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December 10, 1997, Vol 278, No. 22 >
ARTICLE | December 10, 1997

Outcomes Analysis in Asthma FREE

Michael S. Blaiss, MD
JAMA. 1997;278(22):1874-1880. doi:10.1001/jama.1997.03550220080011
Text Size: A A A
Published online
Article
References

Physicians, patients, employers, managed care organizations, insurance companies, and government all want to know how different approaches to management of asthma are improving care. To this end, the field of outcomes analysis in asthma is playing a major role. Clinical, physiologic, humanistic, and economic outcomes are being assessed using different types of general and asthma-specific instruments. Historically, clinical and physiologic outcomes have been of most concern to clinicians. However, humanistic outcomes, such as health-related quality of life and patient satisfaction, shift the focus to the patient. Economic outcomes, especially cost-effectiveness, evaluate how to achieve the best outcomes at the lowest cost. These outcomes have been used to evaluate asthma intervention programs. Several large asthma outcomes research projects, which should define the future of outcomes analysis in asthma, are under way.

REFERENCES

1 +
Donabedian A.  The quality of care: how can it be assessed? JAMA . 1988;;260:1743-1748.
2 +
Ellwood PM.  Shattuck Lecture—Outcomes management: a technology of patient experience . N Engl J Med . 1988;;318:1549-1556.
3 +
Wu AW.  Principles of outcomes assessment . In: Bennett JC, Blum F, eds. Cecil Textbook of Medicine . 20th ed. Philadelphia, Pa: WB Saunders Co; 1996;;1:122-126.
4 +
Epstein RS, Sherwood LM.  From outcomes research to disease management: a guide for the perplexed . Ann Intern Med . 1996;;124:832-837.
5 +
Steinwachs DM, Wu AW, Skinner EA.  How will outcomes management work? Health Aff (Mill-wood) . 1994;;13:153-162.
6 +
Ferguson JH.  Research on the delivery of medical care using hospital firms: proceedings of a work-shop, April 30 and May 1, 1990, Bethesda, Md . Med Care . 1991;;29:JS1-J70.
7 +
Rose R, Weiss KB.  An overview of outcomes measurement in asthma care . Immunol Allergy Clin North Am . 1996;;16:841-858.
8 +
Bukstein DA.  Practical approach to the use of outcomes in asthma . Immunol Allergy Clin North Am . 1996;;16:859-891.
9 +
National Asthma Education and Prevention Program. Expert Panel Report II: Guidelines for the Diagnosis and Management of Asthma . Bethesda, Md: National Institutes of Health; 1997;.
10 +
Meijer A, Griffioen RW, van Nierop JC, Oppenheimer L.  Intractable or uncontrolled asthma: psychosocial factors . J Asthma . 1995;;32:265-274.
11 +
Weiss KB, Gergen PJ, Hodgson TA.  An economic evaluation of asthma in the United States . N Engl J Med . 1992;;326:862-866.
12 +
Centers for Disease Control and Prevention.  Asthma mortality and hospitalization among children and young adults—United States, 1980-1993 . MMWR Morb Mortal Wkly Rep . 1996;;45:350-353.
13 +
Lohr KN, Aaronson NK, Alonso J.  Evaluating quality-of-life and health status instruments: development of scientific review criteria . Clin Ther . 1996;;18:979-992.
14 +
O'Connor GT, Weiss ST.  Clinical and symptom measures . Am J Respir Crit Care Med . 1994;;149( (2) , pt 2):S21-S28
15 +
Torén K, Brisman J, Järvholm B.  Asthma and asthma-like symptoms in adults assessed by questionnaires . Chest . 1993;;104:600-608.
16 +
Brooks SM, Bernstein IL, Raghuprasad PK.  Assessment of airways hyperresponsiveness in chronic stable asthma . J Allergy Clin Immunol . 1990;;85:17-26.
17 +
Richards JM, Bailey WC, Windsor RA.  Some simple scales for use in asthma research . J Asthma . 1988;;25:363-371.
