Interactive applications for patient education and behaviour change in asthma Introduction to Medicine Class 16 2006-2007.

Interactive applications Interactive applications for patient education for patient education and behaviour change and behaviour change

in asthmain asthma

Introduction to Introduction to MedicineMedicineClass 16 2006-2007Class 16 2006-2007

SummarySummary IntroductionIntroduction

AimAim MethodsMethods

Study DesignStudy Design Definition of populationDefinition of population Clinical outcomes evaluatedClinical outcomes evaluated Search strategy – QuerySearch strategy – Query Inclusion/Exclusion criteriaInclusion/Exclusion criteria

ResultsResults DiscussionDiscussion Limitations of our studyLimitations of our study ConclusionConclusion Gantt ChartGantt Chart Site MapSite Map

IntroductionIntroduction

IntroductionIntroductionASTHMAASTHMA chronic disease chronic disease recurrent breathlessness and recurrent breathlessness and

wheezingwheezing high prevalence all over the worldhigh prevalence all over the world undesired clinical outcomesundesired clinical outcomes

treatment strategiestreatment strategies improve asthma outcomesimprove asthma outcomes

World Health Organisation (WHO)World Health Organisation (WHO)Gina Report: Global Strategy for Asthma Management Gina Report: Global Strategy for Asthma Management

and Preventionand Prevention

IntroductionIntroduction• StrategiesStrategies : : acquire self-efficacy and acquire self-efficacy and informationinformation

• Patient education with interactive applicationPatient education with interactive application

• Interactive applications (IA) - computer-based, usually web-based, information packages for patients combine health information, social support decision, or behaviour change

Guevara J.P., BMJ. 2003Guevara J.P., BMJ. 2003Clark NM, BMJ. 2000Clark NM, BMJ. 2000

Murray E., CDSR 2005Murray E., CDSR 2005

• Overcome difficulties

Introduction - AimIntroduction - Aim

• To summarize the results from published studies about the use of interactive applications for education of children and/or adults with asthma;

• Research Question: Are clinical outcomes achieved with

the use of interactive applications better than with usual care?

MethodsMethods

Study DesignStudy Design

Systematic Review:Systematic Review:

Combine the available Combine the available evidence from published evidence from published studies to draw more reliable studies to draw more reliable and generalised conclusions.and generalised conclusions.

Definition of the Definition of the PopulationPopulation

Articles indexed in MedLine inclusively, Articles indexed in MedLine inclusively, identified through a identified through a sensitivy query sensitivy query related to the use of IA in asthma carerelated to the use of IA in asthma care

VariablesVariables

Number of people with outcomesNumber of people with outcomes

Clinical outcomes Clinical outcomes evaluatedevaluated

Score of quality of lifeScore of quality of life Lung functionsLung functions Frequency of symptoms Frequency of symptoms Hospital admitionsHospital admitions Absenteeism to work/schoolAbsenteeism to work/school Emergency room visitsEmergency room visits Asthma knowledgeAsthma knowledge Self-managementSelf-management MedicationMedication Physician consultationPhysician consultation

Search Strategy - QuerySearch Strategy - Query

AND ((interactive[All Fields] AND ("communication"[MeSH Terms] OR AND ((interactive[All Fields] AND ("communication"[MeSH Terms] OR communication[Text Word]) AND applications[All Fields]) OR computerized[All Fields] communication[Text Word]) AND applications[All Fields]) OR computerized[All Fields] OR (telemedicine[MeSH Terms] OR telemedicine[Text Word]) OR (("computers"[TIAB] OR (telemedicine[MeSH Terms] OR telemedicine[Text Word]) OR (("computers"[TIAB] NOT Medline[SB]) OR "computers"[MeSH Terms] OR computer[Text Word]) OR NOT Medline[SB]) OR "computers"[MeSH Terms] OR computer[Text Word]) OR ("internet"[MeSH Terms] OR internet[All Fields]) OR ("software"[MeSH Terms] OR ("internet"[MeSH Terms] OR internet[All Fields]) OR ("software"[MeSH Terms] OR software[Text Word]) OR ("multimedia"[MeSH Terms] OR multimedia[Text Word]) OR software[Text Word]) OR ("multimedia"[MeSH Terms] OR multimedia[Text Word]) OR ("hypermedia"[MeSH Terms] OR hypermedia[Text Word]) OR (www[All Fields] OR ("hypermedia"[MeSH Terms] OR hypermedia[Text Word]) OR (www[All Fields] OR web[All Fields] OR online[All Fields]) OR e-health[All Fields] OR video[All Fields] OR web[All Fields] OR online[All Fields]) OR e-health[All Fields] OR video[All Fields] OR digital[All Fields] OR ("television"[MeSH Terms] OR television[Text Word]) OR digital[All Fields] OR ("television"[MeSH Terms] OR television[Text Word]) OR video[All Fields] OR audio[All Fields])video[All Fields] OR audio[All Fields])

