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Prescribing success: Developing an integrated prescription and eczema action plan for atopic dermatitis. J Am Acad Dermatol 2017; 75:1281-1283. [PMID: 27846960 DOI: 10.1016/j.jaad.2016.08.029] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 08/11/2016] [Accepted: 08/12/2016] [Indexed: 11/20/2022]
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Gatheral TL, Rushton A, Evans DJW, Mulvaney CA, Halcovitch NR, Whiteley G, Eccles FJR, Spencer S. Personalised asthma action plans for adults with asthma. Cochrane Database Syst Rev 2017; 4:CD011859. [PMID: 28394084 PMCID: PMC6478068 DOI: 10.1002/14651858.cd011859.pub2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND A key aim of asthma care is to empower each person to take control of his or her own condition. A personalised asthma action plan (PAAP), also known as a written action plan, an individualised action plan, or a self-management action plan, contributes to this endeavour. A PAAP includes individualised self-management instructions devised collaboratively with the patient to help maintain asthma control and regain control in the event of an exacerbation. A PAAP includes baseline characteristics (such as lung function), maintenance medication and instructions on how to respond to increasing symptoms and when to seek medical help. OBJECTIVES To evaluate the effectiveness of PAAPs used alone or in combination with education, for patient-reported outcomes, resource use and safety among adults with asthma. SEARCH METHODS We searched the Cochrane Airways Group Specialised Register of trials, clinical trial registers, reference lists of included studies and review articles, and relevant manufacturers' websites up to 14 September 2016. SELECTION CRITERIA We included parallel randomised controlled trials (RCTs), both blinded and unblinded, that evaluated written PAAPs in adults with asthma. Included studies compared PAAP alone versus no PAAP, and/or PAAP plus education versus education alone. DATA COLLECTION AND ANALYSIS Two review authors independently extracted study characteristics and outcome data and assessed risk of bias for each included study. Primary outcomes were number of participants reporting at least one exacerbation requiring an emergency department (ED) visit or hospitalisation, asthma symptom scores on a validated scale and adverse events (all causes). Secondary outcomes were quality of life measured on a validated scale, number of participants reporting at least one exacerbation requiring systemic corticosteroids, respiratory function and days lost from work or study. We used a random-effects model for all analyses and standard Cochrane methods throughout. MAIN RESULTS We identified 15 studies described in 27 articles that met our inclusion criteria. These 15 included studies randomised a total of 3062 participants (PAAP vs no PAAP: 2602 participants; PAAP plus education vs education alone: 460 participants). Ten studies (eight PAAP vs no PAAP; two PAAP plus education vs education alone) provided outcome data that contributed to quantitative analyses. The overall quality of evidence was rated as low or very low.Fourteen studies lasted six months or longer, and the remaining study lasted for 14 weeks. When reported, mean age ranged from 22 to 49 years and asthma severity ranged from mild to severe/high risk. PAAP alone compared with no PAAPResults showed no clear benefit or harm associated with PAAPs in terms of the number of participants requiring an ED visit or hospitalisation for an exacerbation (odds ratio (OR) 0.75, 95% confidence interval (CI) 0.45 to 1.24; 1385 participants; five studies; low-quality evidence), change from baseline in asthma symptoms (mean difference (MD) -0.16, 95% CI -0.25 to - 0.07; 141 participants; one study; low-quality evidence) or the number of serious adverse events, including death (OR 3.26, 95% CI 0.33 to 32.21; 125 participants; one study; very low-quality evidence). Data revealed a statistically significant improvement in quality of life scores for those receiving PAAP compared with no PAAP (MD 0.18, 95% CI 0.05 to 0.30; 441 participants; three studies; low-quality evidence), but this was below the threshold for a minimum clinically important difference (MCID). Results also showed no clear benefit or harm associated with PAAPs on the number of participants reporting at least one exacerbation requiring oral corticosteroids (OR 1.45, 95% CI 0.84 to 2.48; 1136 participants; three studies; very low-quality evidence) nor on respiratory function (change from baseline forced expiratory volume in one second (FEV1): MD -0.04 L, 95% CI -0.25L to 0.17 L; 392 participants; three studies; low-quality evidence). In one study, PAAPs were associated with significantly