Improving parental adherence with asthma treatment guidelines: a randomized controlled trial of an interactive website

Exploring the Use of the Behavior Change Technique Taxonomy and the Persuasive System Design Model in Defining Parent-Focused eHealth Interventions: Scoping Review

BACKGROUND

Taxonomies and models are useful tools for defining eHealth content and intervention features, enabling comparison and analysis of research across studies and disciplines. The Behavior Change Technique Taxonomy version 1 (BCTTv1) was developed to decrease ambiguity in defining specific characteristics inherent in health interventions, but it was developed outside the context of digital technology. In contrast, the Persuasive System Design Model (PSDM) was developed to define and evaluate the persuasive content in software solutions but did not have a specific focus on health. Both the BCTTv1 and PSDM have been used to define eHealth interventions in the literature, with some researchers combining or reducing the taxonomies to simplify their application. It is unclear how well the taxonomies accurately define eHealth and whether they should be used alone or in combination.

OBJECTIVE

This scoping review explored how the BCTTv1 and PSDM capture the content and intervention features of parent-focused eHealth as part of a program of studies investigating the use of technology to support parents with therapy home programs for children with special health care needs. It explored the active ingredients and persuasive technology features commonly found in parent-focused eHealth interventions for children with special health care needs and how the descriptions overlap and interact with respect to the BCTTv1 and PSDM taxonomies.

METHODS

A scoping review was used to clarify concepts in the literature related to these taxonomies. Keywords related to parent-focused eHealth were defined and used to systematically search several electronic databases for parent-focused eHealth publications. Publications referencing the same intervention were combined to provide comprehensive intervention details. The data set was coded using codebooks developed from the taxonomies in NVivo (version 12; QSR International) and qualitatively analyzed using matrix queries.

RESULTS

The systematic search found 23 parent-focused eHealth interventions described in 42 articles from various countries; delivered to parents with children aged 1 to 18 years; and covering medical, behavioral, and developmental issues. The predominant active ingredients and intervention features in parent-focused eHealth were concerned with teaching parents behavioral skills, encouraging them to practice and monitor the new skills, and tracking the outcomes of performing the new skills. No category had a complete set of active ingredients or intervention features coded. The two taxonomies conceptually captured different constructs even when their labels appeared to overlap in meaning. In addition, coding by category missed important active ingredients and intervention features.

CONCLUSIONS

The taxonomies were found to code different constructs related to behavior change and persuasive technology, discouraging the merging or reduction of the taxonomies. This scoping review highlighted the benefit of using both taxonomies in their entirety to capture active ingredients and intervention features important for comparing and analyzing eHealth across different studies and disciplines.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-doi.org/10.15619/nzjp/47.1.05.

Digital interventions to improve adherence to maintenance medication in asthma

BACKGROUND

Asthma is the most common chronic lung condition worldwide, affecting 334 million adults and children globally. Despite the availability of effective treatment, such as inhaled corticosteroids (ICS), adherence to maintenance medication remains suboptimal. Poor ICS adherence leads to increased asthma symptoms, exacerbations, hospitalisations, and healthcare utilisation. Importantly, suboptimal use of asthma medication is a key contributor to asthma deaths. The impact of digital interventions on adherence and asthma outcomes is unknown.

OBJECTIVES

To determine the effectiveness of digital interventions for improving adherence to maintenance treatments in asthma.

SEARCH METHODS

We identified trials from the Cochrane Airways Trials Register, which contains studies identified through multiple electronic searches and handsearches of other sources. We also searched trial registries and reference lists of primary studies. We conducted the most recent searches on 1 June 2020, with no restrictions on language of publication. A further search was run in October 2021, but studies were not fully incorporated.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) including cluster- and quasi-randomised trials of any duration in any setting, comparing a digital adherence intervention with a non-digital adherence intervention or usual care. We included adults and children with a clinical diagnosis of asthma, receiving maintenance treatment.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures for data collection. We used GRADE to assess quantitative outcomes where data were available.

