Long-term adherence to inhaled corticosteroids in children with asthma: Observational study

The effect of telephone and short-message follow-ups on compliance and efficacy in asthmatic children treated with inhaled corticosteroid: A randomized controlled trial

BACKGROUND

This study aims to evaluate the effect of telephone and short-message follow-ups on compliance and efficacy in asthmatic children treated with inhaled corticosteroids.

METHODS

A total of 120 children with moderate bronchial asthma who visited the Asthma Outpatient Department of the Affiliated Hospital of Qingdao University were enrolled in the study. They were divided randomly into 3 groups based on the type of follow-up given: a combined telephone and short-message service (Tel + SMS) group, a SMS group, and a control group. After being followed up for 12 weeks, each child's asthma control level was assessed and their lung function was measured.

RESULTS

The compliance rates of children in the Tel + SMS group and SMS group were 86.49% and 56.25%, respectively. The total effective rates of these 2 groups (94.59% and 75.0%, respectively) were significantly higher than the rate of the control group (P < .01). The lung function indicators of the children in all 3 groups were better than those before treatment, although only the Tel + SMS group and SMS group improved significantly (P < .05). The lung function indicators of the large and small airways in the Tel + SMS group and the SMS group were also significantly better than those of the control group (P < .01). The results of the study suggest that 1 of the causes of poor compliance in asthmatic children is fear of an adverse reaction to inhaled corticosteroids.

CONCLUSION

Telephone and short-message follow-ups can increase compliance with inhaled corticosteroid treatment and improve the asthma control levels and lung function of asthmatic children.

The utility of the necessity-concerns framework (NCF) in explaining adherence and parental beliefs about controller medication in Saudi Arabian children with asthma

OBJECTIVE

This study aims to assess beliefs about asthma controller medications among parents of Saudi Arabian children with asthma and the association between these beliefs and medication adherence using the Necessity-Concerns Framework.

METHODS

A cross-sectional survey was provided to parents of children with asthma when they brought their children to routine appointments at local public clinics between May 16 and July 10, 2018. Participants electronically filled out validated Arabic versions of the Medication Adherence Reported Scale (MARS) and Beliefs About Medications Questionnaire (BMQ). Descriptive statistics were used to characterize the study participants, while hierarchical linear regression analysis assessed associations between parental beliefs about controller medications and medication adherence.

RESULTS

A total of 381 parents of children with asthma completed the study survey. The vast majority (89%) of study participants were non-adherent to their children's prescribed medications while only 11% were adherent. Additionally, our study revealed a significantly positive association between adherence and parents' beliefs in the necessity of the medication (p < .001), with concerns about the adverse effects of medication being negatively associated with parental adherence. A higher mean score for medication adherence was reported among the ambivalent groups compared to the accepting, indifferent, and skeptical groups.

CONCLUSIONS

Medication adherence among parents of children with asthma was relatively low. In addition, necessity beliefs were significantly associated with parental adherence to controller medications for their children with asthma. Further studies are warranted to investigate potential factors contributing to poor parental adherence and develop tailored interventions that support parental medication adherence for their asthmatic children.

Preschool children's asthma medication: parental knowledge, attitudes, practices, and adherence

Introduction: As parents or legal guardians primarily care for children with asthma, understanding their knowledge, attitudes, and practices (KAP) barriers to treatment and medication adherence is of essential importance. This study aimed to analyze the KAP toward asthma medication and adherence among preschool-aged asthmatic children's parents and explore the factors influencing adherence. Methods: This cross-sectional study was conducted between February 2023 and April 2023. Parents of preschool children with asthma were asked to complete the questionnaire containing knowledge, attitude, practice dimensions, and demographic characteristics. The Morisky Medication Adherence Scale (MMAS) was used to investigate adherence. Results: A total of 632 valid questionnaires (154 male and 478 female) were included. Parents showed moderate knowledge (9.49 ± 2.86, 63.27%, possible range: 0-15) and moderate attitudes (26.18 ± 2.51, 74.80%, possible range: 7-35) towards asthma medication, while their practices (27.46 ± 5.26, 91.53%, possible range: 6-30) were proactive; however, medication adherence was low (4.84 ± 1.78, total score: 8). The attitude scores (OR = 1.10, 95% CI: 1.01-1.19, P=0.020), practice scores (OR = 1.16, 95%CI: 1.12-1.21, p < 0.001), and smoking (OR = 1.64, 95%CI: 1.14-2.37, p = 0.008) were associated with medication adherence. Discussion: Preschool-aged asthmatic children's parents showed moderate knowledge, attitudes, and proactive practice toward asthma medication. Continuous training and education programs should be provided for parents to improve asthma medication management in preschool children.

Prediction of Asthma Exacerbations in Children

Asthma exacerbations are common in asthmatic children, even among those with good disease control. Asthma attacks result in the children and their parents missing school and work days; limit the patient's social and physical activities; and lead to emergency department visits, hospital admissions, or even fatal events. Thus, the prompt identification of asthmatic children at risk for exacerbation is crucial, as it may allow for proactive measures that could prevent these episodes. Children prone to asthma exacerbation are a heterogeneous group; various demographic factors such as younger age, ethnic group, low family income, clinical parameters (history of an exacerbation in the past 12 months, poor asthma control, poor adherence to treatment, comorbidities), Th2 inflammation, and environmental exposures (pollutants, stress, viral and bacterial pathogens) determine the risk of a future exacerbation and should be carefully considered. This paper aims to review the existing evidence regarding the predictors of asthma exacerbations in children and offer practical monitoring guidance for promptly recognizing patients at risk.

Risk Factors for Non-Adherence to Inhaled Corticosteroids in Preschool Children with Asthma

Non-adherence to asthma controllers increases morbidity among school-aged children. This study aimed to determine non-adherence risk factors in preschool children with asthma. We investigated 172 children <6 years diagnosed with asthma in 2018 and analyzed baseline characteristics and loss of control events extracted from the medical records for four years following diagnosis. At end of follow-up, 79 children had a prescription of inhaled corticosteroids (ICS) and were included in the analyses. Adherence was assessed in a two-year period through pharmacy claims using percentage of days covered (PDC) analyzed dichotomously with non-adherence defined as PDC < 80% and using adherence ratio (AR) defined as days with medical supply divided by days without. Of the 79 children, 59 (74.7%) were classified as non-adherent. In analyses adjusted for sex, age and exacerbations prior to inclusion, adherence was positively associated with having had a loss of control event requiring a step-up in asthma controller (aAR:2.34 [1.10;4.98], p = 0.03), oral corticosteroids (aAR:2.45 [1.13;5.34], p = 0.026) or redeeming a short-acting b2-agonist prescription (aAR:2.91 [1.26;6.74], p = 0.015). Further, atopic comorbidity was associated with increased adherence (aAR:1.18 [1.01;1.37], p = 0.039), whereas having a first degree relative with asthma was associated with worse adherence (aAR:0.44 [0.23;0.84], p = 0.015). This study found poor adherence to ICS among three quarters of preschool children with asthma. Increasing adherence was associated with atopic comorbidity and loss of control events, whereas lower adherence was associated with atopic predisposition. These findings should be considered to improve adherence in preschool children with asthma.

