| A Population Survey of the use of Asthma Action Plans. Where to From Here? | par 0 |
|
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.
| par 6 |
|
ABSTRACT |
|
| Objective: To examine the written relationships between ownership of asthma action plans, asthma morbidity, use of devices and patients perceptions of their asthma management. | par 8 |
| 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 | 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). Those asthmatics with night symptoms weekly or more frequently (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. | par 13 |
| Conclusions: Asthma management in South Australia is sub-optimal. New strategies need to be developed to reduce asthma morbidity. | par 14 |
|
INTRODUCTION |
|
| 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 |
| There is little representative population information on the use and effectiveness of asthma action plans. To facilitate the development of improved strategies to improve asthma outcomes, this study aimed to evaluate the relationships between: (I) demographic factors and written action plan ownership and morbidity, and (II) morbidity and action plan ownership, peak flow meter ownership, ease of access to a general practitioner, self-management confidence and information needs in a representative population sample of self reported asthma patients. | par 18 |
|
METHODS |
|
| The data for this study were collected in the 1996 South Australian Health Omnibus Survey, 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 |
| A person was classified as suffering from asthma 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 (13). | par 21 |
| Univariate analyses, using SPSS Version 8, 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 (14) 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 |
|
RESULTS |
|
| The prevalence of asthma in this study was 11.6% (95% CI 10.3% to 12.9%). Of those with asthma 33% (CI 30.8% to 35.2%) had an 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 |
| 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 |
| The variables significantly associated with nightime asthma symptoms weekly or more frequently 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). People who wakened with asthma weekly or more frequently were no more likely than other people with asthma to possess an asthma action plan (19.8% vs 13.4%). | par 26 |
| 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 |
|
DISCUSSION |
|
| 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. There may be some subgroups exceptions to this conclusion. One subgroup analysis showed that non-smokers wakening frequently were more likely to have an action plan. However, we believe the overall conclusion holds. | par 29 |
| Testing asthma management on a population basis will be difficult since no significant differences in demographic characteristics were found between those who did or did not have a plan. Although many variables were related to the ownership of an asthma plan in the univariate analyses, only 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 suggests that, even for people with an action plan, there are deficiencies in; their information about asthma management; feeling comfortable managing their asthma; and ability to access their doctor when needed. | par 30 |
| In the advanced analyses only non-smokers who experience wakening frequently because of asthma are more likely to have an action plan and a peak flow meter. However, non-smokers were less likely to report they had enough information to deal with worsening asthma and less likely to feel comfortable managing their asthma. Smokers who waken frequently are no more likely than patients with less symptoms to have an asthma action plan and are less likely to find it easy to access their doctor for asthma. It is another marker of the limitations of overall asthma management that a group of people who are more likely to be at the severe end of the asthma spectrum are no more likely to have a plan. 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, or to find it easy to see their doctor (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 |
| What is the way forward? Randomised studies of the implementation of asthma plans show that good educational and skill objectives can be achieved (15-18). However, the complexity of the asthma management problem make it impossible to provide for every contingency the patient will face in dealing with asthma. As 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 (17). Therefore, 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. In the Australian context one controlled trial evaluation of a brief asthma education program demonstrated substantial changes in illness behaviour (17). 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). These programs show that or skilling the patient cannot be achieved in the normal constraints of general practice. Even the brief Australian asthma education program requires 2.5-3 hours group work (17). 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. | par 32 |
| Education of the patient is often confounded by life forces that may have more influence on patient outcomes. Trostle (21) 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. Spaeth (22) points out that most medical education is concerned with the effect of the disease on the patient, but it may be just as important to ascertain the effect of the patient on the disease. It is also appropriate to identify that some of the traditional models of patient education based on health beliefs or compliance frameworks have been seriously questioned (23-25). 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 (25). Before corrective strategies are postulated there is the need for research that clearly articulates the complexity and variability of how asthma management fits in the context of individual patients lives. | par 33 |
