Shared Decision Making for Better Asthma Control

According to global estimates, asthma affects more than 300 million people of all ages, and one-half of asthma patients have poor disease control despite the range of available therapies.¹ These findings highlight the need for more effective strategies to help patients achieve adequate asthma control. To that end, a paper published in Advances in Therapy discussed the importance of open communication and shared decision making between providers and patients as recommended in professional guidelines for asthma treatment.¹ Various studies have linked shared decision making to improvements in disease control, lung function, treatment adherence, and quality of life.^1,2,

The paper offers relevant insights from both a clinician, Kevin Gruffyd-Jones, BM, BCh, MRCGP, a UK-based general practitioner and member of the International Primary Care Respiratory Group, and a patient with asthma, Kjeld Hansen, of Copenhagen, Denmark.¹ Among other points, Mr Hansen explained that it may be difficult for patients to fully understand the benefits of treatment and the effect of their current actions on the future control of their disease. In addition, some patients “might focus more on feigning normality over achieving asthma control,” he wrote. “For example, a person may be embarrassed to display their asthma in front of friends, colleagues or sports teammates,” or may be “reluctant to report too many symptoms to their HCP [healthcare provider], and instead modify their daily behaviour so they only report a manageable number of symptoms.”

Dr Gruffydd-Jones noted that patients often overestimate their level of control, with 1 survey showing that 91% of patients with mild to moderate asthma reported adequate control, although only one-third met the criteria for control as defined by professional guidelines.¹ “Another key aspect, which is not appreciated by many HCPs, is that asthma control is not just assessed by current symptom control, but also by assessing future risk of exacerbations,” he stated.

For shared decision making, both investigators emphasized the importance of regular asthma reviews and personal action plans, which have been shown to improve outcomes in this population.³ However, in a international survey of 1809 physicians, only 37% reported that their patients had received a personal action plan and earlier findings demonstrated a lack of asthma reviews or personal action plans in nearly one-half of asthma patients in the year preceding their deaths.^4,1

A patient’s goals may differ from those defined clinically; thus, “it is important to start discussions by aligning on the patient’s goals, moving away from a symptoms treatment process towards a more holistic approach to healthcare,” the researchers wrote.¹ Clinicians “should then share their aims for good asthma control in terms of current control and reducing future risk,” and a “shared aim can then be developed and incorporated into the individualised self-management plan.”

It is also important to consider disease control within the broader context of the patient’s life, including any comorbid conditions that may influence treatment adherence or other aspects of asthma control. Adequate time should be allotted to explore patients’ medication-related concerns such as adverse events, which are associated with intentional nonadherence, and to address causes of unintentional non-adherence, including incorrect inhaler technique and language barriers.

Drs Gruffyd-Jones and Hansen described recommendations by the Global Initiative for Asthma to reduce the impact of impaired health literacy. These include ordering information from most to least important, speaking slowly and in simple terms rather than medical language, using the teach-back method to confirm the patient’s understanding of instructions, and other tips.¹

To help normalize life for patients with asthma, healthcare providers “need to align on what this means for each individual and then work together to produce a plan that can be applied to the patient’s daily life,” they advised. “Training for [clinicians] on good communication skills and empowering patients to be involved in their asthma management are both critical to ensure effective shared decision-making and, ultimately, improved quality of life for people with asthma.”¹

We interviewed Meredith C. McCormack, MD, MHS, associate professor of medicine in the Division of Pulmonary and Critical Care at the Johns Hopkins University School of Medicine in Baltimore, Maryland, to elaborate on this topic.

What are some ways in which poor communication between providers and patients may affect the patient’s disease control?

Consistent use of medications for asthma remains a challenge; lack of adherence to medications is a significant contributor to poor asthma control. Open communication between providers and patients can help identify barriers to adherence. Cost may be 1 reason patients do not take their medications or take them less frequently than prescribed. Forgetting to take medications is another common problem. 

If a lack of adherence is not identified, clinicians may prescribe additional agents rather than focusing on increasing regular use of currently prescribed medications. Proper technique for the use of inhalers remains a challenge, and education about inhaler technique in the office setting is an opportunity to address this potential pitfall.  

What are some ways providers can improve communication with asthma patients to facilitate better disease control?

Use of visual aids that include photos of different inhalers can help patients identify the medications that they are prescribed. This can start a conversation that begins with open-ended questions, such as, “Show me which inhaler you are using. How often do you it? How many times a week do you remember to use it?” Online videos can also help reinforce proper inhaler technique.  

What should be the focus of future research in this area? 

While there have been major advances in the treatment of allergic asthma, including new injectable biologic medications, there remains a great need for medications for patients with non-allergic asthma. Obesity is a factor associated with more severe asthma and there may unique drivers of asthma morbidity in obese individuals. Research to identify new therapies for this high-risk group are needed. 

Disclosure: One of the study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.

References

1. Gruffydd-Jones K, Hansen K. Working for better asthma control: How can we improve the dialogue between patients and healthcare professionals? Adv Ther. 2020;37(1):1-9.

2. Kew KM, Malik P, Aniruddhan K, Normansell R. Shared decision-making for people with asthma. Cochrane Database Syst Rev. 2017;10(10):CD012330.

3. Gibson PG, Powell H, Coughlan J, et al. Self-management education and regular practitioner review for adults with asthma. Cochrane Database Syst Rev. 2002;1:CD001117.

4. Chapman KR, Hinds D, Piazza P, et al. Physician perspectives on the burden and management of asthma in six countries: The Global Asthma Physician Survey (GAPS). BMC Pulm Med. 2017;17(1):153.