Delivery of supported self-management in asthma reviews: a mixed methods observational study nested in the IMP²ART programme of work
BACKGROUND: Supported self-management (SSM) reduces the risk of asthma attacks, improves asthma control and quality of life. During routine primary care asthma consultations, healthcare professional (HCP) communication and behaviour can influence a person's skills, knowledge and confidence to manage their own condition. Therefore understanding how supported self-management is delivered in UK primary care can help towards improved HCP delivery of care. This PhD project has been nested within the IMPlementing IMProved Asthma self-management as RouTine (IMP2ART) programme, which is a UK-Wide trial, developing and evaluating a strategy delivering patient, professional, and organisational resources to improve self-management. AIMS AND OBJECTIVES: The aim of this PhD project was to assess HCP delivery of supported self-management, including patient-centred care and behaviour change strategies to promote asthma self-management during routine primary care reviews. Additional objectives included to explore the influence of the IMP2ART programme on the delivery of supported self-management, and investigate differences (if any) in remote and face-to-face delivery of asthma care. METHODOLOGY: The PhD programme of work consisted of three phases: 1. Understanding the Evidence Base: Firstly, following systematic realist review methodology, I systematically reviewed the existing evidence investigating the delivery of supported self-management during routine remote asthma consultations. The realist review aimed to; 1) identify and synthesise studies that explored remote asthma consultations and the delivery of supported self-management, 2) explore the context and mechanisms that have contributed to clinically effective, safe and acceptable delivery of supported self-management during remote asthma consultations, and 3) produce recommendations and guidelines for best practice in the delivery of supported self-management during remote consultations for people with asthma. 2. Understanding current clinical practice: I conducted an observational study using video-recordings of routine face-to-face and telephone asthma reviews in a sub-sample of practices participating in the IMP2ART UK-wide cluster-randomised controlled trial (implementation n~4; control n~6). Analytical methods included: ALFA Toolkit Multi-Channel Video Observation, to code and quantify types of speech, Patient-Centred Observation Form and The Behaviour Change Counselling Index, to assess patient-centeredness and behaviour change counselling used by HCPs. 3. Understanding the clinician’s perspective: In the qualitative phase of the PhD, I conducted semi-structured interviews with seven HCPs to explore clinician’s perceptions, opinions and experiences of delivering supported self-management during routine asthma reviews. Interviews were audio recorded, transcribed and findings were explored using thematic analysis. Results of the three phases were initially analysed separately using the outlined approaches. A ‘Triangulation Protocol’ process was then conducted to compare, contrast and amalgamate the findings of the mixed methods approaches. RESULTS: 1. Results of the systematic rapid realist review identified six themes using data from 18 articles to describe how supported self-management is delivered during remote asthma consultations. The findings identified positive benefits associated with remote asthma care including; increased convenience, improved access and attendance at reviews, ability to conduct the core content of an asthma review remotely, completion of asthma action plans, and continuity of care. Typically, these overrode any challenges associated with technological difficulties imposed by remote consultations. The data suggest that overall remote consultations were as, or more highly, accepted than in person consultations for the studies I included, and were as effective and safe as face-to-face reviews. 2. Findings of the observational recordings revealed that HCPs spent the most time during a routine review discussing; an individual’s asthma condition and it’s management, collaboratively reviewing and completing personalised asthma action plan and, training for practical self-management activities (e.g., inhaler technique). Areas of patient-centred care delivery which HCPs discussed using a biopsychosocial focus were; creating and maintaining relationships with patients, as well as discussing asthma action plans and medication reconciliation. HCPs delivered empathetic behavioural discussions, however, did not collaboratively discuss individualised approaches for ways in which a patient could proactively change their behaviour. There was a statistically significant difference for the delivery of supported self-management between IMP2ART implementation and control group healthcare professionals. Healthcare professionals from the IMP2ART implementation group spent a higher percentage of time during routine reviews incorporating and discussing SSM strategies (ALFA) (t (62), =2.122, p =0.038). Professionals of implementation group practices also delivered a more person-centred review (PCOF) (t (60), = 2.06, p = 0.044), and used more behaviour change communication strategies (BECCI) (U= 336.5, p = 0.03) than professionals of the IMP2ART control group. I concluded that, on average, professionals in IMP2ART implementation group practices delivered more effective SSM strategies during routine asthma reviews. Findings from the between group analysis of the face-to-face and remote consultation groups found that on average, both groups spent similar percentages of time on SSM tasks during routine asthma reviews (ALFA). Similarly, both groups had similar scores the delivery of patient-centred care (PCOF) and behaviour change discussions (BECCI), showing no significant differences in healthcare professional delivery of SSM between face-to-face and remote consultations. 3. The findings from the qualitative, semi-structured interviews with healthcare professionals identified five themes. The main findings from the themes included; healthcare professionals shared understanding of supported self-management, barriers and facilitators of supported self-management delivery (including healthcare professional motivations, confidence and time barriers), important strategies for supported self-management delivery (including patient education, asthma action plans and inhaler technique), and that there is a place in primary care for remote asthma care. Five key findings emerged from completing the Triangulation Protocol process, which amalgamated the findings of the three phases of the PhD study; 1. HCP confidence and motivations, and general practice culture are facilitators of effective HCP delivery of supported self-management. 2. Lack of time and large, challenging workloads are perceived as barriers to HCP delivery of supported self-management. 3. HCP and patient asthma education is an effective supported self-management strategy. 4. IMP2ART implementation strategies are associated with increased HCP delivery of asthma supported self-management. 5. Remote consultations devote similar proportion of time to face-to-face reviews for delivery of asthma supported self-management. CONCLUSIONS: HCP communication and behaviour can positively or negatively impact a patient’s ability to self-manage their condition. The insights from this mixed methods PhD programme of work, including the observation of routine asthma reviews, has provided evidence that training programmes directed at providing healthcare professionals with the skills they need to implement a motivating and patient-centred asthma review, in which behaviour change and collaborative supported self-management strategies, can be effective, and should be prioritised during the delivery of routine primary care asthma management. Routine remote reviews are also an acceptable alternative to delivery of supported self-management for asthma care for specific patient groups.
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