Outcomes associated with a negotiated asthma treatment plan

Psychological and Medical Characteristics Associated with Non-Adherence to Prescribed Daily Inhaled Corticosteroid

Medication non-adherence is associated with sub-optimal asthma control. Identification of medical and psychological characteristics associated with non-adherence is important to enable a targeted and personalized approach when working with patients and for the development of interventions to improve patient outcomes by improving medication adherence. We enrolled adults who had diagnosed asthma and who were prescribed daily inhaled corticosteroid medication. We used published and validated instruments to measure medical characteristics including asthma features, practical asthma knowledge and perceived involvement in care and psychological characteristics including anxiety, depression, optimism, and personality traits, to assess the relationship with medication non-adherence. A total of 126 participants provided data, with 64 (50.8%) of the participants identified as non-adherent. Multivariate analyses showed that younger age, high neuroticism scores and a previous asthma hospital admission were associated with non-adherence. Interestingly, depression was associated with a lower risk of non-adherence. This study showed that a personalized medicine approach would include interventions targeting those who are younger, who have been in hospital for asthma and who rate high on the neuroticism personality trait. Given the availability of effective medications for asthma, better understanding of the characteristics associated with non-adherence is important to enhance optimal self-management.

Shared decision making, satisfaction with care and medication adherence among patients with diabetes

OBJECTIVES

We examined factors associated with shared decision making and whether shared decision-making (SDM) was associated with satisfaction with care or with adherence to anti-diabetic medication.

METHODS

A retrospective study was conducted using 2011-2014 Medical Expenditure Panel Survey (MEPS) data. Inclusion criteria were 18 years or older and visit to a usual source of care during the prior 12 months. Exclusion criteria were reported cognitive limitation, proxy response, less than two prescription fills, or missing data on study variables. SDM was assessed using seven MEPS items. Satisfaction with care was assessed using a single MEPS item 12 months after SDM measurement. Adherence was assessed using Medication Possession Ratio in 12 months after SDM measurement.

RESULTS

The weighted sample of 797 respondents represented 15.6 million with diabetes. Being older, male, or uninsured were associated with low SDM. High SDM was associated with higher satisfaction (p < 0.0001). SDM was not associated with adherence.

CONCLUSIONS

Patients with higher SDM were more satisfied with their healthcare. We did not find association between SDM and adherence to antidiabetic medication.

PRACTICE IMPLICATIONS

Involvement in SDM is encouraged to improve patient satisfaction. Providers may consider age, sex and insurance status in facilitating communications to improve SDM.

Moving toward comprehensive acute heart failure risk assessment in the emergency department: the importance of self-care and shared decision making

Nearly 700,000 emergency department (ED) visits were due to acute heart failure (AHF) in 2009. Most visits result in a hospital admission and account for the largest proportion of a projected $70 billion to be spent on heart failure care by 2030. ED-based risk prediction tools in AHF rarely impact disposition decision making. This is a major factor contributing to the 80% admission rate for ED patients with AHF, which has remained unchanged over the last several years. Self-care behaviors such as symptom monitoring, medication taking, dietary adherence, and exercise have been associated with decreased hospital readmissions, yet self-care remains largely unaddressed in ED patients with AHF and thus represents a significant lost opportunity to improve patient care and decrease ED visits and hospitalizations. Furthermore, shared decision making encourages collaborative interaction between patients, caregivers, and providers to drive a care path based on mutual agreement. The observation that “difficult decisions now will simplify difficult decisions later” has particular relevance to the ED, given this is the venue for many such issues. We hypothesize patients as complex and heterogeneous as ED patients with AHF may need both an objective evaluation of physiologic risk as well as an evaluation of barriers to ideal self-care, along with strategies to overcome these barriers. Combining physician gestalt, physiologic risk prediction instruments, an evaluation of self-care, and an information exchange between patient and provider using shared decision making may provide the critical inertia necessary to discharge patients home after a brief ED evaluation.

Shared clinician-patient decision-making about treatment of pediatric asthma: what do we know and how can we use it?

PURPOSE OF REVIEW

Shared decision-making (SDM) is an emerging field that promises to improve healthcare. We aim to explore the concept of SDM, how it has been studied or applied in the treatment of asthma, and how it might be implemented to improve adherence and outcomes in pediatric asthma.

RECENT FINDINGS

Healthcare providers often fail to involve their patients in clinical decision-making by not presenting all available options, associated risks and benefits, in light of the patient's values, preferences, concerns, lifestyle, and perceived barriers to following various treatment regimens. It has been argued that SDM is preferable to a clinician-controlled approach and may improve patient outcomes (increase satisfaction with care, reduce decisional conflict and decisional regret, improve health-related quality of life, and increase decision-specific knowledge). This may be especially important in managing chronic conditions in which adherence to treatment regimen may increase if the patient was actively involved in the decision-making. In pediatrics, the decision process is further complicated by the clinician-parent(s)-child interaction. We found no studies on how to effectively involve and communicate with children at different developmental levels, or how to coalesce the parent and child's perspective to work as a unit.

SUMMARY

SDM has the promise to improve satisfaction with disease management, treatment adherence and patient-centered outcomes in pediatric asthma, but further research is needed to determine its effectiveness and to establish guidelines on how to implement SDM in the clinical setting and incorporate the input and preferences of all stakeholders' perspectives.

"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.

Long-term effects of negotiated treatment plans on self-management behaviors and satisfaction with care among women with asthma

OBJECTIVE

To examine characteristics of women with negotiated treatment plans, factors that contribute to newly forming a treatment plan, and the impact of plans on asthma management, and their satisfaction with care over 2 years.

METHODS

Data came from telephone interviews with 324 women with asthma at baseline, 12 and 24 months. The effect of having a negotiated treatment plan on medication adherence, asking the physician questions about asthma, asthma management self-efficacy, and satisfaction with care was assessed over 24 months. Data were analyzed using mixed models. Analyses controlled for patient characteristics.

RESULTS

Thirty-eight percent of participants reported having a negotiated treatment plan at three time points. Seeing an asthma specialist (χ(2)(1) = 24.07, p < .001), was associated with having a plan. Women who did not have a negotiated treatment plan at baseline, but acquired one at 12 or 24 months, were more likely to report greater urgent office visits for asthma (odds ratio (OR) = 1.37, 95% confidence interval (CI) = 1.07-1.61). No associations were observed between having a plan and urgent healthcare use or symptom frequency. When adjusting for household income, level of asthma control, and specialty of the caregiving provider, women who did not have a negotiated treatment plan (OR = 0.28, 95% CI = 0.09-0.79) and those with a plan at fewer than three time points (OR = 0.30, 95% CI = 0.11-0.83) were less likely to report medication adherence and satisfaction with their care (regression coefficient (standard error) = -0.65 (0.17), p < .001). No differences in asthma management self-efficacy or asking the doctor questions about asthma were observed.

CONCLUSION

Women with asthma who had a negotiated treatment plan were more likely to see an asthma specialist. In the long-term, not having a treatment plan that is developed in partnership with a clinician may have an adverse impact on medication use and patient views of clinical services.