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Asthma management plans: progress and problems

Research on the usefulness, applicability and effectiveness of the Australian Asthma Management Plan should ultimately improve quality of life for people with asthma

MJA 1997; 166: 287

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There have been considerable improvements in morbidity and mortality from asthma in Australia since the publication of the Australian Asthma Management Plan (AMP) in 1989.1,2 The Australian plan was a milestone and many national (e.g., British3 and United States4 ) and international asthma management guidelines (e.g., Global Initiative for Asthma5 ) followed. It outlines six components of good asthma management: (1) assess severity, (2) achieve best lung function, (3) maintain best lung function -- identify and avoid triggers, (4) maintain best lung function with optimal medication, (5) develop an action plan, and (6) educate and review regularly.

Within Australia, the AMP was widely disseminated to doctors and allied health professionals by the National Asthma Campaign through the Asthma management handbook, which has since undergone two revisions, the latest in 1996. Any major public health initiative should be rigorously evaluated before its recommendations become established practice, and the National Asthma Campaign has been monitoring asthma management practices and outcomes since 1990.6

What is the role of an AMP if less than half of asthma sufferers report receiving one? In this issue of the Journal, Beilby and colleagues shed more light on current asthma management and the use of the Australian AMP. As part of a larger general population survey, they included questions on asthma which enabled assessment of the use of whole or part of the AMP. It is important to distinguish between an AMP (the complete six-step package) and specific elements within it, such as having an action plan or having identified trigger factors with one's doctor, as research is still needed to assess the usefulness and applicability of the different components of the AMP. For example, action plans can play a vital role in preventing hospital admissions and death from asthma,7 but not all patients will find them helpful or use them when needed.8 The essential ingredients of an action plan should enable a patient to identify an exacerbation (e.g., by increased bronchodilator use or nocturnal asthma or a decrease in peak flow), increase medication and add oral corticosteroids appropriately and seek timely medical attention. A peak flow meter is not essential to this process, although it is extremely valuable for some patients. Those most likely to benefit from using a peak flow meter include those with previous life-threatening asthma, a history of emergency visits and hospital admissions, and a history of poor perception of airway obstruction.

Gibson et al.9 have shown that the more severe an asthma exacerbation, the less frequently will patients prefer self-management or use of an action plan. In addition, the elderly are more likely to seek advice from their doctors at the time of an acute attack of asthma, rather than make autonomous decisions based on an action plan. Garrett et al.8 have also shown that, among patients admitted to hospital with acute asthma, a minority used their action plans. On the other hand, many patients manage their asthma effectively at home, and avoid the need for emergency medical treatment, possibly as a result of effective use of action plans, although this has been more difficult to quantify. In long-term management, AMP adherence is better in those with more severe asthma, and use of a self-management plan can reduce unscheduled acute care visits, courses of antibiotics and oral corticosteroids, and improve quality of life.7,10

The finding of Beilby et al. that 46% of respondents with asthma reported being given an AMP is very similar to the 42% estimated in the 1994 NSW Health Promotion Survey,11 and the National Asthma Campaign evaluation in 1993.6 However, they found that only a quarter of this 46%, or 11%-12% overall, had a written AMP. This is lower than the 1993 National Asthma Campaign estimate of 20% and is cause for concern.

There is evidence that written advice is more effective than verbal advice alone in improving patient adherence to medication instructions and management strategies.12 Audit data indicate a low rate of use of action plans among people who attend accident and emergency departments with asthma exacerbations. For these reasons the low rate of written AMPs (and therefore, it is assumed, action plans) identified in all studies needs to be addressed. As highlighted by Beilby et al., lack of time in general practice consultations and uncertainty about how to write an action plan may be impediments to more widespread uptake of this important component of the AMP.

