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L’EVOLUZIONE DEGLI INTERVENTI L’EVOLUZIONE DEGLI INTERVENTI EDUCAZIONALI NELLA GESTIONE DEL EDUCAZIONALI NELLA GESTIONE DEL
PAZIENTE ASMATICOPAZIENTE ASMATICO
M. NERIM. NERI
FONDAZIONE S. MAUGERI TRADATE (VA)FONDAZIONE S. MAUGERI TRADATE (VA)
THE COSTS OF ASTHMATHE COSTS OF ASTHMAP J BARNES, B JONSSON,J B KLIMP J BARNES, B JONSSON,J B KLIM
EUR RESPIR J 1996, 9: 636-42EUR RESPIR J 1996, 9: 636-42
• …….asthma costs are substantial, .asthma costs are substantial, representing over 1% of total health representing over 1% of total health care costs in the USAcare costs in the USA
• ……..as for direct costs, hospital cost ..as for direct costs, hospital cost associated with asthma ranged associated with asthma ranged from 18% (Australia) to 79% from 18% (Australia) to 79% (Sweden)(Sweden)
0%
10%
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100%
ASTHMA COSTS (MODIFIED FROM P J BARNES)ASTHMA COSTS (MODIFIED FROM P J BARNES)
% TOTAL COST
D CD C
I CI C
0%
10%
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30%
40%
50%
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70%
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100%
ASTHMA COSTS (MODIFIED FROM P J BARNES)ASTHMA COSTS (MODIFIED FROM P J BARNES)
HOSPHOSP
PHYSPHYS
DRUGSDRUGS
OTHEROTHER
THE COSTS OF ASTHMATHE COSTS OF ASTHMAP J BARNES, B JONSSON,J B KLIMP J BARNES, B JONSSON,J B KLIM
EUR RESPIR J 1996, 9: 636-42EUR RESPIR J 1996, 9: 636-42
• Underuse of prescribed therapy, which includes Underuse of prescribed therapy, which includes compliance, significantly contributes to poor compliance, significantly contributes to poor control of asthma, increased morbidity and control of asthma, increased morbidity and mortality and health care expendituremortality and health care expenditure
EDUCATION ?EDUCATION ?
COME VALUTARE I RISULTATI COME VALUTARE I RISULTATI DELL’EDUCAZIONE ?DELL’EDUCAZIONE ?
• CONOSCENZACONOSCENZA
• MORBILITA’MORBILITA’
• QUALITA’ DELLA VITAQUALITA’ DELLA VITA
• COSTO-BENEFICIOCOSTO-BENEFICIO
CONTROLLED EVALUATION OF THE CONTROLLED EVALUATION OF THE EFFECTS OF PATIENTS EDUCATION ON EFFECTS OF PATIENTS EDUCATION ON
ASTHMA MORBIDITY IN GENERAL ASTHMA MORBIDITY IN GENERAL PRACTICEPRACTICE
S Hilton, B Sibbald, H Ross Anderson, P Freeling The Lancet, 4: 26-29 1986
2 DIFFERENT PATIENT EDUCATION 2 DIFFERENT PATIENT EDUCATION PROGRAMMES FOR ASTHMA IN GENERAL PRACTICE PROGRAMMES FOR ASTHMA IN GENERAL PRACTICE
274 PATIENTS REASSESSED AFTER 1 YEAR274 PATIENTS REASSESSED AFTER 1 YEAR
Group 1: maximum education programmeGroup 1: maximum education programme
Group 2: limited education programmeGroup 2: limited education programme
Group 3: control groupGroup 3: control group
• Only in the maximum Only in the maximum intervention group was a intervention group was a significant improvement in significant improvement in knowledge knowledge of asthma shown.of asthma shown.
• Neither group showed any Neither group showed any change in self-management ability change in self-management ability or asthma morbidity that differed or asthma morbidity that differed significantly from changes in the significantly from changes in the control group. control group.
