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Medication adherence among adult asthma patients : investigating the role for shared decision-making Pollard, Samantha 2017

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 !MEDICATION*ADHERENCE*AMONG*ADULT*ASTHMA*PATIENTS:*INVESTIGATING*THE*ROLE*FOR*SHARED*DECISION5MAKING!*by!!Samantha!Pollard!MSc.,!McMaster!University,!2010!*!!A!THESIS!SUBMITTED!IN!PARTIAL!FULFILLMENT!OF!THE!REQUIREMENTS!FOR!THE!DEGREE!OF!!DOCTOR!OF!PHILOSOPHY!!in!!THE!FACULTY!OF!GRADUATE!AND!POSTDOCTORAL!STUDIES!!(Population!and!Public!Health)!!!!THE!UNIVERSITY!OF!BRITISH!COLUMBIA!(Vancouver)!!! August!2017!!! !©!Samantha!Pollard,!2017! ii Abstract*Background:!Shared!decisionSmaking!(SDM)!has!been!suggested!as!a!means!to!improve!communication!between!patients!and!their!healthcare!providers,!with!the!purposes!of!improving!multiple!asthmaSrelated!health!outcomes.!Despite!mounting!evidence!that!suggests!potential!benefits!attributable!to!SDM,!clinical!uptake!has!been!slow.!!*Objectives:!!The!purpose!of!this!dissertation!is!to!ascertain!the!role!of!SDM!in!asthma!management,!to!determine!the!extent!to!which!SDM!is!currently!being!implemented!into!regular!asthma!care,!and!to!suggest!clinical!implementation!strategies!that!may!facilitate!SDM!implementation!in!BC.!*Methods:!This!project!consists!of!a)!a!systematic!review!of!physician!attitudes!toward!SDM,!b)!a!comprehensive!narrative!literature!review!to!describe!the!proposed!role!of!SDM!in!asthma,!c)!a!population!level!analysis!to!explore!variation!in!adherence!to!controller!medication,!as!well!as!d)!an!online!survey!of!117!adult!asthma!patients!living!in!BC.!!*Results:!Results!of!this!work!show!that!in!general!a)!physicians!support!the!use!of!SDM!in!various!clinical!practice!scenarios,!b)!there!is!a!clear!role!for!SDM!in!treating!asthma!patients!with!the!goal!of!reducing!the!burden!of!controller!medication!nonSadherence,!and!c)!adherence!to!controller!medications!is!subSoptimal,!with!little!variation!being!explained!at!the!population!level.!The!patient!survey!(d)!provided! iii additional!insight!into!this!research!agenda!by!showing!that!while!patients!prefer!to!be!actively!involved!in!treatment!decisionSmaking,!there!is!substantial!variation!in!the!extent!to!which!asthma!patients!are!being!engaged!in!their!care.!Furthermore,!multiple!predictors!of!adherence!that!can!be!addressed!during!the!clinical!encounter!(e.g.!medicationSrelated!concerns)!were!shown!to!impact!selfSreported!treatment!adherence.!!!*Conclusions:*The!results!of!this!project!provide!further!support!for!the!use!of!SDM!in!regular!care!of!asthma!patients.!I!conclude!by!highlighting!the!importance!of!addressing!issues!related!to!adherence!in!an!individual!and!ongoing!basis,!the!value!of!increasing!awareness!about!the!use!of!SDM,!and!the!potentially!valuable!role!of!engaging!nonSphysician!caregivers!in!future!SDM!implementation!efforts.!These!findings!may!guide!future!research!investigations!regarding!SDM!uptake!and!efforts!to!reduce!the!disease!burden!of!asthma.!! *  iv Lay*summary*Background:!Asthma!is!a!common!chronic!disease!that!affects!21!million!North!Americans.!When!asthma!patients!with!moderate!to!severe!asthma!do!not!take!their!medication!regularly,!the!risk!of!poor!health!outcomes!increases.!Engaging!patients!in!decisions!about!their!medication!through!shared!decisionSmaking!(SDM)!may!encourage!patients!to!follow!their!medication!plan.!!!Objectives:!To!determine!the!potential!role!for!SDM!in!asthma.!!!Methods:!This!thesis!consists!of!two!literature!reviews,!an!analysis!of!pharmacy!records,!and!an!online!survey!of!adult!asthma!patients!in!BC.!!Results:!Both!doctors!and!asthma!patients!support!SDM,!but!there!is!no!common!way!to!involve!asthma!patients!in!their!care.!Survey!results!show!that!more!communication!between!doctors!and!their!patients!may!support!patients!to!follow!their!treatment!plan.!!!!Conclusions:!Results!of!this!project!provide!support!for!the!use!of!SDM!in!clinical!care!of!asthma!patients,!and!suggest!recommendations!for!implementation!plans.!!! *  v Preface**Chapters!1!and!7!are!based!on!work!conducted!at!The!Centre!of!Clinical!Epidemiology!and!Evaluation.!I!was!responsible!for!writing!the!chapters.!!!Chapter!2!is!based!on!the!work!conducted!at!The!Centre!of!Clinical!Epidemiology!and!Evaluation.!I!was!responsible!for!identifying!the!research!question,!developing!and!piloting!the!search!strategy,!running!the!search,!analysis,!and!drafting!of!the!manuscript.!Stirling!Bryan!(SB)!and!Nick!Bansback!(NB)!were!involved!in!the!title/abstract!and!full!text!review!phase,!as!well!as!synthesizing!the!results.!A!version!of!chapter!2!is!published!in!Patient!Education!and!Counseling.(1)!!Chapter!3!is!based!on!work!conducted!at!The!Centre!of!Clinical!Epidemiology!and!Evaluation.!I!developed!the!research!questions!and!drafted!the!chapter.!SB,!NB!and!J!Mark!Fitzgerald!reviewed!and!provided!initial!comments!for!revision!of!each!draft!of!the!manuscript.!A!version!of!chapter!3!is!published!in!Allergy.(2)!!Chapter!4!is!based!on!the!work!conducted!at!the!Centre!for!Outcomes!Research!and!Evaluation.!I!developed!the!research!question,!wrote!and!ran!all!analytic!SAS!code,!interpreted!the!results!and!drafted!the!chapter.!The!data!table!used!for!analysis!was!built!by!Dr.!Zafar!Zafari!and!Dr.!Wenjia!Chen.!University!of!BC!Human!Ethics!Certificate:!H08S01287.!!  vi !All!research!was!conducted!at!The!Centre!of!Clinical!Epidemiology!and!Evaluation!and!VGH’s!Gordon!and!Leslie!Diamond!Healthcare!Centre.!I!developed!the!study!documents.!I!wrote!all!R!code!and!conducted!all!of!the!data!analysis.!Statistical!consultation!was!provided!by!Dr.!Penny!Brasher!and!Shannon!Erdelyi.!Ethical!approval!for!chapters!5!and!6!were!provided!by!The!University!of!British!Columbia!Clinical!Research!Ethics!Board!and!Vancouver!Coastal!Health!Research!Institute!Ethics!Board:!H10S01542.!! *  vii Table*of*contents*Abstract*.......................................................................................................................................*ii!Lay*summary*............................................................................................................................*iv!Preface*.........................................................................................................................................*v!Table*of*contents*...................................................................................................................*vii!List*of*tables*..........................................................................................................................*xiii!List*of*figures*...........................................................................................................................*xv!List*of*abbreviations*............................................................................................................*xvi!Acknowledgements*...........................................................................................................*xviii!Chapter*1:*Introduction*.........................................................................................................*1!1.1*Introduction*................................................................................................................................*1!1.1.2!What!is!shared!decisionSmaking?!.................................................................................................!1!1.1.3!Rationale!for!the!current!research!...............................................................................................!3!1.2*Research*objectives*..................................................................................................................*7!1.3*Research*methods*and*results*..............................................................................................*7!1.3.1!Clinical!implications!..........................................................................................................................!10!1.4*Conclusions*................................................................................................................................*11!Chapter*2:*Physician*attitudes*toward*shared*decision5making:*a*systematic*review*........................................................................................................................................*13!2.1*Introduction*..............................................................................................................................*13!2.2*Methods*.......................................................................................................................................*16!  viii 2.2.1!Search!strategy!development!.......................................................................................................!16!2.2.2!Selection!criteria!................................................................................................................................!17!2.2.3!Research!objectives!..........................................................................................................................!17!2.2.4!Article!selection!..................................................................................................................................!18!2.2.5!Data!abstraction!.................................................................................................................................!18!2.2.6!Outcome!reporting!............................................................................................................................!19!2.3*Results*.........................................................................................................................................*21!2.3.1!Search!results!......................................................................................................................................!21!2.3.2!Characteristics!of!included!studies!............................................................................................!21!2.3.3!Physician!preferences!for!patient!participation!in!decisionSmaking!(research!objective!1)!......................................................................................................................................................!36!2.3.4!Factors!associated!with!variation!in!physician!support!for!SDM!(research!objective!2)!......................................................................................................................................................!37!2.4*Discussion*and*conclusion*....................................................................................................*49!2.4.1!Summary!of!findings!.........................................................................................................................!49!2.4.2!Limitations!............................................................................................................................................!50!2.4.3!Conclusions!...........................................................................................................................................!51!2.4.4!Implications!..........................................................................................................................................!52!Chapter*3:*The*burden*of*non5adherence*among*adults*with*asthma:*What*is*the*role*for*shared*decision5making?*.............................................................................*54!3.1*Introduction*..............................................................................................................................*54!3.2*The*burden*of*non5adherence*to*asthma*medications*...............................................*56!3.3*Proposed*solutions*..................................................................................................................*59!3.3.1!Theoretical!framework!....................................................................................................................!63!  ix 3.4*Implementation*challenges*..................................................................................................*74!3.5*Research*implications*............................................................................................................*75!Chapter*4:*Variation*in*adherence*to*controller*medications*in*British*Columbia:*A*population5based*analysis*.........................................................................*77!4.1*Background*................................................................................................................................*77!4.1.1!Evidence!gaps!......................................................................................................................................!77!4.1.2!Research!objectives!..........................................................................................................................!86!4.2*Methods*.......................................................................................................................................*87!4.2.1!Patient!cohort!......................................................................................................................................!87!4.1.2!Statistical!methods!............................................................................................................................!89!4.3*Results*.........................................................................................................................................*93!4.3.1!Characteristics!of!the!study!sample!...........................................................................................!93!4.3.2!Descriptive!statistics!for!explanatory!variables!...................................................................!94!4.3.3!ReScategorization!of!continuous!variables!to!facilitate!bivariate!and!multivariate!analysis!...........................................................................................................................................................!101!4.3.4!Research!question!1:!What!are!the!characteristics!of!asthma!patients!who!do!not!fill!their!controller!prescriptions?!......................................................................................................!102!4.3.5!Research!question!2:!Which!demographic!and!disease!related!factors!explain!variation!in!adherence!to!controller!medication?!.......................................................................!105!4.3.6!Research!question!3:!Does!adherence!to!controller!medication!vary!by!calendar!month?!............................................................................................................................................................!109!4.4*Discussion*...............................................................................................................................*113!4.4.1!Summary!of!findings!......................................................................................................................!113!4.4.2!Strengths!.............................................................................................................................................!119!  x 4.4.3!Limitations!.........................................................................................................................................!120!4.4.4!Implications!and!future!research!.............................................................................................!121!Chapter*5:*A*survey*to*describe*the*state*of*shared*decision*making*in*asthma*management:*Consent*process,*recruitment*procedures*and*participant*demographics*......................................................................................................................*124!5.1*Background*.............................................................................................................................*124!5.2*Patient*population*................................................................................................................*125!5.3*Recruitment*and*consent*procedures*...........................................................................*126!5.4*Privacy*and*confidentiality*of*study*data*.....................................................................*130!5.5*Participant*demographics*.................................................................................................*130!5.6*Generalizability*of*study*sample*.....................................................................................*133!5.7*Strengths*and*limitations*of*recruitment*methods*...................................................*136!5.7.1!Strengths!.............................................................................................................................................!136!5.7.2!Limitations!and!challenges!.........................................................................................................!137!Chapter*6:*Asthma*controller*adherence*and*the*role*for*patient*engagement:*survey*development*and*results*...................................................................................*141!6.1*Background*.............................................................................................................................*141!6.1.1!Objectives!...........................................................................................................................................!141!6.2*Methods*....................................................................................................................................*146!6.2.1!Survey!development!......................................................................................................................!146!6.2.2!Analytic!methods!............................................................................................................................!152!6.3*Results*......................................................................................................................................*153!6.3.1!Descriptive!statistics!for!predictor!variables!.....................................................................!154!  xi 6.3.2!What!role!do!asthma!patients!prefer!to!take!in!the!decisionSmaking!process?!..!157!6.3.3!What!factors!related!to!patientSphysician!communication!and!education!explain!adherence?!....................................................................................................................................................!164!6.3.4!To!what!extent!do!asthma!patients!recall!previous!exposure!to!SDM?!..................!173!6.4*Discussion*...............................................................................................................................*178!6.4.1!Role!preferences!..............................................................................................................................!178!6.4.2!Controller!medication!adherence!............................................................................................!179!6.4.3!Perceived!exposure!to!SDM!........................................................................................................!184!6.4.4!Strengths!.............................................................................................................................................!185!6.4.5!Limitations!.........................................................................................................................................!186!6.4.6!Implications!.......................................................................................................................................!192!Chapter*7:*Conclusions*.....................................................................................................*197!7.1*Introduction*...........................................................................................................................*197!7.2*Summary*of*main*research*findings*..............................................................................*198!7.2.1!Support!for!SDM!..............................................................................................................................!199!7.2.2!Establishing!the!role!for!SDM!in!asthma!...............................................................................!199!7.2.3!Asthma!care!in!BC!...........................................................................................................................!200!7.3*Strengths*..................................................................................................................................*201!7.4*Limitations*..............................................................................................................................*202!7.5*Knowledge*translation*........................................................................................................*202!7.5.1.!Efforts!to!increase!adherence!among!asthma!patients!are!likely!to!benefit!from!individualized!and!ongoing!discussions,!through!the!use!of!SDM!interventions!...........!204!  xii 7.5.2!The!use!of!both!physician!and!nonSphysician!care!givers!in!ascertaining!patients’!disease!and!medicationSrelated!inaccurate!beliefs!or!concerns!may!help!to!increase!treatment!adherence!................................................................................................................................!205!7.5.3!Awareness!of!the!potential!benefits!associated!with!SDM!may!help!to!increase!SDM!uptake!and!improve!health!outcomes!....................................................................................!206!7.6*Furthering*this*research*agenda*.....................................................................................*209!7.7*Conclusions*.............................................................................................................................*210!Bibliography*.........................................................................................................................*211!Appendices*...........................................................................................................................*257!Appendix*A:*Medline*search*strategy*...................................................................................*257!Appendix*B:*PRISMA*2009*flow*diagram*(324)*.................................................................*259!Appendix*C:*Studies*that*have*used*administrative*data*sources*to*address*us*of*asthma*controller*medication*use*.........................................................................................*260!Appendix*D:*Impact*of*participant*follow*up*.....................................................................*263!Appendix*E:*Survey*variable*definitions*..............................................................................*264!Appendix*F:*Construction*of*select*variables*based*on*pre5validated*instruments*............................................................................................................................................................*272!Appendix*G:*Re5definition*of*selected*variables*for*the*bivariate*and*multivariate*analysis,*based*on*original*variable*distribution*.............................................................*274!Appendix*H:*Missing*data*..........................................................................................................*276!Appendix*I:*Multivariate*linear*regression*diagnostics*.................................................*277!Appendix*J:*Multivariate*logistic*regression*diagnostics*...............................................*279!! *  xiii List*of*tables*Table!2.1! Summary!of!studies!reporting!quantitative!results…………………………24!Table!2.2!! Summary!of!studies!reporting!qualitative!results…………………………...33!Table!2.3! Factors!associated!with!support!or!lack!of!support!for!patient!!! ! involvement!in!decisionSmaking!from!the!physician!perspective…….48!Table!3.1!! Physician!competencies!for!SDM!as!proposed!by!Towle!et!al.!…………61!Table!4.1!! Factors!independently!associated!with!adherence!and!nonSadherence!!to!asthma!controller!medication…………………………………………………...79!Table!4.2!! Primary!data!collection!studies!utilizing!administrative!data!explicitly!!! ! assessing!predictors!of!adherence!to!controller!medication……………82!Table!4.3!! Descriptive!statistics!for!continuous!variables………………………………..99!Table!4.4! Descriptive!statistics!for!categorical!variables……………………………...100!Table!4.5!!! Unadjusted!and!adjusted!logistic!regression!to!determine!differences!!! ! between!patients!with!a!PDC!=!0!and!PDC!>!0……………………………...103!Table!4.6:!! Unadjusted!and!adjusted!parametric!bootstrapped!linear!regression!!! ! to!explain!variation!in!adherence!to!controller!medication…………...107!Table!4.7!! Percentage!of!patients!having!filled!a!controller!by!calendar!month!!! ! according!to!the!number!of!ICS!prescriptions!filled!in!the!12Smonth!!! ! period!prior!to!the!index!date……………………………………………………...110!Table!4.8! Percentage!of!patients!having!filled!a!controller!by!calendar!month!!! ! according!to!disease!severity……………………………………………………….112!Table!5.1!! Participant!demographics……………………………………………………………132!  xiv Table!5.2!! Generalizability!of!the!survey!sample…………………………………………..135!Table!6.1!!! Primary!data!collection!studies!assessing!associations!between!SDM!!! ! and!treatment!adherence…………………………………………………………….144!Table!6.2!! Unadjusted!and!adjusted!linear!regression!of!role!preference!(active!v.!!! ! shared)!for!asthma!treatment!decisionSmaking……………………………161!Table!6.3!! Unadjusted!and!adjusted!logistic!regression…………………………...……165!Table!6.4!! Unadjusted!logistic!regression!for!patients!having!visited!an!asthma!!! ! educator……………………………………………………………………………………..170!Table!6.5!! Previous!exposure!to!SDM!for!current!controller!medication(s)..….!175!!!!!!!!!!!*! *  xv List*of*figures*Figure!3.1! Theoretical!framework………………………………………………………….………65!Figure!4.1! !Study!process………………………………………………………………………………88!Figure!4.2! Study!flow!diagram……………………………………………………………………….94!Figure!4.3! Continuity!of!Care!Index!(GP)………………………………………………………...96!Figure!4.4! Continuity!of!Care!Index!(Asthma!Specialists)………………………………..97!Figure!4.5! Charlson!comorbidity!index!………………………………………………………….98!Figure!4.6! Distribution!of!year!of!cohort!entry………………………………………………..99!Figure!4.7! Distribution!of!Adherence!as!measured!by!PDC……………………………101!Figure!4.8! Percentage!of!patients!having!filled!a!controller!by!calendar!month,!!! ! according!to!disease!severity……………………………………………………….113!Figure!5.1! Participant!recruitment……………………………………………………………….129!Figure!6.1! PSDM!“problem!solving”!and!“decisionSmaking”!score!distribution.160!Figure!6.2! Adherence!and!exposure!to!SDM………………………………………………….176!Figure!6.3! Collaborate!scores!by!DM!preference…………………………………………...177!!! !  xvi List*of*abbreviations*AAAQ:!Adult!Asthma!Adherence!Questionnaire!!ACT:!asthma!control!test!!AOR:!Adjusted!odds!ratio!!BC:!British!Columbia!!CCI:!Charleston!comorbidity!index!!CDM:!Clinical!decision!making!!CoC:!Continuity!of!Care!!COPD:!Chronic!obstructive!pulmonary!disease!!DM:!decisionSmaking!!FDA:!Food!and!Drug!Administration!!GP:!general!practitioner!!ICS:!inhaled!corticosteroid!!KT:!Knowledge!translation!!LABA:!long!acting!beta!agonists!!LTRA:!Leukotriene!receptor!antagonist!!MI:!multiple!imputation!!MPR:!medication!possession!ratio!!NS:!nonSsignificant!!OR:!Odds!ratio!!PCC:!patientScentered!care!!PDA:!Patient!decision!aid!!  xvii PDC:!proportion!of!days!covered!!PS:!Problem!solving!!PSDM:!Problem!solving!decisionSmaking!(scale)!!RCT:!randomized!controlled!trial!!SDM:!shared!decision!making!!SE:!standard!error!!SES:!socioSeconomic!status!!SNS:!Subjective!numeracy!scale!!SP:!specialist!!95%!CI:!95%!confidence!interval!!!!!! *  xviii Acknowledgements*I!would!like!to!acknowledge!the!following!individuals!for!their!contribution!to!this!dissertation.!!Dr.!Stirling!Bryan!and!Dr.!Nick!Bansback!for!their!support,!guidance!and!patience!throughout!the!past!6!years.!!!Dr.!Larry!Lynd,!Dr.!Linda!Li,!Dr.!Mohsen!Sadatsafavi,!and!Dr.!Mark!Fitzgerald!for!their!participation!on!my!dissertation!committee,!and!for!the!valuable!feedback!that!they!provided!throughout!the!development!of!the!thesis.!!Mimi!Doyle!Waters!for!her!assistance!in!the!development!of!the!systematic!review!search!strategy.!!Dr.!Wenjia!Chen!and!Dr.!Zafar!Zafari!for!their!assistance!with!chapter!4.!!Roxanne!Rousseau,!Dr.!Nitya!Suparakash,!Suzanne!Richardson,!Pia!Ganz,!Dr.!Penny!Brasher!and!Shannon!Erdelyi!for!their!assistance!with!chapters!5!and!6.!!* *  xix Dedication*!For!my!mother!and!my!husband.!!Thank!you!for!your!endless!support!and!encouragement.!!! *  1 Chapter*1:*Introduction*1.1*Introduction*Support!for!the!prevailing!model!of!the!clinical!encounter!is!experiencing!a!shift!from!paternalism!–!wherein!physicians!play!an!authoritative!role!in!the!clinical!encounter!S!to!a!patientScentered!care!(PCC)!model!where!patients!play!an!active!role!in!the!decisionSmaking!processes.!Multiple!healthcare!systems!have!reported!support!for!more!active!involvement!of!patients!in!the!care!process.(3–5)!The!Institute!of!Medicine!defines!PCC!as!“providing!care!that!is!respectful!of,!and!responsive!to,!individual!patient!preference,!needs,!and!values,!and!ensuring!that!patient!values!guide!all!clinical!decisions”[(4)!p.!3].!While!first!calling!for!increased!communication!and!partnership!between!patients!and!their!physicians,!PCC!recognizes!the!value!of!incorporating!what!matters!most!to!patients,!in!making!decisions!about!their!care.(6)!!!1.1.2*What*is*shared*decision5making?*One!process!for!implementing!a!component!of!PCC!is!shared!decisionSmaking!(SDM).!Shared!decisionSmaking!requires!the!active!participation!of!both!patients!and!their!physicians!at!multiple!stages!of!the!healthcare!encounter.!Specifically,!patients!and!physicians!must!acknowledge!that!there!is!a!decision!to!be!made,!exchange!information,!weigh!the!risks!and!benefits!of!treatment!options,!and!agree!on!the!final!treatment!decision.(7,8)!While!physicians!bring!expert!content!  2 knowledge!to!the!encounter,!patients!bring!information!about!their!personal!values!and!preferences.!What!a!patient!views!as!important!in!determining!the!best!treatment!option!may!differ!from!what!the!physician!assumes!is!important!to!the!patient.(9)!When!both!parties!are!able!to!communicate!about!these!issues,!patients!and!their!physicians!can!then!discuss!various!treatment!options!in!light!of!the!accompanying!risks!and!benefits.!!The!concept!of!SDM!was!formally!introduced!by!Charles!et!al.!in!1997!and!again!in!1999.(7,10)!However,!throughout!the!1980s!and!early!1990’s,!the!value!of!engaging!the!individual!patient!in!decisions!about!his!or!her!healthcare!was!increasingly!acknowledged.(11,12)!!!Shared!decisionSmaking!frequently!garners!support!in!“preferenceSsensitive”!clinical!scenarios!where!multiple!acceptable!treatment!options!exist,!and!professional!opinion!may!vary!with!regard!to!the!optimal!choice.(13,14)As!such,!the!patient’s!personal!values!and!preferences!play!an!important!role!in!determining!the!treatment!plan.(8)Decision!topics!may!include!but!are!not!limited!to!advance!care!planning!for!dementia!patients,(15)!delayed!versus!immediate!breast!reconstruction!following!mastectomy,(16)!controller!treatment!options!for!patients!with!moderate!to!severe!asthma,(17)!prostate!cancer!screening,(18)!breast!conserving!surgery!versus!mastectomy,(19)!mental!health,(20)!as!well!as!the!decision!to!prescribe!antibiotics!for!acute!respiratory!infection.(21)!  3 !Current!evidence!links!SDM!and!decision!support!techniques!with!broadly!positive!patientSreported!outcomes!such!as!increased!satisfaction,!knowledge!and!trust!in!healthcare!providers,!and!decreased!decisional!conflict.!(17,22–26)!!!Although!highSquality!evidence!suggests!that!SDM!may!improve!various!outcomes,!clinical!uptake!has!been!sparse.(27)!Furthermore,!additional!research!is!required!to!determine!which!SDM!interventions!are!the!most!highly!effective!and!in!which!settings.(8)!!!1.1.3*Rationale*for*the*current*research*With!increased!attention!being!paid!to!patient!engagement!in!healthcare,!but!a!corresponding!lack!of!implementation!into!clinical!practice,!further!attention!is!required!to!recommend!strategies!to!promote!clinical!uptake.!Here!I!seek!to!determine!the!state!of!SDM!within!asthma!care!and!to!determine!potential!avenues!for!future!implementation!efforts,!specifically!focused!on!reducing!the!burden!of!asthma!through!a!reduction!in!treatment!nonSadherence.!!The!primary!research!questions!answered!by!this!thesis!are!informed!by!comprehensive!reviews!of!the!literature!that!appear!in!chapters!2!and!3.!These!background!chapters!ascertain!the!extent!to!which!physicians!support!the!use!of!SDM,!determine!what!clinical!scenarios!garner!the!most!support!for!SDM!by!physicians,!and!finally!illustrate!the!proposed!role!for!SDM!in!asthma!management.!  4 The!following!will!briefly!describe!the!methods!and!results!of!chapters!2!and!3,!and!to!describe!how!those!chapters!inform!the!work!reported!in!chapters!4!to!6.!!1.1.3.1$Identifying$variation$in$support$for$SDM$Physician!support!is!a!necessary!requirement!for!the!successful!implementation!of!SDM;!however,!uncertainty!exists!as!to!the!extent!to!which!physicians!endorse!the!use!of!SDM!in!their!current!practices!and!the!variability!of!such!support.!Furthermore,!several!barriers!have!been!suggested!to!explain!why!SDM!uptake!has!been!so!sparse.!Barriers!include!but!are!not!limited!to!concerns!about!the!length!of!time!required!for!an!SDM!encounter,!physicians’!perceptions!of!appropriateness!given!patient!characteristics,!and!the!clinical!context.(27)!Chapter!2!consists!of!a!systematic!review!that!provides!comprehensive!groundwork!for!this!research!program,!by!exploring!the!extent!to!which!physicians!support!the!use!of!SDM.!!!The!results!of!the!systematic!review!(chapter!2)!show!that!physicians!most!frequently!support!SDM!in!“preferenceSsensitive”!scenarios!such!as!chronic!disease!management,!and!where!patients!are!both!willing!and!able!to!participate!in!the!decisionSmaking!process.!Lack!of!support!is!identified!when!clinical!practice!guidelines!clearly!recommended!a!specific!treatment!option,!and!when!the!patient!is!deemed!to!be!unable!or!unwilling!to!engage!in!the!decisionSmaking!process,!although!considerable!variation!was!found!across!clinical!scenarios,!physician!specialties,!and!patient!characteristics.!!  5 !1.1.3.2$Establishing$the$role$for$SDM$in$asthma$As!further!background!review,!chapter!3!provides!a!description!of!the!burden!of!asthma!and!the!proposed!role!of!SDM!in!reducing!some!of!the!negative!health!outcomes!associated!with!asthma!controller!nonSadherence.!I!propose!an!adapted!theoretical!framework!that!illustrates!the!pathways!that!link!SDM!with!intentional!and!nonSintentional!asthma!treatment!nonSadherence.(28)!The!framework!describes!various!predisposing!factors!related!to!adherence!motivation,!as!well!as!the!modifiable!and!nonSmodifiable!factors!that!both!prevent!or!promote!a!given!patient!from!adhering!to!his!or!her!treatment!plan.!The!framework!recognizes!that!SDM!functions!within!a!much!larger!set!of!predisposing!and!motivating!factors!that!impact!adherence,!while!acknowledging!that!individual!and!structural!barriers!can!impede!an!individual’s!ability!to!adhere,!despite!personal!motivation!to!adhere.!!!1.1.3.3$Asthma$as$an$appropriate$clinical$context$for$this$research$Following!the!results!of!the!systematic!review!(chapter!2)!as!well!as!the!review!on!the!nature!of!asthma!management!(chapter!3),!asthma!was!selected!as!a!case!study!for!this!thesis,!for!multiple!reasons.!!!First,!asthma!is!a!preferenceSsensitive!clinical!scenario!where!several!treatment!options!are!available!to!patients!with!varying!modes!of!administration,!dosage,!and!  6 risks!of!adverse!events,!making!asthma!an!ideal!clinical!context!within!which!to!explore!a!role!for!SDM.!!!Second,!adherence!to!asthma!medication!is!poor!and!linked!to!multiple!health!outcomes!such!as!exacerbations,!decreased!quality!of!life,!and!in!some!cases!death.!Therefore,!measureable!outcomes!exist!wherein!the!impact!of!SDM!can!be!investigated.!A!number!of!previous!and!ongoing!investigations!have!addressed!patientSreported!and!clinical!outcomes!associated!with!decision!aids!and!SDM!interventions,!specifically!within!the!context!of!asthma.(17,29–31)!!!Third,!evidence!suggests!the!presence!of!inaccurate!disease!and!medicationSrelated!beliefs,!decisionalSconflict,!and!concerns!that!are!inconsistent!with!those!of!their!physicians,!among!asthma!patients.(9,32–34)!This!suggests!the!need!for!increased!communication!between!patients!and!physicians!to!reduce!the!misdiagnosis!of!patient!preferences.(9)!Therefore,!there!is!a!clear!role!for!increased!communication!and!exchange!on!information!between!patients!and!their!physicians.!!!Finally,!given!the!preferenceSsensitive!nature!of!asthma!management,!asthma!is!a!clinical!scenario!wherein!physicians!are!likely!to!support!the!implementation!of!SDM!(chapter!2).!Therefore,!asthma!is!a!prime!clinical!context!to!explore!the!current!state!of!SDM.!Moreover,!if!we!see!limited!adoption!of!SDM!in!a!clinical!context!such!  7 as!asthma,!it!is!unlikely!that!SDM!or!components!of!SDM!are!being!utilized!in!other!clinical!contexts!where!there!is!likely!less!support!from!physicians.!!!1.2*Research*objectives*The!overarching!objectives!for!this!dissertation!are:!1.! To!describe!the!extent!to!which!physicians!support!the!implementation!of!SDM,!and!in!which!specific!clinical!contexts!(chapter!2);!2.! To!identify!the!role!for!SDM!within!the!context!of!asthma!(chapters!3!and!4);!3.! To!determine!the!extent!to!which!asthma!patients!desire!to!participate!in!their!decision!making!(chapters!5!and!6);!4.! To!explore!the!extent!to!which!SDM!and!specific!components!of!SDM!are!currently!being!implemented!in!asthma!clinical!care!in!BC,!and!the!characteristics!of!those!patients!who!are!more!likely!to!report!being!engaged!(chapters!5!and!6)!5.! To!determine!whether!current!selfSreported!adherence!may!be!associated!with!perceived!previous!exposure!to!SDM!(chapters!5!and!6)!1.3*Research*methods*and*results*Chapter!4!explores!factors!associated!with!adherence!among!adult!patients!with!asthma!in!BC.!The!objective!of!this!crossSsectional!analysis!is!to!estimate!the!burden!of!nonSadherence!among!adult!asthmatics!being!prescribed!controller!medication,!and!to!determine!the!extent!to!which!(administratively!collected)!patientSlevel!  8 factors!can!account!for!variation!in!treatment!adherence.!For!this!analysis,!adherence!is!defined!as!the!amount!of!controller!medication!prescriptions!filled!over!a!12Smonth!period.!The!results!provide!further!evidence!to!support!the!argument!that!adherence!is!a!complex!phenomenon!and!that!very!little!variation!can!be!explained!simply!by!looking!at!individual!demographic!variables!using!administratively!collected!data.!To!provide!a!more!comprehensive!explanation!of!variation!in!adherence,!future!research!should!look!closely!at!additional!predictors!of!nonSadherence!including!but!not!limited!to!asthmaSrelated!education!as!well!as!the!patientSphysician!relationship.!!!Chapter!5!describes!the!development!and!administration!of!an!online!survey!to!a!convenience!sample!from!within!a!previously!existing!cohort!of!adult!asthma!patients.!Specifically,!the!survey!work!sought!answers!to!the!following!five!research!questions:!o! What!role!do!asthma!patients!prefer!to!take!in!the!decisionSmaking!process?!(Thesis!Research!question!3)!o! What!factors!related!to!patientSphysician!communication!and!education!explain!adherence?!(Thesis!Research!question!5)!o! To!what!extent!do!asthma!patients!recall!previous!exposure!to!SDM?!(Thesis!research!question!4)!!o! Is!patientSreported!engagement!in!SDM!associated!with!adherence!to!controller!medication?!(Thesis!Research!question!5)!  9 o! Is!there!an!association!between!preferences!for!decisionSmaking!and!perceived!exposure!to!SDM?!!I!first!describe!the!development!and!recruitment!methods!used!for!the!online!survey!of!adult!asthma!patients!(chapter!5).!Chapter!6!then!describes!the!analyses!conducted!to!address!the!5!research!questions!listed!above.!Results!of!the!survey!(chapter!6)!show!that!patients!report!a!general!preference!for!being!involved!in!most!aspects!of!their!treatment!decisionSmaking!process.!Consistent!with!some!existing!evidence,!younger!patients!and!those!with!higher!income!are!more!likely!to!prefer!an!active!role!in!the!decision!making!process!