Effect of using acoustic flo-tone training device and its smartphone application on enhancing inhalation technique from metered-dose inhaler with spacer in asthmatic children

Aim of study: This research study aims to compare between two different counseling approaches; traditional verbal counseling vs. advanced counseling (in which we used the acoustic Flo-tone training device and its smartphone application combined with traditional verbal counseling) to determine the most beneficial counseling approach for asthmatic children who use metered-dose inhaler (MDI) with spacers concerning inhalation duration and inhalation technique mistakes. Methods: A total of 100 asthmatic children (8-18) years old were randomized into two groups (a control group, and an advanced group). Each group included 50 subjects. Every subject received 3 counseling meetings, one each month. Asthmatic children in the control group were trained on inhalation technique from MDI + spacer verbally (traditional counseling), while asthmatic children in advanced group were trained on inhalation technique from MDI + spacer verbally and by advanced counseling (whistling Flo-tone + smartphone application). At each visit mistakes in inhalation technique steps were; detected, corrected, and recorded and the inhalation duration was measured for every child in each group. Results: In both study groups, the total mean number of inhalation technique mistakes decreased significantly (p < 0.05) from visit 2, also the total mean inhalation durations in seconds showed a significant increase (p < 0.05) from visit 2. A significant (p < 0.05) reduction in the total mean number of mistakes and a significant (p < 0.05) increase in total mean inhalation durations were observed from visit 2 in advanced group compared to control group. Conclusion: Combination between traditional verbal and advanced counseling methods resulted in significant (P < 0.05) improvements in the number of inhalation technique mistakes and inhalation durations from MDI with spacer in children compared to using traditional verbal counseling alone.

Challenges in uncontrolled asthma in pediatrics: important considerations for the clinician

INTRODUCTION

Despite symptoms control being the primary focus of asthma management according to guidelines, uncontrolled asthma is still an issue worldwide, leading to huge costs and asthma deaths at all ages. In childhood, poor asthma control can be even more harmful, as it can irreversibly compromise the children's lung function and the whole family's well-being.

AREAS COVERED

Given the problem extent, this review aims to discuss the leading modifiable causes of uncontrolled asthma in Pediatrics, giving some practical insights regarding the critical role of families and the main tools for monitoring control and drug adherence, even at a distance. The most recent GINA documents were used as the primary reference, along with the latest evidence regarding the management of asthma control and the impact of the COVID-19 pandemic on asthma.

EXPERT OPINION

In managing pediatric asthma, a multidisciplinary, multi-determinant, personalized approach is needed, actively involving families, schools, and other specialists. In addition to current strategies for implementing control, electronic health strategies, new validated asthma control tools, and the identification of novel inflammatory biomarkers could lead to increasingly tailored therapies with greater effectiveness in reaching asthma control.

Acceptability of Serious Games in Pediatric Asthma Education and Self-management: Pilot Study

BACKGROUND

Asthma is the most common chronic pediatric disease. Despite existing tools to manage asthma, 40%-55% of children with asthma experience uncontrolled asthma. Serious games (SGs) represent a novel approach in promoting asthma education and self-management for children.

OBJECTIVE

In this qualitative pilot study with an embedded quantitative design, we aim to use focus groups and questionnaires to describe the perceived role of SGs in different aspects of asthma self-management by children and their parents. These aspects include asthma perception and knowledge, the impact of asthma and barriers to asthma self-management, and the support system for asthma self-management.

METHODS

A total of 5 children with asthma and their parents were invited to participate in an organized gaming session. Children and their parents completed a pregaming questionnaire on their medical history and asthma knowledge. Then, they were invited to test 4 original SG prototypes, after which the children answered a postgaming questionnaire on their asthma knowledge and perception of the SGs. Children and their parents subsequently participated in parallel focus groups, which were video-recorded or audio-recorded, transcribed verbatim, and analyzed by reaching consensus among members of the research team.

RESULTS

The mean age of the children was 10.3 (SD 1.5) years, with 20% (1/5) of the children being male. Qualitative data from the transcripts were coded into three separate domains: asthma self-management perception and knowledge, impact of asthma and barriers to asthma self-management, and support system for asthma self-management. We specifically explored the perceived roles of SGs within each domain. A key takeaway message was identified for each of these three domains: heterogeneity of asthma knowledge and the ability of SGs to encourage knowledge transfer through games, consequences and limitations of asthma and the ability of SGs to allow for identification and management of real-life situations through games, and insufficient support system and the ability of SGs to encourage playing with others for support and shared knowledge.

CONCLUSIONS

Our pilot study explored the role of SGs in the self-management of asthma, as perceived by children and their parents. Our findings support the acceptability of SGs in asthma education and self-management in pediatrics and the necessity for future development in this field.

Adherence to inhaled corticosteroids prescribed once vs twice daily in children with asthma

BACKGROUND

Suboptimal adherence to inhaled corticosteroids (ICS) is associated with poor asthma control. Adult studies suggest that simplification of ICS regimen leads to better adherence.

OBJECTIVE

We aimed to determine whether once-daily, compared with twice-daily, ICS dosing was associated with better adherence among children with asthma.

METHODS

We conducted a retrospective observational study of children with asthma prescribed with either once-daily or twice-daily ICS monotherapy between 2011 and 2019. Our primary adherence outcome was the proportion of prescribed days covered (PPDC)-that is, the number of days for which the drug was dispensed by the pharmacy divided by the number of days for which it was prescribed. The impact of once-daily vs twice-daily ICS regimen on adherence was evaluated using linear multivariable regression analysis adjusting for covariates. Secondary outcomes included the proportion of patients with greater than or equal to 75% adherence analyzed using logistic regression models.

