Chest ACCP Member Benefits
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

Guest Access | Sign In via User Name/Password
This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF) Free
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Article Archive
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via ISI Web of Science (3)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Runge, C.
Right arrow Articles by Schaefer, M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Runge, C.
Right arrow Articles by Schaefer, M.
(Chest. 2006;129:581-593.)
© 2006 American College of Chest Physicians

Outcomes of a Web-Based Patient Education Program for Asthmatic Children and Adolescents*

Claus Runge, PhD; Josef Lecheler, MD; Michael Horn, MD; Jan-Torsten Tews, MD and Marion Schaefer, PhD{dagger}

* From GlaxoSmithKline GmbH & Co. (Drs. Runge and Tews), Munich; CJD Asthmazentrum Berchtesgaden (Dr. Lecheler), Berchtesgaden; Forum Telemedizin GmbH (Dr. Horn), Munich; and Institut of Clinical Pharmacology (Dr. Schaefer), Humboldt-University Berlin, Berlin, Germany. {dagger} A list of participants is given in the Appendix.

Correspondence to: Claus Runge, MD, Kunstwerkerstrasse 179, 45136 Essen, Germany, e-mail: Runge.Claus{at}web.de

Abstract

Background: Asthma is the most common chronic disease among children in Germany. Approaches to reduce the burden of asthma include patient education to improve self-management skills.

Study objectives: We determined whether a continuous Internet-based education program (IEP) as an add-on to a standardized patient management program (SPMP) improves health outcomes of asthma patients at a favorable benefit-cost ratio.

Patients and methods: A total of 438 asthmatic patients aged 8 to 16 years in 36 study centers were enrolled during a 6-month period. We performed a prospective cost-benefit analysis alongside a nonrandomized trial. At baseline and at 6 months and 12 months, health service utilization data were collected.

Interventions: Study participants were assigned to a control group and two intervention groups. Patients in both intervention groups participated in an SPMP. Additionally, patients in one intervention group received the IEP.

Results: Utilization of various health-care services decreased significantly in both intervention groups. From a payer perspective, the benefit-cost ratio of the traditional education program was 0.55. Adding the IEP improved the ratio (0.79). For patients with moderate or severe asthma, the benefit-cost ratios were 1.07 and 1.42 (with IEP), respectively.

Conclusions: The IEP offers the potential to decrease the burden of disease and to realize incremental morbidity cost savings. Subgroup analysis demonstrated that within 1 year, the savings exceed the intervention costs in patients with moderate or severe asthma.

Key Words: asthma • cost-benefit analysis • Internet costs • patient education • quality of life

Asthma is the most common chronic disease in children, affecting approximately 10% of the German pediatric population.1 There is a distinct social burden of asthma, not only for the sick child, but also for the caregiver and the society in general. At the same time, the economic impact due to extensive health-care utilization is high. Health-care expenditures for asthmatic children are roughly three times higher compared to children without asthma.2 A positive correlation has been described between average total costs and degree of asthma severity in several investigations.34

Increased health-care expenditure and morbidity can largely be attributed to poor asthma control, including underuse of antiinflammatory therapy, and poor compliance.5 Therefore, international guidelines recommend the increased use of controller therapy to improve the overall asthma management6 and the participation in comprehensive patient education programs.78 Although there is evidence of the positive economic impact of patient education,91011 < 1% of all asthmatic children in Germany are instructed in a systematic manner per annum. Main reasons for the poor participation rates are insufficient incentives for providers, a lack of patient information about ways to be recruited, and inadequate design of the programs when needs and interests of children and adolescents are considered.12

To address the observed shortcomings of the existing training programs, an Internet-based education program (IEP) had been developed for asthmatic children aged 8 to 16 years. The IEP serves as an add-on to traditional approaches in patient education. The current study assesses the impact of the IEP on health outcomes and economic implications. It is a cost benefit analysis reporting all costs at year 2001 level in Euros without further discounting.

Materials and Methods

Study Design
The current investigation was a nonrandomized, nonstratified, multicenter, real-life study comprising two intervention groups and one control group (Fig 1 ). The investigation was conducted between July 2001 and December 2002 in 36 study centers nationwide, including general practitioner (GP) and specialist offices as well as asthma outpatient facilities of hospitals.


Figure 1
View larger version (16K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 1. Course of the trial in the three study groups. The SPMP started within 4 weeks after the baseline visit. Patients in the IEP group went through the SPMP in combination with IEP during the subsequent months.