(35)!!A!substantial!amount!of!variation!exists!in!terms!of!the!extent!to!which!participants!perceive!being!involved!in!the!decisionSmaking!process.!Results!of!the!multivariate!model!show!that!participants!with!previous!exposure!to!an!asthma!educator!are!more!likely!to!report!being!adherent!to!their!controller!medication.!Conversely,!participants!who!believe!that!their!asthma!does!not!warrant!controller!medication,!and!those!who!are!concerned!about!the!side!effects!of!their!medication,!are!more!likely!to!report!nonSadherence!to!their!current!controller!medication!(research!question.!!Chapter!7!discusses!the!strengths!and!weaknesses!of!the!thesis,!and!outlines!potential!clinical!implications!of!my!work,!and!proposes!next!steps!for!furthering!  10 this!research!agenda.!The!principal!clinical!implications!from!my!research!are!summarized!below.!!1.3.1*Clinical*implications*I!propose!three!clinical!implications!to!inform!care!delivery!and!research,!with!the!overarching!objective!of!reducing!the!burden!of!asthma!in!British!Columbia.!!Efforts'to'increase'adherence'among'asthma'patients'are'likely'to'benefit'from'individualized'and'ongoing'discussions,'through'the'use'of'SDM'interventions'''The!results!of!chapters!4!and!6!show!the!difficulty!in!capturing!a!complete!picture!of!determinants!of!medication!adherence.!More!specifically,!no!clear!subset!of!predictors!is!shown!to!have!a!strong!effect!on!variation!in!adherence.!These!results!suggest!not!that!it!is!a!frivolous!effort!to!try!to!explain!and!predict!adherence,!but!rather!that!efforts!geared!toward!improving!adherence!ought!to!be!considered!at!the!individual!level.!Therefore,!healthcare!providers!treating!asthma!patients!are!encouraged!to!discuss!on!an!individual!and!ongoing!basis!their!patients’!rationales!for!adherence!and!nonSadherence.!!The'use'of'both'physician'and'non>physician'care'givers'in'ascertaining'patients’'disease'and'medication>related'inaccurate'beliefs'or'concerns'may'help'to'increase'treatment'adherence''  11 !Results!of!the!survey!presented!in!chapter!6!show!that!numerous!aspects!of!clinical!care,!such!as!asthma!education!and!knowledge!about!medication,!do!explain!some!variation!in!adherence.!In!addition,!potentially!inaccurate!beliefs!about!asthma!and!medicationSrelated!concerns!are!both!common,!and!are!shown!to!reduce!the!odds!of!adherence.!Furthermore,!results!show!that!efforts!to!increase!adherence!may!benefit!from!engaging!nonSphysician!caregivers!such!as!asthma!educators.!!!Awareness'of'the'potential'benefits'associated'with'SDM'may'help'to'increase'SDM'uptake'and'improve'health'outcomes'''Results!of!chapters!2!and!6!raise!the!concern!that!that!some!patients!may!be!systematically!excluded!from!the!decisionSmaking!process.!This!may!include!patients!who!indicate!a!preference!for!a!passive!approach,!or!those!who!are!perceived!to!be!less!able!or!willing!to!engage.!The!preliminary!results!of!this!work!show!that!various!aspects!of!patient!engagement!can!improve!overall!patient!adherence!and!outcomes,!and!so,!from!an!equity!standpoint,!it!is!possible!that!subSpopulations!of!patients!are!not!reaping!the!benefits!offered!by!SDM.!!1.4*Conclusions*I!have!sought!to!understand!and!explore!the!current!state!of!SDM!within!the!context!of!asthma,!and!to!suggest!specific!opportunities!for!improvement.!This!is!a!timely!and!important!field!of!research!because,!while!the!support!for!SDM!is!increasing!and!  12 the!evidence!base!pointing!to!the!benefits!of!SDM!is!growing,!clinical!implementation!efforts!have!been!slow.(8,36)!The!results!of!this!work!will!guide!strategies!to!improve!patientSphysician!communication!and!the!uptake!of!existing!interventions!to!facilitate!SDM,!with!the!goal!of!improved!patient!outcomes.!Furthermore,!the!results!can!be!used!to!inform!future!research!investigations,!especially!those!targeting!improved!medication!adherence!among!chronic!disease!patient!populations.!!* *  13 Chapter*2:*Physician*attitudes*toward*shared*decision5making:*a*systematic*review*!2.1*Introduction*Over!the!past!2!decades,!there!has!been!a!shift!in!support,!away!from!a!paternalistic!model!of!clinical!decisionSmaking,!towards!an!approach!wherein!the!patient!takes!on!a!more!central!role,!and!decisions!are!reached!in!partnership!between!the!patient!and!the!physician.(10)!I!have!adopted!the!definition!of!SDM!put!forth!by!Charles!et!al.!wherein!a!truly!shared!approach!requires!that!both!the!physician!and!patient!be!involved!in!the!information!exchange!and!decisionSmaking!process;!both!the!physician!and!the!patient!express!treatment!preferences;!and!finally,!the!physician!and!patient!agree!on!treatment!decision.(7,10)!Charles!and!colleagues!initially!focused!their!conception!of!SDM!specifically!on!treatment!decisions,!but!it!has!been!broadened!to!include!a!range!of!health!care!decisions!such!as!disease!management!and!screening.!!!Improvements!in!access!to!health!information!and!treatment!options!have!facilitated!a!more!active!partnership!between!patients!and!physicians.!DecisionSmaking!has!also!become!more!complex,!with!a!variety!of!treatments!available!that!carry!different!risk!profiles!as!well!as!uncertainties!related!to!outcomes,!adverse!events!and!quality!of!life.(37)!In!the!presence!of!uncertainty!regarding!the!optimal!treatment!option,!the!involvement!of!patients!in!their!healthcare!and!treatment!  14 decisionSmaking!becomes!important.(38)!Related!to!this!is!the!opinion!that!SDM!may!be!most!appropriate!or!garner!the!highest!levels!of!support!in!scenarios!where!clinical!equipoise!is!present.(39,40)!!!SDM!has!been!placed!at!the!forefront!of!much!public!and!academic!discussion!in!recent!years,!and!efforts!have!been!made!to!promote!patient/physician!communication!within!the!clinical!and!policy!sphere.(41,42)!Although!support!for!a!shared!approach!has!become!popular!in!the!academic!and!policy!literature!and!has!been!present!in!that!literature!since!the!1990s,!such!a!shift!to!a!more!patientScentered!approach,!in!the!clinical!arena,!has!been!slow!to!develop.!Shared!decisionSmaking!within!the!context!of!clinical!practice!has!been!minimal.(8,43)!Previous!research!suggests!that!lack!of!implementation!may!be!due!to!barriers!such!as!the!perceived!time!required!to!incorporate!patients!into!the!decisionSmaking!process,!physicians’!perceptions!that!the!specific!clinical!scenario!is!inappropriate!for!SDM,!or!physicians’!perceptions!that!the!patient!may!be!unwilling!or!unable!to!participate!in!the!process.(8)!!Proponents!of!SDM!argue!that!the!more!a!patient!is!involved!in!the!treatment!decision!at!hand,!the!more!likely!it!is!that!the!decision!will!be!consistent!with!his!or!her!own!personal!preferences.(44)!Particularly!for!treatment!scenarios!where!there!is!no!“correct”!answer!or!best!treatment!option,!the!most!appropriate!choice!would!be!one!that!is!consistent!with!the!patient’s!lifestyle,!living!situation,!goals!and!  15 personal!preferences.!Previous!research!has!shown!that!patients!in!general!wish!to!participate!in!the!decisionSmaking!process!and,!that!doing!so!may!increase!their!satisfaction!with!care!and!treatment!decisions!(45–48).!Furthermore,!SDM!may!reduce!healthcare!utilization!and!costs,!improve!treatment!adherence,!patient!function,!as!well!as!improving!additional!clinical!outcomes.(25)!!!Attempts!to!determine!physicians’!attitudes!toward!SDM!has!focused!on!healthcare!professionals’!perceived!barriers!and!facilitators!to!incorporating!SDM!into!their!practice.(27)!Physician!reported!barriers!include!but!are!not!limited!to!insufficient!time,!perceptions!that!the!patient!may!be!unable!or!unwilling!to!participate,!and!doubts!about!the!appropriateness!of!SDM!in!some!decision!context.!Frequently!cited!facilitators!include!physicians’!perception!that!the!patient!has!adequate!emotional!support;!the!perception!that!SDM!will!lead!to!better!patient!outcomes,!patient!knowledge,!trust!in!their!physician,!as!well!as!physician!willingness!to!participate!in!the!decisionSmaking!process.!!!Since!the!implementation!and!the!success!of!SDM!are!largely!dependent!on!active!engagement!of!the!treating!physician!(and!care!team),(49)!it!is!important!to!determine!the!overall!level!of!support!for!SDM!that!exists!among!physicians.!Specifically,!the!purpose!of!this!review!is!to!determine!to!what!extent!physicians!currently!support!the!implementation!of!SDM!to!routine!practice,!to!identify!clinical!scenarios!that!garner!the!highest!levels!of!physician!support!and!to!gain!insight!into!  16 the!rationale!behind!those!attitudes.!Since!opinions!and!attitudes!can!be!elicited!via!both!quantitative!(e.g.!surveys)!and!qualitative!means!(e.g.!interviews!and!focus!groups),!both!research!approaches!are!included!in!this!review.!The!results!of!this!review!provide!evidence!to!explain!why!physicians!tend!to!hold!certain!views!toward!SDM,!and!why!resistance!to!SDM!in!certain!care!scenarios!may!exist.!This!work!represents!the!first!systematic!review!of!the!literature!on!this!topic.!!!2.2*Methods*2.2.1*Search*strategy*development*I!developed!the!search!strategy,!in!consultation!with!a!research!librarian!(see!appendix!A).!The!complete!search!was!initially!developed!in!Medline!and!then!adapted!to!each!subsequent!database.!I!executed!the!searches!between!December!19th!and!23rd,!2014.!The!following!databases!were!searched!from!2007!to!current:!Medline,!Embase,!CINAHL,!Cochrane!database!of!randomized!controlled!trials,!and!PsychInfo.!Although!SDM!has!appeared!in!the!literature!for!several!years!prior!to!2007,!the!objective!of!this!review!was!to!ascertain!current!levels!of!support!for!SDM,!rather!than!to!track!the!evolution!of!attitudes!toward!SDM.!Following!the!search!of!electronic!databases!and!article!selection,!references!of!included!studies!were!also!reviewed.!This!review!was!limited!to!published!and!peerSreviewed!literature.!Publication!bias!was!not!formally!assessed.!!  17 2.2.2*Selection*criteria*Studies!that!involved!primary!data!collection!were!included!in!this!review!if!they!reported!physicians’!attitudes!or!opinions!toward!SDM!in!a!qualitative!or!quantitative!manner!and!were!published!in!English!between!2007!and!2014.!!!My!definition!of!“physician”!excluded!practitioners!of!other!health!professions!or!alternative!medicine!techniques.!Studies!that!primarily!examined!physicians’!attitudes!toward!patient!decision!aids!or!methods!used!to!implement!SDM!were!also!excluded.!Review!papers!were!excluded;!however,!reference!lists!of!all!review!papers!that!reported!physicians’!attitudes!toward!SDM!were!scanned!to!ensure!that!all!potentially!eligible!papers!had!been!captured.!!!2.2.3*Research*objectives*Primary!objectives!of!the!review!were!to!identify:!1.! Physician!attitudes!toward!including!patients!in!clinical!decisionSmaking!(research!objective!1)!2.! PhysicianSreported!factors!that!are!associated!with!support!or!lack!of!support!for!SDM!(research!objective!2)!!As!there!is!no!single!definition!used!in!the!literature!for!SDM,!I!included!all!studies!that!discuss!active!involvement!of!patients!in!the!clinical!decisionSmaking!process.!!!  18 2.2.4*Article*selection*Article!selection!was!conducted!in!two!phases:!1)!the!title!and!abstract!review!phase,!and!2)!the!full!text!review!phase.!If!a!paper!met!inclusion!criteria!in!phase!1),!the!full!paper!was!retrieved!and!reviewed!for!potential!inclusion.!Extensive!agreement!testing!at!the!abstract!review!phase!was!conducted.!I,!along!with!either!NB!or!SB!reviewed!approximately!100!identical!abstracts,!and!then!met!to!discuss!and!resolve!discrepancies.!This!process!continued!until!both!reviewers!were!comfortable!with!their!level!of!agreement!and!interpretation!of!the!selection!criteria.!Two!reviewers!(either!SP!and!NB,!or!SP!and!SB)!conducted!title!and!abstract!selection!independently!and!in!duplicate.!In!the!case!of!disagreements!that!could!not!be!resolved,!a!third!reviewer!(either!SB!or!NB)!was!consulted!and!acted!as!a!“tieSbreaker.”!To!assess!interSrater!agreement!at!the!fullStest!review!phase,!Cohen’s!kappa!was!calculated.!This!statistic!was!chosen!because!it!is!used!to!quantify!agreement!for!nominal!data.(50)!!2.2.5*Data*abstraction*A!data!abstraction!form!was!developed!specifically!for!this!review!(see!appendix!B).!!I!developed!the!data!abstraction!form!and!pilot!tested!it!with!NB.!Both!reviewers!applied!the!form!to!a!selection!of!eligible!papers!until!no!further!revisions!to!the!form!were!required,!and!all!items!were!agreed!upon.!I!then!completed!all!data!abstraction!with!verification!from!one!additional!reviewer!(NB!or!SB).!All!disagreements!were!resolved!through!consensus!discussion.!  19 !2.2.6*Outcome*reporting*Given!the!heterogeneity!of!methods!used!for!physician!preference!elicitation!and!outcome!reporting,!studies!that!reported!outcomes!quantitatively!were!categorized!into!two!separate!types:!1.! Those!that!reported!a!rating!of!attitudes!toward!SDM!and!SDMSrelated!behaviors!(e.g.!the!Patient!Practitioner!Orientation!Scale![PPOS])!2.! Those!that!compared!attitudes!toward!SDM!with!other!decisionSmaking!models!(e.g.!Paternalism)!!To!categorize!the!overall!level!of!physician!support!in!each!reviewed!quantitative!paper,!and!to!facilitate!comparison!across!studies,!support!for!SDM!by!physicians!was!categorized!as!follows:!•! “Strong!support!in!favor!of!SDM”!(>!80%!support!for!SDM)!•! “Mild!support!for!SDM”!(60S80%!support!for!SDM)!•! “Indifference!toward!SDM”!(40!<!60%!overall!support)!•! “Lack!of!support!for!SDM”!(<!40%!overall!support)!!!For!example,!to!determine!the!level!of!physician!support,!if!the!study!used!a!6Spoint!Likert!scale!as!was!used!in!the!previously!validated!PPOS!survey;!a!mean!score!of!4.8!or!higher!would!be!categorized!as!“strong!support!for!SDM.”!If!a!study!reported!that!80%!of!physicians!support!the!use!of!SDM,!“strong”!support!was!recorded!on!  20 the!data!abstraction!form.!!I!defined!“level!of!support”!as!reported!physician!support!for!joint!decisionSmaking!between!the!patient!and!physician,!or!support!for!the!patient!to!make!the!final!treatment!decision.!Disagreements!were!resolved!through!consensus!discussion.!!!This!review!includes!studies!that!report!quantitative!frequencies!of!support!for!SDM!as!well!as!qualitatively!reported!outcomes.!The!qualitative!studies!were!narratively!summarized!in!accordance!to!the!manner!in!which!results!were!reported.!Qualitative!studies!were!primarily!included!to!provide!further!insight!into!the!factors!associated!with!support!for!SDM,!and!the!rationale!behind!physician!reported!attitudes.!Given!the!range!of!qualitative!study!designs,!decisional!topics,!and!limited!data!being!reported!within!studies,!I!did!not!apply!a!formal!thematic!or!grounded!theory!analysis!to!the!qualitative!studies.(51,52)!However,!when!comparing!qualitative!results!across!studies,!themes!or!“patterned!responses”!were!identified!through!ongoing!discussion!between!the!three!raters.!A!theme!was!identified!if!it!captured!an!important!concept!related!to!the!primary!research!questions.(51)!!Given!the!heterogeneity!of!study!designs!included!in!the!review,!quantitative!and!qualitative!findings!are!reported!separately,!throughout!the!results!section.!Results!are!reported!according!to!the!two!primary!review!objectives.!SubSheadings!were!identified!following!a!review!and!discussion!of!each!of!the!study!findings.!Although!I!  21 did!not!apply!a!qualitySrating!tool!to!the!included!studies,!major!limitations!were!recorded!in!the!data!abstraction!tool!and!are!reported!in!summary!format!in!the!results!section.!!!2.3*Results*2.3.1*Search*results*The!electronic!search!produced!11,761!references.!Following!abstract!review,!123!references!were!selected!for!full!text!review.!No!additional!papers!were!included!following!the!review!of!reference!lists.!One!additional!paper!was!included!based!on!the!suggestion!from!a!field!expert.!FortySthree!papers!were!selected!for!final!inclusion!after!full!text!review!(see!figure!2.2).!At!the!full!text!phase,!reviewers!had!a!high!level!of!agreement!on!the!eligibility!of!articles,!with!a!Cohen’s!kappa!of!0.83.!!!2.3.2*Characteristics*of*included*studies*Of!the!43!studies,!29!reported!quantitative!results,!and!the!remaining!studies!consisted!of!qualitative!interviews!or!focus!groups.!Fourteen!studies!considered!SDM!within!the!context!of!primary!care,!25!in!secondary!care,!and!4!in!both.!Individual!studies!varied!with!regard!to!the!method!of!preference!elicitation,!ranging!from!preSvalidated!Likert!scale!tools!such!as!the!PPOS,!investigator!developed!tools,!as!well!as!unSvalidated!instruments!(see!tables!2.1!and!2.2).!The!context!within!which!physicians!were!asked!to!express!their!levels!of!support!for!  22 SDM!varied!considerably,!and!included!a!single!clinical!scenario,(53)!a!specific!patient!population,(54)!or!questions!asked!in!terms!of!general!levels!of!support!unrelated!to!specific!patients!to!clinical!scenarios.(55)!In!addition,!studies!varied!with!regard!to!whether!they!assessed!directly!stated!opposition!to!SDM!in!favour!of!alternative!models!(e.g.!paternalism),!or!simply!a!lack!of!support!for!SDM.!!!Of!the!quantitative!studies,!5!(17%)!reported!a!response!rate!of!50%!or!less,!and!an!additional!8!(28%)!did!not!report!recruitment!or!response!rates.!All!14!qualitative!studies!and!3!of!the!29!quantitative!studies!(10%)!used!a!sample!size!of!less!than!30!participants.!!!Individual!studies!varied!in!terms!of!how!they!defined!SDM.!Sixteen!of!the!29!quantitative!studies!(55%)!used!tools!developed!by!the!investigators!that!described!various!aspects!of!SDM,!(54–57)!while!the!remaining!studies!used!preSvalidated!tools!to!ascertain!support!for!SDM,!such!as!the!PPOS,(58–60)!or!the!Control!Preferences!Scale!(CPS)!(see!table!2.1).(61)!Responses!therefore!were!elicited!using!different!response!options,!comparators,!and!scales.!For!example,!Shepherd!et!al.!sought!to!determine!physician!comfort!level!with!various!decisionSmaking!approaches,(62)!while!Caldwell!et!al.!ascertained!physicians!opinions!about!the!relative!importance!of!SDM!on!a!Likert!scale.(55)!Conversely,!Hamann!et!al.!obtained!physician!level!of!agreement!about!the!use!of!SDM!for!a!range!of!specific!decision!topics.(54)!  23 !The!term!“shared!decisionSmaking”!was!not!consistently!defined!in!each!study.!For!example,!the!survey!conducted!by!Davis!et!al.!asked!physicians!about!their!preference!for!the!physician!or!the!patient!in!making!the!final!treatment!decision!with!regard!to!prostate!specific!antigen!screening.!While!not!explicitly!describing!an!SDM!encounter,!responses!referred!to!preferred!level!of!patient!involvement.(63)!Alternatively,!the!survey!conducted!by!Shepherd!et!al,!provided!explicit!descriptions!of!different!decisionSmaking!models!such!as!paternalism,!informed!decisionSmaking!and!SDM.(62)!Table!2.1!and!2.2!provide!a!brief!summary!of!the!instruments!used!in!quantitative!(table!2.1)!and!qualitative!(table!2.2)!work!to!collect!information!about!physician!attitudes!toward!patient!involvement!in!the!decision!process.!24 !Table&2.1:&Summary&of&studies&reporting&quantitative&results& &Author,&date&of&publication,&country&Title& N& Physician&specialty&[or&physician&rank&where&listed]&Decision&context&Instrument&!Murray!2007,!USA!(56)! !Clinical!decision;making:!physicians'!preferences!and!experiences!!!1050! !Primary!care,!medical!specialty!or!surgical!specialty!physicians!!General! !Investigator;developed!questionnaire:!%!approval!of!various!aspects!of!SDM!!Butow!2007,!Australia!(57)!!Health!Professional!and!Consumer!Views!on!Involving!Breast!Cancer!Patients!in!the!Multidisciplinary!Discussion!of!Their!Disease!and!Treatment!Plan!!!238! !Surgery,!radiation!oncology,!medical!oncology!!Breast!cancer!treatment!planning!!Self;developed!questionnaire!to!elicit!preferred!role!in!decision;making.!!Shepherd!2007,!Australia!(62)!!The!context!influences!doctors’!support!of!shared!decision!making!!in!cancer!care!!64! !Oncology! !Cancer!treatment! !Survey!developed!based!on!the!work!of!Charles!et!al.(64)!Physicians!asked!to!rate!their!comfort!levels!with!each!of!the!decision;making!approaches!on!a!five;point!Likert!scale,!ranging!from!“not!comfortable”!to!“extremely!comfortable.”!  25 Table&2.1:&Summary&of&studies&reporting&quantitative&results& &Author,&date&of&publication,&country&Title& N& Physician&specialty&[or&physician&rank&where&listed]&Decision&context&Instrument&!Arnetz!!2008,!Sweden!(65)!!Physicians'!and!Nurses'!Perceptions!of!Patient!Involvement!in!Myocardial!Infarction!Care!!53! !Cardiology! !Myocardial!infarction!care! !Investigator;developed!4;item!Likert!scale!questionnaire.!Responses!ranged!from!“Agree!completely”!to!“Don't!agree!at!all”!!!Carlsen!2008,!Norway!(58)! !Variation!in!practice:!A!questionnaire!survey!of!how!congruence!in!attitudes!between!doctors!and!patients!influence!referral!decisions!!!41! !GP! !General! !PPOS!!Pieterse!2008,!Netherlands!(61)!!Clinician!and!cancer!patient!views!on!patient!participation!in!treatment!decision;making:!a!quantitative!and!qualitative!exploration!!!35! !Oncology! !Preoperative!rectal!cancer!radiotherapy!!CPS![Control!Preferences!Scale]!!Boivin!2008,!Canada!(66)! !Competing!norms:!Canadian!rural!family!physicians’!perceptions!of!clinical!practice!guidelines!and!shared!decision;making!!!17! !GP/!residents! !General! !Focus!groups.!Reported!percent!approval!regarding!various!statements!about!preferred!role!in!decision;making!!  26 Table&2.1:&Summary&of&studies&reporting&quantitative&results& &Author,&date&of&publication,&country&Title& N& Physician&specialty&[or&physician&rank&where&listed]&Decision&context&Instrument&!Cohen!Castle!2008,!Israel!(67)!!Family!physicians’!perceptions,!beliefs,!and!attitudes!regarding!information!sharing!with!prostate!cancer!patients!throughout!the!course!of!the!disease!!382! !GP! !Prostate!cancer!treatment! !11;item!questionnaire!concerning!information!sharing!and!SDM!was!designed!based!on!the!work!of!Charles!et!al.(7)!!Caldwell!2008,!USA!(55)!!Evaluating!attitudes!of!first;year!residents!to!shared!decision!making!!70! !Residents!from!16!specialties! !General! !Investigator;developed!survey!to!assess!perceived!importance!of!SDM.!Survey!included15!items!concerning!medical!decision;making!were!tied!to!a!five;point!Likert!scale!anchored!at!both!ends!by!“Not!Important”!and!“Very!Important.”!!!Hamann!2009,!Germany!(54)!!Psychiatrists’!use!of!shared!decision!making!in!the!treatment!of!schizophrenia:!Patient!characteristics!and!decision!topics!!!181! !Psychiatry! !Schizophrenia! !Investigator;developed!questionnaire:!questions!on!whether!certain!decision!topics!would!be!suit;!able!for!shared!decision;making!!  27 Table&2.1:&Summary&of&studies&reporting&quantitative&results& &Author,&date&of&publication,&country&Title& N& Physician&specialty&[or&physician&rank&where&listed]&Decision&context&Instrument&!van!Til!2010,!Netherlands!(68)!!The!potential!for!shared!decision!making!and!decision!aids!in!rehabilitation!medicine!!126! !Physical!and!rehabilitation!! !Rehabilitation!! !Questionnaire!based!on!the!work!of!Charles!et!al.(64),!eliciting!level!of!comfort!with!SDM.!!Chan!2011,!Malaysia!(59)! !Differences!in!physician!attitudes!towards!patient;centeredness:!across!four!medical!specialties!!!67! !Surgery,!obstetrics!&!gynecology,!oncology,!GP!!Surgery,!obstetrics!&!gynecology,!oncology,!GP!!!PPOS!!!Davis!2011,!USA!(63)! !Physicians’!attitudes!about!shared!decision!making!for!prostate!cancer!screening!!!54! !Academic!clinicians,!community!clinicians,!interns,!residents!!Prostate!Cancer!Screening! !Investigator;developed!26!item!survey!eliciting!attitudes!toward!SDM!for!prostate!cancer!screening.!!Cohen!Castle!2011,!Israel!(69)!!Urologists’!attitudes!regarding!information!sharing!with!prostate!cancer!patients—Is!there!a!common!ground!for!collaboration!with!family!physicians?!!!54! !Urology! !Prostate!Cancer!treatment! !An!11!item!scale!based!on!the!work!of!Charles!et!al.(7)!eliciting!attitudes!toward!various!aspects!of!SDM.!  28 Table&2.1:&Summary&of&studies&reporting&quantitative&results& &Author,&date&of&publication,&country&Title& N& Physician&specialty&[or&physician&rank&where&listed]&Decision&context&Instrument&!Légaré!2011,!Canada!(70)! !Prenatal!screening!for!Down!syndrome:!a!survey!of!willingness!in!women!and!family!physicians!to!engage!in!shared!decision;making!!41! !GP! !Prenatal!Down!Syndrome!screening!!Investigator;developed!clinical!vignette!questionnaire!regarding!their!intended!decision;making!model.!Instrument!was!developed!using!the!theory!of!planned!behavior.!Each!statement!was!measured!on!a!7;point!Likert!scale!ranging!from!−3!(strongly!disagree)!to!+3!(strongly!agree).!!!van!der!Horst!2011,!Switzerland!(71)!!Attitudes!toward!shared!decision;making!and!risk!communication!practices!in!residents!and!their!teachers!!4487! !Internal!medicine,!anesthesiology,!surgery,!gynecology,!pediatrics,!psychiatry,!orthopedic!surgery!residents!and!teachers!!General! !Investigator;developed!questionnaire!regarding!attitudes!toward!SDM.!Responses!ranged!from!“does!not!apply”!to!“fully!applies”!on!a!5;point!Likert!scale.!!!!King!2012,!USA!!(72)!!Perceptions!of!shared!decision!making!and!decision!aids!among!rural!primary!care!clinicians!!174! !Rural!GPs!! !General!! !Investigator!developed!questionnaire!regarding!perceptions!of!SDM!!  29 Table&2.1:&Summary&of&studies&reporting&quantitative&results& &Author,&date&of&publication,&country&Title& N& Physician&specialty&[or&physician&rank&where&listed]&Decision&context&Instrument&!!Olson!2012,!Canada!(53)! !Oncologists’!view!of!informed!consent!and!shared!decision!making!in!pediatric!radiation!oncology!!!59! !Oncology! !Pediatric!oncology! !PPOS!responses!to!a!single!clinical!scenario!!Chan!2012,!Malaysia!(60)! !Attitudes!and!role!orientations!on!doctor;patient!fit!and!patient!satisfaction!in!cancer!care!!!12! !Oncology! !Oncology! !PPOS!!De!Las!Cuevas!2012,!Spain!(73)!!Mental!health!professionals’!attitudes!to!partnership!in!medicine!taking:!a!validation!study!of!the!Leeds!Attitude!to!Concordance!Scale!II!!!225! !Psychiatry! !Mental!health! !!LATCon!II!(Leeds!Attitudes!to!Concordance!Scale)!!Holland!2013,!Norfolk!(74)!!Barriers!to!involving!older!people!in!their!resuscitation!decisions:!the!primary–secondary!care!mismatch!highlights!the!potential!role!of!general!practitioners!!24! !GPs!and!secondary!care!clinicians!!!Resuscitation!! !Investigator!developed!questionnaire.!5!point!Likert!scale!indicating!the!extent!to!which!they!agree!that!it!is!important!to!involve!patients!in!resuscitation!decisions!  30 Table&2.1:&Summary&of&studies&reporting&quantitative&results& &Author,&date&of&publication,&country&Title& N& Physician&specialty&[or&physician&rank&where&listed]&Decision&context&Instrument&!!Flierler!2013,!Switzerland!(75)!!Implementation!of!shared!decision!making!in!anaesthesia!and!its!influence!on!patient!satisfaction!!!213! !Anaesthesiologists!! !Anaesthesia!! !CPS!!Hillyer!2013,!USA!(76)!!!A!survey!of!breast!cancer!physicians!regarding!patient!involvement!in!breast!cancer!treatment!decisions!!!136! !Oncologists,!breast!surgeons!!!Breast!cancer!treatment!!!Adapted!questionnaire!asking!physicians!to!respond!to!10!questions!regarding!decision;making!!!Abiola!2014,!Nigeria!!(77)&!Patient;doctor!relationship:!the!practice!orientation!of!doctors!in!Kano.!!!214! !Unspecified! !General! !PPOS!!!Doring!2014,!Not!reported!(78)&!Trigger!finger:!assessment!of!surgeon!and!patient!preferences!and!priorities!for!decision!making.!!!105! !Hand!surgeons!! !Idiopathic!trigger!finger! !Online!survey!based!on!the!Ottawa!decision!support!frame!work!and!the!control!preferences!scale!!  31 Table&2.1:&Summary&of&studies&reporting&quantitative&results& &Author,&date&of&publication,&country&Title& N& Physician&specialty&[or&physician&rank&where&listed]&Decision&context&Instrument&!Garcia;Retamero!2014,!60!countries!!(79)!&!Factors!predicting!surgeons’!preferred!and!actual!roles!in!interactions!with!their!patients!!!292! !Surgeons!! !Surgery!! !Adapted!questionnaire!asking!physicians!who!should!make!treatment!decisions!!Hageman!2014,!Not!reported!!(80)&!Carpal!tunnel!syndrome:!assessment!of!surgeon!and!patient!preferences!and!priorities!for!decision;making!!!103! !Hand!surgeons!! !Surgery!for!carpel!tunnel!syndrome!!!Survey!based!off!of!the!Ottawa!decision!support!framework!(OSDF)!!!Ishikawa!2014,!Japan!!(81)&!Resident!physicians’!attitudes!and!confidence!in!communicating!with!patients:!a!pilot!study!at!a!Japanese!university!hospital!!!63! !Resident!physicians!!!General!! !PPOS!translated!into!Japanese!!Nguyen!2014,!France!!(82)& Treatment!decision;making!in!the!medical!encounter:!comparing!the!attitudes!of!French!surgeons!and!their!patients!in!breast!cancer!care!47! Surgeons!! Early!stage!breast!cancer!treatment!!Survey!questionnaire!containing!examples!of!four!different!approaches!to!treatment!decision;making:!paternalistic,!‘‘some!sharing’’,!informed!and,!shared.!  32 Table&2.1:&Summary&of&studies&reporting&quantitative&results& &Author,&date&of&publication,&country&Title& N& Physician&specialty&[or&physician&rank&where&listed]&Decision&context&Instrument&! !!! !  33 !Table&2.2:&Summary&of&studies&reporting&qualitative&results& &Author,&date&of&publication,&country&Title& N& Physician&specialty&Decision&context& Method&&!Jaakkola,E.!2007,!UK!and!USA!(83)!!Physicians’!views!on!the!influence!of!patient!participation!on!treatment!decisions! !20! !Psychiatry,!rheumatology, endocrinology,!geriatrics,!gynecology.!!!Schizophrenia!and!osteoporosis! !Interview!!Thistlethwait!2007,!Australia!(84)&!Shared!decision!making!between!registrars!and!patients!!!11! !GP! !General! !Interview/!focus!group!!Beaver!2007,!UK!(37)! !Patient!participation!in!decision!making:!views!of!health!professionals!caring!for!people!with!colorectal!cancer!!!11! !Oncology,!Medical!oncology,!Surgery,!GP,!Specialist!Registrar,!Surgical!Registrar!!!Colorectal!cancer!treatment! !Interview!!Rotar!2008,!Slovenia!(38)!!!How!do!older!patients!and!their!GPs!evaluate!shared!decision;making!in!healthcare?!!!26! !GP! !Elder!care! !Interview!!Watson!2008,!UK!(85)! !Professional!centered!shared!decision!making:!Patient!decision!aids!in!practice!in!primary!care!!!19! !GP! !General! !Focus!groups!  34 Table&2.2:&Summary&of&studies&reporting&qualitative&results& &Author,&date&of&publication,&country&Title& N& Physician&specialty&Decision&context& Method&&!Matlock!2011,!USA!(86)! !Patient!and!Cardiologist!Perceptions!on!Decision!Making!for!Implantable!Cardioverter;Defibrillators:!A!Qualitative!Study!!!11! !Cardiology! !ICD!implantation! !Interview!!Fiks!2011,!USA!(87)! !Contrasting!parents'!and!pediatricians'!perspectives!on!shared!decision;making!in!ADHD.!!!30! !Pediatrics! !ADHD! !Interview!!Muller;Engelmann!2011,!Germany!(88)!!!Shared!decision!making!in!medicine:!The!influence!of!situational!treatment!factors!!!12! !GP! !Multiple! !!Interview!!Shepherd!2011,!Australia!(89)! !Factors!which!motivate!cancer!doctors!to!involve!their!patients!in!reaching!treatment!decisions! !22! !Oncology! !Breast,!colorectal,!gynecological,!hematological!or!prostate/urological!cancer.!!!!Interview!!Luijk!2012,!Netherlands!(90)!!GPs!considerations!in!multimorbidity!Management:!A!qualitative!study!!!25! !GP! !Multi;morbidity! !Interview!!Gachoud!2012,!Canada!(91)& ! !8! !Physicians! !General! !Interview!  35 Table&2.2:&Summary&of&studies&reporting&qualitative&results& &Author,&date&of&publication,&country&Title& N& Physician&specialty&Decision&context& Method&&Meanings!and!perceptions!of!patient;centeredness!in!social!work,!nursing!and!medicine:!a!comparative!study!!!Kahveci,!2014,!Turkey!(92)&!!Shared!decision;making!in!pediatric!intensive!care!units:!A!qualitative!study!with!physicians,!nurses!and!parents!!!8! !Pediatric!intensive!care!physicians! !Pediatric!intensive!care!settings!requiring!life!support!!!Interview!!Zeuner!2014,!USA!(93)& !Physicians’!perceptions!of!shared!decision;making!behaviours:!A!qualitative!study!demonstrating!the!continued!chasm!between!aspirations!and!clinical!practice!!!20! !Surgeons,!OB/GYNs,!medical!oncologists,!internists,!emergency!medicine!physician!!!General! !Interview!!Shepherd!2014,!Manchester!(94)!!!&!Consultant!psychiatrists’!experiences!of!and!attitudes!towards!shared!decision!making!in!Antipsychotic!prescribing,!a!qualitative!study!!!26! !Consultant!psychiatrists!!!Antipsychotic!prescribing! !Interview!36 !2.3.3$Physician$preferences$for$patient$participation$in$decision4making$(research$objective$1)$Quantitative$results$In!general,!there!was!a!relatively!consistent!level!of!support!for!SDM,!as!reported!by!physicians.!However,!support!varied!by!physician!specialty!and!clinical!context.!Of!the!29!quantitative!studies,!12!asked!physicians!directly!to!rate!their!level!of!support!for!SDM!without!an!explicit!comparison!of!SDM!to!other!models!such!as!paternalism.!Of!the!12,!33%!(4/12)!reported!strong!support!for!SDM,!half!(6/12)!reported!mild!support,!and!2!(17%)!reported!indifference!toward!SDM.!Of!note,!none!of!the!12!studies!found!a!lack!of!support!for!SDM.!!!Seventeen!of!the!29!quantitative!studies!asked!physicians!to!compare!their!level!of!support!for!SDM!against!alternative!models!of!decisionMmaking.!All!17!studies!compared!a!SDM!approach!to!a!paternalistic!model!wherein!the!physician!alone!makes!the!treatment!decision.!EightyMtwo!percent!of!these!papers!(14/17)!reported!a!strong!preference!for!either!a!SDM,!or!for!a!model!wherein!the!patient!makes!the!treatment!decision.!The!remaining!three!studies!reported!mild!support!for!patient!participation.!Mild!support!was!identified!in!clinical!scenarios!regarding!anesthesiology!and!surgery.!No!studies!reported!an!overall!preference!for!paternalistic!decisionMmaking.!!  37 2.3.4$Factors$associated$with$variation$in$physician$support$for$SDM$(research$objective$2)$Following!the!review!of!all!included!studies,!three!major!themes!were!identified!with!regard!to!the!factors!associated!with!support!for!SDM.!The!first!theme!includes!physicianMrelated!factors!such!as!specialty,!concerns!about!where!decisional!responsibility!should!fall,!as!well!as!their!interpretation!of!what!an!SDM!encounter!constitutes.!Secondly,!patientMrelated!factors!that!tend!to!influence!support!for!SDM!include!the!physician’s!perception!of!a!patient’s!willingness!or!ability!to!participate!in!the!encounter.!Finally,!disease!and!treatmentMrelated!considerations!also!tend!to!influence!a!physician’s!attitude!toward!SDM.!Each!of!these!general!themes!is!discussed!in!detail,!below.!$2.3.4.2%Physician.related%factors%that%impact%support%for%SDM%Qualitative$results!PhysicianMreported!support!for!SDM!was!heavily!influenced!by!physicianMrelated!factors!such!as!the!availability!of!evidence!and!guidelines!pertaining!to!a!particular!treatment!decision,!the!presence!of!support!for!SDM!from!colleagues,!and!previous!exposure!to!SDM!training.!Five!studies!provided!insight!into!physicianMrelated!factors!that!explain!variability!in!support!for!SDM.!Physicians!tend!to!express!support!for!SDM!in!situations!where!they!do!not!feel!strongly!about!one!treatment!alternative,(85)!and!less!supportive!of!SDM!in!situations!where!compelling!evidence!or!wellMevidenced!clinical!practice!guidelines!exist!in!favor!of!one!treatment!over!  38 the!other.(66,86)!In!situations!where!the!patient!has!little!choice,!or!in!cases!where!one!treatment!option!is!well!established!(e.g.!surgery!in!the!case!of!malignant!tumor!removal),!physicians!tend!to!be!less!favorable!towards!SDM.(37)!For!example,!Matlock!et!al.’s!interview!study!with!11!cardiologists!found!that!in!the!presence!of!strong!guidelines!in!favor!of!one!treatment!option!(namely,!implantable!cardioverterMdefibrillators),!physicians!were!less!likely!to!support!the!involvement!of!the!patient!in!the!decisionMmaking!process.(86)!As!the!authors!state,!where!guidelines!exist!recommending!one!treatment!option,!physicians!may!feel!pressured!to!follow!such!recommendations,!and!thus!may!be!less!likely!to!seek!involvement!from!their!patient.(95)!One!study!of!20!physicians!found!that!support!for!SDM!was!most!common!among!those!who!had!received!training!in!SDMMrelated!communication!skills.(93)!Conversely,!those!who!worked!under!physicians!who!did!not!support!SDM!were!less!likely!to!incorporate!SDM!into!their!practice.!$2.3.4.1%Physician%attitudes%vary%by%specialty%%Quantitative$results$Support!for!SDM!varied!considerably!by!physician!specialty.!For!example,!Chan!et!al!reported!that!among!a!sample!of!67!physicians!responding!to!a!6Mpoint!Likert!scale!rating!levels!of!support!for!SDM,!oncology!physicians!(mean:!5.02,!SD:!0.28),!GPs!(mean:!4.33,!SD:!0.57)!and!physicians!specializing!in!obstetrics!and!gynecology!  39 (mean:!4.19,!SD:!0.76)!held!positive!attitudes!toward!SDM.!In!comparison,!surgeons!reported!the!lowest!levels!of!support!for!SDM!(mean:!2.88,!SD:!0.78.).(59)!Conversely,!among!a!nationally!representative!sample!of!US!physicians!(N=1050)!responding!to!a!survey!about!their!preferred!model!of!care,!physicians!from!surgical!specialties!(including!obstetricians!and!gynecologists)!were!no!more!likely!to!support!paternalism!over!shared!decisionMmaking,!compared!to!primary!care!specialists!(conditional!odds!ratio:!0.74,!95%!CI:!0.43,!1.29).(56)!!In!a!survey!of!residents!and!their!teachers,!participants!were!asked!to!rank!on!a!6Mpoint!scale!ranging!from!“does!not!apply”!to!“fully!applies,”!to!questions!regarding!the!time!required!to!engage!patients,!the!difficulty!associated!with!engaging!patients,!and!patients’!lack!of!understanding.!As!such,!lower!scores!indicate!higher!levels!of!support!for!SDM.!Regarding!selfMreported!negative!attitudes!toward!SDM,!psychiatry!(mean:!3.0!SD:!1.16)!and!gynaecology!residents!(mean:!2.8!SD:!1.14)!reported!lowest!negative!attitudes,!compared!with!internal!medicine!(mean:!3.28!SD:!1.16),!surgical!(mean:!3.18!SD:!1.11),!paediatric!(mean:!3.05!SD:!1.08),!and!orthopaedic!surgery!(mean:!3.17!SD:!1.18).!In!general,!results!did!not!differ!extensively,!although!authors!did!not!report!whether!the!results!differed!significantly!from!one!another.!Similarly,!attitudes!reported!by!psychology!resident!teachers!were!most!favourable!toward!SDM,!with!the!lowest!levels!of!support!reported!by!anaesthesiologists!(mean:!3.37!SD:!1.13).(71)!Teachers!consistently!reported!more!positive!attitudes!toward!SDM,!compared!with!residents,!although!  40 the!investigators!do!not!provide!formal!statistical!comparisons!across!ranks.!An!additional!item!was!included!in!the!survey!to!ascertain!concerns!about!the!time!required!for!SDM.!The!single!item!included!the!following!statement:!“In!the!daily!routine,!too!little!time!is!scheduled!to!explain!the!advantages!and!risks!of!available!treatment!options!to!patients.”!All!teacher!specialties!except!for!anaesthesiologists!reported!lower!ratings!on!opinions!regarding!about!lack!of!time.!One!potential!interpretation!of!this!finding!is!that!more!experienced!physicians!tend!to!be!more!supportive!of!SDM!over!less!experienced!and!perhaps!younger!residents.!Further!investigation!into!this!potential!explanation!is!warranted.!!With!regard!to!involving!patients!in!decisions!for!resuscitation,!Holland!et!al.!found!that!although!both!groups!supported!the!involvement!of!patients!in!the!decisionMmaking!process,!general!practitioners!rated!its!importance!higher!compared!with!hospital!based!clinicians.(74)!This!difference!in!opinion!may!have!been!informed!by!the!fact!that!on!average!hospitalMbased!clinicians!made!significantly!more!CPRMrelated!decisions!per!week!compared!with!GPs!(4.04!vs.!0.28!p:!0.005),!and!thus!may!have!had!more!experience!with!this!specific!clinical!context.!$2.3.4.3%Physicians%report%concerns%with%regard%to%absolving%decisional%responsibility%Quantitative$results$Despite!a!general!support!for!SDM,!some!studies!addressed!physician!concerns!related!implementing!a!shared!approach!to!their!care.!When!asked,!physicians!  41 reported!concerns!about!charging!patients!with!a!complex!decision!and!transferring!decisional!responsibility!to!their!patients.!For!example,!within!the!context!of!breast!cancer!treatment!planning,!a!survey!of!surgeons,!radiation!oncologists!and!medical!oncologists!reported!that!66%!thought!that!including!patients!in!multidisciplinary!care!meetings!could!result!in!information!overload,!and!53%!believed!that!patients!would!not!understand!the!information!being!discussed.(57)!Although!the!majority!of!oncologists!interviewed!by!Olson!et!al.!supported!the!information!of!pediatric!patients’!parents!in!the!decisionMmaking!process,!some!worried!that!doing!so!may!be!inappropriate!given!the!complexity!of!the!decision!being!made.