MAIN RESULTS

We included 40 parallel randomised controlled trials (RCTs) involving adults and children with asthma (n = 15,207), of which eight are ongoing studies. Of the included studies, 30 contributed data to at least one meta-analysis. The total number of participants ranged from 18 to 8517 (median 339). Intervention length ranged from two to 104 weeks. Most studies (n = 29) reported adherence to maintenance medication as their primary outcome; other outcomes such as asthma control and quality of life were also commonly reported. Studies had low or unclear risk of selection bias but high risk of performance and detection biases due to inability to blind the participants, personnel, or outcome assessors. A quarter of the studies had high risk of attrition bias and selective outcome reporting. We examined the effect of digital interventions using meta-analysis for the following outcomes: adherence (16 studies); asthma control (16 studies); asthma exacerbations (six studies); unscheduled healthcare utilisation (four studies); lung function (seven studies); and quality of life (10 studies). Pooled results showed that patients receiving digital interventions may have increased adherence (mean difference of 14.66 percentage points, 95% confidence interval (CI) 7.74 to 21.57; low-certainty evidence); this is likely to be clinically significant in those with poor baseline medication adherence. Subgroup analysis by type of intervention was significant (P = 0.001), with better adherence shown with electronic monitoring devices (EMDs) (23 percentage points over control, 95% CI 10.84 to 34.16; seven studies), and with short message services (SMS) (12 percentage points over control, 95% CI 6.22 to 18.03; four studies). No significant subgroup differences were seen for interventions having an in-person component versus fully digital interventions, adherence feedback, one or multiple digital components to the intervention, or participant age. Digital interventions were likely to improve asthma control (standardised mean difference (SMD) 0.31 higher, 95% CI 0.17 to 0.44; moderate-certainty evidence) - a small but likely clinically significant effect. They may reduce asthma exacerbations (risk ratio 0.53, 95% CI 0.32 to 0.91; low-certainty evidence). Digital interventions may result in a slight change in unscheduled healthcare utilisation, although some studies reported no or a worsened effect. School or work absence data could not be included for meta-analysis due to the heterogeneity in reporting and the low number of studies. They may result in little or no difference in lung function (forced expiratory volume in one second (FEV1)): there was an improvement of 3.58% predicted FEV1, 95% CI 1.00% to 6.17%; moderate-certainty evidence); however, this is unlikely to be clinically significant as the FEV1 change is below 12%. Digital interventions likely increase quality of life (SMD 0.26 higher, 95% CI 0.07 to 0.45; moderate-certainty evidence); however, this is a small effect that may not be clinically significant. Acceptability data showed positive attitudes towards digital interventions. There were no data on cost-effectiveness or adverse events. Our confidence in the evidence was reduced by risk of bias and inconsistency.

AUTHORS' CONCLUSIONS

Overall, digital interventions may result in a large increase in adherence (low-certainty evidence). There is moderate-certainty evidence that digital adherence interventions likely improve asthma control to a degree that is clinically significant, and likely increase quality of life, but there is little or no improvement in lung function. The review found low-certainty evidence that digital interventions may reduce asthma exacerbations. Subgroup analyses show that EMDs may improve adherence by 23% and SMS interventions by 12%, and interventions with an in-person element and adherence feedback may have greater benefits for asthma control and adherence, respectively. Future studies should include percentage adherence as a routine outcome measure to enable comparison between studies and meta-analysis, and use validated questionnaires to assess adherence and outcomes.

Comparing the Effects of Mobile-Based Education and Booklet-Based Education on Iranian Mothers' Perception on Antibiotics: A Quasi-Experimental Study

PURPOSE

The aim of this study was to investigate the effect of mobile-based education in comparison with booklet-based education on mothers' perception on antibiotics.

DESIGN AND METHODS

This quasi-experimental study was performed on 160 mothers of children aged 1 to 6 years (80 in the experimental group and 80 in the control group) who referred to the urban community health centers in Iran. Both groups were taught about the proper use of antibiotics. The experimental group was taught using a mobile application and the control group was taught using a booklet. The Parental Perception on Antibiotics (PAPA) scale was used to collect data at the beginning and two to four weeks after the educational intervention. The data were analyzed using SPSS version 19.

