Rapid Responses to:
|
|
Rapid Responses: Rapid Responses published:
-
![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Treatment is difficult enough without adding patient empowerment
- William Stevenson (17 December 2000)
-
Horses for courses
- Rod Lawson (19 December 2000)
-
Misguided, Guided and Self-Generated Self-Management
- James S Smeltzer (20 December 2000)
-
Asthma Self-management plans in Primary Care
- Terry Kemple (20 December 2000)
-
Wider concept of self-management needed
- Mike Thomas (21 December 2000)
-
Concern over the methodology
- Jennifer Cleland (21 December 2000)
-
Self management in asthma care
- Jack Barnes (22 December 2000)
-
Keep it simple
- John Haughney (26 December 2000)
-
Have self management plans been shown to be effective?
- Peter Black (28 December 2000)
-
A Partnership Approach leads to Effective Self Management
- Pradeep Jayasuriya (28 December 2000)
-
Asthma Management Plans are a Proxy to Education by Members of the Health Care System
- Karen R Cox (10 January 2001)
-
Guided self management palns for asthma
- Jo Douglass (19 January 2001)
|
|
|||
|
William Stevenson, Consultant Radiologist Burnley
Send response to journal:
|
It is clear that self management plans impose an unsustainable burden of extra work on nurses and doctors who must deal with all manner of patients. They are right to be unenthusiastic about this idea, which sounds like something which could be worthy of the WHO, along the lines of the daft Alma-Ata Declaration. I am sure it is difficult enough attempting to deal with the treatment of asthma without the additional hopeless task of patient education. I am a radiologist, but my wife was a respiratory specialist nurse. I have enough difficulty persuading some people to perform the simple task of breathing in and holding the breath (despite simple instruction and demonstration some people will either pant rapidly or will suck in the belly) so the work involved in complex instruction must be onerous indeed. This cannot be achieved, and time should not be wasted on it, except for those patients in which it will in any case be straightforward. |
|||
|
|
|||
|
Rod Lawson, Consultant, Respiratory and General Medicine Royal Hallamshire Hospital
Send response to journal:
|
The article by Jones et al suggesting that there is widespread dissatisfaction with the concept of self-management plans is thought provoking. However, the sweeping conlcusions are difficult to justify; "We found that many patients with mild to moderate asthma....", they say, using a total sample of 32 patients, 12 of whom were deliberated selected as being clearly non-compliant. I can certainly think of examples where patients have been clearly helped by the provision of typed self- management plans. Perhaps, therefore, I should add balance to the debate by making the statement that many patients with mild to moderate asthma find written management plans invaluable? My personal series of cases I have pooled is far greater than 32 patients! Less frivolously, I think the important point to be made is that self- management plans are not a sticking plaster to be applied uniformly to all patients. In the same way that some patients will get on best with an MDI and some with a dry powder inhaler, so there are patients who will appreciate and use a self-management plan, whilst there are those who will not use it or who will actively dislike it. The challenge is to recognise which patients are which and to respond accordingly. More helpful research would quantify how many patients do and don't find plans helpful, and characterise how we can spot those who are likely to respond. I hope the authors will proceed to such studies in the future. |
|||
|
|
|||
|
James S Smeltzer, Consultant, Maternal Fetal Medicine Wellstar Health System
Send response to journal:
|
We have the concensus that noone is helped by the current conception of guided self-management plans: Our friend in radiology is convinced, as are some of the nurses, that the patients are too stupid to manage it. The nurses know they cannot get the patients to follow orders now, much less complicated ones, and the physicians aren't sure that externally imposed inflexible plans are very practical. I agree with the physicians, but the patients most of all. I think the providers should get together with the patients, who are indeed following self-management plans: "All the adults felt that they were already self managing competently and were behaving responsibly by not bothering the doctor or nurse unless necessary. For them self management meant taking drugs as they saw fit, avoiding "triggers" that brought on asthma, and requesting medical assistance only when this self care failed (box). Emphasis was placed on "knowing your own body best," what drugs worked for them, and therefore what to "reorder."" The patients were guiding their own self-management based on the very salient feedback of the response of their own asthma to