Barriers to patient-clinician collaboration in asthma management: the patient experience

The experience of shared decision-making for people with asthma: A systematic review and metasynthesis of qualitative studies

OBJECTIVES

To identify, describe and synthesise the views and experiences of adults living with asthma regarding shared decision-making (SDM) in the existing qualitative literature METHODS: We conducted a comprehensive search of 10 databases (list databases) from inception until September 2023. Screening was performed according to inclusion criteria. Tools from the Joanna Briggs lnstitute were utilised for the purposes of data extraction and synthesis in this study. The data extraction process in this study employed the Capability, Opportunity and Motivation Model of Behaviour (COM-B model) as a framework, and a pragmatic meta-aggregative approach was employed to synthesise the collected results.

RESULTS

Nineteen studies were included in the metasynthesis. Three synthesised themes were identified: the capability of people living with asthma, the opportunities of people living with asthma in SDM, and the motivation of the people living with asthma in SDM.

CONCLUSIONS

We have identified specific factors influencing people living with asthma engaging in SDM. The findings of this study can serve as a basis for the implementation of SDM in people living with asthma and provide insights for the development of their SDM training programs. The ConQual score for the synthesised findings was rated as low. To enhance confidence, future studies should address dependability and credibility factors.

PRACTICE IMPLICATIONS

This review contemplates the implementation of SDM from the perspective of people living with asthma, with the aim of providing patient-centred services for them. The results of this review can benefit the implementation of SDM and facilitate information sharing. It offers guidance for SDM skills training among adults living with asthma, fosters a better doctor-patient relationship and facilitates consensus in treatment decisions, thereby enabling personalised and tailored medical care.

PATIENT OR PUBLIC CONTRIBUTION

Three nursing graduate students participated in the data extraction and integration process, with two students having extensive clinical experience that provided valuable insights for the integration.

Using IT to Improve Outcomes for Children Living With Cancer (SyMon-SAYS): Protocol for a Single-Institution Waitlist Randomized Controlled Trial

BACKGROUND

Children and adolescents with cancer may experience multiple disease- and treatment-related symptoms that negatively affect health-related quality of life. Routine symptom surveillance thus constitutes an important component of supportive care in pediatric oncology. The Symptom Monitoring and Systematic Assessment and Reporting System in Young Survivors (SyMon-SAYS) system will administer, score, interpret, and display the results of symptom assessments captured weekly using patient-reported outcomes presented via the electronic health record (EHR) portal between clinic visits in oncology ambulatory settings, when patients are likely to be more symptomatic. This study is testing a digital system for routine symptom surveillance that includes EHR-based reports to clinicians and alerts for severe symptoms.

OBJECTIVE

In this randomized trial, we are examining the effects of the SyMon-SAYS system on perceived barriers to symptom management, self-efficacy, and symptom severity. Better self-management and timely clinical intervention to address symptoms promote adherence to treatment plans, strengthen child and parent self-efficacy, improve interactions between children, parents, and their clinical providers, and optimize clinical outcomes.

METHODS

The SyMon-SAYS system is integrated into the EHR to streamline the presentation of symptom scores and delivery of alerts for severe symptoms to clinicians using EHR (Epic) messaging functionalities. Children (aged 8 to 17 years) complete the weekly symptom assessment and review the symptom report by logging into the patient portal (Epic MyChart). This single-institution waitlist randomized controlled trial is recruiting 200 children (aged 8-17 years) with cancer and their parents, guardians, or caregivers. Participating dyads are randomly assigned to receive the intervention over 16 weeks (Group A: 16-week SyMon-SAYS intervention; Group B: 8-week usual care and then an 8-week SyMon-SAYS intervention). Analyses will (1) evaluate the efficacy of SyMon-SAYS at week 8 and the maintenance of those effects at week 16; (2) evaluate factors associated with those efficacy outcomes, including contextual factors, adherence to the SyMon-SAYS intervention, demographic characteristics, and clinical factors; and (3) evaluate predictors of adherence to the SyMon-SAYS intervention and preference of SyMon-SAYS versus usual care.

RESULTS

Data collection is currently in progress. We hypothesize that at 8 weeks, those receiving the SyMon-SAYS intervention will report decreased parent-perceived barriers to managing their children's symptoms, increased parent and child self-efficacy, decreased child symptom burden, and ultimately better child health-related quality of life, compared to waitlist controls. Feasibility, acceptability, and engagement from the perspectives of the children with cancer, their parents, and their clinicians will be examined using mixed methods.

CONCLUSIONS

We anticipate that this system will facilitate prompt identification of problematic symptoms. Additionally, we hypothesize that with the availability of graphical symptom reports over time, and timely provider responses, children or parents will become better informed and take an active role in managing their symptoms, which will further improve clinical outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04789720; https://clinicaltrials.gov/study/NCT04789720.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/50993.

The information needs of people with degenerative cervical myelopathy: A qualitative study to inform patient education in clinical practice

BACKGROUND

Individuals with lifelong illnesses need access to adequate information about their condition to make optimal health decisions. Degenerative Cervical Myelopathy (DCM) is the most common form of spinal cord dysfunction in adults worldwide. Its chronic and debilitating nature, varied impact, clinical trajectory, and management options necessitate appropriate informational support to sustain effective clinical and self-directed care strategies. However, before clinicians can meet patients' information needs, they must first have an understanding of their baseline requirements. This study explores the information needs of people with DCM (PwCM). In doing so, it provides a starting point for the development of patient education and knowledge management strategies in clinical practice.

METHODS

Semi-structured interviews with PwCM were conducted using an interview guide. Interviews were audio-recorded and transcribed verbatim. Thematic analysis according to Braun and Clarke's six-phase approach was used to analyse the data. Findings were reported according to the Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines.

RESULTS

Twenty PwCM (65% female, 35% male), with ages ranging from 39 to 74 years old participated in the interviews. The findings indicated that the provision of information to PwCM during clinical interactions varies. Accordingly, PwCM's information needs were broad-ranging, as was the nature of the information they found useful. Three main themes were identified (1) Variation in the provision of information to PwCM during clinical interactions, (2) Variations in the information needs of PwCM, and (3) Information that PwCM find useful.

CONCLUSION

Efforts must turn to adequately educating patients at the time of the clinical encounter. A comprehensive and consistent patient-centered information exchange in DCM is necessary to achieve this.

