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Three Part Question

In [children with asthma] do [written asthma action management plans] reduce [hospital admissions]?

Clinical Scenario

A 6-year-old girl presents for a routine asthma follow-up appointment. She takes 200 µg per day of inhaled budesonide and uses her salbutamol 3–4 times per week. She has been in hospital three times in the last 2 years. The medical student in clinic asks whether you intend to offer a written management plan as these are used widely in adult practice.

Search Strategy

Medline 1950 to May week 4 2008 using the OVID interface limited to the English language
{exp Infant/or exp Child/or exp Adolescent/or exp Child, Preschool/} AND {exp Action plan/ or exp Self management/or exp Written guidelines/or exp Written advice or/exp Discharge plan/or exp Self care/or exp/Education/or exp Home management} AND {exp Exacerbation/or exp Hospital admission/or exp Morbidity/or exp PEFR/or exp Health outcome}. PubMed and EMBASE: no further relevant articles were found.

The references of relevant papers found by this method revealed three further papers included in the analysis. A recent Cochrane review4 and an update of this were found to significantly overlap with this topic area but failed to fully answer our specific question.

Search Outcome

A total of 158 papers found of which five were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Polisena et al, 2007	835 children aged 1–18 years with a diagnosis of asthma or reactive airways disease who had received a prescription for at least 1 asthma medication (bronchodilator or inhaled corticosteroid) in the past year	Observational study. 217 children had an asthma action plan and 618 did not. Significant baseline differences between groups may confound results	Children with asthma action plans had higher hospital utilisation costs ($937 compared to $832). However, a smaller proportion of children in the action plan group had a hospitalisation episode. Thus fewer children accounted for more hospitalisations in the action plan group	265 hospitalisations in the control group (n = 618) compared with 107 in the action plan group (n = 217). This gives an annual rate of 43 hospitalisations/100 children/year in control group and 49 hospitalisations/100 children/year in the asthma plan group (no p value for comparison)	Lack of randomisation to intervention group; selected only based on parental memory of action plan. A larger proportion of children for the action plan group was being seen by a respiratory paediatrician which may have indicated more severe disease
Agrawal et al, 2005	60 children aged between 5 and 12 years with moderate persistent asthma	Prospective randomised parallel group controlled trial to either individualised written asthma home management plan (n = 32) or no plan (n = 28)	Children with a written management plan were half as likely to have an acute asthma event in the first 4 months following randomisation. An event is either a hospital visit, a hospital admission or unscheduled doctor visit	Less acute asthma events in intervention group (p = 0.02) with an annual rate of 300 events/100 children/year in the control group and 150 events/100 children/year in the asthma plan group	Completed in an Indian population. Composite measure prevents direct comparison with other studies. Unclear whether hospitalisation rates are affected
Stevens et al, 2003	200 children aged 18 months to 5 years with a diagnosis of asthma or wheezing	Prospective, randomised, partially blinded, controlled trial completed in 2 centres with either (1) education booklet, written self-management plan and two educational sessions with asthma nurse or (2) usual asthma care for 12 months	Hospital admissions were increased in the intervention group over the 12-month follow-up period	26 hospitalisations/100 children/year in action plan group compared to 19 hospitalisations/100 children/year in action plan group (p = 0.29)	Only performed in pre-school children. Included children with wheeze as well as those with proven diagnosis of asthma. More than one intervention undertaken, that is, action plan plus education and educational booklet
Gillies et al, 1996	102 children aged 3–11 years with moderate or severe asthma who had never used an action plan before	Prospective open study over 6 months via GP surgery. For first 8 weeks no action plan; for following 16 weeks given "traffic-light" symptom based action plan. Children aged 5–11 given PEFR and symptom based action plan	Before and after study. After intervention hospital admissions unchanged (albeit very low rates in any case)	Before provision of asthma action plan, hospitalisation rates 20/100 children/year. At the end of the study (third period) this was unchanged	Short study periods (24 weeks in total) so cannot predict outcomes long term. No control group
Charlton et al, 1994	79 children aged 3–16 years who required admission for their asthma or were seen in an OP department.	Randomised trial to (1) asthma nurse intervention including colour coded PEFR based self-management plan and explanation or (2) standard care with PEFR meter at home but no guidance on self-management. Follow-up at 12 months	Children in the action plan group (n = 42) were slightly more likely to require hospitalisation in the follow-up period (12%) than those without an action plan (n = 37) (3%) (p = NS)	Whilst other measures of asthma control seemed to be improved in the asthma action plan group, hospitalisation rates were 12/100 children/year compared with 3/100 children/year in the control group	Relatively low rates of hospitalisation in both groups and fairly small numbers makes differences between groups difficult to assess