(("asthma"[MeSH Terms] OR asthma[Text Word]))(("asthma"[MeSH Terms] OR asthma[Text Word]))

AND ((clinical[Title/Abstract] AND trial[Title/Abstract]) OR clinical trials[MeSH Terms] AND ((clinical[Title/Abstract] AND trial[Title/Abstract]) OR clinical trials[MeSH Terms] OR clinical trial[Publication Type] OR random*[Title/Abstract] OR random OR clinical trial[Publication Type] OR random*[Title/Abstract] OR random allocation[MeSH Terms] OR therapeutic use[MeSH Subheading])allocation[MeSH Terms] OR therapeutic use[MeSH Subheading])

AND ((("patient education"[MeSH Terms] OR patient education[Text Word]) OR AND ((("patient education"[MeSH Terms] OR patient education[Text Word]) OR (educational[All Fields] AND interventions[All Fields]) OR (psycho-educational[All (educational[All Fields] AND interventions[All Fields]) OR (psycho-educational[All Fields] AND interventions[All Fields]) OR ("self care"[TIAB] NOT Medline[SB]) OR Fields] AND interventions[All Fields]) OR ("self care"[TIAB] NOT Medline[SB]) OR "self care"[MeSH Terms] OR self management[Text Word]) OR prevention[Text Word]) "self care"[MeSH Terms] OR self management[Text Word]) OR prevention[Text Word]) OR (behavioral[All Fields] AND change[All Fields])OR (behavioral[All Fields] AND change[All Fields])

Inclusion CriteriaInclusion Criteria

Controled studies that evaluate the Controled studies that evaluate the eficacy of interactive aplication for eficacy of interactive aplication for asthma pacient educationasthma pacient education

Exclusion CriteriaExclusion Criteria

Articles that were not in English, Articles that were not in English, Portuguese and Spanish.Portuguese and Spanish.

Non-access to the Non-access to the full text of the full text of the articles after : Library Search, Web articles after : Library Search, Web search, contact withauthor and field search, contact withauthor and field experts;experts;

General description of methodsGeneral description of methods

We formulated a query and conducted an We formulated a query and conducted an exhaustive search in PubMed;exhaustive search in PubMed;

The articles were distributed by groups of two The articles were distributed by groups of two people;people;

The title and abstract of articles were read and The title and abstract of articles were read and it were applied the inclusion and exclusion it were applied the inclusion and exclusion criteria in order to exclude or non-exclude it;criteria in order to exclude or non-exclude it;

If the two elements of the group did not reach a If the two elements of the group did not reach a consensus, the article is evaluated by a third consensus, the article is evaluated by a third element;element;

General description of methodsGeneral description of methods

In a second step the full articles In a second step the full articles were were distributed by groups of two people;distributed by groups of two people;

Full text of articles were read and the Full text of articles were read and the inclusion and exclusion criteria were inclusion and exclusion criteria were applied;applied;

In cases that the two elements of the In cases that the two elements of the group did not reach a consensus the group did not reach a consensus the article was evaluated by a third element;article was evaluated by a third element;

Analysing Full TextsAnalysing Full Texts

Which clinical outcomes were evaluated?Which clinical outcomes were evaluated? What was the method of evaluation of the What was the method of evaluation of the

outcomes?outcomes? How long was the intervention?How long was the intervention? What and how was the intervention?What and how was the intervention? Which results were obtained?Which results were obtained? What is the main message of the article?What is the main message of the article?

