Impact of shared decision making on asthma quality of life and asthma control among children

The effect of web-designed education on medication adherence, asthma control and fatigue in patients with asthma: A randomized controlled trial

AIMS

This study aimed to determine the effect of web-designed education developed for asthma patients on drug adherence, asthma control and fatigue.

METHODS

This randomized controlled trial was conducted between August 2021 and January 2022 with 200 individuals suffering from poor asthma control who participated in web-designed education. After the intervention, the asthma patients were followed up for 6 weeks to measure Medication Adherence Report Scale (MARS), Chronic Obstructive Pulmonary Disease and Asthma Fatigue Scale (CAFS), Asthma Control Test (ACT) and Inhalation Devices Usage Techniques Knowledge Test (IDUSTKT). Data were analysed in the Statistical Package for the Social Sciences program using the Chi-square test, Independent t-test, Man-Whitney U test, Wilcoxon test, Paired t-test, Greenhouse-Geisser (F) test and Linear regression.

RESULTS

The web-designed education had a statistically significant effect on the total scores of CAFS, ACT and IDUSTKT for individuals with asthma (p < 0.001). This intervention decreased fatigue levels, improved asthma control and enhanced knowledge of inhalation device usage techniques. Although there was an improvement in medication adherence, this difference was not statistically significant.

CONCLUSION

These results suggest that web-based educational programs can be an effective tool in asthma management and may improve patients' quality of life. Future research should examine the long-term effects of such educational programs and their effectiveness across different demographic groups in more detail.

Unlocking Better Asthma Control: A Narrative Review of Adherence to Asthma Therapy and Innovative Monitoring Solutions

This review addresses the ongoing challenges in asthma management, particularly focusing on patient adherence to inhaler therapy. Asthma, a chronic condition characterized by variable respiratory symptoms and airflow obstruction, can lead to significant morbidity and mortality if not properly managed. Despite advances in inhaler technology and therapeutic options, non-adherence remains a significant barrier to optimal asthma control. This review explores both intentional and unintentional non-adherence, influenced by factors such as age, socioeconomic status, and the complexity of inhaler devices. The Global Initiative for Asthma (GINA) provides guidelines aimed at improving adherence through targeted interventions, and this review examines their application. Common inhaler technique errors, including incorrect inhalation speed, not exhaling before inhaling, and failure to hold breath post-inhalation, are identified as major contributors to inadequate asthma control. Furthermore, the review explores the emerging role of electronic monitoring devices (EMDs), such as CapMedic and DigiHaler, which offer real-time feedback to enhance inhaler technique and adherence. The role of biomarkers in assessing adherence and the potential of personalized treatment strategies, including biologic therapies, are also discussed. Overall, addressing adherence requires a comprehensive approach that integrates patient education, tailored interventions, and technological innovations to achieve better clinical outcomes in asthma management.

Decisions With Patients, Not for Patients: Shared Decision-Making in Allergy and Immunology

Shared decision-making (SDM) is an increasingly implemented patient-centered approach to navigating patient preferences regarding diagnostic and treatment options and supported decision-making. This therapeutic approach prioritizes the patient's perspectives, considering current medical evidence to provide a balanced approach to clinical scenarios. In light of numerous recent guideline recommendations that are conditional in nature and are clinical scenarios defined by preference-sensitive care options, there is a tremendous opportunity for SDM and validated decision aids. Despite the expansion of the literature on SDM, formal acceptance among clinicians remains inconsistent. Surprisingly, a significant disparity exists between clinicians' self-reported adherence to SDM principles and patients' perceptions of its implementation during clinical encounters. This discrepancy underscores a fundamental issue in the delivery of health care, where clinicians may overestimate their integration of SDM, while patients' experiences suggest otherwise. This review critically examines the factors contributing to this inconsistency, including barriers within the health care system, clinician attitudes and behaviors, and patient expectations and preferences. By elucidating these factors in the fields of food allergy, asthma, eosinophilic esophagitis, and other allergic diseases, this review aims to provide insights into bridging the gap between clinician perception and patient experience in SDM. Addressing this discordance is crucial for advancing patient-centered care and ensuring that SDM is not merely a theoretical concept but a tangible reality in the.

Effectiveness of pediatric asthma education program in the context of a general hospital in France: A retrospective real-life study

Objective

To assess the feasibility and effectiveness of a pediatric asthma education program delivered in the context of a French suburban general hospital.

Design

Monocentric retrospective study including children with asthma in Melun, Île-de-France, from January to December 2019. Data collected concerned asthma management, symptoms, education, and knowledge.

Results

We included 262 patients with a median age of 4.5 years. Asthma education (AE) was taught to 226 (86 %) children, 36 with minimal education (ME), 155 (69 %) with an unstructured asthma education program (USEP) and 71 (31 %) a structured asthma education program (SEP). Patients with an SEP had better knowledge of the disease and its treatment as compared with those with a USEP or ME (p < 0.05). Lung function was evaluated for 70 % of children with ME, 90 % with a USEP (p = 0.144) and 77 % an SEP (p = 0.455). Allergy testing was assessed for 42 % of children with ME, 69 % a USEP (p = 0.020) and 57 % an SEP (p = 0.185). Almost all children with USEP (93 %) and SEP (94 %) also had a written asthma action plan as compared with 49 % of the children with ME (p < 0.001). Also, 76 % of children with ME did not have an asthma follow-up as compared with 37 % with a USEP and 52 % an SEP. Overall, 69 % of children with ME had at least one hospitalization within the year as compared with 32 % with a USEP (p = 0.001) and 59 % an SEP (p = 0.506).

