Internet-Based Self-management Plus Education Compared With Usual Care in Asthma

A Randomized Trial

  1. Victor van der Meer, MD;
  2. Moira J. Bakker, RN;
  3. Wilbert B. van den Hout, PhD;
  4. Klaus F. Rabe, MD, PhD;
  5. Peter J. Sterk, MD, PhD;
  6. Job Kievit, MD, PhD;
  7. Willem J.J. Assendelft, MD, PhD;
  8. Jacob K. Sont, PhD; and
  9. for the SMASHING (Self-Management in Asthma Supported by Hospitals, ICT, Nurses and General Practitioners) Study Group
  1. From Leiden University Medical Center, Leiden, and University of Amsterdam, Amsterdam, the Netherlands.

    Abstract

    Background: The Internet may support patient self-management of chronic conditions, such as asthma.

    Objective: To evaluate the effectiveness of Internet-based asthma self-management.

    Design: Randomized, controlled trial.

    Setting: 37 general practices and 1 academic outpatient department in the Netherlands.

    Patients: 200 adults with asthma who were treated with inhaled corticosteroids for 3 months or more during the previous year and had access to the Internet.

    Measurements: Asthma-related quality of life at 12 months (minimal clinically significant difference of 0.5 on the 7-point scale), asthma control, symptom-free days, lung function, and exacerbations.

    Intervention: Participants were randomly assigned by using a computer-generated permuted block scheme to Internet-based self-management (n = 101) or usual care (n = 99). The Internet-based self-management program included weekly asthma control monitoring and treatment advice, online and group education, and remote Web communications.

    Results: Asthma-related quality of life improved by 0.56 and 0.18 points in the Internet and usual care groups, respectively (adjusted between-group difference, 0.38 [95% CI, 0.20 to 0.56]). An improvement of 0.5 point or more occurred in 54% and 27% of Internet and usual care patients, respectively (adjusted relative risk, 2.00 [CI, 1.38 to 3.04]). Asthma control improved more in the Internet group than in the usual care group (adjusted difference, −0.47 [CI, −0.64 to −0.30]). At 12 months, 63% of Internet patients and 52% of usual care patients reported symptom-free days in the previous 2 weeks (adjusted absolute difference, 10.9% [CI, 0.05% to 21.3%]). Prebronchodilator FEV1 changed with 0.24 L and −0.01 L for Internet and usual care patients, respectively (adjusted difference, 0.25 L [CI, 0.03 to 0.46 L]). Exacerbations did not differ between groups.

    Limitation: The study was unblinded and lasted only 12 months.

    Conclusion: Internet-based self-management resulted in improvements in asthma control and lung function but did not reduce exacerbations, and improvement in asthma-related quality of life was slightly less than clinically significant.

    Primary Funding Source: Netherlands Organization for Health Research and Development, ZonMw, and Netherlands Asthma Foundation.

    Article and Author Information

    • Acknowledgment: The authors thank Professor E.F. Juniper for the permission to use a Web-based version of the Asthma Control Questionnaire. The SMASHING (Self-Management of Asthma Supported by Hospitals, ICT, Nurses and General Practitioners) Study Group consists of W.J.J. Assendelft, H.A. Thiadens, M.J. Bakker, W.B. van den Hout, J. Kievit, V. van der Meer, J.K. Sont, A.A. Kaptein, E.R.V.M. Rikkers-Mutsaerts, K.F. Rabe, E.H.D. Bel, P.J. Sterk, S.B. Detmar, W. Otten, H.F. van Stel, A.C. Roldaan, J.C. de Jongste, and P.J. Toussaint.

    • Grant Support: By the Netherlands Organization for Health Research and Development (ZonMw grants 945-04-061 and 920-03-354) and Netherlands Asthma Foundation (grant 3.4.03.45).

    • Potential Financial Conflicts of Interest: Grants received: V. van der Meer (Netherlands Organization for Health Research and Development), W.B. van den Hout (Netherlands Asthma Foundation, Netherlands Organization for Health Research and Development), J.K. Sont (Netherlands Asthma Foundation, Netherlands Organization for Health Research and Development). Grants pending: W.B. van den Hout (Netherlands Asthma Foundation, Netherlands Organization for Health Research and Development), J.K. Sont (Netherlands Asthma Foundation, Netherlands Organization for Health Research and Development).

    • Reproducible Research Statement: Study protocol: Available from Dr. van der Meer (e-mail, v.van_der_meer{at}lumc.nl). Statistical code and data set: Available through written agreements with Dr. van der Meer (e-mail, v.van_der_meer{at}lumc.nl).

    • Requests for Single Reprints: Victor van der Meer, MD, Leiden University Medical Center, Postzone J-10-s, Room J-10-87, Albinusdreef 2, PO Box 9600, 2300 RC Leiden, the Netherlands; e-mail, v.van_der_meer{at}lumc.nl.

    • Current Author Addresses: Drs. van der Meer, van den Hout, Kievit, and Sont and Ms. Bakker: Department of Medical Decision Making, Postzone J-10-S, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, the Netherlands.

    • Dr. Rabe: Department of Pulmonology, Postzone C-3-P, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, the Netherlands.

    • Dr. Sterk: Department of Respiratory Medicine, Postbus 22660, 1100 DD, Amsterdam, the Netherlands.

    • Dr. Assendelft: Department of Public Health and Primary Care, Postzone V-0-P, Leiden University Medical Center, PO Box 9600, 2300 RC Leiden, the Netherlands.

    • Author Contributions: Conception and design: V. van der Meer, W.B. van den Hout, K.F. Rabe, P.J. Sterk, J. Kievit, W.J.J. Assendelft, J.K. Sont.

    • Analysis and interpretation of the data: V. van der Meer, W.B. van den Hout, J. Kievit, J.K. Sont.

    • Drafting of the article: V. van der Meer,W.B. van den Hout, J. Kievit, J.K. Sont.

    • Critical revision of the article for important intellectual content: V. van der Meer, M.J. Bakker, W.B. van den Hout, K.F. Rabe, P.J. Sterk, J. Kievit, W.J.J. Assendelft, J.K. Sont.

    • Final approval of the article: V. van der Meer, M.J. Bakker, W.B. van den Hout, K.F. Rabe, P.J. Sterk, W.J.J. Assendelft, J.K. Sont.

    • Provision of study materials or patients: V. van der Meer, M.J. Bakker, J. Kievit, J.K. Sont.

    • Statistical expertise: V. van der Meer, W.B. van den Hout, J.K. Sont.

    • Obtaining of funding: V. van der Meer, J.K. Sont.

    • Administrative, technical, or logistic support: V. van der Meer, M.J. Bakker, J.K. Sont.

    • Collection and assembly of data: V. van der Meer, M.J. Bakker, W.J.J. Assendelft, J.K. Sont.

    • International Standard Randomized Controlled Trial number: ISRCTN79864465.

    Summary for Patients

    • Summaries for Patients:Internet-Based Program to Assist Patients in Asthma Care Ann Intern Med July 21, 2009 151:I-42; doi:10.1059/0003-4819-151-2-200907210-00001
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