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Asthma action plans: getting the message to patients

Alison Conway
RN BSc(Hons)
Respiratory Nurse Specialist
Department of Respiratory Medicine
Glenfield Hospital
Leicestershire
Regional Trainer
National Respiratory Training Centre
E:alison.conway@uhl-tr.nhs.uk

Asthma is a significant cause of premature death (ageGuidelines for the Management of Asthma in Adults.(3) Asthma deaths appear to be declining by about 6% each year, and a number of large-scale studies have demonstrated that this is probably due to the acknowledgement of asthma as a chronic condition and subsequent improvement in long-term management.(2,4) As with most chronic disease, it is essential that the patient manages their condition on a day-to-day basis and assumes control of their medication regimen. This is generally achieved through the use of self-management plans, which assist the patient in identifying changes in their condition and undertaking action in response to this change.
Self-management plans provide the patient with information on their current medication, signs of deteriorating symptoms and advice on what action to instigate in response to this deterioration.
The first BTS Guidelines for the Management of Asthma in Adults clearly recommended self-management of asthma.(3) They suggested that patients should be taught to manage their own treatment rather than consult their doctor before making changes. Similar advice has been repeated in subsequent revisions of the UK guidelines, and the BTS/SIGN guideline suggests that this terminology should now be altered to "Asthma Action Plans", reflecting preferred patient terminology.(5)
Written action plans have been shown to improve health outcomes as part of self-management education,(6,7) particularly for those patients who have moderate-to-severe disease or have had a recent hospital admission.(8) Indeed, a Cochrane review of 36 trials examining self-management education demonstrated a 40% reduction in hospital admission, 20% reduction in visits to accident and emergency, and similar reductions in night-time symptoms, days off work/school and emergency GP consultations.(9) One study demonstrated that a written asthma action plan was as effective as regular, formal medical review for optimising asthma control.(10)
Asthma action plans need not be complex and are most effective when negotiated and agreed with the individual patient.

"The patient is seen to enter the picture not just as a recipient of drugs and goodwill, but as a partner in management, someone who will and can learn to adjust, anticipate, control their disease with reference back to the carers when needed, but more and more self managing."(11)

Asthma action plans should be personalised to each individual patient and should contain the key elements shown in Table 1.

[[NIP19_table1_26]]

The use of symptom-based or peak expiratory flow (PEF) monitoring action plans will depend on a number of factors, including patient preference, cognitive ability and age. It may be helpful to combine the two so that patients, who are initially aware of deteriorating symptoms, may then initiate PEF monitoring to provide objective measurements, allowing changes in treatment to be triggered. The most important factor, however, is that the plan "fits" the patient and enables them to manage their condition.
Despite a written self-management plan and rescue oral corticosteroids, many patients fail to initiate any form of treatment changes in response deteriorating symptoms. There may be a number of potential reasons for this, such as:

  • Poor perception.
  • Health expectations and beliefs.
  • Health locus of control and autonomy.

Poor perception
Kendrick et al demonstrated that 60% of patients were poor discriminators of their asthma severity.(12) By asking patients to record serial peak flows and symptom scores, they found that many patients had marked deficits in lung function but did not have correlating severity in symptom scores. They suggested that many patients require regular PEF monitoring to determine changes in lung function in order to initiate early changes in treatment and promote self-management. The health professional must ensure that, if this method is adopted, there is not a "trade-off" between compliance with PEF monitoring and taking preventive medication.

Health expectations and beliefs
Perception of symptoms may be further modified by the patient's expectations and previous experience, particularly in the light of prolonged poor control and persistent symptoms. For example, "I've got asthma, therefore I'm likely to have a cough and get breathless. I'm like this most of the time. Sometimes I have to go into hospital but they don't keep me in for long." This proposed idea is further supported by the work of Jones et al.(13) They compared the views of patients and healthcare professionals on the use of self-management plans for asthma. It was clear from the responses of patients that they did not view asthma as a chronic condition, but more as a series of crises, which needed acute intervention and then resolved.

Health locus of control and autonomy
One final suggestion for lack of self-management behaviour in response to worsening symptoms may be that patient preference for autonomy in decision-making significantly decreased during an acute attack.(14,15) Asthma patients wanted to be informed about their condition and its treatment but did not want to take responsibility for treatment alterations when acutely unwell. This has obvious implications for the efficacy and success of self-management programmes.
 
Asthma education
To enable the patient to adhere to treatment regimens it is necessary to provide them with relevant, timely and comprehensible information concerning their disease, medication and disease management. However, this information must be tailored to the individual, taking into account their preconceptions of the disease (disease schema), their environmental circumstances, their cognitive abilities, their coping style, and any other barriers to education (eg, language, visual and auditory acuity).
Understanding the patient's own belief systems and reframing explanations in light of these beliefs is crucial to effective communication.
In the current NHS, where the emphasis is on productivity, the length of time allotted for a consultation may have a detrimental effect on the amount of information given. Many practitioners are forced to provide sufficient information to make the patient "safe" and initiate some form of treatment before the next scheduled visit.
However, the three basic principles of a successful asthma education programme can be summarised as "three Ps and one R":(16)

  • Personalised.
  • Practical.
  • Preventive.
  • Repeated.

