Jay M. Portnoy, MD

Action Plans for Asthma

Douglass J, Aroni R, Goeman D, et al.: A qualitative study of action plans for asthma. BMJ 2002, 324(7344):1003–1005.

Rating: •Of importance.

Introduction: This study was performed to describe howasthma action plans are used, from the perspective ofpatients who have asthma.

Design: The investigators interviewed patients who pre-sented to the emergency room for asthma. The investiga-tors aimed to determine whether the patients had anaction plan, how they used it, and what they found to bemost useful about it.

Results: The investigators interviewed 29 participantswho had action plans provided by their doctors. Mostpatients modified their plan based on their own experi-ences with asthma. The most common reasons given for

modifying the action plans included lack of confidence intheir ability to follow it, the plan not working, and inabil-ity to recognize asthma symptoms. Thirty-three patientsdid not have an action plan, usually because they had notbeen given one by their doctor. Most patients with anaction plan found them useful in the management of theirasthma, whereas most patients without a plan voiced adesire for their doctor to give them one.

Editor’s comments

Current asthma guidelines recommend that patientsshould be provided with a written asthma action plan. Thisstudy confirms that such plans are viewed favorably bypatients. It also emphasizes that plans that are written byphysicians are likely to be modified by patients based ontheir experience. Patients should be asked about such mod-ifications and should be encouraged to discuss them withtheir physician at each visit.

Nonadherence and Pediatric Asthma Morbidity in Inner-city Children

Bauman LJ, Wright E, Leickly FE, et al.: Relationship of adherence to pediatric asthma morbidity among inner-city children. Pediatrics 2002, 110(1 Pt 1):e6.

Rating: •Of importance.

Introduction: This study examined the relationshipbetween risk factors of nonadherence and subsequentasthma morbidity among inner-city children. The aim ofthe study was to determine whether risk factors correlatewith actual nonadherence and whether such nonadher-ence is associated with increased asthma morbidity.

Methods: The study was a multisite, prospective, longi-tudinal panel study of 1199 children 4 to 9 years of agewho had asthma, and their caregivers. It was conducted inemergency departments and clinics at eight research cen-ters in seven US metropolitan inner-city areas. The inves-tigators collected nine morbidity indicators at 3, 6, and 9months after baseline, including hospitalizations,unscheduled visits, days of wheeze/cough, and days ofreduced activities.

Results: Children whose caregivers scored high on Admit-ted Nonadherence experienced significantly worse morbid-ity on eight of the nine measures. Children who scoredhigh on risk factors for Nonadherence measure experi-enced significantly worse morbidity on all nine morbiditymeasures. Multiple and logistic regressions found that theadherence measures had independent significant effects onmorbidity. Combining the measures improved estimates ofmorbidity: children whose caregivers were poor on eitheradherence measure had worse morbidity than those withgood adherence on both (eg, rate of hospitalization wastwice as high), missed more than twice as much school,had poorer overall functioning, and experienced more daysof wheezing and more restricted days of activity.

Editor’s comments

This is the first report I know of documenting that nonadher-ence (admitted, or presumed based on risk factors) indepen-dently and jointly predicts subsequent asthma morbidity.Although physicians have always thought that patients

446 Pediatric Allergy and Immunology

would do better if they followed medical advice, there hasnot been any proof of that presumption. This study indicatesthat patients who do not follow advice do poorly; however,

we still don’t know whether they would do better if they fol-lowed medical advice. The only way to determine that wouldbe to perform an interventional study with randomization.