Intraprofessional boundary crossing in acute paediatric care: A rich journey for general practice and paediatric residents.

BACKGROUND: Achieving optimal collaboration between general practitioners and hospital-based critical care doctors is vital yet challenging, necessitating targeted collaborative training during residency. Despite apparent benefits, implementing intraprofessional learning faces constraints. Understanding its occurrence is crucial for engaging and educating residents. Considering boundaries' learning potential, we developed and evaluated an educational programme for general practitioner (GP) and paediatric (P) residents in paediatric emergency care based on Akkerman's Boundary Crossing Theory. The study investigated how intraprofessional learning mechanisms occurred and what learning conditions facilitated or impeded learning of GP and P residents, aiming to optimise educational programme design for intraprofessional collaboration. METHODS: We developed an educational programme with three activities: joint medical assessments of paediatric patients in each other's context, mutually mini-Clinical Evaluation Exercises (mini-CEXs) about intraprofessional collaboration skills and educational meetings about collaborative care. We performed a qualitative study with a constructivist approach to explore experiences of the programme. We conducted focus group interviews and analysed mini-CEXs, utilising Boundary Crossing theory for template analysis. RESULTS: Ten GP and eight P residents participated in our study. Learning mechanisms of identification and coordination dominated the joint medical assessments. Mini-CEXs stimulated reflection. Educational meetings with supervisors about intraprofessional barriers initiated transformation. Facilitated learning conditions were bidirectional crossing, enthusiastic supervisors, residents being familiar with each other, clear mini-CEX design and authentic paediatric cases. Unclear mutual expectations during joint medical assessments impeded learning of residents. CONCLUSIONS: Working in each other's context triggers learning mechanisms of identification, coordination and reflection, forming the basis for intraprofessional learning in paediatric emergency care for GP and P residents. For development of new collaboration practices, supervisors are necessary to translate reflection into transformation. Mutual responsibilities and expectations should be made more explicit to create a safer intraprofessional learning environment. Our findings extend to other medical training contexts, leveraging boundaries for learning.

Advancing collaboration in health professions education in the general practice domain, developing a national research agenda.

BACKGROUND: Health professions education (HPE) research in the General Practice domain (GP-HPE) is vital for high-quality healthcare. Collaboration among GP-HPE researchers is crucial but challenging. Formulating a research agenda, involving stakeholders, and fostering inter-institutional collaboration can address these challenges and connect educational research and practice. METHODS: We used Q-methodology to explore perspectives on GP-HPE research of participants from all Dutch postgraduate GP training institutes. Participants individually sorted statements based on the relevance of future GP-HPE research for educational practice. Data analysis comprised inverted factor analysis, rotation, and qualitative interpretation of configurations of all statements. The National Meeting on Educational Research took a participatory approach. RESULTS: We included 73 participants with diverse involvement in GP-HPE research. We identified five distinct perspectives, each representing a research focus area for developing and innovating GP education: the clinician scientist, the socially engaged GP, the specific GP identity, the GP as an entrepreneur, and the GP engaged in lifelong learning. DISCUSSION: The resulting five perspectives align with General Practice hallmarks. Q-methodology and a participatory approach facilitated collaboration among stakeholders. Successful inter-institutional collaboration requires a common goal, neutral leadership, participant commitment, regular meetings, audit trail support, process transparency, and reflexivity. Future research should address evidence gaps within these perspectives. CONCLUSION: Using Q-methodology turned out to be valuable for compiling a national research agenda for GP-HPE research. The research process helped to cross boundaries between researchers in different institutions, thus putting inter-institutional collaborative advantage center stage. Our approach could provide a conceivable procedure for HPE researchers worldwide.

A Philosophical Discussion of the Support of Self-Regulated Learning in Medical Education: The Treasure Hunt Approach Versus the (Dutch) "Dropping" Approach.

