Evidence Report/Technology Assessment 

Number 9 

Closing the Quality Gap: 

A Critical Analysis of Quality Improvement Strategies 

Volume 5—Asthma Care 

Prepared for: 

Agency for Healthcare Research and Quality 

U.S. Department of Health and Human Services 

540 Gaither Road 

Rockville, MD 20850 

www.ahrq.gov 

Contract No. 290-02-0017 

Prepared by:

Stanford University-UCSF Evidence-based Practice Center, Stanford, CA 

Series Editors 

Kaveh G. Shojania, M.D., University of California, San Francisco 

Kathryn M. McDonald, M.M., Stanford University 

Robert M. Wachter, M.D., University of California, San Francisco 

Douglas K. Owens, M.D., M.S., VA Palo Alto Health Care System, Palo Alto, California; 

Stanford University

Investigators

Dena M. Bravata, M.D., M.S. 

Vandana Sundaram, M.P.H. 

Robyn Lewis, M.A. 

Allison Gienger, B.A. 

Michael K. Gould, M.D., M.S. 

Kathryn M. McDonald, M.M. 

Paul H. Wise, M.D., M.P.H. 

Jon-Erik C. Holty, M.D., M.S. 

Katherine Hertz, M.D. 

Helen Paguntalan, M.S. 

Christopher Sharp, M.D. 

John Kim, M.D. 

Ewen Wang, M.D. 

Lisa Chamberlain, M.D., M.P.H. 

Lisa Shieh, M.D., Ph.D. 

Douglas K. Owens, M.D., M.S. 

AHRQ Publication No. 04(07)-0051-5 

January 2007 
 

This report is based on research conducted by the Stanford-UCSF Evidence-based Practice Center 

(EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD 

(Contract No. 290-02-0017). The findings and conclusions in this document are those of the 

author(s), who are responsible for its contents, and do not necessarily represent the views of 

AHRQ. No statement in this report should be construed as an official position of AHRQ or of the 

U.S. Department of Health and Human Services. 

The information in this report is intended to help clinicians, employers, policymakers, and others 

make informed decisions about the provision of health care services. This report is intended as a 

reference and not as a substitute for clinical judgment. 

This report may be used, in whole or in part, as the basis for development of clinical practice 

guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage 

policies. AHRQ or U.S. Department of Health and Human Services endorsement of such 

derivative products may not be stated or implied. 
 ii 

This document is in the public domain and may be used and reprinted without permission except 

those copyrighted materials noted for which further reproduction is prohibited without the 

specific permission of copyright holders. 

Suggested Citation: 

Bravata DM, Sundaram V, Lewis R, Gienger A, Gould MK, McDonald KM, Wise PH, Holty 

J-EC, Hertz K, Paguntalan H, Sharp C, Kim J, Wang E, Chamberlain L, Shieh L, Owens DK. 

Asthma Care. Vol 5 of: Shojania KG, McDonald KM, Wachter RM, Owens DK, editors. 

Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Technical 

Review 9 (Prepared by the Stanford University-UCSF Evidence-based Practice Center under 

Contract No. 290-02-0017). AHRQ Publication No. 04(07)-0051-5. Rockville, MD: Agency 

for Healthcare Research and Quality. January 2007.

None of the investigators has any affiliations or financial 

involvement that conflicts with the material presented in 

this report. 
 iii 

Preface 

 The Agency for Healthcare Research and Quality (AHRQ), through its Evidence-Based 

Practice Centers (EPCs), sponsors the development of evidence reports and technology 

assessments to assist public- and private-sector organizations in their efforts to improve the 

quality of health care in the United States. The reports and assessments provide organizations 

with comprehensive, science-based information on common, costly medical conditions and new 

health care technologies. The EPCs systematically review the relevant scientific literature on 

topics assigned to them by AHRQ and conduct additional analyses when appropriate prior to 

developing their reports and assessments. 

 To bring the broadest range of experts into the development of evidence reports and health 

technology assessments, AHRQ encourages the EPCs to form partnerships and enter into 

collaborations with other medical and research organizations. The EPCs work with these partner 

organizations to ensure that the evidence reports and technology assessments they produce will 

become building blocks for health care quality improvement projects throughout the Nation. The 

reports undergo peer review prior to their release. 

 AHRQ expects that the EPC evidence reports and technology assessments will inform 

individual health plans, providers, and purchasers as well as the health care system as a whole by 

providing important information to help improve health care quality. 

 We welcome comments on this evidence report. They may be sent by mail to the Task Order 

Officer named below at: Agency for Healthcare Research and Quality, 540 Gaither Road, 

Rockville, MD 20850, or by e-mail to epc@ahrq.gov. 

Carolyn M. Clancy, M.D. Jean Slutsky, P.A., M.S.P.H. 

Director Director, Center for Outcomes and Evidence 

Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality 

Beth A. Collins Sharp, Ph.D., R.N. Marian D. James, Ph.D., M.A. 

Director, EPC Program EPC Program Task Order Officer 

Agency for Healthcare Research and Quality Agency for Healthcare Research and Quality 
 iv 

Acknowledgments 

We thank Jessie McGowan of the Cochrane Effective Practice and Organisation of Care (EPOC) 

group and Shirley Ward of the Cochrane Consumers and Communication Group for their help 

with the literature searches. Thanks also to Corinna Haberland for help with data abstractions 

and Cristina Galvin for administrative assistance with this report. We also acknowledge with 

much gratitude our expert advisors and peer reviewers who are listed in Appendix D*

.

 

*

 Appendixes cited in this report are provided electronically at http://www.ahrq.gov/clinic/tp/asthmagaptp.htm 
 v 

Structured Abstract 

Objectives: Despite the availability of evidence-based guidelines for the management of 

pediatric and adult asthma, there remains a significant gap between accepted best practices for 

asthma care and actual care delivered to asthma patients. The purpose of this systematic review 

was to evaluate the evidence that quality improvement (QI) strategies can improve the processes 

and outcomes of outpatient care for children and adults with asthma. 

Data Sources: We searched four literature sources: the Cochrane Effective Practice and 

Organisation of Care (EPOC) Group database (1/1966 to 4/2006), MEDLINE® (1/1966 to 

4/2006), the Cochrane Consumers and Communication Group database (1/1966 to 5/2006), and 

bibliographies of retrieved articles. 

Review Methods: We sought English language studies of interventions that included one or 

more QI strategies (e.g., patient education, provider education, audit and feedback) for the 

outpatient management of children or adults with asthma. Included studies were required to be 

either randomized controlled trials, controlled before-after trials, or interrupted time series trials. 

The four primary types of outcomes of interest were measures of clinical status (e.g., asthma 

symptoms, spirometric measures); measures of functional status (e.g., days lost from work or 

school); measures of health services utilization (e.g., hospital admissions); and measures of 

adherence to guidelines (e.g., number of patients given prescriptions for inhaled corticosteroids). 

Results: We identified 3843 potentially relevant articles, of which 200 articles describing 171 

studies met our inclusion criteria. These studies exhibited substantial variation in terms of the 

types of strategies evaluated. However, using broad, pragmatic categories for quality 

improvement strategies, 100 included at least some component of patient education, 94 studies 

included some component of self-monitoring or self-management, 27 included some component 

of organizational change, and 19 included provider education, among others. The studies also 

evaluated heterogeneous patient populations, but these could be broadly categorized into those 

that targeted children or adolescents with asthma or their families (79 studies) and outpatient 

populations with asthma comprised typically of adults (92 studies). Among all studies of 

pediatric asthma evaluating self-monitoring, self-management, or patient education 

interventions, those directed at parents or caregivers, as opposed to at the children themselves 

and not their parents, were more likely to be associated with a statistically significant 

improvement in clinical outcomes (e.g., improvements in asthma symptoms or spirometric 

measures (p=0.02)). Self-monitoring, self-management, or patient education interventions for 

general populations or adults with asthma were associated with improvements in percent 

predicted FEV1 (weighted mean difference: 2.92 percent predicted FEV1; 95% CI 0.92, 4.92; 

p=0.004) and mean peak flow (weighted mean difference: 27.95 L/min; 95% CI 10.75, 45.15; 

(p=0.01). QI interventions that are based explicitly on a theoretical framework, provide multiple 

educational sessions, have longer durations, and use combinations of instructional modalities 

(e.g., small group teaching with role-playing and handouts) are more likely to result in 

improvements for patients than interventions lacking these characteristics. When taken as a 
 vi 

group, the improvements reported in the included studies were often statistically significant but 

possibly only of borderline clinical significance. 

Conclusions: A wide variety of types of QI interventions have been found to improve the 

outcomes and processes of care for children and adults with asthma. Young children with 

asthma benefit most from QI strategies that also include their caregivers or parents. General 

populations with asthma can have clinically significant improvements in spirometric measures 

after participating in self-monitoring, self-management, or patient education interventions—

especially interventions that are based on theoretical frameworks, are of relatively long 

durations, and utilize combinations of educational modalities.
 

vii 

Contents

Executive Summary.........................................................................................................................1 

Technical Review.......................................................................................................................... 11 

Chapter 1. Introduction ................................................................................................................ 13 

 The Quality Gap...................................................................................................................... 14 

 Key Research Questions ......................................................................................................... 15 

Chapter 2. Methods...................................................................................................................... 17 

 Types of Quality Improvement Strategies .............................................................................. 17 

 Inclusion and Exclusion Criteria............................................................................................. 18 

 Search Strategy ....................................................................................................................... 19 

 Data Abstraction and Evaluation ............................................................................................ 19 

 Statistical Analysis.................................................................................................................. 20 

 Univariate Analyses.......................................................................................................... 20 

 Multivariate Analyses ....................................................................................................... 21 

 Peer Review Process............................................................................................................... 21 

Chapter 3. Results........................................................................................................................ 23 

 Results of Literature Search and Article Review Process ...................................................... 23 

 Summary of Included Studies................................................................................................. 24

 General Characteristics of Included Studies..................................................................... 24 

 Results by QI Intervention...................................................................................................... 29 

 Self-Monitoring, Self-Management, or Patient Education Interventions ......................... 29 

Systematic Reviews of Asthma Self-Monitoring, Self-Management, 

or Patient Education.................................................................................................... 30 

General Characteristics of Self-Monitoring, Self-Management, or Patient 

Education Interventions for Children With Asthma ................................................... 31 

 Self-Monitoring or Self-Management Interventions for Children With Asthma ....... 34 

 Patient Education Interventions for Children With Asthma ....................................... 46 

Synthesis of Evidence From Self-Monitoring, Self-Management, or Patient 

Education Interventions for Children With Asthma ................................................... 68 

General Characteristics of Self-Monitoring, Self-Management, or Patient 

Education Interventions for General Populations or Adults With Asthma................. 76 

Synthesis of Evidence From Self-Monitoring, Self-Management, or Patient 

Education Interventions for General Populations or Adults With Asthma............... 104 

Self-Monitoring, Self-Management, or Patient Education Trials Comparing 

Two Intervention Groups Without a Control Group................................................. 113 

 Provider Education Interventions ................................................................................... 128 

 Organizational Change Interventions ............................................................................. 138 

 Organizational Change Interventions for Children With Asthma ............................ 138 

 Organizational Change Interventions for Adults With Asthma................................ 145 
 

viii 

 Audit and Feedback Interventions .................................................................................. 151 

 Facilitated Relay of Clinical Data................................................................................... 154 

 Provider Reminder Interventions.................................................................................... 155 

 Financial Incentives ........................................................................................................ 156 

 Secondary Outcomes ............................................................................................................ 156 

 Costs................................................................................................................................ 157 

 Quality of Life................................................................................................................. 162 

 Reductions in Environmental Allergen Exposure........................................................... 167 

 Tobacco Smoke Exposure............................................................................................... 168 

 Summary Answers to the Key Questions ............................................................................. 171 

Chapter 4. Discussion ................................................................................................................ 173 

 Limitations ............................................................................................................................ 174 

 Future Research .................................................................................................................... 174 

 Conclusions........................................................................................................................... 175 

References and Included Studies ................................................................................................ 177 

List of Acronyms/Abbreviations................................................................................................. 199 

Figures 

Figure 1. U.S. asthma prevalence............................................................................................... 13 

Figure 2. Search results ...............................................................................................................23 

Figure 3. Intervention duration....................................................................................................26 

Figure 4. Intervention settings.....................................................................................................27 

Figure 5. Intervention characteristics: setting and educator type...............................................32 

Figure 6. Number of educational sessions provided by educational strategy .............................33 

Figure 7. Funnel plot: school absenteeism due to asthma..........................................................69 

Figure 8. Self-monitoring, self-management, or patient education studies reporting 

mean number of school days missed due to asthma per month...................................70 

Figure 9. Funnel plot: asthma-related ED/urgent care visits......................................................71 

Figure 10. Funnel plot: hospitalizations due to asthma................................................................72 

Figure 11. Self-monitoring, self-management, or patient education studies reporting mean 

number of emergency department/urgent care visits due to asthma per month ..........74 

Figure 12. Self-monitoring, self-management, or patient education studies reporting mean 

number of hospital days due to asthma per month ......................................................75 

Figure 13. Intervention characteristics: setting and educator type...............................................77 

Figure 14. Number of educational sessions provided by educational strategy .............................78 

Figure 15. Funnel plot: FEV1 percent predicted.........................................................................104 

Figure 16. Funnel plot: mean peak flow.....................................................................................105

Figure 17. Self-monitoring, self-management, or patient education studies reporting 

percent of predicted FEV1..........................................................................................108 

Figure 18. Self-monitoring, self-management, or patient education studies reporting 

mean peak flow..........................................................................................................109 
 

ix 

Figure 19. Self-monitoring, self-management, or patient education studies reporting 

mean days lost from work or school..........................................................................110 

Figure 20. Self-monitoring, self-management, or patient education studies reporting 

urgent care/emergency department visits...................................................................111 

Figure 21. Self-monitoring, self-management, or patient education studies 

reporting hospitalizations...........................................................................................112 

Tables 

Table 1. Definitions of the nine quality improvement strategies used in the Closing 

the Quality Gap Series .................................................................................................17 

Table 2. Design attributes of the included studies .....................................................................24 

Table 3. Association of study design and patient outcomes ......................................................24 

Table 4. Association of sample size and patient outcomes........................................................25 

Table 5. Association of specifying a theoretical framework and patient outcomes ..................26 

Table 6. Association of study duration and patient outcomes ...................................................27 

Table 7. Distribution of included studies by type of QI strategy...............................................27 

Table 8. Association of combinations of QI strategies and patient outcomes ...........................28 

Table 9. Number of studies reporting each outcome .................................................................28 

Table 10. Outcomes reported by the pediatric self-monitoring, self-management, 

or patient education studies..........................................................................................34 

Table 11. Summary of self-monitoring or self-management interventions directed 

at children with asthma ................................................................................................37 

Table 12a. Summary of patient education interventions directed at the parents 

or caregivers of children with asthma..........................................................................49 

Table 12b. Summary of school-based patient education interventions directed at children 

with asthma ..................................................................................................................55

Table 12c. Summary of patient education interventions directed at adolescents 

with asthma ..................................................................................................................60

Table 12d. Summary of outpatient patient education interventions directed at children 

with asthma ..................................................................................................................62

Table 13. Association of pediatric self-monitoring, self-management, or patient 

education intervention characteristics and significant clinical outcomes....................68 

Table 14. Association of pediatric self-monitoring, self-management, or patient education 

intervention characteristics and reductions in school absenteeism..............................69 

Table 15. Association of pediatric self-monitoring, self-management, or patient 

education intervention characteristics and reductions in asthma-related 

emergency department/urgent care visits.....................................................................72 

Table 16. Association of pediatric self-monitoring, self-management, or patient education 

intervention characteristics and reductions in asthma-related hospitalizations ...........73 

Table 17. Outcomes reported by the adult self-monitoring, self-management, 

or patient education studies..........................................................................................79 

Table 18a. Summary of nurse-led self-monitoring, self-management, or patient 

education interventions directed at adults with asthma ...............................................82 
 

x 

Table 18b. Summary of adult self-monitoring, self-management, or patient education 

interventions provided by pharmacists ........................................................................88 

Table 18c. Summary of other self-monitoring, self-management, or patient education 

interventions directed at adults with asthma................................................................90 

Table 19. Association of study/intervention characteristics and improvements 

 in FEV1 percent predicted.........................................................................................105 

Table 20. Association of study/intervention characteristics and improvements 

in mean peak flow......................................................................................................106 

Table 21. Trials comparing two or more intervention groups without a control group 

that did not also receive an intervention ....................................................................115 

Table 22. Summary of provider education interventions for the improvement of asthma 

in children ..................................................................................................................131 

Table 23. Summary of provider education interventions for the improvement of asthma 

in general populations or adults .................................................................................134 

Table 24. Organizational change interventions for children with asthma .................................140 

Table 25. Organizational change interventions for adults with asthma.....................................147 

Table 26. Audit and feedback interventions ..............................................................................152 

Table 27. Summary of studies presenting cost data...................................................................159 

Table 28. Summary of interventions assessing QOL for children with asthma 

and caregivers ............................................................................................................163 

Table 29. Summary of interventions assessing QOL for general populations or adults 

with asthma ................................................................................................................165 

Table 30. Rate of reported tobacco use among patients with asthma and their 

family members .........................................................................................................170 

Appendixes 

Appendix A: Search Strategies by Database 

Appendix B: Data Abstraction Forms 

Appendix C: List of Excluded Studies 

Appendix D: Technical Expert Panel and Peer Reviewers 

Appendices and Evidence Tables for this report are provided electronically at 

http://www.ahrq.gov/downloads/pub/evidence/pdf/qualgap5/asthmagap.pdf. 
1

Executive Summary 

Overview 

Asthma is one of the most common chronic medical conditions in the U.S. It affects 16 

million adults and 6.1 million children and results in two million visits to emergency 

departments, 70,000 hospitalizations, and 5,000 deaths annually. The burden of asthma 

disproportionately affects persons of lower socioeconomic status. Because asthma can neither be 

prevented nor cured, current management objectives are to monitor symptoms and objective 

measures of lung function, to encourage the use of medications that control and prevent 

symptoms with the fewest adverse effects possible, to control the triggers of asthma symptoms to 

which a patient is sensitive (such as house dust mites, tobacco smoke, animal dander, and 

pollens), and to facilitate an asthma care partnership between patients and providers. Effective 

asthma management has been demonstrated to reduce symptoms, hospitalizations, and urgent 

care visits. 

Despite the availability of evidence-based guidelines for the management of pediatric and 

adult asthma, there remains a significant gap between accepted best practices for asthma care and 

actual care delivered to asthma patients. The objective of this systematic review was to evaluate 

the evidence that quality improvement (QI) strategies can improve the processes and outcomes 

of outpatient care for children and adults with asthma, and to identify the most effective 

strategies. 

Key Questions 

The two research questions addressed in this study were: 

Research Question 1: What is the evidence that QI strategies improve the processes and 

outcomes of outpatient care for pediatric and adult populations with asthma? Specifically, which 

QI strategies are effective for improving processes and outcomes of asthma care for specific 

patient populations (e.g., adults, children, low socio-economic status (SES), racial groups, 

urban/rural)? Also, does the setting of the QI intervention (e.g., home, school, clinic) determine 

its effectiveness for improving processes and outcomes of asthma care? 

Research Question 2: Are QI interventions for asthma care that incorporate multiple strategies 

more effective than those that employ a single strategy?

Methodology 

We sought English language evaluations of quality improvement strategies designed to 

improve the outpatient management of children and adults with asthma. We defined QI 

strategies as interventions aimed at reducing the quality gap (the difference between health care 

processes or outcomes observed in practice and evidence-based practices potentially obtainable 
2

on the basis of current professional knowledge). We included articles describing interventions 

with one or more of nine types of QI strategies: patient education, the promotion of selfmonitoring or self-management, provider education, organizational change, audit and feedback, 

provider reminders, patient reminders, facilitated relay of clinical data to providers, and financial 

or legislative incentives. 

Study Design. Because most health care is delivered in settings where continuous QI efforts and 

other temporal changes are occurring, evaluations of QI strategies that are not randomized or 

controlled may be subject to confounding from other QI programs ongoing in the facility or 

region. Thus, included trials were required to have one of three types of study designs: 

randomized controlled trials, controlled before-after trials which included contemporaneous 

observation periods for control and intervention groups, or interrupted time series trials that 

reported data at three or more time points both before and after intervention to facilitate time 

trend analysis. 

Outcomes. Included studies had to report at least one of the four following types of primary 

outcomes: measures of clinical status (e.g., symptoms or symptom-free days, spirometric 

measures, number of asthma attacks); measures of functional status (e.g., days lost from work or 

school); measures of health services utilization (e.g., hospital admissions, ED visits); or 

measures of adherence to guidelines (e.g., number of patients given prescriptions for inhaled 

corticosteroids). 

Literature Sources. We searched four literature sources: MEDLINE® (1966 to April 2006) the 

Cochrane Effective Practice and Organisation of Care (EPOC) Group databases (1966 to April 

2006), the Cochrane Consumers and Communication Group database (1966 to May 2006), and 

bibliographies of retrieved articles.

Data Abstraction. Two independent investigators reviewed the title and abstract of each article 

found in our search to determine if the article met inclusion criteria. All disagreements were 

resolved by repeated review and discussion. Articles requiring full text review were abstracted 

by a single investigator and then verified by a second abstracter. From each of the included 

studies we abstracted data about the study design, study participants, detailed descriptions of the 

QI intervention, and the reported outcomes. 

Statistical Analysis. We performed univariate analyses to describe the patient and intervention 

characteristics of the included studies. For each type of intervention evaluated in a particular 

population (e.g., patient education strategies for children) for which 15 or more studies presented 

data on the same specific outcome (e.g., percent predicted FEV1), we calculated summary 

standardized and weighted mean differences between intervention and control groups at the end 

of the trial using a random effects model. We performed least squares regression (weighted by 

the sample size) to identify associations between the intervention characteristics and 

improvements in these outcomes. For example, for the studies of patient education interventions, 

we evaluated the association of the frequency of educational sessions, the type of educator (e.g., 

nurse, pharmacist), and the setting of the educational program with changes in FEV1. We 
3

performed formal assessments of heterogeneity for our summary weighted mean differences. 

We sought evidence of publication bias by visual inspection of funnel plots. 

 

Findings 

Our searches yielded 3,843 potential relevant articles, of which 200 articles describing 171 

studies met eligibility criteria. 

Assessment for Heterogeneity. The included articles were highly heterogeneous: 

Study design: 134 were randomized controlled trials, 32 were controlled before-after trials, and 5 

were quasi-randomized controlled trials. Out of the total, 35 studies compared two or more 

interventions without a control group that did not also receive a QI intervention. 

QI strategies evaluated: 94 studies described interventions that included a component of selfmonitoring or self-management, 100 included a component of patient education, 18 included 

provider education, 27 included organizational change, five included audit and feedback, and 

four included provider reminders, five included facilitated relay of clinical data to providers, and 

two included financial incentives. The interventions took place between 1976 and 2004 and 

ranged in length from 4 weeks to 5 years (median: 12 months). 

Target populations: 79 studies targeted children (six of which exclusively enrolled adolescents) 

and 92 studies targeted general asthma populations that included primarily adults. 

Given the heterogeneity of the included studies, we synthesized data separately for each 

group of studies that evaluated the same type of QI strategy in the same population. 

Assessment for Publication Bias. Overall, we found no statistically significant association 

between the likelihood of positive outcome with either sample size (p=0.6) or study design 

(p=0.4). Visual inspection of the funnel plots of the association of sample size and the likelihood 

of finding a statistically significant positive outcome also did not suggest substantial publication 

bias for most interventions and outcomes. 

Self-Monitoring, Self-Management, or Patient Education. For the purposes of this report, we 

classified interventions as being principally “self-monitoring or self-management” if the goal of 

the intervention was to improve the ability of people with asthma or their caregivers to take 

actions that can reduce the impact of asthma on their lives. In contrast, we classified 

interventions as being principally patient education if the purpose was to increase asthma 

knowledge or improve inhaler technique without emphasizing patient decision making or 

changing behavior. We recognize that these are somewhat artificial distinctions and that many 

interventions included components of both. 

We found 69 studies evaluating self-monitoring, self-management, or educational strategies 

for children with asthma or their caregivers. 
4

• Of the self-monitoring, self-management, or patient education interventions for children 

with asthma or their caregivers, 43/69 (62%) specifically described an underlying 

conceptual framework or theoretical background as the basis for the intervention. 

Typically, these interventions relied less on lecture-based or pamphlet-based teaching 

methods and more on combination educational modalities that including role-playing, 

videos, and games to reinforce patient learning. In univariate analyses, these studies 

tended to be more likely to report statistically significant improvements in emergency 

department visits (36 studies reported both frequency of emergency department visits and 

described a theoretical framework for the intervention design; p=0.01). 

• Twenty-one studies included educational interventions directed at parents or caregivers—

13/21 (62%) of which found statistically significant improvements in processes and 

outcomes of care for children with asthma. We found that among all studies of pediatric 

asthma evaluating self-monitoring, self-management, or patient education interventions, 

those directed at parents or caregivers were the most likely to be associated with a 

statistically significant improvement in clinical outcomes such as improvements in 

asthma symptoms or spirometric measures (p=0.02). The educational interventions 

directed at young children that did not include parental involvement did not consistently 

find statistically significant improvements in the processes or outcomes of care for the 

asthmatic patients. 

• None of the six patient education interventions that exclusively targeted adolescents 

resulted in statistically significant improvements in medication use, asthma symptoms 

control, or health services utilization. This included studies that relied on peer teachers or 

intensive educational programs from physicians or nurse educators. 

• Twenty-seven self-monitoring, self-management, or patient education studies reported 

the mean (or median) days lost from school. The weighted mean difference in days 

absent between intervention and control groups was -0.11 days/month (95% CI: -0.17, 

-0.05; p=0.0004); however, the studies included in this analysis were highly statistically 

heterogeneous. The longer the intervention duration, the greater the observed reduction 

in asthma-related school absenteeism (p<0.0001). 

• The use of video games or Web-based programs as educational or self-monitoring or selfmanagement tools for children with asthma (eight studies) was not associated 

consistently with statistically significant improvements in outcomes or processes of care 

for children with asthma. 

We identified 78 studies of self-monitoring, self-management, or patient education 

interventions for general populations or adults with asthma. 

• Of these, 17 reported change in percent predicted FEV1 from which we were able to 

calculate individual study and a summary standardized mean difference (between 

intervention and control subjects at the end of the study). These studies were statistically 

homogeneous and produced a weighted mean difference of 2.92 percent predicted FEV1
5

(95% CI: 0.92, 4.92) favoring the intervention groups (p=0.004). The more recent the 

year of publication, the greater the likelihood of finding improvements in percent 

predicted FEV1 (p=0.004). 

• Sixteen studies reported mean peak flow at the end of the study period. The weighted 

mean difference from these 16 (statistically heterogeneous) was 27.95 L/min (95% CI: 

10.75, 45.15) favoring the intervention groups (p=0.01). 

• The use of combinations of educational techniques including individualized interactions, 

group interactions, role-playing, and distribution of printed materials was associated with 

greater improvements in outcomes than the use of single educational techniques. 

• The longest interventions were more likely to report a statistically significant reduction in 

emergency department visits (p=0.02). 

• We did not find that the frequency of patient interactions with the provider of the 

educational intervention was a key factor in producing improvements for patients. 

Provider Education. We found seven articles reporting interventions designed to provide 

training for clinicians caring for children with asthma (typically these programs reviewed asthma 

diagnosis and management guidelines)—all of which found statistically significant reductions in 

patients’ use of medications (several also reported reductions in asthma symptoms and 

emergency department visits). We found eleven additional articles reporting on interventions 

with some component of provider education for adult patients with asthma—55% of these 

reported that providers receiving the education improved adherence to asthma management 

guidelines (most often, providing written asthma management plans and increasing the rate of 

prescription of inhaled corticosteroids). However, only 27% reported improvements in health 

services utilization and only 9% reported improvements in clinical outcomes. The heterogeneity 

among the provider education interventions limited our ability to determine which components 

led to the greatest benefit for patients with asthma. 

Organizational Change. We found 13 studies of organizational change strategies designed 

specifically to benefit children with asthma. 

• These studies were relatively heterogeneous and not as likely as other types of QI 

interventions included in this review to report improvements in outcomes for patients: 

three (23%) reported improvements in clinical outcomes, three (23%) reported 

improvements in health services utilization, and three (23%) reported improvements in 

functional status. The other four studies (31%) reported no improvements for patients 

with asthma. 

• Two of the included studies evaluated the use of directly observed therapy for children 

with asthma (usually by a school nurse). Both studies found that far more children in the 

intervention groups received their inhaled corticosteroids than those who received their 

medications at home. 
6

We found 14 studies of organizational change strategies for general populations or adults 

with asthma. 

• In contrast to the organizational change interventions for children with asthma, these 14 

studies reported considerably more improvements in outcomes for patients. The 

organizational change interventions for general populations or adults were more likely to 

augment providers’ roles (e.g., adding a teaching role to pharmacists already providing 

routine pharmacy care for patients) or augment the types of providers encountered while 

receiving “usual care” (e.g., by adding multidisciplinary teams to routine clinical 

practice). This is in contrast to the addition of specialty care clinics where patients 

receive care that is distinctly separate from their routine health care encounters (these 

specialty clinics were more common for children). 

• 11 of the 12 organizational change interventions that combined self-monitoring, selfmanagement or patient education with organizational changes (such as adding 

pharmacists to multidisciplinary teams) resulted in improvements in the processes and 

outcomes of care for adults with asthma. 

Other QI Interventions. We found five studies describing audit and feedback interventions, 

four articles describing provider reminders, five interventions that utilized the facilitated relay 

of clinical data for the improvement of care for children with asthma, and two articles that 

included financial incentives to improve care for patients with asthma. The small number of 

studies of these types of QI interventions limited our ability to evaluate their effectiveness for 

improving asthma care, but are described individually in this report. 

Costs. Twenty-three studies reported cost data associated with QI interventions for children (13 

studies) and for general populations or adults with asthma (ten studies). 

• Nine studies described the costs associated with intervention implementation: two of 

these found that there was no statistically significant difference between intervention and 

control program direct costs. The other seven studies uniformly found that intervention 

program costs were higher than control program costs. 

• Among the interventions for children with asthma, seven reported asthma-related 

healthcare cost data, five of which reported reduced costs among the intervention groups 

relative to control groups. Among the interventions for general populations or adults 

with asthma, four presented asthma-related healthcare costs, two of which found cost 

savings among the intervention groups. 

Quality of Life. Forty-five of the included studies reported QOL data. 

• They utilized a variety of both generic measures such as the SF-36 and disease-specific 

measures such as the Asthma Quality of Life Questionnaire and the St. George’s 

Respiratory Questionnaire, among others. 
7

• Thirteen of 31 (42%) of the interventions aimed at general populations or adult patients 

resulted in statistically significant improvement in QOL compared to controls, whereas 

only nine of 12 (25%) of the interventions aimed at children produced a similar result. 

The other studies reported no difference between control and intervention groups in terms 

of QOL. Overall, the pediatric QI interventions reported little effect on parent or 

caregiver quality of life. 

• We found that improvements in QOL and clinical status (p=0.02) were correlated, as 

were improvements in QOL and functional status (p=0.04). 

Tobacco Smoke Exposure. Twelve studies reported either post-intervention tobacco exposure 

rates or reported whether there was a difference at the end of the intervention between 

intervention and control subjects. 

• The reported rate of tobacco exposure among children with asthma of lower 

socioeconomic groups was higher than that of higher socioeconomic groups. 

• None of the included interventions resulted in statistically significant reductions in 

tobacco use among patients with asthma or their family members (however, only some of 

these interventions were designed specifically to reduce tobacco smoke exposure). 

• Preliminary evidence suggests that patients with asthma not exposed to tobacco smoke 

may benefit to a somewhat greater extent from QI interventions than those exposed to 

smoke. 

Summary Answers to the Key Questions 

Research Question 1: What is the evidence that QI strategies improve the processes and 

outcomes of outpatient care for pediatric and adult populations with asthma? 

• The QI interventions with the richest evidence base are those that employ selfmonitoring, self-management, or patient education strategies. Specifically, for young 

children—even those from lower socioeconomic groups—educational strategies targeting 

their caregivers or parents can contribute to statistically significant reductions in asthma 

symptoms. For general populations or adults with asthma, numerous educational 

strategies were associated with improvements for patients—however, those that include a 

component of organizational change (e.g., adding a pharmacist to the team caring for the 

patient) were consistently found to improve patient outcomes. 

• Interventions that are based on a theoretical framework, use multiple educational 

sessions, have longer durations, and use combinations of instructional modalities (e.g., 

small group teaching with role-playing and handouts) are more likely to result in 

improvements for patients than interventions lacking these characteristics. 
8

• Provider education strategies directed at clinicians caring for children with asthma have 

resulted in improvements in medication use and adherence to practice guidelines. 

• We found no evidence that the types of QI strategies reviewed in this report are 

consistently associated with improvements in the processes or outcomes of care for 

adolescents. Nor did we find that the QI interventions resulted in statistically significant 

reductions in tobacco smoke exposure, although this was not the primary objective of the 

included studies. 

• The use of school personnel to administer directly observed therapy has been shown to 

increase the rate of inhaled corticosteroid use and reductions in health services utilization 

among school children with asthma, particularly in those who are not exposed to second 

hand smoke. 

• We did not find that a particular setting (or combination of settings) of the QI 

intervention consistently predicted its effectiveness. We did not have sufficient evidence 

to assess the differential benefit of asthma QI strategies in urban vs. rural groups or 

among groups of differing socioeconomic status. 

Research Question 2: Are QI interventions for asthma care that incorporate multiple 

strategies more effective than those that employ a single strategy? 

The majority of the included articles evaluated a single QI strategy. However, 75 studies 

evaluated QI interventions with two or more QI strategies (e.g., interventions that combined both 

patient education and organizational change), 21 studies evaluated QI interventions with more 

than two QI strategies. We found that the greater the number of QI strategies, the more likely a 

study was to report improvements in clinical status (p=0.009). 

Discussion 

Our review had several key findings. 

• Most of the QI interventions in this evidence report were designed to achieve a change in 

behavior. Thus, we reasoned that interventions specifically designed to comport with the 

principles of effective behavior change would be more likely to produce improved 

outcomes for patients. Even among the included studies that “described” a theoretical 

foundation for the design of their intervention (44% overall), many provided very scant 

information about the rationale for the specific design characteristics of the intervention. 

For the QI interventions for which we found large numbers of articles (namely, selfmonitoring, self-management, or patient education), we found that those studies that 

described a theoretical framework were more likely to report statistically significant 

improvements in some outcomes. Given the robust literature on intervention 

characteristics associated with durable behavior change, future QI interventions for 
9

improving asthma care should strive to incorporate those characteristics with a history of 

effectiveness in similar situations. 

• Children, particularly the very young, are unlikely to have either adequate asthma 

knowledge or the capacity to take disease modifying actions without considerable 

assistance from their caregivers. We found that the interventions directed at children that 

did not also include parental involvement were less effective, suggesting that parallel 

educational activities, focusing on parents as well as their children, may be needed. 

• The use of school personnel to administer directly-observed therapy increased the rate of 

inhaled corticosteroid use and decrease health services utilization among school children 

with asthma, particularly those who are not exposed to second-hand smoke. 

• For general populations or adults with asthma, educational interventions, particularly 

those that used combinations of educational modalities and that provided multiple 

educational sessions over longer durations, were associated with statistically significant 

improvements in spirometry and days lost from work. However, the clinical significance 

of these improvements is modest. 

• We found that the greater the number of QI strategies, the more likely a study was to 

report improvements in clinical outcomes. In particular, we found that patient and 

provider education interventions that also included an element of organizational change 

(for example, by adding pharmacists to the clinical team or by instituting an information 

system that facilitates reporting of clinical information between patients and providers) 

were often associated with improvements in outcomes for patients. 

• We found high rates of tobacco exposure among both adults and children with asthma—

particularly in lower socioeconomic groups. While the rates of smoke exposure did not 

change as a result of the QI interventions, some subgroup analyses suggested that 

improvement resulting from the QI strategy were more likely to occur in the groups not 

exposed to tobacco smoke. Given the association between smoke exposure and 

socioeconomic status, it is not clear whether the smoke exposure or other factors 

associated with patient demographics contributed to this trend. 

Future Research 

• None of the six studies of educational interventions that specifically targeted adolescents 

with asthma, even those that relied on peer teachers or intensive educational programs 

from physicians or nurse educators, resulted in statistically significant durable 

improvements in medication use, asthma symptoms control, or health services utilization. 

However, positive effects were seen in studies that included (but did not specifically 

target) adolescents. Clearly, identification of interventions that result in effective 

behavior change for this vulnerable population requires further investigation. 
10

• Many types of QI interventions have not been adequately studied (e.g., audit and 

feedback, provider reminders, facilitated relay). Since some of the studies showed 

promising results, interventions of these types should be studied in rigorously designed 

clinical trials. 

• Relatively few of the included studies reported on the costs associated with their 

interventions. Thus, the extent to which expenditures change with QI interventions for 

asthma has not been well documented. A critical gap in this literature that prevents an 

understanding of the cost-effectiveness of QI programs is that there is not a common 

effectiveness variable such as symptom-free days gained or episode-free days gained. 

Also, since many studies only include the costs and benefits accrued during the first year 

after an intervention, it is difficult to estimate the long-term cost-effectiveness of these 

programs. Given the enormity of the costs associated with asthma care, these are 

critically important areas for future research. 
TECHNICAL REVIEW

13 

Figure 1. U.S. asthma prevalence

Chapter 1. Introduction 

Asthma*1, 2 is one of the most common chronic medical conditions in the U.S. It affects 16 

million adults and 6.1 million children and results in two million visits to emergency 

departments, 70,000 hospitalizations, and 5,000 

deaths annually.3

 Children aged 5 to 17 years have 

the highest prevalence of asthma among all age 

groups in the U.S. (Figure 1). Among children with 

chronic medical conditions, asthma is the most 

common reason for hospitalization and school 

absence.4 The burden of asthma disproportionately 

affects patients of lower socioeconomic status: they 

are more likely to be limited by asthma symptoms, 

to use an emergency department as their usual 

source of care, and to be hospitalized for asthma 

care.3, 5-7 Asthma has serious economic 

consequences: in 1994, slightly more than half of 

the estimated $10.7 billion in asthma-related costs 

were for direct costs, while the rest were indirect 

costs, including those associated with caregiver 

costs, travel and waiting time, and premature death.6 

The Pew Environmental Health Commission 

estimated that totals costs associated with asthma 

care could increase to $18 billion by 2020.7 

In an effort to reduce the burden of asthma on patients, their families, and the U.S. healthcare 

system, the National Asthma Education and Prevention Program of the National Heart, Lung, 

and Blood Institute (NHLBI) has published comprehensive guidelines for diagnosis and 

management of asthma.8, 9 Because asthma can neither be prevented nor cured, current 

management objectives are to monitor symptoms and objective measures of lung function, to 

encourage the use of medications that control and prevent symptoms with the fewest adverse 

effects possible, to control the triggers of asthma symptoms to which a patient is sensitive (such 

as house dust mite, tobacco smoke, animal dander, and pollens), and to educate the patient and 

provider for a partnership in asthma care.6, 10-12 Specifically, the reduction of airway 

inflammation and asthma symptom control is based largely on the use of inhaled corticosteroids, 

 

*

Historical note: References to asthma symptoms have been found in the Nei Ching, a Chinese medicine text 

written between 2500 and 1000 BC and in the Ebers Papyrus, an Egyptian medical reference from around 1550 BC. 

The word asthma is derived from the Greek verb aazein, meaning to exhale with open mouth, to pant, to take a 

“sharp breath.” The word first appears in Homer’s Iliad and Hippocrates first used the word to describe the medical 

condition. Hippocrates wrote that asthma symptoms were more likely to occur in tailors, anglers, and metalworkers. 

Six centuries later, Galen was the first to describe it clinically and noted that it was caused by partial or complete 

bronchial obstruction. Moses Maimonides, a prominent medieval philosopher and physician, wrote a treatise on 

asthma diagnosis, prevention, and treatment. In the 17th century, Bernardino Ramazzini recognized an association 

between asthma and organic dust. The use of bronchodilators started in 1901, but it was not until the 1960s that the 

inflammatory component of asthma was recognized and anti-inflammatories were added to treatment regimens. 
14

inhaled long-acting β-agonists, and leukotriene pathway inhibitors. Breakthrough asthma 

symptoms are treated with inhaled bronchodilators, which relax bronchial smooth muscle.9 In 

general, inhaled corticosteroids, leukotriene receptor antagonists, cromolyn, sustained release 

theophylline, and long acting inhaled β-agonists combined with inhaled corticosteroids are used 

to prevent daily symptoms and recurring exacerbations. Short-acting inhaled β-agonists, and, if 

necessary, oral corticosteroids are used as needed to treat symptoms and exacerbations when 

they occur. Effective asthma management has been demonstrated to reduce symptoms, 

hospitalizations, and urgent care visits.6, 7

The Quality Gap 

Despite the availability of evidence-based guidelines for the management of pediatric and 

adult asthma, there remains a significant gap between accepted best practices for asthma care and 

actual care delivered to asthma patients in the U.S.7, 8 For example, although the National 

Committee for Quality Assurance has found that more patients with asthma are prescribed 

appropriate asthma mediations in recent years (71% in 2003 versus 63% in 2000),13 many 

patients with asthma and their caregivers do not use preventive medications or know how to 

prevent and treat asthma attacks.7 Diette and colleagues evaluated the rate of adherence of 

asthma care with the National Asthma Education and Prevention Program Guidelines for 318 

pediatric patients.14 They found that 55% of patients used long-term controller medications 

daily, 49% had written instructions for handling asthma attacks, 44% had instructions for 

adjustment of medication before exposures, 56% had undergone allergy testing, and 54% had 

undergone pulmonary function testing.14 Other research has shown similarly poor guideline 

adherence among adults with asthma.15, 16 Even simple preventive measures are often neglected 

for asthma patients: patients with asthma are at high risk of developing complications after 

influenza-related illness, yet only one-third of adults and one-fifth of adults younger than 50 

years with asthma receive the flu vaccine annually.17 

A RAND report, “Improving Childhood Asthma Outcomes in the United States: A Blueprint 

for Policy Action” describes three primary barriers to effective management of asthma: the 

complexity of asthma care (i.e., it requires an understanding of the variety of symptoms, triggers, 

and use of multiple medications by clinicians, patients, and caregivers); the costliness of asthma 

care (e.g., patients may not have health insurance or other means to pay for preventive services 

and medications; schools may lack the resources to provide comprehensive asthma prevention 

and treatment services); and the lack of comprehensive strategies to improve asthma prevention 

in health care settings and the community.7

 

Given the prevalence of asthma, its considerable economic effects, the demonstrated gaps 

between high-quality care and demonstrated practice, and the disproportionate effect of poor care 

on lower socioeconomic populations, the Institute of Medicine (IOM) has designated quality 

improvement in asthma care as a priority area.18 Specifically, the IOM report notes that persons 

with mild/moderate persistent asthma often do not receive appropriate treatment.18 The objective 

of this Report is to evaluate the evidence that quality improvement (QI) strategies can improve 

the processes and outcomes of outpatient care for children and adults with asthma. 
15

Key Research Questions 

The specific research questions addressed in this review are: 

Research Question 1: What is the evidence that QI strategies improve the processes and 

outcomes of outpatient care for pediatric and adult populations with asthma? Specifically, which 

QI strategies are effective for improving processes and outcomes of asthma care for specific 

patient populations (e.g., adults, children, low SES, racial groups, urban/rural)? Also, does the 

setting of the QI intervention (e.g., home, school, clinic) determine its effectiveness for 

improving processes and outcomes of asthma care? 

Research Question 2: Are QI interventions for asthma care that incorporate multiple 

strategies more effective than those that employ a single strategy?

17 

Chapter 2. Methods 

We sought articles describing evaluations of quality improvement strategies designed to 

improve the care of patients with asthma. In the sections that follow, we describe the types of QI 

strategies and study designs that we considered eligible for inclusion in this review. 

Types of Quality Improvement Strategies 

We defined QI strategies as interventions aimed at reducing the quality gap (the difference 

between health care processes or outcomes observed in practice and those potentially obtainable 

on the basis of current professional knowledge) for a group of patients representative of those 

encountered in routine practice.19 By modifying several well-established classification 

systems,20-23 we developed a taxonomy of nine QI strategies,19 including patient education, 

provider education, organizational change, audit and feedback, provider reminders, patient 

reminders, facilitated relay of clinical data to providers, financial or legislative incentives, and 

the promotion of self-monitoring or self-management. Table 1 presents the QI strategy 

definitions used for this report. We direct interested readers to a complete description of the 

taxonomy of QI strategies and the methods used to develop it.19 

Table 1. Definitions of the nine quality improvement strategies used in the Closing the Quality Gap series 

Strategy Definition 

Provider reminders Information tied to a specific clinical encounter, provided verbally, in writing, or by 

computer, that is intended to prompt the clinician to recall information, or to consider 

performing a specific process of care (e.g., to make medication adjustments or order 

appropriate screening tests).19

Facilitated relay of clinical 

data to providers

Clinical information collected directly from patients is relayed to the provider in 

situations where the data are not generally collected during a patient visit, or when 

collected using a means other than the existing local medical record system (e.g., 

transmission of a patient’s home glucose level).19

Audit and feedback Any summary of a health care provider’s clinical performance or an institution’s clinical 

performance that is reported, either publicly or confidentially, to or about the clinician or 

institution (e.g., the percentage of a provider's patients who have achieved or have not 

achieved some clinical target).19

Provider education Any intervention that includes one of the following sub-strategies: educational 

workshops, meetings (e.g., traditional Continuing Medical Education (CME)), and 

lectures; educational outreach visits (the use of a trained person who meets with 

providers in their practice settings to disseminate information intended to change the 

provider's practice); or the distribution of educational materials (published or printed 

recommendations for clinical care, including clinical practice guidelines, audio-visual 

materials and electronic publications).19
18

Table 1. Definitions of the nine quality improvement strategies used in the Closing the Quality Gap series 

(continued) 

Strategy Definition 

Patient education Patient education—for individuals or members of a patient group or community, 

presented either in person or via the distribution of printed or audio-visual educational 

materials.19

Promotion of selfmonitoring or selfmanagement

The distribution of materials (e.g., devices for peak flow self-monitoring) or access to 

resources that enhances patients’ ability to manage their condition, the communication 

of clinical test data back to the patient, or follow up phone calls from the provider to the 

patient with recommended adjustments to care.19

Patient reminders Any effort directed toward patients that encourages them to keep appointments or 

adhere to other aspects of self-care.19

Organizational change Changes in the structure or delivery of care designed to improve the efficiency or 

breadth and depth of clinical care. These include the use of disease management or 

case management tactics (coordination of assessment, treatment, and arrangement for 

referrals by a person or multidisciplinary team in collaboration with or supplementary to 

the primary care provider); other personnel or team changes; the use of telemedicine 

(communication and case discussion between distant health care professionals); Total 

Quality Management (TQM) or Continuous Quality Improvement (CQI) approaches 

(quality problem cycles of measurement, intervention design, implementation, and remeasurement); and changes to medical records systems or hospital information 

systems.19

Financial, regulatory, or 

legislative incentives 

Interventions with positive or negative financial incentives directed at providers (e.g., 

“pay for performance” where pay is linked to adherence to some process of care or 

achievement of some target patient outcome). This strategy also included positive or 

negative financial incentives directed at patients, system-wide changes in 

reimbursement (e.g., capitation, prospective payment, or a shift from fee-for-service to 

salary pay structure), changes to provider licensure requirements, or changes to 

institutional accreditation requirements.19

Inclusion and Exclusion Criteria 

We sought English language studies of interventions that included one or more of these nine 

QI strategies for the outpatient management of children and adults with asthma. We adopted the 

NHLBI definition of asthma.8† Included articles had to evaluate QI interventions in the 

outpatient setting. We defined outpatient programs broadly (e.g., including school-based 

programs, self-monitoring or self-management programs, and clinician-based interventions). 

Because most health care is delivered in settings where continuous QI efforts are occurring, 

evaluations of QI strategies that are not randomized or controlled may be subject to confounding 

from other QI programs ongoing in the facility or region. Thus, included trials had to have one 

of three types of study designs: randomized controlled trials (RCTs) (including quasi-RCTs 

which typically allocated patients according to non-random means such as “every other patient” 

 

†

NHLBI Definition: “Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular 

elements play a role, in particular, mast cells, eosinophils, T lymphocytes, neutrophils, and epithelial cells. In 

susceptible individuals, this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, 

and cough, particularly at night and in the early morning. These episodes are usually associated with widespread but 

variable airflow obstruction that is often reversible either spontaneously or with treatment. The inflammation also 

causes an associated increase in the existing bronchial hyperresponsiveness to a variety of stimuli.” 
19

was assigned to the intervention or control group), controlled before-after trials, or interrupted 

time series trials. Given the seasonal nature of asthma in many patients, we required that 

controlled before-after trials included contemporaneous observation periods for control and 

intervention groups. We required that articles reporting interrupted time series trials provided 

data at three or more time points both before and after intervention to facilitate time trend 

analysis. 

Included studies had to report at least one of the four following primary outcomes: measures 

of clinical status (monitoring of medications, symptoms or symptom-free days, peak flow or 

spirometric measures, number of asthma attacks); measures of functional status (days lost from 

work or school, 6-minute walk times, school grades); measures of health services utilization

(hospital admissions, ED visits, unscheduled MD visits); or measures of adherence to guidelines 

(e.g., number of patients given prescriptions for inhaled corticosteroids). 

 

Search Strategy 

We searched four literature sources: MEDLINE® (1966 to April 2006), the Cochrane 

Effective Practice and Organisation of Care (EPOC) Group databases (1966 to April 2006), the 

Cochrane Consumers and Communication Group database (1966 to May 2006), and 

bibliographies of retrieved articles.

The EPOC databases contain the results of extensive periodic searches of MEDLINE® (from 

1966-present), CINAHL® (1982-present), and EMBASE® (1980-present), and hand searches of 

journals and article bibliographies.24 These EPOC searches are aimed at identifying studies that 

attempt to “improve professional practice and the delivery of effective health care services,” 

regardless of clinical topic. The EPOC strategy for identification of studies meeting this 

definition has a sensitivity of 92.4%.24 The articles identified by initial EPOC searches are 

triaged into different registries depending on EPOC’s inclusion/exclusion criteria. The main 

EPOC registry primarily includes studies of provider and system-targeted interventions. To 

maximize our yield of articles, an EPOC research librarian searched the main registry, other 

EPOC registries, as well as the larger database of initially identified articles. 

Because the EPOC databases are restricted to studies targeting provider and system-based 

interventions, we also performed separate searches of the Cochrane Consumers and 

Communication Group database and MEDLINE® to identify articles involving patient education 

or self-monitoring or self-management. The Cochrane Consumers and Communication Group 

database includes studies that focus on “consumers’ interactions with health care professionals, 

services and researchers.”25 Our detailed search strategies are presented in Appendix A*

. 

 

Data Abstraction and Evaluation 

Two independent investigators reviewed the title and abstract of each article found in our 

search to determine if the article met inclusion criteria (Appendix B*). All disagreements were 

resolved by repeated review and discussion. Articles requiring full text review were abstracted 

by a single investigator and then all abstracted data were verified by a second abstracter. 

 

*

 Appendixes cited in this report are provided electronically at http://www.ahrq.gov/clinic/tp/asthmagaptp.htm 
20

Throughout the abstraction process, the investigators engaged in an active dialog about specific 

articles and reviewed questions regarding data abstraction to maintain a consensus approach 

among abstractors. 

From each of the included studies we abstracted data about the study design, participants, 

detailed descriptions of the QI intervention, and the reported outcomes. In addition to the 

primary outcomes, we also abstracted data about the following secondary outcomes: cost of the 

QI strategy implementation; patient or provider satisfaction; quality of life (QOL) outcomes (for 

either patients with asthma or their caregivers); and reduction in environmental allergens (e.g., 

tobacco, pets/dander, cockroach antigen). The complete full-text abstraction form is provided in 

Appendix B*

. 

Multiple articles describing the same population were included only once in our analyses. 

Statistical Analysis 

Univariate Analyses 

We used exploratory univariate analyses to identify the patient, intervention, and study 

design characteristics associated with the four primary outcomes of interest (clinical status, 

functional status, health services utilization, and adherence to guidelines). Because we make 

multiple comparisons, we recommend rejecting the null hypothesis for p values<0.0125 

(0.05 ÷ 4 = 0.0125)—we provide p values and 95% confidence intervals when possible. 

We sought evidence of publication bias by evaluating the association between the sample 

size of a study and the likelihood of that study reporting statistically significant outcomes by 

visual inspection of funnel plots and calculation of unweighted correlation coefficients between 

sample size and the likelihood of reporting statistically significant outcomes. 

For each type of intervention evaluated in a particular population (e.g., patient education 

strategies for children) for which 15 or more studies presented data on the same specific outcome 

(e.g., school absenteeism), we calculated both weighted mean differences and standardized mean 

differences between intervention and control groups at the end of the trial using a random effects 

model. We only performed this calculation for outcomes of 15 or more because the purpose of 

these analyses was to evaluate the predictors of these outcomes and needed to have at least 15 

observations to have the statistical power to find such an effect. We performed these 

calculations using RevMan software version 4.2.8.26 To be included in a weighted mean 

difference or standardized mean difference calculation, studies must report an estimate of 

variance—if the included studies did not report an estimate of variance, we used a mean variance 

from the other studies reporting that outcome. 

The weighted mean difference has the same units as the outcome of interest; thus, it is 

relatively easy to interpret. However, the standardized mean difference, which is unitless and 

therefore somewhat less readily interpretable, is less subject to bias. We present both effect sizes 

in the text. However, we used the more stable standardized mean difference as the dependent 

variable in our regression analyses seeking the association between study and intervention design 

 

*

 Appendixes cited in this report are provided electronically at http://www.ahrq.gov/clinic/tp/asthmagaptp.htm 
21

characteristics and changes in the outcomes of interest (see below, in the section on multivariate 

analyses, for additional details on those analyses). 

To minimize heterogeneity, we only synthesized those studies describing similar 

interventions in similar populations. We performed formal assessments of heterogeneity for our 

summary weighted mean differences and present the Chi2 statistic for heterogeneity. 

Additionally, we calculated the I2 statistic measuring the extent of inconsistency among the 

studies’ results—which is interpreted as the approximate proportion of total variation in study 

estimates that is due to heterogeneity rather than sampling error.26 I2 statistics in excess of 50% 

are considered heterogeneous. 

Multivariate Analyses 

For those types of intervention for which we found 15 or more studies reporting on the same 

outcome, we performed multivariate analyses to evaluate the association between study design 

characteristics (e.g., duration of the study, whether the study specified the use of an underlying 

theoretical or conceptual framework) and intervention characteristics (e.g., the setting of the 

intervention, whether there were multiple QI strategies utilized) and the four primary outcomes 

of interest (i.e., clinical status, functional status, health services utilization, and adherence to 

guidelines). For these analyses, we used the standardized mean difference in the outcome of 

interest as the dependent variable in a weighted least squares regression (weighted by the study 

sample size). 

For those types of interventions for which no specific outcomes were reported by 15 or more 

studies, we performed logistic regression to evaluate the association between study design and 

intervention characteristics and the reporting of statistically significant improvements in each of 

the four primary outcomes of interest. 

Peer Review Process 

A draft of this Evidence Report was sent to a panel of 15 experts in quality improvement, 

patient education, and asthma (Appendix D*

). Their comments were incorporated into the final 

Report. 

 

*

 Appendixes cited in this report are provided electronically at http://www.ahrq.gov/clinic/tp/asthmagaptp.htm 

23 

Chapter 3. Results 

Results of Literature Search and Article Review Process 

Figure 2 presents the results of our search strategy and article review process. Our searches 

yielded 3843 potentially relevant articles of which 530 articles merited full-text review. A total 

of 200 articles reporting on 171 unique populations met our inclusion criteria. Appendix C*

provides the citations of articles excluded after the full text review, along with the reason for 

exclusion. 

Figure 2. Search results 

 

 

*

 Appendixes cited in this report are provided electronically at http://www.ahrq.gov/clinic/tp/asthmagaptp.htm 

Stage 1: Review of title and abstract review 

by two independent investigators

Stage 2: Full text review and abstraction 

by a single investigator

MEDLINE® Search

2920 Citations

Total Number of Articles 

Requiring Full Text Review

530 Citations

Total Number of Potentially 

Relevant Articles

3843

3313 Exclusions

Not an evaluation: 1424

Not about QI: 1279 

Excluded topic: 500

Ineligible study design: 97 

Foreign language: 13

Articles meeting criteria for 

full abstraction

N=200 (describing 171 

unique populations)

EPOC Search

798 Citations

Hand Search

47 Citations

330 Exclusions

Ineligible study design: 113

Abstract only: 15

Thesis/dissertation: 8

Not about QI: 55

No eligible outcomes: 62

Unusable data: 41

Excluded topic: 21

Foreign language: 6

Other: 9

Cochrane Collaborative

78 Citations
24

Summary of Included Studies 

General Characteristics of Included Studies 

The 171 included studies were highly heterogeneous with respect to study design, the types 

of QI strategies evaluated, the populations of interest, and types of outcomes reported. In this 

section, we describe these characteristics (Table 2). 

 

Table 2. Design attributes of the included studies 

Design Attribute 

Number of studies reporting 

this attribute/Total number 

eligible to have this attribute 

All studies (n=171) 

If the unit of analysis differed from the unit of treatment allocation (i.e., the trial was 

“clustered” by provider or clinic) the authors acknowledged this issue or made 

appropriate adjustments 

14/30 

Reported obtaining informed consent 107/171 

Described basing the intervention design on a theoretic or empiric foundation 76/171 

Controlled Before-After Trials (n=32) 

It was specifically reported that measurements in the control group were performed at 

the same time in the intervention group 

30/32 

The criteria used for selecting control sites were explained 31/32 

The control site was comparable to the experimental site in terms of patient and 

provider characteristics 

30/32 

Study Design. Of the included articles, 134 (78%) were RCTs, five (3%) were quasi-RCTs and 

32 (19%) were controlled before-after trials. Of these, 35 (21%) studies compared two or more 

interventions without a control group that did not also receive a QI intervention. (Studies of this 

design all evaluated either self-monitoring, self-management, or patient education interventions.) 

RCTs were much less likely to report statistically significant improvements in the processes 

and outcomes of care for patients with asthma than were studies of other designs (Table 3). 

Table 3. Association of study design and patient outcomes 

Study Design 

Number 

of 

Studies 

Reported 

improvements in 

clinical status 

Reported 

improvements 

in guideline 

adherence 

Reported 

improvements 

in functional 

status 

Reported 

improvements in 

health services 

utilization 

Controlled before-after trial 32 15 (47%) 16 (50%) 2 (6%) 8(25%) 

RCT 134 44 (33%) 32 (24%) 19 (14%) 23 (17%) 

Quasi-RCT 5 4 (80%) 1 (20%) 1 (20%) 4 (80%) 

p value*

 - 0.04 0.012 0.4 0.002 *

Chi squared test of study design × improvement in each type of outcome. We note that not all of the studies were designed to 

evaluate all types of outcomes.

Sample Size. The median sample size was 109 (Interquartile range: 54, 205). Many of the 

included studies were small: 78 (46%) had total sample sizes of 100 subjects or less (Table 4). 
25

We did not find an association between sample size and the likelihood that a study reported 

statistically significant outcomes (Table 4). 

