Discussion
After excluding those who had dropped out, it was found that 70.2% of eCARE patients and 75.8% of routine care patients achieved well-controlled asthma at 5 weeks. Logistic regression analysis showed that there is no statistical difference in the proportion of patients with poor-controlled asthma at baseline who attained well-controlled asthma at the 5-week follow-up between the intervention and control groups (p=0.744). A similar trend was found at the 3-month follow-up, with 71.6% of eCARE patients and 83.1% of routine care patients progressed from poor baseline control to well-controlled asthma. After adjustment using logistic regression, the results showed no statistical difference in the proportion of patients who attained well-controlled asthma in the eCARE group versus the routine care group. In other words, the vast majority of patients, with or without the combination of intervention methods, demonstrated well-controlled asthma at the 5 weeks and 3 months’ points.
It is well known that provision of information and empowerment of patients in any form of self-management programme typically leads to achievable asthma control.7 In this study, our programme consists of asthma counselling where all patients recruited in this study were thoroughly counselled by a trained asthma nurse on disease knowledge, correct inhaler technique and the necessity of inhaled corticosteroid treatment. For the eCARE group, they also received daily and weekly SMS reminders. Our results suggest that eCARE, which was thought to create a higher patient awareness of asthma symptoms, while also reminding patients to adhere to their medication, did not result in improvements in asthma control.
These findings were dissimilar from those of our initial study where greater improvement in ACT (to greater than 20 points) was seen in the intervention group compared with the control group, though the earlier result was not statistically significant.5 There could be several reasons for the ineffectiveness of eCARE. The first was that the eCARE monitoring in this study was shorter compared with the initial study, where the intervention group had 3 months of SMS monitoring.5 The frequency and length of monitoring was reduced to 5 weeks due to the feedback received from the first study, where some patients found the daily monitoring irritating and preferred weekly monitoring. Similar findings were reported by Strandbygaard et al.8
Another possible reason is the clinical profile of patients in the eCARE group compared with the routine group displayed poor asthma control and were generally younger and had shorter durations of asthma. These patients might have had poor perception and insight to their disease, and should therefore have been subjected to more intensive education, monitoring and medical therapy for better outcomes.9 Our findings reveal that there is a need to address the profiles of patients with poor asthma control at EDs.
Decline in patient compliance rate as time passed could also be a reason. Charles et al10 demonstrated a significant improvement in adherence to treatment with an audiovisual reminder device, but at the end of the 6-month study period no difference in clinical outcome between the groups was observed. In a yearlong study by Macedo et al,1 who collected monthly data on lower back pain, patient response rate was lower than that of the study by Kongsted et al,11 who collected weekly pain measures for the lower back over a 4-month period. The differences between these studies were the frequency and duration of the SMS. Arguably, it was possible that more frequent contact would increase response rates and better clinical outcomes but it is difficult to stipulate the period of monitoring for good clinical outcomes. Strandbygaard et al8 reported that the improvements in clinical outcome were commonly seen in the beginning of a clinical trial. For initial improvements to revert, it could take more than 6 months.
The most likely reason is the eCARE is effective only for patients who forget to take their medications since it is essentially a reminder system. Patients who are compliant with their medications or those who are non-compliant on purpose are unlikely to benefit from eCARE.
At 5 weeks, a total of 46 patients from the eCARE programme had dropped out, and the number of participants further decreased over the remaining period of the study. This result was different from that of Macedo et al,1 primarily due to the combination of systems in their study. Hence, SMS alone cannot be used as an alternative to traditional methods of outcome assessment. Macedo et al1 suggested the use of a hybrid system, such as the use of phone interviews for those who did not respond to the SMS, in order to achieve positive outcomes. This finding is an important factor when considering the use of SMS in longitudinal studies because compliance with the study protocol may become more difficult as time passes, as stated by Macedo et al.1
Approximately 95% of patients who remained under the eCARE programme were satisfied with the SMS service. This result was similar to our first study. Further studies should focus on methods to enhance monitoring according to patients’ requirements whereby a patient can adjust the monitoring duration according to their needs on their own. This can potentially increase effectiveness and lead to other positive clinical outcomes.
The proportion of patients with asthma-related ED visits or hospital admissions at 3 months were less than 13% for ED visits and less than 8% for hospital admissions, and were not statistically different between the intervention and control groups. This suggests that eCARE programme did not affect healthcare utilisation among patients. This is expected since eCARE did not affect asthma control.
Limitations
A major limitation is the difficulty in the recruitment of patients into the study. This study had a limited sample size; only 424 patients from two main institutions responded to our invitation to join over the period of 2 years of recruitment. We have observed that patients were reluctant to participate due to the research nature of this study. Caution should therefore be exercised when generalising the results.