General description of methodsGeneral description of methods

We extracted the data from the We extracted the data from the selected articles and inserted it on selected articles and inserted it on SPSS;SPSS;

We conducted a data analysis;We conducted a data analysis; We interpreted and discussed our We interpreted and discussed our

results;results;

ResultsResults

Selection of participantsSelection of participants

Selected Articlesn = 586

(in PubMed search)

Article’s revision by Title and/or Abstract

Excluded Articles: n = 14

Reasons for exclusion:

Full text not available: n = 10Articles not primarily about asthma: n = 1Articles not related to Interactive Applications: n = 1Not controlled Studies: n = 1Articles that did not evaluate the efficacy of the method: n = 1

Revision of the remaining Articles by

full text(n = 27)

Articles Included in the Systematic

Reviewn = 13

Excluded Articles: n = 559

Reasons for exclusion:

Articles not primarily about asthma: n = 502Articles not about children/adults: n = 3Not controlled Studies: n = 11Articles not related to Interactive Applications: n = 41Reviews: n = 2

Included Vs Excluded ArticlesIncluded Vs Excluded Articles

AddAdd

Frequency Frequency Percent Percent

Valid Valid Excluded Excluded

Opponent Opponent

Included Included

Total Total

557557

22

27 27

586 586

95,1 95,1

0,3 0,3

4,64,6

100,0 100,0

Lesser exclusion motiveLesser exclusion motive

FrequencyFrequency PercentPercent

Isn´t primarily about asthmaIsn´t primarily about asthma 502502 85,785,7

Isn't about children/adultsIsn't about children/adults 33 ,5,5

Isn´t a controlled studyIsn´t a controlled study 1111 1,91,9

Isn''t about interactive Isn''t about interactive applicationsapplications

4141 7,07,0

Is a reviewIs a review 22 ,3,3

TotalTotal 559559 95,495,4

Missing Missing SystemSystem 2727 4,64,6

Total Total 586586 100,0100,0

Agreement between evaluatorsAgreement between evaluators

Reviewer1 * Reviewer2Reviewer1 * Reviewer2

CrosstabulationCrosstabulation

Count Count

Symmetric MeasureSymmetric Measure

a. Not assuming the null hypothesis.a. Not assuming the null hypothesis.

b. Using the asymptotic standard error assuming the null hypothesis.b. Using the asymptotic standard error assuming the null hypothesis.

ValueValue Asymp.Asymp.

Std. Std. ErrorErroraa

Approx. TApprox. Tbb Approx. Approx. Sig.Sig.

Measure of Agreement KappaMeasure of Agreement Kappa

N of Valid CasesN of Valid Cases

0,9620,962

586586

0,0260,026 23,30023,300 0,0000,000

Reviewer2 Reviewer2 TotalTotal

ExcludedExcluded IncludedIncluded

Reviewer1 Reviewer1 ExcludedExcluded

IncludedIncluded

557 557

11

11

2727

550550

2828

TotalTotal 558 558 2828 586586

Analysing full textAnalysing full text

Interactive application usedInteractive application used Three types of interactive applications were more frequently used: Three types of interactive applications were more frequently used:

computer programs, video games, web-based education program.computer programs, video games, web-based education program.