their own behavior. We should all recognize this in interacting with our patients in the acute care setting. They are often in front of us specifically because their own algorithms broke down or encountered a situation for which it was not prepared. If we help them figure out when, how and why their system went astray, we can help them improve their knowledge of their disease and its treatment with better self-management algorithms. We need to be non- judgmental enablers for this process. Perhaps we should manage them in focus groups, where they can help (and harm) each other. This is what happens for better or worse over the net. I have not read these asthma protocols. Perhaps they are like the old TR-4 service manual I remember so well: useless if you know what you are doing and incomprehensible if you don't. Perhaps we should conclude that external, imposed, [mis]guided self-management [sic] plans don't work. I personally think this fact is a very favorable reflection on the human spirit, and would have it no other way. As a clinician, I have been reminded countless times that a physician who ignores his patient's observations in favor of his medical learning is a peril to the patient. I was taught this as a junior resident by a young woman in a contraception clinic who asked me if her tampons could make her sick. I asked her what she meant. She told me she had tried a new tampon and gotten a rash, fever and felt like she was going to die. I told her that I'd never heard of anything like that, but if she thought her new tampons made her sick, she should go back to the old ones. Three months later toxic shock syndrome was described in the literature. By luck I had stumbled on the proper response to such a situation. Recognizing the fundamental validity of the patient's experience and using that in the therapeutic alliance is the cornerstone of guided self-management. |
|||
|
|
|||
|
Terry Kemple, General Practitioner Horfield Health Centre, Bristol
Send response to journal:
|
The experience of asthma for patients varies greatly in severity and over time. Most patients with mild or moderate asthma will neither want nor need a formal self-management plan (SMP). Some patients may benefit from a SMP but perhaps only some of the time. The mismatch reported by Jones et al (ref 1) may reflect the uncertainty about which patients need and will use a SMP. We have been conducting a randomised controlled trial in 545 asthmatic patients who use steroid inhalers. These patients were a subgroup of the 1209 patients in our general practice aged over 16 who were recorded as suffering from asthma. A control group was mailed an invitation for the standard treatment based around an annual review (i.e. a review by GP or nurse of symptoms, signs, management and written self- management plans). A second group was sent the invitation for the standard treatment plus a blank standardised written self management plan that could be completed at their annual review. A third group was posted the invitation plus a partially completed personalised self-management plan. Twelve months after the mailshots the patients’ medical records are being checked for measures of process and outcome and the patients are being questioned to assess their understanding of self-management, and their current symptoms. Data collection and analysis continue but there are some clear impressions. Most GPs and practice nurses can provide SMPs. Over two thirds of patients discussed a SMP with a GP or practice nurse in the 12 months of the study. Many of these patients (roughly 20%) report they use and benefit from guided SMP. The challenge for primary care is that GPs and Practice Nurses are willing and able to offer an effective intervention like a written SMP when needed. The challenge for research and development is to inform professionals and patients when and how an intervention is likely to be effective. We need to know how to engage each patient in the effective management of the problems that are important for that patient. Terry Kemple
Ref 1
|
|||
|
|
|||
|
Mike Thomas, GP Minchinhampton
Send response to journal:
|
Editor All concerned with improving standards of asthma care will be interested in the fascinating qualitative data on the unenthusiastic attitudes of patients and health professionals alike to guided self management plans for asthma reported by Jones et al 1. These findings may help to explain the disappointingly poor usage of this intervention, which has been shown to improve outcomes of asthma care in combination with regular practitioner review 2. Recent surveys have shown that contrary to popular conception, there remains a high level of avoidable morbidity in asthmatic patients in the UK3 and in Europe4, and that we are failing to met the goals of asthma management specified in our guidelines. At first sight, the results of this study may dishearten those seeking to improve outcomes by propagating the message of self-management, with