S Hilton et al. Lancet 1986Lancet 1986
RANDOMISED TRIAL OF AN ASTHMA SELF-RANDOMISED TRIAL OF AN ASTHMA SELF-MANAGEMENT PROGRAMME FOR ADULTSMANAGEMENT PROGRAMME FOR ADULTS
RM Allen, MP Jones, B OldenburgRM Allen, MP Jones, B Oldenburg
Thorax 1995; 50: 731-738Thorax 1995; 50: 731-738
The effect of an educational programme was The effect of an educational programme was evaluated in 116 adult asthmatics (12 months of evaluated in 116 adult asthmatics (12 months of follow-up)follow-up)
Group 1: education programmeGroup 1: education programme
Group 2: control Group 2: control
OUTCOMESOUTCOMES
• Asthma knowledge (questionnaire)Asthma knowledge (questionnaire)
• Compliance (diary records)Compliance (diary records)
• Morbidity (diary, spirometry, PEF)Morbidity (diary, spirometry, PEF)
RESULTSRESULTS
• KnowledgeKnowledge and compliance significantly and compliance significantly
increased in the educational group, but the increased in the educational group, but the
impact on impact on morbiditymorbidity was was modestmodest. . RM Allen et al. Thorax 1995Thorax 1995
A SELF MANAGEMENT PLAN IN THE A SELF MANAGEMENT PLAN IN THE TREATMENT OF ADULT ASTHMA R TREATMENT OF ADULT ASTHMA R
Beasley, M Cushley, ST Holgate Beasley, M Cushley, ST Holgate
Thorax 1989; 44: 200-204 Thorax 1989; 44: 200-204
• 36 adult asthmatics 36 adult asthmatics
• open prospective study; no control groupopen prospective study; no control group
AIM: to determine whether routine assessment AIM: to determine whether routine assessment of PEF in association with a self management of PEF in association with a self management plan is effective in the management of asthma. plan is effective in the management of asthma.
RESULTSRESULTSSIGNIFICANT SIGNIFICANT REDUCTIONREDUCTION OF: OF:
• NIGHTS WOKENNIGHTS WOKEN
• DAYS LOST FROM WORKDAYS LOST FROM WORK
• REQUIREMENT ORAL CORTICOSTEROIDSREQUIREMENT ORAL CORTICOSTEROIDS
SIGNIFICANTSIGNIFICANT INCREASE INCREASE OF: OF:
FEV 1 and FVC FEV 1 and FVC
R Beasley et al. R Beasley et al. Thorax 1989Thorax 1989
INFLUENCE ON ASTHMA MORBIDITY OF ASTHMA INFLUENCE ON ASTHMA MORBIDITY OF ASTHMA EDUCATION PROGRAMS BASED ON SELF-EDUCATION PROGRAMS BASED ON SELF-
MANAGEMENT PLANS FOLLOWING TREATMENT MANAGEMENT PLANS FOLLOWING TREATMENT OPTIMIZATION OPTIMIZATION
J Cotè, A Cartier, P Robichaud, H Boutin, JL Malo, M Rouleau, A J Cotè, A Cartier, P Robichaud, H Boutin, JL Malo, M Rouleau, A Fillion, M Lavallèe, M Krusky, LP BouletFillion, M Lavallèe, M Krusky, LP Boulet
Am J Respir Crit Care Med 1997; 155:1509-1514Am J Respir Crit Care Med 1997; 155:1509-1514
AIMAIM to evaluate the effectiveness of an asthma to evaluate the effectiveness of an asthma
education program on morbidity, knowledge, and education program on morbidity, knowledge, and compliance with inhaled corticosteroid treatment in compliance with inhaled corticosteroid treatment in
149 adult asthmatics149 adult asthmatics
METHODSMETHODS Group 1: education + PEF monitoringGroup 1: education + PEF monitoring Group 2: education + symptoms monitoringGroup 2: education + symptoms monitoring Group 3: controlGroup 3: control
RESULTSRESULTS
