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Whether Web-based technologies can improve disease self-management is uncertain. My Asthma Portal (MAP) is a Web-based self-management support system that couples evidence-based behavioral change components (self-monitoring of symptoms, physical activity, and medication adherence) with real-time monitoring, feedback, and support from a nurse case manager.
The aim of this study was to compare the impact of access to a Web-based asthma self-management patient portal linked to a case-management system (MAP) over 6 months compared with usual care on asthma control and quality of life.
A multicenter, parallel, 2-arm, pilot, randomized controlled trial was conducted with 100 adults with confirmed diagnosis of asthma from 2 specialty clinics. Asthma control was measured using an algorithm based on overuse of fast-acting bronchodilators and emergency department visits, and asthma-related quality of life was assessed using the Mini-Asthma Quality of Life Questionnaire (MAQLQ). Secondary mediating outcomes included asthma symptoms, depressive symptoms, self-efficacy, and beliefs about medication. Process evaluations were also included.
A total of 49 individuals were randomized to MAP and 51 to usual care. Compared with usual care, participants in the intervention group reported significantly higher asthma quality of life (mean change 0.61, 95% CI 0.03 to 1.19), and the change in asthma quality of life for the intervention group between baseline and 3 months (mean change 0.66, 95% CI 0.35 to 0.98) was not seen in the control group. No significant differences in asthma quality of life were found between the intervention and control groups at 6 (mean change 0.46, 95% CI –0.12 to 1.05) and 9 months (mean change 0.39, 95% CI –0.2 to 0.98). For poor control status, there was no significant effect of group, time, or group by time. For all self-reported measures, the intervention group had a significantly higher proportion of individuals, demonstrating a minimal clinically meaningful improvement compared with the usual care group.
This study supported the use of MAP to enhance asthma quality of life but not asthma control as measured by an administrative database. Implementation of MAP beyond 6 months with tailored protocols for monitoring symptoms and health behaviors as individuals’ knowledge and self-management skills improve may result in long-term gains in asthma control.
International Standard Randomized Controlled Trial Number (ISRCTN): 34326236; http://www.isrctn.com/ISRCTN34326236 (Archived by Webcite at http://www.webcitation.org/6mGxoI1R7).
The episodic nature of asthma symptoms and exacerbations makes effective self-management of the condition an imperative. Ongoing self-monitoring of asthma control coupled with an individualized written asthma action plan is required to allow patients to quickly identify and address poor disease control and mild exacerbations by increasing medication or contacting a physician [
Providing ongoing communication and self-management support is challenging given limited clinical resources and time [
A review that investigated the effectiveness of using computers to deliver patient self-management programs for chronic illness found that there was insufficient evidence to determine whether computer-enabled interventions were effective compared with no intervention or usual care [
More evidence is needed to determine whether Web-based self-management support systems are helpful in clinical practice and can lead to better outcomes. In addition, more information is needed about the proportion of patients who are willing and able to use a Web-based self-management tool and the functionalities that are most frequently accessed. The primary objective of this study was to compare the impact of access to a customized personal Web-based self-management asthma patient portal, My Asthma Portal (MAP), linked to a case-management system over 6 months compared with usual care on asthma control and asthma quality of life. We hypothesized that at 6 months, use of MAP would be associated with improved asthma control and asthma quality of life.
The McGill University Health Center ethics committee provided approval for this study. Research nurses provided patients with an information brochure, and patients were invited to speak to the research assistant for further information. The research assistant obtained informed patient consent. The detailed protocol is available elsewhere [
Participants were recruited from pulmonary clinics in 2 tertiary care hospitals located in Montreal, Canada. Participants were eligible if they were aged between 18 and 69 years, had a physician diagnosis of asthma, were prescribed at least one rescue medication, classified as having poor asthma control at the time of recruitment by their treating physician, had access to the Internet, reported smoking <20 pack-years, and were fluent in English or French. We excluded individuals with a diagnosis of chronic obstructive pulmonary disease or other serious medical diagnoses (eg, lung cancer), and those with severe mobility limitations. Potentially eligible participants were identified and approached by their pulmonologist or the nursing staff. The research assistant provided additional information about the study, responded to questions, and obtained written consent.
