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How Does Patient Education and Self-management among Asthmatics and Patients with Chronic Obstructive Pulmonary Disease Affect Medication? FRODE GALLEFOSS and PER SIGVALD BAKKE Section of Pulmonary Medicine, Medical Department, Vest-Agder Central Hospital, Kristiansand, Norway; and Department of Thoracic Medicine, University Hospital of Bergen, Bergen, Norway The effect of patient education on steroid inhaler compliance and rescue medication utilization in pa- tients with asthma or chronic obstructive pulmonary disease (COPD) has not been previously investi- gated in a single study. We randomized 78 asthmatics and 62 patients with COPD after ordinary out- patient management. Intervention consisted of two 2-h group sessions and 1 to 2 individual sessions by a trained nurse and physiotherapist. A self-management plan was developed. We registered for 12 mo medication dispensed from pharmacies according to the Anatomical Therapeutic Chemical (ATC) classification index. Steroid inhaler compliance (SIC) was defined as (dispensed/prescribed) 3 100 and being compliant as SIC . 75%. Among asthmatics 32% and 57% were compliant (p 5 0.04) with a median (25th/75th percentiles) SIC of 55% (27/96) and 82% (44/127) (p 5 0.08) in the control and intervention groups, respectively. Patient education did not seem to change SIC in the COPD group. Uneducated patients with COPD were dispensed double the amount of short-acting inhaled b2-ago- nists compared with the educated group (p 5 0.03). We conclude that patient education can change medication habits by reducing the amount of short-acting inhaled b2-agonists being dispensed among patients with COPD. Educated asthmatics showed improved steroid inhaler compliance com- pared with the uneducated patients, whereas this seemed unaffected by education in the COPD group. Gallefoss F, Bakke PS. How does patient education and self-management among asth- matics and patients with chronic obstructive pulmonary disease affect medication? AM J RESPIR CRIT CARE MED 1999;160:2000–2005. Medication regimens for patients with asthma or chronic ob- in the use of bronchodilators or inhaled steroids after an en- structive pulmonary disease (COPD) are particularly vulnera- hanced education program (4). In two of the studies cited (2, ble to adherence problems because of the chronic nature of 3) the compliance was self-reported, whereas the third study the diseases, the use of multiple medications, and the periods (4) based the compliance data on medication prescribed by of symptom remission. Rates of noncompliance in the treat- the patients’ doctors. Only one of the studies presented data ment of asthma may vary from 20 to 80% (1). Factors leading on inhaled steroid compliance (4). No data are available re- to poor compliance are not fully understood, but lack of edu- garding the effect of patient education on medication adher- cation may be one cause (1). ence in the Nordic countries. To our knowledge data are lack- Previous surveys in asthmatics examining the effect of edu- ing on the effect of patient education on compliance in cation programs on compliance have shown conflicting results. patients with COPD as well as comparable studies on asthma Windsor and coworkers (2) reported from a study in 267 adult and COPD. asthmatics that patient education consisting of one individual We performed a randomized, controlled intervention study and one group session gave significantly improved medication in patients with mild to moderate asthma or COPD using a adherence compared with the control group after a 1-yr fol- standardized education program and a self-management plan. low-up. In a controlled intervention study of 116 asthmatics The objectives of the present report are to assess the effect of Allen and coworkers (3) observed an increased compliance 12 patient education on antiobstructive medication dispensed from mo after a 2.5 3 4 h group session. The Grampian Asthma pharmacies. Study of Integrated Care (GRASSIC) did not show any change METHODS (Received in original form January 11, 1999 and in revised form June 23, 1999) Study Design Supported by the Norwegian Medical Association’s Fund for Quality Improve- Between May 1, 1994 and December 1, 1995, 140 consecutive patients ment. were included in the study after having received ordinary consultation Correspondence and requests for reprints should be addressed to Frode Galle- care at our outpatient chest clinic at Central Hospital of Vest-Agder, foss, Lungeseksjonen, med avd, Vest-Agder Sentralsykehus, 4604 Kristiansand, Kristiansand, Norway. At inclusion they signed a written consent and Norway. were then randomized to an intervention group or a control group. Am J Respir Crit Care Med Vol 160. pp 2000–2005, 1999 The control group were followed by their general practitioners, and Internet address: www.atsjournals.org the intervention group received an education program and were then Gallefoss and Bakke: Asthma School, Compliance, and Drug Therapy 2001 also transferred to a 1-yr follow-up by their general practitioners (Fig- technique was checked. At the final teaching the patients received an