Standard versus patient-centred asthma education in the emergency department: a randomised study

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1 Eur Respir J 2008; 31: DOI: / CopyrightßERS Jourals Ltd 2008 Stadard versus patiet-cetred asthma educatio i the emergecy departmet: a radomised study S. Smith*, C. Mitchell #," ad S. Bowler + ABSTRACT: High re-attedace rates are commo after asthma emergecy departmet (ED) care. Iadequate patiet educatio has bee cited as a potetial cause of re-attedace ad the optimal format of educatio is ucertai. The preset study aimed to compare the effectiveess of patiet-cetred educatio (PCE) ad stadard asthma patiet educatio o ED re-attedace. A radomised cotrolled trial was coducted at two ier-city Australia teachig hospitals EDs, where patiets received either stadard patiet educatio (SPE) or PCE. Both groups received a six-topic curriculum. However, PCE patiets reordered the topics accordig to their ow priority ad thus cotrolled the order of educatio. I total, 146 adult patiets presetig to EDs with acute asthma were erolled. After 4 moths, ED re-attedace decreased from 22 to 12% i the PCE group ad remaied uchaged i the SPE group (betwee group odds ratio 0.4, 95% cofidece iterval ( )). I 78 patiets discharged after ED care, the PCE group had fewer re-attedaces after 4 ad 12 moths (0.3 ( ) ad 0.3 ( ), respectively ). PCE patiets with o geeral practitioer care i the precedig 7 days had fewer re-attedaces after 4 ad 12 moths (0.1 ( ) ad 0.2 ( ), respectively). A tred of better asthma cotrol was evidet, with a reductio i activity limitatio. I coclusio, patiet-cetred educatio offers promise as a brief educatio process i the emergecy departmet. However, a large multicetre trial of patiet-cetred educatio is required. KEYWORDS: Asthma, emergecy departmet, patiet educatio Asthma mortality has declied i recet years eve though asthma morbidity cotiues to affect the quality of life of idividualswithasthma[1,2].thisisevidetfrom the umber of people with asthma presetig to emergecy departmets (EDs) [3 5]. Asthma patiets re-attedace rates after receivig ED care ca be as high as 17% [6, 7]. Numerous studies have foud that people with acute asthma receive care that is icosistet with asthma maagemet guidelies, icludig iadequate discharge plaig ad educatio [6, 8 14]. Some studies of patiets with acute asthma have focused itervetios o improvig primary care follow-up via telephoe remiders [15] ad primary care-based educatio [16], which have show very little or o improvemet i patiet behaviour or asthma outcomes. Patiet educatio has bee described as a essetial compoet of asthma maagemet, with cliical guidelies providig the basis for both For editorial commets see pages 920 ad 922. cliical maagemet ad educatio curricula [17]. Prevetio of further episodes of acute asthma is a focus of patiet educatio, although to what extet it is effective remais uclear. Delayed educatio has show limited positive outcomes. A brief, opportue, educatioal itervetio i the ED may be a useful adjuct to curret ED care ad would be cosistet with iteratioal ad atioal guidelies [2, 18]. However, asthma educatio studies poorly describe the teachig ad learig priciples uderpiig the asthma educatio process [19]. Ulike previous studies, the curret study sought to examie the process of educatig patiets through a focus o teachig ad learig behaviour. The method used a learer-cetred approach [20], as the cocepts were cogruet with the cetral teets of patiet-cetred care [21]. Stadard patiet educatio (SPE) differs from a learer-cetred approach as it usually starts with pathophysiology ad eds with the AFFILIATIONS *Cetre for Evidece-Based Medicie, Dept of Primary Health Care, Uiversity of Oxford, Oxford, UK. # School of Medicie, Uiversity of Queeslad, Hersto, " Dept of Respiratory Medicie, Pricess Alexadra Hospital, Woolloogabba, ad + Dept of Medicie, Mater Adult Public Hospital, Raymod Terrace, South Brisbae, Australia. CORRESPONDENCE