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[Dr
Kenneth Thomson]
Dr C: ’I
think they should fit on a credit card’ — laughter!!
This was the reaction of a group of general practitioners in South Wales
(UK), to a suggestion about guided self-management plans for patients
with asthma!
The study embraced the views of 7 GPs with special interest in asthma,
7 other GPs, and 13 practice nurses trained in asthma management; plus
13 compliant and 12 non-compliant adults, and 7 teen-age asthmatics
[1]. The study concluded: “Attempts to introduce self-guided management
plans in primary care are unlikely to be successful. A more patient
centred, patient negotiated plan is needed for asthma care in the community”.
Participant comments:
Moderator:
‘You’re making them (management plans) sound quite dangerous’.
Nurse X: ‘They can be, especially for very intelligent people—they
are the worst’.
Dr B: ‘Every patient is different and needs different advic
e. And only educated patients can deal with the information they are
given anyway. Some of my patients have shown me these plans and I’ve
told them to put them in the bin’.
A UK review
had stated : “Studies have yet to produce incontrovertible evidence
for the benefits of self-treatment plans”. The Welsh authors found
a fundamental mismatch between the views of professionals and patients
on what is a responsible asthma patient, and what patients should be
doing to control their symptoms.
There was a danger of patients misunderstanding the plans initially,
mistakenly thinking they were following them, and not returning for
monitoring (despite free GP care in the UK). Patients with mild and
moderate asthma had a tendency to treat the disease as one of intermittent
acute episodes (needing use of inhalers), and rejecting the idea they
had a chronic disease needing ongoing (preventer) medicine.
Asthma Educators:
—bear
these points in mind, as they could be relevant to some patients in
NZ—especially if their names begin with double Ll…!
But the authors avoid all reference to the Wairarapa Study, which found,
using a credit-card sized self-management plan, that even in this socio-economically
disadvantaged Maori population, 38% of subjects studied were still increasing
their dose of inhaled steroids for deteriorating asthma, in accord with
their plans, 6 years after initial instruction –which is pretty
good [2].
The Welsh study may be comforting to NZers who have no time for asthma
plans. However, we have moved on and up, we do have workable plans proved
in the field, and asthma is becoming acceptable as an ongoing condition
without stigma.
One thing would be agreed both by Welsh and Wairarapa research—long-term
benefits are likely to be greatest “…if recognition of poorly
controlled asthma and its adequate early treatment are continually reinforced
as part of all patients’ regular asthma care”.
ASTHMA
SELF-MANAGEMENT PLANS II
A written
asthma action plan was associated with a 70% reduction in the risk of
death; the use of oral steroids (prednisone tablets) for a severe attack
reduced the death risk by 90%; use of a peak flow meter during the preceding
months also reduced mortality.
These are the conclusions of a case-control study around 89 deaths from
asthma amongst a population of 4 million people in the state of Victoria,
Australia (a report from Melbourne [3]).
In an editorial, our own Wellington experts, Profs Crane and Beasley,
cite a number of studies which do confirm the value of action plans,
including a ‘Cochrane Review’ which concluded that such plans
resulted in a significant reduction in hospital admissions; and they
comment “A written action plan, self-monitoring of peak flow and
the interpretation of key symptoms, together with regular medical review,
now represents optimal management” [4] .
The importance of oral steroids at the onset of an attack of asthma
is emphasised by the Melbourne authors. Extra doses of inhaled steroid
simply do not work in this situation. Adult asthmatics at risk should
be trusted with an ‘emergency pack’ (say 60 mg of prednisone)
with its use included in their written plan.
References:
[1] BMJ 2000; 321: 1507-10; [2] Eur Respir J 2000; 15:
464-69; [3] Am J Resp Crit Care 2001; 163: 3-4; [4] Ibid 12-18
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