fewer days lost from work or study (MD -6.20, 95% CI -7.32 to - 5.08; 74 participants; low-quality evidence). PAAP plus education compared with education aloneResults showed no clear benefit or harm associated with adding a PAAP to education in terms of the number of participants requiring an ED visit or hospitalisation for an exacerbation (OR 1.08, 95% CI 0.27 to 4.32; 70 participants; one study; very low-quality evidence), change from baseline in asthma symptoms (MD -0.10, 95% CI -0.54 to 0.34; 70 participants; one study; low-quality evidence), change in quality of life scores from baseline (MD 0.13, 95% CI -0.13 to 0.39; 174 participants; one study; low-quality evidence) and number of participants requiring oral corticosteroids for an exacerbation (OR 0.28, 95% CI 0.07 to 1.12; 70 participants; one study; very low-quality evidence). No studies reported serious adverse events, respiratory function or days lost from work or study. AUTHORS' CONCLUSIONS Analysis of available studies was limited by variable reporting of primary and secondary outcomes; therefore, it is difficult to draw firm conclusions related to the effectiveness of PAAPs in the management of adult asthma. We found no evidence from randomised controlled trials of additional benefit or harm associated with use of PAAP versus no PAAP, or PAAP plus education versus education alone, but we considered the quality of the evidence to be low or very low, meaning that we cannot be confident in the magnitude or direction of reported treatment effects. In the context of this caveat, we found no observable effect on the primary outcomes of hospital attendance with an asthma exacerbation, asthma symptom scores or adverse events. We recommend further research with a particular focus on key patient-relevant outcomes, including exacerbation frequency and quality of life, in a broad spectrum of adults, including those over 60 years of age.
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Affiliation(s)
- Timothy L Gatheral
- University Hospitals of Morecambe Bay NHS Foundation TrustRespiratory MedicineLancasterUK
| | - Alison Rushton
- Lancashire Care NHS Foundation TrustEducation, Training and Professional Development, Nursing & Quality DirectoratePrestonUK
| | - David JW Evans
- Lancaster UniversityLancaster Health HubLancasterUKLA1 4YG
| | | | | | - Gemma Whiteley
- Lancashire Teaching Hospitals NHS Foundation Trust, Royal Preston HospitalResearch and InnovationPrestonUK
| | | | - Sally Spencer
- Edge Hill UniversityPostgraduate Medical InstituteSt Helens RoadOrmskirkLancashireUKL39 4QP
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Djandji F, Lamontagne AJ, Blais L, Bacon SL, Ernst P, Grad R, Lavoie KL, McKinney ML, Desplats E, Ducharme FM. Enablers and determinants of the provision of written action plans to patients with asthma: a stratified survey of Canadian physicians. NPJ Prim Care Respir Med 2017; 27:21. [PMID: 28364118 PMCID: PMC5434790 DOI: 10.1038/s41533-017-0012-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 12/12/2016] [Accepted: 01/06/2017] [Indexed: 11/09/2022] Open
Abstract
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.
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Affiliation(s)
- Fabienne Djandji
- Clinical Research and Knowledge Transfer Unit on Childhood Asthma, Research Centre, CHU Sainte-Justine, Montreal, Quebec, Canada.
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada.
| | - Alexandrine J Lamontagne
- Clinical Research and Knowledge Transfer Unit on Childhood Asthma, Research Centre, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Lucie Blais
- Faculty of Pharmacy, University of Montreal, Montreal, Quebec, Canada
| | - Simon L Bacon
- Department of Exercise Science, Concordia University, Montreal, Quebec, Canada
- Montreal Behavioural Medicine Centre, CIUSS-NIM, Hopital du Sacré-Coeur de Montreal, Montreal, Quebec, Canada
| | - Pierre Ernst
- Department of Pulmonary Medicine, Jewish General Hospital, Montreal, Quebec, Canada
- Division of Clinical Epidemiology (MUHC) Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Roland Grad
- Department of Family Medicine, McGill University, Montreal, Quebec, Canada
| | - Kim L Lavoie
- Montreal Behavioural Medicine Centre, CIUSS-NIM, Hopital du Sacré-Coeur de Montreal, Montreal, Quebec, Canada
- Department of Psychology, Université du Québec à Montréal, Montreal, Quebec, Canada
| | - Martha L McKinney
- Department of Pediatrics, University of Montreal, Montreal, Quebec, Canada
| | - Eve Desplats
- Applied Clinical Research Unit, Research Centre, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Francine M Ducharme
- Clinical Research and Knowledge Transfer Unit on Childhood Asthma, Research Centre, CHU Sainte-Justine, Montreal, Quebec, Canada.
