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

Shared decision-making for supporting women's decisions about breast cancer screening

BACKGROUND

In breast cancer screening programmes, women may have discussions with a healthcare provider to help them decide whether or not they wish to join the breast cancer screening programme. This process is called shared decision-making (SDM) and involves discussions and decisions based on the evidence and the person's values and preferences. SDM is becoming a recommended approach in clinical guidelines, extending beyond decision aids. However, the overall effect of SDM in women deciding to participate in breast cancer screening remains uncertain.

OBJECTIVES

To assess the effect of SDM on women's satisfaction, confidence, and knowledge when deciding whether to participate in breast cancer screening.

SEARCH METHODS

We searched the Cochrane Breast Cancer Group's Specialised Register, CENTRAL, MEDLINE, Embase, CINAHL, PsycINFO, ClinicalTrials.gov, and the World Health Organization International Clinical Trials Registry Platform on 8 August 2023. We also screened abstracts from two relevant conferences from 2020 to 2023.

SELECTION CRITERIA

We included parallel randomised controlled trials (RCTs) and cluster-RCTs assessing interventions targeting various components of SDM. The focus was on supporting women aged 40 to 75 at average or above-average risk of breast cancer in their decision to participate in breast cancer screening.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed studies for inclusion and conducted data extraction, risk of bias assessment, and GRADE assessment of the certainty of the evidence. Review outcomes included satisfaction with the decision-making process, confidence in the decision made, knowledge of all options, adherence to the chosen option, women's involvement in SDM, woman-clinician communication, and mental health.

MAIN RESULTS

We identified 19 studies with 64,215 randomised women, mostly with an average to moderate risk of breast cancer. Two studies covered all aspects of SDM; six examined shortened forms of SDM involving communication on risks and personal values; and 11 focused on enhanced communication of risk without other SDM aspects. SDM involving all components compared to control The two eligible studies did not assess satisfaction with the SDM process or confidence in the decision. Based on a single study, SDM showed uncertain effects on participant knowledge regarding the age to start screening (risk ratio (RR) 1.18, 95% confidence interval (CI) 0.61 to 2.28; 133 women; very low certainty evidence) and frequency of testing (RR 0.84, 95% CI 0.68 to 1.04; 133 women; very low certainty evidence). Other review outcomes were not measured. Abbreviated forms of SDM with clarification of values and preferences compared to control Of the six included studies, none evaluated satisfaction with the SDM process. These interventions may reduce conflict in the decision made, based on two measures, Decisional Conflict Scale scores (mean difference (MD) -1.60, 95% CI -4.21 to 0.87; conflict scale from 0 to 100; 4 studies; 1714 women; very low certainty evidence) and the proportion of women with residual conflict compared to control at one to three months' follow-up (rate of women with a conflicted decision, RR 0.75, 95% CI 0.56 to 0.99; 1 study; 1001 women, very low certainty evidence). Knowledge of all options was assessed through knowledge scores and informed choice. The effect of SDM may enhance knowledge (MDs ranged from 0.47 to 1.44 higher scores on a scale from 0 to 10; 5 studies; 2114 women; low certainty evidence) and may lead to higher rates of informed choice (RR 1.24, 95% CI 0.95 to 1.63; 4 studies; 2449 women; low certainty evidence) compared to control at one to three months' follow-up. These interventions may result in little to no difference in anxiety (MD 0.54, 95% -0.96 to 2.14; scale from 20 to 80; 2 studies; 749 women; low certainty evidence) and the number of women with worries about cancer compared to control at four to six weeks' follow-up (RR 0.88, 95% CI 0.73 to 1.06; 1 study, 639 women; low certainty evidence). Other review outcomes were not measured. Enhanced communication about risks without other SDM aspects compared to control Of 11 studies, three did not report relevant outcomes for this review, and none assessed satisfaction with the SDM process. Confidence in the decision made was measured by decisional conflict and anticipated regret of participating in screening or not. These interventions, without addressing values and preferences, may result in lower confidence in the decision compared to regular communication strategies at two weeks' follow-up (MD 2.89, 95% CI -2.35 to 8.14; Decisional Conflict Scale from 0 to 100; 2 studies; 1191 women; low certainty evidence). They may result in higher anticipated regret if participating in screening (MD 0.28, 95% CI 0.15 to 0.41) and lower anticipated regret if not participating in screening (MD -0.28, 95% CI -0.42 to -0.14). These interventions increase knowledge (MD 1.14, 95% CI 0.61 to 1.62; scale from 0 to 10; 4 studies; 2510 women; high certainty evidence), while it is unclear if there is a higher rate of informed choice compared to regular communication strategies at two to four weeks' follow-up (RR 1.27, 95% CI 0.83 to 1.92; 2 studies; 1805 women; low certainty evidence). These interventions result in little to no difference in anxiety (MD 0.33, 95% CI -1.55 to 0.99; scale from 20 to 80) and depression (MD 0.02, 95% CI -0.41 to 0.45; scale from 0 to 21; 2 studies; 1193 women; high certainty evidence) and lower cancer worry compared to control (MD -0.17, 95% CI -0.26 to -0.08; scale from 1 to 4; 1 study; 838 women; high certainty evidence). Other review outcomes were not measured.

AUTHORS' CONCLUSIONS

Studies using abbreviated forms of SDM and other forms of enhanced communications indicated improvements in knowledge and reduced decisional conflict. However, uncertainty remains about the effect of SDM on supporting women's decisions. Most studies did not evaluate outcomes considered important for this review topic, and those that did measured different concepts. High-quality randomised trials are needed to evaluate SDM in diverse cultural settings with a focus on outcomes such as women's satisfaction with choices aligned to their values.

Shared decision making and medication adherence in patients with COPD and/or asthma: the ANANAS study

Background: Medication adherence to inhalation medication is suboptimal in patients with COPD and asthma. Shared decision making (SDM) is proposed as an intervention to improve medication adherence. Despite its wide promotion, evidence of SDM's association with greater medication adherence is scarce. Also, it is unknown to what degree patients presently experience SDM and how it is associated with medication adherence. Objective: To (i) assess the level of SDM and (ii) medication adherence, (iii) explore the relation between SDM and medication adherence and iv) investigate possible underlying mechanisms. Methods: Cross-sectional observational study. A survey was distributed among Dutch patients with COPD and/or asthma using inhaled medication. Medication adherence was measured using the Test of Adherence to Inhalers (TAI-10), and SDM by the 9-item Shared Decision-Making questionnaire (SMD-Q-9). Feeling of competence, relatedness and feeling of autonomy from the Self-Determination Theory (SDT) were considered as possible mechanisms. The primary outcome was adherence. Results: A total of 396 patients with complete information on relevant covariates were included. Mean SDM-Q-9 score was 26.7 (SD 12.1, range 0-45) and complete adherence was 41.2%. The odds ratio for the association of SDM with adherence was 1.01 (95% CI: 0.99, 1.02). This only changed minimally when adjusted for mediators (mediating effect <3%). Conclusion: The patient experienced level of SDM in daily practice and medication adherence have room for improvement. No association between SDM and medication adherence was observed. Factors related to feeling of competence, relatedness and feeling of autonomy did not meaningfully explain this finding.

A Shift in Asthma Treatment According to New Guidelines: An Evaluation of Asthma Patients' Attitudes towards Treatment Change

The Global Initiative for Asthma (GINA) has presented a shift in pharmacological asthma treatment. The objective of this study was to explore factors influencing a successful switch to a new asthma treatment approach with a focus on asthma patients' attitudes toward treatment change and supportive initiatives. This study was performed as a case study involving a quantitative questionnaire and a qualitative semi-structured interview. A total of 284 responses were collected from the questionnaire, and 141 responses were included. The results showed that asthma patients thought that effectiveness of the new treatment approach, doctor recommendation, and knowledge of the new treatment approach were the most important factors influencing treatment change considerations. Nine interviews were conducted where the main themes were barriers to a shift in asthma treatment, such as effects and side effects of the new treatment, the role of the general practitioner (GP) and conflicts in agreeing on a treatment plan; as well as facilitators to a shift in asthma treatment, such as trust in the GP and easier inhaler use. We found several supportive initiatives, such as consultation with the GP, handing out information leaflets and a consultation at the pharmacy. In conclusion, this study uniquely identified factors that may influence successful treatment shifts in asthma patients that may be instrumental in understanding similar situations in other pharmacological settings.