 
Intervention Groups
All eligible patients were invited to join a standardized patient management program (SPMP). They had the option to self select additional educational activities with the additional IEP, provided that individual access to the Internet was possible at home, at the study centers, or at school. Data collection in the intervention groups was completed at two subsequent visits scheduled at 6 months (visit 2) and 12 months (visit 3) after enrollment.

Control Group
Due to limited capacities in several study centers, numerous patients were in waiting loops for educational courses. Patients on waiting lists for a future (prescheduled) asthma education program were asked to build the control group (CG). Having consented to take part in the study, these patients were recruited 6 months prior to their scheduled educational intervention. During the 6 months prior to the educational program and during the 6 subsequent months, patient outcomes under usual care were documented. Follow-up of CG patients ended with the initiation of the patient education program after visit 2 (end of waiting period; Fig 1).

At the baseline evaluation (visit 1), information was secured about the child, including recent asthma activity, medication adherence, use of rescue medication, lung function (peak expiratory flow [PEF], FEV1), health-care utilization (eg, number of hospitalizations, number of outpatient visits at GP or specialist, number of emergency visits, medication costs), and quality of life (QoL). Baseline assessment also included demographic characteristics, allergy status, and classification of degree of asthma severity according to national recommendations.13 At all visits, the identical protocol was used in all study groups.

Clinical outcomes and health-care resource use data were documented by treating physicians based on (electronic) patient records. Documentation covered the 6-month periods prior to the baseline and subsequent follow-up visits. An additional caregiver questionnaire provided information about patients’ school absenteeism, caregivers’ loss of workdays due to their child’s asthma, and the number of asthma-related emergencies.

Finally, a patient questionnaire was distributed at all scheduled study visits. It contained a QoL questionnaire (KINDL; Berlin, Germany).14 The KINDL questionnaire is a generic QoL instrument applicable for self administration. It consists of 24 Likert-scale items in the dimensions of physical well-being, psychological well-being, self esteem, family, friends, and social functioning. Furthermore, it is supplemented with a disease-specific asthma module consisting of six further items. Follow-up questionnaires were mailed to GPs, patients, and caregivers in case patient education had taken place in a remote investigator site (four study centers are located in the Alps; country wide, GPs refer their patients to these centers as the centers are specialized in treating asthma and delivering patient education programs in remote areas with low allergen exposure, eg, dust mite).

Intervention
Patients in both intervention groups took part in an SPMP. In a series of educational sessions (5 x 2 h), asthma knowledge and asthma self-management skills were strengthened. Patients were instructed in several disease-related fields (eg, proper use of different inhaler devices, classification of reliever and controller medication, avoidance of asthma triggers, limitation of allergen exposure, peak flow measuring, and its interpretation). During role-playing exercises, critical everyday life situations of asthma patients were simulated in small groups, and possible solutions to daily disease-specific problems were discussed. Content, scope, and results of the SPMP are reported in detail elsewhere.151617

Additional Education in the IEP Group
Patients in the intervention groups were allowed to self select the IEP as an additional module. The IEP (www.forum-telemedizin.de, now www.asthmax.de) includes an additional educational module with an asthma-related quiz and an interactive adventure game incorporating numerous virtual asthma-related situations that have to be managed adequately. Furthermore, a repetition section displaying the educational material of the SPMP is included. In addition, the IEP provides a medical module with individual medication plans, scheduled chats with asthma experts, and an on-line peak flow protocol that is to be maintained by the patient. Communication of registered users, both patients and health-care providers, is feasible in chat rooms or by e-mail. Content for the IEP had been developed by a multidisciplinary team. Over a 6-month period, the IEP was tested successfully in a focus group including 50 children in an inpatient setting.18

Study Subjects
Eligibility criteria for study participation were age between 8 and 16 years and the presence of a confirmed asthma diagnosis for at least 1 year. No other asthma program participation prior to study entry was allowed. Sufficient knowledge of the German language was assumed. Appropriate information about the concept of the study was given to all patients and their caregivers by the investigators, and informed consent was obtained from all participants (intervention and control groups) before study entry.

Methods
Physician- and caregiver-reported resource-use data for asthma care were collected. The primary study outcome measure was the calculation of a benefit-cost ratio for each intervention strategy from both the perspective of health-care insurance and a societal perspective. Prices were adjusted to year 2001 prices. Since the observational period did not exceed 1 year, neither prices nor outcomes were discounted.19 Secondary outcome measures included QoL, lung function, use of rescue medication, and number of days absent from school due to asthma.

