Involvement in treatment decisions: what do adults with asthma want and what do they get? Results of a cross sectional survey

Preferences and perceived involvement in treatment decision making among Chinese patients with chronic hepatitis

OBJECTIVES

The objectives of this study were to measure the preferences for and perceived involvement in treatment decision making among Chinese patients with chronic hepatitis and to explore the factors that may influence patients' preferences. The study also aimed to analyze patients' satisfaction with decision and information provision and their relationships with the decisional role.

METHODS

Semistructured interviews were performed with 178 chronic hepatitis patients. The Control Preferences Scale was translated into Chinese from English and adopted to measure patients' preferred and perceived decisional role. Patients' satisfaction with decision and information provision was also investigated by a 5-point Likert-type scale.

RESULTS

Patients with chronic hepatitis in the study generally preferred a collaborative role (45%) or passive role (44%); only 11% of patients preferred an active role in treatment decision making. The agreement between patients' perceived and preferred role was not perfect (Bowker's S = 33.8, P < 0.001). Age and education level were significantly associated with patients' preferences: Younger, better educated patients tended to prefer more active roles. A total of 54% of patients felt satisfied with treatment decisions, whereas 39% of patients felt satisfied with information provision. Patients' levels of satisfaction with their treatment decisions were correlated not only with the perceived role itself but also with its agreement with the preferred role. Patients' satisfaction with information provision was significantly correlated with patients' preferred role. Moreover, there was a significant correlation between patients' satisfaction with the treatment decision and information provision.

CONCLUSIONS

Patients' preferences for participation in treatment decision making should be considered seriously by doctors during the encounter. Health providers should make a greater effort to improve doctor-patient communication and decrease the mismatch between patients' perceived and preferred decisional role.

Patient's preferences for health scenarios associated with hepatitis C and its treatment

BACKGROUND AND AIM

Antiviral therapy with peg-interferon and ribavirin induces sustained virus eradication in 40%-80% of patients with chronic hepatitis C virus (HCV). We investigated patient views on their involvement in therapeutic decision making and on the desirability of disease and treatment-related outcomes.

METHODS

The control preferences and visual analog scales were administered in a pencil and paper format to a series of 45 patients in order to assess their decisional role, preferences for scenarios of HCV disease and antiviral treatment, and estimates of success required to recommend treatment.

RESULTS

The preferred decisional role of patients was passive in 26 (58%), collaborative in 12 (27%) and active in 7 (15%). Median preference scores ranged from 0.30 to 0.90 for scenarios of disease, from 0.05 to 0.80 for side effects and from 25% to 100% for estimates of benefit to recommend treatment.

CONCLUSIONS

Our patients prefer to defer to the doctor the final decision in starting therapy in a context of shared decision making. Reported preferences for HCV scenarios are in the range discussed in the literature. The wide variability in the values attributed to side effects by patients with chronic hepatitis C as well as in expected probabilities of successful treatment suggests a need for decision analysis tailored to the individual patient.

[Treatment education for patients with asthma]

Randomized studies show that the best results come from patient-focused educational programs based on self-management (written and individualized action plan, self-monitoring, and regular medical review). The simple provision of information about asthma does not improve health outcomes. Teenagers with asthma are the most fragile patients, because of the lack of specific management for them. Repeated sessions are recommended and educational programs, started in childhood, might make it possible to prevent or at least decrease the risks of non-adherence during adolescence. The absence of consensus on educational interventions impedes the legibility of their impact.

Consideration of shared decision making in nursing: a review of clinicians' perceptions and interventions

As the number of individuals with chronic illness increases so has the need for strategies to enable nurses to engage them effectively in daily management of their conditions. Shared decision making between patients and nurses is one approach frequently discussed in the literature. This paper reviews recent studies of shared decision making and the meaning of findings for the nurse-patient relationship. Patients likely to prefer to engage in shared decision making are younger and have higher levels of education. However, there is a lack of evidence for the effect of shared decision making on patient outcomes. Further, studies are needed to examine shared decision making when the patient is a child. Nurses are professionally suited to engage their patients fully in treatment plans. More evidence for how shared decision making affects outcomes and how nurses can successfully achieve such engagement is needed.

