| A population survey of the reported ownership of asthma action plans. Where to from here? | par 0 |
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Authors: | par 1 |
| Professor Richard E Ruffin , FRACP, MD, Head, Division of Medicine, The Queen Elizabeth Hospital, Michell Professor of Medicine, The University of Adelaide, Respiratory Physician, 28 Woodville Rd, WOODVILLE, SOUTH AUSTRALIA 5011 | par 2 |
| Dr David Wilson , PhD, MPH, Centre for Population Studies in Epidemiology, Department of Human Services, 11 Hindmarsh Sq ADELAIDE SOUTH AUSTRALIA 5000 | par 3 |
| Dr Anne Marie Southcott , MBBS (Hons), FRACP, A/Director, Respiratory Medicine, TQEH, Respiratory Physician, 28 Woodville Rd, WOODVILLE, SOUTH AUSTRALIA 5011 | par 4 |
| Dr Brian Smith , MBBS, FRACP, Director, Clinical Epidemiology & Health Outcomes Unit, TQEH, Senior Lecturer, University of Adelaide, Respiratory Physician, 28 Woodville Rd, WOODVILLE, SOUTH AUSTRALIA 5011 | par 5 |
| Dr
R Adams
, MBBS,
FRACP, Research Fellow, Channing Laboratory, Brigham & Women. s
Hospital, Harvard Medical School, 181 Longwood Ave, BOSTON MA 02115-5899 USA
Accepted for publication 26.8.99, electronically published 6.9.99 without editing, then edited and published in print 4.10.99.
This is the first revised version of this paper (25 August 1999). | par 6 |
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ABSTRACT |
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| Objective: To examine the relationships between ownership of written asthma action plans, asthma morbidity, use of devices and patients perceptions of their asthma management. | par 8
Comment Comment |
| Design: A random population survey of the South Australian population aged >15 years using interviewers to administer a questionnaire. | par 9 |
| Setting: The South Australian Population in 1996. | par 10 |
| Participants: Those people self reporting current, doctor diagnosed asthma | par 11 |
| Main Outcome Measures: Prevalence of written asthma action plans, night time awakenings from asthma, ownership of peak flow meters and perceptions of own asthma management | par 12 |
| Results: The ownership of asthma action plans by people with self reported asthma was 33% and has declined since 1995 (42% p<0.001). 15.2% of asthmatics had night symptoms weekly or more frequently and (compared to those without nocturnal symptoms or less frequently than weekly) were more likely to report possession of a peak flow meter and to have written action plans, but were less likely to consider they had been provided with enough information about their asthma, to feel comfortable taking care of their asthma, or to find it easy to see their doctor. Ownership of an asthma action plan was associated with regular corticosteroid use, understanding asthma, having enough information and peak flow meter ownership. | par 13 |
| Conclusions: Asthma management in South Australia is sub-optimal. We must determine if there is a need to be targeting less severe asthmatics and/or improving guideline use by professionals before we develop new strategies to improve asthma outcomes. | par 14
Comment |
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INTRODUCTION |
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| Studies of the use of asthma management plans have shown improved health outcomes for people with asthma (1-3). It has even been claimed that the effect of an asthma management plan can be the achievement of relatively normal lung function (3). There is evidence in Australia that the promotion of asthma plan guidelines by the Thoracic Society of Australia and New Zealand and National Asthma Campaign promotions have led to increased uptake of plans (4). A South Australian study showed that the prevalence of adult asthmatics reporting they had a written action plan almost doubled between 1992 and 1995 (5). However we cannot afford to be complacent about the gains made in the management of asthma (6-8). In one Victorian study of asthma mortality, 45% of cases had been assessed as having only a history of mild or moderate asthma (6). In a second study examining asthma knowledge of Victorian asthma patients, the median score obtained was less than 50% of the total score possible (7). | par 16 |
| Although there is no universal asthma action plan prototype a number of centres have used common elements (1-3). Clark (9) reviewed the elements and re-stated the need for asthmatics to recognise signs/symptoms of asthma; take medications in the prescribed way; manage side effects; remain calm during attacks; recognise and respond to symptoms that require emergency care; communicate effectively with physicians; and, minimise exposure to triggers. However there are serious deficiencies in the education of asthma patients about the important elements (7, 10, 11). The effective implementation of asthma management plans in Australia to date has been seriously questioned by some investigators (8) and Bauman et al have concluded that the treatment and management of asthma is sub-optimal (12). | par 17 |
| This study aims to provide representative population information on the ownership of written asthma action plans and the relationship to asthma morbidity and management factors. | par 18
Comment |
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METHODS |
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| The data for this study were collected in the 1996 South Australian Health Omnibus Survey,(13) a representative survey of adults aged 15 years or older (n= 3010,response 71%). The survey was a multistage, systematic, clustered area sample of persons who live in metropolitan Adelaide and major country centres with a population of over 1000 persons. Hotels, motels, hospitals, nursing homes and other institutions were excluded. The person whose birthday was next in the selected household was interviewed in their home by trained health interviewers. There was no replacement for non-respondents. Up to five call backs were made in an attempt to interview the selected person. The sample was selected from a random sample of Australian Bureau of Statistics collector districts. Within each collector. s district a random starting point was selected and from this point ten households were selected using a fixed skip interval. The data were weighted by age, gender, and geographic region to the estimated resident population data so that the analysis would be representative of the South Australian population. | par 20