patients and professionals alike apparently unwilling to endorse the concept. A closer reading however allows other interpretations. The patients and professionals in the focus groups clearly equated guided self -management with the provision of pre-printed standardised self-management plans, provided either by a local hospital unit or by a pharmaceutical company, and felt that these documents had a very limited role to play for them. However, the cited comments of many of the patients reveal that they were in fact practicing a form of self-management by avoiding triggers and by altering their medication in response to changes in their condition. These actions in themselves are similar to those recommended in plans given by professionals, but unfortunately in the absence of professional involvement they are unguided, determined rather by what the individual patient ‘saw fit’. It is becoming apparent that many patients with asthma do not want to fit into the structures that we have evolved for delivering asthma care5; many do not want to attend for regular review of their asthma and do not want to monitor their peak flow regularly, and consciously or otherwise would rather tolerate symptoms of asthma. These findings indicate the need for us to be more imaginative and patient-centered in our delivery of care. In the instance of self-management plans, this may mean that we should be guiding and assisting our patients to allow them to do more effectively what it seems they want to do- to monitor their asthma in a way appropriate to them, to change their treatment when their clinical condition changes and to use scarce health service resources responsibly and appropriately. What really matters is that the patient has the necessary information, preferably in a retrievable medium, to allow them to act appropriately to changes in their asthma and to know when to call for help. This negotiation and empowerment process may be somewhat time consuming at the onset, and it seems will require a change in mind-set of health professionals. In the longer term however, by introducing greater professional guidance and involvement in what patients are going to do anyway, it may achieve better outcomes and so be both clinically and cost effective. This paper illustrates the current gulf between what patients think they want and what health professionals think they need; a wider conception by both of what constitutes a guided asthma self-management plan may be a step towards bridging it. Mike Thomas 1. Jones A, Pill R, Adams S. Qualitative study of views of health professionals and patients on guided self management plans for asthma. BMJ 2000;321:1507-10. 2. Gibson PG, Coughlan J, Wilson AJ, Abramson M, Bauman A, Hensley MJ, and et al. Self-management education and regular practitioner review for adults with asthma. (Cochrane review) In: Cochrane Library (Issue 2). 2000. Oxford: Update Software. 3. Smith NM. The 'Needs of People with Asthma' survey and initial presentation of the data. Asthma J 2000;5:133-6. 4. Rabe KF, Vermeire PA, Soriano JB, Maier WC. Clinical management of asthma in 1999: the Asthma Insights and Reality in Europe (AIRE) study. Eur Respir J 2000;16:802-7. 5. Price D,.Wolfe S. Delivery of asthma care: patients' use of and views on healthcare services, as determined from a national interview survey. Asthma J 2000;5:141-4. |
|||
|
|
|||
|
Jennifer Cleland, Clinical Lecturer Department of General Practice and Primary Care, University of Aberdeen
Send response to journal:
|
We are concerned about various methodological flaws in the study reported by Jones and colleagues (BMJ2000; 321:1507-10). He and his colleagues concluded from work with focus groups that neither health professionals nor patients were enthusiastic about guided self-management plans. We suggest that aspects of the methodology adopted by Jones and colleagues may have biased the outcome of their study. Focus groups, or group interviews, have been carried out when doing exploratory studies and undoubtedly have their advantages. However, research has indicated that these may not be the most efficient way of gathering data when the subject area is complex or participants hold many different, opposing and interrelated attitudes towards the subject. Stasser and colleagues (1,2) found that during group discussions, information that is not held by at least a couple of group members is less likely to be brought up in the discussion. This suggests that participants in the Jones study who may have had positive attitudes towards self-management of asthma care would not have voiced their views if the majority group were airing negative attitudes. The use of focus groups, therefore, discourages expression of alternative views. The varied locations (schools, surgeries, pubs and the local community hospital) used for group meetings is also of concern. Oppenheim (3)looks at exploratory interviews and advises "a comfortable, unhurried and relaxed