Self-management plans for asthma control and predictors of patient compliance

OBJECTIVE

To evaluate the impact of peak flow or symptom-based self-management plans on asthma control and patients' quality of life and to determine the main psychosocial factors that affect compliance with these plans.

METHODS

The study sample consisted of 63 patients with persistent asthma outpatients. Data collection included demographics, pulmonary functions, symptom scores, and asthma control parameters recorded over the previous 2 consecutive years. A standard asthma self-management education program including personal action plans was given to the patients who were randomly divided into peak flow meter (PFM) (n = 31) or symptom-based (n = 32) action plan groups. Patients were then assessed prospectively for various study outcomes including symptoms, drug compliance, psychiatric co-morbidities, quality of life, and asthma control over the next 12 months. Psychiatric co-morbidities were assessed using Rotter's Internal and External Locus of Control Scale (RIELCS), Beck Depression Inventory (BDI), Structured Clinical Interview for DSM-IV (SCID-I), Spielberger State-Trait-Anxiety Inventory (STAI), and Short Form-36 (SF-36).

RESULTS

Of the 63 patients (79% female; mean age 43), 85% of them had moderately or severely persistent asthma. Baseline demographics, clinical parameters, psychiatric diagnosis, and quality of life were not different between groups. Personal asthma plans increased optimal asthma control significantly. Emergency visits, antibiotic treatments, systemic corticosteroid treatments, and unscheduled visits were fewer than the previous year. Control parameters were better in the PFM group. After the self-management education, the quality of life dimensions, i.e., vitality, total mental and general scores of both groups increased. Frequency of psychiatric co-morbidities decreased from 61.9% to 49.2%. However, state anxiety levels were increased in both groups. These increases were statistically significant in the PFM group. Compliance with the action plans was better in the PFM group. Higher BDI scores were associated with worse compliance. No statistically significant association was found between demographic parameters and the compliance. Although the compliance had decreased in both groups after 6 months, this decrease was greater in the symptom group. Higher RIELCS and mental health scores were associated with better compliance.

CONCLUSION

Introduction of self-management plans improved illness control and quality of life in asthma patients. Use of the PFM and the presence of higher RIELCS and lower BDI scores can be used to predict compliance with the action plans.

Mutual influence in shared decision making: a collaborative study of patients and physicians

OBJECTIVE

To explore how patients and physicians describe attitudes and behaviours that facilitate shared decision making. Background Studies have described physician behaviours in shared decision making, explored decision aids for informing patients and queried whether patients and physicians want to share decisions. Little attention has been paid to patients' behaviors that facilitate shared decision making or to the influence of patients and physicians on each other during this process.

METHODS

Qualitative analysis of data from four research work groups, each composed of patients with chronic conditions and primary care physicians.

RESULTS

Eighty-five patients and physicians identified six categories of paired physician/patient themes, including act in a relational way; explore/express patient's feelings and preferences; discuss information and options; seek information, support and advice; share control and negotiate a decision; and patients act on their own behalf and physicians act on behalf of the patient. Similar attitudes and behaviours were described for both patients and physicians. Participants described a dynamic process in which patients and physicians influence each other throughout shared decision making.

CONCLUSIONS

This study is unique in that clinicians and patients collaboratively defined and described attitudes and behaviours that facilitate shared decision making and expand previous descriptions, particularly of patient attitudes and behaviours that facilitate shared decision making. Study participants described relational, contextual and affective behaviours and attitudes for both patients and physicians, and explicitly discussed sharing control and negotiation. The complementary, interactive behaviours described in the themes for both patients and physicians illustrate mutual influence of patients and physicians on each other.

The development and comprehensibility of a pictorial asthma action plan

OBJECTIVE

Written action plans are regarded as an important part of asthma self-management education and yet they may not be understood by those with limited literacy skills. This study was designed to produce an understandable pictorial asthma action plan.

