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| Journal of the New Zealand Medical Association,
18-June-2004, Vol 117 No 1196
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Application of asthma action plans to childhood asthma:
national survey repeated
Andrew McNally, Chris Frampton, John Garrett, Philip
Pattemore
Asthma action plans facilitate early intervention at home
when an exacerbation occurs.1,8 Increasing the
dose of steroid medication (oral or inhaled) for mild-to-moderate exacerbations
of childhood asthma, and incorporating this as a step in an asthma action plan,
is done with the intention of avoiding consequences such as hospitalisation,
visits to the emergency department, and rescue courses of oral steroid.
In 1997, Garrett et al published the results of a 1995
survey investigating the use of paediatric asthma action plans in New
Zealand.1 Discrepancies were found between
recommendations in asthma management guidelines and the way plans were utilised
in clinical practice. The authors were interested in the use of an increased
dose of inhaled steroid as part of asthma action plans, noting that this was a
common practice lacking proof of benefit.
In the last 7 years, there have been several clinical trials
investigating the efficacy of high-dose inhaled steroids in treating children
experiencing asthmatic exacerbations of varying severity, and in different
settings.7-13. There have also been updates to
some of the major international asthma consensus
documents.2-5
We repeated the original survey to determine whether this
new information had any effect on the clinical application of asthma action
plans and whether doctors typically include an increasing-inhaled-steroid-dose
step.
MethodsA postal questionnaire on the
use of childhood asthma action plans was sent to all paediatricians and
paediatric registrars in New Zealand (297 in total), and to a random sample of
500 of the 2639 registered GPs in New Zealand. The New Zealand Medical Council
statistician carried out selection of the GP sample group and posted the
questionnaires on our behalf. An initial mailout (5 November 2002) and one
follow-up questionnaire (26 November 2002) were sent in order to maximise the
response rate.
The structure of the questionnaire was identical to
that used in 1995. The first question asked respondents whether they provided
children (who were suffering asthma) with an asthma action plan. For those who
answered ‘yes’ they were asked what proportion of these children
were given a plan; expressed as <25%, 25–50%, 50–75%, >75%, or
unknown. We also asked whether a step involving an increased dose of inhaled
steroid was included in the plan and, if so, what were criteria determined the
increase, its magnitude and duration. A blank copy of the plan used by the
respondent was requested.
Respondents who had children with asthma in their care
were then asked a series of questions to ascertain their opinion about the use
of action plans—in particular, their perception of their usefulness in the
management of childhood asthma, and their effect on patient understanding and
compliance with asthma medications.
Demographic information on respondent’s age, sex,
and geographic location was included in the questionnaire. To determine the
representativeness of our sample, comparisons were made between demographic
features of the sample and data provided by the New Zealand Medical Council
Statistician for all New Zealand GPs, paediatricians and paediatric registrars.
Ethical approval was not required for this study.
Comparisons (using chi-squared tests) were made between
the responses of paediatricians / paediatric registrars and GPs for a selection
of questions. We also compared responses to specific questions about the use of
action plans, and compared their use of an increased dose of inhaled steroid
between 1995 and 2002. A p value of <0.05 was regarded as statistically
significant.
ResultsResponse—Of
the 797 questionnaires sent out, 460 (58%) responses were returned.
Paediatricians and paediatric registrars returned 199 questionnaires (67%),
while GPs returned 261 (52%). Twenty questionnaires returned by paediatricians
and paediatric registrars were not included for analysis; comprising 9
paediatricians who indicated they did not treat children with asthma, 6 who were
no longer in clinical practice, and 5 who simply did not answer.
Similarly, 28 questionnaires returned by GPs were not
included for analysis because 16 were no longer in active practice and 12 did
not answer. Therefore, 412 valid responses were used for analysis—179
(60%) from paediatricians and paediatric registrars, and 233 (47%) from
GPs.
Demographic dataPopulation statistics were obtained
from the Medical Workforce 2000 publication supplied by the Medical Council of
New Zealand statistician. The paediatrician/paediatric registrar sample showed
no appreciable deviations from the entire New Zealand paediatrician/paediatric
registrar population for any of the demographic variables. GPs sampled did not
differ from the entire New Zealand GP population with regard to sex and
geographic location. Our sample included more GPs in the older age groups (Table
1).
Table 1 Demographic data of surveyed GPs and
paediatricians / paediatric registrars (GPs n=233; Paediatricians and Paediatric
Registrars n=179)
Use of action plans302 (73.3%) respondents (165 [70.8%]
GPs, and 137 [76.5%] paediatricians / paediatric registrars) indicated that they
used written action plans for children with asthma in their care—compared
to 91.2% of GPs and 76.2% of paediatricians / paediatric registrars in 1995.
