effectiveness of asthma action plans for adults seen in emergency

EFFECTIVENESS OF ASTHMA ACTION
PLANS FOR ADULTS SEEN IN
EMERGENCY DEPARTMENTS FOR ACUTE
ASTHMA: A SYSTEMATIC REVIEW.
Cristina Villa-Roel, MD, MSc, PhD(c)
Department of Emergency Medicine
School of Public Health
University of Alberta
Research team
Britt Voaklander, BKin Student
Taylor Nikel, MD student
Maria Ospina, PhD
Sandra Campbell, MLIS
Brian H. Rowe, MD, MSc, CCFP(EM), FCCP
Disclosure
The research team does not have any affiliation with a
commercial organization that may have a direct or
indirect connection to the content of this presentation.
Dr. Rowe was the principal investigator of one included
trial; however, he was excluded from the selection of
potentially eligible manuscripts and final
inclusion/exclusion decisions.
Acute asthma
• Acute asthma is a common presentation to
emergency departments.
16
90%
 Improve with
treatment
 Safely discharged
• Emergency departments are important settings to
prompt strategies to avoid undesired outcomes.
Rowe et al. Chest 2009; 135:57-65
Rowe & Majumdar. Ann Emerg Med. 2005;45:299-301.
Patients presenting to the ED with acute asthma
Misunderstandings
 Chronic nature
 Triggers
 Role of
medication
 Proper inhaler
techniques
Under-recognition
Under-treatment
 Delay to
therapy
 Excess
morbidity
Gaps in Knowledge
Lack of appropriate
outpatient care
 No access
 Not necessary
 Focus on the
pharmacological
treatment
Gaps in care
Many have never received any asthma education
Boulet et al. Can Respir J. 2013;20:265-69
Evidence on asthma education (adults)
Self-management education and regular practitioner review
for adults with asthma (Review)
Gibson PG, Powell H, Wilson A, Abramson MJ, Haywood P, Bauman A, Hensley MJ, Walters
EH, RobertsJJL
Limited (information only) patient education programs for
adults with asthma (Review)
Symptoms
Hospitalizations
ED visits for asthma
Unscheduled doctors’ visits
Work absenteeism
Episodes of nocturnal
asthma
Indirect costs
Gibson PG, Powell H, Wilson A, Hensley MJ, Abramson MJ, Bauman A, WaltersEH, Roberts
JJL
Quality of life
Education interventions for adults who attend the emergency
room for acute asthma (Review)
Hospitalizations
Outpatient Follow-up
Tapp S, Lasserson TJ, Rowe BH
Relapses
Current guideline recommendations
Post-ED follow-up, review and
education
Written asthma action plans
Action planof :
Date:
Personal goals:
Possible
Triggers
smoke
(circle)
colds
animals
Other
pollens
mold
dust
strong smells
weather changes
strong emotions
Exercise
Asthma under control?
1. Daytime symptoms
Yes
No
Normal life,
regular activities
Cough, wheeze, short of breath,
tight chest, colds, allergies
3 times or less/ week
More than 3 times/week
Continuous & worsening
More than 3 times/week
Relief less than 3-4 hours
Normal
Limit ed
Ver y limit ed
Yes
Maybe
No
85 to 100 %
_____ to _____
60 to 85 %
_____ to _____
Less than 60 %
Less than _____
Adjust
Call for help
3 times or less/ week
4. Physical activity
5. Able to go to school or work
6. Peak expiratory ow
Best value (optional): ________________
Stay controlled
& avoid triggers
What to do:
Continuous & worsening
Some night s
None
2. Nighttime symptoms
3. Reliever
Not at all
+
controllers
reliever
Preventer/Controller: Use DAILY t o co n t ro l airw ay
sw ellin g & o t h er sym p t o m s. Rin se m o u t h af t er each u se.
1
EMERGENCY
AM
Take
(nam e / str en g th )
( colo ur)
(nam e / str en g th )
( colo ur)
2
Very short of breath, trouble
speaking, blue/grey lips / fingernails
PM
Take
( am oun t )
AM
PM
AM
PM
( am o unt )
Take
AM
PM
Take
( am oun t )
( am o unt )
911
Take all asth m a m ed icat io n s
at t h e h ig h est d o se
reco m m en d ed b y yo u r
d o ct or u n t il h elp arriv es.
(Th is m ay in clu d e p red n iso n e)
Reliever/Rescue: Qu ick ly relieves sym p t o m s b y
relaxin g m u scles ar o u n d air w ays.
1
Take
(nam e / str en g th )
Before exercise?
Clin ician :
as need ed
Take
as need ed
( colo ur)
Yes
No
If no im p rovem ent in
d ay s, call your doct or.