METHODS

With advice from a group of doctors and nurses a "standard" written action plan was translated by a medical artist into a series of pictorial images. These were assessed using the techniques of guessability and translucency by a series of adults attending a specialist asthma clinic in London and the same process was subsequently used to assess comprehensibility of the images and plans amongst a group of Somalis living in Manchester, UK and Malaysians in Seremban, Malaysia.

RESULTS

Guessability testing showed that the majority of pictograms were well understood by each of the study groups. Translucency testing revealed close agreement with intended meaning for the majority of the images. One image, depicting extra use of reliever medication scored less well in all populations; two other images scored less well in the Somali and Malaysian groups and reflect less use of certain inhaler devices in other countries. The overall plan was well understood by all patients who were able to adequately recount the appropriate actions to take in different clinical scenarios.

CONCLUSION

We have developed a pictorial asthma action plan understandable by 3 different populations of patients with asthma.

PRACTICE IMPLICATIONS

Pictorial representations have been shown by other studies in other situations to be an effective method of reinforcing the spoken word. The pictorial asthma action plan developed for this study has been shown to be comprehensible, personalised to the individual in the usual fashion. It is now suitable for further evaluation in clinical practice.

Asthma education and monitoring: what has been shown to work

Cochrane systematic reviews and meta-analyses on education and monitoring of asthmatic children have come to divergent conclusions, mainly because of the heterogeneity of education programmes and patients. There is little doubt that education is useful. However, the useful components of the education programmes remain to be elucidated, not only by randomized controlled trials but also by observational studies performed within distinct asthma phenotypes. Any education and monitoring package needs to contain basic explanation about the disease and its influencing factors, as well as inhalation instructions. There is no good evidence to justify home monitoring of lung function; symptom monitoring suffices. Probably, the crucial part of asthma education programmes is a high level of agreement between patient and doctor regarding the goals of the treatment (patient-doctor partnership). Therefore, further exploration of the patient's needs should be worthwhile.

A breath for health: an exploratory study in severe asthma patients in Turkey

BACKGROUND

Severe asthma puts enormous burden on patients. To evaluate asthma-related restrictions on patients' daily lives along with their expectations about future asthma care.

METHODS

A structured questionnaire was administered to severe asthma patients at 25 centers across Turkey. The patients were divided into; uncontrolled (n: 274) and controlled asthma (n: 177) according to the existence of symptoms despite the GINA step 4 or 5 treatment.

RESULTS

A total of 451 patients (F/M: 337/114, mean age: 47.6 +/- 13.2 years) were included; 93% were nonsmokers and 51.2% were atopic. Chronic rhino-sinusitis, ASA/NSAID sensitivity, and osteoporosis were significantly higher in uncontrolled patients. Nearly 70% of the uncontrolled asthmatics defined asthma as disturbing with significant restrictions in daily life. The most important role for medication was symptom relief. One inhaler or one tablet a month was the most preferred form of drug usage. In addition, 30.6% of the patients had tried alternative treatment with herbal remedies. Although patients were willing to become members of an asthma association, they expected the Turkish government to provide special asthma clinics and fund research into new treatments. Controlled patients achieved or were close to achieving asthma control goals. Uncontrolled patients seemed to be more pessimistic in this respect, but they reserved significant levels of hope for the future. Two-thirds of all the patients thought that they would receive better treatment in the next 5 years.

CONCLUSIONS

In this study group, severe asthma patients face significant limitations in their daily lives, but they are optimistic about better asthma control and treatment options in the future.

Measuring the Involvement of People with HIV in Treatment Decision Making Using the Control Preferences Scale

