The Effects of Combining Web-Based eHealth With Telephone Nurse Case Management for Pediatric Asthma Control: A Randomized Controlled Trial
The Effects of Combining Web-Based eHealth With Telephone Nurse Case Management for Pediatric Asthma Control: A Randomized Controlled Trial
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DOI：
10.2196/jmir.1964
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发表时间：
2012-07-01
影响因子：
7.4
通讯作者：
Kim, Jee-Seon
中科院分区：
文献类型：
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作者：
Gustafson, David;Wise, Meg;Kim, Jee-Seon
背景：哮喘是美国最常见的儿科疾病，给低收入和少数族裔家庭带来不成比例的负担，并导致高昂的医疗费用。基于临床的哮喘教育和电话病例管理对哮喘控制的效果好坏参半，电子健康计划和在线游戏也是如此。 目标：测试 (1) CHESS+CM（一种针对哮喘控制不佳的父母和 4-12 岁儿童的系统）对哮喘控制和药物依从性的影响，以及 (2) 作为中介的能力、自我效能和社会支持。 CHESS+CM 包括全自动电子医疗组件（综合健康增强支持系统 [CHESS]）以及通过电话进行的每月护士病例管理 (CM)。 CHESS基于自我决定理论，旨在提高父母和孩子的能力、社会支持和内在动机。方法：我们从美国威斯康星州麦迪逊市和密尔沃基市的管理式医疗机构的档案中识别出符合条件的亲子二人组，向他们发送招募信，并随机将他们（非盲法）分配到照常治疗加哮喘信息的对照组或CHESS + CM。哮喘控制情况通过哮喘控制问卷（ACQ）和自我报告的无症状天数来衡量。药物依从性是药房补充数据和服药数据的综合。通过问卷对社会支持、信息能力和自我效能进行自我评估。所有数据均在 0、3、6、9 和 12 个月时收集。随机分组前 3 周磨合期的哮喘日记提供了基线数据。 结果：在 305 名亲子二人组中，301 名被随机分配，其中 153 名被分配到对照组，148 名被分配到 CHESS+CM。大多数父母是女性（283/301，94%）、非裔美国人（150/301，49.8%），并且孩子的医疗补助状况表明收入较低（154/301，51.2%）； 146 人（48.5%）是单身，301 人中有 96 人（31.9%）受过高中或以下教育。完成率为 153 组对照组中的 127 组 (83.0%) 和 148 组 CHESS+CM 组中的 132 组 (89.2%)。 CHESS+CM 组儿童在 ACQ 上的哮喘控制明显更好（d = -0.31，95% 置信限 [CL] -0.56, -0.06，P = .011），但没有按照无症状天数衡量（d = 0.18，95% CL -0.88, 1.60，P = 1.00）。各组之间的综合依从性评分没有显着差异（d = 1.48%, 95% CL -8.15, 11.11, P = .76）。社会支持是 CHESS+CM 对哮喘控制影响的重要中介因素（α = .200，P = .01；β = .210，P = .03）。自我效能感不显着（α = .080，P = .14；β = .476，P = .01）；信息能力也同样如此（alpha = .079，P = .09；beta = .063，P = .64）。结论：将电话病例管理与电子健康相结合有利于小儿哮喘控制，但不利于药物依从性。需要改进测量药物依从性的方法。在改善小儿哮喘控制方面，社会支持似乎比信息更有效。
Background: Asthma is the most common pediatric illness in the United States, burdening low-income and minority families disproportionately and contributing to high health care costs. Clinic-based asthma education and telephone case management have had mixed results on asthma control, as have eHealth programs and online games.Objectives: To test the effects of (1) CHESS+CM, a system for parents and children ages 4-12 years with poorly controlled asthma, on asthma control and medication adherence, and (2) competence, self-efficacy, and social support as mediators. CHESS+CM included a fully automated eHealth component (Comprehensive Health Enhancement Support System [ CHESS]) plus monthly nurse case management (CM) via phone. CHESS, based on self-determination theory, was designed to improve competence, social support, and intrinsic motivation of parents and children.Methods: We identified eligible parent-child dyads from files of managed care organizations in Madison and Milwaukee, Wisconsin, USA, sent them recruitment letters, and randomly assigned them (unblinded) to a control group of treatment as usual plus asthma information or to CHESS+CM. Asthma control was measured by the Asthma Control Questionnaire (ACQ) and self-reported symptom-free days. Medication adherence was a composite of pharmacy refill data and medication taking. Social support, information competence, and self-efficacy were self-assessed in questionnaires. All data were collected at 0, 3, 6, 9, and 12 months. Asthma diaries kept during a 3-week run-in period before randomization provided baseline data.Results: Of 305 parent-child dyads enrolled, 301 were randomly assigned, 153 to the control group and 148 to CHESS+CM. Most parents were female (283/301, 94%), African American (150/301, 49.8%), and had a low income as indicated by child's Medicaid status (154/301, 51.2%); 146 (48.5%) were single and 96 of 301 (31.9%) had a high school education or less. Completion rates were 127 of 153 control group dyads (83.0%) and 132 of 148 CHESS+CM group dyads (89.2%). CHESS+CM group children had significantly better asthma control on the ACQ (d = -0.31, 95% confidence limits [CL] -0.56, -0.06, P = .011), but not as measured by symptom-free days (d = 0.18, 95% CL -0.88, 1.60, P = 1.00). The composite adherence scores did not differ significantly between groups (d = 1.48%, 95% CL -8.15, 11.11, P = .76). Social support was a significant mediator for CHESS+CM's effect on asthma control (alpha = .200, P = .01; beta = .210, P = .03). Self-efficacy was not significant (alpha = .080, P = .14; beta = .476, P = .01); neither was information competence (alpha = .079, P = .09; beta = .063, P = .64).Conclusions: Integrating telephone case management with eHealth benefited pediatric asthma control, though not medication adherence. Improved methods of measuring medication adherence are needed. Social support appears to be more effective than information in improving pediatric asthma control.