M J Noble

Clinician-assessed poor compliance identifies adults with severe asthma who are at risk of adverse outcomes

Our aim was to determine whether clinician-identified poor compliance is useful in identifying, from among adults with severe asthma, patients with characteristics likely to put them at risk of adverse outcomes. Patients with severe asthma (previous hospital admissions and/or prescribed step 4–5 treatment according to British Thoracic Society guidelines) considered by clinicians to be either compliant (C, N = 41) or poorly compliant (PC, N = 92) with aspects of their recommended management (attendance at appointments, taking medication, and monitoring asthma) provided data on symptoms, health service use, medication, self-management practices, physical and psychological comorbidities, and sociodemographic/socioeconomic characteristics. Cross-sectional univariate analyses were used to examine whether the groups differed with respect to self-reported indicators of asthma morbidity and self-management. Logistic regressions were additionally used to explore psychosocial factors independently associated with patients being identified as PC. Compared with C patients, PC patients had significantly poorer self-reported asthma control in terms of medication use, symptoms, time off work, asthma-specific quality of life, primary care visits, emergency attendances, and hospital admissions. This was coupled with poorer self-management practices. Patients identified as PC also had higher levels of physical and psychological comorbidities, were younger, and faced more difficult social and economic circumstances. We identified significant psychological (anxiety) and social (younger age, not working, number of benefits, adverse family circumstances) factors independently associated with patients being identified as PC. Among adults with severe asthma, clinician-assessed poor compliance was useful in distinguishing between two groups that differed significantly in terms of asthma morbidity indicators, self-management practices, and psychosocial characteristics, which have been previously shown to be associated with hospital admissions, near-fatal attacks, and fatal asthma. We conclude that clinician-assessed poor compliance is a useful marker for identifying patients at risk of these adverse outcomes.

The Coping with Asthma Study: a randomised controlled trial of a home based, nurse led psychoeducational intervention for adults at risk of adverse asthma outcomes

Background: Morbidity and mortality associated with severe asthma might be reduced by interventions that address psychosocial factors contributing to adverse outcomes. A study was undertaken to assess the effectiveness of a 6 month home based psychoeducational intervention delivered by a respiratory nurse specialist for adults at risk of adverse asthma outcomes. Methods: A pragmatic randomised controlled trial was performed in 92 adults registered with hospital or primary care asthma clinics. All had previous hospital admissions and/or were on British Thoracic Society step 4–5 treatment and had failed to attend clinic appointments or were considered to have poor adherence to other aspects of their agreed management. Patients were visited in their homes for assessment and, where appropriate, intervention. The main outcomes measured were symptom control, asthma specific quality of life, and generic health status. Results: At the 6 month primary time point there were no significant differences between usual care and intervention groups in mean symptom control, physical functioning, or mental health scores (differences (with 95% CI) −0.35 (−1.83 to 1.13), 3.10 (−11.42 to 17.63), 0.42 (−10.22 to 11.07), respectively). Small effects on asthma specific quality of life up to 12 months (e.g. adjusted difference at 12 months 0.13 (95% CI 0.02 to 0.25)) and short term effects on generic health status, which mirrored improvements in aspects of self-care observed at the end of the intensive phase of the intervention, were apparent only from fully adjusted analyses. Conclusions: A home based intervention provided by a nurse receiving psychological supervision may have effects on quality of life but is overall of limited long term benefit to adults at risk of adverse asthma outcomes.

Psycho-educational interventions for adults with severe or difficult asthma: a systematic review.

Research highlights psychosocial factors associated with adverse asthma events. This systematic review therefore examined whether psycho-educational interventions improve health and self-management outcomes in adults with severe or difficult asthma. Seventeen controlled studies were included. Characteristics and content of interventions varied even within broad types. Study quality was generally poor and several studies were small. Any positive effects observed from qualitative and quantitative syntheses were mainly short term and, in planned subgroup analyses (involving < 5 trials), effects on hospitalizations, quality of life, and psychological morbidity in patients with severe asthma did not extend to those in whom multiple factors complicate management.

Asthma at-risk registers--can be effective if carefully constructed and correctly implemented.

Asthma at-risk registers — can be effective if carefully constructed and correctly implemented

P175 Cross-sectional and longitudinal relationships of self-management behaviours and other psychological factors with outcomes in patients with severe asthma

Background Psychosocial factors are associated with various manifestations of severe asthma. Wider research and theory highlight complex, bi-directional pathways by which interactions may occur. However, few studies have explored relationships between multiple psychosocial factors and outcomes in severe asthma with these pathways in mind. Objectives This study investigated combined and independent cross-sectional and longitudinal relationships of self-management behaviours, an index of self-management (ISM), anxiety, depression, perceived control (PC) and socio-demographic/economic characteristics with asthma control, quality of life (QoL) and severe attacks amongst asthma patients on high levels of treatment and/or with a history of admissions. Methods Cross-sectional data from 132 adults recruited to a previously reported trial of an intervention and accompanying comparative study were subjected to multiple regression analyses. These systematically examined relationships between psychosocial factors and asthma outcomes, and were used to build final hierarchical regression models in which key clinical variables were controlled for. More limited data from a maximum of 112 patients were used to explore longitudinal relationships, primarily with asthma control. Results Final hierarchical regression models accounted for up to 69% and 73% of the variability in asthma control and QoL respectively (p<0.001) and significantly predicted experience of a severe attack (p<0.001). Variables showing significant independent relationships to outcomes in these models are highlighted in the Abstract P175 Table 1. Some individual behaviours and the ISM showed independent and differing cross-sectional relationships to each outcome. Other psychological factors were related to subjective outcomes but not severe attacks. Relationships of some psychosocial factors (eg, depression, unemployment) to outcomes were not fully mediated by other variables, including self-management behaviours. In longitudinal analyses, there was some evidence for depression directly contributing to poorer subjective outcomes, whilst relationships of PC and anxiety with outcomes were more variable and inconsistent.Abstract P175 Table 1 Regression Control QoL Attack (11 variables entered) (12 variables entered) (6 variables entered) 1. Clinical factors Severity (Sev with ISM) – 2. Self-mgmt behs Overusing reliever – Trigger avoid 3. Psych factors Depression (PC with ISM) Anxiety depression PC N/A 4. Social factors Employment age Employment Age Var. acc. for (R2): 69% 73% app 23–31% (63% using ISM) (72% using ISM) All steps sig (26, 31, 9, 4%) All steps sig (25, 19, 27, 2%) All steps sig (∼10, 6, 17%) Conclusions Emotional and cognitive factors appear at least as important as self-management behaviours in relation to subjective outcomes in severe asthma. Along with a growing body of other research, findings suggest a particular need to identify and address depression amongst patients with severe asthma in practice, as in other chronic diseases.