RESULTS

The results showed that 91.9% of mothers used the knowledge of nurses or other health care providers and 86.3% used their previous experience as the source of information about antibiotics. Also, mothers' perceptions about antibiotics in the subscales of knowledge and beliefs, behaviors, adherence and awareness about antibiotics resistance in the experimental group improved significantly compared to the control group (p < 0.05).

CONCLUSIONS

Mobile-based education was more effective in improving mothers' perception on antibiotics than booklet-based education.

PRACTICE IMPLICATIONS

Health care providers can use mobile-based educational method for different groups of society to promote health in various fields.

Improving adherence in chronic airways disease: are we doing it wrongly?

Non-adherence to medicines is a significant clinical and financial burden, but successful strategies to improve it, and thus bring about significant improvements in clinical outcome, remain elusive. Many barriers exist, including a lack of awareness amongst some healthcare professionals as to the extent and impact of non-adherence and a dearth of skills to address it successfully. Patients may not appreciate that they are non-adherent, feel they cannot disclose it or underestimate its impact on their health in the short and longer term. In describing the evidence-based frameworks that identify the causal factors behind medicines taking (or not taking) behaviours, we can start to personalise interventions to enable individuals to make informed decisions about their treatments and thus overcome real and perceived barriers to adherence.

Medicines non-adherence is common and associated with significant morbidity and mortality. @GrainnedAn and colleagues outline causal factors behind this behaviour and the appropriate individualised interventions available to support optimal medicines use.https://bit.ly/3ejJNTV

New Concepts and Technological Resources in Patient Education and Asthma Self-Management

Asthma is a chronic disease that is associated with significant morbidity and mortality. In general, the use of technology resources or electronic health (e-health) has been shown to have beneficial effects on patients with asthma. E-health can impact a broad section of patients and can be cost-effective and associated with high patient satisfaction. E-health may enable remote delivery of care, as well as timely access to health care, which are some of the common challenges faced by patients with asthma. Web-based asthma self-management systems have been found to improve quality of life, self-reported asthma symptoms, lung function, reduction in asthma symptoms/exacerbations, and self-reported adherence for adults. Social media is commonly being used as a platform to disseminate information on asthma to increase public awareness. It can facilitate asthma self-management in a patient friendly manner and has shown to improve asthma control test scores as well as self-esteem. Text massages reminders can increase awareness regarding asthma treatment and control, thus potentially can improve adherence to medications and asthma outcome. Mobile health applications can support asthma self-management, improve a patient's quality of life, promote medication adherence, and potentially reduce the overall costs for asthma care. Inhaler trackers have shown to be beneficial to asthma outcome in various populations by improving adherence to asthma medications. Barriers such as physician financial reimbursement as well as licensing for rendering tele-healthcare services are important concerns. Other limitations of using technology resources in health care are related to liability, professionalism, and ethical issues such as breach of patient confidentiality and privacy. Additionally, there may be less face-to-face interaction and care of the patient when e-health is used.

Systematic Review of Digital Interventions for Pediatric Asthma Management

BACKGROUND

Pediatric patients with asthma take only approximately half of their prescribed medication. Digital interventions to improve adherence for youth with asthma exist and have the potential to improve accessibility, cost-effectiveness, and customizability.

OBJECTIVE

To systematically review published research examining digital interventions to promote adherence to the treatment of pediatric asthma.

METHODS

A systematic search of the PubMed, Scopus, CINAHL, PsycINFO, and reference review databases was conducted. Articles were included if adherence was an outcome in a randomized controlled trial of a digital intervention for children with asthma. We compared samples, intervention characteristics, adherence measurement and outcomes, as well as additional health outcomes across studies.

RESULTS

Of the 264 articles reviewed, 15 studies met inclusion criteria and were included in the review. Overall, 87% of the digital interventions demonstrated improved adherence and 53% demonstrated improved health outcomes. All the promising interventions included a behavioral component and most were 3 to 6 months in length, delivered through a digital stand-alone medium (eg, automated personalized texts, mobile health apps, and website), and assessed adherence to controller medication.

