Reported use of asthma management plans in South Australia

Abstract

MJA 1997; 166: 298-301  

Introduction

In an attempt to create a unified approach to the management of asthma, a group of "accepted experts" developed the Asthma Management Plan (AMP), a set of consensus guidelines for health professionals.⁷ The Australian AMP comprises six steps:

1. Assessing the severity of asthma;
2. Achieving best lung function;
3. Maintaining best lung function by identifying and avoiding triggers;
4. Maintaining best lung function with optimal medication;
5. Developing an action plan; and
6. Educating the patient and reviewing regularly.

In this study we examine the current use of AMPs and determine the specific elements of the plan that have been adopted by people with asthma and their doctors. Such information is important in planning ongoing asthma management campaigns.  

Methods

For the purposes of our study, we included a number of questions in the Health Omnibus Survey. Respondents were asked whether they had asthma, and if they answered "yes" they were then asked to respond to the questions listed in Box 1. For the purposes of the interviews, we defined:

• Asthma management plans as "a coordinated method of management that covers aspects of your asthma -- medication, trigger factors, lung function measurement, etc.";

• Trigger factors as "incidents that can cause you to have an asthma attack"; and

• An asthma action plan as "written or verbal instructions of what to do if your asthma is out of control, i.e., having a bad attack".

Finally, we considered that patients who reported having an AMP, being told about trigger factors and having an action plan were receiving "good management", and examined factors related to good management. We excluded the optimisation of pharmacological intervention from our definition.

SPSS was used for all statistical analyses.⁹  

Results

Box 2 (below) shows that current medically confirmed asthma was more common among women than men, and declined in prevalence with increasing age. It was also more common among rural than metropolitan respondents, and among Australian-born respondents than those born elsewhere; this difference remained significant after adjusting for age and sex in logistic regression analyses. There was no relationship between current confirmed asthma prevalence and post-secondary education or annual gross household income, even after adjusting for age and sex.

Asthma management plans

Women were more likely than men to have been told about their asthma severity (86.3% v. 75.0%; chi-squared = 6.1; P = 0.01), and those who had been told tended to be younger than those who had not (t = 3.1; P = 0.07). Among those who had been told, reported level of severity increased with advancing age (t = 5.3; P < 0.01). Severity did not vary by sex, but was greater among rural respondents than metropolitan respondents (chi-squared = 8.6; P = 0.01). The reported prevalence of discussing trigger factors and having an action plan increased with increasing asthma severity (see Box 4). It is notable that only 14 (25.4%) of those who had not been told their asthma severity had an action plan.

Men were more likely than women to have no regular doctor for asthma care (22.7% v. 12.4%; chi-squared = 5.7; P = 0.02); there was no difference by age.

Overall, those who had discussed trigger factors did not differ by sex, area of residence or whether they had been told their level of severity. After adjustment for covariates, discussion of trigger factors was more likely among younger respondents (P < 0.05) and those who had a regular doctor (P < 0.01). Among those who had been told their level of severity, logistic regression analysis showed that those with severe asthma were more likely than those with moderate or mild asthma to have discussed trigger factors (P < 0.05). Of those with a regular doctor, source of care was unrelated to discussion of trigger factors. Respondents who reported having an action plan did not vary by age, area of residence or whether they had been told their level of severity. Action plans were more common among women (P < 0.05) and those who had a regular doctor (P < 0.05), and among those who had been told they had moderate or severe asthma than mild asthma (P < 0.01). For respondents with a regular doctor, source of care was unrelated to having an action plan.  

Good management

Discussion

Our finding that 39.5% of respondents had an action plan is a somewhat higher result than those of previous reports,^10,11 possibly indicating an increase in their use. As we found that reported use of action plans did not vary by age, the different age profile of our study compared with that of Comino and colleagues¹⁰ (mean, 39.4 years; range, 15-84 years v. mean, 37.4 years; range, 18-50 years) is unlikely to have contributed to the apparent doubling in prevalence of action plan use that we observed. However, unlike the other study, we included verbal as well as written action plans, and this may have been responsible for the difference.