Issue: Many current educational approaches are intended to cultivate learners' full (learning) potential by fostering self-regulated learning (SRL), as it is expected that those learners with a high degree of SRL learn more effectively than those with a low degree of SRL. However, these attempts to foster SRL are not always successful. Evidence: We considered complexities related to fostering self-regulated learning by use of an analogy. This analogy was based on two (Dutch) children's games: the treasure hunt (children can find a "treasure" by following directions, completing assignments and/or answering questions) and the dropping (pre-teens are dropped in the woods at nighttime with the assignment to find their way back home). We formulated four interrelated philosophical questions. These questions were not formulated with the intention to provide clear-cut answers, but were instead meant to evoke contemplation about the SRL concept. During this contemplation, the implications of definitional issues regarding SRL were discussed by use of the first question: What are the consequences of the difficulties to explicate what is (not) SRL? The second question (How does SRL relate to autonomy?) touched upon the intricate relationship between SRL and autonomy, by discussing the role of social interaction and varying degrees of instruction when fostering SRL. Next, a related topic was addressed by the third question: How much risk are we willing and able to take when fostering SRL? And finally, the importance of and possibilities to assess SRL were discussed by the fourth question (Should SRL be assessed?). Implications: From our contemplations it has become clear that approaches to foster SRL are often insufficiently aligned with the experience and needs of learners. Instead these approaches are commonly defined by contextual factors, such as misconceptions about SRL and lack of leeway for learners. Consequently, we have used principles that apply to both treasure hunts and droppings, to provide guidelines on how to align one's approach to foster SRL with the educational context and experience and needs of learners.

Designing the learning of intraprofessional collaboration among medical residents.

BACKGROUND: To preserve quality and continuity of care, collaboration between primary-care and secondary-care physicians is becoming increasingly important. Therefore, learning intraprofessional collaboration (intraPC) requires explicit attention during postgraduate training. Hospital placements provide opportunities for intraPC learning, but these opportunities require interventions to support and enhance such learning. Design-Principles guide the design and development of educational activities when theory-driven Design-Principles are tailored into context-sensitive Design-Principles. The aim of this study was to develop and substantiate a set of theory-driven and context-sensitive Design-Principles for intraPC learning during hospital placements. METHODS: Based on our earlier research, we formulated nine theory-driven Design-Principles. To enrich, refine and consolidate these principles, three focus group sessions with stakeholders were conducted using a Modified Nominal Group Technique. Next, two work conferences were conducted to test the feasibility and applicability of the Design-Principles for developing intraPC educational activities and to sharpen the principles into a final set of Design-Principles. RESULTS: The theoretical Design-Principles were discussed and modified iteratively. Two new Design-Principles were added during focus group 1, and one more Design-Principle was added during focus group 2. The Design-Principles were categorised into three clusters: (i) Culture: building collaborative relations in a psychologically safe context where patterns or feelings of power dynamics between primary and secondary care physicians can be discussed; (ii) Connecting Contexts: making residents and supervisors mutually understand each other's work contexts and activities; and (iii) Making the Implicit Explicit: having supervising teams act as role models demonstrating intraPC and continuously pursuing improvement in intraPC to make intraPC explicit. Participants were unanimous in their view that the Design-Principles in the Culture cluster were prerequisites to facilitate intraPC learning. CONCLUSION: This study led to the development of 12 theory-driven and context-sensitive Design-Principles that may guide the design of educational activities to support intraPC learning during hospital placements.

Impact of switching to new spirometric reference equations on severity staging of airflow obstruction in COPD: a crosssectional observational study in primary care.

