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See section 1, "Overall Methods Used To Develop This Report," for literature search strategy and tally of results for EPR—3: Full Report 2007 on this component, Education for a Partnership in Asthma Care. Six Evidence Tables were prepared: 3, Asthma Self-Management Education for Adults; 4, Asthma Self-Management Education for Children; 5, Asthma Self-Management Education in Community Settings; 6, Cost-Effectiveness of Asthma Self-Management Education; 7, Methods for Improving Clinical Behaviors: Implementing Guidelines; 8, Methods for Improving Systems Support. Education for a Partnership in Asthma Care requires education for the patient or caregiver about asthma self-management as well as education for clinicians to enhance skills in teaching patients self-management and provide support to implement guidelines-recommended practices. In this component, recommendations are presented on asthma self-management education at multiple points of care, tools for asthma self-management, and provider education.

Evidence is now abundant that asthma self-management education is effective in improving outcomes of chronic asthma. Specific training in self-management skills is necessary to produce behavior that modifies the outcomes of chronic illnesses such as asthma. Expert care, with regular review by health professionals, is necessary but not sufficient to improve outcomes. Patients must actively participate in their own care, which means consciously using strategies and taking actions to minimize exposure to factors that make asthma harder to control and adjusting treatments to improve disease control.

The ultimate goal of both expert care and patient self-management is to reduce the impact of asthma on related morbidity, functional ability, and quality of life. The benefits of educating people who have asthma in the self-management skills of self-assessment, use of medications, and actions to prevent or control exacerbations, include reduction in urgent care visits and hospitalizations, reduction of asthma-related health care costs, and improvement in health status (; ; ; ; ; ; ; ; ; ; ; ; ; ). Other benefits of value from self-management education are reduction in symptoms, less limitation of activity, improvement in quality of life and perceived control of asthma, and improved medication adherence (; ; ; ; ; ; ; ; ). Cost-analysis studies have shown that asthma education can be delivered in a cost-effective manner and that morbidity is reduced as a result, especially in high-risk subjects (; ; ; ; ).

Although not all controlled trials of asthma self-management education have shown positive results, it is notable that controlled studies have demonstrated benefit from patient education programs delivered in a wide range of points of care, including clinics, EDs, hospitals, pharmacies, doctors' offices, schools, and community settings. These results have been achieved through face-to-face educational strategies and the use of new electronic technologies. Referenced studies are from multiple countries. Some outcomes may be dependent on the context of care and may not be completely generalizable.

The Expert Panel recommends that patients be educated at multiple points of care where health professionals and health educators may interact with patients who have asthma (Evidence A or B, depending on point of care). For people who have asthma, many points of care exist outside traditional clinic, office, or hospital settings. An emerging body of evidence suggests that educating people at these points of care creates opportunities to provide an essential link between the patient and the primary clinician, forming a network of support for the patient and clinician outside the clinician's office. In this way, a network of asthma education capability is built that ensures no person who has asthma is left without knowledge or skills.

Although it is beyond the scope of this document to address the issues of asthma education of persons who are not family members and are not health care professionals, those individuals who come into contact with persons with asthma on a regular basis (e.g., teachers, coaches, daycare workers, employers, etc.) should receive some basic education about asthma. Education of these individuals about asthma may help reduce asthma morbidity and mortality and may contribute to earlier diagnosis of this disease. Teachers and coaches should know how to recognize worsening asthma, administer quick-relief medications, and know how and when to call for emergency services.

▪ Clinicians provide to patients asthma self-management education that includes the following essential items: asthma information and training in asthma management skills (Evidence A), self-monitoring (either symptom– or peak flow–based) (Evidence A), written asthma action plan (Evidence B), and regular assessment by a consistent clinician (Evidence B). (See Evidence Table 3: Asthma Self-Management Education for Adults.) ▪ Clinicians involve patients in decisions about the type of self-monitoring of asthma control that they will do (Evidence B) ▪ Clinicians provide all patients with a written asthma action plan that includes instructions for (1) daily management, and (2) recognizing and handling worsening asthma, including self-adjustment of medications in response to acute symptoms or changes in PEF measures. Written asthma action plans are particularly recommended for patients who have moderate or severe persistent asthma, a history of severe exacerbations, or poorly controlled asthma (Evidence B). ▪ Clinicians involve adult patients in the treatment decisionmaking within the context of a therapeutic partnership (Evidence B). ▪ Health professionals and others trained in asthma self-management education be used to implement and teach asthma self-management programs (Evidence B).

