Self-management, autonomy, and quality of life in asthma. Population Medicine Group 91C

Personalization of Conversational Agent-Patient Interaction Styles for Chronic Disease Management: Two Consecutive Cross-sectional Questionnaire Studies

Background

Conversational agents (CAs) for chronic disease management are receiving increasing attention in academia and the industry. However, long-term adherence to CAs is still a challenge and needs to be explored. Personalization of CAs has the potential to improve long-term adherence and, with it, user satisfaction, task efficiency, perceived benefits, and intended behavior change. Research on personalized CAs has already addressed different aspects, such as personalized recommendations and anthropomorphic cues. However, detailed information on interaction styles between patients and CAs in the role of medical health care professionals is scant. Such interaction styles play essential roles for patient satisfaction, treatment adherence, and outcome, as has been shown for physician-patient interactions. Currently, it is not clear (1) whether chronically ill patients prefer a CA with a paternalistic, informative, interpretive, or deliberative interaction style, and (2) which factors influence these preferences.

Objective

We aimed to investigate the preferences of chronically ill patients for CA-delivered interaction styles.

Methods

We conducted two studies. The first study included a paper-based approach and explored the preferences of chronic obstructive pulmonary disease (COPD) patients for paternalistic, informative, interpretive, and deliberative CA-delivered interaction styles. Based on these results, a second study assessed the effects of the paternalistic and deliberative interaction styles on the relationship quality between the CA and patients via hierarchical multiple linear regression analyses in an online experiment with COPD patients. Patients’ sociodemographic and disease-specific characteristics served as moderator variables.

Results

Study 1 with 117 COPD patients revealed a preference for the deliberative (50/117) and informative (34/117) interaction styles across demographic characteristics. All patients who preferred the paternalistic style over the other interaction styles had more severe COPD (three patients, Global Initiative for Chronic Obstructive Lung Disease class 3 or 4). In Study 2 with 123 newly recruited COPD patients, younger participants and participants with a less recent COPD diagnosis scored higher on interaction-related outcomes when interacting with a CA that delivered the deliberative interaction style (interaction between age and CA type: relationship quality: b=−0.77, 95% CI −1.37 to −0.18; intention to continue interaction: b=−0.49, 95% CI −0.97 to −0.01; working alliance attachment bond: b=−0.65, 95% CI −1.26 to −0.04; working alliance goal agreement: b=−0.59, 95% CI −1.18 to −0.01; interaction between recency of COPD diagnosis and CA type: working alliance goal agreement: b=0.57, 95% CI 0.01 to 1.13).

Conclusions

Our results indicate that age and a patient’s personal disease experience inform which CA interaction style the patient should be paired with to achieve increased interaction-related outcomes with the CA. These results allow the design of personalized health care CAs with the goal to increase long-term adherence to health-promoting behavior.

[Patient expectations in asthma care]

Asthma, a common chronic disease characterized by variable levels of severity, requires patient-centered management to achieve the best health outcomes. Studies have highlighted the gap between consensus management recommendations and patient goals, which represent a potential source of therapeutic wandering and of poor compliance. Patient expectations are continually evolving and are dependent on knowledge, feelings and individual experience. From this perspective, listening carefully to patients and caregivers makes it easier to exchange views and define common goals. The active participation of patients at all levels of decision-making and transmission of information may improve asthma control and other quality of life parameters.

Deliberative and Paternalistic Interaction Styles for Conversational Agents in Digital Health: Procedure and Validation Through a Web-Based Experiment

Background

Recent years have witnessed a constant increase in the number of people with chronic conditions requiring ongoing medical support in their everyday lives. However, global health systems are not adequately equipped for this extraordinarily time-consuming and cost-intensive development. Here, conversational agents (CAs) can offer easily scalable and ubiquitous support. Moreover, different aspects of CAs have not yet been sufficiently investigated to fully exploit their potential. One such trait is the interaction style between patients and CAs. In human-to-human settings, the interaction style is an imperative part of the interaction between patients and physicians. Patient-physician interaction is recognized as a critical success factor for patient satisfaction, treatment adherence, and subsequent treatment outcomes. However, so far, it remains effectively unknown how different interaction styles can be implemented into CA interactions and whether these styles are recognizable by users.

Objective

The objective of this study was to develop an approach to reproducibly induce 2 specific interaction styles into CA-patient dialogs and subsequently test and validate them in a chronic health care context.

Methods

On the basis of the Roter Interaction Analysis System and iterative evaluations by scientific experts and medical health care professionals, we identified 10 communication components that characterize the 2 developed interaction styles: deliberative and paternalistic interaction styles. These communication components were used to develop 2 CA variations, each representing one of the 2 interaction styles. We assessed them in a web-based between-subject experiment. The participants were asked to put themselves in the position of a patient with chronic obstructive pulmonary disease. These participants were randomly assigned to interact with one of the 2 CAs and subsequently asked to identify the respective interaction style. Chi-square test was used to assess the correct identification of the CA-patient interaction style.

Results

A total of 88 individuals (42/88, 48% female; mean age 31.5 years, SD 10.1 years) fulfilled the inclusion criteria and participated in the web-based experiment. The participants in both the paternalistic and deliberative conditions correctly identified the underlying interaction styles of the CAs in more than 80% of the assessments (X²_1,88=38.2; P<.001; phi coefficient r_φ=0.68). The validation of the procedure was hence successful.

Conclusions

We developed an approach that is tailored for a medical context to induce a paternalistic and deliberative interaction style into a written interaction between a patient and a CA. We successfully tested and validated the procedure in a web-based experiment involving 88 participants. Future research should implement and test this approach among actual patients with chronic diseases and compare the results in different medical conditions. This approach can further be used as a starting point to develop dynamic CAs that adapt their interaction styles to their users.

Validity of the French version of the Autonomy Preference Index and its adaptation for patients with advanced cancer

BACKGROUND

While patient-centered care is recommended as a key dimension for quality improvement, in case of serious illness, patients may have different expectations regarding information and participation in medical decision-making. In oncology, anticipation of disease worsening remains difficult, especially when patient's preferences towards prognosis medical information are unclear. Valid tools to explore patients' preferences could help targeting end-of-life discussions, which have been shown to decrease aggressiveness of end-of-life care. Our aim was to establish the validity and reliability of the French version of the Autonomy Preference Index (API) among patients with incurable cancer and in primary care setting. Three supplementary items were specifically developed to evaluate preparedness to anticipate disease deterioration among patients with incurable cancer.

METHODS

The psychometric properties of the API translated into French were assessed among patients consecutively recruited from January to March 2017 in the waiting rooms of 19 general practitioners (N = 391) and in an oncology (N = 187) clinic in Paris. Relationships between the newly-developed items and the API subscale scores were studied.

RESULTS

A three correlated factors confirmatory model (two factors related to decision-making and a factor related to information-seeking preferences) showed an acceptable fit on the whole sample and no measurement invariance issue was found across settings, age, sex and educational level. Internal consistency and test-retest reliability were acceptable for the information-seeking and decision-making subscales. One of the newly-developed items on patients' ability to anticipate a decision on the use of artificial respiration if a sudden deterioration of their illness occurred was not related to the API subscale scores.

CONCLUSION

The French version of the API was found valid and reliable for use in general practice and oncology settings. The additional items on patient preparedness to anticipate disease deterioration can be of interest to ensure that patient values guide all end-of-life clinical decisions.

The impact of severe asthma on patients' autonomy: A qualitative study

BACKGROUND

People living with severe asthma may have ongoing debilitating symptoms despite high-dose treatment. Clinical guidelines for severe asthma recommend concepts such as patient centeredness, shared decision making and self-management, at the heart of which lies autonomy.

OBJECTIVE

This study aimed to explore the role of autonomy in patients' narratives about their experiences of living with and managing severe asthma.