Direct Medical Costs
The following asthma-related morbidity measures were calculated for each of the three study groups: average rate of scheduled and unscheduled medical care visits, rate of emergency department visits, and frequency and length of inpatient stays. The monetary values of these measures were determined according to recent estimates and national statistics.2021 Daily asthma medication costs were calculated based on physicians’ prescription records.22 Costs for traditional patient education were derived from existing reimbursement contracts between paymasters and providers and are on a comparable level nationwide. A sickness fund with a market share of approximately 11% reimburses the additional costs of the IEP depending on frequency of use and performance shown by the patient. For the calculation of incremental costs in the IEP group, it was assumed that reimbursement was secured for all participating patients.

Direct Nonmedical Costs
Transportation costs were calculated on the basis of public inner-city transport tariffs, assuming that for every medical care visit a round-trip ticket was needed. Patients using the IEP had to bear Internet access costs.

Indirect Costs
Indirect costs included caregivers’ loss of workdays due to their child’s asthma. Based on national statistics, the average daily gross earning was determined using the human-capital approach.23 All unit costs and sources are summarized in Table 1 .


View this table:
[in this window]
[in a new window]

  		Table 1. Cost Items, Data Sources, and Unit Costs in 2001 Euros

 
Cost-Benefit Analysis
In all study groups, the average costs per patient during the 6 months prior to baseline visit were determined (costs at visit 1) and extrapolated to annual costs (costs at visit 1 x 2). In the intervention groups, the average annual costs during the observational period were subtracted from these baseline costs in order to arrive at the morbidity cost savings (savings = [costs at visit 1 x 2] – [costs at visit 2 + costs at visit 3]).

We arrived at the adjusted benefit in the intervention groups by accounting for potential savings or excess expenditures in the CG (adjusted benefit = savings – [costs CG at visit 1 x 2 – costs CG at visit 2 x 2]). The net benefit in the first year after intervention was calculated by subtracting the intervention costs from the adjusted benefit. Finally, the benefit-cost ratio was determined as the ratio of adjusted benefits and intervention costs. The same method was used to calculate the incremental savings and benefits of the educational activities including the IEP when compared to standard patient education.

Analysis
Baseline demographic (sex, age) and baseline clinical variables (lung function) were compared between the groups using {chi}2 tests for categorical variables and t tests for continuous variables. For comparison of study data with normal distribution, we used the Kolmogorov-Smirnov test. In case of normal distribution of continuous variables, we used the t test for group-specific before/after comparisons. Bonferroni tests were applied for the respective group comparisons.

If no normal distribution was assumed following the Kolmogorov-Smirnov test, patient data for the baseline and follow-up periods were compared intraindividually using nonparametric analysis methods. We used the Wilcoxon signed-rank test for continuous variables. Possible differences between study groups were analyzed using the Mann-Whitney U test. A two-tailed p value < 0.05 was regarded as statistically significant. In order to ensure comparability between groups, all health-care resource data were adjusted to the distribution of asthma severity degrees in the largest of the three study groups.

The weighted average of asthma-severity specific rates (eg, costs), with weights taken from the SPMP group (which was defined as the "standard population," as it is the largest one in patient numbers), provides for each other population (IEP and control group) a summary rate (eg, costs) that reflects the costs that would have been expected if the populations compared had had identical distributions of asthma severity degrees. We have chosen asthma severity as weighting factor as it has a strong impact on asthma-related costs.34 Similar approaches are applied in other disease areas, eg, in comparisons of cancer mortality rates over different decades with changing age structures of underlying populations.24

Results are presented as severity-adjusted mean scores for the population per peer protocol (PPP), for subgroups, and for the intention-to-treat (ITT) population. As a standard in health economic evaluations, one-way sensitivity analyses were performed in order to test for the influence of variations in drug therapy adherence, outpatient visit costs, and intervention costs on the benefit-cost ratio. The data were analyzed using statistical software (Version 10.0; SPSS; Chicago, IL).

Results

The original study sample consisted of 358 patients. A further 80 patients were interested in participating but could not be included as they did not meet inclusion criteria. Complete medical resource use data at all follow-up visits were available for 178 patients (49.7%) who were defined as PPP (Table 2 ). Medical resource use data of 56 study completers were insufficient for analysis (15.6%).


View this table:
[in this window]
[in a new window]

  		Table 2. Number of Patients Per Study Group and Eligibility for Analysis

 
Reasons for study discontinuation (n = 124; 34.6%) were as follows: relocation of patients (n = 6), withdrawal of caregiver consent (n = 6), nonattendance of scheduled follow-up visits (n = 11), no returning of mail questionnaires (n = 41), and relocation of personnel in two study centers (n = 19). Reasons for dropouts were not documented in 41 cases. Patient characteristics are summarized in Table 3 .