▪ Because poor attendance at multiple sessions may be a problem in some populations, consider introducing key messages and essential skills of self-management in the first session and adjusting subsequent sessions to the needs of the patients in the groups (Evidence D). Research comparing lengthy versus condensed or shorter sessions is encouraged. (See Evidence Table 3, Asthma Self-Management for Adults.)

In a large, scientific review of 36 RCTs involving 6,090 adults who had asthma, asthma self-management—accompanied by regular review of medications and asthma control by a medical practitioner—improved health outcomes significantly more than usual care (). All interventions included education, while 15 tested "optimal self-management" that included self-monitoring of symptoms and/or peak flow, regular review by a clinician, and a written asthma action plan. These intervention trials were conducted in primary care, specialty care, hospital inpatient, or community settings. The results of the statistical analysis overall, including meta-analysis where possible, showed self-management education significantly reduced hospitalizations, unscheduled acute visits, and missed work days, as well as improving quality of life. Subgroup analyses compared the intensity of the intervention (optimal self-management with regular review, self-monitoring, and a written asthma action plan versus self-monitoring and regular review versus self-monitoring only versus regular review only versus written asthma action plan with either self-monitoring or regular review). Optimal self-management, including self-monitoring of symptoms and/or peak flow and a written asthma action plan, significantly reduced hospitalizations and ED visits for asthma. There was insufficient power to compare the subgroups with less intensive interventions. There was little effect on lung function: FEV 1 did not change. A statistically significant small mean increase (14.5 L/min, p <0.05) in PEF occurred, however.

Self-management education that included a written asthma action plan appeared more effective than other forms of self-management education. The intensity (number of sessions) of teaching and the number of different components taught had little impact.

Regular review of progress by a concerned clinician is the basis for the patient–clinician partnership necessary to achieve asthma control. In another scientific review, the equivalence and efficacy of different options for asthma self-management were analyzed in 15 RCTs (). In six studies, regular clinical review by physicians who adjusted ICS medications was compared to self-management education allowing self-adjustment of medications by using a written asthma action plan. These two methods for achieving asthma control were found to be equivalent. No significant differences in hospitalization, ED visits, unscheduled doctor's visits, or frequency of nocturnal asthma symptoms were found between patients who self-adjusted their medication and those whose medications were adjusted by their physicians. Two of three studies found no difference between clinician review and self-management in the days lost from work or school, while the third study reported a significant effect of peak-flow-based self-management on work or school absenteeism. Lung function, as measured by FEV 1 , was not significantly improved with peak-flow-based self-adjustment of medications as compared to physician adjustment of medications.

The evidence from this analysis indicates that these two methods of adjusting medications for asthma control (change by physician during office visit or patient self-management according to a written asthma action plan) are equivalent, and the choice depends on the comfort and agreement between the clinician and the patient. Patient self-monitoring is an important tool for patients to assess the level of their asthma control and to adjust treatment according to their action plan.

When self-management is the chosen method for maintaining asthma control, peak-flow-based self-management is equivalent to symptom-based self-management as long as either method also includes a written asthma action plan with instructions on how to recognize and handle worsening asthma, including self-adjustment of medications. In three studies, both methods were found to have an equal impact on ED visits, and one study found peak flow monitoring was more effective in reducing ED visits (). As noted in "Component 1: Measures of Asthma Assessment," the important point is for patients to have a plan for monitoring their asthma, regardless of whether it is peak flow or symptom based. Therefore, the Expert Panel recommends that clinicians involve patients in decisions about the type of self-monitoring they will do. All patients may benefit from a written asthma action plan that includes instructions for (1) daily management, and (2) recognizing and handling worsening asthma, including self-adjustment of medications in response to acute symptoms or changes in PEF measures. Written action plans are particularly recommended for patients who have moderate or severe asthma, a history of severe exacerbations, or poorly controlled asthma. (See "Component 1: Measures of Asthma Assessment" for further discussion of tools for assessing asthma control.)

