Written asthma action plans.

T he first British guidelines for the management of asthma in adults published in 1990 clearly recommended self-management of asthma. The exact statement read: ‘‘As far as possible, patients should be trained to manage their own treatment rather than be required to consult their doctor before making changes’’. Similar advice has been repeated in subsequent revisions of the UK guidelines and in the NHLBI global strategy for asthma management and prevention. The evidence base for these recommendations is strong, and 36 trials comparing self-management education with usual care were reviewed for the Cochrane Library. This review suggested that self-management education could be associated with a reduction in hospital admissions of up to 40%, a reduction in emergency room visits of 20%, and similarly impressive reductions in unscheduled visits to the doctor, night time symptoms, and days off work or school. The authors concluded that training programmes that enabled people to adjust their medication using a written asthma action plan appeared to be more effective than other forms of self-management. In this issue of Thorax Gibson and Powell report the results of a further review to determine what is important about personalised written asthma action plans. They conclude that such plans are best when using 2–4 action points which involve increasing the dose of inhaled steroid and initiation of oral steroid therapy for exacerbations. Plans using peak flow should be based on personal best peak expiratory flow. The evidence, however, is that— despite a 13 year history of such advice being recommended—implementation of these recommendations is poor. Indeed, in one study of a stratified group of 785 adults and children with asthma, only 3% of respondents had been given a written self-management action plan setting out what they should do if their asthma deteriorated. This study was performed in a group of people with asthma of all severities. In another population of 378 individuals surveyed 1 week after an acute episode of asthma necessitating unscheduled access to health care, 28% of patients reported having a written self-management plan. Nevertheless, three quarters of people with clear evidence of out of control asthma had not been equipped with the tools necessary to control their own condition—tools which have been recommended for over 13 years. The question must therefore be asked as to why—in the presence of such a plethora of data in favour of selfmanagement education and personalised asthma action plans—are so few patients actually receiving this advice? Possible reasons include: