University of Michigan
Department of Pediatrics
Evidence-Based Pediatrics Web Site

Question

• In children with asthma, does provision of a written action plan result in fewer unscheduled acute care visits for asthma exacerbation?

Clinical Bottom Lines

1. Children who are given a written action plan have fewer unscheduled acute care visits, less missed school, and fewer symptoms as compared to those that do not have a written action plan.
2. Meta-analysis showed that there is a decrease in unscheduled acute care visits for asthma exacerbation in children who are given symptom-based written action plans versus those who are give peak flow-based written action plans, with a number needed to treat of 8.

Summary of Key Evidence

1. Meta-analysis included all randomized controlled trials in children of (a) written action plan vs no plan, or (b) comparison of different types of written plans.
   
2. Only one RCT compared a written plan with no written plan for children with moderate persistent asthma so meta-analysis was not possible. In these children, who all received a moderate dose daily inhaled steroid and asthma education, with a written plan there was a decrease in acute asthma events (0.5 vs 1.0 events per subject), school days missed (1.5 vs 2.5 days per subject), and symptom score (21.9 vs 33.7) over the study period of 3 months.
   
3. Meta-analysis of 4 RCTs comparing symptom-based and peak flow-based written action plans showed a 27% decrease in acute care visits for asthma exacerbation with symptom-based plans (RR=0.73, 95% CI 0.55 to 0.99, NNT=8).
   
4. Meta-analysis of the 4 RCTs above showed no difference in secondary endpoints including need for oral steroids or hospital admission, or school absenteeism.

Additional Comments

• All consensus statements from governing bodies recommend use of written action plans as part of asthma management.
• The intervention is inexpensive, and unlikely to cause harm. If using a symptom-based plan, providing a plan is not overly time consuming either.

Citation

1. 1. Zemek RL, Bhogal SK, Ducharme FM. Systematic review of randomized controlled trials examining written action plans in children. Arch Pediatr Adolesc Med 2008; 162 (2): 1099-1105.

CAT Author: Allison Cator, MD

CAT Appraisers: Francis McBee Orzulak, MD

Date appraised: April 8, 2009