Planning a digital intervention for adolescents with asthma (BREATHE4T): A theory-, evidence- and Person-Based Approach to identify key behavioural issues.

OBJECTIVES: To describe a transparent approach to planning a digital intervention for adolescents to self-manage their asthma using breathing retraining (BRT), based on an existing, effective adult intervention (BREATHE). METHODS: A theory-, evidence-, and Person-Based Approach was used to maximise the effectiveness and persuasiveness of the intervention. A scoping review and semistructured interviews with target intervention users (N = 18, adolescents aged 12-17 years with asthma and parents) were carried out to explore user perspectives, barriers, and facilitators towards the intended behaviours and potential intervention features. The combined evidence was used alongside and to inform theory-based activities and enabled iterative planning of the intervention. RESULTS: The scoping review identified themes relating to user-specific self-management issues, content, education, training needs, and features for a digital intervention. Interviews elicited potential barriers to intended behaviours such as the anticipated embarrassment of using BRT and concerns around remaining calm. Facilitators included BRT delivered by adolescents who share experiences of asthma and information for performing exercises discreetly. Relevant theoretical frameworks ensured that appropriate psychological constructs were targeted. A behavioural analysis identified six intervention functions and thirty behaviour change techniques. Logic modelling mapped the programme theory and mechanisms, which aims to improve adolescent asthma-related quality of life. CONCLUSIONS: This study gives a transparent insight into the approach followed to plan a self-guided BRT intervention for adolescents and has led to identification of key behavioural issues, enabling relevant intervention content to be chosen. Insight has been given into adolescent perceptions of BRT, which facilitated development of the prototype intervention.

Physiotherapy breathing retraining for asthma: a randomised controlled trial.

BACKGROUND: Despite effective pharmacotherapy, asthma continues to impair quality of life for most patients. Non-pharmacological approaches, including breathing retraining, are therefore of great interest to patients. However, clinicians rarely advocate breathing retraining and access to this intervention is restricted for most patients due to the limited availability of suitable physiotherapists and poor integration of breathing retraining into standard care. We aimed to assess the effectiveness of a digital self-guided breathing retraining intervention. METHODS: In this randomised controlled trial, we recruited patients from 34 general practices in the UK. Eligibility criteria for patients with asthma were broad, comprising a physician diagnosis of asthma, age of 16-70 years, receipt of at least one anti-asthma medication in the previous year, and impaired asthma-related quality of life (Asthma Quality of Life Questionnaire [AQLQ] score of <5·5). We developed a self-guided intervention, which was delivered as a DVD plus a printed booklet (DVDB). Participants were randomly assigned to receive either the DVDB intervention, three face-to-face breathing retraining sessions, or standard care, in a 2:1:2 ratio, for 12 months. Randomisation was achieved using the Southampton Clinical Trials Unit telephone randomisation service by use of random number generators. The primary outcome was the AQLQ score in the intention-to-treat population at 12 months. The trial was powered to show equivalence between the two active intervention groups, and superiority of both intervention groups over usual care. Secondary outcomes included patient-reported and physiological measures of asthma control, patient acceptability, and health-care costs. This trial was registered with International Standard Randomised Controlled Trial Number registry, number ISRCTN88318003. FINDINGS: Between Nov 5, 2012 and Jan 28, 2014, invitations to participate in the study were sent to 15 203 patients with general practitioner-diagnosed asthma, of whom 655 were recruited into the study. AQLQ scores at 12 months were significantly higher in the DVDB group (mean 5·40, SD 1·14) than in the usual care group (5·12, SD 1·17; adjusted mean difference 0·28, 95% CI 0·11 to 0·44), and in the face-to-face group (5·33, SD 1·06) than in the usual care group (adjusted mean difference 0·24, 95% CI 0·04 to 0·44); AQLQ scores were similar between the DVDB group and the face-to-face group (0·04, 95% CI -0·16 to 0·24). There were no significant differences between the randomisation groups in FEV1 or fraction of exhaled nitric oxide. 744 adverse events occurred in 272 patients: 101 (39%) of 261 patients in the DVDB group, 55 (42%) of 132 patients in the face-to-face group, and 132 (50%) of 262 in the usual care group, with patients reporting one or more event. 11 (4%) patients in the DVDB group, four (3%) patients in the face-to-face group, and 20 (8%) patients in the usual care group had a serious adverse event. INTERPRETATION: Breathing retraining programmes improve quality of life in patients with incompletely controlled asthma despite having little effect on lung function or airway inflammation. Such programmes can be delivered conveniently and cost-effectively as a self-guided digital audiovisual programme, so might also reduce health-care costs. FUNDING: UK National Institute of Health Research.

