Impact of Adding a Decision Aid to Patient Education in Adults with Asthma: A Randomized Clinical Trial

Decision aids for people facing health treatment or screening decisions

BACKGROUND

Patient decision aids are interventions designed to support people making health decisions. At a minimum, patient decision aids make the decision explicit, provide evidence-based information about the options and associated benefits/harms, and help clarify personal values for features of options. This is an update of a Cochrane review that was first published in 2003 and last updated in 2017.

OBJECTIVES

To assess the effects of patient decision aids in adults considering treatment or screening decisions using an integrated knowledge translation approach.

SEARCH METHODS

We conducted the updated search for the period of 2015 (last search date) to March 2022 in CENTRAL, MEDLINE, Embase, PsycINFO, EBSCO, and grey literature. The cumulative search covers database origins to March 2022.

SELECTION CRITERIA

We included published randomized controlled trials comparing patient decision aids to usual care. Usual care was defined as general information, risk assessment, clinical practice guideline summaries for health consumers, placebo intervention (e.g. information on another topic), or no intervention.

DATA COLLECTION AND ANALYSIS

Two authors independently screened citations for inclusion, extracted intervention and outcome data, and assessed risk of bias using the Cochrane risk of bias tool. Primary outcomes, based on the International Patient Decision Aid Standards (IPDAS), were attributes related to the choice made (informed values-based choice congruence) and the decision-making process, such as knowledge, accurate risk perceptions, feeling informed, clear values, participation in decision-making, and adverse events. Secondary outcomes were choice, confidence in decision-making, adherence to the chosen option, preference-linked health outcomes, and impact on the healthcare system (e.g. consultation length). We pooled results using mean differences (MDs) and risk ratios (RRs) with 95% confidence intervals (CIs), applying a random-effects model. We conducted a subgroup analysis of 105 studies that were included in the previous review version compared to those published since that update (n = 104 studies). We used Grading of Recommendations Assessment, Development, and Evaluation (GRADE) to assess the certainty of the evidence.

MAIN RESULTS

This update added 104 new studies for a total of 209 studies involving 107,698 participants. The patient decision aids focused on 71 different decisions. The most common decisions were about cardiovascular treatments (n = 22 studies), cancer screening (n = 17 studies colorectal, 15 prostate, 12 breast), cancer treatments (e.g. 15 breast, 11 prostate), mental health treatments (n = 10 studies), and joint replacement surgery (n = 9 studies). When assessing risk of bias in the included studies, we rated two items as mostly unclear (selective reporting: 100 studies; blinding of participants/personnel: 161 studies), due to inadequate reporting. Of the 209 included studies, 34 had at least one item rated as high risk of bias. There was moderate-certainty evidence that patient decision aids probably increase the congruence between informed values and care choices compared to usual care (RR 1.75, 95% CI 1.44 to 2.13; 21 studies, 9377 participants). Regarding attributes related to the decision-making process and compared to usual care, there was high-certainty evidence that patient decision aids result in improved participants' knowledge (MD 11.90/100, 95% CI 10.60 to 13.19; 107 studies, 25,492 participants), accuracy of risk perceptions (RR 1.94, 95% CI 1.61 to 2.34; 25 studies, 7796 participants), and decreased decisional conflict related to feeling uninformed (MD -10.02, 95% CI -12.31 to -7.74; 58 studies, 12,104 participants), indecision about personal values (MD -7.86, 95% CI -9.69 to -6.02; 55 studies, 11,880 participants), and proportion of people who were passive in decision-making (clinician-controlled) (RR 0.72, 95% CI 0.59 to 0.88; 21 studies, 4348 participants). For adverse outcomes, there was high-certainty evidence that there was no difference in decision regret between the patient decision aid and usual care groups (MD -1.23, 95% CI -3.05 to 0.59; 22 studies, 3707 participants). Of note, there was no difference in the length of consultation when patient decision aids were used in preparation for the consultation (MD -2.97 minutes, 95% CI -7.84 to 1.90; 5 studies, 420 participants). When patient decision aids were used during the consultation with the clinician, the length of consultation was 1.5 minutes longer (MD 1.50 minutes, 95% CI 0.79 to 2.20; 8 studies, 2702 participants). We found the same direction of effect when we compared results for patient decision aid studies reported in the previous update compared to studies conducted since 2015.

