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Meta-Analysis
. 2017 Apr 10;4(4):CD011859.
doi: 10.1002/14651858.CD011859.pub2.

Personalised asthma action plans for adults with asthma

Timothy L Gatheral  1 , Alison Rushton  2 , David Jw Evans  3 , Caroline A Mulvaney  3 , Nathan R Halcovitch  4 , Gemma Whiteley  5 , Fiona Jr Eccles  6 , Sally Spencer  7
Affiliations
Meta-Analysis

Personalised asthma action plans for adults with asthma

Timothy L Gatheral et al. Cochrane Database Syst Rev. .

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.

PubMed Disclaimer

Conflict of interest statement

David Evans: provides freelance medical writing services to medical communications agencies.

Alison Rushton: undertook a feasibility study to pilot a locally developed asthma self‐management plan for children and young people within a Clinical Commissioning Group (CCG) locality in the northwest of England. The project was completed in 2015 as part of a Clinical Academic Internship, funded by Health Education England and a northwest CCG. The intern received no payment for including individuals in the study.

Nathan Halcovitch: none.

Fiona Eccles: none.

Timothy Gatheral: none.

Sally Spencer: serves as co‐investigator on the Cochrane Programme Grant supporting this review.

Gemma Whiteley: none.

Caroline Mulvaney: none.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
3
3
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
1.1
1.1. Analysis
Comparison 1 PAAP versus no PAAP, Outcome 1 Number of participants reporting at least 1 exacerbation requiring emergency department visit or hospitalisation.
1.2
1.2. Analysis
Comparison 1 PAAP versus no PAAP, Outcome 2 Asthma symptom scores (change from baseline in ACQ).
1.3
1.3. Analysis
Comparison 1 PAAP versus no PAAP, Outcome 3 Serious adverse events (including deaths).
1.4
1.4. Analysis
Comparison 1 PAAP versus no PAAP, Outcome 4 Quality of life (change from baseline in AQLQ).
1.5
1.5. Analysis
Comparison 1 PAAP versus no PAAP, Outcome 5 Number of participants reporting at least 1 exacerbation requiring systemic corticosteroids.
1.6
1.6. Analysis
Comparison 1 PAAP versus no PAAP, Outcome 6 Measure of respiratory function (change from baseline in FEV1 (L)).
1.7
1.7. Analysis
Comparison 1 PAAP versus no PAAP, Outcome 7 Measure of respiratory function (change from baseline in % predicted FEV1).
1.8
1.8. Analysis
Comparison 1 PAAP versus no PAAP, Outcome 8 Measure of respiratory function (change from baseline in % predicted PEF).
1.9
1.9. Analysis
Comparison 1 PAAP versus no PAAP, Outcome 9 Measure of respiratory function (change from baseline in PEF (L/min)).
1.10
1.10. Analysis
Comparison 1 PAAP versus no PAAP, Outcome 10 Days lost from work or study.
2.1
2.1. Analysis
Comparison 2 PAAP plus education versus education alone, Outcome 1 Number of participants reporting at least 1 exacerbation requiring emergency department visit or hospitalisation.
2.2
2.2. Analysis
Comparison 2 PAAP plus education versus education alone, Outcome 2 Asthma symptom scores (change from baseline in ACQ score).
2.3
2.3. Analysis
Comparison 2 PAAP plus education versus education alone, Outcome 3 Quality of life (change from baseline in AQLQ score).
2.4
2.4. Analysis
Comparison 2 PAAP plus education versus education alone, Outcome 4 Number of participants reporting at least 1 exacerbation requiring systemic corticosteroids.
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Ross 2012 {published data only}
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Sittipunt 2008 {published data only}
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Steurer‐Stey 2010 {published data only}
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Tousman 2009 {published data only}
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Tuazon 2000 {published data only}
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Urek 2005 {published data only}
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References to studies awaiting assessment

Angelini 2010 {published data only}
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References to ongoing studies

NCT02190617 2014 {published data only}
    1. NCT02190617. Guidelines to Practice: Reducing Asthma Health Disparities Through Guideline Implementation (G2P). https://clinicaltrials.gov/show/NCT02190617 2014.
NCT02424409 2015 {published data only}
    1. NCT02424409. Evaluation of the Relapse Rate One Month After Discharge From Emergency Department for Asthmatic Patients Given a Strict Formalized Follow up Protocol. Multicenter, Prospective, Cluster‐randomized. https://clinicaltrials.gov/show/NCT02424409 2015.

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