Studying both patient and staff experience to investigate their perceptions and to target key interactions to improve: a scoping review

OBJECTIVE

The improvement of patient experience (PE) is related to the experience of staff caring for them. Yet there is little evidence as to which interactions matter the most for both patients and staff, or how they are perceived by them. We aimed to summarise the interactions and the perceptions between patients and staff from studies by using both patient and staff experience data in healthcare institutions.

DESIGN

Scoping review.

METHODS

We conducted a scoping review, including studies dealing with PE and staff experience. Two authors independently reviewed each title/abstract and the selected full-text articles. A list of variables (objective, study design, data sources, tools used, results, interactions, perceptions and actions) was charted and summarised using a narrative approach including both qualitative and quantitative data. Studies were grouped according to their objective and the key interactions summarised according to this stratification. The perceptions of patients and staff were identified in the results of selected studies and were classified into four categories: commonalities and disagreements of perceptions, patients' perceptions not perceived by professionals and professional's perceptions not perceived by patients.

RESULTS

A total of 42 studies were included. The stratification of studies by type of objective resulted in six groups that allowed to classify the key interactions (n=154) identified in the results of the selected studies. A total of 128 perceptions related to interaction between patient and staff were reported with the following distribution: commonalities (n=35), disagreements (n=18), patients' perceptions not perceived by professionals (n=47) and professional's perceptions not perceived by patients (n=28). We separated positive and negative perceptions, which resulted in seven scenarios, each with actions that can be carried out for one or both populations to overcome barriers.

CONCLUSION

The study of both patient and staff experience allowed the identification of actions that can be taken to change the perceptions of patients and staff.

Impressions of Conventional Bedside Discharge Teaching Among Readmitted Heart Failure Patients

OBJECTIVE

The purpose of this project was to report patient impressions of discharge teaching delivered by nurses among a population of heart failure (HF) inpatients.

BACKGROUND

Heart failure readmissions are frequently attributed to the quality of discharge teaching delivered by nurses.

METHODS

Thematic analysis, an atheoretical approach to the identification, organization, and analysis of themes in texts, was used to explore the data collected from patient interviews.

RESULTS

Sixteen interviews were conducted with patients readmitted for HF on dedicated cardiac units. Six major themes were identified including: 1) recall of instructions; 2) comprehension; 3) teaching media; 4) follow-up; 5) role of caregivers; 6) mismatch between nurse and patient concerns; and 7) readmission stories.

CONCLUSION

Discharge teaching could be improved by diminishing the volume of print materials distributed to HF patients, providing simple summaries of the most relevant advice, focusing on patient concerns more than the hospital agenda, and directly including home caregivers in teaching.

What Parents Want Doctors to Know: Responses to an Open-Ended Item on an Asthma Questionnaire

OBJECTIVE

Unstructured parental comments could solicit important information about children's asthma, yet are rarely captured in clinical asthma questionnaires. This mixed-methods study describes parents' written responses to an open-ended question in a validated asthma questionnaire.

METHODS

The Pediatric Asthma Control and Communication Instrument (PACCI) asthma questionnaire was administered to parents of children with asthma symptoms presenting to 48 pediatric primary care offices (PPCP), 1 pediatric pulmonology office, and 1 emergency department (ED). Responses to the question, "Please write down any concern or anything else you would like your doctor to know about your child's asthma" were analyzed using a phenomenological approach until thematic saturation was achieved for each site. Logistic regressions tested whether sociodemographic and clinical characteristics were associated with responding to the open-ended question.

RESULTS

Of 7,988 parents who completed the PACCI, 954 (12%) responded to the open-ended question-2% in PPCP, 31% in the ED, and 50% in the pulmonary setting. More severe asthma was associated with higher odds of responding (odds ratio, 2.01; 95% confidence interval, 1.42-2.84). Based on responses provided, we identified 3 communication types: 1) clarifying symptoms, 2) asking questions, and 3) communicating distress. Responses also covered 5 asthma-related themes: 1) diagnostic uncertainty, 2) understanding asthma etiology and prognosis, 3) medication management, 4) impact on child function, and 5) personal asthma characteristics.

CONCLUSION

Parents of children with severe asthma provided clarifying details, asked questions, and relayed health concerns and distress. None of these topics may be easily captured by closed-ended asthma questionnaires.

Asthma self-management in children: a best practice implementation project

INTRODUCTION

Asthma is one of the most common diseases in children. A self-management program can effectively improve the outcomes for children with asthma and reduce the burden on healthcare services.

OBJECTIVES

The aim of this project was to integrate the best evidence on asthma self-management with practice in a children's respiratory clinic and to improve compliance with best practice.

METHODS

Seven audit criteria were developed for the pre- and post-audit based on the best available evidence. The Joanna Briggs Institute (JBI) Practical Application of Clinical Evidence System and Getting Research into Practice audit and feedback tools were used in this project.

RESULTS

The baseline audit showed a gap between clinical practice and the best evidence. The only criterion that achieved high compliance was provision of inhaler guidance (100%). After implementation, there were substantial improvements in compliance for many criteria. Training of clinicians increased from 13% at baseline to 67% at follow-up. Education of parents improved, with specific education about asthma triggers increasing from 55% to 100%, education about warning signs from 30% to 85% and education about effective asthma treatment options from 40% to 85%. Use of written asthma action plans increased from 0% to 25%.

CONCLUSION

Strategies developed in this project were effective at providing necessary information for parents and improved the compliance with evidence. Further implementation strategies and audits are still needed to improve the use of asthma action plans and ensure they are reviewed periodically.

A Scoping Review of International Barriers to Asthma Medication Adherence Mapped to the Theoretical Domains Framework

BACKGROUND

Internationally, adult asthma medication adherence rates are low. Studies characterizing variations in barriers by country are lacking.

OBJECTIVE

To conduct a scoping review to characterize international variations in barriers to asthma medication adherence among adults.

METHODS

MEDLINE, EMBASE, Web of Science (WOS), and CINAHL were searched from inception to February 2017. English-language studies employing qualitative methods (eg, focus groups, interviews) were selected to assess adult patient- and/or caregiver-reported barriers to asthma medication adherence. Two investigators independently identified, extracted data, and collected study characteristics, methodologic approach, and barriers. Barriers were mapped using the Theoretical Domains Framework and findings categorized according to participants' country of residence, countries' gross national income, and the presence of universal health care (World Health Organization definitions).

