!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!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¶metric&bootstrapped&linear®ression&to&explain&variation&in&adherence&to&controller&medication*&&!! Unadjusted&linear®ression& Adjusted&linear®ression&&&&& 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¶metric&bootstrapped&linear®ression&to&explain&variation&in&adherence&to&controller&medication*&&!! Unadjusted&linear®ression& Adjusted&linear®ression&&&&& 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!(%$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. Pollard S, Bansback N, Bryan S. Physician attitudes toward shared decision making: a systematic review. Patient Educ Couns 2015; 98: 1046-1057. 2. Pollard S, Bansback N, FitzGerld JM, Bryan S. The burden of nonadherence among adults with asthma: a role for shared decision-making. Allergy 2017;72:705–712. 3. The British Columbia Patient-Centered Care Framework. 2015http://www.health.gov.bc.ca/library/publications/year/2015_a/pt-centred-care-framework.pdf 4. Institute of Medicine (US) Committee on Quality of Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington (DC): National Academies Press (US) 2001http://www.ncbi.nlm.nih.gov/books/NBK222274/ (accessed 30 Aug2016). 5. Setting Priorities for the B.C. Health System. 2014http://www.health.gov.bc.ca/library/publications/year/2014/Setting-priorities-BC-Health-Feb14.pdf 6. Barry MJ, Edgman-Levitan S. Shared Decision Making — The Pinnacle of Patient-Centered Care. N Engl J Med 2012;366:780–781. 7. Charles C, Gafni A, Whelan T. Shared decision-making in the medical encounter: what does it mean?(or it takes at least two to tango). Soc Sci Med 1997;44:681–692. 212 8. Légaré F, Witteman HO. Shared Decision Making: Examining Key Elements And Barriers To Adoption Into Routine Clinical Practice. Health Aff (Millwood) 2013;32:276–284. 9. Mulley AG, Trimble C, Elwyn G. Stop the silent misdiagnosis: patients’ preferences matter. Bmj 2012;345. 10. Charles C, Gafni A, Whelan T. Decision-making in the physician-patient encounter: revisiting the shared treatment decision-making model. Soc Sci Med 1999;49:651–661. 11. Wennberg JE, Bunker JP, Barnes B. The need for assessing the outcome of common medical practices. Annu Rev Public Health 1980;1:277–295. 12. Kasper JF, Mulley Jr AG, Wennberg JE. Developing Shared Decision-Making Programs to Improve the Quality of Health Care. QRB - Qual Rev Bull 1992;18:183–190. 13. Wennberg JE. Time to tackle unwarranted variations in practice. BMJ 2011;342:d1513. 14. Wennberg JE. Improving the medical decision-making process. Health Aff (Millwood) 1988;7:99–106. 15. Volandes AE, Paasche-Orlow MK, Barry MJ, Gillick MR, Minaker KL, Chang Y et al. Video decision support tool for advance care planning in dementia: randomised controlled trial. BMJ 2009;338:b2159. 213 16. Lee CN, Hultman CS, Sepucha K. Do Patients and Providers Agree About the Most Important Facts and Goals for Breast Reconstruction Decisions?: Ann Plast Surg 2010;:1. 17. Wilson SR, Strub P, Buist AS, Knowles SB, Lavori PW, Lapidus J et al. Shared Treatment Decision Making Improves Adherence and Outcomes in Poorly Controlled Asthma. Am J Respir Crit Care Med 2010;181:566–577. 18. Li J, Berkowitz Z, Richards TB, Richardson LC. Shared Decision Making in Prostate-Specific Antigen Testing With Men Older Than 70 Years. J Am Board Fam Med 2013;26:401–408. 19. Rosenberg SM, Sepucha K, Ruddy KJ, Tamimi RM, Gelber S, Meyer ME et al. Local Therapy Decision-Making and Contralateral Prophylactic Mastectomy in Young Women with Early-Stage Breast Cancer. Ann Surg Oncol 2015;22:3809–3815. 20. Duncan E, Best C, Hagen S. Shared decision making interventions for people with mental health conditions. In: Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd 2010. 21. Coxeter P, Del Mar CB, McGregor L, Beller EM, Hoffmann TC. Interventions to facilitate shared decision making to address antibiotic use for acute respiratory infections in primary care. In: Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd 2015. 22. Tapp H, Kuhn L, Alkhazraji T, Steuerwald M, Ludden T, Wilson S et al. Adapting community based participatory research (CBPR) methods to the implementation of 214 an asthma shared decision making intervention in ambulatory practices. J Asthma 2014;51:380–390. 23. Sobel RM, Paasche-Orlow MK, Waite KR, Rittner SS, Wilson EAH, Wolf MS. Asthma 1-2-3: A Low Literacy Multimedia Tool to Educate African American Adults About Asthma. J Community Health 2009;34:321–327. 24. Nannenga MR, Montori VM, Weymiller AJ, Smith SA, Christianson TJ, Bryant SC et al. A treatment decision aid may increase patient trust in the diabetes specialist. The Statin Choice randomized trial. Health Expect 2009;12:38–44. 25. Joosten E, DeFuentes-Merillas L, De Weert G, Sensky T, Van der Staak C, de Jong CAJ. Systematic review of the effects of shared decision-making on patient satisfaction, treatment adherence and health status. Psychother Psychosom 2008;77:219–226. 26. Stacey D, Légaré F, Lewis K, Barry MJ, Bennett CL, Eden KB et al. Decision aids for people facing health treatment or screening decisions. In: Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd 2017. 27. Légaré F, Ratté S, Gravel K, Graham ID. Barriers and facilitators to implementing shared decision-making in clinical practice: Update of a systematic review of health professionals’ perceptions. Patient Educ Couns 2008;73:526–535. 28. Fransen G a. J, Mesters I, Janssen MJR, Knottnerus JA, Muris JWM. Which patient-related factors determine self-perceived patient adherence to prescribed dyspepsia medication? Health Educ Res 2009;24:788–798. 215 29. Myriam Gagné Be, Légaré F, FCMF MPC, Moisan J, Boulet L-P. Development and Assessment of Shared Decision Making Aids in Asthma. https://pdfs.semanticscholar.org/0f21/dadb0ebaaa6899f8b492f30a639b57ded416.pdf (accessed 22 Feb2017). 30. Gagné ME, Légaré F, Moisan J, Boulet L-P. Impact of Adding a Decision Aid to Patient Education in Adults with Asthma: A Randomized Clinical Trial. PLOS ONE 2017;12:e0170055. 31. Kew KM, Malik P. Shared decision-making for people with asthma. In: Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd 2016. 32. Mowrer JL, Tapp H, Ludden T, Kuhn L, Taylor Y, Courtlandt C et al. Patients’ and providers’ perceptions of asthma and asthma care: a qualitative study. J Asthma 2015;52:949–956. 33. George M, Abboud S, Pantalon MV, Sommers M (Lynn) S, Mao J, Rand C. Changes in clinical conversations when providers are informed of asthma patients’ beliefs about medication use and integrative medical therapies. Heart Lung J Acute Crit Care 2016;45:70–78. 34. Cormiers AD, Légaré F, Simard S, Boulet L-P. Decisional conflict in asthma patients: a cross sectional study. J Asthma 2015;0:1–8. 35. Deber RB, Kraetschmer N, Urowitz S, Sharpe N. Do people want to be autonomous patients? Preferred roles in treatment decision-making in several patient populations. Health Expect 2007;10:248–258. 216 36. Harter M, Weijden GDEM van der, Elwyn G. Policy and practice developments in the implementation of shared decision making: an international perspective. 233 Published Online First: 2011.http://repository.ubn.ru.nl/handle/2066/98219 (accessed 11 Dec2016). 37. Beaver K, Craven O, Witham G, Tomlinson M, Susnerwala S, Jones D et al. Patient participation in decision making: views of health professionals caring for people with colorectal cancer. J Clin Nurs 2007;16:725–733. 38. Rotar-Pavlič D, Švab I, Wetzels R. How do older patients and their GPs evaluate shared decision-making in healthcare? BMC Geriatr 2008;8:9. 39. Elwyn G, Edwards A, Kinnersley P, Grol R. Shared decision making and the concept of equipoise: the competences of involving patients in healthcare choices. Br J Gen Pract 2000;50:892. 