PEDIATRICS Vol. 107 No. 6 June 2001, pp. 1496

Benefits of Asthma Education Programs

To the Editor.

The article by Kelly et al¹ that appeared in the May 2000 issue of Pediatrics demonstrates that a comprehensive program for asthmatic children with Medicaid insurance can reduce health care utilization and save costs. The study was a controlled clinical trial that alternately assigned children with a history of frequent use of emergent health care services for asthma to either usual care or to an intervention using an asthma self-management education program coupled with clinical care that conformed to the National Heart, Lung, and Blood Institute clinical practice guidelines for asthma management.

As opposed to a recent meta-analysis of the effects of asthma education in children,² the authors of this study found significant benefits in favor of the intervention group. Children in the intervention group had a statistically significant increase in their use of preventive practices including influenza vaccination and the use of an antiinflammatory medications. Moreover, children in the intervention group had a statistically significant reduction in emergent health care utilization, manifested by lower ED visits and hospitalizations.

Because the study was not a true randomized trial, it is possible that the groups were unbalanced on a key variable or 2 that might account for some of the effects seen. Indeed, the intervention group had a significantly lower use of antiinflammatory agents at baseline. This suggests that the intervention group may have had poorer access to needed health care services. If this were true, then improvements in access to care as part of the intervention could account for the effects seen in this group.

There were 2 dropouts in the intervention group and none in the control group. Explanations for these dropouts were provided by the authors: 1 subject relocated to another area and another withdrew herself from the study. It is possible that these withdrawals were associated with worse outcomes. If the authors have outcome data on the subject who withdrew herself, it might be useful to include that data in an intention-to-treat analysis to provide a less biased estimate of the effect of the intervention.

Also, it is unclear what component of the intervention may have accounted for the beneficial effects observed in the intervention group. The intervention consisted of both educational and clinical care components. It did not appear possible to disentangle the effects of the educational component from the clinical care component. It would be of interest to replicate the study in the future and incorporate a factorial design whereby the independent effects of both components can be better evaluated.

It is becoming increasingly clear that asthma education programs are beneficial, particularly in adults.^3-5 Despite the caveats given above, studies such as this one by Kelly and colleagues help to demonstrate the beneficial effects of asthma education in children. Additional work on the specific components of asthma educational programs that demonstrate effectiveness and cost-effectiveness may help educators to determine which programs may be most effective in their patient populations.⁶

James Guevara, MD, MPH
Frederic Wolf, PhD
Departments of Pediatrics and Medical Education
University of Washington School of Medicine
Seattle, WA 98195

REFERENCES

1. Kelly C, Morrow A, Shults J, Nakas N, Strope G, Adelman R Outcomes evaluation of a comprehensive intervention program for asthmatic children enrolled in Medicaid. Pediatrics. 2000; 105:1029-1035 [Abstract/Free Full Text]
2. Bernard-Bonnin A, Stachenko S, Bonin D, Charette C, Rousseau E Self-management teaching programs and morbidity of pediatric asthma: a meta-analysis. J Allergy Clin Immunol. 1995; 95:34-41 [CrossRef][Medline]
3. Gibson P, Coughlan J, Abramson M, et al. Effects of self-management education and regular practitioner review in adults with asthma (Cochrane Review). The Cochrane Library. Oxford, UK: Update Software; 1998 (Issue 2)
4. Wolf F, Guevara J, Grum C, Clark N. Effects of self-management educational interventions vs usual care for adults with asthma: a meta-analysis of 23 controlled trials. In press
5. Clark N, Gong M Management of chronic disease by practitioners and patients: are we teaching the wrong things? BMJ. 2000; 320:572-575 [Free Full Text]
6. Clark N, Nothwehr F Self-management of asthma by adult patients. Patient Educ Couns. 1997; 32:S5-S20 [CrossRef][Medline]