(53)!Oncologists!also!mentioned!a!reluctance!to!absolve!responsibility!for!treatment!decisionMmaking,!with!the!concern!that!it!is!the!physician’s!job!to!ensure!that!the!right!decision!is!made.!In!one!scenario!where!physicians!were!asked!whether!they!would!engage!the!parents!of!children!with!cancer!in!the!decisionMmaking!process,!one!physician!feared!that!if!an!adverse!outcome!were!to!occur,!the!parents!would!be!left!with!the!guilt.(53)!!$Qualitative$results!Similar!concerns!arose!repeatedly!among!a!selection!of!qualitative!studies,!wherein!physicians!reported!a!fear!that!patients!would!be!unprepared!to!grasp!the!complexity!of!the!decision,!or!where!patients!lack!the!understanding!or!ability!to!focus!on!the!reality!of!the!decision.(38,86,92,93)!For!example,!with!regard!to!elder!care,!general!practitioners!qualitatively!interviewed!by!Rotar!et!al.!highlighted!the!  42 concern!that!older!patients!may!not!be!prepared!to!engage!in!the!decisionMmaking!process,!based!on!their!experiences!treating!this!patient!population.(38)!While!some!physicians!recognized!that!clinical!decisionMmaking!is!evolving!in!a!direction!that!allows!or!requires!the!patient!to!take!responsibility!of!his!or!her!own!health!and!treatment,!they!also!reported!difficulty!in!relinquishing!control!of!the!final!decision,!especially!in!situations!where!they!held!a!clear!recommendation!for!one!treatment!alternative!over!another.(86)!Somewhat!related!to!this!concern,!20!physicians!interviewed!regarding!their!level!of!comfort!with!SDM!reported!that!although!they!generally!supported!the!idea,!many!were!concerned!about!discussing!uncertainty!with!patients!because!they!feared!that!they!may!come!across!as!incompetent.(93)!Eight!physicians!interviewed!about!SDM!in!the!context!of!pediatric!intensive!care!decisions!reported!that!the!parents!of!patients!lacked!the!understanding!about!the!decisions!being!made,!and!therefore!were!less!supportive!of!absolving!the!responsibility!for!the!decision.(92)!!Finally,!two!qualitative!(84,85)!and!two!quantitative!!(53,57)!studies!report!the!concern!that,!if!involved!in!the!decisionMmaking!process,!patients!would!make!“wrong”!or!“irrational”!decisions.!!!!!  43 2.3.4.4%Physicians%may%lack%clarity%with%regard%to%how%SDM%is%defined%Qualitative$results$As!previously!stated,!there!is!no!single!and!commonly!accepted!definition!for!what!constitutes!a!shared!approach!to!decision!making.!!This!has!implications!for!both!physician!competencies,!as!well!as!implementation!strategies.!Among!three!qualitative!studies!that!reported!on!how!physicians!define!SDM,!findings!further!support!this!concern.(85,87,91)!For!example,!although!the!majority!of!pediatricians!qualitatively!interviewed!by!Fiks!et!al.!were!supportive!of!SDM,!22/30!(73%)!of!the!participating!physicians!described!SDM!as!a!process!wherein!they!tried!to!convince!or!persuade!the!parent!to!agree!to!their!preferred!treatment!option.!A!large!minority!(28%)!of!physicians!interviewed!considered!SDM!to!be!a!partnership!with!patients.(87)!The!results!of!a!focus!group!conducted!with!general!practitioners!reported!that!participants!had!a!difficult!time!distinguishing!SDM!from!simple!information!transfer.(85)!!!2.3.4.5%Reported%versus%actual%approach%to%decision.making%%Quantitative$results$Among!6!studies!that!reported!both!preferred!and!actual!decisionMmaking!behaviours,!the!majority!(N=4)!found!that!support!for!SDM!did!not!consistently!reflect!practical!use.!Specifically,!although!physicians!tended!to!report!a!preference!for!a!shared!or!collaborative!approach!to!decisionMmaking,!decisions!were!typically!made!more!frequently!by!the!physician!alone.(54,68,72,79)!For!example,!in!a!study!  44 by!van!Til,!81%!of!126!physical!and!rehabilitation!physicians!reported!a!high!level!of!comfort!with!the!SDM!approach,!but!only!50%!reported!using!a!shared!approach!in!practice!(68).!A!survey!of!psychiatrists!reported!that!although!there!was!a!high!preference!for!patient!participation!within!the!clinical!encounter,!151!(44%)!of!physicians!stated!that!they!most!frequently!applied!a!paternalistic!decisionMmaking!model!of!decisionMmaking,!and!173!(51%)!reported!that!they!most!frequently!used!SDM.!The!remaining!5%!reported!that!they!most!frequently!applied!an!informed!choice!model.(54)!Similarly,!292!surgeons!surveyed!from!60!countries!reported!that!although!57%!preferred!an!approach!wherein!physician!and!patient!decide!together,!only!36%!reported!this!as!their!decisionMmaking!style!in!practice.!While!only!26%!preferred!a!process!wherein!the!decision!was!made!solely!by!the!physicians,!52%!reported!this!as!their!typical!decisionMmaking!behaviour.(79)!!!Two!additional!studies!reported!that!stated!actual!behaviours!were!concordant!with!preferred!styles.(56,65)!Consistent!with!high!preferences!for!SDM!in!the!context!of!myocardial!infarction!care!(other!than!ICD!implantation),!73.7%!of!physicians!stated!that!they!usually!informed!the!patient!about!various!aspects!of!his!or!her!disease;!65.9%!agreed!that!they!usually!asked!the!patient!about!their!personal!needs,!and!80.0%!usually!discussed!lifestyle!changes!and!provide!additional!resources!to!their!patients!about!continuing!their!care.(65)!Similarly,!a!study!of!general!practitioners!reported!that!75%!prefer!an!SDM!approach,!and!73%!say!they!share!the!decision!with!their!patients.(56)!!  45 !2.3.4.6%Patient.related%factors%that%affect%physician.reported%support%for%SDM%Quantitative$results!In!general,!support!for!SDM!varied!when!considering!patient!characteristics!such!as!the!physician’s!perception!of!patient!competency,!desire!to!be!involved,!and!likelihood!of!benefitting!from!the!shared!approach.!For!example,!within!the!context!of!schizophrenia,!physicians!were!supportive!of!an!SDM!approach!in!situations!where!the!patient!desired!to!be!involved!in!the!decisionMmaking!process,!was!informed!about!their!condition,!and!was!competently!able!to!participate.(54)!Conversely,!physicians!reported!lower!levels!of!support!for!SDM!in!situations!where!the!patient!was!unable!or!unwilling!to!participate!in!the!decisionMmaking!process,!cognitively!impaired,!showed!limited!awareness!about!their!condition,!or!was!otherwise!thought!to!be!limited!in!their!ability!to!participate!in!the!discussion!(e.g.,!children,!and!those!with!chronic!pain).(54,66,68,94)!Physicians!who!participated!in!a!quantitative!survey!about!their!comfort!with!SDM!within!the!context!of!rehabilitation!medicine!expressed!doubt!that!patients!with!chronic!pain!would!be!able!to!actively!engage!in!the!decisionMmaking!process.(68)$$Qualitative$results$In!support!of!the!quantitative!findings,!the!qualitative!studies!that!ascertained!rationale!for!support!for!SDM!found!that!characteristics!such!as!patientMperceived!cognitive!ability!or!likelihood!of!benefit.!Interviews!with!GPs!found!that!SDM!may!be!  46 most!appropriately!applied!in!situations!where!the!patient!was!cognitively!able!to!participate!in!the!decision!making!process.(88)!Consultant!psychiatrists!interviewed!by!Shepherd!et!al.!highlighted!the!concern!that!SDM!may!be!inappropriate!in!situations!where!patients!have!been!diagnosed!with!a!mental!disorder.(94)!Finally,!within!the!context!of!elderMcare,!physicians!interviewed!by!Rotar!et!al.!feared!that!patients!may!be!unable!to!engage!in!this!relatively!new!paradigm!of!decision!making.(38)!!!Two!studies!in!particular!discussed!the!impact!of!treatment!adherence!on!support!for!SDM.(54,83)!Within!the!context!of!decisionMmaking!for!schizophrenia!patients,!physicians!in!Hamann!and!colleagues’!quantitative!survey!reported!reduced!levels!of!support!for!SDM!in!situations!where!patients!showed!poor!adherence!with!their!medications.(54)!Alternatively,!psychiatrists!in!Jaakola’s!qualitative!interview!study!reported!that!an!SDM!approach!to!elicit!patient!preferences!may!serve!as!a!useful!tool!to!increase!treatment!adherence!for!this!patient!population.(83)!This!difference!in!opinion!helps!to!illustrate!the!fact!that!physician!attitudes!vary!depending!on!the!specific!patient!population!under!consideration,!even!within!similar!treatment!contexts!(see!table!2.3).!!!  47 2.3.4.7%Condition.%and%treatment.related%factors%that%affect%physician.reported%support%for%SDM%Qualitative$results!Physicians!tended!to!support!the!use!of!SDM!in!clinical!contexts!where!a!decision!could!be!made!in!a!nonMemergency!setting,!and!in!situations!that!have!been!previously!described!as!“preferenceMsensitive.”!For!example,!results!of!qualitative!investigations!found!that!physicians!tended!to!support!SDM!in!situations!of!severe!or!chronic!disease,!where!multiple!treatment!options!exist,!where!at!least!one!treatment!option!carries!risks!of!adverse!events,!where!treatment!options!have!the!potential!to!impact!a!patient’s!lifestyle!and!selfMimage,!and!where!there!is!uncertainty!around!the!best!possible!treatment!option.(88,89)!Decisions!made!in!general!practice!care!settings,!such!as!outpatient!physician!visits,!tended!to!garner!more!support!for!the!incorporation!of!SDM,!in!comparison!with!hospitalMbased!management.(84)!MullerMEngelmann’s!qualitative!interview!study!reported!that!physicians!were!less!supportive!of!applying!SDM!to!emergency!medical!situations.(88)!$Quantitative$results!In!support!of!the!qualitative!findings,!one!quantitative!study!reported!higher!levels!of!support!for!SDM!in!scenarios!where!the!riskMbenefit!ratio!does!not!clearly!benefit!one!treatment!option!over!another.!GPs!and!residents!tended!not!to!support!SDM!in!emergency!medical!situations.(66)!  48 !Table$2.3:$Factors$associated$with$perceived$support$or$lack$of$support$for$patient$involvement$in$decision4making$from$the$physician$perspective$*Indicates$qualitative$findings$$Support$for$SDM$ Reduced$support$for$SDM$!PhysicianMrelated$ !No!strong!preference!for!one!treatment!option!based!on!the!available!evidence!(85)*!!!Support!evidence!in!favor!of!one!specific!treatment!option(37,66,86)!!Physicians’!mentors!do!not!support!the!use!of!SDM!(93)*!!!PatientMrelated$ !Cognitively!able!(88)*!Poor!treatment!adherence!(83)*!Desire!to!be!involved!in!decision!(54,88*)!!Informed!about!condition!(54)!!!Cognitively!unable!to!participate!(54,66,68,83*,94*)!!Poor!adherence!(54)!Unwilling!to!participate!(83)!Limited!insight!into!condition!OR!treatment!(54,92*,93*)!!Less!educated!(93)*!Children!(68)!!!ConditionM!and!treatmentM!related$ !Chronic!disease!(66,88,90)!*!Cancer!screening!and!treatment!(57,61–63,67,69)!!End!of!life!care!(66)!Severe!disease!(88)*!Multiple!treatment!options!exist!(88,89)*!!Treatment!options!may!affect!patient’s!lifestyle!(89,94)*!Treatment!options!carry!risks!of!adverse!events!(88)*!!!Chronic!pain!(68)!Emergency!medicine!(66,88*)!Hospital!care,!specific!to!psychiatry!(54)!Diagnostic!procedures!(54)!Pediatric!intensive!care!(92)*!!!  49 $2.4$Discussion$and$conclusion$2.4.1$Summary$of$findings$This!review!provides!a!comprehensive!overview!of!the!current!attitudes!expressed!by!various!physician!specialties!regarding!SDM!(see!table!2.3).!The!quantitative!studies!provide!an!overall!estimate!of!support!for!SDM.!For!example,!of!the!12!studies!that!asked!physicians!about!their!level!of!support!for!SDM,!10!(83%)!reported!either!mild!or!strong!support,!while!2!studies!reported!indifference!toward!SDM.!In!comparison!to!more!paternalistic!or!doctorMcentered!decisionMmaking,!a!shared!or!patientMcentered!approach!was!preferred.!Shared!decisionMmaking!garnered!varying!levels!of!support!depending!on!the!clinical!scenario,!patient!characteristics,!as!well!as!personal!opinions!about!the!available!treatment!options.!For!example,!situations!wherein!the!patient!is!determined!to!be!cognitively!able!and!willing!to!participate!in!treatment!or!disease!management!decisions,!as!well!as!those!treatment!contexts!within!which!multiple!therapeutic!options!exist,!tended!to!garner!high!levels!of!support!as!reported!by!physicians.!Physicians!tended!to!report!lower!levels!of!support!in!scenarios!that!lacked!clinical!equipoise,!in!emergency!scenarios,!where!the!physician!held!a!personal!treatment!preference,!or!where!clinical!guidelines!exist!favoring!one!treatment!option.!!!  50 The!qualitative!findings!provide!further!insight!into!physicians’!rationale!for!supporting!SDM!in!their!practices,!such!as!the!presence!of!existing!guidelines,!the!influence!of!mentors!who!support!SDM,!and!the!potential!influence!of!having!received!training!in!SDM.!In!addition,!qualitative!investigations!were!able!to!identify!a!general!lack!of!consistency!among!physicians!in!terms!of!what!constitutes!SDM.!This!finding!brings!to!light!the!implication!that!prior!to!implementation,!a!shared!understanding!of!what!SDM!truly!is!ought!to!be!well!established.!!With!regard!to!preferred!versus!actual!decisionMmaking!styles,!it!appears!that!although!physicians!support!active!engagement!of!patients,!the!decisionMmaking!process!is!more!frequently!controlled!by!the!physician!alone.!This!finding!supports!the!argument!that!while!SDM!has!garnered!support!throughout!both!the!academic!and!policy!literature,!uptake!has!been!sparse.!!!2.4.2$Limitations$The!results!of!this!review!must!be!considered!in!light!of!the!following!limitations.!Firstly,!all!included!studies!relied!on!physician!selfMreport,!and!thus!may!be!at!risk!for!social!desirability!or!reporting!bias.(66)!SDM!is!advocated!in!the!literature!on!ethical!basis,!thereby!introducing!the!potential!for!an!overMreporting!of!support!for!SDM.(73)!As!such,!this!review!may!overMestimate!the!current!levels!of!support!for!SDM.!!  51 Secondly,!17%!of!the!quantitative!reported!a!response!rate!of!50%!or!less,!and!an!additional!8!(28%)!did!not!report!recruitment!or!response!rates.!All!14!qualitative!studies!and!3!of!the!29!quantitative!studies!(10%)!included!used!a!sample!size!of!less!than!30!participants.!Eleven!(38%)!quantitative!studies!provided!no!indication!of!instrument!validation,!which!may!impact!the!internal!validity!of!survey!or!interview!responses.!There!is!a!risk!of!selection!bias!in!each!of!the!included!studies,!since!those!who!choose!to!participate!in!observational!research!considering!attitudes!toward!SDM!may!report!systematically!higher!levels!of!support,!compared!with!those!who!chose!not!to!respond.!!!The!current!review!was!limited!to!only!peerMreviewed!publications!published!in!English!and!accessed!through!the!University!of!British!Columbia;!therefore,!it!is!possible!that!publication!bias!and!language!bias!limit!the!external!validity!of!the!study!findings.!!!2.4.3$Conclusions$As!has!been!stated!previously,!SDM!from!the!physician’s!perspective,!is!likely!to!provide!the!greatest!value!in!clinical!scenarios!where!there!is!no!single!“correct”!decision,!where!evidence!is!inconsistent!or!absent,!or!where!the!best!decision!is!one!that!is!consistent!with!the!individual!patient’s!lifestyle,!abilities,!values,!and!goals.(8,96)!Further!to!this,!the!successful!implementation!of!SDM!is!not!possible!unless!both!the!patient!and!the!physician!have!the!intention!to!engage!in!a!process!  52 of!mutual!information!exchange!and!understanding.(38)!Physicians!must!have!the!skills!required!to!navigate!difficult!decisions,!and!a!clear!understanding!of!the!methods!available.!Evidence!suggests!that!confidence!in!communicating!with!patients!is!associated!with!a!more!shared!approach!to!decisionMmaking.(81)!As!shown!here,!confusion!may!exist!surrounding!the!distinction!between!information!transfer,!and!a!truly!shared!approach.!This!discrepancy!may!also!explain!patients’!reported!dissatisfaction!with!current!levels!of!involvement!in!the!decisionMmaking!process,!as!shown!previously.(97)!A!recent!review!of!patient!reported!barriers!to!SDM!found!that!even!if!patients!are!able!to!participate!in!treatment!decisions,!they!may!still!feel!unwilling!to!engage!with!their!physicians!due!to!modifiable!factors!such!as!the!belief!that!their!doctors!–!as!experts!–!know!best.(98)!Therefore,!motivation!on!the!part!of!the!physician!to!encourage!patient!participation!may!also!improve!patients’!willingness!to!participate.(70)!Previous!research!shows!that!efforts!geared!at!physician!training!do!increase!SDM!implementation!into!clinical!practice.(8,99)!For!these!reasons,!educational!efforts!directed!at!physicians!to!develop!an!understanding!of!what!constitutes!SDM,!and!what!the!intended!goals!of!an!SDM!approach!are,!may!improve!physician!support.!!2.4.4$Implications$Transitioning!to!an!SDM!approach!may!require!extended!consultation!times,!financial!inputs,!potential!revisions!to!medical!school!training,!as!well!as!an!alteration!to!a!physician’s!common!practice!which!can!be!a!difficult!adjustment,!  53 where!training!and!support!are!both!required.(84,100)!As!a!first!step,!support!for!SDM!must!be!garnered!through!additional!empirical!evidence!regarding!the!outcomes!associated!with!such!interventions.!Although!evidence!to!date!has!focused!on!the!impact!of!SDM!in!terms!of!patient!reported!outcomes!such!as!satisfaction!with!treatment,!decisional!conflict,!and!overall!satisfaction!with!care,!its!impact!on!clinical!outcomes!such!as!treatment!adherence,!hospitalizations,!ER!admissions!and!healthcare!utilization!is!limited.!!!Although!this!review!does!not!identify!physician!consensus!as!to!the!most!appropriate!scenario!within!which!to!assess!the!effectiveness!of!SDM,!as!a!primary!area!of!focus,!the!authors!suggest!assessing!the!impact!of!SDM!within!a!clinical!scenario!such!as!chronic!disease!management!where!multiple!therapeutic!options!exist,!where!the!incorporation!of!patient!values!and!preferences!may!be!evaluated!in!terms!of!both!patientMimportant!and!clinical!outcomes,!and!where!outcomes!such!as!treatment!adherence,!adverse!outcomes,!and!clinical!improvement!or!decline!may!be!measured!longMterm.!!!As!a!next!step!to!this!research!agenda,!I!have!selected!asthma!as!an!appropriate!case!study!within!which!to!ascertain!the!current!state!of!SDM,!as!well!as!to!determine!potential!outcomes!associated!with!exposure!to!SDM.!Chapter!4!will!provide!a!comprehensive!overview!of!the!rationale!for!selecting!asthma!as!a!clinical!scenario!to!further!investigate!the!role!of!SDM.!  54 !!Chapter$3:$The$burden$of$non4adherence$among$adults$with$asthma:$What$is$the$role$for$shared$decision4making?$3.1$Introduction$Shared!decisionMmaking!(SDM)!is!supported!as!a!key!component!for!chronic!disease!management!especially!where!multiple!treatment!options!exist.!Shared!decision!making!requires!that!both!physicians!and!patients!are!actively!engaged!in!the!decisionMmaking!process,!including!information!exchange,!expressing!treatment!preferences,!as!well!as!agreement!over!the!final!treatment!decision.!Although!the!concept!of!SDM!appears!well!supported!by!patients,!practitioners!(see!chapter!2),!and!policy!makers!alike,!the!current!challenge!is!to!determine!how!best!to!make!SDM!a!reality!in!everyday!clinical!practice.!!!As!stated!previously,!much!of!the!literature!shows!that!SDM!may!improve!a!range!of!patient!reported!and!clinical!outcomes!(see!chapter!1!and!2).!However,!SDM!may!not!be!appropriate!for!every!clinical!decision,!nor!has!it!been!shown!to!improve!outcomes!in!all!healthcare!decision!scenarios.(20)!In!light!of!this,!the!results!of!chapter!2!were!used!to!inform!the!selection!of!a!decision!context!a)!that!is!likely!to!garner!support!from!physicians!and!patients,!b)!that!is!preference!sensitive,!c)!within!which!the!role!for!SDM!can!be!illustrated,!and!d)!that!has!measurable!  55 outcomes!that!have!hypothesized!outcomes!related!to!SDM.!Within!the!context!of!asthma,!adherence!rates!to!controller!medications!are!poor!and!are!linked!to!negative!outcomes!such!as!poor!asthma!control,!increased!symptoms,!higher!healthcare!expenditures,!and!lower!patient!quality!of!life.(101–106)!It!has!been!suggested!that!SDM!may!improve!treatment!adherence,!and!that!ignoring!patients’!personal!goals!and!preferences!may!result!in!reduced!adherence.(17)!However,!a!more!comprehensive!understanding!of!the!predictors!of!treatment!adherence!is!warranted,!in!order!to!identify!the!specific!role(s)!that!an!SDM!approach!may!play.!!!Here!I!describe!why!SDM!can!enhance!patient!adherence!in!asthma!management!and!improve!clinical!and!patientMrelated!outcomes,!by!proposing!a!theoretical!framework!that!clearly!identifies!the!potential!role!for!SDM.!In!addition,!I!will!explore!the!reasons!why!SDM!has!not!been!implemented!into!routine!clinical!practice.!!Over!the!past!two!decades,!repeated!calls!have!been!made!to!replace!the!paternalistic!approach!to!treatment!decisionMmaking,!in!support!of!a!more!shared!encounter.(6,10)!Here!I!have!adopted!the!definition!of!SDM!proposed!by!Charles!and!colleagues,!wherein!a!truly!shared!approach!consists!of!both!physician!and!patient!involvement!in!the!process!of!information!exchange,!expression!of!treatment!preferences,!and!agreement!on!the!treatment!plan.(10)!SDM!is!typically!considered!appropriate!when!applied!to!nonMemergency!“preference!sensitive”!treatment!  56 scenarios,!where!multiple!therapeutic!options!exist,!and!where!individual!patient!values,!preferences,!goals!and!lifestyle!choices!play!an!important!role!in!deciding!upon!a!particular!treatment.(1,10,17,107)!Specifically,!in!clinical!scenarios!where!ongoing!selfMmanagement!of!chronic!illness!is!required!on!the!part!of!the!patient,!satisfaction!and!treatment!acceptance!may!be!particularly!important!outcomes!of!the!decision!making!process.(107)!!!3.2$The$burden$of$non4adherence$to$asthma$medications$$Asthma!is!a!chronic!inflammatory!disease!associated!with!airway!hyperMresponsiveness!and!variable!symptoms!including!cough,!wheeze,!breathlessness!and!chest!tightness.(108)!Asthma,!globally,!affects!approximately!300!million!people,!including!21.2!million!in!North!America.(103,109,110)!The!prevalence!of!asthma!is!increasing!due!to!multiple!factors!including!greater!exposure!to!antibiotics!in!infancy,!atopic!sensitization,!changes!in!environmental!exposures!like!pollution!and!allergens,!and!diet.(101)!There!is!also!a!significant!economic!burden!associated!with!asthma!due!to!the!direct!and!indirect!costs!and!death.(111)!Worldwide,!approximately!180,000!people!die!annually!from!asthma.(101)!!!The!primary!aim!of!asthma!management!is!to!achieve!control!and!prevent!future!risk,!most!notably!of!exacerbations.!Patients!with!very!mild!asthma!may!only!require!reliever!medications!but!if!patients!require!relief!more!than!three!times!weekly!they!should!normally!be!prescribed!a!controller!medication.!Controller!  57 treatment!options!vary!in!terms!of!administration!route!(orally,!inhaled!or!injected),!convenience,!ease!and!level!of!skill!required!for!administration,!as!well!as!formulation!and!dosage.(103)!!!Currently,!asthma!control!is!poor!among!all!age!groups,!and!is!associated!with!decreased!quality!of!life,(101)!poor!symptom!control,(104)!more!frequent!use!of!rescue!medications,(104)!increased!health!care!utilization,(102)!and!death.(103,104)!Optimal!control!of!asthma!requires!the!availability!of!medications!and!their!use!in!the!context!of!a!proper!selfMmanagement!strategy.!Adherence!to!the!medication!regimen!is!imperative!in!order!for!the!patient!to!experience!therapeutic!benefits.(102,112,113)!!!Although!effective!medications!exist!to!treat!asthma!symptoms!and!prevent!exacerbations,!adherence!is!subMoptimal.(105,106)!The!term!“adherence”!is!defined!as!the!extent!to!which!a!patient!takes!his!or!her!medication!as!prescribed.(114)!Adherence!therefore!has!three!main!components:!a)!initiation,!b)!implementation,!and!c)!discontinuation.!In!the!case!of!asthma,!especially!when!presenting!in!adulthood,!discontinuation!may!be!rare!because!patients!require!medication!on!a!chronic!basis.!Medication!persistence!is!defined!as!the!length!of!time!between!initiation!and!discontinuation.!As!described!by!Vrijens!et!al.,!nonMadherence!may!occur!by!way!of!nonMinitiation,!taking!medication!in!a!fashion!other!than!what!was!prescribed,!and!early!discontinuation!of!medication.(114)!A!common!type!of!nonM  58 adherence!is!underuse,!when!the!patient!takes!less!medication!than!has!been!prescribed!by!their!physician.(115,116)!!!Asthma!medication!adherence!can!be!classified!as!either!intentional!or!nonMintentional.(112)!Intentional!nonMadherence!occurs!when!the!patient!makes!a!conscious!decision!to!discontinue!use,!and!may!occur!in!the!form!of!total!discontinuation,!or!adopting!a!modified!regimen.!NonMintentional!nonMadherence!may!occur!due!to!a!lack!of!understanding!about!the!medication!regimen,!language!barriers,!or!forgetfulness.!NonMintentional!nonMadherers!may!wish!to!be!more!adherent!to!their!medication,!but!factors!such!as!treatment!complexity,!cost!of!medication!or!the!inability!to!prioritize!their!medication!regimen!prevents!such!patients!from!working!their!medication!plan!into!their!daily!lives.(104)!!The!World!Health!Organization!estimates!that!the!current!rate!of!primary!nonMadherence!M!when!the!patient!fails!to!fill!their!medication!prescription!M!ranges!from!6%!to!44%!of!asthma!patients!worldwide.(104)!Adherence!is!not!a!dichotomous!measurement!in!asthma,!and!levels!of!adherence!fluctuate!greatly.(104,113)!In!general,!adherence!to!longMterm!asthma!treatment!is!poor,!and!varies!according!to!disease!severity.(117,118)!Adherence!to!asthma!medication!may!fluctuate!according!to!seasons,!with!greater!adherence!in!the!Spring!and!Fall,!reflecting!the!presence!of!seasonal!allergies!and!viral!infections.!!Estimates!of!adherence!vary!depending!on!how!adherence!is!defined!in!a!given!setting.!For!example,!Gamble!et!  59 al.!found!that!among!182!difficultMtoMtreat!asthma!patients,!65%!filled!more!than!50%!of!their!controller!medication!prescriptions!over!a!period!of!6!months.(119)!In!a!Canadian!study!of!349!asthma!patients!aged!between!12!and!45!years,!investigators!found!that!only!12%!of!participants!selfMreported!correct!use!of!asthma!medication.(120)!A!recent!British!Columbian!populationMbased!analysis!of!patients!with!asthma!prescribed!combination!therapy!estimated!adherence!rates!of!between!16%!and!32%!over!2!years,!as!measured!by!percentage!of!days!covered.(121)!In!addition,!a!patient’s!adherence!to!asthma!therapies!tends!to!decrease!over!time,!posing!a!challenge!for!longMterm!management.(122)!!!Poor!adherence!to!controller!medications!is!associated!with!a!broad!range!of!negative!outcomes!including!poor!asthma!control,!increased!exacerbations,!increased!cost,!increased!hospitalization!rates,!decreased!quality!of!life,!reduced!lung!function,!and!other!lifestyle!limitations!for!the!patient.(102,113,123–125)!Therefore,!implementation!of!effective!strategies!to!improve!treatment!adherence!will!help!to!reduce!the!associated!negative!consequences,!thereby!minimizing!overall!disease!burden.!!!3.3$Proposed$solutions$$Prospective!studies!that!assessed!the!effectiveness!of!a!variety!of!asthma!interventions!have!shown!inconsistent!findings!on!patient!outcomes.!For!example,!interventions!include!but!are!not!limited!to!asthma!action!plans!(a!step!by!step!  60 strategy!to!manage!symptoms!and!prevent!exacerbations),!educational!interventions,!reminder!systems!and!multifaceted!interventions.(122,126–134)!In!response!to!calls!for!a!more!patientMcentered!approach!to!decision!making,!SDM!has!also!been!proposed!as!a!valuable!tool!to!improve!patientMreported!and!clinically!important!outcomes.(17,22)!As!stated!previously,!The!basic!tenant!behind!SDM!is!that!both!patient!and!physician!exchange!valuable!information!and!agree!on!a!treatment!plan!together.(6,100)!The!key!feature!of!mutual!deliberation!and!agreement!on!the!treatment!plan!further!differentiates!SDM!from!educational!interventions!that!rely!on!uniMdirectional!information!transfer!from!the!healthcare!provider,!to!the!patient.(119)!!!There!is!no!universal!characterization!of!SDM!clinical!encounters.!In!fact,!the!process!of!SDM!may!occur!during!a!single!encounter,!or!over!multiple!encounters.(100)!Towle!and!colleagues!have!provided!a!comprehensive!framework!of!proposed!physician!competencies!for!conducting!an!SDM!encounter!(or!a!series!of!encounters)!(see!Table!3.1).(100)!In!order!for!a!truly!shared!approach!to!be!successful,!patients!must!be!willing!and!able!to!provide!their!own!expertise!in!the!form!of!values!and!preferences.!To!facilitate!this!open!communication!between!patients!and!their!care!providers,!patients!also!need!to!have!a!clear!understanding!of!the!role!that!his!or!her!preferences!play!in!the!decision!process.(6)!!!!  61 Table$3.1:$Physician$competencies$for$SDM$as$proposed$by$Towle$et$al.$(97)$$1.!Develop!partnership!with!patient$$2.!Establish!or!review!the!patient’s!preferences!for!information!$$3.!Establish!or!review!patient’s!preferences!for!role!in!decision!making!and!the!existence!and!nature!of!any!uncertainty!about!course!of!action!to!take$$4.!Ascertain!and!respond!to!patient’s!ideas,!concerns!and!expectations$$5.!Identify!choices!and!evaluate!the!research!evidence!in!relation!to!the!individual!patient$$6.!Present!evidence,!taking!into!account!competencies!2!and!3,!framing!effects!etc.!Help!the!patient!to!reflect!on!and!assess!the!impact!of!alternative!decisions!with!regard!to!his!or!her!values!and!lifestyle$$7.!Make!or!negotiate!a!decision!in!partnership!with!the!patient!and!resolve!conflict$$8.!Agree!on!an!action!plan!and!complete!arrangements!for!follow!up$!!Physicians!may!also!use!objective!measures!of!asthmaMrelated!outcomes!such!as!control!or!adherence!in!addition!to!patientMreported!values!and!preference,!to!aid!in!the!decisionMmaking!process.!!For!example,!throughout!the!process!of!information!ascertainment!and!exchange,!the!physician!may!determine!that!the!patient!is!both!nonMadherent!and!experiencing!frequent!exacerbations!that!are!impacting!his!or!her!quality!of!life.!After!discussing!with!the!patient,!the!physician!may!discover!that!the!cost!of!controller!medication!is!a!primary!barrier!to!adherence.!The!physician!and!patient!may!deliberate!over!this!barrier!and!through!the!process!of!information!  62 exchange,!agree!on!a!treatment!that!balances!cost!with!other!potential!outcomes,!such!as!efficacy!and!side!effects.!!!Patient!decision!aids!(PDAs)!have!been!developed!as!a!tool!to!help!implement!SDM!within!a!range!of!clinical!contexts!including!screening!and!surgical!decisionMmaking,!as!well!as!chronic!disease!management,!including!asthma.(30)!Although!the!application!of!PDAs!alone!does!not!qualify!as!a!shared!approach,!PDAs!may!be!incorporated!into!the!shared!encounter!as!a!means!of!informing!the!patient!about!their!disease!and!treatment!options,!as!well!as!the!associated!risks!and!benefits.!Therefore,!PDAs!can!be!used!as!a!part!of!the!SDM!process,!using!print,!audio,!and!video!formats.(135)!For!example,!by!presenting!the!evidence!about!available!treatment!options!(as!described!above!in!table!3.1)!physicians!may!recommend!a!patient!decision!aid!to!help!the!patient!more!fully!understand!and!comprehend!the!choice!at!hand.!Patient!decision!aids!are!used!to!not!only!to!increase!patient!knowledge,!but!also!to!help!the!patient!clarify!his!or!her!values!by!looking!at!personalized!information!about!the!evidence!and!associated!risks!and!benefits!of!various!treatment!options.(135)!Evidence!suggests!that!PDAs!confer!a!number!of!important!benefits,!including:!decreased!decisional!conflict,!improved!communication!between!patient!and!health!care!provider,!increased!knowledge!about!the!disease!and!treatment!options,!and!improved!patient!trust!in!the!provider.!(23,24,26,136–140)!!!  63 Multiple!systematic!reviews!of!the!PDA!literature!have!been!conducted!over!the!past!several!years,!highlighting!the!outcomes!associated!with!their!application!in!various!disease!contexts.!For!example,!a!2005!review!of!cancerMrelated!PDAs!reported!improved!patient!knowledge!for!screening,!prevention!and!treatment!options.(138)!Among!patients!facing!surgical!decisions,!a!recent!review!reported!that!the!use!of!PDAs!resulted!in!more!conservative!treatment!option!choices,!increased!knowledge!and!reduced!decisional!conflict.(139)!An!earlier!review!of!17!randomized!controlled!trials!across!a!range!of!disease!contexts!found!that!the!use!of!PDAs!was!associated!with!reduced!decisional!conflict!and!increased!knowledge.(137)!Finally,!a!2017!Cochrane!review!of!PDAs!for!treatment!and!screening!decisions!obtained!information!from!105!independent!RCTs.!Investigators!found!that!the!use!of!PDAs!resulted!in!increased!knowledge!among!the!52!studies!that!assessed!knowledge!as!an!outcome.!The!use!of!PDAs!also!resulted!in!decreased!decisional!conflict!(N=63!studies)!and!increased!participation!in!the!decision!making!process!(N=24).(26)!!Reviews!consistently!found!that!the!use!of!PDAs!did!not!systematically!increase!anxiety.(26,137–139)!!!3.3.1$Theoretical$framework$The!proposed!framework!is!adapted!from!de!Vries!et!al.!(2003)!and!Fransen!et!al.!(2009)!and!provides!a!visual!depiction!of!the!various!factors!that!impact!a!patient’s!motivation!to!adhere!to!asthma!controller!medication!(see!figure!3.1).(28,141)!The!proposed!framework!recognizes!that!multiple!factors!impact!a!patient’s!willingness!  64 and!ability!to!adhere!to!their!prescribed!medication,!and!assumes!that!treatment!adherence!requires!patient!motivation.!Motivation,!in!turn,!is!related!to!a!range!of!predisposing!factors.!Specifically,!predictors!of!motivation!include!both!modifiable!(e.g.!knowledge,!attitudes)!and!nonMmodifiable!(e.g.!age!and!sex)!factors!that!serve!to!influence!patients’!attitudes!and!perceived!ability!to!adhere.!An!underlying!assumption!of!the!model!is!that!attitudes!(informed!by!predisposing!factors)!inform!action!in!a!direct!manner.(142)!Finally,!the!framework!recognizes!that!despite!patient!motivation,!additional!barriers!–!both!patientMlevel!and!structural!–!may!negatively!impact!a!patient’s!ability!to!fill!an!initial!prescription!or!take!their!medication!as!prescribed.!Such!barriers!include,!but!are!not!limited!to,!the!cost!of!the!medication,!experienced!side!effects,!or!lack!of!access!to!a!general!practitioner!or!specialist!physician.!!!The!theoretical!framework!has!been!adapted!here!to!include!predictors!of!adherence!that!are!specific!to!asthma!controller!medication.!Below!I!describe!the!predisposing!and!motivational!factors!that!have!been!shown!to!impact!treatment!adherence,!while!highlighting!those!factors!that!are!specific!to!asthma!treatment.!Furthermore,!I!identify!predisposing!and!motivational!predictors!that!can!be!addressed!through!an!SDM!encounter.!$$$  65 Figure$3.1:$Theoretical$framework$!!Figure$legend$Bold!font$indicates!factors!that!are!associated!with!adherence!to!asthma!controller!medications,!as!supported!by!empirical!evidence.!Grey!boxes!indicate!predictors!of!adherence!that!are!addressed!by!SDM!interventions.!66 !3.3.1.1%Predisposing%factors%Predisposing!factors!that!predict!motivation!to!adhere!to!asthma!controller!medications!include!patient’s!behavior,!personality!and!biological!factors,!as!well!as!social!and!cultural!predictors.!!Personality!and!biological!traits!such!as!neuroticism!have!been!shown!to!increase!adherence!to!controller!medications,(143)!as!well!as!patientMreported!“good”!or!“excellent”!perceived!health.(116,120)!African!American!ethnicity,(104,118,144)!lower!comorbidity!scores,(144,145)!mild!asthma!(compared!with!severe!disease),(144,146)!younger!age,(144,145)!!female!sex,!(119,144,145)!the!waxing!and!waning!nature!of!asthma,(147)!as!well!as!recent!hospitalization!(119)!have!all!been!associated!lower!adherence!to!asthma!controller!medications.!Social!and!cultural!factors!such!as!lower!health!literacy,(148)!less!education,(118)!lower!socioMeconomic!status,(149,150)!and!lower!income!(104,118)!have!also!been!shown!to!explain!subMoptimal!adherence.!Knowledge!of!the!disease,!severity,!treatment!options,!treatment!regimen!and!dosage!among!adult!patients!with!asthma,!predicts!increased!adherence,!although!not!to!a!consistently!significant!degree.(118,120,151)!!!3.3.1.2%Motivational%factors%Intentional!medication!adherence!requires!motivation!on!the!part!of!the!patient!to!follow!the!prescribed!medication!plan.!Motivation!is!informed!by!a!patient’s!predisposing!factors!as!well!as!his!or!her!attitude!toward!their!disease,!the!  67 medication,!and!their!healthcare!providers.!Modifiable!motivational!factors!that!are!associated!with!poor!adherence!to!asthma!controllers!include!concerns!about!the!medication!and!dependency,(152)!as!well!as!poor!patientMphysician!relationship.(104)!Finally,!patients!who!report!less!fear!of!medication!side!effects!are!more!likely!to!adhere.(118,120)!Patients!may!also!be!less!inclined!to!adhere!to!medication!if!they!believe!their!treatment!is!ineffective!or!unnecessary.(146)!Some!evidence!suggests!that!fear!of!medication!side!effects!serves!as!an!important!predictor!of!nonMadherence!to!ICS!(118),!and!that!such!concerns!are!common!among!patients.!For!example,!a!survey!study!conducted!with!adult!asthma!patients!being!prescribed!an!ICS!(N=238)!found!that!just!under!half!of!participants!(44%)!reported!worrying!about!the!longMterm!effects!of!their!inhalers.(140)!However,!a!more!a!recent!survey!(N=161)!found!that!approximately!79%!of!patients!reported!low!levels!of!concern!about!their!ICS.(153)!!3.3.1.3%Additional%barriers%Despite!a!patient’s!motivation!to!follow!their!medication!regimen,!various!individualM!and!systemMlevel!factors!may!serve!as!additional!adherence!barriers.!PatientMlevel!factors!include,!but!are!not!limited!to,!forgetfulness,!(154)!complexity!of!treatment!regimen,(104,146)!as!well!as!patient!experience!or!perception!of!potential!medication!side!effects!(152)!including!!bad!taste.(104,119,155)!SystemMlevel!factors!that!serve!as!adherence!barriers!include!access!to!healthcare!or!more!specifically,!an!asthma!specialist,!(115,120,146)!as!well!as!medication!cost.(104)!!  68 !3.3.1.4%Mediating%factors%The!relationship!between!SDM!and!treatment!adherence!is!unlikely!to!be!simple!and!linear,!but!rather!it!incorporates!a!range!of!mediating!factors.(156)!Although!a!direct!association!between!lifestyle!choices!such!as!smoking!and!alcohol!consumption!and!medication!adherence!is!unlikely,!increased!exposure!to!symptom!exacerbating!substances!may!impact!a!patient’s!motivation!to!adhere!to!controller!medication.!For!example,!smoking!has!been!shown!to!impede!the!effectiveness!of!inhaled!corticosteroids.(157)!Therefore,!patients!with!asthma!who!smoke!may!be!less!likely!to!continue!his!or!her!medication!based!on!the!presence!of!persistent!symptoms!and!the!subsequent!belief!that!the!medication!is!ineffective.!Other!lifestyle!choices!such!as!exercise!and!exposure!to!allergens!may!have!a!similar!impact!on!treatment!effectiveness!and!subsequent!adherence.!!!Other!social!factors!such!as!living!alone,!which!may!be!associated!with!advanced!age,!sex!and!the!presence!of!additional!comorbidities,!have!also!been!shown!to!predict!nonMadherence!to!controller!mediations.(158)!Predisposing!patient!characteristics!such!as!illnessMspecific!anxiety!may,!on!the!other!hand,!promote!vigilance!to!disease!related!symptoms.!This!increased!awareness!of!asthma!symptoms!may!therefore!increase!the!likelihood!of!adherence.(159)!When!assessing!the!potential!effectiveness!of!any!intervention!geared!toward!improving!adherence,!  69 one!must!recognize!that!multiple!patientMspecific!and!structural!factors!impact!a!patient’s!willingness!and!ability!to!adhere!to!their!prescribed!medication.!!3.3.1.5%The%role%for%shared%decision.making%In!order!to!ascertain!the!role!for!SDM!in!improving!patient!adherence,!it!is!important!to!identify!the!motivating!factors!that!SDM!encounters!are!able!to!address.!One!of!the!primary!components!of!an!SDM!encounter!is!to!inform!the!patient!of!their!disease!status!and!severity,!as!well!as!the!risks!and!benefits!associated!with!the!available!treatment!options.(10)!Therefore,!SDM!directly!aims!to!increase!patient!knowledge.!Knowledge!serves!as!an!important!information!factor!included!in!Fransen’s!adapted!theoretical!framework,!as!a!predictor!of!motivation!to!adhere.!!!In!addition,!recent!investigations!have!shown!that!SDM!positively!influences!patient!attitudes!towards!their!disease,!treatment!options!and!healthcare!providers,!by!increasing!patient!satisfaction,!satisfaction!with!the!treatment!decision,!patient!participation,!emotional!status,!and!by!reducing!decisional!conflict,!within!various!decision!contexts.(25,46,47,156,160,161)!Factors!such!as!these!are!situated!under!the!motivational!predictors!of!adherence!in!the!adapted!theoretical!framework.!Interventions!or!decision!support!techniques!that!are!adapted!to!a!patient’s!personal!attributes!(predisposing!factors)!with!the!objective!of!increasing!  70 knowledge!(informational!factors)!are!in!turn!linked!to!improved!attitude!and!selfMefficacy!(motivational!factors)!