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Table 1. Baseline versus post intervention sociodemographic characteristic Characteristic
Baseline
Pre-intervention
Post Intervention
includes phone follow up
Dropouts Count
Count p-value Count
p-value
+
Total 634
100 516
77.1 –
118 22.9
–
Age yrs
≤20y 39
6.2 29
5.6 0.8
10 8.5
0.34 21-30y
53 8.4
40 7.8
0.79 13
11.0 0.33
31-40y 91
14.4 72
14.0 0.91
19 16.1
0.65 41-50y
161 25.4
134 26.0
0.88 27
22.9 0.56
51-60y 150
23.7 123
23.8 0.1
27 22.9
0.92 60y
140 22.1
118 22.9
0.81 22
18.6 0.38
Total 634
100 516
100 –
118 100.0
–
Ethnicity
Malay 329
51.9 274
53.1 0.73
55 46.6
0.24 Chinese
75 11.8
63 12.2
0.92 12
10.2 0.64
Indian 218
34.4 170
32.9 0.65
48 40.7
0.14 Others
12 1.9
9 1.7
0.97 3
2.5 0.84
Total 634
100 516
100.0 –
118 100.0
–
Gender
Male 237
37.4 192
37.2 0.1
45 38.1
0.93 Female
397 62.6
324 62.8
0.1 73
61.9 0.93
Total 634
100 516
100 –
118 100.0
–
p-value comparing baseline and post intervention using Z test for paired proportions + p-value comparing post intervention and dropouts using Z test for paired proportions
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Improving Asthma Care in Ministry of Health Primary Care Clinics
Table 2. Key Outcome of Intervention Outcome
Baseline
Pre-intervention
Post Intervention
includes phone follow up
p-value Count
Count PEFR
80 161
25.4 126
30.1 0.10
60-80 242
38.2 179
42.8 0.15
60 226
35.6 112
26.8 0.003
Missing 5
0.8 1
0.2 0.46
Total 634
100 418
100.0 –
ACT Score
20-25 227
35.8 273
52.9 0.001
15-19 223
35.2 172
33.3 0.55
15 181
28.5 71
13.8 0.001
Missing 3
0.5 0.0
0.33 Total
634 100
516 100.0
–
Clinical Assessment of Asthma
Controlled 227
35.8 273
52.9 0.001
Partially controlled
223 35.2
172 33.3
0.55 Uncontrolled
181 28.5
71 13.8
0.001 Missing
3 0.5
0.0 0.33
Total 634
100 516
100.0 –
Usage of Preventer
Yes 428
67.5 474
85.9 0.001
No 200
31.5 73
13.2 0.001
Missing 6
0.9 5
0.9 0.82
Total 634
100 552
100.0 –
p-value comparing baseline and post intervention using Z test for paired proportions
10 5
p ro
vin g A
st h
m a C
ar e i
n M in
is tr
y o f H
ea lth P
rim ar
y C
ar e C
lin ic
s
Table 3. Comparison of ACT outcome for patient cohort pre and post intervention Baseline
Controlled Partially controlled
Uncontrolled Total
n 95 CI
n 95 CI
n 95 CI
n 95 CI
LL UL
LL UL
LL UL
LL UL
P o
st in
te rv
e n
ti on
Controlled
166 81
76 86
79 44.1
37 51
28 21.2
14 28
273 52.9 49
57
Partially controlled
32 15.6
11 21
89 49.7
42 57
51 38.6
30 47
172 33.3 29
37
Uncontrolled
7 3.4
1 6
11 6.1
3 10
53 40.2
32 49
71 13.8
11 17
Total
205 39.7 35
44 179
34.7 31
39 132
25.6 22
29 516
– –
–
LL = Lower Limits, UL=upper limits
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Improving Asthma Care in Ministry of Health Primary Care Clinics Baseline asthmatic
status controlled Post intervention
asthmatic status controlled
Male
Sex of patient 95 C I
Female 0.6
0.5
0.4
0.3
Figure 2. Error bar according to gender for ACT score 20-25
Baseline asthmatic status uncontrolled
Post intervention asthmatic status
uncontrolled
Male
Sex of patient 95 C I
Female 0.4
0.3
0.2
0.1
Figure 3. Error bar according to gender for ACT score 15
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Improving Asthma Care in Ministry of Health Primary Care Clinics Baseline asthmatic
status controlled Post intervention
asthmatic status controlled
Malay Chinese
Race of patient 95 C I
Indian Other
1.00 0.75
0.50 0.25
0.00 -0.25
-0.50
Figure 4. Error bar according to ethnicity for ACT score 20-25
Baseline asthmatic status uncontrolled
Post intervention asthmatic status
uncontrolled
Malay Chinese
Race of patient 95 C I
Indian Other
0.8
0.6
0.4
0.2
0.0
-0.2
Figure 5. Error bar according to ethnicity for ACT 15
108
Improving Asthma Care in Ministry of Health Primary Care Clinics Baseline asthmatic
status controlled Post intervention
asthmatic status controlled
1 2
3
Age according to category 95 C I
4 5
6 0.8
0.6
0.4
0.2
Figure 6. Error bar according to age category for ACT 20-25
Baseline asthmatic status uncontrolled
Post intervention asthmatic status
uncontrolled
1 2
3
Age according to category 95 C I
4 5
6 0.5
0.4
0.3
0.2
0.1 0.0
Figure 7. Error bar according to age category for ACT 15
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Improving Asthma Care in Ministry of Health Primary Care Clinics
5.0 DISCUSSION
5.1 Statement of Principle Findings
Asthma control is recognized as a critical aspect of the evaluation and management of the disease. In this study from the 6 participating clinics, a total of 634 respondents
were intervened at baseline. Majority of them were Malays, female and aged between 40 to 50 years old.