Patients' perceptions of the potential of breathing training for asthma: a qualitative study.

BACKGROUND: Poor symptom control is common in asthma. Breathing training exercises may be an effective adjunct to medication; it is therefore important to understand facilitators and barriers to uptake of breathing training exercises. AIMS: To gain insight into patients' perceptions of breathing training exercises designed to help control asthma symptoms. METHODS: Semi-structured think-aloud interviews were conducted with 29 people with asthma about their views of a booklet on breathing training exercises. RESULTS: Thematic analysis showed breathing training exercises were seen as acceptable in principle because they were viewed as nonpharmacological, holistic, unobtrusive, and likely to increase patient confidence in managing symptoms. Anticipated disadvantages included the time required and perceived irrelevance for those with well-controlled asthma. These views were influenced by prior experience of changing breathing, wanting to self-manage asthma, negative views of medication, and perceived asthma control/severity. Anticipated barriers to carrying out the exercises included difficulties with nose breathing, remembering to do them, and persevering with them. Anticipated facilitators included monitoring tools and social support. CONCLUSIONS: The idea of breathing training was viewed positively as an acceptable non-pharmacological treatment that patients can do discreetly to help them breathe more easily and reduce their reliance on medication. Uptake of breathing training may be greater among those who perceive their asthma as severe and/or have negative views of medication. To enhance uptake, it might be helpful to present breathing training exercises as holistic skills that can also benefit those with mild symptoms.

Prospective analysis of LDL-C goal achievement and self-reported medication adherence among statin users in primary care.

BACKGROUND: Improvements in the control of LDL-C levels have occurred in the past decade due to the introduction of increasingly potent statins, such as atorvastatin and rosuvastatin. Many patients, however, do not achieve their LDL-C goals, which presents a practical dilemma for clinicians and highlights the need to identify adherence problems in a clinically relevant manner. OBJECTIVE: The purpose of this study was to evaluate the relationship between LDL-C goal achievement and both medication adherence and beliefs assessed using structured questioning. METHODS: All patients were aged ≥40 years and participated in the cardiovascular risk factor management program STOP-HF (St. Vincent's Screening To Prevent Heart Failure study). One hundred and eighty-five participants who had been prescribed statins, split between those who achieved and those who did not achieve LDL-C goal, were randomly selected for a prospective study examining the relationship between adherence, assessed by the Morisky Medication Adherence Scale (MMAS), and LDL-C goal achievement. Patients' beliefs about medicines were assessed using the Beliefs about Medicines Questionnaire-General (BMQ-G). Main outcome measures were predictors of LDL-C goal achievement and medication adherence and predictors of adherence among patients using the MMAS. RESULTS: The average age of the selected patients was 64.9 (9.9) years; 45% were male, 46% had hypertension, 17.5% had coronary artery disease, and 10% had diabetes. Questionnaires were answered by 119 patients, 71 of whom (59.7%) were goal achievers. LDL-C goal achievers were more likely to respond to the questionnaires than nonachievers (76.8% vs 52.7%; P = 0.002). Fifty-eight respondents (48.7%) reported that they were not fully adherent to medication and in multivariable analysis were twice as likely to miss LDL-C goal compared with those who were adherent. Approximately 25% of patients who reported nonadherence were intentionally so. Patients' beliefs about medicines were a significant predictor of self-reported adherence but not of LDL-C goal achievement. CONCLUSIONS: Medication nonadherence may be responsible for failure to achieve goal in many patients who are prescribed statins. In routine clinical care, the structured MMAS questionnaire may provide clinicians with an effective tool to assess medication nonadherence in the context of statin therapy failure. STOP-HF ClinicalTrials.gov identifier: NCT00921960.

B-type natriuretic peptide measurement in primary care; magnitude of associations with cardiovascular risk factors and their therapies. Observations from the STOP-HF (St. Vincent's Screening TO Prevent Heart Failure) study.

BACKGROUND: An effective prevention strategy for heart failure in primary care requires a reliable screening tool for asymptomatic ventricular dysfunction. Preliminary data indicate that B-type natriuretic peptide (BNP) may be suitable for this task. However, for the most effective use of this peptide, the interrelationships between associated risk factors and their therapies on BNP, and in particular their magnitude of effect, needs to be established in a large primary care population. Therefore, the objective of the study was to establish the extent of the association between BNP, cardiovascular risk factors and their therapies. METHODS: BNP measurement and clinical review was preformed on 1122 primary care patients with cardiovascular risk factors. Multivariate analyses identified significant associates of BNP concentrations which were further explored to establish the magnitude of their association. RESULTS: Associates of BNP were age (1.36-fold increase in BNP/decade), female (1.28), ß-blockers (1.90), myocardial infarction (1.36), arrhythmia (1.98), diastolic blood pressure; all p<0.01. A novel method was devised that plotted median BNP per sliding decade of age for the various combinations of these principal associates. CONCLUSIONS: The data presented underline the importance of considering several clinical and therapeutic factors when interpreting BNP concentrations. Most of these variables were associated with increased concentrations, which may in part explain the observed false-positive rates for detecting ventricular dysfunction using this peptide. Furthermore, the design of studies or protocols using BNP as an endpoint or a clinical tool should take particular account of these associations. This analysis provides the foundation for age, risk factor and therapy adjusted reference ranges for BNP in this setting.