When interpreting the results of the included studies, it is important to consider that few 

presented power calculations and those that did were often underpowered to find small effects. 

This may be particularly relevant for interventions directed at patients with mild asthma where 

the outcomes of interest are relatively rare events such as annual hospitalizations. Additionally, 

many of the included studies evaluated numerous outcomes and did not make adjustments for 

multiple comparisons. Because nearly all of the included studies used the sample size that 

completed the intervention or follow up period in their calculations of effect size (i.e., did not 

perform intention-to-treat analysis), in the evidence tables, we report the number of subjects in 

the intervention and control groups at the end of the trial. For those few studies that did perform 

an intention-to-treat analysis, we present the sample size at the time of randomization or 

treatment allocation. 

Table 4. Association of sample size and patient outcomes 

Sample Size Number of 

Studies§

Reported 

improvements in 

clinical status 

Reported 

improvements 

in guideline 

adherence 

Reported 

improvements 

in functional 

status 

Reported 

improvements in 

health services 

utilization 

Up to 100 subjects 78 28 (36%) 24 (31%) 7 (9%) 16 (21%) 

More than 100 subject 86 34 (40%) 23 (27%) 15 (17%) 17 (20%) 

Odds Ratio*

 (95% CI) - 0.8 (0.4, 1.5) 0.8 (0.4, 1.6) 2.1 (0.82,5.6) 1.0 (0.4,2.1) *

 Mantel-Haenszel Odds Ratio between the smaller and larger studies; §7 studies did not report sample size. We note that not all 

of the studies were designed to evaluate all types of outcomes. 

Intervention Characteristics. Articles often did not report detailed information about the 

interventions. For example, for educational interventions, we were interested in key aspects of 

the interventions such as the teaching modalities used, number of sessions subjects received, 

number of students in the “small groups,” the specific content of the curriculum, the training of 

the instructor, etc. However, the included articles often presented at most a few sentences 

describing the intervention. In the evidence tables in the sections that follow, we present the 

abstracted information on each included study and for those studies with detailed intervention 

descriptions, we noted this. 

From each of the included articles, we abstracted whether the investigators cited previous 

literature or a theoretical framework to describe the evidence base for their proposed 

intervention. The included articles often provided scant information about whether the design of 

the QI intervention had a theoretical basis (e.g., the mechanism by which the chosen intervention 

might influence individual behavior or organizational culture and structure). In other words, 

numerous studies provided little or no answer to the question of why a particular QI strategy was 

selected to address a given problem. Only 76 (44%) of the included studies in our report 

specifically described a theoretical framework for their intervention. When we consider all of 

the included studies (combining across all types of QI strategies), we did not find that the studies 

reporting a theoretical framework were more likely to find improvements in outcomes for 

patients with asthma (Table 5). 
26

Table 5. Association of specifying a theoretical framework and patient outcomes 

Theoretical 

Framework Specified 

Number of 

Studies 

Reported 

improvements in 

clinical status 

Reported 

improvements 

in guideline 

adherence 

Reported 

improvements 

in functional 

status 

Reported 

improvements 

in health 

services 

utilization 

Yes 62 26 (42%) 25 (40%) 14 (22%) 20 (32%) 

No 87 37 (43%) 24 (28%) 8 (9%) 15 (17%) 

Odds Ratio*

 (95% CI) 0.8 (0.4, 1.5) 1.5 (0.75, 2.8) 2.5 (0.97,6.2) 1.9 (0.90,4.0) *

 Mantel-Haenszel Odds Ratio. We note that not all of the studies were designed to evaluate all types of outcomes. 

Subject Characteristics. Studies varied with respect to their target populations of interest. For 

example, 79 studies targeted children exclusively, whereas 92 studies targeted general asthma 

populations that included primarily adults. Throughout this report, we present the interventions 

designed specifically for children separately from those that were for general, primarily adult, 

populations. Six of the 79 studies exclusively enrolled adolescents—they differed in terms of 

their definitions of adolescents (e.g., 12 to 16 years old). In 20 studies, providers (i.e., 

physicians, nurses, or pharmacists) were the target of the intervention (typically, provider 

education or provider reminder interventions). The other interventions were primarily directed at 

patients with asthma or their caregivers. 

We were interested in abstracting data for subjects’ baseline asthma severity (as measured by 

number of medications, number of annual physician and emergency department visits, and 

spirometric values); however, these data were reported sufficiently infrequently and in highly 

heterogeneous manner. To the extent possible, we present asthma severity information on each 

of the included articles in the evidence tables. 

The included articles studied asthma patients from around the world: 73 were from the U.S., 

27 from the U.K., 11 from Australia, 11 from Canada, eight from the Netherlands, five from 

Sweden, 23 from elsewhere in Europe, four from South America, and three from India, among 

others. In the evidence tables, we describe the location where the intervention took place. 

QI Intervention Characteristics. The interventions occurred between 1976 and 2004 and 

ranged in length from 4 weeks to 5 years (median: 12 months) (Figure 3). For those studies that 

reported data at multiple post-intervention intervals, we abstracted data from the longest period 

of follow up. 

Intervention duration. We found that studies with 

longer interventions were more likely to report 

improvements in health services utilization (p=0.011) 

(Table 6). This may be because visits to the emergency 

department or urgent care or hospitalizations are 

relatively rare events (especially among patients with 

less severe asthma) and reductions in these events 

accrue only over longer follow up periods. We did not 

find that longer interventions were associated with 

improvements in clinical status or other outcomes of 

interest. This may be in part due to some initial effects 

of the intervention waning with longer follow up 

periods. 

0

10

20

30

40

50

60

70

80

1 3 6 12 24 36 48 60

Study Duration (months)

Number of Studies

Figure 3. Intervention duration 
27

Table 6. Association of study duration and patient outcomes 

Duration 

(months) 

Number of 

Studies*

Reported 

improvements 

in clinical status 

Reported 

improvements in 

guideline adherence

Reported 

improvements in 

functional status 

Reported 

improvements in 

health services 

utilization 

0-5 33 12 (36%) 12 (36%) 3 (9%) 3 (9%) 

6-10 43 16 (37%) 11 (26%) 6 (14%) 5 (12%) 

12-60 92 35 (38%) 26 (28%) 13 (14%) 27 (29%)§

*

Note: 3 studies did not report their duration of follow up. §Chi squared test, p=0.011. We note that not all of the studies were 

designed to evaluate all types of outcomes.

 Figure 4. Intervention Settings 

Intervention settings. The 

interventions took place in various 

settings including outpatient clinics, 

home, and school (Figure 4). Most of 

the interventions in schools and 

patients’ homes were directed at 

children with asthma or their parents 

or caregivers. 

Types of QI strategies. Table 7 

presents the distribution of type of QI 

strategies implemented in the included 

articles. Most of the included articles 

described self-monitoring, selfmanagement, or patient education 

interventions. None of the included 

articles described patient reminder systems. 

Table 7. Distribution of included studies by type of QI strategy 

QI Strategy Pediatric 

Studies*

General 

Population or 

Adult Studies 

Total 

Self-monitoring or self-management 35 59 94 

Patient or caregiver education 54 46 100 

Provider education 7 11 18 

Organizational change 13 14 27 

Audit and feedback 0 5 5 

Provider reminders 1 3 4 

Patient reminders 0 0 0 

Facilitated relay of clinical data to providers 3 2 5 

Financial, regulatory, or legislative incentives 1 1 2 

*

Note: The pediatric studies described here included only children. The general population or adult studies typically included adults 

only; however, some of these were of general populations of patients with asthma that included both children and adults. 

Combinations of QI strategies. Most of the included articles evaluated a single QI strategy. 

However, 75 studies evaluated QI interventions with two or more QI strategies (e.g., 

0

5

10

15

20

25

30

35

40

45

50

Outpatient

primary care

clinics

Outpatient

specialty

care clinics

(e.g.

pulmonary

clinics)

Home School Community

settings

(e.g.,

community

centers)

Multiple

Settings

Number of Studies

Pediatric Studies Adult/General Population Studies
28

interventions that combined both patient education and organizational change) (Table 8). We 

found 21 studies of interventions of more than two QI strategies. Among those interventions 

with more than one QI strategy, the most common was the combination of self-monitoring, selfmanagement, and patient education. We note that these are overlapping educational 

classifications and can be considered a single, broad-based educational strategy. For those 

interventions including other strategies, organizational change was the next mostly likely to be 

included (e.g., self-monitoring, self-management, or patient education with organizational 

change). We found that the greater the number of QI strategies, the more likely a study was to 

report improvements in clinical status (p=0.009) (but not the other primary outcomes of interest) 

(Table 8). 

Table 8. Association of combinations of QI strategies and patient outcomes 

Number of QI 

Strategies in the 

Intervention 

Number of 

Studies 

Reported 

improvements in 

clinical status 

Reported 

improvements 

in guideline 

adherence 

Reported 

improvements 

in functional 

status 

Reported 

improvements in 

health services 

utilization 

1 96 28 (29%) 27 (28%) 12 (13%) 19 (20%) 

2 54 22 (41%) 18 (33%) 6 (11%) 11 (20%) 

3 17 9 (53%) 4 (24%) 3 (18%) 4 (24%) 

4 4 4 (100%) - 1 (25%) 1 (25%) 

p value*

 - 0.009 0.5 0.8 0.9 *

Chi squared test of number of QI strategies × improvement in each type of outcome. We note that not all of the studies were 

designed to evaluate all types of outcomes. 

Outcomes Evaluated. We abstracted data on four primary outcomes (measures of clinical

status, measures of functional status, measures of health services utilization, and measures of 

adherence to guidelines) and three secondary outcomes (health-related quality of life, exposure 

to environmental triggers such as tobacco smoke, and costs). Table 9 presents the distribution of 

the types of outcomes commonly reported in the included studies. 

 

Table 9. Number of studies reporting each outcome 

Outcomes Pediatric Studies Adult Studies 

Clinical status measures 54 75 

Asthma symptoms 33 44 

Symptom-free days 16 10 

Amount of medication used or prescribed 23 45 

Number of asthma attacks 15 9 

Pulmonary function: peak flow, FEV1, or other spirometric measures 21 42 

Functional status measures 39 36 

Activity restriction 12 13 

Days lost from school/work 33 26 

Health services utilization 53 51 

ED or urgent care visits 43 35 

Hospitalizations 28 39 

Office visits 23 14 
29

Table 9. Number of studies reporting each outcome (continued) 

Outcomes Pediatric Studies Adult Studies

Guideline adherence 44 47 

Adherence with peak flow monitoring 14 15 

Use of self-monitoring or self-management or action plans 14 16 

Inhaler technique 9 16 

Appropriate use of asthma medications 12 21 

Cost 10 13 

Quality of Life 14 31 

Tobacco Exposure Reduction 6 6 

Assessment for Publication Bias. We sought evidence for potential sources of publication bias. 

We found no statistically significant association between sample size and the study reporting a 

positive outcome (p=0.55). This finding was corroborated by visual inspection of the plots of the 

association of sample size and the likelihood of finding a statistically significant positive 

outcome (we present these funnel plots in the sections describing those outcomes). 

Given the heterogeneity of the included studies, we synthesized data separately from each 

group of studies that evaluated the same type of QI strategy in the same population. In the 

sections that follow, we first present the evidence on the effectiveness of each type of QI strategy 

for children and adults with asthma from those studies that compared an intervention group 

receiving the QI strategy compared to a control group receiving usual care. We then present the 

results from those studies that compared more than one intervention group without including a 

control group that did not receive some QI intervention. Finally, we present the results 

synthesizing the outcomes across intervention types. 

Results by QI Intervention 

Self-Monitoring, Self-Management, or Patient Education Interventions 

Inadequate asthma knowledge is an important factor in poor asthma management.27 Asthma 

patients play a key role in their own care by identifying and reducing exposures to factors that 

may worsen their asthma and by adjusting medications to prevent asthma exacerbations. The 

International Consensus Report on the Diagnosis and Treatment of Asthma describes asthma 

management as having six parts, the first of which is “to educate patients to develop a 

partnership in asthma management.”28 The purpose of patient education is defined as “a 

continual process designed to provide the asthma patient and the patient’s family with suitable 

information and training, so that the patient can keep well and adjust treatment according to a 

medication plan developed with the clinician.”28 Clearly, considerable overlap exists between 

patient education and self-monitoring or self-management interventions. 

For the purposes of this report, we classified interventions as being principally selfmonitoring or self-management if the goal of the intervention was to improve the ability of 

people with asthma or their caregivers to take action to reduce the impact of the disease on their 
30

lives, often through better monitoring of their symptoms and physiologic metrics. In contrast, 

we classified interventions as being principally patient education if the purpose was to increase 

asthma knowledge or improve inhaler technique without emphasizing patient decision making or 

changing behavior. We recognize that these are somewhat artificial distinctions and that many 

of the interventions include components of both. Accordingly, we present the evidence from 

self-monitoring, self-management, or patient education interventions in this single section. 

We first briefly describe the results of systematic reviews of self-monitoring or selfmanagement interventions. We then present the general characteristics of the self-monitoring, 

self-management, and patient education interventions encountered in the primary literature. 

Next, we present the results of the individual self-monitoring, self-management, and patient 

education intervention studies separately. However, for those studies that include both types of 

interventions together, we include them in both the self-monitoring, self-management, and 

patient education presentations. Finally we present the results of our synthesis of these studies—

evaluating the components of the self-monitoring, self-management, or patient education 

interventions most associated with improvement in outcomes for patients with asthma. We first 

present the evidence from the interventions directed at children with asthma and their caregivers 

and then present the evidence from the interventions directed at general populations with asthma. 

Systematic Reviews of Asthma Self-Monitoring, Self-Management, 

or Patient Education 

There have been numerous systematic reviews of asthma self-monitoring, self-management 

or patient education—many of which have been methodologically rigorous.10, 29-45 We direct 

interested readers to these reviews for detailed descriptions of their results. In general, the 

results of these systematic reviews highlight the heterogeneity of these literatures, including 

disparities in the relevant information reported about the interventions and the content and 

educational approaches evaluated. A common finding was that interventions directed at 

improving patient knowledge, typically through non-interactive formats (e.g., lecture, video, 

print) do not necessarily improve health outcomes. In contrast, interventions that focus on 

improving self-monitoring or self-management skills through behavior change techniques, often 

result in reductions in health services utilization and asthma symptoms and improve functional 

status. The authors of the systematic reviews described the common methodological weaknesses 

in the evidence base: small sample sizes, lack of long-term follow up, and use of interventions 

without strong theoretical or empirical foundations. 

The research question addressed by many of these reviews was whether written action plans 

improve the outcomes of care for patients with asthma.10, 29, 30, 34, 35, 40 For example, the 2001 

AHRQ funded Evidence Report entitled, “Management of Chronic Asthma”10 (which was used 

to inform the recommendations of the 2002 NHLBI asthma guideline) evaluated whether written 

asthma action plans improve asthma outcomes and, specifically, whether peak flow monitorbased plans are superior to symptom-based plans. They synthesized the evidence from 36 

controlled trials of the efficacy of written asthma action plans to improve outcomes for pediatric 

and adult populations with asthma. The authors found that most study designs were confounded 

by multiple asthma management interventions—only nine studies with a total of 1501 patients 

evaluated self-management programs in isolation.10 Of the five trials comparing a peak flowbased action plan to no action plan, only one found a statistically significant result—a reduction 

in emergency department visits for the peak flow-based action plan group. None of these five 
31

trials reported any other statistically significant difference in any other measure of clinical status 

or health services utilization. The authors note that most studies were underpowered to find 

statistically significant results.10 They concluded that there was insufficient evidence to 

demonstrate an association between the use of written asthma action plans and improved asthma 

outcomes.10 Moreover, they found that there was insufficient evidence to support the hypothesis 

that peak flow monitoring-based plans were superior to symptom-based plans.10 

The 2004 Cochrane review by Toelle and Ram was designed to assess whether the provision 

of a written individualized management plan increased adherence with self-monitoring or selfmanagement behaviors.30 Toelle and Ram concluded that there was insufficient evidence to 

recommend for or against the use of written management plans for asthma. Toelle and Ram 

commented that the failure to demonstrate any difference in health outcomes between written 

individualized plan groups and control groups may be because the provision of a written plan 

does not lead to any change in behavior or that enrollment in a study may lead to similar 

improvements in both control and intervention groups.30

Additionally, although not systematic reviews, the Working Group Reports from the 1998 

World Asthma Meeting are notable for providing succinct descriptions of key trials of a variety 

of self-management and patient education interventions and discussions of important gaps in the 

literature.46, 47 In particular, the article by Partridge and colleagues details the list of selfmanagement skills (including self-monitoring) that are widely accepted as required for effective 

self care and reviews a number of interventions and international efforts to improve patientprovider communication, provider education, and policy-level interventions for asthma care.47

In summary, prior systematic reviews found that non-interactive educational interventions 

were not effective, and that there was insufficient evidence to determine the value of written selfmanagement plans. 

To avoid duplicating the work done in prior reviews, we did not evaluate the comparative 

effectiveness of symptom-based versus peak flow-based self-monitoring or self-management 

interventions. Instead, our aim was to evaluate specific intervention characteristic (e.g., setting, 

teaching strategy, intensity of the intervention) and population characteristics (e.g., adolescents, 

country of residence) associated with improvements in outcomes of care for children and adults 

with asthma. 

General Characteristics of Self-Monitoring, Self-Management, or Patient 

Education Interventions for Children With Asthma 

Study Design Characteristics. Among the included articles, 69 had some component of selfmonitoring, self-management, or education for children with asthma or their caregivers. The 

median duration of the follow up period was 12 months (S.D., 5.8 months). The median sample 

size of these interventions was 90 subjects (Interquartile range: 43, 181). Fifty-nine were RCTs, 

three were quasi-RCTs, and ten were controlled before-after trials. In univariate analysis, the 

longest studies were more likely to have the largest number of subjects (p=0.005). Eleven were 

primarily self-monitoring or self-management, 36 were primarily patient or caregiver education, 

and 13 included both. 

Intervention Characteristics. The included interventions were highly heterogeneous in terms 

of educational materials provided, setting, frequency and duration of contact with asthma 

patients and their caregivers, among other key characteristics. 
32

Forty-three (62%) specifically described an underlying conceptual framework or theoretical 

background as the basis for the intervention. We direct interested readers elsewhere for 

discussions of the theoretic foundations of asthma educational and self-monitoring or selfmanagement interventions which include theories of empowerment, social ecology, selfregulation, and self-efficacy.48-50 In univariate analyses, these studies tended to be more likely to 

report statistically significant improvements in emergency department visits (36 studies reported 

both emergency department visits and described a conceptual framework; p=0.014) but not the 

other outcomes of interest. 

Nineteen of the self-monitoring, self-management, or patient education interventions were 

performed in outpatient primary care and most were taught by either physicians or nurses/nurse 

practitioners (Figure 5). 

Thirty-two (46%) of the self-monitoring, self-management, or patient education interventions 

provided 2 to 5 educational sessions to the children or their caregivers. Twenty-six interventions 

principally provided individualized instruction, six principally used interactive group teaching 

sessions, and 23 used combinations of teaching modalities (Figure 6). 

Figure 5. Intervention characteristics: setting and educator type

0

2

4

6

8

10

12

14

16

18

20

Outpatient primary care clinic

Outpatient specialty care clinic

Home

School

Other community setting

Other or not clear 

Combination

Number of Studies

0

2

4

6

8

10

12

14

16

18

20

Physician

Nurse/nurse practitioner

Pharmacist

Health educator

Other or not specified

Combination

Number of Studies
33

Figure 6. Number of educational sessions provided by educational strategy 

0

5

10

15

20

25

30

35

1 2 to 5 6 to 10 more than 10 other

Number of Educational Sessions

Number Self-management and/or Patient 

Education Studies

Not Sure/Other

Combinations 

Lectures

Interactive groups

Printed materials

Individualized education

Eight studies used video games or Web-based programs as educational or self-monitoring or 

self-management tools for children with asthma.51-58 For example, “Bronkie’s Asthma 

Adventure” (Click Health, Inc, Mountain View, CA) is a Nintendo®-based game that has been 

designed to teach children self-monitoring or self-management strategies and provide feedback 

(in English or Spanish language) on their performance.58 Similarly, the “Asthma Control” video 

game features a superhero named “Spacer” whom the player has to lead through six game levels, 

accumulating points by avoiding both indoor and outdoor triggers/allergens and using controller 

medications.54 The use of video games or Web-based teaching modalities was not associated 

consistently with statistically significant improvements in outcomes or processes of care for 

children with asthma. 

Outcomes Reported. The 69 self-monitoring, self-management, or patient education studies 

reported on a variety of outcomes. The most frequently reported outcomes were asthma 

symptoms, days lost from school or work, urgent care or emergency department visits, and 

hospitalizations due to asthma. Relatively few studies reported on guideline adherence including 

adherence to self-monitoring or self-management plans. Table 10 presents a summary of the 

number of studies reporting each of the primary outcomes of interest. Thirty-one studies 

reported on asthma symptoms; however, these were measured in highly heterogeneous ways 

(e.g., self reported symptoms from children’s diaries, physicians’ ratings of asthma symptoms, 

multiple different asthma symptom questionnaires). Thirty studies reported on days lost from 

school or work due to asthma. Some authors adjusted days lost from school on the basis of 

expected seasonal variation in absenteeism, but most reported school days lost in the intervention 

group compared to the control group. 
34

Table 10. Outcomes reported by the pediatric self-monitoring, self-management, or patient education studies 

Outcomes 

Number of studies 

reporting no difference 

between intervention 

and control subjects (%)

Number of studies 

reporting improvement 

among intervention 

compared with control 

subjects*

(%) 

Number of studies 

reporting this outcome

Clinical status measures§ 21 (44) 27 (56) 48 

Asthma symptoms 13 (42) 18 (58) 31 

Symptom-free days 8 (57) 6 (43) 14 

Amount of medication used or prescribed 12 (67) 6 (33) 18 

Number of asthma attacks 9 (69) 4 (31) 13 

Pulmonary function from peak flow, 

FEV1, or other spirometric measures 13 (65) 7 (35) 20 

Functional status measures 21 (62) 13 (38) 34 

Activity restriction 5 (50) 5 (50) 10 

Days lost from school/work 21 (70) 9 (30) 30 

Health services utilization 27 (63) 16 (37) 43 

ED or urgent care visits 23 (64) 13 (36) 36 

Hospitalizations 19 (83) 4 (17) 23 

Office visits 14 (78) 4 (22) 18 

Guideline adherence 12 (44) 15 (56) 27 

Adherence with PF monitoring 3 (100) 0 (0) 3 

Use of self-monitoring or selfmanagement or action plans 7 (64) 4 (36) 11 

Inhaler technique 3 (43) 4 (57) 7 

Appropriate use of asthma medications 4 (40) 6 (60) 10 

 *Note: In this table, we present data from all studies of pediatric self-monitoring, self-management, or patient education. These 

include those in which the intervention subjects were compared to control subjects who typically received “usual care” and the 

studies which compared two or more groups without a control arm that did not also receive a QI strategy. 

 §For each of the categories of outcomes highlighted in bold (e.g., clinical status measures, functional status measures), we recorded 

whether the study reported one or more statistically significant changes between the intervention and control group at the end of 

the study period in any of the individual metrics associated with that outcome category. 

Self-Monitoring or Self-Management Interventions for Children With Asthma 

Background. The International Consensus Report on Asthma suggests that peak flows of 80 to 

100% of the individual’s best are satisfactory and necessitate only routine treatment.28 Peak 

flows of 50 to 80% of personal best peak flow should stimulate a treatment change (e.g., 

increasing bronchodilators or anti-inflammatory medications).28 Peak flows below 50% of 

personal best should lead the patient to use their urgent medications (e.g., start oral steroids) and 

seek medical attention.28 Most of the self-monitoring or self-management interventions for 

children with asthma utilize a written, often color-coded plan in which instructions and 

medications are labeled (green) for routine care, (yellow) for caution/early treatment, and (red) 

for urgent treatment. The purpose of this section is to present the characteristics of the individual 

self-monitoring or self-management interventions. 
35

Results. We found 35 interventions designed principally for the improvement of self-monitoring 

or self-management of asthma symptoms by children with asthma and their caregivers (24 of 

these studies are presented in Table 11). Nine of the pediatric self-monitoring or selfmanagement studies compared two self-monitoring or self-management interventions without 

including a control group that did not also receive a self-monitoring or self-management 

intervention.55, 56, 59-65 Studies with this design are described in detail in a subsequent section of 

the report (Table 21). 

The studies of pediatric self-monitoring or self-management interventions are notable among 

all the types of studies synthesized for this report, in two ways. First, many of these studies 

reported statistically significant improvements in subjects receiving the intervention—

specifically, 29 (83%) of the pediatric self-monitoring or self-management studies reported at 

least one statistically significant outcome for the recipients of the self-monitoring or selfmanagement intervention compared with the control group. We explore the intervention factors 

associated with improvements in outcomes and processes of care for children with asthma at the 

end of this section (Table 13 through Table 16). 

Second, among the included studies, the reports of self-monitoring or self-management 

interventions were most likely to have described their efforts to design interventions that were 

well-grounded in theoretical frameworks such as social learning theory, cognitive development, 

and behavior change. Twenty-two (63%) of the included pediatric self-monitoring or selfmanagement studies described such a theoretical rationale for either the content of the program 

or the selection of teaching methods employed.52-54, 61, 64, 66-81 Typically, these interventions 

relied less on lecture-based or pamphlet-based teaching methods and utilized multiple 

educational modalities including role-playing, videotapes, and games to reinforce patient 

learning. 

The 35 interventions were heterogeneous with respect to the specific content and delivery 

methods of the self-monitoring or self-management program. However, two programs, Open 

Airways and “Superstuff” are worthy of specific mention because they were the subject of 

multiple evaluations. Five studies evaluated a school-based self-monitoring or self-management 

program utilizing multiple educational components called Open Airways.68-70, 72, 82 This program 

consists of six 40-60 minute group sessions for inner-city third to fifth graders to increase their 

ability to care for their asthma on a daily basis. It includes information about asthma 

pathophysiology, recognizing and responding to asthma symptoms, using asthma medications 

and deciding about when to seek care, staying active, identifying and controlling asthma triggers, 

and managing asthma-related school problems. Interactive teaching methods used in Open 

Airways include group discussions, storytelling, games, and role-playing. Each of these studies 

found important clinical improvements in asthma outcomes for the participants of this selfmonitoring or self-management program (Table 11). The study by Ronchetti and colleagues of 

children receiving asthma care in 12 Italian centers compared the outcomes of three groups: 

subjects receiving Open Airways, subjects receiving another self-monitoring or self-management 

program called Living with Asthma, and control subjects receiving usual care.72 The content of 

the Living with Asthma program is similar to Open Airways and it also uses a group format; 

however, it makes more extensive use of written diaries for developing asthma management 

skills and does not rely as heavily as Open Airways on encouraging group members to share 

problems and develop solutions together. One year after enrollment, patients in the Open 

Airways but not the Living With Asthma groups had fewer emergency treatments for asthma 

than controls (p<0.03).72 
36

Three studies reported evaluations of self-monitoring or self-management programs that 

utilized the “Superstuff” pediatric self-monitoring or self-management kits produced by the 

American Lung Association (or materials developed from “Superstuff”).66, 83, 84 “Superstuff” kits 

include a Parent’s Magazine containing 29 articles on asthma pathophysiology, triggers, 

relaxation techniques, and personal control and decision making. The Children’s Kit includes 

riddles about asthma facts, the “Breathe Easy” board game, puzzles and dolls with self-care 

messages, a comic strip about relaxation exercises, a mystery house for games about discovering 

allergens, a phone book with advice about when to call the doctor and to record emergency 

numbers, and assorted asthma-related door signs, posters, stickers, records, and paper cut-outs. 

In the study by Rakos and colleagues, 20 children with moderate to severe asthma received the 

“Superstuff” kit in the mail with instructions on its self-administration while 23 children received 

usual care.83 One year after receiving the intervention, parental reports suggested a statistically 

significant decrease in “interruptions due to asthma” (p<0.04) but there was no difference in 

school absenteeism between groups. The study by Whitman and colleagues84 provided the 

“Superstuff” kit in addition to eight teaching sessions to 19 children and found that three months 

after the intervention, there was no difference in number of asthma episodes or days without 

asthma between recipients and controls (N=19); however, participant’s knowledge (p=0.02) and 

asthma skills (p<0.01) improved compared to controls. Also, the intervention evaluated by Pérez 

and colleagues for Venezuelan children with asthma was based on a self-monitoring or selfmanagement packaged adapted from Superstuff and Living with Asthma—they found that 

intervention subjects reported fewer asthma crises and their physicians reported less severe 

asthma than among control subjects (Table 11).66 

Of the other studies, numerous reported statistically significantly greater improvements in 

outcomes for the intervention group over the control group. However, often these statistically 

significant findings (e.g., improvement in percent predicted FEV1 of less than five percent) are of 

only modest clinical significance. 

Conclusions. The 35 self-monitoring or self-management interventions, although heterogeneous 

in terms of content delivered and method of instruction, tended to be associated with statistically 

significant improvements in outcomes for children with asthma. Additionally, they tended to be 

grounded in established theoretical or behavioral frameworks. The interventions with wellestablished theoretic foundations typically utilized multiple educational modalities including 

role-playing, videos, and games to reinforce patient learning. Overall, many of the reported 

improvements were of only modest clinical significance.
37 

Table 11. Summary of self-monitoring or self-management interventions directed at children with asthma 

Reference Study Purpose Target population Study Design Type of intervention 

Agrawal et al.85

To evaluate the effects of adding a individualized written asthma homemanagement plan to standard asthma care. 

60 children aged 5-12 years with moderate persistent asthma in India. 

RCT 32 children completed the self-management program that 

included an individualized home-management plan (trained to perform PF measurement, use a PF and symptom diary, and given specific instructions for home medication management based on symptoms and PF measurement). 28 children completed the usual care arm. All subjects were followed weekly for 4 weeks then monthly for 3 additional months (7 visits). 

4 moin thacutdays feweand 

Bartholomew et al.53

To evaluate whether a computer-based asthma selfmanagement tool would increase process and clinical outcomes of care for inner-city children with moderate to several asthma in Houston. 

133 children aged 6-17 with asthma. 

RCT 70 children used the Watch, Discover, Think, and Act

multimedia CD-ROM program for variable amounts of time after their scheduled office visits. The program presents an “adventure game” in which the player makes choices to manage the game character’s asthma (the game’s character is matched with the subject on gender and ethnicity). Within the game, children can learn new skills, identify symptoms, reduce environmental triggers, and take preventative actions. 63 children received usual care with telephone reminders before their scheduled office visits. 

7.9 minterbetwvisit

Burkhart et al.71

To determine the effects of interventions that combine education and behavioral techniques in managing asthma at home. 

42 English-speaking children aged 7-11 years with persistentasthma in Kentucky; Nint=21; Ncon=21. 

RCT Patients received asthma education and instructions on how 

to use an electronic PF meter twice daily and record data in an asthma diary. Patients received three 1-hour individual sessions with a nurse, a contingency management intervention, which consisted of a contingency contract, reinforcement, tailoring, and reminders. The contract outlined requested behaviors (PF monitoring, diary self-reporting) and associated rewards. (We describe the rewards used in the section on financial incentives.) A nurse educator also contacted patients weekly to reinforce teachings. The control group received the teaching sessions but no contingency contract and no follow up calls from nurses. 

At 5 adhethe i(con
38

Table 11. Summary of self-monitoring or self-management interventions directed at children with asthma (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Cicutto et al.77

To evaluate whether an interactive childhood asthma education program improved asthmarelated morbidity among elementary school children in Toronto, Canada. 

256 children with asthma in grades 2 to 5 (aged 6-11 years) and their parents. Nint=132, 

Ncon=124. 

RCT The “Roaring Adventures of Puff (RAP)” consists of 6 

sessions of 50-60minutes held once a week for 6 consecutive weeks. Sessions cover use of PF meters, diary monitoring, trigger identification and control, use of inhalers and medications, symptom recognition and action plan use, and managing asthma exacerbations. Parents are invited to the last session in which children showcase their learning and new skills. The strategies utilized included games, puppetry, and model building to teach about trigger identification, medication use, symptom recognition, sharing information with teachers and parents. 

12 mattevisitschoactiv(p<0

Dahl et al.86 To evaluate the 

effects of a behavioral treatment program when superimposed on medical treatment. 

19 children in Sweden with severe asthma using continual β-agonist 

therapy. Ncon=10, 

Nint=9. 

RCT All patients underwent a 4-week baseline period during which 

a behavioral analysis was made for each child and daily asthma charts were kept. Patients in the intervention group underwent a 4-week intervention period, during which they received four 1-hour individualized behavior therapy treatment sessions in their home or school focusing on discrimination training of asthma signals, self-management techniques for breathlessness, counter-conditioning any learned fear response, contingency management of asthmarelated behavior, and compliance training. The control group received usual care. 

All dcomAftethe signneesignschopatiewas in P

Evans et al.68 To evaluate whether a 

school-based selfmanagement program would increase children’s asthma management skills and other process and clinical outcomes for low income 3rd-5th

graders in public schools in New York. 

204 low income 3rd5th graders in public 

schools in New York, aged 8 to 11 with asthma. 

CBA 93 children attended the Open Airways program’s six 1-hour 

small group sessions (over a 3 week period) in which children learned basic information about asthma, recognizing and responding to symptoms, using medications and when to seek help, keeping physically active, identifying and controlling triggers, and handling problems related to school. 87 control children received no additional self-management training. 

1 yechild(p=0asthsymincrescorThegrouand phys
39

Table 11. Summary of self-monitoring or self-management interventions directed at children with asthma (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Fireman et al.81

To determine whether a nurse teaching selfmanagement skills to children and their caregivers would improve their disease outcomes. 

26 children aged 2-14 with asthma in Pittsburgh 

Sequentially

assigned 

(not 

randomly) 

controlled 

trial 

13 children and their caregivers received 4 individualized sessions with a trained nurse on the use of symptom and medication diaries, two 2-hour group sessions for discussion of asthma management, and phone follow up every 3 months by the nurse. 13 children received usual care. 

13 minterattaand 4.6 authand but betwdiffemon

Homer et al.54

To assess the effectiveness of multimedia educational software program about asthma for inner-city children. 

Children aged 3 to 12 with asthma living in inner-city Boston. Nint=57; 

Ncon=49. 

RCT “Asthma Control” is an interactive educational computer game 

designed to teach children about asthma and its management. The object of the game is to help the main character, Spacer, a superhero with asthma complete all 6 game levels (3 home and 3 outdoor levels). The player uses his or her knowledge of asthma to help Spacer eliminate common indoor allergens and to avoid outdoor allergens. If Spacer’s condition worsens, the program producing coughing and wheezing sounds and he may not be about to jump or run. If the player does not eliminate allergens or use preventive medications, Spacer’s mother blocks his/her exit from home. Study patients were asked to return to the study site 3 times to use the educational computer program. 

Duriwere intertermasthenvimetbehNotestudsmo

LaRoche et al.78

To evaluate a multifamily asthma group self management program designed to be culturally relevant and encouraged group cohesiveness among the attending families. 

24 African American and Hispanic families living in Boston with children aged 7-13 with asthma. 

RCT The 24 experimental families were randomized to receive 

three 1-hour sessions that emphasized collaborative asthma management among patients, parents, and physicians and provided training on asthma symptoms and skills for self management. Half of the experimental families received encouragement to work as a group to share experiences and learn from each other. The 11 control families received no intervention. 

Durithe that feweexpeself-

cont

were manprog$2,2savi$4,6
40

Table 11. Summary of self-monitoring or self-management interventions directed at children with asthma (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Maslennikova et al.82

To assess the effects of a adapting a U.S. self-management educational intervention on asthma outcomes for children in Moscow. 

122 children with asthma and their families living in Moscow. Nint=60; Ncon=62. 

RCT The authors adapted “Open Airways” (developed for low 

literacy children aged 4-7 years) and “Air Power” (developed for average literacy children aged 8-14 years) for similar populations in Moscow. Intervention subjects also received asthma care from clinicians who had been trained “according to the U.S. guidelines for the diagnosis and management of asthma and use of modern asthma medications.” Intervention subjects participated in 4 weekly 1hr sessions. Control subjects received usual care from clinicians who received no additional training. 

1 yechildwere medcomgrouPF mfor cwas chantheomiss

McGhan et al.76

To determine whether the asthma education program “Roaring Adventures of Puff (RAP),” improved asthma management behaviors and health status in elementary school children in Edmonton, Canada. 

136 children with asthma aged 7-12 years. Nint=65; 

Ncon=71. 

RCT Parent and teacher asthma awareness events were held 

within the school setting. The intervention provided recommendations for school asthma guidelines and six educational group sessions for children with asthma described above. 77

9 mexpeappmedasth(p<0betwpossunscsym26% smo

McNabb et al.80

To evaluate whether children with asthma who had not been compliant with standard medical management would benefit from selfmanagement education that could be tailored to their educational and behavioral needs. 

14 children aged 9 to 13 with asthma in northern California. 

RCT Experimental subjects (N=7) received a 30 minute diagnostic 

interview followed by four 45-minute individually tailored weekly sessions with a nurse educator on asthma selfmanagement. Control subjects (N=7) received usual care. 

In ththe emefor tprovnonbetwprogon tvisit
41

Table 11. Summary of self-monitoring or self-management interventions directed at children with asthma (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Morgan et al.,73 Evans 

et al.,74, and 

Sullivan et al.75

To evaluate whether a home-based intervention for innercity children designed to teach caregivers to reduce environmental asthma triggers specific to that child would result in improvements in asthma-related outcomes. (The National Cooperative Inner-City Asthma Study.) 

1,023 families of children aged 5 to 11 with asthma from 8 major U.S. cities. Nint=515, Ncon=518. 

RCT During the 12 month intervention, 2 research assistants 

visited each home 5 to 7 times. Each visit was followed by a phone call to address any barriers to implement the plan. Caregivers were taught about the role of allergens in asthma, mattress covers were installed, families were given a vacuum cleaner with HEPA filter and a HEPA air purifier was set up in the child’s bedroom. Professional pest control was provided. 

Two child(565symscho

Theor Pvisitbetw

of thfor 2 incre$9.2(95% sym

Pérez et al.66 To evaluate the 

effectiveness of a self-management program based on social learning models and self management programs with demonstrated effectiveness on asthma morbidity. 

29 children with asthma aged 6-14 years in Venezuela.

RCT 17 children and their parents were randomized to receive 

asthma education. Parents received two 90 minute sessions on asthma pathophysiology, treatment and psychological factors associated with the disease. Children received six 60-minute self-management training sessions that included modeling, positive reinforcement, group dynamics, behavioral practice, role-playing, and feedback. 

6 mrepophysthan 

Persaud et al.87

To evaluate the effects of a schoolnurse based self management program for school children in Texas. 

36 children aged 8 -12 years with moderate to severe asthma. 

RCT All children had a visit with a primary care provider at the time 

of enrollment during which time they were all given written guidelines for medication use, asthma control and prevention, PF meters, and asthma diaries. Intervention children (N=18) also received 8 individualized, weekly, 20 minute sessions with a school nurse to review asthma symptoms and medication and PF meter use. Control children (N=18) visited the school nurse sporadically, on their own initiation. 

20 wpercfor agrougrouwere 

visitbetw
42

Table 11. Summary of self-monitoring or self-management interventions directed at children with asthma (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Rakos et al.83 To evaluate the 

effectiveness of a self-administered self-management program for pediatric asthma. 

43 children aged 7-12 years with moderate to severe asthma in Cleveland. 

RCT 20 children and their caregivers received a “Superstuff” kit in 

the mail. This program, developed by the American Lung Association, includes a Parent’s Magazine containing 29 articles on asthma pathophysiology, triggers, relaxation techniques, and personal control and decision making. The Children’s Kit includes riddles about asthma facts, “breathe easy” board game, puzzles and dolls with self-care messages, comic strip about relaxation exercises, mystery house to discover allergens, phone book to advise when to call the doctor and record emergency numbers, and asthmarelated door signs, posters, stickers, records, and paper cutouts. 23 children received usual care. 

12 mintersigndue in scThe 

Ronchetti et al.72 To compare the Open Airways 

program to Living With Asthma program among Italian children with asthma. 

209 children with asthma from 12 centers across Italy.

CBA 58 children received either the original version of Open 

Airways or a 4 session abbreviated version, 56 children received either the original version of Living with Asthma or a 4 session abbreviated version (see text for intervention description). 95 children received usual care. 

One the With emecont
43

Table 11. Summary of self-monitoring or self-management interventions directed at children with asthma (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Runge et al52 To evaluate whether 

an internet-based education program as an add-on to a standard patient education program improved health outcomes and reduced costs of children with asthma in Germany. 

178 children with asthma aged 8-16. 

CBA 48 children in the control group received no education until 

after the trial. 86 children received the self-management program of five 2hr sessions in which they used role-playing and small group sessions to teach inhaler use, trigger avoidance, medication management, PF monitoring, and decision making. 44 children received this self-management program plus self-selected to also use the interactive internet adventure game incorporating virtual asthma-related situations in need of management and also provides access 

to online chats with asthma experts, an online PF protocol that can be maintained by the patient, and chat rooms for other users and healthcare providers. 

6 mmaneduemethe self-(p=0signvisit(-67grouSign3 of grouto dreduAdjuwere SMI 

year inter

Tieffenberg et al.67

To evaluate a chronic disease self management program based on behavioral change and learning theory directed at increasing autonomy on the part of children. 

188 children with moderate to severe asthma aged 6 to 15 in Argentina. 

RCT 65 children were randomized to receive 5 weekly 2-hour 

meetings with a reinforcement meeting 2-6 months later. The curriculum included identifying early warning signs and symptoms of an attack, identifying triggers, understanding therapies, and decision making skills through games, drawings, stories, videos, and role-playing. 52 children received usual care. 

12 mexpereguasthabseand no dcom
44

Table 11. Summary of self-monitoring or self-management interventions directed at children with asthma (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Toelle et al.88 To evaluate whether 

a community-based asthma management program could reduce asthma symptoms and lung function among school children in Sydney, Australia. 

132 school children aged 8 to 11 with asthma and all the adults who influence their care including parents, doctors, pharmacists, community nurses and school teachers. 

CBA Children in the intervention group and their parents (Nint=72) 

were invited to attend 2 education session each 2 hours, 1 week apart with a curriculum on asthma triggers, medication use, inhalation technique, use of written self-management plan. These children’s physicians and pharmacists were invited to attend evening workshops during which asthma management guidelines were reviewed. Community nurses and school teachers in the intervention community received an in-service education session at their workplace. All families, children, physicians, and pharmacists who did not attend the intervention sessions were mailed the materials. 60 children received usual care. 

147 53 f(21%attemonFEV

imprnot numsymchansign(p<0diffedays 

Vazquez and Buceta79, 89

To evaluate the effects of adding relaxation training to asthma selfmanagement education to improve the care of children with asthma in Spain. 

27 children with “light or moderate” asthma aged 8 to 13 years. 

CBA 9 children in the control group received usual care; 9 children 

received six 1-hr weekly sessions with their parents on asthma pathophysiology, use of medication, identification of triggers, and breathing exercises; and 9 children received the self-management instruction plus additional training on relaxation techniques at the end of each self-management session. 

At 1both scormanthis grouamofreqmedabse

VelsorFriedrich et al.69

To examine the effects of a schoolbased intervention program on self care abilities, practices and health outcomes of children with asthma. 

102 African American 8-13 year old children with asthma recruited from 8 inner-city public schools in Chicago. 

QRCT

*

The Open Airways educational program utilized an interactive teaching approach applying group discussions, stories, games and role-playing to promote children’s active involvement in the learning process. In six 45-minute sessions offered once a week, small groups of children learned new asthma management skills. Nint=40, Ncon=62. 

5 mprogsignmeaimprnum(p=0medin tescho
45

Table 11. Summary of self-monitoring or self-management interventions directed at children with asthma (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Webber et al.70

To evaluated whether the Open Airways program would reduce asthma morbidity and health services utilization among inner-city children with asthma in the Bronx. 

599 3rd to 5th graders in the Bronx with asthma. 

CBA 599 children in schools with school-based health centers 

were scheduled to attend the Open Airways program (as described in the two prior studies). They were compared with students in schools with school-based health centers that did not offer the Open Airways program (N not specified) and children in control schools without school-based health centers (N not specified). 

Appenrovisitschowithnot fwhooffichosp(no 

Whitman et al.84

To evaluate the effects of a selfmanagement curriculum on asthma knowledge, skills, and “asthma experiences.” 

38 children aged 6 to 14 in Utah. 

RCT 19 children received eight 90-minute classes for children and 

caregivers given twice a week for a month included education on breathing control skills, body relaxations skills, bronchial hygiene silks, and physical conditioning. Additionally, intervention subjects received the “Superstuff” kit described in Rakos.83 19 children received no training. 

Thretherasthasthknow(p<0cont

Note: Eight studies compared two self-management interventions without including a control group that did not also receive a self-management interventi

described in detail in a subsequent section of the report (Table 21). *QRCT=quasi-randomized controlled trials. ED=emergency department. PF=peak flow

CBA=controlled before-after trial.
46 

Photo reproduced with permission.2

Patient Education Interventions for Children With Asthma 

Background. In general, pediatric patient education strategies for asthma are based on 

imparting knowledge about asthma pathophysiology to patients and their parents or caregivers 

and encouraging the appropriate use of peak flow meters and inhaled medications. 

Results. We found 54 evaluations of interventions designed primarily to educate children or 

parents or caregivers of children with asthma (Table 12). The included studies were highly 

heterogeneous with respect to the target of the intervention (e.g., patients 

versus their parents or caregivers), the setting of the intervention (e.g., 

home, school, clinic), and the information being provided (e.g., asthma 

pathophysiology, allergen reduction). Thirty-seven (69%) studies 

demonstrated at least one statistically significant improvement in clinical 

outcomes, functional status, health services utilization, or guideline 

adherence. The studies reporting decreases in health services utilization 

tended to have described a theoretical basis for their intervention (p=0.048). 

Half of the pediatric patient education interventions (N=27) were based on a conceptual or 

theoretical framework (compared to 63% of the self-monitoring or self-management 

interventions). 

In this section (Table 12), we describe the included studies in groups according to these key 

characteristics. (Note: The number of studies described in Table 12 is greater than 54 because 

there is overlap between the school-based interventions and other types of interventions so those 

studies are presented more than once). At the end of this section, we present the results of our 

synthesis of the association between intervention characteristics and likelihood of finding 

statistically significant improvements in the outcomes of interest for patient education or selfmonitoring or self-management interventions.‡

Parent or caregiver education programs. Whereas most school-age children are typically 

considered to be sufficiently mature to benefit from asthma education offered outside the context 

of their families, preschool children learn new skills best within the context of their families, and 

parents are the primary target of the education of the youngest children with asthma (less than 

seven years).90 Among the included articles, we found 21 that included educational interventions 

directed at parents or caregivers (Table 12a)—13 (62%) of which found statistically significant 

improvements in processes and outcomes of care for children with asthma. In particular, this 

type of study was likely to report improvements in clinical outcomes (13 studies found 

improvements in asthma symptoms and other clinical outcomes among the 15 studies reporting 

these types of outcomes). Four studies compared two or more parent or caregiver education 

programs with each other but did not include a control group that did not also receive an 

educational intervention—these are described in Table 21.60, 62, 64, 65 

Notable for its size and methodological rigor, the National Cooperative Inner-City Asthma 

Study (NCICAS) evaluated the effectiveness of a multifaceted, home-based intervention for 

 

‡

Many of the included patient education interventions evaluated changes in asthma knowledge among intervention and control 

participants. Asthma knowledge was not one of our key outcomes of interest; however, we abstracted information about this 

outcome and present it, where available, in Table . Often the asthma knowledge in both groups increased, occasionally, it 

increased to a greater extent in the intervention arm. 
47

1,033 inner city children aged 5 to 11 years with asthma from seven U.S. cities living in census 

tracts in which at least 20% of households had income levels below the federal poverty level.73-75 

The NCICAS evaluated an educational intervention designed to teach caregivers about asthma 

management and to reduce those environmental asthma triggers to which their children had 

positive skin tests.73 Intervention families were given training on asthma triggers, environmental 

controls, and asthma physiology by social workers and were given tools to reduce environmental 

allergens such as vacuum cleaners, pillow covers, and air filters. Two years after enrollment, 

intervention children had more symptom free days (565.1 versus 538.5 days), fewer asthma 

symptoms (p<0.001), days lost from school (0.54 versus 0.71 days per two weeks, p<0.009), and 

lower allergen levels.73 There were no differences in hospitalization rates, physician visits, or 

emergency department between intervention and control groups.74, 75 The cost of the 

intervention was $337 per child for 2 years resulting in an estimated incremental costeffectiveness ratio of $9.20 per symptom-free day gained (95% CI: -$12.56 to $55.29 per 

symptom free day gained).75 We cannot assess the extent to which it was the educational 

component or the reduction in environmental allergens that resulted in improvements for 

intervention subjects. 

The study by Toelle and colleagues88 differed from the others in this section in that it was an 

educational program directed broadly at children with asthma and all the adults who influence 

their care including parents, physicians, teachers, pharmacists, community nurses, and school 

teachers. Six months after the intervention, pulmonary function (FEV1(L) was 2.13 at six 

months vs. 1.78 at baseline) improved in the intervention group but not the control group 

(p<0.001). The number of children with wheeze and symptoms that limited their activity did not 

change but night cough decreased a statistically significant amount in the intervention group 

(37.3% at six months vs. 68.3% at baseline; p<0.001). There was no statistically significant 

difference in physician or emergency department visits or days absent from school. 

School-based education programs. Sixteen of the studies of pediatric QI studies delivered some 

portion of their intervention in schools—13 of these were patient education programs (Table 

12b). Eleven school-based programs (69%) reported statistically significant improvements in 

processes and outcomes of care for children with asthma. Although these interventions all 

occurred in schools, they were highly heterogeneous in terms of the curriculum delivered, 

training of the person(s) delivering the curriculum, intensity of the program, and target audience. 

Two studies used the same 6 session educational program called “The Roaring Adventures of 

Puff.” McGhan and colleagues91 studied the effects of this program in 7 to 12 year old children 

in Edmonton and Cicutto and colleagues evaluated this program in 6 to 11 year olds in 

Toronto.77 In both studies, this program—which is based on asthma practice guidelines, social 

cognitive theory, and self-regulation theory and utilizes numerous teaching modalities including 

puppetry, games, role playing, model building, discussions, and asthma diary recordings—found 

reductions in asthma-related limitations in activity (McGhan et al. reported that in the 

intervention group, 41.5% of children at baseline vs. 29.2% children post-intervention were 

limited in their kinds of play; Cicutto et al. reported 6.2 versus 9.1 days of limited activity in the 

intervention compared to the control group).77, 91 

Adolescent education programs. During adolescence, developmental behavioral changes can 

have adverse effects on asthma management if medication adherence declines or medical 
48

supervision becomes less consistent.92 We found six studies of educational interventions that 

exclusively targeting adolescents with asthma (Table 12c). None of these six adolescent-targeted 

interventions, even those that relied on peer teachers or intensive educational programs from 

physicians or nurse educators, resulted in statistically significant durable improvements in 

inhaled bronchodilator use, asthma symptoms control, or health services utilization. We note 

that five of these were relatively short with interventions lasting eight months or less. 

We found 24 studies of self-monitoring, self-management, or patient education of general 

pediatric populations with asthma that included adolescents. Of these, 18 (75%) reported at least 

one positive outcome. Similarly, adolescents were included in 26 of the interventions directed at 

general populations with asthma—18 (70%) of these reported at least one positive outcome. 

Among these 50 studies that included adolescents as part of their study population but were not 

exclusively targeting adolescents, 14 (28%) reported statistically significant improvements in 

asthma symptoms or disease severity compared to controls and 12 (24%) reported significantly 

fewer emergency department/urgent care visits compared to controls. Because none of these 

studies reported outcomes by age strata, the extent to which these improvements were found 

among adolescents is unclear. 

Outpatient education programs. We found 15 additional studies of educational interventions 

designed for children with asthma that were coordinated from the outpatient setting, sometimes 

including home visits and calls (Table 12d). Several of the included studies that directed the 

educational intervention at children but did not include parental involvement (particularly for 

young children) did not find statistically significant improvements in the processes or outcomes 

of care for the asthmatic patients. Several authors noted that even among families with older 

children, parents did not always respond to the suggestions raised by their children after 

participation in the educational intervention.54 Sometimes this was because parents could not 

afford or were unable to remove environmental factors such as wall-to-wall carpeting in their 

public housing residences.54 Others who were capable of removing some allergens or irritants 

sometimes denied that a particular environmental exposure, such as their smoking, was harmful 

to the child. These observations strongly suggest that parallel educational activities focusing on 

parents as well as their children may be needed. 

Conclusions. Patient education interventions can be effective for improving the processes and 

outcomes of care for children with asthma. In particular, school-based programs and those 

directed at parents or caregivers of young children with asthma (even among lower socioeconomic groups) tend to be associated with the greatest improvements in asthma outcomes. 

However, the effect sizes were often only of borderline clinical significance. Additionally, the 

few QI strategies that exclusively targeted adolescents have not resulted in much success—

emphasizing the need for additional study of this key asthma population. 
49 

Table 12a. Summary of patient education interventions directed at the parents or caregivers of children with asthma

Reference Study Purpose Target population Study Design Type of intervention 

Brook et al.93

867

To compare the parents’ knowledge about asthma after an educational seminar and to compare rates of hospitalization of children with asthma whose parents had participated in the seminar with those of children in the control group. 

Parents of 54 children with asthma treated in the pediatric respiratory service of Wolfson Hospital in Tel Hashomer, Israel. Nint=26, Ncon=28. 

RCT Intervention parents were invited to 

participate in an educational project, which included 1-hour weekly meetings over a four-month period where they received lectures and explanations about various aspects of asthma. Lectures were given by pediatric respiratory therapists, allergists, psychiatrists, social workers, and physiotherapists. Additionally, parents received written information about the chronic disease. 

During 12 interventiofewer hosp3.6 to 1.3 per child t3.1, p<0.0

Brown et al.90§

To evaluate whether homebased asthma education of lowincome parents and their preschool children with asthma would be feasible and result in reductions in asthma morbidity, caregiver QOL, and asthma management behaviors. 

95 low income children with asthma between 1 and 6.99 years of age in the metropolitan areas of Atlanta, GA and Palo Alto, CA. Nint=49, Ncon=46. 

RCT The Wee Wheezers at Home program (was 

an adaptation of the Wee Wheezers program94) included eight 90-minute 

sessions at weekly intervals in families’ homes. Families also received printed materials and homework at each session and videotapes at some sessions. 

At 12 monthe educafewer asthsymptom-fcaregiver aged 1-3 b4-6. There between trgroups for managemutilization.

Butz et al.95 To evaluate the effectiveness of 

a parent and child asthma education program for rural families in Maryland. 

201 children aged 6-12 years with asthma. Nint=112, 

Ncon=89. 

RCT The intervention parents received a 1hr 

education session on asthma management, use of asthma action plan, and early warning signs; a quarterly newsletter, and a resources guide to asthma management that included locations for allergy testing and information about tobacco cessation. The intervention children received two 2-hr interactive sessions on asthma symptoms, use of PF meters and inhalers; a PF meter; a spacer; and a copy of the “My Asthma Coloring Book.” Control group received usual care. 

10 months interventioless shortnand nighttThere wernumber of action planhospitalizacaregiver 
50

Table 12a. Summary of patient education interventions directed at the parents or caregivers of children with asthma (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Clark et al.96, 97

To determine whether health education would increase the ability of parents and children to manage asthma and reduce the use of health services. 

290 families of 310 children aged 4-17 years with asthma recruited from clinics serving low income families in New York City. 

RCT 207 control group children received regular 

care. 103 experimental group children received regular care plus six 1-hour small group sessions offered monthly on managing asthma attacks, taking medication, communicating with physicians, improving school performance, maintaining a healthy home environment, and establishing guidelines for the child’s physical activities. 5 sessions were taught separately for parents and children, 1 was jointly attended. 

1 year after the istatistically signifhospitalizations oHowever, among more pre-intervewere significant rthe experimental control (p=0.04). their children had management pla(p<0.05). The coprogram exceedrealized (for eversaved). Howeve$11.22 for ever $or more pre-inter

97

Eggleston et al.98

To conduct and evaluate a home-based environmental intervention for inner city children in Baltimore (based on the findings of the National Cooperative Inner-City Asthma Study). 

100 children with asthma aged 6-12 years with asthma. Nint=50, Ncon=50. 

RCT Intervention families received 

comprehensive home-based evaluations of environmental triggers and were given air filters, pillow covers, and cockroach extermination as needed. Additionally, they received 3 home visits and a telephone follow up to review allergen reduction principals. 

1 year after the ichildren had fewsymptoms (p=0.0difference in nighrelated symptomsymptoms, acute 

QOL scores. 69least one smokeparents stopped group assignmen

Horner99 To evaluate the effects of 

a school-based education program for children combined with a homebased program for their parents on children with asthma. 

44 families of children with asthma aged 8-12 years in the U.S. participated (not clear how many in the intervention group and the control group). 

RCT Children in the intervention group 

participated in nine 15-minute sessions covering asthma physiology and symptoms, asthma triggers, management decisions using stories, games, posters, and PF meters. Parents received a booklet on asthma pathophysiology, triggers, medication management, use of inhalers and PF meters. 

12 months after tno difference in smanagement by management by intervention and 
51

Table 12a. Summary of patient education interventions directed at the parents or caregivers of children with asthma (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Hung et al.100

To determine the effects of nursing instruction on the mother’s knowledge of asthma medications, inhaler use technique, and her child’s health status. 

82 children aged 5 to 12 years old with asthma attending the pediatric allergy clinic of a medical center in Taipei. Nint=41, 

Ncon=41. 

QRCT

*

 The intervention group received a one time 

individual asthma educational session by a nurse specialist during which they were taught about the objectives of medical treatment, side effects, inhaler use, and the assessment of symptom severity. 

Two months afteintervention mothlikely to have imptechnique (p<0.0less likely to repo(p<0.05).100

LaRoche et al.78 To evaluate the efficacy of a multifamily asthma 

group self management program designed to be culturally relevant and encouraged group cohesiveness among the attending families. 

24 African American and Hispanic families living in Boston with children aged 7-13 with asthma. 

RCT The 24 experimental families were 

randomized to receive three 1-hour sessions that emphasized collaborative asthma management among patients, parents, and physicians and provided training on asthma symptoms and skills for self management. Half of the experimental families received encouragement to work as a group to share experiences and learn from each other. The 11 control families received no intervention. 

During the year aexperimental chishared group exvisits (0.7+0.9) th

children with stanteaching (1.2+1.7

(p=0.04). There management scoprogram cost appatients and the visits was $4,675 

Liu and Feekery27

To evaluate whether attendance at an asthma education clinic would enhance parents’ understanding of asthma, lead to reductions in their children’s asthma severity and to evaluate whether the effectiveness of the intervention is related to its delivery. 

158 families of attending the Asthma Education Clinic and Royal Children’s Hospital in Melbourne, Australia. The control group was recruited from a nearby hospital without an education clinic. 

RCT 3 different types of educational sessions 

with a pediatrician were studied: an individual session with a prior needs assessment; an individual session without prior needs assessment; and a small group session (with 4 or 5 families). 

12 months after ta reduction in asscores among thindividualized gro
52

Table 12a. Summary of patient education interventions directed at the parents or caregivers of children with asthma (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Maslennikova et al.82

To assess the effects of a adapting a U.S. selfmanagement educational intervention on asthma outcomes for children in Moscow. 

