In the age of patient-centricity, the doctor’s role has evolved into helping patients make choices for themselves
Earlier this year the Global Initiative for Asthma (GINA) published new recommendations for asthma management 1 that have been described as possibly “the most fundamental change in asthma management in 30 years”. 2
GINA no longer recommends treating adults and adolescents with short-acting bronchodilators alone. Part of the reason for this change is that GINA is aiming to improve asthma management and reduce exacerbations“while also being concordant with patient behaviour, beliefs and preferences”. 2 Being concordant with patient behaviour, beliefs and preferences can be roughly translated into “being patient-centred”.
You’ve probably noticed that the noise about patient-centred care has become louder over recent years. There are those who claim that it’s getting boring, while others dismiss it as political correctness. Most of these critics pay little respect to the growing evidence base which suggests that patient-centricity is important because it is associated with real clinical outcomes.
Much of the rhetoric about patient-centricity is focused on Google and the latest app. This misses the point on two counts. Firstly, it ignores the fact that the patient-centricity movement started affecting the practice of medicine before Google was first launched in 1998. 3 (See article opposite)
Secondly, it makes the concept all about the rise of the consumer and meeting consumer needs. This ignores the idea that patient-centricity was originally about the quality practice of medicine and improving clinical outcomes.
WHY THE CHANGE?
Of course, GINA would not make a fundamental change in its recommendations for asthma management without a careful review of the existing evidence and large, carefully controlled studies to back it up. An authoritative review of this evidence is beyond the scope of this author and this article, but it does make interesting reading. 2, 4-6
A range of factors influenced these changes, but one which stands out is “adherence”, particularly low adherence to inhaled corticosteroids (ICS). The figure of 25% to 35% real life adherence to ICS is cited. 2 This leaves patients reliant on short-acting beta agonists (SABAs) which are over-used as rescue medication.
Adherence is a concept that has evolved in parallel with patient-centricity. It started as compliance, before morphing into adherence, and more recently has become fragmented with terms such as persistence. Some use the term concordance.
It seems that this evolution amounts to little more than semantic trickery. While it affects the way we think about adherence, and a variety of interventions have been shown to improve adherence to ICS, the impact on outcomes is uncertain and inconsistent. 6
ADHERENCE
At its core, adherence is about patients not doing what they are told, or not using medications properly. Interventions designed to improve adherence are designed to affect patients’ behaviour, to get them to do what they are told. The cynic could say that adherence interventions are designed to manipulate patients’ behaviour to suit the limitations of the product.
The analogy of customer-centricity in the commercial world is useful. The old product-centred world is epitomised by Henry Ford who famously said that people could buy his car in any colour they liked so long as it was black.
Sales people were seen as manipulators seeking to change the buyers’ perceptions to suit the limitations of the product.
Today, people can buy a car in almost any colour they like. More than that, they can change the colour of the interior to personalise the car to suit their fancy and the salesperson has transformed into someone who understands the importance of individualisation and helps the buyer navigate the plethora of choices.
In many respects, the world of asthma management is similar. In the old product-centred world, two major manufacturers made very similar products and sold them on the basis of relatively minor differences.
Today there are a wide variety of options available and the future promises even more. Just as in the commercial world, the age of patient-centricity is all about choice.
It’s easy to imagine that in the age of patient-centricity, adherence is seen as a measure of how well a medication meets patients’ needs, rather than a measure of how badly a patient does what they are told.
It’s early days, but the two major manufacturers appear to be headed down different paths in the development of ICS treatments that meet patients’ needs.
One strategy seems to be about simplification – a once-daily dose will lead to better adherence, while the other strategy seems to be more about individualisation with as-needed dosing. These strategies need time to unfold, gather evidence about their effectiveness and then evolve further. There are certainly interesting times ahead.
THE DOCTORS’ ROLE
It’s easy to imagine that doctors are trying to figure what they should do now.
There has been a fundamental change in the GINA recommendations and changes in treatment options are emerging. Doctors are surely asking themselves: which option is better? What should I recommend to my patients, and why? These are all old-world questions.
Maybe some are wondering which option is better suited to which patients? While this is a better question, because it recognises that different patients are different, it still misses the point. In the age of patient-centricity, the doctor’s role has evolved into helping patients make the choice for themselves.
Now the questions are more about: how can I best explain the options to my patients and help them to decide which suits them best? Now, adherence is more a measure of the extent to which the service provided by the doctor and the medication are meeting the patients’ needs.
Peter Everett is a research and communications consultant with a keen interest in the role of patient behaviour and patient experience in determining clinical outcomes
References:
Global Initiative for Asthma. Global Strategy for Asthma Management and Prevention, 2019. Available from: www.ginasthma.org
lReddel HK et al GINA 2019: a fundamental change in asthma management Treatment of asthma with short-acting bronchodilators alone is no longer recommended for adults and adolescents. Eur Respir J 2019; 53: 1901046.
Wikipedia. History of Google. Accessed August 2019. Access at: https://en.wikipedia.org/wiki/History_of_Google
O’Byrne PM et al The SYGMA programme of phase 3 trials to evaluate the efficacy and safety of budesonide/formoterol given ‘as needed’ in mild asthma: study protocols for two randomised controlled trials. Trials 2017; 18:12
O’Byrne PM et al Inhaled Combined Budesonide–Formoterol as Needed in Mild Asthma. NEJM 2018; 378:1865-1876.
Bateman ED et al As-Needed Budesonide–Formoterol versus Maintenance Budesonide in Mild Asthma. NEJM 2018; 378:1877-87.
Normansell R et al Interventions to improve adherence to inhaled steroids for asthma. Cochrane Database Syst Rev. 2017 Apr; 2017(4): CD012226.