RESULTS

A total of 232 children (61% boys; mean age of 5.8 [3.6] years) were included; 120 children were prescribed once-daily, and 112 twice-daily, ICS. The median PPDC was 66.8% for the once-daily and 57.9% for the twice-daily group (P = .03). Children prescribed once-daily ICS had a 7.2% (95% confidence interval, 1.3-13.1) greater mean PPDC compared with the twice-daily group and greater odds of having PPDC greater than or equal to 75% (71.4% vs 45.5%; odds ratio, 1.80; 95% confidence interval, 1.01-3.26).

CONCLUSION

Our findings suggest that once-daily dosing of ICS is associated with better medication adherence than twice-daily dosing. Whether the gain in adherence leads to better asthma control and health outcomes remains to be evaluated.

Features of successful interventions to improve adherence to inhaled corticosteroids in children with asthma: A narrative systematic review

INTRODUCTION

Nonadherence to inhaled corticosteroids (ICSs) in children with asthma leads to significant morbidity and mortality. Few adherence interventions have been effective and little is known about what contributes to intervention effectiveness. This systematic review summarizes the efficacy and the characteristics of effective interventions.

METHODS

Six databases were systematically searched on October 3, 2020 for randomized control trials measuring adherence to ICS in children with asthma. A narrative synthesis was conducted focusing on intervention efficacy and study reliability. Intervention content was coded based on the National Institute for Health and Care Excellence guidelines for medicines adherence (the Perceptions and Practicalities Approach, PAPA) and behavior change techniques (BCTs), to determine the effective aspects of the intervention.

RESULTS

Of 240 studies identified, 25 were eligible for inclusion. Thirteen of the 25 studies were categorized as being highly reliable. Nine of the 13 interventions were effective at increasing adherence and 6 of those met the criteria for a PAPA intervention. Techniques targeting perceptions and practicalities in successful interventions included rewards, reminders, feedback and monitoring of adherence, pharmacological support, instruction on how to take their ICS/adhere, and information about triggers for symptoms and nonadherence.

CONCLUSION

Adherence interventions in children with asthma have mixed effectiveness. Effective intervention studies were more frequently of higher quality, were tailored to individuals' perceptual and practical adherence barriers, and used multiple BCTs. However, due to the small number of included studies and varying study design quality, conclusions drawn here are preliminary. Future research is needed to test a PAPA-based intervention with a rigorous study design.

Psychosocial factors and lack of asthma knowledge undermine child and adolescent adherence to inhaled corticosteroid

This study aimed to evaluate inhaled corticosteroid (ICS) adherence and identify factors associated with non-adherence in pediatric asthma patients. A total of 134 patients aged 8-18 years old were included. At the first visit, patient adherence, asthma knowledge, and outcome expectation data were collected and recorded. Depression, anxiety, and self-esteem were assessed using psychiatric questionnaires. After providing asthma education, reevaluation of adherence and asthma control was performed at one 3- to 6-month follow-up visit. The mean ICS adherence was 75.9 ± 27.5%. Fifty-seven patients (42.5%) were defined as having poor adherence (<75%). "Intentional" and "hectic lifestyle and forgetfulness" were the main reasons for missing ICS doses in mid-late adolescents and children, respectively. Asthma knowledge generally improved with age. Overall, 89% and 67.7% of patients could define symptoms and triggers of asthma, respectively; however, less than 25% understood how asthma affected their body and the chronic nature of asthma. Patients with ICS adherence <75% had unfavorable expectations from asthma treatment (odds ratio [OR]: 1.05, 95% confidence interval [CI]: 1.01-1.10), and a higher proportion of inhaled short-acting beta-agonist use before exercise (OR: 4.12, 95% CI: 1.27-13.36). Depression and anxiety were frequently found (27.5%) and 23.3%, respectively; p > 0.05). Significant improvement in ICS adherence (p = 0.02) and Asthma Control Test scores (p = 0.02) were observed at the follow-up visit. Patient outcome expectations could be predictors of ICS adherence. Patient education regarding the mechanism and nature of asthma should be considered as an intervention for improving pediatric patient adherence. Psychological evaluation is warranted in pediatric patients with asthma.

Serum Inhaled Corticosteroid Detection for Monitoring Adherence in Severe Asthma

BACKGROUND

Daily inhaled corticosteroids (ICSs) are fundamental to asthma management, but adherence is low.

OBJECTIVES

To investigate (1) whether LC-MS/MS could be used to detect ICSs in serum and (2) whether serum levels related to markers of disease severity.

METHODS

We collected blood samples over an 8-hour period from patients with severe asthma prescribed at least 1000 μg daily of beclomethasone dipropionate equivalent. Following baseline sampling, patients were observed taking their usual morning dose. Subsequent blood samples were obtained 1, 2, 4, and 8 hours postinhalation and analyzed by LC-MS/MS. Correlations between serum ICS levels and severity markers were investigated.

RESULTS

A total of 60 patients were recruited (41 females; 39 prescribed maintenance prednisolone; mean age, 49 ± 12 years; FEV₁, 63 ± 20 %predicted). Eight hours postinhalation, all patients using budesonide (n = 10) and beclomethasone dipropionate (15), and all but 1 using fluticasone propionate (28), had detectable serum drug levels. Fluticasone furorate was detected in 2 patients (of 4), ciclesonide in none (of 7). Low adherence by repeat prescription records (<80%) was identified in 43%. Blood ICS levels correlated negatively with exacerbation rate, and (for fluticasone propionate only) positively with FEV₁ %predicted.

CONCLUSIONS

Commonly used ICSs can be reliably detected in the blood at least 8 hours after dosing, and could therefore be used as a measure of adherence in severe asthma. Higher exacerbation rates and poorer lung function (for fluticasone propionate) were associated with lower blood levels.

CARE: an observational study of adherence to home nebulizer therapy among children with asthma

Background:

The prevalence of pediatric asthma in China is approximately 3%, and asthma remains poorly controlled in many of these patients. This study assessed the rate of adherence to home nebulizer treatment in paediatric patients in China.

Methods:

The CARE study was a 12-week, multicentre, prospective, observational study across 12 tertiary hospitals in China. Patients were aged 0–14 years, clinically diagnosed with asthma and prescribed home nebulizer inhaled corticosteroid (ICS) therapy for ⩾3 months. The primary endpoint was electronically monitored treatment adherence. Patients attended onsite visits at 0, 4, 8 and 12 weeks to assess asthma control, severity and treatment adherence (recorded by electronic monitoring devices and caregivers).