At baseline 35.8 of asthmatics were controlled, 35.6 had a PEFR less than 60 of best predicted value and 67.5 were on preventer medication. 77.1 of all
respondents completed the study. There is no significant sociodemographic difference in term of age, ethnic and gender distribution between the baseline and
the post intervention group and also no difference between those who completed the study and those without any outcome.
After undergoing the interventional package, the proportion of those with asthma controlled increased to 52.9, those with a PEFR less than 60 of best predicted
value decreased to 26.8 and those on preventer medication increased to 85.9. Furthermore proportion of patients with uncontrolled asthma reduced from 25.6
95CI 22-29 to 13.8 95CI 11-17. After the intervention, the asthmatic control among those of Indian ethnicity significantly improved from 25 95CI 18-31
to 42 95CI 35-50 and those aged 41-50 years showed a significant degree of improvement as well from 41 95CI 33-49 to 59 95CI 51-67. One possible
reason is that these groups may have work related exposure to allergen or social allergen and thus may be improved by better treatment strategies such as in the
interventional package. Most epidemiological studies show a significant association between air pollutants and exacerbations of asthma.
5.2 Strengths and Weaknesses of the Study
The monitoring of peak flow measurement which was done at every clinical visit helps in assessing the lung function in a simple way besides the use of the ACT score
which was a key tool as it allowed an objective way of assessing asthma control. Peak expiratory flow has been recommended and used for self-management of asthma.
However poor adherence to daily PEF monitoring suggests that this may not be a practical approach for most patients. Buist et at 2006 has found that peak flow
monitoring has no advantage over symptom monitoring as an asthma management. Despite these, it is shown that only a small proportion of patients with asthma
use a peak flow meter regularly. Another study Turner et al. 1998 has shown that education, regular follow up and an action plan are effective in improving asthma
control and quality of life but the routine use of PFM to guide intervention is not the only way to accomplish these objectives. The ACT is reliable, valid, and responsive to
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Improving Asthma Care in Ministry of Health Primary Care Clinics
changes in asthma control over time in patients new to the care of asthma specialists. A cutoff score of 19 or less identifies patients with poorly controlled asthma. In a
clinical setting the ACT should be a useful tool to help physicians identify patients with uncontrolled asthma and facilitate their ability to follow patients’ progress with
treatment. Wechsler ME.
The introduction of handy asthma control handbook in this study to provide information and knowledge to the patient besides asthma record treatment
book served as tools for self empowerment for both the patient and health care provider. Written asthma action plans WAAPs are recommended by national
and international guidelines to help patients recognize and manage asthma exacerbations. It is found that the key elements of an effective WAAP, including
concise, detailed recommendations regarding asthma exacerbation recognition patient self monitoring and treatment Matthew et al. 2008. Although several
versions of the WAAP exist, all share certain features. In this study by introducing the asthma handbook patients and the health care provider needed to know
that they have to monitor their symptoms or peak expiratory flow PEF to detect deviations from the usual state of controlled asthma. Reminders of warning signs
and symptoms as well as potential precipitating factors or personal triggers were included. By incorporating the ACT score as a guide for patient-initiated treatment,
options to restore control were explicitly provided in writing. In addition danger signs and contact information were included. This information was documented in
the handbook for the patient reference at all time.
This study obtained data on asthma control as opposed to previous studies that mainly focused on asthma severity.
The lack of a control group hampered comparison and historical internal controls were used. It was felt that it is not acceptable to use a control group as patient
identified with uncontrolled asthma could not be left without intervention in the exiting health care provision environment.
The sampling was convenient quota sampling but every patient identified in all 6 clinics were included and offered intervention.
There was a large dropout of patients 22.9 despite attempts to trace them by phone. However analysis showed that those who dropped out were similar in socio-
demographic characteristic.
The diagnosis of asthma in this study was based on healthcare provider clinic judgment and not on any objective criteria.
