Running head: IMPROVING PEDIATRIC ASTHMA MANAGEMENT

Improving Pediatric Asthma Management:
A Quality Improvement Project
Jennifer E. Brown
Arizona State University

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Abstract
Purpose: To educate clinic staff on interventions and education materials which are suitable for
implementation in a pediatric primary care setting, and to improve delivery and documentation
of appropriate asthma interventions and inhaler/spacer education.
Background: Asthma is a chronic illness that impacts 10.9% of the pediatric population in
Arizona. Poor asthma understanding and management leads to high-utilization of emergency
rooms and urgent care clinics, negatively impacting the healthcare economy. Poor asthma
management also leads to decreased health outcomes and impacts on the child’s academic
functioning, mental health, and overall quality of life. Current evidence supports use of written
asthma action plans (WAAP) and inhaler/spacer instruction to improve asthma management.
Methods: The intervention was an evidence-based educational session provided to the staff of a
military, pediatric primary care clinic in southwest Arizona regarding the use of WAAP, the
Asthma Control Test (ACT) and integrated inhaler/spacer instruction. Chart reviews were
conducted to evaluate the documentation of use of WAAP, ACT, and inhaler/spacer education.
Results: Charts were collected from pre-intervention (n = 33) and post-intervention (n = 18).
Data analysis demonstrated a statistically significant higher use of WAAP (U = 0.008, p < 0.05,
d = 0.83). Although there was not a statistically significant change in use of ACT tool, Cohen’s
value (d = 0.48) suggested a moderate positive effect. A Pearson correlation coefficient was also
calculated for the relationship between use of ACT tool and use of WAAP, demonstrating a
moderate positive correlation (r (49) = .372, p < .01).
Conclusions: An evidence-based education session for pediatric staff members is a costeffective and simple method of improving pediatric asthma management practices.
Keywords: asthma, asthma management, primary care, written asthma action plan

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Improving Pediatric Asthma Management
Asthma is a chronic disease of the respiratory system that is characterized by wheezing,
chest tightness, bronchospasm, difficulty breathing, and coughing, particularly nighttime and
early morning coughing (American Lung Association of Arizona [ALAA], 2016; CDC, 2018;
John & Brady, 2017). It is the most common chronic lung disease in children and can range in
severity from mild with intermittent symptoms to severe with sustained symptoms (ALAA,
2016; Burns, 2017). Often asthma can be controlled by taking medications as prescribed by a
healthcare provider and avoiding things that may trigger an asthma attack (CDC, 2017).
Background and Significance
Problem Statement
According to the most recent data from the Centers for Disease Control and Prevention,
approximately 9.2% of children in the United States have a current diagnosis of asthma, while
the rate in Arizona is 10.9% (ALAA, 2016; CDC, 2013). Asthma exacerbations and
complications from asthma are associated with $8.3 billion in health care expenses, of which
28% is caused by emergency department (ED) visits and hospitalizations (Abir et al., 2017).
Asthma is ranked second among the top five mostly costly health conditions for children aged 017 years, with a total of 12.1 million children obtaining healthcare for asthma or chronic
obstructive pulmonary disease (Soni, 2015). A significant amount of ED visits and
hospitalizations can be prevented through proper primary care management, patient education,
and home care (Abir et al., 2017; ALAA, 2016).
The Arizona Department of Health Services (ADHS) has established asthma
management, both in adults and children, as a public health priority (ALAA, 2016). In Arizona,
more than 27,000 ED visits and hospital discharges were attributed to asthma, accounting for

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approximately $150 million in healthcare spending (ALAA, 2016). In line with Healthy People
2020, Arizona has established a goal of reducing asthma-related ED visits and hospitalizations,
reducing asthma-related missed school and work days, and reducing deaths related to asthma and
other chronic lower respiratory diseases by ten percent (ALAA, 2016). In the Arizona
Comprehensive Control Plan, the ADHS has established several objectives to achieve their
asthma management goals (ADHS, n.d.). Some of the pertinent objectives within Arizona’s
control plan include: improving patient’s knowledge and behavior in the self-management of
asthma, educating healthcare providers to ensure the delivery of evidence-based best practice,
and increasing the number of asthmatics in Arizona that receive written asthma management
plans from their healthcare provider (ADHS, n.d.). The objectives highlight the importance of
primary-care based interventions to reduce asthma-related complications, utilization of acute
care services, and ultimately deaths associated with asthma.
Pediatric Asthma Patients
In addition to overall health status, poorly managed asthma has a lasting impact on a
child’s quality of life and missed school days. An asthma diagnosis in children is often
associated with increased reported anxiety and depression symptoms than their healthy peers
(Santos, Crespa, Silva, & Canavarro, 2012; Walker, 2012). Children with poorly controlled
asthma are more likely to experience sleep disturbances, activity limitations, missed days of
school, ED visits, and hospitalizations (Santos et al., 2012; Trent, Zimbro, & Rutledge, 2015). In
a study by Trent et al. (2015), children with poorly controlled asthma missed 33.3% more days
of school than children whose asthma was well-controlled. Missed school days are associated
with asthma exacerbations or lack of asthma control, increased ED or urgent care visits, and
scheduled clinic visits (Hsu, Qin, Beavers, & Mirabelli, 2015). School absenteeism negatively

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impacts a child’s academic performance and should be considered when evaluating the
effectiveness of current asthma management interventions.
Primary Care Interventions
Asthma self-management includes the patient (or parent) being educated on asthma
medications, symptom control, avoidance of triggers, routine scheduled visits with healthcare
provider, and implementation of a written asthma control plan. While a written asthma control
plan is part of holistic asthma management and increases patient/parent knowledge of asthma, it
has not been found to decrease acute visits to the healthcare provider (Tan, Chen, Soo, Ngoh, &
Tai, 2013; Wong, Nathan, deBruyne, Zaki, & Tahir, 2012). Despite this fact, asthma action plans
assist patient’s in making short-term changes to their treatment if their symptoms or peak-flow
measurements deteriorate (Global Initiative for Asthma (GINA), 2018). A systematic review
found that children preferred symptom-based action plans over peak-flow based action plans and
were more likely to continue using these action plans (Bhogal, Zemek, & Ducharme, 2006).
Technology-based interventions and asthma action plans are also becoming more prevalent and
may increase utilization, especially in the adolescent population. The effectiveness of these
technology-based interventions to make a statistically significant impact still requires further
study (Marcano-Belisario, Huckvale, Greenfield, Car, & Gun, 2013).
ER and Urgent Care Utilization
When patients or parents of pediatric asthma patients feel that their child is experiencing
an asthma exacerbation, they will seek care through an acute visit with their healthcare provider.
If these appointments are not available, or if it is after hours, they may be forced to utilize urgent
care or emergency departments. In a study of 62 pediatric patients, 13 patients with uncontrolled
asthma, compared with 2 patients with well-controlled asthma, utilized the ED. This was found

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to be a statistically significant difference in ED utilization (Trent et al., 2015). Another study
found that only 36% of patients who utilized the ED reported having a preventative asthma
healthcare visit in the past twelve months (Gundewar, David, Frey, Fagnano, & Halterman,
2017). These findings suggest that patients with established primary care and provision of
evidence-based management, are more likely to be well-controlled and less likely to utilize ED
and urgent care services.
Summary
Effective application of clinical practice guidelines and patient education to improve selfmanagement abilities have a positive impact on how well a patient’s asthma is controlled.
Uncontrolled asthma has substantial impacts on the child and family quality of life, school
attendance, behavioral health, and utilization of ED/urgent care services. Utilization of these
emergency services and poorly managed asthma, in general, contribute to significant healthcare
cost. It is imperative to implement interventions in primary care that can address these issues and
decrease the number of children with poorly controlled asthma.
Internal Data and PICOT
In a military, pediatric primary care clinic in southwest Arizona, asthma patients are
managed by either primary care providers or the allergy/immunologist. Asthma management is
not standardized, some patients receive a written asthma control plan and others do not. There is
not an asthma educator on staff or current availability of a nurse for this type of intervention.
Preliminary interest in this problem led to an inquiry of current evidence to determine the
best interventions for asthma management. This literature review has led to the clinically
relevant PICOT question, In pediatric patients with asthma (P), how does implementation of