S. Smith Uiversity of Oxford Cetre for Evidece-Based Medicie Dept of Primary Health Care Old Road Campus Headigto Oxford OX3 7LF UK Fax: smithsm01@yahoo.com.au Received: May Accepted after revisio: Jauary SUPPORT STATEMENT This work received support from the Cooperative Research Cetre (CRC) for Asthma ad Asthma Australia, through a Health Educatio ad Health Promotio Scholarship i 2001, ad from a Asthma Foudatio of Queeslad grat i STATEMENT OF INTEREST Statemets of iterest for S. Smith ad S. Bowler ca be foud at statemets.shtml Europea Respiratory Joural Prit ISSN Olie ISSN VOLUME 31 NUMBER 5 EUROPEAN RESPIRATORY JOURNAL

2 S. SMITH ET AL. ASTHMA EDUCATION IN THE EMERGENCY DEPARTMENT importace of ogoig review [22, 23]. Stadard educatio is ofte the way health professioals are educated. The preset authors aimed to compare patiet-cetred educatio (PCE) with SPE, lookig at the subsequet effects o the umber of further ED attedaces ad asthma cotrol. The same curriculum, based o a cliical guidelie, was used for PCE ad SPE. MATERIALS AND METHODS Study desig The preset study was a prospective radomised cotrolled trial of two methods of patiet educatio for people with asthma attedig a ED. PCE [19] was uderpied with learercetred priciples, while SPE represeted the traditioal method of patiet educatio. The primary aim of PCE was a reductio i ED re-attedace rates after 4 ad 12 moths. The secodary aim was to improve asthma cotrol. Asthma cotrol was evideced by the patiet s symptoms ad reliever medicatio use i the 7 days prior to the ED attedace ad at a outpatiet departmet (OPD) visit 4 6 weeks after iitial presetatio. Ethical clearace was obtaied from participatig hospitals (Pricess Alexadra Hospital ad Mater Adult Public Hospital, Brisbae, Australia) ad the Queeslad Uiversity of Techology (Brisbae, Australia) Ethics Committee. Study settig ad populatio The preset study was coducted at two large teachig hospitals i Brisbae, Australia, from August 2001 util August Adult patiets arrivig at the ED with a acute exacerbatio of asthma were ivited to participate after medical clearace was give by the attedig physicia. To be eligible, patiets had to have bee diagosed with asthma prior to this presetatio, aged.18 yrs, able to read ad write Eglish ad have o other cocurret respiratory medical coditio. Patiets were excluded from the study if deemed too ill to participate by the medical officer ad/or required itesive care medical treatmet. Case otes were used to cofirm the participat s eligibility ad to exclude patiets with other respiratory diseases ad coditios that cause dyspoea. Study protocol The procedures ivolved i the cocealed allocatio of patiets to the study are outlied i table 1. Patiets were medically maaged prior to cotact with the researcher. After givig their coset to the study, each of the 146 patiets completed a questioaire ad placed it i a sealed evelope. Patiets were radomised by their day of birth, with odd days receivig the itervetio of PCE (568) ad eve days beig assiged to the cotrol group of SPE (578). The educatio was give to patiets durig their ED presetatio. Staff at both EDs were blid to the radomisatio process, as there was o otificatio of group assigmet i the patiet s chart. Oly the researcher ad the patiet were preset whe the educatio was give. Itervetio The asthma educatio protocol comprised a curriculum commoly used atioally ad iteratioally [17, 22 24]. The curriculum for both groups was primarily based o a cliical guidelie kow as the Australia Six Step Asthma Maagemet Pla (table 2). The cotrol group receivig SPE commeced with step 1 (asthma pathophysiology) ad progressed sequetially through to step 6 (educate ad review; table 2). The study itervetio required the PCE participats to prioritise the six asthma curriculum steps accordig to their perceived eed, ad patiets were educated accordigly so that the topic most importat to them was covered first. The PCE process was