Conclusions

An asthma education program delivered in a general hospital resulted in increased disease knowledge for children and their caregivers, together with reduced acute interventions.

Objectives for algorithmic decision-making systems in childhood asthma: Perspectives of children, parents, and physicians

Objectives

To identify with children, parents and physicians the objectives to be used as parameters for algorithmic decision-making systems (ADMSs) adapting treatments in childhood asthma.

Methods

We first conducted a qualitative study based on semi-structured interviews to explore the objectives that children aged 8-17 years, their parents, and their physicians seek to achieve when taking/giving/prescribing a treatment for asthma. Following the grounded theory approach, each interview was independently coded by two researchers; reconciled codes were used to assess code frequency, categories were defined, and the main objectives identified. We then conducted a quantitative study based on questionnaires using these objectives to determine how children/parents/physicians ranked these objectives and whether their responses were aligned.

Results

We interviewed 71 participants (31 children, 30 parents and 10 physicians) in the qualitative study and identified seven objectives associated with treatment uptake and five objectives associated with treatment modalities. We included 291 participants (137 children, 137 parents, and 17 physicians) in the quantitative study. We found little correlation between child, parent, and physician scores for each of the objectives. Each child's asthma history influenced the choice of scores assigned to each objective by the child, parents, and physician.

Conclusion

The identified objectives are quantifiable and relevant to the management of asthma in the short and long term. They can therefore be incorporated as parameters for future ADMS. Shared decision-making seems essential to achieve consensus among children, parents, and physicians when choosing the weight to assign to each of these objectives.

Real-world use and perceptions of shared decision-making for allergy and asthma care in a US population

Background

Shared decision-making (SDM), the process of engaging patients in their healthcare decisions, is an integral component of personalized medicine. The use of SDM in real-world allergy and asthma care in the United States (US) is unknown. Cross-sectional surveys of allergists and patients in a US population were conducted to assess the use and perceptions of SDM and SDM tools in real-world allergy and asthma care.

Methods

Allergists (N = 101) who were members of the American College of Allergy Asthma & Immunology (ACAAI) and who were also Dynata (a marketing research firm) research partners or in the Allergy & Asthma Network customer database completed an online survey from February-March 2022. Adult patients (N = 110) with asthma, allergy, and/or eczema in the United States who were participants of online research panels hosted by Dynata completed on online survey from February 1-7, 2022.

Results

Based on their own definition, 98% of the allergists reported familiarity with SDM, and 79% reported using it frequently. Allergists reported using SDM with an average of 44% of their patients. The most commonly used tool was the Immunotherapy SDM toolkit (40%); 43% had not used any SDM tool. Among allergists not using SDM or using it infrequently (n = 19), 42% considered it too time-consuming and 37% believed their patients have low health literacy. Of the surveyed patients, 25% reported their provider used SDM "frequently" or "occasionally" when being treated for allergies, asthma, or eczema, and 22% reported using SDM tools with their provider at some point. The most commonly used tool was the Asthma and Allergy Symptom Test (60%). Among patients whose allergists used SDM infrequently or never (n = 56), 70% reported they would be likely to ask their allergist to use SDM more often.

Conclusion

Survey responses revealed a disconnect between allergists and patients regarding SDM use. Barriers to SDM are consistent with those across the healthcare industry. Patients clearly expressed their desire for SDM.

GEMA 5.3. Spanish Guideline on the Management of Asthma

The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).

Perception of Illness and Fear of Inhaled Corticosteroid Use among Parents of Children with Asthma

The most prevalent children's chronic disease worldwide is asthma which has notable negative impacts on patients' and parent's quality of life. Daily inhaled corticosteroids (ICS) therapy is a preferred controller choice. This study was conducted on 148 parents of asthmatic children to establish parents' perception of illness and fear of inhaled corticosteroids using B-IPQ and TOPICOP questionnaires. Children were in the majority male (66.9%), older than five years (58.8%), with comorbidities, and family history of atopy. Parents were female, with a mean age of 38, employed, and with a history of some form of corticosteroid use. Most parents were not afraid of ICS usage (71.6%). Unemployed parents and parents who had no medical education had a statistically significantly higher fear of using ICS (p = 0.002, p = 0.03). A child's illness affects the parents' lives and parents who are afraid of using ICS react more emotionally to the child's illness. Better understanding and less concerned about child's disease are parents of children with controlled asthma. The parents' perspective of children's asthma will affect the duration and dose of ICS treatment they will give to their children and directly influence the level of asthma control.

Patients' preferences in therapeutic decision-making in digestive oncology: a single centre cross-sectional observational study

Considering the preferences in Shared Decision Making (SDM) of patients with Digestive Cancer (DC) is crucial to ensure the quality of care. To date, there is limited information on preferences in SDM of patients with DC. The objectives of this study were to describe digestive cancer patients' preference for involvement in therapeutic decision-making and to identify variables associated with these preferences. An observational prospective study in a French university cancer center has been conducted. Patients completed two questionnaires to qualify and quantify their preference for involvement in therapeutic decision-making: the Control Preference Scale (CPS) and the Autonomy Preference Index (API), which is composed of the Decision Making (DM) score and the Information Seeking (IS) score. Associations between these scores and socio-demographic data, disease-related data, coping strategies (Brief-COPE), physical (QLQ-C30) and psychological (HADS) quality of life were tested. One-hundred fifteen patients returned the questionnaires. The majority of patients reported a passive (49.1%) or a collaborative (43.0%) CPS status. The mean DM score was 39.4 Variables associated with decision-making preferences were occupational status and time since diagnosis. The identification of variables associated with patients' preferences for involvement in decision-making can help make clinicians aware of patients' needs and wishes. However, it can only be determined by interviewing the patient individually.