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enhanced education and a self-management intervention (I) compared to usual care (C),reduce
ED/urgent care utilization (O) within 16 weeks (T)?
Search Strategy
Databases searched for the literature review included Cumulative Index of Nursing and
Allied Health Literature (CINAHL), PubMed, and The Cochrane Library. Keywords included;
asthma management, asthma action plan and asthma AND self-management. The initial search
of asthma management yielded 2.940 results in CINAHL (Appendix A), 21,978 in PubMed
(Appendix B), and 694 in The Cochrane Library (Appendix C). By setting limits to age 18 and
younger and publication date from 2012-2018, resulted in a final yield of 353 studies in
CINAHL (Appendix A) and 399 in PubMed (Appendix B). Publication date restrictions were not
utilized in The Cochrane Library, as the most recent systematic review on pediatric asthma
management had been withdrawn, so the most relevant systematic review was last updated in
2010. The final search with date and age restriction of asthma action plan yielded 35 results in
CINAHL (Appendix A) and 43 in PubMed (Appendix B). The final search with date and age
restriction of asthma AND self-management yielded 79 results in CINAHL (Appendix A) and 57
in PubMed (Appendix B). The results for each of the searches performed in The Cochrane
Library were reviewed for pertinent results based on pediatric population inclusion.
Exclusion criteria included published dates before 2012, with the exception of one
landmark study, studies written in non-English language, unpublished works, or those involving
adults only. Studies included involved children in primary care, specialty, hospital and
community settings in various countries.
From the original database searches, 35 studies were selected using inclusion and
exclusion criteria to be hand-examined to determine if they addressed PICOT elements through

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review of article title and abstract. After critical appraisal of 35 studies, eleven have been chosen
for inclusion in this literature review. From the 35, those excluded were impertinent to this
review (studies of technology-based interventions), included interventions that did not meet
criteria, or were not feasible. The studies included in the review evaluated the relationship
between asthma management or written asthma action plans and various patient health outcomes,
ER/acute appointment utilization, provider ability to educate patients, and/or medication
compliance (Appendix A).
Critical Appraisal and Synthesis of Evidence
The eleven studies selected were analyzed using Melnyk & Fineout-Overholt (2015)
rapid critical appraisal and are presented in evidence tables for analysis of data (Appendix A).
Three studies were level I evidence (well-designed systematic reviews), three studies were level
II evidence (well-designed randomized controlled trials), three level III evidence (not multi-site
studies), one was level IV evidence (questionnaire study), and one was level VI (longitudinal,
retrospective study). The level IV evidence provided insight to caregiver understanding of
WAAP in multiple primary care clinics and differences in outcomes in patients who receive a
WAAP or not (Tan et al., 2013). The level VI evidence evaluated the effectiveness of a
comprehensive asthma wellness program (CAWP) in reducing acute healthcare utilization (Safi
et al., 2016). All but one of the studies measured acute healthcare utilization in some manner,
either ER/urgent care visits, unscheduled doctor appointments, or hospitalizations (Appendix A).
Other measurements included various tools to quantify asthma control, asthma quality of life,
symptom days, peak expiratory flow, or medication compliance. Four of the RCTs and the
questionnaire study performed a power analysis to determine adequate sample size and one of
the studies had a 0% attrition rate. Many of the controlled trials utilized a large sample size and

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an adequate number of studies/participants were included in the SRs (Appendix A). All
studies/reviews required a medical diagnosis of asthma and excluded airway symptoms caused
by other diagnoses. All studies also addressed asthma education and patient-specific outcomes.
Several studies documented use of standardized tools for measurement such as the
Asthma Control Test (ACT), Asthma Quality of Life Questionnaire, and/or Pediatric Caregivers
Quality of Life Questionnaire. The use of these standardized tools suggests reliability and
validity of statistically significant data outcomes. Most of the studies were of high quality,
documenting specific confidence intervals (CI), means, level of significance (p), and/or
covariance (F). The two RCTs that were not double-blinded identified the difficulty in blinding
participants because of study design, one evaluating providers ability to provide hypothetical
patient education based on low-literacy WAAP or standard WAAP and the other attributed
single-blind design to limited resources (Appendix A).
A strong degree of homogeneity was recognized in patient age, only one included adult
patients in addition to pediatric patients in the analysis, however several studies included
information about the caregivers in addition to the pediatric patients. Overall demographics are
very heterogenous, including patients in rural locations and more urban areas, offering education
and interventions in schools, hospitals, and outpatient clinics to underserved populations and
those with access to subspecialists. Despite the heterogeneity of the study locations and
demographics, the consensus in findings suggests that most of the results of the studies should be
transferable. Overall, descriptive definitions of interventions and analysis allow for replication
and implementation.
There was a moderate degree of heterogeneity in interventions applied, ranging from
nurse-led or pharmacist-led education sessions, to in-school and day camp education sessions, to

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varying degrees of WAAP use. All of the studies addressed asthma education in some manner
and five of these demonstrated a statistically significant decrease in acute healthcare utilization
and another demonstrated a non-significant decrease in acute healthcare utilization (Appendix
B). Other outcomes measured had a great heterogeneity and included patient-specific outcomes,
cost-effectiveness, Quality of Life (QoL), and medication adherence. One study was included
that varied greatly from the group, to address the impact of using low-literacy WAAP on
provider explanations during asthma education. No study could be found that assessed the impact
of this intervention on healthcare utilization or other outcomes (Appendix B).
Conclusions
The most consistent outcome across all studies was that an education intervention, when
utilized correctly, decreases the use of acute healthcare services. Although not all studies
demonstrated statistically significant results, most of them indicated a negative trend in acute
healthcare utilization, when it was measured. Overall, provision of a thorough educational
program and/or use of a WAAP are both cost- and time- effective and lead to increased patient
outcomes and decreased healthcare costs. The Global Initiative for Asthma (GINA) 2018
guidelines cite age-appropriate asthma education, including instruction on device usage, and
asthma action plans as appropriate interventions to improve asthma management. These
guidelines are reinforced by information obtained from the literature review. Data collected
suggests that not all providers are providing this education or utilizing asthma action plans with
all pediatric asthma patients.
Purpose Statement
The purpose of this project was to establish consistent guidelines and interventions for
the management of asthma, to educate clinic staff on interventions and education materials which

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are suitable for implementation in a pediatric primary care setting, and to improve adherence to
and documentation of appropriate asthma interventions and inhaler/spacer education. Key
stakeholders include the staff of the pediatric clinic, administration of the medical group, and the
patients and their families. The providers, nurses, and technicians will expand their knowledge of
asthma management strategies while patients and their families will benefit from evidence-based
asthma care. The desired outcome and possible benefit, according the current literature, is a
reduction in acute healthcare utilization and overall improved quality of life experienced by the
patients (Appendix B).
Study Questions
•

Does a provider education intervention improve the likelihood of providers to follow the
Veterans Affairs/Department of Defense (VA/DoD) Clinical Practice Guideline?

•

Does a staff education intervention increase the likelihood that spacer/inhaler instruction
will be provided?

•

Does a provider education intervention increase the use of a written asthma action plan?

•

Does a staff education intervention increase the use of the Asthma Control Test tool?