- Applied Clinical Research Unit, Research Centre, CHU Sainte-Justine, Montreal, Quebec, Canada.
- Department of Social and Preventive Medicine, University of Montreal, Montreal, Quebec, Canada.
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Peláez S, Lamontagne AJ, Collin J, Gauthier A, Grad RM, Blais L, Lavoie KL, Bacon SL, Ernst P, Guay H, McKinney ML, Ducharme FM. Patients' perspective of barriers and facilitators to taking long-term controller medication for asthma: a novel taxonomy. BMC Pulm Med 2015; 15:42. [PMID: 25907709 PMCID: PMC4429418 DOI: 10.1186/s12890-015-0044-9] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Accepted: 04/20/2015] [Indexed: 11/25/2022] Open
Abstract
Background Although asthma morbidity can be prevented through long-term controller medication, most patients with persistent asthma do not take their daily inhaled corticosteroid. The objective of this study was to gather patients’ insights into barriers and facilitators to taking long-term daily inhaled corticosteroids as basis for future knowledge translation interventions. Methods We conducted a collective qualitative case study. We interviewed 24 adults, adolescents, or parents of children, with asthma who had received a prescription of long-term inhaled corticosteroids in the previous year. The one-hour face-to-face interviews revolved around patients’ perceptions of asthma, use of asthma medications, current self-management, prior changes in self-management, as well as patient-physician relationship. We sought barriers and facilitators to optimal asthma management. Interviews were transcribed verbatim and transcripts were analyzed using a thematic approach. Results Patients were aged 2–76 years old and 58% were female. Nine patients were followed by an asthma specialist (pulmonologist or allergist), 13 patients by family doctors or pediatricians, and two patients had no regular follow-up. Barriers and facilitators to long-term daily inhaled corticosteroids were classified into the following loci of responsibility and its corresponding domains: (1) patient (cognition; motivation, attitudes and preferences; practical implementation; and parental support); (2) patient-physician interaction (communication and patient-physician relationship); and (3) health care system (resources and services). Patients recognized that several barriers and facilitators fell within their own responsibility. They also underlined the crucial impact (positive or negative) on their adherence of the quality of patient-physician interaction and health care system accessibility. Conclusions We identified a close relationship between reported barriers and facilitators to adherence to long-term daily controller medication for asthma within three loci of responsibility. As such, patients’ adherence must be approached as a multi-level phenomenon; moreover, interventions targeting the patient, the patient-physician interaction, and the health care system are recommended. The present study offers a potential taxonomy of barriers and facilitators to adherence to long-term daily inhaled corticosteroids therapy that, once validated, may be used for planning a knowledge translation intervention and may be applicable to other chronic conditions. Electronic supplementary material The online version of this article (doi:10.1186/s12890-015-0044-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sandra Peláez
- Clinical Research and Knowledge Transfer Unit on Childhood Asthma, Research Centre, Sainte-Justine University Health Centre Montreal, Quebec, Canada.
| | - Alexandrine J Lamontagne
- Clinical Research and Knowledge Transfer Unit on Childhood Asthma, Research Centre, Sainte-Justine University Health Centre Montreal, Quebec, Canada.
| | - Johanne Collin
- Department of Pharmacology, University of Montreal, Montreal, Quebec, Canada.
| | - Annie Gauthier
- Clinical Research and Knowledge Transfer Unit on Childhood Asthma, Research Centre, Sainte-Justine University Health Centre Montreal, Quebec, Canada.