The environmental impact of inhalers for asthma; a green challenge and a golden opportunity

The propellants in metered-dose inhalers (MDIs) are powerful greenhouse gases, which account for approximately 13% of the NHS's carbon footprint related to the delivery of care. Most MDI use is in salbutamol relievers in patients with poorly controlled disease. The UK lags behind Europe in this regard, with greater reliance on salbutamol MDI and correspondingly greater greenhouse gas emissions; roughly treble our European neighbours'. There has been a broad switch towards MDIs in asthma treatment UK over the last 20 years to reduce financial costs, such that the treatment for two-thirds of asthma patients in the UK is dominated by salbutamol MDI. Strategies that replace overuse of reliever MDIs with regimes emphasising inhaled corticosteroids have the potential to improve asthma control alongside significant reductions in greenhouse gas emissions. Real-world evidence shows that once-daily long-acting combination dry-powder inhalers can improve compliance, asthma control and reduce the carbon footprint of care. Similarly, maintenance and reliever therapy (MART) which uses combination reliever and inhaled steroids in one device (usually a dry-powder inhaler) can simplify therapy, improve asthma control, and reduce greenhouse gas emissions. Both treatment strategies are popular with patients, most of whom would be willing to change treatment to reduce their carbon footprint. By focussing on patients who are currently using high amounts of salbutamol MDI, and prioritising inhaled steroids via dry-powder inhalers, there are golden opportunities to make asthma care in the UK more effective, safer, and greener.

A patient decision aid for mild asthma: Navigating a new asthma treatment paradigm

INTRODUCTION

In mild asthma, as-needed budesonide-formoterol offers similar protection from severe exacerbations as daily inhaled corticosteroids (ICS), with lower ICS exposure but slightly increased symptoms. We sought to develop an electronic decision aid to guide discussions about the pros and cons of these first-line options, while identifying and integrating user preferences.

METHODS

Following International Patient Decision Aid Standards, we created a mild asthma decision aid prototype comparing convenience, clinical outcomes, cumulative ICS dose exposure, costs, and side-effects of each option. After face validation, the prototype was iteratively adapted through rapid-cycle development. Each cycle consisted of a patient focus group and a primary care physician interview. We made user preference-based improvements after each round, until reaching a pre-set stopping criterion (no new critical issues identified). We then performed a summative qualitative content analysis.

RESULTS

Over 5 cycles, we recruited 21 asthma patients (12/21 women, 10/21 ≥ 60 years old) and 5 physicians. Serial changes included simplification and reduction of text and reading level, inclusion of an ICS "myths" section and elaboration of patient-friendly infographics for numerical comparisons. User preferences fell within Content, Format, and tool use Process themes. In response to decision-making preferences, we created a complementary one-page conversation aid for patient-provider use at the point-of-care.

CONCLUSIONS

We present preference-based electronic patient decision and conversation aids for treatment of mild asthma. Our user preference analyses offer useful insights for development of such tools in other chronic diseases. These tools now require integration into point-of-care workflows for measurement of real-world uptake and impact.

The preferences of people with asthma or chronic obstructive pulmonary disease for self-management support: A qualitative descriptive study

AIMS AND OBJECTIVES

The aim of this study was to explore and describe the self-management support (SMS) preferences of adults with asthma and/or chronic obstructive pulmonary disease (COPD).

BACKGROUND

Self-management support interventions have had beneficial outcomes for people with asthma and people with COPD, though challenges remain in their implementation. Increased understanding of the support preferences of people with asthma/COPD can help inform the development of future interventions to address patients' preferences.

DESIGN

A qualitative descriptive design was used.

METHODS

Semi-structured focus group and individual interviews were conducted with 20 adult participants who had asthma and/or COPD in Ireland. Qualitative content analysis was used to analyse interviews. The SRQR reporting guideline was used.

RESULTS

Three themes were identified. Support accessibility included having access to routine and unscheduled support from healthcare professionals with specialist knowledge. Consultation content described the need for comprehensive and person-centred support. The person-provider relationship described the value of healthcare professionals acknowledging patient concerns, noted as a challenge for people with asthma, and continuity in relationships over time.

CONCLUSIONS

Routine support for people with asthma/COPD needs to be comprehensive in addressing the individual patient's challenges. Access to timely advice during exacerbations was a priority for people with asthma/COPD, suggesting that flexible access to services as well as routine review may be optimal for supporting self-management of asthma/COPD. Feeling listened to regarding symptoms experienced may be of intrinsic value to people with asthma/COPD.

RELEVANCE TO CLINICAL PRACTICE

The study emphasises the importance of continued training in communications skills for healthcare professionals supporting people with asthma/COPD, particularly acknowledging the patient's concerns in the context of symptom changes/flare-up. A respiratory nurse specialist was valued as being a care coordinator who could support routine management as well as managing exacerbations, having specialist knowledge and knowing the patient over time.

Health Literacy and Decisional Preferences in Hand Surgery

PURPOSE

Patients increasingly prefer to be involved in health decisions. Shared decisions are associated with less decisional conflict and improved satisfaction. This study examines the relationship between health literacy and preferred decision-making role in patients seeking care for hand problems.

METHODS

We performed a cross-sectional study of 226 patients who were presenting to a hand service for the first time, who were older than 18 years, not pregnant, and fluent and literate in English. Patient demographic information, work status, and education level were collected from the patient. Diagnosis and insurance status were collected from the medical record. Pain interference, depression, and upper extremity function were measured using the Patient-Reported Outcomes Measurement Information System (PROMIS) questionnaires administered with computerized adaptive testing. Health literacy and preferred decision-making role were assessed using the Newest Vital Sign Test and Control Preference Scale, respectively. Discordance between preferred and actual decision-making role was assessed using the Control Preference Scale statements with the words "I prefer" omitted. Bivariate and multivariable logistic regressions were used to assess for factors associated with preferred decision-making role and discordance.

RESULTS

Seventy-eight percent of patients preferred an active or collaborative, rather than a passive, role in decision making. Sixty-one percent felt they had achieved their preferred role. Preferred role and achievement of that role were not associated with health literacy, age, race, insurance, work status, diagnosis, pain intensity, symptoms of depression, and magnitude of self-reported activity limitations. More years of education was associated with a more active preferred decision-making role but not with obtaining that preferred role.

CONCLUSIONS

Most people want to participate in decisions about their care even if they have low health literacy.

CLINICAL RELEVANCE

Hand specialists can seek strategies to help people understand and participate in care decisions.

Primary Care Pre-Visit Electronic Patient Questionnaire for Asthma: Uptake Analysis and Predictor Modeling

Background

mHealth tablet-based interventions are increasingly being studied and deployed in various health care settings, yet little knowledge exists regarding patient uptake and acceptance or how patient demographics influence these important implementation metrics.

Objective

To determine which factors influence the uptake and successful completion of an mHealth tablet questionnaire by analyzing its implementation in a primary care setting.

Methods

We prospectively studied a patient-facing electronic touch-tablet asthma questionnaire deployed as part of the Electronic Asthma Management System. We describe tablet uptake and completion rates and corresponding predictor models for these behaviors.

Results

The tablet was offered to and accepted by patients in 891/1715 (52.0%) visits. Patients refused the tablet in 33.0% (439/1330) visits in which it was successfully offered. Patients aged older than 65 years of age (odds ratio [OR] 2.30, 95% CI 1.33-3.95) and with concurrent chronic obstructive pulmonary disease (OR 2.22, 95% CI 1.05-4.67) were more likely to refuse the tablet, and those on an asthma medication (OR 0.55, 95% CI 0.30-0.99) were less likely to refuse it. Once accepted, the questionnaire was completed in 784/891 (88.0%) instances, with those on an asthma medication (OR 0.53, 95% CI 0.32-0.88) being less likely to leave it incomplete.

Conclusions

Older age predicted initial tablet refusal but not tablet questionnaire completion, suggesting that perceptions of mHealth among older adults may negatively impact uptake, independent of usability. The influence of being on an asthma medication suggests that disease severity may also mediate mHealth acceptance. Although use of mHealth questionnaires is growing rapidly across health care settings and diseases, few studies describe their real-world acceptance and its predictors. Our results should be complemented by qualitative methods to identify barriers and enablers to uptake and may inform technological and implementation strategies to drive successful usage.

Cross-sectional analysis of consumer-facing mHealth apps associated with inhaler monitoring for asthma

OBJECTIVE

This study aimed to describe the current landscape of consumer-directed mHealth apps that communicate with inhalers for asthma.

METHODS

We performed a cross-sectional and systematic analysis of Google Play and the Apple App Stores to identify apps that are consumer-direct and available in English, intended for patients with asthma and communicate with an inhaler-based sensor. We collected information about each app using the app stores and publicly available manufacturer websites. We reported the results descriptively.