RESULTS

Among 2942 unique abstracts, we reviewed 809 full texts. Among these, we identified 47 studies, conducted in 12 countries, meeting eligibility. Studies included a total of 2614 subjects, predominately female (67%), with the mean age of 19.1 to 70 years. Most commonly reported barriers were beliefs about consequences (eg, medications not needed for asthma control, N = 29, 61.7%) and knowledge (eg, not knowing when to take medication, N = 27, 57.4%); least common was goals (eg, asthma not a priority, N = 1, 2.1%). In 27 studies conducted in countries classified as high income (HIC) with universal health care (UHC), the most reported barrier was participants' beliefs about consequences (N = 17, 63.3%). However, environmental context and resources (N = 12, 66.7%) were more common in HIC without UHC.

CONCLUSION

International adherence barriers are diverse and may vary with a country's sociopolitical context. Future adherence interventions should account for trends.

"I did not know it was so important to take it the whole time" - self-reported barriers to medical treatment among individuals with asthma

BACKGROUND

Asthma is an extensive public health problem and inadequate disease control is not uncommon. Individuals' self-perceived barriers to medical treatment for the entire treatment chain (from seeking care for symptoms to using a medicine) have seldom been studied for chronic diseases such as asthma. The aim of this study was to explore self-perceived barriers to medical treatment among individuals with asthma within the framework of AAAQ (availability, accessibility, acceptability and quality).

METHODS

Individuals with asthma visiting the asthma nurse at a primary health care centre, and who currently had a prescription for anti-asthmatic medicines, were informed about the study. The nurse asked the persons for their consent to be contacted by an interviewer. The interview guide was constructed from the elements of AAAQ exploring self-perceived barriers to asthma treatment. Interviews were conducted in Swedish, English, Arabic and Persian. They were transcribed verbatim and a manifest content analysis was conducted.

RESULTS

Fourteen interviews were conducted. There was a large variation in both age and reported number of years with asthma. Self-perceived barriers to asthma treatment were experienced throughout the whole treatment chain. Barriers that emerged were health care accessibility, perceived quality of care, beliefs about medicines, life circumstances, knowledge gap about asthma and medicines, practical obstacles to using medicines, and experiences with treatment. The self-perceived barriers cover all four elements of AAAQ, but there are also some barriers that go beyond those elements (life circumstances and practical obstacles to using medicines).

CONCLUSIONS

Self-perceived barriers among individuals with asthma cover the whole treatment chain. We want to highlight the inadequate information/education of patients leading to knowledge gaps about both disease and the effect of medicines, and also the perceived unsatisfactory treatment at the PHCC, which could partly be counteracted if patients know what to expect from health care visits.

What Means A Quality Professional-Patient Relationship From The Asthmatic Patients' Perspective? A Narrative Review Of Their Needs And Expectations

INTRODUCTION

Poor treatment adherence among asthmatic patients currently remains a public health challenge. One of the most quoted determinants is the quality of the professional-patient relationship although it has clearly not been fully described.

PURPOSE

This study aims at deeply exploring asthmatic patients' needs and expectations about the accompaniment proposed by their healthcare professionals.

METHODS

A rigorous narrative review was performed.

RESULTS

According to patients, what they expect from professionals can be split into eight themes: getting exhaustive information, relying on an available healthcare professional, being more involved into life with one's asthma, being accompanied by a multidisciplinary team, being respected in one's uniqueness, being cared through a humanist approach, feeling the professional is skilled and Other needs.

DISCUSSION AND CONCLUSION

Asthmatic patients' needs have little evolved in 20 years illustrating that if they are met, that would positively affect the way patients want to be followed by healthcare professionals and so, that would increase their treatment adherence. Several recommendations such as setting up a doctor - asthma nurse practitioner binomial or studying a concrete care pathway may help in fulfilling these needs. Finally, this research opens the way to other studies since similar results have been found in populations suffering from other chronic diseases than asthma.

Understanding patients' perceptions of asthma control: a qualitative study

Asthma control is suboptimal for many sufferers despite the existence of effective treatments. Patients' self-management is influenced by their perceptions of asthma and its treatment. This study explored sufferers' perceptions of asthma control and their influence on self-management behaviours.Participants (n=42) recruited from primary and secondary care asthma clinics in London in the UK each underwent a qualitative interview exploring perceptions and experiences of asthma control. Purposive sampling ensured variation in disease severity, degree of asthma control, age and socioeconomic status. Grounded theory was employed in thematic analysis of transcribed interviews.Five themes relating to perceptions of asthma control and self-management were identified: personal meaning of control, intermittent prevention, compromising control to avoid medication, pharmacological agents overemphasised in control and the role of asthma review in control. Within the first theme, some participants had an internal barometer of the level of symptoms that indicated their asthma was getting "out of control" that was set much higher than Asthma Control Test criteria.The findings provide new insights into patients' perceptions of asthma control. Symptoms indicative of poor control were often tolerated as part of living with asthma. Identification of barriers and drivers to self-management highlight potential targets for strategies aimed at optimising asthma management.

Epistemic tensions between people living with asthma and healthcare professionals in clinical encounters

RATIONALE

Asthma is a common respiratory condition with high prevalence rates globally. While there are effective treatments, asthma remains an important health concern as people continue to die from severe attacks. Improving the experiences of, and health outcomes for, people with asthma depends heavily on their interactions with healthcare professionals. Understanding negative clinical encounters will benefit people with asthma and healthcare providers.

OBJECTIVE

To examine epistemic tensions in negative clinical encounters from a patient perspective, with an aim to better understand how patients respond to these tensions. Much of the scholarship on patient interactions with healthcare providers examines interpersonal or structural factors. Thus, focusing our analysis on tensions between lay and expert knowledge in negative clinical encounters provides a novel contribution to this body of scholarship.

METHOD

As part of a larger qualitative study (n = 70) examining the lived experiences of people who have asthma or a child with asthma, semi-structured interviews with 17 participants who described having negative clinical encounters were analyzed for themes.

RESULTS

Participants responded to epistemic tensions in two main ways: (1) by incorporating expert knowledge; and (2) by resisting/challenging expert knowledge. In both cases, participants also described feeling frustrated and uncertain about their or their child's clinical care. We analyze these responses by drawing on Lindström and Karlsson's (2016) conceptualization of epistemic tensions as arising from 3 characteristics of epistemic asymmetry: access, rights, and responsibility.

CONCLUSION

Based on this study, (1) a patient's confidence in claiming epistemic access and asserting epistemic rights when epistemic tensions arise are related to the context and their own history of living with asthma; and (2), epistemic tensions can make visible the power relations in the patient-clinician relationship, which can lead to the exertion of biomedical authority, or the taking up of patient's lay knowledge.

