Does Shared Decision-Making Improve Adherence in Asthma
Does Shared Decision-Making Improve Adherence in Asthma
To evaluate a model of shared decision-making for asthma treatment, appropriate to the needs
 of African American, Latino, Chinese, and other Asian and low income Caucasian patients to
 adherence to asthma controller medications in a two-year randomized clinical trial in 302
 minority and low-income adults, 18-70 years of age, with suboptimally controlled, persistent
 asthma, paralleling a simultaneous evaluation being conducted in 311 Caucasian and
 Asian/Pacific Island adults, (total n=613), and to examine psychological mechanisms mediating
 the effects of the intervention on adherence and of adherence on asthma outcomes.
BACKGROUND:

 Asthma is a chronic inflammatory disorder of the airways. Despite major advances in
 understanding of its pathophysiology and management, asthma outcomes have not shown parallel
 improvement. Many patients with asthma are poorly controlled and have sub-optimal health
 status. Asthma care management by a trained non-physician health professional has developed
 as a means of addressing the problems of patients evidencing poor control and/or poor
 adherence to controller medications. Shared decision making (SDM) between clinician and
 patient has also been proposed as a means of getting greater patient involvement in their
 care, with the idea that this may improve medication adherence and outcomes. However,
 significant patient involvement also might result in less adequate regimens than would
 management based on guidelines (MBG). Even so, increased adherence to a less adequate regimen
 might result in better outcomes than poor adherence to an optimal regimen.

 DESIGN NARRATIVE:

 Better Outcomes of Asthma Treatment (BOAT) is a randomized controlled trial (a collaborative
 study designed to compare the effectiveness of three strategies for managing patients, 18-70
 years of age, with suboptimally controlled, persistent asthma. The three treatment strategies
 are: usual care (UC); management by guidelines (MG); and a third, shared decision making
 (SDM) arm, that seeks to formally involve the patient in the therapeutic decision-making
 process. Under the present grant, 302 study participants were recruited from the membership
 of the Kaiser Permanente - Northern California Region (KPNC), San Francisco, Oakland, and
 Richmond medical centers. In the collaborating grant (No.HL67092-03) 311 patients were
 recruited from Kaiser Permanente clinical facilities in Portland, OR, and Honolulu, HI.
 Patients were randomized equally to the three treatment arms following baseline assessment of
 asthma control, medication use, lung function, and other behavioral and psychological
 characteristics. Their health care utilization for asthma and acquisition of asthma
 medications is being followed for a total of 24 months post-randomization through health
 system records, and they are being reassessed at 12 mos. Those assigned to the care
 management conditions received asthma education and objective feedback on their level of
 asthma control. Those assigned to the MBG condition were prescribed a regimen appropriate to
 the severity of their asthma in accordance with standard guidelines for asthma management.
 Those assigned to the SDM condition participated in a process to elicit their goals for their
 asthma treatment and their priorities regarding their asthma medications, and then engaged in
 a process of shared decision making with the care manager designed to arrive at a prescribed
 regimen that satisfied their goals and preferences. Analysis of the data will compare the two
 care management approaches with usual care and with each other in terms of the primary
 outcomes.
-  Kaiser Health Care Program member for more than 1 yr.

 -  Site: Portland, OR, Honolulu, HI, San Francisco, Oakland, or Richmond, CA.

 -  Confirmed diagnosis of persistent asthma with currently prescribed medications; no
 daily or alternate daily oral corticosteroid

 -  Evidence of poorly controlled asthma: score of >=1 on ATAQ asthma control
 questionnaire1 and either overuse of rescue medication vs. controller medications
 and/or recent emergency visit or hospitalization for asthma

 -  COPD not the primary lung disease diagnosis

 -  Regular use of Inhaled Corticosteroid (ICS) and current/ex-smokers: >= 8% increase in
 FEV1 post-bronchodilator; if no routine ICS use +/- smoking HX: >= 12% increase
 required; non-smokers using ICS regularly not required to reverse