Results:

The full analysis set included 510 patients. Median treatment adherence reported by electronic monitoring devices was 69.9%, and median caregiver-reported adherence was 77.9%. The proportion of patients with well-controlled asthma increased from 12.0% at baseline to 77.5% at visit 4. Increased time between asthma diagnosis and study enrolment was a significant predictor for better adherence [coefficient: 0.01, p = 0.0138; 95% confidence interval (CI): 0.00, 0.01] and asthma control (odds ratio = 1.001, p = 0.0498; 95% CI: 1.000, 1.002). Negative attitude to treatment by the caregiver was associated with poorer asthma control.

Conclusions:

Adherence to home nebulization, a widely used treatment for asthma, was high among Chinese pediatric patients. Asthma control improved with increasing treatment duration. These results suggest that home nebulization of ICS is an effective and recommendable long-term treatment for paediatric patients with asthma.

Trial registration

ClinicalTrials.gov identifier: NCT03156998

The reviews of this paper are available via the supplemental material section.

Inhaled corticosteroid beliefs, complementary and alternative medicine in children presenting to the emergency department for asthma

OBJECTIVE

Negative beliefs about inhaled corticosteroids (ICS) and endorsement of complementary and alternative medicine (CAM) have been associated with medication non-adherence and uncontrolled asthma. The association of CAM and negative health beliefs is not described in children in acute care settings. Our study objective is to determine the relationship between negative ICS beliefs, CAM use and poorly controlled asthma among a predominantly Latino population in an acute care setting.

METHODS

The study was conducted in the pediatric emergency department of a children's hospital. During an ED asthma encounter, validated questionnaires surveyed parents about negative ICS beliefs, CAM use, and asthma health and control. We compared asthma health reports between parents who did or did not endorse negative ICS beliefs or CAM use, by chi-squared test (or a Fisher's exact test where appropriate).

RESULTS

Parents of 174 children identified mostly as Latino with Medicaid insurance and high asthma morbidity. CAM endorsement and negative ICS beliefs were both associated with increased use of lifetime glucocorticoid (p = 0.03 and p=0.01 respectively). While CAM endorsement was associated with less hospitalizations (p = 0.04) and parental report of asthma "getting better" (p = 0.01), CAM users reported trouble with paying for rent or food (p = 0.02). Negative ICS beliefs and CAM endorsement were not associated with medication adherence.

CONCLUSIONS

Negative ICS beliefs are associated with higher number of oral glucocorticoid courses. The association between CAM endorsement and asthma control is varied, but mostly in favor of improved control. Financial difficulties may make CAM use more likely.

Asthma Across Childhood: Improving Adherence to Asthma Management from Early Childhood to Adolescence

Asthma affects nearly 6 million US children. Throughout childhood, children undergo a series of biological, developmental, and psychosocial changes. Thus, factors influencing a child's asthma management differ across 3 essential stages-early childhood (0-5 years), school-aged years (5-12 years), and adolescence (12-18 years)-and require varied intervention by parents, school personnel, clinicians, and the children themselves. Because asthma care in children is characterized by fluctuations in severity and coordination among many stakeholders, optimal asthma control is difficult to achieve in this young population. Challenges in childhood asthma management are reflected in the low rates of children's adherence to medication regimes. Although pharmacological and biological factors addressing age in physicians' treatment choices are well outlined, age-specific approaches to patient-provider communication and asthma-related interventions are also important in improving quality of life for patients with pediatric asthma.

Education makes people take their medication: myth or maxim?

Education on its own doesn't make people take their treatment as intended. However, when it follows shared decision making, in which patient and doctor together agree on the best course of therapeutic action, education helps patients take their treatment. http://bit.ly/2G2XswD.

Assessment of regular drug use and inhaler technique skills in asthmatic children

OBJECTIVE

This study aimed to assess the regular use of long-term asthma-control medication and to determine inhaler techniques in asthmatic children.

METHODS

The study was conducted on asthmatic children aged 6-18 years. Information on rescue and controller medications was given and the proper inhalation technique was demonstrated. One month later, patients and parents were asked to answer a questionnaire on drug use and to demonstrate their inhaler techniques.

RESULTS

One hundred children and/or their parents were interviewed for the study. All of the patients identified long-term asthma-control medications while quick-relief asthma medications were identified by 93% of the patients. Of the patients, 34% described the dose of their quick-relief medication correctly. All steps in the inhalation technique were correctly carried out by 60.6% of patients using a metered-dose inhaler (MDI), 80% of patients using a Turbuhaler, and 58% of patients using a capsule-based dry-powder inhaler (DPI). Of the participants, 73% reported regular use of long-term asthma-control medications. While the mean age of the patients regularly using long-term asthma medications was 9.05±2.5 years, that of patients not compliant with the regular treatment was 10.29±3.26 years (p=0.04). The most common reason for irregular drug use was forgetting to take the drug.

CONCLUSION

Adherence to long-term asthma-control medications tends to be better in younger patients. Since the most common cause of irregular drug use is forgetting to take the drug, repeated training is necessary to ensure asthma control and the successful treatment of asthmatic children.

Parental knowledge and attitudes regarding asthma in their children: Impact of an educational intervention in an Indian population

INTRODUCTION AND OBJECTIVES

Research shows positive effects of asthma education in improving parental knowledge, self-management skills, and reducing healthcare costs. Such studies are lacking in resource-limited countries. We studied the effectiveness of educational intervention in improving the knowledge and attitudes of parents/caregivers of asthmatic children.

METHODS

The study was conducted in the pediatric chest clinic of tertiary hospital (India) over 21 months after ethics committee approval. Recruited parents were randomized into the interventional group (A) receiving education module and control group (B). Parents' asthma knowledge and attitudes were assessed at baseline and 5 months postenrollment using 25-item questionnaire. Detailed demographic data, clinical data, and exacerbations during study were noted.

RESULTS

A total of 75 parents/guardians fulfilling inclusion criteria were analyzed (cases/group A: 37 and controls/group B: 38). 8.3 percent of parents/caregivers were illiterate. Around 36.9% of patients had a family history of allergy/asthma. Mean knowledge scores at follow-up were 12.24 and 9.89 for groups A and B, respectively (P < .05). Parents did better on knowledge items related to chronicity, family history, chronic cough, home administration of steroids in acute severe asthma, and maintaining records of clinical/medications for good control. Intervention group (A) showed significant improvement in most attitude-based questions postintervention as compared with the nonintervention group (B). There was no statistically significant difference in asthma severity and control between the two groups at follow-up.