These observations raise the issue of which components of the AMP matter most. The Australian AMP was written as an expert consensus statement. It provides a systematic and methodical approach to asthma care, but it was not formulated as an evidence-based document -- its recommendations were not based on systematic reviews and have not been ranked according to the strength of the evidence supporting them. Had we waited for this to be done, we would have delayed guidelines which were desperately needed at a time when the prevalence of asthma in Australia was rising,13 asthma mortality was high and morbidity was proving a major cost to the Australian community.14 An evidence-based review of the AMP has been advocated in the National asthma strategies15 and a systematic review of the evidence for the sixth step of the AMP -- educate and review regularly -- is already being undertaken by members of the Thoracic Society of Australia and New Zealand through the Cochrane Collaboration Airways Group.

The article by Beilby and colleagues makes an important contribution to monitoring the use of the AMP. Several positive points emerge. Good management was more likely among those who had a regular doctor, and action plans were more common among those who had moderate or severe asthma. The combination of specialist and GP care resulted in the highest rate of possession of an AMP (82%). This finding concurs with other studies showing the benefits of integrated care,16 and highlights the need to improve communication and joint management strategies between specialists and GPs, hospitals and the community. Further work and consultation are needed to address the barriers to wider use of written action plans and to help facilitate this process for GPs. Considerable resources are needed to clarify which aspects of the AMP are making the greatest contributions to improving asthma outcomes, but this investment will be important in developing the AMP into more strongly evidence-based guidelines.

Christine R Jenkins
Visiting Thoracic Physician, Concord Hospital, Sydney, NSW, and Chairman, National Asthma Campaign

Adrian E Bauman
Associate Professor of Public Health, School of Community Medicine, University of New South Wales, Sydney, NSW

  1. Woolcock AJ, Rubinfeld AR, Seale JP, et al. Asthma management plan 1989. Med J Aust 1989; 151: 650-653.
  2. Australian Bureau of Statistics. Deaths due to diseases and cancers of the respiratory system, 1979-94. Canberra: ABS, 1996: 6-7. (Catalogue No. 3314.0.)
  3. Guidelines for management of asthma in adults: I -- chronic persistent asthma. BMJ 1990; 301: 651-653.
  4. National Asthma Education Program. Expert panel report. Guidelines for the diagnosis and management of asthma. Bethesda, Md.: United States Department of Health and Human Services, August 1991. (Publication No. 91-3042.)
  5. Global Initiative for Asthma. Global strategy for asthma management and prevention. NHLBI/WHO workshop report. Bethesda, Md.: National Heart, Lung and Blood Institute, 1995.
  6. Comino EJ, Mitchell CA, Bauman A, et al. Asthma management in eastern Australia, 1990 and 1993. Med J Aust 1996; 164: 403-406.
  7. Lahdensuo A, Haahtela T, Herrala J, et al. Randomised comparison of guided self management and traditional treatment of asthma over one year. BMJ 1996; 312: 748-751.
  8. Garrett J, Mercer Fenwick J, et al. Peak expiratory flow meters (PEFMs) -- who uses them and how and does education affect the pattern of utilisation? Aust N Z J Med 1994; 24: 521-529.
  9. Gibson PG, Talbot PI, Toneguzzi RC, et al. Self-management, autonomy and quality of life in asthma. Chest 1995; 107: 1003-1008.
  10. Charlton I, Charlton G, Broomfield J, Mullee MA. Evaluation of peak flow and symptoms only self management plans for control of asthma in general practice. BMJ 1990; 301: 1355-1359.
  11. Howell S, Bauman A. NSW health promotion survey databook, December 1995. Sydney: NSW Department of Health, 1995.
  12. Jones K, Tilford S, Robinson YK. Compliance. Health education. London: Chapman and Hall, 1991: 127-130.
  13. Peat JK, van de Berg R, Green WF, et al. Changing prevalence of asthma in Australian children. BMJ 1994; 308: 1591-1596.
  14. National Asthma Campaign. Cost of asthma in Australia. Melbourne: Boston Consulting Group, 1993.
  15. National Asthma Campaign. National asthma strategies: strategies and implementation. Melbourne: NAC: 1996.
  16. Osman LM, Abdulla MI, Russell IT, et al. Integrated care for asthma: matching care to the patient. Eur Respir Dis 1996; 9: 444-448.
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