AUTHORS' CONCLUSIONS

Compared to usual care, across a wide variety of decisions, patient decision aids probably helped more adults reach informed values-congruent choices. They led to large increases in knowledge, accurate risk perceptions, and an active role in decision-making. Our updated review also found that patient decision aids increased patients' feeling informed and clear about their personal values. There was no difference in decision regret between people using decision aids versus those receiving usual care. Further studies are needed to assess the impact of patient decision aids on adherence and downstream effects on cost and resource use.

Systematic review of shared decision-making interventions for people living with chronic respiratory diseases

OBJECTIVE

Shared decision-making (SDM) supports patients to make informed and value-based decisions about their care. We are developing an intervention to enable healthcare professionals to support patients' pulmonary rehabilitation (PR) decision-making. To identify intervention components we needed to evaluate others carried out in chronic respiratory diseases (CRDs). We aimed to evaluate the impact of SDM interventions on patient decision-making (primary outcome) and downstream health-related outcomes (secondary outcome).

DESIGN

We conducted a systematic review using the risk of bias (Cochrane ROB2, ROBINS-I) and certainty of evidence (Grading of Recommendations Assessment, Development and Evaluation) tools.

DATA SOURCES

MEDLINE, EMBASE, PSYCHINFO, CINAHL, PEDRO, Cochrane Central Register of Controlled Trials, the International Clinical Trials Registry Platform Search Portal, ClinicalTrials.gov, PROSPERO, ISRCTN were search through to 11th April 2023.

ELIGIBILITY CRITERIA

Trials evaluating SDM interventions in patients living with CRD using quantitative or mixed methods were included.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers extracted data, assessed risk of bias and certainty of evidence. A narrative synthesis, with reference to The Making Informed Decisions Individually and Together (MIND-IT) model, was undertaken.

RESULTS

Eight studies (n=1596 (of 17 466 citations identified)) fulfilled the inclusion criteria.Five studies included components targeting the patient, healthcare professionals and consultation process (demonstrating adherence to the MIND-IT model). All studies reported their interventions improved patient decision-making and health-related outcomes. No outcome was reported consistently across studies. Four studies had high risk of bias, three had low quality of evidence. Intervention fidelity was reported in two studies.

CONCLUSIONS

These findings suggest developing an SDM intervention including a patient decision aid, healthcare professional training, and a consultation prompt could support patient PR decisions, and health-related outcomes. Using a complex intervention development and evaluation research framework will likely lead to more robust research, and a greater understanding of service needs when integrating the intervention within practice.

PROSPERO REGISTRATION NUMBER

CRD42020169897.

Evaluating Statin Knowledge-Perceptions and Receptivity Following a Comprehensive Lifestyle Modification Program

Background

Though clinical guidelines for cholesterol-lowering therapies advocate for both a trial of lifestyle modification and the initiation of statin medication when appropriate, the extent to which lifestyle modification may alter a patient’s knowledge-perceptions and receptivity towards statins remains unclear.

Methods

Following completion of a 6-month comprehensive lifestyle modification program, perceived changes in knowledge and receptivity towards statins were examined across prespecified subgroups of age, sex, and statin eligibility using a mixed-methods questionnaire. Quantitative and qualitative analyses incorporated binomial tests, McNemar’s test, and thematic analyses.

Results

Among 192 patients who completed the program and exit questionnaire between December 15, 2020 and July 2, 2021, 88.4% of patients indicated a perceived improvement in cholesterol and/or statin knowledge (P < . 0001). 48.2% of patients acknowledged that their receptivity towards taking statins increased (P = . 61). Changes in receptivity were attributed to several identified program themes including improvements in health knowledge and awareness, motivation and empowerment. Patients who noted improvements in their mental health also reported significantly increased receptivity towards statins (P < . 001).

Conclusions

Patients’ perceived knowledge and receptivity towards statins may improve following participation in a comprehensive therapeutic lifestyle modification program. Future research must evaluate the impact of these programs on statin uptake, compliance and outcomes.