This difference was significant for GPs (p<0.001), but
not for paediatricians and paediatric registrars (p=0.549). Overall,
significantly fewer respondents were using asthma action plans for children with
asthma (Table 2). GPs were less likely (than paediatricians / paediatric
registrars) to use action plans in 2002 (p<0.001). The reverse was true in
1995 (Table 3).
Use of an increased dose of inhaled steroidIn total, 184 (61.5%) respondents
who used asthma action plans included a step involving an increase in the dose
of inhaled steroid—compared with a rate of 83.6% in 1995
(p<0.001).
When compared with their 1995 counterparts, GPs in 2002 were
less likely to include a step that involved an increased dose of inhaled steroid
(p=0.003), as were paediatricians and paediatric registrars (p<0.001) [Table
2]. GPs in 2002 were significantly more likely than paediatricians and
paediatric registrars to include a step with an increased dose of inhaled
steroid (p<0.001) [Table 3]. This was also the case in 1995 [Table 3].
Table 2. Use of action plans and an increased dose of
inhaled steroid in action plans
Note: Those who use an increased dose of inhaled
steroid (in action plans) is given as a percentage of the total number of
respondents who indicated that they used action plans for children with
asthma.
Table 3. Comparisons of GPs and paediatricians /
paediatric registrars in 1995 and 2002
DiscussionUpdates of major international
consensus documents released in recent years have stressed the importance of
written asthma action plans in the management of childhood
asthma.2–6 In the last 7 years, there has
been a reduction in the use of an increased dose of inhaled steroid in asthma
action plans for the treatment of acute exacerbations. This may represent a lack
of evidence supporting such an
approach.
The British Thoracic Society (BTS) suggested (in 1997)
doubling the dose of inhaled corticosteroid temporarily where there is a
deterioration in asthma or the first signs of upper respiratory tract infection
in children.2
However, recent guidelines published by the BTS group have
indicated that doubling the dose of inhaled steroid at the time of an
exacerbation is of unproven value.3
Furthermore, The National Heart, Lung and Blood Institute of America tentatively
recommended that for home management of mild asthma exacerbations (Peak
Expiratory Flow >80% predicted or personal best, no wheezing or shortness of
breath), patients should double their dose of inhaled corticosteroid for
7–10 days 4.
The 2002 Australian Asthma Management Handbook made no
comment about increasing the inhaled steroid dose for exacerbations of
paediatric asthma.5 However, space was provided
in the handbook’s paediatric asthma action plan to increase the dose of
preventer medication at the first sign of a cold, or a significant increase in
wheeze or cough. Unfortunately, no such space exists in the Child Asthma Plan
released by the Asthma and Respiratory Foundation of New Zealand in 2000, which
stresses the importance of increasing reliever/bronchodilator medication in the
case of an exacerbation.
In 1994, New Zealand guidelines recommended that adults
double the dose of inhaled steroid during an acute attack, but the same clarity
of instruction was lacking for children.6
However, a 2001 meta-analysis by Holt et al, supported the growing evidence that
doubling inhaled steroid in acute asthma is not clinically valuable in adults
and adolescents.7 Therefore, there is no
consistent evidence to suggest increased doses of inhaled steroid for
exacerbations of asthma are appropriate, despite earlier consensus documents
recommending it.
There has only been one clinical trial investigating an
increased dose of inhaled steroids as a step in a written asthma action
plan.8 Twenty-eight children aged 6–14
years (with mild-to-moderate asthma) were given asthma action plans to take
home, and (if their peak expiratory flow rate (PEFR) dropped below 80% of
baseline for 24 hours or more) they were instructed to double the dose of
inhaled steroid (or their maintenance dose plus placebo) for 3 days.
In the 2 weeks following an exacerbation, there were no
differences found in mean-morning and mean-evening PEFR symptom scores,
spirometric parameters (FEV1, FVC, and
FEF25–75) scores, or parent opinion scores.
Indeed, doubling the dose of beclomethasone had no
beneficial effect when compared with placebo in treating an asthma exacerbation.
This was considered evidence against using such an approach as a step in an
asthma action plan. The results, however, could not be generalised to include
children with severe asthma.
In further studies of pre-school children at home with acute
asthma and without action plans, an increase in the use of inhaled steroid did
not reduce the need for hospitalisation, emergency room visits, and the
requirement of oral steroids (when compared with
placebo).9,10
Oral corticosteroids have been the standard treatment for
severe asthma exacerbations for several years. In some instances, acute therapy
with high-dose inhaled steroids has been found to be at least as effective as
oral steroids; however, no study has found them to be more
efficacious.11–13
Although asthma consensus documents have previously
suggested treating childhood asthma exacerbations with an increased dose of
inhaled steroid, several studies highlight the insufficient evidence supporting
this practice. Our results suggest that GPs, paediatricians, and paediatric
registrars have taken note of this lack of evidence because fewer are including
an increased dose of inhaled steroid as a step in childhood written action
plans.