Multimedia Mixed Reality Interactive Shared Decision-Making Game in Children with Moderate to Severe Atopic Dermatitis, a Pilot Study

(1) Objective: Atopic dermatitis (AD) is a recurring skin disease that affects children’s daily activities and sleep quality. Due to the limitations of children’s understanding and ability to express themselves, shared decision making (SDM) is often made by guardians, which thus affects the acceptance and effectiveness of children’s treatments. Previous studies have demonstrated that involving both children and parents in decision making may help improve treatment outcomes; thus, we designed a multimedia mixed reality (MR) interactive game of SDM for children with moderate to severe AD. (2) Methods: Research participants included 6–18-year-old patients with moderate to severe AD. This research consisted of the following steps: designing SDM; character setting and visual design; performing games; system modification and optimization; screen editing and dubbing; and user testing and questionnaires by the System Usability Scale (SUS). (3) Results: We completed the SDM design for children with moderate to severe AD. Four different treatments were biologics, oral immune-modulating drugs, phototherapy, and wet wrap. An animated PowerPoint slide showed the AD apple rolling around before treatments and the AD apple sleeping soundly after treatments. Instructions with video teaching for the four different treatments were played, and then, the MR was turned on so that the patients could help the AD apple in the metaverse to undergo these four treatments. A total of 12 moderate to severe AD patients and six control patients used the game, all aged between six and eighteen years old, with an average SUS score of 81.0 and a standard error of 2.1 points. Adjective ratings yielded a rating between good and excellent. The game showed acceptable usability. We found no statistically significant differences in SUS scores between patients with and without moderate to severe AD or between boys and girls nor significant associations between SUS and age or severity. The analysis identified that the two items with the lowest SUS scores were “I think that I would need the support of a technical person to be able to use this product” and “I needed to learn a lot of things before I could get going with this product”. Both of these comments show the limitations of this game. (4) Conclusions: Overall, this study provides the first MR SDM game that has passed the SUS and can be used as an aid in clinical SDM.

Clinical Impact of Electronic Monitoring Devices of Inhalers in Adults with Asthma or COPD: A Systematic Review and Meta-Analysis

We conducted a systematic review and meta-analysis to gain insight into the characteristics and clinical impact of electronic monitoring devices of inhalers (EMDs) and their clinical interventions in adult patients with asthma or COPD. The search included PubMed, Web of Science, Cochrane, Scopus and Embase databases, as well as official EMDs websites. We found eight observational studies and ten clinical trials, assessing a wide range of clinical outcomes. Results from the meta-analysis on adherence to inhalers in a period over three months were favourable in the EMD group (fixed effects model: SMD: 0.36 [0.25–0.48]; random effects model SMD: 0.41 [0.22–0.60]). An exploratory meta-analysis found an improvement in ACT score (fixed effect model SMD: 0.25 [0.11–0.39]; random effects model: SMD: 0.47 [−0.14–1.08]). Other clinical outcomes showed mixed results in the descriptive analyses. The findings of this review highlight the benefits of EMDs in the optimization of adherence to inhaled therapy as well as the potential interest in other clinical outcomes.

Health-related quality of life decreases in young people with asthma during the transition from adolescence to young adulthood: a birth cohort study

BACKGROUND

During the transition from paediatric to adult healthcare there is a gap between asthma guidelines and actual management with decreased healthcare consultations and dispensations of asthma medications after the transition to adult healthcare among young people with asthma. How health-related quality of life (HRQoL) develops during the transition from adolescence to young adulthood is unclear. Our aim was therefore to investigate HRQoL among young people with asthma during the transition to adulthood. Further, to assess if level of asthma control and physical activity influence any potential association between asthma and HRQoL.

METHODS

The study population consisted of 2268 participants from the ongoing Swedish population-based prospective birth cohort BAMSE (Barn/Child, Allergy, Milieu, Stockholm, Epidemiology). HRQoL was measured using the instrument EQ-5D-3 L and three general questions. The EQ-5D-3 L consists of the EQ-5D descriptive system and the EQ visual analogue scale (EQ VAS). The EQ-5D-3 L instrument and questions on general health, symptoms and treatment of asthma, and lifestyle factors were based on data from follow-ups at 16 and 24 years. Cross-sectional analyses were made.

RESULTS

At the 24-year follow-up, the adjusted median values of EQ VAS were lower compared with at the 16-year follow-up; among both participants with asthma (80 vs. 85, p < 0.01) and those without asthma (80 vs. 87, p < 0.01). At the 24-year follow-up, participants with uncontrolled asthma had a lower adjusted median EQ VAS score than peers with controlled/partly controlled asthma (75 vs. 80, p = 0.03). Further, young adults with asthma who did not fulfil the WHO recommendations on physical activity had lower EQ VAS scores than peers who did (70 vs. 80, p < 0.01).

CONCLUSION

HRQoL is lower in young adulthood than in adolescence. Young adults with asthma having uncontrolled disease or who are physically inactive appear to be particularly vulnerable.

Implementation of Coach McLungsSM into primary care using a cluster randomized stepped wedge trial design

Background

Asthma is a prevalent chronic disease that is difficult to manage and associated with marked disparities in outcomes. One promising approach to addressing disparities is shared decision making (SDM), a method by which the patient and provider cooperatively make a decision about asthma care. SDM is associated with improved outcomes for patients; however, time constraints and staff availability are noted implementation barriers. Use of health information technology (IT) solutions may facilitate the utilization of SDM. Coach McLungs^SM is a collaborative web-based application that involves pediatric patients, their caregivers, and providers in a personalized experience while gathering patient-reported data. Background logic provides decision support so both audiences can develop a well-informed treatment plan together. The goal of this study is to evaluate the implementation of the Coach McLungs^SM intervention into primary care.

