Assessing adherence to asthma medication and inhaler regimens: a psychometric analysis of adult self-report scales

Poor adherence to recommended regimens is a substantial problem in the clinical management of adults with asthma and other chronic diseases. Research on adherence assessment is complicated by methodological difficulties including limitations associated with the use of self-report measures. In this study, psychometric techniques were used to analyze two self-report scales for assessing adherence to recommended medication and inhaler use regimens in adults with asthma. Results indicated that the two scales had standard deviations large enough to detect variation adherence, had adequate reliability, and reflected the impact of an intervention designed to improve adherence. The results supported the usefulness of these scales for research on adherence. Additional analyses indicated that the two scales could be combined if the research goal required an overall measure of adherence.

Scale for assessing functional impairment in adults with asthma

Improved outcome measures for asthma research, especially measures of functional status and quality of life, have become increasingly important. This research describes one such measure, the University of Alabama at Birmingham (UAB) Functional Impairment Scale. This scale consists of eight items to assess the impact of asthma on various aspects of daily living. The psychometric properties of the UAB Scale were assessed in two samples. The coefficient alpha reliabilities were high in both samples (.83 and .84), and the item-total correlations indicated all items were measuring the same trait. The score distributions covered the entire range of possible scores, and the central tendencies and dispersions confirmed the presence of enough variation to detect differences in functional impairment among individuals. Correlations between the UAB Scale and other asthma-related measures support construct validity. All of these results support the potential usefulness of the UAB Scale.

Hip osteonecrosis secondary to the administration of corticosteroids for feigned bronchial asthma. The clinical spectrum of the factitious disorders

We describe the case of a woman who developed hip osteonecrosis after prolonged use of corticosteroids for feigned bronchial asthma. This type of musculoskeletal manifestation of the factitious disorders has not been reported previously.

Phytoparasitic Nematode Populations in Festuca arundinacea Field Plots in Southwestern Missouri

Field plots of tall rescue (Festuca arundinacea) at two locations on the same experimental farm in southwestern Missouri were sampled (one in 1987-88, the other in 1988-89) to inventory root-parasitic nematodes and to determine whether cultivars or endophyte (Acremonium coenophialum) infection frequencies (EIF) affected nematode population densities within single growing seasons. Plots were planted with seven tall rescue cultivars: Kentucky-31, Kenhy, Johnstone, Martin, Mozark, Missouri-96, and Forager. Kentucky-31 seed with high and low EIF were planted in separate plots. Plant-parasitic nematodes were extracted from soil samples, identified to genus, and enumerated four and three times per year for the 1987-1988 and 1988-1989 studies, respectively. Several plant-parasitic genera were identified from both fields, including Helicotylenchus, Heterodera, Hoplolaimus, Paratylenchus, Pratylenchus, Tylenchorhynchus, and members of genera grouped in the family Tylenchidae. Densities of five of these seven groups of nematodes differed among tall fescue cultivars in the 1987-88 study, but only two out of eight groups did so in the 1988-89 study. Irrespective of tall rescue cultivar, EIF had no consistent impact on nematode densities. The putative suppressive effect of endophyte infection on infection by plant-parasitic nematodes is not detectable within single growing seasons and deserves long-term study in field situations.

Use of focus group methodology to develop an asthma self-management program useful for community-based medical practices

Health education programs developed in academic medical centers are not optimally disseminated to community clinical settings. Strategies are needed to translate the findings of research on health education programs into programs useful in a wide range of health care settings. Focus group techniques were used to provide data for revising a successful university-based asthma self-management program to make it more practical for use by community physicians. Physicians representing a variety of specialties attended the sessions and provided feedback on the utility of various components of the original program. The discussions revealed that many physicians felt they did not have the time or resources to conduct the original program and identified elements viewed as impractical. This physician input contributed significantly to the development of a revised program with a briefer, less costly intervention. The revised program was later evaluated by focus group participants. Eighty-eight percent of those who evaluated the revised program agreed they would be able and willing to use the program in their own practices. As a formative evaluation tool, the focus group technique made available useful information that would have been difficult to obtain through evaluation forms alone.