CONCLUSIONS

Overall, digital interventions aimed at improving adherence are promising and also improve health outcomes in addition to medication adherence. Although future studies using evidence-based adherence assessment and multifactorial design should be conducted, the current literature suggests that both digital stand-alone interventions and interventions combining digital technology with support from a health care team member result in improved adherence and asthma outcomes. Recommendations for digital interventions for pediatric patients with asthma with adherence concerns are provided.

Theory-Based Health Behavior Interventions for Pediatric Chronic Disease Management: A Systematic Review

IMPORTANCE

Pediatric chronic conditions have become a major public health challenge, and behavioral change plays an important role in overcoming this problem. Many health behavior interventions are described as theory-based, but evidence that such programs properly use theoretical constructs is scant.

OBJECTIVE

To identify effective theory-based behavioral interventions that motivate patients and families to adopt better self-management behaviors for chronic disease, to review theoretical constructs from each theory and identify the common elements for action, and to rate the level of evidence for each theory-based chronic disease intervention.

EVIDENCE REVIEW

Medline and PsycINFO electronic databases were searched for relevant randomized clinical trial articles published between January 1, 2000, and June 30, 2016, with English language and article type restrictions. These articles reported original data on children and young adults aged 21 years or younger, measured interventions for a pediatric chronic health problem, and assessed the association between interventions and health behavior, knowledge, and outcomes. The Jadad scale was used to evaluate the methods of each article. Articles that explicitly identified the theoretical basis for the intervention and scored 3 points or higher on the Jadad scale were included in the final analysis.

FINDINGS

The database search yielded a total of 36 187 articles, from which duplicates and those that did not meet the inclusion criteria were eliminated, leaving 129 studies for the full review. Of the 129 studies, 29 (22.5%) had higher Jadad scale scores of 3 or 4 points and underwent the final detailed data abstraction and qualitative synthesis. Five chronic conditions were represented, including asthma (55% [16 of 29]), type 1 diabetes (21% [6 of 29]), obesity (14% [4 of 29]), attention-deficit/hyperactivity disorder (7% [2 of 29]), and autistic spectrum disorder (3% [1 of 29]). Most studies (55% [16 of 29]) used Social Cognitive Theory as the theoretical basis for intervention. The following intervention outcomes were reported: 23 (80%) saw a positive association with health-related behaviors (eg, adherence), 8 (28%) with knowledge, 7 (24%) with attitudes, and 26 (90%) with clinical outcomes. Ten studies (34%) showed results in both health behaviors and health outcomes. Twenty-two studies (76%) demonstrated short-term effects (within 6 months), whereas 12 (41%) reported longer-term changes.

CONCLUSIONS AND RELEVANCE

Identifying effective theory-based behavioral interventions can empower those who are involved in the care of children and young adults with chronic conditions.

Interventions on Adherence to Treatment in Children With Severe Asthma: A Systematic Review

Introduction: Poor adherence to inhaled medication is a commonly encountered problem among children with asthma. However, there is a relatively paucity of data regarding the adherence of children with severe asthma, as well as the merit of any interventions to improve this adherence. Objectives: The aim of this systematic review was to identify the available literature on the rate of adherence and the influence of interventions in improving adherence to controller inhaled medication, in children with severe asthma. Methods: A systematic literature search was performed in MEDLINE/PubMed, Cochrane Library, and Scopus databases. Studies were included in the present review if their target population were children and/or adolescents with severe asthma and presented data on medication adherence before and after a given intervention. Results: A total of seven studies, conducted in USA, Canada, and UK, and published between 2012 and 2018, met the inclusion criteria. Adherence to controller medication was assessed via either objective or subjective measures (questionnaires), or a combination of them. Interventions included communication during pediatric visits and audio-taped medical visits, individualized care programs, electronic monitoring devices, interactive website and peak-flow prediction with feedback. Adherence rates for the baseline (before intervention) or for the control groups ranged from 28 to 67%. In general, there was a significant improvement of adherence after intervention with rates increasing to 49-81%. Conclusion: Adherence rate in children with severe asthma is not satisfactory but it can be improved after proper interventions. Nevertheless, the heterogeneity among adherence assessment tools, and the variety of interventions, in combination with the lack of studies focusing on severe asthma, highlight the need for further research in this field.