CONCLUSIONS

Small group education on asthma in parents/caregivers improves their knowledge and attitudes. Healthcare plans should invest in pediatric asthma education and identify key personnel/opportunities to impart the same in routine care.

They just don't take their medicines: Reframing medication adherence in asthma from frustration to opportunity

Assessing and addressing suboptimal adherence to asthma medications is a key component in the treatment of all children with asthma, particularly those with difficult-to-treat asthma. However, parents often overreport adherence to asthma medications. Increased medication adherence could lead to improved outcomes in the form of better asthma control and decreased asthma exacerbations, as well as decreased healthcare utilization costs. Yet there are many complex factors that affect medication adherence, and barriers are often different in each family. Social determinants of health, complex healthcare relationships, and patient-related factors may all affect medication adherence. Multicomponent patient-centered strategies, as well as strategies that utilize technology and habit formation strategies may be helpful in improving medication adherence. Further study is needed to reliably and sustainably improve medication adherence in children with asthma across the broader population; in some populations, alternate diagnoses, adjusting therapy, and other intervention may be required to improve asthma control and health.

Patient-physician discordance in assessment of adherence to inhaled controller medication: a cross-sectional analysis of two cohorts

OBJECTIVE

We aimed to compare patient's and physician's ratings of inhaled medication adherence and to identify predictors of patient-physician discordance.

DESIGN

Baseline data from two prospective multicentre observational studies.

SETTING

29 allergy, pulmonology and paediatric secondary care outpatient clinics in Portugal.

PARTICIPANTS

395 patients (≥13 years old) with persistent asthma.

MEASURES

Data on demographics, patient-physician relationship, upper airway control, asthma control, asthma treatment, forced expiratory volume in one second (FEV₁) and healthcare use were collected. Patients and physicians independently assessed adherence to inhaled controller medication during the previous week using a 100 mm Visual Analogue Scale (VAS). Discordance was defined as classification in distinct VAS categories (low 0-50; medium 51-80; high 81-100) or as an absolute difference in VAS scores ≥10 mm. Correlation between patients' and physicians' VAS scores/categories was explored. A multinomial logistic regression identified the predictors of physician overestimation and underestimation.

RESULTS

High inhaler adherence was reported both by patients (median (percentile 25 to percentile 75) 85 (65-95) mm; 53% VAS>80) and by physicians (84 (68-95) mm; 53% VAS>80). Correlation between patient and physician VAS scores was moderate (r_s=0.580; p<0.001). Discordance occurred in 56% of cases: in 28% physicians overestimated adherence and in 27% underestimated. Low adherence as assessed by the physician (OR=27.35 (9.85 to 75.95)), FEV₁ ≥80% (OR=2.59 (1.08 to 6.20)) and a first appointment (OR=5.63 (1.24 to 25.56)) were predictors of underestimation. An uncontrolled asthma (OR=2.33 (1.25 to 4.34)), uncontrolled upper airway disease (OR=2.86 (1.35 to 6.04)) and prescription of short-acting beta-agonists alone (OR=3.05 (1.15 to 8.08)) were associated with overestimation. Medium adherence as assessed by the physician was significantly associated with higher risk of discordance, both for overestimation and underestimation of adherence (OR=14.50 (6.04 to 34.81); OR=2.21 (1.07 to 4.58)), while having a written action plan decreased the likelihood of discordance (OR=0.25 (0.12 to 0.52); OR=0.41 (0.22 to 0.78)) (R²=44%).

CONCLUSION

Although both patients and physicians report high inhaler adherence, discordance occurred in half of cases. Implementation of objective adherence measures and effective communication are needed to improve patient-physician agreement.

Longitudinal Patterns of Mexican and Puerto Rican Children's Asthma Controller Medication Adherence and Acute Healthcare Use

Rationale: Researchers tend to study Latinos as a single group, but recent asthma research confirmed differences among Latino subgroups. Variations in controller medication adherence may be a factor in the observed health disparities between Mexican and Puerto Rican children. Adherence is not a stable phenomenon; however, there is a paucity of data on patterns of adherence, sociodemographic predictors of patterns, and variations in asthma-related acute healthcare use by adherence pattern among Latino subgroups. Objectives: To identify patterns of inhaled corticosteroid medication adherence over 12 months among Mexican and Puerto Rican children with persistent asthma, to examine sociodemographic predictors of adherence patterns by ethnicity, and to investigate asthma-related acute healthcare use based on these patterns. Methods: We analyzed controller medication Doser data from Mexican and Puerto Rican children (n = 123; ages 5-12 yr) with persistent asthma who participated with their caregivers in a longitudinal nonintervention study (Phoenix, AZ, and Bronx, NY). Interview and medical record data were collected at enrollment and at 3, 6, 9, and 12 months after enrollment. Results: Forty-seven to fifty-three percent of children had poor adherence (<50%) over each of the follow-up periods (cross-sectional). Children with lowest adherence were Puerto Rican, from nonpoor families, or female. Longitudinal latent class analysis yielded four adherence classes: poor, moderate, decreasing adherence, and increasing adherence. Puerto Rican children had significantly higher odds of "decreasing" (odds ratio [OR], 2.86; 95% confidence interval [CI], 0.40 to 20.50) and "poor" (OR, 5.62; 95% CI, 1.44 to 21.90) adherence than Mexican children. Females had significantly greater odds of "decreasing" (OR, 4.80; 95% CI, 0.73 to 31.74) and "poor" (OR, 5.20; 95% CI, 1.77 to 15.30) adherence group membership than males. The "decreasing" adherence group was comprised of only poor children. Children in the "poor" adherence class had the highest mean number of acute visits and emergency department visits/hospitalizations across all assessment periods. Conclusions: This study demonstrated that unique ethnicity within Latino populations may be associated with different risk levels for suboptimal controller medication adherence, which may be a factor in the observed asthma health disparities between Mexican and Puerto Rican children. Increased understanding of and attention to children's controller medication adherence patterns will provide evidence needed to identify children at highest risk for acute healthcare use and offer more-intensive intervention using less-intensive approaches for those at low risk. Clinical trial registered with www.clinicaltrials.gov (NCT01099800).

Asthma exacerbation prediction: recent insights

PURPOSE OF REVIEW

Asthma attacks are frequent in children with asthma and can lead to significant adverse outcomes including time off school, hospital admission and death. Identifying children at risk of an asthma attack affords the opportunity to prevent attacks and improve outcomes.