18 +
Usherwood TP, Scrimgeour A, Barber JH.  Questionnaire to measure perceived symptoms and disability in asthma . Arch Dis Child . 1990;;65:779-781.
19 +
Li JTC, O'Connell EJ.  Clinical evaluation of asthma . Ann Allergy Asthma Immunol . 1996;;76:1-14.
20 +
McFadden ER.  Clinical physiologic correlates in asthma . J Allergy Clin Immunol . 1986;;77:1-5.
21 +
Murlow CD, Dolmatch BL, Delong ER.  Observer variability in the pulmonary examination . J Gen Intern Med . 1986;;1:364-367.
22 +
Spiteri MA, Cook DG, Clarke SW.  Reliability of eliciting physical signs in examination of the chest . Lancet . 1988;;1:873-875.
23 +
Griffin E, Hakansson L, Fromgren H.  Blood eosinophil number and activity in relation to lung function in patients with asthma and with eosinophilia . J Allergy Clin Immunol . 1991;;87:548-557.
24 +
Horn BR, Robin ED, Theodore J.  Total eosinophil counts in the management of bronchial asthma . N Engl J Med . 1975;;292:1152-1155.
25 +
Enright PL, Lebowitz MD, Cockroft DW.  Physiologic measures: pulmonary function tests: asthma outcome . Am J Respir Crit Care Med . 1994;;149( (2) , pt 2):S9-S18.
26 +
Noviski N, Cohen L, Springer C, et al.  Bronchial provocation determined by breath sounds compared with lungfunction . Arch Dis Child . 1991;;66:952-955.
27 +
Jackson A.  Accuracy, reproducibility, and variability of portable peak flow meters . Chest . 1995;;151:353-359.
28 +
Woolcock AJ, Jenkins CR.  Assessment of bronchial responsiveness as a guide to prognosis and therapy of asthma . Med Clin North Am . 1990;;74:753-765.
29 +
Guyatt GH, Feeny DH, Patrick DL.  Measuring health-related quality of life . Ann Intern Med . 1993;;118:622-629.
30 +
McSweeny AJ, Creer TL.  Health-related quality-of-life assessment in medical care . Dis Mon . 1995;;41:1-71.
31 +
World Health Organization. The First Ten Years of the World Health Organization . Geneva, Switzerland: World Health Organization; 1958;.
32 +
Bergner M.  Measurement of health status . Med Care . 1985;;23:696-704.
33 +
Hyland ME, Ley A, Fisher DW, Woodward V.  Measurement of psychological distress in asthma and asthma management programmes . Br J Clin Psychol . 1995;;34( (pt 4) ):601-611.
34 +
Fitzpatrick R, Fletcher A, Gore S, et al.  Quality of life measures in health care, I: applications and issues in assessment . BMJ . 1992;;305:1074-1077.
35 +
Richards JM Jr, Hemstreet MP.  Measures of life quality, role performance, and functional status in asthma research . Am J Respir Crit Care Med . 1994;;149( (2) , pt 2):S31-S39
36 +
Bergner M, Bobbit RA, Carter WB.  The Sickness Impact Profile: development and final revision of a health status measure . Med Care . 1981;;9:787-805.
37 +
Kaplan RM, Anderson JP.  The Quality of Well-being Scale: rationale for a single quality of life measure . In: Walker SR, Rosser RM, eds. Quality of Life: Assessment and Applications . London, England: Ciba Foundation; 1988;:51-78.
38 +
Ware JE, Sherbourne CD.  The MOS 36-item Short Form Health Survey (SF-36), I: conceptual framework and item selection . Med Care . 1992;;30:473-483.
39 +
Ware JE, Kosinski M, Keller SD.  A 12-item Short Form Health Survey construction of scales and preliminary tests of reliability and validity . Med Care . 1996;;34:220-233.