Design of the Lung Health Study: a randomized clinical trial of early intervention for chronic obstructive pulmonary disease

The Lung Health Study is a multicenter randomized clinical trial. Participants are smokers aged 35-60 with spirometric evidence of moderate lung function impairment. The objective of the trial is to determine whether a program of smoking intervention and use of an inhaled bronchodilator can slow the rate of decline in pulmonary function over a 5-year follow-up period. This paper describes the background, design, sample size (approximately 6000 participants), and power estimates for the trial, as well as the treatment program and the rationale for the choice of inhaled bronchodilator. Plans for analysis of changes in pulmonary function parameters and for analysis of participants' survival and smoking-related morbidity are also discussed.

Asthma severity: a factor analytic investigation

PURPOSE

Reviewers of the asthma research literature have called for improved questionnaires and other measures, particularly for assessing the severity of asthma. To help meet this need, standard multivariate and psychometric techniques were used with data from asthma patients to develop and evaluate a series of scaled questions. Since there is no "gold standard" for assessing asthma severity, we hope this analysis will help improve our ability to more precisely define these important parameters.

PATIENTS AND METHODS

Data were collected through interviews and review of clinic records for 199 adult patients with asthma from a university clinic population. For evaluating the severity of asthma, eight scales assessed asthma duration, the incidence of asthma symptoms, the extent to which asthma is an inconvenience to patients, the incidence of respiratory diseases, medication regimens, medication side effects, and health care utilization. Forced expiratory volume in 1 second as a percentage of predicted normal was included as an objective measure of pulmonary function. A physician rating scale assessed the severity of the underlying disease, not the severity of a particular episode, as either (1) mild (infrequent attacks with interim symptomatic treatment), (2) moderate (more frequent attacks with continuous daily treatment), and (3) severe (continuous symptom with continuous multiple drug regimen, including some systemic steroids).

RESULTS

In the current analysis of data from adult asthma patients, the scales correlated positively with a physician judgment scale. Factor analysis with an oblique rotation yielded three factors that provided a concise summary of asthma severity. We have named the factors (A) Symptom Intensity, (B) Airflow Impairment, and (C) Management Intensity.

CONCLUSION

Asthma severity appears to be multidimensional rather than unidimensional, including at least three components. The physician rating scale, in combination with measures of the three identified factors, could easily be included in other asthma research protocols to provide a standard, brief assessment of asthma severity and might thus promote greater comparability among studies.

Features of asthma in older adults

A study compared clinical and functional features of elderly patients with asthma to younger patients at a university medical center. Older patients had a larger than predicted reduction in pulmonary function parameters even though physician-assessed severity, duration of diagnosed asthma, and smoking status were no different between groups. A significant increase in the comorbid diagnosis of chronic obstructive pulmonary disease was noted in older patients with asthma. These two points support the hypothesis that long-standing asthma may lead to irreversible airflow obstruction. Older patients reported better medication compliance and decreases in some respiratory symptoms and demonstrated lower health care utilization.

Medication adherence patterns in chronic obstructive pulmonary disease

While medical treatment of COPD has advanced, the failure to adhere to regimens for medication poses a significant barrier to effective management. Furthermore, no data are available regarding adherence for patients within the United States. Data from this investigation indicate that 78 outpatients from a medical center in the southeastern region of the United States were prescribed an average of 6.26 medications with both various dosing schedules and different modes of administration. Adherence was poor, with 42 patients (54 percent) underutilizing medications, 39 patients (50 percent) overutilizing medications during periods of respiratory distress, and 24 patients (31 percent) employing ineffective inhaler dosing techniques. Prescription patterns and adherence were not associated with demographic variables; however, adherence was related to classes of medication and situational variables.

Evaluation of the efficacy and cost effectiveness of health education methods to increase medication adherence among adults with asthma

We randomized 135 adult asthma patients to a control group, and 132 patients to an experimental group which received a special health education intervention. Four adherence measures were documented at baseline and 12-month follow-up: correct inhaler use, inhaler adherence, medication adherence, and total adherence rating. Costs to routinely deliver the intervention were $32.03/patient. Experimental group patients exhibited a significantly higher level of improvement in adherence (44 percent) than control group patients (2 percent).