122 children with asthma and their families living in Moscow. Nint=60; Ncon=62

RCT The authors adapted “Open Airways” 

(developed for low literacy children aged 4-7 years) and “Air Power” (developed for average literacy children aged 8-14 years) for similar populations in Moscow. Intervention subjects also received asthma care from clinicians who had been trained “according to the U.S. guidelines for the diagnosis and management of asthma and use of modern asthma medications.” Intervention subjects participated in 4 weekly 1hr sessions. Control subjects received usual care from clinicians who received no additional training. 

1 year after the children in the einhaled anti-inflaincreased by 46the control grouchildren’s PF mthan for control was no differencthe percentage theophylline or βfrom school. 

Mesters et al.101, 102

To evaluate the effects of a caregiver education program for young children in the Netherlands. 

63 general practitioners (GPs) were randomized to provide an educational manual to the caregivers of children aged 0 to 4 with asthma. Nint=31, Ncon=32. 

RCT GPs were given a notebook containing 16 

modules of information on topics related to asthma pathophysiology, medication use, symptom recognition, and trigger identification and reduction. GPs distributed some or all of the modules to the caregivers of patients with asthma. Caregivers differed in terms of the number of modules received and the number of follow up visits with the provider. 

At 12 months aftreatment group emergency and the GP than conboth). No differebetween the gro

Morgan et al.,73

Evans et al.,74, and Sullivan et al.75

To evaluate whether a home-based intervention for inner-city children designed to teach caregivers to reduce environmental asthma triggers specific to that child (as determined through skin testing) would result in improvements in asthmarelated outcomes. (The National Cooperative Inner-City Asthma Study.) 

1023 families of children aged 5 to 11 with asthma in 8 major U.S. cities Nint=515, Ncon=518. 

RCT During the 12 month intervention, 2 

research assistants visited each home 5 to 7 times. Each visit was followed by a phone call to address any barriers to implement the plan. Caregivers were taught about the role of allergens in asthma, mattress covers were installed, families were given a vacuum cleaner with HEPA filter and a HEPA air purifier was set up in the child’s bedroom. Professional pest control was provided. 

Two years after children had mo(565.1 vs. 538.5(p<0.001), days and allergen levdifference in spimeasurements oED, clinic or hosgroups.73-75 The 

was $337 per chan estimate incrration of $9.20 pgained (95% CI: symptom free da
53

Table 12a. Summary of patient education interventions directed at the parents or caregivers of children with asthma (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Pérez et al.66

To evaluate the effectiveness of a selfmanagement program based on social learning models and self management programs with demonstrated effectiveness on asthma morbidity. 

29 children with asthma aged 6-14 years in Venezuela. 

RCT 17 children and their parents were 

randomized to receive asthma education. Parents received two 90 minute sessions on asthma pathophysiology, treatment and psychological factors associated with the disease. Children received six 60-minute self-management training sessions that included modeling, positive reinforcement, group dynamics, behavioral practice, roleplaying, and feedback. 

6 months after treported fewer aphysicians repothan control pati

Stevens et al. 103

To examine the effects of providing an asthma education and written selfmanagement plan to the parents of pre-school children on asthma morbidity. 

177 children aged 18 months to 5 years at the time of admission to the hospital or attendance at the ED for asthma in the U.K. Nint=87, Ncon=90. 

RCT The parents and children in the intervention 

group received a general education booklet about asthma, a written guided selfmanagement plan, and two 2-hour educational sessions given on a one-to-one basis by a specialist nurse in the outpatient clinic. The education sessions focused on personalization of the self-management plan, parental techniques for administering medication, and asthma triggers and symptoms. Children in the control group received usual care. 

After 12 monthsdifference betweadmissions, ED prescriptions for symptoms scoreQOL.103

Tieffenberg et al.67

To evaluate a chronic disease self management program based on behavioral change and learning theory directed at increasing autonomy on the part of children. 

188 children with moderate to severe asthma aged 6 to 15 in Argentina. 

RCT 65 families were randomized to receive 5 

weekly 2-hour meetings with a reinforcement meeting 2-6 months later. The curriculum included identifying early warning signs and symptoms of an attack, identifying triggers, understanding therapies, and decision making skills through games, drawings, stories, videos, and role-playing. 52 children received usual care. 

12 months after experimental suvisits for asthma (p=0.36), and le(p=0.006 for fall/spring semesteremergency visits 
54

Table 12a. Summary of patient education interventions directed at the parents or caregivers of children with asthma (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Toelle et al.88

To evaluate whether a community-based asthma management program could reduce asthma symptoms and lung function among school children in Sydney, Australia. 

132 school children aged 8 to 11 with asthma and all the adults who influence their care including parents, doctors, pharmacists, community nurses and school teachers. Nint=72; Ncon=60. 

CBA Parents and children in the intervention 

group were invited to attend two 2-hr educational session, 1 week apart on asthma triggers, medication use, inhalation technique, and use of written selfmanagement plan. These children’s physicians and pharmacists were invited to attend evening workshops which reviewed asthma management guidelines. Community nurses and school teachers in the intervention community received an inservice education session. All families, children, physicians, and pharmacists who did not attend the intervention sessions were mailed the materials. 

147 teachers anfamilies (74%), 111 physicians (2sessions. 6 moboth FEV1 and d

improved in the the control grouchildren with whlimit activity did decreased signigroup (p<0.001)difference in phyabsent from sch

Wilson et al.94§ Overall goals are that parents gain the 

knowledge, skills and motivation to prevent asthma symptoms; appropriately manage symptoms when they occur; utilize medical, educational and interpersonal resources appropriately for asthma care; communicate effectively with all adults responsible for the child’s care; and promote the psychosocial well-being of the family unit. 

64 families of children between 6 months and 6.5 years old with asthma in the U.S. completed the trial. Nint=33; Ncon=31. 

RCT The Wee Wheezers intervention involved 4 

small group sessions (2 hours each) at oneweek intervals conducted by experienced asthma nurses. Parents of children 0-3 years and 4-6 years met in separate groups. For the 4-6 years group, the initial 45 minutes involved direct instruction to the children, which included videos and lectures, asthma action plans, inhaler use, and information recognition of early signs and triggers. Parents develop a written Asthma Action Plan for use of routine medications and at-home management of acute exacerbations. 

Treatment childrincrease in asthchildren at the emonths). The mfree days in the (8.5 to 10.2 in pin the control groIntervention chiladhere to their tcontrol children children had at land there was nstopped smokin

Note: Nint=number of patients in the intervention group at the end of the study. Ncon=number of patients in the control group at the end of the study. *QRCT

controlled trials. §We direct interested readers to the detailed description of the Wee Wheezers program in the article by Wilson et al.94 and the Wee Wheezer

Brown et al.90 ED=emergency department; PF=peak flow; QOL=quality of life. CBA=controlled before-after trial. 
55

Table 12b. Summary of school-based patient education interventions directed at children with asthma

Reference Study Purpose Target population Study Design Type of intervention 

Christiansen et al.104

To evaluate the effects of a school-based program for Hispanic children with asthma. 

42 children in the 4th

grade (aged 9 to 12 years) in Southeast San Diego with asthma. Nint=27; 

Ncon=15. 

CBA Intervention children attended five 20-min 

sessions at school led by a school nurse practitioner on asthma information, identification of symptoms, reduction of asthma triggers, use of inhalers and PF meters and the development of an action plan. 

After 6 scores than in were nabsenthospita

Cicutto et al.77 To evaluate whether an 

interactive childhood asthma education program “Roaring Adventures of Puff (RAP),” improved asthmarelated morbidity among elementary school children in Toronto, Canada. 

256 children with asthma in grades 2 to 5 (aged 6 to 11) and their parents. Nint=132; Ncon=124. 

RCT RAP consists of 6 sessions of 50-60minutes 

held once a week for 6 consecutive weeks. Sessions cover use of PF meters, diary monitoring, trigger identification and control, use of inhalers and medications, symptom recognition and action plan use, and managing asthma exacerbations. Parents are invited to the last session in which children showcase their learning and new skills. The strategies utilized included games, puppetry, and model building to teach about trigger identification, medication use, symptom recognition, sharing information with teachers and parents. 

12 monattendevisits (pabsentlimitatiocontrol 

Evans et al.68 To evaluate whether a 

school-based selfmanagement program would increase children’s asthma management skills and other process and clinical outcomes for low income 3rd-5th graders 

in public schools in New York. 

204 children aged 8 to 11 with asthma. 

CBA 93 children attended the Open Airways program 

which consisted of six 1-hour small group sessions (over a 3 week period) in which children learned basic information about asthma, recognizing and responding to symptoms, using medications and when to seek help, keeping physically active, identifying and controlling triggers, and handling problems related to school. 87 control children received no additional self-management training. 

1 year childre(p=0.02episode(p=0.00managcontrolbetweeattendaa phys
56

Table 12b. Summary of school-based patient education interventions directed at children with asthma (continued)

Reference Study Purpose Target population Study Design Type of intervention 

Henry et al.105 To evaluate whether a 3 

lesson package about asthma delivered by school teachers to improve symptoms and QOL for children with asthma. 

Year 8 students (aged 13-14 years) in 17 intervention and 15 control schools in New South Wales Australia. Nint=299; 

Ncon=234. 

RCT Each intervention school was invited to send 1 

teacher to a 1-day training seminar to learn to provide a 3 lesson asthma education package designed to be taught within the health/physical education curriculum. 

6 monthsignificaComparstudents improve

Hill et al.106 To determine whether an 

intervention program based on existing school and community resources can reduce school absences and improve participation in sport in children with unrecognized, undertreated asthma. 

Children aged 5-10 years in Newcastle with relatively poorly controlled asthma. Nint=149; Ncon=147. 

RCT Parents of the children with asthma were sent 

letters asking them to take their children for 

assessment by a general practitioner. The GPs reviewed treatment guidelines and use of PF meters. School nurses were given teaching materials on asthma and asked to hold teaching sessions to review with teachers how to review students’ inhaler techniques. 

Over the was no participaasthma 

Horner 99 To evaluate the effects of a 

school-based education program for children combined with a homebased program for their parents on children with asthma. 

44 families of children with asthma aged 8-12 years in the U.S. participated (not clear how many in the intervention group and the control group). 

RCT Children in the intervention group participated in 

nine 15-minute session covering asthma physiology and symptoms, asthma triggers, management decisions using stories, games, posters, and PF meters. Parents received a booklet on asthma pathophysiology, triggers, medication management, use of inhalers and PF meters. 

12 monno diffemanageby childgroups.
57

Table 12b. Summary of school-based patient education interventions directed at children with asthma (continued)

Reference Study Purpose Target population Study Design Type of intervention 

Lwebuga-Mukasa and DunnGeorgiou107

To evaluate the feasibility and effectiveness of a school asthma program in reducing asthma exacerbations among school children. 

Children with asthma aged 4-13 attending 5 elementary school in Buffalo, NY. 

CBA Intervention schools implemented a policy 

requiring that children with diagnosed asthma who have needed daily medications for the condition in the past 12 months, have a health care provider written asthma care plan available at school for home room teachers and the school asthma health team to access. The children, and their parents or guardians and school personnel received a 2-hour educational session on early signs of an asthma attack, medications, how to monitor a response, and when to seek for additional help. They also were educated on recognizing and removing asthma triggers. 

There wtreatmecomparSpring o1996.107

McGhan et al.76

343 

To determine whether the asthma education program “Roaring Adventures of Puff (RAP),” improved asthma management behaviors and health status in elementary school children in Edmonton, Canada. 

136 children with asthma aged 7-12 years. Nint=65; 

Ncon=71. 

RCT Parent and teacher asthma awareness events 

were held within the school setting. The intervention provided recommendations for school asthma guidelines and six educational group sessions for children with asthma described above. 77

9 monthchildren preventimproveplay, (pbetween medicatinhaled an actiovisits, aschool. smoking 

Persaud et al.87 To evaluate the effects of a 

school-nurse based self management program for school children in Texas. 

36 children aged 8 to 12 with moderate to severe asthma. 

RCT All children had a visit with a primary care 

provider at the time of enrollment during which 

time they were all given written guidelines for medication use, asthma control and prevention, PF meters, and asthma diaries. Intervention children (N=18) also received 8 individualized, weekly, 20 minute sessions with a school nurse to review asthma symptoms and medication and PF meter use. Control children (N=18) visited the school nurse sporadically, on their own initiation. 

20 weekchildren higher iinterventhere wevisits pebetween 
58

Table 12b. Summary of school-based patient education interventions directed at children with asthma (continued)

Reference Study Purpose Target population Study Design Type of intervention 

Salisbury et al.108 To compare a nurse-led 

clinic in schools with general practice care for adolescents with asthma. 

382 adolescents with asthma attending secondary schools in Bristol, North Somerset, and South Gloucestershire, U.K.

RCT Adolescents were randomized to receive either 

usual care with a pediatrician or to attend a nurse-run asthma clinic. The care in these school-based clinics was “similar to that offered at a nurse-led asthma clinic in general practice, but the discussion was specifically targeted at the needs and interests of adolescents.”108

At 6 monbetter inhhave a PThere wagroups in lost from services costs of sinterventipatients.1

Shah et al.92 To determine if a peerbased, in-school asthma 

education program can improve HRQL, pulmonary function, and asthma attacks in adolescents with asthma in New South Wales, Australia. 

272 students with asthma aged 12-16 years (grades 7 and 10). Nint=113; 

Ncon=138. 

RCT 3-step approach: Step 1: student volunteers 

were trained as asthma peer leaders during a 6 hour workshop on educating their peers about asthma and its management using games, videos, worksheets, and discussions. Step 2: teams of 3-4 asthma peer leaders conducted three 45-minute health lessons for students in their schools. Leaders used teaching tools to guide students to critically analyze the barriers to asthma management. Step 3: students developed and presented key messages learned in the lessons to their peers. Presentations given by students included short acts, dramas, and songs. All students with asthma were issued a record card to be completed by their doctor. 

The resuall intervecontrol stinterventi

grade an

interventiin days a

graders b

but not thp<0.05). function o

Velsor-Friedrich et al.69

29 

To examine the effects of a school-based intervention program on self care abilities, practices and health outcomes of children with asthma. 

102 African American 8-13 year old children with asthma recruited from 8 inner-city public elementary schools in Chicago. Nint=40, Ncon=62. 

QRCT

*

 The “Open Airways” educational program 

utilized an interactive teaching approach applying group discussions, stories, games and role-playing to promote children’s active involvement in the learning process. In six 45-minute sessions offered once a week, small groups of children learned new asthma management skills. 

5 months treatmenimprovem2.9% imnumber and numNo differmedicati
59

Table 12b. Summary of school-based patient education interventions directed at children with asthma (continued)

Reference Study Purpose Target population Study Design Type of intervention 

Webber et al.70 To evaluated whether the 

Open Airways program would reduce asthma morbidity and health services utilization among inner-city children with asthma in the Bronx. 

599 3rd to 5th graders in the Bronx with asthma. 

CBA 599 children in schools with school-based 

health centers were scheduled to attend the Open Airways program (as described in the two prior studies). They were compared with students in schools with school-based health centers that did not offer the Open Airways program (N not specified) and children in control schools without school-based health centers (N not specified). 

Approximthere wechildren health ceAirways children in office hospitalidifferenc

Note: Nint=number of patients in the intervention group at the end of the study. Ncon=number of patients in the control group at the end of the study. *QRCT=quasi-randomized controlled trials; ED=emergency department; PF=peak flow; QOL=quality of life. CBA=controlled before-after trial. 
60

Table 12c. Summary of patient education interventions directed at adolescents with asthma 

Reference Study Purpose Target population Study Design Type of intervention 

Bynum et al.51

To assess the effectiveness of pharmacists using interactive compressed video (telepharmacy) for teaching MDI technique to rural, adolescents with asthma. 

36 adolescents in grades 7-12 with asthma from junior high and high schools in rural Arkansas. Ncon=21, 

Nint=15. 

RCT All patients had two 15-minute individual sessions with a 

pharmacist. During the 1st session, intervention subjects 

demonstrated their MDI technique and were then counseled by a pharmacist via verbal instructions and demonstrations on any needed corrections to their MDI technique. MDI technique was immediately reassessed and measured again 2-4 weeks later (follow up). The control subjects demonstrated MDI technique, were then given written instructions for MDI technique on a package insert with a placebo inhaler, and their MDI technique was assessed again immediately and 2-4 weeks later (follow up). The sessions took place at local health clinics equipped with interactive compressed video technology. 

At thno siintervMDI intervstatisimprobase(p<0

Cowie et al.109

To determine the effects of an agespecific asthma program on the rate of hospitalizations and QOL. 

62 asthma patients aged 15-20 years old in Calgary. Nint=29; Ncon=33. 

RCT Patients were invited to attend the Young Adult Asthma 

Program (YAAP) and were asked to follow up 1 year after. The program included 2-5 sessions that involved an initial questionnaire, an assessment of inhaler technique, spirometry, and asthma education delivered by a physician, or health educator. 

At six there grouhospcorticlost fsubjesmoksmok

Henry et al.105

To evaluate whether a 3 lesson package about asthma delivered by school teachers to improve symptoms and QOL for children with asthma in New South Wales Australia. 

Year 8 students (aged 13-14 years) in 17 intervention and 15 control schools. Nint=299; 

Ncon=234 had 

asthma. 

RCT Each intervention school was invited to send 1 teacher to a 1-

day training seminar to learn to provide a 3 lesson asthma education package designed to be taught within the health/physical education curriculum. 

6 mowas asthmactivwith studeimpro(p=0
61

Table 12c. Summary of patient education interventions directed at adolescents with asthma (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Salisbury et al.108 To compare a nurse- led clinic in schools 

with general practice care for adolescents with asthma. 

382 adolescents with asthma attending secondary schools in Bristol, North Somerset, and South Gloucestershire, U.K. 

RCT Adolescents were randomized to receive either usual care with 

a pediatrician or to attend a nurse-run asthma clinic. The care in these school-based clinics was “similar to that offered at a nurse-led asthma clinic in general practice, but the discussion was specifically targeted at the needs and interests of adolescents.”108

At 6 had mormansignin telost sterheamonintethan 

Shah et al.92 To determine if a peerbased, in-school 

asthma education program can improve HRQL, pulmonary function, and asthma attacks in adolescents with asthma in New South Wales, Australia. 

272 students with asthma aged 12-16 years (grades 7 and 10). Nint=113; 

Ncon=138. 

RCT Step 1: student volunteers were trained as asthma peer 

leaders during a 6-hr workshop on educating their peers about asthma and its management using games, videos, worksheets, and discussions. Step 2: teams of 3-4 asthma peer leaders conducted three 45-min health lessons for students in their schools. Leaders used teaching tools to guide students to critically analyze the barriers to asthma management. Step 3: students developed and presented key messages learned in the lessons to their peers. Presentations given by students included short acts, dramas, and songs. Students with asthma were issued a “record card” to be completed by their doctor. 

The repocon

gradgrouday10th 

vs. (5.5 no casth

van Es et al.110

To determine if a theory-based educational intervention can improve medication adherence in adolescents with asthma in the Netherlands. 

67 adolescents with asthma aged 11-18 years old and attending secondary school. Nint=33; 

Ncon=34. 

RCT A treating physician and a trained asthma nurse provided 

intensive educational intervention, which involved 4 monthly physician visits, 4 individual visits with asthma nurse, and 3 group sessions. Patients were instructed on medication use, self management, coping skills, communication. 

At 2the somadh10 pprop10=med

Note: Nint=number of patients in the intervention group at the end of the study. Ncon=number of patients in the control group at the end of the study. ED

PF=peak flow; QOL=quality of life
62

Table 12d. Summary of outpatient patient education interventions directed at children with asthma 

Reference Study Purpose Target population Study Design Type of intervention 

Alexander et al.111

To evaluate whether clinical nurse specialist involvement would influence ED utilization by poorly controlled, noncompliant children with asthma. 

21 children (<14 years old) with no regular physician who had had one or more ED visits in Tennessee within the past year. Nint=11; 

Ncon=10. 

RCT Patients were cared for by a CNS (Clinical Nurse 

Specialist) that assumed responsibility for assessment, counseling, and follow up. Education was provided in 2-5 classes or sessions. 

Agtac

Bonner et al.112 To determine the effects 

of a theory-based educational intervention on asthma knowledge, adherence, symptoms, and prescription of antiinflammatory medication in urban Latino and African American families with pediatric asthma. 

119 asthma patients treated in the general pediatric clinic or pulmonary clinic of an urban university hospital in New York. Mean age 9.5years (range: 4.2 to 19.1yrs); Nint=56; 

Ncon=63. 

RCT A trained, bilingual family coordinator delivered 

intensive, individualized educational intervention, which consisted of 3 asthma workshops that stressed management of chronic disease, coached families about ways to improve communication with doctors, accompanied families to clinic visits to facilitate communication, monitored diaries, and stressed avoidance of triggers. The intervention also included allergy testing to help with avoidance of triggers, and home inspection for potential triggers. 

Agdc

Burkhart et al.71 To determine the effects 

of interventions that combine education and behavioral techniques in managing asthma at home. 

42 English-speaking children aged 7-11 years with persistent asthma in Kentucky; Nint=21; 

Ncon=21. 

RCT Patients received asthma education and 

instructions on how to use an electronic PF meter twice daily and record data in an asthma diary. Patients received three 1-hour individual sessions with a nurse, a contingency management intervention, which consisted of a contingency contract, reinforcement, tailoring, and reminders. The contract outlined requested behaviors (PF monitoring, diary self-reporting) and associated rewards. (We describe the rewards used in the section on financial incentives.) A nurse educator also contacted patients weekly to reinforce teachings. The control group received the teaching sessions but no contingency contract and no follow up calls from nurses. 

Ad
63

Table 12d. Summary of outpatient patient education interventions directed at children with asthma (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Deaves113 To determine the 

effectiveness of a health educator in improving outcomes of care for children with asthma in Staffordshire. 

63 children with asthma aged 3-16 years in one of 2 general practices. Nint=32; Ncon=31. 

*

QRCT In a one-time class, children were taught to use PF 

meter and to keep diary records of asthma events. Parents were given an explanation of the mechanisms of asthma and action of treatment prescribed and given a package of written information 

At difcoasnulosintnigres

Glasgow et al.114 Train providers to use and then evaluate the 

feasibility and effectiveness of a general practice-based, proactive system of asthma care in children with moderate to severe asthma. 

Australian children (101 intervention and 73 control) with moderate to severe asthma and a general practitioner and their physicians (12 control and 12 intervention physicians) were enrolled. 

RCT The physicians received 1-to-1 education by one of 

the study authors on a “3+ Visit Plan” (1st visit: 

introduce concept of a contract for asthma care; 2nd

visit: assess patient’s status; 3rd visit: review 

patient’s PF record, complete asthma action plan, and identify triggers; 4th visit: assess progress and answer questions. 

12 intusaninhratanmewesy

GonzálezMartin et al.115 To measure the effects of a pharmaceutical care 

program in children with asthma. 

21 children with stable and moderate asthma in Chile. Nint=11; Ncon=10. 

RCT Children were assigned to either a pharmacist-led 

asthma program or to usual care by their pediatricians. The intervention pharmacists provided both written and verbal instructions to children and parents, information about asthma triggers, treatment alternatives, inhaler techniques, medication side effects, and what to do in the event of an acute attack. 

9 wno do
64

Table 12d. Summary of outpatient patient education interventions directed at children with asthma (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Homer et al.54 To assess the 

effectiveness of multimedia educational software program about asthma for inner-city children. 

Children aged 3 to 12 with asthma living in inner-city Boston. Nint=57; Ncon=49. 

RCT “Asthma Control” is an interactive educational 

computer program designed to teach children about asthma and its management. The object of the game is to help the main character, Spacer, a superhero with asthma complete all 6 game levels (3 home and 3 outdoor levels). The player uses his/her knowledge of asthma to help Spacer eliminated common indoor allergens (e.g., cats, smoke) and to avoid outdoor allergens. If Spacer’s condition worsens, the program producing coughing and wheezing sounds and may not be about to jump or run. If the player does not eliminate allergens or use preventive medications, Spacer’s mother blocks his/her exit from home. Study patients were asked to return to the study site 3 times to use the asthma control educational computer program. 

DutheintterasenmebeNostusm

Hughes et al.116 To determine if education 

clinic visits and home visits (a comprehensive and ambulatory program) for pediatric asthma management can improve asthma outcomes. 

89 children with asthma aged 6-16 years living in Halifax county, Canada. Nint=44; Ncon=45. 

RCT Patients were seen by a pediatric “respiratologist” 

throughout study period at 3-month intervals. Families were provided a special card to be shown if they were to come to hospital ED. At each clinic visit, a physician outlined the asthma management program, which included the topics of avoidance of triggers, exercise, and medication use. Proper aerosol technique and home management of acute exacerbations were reviewed. Each family was given an education pamphlet. During home visits, potential environmental triggers were identified and discussed. If school problems related to asthma were identified, the nurse coordinator contacted the teacher for discussion. 

Thimsc(pto codifnigfrohointfamhaThbogro
65

Table 12d. Summary of outpatient patient education interventions directed at children with asthma (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Kamps et al.117, 118 To establish whether there are differences 

between outpatient management of childhood asthma by pediatricians or by asthma nurses. 

74 children aged 2-16 with chronic persistent asthma in the Netherlands. 

RCT Children were randomly assigned to receive 1 year 

of asthma care by either a pediatrician or a specialist asthma nurse. The asthma nurse provided detailed education about the mechanisms of disease, use of medications, management of acute symptoms, and proper inhaler techniques. 

At becanufrehyheQO

diftersteunvishe

Kelly et al.119 To examine the effects of 

a comprehensive education and outreach program designed to decrease ED utilization and hospitalization for Medicaid-insured children with asthma. 

78 children with asthma aged 2-16 years enrolled in Medicaid and receiving their care in Norfolk, Virginia. 

RCT Intervention children (and their caretakers) were 

enrolled in an education and treatment program in a pediatric allergy clinic. They received 1-on-1 education by a physician and asthma outreach nurse on topics including recognition of triggers, environmental control, early warning signs and symptoms, medication usage and side effects, proper usage of inhalers and PF meters. The nurse contacted intervention families monthly to review the patient’s health status, symptoms, medications, refill prescriptions, and assist with scheduling and transportation to clinic follow up. 

At intto re(9intco

the sueffdechho

LeBaron et al.120

To assess the effects of an educational program on patient compliance with cromolyn. 

31 children aged 6-17 years with mild to moderate asthma not receiving corticosteroids from three private allergy practices in San Antonio, TX. Ncon=16, Nint=15. 

RCT After baseline assessments, patients in the 

education group received 4 monthly sessions during which patients and their parent(s) received individual instruction from a registered nurse on how and when to use cromolyn. Patients in the control group also had 4 monthly follow up visits during which they were allowed to remain for a longer time in the study office than their allergy visits would have typically lasted during which time they could describe to the investigators any problems their asthma. 

AfsiggroattasCobegrocolevexba
66

Table 12d. Summary of outpatient patient education interventions directed at children with asthma (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Perrin et al.121 To determine the effects 

of a controlled trial of a combined education and stress management program on the psychological status and daily activities of children. 

56 children aged 6-14 with asthma in the U.S. Nint=29; Ncon=27. 

RCT The intervention consisted of sessions including 

both an education portion and a stress management exercise. 1st session: physician 

provided education on basic lung function and anatomy and mechanisms of breathing and breathing control. 2nd session: reviewed effects of 

asthma on other bodily functions and patients’ feelings. 3rd session: patients learned methods of 

prevention and treatment. 4th session: review of previous sessions and discussion of exercise, longterm outcomes, growing up with asthma. 

No scme

Runge et al52 To evaluate whether an 

internet-based education program as an add-on to a standard patient education program improved health outcomes and reduced costs of children with asthma in Germany. 

178 children with asthma aged 8-16. 

CBA 48 children in the control group received no 

education until after the trial. 86 children received the self-management program of five 2hr sessions in which they used role-playing and small group sessions to teach inhaler use, trigger avoidance, medication management, PF monitoring, and decision making. 44 children received this selfmanagement plus self-selected to also use the interactive internet adventure game incorporating virtual asthma-related situations in need of management and also access to online chats with asthma experts, an online PF protocol that can be maintained by the patient, and chat rooms for other users and healthcare providers. 

6 mmaedemthe the grsigvistreimamimQOgr58wh46CGspthe 

avbu
67

Table 12d. Summary of outpatient patient education interventions directed at children with asthma (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Shames et al.58 To determine if a multifactorial (behavioral, 

educational and medical) intervention that includes the use of an asthma education video game intended to promote asthma self-management can reduce morbidity among high-risk, schoolaged children. 

59 children 5 to 12 years old of low socioeconomic status (receiving or eligible for Medi-Cal) in the San Francisco and San Jose areas. Nint=59; 

Ncon=60. 

RCT Case managers delivered a 3-session curriculum 

on asthma self-management, helped coordinate appointments, and made follow up phone calls. The intervention included a super Nintendo asthma video game designed to teach self-management strategies and provide feedback on their performance (in Spanish or English) and an 18-hour per day toll-free hotline staffed by pediatric nurses who had access to each participant’s individualized asthma management plan. Patients visited a board certified pediatric allergistimmunologist. Acute and chronic asthma management plans were provided to the families, case managers, and primary care provider. 

At difandanuPF

imin 

Shields et al.122 To evaluate whether an 

educational program for children with asthma could decrease ED use. 

Patients 18 years or younger who had at least 1 ED visit or hospitalization in Chicago for asthma during the prior 4 years. Nint=101; Ncon=104. 

RCT A nurse provided education within classes and 

phone calls and covered 23 instructional objectives with 4 content areas: prevention of attacks, medication management, intervention during asthma attacks, and utilization of health care resources. 

At ED vis

Smith et al.123 To evaluate an 

educational intervention to improve medication compliance in Australia. 

Patients were invited to participate in the study if they had been prescribed continuous medication, spoke English, and were intending to return to the clinic. Nint=93; Ncon=103. 

RCT Within an outpatient specialty care setting, a 

physician provided patients with a one time educational session that included written drug information and behavioral strategies. 

Thbere54

Weingarten et al.124

To evaluate the effects of multi-disciplinary nonpharmaceutical management of childhood asthma. 

21 children with asthma receiving medical care in a general practice in Israel. 

RCT Children were examined by a family physician and 

a physiotherapist and received information about asthma and its treatment. They also received 12 one-hour group sessions with a physiotherapist who discussed chest expansion exercises for improved lung capacity and clearance of secretions. Mothers had 10 two-hour group meetings with social workers to develop coping mechanisms for acute attacks. 

At in the 

Note: *QRCT=quasi-randomized controlled trials. Nint=number of patients in the intervention group at the end of the study. Ncon=number of patients in th

the study. ED=emergency department; PF=peak flow; QOL=quality of life. CBA=controlled before-after trial. 
68 

Synthesis of Evidence From Self-Monitoring, Self-Management, or Patient 

Education Interventions for Children With Asthma 

In this section we present the results of our evaluation of the association of study design 

characteristics (e.g., whether the authors specified a theoretical/conceptual framework, year of 

study, sample size, country), intervention characteristics (e.g., whether parents or caregivers 

were a target of the intervention, the number of educational sessions provided to students, the 

setting in which the intervention took place), and improvements in the outcomes of interest for 

the self-monitoring, self-management, or patient education interventions. We present our 

analyses according to each of the primary outcome types. 

Clinical Outcomes. The 48 studies of pediatric or caregiver education interventions that 

evaluated clinical outcomes were highly heterogeneous with respect to their reporting of asthma 

symptoms, spirometric measures, and asthma attacks. (For example, asthma symptoms were 

reported varyingly as percentage of days with wheeze, amount of daytime wheezing, selfreported severity, and change in physician reported asthma symptoms, among others.) Similarly, 

we were interested in the effect of these interventions on the amount of rescue medications used 

in contrast to routine inhaled corticosteroids; however, the heterogeneity of reporting of these 

outcomes limited our ability to combine them quantitatively. Thus, we evaluated the study 

design and intervention characteristics associated with the finding of one or more statistically 

significant clinical outcomes using logistic regression (Table 13). We found that among all 

studies of pediatric asthma evaluating self-monitoring, self-management, or patient education 

interventions, those directed at parents or caregivers were most likely to be associated with a 

statistically significant improvement in clinical outcomes (p=0.02). However, there is 

insufficient evidence to assess the effect of other key intervention factors such as the intensity of 

the intervention (i.e., number of times the educator met with the child, parents, or caregivers), the 

type of provider of the education (e.g., nurse, physician), setting of the educational intervention 

(e.g., home, school), or the type of educational materials on clinical outcomes. 

Table 13. Association of pediatric self-monitoring, self-management, or patient education intervention 

characteristics and significant clinical outcomes 

Predictor variables Regression 

Coefficients (SE) P value

Intervention duration in months (continuous variable) 0.03 (0.08) 0.7 

Interventions that targeted parents or caregivers vs. children -2.70 (1.16) 0.02 

Studies that specified a theoretical/conceptual framework vs. those that did not -0.06 (0.76) 0.9 

Year of publication (continuous variable) -0.05 (0.06) 0.4 

Number of educational meetings with the subjects (continuous variable) -0.28 (0.62) 0.7 

Model Constant 99.68 (114.42) 0.4 

Model details: Method: Logistic regression. Dependent variable: Any statistically significant clinical outcome. R2=0.3. The 

predictor variables that were entered as continuous variables are so noted in the table. The 38 studies of self-monitoring, selfmanagement, or patient education interventions reporting data for each of the variables in this regression were included in this 

analysis. This analysis was not weighted by sample size. 

Functional Status Outcomes. Twenty-seven studies reported the mean (or median) days lost 

from school in a manner that could be use in a summary analysis (as opposed to providing a 
69

statement indicating that there was no difference between treatment and control groups for 

school absenteeism or a ratio of days in attendance to days absent). For those studies that did not 

specifically report the timeframe over which the school absenteeism was recorded (e.g., days 

absent per month versus per school year); we assumed that the reported days of missed school 

were for the entire study duration. When interpreting these data, we note that not all authors 

specifically identified these data as mean days lost from school and some likely represent other 

parameters such as total days lost from school for the whole cohort. 

Figure 8 (next page) presents the individual study and summary standardized mean 

difference (between intervention and control groups) for school absenteeism per month due to 

asthma. The weighted mean reduction in days 

absent was 0.11 days/month (95% CI: 0.05, 

0.17; p=0.0004). This corresponds to a 

standardized mean reduction in days absent of 

0.53 (95% CI: 0.06, 0.99; p=0.03). However, the 

studies included in this analysis were highly 

statistically heterogeneous (Figure 8). 

Additionally, visual inspection of the funnel plot 

of these data (Figure 7) suggests that there may be 

publication bias affecting this result because most 

of the published studies demonstrated less school 

absenteeism in the intervention group. Thus, 

given this heterogeneity and possibility of 

publication bias, we cautiously conclude that 

among the self-monitoring, self-management, or 

patient education studies reporting mean school 

absenteeism, there may be an overall effect toward reducing asthma-related school absenteeism. 

Moreover, the magnitude of the effect is relatively small. 

We sought study design and intervention characteristics associated with the greatest 

reductions in school absenteeism. For this analysis, we used the standardized mean difference in 

school absenteeism as the dependent variable in a weighted least squares regression. We found 

that the longer the study duration, the greater the expected reduction in asthma-related school 

absenteeism (p<0.0001) (Table 14). 

Table 14. Association of pediatric self-monitoring, self-management, or patient education intervention 

characteristics and reductions in school absenteeism 

Predictor Variables Regression 

Coefficients (SE) P value 

Model Constant 20.974 (95.357) .829 

Intervention duration in months (continuous variable) -0.159 (0.035) <0.0001 

Year of publication (continuous variable) -0.01(0.048) 0.8 

Studies that specified a theoretical/conceptual framework vs. those that did not -1.073 (0.596) 0.09 

Number of educational meetings with the students (continuous variable) 0.450 (0.387) 0.3 

Model details: Weighted least squares regression (weighted by the sample size). Dependent variable: standardized mean 

difference effect size for school absenteeism. R2

=0.68. 22 studies were included in this analysis (because they reported data for 

each of the variables included in this regression).

Figure 7. Funnel plot: school absenteeism due to asthma 

0

100

200

300

400

500

600

700

800

900

1000

-5 -4 -3 -2 -1 0 1

Standardized Mean Difference in School Absenteeism per 

Month Due to Asthma

Sample Size
70 

Notes: The effect sizes presented here are the random effects standardized mean difference (SMD). For those studies that reported the total number of school d

group, we divided the total number of school days missed by the number of subjects in each group to approximate the mean number of days missed per student. 

report a measure of variance, we extrapolated a variance from the studies reporting both mean days absent and a variance about this mean weighted by the sampnumber of school days missed by the duration of the study to calculate the mean number of school days missed per month.

Figure 8. Self-monitoring, self-management, or patient education studies reporting mean number of school days missed due to asthm
71 

Health Services Utilization Outcomes. Among the studies reporting measures of health 

services utilization, 17 studies reported the mean number of asthma-related emergency 

department or urgent care visits and 24 studies reported mean number of hospital days in a 

manner that could be use in summary analyses. For those studies that did not specifically report 

the timeframe over which the emergency department/urgent care visits or hospitalizations were 

recorded; we assumed that they were for the entire study duration. For some studies, the authors 

did not specify whether the reported number of emergency room visits was the total for their 

cohort or the mean visits per group. Because we calculated standardized mean differences (as 

opposed to weighted mean differences which are not normalized by the variance in the reported 

outcome), we included both of these types of data in our analyses. Some studies only reported 

the percentage of patients in each group who had at least one visit to an urgent care or hospital. 

We did not include these data in our standardized mean difference calculations. Physician office 

visits were reported too heterogeneously to be combined (e.g., emergency visits to physician 

office for asthma, regular physician visits for asthma, total outpatient physician visits). 

Asthma-related emergency department or urgent care visits. Figure 11 presents the individual 

study and summary standardized mean difference (between intervention and control groups) for 

mean asthma-related emergency department/urgent care visits per month. The weighted mean 

reduction was 0.01 visits per month (95% CI: 0.00, 0.02; p=0.17). The standardized mean 

difference was -0.12 (95% CI: -0.29, 0.05; p=0.16). Additionally, the studies included in this 

analysis were highly heterogeneous—which can readily be seen from the wide range of reported 

mean visits across the studies (Figure 11-see below). Visual inspection of the funnel plot of 

these data (Figure 9) does not suggest significant publication bias (there are studies 

demonstrating a range of effect size). We conclude that among the self-monitoring, selfmanagement, or patient education studies 

reporting mean emergency visits due to 

asthma, we did not find a statistically 

significant overall effect toward reducing 

asthma-related visits. 

We sought study design and 

intervention characteristics associated 

with the greatest reductions in asthmarelated emergency department/urgent care 

visits. For this analysis, we used the 

standardized mean difference in visits per 

month as the dependent variable in a 

weighted least squares regression. Our 

analysis was limited by the small number 

of studies reporting this outcome. We did 

not find any statistically significant 

predictors of reductions in emergency 

department/urgent care visits (Table 15). 

0

50

100

150

200

250

300

350

400

450

-1.5 -1 -0.5 0 0.5 1

Standardized M ean Difference in Asthm a-related 

Em ergency Departm ent/Urgent Care Visits per Month

Sample Size

Figure 9. Funnel plot: asthma-related ED/urgent care visits 
72

Table 15. Association of pediatric self-monitoring, self-management, or patient education intervention 

characteristics and reductions in asthma-related emergency department/urgent care visits 

Predictor Variables Regression 

Coefficients (SE) P value 

Model Constant -1.52 (2.13) 0.1 

Intervention duration in months (continuous variable) 0.03 (0.01) 0.07 

Number of educational meetings with the students (continuous variable) 0.46 (0.21) 0.08 

Setting in which the intervention took place (categorical variable) 0.07 (0.13) 0.6 

Model details: Weighted least squares regression (weighted by the sample size). Dependent variable: standardized mean 

difference effect size for emergency department/urgent care visits per month. R2

=0.80. 9 studies were included in this analysis 

(because they reported data for each of the variables included in this regression. 

Asthma-related hospitalizations. Figure 12 (see below) presents the individual study and 

summary standardized mean difference (between intervention and control groups) for mean 

hospital days per month due to asthma. The weighted mean difference was a reduction of 0.09 

hospital days per month (95% CI: -0.26, 

+0.08; p=0.3). The standardized mean 

difference was -0.09 (95% CI: -0.26, 0.08; 

p=0.3). Additionally, the studies included in 

this analysis were highly heterogeneous—

which can readily be seen from the wide 

range of reported mean hospital days across 

the studies (Figure 12-see below). Visual 

inspection of the funnel plot of these data 

(Figure 10) also suggests that there may be 

publication bias affecting this result (most 

studies report greater reduction in mean 

hospital days in the intervention group). We 

conclude that among the self-monitoring, 

self-management, or patient education 

studies reporting mean hospital days due to 

asthma, there is no overall effect toward 

reducing asthma-related hospitalizations. 

We sought study design and intervention characteristics associated with the greatest 

reductions in asthma-related hospitalizations. For this analysis, we used the standardized mean 

difference in hospitalizations as the dependent variable in a weighted least squares regression. 

We found that the greater the number of educational sessions provided, the greater the expected 

reduction in asthma-related hospitalizations (p=0.01) (Table 16). However, in none of our 

exploratory analyses was the intensity of the intervention, the type of provider of the education, 

the setting of the educational intervention, the type of educational materials used, or the number 

of QI strategies used in the intervention associated with reductions in school absenteeism (not all 

data shown). 

0

100

200

300

400

500

600

-8 -6 -4 -2 0 2 4 6

Standardized M ean Difference in Hospital Days due to Asthm a per 

Month

Sample Size

Figure 10. Funnel plot: hospitalizations due to asthma 
73

Table 16. Association of pediatric self-monitoring, self-management, or patient education intervention 

characteristics and reductions in asthma-related hospitalizations 

Predictor Variables Regression 

Coefficients (SE) P value 

Model Constant 4.0 (2.13) 0.1 

Intervention duration in months (continuous variable) 0.0004 (0.08) 0.9 

Country of intervention (categorical variable) 0.67 (0.47) 0.2 

Studies that specified a theoretical/conceptual framework vs. those that did not 0.79 (1.10) 0.5 

Number of educational meetings with the students (continuous variable) -2.05 (0.63) 0.01 

Setting in which the intervention took place (categorical variable) -0.31 (0.26) 0.3 

Model details: Weighted least squares regression (weighted by the sample size). Dependent variable: standardized mean 

difference effect size for monthly hospital days. R2

=0.64. 13 studies were included in this analysis (because they reported data 

for each of the variables included in this regression 

Guideline Adherence Outcomes. The 27 studies reporting guideline adherence outcomes were 

highly heterogeneous. We performed logistic regression, using any statistically significant 

guideline adherence outcome as the dependent variable and study/intervention characteristics as 

the independent variables. In none of our analyses was the study design, the use of a 

theoretical/conceptual framework, the duration of the intervention, the frequency of interactions 

with the patient, the type of provider of the education (e.g., nurse, physician), setting of the 

educational intervention (e.g., home, school), the type of educational materials used associated 

with improved outcomes (data not shown). 

Conclusions. We conclude that self-monitoring, self-management, or patient education 

interventions may result in improvements in clinical outcomes for children with asthma—

particularly interventions that include a component directed at parents or caregivers. 

Additionally, longer intervention duration and greater numbers of educational sessions may be 

associated with improvements in functional status. We note that our regression analyses were 

limited by the small number of studies consistently reporting similar outcomes and the 

significant heterogeneity among the studies (which likely reflects, in part, the heterogeneity in 

study populations including key characteristics such as asthma severity and socio-economic 

status). This relatively low statistical power limited our ability to corroborate some of the 

univariate associations described in the preceding sections. 
74 

Notes: The effect sizes presented here are the random effects standardized mean difference (SMD). For the 11 studies that did not report a measure of variancefrom the studies reporting both mean days absent and a variance about this mean weighted by the sample size. We divided the mean number of emergency depaduration of the study to calculate the mean number of visits per month.

Figure 11. Self-monitoring, self-management, or patient education studies reporting mean number of emergency department/urgent 
75

Notes: The effect sizes presented here are the random effects standardized mean difference (SMD). For those studies that reported the total number of hospital divided the total number of hospital days by the number of subjects in each group to approximate the mean number of hospital days missed per subject. For the 

measure of variance, we extrapolated a variance from the studies reporting both mean days absent and a variance about this mean weighted by the sample size. 

hospital days by the duration of the study to calculate the mean number of hospital days per month.

Figure 12. Self-monitoring, self-management, or patient education studies reporting mean number of hospital days due to asthma per 
76 

Photo reproduced with permission.2

General Characteristics of Self-Monitoring, Self-Management, or Patient 

Education Interventions for General Populations or Adults With Asthma 

Background. As for the interventions designed specifically for children, self-monitoring or selfmanagement interventions for general populations with asthma (typically for adults but 

occasionally mixed populations) generally include written instructions 

on how to alter medications based on information about disease status 

as measured either by symptoms or peak flow. It has been 

demonstrated that patients with asthma, regardless of age, often do not 

use their inhalers properly—even the reputedly easy-to-use dry powder 

inhalers have correct usage rates that vary widely (5 to 78%).125 

Because poor inhaler technique can result in decreased delivery of 

medication to the lungs, increased asthma symptoms, higher costs, and 

increased side effects,125 many patient education interventions are 

designed to improve inhaler technique and medication adherence, and to decrease asthma 

symptoms and prevent asthma related co-morbidities. 

Study Design Characteristics. We identified 78 studies of self-monitoring, self-management, 

or patient education interventions for adults—59 of these included a self-monitoring or selfmanagement intervention and 19 focused more on patient education (Table 18). Twenty-four 

studies compared two or more intervention groups without a control that did not also receive a 

QI intervention (presented in Table 21). Most of the patient education interventions for adults 

included at least some minimal component of providing adults with the information that they 

need to make decisions about their own asthma care. Thus, the self-monitoring, selfmanagement, or patient education interventions for adults were overlapping educational 

interventions. Therefore, we present them together, grouping them to the extent possible 

according to common characteristics. 

The median duration of the follow up period was 11 months (S.D., 9.2 months). The median 

sample size of these interventions was 100 subjects (Interquartile range: 51, 187). Sixty-three 

were RCTs, two were quasi-RCTs, and 13 were controlled before-after trials. In univariate 

analysis, the longest studies were more likely to report a statistically significant improvement in 

emergency department visits (p=0.02) but not the other outcomes. 

Intervention Characteristics. These educational interventions were highly heterogeneous with 

respect to the content of the education, the provider of the education, the setting in which the 

education was provided, and the intensity of the education. Some interventions included 

multimedia tools, others used one-on-one formal teaching sessions, and several include 

instructional booklets. 

Of the self-monitoring, self-management, or patient education studies, 24 (31%) specifically 

described an underlying conceptual framework or theoretical background as the basis for the 

intervention—a considerably lower proportion than for pediatric interventions of this type (62%). 

The controlled before-after studies were somewhat more likely to report a conceptual or 

theoretical foundation (38%) than RCTs (27%) (p=0.01). 

Compared to the pediatric educational interventions, the educational interventions for general 

populations or adults were less like to be based in primary care clinics (28% versus 17%) and 
77

more likely to be based in outpatient specialty clinics (e.g., allergy or pulmonary clinics) (12% 

versus 30%) (Figure 5 and Figure 13). Most interventions for general populations or adults were 

taught by nurses/nurse practitioners or physicians (Figure 13). 

Figure 13. Intervention characteristics: setting and educator type 

Thirty-three (42%) of the self-monitoring, self-management, or patient education 

interventions provided two to five educational sessions. Twenty-seven interventions principally 

provided individualized instruction, three principally used interactive group teaching sessions, 

and 27 used combinations of teaching modalities (Figure 14). Five interventions included a 

computer/web-based component—the use of these technologies was not associated with 

statistically significant improvements in outcomes or processes of care for general populations or 

adults with asthma. 

0

5

10

15

20

25

30

Outpatient primary care clinic

Outpatient specialty care clinic

Home

Other community setting

Other or not clear 

Combination

Number of Studies

0

2

4

6

8

10

12

14

16

18

20

Physician

Nurse/nurse practitioner

Pharmacist

Health educator

Other or not specified

Combination

Number of Studies
78

Figure 14. Number of educational sessions provided by educational strategy 

Outcomes Reported. The 78 self-monitoring, self-management, or patient education studies’ 

most frequently reported outcomes were asthma symptoms, urgent care or emergency 

department visits and hospitalizations due to asthma, and amount of asthma medications used 

(Table 17). The 42 studies that reported on asthma symptoms were highly heterogeneous—some 

presented self reported symptoms from patient diaries whereas others evaluated physicians’ 

ratings of asthma symptoms. Similarly, the studies reporting on medication use sometime 

reported frequency of inhaled β-agonist use per patient whereas others reported the number of 

prescriptions for oral corticosteroids for the intervention group over the study interval. 

0

5

10

15

20

25

30

35

1 2 to 5 6 to 10 more than 10 other

Number of Educational Sessions

Number Self-management and/or Patient 

Education Studies

Combinations 

Lectures

Not Sure/Other

Interactive groups

Printed materials

Individualized education
79

Table 17. Outcomes reported by the adult self-monitoring, self-management, or patient education studies 

Outcomes 

Number of studies 

reporting no difference 

between intervention 

and control subjects (%)

Number of studies reporting 

improvement among 

intervention compared with 

control subjects (%)*

Number of 

studies reporting 

this outcome 

Clinical status measures§ 34 (52) 31 (48) 65 

Asthma symptoms 23 (55) 19 (45) 42 

Symptom-free days 6 (67) 3 (33) 9 

Amount of medication used or prescribed 21 (60) 14 (40) 35 

Number of asthma attacks 6 (86) 1 (14) 7 

Pulmonary function from peak flow, 

FEV1, or other spirometric measures 30 (73) 11 (27) 41 

Functional status measures 26 (76) 7 (21) 34¶

Activity restriction 10 (77) 3 (23) 13 

Days lost from school/work 19 (79) 4 (16) 24¶

Health services utilization 32 (71) 13 (29) 45 

ED/urgent care visits 21 (68) 10 (32) 31 

Hospitalizations 30 (83) 6 (17) 36 

Office visits 13 (93) 1 (7) 14 

Guideline adherence 14 (35) 26 (65) 40 

Adherence with PF monitoring 7 (70) 3 (30) 10 

Use of self-management or action plans 8 (62) 5 (38) 13 

Inhaler technique 6 (43) 8 (57) 14 

Appropriate use of asthma medications 9 (47) 10 (53) 19 

Note: ED=emergency department; PF=peak flow. In this table we present data from all studies of pediatric self-monitoring or 

self management or patient education, including the studies which compared two or more groups without a control arm that did 

not also receive a QI strategy. 

§ For each of the categories of outcomes highlighted in bold (e.g., clinical status measures, functional status measures), we 

recorded whether the study reported one or more statistically significant changes between the intervention and control group at

the end of the study period in any of the individual metrics associated with that outcome category. 

¶ One study reported worsened functional status (specifically increased rates of days lost from work/school) for the intervention

group compared to the control group. 

Interventions Led Principally by Nurses and Pharmacists. 21 interventions relied primarily 

on nurses to deliver the self-monitoring or self-management program (Table 18a). (Note: many 

other studies used a combination of physicians, nurses, and other health providers to work in 

concert to provide various elements of the educational materials—the interventions described in 

this section were led exclusively or primarily by nurses.) Six of these compared two or more 

intervention groups without a control that did not also receive a QI intervention (presented in 

Table 21).126-132 Several of the nurse-led interventions lacked key characteristics that would 

seem predictive of being able to produce and detect statistically significant improvements for 

patients: only five reported basing their educational intervention on a theoretical or conceptual 

framework131-136 and seven had sample sizes of 65 subjects or less. 
80

Notable among the interventions in this category for its rigorous design, sample size, 

duration, intensity of educational program provided, duration, and reporting is the study by 

Wilson et al.136 This RCT with four arms enrolled 235 patients aged 18-50 with moderate to 

severe asthma from five Northern California Kaiser Medical Centers. Patients enrolled in the 

small group education program (N=83) met weekly with a nurse-educator for four 90-minute 

education sessions for instruction in asthma and asthma management. The intervention was 

designed based on cognitive learning theory and utilized both verbal and printed instruction 

materials. Patients enrolled in the individual education program (N=81) met weekly with the 

nurse-educator for three to five 45-minute meetings where the educator chose among 18 

instructional modules (covering the same content included in the small-group program) to 

develop a program tailored to the needs of the individual. Intervention patients kept symptommedication diaries. The standard control group (N=71) was given no formal education. An 

information control group (N=75) was given a workbook containing the same basic information 

given to the intervention groups. At 12 months, patients in both the group and individualized 

educational programs were significantly more likely than controls to improve in multiple 

outcomes (p<0.05 for all comparisons) including asthma symptoms (55% and 50%, respectively 

compared to 25% in control group), symptom free days (49% and 51%, respectively compared to 

26% in the control group), and bedroom control practices (62% and 53%, respectively compared 

to 32% in the control group). (See Table 18a for more details on this study.) 

Table 18b presents the six education interventions led principally by pharmacists. All of 

these studies reported finding statistically significant improvements in processes or outcomes of 

care for general populations or adults with asthma. As a group, these interventions had relatively 

more frequent interactions with patients than other educational interventions—for example, the 

brief (3 month) study by Barbanel and colleagues provided patients with an initial individualized 

session followed by weekly calls from a pharmacist to review medications for the next three 

months.137 Similarly, the large study (N=413) by Herborg and colleagues required monthly 

sessions for patients and their pharmacists for a year. Because of the small number of studies of 

this category, we did not have sufficient power to assess whether the frequency of patient 

interactions was consistently associated with the positive outcomes reported among the 

educational interventions led by pharmacists. 

Other General Population or Adult Self-Monitoring, Self-Management, or Patient 

Education Interventions. The 33 studies in Table 18c evaluated a broad range of interventions. 

Among these, the factor most consistently associated with improvements in outcomes for 

patients was the use of combinations of educational techniques and materials including 

individualized interactions, group interactions, role-playing, and printed materials among others. 

Twenty-three of the 27 (85%) self-monitoring, self-management, or patient education 

interventions for adults that utilized combinations of educational modalities found statistically 

significant improvements in processes and outcomes of care for patients. In contrast, the 

interventions that utilized principally a single educational modality were less likely to report 

statistically significant outcomes: 70% (19/27) of the interventions that exclusively used 

individualized education, 66% (2/3) of interventions that exclusively used lectures, 33% (2/6) of 

interventions that exclusively used printed materials, and 33% (1/3) of interventions that 

exclusively used interactive groups found improvements for patients. 
81

We did not find that the frequency of patient interactions with the provider of the educational 

intervention was a key factor in producing improvements for patients. Some interventions 

provided no direct interaction between healthcare providers but still found statistically significant 

improvements in patient outcomes (e.g., the study by Legorreta (one of the largest in this 

systematic review) involved 999 patients who received self-monitoring or self-management and 

educational materials including written materials, peak flow meters, and a video directly from 

their HMO, and were found to have improvement in daily use of steroid inhalers and PF 

meters138). In contrast, other interventions provided intense interactions with patients but failed 

to produce or detect improvements for patients (e.g., the 10 patient study by Grover and 

colleagues in which patients received 15 individualized educational sessions139). 

Similarly, no particular intervention setting was consistently associated with improvements 

in outcomes. In contrast, three of the self-monitoring, self-management, or patient education 

studies were home-based and none found improvements in outcomes for patients.140-142

Three of the included studies133, 143, 144 based their self-management intervention on the 

Wheezers Anonymous program. Developed by Winder and colleagues,143, 144 Wheezers 

Anonymous was based on two effective self-monitoring or self-management programs for 

children (Living with Asthma145 and the Family Asthma Program146) and was designed to 

provide comprehensive asthma education and self-monitoring or self-management skills with 

minimal leader training for use in clinical settings (Table 18c). It uses a combination of teaching 

modalities including lectures, videotaped segments, and discussion sections.143 The relatively 

small study by Kotses and colleagues, found improvements in peak flow measures among 

recipients of Wheezers Anonymous compared to control subjects.144 However, the other studies 

did not report consistent improvement in clinical, functional, or health services utilization 

measures among recipients of Wheezers Anonymous compared to control subjects.133, 143 

Conclusions. Self-monitoring, self-management, or patient education interventions can be 

effective for improving the processes and outcomes of care for adults with asthma. In particular, 

interventions that utilize combinations of educational modalities and those that rely on 

pharmacists to lead the educational effort have been associated with statistically significant 

improvements for patients. 
82 

Table 18a. Summary of nurse-led self-monitoring, self-management, or patient education interventions directed at adults with asthma 

Reference Study Purpose Target population Study Design Type of intervention R

Berg et al.133

To evaluate the effects of a nurseadministered asthma self-management program for patients treated in a rural setting. 

55 patients with asthma prescribed inhaled medications over the age of 18 living in a rural area in the U.S. Ncon=24, 

Nint=31. 

RCT The experimental group received 6 weekly, 2-

hour, nurse led asthma self-management education sessions based on Wheezers Anonymous and kept an asthma diary. The education program was held in the community and included information about self-management behaviors and skills, asthma medications, asthma triggers, and prevention of asthma attacks. The intervention group also recorded medication taking and symptom information daily. The control group received usual care. 

After 7 weeks, there wbetween the interventioaverage totally daily sysymptom-free days, anHowever, the interventadherent to medication group (p=0.043).133

Bolton et al.147

To determine whether a selfmanagement training program decreases ED visits and reduces costs for patients with asthma. 

224 adult patients with asthma aged 18-70 years who visited one of the ED departments of two hospitals (one urban, one suburban) in the U.S. Ncon=118, 

Nint=106. 

RCT The intervention consisted of three one-hour 

small-class interactive educational sessions on asthma that stressed compliance with medical regimens and self-care. The sessions were conducted by a specially trained RN and held at one of two hospital sites. Patients in the control group received no intervention. 

After 12 months, the insignificantly fewer ED vlimited activity (p=0.04There were no significagroups in hospitalizatiocosts were significantly intervention. Howeverand total costs did not groups.147

Cambach et al.148

To determine the differences in efficacy between a pulmonary rehabilitation program within local physiotherapy practices, that include drug treatment and a control condition of drug treatment only. 

Adult patients with asthma aged 18-75 years old in the Netherlands. Nintpre=22, mean age: 40 

yrs.; Ncon-pre=21, mean 

age: 53 yrs. 

RCT Within an outpatient specialty care setting, a 

nurse conducted more than 10 interactive group sessions that comprised techniques of breathing retraining and evacuation of mucus, exercise training (both for lower and upper extremities), patient education, relaxation techniques and recreational activities. 

6 months after the integreater exercise tolera(p<0.05). There was nQOL between the grou
83

Table 18a. Summary of nurse-led self-monitoring, self-management, or patient education interventions directed at adults with asthm

Reference Study Purpose Target population Study Design Type of intervention R

Cowan et al.134

To determine the effects of a regional asthma education center run principally by nurses on reducing asthma related morbidity and improving the quality of prescribing. 

Asthma patients aged 5-45 years living in 2 regions of Quebec referred by their physicians. Nint=8,835; 

Ncon=19,200. 

CBA Patients were referred to the asthma teaching 

program for 2 sessions in which they received teaching from a nurse on disease mechanisms, triggers and inhaler techniques. Printed or audiovisual materials were also distributed to participants. 