BACKGROUND: Severity of airflow obstruction in chronic obstructive pulmonary disease (COPD) is based on forced expiratory volume in one second expressed as percentage predicted (FEV1%predicted) derived from reference equations for spirometry results. AIMS: To establish how switching to new spirometric reference equations would affect severity staging of airflow obstruction in the Dutch primary care COPD patient population. METHODS: Spirometry tests of 3,370 adults aged >40 years with obstruction (postbronchodilator FEV1/forced vital capacity (FVC) <0.70) were analysed. The presence and severity of obstruction were defined using Global Initiative for Chronic Obstructive Lung Disease (GOLD) criteria. Postbronchodilator FEV1%predicted was calculated using three reference equations: corrected European Community of Steel and Coal (ECSC) (currently recommended in Dutch primary care), Swanney et al., and Global Lung Initiative (GLI). Discordances between severity classifications based on these equations were analysed. RESULTS: We studied 1,297 (38.5%) females and 2,073 males. Application of contemporary reference equations (i.e. Swanney and GLI) changed the GOLD severity stages obtained with the ECSC equations, mostly into milder stages. Severity of airflow obstruction was staged differently in 14.0% and 6.3%, respectively, when the Swanney et al. and GLI reference equations were applied. CONCLUSIONS: Compared with the (corrected) ECSC equations, switching to more contemporary reference equations would result in lower FEV1 predicted values and affect interpretation of spirometry by reclassifying 6-14% of primary care COPD patients into different (mostly milder) severity stages. If and how this will affect GPs' treatment choices in individual patients with COPD requires further investigation.

How does portfolio use support self-regulated learning during general practitioner specialty training? A qualitative focus group study.

OBJECTIVES: Portfolios are used to support self-regulated learning (SRL), but the research literature is still inconclusive on their effectiveness. This study explored experiences with portfolio use among different stakeholders, to answer the research question: How does portfolio use support SRL during general practitioner (GP) specialty training? DESIGN: We used a qualitative research design, based on phenomenology. SETTING: Three of the eight training institutes of Dutch GP specialty training participated in this study. PARTICIPANTS: The three stakeholder groups that use the portfolio were included in nine homogenous focus groups: trainees (n=16), supervisors (n=16) and faculty (n=17). All participants had at least 6-month experience with portfolio use. RESULTS: Three themes were identified: SRL with(out) the portfolio, stakeholder dynamics and ambiguities. Respondents were doubtful about the learning benefits of portfolio use, as most trainees used their portfolio to 'check off' what was considered required. Stakeholder dynamics contributed to checking off behaviour in two ways. First, trainees experienced documenting learning activities to be superfluous, since the close relationship with their supervisor already supported SRL sufficiently. Second, faculty often (unintentionally) took portfolio ownership away from trainees, as they instructed trainees to deliver portfolio content that was valuable for assessment. Without ownership, trainees struggled to use the portfolio for SRL. Besides, ambiguities related to portfolio use amplified checking off behaviour. CONCLUSIONS: Portfolio use did not support SRL in our setting. The multipurpose use of the portfolio (for the support of SRL and assessment) was identified as the primary obstacle. Underlying is a conflict that is often present in current medical curricula: agency versus accountability. If the support of SRL is considered a valuable and attainable purpose of portfolio use, it is important to realise that deliberate attention for this purpose is required during the design, guidance, assessment and evaluation of the portfolio.

Lung function decline in relation to diagnostic criteria for airflow obstruction in respiratory symptomatic subjects.

BACKGROUND: Current COPD guidelines advocate a fixed < 0.70 FEV1/FVC cutpoint to define airflow obstruction. We compared rate of lung function decline in respiratory symptomatic 40+ subjects who were 'obstructive' or 'non-obstructive' according to the fixed and/or age and gender specific lower limit of normal (LLN) FEV1/FVC cutpoints. METHODS: We studied 3,324 respiratory symptomatic subjects referred to primary care diagnostic centres for spirometry. The cohort was subdivided into four categories based on presence or absence of obstruction according to the fixed and LLN FEV1/FVC cutpoints. Postbronchodilator FEV1 decline served as primary outcome to compare subjects between the respective categories. RESULTS: 918 subjects were obstructive according to the fixed FEV1/FVC cutpoint; 389 (42%) of them were non-obstructive according to the LLN cutpoint. In smokers, postbronchodilator FEV1 decline was 21 (SE 3) ml/year in those non-obstructive according to both cutpoints, 21 (7) ml/year in those obstructive according to the fixed but not according to the LLN cutpoint, and 50 (5) ml/year in those obstructive according to both cutpoints (p = 0.004). CONCLUSION: This study showed that respiratory symptomatic 40+ smokers and non-smokers who show FEV1/FVC values below the fixed 0.70 cutpoint but above their age/gender specific LLN value did not show accelerated FEV1 decline, in contrast with those showing FEV1/FVC values below their LLN cutpoint.

