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Shared Treatment Decision-making Improves Adherence and Outcomes in Poorly Controlled Asthma.

Am J Respir Crit Care Med. 2009 Dec 17. Wilson SR, Strub P, Buist AS, Knowles SB, Lavori PW, Lapidus J, Vollmer WM, Boat Study Group. Palo Alto Medical Foundation Research Institute, Palo Alto, California, United States.

RATIONALE: Poor adherence to asthma controller medications results in poor treatment outcomes.

OBJECTIVES: 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), non-physician clinicians and patients negotiated a treatment regimen that accommodated patient goals and preferences. In clinician decision making (CDM), 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.

MEASUREMENTS AND MAIN RESULTS: Refill adherence was measured using continuous medication acquisition indices (CMA) â the total daysâ supply acquired per year divided by 365 days. Cumulative controller medication dose was measured in beclomethasone canister-equivalents (CE). Follow-up Year 1: Compared to usual care, SDM resulted in significantly better controller adherence (CMA, 0.67 vs. 0.46; P<0.0001), LABA adherence (CMA, 0.51 vs. 0.40; P=0.0225); higher cumulative controller medication dose (CE, 10.9 vs. 5.2; P<0.0001); significantly better clinical outcomes (asthma-related quality of life, health care utilization, rescue medication use, asthma control, and lung function); and in Year 2, significantly lower rescue medication use, the sole clinical outcome available for that year. Compared to CDM, SDM resulted in significantly better controller adherence (CMA, 0.67 vs. 0.59; PP=0.03), LABA adherence (CMA, 0.51 vs. 0.41; P=0.0143); higher cumulative controller dose (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

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