LEVOLUZIONE DEGLI INTERVENTI EDUCAZIONALI NELLA GESTIONE DEL PAZIENTE

L’EVOLUZIONE DEGLI INTERVENTI EDUCAZIONALI NELLA GESTIONE DEL PAZIENTE ASMATICO M. NERI FONDAZIONE S. MAUGERI TRADATE (VA)

THE COSTS OF ASTHMA P J BARNES, B JONSSON, J B KLIM EUR RESPIR J 1996, 9: 636 -42 • …. asthma costs are substantial, representing over 1% of total health care costs in the USA • …. . as for direct costs, hospital cost associated with asthma ranged from 18% (Australia) to 79% (Sweden)

ASTHMA COSTS (MODIFIED FROM P J BARNES) % TOTAL COST DC IC

ASTHMA COSTS (MODIFIED FROM P J BARNES) HOSP PHYS DRUGS OTHER

THE COSTS OF ASTHMA P J BARNES, B JONSSON, J B KLIM EUR RESPIR J 1996, 9: 636 -42 • Underuse of prescribed therapy, which includes compliance, significantly contributes to poor control of asthma, increased morbidity and mortality and health care expenditure EDUCATION ?

COME VALUTARE I RISULTATI DELL’EDUCAZIONE ? • CONOSCENZA • MORBILITA’ • QUALITA’ DELLA VITA • COSTO-BENEFICIO

CONTROLLED EVALUATION OF THE EFFECTS OF PATIENTS EDUCATION ON ASTHMA MORBIDITY IN GENERAL PRACTICE S Hilton, B Sibbald, H Ross Anderson, P Freeling The Lancet, 4: 26 -29 1986 2 DIFFERENT PATIENT EDUCATION PROGRAMMES FOR ASTHMA IN GENERAL PRACTICE 274 PATIENTS REASSESSED AFTER 1 YEAR Group 1: maximum education programme Group 2: limited education programme Group 3: control group

• Only in the maximum intervention group was a significant improvement in knowledge of asthma shown. • Neither group showed any change in self-management ability or asthma morbidity that differed significantly from changes in the control group. S Hilton et al. Lancet 1986

RANDOMISED TRIAL OF AN ASTHMA SELFMANAGEMENT PROGRAMME FOR ADULTS RM Allen, MP Jones, B Oldenburg Thorax 1995; 50: 731 -738 The effect of an educational programme was evaluated in 116 adult asthmatics (12 months of follow-up) Group 1: education programme Group 2: control

OUTCOMES • Asthma knowledge (questionnaire) • Compliance (diary records) • Morbidity (diary, spirometry, PEF) RESULTS • Knowledge and compliance significantly increased in the educational group, but the impact on morbidity was modest. RM Allen et al. Thorax 1995

A SELF MANAGEMENT PLAN IN THE TREATMENT OF ADULT ASTHMA R Beasley, M Cushley, ST Holgate Thorax 1989; 44: 200 -204 • 36 adult asthmatics • open prospective study; no control group AIM: to determine whether routine assessment of PEF in association with a self management plan is effective in the management of asthma.

RESULTS SIGNIFICANT REDUCTION OF: • NIGHTS WOKEN • DAYS LOST FROM WORK • REQUIREMENT ORAL CORTICOSTEROIDS SIGNIFICANT INCREASE OF: FEV 1 and FVC R Beasley et al. Thorax 1989

INFLUENCE ON ASTHMA MORBIDITY OF ASTHMA EDUCATION PROGRAMS BASED ON SELFMANAGEMENT PLANS FOLLOWING TREATMENT OPTIMIZATION J Cotè, A Cartier, P Robichaud, H Boutin, JL Malo, M Rouleau, A Fillion, M Lavallèe, M Krusky, LP Boulet Am J Respir Crit Care Med 1997; 155: 1509 -1514 AIM to evaluate the effectiveness of an asthma education program on morbidity, knowledge, and compliance with inhaled corticosteroid treatment in 149 adult asthmatics METHODS Group 1: education + PEF monitoring Group 2: education + symptoms monitoring Group 3: control

RESULTS • knowledge and compliance significantly increased in both educated groups • asthma morbidity decreased significantly in all group • between-group differences did not reach statistical significance J Cotè et al. Am J Respir Crit Care Med 1997

ASTHMA SELF-MANAGEMENT EDUCATION PROGRAM BY HOME MONITORING OF PEF JM Ignacio-Garcia, P Gonzalez-Santos Am J Respir Crit Care Med 1995; 151: 353 -359 • 71 adult asthmatics • Prospective controlled study Group 1: education program Group 2: control

RESULTS The experimental group showed a statistically significant improvements in morbidity parameters: • days lost from work • acute asthma attacks • days on antibiotic therapy • physician consultations • emergency room admissions JM Ignacio-Garcia et al. Am J Respir Crit Care Med 1995

RANDOMISED COMPARISON OF GUIDED SELF MANAGEMENT AND TRADITIONAL TREATMENT OF ASTHMA OVER ONE YEAR A Lahhdensuo, T Haahtela, J Herrala, T Kava, K Kiviranta, P Kuusisto, E Peramaki, T Poussa, S Saarelainen, T Svahn Br Med J 1996; 312: 748 -752 • Group 1: education program and PEF guided adjustment of anti-inflammatory therapy • Group 2: traditional treatment • 115 randomised patients with mild to moderately severe asthma