The health professional may be forced to accept that the ideal treatment regimen for the patient may not be the ideal regimen in the patient's eyes.
Attaining a successful asthma management programme for a patient will be achieved through the art of skillful negotiation. This may range from encouraging the patient to stop smoking, to actually getting them to take any medication at all. Involving the patient in the consultation as much as possible and agreeing joint goals will ultimately involve some compromise on both sides, and the healthcare professional must be prepared for and accept this.
Despite the established benefits of asthma action plans, only 6% of people with asthma interviewed in a recent survey had a written plan detailing their use of medication, and only 3% had a plan that told them what to do in the light of increasing symptoms.(17) Even in those patients with the most severe symptoms, only 18% had a plan that described their current medication.
The current BTS/SIGN guideline recognises the importance of asthma action plans,(5) but widespread implementation will take considerable effort and a change in attitude on the part of both patients and healthcare professionals.

References

  1. Barnes N. Asthma: the lung report. London: British Lung Foundation; 1996. p. 12-4.
  2. National Asthma Campaign. National Asthma Audit 1999/2000. London: Direct Publishing Solutions; 1999.
  3. British Thoracic Society. Guidelines for the management of asthma in adults. Statement by the British Thoracic Society, Research Unit of the Royal College of Physicians of London, King's Fund Centre, National Asthma Campaign. BMJ 1990;301:651-3, 797-800.
  4. Bucknall CE, Slack R, Godley CC, Mackay TW, Wright SC. Scottish Confidential Enquiry into asthma deaths (SCIAD) 1994-6. Thorax 1999;54:978-84.
  5. British Thoracic Society/Scottish Intercollegiate Guidelines Network. British Guideline on the management of asthma. Thorax 2003;58 Suppl 1:1-94.
  6. Charlton I, Charlton G, Broomfield J, et al. Evaluation of peak flow and symptoms only self-management plans for control of asthma in primary care. BMJ 1990;301:1355-9.
  7. Lahdensuo A, Haahtela T, Herrala J, et al. Randomised comparison of guided self management and traditional treatment of asthma over one year. BMJ 1996;312:748-52.
  8. Yoon R, McKenzie DK, Bauman A, et al. Controlled trial evaluation of asthma education programme for adults. Thorax 1993;48:110-6.
  9. Gibson PG, Coughlan J, Wilson AJ, et al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Systematic Review (1): CD001117. Oxford: Update Software; 2003.
  10. Powell H, Gibson PG. Options for self-management education for adults with asthma. Cochrane Database Systematic Review (1): CD004107. Oxford: Update Software; 2003.
  11. Lane D. Cited in Pearson R. Asthma management in primary care. Oxford: Radcliffe Medical Press; 1990. p. viii.
  12. Kendrick AH, Higgs CM, Whitfield MJ, Laszlo G. Accuracy of ­perception of severity of asthma: patients treated in general practice. BMJ 1993;307:422-4.
  13. Jones A, Pill R, Adams S. Qualitative study of views of health professionals and patients on guided self management plans for asthma. BMJ 2000;321:1507-10.
  14. Gibson RG, Talbot PI, Toneguzzi RC. Self-management, autonomy and quality of life in asthma. Chest 1995;107:1003-8.
  15. Adams RJ, Smith BJ, Ruffin RE. Patient preferences for autonomy in decision making in asthma management. Thorax 2001;56:126-32.
  16. Osman L. What basic asthma education should be given to all asthma patients. In: National Asthma and Respiratory Training Centre. Ask the experts. London: Class Publishing; 1997. p. 177-8.
  17. Price D, Woolfe S. Delivery of asthma care: patients' use of and views on healthcare services, as ­determined from a nationwide interview survey. Asthma J 2000;5:S12-4.

Resources
Asthma UK (new name for National Asthma Campaign) Providence House
Providence Place
London N1 0NT
T:020 7226 2260
F:020 7704 0740
W:www.asthma.org.uk
Asthma UK Scotland
2a North Charlotte Street
Edinburgh
EH2 4HR
T:0131 226 2544
F:0131 226 2401
National Respiratory
Training Centre
The Athenaeum
10 Church Street
Warwick
CV34 4AB
T:01926 493313
F:01926 493224
W:www.nrtc.org.uk
British Thoracic Society
17 Doughty Street
London
WC1N 2PL
T:020 7831 8778
F:020 7831 8766
E:bts@brit-thoracic.org.uk
W:www.brit-thoracic.org.uk