Convince patients to keep a diary for better outcomes

It gives clinicians better picture of the patient

It isn’t easy to get patients to record their peak flow readings in a daily diary. Many would find that about as much fun as balancing a checkbook. But clinicians can get a better picture of the symptoms a patient reports today when they are backed up by what has been recorded in the diary over time. And this, in turn, will result in better outcomes.

"My experience is that if someone is willing to keep one of the charts for us, he tends to fare a lot better in terms of managing his asthma," says Wilma Light, MD, an allergist in Latrobe, PA.

"The diary gives us an indication if we’re heading for trouble so we can intervene with medicine before it gets too bad," she explains.

Some patients will be quite compliant, but others will not be willing to put time into writing things down, Light says. "Usually, we try to introduce the diary when someone is a new patient so we can learn how [that person] is doing. We tell them it takes some time and effort, but we can learn a lot from this, and many people will be willing to do it for a few weeks."

Light uses a tri-colored diary published by Pedipress Inc. in Amherst, MA. (A sample of the diary for patients age 5 to adult is inserted in this issue.) The diary has two versions: One is for children under age 5, and the other is for a patient age 5 to adult.

The young child’s diary is divided into these four sections:

1. Signs.

This is a place to record asthma indicators such as coughing, wheezing, breathing rate, and chest skin. Parents rate signs from either 0-3 or 0-5 for each of these. Then they add up the numbers in the column and record the total on a separate line.

2. Zones.

Here is where scores are recorded from using the peak flow meter. Green (0) means the current treatment is working. High yellow (1-4) is a signal to avoid triggers and change medication routine. Low yellow (5-8) means you should intensify treatment, and the red zone (9) means the child should receive emergency medicines and see a physician or go to the emergency department.

3. Medicines.

In this section, patients record daily dosages of cromolyn, inhaled steroid, albuterol, oral steroid, and theophylline.

4. Daily.

Parents record the quality of their child’s activity and sleep. The diary also has a place to record the date and to check whether a symptom appeared during the day or night. And patients can mark an "X" if the symptoms appeared after using a bronchodilator. There’s also a blank space to enter comments about triggers and other items.

The diary for older patients has an asthma care zone for patients to mark peak flow rates, both before taking an inhaled bronchodilator and after taking one. Medicines and signs are also charted on the diary.

Diaries are a timesaver for physicians and a way to make asthma treatment more cost-effective, says Thomas Plaut, MD, a pediatrician and the director of Asthma Consultants in Amherst, MA. Plaut has written four books and pamphlets on asthma and founded Pedipress, which publishes pediatric health information.

Physicians simply do not have enough time to spend with their patients to obtain all the information they need. "So the solution is to get the patient to do a lot of the data collecting," he says. "We have to figure out ways that patients can become more involved in their care."

Plaut’s own patients readily use their diaries and sometimes will fax him a copy when they’re traveling overseas. "Instead of talking on an international call for 30 minutes, we’ll settle the problem in five minutes because the diary gives you information that people cannot hold in their brains," he says.

Most patients who use the diary better understand how their symptoms and peak flow relate to their medications, Plaut says. "I tell patients to use the diary twice daily for the first two months, then every morning for two months, and then as often as they find it helpful."

When patients experience symptoms, change their medications, or enter an environment that might exacerbate their asthma, they should start keeping a diary until they have a full understanding of their situation. In addition, Plaut asks patients to keep a diary for the week before they see him. "This is the best way for me to review their current status."

Physicians will have to make some extra effort when they start getting patients to use the diary. But once doctors teach their patients to use the diary, it saves a huge amount of time, Plaut says.

Light says she has experienced this benefit. "It’s almost like an early warning system for some patients. Patients chart their medications and rate how they’re doing in terms of wheezing, coughing, activity level, and sleeping," she adds. "This tells you a lot about what’s going on." For example, a patient’s peak flow readings drop before his symptoms start to appear. The chart will indicate this trend, and the physician might see that the patient has to be cautious, perhaps taking an additional medication to relieve symptoms. Or the physician may increase the dosage, making any adjustments necessary to prevent the patient from returning to the emergency department.

"It tells us more about how they’re doing at different time periods," Light adds. "Often when patients come in for a visit it’s at the best time for asthma symptoms, but we want to know how they do in the morning and evening."

The diary provides the trend data, which are especially important. Light says she usually introduces the concept of an asthma diary when she meets a new patient. It’s a good way to see how the patient is doing. It also establishes a baseline, so the patient knows what a good reading is.

She also will encourage patients to begin charting their peak flow readings when they change medications. (Although, ideally, all patients who have moderate to severe asthma would fill out the diary continuously.) "If they can make it a part of their daily routine, it can really help them," she adds.

(A copy of the asthma peak flow diary is enclosed in this issue. For more samples and a home treatment plan, send a self-addressed, stamped, business envelope to Pedipress Inc., 125 Red Gate Lane, Amherst, MA 01002.)