Shared decision-making in the management of hereditary angioedema: An analysis of patient and physician perspectives

Background: Hereditary angioedema (HAE) is a rare genetic disorder characterized by recurrent, localized episodes of edema. Current treatment guidelines highlight the importance of shared decision-making (SDM) during implementation of HAE management plans. Objective: To determine what constitutes a successful SDM approach in HAE management. Method: Qualitative telephone interviews, which lasted ∼1 hour, were conducted with four HAE physicians and four patients from the APeX-S trial. The physicians were asked to describe the structure and/or content of typical HAE prophylaxis consultations and factors to consider when selecting medications for long-term treatment. Insights from these interviews were used to develop an SDM process diagram. The patients were interviewed to assess how closely the diagram fit their perspectives on the HAE consultation and their involvement in decisions that concerned their care. Interview transcripts were assessed by the interviewer to determine the degree of SDM involvement in each consultation by using qualitative criteria from the literature. Results: Two physicians followed a high-SDM format, and one physician used a "blended" approach. The fourth physician followed a standard (low SDM) format. A successful SDM approach was found to require pre-visit planning, a commitment on behalf of the physician to use SDM methods to learn more about the patient, and empowerment of the patient to reflect on and vocalize his or her preferences and/or needs. Patients engaged in SDM were more likely to proactively request a treatment switch. Conclusion: The adoption of validated HAE-specific treatment decision aids, as well as measures to change the mindsets of patients and physicians, may facilitate successful implementation of SDM in HAE.Clinical Trial Registration: The APeX-S trial was registered with clinicaltrials.gov (NCT03472040).

Allergen immunotherapy and shared decision-making

Clinical decision-making in allergic rhinoconjunctivitis management involves a significant degree of complexity given the number of pharmaceutical agents; the option for allergen immunotherapy (AIT); and the risk for disease advancement, including the development of asthma as well as new environmental allergic sensitivities. Given the complex array of treatment options that are currently available, there is an opportunity to use a shared decision-making (SDM) approach with associated aids and tools that facilitate the interactive participation of practitioners and patients in the SDM process. This article reviews the general constructs of SDM, the unmet need for SDM aids, the collection of patient preference data for allergic rhinoconjunctivitis, the utility of SDM aids which have been specifically created for AIT, and outlines actionable steps to implement AIT SDM in clinical practice.

Decision coaching for people making healthcare decisions

BACKGROUND

Decision coaching is non-directive support delivered by a healthcare provider to help patients prepare to actively participate in making a health decision. 'Healthcare providers' are considered to be all people who are engaged in actions whose primary intent is to protect and improve health (e.g. nurses, doctors, pharmacists, social workers, health support workers such as peer health workers). Little is known about the effectiveness of decision coaching.

OBJECTIVES

To determine the effects of decision coaching (I) for people facing healthcare decisions for themselves or a family member (P) compared to (C) usual care or evidence-based intervention only, on outcomes (O) related to preparation for decision making, decisional needs and potential adverse effects.

SEARCH METHODS

We searched the Cochrane Library (Wiley), Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (Ovid), Embase (Ovid), PsycINFO (Ovid), CINAHL (Ebsco), Nursing and Allied Health Source (ProQuest), and Web of Science from database inception to June 2021.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) where the intervention was provided to adults or children preparing to make a treatment or screening healthcare decision for themselves or a family member. Decision coaching was defined as: a) delivered individually by a healthcare provider who is trained or using a protocol; and b) providing non-directive support and preparing an adult or child to participate in a healthcare decision. Comparisons included usual care or an alternate intervention. There were no language restrictions.

DATA COLLECTION AND ANALYSIS

Two authors independently screened citations, assessed risk of bias, and extracted data on characteristics of the intervention(s) and outcomes. Any disagreements were resolved by discussion to reach consensus. We used the standardised mean difference (SMD) with 95% confidence intervals (CI) as the measures of treatment effect and, where possible, synthesised results using a random-effects model. If more than one study measured the same outcome using different tools, we used a random-effects model to calculate the standardised mean difference (SMD) and 95% CI. We presented outcomes in summary of findings tables and applied GRADE methods to rate the certainty of the evidence.