RESULTS

We identified 6 apps, released as early as 2012. Of these, 5 apps require an external sensor available over the counter to be attached to the patient's inhaler, and 1 app communicates with a prescription-only inhaler that has a built-in sensor and will be dispensed from the pharmacy. Aside from passively monitoring inhaler adherence, all apps facilitate provider communication; serve as a diary; and use notifications, reminders, or alarms for things such as inhaler dose reminders. Additional features vary across apps, including direct pharmacy access for refill requests and telehealth and artificial intelligence to predict future asthma exacerbations.

CONCLUSION

We identified 6 consumer-directed mHealth apps that communicate with inhalers for asthma management. Pharmacists must be prepared to evaluate these apps, particularly in comparison with the first prescription-only inhaler built to communicate with an mHealth app to be released this year. To do so, further research on the outcomes and use of these apps is needed so that pharmacists can make evidence-based recommendations.

Essential Role of Pharmacists in Asthma Care and Management

Asthma, a chronic respiratory disease characterized by chronic airway inflammation, bronchial hyperresponsiveness, and reversible airflow obstruction, poses a substantial economic burden on patients and caregivers alike. Moreover, the heterogeneous nature of the disease and the presence of various phenotypes make the treatment of asthma challenging and nuanced. Despite the availability of several approved pharmacological treatments, approximately half of patients with asthma in the United States experienced exacerbations in 2016, highlighting the need for effective add-on treatments. Furthermore, asthma control remains suboptimal due to low adherence to medications, poor inhaler technique, and several patient-related factors. Importantly, the primary care setting, in which pharmacists play an integral role, represents a critical environment for providing long-term follow-up care for the effective management of chronic diseases, such as asthma. Pharmacists are uniquely positioned to ensure optimal clinical outcomes in patients with asthma since they have the clinical expertise to educate patients on their disease state and the role of asthma medications, provide training on inhalation technique, address patients’ concerns about potential side effects of medications, and improve adherence to therapy. Therefore, in this review article, we discuss the overall role of pharmacists in effective asthma care and management.

"You've got to breathe, you know" - asthma patients and carers' perceptions around purchase and use of asthma preventer medicines

OBJECTIVE

To explore influences on patients' purchase and use of asthma preventer medicines and the perceived acceptability of financial incentives via reduced patient co-payments.

METHODS

Semi-structured telephone or face-to-face interviews were conducted with adults and carers of children with asthma. Interviews were recorded, transcribed verbatim and coded. Data were analysed using thematic analysis via grounded theory.

RESULTS

Twenty-four adults and 20 carers for children aged 3-17 years with asthma were interviewed. For medicines choice, most participants did not consider themselves the primary decision-maker; cost of medicines was an issue for some, but effectiveness was described as more important. For adherence, cost, side-effects, perceived benefit and patient behaviours were important.

CONCLUSIONS

Patient barriers to adherence with asthma preventer medicines including cost are ongoing. Healthcare professionals need to encourage empathic discussion with patients about cost issues. Implications for public health: Asthma patients and carers could benefit from greater involvement and respect within shared decision-making. Healthcare professionals should be aware that cost may be a barrier for patient adherence, and provided with information about the relative costs of guideline-recommended asthma medicines. Patients and healthcare professionals need education around the efficacy of ICS-alone treatment and the rationale behind co-payments, for initiatives around quality use of medicines to succeed.

A Patient-Centered Mobile Health System That Supports Asthma Self-Management (breathe): Design, Development, and Utilization

Background

Uncontrolled asthma poses substantial negative personal and health system impacts. Web-based technologies, including smartphones, are novel means to enable evidence-based care and improve patient outcomes.

Objective

The aim of this study was to design, develop, and assess the utilization of an asthma collaborative self-management (CSM) platform (breathe) using content based on international evidence-based clinical guidelines.

Methods

We designed and developed breathe as a Web-based mobile health (mHealth) platform accessible on smartphones, tablets, or desktop with user-centered design methods and International Organization for Standardization–certified quality development processes. Moreover, breathe was envisioned as a multifunctional, CSM mHealth platform, with content based on international clinical practice guidelines and compliant with national privacy and security specifications. The system enabled CSM (patient, provider, and breathe) and self-monitoring of asthma patients through (1) assessment of asthma control, (2) real-time access to a dynamic asthma action plan, (3) access to real-time environmental conditions, and (4) risk-reduction messaging. The data collection protocol collected user data for 12 months, with clinic visits at baseline and 6 and 12 months. Utilization outcomes included user interactions with the platform, user impressions, self-reported medication use, asthma symptom profile, reported peak flow measurement, and the delivery and impact of email reminders.

Results

We enrolled 138 patients with a mean age of 45.3 years to receive the breathe intervention. Majority were female (100/138, 72.5%), had a smartphone (92/138, 66.7%), and had a mean Asthma Control Test score of 18.3 (SD 4.9). A majority reported that breathe helped in the management of their asthma. Moreover, breathe scored 71.1 (SD 18.9) on the System Usability Scale. Overall, 123 patients had complete usage analytics datasets. The platform sent 7.96 reminder emails per patient per week (pppw), patients accessed breathe 3.08 times, journaled symptoms 2.56 times, reported medication usage 0.30 times, and reported peak flow measurements 0.92 times pppw. Furthermore, breathe calculated patients’ action plan zone of control 2.72 times pppw, with patients being in the green (well-controlled) zone in 47.71% (8300/17,396) of the total calculations. Usage analysis showed that 67.5% (83/123) of the participants used the app at week 4 and only 57.7% (71/123) by week 45. Physician visits, email reminders, and aged 50 years and above were associated with higher utilization.

Conclusions

Individuals with asthma reported good usability and high satisfaction levels, reacted to breathe notifications, and had confidence in the platform’s assessment of asthma control. Strong utilization was seen at the intervention’s initiation, followed by a rapid reduction in use. Patient reminders, physician visits, and being aged 50 years and above were associated with higher utilization.

Trial Registration

ClinicalTrials.gov NCT01964469; https://clinicaltrials.gov/ct2/show/NCT01964469

Patient preferences for a touch screen tablet-based asthma questionnaire

OBJECTIVE

Assessment of asthma control and provision of asthma action plans are seldom performed in practice, partly due to limited time for physicians to ascertain required information. A patient-facing electronic asthma questionnaire could facilitate information collection. We sought to design a touch-tablet asthma questionnaire for use in the clinic waiting room and to describe patient preferences for the content of such a questionnaire.

METHODS

We created a questionnaire prototype based on best evidence and employed rapid-cycle design (semi-structured focus group testing; analysis; corresponding modifications and re-testing) with asthma patients aged ≥16 years. We analyzed transcripts using deductive and inductive content analysis. Quantitative measures included Likert-scale questions and questionnaire completion times.

RESULTS

There were 20 participants across five focus groups (15/20 (75%) female, age 49.1 ± 15.6 years). Content-related themes included: 1) comprehensibility (language) (how questionnaire language affected ease and accuracy of comprehension) and b) information collection (issues arising during information collection in the following identified subthemes: personal asthma symptoms and triggers; asthma control; asthma medications and contact information). Average questionnaire completion time was 11.7 ± 5.9 min. Summative Likert scale responses suggested high levels of question comprehension and confidence with responses.

CONCLUSIONS

Our analysis provides novel insight about how best to formulate and present asthma-related content in an electronic questionnaire. Such questionnaires might facilitate quality improvement by improving efficiency of data collection, enabling better assessment of asthma control and medication adherence, and personalization of asthma action plans. Future studies should measure real-world uptake of such a questionnaire and impact on care.

The Effect of Educational Program on Self-efficacy of Women with Rheumatoid Arthritis: A Randomized Controlled Clinical Trial

BACKGROUND

Rheumatoid Arthritis (RA) is a chronic and inflammatory disorder which is the major cause of disability in adults. Patient training is a vital aspect of nursing care for people with arthritis aiming to enable them to live as independently as possible. In the present study, we aimed to evaluate the effect of the educational program on self-efficacy on women with rheumatoid arthritis.

METHODS

This study was an open randomized controlled clinical trial during May to July 2013. Women (64 participants) with confirmed RA and a mean±SD age of 48.6±9.83 years were enrolled; they were randomly assigned into intervention and control groups (32 in each group). The patients in the intervention group participated in a training programs consisting of two 30-minute sessions per week for 8 consecutive weeks. Data were collected by using Arthritis Self-Efficacy Scale (ASES) and demographic questionnaire. ASES questionnaire was filled in three times by the participants: before, immediately after, and three months after the intervention. Data were analyzed using SPSS software, version 20, and statistical tests including Chi-square and t-test.