40. Freedman B. Equipoise and the ethics of clinical research. N Engl J Med 1987;317:141–145. 41. Elwyn G, Edwards A, Hood K, Robling M, Atwell C, Russell I et al. Achieving involvement: process outcomes from a cluster randomized trial of shared decision making skill development and use of risk communication aids in general practice. Fam Pract 2004;21:337–346. 42. Levinson W, Lesser CS, Epstein RM. Developing Physician Communication Skills For Patient-Centered Care. Health Aff (Millwood) 2010;29:1310–1318. 217 43. Frosch DL, Moulton BW, Wexler RM, Holmes-Rovner M, Volk RJ, Levin CA. Shared decision making in the United States: policy and implementation activity on multiple fronts. Z Für Evidenz Fortbild Qual Im Gesundheitswesen 2011;105:305–312. 44. Briss P, Rimer B, Reilley B, Coates RC, Lee NC, Mullen P et al. Promoting informed decisions about cancer screening in communities and healthcare systems. Am J Prev Med 2004;26:67–80. 45. Baars JE, Markus T, Kuipers EJ, van der Woude CJ. Patients’ preferences regarding shared decision-making in the treatment of inflammatory bowel disease: results from a patient-empowerment study. Digestion 2010;81:113–119. 46. Glass KE, Wills CE, Holloman C, Olson J, Hechmer C, Miller CK et al. Shared decision making and other variables as correlates of satisfaction with health care decisions in a United States national survey. Patient Educ Couns 2012. 47. Loh A, Simon D, Wills CE, Kriston L, Niebling W, Härter M. The effects of a shared decision-making intervention in primary care of depression: a cluster-randomized controlled trial. Patient Educ Couns 2007;67:324–332. 48. Rathert C, Wyrwich MD, Boren SA. Patient-Centered Care and Outcomes A Systematic Review of the Literature. Med Care Res Rev 2013;70:351–379. 49. Légaré F, Stacey D, Graham ID, Elwyn G, Pluye P, Gagnon M-P et al. Advancing theories, models and measurement for an interprofessional approach to shared decision making in primary care: a study protocol. BMC Health Serv Res 2008;8:2. 218 50. Banerjee M, Capozzoli M, McSweeney L, Sinha D. Beyond kappa: A review of interrater agreement measures. Can J Stat 1999;27:3–23. 51. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol 2006;3:77–101. 52. Boyatzis RE. Transforming Qualitative Information: Thematic Analysis and Code Development. SAGE 1998 53. Olson RA, Bobinski MA, Ho A, Goddard KJ. Oncologists’ view of informed consent and shared decision making in paediatric radiation oncology. Radiother Oncol 2011. 54. Hamann J, Mendel R, Cohen R, Heres S, Ziegler M, Bühner M et al. Psychiatrists’ use of shared decision making in the treatment of schizophrenia: patient characteristics and decision topics. Psychiatr Serv 2009;60:1107–1112. 55. Caldwell JG. Evaluating attitudes of first-year residents to shared decision making. Med Educ Online 2008;13:10. 56. Murray E, Pollack L, White M, Lo B. Clinical decision-making: physicians’ preferences and experiences. BMC Fam Pract 2007;8:1–10. 57. Butow P, Harrison JD, Choy ET, Young JM, Spillane A, Evans A. Health professional and consumer views on involving breast cancer patients in the multidisciplinary discussion of their disease and treatment plan. Cancer 2007;110:1937–1944. 219 58. Carlsen B, Aakvik A, Norheim OF. Variation in practice: a questionnaire survey of how congruence in attitudes between doctors and patients influences referral decisions. Med Decis Mak Int J Soc Med Decis Mak 2008;28:262–268. 59. Chan C, Ahmad W. Differences in physician attitudes towards patient!centredness: across four medical specialties. Int J Clin Pract 2012;66:16–20. 60. Chan CMH, Azman WA. Attitudes and role orientations on doctor-patient fit and patient satisfaction in cancer care. Singapore Med J 2012;53:52–56. 61. Pieterse A, Baas-Thijssen M, Marijnen C, Stiggelbout A. Clinician and cancer patient views on patient participation in treatment decision-making: a quantitative and qualitative exploration. Br J Cancer 2008;99:875–882. 62. Shepherd H, Tattersall M, Butow P. The context influences doctors’ support of shared decision-making in cancer care. Br J Cancer 2007;97:6–13. 63. Davis K, Haisfield L, Dorfman C, Krist A, Taylor KL. Physicians’ Attitudes About Shared Decision Making for Prostate Cancer Screening. Fam Med 2011;43:260–266. 64. Charles C, Gafni A, Whelan T. Self!reported use of shared decision!making among breast cancer specialists and perceived barriers and facilitators to implementing this approach. Health Expect 2004;7:338–348. 65. Arnetz JE, Winblad U, Arnetz BB, Höglund AT. Physicians’ and nurses’ perceptions of patient involvement in myocardial infarction care. Eur J Cardiovasc Nurs 2008;7:113–120. 220 66. Boivin A, Legare F, Gagnon MP. Competing norms: Canadian rural family physicians’ perceptions of clinical practice guidelines and shared decision-making. J Health Serv Res Policy 2008;13:79–84. 67. Cohen Castel O, Ungar L, Alperin M, Amiel GE, Karkabi K. Family physicians’ perceptions, beliefs, and attitudes regarding information sharing with prostate cancer patients throughout the course of the disease. Support Care Cancer 2008;16:955–961. 68. van Til JA, Drossaert CHC, Punter RA, Ijzerman MJ. The potential for shared decision-making and decision aids in rehabilitation medicine. J Rehabil Med 2010;42:598–604. 69. Cohen Castel O, Alperin M, Ungar L, Kravtsov I, Amiel GE, Karkabi K. Urologists’ Attitudes Regarding Information Sharing with Prostate Cancer Patients—Is There a Common Ground for Collaboration with Family Physicians? J Cancer Educ 2011;26:315–321. 70. Légaré F, St-Jacques S, Gagnon S, Njoya M, Brisson M, Frémont P et al. Prenatal screening for Down syndrome: a survey of willingness in women and family physicians to engage in shared decision-making. Prenat Diagn 2011;31:319–326. 71. van der Horst K, Giger M, Siegrist M. Attitudes toward shared decision-making and risk communication practices in residents and their teachers. Med Teach 2011;33:e358-63. 221 72. King VJ, Davis MM, Gorman PN, Rugge JB, Fagnan LJ. Perceptions of Shared Decision Making and Decision Aids Among Rural Primary Care Clinicians. Med Decis Making 2012;32:636–644. 73. las Cuevas C, Rivero!Santana A, Perestelo!Perez L, Perez!Ramos J, Gonzalez!Lorenzo M, Serrano!Aguilar P et al. Mental health professionals’ attitudes to partnership in medicine taking: a validation study of the Leeds Attitude to Concordance Scale II. Pharmacoepidemiol Drug Saf 2012. 74. Holland CL, Bowker LK, Myint PK. Barriers to involving older people in their resuscitation decisions: the primary–secondary care mismatch highlights the potential role of general practitioners. Int J Clin Pract 2013;67:379–384. 75. Flierler WJ, Nübling M, Kasper J, Heidegger T. Implementation of shared decision making in anaesthesia and its influence on patient satisfaction. Anaesthesia 2013;68:713–722. 76. Hillyer GC, Hershman DL, Kushi LH, Lamerato L, Ambrosone CB, Bovbjerg DH et al. A survey of breast cancer physicians regarding patient involvement in breast cancer treatment decisions. The Breast 2013;22:548–554. 77. Abiola T, Udofia O, Abdullahi AT. Patientdoctor relationship: The practice orientation of doctors in Kano. Niger J Clin Pract 2014;17:241–247. 78. Döring A-CD, Hageman MGJS, Mulder FJ, Guitton TG, Ring D, Adams J et al. Trigger Finger: Assessment of Surgeon and Patient Preferences and Priorities for Decision Making. J Hand Surg 2014;39:2208–2213.e2. 222 79. Garcia-Retamero R, Wicki B, Cokely ET, Hanson B. Factors predicting surgeons’ preferred and actual roles in interactions with their patients. Health Psychol 2014;33:920–928. 80. Hageman MGJS, Kinaci A, Ju K, Guitton TG, Mudgal CS, Ring D et al. Carpal Tunnel Syndrome: Assessment of Surgeon and Patient Preferences and Priorities for Decision-Making. J Hand Surg 2014;39:1799–1804.e1. 