Our study was based on self-report, and responses were not validated. However, our method of assessing self-reported asthma has been used in a previous validated epidemiological study.¹² There may have been under-reporting in the responses to the questions, even though we used trained interviewers. However, despite these methodological problems, the key measure of the acceptability of the AMP and its elements is their reported use in the community.

We are aware that the term "asthma management plan" may have introduced some problems in that our def inition of the AMP encompassed as - sessment of severity, trigger-factor discussions and the development of an action plan. Hence, it is possible that people who reported using an AMP may have been including the other three elements. However, as a main objective was to compare the uptake of the "complete" AMP with that of its individual elements, we believed it was important to include all these questions in the survey.

We found that certain elements of the AMP are being adopted more frequently than others, which may indicate that patients find these steps more appropriate to their specific needs, or that doctors (GPs and specialists) find certain elements of the AMP easier to use or implement. GPs are the principal providers of asthma care in the community and it is probable that they have a considerable effect on the uptake of the AMP model. Developing a "complete" management plan may be too onerous a task for a busy GP. Conversely, GPs may find the AMP model does not satisfy their individual needs and, as a consequence, choose specific elements from the AMP model for their everyday practice.¹³

Over 80% of our respondents, most of whom had mild to moderate asthma, saw a GP for all or part of their asthma care. As there is evidence that GPs' management of asthma is very variable,^14,15 it is important to concentrate on providing useful and focused education for GPs. Urgent clarification is needed of the key steps within the AMP model that will reduce mortality and morbidity in people with asthma and improve their quality of life.

Interestingly, we found that only 41% of the respondents attending a specialist only had an AMP. As specialists spend more time with their patients and deal with people with more severe asthma, this finding requires further investigation.

It has been suggested that some steps of the AMP may be inappropriate for general application. For example, peak flow meters are supposed to be used in both steps 2 and 3, but Ruffin and Pierce have proposed that aiming to have all asthmatic patients record peak expiratory flow over the long term may not be worthwhile,¹⁶ and that focusing on, for example, those at risk of dying, those in uncertain clinical situations (e.g., those with exercise-induced asthma) and those who are "particularly interested" in monitoring their asthma would be more cost effective. They emphasised the need for a more rigorous scientific approach to examining "the basis for and benefit of" peak expiratory flow.¹⁶

In a more recent paper Gibson et al. state that "action plans have received little controlled evaluation".¹⁷ Among 35 adult asthma patients, they found that the current increase in medication recommended in the AMP action plan had a high failure rate. On the other hand, there is evidence that regular review (step 6 of the AMP) can reduce days lost from work or school¹⁸ and home visits by GPs,¹⁹ and that patient education (step 5) improves symptom control²⁰ and reduces visits to accident and emergency departments.²¹

The guidelines in the AMP model have come to be accepted as the "gold standard" of asthma management in most countries.^22,23 However, what is needed now is a careful re-evaluation ²⁴ to ensure that "unsound practice" does not become formalised.²⁵ A new perspective may be required that embraces the variability in management and clinical encounters.²⁶ Not surprisingly, we found that having a regular doctor is the main determinant of "good management" -- regular review is likely to allow time for the introduction of more steps in the AMP.

The challenge in continuing to evaluate an introduced management program in clinical practice is substantial. If over half the population of asthmatic patients have already been exposed to the asthma management plan in part or in full, how can this be done? Small intensive clinical trials with objective outcomes such as peak flow measurements, or case-control studies comparing asthmatic patients with and without good quality of life, could be performed, but would have the disadvantage of not being generalisable to the population at large. Large population studies with specific outcome measures would rely on the outcome measures being validated against accepted criteria of asthma control.

A national project that used specific health outcomes, such as prescriptions of reliever or preventer agents, and monitored hospital admissions for asthma could be used to evaluate interventions introduced on a State or regional basis. To coordinate and cooperate in such a project would present a challenge to organisations involved in asthma management. There is current interest in coordinated care programs for chronic diseases and the time is right to introduce an evaluation strategy for different interventions in asthma.  

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