Other studies offer evidence of varying effectiveness of patient education. Those studies conducted as RCTs with positive findings confirm the results of the large scientific reviews (; ; ; ; ). In these trials, one conducted across multiple practices in primary care settings (), providing self-management education including an asthma action plan for exacerbations resulted in reduced symptoms, fewer days of restricted activity, and improvement in quality of life. Self-management education also resulted in improved self-confidence to manage asthma () and improved adherence to ICS therapy (; ) (Evidence B). Education that provides information only, without skills training, improves knowledge but does not reduce hospitalizations, ED visits, unscheduled doctor's visits, or lost work days; nor does it improve lung function and medication use (). In this review, patients' reports of symptoms improved in only 2 of the 12 RCTs of information-only programs.

The value of establishing the patient–clinician partnership when teaching asthma self-management was shown in another RCT of asthma education () in which investigators purposely formed partnerships with patients in the intervention group. The control group received education on medication use, role of environmental triggers, and metered-dose inhaler (MDI) technique but no partnership. The educational intervention delivered in the context of the therapeutic relationship produced improved symptom control, quality of life, and lung function measured as FEV 1 in patients in the group who had moderate or severe asthma only. This finding suggests asthma self-management education, reinforced in the context of a therapeutic partnership between clinician and patient, may be especially valuable in patients who have moderate or severe asthma.

Another recent RCT (, ) used the context of the patient-clinician partnership to test the impact of shared decisionmaking about asthma treatment, compared to guideline-based clinician decisionmaking and usual care, in adults who had poorly controlled asthma. Clinician care managers (nurse practitioners, pharmacists, respiratory therapists) met with the patients to adjust therapy in two visits, 1 month apart, followed by three brief telephone calls (at 3, 6, and 9 months) to assess patients' progress in both intervention groups. The unique features of shared decisionmaking included identifying patients' goals and preferences regarding treatment and negotiating a treatment regimen to accommodate best each patient's goals and preferences. Establishing rapport, providing educational information, teaching inhaler technique, writing the prescription, and preparing a written asthma action plan for the patient occurred in both the guidelines and shared-decision groups. The shared-decision group had significantly greater adherence to long-term control medication compared to the guidelines group, and both interventions produced significantly better adherence to asthma control medications than usual care over 12 months of followup.

The results of these two important RCTs suggest the value of shared decisionmaking about asthma treatment in adults. Therefore, the Expert Panel concludes that clinicians should involve adult patients in the treatment decisionmaking within the context of a therapeutic partnership.

A variety of health professionals deliver health education effectively. Recent studies have focused on nurse-educators. Often, specially trained nurses provide asthma education. Three RCTs and three observational studies used advanced practice nurses trained in asthma to deliver self-management education to adults in outpatient settings. In one RCT, a hospital-based nurse specialist delivered self-management education during three sessions (). Compared to patients receiving usual care, the educated patients significantly increased use of ICS; decreased use of SABA for quick relief of symptoms; achieved higher mean and less variable PEF; and had significantly lower symptom scores, doctor visits, and urgent care visits for asthma after 6 months. The reduction in asthma morbidity in this study may have been related to the strong emphasis, during the educational sessions, placed on improving asthma self-management skills during exacerbations. In another RCT, self-management education with peak flow monitoring and a written asthma action plan, individualized to the patient's severity, was delivered in one session that was then reinforced in two subsequent visits (). Compared to the control condition (monitoring only), self-management education significantly improved adherence to ICS medications, quality of life, and perceived control of asthma. In an attempt to reduce high hospitalization rates and health care utilization, another RCT () examined the effectiveness of three educational interventions in adults: "asthma school," an educational booklet, and individual verbal instruction. Asthma school, which included three 4-hour sessions of group education, produced the most significant improvement in quality of life; individual verbal instruction produced the best overall response in terms of both asthma control and quality of life.

used nurse specialists to educate children and adults who had asthma through a standardized 2-hour asthma education program given across seven clinical centers in a large, multisite observational study. The program resulted in significant improvements (decreases) in hospital utilization and missed activity days over 6 months. Two other observational studies of adults who had asthma, in which patients were taught and cared for by specially trained asthma nurses (), showed significantly reduced symptoms and days of activity limitation as well as significantly decreased markers of airway inflammation (). In an attempt to reduce sick days lost from work, a 4-week inpatient asthma rehabilitation program was tested in an observational study that included asthma education, pharmacological optimization, physical training, and coping skill training. The program resulted in significantly reduced sick leave over 3 years (). Rehabilitation programs that require patients to live in the treatment setting are expensive and rare in the United States, but such programs may be useful for those who have severe asthma and are significantly limited by their asthma.

