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Patients with uncontrolled asthma are at increased risk for hospitalization and frequent visits to the emergency department (ED). Self-management skills are widely promoted by health plans and specialty societies with the expectation that they will improve care for people with asthma. Although written action plans and peak flow meters are considered to be key components of asthma self-management, a recent study has shown that despite widespread use, action plans probably do not have a large effect on outcomes when applied to the general asthma population. These are findings from a study by the Blue Cross Blue Shield Association Technology Evaluation Center in Chicago, an Agency for Healthcare Research and Quality
Evidence-based Practice Center (contract 290-97-0015).
A second AHRQ-supported study (HS07834) shows that asthma patients who are counseled by community pharmacists don't improve in lung function or quality of life compared with those who are not counseled. The researchers note, however, that inadequate pharmacy staffing may have limited pharmacists in providing the advice they were trained to provide. Both studies are discussed here.
Lefevre, F., Piper, M., Weiss, K., and others (2002, October). "Do written action plans improve patient outcomes in asthma? An evidence-based analysis." Journal of Family Practice 51(10), pp. 842-848.
A peak flow monitor allows asthma patients to blow into a tube to record the force of expiration, an indication of lung functioning. A written plan typically advises the patient what to do when the peak flow drops a certain amount (indicating lung inflammation), usually adjusting medications, to prevent worsening of the asthma. Both of these approaches are advised, along with medication, to manage asthma. Although written action plans are widely used, there is insufficient evidence to determine whether their use, with or without peak flow monitoring, improves asthma outcomes, according to this analysis.
The investigators systematically reviewed published studies of randomized controlled trials that compared the outcomes of an asthma self-management intervention with and without the use of a written action plan. The studies examined asthma outcomes such as hospitalizations, ED visits, and measures of symptom control and lung function. Of the reviewed studies, nine trials enrolling a total of 1,501 patients, met selection criteria. The majority did not show improved asthma outcomes associated with a written action plan. However, many of the studies had methodologic flaws, and none met the definition of high quality.
Although this review did not establish that written asthma plans are ineffective, it suggests that they will not have a large effect on outcomes when applied to the general population of people with asthma. The indiscriminate application of written action plans to all people who have asthma may be a wasteful use of resources. As a behavioral intervention, the general principle of engaging patients in self-management may be more important than the specific components of these programs. Also, compared with the optimal use of medications, particularly the use of inhaled steroids, the impact of written action plans is likely to be relatively small, particularly on lung function or symptom control. Patients with more severe asthma may be most likely to benefit from self-management interventions.
Stergachis, A., Gardner, J.S., Anderson, M.T., and Sullivan, S.D. (September, 2002). "Improving pediatric asthma outcomes in the community setting: Does pharmaceutical care make a difference?" Journal of the American Pharmaceutical Association 42, pp. 743-752.
This study found that when community pharmacists advised children with asthma how to use metered dose inhalers or about other medication issues it did not affect pediatric asthma outcomes or the use of health care services. However, pharmacists' compliance with the study protocol was low, due in part, to patient- and practice-related obstacles.
The researchers examined asthma outcomes and use of health care services of 330 children, aged 6 to 17 years, who filled asthma medication prescriptions at 14 intervention (153 children) or 18 usual care (177 children) HMO or community pharmacies in Washington State. Intervention (IN) pharmacists were trained to provide individualized asthma management services to these children during patient-pharmacist (and/or parent-pharmacist) encounters for up to 1 year after study enrollment.
IN pharmacists attended or watched a videotape of an 8-hour group training session on age-appropriate goals for asthma management, patient assessment and age-appropriate communication tips, documentation of pharmaceutical care, and the like. They also received followup support via newsletters and site visits. They were expected to establish a relationship with the patient, collect relevant patient data, assess the patient for potential or actual drug-related problems, prioritize and make a plan for resolving each drug-related problem, implement the plan, and provide followup. The children in both groups were similar in age, sex, ethnicity, household income, and duration of asthma.
Of the 153 IN patients, 69 percent received one or more interventions from a pharmacist, most often oral or written information about the treatment plan. Sixty-six percent of patients in the IN group and 39 percent of patients from the UC group reported speaking with the pharmacist once during the study period. There was no evidence that patients in the IN group compared with the UC group experienced improvements in pulmonary function, functional status, quality of life, asthma management, satisfaction with care, or use of antiinflammatory medications, total asthma-related medical care use, or asthma-related school days lost. Although most pharmacists felt they learned what to do, more intensive training programs may be needed. High prescription volume, insufficient staffing, and poor patient motivation were barriers to pharmacists performing recommended interventions.
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