Asthma self management Duncan MacIntyre & Christine Bucknall August 2010

1. Asthma self management Duncan MacIntyre & Christine BucknallAugust 2010

2. Health Belief Model These beliefs make it more likely that patients will follow preventive or therapeutic recommendations • I am susceptible to this health problem • The threat to my health is serious • The benefits of the recommended action outweigh the costs • I am confident that I can carry out the recommended actions successfully

3. Beliefs About Susceptibility • Some patients resist accepting the diagnosis because “it’s not like xx’s asthma” • Resisting the diagnosis reduces the likelihood that the patient will follow the treatment plan • If the patient thinks their condition is not serious, they are less likely to follow the treatment plan

4. Beliefs About Benefits and Costs The benefits of therapy, obvious to the clinician, are often unclear to patients or irrelevant to them • Regimen seen as hard to carry out and confusing • Don’t know what each medicine does • Fear that medicines will cause harm • Don’t understand how therapy will help them do the things they want to be able to do • Financial burden of prescriptions is an issue for some

5. Reasons for failing to have a prescription dispensed… Lost or forgotten prescription Cost Felt drug was unnecessary National Prescription Buyers’ Survey, USA 1985 Did not want to take drug

6. SELF-BELIEF AND CONFIDENCE • Research in psychology shows that when you are confident you can do something successfully: • You do it more often • You are more persistent in the face of difficulty. • Many patients and their families lack confidence that they can manage their asthma • Confidence in self management for an individual involves them understanding their individual susceptibility, the seriousness of their condition, and the balance of risks & benefits of different strategies; and then developing an ability to cope

7. The aftermath of an exacerbation is a particularly good time to address these issues

8. Cochrane review, Asthma self management (36 studies, 6090 patients) •  hospitalisations ( RR 0.64, 95% confidence interval 0.50 to 0.82) •  emergency room visits (RR 0.82, 95% CI 0.73 to 0.94) •  unscheduled visits to the doctor (RR 0.68, 95% CI 0.56 to 0.81) •  days off work or school (RR 0.79, 95% CI 0.67 to 0.93) •  nocturnal asthma (RR 0.67, 95% CI 0.0.56 to 0.79) •  quality of life (standard mean difference 0.29,CI 0.11 to 0.47) • Measures of lung function were little changed.

9. What does an action plan include? • Clear explanation of their diagnosis & different asthma treatments and when to use them • Symptoms / PEF scores to watch for that require increase in treatment • When and where to seek emergency help • When and how to step down medication • Lifestyle advice

10. Evidence for doubling the dose of inhaled CS? • Small pharmacological studies – no benefit; a fourfold increase may be needed • Cochrane review – self management works

11. Tattersfield et al, analysis of exacerbations in Facet study, AJRCCM 1999; 160: 594-9: note the gradual increase in symptoms from 10 days beforehand

12. Self management planning as a communication tool • Talk over the events leading up a (recent) exacerbation • Prior use of therapy (concordance); concerns about medication • early symptoms, especially ones they don’t have when stable are useful warning signs to identify or review a PEF chart they have kept recently and identify PEF levels associated with stable and more symptomatic phases. • Chose a credible symptom or PEF which triggers the plan • Describe plan for increasing inhaled CS; and if appropriate for use of oral steroid • Write it down (Asthma UK Cards) • Review them after next exacerbation - did the plan work? • Adjust if necessary

13. Standard Action PlanInhaled steroid component • Double dose of inhaled CS in response to specific symptoms or PEF • Stay on this double dose until symptom settles, or PEF rises to previous best • Count how many days this took and • Maintain double dose for the same number of days again (= insurance policy) • Go back to regular long term dose • SMART Rx – if 2 consecutive days of 8 doses/day (or specified  in PEF) – seek urgent medical attention or start OCS as above

14. Standard action planOral steroid component • Discuss recognition worsening symptoms indicating an exacerbation • Identify PEFR at time of exacerbation / admission • Agree ‘cut-off’ PEFR which represents significant exacerbation eg 60-70% for 2 days • Steroid dose to be taken on basis of symptoms / PEFR eg prednisolone 30mgs for 4-7days / until control restored • Report exacerbation

15. Standard Action PlanSevere exacerbation Recognition • Symptoms – very tight chest / too wheezy to walk • No or very brief response to reliever • PEFR less than…..eg 50% Action Relief treatment – repeat / dosage Oral steroid Seek help – GP / Hospital

16. PAAP ‘real-life’ benefits • Patients benefit • Feel in control of their asthma / sense of independence • Reduced fear / uncertainty • Improved symptom control = improved QoL • Doctors / nurses benefit • Reduced demands on time • improved patient QoL / outcome = improved professional satisfaction • NHS benefits • NHS saves money from reduced hospital admissions / unnecessary GP visits

17. Patient education – what the guidelines say • Brief simple education linked to patient goals is most likely to be acceptable to patients • At request for a repeat inhaler, and/or a visit to the pharmacist, briefly review pattern of medication use • At consultations for an upper respiratory tract infection, or other known trigger, rehearse self-management in case asthma deteriorates • At an acute consultation, determine actions taken by patient and reinforce or refine PAAP • No patient should leave hospital without a written asthma action plan

18. Summary • Importance of developing self efficacy for patients with chronic disease • Asthma self- management has Grade 1A evidence base; think of it as a tool for discussion • All patients having exacerbations should have a written action plan • Review of AP important to check it is relevant and effective