Methods

Implementation will be evaluated using a stepped wedge randomized control study design at 21 pediatric and family medicine practices within a large, integrated, nonprofit healthcare system. We will measure changes in emergency department visits, hospitalizations, and oral steroid use, which serve as surrogate measures for patient-centered asthma outcomes. We will use a generalized linear mixed models with logit link to test the hypothesis for the reduction in exacerbation rates specifying the fixed effects of intervention and time and random effects for practice and practice*time. This design achieves 84% power to detect the hypothesized effect size difference of 10% in overall exacerbation between control (40%) and intervention (30%) periods (two-sided, p = 0.05). Implementation will be guided using the Expert Recommendations for Implementing Change (ERIC), a compilation of implementation strategies, and evaluated using the CFIR (Consolidated Framework for Implementation Research) and RE-AIM (Reach Effectiveness, Adoption, Implementation, Maintenance).

Discussion

We anticipate that a tailored implementation of Coach McLungs^SM across diverse primary care practices will lead to a decrease in emergency department visits, hospitalizations, and oral steroid use for patients in the intervention group as compared to the control condition.

Trial Registration: Clincaltrials.gov, NCT05059210. Registered 28 September 2021, https://www.clinicaltrials.gov/ct2/show/NCT05059210

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-02030-1.

Challenges in uncontrolled asthma in pediatrics: important considerations for the clinician

INTRODUCTION

Despite symptoms control being the primary focus of asthma management according to guidelines, uncontrolled asthma is still an issue worldwide, leading to huge costs and asthma deaths at all ages. In childhood, poor asthma control can be even more harmful, as it can irreversibly compromise the children's lung function and the whole family's well-being.

AREAS COVERED

Given the problem extent, this review aims to discuss the leading modifiable causes of uncontrolled asthma in Pediatrics, giving some practical insights regarding the critical role of families and the main tools for monitoring control and drug adherence, even at a distance. The most recent GINA documents were used as the primary reference, along with the latest evidence regarding the management of asthma control and the impact of the COVID-19 pandemic on asthma.

EXPERT OPINION

In managing pediatric asthma, a multidisciplinary, multi-determinant, personalized approach is needed, actively involving families, schools, and other specialists. In addition to current strategies for implementing control, electronic health strategies, new validated asthma control tools, and the identification of novel inflammatory biomarkers could lead to increasingly tailored therapies with greater effectiveness in reaching asthma control.

Sociocultural influences on asthma self-management in a multicultural society: A qualitative study amongst Malaysian adults

BACKGROUND

Supported self-management improves asthma outcomes, but implementation requires adaptation to the local context. Barriers reported in Western cultures may not resonate in other cultural contexts. We explored the views, experiences and beliefs that influenced self-management among adults with asthma in multicultural Malaysia.

METHODS

Adults with asthma were purposively recruited from an urban primary healthcare clinic for in-depth interviews. Audio-recordings were transcribed verbatim and analysed thematically.

RESULTS

We interviewed 24 adults. Four themes emerged: (1) Participants believed in the 'hot and cold' concept of illness either as an inherent hot/cold body constitution or the ambient temperature. Hence, participants tried to 'neutralize' body constitution or to 'warm up' the cold temperature that was believed to trigger acute attacks. (2) Participants managed asthma based on past experiences and personal health beliefs as they lacked formal information about asthma and its treatment. (3) Poor communication and variable advice from healthcare practitioners on how to manage their asthma contributed to poor self-management skills. (4) Embarrassment about using inhalers in public and advice from family and friends resulted in a focus on nonpharmacological approaches to asthma self-management practice.

CONCLUSIONS

Asthma self-management practices were learnt experientially and were strongly influenced by sociocultural beliefs and advice from family and friends. Effective self-management needs to be tailored to cultural norms, personalized to the individuals' preferences and clinical needs, adapted to their level of health literacy and underpinned by patient-practitioner partnerships.

PATIENT AND PUBLIC CONTRIBUTIONS

Patients contributed to data. Members of the public were involved in the discussion of the results.

The Prevalence of Asthma among Iranian Children and Adolescent: A Systematic Review and Meta-Analysis

BACKGROUND

Asthma is an important reason for hospitalization in children aged under five years. Information about the current status of asthma in Iranian children can help the Iranian health sector plan carefully and prevent asthma incidence by educating the families. The present systematic review and meta-analysis is aimed at estimating asthma prevalence in Iranian children and adolescents.

METHOD

Data were found using keywords such as prevalence, epidemiology, asthma, adolescent, children, pediatrics, Iran in Web of Science, Scopus, PubMed, Cochrane, and Embase databases. Three national databases, including Magiran, Barakat Pharmed Co (Iran medex), and Scientific Information Databank (SID) were searched until 1 October 2020. Cross-sectional and original studies were included in the study, and then, quality assessment was done using the National Institutes of Health's Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. A pooled estimated prevalence of asthma was calculated using Der Simonian-Laird random model. Egger's test was used to evaluate publication bias. The data were analyzed using the STATA software version 16.

RESULTS

30 studies were selected and investigated. The prevalence of asthma in children and adolescents was 6% and 8%, and the prevalence in boys and girls was 9% and 8%, respectively. Among the asthma symptoms, wheezing had the most prevalence (17% in children and 19% in adolescents) and sleep disturbance had the lowest prevalence (6% in children and 6% in adolescents).