Comment |
| A person was classified as having asthma if they answered yes to each of the following questions - if a) they had ever had asthma, b) their asthma had been confirmed by a doctor, and c) they still had asthma. They were asked if they had an asthma action plan (written instructions of what to do if their asthma is out of control). Morbidity from asthma was assessed by frequency of wakening at night with asthma, which was dichotomised into wakening once a week or more frequently, and wakening less often than once a week. Other morbidity questions were whether in the last twelve months they had lost days from work, school or home duties as a result of asthma, or had been to hospital for asthma. Possession of an asthma action plan and frequency of wakening at night were used as the two dependent study variables. Questions about self-management asked whether they used a peak flow meter and/or a home nebuliser. They were asked what preventive medicine they used regularly for their asthma and which statements from a showcard they felt were true about how their preventer medication worked. Self-management and perception questions included: how they would respond given a bad attack of asthma?; how they would feel getting help for a bad attack?; how they feel taking care of their asthma?; their perception of how they understand asthma; perception of self-management of asthma; given a severe attack, how comfortable they are going to a doctor or hospital with asthma?; the ease and convenience of seeing a doctor for asthma?; and, perception of the information they have to deal with worsening asthma?. Other questions asked about smoking status, educational level and migrant status were asked. Social class was determined using occupational prestige obtained from the Australian Standard Classification of Occupations (14). | par 21
Comment Comment Comment Comment |
| Univariate analyses, using SPSS Version 8,(15) examined the associations of above variables with possession of an asthma management plan and frequency of wakening at night with asthma as the dependent variables using chi-square tests to determine statistical significance. Variables found to be significant at the univariate stage at p=0.25 (16) were entered into three separate logistic regression analyses at single step, using the same dependent variables. Insignificant variables were progressively omitted until satisfactory models were found that explained possession of an asthma plan and frequency of wakening at night. Prior to conducting the logistic regressions, the data were examined for interactions and stratified analyses were used to check homogeneity of associations across different levels of predictor variables. An interaction was found between smoking status and the information that people with asthma perceive they have for dealing with worsening asthma, and the effect of these variables on worsening asthma. An interaction term for the two independent variables was included in the logistic regression analysis for frequency of wakening at night. This interaction term proved significant, (p=0.03) indicating the need to split the model and conduct separate logistic regression analyses of smokers and non-smokers. Before conducting multivariate analyses predictor variables were examined to ensure the models were not subject to multicollinearity. | par 22
Comment |
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RESULTS |
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| The prevalence of asthma in this study was 11.6% (95% CI 10.3% to 12.9%). Of the 349 with asthma 33% (CI 30.8% to 35.2%) had a written asthma action plan and 15.2% (CI 13.7% to 15.7%) were awakened by asthma weekly or more frequently. No significant differences were shown by age, gender, migrant status, education level or socio-economic status for those who possessed an asthma action plan or not; nor for those who were wakened with asthma weekly or more frequently or not (Table 1). | par 24
Comment Comment |
| The variables significantly associated with ownership of an asthma action plan at the univariate level were more likely to: use inhaled corticosteroids regularly; understand the effects of these medications; have a peak flow meter and a home nebuliser; say they understood their asthma; believe they have enough information to deal with worsening asthma; have been admitted to hospital for asthma in the previous twelve months; and, have lost days from work or school in the last twelve months. | par 25
Comment Comment Comment Comment |
| The variables significantly associated with nightime asthma symptoms weekly or more frequently at the univariate level were more likely to: understand the effects of corticosteroids; have a peak flow meter and a home nebuliser; perceive their self-management techniques as poor; and have lost days form work or school in the last twelve months. They were significantly less likely to say it was easy and convenient to see their doctor or to feel comfortable taking care of their asthma. The variable "less likely to believe they have enough information to deal with worsening asthma" approached statistical significance (p=0.06). In people who wakened with asthma weekly or more frequently the ownership of an asthma action plan (19.8% Yes vs 13.4% No) was not a distinguishing factor. | par 26
Comment Comment |
| From the multivariate analyses the variables that best described those who had an asthma action plan were more likely to: use corticosteroids; understand the effects of worsening asthma; have a peak flow meter; and believe they have enough information to deal with worsening asthma (Table 2). The variables that best described non-smokers who waken weekly or more often were more likely to: have a peak flow meter; have an asthma action plan; and less likely to have enough information to deal with worsening asthma; or to feel comfortable taking care of their asthma. Only one variable explained wakening weekly or more often for smokers - was less easy or convenient to access their doctor about asthma. | par 27
Comment Comment |
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DISCUSSION |
