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Guided self management of asthma

Editor—Lahdensuo writes in favour of guided self management plans in patients with asthma and indicates what skills patients might acquire and who may be suitable.1 However, the evidence cited from a recent Cochrane review showing a reduction in morbidity with the use of such plans2 does not convince us of their widespread application to general practice. 
 
The trials in the review were heterogeneous, recruiting patients from hospital clinics after inpatient or emergency room attendance, from general practice, and from advertisements in newspapers and on radio seeking participants. Selection biases may be present—for example, three British trials sought patients from collections of practices (14, 14, and 24 practices in total) and managed to recruit only small numbers of asthma patients (126, 127, and 339 respectively). Many trials had extensive exclusion criteria, at least five trials excluding smokers. Loss to follow up in the original papers varies up to 60.3% and was over 40% in five studies. An American trial offered open access to a special asthma clinic to those in the intervention arm of the study. The reduction in hospital attendance seen may have been balanced in part by patients attending that clinic. Several studies provided free treatment during the trial, but self management plans may have less impact when patients have to buy their drugs. Follow up ranged from 6 to 12 months. What improvements persist over a longer time and whether patients would require or accept further reinforcement of self management plans is not established. 
 
None of the trials established what patients think of self management plans, particularly those who do not accept invitations to attend clinics or who do not adhere to treatment. Professional beliefs that patients should be taught and should be supervised are at odds with a shared decision making model. Lahdensuo quotes Partridge as saying that self management of asthma entails the patient making therapeutic, behavioural, and environmental adjustments in accordance with the advice from healthcare professionals, but Partridge has also pointed out that the patient's perspective may not always be the same as that of the doctor.3,4 
 
Lahdensuo has given us a useful aid on how to guide self management of asthma. However, before we implement these plans in general practice more research is needed on the views of patients.