Using a Home- or Clinic-Based Program to Help Older Adults Manage Their Asthma -- The SAMBA Study

This project has results

Abstracts

Public Abstract

Download this abstract: English (pdf) | Español (pdf) | Audio Recording (mp3)

What was the research about?

Managing asthma can be hard for older adults who have several health problems, take multiple medicines, or don’t know how to treat their asthma. Older adults may also find it hard to travel to a clinic for asthma care.

In this study, the research team tested an asthma self-management program called Supporting Asthma Self-Management Behaviors in Aging Adults, or SAMBA. The team wanted to learn if patients who received SAMBA at a clinic or at home managed their asthma better than those who received usual care for one year. The team also compared patients who received SAMBA at home with patients who received SAMBA at a clinic.

What were the results?

Comparing SAMBA versus usual care. Compared with patients who received usual care, patients who received the SAMBA program had

  • Better asthma control and higher quality of life at six months but not at one year.
  • Better medicine adherence and correct use of a metered dose inhaler at six months and one year. A metered dose inhaler uses pressure to push medicine out.

Patients didn’t differ in hospital stays; emergency room, or ER, visits; and correct use of an inhaler that has medicine in a dry powder form, called a dry powder inhaler.

Comparing home- versus clinic-based SAMBA. After one year, patients who received SAMBA at home or at a clinic didn’t differ in asthma management.

Who was in the study?

The study included 405 patients ages 60 and older with moderate to severe asthma from nine primary care clinics around New York City. Of these, 57 percent were Hispanic, 30 percent were black, and 7 percent were white. The average age was 68, and 85 percent were women.

What did the research team do?

The research team assigned patients by chance to receive SAMBA at home, at a clinic, or to have usual care. In the SAMBA program, trained coaches met with patients in person. At these meetings, coaches asked patients about things that made it hard for them to manage their asthma. Then, the coach and patient created a care plan to meet the patient’s needs and goals. Follow-up meetings focused on asthma control, medicine use, the right way to use an inhaler, and progress with goals. The SAMBA program lasted one year. Patients who received usual care only had no special asthma care apart from regular treatment at their doctor’s clinic.

The research team surveyed patients at the start of the study and again 3, 6, and 12 months later. The surveys asked about asthma control, quality of life, medicine adherence, and inhaler technique. The team also looked at patients’ electronic health records for hospital and ER visits.

Patients, clinicians, members of health departments, and health and patient organizations helped with all aspects of the study.

What were the limits of the study?

Fewer patients enrolled in this study than planned, which could have influenced results. The study took place in only one city. Findings may differ in other locations.

Future research could look at ways to maintain improved asthma control and quality of life beyond six months. Researchers could also include more patients from different regions.

How can people use the results?

Patients and clinicians can use the results when considering ways to help older adults manage their asthma.

Professional Abstract

Objective

To compare the effectiveness of home- and clinic-based self-management support programs with usual care for improving asthma self-management

Study Design

Design Element Description
Design Randomized controlled trial
Population 405 English- or Spanish-speaking patients ages 60 and older with moderate to severe asthma
Interventions/
Comparators
  • SAMBA home- or clinic-based program versus usual care
  • SAMBA home-based program versus SAMBA clinic-based program
Outcomes Asthma control, asthma-related quality of life, hospitalization, ED visits, medication adherence, inhaler technique included metered dose and dry powder
Timeframe 1-year follow-up for primary outcomes

This pragmatic randomized controlled trial examined the effectiveness of a home- and clinic-based program, Supporting Asthma Self-Management Behaviors in Aging Adults (SAMBA), compared with usual care for improving outcomes in patients with moderate to severe asthma. This trial also compared home- and clinic-based SAMBA interventions to determine whether patient outcomes varied by SAMBA delivery setting.

In the SAMBA program, trained coaches screened patients for common barriers to asthma self-management. The program then targeted these barriers to improve patients’ quality of life. The coaches were community health workers in the home-based program and asthma care coaches in the clinic-based program.

Coaches contacted patients by phone and scheduled an in-person meeting in the patient’s home or at a clinic. At the initial meeting, the coach gathered baseline patient information and administered the SAMBA screener. The coach and patient then created a care plan based on patient-reported barriers and goals. The support program lasted one year; follow-up meetings focused on asthma control, medication adherence, inhaler technique, and progress with goals.

Researchers randomized patients to receive SAMBA either at home or at a clinic or to receive usual care only. Usual care included regular care at patients’ primary care practices without any special initiatives for asthma.

The study included 405 patients at nine primary care practices in New York City. Of these, 57% were Hispanic, 30% were black, and 7% were white. The average age was 68, and 85% were female.

Researchers surveyed patients at baseline and again 3, 6, and 12 months later. They examined patients’ electronic health records for information on hospitalizations and emergency department (ED) visits.

