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Use of a diary in asthma management: Examining the impact of documenting on disease management

Use of a diary in asthma management: Examining the impact of documenting on disease management. Melissa A. Valerio, Ph.D. University of Michigan School of Public Health. Overview. Background Methods & Results Study Limitations Summary & Conclusions Directions for Future Research.

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Use of a diary in asthma management: Examining the impact of documenting on disease management

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  1. Use of a diary in asthma management: Examining the impact of documenting on disease management Melissa A. Valerio, Ph.D. University of Michigan School of Public Health

  2. Overview • Background • Methods & Results • Study Limitations • Summary & Conclusions • Directions for Future Research

  3. Background • Asthma in US adults • Children vs. adults • 13.8 million adults have ever been diagnosed • Over 25 million lost work days are estimated • Asthma in women • Higher prevalence • Higher health care utilization rates • Higher asthma death rate (CDC, 2007; NCHS, 2007; CDC, 2001; HRSA, 2003)

  4. Asthma Management • Approaches to asthma management in adults • Self-management strategies • Peak Expiratory Flow (PEF) monitoring • Asthma diary (Kotses, 1991; Clark, 1998; Creer, 1992; Gibson, 1999).

  5. Asthma Diaries • Use of diaries in asthma management (Verbrugge, 1980; Bolger, 2003; Alaszewski, 2006) • Document morbidity • Aid in recall • Capture temporal changes • Types of asthma diaries • Asthma diary questionnaire (Juniper, 1997; 2000) • Medication adherence (Santanello, 1999; Wraight, 2002) • Peak expiratory flow rate (PEFR) monitoring (Gibson, 2001; Hensley, 2003)

  6. Critiques of Diary Use • Research Methods and Analysis of Health Diaries • Critiques • Poor compliance • Poor data quality • Bias due to timing of entries • Adequate analyses of diary data • Amount of time and money • Lack of appropriate statistical methods (Verbrugge, 1980; Shiffman, 2001; Stone, 2002; Bolger, 2003; Alaszewski, 2006)

  7. Theoretical Framework • Theory and Diary use • Social Cognitive Theory (Bandura, 1986; Clark, 2001) • Self-regulation: observation, judgment and reaction • Self-efficacy: asthma specific • Written Emotional Disclosure (Pennebaker, 2004; Sloan, 2004) • Acts of observing and writing • Processing of daily events

  8. Gaps in Literature • Current gaps in the literature • Personal and clinical characteristics associated with use and compliance • Use of a diary and changes in management over time • Examination of theoretical principles or mechanisms associated with diary use

  9. Women with Asthma Study • Effect of self-regulatory education for women with asthma study (Clark, 2007) • Randomized controlled study (N=808) • Longitudinal surveys (baseline and 2 follow-ups) • Women Breathe Free (WBF) educational program • 6 – telephone counseling sessions • Focus on self-regulatory skills • Address gender-related problems • Review of the asthma diary (4 week self-observation period)

  10. Women with Asthma Study • Inclusion criteria • 18 years of age and older • Diagnosis of asthma • Presence of active symptoms • Enrolled as a patient in one of the UM asthma related clinics • Not pregnant

  11. Sources and Type of Data

  12. Study Measures • Scale Measurements • Self-regulation (Zimmerman, 1999) • Quality of life (Juniper, 1997) • Self-efficacy (Clark, 2001) • Others • Unscheduled physician visits • Asthma severity level (NAEPP, 2002) • Demographics

  13. Study Population • Personal demographics (Baseline) • Age: 48 years old (mean) • Education: 70% 2 yr. college or more • Employment: 66% employed • Household income: 29% $40,000 or less • Marital status: 63% married • Race/ethnicity: 83% white

  14. Study Population • Clinical characteristics (Baseline) • Asthma severity level: • 52% intermittent • 13% severe persistent • Other health problems (co-morbidities): 58% • History of smoking (10 pack a year): 27% *Severity classification based on NAEPP guidelines

  15. Women Breathe Free Diary • Components of the Diary • Asthma symptoms, triggers • Medication use • Activities/events • Peak Expiratory Flow rate readings (2x daily) • Hormonal data (menstrual cycle, birth control use, and estrogen replacement therapy)

  16. WBF Diary - Descriptive Data

  17. Data Analysis • Research Question 1: • Data Source: Baseline survey data (tx group, n=424) • Analysis: Logistic regression • Research Question 2: • Data source: Baseline, follow-up 1 and follow-up 2 survey data (all study data) • Analysis: Hierarchical Linear Modeling (HLM) • Outcome variables examined: self-regulation, quality of life, self-efficacy and unscheduled physician visits

  18. Research Question 1 • Are certain personal or clinical characteristics of women associated with a greater likelihood of use of an asthma diary than others?