RECENT FINDINGS

Clinical features, patient behaviours and characteristics, physiological factors, environmental data and biomarkers are all associated with asthma attacks and can be used in asthma exacerbation prediction models. Recent studies have better characterized children at risk of an attack: history of a severe exacerbation in the previous 12 months, poor adherence and current poor control are important features which should alert healthcare professionals to the need for remedial action. There is increasing interest in the use of biomarkers. A number of novel biomarkers, including patterns of volatile organic compounds in exhaled breath, show promise. Biomarkers are likely to be of greatest utility if measured frequently and combined with other measures. To date, most prediction models are based on epidemiological data and population-based risk. The use of digital technology affords the opportunity to collect large amounts of real-time data, including clinical and physiological measurements and combine these with environmental data to develop personal risk scores. These developments need to be matched by changes in clinical guidelines away from a focus on current asthma control and stepwise escalation in drug therapy towards inclusion of personal risk scores and tailored management strategies including nonpharmacological approaches.

SUMMARY

There have been significant steps towards personalized prediction models of asthma attacks. The utility of such models needs to be tested in the ability not only to predict attacks but also to reduce them.

Quality standards in respiratory real-life effectiveness research: the REal Life EVidence AssessmeNt Tool (RELEVANT): report from the Respiratory Effectiveness Group-European Academy of Allergy and Clinical Immunology Task Force

INTRODUCTION

A Task Force was commissioned jointly by the European Academy of Allergy and Clinical Immunology (EAACI) and the Respiratory Effectiveness Group (REG) to develop a quality assessment tool for real-life observational research to identify high-quality real-life asthma studies that could be considered within future guideline development.

METHODS

The resulting REal Life EVidence AssessmeNt Tool (RELEVANT) was achieved through an extensive analysis of existing initiatives in this area. The first version was piloted among 9 raters across 6 articles; the revised, interim, version underwent extensive testing by 22 reviewers from the EAACI membership and REG collaborator group, leading to further revisions and tool finalisation. RELEVANT was validated through an analysis of real-life effectiveness studies identified via systematic review of Medline and Embase databases and relating to topics for which real-life studies may offer valuable evidence complementary to that from randomised controlled trials. The topics were selected through a vote among Task Force members and related to the influence of adherence, smoking, inhaler device and particle size on asthma treatment effectiveness.

RESULTS

Although highlighting a general lack of high-quality real-life effectiveness observational research on these clinically important topics, the analysis provided insights into how identified observational studies might inform asthma guidelines developers and clinicians. Overall, RELEVANT appeared reliable and easy to use by expert reviewers.

CONCLUSIONS

Using such quality appraisal tools is mandatory to assess whether specific observational real-life effectiveness studies can be used to inform guideline development and/or decision-making in clinical practice.

Effect of an Asthma Question Prompt List and Video Intervention on Adolescents' Medication Adherence 12 Months Later

BACKGROUND

Many adolescents do not obtain the maximum benefit from their asthma medications. Improving patient-provider communication may improve adolescents' asthma knowledge, adherence, and clinical outcomes.

OBJECTIVE

To determine how a question prompt list and educational video intervention affect youth- and caregiver-reported medication adherence and self-reported medication problems.

METHODS

Adolescents with persistent asthma (n = 359; 56.4% with moderate to severe asthma) and their caregivers were enrolled in a randomized controlled trial at 4 pediatric clinics. Intervention group families received a question prompt list and watched a short video before seeing the provider; control families received usual care. Youth- and caregiver-reported medication adherence was measured with a Visual Analog Scale, ranging from 0 to 100. Generalized estimating equations were used to determine how the intervention and covariates were associated with medication adherence and reported problems at 12 months.

RESULTS

The intervention was not a significant predictor of medication adherence at 12 months. Higher caregiver education was associated with higher youth-reported adherence (β = 1.1; 95% CI = 0.1, 2.1; P = 0.036) and caregiver-reported adherence (β = 1.2; 95% CI = 0.3, 2.0; P = 0.006). The intervention was associated with fewer caregiver-reported problems at 12 months (β = -0.32; 95% CI = -0.48, -0.16; P < 0.001).

CONCLUSIONS AND RELEVANCE

A question prompt list and educational video decreased the number of caregiver-reported medication problems, but did not significantly affect medication adherence. Further research is needed to develop more effective interventions to improve medication adherence and outcomes.

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.

Adherence to Polyethylene Glycol Treatment in Children with Functional Constipation Is Associated with Parental Illness Perceptions, Satisfaction with Treatment, and Perceived Treatment Convenience

OBJECTIVES

To assess treatment adherence in children with functional constipation and to evaluate the association with parental beliefs about medication, illness perceptions, treatment satisfaction, and satisfaction with information about medication.

STUDY DESIGN

A cross-sectional survey was administered among parents of children with functional constipation treated with polyethylene glycol. Adherence was measured via the Medication Adherence Report Scale (MARS-5, score 5-25), with greater scores indicating better adherence (scores ≥23 were defined as adherent). Beliefs about medication, illness perceptions, satisfaction with treatment, and satisfaction with information about treatment were measured with the Beliefs about Medication Questionnaire, the Brief Illness Perception Questionnaire, the Treatment Satisfaction Questionnaire for Medication (TSQM), and the Satisfaction with Information about Medication Questionnaire. Associations between the questionnaire scores and adherence (MARS-5 score as a continuous variable) were analyzed with regression analyses.

RESULTS

In total, 43 of 115 included children (37%) were adherent (MARS-5 ≥23). Spearman rank correlation test revealed a statistically significant correlation between TSQM-convenience, TSQM-satisfaction, Brief Illness Perception Questionnaire question 8 (emotions), and the MARS-5 score (r_s 0.342, P = .000; r_s 0.258, P = .006; r_s -0.192, P = .044), which suggests that parental perceived treatment convenience, satisfaction with treatment, and illness perceptions may affect adherence in children with functional constipation. In the hierarchical multivariate regression model, 22% of the variability of the MARS-5 score could be explained by the selected predictors. The TSQM-convenience score contributed the most to the model (β: 0.384, P = .000).

CONCLUSIONS

Parents reported low adherence rates in their children with functional constipation. Treatment inconvenience, dissatisfaction with treatment, and the emotional impact of functional constipation may negatively influence treatment adherence.

