Measuring medication adherence in asthma: Development of a novel self-report tool

A Systematic Review of Patient-Reported Adherence Measures in Asthma: Which Questionnaire Is Most Useful in Clinical Practice?

BACKGROUND

Suboptimal adherence to inhaled corticosteroid in asthma is a worryingly prevalent yet modifiable factor in uncontrolled disease. Several objective measures of adherence exist, but they are time-consuming. The use of patient-reported adherence measures (PRAMs) could therefore offer a time-efficient pragmatic approach to assessing adherence in clinical practice and potentially the appropriate interventions to improve it.

OBJECTIVES

To identify the PRAMs available for asthma and assess their psychometric quality, accessibility, and usefulness in clinical practice, as well as to provide recommendations for clinicians based on these findings.

METHODS

We conducted a systematic review of six databases. Articles included in this study were English language, full-text, original, asthma-specific PRAMs or development/validation studies of a generic PRAM that had been administered to adults with asthma, investigated inhaled corticosteroid adherence in adults (aged 18 years and older), and assessed at least one COnsensus-based Standards for the selection of health Measurement INstruments measurement property.

RESULTS

We included 15 PRAM developmental and/or validation studies in this systematic review. Studies evaluated a range of COnsensus-based Standards for the selection of health Measurement INstruments measurement properties, but none evaluated all of them.

CONCLUSIONS

Based on this review, we recommend that when a PRAM is used, it should be the Test of the Adherence to Inhalers. However, the Adherence Starts with Knowledge-20 and Adherence Starts with Knowledge-12 may also be useful. Our results highlight the need for PRAM developers to assess questionnaires robustly and provide guidance for clinicians regarding how to act on PRAM answers by developing materials such as decision support tool kits.

Caregiver's sense of coherence and adherence to paediatric asthma treatment

Asthma is a chronic respiratory condition that needs to be well controlled to avoid compromising patients' quality of life. In the paediatric population, the role of caregivers is essential in this process. Moreover, adequate asthma control is integral to a child's emotional well-being and to improving the child's ability to participate fully in family and social life. One of the main reasons for uncontrolled asthma is low adherence to treatment, by patients and caregivers. Identifying factors mediating the involvement and participation of caregivers through evaluations of caregivers' sense of coherence can help in the adoption of strategies aimed at effectively directing adherence behaviour through educational and motivational interventions. The goal of this review article is to provide an overview of the sense of coherence as a construct of Antonovsky's salutogenic theory, and to identify its role as a key piece in the successful management of asthma in children.

Measuring adherence to inhaled control medication in patients with asthma: Comparison among an asthma app, patient self-report and physician assessment

BACKGROUND

Previous studies have demonstrated the feasibility of using an asthma app to support medication management and adherence but failed to compare with other measures currently used in clinical practice. However, in a clinical setting, any additional adherence measurement must be evaluated in the context of both the patient and physician perspectives so that it can also help improve the process of shared decision making. Thus, we aimed to compare different measures of adherence to asthma control inhalers in clinical practice, namely through an app, patient self-report and physician assessment.

METHODS

This study is a secondary analysis of three prospective multicentre observational studies with patients (≥13 years old) with persistent asthma recruited from 61 primary and secondary care centres in Portugal. Patients were invited to use the InspirerMundi app and register their inhaled medication. Adherence was measured by the app as the number of doses taken divided by the number of doses scheduled each day and two time points were considered for analysis: 1-week and 1-month. At baseline, patients and physicians independently assessed adherence to asthma control inhalers during the previous week using a Visual Analogue Scale (VAS 0-100).

RESULTS

A total of 193 patients (72% female; median [P25-P75] age 28 [19-41] years old) were included in the analysis. Adherence measured by the app was lower (1 week: 31 [0-71]%; 1 month: 18 [0-48]%) than patient self-report (80 [60-95]) and physician assessment (82 [51-94]) (p < 0.001). A negligible non-significant correlation was found between the app and subjective measurements (ρ 0.118-0.156, p > 0.05). There was a moderate correlation between patient self-report and physician assessment (ρ = 0.596, p < 0.001).

CONCLUSIONS

Adherence measured by the app was lower than that reported by the patient or the physician. This was expected as objective measurements are commonly lower than subjective evaluations, which tend to overestimate adherence. Nevertheless, the low adherence measured by the app may also be influenced by the use of the app itself and this needs to be considered in future studies.

Qualitative Interviews to Support Development and Cognitive Debriefing of the Adelphi Adherence Questionnaire (ADAQ©): A Patient-Reported Measure of Medication Adherence Developed for Use in a Range of Diseases, Treatment Modalities, and Countries

Purpose

The Adelphi Adherence Questionnaire (ADAQ©) is a newly developed generic patient-reported outcome (PRO) assessment of medication adherence. The aim was to assess its content validity by conducting cognitive debriefing (CD) interviews with patients prescribed medication(s) of various treatment modalities in a range of therapy areas.

