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Study Objectives: To determine the effectiveness of a cotinine-feedback, behaviorally based education intervention in reducing environmental tobacco smoke (ETS) exposure and health-care utilization of children with asthma., Design: Randomized controlled trial of educational intervention vs usual care., Setting: The pediatric pulmonary service of a regional pediatric hospital., Participants: ETS-exposed, Medicaid/Medi-Cal-eligible, predominantly minority children who were 3 to 12 years old and who were seen for asthma in the hospital's emergency, inpatient, and outpatient services departments (n = 87)., Intervention: Three nurse-led sessions employing behavior-changing strategies and basic asthma education and that incorporated repeated feedback on the child's urinary cotinine level., Measurements: The primary measurements were the urinary cotinine/creatinine ratio (CCR) and the number of acute asthma medical visits. The secondary measurements were number of hospitalizations, smoking restrictions in home, amount smoked, reported exposures of children, and asthma control., Results: The intervention was associated with a significantly lower odds ratio (OR) for more than one acute asthma medical visit in the follow-up year, after adjusting for baseline visits (total visits, 87; OR, 0.32; p = 0.03), and a comparably sized but nonsignificant OR for one or more hospitalization (OR, 0.34; p = 0.14). The follow-up CCR measurement and the determination of whether smoking was prohibited inside the home strongly favored the intervention group (n = 51) (mean difference in CCR adjusted for baseline, -0.38; p = 0.26; n = 51) (60; OR [for proportion of subjects prohibiting smoking], 0.24; p = 0.11; n = 60)., Conclusions: This intervention significantly reduced asthma health-care utilization in ETS-exposed, low-income, minority children. Effects sizes for urine cotinine and proportion prohibiting smoking were moderate to large but not statistically significant, possibly the result of reduced precision due to the loss of patients to active follow-up. Improving ETS reduction interventions and understanding their mechanism of action on asthma outcomes requires further controlled trials that measure ETS exposure and behavioral and disease outcomes concurrently.

The Fresno Asthma Project targeted the entire low-income, inner-city, multiethnic population of Fresno, California. For 36 months following a 6-month planning phase, continuing education was provided to a high proportion of physicians, pharmacists, nurses/respiratory therapists, emergency medical technicians, school personnel, and allied health professionals involved in asthma care in Fresno, including virtually all those providing care/services to the target population. Small group patient education was made available and provided in age- and culturally appropriate formats to patients/families in clinics, hospitals, and schools. General and ethnic media and a Speakers Bureau were used to raise public awareness of asthma as a serious but controllable health problem. This community intervention model is particularly appropriate to multiethnic communities. It is relatively low cost (total direct costs were $140,000 per year), uses existing educational resources, and appears to have minimized counterproductive competition. Although morbidity and mortality trend data are not yet available to monitor program impact, penetration into the target community has been substantial: community physicians refer patients to asthma classes, asthma educator training is ongoing through the local American Lung Association chapter, hospitals and managed care systems serving low- income/MediCal patients offer asthma classes, and public schools and HeadStart are institutionalizing asthma awareness and self-management classes.

Individual and small group approaches to delivering patient education have differing potential advantages, and various criteria can be used to determine which is "better". Individualization of education is possible in either delivery format, as is its absence. Limited evidence regarding the relative effectiveness and cost-effectiveness of different delivery modes is available from direct comparison and meta-analyses of studies comparing either of the approaches with no education or the patient's own pre-education status. This evidence supports the conclusions that: (1) both individual and group education can improve patient outcomes, (2) it is not possible to conclude that the two delivery formats are essentially equivalent in effectiveness, and there is some evidence that group education may more effective for some outcomes, and (3) wide variation in effectiveness exists among programs in both delivery formats. A model continuum of asthma education is presented that takes advantage of the respective strengths of individual and group delivery.