0 1 2 3 4 5 6 7

GSM /SMS

home telephone

w eb based education programme

video game

computer programe

Inte

ract

ive

appl

icat

ion

Number of studies

Follow up timeFollow up time

0 5 10 15 20 25

Runge C, et al 2006

Lieberman DA, 2001

Huss K, 1991

Huss K, 2003

Ostojic V, 2005

Bartholomew LK, 2000

Rasmussen LM, 2004

McPherson AC, 2006

Ross Shegog, 2001

Homer C et al, 2000

Sundberg R, 2004

Guendelman S, 2002

Krishna S, 2003

Aut

hors

Months

Number of individuals of the population per study

0 50 100 150 200 250 300 350 400 450 500

Ostojic V, 2005

Lieberman DA, 2001

Huss K, 1991

Ross Shegog, 2001

Sundberg R, 2004

Huss K, 2003

McPherson AC, 2006

Guendelman S, 2002

Homer C et al, 2000

Bartholomew LK, 2000

Krishna S, 2003

Rasmussen LM, 2004

Runge C, et al 2006

Auth

ors

Number of individuals of the population

ArticleInteractive application

studied

lung function

asthma severity

physician consultations

Medicationhospital

admissionemergency

visits

school/work absence

self-manegement

asthma knowledge

quality of life

Runge C, et al 2006

Web-based education program

 +  

 +    

 +  +  

    + 

Rasmussen LM, 2004

Web-based education program

  +  

           0    0  

Ostojic V, 2005

GSM and SMS  +             + 

McPherson AC, 2006

Computer program

      + 

        + 

Krishna S, 2003

Computer program

    +  + 

 +  +  

  +  

Huss K, 1991Computer program

      +  

      +  

Ross Shegog,

2001

Computer program

              +  

Homer C et al, 2000

Computer program

          - 

  -  

+  

Sundberg R, 2004

Computer program

  -  

              0 

Lieberman DA, 2001

Video game               +   + 

Bartholomew LK, 2000

Video game + 

         0    +  

 +  

Huss K, 2003 Video game  0  - 

             0   0 

Guendelman S, 2002

Program connected to a

home telephone        -  +  + 

      +

+

 -

0 

Significantly improvement of the treatment group vs control group*

Significantly improvement of the control group* vs treatment group

Not significantly differences between the two groups

*The control group also have a paralell intervention (not interactive)

Summary of results of the studiesSummary of results of the studies

Only in one study the allocation of patients to Only in one study the allocation of patients to control and exposed groups was not random.control and exposed groups was not random.

Six of thirteen studies evaluated acquisition of Six of thirteen studies evaluated acquisition of asthma knowledge and five of this observed asthma knowledge and five of this observed better results on intervention group compared better results on intervention group compared with control group while one did not observed with control group while one did not observed significantly differences.significantly differences.

Ten out of the thirteen studies generally Ten out of the thirteen studies generally concluded that the outcomes of individuals using concluded that the outcomes of individuals using interactive applications were better than in interactive applications were better than in control groups.control groups.

DiscussionDiscussion

Interactive applications often achieve Interactive applications often achieve positive outcomes in the target populationspositive outcomes in the target populations

Computer programs is the type of Computer programs is the type of interactive application most investigated.interactive application most investigated.

Web-based programs are less studied but Web-based programs are less studied but have better results in most patients’ have better results in most patients’ outcomes.outcomes.

The results of other interactive The results of other interactive applications are inconsistent.applications are inconsistent.

DiscussionDiscussion

Computer programComputer program:: There is some heterogeneity in the results, but the There is some heterogeneity in the results, but the

majority of the cases lead to several majority of the cases lead to several improvements.improvements.

However, since some articles show that the control However, since some articles show that the control group had better results than the intervention group had better results than the intervention group, it is necessary to evaluate this intervention group, it is necessary to evaluate this intervention in more studies so as to lead to solid conclusions. in more studies so as to lead to solid conclusions.

DiscussionDiscussion

Video gameVideo game:: There are contradictory results, so more studies There are contradictory results, so more studies

about this method must be performed in order to about this method must be performed in order to have a better evaluation.have a better evaluation.

Web-based education program:Web-based education program: Although only two articles are currently available, Although only two articles are currently available,

significant improvements were observed in the significant improvements were observed in the target population.target population.

DiscussionDiscussion

GSM and SMS GSM and SMS :: More studies are necessary since the only article More studies are necessary since the only article

with this interactive method reported good results with this interactive method reported good results in pulmonary function and self-management.in pulmonary function and self-management.

Program connected to a home Program connected to a home telephone:telephone:

Only one article was found, moreover its results Only one article was found, moreover its results were not consistent, with improvements in were not consistent, with improvements in emergency visits, school absence and quality of emergency visits, school absence and quality of life but with negative results as for hospital life but with negative results as for hospital admissions.admissions.