uderpied by the self-determiatio theory, which emphasises autoomy, competece ad relatioship support. A review of this theory of huma motivatio i learer-cetred educatio has bee reported elsewhere [19, 20, 25]. The PCE itervetio also required participats to respod to two opeeded questios: What is the most importat issue for you at the momet? ad What is the most importat asthma issue for you at the momet? Each educatio sessio took,20 mi to complete. The PCE sessios lasted a additioal 5 10 mi as the educator addressed the patiet s issues derived from the two opeeded questios. For both groups, a Asthma Foudatio leaflet was give to patiets to support the verbal advice of the educator ad to take home for future referece. The leaflet coveyed similar iformatio to the asthma educatio curriculum. Oe cliicia (S. Smith) educated all the patiets. Measuremets Demographic, cliical ad asthma cotrol data were collected at the time of attedig the ED (phase 1) ad at the OPD follow-up appoitmet 4 6 weeks later (phase 2). Patiets attedig the follow-up OPD were subsequetly educated agai accordig to the ED radomisatio. Participats attedaces at the ED i the 12 moths prior to the asthma educatio itervetio were recorded through self-report ad secodary care audit data. Re-attedace iformatio was collected through hospital records 4 ad 12 moths after phase 1 (fig. 1). TABLE 1 Procedures i cocealed allocatio of patiets to educatio groups Step Procedures 1 Patiet arrives at emergecy departmet ad is triaged, researcher is otified by phoe of the potetial participat ad travels to hospital 2 Patiet is medically maaged, stabilised ad their chart checked by medical staff; medical officer grats permissio for researcher to see patiet 3 Patiet is give study iformatio the ivited to participate; coset form is siged, date of birth checked ad questioaire give to patiet for completio 4 Patiet educated after completio of questioaire, patiet s chart idicates asthma study without iformatio o group assigmet; outpatiet appoitmet date ad time give to patiet ad recorded i chart c EUROPEAN RESPIRATORY JOURNAL VOLUME 31 NUMBER 5 991

3 ASTHMA EDUCATION IN THE EMERGENCY DEPARTMENT S. SMITH ET AL. TABLE 2 The compoets of the asthma educatio curriculum as related to the six steps of the Australia Asthma Maagemet Pla (AAMP) Step AAMP Asthma educatio curriculum 1 Idetificatio of the high-risk patiet: assess severity What is asthma ad how do I kow I have it? 2 Achieve best lug fuctio How to achieve my best lug fuctio 3 Maitai best lug fuctio: avoid ad idetify trigger factors How to stay well ad idetify ad avoid trigger factors 4 Maitai best lug fuctio: optimise medicatio programme How to stay well through my medicatios 5 Develop a actio pla What is a actio pla ad how do I use it to help my asthma? 6 Educate ad review regularly How ofte do I eed to have educatio ad see the doctor? Asthma cotrol was measured usig the asthma cotrol questioaire (ACQ) by JUNIPER et al. [26]. This validated method records the symptoms from the previous 7 days, alog with b 2 -agoist use. Asthma cotrol data were collected at the time of ED attedace ad agai 4 6 weeks later i the OPD. Participats completed the questioaire idepedetly. Patiets were educated o completio of the questioaire. Statistical aalysis All aalyses were hypothesis drive ad the two primary outcomes of iterest were ED re-attedaces ad asthma cotrol. Paired t-tests, ANOVAs ad ANCOVAs were used to compare meas of data that were ormally distributed. The Eligible ED patiets (=148) Not radomised as refused to participate (=2) Phase 1: PCE Patiet directed, prioritised order of topics to meet their eeds ad educated accordigly Baselie: ED Questioaire Usual care plus PCE (itervetio; =68) Phase 2: OPD 4 6 weeks OPD follow-up ad educatio Asthma cotrol questioaire readmiistered (=23) Phase 3: Outcomes At 4 moths secodary care re-attedace audit data (=66) At 12 moths secodary care re-attedace audit data (=66) Radomisatio (=146) Phase 1: SPE Educator directed, delivered topics i sequetial order as decided by educator or orgaisatio Baselie: ED Questioaire Usual care plus SPE (cotrol; =78) Phase 2: OPD 4 6 weeks OPD follow-up ad educatio Asthma cotrol questioaire readmiistered (=32) Phase 3: Outcomes At 4 moths secodary care re-attedace audit data (=76) At 12 moths secodary care re-attedace audit data (=76) FIGURE 1. Summary of participat flow, umbers ad timig of radomised assigmet, itervetios ad data collectio poits. ED: emergecy departmet; PCE: patiet-cetred educatio; SPE: stadard patiet educatio; OPD: outpatiet departmet. McNemar test was used for repeat measures of categorical data. I aalyses of categorical data with small samples, statistical associatios were assessed usig the Fisher exact test. For previous admissio ad ew admissio data, the Wilcoxo test (oparametric) was used to test the sigificace of differeces betwee two related samples, while the Ma Whitey U-test was used to test for differeces betwee the cotrol ad itervetio groups. Odds ratios (OR) were calculated, with 95% cofidece itervals (CI) beig reported. Logistic regressios were udertake to determie ay differece betwee subgroups, such as those that did or did ot atted a secodary care medical OPD follow-up appoitmet. RESULTS Study populatio I total, 148 adults with acute asthma who sought ED care were ivited to participate i the study (fig. 1). Oly two potetial participats declied. The mea age was cosistet with other asthma studies [22, 23, 27]. However, the study cohort had higher levels of formal educatio ad lower levels of icome tha other study cohorts; 49.2% had a icome,au$20,000, while oly 8% described themselves as uemployed. Despite the low icome levels i compariso to the average Australia icome (AU$55,000), a quarter of the study populatio stated they had private health isurace. Before ED presetatio, participats i both educatio groups had similar prior ED attedaces (table 3). Topic prioritisatio, patiet ad asthma issues May of the patiets i the PCE group chose a differet order for the asthma educatio topics, compared with the stadard curriculum (table 2; pf0.001). At the time of phase 1 ED presetatio, the PCE group s topic order followed a patter of step umbers 3, 2, 4, 5, 6 ad 1. Durig the OPD phase of the study, the patiets prioritisatio chaged i order of importace to steps 4, 3, 2, 5, 6 ad 1. Also, PCE resposes to the two ope-eded questios i the ED geerated a umber of patiet ad asthma issues. These resposes differed slightly to those expressed a umber of weeks later i the OPD (table 4). Primary outcome: re-attedace The SPE group had o reductio i ED re-attedace rate (23%) 4 moths after receivig educatio i the ED. I cotrast, the PCE group had halved the frequecy of re-attedace to 12%. The betwee group compariso (5146) of these differeces was ot statistically sigificat (OR 0.4; 95% CI ( )). However, whe cotrollig for geeral practitioer 992 VOLUME 31 NUMBER 5 EUROPEAN RESPIRATORY JOURNAL

4 S. SMITH ET AL. ASTHMA EDUCATION IN THE EMERGENCY DEPARTMENT TABLE 3 Demographic ad cliical phase 1 compariso of emergecy departmet (ED) patiets with acute asthma i stadard patiet educatio (SPE) ad patiet-cetred educatio (PCE) groups SPE PCE p-value Subjects Demographics Age yrs (31) (29.5) Female Sigle marital status Educatio to Year 12 or above Icome,AU$ Occupatio 0.53 Employed Uemployed 5 11 Studet 8 11 Cliical profile FEV1 % pred % % % 29 18,50% Previous ED attedace Self-reported prior hospital admissio Ambulace use Attedace to a GP withi the previous 7 days * Time of attedace at ED :00 07: :00 16: Admissio to hospital Peak flow moitorig Symptom scorig Legth of time sice diagosis yrs Data are preseted as (media) mea SD, % or mea SD, uless otherwise stated. FEV1: forced expiratory volume i oe secod; % pred: % predicted; GP: geeral practitioer. *: p,0.05, idicatig sigificat differece betwee groups. (GP) differeces at baselie (phase 1), PCE patiets had