METHODS

In-depth semi-structured interviews were video- and/or audio-recorded and transcribed. Data were categorized using a hybrid approach to analysis incorporating both inductive and deductive methods, informed by the self-determination construct of autonomy. Analysis and comparison across and within categories were conducted to develop final themes.

RESULTS

Twenty-nine face-to-face interviews, lasting 1.5-4 hours, were conducted across Australia. Patients' autonomy was enacted or challenged in a range of situations, such as interacting with health-care providers, maintaining employment, managing symptoms, and dealing with threats to self-identity. Two main themes were discerned from the analysis: (a) the desire to live an "unconstrained" life; and (b) preservation of self-identity.

CONCLUSION

Our findings suggest that autonomy is broader than conventional medical concepts such as decision making and information seeking. Future research should consider these findings when developing and implementing patient-driven self-management interventions for those living with severe asthma.

The impact of patient autonomy on older adults with asthma

BACKGROUND

Understanding patient preferences and desire for involvement in making medical decisions is important when managing chronic conditions. Previous studies have used the Autonomy Preference Index (API) in younger patients with asthma to evaluate these preferences.

OBJECTIVE

To identify factors associated with autonomy and to determine whether autonomy is related to asthma outcomes among older adults.

METHODS

A total of 189 older adults (>55 years old) with persistent asthma were included. Preferences for autonomy were assessed using the API, with a higher score indicating higher desire for autonomy. Scores were separated into 2 domains of information-seeking and decision-making preferences. The separated scores were correlated with asthma outcomes and demographic variables. To control for confounding factors, a linear regression analysis was performed.

RESULTS

Higher decision-making preference scores correlated with female sex (P = .007), higher educational level (P = .01), and lower depression scores (P = .04). Regarding outcomes, decision-making scores positively correlated with Mini Asthma Quality of Life Questionnaire (Mini-AQLQ) scores (P = .01). On linear regression analysis, the Mini-AQLQ score remained significantly associated with decision-making preference scores (P = .03). There was no association with asthma control test scores, spirometry values, and health care use. Information-seeking preference scores correlated with educational level (P = .03), but there was no correlation with asthma outcomes.

CONCLUSION

Older adults with asthma and a greater desire for involvement in decision making have better asthma-related quality of life. Future studies with the intention to increase patient autonomy may help establish a causal relationship.

Predicting the preferences for involvement in medical decision making among patients with mental disorders

BACKGROUND

The involvement of patients in medical decision making has been investigated widely in somatic diseases. However, little is known about the preferences for involvement and variables that could predict these preferences in patients with mental disorders.

OBJECTIVE

This study aims to determine what roles mentally ill patients actually want to assume when making medical decisions and to identify the variables that could predict this role, including patients' self-efficacy.

METHOD

Demographic and clinical data of 798 patients with mental disorders from three psychotherapeutic units in Germany were elicited using self-report questionnaires. Control preference was measured using the Control Preferences Scale, and patients' perceived self-efficacy was assessed using the Self-Efficacy Scale. Bivariate and multivariate regression analyses were conducted to investigate the associations between patient variables and control preference.

RESULTS

Most patients preferred a collaborative role (57.5%), followed by a semi passive (21.2%), a partly autonomous (16.2%), an autonomous (2.8%) and a fully passive (2.3%) role when making medical decisions. Age, sex, diagnosis, employment status, medical pretreatment and perceived self-efficacy were associated with the preference for involvement in the multivariate logistic model.

CONCLUSION

Our results confirm the preferences for involvement in medical decisions of mentally ill patients. We reconfirmed previous findings that older patients prefer a shared role over an autonomous role and that subjects with a high qualification prefer a more autonomous role over a shared role. The knowledge about predictors may help strengthen treatment effectiveness because matching the preferred and actual role preferences has been shown to improve clinical outcome.

Personalised asthma action plans for adults with asthma

BACKGROUND

A key aim of asthma care is to empower each person to take control of his or her own condition. A personalised asthma action plan (PAAP), also known as a written action plan, an individualised action plan, or a self-management action plan, contributes to this endeavour. A PAAP includes individualised self-management instructions devised collaboratively with the patient to help maintain asthma control and regain control in the event of an exacerbation. A PAAP includes baseline characteristics (such as lung function), maintenance medication and instructions on how to respond to increasing symptoms and when to seek medical help.

OBJECTIVES

To evaluate the effectiveness of PAAPs used alone or in combination with education, for patient-reported outcomes, resource use and safety among adults with asthma.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register of trials, clinical trial registers, reference lists of included studies and review articles, and relevant manufacturers' websites up to 14 September 2016.

SELECTION CRITERIA

We included parallel randomised controlled trials (RCTs), both blinded and unblinded, that evaluated written PAAPs in adults with asthma. Included studies compared PAAP alone versus no PAAP, and/or PAAP plus education versus education alone.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted study characteristics and outcome data and assessed risk of bias for each included study. Primary outcomes were number of participants reporting at least one exacerbation requiring an emergency department (ED) visit or hospitalisation, asthma symptom scores on a validated scale and adverse events (all causes). Secondary outcomes were quality of life measured on a validated scale, number of participants reporting at least one exacerbation requiring systemic corticosteroids, respiratory function and days lost from work or study. We used a random-effects model for all analyses and standard Cochrane methods throughout.

MAIN RESULTS

We identified 15 studies described in 27 articles that met our inclusion criteria. These 15 included studies randomised a total of 3062 participants (PAAP vs no PAAP: 2602 participants; PAAP plus education vs education alone: 460 participants). Ten studies (eight PAAP vs no PAAP; two PAAP plus education vs education alone) provided outcome data that contributed to quantitative analyses. The overall quality of evidence was rated as low or very low.Fourteen studies lasted six months or longer, and the remaining study lasted for 14 weeks. When reported, mean age ranged from 22 to 49 years and asthma severity ranged from mild to severe/high risk. PAAP alone compared with no PAAPResults showed no clear benefit or harm associated with PAAPs in terms of the number of participants requiring an ED visit or hospitalisation for an exacerbation (odds ratio (OR) 0.75, 95% confidence interval (CI) 0.45 to 1.24; 1385 participants; five studies; low-quality evidence), change from baseline in asthma symptoms (mean difference (MD) -0.16, 95% CI -0.25 to - 0.07; 141 participants; one study; low-quality evidence) or the number of serious adverse events, including death (OR 3.26, 95% CI 0.33 to 32.21; 125 participants; one study; very low-quality evidence). Data revealed a statistically significant improvement in quality of life scores for those receiving PAAP compared with no PAAP (MD 0.18, 95% CI 0.05 to 0.30; 441 participants; three studies; low-quality evidence), but this was below the threshold for a minimum clinically important difference (MCID). Results also showed no clear benefit or harm associated with PAAPs on the number of participants reporting at least one exacerbation requiring oral corticosteroids (OR 1.45, 95% CI 0.84 to 2.48; 1136 participants; three studies; very low-quality evidence) nor on respiratory function (change from baseline forced expiratory volume in one second (FEV1): MD -0.04 L, 95% CI -0.25L to 0.17 L; 392 participants; three studies; low-quality evidence). In one study, PAAPs were associated with significantly fewer days lost from work or study (MD -6.20, 95% CI -7.32 to - 5.08; 74 participants; low-quality evidence). PAAP plus education compared with education aloneResults showed no clear benefit or harm associated with adding a PAAP to education in terms of the number of participants requiring an ED visit or hospitalisation for an exacerbation (OR 1.08, 95% CI 0.27 to 4.32; 70 participants; one study; very low-quality evidence), change from baseline in asthma symptoms (MD -0.10, 95% CI -0.54 to 0.34; 70 participants; one study; low-quality evidence), change in quality of life scores from baseline (MD 0.13, 95% CI -0.13 to 0.39; 174 participants; one study; low-quality evidence) and number of participants requiring oral corticosteroids for an exacerbation (OR 0.28, 95% CI 0.07 to 1.12; 70 participants; one study; very low-quality evidence). No studies reported serious adverse events, respiratory function or days lost from work or study.

