Insight Into Patient Dissatisfaction With Asthma Treatment

Background  Measures of patient satisfaction or dissatisfaction with treatment are increasingly being used as indicators of quality of care. As these measures become more widely used, it is important to know if patient dissatisfaction is associated with important processes or outcomes of medical care.

Methods  Survey of patient-reported asthma management issues using the Asthma Therapy Assessment Questionnaire in a large health maintenance organization in the Pacific Northwest. Associations between patient dissatisfaction with asthma treatment and patient-reported measures of asthma control, patient-provider communication, and belief in asthma medications (self-efficacy) were examined.

Results  Of the 5181 adult members with asthma enrolled in the health maintenance organization, 30% indicated dissatisfaction with current treatment. Dissatisfaction was higher among patients with a higher number of asthma control problems, patient-provider communication problems, or belief in medication problems (eg, failure to believe their medications are useful and inability to take asthma medications as directed). The odds of dissatisfaction with treatment were 2.8 (95% confidence interval [CI], 2.4-3.3; P<.001) for asthma control problems, 2.0 (95% CI, 1.6-2.6; P<.001) for communication problems, and 8.0 (95% CI, 6.7-9.5; P<.001) for belief in medication problems compared with patients without these perceived problems.

Conclusion  Patient dissatisfaction with treatment may be related to important asthma disease management issues.

WITH THE prevalence of asthma on the rise¹ and the annual cost associated with the disease exceeding $5.8 billion (in 1994 dollars),² providers and payers are interested in evaluating the outcomes of asthma care.³ In the past, clinical and economic outcomes of asthma care received attention.^4-8 However, evaluation of patient care across a range of medical conditions increasingly includes measures of patient satisfaction.^9-18 Managed care organizations have started to incorporate patient satisfaction in their report cards to assess the performance of the plans and the quality of patient management programs.^17,19-21 Added importance of patient satisfaction measures may result from the work of the National Committee for Quality Assurance and the Foundation for Accountability, since these organizations have suggested that health plans use patient satisfaction to evaluate care.^22-25 In this context, the potential is large for measures of patient satisfaction or evidence of dissatisfaction to drive accountability and infer level of quality or value of health care.

Most health care research on patient satisfaction has focused on satisfaction with generic aspects of patient care, such as office hours or helpfulness of the staff. It is also reasonable to ask patients with chronic diseases about their satisfaction with treatment, since it is the specific treatment that will likely have the greatest impact on patient outcomes. In addition, patients are generally asked about their overall level of satisfaction as opposed to whether they are dissatisfied with any part of their care. It is possible that the important improvements needed in health care may best be obtained by assessing whether there is evidence of dissatisfaction. This study extends the research on patient satisfaction by specifically studying whether there is evidence of dissatisfaction with asthma treatment and then identifying processes of care associated with treatment dissatisfaction. In addition, we examine whether dissatisfaction is associated with level of asthma control (an outcome of treatment). The findings from this study provide insights into potential areas that may be targets for quality improvement programs.

We studied factors associated with patient dissatisfaction with asthma treatment at Kaiser Permanente, Northwest Region, a large group-model health maintenance organization with approximately 430 000 covered lives, centered in Portland, Ore. The study population was selected based on the following criteria: age of 18 years or older, 2 or more anti-asthma medication dispensings in 1996, and/or a hospital or emergency department visit in 1994, 1995, or 1996. In addition, all individuals needed to have current health plan coverage as of June 1997. The Asthma Therapy Assessment Questionnaire (ATAQ), a 2-page screening questionnaire designed to identify possible disease management problems for patients diagnosed as having asthma, was sent between August and September 1997 to 13 964 members who met the selection criteria. Additional information about the sampling design can be found elsewhere.²⁶ Of the 62% of individuals who responded to the survey, we analyzed data for the 5181 individuals (60%) who reported that they had physician-diagnosed asthma and had taken asthma medications within the past 12 months. Further analysis for this study is based on the results obtained from these 5181 respondents.