The study was a 6-month, multicenter, parallel, 2-arm, pilot, randomized controlled trial (ISRCTN34326236). Participants were randomly assigned to 1 of the 2 conditions: (1) MAP access or (2) usual care. Randomization occurred at the individual patient level in 2 participating pulmonary clinics. Treatment allocation was done by random permutation within blocks with block sizes of 4 and 6 using a computerized algorithm.
MAP was developed to support patient self-management and facilitate communication with the care team between visits using an iterative design process based on behavior change and self-efficacy theory [
Participants were given a MAP username and password, advised that they could access the site from anywhere (eg, home, work, library), and asked to login at least once per week for the 6 months of the study (access to MAP ended after this period). The log-in frequency was decided based on clinician feedback, the fact that symptoms are monitored over 1-week period, and patient feedback on what log-in frequency they believed was feasible as obtained during the development phase. Furthermore, based on a systematic review, the typical Web-based intervention is used once a week [
Within MAP, participants could (1) view their personal health information (eg, asthma medications, other health problems); (2) view general asthma information through links to specific educational websites (Learning Center) and receive information tailored to identified knowledge gaps (eg, current medications); and (3) monitor and receive feedback regarding current self-management practices.
Initial feedback was generated automatically from the MAP system using monitoring information entered by the participant and data from the provincial administrative database sent to MAP from the Medical Office for the twenty first century (MOXXI), an electronic health record with a prescription and computerized drug and disease management system. A summary of the logic for color-coding and recommendations offered has been previously summarized [
Participants communicated and received support as needed from a nurse case manager using MAP. The nurse case-management system was designed to (1) quickly identify patients that may require immediate care; (2) collate relevant medical and monitoring information for each participant; and (3) document case-management information, including interactions (phone and emails), along with advice and interventions provided by the case manager. Upon receiving this notice, the nurse followed up with the participant within 24 hours through the MAP mail system or by telephone. Additional alerts were sent to the nurse case manager when a new participant was enrolled and needed their prescribed action plan reviewed, the participant indicated lack of understanding of the action plan, or there was a change in medication use based on the self-reported adherence monitoring assessment.
The control group did not have access to MAP. All participants in the control and intervention groups continued to receive ongoing asthma care from their pulmonologist throughout the trial, and an asthma nurse provided education and follow-up sessions as needed. Topics (similar to those found in the static learning module of MAP) included the importance of avoiding triggers, taking all asthma medications as prescribed, and using the written action plan. The asthma nurse conducted follow-up phone calls between visits, when appropriate (ie, missed appointments, to clarify aspects of the action plan or prescribed asthma medications).
Automated audit trails (computer logs) were used to evaluate MAP usage rates. Use was defined as the frequency and intensity, mainly the number of times and minutes patients spent logged into the system. Patterns of usage included review of the days/week and amount of time that patients used the system. Features used included the number of times and topic of the messages sent to the nurse case manager.
We also evaluated acceptability and attitude of participants toward the Web portal. We used adapted versions of instruments associated with the technology acceptance model (TAM) to assess perceptions of usefulness and ease of use [
Asthma control at 6 months was evaluated by examining potential overuse (yes/no) of rescue fast-acting bronchodilators (FABA; ie, beta 2-agonists) based on units dispensed for prescriptions as recorded in the provincial drug database that covers drugs dispensed for individuals who are provincially insured, medical services provided, emergency department (ED) visits, and hospitalizations. Excessive use of FABA was chosen because it is associated with an increased risk of hospitalization and asthma mortality [
The Mini-Asthma Quality of Life Questionnaire (MAQLQ) evaluates symptoms, emotions, exposure to environmental stimuli, and activity limitations [
Demographic information such as sex, age, education, and socioeconomic status based on postal code were extracted from the baseline questionnaires. Participants reported on education level at baseline.
The Chronic Disease Self-Efficacy Scale [
The Asthma Control Test (ACT), a 5-point patient-administered survey for assessing asthma control, evaluates patient perceptions of asthma control [
Patient’s beliefs about their medicines were evaluated using the Beliefs about Medicines Questionnaire (BMQ) [
Patient Health Questionnaire (PHQ-9) is a tool based on the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, criteria for identifying depressive symptoms that has been validated and widely used in a number of patient populations, including older adults and patients with asthma [
Health status was evaluated with the EuroQol visual analogue scale (EQ-VAS). Patients were asked to rate their current health state on a 0 (worst imaginable health state) to 100 (best imaginable health state) scale [
Asthma-related ED visits or hospitalizations were extracted from the Quebec provincial insurance database using validated algorithms [
All outcomes were collected at 3 months (halfway) and 6 months (end) with follow-up 9 months later to evaluate persistent effects. Questionnaires were administered in the clinic at baseline and via mail thereafter.