Airway diseases and health literacy (HL) measurement tools: A systematic review to inform respiratory research and practice

OBJECTIVE

To identify and evaluate asthma/COPD measurement tools that assess any of the five health literacy (HL) domains: (1) access, (2) understand, (3) evaluate, (4) communicate, and (5) use, as well as numeracy.

METHODS

MEDLINE/Embase (via Ovid) databases from 1974 to 2016 were searched and complimented by grey literature. Study selection and data extraction were conducted by two reviewers independently.

RESULTS

We identified 65 tools including 40 asthma, 22 COPD, and 3 asthma/COPD focused tools. Thirty tools had been validated and two assessed all five domains. The 'understand' domain was captured in 49 tools, followed by 'access' in 29 tools, 'use' in 24 tools, 'evaluate' in 20 tools, and 'communicate' in 10 tools. Two tools assessed 'numeracy'. Tool content comprised disease physiology, triggers, symptoms, inhaler technique, self-management practices, and rehab programs.

CONCLUSIONS

This review highlights paucity of HL tools that have been validated and/or assess the 'communicate' domain and makes a valuable contribution to filling an existing research gap in the field of HL by determining the deficiencies of such tools.

PRACTICE IMPLICATIONS

Our review uncovers which HL domains are under-measured, justifying the need to develop an airways HL measurement tool which applies the 5-domain model for asthma/COPD management.

What Kind of Information and Communication Technologies Do Patients with Type 2 Diabetes Mellitus Prefer? An Ecuadorian Cross-Sectional Study

PURPOSE

The purpose of this study is to assess the frequency of use of information and communication technologies and patterns of preference among Ecuadorian patients with diabetes.

METHODS

We conducted an anonymous cross-sectional survey on type 2 diabetes mellitus. A chi-square test for association and adjusted regression analyses were performed.

RESULTS

248 patients were enrolled, with a mean sample age of 57.7 years. SMS was the most used ICT (66.0%). The Internet was used by 45.2% of patients to obtain information about diabetes. SMS and email were rated as the most useful ICTs for receiving information (64.5% and 28.1%, resp.) and asking physicians about diabetes (63.8% and 26.1%, resp.). Patients were also interested in receiving disease information (82.4%) and asking physicians about diabetes (84.7%) through WhatsApp. Adjusted logistic regressions revealed that individuals aged 55 years or younger, those with superior degree level, and those with long diabetes history preferred email for receiving information and asking physicians about diabetes compared to those above 55 years, those with low education level, and those with short diabetes history, respectively.

CONCLUSION

Understanding preferences of ICTs among patients with diabetes could facilitate application development targeted towards specific requirements from patients.

Barriers and facilitators of effective self-management in asthma: systematic review and thematic synthesis of patient and healthcare professional views

Self-management is an established, effective approach to controlling asthma, recommended in guidelines. However, promotion, uptake and use among patients and health-care professionals remain low. Many barriers and facilitators to effective self-management have been reported, and views and beliefs of patients and health care professionals have been explored in qualitative studies. We conducted a systematic review and thematic synthesis of qualitative research into self-management in patients, carers and health care professionals regarding self-management of asthma, to identify perceived barriers and facilitators associated with reduced effectiveness of asthma self-management interventions. Electronic databases and guidelines were searched systematically for qualitative literature that explored factors relevant to facilitators and barriers to uptake, adherence, or outcomes of self-management in patients with asthma. Thematic synthesis of the 56 included studies identified 11 themes: (1) partnership between patient and health care professional; (2) issues around medication; (3) education about asthma and its management; (4) health beliefs; (5) self-management interventions; (6) co-morbidities (7) mood disorders and anxiety; (8) social support; (9) non-pharmacological methods; (10) access to healthcare; (11) professional factors. From this, perceived barriers and facilitators were identified at the level of individuals with asthma (and carers), and health-care professionals. Future work addressing the concerns and beliefs of adults, adolescents and children (and carers) with asthma, effective communication and partnership, tailored support and education (including for ethnic minorities and at risk groups), and telehealthcare may improve how self-management is recommended by professionals and used by patients. Ultimately, this may achieve better outcomes for people with asthma.

Developing pictorial asthma action plans to promote self-management and health in rural youth with asthma: A qualitative study

OBJECTIVE

Asthma action plans (AAPs) provide asthma management instructions to families; however, AAPs typically are written at a 7th-9th grade reading level, making them less useful in lower literacy families. There is a need to develop simpler AAP formats and content to optimize their utility across all families, including those who are rural and may be at a risk for literacy concerns. Because using pictures can simplify and enhance health education, our study's aim was to develop a pictorial AAP through a series of focus groups with key stakeholders - youth with asthma, caregivers, and physicians.

METHODS

Fourteen caregiver/youth dyads and four physicians participated in separate focus groups where their preferences for pictorial AAP structure and content were obtained. Focus groups were audio recorded, transcribed, coded with ATLAS.ti, and analyzed for themes.

RESULTS

Youth and their caregivers prefer that the AAPs include simple, cartoon-like pictures customized to the patient. Physicians emphasized AAP's capability to display pictures of controller medication given its importance in preventing asthma exacerbations. A stoplight format, currently used in most written AAPs, received positive reviews. Specific suggestions for pictures showing symptoms, medications, and how to take medication were suggested. Words and short phrases accompanying the pictures were thought to add clarity.

CONCLUSIONS

Key stakeholders viewed pictorial AAPs as positive and potentially effective alternatives to standard written AAPs. It is expected that low literacy youth and caregivers would more easily understand a pictorial AAP presentation, which should facilitate better medication adherence and asthma outcomes in these children.

Information and communication technology use in asthmatic patients: a cross-sectional study in Latin America

Rapid diffusion, low cost and broad availability of information and communication technologies (ICTs) make them an attractive platform for managing care, communication and interventions in asthma. There is little information in Latin America about usage frequency of ICTs in asthmatic patients.

The analysis undertaken consisted of an observational, cross-sectional study that aimed to identify the frequency and type of ICTs most often used by asthmatics. The Spanish version of the Michigan questionnaire was employed in five Latin American countries. Age and educational level was categorised. Logistic regression was performed among these groups concerning the frequency of ICT usage and the level of interest shown in seeking and receiving information about asthma.