•

Does a provider education intervention combined with a patient/family education
intervention decrease the overall utilization of acute healthcare services?
Conceptual Framework and Theoretical Model for Project Development
Bruhn’s theoretical framework for asthma self-management will guide the development

of an educational intervention at a military, pediatric primary care clinic in southwest Arizona
(Bruhn, 1983). This model attempts to explain the multifactorial influences of family, support
system, healthcare utilization, health attitudes, health beliefs, general health needs, and specific
illness needs. The model emphasizes the interaction of these concepts and the need to assess and

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re-assess a patient’s situation to provide the best care possible. The factors mentioned can change
and evolve, thus contributing to a compliant patient becoming non-compliant. The model stresses
the importance of considering the whole picture to promote self-management and overall health.
Military institutions favor a step-wise and organized method for process improvement
and change initiatives. The model for evidence-based practice change by Larabee (2009) will be
utilized to implement the quality improvement project. This model identifies six steps for
practice change; assess the need for change, locate the best evidence, critically analyze the
evidence, design the practice change, implement and evaluate the change in practice, and
integrate and maintain the change in practice (Appendix C). This model emphasizes deliberate
project development and a step-wise approach to facilitate the practice change. Utilizing this
model, a need for change in pediatric asthma education was identified, stakeholders were
included (providers, management, and staff) and evidence was identified and analyzed
(Appendix A & B). Stakeholders were involved throughout the practice change design,
implementation and evaluation. Finally, based on results obtained from the practice, the practice
change will be implemented or adapted as a part of standard care at this clinic.
Project Methods
Ethical Considerations
Protection of human subjects was ensured through appropriate training of all
investigators through Collaborative Institutional Training Initiative (CITI) and approval through
Arizona State University (ASU) Institutional Review Board (IRB). There was no collection of
identifying information during the chart review process. Data collected through chart review
included age and gender of the patient, type of healthcare provider, and compliance with specific
asthma interventions. Pediatric clinic staff provided consent through receipt of an email

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invitation to the education session and participation in said session. Permission to implement the
quality improvement project was obtained from the practice site (Appendix D). Approval for the
project was received from ASU IRB on November 30, 2018 (Appendix E).
Setting and Organizational Culture
This project was implemented in a military, pediatric primary care clinic in southwest
Arizona. The surgeon general of the hospital (SGH) and chief nurse within the medical group are
both supportive of the quality improvement project. The electronic health record used in the
clinic is AHLTA which allows for retrieval of needed data.
Participants
The entire staff of the pediatric clinic was invited to participate in the educational
intervention, as well as the SGH and chief nurse of the medical group. Participation included
four physicians (3 MDs and 1 DO), two nurse practitioners, two nurses, and four technicians.
There were eight women and four men.
Intervention
Intervention design focused on discussion of relevant asthma guidelines and the
importance of certain asthma interventions on overall asthma self-management. The session also
included content on appropriate documentation and coding of asthma interventions to ensure
appropriate billing abilities. Clinic staff members were reminded of the impact of appropriate
self-management on overall asthma control and related utilization of acute healthcare services.
Pediatric primary care providers can improve asthma management and reduce ER/urgent care
utilization by employing an asthma action plan and by making easy to understand, robust, ageappropriate education available to all asthma patients and parents.

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Outcome Measures
Retrospective chart reviews (RCR) were used to evaluate the effect of the education
intervention on the likelihood to use the ACT, WAAP, and provide inhaler/spacer education.
RCR are considered inferior to prospective study design but are appropriate in certain
circumstances. Advantages of this study design include low cost, use of existing records, and
potential to lead to hypothesis for further evaluation which can be completed with prospective
design (Hess, 2004). Some disadvantages of RCR include relying on the accuracy of
documentation by others, there is no randomization or blinding, and it is difficult to establish
cause and effect (Hess, 2004).
Data Collection and Analysis
Effective retrospective chart reviews must include well-defined research questions, have
operationalized variables, use of a standardized abstraction forms, and clearly developed
inclusion and exclusion criteria (Matt & Matthew, 2013). A standardized abstraction form was
developed and used in data collection for pre- and post- intervention charts. Inclusion criteria for
this project were charts for all pediatric clinic patients seen during a 30-day period, with any
reactive airway or asthma diagnosis. These diagnoses included J45.20, J45.21, J45.22, J45.30,
J45.31, J45.32, J45.40, J45.41, J45.42, J45.50, J45.51, J45.52, J45.901, J45.902, J45.909,
J45.990, J45.991, and J45.998. Charts were selected from a 30-day period one year before the
intervention (January 24 – February 23, 2018) and a 30-day period immediately following the
intervention (January 24 – February 23, 2019).
Data extracted during the RCR will be input into IBM SPSS Statistics 24 for data
analysis. The nature of the data will allow for descriptive statistics as well as Mann Whitney U

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for determining relationships between variables. A Cohen’s d was performed to determine the
effect size. Pearson correlation was calculated to determine correlation between variables.
Outcomes
Demographics
Group One: Pre-Intervention.
Charts included in the analysis were selected from a timeframe of January 24, 2018 until
February 23, 2018 (n = 33). The average age of the pediatric patients was 10 years of age (SD =
3.30 years of age). Their ages ranged from three to seventeen years of age (Appendix F). The
sample consists of primarily males, n = 22 (67%) and the remainder were female, n = 11 (33%).
The charts were divided among three different types of healthcare provider of record: medical
doctor (n = 14), doctor of osteopathic medicine (n = 5), and pediatric nurse practitioner (n = 14).
Group Two: Post-Intervention.
Charts included in the analysis were selected from a timeframe of January 24, 2019 until
February 23, 2019 (n=18). The average age of the pediatric patients was 8 years of age (SD =
3.43 years of age). Their ages ranged from two to twelve years of age (Appendix F). The sample
consists of primarily males, n = 13 (72%) and the remainder were female, n = 5 (28%). The
charts were divided among two different types of healthcare provider of record: medical doctor
(n = 9) and pediatric nurse practitioner (n = 9).
Statistical Significance
Written Asthma Action Plan.
Prior to the asthma education intervention, a WAAP was only used in 11 of the 32 cases.
After the intervention, a WAAP was used in 13 of the 18 cases. A Mann-Whitney U test was
calculated examining the use of WAAP with and without asthma education intervention. Charts

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completed after attending the asthma education session demonstrated a statistically significant
higher use of WAAP (U = 0.008, p < 0.05) than those completed prior to the asthma education
session. Cohen’s effect size value (d = 0.83) also suggested a strong clinical significance
(Appendix G).
Asthma Control Test and Inhaler/Spacer Instruction.
Prior to the asthma education intervention, the ACT tool was only used in 9 of 33 charts,
while after the intervention it was used in 9 of the 18 cases. While inhaler/spacer instruction was
documented in 8 of the 33 charts prior to the intervention and in only 2 of the charts after the
intervention, demonstrating a reduction in inhaler/spacer instruction. A Mann-Whitney U test
was calculated examining the use of ACT with and without asthma education intervention.
Charts completed after attending the asthma education session demonstrated a higher use of
ACT, although not statistically significant (U = 0.108, p < 0.05) than those completed prior to
the asthma education session (Appendix G).
Clinical Significance
Although the Mann Whitney U did not demonstrate a significant improvement in use of
ACT after the asthma education intervention, the intervention did demonstrate a positive
influence on this variable. Cohen’s effect size value (d = 0.48) suggested a moderate clinical
significance. A Pearson correlation coefficient was calculated for the relationship between use of
ACT tool and use of WAAP. A moderate positive correlation was found (r (49) = .372, p < .01),
indicating a significant linear relationship between the two variables. Providers who documented
use of the ACT tool were more likely to document use of the WAAP (Appendix G).

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Clinical Implications
Impacts of Project
Both patients, providers, and administrative will see far reaching positive outcomes from
the implementation of this intervention. Patients and their families will also benefit from a more
in-depth understanding of the asthma diagnosis. Secondary gains could include improved
management of asthma symptoms, improved Asthma Control Test (ACT) scores, improved
school attendance, and improved QoL. Providers also have the opportunity to positively impact
the health management of children with a chronic illness and impower the child and parent to
improve their self-management skills. Since some of the outcomes were found to be clinically
and statistically significant, providers and administration could benefit from data that supports
the implementation of a part-time or full-time pediatric asthma educator. Data is still being
collected to determine if utilizing written asthma action plans and providing in-depth, ageappropriate asthma education leads to decreased ER and urgent care utilization, the long-term
outcome of interest.
Sustainability
Since the focus of this project is implementing screening tools, interventions and patient
education in line with all current guidelines for the management of pediatric asthma,
continuation of these components is consistent with best-practice. The project was well received
by the practice site and staff members were willing to share feedback throughout the process.
The administration within the clinic is supportive of the project and would like to see the
education continued during unit meetings or huddles on an interval schedule. The staff of the
pediatric clinic will be left with a quick-reference card, based on feedback, that lists basic
recommendations and relevant coding numbers. Implementation of the recommended

