Shared treatment decision making improves adherence and outcomes in poorly controlled asthma

Am J Respir Crit Care Med. 2010 Mar 15;181(6):566-77. doi: 10.1164/rccm.200906-0907OC. Epub 2009 Dec 17.

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 beta-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 beta-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).

Publication types

  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural

MeSH terms

  • Adrenal Cortex Hormones / therapeutic use
  • Adrenergic beta-Agonists / therapeutic use
  • Anti-Asthmatic Agents / therapeutic use
  • Asthma / drug therapy*
  • Beclomethasone / therapeutic use
  • Bronchodilator Agents / therapeutic use
  • Cromolyn Sodium / therapeutic use
  • Decision Making*
  • Female
  • Follow-Up Studies
  • Humans
  • Male
  • Middle Aged
  • 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
  • Surveys and Questionnaires
  • Theophylline / therapeutic use
  • Treatment Outcome

Substances

  • Adrenal Cortex Hormones
  • Adrenergic beta-Agonists
  • Anti-Asthmatic Agents
  • Bronchodilator Agents
  • Theophylline
  • Beclomethasone
  • Cromolyn Sodium

Associated data

  • ClinicalTrials.gov/NCT00149526
  • ClinicalTrials.gov/NCT00217945