The study was designed to have 80% power (alpha=.05) to detect a 10% difference in proportions of patients whose asthma was classified as out of control. This required a total sample size of 67 participants. To account for attrition and loss to follow-up, an additional 33 subjects were recruited (total 100; 50 per arm). This sample size also allowed us to detect a clinically meaningful difference of 0.5 (SD 0.61) on the MAQLQ scores [
Descriptive statistics, including means for continuous variables and proportions for categorical variables, were used to summarize participant characteristics. Analyses were conducted using an intention-to-treat analysis.
A generalized estimating equation model [
Secondary analyses were conducted to evaluate the mediating effects of depressive symptoms (PHQ), self-efficacy, beliefs about asthma medication (BMQ), and asthma control (ACT). In addition, the MAQLQ was added to the model with poorly controlled asthma as the outcome and asthma control status for the model with MAQLQ as the outcome.
Furthermore, the proportion of individuals in each group who achieved a minimal clinically important difference (MCID) between follow-up evaluations on self-report measures was also examined. The estimated MCID of the MAQLQ was 0.5 [
Of the total patients screened, 17.3% (100/577) met eligibility criteria, consented to participate, and were randomized. The remaining 83% did not meet the inclusion criteria (62.3%, 297/477), declined to participate (4.0%, 19/477), dropped out before randomization (6.1%, 29/477), or did not have sufficient information to approach for recruitment (27.7%, 132/477;
The distribution of characteristics between groups was similar; however, the proportion of individuals with a university degree and in the 0-39 age group was higher in the intervention group as compared with the control group (
Consort diagram of participants in the My Asthma Portal (MAP) trial.
Baseline characteristics of participants in the intervention and control groups.
Characteristic | Intervention (n=47) | Control (n=51) | ||
n (%) | n (%) | |||
Female | 32 (68) | 33 (65) | .72 | |
0-39 | 20 (43) | 14 (27) | .25 | |
40-49 | 10 (21) | 13 (25) | ||
50-59 | 12 (26) | 15 (29) | ||
>60 | 5 (11) | 9 (18) | ||
Never smoker | 26 (55) | 26 (51) | .91 | |
Current smoker | 5 (11) | 7 (14) | ||
Ex-smoker | 15 (32) | 16 (31) | ||
Missing | 1 (2) | 2 (4) | ||
>Higher school | 32 (68) | 26 (51) | .38 | |
High school equivalent | 13 (28) | 22 (43) | ||
<High school | 1 (2) | 1 (2) | ||
Missing | 1 (2) | 2 (4) | ||
Excellent or very good | 8 (17) | 14 (27) | .31 | |
Good | 24 (51) | 19 (37) | ||
Fair or poor | 15 (32) | 18 (35) | ||
None (0-4) | 22 (47) | 27 (53) | .52 | |
Mild (5-9) | 19 (40) | 13 (25) | ||
Moderate (10-14) | 2 (4) | 5 (10) | ||
Moderately severe or severe (15-19 or 20-7) | 4 (8) | 6 (12) | ||
Yes | 33 (70) | 41 (80) | .35 | |
No | 13 (28) | 10 (20) | ||
Missing | 1 (2) | 0 (0) | ||
1 | 7 (15) | 14 (27) | .25 | |
2 | 19 (40) | 17 (33) | ||
3 | 12 (26) | 6 (12) | ||
≥4 | 6 (13) | 10 (20) | ||
Missing | 3 (6) | 4 (8) | ||
No | 38 (81) | 36 (71) | .34 | |
Yes | 7 (15) | 9 (18) | ||
Missing | 2 (4) | 6 (12) | ||
0 | 37 (79) | 38 (75) | .32 | |
1 | 6 (13) | 3 (6) | ||
≥2 | 2 (4) | 4 (8) | ||
Missing | 2 (4) | 6 (12) | ||
0 | 43 (91) | 39 (76) | .48 | |
1 | 2 (4) | 6 (12) | ||
Missing | 2 (4) | 6 (12) | ||
0 | 44 (94) | 43 (84) | .42 | |
1 | 1 (2) | 1 (2) | ||
≥2 | 0 (0) | 1 (2) | ||
Missing | 2 (4) | 6 (12) |
aPHQ: Patient Health Questionnaire.
bFABA (fast-acting bronchodilators) overuse: if the sum of the quantity for all FABAs dispensed was >750+ mg doses of salbutamol 100 mcg, 2 inhalations at a time, or the equivalent for other FABAs over a 9-month period.
cED: emergency department.