No difference between medication use.134

Delaronde et al.149 To identify and educate members of 

a regional managed care organization in the U.S. who were not using asthma medications as recommended by the NHLBI by means of a nurse-administered 6-month telephonic case management intervention. 

134 patients with asthma aged 13-65 years who were not using asthma medications as recommended by the NHLBI. Ncon=67, 

Nint=67. 

RCT After an initial patient telephone assessment, a 

nurse provided monthly telephonic selfmanagement education sessions for six months emphasizing knowledge of the disease process, having an action plan, and knowledge of national guidelines. Compliance with medication use, adherence to the physician-directed asthma management plan, PF monitoring, and trigger minimization and avoidance were assessed during these calls. Patients were also given individualized packets of educational materials. Control patients completed the Mini Asthma Quality of Life questionnaire at baseline and 12 months and were followed for the length of the study. 

Six months after the indifferences were found and control groups in EQOL. When fully adjusintervention asthma meimprovement in dispenthe intervention group control group was note

Donaghy et al.150 and 

Mulloy et al.151

To assess the effectiveness of a structured asthma nurse specialist education intervention. 

46 patients with asthma aged 13-50 years in Ireland. Nint=18, mean age: 

26.2 yrs., Ncon=28, 

mean age: 30.7 yrs. 

RCT Within an outpatient specialty care setting, a 

nurse specialist interviewed patients on asthma technique, reviewed a distributed asthma booklet, and conducted an individual 1-hour asthma action program. Control subjects received usual care. 

At one month after the group had somewhat bmeasures of inhaler usno difference in FEV1 o
84

Table 18a. Summary of nurse-led self-monitoring, self-management, or patient education interventions directed at adults with asthm

Reference Study Purpose Target population Study Design Type of intervention R

Garrett et al.152, 153

To determine the efficacy of establishing a community asthma education center. 

747 patients aged 2-55 years who had received asthma care in the ED in South Auckland. 

CBA 2 nurse specialists and a group of respiratory 

physicians established a community education center run by a nurse and 3 community health workers. The purpose of the education program provided was to educate patients in basic pathophysiology, define and teach trigger avoidance, medications use, inhaler technique and self-management skills (emphasis on PF recordings and symptom diaries), and teach how best to access medical care in response to worsening symptoms. 

At nine months, the intelikely to have preventive better PF meter techniqplans, better knowledge when confronted with wonocturnal awakening, anasthma control than the difference between intermedication compliance, lost from school or workrates (33% for control grintervention group).152

Hayward154 To assess whether 

asthma selfmanagement and education improves patient recognition of asthma episodes resulting in improved self-treatment. 

42 ages 6-74 at a single practice in the U.K. Ncon=19, 

Nint=23. 

RCT Patients in the intervention group attended a 

clinic run by asthma nurse or were telephoned monthly by the nurse for one year. Patients were taught danger signs of worsening asthma and how to react appropriately by increasing medication or seeking medical help. Selfmanagement was based on PF monitoring, and inhaler technique was addressed. The control group received no training or information from the nurse. 

After 12 months, the intesignificant improvement with successful self manof asthma exacerbationsthe control group. There differences between the group in the number of eor number of days abse

Heard et al.155

To test whether asthma clinics (intervention) were more effective in reducing morbidity from asthma than standard medical treatment (control). 

195 asthma patients between the aged 5- 64 years in Australia. 

RCT Each participating practice operated one 3-hour 

asthma clinic (run by trained nurses) once a week, which were. Clinic sessions involved education in asthma management strategies, written asthma management plans, spirometry and PF instruction, and an asthma diary card. Sessions ended with a consultation with the general practitioner. Patients were asked to attend 3 sessions within the 6 month study interval. 

At the end of the study, group were more likely tsmokers than those in thIntervention patients weweekly at night due to aThere were no differencwork or school, having amedications, or health sintervention and control rates of 9% in the controintervention group did no
85

Table 18a. Summary of nurse-led self-monitoring, self-management, or patient education interventions directed at adults with asthm

Reference Study Purpose Target population Study Design Type of intervention R

Janson et al.156

To assess the effects of individual selfmanagement education on adherence to medication, airway inflammation, and clinical outcomes. 

65 adults (age 18-55) with mild to moderate persistent asthma from clinics in the San Francisco Bay area. Ncon=32, Nint=33. 

RCT All patients participated in a 1-week run-in to 

collect baseline data. Then patients were randomized. The intervention group received a 30- min individual education from an advanced practice nurse from the asthma education components provided by the National Institutes of Health guidelines. Additionally, inhaler and PF technique were assessed and corrected, and patients were given self-management plans based on PF zones. Follow up visits occurred with the study coordinator biweekly after the education session to reinforce the information covered. All patients kept asthma diaries. The control group had the same number of study visits of the same duration; however, these visits focused on collecting diaries and collecting data. 

After 7 weeks, there wadherence to inhaled cimproved inhaler technof patients making poschanges (p=0.03) in thcompared to the controbetween-group differenthe use of β-agonists, use of inhaled steroids dose, or monitoring PF 

Levy et al.157

To determine whether patient education by hospital based specialist asthma nurses using guided selfmanagement plans could improve patient recognition and selftreatment of asthma. 

Patients with asthma over age 18 years in London. Nint=103, mean age: 

43 yrs., SE: 2. Ncon=108, mean 

age: 40 yrs., SE: 2. 

RCT Patients were educated on recognition and selftreatment on asthma, assessed on PF meter use 

and inhaler technique, and provided a validated, guided self-management credit card plan. Educational intervention was provided in one 1-hour session, followed by two 30-minute sessions with a nurse specialist (either in person or on the phone). 

The intervention group inhaled steroids during fewer visits to their phyNo difference in asthmwork, or QOL between 
86

Table 18a. Summary of nurse-led self-monitoring, self-management, or patient education interventions directed at adults with asthm

Reference Study Purpose Target population Study Design Type of intervention R

Pilotto et al.158 To assess the ability of nurse-run asthma 

clinics based in general practice compared with usual medical care to produce at least a moderate improvement in the QOL in adults with asthma. 

153 patients with asthma over the age of 18 from general practices in Australia. Ncon=82 , Nint=71. 

RCT Two respiratory nurses conducted asthma clinics 

where baseline data was collected, a review of and instruction about inhaler technique was provided, and a packet of information was distributed to each patient. Follow up visits were scheduled at 2 weeks, 3, 6, and 9 months to review inhaler technique and answer questions. Control patients received usual care by their general practitioner. 

After 9 months, no signthe intervention and coFEV1, ED visits, clinic v

However, significantly intervention group comone or more days of w

Schott-Baer and Christensen 135

To determine the effects of an asthma patient education program utilizing selfmonitoring on patient self-care behaviors. 

36 patients with asthma aged 24-74 years from two Midwest ambulatory care clinics. Ncon=19, Nint=17. 

RCT The intervention consisted of a 3-hour instruction 

program covering the disease process, daily selfmonitoring, self-management techniques and daily log completion (diary). A series of 3 phone calls was made between the time of the intervention and the end of the study to reinforce use of the diary. Patients in the control group received standard care, including information and asthma, prescribed medications and instructions on how to record PF measurements. 

After 6 weeks, no signbetween the interventioor clinic visits and no srecorded PF measurem

Smith et al.141

To determine the effectiveness, in terms of symptom control and QOL, of a psycho-educational program compared to routine care. 

84 patients with severe asthma considered to be poorly adherent to their management program in the U.K. Ncon=42, Nint=42. 

RCT Intervention subjects received a 6 month psychoeducational program of home visits and 

telephone calls from a supervised respiratory nurse specialist. For two months, this included four bi-weekly educational visits, supplemented by brief bi-weekly telephone calls between visits. For four months thereafter, this included monthly telephone calls. Control patients received usual care. 

Six months after the insignificant differences intervention groups in sfunctioning, adherence of medication used or Qmajor baseline score dasthma-specific QOL a (p=0.03).141
87

Table 18a. Summary of nurse-led self-monitoring, self-management, or patient education interventions directed at adults with asthm

Reference Study Purpose Target population Study Design Type of intervention R

Wilson et al.136

To evaluate cognitive, behavioral, and clinical effects for individual and group asthma education programs. 

235 patients ages 18-50 with moderate to severe asthma from five Northern California Kaiser Medical Centers. Ncon=71, Ncon-info=75, 

Ngroup-ed=83, 

Nind-ed=81. 

RCT There were four arms to this study. Patients 

enrolled in the small group education program met weekly with a nurse-educator for four 90-minute education sessions for instruction in asthma and asthma management. The intervention was designed on cognitive learning theory and utilized both verbal and printed instruction materials. Patients enrolled in the individual education program met weekly with the nurse-educator for three to five 45-minute meetings where the educator chose among 18 instructional modules (covering the same content included in the small-group program) to develop a program tailored to the needs of the individual. Intervention patients kept symptom-medication diaries. The standard control group was given no formal education. An information control group was given a workbook containing the same basic information given to the intervention groups. 

At 12 months, patients program showed signifsymptoms (vs. controlsusual control), physiciacontrol or individualizeactivity (vs. usual contrcontrol practices (vs. c(vs. controls) (p<0.05 findividualized group edimprovements in sympfree days (vs. usual coenvironmental control MDI technique (vs. concomparisons). The infgroup showed significafree days (vs. usual co

assessment (vs. usual group education) (p<0.significant difference in hospitalizations, medicor allergen reduction wAd hoc pair wise testinreduction in acute asthgroup education (vs. a

Note: ED=emergency department; PF=peak flow; QOL=quality of life; CBA=controlled before-after trial. 
88

Table 18b. Summary of adult self-monitoring, self-management, or patient education interventions provided by pharmacists 

Reference Study Purpose Target Population Study Design Type of Intervention 

Barbanel et al.137

To evaluate whether a community pharmacist with basic asthma training could improve asthma control by providing self-management advice. 

23 adults aged 18-65 years with asthma living in inner city East London. Nint=12, 

Ncon=11. 

RCT Intervention patients received a 45-60 minute 

individual session from the pharmacist on asthma pathophysiology, recognition and avoidance of triggers, inhaler technique, self-management skills including symptom and PF monitoring, actions in response to worsening symptoms, accessing emergency care, and smoking cessation, if relevant. They received written self-management plans and weekly phone calls for the next 3 months to review plans and answer questions. 

3 months afscore increadecreased (p<0.001).13

Cordina et al.159

To examine the effects of a community pharmacybased education and monitoring program for patients with asthma on a range of patient-specific asthma management outcomes. 

152 patients over the age of 14 who received their asthma prescriptions at private pharmacies in Malta.

CBA A comprehensive asthma education and monitoring 

program was instituted in private pharmacies in Malta for 12 months. The intervention pharmacists reviewed patients asthma symptoms, PF records, medication use, and when necessary suggested changes in treatment to the patient’s physician. 

There was treatment ameasuremelost from woQOL. Therhospitalizatintervention control patiedifferences intervention 

nighttime wimprove thepatients. 159

Herborg et al.160

 To evaluate the effects of the “Danish Therapeutic Outcomes Monitoring” program of increased pharmaceutical care on various outcome and process measures of asthma care. 

413 patients aged of 16-60 years old with moderate-tosevere asthma in Denmark cared for in 16 intervention and 15 control pharmacies. Nint=209, mean age: 38.8 

yrs. Ncon=204, mean age: 42.4 yrs. 

CBA The program consists of 7 steps for establishing a 

patient-pharmacist-physician relationship, collecting patient data, identifying and analyzing drug therapy problems, outlining therapeutic goals, choosing individual intervention and monitoring plan, implementing monitoring and follow up, and documenting and reporting to physician and patient. The intervention required monthly sessions with pharmacists over 1 year. 

12 months aintervention fewer physiimproved astechnique ((p<0.05), anmedications difference in 
89

Table 18b. Summary of adult self-monitoring, self-management, or patient education interventions provided by pharmacists (contin

Reference Study Purpose Target Population Study Design Type of Intervention 

Kelso et al.161, 162

To determine if a comprehensive longterm management program, emphasizing inhaled corticosteroids and patient education would improve outcomes in AfricanAmerican adults with asthma. 

39 African-Americans aged >18 years with moderate to 

severe asthma with recent ED visits or hospitalizations for asthma in Memphis. A control group comparable for all demographic variables was identified via chart review at local hospitals. Ncon=18, Nint=21.

CBA The intervention subjects received 1-hour individual 

asthma education session from a pharmacist emphasizing environmental control and PF meter and inhaler use. Patients were also given the NIH National Asthma Education Program booklet, individualized inhaled corticosteroid prescriptions, albuterol to use “as needed,” and an emergency supply of prednisone. Patients were given PF meters and taught how to use their medications in relation to their PF. The intervention utilized the strategies of role-playing and the distribution of printed or audiovisual materials. Free access to an asthma clinic was provided and an appointment was scheduled within 1 week of their ED visit. 

At two showein bothospigroup

Knoell et al.163

1664

To compare an education program provided by a pharmacist with treatment by a pulmonologist to pulmonologist treatment alone. 

100 asthma patients in OhioNint-pre=45, Age: 8.9% <25 yrs.; 82.2% 25-65 yrs.; 8.9% >/=65. Ncon-pre=55, Age: 14.5% 

<25 yrs.; 74.6% 25-65 yrs.;10.9% >/=65. 

CBA Pharmacist developed and implemented individualized 

education/self-management programs. Within an outpatient specialty care setting, a pharmacist spent 30-60minutes with a patient during the first visit, and had at least one more meeting with the patient over the course of 45-day study. Pharmacist also conferred and coordinated care with a pulmonologist. 

The into havcontromissedrug c

Schulz et al.164

To determine if a pharmacy-based patient education intervention can improve measures of lung function, HRQOL and self-management in asthma patients. 

164 asthma patients in Hamburg. Nint=101 (34.6% M), mean age: 46.3 yrs., SD: 11.4. Ncon=63 (57.4% 

M), mean age: 45.9 yrs., SD: 12.5. 

CBA Pharmacists and patients met at 6-week intervals for a 

total of 9 meetings in 12 months. The study pharmacists were trained to detect and teach patients about inhaler technique, adverse drug reactions, adherence, drug interactions, and the need for additional therapy. 

At 12 was n

rated rated in expcontrosignifi(p=0.0betwesummpopuladditichang

Note: ED=emergency department; PF=peak flow; QOL=quality of life; CBA=controlled before-after trial. 
90

Table 18c. Summary of other self-monitoring, self-management, or patient education interventions directed at adults with asthma 

Reference Study Purpose Target population Study Design Type of intervention R

Allen et al.165

To assess the effects on morbidity and medication compliance of a selfmanagement asthma education program for adults. 

113 patients aged 18-65 years with moderate to severe asthma in Australia. Ncon=57, Nint=56. 

RCT Intervention consisted of four 2.5-hour weekly 

self-management small group education sessions led by asthma educators supplemented by audiovisual, lectures, and written materials. The program focused on improving patient selfmanagement through understanding of asthma physiology, identification and control of triggers, recognition of symptoms and symptom severity, medications, lifestyle and psychosocial factors, inhaler and PF meter use. Patients in the control group kept daily diary records for four weeks corresponding to the period of the education program for the intervention group. 

After 12 months, signiffound to be compliant w(p=0.02) in the intervento the control group. Nwere found between thdays of activity restrictnights with asthma symreporting PFR <70% e

Bailey et al.166; 

Windsor et al.167

To investigate the effects of an asthma intervention program on poor selfmanagement practices. 

225 patients over the age of 18 with mild to severe asthma recruited from the UAB Pulmonary Medicine Clinic. Ncon=101, Nint=124. 

RCT The “UAB Asthma Self-management Program” 

consisted of a skill-oriented self-help workbook, an individualized counseling session with a selfhelp educator that lasted approximately 1 hour 

and focused on the use of the self-care workbook, proper use of medications, selfmonitoring and self-evaluation techniques, early detection of attacks including the use of a PF 

meter, and attack management. Patients also participated in a small group support group and were followed-up via telephone every 2-4 weeks. Patients in the control group received usual care that included a standard set of asthma pamphlets. 

After 12 months, there differences in outcomeand control groups. Hoadjusted to account for improvements in inhalevisits, hospitalizations1

adherence.167 At base

patients smoked. No ruse.167 The interventio

patient versus the cont$3.61 per patient.167
91

Table 18c. Summary of other self-monitoring, self-management, or patient education interventions directed at adults with asthma (co

Reference Study Purpose Target population Study Design Type of intervention R

Bailey et al.168 To develop and evaluate the 

effectiveness of lessresource-intensive self-management programs that may be more appropriate for non-academic healthcare settings. 

232 patients with moderate to severe asthma from a single pulmonary clinic in Alabama. Ncon=78, 

NASMP=78, 

Ncore-element=76. 

RCT The “UAB Asthma Self-management Program,” 

patients were given the same program as described above. Patients also received two follow up calls to discuss any problems and letters encouraging follow up were mailed at 1, 2, and 4 weeks post counseling session. The “UAB Core-Elements Program” group was given a revised, shortened workbook which was reviewed during a brief 15-20 minute one-on-one counseling session. Patients in this group were also trained in the use of inhalers and PF meters. A follow up telephone counseling session was conducted one week later to review the patient’s medication regimen and inhaler and PF meter skills. Patients were sent a follow up letter two weeks later. The usual-care group received standard treatment from their physician and were 

given a standardized set of pamphlets. 

After 24 months, there differences in either intcompared to the controinhaler adherence, astimpairment or the need including ED visits or h

Catov et al.142

To evaluate the effects of a homebased teaching on reducing asthma admissions and ED visits. 

381 Medicaid-insured patients in Pennsylvania aged 2-56 years with one or more hospitalizations or three or more ED visits with a primary diagnosis of asthma Ncon=290, Nint=91. 

CBA Patients in the intervention group received at 

least 3 home visits over 2 months by a respiratory therapist who assessed the home environment for asthma triggers, conducted intensive education about asthma and self-management, including the use of a PF meter, and worked with the patient’s physician to complete an asthma action plan. Patients who were eligible for home visits, but who declined or were unable to be located served as the control group. 

Two study designs werpre/post-test design” adesign with pre/post tefor the more intensive design with pre/post teno significant differencintervention and controhospitalizations.142
92

Table 18c. Summary of other self-monitoring, self-management, or patient education interventions directed at adults with asthma (co

Reference Study Purpose Target population Study Design Type of intervention R

Couturaud et al.169

To assess the effects of an educational program in patients with asthma following treatment readjustment. 

54 adult patients with moderate to severe asthma seen at the outpatient clinic of two university hospitals in France. Ncon=28, Nint=26. 

RCT All patients underwent an initial two-week run-in 

period and treatment readjustment if necessary. All patients were taught how to measure PF, and after the run-in all patients received asthma diary cards. Additionally, patients in the intervention group received 5 individual self-management educational sessions after each scheduled visit to the general practitioner (at 1,3, 6, 9, and 12 months) which included information on asthma, asthma triggers, asthma medications and the proper use of inhaler devices, and detection of asthma flare-ups and self-management strategy. The intervention provided to the control group was not described. 

After 12 months, there between the groups in free days and days off FEV1 (% predicted), QO

or use of self-managemthere was a patients in reported a significantly of oral steroid intake cogroup(p=0.01).169

de Oliveira et al.170

1474

To assess the effectiveness of population-based asthma management intervention especially tailored for deprived low-income populations of poor social and cultural backgrounds in Brazil. 

43 asthma patients. Nint=22, mean age: 

41 yrs. Ncon=21, 

mean age: 38 yrs. 

RCT Study subjects received monthly instruction over 

a 6-month period. The education was given by a physician and consisted of inhaler use training, information about environmental control and triggers and early recognition of warning signs of asthma. Instructional tools included posters, discussion sessions or video presentation, reading materials and diary cards. 

After the 6 month intervhad fewer ED visits (p=symptoms (p=0.04), beimproved inhaler technno difference in hospitagroups.170
93

Table 18c. Summary of other self-monitoring, self-management, or patient education interventions directed at adults with asthma (co

Reference Study Purpose Target population Study Design Type of intervention R

Feifer et al. 171

To determine whether a population-based asthma disease management program, using broadbased educational interventions can have favorable effects on physician and patient adherence to guidelines-based care. 

70,900 patients with asthma patients aged 5-45 years using a specific prescription benefit plan in the U.S. 35,450 patients were in each group. 

CBA During the 12-months following enrollment, 

intervention patients and their physicians received educational materials. Patients in the intervention group received five workbooks and two newsletters. Educational materials emphasized guideline-based elements of asthma pharmacotherapy, self-management techniques, and trigger avoidance. Additionally, patients received refill reminders, prospective compliance reminders, and pollen count alerts by mail. Physicians received asthma management flow sheets to facilitate the tracking and review of patients’ therapy. Patients in the control group received no educational materials, nor did their health-care providers. 

All outcomes were meabetween baseline and The percentage of patidecreased less in the i(p<0.0001), controller pincreased in the intervereliever prescription refintervention group (p<0control group.171

Gallefoss et al.172-175

To evaluate the effects of patient education on patients with mild to moderate asthma and COPD patients. 

71 patients aged 18-70 years with mild to moderate asthma from a single clinic in Norway. Ncon=39, 

Nint=32. 

RCT§ Patients attended two group sessions for asthma 

patients in an outpatient specialty care clinic (one led by a physician in which self care, basic physiology, and prevention of attacks was described and one led by a pharmacist who reviewed asthma drugs) and one or two individual sessions with nurses and physiotherapists in which individualized care plans were developed. Patient received a 19-page booklet with on asthma, compliance, medication, self-care, and self-management plans. 

At 1 year, intervention symptoms (p<0.05), be

(p<0.001), improved F

steroid inhaler complia

control patients (p<0.0intervention group repodays (p=0.001) and nigasthma had no effect oThere was no significathe groups in dispensinoral steroids,173 activity 

hospitalizations, or abs

There was no significathe groups in direct coscosts associated with t
94

Table 18c. Summary of other self-monitoring, self-management, or patient education interventions directed at adults with asthma (co

Reference Study Purpose Target population Study Design Type of intervention R

Ghosh et al.176

To assess the effects of asthma self management training on the health status and resource use of patients with chronic asthma. 

176 patients aged 10-45 with chronic asthma who attended the asthma and allergy clinic in the Department of Respiratory Medicine at the Medical College in Trivandrum, India. Ncon=136, Nint=140. 

RCT The intervention consisted of four 2-hour group 

sessions of asthma self-management education and training during the first month following baseline assessment. Patients in the intervention group were taught to adjust treatment based on severity, which was assessed by PF monitoring and early symptoms. They also kept daily diary recordings of outcome variables including PF values, symptom assessments, and hospitalizations or ED visits. Audiovisual aides supplemented the 2-hour education sessions. The control group received usual care for asthma management including medication. 

At 12 months, the intersignificantly higher PF productive days lost (phospitalizations (p=0.0(p=0.002). There was (p=0.003) and total costhe intervention group, in direct costs found be

Grover et al.139

To determine the efficacy of cognitive behavior therapy as an adjunct to standard pharmacotherapy in bronchial asthma. 

10 asthma patients 18-50 years old in Bangalore. Nint=5; 

Ncon=5. 

RCT The intervention consisted of 15 individual 

sessions which covered asthma physiology, muscle relaxation, cognitive restructuring and coping skills and behavioral counseling to significant others. A health educator delivered education within an outpatient specialty care setting. 

At the end of the intervdifference in asthma sygroups.139
95

Table 18c. Summary of other self-monitoring, self-management, or patient education interventions directed at adults with asthma (co

Reference Study Purpose Target population Study Design Type of intervention R

Hilton et al.177

To test the hypothesis that an improvement in knowledge of asthma and its treatments leads to a reduction in morbidity. 

274 patients with asthma aged 5-70 years cared for by 33 general practitioners in London. Ncon=100, 

Nltd-int=88, Nmax-int=86.

RCT One group received a maximum education 

program, one group a limited education program, and the third was a control group. Both intervention groups received a booklet about asthma and a treatment card. The booklet contained information on basic mechanisms of asthma, trigger factors, types of treatment, modes of action and side-effects of anti-asthmatic drugs, and self management. The treatment card contained information on how the patient’s drugs 

acted and whether they were for symptom relief or preventative. Subjects in the maximum intervention group also received a 10-15 minute interview with his/her doctors which covered the same topics as the booklet, a 35-minute audiocassette which expanded on information in the booklet, and follow up appointments every 3 months with the family doctor for a year. 

After 12 months, there differences among the of attacks, drug compliactivity limitation, numbschool/work, hospitalizfrequency of attacks, frdisturbed by wheezingor the proportion of patregimens changed. Thnumber of days absenhowever, the mean nuschool or work was siggroup than in the interv

Hoskins et al.178

To determine whether selfmanagement plans reduce morbidity from asthma. 

General practitioners in the U.K. were randomized to either provide their asthma patients with selfmanagement plans or to provide usual care. Ncon=151, 

Nint=139. 

RCT General practitioners in the intervention group 

were “invited to issue self-management plans personally to those patients known to have suffered an asthma attack in the past 3 months. The control group were simply asked to identify patients” with asthma.178 No additional 

information was provided about the intervention. 

The unit of randomizatno adjustments were mmonths after the intervdifferences in hospital office visits for asthma intervention and contro
96

Table 18c. Summary of other self-monitoring, self-management, or patient education interventions directed at adults with asthma (co

Reference Study Purpose Target population Study Design Type of intervention R

Jenkinson et al.179 To compare the effects of a patient 

education program presented in either booklet or audio cassette tape form. 

177 patients aged 3 to 49 years with asthma from 8 general practices in the U.K. Ncon=41, Nbook=46, 

Ntape=46, 

Nbook+tape=44. 

RCT Patients were randomized to receive education 

via booklet, audiocassette tape, both booklet and audiocassette tape, or a control group. The booklet was 27 pages: 9 pages described the asthma pathophysiology and prevention measures; 12 pages explained the types and uses of drugs, “how to get the best from them,” and coping with asthma problems; and 6 pages covered what to do when things go wrong in 18 possible scenarios. The audiocassette tape was 34 minutes, half on asthma pathophysiology and the actions of drugs and half presented a conversation between a doctor answering questions from a patient with asthma dealing with a series of asthma related problems. 

After 12 months, there the groups in inhaler teprescribed, medication for asthma, or “perceiv

Johnson et al.180

To evaluate the effectiveness of a comprehensive asthma disease management program. 

Patients with asthma covered by Anthem Blue Cross and Blue Shield insurance in the U.S. Nint=196, 

Ncon=196. 

CBA The intervention lasted 12 months. Intervention 

subjects received teaching that emphasized selfmanagement behaviors such as avoidance of triggers, correct medication use, recognizing symptoms, seeking medical advice, smoking cessation, and adherence to treatment plans. The program is supported by computer generated communications to providers and case managers regarding whether the patient has an action plan, received flu vaccination, has a rescue inhaler, and use of daily controller medications. 

12 months after the intgroup had fewer ED viand hospitalizations (3were no differences in or preventative vaccina
97

Table 18c. Summary of other self-monitoring, self-management, or patient education interventions directed at adults with asthma (co

Reference Study Purpose Target population Study Design Type of intervention R

Kotses et al. 144 To compare the effectiveness of 

personalized asthma self-management recommendations with that of a group self-management program. 

34 adults with mild to severe asthma in the Toledo, OH area. Ncon=12, Nint-group=11, 

Nint-ind=11. 

RCT This study evaluated 3 groups: individualized 

self-management, group self-management, and a control. The individualized self-management education program consisted of identification of each patient’s asthma triggers in a 60-minute session which included the use of PF values as an early warning sign for asthma onset, methods for avoiding precipitants, and instructions for reducing asthma exacerbations (including, as warranted, progressive relaxation techniques). The group self-management education program was based on Wheezers Anonymous (WA) and included two 2.5-hour sessions with video and audio materials and discussions facilitated by a group leader. WA also included the use of PF monitoring. All patients in the intervention groups kept daily asthma diaries. The control group received usual care. 

As compared to the cointervention groups haimprovement in morninmeasured against basesignificant differences PF values, asthma attafrequency of visits to th

Lahdensuo et al.181, 182 To compare the efficacy of an asthma 

self-management program with traditional treatment. 

115 patients aged 18yrs and older with mild to moderate asthma from 3 outpatient clinics in Finland Ncon=59, 

Nint=56. 

RCT Patients in the intervention group received a 2.5-

hr personal self-management education session covering asthma, asthma medications, and the principles of self-management by specially trained nurses with 3 follow up visits at 4 month intervals. They also received physiotherapeutic counseling, including proper breathing and relaxation techniques by physiotherapists, were given guided self-management plans based on PF monitoring, and kept daily asthma diaries. Control patients received usual care. 

After 12 months, there between the interventionumber of courses of acourses of prednisolon(p=0.03). No significangroups were found for hospitalizations, and sscores did show trends fully adjusted for basel

direct costs were 649 Fcontrol group than in th(p=0.05)182 (At the tim

Finnish Marks=1£). 
98

Table 18c. Summary of other self-monitoring, self-management, or patient education interventions directed at adults with asthma (co

Reference Study Purpose Target population Study Design Type of intervention R

Legorreta et al.138

To evaluate the effectiveness of a population-based asthma management program in an HMO setting. 

999 patients aged 5-65 years with moderate to severe asthma from a large HMO in California. Ncon=385, Nint=614. 

CBA Patients in the intervention group received 

educational material (Asthma Control Kit) directly from the HMO designed to educate asthmatic patients in proper or self-management skills. The kit included a PF meter, an Asthma Review Guide, a personal diary, a spacer device, and an educational video. Patients in the control group did not receive any materials but completed baseline and follow up assessments. Due to low participation, results from a second intervention (a nurse-led small-group education program) was not included. 

After 6 months, patienthad significantly greateuse of a steroid inhaler PF meter (p=0.038). Nwere found between thdue to asthma, ED visiasthma.138

Marabini et al.183

To evaluate the effectiveness of a patient education program by a physician in reducing morbidity and improving QOL. 

77 asthma patients aged > 18 years in 

Perugia, Italy. Nint=37, mean age: 

53.1 yrs., SD: 6.8. 

Ncon=40, mean age: 49.3 yrs., SD: 16.8. 

RCT Patients participated in an educational program 

based on “Teach Your patients About Asthma: A Clinician Guide” (NHLBI publication). The three 2-hour sessions conducted by a physician, covered basic information on asthma medications, use of inhalers and PF meters, identification of asthma-warning signs, avoidance of triggers, and development of action/emergency plans. Handouts covering key points were also distributed. Patients were also involved with decision-making and taught how to deal with symptoms early. 

3 months after the inteFEV1, PF, days lost fro

free days, rescue salbuexpenses. 10% of patand 30% were ex-smotobacco rates. Howevhad significantly highethe control group (p<0.

Magar et al.184

To evaluate the effectiveness of a self-management program for adults with asthma. 

Adults (18-60yrs) with asthma in France. Patients enrolled: Ncon=89, Nint=104. 

RCT Intervention subjects received an individualized 

30-60 minute interview to assess their educational needs and to discuss diary and PF meter use. Then they received two 2.5 hr interactive group sessions separated by 15 days that reviewed asthma signs, symptoms, pathophysiology, medication use, avoiding triggers, and self-monitoring using symptoms and PF results. Control subjects were asked to keep a symptom diary and received usual care. 

At 12 months, the interreductions in symptomnighttime wakening, orgreater improvement in 

difficult to interpret from was no significant diffeuse (7% stopped smokcompared to 2% in the 
99

Table 18c. Summary of other self-monitoring, self-management, or patient education interventions directed at adults with asthma (co

Reference Study Purpose Target population Study Design Type of intervention R

Mayo et al. 185 To determine the effect of an outpatient 

program designed to reduce readmissions for asthma exacerbations among adults with asthma. 

104 adult patients with asthma who had been hospitalized at a single hospital in New York. Patients had all had at least 2 hospitalizations in the previous 12 months or 5 ED visits in the previous 24 months. Ncon=57, Nint=47. 

RCT Intervention subjects had 2 initial 1-hour visits 

with a physician or nurse practitioner for discussion of asthma pathophysiology and treatment emphasizing self-management strategies tailored to each patient. During subsequent visits (>30minutes long with frequency determined by the patient preference and asthma severity), medical regimens were tailored to each patient’s asthma pattern to encourage compliance. Patients were taught to use spacers and PF meters and to vary their own treatment according to symptoms, using a PF meter to identify attacks requiring prednisone. The control group received usual care. 

After 8 months, mean hhospital days were sigintervention group com(p<0.004 and p<0.02, 

Moldofsky et al.186

To determine whether a videotape program about asthma would be successful in transferring information about asthma. 

79 adult patients with asthma were recruited from the Gage Research Institute in Toronto. Nint=149, mean age: 24.0 yrs., Ncon=160, 

mean age: 24.8 yrs. 

RCT The intervention group watched an educational 

videotape entitled “Living With your Asthma” consisting of a dialogue between a physician and a well-known professional hockey player who has had asthma all his life. The 55-minute program described the normal structure and function of the lungs, the physiological abnormalities in asthma, the management of asthma by self-care and drug therapy, and the approach to problems commonly encountered by persons with asthma. 

No difference in frequephysicians, FEV1, or ho

Onyirimba et al.187

To determine the effectiveness of clinician-to-patient feedback of inhaled steroid use compared with standard asthma care. 

19 adults from low socioeconomic groups with moderate to severe asthma in Hartford, CT. Nint=9, 

mean age: 45 yrs., Ncon=10, mean age: 53 yrs., SD:14. 

RCT Clinicians reviewed data from an instrument that 

electronically recorded inhaler use. This information was then discussed with the patient at a 4 weekly follow up visits, and suggestions were made about where to keep the inhaler based on when the non-adherence occurred. 

During the 10-week stugroup had improved mthan the control group FEV1 or QOL between 
100

Table 18c. Summary of other self-monitoring, self-management, or patient education interventions directed at adults with asthma (co

Reference Study Purpose Target population Study Design Type of intervention R

Perneger et al.188

To assess the effectiveness of a newly established education program designed to improve patients’ health and functional status. 

115 adults with asthma at a single hospital in Geneva, Switzerland. Ncon=57, Nint=58. 

RCT The interactive education program consisted of 

three 75-minute group education sessions scheduled one week apart and delivered by two respiratory physicians and a physiotherapist. Educational materials were also distributed. The primary purpose of the education methods was the design of individual self-management programs. Patients in the control group underwent a baseline evaluation, received “minimal asthma information,” and were scheduled for a 6-month follow up. 

After 6 months, compathe intervention and covariables. Of these, onsignificantly between thgroups. When adjusteimprovement was seen intervention group comThere were no significagroups in amount of mmissed, limitations on phospitalizations, PF vasubjects were smokers decline in tobacco use intervention. There wamultiple comparisons.1

Put et al.189 To determine if an 

individualized education and cognitive-behavioral intervention would improve asthmarelated behavior. 

25 asthma patients aged 18-65 years in Belgium. Nint=13, 

mean age: 43 yrs., SD: 10. Ncon=12, 

mean age: 48 yrs., SD: 12. 

RCT Patients received a workbook with information, 

exercises, and homework assignments. During six 1-hour individual program sessions, different strategies were employed: psycho-education; behavioral techniques; self-observation/selfmonitoring; stimulus control (change of behavior antecedents); response control (learns to select 

the appropriate behavior to avoid or minimize the influence of stimuli by considering behaviors short term vs. long term consequences); cognitive techniques. In addition, whenever problem areas, such as disease-specific anxiety, were identified, certain parts of the training program were elaborated. 

3 months after the intedifference between grothe day or night. Howesignificantly different bcontrol groups. The AQthe Negative Emotivity and p<0.01, respective
101

Table 18c. Summary of other self-monitoring, self-management, or patient education interventions directed at adults with asthma (co

Reference Study Purpose Target population Study Design Type of intervention R

Rasmussen et al.190

To assess the outcomes associated with an Internetbased asthma management tool. 

253 adults with asthma aged 18-45 years living in Denmark. NcontGP=80, Ncont-sp=88, 

Nint=85 

RCT There were three groups: an internet 

management group, a group receiving treatment from an asthma specialist, and a group receiving care from a general practitioner (GP). The Internet-based management tool was comprised of an electronic asthma diary, an action plan for patients, and a decision support system for physicians. Patients were given PF meters, and the Internet tool’s action plan comprised a 3-color warning system with a written treatment plan. Patients were encouraged to fill out the diary daily and follow instructions given by the computer or physician. Physicians used the decision support system to follow up with patients on therapeutic changes. 

After 6 months, the Intefewer asthma symptomspecialists; p<0.001 coQOL (p=0.03 comparecompared to GPs), and 

compared to specialistGPs). The Internet groacute, unscheduled viscontrol groups (p=0.05among the groups werhospitalizations, or me

Ringsberg et al.191

To measure the effects of a multidisciplinary asthma school in Sweden. 

38 adult asthma patients who had been treated in the hospital where the asthma school was located. Nint=20, 

mean age: 49 yrs. Ncon=18, mean age: 

45 yrs. 

RCT The intervention group was divided into 4 small 

sub-groups that were educated in an asthma school 4 times in the Spring, 2 times in September 1986, and 1 time in January 1987. Classes met once a week and emphasized information on elementary anatomy and physiology, how to prevent asthma attacks by avoiding triggers, drugs, and self-treatment techniques. 

The decrease in numbgreater for the intervenp=0.0001). No differen

time activities, social inactivities.191

Schaffer and Tian192 To compare the effects of a 

theoretically focused audiotape or a standard educational booklet or both on adherence to asthma preventive medication. 

23 adult patients with asthma aged 18 to 65 years in the U.S.; Nint=10; Ncon=13. 

RCT Patients received a 30-minute audiotape 

incorporating 5 topics critical to asthma selfmanagement. Audiotapes included asthmarelated lyrics set to popular tunes to enhance memory. Patients also received a 12-page booklet that covers the same topics as the audiotape but presents the content directly rather than as part of a larger narrative. 

6 months after the intedifferences between grpharmacy adherence (significant difference in groups.192
102

Table 18c. Summary of other self-monitoring, self-management, or patient education interventions directed at adults with asthma (co

Reference Study Purpose Target population Study Design Type of intervention 

Snyder et al.143

To test the effectiveness of the Wheezers Anonymous program in teaching selfmanagement skills to adults with asthma. 

75 adults (mean age 27yrs) with asthma from the Toledo, OH metropolitan area. (No report of the number of subjects allocated to treatment and control groups.) 

RCT The intervention group attended 2 two-hour group 

education sessions (8-12 patients) with 15- to 25-minute didactic videotaped presentations interspersed with 10- to 15- minute discussions led by a respiratory therapist who acted as a moderator 

for group discussion and for practice of the presented information and techniques. The sessions contained information on asthma selfmanagement. In addition to answering questionnaires, patients kept an asthma diary and had their pulmonary function tested at 1, 2, and 3 

months following intervention. The waiting list control group received usual care. 

After 3 months, there difference between tfrequency of asthma 

Sundberg et al.193

To assess the effectiveness of a computerized limited asthma education program designed to suit young people. 

147 patients with asthma aged 18-25 years who were referred to a special asthma outpatient clinic for young adults in Sweden. Ncon=49, 

Nint=48. 

RCT Intervention consisted of an interactive 30-minute 

computer program that provided basic information on asthma, asthma medication use, inhaler and PF meter use, and information about asthma triggers and allergens. At the end of the program, an asthma-trained nurse led a structured discussion with each patient about his/her results. The control group received normal care, and all patients were followed up with the clinic team at 6 and 12 months. 

After 12 months, no found between the ingroups in hospital adprevalence of respiraHowever, a significa

observed in the interthe control group (p=

Verver et al.125

To evaluate whether inhaler technique and respiratory symptoms of patients with asthma can be improved after instruction by a practice assistant. 

6 physicians assistants were trained in the appropriate use of powder inhalers and provided patient education to 48 Dutch asthma patients aged 15-85 years. 

RCT Patients received two training sessions (2 weeks 

apart) on the correct technique for use of dry powder inhalers (and the correct order in which to use multiple inhalers). 

At baseline only 6% powder inhalers corrmade with the “breatwith the “hold your binhaling instructions. between the number symptoms. The patisignificantly reduced errors (p=0.01). Thereported asthma symgroups.125
103

Table 18c. Summary of other self-monitoring, self-management, or patient education interventions directed at adults with asthma (co

Reference Study Purpose Target population Study Design Type of intervention 

Weng194 To evaluate the 

effects of a government sponsored QI intervention with patient and provider education and case management services for patients with asthma. 

1,067 patients with asthma enrolled in the program sponsored by the Taiwanese government. 4,340 patients with asthma who did not enroll in the program served as matched controls. 

CBA Providers received a 6-hour asthma curriculum that 

included conducting pulmonary function testing, use of medications and PF monitoring, environmental controls, and asthma pathophysiology. They were given copies of asthma clinical practice guidelines. Patients received individualized, personally tailored asthma education on recognizing triggers and symptoms, medication use, PF use, and self-monitoring selfmanagement of exacerbations. Case managers (nurses or physician assistants) provided communication between patients, primary care physicians and specialists, and scheduled quarterly follow up. 

1 year after enrollmhad longer hospitabut no difference fnumber of ED visihospitalizations. Hnewly diagnosed winterval, there was 61%) in the intervecontrols.194

Yilmaz and Akkaya195 To evaluate long-term efficacy of a patient 

education program in an asthma outpatient clinic in Istanbul. 

52 patients with asthma aged >16. Nint=25, mean age: 

330.6 yrs. Ncon=27, 

mean age: 28.9 yrs. 

RCT The educational program took place over a 12-

month period and consisted of 6-10 sessions. Patients were provided education through video cassettes, special brochures, and seminars. Physicians checked patients’ inhalation device and reviewed proper usage technique. A telephone help-line was available to the participants. 

3 years after the inFEV1, asthma symhospitalizations, oscores were signifintervention group group (p=0.009).19

Zeiger et al.196

To determine whether facilitated care provided by asthma specialists favorably affect asthma outcomes. 

309 asthma patients aged 6 to 59 with a recent ED visit or hospitalization for asthma years who were San Diego Kaiser Health Plan members. Nint=149, 

Ncon=160. 

QRCT

*

An expedited allergy-clinic evaluation was offered. 

Allergists provided detailed evaluation including history, physical examination, spirometry, inhalant skin tests, and a comprehensive treatment program, including instruction in relevant environmental control measures, asthma education, and individualized medication recommendations. No subject received immunotherapy during study. 

6 months after thethe intervention grasthma symptoms likely to use inhalecromolyn, and had (p=0.017). There absenteeism or sp

*QRCT=quasi-randomized controlled trials. ED=emergency department; PF=peak flow; QOL=quality of life; CBA=controlled before-after trial; NHLBI=Na

Blood Institute. §The design of the study by Gallefoss et al.172 was as follows: Two groups of patients, those with asthma and those with COPD were random

intervention group who received an educational program and a control group who received usual care by their General Practitioners. The patients with asthm

separately. We present only the data for the asthma patients. 
104 

Figure 15. Funnel plot: FEV1 percent predicted 

Synthesis of Evidence From Self-Monitoring, Self-Management, or Patient 

Education Interventions for General Populations or Adults With Asthma 

In this section we present the results of our evaluation of the association of study design 

characteristics (e.g., whether the authors specified a theoretical/conceptual framework, year of 

study, sample size, country), intervention characteristics (e.g., the number of educational 

sessions provided to students, the setting in which the intervention took place), and 

improvements in the outcomes of interest for the self-monitoring, self-management, or patient 

education interventions. We present our analyses according to each of the primary outcome 

types. 

Clinical Outcomes. Sufficient numbers of studies presented results for percent predicted FEV1

and peak flow that these data could be synthesized quantitatively. 

Percent predicted FEV1. Among the self-monitoring, self-management, or patient education 

interventions for general populations or adults with asthma, 17 reported change in percent 

predicted FEV1 from which we were able to calculate individual study and a summary 

standardized mean difference (between intervention and control subjects at the end of the study) 

(Figure 17-see below). These studies were statistically homogeneous and produced a weighted 

mean difference of 2.92 percent change in FEV1 (95% CI: 0.92, 4.92; p=0.004). This 

corresponds to a summary mean difference of 0.13 (95% CI of 0.03, 0.23) favoring the 

intervention groups (p=0.01). The funnel plot from these 17 studies (Figure 15) does not suggest 

substantial publication bias. Of all the quantitative analyses in this report, the data included in 

this calculation are the most robust given the relatively large number of studies reporting the 

same outcome in the same way. However, the statistically significant effect reflects a clinical 

improvement of only borderline significance. 

We sought study design and 

intervention characteristics associated with 

the greatest improvements in percent 

predicted FEV1. For this analysis, we 

used the standardized mean difference 

as the dependent variable in a 

weighted least squares regression. We 

found that the more recent the year of 

publication, the greater the likelihood 

of finding improvements in percent 

predicted FEV1 (p=0.004) (Table 19). 

We denoted the studies with 

interventions performed since 2000 in 

Figure 17 with an asterisk. We cannot 

determine the critical characteristics 

that distinguish these more recent 

studies and that might be associated 

with the improved spirometric 

measures. 

0

100

200

300

400

500

600

-0.4 -0.2 0 0.2 0.4 0.6 0.8 1

Standardized M ean Difference Effect Size for Percent Predicted FEV1

Sample Size per Study
105

 In none of our analyses was the study design, the use of a theoretical/conceptual framework, 

the duration of the intervention, the frequency of interactions with the patient, the type of 

provider of the education (e.g., nurse, physician), setting of the educational intervention (e.g., 

home, school), the type of educational materials used associated with improved outcomes (data 

not shown). 

Table 19. Association of study/intervention characteristics and improvements in FEV1 percent predicted 

Predictor Variables Regression 

Coefficients (SE) P value 

Model Constant -23.6 (6.7) 0.004 

Intervention duration in months (continuous variable) -0.0002 (0.001) 0.8 

Year of publication (continuous variable) 0.01 (0.003) 0.004 

Studies that specified a theoretical/conceptual framework vs. those that did not -0.004 (0.04) 0.9 

Study design (categorical variable) 0.450 (0.387) 0.7 

Model details: Weighted least squares regression (weighted by the sample size). Dependent variable: standardized mean 

difference effect size for percent predicted FEV1. R2

=0.56. 16 studies were included in this analysis (because they reported data 

for each of the variables included in this regression).

Peak flow measurements. Among the self-monitoring, self-management, or patient education 

interventions for general populations or adults, 16 studies reported mean peak flow at the end of 

the study period. Typically, they reported mean peak flow for the intervention and control 

groups and did not specify time of day. If they 

did present mean morning and mean evening 

measurements, we used mean morning 

values in our summary analysis because 

these were the most frequently reported. 

The weighted mean difference in peak flow 

from these 16 (statistically heterogeneous) 

was 27.95 L/min (95% CI: 10.75, 45.15; 

p=0.01). The standardized mean difference 

of 0.26 (95% CI of 0.10, 0.42) favored the 

intervention groups (p=0.001) (Figure 18-

see below). As with the FEV1 results, this 

represents a change of only modest clinical 

relevance. The funnel plot (Figure 16) for 

this analysis does not suggest substantial 

publication bias. 

We sought study design and 

intervention characteristics associated with 

the greatest improvements in mean peak 

flow. For this analysis, we used the standardized mean difference as the dependent variable in a 

weighted least squares regression. We did not find a combination of the intervention or design 

characteristics that explained a statistically significant proportion of the variation in mean peak 

flow (R2

=0.29) (Table 20). 

Figure 16. Funnel plot: mean peak flow 

0

50

100

150

200

250

300

350

400

450

-0.4 -0.2 0 0.2 0.4 0.6 0.8 1

Standardized Mean Difference Effect Size for Mean Peak Flow

Sample Size per Study
106

Table 20. Association of study/intervention characteristics and improvements in mean peak flow

Predictor Variables Regression 

Coefficients (SE) P value 

Model Constant 69.6 (49.1) 0.2 

Intervention duration in months (continuous variable) -0.008 (0.02) 0.7 

Year of publication (continuous variable) -0.35 (0.025) 0.2 

Number of educational meetings with the subjects (continuous variable) -0.05 (0.13) .7 

Studies that specified a theoretical/conceptual framework vs. those that did not -0.13 (0.2) 0.6 

Study design (categorical variable) 0.17 (0.2) 0.9 

Model details: Weighted least squares regression (weighted by the sample size). Dependent variable: standardized mean 

difference effect size for mean peak flow. R2

=0.29. 13 studies were included in this analysis (because they reported data for 

each of the variables included in this regression).

Functional Status Outcomes. Nine studies reported mean days lost from work or school. For 

those studies that did not specifically report the timeframe over which the school absenteeism 

was recorded (e.g., days absent per month versus per school year); we assumed that the reported 

days of missed school were for the entire study duration. When interpreting these data, we note 

that not all authors specifically identified these data as mean days lost from school and some 

likely represent other parameters such as total days lost from school for the whole cohort. We 

calculated the standardized mean difference between intervention and control groups in terms of 

the mean number of days lost from work or school (Figure 19). The nine studies were 

statistically heterogeneous (I2

=73%) and they did not find any statistically significant difference 

in days lost from work or school between intervention and control subjects (weighted mean 

difference of -0.19 days absent per month; 95% CI: -0.40, 0.02; p=0.08; standardized mean 

difference of -0.21; 95% CI: -0.44, 0.02; p=0.08). 

We performed logistic regression, using any statistically significant functional status 

outcome as the dependent variable and study/intervention characteristics as the independent 

variables. In none of our analyses was the study design, year of intervention, the use of a 

theoretical/conceptual framework, the duration of the intervention, the frequency of interactions 

with the patient, the type of provider of the education (e.g., nurse, physician), setting of the 

educational intervention (e.g., home, school), or the type of educational materials used associated 

with improved outcomes in any of our analyses (data not shown). 

Health Services Utilization Outcomes. Twenty-one studies reported urgent care/emergency 

department visit data in such a way that they could be combined quantitatively (Figure 20). 

These studies were highly heterogeneous (I2

=98.9%). They did not find a statistically significant 

difference in urgent care/emergency department visits between intervention and control subjects 

(weighted mean difference -0.23 visits per month; 95% CI: -0.64, 0.18; p=0.26; standardized 

mean difference -0.48; 95% CI: -1.11, 0.14; p=0.13). 

Similarly, 24 studies reported hospitalization rates (Figure 21); however, these were also 

highly heterogeneous (I2=99.4%) and they did not find a statistically significant difference in 

hospitalizations between intervention and control subjects (weighted mean difference -0.34 

hospital days per month; 95% CI: -0.99, 0.31; p=0.3; standardized mean difference -0.58; 95% 

CI of -1.53, 0.37; p=0.23). 
107

We performed logistic regression, using any statistically significant health services utilization 

outcome as the dependent variable and study/intervention characteristics as the independent 

variables. We did not find study design, intervention, or patient characteristics that were 

associated with improved outcomes in any of our analyses (data not shown). 

Guideline Adherence Outcomes. The 40 studies reporting on guideline adherence measures 

were heterogeneous in terms of the specific outcomes evaluated. We performed logistic 

regression, using any statistically significant guideline adherence outcome as the dependent 

variable and study/intervention characteristics as the independent variables. We did not find 

study design, intervention, or patient characteristics that were associated with improved 

outcomes in any of our analyses (data not shown). 

Conclusions. Self-monitoring, self-management, or patient education interventions for general 

populations or adults with asthma can result in improvements in FEV1 and peak flow. However, 

these improvements are of borderline clinical importance. Our analyses suggest that more recent 

studies may result in greater improvements in these spirometric measures. Whether year of the 

intervention reflects other key covariates that could affect spirometric outcomes, is likely. 
108 

Note: The effect sizes presented here are the random effects standardized mean difference (SMD). 

Figure 17. Self-monitoring, self-management, or patient education studies reporting percent of predicted FEV1
109

Note: The effect sizes presented here are the random effects standardized mean difference (SMD). 

Figure 18. Self-monitoring, self-management, or patient education studies reporting mean peak flow 
110

Note: The effect sizes presented here are the random effects standardized mean difference (SMD). 

Figure 19. Self-monitoring, self-management, or patient education studies reporting mean days lost from work or school 
111

Note: The effect sizes presented here are the random effects standardized mean difference (SMD). 

Figure 20. Self-monitoring, self-management, or patient education studies reporting urgent care/emergency department vis
112

Note: The effect sizes presented here are the random effects standardized mean difference (SMD). 

Figure 21. Self-monitoring, self-management, or patient education studies reporting hospitalizations 
113 

Self-Monitoring, Self-Management, or Patient Education Trials Comparing Two 

Intervention Groups Without a Control Group 

Background. Several of the included studies compared two or more intervention groups without 

including a control group that did not also receive a QI intervention. For example, if a study 

provided a 10-session asthma patient education program to the experimental group and a twosession asthma education program to the “control group,” we considered this to be a trial 

comparing two intervention groups (sometime called a study with an “active control group”). In 

this section, we present the results of these studies. 

Results. We found 35 trials that compared two or more intervention groups without a control 

group that did not also receive a QI intervention (Table 21). They all included self-monitoring, 

self-management, or patient education interventions. Typically, these comparative studies were 

designed such that one group received a less intense version of what the second group received. 

Perhaps not surprisingly, these studies generally found improvements in both groups over 

baseline. Thirteen of these 35 (37%) also found differences between the two groups. 

Pediatric interventions. Eleven studies focused exclusively on children and all of these were 

either self-monitoring, self-management, or patient education interventions and two also 

included organizational change components.57, 64 Five studies found statistically significant 

differences between interventions groups. 55, 56, 62, 64, 197 Notable among these was the study of a 

patient education intervention called A.C.T. (Asthma Care Training) for Kids, an intensive 

educational program for children with severe asthma whose content is based on programs with 

demonstrated effectiveness, that was compared to a less intense lecture and discussion 

program.62 The article by Lewis et al. describes the conceptual rationale for the A.C.T. program 

and its contents in more detail than most of the included articles in this review.62 Briefly, the 

program emphasizes that children can control their disease rather than being controlled by it. 

Using the analogy of driving safely, medications and other asthma prevention and treatment 

techniques are color-coded: green for daily medications used to “keep going and prevent 

symptoms,” yellow for “caution” to be used when mild symptoms develop, and red to “stop” the 

disease when severe symptoms occur.62 Participants are taught about underlying asthma 

pathophysiology and symptomatology, reducing asthma triggers, relaxation skills and breathing 

techniques, medication use, and decision making skills. They found that the A.C.T. recipients 

had statistically significantly fewer emergency department visits (2.3 versus 3.7, p<0.001) 

compared with traditional patient education recipients and that, although there were no 

differences in terms of number of hospitalizations, the A.C.T. recipients tended to have shorter 

hospital stays (0.67 versus 1.54 days/child/yr, p<0.001).62 The costs of the program were 

estimated at $125 per A.C.T. recipient and $37.50 per traditional patient education recipient. 

Given the lower emergency department and hospital costs in the A.C.T. group, the authors 

estimated a net incremental savings of $180 per child per year for the sponsoring institution.62 

We did not find that increasing either the frequency or the duration of contact between 

patients and health educators was consistently associated with improvement in outcomes. 

Specifically, five of nine studies compared two (or more) interventions of differing 

interventional frequency or duration and found no statistically significant improvements in any 
114

outcomes. There were no other distinguishing characteristics of the interventions that were 

associated with improved outcomes. 

General population or adult interventions. We found 24 studies that compared two or more QI 

interventions without a control group that did not also receive a QI intervention for general/adult 

populations. Interestingly, only two of these were U.S.-based interventions.198, 199 Eight of 

sixteen studies reported significantly greater improvements in the intensive treatment arm.127, 128, 

200-207 For example, the study by McLean et al.205 compared a lower intensity pharmacistprovided asthma education/management program to a more intense pharmacist-provided asthma 

education program that emphasized asthma action plans, the use of peak flow meters, and other 

self-monitoring or self-management techniques. This study found that the intensive education 

group experienced significantly greater improvement than the less intense intervention: 11% 

improvement in peak flows (p=0.0002), 50% overall decrease in asthma symptoms (p<0.01 for 

most symptoms evaluated), improvement in QOL (<0.05), and decrease in medical visits (but not 

emergency department visits or hospital visits) between groups.205 The various interventions 

presented in these studies were heterogeneous with respect to material presented, type of 

educator, and frequency of interaction with the patients—thus, no particular intervention 

characteristics were associated with the most successful programs. 

Conclusions. Among the trials comparing multiple QI interventions without a control group that 

did not also receive a QI intervention, we found that, in general, all intervention groups tended to 

improve from baseline, but only 37% of studies of this type reported statistically significant 

differences between groups in the outcomes evaluated. The heterogeneity of studies of this type 

limits conclusions about commonalities of interventions associated with clinically meaningful 

improvements. 
115 

Table 21. Trials comparing two or more intervention groups without a control group that did not also receive an intervention 

Reference Study Purpose Target population Study Design Type of interventions 

Pediatric Interventions Butz et al.61

To evaluate the effects of a home-based self management intervention that emphasized symptom recognition and nebulizer use for inner city children with asthma. 

210 children aged 2 to 8 years living in inner city Baltimore with asthma. 

RCT Group A. 105 children received 3 home visits to help 

establish primary care for the children and teach basics of asthma management including PF meter use. Group B. 105 children received 6 home visits 

to teach symptom identification, and the appropriate treatment of these with a home nebulizer. This intervention was based on several previously recognized successful educational programs. 

6 months after enroin terms of self-mangiving asthma medasthma symptoms)differences betweeadherence with self

Chan57 To develop and 

evaluate an Internetbased store-and-forward video monitoring system for children with asthma. 

10 children aged 6 to 17 years with asthma in Hawaii. 

RCT All patients received a home computer system, video 

camera, microphone, and cable access to the internet. They used the camera and computer to demonstrate inhaler technique, record PF measurements and send in twice weekly symptoms diaries. Case managers (pharmacists) reviewed these data twice a week and sent back feedback via email. Group A. 5 patients received asthma education online. Group B. 5 patients received asthma education in the office. These patients used written (rather than electronic) symptom diaries. 

There were no diffethe end of 180 days evaluated (e.g., am

agonists used, PF mcontrol, QOL, or patechnique improved whereas compliancsymptom diary use for both groups. Asbefore the study anfor either group afte

Charlton et al.64

To assess a nurse run asthma clinic in a department of pediatrics. 

79 children aged 3-16 who either required an admission or outpatient visit for asthma in Australia.

RCT Group A. 42 children received a 45 minute 

standardized interview from an asthma nurse with explanations of mechanisms of disease, a selfmanagement plan, PF meter and diary card. Every 3 months they received a notice to have their asthma reviewed by either the asthma nurse or their general practitioner. Group B. 37 children received a 15 minute standardized interview, a diary card and a PF meter but no reminders for follow up. 

12 months after enwere less like to repbut there were no dwheezing or nasal sdifferences in seveGroup A patients spfunction less than 3There were no diffebetween groups, daof office visits.64
116

Table 21. Trials comparing two or more intervention groups without a control group that did not also receive an intervention (continued

Reference Study Purpose Target population Study Design Type of interventions 

Colland et al.60

To evaluate the feasibility of teaching patients and their caregivers to recognize prodromal signs and the adherence to a treatment plan that includes doubling inhaled corticosteroids if prodromal signs occur. 

29 children with moderate asthma in the Netherlands. 

RCT Group A (N=15). Both groups of children received 

individual information from a pediatrician on asthma symptoms, prevention measures, medication and exacerbations during 2 one-hour sessions. Patients’ kept PF, medication, and symptom diaries. They were seen every 2 months for one year. Group B.

14 children received additional information about individual prodromal signs identified by both the patient and caregiver; they were advised to double the daily dose of inhaled corticosteroid for 1 week when these signs occurred. 

