Running head: INDIVIDUALIZED ASTHMA ACTION PLAN

Individualized Asthma Action Plans Reducing Hospitalizations in Pediatrics

Michelle Bartholet
University of South Florida

INDIVIDUALIZED ASTHMA ACTION PLAN

2
Abstract
Clinical problem: Pediatric patients without an individualized asthma action plan are at
an increased risk for uncontrolled asthma exacerbations that result in many missed school days
and frequent emergency department visits.
Objective: To determine that providing patients with an individualized asthma action plan
will result in better control of asthma symptoms and fewer unplanned visits to the emergency
department. PubMed and Google Scholar were used to gather randomized controlled trials
(RCT) about the influence an individualized written asthma action plan on the management of
asthma symptoms. The Centers for Disease Control and Prevention (CDC) and the Agency for
Healthcare Research and Quality (AHRQ) were also accessed to provide guidelines for current
use of asthma management techniques. The key search terms used included action plan, asthma
education, asthma control, and individualized asthma plan.
Results: Current asthma education recommendations suggest that clinicians must provide
self-management education tools in order to ensure necessary asthma control, including a written
asthma action plan, self monitoring of symptoms, and regular follow up appointments (Institute
for Clinical Systems Improvement [ICSI], 2012). Three RCTs conducted in clinical settings
support the use of an individualized written asthma action plan in asthma management. Results
showed better self-management of asthma, better treatment adherence, and use of written plan at
follow up.
Conclusion: Patients that receive an individualized asthma action plan have better
controlled asthma symptoms, fewer serious exacerbations, and overall improved selfmanagement of asthma symptoms.

INDIVIDUALIZED ASTHMA ACTION PLAN

3

Introduction
There are 7.1 million children in America with asthma (Center for Disease Control
[CDC], 2013) resulting in 10.5 million days of school missed for children between the ages of
five to seventeen years each year (CDC, n.d). While asthma deaths are rare among children, in
2009 one in five children went to the emergency department for asthma related care (CDC, n.d).
Individualized patient education is important in reducing the number of adverse health effects
and urgent care visits related to asthma, and the CDC (2013) recommends that every individual
develop a written asthma action plan with their provider. Asthma education guidelines by the
Institute for Clinical Systems Improvement (ICSI) focus on the self-management of symptoms
with the inclusion of a written plan (ICSI, 2015).
The purpose is to evaluate the effectiveness of providing children with asthma an
individualized asthma action plan as a method to reduce the number of asthma exacerbations and
improve overall asthma symptom control. In hospitalized patients ages seven to seventeen with
asthma, does having an individualized written asthma action plan at discharge, compared to no
action plan with discharge teaching, result in better controlled asthma symptoms over the next
year after their hospitalization and receiving their written asthma plan?
Literature Search:
PubMed and Google Scholar were used to obtain clinical trials regarding use of an
individualized asthma action plan with education for improving asthma symptoms and selfmanagement. The CDC and AHRQ were accessed to obtain guidelines for current use of asthma
management techniques, including the use of a written action plan. The key search terms used
included action plan, asthma education, asthma control, and individualized asthma plan. Specific

INDIVIDUALIZED ASTHMA ACTION PLAN

4
age ranges were also searched to focus on the school age and adolescent patients. The literature
was searched between the years 2006 and 2016.
Literature Review
Three randomized control trials (RCT) and one guideline were combined to evaluate the
effectiveness of the use of an individualized written action plan in the management of acute
asthma symptoms. Ducharme et al (2011) designed a trial to examine the effectiveness of
providing a written asthma action plan (WAP) coupled with a prescription (WAP-P) to improve
self management of asthma, including the adherence to medications prescribed. There were 219
children between the ages of one and seventeen randomized into the intervention and control
groups. The intervention group (n=109) received a WAP-P and was measured against those in the
control group (n=110) with only an unformatted prescription (UP) and no written action plan.
The primary goal was to see if the patients given the written asthma action plan would adhere to
their medication schedule and control their asthma better than the control group. Both groups
originally dropped in medication adherence in the first 14 days, however use of the prescribed
medication was higher in the intervention group over the remaining days with a mean group
difference of 16.13%. Overall, more patients with the written plan not only filled their
prescriptions more regularly, but their asthma was also well controlled at the 28 day follow up
compared to the counter group. The primary weakness of this trial was that it was not conducted
as a double-blind experiment, the provider were aware of which patients were to receive the
WAP-P versus the UP. Other weaknesses were that demographics were not included, including
socioeconomic status or race, and that no p values were included in the results. The strengths of
this trial included random assignment of participation, participants were not aware which group
they were placed in, and the instruments used to measure outcomes were valid.