Acupuncture for respiratory disorder: what's the point?

Acupuncture has been an integral part of Traditional Chinese Medicine for thousands of years. It has been used for the treatment of many painful and nonpainful conditions. Its use within Western medicine has increased since the 1970s and acupuncture is now practiced by a variety of healthcare practitioners across Europe. There is an accepted body of evidence to support the use of acupuncture for back or neck pain. Anecdotal evidence from both clinicians and patients suggests there may be some beneficial effect of acupuncture in the treatment of respiratory symptoms, such as bronchospasm, breathlessness and hyperventilation syndromes. Some respiratory clinicians are introducing acupuncture as a treatment modality for the management of respiratory symptoms, despite the lack of available objective evidence to support this practice. This article reviews the available evidence for the use of acupuncture in respiratory disorders and provides discussion of the methodological issues that are evident within this literature. It also highlights reasons for the lack of objective evidence to support acupuncture for respiratory conditions and the difficulties faced by acupuncture researchers when designing randomized, placebo-controlled trials. Currently, there is insufficient evidence to support a recommendation for the use of acupuncture in respiratory disorders.

Effects of acupuncture as a treatment for hyperventilation syndrome: a pilot, randomized crossover trial.

BACKGROUND: Sustained and subtle hyperventilation can result in a wide variety of symptoms, leading to a chronic condition that has been termed hyperventilation syndrome (HVS). Treatment options include physiotherapy, in the form of breathing retraining (BR), but additional approaches aim to reduce the anxiety that is recognized as being a frequent component of this condition. OBJECTIVES: The aim of this study was to evaluate whether acupuncture is an appropriate treatment for HVS to reduce anxiety, and whether a crossover trial is an appropriate study design to evaluate acupuncture in this condition. DESIGN: A single-blind crossover trial was carried out comparing the effects of 4 weeks (30 minutes twice weekly) acupuncture and BR on patients with HVS. SUBJECTS: Ten (10) patients diagnosed with HVS were recruited to the trial and randomized into two groups. Both groups received acupuncture and BR with a washout period of 1 week. OUTCOME MEASURES: The primary outcome measure used was the Hospital Anxiety and Depression (HAD) Scale. Other outcome measures used were the Nijmegen questionnaire and Medical Research Council Dyspnea scale. RESULTS: The results showed statistically significant treatment differences between acupuncture and breathing retraining, in favor of acupuncture. Reductions were found in the HAD A (anxiety) (p = 0.02) and Nijmegen (symptoms) (p = 0.03) scores. There was no statistical evidence of any carryover effects. However, when graphically examining individual anxiety scores, in those who received acupuncture first, there was a reduction in anxiety levels which persisted through the washout period, suggesting that there may have been some carryover effect from this treatment. CONCLUSIONS: This study suggests that acupuncture may be beneficial in the management of HVS in terms of reducing anxiety levels and symptom severity. However, there may be some carryover effect, after acupuncture treatment, which went undetected because the small sample size. This preliminary study provides the basis for a larger, sufficiently powered and methodologically sound trial.

Job satisfaction of physicians with congruent versus incongruent specialty choice.

Choosing a specialty within the occupation of medicine is problematic given the number of available specialty choices. A need exists for the development and modification of inventories to be used to help students with selecting a medical specialty. Furthermore, ratings of job satisfaction, regardless of specialty, are mixed with some physicians regretting choosing medicine as a career. Despite its use in medical specialty counseling, research is lacking regarding the Medical Specialty Preference Inventory (MSPI). We examined the predictive validity of the MSPI and compared job satisfaction of physicians (N=51) whose specialty was correctly (i.e., congruent) versus incorrectly (i.e., incongruent) predicted by the MSPI. The MSPI correctly predicted the specialty for 33%. Congruent physicians had higher job satisfaction than incongruent physicians. Results of this study may help individuals who provide medical specialty counseling or who are involved in designing tools and implementing programs to assist students with medical specialty decision making.