Reducing Asthma Mortality with the Asthma Self-Management Plan System of Care

Richard Beasley and Julian Crane

Department of Medicine, Wellington School of Medicine, Wellington, New Zealand

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The asthma self-management plan system of care was initially introduced in New Zealand and Australia in the late 1980s as a pragmatic and urgent response to increasing asthma mortality. By the early 1990s, asthma self-management plans were recommended in international consensus guidelines as essential in the management of adult asthma (1), despite the lack of randomized controlled clinical trials to asses their efficacy, although the principles on which they were based had been clearly established. Since then a number of randomized placebo-controlled studies have been published and these have demonstrated efficacy in the long-term management of asthma, with their use leading to a reduction in both serious morbidity and the requirement for acute medical care (2). We now have the first substantive evidence, published in this issue of the American Journal of Respiratory and Critical Care Medicine, that the provision of written asthma self-management plans also significantly reduces the risk of mortality (pp. 12- 18) (3).

In the simplest terms, the asthma self-management plan system can be described as the process whereby asthma patients modify their treatment in response to self-assessment of the severity of their asthma, in accordance with predetermined guidelines. This process involves the integration of self-assessment and self-management, and incorporates written guidelines for both the long-term treatment of asthma and the treatment of severe attacks.

Fundamental to the success of this strategy is the ability of patients to recognize a deterioration in their asthma. This requires the assessment of asthma severity through the educated interpretation of key symptoms and measurements of peak flow. Most self-management plans are based on regular long-term use of inhaled corticosteroid therapy in association with the use of oral corticosteroids for major exacerbations. Inhaled -agonists represent the bronchodilator drugs of choice, used as required to relieve symptoms, and with an increased requirement, or a poor or short duration of response, indicating worsening asthma.

Studies of the initial plans based on these principles were not controlled and as a result the findings that their use led to improvement in asthma control needed to be interpreted with caution (4, 5). These initial studies did however serve the purpose of raising the concept of this approach to management, and provided prototype plans that could be more rigorously evaluated in randomized placebo-controlled clinical trials. To date there have been nine such studies of the efficacy of written self-assessment and self-management plans, based primarily on the structure and principles of the original prototype plans (2). These studies have shown that the use of this type of plan leads to a one-third to two-thirds reduction in hospital admissions, emergency room visits, unscheduled visits to the doctor for asthma, days off work, and nocturnal wakening.

Another major goal of asthma management is a reduction in asthma mortality. It is not possible to assess the effect of management regimens on asthma mortality in clinical trials because of the rarity of a fatal outcome even in high-risk groups. The appropriate scientific approach to employ is a case-control study in which one examines all the deaths available within a population group (cases) and a representative proportion of asthmatics sampled at random from the same population group (control subjects). The major advantage of a case-control study over a clinical trial is that it is more efficient, which usually means that a considerably more powerful study can be conducted. This is illustrated in the current study in which it took 3 yr to identify and study 89 deaths from a population of over four million people; a randomized placebo-controlled trial or cohort study of asthma mortality in this population simply would not have been possible.

The crucial issues in the design of such case-control studies are to ensure that the cases and control subjects are similar with respect to their chronic asthma severity, i.e., they come from the same population in terms of their baseline risk of death, and that any differences in chronic asthma severity are controlled for in the analysis. Both of these methodological issues are well addressed in the study by Abramson and coworkers. As a result, we can have confidence in their main findings that the provision of a written asthma action plan was associated with a 70% reduction in the risk of death, that the use of oral steroids for the severe attack reduced the risk of death by 90%, and that the use of a peak flow meter during the preceding months also reduced mortality.

As a result, this study provides further evidence that the asthma self-management plan system of care involving a written action plan, self-monitoring of peak flow and the interpretation of key symptoms, together with regular medical review now represents "optimal" management and should be offered to most adults with asthma. However, before fully embracing this approach it is necessary to acknowledge that a number of issues relating to the structure and implementation of management plans require further study. These include the number of stages; specific peak flow percentages or symptoms indicating each stage; and the intensity and method of implementation, for example, how much peak flow monitoring and symptom recording is optimal. The role of other medications such as long-acting -agonists and leukotriene receptor antagonist drugs, and the relationship between specific therapeutic responses and outcomes will also need to be addressed.

The development and widespread introduction of asthma self-management plans over the last 10 yr arose from concerns about the high rates of asthma mortality and represented a practical method whereby problems identified in asthma mortality surveys could be overcome (6). The evidence from this case-control study that self-management plans reduce the risk of death, in one sense completes the circle, by demonstrating that they could achieve their original purpose.

	References

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1. Lenfant C. International Consensus Report on Diagnosis and Management of Asthma. National Heart, Lung, and Blood Institute, National Institutes of Heath. Bethesda, MD: U.S. Department of Health and Human Services; 1992.

2. Gibson PG, Coughlan J, Wilson AJ, Abramson M, Bauman A, Hensley MJ, Walters EH. Self-management education and regular practitioner review for adults with asthma. Cochrane Library 2000; 1: 1-39 .

3. Abramson MJ, Bailey MJ, Couper FJ, Driver JS, Drummer OH, Forbes AB, McNeil JJ, Walters EH. Are asthma medications and management related to deaths from asthma? Am J Respir Crit Care Med 2000; 163: 12-18 [Abstract/Free Full Text].

4. Beasley R, Cushley M, Holgate ST. A self-management plan in the treatment of adult asthma. Thorax 1989; 44: 200-204 [Abstract/Free Full Text].

5. Charlton I, Charlton G, Broomfield J, Mullee MA. Evaluation of peak flow and symptoms only self management plans for control of asthma in general practice. BMJ 1990; 301: 1355-1359 .

6. Rea HH, Sears MR, Beaglehole R, Fenwick J, Jackson RT, Gillies AJ, O'Donnell TV, Holst PE, Rothwell RP. Lessons from the national asthma mortality study: circumstances surrounding death. NZ Med J 1987; 100: 10-13 .