Implementation of asthma clinical practice guidelines in primary care: A cross-sectional study based on the Knowledge-to-Action Cycle

<p><i>Objective</i>: Based on the Knowledge-to-Action Cycle, we assessed the self-reported implementation and perception of asthma clinical practice guideline (CPG) recommendations in primary care physicians (PCPs), along with the barriers and facilitators to CPG use in primary care. <i>Methods</i>: We conducted a cross-sectional study. Using the extended <i>Asthma Physicians' Practice Assessment Questionnaire</i>^©, PCPs self-reported the following: their knowledge of 15 key asthma CPG recommendations, the perceived usefulness of each of these recommendations, their motivation to apply these recommendations, and their agreement with the content of these recommendations. Participants also reported the barriers and facilitators to CPG use in primary care. <i>Results</i>: Out of the 46 potential participants, 43 physicians completed the questionnaire (response rate: 93%). Results underlined care gaps regarding the provision of asthma education and written action plans, inhaler technique demonstrations, and assessment of patients' concerns. Results showed that the majority of physicians knew the key asthma CPG recommendations, but their motivation to implement them and the perceived usefulness of these recommendations varied from one proposal to another. Main barriers to the implementation of these recommendations were related to time and resources. PCPs stressed the importance of teamwork for enhancing the use of asthma CPGs in primary care. <i>Conclusions</i>: Our results suggest that the implementation of asthma CPGs remains suboptimal in primary care. Interventions addressing the identified barriers and providing facilitators to asthma CPG implementation, such as continuing education, could be implemented and evaluated to sustain asthma CPG use in primary care settings.</p

Consort Flowchart of the study.

<p>Consort Flowchart of the study.</p

Change in PC20 according to response to EVH (Individual data).

<p>Horizontal lines represent the mean. EVH+/EVH-: Subjects with/without a positive response to eucapnic voluntary hyperpnea (% fall in FEV₁ ≥ 10%); Change in PC₂₀ = Post-EVH PC₂₀—Baseline PC₂₀; DC: doubling-concentration. * p<0.05 in change in DC from baseline to post-EVH in MIT PC₂₀ in the same group. § p<0.05, §§ p<0.005 in change in DC from baseline to post-EVH in MIT PC₂₀ between two groups.</p

Two-month within- and between-group changes in scores on the informed, values clarity, support, uncertainty, and effective decision subscales of the DCS (<i>N</i> = 51).

<p>Two-month within- and between-group changes in scores on the informed, values clarity, support, uncertainty, and effective decision subscales of the DCS (<i>N</i> = 51).</p

Impact of Adding a Decision Aid to Patient Education in Adults with Asthma: A Randomized Clinical Trial

<div><p>Background</p><p>Not providing adequate patient education interventions to asthma patients remains a major care gap. To help asthma patients and caregivers discuss inhaled controller medication use, our team has previously developed a decision aid (DA). We sought to assess whether adding this DA to education interventions improved knowledge, decisional conflict, and asthma control among adults with asthma.</p><p>Methods</p><p>A parallel clinical trial (NCT02516449). We recruited adults with asthma, aged 18 to 65 years, prescribed inhaled controller medication to optimize asthma control. Educators randomly allocated participants either to the education + DA or to the education group. At baseline and two-month follow-up, we measured asthma knowledge (primary outcome) with a validated self-administered questionnaire (score –37 to +37). Secondary outcomes included decisional conflict and asthma control. Blinded assessors collected data. Between the two time points, the within- and between-group changes were estimated by generalized linear mixed models.</p><p>Results</p><p>Fifty-one participants (response rate: 53%; age: 44 ± 13 years; women: n = 32) were randomized either to the education + DA group (n = 26) or to the education group (n = 25), and included in statistical analyses. Between baseline and follow-up, mean [95% CI] knowledge scores increased from 21.5 [19.9–23.2] to 25.1 [23.1–27.0] in the education + DA group (<i>P</i> = 0.0002) and from 24.0 [22.3–25.7] to 26.0 [24.0–28.0] in the education group (<i>P</i> = 0.0298). In both of the groups, decisional conflict and asthma control improved. There were no differences between groups.</p><p>Conclusions</p><p>Education improved knowledge, decisional conflict, and asthma control whether the DA was added or not.</p></div

Asthma susceptibility variants are more strongly associated with clinically similar subgroups

