A telephone-based asthma management coaching programme improves QOL in parents of children with asthma, but has no effect on child's QOL or on use of urgent care
- Correspondence to Sarah Latham
Department of Respiratory Medicine, King's College Hospital NHS Foundation Trust, Denmark Hill, London SE5 9RS, UK;
Asthma is the commonest chronic disease in childhood. In the UK, there are 1.1 million children with the condition, equating to approximately three in every classroom.1 Asthma is more common and more severe in the UK than in many other parts of the world,2 and between 20 and 30 children die from the condition per year.
With these statistics in mind, the education of families of children with asthma as to the management of the condition, including appropriate behaviour when asthma deteriorates, is paramount. The use of telemedicine in such education is gaining in popularity, particularly telephone reviews. In addition, the use of such technology is in line with government policy on management of long-term conditions. Telephone reviews for asthma have been shown to be effective in increasing asthma review rates, and in being acceptable to patients and also improving their confidence.3 Most of this research however has been carried out in adults.
Garbutt and colleagues carried out a randomised controlled trial to evaluate the impact of a 12-month structured telephone coaching programme for families of children with asthma aged between 5 and 12 years. The aim was to determine whether the programme could improve parent and child quality of life (QOL) and reduce unscheduled visits because of asthma. Coaching was given by nurses with at least 2 years experience in acute asthma in paediatrics. Comparison was made between groups receiving either usual care or usual care with coaching. Three hundred and sixty-two families were recruited. The coaching focused on four key asthma management behaviours – regular use of ‘controller medications’ (preventers such as inhaled corticosteroids), administering albuterol (salbutamol) at first signs of an asthma exacerbation, having an up-to-date asthma action plan and having a review with the primary care provider every 6 months. Results were that the parental QOL scores improved significantly in the intervention group but there was no difference between groups in the child QOL scores. There was also no difference between the groups in the number of unscheduled visits for asthma; in both there was a similar reduction. The authors' main conclusion was that a telephone coaching programme can improve parental QOL.
This study was different from others of its kind in that it focused on the parents of children aged 5–12. That said, it may have been advantageous to have, as the primary outcome measure, the reduction in unscheduled visits and secondary outcome measures to include Childhood Asthma Control Test (C-ACT) scores of ≥ 19 (ie, indicating good control). In order to manage asthma in children, accurate assessment of asthma control is crucial, and the C-ACT is a validated tool to identify children with poor control of asthma.4 This way, treatment can be escalated or reduced accordingly. The advantage of the C-ACT is that both the child and the parent answer the questions; it is known that frequently, even in young children, their views on asthma may differ from that of their parents. Surprisingly, the authors had not set out to assess asthma control, but have developed their own tool based on the child's recent and long-term asthma morbidity. The disadvantage of this tool seems to be the lack of involvement of the child and a reliance solely on parental reporting.
The four behaviours honed-in on were important, but there is a lot more to educating families of children with asthma than these (eg, ascertaining the beliefs/understanding of the family and, most importantly, their attitude towards treatment such as steroids). This may have been an element in the disappointing lack of difference between the two groups in unscheduled visits. Also, the authors propose that, as a less expensive option, lay asthma coaches (ie, non-medically trained personnel) may provide telephone education. Healthcare professionals involved in the care of patients with asthma should be appropriately trained.5
The study took place in the United States and their model of care differs from the UK. In the UK, there are many asthma-trained nurses in both adults and paediatrics. The authors point out that few paediatricians regularly meet families to assess response to a treatment. This is not the case in the UK as both specialist nurses and respiratory paediatricians routinely run clinics for such cases, likewise in primary care.
There is a definite case for telephone reviews, but for a number of families face-to-face review will be appropriate, especially if there is poor control or where practicalities such as inhaler technique need discussion – the latter is not mentioned in this article. It would also have been interesting to have sought the views of the parents on the coaching.
Competing interests SL has received speaker honoraria from Allen & Hanburys, AstraZeneca and Merck Sharpe and Dohme.