PELICAN: A quality of life instrument for childhood asthma: study protocol of two randomized controlled trials in primary and specialized care in the Netherlands.

BACKGROUND: Asthma is one of the major chronic health problems in children in the Netherlands. The Pelican is a paediatric asthma-related quality of life instrument for children with asthma from 6-11 years old, which is suitable for clinical practice in primary and specialized care. Based on this instrument, we developed a self-management treatment to improve asthma-related quality of life. The Pelican intervention will be investigated in different health care settings. Results of intervention studies are often extrapolated to other health care settings than originally investigated. Because of differences in organization, disease severity, patient characteristics and care provision between health care settings, extrapolating research results could lead to unnecessary health costs without the desired health care achievements. Therefore, interventions have to be investigated in different health care settings when possible. This study is an example of an intervention study in different health care settings. In this article, we will present the study protocol of the Pelican study in primary and specialized care. METHOD/DESIGN: This study consists of two randomized controlled trials to assess the effectiveness of the Pelican intervention in primary and specialized care. The trial in primary care is a multilevel design with 170 children with asthma in 16 general practices. All children in one general practices are allocated to the same treatment group. The trial in specialized care is a multicentre trial with 100 children with asthma. Children in one outpatient clinic are randomly allocated to the intervention or usual care group. In both trials, children will visit the care provider four times during a follow-up of nine months. This study is registered and ethically approved. DISCUSSION: This article describes the study protocol of the Pelican study in different health care settings. If the Pelican intervention proves to be effective and efficient, implementation in primary and specialized care for paediatric asthma in the Netherlands will be recommended. TRIAL REGISTRATION: This study is registered by clinicaltrial.gov (NCT01109745).

How does portfolio use affect self-regulated learning in clinical workplace learning: What works, for whom, and in what contexts?

INTRODUCTION: Portfolio use to support self-regulated learning (SRL) during clinical workplace learning is widespread, but much is still unknown regarding its effectiveness. This review aimed to gain insight in the extent to which portfolio use supports SRL and under what circumstances. METHODS: A realist review was conducted in two phases. First, stakeholder interviews and a scoping search were used to formulate a program theory that explains how portfolio use could support SRL. Second, an in-depth literature search was conducted. The included papers were coded to extract context-mechanism-outcome configurations (CMOs). These were synthesized to answer the research question. RESULTS: Sixteen papers were included (four fulfilled all qualitative rigor criteria). Two primary portfolio mechanisms were established: documenting as a moment of contemplation (learners analyze experiences while writing portfolio reports) and documentation as a reminder of past events (previous portfolio reports aid recall). These mechanisms may explain the positive relationship between portfolio use and self-assessment, reflection, and feedback. However, other SRL outcomes were only supported to a limited extent: formulation of learning objectives and plans, and monitoring. The partial support of the program theory can be explained by interference of contextual factors (e.g., system of assessment) and portfolio-related mechanisms (e.g., mentoring). DISCUSSION: Portfolio research is falling short both theoretically-in defining and conceptualizing SRL-and methodologically. Nevertheless, this review indicates that portfolio use has potential to support SRL. However, the working mechanisms of portfolio use are easily disrupted. These disruptions seem to relate to tensions between different portfolio purposes, which may undermine learners' motivation.

Spirometry expert support in family practice: a cluster-randomised trial.