ure 1). individual treatment plan on the basis of the acquired personal infor- Eligible subjects were patients with bronchial asthma or COPD mation and 2 wk of peak flow monitoring (10). The personal under- between 18 and 70 yr of age, not suffering from any serious disease, standing of the treatment plan with regard to changes in PEF and such as unstable coronary heart disease, heart failure, serious hyper- symptoms was discussed and tested (Table 1). tension, diabetes mellitus, kidney or liver failure. All patients received treatment plans aimed at making early Subjects with stable asthma were to have a prebronchodilator changes in medication at exacerbations. Among the educated asth- FEV1 equal to or higher than 80% of predicted value (5). Further- matics, 94% received standard treatment plans incorporating peak more we required either a positive reversibility test (5), a documented flow monitoring (Table 1). In the COPD group 12 of 26 (46%) re- 20% spontaneous variability (peak expiratory flow [PEF] or FEV1), ceived standard treatment plans. Nonstandard treatment plans incor- or a positive methacholine test (provocative dose causing a 20% de- porated the use of oral steroids as the first line of action in the yellow crease in FEV1 [PD20]) (6). A positive reversibility test required at zone if, for example, the patient already used high dosages of inhala- least a 20% increase (FEV1 or PEF) after inhalation of 400 mg sal- tion steroids as maintenance therapy or could tell that a double or tri- butamol. Because we wanted to include those with mild COPD, sub- ple increase in inhalation steroids previously had marginal effect on jects with COPD were to have a prebronchodilator FEV1 equal to or the course of attacks/exacerbations. Among those 14 patients with higher than 40% and lower than 80% of predicted (7). Among pa- COPD receiving nonstandard treatment plans, eight patients did not tients with COPD 32% were reversible to ipratropium bromide 80 mg want to or were not able to use peak flow monitoring as a basis for and/or salbutamol (8, 9). These measures were obtained from the par- change in medication. For those patients, only symptom-based treat- ticipants’ charts. ment plans were issued (Table 1). Of the eligible patients, the inclusion rate was 92% (78 of 85) and 91% (62 of 68) for the asthma and COPD group, respectively. Outcome Variables Educational Intervention All medication was coded to Defined Daily Dosages (DDD) accord- The educational intervention has been thoroughly described (10). ing to the Anatomical Therapeutic Chemical (ATC) classification Briefly, it consisted of a specially constructed patient brochure, two 2-h index (11, 12) for comparison of medication within the same chemi- group sessions (separate groups for asthmatics and patients with cal–therapeutic groups, thus allowing us to compare those using, for COPD) concentrating on pathophysiology, antiobstructive medica- instance, beclomethasone and budesonide. Prescribed Defined Daily tion, symptom awareness, treatment plans, and physiotherapy. One or Dosage (PDDD) of regular medication (11, 12) is expressed as the two 40-min individual sessions were supplied by both a nurse and a regular dosage recommended by the lung clinic at baseline. Short-act- physiotherapist (Figure 1). With regard to antiobstructive medication ing b2-agonist inhalations were in this study categorized as rescue the following was emphasized: The components of obstruction were medication because it was not recommended as regular medication. explained together with the site of action of the actual medication. Dispensed medication was reported from all local pharmacies through The patient’s pulmonary symptoms were registered and discussed monthly print-outs from the pharmacy data registers. At the 1-yr fol- with emphasis on the early symptoms experienced at exacerbations. low-up all patients were asked whether they had received medication The individual factors causing attacks/exacerbations and concerns re- elsewhere. Only one individual reported this and the data were in- garding adverse effects of medication were discussed and inhalation cluded. Figure 1. Study design and withdrawals. 2002 AMERICAN JOURNAL OF RESPIRATORY AND CRITICAL CARE MEDICINE VOL 160 1999 TABLE 1 MODEL FOR THE STEPWISE TREATMENT PLAN Color Code PEF* Symptoms Treatment Green . 80% No symptoms; occasional use of inhaled Maintenance treatment b2-agonist Yellow 80–60% Start of a cold; night symptoms; cough; Double or triple dosage of inhalation steroids until or increased use of inhaled b2-agonists back in green zone, then continue double or triple dosage for as long a time as outside green zone Orange 60–40% or The effect of inhaled b2-agonists lasts Prednisolone 30–40 mg/d until back in green . 150 L/min , 2 h; shortness of breath on exertion zone, then 10–20 mg/d for as long a time as outside green zone Red , 40% or Inhaled b2-agonists of little help or Take prednisolone 40 mg and high-dose inhaled , 150 L/min effect lasts , 30 min; shortness of b2-agonist and contact doctor immediately breath when talking * In relation to personal best.

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