Respiratory therapists also provide asthma education in hospital, ED, and clinic settings and may direct clinical pathways and algorithms in hospital settings. There are no published RCTs of asthma education programs delivered by respiratory therapists. An observational trial of 60 pediatric patients who attended a special clinic focusing on inhaler technique demonstrated that MDI technique improved significantly after MDI demonstration, teaching, and reinforcement (). Respiratory therapists also participate actively in clinical protocols or pathways that are implemented in acute care settings for management of acute exacerbations in hospitalized patients. Studies of the efficacy and value of clinical pathways is reviewed in the "Provider Education Section: Methods of Improving System Supports—Clinical Pathways." The Expert Panel encourages using health professionals and others trained in asthma self-management education to implement and teach asthma self-management programs.

Negative studies that found little or no benefit of asthma self-management education frequently contained significant design flaws or methodological errors. Several were underpowered to detect significant differences between groups (; ; ) due to small sample size and significant attrition. (See Evidence Table 3, Asthma Self-Management for Adults.) modified the education according to age level but found no incremental benefit from this adjustment. Many of these patients were recruited from EDs immediately after treatment for an acute exacerbation, when they were presumably more open to education, but significant attrition from or no attendance at the educational sessions scheduled outside of the medical care context occurred (; ). Taken together, these studies demonstrate the problems that are created when education programs are not integrated into the patient's regular medical care as well as the low participation of intervention patients in educational programs designed with multiple sessions over time. Because poor attendance at multiple sessions may be a problem in some populations, the Expert Panel's opinion is that the key messages and essential skills of self-management should be introduced in the first session and that subsequent sessions should be adjusted to the needs of the patients in the groups.

The Expert Panel recommends that asthma self-management education be incorporated into routine care for children who have asthma (Evidence A). (See Evidence Table 4, Asthma Self-Management Education for Children.) A meta-analysis of 32 controlled trials of educational interventions for self-management in children and adolescents, involving 3,706 patients, showed significant effects of education in improving the child's self-efficacy and lung function as well as in reducing days with restricted activity, school absences, and ED visits (). No effects were seen on hospitalizations (; ). The authors conducted subgroup analyses to determine the effect of peak flow versus symptom-based monitoring strategies, individual versus group format, single versus multiple sessions, and moderate or severe asthma versus mild or moderate asthma, but the small number of studies in each subgroup did not provide sufficient statistical power to detect significant differences.

Several other controlled studies have also shown positive effects for self-management education in children. A multicenter RCT of education delivered by asthma counselors through group sessions, individual meetings, and telephone followup showed that education significantly reduced days with asthma symptoms (). An RCT of education that combined group sessions, individual meetings, and having the family accompany the patient during doctor visits both decreased frequency of symptoms and activity restriction and increased the families' ability and confidence to self-manage asthma (). A small RCT ( N = 33) with minority families found that group education that emphasized collaborative learning and use of cultural resources increased asthma knowledge and reduced ED visits significantly compared to more didactic group education and to a no-intervention control (). A trial of training to improve children's technique in using a breath-activated inhalation device showed that individual training provided by nurses in a single visit improved inhalation technique and that instructions to practice at home for 2 weeks resulted in further improvements (). These studies provide strong evidence for the benefit of providing structured self-management education to children who have asthma as well as their families in conjunction with ambulatory care for asthma.

▪ At the time of discharge from the ED, clinicians offer brief and focused asthma education (Evidence D) and provide patients with an ED asthma discharge plan with instructions to the patients and family for how to use it (Evidence B). ▪ Before patients are discharged home, assess inhaler techniques for all prescribed medications and reinforce correct technique (Evidence B). ▪ At the time of discharge from the ED, patients be referred for followup asthma care appointment (either PCP or asthma specialist) within 1–4 weeks (Evidence B). If appropriate, consider referral to an asthma self-management education program (Evidence B). ▪ Before patients are discharged from a hospitalization for asthma exacerbations, give them asthma self-management education (Evidence B).