CONCLUSION

The prevalence of asthma in Iranian children and adolescents is lower than in the world. Existing strategies should be pursued followed. Also, guidelines for asthma control and prevention should be considered in the future.

Chronically ill children's participation and health outcomes in shared decision-making: a scoping review

Based on the United Nations Conventions on the Rights of the Child (CRC), it is a child's right to participate in all matters concerning its wellbeing. Little is known about chronically and/or critically ill children's participation in pediatric shared decision-making (SDM). We explored medical literature to see if and how these children participate in pediatric SDM. We searched relevant medical databases published between January 2008 and January 2020 for studies targeting children aged 4-18 years old, suffering from a chronic and/or critical disease. We found 9 relevant studies. SDM interventions mostly used were decision aids (n=8), questionnaires for caretakers/parents and children (n=4), and a SDM toolkit (n=2). Perceived involvement in SDM and knowledge increased amongst children, adolescents, and caretakers following these interventions. Decisional conflict measured using the 0-100 point DCS scale (higher scores indicate more decisional conflict) was reduced by 15.9 points in one study (p<0.01) and 17.8 points in another (95%CI: 13.3-22.9). Lower scores were associated with higher satisfaction with the decision aid by children, caretakers, and clinicians.Conclusion: Stakeholders should advocate initiatives to facilitate a child's participation preferences regarding pediatric SDM since decision support tools help chronically ill children to be more involved in SDM as they increase the children's knowledge and satisfaction and reduce decisional conflicts. What is Known: • Decision aids can help improve participation, knowledge, satisfaction, and health outcomes. • Quality and consistency of the information exchange impact quality and outcome of SDM. What is New: • Depending on a child's age, evolving capacities, and communication and participation preferences, more evidence is needed on which tools are suitable for chronically ill children to ensure their preferred participation in pediatric SDM. • Pediatricians adopt healthcare SDM tools and techniques that do not always take into account that a child's right to participate in pediatric SDM including the tendency to use interventions that are not specifically designed for pediatrics.

[The role of written action plans in the management of asthma]

The Written Action Plan is a tool designed to help people with asthma to manage their condition when they experience an exacerbation. Asthma guidelines are consistent in their recommendation that action plans are useful for all people with asthma, but implementation is not systematic. The evidence base for such plans is limited because of methodological biases, but does support their effectiveness. The recommended action plan involves different color-coded zones which advise patients to adjust their management, such as increasing the level of daily treatment, or introducing oral corticosteroids based on symptoms and peak expiratory flow measurements. Recommendations are much less clear as to how to encourage patients to adopt and take ownership of their plan, although they all recommend that written action plans be incorporated into therapeutic education programs. The published literature shows that those caring for people with asthma may not support action plans because they are uncomfortable with the necessary educational posture and as a consequence of this they are under-utilized by patients. Patient-centered therapeutic education principles help us understand both how to encourage the patient want to have a written action plan and how to co-create it with them so that it is useful and meaningful in their life in order to make it more than just a disconnected tool.

The Relationship Between Decisional Regret and Well-Being in Patients With and Without Depressive Disorders: Mediating Role of Shared Decision-Making

Background: The objectives of this study were two-fold: (1) to assess the relationship between patients' decisional regret and their well-being and (2) to examine the mediated effect of shared decision-making (SDM) on this relationship. Methods: A cross-sectional survey was conducted in five cities in Southern China. Patients were asked to fill out questionnaires assessing their decisional regret, SDM, subjective well-being, and depressive status. Mediation analysis was used to investigate the effect of SDM on the relationship between patients' decisional regret and their subjective well-being. Results: The findings showed significant direct negative effects of decisional regret on subjective well-being and SDM. For non-depressive patients, SDM exerted a significant and indirect effect on reducing the negative influence of decisional regret on subjective well-being. Conclusions: Findings suggest that implementation of SDM can decrease patients' decisional regret and improve their well-being; however, there is a need to examine their depressive status as part of routine healthcare.

The Challenges and Opportunities for Shared Decision Making Highlighted by COVID-19

Shared decision making (SDM) is a management paradigm that empowers patients as partners in their own care in a bidirectional exchange of information and values, and optimize the decision-making process. During the current coronavirus disease 2019 pandemic, there is a greater need to encourage participation in the SDM process. The pandemic has created both challenges and opportunities for delivering care, as system adaptations influence the physician-patient relationship. Although social distancing and health service reallocation can interfere with preference for an in-person visit, these measures also provide an avenue to study and implement virtual SDM processes. Communicating risk at a time of heightened uncertainty may pose a barrier to SDM engagement but provides the opportunity to foster a patient-centered approach within a more personalized context. Social media influence during coronavirus disease 2019 has resulted in an "infodemic" but highlights the importance of patient engagement. The pandemic has changed how we deliver care but allows us to re-evaluate common practices and enhance effectiveness of our management strategies. Navigating the uncertainty of subsequent pandemic waves creates confusion about how to safely reinitiate clinical service. This will require ongoing SDM with our patients and among colleagues through current-and future-challenges. Coronavirus disease 2019 has created many difficulties but has forced us to reexamine how to provide more patient-centered and high-quality care.