setting for a private, confidential talk; anything that might upset or disturb respondents or make them feel pressed or intimidated should be avoided" (p69). Examples of inappropriate places to conduct interviews include a pub! The appropriateness of holding group discussions on guided self-management plans for asthma with asthma patients, nurses or doctors is dubious. Additionally, participant responses may well have been influenced by the location in which the group interview was held. The vignettes used by Jones and colleagues appear to be based on the transcripts collected by the same authors in an earlier paper (4) which categorise patients as 'deniers', 'accepters' and 'pragmatists'. However, all three vignettes seem negatively biased against the patient or at least biased against asthma management. For the 'accepter' vignette (case2), instead of saying that Sue was upset, they could have said "she was relieved when diagnosed" as shown in their previous study that found some patients "who had been suffering symptoms for some time expressed relief" (p195). In addition to this, instead of "I don't need an asthma clinic" a more positive alternative taken from the previous study could have been; "I don't need the doctor as long as the medication is working. I'd let him know if there was a problem"(p197). We suggest that the apparent bias may have triggered off attitudes in the doctors and nurses towards the typical "non compliant" patient rather than self-management plans per se. In turn, the wording of the vignettes may have resulted in putting the patients on the defensive (an 'us' and' them' situation) rather than extracting attitudes towards self-management plans. If the aim of the study was as the title suggests looking at attitudes towards guided self management plans, then why was there no mention of guided self management plans in the vignettes? Previous authors (5) have suggested that it is helpful for vignettes to end with a sentence looking at the way matters are likely to develop in the future i.e. prognosis. This may have been a useful addition to the vignettes used by Jones et al., particularly for the professionals who are likely to have hypothesised their own opinions as to each 'patent's' prognosis - these opinions may have differed widely and may have influenced their feedback. Finally, Jones and colleagues reported that participants were given an additional explanation of guided self-management plans consistent with the British Thoracic Society guidelines. Details of this explanation were not provided although feedback from one participating doctor indicates that they were perceived as complex. The complexity of information on self-management plans may well have influenced the attitudes of participants towards their utility. In conclusion, the conclusions of this study seem to be based on flawed methodology which may not, therefore, accurately reflect the views of patients and professionals towards guided self management plans for asthma. Jennifer Cleland, Clinical Lecturer (jen.cleland@abdn.ac.uk) Mandy Moffat, Doctoral Student (m.moffat@abdn.ac.uk) Both Department of General Practice and Primary Care, University of Aberdeen, Foresterhill Health Centre, Westburn Road, Aberdeen, AB25 2AY References: 1 Stasser G, Titus W. Pooling of unshared information in group decision making: Biased information sampling during discussion. Journal of Personality and Social Psychology 1985;48:1467-1478. 2 Stasser G, Taylor LA, Hanna C. Information sampling in structured and unstructured discussions of three- and six-person groups. Journal of Personality and Social Psychology 1989;57:67-78 3 Oppenheim AN. Questionnaire Design, Interviewing and Attitude Measurement, (new edition). London: Pinter Publishers,1996. 4 Adams S, Pill R, Jones A. Medication, chronic illness and identity: The perspective of people with asthma. Social Science and Medicine 1997;45:189-201 5 Miller T, Velleman R, Rigby K, Orford J, Tod A, Copello A, Bennett G. The use of vignette in the analysis of interview data: Relatives of people with drug problems. Doing Qualitative Analysis in Psychology Hayes N (ed)1997: 201-225 |
|||
|
|
|||
|
Jack Barnes, Director of Research National Asthma Campaign
Send response to journal:
|