AUTHORS' CONCLUSIONS

Analysis of available studies was limited by variable reporting of primary and secondary outcomes; therefore, it is difficult to draw firm conclusions related to the effectiveness of PAAPs in the management of adult asthma. We found no evidence from randomised controlled trials of additional benefit or harm associated with use of PAAP versus no PAAP, or PAAP plus education versus education alone, but we considered the quality of the evidence to be low or very low, meaning that we cannot be confident in the magnitude or direction of reported treatment effects. In the context of this caveat, we found no observable effect on the primary outcomes of hospital attendance with an asthma exacerbation, asthma symptom scores or adverse events. We recommend further research with a particular focus on key patient-relevant outcomes, including exacerbation frequency and quality of life, in a broad spectrum of adults, including those over 60 years of age.

Shared decision-making, health choices and the menopause

Summary

The growing influence of the mass media on public understanding of health care matters has increased both information and misinformation in patients seeking help with menopausal symptoms. The use of shared decision-making strategies provides the opportunity to engage the patient in taking some responsibility for their own treatment. It also allows the identification and correction of any distortions in the perceived balance of evidence for and against any particular treatment. Shared decision-making balances the need to respect patients’ values and autonomy with the drive towards evidence-based medicine and clinical cost-effectiveness. Although ways of achieving such a balance are much discussed, the current need is for research which can identify effective strategies that allow the principles of “shared decision-making” and “evidence-based patient choice” to be validated and applied in clinical practice. Previous research focused on hormone replacement therapy indicates that the patient's decision is the outcome of the way they balance the pros and cons of taking (or not taking) it, and that their satisfaction with the decision is strongly associated with the perception that they have been given information about the full range of treatment available. It therefore seems likely that patients will respond more positively to consultations which include discussion of hormone replacement therapy alongside alternative strategies such as natural remedies and dietary/lifestyle changes. Psychological factors influencing treatment choice and the decision making process are discussed, and clinical and research implications for clinical practice in the menopause clinic examined.

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 participation in medication reviews is desirable but not evidence-based: a systematic literature review

AIM

The aim of this systematic literature review is to investigate which types of patient participation in medication reviews have been practiced and what is known about the effects of patient participation within the medication review process.

METHODS

A systematic literature review was performed in multiple databases using an extensive selection and quality assessment procedure.

RESULTS

In total, 37 articles were included and most were assessed with a weak or moderate quality. In all studies patient participation in medication reviews was limited to the level of information giving by the patient to the professional, mainly on actual drug use. Nine studies showed limited results of effects of patient participation on the identification of drug related problems.

CONCLUSIONS

The effects of patient participation are not frequently studied and poorly described in current literature. Nevertheless, involving patients can improve patients' knowledge, satisfaction and the identification of drug related problems. Patient involvement is now limited to information sharing. The profit of higher levels of patient communication and shared decision making is until now, not supported by evidence of its effectiveness.

Asthma and Chronic Obstructive Pulmonary Disease Overlap Syndrome: Doubled Costs Compared with Patients with Asthma Alone

BACKGROUND

Patients with asthma and chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS) have more rapid disease progression and more exacerbations than do those with either condition alone. Little research has been performed, however, in these patients.

OBJECTIVE

The objective was to summarize the health care utilization, costs, and comorbidities of patients with uncontrolled asthma and patients with ACOS.

METHODS

This retrospective analysis used medical and pharmacy claims from large commercial health plans. The study included patients 6 years or older with a diagnosis of asthma and one or more asthma exacerbation (index event). Patients were classified as having asthma alone or ACOS, and the two groups were matched for age, sex, region, index year, index month, and health plan type. Outcomes included rates of comorbid disease, health care utilization, and costs during the 12 months before and after the index exacerbation.

RESULTS

Among the matched patients with asthma (6,505 ACOS; 26,060 without COPD), mean annual all-cause health care costs were twice as high as for patients with ACOS ($22,393 vs. $11,716; P < 0.0001). Asthma-related costs, representing 29% of total costs, were nearly twice as high among patients with ACOS ($6,319 vs. 3,356; P < 0.0001). Cost differences were driven by large differences in the proportions of patients with an inpatient hospitalization (34.0% vs. 14.6%; P < 0.0001) or emergency department visit (29.6% vs. 19.9%; P < 0.0001). Nearly all prespecified comorbid conditions were more prevalent in the ACOS group.

CONCLUSIONS

Patients with asthma and COPD had nearly double the health care costs as did patients with asthma without COPD. The overall disease profile of patients with asthma should be considered when managing patients, rather than treating asthma as a solitary condition.

Factor structure of the autonomy preference index in people with severe mental illness

People vary in the amount of control they want to exercise over decisions about their healthcare. Given the importance of patient-centered care, accurate measurement of these autonomy preferences is critical. This study aimed to assess the factor structure of the Autonomy Preference Index (API), used widely in general healthcare, in individuals with severe mental illness. Data came from two studies of people with severe mental illness (N=293) who were receiving mental health and/or primary care/integrated care services. Autonomy preferences were assessed with the API regarding both psychiatric and primary care services. Confirmatory factor analysis was used to evaluate fit of the hypothesized two-factor structure of the API (decision-making autonomy and information-seeking autonomy). Results indicated the hypothesized structure for the API did not adequately fit the data for either psychiatric or primary care services. Three problematic items were dropped, resulting in adequate fit for both types of treatment. These results suggest that with relatively minor modifications the API has an acceptable factor structure when asking people with severe mental illness about their preferences to be involved in decision-making. The modified API has clinical and research utility for this population in the burgeoning field of autonomy in patient-centered healthcare.

Family context influences psychological outcomes of depressive symptoms and emotional quality of life in patients with heart failure

BACKGROUND

Although family influences in heart failure (HF) care are considered important, little evidence is available regarding relationships between the family context and specific outcomes for patients with HF.

OBJECTIVE

The aim of this study was to examine the relationships of patient perceptions of family functioning, autonomy support, and perceived criticism, as well as their family member's (FM) HF knowledge, with patient outcomes of depressive symptoms and HF quality of life (QOL).

METHODS

Participants (n = 117) with HF were enrolled in a family partnership intervention study. Self-report questionnaires measuring the HF patient's perceptions of family context and the FM's knowledge were analyzed relative to the HF patient's outcomes using correlations and sequential multivariate regression analyses. Only preintervention, baseline data are reported here.

RESULTS

Age, ethnicity, Charlson comorbidity index, global family functioning, and FM's HF knowledge accounted for 37.8% (P < .001) of the variance in the patient's depressive symptoms. An additional moderating effect of ethnicity on the association between global family functioning and patient's depressive symptoms was significant (change R2 = 0.06, P = .001), resulting in a final model that accounted for 43.3% of depressive symptom variance. Age, ethnicity, global family functioning, and autonomy support accounted for 24.9% (P < .001) of the variance in emotional HF QOL. An additional moderating effect of ethnicity on the association between global family functioning and patient's emotional HF QOL was significant (change R2 = 0.05, P = .009), resulting in a final model that accounted for 28.9% of emotional QOL variance.

CONCLUSIONS

This study underscores the importance of the patient's perspective on family functioning and autonomy support, along with FM's HF knowledge, on HF patient outcomes moderated by ethnicity. Future interventions could target the modifiable patient-family context relationships for improving depressive symptoms and QOL in HF patients. These findings point to the need for greater family assessment to identify those at risk for worse outcomes and to guide family focused interventions.