In total, 673 asthma patients were surveyed. The mean age was 43.44 years. Over two-thirds of the participants were female (68.4%). The most used ICT was the short message service (SMS) (69.9%). SMS and E-mail are useful tools for communicating (i.e. receiving and seeking information) with all asthma patients, irrespective of their age. WhatsApp (61.5%) and Facebook (32.0%) were rated as being the most interesting channels of communication for receiving information. Regression analysis showed that younger asthmatics and asthmatics with higher educational levels were most likely to use almost all forms of ICTs.

ICTs are generally an attractive platform for managing care, communication and interventions to improve asthma care. SMS and E-mail were found to be the preferred ICT forms among users. However, social media forms such as WhatsApp and Facebook may also be appropriate for certain types of patient.

ICT and social media use among asthmatics from Latin Americahttp://ow.ly/TxVj30cKylJ

Design of a pragmatic trial in minority children presenting to the emergency department with uncontrolled asthma: The CHICAGO Plan

Among children with asthma, black children are two to four times as likely to have an emergency department (ED) visit and die from asthma, respectively, compared to white children in the United States. Despite the availability of evidence-based asthma management guidelines, minority children are less likely than white children to receive or use effective options for asthma care. The CHICAGO Plan is a three-arm multi-center randomized pragmatic trial of children 5 to 11years old presenting to the ED with uncontrolled asthma that compares: [1] an ED-focused intervention to improve the quality of care on discharge to home, [2] the same ED-focused intervention together with a home-based community health worker (CHW)-led intervention, and [3] enhanced usual care. All children receive spacers for the metered dose inhaler and teaching about its use. The Patient-Reported Outcomes Measurement Information System (PROMIS) Asthma Impact Scale and Satisfaction with Participation in Social Roles at 6months are the primary outcomes in children and in caregivers, respectively. Other patient-reported outcomes and indicators of healthcare utilization are assessed as secondary outcomes. Innovative features of the CHICAGO Plan include early and continuous engagement of children, caregivers, the Chicago Department of Public Health, and other stakeholders to inform the design and implementation of the study and a shared research infrastructure to coordinate study activities. The objective of this report is to describe the development of the CHICAGO Plan, including the methods and rationale for engaging stakeholders, the shared research infrastructure, and other features of the pragmatic clinical trial design.

Patients´ Variations of Reflection About and Understanding of Long-Term Illness- Impact of Illness Perception on Trust in Oneself or Others

Background:

Patients' understanding of their illness is of great importance for recovery. Lacking understanding of the illness is linked with the patients' level of reflection about and interest in understanding their illness.

Objective:

To describe patients’ variations of reflection about and understanding of their illness and how this understanding affects their trust in themselves or others.

Method:

The study is based on the “Illness perception” model. Latent content analysis was used for the data analysis. Individual, semi-structured, open-ended and face-to-face interviews were conducted with patients (n=11) suffering from a long-term illness diagnosed at least six months prior to the interview. Data collection took place in the three primary healthcare centres treating the participants.

Results:

The results show variations in the degree of reflection about illness. Patients search for deeper understanding of the illness for causal explanations, compare different perspectives for preventing complication of their illness, trust healthcare providers, and develop own strategies to manage life.

Conclusion:

Whereas some patients search for deeper understanding of their illness, other patients are less reflective and feel they can manage the illness without further understanding. Patients' understanding of their illness is related to their degree of trust in themselves or others. Patients whose illness poses an existential threat are more likely to reflect more about their illness and what treatment methods are available.

What patients really think about asthma guidelines: barriers to guideline implementation from the patients' perspective

BACKGROUND

Treatment of asthma does not always comply with asthma guidelines (AG). This may be rooted in direct or indirect resistance on the doctors' and/or patients' side or be caused by the healthcare system. To assess whether patients' concepts and attitudes are really an implementation barrier for AG, we analysed the patients' perspective of a "good asthma therapy" and contrasted their wishes with current recommendations.

METHODS

Using a qualitative exploratory design, topic centred focus group (FG) discussions were performed until theoretical saturation was reached. Inclusion criteria were an asthma diagnosis and age above 18. FG sessions were recorded audio-visually and analysed via a mapping technique and content analysis performed according to Mayring (supported by MAXQDA®). Participants' speech times and the proportion of time devoted to different themes were calculated using the Videograph System® and related to the content analysis.

RESULTS

Thirteen men and 24 women aged between 20 and 77 from rural and urban areas attended five FG. Some patients had been recently diagnosed with asthma, others years previously or in childhood. The following topics were addressed: (a) concern about or rejection of therapy components, particularly corticosteroids, which sometimes resulted in autonomous uncommunicated medication changes, (b) lack of time or money for optimal treatment, (c) insufficient involvement in therapy choices and (d) a desire for greater empowerment, (e) suboptimal communication between healthcare professionals and (f) difficulties with recommendations conflicting with daily life. Primarily, (g) participants wanted more time with doctors to discuss difficulties and (h) all aspects of living with an impairing condition.

CONCLUSIONS

We identified some important patient driven barriers to implementing AG recommendations. In order to advance AG implementation and improve asthma treatment, the patients' perspective needs to be considered before drafting new versions of AG. These issues should be addressed at the planning stage.

TRIAL REGISTRATION

DRKS00000562 (German Clinical Trials Registry).

Home visits are needed to address asthma health disparities in adults

Research on asthma frequently recruits patients from clinics because the ready pool of patients leads to easy access to patients in office waiting areas, emergency departments, or hospital wards. Patients with other chronic conditions, and with mobility problems, face exposures at home that are not easily identified at the clinic. In this article, we describe the perspective of the community health workers and the challenges they encountered when making home visits while implementing a research intervention in a cohort of low-income, minority patients. From their observations, poor housing, often the result of poverty and lack of social resources, is the real elephant in the chronic asthma room. To achieve a goal of reduced asthma morbidity and mortality will require a first-hand understanding of the real-world social and economic barriers to optimal asthma management and the solutions to those barriers.

Internet-based self-management support for adults with asthma: a qualitative study among patients, general practitioners and practice nurses on barriers to implementation

OBJECTIVES

The aim of this study was to explore barriers among patients, general practitioners (GPs) and practice nurses to implement internet-based self-management support as provided by PatientCoach for asthma in primary care.

SETTING

Primary care within South Holland, the Netherlands.

PARTICIPANTS

Twenty-two patients (12 women, mean age 38 years), 21 GPs (6 women, mean age 52 years) and 13 practice nurses (all women, mean age 41 years).

