Does a facilitator-led approach to implementation of a shared decision-making intervention in primary care lead to improved outcomes for patients with asthma?

Problem

Poor outcomes and health disparities related to asthma result in part from difficulty disseminating new evidence and paradigms of care delivery such as shared decision making (SDM) into clinical practice. This study evaluated two approaches where either a “Facilitator-Led” or a “Lunch-and-Learn” dissemination approach was used to implement asthma SDM into primary care practices. We hypothesized that practices receiving the facilitator-led dissemination approach would have a greater percentage of patients reporting having shared in the treatment decision about their asthma care with their provider than patients in the traditional lunch and-learn practices. In addition, patients with asthma in the facilitator-led practices were hypothesized to have a lower proportion of asthma exacerbations than patients in either the traditional lunch-and-learn or usual care control practices.

Approach

30 primary care practices across North Carolina with at least 75 patients with asthma were cluster-randomized into three arms of 10 practices: Facilitator-Led, Lunch-and-Learn, and control (no intervention). The proportion of patients with exacerbation marker such as emergency department visits, inpatient visits, or oral steroid prescriptions were collected 12 months pre and post randomization and compared across the three arms. Patient perceptions of SDM were assessed using anonymous surveys.

Findings

In 75% of patient visits at facilitator-Led practices, patients indicated they participated equally with the provider in making the treatment decision vs. 66% of patient visits from the lunch-and-learn practices (p<0.001). Logistic regression models showed a marginal decrease in patients with ED visits (p=0.09) between the facilitator-led and control arms. All comparisons for steroid prescriptions, ED visits, or asthma exacerbations between arms were not statistically significant. The relative decrease from baseline in the proportion of patients with steroid prescriptions was 15.9% (p<0.001) for facilitator-led, 13.2% (p<0.001) for lunch-and-learn, and 10.6% (p<0.001) for control. The relative decrease in patients with one or more asthma exacerbations was 18.2% (p<0.001) for facilitator-led, 9.5% (p<0.01) for lunch-and-learn, and 10.5% (p<0.01) for control. Compared to baseline, the proportion of patients with ED visits decreased 13.8% (p=0.21) for facilitator-led, decreased 11.6% (p=0.09) for lunch-and learn, and increased 8.9% (p=0.28) for control. The absolute and relative changes in hospitalizations in the three groups were not statistically significant. Facilitator-led dissemination was associated with significant improved patient perception that SDM occurred during an asthma visit when compared to lunch and-learn dissemination practices. Practices across the three arms had significant reductions in steroid prescriptions reflecting a general overall decline in asthma exacerbations with greatest decline for facilitator-led practices.

Consequences

These results support the use of structured approaches such as facilitator-led dissemination of complex interventions, such as shared decision making for asthma management, into primary care practices.