gms | German Medical Science

Background: Structured patient education is the core non-pharmaceutical component of current asthma management according to international guidelines. Aiming at improved asthma self-management it is an integral part of disease management and medical rehabilitation in Germany. Patient education in rehabilitative practice often lacks clear theoretical bases, standardization and evaluation. It is prone to oral presentations with little patient activation and untrained trainers.

Study Question: We hypothesize an evidence-based patient education programme for adult asthma patients in medical rehabilitation based on a constructivist approach, evidence-based contents and criteria for good educational practice (clear structure, participant orientation and cognitive activation) will enhance asthma control and disease-specific knowledge compared to traditional patient education. However, effective patient education is said to be demanding for patients. This may reduce acceptance and satisfaction with the programme.

Methods: We conducted a prospective single-centre controlled trial in an inpatient medical rehabilitation centre (duration: 3 weeks) with adult asthma patients (18-65 years). Intervention patients received the modified patient education programme (MPEP), control patients the usual lecture-based education programme. Timeline: Apr 2013-Nov 2013: recruitment of control group (CC; n=200), Dec 2013 until Feb 2014: Implementation of MPEP, Apr 2014-Nov 2014: recruitment of intervention group (IG; n=200). Data were assessed at admission (t0), discharge (t1) and after 6- and 12 months (t2, t3) with patient-reported questionnaires. The primary outcome was asthma control (ACT). Secondary outcomes included (a.o.) asthma knowledge. We assessed comprehensibility and impact of patient education (COHEP; heiQ) at T1 only. We calculated mean Scores for COHEP and heiQ at T0 and tested statistical significance with the T-Test for unpaired samples. To assess non-response bias we modelled the propensity to participate at t3 (multiple logistic regression). Treatment effects (between group effects) were evaluated separately for each follow-up time point using analysis of covariance (ANCOVA) adjusting for baseline values.

Findings: The t0-sample consisted of 424 rehabilitants with asthma (IG n=209, CG n=215, mean age 50.6 years (SD=9.4), 75,1% females, living a mean of 17,8 (SD=14.1) years with asthma). We observed no statistical significant differences in any of the background variable between IG and CG. At t3 we obtained questionnaires from n=150 (IG) and n=151 (CG) patients (response rate 71.2% rs. 70.2%). IG members were more likely to participate at t3 than CG (OR 1,7; 95%-CI 1,0 to 2,6) as well as patients satisfied with patient education (OR 1,6; 95%-CI 1,0 to 2,6). The intervention group rated trainer skills an average 3 points better than the control group (p=0,005), Transferability, type and amount of (medical) information was rated no different by treatment group. Programme acceptance (heiQ-programme) did not differ substantially between IG and KG (-1,7; 95%-CI -4,0 to 0,7).

At t3 significant increases in ACT and asthma knowledge were maintained in both groups. ACT: IG: +1.6 (95%-CI .83 – 2.3) and CG: +2.0 (95%-CI 1.3 – 2.6), mean difference -.22 (95%-CI -1.1 - .62). t-Test asthma knowledge: IG p=.00, d=1.2, CG p=.00, d=.50). With regard to asthma knowledge after 12 months a trend to significant group*time interaction emerged (p=.08, η2=.010). The small effect in favor of the intervention group can be attributed to the domain self-management knowledge (p=.056 η2=.012). No significant differences between the two programs were observed for asthma control though.

Discussion: The MPEP was not superior to traditional patient education concerning asthma control. The surprisingly little additional effect of the MPEP on asthma outcomes might be explained partly by (a) the quality of the traditional programme and (b) response bias. At least the MPEP improved patient perceived trainer skills and with no side effects on programme acceptance.

Practical implications: Reasons to stick with the MPEP are the coherent educational materials, higher standardization and more patient orientation. Finally, the MPEP permanently increased practical asthma knowledge after 1 year which is a prerequisite for successful daily life disease management.