A prospective multicenter study of written action plans among emergency department patients with acute asthma

Comparing Written Versus Pictorial Asthma Action Plans to Improve Asthma Management and Health Outcomes Among Children and Adolescents: Protocol of a Pilot and Feasibility Randomized Controlled Trial

Background

Asthma is an important focus for pediatric health research as management of asthma symptoms is a significant challenge, and morbidity and mortality among youths with asthma remain prevalent. Treatment guidelines for asthma recommend a written asthma action plan (WAAP) that summarizes individualized instructions for daily medication use. However, WAAPs are typically written at a seventh- to ninth-grade reading level, which can be a barrier to young people in understanding their treatment, having confidence in using a WAAP, and engaging with asthma education.

Objective

Utilizing a feasibility and pilot randomized controlled trial (RCT) design, the objective of the Take Action for Asthma Control study is to test a symptom-based, computer-generated pictorial asthma action plan (PAAP) in comparison with a standard WAAP and assess the feasibility and acceptability of the asthma action plan (AAP) intervention and study procedures. The study has 3 aims: (1) estimate the effect sizes of PAAPs compared with WAAPs on outcomes (eg, AAP knowledge and medication adherence), (2) evaluate feasibility and acceptability of AAP intervention and RCT procedures from the perspectives of key stakeholders, and (3) establish whether parent and youth literacy levels are associated with treatment outcomes.

Methods

This feasibility and pilot RCT is a block randomized, 2-arm, parallel-group clinical trial, lasting 6 months in duration. At baseline, participants will be randomly assigned to receive a PAAP or WAAP generated for them and reviewed with them by their asthma physician. Study procedures will take place over 4 separate time points: a baseline clinic appointment, 1-month telephone follow-up, and 3- and 6-month clinic-based follow-ups. At each time point, data will be collected related to the main outcomes: AAP knowledge, AAP satisfaction, asthma control, pulmonary function, and adherence to daily asthma medication. A sample size of up to 60 participants (aged 8-17 years) will be recruited. Feasibility and acceptability data will be collected via one-to-one qualitative interviews with providers involved in the study and a subgroup of families that participate in the study.

Results

Recruitment and data collection began in May 2017 and were completed in October 2018.

Conclusions

This pilot and feasibility study will test the potential efficacy, feasibility, and acceptability of an AAP intervention and study procedures. The findings will inform the design and delivery of a future definitive trial to assess the efficacy of PAAPs versus WAAPs in supporting asthma self-management among children and adolescents.

International Registered Report Identifier (IRRID)

DERR1-10.2196/11733

[Digital action plan for asthma exacerbations (PANAME)]

BACKGROUND

A written action plan (WAP) reduces emergency visits for asthma exacerbations. However, a WAP is underused and often focused on asthma control. The innovation is an AppWeb that includes an expert software aimed at diagnosing the level of severity of asthma exacerbations and delivering a personalized digital action plan (DAP) when patients are in urgent need of medical advice. Symptoms describing the level of severity of asthma exacerbations and the consequent treatments have been established by working groups of the French Respiratory Societies (SPLF and SP2A for adults and children, respectively). The main objective of the study is to evaluate the effect of the DAP on the frequency of urgent medical attendance. Secondary objectives are to evaluate adherence to the DAP compared to a WAP and the qualitative satisfaction of patients using the DAP.

METHODOLOGY

A randomized, prospective, comparative, multicenter study on two parallel groups, conducted in private practice and in hospitals. In both arms, asthmatic patients (240 children aged 6 to 12 years and 270 adults aged 18 to 50 years) with severe asthma exacerbation(s) during the previous year and an Internet connection via a smartphone or a tablet computer, will have at their disposal a WAP and one arm will have, in addition, the DAP. Included patients will be followed up every three months for one year.

EXPECTED RESULTS

A decrease in the number of urgent medical attendances and better adherence in the WAP+DAP group compared to the WAP group.