RESULTS

The results showed that the mean of self-efficacy scores of the intervention group, immediately and three months after the intervention, significantly enhanced in all dimensions compared with the control group (P<0.001, P<0.001).

CONCLUSION

It can be concluded that training programs is effective for improving self-efficacy in the patients suffering from RA by raising their awareness towards their disease and methods of adaptation with it. But as to the sustainability of the impact of educational courses on self-efficacy, it seems that more research is required. Trial Registration Number: IRCT201308187531N3.

The Seven Stages of Man: The Role of Developmental Stage on Medication Adherence in Respiratory Diseases

The circumstances and drivers of the decision to initiate, implement, or persist with a medication differ for individuals at each developmental stage. For school-age children with asthma, the social environment of their family's cultural beliefs and the influence of peer networks and school policies are strong determinants of medication adherence. The stage of adolescence can be a particularly challenging time because there is a reduction in parental supervision of asthma management as the young person strives to become more autonomous. To illustrate the importance of such factors, adherence interventions in children and young adults with asthma have used peer-based supports and social supports, particularly social media platforms. In older patients, it is internal rather than external factors and age-related decline that pose challenges to medication adherence. Seniors face the challenges of polypharmacy, reduced social support, increased isolation, and loss of cognitive function. Strategies to promote adherence must be tailored to the developmental stage and respective behavioral determinants of the target group. This review considers the different attitudes toward medication and the different adherence behaviors in young and elderly patients with chronic respiratory conditions, specifically asthma and chronic obstructive pulmonary disease. Opportunities to intervene to optimize adherence are suggested.

Enhancing Respiratory Medication Adherence: The Role of Health Care Professionals and Cost-Effectiveness Considerations

Adherence to medication comprises a multiphased temporal process involving (1) initiation of prescribed therapy, (2) implementation as prescribed, and (3) subsequent persistence. Medication adherence remains suboptimal in most patients with long-term respiratory conditions such as asthma and chronic obstructive pulmonary disease (COPD). Interventions have been shown to effectively improve treatment initiation, implementation, and persistence when delivered at the health care professional level or the system level, but demonstration of the cost-effectiveness of these interventions is necessary to ensure their widespread use. This review summarizes how health care professionals can intervene to improve medication adherence in patients with asthma and COPD, provides some examples of effective primary care interventions, and illustrates some of the challenges to optimal implementation arising from cost-effectiveness modeling. Improving adherence is shown to be an economically viable treatment option for patients with asthma and COPD, but there are differences in the health economics pertaining to each condition and setting that can affect whether an intervention is considered cost-effective. Targeting adherence interventions at patients with the greatest to gain, and tailoring them to individual patient needs, may help to optimize cost-effectiveness ratios and improve the probability of positive reimbursement decisions, systemwide implementation, and resultant health benefits.

Shared decision-making for people with asthma

BACKGROUND

Asthma is a chronic inflammatory disease that affects the airways and is common in both adults and children. It is characterised by symptoms including wheeze, shortness of breath, chest tightness, and cough. People with asthma may be helped to manage their condition through shared decision-making (SDM). SDM involves at least two participants (the medical practitioner and the patient) and mutual sharing of information, including the patient's values and preferences, to build consensus about favoured treatment that culminates in an agreed action. Effective self-management is particularly important for people with asthma, and SDM may improve clinical outcomes and quality of life by educating patients and empowering them to be actively involved in their own health.

OBJECTIVES

To assess benefits and potential harms of shared decision-making for adults and children with asthma.

SEARCH METHODS

We searched the Cochrane Airways Trials Register, which contains studies identified in several sources including CENTRAL, MEDLINE, and Embase. We also searched clinical trials registries and checked the reference lists of included studies. We conducted the most recent searches on 29 November 2016.

SELECTION CRITERIA

We included studies of individual or cluster parallel randomised controlled design conducted to compare an SDM intervention for adults and children with asthma versus a control intervention. We included studies available as full-text reports, those published as abstracts only, and unpublished data, and we placed no restrictions on place, date, or language of publication. We included interventions targeting healthcare professionals or patients, their families or care-givers, or both. We included studies that compared the intervention versus usual care or a minimal control intervention, and those that compared an SDM intervention against another active intervention. We excluded studies of interventions that involved multiple components other than the SDM intervention unless the control group also received these interventions.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened searches, extracted data from included studies, and assessed risk of bias. Primary outcomes were asthma-related quality of life, patient/parent satisfaction, and medication adherence. Secondary outcomes included exacerbations of asthma, asthma control, acceptability/feasibility from the perspective of healthcare professionals, and all adverse events. We graded and presented evidence in a 'Summary of findings' table.We were unable to pool any of the extracted outcome data owing to clinical and methodological heterogeneity but presented findings in forest plots when possible. We narratively described skewed data.

MAIN RESULTS

We included four studies that compared SDM versus control and included a total of 1342 participants. Three studies recruited children with asthma and their care-givers, and one recruited adults with asthma. Three studies took place in the United States, and one in the Netherlands. Trial duration was between 6 and 24 months. One trial delivered the SDM intervention to the medical practitioner, and three trials delivered the SDM intervention directly to the participant. Two paediatric studies involved use of an online portal, followed by face-to-face consultations. One study delivered an SDM intervention or a clinical decision-making intervention through a mixture of face-to-face consultations and telephone calls. The final study randomised paediatric general practice physicians to receive a seminar programme promoting application of SDM principles. All trials were open-label, although one study, which delivered the intervention to physicians, stated that participants were unaware of their physicians' involvement in the trial. We had concerns about selection and attrition bias and selective reporting, and we noted that one study substantially under-recruited participants. The four included studies used different approaches to measure fidelity/intervention adherence and to report study findings.One study involving adults with poorly controlled asthma reported improved quality of life (QOL) for the SDM group compared with the control group, using the Asthma Quality of Life Questionnaire (AQLQ) for assessment (mean difference (MD) 1.90, 95% confidence interval (CI) 1.24 to 2.91), but two other trials did not identify a benefit. Patient/parent satisfaction with the performance of paediatricians was greater in the SDM group in one trial involving children. Medication adherence was better in the SDM group in two studies - one involving adults and one involving children (all medication adherence: MD 0.21, 95% CI 0.11 to 0.31; mean number of controlled medication prescriptions over 26 weeks: 1.1 in the SDM group (n = 26) and 0.7 in the control group (n = 27)). In one study, asthma-related visit rates were lower in the SDM group than in the usual care group (1.0/y vs 1.4/y; P = 0.016), but two other studies did not report a difference in exacerbations nor in prescriptions for short courses of oral steroids. Finally, one study described better odds of reporting no asthma problems in the SDM group than in the usual care group (odds ratio (OR) 1.90, 95% CI 1.26 to 2.87), although two other studies reporting asthma control did not identify a benefit with SDM. We found no information about acceptability of the intervention to the healthcare professional and no information on adverse events. Overall, our confidence in study results ranged from very low to moderate, and we downgraded outcomes owing to risk of bias, imprecision, and indirectness.

AUTHORS' CONCLUSIONS

Substantial differences between the four included randomised controlled trials (RCTs) indicate that we cannot provide meaningful overall conclusions. Individual studies demonstrated some benefits of SDM over control, in terms of quality of life; patient and parent satisfaction; adherence to prescribed medication; reduction in asthma-related healthcare visits; and improved asthma control. Our confidence in the findings of these individual studies ranges from moderate to very low, and it is important to note that studies did not measure or report adverse events.Future trials should be adequately powered and of sufficient duration to detect differences in patient-important outcomes such as exacerbations and hospitalisations. Use of core asthma outcomes and validated scales when possible would facilitate future meta-analysis. Studies conducted in lower-income settings and including an economic evaluation would be of interest. Investigators should systematically record adverse events, even if none are anticipated. Studies identified to date have not included adolescents; future trials should consider their inclusion. Measuring and reporting of intervention fidelity is also recommended.

Engaging Older Adults in Health Care Decision-Making: A Realist Synthesis

BACKGROUND

Engagement in healthcare decision making has been recognized as an important, and often lacking, aspect of care, especially in the care of older adults who are major users of the healthcare system.

OBJECTIVE

We aimed to conduct a review of available knowledge on engagement in healthcare decision making with a focus on older patients and their caregivers.