MAIN RESULTS

Out of 12,984 citations screened, we included 28 studies of decision coaching interventions alone or in combination with evidence-based information, involving 5509 adult participants (aged 18 to 85 years; 64% female, 52% white, 33% African-American/Black; 68% post-secondary education). The studies evaluated decision coaching used for a range of healthcare decisions (e.g. treatment decisions for cancer, menopause, mental illness, advancing kidney disease; screening decisions for cancer, genetic testing). Four of the 28 studies included three comparator arms.  For decision coaching compared with usual care (n = 4 studies), we are uncertain if decision coaching compared with usual care improves any outcomes (i.e. preparation for decision making, decision self-confidence, knowledge, decision regret, anxiety) as the certainty of the evidence was very low.  For decision coaching compared with evidence-based information only (n = 4 studies), there is low certainty-evidence that participants exposed to decision coaching may have little or no change in knowledge (SMD -0.23, 95% CI: -0.50 to 0.04; 3 studies, 406 participants). There is low certainty-evidence that participants exposed to decision coaching may have little or no change in anxiety, compared with evidence-based information. We are uncertain if decision coaching compared with evidence-based information improves other outcomes (i.e. decision self-confidence, feeling uninformed) as the certainty of the evidence was very low. For decision coaching plus evidence-based information compared with usual care (n = 17 studies), there is low certainty-evidence that participants may have improved knowledge (SMD 9.3, 95% CI: 6.6 to 12.1; 5 studies, 1073 participants). We are uncertain if decision coaching plus evidence-based information compared with usual care improves other outcomes (i.e. preparation for decision making, decision self-confidence, feeling uninformed, unclear values, feeling unsupported, decision regret, anxiety) as the certainty of the evidence was very low. For decision coaching plus evidence-based information compared with evidence-based information only (n = 7 studies), we are uncertain if decision coaching plus evidence-based information compared with evidence-based information only improves any outcomes (i.e. feeling uninformed, unclear values, feeling unsupported, knowledge, anxiety) as the certainty of the evidence was very low.

AUTHORS' CONCLUSIONS

Decision coaching may improve participants' knowledge when used with evidence-based information. Our findings do not indicate any significant adverse effects (e.g. decision regret, anxiety) with the use of decision coaching. It is not possible to establish strong conclusions for other outcomes. It is unclear if decision coaching always needs to be paired with evidence-informed information. Further research is needed to establish the effectiveness of decision coaching for a broader range of outcomes.

Real-world Drivers Behind Communication, Medication Adherence, and Shared Decision Making In Minority Adults with Asthma

Background:

Inhaled corticosteroids (ICS) are the foundation of asthma management. However, ICS non-adherence is common. Black adults have lower ICS adherence than white adults, which likely contributes, in part, to the asthma disparities that Black adults experience.

Objective:

To explore how Black adults with uncontrolled asthma and their primary care providers communicated about ICS non-adherence and used shared decision-making to identify strategies to increase ICS use.

Design:

Eighty routine clinical visits for uncontrolled asthma were audio recorded and inductively analyzed using methods adapted from grounded theory methodology.

Participants:

Study participants included 80 Black adults (83% female) largely low-income (83% Medicaid) and their 10 primary care providers. The study settings were 2 Federally Qualified Health Centers.

Key Results:

Three overarching themes were identified: (1) ICS misuse and lack of knowledge; (2) external influences informed personal misconceptions about ICS; and (3) patient-provider communication to individualize plan of care.

Conclusions:

Reasons for ICS non-adherence in Black adults with uncontrolled asthma offer potential targets for interventions that facilitate enhanced adherence. Future research should include PCP training on strategies that support patient-centered care, such as communication, shared decision-making and patient engagement.

Systematic Development of Patient Decision Aids: An Update from the IPDAS Collaboration

BACKGROUND

The 2013 update of the evidence informing the quality dimensions behind the International Patient Decision Aid Standards (IPDAS) offered a model process for developers of patient decision aids.

OBJECTIVE

To summarize and update the evidence used to inform the systematic development of patient decision aids from the IPDAS Collaboration.

METHODS

To provide further details about design and development methods, we summarized findings from a subgroup (n = 283 patient decision aid projects) in a recent systematic review of user involvement by Vaisson et al. Using a new measure of user-centeredness (UCD-11), we then rated the degree of user-centeredness reported in 66 articles describing patient decision aid development and citing the 2013 IPDAS update on systematic development. We contacted the 66 articles' authors to request their self-reports of UCD-11 items.

RESULTS

The 283 development processes varied substantially from minimal iteration cycles to more complex processes, with multiple iterations, needs assessments, and extensive involvement of end users. We summarized minimal, medium, and maximal processes from the data. Authors of 54 of 66 articles (82%) provided self-reported UCD-11 ratings. Self-reported scores were significantly higher than reviewer ratings (reviewers: mean [SD] = 6.45 [3.10]; authors: mean [SD] = 9.62 [1.16], P < 0.001).

