Research Article: Impact of online patient reminders to improve asthma care: A randomized controlled trial

Date Published: February 3, 2017

Publisher: Public Library of Science

Author(s): Andrew C. Pool, Jennifer L. Kraschnewski, Jennifer M. Poger, Joshua Smyth, Heather L. Stuckey, Timothy J. Craig, Erik B. Lehman, Chengwu Yang, Christopher N. Sciamanna, Iratxe Puebla.


Asthma is one of the most burdensome chronic illnesses in the US. Despite widespread dissemination of evidence-based guidelines, more than half of the adults with asthma have uncontrolled symptoms.

To examine the efficacy of an online tool designed to improve asthma control.

12-month single blind randomized controlled trial of the online tool (Intervention condition, IC) versus an active control tool (CC).

Patients enrolled in an insurance plan.

Participants were 408 adults (21–60 years of age) with persistent asthma.

At least once each month and before provider visits, participants in the IC answered questions online about their asthma symptoms, asthma medications and asthma care received from providers, such as an asthma management plan. The tool then provided tailored feedback to remind patients 1) to ask health care providers specific questions that may improve asthma control (e.g., additional controller medications) and 2) to consistently perform specific self-care behaviors (e.g., proper inhaler technique). Participants in the CC received similar questions and feedback, yet focused instead on preventive services unrelated to asthma control (e.g., cancer screening).

The main outcome measure was asthma control, as assessed by the 5-question Asthma Control Test (ACT). Secondary outcomes included quality of life, medication use and healthcare utilization (e.g., emergency department visits).

After 12 months, 323 participants completed follow-up measures (79.2%). Participants in the IC reported a greater mean improvement in the ACT score than participants in the CC (2.3 vs. 1.2; p = 0.02) and 9 of 11 individual asthma control survey items showed non-significant improvements favoring the IC. No differences were observed in medication adherence, number of asthma controller medications or health care utilization.

Simple and brief online patient reminders improved asthma control among insured patients. Although future studies are needed to understand the mechanism of the improvement, the magnitude of the effect on asthma control was similar to the addition of an additional controller medication. Given the widespread use of the Internet, simple tools such as this may be useful for improving the control of other chronic diseases as well.

This study is registered at, NCT00921401, “Improving the Quality of Asthma Care Using the Internet”

Partial Text

Asthma is one of the most burdensome chronic illnesses, affecting approximately 25 million people in the US and accounting for nearly 500,000 hospitalizations, 1.9 million emergency department visits and direct medical costs of $18 billion annually [1–3]. Despite widespread dissemination of evidence-based guidelines and effective treatment that have existed for decades, most patients with asthma still have uncontrolled symptoms [4–6]. According to the National Asthma Education and Prevention Program (NAEPP) guidelines, poor asthma control is defined as having daytime symptoms or requiring a short-acting inhaler more than twice weekly, awakening from sleep due to asthma symptoms, or having to reduce activities due to asthma [7]. In a random sample of adults with health insurance, 51.7% had uncontrolled asthma based on an Asthma Control Test (ACT) score of <20 [4]. Similar observations of poor asthma control have been reported in asthma management program evaluations [5,6]. Interventions aimed at improving self-management of asthma control are crucial to reducing the adverse physical and economic impacts associated with this disease. In this randomized controlled trial, we tested the impact of using online patient reminders designed to help patients with persistent asthma ask specific questions during office visits and modify their self-care, in order to improve their asthma control. Each reminder was based on a specific recommendation in the 2007 NAEPP Guidelines [7]. Despite the brevity and simplicity of the intervention (~10 minutes monthly + minimal interactivity), participants randomized to the IC significantly improved their asthma control versus participants in the CC. Intervention participants increased their asthma control, as measured by the Asthma Control Test (ACT) by 1.1 [+2.3, 95% CI (1.6, 2.9) v. +1.2 (0.6, 1.8)] versus controls and had non-significant improvements in 9 of 11 individual asthma control survey items. The magnitude of the effect of using the online tool is similar to that of adding an additional controller medication [43]. We did not, however, observe differences in asthma utilization, such as emergency department (ED) visits or outpatient visits, though the rates of ED utilization (2.3% in the IC and 1.2% in the CC) were low at baseline. A simple and brief online intervention improved asthma control, as measured by the Asthma Control Test, among insured patients in Pennsylvania. Although future studies are needed to understand the mechanism of the improvement, the magnitude of the effect was similar to the addition of an additional controller medication [43]. Given that half of US adults have a chronic illness [52] and that chronic illnesses account for 75% of health care costs [2], it is critical to identify simple tools to help patients in their care and improve outcomes. Online tools have the potential to be used in other conditions, are relatively cost-effective to disseminate and, as observed in this study, may have a significant impact on improving chronic disease management and the public’s health.   Source:


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