40 +
Bousquet J, Knani J, Dhivert H, et al.  Quality of life in asthma, I: internal consistency and validity of the SF-36 questionnaire . Am J Respir Crit Care Med . 1994;;149( (2) , pt 1):371-375.
41 +
Aas K.  Heterogeneity of bronchial asthma . Allergy . 1981;;36:3-10.
42 +
Steinwachs DM, Wu A, Skinner EA, Campbell D. Managed Health Care Association Outcomes Study Baseline Survey Summary Report . Bloomington, Minn: Health Outcomes Institute; 1995;.
43 +
Marks GB, Dunn SM, Woolcock AJ.  An evaluation of an asthma quality of life questionnaire as a measure of change in adults with asthma . J Clin Epidemiol . 1993;;46:1103-1111.
44 +
Storms B, Olden L, Nathan R, Bodman S.  Effect of allergy specialist care on the quality of life in patients with asthma . Ann Allergy Asthma Immunol . 1995;;75:491-494.
45 +
Juniper EF, Guyatt GH, Epstein RS, Ferrie PJ, Jaeschke R, Hiller TK.  Evaluation of impairment of health related quality of life in asthma: development of a questionnaire for use in clinical trials . Thorax . 1992;;47:76-83.
46 +
Juniper EF, Guyatt GH, Ferrie PJ, Griffith LE.  Measuring quality of life in asthma . Am Rev Respir Dis . 1993;;147:832-838.
47 +
Malo JL, Boulet LP, Dewitte JD, et al.  Quality of life of subjects with occupational asthma . J Allergy Clin Immunol . 1993;;91:1121-1127.
48 +
Rowe BH, Oxman AD.  Performance of an asthma quality of life questionnaire in an outpatient setting . Am Rev Respir Dis . 1993;;148:675-681.
49 +
Bender BG.  Measurement of quality of life in pediatric asthma clinical trials . Ann Allergy Asthma Immunol . 1996;;77:438-447.
50 +
Juniper EF, Guyatt GH, Feeny DH, Ferrie PJ, Griffith LE, Townsend M.  Measuring quality of life in children with asthma . Qual Life Res . 1996;;5:35-46.
51 +
Fritz GK, Overholser JC.  Patterns of response to childhood asthma . Psychosom Med . 1993;;51:347-355.
52 +
Creer TL, Wigal JK, Kotses H.  A Life Activities Questionnaire for Childhood Asthma . J Asthma . 1992;;30:467-473.
53 +
Christie MJ, French D, Sowden A.  Development of child-centered disease-specific questionnaires for living with asthma . Psychosom Med . 1993;;51:541-548.
54 +
Ware JE, Snyder MK, Wright R.  Defining and measuring patient satisfaction with medical care . Eval Prog Plann . 1983;;6:247-263.
55 +
Barnett TE, Fatis M, Sonnek D, Torvinen J.  Treatment satisfaction with an asthma management program: a 'five'-year retrospective assessment . J Asthma . 1992;;29:109-116.
56 +
Boe J, Stiksa G, Svensson K, Asbrink E.  New method of evaluating patient preference for different inhalation delivery systems . Ann Allergy . 1992;;68:255-60.
57 +
National Heart, Lung, and Blood Institute, National Institutes of Health.  Socioeconomics . In: Global Strategy for Asthma Management and Prevention: A NHLBI/WHO Workshop Report . Bethesda, Md: US Dept of Health and Human Services; 1994;: chap 8. NIH publication 94-3276.
58 +
Krahn MD, Berka C, Langlois P, et al.  Direct and indirect costs of asthma in Canada . Can Med Assoc J . 1996;;154:821-831.
59 +
Feeny D, Labelle R.  Integrating economic evaluations and quality of life assessments . In: Spilker B, ed. Quality of Life Assessments in Clinical Trials . New York, NY: Raven Press; 1990;:71-84.
60 +
Torrence G.  Measurement of health state utilities for economic appraisal: a review article . J Health Econ . 1986;;5:1-30.