Of the 100 individuals who were randomized, 16 were lost to follow-up at 3 months in the intervention group. Five individuals could no longer be reached, 1 reported having trouble with the pedometer and did not log in, 1 no longer had access to a computer, 1 reported that the study was time-consuming, and the remaining 8 individuals reported lack of time. In addition, one individual at 6 months and another at 9 months postrandomization could no longer be reached. Among these individuals, 5 did not log in to MAP at all, and the remainder logged in 1 to 36 times. Three individuals in the control group were lost to follow-up at 3 months postrandomization.
Access to MAP during the first 3 months ranged from 1 to 69 (mean 24, SD 16), and 0 to 38 between 3 and 6 months; among the 47 individuals who received the intervention, 16% had no logins between 3 and 6 months (
The most frequent reasons for initiating an email by the patient or the nurse was to discuss medications (30%), clarify the action plan (18%), monitor MAP feedback (15%), and conduct follow-ups related to control status (5%). About 61% of alerts to the nurse were related to medication adherence, 17% indicated a need to review the action plan, 11% were because the patient did not log in, and 7% were related to delayed initiation of the action plan by patients.
Usefulness ratings on the TAM were essentially unchanged at baseline and 6 months. A similar pattern was found for the response to the item “I intend to use My Asthma Web portal weekly to help manage my Asthma.”
Average number of logins by week over the 6-month study period.
Usage of My Asthma Portal (MAP) features over time.
When models were reanalyzed with imputed data, the difference in MAQLQ scores between baseline and 3 months for the intervention group was still statistically significant after adjustment for sex, age, asthma medications, education, and self-reported health (mean change 0.52, 95% CI 0.20 to 0.84). In addition, a trend of decreasing scores between the 6 and 9 months was found (mean change –0.35, 95% CI –0.66 to –0.04) for the intervention group. No other statistically significant differences were found between time periods or between groups for MAQLQ scores. There was no significant effect of group, time, or group by time adjusted for sex, age, asthma medications, education, and self-reported health found for poor control status.
The results for differences in MAQLQ scores over time and between groups were similar with adjustment for depression (PHQ), self-efficacy, beliefs about asthma medication (BMQ), self-reported asthma control (ACT), and poor control status at baseline. In addition, depression (PHQ) (mean change –0.27, 95% CI –0.37 to –0.18 for a change of 5 units), self-efficacy (mean change 0.24, 95% CI 0.16 to 0.32), and self-reported asthma control symptoms (ACT) (mean change –0.25, 95% CI –0.30 to –0.20) were all significantly associated with asthma quality of life (MAQLQ). No significant effect of group, time, or group by time or for the explanatory variables was found for poor control status.
Minimal clinically important difference at 6 months on the patient reported outcomes. MAQLQ: Mini-Asthma Quality of Life Questionnaire; ACT: Asthma Control Test; EQ-VAS: EuroQol visual analogue scale; PHQ: Patient Health Questionnaire.
Our study found significant improvements in asthma quality of life over the initial 3 months among individuals using a Web-based asthma self-management intervention compared with those in the control group. There was also a higher proportion of individuals who had an improvement in depression, self-efficacy, and self-reported asthma control over time in the intervention group compared with the control group, suggesting that these were important mediating effects of the MAP intervention on improving asthma quality of life. However, there was no significant effect of the intervention on asthma control over time or for differences between groups in asthma control and asthma-related quality of life.