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interventions during asthma visits does not place a financial burden on the clinic, and could
actually result in higher billing. The administration is also interested in further data and longterm effects to support hiring an asthma educator.
Strengths and Limitations
Retrospective chart reviews have several disadvantages, one of which is relying on others
documentation to retrieve data. In this quality improvement project, subjective information
gathered during time in the clinic does not correlate with data extracted from RCR. Technicians
and healthcare providers report a high rate of inhaler/spacer instruction, which was not
demonstrated during data analysis. One explanation for this discrepancy is that the billing code
and related note were not entered by clinic staff, despite delivery of this education. A quickreference card will be provided to clinic staff to encourage future documentation. RCR allows
for inexpensive retrieval of information to determine correlation and suggest hypotheses for
further research, which was appropriate for this project.
Delivery of an education session to encourage adherence with pediatric asthma
management interventions demonstrated some statistically significant improvement in care
delivery. Evidence demonstrates that use of the ACT tool, WAAP, and inhaler/spacer instruction
at every visit improves patient self-management of asthma symptoms and decreases overall acute
healthcare utilization. While the study period was too short to demonstrate decreased acute
healthcare utilization, it did demonstrate a significant improvement in use of WAAP and a
clinically significant effect on use of the ACT tool. Documentation inconsistencies were believed
to contribute to the lack of statistically significant changes in inhaler/spacer instruction. This
project is a cost-effective method to improve delivery of evidence-based practice and potentially
impact the long-term management of a chronic pediatric illness.

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Elsevier.
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Kuethe, M. C., Vaessen-Verberne, A. A. P. H., Elbers, R. G. & Van Aalderen, W. M. C. (2013).
Nurse versus physician-led care for the management of asthma. Cochrane Database of
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Marcano-Belisario, J. S., Huckvale, K., Greenfield, G., Car, J., & Gunn, L. H. (2013).
Smartphone and tablet self management apps for asthma. Cochrane Database of
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Matt, V. & Matthew, H. (2013). The retrospective chart review: important methodological
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healthcare: A guide to best practice. Philadelphia, PA: Wolters-Kluwer.
Olivera, C. M. X., Vianna, E. O., Bonizio, R. C., de Menezes, M. B., Ferraz, E., Cetlin, A. A., . .
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publications/st472/stat472.pdf
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IMPROVING PEDIATRIC ASTHMA MANAGEMENT

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Appendix A
Evaluation Table

Citation

Theory/
Conceptual
Framework

Design/ Method

Sample/ Setting

Major Variables
& Definitions

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Belice (2017)
Effective
education
parameters for
trigger
remediation in
underserved
children with
asthma: A
systematic
review

PRISMA
flowchart for
study selection

Systematic
Review

N = 17
n = 3278
children

IV- Asthma
education

EPR-3
guidelines to
measure asthma
control

Systematic data
extraction by
one author,
verified by a
second

DV1 – 14
studies
demonstrated SS
decreased in
healthcare
utilization

Chicago, IL
Funded as part
of the Building
Healthy
Communities
Project by BMO
Harris Bank
No bias stated or
found

Purpose: To
identify common
educational
parameters of
existing multitrigger, multicomponent
educational
intervention
approaches

Inclusions:
peer-reviewed
research articles
that address
asthma
education
components
Exclusions:
incorrect
population;
opinion or
editorial; not
research-based;
lacked
educational
component; no
intervention;
qualitative study

DV1 healthcare
utilization
DV2 - asthma
control
DV3 medication use
DV4 - home
environment
DV5 – QoL
and other
components

Healthcare
utilization by
urgent or
unscheduled
clinic visits, ER
visits, or
hospitalizations

Although DV2DV5 were said
to be analyzed –
no data was
given; authors
site lack of EPR3 guidelines as
one barrier and
discuss that all
but one study
evaluated
healthcare
utilization
making it the
most broad
measure to
discuss

Level/Quality of
Evidence;
Application to
practice
Level I
Strength – SR
of multiple
databases
Weakness –
included studies
prior to EPR-3
guidelines which
emphasized
education
Conclusion –
multicomponent
home-based
interventions
showed mixed
results
Feasibility –
limited support
and too complex
to implement in
project

Key: ACT score – asthma control test; CG – control group; DV – dependent variable; ER – emergency room; ES – effect size; ICS – inhaled corticosteroid; IG –
intervention group; IV – independent variable; N – number of studies; n – number of subjects; NIH -National Institute of Health; NINR – National
Institute of Nursing Research; NHLBI – National Heart, Lung, & Blood Institute; outpt – outpatient; PEFR – peak expiratory flow rate; QoL – quality of
life; RCT – randomized controlled trial; SS – statistically significant;WAAP – written asthma action plan

IMPROVING PEDIATRIC ASTHMA MANAGEMENT
Citation

Theory/
Conceptual
Framework

Design/ Method

Sample/ Setting

Major Variables
& Definitions

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Bhogal (2006)
Written action
plans for asthma
in children:
Review

Cochrane
methods of
systematic
review

Systematic
Review

N=4
n = 355 children

PEF was used to
quantify asthma

Purpose: To
evaluate the
independent
effect of
providing versus
not providing a
written action
plan in
children and
adolescents with
asthma and to
compare the
effect of
different written
action plans.

Inclusions:
RCTs that
compared a
WAAP with no
WAAP or that
compared two
different types
of WAAP

IV- WAAP
DV1 - acute care
visits for asthma
exacerbation
DV2 symptomatic
days per week
DV3 exacerbation
requiring oral
steroids or
admission
DV4 - school
absenteeism
DV5 –
lung function
DV6 - symptom
score
DV7 - QoL

Two authors
independently
selected the
trials, assessed
quality, and
extracted the
data; additional
info was
collected by
contacting
original study
authors;
followed
Cochrane
methods of
systematic
review

DV1 –
symptom-based
WAAP had
lower risk (RR
0.73, 95% CI)
NNT to prevent
one acute care
visit was 9
DV2 – peakflow based
WAAP showed
reduction by ½
day (N=2, mean
difference 0.45
days/week, 95%
CI)

Canada
None reported
Ducharme has
received funding
in the past from
Glaxo Wellcome
and Astra
Zeneca and
presented at a
conference
supported by
Merck Frost.
Bhogal and
Zemek report no
conflict of
interest.

Exclusions:
intervention of
interest
something other
than WAAP;
non-RCT;
participants were
adult without
subgroup
analysis of
pediatric
participants

Trials were
combined using
RevMan
analyses

DV3-DV7 – no
significant group
differences
found

Level/Quality of
Evidence;
Application to
practice
Level I

24

Strength –
Cochrane
method of
systematic
review; analyzed
multiple types of
WAAP
Weakness –
only 4 studies;
inconsistent
reporting of
adherence to
monitoring; no
RCT evaluated
if WAAP is
effective
addition to
pediatric asthma
education
Conclusion –
symptom-based
WAAPs are
superior in
preventing acute
care visits
Feasibility –
Supports use of
symptom-based
WAAP; easy to
use; costeffective

Key: ACT score – asthma control test; CG – control group; DV – dependent variable; ER – emergency room; ES – effect size; ICS – inhaled corticosteroid; IG –
intervention group; IV – independent variable; N – number of studies; n – number of subjects; NIH -National Institute of Health; NINR – National
Institute of Nursing Research; NHLBI – National Heart, Lung, & Blood Institute; outpt – outpatient; PEFR – peak expiratory flow rate; QoL – quality of
life; RCT – randomized controlled trial; SS – statistically significant;WAAP – written asthma action plan

IMPROVING PEDIATRIC ASTHMA MANAGEMENT
Citation

Theory/
Conceptual
Framework

Design/ Method

Sample/ Setting

Major Variables
& Definitions

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Horner (2016)
Enhancing
asthma selfmanagement in
rural schoolaged children: A
randomized
controlled trial

Bruhn’s
theoretical
model of asthma
selfmanagement

longitudinal
RCT comparing
2 modes of
intervention
delivery with a
control group

n=257
IG1 n=84
IG2 n=89
CG n=84

16-item home
management
survey

Latent growth
curve modeling
in SAS 9.3

Purpose: To test
the effects of 2
modes of
delivering an
asthma
educational
intervention on
health outcomes
and asthma selfmanagement in
school-aged
children who
live in rural
areas.