INDIVIDUALIZED ASTHMA ACTION PLAN

5
Halterman et al (2006) designed a trial to evaluate whether clinician prompting regarding
the childs symptoms along with individual recommendations improves the practice of
preventative care. There were 226 children with persistent asthma between the ages of two and
twelve years of age randomized into an intervention or control group. The intervention group, or
clinician-prompted group, received a single page written prompt that included the childs
symptoms coupled with guideline recommendations, while the control group was given no
prompt. Patients were followed up on via telephone after the initial interview. The results were
that children in the clinician-prompting intervention group more likely to have had any
preventative measures taken at the visit (87% vs 69%). Visits for the intervention group were
also more likely to include the delivery of their action plan than the control group (50% vs 24%).
The intervention group was also more likely to have a discussion regarding asthma (87% vs
76%) as well as recommendations for asthma follow up appointments than the control (54% vs
37%). The follow up interview and medical chart review data also yielded that preventative
action had been taken in 75% of cases in the intervention group. The primary weakness of this
trial was that it was not conducted as a double-blind experiment, where the physicians knew
which patient was to receive the prompt at the visit. Other weaknesses were that demographics
were not included, including socioeconomic status or race, and that no p values were included in
the results The strengths of this trial included random assignment of participation, participants
were not aware which group they were placed in, the instruments used to measure outcomes
were valid, and interviews were performed blindly. Data was excluded for the follow up if the
child did not complete his or her follow up visit within 60 days of the intervention, or if they
participated in another office visit before the date of the follow up appointment. Rice et al (2015)
designed a trial to evaluate the impact of Lay-Educators for Asthma Program (LEAP), an

INDIVIDUALIZED ASTHMA ACTION PLAN

6
inpatient asthma education program for inner city children with asthma. There were 711 children
between the ages of two and seventeen years chronic asthma that were randomized into an
intervention and control group. The intervention group would receive usual care plus an
additional education intervention while the control group received usual care. The results were
that families randomized to the intervention group were more likely to report use of a controller
(p<0.01), using a valved-holding spacer (p=0.02) and have an asthma action plan (p<0.01).
Asthma self-efficacy scores were significantly improved among those who received the
intervention (p=0.04). The primary weakness of this trial was that it was not conducted as a
double-blind experiment, where the volunteers knew which patients were to receive the
education intervention. Other weaknesses included a high drop out rate of 147, and the reliance
on patients and caregivers to complete the follow-up questionnaires. The strengths of this trial
included random assignment of participation, participants were not aware which group they were
placed in, the instruments used to measure were valid, and demographics of socioeconomic
status referred to. Another strength is that p values were included to show the statistical strength
of the trial.
The guidelines for diagnosis and management of asthma was originally published by the
ICSI and revised by the AHRQ in 2012 (Sveum et al, 2012). One objective of the guideline is to
increase the rate of patients over the age of 5 who have individual written action plans, and as a
result can perform timely as well as accurate assessments of their asthma symptoms. The asthma
education guideline recommends that clinicians provide self-management education, including a
written asthma plan, in order to provide patients with skills to control their asthma symptoms and
improve their overall outcomes. High quality evidence demonstrated that use of individual