AIM: To assess the impact of two modes of spirometry expert support on Family physicians' (FPs') diagnoses and planned management in patients with apparent respiratory disease. METHOD: A cluster-randomised trial was performed with family practices as the unit of randomisation. FPs from 44 family practices recorded their diagnosis and planned management before and after spirometry for 868 patients. Intervention consisted of spirometry interpretation support by either a chest physician or expert software. Both interventions were compared with usual care (i.e. no additional interpretation support). Change in FPs' diagnoses after spirometry served as the primary outcome. Secondary outcomes were referral rate, additional diagnostic tests, and disease management changes. Effects were expressed as percentages and Odds Ratios (OR) with 95% confidence intervals. RESULTS: Diagnoses changed after intervention in all groups: 47.8% (95% CI 41.8 to 53.9) for chest physician support; 45.0% (95% CI 39.5 to 50.6) for software support; and 53.3% (95% CI 47.2 to 59.4) for usual care. Differences in the proportions of changed diagnosis were not statistically significant: chest physician support versus usual care OR 0.79 (95%CI 0.49 to 1.30); software support versus usual care OR 0.72 (95% CI 0.45 - 1.15). There were no differences in secondary outcomes. CONCLUSION: Neither chest physician spirometry support nor expert software spirometry support had a significant impact on FPs' diagnosis of respiratory conditions or management decisions. TRIAL NUMBER: http://www.clinicaltrials.gov/ct/show/NCT00131157?order=1.

Influence of house dust mite impermeable covers on health-related quality of life of adult patients with asthma: results of a randomized clinical trial.

The aim of this study was to evaluate the effect of house dust mite impermeable covers on asthma-specific health-related quality of life in adult asthmatic patients that were trained in guided self-management. In a 2-year randomized placebo-controlled clinical trial, information on the quality of life was collected. The improvement of Mini Asthma Quality of Life Questionnaire (AQLQ) score in the allergens-avoidance group (0.26) was comparable to the improvement in the placebo group (0.30) and not significant. HDM-impermeable covers for pillows, duvets, and mattresses did not result in improved health-related quality of life.

House dust mite allergen avoidance and self-management in allergic patients with asthma: randomised controlled trial.

BACKGROUND: The efficacy of bed covers that are impermeable to house dust mites has been disputed. AIM: The aim of the present study was to investigate whether the combination of 'house dust mite impermeable' covers and a self-management plan, based on peak flow values and symptoms, leads to reduced use of inhaled corticosteroids (ICS) than self-management alone. DESIGN OF STUDY: Prospective, randomised, double blind, placebo-controlled trial. SETTING: Primary care in a south-eastern region of the Netherlands. METHOD: Asthma patients aged between 16 and 60 years with a house dust mite allergy requiring ICS were randomised to intervention and placebo groups. They were trained to use a self-management plan based on peak flow and symptoms. After a 3-month training period, the intervention commenced using house dust mite impermeable and placebo bed covers. The follow-up period was 2 years. Primary outcome was the use of ICS; secondary outcomes were peak expiratory flow parameters, asthma control, and symptoms. RESULTS: One hundred and twenty-six patients started the intervention with house dust mite impermeable or placebo bed covers. After 1 and 2 years, significant differences in allergen exposure were found between the intervention and control groups (P<0.001). No significant difference between the intervention and control groups was found in the dose of ICS (P = 0.08), morning peak flow (P = 0.52), peak flow variability (P = 0.36), dyspnoea (P = 0.46), wheezing (P = 0.77), or coughing (P = 0.41). There was no difference in asthma control between the intervention and control groups. CONCLUSION: House dust mite impermeable bed covers combined with self-management do not lead to reduced use of ICS compared with self-management alone.

Should the diagnosis of COPD be based on a single spirometry test?

