Written action plan in pediatric emergency room improves asthma prescribing, adherence, and control

Am J Respir Crit Care Med. 2011 Jan 15;183(2):195-203. doi: 10.1164/rccm.201001-0115OC. Epub 2010 Aug 27.


Rationale: An acute-care visit for asthma often signals a management failure. Although a written action plan is effective when combined with self-management education and regular medical review, its independent value remains controversial.

Objectives: We examined the efficacy of providing a written action plan coupled with a prescription (WAP-P) to improve adherence to medications and other recommendations in a busy emergency department.

Methods: We randomized 219 children aged 1-17 years to receive WAP-P (n = 109) or unformatted prescription (UP) (n = 110). All received fluticasone and albuterol inhalers, fitted with dose counters, to use at the discretion of the emergency physician. The main outcome was adherence to fluticasone (use/prescribed × 100%) over 28 days. Secondary outcomes included pharmacy dispensation of oral corticosteroids, β(2)-agonist use, medical follow-up, asthma education, acute-care visits, and control.

Measurements and main results: Although both groups showed a similar drop in adherence in the initial 14 days, adherence to fluticasone was significantly higher over Days 15-28 in children receiving WAP-P (mean group difference, 16.13% [2.09, 29.91]). More WAP-P than UP patients filled their oral corticosteroid prescription (relative risk, 1.31 [1.07, 1.60]) and were well-controlled at 28 days (1.39 [1.04, 1.86]). Compared with UP, use of WAP-P increased physicians' prescription of maintenance fluticasone (2.47 [1.53, 3.99]) and recommendation for medical follow-up (1.87 [1.48, 2.35]), without group differences in other outcomes.

Conclusions: Provision of a written action plan significantly increased patient adherence to inhaled and oral corticosteroids and asthma control and physicians' recommendation for maintenance fluticasone and medical follow-up, supporting its independent value in the acute-care setting. Clinical trial registered with www.clinicaltrials.gov (NCT 00381355).

Trial registration: ClinicalTrials.gov NCT00381355.

Publication types

  • Randomized Controlled Trial
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Adolescent
  • Adrenal Cortex Hormones
  • Advance Care Planning / organization & administration*
  • Albuterol / therapeutic use
  • Androstadienes / therapeutic use
  • Asthma / drug therapy
  • Asthma / therapy*
  • Bronchodilator Agents / therapeutic use
  • Child
  • Child Health Services
  • Child, Preschool
  • Drug Prescriptions / statistics & numerical data*
  • Emergency Service, Hospital / organization & administration*
  • Fluticasone
  • Follow-Up Studies
  • Humans
  • Infant
  • Nebulizers and Vaporizers
  • Patient Compliance / statistics & numerical data*
  • Pediatrics / methods
  • Self Care / methods*
  • Single-Blind Method
  • Treatment Outcome


  • Adrenal Cortex Hormones
  • Androstadienes
  • Bronchodilator Agents
  • Fluticasone
  • Albuterol

Associated data

  • ClinicalTrials.gov/NCT00381355