Does Shared Decision-Making Improve Adherence in Asthma?

描述(申请人提供)：哮喘症状控制，不常使用 抢救药物，正常活动，很少/没有紧急就诊， 住院人数和死亡人数是目前可获得的现实预期 药物治疗，但依从性不足会影响控制， 特别是针对少数民族和低收入患者。共享决策(SDM) 提出了引起患者偏好和障碍的管理模式，并 让患者参与选择哮喘疗法。该模型基于 社会/认知学习理论和行为改变理论(患者为主动 代理/激励性面谈、变革准备/可行性)，以及 建议将其作为提高遵从性的一种手段。SDM的对照试验 最近批准资助的模型，专注于疾病结果和 (第二)在342名高加索人和亚太岛屿样本中的依从性 Kaiser成员(波特兰，夏威夷)，同一个团队现在提出了一项平行试验 在300名非洲裔美国人、中国人、拉丁裔和其他少数族裔/低收入凯撒 北加州的会员。主要结果将是以药房为基础的 控制员服药依从性指数，配合抢救用药，哮喘 其次是控制、生活质量和急性哮喘医疗保健利用 结果。干预效果将在少数群体中和在 合并样本(n=642)；疾病结果将在母研究中进行分析。 心理社会特征的测量，潜在的文化联系，将 被添加到联合研究方案中，以调查遵守情况的相关性 和“机械论”假说之间的因果联系态度改变，改进 依从性和疾病后果。在第一阶段，我们将使用以下焦点小组 患者和临床医生要完善干预措施，以适应充分 不同种群的多样性。在第二阶段，患有次优疾病的患者 将使用KP电子数据库招募受控的持续性哮喘。 符合条件的患者(n=300)将随机(1：1：1)接受SDM管理， 以国家指导方针为基础的管理和日常护理。两种情况下的患者 干预部门将在两个会议中与护理经理会面， 根据其分配的模型，对管理计划进行必要的评审和修改， 在3个月、6个月和9个月时打电话。所有参与者将被跟踪2 年，按12和24个月评估。这是一次独特的机会，可以测试 在少数群体中坚持干预，增加 在以白人为主的人群中进行平行试验，并了解 联系态度、依从性和哮喘结果的机制。

DESCRIPTION (provided by applicant): Asthma symptom control, infrequent use of rescue medications, normalized activities, and rare/no emergency visits, hospitalizations, and deaths are realistic expectations of currently available pharmacologic treatment, but inadequate adherence compromises control, especially for minority and low income patients. A shared decision-making (SDM) management model is proposed that elicits patient preferences and barriers and involves the patient in choosing asthma therapy. The model is based on social/cognitive learning theory and behavior change theory (patients as active agents/motivational interviewing, readiness for change/feasibility), and is proposed as a means of improving adherence. A controlled trial of the SDM model, recently approved for funding, focuses on disease outcomes and (secondarily) adherence in a sample of 342 Caucasian and Asia/Pacific Island Kaiser members (Portland, Hawaii), The same team now proposes a parallel trial in 300 African American, Chinese, Latino, and other minority/low-income Kaiser members in Northern California. The primary outcome will be a pharmacy-based controller medication adherence index, with rescue medication use, asthma control, quality of life, and acute asthma health care utilization as secondary outcomes. Intervention effects will be determined among minorities and in the combined sample (n=642); disease outcomes will be analyzed in the parent study. Measures of psychosocial characteristics, potentially culturally-linked, will be added to the joint research protocol to investigate correlates of adherence and "mechanistic" hypotheses re causal links between attitude change, improved adherence, and disease outcomes. In Phase I, we will use focus groups of patients and of clinicians to refine the intervention to accommodate the full diversity of the various populations. In Phase II, patients with suboptimally controlled, persistent asthma will be recruited using KP electronic databases. Eligible patients (n=300) will be randomized (1:1:1) to SDM management, national guidelines-based management, and usual care. Patients in both intervention arms will meet with a care manager in two sessions, have their management plan reviewed and modified as necessary, per their assigned model, and be phoned at 3, 6, and 9 months. All participants will be followed for 2 years and assessed at 12 and 24 mos. This is a unique opportunity to test an adherence intervention in a minority population, increase the value of a parallel trial in a predominantly Caucasian population, and understand the mechanisms linking attitudes, adherence, and asthma outcomes.