Ad ap t ed fro m t h e Laval Ho sp it al Act io n Plan , Bo u t in , H. et . al., 2001
Sept 2007
A
HM
AScT
on Plan
A ti
Healt h Lin k Alb ert a:
w w w .ed u cat io n f o rast h m a.c o m
w w w .can ah o m e .o rg
GINA guidelines. http://www.ginasthma.org
Study Population
n=176
Our data
Report having AAP
n=47 (27%)
Report having no AAP
n=129 (73%)
Home Remedies
only
n=5 (3%)
No AAP
n=134 (76%)
Have potentially
appropriate AAP
n=42 (24%)
Written AAP
n=6
(14% of AAPs)
Verbal AAP
n=36
(86% of AAPs)
Home remedies varied from using a
humidifier to ”Get to fresh air”, ”Breathe
slowly, drink coffee, lay flat, arms up to
open lungs, pound on back”.
Cross et al. Can Respir J. 2014;21:351-56
Results
• Most patients with an AAP took action prior to the ED
visit: no valid anti-inflammatory strategies.
• The first step was to increase asthma medication: no
patients appropriately increased inhaled corticosteroids.
Multivariable analyses
 Use of ICS or ICS/LABA combination agents: aOR = 3.0; 95% CI:
1.14 to 8.07.
 Ever received asthma education: aOR = 3.2; 95% CI: 1.13 to 9.19.
Rationale for our systematic review
• Low uptake of written AAPs (~3%).
• Clinically ineffective strategies to prevent an ED visit.
• Initiatives to improve the uptake, understanding and
early self-activation of valid AAPs during a loss of
asthma control are needed.
Is the provision of written AAPs to adults seen in
EDs for acute asthma an effective strategy to
reduce relapses?
Systematic review
Electronic
references
(n=463)
Grey literature
searches
(n=216)
1. Comprehensive literature
search
2. Unbiased study selection
3. Independent quality/fidelity
assessment
Duplicates
(n=161)
Title and abstract
review
(n=518)
Full‐text review
(n=38)
4. Double data abstraction
5. Summary of evidence/Metaanalysis
Excluded
(n=35)
Included
(n=3)
Characteristics of included studies
Authors
Cowie et al.
Year
1997
Country
Canada
Sample
size
Age (years)
139
Adults and
adolescents
Provision of
the
intervention
Within the
first 12
months of the
ED visit
Outcomes
Relapses
Admissions
Asthma control
6 months
ED visits
Lung function tests
> 18 years
At the time of Knowledge
Cote et al.
2001
Canada
98
old
the ED visit
Quality of life
Compliance with inhale
corticosteroids
PCP follow-up visit
At the time of
Rowe et al.
2013
Canada
80
18-94
after ED discharge
the ED visit
Relapses
Note: ED denotes emergency department; PCP= primary care provider.
RoB
Follow-up
period
L
2 weeks, 6
& 12
months
30 and 90
days
H
Fidelity of the interventions
Study
M
R
M
R
M
R
Cowie
et al.
Cote
et al.
Rowe
et al.
Theoretical Provider
Implementation Receipt
framework Training
Enactment
✗
✓
✓
✗
✗
✗
✓
✓
✗
✗
✓
✓
✓
✗
✗
✗
✓
✓
✗
✗
✗
✓
✓
✗
✗
✗
✓
✓
✗
✗
Borrelli et al. J Consult Clin Psych. 2005;5:852-60
Meta-analysis- relapses
4%
60%
Reduction
Increase
Sensitivity and Subgroup Analyses
Sensitivity:
Low RoB only: RR = 0.4 (95% CI: 0.19, 0.77)
Fixed Effects: RR = 0.5 (95% CI: 0.29, 0.91)
Odds ratio: OR = 0.5 (95% CI: 0.28, 0.95)
Risk Difference: RD = -0.12 (95% CI: -0.23,-0.02)
Subgroups:
Data unavailable on sex, age, severity.
Conclusion
No significant reduction in the proportion of relapses
was associated with the provision of written AAPs to
adults seen in the ED for acute asthma.
There is “teachable moment” for acute asthma in the
ED; however, more research is needed determine
the most effective educational intervention in this
setting.
Reporting of non-pharmacological interventions
needs to be standardized among scientific journals.
Acknowledgements
•
In-kind resources: Emergency Medicine Research Group
(EMeRG), University of Alberta.
•
Britt Voaklander received summer studentships from
AllerGen and the Emergency Strategic Clinical Network.
•
Taylor Nikel received a summer studentship from Alberta
Innovates Health Solutions (AIHS).
•
Dr. Villa-Roel is supported by the Canadian Institutes of
Health Research (CIHR) in partnership with the KT Branch.
•
Dr. Rowe is supported by the CIHR as a Tier I Canada
Research Chair in Evidence-based Emergency Medicine
(Ottawa, ON).
Thanks!
Questions?