Setting: schoolaged children
(grades 2-5) in
33 schools in 5
rural Texas
school districts

IV- Asthma Plan
for Kids
curriculum
(delivered in
school or oneday asthma
camp)
DV1- office
visits
DV2 - ED visits
DV3 hospitalizations
DV4 –
Asthma severity
DV5 – airway
inflammation
and medication
adherence to
ICS

Number of
inhaler
actuations/prescr
ibed dose over
2-week period

DV1 – F(1504)
= 3.94, p=0.048
for asthma class
DV2 – F(1509)
= 3.99, p =
0.046 for asthma
camp
DV3 – F(1266)
= 15.65,
p<0.001 for all
groups; no
significant
difference in
decrease in
hospitalizations
across groups
DV4 – F(1266)
= 43.05, p <
0.001 across
groups; F(1510)
= 8.28, p =
0.004 group
effect for asthma
class
DV5 – no
significant
change; seasonal
effect in Spring
and Winter
(pollen peaks in
TX)

Austin, TX
Grant funding
from the NIH,
NINR, and
NHLBI
Bias – none

Mean age: 8.79

Inclusions:
asthma diagnosis
on school
record; current
asthma
symptoms in the
last 12 mo;
speak either
English or
Spanish; no
significant comorbidity
Attrition:
12.3%

13-item Asthma
Inventory for
Children

RTubeTM

Level/Quality of
Evidence;
Application to
practice
Level II

25

Strength – low
attrition rate;
calculate effect
size and did
power analysis;
guided by
nursing model
Weakness –
limited
generalizability
due to small
region used;
control group
still received
health promotion
education
Conclusion –
increased
education led to
decreased
asthma
symptoms,
better control, &
less ED/hospital
use
Feasibility –
day camp is less
cost-effective
but otherwise
feasible

Key: ACT score – asthma control test; CG – control group; DV – dependent variable; ER – emergency room; ES – effect size; ICS – inhaled corticosteroid; IG –
intervention group; IV – independent variable; N – number of studies; n – number of subjects; NIH -National Institute of Health; NINR – National
Institute of Nursing Research; NHLBI – National Heart, Lung, & Blood Institute; outpt – outpatient; PEFR – peak expiratory flow rate; QoL – quality of
life; RCT – randomized controlled trial; SS – statistically significant;WAAP – written asthma action plan

IMPROVING PEDIATRIC ASTHMA MANAGEMENT
Citation

Theory/
Conceptual
Framework

Design/ Method

Sample/ Setting

Major Variables
& Definitions

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Khan (2014)
Effectiveness of
personalized
written asthma
action plans in
the management
of children with
partly controlled
asthma in
Trinidad: A
randomized
controlled trial

Biophysical
model

RCT – singleblinded

n=91
IG n=45
CG n=46

IVindividualized
WAAP
DV1 ER revisits for
acute asthma
care
DV2 - number
of acute asthma
events
DV3 - repeated
ER visit rates (2
or more)
DV4 - number
of asthma
attacks
DV5 - -number
of unscheduled
doctor visits
DV6 - number
of school days
missed
DV7 - number
of night-time
awakenings with
symptoms
DV8 – mean
change in PEFR

# of ER visits

X2 test

# of acute
asthma attacks

Mann-Whitney
U-test

# of unscheduled
doctor visits

Wilcoxon signed
ranks test

DV1 Reduced in both
groups (p =
0.005 & 0.0002)
DV2 – reduced
in both groups (p
= 0.0064 &
0.0006)
DV3 – lower in
IG but not SS
(p=0.374)
DV4 - lower in
IG but not SS
(p=0.399)
DV5 - lower in
IG but not SS
(p=0.690)
DV6 - lower in
IG but not SS
(p=0.280)
DV7 - lower in
IG but not SS
(p=0.480)
DV8 – better in
IG but not SS
(p=0.457 at 3mo visit and
p=0.866 at 6-mo
visit)

Mt Hope,
Trinidad
Self-funded
Bias – several
potentials for
bias were
addressed and
controlled within
the study

Purpose: To
evaluate the
effectiveness of
adding a
personalized
WAAP in the
treatment of
children with
partly controlled
asthma

Mean age: 6
Setting:
pediatric clinic
at Chaguanas
Health Facility
Inclusions:
partly controlled
asthma; history
of ER/acute care
visit in past
6mo; ability of
child/parent to
follow written
directions
Exclusions:
Uncontrolled
asthmatics; comorbid resp
illness; prior
asthma
education; prior
enrollment in
similar study;
care sought
outside of
Chaguanas
Attrition: 0%

# of missed
school days
# of nighttime
awakenings with
symptoms
PEFR
measurement

Level/Quality of
Evidence;
Application to
practice
Level III – not
multi-site

26

Strength – did
power analysis
& calculated ES;
intentional bias
control;
consistent
follow-up;
blinding of
outcome
assessor
Weakness –
limited
generalizability,
study conducted
in Trinidad;
small sample
size; nonconcealment of
allocation to
paediatrician
Conclusion –
better outcomes
were associated
with use of a
WAAP
Feasibility –
cost-effective
and easy to
implement

Key: ACT score – asthma control test; CG – control group; DV – dependent variable; ER – emergency room; ES – effect size; ICS – inhaled corticosteroid; IG –
intervention group; IV – independent variable; N – number of studies; n – number of subjects; NIH -National Institute of Health; NINR – National
Institute of Nursing Research; NHLBI – National Heart, Lung, & Blood Institute; outpt – outpatient; PEFR – peak expiratory flow rate; QoL – quality of
life; RCT – randomized controlled trial; SS – statistically significant;WAAP – written asthma action plan

IMPROVING PEDIATRIC ASTHMA MANAGEMENT
Citation

Theory/
Conceptual
Framework

Design/ Method

Sample/ Setting

Major Variables
& Definitions

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Kuethe (2013)
Nurse versus
physician-led
care for the
management of
asthma

Cochrane
methods of
systematic
review

Systematic
Review

N=5
n = 588 adults
and children

IV – nurse-led
asthma
management
DV1 – patientrelated outcomes
(exacerbations,
asthma
symptoms)
DV2 - health
economic
outcomes
DV3 - objective
measures of lung
function, airway
reactivity, and
inflammation.

ACT or Asthma
Control
Questionnaire
(ACQ)

Standard
methodological
procedures
expected by
Cochrane
Collaboration;
two review
authors
independently
screened all
studies identified
by search
strategy &
independently
assessed each
study based on
pre-defined
criteria

DV1 – No SS
difference in
exacerbations
between groups
(OR 0.86; 95%
CI, p=0.674);
No SS
difference
between groups
in ACQ scores
(physician led
group p=0.18
and nurse led
group p=0.28)
DV2 – SS lower
cost in nurse-led
group
(EURO156 in
nurse-led,
EURO 189 in
physician-led,
p<0.001)
DV3 – no SS
differences
between groups

Netherlands
No funding
reported
No bias reported

Purpose: To
determine the
effectiveness of
nurse-led asthma
care provided by
a specialized
asthma nurse, a
NP, a PA or an
otherwise
specifically
trained nursing
professional,
working
relatively
independent
from a
physician,
compared to
traditional care
provided by a
physician.