Six Questions for Well-Child Care Redesign

In the United States, well-child care has the goal of providing comprehensive care to children by addressing developmental, behavioral, psychosocial, and health issues through visits at recommended intervals. The preventive care needs of families can outpace the capacity of clinics and practices to provide it, necessitating a redesign of our well-child care system that aligns the structure of preventive care delivery with the needs of families. Here we focus on 6 questions (the what, when, who, why, how, and where) for well-child care redesign for infants and young children. By addressing these key questions and providing recommendations for advancing well-child care redesign in the clinical and research arenas, we hope to accelerate the process of well-child care redesign. In the current political and socioeconomic environment, continuing with well-child care "as usual" will mean that many families will find that their well-child care visits do not fully address the most pressing needs impacting children's health and well-being. It is time to implement and sustain real change in our system for preventive care.

Medication adherence in pediatric asthma: A systematic review of the literature

OBJECTIVE

To provide a systematic review of correlates of adherence to inhaled corticosteroids (ICS) in pediatric asthma across the individual, family, community, and healthcare system domains.

METHODS

Articles assessing medication adherence in pediatric asthma published from 1997 to 2016 were identified using PsychINFO, Medline, and CINAHL. Search terms included asthma, compliance, self-management, adherence, child, and youth. Search results were limited to articles: 1) published in the US; 2) using a pediatric population (0-25 years old); and 3) presenting original data related to ICS adherence. Correlates of adherence were categorized according to the domains of the Pediatric Self-Management Model. Each article was evaluated for study quality.

RESULTS

Seventy-nine articles were included in the review. Family-level correlates were most commonly reported (N = 51) and included socioeconomic status, race/ethnicity, health behaviors, and asthma knowledge. Individual-level correlates were second-most common (N = 37), with age being the most frequently identified negative correlate of adherence. Health care system correlates (N = 24) included enhanced asthma care and patient-provider communication. Few studies (N = 10) examined community correlates of adherence. Overall study quality was moderate, with few quantitative articles (26.38%) and qualitative articles (21.4%) referencing a theoretical basis for their studies.

CONCLUSIONS

All Pediatric Self-Management Model domains were correlated with youth adherence, which suggests medication adherence is influenced across multiple systems; however, most studies assessed adherence correlates within a single domain. Future research is needed that cuts across multiple domains to advance understanding of determinants of adherence.

Incorporating technology to advance asthma controller adherence

PURPOSE OF REVIEW

Technological innovations, including text messaging, smart phone applications, and electronic monitoring devices, aimed at improving asthma controller adherence are being rapidly introduced both into clinical care and directly marketed to patients. This review analyzes recent clinical trials implementing these interventions, with a focus on their benefits and shortcomings.

RECENT FINDINGS

Poor medication adherence continues to exert significant morbidity on patients with asthma. Objective, real-time measures to monitor adherence can overcome the limitations of prior methods, including self-report and prescription refills. Technological advances, especially those incorporating reminder systems, have demonstrated improved controller adherence. The increased adherence in these trials has not translated into consistent clinical improvement, including reducing hospitalizations, emergency department visits, and asthma exacerbations, possibly secondary to study design and poor inhalation technique.

SUMMARY

Novel monitoring and reminder technology can augment patient medication adherence and provide clues to management before escalating therapy. Further studies are needed to investigate the overarching clinical impact of this technology, especially as it grows into routine clinical practice.

A web-based educational video to improve asthma knowledge for limited English proficiency Latino caregivers

OBJECTIVES

To evaluate limited English proficiency (LEP) Latino caregiver asthma knowledge after exposure to an educational video designed for this target group.