Materials and Methods

Targeted literature/instrument review and concept elicitation interviews informed development of the ADAQ©. CD interviews were conducted with 57 adults from the United States of America (USA; n = 21), Spain (n = 18), and Germany (n = 18) who prescribed medication for hypertension, diabetes, depression, schizophrenia, asthma, multiple myeloma, psoriasis, and/or multiple sclerosis. Interviews were conducted in two rounds to explore the relevance and understanding of the item wording, instructions, recall period and response options. Verbatim transcripts were analysed in ATLAS.Ti using thematic analysis. Three expert clinicians provided guidance throughout the study.

Results

ADAQ© items/instructions were well understood and relevant to participants. Key modifications following round 1 included revising instructions to refer to current medication(s) for one condition to reduce cognitive burden, removing two items with lower relevance (specifically those assessing running out of medication and social discouragement), and adding a response option for participants to indicate if they had stopped taking a medication. Minor wording modifications were made following round 2. Subgroup differences in item relevance were explored based on clinical characteristics. Cost of medication was more relevant amongst US participants.

Conclusion

Content validity of the ADAQ© was confirmed in demographically and clinically diverse participants. Psychometric properties of the ADAQ© will be explored in future studies.

Methodological considerations on estimating medication adherence from self-report, electronic monitoring, and electronic healthcare databases using the TEOS framework

AIM

Measuring adherence to medication is complex due to the diversity of contexts in which medications are prescribed, dispensed, and used. The Timelines-Events-Objectives-Sources (TEOS) framework outlined a process to operationalize adherence. We aimed to develop practical recommendations for quantification of medication adherence using self-report (SR), electronic monitoring (EM), and electronic healthcare databases (EHD) consistent with the TEOS framework for adherence operationalization.

METHODS

An adherence methodology working group of the International Society for Medication Adherence (ESPACOMP) analysed implications of the process of medication adherence for all data sources and discussed considerations specific to SR, ED, and EHD regarding the information available on the prescribing, dispensing, recommended and actual use timelines, the four events relevant for distinguishing the adherence phases, the study objectives commonly addressed with each type of data, and the potential sources of measurement error and quality criteria applicable.

RESULTS

Four key implications for medication adherence measurement are common to all data sources: adherence is a comparison between two series of events (recommended and actual use); it refers to one or more specific medication(s); it applies to regular repeated events coinciding with known recommended dosing; and it requires separate measurement of the three adherence phases for a complete picture of patients' adherence. We propose recommendations deriving from these statements, and aspects to be considered in study design when measuring adherence with SR, EM and EHD using the TEOS framework.

CONCLUSION

The quality of medication adherence estimates is the result of several design choices that may optimize the data available.

The Inhaler Technique Questionnaire (InTeQ): Development and Validation of a Brief Patient-Reported Measure

There is a need for instruments designed for patients with asthma to self-report their performance of inhaling steps. We aimed to develop an accessible and easy-to-use patient-reported tool for inhaler technique assessment, which could also serve as a training and monitoring resource for any type of inhaler device, and to evaluate its feasibility, validity, and reliability in adults with asthma. The development was based on literature review and pilot testing with clinicians and patients. The Inhaler Technique Questionnaire (InTeQ) asks about the frequency of performing five steps when using inhalers (on a five-point Likert scale). We analyzed data from adults with persistent asthma (n = 361). We examined the measurement model using Mokken scaling analysis, construct validity by assessing hypotheses on expected discrimination among known groups, and reliability based on internal consistency and reproducibility. Means of the InTeQ items were in the range of 0.23–1.61, and coefficients of homogeneity were above the cutoff point, demonstrating the unidimensionality of the scale. Known groups’ global score differences were statistically significant between patients reporting having “Discussed in detail” or having “Not discussed/Only in general” the inhaler technique with their healthcare providers (p = 0.023). The Cronbach’s alpha coefficient was 0.716, and the intraclass correlation coefficient was 0.775. The InTeQ is a feasible, valid, and reliable instrument for self-reporting inhaler technique on any type of device.

Respiratory Adherence Care Enhancer Questionnaire: Identifying Self-Management Barriers of Inhalation Corticosteroids in Asthma