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| The data obtained in this representative population study paint a bleak picture about the effectiveness of asthma management in Australia assessed by the coverage of asthma action plans. It is disappointing that 6 to 7 years on from the promulgation of guidelines on the implementation of asthma action plans for Australia, only 33% of people with diagnosed asthma had a written plan. A study of deaths from asthma in Victoria (6) found that a proportion of people with mild or moderate asthma died from asthma which may mean that every asthmatic needs an asthma action plan. It is of concern that the current plan ownership (33%) is lower than the 42.1% (p<0.001) reported twelve months earlier using the same survey methodology (5). This may mean that vigilance regarding asthma management plans is declining in the health services although one subgroup analysis showed that non-smokers wakening frequently were more likely to have an action plan. | par 29 |
| The limitations of this study are (i) the absence of objective data to distinguish between asthma severity and asthma control and (ii) the repeatability of the answers to the perception questions need to be established. | par 29a |
| Further, this study has focussed on ownership of written action plans. This means that we do not have knowledge of appropriate use of these plans by patients nor if verbal instructions are being utilised. | par 29b |
| [] Only the use of preventer medication, ownership of a peak flow meter and self-reported understanding of asthma were associated with plan ownership in the multivariate analyses. This association could suggest that the more severe cases have better asthma management. Proof for this idea requires prospective measures (eg lung function, medication doses) to assess the two critical factors of asthma severity and asthma control. Such knowledge could inform us of the potential need to target the less severe asthma population. | par 30
Comment |
| [] Asthmatics with nocturnal symptoms were more likely than those without nocturnal symptoms to report possession of a peak flow meter, and to have asthma action plans, but were less likely to consider they had been provided with enough information about their asthma (non smokers), or to find it easy to see their doctor (smokers) (Table 2). Thus, although those asthmatics with a higher level of morbidity are more likely to receive physical materials to assist in self-care, they continue to have greater unmet needs of ease of general practitioner access, information about asthma and self-management confidence. These analyses reinforce the Bauman et al (1992) warning that management of asthma in Australia is sub-optimal (12). | par 31
Comment Comment |
| What is the way forward? Randomised studies of the implementation of asthma plans show that good educational and skill objectives can be achieved (1, 17-19). However, the complexity of the asthma management problem make it impossible to provide for every contingency the patient will face in dealing with asthma. Asthma management decisions can be difficult because the patient, the daily situation, the science base and the disease are in a state of constant change (1). The objectives of patient asthma management are the development of skills and positive attitudes to problem solving their disease situations, accompanied by sufficient knowledge to make sense of changing morbidity and symptoms. An Australian controlled trial evaluation of a brief asthma education program (2.5 to 3 hours group work) demonstrated substantial changes in illness behaviour (1). These programs show that skilling the patient cannot be achieved in the normal constraints of general practice. Randomised control trials of asthma clinics, where there is an emphasis on self-management, have demonstrated improvements in a range of morbidity and other health related outcomes in a community based setting (20). We must identify other ways of training the patient and focus the clinician on that part of the education program that can be managed in the general practice situation. There is evidence that regular review improves asthma outcomes (21). It is pertinent ot to consider the possibility that inadequate guideline use by health professionals may be contributing to the fall in action plan ownership. Ways to improve guideline use need to include information technology developments. | par 32
Comment Comment |
| [] Trostle (22) has identified that the inability of some people to comply with a treatment regime is an unavoidable by-product of collisions between the clinical world and other competing worlds of work, family, friends and recreation. Often the process required to skill the patient is more than an educational task and there is a need to understand more about the patient context that is affecting outcomes. [] It is appropriate to identify that some of the traditional models of patient education based on health beliefs or compliance frameworks have been seriously questioned (23-24). Patients have to fit their medical problems and medical regimens into the context of their daily lives. In doing so they will vary the advice and instructions given to accommodate the social, psychological, economic and physical influences which are part of their lives (24). There is a need for research that clearly articulates the complexity and variability of how asthma management fits in the context of individual patients lives. The National Asthma Campaign have provided a guide for health professionals to assist with effective patient communication which is a starting point for corrective strategies (25). | par 33
Comment |
| The Australian and New Zealand Asthma Guidelines developed in 1989 (4) provide a list of objectives that would be desirable to achieve for every person with asthma. We therefore know what optimal management of asthma is, but its attainment is elusive. Future strategies must be guided by knowledge from prospective studies defining asthma severity and asthma control as well as those identifying factor which influence guideline use by professionals and the knowledge of context of asthma management for the individual. | par 34 |
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Accepted for publication 26.8.99, electronically published 6.9.99 without editing. This is the first revised version of this paper (25 August 1999). Revisions are shown in blue text. Click here for the original submitted version
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