fewer re-attedaces (F-statistic with oe degree of freedom (F (1) ) 4.84, p50.03). I total, 104 patiets had ot see their GP i the 7 days prior to seekig care at the ED. I this subgroup, those radomised to PCE had sigificatly fewer re-attedaces tha the stadard group (p50.01). Re-attedace rates did ot differ for the 55 patiets who received additioal educatio i the OPD at 4 (p50.68) ad 12 moths (p50.96). However, whe follow-up secodary care ad prior care by the GP was cotrolled for, the PCE patiets had fewer re-attedaces tha the cotrol group (F (1) 5.0, p50.03). For 78 patiets who were treated, educated ad discharged from the ED (ot admitted to a hospital ward), the PCE group had sigificatly fewer re-attedaces at 4 ad 12 moths (OR 0.3, 95% CI ( ) ad OR 0.3, 95% CI ( ), respectively; TABLE 4 Most importat patiet ad asthma issues from two ope-eded questios, at the time of attedig the emergecy departmet (ED) ad outpatiet departmet (OPD) follow-up ED OPD Most importat issues Employmet issues Stayig healthy Fiacial pressures Lifestyle issues Family resposibilities Educatio ad employmet obligatios Relatioship issues Legal ad fiacial cocers Most importat asthma issues Elimiatio of symptoms Cotrollig asthma Prevetio Plaig for future attacks Cotrollig asthma Side-effects of medicatios c EUROPEAN RESPIRATORY JOURNAL VOLUME 31 NUMBER 5 993

5 ASTHMA EDUCATION IN THE EMERGENCY DEPARTMENT S. SMITH ET AL. All patiets a) b) Patiets ot admitted to hospital ward Patiets admitted to hospital ward Not admitted to hospital ward, o prior GP care Not admitted to hospital ward, prior GP care Admitted to ward, o prior GP care Admitted to ward, prior GP care Patiets with asthma for >10 yrs Patiets with asthma for >10 yrs, ot admitted to hospital ward Patiets with asthma for >10 yrs, admitted to hospital ward Patiets with asthma for >10 yrs, o prior GP care Patiets with asthma for >10 yrs, prior GP care Favours Favours Favours Favours patiet-cetred stadard patiet-cetred stadard FIGURE 2. Re-attedace to the emergecy departmet of all patiets at a) 4 moths ad b) 12 moths after phase 1 educatio. Data are preseted as odds ratio (h) ad 95% cofidece iterval ( ). GP: geeral practitioer. fig. 2). Furthermore, i this patiet subgroup of those who also had ot received recet GP care (563), the PCE patiets were less likely to re-atted (0.1 ( ) ad 0.2 ( ) after 4 ad 12 moths, respectively; fig. 2). Additioally, people who had bee diagosed with asthma for.10 yrs also appeared to beefit from the PCE process. These patiets had fewer ED visits withi 4 moths of beig educated, although this was ot sustaied util 12 moths (0.2 ( ) ad 0.3 ( ), respectively; fig. 2). I the preset study, forced expiratory volume i oe secod (FEV1) values were utilised to assess levels of acute asthma severity. Asthma severity was ot associated with havig see a GP i the 7 days prior to presetig to the ED (p50.57) or with hospital admissio (p50.14). Secodary outcome: asthma cotrol Asthma cotrol was reported i two formats: first with all seve questios of the ACQ (symptoms, b 2 -agoist use ad FEV1) ad secodly with six questios pertaiig to symptoms ad b 2 -agoist use (table 5). Asthma cotrol i all 55 patiets improved betwee the ED (phase 1) ad OPD follow-up (phase 2). However, whe asthma cotrol group differeces at time of etry to the study were cotrolled for, a tred towards the PCE group gaiig better cotrol ca be see (F (1) 2.13, p50.13). More specifically, the SPE group reported more activity limitatio, with the PCE havig a greater mea chage differece that was sigificat betwee groups (p50.03). Overall, the mea differece betwee educatioal groups from phase 1 (ED) ad phase 2 (OPD) cofirms a tred of better asthma cotrol for the PCE group (table 5). I the subgroup of 40 patiets discharged from the ED, patiets receivig the PCE itervetio reported better asthma cotrol (all criteria mea differece -6.59, 95% CI ( )) ad fewer symptoms (mea differece -6.55, 95% CI ( )). The high