Introduction: Suboptimal self-management of inhaled corticosteroids (ICS) in asthma patients is frequently observed in clinical practice and associated with poor asthma control. Driving factors for suboptimal self-management are complex and consist of a range of behavioral barriers (cognitive, affective and practical) with a considerable inter-individual variability. Identification of individual barriers facilitates the use of corresponding behavior change techniques and tailored care to improve asthma treatment outcomes. Objective: This study describes the development and validation of the 'Respiratory Adherence Care Enhancer' (RACE) questionnaire to identify individual barriers to self-management of ICS therapy in asthma patients. Methods: The development included: 1) an inventory of self-management barriers based on a literature review, 2) expert assessment on relevance and completeness of this set, linking these barriers to behavioral domains of the Theoretical Domains Framework (TDF) and 3) the formulation of corresponding questions assessing each of the barriers. A cross-sectional study was performed for validation. Primary care asthma patients were invited to fill out the RACE-questionnaire prior to a semi-structured telephonic interview as golden standard. Barriers detected from the questionnaire were compared to those mentioned in the interview. Results: The developed questionnaire is made up of 6 TDF-domains, covering 10 self-management barriers with 23 questions. For the validation 64 patients completed the questionnaire, of whom 61 patients were interviewed. Cronbach's alpha for the consistency of questions within the barriers ranged from 0.58 to 0.90. Optimal cut-off values for the presence of barriers were determined at a specificity between 67 and 92% with a sensitivity between 41 and 83%. Significant Areas Under the Receiver Operating Curves values were observed for 9 barriers with values between 0.69 and 0.86 (p-value <0.05), except for 'Knowledge of ICS medication' with an insignificant value of 0.53. Conclusion: The RACE-questionnaire yields adequate psychometric characteristics to identify individual barriers to self-management of ICS therapy in asthma patients, facilitating tailored care.

Determining Persistence with an Inhaled Corticosteroid in Asthma: Assessment Using an Objective Measurement vs the Self-Reported Foster Score

INTRODUCTION

Adherence with controller medication is a major challenge in asthma management. Thus, a reliable method of measurement is mandatory to assess adherence.

AIM

To examine the test-retest reliability on adherence with inhaled corticosteroids in adults with asthma using, a self-reported adherence score (Foster score).

METHODS

Patients with asthma and >1 routine follow-up appointment at a university hospital outpatient clinic reported Foster scores. The objective Medication Possession Ratio (MPR) was calculated based on pharmacy redemption data and physician-prescribed doses of inhaled corticosteroids. The difference between Foster score and MPR at the first and second visit was assessed using a Bland-Altman plot, outcomes reported as limits of agreements and bias. Foster scores from both visits were used to calculate an intraclass correlation coefficient (ICC).

RESULTS

Self-reported adherence with asthma controller medication measured by Foster score was significantly higher than the objective MPR (p < 0.0001). The Bland-Altman plot for MPR and Foster score at the first and second visit showed upper and lower limits of agreement of 83.5 - (-1.6) and 80.9 - (-6.9) and bias was 41.0 and 37.0, respectively. Of the included patients, 93.1% reported identical Foster scores between visits, resulting in an excellent ICC of 0.92. Absolute median difference between Foster scores and MPR at first and second visit was 8.7 percentage points (p = 0.049).

CONCLUSION

Foster score shows an excellent ICC; however, its poor agreement with objective measures of adherence suggests that clinicians should not rely on Foster scores alone to assess adherence with inhaled corticosteroids in patients with asthma.

Exploring Validated Self-Reported Instruments to Assess Adherence to Medications Used: A Review Comparing Existing Instruments

OBJECTIVE

To provide an overview of instruments that measure adherence to medications to facilitate selection of an instrument and to provide a summary of some published adherence assessment tools tailored to be used by the healthcare team, especially the pharmacists.

DATA SOURCES

Studies were identified via PubMed, Medline, Embase, and Google Scholar using the search terms medication adherence, compliance, persistence, combined with the terms questionnaire, scale, survey, self-report, and instrument.

STUDY SELECTION

Articles written in English, describing questionnaire instruments that were psychometrically evaluated (reporting a good coefficient of internal consistency, reliability assessed through Cronbach's alpha, and had been validated against a subjective or objective measure), and containing 30 or fewer items were included.

DATA SYNTHESIS

Twelve instruments were identified and included in this review. Instruments were reviewed by evaluating specific characteristics (number of items, sample size, reliability, sensitivity, specificity, questionnaire completion time, criterion validity, and component analysis).

CONCLUSION

Various instruments are used to assess patient adherence to medications; however, no single one performs well on all criteria. Every instrument has different advantages and unique properties. A particular instrument can be chosen after considering certain factors, such as the specific requirements, population, the needed time to complete the questionnaire, the sensitivity, and the specificity of the questionnaire. Moreover, there is a recognized need to provide primary care medication adherence services customized to patient's needs. A link for teamwork between healthcare providers such as pharmacists and patients is needed. This link can be a validated instrument to assess patient's adherence to medication.