View this table:
[in this window]
[in a new window]

  		Table 3. Demographic and Clinical Variables by Study Group*

 
Compared to both intervention groups, significantly more patients in the CG were male. In the IEP group, significantly more patients presented with allergies when compared to the SPMP group.

Although not statistically significant (p = 0.17), the proportion of patients with moderate or severe asthma in the IEP group (65.9%, n = 29) tended to be higher than in the SPMP group (44.2%; n = 38) and in the CG (39.6%; n = 19). At baseline, a total of 116 patients (65.2%) received inhaled corticosteroids, with no statistically significant differences between groups.

Table 4 shows major characteristics of the PPP and the group of noncompleters at baseline assessment. Patients who did not complete the study tended to use more health-care resources. Among the patients who were assigned to the intervention groups, study completers had significantly lower morbidity costs at baseline when compared to noncompleters.


View this table:
[in this window]
[in a new window]

  		Table 4. Comparison of Study Completers and Dropouts

 
The medical outcomes of the PPP are summarized in Table 5 . Various improvements were reported in all study groups, but patients using the IEP were the only ones to experience a statistically significant short-term reduction in asthma-related emergencies and a long-term decrease in the daily use of rescue medication. During the follow-up year, morbidity costs savings in the IEP group were due to a reduction in physician consultations (56%), asthma-related emergency treatments (75%), and daily medication costs (52%) [Fig 2 ].


View this table:
[in this window]
[in a new window]

  		Table 5. Medical Resource-Use Data, Use of Rescue Medication, and School Absenteeism in the Observation Period

 

Figure 2
View larger version (18K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 2. Cost development during the observation period. Results are shown as average costs per patient and 6-month period. T0 = baseline; T1 = visit 2; T2 = visit 3.

 
Compared to the year prior to baseline, average morbidity cost savings during the first year after intervention made up 461Formula from a health insurance perspective and 467Formula from a societal perspective in the IEP group. Patients in the IEP group had significant reductions (p < 0.05) in both days off school (– 75%) and average daily use of rescue medications (– 77%) when comparing visit 2 data with baseline.

In the CG, significant improvements (p < 0.05) were observed when analyzing the number of outpatient visits (– 6%) and the number of lost school days (– 35%) before and after the trial initiation. Benefits in the usual care group reached 1.55Formula from a paymaster perspective and 58Formula from a societal perspective. Patients receiving the SPMP alone had better outcomes than control subjects, eg, significantly (p < 0.05) less physician consultations (– 44%), emergency treatments (– 67%), and days off school (– 71%) in the follow-up period.

In contrast to the IEP group, the reduction in the average daily use of rescue medication among SPMP patients did not reach a statistically significant level. Compared to the IEP group, it took longer to realize a statistically significant reduction in the number of emergencies. Morbidity cost savings in the traditional patient education group (SPMP) were lower when compared to IEP group patients and added up to 301Formula from a paymaster perspective and 333Formula from a societal perspective. Adjusted benefit, net benefit, and benefit-cost-ratio applicable to the two intervention groups are summarized in Table 6 .


View this table:
[in this window]
[in a new window]

  		Table 6. Results of the Cost-Benefit Analysis*

 
From a health-care insurance perspective, it cost 585Formula to deliver education including the IEP; 461Formula was saved in health expenses. Adjusting for benefits in the control group, 0.79Formula was saved for every 1.00Formula spent in the first year after intervention.

Adding the IEP to the SPMP yields incremental morbidity cost savings of 160Formula (direct costs) at an additional average cost of 44Formula when compared to the SPMP alone. This translates into a benefit-cost ratio of 3.65.

Lung function as measured with PEF increased significantly (p > 0.05) in all study groups. FEV1 did not change significantly over time in any of the three groups. Changes in lung function are shown in Table 7 .

Subgroup Analysis
Subgroup analysis of the main study outcome shows higher benefit-cost ratios for patients with moderate persistent or severe persistent asthma (1.42 in the IEP group) and for patients with any emergency 6 months prior to the study entry (1.21 in the IEP group) [Table 6].

Sensitivity Analysis
In the framework of one-way sensitivity analysis, several cost items and assumptions have been modified in order to test for their impact on the benefit-cost ratio (Table 8 ). The ratio is most sensitive to changes in the drug adherence. Assuming a constant reduction in morbidity cost savings in the year following the observational period, ie, allocating just 50% of the educational costs to the observational period, the benefit-cost ratio becomes > 1 for the IEP group while getting close to 1 for patients within the SPMP group. The benefit-cost ratio is more robust to elevations of GP fees and the IEP reimbursement level.


