LAUSR

Asthma presents a paradigm for the benefits of self-management, more than any other chronic disease. This is due to both the rapid and unpredictable nature of asthma worsenings and the remarkable ability for inhaled anti-inflammatory medications to mitigate these worsenings. This self-management is operationalized through a written asthma action plan (AAP)—a simple piece of paper with a “green zone” describing good asthma control and reinforcing baseline medications, a “yellow zone” describing acute loss of control and corresponding instructions for therapeutic intensification, and a “red zone” indicating severe symptoms prompting immediate medical assistance. The functional principle of this tool is simple: if patients quickly intensify therapy when their asthma starts to worsen, they can avert a full-blown flare and the need for urgent healthcare and systemic corticosteroids. Throughout the 1990s, this intuitive concept was put to the test in a series of randomized-controlled trials (RCTs). In 2000, and again in 2003, Gibson and colleagues systematically reviewed these data in a Cochrane review of 18 RCTs, concluding that use of a written AAP in conjunction with education and regular clinical review significantly reduces hospitalizations, emergency room visits, unscheduled visits to the doctor, number of days off work or school, and nocturnal asthma symptoms, and significantly improves quality of life. Accordingly, as early as 1996, asthma guidelines across the world recommended that each asthma patient should receive an AAP. Yet over 20 years later, use of AAPs remains a niche practice, and a glaring example of ineffective respiratory guideline implementation. Only 29% of patients received an AAP in a 2001 Australian study, and 23% in a 2006 UK report. More recent data are even more disappointing, with only 4% of surveyed Canadian primary care physicians reporting consistently providing a written AAP, and only 2% of Canadian and American patients having actually received one. Although this problem has mostly been reported in primary care, where the majority of asthma patients are seen, AAP delivery remains below 50% even in tertiary care centers. So what went wrong? Primary care barriers to AAP delivery have been well-described. Some barriers have to do with the AAPs themselves. Our analysis of 69 AAPs collected from prior RCTs and existing asthma programs across the world demonstrated large variability in both their content and format, and poor usability. Most plans were developed ad-hoc, and by content experts exclusively. Other barriers exist at the level of providers, the practice environment, and the overall health care system. Qualitative studies indicate that a majority of physicians consider AAPs to be important, but fail to provide them due to lack of time. In addition, physicians are limited by lack of experience and confidence in generating appropriate AAP recommendations, lack of confidence in their patients’ ability to utilize them, and lack of their availability at the point of care. In one study, 30% of physicians attending an asthma skills workshop were unable to prepare an adequate AAP, with the main knowledge gap surrounding how to change therapy in the yellow zone of the AAP. In turn, this knowledge gap may be driven by poor guidance. Primary care physicians complain that guidelines are too lengthy, ambiguous, and complex, and are presented in too rigid a fashion for practical application in individual patients. Our recent analysis identified corresponding concerns with the “implementability” of several guidelines. Although the most recent Canadian Asthma Guideline (2012) attempts to address this knowledge gap by providing evidence-based recommendations for changes to therapy in the yellow zone of the AAP, this complex process remains challenging to operationalize. In order to try to address these knowledge and usability barriers, our group sought to develop a practical, evidence-based, point-ofcare guide for populating adult AAP yellow zone instructions. To achieve this, we started with a review of AAP guidance found in major asthma guidelines published in the last five years (including the Global Initiative for Asthma (GINA), British Thoracic Society/ Scottish Intercollegiate Guideline Network (BTS/SIGN), and Canadian Thoracic Society (CTS) guidelines). We supplemented this with a systematic literature search for relevant reports published more recently. Based on the synthesis of these data, we established evidence-based rules for changes to therapy in the AAP yellow zone. Next, we tested the applicability of these rules across common baseline controller medication dose and frequency regimens in Canada, USA, and Europe. As expected, we discovered several operational challenges in applying these recommendations. In some cases, guidelines provided no clear approach. In others, the universal recommendation to increase ICS dosing by 4–5 fold in the yellow zone could not be applied because dosing would exceed jurisdictional regulatory dose limits. These issues affected 15 of 43 (35%) common European dose regimens; however we were able to identify and recommend alternate evidence-based approaches in 8 of these 15 (53%) circumstances. Dose increases in the AAP yellow zone can also be achieved in a variety of ways, including changes to the number and/or frequency of inhalations, through addition of a new inhaler, or through temporary replacement of the baseline medication with a more