METHODS

We conducted a realist synthesis focusing on strategies for engagement of older patients and their caregivers in healthcare decision making. The synthesis encompassed theoretical frameworks and both peer-reviewed and grey literature. Expert consultations included interviews (n = 2) with academics and group consultations (n = 3) with older adults and their caregivers. Abstracts that reported description, assessment, or evaluation of strategies for engagement of adult patients, families, or caregivers (i.e., that report on actual experiences of engagement) were included.

RESULTS

The search generated 15,683 articles, 663 of which were pertinent to healthcare decision making. Theoretical and empirical work identified a range of strategies and levels of engagement of older patients and their families in healthcare decision making. The importance of communication emerged as a key recommendation for meaningful engagement among providers and patients and their caregivers. The principles developed in this study should be implemented with consideration of the context in which care is being provided.

CONCLUSIONS

We have developed a framework that promotes the engagement of patients and their caregivers as equal partners in healthcare decision making. Future research should implement and test the framework in various clinical settings.

Inhaler Technique in Asthma: How Does It Relate to Patients' Preferences and Attitudes Toward Their Inhalers?

Background: Correct inhaler technique can increase medication efficacy, reducing both dose and side effects. Patient preference for inhaler device has not been fully explored, and we hypothesized that if patients have a preference and can choose their inhaler, they might be more likely to use it correctly. Our aim was to determine the preferences, attitudes, and perceptions of patients with asthma toward their inhalers, and to evaluate whether any of these factors were related to inhalation technique.

Methods: Twenty-five patients with asthma (mean age 43.1 years) participated. Qualitative semi-structured interviews and quantitative patient satisfaction and preference questionnaires (PASAPQ) were used to explore patients' preferences, attitudes, and perceptions about their inhalers. Objective inhalation technique assessment was performed. Data were triangulated to identify characteristics that could indicate a relationship between inhaler technique, satisfaction, preference, and decision making.

Results: Themes from qualitative interviews were as follows: asthma inhalers and expectations; inhaler preference; characteristics of an ideal inhaler; perceived effectiveness of inhalers; and inhalers and patient decision making. PASAPQ scores indicated that all patients were at least “somewhat satisfied” with their inhalers, regardless of technique. Only 12% of inhalers were used correctly, despite pilot PASAPQ data suggesting that most patients were confident with their technique. The inhaler technique was unlikely to be related to satisfaction, perception of inhaler devices, or choice in device selection. Patients with correct inhaler technique were more aware of their asthma and expressed motivation to achieve optimal asthma control.

Conclusions: The majority of the asthmatic patients did not use their inhaler(s) correctly, despite most having confidence in their technique. Patients attributed confidence in their inhaler technique to their belief that their inhaler was effective. Most patients had not been involved in decision making about which inhalation device to use. These findings highlight the lack of understanding of the important role of correct inhaler technique in asthma management.

Patient-physician relationship in the management of asthma: Multicentric approach in Latin America

OBJECTIVE

To investigate and compare how Latin American physicians rate themselves on the use of communication strategies in the management of asthma patients, and to explore their personal experience and opinions on asthma treatment.

METHODS

A cross-sectional survey of physicians attending international medical conferences in Latin America was conducted. Participants rated themselves on frequency of use of 24 communication strategies using a 5-point Likert scale. For statistical analysis, self-rating responses were divided into two classes: very likely to (always or often on a Likert scale) and not very likely to (sometimes, seldom or never on a Likert scale). Participants also answered 4 multiple choice questions about management of asthma patients. Overall responses were analyzed using descriptive statistics and Chi-square. Multivariate logistic regression analysis was performed to evaluate self-ratings by country, gender, practice area (GP or specialist) and age.

RESULTS

A total of 304 physicians from Ecuador, Argentina and Peru responded. Overall, the majority of respondents rated themselves very likely to use 21 of the 24 communication strategies. Some significant differences were observed in self-ratings among physicians from different countries, between males and females, between GPs and specialists and between younger and older physicians. Responses to the multiple choice questions showed that 79.6% of the respondents believed that most or almost all patients can achieve asthma control.

CONCLUSIONS

A high percentage of the Latin American physicians surveyed rated themselves very likely to use good communication strategies when managing asthma patients and felt that asthma control can be achieved in most or almost all patients.

Evaluation of factors affecting adherence to asthma controller therapy in chest clinics in a sub-Saharan African setting: a cross-sectional study

BACKGROUND

Adherence to controller therapy in asthma is a major concern during the management of the disease.

OBJECTIVE

To determine the adherence rate and identify the predictors of low adherence to asthma controller therapy.

METHODS

A cross-sectional study including asthma patients was conducted from November 1, 2012 to May 31, 2013 in 4 chest clinics in Cameroon. The adherence to asthma treatment was rated using Morisky Medication Adherence Scale. A multivariate logistic regression analysis was performed for the identification of factors associated with adherence to asthma treatment.

RESULTS

Among the 201 asthma patients included, 133 (66.2%) were female. The mean age of participants was 41.2 years. Sixty-one (30.3%) of the patients did not visit the chest physician during the last year prior to the study. Asthma was well controlled in 118 patients (58.7%). The prevalence of low adherence rate to asthma controller therapy was 44.8% and the absence of any chest specialist visit within the last 12 months was the only factor associated with the low adherence rate to asthma treatment (OR 5.57 ; 95% CI 2.84-10.93).

CONCLUSION

The adherence rate to asthma controller therapy in Cameroon is low and it could be improved if scheduled visits are respected by patients.

Patients' needs in asthma treatment: development and initial validation of the NEAT questionnaire

OBJECTIVE

We aimed to develop and tentatively validate an instrument assessing patients' needs related to asthma treatment.

METHODS

Patients were recruited through various approaches (e.g. physicians, pharmacies and patient organizations). Utilizing a mixed methods design, we first conducted five focus groups to explore needs among patients. Next, we devised an item pool which was revised, reduced and evaluated by patients. Finally, data from a survey (n = 362) were used to further reduce the item pool and to examine the questionnaire's psychometric properties and validity.

RESULTS

Four broad needs categories emerged from the focus groups: (1) information needs; (2) consideration of patient views in diagnosis; (3) consideration of patient views in treatment planning; and (4) addressing patients' fears. We devised 45 items, which were reduced to 22 items based on patient feedback. The survey data suggested a 13-item scale with four subscales ("patient expertise", "drug effects", "handling drugs" and "exacerbations"). Cronbach's alpha was acceptable for those subscales (>0.7) and for the total score (0.9). Increasing scores on subscales and the total score (implying more unmet needs) showed close and consistent associations with poor asthma control, reduced quality of life and low treatment satisfaction.

CONCLUSIONS

The development process of the Needs in Asthma Treatment (NEAT) questionnaire ensured that needs of asthma patient are captured with high validity. The NEAT questionnaire has been shown to be valid, thereby representing a promising tool for research and delivery of patient-centered care.

Challenges in shared decision making in advanced cancer care: a qualitative longitudinal observational and interview study

Background

Patients' preferences and expectations should be taken into account in treatment decision making in the last phase of life. Shared decision making (SDM) is regarded as a way to give the patient a central role in decision making. Little is known about how SDM is used in clinical practice in advanced cancer care.

Objective

To examine whether and how the steps of SDM can be recognized in decision making about second‐ and third‐line chemotherapy.

Methods

Fourteen advanced cancer patients were followed over time using face‐to‐face in‐depth interviews and observations of the patients' out‐clinic visits. Interviews and outpatient clinic visits in which treatment options were discussed or decisions made were transcribed verbatim and analysed using open coding.

Results

Patients were satisfied with the decision‐making process, but the steps of SDM were barely seen in daily practice. The creation of awareness about available treatment options by physicians was limited and not discussed in an equal way. Patients' wishes and concerns were not explicitly assessed, which led to different expectations about improved survival from subsequent lines of chemotherapy.

Conclusion

To reach SDM in daily practice, physicians should create awareness of all treatment options, including forgoing treatment, and communicate the risk of benefit and harm. Open and honest communication is needed in which patients' expectations and concerns are discussed. Through this, the difficult process of decision making in the last phase of life can be facilitated and the focus on the best care for the specific patient is strengthened.