CONCLUSIONS

Decision aid developers have embraced principles of user-centered design in the development of patient decision aids while also underreporting aspects of user involvement in publications about their tools. Templates may reduce the need for extensive development, and new approaches for rapid development of aids have been proposed when a more detailed approach is not feasible. We provide empirically derived benchmark processes and a reporting checklist to support developers in more fully describing their development processes.[Box: see text].

Clinician perspectives on a culturally adapted patient decision aid concerning maintenance therapy for asthma

BACKGROUND AND OBJECTIVE

Patients with persistent asthma often show poor adherence to inhaled corticosteroids (ICS). Shared decision-making can improve adherence rates in this population. Patient decision aids (PDAs) are tools to facilitate shared decision-making. To date, only one PDA, developed in a Canadian French-speaking population, exists for patients considering ICS maintenance therapy. This PDA has been culturally adapted in this study to contextualize to the needs of multi-ethnic Asian patients in Singapore. This study explored the views of local clinicians on the content, design and implementation of this newly-adapted PDA.

METHODS

24 clinicians, who were purposively sampled from polyclinics and a tertiary institution, were interviewed on the content, design and implementation of the PDA. The interviews were audio-recorded, transcribed and analyzed via thematic analysis.

RESULTS

Clinicians generally accepted the design of the PDA. They suggested for the target users to be patients on Step 2 of GINA guidelines and the number of options to be reduced from four to two (do nothing or start inhaled corticosteroids). Moreover, they supported including a list of values for patients to select from given that Asian patients often do not articulate their values readily. The addition of more visual aids, the production of multilingual Asian editions and the involvement of nurses to administer the PDA was also suggested.

CONCLUSION

The PDA was culturally-adapted with local clinicians' perspectives to target multi-ethnic Asian patients with persistent asthma (Step 2 GINA guidelines). The main changes include a list of values and addition of visual aids.

Patient perspectives on the treatment burden of injectable medication for hereditary angioedema

Hereditary angioedema (HAE) is a rare, chronic disease characterized by debilitating swelling episodes in various parts of the body. Patients experience significant burdens related to the symptoms and management of HAE, which can affect their daily lives and reduce their overall quality of life. Prophylactic treatment options have expanded in the past decade to the benefit of patients; however, these therapies require scheduled injections, which can be painful, burdensome, and time consuming. We conducted an online survey of patients with HAE in the USA to better understand their experiences with available prophylactic medications and the associated treatment burdens. Our survey results suggest that most patients are satisfied with their current therapies but desire novel medications with a simpler route of administration and that, although most patients experience significant treatment-related burdens, they learn to cope with these challenges over time.

Physician and patient perspectives on the management of hereditary angioedema: a survey on treatment burden and needs

Hereditary angioedema (HAE) is a rare disorder caused by genetic mutations that lead to recurrent episodes of swelling in various parts of the body. Prophylactic treatment is common for patients with HAE, and the therapeutic options have expanded in recent years. The current standard of care for prophylactic HAE therapies is subcutaneous treatment, which can be self-administered at home, greatly improving patient quality of life. As new therapies emerge, it is important for patients and physicians to discuss the risks and benefits associated with each treatment to develop an individualized approach to HAE management. We conducted surveys of patients with HAE and physicians who treat patients with HAE to identify prescribing trends for prophylactic HAE treatments and the impact that such treatments has on patients. Our results confirmed that newer, subcutaneous therapies are prescribed for HAE prophylaxis more frequently than other therapies in the United States and that treatment burdens still exist for patients with HAE. We found that physicians and patients were not always aligned on how treatment choices affect patients' lives, which may mean that there are opportunities for enhanced patient-physician dialog and shared decision-making in HAE management in the United States.

Group-randomized trial of tailored brief shared decision-making to improve asthma control in urban black adults

AIMS

To assess the intervention effects of BREATHE (BRief intervention to Evaluate Asthma THErapy), a novel brief shared decision-making intervention and evaluate feasibility and acceptability of intervention procedures.

DESIGN

Group-randomized longitudinal pilot study.