| In conclusion the problem of asthma management is complex. 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 and will remain so unless we seriously review the process of achieving it. | par 34 |
|
REFERENCES |
|
| 1 Yoon R, McKenzie DK, Bauman A, Miles DA. Controlled trial evaluation of an asthma program for adults. Thorax 1993; 48: 1110-1116. | par 36 |
| 2 Comino EJ, Mitchell CA, Bauman A, Henry RL, Robertson CF, Abramson MJ, Ruffin R, Landau L. Asthma management in eastern Australia. Medical Journal of Australia 1996; 164: 403-406. | par 37 |
| 3 Beasley R, Cushley M, Holgate ST. A self-management plan in the treatment of adult asthma. Thorax 1989; 44: 200-204. | par 38 |
| 4 Woolcock A, Rubinfeld AR, Seale P, Landau LL, Antic R, Mitchell C, Rea HH, Zimmerman P. Asthma management plan, 1989. Medical Journal of Australia 1989; 151: 650-53. | par 39 |
| 5 Adams R, Ruffin R, Wakefield M, Campbell D, Smith B. Asthma prevalence, morbidity and management practices in South Australia, 1992-1995. Australian New Zealand Journal of Medicine 1997; 27: 672-79. | par 40 |
| 6 Robertson C, Rubinfeld AR, Bowes G. Deaths from asthma in Victoria: a twelve-month survey. Medical Journal of Australia 1990; 152: 511-17. | par 41 |
| 7 Rubinfeld AR, Dunt DR, McLure BG. Do patients understand asthma? A community survey of asthma knowledge. Medical Journal of Australia 1988; 149: 526-30. | par 42 |
| 8 Bauman A, Young L, Peat JK, Hunt J, Larkin P. Asthma under-recognition and under-treatment in an Australian community. Australian New Zealand Journal of Medicine 1992; 22:36-40. | par 43 |
| 9 Clark NM. Asthma self-management education. Research and implications for clinical practice. Chest 1989; 95(5):1110-13. | par 44 |
| 10 Coates JR, Steven ID, Beilby J, Coffey G, Litt JCB, Wagner C. Knowledge of and reported asthma management among South Australian general practitioners. British Journal of General Practice 1994; 44: 123-26. | par 45 |
| 11 Jenkins CR, Bauman A. Asthma management plans: progress and problems. Medical Journal of Australia 1997; 166: Editorial: 287-88. | par 46 |
| 12 Bauman A, Mitchell CA, Henry RL, Robertson CF, Abramson MJ, Comino EJ, Hensley MJ, Leeder SR. Asthma morbidity in Australia: an epidemiological study. Medical Journal of Australia 1992; 156: 827-31 | par 47 |
| 13 Kelley JL, Evans MDR, Using ASCO for socio-economic analysis: assessment and conversion intro status and prestige indices. Canberra 1988: Research School of Social Sciences, Australian National University. | par 48 |
| 14 Hosmer DW, Lemeshow S. Applied logistic regression. New York 1989: John Wiley. | par 49 |
| 15 Wilson-Pessano SR, McNabb WL. The role of patient education in the management of childhood asthma. Preventive Medicine 1985; 14: 670-687. | par 50 |
| 16 Clark NM, Feldman CH, Evans D, Duzey O, Levison MJ, Wasilewski Y, Kaplan D, Rips J, Mellins RB. Managing better: children, parents and asthma. Patient Education & Counselling 1986; 8: 27-38. | par 51 |
| 17 Yoon R, McKenzie DK, Bauman A, Miles DA. Controlled trial evaluation of an asthma education programme for adults. Thorax 1993; 48: 1110-16. | par 52 |
| 18 D. Sousa WD, Crane J, Burgess C, Te Karu H, Fox C, Harper M, Robson B, Howden-Chapman P, Crossland L, Woodman K, Pearce N, Pomare E, Beasley R. Community-based asthma care: trial of a . credit card. asthma self-management plan. European Respiratory Journal 1994; 7: 1260-65. | par 53 |
| 19 Clark NM, Gotsch A, Rosenstock IR. Patient, professional, and public education behavioural aspects of asthma: a review of strategies for change and need research. Journal of Asthma 1993; 30(4): 241-255. | par 54 |
| 20 Lahdenso A, Haajtela T, Herrala J, Kava T, Kiviranta K, Kuusisto P, Peramaki E, Poissa T, Saarelainen S, Svahn T. Randomised comparison of guided self-management and traditional treatment of asthma over one year. British Medical Journal 1996; 312: 748-52. | par 55 |
| 21 Trostle JA. Medical compliance as an ideology. Social Science and Medicine 1988; 18: 1299-1308. | par 56 |
| 22 Spaeth GL. Visual loss in a glaucoma clinic. Sociological considerations. Investigations in Opthalmology 1970; 9(1): 73-82. | par 57 |
| 23 Carter WB. Psychology and decision making: modelling health behaviour with multiattribute theory. Journal of Dental Education 1992; Dec: 800-807. | par 58 |
| 24 Glanz K, Lewis FM, Rimmer BK (Eds). Health Behaviour and Education. Theory research and practice. San Francisco 1991: Jossey Bass. | par 59 |
|
25 Morris SL, Schulz RM. Medication compliance: the patients. perspective. Clinical Therapy 1993; 15(3): 593-606. | par 60 |
| Note: Click here to see a revised version of this table Table 1: Variables associated with ownership of an action plan and the likelihood of wakening with asthma on a weekly basis or more frequently.
| par 61 |
| par 62 |
| Note: Click here to see a revised version of this table. Table 2 Logistic Regression Analyses of Variables Associated with Ownership Of an Asthma Management Plan and Frequency of Wakening at Night with Asthma
| par 63 |
|
Accepted for publication 26.8.99, electronically published 6.9.99 without editing.
|