Asthma self management in adults: a review of current literature

Self management programs for chronic conditions, such as asthma, have an important place in healthcare delivery. When properly implemented, they can curb the impact of disease and reduce both the high personal costs for individuals and significant financial costs for health care systems. The purpose of this review was to establish an understanding of current published literature on asthma self management programs in adults and to identify any reported attributes or components which serve to either assist or obstruct the uptake of self management strategies. Electronic data sources including Scopus, Proquest 5000, CINAHL, PubMed and Web of Science were accessed and literature searches were conducted using the key terms: asthma, chronic disease, self management, morbidity, quality of life, health outcomes, patient education and best practice. Inclusion criteria for the search included journal articles relating to adults with asthma published in English in peer reviewed journals from 1995 to 2011. Exclusion criteria included research targeting children, parents of children or families; and articles examining Asthma and COPD (or any other co-morbidity). Sixty four articles were included in this review due to their relevance to the major components of asthma self management, as defined by the Australian Asthma Management Handbook. A major conclusion from this review was that the uptake of asthma self management strategies is poor despite global recommendations for over twenty years; and that a likely reason for this is that generic asthma self management advice does not engage the individual with asthma.

Judgment skills, a missing component in health literacy: development of a tool for asthma patients in the Italian-speaking region of Switzerland

BACKGROUND

Health literacy has been recognized as an important factor influencing health behaviors and health outcomes. However, its definition is still evolving, and the tools available for its measurement are limited in scope. Based on the conceptualization of health literacy within the Health Empowerment Model, the present study developed and validated a tool to assess patient's health knowledge use, within the context of asthma self-management.

METHODS

A review of scientific literature on asthma self-management, and several interviews with pulmonologists and asthma patients were conducted. From these, 19 scenarios with 4 response options each were drafted and assembled in a scenario-based questionnaire. Furthermore, a three round Delphi procedure was carried out, to validate the tool with the participation of 12 specialists in lung diseases.

RESULTS

The face and content validity of the tool were achieved by face-to-face interviews with 2 pulmonologists and 5 patients. Consensus among the specialists on the adequacy of the response options was achieved after the three round Delphi procedure. The final tool has a 0.97 intra-class correlation coefficient (ICC), indicating a strong level of agreement among experts on the ratings of the response options. The ICC for single scenarios, range from 0.92 to 0.99.

CONCLUSIONS

The newly developed tool provides a final score representing patient's health knowledge use, based on the specialist's consensus. This tool contributes to enriching the measurement of a more advanced health literacy dimension.

Managing older patients with coexistent asthma and chronic obstructive pulmonary disease: diagnostic and therapeutic challenges

Asthma and chronic obstructive pulmonary disease (COPD) are common obstructive airway diseases, especially among older people. These conditions are associated with a significant and increasing disease burden. The diagnosis and management of asthma and COPD in older populations are complex, and consequently clinicians are faced with many therapeutic and diagnostic challenges. Both aging and obstructive airway diseases are associated with complex co-morbidities and these coexisting illnesses confound management. Moreover, the age-related physiological changes that occur in the lungs may lead to airflow limitation, and this may be difficult to distinguish from an active disease state. In practice, management of asthma and COPD is informed by disease-specific clinical practice guidelines; however, most older people with these conditions are excluded from clinical trials that are designed to inform practice, creating major evidence gaps. Furthermore, seldom do clinical practice guidelines consider the complexities of management in older populations. The problems experienced by older people are complex and multifactorial and our approach to management must reflect these challenges. Opportunities exist to improve the management and outcomes for older people with obstructive airway disease and there is an urgent need for clinical trials to test management approaches in this population; current research must consider the challenges and evidence gaps that exist.

Information giving and involvement in treatment decisions: is more really better? Psychological effects and relation with adherence

OBJECTIVES

The aim of this study is to improve our understanding of the ways in which a medical consultation style relates to satisfaction and adherence.

DESIGN

Participants completed questionnaires about preferred and perceived consultation styles; psychological variables such as satisfaction, anxiety and depression; and questions about taking medication. Questionnaires were completed prior to the consultation, immediately after, three months later and one year later. Doctors also completed a scale on completion of the consultation. The decisions in question related to women seeking advice about Hormone Replacement Therapy (HRT) and decisions about pain management.

RESULTS

Patients expressed preferences for information about the treatment options and for active involvement in the decision process. The extent to which patients perceived themselves as having received information about the treatment options was a particularly consistent predictor of satisfaction. The extent to which patients perceived themselves as having been prepared for the side effects of HRT was a consistent predictor of anxiety.

CONCLUSIONS

Perceptions of the amount of information received about medical options, including information preparing individuals for potential side effects of medication, appears to be more important to satisfaction and anxiety, than actual involvement in the decision.

The paucity of ethical analysis in allergology

While a growing body of research is uncovering the aetiology and effective treatments for allergy, research that assess the broader ethical implications of this disease is lacking significantly. This article will demonstrate both the paucity of academic research concerning ethical implications in allergy and explain why ethical analysis is integral to formulating effective health strategies for allergic disease. An exhaustive literature search of publications in French and English identified less than 35 academic articles focussed on the topic of ethics and allergy; this is a miniscule number when compared to the amount of articles published on ethical issues related to other chronic illnesses, such as obesity. It is important to demonstrate to allergy specialists the need for, and utility of, further incorporating ethical analyses in allergology; the current success of Ethical, Legal, Social Implications (ELSI) research programmes in human genetics and nanotechnology will serve as notable examples. Indeed, future research and innovation in allergy will undoubtedly encounter ethical dilemmas and the allergology community should play a significant role in helping to address these issues. However, incorporating ethical analyses in allergology does not imply that the allergology community must acquire extensive knowledge in bioethics; instead, interdisciplinary research that incorporates expertise from allergology and bioethics would enable allergy specialists to advance critical knowledge development in this largely overlooked domain of study.

Self-care after traumatic injury and the use of the therapeutic self care scale in trauma populations

AIMS

To report a correlational study of the relationship between gender, age, severity of injury, length of hospital stay and self-care behaviour in patients with traumatic injuries.

BACKGROUND

This study may provide a foundation for targeted nursing intervention and education programmes to help patients better recover from their injury, which is a fundamental aspect of nursing.

DESIGN

A longitudinal cohort study.

METHOD

This study of patients hospitalized for traumatic injury was conducted from May 2006-November 2007. The Therapeutic Self Care Scale along with demographic and clinical data, were completed at 3 and 6 months after hospital discharge. Using data from the 3-month survey, the validity and reliability of the scale was calculated. Multiple regression was used to identify predictors of self-care at 3 and 6 months.

FINDING

Participants (n = 125) completed the questionnaire at 3 months and 103 participants completed it at 6 months. Self-care was high on both occasions and high self-care at 3 months was related to high self-care at 6 months. Older participants reported higher self-care at 3 months compared with younger patients. Factor analysis of the scale revealed three clear components; taking medication, recognition and managing symptoms and managing changes in health conditions, which explained a total of 59·8% of the variance. The 10-item revised scale was reliable.

CONCLUSION

The findings indicate that self-care remains fairly high and stable in the first 6 months after trauma. The revised Therapeutic Self Care Scale was valid and reliable in the trauma population.

Patient preferences for shared decisions: a systematic review

OBJECTIVES

Empirical literature on patient decision role preferences regarding treatment and screening was reviewed to summarize patients' role preferences across measures, time and patient population.

METHODS

Five databases were searched from January 1980 to December 2007 (1980-2007 Ovid MEDLINE, Cochrane Database of Systematic Reviews, PsychInfo, Web of Science and PubMed (2005-2007)). Eligible studies measured patient decision role preferences, described measures, presented findings as percentages or mean scores and were published in English from any country. Studies were compared by patient population, time of publication, and measure.

