Shared treatment decision making improves adherence and outcomes in poorly controlled asthma.
BACKGROUND
Poor adherence to asthma controller medications results in poor treatment outcomes.


OBJECTIVE
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.


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).
Wilson
Sandra R
SR
Palo Alto Medical Foundation Research Institute, CA 94301, USA. wilsons@pamfri.org
Strub
Peg
P
Buist
A Sonia
AS
Knowles
Sarah B
SB
Lavori
Philip W
PW
Lapidus
Jodi
J
Vollmer
William M
WM
D000305:Adrenal Cortex Hormones / Q000627:therapeutic use; D000318:Adrenergic beta-Agonists / Q000627:therapeutic use; D018927:Anti-Asthmatic Agents / Q000627:therapeutic use; D001249:Asthma / Q000188:drug therapy*; D001507:Beclomethasone / Q000627:therapeutic use; D001993:Bronchodilator Agents / Q000627:therapeutic use; D004205:Cromolyn Sodium / Q000627:therapeutic use; D003657:Decision Making; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance / Q000706:statistics & numerical data*; D010353:Patient Education as Topic / Q000379:methods / Q000706:statistics & numerical data; D010358:Patient Participation / Q000379:methods / Q000706:statistics & numerical data*; D017060:Patient Satisfaction; D010817:Physician-Patient Relations; D011788:Quality of Life; D012129:Respiratory Function Tests / Q000379:methods / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires; D013806:Theophylline / Q000627:therapeutic use; D016896:Treatment Outcome
D000305:Adrenal Cortex Hormones; D000318:Adrenergic beta-Agonists; D018927:Anti-Asthmatic Agents; D001993:Bronchodilator Agents; D013806:Theophylline; D001507:Beclomethasone; D004205:Cromolyn Sodium