Clinical guidelines indicate that a chronic obstructive pulmonary disease (COPD) diagnosis is made from a single spirometry test. However, long-term stability of diagnosis based on forced expiratory volume in 1 s over forced vital capacity (FEV1/FVC) ratio has not been reported. In primary care subjects at risk for COPD, we investigated shifts in diagnostic category (obstructed/non-obstructed). The data were from symptomatic 40+ years (ex-)smokers referred for diagnostic spirometry, with three spirometry tests, each 12±2 months apart. The obstruction was based on post-bronchodilator FEV1/FVC < lower limit of normal (LLN) and <0.70 (fixed ratio). A total of 2,352 subjects (54% male, post-bronchodilator FEV1 76.5% predicted) were studied. By LLN definition, 32.2% were obstructed at baseline, but 32.2% of them were no longer obstructed at years 1 and/or 2. By fixed ratio, these figures were 46.6 and 23.8%, respectively. Overall, 14.3% of subjects changed diagnostic category by 1 year and 15.4% by 2 years when applying the LLN cut-off, and 15.1 and 14.6% by fixed ratio. Change from obstructed to non-obstructed was more likely for patients with higher body mass index (BMI) and baseline short-acting bronchodilator (SABA) users, and less likely for older subjects, those with lower FEV1% predicted, baseline inhaled steroid users, and current smokers or SABA users at year 1. Change from non-obstructed to obstructed was more likely for males, older subjects, current smokers and patients with lower baseline FEV1% predicted, and less likely for those with higher baseline BMI. Up to one-third of symptomatic (ex-)smokers with baseline obstruction on diagnostic spirometry had shifted to non-obstructed when routinely re-tested after 1 or 2 years. Given the implications for patients and health systems of a diagnosis of COPD, it should not be based on a single spirometry test.

Asthma education tailored to individual patient needs can optimise partnerships in asthma self-management.

This paper studies the effects of patient education, tailored to individual needs of patients as part of an asthma self-management program. A tailored education program was designed which took into account individual information needs of patients by using a feedback instrument. Totally 98 steroid dependent asthmatics entered the tailored education program, 95 patients received usual care. Outcome measures were information exchanged and patient satisfaction. Study duration was 6 months. Patients in the tailored education group showed a significant reduction in information need (P=0.005). Patient satisfaction increased from 87.9 to 93.7 in this group while this did not change in the usual care group (P=0.000). Use of this tailored education program improved the GP-patient interaction within the context of a clinically effective asthma self-management program. Findings from this study may be applicable to other chronic conditions as well.

Implementation strategies of internet-based asthma self-management support in usual care. Study protocol for the IMPASSE cluster randomized trial.

BACKGROUND: Internet-based self-management (IBSM) support cost-effectively improves asthma control, asthma related quality of life, number of symptom-free days, and lung function in patients with mild to moderate persistent asthma. The current challenge is to implement IBSM in clinical practice. METHODS/DESIGN: This study is a three-arm cluster randomized trial with a cluster pre-randomisation design and 12 months follow-up per practice comparing the following three IBSM implementation strategies: minimum strategy (MS): dissemination of the IBSM program; intermediate strategy (IS): MS + start-up support for professionals (i.e., support in selection of the appropriate population and training of professionals); and extended strategy (ES): IS + additional training and ongoing support for professionals. Because the implementation strategies (interventions) are primarily targeted at general practices, randomisation will occur at practice level.In this study, we aim to evaluate 14 primary care practices per strategy in the Leiden-The Hague region, involving 140 patients per arm. Patients aged 18 to 50 years, with a physician diagnosis of asthma, prescription of inhaled corticosteroids, and/or montelukast for ≥3 months in the previous year are eligible to participate. Primary outcome measures are the proportion of referred patients that participate in IBSM, and the proportion of patients that have clinically relevant improvement in the asthma-related quality of life. The secondary effect measures are clinical outcomes (asthma control, lung function, usage of airway treatment, and presence of exacerbations); self-management related outcomes (health education impact, medication adherence, and illness perceptions); and patient utilities. Process measures are the proportion of practices that participate in IBSM and adherence of professionals to implementation strategies. Cost-effective measurements are medical costs and healthcare consumption. Follow-up is six months per patient. DISCUSSION: This study provides insight in the amount of support that is required by general practices for cost-effective implementation of IBSM. Additionally, design and results can be beneficial for implementation of other self-management initiatives in clinical practice. TRIAL REGISTRATION: the Netherlands National Trial Register NTR2970.

