ADAPT-NC FLOW DisseminationAsthma Shared Decision Making (SDM)

Comparing Traditional and Participatory Dissemination of a

Shared Decision Making Intervention

Background

• Asthma is a complex chronic illness that is difficult to manage, particularly in disadvantaged populations with multiple barriers– Disparities in health outcomes– Poor medical compliance– High healthcare costs

• Failure to address patients’ individual goals and preferences may contribute to non-adherence

• Shared decision making (SDM) is valuable tool in self-management

Shared Decision Making

• SDM is a process based on principles of motivational interviewing that takes into account patients’ individual treatment goals and medication preferences, aiming to promote adherence and improve outcomes– The patient provides information on values, preferences,

lifestyle, beliefs, and current knowledge about the illness and its treatment

– The physician provides all relevant information, benefits and risks of various treatments, and potential effects on the patient's psychological and social well being

ACE Study

• Carolinas HealthCare System• Charlotte, NC• Department of Family Medicine• September 2010 – September 2013

ACE Study Objectives

• Develop a SDM intervention for patients with asthma using a participatory approach

• Improve outcomes by implementing SDM asthma clinics

• Advance chronic disease self-management of asthma through SDM

ACE Study Setting

• 6 PBRN primary care practices within Carolinas HealthCare System (CHS) across Charlotte, NC

• “Safety net” practices serving a predominantly Medicaid, Medicare and indigent population, encompassing the majority of the community’s poorly controlled asthma patients

• English- and Spanish-speaking pediatric, adolescent, and adult patients with persistent and/or poorly controlled asthma

ACE Study Clinics and Disease Distribution

ACE Study Sites• North Park Family (NP)

• Largely Hispanic and pediatric

• Teen Health Connection (THC)• Adolescent sub-specialty

• Biddle Point Family (BP)• Urban, predominantly African American

• Elizabeth Family Medicine (EFM)• Residency program, >50% African American

• Myers Park Pediatrics (MPP)• Residency program, high proportion Hispanic

• Myers Park Internal Medicine (MPIM)• Residency program, medically complex

The SDM Team

• Physician champion(s)• Practice manager• Nurse manager• Registration supervisor• ± Interpreter• Health coach(es)– Pharmacist, nurse (RN, LPN), care coordinator,

patient educator

ACE Study Methods• A participatory approach engaged core members from each practice,

including a physician champion• Monthly SDM advisory board meetings

– Location rotated to each site to foster inclusiveness • Providers, staff and health coaches were trained in SDM using an

evidence-based decision support toolkit– ACE Study decision support tools were developed by the Better Outcomes of

Asthma Treatment (BOAT) study group and revised based on the 2007 NIH asthma guidelines• Adapted for pediatrics, Hispanics, low health literacy

• The resulting asthma SDM half-day clinics were individualized to capture each practice’s unique culture, focusing on sustainability and productivity

• Focus groups with patients and providers were held for process improvement and to provide feedback

Set the Stage• Establish rapport• Describe shared decision making

approach

Gather Patient Information• Asthma symptoms and perceptions of

control• Medication use• Alternative treatments used• Environmental triggers• Identify patient goals

Provide Information (Health Coach)• Determine current understanding of

asthma• Review what asthma is and how it is

treated• Confirm comprehension of information

Negotiation (Health Coach)• Summarize patient goals and information• Review spirometry results with patient• Provide assessment of patient’s current

symptom control and treatment level • Determine current asthma severity level • Work with patient to define medication

preferences• Discuss regimen options• Negotiate a decision about treatment

Wrap Up (PCP)• Physical examination• Teach back• Update Asthma Health Maintenance in

the EMR• Write/Fax prescription(s)• Review proper inhaler technique • Give Asthma Action Plan and diary • Set up follow up appointment

ACE Study Outcomes Measured• Patients’ perception of SDM using a short survey question• Electronic medical record (EMR) documentation of

asthma appropriate care measures: – Flu vaccination– Symptoms assessment– Controller medication use