RESULTS • Unscheduled visits • Days off work lower • Courses of antibiotics • Courses of prednisolone • Quality of life score higher in the self management group than in traditionally treated group A Lahhdensuo et al. Br Med J 1996

A RANDOMIZED TRIAL COMPARING PEAK EXPIRATORY FLOW AND SYMPTOM SELFMANAGEMENT PLANS FOR PATIENTS WITH ASTHMA ATTENDING A PRIMARY CARE CLINIC MO Turner, D Taylor, R Bennet, JM Fitzgerald Am J Respir Crit Care Med 1998; 157: 540 -546 . 6 month prospective randomised study. 92 patients with asthma. two asthma self-management plans: * PEF based * symptoms based

RESULTS SIGNIFICANT IMPROVEMENTS IN : QUALITY OF LIFE SYMPTOM SCORES HOSPITALIZATION FEV 1 * PEF based = * symptoms based MO Turner et al. Am J Respir Crit Care Med 1998

THE IMPACT OF HEALTH EDUCATION ON FREQUENCY AND COST OF HEALTH CARE USE BY LOW INCOME CHILDREN WITH ASTHMA N M CLARK, C H FELDMAN, D EVANS, M J LEVISON, Y WASILEWSKY, R B MELLINS J ALLERGY CLIN IMMUNOL 1986; 78: 108 -15 RESULTS The education program reduced health care costs for children with one or more hospitalizations, savings $ 11. 22 for every $ 1. 00 spent to deliver health education

SELF- MANAGEMENT TEACHING PROGRAMS AND MORBIDITY OF PEDIATRIC ASTHMA: A META-ANALYSIS AC BERNARD-BONNIN, S STACHENKO, D BONIN; C CHARETTEN E ROUSSEAU J ALLERGY CLIN IMMUNOL, 1995; 95, 1: 34 -41 CONCLUSIONS Self-management teaching programs do not seem to reduce morbidity and future programs should focus more on intermediate outcomes such as behaviour

COST-EFFECTIVENESS OF A STRUCTURED TREATMENT AND TEACHING PROGRAMME ON ASTHMA C Trautner, B Richter, M Berger Eur Respir J 1993; 6: 1485 -1491 • ADULT PATIENTS WITH MODERATE TO SEVERE ASTHMA • 5 -DAYS IN-PATIENTS PROGRAMME • 3 -YEARS FOLLOW-UP

RESULTS IN THE THREE YEARS POST- • • • INTERVENTION DECREASE OF: DAYS SPENT IN HOSPITAL DAYS OF ABSENCE FROM WORK ACUTE SEVERE ASTHMA ATTACKS PHYSICIAN CONSULTATIONS NET BENEFITS OF DM 12. 850 PER PATIENT IN THREE YEARS C Trautner, B Richter, M Berger Eur Respir J 19936: 1485 -1491

RESULTS • Morbidity outcomes year before vs year following n° of admission days n° working days lost n° asthma attacks n° urgent examinations • Cost/benefit analysis: Savings after 1 year CP = $ 1, 894 RP= $ 1, 697 Net cost-benefit exceeding $ 1, 000 in both programmes M Neri et Al Allergy 1996

RIUNIONE EDUCAZIONALE SINGOLA • TARIFFARIO REGIONE LOMBARDIA 8393

ASTHMA EDUCATION L P BOULET, K R CHAPMAN L W GREEN , J M FITZGERALD CHEST 1994 106, 4: 184 -196 S • … at least in some settings and population, structured educational intervention can reduce asthma morbidity • … research must define optimal methods, assess cost-effectiveness • …programs should focus on high risk groups

DIFFERENTIAL INFLUENCES ON ASTHMA SELF-MANAGEMENT KNOWLEDGE AND SELFMANAGEMENT BEHAVIOUR IN ACUTE SEVERE ASTHMA J KOLBE, M VAMOS, W FERGUSSON, G HELKIND, J GARRETT CHEST 1996 110, 6: 1463 -68 • …while the acquisition of practical asthma knowledge is important. . . , it is not itself sufficient for satisfactory self-management behaviour • . . . physician-patient relationship was associated positively with both knowledge and behaviour

IN ITALIA • DAL 1990 NUMEROSE INIZIATIVE A CARATTERE LOCALE TIPO “SCUOLA DELL’ASMA” • 1995 TRADUZIONE ED ADATTAMENTO LINEE-GUIDA GINA • 1998 -99 PROGETTO GARDA • 1999 PROPOSTA AIPO REGIONE EMILIA -ROMAGNA

CONCLUSIONI: IN QUALE DIREZIONE STIAMO ANDANDO? • INTERVENTO MEDICO CENTRATO SULLA PERSONA MALATA • INTERVENTO GESTITO USUALMENTE DAL MEDICO GENERALISTA • INTERVENTO BASATO SUI PRESUPPOSTI DELL’EVIDENZA • INTERVENTO SOTTOPOSTO A VALUTAZIONE CONTINUA