A systematic review by the Cochrane Airways Group has shown that training patients in asthma self-management which involves self-monitoring of either peak expiratory flow or symptoms, coupled with regular medical review and a written action plan appeared to improve health outcomes for adults with asthma. In addition, self-management education reduced hospitalizations, visits by the doctor, unscheduled visits to the doctor, days off work or school and nocturnal asthma. Finally, training programmes that enabled people to adjust their medication using a written action plan appeared to be more effective than other forms of asthma self-management and significant improvements in lung function were achieved (24).
The Cochrane Airways Group has also shown that non-comprehensive approaches such as the use of limited education about asthma (information only) do not appear to improve health outcomes in adults with asthma although perceived symptoms may improve (24).
Therefore, patient education and self-management should be integral components of any plan for long-term control of asthma. In particular, economic appraisals of asthma self-management programmes have shown them to be cost-effective both in terms of direct costs (mainly averted hospitalizations and reduced emergency department use) and in terms of indirect costs (e.g. productivity losses and missed school days).The cost-benefit ratios are between 1: 2.5 and 1: 7. Ratios are even better in programmes directed at high-risk groups and patients with severe asthma (25-27). Some examples of studies that reported net cost-savings are described below.
The Open Airways programme of six 1-hour monthly sessions instructed low-income parents of 310 urban children with asthma in the management steps to be taken both by the children and their parents. The programme found that 44% of the parents lacked confidence in their ability to manage asthma attacks, believing they should take their children to the hospital emergency department for all episodes, whether mild or severe. Compared to a control group, participation in the Open Airways programme reduced emergency department visits and hospitalizations for asthma among those who had been hospitalized during the previous year by half, resulting in savings of US 11.22 for every dollar spent (28).
An Italian study evaluated two structured educational programmes on asthma. The study found that the savings per patient in terms of reduced morbidity were US 1894.70 (for the intensive programme (IP)) and US 1697.80 (for the brief programme (BP)).The net benefit was US 1181.50 for IP and US 1028.00 for BP and the cost-benefit ratio per dollar spent was 1: 2.6 for IP and 1: 2.5 for BP (29).
In a programme at Henry Ford Hospital in Detroit, Michigan, in 1986-1987 involving three, 1-hour, education sessions in small groups, a registered nurse taught patients about the importance of medication adherence, methods to control and prevent asthma attacks, relaxation exercises and smoking cessation. For just US 85 per person in annual programme costs, this intervention reduced the cost of emergency department visits by US 623 per person during the following year. The programme also reduced the number of days on which the activity of participants was limited because of asthma by 35% compared to a control group (30).
In Germany a structured intervention programme produced net benefits of DM 12 850 (in 1991 DM) per patient within 3 years. Within the health care sector, the net benefits were DM 5 900. Within 3 years, the paying bodies saved DM 2.70, and society as a whole saved DM 5.00 on each DM spent on the programme (cost-saving ratios 1: 2.7 and 1: 5).The authors concluded that the intervention produced net monetary benefits. This result was stable even when tested with different outcome measures. Such a programme is therefore worthwhile, not only for its demonstrated medical benefits, but also for its economic savings (31).
In a study in the United States, adult patients with asthma learned self-management skills in seven 90- minute, group sessions at Ohio University in Athens, Ohio. Participants were asked to keep a weekly record of peak flow rates and of any attacks they experienced. They also kept a workbook to record the information that was later used to calculate costs and benefits. At a programme cost of US 208 per patient, annual asthma-related costs for each patient were reduced by an average of nearly US 500 in the year following the programme, primarily from reductions in hospitalizations and work absences. The researchers have also adapted an individualized intervention for use in doctors' surgeries (32). The subsequent economic evaluation of this study showed that the programme was beneficial, reducing the cost of asthma to each patient by US 475.29. The benefit came primarily from reductions in hospital admissions (reduced from US 18 488 to US 1538) and income lost as a result of asthma (reduced from US 11 593 to US 4 589).The asthma self-management programme cost US 208.33 per patient. A comparison of the costs of the programme with the benefits produced a 1: 2.28 cost-benefit ratio, demonstrating that the programme more than paid for itself (33).
The Harvard Community Health Plan, a large staff-model HMO, reduced the annual rate of paediatric emergency-department admissions related to asthma by 79% and hospital admissions by 86% using a single outreach nurse for 8 hours per week. In addition to instructing patients in asthma management, medications, triggers, and the use of inhalers and peak-flow meters, the nurse maintained regular telephone contact with the families to ensure compliance with individualized treatment plans. Patients participated for between 6 months and 2 years. At a cost of just US 11 115 per year, this intervention saved approximately US 87 000 in 1993 dollars (34).
In the Wee Wheezers programme, four small-group sessions of about 2 hours each were conducted to instruct parents of children under the age of 7 years how to help their children manage asthma attacks, communicate with health professionals, and promote the psychosocial well-being of the family unit. The last two sessions included 45 minutes of direct instruction for children aged 4-6 years. On average, the children reported 0.9 fewer sick days and 5.8 more symptom-free days, and their parents reported 4.4 more nights of uninterrupted sleep during the month preceding the follow-up questionnaire. The programme cost approximately US 26 per child (35).
To sum up, best practices in asthma control and in enhancement of adherence must include and reinforce the links between education and self-management. Not surprisingly, there is high quality evidence to support the efficacy and cost-effectiveness of guided self-management plans. Furthermore, most studies have reported net cost-savings.