Tailored Self-Management Program Improves Asthma Care in Older Patients

Alex D. Federman, MD, MPH

A self-management program that addresses barriers to care has been shown to improve asthma treatment outcomes in older patients.

A new study involving nearly 400 adult patients with asthma found significant improvements in quality of life, treatment adherence, inhaler technique, and even emergency department visits when patients were provided needs-tailored care from asthma care coaches.

The Supporting Asthma Self-Management Behaviors in Older Adults (SAMBA) trial—led by Alex D. Federman, MD, MPH, of the Division of General Internal Medicine at Icahn School of Medicine at Mount Sinai—was a three-arm, randomized, study across primary care practices and patient residences based in New York City.

Federman and colleagues identified 406 eligible, consenting patients with persistent, uncontrolled asthma, aged 60 years and older through an electronic medical record (EMR) database. Patients were randomized to either home- or clinic-based intervention, or control.

The intervention program is comprised of 3 general steps: an initial screening to identify barriers to patients’ self-management and care for their asthma; established targeted actions that address such barriers; and reinforcement of practices. The barriers are distinguished from 21 domains of psychosocial, cognitive, physical and mental health, and environmental challenges.

Such barriers are highly prevalent in the observed patient population, Federman told MD Magazine®.

“Certainly with populations like we studied here—low-middle income population in an urban setting—when clinicians are working with these patients, there are going to be a whole range of factors that might affect control of their asthma,” he explained.

In those circumstances, he said, it’s going to become more difficult for a physician to solely identify the underlying cause of poor asthma control.

There’s the benefit of the intervention program. Patients were managed by asthma care coaches (ACCs) who conducted the screening assessments and identified individual barriers. As investigators noted, the SAMBA program design was an embrace of the teach-to-goal concept—rather than the broad disease education frequently provided to patients.

Investigators assessed for primary outcomes of improved scores on the Asthma Control Test (ACT), Mini Asthma Quality of Life Questionnaire (mAQLQ), Medication Adherence Rating Scale (MARS), metered dose inhaler technique, and rate of emergency department visits for asthma care.

Of the 391 patients to receive treatment, mean age was 67.8 years, with just 58 (15.1%) being men. ACT scores were bettered among intervention patients than those on control, (difference-in-differences at 3 months: 1.2 [95% CI, 0.2 - 2.2; P = .02]; 6 months: 1.0 [95% CI: 0.0-2.1; P= .049]; 12 months: 0.6 [95% CI, −0.5 to 1.8; P = .28]).

Intervention patients reported fewer mean emergency department visits at 12 months than control, and they also reported statistically significant improvements for quality of life, medication adherence, and inhaler technique. Outcome differences were not significant between patients receiving either in-home or at-practice intervention.

Investigators concluded a system which identifies barriers to asthma self-care and provides targeted support is effective toward improving proper patient self-care, asthma control, and overall quality of life. Federman added there were educational benefits for the involved care providers.

“Certainly, the results—in terms of reduced emergency department visits and improvement in asthma control—were key outcomes,” he said. “But aside from those, what we learned in the process was that with patients who struggle with their management of their chronic diseases, especially in older age, is they have to deal with issues on a daily basis.”

Federman cited issues with self-medicating—both administering and remembering inhaler therapy—and asthma triggers as particular pain points for older asthma patients trying to self-medicate.

He and his colleagues now want to apply such assessments and programs to patients with chronic obstructive pulmonary disease (COPD). The team is seeking funding for a Chicago-based study of patients with COPD under the SAMBA program.

The study, “Effect of a Self-management Support Intervention on Asthma Outcomes in Older Adults,” was published online in JAMA Internal Medicine.