Shared Treatment Decision Making Improves Adherence and Outcomes in Poorly Controlled Asthma

Abstract

Rationale: Poor adherence to asthma controller medications results in poor treatment outcomes. Objectives: To compare controller medication adherence and clinical outcomes in 612 adults with poorly controlled asthma randomized to one of two different treatment decision-making models or to usual care. Methods: In shared decision making (SDM), nonphysician clinicians and patients negotiated a treatment regimen that accommodated patient goals and preferences. In clinician decision making, treatment was prescribed without specifically eliciting patient goals/ preferences. The otherwise identical intervention protocols both provided asthma education and involved two in-person and three brief phone encounters. Measurements and Main Results: Refill adherence was measured using continuous medication acquisition (CMA) indices-the total days' supply acquired per year divided by 365 days. Cumulative controller medication dose was measured in beclomethasone canister equivalents. In follow-up Year 1, compared with usual care, SDM resulted in: significantly better controller adherence (CMA, 0.67 vs. 0.46; P , 0.0001) and long-acting b-agonist adherence (CMA, 0.51 vs. 0.40; P 5 0.0225); higher cumulative controller medication dose (canister equivalent, 10.9 vs. 5.2; P , 0.0001); significantly better clinical outcomes (asthma-related quality of life, health care use, rescue medication use, asthma control, and lung function). In Year 2, compared with usual care, SDM resulted in significantly lower rescue medication use, the sole clinical outcome available for that year. Compared with clinician decision making, SDM resulted in: significantly better controller adherence (CMA, 0.67 vs. 0.59; P 5 0.03) and long-acting b-agonist adherence (CMA, 0.51 vs. 0.41; P 5 0.0143); higher cumulative controller dose (CMA, 10.9 vs. 9.1; P 5 0.005); and quantitatively, but not significantly, better outcomes on all clinical measures. Conclusions: Negotiating patients' treatment decisions significantly improves adherence to asthma pharmacotherapy and clinical outcomes. Clinical trials registered with www.clinicaltrials.gov (NCT00217945 and NCT00149526).

Nordic consensus statement on the systematic assessment and management of possible severe asthma in adults

“…A shared-care approach to asthma management improves outcomes [36,37], and requires development of a partnership between the asthmatic and the health care providers. Perhaps more than in other diseases patients require good partnerships for adequate treatment, they must learn to recognize potential triggers and symptoms of exacerbations, when to adjust medications and contact health care personnel [13,38].…”

“…Finally, some patients have difficulty in being adherent due to difficulties using the device, or because of a regimen with multiple inhalers is overwhelming [13]. Patients with intentional non-adherence due to side effects may need an empathic discussion about the pros and cons of their treatment [36], whereas patients with non-intentional adherence due to forgetfulness may need a more feasible regimen such as once-daily dosing [100], and inhaler reminders [101,102]. …”

Influence of Body Mass Index on Effects of a Shared Asthma Treatment Decision-Making Intervention

“…Understanding the influence of BMI and obesity on effectiveness of interventions to improve asthma control will help clinicians better care for obese patients with asthma. The Better Outcomes of Asthma Treatment study, a randomized controlled trial in 612 adults with poorly controlled asthma, found that a shared treatment decision-making (SDM) intervention improved controller medication adherence and clinical outcomes (4). Given the increased attention to the links between obesity and asthma, we conducted post hoc analyses to investigate whether baseline BMI modified the SDM intervention effects on asthma medication acquisition outcomes (fill/ refill adherence and regimen strength) and clinical outcomes in the follow-up year.…”

“…Note that estimates based on multivariable regression models that were stratified by BMI category. Each model included group assignment, the five randomization balancing variables (4), and the baseline controller CMA.…”

Is patient-centred care a tautology?: View from the Netherlands

“…Several studies have shown that GPs' judgment in balancing these factors really works and is appreciated by both patients and their doctors. 2,3 Stimulating doctors to perform better in this respect by educating them and giving them feedback on their performance has also shown to improve quality of care. 4 Feedback from patients should be an essential part of care, and surveys and patients' advisory boards could be very helpful.…”