Objectives. Since 1983, HIV patients have been advocating for participatory decision making. This study measures the involvement that HIV-positive people perceive in treatment decision making. A secondary objective is to assess the validity of the instrument used to examine decisional roles, the Control Preferences Scale (CPS). Method. The authors interviewed 79 HIV-positive people, a sub-sample of a study on long survival with HIV, diverse with respect to ethnicity, age, gender, and sexual orientation. They compared the self- and researcher-rated decisional roles of participants on the CPS. They also assessed how well the CPS corresponds with Charles's paternalistic, shared- and informed-choice models of decision making about treatment based on decisional roles and information exchange. Results. Most participants (75%) perceived collaborative/active involvement in decision making. Agreement (Kendall's tau-b ) between self- and researcher-rated decisional roles on the CPS was 0.82, whereas agreement between self-ratings on the CPS and researcher ratings on Charles's classification was 0.60. Charles's classification was difficult if participants had chosen not to take their prescribed medication without being adequately informed about the risky consequences of this decision. Conclusions. In this study, HIV-positive people perceived a high level of involvement in decision making. Reliability and convergent validity of the CPS was high. Charles's classification was problematic because decisional roles and information exchange are distinct dimensions. Some people make risky treatment decisions on their own without being adequately informed. The CPS is a useful instrument to measure decisional role perceptions of HIV-positive people but needs to be complemented by an instrument measuring treatment knowledge.

The clinician-patient partnership paradigm: outcomes associated with physician communication behavior

OBJECTIVE

To identify physician communication behaviors associated with perceptions of quality of care and predictive of positive patient outcomes.

PATIENTS AND METHODS

A total of 452 families seeing 48 pediatricians for a child's asthma participated. Perceptions and health care use were assessed at baseline and after 12 months through interviews and medical records. The measures used were 10 physician communication behaviors and 6 items describing physician's performance, asthma office visits, emergency department visits, and hospitalization.

RESULTS

Positive perceptions of physicians' performance were related to (P < or = .05) careful listening, inquiring about at-home management, nonverbal attention, interactive conversation, tailoring short-term goals, and long-term therapeutic plan. Loss in health care use was predicted (P < or = .05) by interactive conversation, short-term goals, criteria for decision making, long-term treatment plan, and tailoring according to needs. The use of these techniques did not lengthen the patient visit. A clinician-patient partnership paradigm is provided based on these findings.

CONCLUSIONS

The specific clinician communication behaviors predicted reduced health care use and positive perceptions of quality of care.

Features of asthma management: quantifying the patient perspective

BACKGROUND

In the management of asthma, features of care important to patients may not be fully appreciated. This study quantifies the importance of different features of asthma management from the patient perspective. This may assist in the development of personalised management strategies.

METHODS

We used the technique of discrete choice experiment (DCE). Patients over 18 years of age with asthma, prescribed and taking medicine at step 3 of the UK guidelines were recruited from 15 general (family) practices in three areas of the UK. 147 evaluable questionnaires were returned from a total of 348 sent out. The outcome measures were the relative importance to patients of features of asthma management and the impact of changes in asthma management, as measured by utility shift between the features tested.

RESULTS

The largest shift in mean utility values was recorded in "number of inhalers" and "use of inhaled steroid". Use of a personal asthma action plan was ranked next highest.

CONCLUSION

This study suggests that adults with moderate or severe asthma would trade some improvements in symptom relief in favour of, for example, simpler treatment regimens that use as few inhalers as possible and a lower dose of inhaled steroid.

Asthma patients with low perceived burden of illness: a challenge for guideline adherence

RATIONALE AND AIMS

The reason why many patients seem to tolerate suffering from sub-optimal treated asthma remains unclear. The aim was to evaluate the guideline adherence combined with quality of life of patients with moderate to severe asthma.

METHODS

256 asthma patients from 43 primary care practices in Saxony-Anhalt filled in a questionnaire including the Asthma Quality of Life Questionnaire (AQLQ), the Patient Health Questionnaire (PHQ-D) and questions evaluating the asthma severity, medication and self-management.

RESULTS

43.4% suffered from moderate to severe asthma. Drug treatment accorded with guidelines in 36.9%, drug dosage of inhaled steroids was too low in 34.3%, and 21.5% were not treated according to guidelines. A total of 7.3% of the patients received end-of-dose therapy. AQLQ declined and depression rose with asthma severity and guideline non-adherence (P < 0.001). Only 29.1% received asthma education. However, 64.5% of the patients without education did not want to receive education. They had a higher quality of life, lower depression (P < 0.001) and lower use of steroids (P = 0.016). Higher depression scores where related with hospital admission (OR 3.29; 95% CI 1.57-6.87 for each quartile of PHQ-D) and unscheduled home visits or ambulatory care (OR 1.58; 1.07-2.33).