INDIVIDUALIZED ASTHMA ACTION PLAN

7
asthma education to improve self-management reduces asthma morbidity, including lost work or
school days, unscheduled office visits, and unscheduled hospital admissions.
Synthesis
Rice et al (2015) demonstrated that the inclusion of an individualized written action plan
had a statistically significant effect on asthma control through the use of a controller (p<0.01)
and significantly improved self-efficacy score among those who received the intervention
(p=0.04). Halterman et al (2006) reported that the patients who received an asthma action prompt
were more likely to take preventative asthma measures (87% vs 69%), as well as the significant
delivery of an asthma action plan at follow up (50% to 24%). Ducharme et al (2011)
demonstrated that inclusion of a written plan along with a prescription allowed for better
medication adherence. Finally, the guidelines recommend asthma action plan education to
improve self-management and symptoms, and are supported through high quality evidence.
These research findings together show that individualized education is important in improving
self-management of asthma and better control over asthma symptoms in children between the
ages of five and seventeen. Individualized discussions with patients improves medication
adherence, allows for better preventative care, and overall improvement in symptom
management. These findings imply that this improvement in self-management could reduce the
number of unscheduled emergency department visits and the number of missed school days,
however additional research is warranted to sbstantiate this relationship. Additional research is
required to determine whether or not demographics such as socioeconomic status, gender,
education, or race play a role in the effectiveness of an asthma action plan. Research is also
required to then determine if these demographics should be taken into consideration when
providing a teaching plan that compensates for the individuals health literacy level.

INDIVIDUALIZED ASTHMA ACTION PLAN

8
Clinical Recommendations
Guidelines recommend an asthma action plan be included into routine asthma education
to improve self-management of asthma symptoms and overall control. Individualized asthma
education can be used in combination with prescription therapies to reduce exacerbations and
improve symptoms. Despite additional research requirements to perfect this practice,
individualized education compared to standard teaching improves self-management of asthma
symptoms in these pediatric patients with asthma. It is therefore important to implement this type
of teaching into practice so that individualized teaching does become the standard norm. I
recommend that at each primary care visit, physicians determine the patients symptoms and
triggers in order to develop an individualized asthma action plan. At each subsequent visit, this
plan can be updated based on the effectiveness of the plan and the patients self-efficacy score. It
would also be the nurses responsibility to enforce this teaching and ensure the patients
understand what was prescribed and implemented by the physician. I believe this would be
valuable in the community health setting, especially in areas where either asthma is prevalent or
health literacy is low in order to improve self-management and long term outcomes.

INDIVIDUALIZED ASTHMA ACTION PLAN

9

References
Ducharme, F. M., Zemek, R. L., Chalut, D., Mcgillivray, D., Noya, F. J., Resendes, S., . . .
Zhang, X. (2011). Written Action Plan in Pediatric Emergency Room Improves Asthma
Prescribing, Adherence, and Control. Am J Respir Crit Care Med American Journal of
Respiratory and Critical Care Medicine, 183(2), 195-203. doi:10.1164/rccm.2010010115oc
Center for Disease Control (2013). Asthma facts: CDCs national asthma control program
grantees. Retrieved June 10, 2016, from
http://www.cdc.gov/asthma/pdfs/asthma_facts_program_grantees.pdf
Center for Disease Control (n.d). Asthmas impact on the nation. Retrieved June 10, 2016, from
http://www.cdc.gov/asthma/impacts_nation/asthmafactsheet.pdf
Halterman, J. S., Fisher, S., Conn, K. M., Fagnano, M., Lynch, K., Marky, A., & Szilagyi, P. G.
(2006). Improved Preventive Care for Asthma. Arch Pediatr Adolesc Med Archives of
Pediatrics & Adolescent Medicine, 160(10), 1018. doi:10.1001/archpedi.160.10.1018
Rice, J. L., Matlack, K. M., Simmons, M. D., Steinfeld, J., Laws, M. A., Dovey, M. E., & Cohen,
R. T. (2015). LEAP: A randomizedcontrolled trial of a lay-educator inpatient asthma
education program. Patient Education and Counseling, 98(12), 1585-1591.
doi:10.1016/j.pec.2015.06.020
Sveum R, Bergstrom J, Brottman G, Hanson M, Heiman M, Johns K, Malkiewicz J, Manney S,
Moyer L, Myers C, Myers N, OBrien M, Rethwill M, Schaefer K, Uden D. (2012)
Diagnosis and management of asthma. Bloomington (MN): Institute for Clinical Systems

INDIVIDUALIZED ASTHMA ACTION PLAN

10
Improvement (ICSI). National Guideline Clearinghouse. Retrieved June 20, 2015, from
http://www.guideline.gov/content.aspx?id=38255&search=asthma+education