Is the lack of a written asthma plan a risk factor for death from asthma?

Lack of a Written Asthma Action Plan as a Risk Factor for Asthma Death

Yes, the lack of a written asthma action plan is definitively a risk factor for death from asthma, with evidence showing that written action plans are associated with a 70% reduction in mortality risk among patients with severe persistent asthma presenting acutely to hospitals. 1, 2

Direct Evidence Linking Lack of Action Plans to Mortality

The strongest evidence comes from a well-conducted case-control study comparing 51 patients who died from asthma to 202 patients presenting to hospitals with acute asthma. This study demonstrated that written action plans were associated with a 70% reduction in the risk of death from asthma. 1, 2 This finding is particularly compelling because it directly measured mortality as the outcome, not just surrogate markers like hospitalizations or emergency department visits.

Guideline Recognition of This Risk Factor

The National Asthma Education and Prevention Program (NAEPP) Expert Panel Report 3 explicitly identifies lack of a written asthma action plan as a recognized risk factor for both severe exacerbations and asthma-related death. 3, 4 This classification places it among other high-risk factors such as previous ICU admission for asthma, multiple hospitalizations, and difficulty perceiving symptom severity.

Supporting Evidence from Emergency Department Studies

Additional research reinforces this relationship by showing that lack of a written asthma action plan is independently associated with frequent emergency department visits (OR 3.3, P = 0.03), which themselves are markers of poorly controlled disease and increased mortality risk. 5 Patients who frequently visit emergency departments—defined as three or more visits per year—are substantially more likely to lack written action plans and face higher mortality risk.

Mechanism of Benefit

Written action plans reduce mortality through several mechanisms:

• They provide explicit, patient-specific instructions on how to adjust medications during worsening symptoms, preventing delays in escalating therapy 1
• They encourage patients to seek care before an attack becomes life-threatening, rather than waiting until severe respiratory compromise develops 1
• They help patients recognize deterioration earlier, which is critical since difficulty perceiving asthma symptoms is itself an independent mortality risk factor 3, 4

Broader Context: Action Plans as Part of Self-Management

While randomized controlled trials examining written action plans in isolation showed inconclusive results due to methodologic limitations, a Cochrane review of 25 studies found that self-management with written action plans significantly reduced asthma-related hospital admissions (OR 0.35) and emergency department visits (OR 0.55). 1 The NAEPP panel continues to recommend written action plans despite the inconclusive isolated evidence, recognizing their low cost, minimal risk, and potential mortality benefit. 1

Clinical Implications and Common Pitfalls

The most dangerous clinical error is underestimating the importance of providing written action plans to all asthma patients, particularly those with moderate to severe persistent disease. 3 Many busy physicians fail to provide written action plans, leaving patients without clear guidance during exacerbations. 1

Key preventable factors in asthma deaths include:

• Inadequate patient education on recognizing risk and appropriate action when control deteriorates 6
• Poor adherence with or complete lack of written asthma action plans 6
• Failure to provide explicit instructions for medication adjustment during attacks 1

Specific High-Risk Populations Requiring Action Plans

Certain patient groups have particularly elevated mortality risk when lacking written action plans:

• Patients with severe persistent asthma (the population in which the 70% mortality reduction was demonstrated) 1, 2
• Patients with previous near-fatal asthma requiring intubation or ICU admission (who have approximately 10% mortality risk in the following year) 3
• Patients with difficulty perceiving asthma symptoms or exacerbation severity 3, 4
• Patients with psychiatric disease or psychosocial problems 3, 4, 6

Every asthma patient should receive a written action plan as part of comprehensive self-management education, with particular urgency for those with any of the above high-risk features. 1