There were no diffeterms of number of reported asthma-reabsence from schowork at 1-year post 

increased in both gbetween the groupsrecognition of prodr

Greineder et al.197

To evaluate the economic effects of an asthma outreach program that included an allergy nurse, allergy nurse practitioner, and allergist. 

57 children (aged 1-15 yrs) with asthma in Boston. 

RCT Group A. 28 patients had a single visit “typically 

lasting several hours” with an allergy nurse who provided individual asthma education on asthma, triggers, medications, inhaler and PF meter use, environmental control and a written asthma action plan. Group B. 29 patients received the same education as in Group A and then continue to have “regular” follow up by the nurse—mostly over the phone but with in person visits “as needed.” 

At the end of the 2 experienced reducthospitalizations, anpatients improved sGroup A patients: 5visits (p=0.0002), 7(p<0.05), and 71% (p<0.001).197

Guendelman et al.55

To compare the effectiveness of an interactive device for children to report asthma symptoms with an asthma symptom diary. 

Inner-city children aged 8 to 16 years in Oakland with persistent asthma. 

RCT All children received a standardized teaching session 

by a nurse during which they received a PF meter and educated on its use, and the appropriate use of asthma medications. Group A. 66 children were 

randomized to receive the Health Buddy device which they used to answer questions from a nurse about their asthma symptoms and send to the answers to a remote, secure server. Group B. 68 children recorded their symptoms in an asthma diary. 

12 weeks after enrodecrease in asthma PF readings in the children were less lsymptoms (p=0.03) There were no diffeterms of school abshospitalizations.55
117

Table 21. Trials comparing two or more intervention groups without a control group that did not also receive an intervention (continued

Reference Study Purpose Target population Study Design Type of interventions 

Krishna et al.56

To evaluate whether the addition of a multimedia asthma education program to a standard education program improves outcomes for children with asthma. 

246 children aged <18 with asthma in Missouri and their caregivers. 

RCT Group A. 121 children received 1.5 hours of asthma 

education over 3 visits by a nurse using instructional sheets from the “Caring for Kids With Asthma” series—each of which describes specific aspects of care for asthma such as medication use. Then at each subsequent visit they received 15 minutes of additional individualized training on use of devices and medication and a detailed written self management plan. Group B. 107 children received this printed and verbal teaching and also used the 1h 20min Interactive Multimedia Program for Asthma Control and Tracking (IMPACT) for additional reinforcement of asthma skills and knowledge by taking the subject through 4 clinical vignettes. 

12 months after entheir asthma knowlesignificantly greater Both groups had imsymptoms, medicaturgent visits to physbaseline (p<0.05). significantly greater asthma symptoms number of annual E(p<0.01) than the cdifferences in betwelimitation, nights of visits to the physiciaabsenteeism.56

Lewis et al.62 To compare the ACT (Asthma Care Training) 

program with conventional patient education. 

Children with severe asthma aged 7-12 yrs in Los Angeles. 

RCT Group A. 28 patients received three 1.5 hour 

sessions consisting of a lecture with discussion in groups of 12-25 people with demonstrations of relaxation and breathing exercises designed to give the child more responsibility for his/her care. Group B. 48 patients received the ACT program: five 1-hour session at weekly intervals (some taught by school teachers, others by a physician). Children and parents are taught the same content but in separate sessions. A detailed description of this curriculum is presented in 62.

ACT recipients (groED visits (2.3 vs. 3.patients. There wenumber of hospitaligroup tended to havs. 1.54 days/child/rated their child’s hyear after the progrratings decreased scosts of the program recipient and $37.5Given the lower hosthe authors estimatper child for the spo
118

Table 21. Trials comparing two or more intervention groups without a control group that did not also receive an intervention (continued

Reference Study Purpose Target population Study Design Type of interventions 

Walders et al.59

To assess the effects of an interdisciplinary intervention on asthma symptoms and health care utilization. 

175 children aged 4-12 years with asthma in Cleveland. 

RCT Group A. 86 children were evaluated by a pediatric 

pulmonologist who developed a written asthma treatment plan for each child who also received a spacer, PF meter, and prescription for a 1-month supply of medications. Group B. 89 children 

received everything that Group A received and also received a 1hr educational session with a nurse or social worker on asthma pathophysiology, triggers, and treatment; an additional individualized problemsolving visit with a psychologist; and access to a nurse telephone hotline. 

12 months after endifference between symptom days or shospitalizations, or over baseline).59

Wensley and Silverman63

To evaluate the incremental effectiveness of adding routine PF monitoring to symptom-based guided self-management. 

90 children aged 7-14yrs with physician diagnosed asthma in the U.K. 

RCT Group A. 44 children and their caregivers were given 

training in spirometry and symptom recording in a 30-90 min session. A color-coded plan was provided with instructions for medication adjustment on the basis of both symptoms and PF measurements. Written symptom diary completed daily. Children were visited every 4 weeks for 3 months to update the self management plan. Group B. 46 children and their caregivers received a symptom diary and selfmanagement plan based on symptoms but no PF meters or instructions on their use. 

Compliance with wrover time in both gr79% at month 3. Tbetween groups in of symptom-free daparameter (includinhospital or general prescriptions, or da
119

Table 21. Trials comparing two or more intervention groups without a control group that did not also receive an intervention (continued

Reference Study Purpose Target population Study Design Type of interventions 

Yoos et al.65

To evaluate the incremental benefit of PF meter use as an adjunction to symptom recognition and selfmanagement of asthma. 

168 patients aged 6-19 years with asthma from 11 primary care settings in the U.S. and their families. At enrollment, NGroup A=56, NGroup 

B=55, NGroup C=57; 

however, at 1-year, 32 patients did not complete the final post-exit interview. It is not clear which groups these patients belonged to. 

RCT Patients in all groups received asthma education 

during a home visit from a nurse regarding asthma pathophysiology, symptom recognition, triggers, medications, and treatment goals and were given written materials with personal action plan for symptom management to reinforce this information. Group A. 56 patents received training in subjective asthma symptom recognition. Group B. 55 patients received subjective asthma symptom recognition and PF meter training with instructions to use PF meter at the time of increased symptoms. Group C. 57 patients received subjective asthma symptom recognition training and PF meter training with instructions to do both routine twice daily PF monitoring and at the time of increases in asthma symptoms. Each group had a practice period of 2 weeks, after which they were followed up. All patients kept asthma diaries. 

All outcomes were terms of change fromeasurement. Aftesignificant differencchange in spiromet

was also no significGroups A and C or symptom-days; howsignificant improvemGroup A in symptommonths, there were among the groups hospitalizations, ED However, the averacharges due to red$82 per child for Grfor Group B childreC children.65

General Population or Adult Interventions Adams et al.140 To compare symptom vs. PF monitoring for 

detecting asthma flares. 

134 adults with moderate to severe asthma who are not poor perceivers of bronchoconstriction in Australia. 

RCT Group A. 61 patients were given a written, selfmanagement action plan based on symptom 

monitoring. Group B. 73 patients were given a written, self-management action plan based on PF monitoring. All patients were called monthly for monitoring and reinforcement of the use of the action plans.

There were no diffehospitalizations, or between the groups (Compared with the both groups had sigof these outcomes)between groups in 

and 86% of the PF appropriate use of a
120

Table 21. Trials comparing two or more intervention groups without a control group that did not also receive an intervention (continued

Reference Study Purpose Target population Study Design Type of interventions 

Ayres and Campbell 208

To assess the efficacy of an asthma selfmanagement plan based on PF measurements compared to a standard dose regimen. 

125 adults in the U.K. with asthma over the age of 17 with nocturnal symptoms. Ncon=64, Nint=61. 

RCT Group A. 64 patients in the “doctor-managed 

regimen” group made 4 visits to the clinic at 6-week intervals as well, and they had their medication adjusted by the investigator based on their diary card data. Group B. 61 patients in the “self-management regimen” received a written personalized selfmanagement plan based on PF monitoring at initial assessment and continued to make 4 visits to the clinic at 6-week intervals to have lung function and asthma severity measured. Patients also completed diary cards twice a day and PF charts. 

After 6 months, no found between the in sleep disturbancehospitalizations, or 

Baldwin et al.209 To compare the effectiveness of verbal 

vs. written instructions for asthma selfmanagement. 

50 adults with asthma in the U.K. 

RCT All patients were instructed in the use of PF meters, 

asked to record daily PF measurements, given handouts on asthma. Patients returned to the asthma clinic for 3 visits, 3 months apart. Group A. 25 

patients received verbal instructions on asthma management. Group B. 25 patients received written instructions on asthma management. 

Significant differencrandomization comthe results (Group A than Group B). Hosignificant improvemover the course of t

Bheekie et al.200 To compare the use of patient-performed PF 

and symptom monitoring as asthma self-management in a program run by community pharmacists. 

61 patients >6 

years old with asthma from 5 community pharmacies in South Africa. NGroup 

A=21, NGroup B=40.

RCT Group A. 21 patients were taught how to score their 

symptoms and received personalized selfmanagement plans based on symptom monitoring. Group B. 40 patients were taught how to monitor their PF and received personalized self-management plans based on PF readings, which these patients were instructed to monitor twice-daily before the use of bronchodilators. All patients kept diary cards to monitor their asthma. 

After 2 months, Grosignificantly more liuse their self-manaappropriately (p<0.indicated in their seHowever, there was groups in rates of swhen considered amanagement plan.2
121

Table 21. Trials comparing two or more intervention groups without a control group that did not also receive an intervention (continued

Reference Study Purpose Target population Study Design Type of interventions 

Charlton et al.126 To compare a PF self management plan for 

asthma with a symptoms only plan. 

115 patients in a U.K. general practice nurse run clinic (46 children and 69 adults) with asthma randomized to PF (N=51) verses symptom only (N=64) group. 

RCT All patients met individually with a nurse for an initial 

45 minute interview with a 15 minute session 1 week later for spirometry and a check of inhaler technique. All patients had follow up visits at least every 8 weeks where topics such as smoking, holidays, provoking factors, and emergency treatments were discussed. Group A. 64 patients were given self-management plans based on symptoms. Group B. 51 patients 

were given self-management plans based on PF readings. One week later, there was a 15 minute follow up. Patients were followed-up thereafter every eight weeks. 

After 12 months, thsignificant differencsymptom only groumedication usage ophysician for asthmverses children, agbetween interventio

Côté et al.201-203 To compare the effectiveness of asthma 

education with an action plan based on symptom monitoring with an action plan based on PF monitoring. 

149 adults with moderate to severe asthma in Québec. 

RCT Group A. 54 patients received only instructions from 

their “respirologist” regarding medication use, asthma triggers, and use of asthma symptom diary. Group 

B. 45 patients received the Group A intervention plus 1 hour individual counseling with a “specialized educator.” They were asked to record their asthma symptom score daily and adjust medications according to a symptom-based action plan. Group C.50 patients received the Group A intervention plus 1 hour individual counseling with a “specialized educator.” They were asked to measure their PFs twice daily and adjust medications according to a PFbased action plan. 

At 12 months, when patients (Group B apatients (Group A), symptoms scores dnumber of days per symptoms increase

improved for all gromore improved amocontrols.201, 202 Act

significantly more lireduce household dgroup (p<0.001), buexposure to domes

action plan and PF higher in Group C cand p=0.03, respecdifferences were focompliance with tre

ED visits, courses ofrom work or schoo

improvements in aistudy.201
122

Table 21. Trials comparing two or more intervention groups without a control group that did not also receive an intervention (continued

Reference Study Purpose Target population Study Design Type of interventions 

Cowie et al.127

To evaluate the effects of a symptom-based versus a PF-based action plan in preventing acute exacerbations in subjects with poorly controlled asthma. 

139 adult and adolescent patients who had attended an ED or clinic in Calgary for urgent treatment of asthma in the previous 12 months. 

RCT Patients in all groups received a 30 to 60 minute 

baseline interview, spirometry assessment, and an individual education session provided by a nurse covering asthma, asthma triggers, medication, and inhalation devices. Inhaler technique was checked and corrected if necessary. Group A. 48 patients 

received no further intervention (no action plan group). Group B. 45 patients were given written 

four-step action plans detailing different response actions based on symptom-monitoring. Group C. 46 

patients were given written four-step action plans based on PF readings. Patients in Groups A and B also received prescriptions for prednisone for use in the third step of the self-management plan. 

After six months, thED visits in Group C (p=0.002). There wamong the groups 

agonist utilization, snight waking with acorticosteroid, or nuprednisone taken.12

Drummond et al.,210211 Osman et al.,212and Buckingham et al.213

To evaluate a personalized computer supported education program for asthma patients (Group 1A/B). To evaluate the use of a PF meter based selfmanagement intervention. 

801 adults with asthma in Scotland.

RCT 

with 

3x3x3 

design

Group 1A. 349 patients received “conventional oral education at outpatient visits.” Group 1B. 363 

patients took part in an enhanced education program (4 personalized booklets, sent by mail). Group 2A. 

251 patients received no self-management advice. Group 2B. 254 received a PF meter, shown how to use it, and individually tailored self-management guidelines to follow when they identified changes in PF. 

12 months after the difference between outcomes including sleep disturbance, or inhaled steroids, number of general asthma. 210-212 Tota

asthma was estima£40.11/patient/annu£62.12/patient/annu
123

Table 21. Trials comparing two or more intervention groups without a control group that did not also receive an intervention (continued

Reference Study Purpose Target population Study Design Type of interventions 

IgnacioGarcia and GonzalesSantos204

To determine the usefulness of an objective measure of lung function in association with an educational program and a medication selfmanagement plan in reducing morbidity in adult patients with asthma. 

70 patients with asthma ages 14-65 from an outpatient asthma clinic in Spain. Ncon=35, 

Nint=35. 

RCT During an initial assessment, all patients were given 

individualized therapeutic schedules and taught proper inhaler technique and how to use a PF meter they were given. Group A. 35 patients used symptoms only and spirometric data for following physicians’ treatment plans. Group B. 35 patients monitored themselves using PF readings, which were the basis for their therapeutic plan. This was coupled with educational intervention—a 30-min session regarding the role of asthma medication and symptom management. All patients were followed up at 3, 5, and 6 months where their inhaler technique, compliance with PF measurement, and diary cards were checked and spirometry was performed. 

After 6 months, sigintervention group cwere found in days acute asthma exac(p<0.05), physician nocturnal wakening improvements were (p<0.002), FVC1 (p

fenterol and prednis(p<0.008). An obseof hospital admissiointervention did not significance.204

JansonBjerklie and Shnell198

To identify self-care strategies used to control asthma symptoms and to determine the effect of PF information on selection of self-care strategies. 

28 adult patients with asthma in the U.S. NA=15, NB=13.

RCT All patients participated in an interview during which 

they gave information about their asthma history, frequency of symptoms, and strategies to control their asthma. All patients were then instructed on how to use and Asthma Care Log to record information about their symptom episodes. Group B. 13 patients were 

told to also record PF 3 times at the beginning and end of each episode, and told high numbers meant good flow and open airways. 

After 3 months, thethe groups in sympwith medication. H

intervention group usignificantly less tha(p<0.05).198

Jones et al.214 To compare asthma self-management 

program using homebased PF measurement with a program of planned clinic visits for asthma management. 

90 practices with patients aged 15-40 years with asthma requiring daily inhaled corticosteroids in the U.K. were invited to participate. 

RCT All patients had 5 visits over 6 months and were 

taught to use symptom diaries. Group A. 33 patients 

assigned to the self management group received a PF meter, instructed in its use, and given written instructions for how to change their medication regimen in response to PF measurements. Group B.

39 patients assigned to the planned visit group had their medications changed by providers in clinic on the basis of their symptom diaries. 

No difference betwe

or PF; days lows frovisits, hospitalizatioQOL at 6 months aCompared to baselsignificant decreasedaily life and improvsignificant improvemFCV between visits between visits 1 an
124

Table 21. Trials comparing two or more intervention groups without a control group that did not also receive an intervention (continued

Reference Study Purpose Target population Study Design Type of interventions 

Kauppinen et al. 215-217

To evaluate the effects of an intensive selfmanagement education program on adults with asthma. 

134 newly diagnosed adults with asthma in Finland. 

RCT Group A. 70 patients received training in use of 

inhaled medications and PF meters (which they were issued), they received verbal information and were shown a video (two visits). Group B. 64 patients 

also received every three months for a year additional training with “repetition of self-management instructions, principles of asthma treatment and use of drugs.” Additionally, they received two 2-hr educational visits at 6 and 9 months by a nurse and physiotherapist on “social affairs” and “rehabilitation.” 

There was no signigroups at 5 years fohyper-responsiveneor total costs attribu

Kemple and Rogers218

To evaluate postal prompts to increase patients’ understanding and use of selfmanagement plans. 

545 patients with asthma over age 16 in the U.K. NGroupA=197, 

NGroupB=187, NGroupC=161. 

RCT Group A. 197 patients were mailed an invitation to 

have a medical review of their asthma symptoms, treatments, and asthma action plans. Group B. 187 

patients were mailed a similar invitation for medical review with a blank asthma self-management plan. Group C. 161 received the invitation for the medical review with a partially-completed personalized action plan to be completed at the time of the review with their health care practitioner. 

Overall, there was a Group A, 45% of Gpatients attended thafter the interventiodifferences among visits, or hospitaliza

LópezViña and del CastilloArévalo128

To compare selfmanagement education program alone to one that includes PF monitoring. 

100 adults with asthma in Spain. 

RCT Group A. 44 patients received personalized selfmanagement plan with nurse provided education on 

asthma management and medication information. Group B. 56 patients received this same education and they also received and color-coded self management and diary cards to record symptoms, medications, and PFs. For all patients, follow up visits were scheduled at 15 and 30 days after enrollment and every 3 months thereafter until 1 year after enrollment. 

At 12 months, Grouadherent to their trep=0.05) and had hi0.03) than Group A were no differences symptoms, reported school/work absenthospital admissionsFEV1 although man

improved from base
125

Table 21. Trials comparing two or more intervention groups without a control group that did not also receive an intervention (continued

Reference Study Purpose Target population Study Design Type of interventions 

Malo et al.219 To compare symptom vs. PF monitoring for 

detecting asthma flares. 

60 adults with moderate to severe asthma in Canada. 

RCT with

Crossover of 

arms 

Group A. Recorded PFs twice a day for six months first then recorded symptoms twice a day for six months. 40 subjects finished the first six month, 20 finished both. Group B. Recorded symptoms twice a day for six months first then recorded PFs twice a day for six months. 40 subjects finished the first six month, 20 finished both.

19 (61%) of the totawere reported while diaries and 12 (39%were using PF mete

McLean et al.205

To evaluate the effects of two levels of asthma care by pharmacists on clinical, economic, and QOL outcomes. 

20 pharmacists caring for patients with poorly controlled asthma in British Columbia. 

QuasiRCT Group A. Patients were taught inhaler technique, completed monthly asthma diaries of PFs, 

symptoms, medication use, ED visits, and days off from work/school. Patients encouraged to come once a month for new diaries or at least quarterly. Group B. Patients received everything that Group A received plus intensive asthma education and instruction on the use of PF meters and spacer devices. They received private 1hr counseling sessions every 2-3wks for at least 3 wks, then every 3 months for at least 9 months. 

Both groups experiimprovements over education group reimprovement than t11% improvement decrease in asthma symptoms evaluatedecrease in medicahospital visits).205

Neri et al.220, 221

To evaluate the effects of patient education on pulmonary function and inhaler technique among adults with asthma. 

35 adults with asthma in Italy. 

RCT Group A. 17 patients received a medical exam every 

two months for 1 year. Group B. 18 patients also received six 1-hour lessons “based on the content of an educational booklet on asthma.”

At 1 year, there wagroups in terms of nnumber of work dayadmissions.221 Thebetween the two grasthma knowledgeduring inhaler use e

cost per patient wafor Group A.221 Co

significant improveminhaler technique in 
126

Table 21. Trials comparing two or more intervention groups without a control group that did not also receive an intervention (continued

Reference Study Purpose Target population Study Design Type of interventions 

Ostojic et al.206 To assess the feasibility and reliability of GSM 

SMS as a tool of asthma monitoring and to ascertain its effects on control of asthma. 

16 patients with moderate persistent asthma from a single clinic in Croatia Ncon=8, 

Nint=8. 

RCT All patients had a 1-hour asthma self-management 

education session with a specialist at the clinic and were given a self-management plan and a PF monitor. Patients noted PF measurements, medication use and symptoms in a diary. Group A. 8 patients were seen in the office at the end of the study to review their asthma diaries. Group B. 8 patients sent their PF results daily to physicians via a short-message service (SMS) that used Asthma Center 0.90 Software to compute maximal, minimal, and mean PF, PF variability, and compliance. They then received weekly instructions by SMS from an asthma specialist on therapy adjustments and recommended follow up. 

After 4 months, no the intervention and found in mean PF, 

measurement, daily agonists, wheezingHowever, when comthe intervention grocoughing (p<0.05) The additional cost was 1.67€ ($1.3 pe

Schonlau et al.199

To examine whether a collaborative to improve asthma care influenced processes and outcomes of care for adults with asthma. 

6 healthcare organizations from across the U.S. and Puerto Rico sent teams of 3-4 participants for collaborative learning. 

CBA The intervention group (6 sites, 123 patients) sent 3-4 

person teams to 3 2-day learning sessions to promote changes in asthma care based on best practices and continuous quality improvement (the curriculum was not described in detail). 2 of 3 control sites (62 patients) had active quality improvement programs for asthma (also not described in any detail). 

At 12 months after intervention group wto attend educationthere were no differterms of having a wsetting, PF monitormedications, QOL, 

Thapar222 To compare individual 

vs. group asthma education sessions. 

69 adults with asthma in Wales. 

RCT Group A. 34 patients received 20 minute 

individualized asthma education by a physician with a 5-10 minute follow up session at 3-4months. Group B. 34 patients received a 35 minute group asthma education program by the same physician (4-6 patients per group) with a 10-15 minute follow up session at 3-4 months. 

At 4-5 months after there was no differeself-rated “wheezinKnowledge increascompared to baseli

Thomas et al.129 To compare patient education by an asthma 

nurse with breathing retraining by a physiotherapist. 

33 adults with asthma in the U.K. 

RCT Group A. 16 adults were given a 60 minute group 

education session by an asthma nurse on asthma. Group B. 17 adults were trained by a physiotherapist in a small group session for 45 minutes followed by 15 minute individual sessions 1 and 2 weeks later (total time 75 minutes) in proper breathing techniques. 

There was no differuse between the twintervention. There one domain of QOL group compared to (p<0.05).129
127

Table 21. Trials comparing two or more intervention groups without a control group that did not also receive an intervention (continued

Reference Study Purpose Target population Study Design Type of interventions 

Turner et al.130 To compare the effectiveness of action 

plans using either PF monitoring or symptoms to guide selfmanagement. 

92 patients with moderate to severe asthma using inhaled corticosteroids from a primary care clinic in Vancouver NGroup A=48, 

NGroup B=44. 

RCT All patients were given individualized asthma 

education by a registered nurse, and selfmanagement plans were reviewed in detail. The initial visit consisted of thirty minutes of asthma education and discussion, and follow up visits were scheduled monthly for six months. Patients also kept daily diary cards. Group A. 48 patients’ selfmanagement plans were based on symptoms Group 

B. 44 patients’ self-management plans were based on PF. Therefore, patients with self-management plans based on PF were also instructed in the use of a PF meter. 

After 6 months, no found between the 

symptom scores, thsteroids, number of ED visits, or hospita

Van der Palen et al.131 and 

Klein et al.132

To assess whether including an action plan in a self-management education program improves asthma outcomes. 

245 adults with stable moderatesevere asthma in the Netherlands. 

RCT Group A. 122 patients received self-management 

training and education by an asthma nurse in three 90-min small group sessions. Content included asthma pathophysiology, medication use and sideeffects, asthma triggers, symptom identification, PF meter and inhaler technique. Group B. 123 patients also received instructions on how to use an action plan to treat exacerbations. 

At 1 year, there wegroups in adherencaction plans.131 At 

differences betweeincluding PF, frequesymptom-free days hospitalizations.132 

inhaler technique (p

QOL.132

Yoon et al.207

To evaluate the effectiveness of a brief (3hour) patient education program to decrease readmission rates. 

76 Australian adults recently discharged after an admission for a severe asthma exacerbation. 

RCT All patients received a PF meter and were shown how 

to use it and record values from it. Group B. 28 intervention subjects also received a single 3hr educational session that emphasized improved inhaler and PF monitor use and self adjustment of the dosage of phrophylactic meds according to a PFs and a treatment plan. Included interactive lecture, videotape, individual training, and a practice session.

10 months after the intervention patientwere readmitted for intervention and 7 cfor asthma (p<0.01work or school betwsteroids, or reporte

Note: ED=emergency department; PF=peak flow; QOL=quality of life; CBA=controlled before-after trial.
128 

Provider Education Interventions 

Background. The purpose of provider education programs is to inform providers about asthma 

treatment guidelines and to develop their skills in educating patients and their caregivers about 

asthma self-monitoring or self-management (whether for providers caring for children or for 

adults with asthma).223 Health care providers include nurses, nurse practitioners, physicians, 

physical therapists, and pharmacists, among others. 

 

Results. Eighteen of the included studies reported on the efficacy of provider education to 

improve the outcomes and processes of care for patients with asthma. 

Interventions targeting providers of children with asthma. We found seven articles reporting 

interventions designed to provide training for clinicians caring for children with asthma (Table 

22).114, 223, 224 The Pediatric Asthma Care PORT (Patient Outcomes Research Team), conducted 

a RCT designed to assess the effectiveness of three strategies (physician-peer leaders, peer 

leaders in combination with asthma nurse visits, and usual care) to implement guidelines for 

childhood asthma (funded by AHRQ), which is noteworthy for several reasons: It is an 

effectiveness study intended to evaluate the effects of implementing QI interventions in realworld primary care practices (rather than an efficacy trial in a controlled trial environment), it 

included 42 primary care practices in four health care organizations around the country (Boston, 

Seattle, and Chicago), it is one of the largest included trials (with 638 patients), and it had a 

relatively long intervention and follow up period (two years). At the end of the two year follow 

up period, compared with the usual-care arm (N=199), patients randomized to the physician-peer 

leader arm (N=226) had annual increase of 6.5 symptom-free days, whereas those randomized to 

the physician-peer leader and nurse visit arm (N=213) had an annual increase of 13.3 symptomfree days over usual care patients.225, 226 The average number of physician visits during the two 

year trial was higher in the physician-peer leader and nurse visit arm as was regular use of 

inhaled controller medications (not found for physician-peer leader only patients).226, 227 Total 

treatment and intervention costs per year per patient were $1292 for PACI, $504 for physicianpeer leaders, and $385 for usual care. The incremental cost-effectiveness compared to usual care 

was$18/symptom-free day for that physician-peer leader arm and $69/symptom-free day for the 

physician-peer leader with nurse visit arm.225

The study by Homer and colleagues228 is notable for its methodological rigor. For this study, 

a physician, nurse, and front office staff person from 22 practices in Boston and Detroit were 

invited to three 1-day educational sessions on quality improvement strategies for asthma based 

on the Chronic Care Model and concepts from QI theory including the Model for Improvement 

(a specific approach to QI that emphasized small, incremental tests of change).228 Additional 

support was provided through biweekly conference calls, an active e-mail list, and performance 

feedback based on review of monthly team reports. The study specifically describes the authors’ 

research hypotheses, study outcome measures, power calculations, and detailed information 

about the baseline characteristics of the study population. Further, they performed an intention 

to treat analysis and evaluated the effect of the intervention by comparing the change from 

baseline for the intervention group with the change from baseline in the control group (21 

additional practices) adjusting for the effects of state, practice size, age, and gender. They found 
129

no intervention effect; however, the study serves as model for rigorous analysis and reporting of 

provider education interventions. 

With the study just described by Homer and colleagues as the one exception,228 all of the 

other studies found statistically significant improvements in use of medications (most often 

increases in the use of inhaled controller medications) (Table 22). Several also found 

improvements in asthma symptoms and reductions in emergency department use. All of the 

studies gave providers some information about current asthma treatment guidelines, about 

appropriate follow up for patients with asthma, and some training to encourage providers to 

teach patients (and their caregivers) about asthma self-monitoring or self-management 

(particularly through the use of asthma action plans). The interventions differed in terms of their 

intensity and scope of training. For example, the study by Evans and colleagues evaluated an 

intervention designed to train all the staff (including physicians, nurses, and clerical staff) at 

selected pediatric clinics serving low-income minority children in New York City.224 All staff 

were included in the training because the developers of the intervention wanted to ensure that 

everyone in the clinic understood the program and how they could contribute to it. All staff 

received five three-hour educational sessions over a five month period and then two additional 

three-hour sessions at the end of the one-year follow up period to give staff opportunities to 

discuss specific patients and reinforce communications skills. Intervention physicians also spent 

three hours observing a Columbia faculty physician treating children with asthma in a tertiary 

care setting. They found that, two years after the intervention, the intervention clinics had 

enrolled more new asthma patients (40/100 vs. 16/100, p<0.01), a greater percentage of asthma 

patients returning for treatment (42% vs. 12%, p<0.001), a greater annual frequency of scheduled 

visits per patient (1.85 vs. 0.88, p<0.001), and a greater proportion of patients on inhaled βagonists and corticosteroids than control clinics.224 In contrast, the physicians in the educational 

intervention described by Glasgow and colleagues received a single one-on-one session training 

them in the use of a multi-visit asthma treatment plan.§114 At 12 months after this intervention, 

Glasgow also showed statistically significant effects: the intervention children had increased use 

of written asthma action plans (44% versus 34%) and pressurized metered dose inhalers with a 

spacer (62% versus 38%), decreased rates of speech-limiting wheezing (5% versus 18%), and 

were less likely to use reliever medications more than 4 days of the week (9% versus 30%). 

There was no difference in symptom-free days or ED visits.114 

Interventions targeting providers of general population or adults with asthma. We found 11 

studies reporting on interventions with some component of provider education for general 

populations or adult patients with asthma (Table 23). One of these compared two intervention 

groups without a control that did not also receive a QI intervention (Table 21).199 

Four studies evaluated interventions that combined provider education with a component of 

provider feedback (Table 26).229-232 Two of these four combination interventions were 

associated with improvements in provider prescribing practice. For example, the study by 

Cordina and colleagues of an intervention in which Maltese pharmacists were trained to provide 

patient education and monitoring of asthma symptoms found improvements in inhaler technique, 

nighttime wheezing, and patient-reported hospitalizations for asthma (there are additional details 

 

§

The article by Glasgow and colleagues provides a detailed description of what actions the physician should take at 

each of the recommended clinic visits. 
130

about this study in the section on organizational change interventions, Table 25).159 In contrast, a 

Swedish study of pharmacists/clinical pharmacologists visiting groups of primary care providers 

to teach them about asthma treatments and to encourage self management found no statistically 

significant change in prescribing practices.231

As a group, 55% of these 11 provider education interventions reported that providers 

receiving the education improved adherence to asthma management guidelines (most often, 

providing written asthma management plans and increased prescription of inhaled 

corticosteroids). They were less likely to report improvements in health services utilization 

(27%) or improvements in clinical outcomes (9%). 

Conclusions. Most provider education interventions include components of training in current 

asthma therapies, follow up, and self-monitoring or self-management and most reported 

improvements in the prescription of inhaled controller medications. Given the heterogeneity in 

the studies and relatively small number of studies, we cannot evaluate the specific provider 

education intervention characteristics likely to be associated with improvements in clinical 

outcomes for patients. Moreover, given the wide variation in the types of interventions included, 

we cannot specify which educational components led to the greatest benefit. 
131 

Table 22. Summary of provider education interventions for the improvement of asthma in children 

Reference Study Purpose Target population Study Design Type of intervention 

Clark et al.233, 234

and Brown et. al223

To evaluate the long-term effects of an interactive seminar for physicians based on principles of self-regulation on patient care and outcomes. 

67 general pediatricians (Nint=34, Ncon=33) and 

their patients with asthma aged 1-12 years (Nint=202, 

Ncon=167) from Ann Arbor, 

MI and New York, NY. 

RCT Intervention physicians received 2 interactive, 

multimedia, small group, 2.5-hour seminars that focused on optimal clinical practice based on NAEPP expert panel guidelines and patient teaching and communication. They included brief lectures from a local asthma expert and video showing effective clinician teaching and communication behaviors, case studies of clinical problems, a protocol for self assessment, and a review of messages to communicate and materials to distribute to patients/families. Control group physicians received no intervention. 

2 years physicito provadjust when a (p=0.02for patitherapy (p=0.02differenproporprescri

numbemonthsphysicihospita12 than Data w

Evans et al.224

To evaluate the effects of provider training based on National Asthma Education and Prevention Program on all staff at selected pediatric clinics serving low-income minority children in New York City. The authors hypothesized that the intervention clinics would have increased numbers of children diagnosed with asthma and receiving continuing care and increased use of new pharmacologic and educational treatment methods. 

11 clinics in the study group (with 80 staff) served 3,118 patients and 11 clinics in the control group (with 54 staff) served 2,487 patients. 36% were Medicaid recipients. 

RCT Staff received five 3-hour educational sessions 

over a 5 month period. All staff (including clerical staff) participated in each session to ensure that everyone in the clinic understood the program and how they could contribute to it. 2 additional 3-hour sessions were held at the end of the 1year follow up period to give staff opportunities to discuss specific patients and reinforce communications skills. The second component of the intervention was a tutorial session with which the intervention physicians each spent 3 hours observing a Columbia faculty physician treating children with asthma. Outcomes were assessed over a 2 year period. 

2 years intervenew asp<0.01patient12%, pof sche0.88, ppatient

cortico
132

Table 22. Summary of provider education interventions for the improvement of asthma in children (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Finkelstein et al.,227, 235 Sullivan et al.,225and Lozano et al.226

The Pediatric Asthma Care Patient Outcomes Research Team (I and II) compared 2 asthma care strategies in children with mild to moderate asthma with usual care in the primary care setting. 

42 primary care clinics in 4 health care organizations in Chicago, Seattle, and Boston that cared for 638 children aged 3-17 years with mild to moderate persistent asthma. 

RCT A peer leader-based physician behavior change 

intervention (PLE) and a practice-based redesign intervention (PACI) were compared with usual care. The PLE strategy involved training a pediatrician (in 2 workshops and through monthly contact from an educational coordinator and ongoing learning network for peer leaders) at each of the practices sites as an asthma expert and champion. The peer leader functioned as a change agent within the practice and provided support, education, and feedback to other members of the practice. The PACI strategy involved 4-5 scheduled asthma care visits with an asthma care nurse who provided standardized assessments, care planning, coordination with primary care physicians, and self-management tools for the patients and their families. Between visits, the asthma nurse provided phone follow up. The PACI arm included all the components of the PLE arm. 

At 2 yearm (NPLE ar6.5 symthose r(N=213SFD ov

averagthe 2 ythe usuarm (pPACI a

differennumbePACI pregular care suno simpatient

intervewere $$385 focost-efwas$1PACI.2

Glasgow et al.114 Train providers to use and then evaluate the feasibility and 

effectiveness of a general practice-based, proactive system of asthma care in children with moderate to severe asthma. 

Australian children (101 intervention and 73 control) with moderate to severe asthma and a general practitioner and their physicians (12 control and 12 intervention physicians) were enrolled. 

RCT The physicians received 1-to-1 education by 

one of the study authors on a “3+ Visit Plan” (1st

visit: introduce concept of a contract for asthma care; 2nd visit: assess patient’s status; 3rd visit: 

review patient’s PF record, complete asthma action plan, and identify triggers; 4th visit: 

assess progress and answer questions. 

12 monintervewritten pressuspacerwheezrelievethe wesympto
133

Table 22. Summary of provider education interventions for the improvement of asthma in children (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Homer et al.228 To implement a multi- disciplinary provider education 

program in a large number of practices and evaluate its effects on asthma outcomes for children. 

43 practices in Boston and Detroit with 13,878 pediatric patients (aged 2-17) with asthma. 

RCT Intervention practices (N=22) sent a 3-member 

multidisciplinary team (physician, nurse, and front office staff person) to three 1-day learning sessions on quality improvement strategies for asthma. Additional support was provided through biweekly conference calls, an active email list, and performance feedback based on review of monthly team reports. Control practices (N=21) received no intervention during the experimental year. 

After cchild aclusterinterveasthma attacksor asth

Maslennikova et al.82

To assess the effects of a adapting a U.S. selfmanagement educational intervention on asthma outcomes for children in Moscow. 

122 children with asthma and their families living in Moscow. Nint=60; Ncon=62.

RCT The authors adapted “Open Airways” 

(developed for low literacy children aged 4-7 years) and “Air Power” (developed for average literacy children aged 8-14 years) for similar populations in Moscow. Intervention subjects also received asthma care from clinicians who had been trained “according to the U.S. guidelines for the diagnosis and management of asthma and use of modern asthma medications.” Intervention subjects participated in 4 weekly 1hr sessions. Control subjects received usual care. 

1 year childreon inhaincreasfor the Interveimprov(p<0.0terms otheophfrom sc

Toelle et al.88

To evaluate whether a community-based asthma management program could reduce asthma symptoms and lung function among school children in Sydney, Australia. 

132 school children aged 8 to 11 with asthma and all the adults who influence their care including parents, doctors, pharmacists, community nurses and school teachers. Nint=72; 

Ncon=60. 

CBA Intervention group participant were invited to 

attend 2 education sessions each 2 hours, 1 week apart on asthma triggers, medication use, inhalation technique, use of written selfmanagement plan. These children’s physicians and pharmacists were invited to attend workshops on asthma management guidelines. Intervention community nurses and teachers received workplace in-service education sessions. All families, children, physicians, and pharmacists who did not attend the intervention sessions were mailed the materials. 

147 teafamilie11 physessioboth Fthe integroup (signific(p<0.0differensymptoED vis

Note: ED=emergency department; PF=peak flow; NAEPP=National Asthma Education and Prevention Program; CBA=controlled before-after trial. 
134

Table 23. Summary of provider education interventions for the improvement of asthma in general populations or adults 

Reference Study Purpose Target population Study Design Type of intervention 

Cordina et al.159

To examine the effects of a community pharmacy-based education and monitoring program for patients with asthma on a range of patientspecific asthma management outcomes. 

152 patients over the age of 14 who received their asthma prescriptions at private pharmacies in Malta. 

CBA A comprehensive asthma education and 

monitoring program was instituted in private pharmacies in Malta for 12 months. The intervention pharmacists reviewed patients asthma symptoms, PF records, medication use, and when necessary suggested changes in treatment to the patient’s physician. 

Thebetgroselffrom relarepamtha(p<heainteto rmotech

Daniels et al.236

To assess the effectiveness of an intervention designed to increase compliance with national asthma care guidelines in primary care safety net health centers serving high-disparity patient populations 

16 federally-funded community health centers in eight southeastern states in the U.S. Ncon=9, 

Nint=7. 

RCT The intervention consisted of three components: 

resources (asthma kits including PF meter, MDI spacer device, educational materials) which clinicians were encouraged to give to patients, training of all health center staff in asthma care guidelines which emphasized the need for patients to have Management, action, and prevention plans, and tools or templates for practice-level systems change (asthma flow sheets and standing orders). Control group sites received copies of the national asthma guidelines and one asthma resource kit with information on how they could obtain more at a discounted price. 

Thebetsitehad MDregbeecouresor awas inteconwho recdochist
135

Table 23. Summary of provider education interventions for the improvement of asthma in general populations or adults (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Feifer et al. 171

To determine whether a population-based asthma disease management program, using broadbased educational interventions can have favorable effects on physician and patient adherence to guidelinesbased care. 

70,900 patients with asthma patients aged 5-45 years using a specific prescription benefit plan in the U.S. 35,450 patients were in each group. 

CBA During the 12-months following enrollment, 

intervention patients and their physicians received educational materials. Patients in the intervention group received five workbooks and two newsletters. Educational materials emphasized guideline-based elements of asthma pharmacotherapy, self-management techniques, and trigger avoidance. Additionally, patients received refill reminders, prospective compliance reminders, and pollen count alerts by mail. Physicians received asthma management flow sheets to facilitate the tracking and review of patients’ therapy. Patients in the control group received no educational materials, nor did their health-care providers. 

All chamoperconthe conincr(p<refiintecom

Gorton et al.237

To evaluate the effect of three different methods of disseminating asthma guidelines on physicians’ behavior and attitudes toward education strategies 

76 primary care physicians in four Area Health Education Centers (AHECs) at the University of Arkansas for Medical Sciences. A total of 375 patient records were reviewed. Ncon=17, NA=11, 

NB=17, NC=18. 

CBA The study had 1 control group and 3 intervention 

groups. All intervention groups received the executive summary of the asthma guidelines produced by the National Institutes of Health (NIH). Physicians in Group A also received a 10-page summary of the guidelines, 2 telephone calls from “academic detailing” peer physicians, and were invited to attend a half-day continuing medical education (CME) conference. Physicians in Group B completed 4 computer-based modules, a computer conference with a moderator to discuss the guidelines. Physicians in Group C received a videocassette created for cable medical television, 4 facsimile messages in the 

hospital mailbox (weekly, for 4 weeks), and 4 posters were displayed in prominent locations in the hospital (monthly, for 4 months). Group C was also invited to the CME conference and received an audiocassette of the conference. Physicians in the control group received educational materials after the completion of the project. 

AfteGroappsignphycomincrmophyB pmoconp<0no termspirwhino any the 
136

Table 23. Summary of provider education interventions for the improvement of asthma in general populations or adults (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Lagerløv et al.230

To evaluate the effects of a newly developed form of group education for improving the quality of prescribing in primary health care. 

190 GPs responsible for the care of asthma patients in Norway. 

CBA Like the control group, the intervention group 

participated in 2 group meetings—during one they discussed asthma diagnosis, and the key information for making treatment decisions. At the second meeting international and national guidelines for treating asthma were presented. The group then agreed on common quality criteria for what they found to be acceptable and unacceptable prescribing practices. Feedback on their prescription behaviors was given relative to the agreed upon quality criteria. 

Thenuminte“ac(p=

Lundborg et al.231 To develop, implement, and evaluate a new 

educational model, with messages based on available national guidelines aimed at improving prescribing in primary care. 

204 GPs responsible for the care of asthma patients in Sweden. 

CBA GPs were asked to attend 2 group sessions. 

During the 1st session, individual feedback on written simulated cases was given and discussed. During the 2nd session, feedback on individual prescribing was presented and discussed. GPs were expected to: start/increase inhaled corticosteroids when bronchodilator use is too high; treat asthma exacerbations with antiinflammatory treatment and not routinely with antibiotics; and 3) not start long-acting β2-agonists 

when the patient is on a sub-optimal level of inhaled corticosteroids. 

Botgroprecor

Rossiter et al.232 To determine the potential of a disease management 

program in terms of improving the health of low-income Medicaid patients while achieving cost savings in providing treatment. 

Virginia Medicaid population with moderate to severe asthma 

(a designation based on assessment of claims) who received care in a primary-care case management program (fee-for-service and HMO-based practices were excluded). 

See 

note§ Providers in primary-case-management programs with asthma patients were identified, and those 

who volunteered received an education workshop to improve communication skills and to inform them about current asthma treatment recommendations. Additionally, most participants also received intermittent feedback regarding who among their patients might benefit from further asthma education and treatment. 

The impβ-acorsignvisiposgreclaireceduprojproincr
137

Table 23. Summary of provider education interventions for the improvement of asthma in general populations or adults (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Tomson et al.238

To assess the effects of a provider education program on prescribing practices and physician and patient knowledge of asthma. 

General practitioners practicing in primary care clinics of Stockholm County (Sweden) (of whom 44 practicing in a similar region were assigned to the intervention group and 19 in a different region were assigned to the control group). 

CBA

*

A clinical pharmacologist and pharmacist visited the intervention practices and met with physicians in groups to discuss the treatment of asthma and to provide written information encouraging the use of inhaled glucocorticoids for prophylaxis, the use of PF meters, and testing to distinguish patients with COPD and asthma. 

Siginterecmeits udiffepra

Veninga et al.229

To evaluate the effects of a newly developed form of group education for improving the quality of prescribing in primary health care. 

181 general practitioners (GPs) responsible for the care of asthma patients in the Netherlands. 

CBA Intervention providers received group education 

on asthma prescribing and performed a selflearning audit program for peer groups. During 2 meetings, groups met with a moderator with individual feedback material for all members of the groups; anonymity was not maintained by mutual agreement; use of case vignettes which the GPs had received by mail prior to the meetings; individualized feedback on prescribing provided at second meeting. 

Inccorinte

Weng194 To evaluate the effects of 

a government sponsored QI intervention with patient and provider education and case management services for patients with asthma. 

1067 patients with asthma enrolled in the program sponsored by the Taiwanese government. 4,340 patients with asthma who did not enroll in the program served as matched controls. 

CBA Providers received a 6-hour asthma curriculum 

that included conducting pulmonary function testing, use of medications and PF monitoring, environmental controls, and asthma pathophysiology. They were given copies of asthma clinical practice guidelines. Patients received individualized, personally tailored asthma education on recognizing triggers and symptoms, medication use, PF use, and self-management of exacerbations. Case managers (nurses or physician assistants) provided communication between patients, primary care physicians and specialists, and scheduled quarterly follow up. 

1 yeintehosno the hospatasththe(by com

*CBA=controlled before-after trials §The intervention group for this study was selected from providers in specified geographic areas. Medicaid claims were 

intervention area and non-intervention areas. Comparisons were made over time (ITS-like, with only two “before” measures but with explanation that analys

period yielded little change in variables) and between groups. Note: ED=emergency department; PF=peak flow; QOL=quality of life. 
138 

Organizational Change Interventions 

Organizational Change Interventions for Children With Asthma 

Background. The studies of organizational change interventions designed to improve the 

processes and outcomes of care for children with asthma fall broadly into two categories: those 

that augment the care provided in general pediatrics clinics and those that provide an increased 

level of care in schools. Whereas the interventions described in the section on patient education 

(Table 12b) were asthma education programs in schools that often just taught children about the 

disease and its management, the school-based interventions described in this section all added 

increased levels of asthma care provided in the school setting. Asthma in children affects 

schools in several ways: Ongoing disease management typically happens while children are in 

school and life-threatening acute asthma symptoms can occur at school. Asthma is a leading 

cause of illness-related school absenteeism and this absenteeism often necessitates “make up” 

school work for these children and their teachers. Thus, schools are a natural site for asthmabased education and management programs. 

Results. We found 13 studies of organizational change strategies designed specifically for 

children with asthma (Table 24).108, 115, 117, 119, 124, 239-241 Two of these studies compared two or 

more intervention groups without a control that did not also receive a QI intervention and are 

presented with studies of that design (Table 21). As a group of interventions, these were 

relatively heterogeneous and not as likely as other types of QI interventions to report 

improvements in outcomes for patients: three studies reported improvements in clinical 

outcomes, three studies reported improvements in health services utilization, and three studies 

reported improvements in functional status. They were more likely to report improvements in 

terms of the number of asthma patients receiving inhaled controller medications. 

 

Asthma specialty clinics/care. Nine studies compared usual asthma care to asthma care 

augmented by providers with special training (i.e., nurses, 108, 117, 118, 225-227, 235 pharmacists,115, 241 

psychologists and physiotherapists).124 

The Pediatric Asthma Care PORT (Patient Outcomes Research Team), a RCT designed to 

assess the effectiveness of three strategies (physician-peer leaders (PLE), peer leaders in 

combination with asthma nurse visits (PACI), and usual care) to implement guidelines for 

childhood asthma found that, at the end of the two year follow up period, compared with the 

usual-care arm (N=199), patients randomized to the PLE arm (N=226) had annual increase of 6.5 

symptom-free days (SFD), whereas those randomized to the PACI arm (N=213) had an annual 

increase of 13.3 SFD over usual care patients.225, 226 The average number of physician visits 

during the two year trial was higher in the PACI arm as was regular use of inhaled controller 

medications (not found for PLE patients).226, 227 Total treatment and intervention costs per year 

per patient were $1,292 for PACI, $504 for PLE, and $385 for usual care. The incremental costeffectiveness compared to usual care was$18/SFD for PLE and $69/SFD for PACI.225

The RCT by Kelly and colleagues of low income children in Virginia who were randomized 

to receive comprehensive education and management by a physician allergist with monthly 

phone follow up by an outreach nurse found that children in the intervention group were less 

likely to visit an emergency department or require hospitalization than control children (95% 
139

versus 23%; p<0.001).119 The rate of smoking was high in both the intervention and control 

households (47% and 50%, respectively). Subgroup analysis suggested a trend toward greater 

effectiveness of the intervention to decrease hospitalizations among children residing in smokefree households.119

School-based directly-observed therapy programs. Two of the included studies evaluated the 

use of directly observed therapy for children with asthma. Long-term asthma control therapies 

work best when taken on a consistent basis, but compliance with this treatment is a known 

problem—schools provide an opportunity for directly-observed therapy among pediatric patients. 

Anderson and colleagues compared outcomes among asthma patients attending the Kunsberg 

school in Denver (designed specifically for children with chronic health conditions) to outcomes 

among a matched group of children with asthma attending regular schools.239 The Kunsberg 

school had a nurse administrator, two nurses, a social worker, and teachers familiar with methods 

for managing children with chronic medical conditions who provided a range of patient and 

parent asthma educational interventions, case management including communication with 

primary care providers, and daily directly observed medical therapy. At the Kunsberg school, 

nurses reported that 89% of children with asthma received their inhaled corticosteroids on a daily 

monitored basis.239 Compared with controls, children enrolled in the Kunsberg school had fewer 

hospitalizations, ED visits, and follow up visits for their asthma.239 A survey of school nurse and 

parents indicated that improved medication compliance resulted from directly-observed therapy 

and an overall increased structure of care resulted in better outcomes.239 Given the resources 

available to children in this type of school, it may be difficult to generalize their results to other 

school settings. 

Another study, a RCT by Halterman and colleagues specifically evaluated the role of 

directly-observed therapy.240 Their study population of children aged 3 to 7 years with asthma 

from urban and primarily minority and low-income demographic groups received their daily 

dose of inhaled corticosteroids from the school nurse. The control group continued to receive 

their inhalers at home. Overall, children in the intervention group had a reported 84% 

compliance rate with inhaled corticosteroids versus 63% among the control group. Children in 

the intervention group missed significantly fewer days of school and had more symptom-free 

days than did children in the control group. In a post-hoc analysis, it was found that all 

statistically significant improvements that were observed in the study were found in those 

patients not exposed to second-hand smoke. (Overall, 44% of children with asthma enrolled in 

the study lived in a home with at least one smoker.) 

Conclusions. From the few studies of this type, we conclude that augmenting usual asthma care 

with additional specialty asthma clinics staffed by asthma-trained nurses and pharmacists can be 

effective. Directly-observed therapy may increase the rate of inhaled corticosteroid use and 

improve clinical outcomes among school children with asthma, particularly those who are not 

exposed to second hand smoke. 
140 

Table 24. Organizational change interventions for children with asthma 

Reference Study Purpose Target population Study Design Type of intervention 

Anderson et al.239

To assess the health-related benefits of a daily program of a school-based disease management program. 

18 asthma patients attending the Kunsberg school in Denver (mostly of low socioeconomic groups) were compared to 36 control children with asthma from the Denver area attending different schools. 

CBA

*

 The Kunsberg school has a nurse 

administrator, two nurses, a social worker, and teachers familiar with methods for managing children with chronic medical conditions who provide a range of patient and parent asthma educational interventions, case management including communication with primary care providers, and daily directly observed medical therapy. 

At the Kundsberg school, children with asthma rececorticosteroids on a daily controls, children enrolled fewer hospitalizations (p=follow up visits for their asclinic costs for asthma caKunsberg children compachildren ($8,122/year vs. nurses and parents indicacompliance resulted from overall increased structuroutcomes.239

Bynum et al.51

To assess the effectiveness of pharmacists using interactive compressed video (telepharmacy) for teaching metered dose inhaler (MDI) technique to rural, adolescents with asthma. 

36 adolescents in grades 7-12 with asthma from junior high and high schools in rural Arkansas. Ncon=21, Nint=15. 

RCT All patients had two 15-minute individual 

sessions with a pharmacist. During the 1st

session, intervention subjects demonstrated their MDI technique to the pharmacist who provided via verbal instructions and demonstrations on improved MDI technique. The control subjects demonstrated MDI technique, were then given written instructions for MDI technique from a package insert for their placebo inhaler. The sessions took place at local health clinics equipped with interactive compressed video technology. 

At the 4 week follow up, tbetween the intervention technique. However, theimprovement in the intervcontrol group (p<0.001) i
141

Table 24. Organizational change interventions for children with asthma (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Finkelstein et al.,227, 235

Sullivan et al.,225 and 

Lozano et al.226

The Pediatric Asthma Care Patient Outcomes Research Team (I and II) compared 2 asthma care strategies in children with mild to moderate asthma with usual care in the primary care setting. 

42 primary care clinics in 4 health care organizations in Chicago, Seattle, and Boston that cared for 638 children aged 3-17 years with mild to moderate persistent asthma. 

RCT A peer leader-based physician behavior change 

intervention (PLE) and a practice-based redesign intervention (PACI) were compared with usual care. The PLE strategy involved training a pediatrician (in 2 workshops and through monthly contact from an educational coordinator and ongoing learning network for peer leaders) at each of the practices sites as an asthma expert and champion. The peer leader functioned as a change agent within the practice and provided support, education, and feedback to other members of the practice. The PACI strategy involved 4-5 scheduled asthma care visits with an asthma care nurse who provided standardized assessments, care planning, coordination with primary care physicians, and selfmanagement tools for the patients and their families. Between visits, the asthma nurse provided phone follow up. The PACI arm included all the components of the PLE arm. 

At 2 years, co(N=199), patie(N=226) had afree days (SFthe PACI arm of 13.3 SFD o

The average nthe 2 yr trial wusual-care arm(p=0.002) for other two armin terms of the visits. PACI pregular controcare subjects similar effect w

Total treatmenper patient wePLE, and $38cost-effectivenwas$18/SFD 

GonzálezMartin et al.115

To measure the effects of a pharmaceutical care program in children with asthma. 

13 children with stable and moderate asthma in Chile. 

RCT Children were assigned to either a pharmacist-led 

asthma program or to usual care by their pediatricians. The intervention pharmacists provided both written and verbal instructions to children and parents, information about asthma triggers, treatment 

alternatives, inhaler techniques, medication side effects, and what to do in the event of an acute attack. 

9 weeks after differences in health-related 
142

Table 24. Organizational change interventions for children with asthma (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Halterman et al 240

To determine whether a systematic, schoolbased asthma screening, coupled with primary care provider notification of asthma severity, would prompt providers to take preventative medication action. 

180 children aged 3 to 7 years with mild persistent or more severe asthma and who were from urban and primarily minority and low-income demographic groups in Rochester, New York. 

RCT The intervention cohort received their daily dose of 

inhaled corticosteroids from the school nurse. The control group continued, as usual, to receive their inhaled corticosteroids at home. Children were followed for a mean of 2.9 years (range 1-6). 

Children in the reported 84% corticosteroids group. Childrmissed signifivs. 8.8 days, psymptom-free months (p=0.0group. No othdifferences in care utilization in both groups time. In additdirectly observimprovement than that amochildren. In a that all significthose patients smoke. 240

Kamps et al.117, 118

To establish whether there are differences between outpatient management of childhood asthma by pediatricians or by asthma nurses. 

74 children aged 2-16 with chronic persistent asthma in the Netherlands. 

RCT Children were randomly assigned to receive 1 year of 

asthma care by either a pediatrician or a specialist asthma nurse. The asthma nurse provided detailed education about the mechanisms of disease, use of medications, management of acute symptoms, and proper inhaler techniques. 

At 1 year, thechildren receivpediatrician thterms of symphyperresponsdisease-specidifferences beinhaled or oraantibiotics, unvisits, hospitacosts.118
143

Table 24. Organizational change interventions for children with asthma (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Kelly et al.119 To examine the 

effects of a comprehensive education and outreach program designed to decrease emergency department utilization and hospitalization for Medicaid-insured children with asthma. 

78 children with asthma aged 2-16 years enrolled in Medicaid and receiving their care in Norfolk, Virginia. 

RCT Intervention children (and their caretakers) were 

enrolled in an education and treatment program in a pediatric allergy clinic. They received 1-on-1 education by a physician and asthma outreach nurse on topics including recognition of triggers, environmental control, early warning signs and symptoms, medication usage and side effects, proper usage of inhalers and PF meters. The nurse contacted intervention families on a monthly basis to review the patient’s health status, symptoms, medications, refill prescriptions, and assist with scheduling and transportation to clinic follow up. 

At the end of tintervention gED visit and minfluenza vacc47% of the intcontrol group the home. Sutrend toward gintervention to among childrehouseholds.11

MangioneSmith et al.242

To examine whether a collaborative to improve pediatric asthma care positively influenced processes and outcomes of care. 

Children aged 2-17 receiving care in 13 primary care clinics (9 experimental and 3 control) across the participating in a collaborative to improve the care of children with asthma. 

CBA Each participating clinic sent a team of 3 to 5 health 

care providers for three 2-day sessions to learn “proven strategies for improving care and refine plans for incorporating such strategies within their organizations.” 

385 children rclinics and 12control clinicsthe interventiochildren were measurementwritten action asthma follow (p=0.004), receducation (p<inhaler use (pscores (p=0.0between groucontroller medschool absentdays.242
144

Table 24. Organizational change interventions for children with asthma (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Salisbury et al.108 To compare a nurse-led clinic in 

schools with general practice care for adolescents with asthma. 

382 adolescents with asthma attending secondary schools in Bristol, North Somerset, and South Gloucestershire, U.K. 

RCT Adolescents were randomized to receive either usual 

care with a pediatrician or to attend a nurse-run asthma clinic. The care in these school-based clinics was “similar to that offered at a nurse-led asthma clinic in general practice, but the discussion was specifically targeted at the needs and interests of 

adolescents.” 108

At 6 months, ibetter inhaler have a PF meThere was no groups in termfrom school, uservices utilizacosts of six mintervention athe control pa

Stergachis et al.241

575

To assess the effects of a pharmaceutical care program on changes in disease control, functional status, and health services utilization for pediatric and adolescent patients. 

330 children aged 6-17 years with moderate to severe asthma (Nint=153; 

Ncon=177) in Seattle. 

RCT Pharmacists received an 8-hour training session on 

management assessment, drug delivery technique and general principles of pediatric asthma care. Specific topics included instructions on how to establish relationship with patients, collect data, assess drug related problems, and implement and plan follow up. 

At 12 months, groups in PF, 

technique, dainhaled corticoutilization. 241

Weingarten et al.124

To evaluate the effects of multidisciplinary nonpharmaceutical management of childhood asthma. 

21 children with asthma receiving medical care in a general practice in Israel. 

RCT Children were examined by a family physician and a 

physiotherapist and received information about asthma and its treatment, they also received 12 onehour group sessions with a physiotherapist who discussed chest expansion exercises for improved lung capacity and clearance of secretions. Mothers had 10 two-hour group meetings with social workers to develop coping mechanisms for acute attacks. 

At the end of intervention ggroup.124

Note: *CBA=controlled before-after trials; ED=emergency department; PF=peak flow; QOL=quality of life
145 

Organizational Change Interventions for Adults With Asthma 

Background. Most of the QI strategies that involve organizational change are designed to create 

new opportunities for patients to receive comprehensive education and monitoring of 

symptoms—often by creating asthma specialty clinics in the general practice setting or by 

creating asthma-specific clinics in other settings (e.g., pharmacies, specialists’ offices). For 

example, recognizing that most patients receive their asthma care in primary care settings, the 

development of asthma clinics within the general practices of the United Kingdom has been 

encouraged (a 1993 national survey found that 77% of general practices in the U.K. ran asthma 

clinics).243 

Results. We found 14 studies of organizational change strategies for general populations of 

adults with asthma (Table 25). Three of these studies compared two or more intervention groups 

without a control that did not also receive a QI intervention and are presented with studies of that 

design (Table 21). 