RESULTS

115 studies were eligible. The majority of patients preferred sharing decisions with physicians in 63% of the studies. A time trend appeared. The majority of respondents preferred sharing decision roles in 71% of the studies from 2000 and later, compared to 50% of studies before 2000. Measures themselves, in addition to patient population, influenced the preferred decision roles reported.

CONCLUSION

Findings appear to vary with the measure of preferred decision making used, time of the publication and characteristics of the population.

PRACTICE IMPLICATIONS

The role preference measure itself must be considered when interpreting patient responses to a measure or question about a patient's preference for decision roles.

Patient-centered care and its effect on outcomes in the treatment of asthma

Patient-centered care may be pivotal in improving health outcomes for patients with asthma. In addition to increased attention in both research and clinical forums, recent legislation also highlights the importance of patient-centered outcomes research in the Patient Protection and Affordable Care Act. However, whether patient-centered care has been shown to improve outcomes for this population is unclear. To answer this question, we performed a systematic review of the literature that aimed to define current patient-focused management issues, characterize important patient-defined outcomes in asthma control, and identify current and emerging treatments related to patient outcomes and perspectives. We used a parallel search strategy via Medline(®), Cochrane Central Register of Controlled Trials, CINAHL(®) (Cumulative Index to Nursing and Allied Health Literature), and PsycINFO(®), complemented with a reference review of key articles that resulted in a total of 133 articles; 58 were interventions that evaluated the effect on patient-centered outcomes, and 75 were descriptive studies. The majority of intervention studies demonstrated improved patient outcomes (44; "positive" results); none showed true harm (0; "negative"); and the remainder were equivocal (14; "neutral"). Key themes emerged relating to patients' desires for asthma knowledge, preferences for tailored management plans, and simplification of treatment regimens. We also found discordance between physicians and patients regarding patients' needs, beliefs, and expectations about asthma. Although some studies show promise regarding the benefits of patient-focused care, these methods require additional study on feasibility and strategies for implementation in real world settings. Further, it is imperative that future studies must be, themselves, patient-centered (eg, pragmatic comparative effectiveness studies) and applicable to a variety of patient populations and settings. Despite the need for further research, enough evidence exists that supports incorporating a patient-centered approach to asthma management, in order to achieve improved outcomes and patient health.

Asthma in older adults

Asthma in older people is common and is characterised by underdiagnosis and undertreatment. Ageing is associated with unique issues that modify expression, recognition, and treatment of the disease. In particular, asthma and chronic obstructive pulmonary disease (COPD) both overlap and converge in older people. This concurrence, together with absence of precise diagnostic methods, makes diagnosis complex. A multidimensional assessment that addresses airway problems, comorbidities, risk factors, and management skills will draw attention to key needs for intervention. Increased attention to the complications of asthma and obstructive airway disease in older people is needed, specifically to develop effective systems of care, appropriate clinical practice guidelines, and a research agenda that delivers improved health outcomes.

Decision-making role preferences among patients with HIV: associations with patient and provider characteristics and communication behaviors

BACKGROUND

A preference for shared decision-making among patients with HIV has been associated with better health outcomes. One possible explanation for this association is that patients who prefer a more active role in decision-making are more engaged in the communication process during encounters with their providers. Little is known, however, about patient and provider characteristics or communication behaviors associated with patient decision-making preferences in HIV settings.

OBJECTIVE

We examined patient and provider characteristics and patient-provider communication behaviors associated with the decision-making role preferences of patients with HIV.

DESIGN

Cross-sectional analysis of patient and provider questionnaires and audio recorded clinical encounters from four sites.

PARTICIPANTS

A total of 45 providers and 434 of their patients with HIV.

MEASURES

Patients were asked how they prefer to be involved in the decision-making process (doctor makes all/most decisions, patients and doctors share decisions, or patients make decisions alone). Measures of provider and patient communication behaviors were coded from audio recordings using the Roter Interaction Analysis System.

MAIN RESULTS

Overall, 72% of patients preferred to share decisions with their provider, 23% wanted their provider to make decisions, and 5% wanted to make decisions themselves. Compared to patients who preferred to share decisions with their provider, patients who preferred their provider make decisions were less likely to be above the age of 60 (ARR 0.09, 95% CI 0.01-0.89) and perceive high quality provider communication about decision-making (ARR 0.41, 95% CI 0.23-0.73), and more likely to have depressive symptoms (ARR 1.92, 95% CI 1.07-3.44). There was no significant association between patient preferences and measures of provider or patient communication behavior.

CONCLUSION

Observed measures of patient and provider communication behavior were similar across all patient decision-making role preferences, indicating that it may be difficult for providers to determine these preferences based solely on communication behavior. Engaging patients in open discussion about decision-making preferences may be a more effective approach.

Quality of life and autonomy preferences in stable asthmatics: a developing country scenario

BACKGROUND AND OBJECTIVE

The quality of life (QOL) and autonomy preferences of asthmatics in developing countries have been sparingly researched, with a resulting lack of management strategies. This study determined the asthma-specific QOL and autonomy preferences of a population of asthmatics in a developing country and their association with relevant sociodemographic and clinical characteristics.

METHODS

A cross-sectional study using the Asthma Quality of Life Questionnaire and the Asthma Autonomy Questionnaire was performed on a population of stable asthmatics recruited from a tertiary care centre in India. Severity of the disease was assessed by spirometry.

RESULTS

The study population comprised 80 asthmatics. The mean (SD) overall QOL score was 5.04 (0.97). This was significantly associated with history of hospitalization during the previous year for an asthma attack (P < 0.01) and with FEV(1) (P < 0.05) on univariate analysis; on multivariate analysis, only history of hospitalization was significant. Autonomy preferences of the patients showed higher scores for information-seeking (mean (SD) = 78.95 (16.35) ) than decision-making (mean (SD) = 38.21 (14.6)). The information-seeking preferences had a negative correlation with age (P < 0.01) and a positive correlation with education status (P < 0.01) and decision-making correlated with education status (P < 0.05). A minority of patients (19%) indicated a preference for a greater say in decision-making than their physicians. There was a lower tendency for decision-making when given a 'severe exacerbation' scenario than in 'mild exacerbation' (P < 0.001) or 'stable disease' (P < 0.001).

CONCLUSIONS

Hospitalization history and FEV(1) values are the parameters having the most significant impact on the QOL of asthmatics. There is a clear desire to obtain more information about the disease but most patients do not endorse the idea of making independent disease-related decisions.

Views of treatment decision making from adolescents with chronic illnesses and their parents: a pilot study

OBJECTIVE

Shared decision making may increase satisfaction with health care and improve outcomes, but little is known about adolescents' decision-making preferences. The primary purpose of this study is to describe the decision-making preferences of adolescents with chronic illnesses and their parents, and the extent to which they agree.

DESIGN

Survey.

SETTING AND PARTICIPANTS

Participants were 82 adolescents seen at one of four paediatric chronic illness subspecialty clinics and 62 of their parents.

MAIN VARIABLES

Predictor variables include sociodemographics, health parameters, risk behaviour, and physical and cognitive development. The main outcome variable is preferences for decision-making style.

RESULTS AND CONCLUSIONS

When collapsed into three response categories, nearly equal percentages of adolescents (37%) and parents (36%) preferred shared decision making. Overall, the largest proportion of adolescents (46%) and parents (53%) preferred passive decision making compared to active or shared decision making. Across five response choices, 33% of pairs agreed. Agreement was slight and not significant. Improved general health perceptions (OR=0.76, 95% CI=0.59-0.99) and improved behaviour (OR=0.75, 95% CI=0.56-0.99) were significantly associated with parents' preferences for less active decision making. Older age was significantly associated with agreement (OR 1.58, 95% CI=1.09-2.30) between parents and adolescents. The paucity of significant predictor variables may indicate physicians need to inquire directly about patient and parent preferences.

