Written Action Plans for Asthma and COPD: What the Trials Show
The paper alone was never the whole intervention.
A patient with asthma wakes in the night, short of breath, and the reliever is not lasting as long as it did last week. Nobody at the clinic is awake. What happens next depends on what the patient was told to do, and whether anyone wrote it down.
Written action plans for asthma and COPD work best as part of a package: education, a personal plan that says when and how to change treatment, and regular review. In that form, Cochrane reviews link them to fewer hospital admissions. The plans that say when and how to act do better than general advice, and many patients never receive one.
Few written plans have been tested this often. Their lessons reach well beyond the lungs.
What the asthma reviews found
A 2003 Cochrane review by Gibson and colleagues pooled 36 trials (opens in a new tab) of self management education in adults with asthma. Education reduced hospitalizations (relative risk 0.64), emergency room visits (0.82) and unscheduled doctor visits (0.68). Quality of life improved. Lung function changed little.
The education in those trials was more than a handout. The reviewers credited self monitoring, by peak flow or by symptoms, "coupled with regular medical review and a written action plan" for the benefit. Programs that trained patients to adjust their own medication with a written plan appeared more effective than other forms of self management.
A much larger synthesis reached the same answer. In 2017, Pinnock and colleagues reviewed 27 systematic reviews covering 244 trials (opens in a new tab), plus 13 newer trials. Supported self management reduced hospitalizations, emergency visits and unscheduled consultations across many cultures and settings, without significantly raising total healthcare costs.
They named three core components: patient education, an action plan and regular professional review.
What makes a written action plan work
Not every plan performed equally. Gibson and Powell examined 26 trials (opens in a new tab) to find which parts of an asthma action plan mattered. They called a plan complete when it told the patient when to increase treatment, and how.
Individualized, complete plans with two to four action points consistently improved outcomes. Plans that gave only general advice improved knowledge and symptoms. Action points based on the patient's personal best peak flow worked; points based on a predicted value did not.
That is the finding most worth carrying into other written plans. "Call us if you get worse" is general advice. "If I need my reliever more than ____ times in a day, I will start ____ and call the office the same day" is an action point. The blanks are the clinician's to fill.
A companion review by Powell and Gibson compared ways of delivering self management (opens in a new tab). Patients adjusting their medication with a written plan did as well as patients whose doctor adjusted it at review. Plans based on peak flow and plans based on symptoms were equivalent.
One trial in that review found no difference in healthcare use between verbal instruction and a written plan. The reviewers also warned that reducing the intensity of education or review may reduce the benefit. The paper alone was never the whole intervention.
What the COPD reviews found
In COPD, a 2017 Cochrane review by Lenferink and colleagues included 22 studies with 3,854 people (opens in a new tab). Every program combined a written plan for flare ups with ongoing contact in which the care team gave the patient feedback.
Patients in these programs had better quality of life scores and fewer respiratory hospital admissions (odds ratio 0.69, moderate quality evidence). There was no clear difference in admissions for any cause, the number of flare ups or overall mortality. An exploratory analysis found a small rise in respiratory deaths, on very low quality evidence. The authors advised that plans take the patient's other conditions into account.
A second Cochrane review, by Howcroft and colleagues, tested simpler versions (opens in a new tab): an action plan with brief education, without a full self management program. Across seven trials and 1,550 people, plans lowered the odds of hospital admission and of emergency visits. They also increased courses of oral steroids and antibiotics.
That last finding is the purpose of a COPD plan. It is meant to change what the patient does early, and that includes starting medication. A plan that leads to more steroid courses has to be one the clinician is prepared to stand behind.
Many patients never receive one
The evidence is old and consistent, but delivery lags. Simon and Akinbami used national survey data to track US children with asthma who had ever received an action plan (opens in a new tab). The share rose from 41.7 percent in 2002 to 50.7 percent in 2013. About half had never received one.
That is a question any practice can ask about its own written plans: what share of patients leave with one?
What other written plans can take from this
Respiratory medicine has tested written plans for decades. Four lessons apply to almost any condition:
A written plan works best alongside education and review, not as a page on its own.
A useful plan says when to act and how, in specific terms the patient can follow.
A plan that changes behavior changes treatment, so every action point belongs to the clinician.
Many patients who should have a plan never get one, so delivery is worth counting.
Care plans such as asthma, COPD and albuterol can support the education piece. The action points themselves stay with the clinician who knows the patient.
A plan helps when it is specific, explained and reviewed.
Every patient with a chronic condition deserves a plan for the bad night, written before it comes.
Let's Complete the Care.
