Do written action plans improve patient outcomes in asthma? An evidence-based analysis

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Original Research

Do written action plans improve patient outcomes in asthma? An evidence-based analysis

J Fam Pract. 2002 October;51(10):842-848

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References

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13. Jones KP, Mullee MA, Middleton M, et al. Peak flow based asthma self-management: a randomised controlled study in general practice. British Thoracic Society Research Committee. Thorax 1995;50(8):851-7.

14. Drummond N, Abdalla M, Beattie JAG, et al. Effectiveness of routine self monitoring of peak flow in patients with asthma. Grampian Asthma Study of Integrated Care GRASSIC). BMJ 1994 Feb. 26;308(6928):564-7.

15. Ayres JG, Campbell LM. A controlled assessment of an asthma self-management plan involving a budesonide dose regimen. OPTIONS Research Group. Eur Respir J 1996;886-92.

16. Cowie RL, Revitt SG, Underwood MF, et al. The effect of a peak flow-based action plan in the prevention of exacerbations of asthma. Chest 1997;112(6):1534-8.

17. Cote J, Cartier A, Robichaud P, et al. Influence on asthma morbidity of asthma education programs based on self-management plans following treatment optimization. Am J Respir Crit Care Med 1997;155(5):1509-14.

18. Ignacio-Garcia JM, Gonzalez-Santos P. Asthma self-management education program by home monitoring of peak expiratory flow. Am J Respir Crit Care Med 1995;151(2 Pt 1):353-9.

19. Charlton I, Antoniou AG, Atkinson J, et al. Asthma at the interface: bridging the gap between general practice and a district general hospital. Arch Dis Child 1994;70(4):313-8.

20. Turner MO, Taylor D, Bennett R, et al. A randomized trial comparing peak expiratory flow and symptom self-management plans for patients with asthma attending a primary care clinic. Am J Respir Crit Care Med 1998;157(2):540-6.

21. Charlton I, Charlton G, Broomfield J, et al. Evaluation of peak flow and symptoms only self-management plans for control of asthma in general practice. BMJ 1990;301(6765):1355-9.