DESIGN

A qualitative study using focus groups and interviews.

OUTCOMES

Barriers as perceived by patients, GPs and practice nurses to implementation of PatientCoach.

METHODS

10 focus groups and 12 interviews were held to collect data: 4 patient focus groups, 4 GP focus groups, 2 practice nurse focus group, 2 patient interviews, 5 GP interviews and 5 practice nurse interviews. A prototype of PatientCoach that included modules for coaching, personalised information, asthma self-monitoring, medication treatment plan, feedback, e-consultations and a forum was demonstrated. A semistructured topic guide was used. Directed content analysis was used to analyse data. Reported barriers were classified according to a framework by Grol and Wensing.

RESULTS

A variety of barriers emerged among all participant groups. Barriers identified among patients include a lack of a patient-professional partnership in using PatientCoach and a lack of perceived benefit in improving asthma symptoms. Barriers identified among GPs include a low sense of urgency towards asthma care and current work routines. Practice nurses identified a low level of structured asthma care and a lack of support by colleagues as barriers. Among all participant groups, insufficient ease of use of PatientCoach, lack of financial arrangements and patient characteristics such as a lack of asthma symptoms were reported as barriers.

CONCLUSIONS

We identified a variety of barriers to implementation of PatientCoach. An effective implementation strategy for internet-based self-management support in asthma care should focus on these barriers.

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.

Self-care for people coping with long-term health conditions in the community: the views of patients and GPs

Purpose

Long-term health problems put great pressures on health and social care services. Supporting ‘self-care’ has measurable benefits in helping patients cope better, but is difficult to do in practice. This review aims to help improve services by exploring existing evidence about the views of patients and GPs.

Design/methodology/approach

The search terms were identified following detailed discussion with service users. Five databases (PUBMED, CINAHL, TRIP, SCIE and PSYCINFO) were interrogated against pre-set questions and criteria. The data were managed in EndNote v6 and analysed in a series of Word tables.

Findings

37 community-based studies were identified, covering diverse chronic illnesses. Analysis of ‘barriers and enablers’ showed a very complex picture, with health systems often actively inhibiting the responsiveness and flexibility which support self-care. Directly seeking service user and practitioner views could shape more effective services

Research limitations/implications

Further research is needed into: the purpose and outcomes of user involvement, the relationship between integrated care and self-care, how patient motivation and resilience can be encouraged in primary care and the effect of current incentive schemes on self-care support Due to organisational changes, eligible studies were reviewed by one researcher only and these were mainly qualitative studies lacking generalisability. However, the results spanned a range of settings and health conditions. They are also clearly supported by later primary research findings

Practical implications

Several evidence-based, achievable opportunities to improve self-care support in primary care settings are identified

Originality/value

This service-user study, offers detailed analysis of what helps or hinders self-care in everyday life

A metasynthesis of factors affecting self-management of chronic illness

AIM

To identify factors that may serve as facilitators and barriers to self-management described by adults living with chronic illness by conducting a qualitative metasynthesis.

BACKGROUND

Self-management is an individuals' active management of a chronic illness in collaboration with their family members and clinicians.

DESIGN

Qualitative metasynthesis.

DATA SOURCES

We analysed studies (N = 53) published between January 2000-May 2013 that described factors affecting self-management in chronic illness as reported by adults aged over 18 years with chronic illness.

REVIEW METHODS

Sandelowsi and Barroso approach to qualitative metasynthesis: literature search; quality appraisal; analysis and synthesis of findings.

RESULTS

Collectively, article authors reported on sixteen chronic illnesses, most commonly diabetes (N = 28) and cardiovascular disease (N = 20). Participants included men and women (mean age = 57, range 18-94) from 20 countries representing diverse races and ethnicities. We identified five categories of factors affecting self-management: Personal/Lifestyle Characteristics; Health Status; Resources; Environmental Characteristics; and Health Care System. Factors may interact to affect self-management and may exist on a continuum of positive (facilitator) to negative (barrier).

CONCLUSION

Understanding factors that influence self-management may improve assessment of self-management among adults with chronic illness and may inform interventions tailored to meet individuals' needs and improve health outcomes.

General practitioner-delivered adherence counseling in asthma: feasibility and usefulness of skills, training and support tools

OBJECTIVE

Poor medication adherence contributes to uncontrolled asthma in primary care. Good doctor-patient communication around adherence increases patients' medication taking but general practitioners (GPs) often feel poorly equipped to provide effective adherence counseling. This study aimed to assess the feasibility and usefulness of adherence counseling training, skills and support tools for GPs.

METHODS

Twenty-five GPs enrolled in a 6-month cluster randomized-controlled trial of adherence interventions for asthma were randomized to an intervention delivering personalized adherence discussions. They received 2 hours training in delivering brief, motivational-interviewing-based adherence counseling and were provided with asthma-specific counseling support tools. At baseline, post-training and study end, GPs rated the training, reported confidence/frequency of using counseling skills and satisfaction with their consultations, and commented on support tools. Patients reported their barriers to adherence and rated their GPs empathy at baseline and at 6-months.

RESULTS

96% of GPs rated adherence counseling training as very/extremely useful. At the end of the study (17 ± 4 months) GPs' confidence in using counseling skills increased, as did the frequency they applied the skills and their satisfaction with consultations. GPs were positive about counseling support tools, stating that they were easy to use and facilitated covering more ground within single consultations. Half the GPs expressed some difficulty implementing counseling due to time constraints. Patients reported good GP empathy and no significant change in adherence barriers.

CONCLUSIONS

GPs valued counseling training and support tools. Although implementation was sometimes challenging, GPs reported increased frequency of use and confidence in applying adherence counseling skills, which persisted for 17 months.

Attitudes of healthcare professionals providing pulmonary rehabilitation toward partnership in care

OBJECTIVES

This multicenter study sought to explore attitudes of pulmonary rehabilitation (PR) professionals toward self-management and which patients' competencies are considered important.

BACKGROUND

Self-management in patients with chronic obstructive pulmonary disease (COPD) requires a patients' active role. Whether patient-clinician partnership in care is supported by PR professionals remains unknown.

METHODS

Attitudes of 75 PR professionals were assessed using an online version of the Clinician Support - Patient Activation Measure (CS-PAM) 13™.

RESULTS

Mean CS-PAM 13™ activation score was 66.5 (11.9) points - professionals support patient's participation in the care process. However, competencies related to patient as member of a care team and patient as an independent information seeker were only extremely important for 30.7-38.7% and 9.3-17.3% of the professionals, respectively.