Development and Validation of a Questionnaire to Measure Medication Adherence to Direct-Acting Agents in Patients with Hepatitis C

This study aims to develop a new self-report tool (HCV-AD) measuring adherence factors, intentional or unintentional, during Hepatitis C Virus (HCV) treatment with direct-acting antivirals (DAA) aiming to achieve high efficacy, otherwise resulting in drug resistance and treatment failure. Two phases were conducted: in the first phase, items were generated based on an extensive literature review, and, in the second phase, a prospective cohort study was conducted using HCV patients from Gastroenterology Department from University County Hospital of Craiova, Romania (n = 222), to evaluate the validity and reliability of the questionnaire. A number of 19 items were generated following a systematic review and through expert opinion. The internal consistency reliability was evaluated using Cronbach’s alpha. The construct validity was assessed using correlations with two other instruments: visual analog scale (VAS) and medication possession ratio (MPR). The final questionnaire (HCV-AD10) was derived through exploratory factor analysis, with 82% of total variance explained. This instrument appeared as a reliable and valid measure for medication adherence, with Cronbach’s alpha (0.867) and significant high positive correlations between adherence scores calculated with HCV-AD10 and VAS (ρ = 0.61, p < 0.001) or with HCV-AD10 and MPR (ρ = 0.75, p < 0.001). This research would make a worthwhile contribution to HCV management.

Self-reported vs. objectively assessed adherence to inhaled corticosteroids in asthma

BACKGROUND

Adherence to inhaled corticosteroids (ICS) in asthma is vital for disease control. However, obtaining reliable and clinically useful measures of adherence remains a major challenge. We investigated the association between patient-reported adherence and objectively measured adherence based on filled prescriptions with inhaled corticosteroids in adults with asthma.

METHODS

In total, 178 patients with asthma were asked to self-assess adherence during routine visits at a respiratory outpatient clinic. Self-assessment was performed using Foster score ("How many days in a 7-day week do you take your medication as prescribed?", with the answer divided by 7). Objective adherence was calculated as medication possession ratio (MPR). Bivariate and multivariable linear regression, adjusted for age, sex, FEV1, GINA treatment step, excessive use of SABA, and history of exacerbations were used for analyses.

RESULTS

Of the included patients, 87.6% reported a Foster score of 100%, while the mean ICS MPR was 54.0% (SD 25%). Complex regimens such as twice-daily dosing or dual inhaler-use were associated with lower adherence (p = 0.015 and p < 0.001, respectively). Foster score was predictive of ICS MPR, with an absolute 32% increase in MPR between patients reporting Foster scores of 0 and 100% (95% CI 13-50%, p < 0.001). Female sex predicted higher ICS MPR (p = 0.019). Previous asthma-related hospitalization(s) predicted lower ICS MPR (p = 0.039).

CONCLUSION

Although a weak association was found between Foster score and ICS MPR, findings do not support the use of Foster score, and by that self-reported adherence, as a reliable marker of controller adherence in asthma due to significant mismatch between patient-reported adherence and MPR. Future studies should address the complex interplay between patient-reported and objectively assessed adherence to controller medication in asthma.

Smartphone App for monitoring Asthma in children and adolescents

PURPOSE

The asthma stepwise treatment approach recommended is based on monitoring patients' symptoms. The Asthma Research in Children and Adolescents (ARCA) cohort was created to provide evidence about the evolution of persistent asthma. This manuscript describes the development of an electronic health tool, comprising a mobile health application for patients with asthma and its associated online platform for pediatricians to monitor them.

METHODS

The development process followed 7 phases: the first 5 (Conceptualization, Preparation, Assessment scheduling, Image and user interface, and Technical development) defined and designed the tool, followed by a testing phase (functionality assessment and pilot test with ARCA patients), and a last phase which evaluated usability. Since the target population was aged 6-16 years, three versions were designed within the same smartphone application: parents/proxy, children, and adolescents. The online platform for pediatricians provides real-time information from the application: patients' responses over time with color-coded charts (red/amber/green, as in traffic lights).

RESULTS

The pilot test through semi-structured phone interviews of the first 50 participants included in the ARCA study (n = 53) detected their misunderstandings. Pediatricians were trained to emphasize that the application is free of charge and requires monthly answers. Median of the System Usability Scale scores (n = 85), ranging 0 (negative)-100 (positive), was > 93 in the three age versions of the application.

CONCLUSIONS

Technology has the capability of transforming the use of patient-reported outcomes. Describing all the development phases of a mobile health application for monitoring children and adolescents with asthma may increase the knowledge on how to design applications for young patients.

TEOS: A framework for constructing operational definitions of medication adherence based on Timelines-Events-Objectives-Sources

AIMS

Managing adherence to medications is a priority for health systems worldwide. Adherence research is accumulating, yet the quality of the evidence is reduced by various methodological limitations. In particular, the heterogeneity and low accuracy of adherence measures have been highlighted in many literature reviews. Recent consensus-based guidelines advise on best practices in defining adherence (ABC) and reporting of empirical studies (EMERGE). While these guidelines highlight the importance of operational definitions in adherence measurement, such definitions are rarely included in study reports. To support researchers in their measurement decisions, we developed a structured approach to formulate operational definitions of adherence.