81. Ishikawa H, Eto M, Kitamura K, Kiuchi T. Resident physicians’ attitudes and confidence in communicating with patients: A pilot study at a Japanese university hospital. Patient Educ Couns 2014;96:361–366. 82. Nguyen F, Moumjid N, Charles C, Gafni A, Whelan T, Carrère M-O. Treatment decision-making in the medical encounter: Comparing the attitudes of French surgeons and their patients in breast cancer care. Patient Educ Couns 2014;94:230–237. 83. Jaakkola E. Physicians’ views on the influence of patient participation on treatment decisions - an explorative study. Health Serv Manag Res Off J Assoc Univ Programs Health Adm HSMC AUPHA 2007;20:174–182. 84. Thistlethwaite J, Heal C, Nan Tie R, Evans R. Shared decision making between registrars and patients: web based decision aids. Aust Fam Physician 2007;36:670–672. 85. Watson DB, Thomson R, Murtagh M. Professional centred shared decision making: patient decision aids in practice in primary care. BMC Health Serv Res 2008;8:5. 223 86. Matlock DD, Nowels CT, Masoudi FA, Sauer WH, Bekelman DB, Main DS et al. Patient and Cardiologist Perceptions on Decision Making for Implantable Cardioverter!Defibrillators: A Qualitative Study. Pacing Clin Electrophysiol 2011. 87. Fiks AG, Hughes CC, Gafen A, Guevara JP, Barg FK. Contrasting parents’ and pediatricians’ perspectives on shared decision-making in ADHD. Pediatrics 2011;127:e188–e196. 88. Muller-Engelmann M, Keller H, Donner-Banzhoff N, Krones T. Shared decision making in medicine: the influence of situational treatment factors. Patient Educ Couns 2011;82:240–246. 89. Shepherd HL, Butow PN, Tattersall MHN. Factors which motivate cancer doctors to involve their patients in reaching treatment decisions. Patient Educ Couns 2011;84:229–235. 90. Luijks HD, Loeffen MJ, Lagro-Janssen AL, Weel C van, Lucassen PL, Schermer TR. GPs’ considerations in multimorbidity management: a qualitative study. Br J Gen Pract 2012;62:e503–e510. 91. Gachoud D, Albert M, Kuper A, Stroud L, Reeves S. Meanings and perceptions of patient-centeredness in social work, nursing and medicine: A comparative study. J Interprof Care 2012;26:484–490. 92. Kahveci R, Ayhan D, Döner P, Cihan FG, Koç EM. Shared Decision-Making in Pediatric Intensive Care Units: A Qualitative Study with Physicians, Nurses and Parents. Indian J Pediatr 2014;81:1287–1292. 224 93. Zeuner R, Frosch DL, Kuzemchak MD, Politi MC. Physicians’ perceptions of shared decision-making behaviours: a qualitative study demonstrating the continued chasm between aspirations and clinical practice. Health Expect 2014;:n/a-n/a. 94. Shepherd A, Shorthouse O, Gask L. Consultant psychiatrists’ experiences of and attitudes towards shared decision making in antipsychotic prescribing, a qualitative study. BMC Psychiatry 2014;14:127. 95. Sanders T, Harrison S, Checkland K. Evidence-based medicine and patient choice: the case of heart failure care. J Health Serv Res Policy 2008;13:103–108. 96. Politi MC, Lewis CL, Frosch DL. Supporting Shared Decisions When Clinical Evidence Is Low. Med Care Res Rev 2013;70:113S–128S. 97. Sheridan NF, Kenealy TW, Kidd JD, Schmidt-Busby JIG, Hand JE, Raphael DL et al. Patients’ engagement in primary care: powerlessness and compounding jeopardy. A qualitative study. Health Expect 2012;:n/a-n/a. 98. Joseph-Williams N, Elwyn G, Edwards A. Knowledge is not power for patients: A systematic review and thematic synthesis of patient-reported barriers and facilitators to shared decision making. Patient Educ Couns 2014;94:291–309. 99. Légaré F, Stacey D, Turcotte S, Cossi M-J, Kryworuchko J, Graham ID et al. Interventions for improving the adoption of shared decision making by healthcare professionals. In: Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd 225 2014http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006732.pub3/abstract (accessed 25 Nov2015). 100. Towle A, Godolphin W. Framework for teaching and learning informed shared decision making. BMJ 1999;319:766–771. 101. Braman SS. THe global burden of asthma*. CHEST J 2006;130:4S–12S. 102. Williams LK, Pladevall M, Xi H, Peterson EL, Joseph C, Lafata JE et al. Relationship between adherence to inhaled corticosteroids and poor outcomes among adults with asthma. J Allergy Clin Immunol 2004;114:1288–1293. 103. GINA Report, Global Strategy for Asthma Management and Prevention | Documents / Resources | GINA. http://www.ginasthma.org/documents/4 (accessed 10 Feb2014). 104. Sabate E. Adherence to long-term therapies: evidence for action. 2003. 105. Sadatsafavi M, Lynd L, Marra C, Carleton B, Tan WC, Sullivan S et al. Direct health care costs associated with asthma in British Columbia. Can Respir J J Can Thorac Soc 2010;17:74–80. 106. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005;353:487–497. 107. Murray E, Charles C, Gafni A. Shared decision-making in primary care: Tailoring the Charles et al. model to fit the context of general practice. Patient Educ Couns 2006;62:205–211. 226 108. Global Strategy for Asthma Management and Prevention, 2016. Global Initiative for Asthmawww.ginasthma.org 109. Government of Canada SC. Asthma, by sex, provinces and territories (Number of persons). 2013.http://www.statcan.gc.ca/tables-tableaux/sum-som/l01/cst01/health50a-eng.htm (accessed 10 Feb2014). 110. FastStats. http://www.cdc.gov/nchs/fastats/asthma.htm (accessed 11 Jun2015). 111. Accordini S, Bugiani M, Arossa W, Gerzeli S, Marinoni A, Olivieri M et al. Poor Control Increases the Economic Cost of Asthma. Int Arch Allergy Immunol 2006;141:189–198. 112. Horne R. Compliance, adherence, and concordance*: Implications for asthma treatment. CHEST J 2006;130:65S–72S. 113. Boulet L-P, Vervloet D, Magar Y, Foster JM. Adherence: The Goal to Control Asthma. Clin Chest Med 2012;33:405–417. 114. Vrijens B, De Geest S, Hughes DA, Przemyslaw K, Demonceau J, Ruppar T et al. A new taxonomy for describing and defining adherence to medications. Br J Clin Pharmacol 2012;73:691–705. 115. Diette GB, Wu AW, Skinner EA, et al. Treatment patterns among adult patients with asthma: Factors associated with overuse of inhaled β-agonists and underuse of inhaled corticosteroids. Arch Intern Med 1999;159:2697–2704. 227 116. Hee Hong S, Sanders BH, West D. Inappropriate use of inhaled short acting beta-agonists and its association with patient health status. Curr Med Res Opin 2005;22:33–40. 117. Sadatsafavi M, Lynd LD, De Vera MA, Zafari Z, FitzGerald JM. One-year outcomes of inhaled controller therapies added to systemic corticosteroids after asthma-related hospital discharge. Respir Med 2015;109:320–328. 118. Apter AJ, Boston RC, George M, Norfleet AL, Tenhave T, Coyne JC et al. Modifiable barriers to adherence to inhaled steroids among adults with asthma: It’s not just black and white. J Allergy Clin Immunol 2003;111:1219–1226. 119. Gamble J, Stevenson M, McClean E, Heaney LG. The Prevalence of Nonadherence in Difficult Asthma. Am J Respir Crit Care Med 2009;180:817–822. 120. Jobin M-S, Moisan J, Bolduc Y, Dorval E, Boulet L-P, Gregoire J-P. Factors associated with the appropriate use of asthma drugs. Can Respir J J Can Thorac Soc 2011;18:97–104. 121. Sadatsafavi M, Lynd L, Marra C, Bedouch P, FitzGerald M. Comparative outcomes of leukotriene receptor antagonists and long-acting β-agonists as add-on therapy in asthmatic patients: A population-based study. J Allergy Clin Immunol 2013;132:63–69. 122. Apter AJ, Wang X, Bogen DK, Rand CS, McElligott S, Polsky D et al. Problem solving to improve adherence and asthma outcomes in urban adults with moderate or 228 severe asthma: A randomized controlled trial. J Allergy Clin Immunol 2011;128:516–523.e5. 