• knowledgeknowledge and compliance and compliance significantly increased in both significantly increased in both educated groups educated groups
• asthma asthma morbiditymorbidity decreased decreased significantly in all groupsignificantly in all group
• between-group differences did between-group differences did not reach statistical significancenot reach statistical significance
J Cotè et al. Am J Respir Crit Care Med 1997Am J Respir Crit Care Med 1997
ASTHMA SELF-MANAGEMENT EDUCATION ASTHMA SELF-MANAGEMENT EDUCATION PROGRAM BY HOME MONITORING OF PEFPROGRAM BY HOME MONITORING OF PEF
JM Ignacio-Garcia, P Gonzalez-SantosJM Ignacio-Garcia, P Gonzalez-Santos
Am J Respir Crit Care Med 1995; 151:353-359Am J Respir Crit Care Med 1995; 151:353-359
• 71 adult asthmatics 71 adult asthmatics
• Prospective controlled studyProspective controlled study
Group 1: education program Group 1: education program
Group 2: controlGroup 2: control
RESULTSRESULTSThe experimental group showed a statistically The experimental group showed a statistically significant improvements in significant improvements in morbidity morbidity parameters:parameters:
• days lost from workdays lost from work
• acute asthma attacksacute asthma attacks
• days on antibiotic therapydays on antibiotic therapy
• physician consultationsphysician consultations
• emergency room admissionsemergency room admissions
JM Ignacio-Garcia et al. JM Ignacio-Garcia et al. Am J Respir Crit Care Med 1995Am J Respir Crit Care Med 1995
RANDOMISED COMPARISON OF GUIDED RANDOMISED COMPARISON OF GUIDED SELF MANAGEMENT AND TRADITIONAL SELF MANAGEMENT AND TRADITIONAL
TREATMENT OF ASTHMA OVER ONE YEAR TREATMENT OF ASTHMA OVER ONE YEAR
A Lahhdensuo, T Haahtela, J Herrala, T Kava, K Kiviranta, P A Lahhdensuo, T Haahtela, J Herrala, T Kava, K Kiviranta, P Kuusisto, E Peramaki, T Poussa, S Saarelainen, T Svahn Kuusisto, E Peramaki, T Poussa, S Saarelainen, T Svahn
Br Med J 1996; 312: 748-752Br Med J 1996; 312: 748-752
• Group 1: education program and PEF guided Group 1: education program and PEF guided adjustment of anti-inflammatory therapy adjustment of anti-inflammatory therapy
• Group 2: traditional treatmentGroup 2: traditional treatment
• 115 randomised patients with mild to 115 randomised patients with mild to moderately severe asthma moderately severe asthma
RESULTSRESULTS
• Unscheduled visitsUnscheduled visits
• Days off workDays off work
• Courses of antibiotics Courses of antibiotics
• Courses of prednisoloneCourses of prednisolone
lowerlower
• Quality of life score Quality of life score higherhigher
in the self management group than in in the self management group than in traditionally treated grouptraditionally treated group
A Lahhdensuo et al. A Lahhdensuo et al. Br Med J 1996Br Med J 1996
A RANDOMIZED TRIAL COMPARING PEAK A RANDOMIZED TRIAL COMPARING PEAK EXPIRATORY FLOW AND SYMPTOM SELF-EXPIRATORY FLOW AND SYMPTOM SELF-
MANAGEMENT PLANS FOR PATIENTS WITH MANAGEMENT PLANS FOR PATIENTS WITH ASTHMA ATTENDING A PRIMARY CARE CLINIC ASTHMA ATTENDING A PRIMARY CARE CLINIC
MO Turner, D Taylor, R Bennet, JM FitzgeraldMO Turner, D Taylor, R Bennet, JM Fitzgerald