CONCLUSION

There is a large variation of asthma severity which can partly be explained by the guideline adherence of medication and deficits of patients' management. The perceived burden of illness plays a more important role for education and self-management than the real severity of disease. Therefore, target-oriented interventions are needed to identify and motivate patients at risk.

Preferences for involvement in treatment decision-making generally and in hormone replacement and urinary incontinence treatment decision-making specifically

OBJECTIVE

To explore whether preferences for involvement in treatment decision-making change depending on the context and factors associated with preferences.

METHODS

A national telephone survey of 1000 randomly selected Norwegian women aged 18 years or over using the Control Preferences Scale (CPS) to assess preferences.

RESULTS

More women preferred an active role when asked about hormone replacement therapy (HRT) and urinary incontinence (UI) treatment decision-making specifically than when asked a question about preferences for involvement when generally making treatment decisions. Higher education and very good general health were significantly associated with preferring an active role in HRT and UI treatment decision-making. A negative attitude towards HRT was also significantly associated with preferring an active role when considering HRT. Women with higher educational levels were significantly more likely to choose an option from the CPS that indicated a preference for wanting more involvement in HRT decision-making compared to treatment decision-making generally.

CONCLUSIONS

Women's preferences for involvement in treatment decision-making change depending on the context as do factors associated with role preferences.

PRACTICE IMPLICATIONS

Health care professionals need to be aware that patients' preferences may change depending on the context of the treatment decision.

"It's my body'': does patient involvement in decision making reduce decisional conflict?

OBJECTIVE

This study explores how much people with HIV/AIDS wanted and how much they actually perceived being involved in the decision to take or not to take antiretroviral treatment (ART). The congruence between desired and perceived decisional involvement was also related to decisional conflict.

METHOD

Cross-sectional (N = 79), the Control Preferences Scale assessed patients' preferred versus perceived role in treatment decision making. The Decisional Conflict Scale measured patients' perceived difficulties in decision making.

RESULTS

Although a minority of patients (32%) perceived their role as shared decision making, the majority (59%) preferred shared decision making. Some did not desire shared decision making, with 28% preferring to decide on their own versus 13% wanting their physicians to decide for them. Overall, 58% did not feel they had achieved their desired role in decision making (half of whom perceived more control and the other half less control than preferred). Participants declining ART felt more pressure to decide alone compared with those taking ART (P < 0.01). Decisional conflict was expressed by 53% and was highest when physicians unilaterally made decisions about ART for patients who preferred shared decision making (P < 0.001).

CONCLUSIONS

In this study, most physicians do not meet their patients' desired roles in decision making. One-third of people taking ART feel less involved than they desire. More critically, half of those declining ART feel pressured to decide alone, suggesting that physicians should remain involved in the decision to reject treatment, as this requires careful monitoring and periodical revisiting. Because lack of shared decision making is related to decisional conflict, physicians may reduce decisional conflict by meeting patients' desires for shared decision making.

Higher preference for participation in treatment decisions is associated with lower medication adherence in asthma patients

OBJECTIVE

To investigate the interrelations between medication adherence, self-management, preference for involvement in treatment decisions and preference for information in asthma patients in primary care.

METHODS

One hundred and eighty-five patients from 43 practices completed a series of questionnaires, which included the 'Autonomy Preference Index' (API) [range=0-100], the four-item Morisky self-report medication adherence questionnaire and structured questions about asthma severity, medication and self-management.

RESULTS

The mean (S.D.) for participation preference was 34.5 (15.3) whereas the mean (S.D.) for information preference was 91.1 (9.7). Higher participation preference was associated with stopping medication when feeling better (OR 1.03; 95%CI 1.01-1.06) or feeling worse (OR 1.02; 95%CI 1.0-1.05) but it was not related to asthma severity. Higher information preference was associated with non-adherence to medication (Spearman correlation coefficient 0.166; p=0.035) as well as the wish to receive asthma education (p=0.04) and usage of peak flow meter (p=0.05).

CONCLUSION

Participation preference was low in general. Higher preference for involvement may entail more motivation for self-management but also lower medication adherence. This may be explained by a continuous internal negotiation process to accept the potentially lifelong demands of the disease.