123. Gillissen A. Patient adherence in asthma. J Physiol Pharmacol 2007;58:205. 124. Williams LK, Peterson EL, Wells K, Ahmedani BK, Kumar R, Burchard EG et al. Quantifying the proportion of severe asthma exacerbations attributable to inhaled corticosteroid nonadherence. J Allergy Clin Immunol 2011;128:1185–1191.e2. 125. Murphy AC, Proeschal A, Brightling CE, Wardlaw AJ, Pavord I, Bradding P et al. The relationship between clinical outcomes and medication adherence in difficult-to-control asthma. Thorax 2012;67:751–753. 126. Schaffer SD, Tian L. Promoting Adherence Effects of Theory-Based Asthma Education. Clin Nurs Res 2004;13:69–89. 127. Levy ML, Robb M, Allen J, Doherty C, Bland JM, Winter RJD. A randomized controlled evaluation of specialist nurse education following accident and emergency department attendance for acute asthma. Respir Med 2000;94:900–908. 128. Morice AH, Wrench C. The role of the asthma nurse in treatment compliance and self-management following hospital admission. Respir Med 2001;95:851–856. 129. Côté J, Bowie DM, Robichaud P, Parent J-G, Battisti L, Boulet L-P. Evaluation of Two Different Educational Interventions for Adult Patients Consulting with an Acute Asthma Exacerbation. Am J Respir Crit Care Med 2001;163:1415–1419. 229 130. Janson SL, McGrath KW, Covington JK, Cheng S-C, Boushey HA. Individualized asthma self-management improves medication adherence and markers of asthma control. J Allergy Clin Immunol 2009;123:840–846. 131. Patel MR, Valerio MA, Sanders G, Thomas LJ, Clark NM. ASthma action plans and patient satisfaction among women with asthma. Chest 2012;142:1143–1149. 132. Tran N, Coffman JM, Sumino K, Cabana MD. Patient reminder systems and asthma medication adherence: a systematic review. J Asthma 2014;51:536–543. 133. Foster JM, Usherwood T, Smith L, Sawyer SM, Xuan W, Rand CS et al. Inhaler reminders improve adherence with controller treatment in primary care patients with asthma. J Allergy Clin Immunol 2014; 134: 1260-1268. 134. Strandbygaard U, Thomsen SF, Backer V. A daily SMS reminder increases adherence to asthma treatment: A three-month follow-up study. Respir Med 2010;104:166–171. 135. O’Connor AM, Llewellyn-Thomas HA, Flood AB. Modifying Unwarranted Variations In Health Care: Shared Decision Making Using Patient Decision Aids. Health Aff Chevy Chase 2004;:VAR63-72. 136. O’Connor AM, Stacey D, Barry MJ, Col NF, Eden KB, Entwistle V et al. Do patient decision aids meet effectiveness criteria of the international patient decision aid standards collaboration? A systematic review and meta-analysis. Med Decis Making 2007;27:554–574. 230 137. O’Connor AM, Rostom A, Fiset V, Tetroe J, Entwistle V, Llewellyn-Thomas H et al. Decision aids for patients facing health treatment or screening decisions: systematic review. BMJ 1999;319:731–734. 138. O’Brien MA, Whelan TJ, Villasis-Keever M, Gafni A, Charles C, Roberts R et al. Are Cancer-Related Decision Aids Effective? A Systematic Review and Meta-Analysis. J Clin Oncol 2009;27:974–985. 139. Knops AM, Legemate DA, Goossens A, Bossuyt PMM, Ubbink DT. Decision Aids for Patients Facing a Surgical Treatment Decision: A Systematic Review and Meta-analysis. Ann Surg 2013;257:860–866. 140. Menckeberg TT, Bouvy ML, Bracke M, Kaptein AA, Leufkens HG, Raaijmakers JAM et al. Beliefs about medicines predict refill adherence to inhaled corticosteroids. J Psychosom Res 2008;64:47–54. 141. de Vries H, Mudde A, Leijs I, Charlton A, Vartiainen E, Buijs G et al. The European Smoking prevention Framework Approach (EFSA): an example of integral prevention. Health Educ Res 2003;18:611–626. 142. Ajzen I, Fishbein M. Attitude-behavior relations: A theoretical analysis and review of empirical research. Psychol Bull 1977;84:888–918. 143. Emilsson M, Berndtsson I, Lötvall J, Millqvist E, Lundgren J, Johansson A et al. The influence of personality traits and beliefs about medicines on adherence to asthma treatment. Prim Care Respir J 2011;20:141–147. 231 144. Bender BG, Pedan A, Varasteh LT. Adherence and persistence with fluticasone propionate/salmeterol combination therapy. J Allergy Clin Immunol 2006;118:899–904. 145. Williams LK, Joseph CL, Peterson EL, Wells K, Wang M, Chowdhry VK et al. Patients with asthma who do not fill their inhaled corticosteroids: A study of primary nonadherence. J Allergy Clin Immunol 2007;120:1153–1159. 146. Bender BG. Overcoming barriers to nonadherence in asthma treatment. J Allergy Clin Immunol 2002;109:S554–S559. 147. George M, Freedman TG, Norfleet AL, Feldman HI, Apter AJ. Qualitative research-enhanced understanding of patients’ beliefs: Results of focus groups with low-income, urban, African American adults with asthma. J Allergy Clin Immunol 2003;111:967–973. 148. O’Conor R, Wolf MS, Smith SG, Martynenko M, Vicencio DP, Sano M et al. HEalth literacy, cognitive function, proper use, and adherence to inhaled asthma controller medications among older adults with asthma. Chest 2015;147:1307–1315. 149. Lynd LD, Sandford AJ, Kelly EM, Paré PD, Bai TR, FitzGerald JM et al. Reconcilable differences*: A cross-sectional study of the relationship between socioeconomic status and the magnitude of short-acting β-agonist use in asthma. Chest 2004;126:1161–1168. 232 150. Blanc PD, Yen IH, Chen H, Katz PP, Earnest G, Balmes JR et al. Area-level socio-economic status and health status among adults with asthma and rhinitis. Eur Respir J 2006;27:85–94. 151. Apter AJ, Wan F, Reisine S, Bender B, Rand C, Bogen DK et al. The association of health literacy with adherence and outcomes in moderate-severe asthma. J Allergy Clin Immunol 2013;132:321–327. 152. Cooper V, Metcalf L, Versnel J, Upton J, Walker S, Horne R. Patient-reported side effects, concerns and adherence to corticosteroid treatment for asthma, and comparison with physician estimates of side-effect prevalence: a UK-wide, cross-sectional study. NPJ Prim Care Respir Med 2015;25:15026. 153. Driesenaar JA, Smet PAGMD, Hulten R van, Horne R, Zwikker H, Bemt B van den et al. Beliefs about inhaled corticosteroids: Comparison of community pharmacists, pharmacy technicians and patients with asthma. J Asthma 2016;0:1–8. 154. Weinstein AG. Asthma Adherence Management for the Clinician. J Allergy Clin Immunol Pract 2013;1:123–128. 155. DiMatteo M, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: Meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med 2000;160:2101–2107. 156. Quaschning K, Körner M, Wirtz M. Analyzing the effects of shared decision-making, empathy and team interaction on patient satisfaction and treatment 233 acceptance in medical rehabilitation using a structural equation modeling approach. Patient Educ Couns 2013;91:167–175. 157. Lazarus SC, Chinchilli VM, Rollings NJ, Boushey HA, Cherniack R, Craig TJ et al. Smoking Affects Response to Inhaled Corticosteroids or Leukotriene Receptor Antagonists in Asthma. Am J Respir Crit Care Med 2007;175:783–790. 158. Byles JE. How do the psychosocial consequences of ageing affect asthma management. Med J Aust 2005;183:S30–2. 159. Mora PA, Halm E, Leventhal H, Ceric F. Elucidating the relationship between negative affectivity and symptoms: The role of illness-specific affective responses. Ann Behav Med 2007;34:77–86. 160. LeBlanc A, Kenny DA, O’Connor AM, Légaré F. Decisional Conflict in Patients and Their Physicians: A Dyadic Approach to Shared Decision Making. Med Decis Making 2009;29:61–68. 161. Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ Can Med Assoc J 1995;152:1423. 162. Street Jr. RL, Makoul G, Arora NK, Epstein RM. How does communication heal? Pathways linking clinician–patient communication to health outcomes. Patient Educ Couns 2009;74:295–301. 