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QUESTIONS: Is regular medical review (RMR) better than written self management plans for optimising asthma control in adults with asthma who use inhaled corticosteroids? Do health outcomes differ for written self management plans based on peak expiratory flow self management (PFSM) and those based on symptom self monitoring (SSM)?
Studies were identified by searching the Cochrane Airways Group Special Register of Controlled Trials (which comprises results of searching Medline, EMBASE/Excerpta Medica, and CINAHL), and reviewing bibliographies of relevant articles.
Studies were selected if they were randomised controlled trials (RCTs) of ≥2 self management asthma education interventions in adult patients with asthma who were >16 years of age, and reported relevant health outcomes.
2 reviewers independently extracted data on sample size, demographic characteristics, details of the intervention, setting, study quality, and outcomes. Outcomes included forced expiratory volume in 1 second (FEV1), peak expiratory flow, hospital admissions, emergency department visits, unscheduled doctor visits, days lost from work or school, and use of rescue medications.
15 RCTs (2460 patients) met the selection criteria. Meta-analyses were done using a fixed effects model. Primary comparisons included optimal self management with RMR (6 RCTs) comparing 2 interventions that optimised asthma control using dose adjustment of inhaled corticosteroids either by active RMR or an individualised written self management plan where dose adjustment was based on PFSM or SSM. Meta-analysis of 3 RCTs (n=707) showed that the groups did not differ for FEV1 or peak expiratory flow (table⇓). The groups did not differ for hospital admissions for asthma (4 RCTs), emergency department visits (1 RCT), unscheduled doctor visits(3 RCTs), days off work or school (2 RCTs), nocturnal asthma (3 RCTs), or disrupted days (1 RCT).
The other primary comparison was PFSM with SSM (6 RCTs). Meta-analysis showed that the groups did not differ for hospital admissions (4 RCTs, n=412), emergency department visits (5 RCTs, n=512) (table⇑), unscheduled doctor visits, days lost from work, or corticosteroid use.
Regular medical review is not better than written self management plans in adults with asthma who use inhaled corticosteroids. Self management plans based on peak expiratory flow self management did not differ from those based on symptom self monitoring, for optimising asthma control.
Evidence suggests that the global prevalence of asthma is increasing by as much as 50% every 10–15 years.1 Usually, asthma can be controlled so that an individual experiences minimal symptoms (cough, wheeze, shortness of breath) and few disruptions in usual daily activities. As a result, the goal of asthma care guidelines internationally is to achieve minimal experience of symptoms and disruption because of asthma while using the least amount of medication.1–,4 Typically, core elements of asthma practice guidelines include confirming the diagnosis, providing appropriate medications, using environmental control strategies to minimise or avoid exposure to triggers, and providing asthma education and support for self management.1–,4
Previous work by Gibson et al established that adults with asthma who receive self management education, RMR, and a written action plan show important improvements in asthma outcomes, such as use of healthcare services (emergency department visits and unscheduled doctor visits), days lost from work, nocturnal asthma, indirect costs, and quality of life.5 Furthermore, Gibson et al’s work highlighted the fact that less intensive education programmes are not as beneficial,5–,6 specifically programmes that provide only patient information. The reviews by Wolf et al and Powell and Gibson extend our current understanding of key aspects of asthma care, education, and self management.
The review by Powell and Gibson suggests that optimal asthma control in adults, through the adjustment of medications, can be achieved equally well using either a written action plan or RMR. Furthermore, the action plan can be based on symptom experience alone or peak flow measurements plus symptoms. This finding is important because it shows that patients have the ability to self adjust medications according to a written plan developed in conjunction with asthma care providers. Thus, individuals who prefer to be more actively involved in their own care can adjust medications as a stepped course of action without seeking medical assistance.
An action plan is a written set of instructions that helps patients to self monitor the level of asthma control through symptom experience and/or peak flow measurements and outlines steps to maintain or regain asthma control. The action plan sets individual parameters for monitoring asthma control and steps to respond to the level of asthma control, such as increasing the dose of inhaled corticosteroid, starting an oral glucocorticoid, or seeking medical attention. The importance of action plans or self management plans for achieving optimal control is acknowledged in asthma care guidelines.1–,4
The review by Wolf et al shows that the benefits of asthma self management programmes also apply to children and adolescents. All of the studies included in this review provided action plans and education on asthma prevention and management of worsening asthma.
In summary, these reviews establish the importance of the recommendations of asthma care guidelines. Patients with asthma should receive self management education and a written action plan, based on symptoms or peak expiratory flow, which is tailored to individual needs. After determining a patient’s ability to follow an action plan and readiness to learn, nurses need to ensure that each patient has an action plan that is understood and used appropriately, and that the recommended medications are used with appropriate techniques. Asthma education should be regarded as a process, rather than a single event, with ongoing reassessment and reinforcement at each encounter.
Source of funding: Cooperative Research Centre for Asthma, Australia.
For correspondence: Dr P Gibson, Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia..
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