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Why are WPAAPs underused by health professionals?

Written, personalised asthma action plans are an important component of successful asthma education and self-management. But recent figures show that many people with asthma do not have such a plan, and that healthcare professionals provide most of the barriers …

Sally Rose
RN BSc(Hons)
Asthma Nurse Specialist
Asthma UK

Written, personalised asthma action plans (WPAAPs) and their use are recommended in the BTS/SIGN British Guideline on the management of asthma.(1) A Cochrane Library Systematic Review suggested that self-management education could help improve health outcomes for people with asthma, and the authors of the review concluded that training programmes that enable people to adjust their medication using a written asthma action plan appears to be more effective than other forms of self-management.(2) Yet many people with asthma do not have such a plan, in spite of the evidence that supports its effectiveness.
Studies into the numbers of people who have been given a written asthma action plan present a disappointing picture. One study recorded that only 3% of adults and children with asthma had been given a WPAAP setting out what they should do if their asthma deteriorated.(3) Recent survey data from Asthma UK found that only 21% of respondents have been given a WPAAP.(4)
So why are WPAAPs not more widely used? Possible reasons include both patient and health professional factors.

Patient factors
There are undoubtedly some patients who would prefer not to have a plan. One qualitative study found that patients believed plans were a good idea for other people with asthma, but not for themselves. They felt that they knew their own asthma well enough to deal with it without the use of a written plan.(5) People with well-controlled, mild, stable asthma may feel WPAAPs are irrelevant for them. Other patient factors may  nclude practical considerations such as literacy and language barriers.
But evidence from Asthma UK reveals that 65% of people without a WPAAP don't have one because they haven't been offered one or don't know what it is. Of those who do have a plan, 85% said they found it helpful in controlling their asthma.4 These results would suggest that most people are receptive to having a WPAAP and it is therefore up to health professionals to be more proactive in increasing their use.

Health professional factors
There may be several reasons why health professionals are reluctant to use WPAAPs. Working on the Asthma UK Adviceline puts the author in a unique position to hear about some of the issues surrounding the poor take-up of WPAAPs. Although the bulk of calls and emails are from people with asthma and their carers, healthcare professionals also contact the service, seeking advice and information on aspects of asthma management. Issues surrounding the implementation of WPAAPs are common themes. Examples are addressed under the following headings:

  • Time.
  • Training.
  • Tools.
  • Treatments.

Time
One of the most common barriers to implementing WPAAPs is perceived lack of time.(6) But it is surely an investment that is worth making, in light of Cochrane Review evidence that suggests that as part of a programme of self-management education, written plans can help reduce hospital admissions, emergency episodes and unscheduled visits to the doctor.2
Currently, the Quality and Outcomes Framework (QOF) of the GMS contract does not have a formal requirement to include an action plan as part of the required annual asthma review, although the supporting QOF documentation recommends that they should be considered.(7) Nurses have said that this is one of the reasons why they are discouraged from spending appointment time writing and discussing WPAAPs. If it becomes a formal indicator under the QOF system, it would be interesting to see if the percentage of patients with a WPAAP rises significantly. 
The BTS/SIGN Guideline recommends that everyone with asthma should have a WPAAP, and it can be argued that because of the variable nature of asthma, everyone diagnosed with the condition is susceptible to deteriorating control and therefore needs to know what to do when symptoms get worse.(8) However, the evidence base is more compelling for those with severe asthma, and in practice it may be prudent for nurses to prioritise those who would most benefit from a WPAAP.(1) An evidence-based review of the key components of successful WPAAPs found that those who included recommendations for both inhaled and oral corticosteroids consistently improved health outcomes.8 This would support the use of WPAAPs in people on treatment steps 2 and 3.(1)

Training
Another barrier to implementing WPAAPs appears to be lack of awareness of relevant guidelines and recommendations.(6) One way to address this is through formalised training. Training for the healthcare professional is an essential part of implementing successful asthma management and the BTS/SIGN guideline states that "in primary care, people with asthma should be reviewed regularly by a nurse or doctor with appropriate training in asthma management."(1) Training can be accessed through organisations such as Education For Health and Respiratory Education UK.
Health professionals can find ongoing support from asthma nurse specialists at the Asthma UK Adviceline. The Asthma UK website also has a section dedicated to health professionals that offers further information and resources.

Tools
WPAAPS should focus on patients' individual needs, but health professionals are not always sure of the best way to go about developing a plan.(1) Using a template or partially printed plan can be helpful as it provides structure while still allowing scope for personalising the plan. Asthma UK provides this resource as part of their Be In Control materials. The plan includes information on: what asthma treatments should be taken; when and at what doses; what to do when asthma symptoms have deteriorated; and what to do in an emergency situation. Plans for younger children (under five years old) can be downloaded by parents and carers directly from the Asthma UK website. Drug companies also produce action plans, but these tend to be biased towards using that company's particular medication so the concept of tailoring a WPAAP to the individual patient may be compromised.
WPAAPs are a partnership between patients and healthcare professionals, and it should be remembered that traditional written media might not always be the best choice for some groups of patients. More innovative ways of producing action plans to support self-management may need to be considered.(1) A recent successful example comes from a GP practice in Stockport, which has successfully piloted an online monitoring service for people with asthma. Through online contact, personalised asthma action plans can be created and adjusted.(9) This makes it ideal for patients who are unable to attend the practice (eg, because of working hours), and may also be welcomed by other specific patient groups such as teenagers.