METHODS

In total, 80 adults with uncontrolled persistent asthma participated in a trial comparing BREATHE (N = 40) to a dose-matched attention control intervention (N = 40). BREATHE is a one-time shared decision-making intervention delivered by clinicians during routine office visits. Ten clinicians were randomized and trained on BREATHE or the control condition. Participants were followed monthly for 3 months post-intervention. Data were collected from December 2017 - May 2019 and included surveys, lung function tests, and interviews.

RESULTS

Participants were Black/multiracial (100%) mostly female (83%) adults (mean age 45). BREATHE clinicians delivered BREATHE to all 40 participants with fidelity based on expert review of audiorecordings. While the control group reported improvements in asthma control at 1-month and 3-month follow-up, only BREATHE participants had better asthma control at each timepoint (β = 0.77; standard error (SE)[0.17]; p ≤ 0.0001; β = 0.71; SE[0.16]; p ≤ 0.0001; β = 0.54; SE[0.15]; p = .0004), exceeding the minimally important difference. BREATHE participants also perceived greater shared decision-making occurred during the intervention visit (β = 7.39; SE[3.51]; p = .03) and fewer symptoms at follow-up (e.g., fewer nights woken, less shortness of breath and less severity of symptoms) than the controls. Both groups reported improved adherence and fewer erroneous medication beliefs.

CONCLUSION

BREATHE is a promising brief tailored intervention that can be integrated into office visits using clinicians as interventionists. Thus, BREATHE offers a pragmatic approach to improving asthma outcomes and shared decision-making in a health disparity population.

IMPACT

The study addressed the important problem of uncontrolled asthma in a high-risk vulnerable population. Compared with the dose-matched attention control condition, participants receiving the novel brief tailored shared decision-making intervention had significant improvements in asthma outcomes and greater perceived engagement in shared decision-making. Brief interventions integrated into office visits and delivered by clinicians may offer a pragmatic approach to narrowing health disparity gaps. Future studies where other team members (e.g., office nurses, social workers) are trained in shared decision-making may address important implementation science challenges as it relates to adoption, maintenance, and dissemination. TRAIL REGISTRATION: clinicaltrials.gov # NCT03300752.

Hereditary angioedema and shared decision making

Clinical decision-making in hereditary angioedema (HAE) management involves a high degree of complexity given the number of therapeutic agents that are available and the risk for significant morbidity and potential mortality attributable to the disease. Given this complexity, there is an opportunity to develop shared decision-making (SDM) aids and/or tools that would facilitate the interactive participation of practitioners and patients in the SDM process. This article reviews the general constructs of SDM, the unmet need for SDM in HAE, and the steps necessary to create a SDM tool specific for HAE, and outlines the challenges that must be navigated to guide the establishment and widespread implementation of SDM in the management of HAE.

Improving detection of work-related asthma: a review of gaps in awareness, reporting and knowledge translation

Background

Work-related asthma (WRA) accounts for up to 25% of all adults with asthma. Early diagnosis is key for optimal management as delays in diagnosis are associated with worse outcomes. However, WRA is significantly underreported and the median time to diagnosis is 4 years. The objective of this review is to identify the gaps in awareness and reporting of WRA and identify gaps in current knowledge translation strategies for chronic disease in general, and asthma specifically. This will identify reasons for delays in WRA diagnosis, as well inform suggestions to improve knowledge translation strategies for dissemination and implementation of WRA prevention and management guidelines.

Methods

Non-systematic literature reviews were conducted on PubMed with a focus on work-related asthma screening and diagnosis, and knowledge translation or translational medicine research in asthma and chronic disease. In total, 3571 titles and abstracts were reviewed with no restriction on date published. Of those, 207 were relevant and fully read. Another 37 articles were included and reviewed after citation reviews of articles from the initial search and from suggestions from editors. In total, 63 articles were included in the final review.

Results

Patients, employers, and healthcare professionals lack awareness and under-report WRA which contribute to the delayed diagnosis of WRA, primarily through lack of education, stigma associated with WRA, and lack of awareness and screening in primary care. Knowledge translation strategies for asthma research typically involve the creation of guidelines for diagnosis of the disease, asthma care plans and tools for education and management. While there are some prevention programs in place for certain industries, gaps in knowledge translation strategies including lack of screening tools currently available for WRA, poor education of employers and physicians in identifying WRA, and education of patients is often done post-diagnosis and focuses on management rather than prevention or screening.

