Medical care and self-management support for asthma in primary care: a comparison between France and the United Kingdom A.Dima, E. van Ganse, H. Le Cloarec, M. de Bruin and the ASTRO-LAB group

Background Managing asthma = medical care & self-management support Clinical guidelines & behavioral research  routine asthma care activities What happens in primary care? How can we improve guideline implementation?

ASTRO-LAB European project (FP7) Primary objective - LABA safety Prospective cohort of asthma patients in France and the UK Comparison of asthma management in primary care

OBJECTIVE To compare practitioner-reported routine asthma care in France and the United Kingdom: variations in routine care system- and practitioner-specific facilitators

METHODS No comprehensive tools available, so develop new: Review guidelines for medical & self-management support items Limited information behavioural support: from wider literature Interviews with Health Care Providers (HCPs) & Patients Questionnaire construction & translation, HCP cognitive interviewing Self-reported HCP questionnaire online (anonymous) Determinants: Background: practice characteristics, HCP training & demographics Socio-cognitive: attitudes, social norms, perceived control, intentions

Example items care activities Repeated lung function tests for patients over 8 Identify asthma triggers Assess smoking status for patients over 13 Allergy testing Assess comorbidities Medical care activities (12 items) Explain the difference between asthmatic and normal airways Explain common side-effects and how to deal with them Discuss common barriers to taking inhalers as prescribed Ask patients to identify daily routines to link to inhaler use Develop with patients a written action plan for inhaler use Self-management support (25 items)

Example items: socio-cognitive Attitude I think that it is (not at all) my responsibility, a priority, useful… Social norms Patients expect me to provide… Clinicians like me provide… Perceived control I expect to be able to… Self-efficacy/skills I am confident that I can provide… even when… …I have limited time, …the patient is an adolescent, …the patient has lower education, …the patient is reluctant to discuss Intention I intend to provide… to most patients

Results: sample THIN 50 Practices 68 GPs 52 nurses CNGE 156 GPs

Medical care activities: frequencies % French GPs % UK HCPs Assess smoking status for patients over 13 years old 98.7% 98.3% Step-up treatment if patients have poor asthma control 97.4% 99.2% Question patients to identify asthma triggers 94.9% 89.2% ... Perform or refer to allergy testing 75.6% 10.0% Assess smoking status of co-inhabitants 73.7% 64.2% Ask patients whether they have been able to manage triggers 60.9% 57.5% Use a validated set of questions to assess symptoms/control 19.2% 77.5% MEAN (SD) 9.3 (1.6) 9 (1.8) YES to all items 6.4% 5%

Self-mgmt support: frequencies Activities % French GPs % UK HCPs Explain difference preventer – reliever 98.7% 99.2% Discuss what to do if symptoms increase 96.2% 98.3% Discuss the importance of adherence 93.6% … Plan storing spare inhalers handy places 78.9% 62.5% Discuss inhaler preferences 73.7% 69.2% Discuss symptom monitoring 39.1% 80.8% Ask about linking daily routines with inhaler use 32.1% 61.7% Develop a written action plan 28.2% 43.3% Encourage to use reminders 20.5% 35.8% MEAN (SD) 17.2 (4.2) 19.72(4.3) YES to all items 3.2% 15%

Total scores in France and the UK

Structure of care Is there a shared approach to asthma care provision? If 20 HCPs score 8/12 points, likely to deliver the same? If 20 HCPs score 10/12 points, likely to add the same? Medical care: UK: 5/12 activities on trigger management FR: No item clustering Self-management support: UK: 17/25 activities form a single scale (H=.41) from ‘basic’ care (discussing adherence barriers, 94.17%) to ‘comprehensive’ care (advise reminder use, 35.83%). FR: 9/25 activities in single scale (H=.37, medication intake advice), + items with less clear structure (inhaler technique training, difficulties).

