Transcript Document

Asthma self management
Duncan MacIntyre & Christine
Bucknall
August 2010
Health Belief Model
These beliefs make it more likely that patients will
follow preventive or therapeutic recommendations
– I am susceptible to this health problem
– The threat to my health is serious
– The benefits of the recommended action outweigh the
costs
– I am confident that I can carry out the recommended
actions successfully
Beliefs About Susceptibility
• Some patients resist accepting the diagnosis
because “it’s not like xx’s asthma”
• Resisting the diagnosis reduces the likelihood that
the patient will follow the treatment plan
• If the patient thinks their condition is not serious,
they are less likely to follow the treatment plan
Beliefs About Benefits and Costs
The benefits of therapy, obvious to the clinician, are
often unclear to patients or irrelevant to them
•
•
•
•
Regimen seen as hard to carry out and confusing
Don’t know what each medicine does
Fear that medicines will cause harm
Don’t understand how therapy will help them do
the things they want to be able to do
• Financial burden of prescriptions is an issue for
some
Reasons for failing to have a
prescription dispensed…
Lost or forgotten prescription
Cost
Felt drug was unnecessary
Did not want to take drug
National Prescription Buyers’ Survey,
USA 1985
SELF-BELIEF AND CONFIDENCE
• Research in psychology shows that when you are confident you can do
something successfully:
– You do it more often
– You are more persistent in the face of difficulty.
• Many patients and their families lack confidence that they can manage
their asthma
• Confidence in self management for an individual involves them
understanding their individual susceptibility, the seriousness of their
condition, and the balance of risks & benefits of different strategies;
and then developing an ability to cope
The aftermath of an exacerbation is a
particularly good time to address these
issues
Cochrane review, Asthma self
management (36 studies, 6090
patients)
•  hospitalisations ( RR 0.64, 95% confidence interval 0.50 to
0.82)
•  emergency room visits (RR 0.82, 95% CI 0.73 to 0.94)
•  unscheduled visits to the doctor (RR 0.68, 95% CI 0.56 to
0.81)
•  days off work or school (RR 0.79, 95% CI 0.67 to 0.93)
•  nocturnal asthma (RR 0.67, 95% CI 0.0.56 to 0.79)
•  quality of life (standard mean difference 0.29,CI 0.11 to
0.47)
• Measures of lung function were little changed.
What does an action plan include?
•
•
•
•
•
Clear explanation of their diagnosis &
different asthma treatments and when to
use them
Symptoms / PEF scores to watch for that
require increase in treatment
When and where to seek emergency help
When and how to step down medication
Lifestyle advice
Evidence for doubling the dose of
inhaled CS?
• Small pharmacological studies – no benefit;
a fourfold increase may be needed
• Cochrane review – self management works
Tattersfield et al, analysis of exacerbations in Facet
study, AJRCCM 1999; 160: 594-9: note the gradual
increase in symptoms from 10 days beforehand
Self management planning as a
communication tool
• Talk over the events leading up a (recent) exacerbation
– Prior use of therapy (concordance); concerns about medication
– early symptoms, especially ones they don’t have when stable are useful
warning signs to identify or
review a PEF chart they have kept recently and identify PEF levels
associated with stable and more symptomatic phases.
• Chose a credible symptom or PEF which triggers the plan
• Describe plan for increasing inhaled CS; and if appropriate for
use of oral steroid
• Write it down (Asthma UK Cards)
• Review them after next exacerbation - did the plan work?
• Adjust if necessary
Standard Action Plan
Inhaled steroid component
• Double dose of inhaled CS in response to specific
symptoms or PEF
• Stay on this double dose until symptom settles, or
PEF rises to previous best
• Count how many days this took and
• Maintain double dose for the same number of days
again (= insurance policy)
• Go back to regular long term dose
• SMART Rx – if 2 consecutive days of 8 doses/day
(or specified  in PEF) – seek urgent medical
attention or start OCS as above
Standard action plan
Oral steroid component
• Discuss recognition worsening symptoms
indicating an exacerbation
• Identify PEFR at time of exacerbation / admission
• Agree ‘cut-off’ PEFR which represents significant
exacerbation eg 60-70% for 2 days
• Steroid dose to be taken on basis of symptoms /
PEFR eg prednisolone 30mgs for 4-7days / until
control restored
• Report exacerbation
Standard Action Plan
Severe exacerbation
Recognition
• Symptoms – very tight chest / too wheezy to walk
• No or very brief response to reliever
• PEFR less than…..eg 50%
Action
Relief treatment – repeat / dosage
Oral steroid
Seek help – GP / Hospital
PAAP ‘real-life’ benefits
• Patients benefit
– Feel in control of their asthma / sense of independence
– Reduced fear / uncertainty
– Improved symptom control = improved QoL
• Doctors / nurses benefit
– Reduced demands on time
– improved patient QoL / outcome = improved
professional satisfaction
• NHS benefits
– NHS saves money from reduced hospital admissions /
unnecessary GP visits
Patient education – what the
guidelines say
•
•
•
•
•
Brief simple education linked to patient goals is
most likely to be acceptable to patients
At request for a repeat inhaler, and/or a visit to the
pharmacist, briefly review pattern of medication use
At consultations for an upper respiratory tract
infection, or other known trigger, rehearse selfmanagement in case asthma deteriorates
At an acute consultation, determine actions taken
by patient and reinforce or refine PAAP
No patient should leave hospital without a written
asthma action plan
Summary
1. Importance of developing self efficacy for
patients with chronic disease
2. Asthma self- management has Grade 1A
evidence base; think of it as a tool for discussion
3. All patients having exacerbations should have a
written action plan
4. Review of AP important to check it is relevant
and effective