title: Do written action plans improve patient outcomes in asthma? An evidence-based analysis.
abstract: OBJECTIVE
  Current guidelines recommend use of written action plans and peak flow monitoring as key components of asthma care. Our study assesses whether written action plans, with or without peak flow monitoring, have an independent effect on outcomes when used as a component of asthma self-management.
  
  
  METHODS
  This was a systematic review of published studies. Two independent reviewers followed a prospective protocol for study selection and data abstraction. Outcome data were synthesized qualitatively; they were not appropriate for quantitative meta-analysis. Our comprehensive literature search used MEDLINE, EMBASE, the Cochrane Library, and a hand search of recent bibliographies. The search was limited to full-length, peer-reviewed articles with abstracts in English. The studies were randomized controlled trials that compared the outcomes of an asthma self-management intervention with and without the use a written action plan. The primary outcomes of interest are utilization measures, such as hospitalizations and ER visits. Other outcomes of interest include measures of symptom control and lung function.
  
  
  METHODS
  There were 1501 evaluable patients with asthma; 1410 adults and 91 children.
  
  
  METHODS
  We measured the frequency of waiting and examination room companions, the reasons for accompaniment, the influence on the encounter, and the overall helpfulness of the companion as assessed by patients and companions. We also determined the physicianamprsquos assessment of the companionamprsquos influence, helpfulness, and behavior during the encounter.
  
  
  RESULTS
  Nine randomized controlled trials enrolling a total of 1501 patients met selection criteria. The majority of comparisons in these studies do not demonstrate improved outcomes associated with a written action plan. There are notable methodologic limitations: studies reporting negative findings lack sufficient power, and studies reporting positive findings demonstrate systematic bias.
  
  
  CONCLUSIONS
  Although written action plans are widely used, there is insufficient evidence to determine whether their use, with or without peak flow monitoring, improves outcomes.
authors.affiliation: Technology Evaluation Center, Blue Cross and Blue Shield Association (BCBSA), Chicago, IL 60611, USA. f-lefevre@northwestern.edu
authors.forename: Frank
authors.initials: F
authors.lastname: Lefevre
authors.forename: Margaret
authors.initials: M
authors.lastname: Piper
authors.forename: Kevin
authors.initials: K
authors.lastname: Weiss
authors.forename: David
authors.initials: D
authors.lastname: Mark
authors.forename: Noreen
authors.initials: N
authors.lastname: Clark
authors.forename: Naomi
authors.initials: N
authors.lastname: Aronson
mesh_terms: D000328:Adult; D001249:Asthma / Q000628:therapy*; D002648:Child; D006801:Humans; D010043:Outcome and Process Assessment, Health Care; D010347:Patient Care Planning; D010366:Peak Expiratory Flow Rate; D055656:Prescriptions; D012648:Self Care