61 +
Weinstein MC, Stason B.  Foundation of cost-effective analysis for health and medical practices . N Engl J Med . 1977;;296:716-721.
62 +
Sullivan S, Elixhauser A, Buist AS, Luce BR, Eisenberg J, Weiss KB.  National Asthma Education and Prevention Program working group report on the cost-effectiveness of asthma care . Am J Respir Crit Care Med . 1996;;154( (3) , pt 2):S84-S95.
63 +
Sullivan SD.  Cost and cost-effectiveness in asthma . Immunol Allergy Clin North Am . 1996;;16:819-839.
64 +
Bolton MB, Tilley BC, Kuder J, Reeves T, Schultz LR.  The cost and effectiveness of an education program for adults who have asthma . J Gen Intern Med . 1991;;6:401-407.
65 +
McFadden ER Jr, Elsanadi N, Dixon L, et al.  Protocol therapy for acute asthma: therapeutic benefits and cost savings . Am J Med . 1995;;99:651-661.
66 +
Korenblat PE, Korenblat-Hanin M, Gaioni SJ.  An asthma center: outcomes validation . J Allergy Clin Immunol . 1995;;95:222.
67 +
Lahdensuo A, Haahtela T, Herrala J, et al.  Randomised comparison of guided self management and traditional treatment of asthma over one year . BMJ . 1996;;312:748-752.
68 +
Kelso TM, Self TH, Rumbak MJ, Stephens MA, Garrett W, Arheart KL.  Educational and long-term therapeutic intervention in the ED: effect on outcomes in adult indigent minority asthmatics . Am J Emerg Med . 1995;;13:632-637.
69 +
Mayo PH, Richman J, Harris HW.  Results of a program to reduce admissions for adult asthma . Ann Intern Med . 1990;;112:864-871.
70 +
Greineder DK, Loane KC, Parks P.  Reduction in resource utilization by an asthma outreach program . Arch Pediatr Adolesc Med . 1995;;149:415-420.
71 +
Bailey WC, Richards JM, Brooks M.  A randomized trial to improve self-management practices of adults with asthma . Arch Intern Med . 1990;;150:1664-1668.
72 +
Doan T, Grammer LC, Yarnold PR.  An intervention program to reduce the hospitalization cost of asthmatic patients requiring intubation . Ann Allergy Asthma Immunol . 1996;;76:513-518.
73 +
 Initiatives in asthma outcomes . Med Outcomes Trust Monitor . 1996;;1( (2) ):3-4 Summaries.

Figures

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Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Donabedian A.  The quality of care: how can it be assessed? JAMA . 1988;;260:1743-1748.
2 +
Ellwood PM.  Shattuck Lecture—Outcomes management: a technology of patient experience . N Engl J Med . 1988;;318:1549-1556.
3 +
Wu AW.  Principles of outcomes assessment . In: Bennett JC, Blum F, eds. Cecil Textbook of Medicine . 20th ed. Philadelphia, Pa: WB Saunders Co; 1996;;1:122-126.
4 +
Epstein RS, Sherwood LM.  From outcomes research to disease management: a guide for the perplexed . Ann Intern Med . 1996;;124:832-837.
5 +
Steinwachs DM, Wu AW, Skinner EA.  How will outcomes management work? Health Aff (Mill-wood) . 1994;;13:153-162.
6 +
Ferguson JH.  Research on the delivery of medical care using hospital firms: proceedings of a work-shop, April 30 and May 1, 1990, Bethesda, Md . Med Care . 1991;;29:JS1-J70.
7 +
Rose R, Weiss KB.  An overview of outcomes measurement in asthma care . Immunol Allergy Clin North Am . 1996;;16:841-858.
8 +
Bukstein DA.  Practical approach to the use of outcomes in asthma . Immunol Allergy Clin North Am . 1996;;16:859-891.
9 +
National Asthma Education and Prevention Program. Expert Panel Report II: Guidelines for the Diagnosis and Management of Asthma . Bethesda, Md: National Institutes of Health; 1997;.
10 +
Meijer A, Griffioen RW, van Nierop JC, Oppenheimer L.  Intractable or uncontrolled asthma: psychosocial factors . J Asthma . 1995;;32:265-274.
11 +
Weiss KB, Gergen PJ, Hodgson TA.  An economic evaluation of asthma in the United States . N Engl J Med . 1992;;326:862-866.
12 +
Centers for Disease Control and Prevention.  Asthma mortality and hospitalization among children and young adults—United States, 1980-1993 . MMWR Morb Mortal Wkly Rep . 1996;;45:350-353.
13 +
Lohr KN, Aaronson NK, Alonso J.  Evaluating quality-of-life and health status instruments: development of scientific review criteria . Clin Ther . 1996;;18:979-992.
14 +
O'Connor GT, Weiss ST.  Clinical and symptom measures . Am J Respir Crit Care Med . 1994;;149( (2) , pt 2):S21-S28
15 +
Torén K, Brisman J, Järvholm B.  Asthma and asthma-like symptoms in adults assessed by questionnaires . Chest . 1993;;104:600-608.
16 +
Brooks SM, Bernstein IL, Raghuprasad PK.  Assessment of airways hyperresponsiveness in chronic stable asthma . J Allergy Clin Immunol . 1990;;85:17-26.
17 +
Richards JM, Bailey WC, Windsor RA.  Some simple scales for use in asthma research . J Asthma . 1988;;25:363-371.
18 +
Usherwood TP, Scrimgeour A, Barber JH.  Questionnaire to measure perceived symptoms and disability in asthma . Arch Dis Child . 1990;;65:779-781.
19 +
Li JTC, O'Connell EJ.  Clinical evaluation of asthma . Ann Allergy Asthma Immunol . 1996;;76:1-14.
20 +
McFadden ER.  Clinical physiologic correlates in asthma . J Allergy Clin Immunol . 1986;;77:1-5.
21 +
Murlow CD, Dolmatch BL, Delong ER.  Observer variability in the pulmonary examination . J Gen Intern Med . 1986;;1:364-367.
22 +
Spiteri MA, Cook DG, Clarke SW.  Reliability of eliciting physical signs in examination of the chest . Lancet . 1988;;1:873-875.
23 +
Griffin E, Hakansson L, Fromgren H.  Blood eosinophil number and activity in relation to lung function in patients with asthma and with eosinophilia . J Allergy Clin Immunol . 1991;;87:548-557.
24 +
Horn BR, Robin ED, Theodore J.  Total eosinophil counts in the management of bronchial asthma . N Engl J Med . 1975;;292:1152-1155.
25 +
Enright PL, Lebowitz MD, Cockroft DW.  Physiologic measures: pulmonary function tests: asthma outcome . Am J Respir Crit Care Med . 1994;;149( (2) , pt 2):S9-S18.
26 +
Noviski N, Cohen L, Springer C, et al.  Bronchial provocation determined by breath sounds compared with lungfunction . Arch Dis Child . 1991;;66:952-955.
27 +
Jackson A.  Accuracy, reproducibility, and variability of portable peak flow meters . Chest . 1995;;151:353-359.
28 +
Woolcock AJ, Jenkins CR.  Assessment of bronchial responsiveness as a guide to prognosis and therapy of asthma . Med Clin North Am . 1990;;74:753-765.
29 +
Guyatt GH, Feeny DH, Patrick DL.  Measuring health-related quality of life . Ann Intern Med . 1993;;118:622-629.
30 +
McSweeny AJ, Creer TL.  Health-related quality-of-life assessment in medical care . Dis Mon . 1995;;41:1-71.
31 +
World Health Organization. The First Ten Years of the World Health Organization . Geneva, Switzerland: World Health Organization; 1958;.
32 +
Bergner M.  Measurement of health status . Med Care . 1985;;23:696-704.