(see!figure!3.1).!!!!While!increased!communication!between!patients!and!their!caregivers!may!have!direct!therapeutic!effects!such!as!reducing!patient!anxieties,(162)!SDM!is!likely!to!further!work!in!an!indirect!manner!by!appealing!to!patients!predisposing!social,!cultural!and!behavioral!characteristics.!For!example,!the!physician!or!care!team!may!apply!a!decision!aid!tailored!to!a!patient’s!specific!level!of!education!or!health!literacy,!thereby!increasing!knowledge!and!improving!attitudes!and/or!feelings!of!selfMefficacy.!Patient!empowerment!through!increased!knowledge!or!ownership!of!the!decision!may!further!increase!an!individual’s!perceived!ability!to!adhere.!Additionally,!through!the!process!of!information!exchange,!providers!will!consider!patientMimportant!factors!such!as!lifestyle!and!abilities!when!discussing!and!weighing!appropriate!treatment!options.!Furthermore,!SDM!promotes!communication!between!patients!and!their!caregivers,!which!has!itself!been!shown!to!increase!trust,!as!a!predictor!of!motivation!to!adhere.(163)!!The!results!of!chapter!2!show!that!there!are!multiple!patientMrelated!factors!that!physicians!believe!to!be!important!in!determining!whether!or!not!to!apply!an!SDM!model!of!care.!For!example,!physicians!tend!to!support!SDM!in!scenarios!where!patients!hold!knowledge!about!their!condition!as!well!as!the!treatment!options.!As!shown,!SDM!may!work!directly!to!improve!patient!knowledge!and!awareness,!  71 thereby!potentially!fostering!increased!support!for!engagement!from!their!physicians.!!!3.3.1.5.1!Existing!evidence!!Previous!investigations!have!provided!strong!evidence!supporting!the!relationship!between!SDM!and!subsequent!adherence,!both!within!asthma,(17)!as!well!as!other!chronic!disease!settings.(164)!A!study!published!in!2010!assessed!the!impact!of!a!SDM!intervention!on!multiple!asthma!related!outcomes!such!as!treatment!adherence.(17)!The!3Marm!randomized!controlled!trial!was!conducted!among!poorly!controlled!asthma!patients!to!determine!the!effect!of:!a)!a!SDM!intervention;!b)!a!clinical!decision!making!(CDM)!intervention!wherein!patient!goals!and!preferences!were!not!elicited!and!the!asthma!care!managers!recommended!a!treatment!option!to!the!patient!based!on!current!asthma!guidelines;!and!c)!usual!care.!The!average!lengths!of!the!initial!SDM!and!CDM!intervention!visits!were!106!and!77!minutes,!respectively.!!!Compared!with!the!usual!care!control!group,!SDM!intervention!patients!were!more!adherent!over!the!12Mmonth!follow!up!(p<0.001),!had!better!asthma!control,!(p=0.002),!fewer!asthmaMrelated!medical!visits!(p=0.0161)!and!higher!quality!of!life!scores!(p<0.001).!Over!the!12Mmonth!follow!up!period,!adherence!in!the!SDM!intervention!arm!was!significantly!higher!than!the!CDM!arm!(p!=0!.029).!!!  72 Patients!in!the!SDM!arm!acquired!more!beclomethasone!canister!equivalents)!(p=0.005),!inhaled!corticosteroidM!long!acting!beta!antagonist!(ICSMLABA)!and!combination!inhalers!(p=0.005),!compared!with!the!CDM!arm.!Patients!in!the!SDM!intervention!arm!showed!improved!asthma!control!(p=0.42),!and!improved!quality!of!life!(p=0.33),!although!not!to!a!statistically!significant!level.!At!followMup!year!1,!the!mean!adherence!for!the!SDM!group!was!67%!compared!with!59%!in!the!CDM!arm!(p=!0.029)!and!46%!in!the!usual!care!arm!(p=!<0.0001).!Adherence!was!measured!using!continuous!medication!acquisition!for!all!controllers.!The!adherence!measure!ranged!from!0M100%!with!100%!indicating!perfect!adherence!over!the!follow!up!period.!!Over!the!2Myear!follow!up,!adherence!to!all!controllers!remained!higher!in!the!SDM!intervention!arm!(approximately!47%)!compared!with!CDM!(approximately!42%);!however,!the!difference!was!not!statistically!significant!(p=0.34).!Adherence!in!the!usual!care!group!was!slightly!higher!than!that!of!the!CDM!arm,!at!2Myear!follow!up!(approximately!43%).!As!well,!SDM!intervention!patients!showed!significantly!higher!regimen!potency!(p=0.04)!and!use!of!combination!inhalers!at!2Myear!follow!up.!Although!results!were!not!statistically!significant!in!year!1!or!2,!patients!in!the!SDM!arm!also!used!less!rescue!medications,!which!may!be!interpreted!as!an!indicator!for!a!greater!reduction!in!asthma!symptoms!among!SDM!intervention!patients!compared!with!CDM!patients.!This!result!is!important!from!a!riskMreduction!  73 standpoint,!wherein!negative!health!outcomes!such!as!ER!admissions!and!increased!healthcare!costs!are!associated!with!excessive!use!of!rescue!medication.(165–167)!!!The!SDM!intervention!was!successful!in!addressing!both!predisposing!and!motivational!predictors!of!adherence.!Via!the!use!of!information!provision,!identifying!patient!goals!and!preferences,!discussing!treatment!options!in!light!of!patientMreported!goals!and!preferences,!and!negotiation!of!a!final!treatment!decision,!the!SDM!intervention!improved!a!range!of!asthmaMrelated!outcomes,!particularly!over!the!12Mmonth!period.!The!increased!medication!adherence!and!potency!and!decreased!use!of!rescue!medications!in!the!SDM!arm!may!be!interpreted!as!indicators!not!only!of!improved!knowledge!and!attitudes!about!their!disease!and!treatment!plan,!but!also!their!perceived!locus!of!control!and!selfMefficacy.!As!previously!argued,!SDM!may!empower!patients!and!provide!them!with!the!confidence!to!manage!their!disease,!and!increase!the!perception!that!they!are!in!control!of!their!illness.!!!Despite!the!promising!results,!several!years!have!passed!since!this!trial!was!published!yet!little!progress!has!been!made!towards!implementing!SDM!into!clinical!practice.(27)!Since!SDM!is!so!well!supported!throughout!the!policy!and!academic!literature,!and!interventions!such!as!this!one!have!shown!to!be!effective!in!improving!various!patient!and!clinically!important!outcomes,!why!is!it!not!commonplace!in!clinical!settings?!  74 !3.4$Implementation$challenges$As!is!so!often!the!case,!challenges!arise!when!attempting!to!implement!interventions!into!clinical!practice!that!have!proven!themselves!to!be!effective!within!the!confines!of!wellMfunded!and!controlled!research!venues.!As!described!above,!although!Wilson!et!al.’s!findings!are!promising,!one!concern!is!whether!a!similar!intervention!could!be!successfully!implemented!into!practice,!since!healthcare!budgets!tend!not!to!provide!funding!for!allied!health!professionals!to!educate!asthma!patients.!Additionally,!the!time!required!to!complete!similar!interventions!may!not!be!feasible.!A!recent!review!conducted!by!Stacey!and!colleagues!found!that!the!average!time!to!complete!a!decision!aid!intervention!is!24!minutes.(26)!Particularly!in!areas!that!adhere!to!feeMforMservice!physician!payment!models,!a!lengthily!time!investment!may!be!an!insurmountable!barrier!to!implementation.!When!asked,!physicians!frequently!cite!the!time!required!to!engage!patients!as!a!significant!deterrent!to!implementing!SDM!into!their!practice.(168)!Further!to!this,!the!costs!associated!with!the!proposed!intervention!and!associated!time!ought!to!be!carefully!considered!in!conjunction!with!the!potential!benefits.!!!Structural!processes!may!serve!as!additional!impediments!to!SDM!through!limiting!the!choice!of!treatments!available.!For!example,!under!specific!health!insurance!structures,!especially!those!with!limited!list!formularies,!physicians!may!be!permitted!to!offer!only!a!selection!of!the!available!treatment!options.!In!these!cases,!  75 the!role!for!patient!values!and!preferences!may!be!limited!in!light!of!fewer!treatment!options.!!!More!recently,!investigations!have!begun!to!assess!efforts!to!incorporate!SDM!into!clinical!practice.(22,169–171)!Tapp!and!colleagues!engaged!patient!and!healthcare!providers!in!implementing!an!asthmaMrelated!SDM!delivery!intervention!into!6!practices!in!the!United!States.(22)!The!intervention!was!well!received!by!both!patients!and!physicians,!and!participating!practices!intended!to!continue!the!intervention!beyond!the!completion!of!the!study.!Although!this!particular!study!did!not!assess!outcomes!such!as!improvement!in!asthma!control,!adherence!or!patient!satisfaction!with!treatment,!it!is!a!first!step!to!address!the!ongoing!challenge!of!incorporating!SDM!into!clinical!practice.!However,!the!limited!evidence!that!has!been!produced!with!regard!to!SDM!implementation!further!supports!the!need!for!a!more!comprehensive!assessment!of!the!current!state!of!SDM!in!current!practice.!3.5$Research$implications$While!policy!makers,!physicians!and!their!patients’!support!increased!patient!engagement,!the!evidence!particularly!regarding!clinically!important!outcomes!associated!with!SDM!has!been!slower!to!develop.!Within!the!context!of!asthma,!strong!evidence!suggests!that!SDM!interventions!can!provide!benefits!related!to!adherence,!control!and!symptom!resolution.!However,!little!has!been!done!in!the!last!several!years!to!implement!SDM!into!the!clinical!areas!that!promise!the!most!benefit.!Here,!I!suggest!that!future!research!investigations!seek!not!only!to!  76 determine!the!efficacy!of!SDM!interventions,!but!also!to!provide!insight!into!the!more!prominent!effectiveness!challenges,!namely!implementation!into!clinical!practice!settings.!!Chapter!4!will!provide!the!groundwork!for!a!more!comprehensive!investigation!into!the!role!for!SDM!in!asthma!management.!Using!a!large,!population!based!sample!of!adult!asthma!patients!living!in!British!Columbia,!I!will!answer!the!following!two!research!questions:!1.! What!is!the!prevalence!of!nonMadherence!among!adult!asthma!patients!who!are!currently!being!prescribed!controller!medication?!2.! To!what!extent!can!variables!related!to!individual!patient!demographics!and!disease!severity!use!explain!variation!in!adherence?!!Investigating!these!two!research!questions!will!allow!me!to!further!establish!asthma!as!an!appropriate!venue!within!witch!to!ascertain!outcomes!related!to!SDM.!Furthermore,!I!aim!to!highlight!the!issue!that!adherence!is!a!complex!phenomenon!and!variation!is!likely!to!be!influenced!by!multiple!factors,!at!least!some!of!which!can!be!addressed!through!the!patientMphysician!encounter.!! $  77 Chapter$4:$Variation$in$adherence$to$controller$medications$in$British$Columbia:$A$population4based$analysis$!4.1$Background$As!described!in!chapter!3,!asthma!results!in!a!heavy!patient!and!healthcare!systemMlevel!burden!in!many!jurisdictions!including!British!Columbia,(172)!and!adherence!to!asthma!therapies!is!subMoptimal!among!both!pediatric!and!adult!patients.(105,106,121,145,173)!Disease!control!is!directly!related!to!adherence!to!controller!medications,!and!is!consistently!poor!among!asthma!patients.(105)!Furthermore,!poor!control!is!associated!with!decreased!quality!of!life,!increased!healthcare!expenditures,!and!in!the!absence!of!regular!antiMinflammatory!therapy,!potentially!death.(103,105,111,174)!An!important!aspect!of!evaluating!adherence!and!preventing!nonMadherence!is!to!identify!factors!that!are!associated!with!nonMadhere!to!controller!medications.!The!present!chapter!consists!of!a!populationMlevel!multivariate!analysis!to!investigate!demographic!and!disease!related!variables!that!are!associated!with!treatment!nonMadherence.!!!4.1.1$Evidence$gaps$Multiple!studies!have!been!conducted!to!assess!the!potential!impact!of!both!modifiable!and!nonMmodifiable!factors!on!treatment!adherence,!but!uncertainties!  78 remain!with!regard!to!the!role!of!various!patientMrelated!factors.!Prior!to!selecting!variables!for!the!current!analysis,!a!brief!review!of!the!literature!was!conducted!to!determine!which!administrative!data!variables!have!been!used!previously!to!address!issues!related!to!asthma!controller!use.!A!review!of!these!studies!provided!insight!into!how!best!to!capture!concepts!such!as!disease!severity,!using!pharmacy!records!databases.!The!review!produced!two!types!of!primary!data!collection!studies,!those!that!do!not!explicitly!provide!associations!between!explanatory!variables!and!treatment!adherence!(see!appendix!C),!and!those!that!explicitly!consider!predictors!of!controller!adherence!(table!4.2).!Based!on!the!results!of!the!literature!review,!table!4.1!describes!both!modifiable!and!nonMmodifiable!factors!that!have!been!shown!to!predict!adherence!and!nonMadherence!to!asthma!controller!medication,!using!both!experimental!and!observational!study!designs.!Some!factors!listed!as!“modifiable”!may!be!considered!to!be!more!longMterm!goals!of!increased!communication!between!patients!and!their!care!givers!(e.g.!changing!beliefs!and!attitudes!about!medication!necessity).!For!example,!the!role!of!age,(175–178)!sex,(145,178,179)!communication!with!healthcare!providers,(145,175,177)!has!not!been!adequately!established!using!the!available!literature.!While!some!evidence!supports!the!claim!that!lower!socioMeconomic!status!is!associated!with!poor!adherence,!results!across!studies!have!not!been!consistent.(145,175,179–181)!At!least!some!of!the!variation!in!study!findings!may!be!due!to!the!considerable!variation!in!study!designs,!definitions!used!for!adherence,!as!well!as!the!source!and!objectivity!of!the!information!obtained.!Developing!a!clear!picture!of!the!factors!that!  79 are!associated!with!variation!in!adherence!will!aid!in!the!development!of!strategies!geared!toward!increasing!adherence!among!atMrisk!populations.!!!Table$4.1:$Factors$independently$associated$with$adherence$and$non4adherence$to$asthma$controller$medication$%$$ Non4modifiable$factors$$ (Potentially)$Modifiable$factors$$$Factors$associated$with$higher$adherence%!•! Female!sex,(179)!!•! Higher!age!(177,178,182)!!•! Increased!length!of!time!since!diagnosis!(181)!•! Greater!asthma!severity!(177,178,182)!!!!•! Higher!selfMreported!mental!health!scores!(as!measured!using!theSFM36)(181)!•! Length!of!time!a!patient!spends!with!prescriber!(177)!•! Increased!selfMperceived!asthma!severity!(179,181)!!•! Presence!of!a!fixed!asthma!medication!routine!(179)!!•! Having!taken!physician’s!advice!regarding!medication!(179)!•! Belief!that!controller!medication!is!important!(179)!!•! Belief!that!controller!medication!is!effective!(179,181)!•! Belief!that!controller!medication!is!necessary!(175)!•! Understanding!the!benefits!of!ICS!(118)!•! Belief!in!the!benefit!of!asthma!exacerbation!trigger!avoidance!(181)!•! Higher!number!of!metered!dose!instructors!(e.g.!physicians,!respiratory!therapists,!nurses)!(181)!•! Once!daily!medication!regimen!(versus!>once!daily!regimen)!(182)!!!$Factors$associated$with$higher!non4adherence%!•! African!American!ethnicity!(118,145,182)!!•! Younger!age!(145)!!•! Female!sex!(118,145,182)!•! Impulsivity!(183)!!•! Lower!rescue!medication!use!(145)!•! Doubts!about!medication!necessity!or!importance!(175,179)!!•! Perceived!lack!of!asthma!symptoms!(179)!!•! Fear!of!side!effects!(175)!•! Poor!communication!with!health!care!  80 Table$4.1:$Factors$independently$associated$with$adherence$and$non4adherence$to$asthma$controller$medication$%$$ Non4modifiable$factors$$ (Potentially)$Modifiable$factors$! provider(180)!•! Concerns!about!medication!(175)!•! Lower!education!(180)!! !!Results!of!the!literature!review!show!that!administrative!variables!used!to!consider!research!questions!related!to!asthma!include!patient!demographics!(e.g.!age!and!sex),(117,178,184)!comorbidities,(117)!socioeconomic!status!(e.g.!social!assistance!status!and!area!of!residence),(117,178,184)!inpatient!and!outpatient!health!resource!use!(e.g.!emergency!department![ED]!and!outpatient!visits),(121,178,184)!and!indicators!for!asthma!severity!and!control!(e.g.!short!acting!beta!agonist![SABA]!and!oral!corticosteroid![OCS]!use).(117,121,178).!One!study!also!considered!the!number!of!prescribing!physicians!and!prescribing!physician’s!specialty!(see!appendix!C).(184)!Likely!due!to!the!fact!that!inhaled!corticosteroids!(ICS)!are!most!commonly!prescribed!as!part!of!longMterm!asthma!treatment,!such!medications!were!consistently!included!in!the!outcome!measure.!!Table!4.3!shows!the!methods!and!results!of!three!studies!that!were!conducted!to!explicitly!explore!predictors!of!controller!medication!adherence,!using!pharmacy!records!databases.!Jones!et!al!(2003)!sought!to!determine!whether!adherence!differed!between!patients!being!prescribed!oral!versus!inhaled!controller!therapy,!using!pharmacy!claims!data.(185)!Authors!investigated!differences!in!adherence!  81 rates!across!treatment!regimens.!A!more!recent!study!conducted!by!Wells!et!al!(2013)!investigated!whether!once!versus!multiple!daily!dosing!of!controller!medication!predicted!treatment!adherence,!using!data!extracted!from!an!electronic!prescribing!database.(182)!Finally,!Taylor!et!al!(2014)!investigated!the!role!of!various!demographic!and!disease!related!predictors!of!adherence!to!ICS!medication,!using!the!UK’s!Clinical!Practice!Research!Datalink!(CPRD)!database.(177)!!!Across!the!three!studies,!patientMlevel!factors!related!to!increased!adherence!included!older!age,(177,182,185)!exacerbations,(177)!and!previous!adherence.!In!addition,!annual!improvement!in!severity!status!was!associated!with!increased!adherence!to!ICS.!Conflicting!results!can!be!seen!with!regard!to!the!impact!of!disease!severity!on!adherence.(177,182,185)!One!study!considered!the!role!of!continuity!of!care,!as!indicated!by!the!length!of!time!that!the!patient!spent!in!the!cohort,!and!therefore!with!a!prescriber.(177)!Considering!the!evidence!from!the!three!existing!investigations!into!adherence!using!administrative!data,!the!role!of!socioeconomic!status,!sex!and!continuity!of!care!and!disease!severity!are!not!well!established.(177,182,185)!As!shown!in!table!4.2,!pMvalues!are!not!consistently!reported!in!the!individual!studies.!!!!!82 Table&4.2:&Primary&data&collection&studies&utilizing&administrative&data&explicitly&assessing&predictors&of&adherence&to&controller&medication&of&effect&in&relation&to&higher&adherence&&First&author&(date&of&publication)&N& Medications&included&in&definition&of&“controller”&(Adherence&measure)&&Explanatory&variable&(indicator)&&Direction&of&effect&(PHvalue)&Jones,'2003'(185)' 23,225' ICS,'LTRA,'LABA'(sum'of'days’'supply'of'prescriptions'dispensed'from'index'prescription'date'to'last'refill'date/'duration'of'therapy)'Number'of'SABA'prescriptions'(Disease'severity)'''Age'Increased'(PNvalue'not'reported)''Increased'(PNvalue'not'reported)'Wells,'2013'(182)' 1302' ICS' Age' '''Female'sex''Number'of'oral'corticosteroid'and'SABA'fills'in'the'year'prior'to'the'index'date'(Disease'severity)''Patient'being'prescribed'additional'controller'medication'Increased'(PNvalue'not'reported)'''Not'reported''Increased'(PNvalue'not'reported)'''Not'reported'Taylor,'2014'(177)' 97,456' ICS'(Prescription'possession'ratio)' Age'(years)'''The'number'of'years'patient'spent'in'the'cohort'(Continuity'of'care)''Average'SABA'doses'per'day'(Asthma'control)''BTS/SIGN'guidelines'indicators'for'asthma'Increased'(P<.05)'''Increased'(P<.05)'''Increased'(P<.05)''Decreased'83 Table&4.2:&Primary&data&collection&studies&utilizing&administrative&data&explicitly&assessing&predictors&of&adherence&to&controller&medication&of&effect&in&relation&to&higher&adherence&&First&author&(date&of&publication)&N& Medications&included&in&definition&of&“controller”&(Adherence&measure)&&Explanatory&variable&(indicator)&&Direction&of&effect&(PHvalue)&severity''Number'of'exacerbationNrelated'hospitalizations'and'asthma'exacerbations'treated'in'primary'care'(Exacerbations)''Previous'adherence'''Annual'improvement'in'asthma'severity'status''(P<.05)''Increased'(P'<.05)''''Increased'(P<.05)'''Increased'(P<.05)'''''84 Regarding)the)outcome)measure)used)to)estimate)adherence,)there)is)a)lack)of)consistency)regarding)the)specific)medications)included.)The)two)more)recent)analyses)include)only)ICS)in)the)definition)of)adherence,(177,182))while)Jones)et)al)(2003))include)ICS,)LTRA,)and)LABA)medications.(185))Likely)due)to)the)frequency)of)ICS)prescriptions,)ICS)are)consistently)included)in)the)adherence)outcome)measure.(117,121,177,178,182,184,185))))Based)on)the)existing)literature,)several)evidence)gaps)exist.)Firstly,)to)the)best)of)my)knowledge,)no)comprehensive)populationPlevel)analysis)has)considered)demographic)and)diseasePrelated)predictors)of)adherence,)where)the)outcome)measure)includes)all)controller)medications.)Doing)so)will)capture)patients)who)switch)controller)medications)during)the)study)period,)but)maintain)overall)adherence.)))Secondly,)the)role)of)continuity)of)care)is)not)well)established)and)warrants)further)investigation.)Specifically,)understanding)the)underlying)mechanism)that)links)regular)communication)with)one)or)a)few)prescribing)healthcare)providers)to)adherence)may)further)highlight)the)importance)of)the)patientPphysician)relationship.))Thirdly,)the)current)evidence)does)not)provide)an)overall)estimate)of)the)extent)of)variation)in)adherence)that)can)be)explained)by)specific)predisposing)predictors)of)adherence)(see)chapter)3)theoretical)framework),)such)as)demographic)and)85 severityPrelated)variables.)Providing)an)overall)coefficient)of)variation)will)aid)in)determining)whether)additional)patientPlevel)variables)ought)to)be)more)carefully)considered)when)both)predicting)and)explaining)adherence)in)this)population.)This)may)further)establish)the)role)of)SDM)to)address)informational)and)motivating)predictors)of)adherence)(see)chapter)3)theoretical)framework).)))Finally,)no)previous)populationPlevel)analysis)has)specifically)sought)to)determine)the)extent)to)which)adherence)to)controller)medication)varies)by)calendar)month.)This)analysis)will)add)to)the)existing)literature)by)investigating)monthly)variation)in)adherence)over)a)onePyear)period.)As)previously)stated,)prospective)analyses)using)annual)measures)of)adherence)typically)show)low)adherence.)One)hypothesis)to)explain)this)finding)is)that)adherence)may)fluctuate)according)to)environmental)triggers)that)are)attributable)to)seasonality,)even)in)light)of)the)fact)that)controller)medication)is)intended)to)be)taken)regardless)of)the)presence)of)symptoms.(186–188))Simple)yearlong)measures)of)adherence)fail)to)capture)the)potential)for)seasonal)variability.)For)example,)healthcare)use)such)as)ED)admissions)have)been)shown)to)increase)during)the)spring)and)fall)months,)among)both)pediatric)and)adult)populations.(188,189))Correspondingly,)it)is)possible)that)adherence)to)controller)medication)may)follow)a)similar)pattern.)Although)this)phenomenon)has)been)suggested,)limited)populationPlevel)evidence)exists)to)support)this)claim.)Previous)evidence)supports)the)argument)that)patients)in)generally)good)health)have)less)incentive)to)adhere)to)their)treatment)plan,)while)adherence)improves)in)the)presence)of)increased)exacerbations.(177))Providing)a)more)comprehensive)86 description)of)the)extent)to)which)patients)in)various)severity)categories)practice)seasonal)variation)in)adherence)may)serve)as)a)useful)tool)to)physicians)treating)asthma)patients,)specifically)to)identify)patients)with)severe)and)uncontrolled)disease)who)may)benefit)from)increased)and)consistent)adherence)to)their)treatment)plan.)))4.1.2%Research%objectives%The)purpose)of)the)current)analysis)is)to)address)the)following)two)primary)research)questions:))a)! Research)question)1:)What)are)the)characteristics)of)asthma)patients)who)do)not)fill)their)controller)prescriptions)during)a)onePyear)period?)b)! Research)question)2:)Which)demographic)and)diseasePrelated)factors)can)explain)variation)in)adherence)to)controller)medications?))and)the)following)secondary)research)question:)c)! Research)question)3:)Does)adherence)to)controller)medications)vary)by)calendar)month?)All)inferences,)opinions,)and)conclusions)drawn)in)this)study)are)those)of)the)authors,)and)do)not)reflect)the)opinions)or)policies)of)the)Data)Steward(s).)%87 4.2%Methods%4.2.1%Patient%cohort%%The)BC)provincial)health)insurance)program)collects)information)on)the)health)resource)use)of)every)legal)BC)resident.)Population)Data)BC)provides)data)linkage)as)well)as)access)to)the)health)services)database.(190))For)the)current)study,)data)for)fiscal)years)1997)to)2011)were)retrieved.(191–194))The)following)components)were)extracted)from)the)vital)statistics,)registry)and)census)databases:)patient)demographics,)neighborhood)income,)and)registration)status)of)each)subject)with)the)BC)provincial)health)plan.(121))Secondly,)the)Medical)Services)Plan)(MSP))collects)all)outpatient)services)that)result)in)a)billing)record)and)includes)at)least)one)ICDP9)code)for)the)service.)In)addition,)MSP)captures)the)cost)of)the)service)and)the)specialty)of)the)healthcare)professional)issuing)the)code.)Thirdly,)BC)PharmaNet)Database)records)drug)dispensations)in)BC,)except)for)those)of)First)Nations,)The)Royal)Canadian)Mounted)Police,)and)the)military.(121)))Patients)were)considered)to)have)asthma)using)a)validated)case)definition.(195,196))The)definition)required)each)patient)to)have)at)least)one)of)the)following)criteria)within)a)12Pmonth)period)between)1997)and)2011:)one)or)more)asthmaPrelated)hospitalization)(codes)of)the)International)Classification)of)Diseases)9th)edition)(ICDP9):)493.x,)10th)edition)(ICDP10):)J45,)J46);)two)or)more)physician)visits)with)diagnostic)ICD)codes)of)asthma;)or)filling)four)or)more)prescriptions)for)asthmaPrelated)medications)(see)figure)4.1).)For)the)current)analysis,)patients)were)required)to)satisfy)the)case)definition)of)asthma)described)above,)and)to)have)filled)at)least)88 one)prescription)for)an)ICS)within)the)12Pmonth)period)prior)to)the)index)date.)The)purpose)of)requiring)a)previous)prescription)for)an)ICS)was)to)increase)the)probability)that)the)analytic)sample)would)include)only)asthma)patients)who)were)being)prescribed)controller)medications)on)a)longPterm)basis.)I)sought)to)exclude)mild)asthma)patients)who)were)not)being)prescribed)controller)medications)for)their)ongoing)disease)management.))))Figure%4.1:%Study%process%))The)sample)was)further)limited)to)adult)patients)between)the)ages)of)18)and)55.)Adults)above)the)age)of)55)were)excluded)to)reduce)the)likelihood)that)those)with)chronic)obstructive)lung)disease)(COPD))may)be)falsely)categorized)as)having)asthma.(196))12%month%period%leading%up%to%index%date:Any)one)of)the)following:)one)or)more)asthmaPrelated)hospitalisation)(codes)of)the)International)Classification)of)Diseases)9th)edition)(ICDP9):)493.x,)10th)edition)(ICDP10):)J45,)J46);)two)or)more)physician)visits)with)diagnostic)ICD)codes)of)asthma;)or)filling)four)or)more)prescriptions)for)asthmaPrelated)medications)ANDPatient)filled)at)least)one)ICS)prescription)during)the)12Pmonth)period)prioir)to)the)index)dateIndex%date:Date)that)patient)met)the)inclusion)criteriaStudy%period:12)months)following)index)date89 )The)“index)date”)was)defined)as)the)date)at)which)each)patient)met)the)asthma)case)definition.)Patients)included)in)this)analysis)were)required)to)be)enrolled)in)the)database)for)12)months)leading)up)to)the)index)date,)and)12)months)following)the)index)date,)in)order)to)be)able)to)ascertain)a)12Pmonth)measure)of)adherence.))Each)patient)was)followed)for)12)months)following)the)index)date)for)the)purposes)of)this)analysis,)in)order)to)assess)adherence.)Therefore,)the)study)period)constitutes)the)12Pmonth)time)frame)following)the)index)date.))4.1.2%Statistical%methods%4.2.2.1%Primary%outcome%variable%Controller)medications)were)defined)as)ICS,)ICS)with)LABA,)LABA)alone,)leukotriene)receptor)antagonists)(LTRA))or)theophylline.)Adherence)was)defined)as)the)proportion)of)days)covered)(PDC))during)the)followPup)period.)Proportion)of)days)covered)was)calculated)as)the)number)of)days)in)the)onePyear)period)following)the)index)date.)Therefore,)a)PDC)of)1)(or)100%))indicates)that)the)patient)filled)enough)prescriptions)to)be)covered)for)an)entire)year)(365)days),)suggesting)perfect)adherence.)A)PDC)of)0)(or)0%))indicates)that)a)patient)did)not)fill)a)single)asthma)controller)prescription)during)the)index)period)(e.g.)0)days)covered).)Proportion)of)days)covered)is)a)commonly)used)and)recommended)measure)of)adherence)calculated)using)administrative)data.(195,197–199))In)contrast)to)other)measures)such)as)the)medication)possession)ratio)(MPR),)PDC)provides)a)more)conservative)90 estimate)of)adherence,)and)does)not)allow)for)a)calculation)above)100%)(as)it)does)not)double)count)medications)with)overlapping)prescription)times).The)use)of)PDC)has)been)validated)in)multiple)disease)contexts.(200)))To)assess)the)prevalence)of)seasonal)variation)in)adherence,)an)indicator)variable)was)calculated)to)determine)whether)or)not)each)patient)filled)a)controller)medication)prescription)during)each)individual)month)of)follow)up.)))4.2.2.2%Explanatory%variables%Demographic)explanatory)variables)include)neighborhood)income)quintile)as)an)indicator)for)socioeconomic)status)(neighborhood)income)quintile),)sex,)and)age.)%The)BicePBoxerman)continuity)of)care)(CoC))measure)was)included)in)the)current)analysis.(201))The)measure)captures)the)extent)to)which)the)patient)visited)multiple)care)providers)during)the)12Pmonths)prior)to)the)index)date.)A)CoC)measure)of)1)indicates)that)the)patient)saw)exactly)one)GP)or)specialist)during)this)period.)As)the)CoC)score)decreases,)a)greater)number)of)care)providers)were)visited,)indicating)a)lack)of)CoC.(201))Previous)evidence)shows)that)higher)CoC)is)linked)to)lower)healthcare)expenditures,)and)higher)overall)quality)of)care.(201))In)addition,)CoC)may)be)an)indicator)of)patientPphysician)communication,(202))which)in)turn)may)predict)treatment)adherence)(see)chapter)3).)Continuity)of)care)related)to)GP)visits)was)indicated)by)an)outpatient)visit)with)the)general)practitioner)(ICD)code:)00).)Continuity)of)care)related)to)specialist)physicians)was)indicated)by)an)outpatient)91 visit)with)codes)related)to)internal)medicine,)clinical)immunizations)and)allergy,)and)respirology)(ICD:)codes)15,)45)and)49).(203,204)%)Frioozi)et)al.)have)developed)a)combined)measure)to)estimate)asthma)severity)based)on)administrative)health)data.)The)measure)categorizes)patients)into)“mild,”)“moderate,”)and)“severe”)disease)based)on)previous)12Pmonth)average)daily)doses)of)ICS,)LABA,)LTRA,)theophylline,)SABA,)as)well)as)indicators)for)asthma)exacerbations,)such)as)the)use)of)oral)corticosteroids,)asthmaPrelated)ED)admissions,)and)hospitalizations.(182,205,206))This)measure)has)been)validated)against)the)Canadian)Asthma)Consensus)Guidelines,)is)correlated)with)lung)function,)asthmaPrelated)hospitalizations)and)asthma)exacerbations,(195,205))and)has)been)used)in)previous)studies)as)a)measure)of)severity)using)administrative)data.(195,196,207))To)describe)healthcare)use)and)asthmaPrelated)exacerbations)during)the)study)period,)number)of)asthmaPrelated)hospitalizations)and)ED)visits)were)obtained,)along)with)number)of)oral)corticosteroid)and)SABA)prescriptions)filled.)ED)visits)were)calculated)using)an)algorithm)based)on)feePforPservice)physician)payments,)ambulance)data,)and)hospital)admissions)data.)This)measure)has)previously)been)validated)against)objective)ED)data)provided)by)BC’s)Ministry)of)Health.(208))Results)of)the)validation)study)found)that)the)algorithm)was)able)to)capture)approximately)83%)of)ED)visits,)through)the)use)of)administrative)datasets.)Variables)related)to)health)resource)use)and)rescue)medication)are)included)in)the)severity)measure,)and)therefore)are)presented)here)only)in)the)descriptive)univariate)analysis.)92 )As)an)indicator)of)patients’)overall)health)and)comorbidities,)the)Charlson)comorbidity)index)(CCI))was)calculated)for)each)patient.)The)CCI)is)a)widely)used)measure)of)number)and)severity)of)comorbidities)that)is)commonly)calculated)using)administrative)datasets.(203,204,209))))Finally,)given)that)patients)were)enrolled)into)the)cohort)over)an)extended)period)(1997)to)2011),)the)potential)for)a)period)effect)was)captured)by)including)the)year)that)each)patient)entered)the)cohort.))4.2.2.3%Multivariate%modeling%To)address)the)first)research)question,)a)multivariate)logistic)regression)was)conducted)to)determine)whether)significant)differences)exist)between)those)patients)who)filled)at)least)one)controller)prescription)during)the)study)period,)and)those)who)filled)no)controller)prescriptions)during)the)study)period.)To)address)the)second)research)question,)a)multivariate)linear)regression)analysis)was)conducted,)wherein)PDC)was)included)as)a)continuous)variable.)It)was)expected)that)adherence)would)follow)a)nonPnormal)distribution)and)therefore)would)not)facilitate)a)linear)regression)analysis.)Furthermore,)I)anticipated)that)a)proportion)of)patients)may)have)not)filled)any)prescriptions)during)the)index)period,)resulting)in)a)PDC)of)0.)For)this)reason,)it)is)unlikely)that)the)conditions)for)the)validity)of)inference)based)on)linear)regression)(namely)the)normality)of)residuals))would)be)met.)As)such,)a)linear)regression)with)parametric)bootstrapping)was)considered.(210))In)this)approach,)93 inference)(calculating)pPvalues,)quantifying)confidence)intervals))is)made)through)generating)multiple)bootstrap)sets)of)data)and)fitting)linear)regression)separately)within)each)set.)PPvalues)and)confidence)intervals)were)then)derived)from)the)point)estimates)of)regression)coefficients)across)bootstrap)sets.)))Both)multivariate)models)were)constructed)to)include)all)explanatory)variables)that)explained)adherence)at)the)p=0.05)significance)level.)To)address)multicollinearity)at)the)multivariate)level,)changes)to)standard)errors)and)effect)estimates)were)reviewed.)For)the)linear)model,)multicollinearity)was)further)addressed)by)reviewing)tolerance)statistics.)A)tolerance)of)less)than)0.01)(and)a)corresponding)variance)inflation)factor)above)10))may)indicate)potential)multicollinearity.(211))))Finally,)to)address)seasonal)variation)in)adherence,)descriptive)statistics)were)produced)to)determine)whether)any)clear)patterns)exist,)across)various)disease)severity)levels.)All)analyses)were)conducted)using)SAS)Enterprise)4.3,)Cary,)NC,)USA.(212)))4.3%Results%4.3.1%Characteristics%of%the%study%sample%A)total)of)215,)920)patients)met)the)case)definition)for)asthma)during)the)entire)study)period)(1997)to)2011).)After)applying)additional)exclusions,)72,952)patients)94 were)included)in)the)analysis.)Given)the)minimal)amount)of)missing)data)points)(2.5%),)I)applied)casePwise)deletion)to)handle)the)missing)data)(see)figure)4.2).)%Figure%4.2:%Study%flow%diagram%))4.3.2%Descriptive%statistics%for%explanatory%variables%The)mean)age)of)this)sample)was)37)years)(SD:)11))(see)figure)4.3).)ThirtyPsix)percent)of)the)sample)was)male.)SocioPeconomic)status)was)relatively)evenly)distributed)across)the)5)categories)(see)tables)4.2)and)4.3).))Patients%who%met%the%case%definition%for%asthma%1997%I 2011:N)=)215,)920Included%for%analysis:N)=)72,952Excluded:%No)ICS)prescription)filled)during)the)12Pmonth)period)prioir)to)the)index)dateN)=)141,067Invalid)cases/)Missing)dataN)=)190195 )NinetyPfour)percent)(N)=)68,597))of)the)patient)sample)was)identified)as)having)mild)asthma,)while)5.1%)(N)=)3,703))and)0.9%)(N)=)684))were)moderate)and)severe,)respectively.)During)the)12Pmonth)period)prior)to)the)index)date,)6.5%)of)patients)visited)an)asthma)specialist,)while)55%)of)patients)visited)a)GP)for)their)asthma.)))During)the)12Pmonth)period)following)the)index)date,)99.2%)of)the)sample)was)not)hospitalized)for)an)asthmaPrelated)reason.)The)number)of)hospitalizations)among)the)remaining)480)patients)ranged)from)0P16.)Some)4.5%)of)the)patient)sample)was)admitted)to)the)ED)for)asthma)related)reasons)at)least)once.)ThirtyPone)percent)of)the)patient)sample)did)not)fill)any)SABA)prescriptions,)while)the)remaining)70%)filled)between)1)and)50)SABA)prescriptions.)Over)98%)of)patients)filled)12)or)fewer)SABA)prescriptions)during)the)12Pmonth)period)following)the)index)date.)EightyPfive)percent)of)the)sample)did)not)fill)any)oral)corticosteroid)(OCS))prescriptions)during)this)period,)while)the)remaining)fifteen)percent)filled)between)1)and)67)OCS)prescriptions.)Close)to)100%)of)patients)filled)12)or)fewer)OCS)prescriptions)during)the)12Pmonth)period)following)the)index)date.)Only)10)patients)filled)greater)than)21)prescriptions)for)an)OCS)during)this)period.))Among)70,045)patients)who)had)visited)a)GP)during)the)index)period,)the)mean)value)was)0.5)with)a)median)of)0.045)(see)figure)4.3).)Among)18,592)patients)who)had)visited)a)specialist)during)the)index)period,)the)mean)value)was)0.17)and)a)96 median)value)of)0.03)(see)figure)4.4),)which)suggests)a)highly)skewed)and)bimodal)distribution.)Both)of)these)measures)indicate)overall)low)continuity)of)care.)))%Figure%4.3:%Continuity%of%Care%Index%(GP)%%%% %97 Figure%4.4:%Continuity%of%Care%Index%(Asthma%Specialists)%%)As)a)measure)of)patient)comorbidities,)CCI)scores)ranged)from)0P13)with)a)mean)of)0.27)and)a)median)of)0.)The)distribution)of)CCI)was)highly)skewed,)with)96%)patients)having)a)CCI)of)0)or)1.)(see)figure)4.5)))%% %98 Figure%4.5:%Charlson%comorbidity%index%%%%Finally,)45%)of)patients)entered)the)cohort)prior)to)2000,)and)the)highest)proportion)of)patients)(23.28%))entered)the)cohort)in)1997)(see)figure)4.6).)See)tables)4.4)and)4.5)for)a)description)of)each)variable)distribution.)The)highly)skewed)distribution)is)not)surprising)in)light)of)the)fact)that)enrollment)into)the)cohort)began)in)1997.))% %99 Figure%4.6:%Distribution%of%year%of%cohort%entry)))Table%4.3:%descriptive%statistics%for%continuous%variables%%N=%72,952%Continuous%Variable% Range% Mean% SD% Median% IQR%Adherence)(PDC)) 0P100) 21.7%) 22.8%) 13.9%) 24.38%)Age) 18P55) 37.43) 11.03) 38.5) 18.39)Charlson)comorbidity)index) 0P13) 0.27) 0.77) 0) 0)Number)of)SABA)prescriptions)filled)(12Pmonth)period)following)index)date)) )0P50) )2.06) )3.02) )1) )3.0)Number)of)OCS)prescriptions)filled)(12Pmonth)period)following)index)date)) )0P67) )0.27) )0.98) )0) )0)Continuity)of)care)GP)Specialist) )0P1)0P1) )0.5)0.18) )0.35)0.33) )0.45)0.03) )0.69)0.13)%100 %Table%4.4:%descriptive%statistics%for%categorical%variables%N=%72,952%%Categorical%variable% Frequency%%%Controller%prescription%filled%(12Imonth%period%following%index%date)%83.4%)Sex%Male) )36%)Year%of%cohort%entry%1997P1999)2000P2002)2003P2005)2006P2008)2009P2011%)45.0%)23.3%)15.2%)11.3%)5.2%)Socioeconomic%status%Quintile)1)Quintile)2)Quintile)3)Quintile)4)Quintile)5%)22.12%)20.85%)19.93%)19.26%)17.83%)Patients%with%at%least%one%asthmaIrelated%GP%visit%(12Imonth%period%leading%up%to%index%date)%)55%)Patients%with%at%least%one%asthmaIrelated%Specialist%visit%(12Imonth%period%leading%up%to%index%date)%)6.5%)Patients%with%at%least%one%asthmaIrelated%ED%visit%(12Imonth%period%following%index%date)%)4.5%)Patients%with%at%least%one%asthmaIrelated%hospitalization%(12Imonth%period%following%index%date)%)0.008%)Firoozi%severity%index%(12Imonth%period%leading%up%to%index%date)%%Mild)asthma)Moderate)asthma)Severe)asthma%))94%)5%)1%)%12Imonth%Proportion%of%Days%Covered%83.4%)of)the)sample)filled)at)least)one)controller)medication)prescription)during)the)study)period)(see)figure)4.7).)The)distribution)of)adherence)was)positively)skewed)with)a)median)PDC)of)13.9%)(IQR:)24.38%))))101 Figure%4.7:%Distribution%of%Adherence%as%measured%by%PDC%))Among)those)patients)with)a)PDC)>0,)adherence)ranged)from)0.27%)to)100%)with)a)mean)of)26.1%)(SD:)22.6%))and)a)median)of)16.9%)(IQR:)27.12%))Only)35.6%)of)the)sample)had)a)PDC)greater)than)75%)indicating)overall)poor)adherence)with)substantial)variation,)consistent)with)previous)research.))4.3.3%ReIcategorization%of%continuous%variables%to%facilitate%bivariate%and%multivariate%analysis%Following)initial)data)exploration,)CCI,)CoC,)and)year)of)cohort)entry)were)categorized)based)on)their)distributions.)Although)there)is)no)wellPdetermined)102 threshold)for)categorizing)the)BicePBoxerman)CoC)Index,)previous)investigators)have)used)the)distribution)to)inform)the)categories.(213,214))For)both)specialist)and)GP)CoC)variables,)a)substantial)number)of)patients)did)not)visit)a)healthcare)provider)during)the)index)period)(see)section)4.3.2).)These)individuals)are)categorized)as)“No)GP)visits)during)the)index)period.”)Among)those)that)did)visit)a)GP)or)specialist)during)the)index)period,)CoC)variables)range)from)0P1.)Charlson)comorbidity)index)was)rePdefined)into)three)categories:)those)with)a)CCI)of)0,)1)and)greater)than)1,)given)the)highly)skewed)nature)of)the)distribution.)Finally,)to)reduce)the)number)of)“year)of)entry”)categories,)the)variable)was)rePdefined)using)3Pyear)differentials.)Where)appropriate)(e.g.)age)and)CCI))multiple)categorizations)were)tested.)Likely)given)the)large)sample)size)and)corresponding)small)effect)sizes,)the)impact)of)alternative)cut)points)was)minimal.)Therefore,)the)original)variable)distributions)were)maintained)(e.g.)age))or)categorized)according)to)meaningful)thresholds)(e.g)CCI)and)CoC).))4.3.4%Research%question%1:%What%are%the%characteristics%of%asthma%patients%who%do%not%fill%their%controller%prescriptions?