View this table:
[in this window]
[in a new window]

  		Table 8. Calculation of Adjusted Costs*

 
QoL
QoL as indicated by the KINDL total QoL score increased significantly (p < 0.05) in both intervention groups. QoL decreased to a little but nonsignificant extent in the CG. Statistically significant (p < 0.05) improvements were observed in four domains of the KINDL questionnaire among patients using the IEP and in three domains among patients receiving the SPMP (Fig 3 ). Statistically significant improvements (p < 0.05) were also observed in the asthma-specific module in both intervention groups.


Figure 3
View larger version (39K):
[in this window]
[in a new window]
[Download PPT slide]
  		Figure 3. Changes in QoL as measured with the KINDL questionnaire. Results are presented by domains and as a total score for baseline and follow-up visits. See Figure 2 legend for expansion of abbreviations.

 
IEP Use
On average, patients were logged in to the IEP for 2 h/mo, as indicated by the provider who maintains the IEP. The peak flow protocol section, the patient chat room, and the asthma adventure game were the most widely used modules.

Discussion

The positive impact of the SPMP is fortified by the additional IEP as demonstrated in several outcome measures, including morbidity costs savings, QoL, absenteeism from school, number of asthma-related emergencies, and use of short-acting ß-agonists. Our subgroup analysis demonstrates that, within 1 year, morbidity cost savings exceed the intervention costs in patients who belong to risk groups (benefit-cost ratio > 1). Similar findings that reflect the influence of target population characteristics on the results can be found for other asthma education programs in the literature.8910

Unsurprisingly, PEF increased significantly in our growing children in all three groups over time. Presumably, sample size was not big enough to detect any statistically differences in PEF gain between groups if there were any. At study entry, we observed minor impairment in lung function as measured by the FEV1. We did not observe any significant improvements in FEV1 values in the course of the investigation in any of the groups. Since lung function (PEF, FEV1) has not been recorded continuously throughout the study, missing data prevent us from drawing conclusions of the effects of the patient education program on lung function. However, several aspects remain to be discussed, since particularities in the study design and the patient population might limit the general transferability of our findings.

Lack of Randomization
As far as patient characteristics are concerned, significantly more patients in the CG were male compared to the intervention groups. Moreover, lower initial morbidity costs in the CG and the dissimilar distribution of asthma severity degrees reflect a selection bias within the framework of the chosen naturalistic study design. As asthma severity is the main predictor of health-care costs, we have addressed this issue by weighting the group-specific costs according to the underlying distribution of asthma severity. This approach gave us a valid approximation for the primary study outcome.

There are various possible explanations for the trend to include more severely ill patients in the intervention groups. First of all, physicians might have a tendency to offer a new technology to more severely ill patients, a phenomenon that is known from other disease areas as "launch bias." Additionally, asthma-related complications (eg, hospitalization or frequent asthma attacks) could be driving factors. At the same time, negative experiences such as emergency department visits might increase the motivation of patients and caregivers to take part in educational activities.

The problem of positive selection could have been avoided by randomization of patients. This was not done for two reasons: First of all, potential candidates with poor asthma control and an urgent need for educational activities could have been prevented from being randomized to one of the two intervention groups. The study investigators had rejected this approach categorically at an initial study conference: no one was ready to accept that severely ill patients would be barred from a scientifically proven intervention such as the SPMP in case of being randomized to a CG.

The second reason for not randomizing patients was study feasibility. If patients without constant access to the Internet had been randomized to the IEP group, patient recruitment numbers would have dropped significantly. Since there is just a limited pool of providers offering a small number of educational courses per year, the recruitment period would have been far too short.

The benefit-cost ratio of 0.55 for the SPMP alone is comparable to results previously reported by Clark et al9 and Scholtz et al17 for their approaches to educate preselected patient groups. They realized benefit-cost ratios of 0.62 and 0.61, respectively.

As to the efficiency of patient education in selected risk groups, our findings are also in line with former studies: for every US dollar spent in educational activities, Lewis et al,25 Clark et al,9 and O’Brien26 reported savings of $2.43, $11.22, and $1.48, respectively.10 This compares to savings of 1.42Formula for every Euro spent (SPMP plus IEP) in patients with moderate persistent or severe persistent asthma and savings of 1.21Formula in patients with a prior hospitalization, respectively.