Dear Editor We applaud the prominence given to self management in asthma (BMJ 2000;321:1507-10 and BMJ 2000;321:11482-3) but are concerned that the work of Jones and colleagues is open to misinterpretation. He and his colleagues conclude from "exploratory" work with focus groups that 'attempts to introduce self guided management plans for asthma in primary care are unlikely to be successful' - a conclusion unsupported by evidence. As Thoonen's editorial points out, patients are managing their own care but without health care professional's help, a finding supported by recent interviews undertaken by the National Asthma Campaign (NAC) which revealed significant asthma morbidity and only 6% of patients recalling any kind of written advice on how to take asthma treatment. , It is striking that Australian work has shown greater primary care use of self- management plans. What the research of Jones and his colleagues tells us is the size of the problem involved in encouraging some asthma nurses and primary care doctors to take on the challenge. But in the light of the evidence, we should not be daunted by that task. We need to empower, rather than simply seeking to educate, patients. We need to overcome the belief that self-management plans are complex (it is unclear from the paper what complexity of self-management was portrayed to the study participants). And additional barriers - that self management is not appropriate for most patients and the belief that education alone is the key to success - are also not supported by evidence. The 'Be in Control' initiative being launched by the NAC on January 30th 2001 is designed to make self management easier for busy health care professionals; and should meet the plea from doctors and asthma nurses in the study who feel that advice should be simple and patient focused rather than simply generic. As far as patients are concerned, we see nothing new in this study, and important omissions. Responses about denial and non-compliance are already well known, with some of this knowledge coming from previous work from Jones, Pill and Adams. But we also know from the NAC telephone helpline and other surveys that those with asthma dislike the uncertainty associated with the condition. How they are helped to address that provides an important route to gaining acceptance for proactive self management. Each patient requires an approach which recognises their own particular circumstance. Not everybody needs a detailed personal asthma action plan, but everybody does need to know what to do in the event of deteriorating control of their asthma. Yours sincerely Martyn Partridge
Greta Barnes
David Price
Jack Barnes
1. Price DB, Wolfe S. Patient's use and views on the service provided. Asthma J 2000;5:141-4. 2. Strachan D P. Defining unmet need. Asthma J 2000;5:137-40 3. Beilby J, Wakefield M, Ruffin R. Reported use of asthma management plans in South Australia. Med J Aust 1997; 166: 298-301. 4. Gibson PG, Coughlan J, Wilson AJ, Abramson M, Bauman A, Hensley MJ et al. Self.management education and regular practitioner review for adults with asthma Cochrane Database Syst Rev 2000;3:CD001117. 5. Gibson PG, Coughlan J, Wilson AJ, Hensley MJ, Abramson M, Bauman A, Walters EH. Limited (information only) patient education programs for adults with asthma (Cochrane Review). In: The Cochrane Library, Issue 3, 2000. Oxford: Update Software. |
|||
|
|
|||
|
John Haughney, General Practitioner Alison Lea Medical Centre, Calderwood, East Kilbride
Send response to journal:
|
Jones et al describe attitudes to guided self management plans in asthma care (1). What constitutes a self management plan? This debate concludes that complex, pre-determined, structured documents fail to find favour with either clinicians or people with asthma. Has the management of asthma become too formidable? Can we make it simpler? Asthma varies over time and in severity in the individual; its presentation and course vary greatly from patient to patient. And, therefore, so should its management algorithm and therapy. Effective interventions are necessary; the patient's involvement is essential. Self management plans will contribute to better asthma control provided they are simple, sensible, practical and achievable. They should be agreed to be so by clinician and user. Safety and effectiveness should not be forgotten. Dr John Haughney Alison Lea Medical Centre Calderwood East Kilbride G74 3BE haughney@gpiag-asthma.org 1. Jones A, Pill R, Adams S. Qualitative study of views of health professionals and patients on guided self management plans for asthma. BMJ 2000;321:1507-10 | |||
|
|
|||
|
Peter Black, Associate Professor Department of Medicine, University of Auckland, New Zealand
Send response to journal:
|
Jones and colleagues report that general practitioners and asthma nurses are ambivalent about the value of self guided management plans for asthma(1). It is noteworthy that the nurses stressed the importance of patient education and ongoing monitoring. The doctors also stressed the need for continuing education and dialogue. The doubts expressed by the doctors and nurses appear to relate to the value of self management plans that instruct the patients to adjust to their medication according to Peak Expiratory Flows and/or symptoms. This begs the question as to whether guided self management plans confer any benefit over intensive education and regular review. Gibson and his colleagues examined this question in a systematic review(2). The combination of education, self management and regular review was compared with usual care in 22 studies. Self management was associated with a reduction in hospitalisations, unscheduled