163. Ommen O, Thuem S, Pfaff H, Janssen C. The relationship between social support, shared decision-making and patient’s trust in doctors: a cross-sectional survey of 234 2,197 inpatients using the Cologne Patient Questionnaire. Int J Public Health 2010;56:319–327. 164. Bauer AM, Parker MM, Schillinger D, Katon W, Adler N, Adams AS et al. Associations between antidepressant adherence and shared decision-making, patient-provider trust, and communication among adults with diabetes: diabetes study of Northern California (DISTANCE). J Gen Intern Med 2014;29:1139–1147. 165. Silver HS, Blanchette CM, Kamble S, Petersen H, Letter MA, Meddis D et al. Relationship between short-acting β2-adrenergic agonist use and healthcare costs. Am J Manag Care 2011;17:19–27. 166. Stanford RH, Shah MB, D’Souza AO, Dhamane AD, Schatz M. Short-acting β-agonist use and its ability to predict future asthma-related outcomes. Ann Allergy Asthma Immunol 2012;109:403–407. 167. Paris J, Peterson EL, Wells K, Pladevall M, Burchard EG, Choudhry S et al. Relationship between recent short-acting β-agonist use and subsequent asthma exacerbations. Ann Allergy Asthma Immunol 2008;101:482–487. 168. Gravel K, Graham ID. Barriers and facilitators to implementing shared decision-making in clinical practice: update of a systematic review of health professionals’ perceptions. Patient Educ Couns 2008;73:526–535. 169. Lloyd A, Joseph-Williams N, Edwards A, Rix A, Elwyn G. Patchy ‘coherence’: using normalization process theory to evaluate a multi-faceted shared decision making implementation program (MAGIC). Implement Sci 2013;8:102. 235 170. Tapp H, Hebert L, Dulin M. Comparative effectiveness of asthma interventions within a practice based research network. BMC Health Serv Res 2011;11:188. 171. Advancing Quality Alliance. Your health, your decision: evaluation and output report of the AQuA workstream within the national shared decision making programme. 2013http://arma.uk.net/wp-content/uploads/2013/05/Your-Health-Your-Decision-Evaluation-Report.pdf. 172. Ismaila AS, Sayani AP, Marin M, Su Z. Clinical, economic, and humanistic burden of asthma in Canada: a systematic review. BMC Pulm Med 2013;13:1. 173. Bårnes CB, Ulrik CS. Asthma and Adherence to Inhaled Corticosteroids: Current Status and Future Perspectives. Respir Care 2015;60:455–468. 174. Vollmer WM, Markson LE, O’Connor E, Sanocki LL, Fitterman L, Berger M et al. Association of Asthma Control with Health Care Utilization and Quality of Life. Am J Respir Crit Care Med 1999;160:1647–1652. 175. Horne R, Weinman J. Self-Regulation and Self-Management in Asthma: Exploring the Role of Illness Perceptions and Treatment Beliefs in Explaining Non-Adherence to Preventer Medication. Psychol Health 2002;17:17. 176. Krigsman K, Moen J, Nilsson JLG, Ring L. Refill adherence by the elderly for asthma/chronic obstructive pulmonary disease drugs dispensed over a 10-year period. J Clin Pharm Ther 2007;32:603–611. 236 177. Taylor A, Chen L-C, Smith MD. Adherence to inhaled corticosteroids by asthmatic patients: measurement and modelling. J Clin Pharm 2014;36:112–119. 178. Marceau C, Lemière C, Berbiche D, Perreault S, Blais L. Persistence, adherence, and effectiveness of combination therapy among adult patients with asthma. J Allergy Clin Immunol 2006;118:574–581. 179. Ulrik CS, Backer V, Søes-Petersen U, Lange P, Harving H, Plaschke PP. The Patient’s Perspective: Adherence or Non-adherence to Asthma Controller Therapy? J Asthma 2006;43:701–704. 180. Apter AJ, Reisine ST, Affleck G, Barrows E, ZuWALLACK RL. Adherence with Twice-daily Dosing of Inhaled Steroids. Am J Respir Crit Care Med 1998;157:1810–1817. 181. Smet BDD, Erickson SR, Kirking DM. Self-Reported Adherence in Patients with Asthma. Ann Pharmacother 2006;40:414–420. 182. Wells KE, Peterson EL, Ahmedani BK, Williams LK. Real-world effects of once vs greater daily inhaled corticosteroid dosing on medication adherence. Ann Allergy Asthma Immunol Off Publ Am Coll Allergy Asthma Immunol 2013;111:216–220. 183. Axelsson M, Emilsson M, Brink E, Lundgren J, Torén K, Lötvall J. Personality, adherence, asthma control and health-related quality of life in young adult asthmatics. Respir Med 2009;103:1033–1040. 237 184. Blais L, Kettani F-Z, Beauchesne M-F, Lemiere C, Perreault S, Forget A. New measure of adherence adjusted for prescription patterns: the case of adults with asthma treated with inhaled corticosteroid monotherapy. Ann Pharmacother 2011;45:335–341. 185. Jones C, Santanello NC, Boccuzzi SJ, Wogen J, Strub P, Nelsen LM. Adherence to Prescribed Treatment for Asthma: Evidence from Pharmacy Benefits Data. J Asthma 2003;40:93–101. 186. Engelkes M, Janssens HM, de Jongste JC, Sturkenboom MCJM, Verhamme KMC. Prescription patterns, adherence and characteristics of non-adherence in children with asthma in primary care. Pediatr Allergy Immunol 2016;27:201–208. 187. Payne D, Balfour-Lynn I. Children with difficult asthma: a practical approach. J Asthma 2001;38:189–203. 188. Kimes D, Levine E, Timmins S, Weiss SR, Bollinger ME, Blaisdell C. Temporal dynamics of emergency department and hospital admissions of pediatric asthmatics. Environ Res 2004;94:7–17. 189. Silverman RA, Stevenson L, Hastings HM. Age-related seasonal patterns of emergency department visits for acute asthma in an urban environment. Ann Emerg Med 2003;42:577–586. 190. Population Data BC. BC Minist. Health. http://www.popdata.bc.ca/data 238 191. CIHI [creator]. Discharge Abstract Database (Hospital Separations). Population Data BC [publisher]. Data Extract. MOH. 2011. Available at: http://www.popdata.bc.ca/data. (Accessed: 5 March 2017). 192. British Columbia Ministry of Health [creator]. Consolidation File (MSP Registration & Premium Billing). Population Data BC[publisher]. Data Extract. MOH. 2011. Available at: http://www.popdata.bc.ca/data. (Accessed: 5 March 2017). 193. British Columbia Ministry of Health [creator]. PharmaNet. BC Ministry of Health [publisher]. Data Extract. Data Stewardship Committee. 2011. Available at: http://www.popdata.bc.ca/data. (Accessed: 5 March 2017). 194. BC Vital Statistics Agency [creator]. Vital Statistics Deaths. Population Data BC [publisher]. Data Extract. BC Vital Statistics Agency. 2011. Available at: http://www.popdata.bc.ca/data. (Accessed: 5 March 2017). 195. Chen W, Marra CA, Lynd LD, FitzGerald JM, Zafari Z, Sadatsafavi M. The natural history of severe asthma and influences of early risk factors: a population-based cohort study. Thorax 2016;71:267–275. 196. Bedouch P, Marra CA, FitzGerald JM, Lynd LD, Sadatsafavi M. Trends in Asthma-Related Direct Medical Costs from 2002 to 2007 in British Columbia, Canada: A Population Based-Cohort Study. PLoS ONE 2012;7. 197. Nau DP. Proportion of days covered (PDC) as a preferred method of measuring medication adherence. Springf VA Pharm Qual Alliance Published Online First: 2012.http://ep.yimg.com/ty/cdn/epill/pdcmpr.pdf (accessed 4 Dec2016). 239 198. Hess LM, Raebel MA, Conner DA, Malone DC. Measurement of Adherence in Pharmacy Administrative Databases: A Proposal for Standard Definitions and Preferred Measures. Ann Pharmacother 2006;40:1280–1288. 199. Sadatsafavi M, FitzGerald M, Marra C, Lynd L. Costs and Health Outcomes Associated With Primary vs Secondary Care After an Asthma-Related Hospitalization: A Population-Based Study. Chest 2013;144:428–435. 200. Karve S, Cleves MA, Helm M, Hudson TJ, West DS, Martin BC. Prospective Validation of Eight Different Adherence Measures for Use with Administrative Claims Data among Patients with Schizophrenia. Value Health 2009;12:989–995. 201. Romano MJ, Segal JB, Pollack CE. The Association Between Continuity of Care and the Overuse of Medical Procedures. JAMA Intern Med 2015;175:1148–1154. 