In contrast to the organizational change interventions for children with asthma, the studies of 

organization change interventions for general populations or adults with asthma reported 

considerably more improvements in clinical outcomes. We cannot clearly identify the 

distinguishing characteristics between the organizational change interventions for pediatric 

versus adult populations; however, the organizational change studies in this section were more 

likely to augment providers’ roles (e.g., adding a teaching role to pharmacists already providing 

routine pharmacy care for patients) or augment the types of providers encountered while 

receiving “usual care” (e.g., by adding multidisciplinary teams to routine clinical practice). This 

is in contrast to the addition of specialty care clinics where patients receive care that is distinctly 

separate from their routine health care encounters (these specialty clinics were more common for 

children). 

For example, none of the three articles that described nurse-run asthma clinics within general 

care practices found statistically significant improvements in processes or outcomes of care for 

asthma patients.155, 158, 244 However, several of the other organizational change interventions did 

result in improvements in the processes and outcomes of care for patients with asthma. For 

example, the ambitious intervention described by Cordina and colleagues provided training for 

pharmacists in Malta to assume a greater role in patient education, monitoring of asthma status 

(including monthly review of patients’ medication use, peak flow records, and symptoms), and to 

recommend treatment changes to patients’ physicians (as needed).159 This represented “a major 

change in conventional practice for Maltese pharmacists” and resulted in a lower rate of selfreported hospitalizations (no patients in the intervention group versus eight patients in the control 

group) and nighttime wheezing (20% versus 36%). 

Two interventions associated with improvements in clinical outcomes for patients utilized 

computer tools to facilitate asthma management.180, 190 One such intervention, described by 

Johnson and colleagues,180 was a comprehensive asthma disease management program in which 

subjects received asthma education and providers and case managers received computer 

generated communications regarding whether the patient had an action plan, received influenza 

vaccinations, had rescue inhalers, and reported on patients’ use of daily controller medications. 

This study reported that 12 months after the intervention, the intervention group (196 patients) 

had fewer emergency department visits (118 versus 305, p<0.0001) and hospitalizations (39 
146

versus 114, p<0.0001) than the control group (196 subjects) albeit no differences in use of 

asthma medications or preventative vaccinations.180

Three of the studies of organizational change interventions reported smoking rates for 

participants—in general, these rates were relatively high and recalcitrant to change. For 

example, in the 1994 study of the implementation of the Scottish health board’s asthma 

education and treatment protocol in general practices, 20-25% of asthma patients studied 

reported smoking at baseline and there was no statistically significant reduction in smoking as a 

result of the program.243 Similarly, the intervention reported by Garrett and colleagues of 

patients (principally from lower socioeconomic groups) receiving care in a South Auckland 

asthma community education center found even higher baseline smoking rates (33%-34%), 

which did not change after nine months enrollment in the education center.152, 153 

Conclusions. Interventions that augment the “routine care” being provided to patients both in 

their physicians’ offices and in pharmacies were associated with improved outcomes for patients. 

For example, technologies that enhance communication of patient information to providers can 

result in statistically significant improvements in outcomes of care for patients.
147 

Table 25. Organizational change interventions for adults with asthma 

Reference Study Purpose Target population Study Design Type of intervention R

Barbanel et al.137

To evaluate whether a community pharmacist with basic asthma training could improve asthma control by providing selfmanagement advice. 

23 adults aged 18-65 years with asthma living in inner city East London. Nint=12, 

Ncon=11. 

RCT Intervention patients received a 45-60 minute 

individual session from the pharmacist on asthma pathophysiology, recognition and avoidance of triggers, inhaler technique, self-management skills including symptom and PF monitoring, actions in response to worsening symptoms, accessing emergency care, and smoking cessation, if relevant. They received written self-management plans and weekly phone calls for the next 3 months to review plans and answer questions. 

3 months after the interventincreased in the control grointervention group (p<0.001

Cordina et al.159

To examine the effects of a community pharmacy-based education and monitoring program for patients with asthma on a range of patientspecific asthma management outcomes. 

152 patients over the age of 14 who received their asthma prescriptions at private pharmacies in Malta. 

CBA

*

 A comprehensive asthma education and monitoring 

program was instituted in private pharmacies in Malta for 12 months. The intervention pharmacists reviewed patients asthma symptoms, PF records, medication use, and when necessary suggested changes in treatment to the patient’s physician. 

There was no significant difcontrol groups in terms of Pinhaler use, days lost from QOL. There were fewer seasthma among intervention control patients (8/66) (p<0health services utilization. 

less likely to report nighttimimprove their inhaler techni
148

Table 25. Organizational change interventions for adults with asthma (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Garrett et al.152, 153

To determine the efficacy of establishing a community asthma education center. 

747 patients aged 2-55 years who had received asthma care in the ED in South Auckland. 

CBA 2 nurse specialists and a group of respiratory physicians 

established a community education center run by a nurse and 3 community health workers. The purpose of the education program provided was to educate patients in basic pathophysiology, define and teach trigger avoidance, medications use, inhaler technique and selfmanagement skills (emphasis on PF recordings and symptom diaries), and teach how best to access medical care in response to worsening symptoms. 

At nine months, the intlikely to have preventivand better PF meter temanagement plans, beaction to take when coasthma, less nocturnal reported asthma controThere was no differencstudy patients in medicadmissions, days lost fQOL, or smoking rates 34% for the interventio

Heard et al.155

To test whether asthma clinics (intervention) were more effective in reducing morbidity from asthma than standard medical treatment (control). 

195 asthma patients aged 5-64 years in Australia. 

RCT Each participating practice operated one 3-hour asthma 

clinic (run by trained nurses) once a week, which were. Clinic sessions involved education in asthma management strategies, written asthma management plans, spirometry and PF instruction, and an asthma diary card. Sessions ended with a consultation with the general practitioner. Patients were asked to attend 3 sessions within the 6 month study interval. 

At the end of the studygroup were more likely smokers than those in Intervention patients wweekly at night due to There were no differenwork or school, having medications, or health intervention and controrates of 9% in the contintervention group did 

Johnson et al.180

To evaluate the effectiveness of a comprehensive asthma disease management program. 

Patients with asthma covered by Anthem Blue Cross and Blue Shield insurance in the U.S. Nint=196, 

Ncon=196. 

CBA The intervention lasted 12 months. Intervention subjects 

received teaching that emphasized self-management behaviors such as avoidance of triggers, correct medication use, recognizing symptoms, seeking medical advice, smoking cessation, and adherence to treatment plans. The program is supported by computer generated communications to providers and case managers regarding whether the patient has an action plan, received flu vaccination, has a rescue inhaler, and use of daily controller medications. 

12 months after the intgroup had fewer ED viand hospitalizations (3were no differences in preventative vaccinatio
149

Table 25. Organizational change interventions for adults with asthma (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Jones and Mullee244 To compare the outcome of 

asthma care in two similar practices when on practice provided proactive, nurserun care for asthma and the other continued with a traditional (reactive) approach to the disease. 

141 asthma patients aged 5-65 years receiving care in two general practices in the Southampton area of the U.K. 

CBA The intervention practice established a nurse-led asthma 

clinic in which specialist nurses identified patients with asthma, developed a therapeutic plan for these patients, and developed a “call” system to contact patients with asthma for assessment and follow up. 

There were no significaintervention and controsymptoms, health servuse.244

Pilotto et al.158

To assess the ability of nurserun asthma clinics based in general practice compared with usual medical care to produce at least a moderate improvement in the QOL in adults with asthma. 

153 patients with asthma over the age of 18 from general practices in Australia. Ncon=82 , 

Nint=71. 

RCT Two respiratory nurses conducted asthma clinics where 

baseline data was collected, a review of and instruction about inhaler technique was provided, and a packet of information was distributed to each patient. Follow up visits were scheduled at 2 weeks, 3, 6, and 9 months to review inhaler technique and answer questions. Control patients received usual care by their general practitioner. 

After 9 months, no signthe intervention and coFEV1, ED visits, clinic v

However, significantly group compared to the days of work (p=0.004

Rasmussen et al. 190

To assess the outcomes associated with an Internetbased asthma management tool. 

253 adults with asthma aged 18-45 years living in Denmark. Ncont-GP=80, 

Ncont-sp=88, Nint=85. 

RCT There were three groups: an internet management 

group, a group receiving treatment from an asthma specialist, and a group receiving care from a general practitioner (GP). The Internet-based management tool was comprised of an electronic asthma diary, an action plan for patients, and a decision support system for physicians. Patients were given PF meters, and the Internet tool’s action plan comprised a 3-color warning system with a written treatment plan. Patients were encouraged to fill out the diary daily and follow instructions given by the computer or physician. Physicians used the decision support system to follow up with patients on therapeutic changes. 

After 6 months, the Intefewer asthma symptomspecialists; p<0.001 co(p=0.03 compared to sto GPs), and better FE

specialists, p<0.001 coInternet group had signunscheduled visits comgroups (p=0.05). No sthe groups were found or medication complian
150

Table 25. Organizational change interventions for adults with asthma (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Swanson et al.243

To evaluate the effects of a health board program on asthma care in general practice in terms of patients’ service and use of selfmanagement. 

400 patients aged 2-50 years with asthma receiving care in registered general practices in the U.K. between 1992 and 1994. 

CBA The Scottish health board developed an asthma 

program which included protocols for asthma treatment, assessment and follow up record cards for use in 

asthma clinics, and PF diaries. 

Chart reviews of patienadhering to the health those of patients receivpractices. There was nbetween patients in terpractitioner visits or howork or school, nighttimsmoking rates (20% fofor the control group); intervention group werclinic visits than controand more likely to have management plans.243

Verver et al.125

To evaluate whether inhaler technique and respiratory symptoms of patients with asthma can be improved after instruction by a practice assistant. 

6 physicians assistants were trained in the appropriate use of powder inhalers and provided patient education to 48 Dutch asthma patients aged 15-85 years. 

RCT Patients received two training sessions (2 weeks apart) 

on the correct technique for use of dry powder inhalers (and the correct order in which to use multiple inhalers). 

At baseline only 6% of powder inhalers correcmade with the “breathe the “hold your breath foinstructions. There wanumber of inhaler erropatients in the instructithe number of inhaler uwas no difference in rebetween the two group

Weng194 To evaluate the 

effects of a government sponsored QI intervention with patient and provider education and case management services for patients with asthma. 

1,067 patients with asthma enrolled in the program sponsored by the Taiwanese government. 4,340 patients with asthma who did not enroll in the program served as matched controls. 

CBA Providers received a 6-hour asthma curriculum that 

included conducting pulmonary function testing, use of medications and PF monitoring, environmental controls, and asthma pathophysiology. They were given copies of asthma clinical practice guidelines. Patients received individualized, personally tailored asthma education on recognizing triggers and symptoms, medication use, PF use, and self-management of exacerbations. Case managers (nurses or physician assistants) provided communication between patients, primary care physicians and specialists, and scheduled quarterly follow up. 

1 year after enrollmentlonger hospital stays (bdifference from control visits or number of hosamong patients newly the study interval, there (by 61%) in the intervecontrols.194

Note: *CBA=controlled before-after trials; ED=emergency department; PF=peak flow; QOL=quality of life. 
151 

Audit and Feedback Interventions 

 

Background. Updated guidelines for asthma treatment are made widely available, but their 

implementation may nonetheless be delayed. Audit and feedback interventions are generally 

designed to help providers improve their patient care by adopting current practice 

recommendations. 

Results. We found five studies describing audit and feedback interventions (Table 26).229-232 

All of these studies evaluated interventions that were combinations of provider education with a 

component of provider feedback and all reported at least some minimal improvements in 

outcomes for patients. Three of these articles were from European countries instituting the same 

intervention—group educational sessions for providers during which providers first reviewed 

theoretical cases of patients with asthma and then discussed clinical decision-making for asthma 

care as well as their own individual prescribing practices.229-231 During these group sessions, 

providers were confronted with feedback about their actual treatment choices. These 

interventions were designed based on the premise that behavioral change requires both buy-in on 

the part of providers and a psychological change. Two of the interventions with this group 

session design found statistically significant improvements in prescribing practice. 

Conclusions. We found no studies that evaluated audit and feedback strategies for clinicians in 

isolation. Two of the four interventions that combined audit and feedback with provider 

education were associated with improvements in provider prescribing practice. These types of 

interventions may be promising but there is currently scant evidence about their efficacy. 
152 

Table 26. Audit and feedback interventions 

Reference Study Purpose Target population Study Design Type of intervention 

Johnson et al.180

To evaluate the effectiveness of a comprehensive asthma disease management program. 

Patients with asthma covered by Anthem Blue Cross and Blue Shield insurance in the U.S. Nint=196, Ncon=196. 

CBA

*

 The intervention lasted 12 months. Intervention subjects 

received teaching that emphasized self-management behaviors such as avoidance of triggers, correct medication use, recognizing symptoms, seeking medical advice, smoking cessation, and adherence to treatment plans. The program is supported by computer generated communications to providers and case managers regarding whether the patient has an action plan, received flu vaccination, has a rescue inhaler, and use of daily controller medications. 

12 months after the ingroup had fewer ED vand hospitalizations (were no differences in preventative vaccinat

Lagerløv et al.230

To evaluate the effects of a newly developed form of group education for improving the quality of prescribing in primary health care. 

190 GPs responsible for the care of asthma patients in Norway. 

CBA Like the control group, the intervention group participated 

in 2 group meetings—during one they discussed asthma diagnosis, and the key information for making treatment decisions. At the second meeting international and national guidelines for treating asthma were presented. The group then agreed on common quality criteria for what they found to be acceptable and unacceptable prescribing practices. Feedback on their prescription behaviors was given relative to the agreed upon quality criteria. 

There was an increastreated by interventioacceptable medicatio

Lundborg et al.231 To develop, implement, and 

evaluate a new educational model, with messages based on available national guidelines aimed at improving prescribing in primary care. 

204 GPs responsible for the care of asthma patients in Sweden. 

CBA GPs were asked to attend 2 group sessions. During the 

1st session, individual feedback on written simulated cases was given and discussed. During the 2nd session, feedback on individual prescribing was presented and discussed. GPs were expected to: start/increase inhaled corticosteroids when bronchodilator use is too high; treat asthma exacerbations with anti-inflammatory treatment and not routinely with antibiotics; and 3) not start longacting β2-agonists when the patient is on a sub-optimal 

level of inhaled corticosteroids. 

Both the intervention increases in the presccorticosteroids.231
153

Table 26. Audit and feedback interventions (continued) 

Reference Study Purpose Target population Study Design Type of intervention 

Rossiter et al.232

To determine the potential of a disease management program in terms of improving the health of lowincome Medicaid patients while achieving cost savings in providing treatment. 

Virginia Medicaid population with moderate to severe asthma (a designation based on assessment of claims) who received care in a primary-care case management program (feefor-service and HMO-based practices were excluded). 

See note Providers in primary-case-management programs with 

asthma patients were identified, and those who volunteered received an education workshop to improve communication skills and to inform them about current asthma treatment recommendations. Additionally, most participants also received intermittent feedback regarding who among their patients might benefit from further asthma education and treatment. 

The intervention groupractices for β-agoniscorticosteroids. The pon emergency visits, intervention. This benMedicaid claimants wfeedback in addition tThe projected direct c$3-4 for every increm

Veninga et al.229

To evaluate the effects of a newly developed form of group education for improving the quality of prescribing in primary care. 

181 general practitioners (GPs) responsible for the care of asthma patients in the Netherlands. 

CBA Intervention providers received group education on 

asthma prescribing and performed a self-learning audit program for peer groups. During 2 meetings, groups met with a moderator with individual feedback material for all members of the groups; anonymity was not maintained by mutual agreement; use of case vignettes which the GPs had received by mail prior to the meetings; individualized feedback on prescribing provided at second meeting. 

Increased use of inhathe intervention group

Note: The intervention group for this study was selected from providers in specified geographic areas. Medicaid claims were compared between the intervenintervention areas. Comparisons were made over time (ITS-like, with only two “before” measures but with explanation that analysis of a longer pre-interventchange in variables) and between groups. Note: *CBA=controlled before-after trials; ED=emergency department; PF=peak flow. 
154 

Facilitated Relay of Clinical Data 

Background. Most studies of facilitated relay of clinical data to providers involve inserting 

letters or reports of patient information collected from the patients, their medical records, or 

insurance records into the charts of patients for providers to review. 

Results. Our search identified five interventions that utilized the facilitated relay of clinical data 

for the improvement of care for patients with asthma: three that targeted providers for children 

and two for providers for adults. Two studies compared two or more intervention groups without 

a control that did not also receive a QI intervention (Table 21).57, 206

In one intervention, facilitators reviewed the charts of children with asthma being cared for in 

general practice in Scotland.245, 246 Children in the intervention group (n=1585) had their charts 

reviewed by a facilitator who placed a project sticker on the outside of the chart and, inside, 

created a separate section devoted to asthma care including a protocol for managing acute asthma 

attacks and a letter to their providers suggesting that they review the patient and asthma 

treatment guidelines. Control group children (n=1563) received usual care. One year after the 

intervention, the intervention group was more likely to have appointments for asthma care (568 

versus 242 appointments), new diagnoses of asthma (249 versus 104 patients, and receive 

prescriptions for inhaled cromoglycate (128 versus 78 patients). Hospitalizations and hospital 

care costs decreased in the intervention group and rose in the control group (25 versus 28 

admissions; total costs 20,727£ versus 19,650£).245 Outpatient primary care costs rose in the 

intervention group and fell in the control group (total costs 37,243£ versus 27,990).245 However, 

at four years after the intervention, the processes and outcomes of care were similar in 

intervention and control groups. The overall reduction in costs seen in the intervention group 

was equivalent to the cost of the facilitator.246

In the study by Halterman and colleagues,247 parents of children aged 3 to 7 years entering 

school completed a screening form that inquired about chronic diseases including asthma. 

Parents of children with asthma identified through this screening were interviewed about asthma 

symptoms, emergency visits, and asthma hospitalizations. Children were then randomized to 

either the control group (N=77) which received usual care or the provider notification group 

(N=74) for whom the information obtained from the parental interview was sent via fax to the 

primary care providers with a copy of the 2002 NHLBI asthma management guidelines. Three 

to six months after the intervention, there was no difference in terms of new medications 

prescribed, changes in medication doses, discussion about environmental controls, referral to 

asthma or allergy specialists, or requests for asthma follow up appointments between the groups. 

247

In the study by Coleman and colleagues, drug utilization information collected from 135 

adult Connecticut Medicaid patients using high doses of inhaled β2-agonists was compared to 

510 adult patients using normal doses of inhaled β2-agonists.248 Letters were sent to providers 

and pharmacies of the high dose group explaining the rationale for the drug utilization review 

and the specific problem identified for the specific patient (e.g., high dose inhaled β2-agonists 

use or under-utilization of long-term control agents).248 Seven months after the letters were sent, 

there were no statistically significant differences between control and intervention groups in 

terms of use of inhaled medications or health services utilization. 
155

Conclusions. Two of the five studies of facilitated relay of clinical information reported 

improvements in clinical outcomes. There are too few studies of facilitated relay of clinical 

information for asthma to determine the overall effectiveness of these interventions for 

improving the processes and outcomes of care for asthma. 

Provider Reminder Interventions 

Background. Treatment guidelines for asthma have been widely available, yet not widely 

implemented. Provider reminder systems for asthma care are designed to use information from 

clinical practice guidelines applied to patient-specific information to provide reminders to 

providers at the point of care. 

Results. We found four articles describing provider reminders.114, 249-251 They described highly 

heterogeneous interventions (e.g., paper-based versus computer-based, some readily adopted by 

providers versus others that providers found more cumbersome to include in routine clinical 

practice). 

The study by White and colleagues, which evaluated a paper-based reminder implemented 

over two years in 23 general practices in England, found no improvement in patient reported 

symptoms, use of health services, or prescribing.**251 Similarly, the evaluation of an 

implementation of a computerized clinical decision support system for the management of 

asthma in 62 general practices in England by Eccles and colleagues found that the system had no 

statistically significant effect on health services utilization, prescribing practices, or patientreported asthma outcomes 12 months after implementation.††249 

In contrast, the evaluation of a computerized clinical decision support system for asthma care 

in 17 general practices in England by McCowan and colleagues found that although fewer 

patients in the intervention group sought primary care for their asthma at six months after 

implementation (22% versus 34%; OR 0.59 [95% CI 0.37-0.95]), there was no statistically 

significant change in the use of peak flow meters, self management plans, self-reported 

symptoms, prescribing of maintenance medications, or hospitalizations.250 Interestingly, 

McCowan and colleagues found a lower rate of asthma exacerbations in the intervention group 

than in the control group (8% versus 17%; OR 0.43 [95% CI 0.21-0.85]) but no difference in use 

of oral steroids to manage these attacks.250 (For details of the study by Glasgow and 

colleagues114 which implemented a provider education intervention that reminded providers to 

schedule a follow up appointment for patients—see the provider education section). 

Conclusions. The results of the studies of provider reminders to improve the care of patients 

with asthma are mixed. The small number of studies of reminder interventions limits our ability 

to determine their overall effectiveness for improving the processes and outcomes of care for 

asthma. 

 

** White and colleagues provide copies of both their data collection forms and reminder notices in this article. 

†† The decision support system used in this study was based on currently available software to support prescribing 

decisions for acute conditions. More information about this software is available in Purves IN. PRODIGY: 

Implementing clinical guidance using computers. Br J Gen Pract 1998;48:1552-3. 
156

Financial Incentives 

Background. The annual health care costs attributed to asthma exceed $6 billion. If the 

provision of financial incentives could statistically significantly reduce costly emergency 

department visits or asthma hospitalizations, they could be highly cost-effective. 

Results. Financial incentives are typically intended to be used to change the behavior of 

providers. We found no interventions that utilized financial incentives directed at providers. 

However, we found two interventions that included financial incentives to change patient 

behavior. The first intervention, described by Burkhart and colleagues (Table 11), encouraged 

children with asthma to contract with their parents and caregivers to perform daily asthma selfmonitoring or self-management behaviors.71 For each completed self-monitoring or selfmanagement task, parents gave their children a sticker-star. 71 When five stars had been 

awarded, children received a pre-negotiated award including special activities (43%), a toy or 

game (24%), pizza or other fast food (19%), or a monetary reward (14%).71 They found no 

difference in adherence with peak flow monitoring between the intervention and the usual-care 

(control group) children.71 

The second intervention, described by Baren and colleagues, recruited patients aged 16 to 46 

years who had recently visited the University of Pennsylvania emergency department for asthma 

exacerbation. The patients in the intervention group (N=95) were provided a free 5-day course 

of oral prednisone, two taxi-cab vouchers for transportation to and from their primary care 

provider (PCP), and a telephone reminder to make an appointment with their PCP. The patients 

in the control group (N=83) received a short course of oral steroid therapy and were given 

instructions and prescriptions at the discretion of the treating physician. The main outcome 

measure was whether patients successfully followed up with a PCP after their emergency 

department visit. Patients in the intervention group were more likely (46.3%) than patients in the 

control group (28.9%) to follow up with their PCP ([RR]1.6; 95% CI 1.1, 2.4).252 

Conclusions. There is insufficient evidence to assess the effectiveness of QI interventions 

utilizing financial incentives. 

Secondary Outcomes 

For a study to be included in this review, it had to report one or more of the primary 

outcomes of interest. From the included articles, we also abstracted data about three secondary 

outcomes of interest: cost, quality of life, and reduction in asthma triggers/allergens such as 

exposure to tobacco smoke (Appendix B*

). In the evidence tables presented throughout this 

report, we also present data from the included studies on these secondary outcomes. In this 

section, we summarize the results of the effects of QI interventions on these secondary outcomes. 

When interpreting these results, we note that our literature search was not designed to find all 

articles presenting results for these secondary outcomes. Thus, we are likely to be missing 

 

*

 Appendixes cited in this report are provided electronically at http://www.ahrq.gov/clinic/tp/asthmagaptp.htm 
157

articles describing the effects of QI interventions for asthma that were targeted at specifically 

improving these outcomes. 

Costs 

Background. In 1990, the direct medical costs attributed to asthma care in the U.S. were $3.6 

million.253 This included physician visits and medications; however, the greatest proportion 

(nearly $3 million) was attributed to emergency department visits and hospitalizations.253 Since 

only a small proportion of patients with asthma require emergency department and hospital care, 

it has been estimated that 5% of patients with asthma account for more than 70% of the costs.254 

(We direct interested readers elsewhere for reviews of the cost-effectiveness of programs 

directed at this “high cost” group of patients.255, 256) In general, given the large number of 

patients with asthma in the U.S., even minimally effective programs can be quite cost-effective 

(e.g., cost-effectiveness analyses of interventions in children with mild to moderate asthma have 

estimated that treatment with inhaled corticosteroids costs approximately $11/symptom-free day 

gained257 and that a community-based education program for inner-city children costs $9/ 

symptom-free day gained75). In this section, we summarize the cost data provided by the 

included articles. 

Results. Twenty-three studies reported cost data: 13 were QI interventions for children and ten 

were QI interventions for general populations or adults with asthma. Table 27 presents three 

types of cost data reported in the included articles: costs associated with the implementation of 

the interventions, asthma-related healthcare costs for study subjects, and other types of costs. 

Intervention costs. Nine studies described the costs associated with intervention implementation. 

Two of these found that there was no statistically significant difference between intervention and 

control program direct costs.172-176 The other seven studies uniformly found that intervention 

program costs were higher than control program costs. 

Asthma-related healthcare costs. Among the interventions for children with asthma, seven 

reported asthma-related healthcare cost data, five of which reported reduced costs among the 

intervention groups (Table 27). Among the interventions for general populations or adults with 

asthma, four presented asthma-related healthcare costs. Two of these reported cost savings 

among the intervention groups. The study by Bolton and colleagues of a patient education 

intervention found that, after 12 months, emergency department costs were statistically 

significantly less for the intervention group than for the control (p<0.02); however, physician and 

hospitalization costs did not statistically significantly differ between groups.147 The study by 

Rossiter and colleagues of a diseases management program for Virginia Medicaid recipients 

found that the projected direct cost savings of their audit and feedback/provider educational 

program was $3 to $4 for every incremental dollar spent on the intervention.232 Additionally, 

they estimated that the projected Medicaid savings of the program was $839 per physician 

trained.232 The other two studies found no difference in asthma-related healthcare costs between 

intervention and control subjects. 
158

Other costs. Twelve studies reported other types of cost data, including indirect costs associated 

with the intervention and analyses of incremental cost-effectiveness. These studies were 

heterogeneous with respect to cost accounting methods utilized and cost data reported. 

Conclusions. In general, we conclude that the implementation of QI interventions for asthma 

cost more than usual care. The extent to which savings may be reaped from these interventions 

has not been consistently documented. A critical gap in this literature that prevents an 

understanding of the cost-effectiveness of QI programs is that there is not a common 

effectiveness variable such as symptom-free days gained or episode-free days gained. Also, 

since many studies only include the costs and benefits accrued during the first year after an 

intervention, it is difficult to estimate the long-term cost-effectiveness of these programs. 
159 

Table 27. Summary of studies presenting cost data 

Reference Table Intervention Cost Data Asthma-related Healthcare Cost Data 

Interventions for children with asthma 

Anderson et al.239 Table 24 No data. Hospital and clinic costs for asthma care decreased by 80% in the Kunsberg school 

(intervention) children compared to a 19% decrease in control children ($8,122/year vs. $1,588/year). 239

No data. 

Clark et al.96, 97 Table 12a No data. No data. The cost of delive

healthcare saving$0.62 were saved$11.22 for every more pre-interven

Finkelstein et al.,227, 235

Sullivan et al.,225 and Lozano et al.226

Table 22 Table 24 

No data. No data. Total treatment a

patient were $1,2$504 for less inteusual care. The compared to usuaday gained for lesfree day gained fointerventions.225

Greineder et al.197 Table 21 No data. At the end of the 2 year study period, both groups experienced reductions health care 

costs. The more intensive treatment group improved significantly more than the less intensive treatment group with 71% fewer outof-plan costs (p<0.001).197

No data. 

Kamps et al.117, 118 Table 12d Table 24 No data. At 1 year, there was no difference between the groups in terms of overall healthcare 

costs.118

No data. 

LaRoche et al.78

Table 11 Table 12a 

The intervention program cost approximately $2,295 (for 11 patients).78 The savings from reduced ED visits was $4,675 (for 11 patients).78 No data. 

Lewis et al.62 Table 21 The costs of the program were estimated at 

$125/intervention recipient and $37.50 per control recipient.62

No data. Given the lower h

group, the authorsavings per child 
160

Table 27. Summary of studies presenting cost data (continued) 

Reference Table Intervention Cost Data Asthma-related Healthcare Cost Data 

McCowan et al.245, 246

See text describing Facilitated Relay Interventions 

No data. 1 year after the intervention, hospital care 

costs decreased in the intervention group and rose in the control group.245 Outpatient primary care costs rose in the intervention group and fell in the control group.245

The reduction in cgroup was equivafacilitator.246

McNabb et al.80 Table 11 No data. No data. At 12 months, the

$507 per child saED visits. 80

Morgan et al.,73

Evans et al.,74, 

and Sullivan et al.75

Table 11 Table 12a 

The cost of the intervention was $337 per child for 2 years.75 No data. The program resu

cost-effectivenesday gained (95% symptom free day 

Runge et al52 Table 11 

Table 12d 

It cost 585€ to deliver the intervention.52 The intervention reduced asthma costs by 

461€.52 Adjusting for ben

were saved for evduring the 1st yea

Salisbury et al.108

Table 12b Table 12c Table 24 

No data. No data. At 6 months, the 

care for the intethan for the con

Yoos et al.65 Table 21 No data. The average reduction in health care charges 

due to reduced healthcare utilization was $82 per child for control children, $162 per child for children asked to monitor their PF when symptoms increased, and $61 per child for the daily PF monitoring children.65

No data. 

Interventions for general populations or adults with asthma 

Bailey et al.166; 

Windsor et al.167

Table 18c The intervention program cost $32.03 per 

patient versus the control program, which cost $3.61 per patient.167

No data. No data. 

Bolton et al.147 Table 18a No data. After 12 months, ED costs were significantly 

less (p<0.02) for the intervention. However, physician and hospitalization costs did not significantly differ between groups.147

Total costs did nogroups.147
161

Table 27. Summary of studies presenting cost data (continued) 

Reference Table Intervention Cost Data Asthma-related Healthcare Cost Data 

Drummond et al.,210 211

Osman et al.,212

and Buckingham et al.213

Table 21 No data. No data. Total cost of integ

estimated to be ££62.12/patient/ye

Gallefoss et al.172-175

Table 18c At 1 year, there was no significant 

difference found between the groups in direct costs associated with the program.174

No data. At 1 year, there w

found between thtotal costs associ

Ghosh et al.176 Table 18c At 12 months, there was no significant 

difference in direct costs found between the two groups. 176

No data. At 12 months, the

(p=0.003) and totwith the intervent

Kauppinen et al. 215-217 Table 21 No data. There was no significant difference between the groups at 5 years for total costs attributed 

to asthma care.217

No data. 

Knoell et al.163 Table 18b No data. No differences in drug costs.163 No data. Lahdensuo et al.181, 182

Table 18c The total direct costs were 649 Finnish 

Marks less in the control group than in the experimental group (p=0.05).182 (At the 

time of publication: 8.84 Finnish Marks=1£.) 

No data. No data. 

Ostojic et al.206 Table 21 The additional cost of the intervention per 

patient, per week was 1.67€ ($1.3 per 1 Euro).206

No data. No data. 

Rossiter et al.232

Table 23 Table 26 

No data. The projected direct cost savings of the 

program is $3-4 for every incremental dollar spent. The projected Medicaid savings of the program was $839 per physician trained.232

No data. 
162 

Quality of Life 

Background. Poorly controlled asthma can result in symptoms that limit a person’s ability to 

participate in the routine activities of daily life. Thus, health-related quality of life (QOL) is an 

important metric for evaluating the effects of an asthma QI intervention. A retrospective 

analysis of 8994 patients from 27 RCTs of trials of various interventions for patients with 

persistent asthma that reported FEV1, Asthma Quality of Life Questionnaire (AQLQ) scores, and 

self-reported symptoms found that percent predicted FEV1 and symptom-free days were weakly 

correlated with AQLQ scores.258 Further, they found that changes in percent predicted FEV1

correlated weakly with changes in SFD but was more strongly correlated with changes in overall 

AQLQ scores (r=0.26 and 0.38, respectively; p<0.001).258 This study suggests that directly 

measuring changes in QOL may evaluate important aspects of patient’s asthma experiences not 

fully accounted for by objective measures such as lung function.258 

Results. Forty-five of the included studies reported QOL data. They utilized a variety of 

generic measures such as the SF-36 and disease-specific measures such as the Asthma Quality of 

Life Questionnaire and the St. George’s Respiratory Questionnaire, among others.

Thirteen of 31 (42%) of the interventions aimed at general populations or adult patients and 

only three of 12 (25%) of interventions aimed at children resulted statistically significant 

improvement in QOL compared to controls. Overall, the pediatric QI interventions reported 

little effect on parent or caregiver quality of life. 

As has been previously reported,258 we found an association between improvements in 

clinical status and improvements in QOL: Of the 27 studies that found no statistically significant 

difference between intervention and control groups, only seven reported any statistically 

significant clinical outcomes. However, of the 18 studies that reported a statistically significant 

improvement in quality of life, 15 reported at least one statistically significant clinical outcome. 

We calculated an unweighted correlation between studies reporting statistically significant 

improvements in QOL and clinical measures (r=0.4, p=0.019) and functional status measures 

(r=0.4, p=0.037). We found no associations between QOL and other study design, intervention 

design, or patient characteristics. 

Improving QOL for children with asthma. Fourteen studies of QI interventions for children with 

asthma reported QOL results—this includes the 12 described above plus two that were directed 

at caregivers of children with asthma (Table 28). Of these, only four found significantly better 

quality of life among the intervention group compared to the control group. Of the nine studies 

that found no statistically significant difference in any outcome, six were self-monitoring, selfmanagement, or patient education interventions whose principal educational modality was 

individualized, or “one-on-one”, educational sessions. 

Three of the four studies that reported parental/caregiver QOL outcomes showed no 

statistically significant difference between the groups.63, 95, 103 The study by Brown and 

colleagues of home-based asthma education program for low-income parents of children in preschool found a statistically significant difference between the parents or caregivers of children 

aged 1 to 3 years, but no statistically significant difference for parents or caregivers of children 

aged 4 to 6 years.90 All of the studies that reported parent or caregiver QOL outcomes were 

parent or caregiver education or self-monitoring or self-management interventions. 
163

Improving the QOL for general populations or adults with asthma. Thirty-one studies of QI 

strategies for general populations or adults with asthma reported QOL results (Table 29). Of 

these, 18 found no statistically significant difference in quality of life at follow up between the 

intervention and control groups. However, 13 studies did show statistically significantly higher 

quality of life outcomes in the intervention group compared to the control group at follow up. 

We found no intervention characteristics that were clearly associated with statistically significant 

improvements in patient quality of life. However, of the eight nurse-led interventions that 

reported quality of life outcomes, none reported statistically significant differences between the 

intervention and control groups. 

Conclusions. QI strategies can improve QOL for patients with asthma. This benefit is 

correlated with improvements clinical outcomes and functional status. Among the included 

studies, QOL was less likely to change for children or their parents or caregivers. The relatively 

small numbers of studies reporting QOL measures limits our ability to identify specific 

interventional characteristics most associated with improvements in QOL. 

Table 28. Summary of interventions assessing QOL for children with asthma and caregivers 

Reference Evidence 

Tables 

Duration of 

Follow up 

Caregiver 

QOL 

assessed

Type of intervention QOL Result 

Brown et 

al.90 Table 12a 12 months 

after 

intervention 

√ Home-based asthma 

education of low-income 

parents of children in preschool. 

Education group experiences better 

caregiver QOL among those children 

aged 1-3 but not those children aged 

4-6.90

Butz et 

al.95 Table 12a 10 months 

after 

enrollment 

√ Parent and child asthma 

education. 

No differences in caregiver or child 

QOL.95

Chan57

Table 21 6 months Child asthma education online 

vs. outpatient education. 

There were no differences between 

the groups at the end of for QOL.57 

Eggleston 

et al.98 Table 12a 12 months 

after 

intervention 

Home-based parent or 

caregiver asthma education of 

parents in the inner-city. 

There were no difference in QOL 

scores.98 

GonzálezMartin et 

al.115

Table 12d 

Table 24 

2 months 

after 

enrollment 

Organizational change and 

patient education provided by 

pharmacists. 

There were no differences in any 

domains of health-related QOL.115

Henry et 

al.105 Table 12b 

Table 12c 

6 months 

after 

intervention 

School-based patient 

education program for 

adolescents. 

Compared with control students, 

intervention students had small but 

significant improvements in total 

QOL (p=0.003).105

Kamps et 

al.117, 118

Table 12d 

Table 24 

12 months Organizational change and 

patient education intervention 

comparing care by a 

pediatrician or specialist 

asthma nurse. 

There was no difference between 

children receiving asthma care from 

a pediatrician than from a nurse 

specialist in terms of diseasespecific QOL.117 
164

Table 28. Summary of interventions assessing QOL for children with asthma and caregivers (continued) 

Reference Evidence 

Tables 

Duration of 

Follow up 

Caregiver 

QOL 

assessed

Type of intervention QOL Result 

Mangione

-Smith et 

al.242

Table 24 16 months 

after the 

intervention 

Organizational change 

strategy in which intervention 

clinics participated in a 

collaborative. 

Intervention children were more 

likely to have higher QOL scores 

(p=0.03).242

Runge et 

al.52 Table 11 

Table 12d 

6 months 

after 

enrollment 

Self-monitoring, selfmanagement, and patient 

education program. One arm 

evaluated the use of an 

internet-based education 

program. 

Significant improvements were seen 

in 3 of 8 QOL domains in both 

intervention groups but not in the 

CG.52

Salisbury 

et al.108 Table 12b 

Table 12c 

Table 24 

6 months School-based, nurse led 

education and asthma care 

clinics for adolescents. 

There was no significant difference 

between groups in terms of health 

related QOL. 108 

Shames 

et al.58 Table 12d 12 months Patient education program 

including the use of a video 

game. 

There were some improvements in 

health related QOL in the 

intervention group.58

Stevens 

et al. 103 Table 12a 12 months √ Parent or caregiver education 

for parents of children in preschool. 

There was no significant difference 

between the groups in 

parental/caregiver QOL.103

Walders 

et al.59 Table 21 12 months 

after 

enrollment 

Pediatric self-monitoring, selfmanagement, and education 

program. 

There was no difference between 

groups in terms of QOL (both groups 

improved over baseline).59 

Wensley 

and 

Silverman

63

Table 21 3 months √ PF-based vs. symptom-based 

self-management programs. 

There was no difference between 

groups in child or caregiver QOL.63
165

Table 29. Summary of Interventions assessing QOL for general populations or adults with asthma 

Reference Reference 

Table 

Duration of 

Follow up Type of Intervention Results 

Cambach et 

al.148 Table 18a 6 months 

after 

intervention 

Patient education, self-monitoring, or 

self-management training by a nurse. 

No difference in QOL between the 

groups.148

Cordina et 

al.159 Table 18b 

Table 23 

Table 25 

12 months Patient education, self-monitoring or 

self management training by 

pharmacists who received 

specialized education. 

No difference in QOL between the 

groups. 159

Côté et al.201-

203 Table 21 12 months Patient education, self-monitoring, or 

self-management training based on 

either symptoms or PF. 

QOL scores improved for all groups 

but were significantly more improved 

among action plan patients than 

controls.201, 202 

Couturaud et 

al.169 Table 18c 12 months Patient education, self-management 

training. 

No difference in QOL between the 

groups.169

de Oliveira et 

al.170

1474

Table 18c 6 months Patient education, self-management 

training by a physician. 

The intervention group had 

significantly higher QOL scores 

(p=0.0005).170

Delaronde et 

al.149 Table 18a 6 months 

after 

intervention 

Patient education, self-management 

by a nurse. 

No difference were in QOL between 

the groups.149

Gallefoss et 

al.172-175 Table 18c 12 months Patient education, self-management training by a physician, pharmacist, 

nurse, and physiotherapist. 

Intervention patients had better 

health related QOL (p<0.001) 

compared with control patients. 

(p<0.05).172 

Garrett et 

al.152, 153

Table 18a 

Table 25 

9 months A community health center was 

created where a patient education, 

self-management training program 

run by a nurse and community health 

workers. 

QOL was measured as “improvement 

of ability to do things [patients] liked.” 

No difference in QOL between the 

groups.152

Herborg et 

al.160 Table 18b 12 months 

after 

intervention 

Patient education, self-management 

training by a pharmacist. 

Intervention patients had more 

significantly improved health-related 

QOL than control patients 

(p<0.05).160

Janson et 

al.156 Table 18a 2 months Patient education, self-management 

training by a nurse. 

No difference between the groups in 

QOL.156

Jones et 

al.214 Table 21 6 months 

after 

intervention 

Patient education, self-management 

training or a doctor-managed 

regimen. 

No difference between the groups in 

QOL.214

Kauppinen et 

al. 215-217 Table 21 60 months Patient education or selfmanagement training of varying 

intensity. 

No difference between the groups in 

QOL.217 

Knoell et 

al.163 

1664

Table 18b 1.5 months Patient education, self-management 

training by a pharmacist. 

No difference between the groups in 

QOL.163
166

Table 29. Summary of Interventions assessing QOL for general populations or adults with asthma (continued) 

Reference Reference 

Table 

Duration of 

Follow up Type of Intervention Results 

Lahdensuo et 

al.181, 182

Table 18c 12 months Patient education, self-management 

training and physiotherapeutic 

counseling. 

QOL scores did show trends toward 

significance when fully adjusted for 

baseline scores.181 

Levy et al.157 Table 18a 6 months Patient education, self-management 

training by a nurse. 

No difference between the groups in 

QOL.157 

Magar et 

al.184 Table 18c 12 months Patient education, self-management 

training. 

The intervention group had higher 

QOL scores compared to the control 

group.184 

Marabini et 

al.183 Table 18c 3 months 

after 

intervention 

Patient education, self-management 

training by a physician. 

The intervention group had 

significantly higher overall QOL 

compared to the control group 

(p<0.05).183

McLean et 

al.205 Table 21 12 months Patient education, self-management 

training. 

QOL scores were significantly higher 

overall for the intervention group 

compared to control (p<0.05).205

Onyirimba et 

al.187 Table 18c 2.5 months Patient education, self-management 

training. 

No difference between the groups in 

QOL. 187

Perneger et 

al.188 Table 18c 6 months Patient education, self-management 

training by two respiratory physicians 

and a physiotherapist. 

No difference between the groups in 

overall QOL.188

Pilotto et 

al.158 Table 18a 

Table 25 

9 months Nurses created asthma clinic and 

provided patient education, selfmanagement training. 

No difference between the groups in 

QOL.158

Put et al.189 Table 18c 3 months 

after 

intervention 

Patient education, self-management 

training. 

QOL scores were significantly 

different between the intervention and 

control groups. The AQLQ scores 

were higher and Negative 

Emotionality Scale (NEM) were lower 

(p<0.0001 and p<0.01, 

respectively).189

Rasmussen 

et al.190 Table 18c 

Table 25 

6 months Patient education or selfmanagement training through an 

Internet-based decision support 

system that physicians also used to 

follow up with patients vs. care by a 

specialist or general practitioner. 

The Internet group had significantly 

higher QOL (p=0.03 compared to 

specialists, p=0.04 compared to 

GPs).190 

Schaffer and 

Tian192 Table 18c 6 months 

after 

intervention 

Patient education, self-management 

training. 

No difference between the groups in 

QOL.192

Schonlau et 

al.199 Table 21 12 months 

after 

intervention 

Provider education to promote 

changes in asthma care. 

No difference between the groups in 

QOL.199
167

Table 29. Summary of Interventions assessing QOL for general populations or adults with asthma (continued) 

Reference Reference 

Table 

Duration of 

Follow up Type of Intervention Results 

Schulz164 Table 18b 12 months 

after 

intervention 

Patient education, self-management 

training by a pharmacist. 

 

Patients in the intervention group had 

significantly higher overall QOL 

scores (p=0.02); however, there was 

no significant difference between the 

groups in SF-36 mental summary 

score.164

Smith et al.141 Table 18a 6 months 

after 

intervention 

Home-based patient education, selfmanagement training provided by a 

nurse. 

No difference between the groups in 

QOL. When adjusted for major 

baseline score differences, there was 

an improvement in asthma-specific 

QOL (p=0.03).141

Sundberg et 

al.193 

Table 18c 12 months Patient education, self-management 

training by a nurse with the aid of a 

computer program. 

No difference between the groups in 

QOL.193

Thomas et 

al.129 Table 21 6 months 

after 

intervention 

Patient education, self-management 

training by nurses compared to 

breathing retraining by 

physiotherapists. 

There was a slight improvement in 

one domain of QOL in the breathing 

retraining group compared to the 

nurse educator group (p<0.05).129

Turner et 

al.130 Table 21 6 months Both groups received patient 

education by a nurse. Groups then 

received self-management plans 

based on either symptoms or PF. 

No difference between the groups in 

QOL.130

Yilmaz and 

Akkaya195 Table 18c 36 months Patient education, self-management 

training. 

QOL scores were significantly higher 

in the intervention group compared to 

the control group (p=0.009).195 

Reductions in Environmental Allergen Exposure 

Background. Identifying and reducing exposure to environmental allergens that can exacerbate 

asthma symptoms is a critical component of asthma prevention. There is a large literature of 

interventions specifically targeting allergen exposure which we did not review; however, among 

the included studies, we abstracted information regarding whether the intervention resulted in 

reductions in environmental allergens. 

Results. Five studies reported the effects of their interventions on environmental 

allergens.73-75,98 All were self-monitoring, self-management, or patient education interventions 

and two targeted children with asthma. These studies as a group are notable for their relatively 

large sample sizes (range: 65-937; median 129). 

The large National Cooperative Inner-City Asthma Study73-75 was a RCT of 1,023 families of 

children with asthma in eight major U.S. cities to evaluate whether a home-based intervention for 

inner-city children designed to teach caregivers to reduce environmental asthma triggers specific 

to that child (as determined through skin testing) would result in improvements in asthma-related 

outcomes. During the 12 month intervention, research assistants visited each home five to seven 
168

times. Each visit was followed by a phone call to address any barriers to implementing the plan. 

Caregivers were taught about the role of allergens in asthma, mattress covers were installed, 

families were given a vacuum cleaner with HEPA filter, and a HEPA air purifier was set up in 

the child’s bedroom. Professional pest control was provided. Two years after enrollment, 

intervention children had more symptom free days (565.1 vs 538.5 days), fewer asthma 

symptoms (p<0.001), days lost from school (0.54 versus 0.71 days per two weeks, p<0.009), and 

lower allergen levels than control children.73 There was no difference in spirometry or peak flow 

measurements or unscheduled visits to the emergency department, clinic or hospital between the 

two groups.73-75 The cost of the intervention was $337 per child for 2 years resulting in an 

estimate incremental cost-effectiveness ration of $9.20 per symptom-free day gained (95% CI: 

-$12.56 to $55.29 per symptom free day gained).75

The study by Eggleston and colleagues was a RCT of home-based environmental 

intervention for 100 children with asthma living in inner city Baltimore based on the National 

Cooperative Inner-City Asthma Study.98 As part of the intervention, families received 

comprehensive home-based evaluations of environmental triggers and were given air filters, 

pillow covers, and cockroach extermination as needed. Additionally, they received three home 

visits and a telephone follow up to review allergen reduction principals. One year later, the 

intervention children had fewer daytime asthma symptoms (p=0.02) but there were no difference 

in nighttime symptoms, exercise-related symptoms, exercise-limiting symptoms, acute visits for 

asthma, FEV1, or QOL scores.98 

The other three self-monitoring or self-management patient education interventions all 

reported environmental allergen reductions in the intervention groups.136, 156, 201-203

Conclusions. QI improvement strategies can reduce environmental allergens. In particular, 

home-based environmental control interventions can be effective and may be cost-effective. 

Patient education and self-monitoring or self-management programs can effectively motivate 

persons with asthma to reduce environmental allergens. 

Tobacco Smoke Exposure 

Background. Exposure to tobacco smoke is a well-recognized trigger for asthma.259-264 In most 

developed countries the prevalence of active smoking in adults with asthma is about 25%.265

Between 25% and 43% of all children in the U.S. are regularly exposed to 

tobacco smoke.266, 267 As exposure to environmental tobacco smoke 

increases, acute exacerbations of asthma increase, pulmonary function 

decreases, and therapeutic responses to corticosteroids become impaired.268

The mechanism of corticosteroid resistance in smokers with asthma is 

currently unexplained but could be due to alterations in airway inflammatory 

cell phenotypes, changes in glucocorticoid receptor alpha-to-beta ratio, and 

reduced histone deacetylase activity.265, 269 Cigarette smoking also increases the clearance of 

drugs such as theophylline by induction of metabolizing enzymes. A complete review of 

effective interventions for the reduction of tobacco smoke exposure is outside the scope of our 

review. However, several of the included studies described changes in tobacco exposure among 

patients with asthma. In this section we summarize their results. 

at www.who.int/tobaccoPhoto publicly available 
169

Results. Twelve studies reported either post-intervention tobacco exposure rates or reported 

whether there was a difference at the end of the intervention between intervention and control 

subjects (Table 30). When interpreting these results, we note that reducing tobacco exposure 

may not have been a primary aim of these studies and small sample sizes may have limited their 

ability to detect relatively rare events (such as identifying one or two people who stopped 

smoking). 

Not surprisingly, we found that rates of tobacco exposure seemed to be negatively correlated 

with socioeconomic status. For example, the study by Eggleston and colleagues of inner city 

children in Baltimore, 73% of whom lived below the 2000 federal poverty level, reported that up 

to 69% of children with asthma were exposed to tobacco smoke.98 

None of the QI interventions resulted in a statistically significant reduction in tobacco use 

(although only a few were specifically designed to reduce tobacco use). None of the studies was 

specifically designed to evaluate the differences in processes or outcomes of care between those 

exposed to smoke and those who were not exposed to smoke; however, several noted that 

improvements were more likely to be found among those who were not exposed. 

Conclusions. We note that this section does not provide a comprehensive assessment of 

interventions to reduce tobacco exposure among patients with asthma—it is intended simply to 

summarize the results of tobacco exposure as reported in the included studies of QI interventions 

for asthma and we emphasize that most of the included interventions were not designed to 

specifically assess or reduce tobacco exposure. The reported rate of tobacco exposure among 

children of lower socioeconomic groups was higher than that of higher socioeconomic groups. 

None of the included interventions resulted in a reduction in tobacco smoke exposure among 

patients with asthma or their family members. 
170

Table 30. Rate of reported tobacco use among patients with asthma and their family members 

Reference Target Population Demographics Baseline 

Smoking* Results of Intervention 

Cowie et 

al.109 Adolescents with 

severe asthma in 

Calgary 

None reported 53% No change in smoking rates after the study.109

Eggleston 

et al.98 Inner city children 

with asthma aged 6-

12 years with 

asthma in Baltimore. 

73% of families lived 

below the 2000 

federal poverty level 

69% After the intervention, 2 parents stopped smoking (did 

not report group assignment of these parents).98

Halterman 

et al.240 

Children with asthma 

3-7 years from 

urban, primarily 

minority low-income 

demographic groups 

in Rochester, NY 

32% Hispanic; 59% 

Black; 53% parents 

were not high school 

graduates; 62% 

received public 

assistance; 15% 

private insurance 

44% Children in the intervention group missed significantly 

fewer days of school and experienced more symptomfree days during the early winter months than did 

children in the control group. In a post-hoc analysis, it 

was found that all significant improvements were found 

in those patients not exposed to second-hand 

smoke.240

Heard et 

al.155 Asthma patients 

aged 5-64 years 

receiving care in 

general practices in 

Australia 

None reported. 11% Intervention patients were more likely to own PF meters 

and to smoke but less likely to wake at night due to 

asthma than control group patients. Baseline smoking 

rates did not change.155

Hughes et 

al.116 

Children with asthma 

aged 6-16 years 

living in Halifax 

county, Canada 

None reported 57-60% 60% of intervention families and 57% of control families 

had at least one smoker in the home at the start of the 

intervention. During the home visit, the role of cigarette 

smoke as an asthma trigger was addressed, parents 

were discouraged from smoking in the home, and 

participation in smoking cessation programs was 

encouraged. At the end of the intervention, 52% of 

intervention families and 51% of control families still 

had at least one smoker (no difference between 

groups).116

Kelly et 

al.119 Children with asthma 

2 to 16 years old 

enrolled in Medicaid 

in Norfolk, Virginia 

94% Black 

100% Medicaid 

recipients 

49% Subgroup analysis suggested trend toward greater 

effectiveness of the intervention program to decrease 

hospitalization among children in smoke-free 

households compared to those households with 

smokers. A similar trend was noted among children 

living in households with continuous telephone service 

compared to those whose telephone service had been 

disconnected.119

Magar et 

al.184 Adults (18-60yrs) 

with asthma in 

France. Ncon=89, 

Nint=104. 

None reported. Not 

reported.

There was no significant difference in the rate of 

tobacco use—7% stopped smoking in the intervention 

group compared to 2% in the control, p=0.18.184

Perneger 

et al.188 115 adults with 

asthma in Geneva, 

Switzerland 

Swiss nationality 

55%; University 

education 18% 

21% No change in smoking rates at the end of the 

intervention.188

Schulz et 

al.164 164 asthma patients in Hamburg. Nint=101; 

Ncon=63 

37% unemployed 23% No change in smoking rates.164
171

Table 30. Rate of reported tobacco use among patients with asthma and their family members (continued) 

Reference Target Population Demographics Baseline 

Smoking* Results of Intervention 

Swanson 

et al.243 Asthma patients 

aged 2-50 years in 

Scotland 

None reported. 23% There was no significant difference between groups in 

smoking rates.243

Wilson et 

al.136 235 patients ages 

18-50 with moderate 

to severe asthma 

from five Northern 

California Kaiser 

Medical Centers. 

None reported. 10% No significant difference in smoking status between 

groups.136

Wilson et 

al.94 Families of children 6 

months to 7 years 

old with asthma in 

the U.S. 

89%White/Caucasian 

52% of mothers were 

college graduates 

16% None of the family members stopped smoking. 

Intervention children did have improvements in 

symptom-free days.94

*

This represents the pre-intervention rate in the study population of at least one smoker at home. 

Summary Answers to the Key Questions 

Research Question 1: What is the evidence that QI strategies improve the processes and 

outcomes of outpatient care for pediatric and adult populations with asthma? Specifically, 

which QI strategies are effective for improving processes and outcomes of asthma care for 

specific patient populations (e.g., adults, children, low SES, racial groups, urban/rural)? 

A wide variety of types of QI interventions have been found to improve the outcomes and 

processes of care for children and adults with asthma. The QI interventions with the richest 

evidence base are those that employ self-monitoring, self-management, or patient education 

strategies. Specifically, for young children—even those from lower socioeconomic groups—

educational strategies targeting their caregivers/parents can contribute to statistically significant 

reductions in asthma symptoms. For general populations or adults with asthma, educational 

strategies that include a component of organizational change (e.g., adding a pharmacist to the 

team caring for the patient) have be shown to improve outcomes. Interventions that are based on 

a theoretical framework, use multiple educational sessions, have longer durations, and use 

combinations of instructional modalities (e.g., small group teaching with role-playing and 

handouts) are more likely to result in improvements for patients than interventions lacking these 

characteristics. 

Additionally, the use of school personnel to administer directly-observed therapy may 

increase the rate of inhaled corticosteroid use among school children with asthma, particularly 

those who are not exposed to second-hand smoke. Provider education strategies directed at 

clinicians caring for children with asthma have resulted in improvements in medication use and 

adherence to practice guidelines. There is insufficient evidence to assess the effectiveness of 

audit and feedback strategies, provider reminders, facilitated relay of clinical data, and financial 

incentives. 
172

Also, does the setting of the QI intervention (e.g., home, school, clinic) determine its 

effectiveness for improving processes and outcomes of asthma care? 

We did not find that a particular setting (or combination of settings) of the QI intervention 

consistently predicted its effectiveness. 

Research Question 2: Are QI interventions for asthma care that incorporate multiple 

strategies more effective than those that employ a single strategy?

The majority of the included articles evaluated a single QI strategy. However, 75 studies 

evaluated QI interventions with two or more QI strategies and 21 studies evaluated intervention 

with more than two QI strategies. Among those interventions with more than one QI strategy, 

the most common combination was self-monitoring or self-management and patient education. 

We found that the greater the number of QI strategies, the more likely a study was to report 

improvements in clinical status (p=0.009). We note that clinical outcomes were the most 

frequently reported and that we may have lacked sufficient evidence to find an effect for the 

other outcomes of interest. 
173 

Chapter 4. Discussion 

This systematic review of 171 QI interventions for asthma care had several key findings. 

First, we note that most of the QI interventions in this the evidence report were designed to 

achieve a change in behavior—on the part of patients with asthma, or their parents or caregivers, 

or their healthcare providers. Our results confirmed what has been demonstrated in the literature 

of fields such as psychology and organizational theory: Some behaviors (such as adopting a 

practice of measuring one’s peak flow when asthma symptoms start to flare up) are easier to 

change than others (such as stopping smoking). Given that an objective of the QI interventions 

was to change behavior, we reasoned that interventions specifically designed on the principles of 

effective behavior change would be more likely to produce improved outcomes for patients. For 

example, evaluations of behavior change interventions have demonstrated that a key component 

of successful interventions is understanding the barriers to providing high quality care. The 

included studies rarely described even basic information about underlying reasons for gaps in 

care that their interventions were trying to address. Even among the included studies that 

described a theoretical foundation for the design of their intervention (44% overall), many 

provided very scant information about the rationale for the specific design characteristics of the 

intervention. For the QI interventions for which we found large numbers of articles (namely, 

self-monitoring, self-management, or patient education), we did find that those studies that 

described a theoretical framework were more likely to report statistically significant 

improvements in some outcomes. Given the robust literature on intervention characteristics 

associated with durable behavior change, future QI interventions for asthma care should strive to 

incorporate those characteristics with a history of effectiveness in similar situations. 

Second, children, particularly the very young, are unlikely to have either adequate asthma 

knowledge or the capacity to take disease modifying actions without considerable assistance 

from their caregivers. Not surprisingly, we found that the interventions directed at children that 

did not also include parental involvement were less effective, suggesting that parallel educational 

activities, focusing on parents as well as their children, may be needed. Also, the use of school 

personnel to administer directly-observed therapy may increase the rate of inhaled corticosteroid 

use and decrease health services utilization among school children with asthma, particularly 

those who are not exposed to second-hand smoke. These findings are congruent with the 

theoretical framework set out by several authors on behavior change for asthma. Namely, that 

the successful management of asthma requires both knowledge about the disease, its prevention, 

and treatment and also the capacity to take action to modify exposure to triggers and change 

medication use in response to changes in disease status. 

