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Explaining differences in asthma medical care and self-management support

Published online: May 9, 2018

Uncontrolled asthma remains prevalent, with high costs for individuals and society. To support patients in achieving and maintaining asthma control, asthma care guidelines recommend that healthcare professionals deliver medical and self-management support. Although several studies suggest that asthma care delivery is suboptimal, research on this topic is still incipient. This study aimed to expand that evidence base through examining both asthma medical care and asthma self-management support provided in primary care; exploring how much (i.e., the amount) of guideline-recommended activities were routinely delivered to patients;  how consistent asthma care was across care providers; and identifying factors that explain differences in the quality of asthma care between countries, clinics, and health care providers.

This study, published by a multi-disciplinary team of authors (de Bruin, Dima, Texier and van Ganse) in the The Journal of Allergy and Clinical Immunology: In Practice, uses data collected as part of a European Commission funded cohort study in France and the United Kingdom. Based on a review of scientific literature and asthma care guidelines, as well as interviews and think-aloud studies with patients and primary care professionals, two surveys were developed. The surveys capture asthma medical care and self-management support, healthcare practice and provider characteristics, and health care professional psychosocial factors expected to predict quality of care delivery. The survey was completed online by 276 primary care providers, and various measures were taken to prevent social desirability in responses. Multiple checks suggested the assessments were valid. Statistical analyses (i.e., Mokken Scaling, a non-parametric Item Response Theory method) allowed us to examine both the amount (number of guideline-recommended asthma care activities delivered) and consistency (the degree to which different health care providers deliver similar care) of asthma medical care and self-management support. Regression analyses were used to examine which factors explained differences in the quality of asthma care between and across countries.

On average, the 276 health care providers reported delivering 74.2% of guideline-recommended care. Providers delivering a lower amount of guideline-recommended asthma care varied widely in what care they were delivering. Health care providers delivering a higher amount of asthma care usually delivered care that was very similar. Providers from the U.K. reported more and more consistent asthma self-management support than French health care providers. No differences were observed between countries in the quality of medical care. The difference in the quality of self-management support between countries was almost entirely explained by the presence of practice nurses in the U.K. Having had more training in asthma care and self-management support, more positive social norms, and higher confidence in one’s ability to deliver high-quality asthma care explained better quality of care across health care providers in both countries.

Our findings suggest that changes in resources (i.e., involving nurse practitioners in asthma care delivery), more asthma-specific and patient education training for health care providers, and providing normative feedback to individual providers could enhance the quality of asthma care in the U.K. and France. These findings need to be corroborated in a future multi-site intervention trial. A possible limitation of the current study was the self-reported nature of the data; it could be that the quality of care has been overreported. However, the data required for this in-depth examination of asthma care are not routinely collected, and the alternative ways of collecting the data were too resource intensive (e.g., audio recording and coding many consultations across hundreds of health care providers in multiple countries). Instead, we carefully designed a survey with patients and providers to be accurate and non-judgemental, ensured anonymity during online survey completion, and ran multiple checks that provide support for the validity of these data.

The Journal of Allergy and Clinical Immunology: In Practice is an official journal of the AAAAI, focusing on practical information for the practicing clinician.

Explaining the amount and consistency of medical care and self-management support in asthma: a survey of primary care providers in France and the United Kingdom