کاهش مصرف بیمارستانی از طریق آموزش خودمدیریتی برای افراد مبتلا به آسم مزمن

The purpose of this study was to assess the impact of asthma Self Management Training on the health status and resource use of patients with chronic asthma. The study consisted of a randomized control design of chronic asthmatic patients in a tertiary care center in India. The intervention group (153 patients) received four training sessions in addition to the regular care provided to the control group (150 patients). Health status and resource use were measured at baseline and over a one year follow-up period. The intervention group had significantly better health status (measured by breathing ability), fewer productive days lost, and lower resource use (hospitalizations and emergency room visits) than the control group. Total annual costs (direct and indirect) were also lower, though physician costs were not included in the assessment. Therefore, incorporation of asthma Self Management Training as part of clinical management of asthma can result in improvements in health status and reductions in hospital use.

This manuscript describes the development and initial validation of a self-report questionnaire designed to assess an individual's readiness to adopt a self-management approach to their chronic pain condition. Theory and preliminary empirical work informed the development of a pool of items that were administered to a sample of individuals reporting chronic pain. Analyses of the data support a four factor measure that is consistent with the transtheoretical model of change and associated stages of change model. Each of the four factors, precontemplation, contemplation, action, and maintenance, was found to be internally consistent and stable over time. There was also substantial support for each factor's discriminant and criterion-related validity.

A total of 276 subjects (136 control and 140 intervention patients) completed the three follow-up periods. Table 2 gives basic information on the patients at baseline. The two groups of patients were similar in terms of sex and age distribution. Both groups had a greater proportion of females than males, and the age distribution was fairly uniform in the range from 10 to 45 yr. Health status and use measures during the month prior to the start of the study did not differ significantly between the groups. Table 2. Baseline characteristics Variable Control (n=136) Intervention (n=140) Significance (p-value) Male 43% 39% 0.49 Age Distribution (years) 10–19 33% 27% 0.34 20–29 18% 23% 0.19 30–39 31% 29% 0.17 40–45 18% 21% 0.37 Mean PEFR 274 (67) 281 (65) 0.35 Hospital days per patient during prior month 0.68 (1.45) 0.65 (1.32) 0.96 Emergency visits during prior month 1.15 (1.75) 1.02 (1.64) 0.57 Direct cost of treatment during prior month (Rs.)a 263 (160) 264 (156) 0.50 Standard deviations in parentheses. aIncludes hospitalization, emergency room, and drug use. Table options Table 3 summarizes the values of the outcome variables during the three follow-up months over the year following the baseline interview for control and intervention groups. All improvements in the health outcome measures were statistically significant at p<0.001. Mean PEFR was improved by 14.5% in the intervention group relative to the control group. The intervention group had 48.5% fewer productive days lost. Table 3. Outcome measures (average per patient during year after baseline) Variable Control (n=136) Intervention (n=140) Difference (%) Significance (p-value) Health outcome measures Mean PEFR 290 (77.69) 332 (50.78) 14.5% <0.001 Productive days losta 34.1 (38.8) 17.6 (24.2) −48.5% 0.003 Resource use measures Hospital days (all patients)a 12.5 (19.8) 5.8 (10.7) −53.2% 0.016 Percent hospitalizedb 36.8% 27.1% −26.2% 0.043 ER visits (all patients)a 21.8 (25.0) 11.6 (16.2) −46.7% 0.002 Patients with ER visitsb 50.0% 42.9% −14.3% 0.117 Cost estimates (in rupees)c Intervention costs 0 160 n.a. n.a. Direct costsa,d 5052 (3540) 4224 (2056) −16.4% 0.301 Indirect costsa 1704 (1940) 879 (1212) −48.5% 0.003 Total average costsa 6756 (5340) 5263 (3236) −22.0% 0.036 Standard deviations are in parentheses. aA non-parametric statistical test (Mann–Whitney) was used because of the skewed distribution. bRepresents the average per three month period. cCurrency: 25 Indian Rupees=$1 US at the time of the study. dIncludes hospitalization, emergency room, and drug use. Table options Effects of the intervention on resource use measures were also generally statistically significant. The intervention group had a 53.2% reduction in days hospitalized overall, and the likelihood of a patient having any hospitalization was reduced 26% (from 37% to 27%). Furthermore, among patients hospitalized, the average days hospitalized during the year fell from 38 days for the control group to 22 days for the intervention group (not shown in the table). The intervention group experienced a 46.7% reduction in emergency room visits overall, and the likelihood of having any emergency visits fell by 14% (though the latter was not statistically significant). Among patients with ER visits, the average number of visits fell from 43.6 to 27.2 (not shown in the table). Analysis of direct and indirect costs indicated that the intervention group incurred indirect costs that were 48% less (p=0.003). Direct costs were lower for the intervention group by 16%, though this reduction was not statistically significant when compared to the control group. The average total costs for intervention group members were 22% less than for control group members (Rs. 5263 versus Rs. 6756). The cost reductions from the SMT intervention over the year, therefore, more than offset the intervention costs which were only incurred once at the beginning. The reduction is due largely to the reduction in indirect costs, however, and the costs of physician visits not related to medication were not included. Furthermore, refresher training courses might be required to sustain the savings in subsequent years. Sensitivity analysis under different assumptions regarding the cost estimates did not alter any of these findings.