Third, we were interested in evaluating whether interventions that combined multiple QI 

strategies would be more likely to benefit patients with asthma than those that utilized a single 

strategy. We found that the greater the number of QI strategies, the more likely a study was to 

report improvements in clinical outcomes. In particular, we found that patient and provider 

education interventions that also included an element of organizational change (for example, by 

adding pharmacists to the clinical team or by instituting an information system that facilitates 

reporting of clinical information between patients and providers) were often associated with 

improvements in outcomes for patients. 
174

Finally, we set out to identify and catalog a broad array of studies that might inform the 

design and implementation of future asthma QI interventions. By assembling the information on 

these studies, we are able to generate hypotheses about the comparative advantage of different 

QI strategies for improving asthma care. The QI strategies with the greatest body of evidence of 

effectiveness include the self-monitoring, self-management, or patient education interventions. 

Other strategies worked well in specific circumstances. There is not sufficient evidence to 

determine definitively which strategy or strategies work best for a given situation. However, the 

strength of our approach is that we describe the range of QI interventions that have been 

evaluated under numerous clinical circumstances so that others may review the evidence relevant 

to their particular constraints. 

 

Limitations 

This review has several limitations. First, the included articles were highly heterogeneous 

with respect to the rigor of the QI strategies implemented, the quality of their study designs, and 

the details provided about each. We had hoped to be able to identify specific intervention 

characteristics associated with the greatest improvements for patients with asthma. However, we 

were limited by the lack of detailed information about the interventions or baseline data for the 

outcomes of interest. Absence of specific information about the intervention’s design limits 

reproducibility and understanding of the extent to which interventions may be relevant for use in 

other populations or other settings. 

Second, we were limited in our ability to detect benefits for those QI strategies for which 

there have only been a small number of published studies that met our inclusion criteria. 

Similarly, because too few studies reported the same specific outcomes (e.g., improvement in 

FEV1 or hospitalizations within a given time frame), we used a composite outcome for some of 

our analysis (namely, any statistically significant result reported for one or more of the four 

outcomes of interest: clinical status, functional status, health services utilization, or guideline 

adherence). The use of this composite outcome limited our ability to delineate which QI 

strategies were more likely to be associated with improvements in each of the four outcomes of 

interest. 

Third, for some of the outcomes reported by the included articles, it is difficult to evaluate 

their clinical relevance. For example, some studies reported that the intervention group was 

found to have improvements in inhaler technique relative to the control group; however, we 

could not evaluate the clinical relevance of this finding—was the incremental improvement in 

technique of sufficient magnitude that patients would likely have fewer symptoms or require 

fewer hospitalizations? 

Finally, for studies that reported outcomes at multiple time points during and after the 

intervention, we only abstracted information about the longest period of follow up. Therefore, 

we may have missed initial improvements in outcomes if they were not durable over time. 

Future Research 

Our results suggest that QI interventions that specifically target adolescents require 

additional evaluations. None of the six studies of educational interventions that exclusively 
175

enrolled adolescents with asthma resulted in statistically significant durable improvements in 

medication use, asthma symptoms control, or health services utilization. However, some of the 

other interventions that included adolescents in their populations did find improvement—the 

extent to which they resulted in improvements specifically for adolescents is unknown. Clearly, 

identification of interventions that result in effective behavior change for this vulnerable 

population requires further investigation. 

Additionally, some authors found that improvements from QI interventions were more likely 

to occur among patients who were not exposed to tobacco smoke. A potentially confounding 

factor is that tobacco use was more common in lower socioeconomic groups. These findings 

suggest the need for additional research to evaluate whether the differential response to QI 

interventions is related to smoke exposure, socioeconomic status, or other factors. 

For some QI strategies, we found a statistically significant association between the year that 

the intervention was performed and improvements in patient outcomes. However, we did not 

identify why more recent interventions might produce incrementally better outcomes for subjects 

relative to controls. This is an area for further investigation. 

A number of QI interventions have not been adequately studied (e.g., audit and feedback, 

provider reminders, facilitated relay). Interventions of these types should be studied in 

rigorously designed clinical trials. 

Relatively few of the included studies reported on the costs associated with their 

interventions. Thus, the extent to which savings may be obtained from QI interventions for 

asthma has not been well documented. A critical gap in this literature that prevents an 

understanding of the cost-effectiveness of QI programs is that there is not a common 

effectiveness variable such as symptom-free days gained or episode-free days gained. Also, 

since many studies only include the costs and benefits accrued during the first year after an 

intervention, it is difficult to estimate the long-term cost-effectiveness of these programs. Given 

the enormity of the costs associated with asthma care, these are critically important areas for 

future research. 

Conclusions 

A wide variety of types of QI interventions have been found to improve the outcomes and 

processes of care for children and adults with asthma. The QI interventions with the richest 

evidence base are those that employ self-monitoring, self-management, or patient education 

strategies. Young children with asthma benefit most from QI strategies that also include their 

caregivers/parents. In general, interventions that are based on a theoretical framework, use 

multiple educational sessions, have longer durations, and use combinations of instructional 

modalities are more likely to result in improvements for patients than interventions lacking these 

characteristics. 

177 

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List of Acronyms/Abbreviations 

Acronyms/Abbreviations Definition 

AHRQ Agency for Healthcare Research and Quality 

CBA Controlled Before-After Trial 

CME Continuing Medical Education 

COPD Chronic obstructive pulmonary disease 

CQI Continuous Quality Improvement 

ED Emergency Department 

EPC Evidence-based Practice Center 

EPOC Cochrane Effective Practice and Organisation of Care 

FEV1 Forced Expiratory Volume in 1 second 

HEPA filter High efficiency particulate air filter 

IOM Institute of Medicine 

NHLBI National Heart, Lung, and Blood Institute 

PF Peak Flow 

QI Quality Improvement 

QOL Quality of Life 

QRCT Quasi-Randomized Controlled Trial 

RCT Randomized Controlled Trial 

TQM Total Quality Management 
APPENDIXES 

to 

“Closing the Quality Gap: A Critical Analysis of Quality Improvement 

Strategies, Volume 5—Asthma Care” 

Prepared by the Stanford University-UCSF 

Evidence-based Practice Center 

(Contract #290-02-0017) 
A-1 

Appendix A: Search Strategies by Database 

EPOC Database Search (for QI interventions directed at 

organizational change and at providers) 

#1 Targets the clinical condition of asthma 

All fields: 

Asthma* OR Anti-asthmatic or Bronchial Hyperreactivity OR Respiratory Hypersensitivity or 

Reactive airway* 

#2 Targets community-based programs/school-based programs 

All fields: 

“School health services” or “Adolescent Health Services” or “Child Care” or “school health” 

or “community health services” or “home care” 

Title/abstract field: 

School OR Community OR Home 

#3 Targets self-monitoring or self-management, patient education, and care by others 

MeSH terms: 

Patient education OR Self care OR Consumer Participation OR Patient Participation OR 

Peak expiratory flow rate OR Consumer Participation OR Patient care planning OR 

Health promotion 

Title/abstract terms: 

Self-monitoring or self-management OR self management OR Patient education OR Self care 

OR Self-care 

Parent* care OR Proxy care OR Peak flow OR Action plan OR Symptom diary OR 

Monitor OR 

Publication type term: 

Patient education handout

Cochrane Consumer Group Registry Search (for QI 

strategies directed at patients and non-providers) 

#1: Targets the clinical condition of asthma 

MeSH terms: 

Asthma OR Anti-asthmatic agents OR Asthma/Drug Therapy OR Bronchial Hyperreactivity 

OR Respiratory Hypersensitivity 

Title/abstract terms: 

Asthma* OR Reactive airway* 
A-2 

#2: Targets self-monitoring or self-management, patient education, and care by others 

MeSH terms: 

Patient education OR Self care OR Consumer Participation OR Patient Participation OR 

Peak expiratory flow rate OR Consumer Participation OR Patient care planning OR 

Health promotion OR 

Title/abstract terms: 

Self-monitoring or self-management OR self management OR Patient education OR Self care 

OR Self-care 

Parent* care OR Proxy care OR Peak flow OR Action plan OR Symptom diary OR 

Monitor 

#3: Search terms for specific codes used in the registry 

(asthma* or anti-asthmatic or "bronchial hyperactivity" or "respiratory 

hypersensitivity" or "reactive airway*") and (Ca-m or Ca-t or N6* or N8g or 

"patient education" or "consumer participation" or "patient participation" 

or "patient care planning" or "health promotion" or self-monitoring or self-management or "self 

management" or self-care or "self care" or "peak expiratory flow rate" ) 

Medline Search Strategy for EPC Asthma Project 

#1 Targets the clinical condition of asthma (yield 95,494) 

Asthma [mh] OR Anti-asthmatic agents [mh] OR Asthma/Drug Therapy [mh] OR Bronchial 

Hyperreactivity [mh] OR Respiratory Hypersensitivity [mh] OR Asthma* [ti] OR Reactive 

airway* [ti] OR Wheez* [ti] 

#2 Targets the location of the intervention (yield 223,075) 

School Health Services [mh] OR Adolescent Health Services [mh] OR Child Care [mh] OR 

Home Care Services [mh] OR School [ti] OR Community [ti] OR Home [ti] OR Work[ti] 

#3 Targets self-monitoring or self-management studies (yield 119,216) 

Patient education [mh] OR Self care [mh] Consumer Participation [mh] OR patient compliance 

[mh] OR Patient Participation [mh] OR Peak expiratory flow rate [mh] OR Patient care planning 

[mh] OR Health Promotion [mh] OR Self medication [mh] OR Caregivers [mh] OR Selfmonitoring or self-management [ti] OR self management [ti] OR Patient education [ti] OR Self 

care [ti] OR Self-care [ti] OR Parental care [ti] OR Peak flow [ti] OR Action plan [ti] OR 

Symptom diary [ti] OR Monitor [ti] OR Care give* [ti] OR Caregive* [ti] OR Self-medication 

[ti] OR self medication [ti] OR empowerment[ti] OR patient education handout [Publication 

Type] 

#4 Combine Searches #1 AND (#2 OR #3) (yield 6,125) 

#5 Systematic review search string (yield 48,084) 

(meta-analysis [pt] OR meta-analysis [tw] OR metanalysis [tw]) OR ((review [pt] OR guideline 

[pt] OR consensus [ti] OR guideline* [ti] OR literature [ti] OR overview [ti] OR review [ti] OR 
A-3 

Decision Support Techniques [mh]) AND ((Cochrane [tw] OR Medline [tw] OR CINAHL [tw] 

OR (National [tw] AND Library [tw])) OR (handsearch* [tw] OR search* [tw] OR searching 

[tw]) AND (hand [tw] OR manual [tw] OR electronic [tw] OR bibliographi* [tw] OR database* 

OR (Cochrane [tw] OR Medline [tw] OR CINAHL [tw] OR (National [tw] AND Library 

[tw]))))) OR ((synthesis [ti] OR overview [ti] OR review [ti] OR survey [ti]) AND (systematic 

[ti] OR critical [ti] OR methodologic [ti] OR quantitative [ti] OR qualitative [ti] OR literature [ti] 

OR evidence [ti] OR evidence-based [ti]))) BUTNOT (case reports [pt] OR case* [ti] OR report 

[ti] OR editorial [pt] OR comment [pt] OR letter [pt]) 

#6 Original research search string (yield 2,506,960) 

Randomised [ti] OR Randomized [ti] OR Controlled [ti] OR intervention [ti] OR evaluation [ti] 

OR impact [ti] OR effectiveness [ti] OR Evaluation [ti] OR Studies [ti] OR study [ti] 

Comparative [ti] OR Feasibility [ti] OR Program [ti] OR Design [ti] OR Clinical Trial [pt] OR 

Randomized Controlled Trial [pt] OR Epidemiologic Studies [mh] OR Evaluation Studies [mh] 

OR Comparative Study [mh] OR Feasibility Studies [mh] OR Intervention Studies [mh] OR 

Program Evaluation [mh] OR Epidemiologic Research Design [mh] 

#7 Commentaries and news reports search string (yield 1,890,529) 

(editorial [pt] OR comment [pt] OR letter [pt] OR news [pt] OR newspaper article [pt] OR case 

reports[pt]) 

#8 Combine searches: #5 OR # 6 (yield 2,537,556) 

#9 Combine searches: #4 AND #8 (yield 3,112) 

#10 Combine searches: #9 BUTNOT #7 (yield 3,003) 

#11 Limit to English language, Human (yield 2788) 
B-1 

Appendix B: Data Abstraction Forms 

Level One (Screening Title and Abstract) Form 

1. Does the article report or evaluate the results of an intervention (whether performed by the investigators or not)? 

o Yes 

o No {exclusion}

o Can't Tell {retrieve article and rescreen}

 

2. Does the article involve quality improvement or a QI strategy? 

o Yes - involves quality improvement or a QI strategy 

o Yes - systematic review of evaluations of a QI strategy 

o No {exclusion}

o Can't Tell {retrieve article and rescreen} 

***Only answer questions 3-4 if questions 1-2 were answered “yes”*** 

3. Should this article proceed to full text review for this topic? 

o Yes - evaluates a QI strategy for asthma {promotion to full text)

o No – ineligible topic (focused on inpatient care) {exclusion}

o No - not an evaluation or not QI {exclusion} 

o Can't tell - need article {retrieve article and rescreen} 

4. What type of study design was used? 

o RCT or quasi-RCT {promotion to full text}

o CBA* or ITS ** {promotion to full text}

o Cohort study; before-after or time series not meeting CBA* or ITS** definitions {exclusion} 

o Observational (e.g., cross-section, case-control) {exclusion} 

o Systematic review or meta-analysis {exclusion}

o Economic or decision analysis, modeling {exclusion} 

o Non-research (commentary, review, news) {exclusion} 

o Qualitative research (e.g., focus groups) {exclusion} 

o Guideline or consensus statement {exclusion} 

o Can't tell (need article) {retrieve article and rescreen}

* Controlled Before After (CBA) requires contemporaneous observation periods for control and intervention groups 

AND judgment that control represents a comparable group or setting. 

 

** Interrupted time series (ITS) requires statement of well-defined time period for intervention implementation AND 

data measurement for at least three time points before and after intervention. 

 

Note: At this stage of triage, err on the side of inclusion if there is a reasonable chance the study is an RCT, CBA, 

or ITS. Similarly, if there is a reasonable chance article is a systematic review, designate it as such so article can be 

pulled. 
B-2 

Level Two (Full Text) Abstraction Form 

1. Does this article merit full text abstraction? 

o Yes 

o No - not QI or not an evaluation of a QI strategy 

o No - ineligible study design (i.e., not RCT, CBA or ITS) 

o No - excluded topic (focused only on inpatient care) 

o No - no eligible outcomes* 

o No - data not reported in a usable way 

o No - foreign language 

o No - other (explain) 

o No - Self management articles 

 

 *Eligible outcomes are: Measures of clinical status (monitoring of medications, symptoms or symptom-free days, peak flow or 

spirometric measures, number of asthma attacks); Measures of functional status (days lost from work or school*, 6-minute walk 

times, school grades); Health services utilization (hospital admissions, ED visits, unscheduled MD visits); Use of self monitoring 

tools (written care plan or self-monitoring or self-management plan); and Adherence to guidelines 

**Secondary outcomes (should only be abstracted if clinical outcomes are present): Cost; Patient or Provider Satisfaction; QOL

outcomes (of either patients or caregivers); and Reduction in Environmental Allergens (e.g., Tobacco, pets/dander, cockroach 

antigen) 

2. Does this article present data overlapping with another article? 

o Exclude this article as a duplication publication (identify included citation being duplicated) 

o Include this article but obtain listed citation to help with abstraction (e.g. separate methods paper, identify required 

citation) 

o No or N/A 

 

3. Does abstraction of this study require information from methods or results reported in other citations? 

o Yes (specify) 

o No 

 

4. What category of study question is addressed by the article? 

o Can QI strategies increase the prescribing of inhaled corticosteroids for patients with asthma? 

o Can QI strategies improve the processes of care for asthma? 

o Can QI strategies improve clinical outcomes for patients with asthma? 

o Can QI strategies reduce health services utilization for patients with asthma? 

o Other (explain) 

o None of the above 

 

5. Does the article report data for more than one comparison (i.e., should it be abstracted as more than one study)? 

o Yes (specify which comparison is being abstracted here and which others will be abstracted elsewhere) 

o No 

 

6. Does this article provide references that might lead to additional included studies? 

o Yes (please type in the citation numbers here) 

o No 

 

Study Design Information 

7. Describe the purpose of this study (specify the objective of the intervention). 

 

8. What was the study design? 

o Randomized trial (state method of randomization if described) 

o Quasi-randomized trial (state basis for treatment allocation, e.g. alternating patients, calendar date, even or odd 

identification numbers) 

 
B-3 

o Controlled before-after study* 

o Interrupted time series** 

 

*Controlled Before-After (CBA) requires contemporaneous observation periods for control and intervention groups AND 

judgment that control represents a comparable group or setting. 

**Interrupted Time Series (ITS) requires statement of well-defined time period for intervention implementation AND 

measurement of data at three or more time points both before and after intervention 

 

9. What was the unit of randomization or treatment allocation? 

o Patient 

o Parent or caregiver 

o Teacher 

o Episode of care 

o Clinic day 

o Provider 

o Clinic or practice 

o Firm (describe) 

o Institution 

o Community 

o Other (specify) 

o Not applicable - ITS study (skip to question 24) 

10. For the unit of treatment allocation, state sample size in each group (If sample size differs for outcomes, detail differences in 

"Sample size differs by outcome" text box) 

o Control group - PRE 

o Control group - POST 

o Intervention group - PRE 

o Intervention group - POST 

o Sample size differs by outcome 

o Not stated or not clear (explain) 

11. If unit of analysis differed from unit of treatment allocation (e.g. providers randomized but patient outcomes analyzed), state 

sample size in each group. Use text box for "Sample size differs by outcome"- give details. 

o Control group - PRE 

o Control group - POST 

o Intervention group - PRE 

o Intervention group - POST 

o Sample size differs by outcome (specify) 

o Not stated or not clear 

o Not applicable (unit of analysis same as unit of treatment allocation above) 

 

12. If unit of analysis differed from unit of treatment allocation, did authors acknowledge this issue or make appropriate 

adjustments? 

o Yes (describe) 

o No 

o Not applicable (unit of analysis did not differ from unit of treatment allocation) 

 13. Was there adequate concealment of treatment allocation? 

o Yes (unit of allocation was institution, team or professional and randomization process explicitly described, OR unit of 

allocation was patient or episode of care and some form of centralized randomization scheme or sealed envelopes used) 

o Not clear (only partially meets above criteria) or not stated - specify which 

o No inadequate concealment (enrollment of patients in alternation or through use of even/odd identifying numbers OR 

unit of allocation was patient or episode of care and reported use of any allocation process that is entirely transparent 

before assignment (e.g., open list of random numbers) OR allocation was altered by investigators, professionals or 

patients) 

 
B-4 

14. Was informed consent obtained? (Check all that apply) 

o Obtained from patients 

o Obtained from parents or caregivers 

o Obtained from providers 

o Obtained from other study participants (specify) 

o Not obtained or not stated (specify) 

15. Was IRB approval obtained by investigators? 

o Yes 

o No or not stated 

Design Criteria for Randomized and Quasi-Randomized Trials 

(If study is a CBA, skip to question 21; if ITS, skip to question 24) 

 

16. Did the study have a cross over design? (Patients randomized to a sequence of interventions such as treatment A followed by

treatment B in one group and treatment B followed by treatment A in the other group). 

o Yes (describe) 

o No 

o Not sure (clarify with other reviewers before proceeding) 

17. Were patients blind to intervention/treatment allocation? 

o Yes 

o No 

o Not sure (explain) 

o Not applicable (patients not actively involved in study - e.g. provider-focused intervention with patient level data 

obtained retrospectively from charts) 

 

18. Were caregivers blind to intervention/treatment allocation? 

o Yes 

o No 

o Not sure (explain) 

o Not applicable (caregivers not actively involved in study) 

 

19. Were providers blind to intervention/treatment allocation? 

o Yes 

o No 

o Not sure (explain) 

o Not applicable (explain) 

 

 20. Were outcomes assessors blinded to intervention/treatment allocation? 

o Yes 

o No 

o Not sure (explain) 

o Not applicable (explain) 

 

 (Now skip to question 27) 

 

Design Criteria for CBA Trials 

21. Were measurements in the control group performed at the same time as the intervention group? 

o Yes 

o No 

o Unclear 

 
B-5 

22. Were the criteria used for selecting the control site explained? 

o Yes (describe) 

o No 

 

23. Was the control site comparable (in both patients and providers)? 

o Yes 

o No (explain why not) 

o Unclear (describe) 

(Now skip to question 27.) 

 

Design Criteria for ITS Trials 

24. Was the intervention performed independent of other quality improvement efforts or other changes? 

o Yes 

o No 

o Unclear 

25. Was the intervention unlikely to affect data collection? 

o Yes 

o No 

o Unclear 

 

26. Was the data analyzed using a formal test for trend (time series ANOVA or regression)? 

o Yes 

o No 

o Unclear 

 

27. (For all studies) Do any methodological aspects of the study design not captured above seriously undermine appropriateness 

of inclusion of this study? 

o Yes (explain) 

o No (use text box to document any noteworthy methodological features) 

 

 

 

Study Setting and Participants 

28. Briefly describe the inclusion and exclusion criteria for the CONTROL group. 

29. Briefly describe the inclusion and exclusion criteria for the INTERVENTION group. 

 

(We are particularly interested in measures of the baseline asthma severity of the control and intervention groups. If the authors 

provide baseline number of asthma medications, numbers of ED or physician visits, or other markers of asthma severity, please 

record these in the pre-intervention portions of the results section) 

30. Where did the study take place? 

o US (specify) 

o Non-US (specify) 

 

 31. When did the study take place? 

o If supplied, give exact dates of study period (beginning to end of intervention period) 

o Not reported 

 

32. Who or what was the target of the intervention? (check all that apply) 

o Patients 

o Teachers 
B-6 

o Parents or other caregivers 

o Pharmacists 

o Providers (i.e., individual clinicians, school nurses) 

o Entire population of a geographic area 

o Other (describe) 

 

 33. Describe the demographics of the CONTROL population. 

Age (describe) 

Gender (describe) 

Race/ethnicity (describe) 

Educational status (describe) 

Socioeconomic status (describe) 

Urban/Rural information (describe) 

Baseline asthma severity or control (describe) 

 

34. Describe the demographics of the INTERVENTION population. 

Age (describe) 

Gender (describe) 

Race/ethnicity (describe) 

Educational status (describe) 

Socioeconomic status (describe) 

Urban/Rural information (describe) 

Baseline asthma severity or control (describe) 

 

35. If the study evaluated CAREGIVERS, please describe the demographics of the CAREGIVER population. 

Age (describe) 

Gender (describe) 

Race/ethnicity (describe) 

Educational status (describe) 

 Socioeconomic status (describe) 

 Urban/rural information (describe) 

36. Does the intervention specifically target pediatric asthmatics? 

o Yes, pediatric intervention 

o No 

 

37. In what setting was the intervention delivered? (check all that apply—for example, for an educational program delivered by a 

nurse educator in a pulmonologist’s office that increases home use of self-monitoring or self-management tools, check both 

Outpatient specialty care clinic and Home) 

o Outpatient primary care clinic 

o Outpatient specialty care clinic (specify type of specialist (e.g. pulmonologist, allergist) 

o Urgent care or walk-in clinic 

o Emergency department 

o Academic healthcare setting 

o VA healthcare setting 

o Home 

o School 

o Work-place 

o Other community setting (e.g., church, community center) (describe) 

o Other or not clear (describe) 

o Not stated 

Quality Improvement Attributes of Intervention 

38. Did the investigators identify a specific quality gap (a difference between optimal and actual care) in the study population? 

o Yes (describe) 

o No 

 
B-7 

39. Did the investigators cite previous literature (or a theoretical framework) to describe the evidence base for their proposed 

intervention? 

o Yes (describe) 

o No 

40. Describe the intervention provided to the CONTROL population? 

o No intervention or usual care (describe) 

o Some form of low intensity intervention (describe) 

o No true control - just two or more different types of intervention (discuss with other reviewers; study may need to be 

excluded) 

41. Describe the intervention provided to the EXPERIMENTAL population? 

 

42. Did the study intervention involve PATIENT, PARENT OR CAREGIVER, OR PROVIDER EDUCATION? 

o Yes 

o No patient, caregiver, or provider education (skip to question 48) 

 

43. What was the content of the educational material? 

o Correct use of metered dose inhalers, nebulizers, and peak flow meters 

o Use of asthma diary or other self-monitoring device 

o General information about asthma pathophysiology and treatment 

o Information about reduction in tobacco use 

o Information about reduction in other environmental allergen 

o Other (describe) 

 

44. Who was responsible for delivery of the educational content? (check all that apply) 

o Physician educating patients/parents or caregivers/teachers 

o Physicians educating physician colleagues 

o Expert opinion leader (describe how selected) 

o Nurse or nurse practitioner 

o Pharmacist 

o Pharmaceutical sales representative 

o Other ancillary health provider (describe) 

o Health educator 

o Parent or caregiver 

o School Teacher 

o Peers 

o No specific delivery person (e.g. entirely mailed, computer-based, or passively distributed content) 

o Other (describe) 

 

45. Which of the following educational strategies was used? 

o One-on-one session, in person or via telephone 

o Role-playing or practicing of particular behaviors 

o Interactive group sessions (e.g. classes, workshops) 

o Traditional didactic group teach via meetings or lectures (e.g. traditional CME) 

o Distribution of printed or audiovisual materials (e.g. pamphlets or poster in waiting room, published or printed 

recommendations for clinical care such as clinical practice guidelines, audio-visual materials and electronic 

publications) 

o Community-wide mass media efforts (e.g. television advertisements or billboards) 

o Interactive computer-based learning 

o Educational outreach visits (e.g. “academic detailing”—a trained person who met with providers in their practice 

setting to give information with the intent of changing the provider's practice) 

o Provision of clinical data to patient or caregiver (e.g. test results) 

o Consensus-building sessions (e.g. for development of guideline) 

o Not sure or other (describe) 
B-8 

46. How intense was the educational intervention? 

o 1-time class, session with an educator, or provision of educational materials 

o 2-5 classes or sessions 

o 6-10 classes or session 

o More than 10 sessions 

o Other or unclear (describe) 

 

47. Did the QI strategy involve patient education? 

o Yes 

o No patient education 

 

48. Was the intervention designed to promote PATIENT SELF-MONITORING OR SELF-MANAGEMENT? If yes, please 

indicate the objectives of the intervention: (check all that apply) 

o Get information about asthma 

o Become motivated to avoid future asthma exacerbations 

o Identify asthma triggers and behaviors that may lead to asthma exacerbations 

o Encourage the use of self monitoring of symptoms (e.g., through asthma diary) 

o Encourage the use of self monitoring of disease status (e.g., through peak flows) 

o Identify attitudes that reduce chances of successful implementation of new behavior 

o Attempt to implement new, asthma self-monitoring or self-management plan 

o Evaluate the efficacy of those attempts 

o Identify barriers and facilitating features present in his/her life 

o Develop the skills s/he needs to overcome those barriers 

o Practice those skills and see them modeled by peers 

o Implement newly acquired information and skills 

o Maintain asthma self-monitoring or self-management behaviors 

o Others (describe) 

 

 49. Provide additional detail about the PATIENT-SELF MANAGEMENT strategy provided to the CONTROL group not 

captured in Question 48. 

 

 50. Provide additional detail about the PATIENT-SELF MANAGEMENT strategy provided to the INTERVENTION group not 

captured in Question 48. 

 

51. Did the QI strategy involve PARENT or CAREGIVER education? 

o Yes 

o No parent or caregiver education 

 

52. Was the intervention designed to promote PARENT OR CAREGIVER SELF MANAGEMENT? If yes, please indicate the 

objectives of the intervention: (check all that apply) 

o Get information about asthma 

o Become motivated to avoid future asthma exacerbations 

o Identify asthma triggers and behaviors that may lead to asthma exacerbations 

o Encourage the use of self monitoring of symptoms (e.g., through asthma diary) 

o Encourage the use of self monitoring of disease status (e.g., through peak flows) 

o Identify attitudes that reduce chances of successful implementation of new behavior 

o Attempt to implement new, asthma self-monitoring or self-management plan 

o Evaluate the efficacy of those attempts 

o Identify barriers and facilitating features present in his/her life 

o Develop the skills s/he needs to overcome those barriers 

o Practice those skills and see them modeled by peers 

o Implement newly acquired information and skills 

o Maintain asthma self-monitoring or self-management behaviors 

o Others (describe) 

 
B-9 

 53. Provide additional detail about the PARENT OR CAREGIVER-MANAGEMENT strategy provided to the CONTROL not 

captured in Question 52. 

 

54. Provide additional detail about the PARENT OR CAREGIVER-MANAGEMENT strategy provided to the INTERVENTION 

group not captured in Question 52. 

 

55. Did the QI strategy involve PROVIDER EDUCATION? 

o Yes 

o No 

 

56. Did the QI strategy involve a PROVIDER REMINDER system*? 

o Chart based decision support or reminder system* 

o Computer based reminder* or decision support* 

o Not sure 

o No or N/A 

 * Patient or provider encounter specific information, provided verbally, on paper or on a computer screen, which is intended to 

prompt provider to recall information at the time of the patient encounter (e.g., reminder to include inhaled corticosteroids in a 

patient’s medical regimen) 

57. Did the QI strategy involve provider AUDIT AND FEEDBACK*? (check all that apply) 

o Feedback to individual provider (state if confidential) 

o Feedback about clinic or practice performance only 

o Public reporting of performance data (state if individual data or data for a group or institution) 

o Benchmarking** 

o Not sure or other 

o No or N/A 

 

*Any summary of clinical performance of health care over a specified period of time. 

**Benchmarking refers to the provision of performance data from institutions or providers regarded as "leaders in the field." 

These data provide targets for other providers and institutions to emulate. 

 

58. Did the QI strategy involve ORGANIZATIONAL CHANGE? 

o Adding new members to team (e.g. adding a clinical pharmacist to clinic, or creation of a call center for patients) or 

creating multidisciplinary teams 

o Revision of professional roles among health professionals (e.g. nurse practitioner or pharmacist given prescribing 

authority) 

o Increased staffing without changes in roles (e.g., adding more nurses) 

o TQM/CQI - cycles of measurement of quality problems, design of interventions, implementation and re-measurement 

o Changes in medical records systems -- e.g. changing from paper to computerized records, patient tracking systems 

o Communication and case discussion between distant health professionals (e.g., telemedicine) 

o Not sure or other 

o No or N/A 

 

59. If the intervention involved changes to medical record systems, what type of change was instituted? 

o Change from paper to computerized records 

o Implementation of computerized provider order entry (CPOE) 

o New patient tracking system 

o Other (describe) 

o Not applicable - No change to medical record system 

 60. Did the intervention involve FINANCIAL INCENTIVES DIRECTED AT PROVIDERS? 

o Financial incentives for achievement of performance goals 

o Change in reimbursement system (i.e., capitation) 

o Other (describe) 

o No component of provider-directed financial incentives 
B-10 

61. Did the intervention involve REGULATORY CHANGES DIRECTED AT PROVIDERS? 

o Restriction of formulary to cover only certain asthma medications 

o Authorization from another physician required to prescribe asthma medications 

o Authorization from health plan required to prescribe asthma medications 

o Restriction of access to pharmaceutical sales representatives 

o Other (describe) 

o No component of provider-directed regulatory changes 

 

62. Did the intervention involve FINANCIAL OR REGULATORY INCENTIVES DIRECTED AT PATIENTS? 

o Additional charge (co-payment) for specific asthma medications 

o Additional charge (co-payment) for visits or phone calls 

o Change in health insurance premiums 

o Other (describe) 

o No component of patient-directed financial or regulatory incentives 

63. Did the intervention involve FINANCIAL OR REGULATORY INCENTIVES DIRECTED AT A PRACTICE OR HEALTH 

SYSTEM? 

o Yes (describe) 

o No component of health-system-directed financial or regulatory incentives 

 

64. Did a clinical information system play a role in design or implementation of intervention? 

o Identification or group allocation of eligible patients or providers 

o Reminders generated by existing clinical information system 

o Decision support at point of care (e.g., for provider order entry) 

o Facilitated communication between providers (e.g., generated emails between members of care team) 

o Audit data gathered from clinical information system to design QI strategy (e.g., audit and feedback, TQM, provider 

education, financial incentives) 

o Other 

o No role for a clinical information system 

 

65. Use textbox to state any important study features of the QI intervention or concerns not captured above. 

66. For unit of treatment allocation (e.g., clinics, providers, patients), were results reported for at least 80% of participants? 

o Yes (state %) 

o No (state %) 

o Not stated or not clear 

 

67. If unit of analysis differed from unit of treatment allocation (e.g., providers randomized, but patient level outcomes analyzed), 

were results reported for at least 80% of participants? 

o Yes (state %) 

o No (state %) 

o Not stated or not clear 

o Not applicable (unit of analysis same as unit of treatment allocation) 

 

68. What was the length of the study follow up period? (describe) 

 

69. Were the reported outcomes measured at multiple time points? 

o Yes (describe) 

o No 

(If outcomes were reported at multiple time points, please use the data for the latest time, provided that this time is still part of the 

intervention period. For e.g. if a study reports follow up at 3, 6, 9 and 12 months, use the 12 month data. However, if they report 

follow up at 3 and 6 months, and then state they completed the study and then did a follow up assessment 2 years after study 

completion, report data from the 6 month period. Make a notation in the comments section that there is also data available from a 

two year follow up.) 
B-11 

PRIMARY OUTCOMES 

Measures of Clinical Status 

70. Which of the following measures of clinical status were reported? 

o Frequency of rescue bronchodilators used 

o Use of inhaled corticosteroid 

o Inhaled corticosteroid prescriptions 

o Bronchodilators prescriptions 

o Asthma symptoms 

o Asthma attacks 

o Symptom-free days 

o Peak flows 

o Spirometric data 

o Other measure of clinical status (specify) 

o No measurement of clinical status 

 Please provide the data for the following outcomes. If the study reports different units of measurement (e.g. median 

instead of mean or S.E. instead of SD), please indicate that when recording the data. 

 If the study does not report the data in the format provided by the table, but instead reports data as a change in the post 

intervention period, please record the change data in the comments column. Report any other concerns about the outcome in the 

comments column. 

Measure 

Reported and 

Units 

N 

pre 

Mean 

Pre 

SD 

pre 

N 

post 

Mean 

Post 

SD 

post 

Significant 

difference 

between 

groups 

No 

Significant 

difference 

Comments 

71. Frequency of 

rescue 

bronchodilators used 

CONTROLS 

 

72. Frequency of 

rescue 

bronchodilators used 

INTERVENTN 

 

73. Use of inhaled 

corticosteroids 

CONTROLS 

 

74. Use of inhaled 

corticosteroids 

INTERVENTN 

 

75. Inhaled 

corticosteroids 

prescriptions 

CONTROLS 

 

76. Inhaled 

corticosteroids 

prescriptions 

INTERVENTN 

 

77. 

Bronchodilators 

prescriptions 

CONTROLS 

 

78. Bronchodilators 

prescriptions 

INTERVENTN 

 
B-12 

Measures of Guideline Adherence 

95. Which of the following measures of guideline adherence were reported? 

o Adherence to a guideline for asthma prescribing 

o Adherence to clinician recommendation by patient 

o Other measure of guideline adherence (specify) 

79. Asthma 

symptoms 

CONTROLS 

 

80. Asthma 

symptoms 

INTERVENTN 

 

81. Asthma attacks 

CONTROLS 

 

82. Asthma attacks 

INTERVENTN 

83. Symptom-free 

days CONTROLS 

84. Symptom-free 

days INTERVENTN 

85. Peak flows 

CONTROLS 

86. Peak flows 

INTERVENTN 

87. Spirometric data 

CONTROLS 

88. Spirometric data 

INTERVENTN 

89. Other measure of 

clinical status 1 

(specify) 

CONTROLS 

91. Other measure of 

clinical status 1 

(specify) 

INTERVENTN 

 

92. Other measure of 

clinical status 2 

(specify) 

CONTROLS 

 

93. Other measure of 

clinical status 2 

(specify) 

INTERVENTN 

 

94. Other measure of 

clinical status 3 

(specify) 

CONTROLS 

 

95. Other measure of 

clinical status 3 

(specify) 

INTERVENTN 

 
B-13 

 Measures of Asthma Functional Status Outcomes 

102. Which of the following measures of asthma functional status outcomes were reported? 

o Days lost from school/work for patients 

o Days lost from school/work for parents or caregivers 

o 6-minute walk times 

o School grades 

o Other measure of asthma functional status (specify) 

o No measurement of asthma functional status 

Measure 

Reported 

and Units 

N 

pre 

Mean 

Pre 

SD 

pre 

N 

post 

Mean 

Post 

SD 

post 

Significant 

difference 

between groups 

as reported by 

author 

No Significant 

difference 

between groups 

as reported by 

author 

Comments

96. Adherence to a 

guideline for asthma 

prescribing 

CONTROLS 

 

97. Adherence to a 

guideline for asthma 

prescribing 

INTERVENTN 

 

98. Adherence to 

clinician 

recommendation by 

patient CONTROLS 

 

99. Adherence to 

clinician 

recommendation by 

patient 

INTERVENTN 

 

100. Other measure 

of guideline 

adherence 

CONTROLS 

 

101. Other measure 

of guideline 

adherence 

INTERVENTN 

 

Measure 

Reported 

and Units 

N 

pre 

Mean 

Pre 

SD 

pre 

N 

post 

Mean 

Post 

SD 

post 

Significant 

difference 

between groups 

as reported by 

author 

NO 

Significant 

difference 

between groups 

as reported by 

author 

Comments

103. Days lost from 

school/work for 

patients CONTROLS 

 

103. Days lost from 

school/work for 

patients CONTROLS 

104. Days lost from 

school/work for 

patients 

INTERVENTN 
B-14 

Measures of Self-monitoring or self-management 

115. Which of the following measures of asthma self-monitoring or self-management were reported? 

o Rate of adherence to a care plan or self-monitoring or self-management plan 

o Self-efficacy 

o Other measure of self-monitoring or self-management (specify) 

105. Days lost from 

school/work for 

parents or caregivers 

CONTROLS 

 

106. Days lost from 

school/work for 

parents or caregivers 

INTERVENTN 

107. 6-minute walk 

times CONTROLS 

 

108. 6-minute walk 

times 

INTERVENTN 

109. School grades 

CONTROLS 

110. School grades 

INTERVENTN 

111. Other measure 

of asthma functional 

status 1 (specify) 

CONTROLS 

112. Other measure 

of asthma functional 

status 1 (specify) 

INTERVENTN 

113. Other measure 

of asthma functional 

status 2 (specify) 

CONTROLS 

114. Other measure 

of asthma functional 

status 2 (specify) 

INTERVENTN 

Measure 

Reported 

and Units 

N 

pre 

Mean 

Pre 

SD 

pre 

N 

post 

Mean 

Post 

SD 

post 

Significant 

difference 

between 

groups as 

reported by 

author 

No Significant 

difference 

between 

groups as 

reported by 

author 

Comments 

116. Rate of 

adherence to care 

plan or selfmonitoring or selfmanagement plan 

CONTROLS 

 

117. Rate of 

adherence to care 

plan or selfmonitoring or selfmanagement plan 

INTERVENTN 

 
B-15 

 

Measures of Health Services Utilization 

124. Which of the following measures of health services utilization were reported? 

o Unscheduled visits with a health care provider 

o Unscheduled visits to an emergency department or urgent care clinic 

o Hospitalizations 

o Other measure of health services utilization (specify) 

o No measure of health services utilization 

118. Self-efficacy 

CONTROLS 

 

119. Self-efficacy 

INTERVENTN 

120. Other measure 

of asthma selfmonitoring or selfmanagement 

1(specify) 

CONTROLS 

 

121. Other measure 

of asthma selfmonitoring or selfmanagement 1 

(specify) 

INTERVENTN 

 

122. Other measure 

of asthma selfmonitoring or selfmanagement 2 

(specify) 

CONTROLS 

 

123. Other measure 

of asthma selfmonitoring or selfmanagement 2 

(specify) 

INTERVENTN 

 

Measure 

Reported 

and Units 

N 

pre 

Mean 

Pre 

SD 

pre 

N 

post 

Mean 

Post 

SD 

post 

Significant 

difference 

between groups 

as reported by 

author 

No Significant 

difference 

between groups 

as reported by 

author 

Comments 

125. Unscheduled 

visits with a health 

care provider 

CONTROLS 

 

126. Unscheduled 

visits with a health 

care provider 

INTERVENTN 

127. Unscheduled 

vests to an 

emergency 

department or urgent 

care clinic 

CONTROLS 

 
B-16 

SECONDARY OUTCOMES 

DO NOT ABSTRACT THESE OUTCOMES UNLESS AT LEAST ONE PRIMARY OUTCOME HAS BEEN 

REPORTED. 

PLEASE BE SPECIFIC WHEN REPORTING THE TYPE OF OUTCOME AND UNIT OF MEASUREMENT. ONLY 

ABSTRACT DATA ON WHETHER OR NOT THE AUTHORS REPORTED SIGNIFICANT DIFFERENCES 

BETWEEN THE CONTROL AND INTERVENTION GROUPS. 

 

133. Which of the following secondary outcomes were reported? 

o Costs 

o Quality of Life 

o Provider Satisfaction 

o Patient Satisfaction with care 

o Parent or Caregiver satisfaction with care 

o Reduction in Exposure to Environmental Allergens 

o No secondary outcomes reported 

 

Specific Outcome Reported Unit of 

Measurement 

Significant difference 

between groups as 

reported by author 

No Significant difference 

between groups as 

reported by author 

Comments 

134. Total costs of asthma 

medications to a practice, hospital 

or health care system 

 

135. Cost of health services 

utilization 

136. Other measure of cost 1 

(specify) 

137. Other measure of cost 2 

(specify) 

138. Quality of Life 1 (specify) 

139. Quality of Life 2 (specify) 

140. Quality of Life 3 (specify) 

141. Quality of Life 4 (specify) 

142. Quality of Life 5 (specify) 

143. Provider satisfaction 

144. Patient satisfaction with care 

145. Parent or caregiver 

satisfaction with care 

 

128. Unscheduled 

vests to an 

emergency 

department or urgent 

care clinic 

INTERVENTN 

 

129. Hospitalizations 

CONTROLS 

 

130. Hospitalizations 

INTERVENTN 

131. Other measure 

of health services 

utilization (specify) 

CONTROLS 

132. Other measure 

of health services 

utilization (specify) 

INTERVENTN 
B-17 

146. Reduction in environmental 

allergen 1 (specify) 

 

147. Reduction in environmental 

allergen 2 (specify) 

148. Reduction in environmental 

allergen 3 (specify) 

149. Reduction in environmental 

allergen 4 (specify) 

150. Reduction in environmental 

allergen 5 (specify) 

151. Use textbox to state any important results or study concerns not captured above (e.g., reduction in environmental allergens, 

quality of life, etc.) 

 
C-1 

Appendix C: List of Excluded Studies 

Citation Reason for Exclusion 

Abdulwadud O, Abramson M, Forbes A, James A, Walters E. Evaluation of a randomised controlled 

trial of adult asthma education in a hospital setting. Thorax. 1999;54(6):493-500. 

No eligible outcomes 

Abisheganaden J, Ng SB, Lam KN, Lim TK. Peak expiratory flow rate guided protocol did not 

improve outcome in emergency room asthma. Singapore Med J. Nov 1998;39(11):479-484. 

Ineligible study design 

Agertoft L, Pedersen S. Importance of training for correct Turbuhaler use in preschool children. Acta 

Paediatr. Aug 1998;87(8):842-847. 

Reported data not usable 

Akerman MJ, et al. A successful effort to improve asthma care outcome in an inner-city emergency 

department. J Asthma. May 1999;36(3):295. 

Excluded topic 

Akkaya E, Yilmaz A, Ece F, Bayramguler B, Baran A, Akakca A. Effects of patient education to the 

life quality in asthma patients: 3 years experience [abstract]. Eur Respir J Suppl. 1997;10 Suppl 

25:194S. 

Abstract 

Alexander J, Divin-Cosgrove C, Faner ML, O'Connell M. Increasing the knowledge base of asthmatics 

and their families through asthma clubs along the southwest border. J Am Acad Nurse Pract. Jul 

2000;12(7):260-266. 

Ineligible study design 

Amirav I, Goren A, Kravitz RM, Pawlowski NA. Physician-targeted program on inhaled therapy for 

childhood asthma. J Allergy Clin Immunol. Apr 1995;95(4):818-823. 

No eligible outcomes 

Anthonisen NR, Connett JE, Kiley JP, et al. Effects of smoking intervention and the use of an inhaled 

anticholinergic bronchodilator on the rate of decline of FEV1. The Lung Health Study. JAMA. Nov 

16 1994;272(19):1497-1505. 

Excluded topic 

Arbes SJ, Sever M, Archer J, et al. Abatement of cockroach allergen (Bla g 1) in low-income, urban 

housing: A randomized controlled trial.[comment]. J Allergy Clin Immunol. 2003;112(2):339-345. 

No eligible outcomes 

Aronson N, Lefevre F, Piper M, et al. Management of chronic asthma. Evid Rep Technol Assess 

(Summ). Sep 2001(44):1-10. 

Other 

Asthma program targets patient and physician compliance; wins first DM excellence award. Healthc 

Demand Dis Manag. Dec 1998;4(12):181-184; suppl 181-184. 

Ineligible study design 

Bailey WC, Richards JM, Jr., Manzella BA, Windsor RA, Brooks CM, Soong SJ. Promoting selfmonitoring or self-management in adults with asthma: an overview of the UAB program. Health 

Educ Q. Fall 1987;14(3):345-355. 

Reported data not usable 

Baltins M, Holsta A, Silins V, Krams A. Strategy for patient education in asthma [abstract]. Eur Respir 

J Suppl. 1995;8 Suppl 19:114. 

Abstract 

Barrett JC. Effects of nursing intervention on teacher inclusion anxiety. The University of Alabama at 

Birmingham ** D. 1996(172 p). 

Thesis/Dissertation 

Barta PJ, Brodsky KL. Approaches to asthma care. Medicaid health plans pilot programs to combat a 

complex health issue. Healthplan. Mar-Apr 2002;43(2):42-45. 

Ineligible study design 

Becker A, Watson W, Ferguson A, Dimich-Ward H, Chan-Yeung M. The Canadian asthma primary 

prevention study: outcomes at 2 years of age. J Allergy Clin Immunol. Apr 2004;113(4):650. 

Excluded topic 

Berwick DM, Yox SB. Change leads to improvement: pediatric asthma and breast cancer care. HMO 

Practice. Jun 1995;9(2):75. 

Ineligible study design 

Blackstien-Hirsch P, Anderson G, Cicutto L, McIvor A, Norton P. Implementing continuing education 

strategies for family physicians to enhance asthma patients' quality of life. J Asthma. May 

2000;37(3):247. 

Ineligible study design 
C-2 

Citation Reason for Exclusion 

Blixen C, Hammel J, Murphy D, Ault V. Feasibility of a nurse-run asthma education program for 

urban African- Americans: a pilot study. J Asthma. 2001;38(1):23-32. 

Excluded topic 

Blumenthal MN, Cushing RT, Fashingbauer TJ. A community program for the management of 

bronchial asthma. Ann Allergy. Jul 1972;30(7):391-398. 

Ineligible study design 

Bobb C, Ritz T. Do asthma patients in general practice profit from a structured allergy evaluation and 

skin testing? A pilot study. Respir Med. Nov 2003;97(11):1180-1187. 

Not an evaluation of a QI 

intervention 

Borrelli B, McQuaid E, Becker B, et al. Motivating parents of kids with asthma to quit smoking: the 

PAQS project. Health Educ Res. 2002;17(5):659-669. 

Reported data not usable 

Bosnic-Anticevich S, Donnelly A, Saini B. The effect of a peer-led asthma education program on 

asthma knowledge, confidence and skills [Abstract]. Proceedings of the Thoracic Society of 

Australia & New Zealand, Annual Scientific Meeting, Adelaide, 4-9 April 2003. 2003. 

Abstract 

Boulet LP, Boutin H, Cote J, Leblanc P, Laviolette M. Evaluation of an asthma self-monitoring or selfmanagement education program. J Asthma. 1995;32(3):199-206. Ineligible study design 

Brambilla R. Eformoterol in elderly patients: a follow-up. Br J Clin Pract Suppl. Sep 1995;81:6-7. Not an evaluation of a QI 

intervention 

Bramson R. Self-monitoring or self-management of asthma. J Fam Pract. Jul 1996;43(1):21-22. Ineligible study design 

Brandt HD, Muntingh GL. Decreasing asthma morbidity. S Afr Med J. Dec 1994;84(12):842-844. No eligible outcomes 

Brazil K. The influence of health education on family adaption to childhood asthma [Dissertation]. 

University of Toronto. 1992. 

Thesis/Dissertation 

Brewin AM, Hughes JA. Effect of patient education on asthma management. Br J Nurs. Jan 28-Feb 8 

1995;4(2):81-82, 99-101. 

Excluded topic 

Bright P, Burge PS. Occupational lung disease. 8. The diagnosis of occupational asthma from serial 

measurements of lung function at and away from work. Thorax. Aug 1996;51(8):857-863. 

Ineligible study design 

Bundy DG, Berkoff MC, Ito KE, Rosenthal MS, Weinberger M. Interpreting subgroup analyses: is a 

school-based asthma treatment program's effect modified by secondhand smoke exposure? 

comment. Arch Pediatr Adolesc Med. May 2004;158(5):469. 

Ineligible study design 

Bunjaroonsilp N, Bunnag A, Jungsomjatepaisal W, Pongsaranunthakul Y, Maksuwan D. Effectiveness 

of the nurse-run asthma self-monitoring or self-management program for sick children of the 

university hospitals in Bangkok. Thai J Nurs. 2002;6(3):128. 

Other 

Burkhart PV, Dunbar-Jacob JM, Rohay JM. Accuracy of children's self-reported adherence to 

treatment. J Nurs Scholarsh. 2001;33(1):27-32. 

No eligible outcomes 

Cabana MD, Le TT. Challenges in asthma patient education. J Allergy Clin Immunol. Jun 

2005;115(6):1225-1227. 

Not an evaluation of a QI 

intervention 

Callahan K, Eggleston P, Rand C, Kanchanaraksa S, Swartz L, Wood R. Knowledge and practice of 

dust mite control by specialty care. Ann Allergy Asthma Immunol. 2003;90(3):302-307. 

No eligible outcomes 

Campbell TM, Stamm PL, Johnson JR. Improving drug use in a capitated program for the poor. Am J 

Health Syst Pharm. Nov 1 1997;54(21):2449-2450. 

Ineligible study design 

Capen CL, Sherman JM. Fatal asthma in children: a nurse managed model for prevention. J Pediatr 

Nurs. Dec 1998;13(6):367-375. 

Ineligible study design 

Castro M, Zimmermann NA, Crocker S, Bradley J, Leven C, Schechtman KB. Asthma intervention 

program prevents readmissions in high healthcare users. Am J Respir Crit Care Med. Nov 1 

2003;168(9):1095-1099. 

Excluded topic 

Catrambone CD. Effect of a case management intervention on symptoms of asthma in high risk 

children. Rush university, college of nursing ** 2000 d. 2000(141 p). 

Thesis/Dissertation 
C-3 

Citation Reason for Exclusion 

Chandler MH, Clifton GD, Louis BA, Coons SJ, Foster TS, Phillips BA. Home monitoring of 

theophylline levels: a novel therapeutic approach. Pharmacotherapy. 1990;10(4):294-300. 

Excluded topic 

Chan-Yeung M, Manfreda J, Dimich-Ward H, Ferguson A, Watson W, Becker A. A randomized 

controlled study on the effectiveness of a multifaceted intervention program in the primary 

prevention of asthma in high-risk infants. Arch Pediatr Adolesc Med. Jul 2000;154(7):657-663. 

No eligible outcomes 

Charlton I, Charlton G, Broomfield J, Mullee MA. Audit of the effect of a nurse run asthma clinic on 

workload and patient morbidity in a general practice. Br J Gen Pract. Jun 1991;41(347):227-231. 

Ineligible study design 

Charlton I. Self-monitoring or self-management plans for asthma control. Nurs Times. May 15-21 

1991;87(20):52. 

other 

Chiang LC, Huang JL, Yeh KW, Lu CM. Effects of a self-monitoring or self-management asthma 

educational program in Taiwan based on PRECEDE-PROCEED model for parents with asthmatic 

children. J Asthma. Apr 2004;41(2):205-215. 

Reported data not usable 

Chouaid C, Bal JP, Fuhrman C, Housset B, Caudron J. Standardized protocol improves asthma 

management in emergency department. J Asthma. Feb 2004;41(1):19. 

Ineligible study design 

Chowienczyk PJ, Parkin DH, Lawson CP, Cochrane GM. Do asthmatic patients correctly record home 

spirometry measurements? BMJ. Dec 17 1994;309(6969):1618. 

Not an evaluation of a QI 

intervention 

Clancy K. Avoid irritants to reduce breathlessness. Prof Nurse. Feb 2005;20(6):29. Not an evaluation of a QI 

intervention 

Clark NM, Brown R, Joseph CL, Anderson EW, Liu M, Valerio MA. Effects of a comprehensive 

school-based asthma program on symptoms, parent management, grades, and absenteeism. Chest. 

May 2004;125(5):1674-1679. 

Reported data not usable 

Clark NM, Evans D, Mellins RB. Patient use of peak flow monitoring. Am Rev Respir Dis. Mar 

1992;145(3):722-725. 

Ineligible study design 

Clark NM. Asthma self-monitoring or self-management education. Research and implications for 

clinical practice. Chest. May 1989;95(5):1110-1113. 

Ineligible study design 

Cloosterman SG, Schermer TR, Bijl-Hofland ID, et al. Effects of house dust mite avoidance measures 

on Der p 1 concentrations and clinical condition of mild adult house dust mite-allergic asthmatic 

patients, using no inhaled steroids. Clin Exp Allergy. Oct 1999;29(10):1336-1346. 

Not an evaluation of a QI 

intervention 

Coleman R, Gill G, Wilkinson D. Noncommunicable disease management in resource-poor settings: a 

primary care model from rural South Africa. Bull World Health Organ. 1998;76(6):633-640. 

Ineligible study design 

Colland VT. Learning to cope with asthma: a behavioural self-monitoring or self-management program 

for children. Patient Educ Couns. Dec 31 1993;22(3):141-152. 

No eligible outcomes 

Comino EJ, Mitchell CA, Bauman A, et al. Asthma management in eastern Australia, 1990 and 1993. 

Med J Aust. Apr 1 1996;164(7):403-406. 

Ineligible study design 

Coover L, Vega C, Persky V, et al. A collaborative model to enhance the functioning of the school 

child with asthma. Chest. Oct 1999;116(4 Suppl 1):193S-195S. 

Ineligible study design 

Costante C. Asthma: promoting best practice in the school setting. Nasnewsletter. Mar 2000;15(2):12. Not an evaluation of a QI 

intervention 

Couriel J, Littleton V, Milnes L, Barow S. Patient education for children attending an accident and 

emergency (a & e) department with acute asthma - a randomised controlled study. European 

Respiratory Society; 1999 Oct 9-13; Madrid, Spain. 1999:P1756. 

Other 

Crain EF, Walter M, O'Connor GT, et al. Home and allergic characteristics of children with asthma in 

seven U.S. urban communities and design of an environmental intervention: the Inner-City Asthma 

Study. Environ Health Perspect. Sep 2002;110(9):939-945. 

Ineligible study design 
C-4 

Citation Reason for Exclusion 

Creer TL, Backial M, Burns KL, et al. Living with Asthma. I. Genesis and development of a selfmonitoring or self-management program for childhood asthma. J Asthma. 1988;25(6):335-362. No eligible outcomes 

Creer TL, Caplin DA, Holroyd KA. A self-monitoring or self-management program for adult asthma: 

part IV, Analysis of context and patient behaviors. J Asthma. Jul-Aug 2005;42(6):455-462. 

Reported data not usable 

Crockett A, Leonard A. Local asthma guidelines can help reduce hospital admissions. Asthma J. 

2001;6(1):31. 

Ineligible study design 

Darr MS, Self TH, Ryan MR, Vanderbush RE, Boswell RL. Content and retention evaluation of an 

audiovisual patient-education program on bronchodilators. Am J Hosp Pharm. May 1981;38(5):672-

675. 

No eligible outcomes 

de Blay F, Fourgaut G, Hedelin G, et al. Medical Indoor Environment Counselor (MIEC): role in 

compliance with advice on mite allergen avoidance and on mite allergen exposure. Allergy. Jan 

2003;58(1):27-33. 

No eligible outcomes 

De Blay F, Fourgaut G, Lieutier-Colas F, et al. Mite allergen reduction: Role of an indoor technician in 

patients compliance and allergen exposure. J Allergy Clin Immunol. 2001;107(2):S218. 

Abstract 

de Oliveira MA, Bruno VF, Ballini LS, BritoJardim JR, Fernandes AL. Evaluation of an educational 

program for asthma control in adults. J Asthma. 1997;34(5):395-403. 

Ineligible study design 

Demiralay R. Comparison of the effects of three forms of individualized education on asthma 

knowledge in asthmatic patients. Turk J Med Sci. 2002;32(1):57-64. 

No eligible outcomes 

Design and implementation of a patient education center for the Childhood Asthma Management 

Program. Childhood Asthma Management Program Research Group. Ann Allergy Asthma Immunol. 

Dec 1998;81(6):571-581. 

Not an evaluation of a QI 

intervention 

Deter H, Allert G. Group therapy for asthma patients: a concept for the psychosomatic treatment of 

patients in a medical clinic--a controlled study. Psychotherapy & Psychosomatics. 1983;40(1-4):95-

105. 

Not an evaluation of a QI 

intervention 

Diaz Vazquez C, Riano Galan I, Cobo Ruisanchez A, Orejas Rodriguez-Arango G, Sandoval Gutierrez 

L, Florido Mancheno I. Reduction in the number of hospitalizations for asthma. Quality assurance 

program for the management of asthma crises in a district hospital. Spanish. An Esp Pediatr. Nov 

1998;49(5):456. 

Foreign language article 

language 

Dickinson J, Hutton S, Atkin A, Jones K. Reducing asthma morbidity in the community: the effect of a 

targeted nurse-run asthma clinic in an English general practice. Respir Med. Nov 1997;91(10):634-

640. 

Reported data not usable 

Dickinson J, Hutton S, Atkin A. Implementing the British Thoracic Society's guidelines: the effect of a 

nurse-run asthma clinic on prescribed treatment in an English general practice. Respir Med. Feb 

1998;92(2):264-267. 

Ineligible study design 

Dinelli DL, Higgins JC. Case management of asthma for family practice patients: a pilot study. Mil 

Med. Mar 2002;167(3):231-234. 

Ineligible study design 

Doherty SR, Jones PD. Use of an 'evidence-based implementation' strategy to implement evidencebased care of asthma into rural district hospital emergency departments. Rural Remote Health. JanMar 2006;6:529. 

Excluded topic 

Dolinar RM, Kumar V, Coutu-Wakulczyk G, Rowe BH. Pilot study of a home-based asthma health 

education program. Patient Educ Couns. Apr 2000;40(1):93-102. 

No eligible outcomes 

Dosa N, Ilardi D. An opportunity for school nurses and pediatricians to collaborate. School Nurse 

News. Nov 2003;20(5):16-22. 