TABLE 1

Study characteristics

Study	Patient popultation	Study Arms	Intervention components	Outcomes reported	Asthma quality indicators met
Optimal medical management vs. optimal medical management + PFM action plan
Jones 1995¹⁴	Inclusions: patients using ICS	Usual care	SxD, FU	Ut, LF, Sx	Pow, Med
	Exclusions: patients on oral steroids or using peak flow meters at home	PFM action plan	AP, PF, SxD, FU
	Mean age: 29.5 years
	Severity level: Mild–moderate
Drummond 1994 (GRASSIC)¹⁵	Inclusion: FEV1 reversibility 20% or greater	Usual care	FU	Ut, LF, Med Ex	Pow, Rev
	Exclusions: patients who already owned a PFM	PFM action plan	AP, PF, FU
	Mean age: 50.8 years
	Severity level: Mild–severe
Ayres 1995¹⁶	Inclusions: maximum PEF variability, 0.15%; minimum nights/week with symptoms, 3; minimum use of ICS or sodium cromoglycate, 3 months	Usual care	SxD, FU	LF, Sx, Ex	Pow, Med
	Mean age: 45 years	PFM action plan	AP, PF, SxD, FU
	Severity level: Moderate–severe	PFM action plan	AP, PF, SxD, FU
Cowie 1997¹³	Inclusions: treatment for an exacerbation of asthma in an ER asthma clinic; history of receiving urgent treatment for asthma in the previous 12 months	Usual care	Ed, SxD, FU	Ut, PF, Med, Ex	None
	Mean age: 37.8 years	PFM action plan	AP, PF, Ed, SxD, FU
	Severity level: Mild–severe	PFM action plan	AP, PF, Ed, SxD, FU
Cote 1997¹⁷	Inclusions: FEV₁postbronchodilator 85-100 % of predicted; PEF, at minimum, 85 % of predicted; minimum PEF variability, 0%; Methacholine	Usual care	Ed	Ut, LF, Med	Exc, Rev, Com
	Exclusions: patients having previously taken an asthma educational program	PFM action plan	Ed, Cn, AP, PF
	Mean age: 36.5 years Severity level: Mild	PFM action plan	Ed, Cn, AP, PF
Usual care + PFM use alone vs. usual care + PFM action plan
Ignacio-Garcia 1995¹⁸	Inclusions: patients from outpatient asthma clinic with asthma for 2 years	Usual care + PFM	PF, SxD, FU	Ut, LF, Med	None
	Mean age: 41.9 years	Usual care + PFM action plan	PF, AP, Ed, SxD, FU
	Severity level: Mild–severe	Usual care + PFM action plan	PF, AP, Ed, SxD, FU
Charlton 1994¹⁹	Inclusion: patients with inpatient or outpatient visit for asthma	Usual care + PFM	PF, Ed, SxD, FU	Ut, Sx, Med, Ex	None
	Mean age: 6.5 years	Usual care + PFM action plan	PF, AP, Ed, SxD, FU
	Severity level: Mild–moderate	Usual care + PFM action plan	PF, AP, Ed, SxD, FU
PFM action plan vs. Symptom action plan
Turner 1998²⁰	Inclusions: Maximum methacholine PC₂₀, 7.9; using ICS	Symptom action plan	AP, Ed, SxD, Cn BM, EM	Ut, LF, Sx, Med	Exc, Com
	Exclusions: previous PFM use; significant comorbid conditions	PFM action plan	PF, AP, Ed, SxD, Cn BM, EM
	Mean age: 34.1 years
	Severity level: Mild–severe
Charlton 1990²¹	Inclusions: patients on repeat prescribing register	Symptom action plan	AP, Ed, FU	Ut, Med	None
	Mean age: NR	PFM action plan	PF, AP, Ed, FU, Cn	Ut, PF, Med, Ex	None
	Severity level: Mild–severe (?)	PFM action plan	PF, AP, Ed, FU, Cn	Ut, PF, Med, Ex	None
Cowie 1997¹⁶	Inclusions: treatment for an exacerbation of asthma in an ER, or asthma clinic; history of receiving urgent treatment for asthma in the previous 12 months	Symptom action plan	AP, Ed, SxD, FU
Cowie 1997¹⁶		PFM action plan	AP, PF, Ed, SxD, FU
Cote 1997¹⁷	Inclusions: FEV₁postbronchodilator, 85-100 % of predicted; PEF, at minimum, 85 % of predicted; minimum PEF variability, 0%; Methacholine	Symptom action plan	Ed, AP	Ut, LF, Med	Exc, Rev, Com
Cote 1997¹⁷	Exclusions: previous enrollment in an asthma educational program	PFM action plan	Ed, Cn, AP, PF	Ut, LF, Med	Exc, Rev, Com
Eligibility criteria: ICS = inhaled corticosteroid; FEV1 = forced expiratory volume in 1 second; PEF = peak expiratory flow; PFM = peak flow meter; ER = emergency room; PC20 = 20% fall in FEV1 Intervention components: PF = Peak flow meter; AP = Written Action Plan; Ed = Education; SxD = Symptom diary; FU = Follow-up visits; Cn = Counseling; BM = Behavior modification; EM = Environmental modification
Outcomes: Ut = Utilization measures; LF= Lung function measurements; Sx = Symptom=based measurements; Med = Medication use; Ex = Exacerbations of asth ma Asthma Quality Indicators: Exc = Accounted for excluded patients; Pow = Reported power calculations; Rev = Established reversibility of airway obstruction; Med = Controlled for other medication use; Com = Reported compliance; Sea = Addressed seasonality.

TABLE 2

Power calculations for hospitalizations per patient per year

Assumed control mean	Possible treatment mean	% decrease	N needed per study arm
0.10	0.075	25	3077
0.10	0.05	50	770
0.10	0.025	75	342
0.20	0.015	25	770
0.20	0.10	50	193
0.20	0.05	75	86
0.30	0.225	25	342
0.30	0.15	50	86
0.30	0.075	75	38
Studies were identified that contained baseline rates on hospitalizations/patient/year, or information that allowed calculation of this parameter (Drummond, Abdalla, Beattie et al., 1994; Cote, Cartier, Robichaud et al. 1997; Cowie, Revitt, Underwood et al., 1997; Ignacio-Garcia and Gonzalez-Santos, 1995). Baseline rates of hospitalization varied in these studies from 0.04-0.29/patient/year. Standard deviations for this outcome were available only in two studies; Cote, Cartier, Robichaud et al. (1997) reported an SD of 0.30 for this variable, and an SD of 0.35 was calculated from the confidence intervals reported in GRASSIC (Drummond, Abdalla, Beattie et al., 1994). For the calculations, the more conservative 0.35 estimate for SD was used.
Number of patients per study arm were estimated for 80 percent power at the 5 percent significance level using control arm means of 0.10, 0.20, and 0.30 hospitalizations/patient/year. The expected reduction in this variable was tested along a spectrum from 25-75 percent.

Written action plan versus no written action plan

All 5 studies used a peak flow meter based written action plan. All reported utilization outcomes, but the types and units of measurement were not consistent across studies (Table 2). Additionally, 4 studies reported on symptoms,^13-16 and 3 reported lung function outcomes.^13-15