Research nurses as practice facilitators to disseminate an asthma shared decision making intervention

Background

Practice facilitation is a method of introducing and sustaining organizational change. It involves the use of skilled healthcare professionals called practice facilitators (PFs) to help address the challenges associated with implementing evidence-based guidelines and complex interventions into practice. PFs provide a framework for translating research into practice by building relationships, improving communication, fostering change, and sharing resources. Nurses are well positioned to serve as PFs for the implementation of complex interventions, however, there is little evidence currently available to describe nurses in this role. Additionally, the best strategies to implement complex interventions into practices are still not fully understood. Combining practice facilitation with the train-the-trainer model has the potential to spread knowledge and skills. Shared decision making (SDM), which involves patients and providers jointly engaging in decisions around treatment options, has been shown to improve outcomes for patients with asthma. The goal of this manuscript is to describe and evaluate the practice facilitation process from the ADAPT-NC Study which successfully utilized research nurses to implement a complex asthma SDM toolkit intervention into primary care practices.

Methods

As part of a larger study, 10 primary care practices were recruited for a facilitator-led dissemination intervention involving a 12-week rollout of an asthma SDM toolkit (trial registration: 1.28.2014, #NCT02047929). An experienced lead PF trained research nurses as PFs from each of the 4 participating practice-based research networks (PBRNs) in a train-the-trainer model utilizing a one-day training event and subsequent remote meetings. Evaluation of PF engagement was measured through process improvement surveys.

Results

Overall, the asthma SDM intervention was successfully implemented within the 4 PBRNs. All 10 facilitator-led practices remained engaged with their PFs, with 8 out of the 10 practices able to incorporate and sustain SDM visits or clinics. Responses from the surveys for process improvement yielded improved PF communication and team dynamics over time.

Conclusions

This study demonstrated effective use of research nurses as practice facilitators during the dissemination of an asthma SDM intervention into primary care practices, adding to the knowledge of best practices by describing a model of large-scale implementation of a complex intervention through practice facilitation with nurses.

Trial registration

“Comparing Traditional and Participatory Dissemination of a Shared Decision Making Intervention” was retrospectively registered at https://clinicaltrials.gov/ on January 28th, 2014 (NCT02047929).

Evaluation of a shared decision-making intervention for pediatric patients with asthma in the emergency department

BACKGROUND

Asthma is a difficult-to-manage chronic disease marked with associated outcome disparities including an increase rate of emergency department (ED) visits for uncontrolled asthma among patients who are most at-risk. Shared decision making (SDM) is a process by which the patient and provider jointly make a healthcare choice. SDM improves patient outcomes; however, implementation barriers of time constraints and staff availability are limitations. The use of health IT solutions may increase the adoption of SDM, but best practices for implementation are not well understood. The Consolidated Framework for Implementation Research (CFIR) is a flexible comprehensive model used to identify barriers and facilitators influencing implementation. The goal of this study is to implement an innovative web-based pediatric SDM tool in the real-world setting of two large healthcare system EDs through the following aims: (1) convene a patient, research, and ED stakeholder advisory board to oversee review of protocol and study materials prior to implementation, (2) implement the SDM intervention where providers and staff will be trained to incorporate use of this SDM intervention, (3) conduct on-going evaluation of barriers, facilitators, and implementation outcomes to tailor implementation in the EDs, (4) evaluate patient-centered outcomes of primary care utilization and changes in ED visits and hospitalizations before and after the SDM intervention, and (5) understand and document best practices for ED implementation.

METHODS

The CFIR model will guide the implementation evaluation. Researchers will administer surveys to the clinical team and patients at baseline, 3, 6, and 12 months to inform implementation design, determine barriers and facilitators, and resource-needs to allow for real-time process adjustments within the EDs. Focus group or key-informant interviews and analysis will provide additional feedback to the stakeholder team to iterate the implementation process. Researchers will track patient-centered outcomes including increased primary care, ED, and inpatient utilization over the duration of the study.

DISCUSSION

To advance asthma care and the field of implementation science, further research is needed to assess best practices for incorporating SDM into high-need healthcare settings such as the ED. This knowledge will facilitate improved outcomes and appropriate policy changes towards further use of SDM interventions in local and national acute care settings.

Application of Once-Monthly Self-Reported ACT Questionnaire in Management of Adherence to Inhalers in Outpatients with Asthma

PURPOSE

Poor medication adherence can negatively affect health outcomes of patients with asthma from medication and significantly increase the healthcare costs. Management of adherence to inhalers remains a challenging topic in the long-term management of patients with asthma. We aim to evaluate the role of asthma control test (ACT) in the management of adherence to inhalers in outpatients with asthma.

PATIENTS AND METHODS

Six hundred twenty-seven outpatients with asthma admitted to the clinic of respiratory medicine in a tertiary hospital in northwestern China during 2016 to 2019 were randomly divided into observation group (n= 315) and control (n= 312) and received standard inhalant therapy for 6 months and lung function test before and after treatment. The patients in the observation group took ACT questionnaires at the end of each month, while the patients in control only took an ACT at the end of the last month. The 'Test of Adherence to Inhalers' (TAI) questionnaire was used to evaluate the patients' adherence to inhalant therapy.

RESULTS

All patients completed the study. The ACT scores in the observation group showed a gradual increase month by month. The TAI results indicated that adherence to inhalers of patients in the observation group was significantly better than that in control and the patients' non-adherence pattern in the observation group, with significantly lower erratic non-adherence, was also different from that in control. After 6 months of treatment, the lung function indexes and their relative improvement and the ACT scores in the observation group were significantly better or higher than those in control.

CONCLUSION

The once-monthly self-reported ACT can effectively improve the adherence to inhalers of outpatients with asthma mainly by addressing erratic non-adherence and improve the treatment effects, and thus deserves widespread use in the treatment adherence management in patients with asthma.