Treatments
Another barrier to the successful implementation of WPAAPs is confusion around asthma treatments. The available choice of inhaled medicines and devices can seem daunting. Visual guides such as that in MIMS for Nurses can be helpful. It is important to stay up-to-date with available treatments and changes in licensing as it can have a significant effect on what goes into a WPAAP. For example, the licence for combined asthma therapy budesonide/formoterol (Symbicort [AstraZeneca]) has recently been extended so that the lower two strengths of the drug (Symbicort 100/6 and 200/6) can be used for both maintenance and reliever therapy.(10,11) The recently updated BTS/SIGN guideline states that: "Studies in which the dose of a combination inhaler budesonide/formoterol is adjusted according to symptoms have shown good levels of asthma control."(1)
A very common question that Asthma UK Adviceline nurses hear from health professionals is: "Should I advise patients to double the dose of inhaled corticosteroids when their asthma gets worse?" The BTS/SIGN guideline states that in adults, doubling the dose of ICS has not been shown to be effective. This does not mean it is contraindicated though, and many health professionals still include the advice as part of a WPAAP saying that in their clinical experience, increasing the dose of ICS at the first sign of an exacerbation does help some patients.
Professor Martyn Partridge provides some helpful comments on this controversy:
"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 [...] also works by reminding the noncompliant 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 that involved reducing the dose of inhaled steroid when well controlled, and then quadrupling it at the first sign of loss of control of asthma."(6)

Conclusion
The BTS/SIGN Guideline states that "Patients with asthma should be offered self-management education that should focus on individual needs, and be reinforced by a written action plan."1 But the use of WPAAPs is not widespread. Barriers to the use of WPAAPs may include some patient factors, but Asthma UK statistics suggest that healthcare professionals provide most of the barriers. Addressing issues such as training needs, familiarity with medication, and the type of action plan tool used may help health professionals be more proactive in extending the use of WPAAPs. Further research into the reasons for poor uptake of WPAAPs would also be helpful.

In the news...

Diaries aid asthma control
A study of women with asthma has found that those who keep an asthma diary have a higher level of control over their condition than those who don't.
Researchers at the University of Michigan, USA, found that women who used an asthma diary had significantly better self-efficacy, fewer unscheduled visits to their doctor and higher levels of asthma management.
Researchers also found older women and those with a higher education were more likely to keep a diary, while those with more severe asthma and a history of smoking were less likely to do so.
Kate Jarvis, Asthma UK's Health Promotion Manager, said: "We know that keeping a symptom diary or peak flow diary can be beneficial to people with asthma as it helps them closely monitor their asthma, identify triggers and tell if their asthma is getting better or worse. It's also a really useful record they can take to their doctor to aid discussion about their asthma and medicines. "However it's important people with asthma have a review at least once a year or more often if symptoms are severe, or worsen."

Asthma UK. 25 October 2007.

For daily news, go to NursingInPractice.com

References

  1. British Thoracic Society and Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. Revised edition; 2007. Available from: http://www.brit-thoracic.org.uk/c2/uploads/asthma_fullguideline2007.pdf
  2. Gibson PG, Powell H, Coughlan J, et al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Syst Rev 2002;3.
  3. Price D, Wolfe S. Delivery of asthma care: patients' use of and views on healthcare services as determined from a nationwide interview survey. Asthma J 2000;5:141-4.
  4. National Asthma Panel 2007, Asthma UK.
  5. Jones A, Pill R, Adams S. Qualitative study of use of health professionals and patients on guided self management plans for asthma. BMJ 2000;321:1507-10.
  6. Partridge MR. Written asthma action plans [editorial]. Thorax 2004;59:87-8.
  7. Department of Health. Quality and outcomes framework. London: DH; 2004. Available from: http://www.dh.gov.uk/prod_consum_dh/idcplg?IdcService=GET_FILE&dID=8581&...
  8. Gibson PG, Powell H. Written action plans for asthma: an evidence-based review of the key components. Thorax 2004;59:94-9.
  9. Stockport practice pioneers online asthma self-care. E-Health Insider August 2007. Available from: http://www.ehiprimarycare.com/news/2921/stockport_practice_pioneers_onli...
  10. EMC. Symbicort turboinhaler 100/6, inhalation powder. Available from: http://emc.medicines.org.uk/emc/assets/c/html/displaydoc.asp?documentid=...
  11. EMC. Symbicort 200/6 turboinhaler inhalation powder. Available from: http://emc.medicines.org.uk/emc/assets/c/html/displaydoc.asp?documentid=...

Resources
Asthma UK
W: www.asthma.org.uk
Asthma UK Adviceline
T: 08457 01 02 03
Education for Health
W: www.education
forhealth.org.uk
Respiratory Education UK
W: www.respiratoryeduk.com
MIMS for Nurses (subscriptions)
W: www.haymarket.com
BTS/SIGN British Guideline on the Management of Asthma - Revised Edition 2007
W: www.brit-thoracic.org.uk
  
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