%At)the)bivariate)level,)all)potential)explanatory)variables)were)significantly)associated)with)the)dichotomous)outcome)variable)(PDC)=)0,)PDC)>0))except)socioeconomic)status,)age)and)CoC)for)specialist)visits.)(See)table)4.5))))) )103 )Table%4.5:%%Unadjusted%and%adjusted%logistic%regression%to%determine%differences%between%patients%with%a%PDC%=%0%and%PDC%>%0%) ) Unadjusted%logistic%regression%Adjusted%logistic%regression%) Odds%ratio% 95%%CI% Adjusted%odds%ratio%95%%CI%Age% 1.024) 1.022) 1.026) 1.022) 1.020) 1.024)Charlson%comorbidity%index%) ) ) ) ) )CCI)=)0) 0.682) 0.609) 0.763) 0.762) 0.679) 0.854)CCI)=)1) 0.953) 0.842) 1.079) 1.005) 0.887) 1.139)CCI)>)1) Ref.) ) ) ) ) )Year%of%cohort%entry%) ) ) ) ) )1997P1999)) 1.941) 1.788) 2.107) 1.688) 1.551) 1.836)2000P2002)) 1.317) 1.210) 1.434) 1.254) 1.150) 1.367)2003–2005)) 1.272) 1.163) 1.391) 1.237) 1.130) 1.355)2006–2008)) 1.189) 1.084) 1.305) 1.178) 1.071) 1.294)2009–2011)) Ref.)) ) ) ) ) )Firoozi%severity%index%) ) ) ) ) )Mild) 0.588) 0.458) 0.756) 0.378) 0.293) 0.486)Moderate) 0.757) 0.58) 0.989) 0.594) 0.454) 0.777)Severe) Ref.) ) ) ) ) )Continuity%of%care%(GP)%) ) ) ) ) )No.)GP)visits)during)the)index)period) 2.497) 2.125) 2.934) 2.454) 2.087) 2.886)0)P)0.2) 0.618) 0.584) 0.655) 0.743) 0.700) 0.789)0.2)P)0.45) 0.681) 0.643) 0.722) 0.741) 0.698) 0.785)0.45)P)0.89) 0.776) 0.732) 0.824) 0.782) 0.737) 0.831)>)0.89) Ref.)) ) ) ) ) )Continuity%of%care%(specialist)%) ) ) ) ) )No.)specialist)visits)during)the)index)period) 1.025) 0.922) 1.14) ) ) )104 Table%4.5:%%Unadjusted%and%adjusted%logistic%regression%to%determine%differences%between%patients%with%a%PDC%=%0%and%PDC%>%0%) ) Unadjusted%logistic%regression%Adjusted%logistic%regression%) Odds%ratio% 95%%CI% Adjusted%odds%ratio%95%%CI%0)P)0.32) 0.984) 0.876) 1.106) ) ) )0.32)P)0.132) 1.088) 0.956) 1.239) ) ) )0.132)P)0.999) 1.219) 1.039) 1.431) ) ) )1) Ref.) ) ) ) ) )Sex% ) ) ) ) ) )Female) 1.05) 1.009) 1.095) )) )) ))Male) Ref.) ) ) ) ) )Neighbourhood%income%quintile%) ) ) ) ) )Quintile)1) 1.011) 0.95) 1.076) )) )) ))Quintile)2) 0.957) 0.898) 1.018) )) )) ))Quintile)3) 0.953) 0.894) 1.015) )) )) ))Quintile)4) 1.023) 0.959) 1.092) )) )) ))Quintile)5) Ref.) ) ) ) ) ))))At)the)multivariate)level,)a)lower)odds)of)adherence)was)attributable)to)patients)with)a)CCI)of)0)versus)patients)with)a)CCI)of)1)(AOR)=)0.762,)95%)CI)=)0.679,)0.854).)Higher)disease)severity)was)associated)with)increased)odds)of)adherence,)following)a)dosePresponse)pattern)(see)table)4.4).)Consistent)with)some)existing)literature,)higher)age)was)also)associated)with)a)very)slight)increase)in)the)odds)of)adherence)(AOR)=)1.022,)95%)CI)=)1.020,)1.024).))Patients)with)no)general)practitioner)(GP))visits)in)the)12Pmonth)prePindex)period)had)approximately)2.5)times)the)odds)of)adherence)during)the)index)period,)compared)to)those)with)a)CoC)score)greater)than)0.89)(95%)CI)=)2.087,)2.886).)However,)among)patients)with)a)CoC)score,)a)higher)score)was)associated)with)increased)odds)of)adherence.)105 )Finally,)evidence)for)a)period)effect)can)be)seen)by)assessing)the)relationship)between)“year)of)cohort)entry”)and)adherence.)Patients)entering)the)cohort)earlier,)tended)to)show)higher)odds)of)adherence)compared)to)those)entering)the)cohort)between)2009)and)2011.))Likelihood)ratio)and)Wald)statistics)both)produced)a)pPvalue)of)<.0001,)indicating)that)at)least)one)of)the)predictor)variables)values)is)not)equal)to)0,)which)suggests))overall)model)significance.(215))As)a)measure)of)predictive)power)using)the)Cox)&)Snell’s)pseudoPR)squared)measure,(216))the)logistic)model)explains)approximately)4%)of)the)differences)between)those)patients)with)a)PDC)=)0)to)those)with)a)PDC)>0.(217)))4.3.5%Research%question%2:%Which%demographic%and%disease%related%factors%explain%variation%in%adherence%to%controller%medication?%At)both)the)bivariate)and)multivariate)levels,)all)explanatory)variables)served)as)statistically)significant)predictors)of)adherence.)The)results)of)the)multivariate)linear)regression)are)generally)consistent)with)the)logistic)regression)(research)question)1),)showing)that)higher)adherence)is)associated)with)higher)age)(Mean)=)0.002,)95%)CI)=)0.002,)0.003),)higher)CCI,)earlier)year)of)cohort)entry,)higher)disease)severity,)and)higher)socioeconomic)status)(see)table)4.6).)Compared)to)males,)females)show)slightly)lower)adherence)with)significance)(Mean)=)P0.004,)95%)CI)=)P0.009,)0.001).)However,)the)impact)of)disease)severity)is)more)pronounced.)For)example,)the)mean)106 change)in)PDC)comparing)those)with)mild)disease)to)those)with)severe)disease)is)P0.228)(95%)CI)=)P0.261,)P0.192).))) )107 !Table&4.6:&Unadjusted&and&adjusted&parametric&bootstrapped&linear&regression&to&explain&variation&in&adherence&to&controller&medication*&&!! Unadjusted&linear&regression& Adjusted&linear&regression&&&&& Mean&& SE&&& 95%&CI& P&value&&& Mean&& SE&&& 95%&CI& P&value&&&Age&&& 0.003!! <0.001!!! 0.002!!! 0.003!!! <0.001!!! 0.002! <0.001! 0.002! 0.003! <0.001!CCI&&& ! ! ! ! ! ! ! ! ! !CCI!=!0!!! +0.056!! 0.007!!! +0.072!!! +0.044!!! <0.001!!! +0.042! 0.007! +0.057! +0.031! <0.001!CCI!=!1!!! +0.014!! 0.007!!! +0.031!!! +0.002!!! 0.014!!! +0.007! 0.007! +0.023! 0.004! 0.090!CCI!>!1!!! Ref.!! !!! !!! !!! !!! ! ! ! ! !Year&of&cohort&entry&&&&! ! ! ! ! ! ! ! ! !1997!–!1999!!!! 0.079!! 0.006!!! 0.067!!! 0.091!!! <0.001!!! 0.065! 0.006! 0.053! 0.077! <0.001!2000!–!2002!!!!! 0.002!! 0.006!!! +0.009!!! 0.014!!! 0.354!!! 0.006! 0.006! +0.005! 0.017! 0.133!2003!–!2005!!!! 0.003!! 0.006!!! +0.010!!! 0.015!!! 0.351!!! 0.009! 0.006! +0.002! 0.021! 0.059!2006!–!2008!!!! +0.001!! 0.007!!! +0.014!!! 0.012!!! 0.443!!! 0.008! 0.006! +0.005! 0.020! 0.111!2009!–!2011!!!! Ref.!! !!! ! !!! !!! ! ! ! ! !Firoozi&severity&index&&&! ! ! ! ! ! ! ! ! !!!Mild!!! +0.175!! 0.017!!! +0.208!!! +0.141!!! <0.001!!! +0.228! 0.017! +0.261! +0.192! <0.001!Moderate!!! +0.067!! 0.019!!! +0.103!!! +0.030!!! <0.001!!! +0.101! 0.018! +0.135! +0.064! <0.001!Severe!!! !!Ref.! !!! !!! !!! !!! ! ! ! ! !Continuity&of&care&(GP)&&&! ! ! ! ! ! ! ! ! !No.!GP!visits!during!the!index!period! 0.155!! 0.009!!! 0.139!!! 0.174!!! <0.001!!! 0.153! 0.009! 0.137! 0.171! <0.001!0!+!0.2! +0.073!! 0.004!!! +0.081!!! +0.066!!! <0.001!!! +0.051! 0.004! +0.059! +0.044! <0.001!0.2!+!0.45! +0.068!! 0.004!!! +0.075!!! +0.060!!! <0.001!!! +0.056! 0.004! +0.064! +0.049! <0.001!0.45!+!0.89! +0.056!! 0.004!!! +0.065!!! +0.049!!! <0.001!!! +0.054! 0.004! +0.063! +0.047! <0.001!108 Table&4.6:&Unadjusted&and&adjusted&parametric&bootstrapped&linear&regression&to&explain&variation&in&adherence&to&controller&medication*&&!! Unadjusted&linear&regression& Adjusted&linear&regression&&&&& Mean&& SE&&& 95%&CI& P&value&&& Mean&& SE&&& 95%&CI& P&value&&&>!0.89! Ref.!! !!! !!! !!! !!! ! ! ! ! !Continuity&of&care&(specialist)&&&! ! ! ! ! ! ! ! ! !No.!specialist!visits!during!the!index!period! 0.01!! 0.007!!! +0.002!!! 0.023!!! 0.056!!! 0.004! 0.006! +0.008! 0.017! 0.259!0!+!0.32! 0.029!! 0.008!!! 0.013!!! 0.045!!! <0.001!!! 0.025! 0.008! 0.010! 0.041! 0.001!0.32!+!0.132! 0.041!! 0.009!!! 0.024!!! 0.059!!! <0.001!!! 0.030! 0.009! 0.013! 0.047! <0.001!0.132!+!0.999! 0.021!! 0.010!!! +0.001!!! 0.039!!! 0.028!!! 0.015! 0.010! +0.005! 0.034! 0.075!1! Ref.!! !!! !!! !!! !!! ! ! ! ! .!Neighborhood&income&quintile&&&! ! ! ! ! ! ! ! ! !1!!! +0.004!! 0.005!!! +0.014!!! 0.005!!! 0.179!!! +0.003! 0.005! +0.013! 0.005! 0.218!2!!! +0.015!! 0.004!!! +0.023!!! +0.007!!! <0.001!!! +0.012! 0.004! +0.020! +0.004! 0.001!3!!! +0.014!! 0.004!!! +0.022!!! +0.006!!! <0.001!!! +0.011! 0.004! +0.019! +0.003! 0.003!4!!! +0.005!! 0.005!!! +0.014!!! 0.004!!! 0.138!!! +0.005! 0.005! +0.014! 0.004! 0.147!5!!! Ref.!! !!! !!! !!! !!! ! ! ! ! !Sex&&& !!! !!! !!! !!! !!! !!! !!! !!! !!! !!!Female!! +0.017!! 0.001!! +0.022!!! +0.011!!! <0.001!!! +0.004! 0.002! +0.009! 0.001! 0.042!Male!! Ref.!! !!! ! !!! !!! ! ! ! ! .!*Mean!estimates!are!reported!using!non+bootstrapped!linear!regression.!All!standard!errors,!confidence!intervals!and!p+values!use!bootstrapped!estimates.!!109 !!The!R2!value!shows!that!the!model!explains!approximately!10.3%!of!the!variation!in!adherence.!With!a!model!F@statistic!p!value!of!<0.001,!the!overall!fit!of!the!model!is!statistically!significant.!!!4.3.6%Research%question%3:%Does%adherence%to%controller%medication%vary%by%calendar%month?%Table!4.7!shows!the!proportion!of!patients!who!filled!at!least!one!controller!medication!prescription!in!each!calendar!month.!Patients!were!categorized!according!to!the!number!of!ICS!prescriptions!they!had!filled!in!the!12@month!period!prior!to!the!index!date.!Unsurprisingly,!adherence!proportions!increase!with!higher!numbers!of!ICS!prescriptions!filled!prior!to!the!index!date.!This!supports!the!claim!that!previous!adherence!predicts!future!adherence,!but!is!likely!confounded!by!additional!factors!such!as!disease!severity!and!date!of!asthma!diagnosis.!!! !110 !!!!The!greatest!amount!of!monthly!variation!can!be!detected!among!those!who!have!filled!at!least!3!ICS!prescriptions!during!the!pre@index!period.!Comparing!across!ICS!categories,!adherence!proportions!tend!to!be!highest!in!November!and!lowest!in!March.!!A!similar!descriptive!analysis!was!calculated!according!to!disease!severity!(see!table!4.8!and!figure!4.8).!Patients!with!more!severe!disease!had!the!highest!proportions!of!Table%4.7:%Percentage%of%patients%having%filled%a%controller%by%calendar%%month%according%to%the%number%of%ICS%prescriptions%filled%in%the%12Gmonth%period%prior%to%the%index%date%Month% 1%ICS%Rx%12Gmonth%period%prior%to%index%date%(N%=%62,549)%2%ICS%12Gmonth%period%prior%to%index%date%(N%=%%8,769)%3%or%more%ICS%12Gmonth%period%prior%to%index%date%(N:%1,634)%%January! 10.8! 18.78! 27.72!February! 10.46! 17.92! 27.17!March! 11.42! 20.44! 27.36!April! 10.95! 19.14! 28.09!May! 11.01! 19.91! 28.95!June! 10.28! 19.6! 29.99!July! 10.22! 19.2! 28.46!August! 10.09! 18.38! 30.91!September! 11.29! 19.92! 29.31!October! 11.56! 21.12! 27.91!November! 11.75! 20.88! 31.7!December! 11.57! 20.55! 31.09!111 adherence!within!any!calendar!month,!and!overall.!These!results!are!consistent!with!the!current!multivariate!analyses!as!well!as!the!existing!literature.!!!Within!the!severe!disease!category,!the!greatest!amount!of!variation!could!be!detected.!The!lowest!proportions!of!controller!medication!prescription!fills!are!shown!in!February!and!March,!with!the!highest!proportions!shown!in!November!and!December.!The!multi@modal!distribution!shows!that!while!the!variation!may!not!necessarily!be!attributable!to!a!specific!seasonal!effect,!some!variation!by!month!does!appear!to!exist.!Little!variation!can!be!detected!in!the!mild!disease!category,!however,!there!is!a!slightly!increased!prevalence!of!prescription!filling!during!the!late!spring!and!again!in!the!fall.!% %112 Table%4.8:%Percentage%of%patients%having%filled%a%controller%by%calendar%month%according%to%disease%severity%%Month% Mild%disease%(N%=%68,597)%Moderate%disease%%(N%=%3,707)%Severe%disease%(N%=%648)%January! 11.70! 17.86! 26.08!February! 11.29! 17.64! 24.69!March! 12.48! 17.64! 24.85!April! 11.88! 17.89! 27.01!May! 12.05! 17.78! 27.47!June! 11.36! 18.05! 27.47!July! 11.25! 17.64! 26.85!August! 11.02! 18.91! 25.62!September! 12.26! 18.80! 27.78!October! 12.56! 20.47! 25.46!November! 12.77! 20.42! 27.78!December! 12.57! 19.69! 30.25!%% %113 Figure%4.8:%Percentage%of%patients%having%filled%a%controller%by%calendar%month,%according%to%disease%severity%%%%4.4%Discussion%4.4.1%Summary%of%findings%The!results!of!the!multivariate!analysis!highlight!patient@related!factors!that!are!associated!with!adherence!to!long@term!asthma!controller!medication,!and!may!help!to!provide!potential!explanations!for!variation!in!adherence.!!05101520253035Mild!disease!(N!=!68,597)Moderate!disease!(N!=!3,707)Severe!disease!(N!=!648)114 !4.4.1.1!Adherence!!Descriptive!analyses!of!this!population@based!sample!show!that!12@month!adherence!to!controller!medications!among!adult!asthma!patients!living!in!British!Columbia!is!poor,!with!approximately!16%!of!this!patient!population!having!not!filled!any!prescriptions!during!the!index!period.!This!finding!is!consistent!with!previous!evidence.(105,106,218)!These!results!may!be!impacted!by!the!fact!that!the!majority!of!patients!included!in!this!sample!are!considered!to!have!mild!disease,!despite!attempts!to!reduce!the!sample!to!only!those!with!a!true!diagnosis!of!asthma.!!!4.4.2.3!Comparison!across!the!two!multivariate!models!(research!questions!1!and!2)!Both!multivariate!models!show!consistent!results!in!terms!of!the!direction!and!magnitude!of!effect.!In!summary,!higher!age!is!associated!increased!adherence,!as!is!higher!disease!severity,!higher!CCI!and!lack!of!GP!visits.!However,!among!patients!who!did!visit!a!GP!during!the!pre@index!period,!those!with!a!higher!CoC!(GP)!showed!greater!adherence.!!!!Although!previous!evidence!is!conflicting,!the!current!analysis!shows!that!more!severe!asthma!is!associated!with!better!treatment!adherence.!These!results!are!not!surprising!in!light!of!the!fact!that!patients!with!severe!disease!likely!require!more!frequent!medication!to!reduce!asthma!symptoms.!!115 !Higher!CCI!was!shown!to!be!associated!with!higher!adherence!in!both!the!linear!and!the!logistic!regression!models.!CCI!may!be!an!indicator!for!medication!regimen!complexity,!suggesting!that!patients!who!are!being!prescribed!fewer!medications!are!likely!to!be!more!adherent.!These!results!may!suggest!that!the!medication!regimen!complexity!attributable!to!higher!CCI!scores!may!positively!impact!a!patient’s!ability!or!willingness!to!remain!adherent!to!a!daily!treatment!plan.!These!results!are!surprising!since!one!prevailing!hypothesis!is!that!patients!managing!multiple!comorbidities!may!incur!additional!challenges!with!managing!their!medication!plans.(178)!Furthermore,!there!may!be!personal!cost!implications!that!serve!as!additional!barriers!to!adherence,!among!those!patients!who!are!being!prescribed!multiple!medications.!However,!these!results!may!suggest!that!patients!managing!multiple!comorbidities!may!be!more!vigilant!with!their!medications,!or!this!finding!may!be!influenced!by!increased!frequency!of!healthcare!use!or!communication!with!healthcare!providers.!!Based!on!the!results!of!the!two!multivariate!analyses,!the!role!of!sex!in!explaining!adherence!is!minimal.!There!was!no!difference!in!the!odds!of!having!filled!a!controller!prescription!when!comparing!males!and!females!(research!question!1).!According!to!the!linear!regression,!being!female!was!associated!with!lower!mean!adherence!scores,!but!only!to!a!very!minimal!extent.!These!findings!are!consistent!with!previous!literature!that!has!not!found!evidence!for!an!association!between!sex!and!adherence.(145,179,182)!!116 !Finally,!when!comparing!patients!who!do!and!do!not!fill!any!of!their!controller!medications!(research!question!1),!SES!and!CoC!(specialist)!did!not!explain!differences!between!the!two!groups.!However,!when!addressing!variation!in!adherence!(research!question!2),!these!two!variables!were!shown!to!explain!adherence.!Results!of!the!linear!regression!show!that!that!higher!SES!is!associated!with!better!adherence!as!measured!by!PDC,!although!no!gradient!was!found!across!the!5!levels!of!SES.!As!stated!previously,!studies!explicitly!addressing!the!link!between!SES!and!adherence!are!not!consistent!in!their!findings.(145,175,179,180)!However,!some!additional!work!has!shown!that!adherence!inferred!via!symptom!control!is!associated!with!higher!SES.(149,150)!The!mechanisms!by!which!SES!may!influence!disease!control!and!severity!may!include!increased!exposure!to!pollutants!or!irritants.(150)!!The!linear!regression!also!shows!that!a!CoC!(specialist)!score!of!1!(indicating!high!continuity!of!care)!is!associated!with!reduced!adherence,!when!compared!with!lower!CoC!categories!(excluding!0).!This!finding!is!inconsistent!with!the!conventional!wisdom,!that!continuity!of!care!is!associated!with!greater!adherence.!The!hypothesized!causal!pathway!is!that!having!a!single!prescriber!would!facilitate!increased!communication!and!therefore!increased!adherence.!CoC!did!not!appear!to!be!collinear!with!disease!severity.!These!results!may!be!impacted!by!the!fact!that!approximately!75%!of!the!sample!did!not!visit!a!specialist!during!the!12@month!period.!!117 !Finally,!both!models!show!that!having!entered!the!cohort!earlier!increased!the!likelihood!of!adherence.!According!to!the!linear!analysis,!lower!adherence!was!shown!among!patients!who!entered!the!cohort!between!2009!and!2011,!compared!with!those!who!entered!the!cohort!between!1997!and!1999.!Unmeasured!confounders!may!help!to!explain!this!finding,!such!as!changes!to!prescribing!patterns,!clinical!practice!guidelines!for!asthma!management,!or!changes!in!patient!attitudes!toward!asthma!medication,!over!time.(219)!safety!concerns!related!to!the!use!of!LABA!were!announced!by!the!Food!and!Drug!Administration!(FDA)!in!2005,!which!subsequently!resulted!in!a!decreased!use!of!ICS@LABA!among!both!pediatric!and!adult!populations.(54)!In!2007,!the!National!Heart,!Lung,!and!Blood!Institute!practice!guidelines!echoed!these!concerns.(220)!Additionally,!a!Canadian!3@year!prospective!analysis!conducted!between!1996!and!1998!showed!a!decreasing!trend!in!ICS!prescriptions.(221)!Although!the!decreasing!trend!in!ICS!prescriptions!cannot!be!extrapolated!beyond!the!length!of!the!study,!results!suggest!that!prescribing!patterns!may!fluctuate!over!time.!It!is!possible!that!some!of!this!variation!in!adherence!may!be!explained!by!policy!or!prescribing!changes,!or!changes!in!patient!behaviours.!!!4.4.2.4!Variation!in!adherence!The!results!of!the!exploratory!analysis!addressing!variation!in!adherence!by!calendar!month!suggests!that!variation!can!be!detected,!particularly!within!patient!groups!with!a!previous!history!of!prescription!fills,!and!greater!disease!severity.!!118 There!are!two!potential!limitations!that!may!impact!the!interpretation!of!these!findings.!!!Firstly,!the!current!analysis!provides!only!a!brief!snapshot!of!potential!seasonal!variation!in!adherence.!In!order!to!capture!a!valid!measure!of!variation,!patients!ought!to!be!filling!their!prescriptions!on!a!semi@regular!basis!over!an!extended!period!of!time.!Among!the!sub@group!of!severe!asthma!patients!who!are!likely!to!have!filled!the!greatest!number!of!prescriptions!over!the!12@month!period,!slight!increases!in!prescription!filling!can!be!detected!around!April,!May,!September,!November!and!December!(figure!4.9).!!It!should!also!be!noted!that!only!648!patients!(<!1%)!in!this!sample!are!categorized!as!having!severe!disease.!!!Secondly,!in!the!province!of!BC,!health!insurance!plans!such!as!Fair!PharmaCare!reset!on!January!1st!of!each!year,!at!which!point!registrant!deductibles!are!re@calculated!based!on!family!income.(222)!The!majority!of!BC!residents!are!covered!by!Fair!Pharmacare.!Therefore,!the!higher!proportions!of!prescriptions!being!filled!in!December!may!be!attributable!to!patients!desire!to!reach!their!deductible!by!the!end!of!the!year.!Patients!may!wish!to!fill!their!most!recent!medication!prescriptions!within!the!current!year.!If!this!is!the!case,!it!is!not!surprising!to!see!lower!adherence!proportions!in!the!early!months!(particularly!February!and!March),!since!controller!medications!are!often!prescribed!in!100@day!dosages.(223)!Despite!these!potential!explanations,!the!findings!of!this!preliminary!analysis!are!consistent!with!previous!119 research!that!suggest!asthma@related!symptoms!and!healthcare!use!vary!according!to!seasonal!changes!and!increases!in!environmental!triggers.(188,189)!!!4.4.2%Strengths%This!investigation!adds!a!valuable!contribution!to!the!existing!literature!by!further!clarifying!the!role!of!various!demographic!and!disease!related!variables!that!explain!adherence!to!controller!therapy!among!adult!asthma!patients.!I!further!highlight!the!finding!that!adherence!is!a!highly!complex!phenomenon!that!cannot!adequately!be!explained!by!demographic!and!disease!related!variables.!One!potentially!valuable!implication!of!this!finding!is!that!it!serves!to!identify!the!potential!role!of!addressing!issues!related!to!non@adherence!at!the!individual!level.!Patient!behaviors!that!predict!adherence!are!likely!to!be!informed!by!a!multitude!of!factors!including!but!not!limited!to!attitudes!and!beliefs,!concerns,!self@efficacy!and!lifestyle!(see!chapter!3).!Therefore,!I!propose!that!further!efforts!to!explain!and!predict!adherence!on!an!individual!and!ongoing!basis!are!warranted.!Furthermore,!the!results!of!this!investigation!can!be!generalized!to!the!population!of!adult!asthma!patients!in!BC!due!to!the!population@level!nature!of!the!sample.!Finally,!this!analysis!provides!initial!insight!into!the!potential!seasonal!nature!of!adherence,!while!proposing!potential!implications!and!avenues!for!future!research.!!!120 4.4.3%Limitations%This!analysis!is!limited!to!the!variables!that!were!available!using!the!administrative!dataset.!As!such,!some!of!the!variables!selected!as!indicators,!may!lack!construct!validity.!For!example,!the!measure!of!SES!is!based!on!a!pre@defined!neighborhood!income!quintile.!A!more!robust!and!individual@level!indicator!of!SES!may!include!household!income!or!individual!education!level.!Of!course,!both!of!these!preferred!variables!are!not!consistently!captured!using!administrative!datasets.!Existing!evidence!suggests!that,!among!asthma!patients,!aggregate!measures!of!SES!are!not!consistent!with!individual@level!SES!such!as!patient!reported!income!and!education.(224)!As!stated!previously,!a!measure!of!continuity!of!care!that!captures!the!frequency!of!physician!visits!may!provide!further!insight!into!the!relationship!between!patient@physician!communication!and!adherence.!!Although!PharmaNet!is!a!useful!and!comprehensive!resource!for!capturing!prescription!refill!history,!there!are!limitations!associated!with!its!use.!Firstly,!the!database!only!captures!the!extent!to!which!each!patient!filled!his!or!her!medication.!The!corresponding!assumption!is!that!all!medications!dispensed!by!the!pharmacies!were!inhaled!and!inhaled!correctly.!Regarding!the!latter,!inhaler!misuse!is!a!common!occurrence!among!asthma!patients,!and!is!strongly!associated!with!poor!control.(225–227)!Therefore,!it!is!likely!that!adherence!calculated!using!proxy!measures!over@estimate!true!adherence.!A!future!study!with!the!objective!of!estimating!adherence!rates!would!benefit!from!obtaining!information!about!patient!inhaler!technique,!and!the!presence!of!inhaler!use!related!education.!121 !Secondly,!PharmaNet!only!captures!medications!dispensed!through!pharmacies.!While!this!measure!does!capture!the!majority!of!medications!being!dispensed,!it!does!not!account!for!medications!purchased!online!or!sampling.!Individuals!may!choose!to!purchase!medications!if!they!are!under@insured!and!are!able!to!locate!cheaper!medications!through!online!vendors!or!from!overseas!which!is!a!common!experience!especially!in!subjects!from!China!and!India.(228)!Therefore,!the!population!of!patients!captured!by!the!PharmaNet!database!may!not!be!completely!representative!of!the!BC!adult!asthma!patient!population.!However,!as!stated!previously,!it!is!likely!that!this!sample!is!largely!representative!of!asthma!patients!in!BC!given!that!the!majority!of!prescriptions!are!filled!and!recorded!through!pharmacies.!!4.4.4%Implications%and%future%research%%Findings!from!the!current!analysis!illustrate!that!a!wide!range!of!patient@related!factors!help!explain!adherence!to!long@term!asthma!controller!therapy,!although!the!vast!majority!of!variation!in!adherence!is!left!unexplained.!These!results!support!the!claim!that!adherence!is!a!complicated!outcome!that!cannot!be!explained!or!maintained!by!simply!addressing!demographic!patient!characteristics,!disease!severity!or!comorbidities.!Results!of!the!current!analyses!can!be!used!to!inform!further!investigations!into!additional!variables!that!may!play!a!more!prominent!role!in!treatment!adherence!to!medication!for!chronic!conditions!–!namely!the!factors!that!inform!individual!behaviours.!Additional!insight!is!likely!to!be!gained!by!122 broadening!the!types!of!explanatory!variables!to!include!those!related!to!the!quality!of!the!patient@physician!relationship.!For!example,!previous!research!supports!the!claim!that!increased!education!and!communication!with!physicians!may!serve!as!a!valuable!tool!to!increase!adherence.(17,130,229–231)!As!stated!previously,!variables!related!to!the!patient@physician!encounter!–!such!as!continuity!of!care!@!are!difficult!to!capture!using!administrative!data.!A!future!investigation!ought!to!consider!whether!the!quality!of!patient@physician!encounters!further!explains!variation!in!adherence.!Increase!patient!engagement!in!care!using!methods!such!as!shared!decision!making!(SDM),!have!been!proposed!to!improve!various!asthma!related!outcomes!including!but!not!limited!to!treatment!adherence!(see!chapter!3).!Chapters!5!and!6!of!this!dissertation!will!specifically!address!the!extent!to!which!SDM!has!been!recently!implemented!into!asthma!care!in!BC,!and!to!begin!to!explore!the!potential!association!between!SDM!and!treatment!adherence!among!a!sample!of!adult!asthma!patients.!%With!regard!to!the!secondary!research!question,!further!research!into!the!prevalence!and!implications!of!seasonal!variation!in!controller!medication!adherence!is!warranted.!Results!of!the!current!analysis!suggest!that!there!may!be!some!variation!in!adherence!attributable!to!seasonality,!particularly!among!patients!with!severe!disease.!An!important!next!step!in!this!research!investigation!is!to!provide!a!more!valid!estimate!of!the!prevalence!of!seasonal!variation!in!adherence,!and!to!determine!whether!seasonal!variation!in!adherence!can!be!linked!to!disease!control.!More!specifically,!do!patients!who!practice!seasonal!adherence!show!123 greater!symptoms,!use!of!rescue!medication!and!health!resource!use?!If!the!answer!to!this!question!is!“no,”!then!perhaps!long@term!adherence!measures!that!capture!averages!(e.g.!PDC!and!MPR)!may!be!suboptimal!indicators!of!disease!control.!If!it!is!the!case!that!patients!who!practice!seasonal!adherence!experience!systematically!higher!disease!burden,!physicians!may!use!this!information!to!increase!communication!with!these!patients!and!ensure!their!understanding!of!the!value!of!maintaining!annual!adherence,!even!in!the!absence!of!symptoms!and!environmental!triggers.!! !! %124 Chapter%5:%A%survey%to%describe%the%state%of%shared%decision%making%in%asthma%management:%Consent%process,%recruitment%procedures%and%participant%demographics%%5.1%Background%%In!chapter!3,!I!proposed!a!theoretical!framework!suggesting!that!various!modifiable!and!non@modifiable!factors!are!associated!with!adherence!to!controller!medications!among!adult!asthma!patients.!Subsequently!in!chapter!4,!I!investigated!the!extent!to!which!select!patient!demographics!and!severity@related!variables!may!explain!variation!in!adherence.!Based!on!the!analysis!results,!I!conclude!that!little!variation!in!treatment!adherence!is!attributable!to!patient@related!factors!such!as!age,!sex!and!SES!!In!order!to!further!my!research!investigation,!I!proposed!a!next!step,!to!seek!a!more!comprehensive!explanation!of!variation!in!adherence!behaviour,!through!the!collection!of!information!from!asthma!patients!on!modifiable!aspects!of!the!clinical!encounter.!Here!I!seek!to!consider!more!comprehensively!the!role!that!SDM!may!play!in!addressing!the!informational!and!motivational!predictors!of!treatment!adherence!(see!chapter!3!theoretical!framework).!I!have!taken!this!forward!through!a!formal!survey,!the!specific!objectives!of!which!were!to!answer!the!following!descriptive!questions.!! 1.! What!role!do!asthma!patients!prefer!to!take!in!the!decision@making!process?!125 2.! What!factors!related!to!patient@physician!communication!and!education!explain!adherence?!3.! To!what!extent!do!asthma!patients!recall!previous!exposure!to!SDM?! !a.! Is!patient@reported!engagement!in!SDM!associated!with!adherence!to!controller!medication?!b.! Is!there!an!association!between!preferences!for!decision@making!and!perceived!exposure!to!SDM?!Chapters!5!and!6!serve!to!address!these!5!research!questions!in!relation!to!the!over@arching!objective!of!the!thesis!which!are!to!ascertain!the!extent!to!which!components!of!SDM!are!being!incorporated!into!clinical!care,!and!to!determine!whether!these!efforts!are!linked!to!improved!adherence!among!adult!asthma!patients.!The!current!chapter!describes!the!demographic!characteristics!of!asthma!patients!who!agreed!to!participate!in!a!cross@sectional!survey!about!their!use!of!asthma!medication!and!healthcare!decision@making.!Chapter!6!describes!the!survey!development!process,!the!outcomes!measured!in!the!survey,!as!well!as!the!results!relating!to!all!primary!and!secondary!research!objectives.!!%5.2%Patient%population%%Patients!recruited!for!participation!in!the!current!survey!consist!of!adult!asthma!patients!who!previously!participated!in!the!Economic!Burden!of!Asthma!(EBA)!study.(232–234)!EBA!patients!were!initially!recruited!using!a!random@digit!dial!technique,!sampling!from!BC’s!Vancouver!and!Okanagan!census!sub@divisions,!126 which!together!included!both!urban!and!rural!households.(232)!Individuals!were!eligible!for!the!EBA!study!if!they:!1.! Had!a!diagnosis!of!asthma!by!a!physician;!2.! Had!a!self@reported!health!care!interaction!related!to!asthma!(physician!visit,!ED!visit,!hospitalization)!in!the!past!5!years;!and!3.! Were!able!to!read!and!speak!English.!Patients!were!excluded!from!the!EBA!study!if!they:!1.! Were!unable!to!provide!informed!consent!due!to!language!difficulties!or!cognitive!impairment;!2.! Had!a!smoking!history!of!greater!than!10!pack/year!(this!would!have!excluded!patients!with!possible!COPD);!3.! Planned!to!move!out!of!the!province!in!the!next!12!months;!or!4.! Were!unable!to!undergo!methacholine!challenge!test!due!to!non@asthma!related!reasons!(e.g.!patients!with!cerebral!aneurysm,!pregnant!and!breastfeeding!participants).!For!the!current!survey,!EBA!patients!under!the!age!of!19,!and!those!who!were!unable!to!complete!an!online!survey!were!excluded.!!5.3%Recruitment%and%consent%procedures%My!initial!sampling!frame!consisted!of!EBA!patients!who!had!previously!consented!for!future!research.!Potential!survey!participants!were!contacted!either!by!telephone!or!email.!A!maximum!of!three!attempts!at!initial!contact!were!made!for!each!participant.!If!contact!was!made!and!the!participant!expressed!interest!in!127 participating!in!the!online!survey,!the!participant!was!then!sent!their!participant!ID!code,!and!the!survey!link,!which!included!the!online!consent!form.!Those!who!did!not!respond!to!the!survey!invitation!within!a!minimum!of!one!month!received!a!reminder!email,!and!then!a!telephone!call!one!week!later.!!!Patient!recruitment!occurred!between!March!and!September!2016.!In!total,!471!telephone!and!email!attempts!were!made!to!recruit!participants.!Of!325!patients!who!were!successfully!contacted,!165!agreed!to!participate,!and!117!completed!the!survey.!I!was!unable!to!obtain!the!characteristics!of!those!EBA!patients!who!did!not!choose!to!participate!(see!figure!5.1).!!Fewer!than!90!participants!had!completed!the!online!survey!following!initial!recruitment!efforts.!Given!this!limited!number!of!respondents,!I!decided!to!increase!the!sampling!frame.!Following!the!completion!of!the!original!EBA!study,!not!all!participants!had!been!successfully!followed!up!to!ask!whether!they!would!be!willing!to!participate!in!future!research.!For!phase!2,!EBA!participants!for!whom!I!did!not!have!documented!preference!regarding!their!wish!to!participate!in!future!research!were!contacted.!As!per!guidance!from!the!UBC!Clinical!Research!Ethics!Board,!initial!contact!was!made!via!email!for!those!EBA!participants!who!had!provided!a!valid!email!address!during!the!EBA!study!I!contacted!potential!participants!via!telephone!only!in!situations!where!no!valid!email!address!was!recorded!in!the!EBA!patient!file.!Only!a!single!attempt!at!communication!was!made.!Following!the!receipt!of!a!completed!survey,!a!$15!gift!card!was!mailed!to!each!participant.!!128 !Eighty@five!percent!of!patients!that!were!successfully!contacted!(N=194)!consented!to!participate!in!the!survey!(N=165).!In!total,!14!potential!participants!explicitly!stated!that!they!did!not!wish!to!participate!in!the!survey.!Stated!reasons!for!refusal!included!not!having!access!to!a!computer!or!an!email!address!(N=9),!or!personal!circumstances!(N=1).!Three!potential!participants!did!not!provide!a!rationale!for!refusal,!and!one!believed!that!his/!her!asthma!was!too!mild!such!that!he/she!should!not!be!considered!eligible!(see!figure!5.1).!%% %129 Figure%5.1:%Participant%recruitment%%!!Of!the!165!participants!who!consented!to!participate,!93!(56.3%)!completed!the!survey!without!being!followed!up.!Following!up!with!72!participants!resulted!in!an!additional!24!surveys!submitted!(33.3%).!Participants!most!often!could!not!recall!being!sent!the!survey!materials,!or!had!simply!forgotten!to!complete!the!survey.!Most!often,!no!reasons!were!given,!and!attempts!made!to!follow!up!with!the!participant!were!unsuccessful,!therefore!rationale!for!dropouts!are!not!reported!(see!appendix!D).!!Participants%contacted%Previously!consented!!(N!=!206)Confirmed!interest!in!future!research(N!=!119)Total%N%contactedN =!325Could!not!make!contact!N!=!131 Made!contactN!=!194!Not!interested!in!future!researchN!=!15 Declined!!!N!=!14 Consented%N%=%165Total%completed%surveysN=%117130 5.4%Privacy%and%confidentiality%of%study%data%I!developed!and!distributed!the!survey!using!UBC’s!FluidSurveys.(235)!To!safeguard!anonymity!of!responses,!I!did!not!collect!participant!names!and!email!addresses!through!the!survey.!!The!research!coordinator!assisting!with!the!survey!retained!and!stored!the!list!of!EBA!IDs!and!corresponding!four@digit!survey!IDs!on!a!password!protected!computer!in!a!locked!office!at!Vancouver!General!Hospital.!Participant!ID!codes!were!not!attached!to!their!survey!link,!to!ensure!participant!anonymity.!!An!ID!code!was!required!in!order!to!link!their!responses!to!their!EBA!ID!so!that!they!could!be!identified!and!reimbursed!for!participation.!I!maintained!all!survey!data!downloaded!from!Fluid!on!the!Centre!for!Clinical!Epidemiology!and!Evaluation’s!Shared!Drive.!The!Shared!Drive!is!password!protected.!!!This!survey!study!received!approval!from!the!University!of!British!Columbia’s!Clinical!Research!Ethics!Board!(H10@01542).!%5.5%Participant%demographics%Following!471!attempts!at!contact,!165!patients!consented!to!participate!in!this!online!survey,!resulting!in!117!completed!surveys!that!were!used!for!the!analysis!presented!in!chapter!6.!!In!general,!the!sample!was!variable!in!terms!of!age,!with!a!generally!high!annual!household!income,!high!education,!with!relatively!low!recent!asthma@related!healthcare!resource!use.!A!small!majority!of!participants!were!female!(58%).!Eighty@two!participants!self@reported!as!white/Caucasian!ethnicity,!131 and!69%!reported!having!completed!4@year!college!or!university.!Fifty@eight!percent!of!respondents!reported!an!annual!household!income!of!$80,000!or!more.!The!mean!age!of!participants!was!56!(range:!22@86,!SD:!14.4)!(see!table!5.1).!!!!The!majority!of!respondents!reported!having!at!least!one!comorbidity!with!a!range!of!0@6.!The!distribution!of!the!number!of!comorbidities!was!highly!positively!skewed.!The!most!commonly!reported!condition!was!back!pain!(N=!35)!followed!by!osteoarthritis!(N=!27)!and!high!blood!pressure!(N=22).!Thirty!percent!of!participants!(N=35)!reported!having!no!comorbidities.!! !132 !Table%5.1:%Participant%demographics%%Demographic%variable% N%(total%N%=%117)%or%Mean%(SD)%Gender%Female!Male!Other!!!68!(58%)!49!(42%)!0!!Ethnicity%White/Caucasian!Chinese!South!Asian!Philipino!Other!!96!(82%)!9!(7.6%)!4!(3.4%)!3!(2.6%)!5!(4.3%)!!Age%%! Mean:!56!(SD:!14.4)!Missing!data:!2!!!Number%of%comorbidities%per%survey%respondent%%0!1!2!3!4!5!6!!!Median:!1!(range:!0@6)!!35!(29.9%)!39!(33.3%)!26!(22.2%)!7!(5.9%)!6!(5.1%)!2!(1.7%)!2!(1.7%)!!Annual%household%income%Less!than!$20,000!$20,000!to!$39,999!$40,000!to!$59,999!$60,000!to!$79,999!$80,000!or!more!!!!!!!!6!(5.4%)!10!(9%)!16!(14.1%)!14!(12.6%)!65!(58.6%)!Missing!data:!6!!!Education%(total%N)%Four@Year!College/!University!Some!college!!High!school!Middle!school!Primary!school!!!81!(69%)!32!(27.3%)!2!(1.7%)!1!(0.85%)!1!(0.85%)!!!133 Healthcare%use%within%the%past%year%%Visited!a!doctor!for!asthma!!Visited!the!hospital!Visited!the!ER!!!!58!(49.5%)!1!(0.85%)!4!(3.4%)!!!5.6%Generalizability%of%study%sample%The!current!sample!can!be!generalized!to!three!separate!populations:!!the!population!of!the!original!EBA!cohort,!adult!asthma!patients!in!BC,!and!the!sample!of!BC!asthma!patients!used!for!the!chapter!4!cross@sectional!analysis.!!!Although!I!do!not!have!demographic!information!on!the!non@responders,!previous!publications!that!have!reported!the!demographic!characteristics!of!the!entire!adult!EBA!cohort!are!useful!in!determining!the!representativeness!of!the!current!sample.(232)!Participants!in!this!survey!and!the!larger!EBA!cohort!were!predominantly!older!individuals!with!high!education,!income,!with!a!majority!reporting!white/Caucasian!ethnicity.!Table!5.2!shows!the!distribution!of!comparable!demographic!characteristics!with!the!primary!and!larger!EBA!cohort.(236)!In!general,!the!characteristics!of!the!current!analytic!sample!are!very!similar!to!those!of!the!larger!EBA!cohort!(see!chapter!7),!suggesting!a!lack!of!non@repose!bias!based!on!the!variables!that!I!assessed.(237,238)!For!example,!the!current!analytic!sample!is!similar!to!the!larger!adult!EBA!cohort!on!measured!characteristics!such!as!age,!gender!distribution,!ethnicity,!income!and!education.!!134 In!comparison!with!the!general!population!of!asthma!patients!over!the!age!of!12!in!Canada,!a!much!higher!proportion!of!the!current!analytic!sample!reported!well@controlled!disease!(75%!v.!34.4%)!and!exposure!to!an!asthma!educator!(38%!v.!5.6%).(239,240)!Characteristics!related!to!sex!and!recent!healthcare!use!!were!very!similar.!Given!the!differences!in!characteristics!between!the!current!sample!and!the!larger!population!of!adult!asthma!patients!in!BC,!this!impacts!the!generalizability!of!the!study!findings.!For!example,!those!who!participate!in!research!studies!may!be!systematically!more!interested!in!their!own!health!due!to!previous!involvement!in!and!completion!of!a!longitudinal!cohort!study,!reflecting!higher!adherence!rates,!preferences!for!SDM,!and!perhaps!even!the!ability!to!recall!encounters!with!their!healthcare!professionals.!!Demographic!characteristics!for!the!current!analytic!sample!compared!with!the!analytic!sample!in!chapter!4!are!similar!in!terms!of!gender!distribution,!recent!healthcare!use!and!the!presence!of!comorbidities!(see!table!5.2).!I!cannot!compare!age!distributions!because!the!analytic!sample!for!chapter!4!included!only!those!individuals!age!18!to!55,!versus!the!current!sample!that!ranges!in!age!from!22!to!86.!!! !135 !Table%5.2:%Generalizability%of%the%survey%sample%%% Current%analytic%sample%(age%18+)%(chapter%5%and%6)%Adult%asthma%patients%(age%18G55)%in%BC%(chapter%4)%Adult%EBA%cohort%(232)%Canadian%asthma%patients%over%the%age%of%12%(109,239)%%Mean%age%%%56! 37! 52! NR!%Female%%58%! 64%! 67%! 58%!%Median%number%%of%comorbidities%%%1!! 0!(CCI)! NR! NR!%Ethnicity%(%%white)%%82%! NR! 82%! NR!%Recent%GP%visit% 49%!(previous!12@months)!!55%!(12@months!prior!to!index!date)!!96%!(index!period)!NR! 62%!Recent%hospitalization%%0.85%!! NR! NR! NR!Income:%>%$60,000%%67%! NR! 72%! NR!Education:%postGsecondary%%69%! NR! 75%! NR!WellGcontrolled%asthma%%75%! NR! NR! 34%!Ever%having%seen%an%asthma%educator%%38%! NR! NR! 5.6%!NR!=!not!reported!136 5.7%Strengths%and%limitations%of%recruitment%methods%5.7.1%Strengths%Multiple!strengths!contribute!to!the!validity!of!the!findings!that!will!be!reported!in!the!next!chapter.!Firstly,!the!online!survey!format!was!selected!for!purposes!of!speed,!and!cost.(241)!In!addition,!electronic!survey!administration!reduces!the!need!for!data!cleaning,!and!reduces!the!potential!for!error!related!to!interpreting!imputing!hand!written!data.!!!Secondly,!the!online!nature!of!the!anonymous!survey!instrument!served!to!eliminate!interviewer!bias,!and!to!reduce!social!desirability!bias,!while!allowing!participants!to!complete!the!survey!at!their!own!pace.!As!stated!previously,!I!hypothesize!that!participants!may!over@report!socially!desirable!responses!such!as!those!related!to!medication!use!and!asthma!control.!Using!an!online!format!and!ensuring!participant!anonymity!