Using the Consolidated Framework for Implementation Research (CFIR) to evaluate implementation effectiveness of a facilitated approach to an asthma shared decision making intervention

OBJECTIVE

To describe the evaluation of implementation effectiveness of an asthma shared decision making (SDM) intervention at the 10 individual facilitator-led primary care practices in the ADAPT-NC Study using the Consolidated Framework for Implementation Research (CFIR).

METHODS

Practices were scored across 40 CFIR constructs within 5 domains using a previously published scoring system of -2 to +2. Based on overall construct scores, practices were then classified as high, medium, or low adopters. To evaluate clinical outcomes, changes in asthma exacerbations were assessed for emergency department (ED) visits, hospitalizations, and oral steroid prescription orders. Using regression analysis, the absolute change in percent for each outcome relative to the CFIR score for each practice was analyzed. (Trial registration #NCT02047929).

RESULTS

Implementation effectiveness was reflected in CFIR score differences with 7 high, 1 medium, and 2 low adopter practices. High adopters mostly scored well across all domains. Weaknesses were consistent amongst the 2 low adopters with lower scores in the Inner Setting, Characteristics of Individuals, and Process domains. While no significant correlations were seen between the practices' CFIR scores and the absolute change in ED visits, hospitalizations, or oral steroid prescription orders, practices with higher percentages of children had greater improvements in clinical outcomes.

CONCLUSIONS

The CFIR was used to evaluate the asthma SDM intervention implementation at 10 facilitator-led practices. While there was no significant correlation between higher implementation effectiveness and greater improvement in clinical outcomes, practices with a higher proportion of pediatric patients did experience a significant reduction in overall exacerbations post-implementation.

Evaluation of a shared decision-making communication skills training for physicians treating patients with asthma: a mixed methods study using simulated patients

Background

Shared decision-making (SDM) is a key principle in asthma management, but continues to be poorly implemented in routine care. This study aimed to evaluate the impact of a SDM communication skills training for physicians treating patients with asthma on the SDM behaviors of physicians, and to analyze physician views on the training.

Methods

A mixed methods study with a partially mixed sequential equal status design was conducted to evaluate a 12 h SDM communication skills training for physicians treating patients with asthma. It included a short introductory talk, videotaped consultations with simulated asthma patients, video analysis in small group sessions, individual feedback, short presentations, group discussions, and practical exercises. The quantitative evaluation phase consisted of a before (t0) after (t1) comparison of SDM performance using the observer-rated OPTION⁵, the physician questionnaire SDM-Q-Doc, and the patient questionnaire SDM-Q-9, using dependent t-tests. The qualitative evaluation phase (t2) consisted of a content analysis of audiotaped and transcribed interviews.

Results

Initially, 29 physicians participated in the study, 27 physicians provided quantitative data, and 22 physicians provided qualitative data for analysis. Quantitative results showed significantly improved performance in SDM following the training (t1) when compared with performance in SDM before the training (t0) (OPTION⁵: t (26) = − 5.16; p < 0.001) (SDM-Q-Doc: t (26) = − 4.39; p < 0.001) (SDM-Q-9: t (26) = − 5.86; p < 0.001). The qualitative evaluation showed that most physicians experienced a change in attitude and behavior after the training, and positively appraised the training program. Physicians considered simulated patient consultations, including feedback and video analysis, beneficial and suggested the future use of real patient consultations.

Conclusion

The SDM communication skills training for physicians treating patients with asthma has potential to improve SDM performance, but would benefit from using real patient consultations.

Spread tools: a systematic review of components, uptake, and effectiveness of quality improvement toolkits

BACKGROUND

The objective was to conduct a systematic review of toolkit evaluations intended to spread interventions to improve healthcare quality. We aimed to determine the components, uptake, and effectiveness of publicly available toolkits.

METHODS

We searched PubMed, CINAHL, and the Web of Science from 2005 to May 2018 for evaluations of publicly available toolkits, used a forward search of known toolkits, screened references, and contacted topic experts. Two independent reviewers screened publications for inclusion. One reviewer abstracted data and appraised the studies, checked by a second reviewer; reviewers resolved disagreements through discussion. Findings, summarized in comprehensive evidence tables and narrative synthesis addressed the uptake and utility, procedural and organizational outcomes, provider outcomes, and patient outcomes.

RESULTS

In total, 77 studies evaluating 72 toolkits met inclusion criteria. Toolkits addressed a variety of quality improvement approaches and focused on clinical topics such as weight management, fall prevention, vaccination, hospital-acquired infections, pain management, and patient safety. Most toolkits included introductory and implementation material (e.g., research summaries) and healthcare provider tools (e.g., care plans), and two-thirds included material for patients (e.g., information leaflets). Pre-post studies were most common (55%); 10% were single hospital evaluations and the number of participating staff ranged from 17 to 704. Uptake data were limited and toolkit uptake was highly variable. Studies generally indicated high satisfaction with toolkits, but the perceived usefulness of individual tools varied. Across studies, 57% reported on adherence to clinical procedures and toolkit effects were positive. Provider data were reported in 40% of studies but were primarily self-reported changes. Only 29% reported patient data and, overall, results from robust study designs are missing from the evidence base.

CONCLUSIONS

The review documents publicly available toolkits and their components. Available uptake data are limited but indicate variability. High satisfaction with toolkits can be achieved but the usefulness of individual tools may vary. The existing evidence base on the effectiveness of toolkits remains limited. While emerging evidence indicates positive effects on clinical processes, more research on toolkit value and what affects it is needed, including linking toolkits to objective provider behavior measures and patient outcomes.

TRIAL REGISTRATION

PROSPERO registration number: PROSPERO 2014: CRD42014013930 .