All data presented herein come from the ATAQ, which was developed as a disease management tool to identify individuals whose asthma management may be suboptimal. This brief, self-administered questionnaire assesses several asthma management domains and levels of asthma control.²⁶ It also includes several additional items, such as whether the patients have been told by a provider that they have asthma, whether they have been told they have chronic obstructive pulmonary disease (COPD), and whether they were currently taking medication for asthma. For this study, we examined the relation between patient treatment dissatisfaction and 3 patient-reported measures: (1) level of asthma control, (2) patient-provider communication, and (3) belief in medication.

Patient dissatisfaction was assessed by the question, "Are you dissatisfied with any part of your current asthma treatment?" Patients could respond yes, no, or unsure. We combined the yes and unsure response categories, so patients expressing no dissatisfaction with asthma treatment were distinguished from those who were or might be dissatisfied.

To assess level of asthma control, the ATAQ asks about the following: (1) self-perception of asthma control; (2) missed work, school, or normal daily activities due to asthma; (3) nighttime waking due to asthma symptoms; and (4) use of "quick relief" inhaler medication (defined in terms of the number of puffs a day the patient took the inhaler). All items ask about control in the past 4 weeks. Respondents were assessed as either having or not having a control problem in each of these dimensions, and the number of control problems was then summed to provide an index ranging from 0 to 4.

To assess patient-provider communication, the ATAQ asks about the following: (1) physician or medical provider review of medications, (2) physician or medical provider involvement of the patient in decision making, (3) physician or medical provider knowledge of patient medication preferences, (4) patient having an action plan for asthma attacks, and (5) patient having an action plan when not having an asthma attack. Respondents were assessed as either having or not having a patient-provider communication problem in each of these dimensions, and the number of problems was then summed to provide an index ranging from 0 to 5.

To assess patients' belief in medication, the ATAQ asks about the following: (1) patients' belief in the usefulness of their asthma medications to control their asthma and (2) belief that they can take their medications as directed. Respondents were assessed as either having or not having a belief in medication problem in each of these dimensions, and the number of problems was then summed to provide an index ranging from 0 to 2.

Most of the questions comprising the asthma control, patient-provider communication, and belief in medications domains had yes, no, and unsure response options. For some questions, a yes indicated a potential problem in asthma management, whereas for other questions the no response was an indicator of a potential asthma management problem. The unsure responses were grouped with the question-specific answer that indicated a potential problem in asthma disease management.

Bivariate associations were assessed between patient dissatisfaction with their current asthma treatment and each of the individual questions that comprise the asthma control, patient-provider communication, and belief in medication domains as well as the count of the number of problems observed within each domain. χ² Tests with continuity corrections were used for the 2 × 2 tables. Mantel-Haenszel tests for trends were used to evaluate treatment dissatisfaction by the number of problems observed within each domain. Other bivariate associations were assessed with a general Pearson χ² test. Next, we ran a logistic regression analysis of patient dissatisfaction. The logistic model included variables for patient age (18-25, 26-45, 46-55, 56-65, and >65 years), sex, coexistence of COPD and indicator variables for the presence of asthma control problems, patient-provider communication problems, and belief in medication problems (one or more issues = 1, no issues = 0). Odds ratios (ORs) and 95% confidence intervals (CIs) are presented for the logistic regression. A separate logistic regression model was also analyzed to study the influence of the individual questions of the asthma control, patient-provider communication, and belief in medication domains.

Sixty-seven percent of the respondents were female. The age distribution of the study population was as follows: 36% were 18 to 45 years, 40% were 46 to 65 years, and 24% were older than 65 years. The proportion of the population with both asthma and COPD was 19.4%. Overall, 30% of the patients were dissatisfied with their asthma treatment as indicated by a yes or unsure response to the question. The percentage dissatisfied did not vary significantly by patient age (P = .10). Men were somewhat more dissatisfied than women (32.1% vs 29.3%, respectively; P = .05). A greater percentage of patients with asthma and COPD were dissatisfied compared with those without COPD (33.5% vs 29.2%, respectively; P = .02).