Comment(s)

The British Thoracic Society recommends that "patients with asthma be given written personalised action plans to reinforce self-management education". In particular "prior to discharge in-patients should receive written personalised action plans from a clinician with expertise in asthma management" (SIGN). This sentiment is echoed in many national and international guidelines (EPR-3). In adult patients with asthma, the health benefits of these self-management plans has been proven (Beasley, Burgess) but whether this can be applied to children at all remains controversial (Bhogal). Previous attempts to answer the vexed question of whether written asthma management plans are beneficial in children with asthma have identified a paucity of high-quality evidence on which to base this decision (Bhogal). Most of the studies included in their analyses (four out of five) merely compared different types of written action plan.

By reviewing all the available data (and considering studies with imperfect design) we can make some cautious judgements about the impact of written management plans on hospitalisation rates. Not only do these seem to be ineffective, but in four out of five studies we saw increases in hospitalisation. Could written management plans be harmful and if so, how?.

One possible answer to this conundrum comes from looking at the impact of educational interventions on concordance in children with asthma. Paton has shown that education may actually reduce concordance. Whilst this finding seems counterintuitive, it may explain how a combined education programme and written management plan might potentially do more harm than good.

Reading through the studies another pattern emerges. This is one of reported benefit in symptom reduction and unscheduled healthcare attendances that fall short of hospital admission. Initially this seems at odds with an observed increased rate of hospitalisation, but written plans might discourage attendance at the general practitioner or emergency department until the child has deteriorated to a point where hospitalisation is inevitable.

Editor Comment

GP, general practitioner; OP, outpatient; PEFR, peak expiratory flow rate.

Clinical Bottom Line

National guidelines continue to recommend the provision of written asthma management plans in adults and children with asthma. (Grade D)

Whilst there is good evidence for this practice in adults (grade A), evidence is lacking in children and worryingly hospitalisations may be increased in those receiving written management plans.

References

1. BTS; SIGN. British guideline on the management of asthma. Thorax 2008;63(Suppl IV):iv1–121.
2. National Asthma Education and Prevention Programme. Expert panel report 3 (EPR-3): guidelines for the diagnosis and management of asthma – summary report 2007 J Allergy Clin Immunol 2007;120(Suppl 5):S94–138.
3. Beasley R, Cushley M, Holgate ST. A self management plan in the treatment of adult asthma. Thorax 1989;44:200–4.
4. Burgess C, Ayson M, Crane J, et al. Trial of a ‘credit-card’ asthma self management plan in a high risk group of patients with asthma. J Allergy Clin Immunol 1997;97:1085–92.
5. Bhogal SK, Zemek RL, Ducharme FM. Written action plans for asthma in children. Cochrane Database Syst Rev 2006;(3):CD005306.
6. Polisena J, Tam S, Lodha A, et al. An economic evaluation of asthma action plans for children with asthma. J Asthma 2007;44:501–8.
7. Agrawal SK, Singh M, Mathew JL, et al. Efficacy of an individualized written home-management plan in the control of moderate persistent asthma: a randomized controlled trial. Acta Paediatr 2005;94:1742–6.
8. Stevens CA, Wesseldine LJ, Couriel JM, et al. Parental education and self-management of asthma and wheezing in the pre-school child: a randomised controlled trial. Thorax 2002;57:39–44.
9. Gillies J, Barry D, Crane J, et al. A community trial of a written self management plan for children with asthma. Asthma Foundation of NZ Children’s Action. N Z Med J 1996;109:30–3.
10. 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;70:313–18.
11. Zemek RL, Bhogal SK, Ducharme FM. Systematic review of randomized controlled trials examining written action plans in children. Arch Pediatr Adolesc Med 2008;162:157–63.
12. Paton JY, Love AM, Hart C, et al. Parental attitudes to asthma treatment: their significance for medication administration and outcome of an educational intervention. Arch Dis Child 2002;86(Suppl I):P17.