.02], P = 0.55). Total costs of providing 101 telephone versus 68 face-to-face asthma reviews were also similar (telephone = pounds sterling 725.84 versus surgery = pounds sterling 755.70), but mean cost per consultation achieved was lower in the telephone arm (telephone = pounds sterling 7.19 [SD = 2.49] versus surgery = pounds sterling 11.11 [SD = 3.50]; mean difference = - pounds sterling 3.92 [95% confidence interval = - pounds sterling 4.84 to pounds sterling 3.01], P <0.001).
                Telephone consultations enable a greater proportion of asthma patients to be reviewed at no additional cost to the health service. This mode of delivering care improves access and reduces cost per consultation achieved. We have developed a tele-medicine system to monitor the airway status at home for patients with poorly controlled asthma, whereby a nurse provides instructions to individuals via the telephone to help them manage exacerbation under the supervision of their physicians. We examined the effectiveness of this system with a randomized control study. Patients with high hospitalization risk were enrolled in the study by screening patients for those with multiple previous emergency room visits and randomly assigned to either the tele-medicine or control group. After six months of participation in the program, the number of emergency room visits decreased significantly and the activities of daily living were improved in the tele-medicine group. Most of the patients in the tele-medicine group were able to continue measuring and transmitting peak expiratory flow (PEF) value successfully, and at six months had noticed an improvement in PEF. We therefore conclude that the system effectively contributes to the management of poorly controlled asthma. In addition, further consideration suggests that the reduction of emergency room visits may lead to reduction in hospitalization since we found a good correlation between number of emergency room visits and hospitalization from the studies published previously. Attendance for routine asthma reviews is poor. A recent randomised controlled trial found that telephone consultations can cost-effectively and safely enhance asthma review rates; however, concerns have been expressed about the generalisability and implementation of the trial's findings.
                To evaluate the effectiveness of a telephone option as part of a routine structured asthma review service.
                Phase IV controlled before-and-after implementation study.
                A large UK general practice.
                Using existing administrative groups, all patients with active asthma (n = 1809) received one of three asthma review services: structured recall with a telephone-option for reviews versus structured recall with face-to-face-only reviews, or usual-care (to assess secular trends). Main outcome measures were: proportion of patients with active asthma reviewed within the previous 15 months (Quality and Outcomes Framework target), mode of review, enablement, morbidity, and costs to the practice.
                A routine asthma review was provided for 397/598 (66.4%) patients in the telephone-option group compared with 352/654 (53.8%) in the face-to-face-only review group: risk difference 12.6% (95% confidence interval [CI] = 7.2 to 17.9, P<0.001). The usual-care group achieved a review rate of 282/557 (50.6%). Morbidity was equivalent in the three groups; however, enablement (P = 0.03) and confidence (P = 0.007) in asthma management were greater in the telephone-option versus face-to-face-only group. The cost per review achieved by providing the telephone-option service was lower than the face-to-face-only service (10.03 pounds versus 12.74 pounds, mean difference 2.71 pounds; 95% CI = 1.92 to 3.50, P<0.001); usual-care costs were 11.85 pounds per review achieved.
                Routinely offering telephone reviews cost-effectively increased asthma review rates, enhancing patient enablement and confidence with management, with no detriment to asthma morbidity. Practices should consider a telephone option for their asthma review service. The goal was to determine whether home asthma telemonitoring with store-and-forward technology improved outcomes, compared with in-person, office-based visits.
                A total of 120 patients, 6 to 17 years of age, with persistent asthma were assigned randomly to the office-based or virtual group. The 2 groups followed the same ambulatory clinical pathway for 12 months. Office-based group patients received traditional in-person education and case management. Virtual group patients received computers, Internet connections, and in-home, Internet-based case management and received education through the study Web site. Disease control outcome measures included quality of life, utilization of services, and symptom control.
                A total of 120 volunteers (45 female) were enrolled. The groups were clinically comparable (office-based: 22 female/38 male; mean age: 9.0 +/- 3.0 years; virtual: 23 female/37 male; mean age: 10.2 +/- 3.1 years). Virtual patients had higher metered-dose inhaler with valved holding chamber technique scores than did the office-based group at 52 weeks (94% vs 89%), had greater adherence to daily asthma symptom diary submission (35.4% vs 20.8%), had less participant time (636 vs 713 patient-months), and were older. Caregivers in both groups perceived an increase in quality of life and an increase in asthma knowledge scores from baseline. There were no other differences in therapeutic or disease control outcome measures.
                Virtual group patients achieved excellent asthma therapeutic and disease control outcomes. Compared with those who received standardized office-based care, they were more adherent to diary submission and had better inhaler scores at 52 weeks. Store-and-forward telemedicine technology and case management provide additional tools to assist in the management of children with persistent asthma. Home peak expiratory flow (PEF) measurement is recommended by asthma guidelines. In a 16-week randomized controlled study on 16 subjects with asthma (24.6 6.5 years old, asthma duration small ze, Cyrillic 6 months), we examined Global System for Mobile Communications (GSM) mobile telephone short-message service (SMS) as a novel means of telemedicine in PEF monitoring. All subjects received asthma education, self-management plan, and standard treatment. All measured PEF three times daily and kept a symptom diary. In the study group, therapy was adjusted weekly by an asthma specialist according to PEF values received daily from the patients. There was no significant difference between the groups in absolute PEF, but PEF variability was significantly smaller in the study group (16.12 +/- 6.93% vs. 27.24 +/- 10.01%, p = 0.049). forced expiratory flow in 1 second (FEV1; % predicted) in the study group was slightly but significantly increased (81.25 +/- 17.31 vs. 77.63 +/- 14.80, p = 0.014) and in the control group, unchanged (78.25 +/- 21.09 vs. 78.88 +/- 22.02, p = 0.497). Mean FEV1 was similar in the two groups both before and after the study. Controls had significantly higher scores for cough (1.85 +/- 0.43 vs. 1.42 +/- 0.28, p < 0.05) and night symptoms (1.22 +/- 0.23 vs. 0.85 +/- 0.32, p < 0.05). There was no significant difference between the groups in daily consumption of inhaled medicine, forced vital capacity, or compliance. Per patient, per week, the additional cost of follow-up by SMS was Euros 1.67 (equivalent to approximately $1.30 per 1 Euro), and SMS transmission required 11.5 minutes. Although a study group of 40 patients is needed for the follow-up study to achieve the power of 80% within the 95% confidence interval, we conclude that SMS is a convenient, reliable, affordable, and secure means of telemedicine that may improve asthma control when added to a written action plan and standard follow-up. The increased prevalence, morbidity, mortality, and health costs associated with asthma among children suggest the need for accessible asthma education. This study examined the effect of telepharmacy counseling, using interactive compressed video, on metered-dose inhaler (MDI) technique and patient satisfaction among adolescents with asthma in rural Arkansas. The telepharmacy counseling provided accessible education regarding MDI technique for adolescents in this study. Twenty percent of the adolescents who participated had never been shown the appropriate use of an MDI. The study used an experimental design with random assignment of participants to a telepharmacy counseling group (n = 15) or a control group (n = 21). Both groups participated in pre-test, post-test, and 2- to 4-week follow-up assessments for MDI technique and patients satisfaction (follow-up assessment only) via interactive compressed video. Results indicated that from pre-test to follow-up the telepharmacy counseling group showed more improvement in MDI technique than participants in the control group (p < 0.001). There was no significant difference between the telepharmacy counseling group and control group in satisfaction with the instructional sessions (p = 0.132). Both groups had high levels of satisfaction with the telepharmacy sessions. The study findings demonstrated that patient education provided by pharmacists via interactive compressed video was superior to education provided via written instructions on an inhaler package insert. Interactive compressed video is an effective medium for teaching and improving MDI technique in this rural, adolescent, predominantly African-American population. To test the ability of an automated telephone outreach intervention to reduce acute healthcare utilization and improve quality of life among adult asthma patients in a large managed care organization.