Characteristics and correlates of asthma in a university clinic population

To contribute more comprehensive information about the characteristics of asthma, this article analyzed patients served by the University of Alabama at Birmingham Comprehensive Asthma Program. Their physicians rated one fifth of these patients as having "severe" asthma with the remainder about equally divided between "moderate" and "mild". One in two first received a diagnosis of asthma ten or more years previously. Common comorbidities were hypertension, obesity, rhinitis, bronchitis, sinusitis, and arthritis. One half had visited an emergency room or been hospitalized for asthma in the past year. Inhaled bronchodilators and continuous theophylline were the most commonly prescribed medications. Side effects, especially tachycardia and insomnia, were common and almost exclusively associated with theophylline or corticosteroid therapy. Spirometric assessment showed chronic airflow obstruction in those with more severe asthma. Prevalence of respiratory symptoms, intensity of medication regimen, incidence of side effects, and health care utilization increased as asthma severity increased.

A randomized trial to improve self-management practices of adults with asthma

The prevalence and impact of adult asthma are substantial, and poor self-management practices, especially failures to adhere to treatment regimens, appear to be a significant problem. Desirable characteristics of an intervention program to improve self-management were identified through needs assessment and review of existing patient education resources. A comprehensive program was developed that integrated a workbook with one-to-one counseling and adherence-enhancing strategies. A longitudinal 1-year study compared patients receiving this self-management program with "usual care" patients receiving standard asthma pamphlets. Patients were randomly assigned to conditions. Baseline score and asthma severity were statistically controlled. Self-management patients had substantially better adherence than usual care patients, as well as improved functional status, at follow-up. Hospital and emergency department visits decreased in both groups but did not differ between groups.

Why tuberculosis is not prevented

Because of the effectiveness of isoniazid in treating tuberculosis infection, progression to tuberculosis should be largely preventable. Thus, each case of tuberculosis that occurs may be viewed as a "failure" of the prevention system. We studied the reasons for these "failures" at three centers in different geographic areas in the United States. Two hundred seventy-nine patients with bacteriologically confirmed tuberculosis were evaluated by means of a questionnaire. Our results suggest three main reasons for these missed opportunities of tuberculosis prevention. (1) Patients are out of the health care system until they develop tuberculosis. (2) Patients are in the system but are either not screened for tuberculous infection or, if screened, are not offered preventive therapy when it is appropriate. (3) Because of false negative skin test results, screening may be ineffective at the time it is applied. Advances in tuberculosis prevention will require attention to these areas.

Corticosteroids in asthma

The use of corticosteroids in the treatment of asthma has significantly decreased the morbidity and mortality from this disease. However, corticosteroids have devastating side effects when given frequently or for prolonged periods. High doses of systemic corticosteroid preparations should be used only during bouts of acute bronchospasm, whereas the lowest possible dose needed to control symptoms is recommended for the treatment of chronic asthma. Aerosolized steroids offer an alternative to systemic preparations and have less associated morbidity. Various corticosteroid preparations have various potencies and durations of action that need to be considered. Patients with coexisting liver disease require preparations that do not need hepatic hydroxylation, whereas patients with congestive heart failure require preparations that minimize salt retention. When asthma and pregnancy coexist, it is vital that symptoms of bronchospasm are controlled to protect the fetus. During stressful situations, such as surgery, it is important to consider the possibility of hypothalamic-pituitary-adrenal axis suppression if the asthmatic patient has been previously treated with corticosteroids.

Peak flow meters: are they monitoring tools or training devices?

Previous studies have been inconclusive as to whether peak flow meter use teaches asthma patients to better perceive their own pulmonary functioning. This investigation utilized a delayed baseline design to determine if pulmonary awareness could be improved among a sample of 24 adult patients who compared daily peak expiratory flow rates (PEFR) with asthma symptom ratings. Results indicated that among this sample of adult patients: (i) perception of pulmonary functioning was poor, (ii) adherence to peak flow meter use was poor, and (iii) among patients who use peak flow meters daily, self-perception of pulmonary functioning did not improve significantly. Summary tables and descriptive statistics for pulmonary functioning are provided, and treatment implications are discussed.