| | - Roland M Grad
- Department of Family Medicine, Jewish General Hospital, Montreal, Quebec, Canada.
| | - Lucie Blais
- Department of Pharmacology, University of Montreal, Montreal, Quebec, Canada.
| | - Kim L Lavoie
- Department of Psychology, Université du Québec à Montréal, Montreal, Quebec, Canada.
| | - Simon L Bacon
- Department of Exercise Sciences, Concordia University, Montreal, Quebec, Canada.
| | - Pierre Ernst
- Department of Pulmonary Medicine, Jewish General Hospital, Montreal, Quebec, Canada. .,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.
| | - Hélène Guay
- Institut national d'excellence en santé et en services sociaux, Quebec, Quebec, Canada.
| | - Martha L McKinney
- Department of Paediatrics, University of Montreal, Montreal, Quebec, Canada.
| | - Francine M Ducharme
- Clinical Research and Knowledge Transfer Unit on Childhood Asthma, Research Centre, Sainte-Justine University Health Centre Montreal, Quebec, Canada. .,Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada. .,Department of Paediatrics, University of Montreal, Montreal, Quebec, Canada. .,Department of Social and Preventive Medicine, University of Montreal, Montreal, Quebec, Canada. .,Departments of Pediatrics and of Social and Preventive Medicine, Associate Director of Clinical Research, Research Centre, CHU Sainte-Justine, 3175 Côte Sainte-Catherine, Room 7939, Montreal, Quebec, H3T 1C5, Canada.
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Development and pretesting of an electronic learning module to train health care professionals on the use of the Pediatric Respiratory Assessment Measure to assess acute asthma severity. Can Respir J 2013; 20:435-41. [PMID: 24046819 DOI: 10.1155/2013/148645] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Severity-specific guidelines based on the Pediatric Respiratory Assessment Measure (PRAM), a validated clinical score, reduce pediatric asthma hospitalization rates. OBJECTIVE To develop, pretest the educational value of and revise an electronic learning module to train health care professionals on the use of the PRAM. METHODS The respiratory efforts of 32 children with acute asthma were videotaped and pulmonary auscultation was recorded. A pilot module, composed of a tutorial and 18 clinical cases, was developed in French and English. Health care professionals completed the module and provided feedback. The performance of participants, case quality and difficulty, and learning curve were assessed using the Rasch test; quantitative and qualitative feedback served to revise the module. RESULTS Seventy-two participants (19 physicians, 22 nurses, four respiratory therapists and 27 health care trainees) with a balanced distribution across self-declared expertise (26% beginner, 35% competent and 39% expert) were included. The accuracy of experts was superior to beginners (OR 1.79, 1.15 and 2.79, respectively). Overall performance significantly improved between the first and latter half of cases (P<0.001). Participants assessed the module to be clear (96%), relevant (98%), realistic (94%) and useful (99%) to learn the PRAM. The qualitative⁄quantitative analysis led to the deletion of three cases, modification of remaining cases to further enhance quality and reordering within three levels of difficulty. DISCUSSION Using rigorous educational methods, an electronic module was developed to teach health care professionals on use of the PRAM score. Using the back-translation technique, both French and English versions were developed and validated simultaneously. The pilot module comprised a tutorial and three case-scenario sections, and was tested on a target audience of physicians, nurses, respiratory therapists and medical trainees. CONCLUSION The final electronic learning module met the clarity and quality requirements of a good teaching tool, with a demonstrated learning effect and high appreciation by health care professionals. Available in French and English, it is offered to facilitate implementation of PRAM-based acute pediatric asthma guidelines.
