Do Written Self-Management Plans Improve Asthma Control? The Evidence Is Not Conclusive

University of British Columbia McDonald Research Laboratories, St Paul’s Hospital, Vancouver, British Columbia Correspondence: Dr Tony Bai, University of British Columbia McDonald Research Laboratories, St Paul’s Hospital, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6. Telephone 604 806-8704, fax 604 806-8351, e-mail tbai@mrl.ubc.ca Three components of asthma care have been promulgated by national asthma guidelines: patient education, regular review and written self-management plans. Unfortunately, the individual effects of each of these three components of a comprehensive asthma care program are difficult to separate. The available trials (2-9) are too small and the results are too inconsistent, with potential biases in patient selection and withdrawals, and problems with data collection and analyses, for any firm conclusions to be made as to the contribution of written self-management plans. In the trenches, beyond the world of efficacy studies in academia, the picture is rather bleak: the Asthma in Canada survey (10), involving 1001 randomly selected asthmatic participants, reported that only 19% had received a written action plan. Jin et al (11) surveyed Canadian specialists and family physicians, and found that the majority of the Canadian physicians did not prescribe written action plans. Thus, it is clear that the adoption of written action plans in Canada has been poor. Why do physicians not follow guidelines? Qualitative research shows that action plans are actually unpopular with both patients and health care professionals. Jones et al (12) reported that almost all participants were ambivalent about the usefulness or relevance of written action plans. The variability of design and recommendations of peak flow-based plans reveals an uncertainty as to the correct advice, and many plans are confusing to patients and health professionals who are not experts in asthma care. The Asthma in Canada survey showed that only 11% of asthmatic patients who had an action plan recalled that it contained information on how to deal with a flare-up; clearly these data question the ‘real world’ effect of written plans. The first step on written plans is increased frequency and dose of inhaled corticosteroids (ICSs). Is this an evidence-based recommendation? The evidence is not overwhelming, and results of good studies have been negative (13). Even in a clinical trial setting, when oral prednisone was indicated according to the plan, patients were adherent only 56% of the time (14). Peak flow plans are also imprecise – peak flow is well known both to underestimate the severity of outflow obstruction and to be relatively insensitive to major changes in the degree of airflow obstruction. Douglass et al (15) reported that some occupational groups are less likely to have selfmanagement plans, presumably reflecting perceived barriers by physicians to implementing plans in these groups. Interestingly, the most likely groups to have action plans were those least likely to need them! Most proponents of written asthma self-management plans propose that they should be targeted to those most at risk. These targeted groups include adolescents and young adults, who often will not or cannot read these plans. Health educators recommend that all printed material for health education be at a readability level of grade 5 or lower; however, not one of the national action plans meets this guideline, with a mean readability level of grade 8 (16). Furthermore, a recent, randomized, controlled trial of an asthma program, including a written action plan, in this high risk group showed no benefit (9). Several decades ago, most patients were treated with shortacting, inhaled beta-agonists and oral, slow-release theophyllines, and asthma control was very poor in a substantial fraction of patients – action plans had much greater intuitive sense at that time. However, with improved education and improved therapy – first by improved ICSs (including improved steroids, devices and regimens) and then by combination devices of long-acting beta-agonists and ICSs – asthma control is now much easier to achieve. Thus, the theoretical need for widespread prescription of written action plans has diminished. Moreover, written self-management plans may be a surrogate for education, ie, their primary concern is reinforcing the need to take ICSs regularly. This was shown by Cote et al (6) – the single most important effect of an asthma education program based on self-management skills was adherence to ICS use. A similar inference can be drawn from the work of Suissa et al (17), using the Saskatchewan database – simply taking a low dose of inhaled steroids prevents asthma