When program costs (585Formula in the IEP group) are compared to the average cost-of-illness level among study individuals at baseline (approximately 1,200Formula per annum in the IEP group), it is not surprising that cost savings did not exceed program costs in the entire study population within the first year after intervention. But given the significant decline in morbidity costs, it can be assumed that a break-even for the entire study population might be arrived at in the subsequent year. In the light of evidence generated in earlier studies2728 that demonstrated that patient education programs yield further cost savings in the long term, it is conceivable that this might also be true for the SPMP (plus IEP). Nevertheless, this assumption will need to be established empirically.

As our findings are based on the PPP, which is likely to represent the most compliant and motivated patients, we reckon that our results might be too optimistic. This is underlined by the results calculated for the population ITT. After replacing missing values by the group-specific averages, lower benefit-cost ratios were observed for the ITT population. Noncompleters in the two intervention groups were characterized by significantly higher initial morbidity costs at baseline assessment when compared to study completers. Although scope for improvement was higher among these noncompleters, the education programs did not turn out to be as effective in these patients. Consequently, it will be of importance to develop strategies that will improve asthma management and compliance for these target groups.

The majority of patients enrolled in this study (65.2%) received inhaled steroids at baseline assessment. In contrast, earlier findings29 showed substantial underuse of inhaled steroids in patients with asthma in Germany. According to Lagerlov et al,30 only 31% of all asthmatic patients received inhaled steroids in a German study sample. An analysis from Maziak and colleagues31 proved that even among children with diagnosed asthma and > 12 wheezing attacks in the preceding year, only 42% had used inhaled steroids and only 21% reported regular use. As prescription of inhaled steroids to children with persistent symptoms is considered an important indicator of good adherence to asthma treatment guidelines, it can be assumed that the investigators in this study represent a positive selection of physicians fostering the need for antiinflammatory therapy as recommended.

In this context, it is remarkable that drug costs in the intervention groups decreased significantly, although past queries have shown the opposite phenomenon in the aftermath of educational activities.32 Obviously, there is no backlog demand in the investigated population, and better compliance has given leeway to dose reductions, at least in the intervention groups.

Another hint at a relatively good asthma control in the pre-run to the current survey is the small number of hospitalizations recorded for study participants. In contrast to population-based surveys in which hospitalization costs make up between 53% and 72% of all direct costs,3 the initial range of 3% (IEP group) to 7% (SPMP group) in our study documents the potential selection bias of well-controlled asthmatics when compared to the average.

Despite the above-average quality level of care at baseline, study participants benefited from patient education. In the second half of the observation period, only one patient (2%) in the IEP group and four patients (5%) in SPMP group had an emergency event. This approximates the Global initiative for Asthma recommendations (available at www.ginasthma.com) that demand the absence of any asthma-related emergency.

Health-care utilization data and work absence of caregivers were recorded retrospectively at each of the study visits. This might raise the presumption that these data are subject to a recall bias. However, doctors performed out major parts of this documentation (eg, number of outpatient visits) based on (electronic) patient records. If necessary, patients and caregivers provided additional information on number and devolution of emergencies (emergency department visits and ambulance transports). These data seem to be easily recollected by patients and caregivers due to their drastic consequences. Furthermore, a precedent study27 has proven a high consistency between the data provided by patients and that provided by the health insurance agencies. Therefore we consider the potential overestimation or underestimation of health-care resource use as minimal.

We find our results encouraging enough to anticipate further implementation activities in cooperation with local and regional paymasters. In either case, regional campaigns boosting the use of the IEP will have to be accompanied by continuous economic evaluations in order to verify its long-term effects on medical and economic outcomes and to quantify the effects on the benefit-cost ratio when both patient and provider groups will be expanded.

Appendix

The supporters and active study investigators in the following institutions participated in this study: CJD Berchtesgaden, Klinik Schönsicht, Klinik Santa Maria, Marien-Hospital Wesel, Kinderklinik Gilead, Prinzregent Luitpold Kinderklinik, Praxis Dr. Laub, Institut für Verhaltensmedizin IAV, Praxis Dr. Straub/Dr. Köhler, Praxis Dr. Blum/Dr. Butsch v.d. Heydt, Praxis Dr. Averbeck, Praxis Dr. Bolz, Kinderklinik des Klinikums Nürnberg-Süd, Praxis Dr. Bulle, Praxis Dr. Maier, Fachkliniken Wangen, Asthmazentrum Rhein-Main, Praxis Dr. Weißhaar, Jugenddorf Dortmund, Universitätsklinik Erlangen, Praxis Dr. Potthast, Praxis Dr. Weber, St. Johannes Hospital, Praxis Dr. Gall, Praxis Dr. Silbermann, Kreisklinikum Traunstein, Praxis Dr. Lindner, IAV Berlin, Praxis Dr. Bastian, Praxis Dr. Brosi, Praxis Dr. Shetty, Praxis Dr. Wässer, Praxis Dr. Liefring, Praxis Drs. Schleupner/Boudriot, Klinik Hochried, Dr. Meierjuergen/Barmer Ersatzkasse.