Setting: primary
care and hospital
Inclusions:
RCTs
Exclusions: not
related to nurseled care; not
related to
follow-up; cointerventions
present that
distracted from
objective of
review or had no
clear diagnosis
of asthma

Asthma Quality
of Life
questionnaire

RevMan 2008

Level/Quality of
Evidence;
Application to
practice
Level I

27

Strength –
Cochrane SR;
reviews option
that may be
more costeffective
Weakness –
only 5 studies
Conclusion –
No significant
difference
between nurseled and
physician-led
care; nurse-led
care may be
appropriate in
pts with wellcontrolled
asthma
Feasibility –
cost-effective;
supports use of
additional
personnel in
management of
asthma pts

Key: ACT score – asthma control test; CG – control group; DV – dependent variable; ER – emergency room; ES – effect size; ICS – inhaled corticosteroid; IG –
intervention group; IV – independent variable; N – number of studies; n – number of subjects; NIH -National Institute of Health; NINR – National
Institute of Nursing Research; NHLBI – National Heart, Lung, & Blood Institute; outpt – outpatient; PEFR – peak expiratory flow rate; QoL – quality of
life; RCT – randomized controlled trial; SS – statistically significant;WAAP – written asthma action plan

IMPROVING PEDIATRIC ASTHMA MANAGEMENT
Citation

Theory/
Conceptual
Framework

Design/ Method

Sample/ Setting

Major Variables
& Definitions

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Olivera (2016)
Asthma selfmanagement
model:
randomized
controlled trial

Asthma selfmanagement
model and
Wilkinson’s
learning
methodology

Longitudinal,
prospective RCT

n = 119
IG n = 59
CG n = 60

IV- pharmacistled selfmanagement
meetings, onehour length,
monthly for four
months
DV1 - asthma
knowledge
DV2 - inhaler
handling
DV3 medication
adherence
DV4 pulmonary
function
DV5 - QoL

34-item
questionnaire

Means of tables

DV1 –
statistically
significant
increase in
knowledge (p <
0.0001)
DV2 –
significant intraand intergroup
increase in
correct inhaler
handling (p <
0.0001)
DV3 –
significant
increase in
adherence in IG
(p = 0.0113)
DV4 – increase
in mean forced
vital capacity in
IG (p = 0.0287)
DV5 – increased
QoL in IG, not
in CG

Sao Paulo,
Brazil
Supported by
‘Coordenacao de
Aperfeiccoamen
to de Pessoal de
Nivel Superior CAPES’ and
‘Fundacao de
Amparo a
Pesquisa do
Estado de Sao
Paulo –
FAPESP’, Brazil
(a federal,
postgraduate
education
agency and a
public research
foundation)
No bias
identified

Purpose: To test
an original selfmanagement
model directed
at the asthmatic
population

Setting: outpt
asthma clinic,
University
Hospital
Inclusions:
asthmatic pts
with different
degrees of
disease severity;
access to public
health system;
without
cognitive
diseases that
would impair
participation in
the study
Exclusions:
occurrence of
severe adverse
events; inability
to execute the
protocol; having
conditions that
may affect the
results of the
study; nonadhesion to
clinical protocol

Inhaler use
evaluated by a
validated tool
(not named)
Morisky-Green
test &
prescription
renewal tracking
Spirometry with
Koko spirometer
and its
programme
Outcomes
Studies 36-item
short form
survey with
certified
translation to
Portugese

Mixed-effects
linear regression
models
SAS version 9.0
Fisher’s exact
test
R programme
for graph
construction

28

Level/Quality of
Evidence;
Application to
practice
Level III – single
site

Strength –
consistent preand postassessments by
one investigator;
multi-disciplinary
Weakness –
limited
generalizability,
conducted at one
site in Sao Paulo,
Brazil; singleblind study
Conclusion –
asthma selfmanagement
programs are
effective in
improving
outcomes and
QoL
Feasibility –
cost-effective,
requires multidisciplinary
inclusion

Key: ACT score – asthma control test; CG – control group; DV – dependent variable; ER – emergency room; ES – effect size; ICS – inhaled corticosteroid; IG –
intervention group; IV – independent variable; N – number of studies; n – number of subjects; NIH -National Institute of Health; NINR – National
Institute of Nursing Research; NHLBI – National Heart, Lung, & Blood Institute; outpt – outpatient; PEFR – peak expiratory flow rate; QoL – quality of
life; RCT – randomized controlled trial; SS – statistically significant;WAAP – written asthma action plan

IMPROVING PEDIATRIC ASTHMA MANAGEMENT
Citation

Theory/
Conceptual
Framework

Design/ Method

Sample/ Setting

Major Variables
& Definitions

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Safi (2016) A
comprehensive
pediatric asthma
management
program reduces
emergency
department visits
and
hospitalizations.

Asthma selfmanagement
model

Longitudinal,
retrospectice
study

n = 172

IVcomprehensive
program that
includes initial
clinical
assessment,
frequent followup, asthma
education,
facilitation of
support services,
and clinical
monitoring of
outcomes;
optional in-home
allergen
assessments

Review of charts
over 9 year
period

Wilcoxon
matched-pairs
signed-rank test;
mean & median

Preprogram
DV1 – 0.99
DV2 – 1.19
DV3 – 3.61

Ann Arbor, MI
Supported by the
University of
Michigan School
Department of
Pediatrics and
Communicable
Diseases
No bias
identified

Purpose: To
assess the
effectiveness of
the Children’s
Asthma
Wellness
Program
(CAWP) in
reducing ED
visits/hospitaliza
tions and
improving
asthma
management

Setting: outpt
asthma clinic
Program
Inclusions: age
36 months to 18
years; at least
one recent ED
visit or
hospitalization
due to acute
asthma
symptoms
Program
Exclusions:
asthma
symptoms
caused by
diagnosis other
than asthma,
such as recurrent
aspiration or
airway malacia
Study
Exclusion:
patients without
1-2 yrs of preand postprogram data
available

DV1 - ED visits
DV2 –
hospitalizations
DV3 hospitalization
days

Postprogram
DV1 – 0.23
DV2 – 0.14
DV3 – 0.34
P<0.0001

Level/Quality of
Evidence;
Application to
practice
Level VI

29

Strength –
limited analysis
to pts with 1-2
yrs of pre- and
post- data
Weakness –no
consideration of
QoL, pulmonary
function, asthma
control test
scores or steroid
use; possibly
missing data
from care at
outside hospitals
Conclusion –
demonstrates +
effect of
program on ED
/hospital use
Feasibility –
implementation
of entire
program would
be costly and not
time effective,
but one part is
intense asthma
and device use
education

Key: ACT score – asthma control test; CG – control group; DV – dependent variable; ER – emergency room; ES – effect size; ICS – inhaled corticosteroid; IG –
intervention group; IV – independent variable; N – number of studies; n – number of subjects; NIH -National Institute of Health; NINR – National
Institute of Nursing Research; NHLBI – National Heart, Lung, & Blood Institute; outpt – outpatient; PEFR – peak expiratory flow rate; QoL – quality of
life; RCT – randomized controlled trial; SS – statistically significant;WAAP – written asthma action plan

IMPROVING PEDIATRIC ASTHMA MANAGEMENT
Citation

Theory/
Conceptual
Framework

Design/ Method

Sample/ Setting

Major Variables
& Definitions

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Sheares (2015)
Do patients of
subspecialist
physicians
benefit from
written asthma
action plans?

Biophysical
model

Prospective,
RCT with
parallel groups;
randomized
block, mixedeffects factorial
design was used,
as doubleblinding was not
possible

n = 407
IG n =204 (141
children)
CG n =203 (131
children

IV- WAAP
DV1 - asthma
symptoms
frequency
DV2 - ER visits
for asthma
DV3 - asthma
QoL
DV4 hospitalizations
DV5 - days with
activity
limitation

3-item
questionnaire
about asthma
symptoms

Poisson
regression
analysis

DV1 - both
groups
demonstrated a
significant
reduction in all
three asthma
symptom
variables
(p<0.0001); no
significant
difference
between groups
DV2 –
significant
reduction in ER
visits for asthma
in both groups
(p<0.0001 for
IG & p=0.0006
for CG)
DV3 -no
between group
differences in
PACQOL but a
significant
increase in
scores in both
groups
(p<0.0001)
DV4 – no
significant
reduction
DV5 –
significant
decrease in both
groups

New York, NY
NIH/NHLBI
grant and the
National Center
for Advancing
Translational
Sciences, NIH
Bias: Patients
recruited to the
study were being
seen by
subspecialists,
not primary care

Purpose: To
assess the
efficacy of
written
instructions in
the form of a
WAAP provided
by subspecialist
physicians as
part of usual
asthma care
during office
visits.

