Appendix 3
EVIDENCE-BASED REVIEW OF THE ASTHMA MANAGEMENT PLAN
The Asthma Management Plan published by The Thoracic Society of Australia and New Zealand in 1989 has been the basis of the National Asthma Campaign's activities. This six-step consensus plan is the accepted template for asthma management in Australia. An evidence-based review is underway.
Step 1: Know how severe your asthma is
Step 2: Achieve your best lung function
Step 3: Avoid asthma triggers
Step 4: Stay at your best
Step 4: Have an action plan
Step 6:
Educate and review regularly Methods: A National Asthma Campaign (Australia)
working party, funded by NSW Health is currently examining and grading the
evidence behind the recommendations of the Asthma Management Plan.
Clinically relevant questions have been generated for the recommendations made
in Step 6. These have been investigated in a series of systematic reviews
undertaken by members of the Cochrane Airways Group. A full description of
the methods and results is available on the Cochrane Database of Systematic
Reviews. The system of grading the evidence is detailed in Apppendix 2.
1. Education to Improve Asthma Knowledge in Adults
Question: Does the provision of information about asthma and its management
improve asthma outcomes in adults? Answer: In eleven randomised controlled
trials, no clinically important differences were demonstrated in
hospitalisation, FEV1, PEF or unscheduled visits to the doctor for asthma,
between those who were provided education (using information only) and those who
were not. Some improvement was noted in self-reported symptoms of asthma.
Level of Evidence: Level 1b Clinical Comment/Recommendation:
Careful consideration is required in planning interventions for asthma to ensure
that they enable patients to acquire skills and not simply information about
asthma.
2. Optimal Self-Management versus Usual Care
Optimal self-management education is a structured program conducted over time
which teaches people about asthma, how to detect and manage deteriorating
asthma, and encourages optimal use of medications. Essential components
are:
Question: Does the provision of optimal self-management
education improve asthma outcomes in adults with asthma?
Answer: Optimal self-management education leads to a clinically significant
reduction in hospitalisations, emergency room visits, and unscheduled visits to
the doctor for asthma. Statistically significant (but not clinically
significant) improvements also occurred in lung function as measured by FEV1 and
PEF. Successful completion of an optimal self-management education program by
20 patients prevents one hospitalisation, whereas successful completion by eight
patients prevents one emergency department visit. Level of Evidence: Level 1a
Clinical Comment/Recommendation: Optimal self-management
involves the doctor and the patient in a therapeutic alliance
which conveys knowledge, ensures the acquisition of
self-management skills and use of a tailored self-management
plan, and entails regular review and optimising of medication.
Barriers to this comprehensive approach to asthma management
need to be identified in order to secure better outcomes and
greater cost benefit for interventions.
3. Symptoms versus Peak Flow Self-Monitoring:
Question: Is there a difference using peak flow or symptoms as the basis of
self-monitoring in conjunction with optimal self-management? Answer: No
difference has been demonstrated in the four studies which compared these two
forms of self-monitoring. However, there is limited data available on this
topic. Level of Evidence: Level 1b Clinical Comment/Recommendation:
Action Plans and self-monitoring should be tailored to patient skill levels and
lifestyle and may be based on either peak flow or symptoms.
4. Doctor Managed versus Self-Managed:
Question: Is there a difference between subjects who are managed by regular
review with their doctor and those who are instructed in optimal
self-management? Answer: Five studies compared subjects who managed their own
asthma using optimal self-management (peak flow or symptoms) with subjects who
regularly visited the doctor for their management. The doctors provided
periodic, structured, clinical review visits which involved assessment of
medication use and asthma severity based on symptoms and lung function.
There was no reported difference between the two groups. Level of Evidence:
Level 1b Clinical Comment/Recommendation: The clinical relevance of these
results is that patients who are unsuitable for self-management education can
still achieve benefit from a structured program of regular medical review.