• Asthma-related emergency room (ER) visits and hospitalizations

• Oral steroid prescription orders for acute exacerbations pre- and post-intervention

ACE Study Results

• Since June 2011, 258 English- and Spanish-speaking pediatric, adolescent, and adult patients with persistent and/or poorly controlled asthma have participated in 358 SDM half-day clinic visits

Of the 319 patients surveyed to date, 86% reported the decision was sharedbetween the patient and provider, with 73% stating it was shared equally

SDM Survey Responses: Who Made the Treatment Decision?

n = 319

Provider Alone11%

Mostly Provider7%

Patient and Provider Equally

73%

Mostly Patient6%

Patient Alone3%

SDM Survey Responses: Who Made the Treatment Decision?

n = 319

EMR documentation of all asthma appropriate care measures has improved from baseline

Baseline Q1 2011 Q2 2011 Q3 2011 Q4 2011 Q1 2012 Q2 2012 Q3 2012 Q4 2012 Q1 2013 Q2 20130.0

20.0

40.0

60.0

80.0

100.0

120.0

CHS Faculty Physicians NetworkAsthma Appropriate Care Measures

Perc

ent

First Clinic Kick Off

Change in Asthma ER Visits

SDM Toolkit (n=212)**

SDM Exposed (n=1236)*

Control (n=8159)

0%

5%

10%

15%

20%

15.6%

8.0%

1.8%

9.0%

6.3%

1.7%

Prior 6 months Post 6 months

Perc

ent o

f pati

ents

↓42% ↓21% ↓6%

*p<0.10; **p<0.05

Change in Asthma Hospitalizations

SDM Toolkit (n=212)

SDM Exposed (n=1236)**

Control (n=8159)**-5%

0%

5%

10%

15%

20%

3.8%6.7%

1.0%1.9%3.5%

0.7%

Prior 6 months Post 6 months

Perc

ent o

f pati

ents

↓50% ↓48% ↓30%

*p<0.10; **p<0.05

Change in Oral Steroid Prescription Orders

SDM Toolkit (n=212)*

SDM Exposed (n=1236)**

Control (n=8159)**

0%

10%

20%

30%

40%

50%

25.9%18.1% 20.5%19.8%

15.1%18.5%

Prior 6 months Post 6 months

Perc

ent o

f pati

ents ↓24% ↓17% ↓10%

*p<0.10; **p<0.05

Change in Oral Steroid Prescription Orders

SDM Toolkit (n=237)**

SDM Exposed (n=1267)**

Control (n=8303)**

0%

10%

20%

30%

40%

19.4%

12.3% 14.8%10.5% 8.1%

11.0%

Prior 3 months Post 3 months

Perc

ent o

f pati

ents ↓46% ↓34% ↓26%

*p<0.10; **p<0.05

• “… It’s very educational… It helped me a lot, it helped me a lot.”

• “You freely can ask questions and they answer them and they show you things and they [tell] you about the breathing and the mucus building up in you lungs and you know it helped… it helped me.”

• “… I did learn something because I used albuterol and Qvar for my asthma and… didn’t know when to use which one… and when I went there they told me that I was not using the right medication at the right time… But then when they taught me how to use it, I started to feel much better later on.”

Qualitative Data:Quotes from Patient Focus Groups

ACE Study Conclusions

• Reductions in ER visits, hospitalizations and oral steroid prescription orders for acute exacerbations were seen in a largely underserved population of uncontrolled asthmatics within CHS in Charlotte, NC

• SDM is a valuable tool in chronic disease self-management that is associated with improved asthma-related outcomes

• Further dissemination of the intervention could positively affect the asthma community locally, regionally and even nationally

Comparing Traditional and Participatory Dissemination of a

Shared Decision Making Intervention

FLOW Dissemination

• Facilitator-Led Participant Owned (FLOW) Approach to Dissemination

• This approach to dissemination allows clinics some freedom to tailor the SDM Toolkit and training process for their specific environment and patient population while maintaining fidelity of certain key elements that are felt to be essential for success. The expertise of the trained Practice Facilitator will help guide the process of implementation at the practice level.