DiscussionDiscussion In general, the outcomes with more considerable improvements In general, the outcomes with more considerable improvements

were knowledge about asthma, absenteeism and the need of were knowledge about asthma, absenteeism and the need of medication. medication.

This can be explained since these applications, by using methods This can be explained since these applications, by using methods like games that are more attractive to a young population, may like games that are more attractive to a young population, may allow them to learn more efficiently with this kind of approach.allow them to learn more efficiently with this kind of approach.

The adult’s population is not so open to these interactive The adult’s population is not so open to these interactive methods.methods.

On the contrary, as for the more practical results such as asthma On the contrary, as for the more practical results such as asthma severity, quality of life or even emergency visits, there is not, in severity, quality of life or even emergency visits, there is not, in general, a significant improvement. This may seem a paradox general, a significant improvement. This may seem a paradox since the theoretical knowledge has improved.since the theoretical knowledge has improved.

It was not possible to perform a It was not possible to perform a comparison among some studies comparison among some studies because there were articles that studied because there were articles that studied the same interactive aplications but the same interactive aplications but whose outcomes evaluated were whose outcomes evaluated were different.different.

It is also important to mention that some It is also important to mention that some of the articles that studied the effect of of the articles that studied the effect of computer programs had a time of computer programs had a time of intervention superior than others.intervention superior than others.

Limitations of our studyLimitations of our study

Limitations of our studyLimitations of our study

Relatively to the number of Relatively to the number of participantsparticipants::– there was a discrepancy among there was a discrepancy among

some studies and there was not a some studies and there was not a strong representation of the whole strong representation of the whole asthmatic population since 9 asthmatic population since 9 studies were about young children studies were about young children and only 4 about adults.and only 4 about adults.

Limitations of our studyLimitations of our study

Having in mind cited limitationsHaving in mind cited limitations

Is not possible at this time to Is not possible at this time to establish the usefulness of establish the usefulness of

interactive methods for education interactive methods for education and behaviour change of asthma and behaviour change of asthma

patients.patients.

ConclusionConclusion

The theme of this systematic review is a recent subject The theme of this systematic review is a recent subject and still has many limitations:and still has many limitations:

It is necessary to find ways of increasing adherence of It is necessary to find ways of increasing adherence of participants in the studies and, as interactive applications participants in the studies and, as interactive applications are widely used by younger people, this can affect the are widely used by younger people, this can affect the results when we compare studies with adults results when we compare studies with adults versusversus studies with children. studies with children.

The results from the articles included in this The results from the articles included in this systematic review are very diversesystematic review are very diverse

ConclusionConclusion The use of interactive applications seem to be promising The use of interactive applications seem to be promising

for improving patient education and promoting behaviour for improving patient education and promoting behaviour change, but more studies on the best options and on its change, but more studies on the best options and on its effects in asthma outcomes are necessary.effects in asthma outcomes are necessary.

Moreover, more studies about the use of interactive Moreover, more studies about the use of interactive applications that account for the specific needs of each applications that account for the specific needs of each individual could be the purpose of new studies. individual could be the purpose of new studies.

Asthma can severely affect the patients’ lives in different Asthma can severely affect the patients’ lives in different manners. In consequence, every effort maid with the aim manners. In consequence, every effort maid with the aim of improving patient education and promoting behaviour of improving patient education and promoting behaviour change (increasing self-management) is meaningful and change (increasing self-management) is meaningful and necessary. necessary.

GanttGantt ChartChart

Site MapSite Map

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AuthorsAuthors Almeida P, Caetano F, Carvalho A, Almeida P, Caetano F, Carvalho A,

Fernandes S, Gaspar J, Loureiro M, Fernandes S, Gaspar J, Loureiro M, Marques C, Neves N, Rollo A, Sousa Marques C, Neves N, Rollo A, Sousa C, Sousa C, Sousa S.C, Sousa C, Sousa S.

SupervisorsSupervisorsFonseca, MD, PhDFonseca, MD, PhD