Children with asthma who keep track of their daily symptoms with a written plan take significantly fewer trips to the emergency department than children who use plans based on peak-flow monitoring, according to a recent review.
“It is our theory that children using the symptom-based plan will use it more often if it [is effective in getting them] to control asthma by taking preventive medication,” said Roger Zemek, a review co-author and physician at the Children’s Hospital of Eastern Ontario in Canada.
The data analysis showed that compared to using a peak-flow plan, using a symptom-based plan reduced kids’ need to visit the emergency department or doctor for severe asthma symptoms by 27 percent.
After receiving an asthma diagnosis, patients often work with their health care providers to create an asthma action plan. The plan is a personalized, written set of instructions that tells patients how to manage chronic symptoms of asthma, as well as prevent and manage acute symptoms that require emergency medical care.
Asthma plans may include a list of triggers that worsen asthma and names and dosages of medications to take to control symptoms.
With an asthma action plan, doctors instruct patients to keep daily tabs on their asthma in one of two ways: by monitoring asthma symptoms or by monitoring peak-flow readings. A peak-flow meter is a handheld device that measures lung function and determines how well a person’s asthma is being controlled.
The review appears in the current issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.
The authors mined four previously published randomized controlled trials involving 355 children and adolescents. Two of the studies took place in the United States; the other two were conducted in the United Kingdom. Each compared the effectiveness of symptom-based asthma action plans to action plans based on peak-flow monitoring.
Researchers determined that only nine children needed to use a symptom-based action plan to prevent one asthma flare that required a doctor or hospital visit. There were no significant differences between the two types of plans in terms of missed school days, missed work time for parents or hospital admissions for asthma symptoms.
Not only did the symptom-based plans reduce the risk of asthma flares, but children also preferred them to peak-flow monitoring plans, although parents did not show a preference. In addition, more children in the symptom-based group continued using their action plan after the study’s end.
“Research outside of this review has shown that children do have difficulty using peak-flow monitors and they have been found to not measure accurately the true inflammation. Using the symptom-based plan requires less of a time constraint on children and families, in addition to providing a medical benefit,” Zemek said.
Despite children’s preference for symptom-based plans, those assigned to peak-flow plans did have a greater reduction in the number of days per week they experienced asthma symptoms.
“[This finding] was surprising in the sense that this was the opposite direction of the primary outcome that children using symptom-based plans had less acute care visits,” Zemek said. The reviewers suggested that the cut-off values used for the peak-flow plans might be more conservative than the symptom-based plans, so children might seek medical attention sooner by using the peak-flow based plans.
The authors say that this review is unique in that it compares the effectiveness of asthma action plans in a pediatric population, whereas previous reviews have focused on adults.
“The reason why their main finding is key is that a vast chunk of health care spending is actually for acute care health care use, such as going to the doctor and emergency department visits. I think that from a financial standpoint, we have something to gain by reducing acute care visits,” said Jerry Krishnan, M.D., assistant professor of medicine and epidemiology at Johns Hopkins School of Medicine.
The authors of this review stressed that the action plan that children can and will consistently use is superior. But Krishnan suggested that asthma action plans may not work for every child or patient, especially those who struggle with poor health literacy.
“If you impose a challenging action plan that involves multiple steps and decisions, that’s going to make it difficult to use,” Krishnan said. “We need to make written action plans more user-friendly and easy to understand.”
In the last five years, Francine Ducharme, the lead author of this review received support from the pharmaceutical companies Glaxo Wellcome, AstraZeneca and Merck Frosst. The other authors report no conflict of interest.
Bhogal, S, Zemek R, Ducharme FM. Written action plans for asthma in children (Review). The Cochrane Database of Systematic Reviews 2006, Issue 3.
Health Behavior News Service
Revision date: July 4, 2011
Last revised: by Jorge P. Ribeiro, MD