Difficult vs. Severe Asthma: Definition and Limits of Asthma Control in the Pediatric Population

Evaluating the degree of disease control is pivotal when assessing a patient with asthma. Asthma control is defined as the degree to which manifestations of the disease are reduced or removed by therapy. Two domains of asthma control are identified in the guidelines: symptom control and future risk of poor asthma outcomes, including asthma attacks, accelerated decline in lung function, or treatment-related side effects. Over the past decade, the definition and the tools of asthma control have been substantially implemented so that the majority of children with asthma have their disease well controlled with standard therapies. However, a small subset of asthmatic children still requires maximal therapy to achieve or maintain symptom control and experience considerable morbidity. Childhood uncontrolled asthma is a heterogeneous group and represents a clinical and therapeutic challenge requiring a multidisciplinary systematic assessment. The identification of the factors that may contribute to the gain or loss of control in asthma is essential in differentiating children with difficult-to-treat asthma from those with severe asthma that is resistant to traditional therapies. The aim of this review is to focus on current concept of asthma control, describing monitoring tools currently used to assess asthma control in clinical practice and research, and evaluating comorbidities and modifiable and non-modifiable factors associated with uncontrolled asthma in children, with particular reference to severe asthma.

Reported Problems and Adherence in Using Asthma Medications Among Adolescents and Their Caregivers

BACKGROUND

Many factors affect youth adherence to asthma medications. Better understanding of the relationship between problems reported by youth in using asthma medications, self-efficacy, outcome expectations, and adherence is needed.

OBJECTIVE

The study examined the relationship between youth and caregiver problems in using asthma medications, asthma management self-efficacy, outcome expectations, and youth- and caregiver-reported adherence to asthma controller medications.

METHODS

Adolescents with persistent asthma and their caregivers were recruited at 4 pediatric practices. Youth were interviewed after their medical visit while caregivers completed a questionnaire. Multivariable linear regression was used to analyze the data.

RESULTS

Of 359 participating youth, 319 were on controller medications. Youth reported 60% average adherence, whereas caregivers reported 69%. Youth who reported difficulty using their inhaler correctly and youth who reported difficulty remembering to take their medications were significantly less likely to be adherent. Caregivers who reported that it was hard to remember when to give the asthma medications were significantly less likely to report their child being adherent. Both youth and caregivers with higher outcome expectations were significantly more likely to self-report being adherent.

CONCLUSIONS

Pharmacists and other health care providers should consider asking youth and caregivers about problems in using asthma medications, self-efficacy in managing asthma, and outcome expectations for following treatment regimens, so that they can help youth overcome difficulties they might have in managing their asthma.

Severe Asthma in Children

Severe asthma in children is associated with significant morbidity and is a highly heterogeneous disorder with multiple clinical phenotypes. Cluster analyses have been performed in several groups to explain some of the heterogeneity of pediatric severe asthma, which is reviewed in this article. The evaluation of a child with severe asthma includes a detailed diagnostic assessment and excluding other possible diagnoses and addressing poor control due to comorbidities, lack of adherence to asthma controller medications, poor technique, and other psychological and environmental factors. Children with severe asthma require significant resources including regular follow-up appointments with asthma education, written asthma action plan, and care by a multidisciplinary team. Management of pediatric severe asthma now includes emerging phenotypic-directed therapies; however, continued research is still needed to further study the long-term outcomes of pediatric severe asthma and its treatment.

A randomised clinical trial of feedback on inhaler adherence and technique in patients with severe uncontrolled asthma

In severe asthma, poor control could reflect issues of medication adherence or inhaler technique, or that the condition is refractory. This study aimed to determine if an intervention with (bio)feedback on the features of inhaler use would identify refractory asthma and enhance inhaler technique and adherence.Patients with severe uncontrolled asthma were subjected to a stratified-by-site random block design. The intensive education group received repeated training in inhaler use, adherence and disease management. The intervention group received the same intervention, enhanced by (bio)feedback-guided training. The primary outcome was rate of actual inhaler adherence. Secondary outcomes included a pre-defined assessment of clinical outcome. Outcome assessors were blinded to group allocation. Data were analysed on an intention-to-treat and per-protocol basis.The mean rate of adherence during the third month in the (bio)feedback group (n=111) was higher than that in the enhanced education group (intention-to-treat, n=107; 73% versus 63%; 95% CI 2.8%-17.6%; p=0.02). By the end of the study, asthma was either stable or improved in 54 patients (38%); uncontrolled, but poorly adherent in 52 (35%); and uncontrolled, but adherent in 40 (27%).Repeated feedback significantly improved inhaler adherence. After a programme of adherence and inhaler technique assessment, only 40 patients (27%) were refractory and adherent, and might therefore need add-on therapy.

Traditional Therapies for Severe Asthma

Severe asthma is a complex and heterogeneous disease. The European Respiratory Society and American Thoracic Society guidelines define severe asthma for patients 6 years or older as "asthma which requires treatment with high-dose inhaled corticosteroids…plus a second controller or systemic corticosteroids to prevent it from becoming 'uncontrolled' or which remains 'uncontrolled' despite this therapy." This article reviews available traditional therapies, data behind their uses in severe asthma, and varying recommendations. As various asthma endotypes and phenotypes are better understood and characterized, targeted therapies should help improve disease outcomes, efficacy, and cost-effectiveness.

Electronic monitoring of adherence to inhaled corticosteroids: an essential tool in identifying severe asthma in children

International guidelines recommend that severe asthma can only be diagnosed after contributory factors, including adherence, have been addressed. Accurate assessment of adherence is difficult in clinical practice. We hypothesised that electronic monitoring in children would identify nonadherence, thus delineating the small number with true severe asthma.Asthmatic children already prescribed inhaled corticosteroids were prospectively recruited and persistence of adherence assessed using electronic monitoring devices. Spirometry, airway inflammation and asthma control were measured at the start and end of the monitoring period.93 children (62 male; median age 12.4 years) were monitored for a median of 92 days. Median (range) monitored adherence was 74% (21-99%). We identified four groups: 1) good adherence during monitoring with improved control, 24% (likely previous poor adherence); 2) good adherence with poor control, 18% (severe therapy-resistant asthma); 3) poor adherence with good control, 26% (likely overtreated); and 4) poor adherence with poor control, 32%. No clinical parameter prior to monitoring distinguished these groups.Electronic monitoring is a useful tool for identifying children in whom a step up in treatment is indicated. Different approaches are needed in those who are controlled when adherent or who are nonadherent. Electronic monitoring is essential in a paediatric severe asthma clinic.

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.