METHODS

A cross-sectional, interventional study was performed. We aimed to evaluate the post-test impact on asthma knowledge from baseline after exposure to a patient-centered, evidence-based, and professionally produced Spanish asthma educational video. Participants included LEP Latino caregivers of children 2-12 years old with persistent asthma. Enrollment was performed during ED encounters or scheduled through a local community organization. Asthma knowledge was measured with a validated Spanish parental asthma knowledge questionnaire. Differences in mean scores were calculated with a paired t-test.

RESULTS

Twenty caregivers were enrolled. Participants included mothers (100%) from Puerto Rico (75%), with a high-school diploma or higher (85%), with no written asthma action plan (65%), whose child's asthma diagnosis was present for at least 3 years (80%). Mean baseline asthma knowledge scores improved 8 points from 58.4 to 66.4 after watching the educational video (95% CI 5.3-10.7; t(19) = 6.21, p < 0.01). Knowledge improvements were similar across the ED and community groups. Knowledge gains were observed in the areas of ED utilization, medication usage, and activity limitations.

CONCLUSIONS

The developed educational video improved caregiver asthma knowledge for a Latino population facing communication barriers to quality asthma care. Dissemination of this educational resource to LEP caregivers has the potential to improve pediatric asthma care in the United States.

The Nature of Family Engagement in Interventions for Children With Chronic Conditions

Recognizing the bi-directional relationship between family functioning and child well-being in the context of childhood chronic conditions, researchers have tested family-focused interventions aimed at promoting both child and family well-being through improving the family's condition management capacity. Based on a sample of 70 interventions for families in which there was a child with a chronic physical condition, this analysis examined the nature of family engagement in the interventions. Data were extracted from the intervention reports using a standardized template; conventional content analysis was used to describe family engagement. Interventions varied in focus, structure, and level of family engagement. Investigators most often sought to improve condition control or management, with parent engagement focused on improving capacity to manage the treatment regimen. Few investigators addressed capacity building in the context of family functioning. Recommendations are made for reporting standards for family-focused interventions and for enhancing the family systems grounding of interventions.

Difference in Effectiveness of Medication Adherence Intervention by Health Literacy Level

CONTEXT

There is little research investigating whether health information technologies, such as interactive voice recognition, are effective ways to deliver information to individuals with lower health literacy.

OBJECTIVE

Determine the extent to which the impact of an interactive voice recognition-based intervention to improve medication adherence appeared to vary by participants' health literacy level.

DESIGN

Promoting Adherence to Improve Effectiveness of Cardiovascular Disease Therapies (PATIENT) was a randomized clinical trial designed to test the impact, compared with usual care, of 2 technology-based interventions that leveraged interactive voice recognition to promote medication adherence. A 14% subset of participants was sent a survey that included questions on health literacy. This exploratory analysis was limited to the 833 individuals who responded to the survey and provided data on health literacy.

MAIN OUTCOME MEASURES

Adherence to statins and/or angiotensin-converting enzyme inhibitors and/or angiotensin II receptor blockers.

RESULTS

Although intervention effects did not differ significantly by level of health literacy, the data were suggestive of differential intervention effects by health literacy level.

CONCLUSIONS

The differences in intervention effects for high vs low health literacy in this exploratory analysis are consistent with the hypothesis that individuals with lower health literacy may derive greater benefit from this type of intervention compared with individuals with higher health literacy. Additional studies are needed to further explore this finding.

Non-adherence in children with asthma reviewed: The need for improvement of asthma care and medical education

Adherence to daily inhaled corticosteroid therapy is a key determinant of asthma control. Therefore, improving adherence to inhaled corticosteroids is the most effective method through which healthcare providers can help children with uncontrolled asthma. However, identifying non-adherent patients is difficult, and electronic monitoring is the only reliable method to assess adherence. (Non-)adherence is a complex behavioural process influenced by many interacting factors. Intentional barriers to adherence are common; driven by illness perceptions and medication beliefs, patients and parents deliberately choose not to follow the doctor's recommendations. Common non-intentional barriers are related to family routines, child-raising issues, and to social issues such as poverty. Effective interventions improving adherence are complex, because they take intentional and non-intentional barriers to adherence into account. There is evidence that comprehensive, guideline-based asthma self-management programmes can be successful, with excellent adherence and good asthma control. Patient-centred care focused on healthcare provider-patient/parent collaboration is the key factor determining the success of guided self-management programmes. Such care should focus on shared decision-making as this has been shown to improve adherence and healthcare outcomes. Current asthma care falls short because many physicians fail to adhere to asthma guidelines in their diagnostic approach and therapeutic prescriptions, and because of the lack of application of patient-centred health care. Increased awareness of the importance of patient-centred communication and increased training in patient-centred communication skills of undergraduates and experienced attending physicians are needed to improve adherence to daily controller therapy and asthma control in children with asthma.