  19. Research Question 1: Findings • Differences in diary users and non-users: • Significantly more likely to use • Participants 50 years of age and older (p<0.05) • Participants with a post-graduate education level (p<0.05) • Significantly less likely to use • Participants with severe asthma (p<0.05) • Participants with a history of smoking (p<0.01) • Neither employment, income, marital status nor the report of co-morbidities were predictors of diary use.

  20. Research Question 2 • Are there differences in asthma self-management outcomes between women who used the asthma diary for any period of time (treatment group) versus those that did not (dropped from treatment group and those randomized to the control group)?

  21. Research Question 2: Findings Self-regulation • Trend towards better self-regulation across time for users of this diary Quality of Life • Significant improvement in quality of life scores for both women who used this diary (p<0.05) and those that did not over time (p<0.01)

  22. Research Question 2: Findings Self-efficacy • Higher levels of self-efficacy over time were found between participants who used this diary versus those that did not (p=0.01) # of unscheduled physician visits for asthma in past 12 mos.(Poisson count distribution) • Participants who used this asthma diary had significantly lower rates of unscheduled physician visits over time compared to participants that did not use the diary (p<0.05)

  23. Research Question 3 • Does the use of an asthma diary improve an individual’s observation of asthma? Does the diary enable feedback that is perceived to be useful and educational? Data sources • In-depth face-to-face interviews with randomly selected participants from the treatment group that used the diary (n=21) • 1 focus group session with randomly selected control participants (n=12)

  24. Geographic Distribution of In-depth Interview Participants

  25. Domain 1: Asthma Management • Difficulties in management • Impact of seasonal effects (i.e., sudden changes in weather, variability) • Impact of asthma on family responsibilities and daily activities • Changes due to diary use • Increased understanding of asthma • Making connections not previously made

  26. Domain 1: Asthma Management “After my experience with the diary I think I felt that my lungs – I could see that my lungs weren’t – I did have something. And something’s going on there. It wasn’t just – I couldn’t just overlook it anymore. So it was right there in front of my face. When you have to look at, oh wow, you know, runny nose every morning, itchy throat every morning, using that Albuterol every single day several times.”

  27. Domain 2: Diary Use and Completion • Provider communication and feedback • Almost none of the participants received feedback about their diaries from a clinician • Accurate recall of amount and type of symptoms, triggers • Expectations for feedback and review of diary data • Completion of the diary • Repetitive • Not Burdensome • Who should use a diary • Newly diagnosed patient • Person who has been living with asthma for some time

  28. Domain 3: Act of Documenting • Identification of patterns and needs • Forces review and recall • “Seeing” activities • Increased awareness

  29. Domain 3: Act of Documenting “…When you see it on paper you start to think ‘cause you know, you’re going through your regular day. And you don’t write down, well I had breakfast. I did this. I did that. You just go about your day. However, when you’re having a bad day it’s – you can go back and think, oh yeah, I was doing – I was cleaning the upstairs and I washed the sheets. And I did this. And I was up and down. And you think about things. And you think, well maybe I’ll spread it out during the week and not do all the stuff on one day.”

  30. Significance • First study to explore who uses asthma diaries in an adult population and what they think about diary use • First effort to explore theoretical principles (self-regulation, written disclosure) in asthma diary use • Targeted a practice (recommending diaries) that is widely used and accepted in asthma, but minimally studied

  31. Study Limitations • Population primarily white (13% African American), high income, highly educated, and with intermittent asthma • No males were included in the study • The impact of this diary cannot be fully examined independently of the intervention

  32. Practical Implications • Clinicians and researchers should consider these factors when recommending diaries for asthma management and data collection • Future studies should be sensitive to differences in use of diaries and account for them in analyses and report them in findings

  33. Directions for Future Research • Most beneficial duration for use of an asthma diary • Experiences of participants that did not use the asthma diary • Benefit to underserved populations • Uses as a tool for improving functional health literacy

  34. Summary • Personal and clinical characteristics (age, education, and asthma severity) distinguish individuals who use an asthma diary from those who do not. • The patterns and connections between symptoms, triggers and activities and events identified in the diary may enhance understanding and directly impact long term outcomes. • The long-term benefits of asthma diary use may not be fully understood.

  35. Domain 2: Diary Use and Completion “I do see how one thing though for people who have had it for a long time, you’re assuming you know all of your triggers. And yet asthma does change as we--as we grow older. And there may be things that are new triggers in our life that we don’t even think about because we’re so used to what our triggers are. And this [diary] might be something that might help you to find other triggers that you’re not even aware of.”

  36. Survey Nonresponse over Time • Attrition over time • Baseline to follow-up 1 nonresponse • Non-significant differences by smoking history, owning a peak flow meter, having an asthma treatment plan and report of co-morbidities • Significant differences by asthma severity level and race/ethnicity • Follow-up 1 to follow-up 2 nonresponse • Survey nonresponse trends for follow-up 1 to follow-up 2 were similar to differences found for baseline to follow-up 1 nonresponse. • Only significant difference by owning a peak flow meter

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