Can we trust what parents tell us? A systematic review

Taking a history is a key diagnostic instrument in paediatric consultations. Numerous issues potentially reduce the history's reliability. Therefore, paediatricians have always expressed ambivalence regarding history taking from parents, both valuing and distrusting it. In this review, we describe how parents build and present a description of their child's health issues in the conceptual framework of self-regulation theory. We performed a systematic review on the literature on the reliability of history taking. No studies examined the reliability of history taking from parents, but there is a considerable body of evidence on the issue of mutual trust in relationships between health care professionals and patients. Because trust is a dynamic relational phenomenon, taking a patient centred approach in consultations is likely to increase the patients' and parents' trust in the health care professional, and their willingness to follow the health care professional's treatment proposals. We provide evidence based recommendations on how to build and maintain trust in paediatric consultations by taking a patient centred approach in such consultations.

Managing the pediatric patient with refractory asthma: a multidisciplinary approach

Children with asthma that is refractory to high levels of prescribed treatment are described as having problematic severe asthma. Those in whom persistent symptoms result from a failure of basic asthma management are described as having "difficult asthma", while those who remain symptomatic despite these factors having been addressed are described as having "severe therapy-resistant asthma" (STRA). The majority of children have difficult asthma; asthma that is poorly controlled because of a failure to get the basics of asthma management right. Modifiable factors including nonadherence to medication, persistent adverse environmental exposures, and psychosocial factors often contribute to poor control in these patients. As our skill in identifying and addressing modifiable factors has improved, we have found that a progressively smaller proportion of our clinic patients is categorized as having true STRA, resulting in an infrequent resort to escalation of treatment. Many of the modifiable factors associated with the diagnosis of difficult asthma can be identified in a general pediatric clinic. Characterization of more complex factors, however, requires the time, skill, and expertise of multiple health care professionals within the asthma multidisciplinary team. In this review, we will describe the structured approach adopted by The Royal Brompton Hospital in the management of the child with problematic severe asthma. We highlight the roles of members of the multidisciplinary team at various stages of assessment and focus on prominent themes in the identification and treatment of modifiable factors.

The use of inhaled corticosteroids in pediatric asthma: update

Despite the availability of several formulations of inhaled corticosteroids (ICS) and delivery devices for treatment of childhood asthma and despite the development of evidence-based guidelines, childhood asthma control remains suboptimal. Improving uptake of asthma management plans, both by families and practitioners, is needed. Adherence to daily ICS therapy is a key determinant of asthma control and this mandates that asthma education follow a repetitive pattern and involve literal explanation and physical demonstration of the optimal use of inhaler devices. The potential adverse effects of ICS need to be weighed against the benefit of these drugs to control persistent asthma especially that its safety profile is markedly better than oral glucocorticoids. This article reviews the key mechanisms of inhaled corticosteroid action; recommendations on dosage and therapeutic regimens; potential optimization of effectiveness by addressing inhaler technique and adherence to therapy; and updated knowledge on the real magnitude of adverse events.

How to manage a child with difficult asthma?

INTRODUCTION

Children with difficult asthma have significant morbidity and fail to achieve asthma control despite being prescribed high dose maintenance treatment. If control remains poor after diagnostic confirmation, detailed assessments of the reasons for asthma being difficult-to-control are needed. Underlying modifiable factors including non-adherence to medication, persistent environmental exposures that trigger asthma symptoms and psychosocial factors contribute to poor control in these patients.

AREAS COVERED

The focus of this review is to provide a practical approach to the diagnosis and management of difficult asthma including an overview of long term assessments to identify potential progression to true, severe asthma. A multi-disciplinary team is critical to enable modifiable factors to be identified and addressed. Significant resources are required to manage paediatric difficult asthma optimally and only specialist centres should be tasked with the assessment of these patients. Although this may have an impact on healthcare resources, long term benefits for lung health are significant. Expert commentary: The management of paediatric difficult asthma is not simple and involves numerous professionals with varied expertise. However, if it is not undertaken with the appropriate skills, there is a significant risk of children receiving inappropriate invasive investigations and therapies that will have no impact on morbidity.

Is the MARS questionnaire a reliable measure of medication adherence in childhood asthma?

OBJECTIVE

To assess the reliability of the Medication Adherence Report Scale (MARS-5) for assessing adherence in clinical practice and research.

METHODS

Prospective cohort study following electronically measured inhaled corticosteroids (ICS) adherence for 1 year in 2-13-year-old children with persistent asthma. The relationship between electronically measured adherence and MARS-5 scores (ranging from 5 to 25) was assessed by Spearman's rank correlation coefficient. A ROC (receiver operating characteristic) curve was performed testing MARS-5 against electronically measured adherence. Sensitivity, specificity, positive and negative likelihood ratios of the closest MARS-5 cut-off values to the top left-hand corner of the ROC curve were calculated.

RESULTS

High MARS scores were obtained (median 24, interquartile range 22-24). Despite a statistically significant correlation between MARS-5 and electronically assessed adherence (Spearman's rho = 0.47; p < 0.0001), there was considerable variation of adherence rates at every MARS-5 score. The area under the ROC curve was 0.7188. A MARS-5 score ≥23 had the best predictive ability for electronically assessed adherence, but positive and negative likelihood ratios were too small to be useful (1.65 and 0.27, respectively).

CONCLUSIONS

Self-report using MARS-5 is too inaccurate to be a useful measure of adherence in children with asthma, both in clinical practice and in research.

The Digital Asthma Patient: The History and Future of Inhaler Based Health Monitoring Devices

The wave of digital health is continuously growing and promises to transform healthcare and optimize the patients' experience. Asthma is in the center of these digital developments, as it is a chronic disease that requires the continuous attention of both health care professionals and patients themselves. The accurate and timely assessment of the state of asthma is the fundamental basis of digital health approaches and is also the most significant factor toward the preventive and efficient management of the disease. Furthermore, the necessity of inhaled medication offers a basic platform upon which modern technologies can be integrated, namely the inhaler device itself. Inhaler-based monitoring devices were introduced in the beginning of the 1980s and have been evolving but mainly for the assessment of medication adherence. As technology progresses and novel sensing components are becoming available, the enhancement of inhalers with a wider range of monitoring capabilities holds the promise to further support and optimize asthma self-management. The current article aims to take a step for the mapping of this territory and start the discussion among healthcare professionals and engineers for the identification and the development of technologies that can offer personalized asthma self-management with clinical significance. In this direction, a technical review of inhaler based monitoring devices is presented, together with an overview of their use in clinical research. The aggregated results are then summarized and discussed for the identification of key drivers that can lead the future of inhalers.