PRACTICE IMPLICATIONS

Patients with lower medication adherence may possibly be addressed and empowered by their enhanced preference for participation in treatment decisions. Physicians offering to share treatment decisions may utilise the patients' participation preference to enhance medication adherence. Due to varying participation preferences, optimal patient preference matching, which involves more flexible use of different communication styles, may be necessary to improve outcomes.

General preferences for involvement in treatment decision making among European women with urinary incontinence

Current health care policies advocate patient participation in treatment decision making. Little evidence on possible differences between European women's preferences for involvement in this process exists. In this study we explore preferences for involvement in treatment decision making in 15 European countries in a sample of 9434 women seeking treatment for urinary incontinence in an outpatient setting. Their generally preferred role in treatment decisions was assessed using the Control Preferences Scale. Results show variations within and between countries in preferences for involvement in treatment decision making. The 'collaborative role' was the most preferred role in Austria, Belgium, Denmark, France, Germany, Ireland, Sweden, Switzerland, the Netherlands and the UK. In Greece, Portugal and Spain the 'passive role' was most preferred. Over a third of women in Denmark, Finland and Norway preferred an 'active role'. Multinominal regression analyses found that, after adjusting for case mix and factors previously associated with role preferences, country membership was strongly associated with role preferences, with women living in Southern European countries preferring a more passive role. Such clear differences are of interest in the current health care environment where active patient participation is being encouraged. Greater efforts need to be made to establish whether patient preferences are genuine or merely a learned response influenced by cultural attitudes and traditions so that a balance can be struck between assisting women to play a more active role in the treatment decision-making process without disregarding some women's genuine preferences to play a more passive role.

Treating asthma with a self-management model of illness behaviour in an Australian community pharmacy setting

Asthma affects a considerable proportion of the population worldwide and presents a significant health problem in Australia. Given its chronic nature, effective asthma self-management approaches are important. However, despite research and interventions targeting its treatment, the management of asthma remains problematic. This study aimed to develop, from a theoretical basis, an asthma self-management model and implement it in an Australian community pharmacy setting in metropolitan Sydney, using a controlled, parallel-groups repeated-measures design. Trained pharmacists delivered a structured, step-wise, patient-focused asthma self-management program to adult participants over a 9-month period focusing on identification of asthma problems, goal setting and strategy development. Data on process- clinical- and psychosocial-outcome measures were gathered. Results showed that participants set an average of four new goals and six repeated goals over the course of the intervention. Most common goal-related themes included asthma triggers, asthma control and medications. An average of nine strategies per participant was developed to achieve the set goals. Common strategies involved visiting a medical practitioner for review of medications, improving adherence to medications and using medications before exercise. Clinical and psychosocial outcomes indicated significant improvements over time in asthma symptom control, asthma-related self-efficacy and quality of life, and negative affect. These results suggest that an asthma self-management model of illness behaviour has the potential to provide patients with a range of process skills for self-management, and deliver improvements in clinical and psychosocial indicators of asthma control. The results also indicate the capacity for the effective delivery of such an intervention by pharmacists in Australian community pharmacy settings.

Factors affecting adherence to asthma treatment in an international cohort of young and middle-aged adults

BACKGROUND

A major reason of the poor control of asthma is that patients fail to adhere to their treatment. The aim of the study was to identify factors affecting changes in asthma treatment adherence in an international cohort.

METHODS

A follow-up study was carried out by means of a structured clinical interview in 971 subjects with asthma from 12 countries who participated in both the European Community Respiratory Health Survey: ECRHS-I (1990-94) and ECRHS-II (1998-2002). Subjects were considered adherent if they reported they normally took all the prescribed drugs. A logistic model was used to study the adjusted effect of the determinants.