Conclusion

Future knowledge translation strategies should focus on educating employees and employers well before potential exposure to agents associated with WRA and screening for WRA in primary care to enable health care providers to recognize and diagnose WRA.

A review of shared decision-making: A call to arms for health care professionals

OBJECTIVE

To illustrate the use of shared decision-making (SDM) and SDM tools and aids as the essential components in the care of asthma.

DATA SOURCES

We reviewed individual randomized controlled studies conducted between 1998 and 2020 to compare SDM interventions and the use of SDM tools and aids for the care of asthma. All studies were published or translated in English.

STUDY SELECTIONS

We excluded studies of interventions that involved multiple components other than the SDM intervention unless the control group also received these interventions. We evaluated the existing literature on both SDM tools and aids and the process of SDM to summarize in this review.

RESULTS

Shared decision-making tools and aids most commonly clarify the diagnostics and options for a treatment. The 6 elements of SDM were clearly supported. We found no considerable association between the presence of these elements of SDM and asthma outcomes.

CONCLUSION

We found that SDM for asthma and SDM tools and aids were often made to transfer information about asthma treatment options and their harms and benefits. The correlation between their support of SDM key elements and their impact on asthma outcomes is often difficult to ascertain but when present, there was positive correlation to improving risk communication, adherence, patient satisfaction, and possibly decreasing liability.

A system uptake analysis and GUIDES checklist evaluation of the Electronic Asthma Management System: A point-of-care computerized clinical decision support system

OBJECTIVE

Computerized clinical decision support systems (CCDSSs) promise improvements in care quality; however, uptake is often suboptimal. We sought to characterize system use, its predictors, and user feedback for the Electronic Asthma Management System (eAMS)-an electronic medical record system-integrated, point-of-care CCDSS for asthma-and applied the GUIDES checklist as a framework to identify areas for improvement.

MATERIALS AND METHODS

The eAMS was tested in a 1-year prospective cohort study across 3 Ontario primary care sites. We recorded system usage by clinicians and patient characteristics through system logs and chart reviews. We created multivariable models to identify predictors of (1) CCDSS opening and (2) creation of a self-management asthma action plan (AAP) (final CCDSS step). Electronic questionnaires captured user feedback.

RESULTS

Over 1 year, 490 asthma patients saw 121 clinicians. The CCDSS was opened in 205 of 1033 (19.8%) visits and an AAP created in 121 of 1033 (11.7%) visits. Multivariable predictors of opening the CCDSS and producing an AAP included clinic site, having physician-diagnosed asthma, and presenting with an asthma- or respiratory-related complaint. The system usability scale score was 66.3 ± 16.5 (maximum 100). Reported usage barriers included time and system accessibility.

DISCUSSION

The eAMS was used in a minority of asthma patient visits. Varying workflows and cultures across clinics, physician beliefs regarding asthma diagnosis, and relevance of the clinical complaint influenced uptake.

CONCLUSIONS

Considering our findings in the context of the GUIDES checklist helped to identify improvements to drive uptake and provides lessons relevant to CCDSS design across diseases.

Decision aids that facilitate elements of shared decision making in chronic illnesses: a systematic review

BACKGROUND

Shared decision making (SDM) is a patient-centered approach in which clinicians and patients work together to find and choose the best course of action for each patient's particular situation. Six SDM key elements can be identified: situation diagnosis, choice awareness, option clarification, discussion of harms and benefits, deliberation of patient preferences, and making the decision. The International Patient Decision Aid Standards (IPDAS) require that a decision aid (DA) support these key elements. Yet, the extent to which DAs support these six key SDM elements and how this relates to their impact remain unknown.

METHODS

We searched bibliographic databases (from inception until November 2017), reference lists of included studies, trial registries, and experts for randomized controlled trials of DAs in patients with cardiovascular, or chronic respiratory conditions or diabetes. Reviewers worked in duplicate and independently selected studies for inclusion, extracted trial, and DA characteristics, and evaluated the quality of each trial.

RESULTS

DAs most commonly clarified options (20 of 20; 100%) and discussed their harms and benefits (18 of 20; 90%; unclear in two DAs); all six elements were clearly supported in 4 DAs (20%). We found no association between the presence of these elements and SDM outcomes.