Figure 1 shows the association between the number of asthma disease management problems and patient dissatisfaction with treatment. The proportion of respondents who reported dissatisfaction with their asthma treatment was directly related to increasing numbers of control problems. For example, among those who had no (0) control problems, 16% were dissatisfied, whereas among patients with 4 control problems, 70% were dissatisfied. Similarly, the proportion of patients who reported dissatisfaction increased with increase in communication and belief in medication problems. All 3 associations were significant (P = .001). Table 1, Table 2, Table 3, and Table 4 explore these associations in greater detail by looking at the association of dissatisfaction with each component of these 3 indices.

Analysis of individual asthma control problems (Table 1) revealed more than half of the patients being dissatisfied with their asthma treatment if they thought in the past 4 weeks their asthma was not controlled (58.5%), they missed activities due to asthma (50.5%), or they were high users of quick relief medication (53.9%). Interestingly, only 41.8% of patients waking up at night because of their asthma were dissatisfied with their treatment. In contrast, between 18% and 29% of the patients were dissatisfied with their treatment when they did not have one of these asthma control problems.

Table 2 shows the distribution of patient-provider communication problems. Among all the patient-provider communication issues studied, the highest percentage of treatment dissatisfaction was observed among patients who reported that their physician or medical provider did not involve them in treatment decisions (49.8%) and among patients who reported that their physician or medical provider did not know their medication preferences (46.7%).

Table 3 summarizes the association of dissatisfaction with the 2 beliefs in medication issues: ability to take medications as directed and belief that medication is useful in controlling asthma. These 2 problems exhibited the strongest associations with dissatisfaction, with 64.6% and 74.9% of the patients who reported these problems, respectively, indicating dissatisfaction with their current asthma treatment.

The presence of asthma control problems, patient-provider communication problems, and belief in medication problems was significantly associated with treatment dissatisfaction in logistic regression analysis that adjusted for patient age, sex, and coexistence of asthma and COPD (Table 4). The odds of dissatisfaction with asthma treatment were almost 3 times higher for patients with asthma control issues (OR, 2.8; 95% CI, 2.4-3.2; P<.001) and 2 times higher for patients with patient-provider communication issues (OR, 2.0; 95% CI, 1.6-2.6; P<.001) compared with patients without these perceived problems. Patients with belief in medication issues had an odds of dissatisfaction that was 8 times higher (95% CI, 6.7-9.5; P<.001) than patients without these medication problems. The C statistic²⁷ for the logistic regression model was 0.77, indicating a good fit of the model to the study population.

Not shown, a separate logistic regression model was used to analyze the influence of individual components of the asthma control, patient-provider communication, and belief in medication domains. Three items in the patient-provider communication domain were not significantly associated with treatment dissatisfaction: (1) if the physician or medical provider had reviewed medications with the patient in the last year, (2) if the patient had a written treatment plan for asthma attacks, and (3) if the patient had a written treatment plan when not having an asthma attack. All other questions comprising the patient-provider communication domain and all questions of the asthma control and belief in medications domains were significantly associated with treatment dissatisfaction in the direction anticipated.

Thirty percent of the adult patients with asthma in our study population were dissatisfied with their current asthma treatment. Dissatisfaction was significantly associated with asthma control problems, patient-provider communication problems, and issues with the patients' belief in their medication. The findings of this study suggest that important aspects of care are associated with patient dissatisfaction with asthma treatment, implying that evidence of patient dissatisfaction may warrant serious consideration in quality improvement programs.

Insufficient knowledge and inappropriate beliefs about asthma are considered major barriers to self-management of asthma.^28,29 Our study suggests that patient confidence in their medications and their ability to take the medications as directed have a profound influence on dissatisfaction with treatment. The odds of treatment dissatisfaction were 8 times higher among patients who reported uncertainty about the efficacy of their asthma medication or their ability to take the medication as directed than those without these disease management problems. Given the current state of asthma treatment, it should be possible to identify regimens that patients believe will control their disease and that they can follow as directed by their providers.