The proportion of poor control status seemed to worsen slightly in the intervention group and to improve in the usual care group during the study. This was not surprising, as the control group might also benefit from being included in a study. This suggested, however, that when patients reduced their interaction with MAP it might not be because they had learned how to self-manage their condition. Other potential reasons might be a loss of interest in the system, or feeling overwhelmed and unable to log in when symptoms worsened. Identifying mechanisms to keep individuals engaged and motivated to use systems such as MAP, which are relatively simple to integrate into daily activities, is important. Strategies found to be effective to increase the use of Web-based systems include primary task support that includes delivering the intervention in a stepwise approach as individuals’ knowledge and behavioral changes progress and matching content and features of the intervention to the individuals’ needs and health [
Ongoing access by participants using MAP supports the feasibility of using the system to deliver self-management for individuals who accept to start using the system. Also, the fact that logins decreased over time may reflect that once individuals learned about their medications and action plan they found less benefits of logging in to report symptoms and receive feedback that they became more familiar with over time. This reflects the importance of tailoring content and features of Web-based interventions over time to changes in individuals’ knowledge, confidence, and symptoms as supported by previous reviews of self-management technology-based interventions [
Similar to our findings, a recent review of systematic reviews [
Furthermore, a consistent finding across systematic reviews of technology-enabled self-management is that interventions with multiple behavioral change techniques appear, on the whole, to be more effective than those using fewer techniques [
Linking the mechanisms by which self-management interventions are expected to have an effect is important to guide the selection of functionalities that should be included in technology-based interventions. The features and decision support tools in MAP are based on the principles of self-management skill development [
One of the limitations of this trial was that we did not evaluate adherence to asthma treatment. This limited our ability to evaluate the impact of MAP on adherence as an intermediate effect to improve asthma control. Also, the number of participants lost to follow-up and missing data resulted in a relatively small, but sufficient, sample size. Comparison of baseline characteristics and imputation to evaluate the impact of missing data provided insight into the characteristics of individuals who dropped out, and the implications for feasibility and the need to tailor the intervention. Previous reviews of computer-based asthma interventions reported attrition rates of up to 23% [
Another consideration is that care in specialty clinics was more intensive in terms of providing patients with case management and self-management support compared with primary care, which likely contributed to making it more challenging to find an effect. We would expect a larger difference in outcome between the Web-based tool and usual care in a primary care setting. Also, given the relatively small sample for this trial, about half had disease for >10 years and therefore had a greater opportunity to learn and improve asthma self-management behaviors prior to starting the trial. MAP may have greater impact among individuals in relatively earlier phases post-asthma diagnosis when learning self-management skills is new for them. This represents another promising avenue for future research.
Furthermore, the material and recommendations presented to participants in response to monitoring information were static for the entire 6-month period. Adapting the monitoring protocol and material and recommendations based on individuals’ progression and time using the system may enhance usage and impact on outcomes.
Finally, from the time the trial was registered there were changes made to the design prior to the start of the trial, including expanding the inclusion for age from ≤60 to ≤69 and removing the criteria for full healthcare coverage and the need for the primary care physician to be using the asthma decision support.
There is growing interest in the potential of the Web-based and other digital media as a platform to deliver more tailored self-management support, while maintaining cost-effectiveness, with greater scope for integration into the everyday lives of those with asthma. The MAP intervention had a significant impact on improving asthma-related quality of life and other related outcomes including self-efficacy, depressive symptoms, and beliefs about medication. Furthermore, the effects of MAP were maintained at 6 months and began to decrease once the use of MAP ended between 6 and 9 months, suggesting that ongoing support might result in reduced exacerbations in the long term as opposed to usual care alone. Technology renders self-management support between clinical visits feasible. Future work is needed to identify tailored protocols for monitoring symptoms and health behaviors as individuals learn how to self-manage, and to assess the impact of MAP on asthma control and health-related quality of life beyond 6 months. Based on these results, a larger-cluster randomized trial will be designed with an updated version of MAP that will allow us to evaluate the long-term impact of tailored self-management, adjusting for multiple covariates over time.
My Asthma Portal (MAP) monitoring business rules.
Changes in asthma quality of life and asthma control status over time.
Asthma Control Test
emergency department
EuroQol visual analogue scale
My Asthma Portal
Mini-Asthma Quality of Life Questionnaire
Patient Health Questionnaire
This study was supported by a Canadian Institutes of Health Research operating grant (CIHR 89859, 217090, 204847), a Career Award for SA from the Fond de Recherche en Santé du Quebec (FRQS #13870), and a Canadian Foundation of Innovation Medical Informatics Infrastructure Grant (15649). The authors wish to acknowledge Pascale Rioux, Danielle Beaucage, and Dr Ron Olvenstein for their helpful input in the implementation of MAP and study recruitment.
None declared.