visits to the doctor, days off work and nocturnal asthma. It is not clear however, from these studies, whether the benefit was due to intensive education and regular follow-up as opposed to the self management plans. This question can be addressed by studies where both groups have regular follow-up and ongoing education and where the only difference between the two groups is the use of a guided self management plan. The few studies that have done this have failed to demonstrate any additional benefit from self management plans(3-6). Ayres et al randomised 120 patients to dose adjustments made by a physician or to a self management plan(3). Both groups were seen at 6 weekly intervals. At the end of six months there was no difference between the groups in symptoms or lung function. The GRASSIC study randomised 569 patients to conventional monitoring or self monitoring with a peak flow meter(4). The latter group was given guidelines on adjusting medicines according to their peak flow. All patients were reviewed at 3 monthly intervals. At one year there was no difference between the groups in lung function, medication use or hospital admissions. The views reported by Jones and his coworkers(1) are supported by the published evidence. There may be selected patients who benefit from guided self management plans but for the most part it may be more productive to focus on regular follow-up and repeated education. Peter Black 1. Jones A, Pill R, Adams S. Qualitative study of views of health professionals and patients on guided self management plans for asthma. BMJ 2000; 321; 1507-1510. 2. Gibson PG, Coughlan J, Wilson AJ, Abramson M, Bauman A, Hensley MJ, Walters EH. Self-management and regular practitioner review for adults with asthma. The Cochrane Library. 2000: Volume 3. Update Software, Oxford. 3. Ayres JG, Campbell LM, Follows RMA. A controlled assessment of an asthma self-management plan involving a budesonide dose regime. Eur Respir J 1996; 9; 886-892. 4. Osman LM, Abdalla MI, Beattie JA et al. Reducing hospital admission through computer supported education for asthma patients. Grampian Study of Integrated Care (GRASSIC). BMJ 1994; 308: 568-71. 5. Jones KP, Mullee MA, Middleton M, Chapman E, Holgate ST. Peak flow based self management: a randomised controlled study in general practice. British Thoracic Society Research Committee. Thorax 1995; 50: 851-857. 6. van Essen-Zandvliet E,. Lans C, Denteneer A, van Stel H, Colland V. Can asthma exacerbations in children be reduced by using prodromal signs in a self management plan? (abstract). Am J Respir Crit Care Med 1999; 159: A757. |
|||
|
|
|||
|
Pradeep Jayasuriya, Acting Director Royal Australian College of General Practitioners, WA Research Unit
Send response to journal:
|
The emerging challenge for health policy makers is to maintain the quality of life and functional capacity of those with a chronic illness, within economic constraints and despite system barriers. The organisation and principles of primary care appear ideally suited to adopting self management approaches in the care of people with chronic diseases. The study by Jones et al is important in raising several issues in relation to self management in primary care. Their conclusions however must be viewed within the context of the chosen intervention and limitations of study design. They point out that an ongoing partnership needs to be formed with patients, but they then trial a guided self management approach that is clinician developed. This approach has little ownership by either the practitioners implementing the program, or the recipients of the program. Inherent to the success of these plans is the understanding that it is designed using a partnership approach that is fundamental to any self management process. Similarly, concepts such as 'compliance' do not reflect patient centred medicine or a partnership approach, but rather a directed, traditional medical model approach. Compliance implies the extent to which a patient follows medications and recommendations2. Non adherence should not be regarded as a defiant behaviour, but rather a person's conscious and often reasoned decision not to follow a prescriptive regimen or change a behaviour. In addition to the limitations inherent with this particular self management plan, the selected study design restricts the generalisability of the findings. In particular the finding 'guided self management plans for adults with mild to moderate asthma are unlikely to be accepted or sustained in primary care' needs to interpreted cautiously. The finding particularly conflicts with some of the values of primary care which are highly conducive to a self management approach. Thoonen and van Weel 3 report that ownership of guidelines is essential to guaranteeing implementation. This is true not only for GPs and nurses, but also for patients. Criticism should be perhaps aimed at the fact that the self management intervention was a written