Effective management of severe asthma (SA) requires a partnership (shared decision making) between a patient and their health care provider (HCP), in addition to ongoing treatment modification to achieve disease control and reduce symptoms, activity limitations and the risk for exacerbation, persistent airflow limitation, and mortality, explains Reynold A. Panettieri Jr, MD. “Precise evaluation of asthma control and treatment effectiveness by HCPs is key for optimal disease management,” he says. “Previous studies, however, have shown that patient and HCP assessment of asthma symptom control and treatment satisfaction often do not align with one another. HCPs often underestimate asthma control and patient satisfaction, while patients are more likely to report treatment effectiveness than specialists.” Regardless of the importance of evaluating asthma control and treatment effectiveness, he adds, no large studies in the United States have assessed the accuracy of HCP and patient assessments.
For a paper published in the Journal of Asthma, Dr. Panettieri and colleagues conducted an analysis of CHRONICLE, an ongoing, real-world, observational study of patients with SA treated by US subspecialists. Asthma control was assessed using the patient-competed Asthma Control Test (ACT) and specialist clinical assessment of control. Treatment effectiveness was evaluated with the Global Evaluation of Treatment Effectiveness (GETE), a five-point categorical scale of treatment effectiveness that was completed by patients and specialists. A total of 1,109 patients who completed online surveys at enrollment were included. “Our study represents the first large, real-world evaluation of concurrently reported asthma control and perceived treatment effectiveness among US patients with SA and their treatment subspecialists,” he says.
Dr. Panettieri and colleagues found that specialist physicians tended to overestimate asthma control relative to control determined by the patient’s ACT score, particularly among patients not receiving biologic therapy. Compared with 67% of patients with uncontrolled asthma by ACT, 44% were uncontrolled according to specialist evaluation; 54% of patients who were uncontrolled according to the ACT were deemed controlled by specialists, indicating overestimation of asthma control. Based on the ACT score, asthma control was more common for patients receiving biologics compared with other treatments.
Discord Can Induce Poor Treatment AdherencePatients who completed the GETE at enrollment and had a specialist evaluation (N=1,009) reported treatment effectiveness more often than their specialists. Specialists noted some improvement for 71% of patients and no improvement or worsening for 29% of patients (Table). “There was little alignment between the patients’ assessment and that of the provider,” he says. “As a consequence, this discord evokes poor treatment adherence and loss of confidence in the therapeutic approach.”
Although physician judgment typically prevails in clinical practice, the study team’s findings show that a validated tool like the ACT adds benefit through its quantitative assessment of specific patient-reported symptoms and impairments. “Our findings emphasize that patient assessments with validated instruments should be performed more regularly and given more consideration in specialists’ judgments of asthma control,” Dr. Panettieri says. “According to US National Asthma Education and Prevention Program guidelines, it is recommended that providers use the ACT or comparable validated instruments to influence therapy in patients with SA.”
In the future, Dr. Panettieri and colleagues would like to see providers give greater consideration to validated tools such as ACT and others to guide decisions about disease management and treatment in patients with SA. “It’s imperative that clinicians embrace shared decision making between patients and providers when it comes to treatment. Furthermore, clinicians should follow up with patients regularly to see if the treatment is meeting their needs.”