5. Education versus No Education in Patients Presenting to the Emergency Department:
Question: Do patients who receive asthma education during visits to an emergency
department, experience improvements in their asthma outcomes? Answer: There
appears to be a reduction in repeat visits to the emergency department in those
subjects who are at a higher risk of experiencing asthma attacks, if they
receive any form of education (either information only or self-management).
Level of Evidence: Level 1b Clinical Comment/Recommendation: The
population of patients who present to casualty may be at high risk for asthma
exacerbations and hospital admission. Provision of even brief education
before discharge can reduce re-presentation rates.
RESEARCH REQUIRED:
The evidence-based review of the sixth step of the Australian asthma management
plan has already highlighted areas where further research is needed. The
other five steps are currently under review and it is clear that many simple
questions in asthma management have not been addressed by randomised controlled
trials. The evidence-based review is enabling us to better identify the
areas of clinical management that require ongoing research and also highlights
those hitherto accepted principles of management which lack quality evidence.
The real challenge is to translate the results of the evidence-based approach
into guidelines which are succinct, user-friendly, reflect the findings and can
be implemented to achieve better outcomes for asthma.
There are many pressing unanswered questions in asthma and in
Australia at present there are varieties of funding avenues and
diverse expertise, with no coordinated system for establishing
priorities in research funding. The National Asthma Strategy
Implementation Plan has established priorities for asthma
research, but individual funding bodies tend to allocate funds
according to track record and merit rather than by establishing
the vital areas in need of further investigation. Primary
prevention of asthma remains only a theoretical possibility at present. We do
not understand how to control early life allergen exposure and there may be
important allergens which are not yet recognised. Further research is needed to
delineate the reasons for the rise in asthma prevalence, the change in
pathophysiology which accounts for the transition of asthma from childhood to
adult life, the events which cause a return of symptoms in adults after long
symptom-free intervals and the factors which determine long-term lung function
decline. This is crucial to understanding how we might effectively intervene and
reduce the morbidity of asthma in adults and children. The research agenda
for the millennium must include adherence as a major issue, i.e. investigation
of the most effective adherence interventions for health professionals and
people with asthma. More funding of public health initiatives is needed.
Although an assessment of the cost of asthma in Australia has been undertaken,
this is now dated and another is required, accurately detailing the burden of
disease. We do not have a system for collecting information on asthma
presentations to general practice and emergency departments, nor to track
hospital admissions and follow-up. This is needed in order to argue the case for
funding and resources to tailor the health care system to more appropriately
intervene and identify problem areas. Although real efforts are being made in
the area of evidence-based medicine, we need to undertake research to better
understand the optimal process by which evidence-based medicine is translated
into guidelines and implemented to effect better health outcomes. The quality
of strength of evidence for the guideline intervention is coded from highest to
lowest as follows:
Levels of evidence for classifying the quality of studies
assessment interventions#
Level of Evidence |
Description of Study Types from which Evidence is Derived |
Risk of Bias
|
I |
Systematic review of all relevant randomised controlled
trials Large multicentre RCTs |
(a)
Low No unexplained heterogeneity of effect between studies or centres (b) Moderate Unexplained heterogeneity of effect between studies or centres or where heterogeneity of effect is not explored. |
II |
One or more randomised controlled trials and studies |
(a)
Low
(b)
Moderate |
III |
Controlled trials without randomisation Cohort,
case-control
Analytic studies1 Multiple time series
Before and after studies (preferably from more than
one centre or research group) |
(a)
Low
(b) Moderate* |
| IV | Other observational studies
|
|
| V | Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees. |
# Further research is underway to examine if there is variation in the levels of evidence provided by analytical observation studies and a range of quasi experimental studies.
1 If more than one randomised controlled trial or study is available, the results can be combined in a meta-analysis. The combined results would change the level of evidence from II to I.
* Hospital based case-control studies would not be rated higher than IIIb.