Background

Asthma is a chronic respiratory syndrome characterized by airway inflammation and a variety of symptoms including coughing, wheezing, and shortness of breath. More than 8 percent of both adults and children in the United States have asthma, and in 2016 asthma accounted for 1.7 million emergency department visits and more than 3,500 deaths.¹ Asthma can significantly reduce patients’ and families’ quality of life and affects attendance at school, work, and participation in recreational activities. Half of adults and nearly 40 percent of children report poorly controlled or uncontrolled asthma, although a wide variety of pharmacological and other interventions are available to improve asthma control and reduce the frequency and burden of symptoms.²

Patients and families can play a substantial role in minimizing the burden of asthma through careful medication management, reducing exposure to environmental triggers, and responding rapidly to exacerbations.³ However, understanding the complex interaction between respiratory physiology, asthma triggers, short- and long-term medications, and rescue therapies requires significant education and training that may be challenging for patients and caregivers. Clinical practice guidelines developed by the National Heart, Lung and Blood Institute therefore emphasize formal and comprehensive asthma self-management education (AS-ME) as a key component of optimal asthma care.⁴ National standards for AS-ME have been published,⁵ and the Centers for Disease Control and Prevention (CDC) recently introduced a new technical package aimed at improving asthma control, EXHALE, that highlights AS-ME as a vital strategy within a continuum of approaches to improve asthma care. EXHALE describes AS-ME as a strategy to teach

“…basic facts about asthma, roles of medications, how to use medications correctly, what to do when asthma symptoms worsen, and how to reduce exposure to asthma triggers…Effective AS-ME can be delivered in a variety of settings (e.g., individual, family, or group education in a clinic, school, pharmacy, or community) by a variety of providers (e.g., nurses, respiratory therapists, certified asthma educators, or community health workers) …[and] requires repetition and reinforcement.”⁶

Dozens of AS-ME packages have been developed and disseminated by various organizations and agencies, and many packages or their components have been examined in controlled studies. A recent review of reviews³ synthesized the findings of 27 systematic reviews encompassing 270 randomized controlled trials of AS-ME approaches. The authors found that AS-ME improves asthma control and reduces healthcare utilization, and can be implemented for diverse populations in varying settings. Other recent reviews have also suggested the value of AS-ME for improving asthma outcomes⁷ and quality of life.⁸

Despite the widespread use and evaluation of AS-ME packages, there remains uncertainty about their optimal design, characteristics, and implementation. Heterogeneity in content, format, delivery mechanisms, targeted populations, and other features complicates efforts to identify best practices in designing packages. Additionally, different populations and types of learners may need different educational approaches and strategies. As the prevalence and burden of asthma remain high,^1,2 there is increasing interest by clinical experts, patient advocates, public health leadership, and policymakers to identify and invest resources in effective interventions. Future packages would benefit from a structured framework delineating the current state of AS-ME practice, knowledge, and research.

This Technical Brief mapped the ecosystem of current AS-ME packages. We identified the different components that comprised selected AS-ME packages that are used in the United States, and examined, compared, and organized their key characteristics to enable a better understanding of current practice. We summarized important elements of their scope, design, content, and target audience, and included evidence, when available, addressing their effectiveness, feasibility, and user satisfaction. Our analysis also highlighted factors affecting implementation, including public availability and cost, user literacy, mode of delivery, and ease of use. Finally, we identified key gaps in knowledge about optimal AS-ME packages, and illuminated the practical challenges to future work in this field.

Guiding Questions

GQ 1: What are the characteristics of AS-ME packages, and how do they vary?

Audience

• Who is included in the intended audience?
• Are packages focused on, or limited to, specific patient characteristics?
• What level of literacy is required? Are packages offered in multiple languages?

Delivery and use of AS-ME packages

• What is the setting for delivery of education?
• Is education self-directed, or delivered by an instructor (if so, whom)?
• What aspects of the package are interactive?
• What mediums are used to deliver education and facilitate communication?
• What is the timeframe?
• How are packages initially accessed? Is there a clinical gatekeeper (e.g., referral or login permission needed)?

Educational content

• What key content areas are addressed?
• How do packages address cognitive, psychological, and/or emotional components of asthma and asthma self-management?
• What tools are provided to recipients as components of the packages?
• What evidence supports the validity of the content? Does the content align with national asthma guidelines?
• When were the packages designed/updated?
• Are explicit educational goals identified? How is individual learning/progress evaluated?

GQ 2: What is the context and implementation of AS-ME packages?

• Who develops the packages?
• Are packages publicly available? Is there a fee? Are they protected by copyright?
• How much does it cost to develop, produce, promote, disseminate, and use packages?
• Who pays for educational packages?
• Do recipients earn a certification of completion?
• Is there a process to sustain/support retention of learning over time?
• What factors are important facilitators and barriers to implementation of AS-ME?
• How is technology used to support implementation?
• If education is guided by an instructor, how are instructors identified and trained?
• Are current/future workforce resources adequate to provide instruction?
• How is implementation evaluated?

GQ 3: What is the current evidence addressing AS-ME packages?

• What asthma outcomes are measured? Are packages associated with good outcomes?
• What patient-centered outcomes are measured? Are packages associated with good outcomes?
• What implementation outcomes are measured? Are packages associated with good outcomes?
• How applicable is current evidence to various populations and settings?

GQ 4: What future research is needed to close evidence gaps regarding AS-ME packages?

• What additional evaluation is needed on existing AS-ME packages?
• Are different evaluation approaches needed to assess AS-ME?
• What new types of packages, or components and features of packages, may be needed?
• Is further evaluation needed focusing on specific patient populations? Are some populations not adequately addressed by current packages?