Relationship between house dust mite (HDM) allergen exposure level and inhaled corticosteroid dosage in HDM-sensitive asthma patients on a self management program.

AIM: To assess whether exposure to house dust mite (HDM) allergens hampers a tapering off of inhaled corticosteroid (ICS) dosage in HDM-sensitive asthma patients. METHODS: Asthma patients sensitised to HDM allergens and using ICS were selected from general practices for this observational study. Dust samples from bed mattresses were taken to assess exposure ('no', 'low', 'intermediate' or 'high') to HDM allergens with a semi-quantitative test (Acarex). Patients were trained to use a self management plan to adjust the dose of ICS according to symptoms and peak flow. The observation period was three months. RESULTS: Outcomes from 123 patients were analysed. Within the 'no' and 'low' HDM exposure groups the proportion of patients who increased the dosage of their ICS medication was significantly lower than the proportion who tapered off or remained on the same dose of ICS. The group with high exposure to HDM allergens had the highest proportion of patients who increased their dose of ICS (p = 0.055). CONCLUSIONS: High exposure to HDM allergens seems to coincide with the use of higher dose ICS treatment in asthma patients sensitised to HDM allergens.

Willingness of patients to perform self-management of asthma and the role of inhaled steroids.

OBJECTIVE: Asthma self-management is a generally accepted effective treatment strategy for asthma patients. Acceptance by patients may be a barrier for successful implementation. In this study, the role of inhaled steroids in starting asthma self-management is described. DESIGN: Cross-sectional explorative study. SETTING: General practice. SUBJECTS: 283 adult steroid-requiring asthma patients were invited by their GP to participate in a self-management programme. MAIN OUTCOME MEASURES: In a multivariate logistic regression model, the relation between baseline dosage of inhaled steroids, occupational status, age and sex as independent variables and willingness to participate as dependent variables was explored. RESULTS: Of all invited, 148 (52%) were willing to participate. Subjects not using inhaled steroids were least willing to participate (43/143 = 30%). Subjects with low doses of inhaled steroids ( < 400 mcg daily) were most willing to participate (44/54 = 81%). Unemployed asthmatics had a higher tendency to participate than patients with a regular job. CONCLUSION: Acceptance of self-management by patients is not a limiting issue in promoting self-management of asthma in general practice. High acceptance in patients taking low or intermediate doses of inhaled steroids makes general practice the most appropriate setting for self-management. A selection procedure is recommended.

Randomized controlled economic evaluation of asthma self-management in primary health care.

In this randomized controlled economic evaluation we compared guided asthma self-management with usual asthma care according to guidelines for Dutch family physicians. Nineteen family practices were randomized, and 193 adults with stable asthma (98 self-management, 95 usual care) were included and monitored for 2 years. We hypothesized that introducing self-management would not compromise asthma control and cost would be equal to or lower than in usual care. Patient-specific cost data were collected, preference-based utilities were assessed, and incremental cost per quality-adjusted life year (QALY) and successfully treated week gained was calculated. Self-management patients gained 0.039 QALY (95% confidence interval [CI], 0.003 to 0.075) and experienced 81 (95% CI, 78 to 84) successfully treated weeks in 2 years' time; the corresponding figures for usual care were 0.024 (95% CI, -0.022 to 0.071) and 75 (95% CI, 72 to 78). Total costs were 1,084 euros(95% CI, 938 to 1,228) for self-management and 1,097 euros (95% CI, 933 to 1,260) for usual care. Self-management patients consumed 1,680 (95% CI, 1,538 to 1,822) puffs of budesonide, usual care patients 1,897 (95% CI, 1,679 to 2,115). Mean productivity cost due to limited activity days was 213 euros lower among self-management patients. When all costs were included, self-management was cost-effective on all outcomes. The probability that self-management was cost-effective relative to usual care in terms of QALYs was 52%. We conclude that guided self-management is a safe and efficient alternative approach compared with asthma treatment usually provided in Dutch primary care.