RESULTS

The net change in adherence to anti-asthmatic treatment per 10 years of follow-up was -2% (95% CI: -9.5, 5.5), 7.5% (-2.6, 17.6), 15.0% (6.6, 23.5) and 19.8% (4.1, 35.5), respectively, in Nordic, Mediterranean, Continental and extra-European areas. Among the 428 non-adherent subjects in ECRHS-I, having regular consultations with health care professionals was the strongest predictor of increased adherence (OR 3.32; 95% CI: 1.08-10.17). Among the 543 adherent subjects in ECRHS-I, using inhaled corticosteroids significantly predicted a persistence of adherence (OR 2.04; 95% CI: 1.11-3.75). No effect of gender, age, duration of the disease, smoking habit and educational level was observed.

CONCLUSIONS

Our findings highlight the key role of doctors and nurses in educating and regularly reviewing the patients and support the efforts for an improvement of clinical communication.

Quality of care in patients with asthma and rhinitis treated by respiratory specialists and primary care physicians: a 3-year randomized and prospective follow-up study

BACKGROUND

Previous studies evaluating asthma care provided by primary care providers and respiratory specialists (RSs) are limited by short observation periods and nonrandomized designs.

OBJECTIVE

To evaluate long-term outcomes in patients with asthma and rhinitis randomly selected to be cared for by RSs or primary care specialists.

METHODS

In a randomized, 3-year, longitudinal study, 472 patients with asthma and allergic rhinitis were cared for by RSs or primary care physicians. Outcome measures, including disease severity, lung function, medication use, compliance, and self-management knowledge, were compared between groups.

RESULTS

Compared with patients followed up by primary care providers, those in the RS group had reduced asthma severity (P = .046), significantly fewer days with asthma symptoms (P < .01), and improved asthma self-management knowledge (P < .01). At baseline, most patients were undertreated. This value was significantly reduced from 74% to 37% in the RS group and from 71% to 57% in the primary care physician group. We found odds ratios of 8.5 (95% confidence interval, 2-43; P < .01) for worsening of asthma and 0.3 (95% confidence interval, 0.1-0.9; P = .04) for asthma improvement when followed up by primary care physicians, which indicates that primary care follow-up increases the risk of worsening of asthma and decreases the chance of improving. Similar results were observed in patients with allergic rhinitis, although the findings were less pronounced.

CONCLUSION

Treatment and follow-up by an RS ensured better quality of care in patients with asthma and rhinitis.

Complementary therapy use by patients and parents of children with asthma and the implications for NHS care: a qualitative study

BACKGROUND

Patients are increasingly using complementary therapies, often for chronic conditions. Asthma is the most common chronic condition in the UK. Previous research indicates that some asthma patients experience gaps in their NHS care. However, little attention has been given to how and why patients and parents of children with asthma use complementary therapies and the implications for NHS care.

METHODS

Qualitative study, comprising 50 semi-structured interviews with a purposeful sample of 22 adults and 28 children with asthma (plus a parent), recruited from a range of NHS and non-NHS settings in Bristol, England. Data analysis was thematic, drawing on the principles of constant comparison.

RESULTS

A range of complementary therapies were being used for asthma, most commonly Buteyko breathing and homeopathy. Most use took place outside of the NHS, comprising either self-treatment or consultation with private complementary therapists. Complementary therapies were usually used alongside not instead of conventional asthma treatment. A spectrum of complementary therapy users emerged, including "committed", "pragmatic" and "last resort" users. Motivating factors for complementary therapy use included concerns about conventional NHS care ("push factors") and attractive aspects of complementary therapies ("pull factors"). While participants were often uncertain whether therapies had directly helped their asthma, breathing techniques such as the Buteyko Method were most notably reported to enhance symptom control and enable reduction in medication. Across the range of therapies, the process of seeking and using complementary therapies seemed to help patients in two broad ways: it empowered them to take greater personal control over their condition rather than feel dependant on medication, and enabled exploration of a broader range of possible causes of their asthma than commonly discussed within NHS settings.

CONCLUSION

Complementary therapy use reflects patients' and parents' underlying desire for greater self-care and need of opportunities to address some of their concerns regarding NHS asthma care. Self-management of chronic conditions is increasingly promoted within the NHS but with little attention to complementary therapy use as one strategy being used by patients and parents. With their desire for self-help, complementary therapy users are in many ways adopting the healthcare personas that current policies aim to encourage.