202. Katz DA, McCoy K, Sarrazin MV. Does Improved Continuity of Primary Care Affect Clinician–Patient Communication in VA? J Gen Intern Med 2014;29:682–688. 203. Needham DM, Scales DC, Laupacis A, Pronovost PJ. A systematic review of the Charlson comorbidity index using Canadian administrative databases: a perspective on risk adjustment in critical care research. J Crit Care 2005;20:12–19. 204. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: Development and validation. J Chronic Dis 1987;40:373–383. 240 205. Firoozi F, Lemière C, Beauchesne M-F, Forget A, Blais L. Development and validation of database indexes of asthma severity and control. Thorax 2007;62:581–587. 206. Jacob C, Haas JS, Bechtel B, Kardos P, Braun S. Assessing asthma severity based on claims data: a systematic review. Eur J Health Econ 2017;18:227–241. 207. Boulet LP, Becker A, Bérubé D, Beveridge R, Ernst P. Canadian asthma consensus report, 1999. CMAJ Can Med Assoc J 1999;161:S1. 208. McKendry R, Reid RJ, McGrail KM, Kerluke KJ. Emergency Rooms in British Columbia: A pilot project to validate current data and describe users. Centre for Health Services and Policy Research 2002 209. Chen W, Lynd LD, FitzGerald JM, Marra CA, Balshaw R, To T et al. Excess medical costs in patients with asthma and the role of comorbidity. Eur Respir J 2016;48:1584–1592. 210. Plackett RL. Some Theorems In Least Squares. Biometrika 1950;37:149–157. 211. O’brien RM. A Caution Regarding Rules of Thumb for Variance Inflation Factors. Qual Quant 2007;41:673–690. 212. Analytics, Business Intelligence and Data Management. http://www.sas.com/en_ca/home.html (accessed 4 Feb2017). 241 213. DuGoff EH, Bandeen-Roche K, Anderson GF. Relationship between continuity of care and adverse outcomes varies by number of chronic conditions among older adults with diabetes. J Comorbidity 2016;6:65–72. 214. Gruneir A, Bronskill SE, Maxwell CJ, Bai YQ, Kone AJ, Thavorn K et al. The association between multimorbidity and hospitalization is modified by individual demographics and physician continuity of care: a retrospective cohort study. BMC Health Serv Res 2016;16:154. 215. SAS annotated output: Proc Logistic. 2017.http://www.ats.ucla.edu/stat/sas/output/sas_logit_output.htm 216. Allison P. Measures of Fit for Logistic Regression. https://support.sas.com/resources/papers/proceedings14/1485-2014.pdf 217. Generalized Coefficient of Determination. SASSTATR 92 Users Guide Second Ed. 2017.https://support.sas.com/documentation/cdl/en/statug/63033/HTML/default/viewer.htm#statug_logistic_sect031.htm 218. Copher R, Buzinec P, Zarotsky V, Kazis L, Iqbal SU, Macarios D. Physician perception of patient adherence compared to patient adherence of osteoporosis medications from pharmacy claims. www.informapharmascience.com/cmo. 2010.http://informahealthcare.com/doi/abs/10.1185/03007990903579171 (accessed 7 Oct2013). 219. Butler MG, Zhou EH, Zhang F, Wu Y, Wu AC, Levenson MS et al. Changing patterns of asthma medication use related to US Food and Drug Administration long-242 acting β2-agonist regulation from 2005-2011. J Allergy Clin Immunol 2016;137:710–717. 220. Health NI of, others. National Heart, Lung, and Blood Institute Expert panel report 3: Guidelines for diagnosis and management of asthma. US Dep Health Hum Serv Retrieved Httpwww Nhlbi Nih Govguidelinesasthmaasthgdln Htm 2007. 221. Lynd LD, Guh DP, Paré PD, Anis AH. Patterns of inhaled asthma medication use*: A 3-year longitudinal analysis of prescription claims data from british columbia, canada. Chest 2002;122:1973–1981. 222. Health M of. Fair PharmaCare Plan - Province of British Columbia. http://www2.gov.bc.ca/gov/content/health/health-drug-coverage/pharmacare-for-bc-residents/who-we-cover/fair-pharmacare-plan (accessed 11 Mar2017). 223. Health M of. About PharmaCare - Province of British Columbia. http://www2.gov.bc.ca/gov/content/health/health-drug-coverage/pharmacare-for-bc-residents/about-pharmacare (accessed 11 Mar2017). 224. Marra CA, Lynd LD, Harvard SS, Grubisic M. Agreement between aggregate and individual-level measures of income and education: a comparison across three patient groups. BMC Health Serv Res 2011;11:69. 225. Levy ML, Hardwell A, McKnight E, Holmes J. Asthma patients’ inability to use a pressurised metered-dose inhaler (pMDI) correctly correlates with poor asthma control as defined by the Global Initiative for Asthma (GINA) strategy: a retrospective analysis. Prim Care Respir J 2013;22:406–411. 243 226. Hamdan A-J, Ahmed A, Abdullah A-H, Khan M, Baharoon S, Salih SB et al. Improper inhaler technique is associated with poor asthma control and frequent emergency department visits. Allergy Asthma Clin Immunol 2013;9:1. 227. Harnett CM, Hunt EB, Bowen BR, O’Connell OJ, Edgeworth DM, Mitchell P et al. A study to assess inhaler technique and its potential impact on asthma control in patients attending an asthma clinic. J Asthma 2014;51:440–445. 228. Orsolini L, Francesconi G, Papanti D, Giorgetti A, Schifano F. Profiling online recreational/prescription drugs’ customers and overview of drug vending virtual marketplaces. Hum Psychopharmacol Clin Exp 2015;30:302–318. 229. Baptist AP, Ross JA, Yang Y, Song PXK, Clark NM. A Randomized Controlled Trial of a Self-Regulation Intervention for Older Adults with Asthma. J Am Geriatr Soc 2013;61:747–753. 230. Bailey WC, Richards JM, Jr, Brooks C, Soong S, Windsor RA et al. A randomized trial to improve self-management practices of adults with asthma. Arch Intern Med 1990;150:1664–1668. 231. Gibson PG, Powell H, Wilson A, Abramson MJ, Haywood P, Bauman A et al. Self-management education and regular practitioner review for adults with asthma. In: Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd 2002http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001117/abstract (accessed 28 Jan2014). 244 232. Chen W, FitzGerald JM, Rousseau R, Lynd LD, Tan WC, Sadatsafavi M. Complementary and alternative asthma treatments and their association with asthma control: a population-based study. BMJ Open 2013;3:e003360. 233. Sadatsafavi M, Chen W, Tavakoli H, Rolf JD, Rousseau R, FitzGerald JM et al. Saving in medical costs by achieving guideline-based asthma symptom control: a population-based study. Allergy 2016;71:371–377. 234. Sadatsafavi M, Rousseau R, Chen W, Zhang W, Lynd L, FitzGerald JM. The Preventable Burden of Productivity Loss Due to Suboptimal Asthma Control: A Population-Based Study. Chest 2014;145:787–793. 235. 12 York Street 2nd Floor, Ottawa OK 5S6, Canada. Anonymous Survey. FluidSurveys. http://fluidsurveys.com/blog/anonymous-survey/ (accessed 10 Sep2015). 236. Sadatsafavi M, Chen W, Tavakoli H, Rolf JD, Rousseau R, FitzGerald JM et al. Saving in medical costs by achieving guideline-based asthma symptom control: a population-based study. Allergy 2016;71:371–377. 237. Halbesleben JRB, Whitman MV. Evaluating Survey Quality in Health Services Research: A Decision Framework for Assessing Nonresponse Bias. Health Serv Res 2013;48:913–930. 238. Davern M. Nonresponse Rates are a Problematic Indicator of Nonresponse Bias in Survey Research. Health Serv Res 2013;48:905–912. 245 239. Government of Canada PHA of C. Fast Facts about Asthma - Data compiled from the 2011 Survey on Living with Chronic Diseases in Canada - Public Health Agency Canada. 2014.http://www.phac-aspc.gc.ca/cd-mc/crd-mrc/asthma_fs_asthme-eng.php (accessed 22 Nov2016). 240. Government of Canada SC. Survey on Living with Chronic Diseases in Canada (SLCDC). 2010.http://www23.statcan.gc.ca/imdb/p2SV.pl?Function=getSurvey&Id=84771 (accessed 22 Nov2016). 241. Cook C, Heath F, Thompson RL. A Meta-Analysis of Response Rates in Web- or Internet-Based Surveys. Educ Psychol Meas 2000;60:821–836. 242. Edwards P, Roberts I, Clarke M, DiGuiseppi C, Pratap S, Wentz R et al. Increasing response rates to postal questionnaires: systematic review. BMJ 2002;324:1183. 