METHODS

A group of adherence and research methodology experts used theoretical, methodological and practical considerations to examine the process of applying adherence definitions to various research settings, questions and data sources. Consensus was reached through iterative review of discussion summaries and framework versions.

RESULTS

We introduce TEOS, a four-component framework to guide the operationalization of adherence concepts: (1) describe treatment as four simultaneous interdependent timelines (recommended and actual use, conditional on prescribing and dispensing); (2) locate four key events along these timelines to delimit the three ABC phases (first and last recommended use, first and last actual use); (3) revisit study objectives and design to fine-tune research questions and assess measurement validity and reliability needs, and (4) select data sources (e.g., electronic monitoring, self-report, electronic healthcare databases) that best address measurement needs.

CONCLUSION

Using the TEOS framework when designing research and reporting explicitly on these components can improve measurement quality.

Development of a PATIENT-Medication Adherence Instrument (P-MAI) and a HEALTHCARE PROFESSIONAL-Medication Adherence Instrument (H-MAI) using the nominal group technique

To date, several medication adherence instruments have been developed and validated worldwide. However, most instruments have only assessed medication adherence from the patient’s perspective. The aim was to develop and validate the PATIENT-Medication Adherence Instrument (P-MAI) and the HEALTHCARE PROFESSIONAL-Medication Adherence Instrument (H-MAI) to assess medication adherence from the patient’s and healthcare professional (HCP)’s perspectives. The P-MAI-12 and H-MAI-12 were developed using the nominal group technique. The face and content validity was determined by an expert panel and piloted. The initial version of these instruments consisted of 12 items were validated from October-December 2018 at a primary care clinic in Malaysia. Included were patients aged ≥21 years, diagnosed with diabetes mellitus, taking at least one oral hypoglycaemic agent and who could understand English. The HCPs recruited were family medicine specialists or trainees. To assess validity, exploratory factor analysis (EFA) and concurrent validity were performed; internal consistency and test-retest were performed to assess its reliability. A total of 120/158 patients (response rate = 75.9%) and 30/33 HCPs (response rate = 90.9%) agreed to participate. EFA found three problematic items in both instruments, which was then removed. The final version of the P-MAI-9 and the HMAI-9 had 9 items each with two domains (adherence = 2 items and knowledge/belief = 7 items). For concurrent validity, the total score of the P-MAI-9 and the H-MAI-9 were not significantly different (p = 0.091), indicating that medication adherence assessed from both the patient’s and HCP’s perspectives were similar. Both instruments achieved acceptable internal consistency (Cronbach’s α: P-MAI-9 = 0.722; H-MAI-9 = 0.895). For the P-MAI-9, 7/9 items showed no significant difference between test and retest whereas 8/9 items in the H-MAI-9 showed significant difference at test and retest (p>0.05). In conclusion, the P-MAI-9 and H-MAI-9 had low sensitivity and high specificity suggesting that both instruments can be used for identifying patients more likely to be non-adherent to their medications.

Measurement Properties of Existing Patient-Reported Outcome Measures on Medication Adherence: Systematic Review

BACKGROUND

Medication adherence is essential for improving the health outcomes of patients. Various patient-reported outcome measures (PROMs) have been developed to measure medication adherence in patients. However, no study has summarized the psychometric properties of these PROMs to guide selection for use in clinical practice or research.

OBJECTIVE

This study aims to evaluate the quality of the PROMs used to measure medication adherence.

METHODS

This study was guided by the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidelines. Relevant articles were retrieved from the EMBASE, PubMed, Cochrane Library, Web of Science, and CINAHL (Cumulative Index to Nursing and Allied Health Literature) databases. The PROMs were then evaluated based on the COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) guidelines.

RESULTS

A total of 121 unique medication adherence PROMs from 214 studies were identified. Hypotheses testing for construct validity and internal consistency were the most frequently assessed measurement properties. PROMs with at least a moderate level of evidence for ≥5 measurement properties include the Adherence Starts with Knowledge 20, Compliance Questionnaire-Rheumatology, General Medication Adherence Scale, Hill-Bone Scale, Immunosuppressant Therapy Barrier Scale, Medication Adherence Reasons Scale (MAR-Scale) revised, 5-item Medication Adherence Rating Scale (MARS-5), 9-item MARS (MARS-9), 4-item Morisky Medication Adherence Scale (MMAS-4), 8-item MMAS (MMAS-8), Self-efficacy for Appropriate Medication Adherence Scale, Satisfaction with Iron Chelation Therapy, Test of Adherence to Inhalers, and questionnaire by Voils. The MAR-Scale revised, MMAS-4, and MMAS-8 have been administered electronically.

CONCLUSIONS

This study identified 121 PROMs for medication adherence and provided synthesized evidence for the measurement properties of these PROMs. The findings from this study may assist clinicians and researchers in selecting suitable PROMs to assess medication adherence.

