The effect of a peak flow-based action plan in the prevention of exacerbations of asthma. A randomized trial of peak-flow and symptom-based action plans in adults with moderate-to-severe asthma. [Hospitalization reduction by an asthma tele-medicine system]. Effectiveness of routine self monitoring of peak flow in patients with asthma. Grampian Asthma Study of Integrated Care (GRASSIC). Peak flow monitoring for guided self-management in childhood asthma: a randomized controlled trial. A randomized trial comparing peak expiratory flow and symptom self-management plans for patients with asthma attending a primary care clinic. Influence of peak expiratory flow monitoring on an asthma self-management education programme. Comparison of an enhanced versus a written feedback model on the management of Medicare inpatients with venous thrombosis. Peak flow based asthma self-management: a randomised controlled study in general practice. British Thoracic Society Research Committee.
To determine the effect of a symptom-based and a peak flow-based action plan in preventing acute exacerbations in subjects with poorly controlled asthma.
                A randomized controlled trial in which subjects who had required urgent treatment for their asthma were allocated to receive no action plan, a symptom-based plan, or a peak flow-based action plan.
                A university hospital asthma clinic.
                One hundred fifty subjects were recruited after attending an emergency department or a clinic for urgent treatment of asthma.
                All subjects received evaluation and education for asthma before being randomly allocated to receive no action plan, a symptom-based action plan, or a peak flowmeter and a peak flow-based action plan.
                Subjects were assessed by questionnaire at 3 and 6 months after enrollment with questions relating to their asthma control and their need for urgent treatment or hospital admission for asthma.
                At 6 months after enrollment, although all three intervention groups experienced improvement in their asthma control, there was a striking reduction in emergency department visits for asthma only in the peak flow-based action plan group (p=0.006). No significant difference in emergency visits was apparent between the symptom-based action plan and no action plan groups.
                We conclude that a peak flow-based action plan is effective, at least in the short term, in protecting patients with asthma against severe exacerbations of their disease. Peak flow meters (PFM) continue to be recommended as an important part of asthma self-management plans. It remains unclear if there is an advantage in using PFM in people with moderate-to severe asthma who are not poor perceivers of bronchoconstriction.
                Prospective, randomized controlled trial of 134 adults with moderate-to-severe asthma who did not have evidence of poor perception of bronchoconstriction on histamine challenge testing, who were recruited from inpatients and outpatients of a university teaching hospital. Comparison was made over 12 months of the effectiveness of written action plans using either peak flow monitoring or symptoms to guide management. Subjects were contacted at monthly intervals by telephone for reinforcement and evaluation of use of the action plans, and to provide ongoing education. Spirometry and PD20 histamine were measured at 3-monthly intervals. Measures of health care utilization and morbidity (asthma exacerbations; hospitalizations; emergency department (ED) visits; days absent from work or school due to asthma; medication use and a self-rating of asthma severity) were made monthly. A psychosocial questionnaire (attitudes and beliefs, state-trait anxiety, denial) was given at entry and at 12-months or at withdrawal from the study.
                There were significant improvements for both groups for hospitalizations, ED visits, days off from school or work, and PD20 histamine, but no between-group differences. Appropriate use of action plans was 85% in the symptoms group and 86% in the PFM group. For all subjects, those who subsequently had an ED visit had significantly higher levels of denial (P=0.04) and lower scores for self-confidence (P=0.04), compared to those who did not have an ED visit.
                Use of written action plans, combined with regular contact to reinforce self-management, improved airway reactivity and reduced health care utilization. However, use of PFM was not superior to symptom-based plans. We examined an effectiveness of a new asthma telemedicine system in reducing hospitalizations using a multi-site randomized control study. In this program, a nurse under physician supervision monitors the patient's airway status at home and provides instructions to individuals via the telephone, helping them manage exacerbations as well as reinforcing proper use of a zone-controlled management plan. Patients with a high risk for hospitalization were screened based on the numbers of emergency room visits and hospitalizations found in a previous study and randomly assigned to either the telemedicine or control group. After a six-month study period, an 83% reduction in hospitalization was demonstrated in the telemedicine group versus the control group, with a P value of 0.01. Improvement of peak expiratory flow and symptoms were also shown in the study group. We conclude that the key success factors in home asthma management for poorly controlled asthma patients are early detection of exacerbations through daily peak flow monitoring, compliance with prescribed daily prophylactic anti-inflammatory steroid medications, and immediate action as specified by a zone-controlled action plan upon the first signs of deterioration. To evaluate the effectiveness of routine self monitoring of peak flow for asthma outpatients.