                Randomized clinical trial.
                Patients with persistent asthma were randomly assigned to telephone outreach (automated = 3389, live caller = 192) or usual care (n = 3367). Intervention participants received 3 outreach calls over a 10-month period. The intervention provided brief, supportive information and flagged individuals with poor asthma control for follow-up by a provider. A survey was mailed to 792 intervention participants and 236 providers after the intervention. Additional feedback was obtained as part of the final intervention contact.
                The intent-to-treat analysis found no significant differences between the intervention and usual-care groups for medication use, healthcare utilization, asthma control, or quality of life. Post hoc analyses found that, compared with the control group, individuals who actually participated in the intervention were significantly more likely to use inhaled steroids and to have had a routine medical visit for asthma during the follow-up period and less likely to use short-acting beta-agonists. They also reported higher satisfaction with their asthma care and better asthma-specific quality of life. Of surveyed providers, 59% stated the program helped them to clinically manage their asthma patients and 70% thought the program should be continued.
                This study did not find improved health outcomes in the primary analyses. The intervention was well accepted by providers, however, and the individuals who participated in the calls appeared to have benefited from them. These findings suggest that further studies of automated telephone outreach interventions seem warranted. There is a high non-attendance rate for traditional clinic-based routine asthma care in general practice. Alternative methods of providing routine asthma care need to be examined.
                To examine the cost and effectiveness of targeted routine asthma care in general practice using telephone triage, compared to usual clinic care.
                An open randomised controlled trial.
                A single semi-rural practice in the southwest of England.
                Adult patients with asthma were randomised to receive either their routine asthma care in the surgery or care by telephone triage. Asthma control parameters, health status and NHS resource utilisation were measured over the 12-month study period.
                One hundred and ninety-four patients were randomised and 35% per cent more patients (n = 84 versus n = 62) received more than one consultation in the telephone group. Asthma control as measured by the asthma control questionnaire (ACQ) was similar in the clinic and telephone groups: mean change in ACQ = -0.11 (95% CI = -0.32 to 0.11) versus -0.18 (95% CI = -0.38 to 0.02). Mean NHS costs were 210 pounds sterling per patient per year in the telephone group compared to 334 pounds sterling in the clinic group (P-value of bootstrapped difference = 0.071).
                Targeted routine asthma care by telephone triage of adult asthmatics can lead to more asthma patients being reviewed, at less cost per patient and without loss of asthma control compared to usual routine care in the surgery. We examined an effectiveness of a new asthma telemedicine system in reducing hospitalizations using a multi-site randomized control study. In this program, a nurse under physician supervision monitors the patient's airway status at home and provides instructions to individuals via the telephone, helping them manage exacerbations as well as reinforcing proper use of a zone-controlled management plan. Patients with a high risk for hospitalization were screened based on the numbers of emergency room visits and hospitalizations found in a previous study and randomly assigned to either the telemedicine or control group. After a six-month study period, an 83% reduction in hospitalization was demonstrated in the telemedicine group versus the control group, with a P value of 0.01. Improvement of peak expiratory flow and symptoms were also shown in the study group. We conclude that the key success factors in home asthma management for poorly controlled asthma patients are early detection of exacerbations through daily peak flow monitoring, compliance with prescribed daily prophylactic anti-inflammatory steroid medications, and immediate action as specified by a zone-controlled action plan upon the first signs of deterioration.
Telehealthcare interventions are unlikely to result in clinically relevant improvements in health outcomes in those with relatively mild asthma, but they may have a role in those with more severe disease who are at high risk of hospital admission. Further trials evaluating the effectiveness and cost-effectiveness of a range of telehealthcare interventions are needed.