Setting: seven
hospital-based
subspecialty
clinics in New
York City; 5 of
which served
primarily
minority patients
Inclusions: new
patients to the
practice, never
seen by a
subspecialist
before, never
received a
WAAP
Exclusions:
comorbid
condition
affected lung
health
Attrition:
20.6%

Juniper Mini
Asthma QoL
Questionnaire
for adult patients
Pediatric
Asthma
Caregivers QoL
(PACQOL)
Questionnaire
for pediatric
patients
3-item
questionnaire
regarding
WAAP

Linear
regression
analysis
Paired t-test
Chi-squared test
Fisher exact test
SAS 9.2

Level/Quality of
Evidence;
Application to
practice
Level II

30

Strength –
power analysis
was conducted
Weakness –only
included
subspecialists;
limited
demographic
variability
Conclusion –
considering pts
treated by a
subspecialist,
there was no
significant
difference noted
between groups
provided with a
WAAP & those
who received
provider
instruction only.
Feasibility – use
of a WAAP or
provider-based
instruction is
feasible;
sometimes
referral to a
subspecialist is
not available

Key: ACT score – asthma control test; CG – control group; DV – dependent variable; ER – emergency room; ES – effect size; ICS – inhaled corticosteroid; IG –
intervention group; IV – independent variable; N – number of studies; n – number of subjects; NIH -National Institute of Health; NINR – National
Institute of Nursing Research; NHLBI – National Heart, Lung, & Blood Institute; outpt – outpatient; PEFR – peak expiratory flow rate; QoL – quality of
life; RCT – randomized controlled trial; SS – statistically significant;WAAP – written asthma action plan

IMPROVING PEDIATRIC ASTHMA MANAGEMENT
Citation

Theory/
Conceptual
Framework

Design/ Method

Sample/ Setting

Major Variables
& Definitions

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Tan (2013)
Effects of a
written asthma
action plan on
caregivers’
management of
children with
asthma: a crosssectional
questionnaire
survey

Asthma selfmanagement
model

Questionnaire
survey to
caregivers of
children with a
WAAP and
without a
WAAP

n = 169
IG n = 94
CG n = 75

IV- WAAP
DV1- caregiver
understanding of
asthma
symptoms
DV2 - use of
asthma
medications
DV3 - acute care
consultation
DV4 - selfmanagement

Asthma Control
Test (ACT)

X2 test

DV1- IG
caregivers had
increased
understanding in
two categories
(p=0.025;
p=0.005)
DV2 – overall
greater
knowledge in IG
DV3 - no SS in
comfort
discontinuing
meds without
contacting
physician first
DV4 – no SS in
caregivers’
preference for
self-adjustment
& confidence in
selfmanagement
(p=0.382 &
p=0.817)

Singapore
Received a small
grant from
SingHealth
Polyclinics and
Ngee Ann
Polytecnic
(Singapore)
No bias stated or
found

Purpose: To
determine the
differences in
outcomes
between children
with a WAAP
and without a
WAAP

Setting: nine
public primary
care clinics in
eastern and
southern
Singapore
Inclusions:
primary
caregivers (at
least 75% of
awake hours) of
children
diagnosed with
asthma
Attrition: 0%

Questionnaire

Logistic
regression
analysis
Odds Ratio
estimate
STATA
software V.11

Level/Quality of
Evidence;
Application to
practice
Level IV

31

Strength –
performed
power analysis;
based on
previous welldesigned
qualitative study
Weakness – not
RCT; no info on
caregiver
literacy or
socioeconomic
status; limited
generalizability,
conducted in 9
districts in
Singapore
Conclusion – A
WAAP
improved
caregivers’
understanding of
asthma &
symptom
management
Feasibility –
WAAPs are
widely available
and easy to
implement; costeffective

Key: ACT score – asthma control test; CG – control group; DV – dependent variable; ER – emergency room; ES – effect size; ICS – inhaled corticosteroid; IG –
intervention group; IV – independent variable; N – number of studies; n – number of subjects; NIH -National Institute of Health; NINR – National
Institute of Nursing Research; NHLBI – National Heart, Lung, & Blood Institute; outpt – outpatient; PEFR – peak expiratory flow rate; QoL – quality of
life; RCT – randomized controlled trial; SS – statistically significant;WAAP – written asthma action plan

IMPROVING PEDIATRIC ASTHMA MANAGEMENT
Citation

Theory/
Conceptual
Framework

Design/ Method

Sample/ Setting

Major Variables
& Definitions

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Wong (2012)
Does a written
asthma action
plan reduce
unscheduled
doctor visits in
children?

Asthma selfmanagement
model

Single-blinded
RCT

n = 80
IG n = 40
CG n = 40

IV- symptombased WAAP

Asthma Control
Test or Child
Asthma Control
Test

SPSS version 16

DV1 – no
significant
difference
between groups
DV2 – no
significant
difference
between groups
DV3 – no
significant
difference;
overall increase
in patient’s with
controlled
asthma in both
groups
DV4 – no
significant
difference
between groups
DV5 – no
significant
improvement in
scores between
visit 1 and visit
4

Kuala Lumpus,
Malaysia
WAAP printing
was sponsored
by
GlaxoSmithKlin
e (GSK)
Malaysia
Bias – GSK was
not involved in
the design of the
WAAP, protocol
of the study or
collection of
data, analyzing
of data,
interpretation of
results or
decision to
publish; no other
bias stated

Purpose: To
evaluate the
impact of a
WAAP vs.
verbal
counseling on
reducing
unscheduled
doctor visits, on
asthma control,
and QoL in
children with all
severities of
asthma

Mean age: 12
Setting:
pediatric asthma
clinic at
University
Malaya Medical
Centre
Inclusions:
pediatric asthma
patients ages 617
Attrition:
6.25%

DV1 - ER visit
or acute
physician visit
DV2 - asthma
exacerbations
DV3 - asthma
control
DV4 - ACT
score
DV5 - QoL
Definition:
Asthma –
recurrent
episodes of
wheezing, cough
and shortness of
breath and still
requiring asthma
treatment at the
time of
enrollment

Standardized
Pediatric
Asthma Quality
of Life
Questionnaire
(PAQLQ)
Parental recall
about asthma
exacerbations
and unscheduled
doctor visits

Chi-square test
Fisher’s exact
test

Level/Quality of
Evidence;
Application to
practice
Level III –
single-blinded

32

Strength –
explores a
previously
unstudied
comparison of
WAAP vs. none;
computerized
randomization
Weakness –
only singleblinded; most
pts were well
controlled; small
sample size
Conclusion –
No significant
reduction in
asthma
exacerbations or
improvement in
asthma control
or QoL
Feasibility –
does not
demonstrate
positive effect of
WAAP,
especially in
well-controlled
asthmatics

Key: ACT score – asthma control test; CG – control group; DV – dependent variable; ER – emergency room; ES – effect size; ICS – inhaled corticosteroid; IG –
intervention group; IV – independent variable; N – number of studies; n – number of subjects; NIH -National Institute of Health; NINR – National
Institute of Nursing Research; NHLBI – National Heart, Lung, & Blood Institute; outpt – outpatient; PEFR – peak expiratory flow rate; QoL – quality of
life; RCT – randomized controlled trial; SS – statistically significant;WAAP – written asthma action plan

IMPROVING PEDIATRIC ASTHMA MANAGEMENT
Citation

Theory/
Conceptual
Framework

Design/ Method

Sample/ Setting

Major Variables
& Definitions

Measurement/
Instrumentation

Data Analysis
(stats used)

Findings/
Results

Yin (2015) A
low-literacy
asthma action
plan to improve
provider asthma
counseling: A
randomized
study

Health literacy
skills framework

Randomizedcontrolled study

n = 119
IG n = 61
CG n = 58

IV- low-literacy
WAAP

Trained RA
interviews with
pediatricians

SPSS 20.0

Audio
recordings were
transcribed by
RAs blinded to
intervention
status with
verification by
2nd RA

X2 and logistic
regression

DV1- IG was
more likely to
mention timing
of medications
(96.7% vs
51.7%, p<0.001)
DV2 – 80% of
IG mentioned
spacers, less
than 50% of CG
did (p<0.001)
DV3 – IG was
more likely to
reinforce need
for everyday
medications
(93.4% vs
34.5%, p<0.001)
DV4 – IG was
more likely to us
explicit
respiratory signs
(54.1% vs.
3.4%, p<0.001)
DV5 – similar
timing of
counseling in
both groups (3.9
vs 3.8 min,
p=0.8)