CONCLUSIONS

DAs for selected chronic conditions are mostly designed to transfer information about options and their harms and benefits. The extent to which their support of SDM key elements relates to their impact on SDM outcomes could not be ascertained.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration number: CRD42016050320 .

Does a Patient-Directed Financial Incentive Affect Patient Choices About Controller Medicines for Asthma? A Discrete Choice Experiment and Financial Impact Analysis

BACKGROUND

In Australia, many patients who are initiated on asthma controller inhalers receive combination inhaled corticosteroid/long-acting beta₂-agonist (ICS/LABA) despite having asthma of sufficiently low severity that ICS-alone would be equally effective and less costly for the government.

METHODS

We conducted a discrete choice experiment (DCE) in a nationally representative sample of adults (n = 792) and parents of children (n = 609) with asthma. Mixed multinomial models were estimated and calibrated to reflect the estimated market shares of ICS-alone, ICS/LABA and no controller. We then simulated the impact of varying patient co-payment on demand and the financial impact on government pharmaceutical expenditure.

RESULTS

Preference for inhaler decreased with increasing costs to the patient or government, increasing chance of a repeat visit to the doctor, and if fewer symptoms were present. Adults preferred high-strength controllers, but parents preferred low-strength inhalers for children (general beneficiaries only). The DCE predicted a higher proportion choosing controller treatment (89%) compared to current levels (57%) at the current co-payment level, with proportionately higher uptake of ICS-alone and a lower average cost per patient [32.73 Australian dollars (AU$) c.f. AU$38.54]. Reducing the co-payment on ICS-alone by 50% would increase its market share to 50%, whilst completely removing the co-payment would only have a small marginal impact on market share, but increased average cost of treatment to the government to AU$41.04 per person.

CONCLUSIONS

Patient-directed financial incentives are unlikely to encourage much switching of medicines, and current levels of under-treatment are not explained by patient preferences. Interventions directed at prescribers are more likely to promote better use of asthma medicines.

Shared decision making for the allergist

OBJECTIVE

Shared decision making (SDM) is becoming more commonly appreciated and used in medical practice as a way to empower patients who are facing treatment preference-sensitive conditions, such as allergic rhinitis, atopic dermatitis, food allergy, and persistent asthma. The purpose of this review is to educate the allergy health care provider about how SDM works and provide practical advice and allergist-specific SDM resources.

DATA SOURCES

PubMed and online patient decision aid resources.

STUDY SELECTIONS

Studies and reviews relevant to SDM and patient decision aids relevant to the allergy health care provider were selected for discussion.

RESULTS

There are ethical, practical, economic, and psychological imperatives for the implementation of quality SDM, particularly for chronic diseases. Many benefits and barriers of SDM have been identified and models have been developed to encourage implementation of quality SDM. For the allergy health care provider, SDM for asthma has been shown to improve adherence, outcomes, and patient satisfaction with care. Patient decision aids are useful tools for SDM and have recently been developed for allergen immunotherapy, severe asthma, and atopic dermatitis.

CONCLUSION

Effective SDM has been shown to improve adherence and lead to better outcomes. SDM should be universally implemented as a key component of patient-centered health care. Allergy health care providers should work with their patients to reach treatment decisions that align with their values and preferences.

Patient Perspectives on a Text Messaging Program to Support Asthma Management: A Qualitative Study

Introduction. This study investigated participants' acceptance of a short messaging service (SMS) intervention designed to support asthma management, including suggestions regarding program delivery and message content. Methods. Individual and group interviews were conducted with patients from a safety-net health care system in Denver, Colorado. Eligible participants were English or Spanish speakers between the ages of 13 and 40 years, with diagnosed persistent asthma. All individual and group interviews were digitally recorded, transcribed, translated from Spanish to English (where applicable), and analyzed for thematic content by experienced analysts using established qualitative content techniques. The qualitative software package ATLAS.ti was used for data analysis and management. Results. This study included a total of 43 participants. In general, participants were receptive toward the SMS program and supported the use of tailored and interactive messages. Adolescents supported the idea of enhancing care by sending messages to a support person, such as a parent or guardian. However, adults were less receptive toward this idea. Participants also preferred directive educational messages and cues to action, while general messages reminding them of their asthma diagnosis were viewed less favorably. Implications. The results from this study will inform a randomized control trial evaluating the efficacy of the SMS intervention.

Shared decision-making for people with asthma

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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