Determinants total scores n.s.: demographics, practice characteristics, experience in asthma care, communication training, attitudes, perceived control, intention Predictors of medical care Step 1 Step 2 Step 3 Intercept 8.98*** French GPs (vs UK HCPs) 0.29 UK nurses (vs GPs) - Asthma specific training Social norms for self-mgmt support Self-efficacy for self-mgmt support adj R2 (Δ R2) .004; ns *** p<.001; ** p<.01; * p<.05

Determinants total scores n.s.: demographics, practice characteristics, experience in asthma care, communication training, attitudes, perceived control, intention Predictors of medical care Step 1 Step 2 Step 3 Intercept 8.98*** 7.67*** French GPs (vs UK HCPs) 0.29 1.02*** UK nurses (vs GPs) - 1.33*** Asthma specific training 0.83*** Social norms for self-mgmt support Self-efficacy for self-mgmt support adj R2 (Δ R2) .004; ns .10(.09); p<.001 *** p<.001; ** p<.01; * p<.05

Determinants total scores n.s.: demographics, practice characteristics, experience in asthma care, communication training, attitudes, perceived control, intention Predictors of medical care Step 1 Step 2 Step 3 Intercept 8.98*** 7.67*** 5.21*** French GPs (vs UK HCPs) 0.29 1.02*** 1.04*** UK nurses (vs GPs) - 1.33*** 0.72* Asthma specific training 0.83*** 0.74** Social norms for self-mgmt support 0.29** Self-efficacy for self-mgmt support 0.27** adj R2 (Δ R2) .004; ns .10(.09); p<.001 .19 (.10); p<.001 *** p<.001; ** p<.01; * p<.05

Determinants total scores n.s.: demographics, practice characteristics, experience in asthma care, attitudes, perceived control, intention Predictors of self-mgmt support Step 1 Step 2 Step 3 Intercept 19.7*** French GPs (vs UK HCPs) -2.5*** UK nurses (vs GPs) - Asthma specific training Communication undergrad training Social norms for self-mgmt support Self-efficacy for self-mgmt support adj R2 (Δ R2) .08; p<.001 *** p<.001; ** p<.01; * p<.05

Determinants total scores n.s.: demographics, practice characteristics, experience in asthma care, attitudes, perceived control, intention Predictors of self-mgmt support Step 1 Step 2 Step 3 Intercept 19.7*** 15.01*** French GPs (vs UK HCPs) -2.5*** 0.84 UK nurses (vs GPs) - 5.81*** Asthma specific training 1.42** Communication undergrad training 1.36* Social norms for self-mgmt support Self-efficacy for self-mgmt support adj R2 (Δ R2) .08; p<.001 .24(.17); p<.001 *** p<.001; ** p<.01; * p<.05

Determinants total scores n.s.: demographics, practice characteristics, experience in asthma care, attitudes, perceived control, intention Predictors of self-mgmt support Step 1 Step 2 Step 3 Intercept 19.7*** 15.01*** 7.91*** French GPs (vs UK HCPs) -2.5*** 0.84 0.95 UK nurses (vs GPs) - 5.81*** 4.11*** Asthma specific training 1.42** 1.21* Communication undergrad training 1.36* 1.24* Social norms for self-mgmt support 1.07*** Self-efficacy for self-mgmt support 0.51* adj R2 (Δ R2) .08; p<.001 .24(.17); p<.001 .35 (.12) ; p<.001 *** p<.001; ** p<.01; * p<.05

Conclusions Substantial variability in provision of asthma care Common approach to asthma care stronger in the UK collaboration between GPs and nurses – facilitator of asthma care in the UK Training, positive norm perceptions and skills regarding self-management support – facilitators of comprehensive care. Project funded by the European Commission through the Seventh Framework Programme under GA n° 282593 - http://www.astrolab-project.eu

Further questions… Are all activities necessary for good asthma control? Is routine delivery needed (for most patients)? Do other HCPs deliver this care? What NEEDS & CAN be improved?

THANK YOU Project funded by the European Commission through the Seventh Framework Programme under GA n° 282593 http://www.astrolab-project.eu