New York, NY
and Chicago, IL
Health
Resources and
Services
Administration;
career
development
grants from
Robert Wood
Johnson
Physician
Faculty Scholars
program; Kids
of NYU
Foundation
No bias stated or
found

Purpose: To
examine whether
use of a lowliteracy WAAP
can improve
provider asthma
counseling, as
assessed with a
hypothetical
scenario
involving a
parent of a child
with persistent
asthma

Similar
demographics
between groups
regarding age
and variation of
training
Setting: two
academic centers
Inclusions:
pediatricians
who care for
children with
asthma
Exclusions:
Must at least be
at end of intern
year
Attrition: 0%

DV1- provider
description of
timing of
medications
DV2 - use of
spacer
DV3 maintenance
medications
DV4 explanation of
signs &
symptoms
DV5 - time of
counseling
Definition:
Asthma –
recurrent
episodes of
wheezing, cough
and shortness of
breath and still
requiring asthma
treatment at the
time of
enrollment

Analyzed
according to
evidence-based
characteristics

2-tailed t-test

Level/Quality of
Evidence;
application to
practice
Level II

33

Strength –
performed
power analysis;
analysis of DV
was blinded to
RAs
Weakness – not
a study of realworld practice;
did not address
time to fill in
WAAP; only
studied
physicians;
convenience
sample – affects
generalizability
Conclusion –
low-literacy
WAAP
improves
providers
education
delivery
Feasibility –
very simple to
implement; no
increased time
commitment;
cost effective &
useful

Key: ACT score – asthma control test; CG – control group; DV – dependent variable; ER – emergency room; ES – effect size; ICS – inhaled corticosteroid; IG –
intervention group; IV – independent variable; N – number of studies; n – number of subjects; NIH -National Institute of Health; NINR – National
Institute of Nursing Research; NHLBI – National Heart, Lung, & Blood Institute; outpt – outpatient; PEFR – peak expiratory flow rate; QoL – quality of
life; RCT – randomized controlled trial; SS – statistically significant;WAAP – written asthma action plan

Bhogal

Horner

Khan

Kuethe

Olivera

Safu

Sheares

Tan

Wong

Yin

Appendix B
Synthesis Table

Year

2017

2006

2016

2014

2013

2016

2016

2015

2013

2012

2015

LOE

I

I

II

II/III

I

II/III

IV

II

VI

III

II/III

Design

SR

SR

RCT

RCT

SR

RCT

LR

RCT

CQ

RCT

RCT

Length

14y

25y

1y

1y

12y

19m

9y

4y

6m

18m

4m

AE

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

WAAP
NL

X

X

X

X

Interventions

PL

X

SC

X

HAA

X

X
X

FFU
AHU

Outcomes

34

Belice
Basics

IMPROVING PEDIATRIC ASTHMA MANAGEMENT

X

SS

SS

SS

S/SS

NS

SS

LF (PEF)

NS

QoL

NS

NS



NS

SS

NS

SS

NS



NS

SS


Asthma Knowledge
School Absence

SS



SS
NS





NS

IE

SS

Key: AE – asthma education; AHU – acute healthcare utilization; FFU – frequent follow-up; HAA – home allergen assessment; IE – inferred effect; LF (PEF) –
lung function (peak expiratory flow); LOE – level of evidence; NL – nurse-led; NS – no significance or no change; PL – pharmacist-led; QoL – Qualify
of Life; SC – specific curriculum; SS – statistically significant; S/SS – Symptom/Severity Score; Sx – symptoms; WAAP – written asthma action plan;

 - increase or decrease in outcome;  - increase in outcome in both IG and CG

IMPROVING PEDIATRIC ASTHMA MANAGEMENT
Asthma Exacerbation
Sx Days

SS NS
SS

NS

Proper Use
Steroid Needed
Nighttime sx

NS

SS

Med Adherance

35

SS

X

SS



NS



Understandable

SS

Key: AE – asthma education; AHU – acute healthcare utilization; FFU – frequent follow-up; HAA – home allergen assessment; IE – inferred effect; LF (PEF) –
lung function (peak expiratory flow); LOE – level of evidence; NL – nurse-led; NS – no significance or no change; PL – pharmacist-led; QoL – Qualify
of Life; SC – specific curriculum; SS – statistically significant; S/SS – Symptom/Severity Score; Sx – symptoms; WAAP – written asthma action plan;

 - increase or decrease in outcome;  - increase in outcome in both IG and CG

IMPROVING PEDIATRIC ASTHMA MANAGEMENT
Appendix C
Figure 1
Bruhn’s Theory of Asthma Self-Management

36

IMPROVING PEDIATRIC ASTHMA MANAGEMENT
Appendix D
Site Approval Letter

37

IMPROVING PEDIATRIC ASTHMA MANAGEMENT
Appendix E
IRB Approval Letter

38

IMPROVING PEDIATRIC ASTHMA MANAGEMENT

39

Appendix F
Outcome Demographics
Figure 1
Group One Age
Descriptive Statistics
N

Minimum

Age

33

Valid N (listwise)

33

3.00

Maximum

Mean

17.00

Std. Deviation

10.1212

3.29543

Figure 2
Group One Gender
Gender
Cumulative
Frequency
Valid

Percent

Valid Percent

Percent

Male

22

66.7

66.7

66.7

Female

11

33.3

33.3

100.0

Total

33

100.0

100.0

Figure 3
Group One Provider Type
Provider
Cumulative
Frequency
Valid

Percent

Valid Percent

Percent

MD

14

42.4

42.4

42.4

DO

5

15.2

15.2

57.6

NP

14

42.4

42.4

100.0

Total

33

100.0

100.0

IMPROVING PEDIATRIC ASTHMA MANAGEMENT

40

Figure 4
Group Two Age
Descriptive Statistics
N

Minimum

Age

18

Valid N (listwise)

18

2.00

Maximum

Mean

12.00

Std. Deviation

7.7222

3.42664

Figure 5
Group Two Gender
Gender
Cumulative
Frequency
Valid

Male

Valid Percent

Percent

13

72.2

72.2

72.2

5

27.8

27.8

100.0

18

100.0

100.0

Female
Total

Percent

Figure 6
Group Two Provider Type
Provider
Cumulative
Frequency
Valid

Percent

Valid Percent

Percent

MD

9

50.0

50.0

50.0

NP

9

50.0

50.0

100.0

18

100.0

100.0

Total

IMPROVING PEDIATRIC ASTHMA MANAGEMENT

41

Appendix G
Statistical Outcomes
Figure 1
Mann Whitney U
Test Statisticsa
Inhaler/Spacer
Use of ACT

Use of WAAP

Education

Mann-Whitney U

229.500

181.500

258.000

Wilcoxon W

790.500

742.500

429.000

-1.607

-2.633

-1.118

.108

.008

.264

Z
Asymp. Sig. (2-tailed)

a. Grouping Variable: Pre- and Post- Group

Figure 2
Cohen’s d for ACT use

Figure 3
Cohen’s d for WAAP

IMPROVING PEDIATRIC ASTHMA MANAGEMENT

42

Figure 4
Spearman’s rho
Correlations
Provider
Spearman's

Provider

rho

Correlation

Use of

Use of

Inhaler/Spacer

ACT

WAAP

Education

1.000

-.302*

.000

.052

.

.031

1.000

.717

51

51

51

51

-.302*

1.000

.372**

-.158

.031

.

.007

.268

51

51

51

51

.000

.372**

1.000

-.070

1.000

.007

.

.626

51

51

51

51

.052

-.158

-.070

1.000

.717

.268

.626

.

51

51

51

51

Coefficient
Sig. (2-tailed)
N
Use of ACT

Correlation
Coefficient
Sig. (2-tailed)
N

Use of WAAP

Correlation
Coefficient
Sig. (2-tailed)
N

Inhaler/Spacer

Correlation

Education

Coefficient
Sig. (2-tailed)
N

*. Correlation is significant at the 0.05 level (2-tailed).
**. Correlation is significant at the 0.01 level (2-tailed).