View this table:
[in this window]
[in a new window]

  		Table 7. Results of Lung Function Tests

 
Acknowledgements

The authors thank all patients and their relatives for their cooperation in this study.

Footnotes

Abbreviations: CG = control group; GP = general practitioner; IEP = Internet-based education program; ITT = intention to treat; PEF = peak expiratory flow; PPP = population per peer protocol; QoL = quality of life; SPMP = standardized patient management program

GlaxoSmithKline Germany has cofinanced the development of the IEP. GlaxoSmithKline has also financed the entire study including an investigator bonus of 25 Euros for every complete control group patient documentation. Furthermore, GlaxoSmithKline has arranged three investigators meetings between 2001 and 2003. Travel expenses were refunded at the initial meeting.

The IEP was designed by the enterprise Forum Telemedizin GmbH, which is owned and headed by Dr. Horn, who provided private funds in addition to the financial support granted by GlaxoSmithKline.

Dr. Lecheler has not received any honoraria from GlaxoSmithKline in this investigation, but in some cases travel expenses were refunded by GlaxoSmithKline.

Representing an institution that owns the intellectual property rights of a traditional patient education program, Dr. Lecheler has advised Dr. Horn in designing the Internet education tool. In the past, Dr. Lecheler was a paid consultant/speaker in several projects with GlaxoSmithKline involvement. Professor Schaefer was the doctoral thesis advisor of the first author, Dr. Runge, whose thesis deals with the IEP. In the past, Professor Schaefer has raised third-party funds from different pharmaceutical companies.

Drs. Runge and Tews are employees of GlaxoSmithKline.

Received for publication March 2, 2004. Accepted for publication October 5, 2005.