Enablers and determinants of the provision of written action plans to patients with asthma: a stratified survey of Canadian physicians

Despite national recommendations, most patients with asthma are not given a written action plan . The objectives were to ascertain physicians' endorsement of potential enablers to providing a written action plan, and the determinants and proportion, of physician-reported use of a written action plan. We surveyed 838 family physicians, paediatricians, and emergency physicians in Quebec. The mailed questionnaire comprised 102 questions on asthma management, 11 of which pertained to written action plan and promising enablers. Physicians also selected a case vignette that best corresponded to their practice and reported their management. The survey was completed by 421 (56%) physicians (250 family physicians, 115 paediatricians and 56 emergency physicians); 43 (5.2%) reported providing a written action plan to ≥70% of their asthmatic patients and 126 (30%) would have used a written action plan in the selected vignette. Most (>60%) physicians highly endorsed the following enablers: patients requesting a written action plan, adding a blank written action plan to the chart, receiving a copy of the written action plan completed by a consultant, receiving a monetary compensation for its completion, and having another healthcare professional explain the completed written action plan to patients. Four determinants were significantly associated with providing a written action plan: being a paediatrician (RR:2.1), treating a child (RR:2.0), aiming for long-term asthma control (RR:2.5), and being aware of national recommendations to provide a written action plan to asthmatic patients (RR:2.9). A small minority of Quebec physicians reported providing a written action plan to most of their patients, revealing a huge care gap. Several enablers to improve uptake, highly endorsed by physicians, should be prioritised in future implementation efforts.

ASTHMA

ENCOURAGING DOCTORS TO PROVIDE WRITTEN ACTION PLANS: Changes to practice organization and doctors' perceptions should encourage the provision of written action plans for all asthma patients. International guidelines state that effective long-term treatment of asthma requires educated self-management, regular reviews and provision of a written action plan (WAP). However, many patients have poor asthma control and as few as 30 per cent have a WAP. Fabienne Djandji at the Saint-Justine University Central Hospital in Montreal, Canada, and co-workers conducted a survey of 421 doctors to determine their attitudes and provision of WAPs. Only 5.2 per cent of respondents provided WAPs to patients; those treating children or aiming for long-term asthma control were more likely to do so. The doctors said that incentives to provide WAPs would include requests from patients themselves, being paid to complete WAPs and having extra support from specialists or other health care professionals such as pharmacists.

[Knowledge and experience of 2- to 15-year-old children's parents consulting in pediatric emergency departments for asthma]

INTRODUCTION

This study aimed at assessing parents' knowledge and perception in relation to their child's condition when arriving at the emergency ward following an asthma attack. The overall objective was to determine how parent education could be improved.

MATERIALS AND METHODS

This study was conducted over 9 months as a multicenter descriptive and qualitative study based on a self-administered questionnaire for parents of asthmatic children, aged 2-15 years.

RESULTS

The questionnaire was delivered to 88 children out of 1472 (6%). Approximately 69% of the children included in the study presented with partially controlled or uncontrolled asthma. Fifty percent of the patients were insufficiently monitored and without therapy. Half of the parents said they had never received any information concerning their child's condition. The majority (86%) did not know the basic cause of the disease, 30% percent were unable to detect the features of clinical exacerbation, and 17% were not using an adequate emergency protocol. The illness experience was relatively easy for two-thirds of the children and the parents' perceptions were in line in 50% of the cases.

DISCUSSION

Knowledge of parents and their children suffering from asthma is insufficient for optimal control and disease management. Instructions on detecting the signs of asthma severity as well as the establishment of an individualized emergency protocol and medical follow-up should be of prime concern and could reduce emergency department use.

CONCLUSION

Doctors have a key role to play in educating and explaining disease characteristics to patients and their families. Therapeutic education also needs to be intensified.

Action plans in patients presenting to emergency departments with asthma exacerbations: Frequency of use and description of contents

BACKGROUND

Although underused, written asthma action plans (AAPs) are associated with reduced numbers of emergency department (ED) visits and hospitalizations.

OBJECTIVE

To describe the frequency of use and contents of any AAPs reported by patients presenting with exacerbations to three urban Canadian EDs.