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Evaluation, modification and validation of a set of asthma illustrations in children with chronic asthma in the emergency department. Can Respir J 2012; 19:26-31. [PMID: 22332128 DOI: 10.1155/2012/367487] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES To test, modify and validate a set of illustrations depicting different levels of asthma control and common asthma triggers in pediatric patients (and⁄or their parents) with chronic asthma who presented to the emergency department at the Children's Hospital of Eastern Ontario, Ottawa, Ontario. METHODS Semistructured interviews using guessability and translucency questionnaires tested the comprehensibility of 15 illustrations depicting different levels of asthma control and common asthma triggers in children 10 to 17 years of age, and parents of children one to nine years of age who presented to the emergency department. Illustrations with an overall guessability score <80% and⁄or translucency median score <6, were reviewed by the study team and modified by the study's graphic designer. Modifications were made based on key concepts identified by study participants. RESULTS A total of 80 patients were interviewed. Seven of the original 15 illustrations (47%) required modifications to obtain the prespecified guessability and translucency goals. CONCLUSION The authors successfully developed, modified and validated a set of 15 illustrations representing different levels of asthma control and common asthma triggers. PRACTICE IMPLICATIONS These illustrations will be incorporated into a child-friendly asthma action plan that enables the child to be involved in his or her asthma self-management care.
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Mammen J, Rhee H. Adolescent Asthma Self-Management: A Concept Analysis and Operational Definition. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2012; 25:180-189. [PMID: 23285426 DOI: 10.1089/ped.2012.0150] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Accepted: 08/15/2012] [Indexed: 11/12/2022]
Abstract
BACKGROUND: Adolescents with asthma have a higher risk of morbidity and mortality than other age groups. Asthma self-management has been shown to improve outcomes; however, the concept of asthma self-management is not explicitly defined. METHODS: We use the Norris method of concept clarification to delineate what constitutes the concept of asthma self-management in adolescents. Five databases were searched to identify components of the concept of adolescent asthma self-management, and lists of relevant subconcepts were compiled and categorized. RESULTS: Analysis revealed 4 specific domains of self-management behaviors: (1) symptom prevention; (2) symptom monitoring; (3) acute symptom management; and (4) communication with important others. These domains of self-management were mediated by intrapersonal/cognitive and interpersonal/contextual factors. CONCLUSIONS: Based on the analysis, we offer a research-based operational definition for adolescent asthma self-management and a preliminary model that can serve as a conceptual base for further research.
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Affiliation(s)
- Jennifer Mammen
- School of Nursing, University of Rochester , Rochester, New York
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Gupta S, Wan FT, Ducharme FM, Chignell MH, Lougheed MD, Straus SE. Asthma action plans are highly variable and do not conform to best visual design practices. Ann Allergy Asthma Immunol 2012; 108:260-5.e2. [PMID: 22469446 DOI: 10.1016/j.anai.2012.01.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Revised: 12/31/2011] [Accepted: 01/27/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND Asthma action plans improve asthma outcomes and are recommended in guidelines. However, delivery by physicians and usage by patients remain low. This may be because of variability in existing plans and a failure to consider visual design and usability factors in plan development. OBJECTIVE To characterize the variability in both the content and the format of existing plans, and the extent to which their format conforms to evidence-based visual design recommendations. METHODS We collected plans from the internet, Canadian experts and associations, guidelines, and published trials. We inductively developed analytic criteria for format and content analyses. RESULTS We collected 69 unique English or French-language adult outpatient plans from around the world. We found large variability in format, and plans fulfilled a mean of only 3.5 out of 8 evidence-based visual design recommendations. Content was also variable, including different descriptions of the baseline clinical state and descriptions and instructions at each "action point" (point recommending a change in treatment). CONCLUSION Existing plans vary widely in content and format. Accordingly, studies evaluating the effectiveness of action plans may not be directly comparable. Also, visual design may affect usability, uptake, and effectiveness. Our results suggest that this has not been adequately addressed in most plans, and design evidence and experts should be included in future development.
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Affiliation(s)
- S Gupta
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Ducharme FM, Zemek RL, Chalut D, McGillivray D, Noya FJD, Resendes S, Khomenko L, Rouleau R, Zhang X. Written action plan in pediatric emergency room improves asthma prescribing, adherence, and control. Am J Respir Crit Care Med 2010; 183:195-203. [PMID: 20802165 DOI: 10.1164/rccm.201001-0115oc] [Citation(s) in RCA: 121] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
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).
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