Evaluation of a web-based asthma self-management system: a randomised controlled pilot trial

BACKGROUND

Asthma is the most common chronic condition of childhood and disproportionately affects inner-city minority children. Low rates of asthma preventer medication adherence is a major contributor to poor asthma control in these patients. Web-based methods have potential to improve patient knowledge and medication adherence by providing interactive patient education, monitoring of symptoms and medication use, and by facilitation of communication and teamwork among patients and health care providers. Few studies have evaluated web-based asthma support environments using all of these potentially beneficial interventions. The multidimensional website created for this study, BostonBreathes, was designed to intervene on multiple levels, and was evaluated in a pilot trial.

METHODS

An interactive, engaging website for children with asthma was developed to promote adherence to asthma medications, provide a platform for teamwork between caregivers and patients, and to provide primary care providers with up-to-date symptom information and data on medication use. Fifty-eight (58) children primarily from inner city Boston with persistent-level asthma were randomised to either usual care or use of BostonBreathes. Subjects completed asthma education activities, and reported their symptoms and medication use. Primary care providers used a separate interface to monitor their patients' website use, their reported symptoms and medication use, and were able to communicate online via a discussion board with their patients and with an asthma specialist.

RESULTS

After 6-months, reported wheezing improved significantly in both intervention and control groups, and there were significant improvements in the intervention group only in night-time awakening and parental loss of sleep, but there were no significant differences between intervention and control groups in these measures. Emergency room or acute visits to a physician for asthma did not significantly change in either group. Among the subgroup of subjects with low controller medication adherence at baseline, adherence improved significantly only in the intervention group. Knowledge of the purpose of controller medicine increased significantly in the intervention group, a statistically significant improvement over the control group.

CONCLUSIONS

This pilot study suggests that a multidimensional web-based educational, monitoring, and communication platform may have positive influences on pediatric patients' asthma-related knowledge and use of asthma preventer medications.

Improving adherence to cardiovascular disease medications with information technology

OBJECTIVES

Evaluate the utility of 2 electronic medical record (EMR)-linked, automated phone reminder interventions for improving adherence to cardiovascular disease medications.

STUDY DESIGN

A 1-year, parallel arm, pragmatic clinical trial in which 21,752 adults were randomized to receive either usual care (UC) or 1 of 2 interventions in the form of interactive voice recognition calls-regular (IVR) or enhanced (IVR+). The interventions used automated phone reminders to increase adherence to cardiovascular disease medications. The primary outcome was medication adherence; blood pressure and lipid levels were secondary outcomes.

METHODS

The study took place in 3 large health maintenance organizations. We enrolled participants who were 40 years or older, had diabetes mellitus or atherosclerotic cardiovascular disease, and were suboptimally adherent. IVR participants received automated phone calls when they were due or overdue for a refill. IVR+ participants received these phone calls, plus personalized reminder letters, live outreach calls, EMR-based feedback to their primary care providers, and additional mailed materials.

RESULTS

Both interventions significantly increased adherence to statins and angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs) compared with UC (1.6 to 3.7 percentage points). Adherence to ACEIs/ARBs was also significantly higher for IVR+ relative to IVR participants. These differences persisted across subgroups. Among statin users, IVR+ participants had significantly lower low-density lipoprotein (LDL) levels at follow-up compared with UC (Δ = -1.5; 95% CI, -2.7 to -0.2 mg/dL); this effect was seen mainly in those with baseline LDL levels ≥ 100 mg/dL (Δ = -3.6; 95% CI, -5.9 to -1.3 mg/dL).

