Weekly self-monitoring and treatment adjustment benefit patients with partly controlled and uncontrolled asthma: an analysis of the SMASHING study

Abstract

Background: Internet-based self-management has shown to improve asthma control and asthma related quality of life, but the improvements were only marginally clinically relevant for the group as a whole. We hypothesized that self-management guided by weekly monitoring of asthma control tailors pharmacological therapy to individual needs and improves asthma control for patients with partly controlled or uncontrolled asthma.

Methods: In a 1-year randomised controlled trial involving 200 adults (18-50 years) with mild to moderate persistent asthma we evaluated the adherence with weekly monitoring and effect on asthma control and pharmacological treatment of a self-management algorithm based on the Asthma Control Questionnaire (ACQ). Participants were assigned either to the Internet group (n = 101) that monitored asthma control weekly with the ACQ on the Internet and adjusted treatment using a self-management algorithm supervised by an asthma nurse specialist or to the usual care group (UC) (n = 99). We analysed 3 subgroups: patients with well controlled (ACQ <or= 0.75), partly controlled (0.75>ACQ <or= 1.5) or uncontrolled (ACQ>1.5) asthma at baseline.

Results: Overall monitoring adherence was 67% (95% CI, 60% to 74%). Improvements in ACQ score after 12 months were -0.14 (p = 0.23), -0.52 (p < 0.001) and -0.82 (p < 0.001) in the Internet group compared to usual care for patients with well, partly and uncontrolled asthma at baseline, respectively. Daily inhaled corticosteroid dose significantly increased in the Internet group compared to usual care in the first 3 months in patients with uncontrolled asthma (+278 microg, p = 0.001), but not in patients with well or partly controlled asthma. After one year there were no differences in daily inhaled corticosteroid use or long-acting beta2-agonists between the Internet group and usual care.

Conclusions: Weekly self-monitoring and subsequent treatment adjustment leads to improved asthma control in patients with partly and uncontrolled asthma at baseline and tailors asthma medication to individual patients' needs.

Figure 1

Algorithm based on consecutive ACQ scores to adjust medical treatment [10]. * At entry the evaluation period is bypassed.

Figure 2

Flow diagram of subject progress through the study.

Figure 3

Monitoring adherence (percentages) for patients with well controlled (n = 75), partly controlled (n = 71) or uncontrolled asthma at baseline (n = 54).

Figure 4

ACQ scores during study follow-up for patients with well controlled (panel I; n = 75), partly controlled (panel II; n = 71) or uncontrolled asthma at baseline (panel III; n = 54). P-values represent statistical significance of change scores between Internet group and usual care. Error bars indicate the standard error of the mean.

Figure 5

Mean daily dose of inhaled corticosteroids (μg) during study follow-up for patients with well controlled (panel I; n = 75), partly controlled (panel II; n = 71) or uncontrolled asthma at baseline (panel III; n = 54). P-values represent statistical significance of change scores between Internet group and usual care. Error bars indicate the standard error of the mean.