If the exacerbation is mild to moderate, an increase in
reliever/bronchodilator medication may be adequate treatment. Another
explanation in New Zealand may be the altered format of the pre-printed
Childhood Asthma Action Plan. Specifically, for the last 6 years, the plan has
not specifically included instructions for parents to increase the dose of their
child’s preventer medication.
The other significant finding from our study is the overall
decline in the use of written Asthma Action Plans for children with asthma. This
decrease was significant for GPs in particular. Many GPs, however, may be giving
their patients verbal asthma management plans, which incorporate an increased
dose of inhaled steroid where an exacerbation occurs. GPs have short
consultation times so a brief verbal explanation may be viewed as more efficient
than explaining a written asthma action plan in depth.
Furthermore, verbal action plans may be considered more
conducive to enhancing effective communication between child, parent, and
doctor, ultimately strengthening the patient-doctor relationship. Our survey did
not account for the use of verbal asthma plans. Indeed, there is no strong
evidence showing that written action plans are
beneficial14—they are believed to promote
better self-management, however.15
On analysis, our use of a random sample, and the ability to
ascertain the representativeness of respondents, diminished selection bias. The
capacity of respondents to precisely remember aspects of behaviour (recall bias)
and their perception of the preferred answer (response bias) were, however,
beyond our control.
Although our survey’s overall response rate (58%) was
below expectations, it is comparable to that achieved in other postal surveys.
In retrospect, it would have been helpful to break the ‘paediatric’
component into ‘registrars’ and ‘practicing
paediatricians’—to identify any difference in practice between
‘registrars’ and ‘practicing paediatricians’ and to
identify any effect from relatively recent education in the role of inhaled
steroids in acute asthma versus longstanding practice.
In attempting to be consistent when comparing the two
surveys we did not break the ‘paediatric’ component into
‘registrars’ and ‘practicing paediatricians’.
Interpretation of results depends on the severity and number of asthmatics seen
by GPs, paediatricians, and paediatric registrars. We assumed that
paediatricians and paediatric registrars see children with severe asthma more
often.
In conclusion, the application of childhood asthma action
plans by New Zealand GPs, paediatricians, and paediatric registrars has changed.
Specifically, there has been an overall decline in the use of written asthma
action plans, and fewer practitioners are incorporating an increased dose of
inhaled steroid in these plans.
Part of this change is evidence based, as recent results
from clinical trials do not support the role of high-dose inhaled steroid in
treating childhood asthma exacerbations. Despite this, 86.5% of GPs continue to
include a step that increases the dose of inhaled steroid.
GPs generally have a looser control of their patients
compared to paediatricians and paediatric registrars, so it is likely that
significant numbers of children will be taking higher doses of inhaled steroids
for longer periods of time—this is still far from ideal, and potentially
dangerous.
Finally, inconsistency remains (between recommendations in
consensus documents) about the use of asthma action plans and the actual
application of them in New Zealand. Our survey shows that not all children with
asthma are receiving a written asthma plan, despite this plan being recommended
in asthma consensus documents.
Author information:
Andrew McNally, Medical Student, Department of Paediatrics, Christchurch School
of Medicine and Health Sciences, University of Otago, Christchurch; Chris
Frampton, Biostatistician, Department of Medicine, Christchurch School of
Medicine and Health Sciences, University of Otago, Christchurch; John Garrett,
Paediatric Registrar, Department of Paediatrics, Christchurch Hospital,
Christchurch; Philip Pattemore, Senior Lecturer in Paediatrics, Christchurch
School of Medicine and Health Sciences, University of Otago,
Christchurch
Acknowledgements:
This project was undertaken as a Summer Studentship in the Department of
Paediatrics at the Christchurch School of Medicine and Health Sciences. (The
Asthma and Respiratory Foundation of New Zealand sponsored Andrew McNally.) The
authors thank the Asthma and Respiratory Foundation and Asthma New Zealand (for
assisting with project expenses), the Medical Council of New Zealand (for
assistance in posting the questionnaires), Kay Read (for all of her
administrative support), and many paediatricians, paediatric registrars and
general practitioners throughout New Zealand (for taking the time to respond to
our survey).
Correspondence:
Andrew McNally, Medical Student, Department of Paediatrics, Christchurch School
of Medicine and Health Sciences, P O Box 4345, Christchurch. Fax: (03) 364 0747;
email:
andrewjohnmcnally@hotmail.com
References:
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