CONCLUSIONS

Technology-based tools, in conjunction with an EMR, can improve adherence to chronic disease medications and measured cardiovascular disease risk factors.

A cluster-randomized trial shows telephone peer coaching for parents reduces children's asthma morbidity

BACKGROUND

Childhood asthma morbidity remains significant, especially in low-income children. Most often, asthma management is provided by the child's primary care provider.

OBJECTIVE

We sought to evaluate whether enhancing primary care management for persistent asthma with telephone-based peer coaching for parents reduced asthma impairment and risk in children 3 to 12 years old.

METHODS

Over 12 months, peer trainers provided parents with asthma management training by telephone (median, 18 calls) and encouraged physician partnership. The intervention was evaluated in a cluster-randomized trial of 11 intervention and 11 usual care pediatric practices (462 and 486 families, respectively). Patient outcomes were assessed by means of telephone interviews at 12 and 24 months conducted by observers blinded to intervention assignment and compared by using mixed-effects models, controlling for baseline values and clustering within practices. In a planned subgroup analysis we examined the heterogeneity of the intervention effect by insurance type (Medicaid vs other).

RESULTS

After 12 months, intervention participation resulted in 20.9 (95% CI, 9.1-32.7) more symptom-free days per child than in the control group, and there was no difference in emergency department (ED) visits. After 24 months, ED visits were reduced (difference in mean visits/child, -0.28; 95% CI, -0.5 to -0.02), indicating a delayed intervention effect. In the Medicaid subgroup, after 12 months, intervention participation resulted in 42% fewer ED visits (difference in mean visits/child, -0.50; 95% CI, -0.81 to -0.18) and 62% fewer hospitalizations (difference in mean hospitalizations/child, -0.16; 95% CI, -0.30 to -0.014). Reductions in health care use endured through 24 months.

CONCLUSIONS

This pragmatic telephone-based peer-training intervention reduced asthma impairment. Asthma risk was reduced in children with Medicaid insurance.

Systematic review and meta-analysis of psychological interventions to promote treatment adherence in children, adolescents, and young adults with chronic illness

OBJECTIVE

This meta-analysis examined the effectiveness of recent adherence-promoting interventions for youth with chronic health conditions.

METHODS

Peer-reviewed randomized controlled trials of adherence-promoting interventions for youth with a chronic illness published between 2007 and 2013 (n = 23) were reviewed. Intervention delivery (in-person vs. technology-based) and outcome measurement (e.g., self-report) were examined as potential moderators of treatment effects.

RESULTS

Mean effect sizes were small at posttreatment (d = 0.20, 95% confidence interval (CI): 0.08, 0.31, n = 23) and follow-up (d = 0.29, 95% CI: 0.15, 0.43, n = 9). Intervention delivery and outcome measurement did not account for variation in treatment effects (p > .05).

CONCLUSIONS

The small treatment effects of recent adherence-promoting intervention (APIs) reflect the methodological limitations of the included studies and the need to reexamine the delivery and mechanisms of adherence-promoting interventions.

Medication adherence in asthma patients

PURPOSE OF REVIEW

Although current asthma guidelines stress the importance of assessing and enhancing adherence to asthma treatment, medication adherence rates in asthma patients are consistently low in practice. In this review, we summarize current literature on method of measurement, prevalence, outcome and intervention of medication adherence in asthma patients.

RECENT FINDINGS

Nonadherence to prescribed treatment continues to be a frequent problem in patients with asthma even in recent years. Objective measurement of adherence should be implemented whenever possible. Review of pharmacy refill data or electronic monitoring of inhaler actuation may be a preferred method to assess adherence. Educational programmes should be specifically designed to address the unmet need and specific reasons for nonadherence for the target population. Large, well designed clinical trials to assess the efficacy of remote electronic monitoring and reminder systems to improve adherence are needed.

SUMMARY

There is an urgent clinical need for systematic, proven methods to assess and address medication nonadherence in asthma patients.