1. Faculdade de Medicina da Universidade do Porto Introdução à Medicina ASTHMA Is home monitoring more effective than usual care? Class 19 Coordinator: Dr. João Fonseca

2. INTRODUCTION

3. ASTHMA  chronic inflammatory disorder of the airways 1  chronically inflamed airways are hyperresponsive; they become obstructed and airflow is limited (by bronchoconstriction, mucus plugs, and increased inflammation) when airways are exposed to various risk factors 1 1. “Pocket Guide for Asthma Management and Prevention” www.ginasthma.com

4. Background  300 million people worldwide now have asthma 1  His control is possible, but it isn’t accomplished in most cases: - 75% of asthma admissions are avoidable 2 - 40% of asthma patients don’t react properly when their symptoms worsen 2 - 50% of asthma patients admitted with acute asthma have had alarming symptoms a week before admission 2 - 60% of asthma patients are poor at judging their dyspnoea 2 1. Global Burden of Asthma Repor 2. Guided self management of asthma - how to do it. Aarzne Lahdensuo

5. Rationale behind our aim Monitorization between observations at medical facilities may: –detect early negative events –provide a better insight to the variations of the disease –foster patients participation in their own care. Insufficiently known methods and patients ’ characteristics that have better outcomes with home monitoring It is necessary summarize the information of the studies

6. Systematic review –address a specific clinical question 1 –require a comprehensive literature search, 1 –use explicit selection criteria to identify relevant studies 1 –assess the methodologic quality of included studies 1 –explore differences among study results 1 1. Montori VM, Swiontkowski MF, Cook DJ. Methodologic issues in systematic reviews and meta-analyses.

7. AIM  Primary aim: summarize the available controlled studies about the clinical benefits of asthma patients to monitoring their disease outside medical facilities (home monitoring / self- monitoring)  Secondary aim: to compare the clinical efficacy of different techniques of home monitoring

8. METHODS

9.  Randomised controlled studies  Indexed at SCOPUS and Medline  Assessing the benefits of using home monitoring in patients with asthma Literature research

10. Pubmed (asthm*[MeSH] OR asthm*[TIAB]) (asthm*[MeSH] OR asthm*[TIAB])AND (((clinical[Title/Abstract] AND trial[Title/Abstract]) OR clinical trials[MeSH Terms] OR clinical trial[Publication Type] OR random*[Title/Abstract] OR random allocation[MeSH Terms] OR therapeutic use[MeSH Subheading])) AND AND (("self management"[TIAB] OR ("self care"[TIAB] OR “self care”[MeSH]) OR “self-monitoring”[TIAB]) AND ("peak-flow-meter"[TIAB] OR (spirometry[TIAB] OR spirometry[MeSH]) OR telemedicine[TIAB] OR "communication tecnhologies"[TIAB] OR ehealth[TIAB] OR “home automated telemanagement”[TIAB] OR Internet*[TIAB] OR mobile[TIAB])) Limits: Publication Date 1996-2005, English, Randomized Controlled Trial, Humans

11. Scopus TITLE-ABS-KEY(*asthma)AND ((TITLE-ABS-KEY("self-management" OR "self care" OR "self-monitoring")) AND (TITLE-ABS-KEY("peak-flow-meter" OR spirometry OR telemedicine OR "communication technologies" OR ehealth OR "home outomated telemanagement" OR internet OR mobile)) AND TITLE-ABS-KEY(random* OR trial OR control*)) AND TITLE-ABS-KEY(random* OR trial OR control*)) Limits: DOCTYPE "ar" AND PUBYEAR 1996-2005

12. Flowchart FAZER HIPERLIGAÇÂO

13. Inclusion criteria Articles which describe and evaluate the health care of patients outside hospital, with asthmaArticles which describe and evaluate the health care of patients outside hospital, with asthma Articles which compare the clinical outcomes of children and adults with asthma that performed self- monitoring with those who do not performed self- monitoringArticles which compare the clinical outcomes of children and adults with asthma that performed self- monitoring with those who do not performed self- monitoring