A repeated short educational intervention improves asthma control and quality of life

We assessed the effectiveness of an asthma educational programme based on a repeated short intervention (AEP-RSI) to improve asthma control (symptom control and future risk) and quality of life. A total of 230 adults with mild-to-moderate persistent uncontrolled asthma participated in a 1-year cluster randomised controlled multicentre study. The AEP-RSI was given in four face-to-face sessions at 3-month intervals, and included administration of a written personalised action plan and training on inhaler technique. Centres were randomised to the AEP-RSI (intervention) group or usual clinical practice group. Specialised centres using a standard educational programme were the gold standard group. A significant improvement in the Asthma Control Test score was observed in all three groups (p<0.001), but improvements were higher in the intervention and gold standard groups than in the usual clinical practice group (p=0.042), which also showed fewer exacerbations (mean±sd; 1.20±2.02 and 0.56±1.5 versus 2.04±2.72, respectively) and greater increases in the Mini Asthma Quality of Life Questionnaire scores (0.95±1.04 and 0.89±0.84 versus 0.52±0.97, respectively). The AEP-RSI was effective in improving asthma symptom control, future risk and quality of life.

Towards tailored and targeted adherence assessment to optimise asthma management

In this paper, we aim to emphasise the need for a more comprehensive and tailored approach to manage the broad nature of non-adherence, to personalise current asthma management. Although currently several methods are available to measure the extent of asthma patients' adherence, the vast majority do not incorporate confirmation of the actual inhalation, dose and inhalation technique. Moreover, most current measures lack detailed information on the individual consequences of non-adherence and on when and how to take action if non-adherence is identified. Notably, one has to realise there are several forms of non-adherence (erratic non-adherence, intelligent non-adherence and unwitting non-adherence), each requiring a different approach. To improve asthma management, more accurate methods are needed that integrate measures of non-adherence, asthma disease control and patient preferences. Integrating information from the latest inhaler devices and patient-reported outcomes using mobile monitoring- and feedback systems ('mHealth') is considered a promising strategy, but requires careful implementation. Key issues to be considered before large-scale implementation include patient preferences, large heterogeneity in patient and disease characteristics, economic consequences, and long-term persistence with new digital technologies.

A qualitative analysis of approaches to contraceptive counseling

CONTEXT

Underuse and inconsistent use of contraceptives contribute to the continued high rate of unintended pregnancy in the United States. High-quality interaction between patient and provider about contraception is associated with improved contraceptive use, yet little is known about how providers support patients in the decision-making process.

METHODS

A random sample of 50 family planning visits by patients in the San Francisco Bay Area was selected from a larger sample of 342 audio-recorded visits to six clinics between 2009 and 2012. In qualitative analysis guided by grounded theory techniques, transcripts were assessed to determine counseling approaches and patterns in the use of these approaches.

RESULTS

Providers employed three counseling approaches: foreclosed (in 48% of visits), characterized by discussion of few contraceptive methods and method selection by the patient with no involvement from the provider; informed choice (30%), characterized by detailed description of multiple methods, but little or no interaction between the patient and the provider; and shared decision making (22%), characterized by the provider's interactive and responsive participation with the patient in method selection. Use of these approaches varied by patient's age: Women 25 or younger experienced the foreclosed approach more often than older women, and patients older than 35 were far more likely than their younger counterparts to experience the shared decision-making approach.

CONCLUSIONS

Most visits did not include interactive engagement between the patient and the provider. Contraceptive counseling interventions should encourage providers to responsively engage with patients of all ages to better meet their contraceptive needs.

Arthritis patients' motives for (not) wanting to be involved in medical decision-making and the factors that hinder or promote patient involvement

The aim of this study is to gain insight into arthritis patients' motives for (not) wanting to be involved in medical decision-making (MDM) and the factors that hinder or promote patient involvement. In-depth semi-structured interviews were conducted with 29 patients suffering from Rheumatoid Arthritis (RA). Many patients perceived the questions about involvement in MDM as difficult, mostly because they were unaware of having a choice. Shared decision-making (SDM) was generally preferred, but the preferred level of involvement varied between and within individuals. Preference regarding involvement may vary according to the type of treatment and the severity of the complaints. A considerable group of respondents would have liked more participation than they had experienced in the past. Perceived barriers could be divided into doctor-related (e.g. a paternalistic attitude), patient-related (e.g. lack of knowledge) and context-related (e.g. too little time to decide) factors. This study demonstrates the complexity of predicting patients' preferences regarding involvement in MDM: most RA patients prefer SDM, but their preference may vary according to the situation they are in and the extent to which they experience barriers in getting more involved. Unawareness of having a choice is still a major barrier for patient participation. The attending physician seems to have an important role as facilitator in enhancing patient participation by raising awareness and offering options, but implementing SDM is a shared responsibility; all parties need to be involved and educated.

Patient participation in decisions about disease modifying anti-rheumatic drugs: a cross-sectional survey

BACKGROUND

Involvement of patients in decision-making about medication is currently being advocated. This study examined (the concordance between) inflammatory arthritis patients' preferred and perceived involvement in decision-making in general, and in four specific decisions about Disease-Modifying Anti-Rheumatic Drugs (DMARDs). Furthermore, this study examined how patients' involvement is related to satisfaction about decision-making and which factors are related to preferred roles, perceived roles and concordance.

METHODS

Using a cross-sectional survey, 894 patients diagnosed with Rheumatoid Arthritis, Psoriatic Arthritis or Ankylosing Spondylitis were sent a questionnaire which focused on medical decisions in general and on four specific decisions: (a) starting with a traditional DMARD; (b) starting to inject methotrexate; (c) starting a biological DMARD; and (d) decreasing or stopping a DMARD. For each decision preferred and perceived involvement in decision-making was assessed using the Control Preference Scale. Concordance was calculated by subtracting the scores for perceived role from scores for the preferred role. Furthermore, satisfaction with the decision process and socio-demographic, health-related, patient-related and physician-related variables were assessed.

RESULTS

The response rate was 58%. For all decisions, most patients (59%-63%) preferred Shared Decision-Making (SDM). SDM was perceived frequently (26%-55%) and patients' preferences were met in 54% of the respondents. Yet, in some specific decisions, 26% to 54% of patients would have liked more participation. Perceiving less participation then preferred was associated with less satisfaction with the decision-process, but perceiving more participation than preferred was not. Our results did not reveal any meaningful models to predict preferred or perceived participation in decision-making in general or with reference to specific decisions about DMARDs.

CONCLUSIONS

Most arthritis patients prefer to be involved in decisions about their medication and SDM is perceived frequently. Yet, in some specific decisions patient participation can be further improved. Patients especially prefer more participation in decision-making regarding starting a first traditional DMARD, which occurs most commonly in newly diagnosed patients. Whereas perceiving too little participation was associated with decreased satisfaction, perceiving too much participation was not. Therefore, rheumatologists should urge patients to participate in every medical decision.

Continuing discrepancy between patient perception of asthma control and real-world symptoms: a quantitative online survey of 1,083 adults with asthma from the UK

Background:

Previous studies have identified a discrepancy between patient perception of asthma control and real-world symptoms; despite several hypotheses, the reasons remain unclear.

Aims:

To explore patients' experiences of asthma symptoms and disease management and their educational needs in the UK; to assess recent progress in asthma control and management.

Methods:

A quantitative questionnaire-based online survey of UK patients aged ≥18 years with self-reported asthma.

Results:

Of the 1,083 individuals (55% female, 49% aged ≥55 years) who completed the survey, 79% described their asthma control as ‘good’ or ‘very good’. Despite this, in the previous 2 years, 65% had experienced ‘frequent’ day-time symptoms, 37% had ‘frequent’ night-time symptoms, and 25% had used oral steroids for asthma; 41% of those prescribed a reliever inhaler used it ≥1 a day. Overall, 76% had a ‘good’ or ‘very good’ relationship with their healthcare professional (HCP); 32% had not attended regular asthma reviews and only 12% were using a personal asthma action plan. Moreover, 70% of respondents felt that they had the ‘main responsibility’ for managing their asthma; 29% believed this responsibility to be shared with their HCP.

Conclusions:

This survey indicates a continuing discrepancy between patient perception of asthma control and real-world symptoms, with little change from previous studies. Many patients accept symptoms as the norm. The diversity among respondents' attitudes demonstrates a need to help patients change some of their beliefs and understanding about asthma, and to improve asthma management with better education about the understanding of control for patients and HCPs.

Patients' preferences for participation in treatment decision-making at the end of life: qualitative interviews with advanced cancer patients

PURPOSE

Patients are often encouraged to participate in treatment decision-making. Most studies on this subject focus on choosing between different curative treatment types. In the last phase of life treatment decisions differ as they often put more emphasis on weighing quantity against quality of life, such as whether or not to start treatment aimed at life prolongation but with the possibility of side effects. This study aimed to obtain insight into cancer patients' preferences and the reasons for patients' preferred role in treatment decision-making at the end of life.

