Asthma is a common chronic inflammatory disease of the airways, typically characterized by symptoms such as wheeze, shortness of breath, and coughing. Despite the wide availability of effective therapy, long-term management of asthma falls for short of the goals set in guidelines, and many patients do experience a profound burden of disease.
Self-management is an essential component in the proactive management of asthma[1, 4] because it helps patients to reach their treatment goals and enables patients to manage symptoms, treatment, physical and psychosocial consequences, and lifestyle changes inherent in living with a chronic condition. However, the uptake of self-management in clinical practice may be hampered because easy-use tools that enhance sustained uptake of action plan usage by patients are lacking in today’s practice, and patients can experience a lack of ownership of these action plans. Not surprisingly, a minority of general practices provide patients with written action plans[8, 9].
Internet technology is increasingly being seen as an appealing tool for self-management for patients with chronic disease[10–12]. Telehealth care in asthma is defined as healthcare being delivered from a distance, facilitated electronically, and involving the exchange of information through the personalized interaction between a healthcare professional using their skills, judgment, and the patient providing information. Telehealth care may overcome barriers towards optimal care in patients with mild to moderate asthma. More specifically, internet technology can be employed for ongoing individualized management of the patient.
Internet-based self-management (IBSM) support in asthma consists of the following components: internet-based asthma monitoring, internet-based goal setting, decision support with a treatment plan, online medical review, tailored online information, and communication with a healthcare provider. Recently, we have shown that such IBSM can improve asthma-related quality of life, asthma control, the number of symptom-free days, and lung function in patients with mild to moderate persistent asthma, as compared to usual care. In a cost-utility analysis, it was demonstrated that IBSM support can be as effective as current asthma care with regard to quality of life in terms of patient utilities, and costs are similar over a one-year period.
Therefore, the current challenge is to implement IBSM support in routine asthma management within primary care. Patients that are most likely to be willing to participate and benefit from (internet-based) self-management are those with partially controlled or uncontrolled asthma[18–20]. These patients constitute about two-thirds of the asthma population in primary care.
A structured implementation strategy is needed to incorporate IBSM in current clinical practice and subsequently into a patient’s daily life. Implementation strategies for IBSM, consisting of several components (so-called ‘multi-faceted implementation strategy’) are suggested to be more effective in changing current clinical practices. In addition, tailoring the implementation strategy to barriers and facilitators experienced by the target group—patients with asthma, practice nurses (PNs), and general practitioners (GPs)—is recommended[22–24]. Such barriers can be identified at different levels of healthcare system: innovation, the individual patient (i.e., illness perceptions), professional level, societal context (opinion of colleagues), organisational context (organisation of care process), and economic and political contexts.
Prior to this project, we conducted focus groups and interviews with patients and professionals for exploring barriers and facilitators for usage of IBSM in primary care[26
]. These barriers were identified at patient and professional/organizational level. Main barriers at the patient level were unawareness of their level of asthma control and subsequent possibility for improvement, and patients often do not perceive asthma as a chronic condition and experience difficulties of integrating self-management activities into daily life. Main barriers at the professional level (PN, GP) and organizational level were unawareness of the level of asthma control of patients, lack of structure of asthma care, and lack of structure of routine asthma consultations within general practice and lack of time. Consequently, we developed three implementation strategies (the strategies will be described in more detail below):
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).
Extended strategy (ES): IS + additional training and ongoing support for professionals.
In summary, the MS strategy has not been tailored to previously identified barriers and corresponds with commonly used implementation strategies (i.e., dissemination of the innovation only). This is in contrast with the IS strategy, which specifically have been developed for addressing previous identified barriers. The ES strategy is the most extensive and time-intensive strategy. Currently, there are only sparse data on the effectiveness and cost-effectiveness of implementation strategies for IBSM in primary care. This information is particularly important for the time-intensive implementation interventions, such as selection of the appropriate population, professional training, and ongoing support for professionals in IBSM support.
To evaluate the impact of these three different implementation strategies for IBSM in current clinical practice, we have proposed four hypotheses, which are constructed to compare the effect of tailoring implementation strategies to identified barriers (IS and ES) versus a commonly used, non-tailored strategy (MS):
More general practices will participate in IBSM in the IS or ES strategy as compared with the MS strategy;
The proportion of referred patients who participate in the IBSM program in the ES or IS strategy will be greater as compared with the MS strategy;
The proportion of referred patients who participate in the IBSM program in the ES or IS strategy will be greater as compared to the MS strategy;
The ES and the IS strategy will be more cost-effective as compared to the MS strategy.
The objectives of this study are to investigate the effectiveness and cost-effectiveness of a MS strategy, as compared to an IS strategy and an ES strategy in a three-arm, cluster randomized trial. Because these different implementation strategies have a sequence of effects, the evaluation is aimed to assess to what extent: practices participate in IBSM; IBSM improves asthma related quality of life; patients participate in IBSM; and the various implementation strategies are cost-effective.