METHODS

Prospective data were collected through ED interview and chart review. Descriptive analyses used proportions and medians with interquartile range; multivariable logistic regression was used for the adjusted analyses.

RESULTS

Among 176 enrolled patients, the median age was 27 years (interquartile range 23 to 39 years) and 97 (55%) were female. Few (n=42 [24%]) reported having AAPs at ED presentation and only six were written. Most (n=35 [75%]) patients with any AAP took action before the ED visit; none used a valid anti-inflammatory strategy. The first step of 27 plans was to increase asthma medication; no patients appropriately increased inhaled corticosteroids (ICS). In multivariable analyses, only the use of either ICS or ICS⁄long-acting β-agonist combination agents (31% had AAPs versus 12% did not have AAPs (adjusted OR 3.0 [95% CI 1.14 to 8.07]) and asthma education (47% had AAPs versus 21% did not have AAPs, adjusted OR 3.2 [95% CI 1.13 to 9.19]) were independently associated with AAP possession.

CONCLUSION

Possession of AAPs among patients presenting to the ED with acute asthma was low, and only one in 10 AAPs were written. Patients who reported having any AAP used ineffective strategies to abort or mitigate the severity of an ED visit. Increasing frequency of written AAPs and improving their contents holds immediate promise in improving outcomes related to asthma.

Asthma action plans and patient satisfaction among women with asthma

BACKGROUND

Asthma action plans (AAPs) are a priority recommendation of the National Asthma Education and Prevention Program and have been shown to positively affect health outcomes. Patient satisfaction is an important clinical outcome, yet little is known about its association with receiving an AAP. This study examined the association between having an AAP and behaviors to keep asthma in control and patient satisfaction with care.

METHODS

The study design was a cross-sectional analysis of baseline data from a randomized trial evaluating a self-management program among 808 women with asthma. Participants reported demographic information, interactions with clinicians, whether they had an AAP and owned a peak flow meter, self-management behaviors, and symptoms.

RESULTS

The mean age of the participants was 48 ±13.6 years, 84% (n= 670) were satisfied with their asthma care, and 48% (n= 383) had a written AAP from their physician. Women not having an AAP were less likely to take asthma medication as prescribed [ x 2 (1) = 13.68, P , .001], to initiate a discussion about asthma with their physicians [ x 2 (1) = 26.35, P < .001], and to own a peak fl ow meter [ x 2 (1) =77.84, P < .001]. Adjusting for asthma control, income, and medical specialty,women who did not have an AAP were more likely to report dissatisfaction with their asthma care (OR, 2.07; 95% CI, 1.35-3.17; P < .001).

CONCLUSIONS

Women without an AAP were less likely to initiate discussions with their physicians,take medications as prescribed, and own a peak fl ow meter to monitor asthma, all considered important self-management behaviors. They were also less satisfied with their care. Not having an AAP may affect interactions between patient and physician and clinical outcomes.

Preventing emergency department visits and hospitalizations for asthma by use of oral corticosteroids at home: are we adhering to national guidelines?

BACKGROUND

Oral corticosteroids (OCS) in the home management of asthma exacerbations have been recommended in the NIH/NHLBI guidelines since 1991. As a routine component of written action plans, OCS treatment at home is associated with reduced emergency department (ED) visits and hospitalizations as well as decreased mortality.

METHODS

A literature search of English language journals from 1991 to 2009 was performed using several databases, including PubMed, EMBASE, and SCOPUS. We assessed studies that evaluated adherence to national guidelines for home management of asthma exacerbations.

RESULTS

Our review of the literature found that several studies reveal that a small percentage (<3-26%) of patients are receiving OCS at home to manage asthma exacerbations prior to an ED visit. Additional studies were found showing very low use of written action plans, strongly suggesting lack of OCS for home management of asthma exacerbations.

CONCLUSIONS

Despite evidence of reduced ED visits and hospitalizations and the recommendations of national and international guidelines, the home use of OCS in managing asthma exacerbations remains unacceptably low. New strategies are needed to ensure home use of OCS as part of written action plans to prevent ED visits and hospitalizations for asthma exacerbations.