METHODS

28 advanced cancer patients were included at the start of their first line treatment. In-depth interviews were held prior to upcoming treatment decisions whether or not to start a life prolonging treatment. The Control Preference Scale was used to start discussing the extent and type of influence patients wanted to have concerning upcoming treatment decision-making. Interviews were audio taped and transcribed.

RESULTS

All patients wanted their physician to participate in the treatment decision-making process. The extent to which patients themselves preferred to participate seemed to depend on how patients saw their own role or assessed their own capabilities for participating in treatment decision-making. Patients foresaw a shift in the preferred level of participation to a more active role depending in the later phase of illness when life prolongation would become more limited and quality of life would become more important.

CONCLUSION

Patients vary in how much involvement they would like to have in upcoming treatment decision-making. Individual patients' preferences may change in the course of the illness, with a shift to more active participation in the later phases. Communication about patients' expectations, wishes and preferences for participation in upcoming treatment decisions is of great importance. An approach in which these topics are openly discussed would be beneficial.

Congruence between patients' preferred and perceived participation in medical decision-making: a review of the literature

Background

Patients are increasingly expected and asked to be involved in health care decisions. In this decision-making process, preferences for participation are important. In this systematic review we aim to provide an overview the literature related to the congruence between patients’ preferences and their perceived participation in medical decision-making. We also explore the direction of mismatched and outline factors associated with congruence.

Methods

A systematic review was performed on patient participation in medical decision-making. Medline, PsycINFO, CINAHL, EMBASE and the Cochrane Library databases up to September 2012, were searched and all studies were rigorously critically appraised. In total 44 papers were included, they sampled contained 52 different patient samples.

Results

Mean of congruence between preference for and perceived participation in decision-making was 60% (49 and 70 representing 25^th and 75^th percentiles). If no congruence was found, of 36 patient samples most patients preferred more involvement and of 9 patient samples most patients preferred less involvement. Factors associated with preferences the most investigated were age and educational level. Younger patients preferred more often an active or shared role as did higher educated patients.

Conclusion

This review suggests that a similar approach to all patients is not likely to meet patients’ wishes, since preferences for participation vary among patients. Health care professionals should be sensitive to patients individual preferences and communicate about patients’ participation wishes on a regular basis during their illness trajectory.

Knowledge is not power for patients: a systematic review and thematic synthesis of patient-reported barriers and facilitators to shared decision making

OBJECTIVE

To systematically review patient-reported barriers and facilitators to shared decision making (SDM) and develop a taxonomy of patient-reported barriers.

METHODS

Systematic review and thematic synthesis. Study findings/results for each included paper were extracted verbatim and entered into qualitative software for inductive analysis.

RESULTS

Electronic and follow-up searches yielded 2956 unique references; 289 full-text articles were retrieved, of which 45 articles from 44 unique studies met inclusion criteria. Key descriptive themes were grouped under two broad analytical themes: how the healthcare system is organized (4 descriptive themes) and what happens during the decision-making interaction (4 descriptive themes, 10 sub-themes). Predominant emergent themes related to patients' knowledge and the power imbalance in the doctor-patient relationship. Patients need knowledge and power to participate in SDM - knowledge alone is insufficient and power is more difficult to attain.

CONCLUSION

Many barriers are potentially modifiable, and can be addressed by attitudinal changes at the levels of patient, clinician/healthcare team, and the organization. The results support the view that many patients currently can't participate in SDM, rather than they won't participate because they do not want to.

PRACTICE IMPLICATIONS

Future implementation efforts should address patient-reported factors together with known clinician-reported barriers and the wider organizational context.

Birth control: to what extent do women report being informed and involved in decisions about pregnancy and birth procedures?

Background

Health policy, guidelines, and standards advocate giving patients comprehensive information and facilitating their involvement in health-related decision-making. Routine assessment of patient reports of these processes is needed. Our objective was to examine decision-making processes, specifically information provision and consumer involvement in decision-making, for nine pregnancy, labour, and birth procedures, as reported by maternity care consumers in Queensland, Australia.

Methods

Participants were women who had a live birth in Queensland in a specified time period and were not found to have had a baby that died since birth, who completed the extended Having a Baby in Queensland Survey, 2010 about their maternity care experiences, and who reported at least one of the nine procedures of interest. For each procedure, women answered two questions that measured perceived (i) receipt of information about the benefits and risks of the procedure and (ii) role in decision-making about the procedure.

Results

In all, 3,542 eligible women (34.2%) completed the survey. Between 4% (for pre-labour caesarean section) and 60% (for vaginal examination) of women reported not being informed of the benefits and risks of the procedure they experienced. Between 2% (epidural) and 34% (episiotomy) of women reported being unconsulted in decision-making. Over one quarter (26%) of the women who experienced episiotomy reported being neither informed nor consulted.

Conclusions

There is an urgent need for interventions that facilitate information provision and consumer involvement in decision-making about several perinatal procedures, especially those performed within the time-limited intrapartum care episode.

Using communication skills to improve adherence in children with chronic disease: the adherence equation

Nonadherence to maintenance medication is common in paediatric chronic conditions. Despite the common belief that nonadherence is therapy-resistant, and the apparent lack of evidence for successful interventions to improve adherence, there is, in fact, a considerable body of evidence suggesting that adherence can be improved by applying specific communicative consultation skills. These can be summarized as the adherence equation: adherence=follow-up+dialogue+barriers and beliefs+empathy and education => concordance. Close follow-up of children with a chronic condition is needed to establish a therapeutic partnership with the family. Teaching self management skills is not a unidirectional process of providing information, but requires a constructive and collaborative dialogue between the medical team and the family. Identifying barriers to adherence can be achieved in a non-confrontational manner, by showing a genuine interest what the patient's views and preferences are. In particular, parental illness perceptions and medication beliefs should be identified, because they are strong drivers of nonadherence. Through empathic evidence-based education, such perceptions and beliefs can be modified. By applying these strategies, concordance between the child's family and the medical team can be achieved, resulting in optimal adherence to the jointly created treatment plan.

Adherence in severe asthma

Adherence in asthma is an important cause for concern. Although nearly 50% of asthma patients are considered poorly adherent to therapeutic advices, adherence is still difficult to assess, understand and improve despite major medical consequences. In this review, we revisited the literature of the last 10 years related to adherence in severe asthma. The concepts have changed and "compliance" is usually replaced by "adherence". Assessment of adherence is addressing ethical issues, but provides important insight into difficult-to-treat asthma. Different tools have been used but none is routinely recommended. Health-related outcomes (poor control, exacerbations, hospitalizations, lung function decline), which are clearly associated with severe asthma, are often worsened by non-adherence with consequences also on patient related outcomes (quality of life). The potential behaviour associated with non-adherence and all other related factors including easy-to-recognize psychological traits can help for patient's future management. Therapeutic educational interventions have been recognized with a scientifically proven efficiency even though evolution and improvements are needed. A multidisciplinary approach is required in severe asthma. Therapeutic adherence for a given patient is always a prerequisite to any other aspects when addressing severe asthma phenotypes. Severe asthma should be considered only in those who still experienced poor asthma outcomes despite optimal adherence. At a glance, poor adherence and severe asthma should be considered antinomic. Better understanding of the causes and customised management are potential future directions.

A person-centred lifestyle change intervention model: working with older people experiencing chronic illness

A person-centred health promotion model of care to improve self-care and lifestyle changes for older people with chronic illnesses is conceptualized in this paper. The model supports effective interpersonal communication with nurses and health-care consumers and is developed to concept stage. Older people with chronic illnesses who experience stress, anxiety or social isolation are more likely to be admitted and re-admitted to acute hospitals. Interventions to decrease the risk factors are frequently unsuccessful in this patient group. Programmes, led by nurses, aimed at reducing stress, anxiety and social isolation while supporting older people postdischarge from hospital might be successful. The model integrates research from synthesized case studies and a critical literature review. The practices of interrelating four key elements-'construct', 'context', 'process' and 'outcome'-are proposed for nurses to assist patients advancing self-care and lifestyle change. The model is designed for implementation in outpatient, clinic or community settings.

Asthma self-management: a study in an emergency room of a chest hospital in delhi, India

OBJECTIVES

Poorly controlled asthma imposes a considerable burden and is a serious public health problem in the developing world. A key challenge for healthcare professionals is to help patients to engage in self-management behaviours with optimal adherence to appropriate treatment. The aim of the present study was to investigate the pattern of self-management in asthmatic patients enrolled as out-patients in a tertiary care referral public chest hospital, in Delhi, India.