Difficult asthma: people's perspectives on taking corticosteroid therapy

AIMS AND OBJECTIVES

This study aimed to explore the experiences of patients with difficult asthma, who take corticosteroid therapy, and provide insight into why some patients comply with therapy, whilst others do not.

BACKGROUND

Asthma is growing in prevalence and affects more than 100 million people worldwide. Corticosteroids are the mainstay treatment but, despite considerable risk to the individual in terms of morbidity and mortality, compliance is low. Previous research has been mainly quantitative and analysed variables associated with compliance, doing little to increase professional understanding of the patient's perspective on taking corticosteroid treatment.

METHODS

A hermeneutic phenomenological approach was selected as most appropriate for this study. Unstructured interviews were undertaken with a purposive sample of 10 participants. Interviews were taped, transcribed and the data were analysed using a multi-step technique described by Holloway.

FINDINGS

Fear of side effects was the strongest theme to emerge; illustrated by the negative images participants described such as weight gain, anxiety, irritability and depression. Participants related control and power over their condition to knowledge and information. They wanted more information, but believed that health professionals assumed they were already well informed. Costs and benefits of treatment were weighed up before decisions were made. Participants described feelings of 'not being themselves' and personality changes resulting in the loss of their role within relationships. Routine, time and opinions of significant others, also impacted on taking steroids.

CONCLUSION

Decision-making was a complex process, involving evaluation of the personal costs and benefits of treatment; fear of side effects was the dominant concern. Compliance with treatment saves lives in this population.

RELEVANCE TO CLINICAL PRACTICE

This study uncovers issues participants consider when making decisions regarding adherence and highlights the importance of the nurse's role in eliciting patients' concerns and the providing appropriate information to allay fears and misconceptions.

An evaluation of a community pharmacy-based rural asthma management service

OBJECTIVE

To compare the effect of a pharmacist-delivered rural asthma management service (RAMS) on health outcomes for people with asthma in a rural/regional area with 'standard care' delivered through community pharmacies.

DESIGN

A parallel group controlled repeated measures study.

SETTING

Community pharmacies in Central West New South Wales.

INTERVENTION

Standardised protocols and resources based on national asthma management guidelines, delivered by specially trained community pharmacists. Patients visited the pharmacy at baseline and 1, 3 and 6 months after baseline in the intervention group and at baseline plus 6 months after baseline in the control group.

PARTICIPANTS

The intervention pharmacists (n = 12) were trained to deliver the RAMS model, while control pharmacists (n = 8) provided standard asthma care to their recruited patients. Fifty-one and 39 patients were recruited by intervention and control pharmacists.

MAIN OUTCOME MEASURE

Asthma severity score which was a composite score based on recency, frequency and severity of asthma symptoms, and asthma history.

RESULTS

Data compared at the final visit between groups indicated that the RAMS patient group demonstrated a significant reduction in the asthma severity scores (7.9 +/- 2.6 versus 10.4 +/- 2.6, P < 0.001); a reduction in the risk of non-adherence to medication scores (1.6 +/- 0.7 versus 2.3 +/- 1.1, P < 0.001); and an increase in the proportion of patients owning a written action plan (50% versus 23%, P = 0.04).

CONCLUSIONS

These results indicated that the community pharmacy-based RAMS model can improve asthma outcomes for patients in rural settings, and similar models for asthma and other chronic diseases should be tested rigorously and adopted in rural primary care practice.

Patient-centered education: applying learner-centered concepts to asthma education

OBJECTIVE

To review studies of patient-centered asthma education.

METHOD

CINAHL, Medline, Psycinfo, Eric, PsycARTICLES, and web of science databases were searched. RESULTS Asthma education programs are often based on health behavior theories. Many studies lack rigor in the assessment of the program's efficacy and effectiveness. Asthma education that promotes self-management primarily uses a problem-based approach. Few studies have examined the way educators teach and patients learn. Patient-centered approaches to education have mainly focused on communication between the patient and the health professional. Decision making as part of shared responsibility may vary with every patient. Patient-centered care shares similarities with the Self-Determination Theory as a learner-centered approach to education.

CONCLUSIONS

Many asthma education studies have been completed with varying levels of efficacy and effectiveness reported. Most programs focus on changing behavior with few studies examining educator behavior and/or the patient's learning styles. With a patient-centered approach being the preferred model of care, the incorporation of learner-centered approaches to patient education may prove useful in the future.

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

OBJECTIVE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Understanding the potential role of mobile phone-based monitoring on asthma self-management: qualitative study

BACKGROUND

National and international healthcare policy increasingly seeks technological solutions to the challenge of providing care for people with long-term conditions. Novel technologies, however, have the potential to change the dynamics of disease monitoring and self-management. We aimed to explore the opinions and concerns of people with asthma and primary care clinicians on the potential role of mobile phone monitoring technology (transmitting symptoms and peak flows, with immediate feedback of control and reminder of appropriate actions) in supporting asthma self-management.

METHODS

This qualitative study recruited 48 participants (34 adults and teenagers with asthma, 14 asthma nurses and doctors) from primary care in Lothian (Central Scotland) and Kent (South East England). Thirty-nine participated in six focus groups, which included a demonstration of the technology; nine gave in-depth interviews before and after a 4-week trial of the technology.

RESULTS

Participants considered that mobile phone-based monitoring systems can facilitate guided self-management although, paradoxically, may engender dependence on professional/technological support. In the early phases, as patients are learning to accept, understand and control their asthma, this support was seen as providing much-needed confidence. During the maintenance phase, when self-management predominates, patient and professionals were concerned that increased dependence may be unhelpful, although they appreciated that maintaining an on-going record could facilitate consultations.

CONCLUSION

Mobile phone-based monitoring systems have the potential to support guided self-management by aiding transition from clinician-supported early phases to effective self-management during the maintenance phase. Continuing development, adoption and formal evaluation of these systems should take account of the insights provided by our data.

Can patients' preferences for involvement in decision-making regarding the use of medicines be predicted?

OBJECTIVE

The current study aimed to develop a model of patients' preferences for involvement in decision-making concerning the use of medicines for chronic conditions in the UK and test it in a large representative sample of patients with one of two clinical conditions.

METHODS

Following a structured literature review, an instrument was developed which measured the variables that had been identified as predictors of patients' preferences for involvement in decision making in previous research. Five hundred and sixteen patients with rheumatoid arthritis or type 2 diabetes were recruited from outpatient and primary care clinics and asked to complete the instrument.

RESULTS

Multivariate analysis revealed that age, social class and clinical condition were associated with preferences for involvement in decision-making concerning the use of medicines for chronic illness but gender, ethnic group, concerns about medicines, beliefs about necessity of medicines, health status, quality of life and time since diagnosis were not. In total, the fitted model explained only 14% of the variance.

CONCLUSION

This study has demonstrated that current research does not provide a basis for predicting patients' preferences for involvement in decision-making.

PRACTICE IMPLICATIONS

Building concordant relationships may depend on practitioners developing strategies to establish individuals' preferences for involvement in decision-making as part of the ongoing prescriber-patient relationship.

Understanding asthma in older Australians: a qualitative approach

WHAT WE NEED TO KNOW: Are there differences in symptom interpretation in older people with asthma? What are effective drug delivery strategies in older people to maximise adherence and minimise side effects? How do older people with asthma manage their asthma? Are self-management strategies as appropriate as they are in younger age groups? Do older people with asthma take appropriate steps in an emergency? Do they own or act on asthma action plans? WHAT WE NEED TO DO: Identify the specific barriers that prevent the optimal care of older people with asthma. Address systematic barriers, such as cost and immobility, that reduce access to effective treatments. Ensure older people with asthma receive appropriate asthma treatment. Explore asthma self-management strategies in older people to develop effective algorithms. Educate health professionals to provide optimal asthma treatments and deliver appropriate education designed specifically for older people.