Background: Optimal asthma management requires accurate assessment of asthma severity., Objective: To compare patients' perceptions of their asthma severity with that obtained by using the guidelines published by the National Asthma Education and Prevention Program's Expert Panel and with functional impairment measured by spirometry and numeric criteria of the American Thoracic Society., Methods: We enrolled 323 patients age 18 to 50 years who were members of the Kaiser Foundation Health Plan for > or = 1 year in a randomized control trial of an asthma education program. Each had a confirmed diagnosis of bronchial asthma and had been receiving antiasthma medication for > or = 1 year. Patients rated the severity of their asthma. Office spirometry was performed, and, using the Mini-Wright peak flow meter, patients kept 2-week diaries of at-home recordings of morning and evening peak expiratory flow rates., Results: A statistically significant association was noted between patients' perceptions of asthma severity and both medication severity rating (P < .001) and diurnal variation rating (P = .003) and evening peak expiratory flow rate percentage (P = .019). In comparison with a severity composite based on criteria of the National Asthma Education Program, 54% of patients accurately estimated asthma severity, 27% overestimated, and 20% underestimated severity., Conclusion: A clinically significant proportion of asthmatic patients substantially underestimate disease severity and thereby may be at risk of increased mortality or morbidity.

We studied smoking status in relation to parental attendance at an asthma education program for child patients of a health maintenance organization. Nonattendance rates were 24%, 42%, and 78% in nonsmoking, one-smoker, and two-or-more-smoker families, respectively, and 33% overall. Only the number of smokers (odds ratio [OR] = 3.1; 95% confidence interval [CI] = 1.8, 5.3) and perceived adverse impact of asthma on the family (OR = 0.4; 95% CI = 0.2, 0.9) were retained in a multivariate model that correctly classified 73% of families; demographic characteristics, frequency of asthma symptoms, and health care use were rejected. There was a tendency for smoking parents to deny that their child had asthma (17% among families with two or more smokers; 9% among nonsmoking families). Asthma education programs may fail to involve parents who smoke.

A randomized control trial of the Wee Wheezers asthma education program was conducted with 76 children < 7 years of age, 31% of whom were on a medication regimen consistent with mild, 51% with moderate, and 18% with moderately severe/severe asthma. Treatment children showed improved morbidity at 3-month follow-up relative to the changes in the controls: increased symptom-free days in the preceding 2 weeks (mean change of +2.2 vs. -2.6 in the controls; p = .004) and month (+2.0 vs. -3.8; p < .02), fewer nights of parental sleep interruption in a typical week (+0.7 vs. +1.8; p < or = .05), and a trend toward fewer asthma sick days (-0.2 vs +0.7; p = ns). These improvements were accompanied by significantly better parental asthma management compared with controls (more consistent use of preventive medications, p < or = .01; early symptom intervention, [corrected] p < or = .05) and trends toward more restrictions on smoking in the home (p < .07) and decreased parental confusion about asthma treatment (p < .11). This study provides evidence that a multisession program of asthma education for parents can improve parental asthma management and clinical outcomes in very young children and provides information on the validity and sensitivity of various asthma outcome measures in this age group.

We conducted an exploratory analysis of several prospectively obtained objective measures of disease activity to derive a predictive model of hospitalization for asthma among 310 adults, ages 18 to 50 yr, with moderate to severe asthma. Baseline characteristics associated with increased risk of hospitalization in the succeeding year include (1) prior year hospitalization, (2) moderate or severe respiratory impairment, (3) a medication regimen consistent with severe asthma, (4) a history of significant systemic steroid use, (5) maximum overnight PEF variability > 40%, and (6) mean evening PEF < 60% of predicted (relative risk = 6.5, 6.9, 8.1, 3.7, 3.0, and 3.2, respectively). Recursive partitioning analysis, depicted as a "classification tree," provided a more sensitive (94%) and specific (68%) multivariate description of the data set than either logistic regression (87 and 48%, respectively) or a simple additive risk model (46 and 93%, respectively). Patients with very high (> 50%), moderately elevated (10 to 15%), and very low (< 5%) risk of hospitalization were identified on the basis of particular combinations of prior hospitalization history, level of respiratory impairment, and medication regimen. Overnight variability and mean evening PEF measured at home over a 2-wk period proved less informative for risk stratification than respiratory impairment determined once at baseline by office spirometry. The findings warrant replication and extension in other populations with the goal of developing decision rules for risk stratification and effective interventions for risk reduction.