Other 

D'Souza W, Burgess C, Ayson M, Crane J, Pearce N, Beasley R. Trial of a "credit card" asthma selfmonitoring or self-management plan in a high-risk group of patients with asthma. J Allergy Clin 

Immunol. May 1996;97(5):1085-1092. 

Ineligible study design 
C-5 

Citation Reason for Exclusion 

D'Souza W, Crane J, Burgess C, et al. Community-based asthma care: trial of a "credit card" asthma 

self-monitoring or self-management plan. Eur Respir J. Jul 1994;7(7):1260-1265. 

Ineligible study design 

D'Souza WJ, Slater T, Fox C, et al. Asthma morbidity 6 yrs after an effective asthma self-monitoring 

or self-management programme in a Maori community. Eur Respir J. Mar 2000;15(3):464-469. 

Ineligible study design 

D'Souza WJ, Te Karu H, Fox C, et al. Long-term reduction in asthma morbidity following an asthma 

self-monitoring or self-management programme. Eur Respir J. Mar 1998;11(3):611-616. 

Ineligible study design 

Edgren KK, Parker EA, Israel BA, et al. Community involvement in the conduct of a health education 

intervention and research project: Community Action Against Asthma. Health Promot Pract. Jul 

2005;6(3):263-269. 

Not an evaluation of a QI 

intervention 

Education and follow-up. CMAJ. Sep 13 2005;173(6 Suppl):S51-55. Ineligible study design 

Einhorn E, DiMaio MF. An interdisciplinary program to control pediatric asthma. Continuum Soc Soc 

Work Leadersh Health Care. May-Jun 2000;20(3):8-13. 

Not an evaluation of a QI 

intervention 

Emmerton L, Shaw J, Kheir N. Asthma management by New Zealand pharmacists: a pharmaceutical 

care demonstration project. J Clin Pharm Ther. Oct 2003;28(5):395. 

Ineligible study design 

Emond SD, Woodruff PG, Lee EY, Singh AK, Camargo CA, Jr. Effect of an emergency department 

asthma program on acute asthma care. Ann Emerg Med. Sep 1999;34(3):321-325. 

Ineligible study design 

Emtner M, Herala M, Stalenheim G. High-intensity physical training in adults with asthma. A 10-week 

rehabilitation program. Chest. Feb 1996;109(2):323-330. 

Ineligible study design 

Erickson S, Tolstykh I, Selby JV, Mendoza G, Iribarren C, Eisner MD. The impact of allergy and 

pulmonary specialist care on emergency asthma utilization in a large managed care organization. 

Health Serv Res. Oct 2005;40(5 Pt 1):1443-1465. 

Ineligible study design 

Erickson SR, Ascione FJ, Kirking DM, Johnson CE. Use of a paging system to improve medication 

self-monitoring or self-management in patients with asthma. J Am Pharm Assoc (Wash). Nov-Dec 

1998;38(6):767-769. 

Ineligible study design 

Evans D, Clark NM, Feldman CH. School health education programs for asthma. Clin Rev Allergy. 

Aug 1987;5(3):207-212. 

Ineligible study design 

Feder G, Griffiths C, Highton C, Eldridge S, Spence M, Southgate L. Do clinical guidelines introduced 

with practice based education improve care of asthmatic and diabetic patients? A randomised 

controlled trial in general practices in east London. BMJ. Dec 2 1995;311(7018):1473. 

No eligible outcomes 

Feder G, Griffiths C. The dissemination of asthma and diabetes guidelines to inner-city general 

practice. An evaluation in east London non-training general practices. A personal account of the first 

year of life of the Lambeth Community Care Centre. 1995. 

Other 

Fedullo AJ, Swinburne AJ, McGuire-Dunn C. Complaints of breathlessness in the emergency 

department. The experience at a community hospital. N Y State J Med. Jan 1986;86(1):4-6. 

Not an evaluation of a QI 

intervention 

Ferguson RG, Webb A. Childhood asthma: an outpatient approach to treatment. Can Nurse. Feb 

1979;75(2):36-39. 

Ineligible study design 

Finkelstein J, O'Connor G, Friedmann RH. Development and implementation of the home asthma 

telemonitoring (HAT) system to facilitate asthma self-care. Medinfo. 2001;10(Pt 1):810. 

Ineligible study design 

Fischer L, Scott L, Boonstra D, et al. Pharmaceutical care for patients with chronic conditions. J Am 

Pharm Assoc (Wash). 2000;40(2):174-180. 

No eligible outcomes 

Fisher EB, Jr., Strunk RC, Sussman LK, et al. Acceptability and feasibility of a community approach to 

asthma management: the Neighborhood Asthma Coalition (NAC). J Asthma. 1996;33(6):367-383. 

Reported data not usable 

Fisher EB, Strunk RC, Sussman LK, Sykes RK, Walker MS. Community organization to reduce the 

need for acute care for asthma among African American children in low-income neighborhoods: the 

Neighborhood Asthma Coalition. Pediatrics. Jul 2004;114(1):116-123. 

Reported data not usable 
C-6 

Citation Reason for Exclusion 

Ford M, Havstad S, Tilley B, Bolton M. Health outcomes among African American and Caucasian 

adults following a randomized trial of an asthma education program. Ethn Health. 1997 

1997;2(4):329-339. 

Reported data not usable 

Ford ME, Edwards G, Rodriguez JL, Gibson RC, Tilley BC. An empowerment-centered, church-based 

asthma education program for African American adults. Health Soc Work. Feb 1996;21(1):70-75. 

Reported data not usable 

Francis C. Asthma care in a school environment. Nurs Times. Sep 14-20 2000;96(37):43-45. Ineligible study design 

Francis C. School clinics for adolescents with asthma. Prof Nurse. May 2001;16(8):1281-1284. Reported data not usable 

Freeman LW, Welton D. Effects of imagery, critical thinking, and asthma education on symptoms and 

mood state in adult asthma patients: a pilot study. J Altern Complement Med. Feb 2005;11(1):57-68. 

Ineligible study design 

Freemantle N, The Ebor Trialists. A Randomised trial of the effect of Evidence Based OutReach visits 

by community pharmacists on prescribing in English primary care (EBOR). 2001. 

Other 

Frost L, Kieckhefer GM, Rubino C. Incorporating research into a community asthma program. Pediatr 

Nurs. May-Jun 1988;14(3):197-200. 

Reported data not usable 

Galant DM. Effect of feedback to physicians on asthma patients' health-related quality of life. 

Dissertation Abstracts International: Section B: the Sciences & Engineering. 1999;60(2-B). 

Abstract 

Gallefoss F, Bakke P. Does smoking affect the outcome of patient education and self-monitoring or 

self-management in asthmatics? Patient Educ Couns. Jan 2003;49(1):91-97. 

Reported data not usable 

Gallefoss F, Bakke P. Effect of patient education on compliance in asthmatics and chronic obstructive 

lung disease [abstract]. Am J Respir Crit Care Med. 1998;157(3 Suppl):A275. 

Abstract 

Gallefoss F, Bakke PS, Kjaersgaard P. Health related quality of life assessment after patient education 

in a randomised study on bronchial asthma and chronic obstructive pulmonary disease [abstract]. 

Eur Respir J Suppl. 1998;12 Suppl 28:227S. 

Abstract 

Gallefoss F, Bakke PS. Patient satisfaction with healthcare in asthmatics and patients with COPD 

before and after patient education. Respir Med. Nov 2000;94(11):1057-1064. 

No eligible outcomes 

Gani F, Pozzi E, Crivellaro MA, et al. The role of patient training in the management of seasonal 

rhinitis and asthma: clinical implications. Allergy. Jan 2001;56(1):65-68. 

Excluded topic 

Gardida A, Rojas M, Tavera C, Catalan M. [Evaluation of an educational program to control asthma in 

school age children in the Morelos state, Mexico]. Revista del Instituto Nacional de Enfermedades 

Respiratorias. 2002;15(1):27-30. 

Foreign language article 

language 

Gebert N, Hummelink R, Konning J, et al. Efficacy of a self-monitoring or self-management program 

for childhood asthma--a prospective controlled study. Patient Educ Couns. Nov 1998;35(3):213-220. 

No eligible outcomes 

George M, O'Dowd L, Martin I, et al. A comprehensive educational program improves clinical 

outcome measures in inner-city patients with asthma. Arch Intern Med. Aug 9-23 

1999;159(15):1710-1716. 

Excluded topic 

Georgiou A, Buchner DA, Ershoff DH, Blasko KM, Goodman LV, Feigin J. The impact of a largescale population-based asthma management program on pediatric asthma patients and their 

caregivers. Ann Allergy Asthma Immunol. Mar 2003;90(3):308-315. 

Ineligible study design 

Ghory JE. The pre-school child in an asthma rehabilitation program. J Asthma Res. Sep 1973;11(1):37-

42. 

Ineligible study design 

Gibbs S, Waters WE, George CF. The benefits of prescription information leaflets (1). Br J Clin 

Pharmacol. Jun 1989;27(6):723-739. 

Reported data not usable 

Gibson P, Shah S, Mamoon H. Peer-led asthma education for adolescents: impact evaluation. J 

Adolesc Health. 1998;22(1):66-72. 

No eligible outcomes 
C-7 

Citation Reason for Exclusion 

Gibson PG, Coughlan J, Abramson M. Self-monitoring or self-management education for adults with 

asthma improves health outcomes. West J Med. May 1999;170(5):266. 

Ineligible study design 

Gillies J, Barry D, Crane J, et al. A community trial of a written self management plan for children 

with asthma. Asthma Foundation of NZ Children's Action. N Z Med J. Feb 9 1996;109(1015):30-33. 

Ineligible study design 

Gipson JS, Millard MW, Kennerly DA, Bokovoy J. Impact of the national asthma guidelines on 

internal medicine primary care and speciality practice. Baylor University Medical Center 

Proceedings. October 2000;13(4):407-412. 

Ineligible study design 

Godoy N, Howard K, Cassino C, Ciotoli C, Ziegler P, Reibman J. Asthma education in the emergency 

department improves patient knowledge and behavior [abstract]. Am J Respir Crit Care Med. 

1998;157(3 Suppl):A837. 

Abstract 

Goldberg R, Chan L, Haley P, Harmata-Booth J, Bass G. Critical pathway for the emergency 

department management of acute asthma: effect on resource utilization. Ann Emerg Med. May 

1998;31(5):562-567. 

Ineligible study design 

Grainger-Rousseau T-J. A model for community pharmacist involvement with general practitioners in 

the management of asthma patients. Appl Ther. 1996;1:145-161. 

Reported data not usable 

Grant IW. Asthma in New Zealand. Br Med J (Clin Res Ed). Jan 29 1983;286(6362):374-377. Not an evaluation of a QI 

intervention 

Griffin KW, McNabb WL, Shields MC. Telephone instruction as an adjunct to patient education of 

children with asthma. J Healthc Educ Train. 1989;4(1):1-6. 

Reported data not usable 

Griffiths C, Foster G, Barnes N, et al. Specialist nurse intervention to reduce unscheduled asthma care 

in a deprived multiethnic area: the east London randomised controlled trial for high risk asthma 

(ELECTRA). BMJ. Jan 17 2004;328(7432):144. 

No eligible outcomes 

Griffiths C. (ELECTRA study):Can asthma liaison nurses cost effectively reduce unscheduled care for 

patients with high risk asthma? - a randomised controlled trial. National Research Register. 2000. 

Other 

Griffiths CJ. Educational outreach: a key to implementing asthma guidelines? Qual Health Care. 

2000;8:73. 

Ineligible study design 

Guevara JP, Wolf FM, Grum CM, Clark NM. Effects of educational interventions for self management 

of asthma in children and adolescents: systematic review and meta-analysis. BMJ. Jun 14 

2003;326(7402):1308-1309. 

Ineligible study design 

Guevara JP, Wolf FM, Grum CM, Clark NM. Learning about asthma: educational programmes 

improve the ability of children and teenagers to manage their asthma. BMJ. 2003;326. 

Ineligible study design 

Gustafsson PA, Kjellman NI, Cederblad M. Family therapy in the treatment of severe childhood 

asthma. J Psychosom Res. 1986;30(3):369-374. 

Not an evaluation of a QI 

intervention 

Haahtela T, Klaukka T, Koskela K, Erhola M, Laitinen LA. Asthma programme in Finland: a 

community problem needs community solutions. Thorax. Oct 2001;56(10):806-814. 

Ineligible study design 

Hadjianastassiou VG, Karadaglis D, Gavalas M. A comparison between different formats of 

educational feedback to junior doctors: a prospective pilot intervention study. J R Coll Surg Edinb. 

Dec 2001;46(6):354. 

No eligible outcomes 

Hanks S, Strudley M. Asthma in the classroom. Nurs Stand. Nov 7-13 1990;5(7):49-51. Ineligible study design 

Harper T, Wizowski L. Group plus individual education improved quality of life and lung function in 

patients with asthma [commentary on Gallefoss F, Bakke PS, Kjaersgaard P. Quality of life 

assessment after patient education in a randomized controlled study on asthma and chronic 

obstructive pulmonary disease. Am J Respir Crit Care Med 1999 Mar;159:812-7]. Evid Based Nurs. 

1999 1999;2(4):118. 

Ineligible study design 

Hazell J, Henry RL, Francis JL, Halliday JA. Teacher initiated improvement of asthma policy in 

schools. J Paediatr Child Health. Dec 1995;31(6):519-522. 

Ineligible study design 
C-8 

Citation Reason for Exclusion 

Hendricson WD, Wood PR, Hidalgo HA, et al. Implementation of individualized patient education for 

Hispanic children with asthma. Patient Educ Couns. Nov 1996;29(2):155-165. 

No eligible outcomes 

Hindi-Alexander M, Cropp GJ. Community and family programs for children with asthma. Ann 

Allergy. Mar 1981;46(3):143-148. 

No eligible outcomes 

Hindi-Alexander MC, Throm J, Middleton E, Jr. Collaborative asthma self-monitoring or selfmanagement. Evaluation designs. Clin Rev Allergy. Aug 1987;5(3):249-258. Ineligible study design 

Hockemeyer J, Smyth J. Evaluating the feasibility and efficacy of a self-administered manual-based 

stress management intervention for individuals with asthma: results from a controlled study. Behav 

Med. Winter 2002;27(4):161-172. 

Not an evaluation of a QI 

intervention 

Holcomb SS. Asthma update 2005: guidelines for pregnant women. Dimens Crit Care Nurs. Nov-Dec 

2005;24(6):263-266. 

Not an evaluation of a QI 

intervention 

Holzheimer L, Mohay H, Masters IB. Educating young children about asthma: comparing the 

effectiveness of a developmentally appropriate asthma education video tape and picture book. Child 

Care Health Dev. Jan 1998;24(1):85-99. 

Reported data not usable 

Home-taught pediatric asthma program improves outcomes, cuts hospital, physician visits. Health Care 

Cost Reengineering Rep. Mar 1997;2(3):40-43. 

Reported data not usable 

Horner SD. Using the Open Airways curriculum to improve self-care for third grade children with 

asthma. J Sch Health. Oct 1998;68(8):329-333. 

Ineligible study design 

Hovell MF, Meltzer SB, Wahlgren DR, et al. Asthma management and environmental tobacco smoke 

exposure reduction in Latino children: a controlled trial. Pediatrics. Nov 2002;110(5):946-956. 

No eligible outcomes 

How asthma friendly is your school? National Heart, Lung, and Blood Institute. National Asthma 

Education and Prevention Program. School Asthma Education Subcommittee. J Sch Health. Apr 

1998;68(4):167-168. 

Ineligible study design 

Huss K, Huss R, Squire E, et al. Computer education for asthmatics: what effects? J Nurs Care Qual. 

1992;6(3):57-66. 

No eligible outcomes 

Huss K, Salerno M, Huss RW. Computer-assisted reinforcement of instruction: effects on adherence in 

adult atopic asthmatics. Res Nurs Health. Aug 1991;14(4):259-267. 

No eligible outcomes 

Huss K, Winkelstein M, Nanda J, Naumann PL, Sloand ED, Huss RW. Computer game for inner-city 

children does not improve asthma outcomes. J Pediatr Health Care. Mar-Apr 2003;17(2):72-78. 

No eligible outcomes 

Hyland ME, Kenyon CA, Allen R, Howarth P. Diary keeping in asthma: comparison of written and 

electronic methods. BMJ. Feb 20 1993;306(6876):487-489. 

No eligible outcomes 

Hyman D. Reorganizing health systems to promote best practice medical care, patient self-monitoring 

or self-management, and family-centered care for childhood asthma. Ethn Dis. Summer 2003;13(3 

Suppl 3):S3-94-98. 

Not an evaluation of a QI 

intervention 

Im J. Evaluation of effectiveness of an asthma clinic managed by an ambulatory care pharmacist. Calif 

J Hosp Pharm. 1989;39:182-186. 

Ineligible study design 

Indinnimeo L, Midulla F, Hindi-Alexander M, et al. Controlled studies of childhood asthma selfmonitoring or self-management in Italy using the "open airways" and "living with asthma" 

programs: a preliminary report. Health Educ Q. Fall 1987;14(3):291-308. 

No eligible outcomes 

Irvine L, Crombie IK, Clark RA, et al. Advising parents of asthmatic children on passive smoking: 

randomised controlled trial. BMJ. May 29 1999;318(7196):1456-1459. 

No eligible outcomes 

Jans MP, Schellevis FG, Le Coq EM, Bezemer PD, van Eijk JT. Health outcomes of asthma and 

COPD patients: the evaluation of a project to implement guidelines in general practice. Int J Qual 

Health Care. Feb 2001;13(1):17. 

Reported data not usable 
C-9 

Citation Reason for Exclusion 

Jans MP, Schellevis FG, Van Hensbergen W, van Eijk JT. Improving general practice care of patients 

with asthma or chronic obstructive pulmonary disease: evaluation of a quality system see comments. 

Eff Clin Pract. Jan-Feb 2000;3(1):16. 

Reported data not usable 

Jones CA, Clement LT, Hanley-Lopez J, et al. The Breathmobile Program: structure, implementation, 

and evolution of a large-scale, urban, pediatric asthma disease management program. Dis Manag. 

Aug 2005;8(4):205-222. 

Ineligible study design 

Joseph V. A study compliance to two alternative drug regimens and the effect of health education on 

drug compliance in school age children with bronchial asthma. Nurs J India. Jul 2004;95(7):153-

154. 

Not an evaluation of a QI 

intervention 

Joyce N. A blow for accuracy. Nurs Stand. Mar 1-7 2000;14(24):22. Ineligible study design 

Kaplan DL, Rips JL, Clark NM, Evans D, Wasilewski Y, Feldman CH. Transferring a clinic-based 

health education program for children with asthma to a school setting. J Sch Health. Sep 

1986;56(7):267-271. 

No eligible outcomes 

Kattan M, Stearns SC, Crain EF, et al. Cost-effectiveness of a home-based environmental intervention 

for inner-city children with asthma. J Allergy Clin Immunol. Nov 2005;116(5):1058-1063. 

Reported data not usable 

Kauppinen R, Sintonen H, Pekurinen M. Economic evaluation of intensive vs. conventional patient 

education and supervision for self-monitoring or self-management of asthma [abstract]. 12th Annual 

Meeting of the International Society of Technology Assessment in Health Care; 1996 Jun 23-26. 

1996:5. 

Abstract 

Kemp VH, Baker RR. School-based asthma screening program. J Am Acad Nurse Pract. Nov 

1997;9(11):511-513. 

Not an evaluation of a QI 

intervention 

Kerac M, Montgomery H, Johnson N. A low cost spacer device used for asthma treatment in a Calcutta 

street clinic to improve efficacy of metered dose inhalers. Trop Doct. Oct 1998;28(4):228-229. 

Not an evaluation of a QI 

intervention 

Killian JM, Naessens JM, Kelley LK, Angstman GL. Baseline results for the assessment of the impact 

of clinical guidelines for pediatric asthma on medical care utilization. In: Data needs in an era of 

health reform: proceedings of the 25th Public Health Conference on Records and Statistics and the 

National Committee on Vital and Health Statistics 45th Anniversary Symposium, July 17-19, 1995, 

Washington, D.C. 1995. 

Ineligible study design 

Klingelhofer EL, Gershwin ME. Asthma self-monitoring or self-management programs: premises, not 

promises. J Asthma. 1988;25(2):89-101. 

Ineligible study design 

Klinnert MD, Liu AH, Pearson MR, Ellison MC, Budhiraja N, Robinson JL. Short-term impact of a 

randomized multifaceted intervention for wheezing infants in low-income families. Arch Pediatr 

Adolesc Med. Jan 2005;159(1):75-82. 

Reported data not usable 

Kokubu F, Nakajima S, Ito K, et al. Hospitalization reduction by an asthma tele-medicine system. 

Japanese. Arerugi. Jan 2000;49(1):19. 

Foreign language article 

language 

Kotses H, Bernstein IL, Bernstein DI, et al. A self-monitoring or self-management program for adult 

asthma. Part I: Development and evaluation. J Allergy Clin Immunol. Feb 1995;95(2):529-540. 

Reported data not usable 

Kotses H, Stout C, Wigal JK, Carlson B, Creer TL, Lewis P. Individualized asthma self-monitoring or 

self-management: a beginning. J Asthma. 1991;28(4):287-289. 

Reported data not usable 

Krieger JK, Takaro TK, Allen C, et al. The Seattle-King County healthy homes project: 

implementation of a comprehensive approach to improving indoor environmental quality for lowincome children with asthma. Environ Health Perspect. Apr 2002;110 Suppl 2:311-322. 

Reported data not usable 

Labelle M, Beaulieu M, Renzi P, Rahme E, Thivierge RL. Integrating clinical practice guidelines into 

daily practice: impact of an interactive workshop on drafting of a written action plan for asthma 

patients. J Contin Educ Health Prof. Winter 2004;24(1):39. 

Ineligible study design 
C-10 

Citation Reason for Exclusion 

Laurant M, Hermens RP, Braspenning JC, Sibbald B, Grol RP. Impact of nurse practitioners on 

workload of general practitioners: randomised controlled trial. BMJ. Apr 17 2004;328(7445):927. 

No eligible outcomes 

Lawrence G. Asthma self-monitoring or self-management programs can reduce the need for hospitalbased asthma care. Respir Care. Jan 1995;40(1):39-43. Ineligible study design 

Le Clainche L, Le Bourgeois M, Delacourt C, Scheinmann P, de Blic J. Between Scylla and Carybdis: 

how to monitor severe asthma in early childhood? Pediatr Allergy Immunol. 1998;9(11 Suppl):37-

41. 

Not an evaluation of a QI 

intervention 

Lewis BE. Research at Fallon Community Health Plan. Med Care Res Rev. Mar 1996;53 Suppl:S92-

103. 

Ineligible study design 

Lewis MA, de la Sota A, Rachelefsky G, Lewis CE, Quinones H, Richards W. ACT-asthma control y 

tratamiento para ninos: a progress report. Health Educ Q. Fall 1987;14(3):281-290. 

Reported data not usable 

Lincicome V, Lozano P, Jones C, et al. The nurse-patient collaboration: Experiences with a selfmonitoring or self-management support intervention for asthma. J Allergy Clin Immunol. 

2001;107(2):S73. 

Abstract 

Lindberg M, Ahlner J, Ekstrom T, Jonsson D, Moller M. Asthma nurse practice improves outcomes 

and reduces costs in primary health care. Scan J Caring Sci. Mar 2002;16(1):73. 

Ineligible study design 

Lindberg M. Evaluation of nurse-run asthma clinics in primary care. Higher quality for less money? . 

Swedish. Lakartidningen. May 16 2002;99(20):2277. 

Foreign language article 

language 

Lundborg CS, Wahlstrom R, Diwan VK, Oke T, Martenson D, Tomson G. Combining feedback from 

simulated cases and prescribing. Design and implementation of an educational intervention in 

primary care in Sweden. Int J Technol Assess Health Care. Summer 1999;15(3):458. 

No eligible outcomes 

Lurie N, Bauer EJ, Brady C. Asthma outcomes at an inner-city school-based health center. J Sch 

Health. Jan 2001;71(1):9-16. 

Ineligible study design 

Macarthur C, Calpin C, Parkin PC, Feldman W. Factors associated with pediatric asthma readmissions. 

J Allergy Clin Immunol. Nov 1996;98(5 Pt 1):992-993. 

Not an evaluation of a QI 

intervention 

Madge P, McColl J, Paton J. Impact of a nurse-led home management training programme in children 

admitted to hospital with acute asthma: a randomised controlled study. Thorax. Mar 1997;52(3):223-

228. 

Excluded topic 

Maes S, Schlosser M. Changing health behaviour outcomes in asthmatic patients: a pilot intervention 

study. Soc Sci Med. 1988;26(3):359-364. 

Reported data not usable 

Maggio L. Asthma Education Project: "the asthma warriors". Ambul Outreach. Spring 1998:9. Ineligible study design 

Maiman LA, Green LW, Gibson G, MacKenzie EJ. Education for self-treatment by adult asthmatics. 

JAMA. May 4 1979;241(18):1919-1922. 

No eligible outcomes 

Marabini A, Brugnami G, Currad iF, et al. Short-term effectiveness of an asthma patient education 

program [abstract]. Am J Respir Crit Care Med. 1998;157(3 Suppl):A737. 

Abstract 

Marini A, Agosti M, Motta G, Mosca F. Effects of a dietary and environmental prevention programme 

on the incidence of allergic symptoms in high atopic risk infants: three years' follow-up. Acta 

Paediatr Suppl. May 1996;414:1-21. 

Not an evaluation of a QI 

intervention 

Marks MK, Hynson JL, Karabatsos G. Asthma: communication between hospital and general 

practitioners. J Paediatr Child Health. Jun 1999;35(3):251. 

No eligible outcomes 

Martin RJ, Pak J, Kunselman SJ, Cherniack RM. Assessment of the AirWatch lung function 

monitoring system.Asthma Clinical Research Network (ACRN). J Allergy Clin Immunol. Mar 

1999;103(3 Pt 1):535-536. 

Not an evaluation of a QI 

intervention 

Matthews B, Dickinson A, Cram F. Establishment and evaluation of a preschool asthma programme: a 

pilot study. Nurs Prax N Z. Nov 1998;13(3):25-34. 

Ineligible study design 
C-11 

Citation Reason for Exclusion 

McCarthy MJ, Herbert R, Brimacombe M, Hansen J, Wong D, Zelman M. Empowering parents 

through asthma education. Pediatr Nurs. Sep-Oct 2002;28(5):465. 

No eligible outcomes 

McConnell R, Jones C, Milam J, et al. Cockroach counts and house dust allergen concentrations after 

professional cockroach control and cleaning. Ann Allergy Asthma Immunol. Dec 2003;91(6):546-

552. 

Not an evaluation of a QI 

intervention 

McDermott MF, Murphy DG, Zalenski RJ, et al. A comparison between emergency diagnostic and 

treatment unit and inpatient care in the management of acute asthma. Arch Intern Med. Oct 13 

1997;157:2055. 

Not an evaluation of a QI 

intervention 

McEwen M, Johnson P, Neatherlin J, Millard MW, Lawrence G. School-based management of chronic 

asthma among inner-city African-American schoolchildren in Dallas, Texas. J Sch Health. May 

1998;68(5):196-201. 

Ineligible study design 

McMullen AH, Yoos HL, Kitzman H. Peak flow meters in childhood asthma: parent report of use and 

perceived usefulness. J Pediatr Health Care. Mar-Apr 2002;16(2):67-72. 

No eligible outcomes 

Meinert R, Frischer T, Kuehr J. The "healthy passive smoker": relationship between bronchial hyperreactivity in school children and maternal smoking. J Epidemiol Community Health. Jun 

1994;48(3):325-326. 

Not an evaluation of a QI 

intervention 

Meng A, McConnell S. Asthma education: special applications for the school-age child. Nurs Clin 

North Am. Dec 2003;38(4):653-664. 

No eligible outcomes 

Meng A. A school-based asthma clinic: a partnership model for managing childhood asthma. Nurse 

Pract Forum. Mar 2000;11(1):38-47. 

Ineligible study design 

Millard MW, Johnson PT, McEwen M, et al. A randomized controlled trial using the school for antiinflammatory therapy in asthma. J Asthma. 2003;40(7):769-776. Reported data not usable 

Mitchell EA, Ferguson V, Norwood M. Asthma education by community child health nurses. Arch Dis 

Child. Dec 1986;61(12):1184-1189. 

No eligible outcomes 

Molimard M. How to achieve good compliance and adherence with inhalation therapy. Curr Med Res 

Opin. 2005;21 Suppl 4:S33-37. 

Not an evaluation of a QI 

intervention 

Morice AH, Wrench C. The role of the asthma nurse in treatment compliance and self-monitoring or 

self-management following hospital admission. Respir Med. Nov 2001;95(11):851-856. 

Excluded topic 

Morlion B, Verbandt Y, Paiva M, et al. A telemanagement system for home follow-up of respiratory 

patients. IEEE Eng Med Biol Mag. Jul-Aug 1999;18(4):71-79. 

Ineligible study design 

Moscato G, Godnic-Cvar J, Maestrelli P, Malo JL, Burge PS, Coifman R. Statement on self-monitoring 

of peak expiratory flows in the investigation of occupational asthma. Subcommittee on Occupational 

Allergy of European Academy of Allergy and Clinical Immunology, American Academy of Allergy 

and Immunology, European Respiratory Society, American College of Allergy, Asthma and 

Immunology. Ann Allergy Asthma Immunol. Sep 1995;75(3):233-238. 

Ineligible study design 

Moscato G, Godnic-Cvar J, Maestrelli P, Malo JL, Burge PS, Coifman R. Statement on self-monitoring 

of peak expiratory flows in the investigation of occupational asthma. Subcommittee on Occupational 

Allergy of the European Academy of Allergology and Clinical Immunology. American Academy of 

Allergy and Clinical Immunology. European Respiratory Society. American College of Allergy, 

Asthma and Immunology. Eur Respir J. Sep 1995;8(9):1605-1610. 

Ineligible study design 

Moscato G, Godnic-Cvar J, Maestrelli P, Malo JL, Sherwood Burge P, Coifman R. Statement on selfmonitoring of peak expiratory flow in the investigation of occupational asthma. Subcommittee on 

Occupational Allergy of the European Academy of Allergology and Clinical Immunology. Allergy. 

Sep 1995;50(9):711-717. 

Ineligible study design 

Moscato G, Godnic-Cvar J, Maestrelli P. Statement on self-monitoring of peak expiratory flows in the 

investigation of occupational asthma. Subcommittee on Occupational Allergy of European Academy 

of Allergy and Clinical Immunology. J Allergy Clin Immunol. Sep 1995;96(3):295-301. 

Ineligible study design 
C-12 

Citation Reason for Exclusion 

Moudgil H, Marshall T, Honeybourne D. Asthma education and quality of life in the community: a 

randomised controlled study to evaluate the impact on white European and Indian subcontinent 

ethnic groups from socioeconomically deprived areas in Birmingham, UK. Thorax. Mar 

2000;55(3):177-183. 

Reported data not usable 

Murray MD, Loos B, Tu W, Eckert GJ, Zhou XH, Tierney WM. Work patterns of ambulatory care 

pharmacists with access to electronic guideline-based treatment suggestions. Am J Health Syst 

Pharm. 1999;56(3):225. 

No eligible outcomes 

Nair SJ, Daigle KL, DeCuir P, Lapin CD, Schramm CM. The influence of pulmonary function testing 

on the management of asthma in children. J Pediatr. Dec 2005;147(6):797-801. 

Not an evaluation of a QI 

intervention 

Narhi U, Airaksinen M, Tanskanen P, Erlund H. Therapeutic outcomes monitoring by community 

pharmacists for improving clinical outcomes in asthma. J Clin Pharm Ther. Jun 2000;25(3):177-183. 

Ineligible study design 

National Asthma Education and Prevention Program. Resolution on asthma management at school. 

School Nurse News. Nov 2002;19(5):16-17. 

Not an evaluation of a QI 

intervention 

Neville R, Clark R. The Childhood Asthma Project 1990-93. A report on a controlled trial of an audit 

facilitator on the diagnosis and treatment of childhood asthma in general practice. 1995. 

Other 

Nies MA, Bickes JT, Schim SM, Johnson AL. Model for community health nursing care: application 

to an integrated asthma intervention program. J Sch Nurs. Apr 2002;18(2):74-78. 

Ineligible study design 

Niksic D, Saracevic E, Cemerlic-Kulic A, Kurspahic-Mujcic A, Bajraktarevic S, Niksic H. Evaluation 

of efficiency practical issues in the management of childhood asthma. Bosn J Basic Med Sci. Nov 

2005;5(4):40-45. 

Ineligible study design 

Oprehek J, Gayard P, Grimaud C, Charpin J. Patient error in use of bronchidilator metered aerosols. Br 

Med J. Jan 10 1976;1(6001):76. 

Not an evaluation of a QI 

intervention 

Osman LM, Calder C, Godden DJ, et al. A randomised trial of self-monitoring or self-management 

planning for adult patients admitted to hospital with acute asthma. Thorax. Oct 2002;57(10):869-

874. 

Excluded topic 

Parcel GS, Nader PR, Tiernan K. A health education program for children with asthma. J Dev Behav 

Pediatr. Sep 1980;1(3):128-132. 

No eligible outcomes 

Parcel GS, Nader PR. Evaluation of a pilot school health education program for asthmatic children. J 

Sch Health. Oct 1977;47(8):453-456. 

Ineligible study design 

Partridge MR, Fabbri LM, Chung KF. Delivering effective asthma care--how do we implement asthma 

guidelines? Eur Respir J. Feb 2000;15(2):235. 

Not an evaluation of a QI 

intervention 

Path inventory facilitates benchmarking care paths. Healthc Benchmarks. Nov 1997;4(11):159-161. Not an evaluation of a QI 

intervention 

Patient/provider education is cornerstone of successful DM approach to asthma. Dis Manag Advis. Sep 

2000;6(9):144-146, 132, suppl 141 p. 

Ineligible study design 

Patterson EE, Brennan MP, Linskey KM, Webb DC, Shields MD, Patterson CC. A cluster randomised 

intervention trial of asthma clubs to improve quality of life in primary school children: the School 

Care and Asthma Management Project (SCAMP). Archives of Disease in Childhood. Aug 

2005;90(8):786-791. 

Ineligible study design 

Pauley TR, Magee MJ, Cury JD. Pharmacist-managed, physician-directed asthma management 

program reduces emergency department visits. Ann Pharmacother. Jan 1995;29(1):5-9. 

Ineligible study design 

Peak flow-based compared to symptom-based written action plans. J Allergy Clin Immunol. Nov 

2002;110(5 Suppl):S192-196. 

Not an evaluation of a QI 

intervention 

Pearce MJ, Begg EJ. Encouraging consensus cost effective drug therapy: five years experience with a 

hospital drug utilisation review programme. N Z Med J. Mar 281997;110(1040):92. 

Excluded topic 
C-13 

Citation Reason for Exclusion 

Perry CS, Toole KA. Impact of school nurse case management on asthma control in school-aged 

children. J Sch Health. Sep 2000;70(7):303-304. 

Ineligible study design 

Persky V, Coover L, Hernandez E, et al. Chicago community-based asthma intervention trial: 

feasibility of delivering peer education in an inner-city population. Chest. Oct 1999;116(4 Suppl 

1):216S-223S. 

Reported data not usable 

Petheram IS, Jones DA, Collins JV. Assessment and management of acute asthma in the elderly: a 

comparison with younger asthmatics. Postgrad Med J. Mar 1982;58(677):149-151. 

Not an evaluation of a QI 

intervention 

Pharmacotherapy--add-on therapies. CMAJ. Sep 13 2005;173(6 Suppl):S37-38. Not an evaluation of a QI 

intervention 

Pinnock H, Bawden R, Proctor S, et al. Accessibility, acceptability, and effectiveness in primary care 

of routine telephone review of asthma: pragmatic, randomised controlled trial. BMJ. Mar 1 

2003;326(7387):477. 

No eligible outcomes 

Pituch M, Bruggeman J. Lungs unlimited: a self-care program for asthmatic children and their families. 

Child Today. Jul-Aug 1982;11(4):6-10. 

Ineligible study design 

Poirier S, LeLorier J, Page V, Lacour A. The effect of a $2 co-payment on prescription refill rates of 

Quebec elderly and its relationship to socio-economic status. Can Pharm J. 1998;131(1):30. 

Not an evaluation of a QI 

intervention 

Poulsen SS, Petersen BN. Letter: Letter to the editor. Scand J Respir Dis. 1976;57(2):97-98. Not an evaluation of a QI 

intervention 

Premaratne UN, Sterne JA, Marks GB, Webb JR, Azima H, Burney PG. Clustered randomised trial of 

an intervention to improve the management of asthma: Greenwich asthma study. BMJ. May 8 

1999;318(7193):1251. 

Reported data not usable 

Program succeeds tackling two diseases with one approach. Dis Manag Advis. Oct 2002;8(10):145-

149. 

Ineligible study design 

Rachelefsky GS, Lewis CE, de la Sota A, Lewis MA. ACT (asthma care training) for kids. A 

childhood asthma self-monitoring or self-management program. Chest. Jan 1985;87(1 Suppl):98S100S. 

Ineligible study design 

Rance K, Trent C. Broccoli and pixie stix. Profile of a pediatric asthma program. Adv Nurse Pract. Mar 

2004;12(3):47-48. 

Ineligible study design 

Rance KS, Trent CA. Profile of a primary care practice asthma program: improved patient outcomes in 

a high-risk population. J Pediatr Health Care. Jan-Feb 2005;19(1):25-32. 

Ineligible study design 

Ratima MM, Fox C, Fox B, et al. Long-term benefits for Maori of an asthma self-monitoring or selfmanagement program in a Maori community which takes a partnership approach. Aust N Z J Public 

Health. Dec 1999;23(6):601-605. 

Ineligible study design 

Reddel HK, Toelle BG, Marks GB, Ware SI, Jenkins CR, Woolcock AJ. Analysis of adherence to peak 

flow monitoring when recording of data is electronic. BMJ. Jan 19 2002;324(7330):146-147. 

Not an evaluation of a QI 

intervention 

Redline S, Gruchalla RS, Wolf RL, et al. Development and validation of school-based asthma and 

allergy screening questionnaires in a 4-city study. School Nurse News. Nov 2004;21(5):12-14. 

Not an evaluation of a QI 

intervention 

Richards W, Church JA, Roberts MJ, Newman LJ, Garon MR. A self-help program for childhood 

asthma in a residential treatment center. Clin Pediatr (Phila). Jul 1981;20(7):453-457. 

Ineligible study design 

Richardson CR. Homemade spacers useful in asthma treatment. J Fam Pract. Dec 1999;48(12):997. Not an evaluation of a QI 

intervention 

Ringsberg KC, Timpka T. Clinical health education for patients with asthma-like symptoms but 

negative asthma tests. Allergy. 2001;56(11):1049-1054. 

Excluded topic 
C-14 

Citation Reason for Exclusion 

Robichaud P, Laberge A, Allen MF, et al. Evaluation of a program aimed at increasing referrals for 

asthma education of patients consulting at the emergency department for acute asthma. Chest. Nov 

2004;126(5):1495-1501. 

No eligible outcomes 

Roemer W, Hoek G, Brunekreef B. Pollution effects on asthmatic children in Europe, the PEACE 

study. Clin Exp Allergy. Aug 2000;30(8):1067-1075. 

Not an evaluation of a QI 

intervention 

Rohl BJ, Meyer LC, Lung CL. An individualized, comprehensive asthma care treatment program. Med 

Interface. Mar 1994;7(3):121-123, 134. 

Ineligible study design 

Roque F, Walker L, Herrod P, Pyzik T, Clapp W. The Lawndale Christian Health Center Asthma 

Education Program. Chest. Oct 1999;116(4 Suppl 1):201S-202S. 

Ineligible study design 

Ross DJ. Ten years of the SWORD project. Surveillance of Work-related and Occupational 

Respiratory Disease. Clin Exp Allergy. Jun 1999;29(6):750-753. 

Not an evaluation of a QI 

intervention 

Ross S, Togger D, Desjardins D. Asthma disease management program cuts readmissions. Hosp Case 

Manag. Oct 1998;6(10):197-200. 

Ineligible study design 

RTs, doctors team up to lead successful asthma program. Healthc Demand Dis Manag. Jun 

1999;5(6):81-85. 

Ineligible study design 

Rundall TG, Shortell SM, Wang MC, et al. As good as it gets? Chronic care management in nine 

leading US physician organisations. BMJ. Oct 26 2002;325(7370):958-961. 

Excluded topic 

Rupp MT, McCallian DJ, Sheth KK. Developing and marketing a community pharmacy-based asthma 

management program. J Am Pharm Assoc (Wash). Nov-Dec 1997;NS37(6):694-699. 

Ineligible study design 

Saini B, Krass I, Armour C. Development, implementation, and evaluation of a community pharmacybased asthma care model. Ann Pharmacother. Nov 2004;38(11):1954-1960. Reported data not usable 

Sauro A, Scalzitti F, Buono N, et al. Spirometry is really useful and feasible in the GP's daily practice 

but guidelines alone are not. Eur J Gen Pract. Mar 2005;11(1):29-31. 

Reported data not usable 

Savage I, Goodyear L. Providing information on metered dose inhaler technique: Is multimedia as 

effective as print? Family Practice. 2003;20(5):552-557. 

No eligible outcomes 

Schermer TR, Thoonen BP, van den Boom G, et al. Randomized controlled economic evaluation of 

asthma self-monitoring or self-management in primary health care. Am J Respir Crit Care Med. Oct 

15 2002;166(8):1062-1072. 

No eligible outcomes 

Schlosser M. Patient-education in asthma and COPD: differences and similarities [abstract]. Eur Respir 

J Suppl. 1995;8 Suppl 19:216S. 

Abstract 

Schmaling K, Blume A, Afari N. A randomized controlled pilot study of motivational interviewing to 

change attitudes about adherence to medications for asthma. J Clinl Psych Med Settings. 

2001;8(3):167-172. 

No eligible outcomes 

Schneeweiss S, Maclure M, Carleton B, Glynn RJ, Avorn J. Clinical and economic consequences of a 

reimbursement restriction of nebulised respiratory therapy in adults: direct comparison of 

randomised and observational evaluations. BMJ. 2004;328(7439):560. 

Not an evaluation of a QI 

intervention 

Schneider MR, Melton BH, Reisch JS. Effects of a progressive exercise program on absenteeism 

among school children with asthma. J Sch Health. Feb 1980;50(2):92-95. 

Not an evaluation of a QI 

intervention 

Schonberger HJ, Dompeling E, Knottnerus JA, et al. The PREVASC study: the clinical effect of a 

multifaceted educational intervention to prevent childhood asthma. Eur Respir J. Apr 

2005;25(4):660-670. 

Excluded topic 

Schonberger HJ, Maas T, Dompeling E, Knottnerus JA, van Weel C, van Schayck CP. Compliance of 

asthmatic families with a primary prevention programme of asthma and effectiveness of measures to 

reduce inhalant allergens--a randomized trial. Clin Exp Allergy. Jul 2004;34(7):1024-1031. 

No eligible outcomes 
C-15 

Citation Reason for Exclusion 

Schreurs KM, Colland VT, Kuijer RG, de Ridder DT, van Elderen T. Development, content, and 

process evaluation of a short self-monitoring or self-management intervention in patients with 

chronic diseases requiring self-care behaviours. Patient Educ Couns. Oct 2003;51(2):133-141. 

Reported data not usable 

Schulte A, Musolf J, Meurer JR, Cohn JH, Kelly KJ. Pediatric asthma case management: a review of 

evidence and an experimental study design. J Pediatr Nurs. Aug 2004;19(4):304-310. 

Ineligible study design 

Serrier P, Muller D, Sevin C, Mechin H, Chanal I. Evaluation of an educational program on asthma for 

pharmacists . French. Presse Med. Nov 25 2000;29(36):1987. 

Foreign language article 

language 

Shah S, Gibson PG, Wachinger S. Recognition and crisis management of asthma in schools. J Paediatr 

Child Health. Aug 1994;30(4):312-315. 

Ineligible study design 

Shegog R, Bartholomew LK, Parcel GS, Sockrider MM, Masse L, Abramson SL. Impact of a 

computer-assisted education program on factors related to asthma self-monitoring or selfmanagement behavior. J Am Med Inform Assoc. Jan-Feb 2001;8(1):49-61. 

No eligible outcomes 

Shelledy D, McCormick S, LeGrand T, Cardenas J, Peters J. The effect of a pediatric asthma 

management program provided by respiratory therapists on patient outcomes and cost. Heart & 

Lung. 2005;34(6):423-428. 

Ineligible study design 

Sly PD. Peak expiratory flow monitoring in pediatric asthma: is there a role? J Asthma. 

1996;33(5):277-287. 

Not an evaluation of a QI 

intervention 

Sly RM. Evaluation of a sound-slide program for patient education. Ann Allergy. Feb 1975;34(2):94-

97. 

No eligible outcomes 

Smeele IJ, Van Schayck CP, Grol R, et al. Implementing national guidelines on asthma/COPD in 

general practice; the effects of continuous monitoring and feedback at patient level dissertation. 

1998. 

Thesis/Dissertation 

Smeele IJM, Grol R, Van Schayck CP, Van den Bosch W, Van den Hoogen HJM, Muris JWM. Can 

small group education and peer review improve care for patients with asthma/chronic obstructive 

pulmonary disease? Qual Health Care. Jun 1999;8(2):92. 

Reported data not usable 

Smeele IJM, Grol R, Van Schayck CP, Van den Bosch W, Van den Hoogen HJM, Muris JWM. 

Improving care for patients with asthma/COPD. A randomized experimental study on the effects of 

an intensive small group education and peer review programme on care provision and patient 

outcomes dissertation. 1998. 

Thesis/Dissertation 

Smith BJ, McElroy HJ, Ruffin RE, et al. The effectiveness of coordinated care for people with chronic 

respiratory disease. comment. Med J Aust. 2002;177(9):481. 

Excluded topic 

Sommaruga M, Spanevello A, Migliori GB, Neri M, Callegari S, Majani G. The effects of a cognitive 

behavioural intervention in asthmatic patients. Monaldi Arch Chest Dis. Oct 1995;50(5):398-402. 

Not an evaluation of a QI 

intervention 

Sondergaard J, Andersen M, Vach K, Kragstrup J, Maclure M, Gram LF. Detailed postal feedback 

about prescribing to asthma patients combined with a guideline statement showed no impact: a 

randomised controlled trial. Eur J Clin Pharmacol. May 2002;58(2):127. 

Reported data not usable 

Sorrells VD, Chung W, Schlumpberger JM. The impact of a summer asthma camp experience on 

asthma education and morbidity in children. J Fam Pract. Nov 1995;41(5):465-468. 

Ineligible study design 

Spector SL. Is your asthmatic patient really complying? Ann Allergy. Oct 1985;55(4):552-556. Not an evaluation of a QI 

intervention 

Sperber K, Ibrahim H, Hoffman B, Eisenmesser B, Hsu H, Corn B. Effectiveness of a specialized 

asthma clinic in reducing asthma morbidity in an inner-city minority population. J Asthma. 

1995;32(5):335. 

Ineligible study design 

Steinwachs DM, Wu AW, Skinner EA. How will outcomes management work? Health Aff 

(Millwood). Fall 1994;13(4):153-162. 

No eligible outcomes 
C-16 

Citation Reason for Exclusion 

Summaries for patients. The effects of a smoking cessation program on long-term survival in smokers 

with mild lung disease. Ann Intern Med. Feb 15 2005;142(4):I12. 

Excluded topic 

Swartz LJ, Callahan KA, Butz AM, et al. Methods and issues in conducting a community-based 

environmental randomized trial. Environ Res. Jun 2004;95(2):156-165. 

Reported data not usable 

Tai S, Nazareth I, Donegan C, Haines A. Evaluation of general practice computer templates: Lessons 

from a pilot randomised controlled trial. Methods Inf Med. Sep 1999;38(3):177. 

No eligible outcomes 

Talabere L. The effects of an asthma education program on selected health behaviors of school-age 

children who have recently experienced an acute asthma episode. The Ohio State University ** 

Ph.D. (260 p). 1990. 

Thesis/Dissertation 

Tamaoki J, Chiyotani A, Sakai A, Takemura H, Konno K. Effect of menthol vapour on airway 

hyperresponsiveness in patients with mild asthma. Respir Med. Aug 1995;89(7):503-504. 

Not an evaluation of a QI 

intervention 

Tanyeli G, Demir R, Ozylimaz S, Kiyan E, Gurses N. Effects of a comprehensive rehabilitation 

program and patient education on posture and breathing patterns in asthmatics. Eur Respir J. 

2001;18(Suppl 33):299s. 

Abstract 

Teo S, Hanson R, Van Asperen P, et al. Improving asthma documentation in a paediatric emergency 

department. J Paediatr Child Health. Apr 1995;31(2):130. 

Ineligible study design 

Thoonen BP, Schermer TR, Jansen M, et al. Asthma education tailored to individual patient needs can 

optimise partnerships in asthma self-monitoring or self-management. Pat Educ Couns. Aug 

2002;47(4):355. 

No eligible outcomes 

Thoonen BP, Schermer TR, Van Den Boom G, et al. Self-monitoring or self-management of asthma in 

general practice, asthma control and quality of life: a randomised controlled trial. Thorax. Jan 

2003;58(1):30-36. 

Reported data not usable 

Tilly KF, Garvey NJ, Gold M, Powell E, Proudlock ML. Outcomes management and asthma education 

in a community hospital: ongoing monitoring of health status. Qual Manag Health Care. Spring 

1996;4(3):67-78. 

Ineligible study design 

Tinkelman D, Wilson S. Asthma disease management: regression to the mean or better? Am J Manag 

Care. Dec 2004;10(12):948-954. 

No eligible outcomes 

Tschopp JM, Frey JG, Janssens JP, et al. Asthma outpatient education by multiple implementation 

strategy. Outcome of a programme using a personal notebook. Respiratory Medicine. Mar 

2005;99(3):355-362. 

Ineligible study design 

Tschopp JM, Frey JG, Pernet R, et al. Bronchial asthma and self-monitoring or self-management 

education: implementation of Guidelines by an interdisciplinary programme in health network. 

Swiss Med Wkly. Feb 23 2002;132(7-8):92-97. 

Ineligible study design 

Tsoukleris MG, Michocki RJ. Geriatrics for the clinician. Inhalation therapy and the elderly: what 

every physician should consider. Md Med J. Dec 1995;44(12):1049-1052. 

Not an evaluation of a QI 

intervention 

Vafiadou M, Ranuro R. Managing asthma: a pediatric program that works. Caring. Nov 

1999;18(11):16-21. 

Ineligible study design 

Van Asperen P, Jandera E, De Neef J, Hill P, Law N. Education in childhood asthma: a preliminary 

study of need and efficacy. Aust Paediatr J. Feb 1986;22(1):49-52. 

No eligible outcomes 

van Walraven C, Forster A. Effect of follow-up physician visits on emergency readmissions. comment. 

Am J Med. Sep 2002;113(4):347. 

Ineligible study design 

Velsor-Friedrich B, Srof B. Asthma self-monitoring or self-management programs for children. Part II: 

Empiric evaluation of programs and recommendations. J Child Fam Nurs. May-Jun 2000;3(3):173-

190; quiz 191, 190. 

Ineligible study design 
C-17 

Citation Reason for Exclusion 

Veninga CC, Lagerlov P, Wahlstrom R, et al. Evaluating an educational intervention to improve the 

treatment of asthma in four European countries. Drug Education Project Group. Am J Respir Crit 

Care Med. Oct 1999;160(4):1254. 

Reported data not usable 

Veninga N. Improving prescribing in general practice dissertation. Thesis. 2000. Thesis/Dissertation 

Verstappen WH, van der Weijden T, Sijbrandij J, et al. Effect of a practice-based strategy on test 

ordering performance of primary care physicians: a randomized trial. JAMA. May 14 

2003;289(18):2407. 

No eligible outcomes 

Vilar ME, Reddy BM, Silverman BA, et al. Superior clinical outcomes of inner city asthma patients 

treated in an allergy clinic. Ann Allergy Asthma Immunol. Mar 2000;84(3):299-303. 

No eligible outcomes 

Wakefield M, Banham D, McCaul K, et al. Effect of feedback regarding urinary cotinine and brief 

tailored advice on home smoking restrictions among low-income parents of children with asthma: a 

controlled trial. Prev Med. Jan 2002;34(1):58-65. 

No eligible outcomes 

Warburton CJ, Niven RM, Pickering CA, Fletcher AM, Hepworth J, Francis HC. Domiciliary air 

filtration units, symptoms and lung function in atopic asthmatics. Respir Med. Nov 

1994;88(10):771-776. 

Not an evaluation of a QI 

intervention 

Ward A, Willey C, Andrade S. Patient education provided to asthmatic children: a historical cohort 

study of the implementation of NIH recommendations. J Asthma. Apr 2001;38(2):141-147. 

Ineligible study design 

Watson E, Young L. Re-engineering care delivery to improve the health outcome of asthmatics in 

Campbelltown, New South Wales. Medinfo. 1995;8(Pt 1):545. 

No eligible outcomes 

Webber MP, Carpiniello KE, Oruwariye T, Lo Y, Burton WB, Appel DK. Burden of asthma in innercity elementary schoolchildren: do school-based health centers make a difference? Arch Pediatr 

Adolesc Med. Feb 2003;157(2):125-129. 

Not an evaluation of a QI 

intervention 

Weinberger M, Murray MD, Marrero DG, et al. Effectiveness of pharmacist care for patients with 

reactive airways disease: a randomized controlled trial. JAMA. Oct 2 2002;288(13):1594-1602. 

Excluded topic 

White M, Michaud G, Pachev G, Lirenman D, Kolenc A, FitzGerald JM. Randomized trial of problembased versus didactic seminars for disseminating evidence-based guidelines on asthma management 

to primary care physicians. J Contin Educ Health Prof. 2004;24(4):237-243. 

No eligible outcomes 

White PT, Pharoah CA, Anderson HR, Freeling P. Randomized controlled trial of small group 

education on the outcome of chronic asthma in general practice see comments. J R Coll Gen Pract. 

May 1989;39(322):182. 

Not an evaluation of a QI 

intervention 

Wiegers TA, Kerkstra A. COPD home visit with children. Comparison of the quality of various models 

. Dutch. Verpleegkunde. Aug 1993;8(2):80. 

Foreign language article 

language 

With little to go on but much to gain, small IPA starts asthma DM program. Healthc Demand Dis 

Manag. Jun 1998;4(6):94-95. 

Not an evaluation of a QI 

intervention 

Witt K, Knudsen E, Ditlevsen S, Hollnagel H. Academic detailing has no effect on prescribing of 

asthma medication in Danish general practice: a 3-year randomized controlled trial with 12-monthly 

follow-ups. Family Practice. 2004;21(3):248. 

Reported data not usable 

Worth H, Dhein Y, Woehl A, Schacher C, Volmer T. Economic benefits of an outpatient education 

programme (AFAS) for adult asthmatics. Eur Respir J. 2001;18(Suppl 33):188s. 

Abstract 

Worth H. Patient education in asthmatic adults. Lung. 1990;168 Suppl:463-468. Ineligible study design 

Wraight JM, Cowan JO, Flannery EM, Town GI, Taylor DR. Adherence to asthma self-monitoring or 

self-management plans with inhaled corticosteroid and oral prednisone: A descriptive analysis. 

Respirology. Jun 2002;7(2):133-139. 

Ineligible study design 

Written action plans compared to medical management alone. J Allergy Clin Immunol. Nov 

2002;110(5 Suppl):S183-191. 

Ineligible study design 
C-18 

Citation Reason for Exclusion 

Yamada EG. Asthma--the shift from episodic treatment to ongoing prevention, education, and 

management. West J Med. Dec 1998;169(6):377. 

Ineligible study design 

Yang M, Chiang C, Yao G, Wang K. Effect of medical education on quality of life in adult asthma 

patients. J Formos Med Assoc. 2003;102(11):768-774. 

No eligible outcomes 

Yawn BP, Algatt-Bergstrom PJ, Yawn RA, et al. An in-school CD-ROM asthma education program. J 

Sch Health. Apr 2000;70(4):153-159. 

No eligible outcomes 

Yawn BP, Wollan P, Scanlon PD, Kurland M. Outcome results of a school-based screening program 

for undertreated asthma. Ann Allergy Asthma Immunol. May 2003;90(5):508-515. 

Not an evaluation of a QI 

intervention 

Yoon R, McKenzie D, Bauman A. Randomised controlled trial evaluation of an asthma education 

program. Hosp Pharm. 1989;19(1):51. 

Abstract 

Yoon R, McKenzie DK, Miles DA, Bauman A. Characteristics of attenders and non-attenders at an 

asthma education programme. Thorax. Dec 1991;46(12):886-890. 

No eligible outcomes 

Yoos HL, McMullen A, Bezek S, et al. An asthma management program for urban minority children. J 

Pediatr Health Care. Mar-Apr 1997;11(2):66-74. 

Ineligible study design 

Young NL, Foster AM, Parkin PC, et al. Assessing the efficacy of a school-based asthma education 

program for children: a pilot study. Can J Public Health. Jan-Feb 2001;92(1):30-34. 

No eligible outcomes 

Zieve FJ, Ciesco E. Computer-focused modification of physician prescribing behavior. Proc Annu 

Symp Comput Appl Med Care. 1992:617. 

Excluded topic 

Zimbro KMS. Explanatory power of the behavior model of utilization for pediatric asthma health care 

in an urban managed care setting. Old Dominion University. Ph.D. 2000(267 p). 

Thesis/Dissertation 
D-1 

Appendix D: Technical Expert Panel and Peer 

Reviewers 

Technical Expert Panel 

Martin Eccles, M.D., Centre for Health Services Research, University of Newcastle upon Tyne,

EPOC 

Russell Glasgow, Ph.D., Kaiser Permanente, Colorado 

Jeremy Grimshaw, M.B.Ch.B., Ph.D., University of Ottawa, Cochrane Collaboration Effective 

Practice and Organisation of Care Group (EPOC) 

Charles Homer, M.D., M.P.H., National Institute for Children’s Health Care Quality 

Harmon Jordan, Sc.D., previously with New England Medical Center Evidence-based Practice 

Center, currently at Abt Associates 

Val Lawrence, M.D., M.Sc., The University of Texas Health Science Center at San Antonio and 

South Texas Veterans Health Care System 

Andrew Oxman, M.D., M.Sc., Department of Health Services Research, Norwegian Directorate 

for Health and Social Welfare, EPOC 

Sandra Wilson, Ph.D., Department of Health Services Research, Palo Alto Medical Foundation 

James Zazzali, Ph.D., RAND 

Peer Reviewers 

David Atkins, M.D., M.P.H., Chief Medical Officer, Agency for Healthcare Research and 

Quality, Center for Outcomes and Evidence 

William Bailey, M.D., The Kirklin Clinic 

Homer Boushey, M.D., Past President ATS, Professor, Department of Medicine, Division of 

Pulmonary and Critical Care Medicine, University of California San Francisco 

Noreen Clark, Ph.D., Professor and Dean, University of Michigan School of Public Health 

Peter Cvietusa, M.D., Kaiser Permanente 

Rob Fulwood, Ph.D., M.S.P.H., Senior Manager Public Health Program Development, 

NHLBI/OPEC 

Kevin Weiss, M.D., M.P.H., F.A.C.P., Midwest Center for Health Services and Policy Research, 

Hines VA Hospital, The Center for Health Care Studies, Northwestern University Feinberg 

School of Medicine, Chicago 

Barbara Yawn, M.D., M.Sc., American Academy of Family Physicians