Patients prioritize short-term improvements over long-term risks in asthma care
Click Here to Manage Email Alerts
Key takeaways:
- Priorities included fewer asthma attacks requiring urgent health care visits and fewer exacerbations needing oral corticosteroids.
- Patients would increase rescue medication use in exchange for these decreases.
Patients with asthma preferred convenient management options that prioritized decreases in short-term morbidity over long-term goals, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice.
By understanding patient preferences, physicians may better facilitate shared decision-making, Ileen Gilbert, MD, senior field physician, U.S. Medical Affairs-Respiratory, AstraZeneca, and colleagues wrote.
The Global Initiative for Asthma (GINA) and National Asthma Education and Prevention Program (NAEPP) guidelines both emphasize that physicians need to account for patient goals and preferences in determining asthma management plans, Gilbert told Healio.
“We also know that the FDA has guidance on how to include the patient voice in the development of new therapies,” she said. “The FDA guidance is quite specific on the scientific methodology with which patient preferences and goals can be assessed.”
Gilbert said that she and her colleagues wanted to use this scientific methodology to better understand what patients most want from their asthma management and what tradeoffs they would be most willing to make to achieve their top goals.
“This is particularly timely, as both NAEPP and GINA are supporting new management paradigms for rescue therapy,” she said.
Study design, results
The online discrete choice experiment surveyed 1,184 adults (60% women; 68% white; mean age, 49.2 years) with asthma, with 67% treated for mild asthma and 52% seeing a specialist for asthma.
Patients with asthma face a huge burden regardless of disease severity, access to care, education, race and ethnicity, Gilbert said, with more than 50% of the study population experiencing uncontrolled asthma.
Patient preferences included reducing the number of attacks that required an urgent visit to a health care professional from three a year to none a year; reducing exacerbations that require oral corticosteroids (OCS) from six bursts a year to none a year; and reducing the average need for rescue medication from daily to zero days a week.
Also, patients preferred reducing the risk for oral thrush from 30% a year to 5% a year; reducing weight gain from 10 lbs to none; and reducing the 5-year risk for diabetes from 15% to 5%. Patients expressed a preference for using a single inhaler over using a nebulizer and inhaler together as well.
Home management treatment plans were the least valued attribute of treatment, the researchers found, with patients preferring plans enabling them to self-adjust medication without consulting their provider instead of plans where the provider determines medication adjustments.
“Despite the decades-long emphasis that has been placed on the development of asthma action plans, patients do not understand or use them,” Gilbert said.
The survey also assessed the tradeoffs that patients would be willing to make in their care.
Patients reported that to avoid one attack a year that would require an urgent visit to a health care provider, they would accept on average a 6.5% (95% CI, 5.5% to 7.5%) increase in 5-year diabetes risk, 2.3 (95% CI, 2.1-2.6) additional exacerbations that required OCS per year, a 13.4% (95% CI, 11.8% to 14.9%) increase in yearly oral thrush risk, and 4.8 lbs (95% CI, 4.2-5.4 lbs) in weight gain.
Patients also reported that to avoid one exacerbation requiring OCS per year, they on average would accept a 2.8% increase (95% CI, 2.3%-3.3%) in 5-year risk for diabetes, 0.4 (95% CI, 0.4-0.5) additional attacks per year requiring an urgent visit to a health care provider, a 5.8% increase (95% CI, 5% to 6.5%) increase in yearly oral thrush risk and 2.1 lbs (95% CI, 1.8-2.4 lbs) in weight gain.
Additionally, patients said they would accept an increase in rescue medication use from no weekly use to 7 days a week in exchange for a decrease of 1.2 attacks per year requiring an urgent visit to a health care professional and a decrease of 2.8 exacerbations requiring OCS use per year on average.
Similarly, patients would accept a 5.8% increase in yearly risk for thrush in exchange for rescue and maintenance treatment with a single inhaler instead of two inhalers of the same device type on average.
Reductions in exacerbations requiring OCS (OR = 0.83; 95% CI, 0.72-0.96), risks for oral thrush (OR = 0.84; 95% CI, 0.71-1) and weight gain (OR = 0.63; 95% CI, 0.55-0.71) were less valuable to men than to women.
Similarly, reductions in exacerbations requiring OCS (OR = 0.78; 95% CI, 0.64-0.95), weight gain (OR = 0.84; 95% CI, 0.71-1) and using a single inhaler for rescue and maintenance therapy instead of a nebulizer for rescue therapy and an inhaler for maintenance (OR = 0.82; 95% CI, 0.68-0.99) were less valuable to Black or African American patients compared with other patients.
Hispanic patients expressed a greater preference for decreasing the number of attacks that require an urgent visit to a health care professional (OR = 1.29; 95% CI, 1.06-1.57) and reducing risk for oral thrush (OR = 1.2; 95% CI, 1.01-1.43) than other patients.
However, Hispanic patients expressed less preference for a single inhaler for rescue and maintenance treatment over a combination of a nebulizer for rescue treatment and an inhaler for maintenance (OR = 0.75; 95% CI, 0.61-0.91) compared with other patients.
Patient preferences also varied based on whether they lived in urban, suburban or rural areas, as well as on how well their asthma was controlled, whether their asthma was mild or moderate to severe, and whether their asthma was managed by a specialist.
Conclusions, next steps
Gilbert called these findings both old and new, as poor asthma control and the high burden of asthma attacks and exacerbations requiring OCS have been known for decades. These burdens also are ubiquitous and not just experienced by less educated, underserved and under-resourced populations, she continued.
“What is new is that the way in which we have been approaching this morbidity is not necessarily aligned with patient preferences and goals,” Gilbert said.
Patients do not value home management plans, and they underappreciate the long-term risks of systemic steroids, she said. They also want single-device treatments that will meet their goals.
“Putting the preference and tradeoff data together supports the paradigm shift in rescue therapy recommended by GINA — to treat symptoms and inflammation concomitantly regardless of severity, control and maintenance adherence,” she said.
Based on these findings, the researchers concluded that treatment attributes with an emphasis on improving benefits and reducing risks significantly affected patient preferences.
“Patients are more concerned about short-term outcomes of treatment, both efficacy and safety, than long-term adverse events, which means greater education is needed to ensure overall morbidity improvements,” Gilbert said.
The researchers also said their findings indicate how understanding patient values may be a useful starting point for shared decision-making, aligning patient preferences with asthma management recommendations.
“Doctors need to be aware of what their patients want and take preferences and goals into shared decision-making conversations about asthma management plans,” Gilbert said. “This study can heighten awareness of patient preferences and lead to better follow-through with shared management plans.”
This study focused on adults, Gilbert said, but she and her colleagues also have similar data about children and adolescents.
“We are in the process of analyzing and publishing these findings,” she said.
For more information:
Ileen Gilbert, MD, can be reached at ileen.gilbert@astrazeneca.com.