Development of an Item Bank to Measure Medication Adherence: Systematic Review

Background

Medication adherence is important in managing the progression of chronic diseases. A promising approach to reduce cognitive burden when measuring medication adherence lies in the use of computer‐adaptive tests (CATs) or in the development of shorter patient-reported outcome measures (PROMs). However, the lack of an item bank currently hampers this progress.

Objective

We aim to develop an item bank to measure general medication adherence.

Methods

Using the preferred reporting items for systematic review and meta-analysis (PRISMA), articles published before October 2019 were retrieved from PubMed, Embase, CINAHL, the Cochrane Library, and Web of Science. Items from existing PROMs were classified and selected (“binned” and “winnowed”) according to standards published by the Patient-Reported Outcomes Measurement Information System (PROMIS) Cooperative Group.

Results

A total of 126 unique PROMs were identified from 213 studies in 48 countries. Items from the literature review (47 PROMs with 579 items for which permission has been obtained) underwent binning and winnowing. This resulted in 421 candidate items (77 extent of adherence and 344 reasons for adherence).

Conclusions

We developed an item bank for measuring general medication adherence using items from validated PROMs. This will allow researchers to create new PROMs from selected items and provide the foundation to develop CATs.

Measuring and reporting treatment adherence: What can we learn by comparing two respiratory conditions?

Medication non-adherence, defined as any deviation from the regimen recommended by their healthcare provider, can increase morbidity, mortality and side effects, while reducing effectiveness. Through studying two respiratory conditions, asthma and tuberculosis (TB), we thoroughly review the current understanding of the measurement and reporting of medication adherence. In this paper, we identify major methodological issues in the standard ways that adherence has been conceptualised, defined and studied in asthma and TB. Between and within the two diseases there are substantial variations in adherence reporting, linked to differences in dosing intervals and treatment duration. Critically, the communicable nature of TB has resulted in dose-by-dose monitoring becoming a recommended treatment standard. Through the lens of these similarities and contrasts, we highlight contemporary shortcomings in the generalised conceptualisation of medication adherence. Furthermore, we outline elements in which knowledge could be directly transferred from one condition to the other, such as the application of large-scale cost-effective monitoring methods in TB to resource-poor settings in asthma. To develop a more robust evidence-based approach, we recommend the use of standard taxonomies detailed in the ABC taxonomy when measuring and discussing adherence. Regimen and intervention development and use should be based on sufficient evidence of the commonality and type of adherence behaviours displayed by patients with the relevant condition. A systematic approach to the measurement and reporting of adherence could improve the value and generalisability of research across all health conditions.

Impact of a paediatric-adult care transition programme on the health status of patients with sickle cell disease: study protocol for a randomised controlled trial (the DREPADO trial)

BACKGROUND

Thanks to advancements in medical care, a majority of patients with sickle cell disease (SCD) worldwide live beyond 18 years of age, and therefore, patients initially followed in paediatric departments are then transferred to adult departments. This paediatric-adult care transition is a period with an increased risk of discontinuity of care and subsequent morbidity and mortality. During this period, the patient will have to manage new interlocutors and places of care, and personal issues related to the period of adolescence. To take into consideration all these aspects, an interesting approach is to use the whole system approach to the patient, as presented in the biopsychosocial approach. The aim of this trial is to evaluate the impact of the proposed biopsychosocial paediatric-adult transition programme.

METHODS

The DREPADO study is a multicentre randomised control trial comparing a control group (Arm A) to an interventional group with a paediatric-adult transition programme based on a biopsychosocial approach (Arm B). To be included, patients should have the SS, SC, or Sβ form of sickle cell disease and be aged between 16 and 17 years. The randomisation in a 1:1 ratio assigns to Arm A or B. The primary outcome is the number of hospital admissions and emergencies for complications in the index hospital, in the 2 years after the first consultation in the adult department of care. Secondary outcomes consider the quality of life, but also include coping skills such as sense of self-efficacy and disease knowledge. To provide patient and parent knowledge and coping skills, the transition programme is composed of three axes: educational, psychological, and social, conducted individually and in groups.

DISCUSSION

By providing self-care knowledge and coping skills related to SCD and therapeutics, helping empower patientsin relation to pain management and emotions, and facilitating the relationship to oneself, others, and care in Arm B of the DREPADO study, we believe that the morbidity and mortality of patients with SCD may be reduced after the proposed paediatric-adult transition programme.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03786549; registered on 17 December 2018; https://clinicaltrials.gov/.