(through!the!use!of!the!four@digit!ID!codes)!likely!reduced!the!potential!for!associated!information!biases.!!Thirdly,!participants!were!permitted!to!return!to!the!survey!multiple!times!before!submitting.!The!objective!for!allowing!multiple!attempts!was!to!reduce!the!potential!for!respondent!fatigue,!and!non@response.!Anecdotally,!when!speaking!with!participants!about!the!length!of!the!survey,!a!few!stated!that!they!were!relieved!to!hear!that!they!were!not!required!to!complete!the!survey!in!one!sitting.!!!137 Finally,!I!developed!the!survey!to!be!completed!within!30!minutes!to!minimize!respondent!burden.!The!average!time!to!completion!was!approximately!20!minutes.!Previous!research!has!shown!that!instrument!brevity!is!associated!with!increased!response!rates.(242,243)!!!5.7.2%Limitations%and%challenges%5.7.2.1!Recruitment!!Among!contacted!potential!participants,!the!final!response!rate!was!60%,!and!71%!among!consenting!participants.!While!no!formal!meaningful!threshold!for!response!rates!has!been!adopted!in!the!literature,!a!threshold!of!60%!is!often!reported!as!adequate.(243,244)!As!response!rates!are!dependent!on!the!characteristics!of!those!being!recruited,!it!may!not!be!surprising!to!see!a!relatively!high!rate,!given!that!our!sampling!frame!was!well@educated!with!a!high!average!income!and!a!previous!interest!in!research!related!activities.(245)!!!Two!issues!were!identified!as!impacting!recruitment:!1.! Inability!to!make!initial!contact!with!potential!participants!2.! Failure!to!obtain!completed!surveys!from!consenting!participants!!Of!325!potential!participants!approached,!131!(40%)!could!not!be!contacted.!Failure!to!communicate!with!participants!was!typically!due!to!incorrect/outdated!contact!information!on!file,!or!lack!of!response!to!telephone!and!email!messages.!Few!138 participants!returned!such!calls,!suggesting!that!further!attempts!at!communication!initiated!by!the!researcher!may!be!more!successful!than!relying!on!the!participant!to!return!a!phone!call!or!email.!!!Given!that!the!original!EBA!cohort!study!was!completed!3!years!prior,!it!is!possible!that!participants!had!moved!or!changed!their!contact!information.!This!remains!a!limitation!of!relying!on!previously!collected!data.!Finally,!the!effectiveness!of!initial!attempts!at!contact!as!well!as!follow!up!reminders!sent!via!email!may!also!have!been!impacted!by!individuals’!use!of!email!filters!and!junk!mail!folders.(246)!!5.7.2.2!Participant!follow!up!Attempts!made!to!follow!up!on!participants!who!had!consented!to!participate!but!did!not!return!a!completed!survey!were!only!mildly!successful.!A!potential!explanation!for!this!lack!of!success!is!that!much!of!the!follow@!up!phase!of!recruitment!was!conducted!between!June!and!August.!Although!pre@notification!and!follow!up!reminders!have!shown!to!increase!participation!and!response!speed,!any!potential!benefit!may!have!been!mitigated!by!attempts!to!recruit!and!follow!up!during!the!summer!months.(247)!!!Additionally,!follow@ups!were!delayed!due!to!a!change!in!study!personnel.!For!this!reason,!initial!follow!up!for!some!participants!occurred!2!to!3!months!after!they!had!initially!consented!to!participate.!Consequently,!participants!who!had!previously!consented!but!were!not!followed!up!within!a!shorter!time!frame!may!have!forgotten!139 about!the!survey!or!lost!interest!due!to!this!time!lag.!A!future!research!study!using!similar!methods!would!benefit!from!contacting!participants!for!follow!up!within!a!shorter!time!frame.!!5.7.2.3!NonDresponse!bias!!Several!attempts!to!reduce!non@response!were!used,!including!personalized!telephone!and!email!communication,!as!well!as!follow!up!reminders.(241,246)!It!is!unclear!whether!attempts!to!follow!up!on!previously!consented!participants!and!increase!the!sampling!frame!decreased!nonresponse!bias,!although!the!efforts!did!increase!the!overall!sample!size,!thereby!reducing!random!error.!!!Further!attempts!to!reduce!non@response!included!ensuring!that!participants!understood!that!the!survey!was!anonymous!and!that!they!were!not!required!to!provide!an!answer!to!each!question!on!the!survey.!The!only!question!that!participants!were!required!to!complete!was!the!consent!procedure,!and!the!item!asking!for!their!four@digit!ID.!A!concern!identified!a!priori!was!that!given!the!nature!of!the!questions!(disease!status,!medication!names,!and!demographics)!participants!may!view!the!survey!items!and!subsequently!decide!not!to!participate.!Ensuring!that!participants!were!aware!that!they!could!skip!questions!was!intended!to!reduce!complete!non@response.!!This!survey!required!that!participants!be!familiar!and!comfortable!with!computers,!thereby!excluding!those!who!are!unwilling!or!unable!to!participate!in!electronic!140 research!studies.!While!less!than!10!participants!explicitly!declined!participation!due!to!the!online!format,!it!is!possible!that!a!larger!group!of!potential!participants!refused!participation!for!this!reason,!without!communicating!this!to!the!study!team.!However,!when!comparing!the!age,!ethnicity!and!education!distributions!between!the!current!analytic!sample!and!the!larger!EBA!cohort,!there!is!no!clear!evidence!of!under@representation!(see!table!5.2).!In!the!following!chapter!I!will!describe!the!methods!used!to!develop!the!survey!instrument!and!for!data!analysis.!Further!to!this,!the!results!of!the!survey!findings!will!be!presented.! %141 Chapter%6:%Asthma%controller%adherence%and%the%role%for%patient%engagement:%survey%development%and%results%!6.1%Background%Over!the!past!20!years,!a!significant!amount!of!attention!has!been!paid!to!outcomes!related!to!patient!participation!in!their!own!healthcare!decision@making.!Some!studies!have!shown!that!patients!who!actively!participate!in!their!healthcare!decision@making!report!higher!levels!of!satisfaction(46),!reduced!decisional!conflict!(160)!and!improved!emotional!status.(25,161)!Evidence!also!suggests!that!shared!decision@making!(SDM)!may!improve!clinical!outcomes!such!as!symptom!resolution,(161)!a!reduction!in!hospital!re@admissions,!(17)!as!well!as!improved!disease!monitoring.(248,249)!While!dependent!on!clinical!and!patient!context,!both!patient!and!physician!preferences!for!a!more!active!approach!have!increased!in!recent!years.(1,250)!Although!high!quality!evidence!has!identified!several!potential!benefits!to!be!associated!with!active!patient!involvement!as!well!as!patients’!reported!desire!to!participate,!clinical!uptake!has!been!low.!%!6.1.1%Objectives%This!survey!research!was!a!response,!in!part,!to!current!concerns!that!SDM!implementation!has!been!slow!across!multiple!disease!contexts.!The!overarching!goal!of!this!survey!was!to!provide!a!description!of!the!state!of!SDM!in!asthma!care!in!142 BC,!as!well!as!to!suggest!potential!avenues!for!clinical!implementation.!In!light!of!this,!below!I!describe!the!three!specific!research!objectives.!!In!chapter!2,!I!reported!that!physicians!are!generally!more!supportive!of!engaging!patients!who!are!both!able!and!willing!to!participate!in!the!decision@making!process.(1,54,88)!Factors!that!may!also!be!related!to!this!preference!are!a!patient’s!perceived!literacy,!numeracy!and!socioeconomic!status.(54,92,93)!A!potential!implication!of!this!finding!is!that!physicians!may!be!more!likely!to!engage!a!patient!in!their!treatment!decision!if!they!perceive!that!the!patient!is!interested!in!participating.!If!physicians!are!systematically!engaging!only!patients!whom!they!believe!will!benefit!from!a!shared!encounter,!this!may!result!in!a!specific!population!of!patients!being!underserved!by!SDM.!The!potential!inequity!resulting!from!a!systematic!exclusion!of!certain!patient!groups!may!further!contribute!to!increased!but!preventable!disease!burden!within!specific!clinical!subpopulations.!Therefore,!a!primary!objective!of!this!investigation!is!to!identify!the!characteristics!of!patients!who!do!and!do!not!desire!to!participate!in!SDM!(research!question!#1).!!As!a!second!objective,!I!will!investigate!which!factors!related!to!the!decision@making!encounter!explain!adherence!to!asthma!controller!medications!(research!question!#2).!This!research!question!was!developed!in!response!to!the!existing!literature,!as!well!as!chapter!4!which!reports!that!adherence!cannot!be!fully!explained!at!the!population!level,!and!that!further!insight!into!aspects!of!the!patient/physician!relationship!and!the!clinical!encounter!may!be!warranted.!Previous!work!supports!143 this!hypothesis.!For!example,!several!factors!that!serve!as!individual!components!of!the!SDM!encounter!have!been!shown!to!increase!adherence,!including!but!not!limited!to!increased!length!of!consultation!time,!treatment!acceptance,!patient!satisfaction!with!the!physician’s!education!skills,!and!decision!aids.(249,251–256)!A!smaller!number!of!studies!have!explicitly!investigated!the!link!between!treatment!adherence!and!comprehensive!SDM!interventions,!although!there!is!currently!a!lack!of!consistency!between!studies!(see!table!6.1).!Studies!that!assess!only!the!impact!of!decision!aids!on!SDM!are!excluded!from!table!6.1.!!%144 Table&6.1:&&Primary&data&collection&studies&assessing&associations&between&SDM&and&treatment&adherence&&First&author&Year& N& Study&design&Clinical&decision&context&Adherence&measure&Patient&perceived&vs.&actual&level&of&SDM&measured&Intervention&format& Association&between&SDM&and&adherence&(p&<&.05)&Aljumah((257) (& 2015( 220( RCT( Depression( Self=reported( Actual( Comparison(of(SDM(versus(usual(care(control.(Pharmacists(in(the(SDM(group(were(trained(in(SDM(competencies.( Yes(Bauer((164) ((& 2014( 1523( Prospective(cohort( Diabetes( Pharmacy(records( Perceived( Written(survey/(web(based(survey/(Interviewer(assisted(interview((Modified(IPCI(instrument)((Yes(Matthias((258) ((& 2014( 79( Cross(sectional( Mental(health( Self=reported(( Actual( Patient=physician(clinical(encounters(were(recorded(and(coded(for(SDM(components((Yes(De(Las(Cuevas((259) ((& 2014( 967( Cross(sectional(survey( (Psychiatric(medication( Self=reported( Perceived( Face(to(face((control(preference(scale)(( No(Tinsel((260) (& 2013( 1120( Cluster(RCT( Anti=hypertensive(therapy( Self=reported( Perceived( Comparison(of(SDM(versus(usual(care(control.(Physicians(in(the(SDM(group(were(trained(in(SDM(competencies.((No(Wilson((17) (& 2010( 612( RCT( Asthma( Pharmacy(records( Actual( Comparison(of(SDM(and(clinical(decision=making(intervention(( Yes(Loh((47) (& 2007( 405( Cluster(RCT( Depression( Self=reported((Physician(and(patient(assessments)(Actual( Comparison(of(SDM(versus(usual(care(control.(Physicians(in(the(SDM(group(were(trained(in(SDM.( No(145 Finally,(the(current(investigation(seeks(to(further(this(research(agenda(by(looking(more(closely(at(specific(aspects(of(SDM(that(may(serve(as(effective(strategies(to(improve(adherence(among(adult(asthma(patients.(As(such,(the(third(objective(of(this(study(is(to(describe(the(extent(to(which(asthmaArelated(education(and(SDM(are(being(incorporated(into(clinical(practice((research(question(#3).(((In(summary,(the(primary(objectives(of(the(current(chapter(are(to(address(the(following(research(questions:(1.! What(role(do(asthma(patients(prefer(to(take(in(the(decisionAmaking(process?(2.! What(factors(related(to(patientAphysician(communication(and(education(explain(adherence?(3.! To(what(extent(do(asthma(patients(recall(previous(exposure(to(SDM?( (a.! Is(patientAreported(engagement(in(SDM(associated(with(adherence(to(controller(medication?(b.! Is(there(an(association(between(preferences(for(decisionAmaking(and(perceived(exposure(to(SDM?(Addressing(these(five(research(questions(will(help(to(fill(the(current(evidence(gaps(with(regard(to(patient(preferences(for(involvement(in(their(care,(the(potential(role(for(SDM(in(improving(treatment(adherence(to(asthma(controller(medication,(as(well(as(to(address(the(state(of(SDM(clinical(implementation.(((146 6.2$Methods$6.2.1$Survey$development$I(developed(the(initial(draft(of(the(survey(tool,(and(revisions(were(made(in(consultation(with(thesis(committee(members.(The(survey(was(piloted(on(a(small(number(of(asthma(and(general(population(individuals(throughout(the(fall(of(2015.(The(survey(was(piloted(using(multiple(devices(including(Mac(and(PC(computers,(iPads,(iPhones(and(Android(phones.(Feedback(was(requested(for(item(clarity,(instructions,(format,(and(survey(length.(Piloting(continued(until(no(further(suggestions(for(revision(were(made.(((As(stated(in(chapter(5,(the(only(items(that(participants(were(required(to(complete(were(the(entry(of(their(4Adigit(ID(and(the(provision(of(consent,(in(order(to(proceed(to(the(main(survey.(Items(were(not(randomized.(Nested(questions(were(included(such(that,(for(example,(if(a(participant(was(not(being(prescribed(controller(medication,(he(or(she(would(not(be(asked(questions(regarding(controllers(or(the(decisionAmaking(process(for(controllers.(Between(1(and(10(items(were(included(per(page.(The(survey(was(a(total(of(30(pages(long((including(the(consent(form(and(4Adigit(ID(entry(page).(Where(relevant,(an(item(indicating(“I(am(unsure”(or(“I(cannot(remember”(was(included.((See(Appendix(E(for(a(complete(list(of(survey(items.(The(following(domains(were(included:(147 1.! Patient(demographics(including(age,(gender,(income,(education,(time(since(diagnosis(and(comorbidities(2.! SelfAreported(adherence(and(patient(identified(barriers(to(adherence((3.! Exposure(to(asthmaArelated(education((e.g.(inhaler(instructions,(asthma(action(plans(and(asthma(educators)(4.! Asthma(medications(being(prescribed(5.! Asthma(control((6.! HealthArelated(literacy(and(numeracy(7.! Number(and(type(of(recent(healthcare(use(8.! The(extent(to(which(patients(desire(to(be(involved(in(decisions(about(their(asthma(medication(9.! The(extent(to(which(patients(report(that(they(were(involved(in(the(decision(about(their(current(controller(medication((The(following(describes(the(items(chosen(for(inclusion(in(the(survey(instrument.(See(appendix(F(for(a(description(of(the(preAvalidated(instrument(variable(definitions(used(for(the(analysis.($6.2.1.1%Adherence%SelfAreported(adherence(to(controller(medication(is(based(on(the(Adult(Asthma(Adherence(Questionnaire((AAAQ).(261,262)(I(included(the(statement,(“I(follow(my(asthma(medication(plan”(as(an(indicator(of(patient(adherence.(262)(The(AAAQ(148 adherence(indicator(been(shown(to(have(high(construct(validity,(and(predicts(adherence(as(measured(through(administrative(databases.(261)(Other(measures(of(selfAreported(adherence(are(lengthy(and(therefore(add(to(respondent(burden,((263)(or(lack(the(predictive(power(of(the(AAAQ.(264)(The(additional(AAAQ(items(pertain(to(patient(perceived(barriers(to(adherence((e.g.(cost(of(medication(and(medication(side(effects).(One(additional(item(was(included(to(capture(patientAreported(concerns(about(controller(medication(side(effects.((6.2.1.2%Perceived%exposure%to%SDM%The(3Aitem(CollaboRATE(tool(was(used(to(determine(the(extent(to(which(patients(believed(that(effort(was(made(to(engage(them(in(the(decision(making(process(about(their(controller(medication.(265,266)(Although(a(paucity(of(tools(exist(to(ascertain(patientAreported(perceptions(of(involvement(in(their(care(–(such(as(the(OPTION(scale(A(many(are(lengthy,(focus(on(one(specific(clinical(encounter,(or(rate(low(on(various(validity(metrics.(265,267)(In(contrast,(the(CollaboRATE(scale(has(been(developed(to(be(completed(within(30(seconds(thereby(reducing(respondent(burden,(and(demonstrates(discriminant(and(concurrent(validity,(intraArater(reliability(as(well(as(sensitivity(to(change,(when(compared(against(other(measures(such(as(the(9Aitem(SDMAQA9.(266)(Furthermore,(the(brevity(and(validity(associated(with(CollaboRATE(have(popularized(the(instrument,(thereby(facilitating(comparison(across(clinical(scenarios(and(patient(populations.(The(CollaboRATE(survey(has(been(validated(and(tested(on(various(patient(populations(using(both(a(10Apoint(scale(and(a(5Apoint(anchored(scale.(Since(there(is(no(evidence(to(suggest(which(scale(option(is(149 superior,(I(used(the(5Apoint(anchored(scale(option.(266)(((6.2.1.3%Preference%for%involvement%in%the%decision=making%process%The(Problem(Solving(DecisionAmaking(Scale((PSDM)(patient(survey(was(included(to(capture(the(extent(to(which(asthma(patients(wish(to(be(involved(in(their(decisions(about(controller(medication.(268).(The(tool(uses(as(a(5Apoint(Likert(scale(and(determines(patients’(reported(preferences(for(involvement(in(various(aspects(of(the(decisionAmaking(encounter.(Based(on(the(responses(to(the(6(questions,(the(instrument(then(categorizes(respondents(into(support(for(a(either(passive(role(in(decisionAmaking,(autonomous,(or(shared(preference(for(both(the(“problem(solving”(questions((N=4)(and(the(“decisionAmaking”(questions((N=2).(269)(This(item(was(selected(for(its(brevity,(as(well(as(the(fact(that(the(PSDM(scale(specifically(addresses(multiple(facets(of(the(clinical(encounter.((6.2.1.4%Exposure%to%asthma=related%education%To(ascertain(the(extent(to(which(patients(had(been(exposed(to(existing(clinical(interventions,(I(included(the(following(items:(1.! Have(you(ever(heard(of(an(asthma(action(plan,(before(today?(2.! Did(you(ever(get(a(written(action(plan(for(managing(your(asthma?(3.! Were(you(involved(in(developing(your(asthma(action(plan?(4.! Have(you(seen(a(specialist(for(your(asthma?(5.! Have(you(ever(had(teaching(from(an(asthma(educator?(150 Individual(items(were(selected(on(the(basis(of(consultation(with(asthma(specialists(and(committee(members.(A(selection(of(the(items(chosen(had(previously(been(included(on(the(EBA(patient(survey((e.g.(questions(2,(4(and(5).(((6.2.1.5%Health%literacy%and%numeracy%Health(literacy(can(be(defined(as(“the(degree(to(which(individuals(have(the(capacity(to(obtain,(process,(and(understand(basic(healthArelated(decisions.”(270)(Within(the(context(of(asthma,(poor(health(literacy(is(associated(with(decreased(adherence,(asthma(control,(quality(of(life,(lower(medicationArelated(knowledge,(difficulty(managing(the(disease,(poor(inhaler(technique,(days(lost(from(usual(activities,(as(well(as(increased(morbidity(and(hospitalizations.(151,271–275)(The(3ASQ(tool(has(been(previously(validated(and(shown(to(have(high(sensitivity(and(specificity(when(compared(against(preAexisting(measures(such(as(the(Short(Test(of(Functional(Health(Literacy(in(Adults(and(the(Rapid(Estimate(of(Adult(Literacy(in(Medicine.(276–278)((%The(Subjective(Numeracy(Scale((SNS),(developed(by(Fagerlin(and(colleagues,(provides(a(subjective(measure(of(health(numeracy.(279)(The(threeAitem(short(form(SNS(is(used(to(assess(patient(perceptions(of(their(comfort(level(with(numbers.(While(objective(measures(of(numeracy(have(been(developed((e.g.(Test(of(Functional(Health(Literacy(in(Adults(and(Objective(Numeracy(Scale),(many(research(participants(dislike(aptitude(tests(as(part(of(a(survey.(279)(The(threeAitem(SNS(has(been(validated(against(the(previously(existing(SNS((8Aitem)(with(high(correlation,(internal(151 reliability,(and(validity.(280)(The(original((8Aitem)(SNS(has(been(validated(against(objective(measures(of(numeracy,(with(high(internal(consistency(and(correlation.(Furthermore,(both(the(8(and(3Aitem(SNS(can(be(completed(in(less(time(than(existing(objective(measures(of(numeracy.(279)(I(therefore(chose(the(3Aitem(SNS(to(further(reduce(respondent(burden(while(obtaining(a(valid(estimate(of(health(numeracy.((6.2.1.6%Current%asthma%control%The(Asthma(Control(Test((ACT)(was(included(to(measure(patientAperceived(asthma(control.(The(ACT(is(a(brief(5Aitem(instrument(that(provides(an(indication(of(how(well(the(patient’s(asthma(is(controlled.(281)(ACT(response(options(refer(to(the(frequency(of(various(symptoms(experienced(within(the(past(4(weeks.(Scores(range(from(1(to(25.(A(score(of(≥20(indicates(potentially(wellAcontrolled(asthma,(and(lower(scores(indicate(poorer(control.(((6.2.1.7%Additional%survey%variables%A(range(of(additional(variables(were(collected(to(ascertain(information(about(participant(demographics,(current(medication(use,(concerns(about(inhaled(steroids,(exposure(to(asthma(related(education(as(well(as(asthma(action(plans.(See(Appendix(E(for(a(complete(list(of(survey(items.((Two(additional(variables(were(created(after(survey(responses(were(received,(to(capture:((152 a)! Length(of(time(passed(since(initial(asthma(diagnosis((Current(age(–(Age(at(diagnosis)(b)! Number(of(asthma(rescue(or(controller(medications(currently(being(prescribed(for(their(asthma((obtained(from(participant(reported(names(of(medications)(6.2.2$Analytic$methods$6.2.2.1%Initial%data%exploration%To(begin,(outcome(and(explanatory(variables(were(explored(to(determine(measures(of(central(tendency,(variation,(and(frequency.(I(chose(to(collapse(or(dichotomize(specific(variables(in(the(event(of(small(cell(sizes(or(limited(variation(in(the(item((e.g.(income(and(education).(Variables(with(little(to(no(variation(were(removed(from(further(analysis((e.g.(having(been(taught(how(to(use(an(inhaler).((Throughout(the(process(of(univariate(analysis,(I(assessed(the(prevalence(of(missing(data(points((e.g.(questions(with(no(response).(CaseAwise(deletion(was(selected(as(the(method(to(handle(missing(data(in(the(case(where(less(than(5%(of(cases(included(missing(data(points.(Multiple(imputation((MI)(was(considered(for(the(final(multivariate(model(if(greater(than(5%(missing(data(was(identified(within(the(analytic(sample.(Multiple(imputation(allows(for(the(use(of(the(complete(sample(size(by(predicting(the(value(of(a(missing(data(point(based(on(the(distribution(of(the(observed(values.(282)(MI(does(not(distort(standard(errors(and(hypothesis(tests(in(the(way(that(simpler(methods(such(as(mean(imputation(may.(283)(R(software,(using(153 the(“mi”(package,(completes(the(missing(values(with(imputed(values(that(are(randomly(sampled(from(the(observed(dataset,(using(a(bootstrapping(mechanism.(284)(A(priori,(no(ceiling(effect(was(applied(such(that(in(the(case(of(a(specific(proportion(of(missing(cases,(the(variable(would(be(excluded(from(analysis.(6.2.2.2%Multivariate%analysis%The(appropriate(model((multiple(linear(or(logistic)(was(initially(selected(based(on(the(distribution(of(the(outcome(variable.(Given(the(explanatory(nature(of(the(models,(I(included(all(explanatory(variables(that(were(shown(to(be(statistically(significant(at(the(p=0.05(level(of(statistical(significance.(R(software(was(used(for(all(analyses.(285)(Both(unadjusted((bivariate)(and(adjusted((for(all(additional(explanatory(variables)(results(are(presented.((6.3$Results$The(results(presented(here(are(based(on(responses(from(117(completed(surveys.(Details(about(recruitment(and(response(rates,(along(with(participant(demographics(were(presented(in(chapter(5((see(table(5.1).(The(following(sections(describe(data(cleaning(and(the(distributions(and(frequency(of(remaining(survey(items.($Returned(surveys(were(largely(complete(and(free(of(identifiable(errors.(The(variable(for(age(at(first(asthma(diagnosis(did(require(data(cleaning.(Upon(initial(data(exploration,(6(respondents((presumably)(entered(in(the(year(that(they(were(diagnosed((e.g.(1999),(instead(of(entering(their(age(at(diagnosis.(Since(current(age(154 was(included(as(a(survey(item,(the(following(formula(was(used(to(calculate(correct(age(at(diagnosis((Age$at$Diagnosis$Corrected):(Time$Since$Diagnosis$=$2016$–$(participant$entered$year$of$diagnosis)$Current$age$–$Time$Since$Diagnosis$=$Age$at$Diagnosis$Corrected$(6.3.1$Descriptive$statistics$for$predictor$variables$The(mean(length(of(time(since(initial(diagnosis(was(29(years((SD:(16.3)(with(a(range(of(0(to(75(years(and(3(missing(data(points.(One(participant(indicated(that(he(or(she(was(diagnosed(for(the(first(time(in(2016,(which(may(indicate(a(misunderstanding(of(the(question,(since(everyone(having(participated(in(the(EBA(study(were(required(to(have(a(physician(diagnosis(of(asthma(at(the(time(of(cohort(entry.(The(median(age(at(initial(asthma(diagnosis(was(22((SD:(20.1)(with(a(range(of(1(to(78.(TwentyAfive(percent(of(the(114(respondents(were(diagnosed(on(or(before(the(age(of(10.(((Numeracy(scores(were(highly(negatively(skewed(toward(the(top(score.(For(this(reason,(I(reAcoded(the(combined(numeracy(variable(into(tertiles(based(on(the(initial(distribution((see(table(6.2).(Very(little(variation(was(shown(on(each(of(the(literacy(items.(For(each(individual(question,(93%((109)(of(respondents(provided(either(of(the(two(highest(confidence(ratings.(For(this(reason,(the(literacy(items(were(excluded(from(the(bivariate(and(multivariate(analyses.($SixtyAone(percent(of(respondents(had(heard(of(an(asthma(action(plan(but(only(18%(of(the(sample(had(received(a(plan.(FiftyAseven(percent(of(those(who(had(received(a(155 plan(had(participated(in(the(development(of(their(action(plan((N=12).(Nearly(all(respondents((N=115)(reported(having(received(at(least(some(form(of(training(with(their(inhalers((variable(excluded(from(further(analysis),(and(frequently(listed(family(doctors,(specialists,(asthma(educators,(nurses(and(pharmacists(as(those(who(provided(the(training.(Given(the(lack(of(variability(on(this(item,(“having(received(training(with(inhalers”(was(removed(from(further(analysis.((Just(fewer(than(50%((N=58)(of(respondents(had(visited(a(doctor(within(the(past(year(for(their(asthma,(but(few(had(been(admitted(to(the(emergency(department((ED)((N=4)(or(the(hospital((N=1)(during(that(time.(Because(of(the(low(event(rate,(ED(and(hospitalizations(were(excluded(from(further(analysis.((Of(117(respondents,(89(reported(currently((within(the(past(12(months)(being(prescribed(controller(medication,(and(84(reported(that(they(were(currently(being(prescribed(a(rescue(medication.(When(asked(to(list(the(names(of(their(medications,(27%(of(those(being(prescribed(controllers(listed(a(rescue(medication((e.g.(Ventolin)(or(another(type(of(medication((e.g.(homeopathic(remedy)(as(their(current(controller.(((Respondents(reported(having(wellAcontrolled(asthma,(on(average.(The(median(score(among(115(respondents(who(provided(valid(data(was(22,(with(a(range(of(8(to(25,(indicating(that(this(sample(is(generally(wellAcontrolled.((For(the(bivariate(and(multivariate(analyses,(the(total(ACT(variable(was(categorized(as(“wellAcontrolled”(or(156 “not(wellAcontrolled”(using(a(cut(point(of(20.(This(cut(point(is(used(in(the(publically(available(online(version(of(the(ACT.(286)(((FortyAfour(percent((N=39/89)(of(respondents(reported(being(adherent(to(their(asthma(medication(plan((see(figure(6.7).(Of(the(89(respondents(currently(being(prescribed(controllers,(91%((N=81)(had(reportedly(filled(their(most(recent(controller(prescription.(One(respondent(did(not(report(an(answer(to(the(adherence(item.(Eleven(percent(of(patients(either(agreed(completely(or(mostly(to(the(statement(that(they(forget(to(take(at(least(one(of(their(inhaled(steroids(doses(each(day.(Alternatively,(33%(completely(disagreed(with(this(statement,(suggesting(general(adherence(to(their(controller(medication.((Among(patients(who(had(been(prescribed(a(controller(within(the(past(year((N=89),(43%(agreed(either(completely(or(mostly(with(the(statement(that(their(asthma(is(mild(and(therefore(does(not(require(controller(medication.(An(additional(35%(either(disagreed(completely(or(mostly(with(this(statement.(FiftyAseven(percent(of(patients(being(prescribed(controllers(disagreed(completely(or(mostly(with(the(claim(that(inhaled(steroids(cause(side(effects.(Conversely,(16%(agreed(completely(or(mostly(to(this(statement.(TwentyAfive(percent(of(respondents(reported(being(concerned(about(medication(side(effects((either(completely(or(mostly(agreeing),(and(47%(lacked(concern.(Finally,(76%(of(patients(disagreed(with(the(statement(that(they(could(not(afford(their(medication,(while(only(7%(agreed.(To(investigate(the(potential(validity(of(this(finding,(I(tested(the(hypothesis(that(perhaps(patients(who(are(well(controlled(157 are(more(likely(to(report(that(their(disease(is(mild(and(does(not(warrant(regular(controller(medication.(This(hypothesis(is(based(on(the(assumption(that(higher(disease(severity(is(associated(with(poorAcontrol.(No(association(was(found(between(the(belief(that(asthma(is(mild,(and(current(asthma(control((AOR:(1.045,(95%(CI:(0.951,(1.152).(This(finding(suggests(that(that(perceived(disease(severity(is(independent(of(disease(control.(((Based(on(the(results(of(the(initial(data(and(the(associated(small(withinAcell(sample(sizes,(I(dichotomized(several(variables(to(facilitate(the(bivariate(and(multivariate(analysis((see(appendix(G).(See(appendix(H(for(a(description(of(missing(data(points.(Bivariate(statistics(were(conducted(using(caseAwise(deletion.(The(following(will(describe(the(results(pertaining(to(each(of(the(three(objectives(posed(at(the(outset(of(this(chapter.((6.3.2$What$role$do$asthma$patients$prefer$to$take$in$the$decisionAmaking$process?$(6.3.2.1%Descriptive%statistics%Using(the(PSDM(scale,(respondents(were(asked(6(questions(about(their(preference(for(participation(in(making(the(diagnosis,(selecting(treatments,(identifying(and(weighing(the(acceptability(of(risks(and(benefits(and(making(the(final(treatment(decision.(((158 A(“problem(solving”((PS)(score(was(created(for(the(4(items(that(pertain(to(diagnosis(and(treatment(options.(269)(FiftyAseven(percent(of(respondents(wanted(the(physician(alone(or(mostly(the(physician(to(diagnose(the(health(issue.(No(respondents(wished(to(make(this(determination(on(their(own.(The(majority(of(respondents((74%)(also(wished(for(the(physician(to(play(the(main(role((doctor(alone(or(mostly(the(doctor)(in(determining(what(the(treatment(options(are,(what(the(associated(risks(and(benefits(are((62%),(and(the(likelihood(that(those(risks(and(benefits(are(to(happen((70%).(On(a(scale(from(1A5,(the(mean(problemAsolving(score(was(2.0((SD:(0.63)(with(a(maximum(of(3.2((see(figure(6.1).(A(score(of(1(indicates(that(the(participant(preferred(the(doctor(to(make(the(decision,(whereas(a(score(of(5(indicates(that(the(patient(preferred(the(sole(responsibility.(((A(“decisionAmaking”((DM)(score(was(created(for(the(two(items(pertaining(to(who(should(decide(about(the(acceptability(of(the(treatment(option(risks(and(benefits,(and(who(should(make(the(final(treatment(decision:((269)((Given$the$risks$and$benefits$of$these$possible$treatments,$who$should$decide$how$acceptable$those$risks$and$benefits$are$for$you?$Given$all$the$information$about$risks$and$benefits$of$the$possible$treatments,$who$should$decide$which$treatment$option$should$be$selected?$(Respondents(wished(to(take(a(more(active(role(in(determining(how(acceptable(those(risks(and(benefits(are,(and(in(determining(the(final(treatment(option.((FortyAtwo(percent(thought(that(they(alone(or(mostly(they(should(decide(how(acceptable(the(159 risks(and(benefits(of(treatment(options(are,(and(40%(thought(that(this(should(be(a(joint(decision(with(their(physician.(Regarding(the(final(treatment(choice,(27%(of(respondents(thought(that(they(alone(or(mostly(they(should(make(this(decision,(and(an(additional(46%(thought(that(the(patient(and(physician(should(share(this(responsibility,(jointly.(The(continuous(DM(variable(was(normally(distributed(with(a(mean(score(of(3.1((SD:(0.88),(indicating(a(preference(for(a(shared(approach((both(physician(and(patient(should(make(these(decisions(together,(sharing(equal(responsibility)((see(figure(6.1).(((As(hypothesized,(patients(preferred(to(take(a(more(passive(role(in(determining(treatment(options(as(well(as(the(risks(and(benefits(associated(with(those(available(treatment(options,(but(preferred(to(take(a(more(active(approach(to(deciding(on(the(acceptability(of(the(risks(and(benefits,(and(making(the(final(treatment(choice((see(figure(6.1).(Results(of(the(tAtest(show(that(there(is(a(significant(difference(in(means(for(the(two(PS(and(DM(scores((<.0001).(($$ $160 Figure$6.1:$PSDM$“problem$solving”$and$“decision$making”$score$distribution$((((((((((((((((((((((((((((((((((((((((((((((((I(selected(the(continuous,(normally(distributed(“decisionAmaking”((DM)(score(as(the(primary(outcome(variable(to(address(this(research(question.(I(conducted(unadjusted(linear(regression(to(ascertain(linear(relationships(between(the(outcome(variable(and(all(potential(explanatory(variables((see(table(6.2).(All(bivariate(associations(with(a(pAvalue(of(p=0.25(or(less(were(investigated(for(inclusion(in(the(final(model.(( (161 (Table$6.2:$Unadjusted$and$adjusted$linear$regression$of$role$preference$(active$v.$shared)$for$asthma$treatment$decisionAmaking$$Explanatory$variable$ Unadjusted$linear$regression$analysis$$$Adjusted$linear$regression$analysis$$$$ Beta( SE( PAvalue( Beta( SE( PAvalue(Gender$Male(Female$ (A0.159((Ref.((0.166( (0.34( ( ( (Age$ A0.016( .006( 0.005( A0.013( 0.005( .018(Ethnicity$$(White/(Caucasian(NonAWhite/(Caucasian$((0.2121(Ref.(((0.213( ((0.322( ( ( (Number$of$comorbidities$$0(1(2(3(or(more$((Ref.(A0.113(A0.209(A0.287((((0.207(0.230(0.263((((0.586(0.366(((0.277(( ( (Number$of$asthma$medications$(0((or(did(not(report)(1(2(or(more$(((Ref.(A0.172(0.095(((((0.271(0.245(((((0.527(0.700(( ( (Currently$being$prescribed$controller$medication$$Not$currently$being$prescribed$controller$medication$A0.123((((Ref.(0.192( 0.522( ( ( (Length$of$time$since$asthma$diagnosis$0.009( 0.005( 0.065( ( ( (Greater$than$$80,000$annual$household$income$$Less$than$$80,000$annual$household$income$0.602(((Ref.(0.160( 0.001( 0.550( 0.157( 0.0006(4Ayear$university$$Less$than$4$years$university$$$0.309((Ref.( 0.176( 0.082( ( ( (Well$controlled$asthma$$0.105(( 0.189( 0.58( ( ( (162 Table$6.2:$Unadjusted$and$adjusted$linear$regression$of$role$preference$(active$v.$shared)$for$asthma$treatment$decisionAmaking$$Explanatory$variable$ Unadjusted$linear$regression$analysis$$$Adjusted$linear$regression$analysis$$$Not$wellAcontrolled$asthma$ Ref.(Has$heard$of$an$asthma$action$plan$$Has$not$heard$of$an$asthma$action$plan$A0.259(((Ref.(0.166( 0.123( ( ( (Has$an$asthma$action$plan$$Does$not$have$an$action$plan$A0.183(((Ref.(0.213( 0.393( ( ( (Ever$had$teaching$from$an$asthma$educator$$Never$had$teaching$from$an$asthma$educator$A0.219(((Ref.(0.168( 0.196( ( ( (Has$seen$a$specialist$for$asthma$$Has$not$seen$as$specialist$A0.164(((Ref.(0.192( 0.396( ( ( (Past$year$asthmaArelated$GP$visit$$No$past$year$asthmaArelated$GP$visit$A0.186(((Ref.(0.163( 0.256( ( ( (Numeracy$(Score(3A14(Score(15A17(Score(18$((Ref.(0.199(0.590((((0.199(0.206((((0.321(0.005((((( ( (%6.3.2.2%Results%At(the(bivariate(level,(increased(preference(for(participation(in(the(decisionAmaking(process(was(associated(with(younger(age,(higher(income,(higher(education(level,(and(higher(numeracy.(((163 Using(unadjusted(linear(regression,(7(variables(were(identified(as(having(a(linear(association(with(the(DM(score,(at(the(0.25(significance(level.(The(following(variables(were(investigated(further(for(the(multivariate(logistic(model:(1.! Age(2.! Education(3.! Income(4.! Heard(of(an(asthma(action(plan(5.! Teaching(from(an(asthma(educator(6.! Length(of(time(since(asthma(diagnosis(7.! Numeracy((The(multivariate(model(included(all(significant((p(<(0.05)(explanatory(variables.(I(began(with(a(model(including(only(the(outcome(variable(and(age.(Following(the(inclusion(of(each(subsequent(variable,(I(assessed(changes(to(the(pAvalue,(the(estimate(and(the(standard(errors.(With(7(missing(cases((5.9%),(I(applied(multiple(imputation(to(the(final(multivariate(model.((((The(final(model(included(only(age(and(income(as(statistically(significant(explanatory(variables((see(table(6.4).(SelfAreported(annual(household(income(of($80,000(or(greater((Beta(=(0.550,(p(=(0.001)(and(lower(age(were(associated(with(a(greater(preference(for(a(more(active(approach(to(the(final(decisionAmaking(process((Beta(=(A0.013,(p(=(.018)(((The(results(of(this(analysis(show(that(while(those(with(higher(income(and(those(who(are(younger(tend(to(prefer(a(more(active(approach(to(the(decisionAmaking(process,(these(patient(characteristics(alone(do(not(serve(to(explain(a(substantial(amount(of(variation(in(preferences((See(appendix(I(for(regression(diagnostics).((164 (6.3.3$What$factors$related$to$patientAphysician$communication$and$education$explain$adherence?$As(a(second(research(question,(I(sought(to(determine(the(extent(to(which(adherence(could(be(explained(by(modifiable(predictors(related(specifically(to(the(healthcare(encounter.(With(reference(to(the(theoretical(framework(presented(in(chapter(3,(for(the(multivariate(model(I(chose(to(explicitly(include(variables(related(to(“informational”(and(“motivational”(predictors(of(adherence((see(chapter(3).(The(outcome(was(defined(as(a(dichotomous(variable,(indicating(selfAreported(adherence.(Bivariate(analyses(were(conducted(using(caseAwise(deletions.((6.3.3.1%Results%At(the(bivariate(level,(being(older,(having(more(comorbidities,(better(asthma(control,(previous(exposure(to(an(asthma(educator,(and(having(seen(a(specialist(in(the(past(year,(were(shown(to(increase(the(odds(of(adherence.(Conversely,(factors(associated(with(decreased(odds(of(adherence(included(male(gender,(higher(income,(greater(preference(for(an(active(approach(to(decisionAmaking,(the(belief(that(asthma(is(mild(and(does(not(warrant(controller(medication,(as(well(as(concerns(about(asthma(medication.(( (165 (Table$6.3:$Unadjusted$and$adjusted$logistic$regression$$Outcome:$Adherence$to$controller$medication$$$ Unadjusted$logistic$regression$Adjusted$logistic$regression$Explanatory$variable$ $Odds$ratio$95%$CI$ P$value$ Odds$ratio$95%$CI$P$value$Gender$$Male$$Female$(0.569( (Ref.((0.226,(1.385( (0.221( ( ( (Age$ 1.028( 0.998,(1.062( 0.076( ( ( (Ethnicity$White/Caucasian$$NonAwhite$(0.993( (Ref.((0.350,(2.889( (0.990( ( ( ($Number$of$comorbidities$$0$1$$$2$$$3(or(more$(((Ref.(1.125( ((2.363( ((4.000( (((((0.214,(1.085( (0.356,(3.571( (0.772,(7.571(((((0.840( ((0.137( ((0.060(( ( (Number$of$asthma$medications$$1(2(( ((3(or(more($$(((Ref.(1.231( ((0.727( (((((0.442,(3.511( (0.188,(2.699(((((0.692( ((0.636(( ( (Length$of$time$since$asthma$diagnosis*$$1.006( 0.980,(1.032( 0.643( ( ( (Time$since$decision$was$made$(0A36$years)$$0.981( 0.926,(1.036( 0.501( ( ( (Income$ ( ( ( ( ( (166 Table$6.3:$Unadjusted$and$adjusted$logistic$regression$$Outcome:$Adherence$to$controller$medication$$$ Unadjusted$logistic$regression$Adjusted$logistic$regression$Explanatory$variable$ $Odds$ratio$95%$CI$ P$value$ Odds$ratio$95%$CI$P$value$$Income$($80,000(annual(household(income(or(greater((Less(than(80,000(annual(household(income$(((0.329( (((Ref.((((0.131,(0.801((((0.016(Education$$4Ayear(college/university((less(than(4Ayear(college(university)$((0.722( (Ref.(((0.285,(1.819(((0.488( ( ( (WellAcontrolled$asthma*$$Yes( (No$(((2.768( (Ref.((((1.082,(7.607((((0.0389(( ( (Has$heard$of$an$asthma$action$plan$$Yes( (No$(((1.378( (Ref.((((0.590,(3.238((((0.459(( ( (Ever$had$teaching$from$an$asthma$educator$$Yes( (No(((((3.594( (Ref.(((((1.499,(8.956(((((0.005(((((3.8(((((1.42,(10.95(((((0.009( ((PastAyear$asthmaArelated$specialist$visit$$Yes( (No((((3.069( (Ref.((((0.976,(11.740((((0.071(( ( (167 Table$6.3:$Unadjusted$and$adjusted$logistic$regression$$Outcome:$Adherence$to$controller$medication$$$ Unadjusted$logistic$regression$Adjusted$logistic$regression$Explanatory$variable$ $Odds$ratio$95%$CI$ P$value$ Odds$ratio$95%$CI$P$value$PastAyear$asthmaArelated$GP$visit$$Yes( (No((((1.380023((Ref.((((0.592,(3.258((((0.457(( ( (Numeracy$$Score(0A14(Score(15A17(((Score(18($((Ref.(0.617( ((1.169((((0.210,(1.789( (0.389,(3.535((((0.373( ((0.780(( ( (DecisionAmaking$score$(PSDM)$0.565( 0.324,(0.936( 0.033( ( ( ( (ProblemASolving$score$(PSDM)$0.620( 0.302,(1.24( 0.181( ( ( (Physician$provided$a$sample$of$controller$medication$$Yes( (No(((((0.3589((Ref.(( ((((0.405(( ( ((My$asthma$is$mild$and$does$not$require$regular$preventative$treatment:$$$I(agree1((I(disagree2($My$inhaled$steroid$causes$side$effects:$$((((( (0.247( (Ref.(( (((((((( (0.098,(0.593( ((((((((((0.002( (((((((((((0.273( (((((((((((0.099,(0.710( ((((((((((0.009( (((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((1(“I(agree”(was(a(collapsed(variable(based(on(the(following(responses:(“I(agree(completely,”(“I(agree(mostly,”(and(“I(agree(somewhat.”((2(“I(disagree”(was(a(collapsed(variable(based(on(the(following(responses:(“I(disagree(completely,”(“I(disagree(mostly,”(and(“I(disagree(somewhat.” 168 Table$6.3:$Unadjusted$and$adjusted$logistic$regression$$Outcome:$Adherence$to$controller$medication$$$ Unadjusted$logistic$regression$Adjusted$logistic$regression$Explanatory$variable$ $Odds$ratio$95%$CI$ P$value$ Odds$ratio$95%$CI$P$value$$I(agree( (I(disagree($I$am$concerned$about$the$side$effects$of$my$inhaled$steroids:$$I(agree( (I(disagree($$I$can't$afford$my$inhaled$steroid$medication:$$$I(agree( (I(disagree($(0.888( (Ref.( (((((0.417( (Ref.( ((((((0.769( (Ref.