1. 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

2. 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?

3. 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

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

5. 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

6. 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)

7. 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

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

9. 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%

10. 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%

11. Total scores in France and the UK

12. 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).

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

20. 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°

21. 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?

22. THANK YOU Project funded by the European Commission through the Seventh Framework Programme under GA n°