References

  1. Weiland, SK, von Mutius, E, Hirsch, T, et al (1999) Prevalence of respiratory and atopic disorders among children in the East and West of Germany five years after unification. Eur Respir J 14,862-870[Abstract/Free Full Text]
  2. Lozano, P, Sullivan, SD, Smith, DH, et al The economic burden of asthma in US children: estimates from the National Medical Expenditure Survey. J Allergy Clin Immunol 1999;104,957-963[CrossRef][ISI][Medline]
  3. Graf von der Schulenburg, JM, Greiner, W, Molitor, S, et al Cost of asthma therapy in relation to severity: an empirical study [in German]. Med Klin 1996;91,670-676[Medline]
  4. Godard, P, Chanez, P, Siraudin, L, et al Costs of asthma are correlated with severity: a 1-yr prospective study. Eur Respir J 2002;19,61-67
  5. Barnes, PJ, Jonsson, B, Klim, JB The costs of asthma. Eur Respir J 1996;9,636-642[Abstract]
  6. Bousquet, J Global Initiative for Asthma (GINA) and its objectives. Clin Exp Allergy 2000;30(Suppl 1),2-5[CrossRef]
  7. Clark, NM Asthma self-management education. Chest 1989;95,1110-1113[Free Full Text]
  8. Guevara, JP, Wolf, FM, Grum, CM, et al Effects of educational interventions for self management of asthma in children and adolescents: systematic review and meta-analysis. BMJ 2003;326,1308-1309[Abstract/Free Full Text]
  9. Clark, NM, Feldman, CH, Evans, D, et al The impact of health education on frequency and cost of health care use by low income children with asthma. J Allergy Clin Immunol 1986;78,108-115[CrossRef][ISI][Medline]
  10. Volmer, T Economic considerations of patient education [in German]. Pneumologie 1997;51,850-857[Medline]
  11. Smith, DH, Malone, DC, Lawson, KA, et al A national estimate of the economic costs of asthma. Am J Respir Crit Care Med 1997;156,787-793[Abstract/Free Full Text]
  12. Expert committee report for the German Ministry of Health 2000/2001 [in German]. Available at: www.svr-gesundheit.de/gutacht/gutalt/gutaltle.htm 2002. Accessed February 17, 2006
  13. Wettengel, R Recommendations for the treatment of asthma in adults and children [in German]. Pneumologie 1998;52,591-601[Medline]
  14. Ravens-Sieberer, U, Bullinger, M Assessing health-related quality of life in chronically ill children with the German KINDL: first psychometric and content analytical results. Qual Life Res 1998;7,399-407[CrossRef][ISI][Medline]
  15. Szczepanski, R, Konning, J, Lob-Corzilius, T, et al Analysis of the current status of asthma education for children and adolescents in German-speaking countries [German]. Pneumologie 1993;47,583-587[Medline]
  16. Szczepanski, R, Gebert, N, Hummelink, R, et al Outcome of structured asthma education in childhood and adolescence [in German]. Pneumologie 1996;50,544-548[Medline]
  17. Scholtz, W, Haubrock, M, Lob-Corzilius, T, et al Cost-effectiveness studies of ambulatory educational programs for children with asthma and their families [in German]. Pneumologie 1996;50,538-543[Medline]
  18. Runge, C, Tews, JT, Lecheler, J, et al Do young asthmatics accept patient education via internet? Findings of a study to test a new approach. Eur J Med Res 2003;7(suppl 1),68
  19. Drummond, MF, O’Brien, B, Stoddart, GL, et al Methods for the economic evaluation of health care programmes 2nd ed. 1997,107-108 Oxford University Press. Oxford, UK:
  20. Woehl A. The usefulness of health economic evaluations in the health care system: the example of a cost-benefit-analysis of an asthma education program [in German]. Diploma Thesis: 2000; 44
  21. Official statistic yearbook 2001 [in German]. Stuttgart, Germany: Metzler-Poeschel, 2001; 442
  22. Rote Liste 2002. 2002 Editio Cantor Verlag GmbH. Aulendorf, Germany:
  23. German recommendations for health care economic evaluation studies: revised version of the Hannover consensus [in German]. Med Klin 2000;95,52-55
  24. Hennekens, CH, Buring, JE Measures of disease frequency and association. Mayrent, SL eds. Epidemiology in medicine. 1987,54-98 Little, Brown and Company. Boston, MA:
  25. Lewis, CE, Rachelefsky, G, Lewis, MA, et al A randomized trial of A.C.T. (asthma care training) for kids. Pediatrics 1984;74,478-486[Abstract/Free Full Text]
  26. O’Brien, KP Managed care and the treatment of asthma. J Asthma 1995;32,325-334[ISI][Medline]
  27. Trautner, C, Richter, B, Berger, M Cost-effectiveness of a structured treatment and teaching programme on asthma. Eur Respir J 1993;6,1485-1491[Abstract]
  28. Weinstein, AG, Mckee, L, Stapleford, J, et al An economic evaluation of short-term inpatient rehabilitation for children with severe asthma. J Allergy Clin Immunol 1996;98,264-273[CrossRef][ISI][Medline]
  29. Vermeire, PA, Rabe, KF, Soriano, JB, et al Asthma control and differences in management practices across seven European countries. Respir Med 2002;96,142-149[CrossRef][ISI][Medline]
  30. Lagerlov, P, Veninga, CC, Muskova, M, et al Asthma management in five European countries: doctors’ knowledge, attitudes and prescribing behaviour; Drug Education Project (DEP) group. Eur Respir J 2000;15,25-29[Abstract]
  31. Maziak, W, von Mutius, E, Beimfohr, C, et al The management of childhood asthma in the community. Eur Respir J 2002;20,1476-1482[Abstract/Free Full Text]
  32. Neri, M, Migliori, GB, Spanevello, A, et al Economic analysis of two structured treatment and teaching programs on asthma. Allergy 1996;51,313-319[ISI][Medline]
  33. Hospital statistics: cost structure of the hospitals in 2001 [in German]. Available at: www.dkgev.de. Accessed November 12, 2002
  34. Bavarian Red Cross. Emergency medical services in Bavaria [in German]. Available at: www.brk-weilheim-schongau.de/rettungsdienst/RD-Start2.htm. Accessed November 12, 2002
  35. Ministry of Economics. New tariffs for the county [in German]. Available at: www.nahverkehr.nrw.de. Accessed October 7, 2002
  36. Deutsche Telekom. New tariffs effective from 01/11/2002 [in German]. Available at: www.service.t-online.de. Accessed October 7, 2002




This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF) Free
Right arrow Submit a response
Right arrow Alert me when this article is cited
Right arrow Alert me when eLetters are posted
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in ISI Web of Science
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to My Personal Article Archive
Right arrow Download to citation manager
Right arrow reprints & permissions
Citing Articles
Right arrow Citing Articles via ISI Web of Science (3)
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Runge, C.
Right arrow Articles by Schaefer, M.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Runge, C.
Right arrow Articles by Schaefer, M.

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS