• asthma
• asthma action plan

The first British guidelines for the management of asthma in adults published in 1990 clearly recommended self-management of asthma. The exact statement read: “As far as possible, patients should be trained to manage their own treatment rather than be required to consult their doctor before making changes”.¹ Similar advice has been repeated in subsequent revisions of the UK guidelines^2–4 and in the NHLBI global strategy for asthma management and prevention.⁵

The evidence base for these recommendations is strong, and 36 trials comparing self-management education with usual care were reviewed for the Cochrane Library.⁶ This review suggested that self-management education could be associated with a reduction in hospital admissions of up to 40%, a reduction in emergency room visits of 20%, and similarly impressive reductions in unscheduled visits to the doctor, night time symptoms, and days off work or school. The authors concluded that training programmes that enabled people to adjust their medication using a written asthma action plan appeared to be more effective than other forms of self-management. In this issue of Thorax Gibson and Powell⁷ report the results of a further review to determine what is important about personalised written asthma action plans. They conclude that such plans are best when using 2–4 action points which involve increasing the dose of inhaled steroid and initiation of oral steroid therapy for exacerbations. Plans using peak flow should be based on personal best peak expiratory flow.

The evidence, however, is that—despite a 13 year history of such advice being recommended—implementation of these recommendations is poor. Indeed, in one study of a stratified group of 785 adults and children with asthma, only 3% of respondents had been given a written self-management action plan setting out what they should do if their asthma deteriorated.⁸ This study was performed in a group of people with asthma of all severities. In another population of 378 individuals surveyed 1 week after an acute episode of asthma necessitating unscheduled access to health care, 28% of patients reported having a written self-management plan.⁹ Nevertheless, three quarters of people with clear evidence of out of control asthma had not been equipped with the tools necessary to control their own condition—tools which have been recommended for over 13 years.

The question must therefore be asked as to why—in the presence of such a plethora of data in favour of self-management education and personalised asthma action plans—are so few patients actually receiving this advice? Possible reasons include:

• Patient factors (very stable well controlled disease; patient does not wish to take control of his/her condition¹⁰).

• Health professional factors, for example:

  • – lack of awareness of the recommendations;

  • – erroneous belief that all asthma attacks are acute;

  • – lack of confidence in patients self-managing their own condition;

  • – dislike of self-management because (in some healthcare systems) it leads to loss of income;

  • – lack of physician confidence in teaching patients self-management skills;

  • – perceived lack of time.

Failure to implement recommendations contained within guidelines is, of course, not confined to failure to offer patients with asthma written personalised action plans. However, there may be specific barriers to implementation of such educational advice because of lack of specific training and knowledge regarding what should be given in the way of self-management advice and personal asthma action plans. Non-availability of partially preprinted material on to which advice may be written may also lead to patients not receiving such plans.

Numerous studies have shown that, at least among adults, most asthma exacerbations, while often severe, are not acute. One study showed that 56% of adults admitted to hospital with severe asthma had experienced night time waking for at least 5 nights before admission.¹¹ In another national census of those attending UK accident and emergency departments with asthma, one fifth of adults had been kept awake by their asthma for more than 3 nights before attendance.¹² A study in Canada found that one fifth of patients with asthma admitted to hospital and one fifth of those requiring intensive care had had symptoms for at least 21 days before admission.¹³ These studies suggest that, for most patients with troublesome asthma, plenty of time was available for either the patient or the doctor to alter treatment to avoid deterioration to the point where the patient needed to be admitted to hospital.

“There can be no further excuse for delaying widespread implementation of . . . written personal asthma action plans”

In some healthcare systems the concept of devolving care to the patient may have negative financial implications for health professionals. This might lead to them being reluctant to implement recommendations regarding the issuing of personal asthma action plans. It would be a pity if the beneficial results from 36 good clinical trials were to be negated by such financial considerations. Perhaps such colleagues could be convinced of the advantages of a partnership approach to medical care by pointing out that, in another study, over 30% of patients who scored their physicians as being “non-participatory” changed physicians over the subsequent year, whereas those who scored their physicians as being “participatory” were half as likely to report that they would change their physician in the following 12 months.¹⁴

Time is needed to teach patients how to recognise signs of deteriorating asthma and to teach self-management skills, but Clark and colleagues have shown that such training, when offered in the context of an interactive educational seminar, can have a lasting effect on physician behaviour and better outcomes, and consultation times are not necessarily extended.¹⁵ In some healthcare systems such tasks are helpfully shared with nursing colleagues.

In their paper in this issue of Thorax, Gibson and Powell⁷ emphasise that action plans which involve both increasing inhaled steroid dosage and taking steroid tablets are the most effective, yet some may perceive a controversy with regard to increasing the dose of inhaled steroids. The British asthma guidelines⁴ state that the value of doubling the dose of inhaled steroids is unproven. However, this statement must be seen within the context of most of the published studies of self-management education which have included a description of the action plans used, recommending a doubling or trebling of the dosage of inhaled steroids. This paradox can be explained either by understanding that advice to double the inhaled steroids is only effective if given within the wider context of self-management education, or by an appreciation that it is the concept of varying dosage of medications that is important rather than the actual magnitude of change. It may be that the advice in zone 2 of a personalised asthma action plan also works by reminding the non-compliant patient to take his or her inhaled steroid. A further explanation is that doubling alone may not be sufficient. An Italian study suggested that the most efficacious interventions were probably those which involved reducing the dose of inhaled steroid when well controlled and then quadrupling it at the first sign of loss of control of asthma.¹⁶ The need for us to teach patients how to both increase and decrease their dose of inhaled steroids is exemplified by recent work which showed that, in a group of adults with asthma, the active practice of stepping down treatment was associated with a mean reduction in daily inhaled steroid usage of 348 μg beclomethasone equivalent per day, with equally good outcomes to those who had stayed on a fixed dose.¹⁷

Patients with many long term conditions fail to comply with their therapeutic regimen. Many understandably express negative views regarding their “dependence” on regular medication, and many patients stop, start, or vary the dose of their medication. Self-management education and the issuing of personalised written action plans permit us to hand control of their condition to patients in such a way that they vary their dose of medication in a scientific manner, rather than according to whim. Patients dislike the uncertainty associated with a variable condition such as asthma, and they dislike dependency upon health professionals. Teaching patients how to vary their dose of asthma medication according to their symptoms and according to the severity of their condition returns control to them and has been shown to be associated with enhanced compliance.¹⁸ Health service usage by those with asthma is reduced by such actions and it is likely that, overall, there may be a reduced usage of medication and financial benefits.¹⁹ There can be no further excuse for delaying widespread implementation of the issuing of written personal asthma action plans. Gibson and Powell have given us a clear steer as to the important constituents of such plans. Further research is still needed into which subgroups of those with asthma benefit most, and why, for some such as the repeatedly hospitalised,²⁰ such benefit is less.

How we encourage self-management education and the issuing of personalised asthma action plans by health professionals is similarly unclear.²¹ Part of the failure may have been our failure to teach better what is involved or may reflect poor availability of materials. Part may reflect lack of motivation of healthcare professionals or lack of time. It will be of interest to see how much the financial incentive of the asthma 3+ visit plan in primary care improves implementation in Australia.²²