Achieving Good Outcomes for Asthma Living (GOAL): mixed methods feasibility and pilot cluster randomised controlled trial of a practical intervention for eliciting, setting and achieving goals for adults with asthma.

Gaylor Hoskins,Petra Rauchhaus,Brian Williams,Marjon van der Pol,Peter Donnan,Purva Abhyankar,Aziz Sheikh,Hilary Pinnock,Anne Taylor,Edward Duncan

doi:10.1186/s13063-016-1684-7

Abstract

BackgroundDespite being a core component of self-management, goal setting is rarely used in routine care. We piloted a primary care, nurse-led intervention called Achieving Good Outcomes for Asthma Living (GOAL) for adults with asthma. Patients were invited to identify and prioritise their goals in preparation for discussing and negotiating an action/coping plan with the nurse at a routine asthma review.MethodsThe 18-month mixed methods feasibility cluster pilot trial stratified and then randomised practices to deliver usual care (UC) or a goal-setting intervention (GOAL). Practice asthma nurses and adult patients with active asthma were invited to participate. The primary outcome was asthma-specific quality of life. Semi-structured interviews with a purposive patient sample (n = 14) and 10 participating nurses explored GOAL perception. The constructs of normalisation process theory (NPT) were used to analyse and interpret data.ResultsTen practices participated (five in each arm), exceeding our target of eight. However, only 48 patients (target 80) were recruited (18 in GOAL practices). At 6 months post-intervention, the difference in mean asthma-related quality of life (mAQLQ) between intervention and control was 0.1 (GOAL 6.20: SD 0.76 (CI 5.76–6.65) versus UC 6.1: SD 0.81 (CI 5.63–6.57)), less than the minimal clinically important difference (MCID) of 0.5. However, change from baseline was stronger in the intervention group: at 6 months the change in the emotions sub-score was 0.8 for intervention versus 0.2 for control. Costs were higher in the intervention group by £22.17.Routine review with goal setting was considered more holistic, enhancing rapport and enabling patients to become active rather than passive participants in healthcare. However, time was a major barrier for nurses, who admitted to screening out patient goals they believed were unrelated to asthma.ConclusionsThe difference in AQLQ score from baseline is larger in the intervention arm than the control, indicating the intervention may have impact if appropriately strengthened. The GOAL intervention changed the review dynamic and was well received by patients, but necessitated additional time, which was problematic in the confines of the traditional nurse appointment. Modification to recruitment methods and further development of the intervention are needed before proceeding to a definitive cluster randomised controlled trial.Trial registration ISRCTN18912042. Registered on 26 June 2012.Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-016-1684-7) contains supplementary material, which is available to authorized users.

Highlights

Despite being a core component of self-management, goal setting is rarely used in routine care
The Good Outcomes for Asthma Living (GOAL) intervention changed the review dynamic and was well received by patients, but necessitated additional time, which was problematic in the confines of the traditional nurse appointment
Based on our previous experience working with asthma-trained nurses in primary care [59] and the published literature [60], we aimed to recruit 80 patients with active asthma from eight practices across two health boards (i.e. 10 patients per practice resulting in 40 in each arm) in the hope that this would allow sufficient data to estimate recruitment, compare the groups, calculate the intra-cluster correlation coefficient (ICC), estimate effect size, explore the acceptability of the goalsetting tool and be a small enough target for each practice to achieve with relative ease

Summary

Introduction

Despite being a core component of self-management, goal setting is rarely used in routine care. PAAPs focus on adherence to medication/monitoring and early recognition/remediation of exacerbations and are core components of effective self-management [29,30,31,32,33] They do not incorporate the wider needs and views of the individuals who have to integrate the management of the disease into their daily lives. Divergent perceptions of asthma and how to manage it, and a mismatch between what patients want and need from plans and what is provided by professionals, are barriers to success [29, 30, 33] To overcome these barriers, there is a need both to identify and address individual patient goals [36] in the wider context of their life and family [33]. Active patient engagement allied with appropriate selfmanagement training of motivated and supported health professionals are key elements for any effective self-management intervention [28]

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