243. Sinkowitz-Cochran RL. Survey Design: To Ask or Not to Ask? That is the Question…. Clin Infect Dis 2013;56:1159–1164. 244. Johnson TP. Response Rates and Nonresponse Errors in Surveys. JAMA 2012;307:1805. 245. Sax LJ, Gilmartin SK, Bryant AN. Assessing Response Rates and Nonresponse Bias in Web and Paper Surveys. Res High Educ;44:409–432. 246. Shih T-H, Fan X. Comparing Response Rates from Web and Mail Surveys: A Meta-Analysis. Field Methods 2008;20:249–271. 246 247. Sheehan KB. E-mail Survey Response Rates: A Review. J Comput-Mediat Commun 2001;6:0–0. 248. Ludman E, Katon W, Bush T, Rutter C, Lin E, Simon G et al. Behavioural factors associated with symptom outcomes in a primary care-based depression prevention intervention trial. Psychol Med 2003;33:1061–1070. 249. Korff MV, Katon W, Rutter C, Ludman E, Simon G, Lin E et al. Effect on Disability Outcomes of a Depression Relapse Prevention Program. Psychosom Med 2003;65:938–943. 250. Chewning B, Bylund CL, Shah B, Arora NK, Gueguen JA, Makoul G. Patient preferences for shared decisions: A systematic review. Patient Educ Couns 2012;86:9–18. 251. Weiss MC, Platt J, Riley R, Chewning B, Taylor G, Horrocks S et al. Medication decision making and patient outcomes in GP, nurse and pharmacist prescriber consultations. Prim Health Care Res Dev 2014;:1–15. 252. van Geffen ECG, Hermsen JHCM, Heerdink ER, Egberts ACG, Verbeek-Heida PM, van Hulten R. The decision to continue or discontinue treatment: experiences and beliefs of users of selective serotonin-reuptake inhibitors in the initial months--a qualitative study. Res Soc Adm Pharm 2011;7:134–150. 253. Haskard Zolnierek KB, DiMatteo MR. Physician Communication and Patient Adherence to Treatment: A Meta-analysis. Med Care 2009;47:826–834. 247 254. Kuntz JL, Safford MM, Singh JA, Phansalkar S, Slight SP, Her QL et al. Patient-centered interventions to improve medication management and adherence: a qualitative review of research findings. Patient Educ Couns 2014;97:310–326. 255. LeBlanc A, Wang AT, Wyatt K, Branda ME, Shah ND, Van Houten H et al. Encounter Decision Aid vs. Clinical Decision Support or Usual Care to Support Patient-Centered Treatment Decisions in Osteoporosis: The Osteoporosis Choice Randomized Trial II. PLoS ONE Electron Resour 2015;10. 256. Schoenthaler AM, Schwartz BS, Wood C, Stewart WF. Patient and physician factors associated with adherence to diabetes medications. Diabetes Educ 2012;38:397–408. 257. Aljumah K, Hassali MA. Impact of pharmacist intervention on adherence and measurable patient outcomes among depressed patients: a randomised controlled study. BMC Psychiatry Published Online First: 2015. 258. Matthias MS, Fukui S, Kukla M, Eliacin J, Bonfils KA, Firmin RL et al. Consumer and relationship factors associated with shared decision making in mental health consultations. Psychiatr Serv 2014;65:1488–1491. 259. De Las Cuevas C, Penate W, de Rivera L. To what extent is treatment adherence of psychiatric patients influenced by their participation in shared decision making? Patient Prefer Adherence 2014;:1547–1553. 248 260. Tinsel I, Buchholz A, Vach W, Siegel A, Dürk T, Buchholz A et al. Shared decision-making in antihypertensive therapy: a cluster randomised controlled trial. BMC Fam Pract 2013;14:135. 261. Schatz M, Zeiger RS, Yang S-J, Weinstein AG, Chen W, Saris-Baglama RN et al. Development and Preliminary Validation of the Adult Asthma Adherence QuestionnaireTM. J Allergy Clin Immunol Pract 2013;1:280–288. 262. De Vera MA, Sadatsafavi M, Tsao NW, Lynd LD, Lester R, Gastonguay L et al. Empowering pharmacists in asthma management through interactive SMS (EmPhAsIS): study protocol for a randomized controlled trial. Trials 2014;15:488. 263. Hahn SR, Park J, Skinner EP, Yu-Isenberg KS, Weaver MB, Crawford B et al. Development of the ASK-20 Adherence Barrier Survey*. Curr Med Res Opin 2008;24:2127–2138. 264. McHorney CA, Victor Spain C, Alexander CM, Simmons J. Validity of the adherence estimator in the prediction of 9-month persistence with medications prescribed for chronic diseases: A prospective analysis of data from pharmacy claims. Clin Ther 2009;31:2584–2607. 265. Elwyn G, Barr PJ, Grande SW, Thompson R, Walsh T, Ozanne EM. Developing CollaboRATE: A fast and frugal patient-reported measure of shared decision making in clinical encounters. Patient Educ Couns 2013;93:102–107. 249 266. Barr PJ, Thompson R, Walsh T, Grande SW, Ozanne EM, Elwyn G. The Psychometric Properties of CollaboRATE: A Fast and Frugal Patient-Reported Measure of the Shared Decision-Making Process. J Med Internet Res 2014;16. 267. Scholl I, Koelewijn-van Loon M, Sepucha K, Elwyn G, Legare F, Harter M et al. Measurement of shared decision making - a review of instruments. Z Evidenz Fortbild Qual Im Gesundheitswesen 2011;105:313–324. 268. Deber RB, Kraetschmer N, Irvine J. WHat role do patients wish to play in treatment decision making? Arch Intern Med 1996;156:1414–1420. 269. Kraetschmer N, Sharpe N, Urowitz S, Deber RB. How does trust affect patient preferences for participation in decision-making? Health Expect 2004;7:317–326. 270. Health Literacy: A Prescription to End Confusion. http://www.nap.edu/openbook.php?isbn=0309091179 (accessed 5 Aug2014). 271. Shotkin P, Perry S, Zhao P, Szabo A, Gilbert A. Health Literacy And Asthma Morbidity. Am J Respir Crit Care Med 2013;187. 272. Federman AD, Wolf MS, Sofianou A, Martynenko M, O’Connor R, Halm EA et al. Self-Management Behaviors in Older Adults with Asthma: Associations with Health Literacy. J Am Geriatr Soc 2014;62:872–879. 273. Rosas-Salazar C, Apter AJ, Canino G, Celedón JC. Health literacy and asthma. J Allergy Clin Immunol 2012;129:935–942. 250 274. Paasche-Orlow MK, Riekert KA, Bilderback A, Chanmugam A, Hill P, Rand CS et al. Tailored Education May Reduce Health Literacy Disparities in Asthma Self-Management. Am J Respir Crit Care Med 2005;172:980–986. 275. Adams R et al. Inadequate health literacy is associated with increased asthma morbidity in a population sample. J Allergy Clin Immunol 2009;124:601–603. 276. Chew LD, Griffin JM, Partin MR, Noorbaloochi S, Grill JP, Snyder A et al. Validation of Screening Questions for Limited Health Literacy in a Large VA Outpatient Population. J Gen Intern Med 2008;23:561–566. 277. Chew L, Bradley K, Boyko E. Brief questions to identify patients with inadequate health literacy. Health (N Y) 2004;11. 278. Sayah FA, Majumdar SR, Egede LE, Johnson JA. Measurement properties and comparative performance of health literacy screening questions in a predominantly low income African American population with diabetes. Patient Educ Couns 2014;97:88–95. 279. Fagerlin A, Zikmund-Fisher BJ, Ubel PA, Jankovic A, Derry HA, Smith DM. Measuring Numeracy without a Math Test: Development of the Subjective Numeracy Scale. Med Decis Making 2007;27:672–680. 280. McNaughton CD, Cavanaugh KL, Kripalani S, Rothman RL, Wallston KA. Validation of a Short, 3-Item Version of the Subjective Numeracy Scale. Med Decis Making 2015;:0272989X15581800. 251 281. Asthma Control Test. Asthma Control Test. http://www.asthma.com/tools/act-adult.html (accessed 10 Feb2014). 282. Gelman A. Package ‘mi’: Missing Data Imputation and Model Checking. 2015https://cran.r-project.org/web/packages/mi/mi.pdf 283. Allison PD. Missing data. Sage publications 2001https://books.google.ca/books?hl=en&lr=&id=LJB2AwAAQBAJ&oi=fnd&pg=PP1&dq=missing+data+Paul+Allison&ots=RmxLWMxy9g&sig=p_WBDSFmOR886aV_t7eQ1lYVO7c (accessed 11 Oct2016). 284. Su Y-S, Gelman A, Hill J, Yajima M, others. Multiple imputation with diagnostics (mi) in R: Opening windows into the black box. J Stat Softw 2011;45:1–31. 