Visits to the ED for asthma exacerbation have been characterized as a moment of opportunity for providing asthma education, inhaler technique training, and referral for followup with the PCP; yet there are very few RCTs of asthma education in the ED for patients who have exacerbations. Previous asthma guidelines (; ) have recommended at least some asthma education at the time of discharge from the ED for an exacerbation. One observational study conducted in the EDs of a province of Canada found that only 78 percent of patients received even brief education, and the focus was usually on medicines (46 percent) or inhaler technique (73 percent). Only 38 percent were counseled on triggers of exacerbations, and only 32 percent were referred to an asthma education program ().

Patients who present to the ED with acute asthma are a source for identifying self-management problems. Observational studies (; ) show that many of these patients have poor knowledge of self-management and have a high frequency of ED visits (; ). Moreover, many adults seem to delay seeking care for acute asthma for a variety of reasons, including fear of being treated with systemic steroids (). These observations suggest a role for asthma education, yet there is little evidence from RCTs of the benefit of targeted education in the ED setting. A survey of 77 asthma researchers based in EDs showed that, despite agreeing that patient education was very important, few EDs have or use asthma education programs ().

Targeting high-risk patients for asthma education at the ED visit has been explored in two RCTs (; ) and in two observational studies (, ). In one RCT, limited education in the ED in inhaler technique and use of a written asthma action plan was compared to a comprehensive, structured educational program and usual care (). ED revisits were not different among the groups in the first 6 months after the intervention, but revisits declined significantly more in the structured education group by 12 months; however, reinforcement of self-management education was provided at the 6-month point only to the structured education group. In a second RCT, provided three asthma education sessions to patients after a visit to the ED. Despite significant attrition from attendance at sessions, followup was completed with 76 percent of the study sample, and, adjusting for baseline differences, the intervention group had fewer ED visits than controls at 12-month followup ( p = .06). In a race-specific reanalysis of the study data, found that African American and Caucasian patients experienced similar benefits from the program.

Most other RCTs of education for adults in the ED setting focus on teaching inhaler technique for delivery of SABA. conducted an RCT in the ED to compare teaching MDI technique to 61 adults who had asthma and nebulizer delivery of bronchodilator to 32 adults who had COPD. Median teaching time required to teach and administer MDI-delivered bronchodilator medication was 6.5 minutes. The authors concluded that teaching use of MDI with spacer delivery of bronchodilator is feasible in the ED for treatment of acute asthma exacerbation. This study suggests that patients can learn about and use MDIs in the acute care setting and that the ED provides an opportunity to teach correct inhaler technique.

Despite being provided with MDIs and instructions for using them, a significant proportion of children continue to use nebulizers at home after discharge from the ED (). Use of MDIs by children may be complicated, however, by numerous errors in technique, potentially rendering the devices ineffective. evaluated children's skills in using an MDI and a peak flow meter in the ED and found a significant proportion were using these devices incorrectly with a large number of errors. Dry-powder inhaler (DPI) use appears to be associated with a rate of poor inhalation technique similar to that of the use of MDIs (). Inhaler technique may be improved with tailored educational interventions aimed at specific problems (). The Expert Panel concludes that it is important to assess inhaler techniques for all prescribed medications and reinforce correct technique before patients are discharged home.

ED clinicians encourage patients seen for acute exacerbation to follow up with their PCPs, and ED clinicians often encourage participation in an asthma education program. found that ED clinicians can motivate some patients to attend an asthma educational program following discharge from the ED by giving a brief educational message and facilitating followup attendance at the educational program. However, others have found that ED discharge instructions that include recommending attendance at an educational session and keeping an appointment with a PCP are not adhered to in any consistent way, and even when appointments are kept, there is no impact on long-term outcomes (, ). In one RCT, however, the short-term outcome of contact with the PCP did improve (). These studies refer specifically to referral to the PCP. The findings may not be true for facilitated referrals to an asthma specialist. Both an observational study () and an interventional study () suggest that better outcomes may result for patients referred from the ED to asthma specialists.