Specific Interventions for Older Adults With Asthma Reduce ED Visits, Improve Control

A recent study showed that older adults with uncontrolled asthma can benefit from interventions that tailor self-management support to improve various factors that impede asthma control, including those related to psychosocial, health, function, and cognitive barriers.

Most programs to improve self-management of asthma are aimed at a younger population, but the researchers said that older adults with asthma (making up about 7% of those 65 or older) suffer more symptoms and hospitalizations than younger patients. Generalized asthma education can overwhelm older patients, the researchers said. As a remedy, asthma care coaches delivered a personalized intervention in the home or in primary care practices.

During the 3-arm randomized clinical trial conducted between February 2014 and December 2017, researchers compared the intervention, called Supporting Asthma Self-Management Behaviors in Older Adults (SAMBA), with usual care on self-management behaviors and outcomes. SAMBA is a comprehensive screening for barriers to asthma control and self-management from among 21 domains of psychosocial, cognitive, physical and mental health, and environmental barriers.

Adults 60 years and older with persistent, uncontrolled asthma were identified from electronic health records at an academic medical center and a federally qualified health center. Of 1349 patients assessed for eligibility, 406 met eligibility criteria, consented to participate, and were randomized to 1 of 3 groups: home-based intervention, clinic-based intervention, or control (usual care). A total of 391 patients were included.

Of the 391 patients who received treatment, the majority were female, and the mean (SD) age was 67.8 (7.4) years.

Results showed a significant difference, with the proportion of intervention patients visiting the emergency department (ED) for asthma at 6%, compared with 12% in the control group.

By specifically targeting social determinants of health and other drivers of health-related behaviors, researchers said the intervention “is a promising model of self-management support and disease control for older adults with asthma, and possibly other chronic diseases.”

The SAMBA intervention includes 3 elements:

• Screening to identify barriers to asthma self-management and control
• Targeted actions to address the barriers
• Positive reinforcement over time

During follow-up, the coaches assessed asthma control, medication adherence, and inhaler technique, and checked on progress with goals.

As an example of the intervention, the asthma care coach would conduct a screening assessment in order to identify the barriers to self-care. The patient might have improper controller technique, may not take controller medication consistently, and might have an infestation of asthma triggers, like cockroaches.

As part of the process, the coach would connect the patient with a pest-remediation service, paid for by the city if the resident is low-income; teach proper inhaler technique; encourage the patient to discuss cost with her physician; and educate the patient about the chronic nature of asthma to correct any beliefs about it being an intermittent disease.

Primary outcomes were the Asthma Control Test, Mini Asthma Quality of Life Questionnaire, Medication Adherence Rating Scale, metered dose inhaler technique, and ED visits for asthma care. Primary analyses compared intervention (home- or clinic-based) with usual care.

After accounting for baseline scores, scores on the asthma control test were better in the intervention groups vs the control group (difference-in-differences at 3 months: 1.2; 95% CI, 0.2-2.2; P = .02; 6 months: 1.0; 95% CI, 0.0-2.1; P  = .049; 12 months: 0.6; 95% CI, −0.5 to 1.8; P  = .28; and overall: χ² = 13.4, with 4 degrees of freedom; P  = .01).

ED visits were lower at 12 months for the intervention groups versus the control group (16 [6.2%] vs 17 [12.7%]; P  = .03; adjusted odds ratio, 0.8; 95% CI, 0.6-0.99; P  = .03).

Statistically significant improvements were observed for the intervention versus control patients in quality of life (overall effect: χ² = 10.5, with 4 degrees of freedom; P  = .01), medication adherence (overall effect: χ² = 9.5, with 4 degrees of freedom; P = .049), and inhaler technique (metered-dose inhaler technique, correctly completed steps at 12 months, median [range]: 75% [0%-100%] vs 58% [0%-100%]).

Researchers also sought to determine whether home-based delivery of the program would confer greater benefit for patients with mobility or other challenges in getting to a clinic. However, there were no significant differences in outcomes were observed between patients receiving the intervention in home vs in an office.

Reference

Federman AD, O'Conor R, Mindlis I, et al. Effect of a self-management support intervention on asthma outcomes in older adults: The SAMBA study randomized clinical trial [published online June 10, 2019]. JAMA Intern Med. doi:10.1001/jamainternmed.2019.1201.