ASTHMA: PEAK FLOW TRIGGERED STEPPED CARE REDUCES REVISITS TO A&E

Cowie RL, Revitt SG, Underwood MF, Field SK: The effect of a peak flow-based action plan in the prevention of exacerbations of asthma. Chest 1997;112:1534-8.
Appraised by: Sackett at the CEBM; Sunday, March 01, 1998
Three-part Question: In asthma patients seen in A&E, would triggering subsequent self-Rx on the basis of peak-flow reduce subsequent visits and hospitalisations?
Search Terms: found on routine EBMJ surveillance

The Study:
Non-blinded concealed randomised controlled trial with intention-to-treat.
Adolescent or adult asthmatics severe enough to have required A&E treatment (beta-agonist by aerosol +/- oral/parenteral steroid.
Control group (combined N = 93; 93 analysed): 1. regular care & 2. stepped care (increased inhaled steroid, then oral prednisone, then to A&E) with steps based on increasing symptoms and failure to obtain >30-120 minutes relief from beta-agaonists.
Experimental group (N = 46; 46 analysed): Stepped care plus 45 minutes instruction (by nurse) in use of Wright peak-flow meter, with doubling inhaled steroid at =<70% predicted or =>20% diurnal variation; oral prednisone at =<50% and to A&E at =<30%.

The Evidence:

Outcome	Time to Outcome	CER	EER	RRR	ARR	NNT
A&E visit for urgent asthma treatment	6 months	0.355	0.109	69%	0.246	4
95% Confidence Intervals:				32% to 100%	0.113 to 0.379	3 to 9
Admitted for asthma	6 months	0.086	0.043	50%	0.043	23
95% Confidence Intervals:				-45% to 100%	-0.039 to 0.125	NNT = 8 to INF NNH = 26 to INF;

Comments:

1. Routine and symptom-triggered care results pooled.
2. total amounts of inhaled and oral steroids didn't differ among the treatment groups.
3. Patients were not told that A&E visits were the outcome measure.

Expiry date: 1 Jan1999

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