The way physicians or medical providers interact with patients appears to have an important influence on patient dissatisfaction. Among patients who believed that they were not involved in decision making, half were dissatisfied with their current treatment. This could be partly because of restriction in time that physicians spend with their patients during a regular visit and current pressure to improve the efficiency of health care provision.^30-32 In another study, assessing the effectiveness of a one-on-one nurse education program, Forshee at al³³ found that better patient education and improved communication between patient and provider were associated with decreased urgent care utilization and hospital admission rates. If there is a link between lack of patient-provider communication, dissatisfaction with treatment, and resource use, approaches to improving communication should be explored. Interestingly, lack of written treatment plans was not associated with treatment dissatisfaction in our multiple logistic regression models. Lieu and colleagues⁴ showed that having a written treatment plan is associated with reduced health care utilization. These findings raise the possibility that the verbal communication between the patient and provider that accompanies the treatment plan may be as important as the written document. Provider education and availability of office-based tools such as templates for treatment plans could foster communication and possibly decrease patient dissatisfaction, particularly if actual communication is fostered by having these office-based tools.^15,32

Although patient-provider communication and belief in medications are measures of process of care, level of asthma control is a measure of the outcome of care. In this study, patients with worse clinical outcomes, as measured by asthma control problems, were more dissatisfied with their treatment than patients with better clinical outcomes. A study by Vollmer et al²⁶ demonstrated the cross-sectional association of asthma control issues with quality of life and self-reported health care utilization. Although the relation between satisfaction and resource use was not assessed in that study, Druss et al,³⁴ found patient dissatisfaction (in terms of low level of satisfaction) to be associated with health care utilization. The results from these 2 studies indicate the potential for the measures of dissatisfaction to be associated with other important outcomes of care.

The findings from this study raise concern about whether or not patients are reluctant to express dissatisfaction with treatment. Not all patients with disease management problems were dissatisfied. For example, about half of the patients with nocturnal asthma did not report dissatisfaction, indicating that perhaps patients with asthma may accept a lower level of functioning than possible.

A study by Osman³⁵ suggests that patients are not always able to raise to their providers all the asthma-related issues that are important to them. In addition, past studies^9,11 suggest that patients want more information on the nature of their disease and medication use and seek better relationships with their physicians. In this context, a disease management tool such as the ATAQ may be useful to evaluate asthma management problems that may influence treatment dissatisfaction and that can be verified and followed up by a health care provider.

The results of this study only represent the perspective and disease management problems experienced by the responders of the survey. Whether the nonresponders are more or less dissatisfied with their current asthma treatment is unknown. Also, the outcome measure (patient dissatisfaction with asthma treatment) and the tools for measuring the 3 disease management constructs are both subjective measures and subject to the same limitations associated with patient-reported data. Although the study results have depicted a distinctive relation between patient dissatisfaction and the 3 asthma disease management constructs, only future research can quantify whether positive steps contributing to improvement in each of these 3 disease management domains can decrease patient dissatisfaction. In addition, disease management constructs (such as patient concern with involvement in decision making) may be another measure of dissatisfaction. There is not a clear conceptual framework for the factors that influence patient dissatisfaction with asthma treatment. It is possible that other important factors associated with treatment dissatisfaction were not measured in this study.

Apart from marketing research, patient satisfaction is increasingly being used as an outcome measure for clinical trials and disease management programs,³⁶ and further consideration should be given to the distinctions between measures of satisfaction and evidence of dissatisfaction. This study has highlighted the fact that patient dissatisfaction can reflect poor disease outcome (ie, poor asthma control), problems with the process of care (in terms of communication issues such as physician understanding of patient preference), and problems related to the patients' belief in their medication. The findings further support the idea that concentrating on more personal care would result in better communication and more patient involvement, resulting in better quality of care and hence decreased patient dissatisfaction.³⁷ Overall, our findings suggest that when patients express dissatisfaction with current asthma treatment, there may be disease management problems that can be rectified to potentially improve patient outcomes.

Accepted for publication August 31, 2000.

Corresponding author and reprints: Leona E. Markson, ScD, Outcomes Research and Management, Merck & Co, Inc, PO Box 4, WP39-164, West Point, PA 19486-0004.