CONCLUSION

PR professionals embrace the idea of a patients' active role in the process of COPD self-management. Nonetheless, endorsement of the patient's involvement as an independent information seeker is needed.

Patient assessment of primary care physician communication: segmentation approach

Purpose

– The purpose of this paper is to examine how patient assessment of primary care physician (PCP) communication is related to patient satisfaction with the PCP, patient perception of PCP professional competence, patient assessment of the relationship with the doctor and patient demographic characteristics using a segmentation approach.

Design/methodology/approach

– The authors surveyed 514 adult patients waiting for appointments with their PCPs in two US primary care clinics. A latent class analysis was used to identify mutually exclusive unobserved homogeneous classes of patients.

Findings

– The authors identified three distinct classes/groups with regard to patient assessment of physician communication and the physician-patient relationship. The largest group (53 percent of the sample) assessed their PCP communication and other doctor-patient relationship aspects as excellent. However, 37 percent provided mostly negative assessments, expressed high general dissatisfaction with the physician and disagreed with the statement that their PCP was well qualified to manage their health problems. These patients were on average more educated and affluent and the group included more males. About 10 percent of patients expressed generally lower satisfaction with the PCP, though their dissatisfaction was not as extreme as in the highly dissatisfied group.

Research limitations/implications

– Further studies are needed to help physicians develop skills to communicate with different patients.

Originality/value

– Patient segmentation can be an important tool for healthcare quality improvement particularly for emerging approaches to primary care such as patient-centered care.

The evolution of mobile apps for asthma: an updated systematic assessment of content and tools

BACKGROUND

Interest in mobile apps that support long-term conditions such as asthma is matched by recognition of the importance of the quality and safety of apps intended for patient use. We assessed how changes over a 2-year period affected the clinical suitability of apps providing self-management information and tools for people with asthma by updating a review first performed in 2011.

METHODS

Systematic content assessment of all apps for iOS and Android examining the comprehensiveness of asthma information, consistency with the evidence base for asthma self-management and adherence to best practice principles for trustworthy content, comparing the quality of apps available in 2011 to those released since.

RESULTS

Between 2011 and 2013, numbers of asthma apps more than doubled from 93 to 191, despite withdrawal of 25% (n = 23/93) of existing apps. Newer apps were no more likely than those available in 2011 to include comprehensive information, such as the use of action plans, or offer guidance consistent with evidence; 13% (n = 19/147) of all apps, and 39% (n = 9/23) of those intended to manage acute asthma, recommended self-care procedures unsupported by evidence. Despite increases in the numbers of apps targeting specific skills, such as acute asthma management (n = 12 to 23) and inhaler technique (from n = 2 to 12), the proportion consistent with guidelines (17%, n = 4/23) and inhaler instructions (25%, n = 3/12), respectively, was low, and most apps provided only either basic information about asthma (50%, n = 75/147) or simple diary functions (24%, n = 36/147).

CONCLUSIONS

In addition to persisting questions about clinical quality and safety, dynamic aspects of app turnover and feature evolution affect the suitability of asthma apps for use in routine care. The findings underline the need for coordinated quality assurance processes that can adapt to changing clinical and information governance-related risks, ensure compliance with the evidence base and reflect local variations in clinical practice. It is unclear if substantial clinical benefits can be realized from a landscape dominated by low quality generic information apps and tools that do not adhere to accepted medical practice.

Complex interventions reduce use of urgent healthcare in adults with asthma: systematic review with meta-regression

INTRODUCTION

Asthma accounts for considerable healthcare expenditure, a large proportion of which is attributable to use of expensive urgent healthcare. This review examines the characteristics of complex interventions that reduce urgent healthcare use in adults with asthma.

METHOD

Electronic searches of MEDLINE, EMBASE, PSYCINFO, CINAHL, the British Nursing Library and the Cochrane library, from inception to January 2013 were conducted. Studies were eligible for inclusion if they: i) included adults with asthma ii) assessed the efficacy of a complex intervention using randomised controlled trial design, and iii) included a measure of urgent healthcare utilisation at follow-up. Data on participants recruited, methods, characteristics of complex interventions and the effects of the intervention on urgent healthcare use were extracted.

RESULTS

33 independent studies were identified resulting in 39 comparisons altogether. Pooled effects indicated that interventions were associated with a reduction in urgent healthcare use (OR = 0.79, 95% CI = 0.67, 0.94). When study effects were grouped according to the components of the interventions used, significant effects were seen for interventions that included general education (OR = 0.77, 95% CI = 0.64, 0.91), skills training (OR = 0.64, 95% CI = 0.48, 0.86) and relapse prevention (OR = 0.75, 95% CI = 0.57, 0.98). In multivariate meta-regression analysis, only skills training remained significant.

CONCLUSIONS

Complex interventions reduced the use of urgent healthcare in adults with asthma by 21%. Those complex interventions including skills training, education and relapse prevention may be particularly effective in reducing the use of urgent healthcare in adults with asthma.

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.

Experiences addressing health-related financial challenges with disease management among African American women with asthma

OBJECTIVE

Despite economic hardship, compliance with self-management regimens is still evident among individuals and families managing chronic disease. The purpose of this study was to describe how women with asthma address cost-related challenges to management of their condition.

METHODS

In 2012 and 2013, four focus groups were conducted in Southeast Michigan with 26 African American women with asthma, recruited based on maximum variation sampling procedures. A semi-structured interview protocol was employed by trained facilitators. Coded transcripts were analyzed for themes regarding means to reduce the impact of the cost of asthma management.

RESULTS

Major themes identified were acceptance of the status quo; stockpiling and sharing medicines; utilizing community assistance programs; reaching out to healthcare providers and social networks for help; foregoing self-management; and utilizing urgent care.

CONCLUSIONS

Awareness of strategies that are helpful to patients in reducing out-of-pocket costs may better equip service providers and others to develop interventions to make useful strategies more widely available.

"No other choice": reasons for emergency department utilization among urban adults with acute asthma

OBJECTIVES

Asthma is considered "ambulatory care-sensitive," yet emergency department (ED) visits remain common. Few studies have examined how ED asthma patients choose their sites of urgent care. The authors explored reasons for asthma-related ED use among adults.