Patients' preference for involvement in medical decision making: a narrative review

OBJECTIVE

This review aimed to clarify present knowledge about the factors which influence patients' preference for involvement in medical decision making.

METHODS

A thorough search of the literature was carried out to identify quantitative and qualitative studies investigating the factors which influence patients' preference for involvement in decision making. All studies were rigorously critically appraised.

RESULTS

Patients' preferences are influenced by: demographic variables (with younger, better educated patients and women being quite consistently found to prefer a more active role in decision making), their experience of illness and medical care, their diagnosis and health status, the type of decision they need to make, the amount of knowledge they have acquired about their condition, their attitude towards involvement, and the interactions and relationships they experience with health professionals. Their preferences are likely to develop over time as they gain experience and may change at different stages of their illness.

CONCLUSION

While patients' preferences for involvement in decision making are variable and the process of developing them likely to be highly complex, this review has identified a number of influences on patients' preference for involvement in medical decision making, some of which are consistent across studies.

PRACTICE IMPLICATIONS

By identifying the factors which might influence patients' preference for involvement, health professionals may be more sensitive to individual patients' preferences and provide better patient-centred care.

Asthma patients' knowledge, perception, and adherence to the asthma guidelines

Asthma patients' knowledge and perceptions about asthma management regimens have been shown to correlate with the quality of their asthma management and outcomes. This study addresses adult ambulatory asthma patients' knowledge and perception of the asthma management guidelines issued by the National Asthma Education and Prevention Program. We interviewed 76 patients at three adult medicine outpatient clinics. Of 37 patients who knew about peak flow monitoring, 21 found it to be useful, only 10 were using it regularly, and 7 had a notation about it in their chart. Eight patients knew about patient self-assessment forms, 6 found them useful, 3 had used one recently, and only 1 patient had one in the chart. Six patients knew about asthma action plans, 4 of them thought that these plans were useful, but only 1 patient was actively using it. This study demonstrates major gaps in the asthma patients knowledge, perceptions, and their adherence to recommendations and also with the documentation in the medical record.

Adverse psychological outcomes in colorectal cancer screening: does health anxiety play a role?

People who are anxious about their health are more likely to misinterpret health information as personally threatening and less likely to be reassured by medical investigations that show they are free from disease. Consequently, health anxious people would be expected to react more adversely to cancer screening, but this possibility has rarely been explored. The moderating role of health anxiety on the psychological impact of participating in colorectal cancer screening was examined among a sub-sample of 3535 participants in a large, community-based trial of colorectal cancer screening in the UK. The screening modality was flexible sigmoidoscopy, which examines the bowel for pre-cancerous polyps. It was predicted that health anxiety would be associated with more worry about cancer before screening, a greater increase in worry if polyps were detected, and less reassurance after a clear result. As expected, health anxious participants were more anxious and more worried about bowel cancer both before and after screening. However, they experienced greater reductions in anxiety and worry about cancer following the examination. They reported lower levels of reassurance following screening, but also expressed more positive reactions to the experience. The positive psychological benefits of attending medical investigations should be examined in future work, because this may go some way towards explaining why health anxious people repeatedly seek medical interventions.

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

BACKGROUND

Current healthcare policy advocates patient participation in treatment decision making. However, in asthma there is little evidence regarding patients' views on such involvement. This study explored the preferred and perceived level of involvement in treatment decisions, rationales for role preference, perceived facilitators of/barriers to involvement, and the interrelationship of role preference and demographic variables in a sample of patients with asthma.

METHODS

A cross sectional survey was performed of 230 adults with clinician diagnosed asthma from 10 primary care sites and one specialist respiratory centre in north-west England. Preferred role in treatment decisions was assessed using the Control Preferences Scale.

RESULTS

Fifty five (23.9%) preferred an active role, 82 (35.7%) a collaborative role, and 93 (40.4%) a passive role; 19 (8.2%) perceived their role as active compared with 45 (19.6%) collaborative and 166 (72.2%) passive. Only 33.5% (n = 77) of respondents attained their most preferred role; 55.2% (n = 127) were less involved than they preferred. Patient related, professional related, and organisational factors, especially quality and duration of consultations, facilitated or hampered involvement. Role preferences were not strongly associated with demographic variables or asthma severity.

CONCLUSIONS

This study in patients with asthma highlights the fact that there is a need for professional and patient education regarding partnership working, skilful communication, and innovative approaches to service delivery.

Economic assessment of adjustable maintenance treatment with budesonide/formoterol in a single inhaler versus fixed treatment in asthma

OBJECTIVES

To compare the costs and effectiveness of adjustable maintenance dosing with budesonide/formoterol in a single inhaler versus fixed dosing in adults with asthma.

METHODS

In this prospective, randomised, open-label, parallel-group, multicentre trial conducted in Germany, patients with asthma received budesonide/formoterol 160 microg/4.5 microg in a single inhaler (Symbicort Turbuhaler with two inhalations twice daily for a 4-week run-in period. Patients were then randomised to either adjustable maintenance dosing (one inhalation twice daily, stepping up to four inhalations twice daily for 1 week if asthma worsened; n=1679) or fixed dosing (two inhalations twice daily; n=1618) for 12 weeks. The primary efficacy variable was the change in health-related quality of life (HR-QOL), measured using the Asthma Quality of Life Questionnaire (standardised) during the randomised treatment period. Resource utilisation data were collected in parallel and combined with German unit costs to estimate direct and indirect costs (year 2001 values).

RESULTS

Both treatment regimens were equally effective in maintaining HR-QOL and asthma control during the randomised treatment period. However, overall, patients in the adjustable maintenance dosing group took fewer daily inhalations of budesonide/formoterol than those in the fixed-dosing group (mean: 2.63 vs 3.82 inhalations; p<0.001). Adjustable maintenance dosing was associated with significantly lower asthma-related direct costs compared with fixed dosing (mean: 221 euro vs 292 euro; p<0.001). This pattern was maintained when patients were stratified into those with peak expiratory flow (PEF) of 60% to <80% predicted normal and those with PEF of>/=80% predicted normal and when total costs were considered.

CONCLUSION

Adjustable maintenance dosing with budesonide/formoterol in a single inhaler maintained HR-QOL in adult patients with asthma at a significantly lower cost than fixed dosing.

Health-related quality of life in asthma studies. Can we combine data from different countries?

The aim was to compare health-related quality of life (HRQL) in patients with asthma from 4 countries, and to investigate the correlations between HRQL and clinical indices.341 patients; 140 (Sweden), 54 (Norway), 65 (the Netherlands) and 82 (Greece) were treated with formoterol fumarate 4.5 microg or with terbutaline sulphate 0.5mg for 12 weeks inhaled 'on demand' via Turbuhaler. The Asthma Quality of Life Questionnaire (AQLQ) and clinical indices were assessed. The mean baseline AQLQ overall scores in Sweden (4.97), in the Netherlands (5.04), in Norway (4.68) and in Greece (4.68) were in the same range, however, with a significant difference between the four countries (p=0.038). When comparing AQLQ, activity limitation and symptoms domains, the differences between the countries were not statistically significant. The cross-sectional correlations between AQLQ overall score and the clinical indices were similar in all four countries. The magnitude of change in AQLQ was consistent with the other clinical variables. The correlations between change in AQLQ overall score and change in clinical indices were low to medium in all countries. In conclusion, the consistency of cross-sectional correlations between the AQLQ overall and clinical indices across countries supports the validity of translations of the AQLQ used in this study. There were differences in baseline values between the countries. The treatment response in AQLQ differed to the same extent as other clinical indices. When combining HRQL data from different countries, there might be cultural, gender and socio-economic differences, explaining different responses to treatment.