Am J Respir Crit Care Med 1998; 157:540-546Am J Respir Crit Care Med 1998; 157:540-546
. 6 month prospective randomised study. 6 month prospective randomised study
. 92 patients with asthma. 92 patients with asthma
. two asthma self-management plans:. two asthma self-management plans:
* PEF based * symptoms based * PEF based * symptoms based
RESULTSRESULTS
SIGNIFICANT IMPROVEMENTS IN :SIGNIFICANT IMPROVEMENTS IN :
QUALITY OF LIFEQUALITY OF LIFE
SYMPTOM SCORESSYMPTOM SCORES
HOSPITALIZATIONHOSPITALIZATION
FEV 1FEV 1
* PEF based = * symptoms based * PEF based = * symptoms based
MO Turner et al. Am J Respir Crit Care Med 1998MO Turner et al. Am J Respir Crit Care Med 1998
THE IMPACT OF HEALTH EDUCATION ON THE IMPACT OF HEALTH EDUCATION ON
THE IMPACT OF HEALTH EDUCATION ON THE IMPACT OF HEALTH EDUCATION ON FREQUENCY AND COST OF HEALTH CARE FREQUENCY AND COST OF HEALTH CARE
USE BY LOW INCOME CHILDREN WITH USE BY LOW INCOME CHILDREN WITH ASTHMAASTHMA
N M CLARK, C H FELDMAN, D EVANS, M J LEVISON, N M CLARK, C H FELDMAN, D EVANS, M J LEVISON, Y WASILEWSKY, R B MELLINSY WASILEWSKY, R B MELLINS
J ALLERGY CLIN IMMUNOL 1986; 78: 108-15J ALLERGY CLIN IMMUNOL 1986; 78: 108-15RESULTSRESULTS
The education program The education program reduced health care reduced health care costscosts for children with one or more for children with one or more hospitalizations, savings $ 11.22 for every $ hospitalizations, savings $ 11.22 for every $ 1.00 spent to deliver health education1.00 spent to deliver health education
SELF- MANAGEMENT TEACHING PROGRAMS SELF- MANAGEMENT TEACHING PROGRAMS AND MORBIDITY OF PEDIATRIC ASTHMA: A AND MORBIDITY OF PEDIATRIC ASTHMA: A
META-ANALYSISMETA-ANALYSISAC BERNARD-BONNIN, S STACHENKO, D BONIN; C AC BERNARD-BONNIN, S STACHENKO, D BONIN; C
CHARETTEN E ROUSSEAUCHARETTEN E ROUSSEAUJ ALLERGY CLIN IMMUNOL,1995; 95, 1:34-41J ALLERGY CLIN IMMUNOL,1995; 95, 1:34-41
CONCLUSIONSCONCLUSIONS
Self-management teaching programs Self-management teaching programs do not do not seem to reduce morbidityseem to reduce morbidity and future and future programs should focus more on programs should focus more on intermediate outcomes such as intermediate outcomes such as behaviourbehaviour
COST-EFFECTIVENESS OF A STRUCTURED COST-EFFECTIVENESS OF A STRUCTURED TREATMENT AND TEACHING PROGRAMME ON TREATMENT AND TEACHING PROGRAMME ON
ASTHMAASTHMAC Trautner, B Richter, M BergerC Trautner, B Richter, M BergerEur Respir J 1993; 6:1485-1491Eur Respir J 1993; 6:1485-1491
• ADULT PATIENTS WITH MODERATE ADULT PATIENTS WITH MODERATE TO SEVERE ASTHMATO SEVERE ASTHMA• 5-DAYS IN-PATIENTS PROGRAMME5-DAYS IN-PATIENTS PROGRAMME• 3-YEARS FOLLOW-UP 3-YEARS FOLLOW-UP
RESULTSRESULTS IN THE THREE YEARS POST-IN THE THREE YEARS POST-
INTERVENTIONINTERVENTION DECREASE OF:DECREASE OF:• DAYS SPENT IN HOSPITALDAYS SPENT IN HOSPITAL
• DAYS OF ABSENCE FROM WORKDAYS OF ABSENCE FROM WORK
• ACUTE SEVERE ASTHMA ATTACKSACUTE SEVERE ASTHMA ATTACKS
• PHYSICIAN CONSULTATIONSPHYSICIAN CONSULTATIONS
• NET BENEFITS OF DM 12.850 PER PATIENT NET BENEFITS OF DM 12.850 PER PATIENT IN THREE YEARSIN THREE YEARS