<p><i>Objective</i>: Genome-wide association studies (GWAS) identified single nucleotide polymorphisms (SNPs) reproducibly associated with asthma. This study evaluated whether GWAS-nominated SNPs are more strongly associated with asthma patients sharing the same clinical characteristics in order to refine the role of recently identified genes. <i>Methods</i>: Analyses were performed in unrelated French Canadian subjects (566 cases and 416 controls) with data collected on lung function, blood cell counts, atopy, disease history and medication. Previously defined asthma subgroups were used for analysis: 1) older patients with low atopy and low lung function, 2) high atopy, 3) young non-smoking women and 4) high smoking history. Allele frequencies of 68 GWAS-nominated SNPs were compared between controls and cases or controls and subgroups of cases defined by cluster analysis. <i>Results</i>: Twelve GWAS-nominated SNPs demonstrated evidence of replication (<i>p</i> value < 0.05) for association with asthma. In phenotypically similar asthma patients, rs10197862, located in <i>IL1RL1/IL18R1</i>, was the most strongly associated SNP with the high atopy subgroup (<i>p</i> = 0.0009). SNPs located at the <i>IL33</i> and the <i>STARD3</i>/<i>PGAP3</i> loci were also associated with the high atopy subgroup. Two SNPs, rs1544791 (<i>PDE4D</i>) and rs3806932 (<i>TSLP</i>), were more strongly associated with the high smoking history subgroup than with asthma or any other subgroups. All 10 SNPs that replicated for asthma <i>per se</i> and within subgroups had lower <i>p</i> values in subgroups. Moreover, 12 SNPs were only replicated in a subgroup. <i>Conclusion</i>: This study shows that the majority of GWAS-nominated SNPs are more strongly associated with homogeneous subgroups of asthma than broadly defined asthma.</p

Flow of participants through the study.

<p><b>CONSORT flow diagram.</b> Adapted from the CONSORT 2010 Flow Diagram [<a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0170055#pone.0170055.ref058" target="_blank">58</a>].</p

Effectiveness of an asthma integrated care program on asthma control and adherence to inhaled corticosteroids

<div><p></p><p><i>Objective</i>: To measure the effectiveness of an integrated care program for individuals with asthma aged 12–45 years, on asthma control and adherence to inhaled corticosteroids (ICS). <i>Methods</i>: Researchers used a theoretical model to develop the program and assessed effectiveness at 12 months, using a pragmatic controlled clinical trial design. Forty-two community pharmacists in Quebec, Canada recruited participants with either uncontrolled or mild-to-severe asthma. One group was exposed to the program; another received usual care. Asthma control was measured with the Asthma Control Questionnaire; ICS adherence was assessed with the Morisky medication adherence scale and the medication possession ratio. Program effectiveness was assessed with an intention-to-treat approach using multivariate generalized estimating equation models. <i>Results</i>: Among 108 exposed and 241 non-exposed, 52.2% had controlled asthma at baseline. At 12-months, asthma control had improved in both groups but the interaction between study groups and time was not significant (<i>p</i> = 0.09). The proportion of participants with good ICS adherence was low at baseline. Exposed participants showed improvement in adherence and the interaction between study groups and time was significant (<i>p</i> = 0.02). <i>Conclusion</i>: An integrated intervention, with healthcare professionals collaborating to optimize asthma control, can improve ICS adherence.</p></div

Gene-Metabolite Expression in Blood Can Discriminate Allergen-Induced Isolated Early from Dual Asthmatic Responses

<div><p>Some asthmatic individuals undergoing allergen inhalation challenge develop an isolated early response whereas others develop a dual response (early plus late response). In the present study we have used transcriptomics (microarrays) and metabolomics (mass spectrometry) of peripheral blood to identify molecular patterns that can discriminate allergen-induced isolated early from dual asthmatic responses. Peripheral blood was obtained prior to (pre-) and 2 hours post allergen inhalation challenge from 33 study participants. In an initial cohort of 14 participants, complete blood counts indicated significant differences in neutrophil and lymphocyte counts at pre-challenge between early and dual responders. At post-challenge, significant genes (<i>ALOX15</i>, <i>FADS2</i> and <i>LPCAT2</i>) and metabolites (lysolipids) were enriched in lipid metabolism pathways. Enzymes encoding for these genes are involved in membrane biogenesis and metabolism of fatty acids into pro-inflammatory and anti-inflammatory mediators. Correlation analysis indicated a strong negative correlation between <i>ALOX15</i>, <i>FADS2</i>, and <i>IL5RA</i> expression with 2-arachidonoylglycerophosphocholine levels in dual responders. However, measuring arachidonic acid and docosahexaenoic acid levels in a validation cohort of 19 participants indicated that the free form of DHA (nmoles/µg of protein) was significantly (p = 0.03) different between early and dual responders after allergen challenge. Collectively these results may suggest an imbalance in lipid metabolism which dictates pro- (anti-) inflammatory and pro-resolving mechanisms. Future studies with larger sample sizes may reveal novel mechanisms and therapeutic targets of the late phase asthmatic response.</p></div

Demographics of study participants of the validation cohort.

a<p>geometric mean (PC20 values are measured on a log scale);</p>b<p>[PC₂₀]pre/[PC₂₀]post;</p>c<p>p<0.001 versus ER group.</p