umber of patiets that did ot atted the OPD medical follow-up appoitmet meat that comparisos usig asthma cotrol as a outcome were limited. I a aalysis that icluded oly the 55 patiets that had full follow-up, there was a osigificat positive effect of the PCE (p50.13). To carry out a itetioto-treat (ITT) aalysis, asthma cotrol was modelled usig baselie demographic data (age, sex, occupatio, educatio level ad icome level) ad asthma cotrol at ED presetatio from patiets with complete data. Missig values for asthma cotrol at follow-up were imputed usig this model; imputed ad observed values were used i the ITT aalysis, resultig i a osigificat positive effect of PCE (p50.31). Limitatios Studies udertake i the ED are iheretly difficult, with competig priorities for patiets ad health professioals. To overcome this difficulty, oe researcher educated all patiets ivolved i the study, which itroduced a potetial bias. By usig the same curriculum for both groups ad the researcher esurig, i the most part, that the same words were used for each topic, irrespective of the assiged educatio group, the potetial bias was reduced. Asthma emergecy presetatios durig the data collectio period may have bee affected due to uusually mild summer ad witer seasos, which could have decreased the asthma cotrol scores. More patiets i the cotrol SPE group tha i the PCE group retured to the OPD ad received educatio, which could have limited the impact of the PCE itervetio i reducig re-attedaces. There was a potetial for cotamiatio i patiets who were admitted to a hospital ward because asthma educatio forms usual i-patiet care at both study hospitals. Although the researcher was usually o call 24 h?day -1 7days?week -1 over the 12-moth study period, there were some days whe the researcher was ot available. O average, the researcher was off call for oe weeked i three, durig which time potetial study participats were ot give the opportuity to participate. 994 VOLUME 31 NUMBER 5 EUROPEAN RESPIRATORY JOURNAL

6 S. SMITH ET AL. ASTHMA EDUCATION IN THE EMERGENCY DEPARTMENT TABLE 5 Asthma cotrol questioaire at phase 1 ad phase 2 Phase 1 ED SPE Phase 2 p-value Phase 1 PCE Phase 2 p-value Mea chage differece betwee groups p-value OPD ED OPD Symptoms All , , Noctural wakig (75) (32), (63) (23), Morig symptoms (76) (32), (63) (23), Activity limitatio (76) (32) (62) (23), * Shortess of breath (76) (32), (63) (23), Wheeze (76) (32), (63) (23), b 2 -agoist use (74) (31), (60) (23), FEV1 % pred (72) (25), (61) (21), All criteria , , Data are preseted as mea SD (), uless otherwise stated. SPE: stadard patiet educatio; PCE: patiet-cetred educatio; FEV1: forced expiratory volume i oe secod; % pred: % predicted. *: p,0.05, idicatig sigificat differece betwee groups. All variables were rated o a 0 6 scale where 05o symptoms, ormal FEV1 % pred ad miimal b 2 -agoist use. A umber of participats (61.8%; PCE566%; SPE558%) did ot atted their OPD appoitmet despite utilisatio of a umber of remider strategies previously reported to be successful [28]. These strategies icluded makig the appoitmet at the time the patiet preseted to the ED ad cotactig the patiet by telephoe the ight before their appoitmet. However, the preset retur rate to the OPD was cosistet with other public hospital asthma studies [29, 30]. Aalysis of data idicated o differece i demographic ad cliical characteristics or prior care from a GP betwee patiets that did or did ot retur for follow-up. DISCUSSION A systematic review of the limited asthma educatio for adults reports little beefit for the patiet i the way it is curretly practised ad idetifies a eed for recosideratio [31]. I the preset study, the traditioal method of teachig patiets was challeged through the applicatio of a learer-cetred process that shared commo elemets to patiet-cetred care [19]. The PCE also icorporated the ackowledgemet of issues facig patiets, i additio to their asthma, as the first step i buildig a therapeutic