Prevalence and predictors of adherence to inhaled corticosteroids in young adults (15-30 years) with asthma: a systematic review and meta-analysis

Objective: Adherence to inhaled corticosteroids (ICS) is an essential part of asthma management throughout the lifespan; however, this may be particularly challenging during the transition into adulthood. This systematic review aimed to determine the prevalence and predictors of adherence to ICS in emerging adulthood.Data sources: MEDLINE, PsycINFO, EMBASE, Scopus, and CINAHL were searched with search terms for asthma, ICS, adherence, young adults, and predictors combined.Study selection: Studies with participants with diagnosed asthma, currently prescribed ICS, a mean age between 15 and 30 years and reporting the prevalence and/or assessing predictor(s) of adherence using quantitative methods were included.Results: Twenty-nine studies were identified for inclusion (K = 29, N = 187 401). A random effect meta-analysis revealed the pooled prevalence of adherence was 28% (95% CI = 20-38%, k = 16) in studies that provided quantitative information on adherence. Adherence was higher in studies with a mean age <18 years (36%; 95% CI = 36-37%, k = 4). Studies using self-report measures provided higher estimates of adherence (35%; 95% CI = 28-42%, k = 10) than studies using pharmacy refill data (20%; 95% CI = 9-38%, k = 6). A narrative review identified personality, illness perceptions, and treatment beliefs as potentially important predictors of adherence.Conclusion: Adherence is sub-optimal during emerging adulthood, particularly after age 18. More reliable and objective measures are needed to precisely characterize adherence. Greater research and practice attention to emerging adulthood are needed to guide self-management support in those living with asthma at this important lifespan stage.Systematic review registration number: CRD42018092401.

Does adherence to inhaled corticosteroids predict asthma-related outcomes over time? A cohort study

Inhaled corticosteroids (ICS) adherence is important for asthma management. Current evidence on the impact of ICS adherence on outcomes is mostly based on correlational analyses of between-person data. Although it is widely acknowledged that asthma outcomes fluctuate over time, evidence on predictors of within-person change is scarce. We aimed to quantify these fluctuations and the longitudinal relationships between ICS adherence and outcomes at both between- and within-person levels.A prospective cohort of persistent asthma patients in France and the UK (n=847, age 6-40 years) provided 3756 reports over up to 2 years via computer-assisted telephone interviews and text messages on ICS adherence, asthma control, reliever medication use and exacerbations. We examined adherence-outcome relationships via longitudinal models, controlling for confounders, including severity.Considerable within-person variability was found for exacerbations (91%), asthma control (59%) and reliever use (52%); 431 (11.5%) reports signalled exacerbations and 2046 (54.5%) poor control. At between-person level, patients with higher average adherence were more likely to report asthma control (OR 1.25, 95% CI 1.06-1.47), but not asthma exacerbations (OR 0.99, 95% CI 0.87-1.12) or lower reliever use (b -0.0004, 95% CI -0.089-0.088). At within-person level, higher-than-usual adherence was associated with higher concomitant reliever use (b 0.092, 95% CI 0.053-0.131) and lower subsequent reliever use (b -0.047, 95% CI -0.005- -0.088); it was unrelated to asthma control (OR 0.93, 95% CI 0.84-1.02) or exacerbations (OR 1.04, 95% CI 0.94-1.16).Patients maintaining high ICS adherence over time have better asthma control. Temporarily increasing ICS adherence tends to be simultaneous to higher reliever use and reduces reliever use later on. Causes of within-person variation in outcomes require more investigation.

Effects of short- and long-acting beta-agonists on asthma exacerbations: a prospective cohort

BACKGROUND

In asthma, short- and long-acting β-agonists (SABAs and LABAs) should be used together with inhaled corticosteroids (ICS), and regular use is inappropriate.

OBJECTIVE

To assess the relationship between patterns of use of therapy and asthma exacerbations (AEx).

METHODS

Patients with asthma (6-40 years) were enrolled in France and the United Kingdom. Prescribing data, computer-assisted telephone interviews (CATIs), and text messages assessed medication use and AEx over a maximum period of 24 months. Generalized linear mixed models provided AEx risks associated with therapy.

RESULTS

Among the 908 patients (median age: 20.0 years, 46.6% women, 24.5% children) answering a total of 4248 CATIs over 486 (±235) days, regular (ie, daily) use was more frequent for single LABAs and fixed dose combinations (FDCs) than for single ICS (75.6%, 70.1%, and 65.4% of investigated periods of use, respectively). Regular (ie, daily or almost daily) SABA use was observed for 21.1% of periods of use. Altogether, 265 patients (29.2%) experienced 1 or more AEx. The ORs for AEx risk related to regular vs no use of FDCs, single ICS, and single LABAs were 0.98 (95% CI = [0.73-1.33]), 0.90 (95% CI = [0.61-1.33]), and 1.29 (95% CI = [0.76-2.17]), respectively, after adjustment for cotherapy, sociodemographic, and disease characteristics. The OR was 2.09 (95% CI = [1.36-3.21]) in regular SABA users.

CONCLUSION

Inhaled corticosteroids and FDCs were often used intermittently, whereas SABAs and LABAs could be used regularly, and exacerbations were frequent. Compared with non-users, the risk of exacerbation increased moderately under regular use of single LABAs, whereas it doubled, significantly, in regular SABA users, likely in relationship with poor overall asthma control.

