Training Staff at Doctors' Offices to Use Shared Decision-Making with Patients Choosing Asthma Treatments [Internet]

Excerpt

Background: Currently, an estimated 24 million people in the United States, including 12% of all children, have asthma. Almost 50% of these children experience an asthma attack each year. Shared decision-making (SDM) during the patient–provider visit increases adherence to medication and improves outcomes that are important for patients, such as decreased emergency department (ED) visits. Despite evidence for the effectiveness of new methods such as SDM, multiple barriers prevent clinicians from incorporating them into their practices. And knowledge of effective approaches for successful dissemination of SDM is lacking. In brief, asthma is a serious and prevalent chronic condition for which SDM is known to improve outcomes, but SDM for asthma treatment has not been successfully implemented into primary care settings. We conducted a trial to identify effective ways to disseminate SDM for asthma treatment in primary care.

Objectives: The Asthma Dissemination Around Patient-Centered Treatments in North Carolina (ADAPT-NC) study (1) compared the effectiveness of lunch-and-learn (traditional) and facilitator-led (participatory) dissemination strategies for an SDM intervention, and (2) determined which strategy resulted in practices more effectively adopting an SDM approach to asthma management. We evaluated the effectiveness of the dissemination models by the level of patient involvement in the decision-making process for the lunch-and-learn and facilitator-led arms. We assessed the effectiveness of the models by comparing asthma exacerbation metrics across the 3 arms.

Methods: This cluster-randomized study involved 30 primary care practices associated with 4 practice-based research networks in North Carolina. Practices were randomized to 3 study arms. Practices randomized to the facilitator-led dissemination arm (n = 10) received a facilitator-led, participatory, tailored approach to implementation. Those randomized to the traditional lunch-and-learn active dissemination arm (n = 10) received a 1-hour training on SDM at their clinical site and a refresher 1 year later. Practices randomized to the usual care control arm (n = 10) did not receive active dissemination by the study team. To assess the level of patient involvement in the decision-making process (the primary outcome), we used anonymous surveys to compare patients' perceptions of having shared in the decision in the 2 active dissemination arms. To compare differences in asthma exacerbation metrics (the secondary outcome), we collected data on ED visits, hospitalizations, and oral steroid prescriptions for asthma for Medicaid patients and compared the data among the 3 arms. For asthma exacerbations, we calculated the odds ratio using adjusted logistic regression with 95% CI. We calculated all comparisons for outcomes at the practice level.

Results: In 74.9% (95% CI, 71.7%-78.1%) of patient visits at facilitator-led practices, patients indicated that they participated equally with the provider in making the treatment decision, compared with 66.3% (95% CI, 62.8%-69.8%) in the lunch-and-learn practices. Control group practices were not surveyed. All other comparisons among the 3 arms of the study—for steroid prescriptions, ED visits, hospitalizations, and asthma exacerbations—were not significant. The within-arm decrease from baseline in the proportion of patients with steroid prescriptions was 15.9% (P < .001) for facilitator-led, 13.2% (P < .001) for lunch-and-learn, and 10.6% (P < .001) for control. The within-arm decrease in patients with ≥1 exacerbations was 18.2% (P < .001) for facilitator-led, 9.5% (P = .005) for lunch-and-learn, and 10.5% (P = .008) for control.

Conclusions: Facilitator-led dissemination was associated with a significantly higher proportion of patients equally sharing in decision-making with the provider during an asthma visit compared with lunch-and learn dissemination. These results support the use of structured approaches (such as facilitator-led dissemination of complex interventions) to SDM in primary care practices.

Limitations: The surveys were given to a convenience sample of asthma patients after asthma visits, regardless of insurance status; therefore, the survey results cannot be directly linked to the asthma exacerbation outcome measures collected from the state Medicaid network.