The impact of a question prompt list and video intervention on teen asthma control and quality-of-life one year later: results of a randomized trial

Objective: This study examined whether youth who received an asthma question prompt list/video intervention were more likely to have their asthma controlled and better quality-of-life at 12 months than youth who received usual care.Methods: English or Spanish-speaking youth ages 11-17 were enrolled and randomized to intervention or usual care. The 185 youth and parents in the intervention group watched the video on an iPad and then received a one-page asthma question prompt list to complete before their visits. One hundred seventy-four received usual care. Baseline and 6-month visits were audio-tape recorded. Generalized Estimating Equations were used to predict a youth's quality-of-life and whether asthma was controlled at 12 months.Results: Asthma control and quality-of-life improved significantly from baseline to 12-month follow-up in both intervention and usual care groups. Baseline asthma control and quality-of-life were significantly associated with 12-month asthma control and quality-of-life, respectively. Adolescents on a control medication at baseline were significantly more likely to have their asthma controlled at 12 months.Conclusions: Asthma control and quality-of-life did not improve significantly more in the intervention group than in the usual care group.

Asthma control and quality of life in adolescents: The role of illness perceptions, medication beliefs, and adherence

Objective: Asthma control and quality of life (QoL) are important disease outcomes for asthma patients. Illness perceptions (cognitive and emotional representations of the illness) and medication beliefs have been found to be important determinants of medication adherence, and subsequently disease control and QoL in adults with asthma. In adolescents, this issue needs further elucidation. Therefore, the aim of this study was to explore the relationship between illness perceptions, medication beliefs, medication adherence, disease control, and QoL in adolescents with asthma.Methods: In this cross-sectional study, we used baseline data of adolescents with asthma (age 12-18 years) who participated in the ADolescent Adherence Patient Tool (ADAPT) study. Questionnaires were administrated online, and included sociodemographic variables and validated questionnaires measuring self-reported illness perceptions, medication beliefs, medication adherence, disease control, and QoL.Results: Data of 243 adolescents with asthma were available; age 15.1 ± 2.0 years and 53% females. More than half of these adolescents (62%; n = 151) reported to be non-adherent (Medication Adherence Report Scale ≤23) and 77% (n = 188) had uncontrolled asthma. There was a strong positive correlation between disease control and QoL (r = 0.74). All illness perceptions items were correlated with disease control and QoL, with the strongest correlation between 'identity' (symptom perception) and QoL (r=-0.66). Medication adherence was correlated to medication beliefs (r = 0.38), disease control (r = 0.23), and QoL (r = 0.14), whereas medication beliefs were only associated with adherence.Conclusions: Stimulating positive illness perceptions and medication beliefs might improve adherence, which in turn might lead to improved disease control and better QoL.

Shared decision making and time to exacerbation in children with asthma

Objective: Although shared decision making (SDM) is a promising approach for improving outcomes for patients with chronic diseases, no evidence currently supports the use of SDM to delay asthma exacerbations. We evaluated the impact of an SDM intervention implemented by providers in a real-world setting on time to exacerbation in children with asthma. Methods: This study used a prospective cohort observed between 2011 and 2013 at five primary care practices that serve vulnerable populations (e.g., Medicaid and uninsured patients) in Charlotte, NC. Patients aged 2 to 17 receiving SDM were matched to those receiving usual care using propensity scores. Time to asthma exacerbation (asthma hospitalization, emergency department visit or oral steroid prescription in the outpatient setting) was compared between groups using Kaplan-Meier curves and conditional Cox proportional hazards models. Results: The cohort included 746 children, 60.5% male and 54.2% African American, with a mean age of 8.6 years. Of these, 625 received usual care and 121 received SDM. The final analysis included 100 matched pairs of children. Kaplan-Meier curves showed longer exacerbation-free time for patients in the SDM intervention compared to those in usual care (p = 0.005). The difference in risk of experiencing an exacerbation was marginally significant between the two groups (HR = 0.56, 95% C.I. = 0.29-1.08, p = 0.08). Conclusions: SDM was found to delay exacerbations among children with asthma. Clinicians should consider incorporating patient preferences in treatment decisions through SDM as a means for longer exacerbation-free time among children with poor asthma control.

Patient and provider perspectives on uptake of a shared decision making intervention for asthma in primary care practices

OBJECTIVE

Poor outcomes and health disparities related to asthma result in part from difficulty disseminating new evidence such as shared decision making (SDM) into clinical practice. As part of a three-arm cluster randomized dissemination study, evaluation of the impact of different dissemination methods was studied. Here we evaluate themes from patient and provider focus groups to assess the impact of a facilitated, traditional dissemination approach, or no intervention, on patient and provider perspectives of asthma care.

METHODS

Using semi-structured questions, twenty-four pre- and post-intervention focus groups with patients and providers took place across primary care practices. Discussions were held in all three arms both before and after the time of intervention rollout. Audio recordings were transcribed and analyzed for themes.

RESULTS

Across all sites patients and providers discussed themes of communication, asthma self-management, barriers, education, and patient awareness. After the intervention, compared to traditional sites, facilitated practices were more likely to discuss themes related to SDM, such as patient-centered communication, patient-provider negotiation on treatment plan, planning, goal-setting, and solutions to barriers.

CONCLUSIONS

Emergent themes allowed for further understanding of how the SDM implementation was perceived at the patient and provider level. The facilitated implementation was associated with higher adoption of the SDM intervention. These themes and supporting quotes add to knowledge of best practices associated with implementing an evidence-based SDM intervention for asthma into primary care and will inform researchers, practices, and providers as they work to improve adoption of evidence-based interventions into practice.