33 +
Hyland ME, Ley A, Fisher DW, Woodward V.  Measurement of psychological distress in asthma and asthma management programmes . Br J Clin Psychol . 1995;;34( (pt 4) ):601-611.
34 +
Fitzpatrick R, Fletcher A, Gore S, et al.  Quality of life measures in health care, I: applications and issues in assessment . BMJ . 1992;;305:1074-1077.
35 +
Richards JM Jr, Hemstreet MP.  Measures of life quality, role performance, and functional status in asthma research . Am J Respir Crit Care Med . 1994;;149( (2) , pt 2):S31-S39
36 +
Bergner M, Bobbit RA, Carter WB.  The Sickness Impact Profile: development and final revision of a health status measure . Med Care . 1981;;9:787-805.
37 +
Kaplan RM, Anderson JP.  The Quality of Well-being Scale: rationale for a single quality of life measure . In: Walker SR, Rosser RM, eds. Quality of Life: Assessment and Applications . London, England: Ciba Foundation; 1988;:51-78.
38 +
Ware JE, Sherbourne CD.  The MOS 36-item Short Form Health Survey (SF-36), I: conceptual framework and item selection . Med Care . 1992;;30:473-483.
39 +
Ware JE, Kosinski M, Keller SD.  A 12-item Short Form Health Survey construction of scales and preliminary tests of reliability and validity . Med Care . 1996;;34:220-233.
40 +
Bousquet J, Knani J, Dhivert H, et al.  Quality of life in asthma, I: internal consistency and validity of the SF-36 questionnaire . Am J Respir Crit Care Med . 1994;;149( (2) , pt 1):371-375.
41 +
Aas K.  Heterogeneity of bronchial asthma . Allergy . 1981;;36:3-10.
42 +
Steinwachs DM, Wu A, Skinner EA, Campbell D. Managed Health Care Association Outcomes Study Baseline Survey Summary Report . Bloomington, Minn: Health Outcomes Institute; 1995;.
43 +
Marks GB, Dunn SM, Woolcock AJ.  An evaluation of an asthma quality of life questionnaire as a measure of change in adults with asthma . J Clin Epidemiol . 1993;;46:1103-1111.
44 +
Storms B, Olden L, Nathan R, Bodman S.  Effect of allergy specialist care on the quality of life in patients with asthma . Ann Allergy Asthma Immunol . 1995;;75:491-494.
45 +
Juniper EF, Guyatt GH, Epstein RS, Ferrie PJ, Jaeschke R, Hiller TK.  Evaluation of impairment of health related quality of life in asthma: development of a questionnaire for use in clinical trials . Thorax . 1992;;47:76-83.
46 +
Juniper EF, Guyatt GH, Ferrie PJ, Griffith LE.  Measuring quality of life in asthma . Am Rev Respir Dis . 1993;;147:832-838.
47 +
Malo JL, Boulet LP, Dewitte JD, et al.  Quality of life of subjects with occupational asthma . J Allergy Clin Immunol . 1993;;91:1121-1127.
48 +
Rowe BH, Oxman AD.  Performance of an asthma quality of life questionnaire in an outpatient setting . Am Rev Respir Dis . 1993;;148:675-681.
49 +
Bender BG.  Measurement of quality of life in pediatric asthma clinical trials . Ann Allergy Asthma Immunol . 1996;;77:438-447.
50 +
Juniper EF, Guyatt GH, Feeny DH, Ferrie PJ, Griffith LE, Townsend M.  Measuring quality of life in children with asthma . Qual Life Res . 1996;;5:35-46.
51 +
Fritz GK, Overholser JC.  Patterns of response to childhood asthma . Psychosom Med . 1993;;51:347-355.
52 +
Creer TL, Wigal JK, Kotses H.  A Life Activities Questionnaire for Childhood Asthma . J Asthma . 1992;;30:467-473.
53 +
Christie MJ, French D, Sowden A.  Development of child-centered disease-specific questionnaires for living with asthma . Psychosom Med . 1993;;51:541-548.