((0.354,(2.196( ((((((0.171,(0.987( (((((((0.230,(2.423((0.799( (((((((0.0496(((((((((0.657( (((((((((((0.289( (((((((((((((((((0.099,(0.773((((((((((0.0169((After(removing(variables(not(directly(related(to(the(healthcare(encounter(from(the(model((age,(gender,(comorbidities,(income,(asthma(control(and(income)(the(following(variables(were(investigated(further(for(the(multivariate(analysis:(•! Having(had(teaching(from(an(asthma(educator(•! Past(year(asthma(related(specialist(visit(•! Decision(Making(score((indicating(preference(for(role(in(decision(making(process)(•! Problem(Solving(score((indicating(preference(for(role(in(decision(making(process)(•! Belief(that(asthma(is(mild(and(does(not(require(regular(preventative(treatment(•! Concern(about(medication(side(effects((169 Results(of(the(multivariate(investigation(show(that(patientAreported(exposure(to(an(asthma(educator,(beliefs(about(disease(severity(and(concerns(about(medication(side(effects(help(to(explain(the(odds(of(selfAreported(adherence((see(table(6.3).(((Having(reported(exposure(to(an(asthma(educator(was(associated(with(an(increased(odds(of(adherence((OR=(3.8,(95%(CI:(1.42,(10.95),(while(concerns(about(steroids(as(well(as(the(belief(that(asthma(is(mild(and(does(not(warrant(controlled(medication(were(both(associated(with(decreased(odds(of(adherence((OR(=(0.29(and(0.27,(respectively).(While(recognizing(the(wide(variation((confidence(intervals)(in(the(expected(estimates,(the(results(show(that(multiple(features(of(the(clinical(encounter(related(to(accurate(knowledge(and(beliefs(may(potentially(impact(a(patient’s(likelihood(of(adhering(to(his(or(her(medication((see(appendix(J(for(regression(model(diagnostics).((6.3.3.1.1(Investigating(the(specific(role(of(asthma(educators((Given(the(large(measure(of(effect(shown(between(previous(exposure(to(asthma(educators(and(adherence,(I(sought(to(more(closely(consider(potential(differences(between(those(who(reported(exposure(to(educators,(and(those(who(had(not.(The(purpose(of(this(secondary(analysis(was(to(investigate(potential(systematic(differences(between(patients(who(do(and(do(not(report(ever(having(attended(an(educator(appointment.((see(table(6.4).((( (170 (Table$6.4:$Unadjusted$logistic$regression$for$patients$having$visited$an$asthma$educator$$Explanatory$variable$ Total$N3$$Odds$ratio$ 95%$CI$Gender$$Male(Female$ 117( (0.506(Ref.( (0.227,(1.096(Age*$ 115( 1.028( 0.998,(1.062(Ethnicity$White/Caucasian(NonAwhite$ 117( (0.975(Ref.( (0.373,(2.674($Number$of$comorbidities$$0(1(2(3(or(more($(117( ((Ref.(1.618(4.622(1.204((((0.601,(4.523(1.589,(14.415(0.313,(4.309(Number$of$asthma$medications$$1(2((3(or(more($88( ((Ref.(1.231(0.727((((0.442,(3.511(0.188,(2.699((Length$of$time$since$asthma$diagnosis*$$114( 0.992( 0.968,(1.016(Time$since$decision$about$current$controller$medication$was$made$(0A36$years)$$52( 1.017( 0.963,(1.076(Income*$$80,000(annual(household(income(or(greater((Less(than(80,000(annual(household(income($111( (0.407( ((Ref.((0.184,(0.885((Education$4Ayear(college/university((less(than(4Ayear(college(university$117( (0.924(Ref.( (0.414,(2.101(((((((((((((((((((((((((((((((((((((((((((((((((((((((((3(Sample(size(is(included(because(some(survey(items(were(provided(to(a(subset(of(participants.(For(example,(only(those(who(were(currently(being(prescribed(controller(medication((n=89)(and(who(could(recall(the(decisionAmaking(encounter((N=52)(were(provided(with(the(Collaborate(instrument.(All(demographic(questions(and(items(pertaining(to(role(preferences(were(asked(of(the(entire(sample.(171 Table$6.4:$Unadjusted$logistic$regression$for$patients$having$visited$an$asthma$educator$$Explanatory$variable$ Total$N3$$Odds$ratio$ 95%$CI$WellAcontrolled$asthma$$Yes(No$115( ((0.969(Ref.(((0.411,(2.361((Has$heard$of$an$asthma$action$plan$$Yes(No$117( ((5.347(Ref.(((2.412,(12.337(PastAyear$asthmaArelated$specialist$visit$$Yes(No($116( (((3.661(Ref.((((1.364,(11.688(PastAyear$asthmaArelated$GP$visit$$Yes(No($117( ((2.508(Ref.(((1.172,(5.514(Numeracy$$Score(0A14(Score(15A17(Score(18(117( ((Ref.(0.934(0.405((((0.372,(2.351(0.144,(1.095(DecisionAmaking$score$(PDSM)$ 117( 0.754( 0.487,(1.153(ProblemASolving$score$(PDSM)$ 116( 1.333( 0.733,(2.461(Physician$provided$a$sample$of$controller$medication$$Yes(No$89( (( (((1.483(Ref.((((0.637,(3.492(I$forget$to$take$at$least$one$dose$of$my$inhaled$steroid$each$day$$I(agree(I(disagree($My$asthma$is$mild$and$does$not$require$regular$preventative$treatment:$$$I(agree(I(disagree($My$inhaled$steroid$causes$side$effects:$$88( (((((89( (((((89((((0.457(Ref.( ((((0.426(Ref.( (((((0.166,(1.168((((((0.177,(0.997((((172 Table$6.4:$Unadjusted$logistic$regression$for$patients$having$visited$an$asthma$educator$$Explanatory$variable$ Total$N3$$Odds$ratio$ 95%$CI$$I(agree(I(disagree($$I$am$concerned$about$the$side$effects$of$my$inhaled$steroids:$$I(agree(I(disagree($$I$can't$afford$my$inhaled$steroid$medication:$$$I(agree(I(disagree($(((((88( ((((((89( (((2.286(Ref.( (((((1.576016(((((((1.877611(((0.931,(5.735(((((((0.672,(3.748(((((((0.610,(5.906(Previous$exposure$to$SDM$(CollaboRATE:$0A12)$$52( (1.062( (0.888,(1.281(Adherent$to$controller$medication$$Yes(No$88( ((3.69655(Ref.(((1.546,(9.199((At(the(bivariate(level,(a(higher(OR(of(having(seen(an(asthma(educator(was(associated(with(past(year(encounter(with(a(GP((OR(=(2.508,(95%(CI(=(1.172,(5.514)(or(a(specialist((OR(=(3.661,(95%(CI(=(1.364,(11.688),(having(heard(of(an(asthma(action(plan((OR(=(5.347,(95%(CI(=(2.412,(12.337),(and(lower(income((OR(=(0.407,(95%(CI(=(0.184,(0.885).(Patients(who(agreed(with(the(claim(that(their(asthma(is(mild(and(does(not(require(controller(medication,(were(less(likely(to(report(having(seen(an(educator((OR=0.426,(95%(CI(=(0.177,(0.997).(Patients(who(reported(having(2(comorbidities(were(more(likely(to(report(having(seen(an(educator(when(compared(to(those(with(173 no(comorbidities((OR(=(4.622,(95%(CI(=(1.589,(14.415)(although(there(was(no(significant(relationship(reported(when(comparing(those(with(3(or(more(comorbidities(to(those(with(none.(As(previously(discussed((research(question(#2),(patients(who(selfAreported(as(being(adherent(to(their(controller(medication(had(3.7(times(the(odds(of(reporting(exposure(to(an(asthma(educator((95%(CI(=(1.546,(9.199).((The(results(of(this(hypothesis(generating(exploration(suggest(that(asthma(patients(who(are(interacting(more(frequently(with(their(physicians((GPs(or(specialists)(about(their(asthma(are(more(likely(to(visit(an(educator.(These(findings(are(not(surprising,(since(it(is(likely(that(patients(who(have(more(severe(disease(or(require(more(resources(to(help(manage(their(disease(are(likely(to(be(more(frequently(be(referred(to(an(asthma(educator.(Exposure(to(asthma(educators(may(therefore(serve(as(an(indication(of(disease(severity,(or(patients’(difficulty(managing(medications.(Interestingly,(exposure(to(asthma(educators(was(not(consistently(associated(with(current(asthma(control,(number(of(medications(being(taken(for(asthma,(or(number(of(comorbidities.((6.3.4$To$what$extent$do$asthma$patients$recall$previous$exposure$to$SDM?$6.3.4.1%Descriptive%statistics%(The(final(main(objective(of(this(study(was(to(estimate(the(extent(to(which(SDM(has(been(implemented(into(clinical(practice,(from(the(perspective(of(asthma(patients(174 having(made(a(decision(about(asthma(controller(medication.(Of(the(89(respondents(who(reported(receiving(a(controller(medication(within(the(past(12(months,(52((58%)(recalled(the(decisionAmaking(encounter(wherein(their(current(prescription(was(first(prescribed.(The(median(length(of(time(respondents(reported(since(they(were(first(prescribed(their(current(controller(was(8(years((2008).(The(range(of(recall(for(this(encounter(was(0A36(years.(((Among(the(52(respondents(being(prescribed(controllers(who(recalled(the(decisionAmaking(encounter(s),(CollaboRATE(scores(were(roughly(normally(distributed(with(a(mean(score(of(7.1((SD:(3.1)(and(a(range(of(0A12.(Two(respondents(indicated(that(no(effort(at(all(was(made(to(help(the(patient(understand(his(or(her(health(issues,(listen(to(what(mattered(to(him(or(her,(or(to(include(what(mattered(to(him(or(her(most(in(choosing(what(to(do(next((indicating(a(CollaboRATE(score(of(0).(Alternatively,(7(patients(rated(that(every(effort(was(made(by(the(physician(on(each(of(these(three(items((indicating(a(score(of(12).($6.3.4.2%Is%perceived%exposure%to%SDM%associated%with%adherence%to%controller%medication?%Of(the(89(patients(having(been(prescribed(a(controller(medication(in(the(previous(12(months,(52(recalled(the(encounter(with(their(physician(where(the(decision(was(made(to(prescribe(the(current(treatment.(Table(6.5(shows(that(less(than(25%(of(patients(reported(that(no(effort(was(made(at(all(to(help(them(understand(their(175 health(issues,(listen(to(the(things(that(matter(most,(or(include(what(matters(most(to(the(patient(in(choosing(what(to(do(next.(Conversely,(between(15(and(17%(reported(that(every(effort(was(made,(on(each(of(the(three(survey(items.(These(results(show(that(variation(exists(with(regard(to(the(extent(to(which(patients(believe(that(they(are(being(involved(in(their(treatment(related(decisions.((Table$6.5:$Previous$exposure$to$SDM$for$current$controller$medication(s)$$(N=52)$How(much(effort(was(made(to(help(you(understand(your(health(issues?( No(effort/a(little:(Some/(a(lot:(Every(effort:( 10((19%)(33((63%)(9((17%)(How(much(effort(was(made(to(listen(to(the(things(that(matter(most(to(you(about(your(health(issues?(No(effort/a(little:(Some/(a(lot:(Every(effort:( 10((19%)(23((44%)(8((15%)(How(much(effort(was(made(to(include(what(matters(most(to(you(in(choosing(what(to(do(next?((No(effort/a(little:(Some/(a(lot:(Every(effort:( 13((25%)(20((38%)(9((17%)((Results(of(the(simple(logistic(regression(provided(a(pAvalue(of(0.84((AOR:(1.0185,(95%(CI:(0.851,(1.222)(suggesting(no(difference(in(CollaboRATE(scores(when(comparing(those(who(are(and(are(not(adherent(to(their(controller(medication((see(figure(6.2).((($ $176 Figure$6.2:$Adherence$and$exposure$to$SDM$(6.3.4.3%Is%there%an%association%between%preferences%for%decision=making%and%perceived%exposure%to%SDM?%As(a(final(research(question,(I(assessed(the(association(between(increasing(desire(to(take(an(active(approach(to(decisionAmaking(and(perceived(previous(exposure(to(SDM.(Addressing(this(question(helps(to(answer(the(question(of(whether(patients(are(participating(in(their(healthcare(encounters(to(the(extent(that(they(would(like.((Of(89(patients(currently(being(prescribed(controllers,(52(recalled(the(encounter(s)(where(the(decision(was(made(regarding(their(current(controller(medication.(177 Initially,(decisionAmaking(scores(ranged(from(1A5(and(CollaboRATE(scores(ranged(from(0A12.(The(Pearson’s(correlation(coefficient(of(A0.01((pAvalue(=0.89)(suggests(that(there(is(no(association(between(decisionAmaking(preference(and(perceived(exposure(to(SDM.((When(coding(the(decisionAmaking(variable(as(a(dichotomous(outcome,(33(respondents((63%)(preferred(to(keep(or(share(the(decision,(whereas(19(preferred(to(hand(over(the(decision(to(their(physician((see(figure(6.3).(((Figure$6.3:$Collaborate$scores$by$DM$preference$(178 No(significant(difference(in(mean(CollaboRATE(scores(comparing(those(who(prefer(an(active/shared((keep(or(share(decisional(responsibility)(versus(a(passive(approach((hand(over(decision(to(physician).(This(very(preliminary(investigation(suggests(that(patients(may(not(be(playing(the(role(that(they(would(prefer(to,(in(their(decisionAmaking(encounters.(Interestingly,(patients(who(preferred(to(hand(over(their(decision(to(physicians(reported(a(systematically(higher(CollaboRATE(score,(indicating(that(they(may(have(been(playing(a(more(active(approach(than(they(would(have(preferred.(Conversely,(patients(who(preferred(to(play(a(more(active(role(by(keeping(the(decisional(responsibility(or(sharing(in(the(decisionAmaking(process,(had(a(slightly(lower(mean(CollaboRATE(score.(A(more(highly(powered(analysis(would(likely(provide(more(insight(into(this(relationship.(((Results(of(further(initial(bivariate(data(exploration(show(that(reported(engagement(in(the(treatment(decisionAmaking(process(was(not(associated(with(any(of(the(explanatory(variables(under(consideration((data(not(shown).(This(finding(suggests(that(there(are(no(consistent(differences(between(those(who(report(exposure(to(SDM,(and(those(who(do(not.(($6.4$Discussion$6.4.1$Role$preferences$PatientAreported(role(preferences(shown(here(are(consistent(with(previous(research(that(has(used(this(item.(That(is,(patients(prefer(increased(physician(involvement(179 with(regard(to(the(problem(solving(items,(but(wish(to(take(a(more(active(role(in(weighing(the(acceptability(of(risks(and(making(the(final(treatment(decision.(35)(These(results(are(consistent(with(clinical(contexts(showing(that(younger(individuals(tend(to(prefer(a(more(active(role(in(their(decisionAmaking(process.(35)(This(may(reflect(the(changing(medical(decisionAmaking(model;(wherein(younger(people(are(used(to(being(more(actively(involved(in(their(care.(While(younger(age(may(be(associated(with(the(desire(to(take(an(active(approach,(at(the(bivariate(level,(age(was(not(associated(with(reported(exposure(to(SDM.(This(finding(supports(the(claim(that(selfAreported(preference(for(involvement(in(the(decisionAmaking(process(is(not(necessarily(reflective(of(patient(reported(experiences(in(the(clinical(encounter.(These(findings(are(consistent(with(a(recent(Cochrane(review(reporting(that,(within(cancer,(patients(prefer(a(more(active(role(than(the(role(that(they(experienced.(287)((6.4.2$Controller$medication$adherence$PatientAreported(adherence(was(consistent(with(existing(literature,(and(was(higher(than(the(adherence(reported(using(the(administrative(data(set((chapter(4).(105,106,288)(This(may(be(explained(at(least(partially(by(the(selfAreported(nature(of(adherence,(although(attempts(were(made(to(reduce(social(desirability(bias(by(using(a(preAvalidated(measure(of(adherence.(Using(a(sampling(frame(of(patients(with(previous(participation(in(research(may(have(resulted(in(a(more(highly(adherent(sample(than(can(be(generalized(to(the(broader(population(of(adult(asthma(patients.(((180 Referring(back(to(the(theoretical(framework(proposed(in(chapter(3,(multiple(informational(and(motivating(factors(were(shown(here(to(be(associated(with(selfAreported(adherence.(The(multivariate(analysis(addressing(modifiable(predictors(of(adherence(shows(that(the(belief(that(regular(medication(is(unnecessary(decreases(the(odds(of(adherence,(along(with(concerns(about(medication(side(effects((AOR(=(0.27(and(0.29,(respectively).(Having(been(exposed(to(an(asthma(educator(is(also(associated(with(increased(odds(of(adherence,(when(accounting(for(beliefs(and(concerns(about(disease(status(and(medication(necessity((AOR(=(3.8).(These(findings(are(consistent(with(previous(studies(suggesting(that(inaccurate(beliefs(and(concerns(about(medications(are(associated(with(decreased(adherence,(further(validating(the(current(findings.(175,179)(For(example,(a(recent(observational(study(of(adult(asthma(patients(found(that(those(who(held(the(beliefs(that(asthma(does(not(exist(in(the(absence(of(symptoms(and(that(asthma(is(curable,(selfAreported(lower(adherence.(288)(((These(findings,(coupled(with(the(results(of(the(current(study,(suggest(two(potential(implications.(Firstly,(inaccurate(beliefs(about(medication(and(asthma(are(likely(to(be(prevalent(among(adult(asthma(patients,(and(secondly,(the(presence(of(such(inaccurate(beliefs(may(have(detrimental(implications(on(a(patient’s(motivation(to(adhere(to(their(treatment(plan.(If(the(assumption(is(true(that(misguided(fears,(beliefs(or(concerns(can(be(addressed(through(improved(communication(with(healthcare(providers,(then(these(findings(support(the(use(of(more(active(engagement(in(decisions(about(asthma(treatments.(180)((181 (An(additional(explanation(is(that(the(belief(that(medication(is(unnecessary(may(not(exclusively(be(based(on(lack(of(education(about(the(disease.(Some(asthma(patients(may(consciously(choose(to(take(“medication(holidays”(wherein(the(prescription(is(followed(during(periods(of(disease(flareAups(only((e.g.(Spring(and(Fall(months).(289)(The(concept(of(“medication(holidays”(or(“educated(nonAadherence”(has(been(discussed(previously(in(chapter(4.(While(some(variation(was(identified,(a(clear(seasonal(pattern(could(not(be(inferred.(Future(research(ought(to(investigate(the(rationale(behind(medication(cessation,(as(well(as(the(longAterm(outcomes(of(those(patients(who(practice(educated(nonAadherence.(((FortyAeight(percent(of(respondents(reported(that(they(agreed(“somewhat,”(“mostly,”(or(“completely,”(with(the(statement(that(they(were(concerned(about(the(side(effects(of(their(controllers.(These(results(confirm(the(potential(presence(of((“corticophobia”(–(wherein(patients(fear(taking(ICS(due(to(perceived(likelihood(of(side(effects.(290,291)(Previously(reported(misconceptions(include:(the(idea(that(ICS(dosages(need(to(increase(over(time,(that(they(build(muscle,(cause(brittle(bones(and(infection,(and(that(the(continued(use(of(ICS(can(lead(to(weight(gain(and(stunted(growth.(290)(A(number(of(these(concerns(are(related(to(the(misconception(that(ICS(contain(anabolic(steroids(and(therefore(will(carry(the(same(effects.(These(results(further(support(the(important(role(of(educating(patients(about(their(disease(and(medication(options.((182 FortyAnine(percent(of(respondents(who(were(being(prescribed(controller(medication(agreed((completely,(mostly(or(somewhat)(that(they(were(concerned(about(their(controller’s(side(effects.(Given(that(concerns(are(related(to(likelihood(of(adhering(to(the(prescribed(medication(plan,(one(potential(implication(of(this(finding(is(that(increased(communication(with(patients(about(the(risks(associated(with(inhaled(steroids(may(serve(to(alleviate(concerns(and(motivate(patients(to(remain(adherent.(Similarly,(informing(patients(about(the(necessity(of(daily(medication(may(increase(motivation(to(adhere.(Previous(reports(suggest(that(patients(infrequently(relay(this(information(to(their(physicians.(290)(((Respondents(who(reported(exposure(to(an(asthma(educator(were(more(likely(to(report(adherence(to(their(medication,(both(at(the(bivariate(level(and(as(part(of(the(multivariate(model.(One(potential(explanation(for(this(finding(is(that(patients(who(are(referred(to(asthma(educators(differ(systematically(from(those(who(do(not.(Within(the(Canadian(context,(patients(who(are(referred(to(specialty(clinics(are(more(likely(to(be(exposed(to(an(educator.(This(patient(population(typically(has(more(severe(and(poorly(controlled(disease,(compared(with(the(larger(population(of(asthma(patients.(A(typical(patient(whose(disease(is(being(managed(by(their(GP(is(less(likely(to(be(referred(to(an(asthma(educator.(Therefore,(the(strong(magnitude(of(effect(with(adherence(may(potentially(be(confounded(by(increased(exposure(to(respirologists(or(disease(severity.(((183 Alternatively,(previous(studies(support(the(current(findings,(that(exposure(to(asthma(educators(and(personalized(educational(interventions(are(associated(with(numerous(improved(health(outcomes(such(as(increased(knowledge,(improved(inhaler(technique(and(asthma(control,(higher(adherence,(and(reduced(unscheduled(healthcare(use.(130,290,292)(Consistent(with(the(results(of(this(survey,(these(findings(support(the(use(of(educators(within(the(asthma(care(and(management(team(as(an(existing(clinical(intervention(that(may(currently(be(underutilized.(Future(investigations(should(more(comprehensively(ascertain(specific(differences(between(those(who(are(and(are(not(being(exposed(to(asthma(educators.(More(specifically,(an(important(research(question(to(pose(is(whether(those(who(are(most(likely(to(benefit(from(the(use(of(asthma(educators((e.g.(those(with(poor(control,(low(adherence(or(those(who(lack(accurate(knowledge(about(their(medications)(are(able(and(willing(to(access(these(resources.((With(reference(to(the(theoretical(framework(proposed(in(chapter(3,(the(results(of(this(survey(show(that(awareness,(informational(and(motivational(predictors(of(adherence(play(significant(roles(in(explaining(adherence(to(controller(therapy(among(adult(asthma(patients.(While(difficult(to(measure,(awareness,(informational(and(motivational(factors(that(are(impacted(through(increased(knowledge(and(communication(with(the(healthcare(team(may(in(turn(bear(on(the(patient’s(selfAefficacy,(and(further(serve(to(increase(the(likelihood(to(adhere(to(one’s(treatment(plan.((184 6.4.3$Perceived$exposure$to$SDM$At(the(univariate(level,(there(was(a(wide(range(of(variation(reported(regarding(the(extent(to(which(patients(perceive(being(involved(in(the(decisions(about(their(current(controller(medication.(The(results(of(the(CollaboRATE(item(are(consistent(with(previous(studies(addressing(patientAperceived(involvement(in(their(care.(For(example,(a(recent(survey(using(the(SDMAQA9(questionnaire(found(that(among(a(nationally(representative(sample(of(479(patients,(the(mean(score(was(67.6(with(a(standard(deviation(of(26.6,(with(higher(scores((0A100)(indicated(greater(perceived(involvement(in(the(decisionAmaking(process.((A(more(recent(survey(of(psychiatric((mean(perceived(involvement:(68.38(SD:(19.7)(and(primary(care(patients((mean(perceived(involvement:(67.5,(SD:(21.9)(provided(similar(results.(293)(((These(results(suggest(that(there(is(no(standard(method(or(frequency(of(patient(involvement(in(decisions(about(their(controller(medication.(One(explanation(for(this(lack(of(consistency(is(that(perhaps(physicians(are(deciding(to(engage(patients(based(on(individual(patientAlevel(characteristics,(as(was(suggested(in(Chapter(3.(However,(initial(bivariate(analyses(show(that(there(were(no(systematic(differences(in(mean(CollaboRATE(scores(on(a(wide(range(of(demographic,(education(and(barrier(related(variables.(It(is(likely(that(this(result(may(be(impacted(by(the(small(sample(size(available(for(the(analysis.((At(the(bivariate(level,(no(association(was(found(between(patients’(selfAreported(perceived(exposure(to(SDM,(and(adherence(to(their(current(controller(medication.(185 While(these(results(are(inconsistent(with(some(previous(findings,(there(are(important(differences(to(note.(17)(Firstly,(the(confidence(in(the(effect(estimate(is(limited(due(to(sample(size.(Secondly,(and(as(previously(stated,(the(ability(to(accurately(recall(this(encounter(may(have(been(difficult,(and(may(have(been(biased(by(their(subsequent(experience(with(their(treatment,(or(their(overall(relationship(with(their(provider.(However,(despite(the(limitations(of(this(study(design,(it(is(alternatively(possible(that(the(way(in(which(patients(are(being(engaged(in(their(care(for(decisions(about(controller(medication(does(vary(considerably(and(is(not(associated(with(increased(adherence.(((Once(again,(given(the(limited(sample(size(used(for(this(investigation,(it(was(not(possible(to(investigate(comprehensively(concordance(between(role(preferences(and(perceived(exposure(to(SDM,(or(the(impact(that(concordance(may(have(on(treatment(adherence.(The(bivariate(analysis(showed(no(significant(association(between(a(patient’s(preferred(role,(and(their(perceived(exposure(to(SDM.(However,(future(research(should(consider(this(relationship(in(a(more(comprehensive(manner,(to(determine(the(importance(of(ascertaining(a(patient’s(preference(for(participating(in(their(healthcare(encounter.(259)((((6.4.4$Strengths$This(online(survey(was(administered(to(capture(information(about(the(state(of(SDM(within(the(context(of(asthma,(using(a(sample(of(adult(asthma(patients.(This(survey(is(the(first(of(its(kind(to(specifically(address(outcomes(associated(with(specific(aspects(186 of(SDM(in(clinical(practice(for(asthma.(The(survey(provides(an(analysis(of(the(frequency(of(patient(engagement(in(healthcare(decisions(about(asthma,(the(characteristics(of(those(patients,(the(specific(ways(in(which(patients(are(being(engaged,(and(how(patient(engagement(may(link(to(treatment(adherence.(Administering(this(online(survey(to(a(sample(of(adult(asthmatic(patients(also(provided(the(opportunity(to(explore(hypotheses(regarding(the(possible(role(of(extending(implementation(of(SDM(beyond(the(role(of(the(treating(physician(to(include(nonAphysician(asthma(educators.(The(results(of(this(survey(may(be(used(to(generate(further(hypotheses(regarding(SDM(implementation(efforts,(and(to(further(investigate(specific(outcomes(associated(with(SDM.((As(stated(in(chapter(5,(the(sample(is(representative(of(both(the(EBA(cohort(and(the(general(population(of(asthma(patients(living(in(BC,(on(a(number(of(measured,(demographic(characteristics.(These(results(further(suggest(that(survey(findings(may(be(generalized(to(the(larger(population(of(adult(asthma(patients,(despite(the(use(of(a(small(analytic(sample.(288)(Finally,(the(use(of(preAvalidated(survey(tools(allows(for(comparison(of(the(results(across(different(studies(and(different(clinical(populations.(((6.4.5$Limitations$$6.4.5.1%Information%bias%The(results(of(this(survey(must(be(considered(in(light(of(several(methodological(limitations.(Firstly,(information(that(is(selfAreported(may(be(biased(due(to(issues(187 related(to(recall(and(social(desirability.(For(example,(survey(participants(may(be(likely(to(overAreport(desirable(behaviors(such(as(adherence,(resulting(in(an(invalid(prevalence(estimate.(To(address(the(validity(of(this(item,(I(assessed(the(adherence(measure(against(asthma(control(scores,(based(on(the(known(association(between(adherence(and(control.(Results(show(that(respondents(with(better(control(are(nearly(3(times(more(likely(to(report(adherence,(compared(with(those(who(are(not(wellAcontrolled((OR:(2.768,(95%(CI:(1.082,(7.608).(Finally,(when(comparing(the(prevalence(of(adherence(reported(in(the(current(analysis(with(previous(uses(of(the(AAAQ,(there(does(not(appear(to(be(any(obvious(sign(of(systematic(overAreporting.(These(findings(support(the(use(of(the(adherence(outcome(measure(applied(in(this(survey.(In(addition,(the(use(of(an(anonymous(online(survey(may(have(helped(to(reduce(the(potential(for(social(desirability(bias.((A(second(potential(limitation(relates(to(measurement(error.(While(the(majority(of(survey(instruments(had(been(previously(validated((e.g.(CollaboRATE,(SNS,(PSDM),(some(survey(items(were(included(specifically(for(this(investigation.(Although(the(completed(survey(was(pilot(tested(on(a(small(sample(of(asthma(patients(and(general(population(participants,(the(newly(included(items(did(not(undergo(formal(sensibility(testing.(Such(testing(would(have(investigated(adequate(understanding(of(the(new(items,(redundancy(or(missing(items,(as(well(as(appropriateness(of(items.(294)(Given(the(limited(number(of(new(items(included(in(the(survey(in(addition(to(the(use(of(a(pilot(testing(phase,(lack(of(formal(sensibility(testing(should(be(considered(a(minor(limitation(to(this(work.((((188 (A(more(problematic(limitation(concerns(the(issue(of(recall(bias.(As(stated(previously,((patients(were(asked(to(recall(a(treatment(decision(making(encounter(that(occurred(between(0(and(36(years(prior((with(a(median(of(8(years(prior).(Given(the(extensive(time(lapsed(since(the(decisionAmaking(encounter,(recalled(estimates(may(lack(validity.(There(is(a(wide(literature(that(addresses(issues(related(to(measurement(error,(and(the(accuracy(of(relying(on(selfAreported(data,(across(a(range(of(exposures.(295,296)(Recall(may(be(related(not(only(to(the(specific(exposure(being(considered,(but(also(to(other(factors(such(as(social(desirability,(patient(characteristics,(the(manner(by(which(the(information(is(obtained,(and(the(significance(of(the(event.(296)(Although(no(clear(threshold(for(recall(is(recommended(when(being(asked(to(recall(one(specific(event,(a(shorter(recall(period(is(likely(to(reduce(the(potential(for(measurement(error.(295)(A(future(investigation(would(likely(overcome(this(limitation(by(surveying(patients(at(the(time(of(the(decisionAmaking(encounter(s).(((Thirdly,(the(results(of(this(survey(cannot(adequately(estimate(the(extent(to(which(patients(are(currently(being(engaged(in(their(decisions.(As(stated(previously,(50%(of(patients(made(the(decision(about(their(current(controller(between(8(and(36(years(prior(to(the(survey.(Given(the(recent(attention(being(paid(to(SDM(throughout(the(healthcare(and(policy(literature,(it(is(possible(that(clinical(care(encounters(have(changed(considerably(over(the(past(several(years.(An(initial(bivariate(analysis((tAtest)(shows(that(there(are(no(differences(in(reported(exposure(to(SDM(when(189 comparing(those(who(made(their(treatment(decision(within(the(past(7(years(to(those(who(made(the(decision(8(years(prior,(or(later((p(=(.51).(Although(it(is(challenging(to(predict(whether(estimates(of(exposure(to(SDM(are(systematically(under(or(overAreported(by(this(sample,(the(estimate(is(likely(to(be(subject(to(recall(error.(((Fourthly,(with(regard(to(perceived(exposure(to(SDM(and(other(education(related(sources,(it(is(possible(that(large(number(of(the(sample(may(have(been(exposed(to(a(small(number(of(GPs(and(Specialists.(I(do(not(have(information(about(the(names(of(physicians(that(patients(had(visited(for(their(asthma(treatment.(However,(given(that(patients(were(recruited(through(random(digit(dial(A((the(likelihood(that(the(estimates(of(SDM(exposure(are(based(on(a(small(number(of(care(providers(is(minimal.(((Finally,(the(results(should(be(considered(in(light(of(confounding(variables(that(may(further(impact(the(relationship(between(explanatory(variables(and(the(measured(outcomes.(For(example,(as(discussed(in(chapter(4,(income(may(serve(as(an(important(third(variable(when(considering(predictors(of(adherence.(While(FairPharmaCare(may(cover(individuals(to(a(certain(extent,(the(cost(of(the(medication(beyond(the(deductible(may(be(prohibitive(to(certain(patients.(For(this(reason,(a(future(investigation(may(further(consider(structural(barriers(to(adherence(that(could(potentially(be(addressed(through(an(SDM(encounter,(such(as(the(potential(cost(of(a(medication.(((190 6.4.5.2%Sample%size%Secondly,(a(major(limitation(of(this(survey(is(the(relatively(small(sample(size.(For(this(reason,(much(of(the(analyses(presented(in(this(chapter(should(be(interpreted(as(hypothesis(generating.(For(example,(a(relatively(small(number(of(patients(were(able(to(recall(and(provide(information(about(the(process(by(which(they(came(to(the(decision(about(their(controller(medication((n=52).(Therefore,(I(was(unable(to(conduct(a(multivariate(analysis(to(address(factors(that(explain(perceived(exposure(to(SDM.(((Furthermore,(the(limited(sample(size(and(dichotomization(of(select(variables(may(have(resulted(in(error(related(to(the(estimates.(For(example,(at(the(bivariate(level,(lower(income(was(shown(to(be(associated(with(increased(adherence,(a(finding(that(runs(counter(to(the(existing(evidence((OR(=(0.0329,(95%(CI:(0.131,(0.801).(One(potential(explanation(for(this(is(that(the(true(variability(in(income(is(masked(due(to(the(dichotomization(of(the(variable.(Patients(were(categorized(as(selfAreporting(an(annual(household(income(of(above(or(below($80,000.(Doing(so(relies(on(the(assumption(of(withinAcategory(homogeneity.(It(is(possible(that(a(larger(sample(would(have(allowed(the(use(of(a(continuous(measure(of(income((or(a(greater(number(of(categories)(and(may(have(produced(a(more(accurate(result.(The(current(hypothesis(is(that(higher(income(and(other(indicators(of(socioeconomic(status(are(in(fact(associated(with(higher(adherence.((191 The(results(do,(however,(provide(preliminary(insight(into(the(potential(direction(of(effect,(with(regards(to(the(characteristics(of(patients(reporting(involvement(in(their(care,(and(the(potential(association(between(adherence(and(SDM.(Therefore,(these(findings(must(be(interpreted(as(hypothesis(generating,(and(may(be(used(to(further(investigate(similar(associations(using(a(larger(sample(of(patients.(((6.4.5.3%Characteristics%of%the%sampling%frame%This(sample(was(recruited(from(a(highly(educated(and(wellAcontrolled(population(of(asthma(patients.(As(a(result,(the(current(sample(lacked(variability(on(a(number(of(variables,(such(as(literacy,(numeracy,(education,(and(income.(It(is(likely(that(by(using(a(more(heterogeneous(sampling(frame,(I(would(see(a(more(variation(on(these(items.(As(a(result(of(the(lack(of(variability,(many(of(the(variables(included(in(the(bivariate(and(multivariate(analyses(were(collapsed(or(dichotomized,(resulting(in(a(loss(of(information.(Given(the(characteristics(of(this(sample,(these(results(cannot(be(generalized(to(a(broader(population(of(poorly(controlled(asthma(patients.((6.4.5.4%Cross=sectional%study%design%Firstly,(this(survey(uses(a(cross(sectional(study(design,(and(therefore(no(inference(about(causal(relationships(can(be(made.(For(example,(while(adherence(is(associated(with(exposure(to(an(asthma(educator,(it(is(possible(that(those(patients(who(are(more(likely(to(be(adherent(to(their(medications(are(also(more(likely(to(take(an(active(approach(to(their(care(by(attending(educator(appointments.(Similarly,(while(192 concerns(about(medication(may(result(in(reduced(adherence,(lower(adherence(may(result(in(poor(control(and(increased(symptoms,(in(turn(raising(patient(concerns(about(the(effectiveness(of(their(prescribed(controller.(The(results(of(this(survey(should(be(used(to(posit(potential(relationships(as(well(as(to(inform(future(prospective(investigations(assessing(both(predictors(of(patient(participation(in(healthcare(decisions,(as(well(as(modifiable(predictors(of(adherence.((6.4.6$Implications$6.4.6.1%Non=physician%caregivers%Based(on(the(current(findings,(existing(interventions(such(as(asthma(action(plans(and(asthma(educators(are(potentially(being(underutilized.(Additionally,(results(of(the(survey(show(that(the(addition(of(nonAphysician(caregivers(such(as(asthma(educators(may(serve(as(important(resources(to(improve(communication(and(adherence(among(adult(asthma(patients.(Before(recommending(that(additional(health(resources(be(directed(to(implementing(more(educators(into(clinical(practice,(it(is(important(to(consider(potential(explanations(for(this(finding.(((Firstly,(it(is(possible(that(systematic(differences(between(patients(who(are(provided(with(access(to(asthma(educators(through(referrals,(and(those(who(are(not(referred(to(these(services.(Similarly,(differences(may(exist(between(those(patients(who(follow(through(with(a(referral(to(an(asthma(educator,(compared(with(those(who(choose(not(to,(with(regard(to(their(level(of(adherence(to(asthma(medication(and(disease(control.(193 Therefore,(the(variation(in(adherence(shown(between(the(two(groups(may(be(confounded(by(specific(patient(characteristics(such(as(socioeconomic(status,(disease(severity,(physician(attitudes,(or(patient(comorbidities.(A(future(investigation(would(benefit(from(determining(whether(there(are(there(specific(patient(groups(who(are(being(systematically(denied(equitable(access(to(these(services.((Results(of(the(survey(as(well(as(the(existing(literature(show(that(exposure(to(asthma(educators(is(low(in(BC(and(Canada.(This(may(be(due(to(the(fact(that(access(to(asthma(educators(in(BC(is(typically(provided(through(specialty(clinics,(rather(than(through(primary(care(settings,(which(speaks(to(the(nonAintegration(of(structured(education(into(regular(asthma(care.(297)(Furthermore,(many(institutions(do(not(offer(asthma(education(services(even(within(specialty(practices.(298)(Therefore,(only(a(small(number(of(asthma(patients(are(being(referred(to(educators(by(their(physicians.(297,298)(Hesitancy(to(refer(patients(to(educators(may(be(due(in(part(to(physicians’(preference(to(maintain(exclusive(care(of(their(patients.(298)(Finally,(many(patients(are(not(aware(that(asthma(educator(services(are(available(to(them.(Of(those(who(are(aware,(some(may(be(unable(or(unwilling(to(attend(the(appointment(after(being(referred(through(their(physician.(297)((In(addition(to(asthma(educators,(decision(coaches(have(been(suggested(to(aid(patients(in(the(decisionAmaking(process(regarding(preference(sensitive(decisions.(299–301)(A(role(that(can(be(taken(on(by(health(professionals(such(as(nurses(or(genetic(counselors,(decision(coaches(work(with(patients(to(determine(194 levels(of(decisional(conflict,(apply(decision(support(techniques(such(as(decision(aids,(and(assess(potential(barriers(to(implementing(the(decision.(Decision(coaches(may(be(external(to(the(healthcare(team.(Alternatively,(the(role(of(the(decision(coach(may(be(adopted(by(a(nurse(or(other(caregiver(already(integrated(into(the(care(process.(Available(evidence(suggests(that(that(patients(who(undergo(decision(coaching(benefit(in(terms(of(increased(knowledge(and(satisfaction.(301,302)(Barriers(to(the(implementation(of(decision(coaching(are(similar(to(those(of(SDM,(such(as(the(lack(of(awareness(or(knowledge(about(decision(coaching,(and(availability(of(training(for(decision(coaching.(300)((Finally,(further(economic(evaluation(including(of(asthma(educators(and(decision(coaches(into(standard(asthma(care(is(warranted.(Previous(costAeffectiveness(studies(in(both(adult(and(pediatric(populations(show(that(the(use(of(asthma(educators(is(associated(with(cost(savings(attributable(to(reduced(hospitalizations,(reduction(in(length(of(hospital(stays,(and(ER(visits.(303,304)(Although(a(recent(Cochrane(review(showed(that(the(impact(of(SDM(on(the(length(of(consultation(times(is(unclear,(99)(physicians(often(state(time(constraints(as(a(barrier(to(implementing(SDM(into(practice.(27)(However,(despite(evidence(in(favour(of(asthma(educators,(there(is(no(standard(funding(model(in(place(to(support(the(use(of(these(and(other(nonAphysician(care(providers(within(the(asthma(care(process.(297)(((In(summary,(research(into(the(issues(surrounding(the(potential(underAuse(of(nonAphysician(caregivers(to(assist(the(adoption(of(SDM(may(inform(further(195 implementation(efforts.(Specifically,(addressing(issues(related(to(access,(barriers(such(as(intervention(duration,(and(a(more(comprehensive(look(at(both(patientArelated(outcomes(and(costAeffectiveness(outcomes,(is(a(valuable(and(timely(next(step(to(the(current(research(endeavor.(300)((6.4.6.2%Medication=related%beliefs%and%concerns%Linking(back(to(the(theoretical(framework(described(in(chapter(3,(motivating(factors(such(as(beliefs(and(concerns(were(shown(here(to(correlate(with(adherence(to(controller(medication.(For(example,(despite(being(prescribed(at(least(one(controller(asthma(medication(in(the(12Amonths(prior(to(the(survey,(55%(of(patients(held(the(belief(that(their(asthma(is(mild(and(does(not(require(regular(controller(medication.(This(finding(suggests(that(although(patients(are(being(prescribed(medications(that(are(intended(to(be(taken(daily,(patients(may(be(undereducated(about(their(disease(status(or(the(purpose(of(the(medication.(An(additional(finding(suggests(that(the(absence(of(treatmentArelated(side(effects(does(not(necessarily(reflect(a(lack(of(concern(about(their(potential,(and(that(the(presence(of(disease(and(medication(related(beliefs(and(concerns(are(shown(to(be(associated(with(decreased(selfAreported(adherence.(Therefore,(future(clinical(efforts(may(focus(on(ensuring(that(patients(hold(accurate(beliefs(about(their(disease,(and(that(concerns(are(elicited(and(considered(when(determining(the(treatment(plan.(Implications(of(this(finding,(with(regard(to(clinical(implementation,(is(discussed(in(further(detail(in(chapter(7.((196 6.4.6.3%SDM%implementation%Despite(the(limitations(described(above,(the(results(of(this(survey(help(to(highlight(considerable(variation(with(regard(to(the(extent(to(which(patients(are(being(engaged(in(their(healthcare(decisions(for(asthma(controller(medication.(These(hypothesisAgenerating(results(suggest(that,(to(date,(there(is(no(standard(frequency(or(method(for(engaging(patients(in(their(care(about(decisions(for(asthma(treatment.(As(previous(authors(have(stated,(there(is(a(gap(between(the(mounting(evidence(in(favour(of(SDM,(and(the(limited(extent(to(which(the(knowledge(has(been(translated(into(practice.(My(findings(support(this(argument.((( $197 Chapter$7:$Conclusions$$7.1$Introduction$Attempts(to(reduce(the(overall(burden(of(asthma(in(Canada(are(ongoing.(Shared(decisionAmaking((SDM)(has(been(proposed(as(a(potential(solution(to(reducing(the(health(burdens(associated(with(nonAadherence(to(controller(medication.(This(dissertation(has(provided(an(evidenceAbased(investigation(into(the(role(of(SDM(in(improving(adherence(among(adult(asthma(patients(in(BC.(The(results(of(this(project(provide(further(support(for(the(use(of(SDM(in(regular(clinical(care(of(asthma(patients,(and(suggest(recommendations(for(potential(clinical(implementation(strategies.((Throughout(the(preceding(chapters(I(have(shown(that(both(physicians(and(patients(generally(support(the(use(of(SDM.(I(have(proposed(a(theoretical(framework(that(clearly(defines(the(role(of(SDM(in(improving(outcomes(related(to(asthma(–(namely(adherence(to(controller(medication.