guide that was not owned by any of those working together. Certainly some patients do not want to self manage, but everyone should be given the opportunity if that is what they wish. The belief that health providers can choose who will benefit is not substantiated by the literature. Approaches such as the Transtheoretical model could of great benefit to GPs and other health care professionals as it underscores the necessity to tailor programs to the actual needs of patients through discussion with them to achieve the best outcome possible.4 What is ultimately necessary is not for the imposition of well intentioned externally designed plans, but rather the acquisition of skills and knowledge by providers and consumers that is supported by a self management culture that integrates with existing practice. 1. Jones A, Pill R, Adams S. Qualitative study of views of health professionals and patients on guided self management plans for asthma. BMJ 2000; 321: 1507-1510 2. Leickly FE, Wade SL, Crain E, Kruszon-Moran D, Wright EC, Evans R. Self-reported adherence, management behaviour and barriers to care after an emergency department visit by inner city children with asthma. Pediatrics 1998; 101: 5 3. Thoonen B, Van Weel C. Self management in asthma care. BMJ 2000; 321: 1482-1483 4. Cassidy CA. Using the transtheoretical model to facilitate behaviour change in patients with chronic illness. J Am Ac Nrs Pract 1999; 11 (7): 281 - 285 Sally Roach, Linda Thoms, Pradeep Jayasuriya,. Royal Australian College of General Practitioners, WA Research Unit. 17 Lemnos Street, Shenton Park. Western Australia 6010. wagpres@racgp.org.au |
|||
|
|
|||
|
Karen R Cox, Office of Clinical Effectiveness University of Missouri Health System
Send response to journal:
|
The authors conclude that “neither health professionals nor patients were enthusiastic about guided self management plans”, they are “ambivalent about their usefulness or relevance” and “most professionals opposed their use”. I have two serious concerns about the conclusions reached. First, I am concerned about the vignettes used to “stimulate comment…”, and second, I am concerned about the participants’ lack of experience with asthma plans. The vignettes depict varying levels of understanding and acceptance of the asthma diagnosis; there is NO mention of asthma plans in terms of their access or use. Further, the authors do not describe any link between these vignettes and an appraisal of the utility, relevance and/or satisfaction with asthma plans. As for the subjects selected in this study, the authors describe dismal understanding or use of plans by both the professional and patient participants. Specifically, “health professionals and patients were aware of guided self management plans, but general practitioners and nurses made little use of them and their experience was limited to the plans given out by the hospitals or, in the case of some nurses, by drug companies. Although all patients agreed that guided self management plans may be of use to other people with asthma, only one was currently using a plan (1 of 32) and only five claimed to have done so in the past” yet “most (patient) participants claimed they would try plans if offered”. Specifically, with regard to nurse participants, their qualitative expressions selected for publication demonstrated a very shallow understanding of the processes needed to develop capable care partners particularly with patients who have a chronic illness. For a patient to develop competency, necessary (but not sufficient) ingredients are knowledge and experience. Yet, these nurses gave “just a few pointers”, or “two or three instructions” but “only to patients who had accepted and understood their condition and were using drugs correctly” (obviously the more competent patient who is less likely to need to refer to an asthma plan). Yet, these nurses interpreted asthma plans as inappropriate for both patients newly diagnosed and patients who tended to not seek regular check-ups! Clearly, these are the patients who have little knowledge and experience and would be highly likely to refer to a written asthma plan containing information about symptoms to monitor, triggers to avoid, when and with what to self-treat, and when to contact a health care provider. The author’s general remarks about physician participants centered around a lack of belief that many patients had capacity for self management AND for some participants, it was inappropriate for the doctor to try strategies to encourage compliance since this was a nurse delegated task. Opposite from the perceptions of the nurses, some physicians expressed the belief that asthma plans encouraged dependency on the physician! One physician is quoted as saying “Every patient is different and needs different advice. And only educated patients can deal with the information they are given anyway. Some of my patients have shown me these plans, and I’ve told them to put them in