Shared decision making and time to exacerbation in children with asthma

ABSTRACT

Objective: Although shared decision making (SDM) is a promising approach for improving outcomes for patients with chronic diseases, no evidence currently supports the use of SDM to delay asthma exacerbations. We evaluated the impact of an SDM intervention implemented by providers in a real-world setting on time to exacerbation in children with asthma. Methods: This study used a prospective cohort observed between 2011 and 2013 at five primary care practices that serve vulnerable populations (e.g., Medicaid and uninsured patients) in Charlotte, NC. Patients aged 2 to 17 receiving SDM were matched to those receiving usual care using propensity scores. Time to asthma exacerbation (asthma hospitalization, emergency department visit or oral steroid prescription in the outpatient setting) was compared between groups using Kaplan–Meier curves and conditional Cox proportional hazards models. Results: The cohort included 746 children, 60.5% male and 54.2% African American, with a mean age of 8.6 years. Of these, 625 received usual care and 121 received SDM. The final analysis included 100 matched pairs of children. Kaplan–Meier curves showed longer exacerbation-free time for patients in the SDM intervention compared to those in usual care (p = 0.005). The difference in risk of experiencing an exacerbation was marginally significant between the two groups (HR = 0.56, 95% C.I. = 0.29–1.08, p = 0.08). Conclusions: SDM was found to delay exacerbations among children with asthma. Clinicians should consider incorporating patient preferences in treatment decisions through SDM as a means for longer exacerbation-free time among children with poor asthma control.

KEYWORDS:

• Emergency department
• hospitalization
• oral steroid
• practice-based research
• propensity score matching
• survival analysis

Declaration of interest

Dr Blanchette reports being employed and receiving consulting fee from Precision Health Economics, receiving consulting fee from Grifols and United Therapeutics, and receiving research fund as principal investigator at Teva Pharmaceuticals and Novartis Pharmaceuticals. Dr Dulin reports receiving consulting fee from Tresata. The authors alone are responsible for the content and writing of the paper.

Funding

All phases of this study were supported by the Agency for Healthcare Research and Quality Grant Number 1R18HS019946-01.