54 +
Ware JE, Snyder MK, Wright R.  Defining and measuring patient satisfaction with medical care . Eval Prog Plann . 1983;;6:247-263.
55 +
Barnett TE, Fatis M, Sonnek D, Torvinen J.  Treatment satisfaction with an asthma management program: a 'five'-year retrospective assessment . J Asthma . 1992;;29:109-116.
56 +
Boe J, Stiksa G, Svensson K, Asbrink E.  New method of evaluating patient preference for different inhalation delivery systems . Ann Allergy . 1992;;68:255-60.
57 +
National Heart, Lung, and Blood Institute, National Institutes of Health.  Socioeconomics . In: Global Strategy for Asthma Management and Prevention: A NHLBI/WHO Workshop Report . Bethesda, Md: US Dept of Health and Human Services; 1994;: chap 8. NIH publication 94-3276.
58 +
Krahn MD, Berka C, Langlois P, et al.  Direct and indirect costs of asthma in Canada . Can Med Assoc J . 1996;;154:821-831.
59 +
Feeny D, Labelle R.  Integrating economic evaluations and quality of life assessments . In: Spilker B, ed. Quality of Life Assessments in Clinical Trials . New York, NY: Raven Press; 1990;:71-84.
60 +
Torrence G.  Measurement of health state utilities for economic appraisal: a review article . J Health Econ . 1986;;5:1-30.
61 +
Weinstein MC, Stason B.  Foundation of cost-effective analysis for health and medical practices . N Engl J Med . 1977;;296:716-721.
62 +
Sullivan S, Elixhauser A, Buist AS, Luce BR, Eisenberg J, Weiss KB.  National Asthma Education and Prevention Program working group report on the cost-effectiveness of asthma care . Am J Respir Crit Care Med . 1996;;154( (3) , pt 2):S84-S95.
63 +
Sullivan SD.  Cost and cost-effectiveness in asthma . Immunol Allergy Clin North Am . 1996;;16:819-839.
64 +
Bolton MB, Tilley BC, Kuder J, Reeves T, Schultz LR.  The cost and effectiveness of an education program for adults who have asthma . J Gen Intern Med . 1991;;6:401-407.
65 +
McFadden ER Jr, Elsanadi N, Dixon L, et al.  Protocol therapy for acute asthma: therapeutic benefits and cost savings . Am J Med . 1995;;99:651-661.
66 +
Korenblat PE, Korenblat-Hanin M, Gaioni SJ.  An asthma center: outcomes validation . J Allergy Clin Immunol . 1995;;95:222.
67 +
Lahdensuo A, Haahtela T, Herrala J, et al.  Randomised comparison of guided self management and traditional treatment of asthma over one year . BMJ . 1996;;312:748-752.
68 +
Kelso TM, Self TH, Rumbak MJ, Stephens MA, Garrett W, Arheart KL.  Educational and long-term therapeutic intervention in the ED: effect on outcomes in adult indigent minority asthmatics . Am J Emerg Med . 1995;;13:632-637.
69 +
Mayo PH, Richman J, Harris HW.  Results of a program to reduce admissions for adult asthma . Ann Intern Med . 1990;;112:864-871.
70 +
Greineder DK, Loane KC, Parks P.  Reduction in resource utilization by an asthma outreach program . Arch Pediatr Adolesc Med . 1995;;149:415-420.
71 +
Bailey WC, Richards JM, Brooks M.  A randomized trial to improve self-management practices of adults with asthma . Arch Intern Med . 1990;;150:1664-1668.
72 +
Doan T, Grammer LC, Yarnold PR.  An intervention program to reduce the hospitalization cost of asthmatic patients requiring intubation . Ann Allergy Asthma Immunol . 1996;;76:513-518.
73 +
 Initiatives in asthma outcomes . Med Outcomes Trust Monitor . 1996;;1( (2) ):3-4 Summaries.

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