METHODS

From May to September 2012, semistructured qualitative interviews were conducted with a convenience sample of patients visiting a high-volume urban ED for asthma. A piloted interview guide was used; it had open-ended questions derived from clinical experience and a focus group of asthmatic adults who frequently use the ED for care. Interviews were conducted until theme saturation was reached. Interview transcripts and field notes were entered into NVivo 10 and double-coded, using an iterative process to identify patterns of responses, ensure reliability, examine discrepancies, and achieve consensus through content analysis.

RESULTS

Patients view their asthma symptoms in two categories: those they can manage at home and those requiring a provider's attention. Preferred site of acute asthma care varied, but most patients felt that they had little choice for acute exacerbations. Specific reasons for ED visits included wait times, acuity, insurance status, ED resources/expertise, lack of symptom improvement, lack of asthma medication, inability to access outpatient provider, referral by outpatient provider, and referral by friend or family member.

CONCLUSIONS

Barriers to urgent outpatient care may contribute to ED use for asthma. Additionally, patients with asthma exacerbations may not recognize a need for provider attention until the need is urgent. Efforts to identify patients with acute asthma early and to increase access to urgent outpatient care may reduce asthma-related ED visits.

Self-management of multiple chronic conditions among African American women with asthma: a qualitative study

OBJECTIVE

African American women are disproportionately burdened by asthma morbidity and mortality and may be more likely than asthma patients in general to have comorbid health conditions. This study sought to identify the self-management challenges faced by African American women with asthma and comorbidities, how they prioritize their conditions and behaviors perceived as beneficial across conditions.

METHODS

In-depth interviews were conducted with 25 African-American women (mean age 52 years) with persistent asthma and at least one of the following: diabetes, heart disease or arthritis. Information was elicited on women's experiences managing asthma and concurrent health conditions. The constant-comparison analytic method was used to develop and apply a coding scheme to interview transcripts. Key themes and subthemes were identified.

RESULTS

Participants reported an average of 5.7 comorbidities. Fewer than half of the sample considered asthma their main health problem; these perceptions were influenced by beliefs about the relative controllability, predictability and severity of their health conditions. Participants reported ways in which comorbidities affected asthma management, including that asthma sometimes took a "backseat" to conditions considered more troublesome or worrisome. Mood problems, sometimes attributed to pain or functional limitations resulting from comorbidities, reduced motivation for self-management. Women described how asthma affected comorbidity management; e.g. by impeding recommended exercise. Some self-management recommendations, such as physical activity and weight control, were seen as beneficial across conditions.

CONCLUSIONS

Multiple chronic conditions that include asthma may interact to complicate self-management of each condition. Additional clinical attention and self-management support may help to reduce multimorbidity-related challenges.

Impacts of online peer support for children with asthma and allergies: It just helps you every time you can't breathe well"

Children with asthma and allergies experience social isolation and gaps in social support particularly from peers. The objective of this pilot study was to design and test an accessible online support intervention for these children. Support was delivered by peer mentors with asthma and allergies and a professional. Weekly support groups were conducted over 8 weeks using Go to Meeting and Club Penguin. Quantitative measures and a qualitative interview were administered. Significant increases in perceived support and support-seeking coping and trends in decreased loneliness emerged at post-test. Participants also reported increased self-confidence and satisfaction with the intervention.

Online support for children with asthma and allergies

Children with asthma and allergies experience social isolation and gaps in social support particularly from peers. The objective of this pilot study was to design and test an accessible online support intervention for these children. Children (n = 27) aged 7 to 11 from across Canada participated. GoToMeeting was employed for the support group sessions and Club Penguin for social connections during and between support group meetings. Content included: strategies for coping with asthma and allergies, role playing and games to help children deal with difficult situations, fun and enjoyment, and presentations by positive role models. Participation in the online peer support intervention was high, 86.3% on average over the 8-week intervention. By sharing their experiences, listening to peers' experiences, and role playing, children were introduced to practical skills: problem solving, communicating, seeking support, and self-advocacy.

Perceptions and Practices of Adults With Asthma

This article describes a qualitative study that investigated the experiences, attitudes, and opinions of adults with asthma regarding self-managing their disease. Focus groups were conducted with 22 adults living in metropolitan and regional New South Wales, Australia. Key findings were that the perceived stigma of asthma, the need for social support, and the need for “asthma-friendly general practitioners” concerned participants more than formal self-management procedures such as written Asthma Action Plans and medication regimes. Social cognitive theory was used to explain the fluid relationship between persons with asthma, their environment, and their behavior in relation to self-management strategies and in identifying patient-centered approaches. This qualitative research suggests that asthma is viewed as a specific, individualized condition best managed from the perspective of patients’ disease experience and environmental context and not one that is appropriately represented by collective, generic self-management recommendations. The authors’ findings suggest that self-management outcomes can be improved by recognizing the variance in self-efficacy levels between individuals and tailoring environmental and social support strategies around these.

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 management failure: a flaw in physicians' behavior or in patients' knowledge?

OBJECTIVES

Patient-physician communication and patients' knowledge about asthma are relevant factors that influence health outcomes. The aim of this study was to explore general practitioners' (GPs) behaviors, asthma patients' knowledge requirements, and the relationship between physicians' communicative issues, and failures in patients' knowledge.

METHODS

GPs participating in a continuing medical education program on asthma completed an ad hoc survey on communicative style and recruited at least three adult asthma patients to indicate, among 10 options, three aspects of asthma about which they felt less informed.

RESULTS

The survey was completed by 2332 GPs (mean age 54.39 ± 5.93 years) and 7884 patients (mean age 49.59 ± 18.03 years). Several ineffective strategies emerged in the physicians' behaviors: 28.5% of GPs did not encourage patients to express doubts, expectations, or concerns; 39.4% tried to frighten patients concerning disease-related risks; only 25.7% used a written action plan. In addition, 18.6% of GPs were not averse to informing the patient about potential side effects; 16.3% did not try to simplify asthma treatment; approximately 30% considered ease of use when selecting drugs; 18% were not disposed to carry out a partnership with the patient; 36.9% were unlikely to involve the patient in asthma management; and 73% tried to retain control over their patients. Finally, 90.3% of GPs declared they want to be consulted before any treatment change. The three topics on which patients felt less informed were the meaning of asthma control (14% of patients); integration of asthma into daily life (13.3%); and periodic checkups (12.7%). There were significant associations between patients' choices and physicians' answers.

CONCLUSION

These results demonstrate that in general medicine the recommendations of international guidelines on education, communication, and development of a doctor-patient partnership are still ignored and that patients' educational priorities may differ from those identified by medical specialists and by patients belonging to patients' associations.