Evaluation of the impact of a pharmaceutical care program in children with asthma

The objective of this study was to evaluate the impact of a pharmaceutical care program on children with asthma. A comprehensive asthma education and monitoring program that includes basic asthma knowledge, symptoms and exacerbation evaluation, pharmacotherapy assessment including inhaler technique, and quality of life measurements was developed and applied in an outpatient paediatric clinic of the Catholic University of Chile. All patients with moderate asthma scheduled for outpatient visits with their internist over a 1-year period were referred for pharmacist intervention. Patients (aged 7-17) with moderate asthma attending the clinic were allocated to the intervention (group A) or control group (group B). Intervention patients were educated on their disease, pharmacotherapy, self-management, and inhalation techniques. The group B were children with their regular treatment for asthma but without pharmaceutical intervention. A paediatric asthma quality of life questionnaire (PAQLQ) was applied to both groups at 0, 2, and 9 weeks to assess the quality of life. Spirometry was done at the beginning and at the completion of the 9-week study. Beta-agonists used by each patient were also recorded. Eleven children (10.0+/-0.7 years) were included in the pharmaceutical care program, and ten children (9.9+/-0.6 years) in group B. For the individual domains of activities (A), emotions (E), and symptoms (S) there was a significant improvement in the children who received pharmaceutical care in comparison with those who did not receive it. The scores of group B did not change during the 9 weeks of follow-up. There were no significant changes in spirometric values in either group.

Qualitative analysis of living with heart failure

BACKGROUND

The incidence of heart failure has been described as epidemic in proportion. Although literature abounds surrounding issues of epidemiology, pathophysiology, and treatment issues for those with heart failure, little is known about the day-to-day experiences of adults living with this chronic illness.

OBJECTIVES

The purpose of this study was to describe and analyze the experience of adults who are living with heart failure. The specific aims were to describe the problems, challenges, and processes of living with heart failure, to identify strategies and tactics adults use to live with heart failure, and to provide a model that articulates what the participants described.

METHODS

Principles of naturalistic inquiry were used to describe problems, challenges, and processes of living with heart failure. Six women and 5 men participated in in-depth interviews that lasted from 40 minutes to 100 minutes. Data were collected and analyzed with the constant, comparative method.

RESULTS

Participants' use of language referring to wind and water in describing their heart failure symptoms led to discovery of navigating and aspects of navigational science as metaphors for living with heart failure. The 3 main categories of the resulting model were called experiencing turbulence, navigating, and finding safe harbor.

CONCLUSIONS

Use of the model for living with heart failure may provide for creation of interventions for adults to improve their ability to manage their own care in the face of this potentially devastating illness.

Decision-making in children with asthma and their parents

PURPOSE

To learn how children with asthma and their parents make treatment-related decisions.

DATA SOURCES

Verbatim transcripts of focus group interviews of 28 school age children with asthma and their parents. Children had attended an educationally based asthma camp program. Questions related to choices parents and children made regarding implementation of their asthma treatment plans both, at home and at school.

CONCLUSIONS

Parents and children made many non-adherence decisions especially with respect to preventive aspects of the treatment plan. Symptoms were the driving force for children's decisions. Parents and children had concerns about implementing the management plan at school. Parents and children may not perceive asthma treatment options as true choices, thus affecting motivation for adherence.

IMPLICATIONS

Practitioners need to form partnerships with parents and children in developing treatment goals. Goals should focus on achievement of normal daily activities. Asthma education needs to be concrete and include school personnel. Practitioners need to give families positive, informational feedback.

Patients' views of the burden of asthma: a qualitative study

OBJECTIVES

To explore the burden of asthma on the lives of people presenting to hospital emergency departments for asthma treatment.

DESIGN

A qualitative study. Consenting individuals with asthma who presented to emergency departments were interviewed in-depth, and interviews were taped, transcribed and thematically analysed. Questionnaire data on medication use, respiratory health and asthma knowledge were also collected. Asthma severity was determined from the medical records.

SETTING

A tertiary teaching hospital and a suburban hospital during March and April 2000, and a rural hospital during July and August 2000.

PARTICIPANTS

Sixty-two participants (19 male and 43 female), aged 18-70 years.

RESULTS

The burden of asthma was broad, affecting social life, personal relationships, employment and finances. The cost of asthma medication was an issue for nearly two-thirds of participants. Individuals performed their own "cost-benefit analysis" for medication use, weighing up expense, perceived side effects and potential benefits. As a consequence, several participants chose to alter their medication dose, or not to take prescribed medications. For some participants, asthma directly contributed to diminished employment opportunities.

CONCLUSIONS

To achieve a therapeutic partnership, doctors need to be aware of the substantial social, personal and financial burden of asthma for their patients. They should also recognise that patients' perceptions of treatment cost may compromise treatment adherence.

A qualitative exploration of treatment decision-making role preference in adult asthma patients

OBJECTIVES

To explore preferred treatment decision-making roles, and rationales for role preference, and to identify perceived facilitators to and barriers from attaining preferred role.

DESIGN

Qualitative design.

SETTING AND PARTICIPANTS

One secondary care and four primary care sites in North-west England. Purposive sample of 32 adult asthma patients with varied socio-economic backgrounds and disease severity.

METHODS

Tape-recorded focused-conversation style interviews. Interview topic guide derived from the literature. Sort cards employed to provide the focus for exploration of role preferences.

RESULTS

Active (n = 7), collaborative (n = 11) and passive (n = 14) decisional role preferences were identified. Respondents cited level of knowledge; trust; duration of condition; severity of condition at the decisional juncture; lifelong nature of asthma; a perception that 'it is my body'; characteristics of the individual and their response to health professionals as influencing role preference. Perceived facilitators and barriers to participation included condition-related knowledge, practical issues (e.g. lack of time during consultation) and clinicians' interpersonal skills.

CONCLUSIONS

Most respondents wished to contribute to or feel involved in treatment decision-making, but not necessarily to control it. Some hindrances to participation would be amenable to intervention. The quality of the provider-patient relationship is central to facilitating participation.

Education and self-management: a one-year randomized trial in stable adult asthmatic patients

OBJECTIVE

to assess the effects of an educational program in asthmatic patients, following treatment readjustment.

METHODS

moderate to severe asthmatic adults underwent a run-in period (up to 45 days) in order to optimize their treatment. Patients were then randomized to an educational or control group over a one-year period. Education consisted of five individual sessions covering: pathophysiology of asthma, role of medication and side-effects, asthma triggers and their avoidance, detection of an asthma flare-up, and self-management plan based on symptoms and peak-flow monitoring. MAIN OUTCOME CRITERION: symptom-free days over the study period (SFD).

RESULTS

a total of 72 patients were enrolled (36 in the "education group" and 36 in the "control group"), 54 of whom completed the study. Mean SFD was comparable in the two groups (88% in the education group and 89% in the control group, respectively). When the analysis was restricted to the education group, those patients who complied perfectly with the action plan (n = 5) exhibited a higher SFD, compared to the others (97% vs. 87%, p = 0.009).

CONCLUSION

both education and control groups showed high and comparable percentages of SFD. Compliance with self-management plans appears to be an important determining factor in educational programs.

An exploratory study of priority information needs in adult asthma patients

The aim of this study was to gain insight into patients' perspectives on key information needs regarding their asthma. Focused conversation-style interviews were conducted with a purposive sample of 32 patients (aged 18-84 years; males=17, females=15) from five sites (four primary care, one secondary care) in North West England. Interviews were tape recorded and transcribed verbatim, then subjected to line-by-line content analysis. Nine core information needs were identified: current medications; new therapies; medication side effects; triggers of an asthma attack; lifestyle issues; asthma causation; effects of asthma; long term outcome; and symptom control. Individual differences in information need were apparent, as were differences according to asthma severity. The findings highlight some of the challenges facing health professionals when information-giving. The study's findings could be used in a clinical context to facilitate discussion or to tailor information, and could also provide a basis for future quantitative studies.