Purpose: Excess morbidity and mortality due to asthma, aggravated by demonstrably poor patient self-management practices, suggest the need for formal patient education programs. Individual and group asthma education programs were developed and evaluated to determine their cognitive, behavioral, and clinical effects., Patients and Methods: We compared changes in asthma symptoms, utilization of medical services, knowledge about asthma, metered-dose inhaler (MDI) technique, and self-management behaviors for 323 adult Kaiser Permanente patients with moderate to severe asthma who were randomly assigned to small-group education, individual teaching, or 1 of 2 control conditions--an information (workbook) control or usual control (no formal asthma education). Data were collected from patients by questionnaire, diary, and physical examination at enrollment and at 5 months and 1 year after intervention. Medical record data on these patients were abstracted for a total 3-year period, from 1 year before to 2 years after enrollment., Results: Compared with the usual control, the self-management education programs were associated with significant improvements in control of asthma symptoms (reduced "bother" due to asthma and increased symptom-free days), MDI technique, and environmental control practices. Small-group education also was associated with significant improvements in physician evaluation of the patients' asthma status and in patients' level of physical activity. For both group and individual education recipients, improvement in MDI technique was positively correlated with improved control of symptoms; however, the degree of improvement in symptoms was greater than that which could be accounted for on the basis of improvement in MDI technique alone. The time course over which changes occurred in the various outcome measures suggests the mechanism by which education resulted in improvement in the patient's status. Significant improvements in MDI technique and environmental control practices were manifest immediately following education (5-month follow-up) and at the 1-year follow-up. Significant improvements in symptom measures were not apparent until the 1-year follow-up. The rate of utilization of medical care for acute exacerbations decreased between baseline and the 2-year follow-up period, but this decrease did not differ significantly among treatment conditions. However, there was a trend toward greater reduction in patients receiving small-group education. An ad hoc finding of a significant difference favoring small-group education between the baseline and the second follow-up year acute visit rates was observed. This result must be regarded as tentative, since it is not clear that unambiguous statistical significance is attained in the light of multiplicity issues. However, this trend is consistent with the antecedent benefits of the small-group education, and appears to warrant further investigation., Conclusions: Carefully designed asthma education programs for adults can improve patients' understanding of their condition and its treatment and increase their motivation and confidence that the condition can be controlled, thereby increasing their adherence to the treatment regimen and management of symptoms, and, in turn, improving control of symptoms. Both small-group education and individual education were associated with significant benefits, but the group program was simpler to administer, better received by patients and educators, and more cost-effective. The results show promise for improving clinical outcomes, through well-designed educational programs, for patients with asthma and other chronic health problems.

This article summarizes the considerable progress that has been made in characterizing the behaviors of patients and family members that contribute to good or poor outcomes of asthma care and in developing educational programs shown to be effective in improving patient outcomes. Research needs are identified, including the need for better understanding of the antecedents of patient behaviors and their relative (quantitative) contribution to outcomes of asthma care of techniques to alter patient and family management behavior to improve outcomes, especially among particular patient subgroups are described. In addition, the asthma management practices of physicians are examined, such as the frequency with which recommended versus less desirable approaches to the diagnosis and treatment of asthma are used. Critical to this research was the development or refinement and the standardization of measures of individual patient behavior (including compliance behaviors), asthma morbidity, and utilization of medical services related to asthma.

To define the specific objectives of a planned behavioral intervention directed toward parents of very young children with asthma, 574 detailed descriptions of ineffective and effective asthma management behaviors of parents of infants and young children (through 6 years of age) with asthma were collected via interviews with 117 physicians and other health professionals and 112 parents. Analysis of these data resulted in the identification of 130 ineffective and effective asthma management behaviors of parents that could be grouped in five major areas of responsibility: symptom intervention; symptom prevention; use of medical and educational resources; communication among caregivers; and child development and family relationships. This report presents the methodology of the study, describes the identified behaviors, and discusses implications of the results for the development of a behavioral intervention to improve asthma management by parents.

The article presents a study which investigates whether the addition of peak flow monitoring to symptom monitoring is effective in treating older adults with moderate-to-severe asthma (MTSA). The study let the patients attend small group sessions including a review of asthma diaries. The result showed that the effectiveness of adding peak flow monitoring to symptom monitoring is the same as that of symptom monitoring alone.