Journal Article

Shared Treatment Decision Making Improves Adherence and Outcomes in Poorly Controlled Asthma

Buist, A. Sonia, Vollmer, William M., Lapidus, Jodi, Wilson, Sandra R., Knowles, Sarah B., Strub, Peg, Lavori, Philip W.

2010

Overview

Abstract Rationale Poor adherence to asthma controller medications results in poor treatment outcomes. Objectives To compare controller medication adherence and clinical outcomes in 612 adults with poorly controlled asthma randomized to one of two different treatment decision-making models or to usual care. Methods In shared decision making (SDM), nonphysician clinicians and patients negotiated a treatment regimen that accommodated patient goals and preferences. In clinician decision making, treatment was prescribed without specifically eliciting patient goals/preferences. The otherwise identical intervention protocols both provided asthma education and involved two in-person and three brief phone encounters. Measurements and Main Results Refill adherence was measured using continuous medication acquisition (CMA) indices—the total days' supply acquired per year divided by 365 days. Cumulative controller medication dose was measured in beclomethasone canister equivalents. In follow-up Year 1, compared with usual care, SDM resulted in: significantly better controller adherence (CMA, 0.67 vs. 0.46; P < 0.0001) and long-acting β-agonist adherence (CMA, 0.51 vs. 0.40; P = 0.0225); higher cumulative controller medication dose (canister equivalent, 10.9 vs. 5.2; P < 0.0001); significantly better clinical outcomes (asthma-related quality of life, health care use, rescue medication use, asthma control, and lung function). In Year 2, compared with usual care, SDM resulted in significantly lower rescue medication use, the sole clinical outcome available for that year. Compared with clinician decision making, SDM resulted in: significantly better controller adherence (CMA, 0.67 vs. 0.59; P = 0.03) and long-acting β-agonist adherence (CMA, 0.51 vs. 0.41; P = 0.0143); higher cumulative controller dose (CMA, 10.9 vs. 9.1; P = 0.005); and quantitatively, but not significantly, better outcomes on all clinical measures. Conclusions Negotiating patients' treatment decisions significantly improves adherence to asthma pharmacotherapy and clinical outcomes. Clinical trials registered with www.clinicaltrials.gov (NCT00217945 and NCT00149526).

• Publisher: Oxford University Press,American Thoracic Society
• Subject: A. Asthma and Allergy / Adrenal Cortex Hormones - therapeutic use / Adrenergic beta-Agonists - therapeutic use / Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy / Anti-Asthmatic Agents - therapeutic use / Asthma / Asthma - drug therapy / Beclomethasone - therapeutic use / Biological and medical sciences / Bronchodilator Agents - therapeutic use / Chronic illnesses / Clinical outcomes / Cromolyn Sodium - therapeutic use / Decision Making / Drug therapy / Emergency and intensive cardiocirculatory care. Cardiogenic shock. Coronary intensive care / Female / Follow-Up Studies / Humans / Hypotheses / Intensive care medicine / Intervention / Male / Medical sciences / Middle Aged / Observational studies / Patient compliance / Patient Compliance - statistics & numerical data / Patient Education as Topic - methods / Patient Education as Topic - statistics & numerical data / Patient Participation - methods / Patient Participation - statistics & numerical data / Patient Satisfaction / Physician-Patient Relations / Quality of Life / Respiratory Function Tests - methods / Respiratory Function Tests - statistics & numerical data / Spirometry / Surveys and Questionnaires / Theophylline - therapeutic use / Treatment Outcome