the bin”. The development of an asthma action plan is preceded by an actual diagnosis of asthma and then education about symptoms, triggers, medications, and when/how to contact the physician. All of this takes a significant amount of time and energy and our current practice of 10-20 minute clinic appointments makes this very difficult to operationalize. Last August, we conducted one focus group of parents who managed asthma on behalf of their young child. These parents represented a range of severity and duration of asthma experiences. As a nurse manager, I made the assumption that those parents who were very experienced would not need a plan because it would be “in their head”. Much to my surprise, all of the participants said they knew exactly where their child’s asthma plan was located. Further, all of them admitted to using the plan every time the child’s symptoms flared (since all of the children’s symptoms flared intermittently). The BMJ study does not dissuade me that the National Heart, Lung, Blood Institute standard that asthma management plans are highly useful. I believe that asthma plans are essential in developing competent care givers/patients, particularly in persons whose symptoms are intermittent or where there is limited experience with the condition (those who are newly diagnosed). These persons (intermittent symptoms and/or new diagnosis) are the persons more likely to be treated by Family Practice physicians and Pediatricians, thus the need to invest the time and energy in developing competency of patients and care givers through the use of asthma management plans. |
|||
|
|
|||
|
Jo Douglass
Send response to journal:
|
Editor - Jones, Pill and Adams (1) in their qualitative study on asthma self-management plans challenge us by their description of patient and health practitioner treatment preferences that diverge widely from internationally promulgated asthma treatment guidelines. However, clinician acceptance of the attitudes reported in this study risks introducing standards of care which are known to be suboptimal. In asthma, Level 1 evidence does exist to support the efficacy of a comprehensive strategy of asthma education, self-management and ongoing review in improving objective medical outcomes (2). Why did this study by Jones' and colleagues reach such different conclusions with regard to patient and health practitioner attitudes? A recent global question has been what are the barriers to the adoption of evidence-based guidelines by health practitioners(3)? It has been established that the beliefs of edical practitioners surrounding medical information are critical to subsequent clinical actions (4) and that local ownership of guidelines is critical to implementation. The study sample of patients, nurses and doctors was recruited from one region of Wales where health practitioners did not perceive asthma management plans as useful. How involved have these health professionals been in any regional development of asthma management plans? In the absence of involvement, patients may simply be reflecting the views of their doctors and clinical nurses regarding the utility of asthma management plans. With regard to patient perspectives, it would be critical to understand how Jones, Pill and Adams derived their categorisation of patients as compliant or non-compliant. Was it self-definition, health practitioner- defined, or a combination? Methodological rigour in qualitative research requires transparency of the research process in dissemination of results, notwithstanding the limitations imposed by publication vehicles (5). Given the significance of this issue a better understanding of these choices and their influence on data analysis and interpretation would enable readers to better assess the results of this pilot study. For too long patients have been the "silent voice" in the construction of treatment guidelines and asthma is not an exception. Jones, Pill and Adams should be commended for listening to patients as well as clinicians. The issues raised by this study mandate a more comprehensive qualitative study of the attitudes of individual asthma patients to established treatment guidelines in order to ensure that valuable principles are not dismissed on pilot evidence. Jo Douglass
Rosalie Aroni
Dianne Goeman
Susan Sawyer
Michael Abramson
Kay Stewart
Frank Thien
References: 1) Jones A, Pill R, Adams S. Qualitative study of views of health professionals and patients on guided self management plans for asthma. BMJ 2000; 321: 1507-1510. 2) Gibson PG, Coughlan J, Wilson AJ, Abramson M, Bauman A, Hensley MJ et al. Self-management, education and regular practitioner review for adults with asthma. Cochrane Database Syst Rev 2000; 3: CD 001117. 3) Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999; 282: 1458-1465. 4) Graham I. I believe therefore I practise. Lancet 1996; 347: 4- 5. 5) Mays N, Pope C. Assessing quality in qualitative research. BMJ 2000; 320: 50-52. |
|||