Results Summary
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.
- Fewer emergency room, or ER, visits at one year.
Patients didn’t differ in 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 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.
| How this project fits under PCORI’s Research Priorities PCORI identified asthma in African American and Hispanic/Latino populations as an important research topic. Patients, clinicians, and others wanted to learn how to encourage care that follows national asthma guidelines and improves patient-centered outcomes for African American and Hispanic/Latino populations. In 2013, PCORI launched an initiative on Treatment Options for African Americans and Hispanics/Latinos with Uncontrolled Asthma. The initiative funded this research project and others. |
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 |
|
| Outcomes | Asthma control, asthma-related quality of life, 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 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
Emergency department visits were lower in the SAMBA group compared to the usual care group at 12 months (p<.05).
The two groups did not differ in 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, metered dose inhaler technique, and fewer ED visits than usual care for up to one year. The interventions did not improve 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.
| How this project fits under PCORI’s Research Priorities PCORI identified asthma in African American and Hispanic/Latino populations as an important research topic. Patients, clinicians, and others wanted to learn how to encourage care that follows national asthma guidelines and improves patient-centered outcomes for African American and Hispanic/Latino populations. In 2013, PCORI launched an initiative on Treatment Options for African Americans and Hispanics/Latinos with Uncontrolled Asthma. The initiative funded this research project and others. |
Final Research Report
View this project's final research report.
Journal Citations
Article Highlight: For a range of reasons, older adults have more trouble managing asthma than younger patients. Researchers in this study developed and tested a program called Supporting Asthma Self-Management Behaviors in Aging Adults (SAMBA) that screened patients for barriers to receiving and managing their care, and then worked with patients to overcome those barriers. Among other outcomes, patients who used SAMBA were half as likely to end up in the emergency room as patients who didn’t use SAMBA, the research team reported in JAMA Internal Medicine.
Results of This Project
Related Journal Citations
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.