Patients, clinicians, city and state health department representatives, employees from community-based health service organizations, and members of advocacy organizations contributed throughout the study.

Results

SAMBA versus usual care. Compared with patients who received usual care, patients in SAMBA had greater improvements in

  • Asthma control (p=0.01) and quality of life (p<0.05) at 3 and 6 months but not at 12 months
  • Medication adherence (p<0.05) and metered dose inhaler technique (p<0.001) at 3, 6, and 12 months

The two groups did not differ in hospitalizations, ED visits, or dry powdered inhaler technique.

Home- versus clinic-based SAMBA. Compared with the clinic-based SAMBA group, patients in the home-based SAMBA group reported greater quality of life at 6 months (p<0.05) but not at 3 and 12 months. The home- and clinic-based SAMBA groups did not differ in other outcomes at 3, 6, or 12 months.

Limitations

Fewer patients enrolled in the study than originally planned, which may have limited the ability to detect differences in treatment effects. The study took place in one city. Findings may differ for other areas.

Conclusions and Relevance

Receiving SAMBA at home or at a clinic resulted in better asthma control, quality of life, medication adherence, and metered dose inhaler technique than usual care for up to one year. The interventions did not improve asthma-related hospitalizations, ED visits, or dry powdered inhaler technique.

Future Research Needs

Future studies could explore ways to maintain improved asthma control and quality of life beyond six months. Researchers could also include a larger number of patients from different geographic regions.

This project's final research report is expected to be available by November 2019.

Peer Review Summary

Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also assesses how the project addressed PCORI’s Methodology Standards. During peer review, experts read a draft report of the research and provide comments about the report. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. These reviewers cannot have conflicts of interest with the study.

The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve descriptions of the conduct of the study or to clarify the connection between results and conclusions. Sometimes, awardees revise their draft reports twice or more to address all of the reviewers’ comments. 

Peer reviewers commented, and the researchers made changes or provided responses. The comments and responses included the following:

  • The reviewers asked for additional detail on how the organizations hired, employed, and supervised community health workers and care coaches in clinics. They also asked for additional detail on how community health workers and care coaches worked within the care system. The researchers explained that four separate organizations provided the coaching staff used in the study and that  each organization had its own processes for hiring, supervision, and documenting procedures. The researchers said they did observe commonalities among the type of people employed in these roles and expanded the description of staff in the report.
  • Reviewers observed that the study designated many primary outcomes but was best powered for the asthma control test (ACT) and asthma quality of life questionnaire (AQLQ), suggesting that in hindsight those measures should have been considered primary and the other outcomes secondary. The researchers agreed that it would have been appropriate to designate only the ACT and AQLQ measures as primary outcomes. However,  for consistency with other reports, they requested keeping the existing primary and secondary outcome designations.
  • Reviewers wondered if staff who work with patients with a variety of chronic illnesses could administer the intervention  as part of a menu of potential interventions. This should be possible. The researchers explained that they originally hoped to develop a platform to support people with any chronic disease, given that people with chronic illnesses face common challenges and often have multiple illnesses. The researchers added some text about this in the discussion section.
  • Reviewers also noted that in the comparison of clinic- versus home-based intervention delivery, there were no significant differences. The researchers similarly added a comment to the discussion suggesting that health systems could choose between either format for delivering the intervention. The researchers did add the caveat, however, that this comparison was not powered to test for noninferiority.

Conflict of Interest Disclosures

View the COI disclosure form.

Journal Articles

Results of This Project

JAMA Internal Medicine

Effect of a Self-management Support Intervention on Asthma Outcomes in Older Adults: The SAMBA Study Randomized Clinical Trial

Related Articles

The Journal of Allergy and Clinical Immunology

Enrolling African-American and Latino Patients with Asthma in Comparative Effectiveness Research: Lessons Learned From Eight Patient-Centered Studies

Journal of Asthma

A qualitative investigation of the impact of asthma and self-management strategies among older adults

Contemporary Clinical Trials

Rationale and design of a comparative effectiveness trial of home- and clinic-based self-management support coaching for older adults with asthma

Project Details

Principal Investigator
Alex Federman, MD, MPH
Project Status
Completed; PCORI Public and Professional Abstracts Posted
Project Title
Clinic-Based vs. Home-Based Support to Improve Care and Outcomes for Older Asthmatics
Board Approval Date
December 2013
Project End Date
January 2019
Organization
Icahn School of Medicine at Mount Sinai
Year Awarded
2013
State
New York
Year Completed
2018
Project Type
Research Project
Health Conditions 
Respiratory Diseases
Asthma
Funding Announcement
Asthma Treatment Options for African Americans and Hispanics/Latinos
Project Budget
$3,153,311
Study Registration Information
HSRP20143420
NCT02316223
Page Last Updated: 
April 18, 2019