                Pragmatic randomised trial.
                Hospital outpatient clinics and general practices in north east Scotland.
                Use of bronchodilators and inhaled and oral steroids; number of general practice consultations and hospital admissions for asthma; sleep disturbance and other restrictions on normal activity; psychological aspects of health including perceived control of asthma.
                After one year there were no significant differences between patients randomised between self monitoring of peak flow and conventional monitoring. However, those given a peak flow meter recorded an increase in general practice consultations that was nearly significant. Among patients whose asthma was judged on entry to be more severe, those allocated to self monitoring used more than twice as many oral steroids (2.2; 95% confidence interval 1.1 to 4.6). Patients who already possessed a peak flow meter at the start of the study recorded higher morbidity over the course of the year than those eligible for randomisation.
                Prescribing peak flow meters and giving self management guidelines to all asthma patients is unlikely to improve mortality or morbidity. Patients whose asthma is severe may benefit from such an intervention. We asked whether the addition of PEF recordings to a symptom-based self-management plan improved outcome in school children with asthma. In an open-randomized, parallel-group, controlled trial, we studied children aged 7-14 years with moderate asthma. After a 4-week run-in, 90 children were randomized to receive either PEF plus symptom-based management or symptom-based management alone for 12 weeks. Thresholds for action based on PEF were 70% of best (for increasing inhaled steroids) and 50% of best (for commencing prednisolone). Children were asked to perform twice-daily spirometry at home (using an electronic recording spirometer that revealed only PEF to the study group alone) and to record a symptom diary. The mean daily symptom score was the main outcome. There were no differences between groups in mean symptom score or in spirometric lung function, PEF, quality of life score, or reported use of health services over 12 weeks. During acute episodes, children responded to changes in symptoms by increasing their inhaled steroids at a mean value of PEF of greater than 70% of best so that overall PEF did not contribute to this important self-management decision. Knowledge of PEF did not enhance self-management even during acute exacerbations. Great emphasis is placed on educating asthmatics to use action plans to achieve better control of symptoms. The use of peak flow meters (PFM) has been recommended as an important part of self-management plans. We studied 92 (47 F) adult patients with asthma in a primary care setting to compare the effectiveness of action plans using either peak flow monitoring or symptoms to guide self-management. Each patient was instructed in the use of the action plan in the context of a 6-mo asthma education program taught by a nurse. Patients were already using inhaled corticosteroids or were newly prescribed corticosteroids by their family physician. Forty-four patients were randomized to the PFM group and 48 to the symptoms group. Spirometry, symptom scores, quality of life, medication use, and measures of health care utilization and morbidity (emergency department visits, hospitalizations, unscheduled doctor visits, and days lost from work or school) were recorded at baseline and throughout the study period. PC20 methacholine was measured at the first and at the final visits. There were significant improvements within groups for FEV1, symptoms score, PC20 methacholine, and quality of life, but no between-group differences. A significant shift from higher to lower daily use of beta-agonists (p < 0.008 for both groups) and significant shifts to higher daily doses of inhaled steroids (p < 0.001) occurred in each group. Adherence to the self-management plans was only 65% in the PFM group and 52% in the symptoms group. Outcomes for health care utilization were similar except for fewer patients making unscheduled doctor visits within the PFM group. Our findings show that education, regular follow-up, and an action plan are effective in improving asthma control and quality of life, but the routine use of PFM to guide interventions is not the only way to accomplish these objectives. We assessed whether peak expiratory flow monitoring added to a self-management education programme reduced morbidity and improved pulmonary function and adherence to treatment in 100 asthma patients (aged 17-65 years) with adequate treatment and regular 1-year follow-up. Patients randomized to the experimental group used peak expiratory flow readings as the basis for their therapeutic plan coupled with educational intervention, whereas patients in the control group received the same educational intervention and used symptoms only to guide self-management. Morbidity parameters, functional status and adherence to medical regimens improved in