alliace to support the educator patiet relatioship. Health professioals who may be uaware of their patiet s social cotext ad curret asthma practices could possibly cotribute to the less desirable outcome of ogoig symptoms ad icreasig complex treatmet regimes [32 34]. By usig this PCE method, cliical guidelies ca be coveyed usig a learer-cetred process resultig i positive outcomes for patiets, with both their ad the health professioals eeds beig met. The curret authors believe that the PCE process goes part way to addressig a umber of the patiet educatio issues facig health professioals, such as the diverse perspectives of patiets ad health professioals ad the difficulty health professioals face i traslatig cliical guidelies to patiets [35 37]. Some ED studies of patiets with acute asthma have focused o improvig primary care follow-up through telephoe remiders [15] ad primary care-based educatio [16], which have show very little or o improvemet i patiet behaviour or asthma outcomes. Furthermore, a disproportioately high umber of patiets who do ot have regular cotact with their GP are admitted to hospital after seekig emergecy care [38]. The PCE educatio method ad its timig have the potetial to beefit this particular patiet group, as the fidigs of the preset study suggest that patiets i the PCE group without prior GP care had fewer re-attedaces. Whether patiets re-egaged with the primary physicia rather tha relyig o secodary care is still yet to be ascertaied. Participats radomised to PCE group were asked what the most importat issue was for them at that momet, ad were advised to alert the educator to evets/beliefs or cocers ad fears that were affectig them [39, 40]. The actio of ackowledgig the patiet s cocers idicates that the health professioal is cocered about them as a idividual [40, 41]. The curret authors suggest that this actio may ecourage patiets to be active participats, rather tha takig a passive role while they deal iterally with other issues. The PCE group was also asked what the most importat asthma issue was for them, ad themes from participats resposes reflect the past Australia Natioal Asthma Coucil s campaigs. The preset authors believe that the themes from the patiet resposes will reassure health professioals ad orgaisatios, such as the Australia Natioal Asthma Coucil, that their campaigs are targetig appropriate asthma issues that are of cocer to patiets. The results of the preset study idicate that whe patiets are give a list of topics ad the autoomy to choose the order i which they are to be delivered durig the educatio process, they differed sigificatly i their choice from the stadard format i curret use. The PCE approach ackowledges that differet patiets with asthma may eed specific iformatio related to certai topics at differet times i their life [42]. The chage i prioritisatio of topics betwee phase 1 ad phase 2 c EUROPEAN RESPIRATORY JOURNAL VOLUME 31 NUMBER 5 995

7 ASTHMA EDUCATION IN THE EMERGENCY DEPARTMENT S. SMITH ET AL. further supports this premise. A stadard curriculum delivered by meas of a patiet-cetred approach to asthma educatio, usig learer-cetred elemets, may go part way towards addressig these issues ad provide a sustaiable approach to asthma educatio i the ED. The preset study suggests that a learer-cetred approach to asthma educatio may be useful i reducig re-attedaces to the emergecy departmet ad, therefore, has importat implicatios for the way health professioals educate patiets. The ucomplicated, brief, patiet-cetred educatio process usig a basic chroic disease guidelie curriculum may be of value, particularly for people who are treated, educated ad discharged from the emergecy departmet. The patietcetred educatio approach eeds further study ad extesio to cofirm ad geeralise the results. ACKNOWLEDGEMENTS The authors are grateful to R. Ruffi (Uiversity of Adelaide, Adelaide, Australia), P. 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