Written action plan in pediatric emergency room improves asthma prescribing, adherence, and control

RATIONALE

An acute-care visit for asthma often signals a management failure. Although a written action plan is effective when combined with self-management education and regular medical review, its independent value remains controversial.

OBJECTIVES

We examined the efficacy of providing a written action plan coupled with a prescription (WAP-P) to improve adherence to medications and other recommendations in a busy emergency department.

METHODS

We randomized 219 children aged 1-17 years to receive WAP-P (n = 109) or unformatted prescription (UP) (n = 110). All received fluticasone and albuterol inhalers, fitted with dose counters, to use at the discretion of the emergency physician. The main outcome was adherence to fluticasone (use/prescribed × 100%) over 28 days. Secondary outcomes included pharmacy dispensation of oral corticosteroids, β(2)-agonist use, medical follow-up, asthma education, acute-care visits, and control.

MEASUREMENTS AND MAIN RESULTS

Although both groups showed a similar drop in adherence in the initial 14 days, adherence to fluticasone was significantly higher over Days 15-28 in children receiving WAP-P (mean group difference, 16.13% [2.09, 29.91]). More WAP-P than UP patients filled their oral corticosteroid prescription (relative risk, 1.31 [1.07, 1.60]) and were well-controlled at 28 days (1.39 [1.04, 1.86]). Compared with UP, use of WAP-P increased physicians' prescription of maintenance fluticasone (2.47 [1.53, 3.99]) and recommendation for medical follow-up (1.87 [1.48, 2.35]), without group differences in other outcomes.

CONCLUSIONS

Provision of a written action plan significantly increased patient adherence to inhaled and oral corticosteroids and asthma control and physicians' recommendation for maintenance fluticasone and medical follow-up, supporting its independent value in the acute-care setting. Clinical trial registered with www.clinicaltrials.gov (NCT 00381355).

The effect of emergency department crowding on length of stay and medication treatment times in discharged patients with acute asthma

OBJECTIVES

This study sought to determine if emergency department (ED) crowding was associated with longer ED length of stay (LOS) and time to ordering medications (nebulizers and steroids) in patients treated and discharged with acute asthma and to study how delays in ordering may affect the relationship between ED crowding and ED LOS.

METHODS

A retrospective cohort study was performed in adult ED patients aged 18 years and older with a primary International Classification of Diseases, 9th Revision (ICD-9), diagnosis of asthma who were treated and discharged from two EDs from January 1, 2007, to January 1, 2009. Four validated measures of ED crowding (ED occupancy, waiting patients, admitted patients, and patient-hours) were assigned at the time of triage. The associations between the level of ED crowding and overall LOS and time to treatment orders were tested by analyzing trends across crowding quartiles, testing differences between the highest and lowest quartiles using Hodges-Lehmann distances, and using relative risk (RR) regression for multivariable analysis.

RESULTS

A total of 1,716 patients were discharged with asthma over the study period (932 at the academic site and 734 at the community site). LOS was longer at the academic site than the community site for asthma patients by 90 minutes (95% confidence interval [CI] = 79 to 101 minutes). All four measures of ED crowding were associated with longer LOS and time to treatment order at both sites (p < 0.001). At the highest level of ED occupancy, patients spent 75 minutes (95% CI = 58 to 93 minutes) longer in the ED compared to the lowest quartile of ED occupancy. In addition, comparing the highest and lowest quartiles of ED occupancy, time to nebulizer order was 6 minutes longer (95% CI = 1 to 13 minutes), and time to steroid order was 16 minutes longer (95% CI = 0 to 38 minutes). In the multivariable analysis, the association between ED crowding and LOS remained significant. Delays in nebulizer and steroid orders explained some, but not all, of the relationship between ED crowding and ED LOS.

CONCLUSIONS

Emergency department crowding is associated with longer ED LOS (by more than 1 hour) in patients who ultimately get discharged with asthma flares. Some but not all of longer LOS during crowded times is explained by delays in ordering asthma medications.