(Further(to(this,(I(have(conducted(a(population(level(analysis(to(show(that(adherence(cannot(be(easily(explained(or(predicted,(and(that(effective(solutions(for(reducing(nonAadherence(ought(to(consider(individualApatient(level(barriers.(Finally,(the(results(of(the(empirical(survey(show(that(variation(in(adherence(can(be(explained(by(patient(level(factors(that(may(be(directly(addressed(through(increased(communication(between(patients(and(their(asthma(198 care(providers.(Below(I(summarize(the(main(findings(of(this(thesis,(and(outline(implications(for(both(clinical(care(and(future(research.((7.2$Summary$of$main$research$findings$The(primary(objectives(for(this(thesis(were(to(address(the(following(5(research(objectives:(1.! To(describe(the(extent(to(which(physicians(support(the(implementation(of(SDM,(and(in(which(specific(clinical(contexts((chapter(2);(2.! To(identify(the(role(for(SDM(within(the(context(of(asthma((chapters(3(and(4);(3.! To(determine(the(extent(to(which(asthma(patients(desire(to(participate(in(their(decision(making((chapters(5(and(6);((4.! To(explore(the(extent(to(which(SDM(and(specific(components(of(SDM(are(being(implemented(in(asthma(clinical(care(in(BC,(and(the(characteristics(of(those(patients(who(are(more(likely(to(report(being(engaged((chapters(5(and(6)(5.! To(determine(whether(current(selfAreported(adherence(may(be(associated(with(perceived(previous(exposure(to(SDM((chapters(5(and(6)((The(following(summarizes(the(main(findings(of(the(thesis(work.(199 $7.2.1$Support$for$SDM$Chapters(2(and(6(provide(evidence(to(support(the(claim(that(both(physicians(and(patients(desire(patient(involvement(in(the(decisionAmaking(process.(Physicians(generally(support(the(use(of(SDM(in(situations(where(patients(are(willing(and(able(to(participate,(and(where(decisions(are(preferenceAsensitive.(Patients(in(particular(prefer(to(participate(in(decisions(about(the(acceptability(of(treatment(option(risks(and(benefits,(as(well(as(the(final(treatment(decision.(Although(support(varies(according(to(a(number(of(patient,(physician(and(conditionArelated(factors,(these(findings(provide(further(support(for(the(claim(that(there(exists(an(overarching(desire(for(patient(participation,(particularly(in(chronic(disease(management(decisions.((7.2.2$Establishing$the$role$for$SDM$in$asthma$Chapters(3(to(6(provide(novel(contributions(to(the(existing(literature(by(further(establishing(the(role(of(SDM(in(the(context(of(asthma.(Chapter(3(contributes(to(the(overarching(research(agenda(by(clearly(describing(the(role(for(SDM(in(reducing(the(health(burden(of(asthma(by(increasing(treatment(adherence.(((The(results(of(the(populationAbased(analysis(presented(in(chapter(4(support(the(argument(that(further(insight(into(individual(patient(behaviours(may(more(comprehensively(explain(variation(in(adherence(to(controller(medication.(The(lack(200 of(variation(in(adherence(explained(using(demographic(and(diseaseArelated(variables(highlights(the(need(to(consider(patient(rationale(for(adherence(at(the(individual(level,(with(closer(attention(being(paid(to(the(patientAphysician(relationship.((Finally,(the(patient(survey((chapters(5(and(6)(shows(that(multiple(components(related(to(the(clinical(encounter(such(as(exposure(to(asthma(educators,(as(well(as(disease(and(treatmentArelated(beliefs(and(concerns(help(to(further(explain(adherence(to(controller(medication.(Combined,(the(results(of(these(4(chapters(suggest(that(there(is(a(clear(role(of(SDM(in(asthma(management(in(reducing(the(health(burdens(associated(with(nonAadherence.((7.2.3$Asthma$care$in$BC$The(results(of(chapter(6(suggest(that(considerable(variation(exists(with(regard(to(patientAreported(perceived(exposure(to(SDM(for(asthma(care.(Participants(also(report(variation(in(exposure(to(various(forms(of(asthmaArelated(education(such(as(asthma(action(plans(and(asthma(educators,(and(exposure(to(asthma(educators(is(shown(to(increase(adherence(to(controller(therapy.(Until(recently,(many(SDM(interventions(have(focused(on(the(role(of(physicians(in(implementing(SDM(into(their(practice.(These(findings(may(prompt(further(investigations(into(the(potential(role(of(increasing(communication(between(patients(and(their(asthma(caregivers,(not(limited(to(physicians.(((201 7.3$Strengths$$Firstly,(the(systematic(review(adds(to(the(existing(literature(that(addresses(SDM(implementation(barriers(by(proposing(clinical(scenarios(wherein(physicians(are(most(likely(to(support(the(use(of(SDM(in(their(practice,(such(as(preferenceAsensitive(chronic(disease(scenarios,(and(encounters(wherein(the(patient(is(deemed(to(be(both(able(and(willing(to(participate.(8,27)(((As(further(background(to(providing(a(clear(linkage(between(SDM(and(asthma(treatment(adherence,(chapter(3(presents(a(theoretical(framework(focused(specifically(on(the(role(for(SDM(in(asthma.(The(theoretical(framework(can(be(adapted(and(modified(to(other(chronic(disease(contexts.((The(primary(strength(of(the(populationAbased(crossAsectional(analysis((chapter(4)(is(to(highlight(the(complex(nature(of(adherence,(and(the(challenges(with(measuring(adherence(using(administrative(data.(From(a(statistical(modeling(perspective,(the(multivariate(regression(analyses(fail(to(adequately(capture(adherence.(However,(from(a(clinical(and(policy(perspective,(the(analyses(provide(valuable(insight(into(the(challenges(in(explaining(why(one(individual(may(adhere(to(their(medication,(and(another(patient(may(not.(((Finally,(the(online(survey(provides(insight(into(the(extent(to(which(components(of(SDM(are(being(implemented(into(clinical(practice,(and(further(explains(variation(in(202 adherence(at(the(individual(level,(by(specifically(addressing(factors(related(to(the(decisionAmaking(encounter(and(the(patientAphysician(relationship.(((7.4$Limitations$The(implications(of(the(crossAsectional(survey((chapters(5(and(6)(must(be(interpreted(in(light(of(the(limited(sample(size,(the(length(of(time(since(initial(prescription,(as(well(as(recall(difficulty(and(potential(bias.(As(discussed(in(chapter(6,(a(future(prospective(investigation(utilizing(a(sample(of(newly(diagnosed(asthma(patients,(would(likely(overcome(some(of(the(limitations(resulting(from(the(current(analysis.(A(larger(scale(prospective(design(was(logistically(and(financially(infeasible(for(this(project.((7.5$Knowledge$translation$$Knowledge(translation((KT)(is(a(process(that(includes(the,(“synthesis,(dissemination,(exchange(and(ethically(sound(application(of(knowledge(to(improve(health,(provide(more(effective(health(services(and(products(and(strengthen(the(healthcare(system”.(305)(Although(the(creation(of(research(evidence(is(a(necessary(component(for(the(translation(of(knowledge(into(clinical(implementation(strategies,(research(alone(is(not(sufficient.(306)(Health(systems(regularly(underAuse(research(evidence(and(fail(to(apply(the(findings(to(clinical(practice,(which(results(in(health(system(inefficiency(as(well(as(preventable(mortality(and(morbidity(across(a(range(of(conditions.(306,307)(Developed(to(investigate(strategies(to(promote(integration(of(203 interventions(within(the(context(of(telemedicine,(the(normalization(process(theory(proposes(that(in(order(for(an(intervention(or(practice(to(become(entrenched(as(a(core(component(of(an(organization,(the(intervention(must(first(be(implemented,(embedded(and(then(integrated(and(sustained(over(a(period(of(time.(308)(A(term(used(by(Carl(May(is(that(of(“collective(action”(–(or(the(enacting(of(a(practice(among(members(of(the(institution.(This(concept(recognizes(the(fact(that(behavioral(change(is(not(simply(the(adoption(of(intention(at(the(individual(level,(but(that(there(are(social(structures(within(or(external(to(the(institution(that(also(play(an(important(role.(309)(The(recommendations(posed(in(this(chapter(attempt(to(promote(collective(action(through(increased(understanding(and(awareness(about(the(complex(nature(of(adherence(as(well(as(the(proposed(role(for(SDM.(((To(date,(much(of(the(evidence(that(supports(the(use(of(SDM(has(failed(to(be(implemented(into(routine(care.(Despite(this,(knowledge(translation(interventions(have(been(developed(for(implementation(of(SDM(into(clinical(settings.(For(example,(decision(aids(have(been(shown(to(increase(patient(knowledge,(reduce(decisional(conflict,(and(promote(patient(participation(in(the(decision(making(process.(26)(Promoting(physician(and(patient(knowledge(about(the(value(of(SDM(as(well(as(the(associated(benefits,(may(facilitate(the(uptake(of(such(existing(interventions(so(that(they(can(be(routinely(applied(into(clinical(practice.(((While(recognizing(the(limitations(of(this(work,(I(present(three(clinical(implications(that(are(geared(toward(physicians(and(other(healthcare(providers(treating(asthma(204 patients.(Their(purpose(is(to(facilitate(and(increase(in(communication(between(healthcare(professionals(and(asthma(patients,(while(promoting(a(focus(on(implementation(of(SDM(into(clinical(care.($7.5.1.$Efforts$to$increase$adherence$among$asthma$patients$are$likely$to$benefit$from$individualized$and$ongoing$discussions,$through$the$use$of$SDM$interventions$The(results(of(chapters(4(and(6(show(that(variation(in(adherence(cannot(be(adequately(captured(using(populationAlevel(analyses.(Given(the(lack(of(similar(analyses(by(other(investigators,(it(is(difficult(to(compare(the(results(of(these(findings,(within(the(context(of(asthma.(177,178)(While(the(current(results(show(that(both(demographic(and(diseaseArelated(variables(explain(some(of(this(variation,(the(concept(of(adherence(is(not(one(that(can(be(easily(predicted(or(explained.(((The(implication(of(this(finding(is(not(that(it(is(a(frivolous(effort(to(try(to(explain(and(predict(adherence,(but(rather(that(efforts(geared(toward(improving(adherence(ought(to(be(considered(at(the(individual(patient(level.(Therefore,(physicians(and(other(caregivers(aiding(in(the(decisionAmaking(process(must(understand(the(value(of(ascertaining(patientAreported(rationale(for(nonAadherence(and(barriers(to(adherence(on(an(individual(and(ongoing(basis.(($205 7.5.2$The$use$of$both$physician$and$nonAphysician$care$givers$in$ascertaining$patients’$disease$and$medicationArelated$inaccurate$beliefs$or$concerns$may$help$to$increase$treatment$adherence$Two(specific(findings(from(the(online(survey(suggest(the(potential(benefits(associated(with(engaging(patients(about(their(disease(and(medicationArelated(beliefs(and(concerns.(Firstly,(consistent(with(the(existing(literature,(results(of(the(survey(show(that(it(is(not(uncommon(for(patients(to(hold(misconceptions(about(their(medications,(as(well(as(concerns(about(the(use(of(controller(therapy.(32,33)(Furthermore,(the(presence(of(concerns(and(beliefs(about(the(need(for(controller(medication(are(shown(to(be(associated(with(poorer(adherence((chapter(6).(This(conclusion(is(substantiated(further(by(previous(evidence(suggesting(that(patients(who(are(more(knowledgeable(about(their(disease(management,(and(those(who(hold(realistic(expectations(tend(to(have(improved(outcomes,(across(a(range(of(chronic(diseases(and(surgical(conditions.(310,311)(Therefore,(engaging(patients(in(an(ongoing(basis(about(their(disease(and(medicationArelated(beliefs(and(concerns(is(likely(to(improve(patient(knowledge,(and(subsequent(adherence.(This(requires(open(and(continued(discussions(between(patients(and(their(physicians(or(other(care(providers,(a(strategy(that(has(been(promoted(elsewhere(with(regard(to(chronic(disease(management.(312)(If(healthcare(providers(treating(asthma(patients(do(not(initiate(these(discussions,(uncertainties(regarding(these(individual(level(predictors(of(nonAadherence(will(likely(remain.((206 Secondly,(results(of(the(survey(show(that(patient(reported(exposure(to(asthma(educators(explained(an(increase(in(treatment(adherence,(even(when(controlling(for(beliefs(and(concerns(about(asthma(and(the(need(for(controller(medication.(This(finding(has(implications(for(the(potential(role(of(more(systematically(engaging(nonAphysician(caregivers(in(the(regular(clinical(care(of(asthma(patients.(As(discussed(in(chapter(6,(these(findings(are(preliminary,(and(more(research(is(required(to(determine(the(characteristics(of(patients(being(exposed(to(educators.(However,(these(findings(do(suggest(that(perhaps(the(onus(for(SDM(implementation(ought(to(extend(beyond(that(of(the(treating(physician.($7.5.3$Awareness$of$the$potential$benefits$associated$with$SDM$may$help$to$increase$SDM$uptake$and$improve$health$outcomes$The(results(of(the(systematic(review((chapter(2)(illustrate(that(physicians(tend(to(be(more(supportive(of(engaging(patients(who(are(willing(and(able(to(participate,(as(well(as(those(who(have(an(understanding(of(their(condition.(The(implication(here(is(that(physicians(may(select(whom(to(engage(in(SDM,(based(on(a(set(of(perceived(patientAcharacteristics.(A(potential(consequence(of(this(selection(process(is(that(there(may(be(a(subAset(of(patients(who(not(being(approached(to(engage(in(the(decisionAmaking(process.((Results(of(the(online(survey(show(that(patients(with(a(greater(preference(for(participation(in(the(decisionAmaking(process(tend(to(be(younger,(with(a(higher(average(annual(household(income((chapter(6).(These(results(are(consistent(with(207 existing(literature(showing(that(vulnerable(populations(such(as(the(elderly,(immigrants(and(those(with(lower(SES(are(less(likely(to(report(an(interest(in(SDM.(313)(Given(the(outcomes(that(are(suggested(in(the(literature(related(to(involvement(in(decisionAmaking,(the(potential(underAutilization(of(patient(engagement(may(have(undue(negative(impacts(on(a(specific(subset(of(asthmatics.(((An(implication(of(this(finding(is(that(there(is(the(potential(for(systematic(bias(related(to(those(who(are(and(are(not(being(engaged(in(their(decision(making(processes.(8)(As(Légaré(and(colleagues(point(out,(we(ought(not(to(engage(only(those(patients(for(whom(it(is(easier(to(communicate(with.(8)(While(it(may(be(a(challenge(to(engage(those(who(prefer(a(passive(role,(doing(so(may(result(in(a(systematic(inequity(of(care.(Previous(evidence(suggests(that(that(patients(who(have(taken(an(active(role(in(their(healthcare(decisions(benefit(in(terms(of(physical(and(social(functioning(as(well(as(quality(of(life,(even(among(those(who(reportedly(prefer(a(passive(role.(314)(Further(to(this,(a(recent(systematic(review(reported(that(SDM(interventions(directed(toward(disadvantaged(populations((e.g.(those(with(lower(literacy(levels)(were(shown(to(increase(preference(for(a(collaborative(approach(to(decision(making,(among(other(outcomes.(315)(The(review(also(highlights(the(finding(that(certain(SDM(interventions(may(in(fact(have(a(greater(impact(on(outcomes(for(disadvantaged(individuals,(compared(with(high(literacy(and(SES(patients.(((A(potential(solution(to(this(challenge(is(to(ensure(that(patients(are(made(aware(of(the(valuable(role(they(play(in(the(decisionAmaking(process.(Moreover,(patients(who(208 fear(that(they(lack(the(content(knowledge(to(participate(in(the(process,(or(fear(being(labeled(a(“difficult”(patient(for(seeking(active(engagement,(should(be(informed(of(the(important(role(that(their(personal(value(and(preferences(can(play(in(determining(the(optimal(treatment(option.(316)(Doing(so(may(increase(communication,(trust(and(selfAefficacy(among(patients(who(have(misconceptions(about(their(expected(or(preferred(role(in(the(encounter.(As(proposed(in(the(chapter(3(theoretical(framework,(patients(who(have(a(greater(sense(of(selfAefficacy(regarding(their(disease(and(treatment(options(are(more(likely(to(adhere(to(the(given(treatment(plan.(If(patients(are(more(willing(to(participate(and(have(an(understanding(of(the(important(role(that(they(play,(they(may(be(more(likely(to(reap(the(benefits(of(active(engagement.(((Although(patient(and(physician(awareness(of(the(value(of(SDM(is(imperative(for(implementation,(a(further(challenge(may(serve(as(a(barrier(to(acting(on(this(awareness(–(that(of(the(patient’s(perception(of(the(power(dynamic(within(the(clinical(encounter.(317,318)(This(perception(is(informed(by(the(opinion(that(physicians(hold(the(legitimate(knowledge,(and(patients(are(reliant(on(their(physicians(to(make(decisions(and(provide(care.(319)(As(stated(at(the(beginning(of(this(thesis,(there(has(been(a(shift(away(from(the(perception(that(“doctor(knows(best”(and(that(patients(lack(valuable(knowledge(to(contribute(to(the(decisionAmaking(process.(However,(recent(evidence(shows(that(patients(may(still(find(it(difficult(to(voice(their(opinions(within(the(medical(encounter.(317)(Furthermore,(the(power(dynamic(between(physicians(and(their(patients(may(be(challenging(to(overcome,(even(through(increased(physician(training.(320)(((209 (Interventions(such(as(group(medical(visits(have(been(proposed(in(an(effort(to(promote(patient(centered(care(in(certain(clinical(scenarios(such(as(chronic(disease(management(and(mental(health.(321)(In(comparison(to(oneAonAone(medical(encounters,((group(medical(visits(have(been(shown(to(make(patients(feel(safer(and(supported,(322)(which(may(aid(in(mitigating(the(power(differential.(Group(medical(visits(may(work(in(concert(with(the(previous(recommendation(to(integrate(nonAphysician(care(givers(into(the(SDM(implementation(process,(by(considering(nurse(and(nurseAlead(group(visits.(323)(((7.6$Furthering$this$research$agenda$Based(on(the(results(of(this(thesis,(it(can(be(concluded(that(there(is(a(clear(role(for(SDM(in(asthma(management,(but(uptake(has(been(inconsistent(in(BC.(Therefore,(further(research(is(required(to(specifically(address(optimal(and(specific(strategies(for(implementing(SDM(in(routine(asthma(care.(Furthermore,(as(has(been(stated(previously,(much(of(the(literature(regarding(SDM(has(focused(exclusively(on(the(patientAphysician(relationship,(299)(suggesting(that(it(is(the(responsibility(of(treating(physicians(to(become(trained(in(SDM(competencies,(implement(SDM(and(do(so(within(time(and(resource(constraints.(However,(the(results(of(this(thesis(show(that(further(investigation(into(the(potential(health(and(economic(impact(of(more(formal(engagement(of(nonAphysician(caregivers(in(SDM(uptake(is(warranted.(((210 7.7$Conclusions$This(research(has(provided(a(description(of(the(state(of(SDM(in(asthma(as(well(as(the(potential(outcomes(associated(with(increased(patient(engagement.(The(results(of(this(dissertation(can(be(used(to(inform(future(research(designed(to(further(explain(variation(in(adherence(to(controller(medication(among(asthma(patients,(at(the(individual(level.(In(addition,(this(project(provides(the(groundwork(to(further(address(issues(related(to(SDM(implementation,(with(a(specific(focus(on(calling(for(a(broader(integration(of(health(professionals(to(aid(in(uptake(efforts.(Healthcare(providers(treating(asthma(patients(may(use(these(findings(to(further(understand(the(value(of(increasing(communication(with(their(patients(and(utilizing(nonAphysician(educational(resources.((( $211 Bibliography$1. 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(257 Appendices$Appendix$A:$Medline$search$strategy$$(1.(shared(decision(making.mp.(2.((patient$(adj3(participation).mp.([mp=title,(abstract,(original(title,(name(of(substance(word,(subject(heading(word,(protocol(supplementary(concept,(rare(disease(supplementary(concept,(unique(identifier](3.(Patient(Participation/(4.(Patient(Education(as(Topic/mt([Methods](5.(PatientACentered(Care/(6.(Communication/(7.((patient(centered(or(patient(centred).mp.(8.(Physician's(Practice(Patterns/(9.(exp(Attitude/(10.(exp(Physicians/(11.(9(and(10(12.(Professional(Practice/(13.(PhysicianAPatient(Relations/(14.("Attitude(of(Health(Personnel"/(15.((attitude$(or(belief$(or(opinion$).mp.([mp=title,(abstract,(original(title,(name(of(substance(word,(subject(heading(word,(protocol(supplementary(concept,(rare(disease(supplementary(concept,(unique(identifier](16.((physician$(or(general(practitioner$(or(GP).mp.([mp=title,(abstract,(original(title,(name(of(substance(word,(subject(heading(word,(protocol(supplementary(concept,(rare(disease(supplementary(concept,(unique(identifier](17.(15(and(16(18.(editorial/(19.(letter/(20.(comment/(21.(18(or(19(or(20(22.(animals/(not((animals/(and(humans/)(23.(decision(making/(or(choice(behavior/(or(consensus/(or("dissent(and(disputes"/(or(refusal(to(participate/(or(negotiating/(or(uncertainty/(24.(2(and(23(25.(6(and(23(26.(7(and(23(27.(10(and(23(28.(1(or(3(or(4(or(5(or(24(or(25(or(26(29.(8(or(11(or(12(or(13(or(14(or(17(or(27(30.(28(and(29(31.(limit(30(to(yr="2000(ACurrent"*(32.(limit(31(to(english(language(258 33.(32(not(21(34.(33(not(22(*(The(search(strategy(was(developed(to(include(all(references(from(2000(to(current.(However,(only(those(references(published(after(2006(were(screened(for(inclusion(in(this(review.(( (259 Appendix$B:$PRISMA$2009$flow$diagram$(324)$(($$((((( $Records)identified)through)database)searching)[n)=)))11,761])Screening(Included(Eligibility(Identification( Additional)records)identified)through)other)sources)[n)=1])Records)screened)[n)=))11,762])Records)excluded)[n)=)))11,639])Full!text)articles)assessed)for)eligibility)[n)=123])Full!text)articles)excluded,)with)reasons)[n)=))80)])Studies)included)in)quantitative)synthesis)[n)=))29)]))Studies)included)in)the)qualitative)synthesis)[n)=)14]))260 Appendix$C:$Studies$that$have$used$administrative$data$sources$to$address$us$of$asthma$controller$medication$use$(First$author,$date$author$Controller$medications$Adherence$measure$Explanatory$variables$obtained$through$administrative$databases$Sadatsafavi,(2015((117)( ICS,(long(acting(beta(agonist((LABA),(leukotriene(receptor(antagonist((LTRA),(systemic(corticosteroids((SCS)(Medication(possession(ratio((MPR)( •! Age(•! Sex(•! Number(of(asthma(related(hospitalizations(in(the(year(preceding(the(index(date(•! Number(of(SABA(canisters(received(in(the(year(preceding(index(date(•! Number(of(ICS(canisters(received(in(the(year(preceding(the(index(date(•! Charlson(comorbidity(index(Blais,(2011((184)( ICS(monoAtherapy( Proportion(of(prescribed(days(covered((PPDC)( •! Sex(•! Area(of(residence(•! Social(assistance(status(•! Number(of(outpatient(visits(for(asthma(•! Number(of(outpatient(visits(for(all(causes(•! Number(of(prescribing(physicians(for(asthma(medications(•! Number(of(pulmonary(function(tests(•! SABA(use(per(week(((Exacerbations(and(control.)(•! Number(of(oral(corticosteroid(prescriptions((Exacerbations)(•! Number(of(asthma(related(ED(visits((Exacerbations)(•! Number(of(asthma(related(hospitalizations((Exacerbations)(•! Prescribing(physician(speciality((GP,(respirologist,(paediatrician)(•! Comorbidities(Sadatsafavi,(2013((121)( ICS,(LTRA,(LABA( Proportion(of(days(covered((PDC)( •! AsthmaArelated(hospitalization(261 First$author,$date$author$Controller$medications$Adherence$measure$Explanatory$variables$obtained$through$administrative$databases$•! An(asthmaArelated(outpatient(visit(•! Total(number(of(asthmaArelated(medication(dispensations(•! Number(of(oral(corticosteroid(dispensations(•! AsthmaArelated(direct(medical(costs((outpatient(visits,(hospitalizations(and(medications)(Marceau,(2006(178)( ICS,((LABA(( number(of(prescriptions(of(either(a(combination(or(a(concurrent(therapy(filled(during(the(first(year(of(treatment.(•! Number(of(ICS(prescriptions(filled(in(the(year(preceding(cohort(entry((Disease(severity)(•! Number(of(prescriptions(OCS(prescriptions(filled(in(the(year(preceding(cohort(entry(•! Number(of(ICS(prescriptions(or(ICS(filled(in(the(year(preceding(cohort(entry(•! Number(SABA(prescriptions(filled(in(the(year(preceding(cohort(entry(•! Filled(prescription(of(an(oral(corticosteroids,(or(a(visit(to(an(ED(or(a(hospitalization(for(asthma((Exacerbations)(•! Age(•! Sex(•! Receipt(of(social(assistance(•! Area(of(residence(•! Number(of(medications(filled(in(the(year(preceding(cohort(entry((•! prescribed(daily(dose(of(ICS(at(treatment(initiation((Disease(severity)(•! Asthma(related(GPAvisits(in(the(year(preceding(cohort(entry((Disease(severity)(•! Asthma(related(hospitalizations(in(the(year(preceding(cohort(entry((Disease(severity)(•! Asthma(related(ER(admissions(in(the(year(preceding(cohort(entry((Disease(severity)(262 First$author,$date$author$Controller$medications$Adherence$measure$Explanatory$variables$obtained$through$administrative$databases$•! at(least(1(prescription(of(antileukotrienes(in(the(year(preceding(cohort(entry((Disease(severity)(•! at(least(1(prescription(of(theophyliene(in(the(year(preceding(cohort(entry((Disease(severity)((( $263 Appendix$D:$Impact$of$participant$follow$up$(((( (Total number of surveys sentN = 165Surveys returned without a reminder emailN = 93Additional surveys returned after one reminder emailN = 13Additional surveys returned after two reminder emailsN = 11Total number of surveys returnedN = 117264 Appendix$E:$Survey$variable$definitions$Heading$ Question$ Variable$type$ Initial$Coding$Demographics( What(is(your(household's(income(range,((before(tax)?( Categorical/(Continuous( (0:(no(income(or(less(than(20,000(1:(20A39,999(2(40A59,999(3:(60A79,999(4:(80(or(more((( What(is(the(highest(level(of(schooling(you(have(completed?( Categorical( 0:(primary(school(1:(middle(school(2:(high(school(3:(some(college(4:(four(year(college/university((( The(following(is(a(list(of(common(health(problems.(Please(indicate(if(you(currently(have(the(problem((even(if(the(problem(is(under(control(with(treatment)(Categorical((*Will(also(be(categorized(in(terms(of(number(of(comorbidities((e.g.(0(versus(at(least(one,(or(N(number(of(comorbidities((1:(heart(disease(2:(high(blood(pressure(3:(lung(disease(4:(diabetes(5:(ulcer(or(stomach(disease(6:(kidney(disease(7:(liver(disease(8:(anemia(or(other(blood(disease(9:(cancer(10:(depression(11:(osteoarthritis(or(degenerative(arthritis(12:(back(pain(13:(rheumatoid(arthritis(((( What(is(your(gender?( Categorical( 0:(female(1:(male(2:(other((text(box(provided(to(specify(gender)((( What(is(your(age?( Numeric/( (265 Heading$ Question$ Variable$type$ Initial$Coding$Continuous(( Please(select(the(racial(or(cultural(group(s)(to(which(you(belong.( Categorical( 1:(White/(caucasian(2:(South(Asian((e.g.,(East(Indian,(Pakistani,(Sri(Lankan,(etc.)(3:((Chinese(4:(Black(5:(Filipino(6:((Latin(American(7:((Arab(8:((Southeast(Asian((e.g.,(Vietnamese,(Cambodian,(Malaysian,(Laotian,(etc.)(9:((West(Asian((e.g.,(Iranian,(Afghan,(etc.)(10:((Korean(11:((Japanese(12:Other,(please(specify((Asthma((education/control/(Healthcare(use)(What(age(were(you(when(you(were(told(you(had(asthma?((( Numeric/(continuous( (( Have(you(seen(a(specialist(for(your(asthma?( Categorical( 0=(no/(I(cannot(remember(1=(yes( (( Has(anyone(shown(you(how(to(use(your(inhaler?(( Categorical( 0=(no/(I(cannot(remember(1=(yes( (( Who(has(shown(you(how(to(use(your(inhaler?( Categorical((*will(also(be(categorized(as(“no(teaching”(versus(“any(teaching”((1;(my(family(doctor(2:(my(asthma(specialist(3:(a(nurse(4:(my(asthma(educator(5:(a(friend(6:(family(member(7:(other((text(box(provided)(266 Heading$ Question$ Variable$type$ Initial$Coding$8:(I(do(not(use(an(inhaler((( Did(you(ever(get(a(written(action(plan(for(managing(your(asthma?( Categorical( 0=(no/(I(cannot(remember(1=(yes( (( Have(you(ever(had(teaching(about(your(asthma(from(an(asthma(educator?((Categorical( 0=(no/(I(cannot(remember(1=(yes( (( In(the(past(year,(have(you(visited(a(doctor(due(to(your(asthma?( Categorical( 0=(no/(I(cannot(remember(1=(yes( (( In(the(past(year,(how(many(times(have(you(visited(a(doctor(due(to(your(asthma?(Continuous( (( In(the(past(year,(have(you(visited(an(emergency(department(due(to(your(asthma?(Categorical( 0=(no/(I(cannot(remember(1=(yes( (( In(the(past(year,(how(many(times(have(you(visited(an(emergency(department(due(to(your(asthma?(Continuous( (( In(the(past(year,(have(you(been(hospitalized(due(to(your(asthma?( Categorical( 0=(no/(I(cannot(remember(1=(yes( (( In(the(past(year,(how(many(times(have(you(been(hospitalized(due(to(your(asthma?(Continuous( (( Are(you(currently(being(prescribed(asthma(controller(medication?( Categorical( 0=(no(1=(yes(2=(I(am(unsure((( What(is(the(name(of(the(asthma(medication(s)(that(you(are(currently( Open( (267 Heading$ Question$ Variable$type$ Initial$Coding$being(prescribed?(( Have(you(filled(your(most(recent(controller(medication(prescription?(Categorical( 0=(no/(I(cannot(remember(1=(yes( (( When(you(were(first(prescribed(your(controller(medication,(did(your(doctor(provide(you(with(a(sample(of(the(medication?(Categorical( 0=(no/(I(cannot(remember(1=(yes( (( Did(you(take(the(medication(samples(that(your(doctor(provided(you?(Categorical( 0=(no/(I(cannot(remember(1=(yes( (( Have(you(ever(heard(of(an(asthma(action(plan,(before(today?( Categorical( 0=(no/(I(cannot(remember(1=(yes( (( Were(you(involved(in(developing(your(asthma(action(plan?( Categorical( 0=(no/(I(cannot(remember(1=(yes( (( When(was(your(current(action(plan(first(given(to(you?( Date(–(categorical(( (( When(was(your(asthma(action(plan(last(updated?( Date(–(categorical(( (( Do(you(recall(the(first(time(your(doctor(prescribed(the(asthma(controller(medication(that(you(are(currently(being(prescribed?(Categorical( 0=(no(1=(yes( (( When(were(you(first(prescribed(the(asthma(controller(medication(that(you(are(currently(being(prescribed?(Date( ( (( Are(you(currently(being(prescribed(rescue( Categorical( 0=(no(1=(yes(268 Heading$ Question$ Variable$type$ Initial$Coding$medication?( (( What(is(the(name(of(the(rescue(medication(s)(that(you(are(currently(being(prescribed?(Open(text( (( Do(you(recall(the(first(time(your(doctor(prescribed(the(asthma(rescue(medication(that(you(are(currently(being(prescribed?(Categorical( 0=(no(1=(yes( (( When(were(you(first(prescribed(the(asthma(rescue(medication(that(you(are(currently(being(prescribed?(Date(( ( (Participant(feedback((Final(survey(question)( Is(there(anything(else(you(would(like(to(share(with(us(on(this(topic?( Open(text( (SelfAreported(measure(of(adherence.$$See(Table(2$I(follow(my(asthma(medication(plan( Categorical((( 1:(I(agree(completely(2:(I(agree(mostly(3:(I(agree(somewhat(4:(I(disagree(somewhat(5:(I(disagree(mostly(6:(I(disagree(completely((I(forget(to(take(at(least(one(dose(of(my(inhaled(steroid(each(day(My(asthma(is(mild(and(does(not(require(regular(preventative(medication(My(inhaled(steroid(causes(side(effects(I(am(concerned(about(the(side(effects(of(my(inhaled(steroids((item(added(but(is(not(included(in(the(validated(version(of(the(AAAQ)(I(can’t(afford(my(inhaled(steroid(medication(How(much(effort(was( Continuous(( 0:(No(effort(at(all4(((((((((((((((((((((((((((((((((((((((((((((((((((((((((4(The(original(Collaborate(scale(lists(this(item(as(“No(effort(was(made.”(An(error(appears(in(the(survey(instrument(where(this(item(is(listed(as(“No(effort(at(all.”(The(269 Heading$ Question$ Variable$type$ Initial$Coding$Experience(with(SDM:(CollaboRATE$$See(Table(2$made(to(help(you(understand(your(health(issue?( ( 1:(a(little(effort(was(made(2.(Some(effort(was(made(3.(A(lot(of(effort(was(made(4.(Every(effort(was(made((How(much(effort(was(made(to(listen(to(the(things(that(matter(most(to(you(about(your(health(issues?(How(much(effort(was(made(to(include(what(matters(most(to(you(in(choosing(what(to(do(next>(Literacy:(3ASQ$$See(Table(2$ 1.(How(confident(are(you(filling(out(forms(by(yourself?(((Categorical/(Continuous( Extremely(Quite(a(bit((Somewhat(A(little(bit(Not(at(all((All(of(the(time(Most(of(the(time(Some(of(the(time(A(little(of(the(time(None(of(the(time((((All(of(the(time(Most(of(the(time(Some(of(the(time(A(little(of(the(time(None(of(the(time((((2.How(often(do(you(have(someone(help(you(read(hospital(materials?(((((3.(How(often(do(you(have(problems(learning(about(your(medical(condition(because(of(difficulty(reading(hospital(materials?(Numeracy:(SNS$$See(Table(2$ How(good(are(you(at(working(with(fractions?( Categorical(( 1:(not(good(at(all(2:(2(3:(3(4:(4(5:(5(6:(extremely(good(((((((((((((((((((((((((((((((((((((((((((((((((((((((((incorrect(item(was(retrieved(from(a(publication(using(the(CollaboRATE(scale,(but(was(later(revised(to(list(the(correct(anchor.(270 Heading$ Question$ Variable$type$ Initial$Coding$(How(good(are(you(at(figuring(out(how(much(a(tAshirt(will(cost(if(it(is(25%(off?(Categorical(( 1:(not(good(at(all(2:(2(3:(3(4:(4(5:(5(6:(extremely(good((How(often(do(you(find(numerical(information(to(be(useful?( Categorical( 1:(never(2:(2(3:(3(4:(4(5:(5(6:(Very(often((Preference(for(SDM:(PSDMS$$See(Table(2$Who(should(determine((diagnose)(what(the(likely(causes(of(your(symptoms(are?(Continuous(( 1.(the(doctor5(2.(mostly(the(doctor(3.(both(equally(4.(mostly(me(5.(me(alone((Who(should(determine(what(the(treatment(options(are?(Who(should(determine(what(the(risks(and(benefits(for(each(treatment(option(are?(Who(should(determine(how(likely(each(of(these(risk(and(benefits(are(to(happen?(Given(the(risks(and(benefits(of(these(possible(treatments,(who(should(decide(how(acceptable(those(risks(and(benefits(are(for(you?(Given(all(the(information(about(risks(((((((((((((((((((((((((((((((((((((((((((((((((((((((((5(The(original(PSDM(scale(includes(this(item(as(“the(doctor(alone.”(A(typo(appears(in(the(survey(instrument(where(this(item(is(listed(as(“the(doctor.”(271 Heading$ Question$ Variable$type$ Initial$Coding$and(benefits(of(the(possible(treatments,(who(should(decide(which(treatment(option(should(be(selected?(Asthma(control:(ACT$$See(Table(2$1.(In(the(past(4(weeks,(how(much(of(the(time(did(your(asthma(keep(you(from(getting(as(much(done(at(work,(school,(or(at(home?(Categorical( 1:(all(of(the(time(2:(most(of(the(time(3:(some(of(the(tome(4:(a(little(of(the(time(5:(none(of(the(time((( 2.(During(the(past(4(weeks,(how(often(have(you(had(shortness(of(breath?(Categorical( 1:(more(than(once(a(day(2:(once(a(day(3:(3(to(6(times(a(week(4:(once(or(twice(a(week(5:(not(at(all((( 3.(During(the(past(4(weeks,(how(often(did(your(asthma(symptoms((wheezing,(coughing,(shortness(of(breath,(chest(tightness(or(pain)(wake(you(up(at(night(or(earlier(than(usual(in(the(morning?(Categorical( 1:(4(or(more(nights(a(week(2:(2(or(3(nights(a(week(3:(once(a(week(4:(once(or(twice(5:(not(at(all((( 4.(How(would(you(rate(your(asthma(control(during(the(past(4(weeks?(Categorical( 1:(not(controlled(at(all(2:(poorly(controlled(3.(somewhat(controlled(4.(well(controlled(5.(completely(controlled((( 5.(During(the(past(4(weeks,(how(often(have(you(used(your(rescue(inhaler(or(nebulizer(medication((such(as(albuterol)?(Categorical( 1:(3(or(more(times(per(day(2:(1(or(2(times(per(day(3:(2(or(3(times(per(day(4:(once(a(week(or(less(5:(not(at(all(((272 Appendix$F:$Construction$of$select$variables$based$on$preAvalidated$instruments$Category$ Method$of$calculation/$Cutoff$ Predicted$distribution$AAAQ:(self(reported(adherence((Anything(other(than(“I(agree(completely”(constitutes(nonAadherence((261)( (Each(item(assigned(0/1(scoring.((No(summary(score(is(calculated((Based(on(previous(testing(of(this(item,(approx.(42%(are(categorized(as(nonAadherent(261)(CollaboRATE:(Patient(reported(exposure(to(SDM(This(survey(uses(CollaboRATE(5((with(a(5(point(likert(scale)((1)! Continuous(outcome:(sum(scores(on(the(3(items(on(the(original(scale(from(0(to(12((266)((2)! Binary(outcome((CollaboRATE(topscore):(A(patient(is(coded(as(1(if(they(responded(“every(effort”(to(each(of(the(3(items.(All(other(patients(are(coded(as(0.(266)(((((Preference(for(SDM:(PSDMS( To(determine(preferred(role,(mean(scores(are(computed(separately(for(the(PS(and(DM(dimensions(and(placed(into(one(of(three(classifications:((•! hand(over((mean(score(on(that(dimension(<3)(•! share((mean(score(between(3(and(3.99)(•! keep((mean(score(>(4).(These(classified(PS(and(DM(scores(are(then(used(to(place(respondents(into(one(of(three(categories.((•! Passive(patients(wish(to(hand(off(both(PS(and(DM(•! autonomous(patients(want(to(Approx.(48%(prefer(a(shared(role,(50%(a(passive(role,(and(the(remaining(2%(an(autonomous(role((269)((273 Category$ Method$of$calculation/$Cutoff$ Predicted$distribution$retain(some(control(of(both(PS(and(DM((keep(PS,(and(share(or(keep(DM)(•! shared(patients(want(to(hand(off(or(share(PS(but(share(or(keep(DM((269)(Literacy:(3ASQ$ Each(of(the(three(items(is(assigned(a(score(of(0A4((Each(of(the(three(items(will(be(tested(separately.(276)(278)(((Numeracy:(SNS$ ( Each(item(is(rated(on(a(1A6(point(likert(scale((with(only(two(anchors(at(each(end.(A(summary(score(between(3(and(18(is(calculated.(280)((Asthma(control(test$ All(items(scored(on(1A5(scale,(added(up(to(create(a(total(score(out(of(25.((5A19:((Your(asthma(symptoms(may(not(be(well(controlled((20A25:(Your(asthma(symptoms(may(be(well(controlled((Item(will(also(be(tested(as(a(continuous(variable((5A15)((Previous(investigations(using(mild(asthma(patients(estimate(well(controlled(asthma(at(48%,(29%(somewhat(controlled,(and(23%(poorly(controlled.(325)(Among(the(general(population(of(asthma(patients(in(BC,(poor(control(is(estimated(to(be(present(in(approximately(63%.(105)(((( $274 Appendix$G:$ReAdefinition$of$selected$variables$for$the$bivariate$and$multivariate$analysis,$based$on$original$variable$distribution$(Variable$ Original$distribution$ ReAdefinition$for$the$purposes$of$analysis$Ethnicity$$(82%(“white/Caucasian”(ethnicity(Small(cell(sizes(on(most(other(ethnicities(1=(white(0(=(nonAwhite(Education$$69%(fourAyear(college/(university(Small(sample(sizes(for(primary(to(high(school(1(=(four(year(college/university(0(=(less(than(4(year(college/(university(Comorbidities$ WideAranging(distribution(for(individual(comorbidities.(Will(investigate(as(per(number(of(comorbidities(reported(per(patient(as(a(potential(indicator(of(treatment(complexity.(0(=(0(comorbidities((1(=(1(comorbidity((2(=(2(comorbidities((3(=(3(or(more(comorbidities((Numeracy((created(as(a(categorical(and(numeric(variable)$ Highly(negatively(skewed(Not(appropriate(for(parametric(testing(Median(numeracy(score(of(16.(ReAcategorized(per(distribution(into(tertiles.(1(=(3A14(2(=(15A17(3(=(18(Asthma(Control$((((((((((((($((((((((((((($ Highly(negatively(skewed(Not(appropriate(for(parametric(testing(Median(ACT(score(of(22(Select(previously(defined(threshold(of(20,(for(analysis(Well(controlled((ACT(score(=>(20)(=(1(Not(well(controlled((ACT(score(<(20)(=(0(Who(should(determine((diagnose)(what(the(likely(causes(of(your(symptoms(are?($$Who(should(determine(what(the(treatment(options(are?($$Who(should(determine(what(the(risks(and(benefits(for(each(treatment(option(are?($$Very(small(sample(sizes(for(the(“me”(and(“mostly(me”(items.(Given(the(skewed(distribution,(will(categorize(as(shared/active(approach(preferred(versus(passive(approach(preferred(for(the(analysis(1(=(Mostly(me/Both(equally(0(=(Mostly(the(doctor/(the(doctor((275 Variable$ Original$distribution$ ReAdefinition$for$the$purposes$of$analysis$Who(should(determine(how(likely(each(of(these(risks(and(benefits(are(to(happen?($I(forget(to(take(at(least(one(dose(of(my(inhaled(steroid(each(day$$My(asthma(is(mild(and(does(not(require(regular(preventative(treatment$$My(inhaled(steroid(causes(side(effects($$I(can't(afford(my(inhaled(steroid(medication($$I(am(concerned(about(the(side(effects(of(my(inhaled(steroid$$Small(sample(sizes(for(certain(items.(Given(the(skewed(distribution,(will(categorize(as(general(agreement(versus(general(disagreement(for(the(analysis(1(=(I(agree((completely,(mostly,(somewhat)(0(=(I(disagree((somewhat,(mostly,(completely)((( $276 Appendix$H:$Missing$data$Item$ N$missing$ %$Missing$Income$ 6( 5%(Literacy((Reading)$ 1( <1%(Age(at(Asthma(Diagnosis$ 2( 1.7%(Problem(Solving(Decision(Making(Scale((Who(should(diagnose?)$$2( 1.7%(Adherence$ 1( <1%(Adherence(barrier((forget(to(take(medication)$ 2( 1.7%(Adherence(barrier((side(effects)$ 1( <1%(Adherence(barrier((concerned(about(side(effects$ 1( <1%(Adherence(barrier((cost)$ 1( <1%(Age$ 2( 1.7%(Asthma(Control((Work)$ 1( <1%(Asthma(Control((Symptoms)$ 1( <1%(($( $277 Appendix$I:$Multivariate$linear$regression$diagnostics$Adjusted(RAsquared(=(0.1254.(Age(and(income(explain(approximately(12.5%(of(the(variability(in(role(preference(for(the(decisionAmaking(process.(Model(pAvalue(for(the(FAstatistic(=(0.0002855.(The(multivariate(model(is(statistically(significant.(The(slope(is(not(equal(to(0.((Residuals(vs.(Fitted(plot:(Indicates(that(the(relationship(between(age,(income(and(role(preferences(is(approximately(linear.(QQAplot:(The(model(is(approximately(normally(distributed.(278 $$ $279 (Appendix$J:$Multivariate$logistic$regression$diagnostics$Tests(for(goodness(of(fit:(Pseudo(R2( =(1A(residual(deviance/null(deviance((=(1A((97.694/(118.056)(=(17.3(Conclusion:(The(multivariate(model(explains(approximately(17.3%(of(variation(in(adherence.(((Pearson’s(X2(( =(sum((Pearson’s(residuals)2(=(84.83572((p(=(.113)(Null(hypothesis(=(the(fitted(model(is(correct.(216)(Conclusion:(Fail(to(reject(the(hypothesis(that(the(fitted(model(is(correct.($($(

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