Daily inhaled corticosteroids (ICS) have been the standard of care for asthma for decades but remain underused in real-world practice, partly due to steroid aversion and suboptimal communication between patients and providers. Recently, four seminal trials have led to a major change in the asthma treatment paradigm, showing that as-needed ICS-formoterol carries a similar benefit to daily ICS therapy for reduction of severe asthma exacerbations. While as-needed ICS-formoterol is additionally associated with >80% reduced cumulative ICS exposure (vs. daily ICS), it also comes with a cost of increased day-to-day asthma symptoms. Given these pros and cons that directly impact the patient, it has become even more critical to gauge patient preferences in choosing the best treatment for mild asthma.
We aimed to design a patient decision aid (DA) to help asthma patients and their primary care providers to discuss first-line mild asthma medication options in order to mutually agree upon an evidence- and preference-based decision regarding asthma therapy.
Following the International Patient Decision Aid Standards, we assembled a steering committee comprising of clinical, knowledge translation, and DA experts, and primary care and patient representatives to determine the index decision targeted by the DA and which options and outcomes to present in the DA (the latter based on a literature review). We then worked with a graphic designer to format a paper-based prototype of the DA (based on the Ottawa Personal Decision Guide). To optimize DA content and format, we plan to embark upon a rapid-cycle design process. This process entails: (1) DA acceptability, usability, and content testing in sequential rounds, each comprised of one focus group with 3 to 5 asthma patients and 1 interview with a primary care physician; (2) qualitative analysis of focus group and interview findings after each round; (3) corresponding modifications to the DA; and (4) re-testing of the modified DA in the next round. This process continues until no new critical acceptability-, usability-, and content-related issues emerge (i.e. stopping criteria reached). A final summative qualitative content analysis will be performed to determine overall user preferences.
The paper-based DA was designed for patients having asthma symptoms 2 or more times per month, with the following index decision: “Which asthma medication should you take to best manage your asthma?” Medication options included: (a) as-needed rescue medication only (given observational studies showing that this is what many patients do, despite recommendations for ICS); (b) as-needed ICS-formoterol combination; and (c) daily ICS + as-needed rescue medication. Clinical outcomes included: weeks with well-controlled asthma, rate of severe exacerbations, lung function, airway inflammation, and cumulative ICS exposure. The rapid-cycle design process is currently underway; results will be presented at the meeting.
We are co-designing a user-centered DA prototype to assist patients and primary care providers in sharing decisions about medications for mild asthma. Next, we will embed this DA into the Electronic Asthma Management System (eAMS) in order to address known barriers to shared decision-making and DA uptake, and then evaluate its real-world uptake and impact.