METHODS

The study population was adult asthma patients (n=200) visiting the emergency room (December 2008-December 2009) of a chest hospital for asthma exacerbation. The data was collected through a questionnaire regarding the self-management of asthma.

RESULTS

Enrolled patients (64.0% female) were registered as asthma out-patients in the study hospital for a mean of 5.4±4.4 years. Patients visiting the emergency room (ER) and having an unscheduled visit to doctor at least twice in the previous 12 months were 86.5% and 91.0%. Patients were classified according to the disease severity as having intermittent (17.0%) or persistent (83.0%) asthma. Not all patients had metered dose inhalers at home. Only 2.0% of patients were prescribed peak flow meters and were keeping a diary of their readings. With one exception, patients did not have written action plans for treatment provided by doctor or health facility. No statistical difference was found in the pattern of self-management of patients having persistent or intermittent asthma.

CONCLUSIONS

Findings revealed poor self-management of asthma and poor communication from doctors regarding self-management to the patients. Suitable actions and interventions are needed by health professionals to implement patient self-management asthma programme for optimum asthma control.

The relationship-based care model: evaluation of the impact on patient satisfaction, length of stay, and readmission rates

OBJECTIVE

The objective of this study was to assess the impact of the implementation of the relationship-based care (RBC) model on patient satisfaction, length of stay, and readmission rates in hospitalized patients.

BACKGROUND

RBC model promotes organizational viability in critical areas that measure success, inclusive of clinical quality, patient satisfaction, and robust financial standing.

METHODS

A retrospective secondary analysis of aggregate patient satisfaction data, length of stay, and readmission rates at a rural Texas hospital was reviewed for the years 2009 and 2010. This study compared preimplementation data for year 2009 with postimplementation data for year 2010.

RESULTS

Data support the positive influential impact of RBC model. A negative correlation was noted with readmission rates and a concomitant positive correlation with length of stay. Overall satisfaction with nursing did not reveal a significant correlation to the new care model.

CONCLUSIONS

RBC model supports a patient-centered, collaborative care environment, maximizing potential reimbursement.

Patient preferences and healthcare outcomes: an ecological perspective

This article examines the nature of patients' preferences for healthcare and whether clinician accommodation of patient preferences influences health outcomes. First, we provide a conceptualization of patient preferences along with their key attributes. Second, we review research on the relationship between health outcomes and patient preferences for treatments and for the process of care (e.g., preferred involvement in decision-making). Third, following a critique of this literature, we present an ecological model of patient preferences that, while acknowledging that patient preferences may emerge from various contexts (e.g., family or media exposure), we focus on the important role that clinical encounters and patients' health-related experiences play in the elicitation and construction of patient preferences. Fourth, we propose two pathways, one behavioral (adherence) and the other psychological (sense of autonomy or satisfaction with decision), through which meeting patient preferences could lead to better health outcomes. Fifth, we discuss how preferences can be elicited and clarified through patient-centered conversations. We conclude with implications for future research and clinical practice.

Moving towards effective chronic illness management: asthma as an exemplar

The United States health care system is at a pivotal point in its ability to manage chronic illness. The demands and philosophical differences between the management of acute and chronic illnesses suggest the need for different strategies for effective and efficient management of chronic illness. The purpose of this article is to discuss the Chronic Care Model and the collaborative approach to managing chronic illnesses. Asthma, as an exemplar, will be used to illustrate the need for the development of new models of collaborative care for the treatment of chronic illnesses.

Shared decision making or paternalism in nursing consultations? A qualitative study of primary care asthma nurses' views on sharing decisions with patients regarding inhaler device selection

BACKGROUND

Although patients with asthma would like more involvement in the decision-making process, and UK government policy concerning chronic conditions supports shared decision making, it is not widely used in practice.

OBJECTIVE

To investigate how nurses approach decision making in relation to inhaler choice and long-term inhaler use within a routine asthma consultation and to better understand the barriers and facilitators to shared decision making in practice.

SETTING AND PARTICIPANTS

Semi-structured interviews were conducted with post-registration, qualified nurses who routinely undertook asthma consultations and were registered on a respiratory course. Interviews were recorded, transcribed and analysed using the Framework approach.

RESULTS

Twenty participants were interviewed. Despite holding positive views about shared decision making, limited shared decision making was reported. Opportunities for patients to share decisions were only offered in relation to inhaler device, which were based on the nurse's pre-selected recommendations. Giving patients this 'choice' was seen as key to improving adherence.

DISCUSSION

There is a discrepancy between nurses' understanding of shared decision making and the depictions of shared decision making presented in the academic literature and NHS policy. In this study, shared decision making was used as a tool to support the nurses' agenda, rather than as a natural expression of equality between the nurse and patient.

CONCLUSION

There is a misalignment between the goals of practice nurses and the rhetoric regarding patient empowerment. Shared decision making may therefore only be embraced if it improves patient outcomes. This study indicates attitudinal shifts and improvements in knowledge of 'shared decision-making' are needed if policy dictates are to be realised.

Assessing asthma control in UK primary care: use of routinely collected prospective observational consultation data to determine appropriateness of a variety of control assessment models

BACKGROUND

Assessing asthma control using standardised questionnaires is recommended as good clinical practice but there is little evidence validating their use within primary care. There is however, strong empirical evidence to indicate that age, weight, gender, smoking, symptom pattern, medication use, health service resource use, geographical location, deprivation, and organisational issues, are factors strongly associated with asthma control. A good control measure is therefore one whose variation is most explained by these factors.

METHOD

Eight binary (Yes = poor control, No = good control) models of asthma control were constructed from a large UK primary care dataset: the Royal College of Physicians 3-Questions (RCP-3Qs); the Jones Morbidity Index; three composite measures; three single component models. Accounting for practice clustering of patients, we investigated the effects of each model for assessing control. The binary models were assessed for goodness-of-fit statistics using Pseudo R-squared and Akaikes Information Criteria (AIC), and for performance using Area Under the Receiver Operator Characteristic (AUROC). In addition, an expanded RCP-3Q control scale (0-9) was derived and assessed with linear modelling. The analysis identified which model was best explained by the independent variables and thus could be considered a good model of control assessment.

RESULTS

1,205 practices provided information on 64,929 patients aged 13+ years. The RCP-3Q model provided the best fit statistically, with a Pseudo R-squared of 18%, and an AUROC of 0.79. By contrast, the composite model based on the GINA definition of controlled asthma had a higher AIC, an AUROC of 0.72, and only 10% variability explained. In addition, although the Peak Expiratory Flow Rate (PEFR) model had the lowest AIC, it had an AUROC of 71% and only 6% of variability explained. However, compared with the RCP-3Qs binary model, the linear RCP-3Q Total Score Model (Scale 0-9), was found to be a more robust 'tool' for assessing asthma control with a lower AIC (28,6163) and an R-squared of 33%.

CONCLUSION

In the absence of a gold standard for assessing asthma control in primary care, the results indicate that the RCP-3Qs is an effective control assessment tool but, for maximum effect, the expanded scoring model should be used.

Health Professionals’ Preparation for Supporting Children and Parents Affected by Asthma and Allergies

Although social support originates from sources both informal (eg, family, peers) and formal (eg, health professionals), most reported research focuses on informal support providers. The perspectives and learning needs of health professionals as potential support providers for children and families affected by asthma and allergies form a gap in the reported research. The objective of this study was to assess health professionals’ learning needs and preferences pertinent to the support and education of children with asthma and allergies. A 26-item online survey and qualitative interviews (n, 10) elicited information from health professionals about the perceived support and educational needs of children with asthma and allergies, experience and challenges working with children, health professionals’ educational needs regarding support of children, and continuing education needs and barriers. Health professionals believed that children needed professional education, support, and strategies to reduce the effects of asthma and allergies on their lifestyle. Time (66.0%) and cost (80.9%) were significant barriers to non-Web-based education, but only 14.6% rated time and cost a barrier to Web-based education. Family or work commitments were slightly greater obstacles for non-Web-based education (63.8%) than for Web-based education (51.2%). Although these health professionals were interested in learning from and connecting with their peers, promoting peer support for children with asthma and allergies received a lower rating on their list of educational needs. This needs assessment study confirms that health professionals have limited time, funds, and options for asthma- and allergy-related professional development activities. It validates the need and value of Web-based education with access to an instructor, experts, and group discussions, and it supports the inclusion of asthma-specific information and practical skills for teaching children and for addressing challenges when teaching. Exposure to and understanding of the value of incorporating peer support and social support into existing health programs may be limited.