C Trautner, B Richter, M BergerC Trautner, B Richter, M Berger Eur Respir J 19936:1485-1491Eur Respir J 19936:1485-1491
• MorbidityMorbidity outcomes year before vs year following outcomes year before vs year following n° of admission daysn° of admission days n° working days lostn° working days lost n° asthma attacksn° asthma attacks n° urgent examinationsn° urgent examinations
• Cost/benefit analysis:Cost/benefit analysis:Savings after 1 year Savings after 1 year CP = $ 1,894CP = $ 1,894 RP= $ 1,697 RP= $ 1,697 Net cost-benefitNet cost-benefit exceeding $ 1,000 in both exceeding $ 1,000 in both programmes programmes M Neri et Al M Neri et Al Allergy 1996Allergy 1996
RESULTSRESULTS
RIUNIONE EDUCAZIONALE SINGOLARIUNIONE EDUCAZIONALE SINGOLA
• TARIFFARIO REGIONE TARIFFARIO REGIONE LOMBARDIA 8393LOMBARDIA 8393
ASTHMA EDUCATIONASTHMA EDUCATIONL P BOULET, K R CHAPMANL P BOULET, K R CHAPMAN
L W GREEN , J M FITZGERALDL W GREEN , J M FITZGERALDCHEST 1994 106, 4: 184-196SCHEST 1994 106, 4: 184-196S
• … … at least in some settings and population, at least in some settings and population, structured educational intervention can structured educational intervention can reduce asthma morbidityreduce asthma morbidity
• … … research must define optimal methods, research must define optimal methods, assess cost-effectivenessassess cost-effectiveness
• ……programs should focus on high risk programs should focus on high risk groupsgroups
DIFFERENTIAL INFLUENCES ON ASTHMA DIFFERENTIAL INFLUENCES ON ASTHMA SELF-MANAGEMENT KNOWLEDGE AND SELF-SELF-MANAGEMENT KNOWLEDGE AND SELF-
MANAGEMENT BEHAVIOUR IN ACUTE MANAGEMENT BEHAVIOUR IN ACUTE SEVERE ASTHMASEVERE ASTHMA
J KOLBE, M VAMOS, W FERGUSSON, G HELKIND, J KOLBE, M VAMOS, W FERGUSSON, G HELKIND, J GARRETTJ GARRETT
CHEST 1996 110,6:1463-68CHEST 1996 110,6:1463-68
• ……while the acquisition of practical asthma while the acquisition of practical asthma knowledge is important..., it is not itself knowledge is important..., it is not itself sufficient for satisfactory self-management sufficient for satisfactory self-management behaviourbehaviour
• ... ... physician-patient relationshipphysician-patient relationship was associated was associated positively with both knowledge and behaviour positively with both knowledge and behaviour
IN ITALIAIN ITALIA
• DAL 1990 NUMEROSE INIZIATIVE A DAL 1990 NUMEROSE INIZIATIVE A CARATTERE LOCALE TIPO “SCUOLA CARATTERE LOCALE TIPO “SCUOLA DELL’ASMA”DELL’ASMA”
• 1995 TRADUZIONE ED ADATTAMENTO 1995 TRADUZIONE ED ADATTAMENTO LINEE-GUIDA GINALINEE-GUIDA GINA
• 1998-99 PROGETTO GARDA1998-99 PROGETTO GARDA• 1999 PROPOSTA AIPO REGIONE EMILIA-1999 PROPOSTA AIPO REGIONE EMILIA-
ROMAGNAROMAGNA
CONCLUSIONI: IN QUALE CONCLUSIONI: IN QUALE DIREZIONE STIAMO ANDANDO?DIREZIONE STIAMO ANDANDO?
• INTERVENTO MEDICO CENTRATO INTERVENTO MEDICO CENTRATO SULLA PERSONA MALATASULLA PERSONA MALATA
• INTERVENTO GESTITO USUALMENTE INTERVENTO GESTITO USUALMENTE DAL MEDICO GENERALISTADAL MEDICO GENERALISTA
• INTERVENTO BASATO SUI INTERVENTO BASATO SUI PRESUPPOSTI DELL’EVIDENZAPRESUPPOSTI DELL’EVIDENZA
• INTERVENTO SOTTOPOSTO A INTERVENTO SOTTOPOSTO A VALUTAZIONE CONTINUAVALUTAZIONE CONTINUA