14. Not related with our aimNot related with our aim  Intervention only  Pharmacologic treatment;  Exclusively turned to education of patients and professionals No control groupsNo control groups Non-randomizedNon-randomized Exclusion criteria

15. Data gathering  Article data were registered on tables in RevMan and Excel

16. RESULTS

17. Articles selection

18. Excluded articles

19. Summary of excluded articles  12 articles – not related with our aim  5 articles – not RCT  2 articles – no control group  2 articles – full text article not available

20. Identification of included articles Article ID AuthorTittleDate of publicati on Journal/Book/Source 1Rasmussen, L.M., Phanareth, K., Nolte, H., Backer, V.. Internet-based monitoring of asthma: A long-term, randomized clinical study of 300 asthmatic subjects. 2005Journal of Allergy and Clinical Immunology 2Ostojic, V., Cvoriscec, B., Ostojic, S.B., Reznikoff, D., Stipic- Markovic, A., Tudjman, Z.. Improving asthma control through telemedicine: A study of short-message service. 2005Telemedicine Journal and e-health 3Wensley, D., Silverman, M.. Peak flow monitoring for guided self- mamagement in childhood asthma: A randomized controlled trial 2004American Journal of Respiratory and Critical Care Medicine 4Turner MO, Taylor D, Bennett R, Fitzgerald JM.. A randomized trial comparing peak expiratory flow and symptom self- management plans for patients with asthma attending a primary care clinical. 1998, Feb AM J Respir Crit Care Med 5Adams, R.J., Beath, K., Homan, S., Campbell, D.A., Ruffin, R.E.. A randomized trial of peak-flow and symptom-based action plans in adults with moderate-to-severe asthma 2001Respirology

21. General information of included articles StudyDesignParticipantsInterventionsOutcomesStudy completion 1 Rasmussen L.M., 2005 RCT300 asthmatic subjects -questionaries, -spirometry, -measurement of airway responsiveness -internet based monitoring -symptoms, -quality of life, -lung function, -air responsiveness 2 Ostojic, V, 2005 RCT16 asthmatic subjects -office visits -1 hour asthma education session with a specialist at the clinic -PEF was to be determined three times per day -asthma monitoring by GSM and SMS -Events during study period, - Average symptom score, - spirometry, -PEF by time of day (L/min), -PEF variability, -Daily consumption of inhaled medication, Cost of monitoring (per week, per patient) (money and time 3 Wensley, D., 2004 RCT90 asthmatic childre n -spirometry-quality of life -self-managementAmong 90 participants only one withdrawaled 4 Turner MO, 1998 RCT92 asthmatic adults -asthma education -peak expirotory flow -Symptom self- management plans -ED visits and/or hospitalization for asthma unscheduled -doctor visits, -days absent from school or work courses of prednisone and respiratory tract infections 5 Adams R.J., 2001 RCT134 asthmatic adults (82 females and 52 males) -symptom-based action plans -peak expiratory flow -quality of life -self-managementFrom the original group of one 134 patients, 21(15%) completed between 3 and 5 months of follow- up, 25(19%) between 6 and 11 months and 88(66%) completed the 12 months of follow- up. Among those patients who discontinued the study prior to 12 months 30 gave up due to lack of interest.

22. Methods of included articles

23. Results of included articles

24. Summary of results Clinical benefits of asthma patients to monitoring their disease outside medical facilities: – –Turner MO, 1998 – positive – –Rasmussen L.M., 2005 – positive – –Ostojic, V, 2005 - positive Clinical efficacy of different techniques of home monitoring: – –Turner MO, 1998 – no significative differences – –Wensley, D., 2004 – no significative differences – –Adams R.J., 2001 – no significative differences

25. ACKNOWLEDGEMENTS We would like to thank:  Dr. João Fonseca because he helped us during our work  Professor Altamiro da Costa Pereira for showing us what we should change.