both groups, although the percentage of patients with satisfactory adherence was significantly better in the group with peak expiratory flow monitoring (83%) than in controls (52%) (P = 0.05). The multivariate analysis showed that severity of asthma (odds ratio 9.28, 95% confidence interval 1.87-45.96, P = 0.006 for moderate asthma) and type of self-management education programme (odds ratio: 6.19; 95% confidence interval: 2.04-18.81; P = 0.001 for the use of peak expiratory flow readings) were the only independent predictors of adherence to treatment. However, a statistically significant association between adherence and use of peak expiratory flow monitoring was only found in patients with moderate asthma (P = 0.0009). We conclude that peak expiratory flow monitorization in optimal conditions (adequate medical regimen, individualized self-management education and regular follow-up) showed a beneficial effect on adherence to prescribed regimens only in patients with moderate asthma. A multistate randomized study conducted under the Health Care Financing Administration's (HCFA's) Health Care Quality Improvement Program (HCQIP) offered the opportunity to compare the effect of a written feedback intervention (WFI) with that of an enhanced feedback intervention (EFI) on improving the anticoagulant management of Medicare beneficiaries who present to the hospital with venous thromboembolic disease.
                Twenty-nine hospitals in five states were randomly assigned to receive written hospital-specific feedback (WFI) of feedback enhanced by the participation of a trained physician, quality improvement tools, and an Anticoagulant Management of Venous Thrombosis (AMVT) project liaison (EFI). Differences in the performance of five quality indicators between baseline and remeasurement were assessed. Quality managers were interviewed to determine perceptions of project implementation.
                No significant differences in the change from baseline to remeasurement were found between the two intervention groups. Significant improvement in one indicator and significant decline in two indicators were found for one or both groups. Yet 59% of all quality managers perceived the AMVT project as being successful to very successful, and more EFI quality managers perceived success than did WFI managers (71% versus 40%). In the majority of EFI hospitals, physician liaisons played an important role in project implementation.
                Study results indicated that the addition of a physician liaison, quality improvement tools, and a project liaison did not provide incremental value to hospital-specific feedback for improving quality of care. Future studies with larger sample sizes, lengthier follow-up periods, and interventions that include more of the elements shown to affect practice behavior change are needed to identify an optimal feedback model for use by external quality management organizations. Peak flow based asthma self-management plans have been strongly advocated in consensus statements, but convincing evidence for the effectiveness of this approach has been largely lacking.
                A randomised controlled trial was conducted in 25 general practices comparing an asthma self-management programme based on home peak flow monitoring and surgery review by a general practitioner or practice nurse with a programme of planned visits for surgery review only over a six month period.
                Seventy two subjects (33 in the self-management group and 39 in the planned visit group) completed the study protocol, but diary card data for at least three months were available on a total of 84 (39 in the self-management group and 45 in the planned visit group). Teaching self-management took longer than the planned visit review. In the self-management group home peak flow monitoring was felt to be useful by doctors and patients in 28 (85%) and 27 (82%) cases, respectively. There were no between group differences during the study period in terms of lung function, symptoms, quality of life, and prescribing costs. Only within the self-management group were improvements noted in disturbance of daily activities and quality of life. Possible explanations for these negative results include small numbers of subjects, the mild nature of their asthma, and inappropriate self-management strategies for such patients.
                Rigid adherence to long term daily peak flow measurement in the management of mild asthma in general practice does not appear to produce large changes in outcomes. Self-management and the use of prescribed peak flow meters need to be tailored to individual circumstances.
The evidence suggests that symptom-based WAP are superior to peak flow WAP for preventing acute care visits although there is insufficient data to firmly conclude whether the observed superiority is conferred by greater adherence to the monitoring strategy, earlier identification of onset of deteriorations, higher threshold for presentation to acute care settings, or the specific treatment recommendations.