285. The R Project for Statistical Computing. https://www.r-project.org 286. Jia CE, Zhang HP, Lv Y, Liang R, Jiang YQ, Powell H et al. The Asthma Control Test and Asthma Control Questionnaire for assessing asthma control: Systematic review and meta-analysis. J Allergy Clin Immunol 2013;131:695–703. 287. Tariman JD, Berry DL, Cochrane B, Doorenbos A, Schepp K. Preferred and actual participation roles during health care decision making in persons with cancer: a systematic review. Ann Oncol 2010;21:1145–1151. 288. Sofianou A, Martynenko M, Wolf MS, Wisnivesky JP, Krauskopf K, Wilson EAH et al. Asthma Beliefs Are Associated with Medication Adherence in Older Asthmatics. J Gen Intern Med 2013;28:67–73. 252 289. Van Dole KB, Swern AS, Newcomb K, Nelsen L. Seasonal patterns in health care use and pharmaceutical claims for asthma prescriptions for preschool- and school-aged children. Ann Allergy Asthma Immunol 2009;102:198–204. 290. Boulet L-P. PErception of the role and potential side effects of inhaled corticosteroids among asthmatic patients. CHEST J 1998;113:587–592. 291. Osman LM, Russell IT, Friend JA, Legge JS, Douglas JG. Predicting patient attitudes to asthma medication. Thorax 1993;48:827–830. 292. Wilson SR, Scamagas P, German DF, Hughes GW, Lulla S, Coss S et al. A controlled trial of two forms of self-management education for adults with asthma. Am J Med 1993;94:564–576. 293. De las Cuevas C, Peñate, Perestelo-Pérez L, Serrano-Aguilar. Shared decision making in psychiatric practice and the primary care setting is unique, as measured using a 9-item Shared Decision Making Questionnaire (SDM-Q-9). Neuropsychiatr Dis Treat 2013;:1045. 294. Burns KEA, Duffett M, Kho ME, Meade MO, Adhikari NKJ, Sinuff T et al. A guide for the design and conduct of self-administered surveys of clinicians. Can Med Assoc J 2008;179:245–252. 295. Althubaiti A. Information bias in health research: definition, pitfalls, and adjustment methods. [Review]. J Multidiscip Healthc 2016;:211–217. 296. Coughlin SS. Recall bias in epidemiologic studies. J Clin Epidemiol 1990;43:87–91. 253 297. Boulet L-P, Boulay M-È, Gauthier G, Battisti L, Chabot V, Beauchesne M-F et al. Benefits of an asthma education program provided at primary care sites on asthma outcomes. Respir Med 2015;109:991–1000. 298. Robichaud P, Laberge A, Allen M-F, Boutin H, Rossi C, Lajoie P et al. Evaluation of a Program Aimed at Increasing Referrals for Asthma Education of Patients Consulting at the Emergency Department for Acute Asthma. CHEST 2004;126:1495–1501. 299. Légaré F, Stacey D, Pouliot S, Gauvin F-P, Desroches S, Kryworuchko J et al. Interprofessionalism and shared decision-making in primary care: a stepwise approach towards a new model. J Interprof Care 2011;25:18–25. 300. Stacey D, Murray MA, Légaré F, Sandy D, Menard P, O’Connor A. Decision Coaching to Support Shared Decision Making: A Framework, Evidence, and Implications for Nursing Practice, Education, and Policy. Worldviews Evid Based Nurs 2008;5:25–35. 301. Stacey D, Kryworuchko J, Bennett C, Murray MA, Mullan S, Légaré F. Decision Coaching to Prepare Patients for Making Health Decisions A Systematic Review of Decision Coaching in Trials of Patient Decision Aids. Med Decis Making 2012;32:E22–E33. 302. Kennedy ADM, Sculpher MJ, Coulter A, Dwyer N, Rees M, Abrams KR et al. Effects of decision aids for menorrhagia on treatment choices, health outcomes, and costs: a randomized controlled trial. JAMA 2002;288:2701–2708. 254 303. Karnick P, Margellos-Anast H, Seals G, Whitman S, Aljadeff G, Johnson D. The pediatric asthma intervention: a comprehensive cost-effective approach to asthma management in a disadvantaged inner-city community. J Asthma 2007;44:39–44. 304. Castro M, Zimmermann NA, Crocker S, Bradley J, Leven C, Schechtman KB. Asthma Intervention Program Prevents Readmissions in High Healthcare Users. Am J Respir Crit Care Med 2003;168:1095–1099. 305. +Government of Canada CI of HR. About us - CIHR. 2005.http://www.cihr-irsc.gc.ca/e/29418.html (accessed 15 Dec2016). 306. Straus SE, Tetroe J, Graham I. Defining knowledge translation. Can Med Assoc J 2009;181:165–168. 307. Madon T, Hofman KJ, Kupfer L, Glass RI. Implementation Science. Science 2007;318:1728–1729. 308. May CR, Mair F, Finch T, MacFarlane A, Dowrick C, Treweek S et al. Development of a theory of implementation and integration: Normalization Process Theory. Implement Sci 2009;4:29. 309. May C, Finch T. Implementing, Embedding, and Integrating Practices: An Outline of Normalization Process Theory. Sociology 2009;43:535–554. 310. Myers SS, Phillips RS, Davis RB, Cherkin DC, Legedza A, Kaptchuk TJ et al. Patient Expectations as Predictors of Outcome In Patients with Acute Low Back Pain. J Gen Intern Med 2008;23:148–153. 255 311. Henn RF, Kang L, Tashjian RZ, Green A. Patients’ Preoperative Expectations Predict the Outcome of Rotator Cuff Repair. J Bone Jt Surg Am 2007;89:1913–1919. 312. Kaplan RS, Haas DA, Warsh J. Adding Value by Talking More. N Engl J Med 2016;375:1918–1920. 313. Kiesler DJ, Auerbach SM. Optimal matches of patient preferences for information, decision-making and interpersonal behavior: Evidence, models and interventions. Patient Educ Couns 2006;61:319–341. 314. Hack TF, Degner LF, Watson P, Sinha L. Do patients benefit from participating in medical decision making? Longitudinal follow-up of women with breast cancer. Psychooncology 2006;15:9–19. 315. Durand M-A, Carpenter L, Dolan H, Bravo P, Mann M, Bunn F et al. Do Interventions Designed to Support Shared Decision-Making Reduce Health Inequalities? A Systematic Review and Meta-Analysis. PLOS ONE 2014;9:e94670. 316. Frosch DL, May SG, Rendle KAS, Tietbohl C, Elwyn G. Authoritarian Physicians And Patients’ Fear Of Being Labeled ‘Difficult’ Among Key Obstacles To Shared Decision Making. Health Aff (Millwood) 2012;31:1030–1038. 317. Joseph-Williams N, Edwards A, Elwyn G. Power imbalance prevents shared decision making. BMJ 2014;348:g3178. 318. Koeck C. Imbalance of power between patients and doctors. BMJ 2014;349:g7485. 256 319. Nimmon L, Stenfors-Hayes T. The ‘Handling’ of power in the physician-patient encounter: perceptions from experienced physicians. BMC Med Educ 2016;16:114. 320. Pilnick A, Dingwall R. On the remarkable persistence of asymmetry in doctor/patient interaction: A critical review. Soc Sci Med 2011;72:1374–1382. 321. Geller JS, Kulla J, Shoemaker A. Group Medical Visits Using an Empowerment-based Model as Treatment for Women with Chronic Pain in an Underserved Community. Glob Adv Health Med 2015;4:27–31. 322. Lavoie JG, Wong ST, Chongo M, Browne AJ, MacLeod ML, Ulrich C. Group medical visits can deliver on patient-centred care objectives: results from a qualitative study. BMC Health Serv Res 2013;13:155. 323. Housden L, Wong ST, Browne AJ, Dawes M. Complexities of Introducing Group Medical Visits With Nurse Practitioners in British Columbia. Policy Polit Nurs Pract 2016;17:198–207. 324. Moher D, Liberati A, Tetzlaff J, Altman DG, for the PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 2009;339:b2535–b2535. 325. Schatz M, Sorkness CA, Li JT, Marcus P, Murray JJ, Nathan RA et al. Asthma Control Test: Reliability, validity, and responsiveness in patients not previously followed by asthma specialists. J Allergy Clin Immunol 2006;117:549–556. (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$Tests(for(goodness(of(fit:(Pseudo(R2( =(1A(residual(deviance/null(deviance((=(1A((97.694/(118.056)(=(17.3(Conclusion:(The(multivariate(model(explains(approximately(17.3%(of(variation(in(adherence.(((Pearson’s(X2(( =(sum((Pearson’s(residuals)2(=(84.83572((p(=(.113)(Null(hypothesis(=(the(fitted(model(is(correct.(216)(Conclusion:(Fail(to(reject(the(hypothesis(that(the(fitted(model(is(correct.($($(