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Winter, 2012

GIP in Focus

Patient Engagement = The Key to Easier Breathing

When Dr. James Li speaks of engagement, he's not talking about someone getting down on bent knee, ring in hand.

"Patients need to engage with their clinicians in order for an asthma action plan to be effective," said Li, M.D., Ph.D., an asthma and allergy specialist and chair of the Division of Allergic Diseases in the Mayo Clinic's Department of Internal Medicine. "Just having the piece of paper alone—without having the skills or knowledge to understand it—does not improve the care and control of asthma."

Map of doctor, mother and daughter looking at an Asthma Action Plan

When it comes to developing asthma action plans, the National Asthma Education and Prevention Program's (NAEPP) clinical practice guidelines recommend that clinicians involve patients and caregivers in making decisions about treatment, and provide tools and materials to help educate and empower them to understand and follow the plan. In other words, the guidelines emphasize shared decision-making.

"The goal or goals should be excellent asthma care and control, including being able to recognize and treat exacerbations," said Li. "The danger is in making the AAP a goal in and of itself."

A written asthma action plan is just one component—although an important one—of a comprehensive approach to improving asthma care and control. The NAEPP's clinical practice guidelines recommend that all patients who have asthma receive a written AAP that includes instructions for daily treatment and for recognizing and managing asthma.

Like diabetes and high blood pressure, asthma is a lifelong illness.

"Asthma is chronic, meaning it's there all the time, so it warrants attention every day," said Li.. "Written directions help us remember what's what: It's easy to get inhalers mixed up, and it can be difficult to remember which pill is which, especially when you have multiple medications."

Unfortunately, despite the important role of having written instructions, the Centers for Disease Control and Prevention's (CDC) National Health Interview Survey reported that in 2008 only 34% of eligible patients received a written AAP to help them manage their asthma.

Why aren't more clinicians issuing written AAPs? For some clinicians, barriers include the belief that AAPs are not useful for all asthma patients or take too much time to write for too little benefit. Dr. Li notes that another barrier is the concern that patients and clinicians will misinterpret the purpose of an AAP, viewing it as a goal by itself rather than as a tool to help control asthma every day. Without asthma self-management education, patients may also let other critical actions for controlling asthma, such as seeing a clinician for planned follow-up asthma visits, using recommended inhaled corticosteroids, and controlling environmental triggers, fall by the wayside.

“The key is to motivate patients to learn more about their asthma in order for the AAP to be effective,” said Li.

Another key to improved patient understanding and adherence is helping clinicians create a good written AAP. Dr. Li and his colleagues provide such guidance in "Formulating an Effective and Efficient Asthma Action Plan," published in the November 2008 Mayo Clinic Proceedings. This article includes practical suggestions and detailed recommendations for educating and empowering patients on how to use the written AAP to monitor and manage their asthma.

The goal of Li and his co-authors is to assist clinicians in creating a written AAP that not only "clearly defines the decision (action) points, expected response, and expected time of response," but also can be easily integrated into a busy practice. "To facilitate issuance of a written AAP, an electronic version should be made available either in the electronic medical record or as a form with prefilled options for ease of customization to a patient's condition," stated Li and his colleagues in the review.

The review acknowledges that although there are multiple versions of AAPs, they have the following features in common:

  • Guidance to patients for monitoring symptoms or peak expiratory flow (with a peak flow meter) to detect changes
  • Reminders of warning signs and symptoms, as well as potential precipitating factors or personal triggers
  • Explicit patient-initiated treatment options to restore control
  • Expected response time, danger signs, and contact information
  • Clearly defined, personalized action points that teach the patient to recognize and respond to an exacerbation (including determining when to use medication, which medication to use and how much, and how long to use it)

In combination with other measures, AAPs are important additions to the arsenal of clinical tools that assist clinicians in empowering their patients—by providing them with a guide for controlling and responding to their asthma—thus allowing them to take a more active role in the management of their condition.

One could think of it as a blueprint for a mutual beneficial relationship.

Previous | Next: Asthma Research into Action

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Last Updated February 2012




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