Adherence stages measured by patient-reported outcome instruments in adults with asthma: a scoping review

Objective: Individuals who are adherent to their asthma inhaled maintenance medication: (1) initiate their treatment (take the first dose); (2) implement it (take it as per prescribed dosing regimen); and persist with it (take it for the entire prescribing period). To avoid unnecessary hospitalizations and costs, patient adherence should be routinely assessed. To this end, we aimed to identify patient-reported outcome instruments (PROs) used for measurement of patient adherence to inhaled maintenance medication in asthmatic adults and to report on the adherence stage that these instruments measured. Data sources: We conducted a scoping review of six databases. Study selection: We searched for studies in which PROs were used to measure patient adherence to inhaled maintenance medication in asthmatic participants aged ≥18 years. We extracted and synthesized data in order to list the available PROs and to report the adherence stages that these instruments measured. Results: We included 186 studies (87 PROs). Among all 87 instruments, none were found to measure all three adherence stages. We found that 1 measured initiation, 2 evaluated initiation and implementation, 74 assessed implementation, 7 measured implementation and persistence. The most used instrument (n = 41 studies or 22%) was the Self-Reported Medication-Taking Scale, which was found to assess implementation only. Conclusion: Our results suggest that no single PRO exists to measure initiation, implementation and persistence with asthma inhaled maintenance medication. Results from this review could therefore guide the development or refinement of PROs that would aim to measure all three adherence stages.

New insights to improve treatment adherence in asthma and COPD

Chronic respiratory diseases such as asthma and COPD are typically managed by daily inhaled medication. However, the efficacy of an inhaled medication depends upon a patient's adherence to therapy, which refers to whether the medication is actually taken as prescribed. In patients with these diseases, higher adherence has been associated with better health outcomes, such as improved disease control and a reduction in severe and potentially costly exacerbations. Adherence is a multifaceted concept that includes medication-related, intentional, and unintentional reasons that patients may or may not take their medication as directed. The purpose of this integrative review is to present the individual patient factors that contribute to suboptimal adherence to inhaled therapies and the associated effects on health outcomes, while also highlighting evidence-based strategies for health care providers to improve adherence to such therapies in patients with asthma or COPD. Working closely with patients to establish a model of shared decision-making, which takes patient beliefs and preferences into account when choosing treatment options, has the potential to improve adherence and overall patient outcomes in the management of asthma and COPD.

Adherence to treatment in allergic respiratory diseases

Introduction: Asthma and allergic rhinitis (AR) are chronic conditions in which management needs adherence to prescribed drugs. Despite the benefits of regular maintenance of asthma and AR therapy, low adherence is a frequent issue in clinical practice. Areas covered: The aim of this review is to provide a targeted analysis of the more recent literature on adherence in asthma and AR, focused on the following areas: adherence extent, barriers and consequences, effects of educational interventions and use of new technologies to improve the level of adherence. Expert commentary: Despite the extent, reasons and effects of this problem being well known, non-adherence in asthma and allergic AR remains worryingly high. Poor adherence leads to unsatisfactory health outcomes, with a negative impact on patients and society. Recent literature suggests that successful programs to improve adherence should include a combination of strategies. The new technologies represent a promising tool to improve adherence.

Patient-reported outcome instruments that evaluate adherence behaviours in adults with asthma: a systematic review of measurement properties

AIM

The aim of the present study was to identify systematically the measurement properties of patient-reported outcome instruments (PROs) that evaluate adherence to inhaled maintenance medication in adults with asthma.

METHODS

We conducted a systematic review of six databases. Two reviewers independently included studies on the measurement properties of PROs that evaluated adherence in asthmatic participants aged ≥18 years. Based on the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN), the reviewers: (i) extracted data on internal consistency, reliability, measurement error, content validity, structural validity, hypotheses testing, cross-cultural validity, criterion validity and responsiveness; (ii) assessed the methodological quality of the included studies; (iii) assessed the quality of the measurement properties (positive or negative); and (iv) summarized the level of evidence (limited, moderate or strong).

RESULTS

We screened 6068 records and included 15 studies (14 PROs). No studies evaluated measurement error or responsiveness. Based on methodological and measurement property quality assessments, we found limited positive evidence of: (i) internal consistency of the Adherence Questionnaire, Refined Medication Adherence Reason (MAR) scale, Medication Adherence Report Scale for Asthma (MARS-A) and Test of the Adherence to Inhalers (TAI); (ii) reliability of the TAI; and (iii) structural validity of the adherence questionnaire, MAR scale, MARS-A and TAI. We also found limited negative evidence of: (i) hypotheses testing of the Adherence Questionnaire; (ii) reliability of the MARS-A; and (iii) criterion validity of the MARS-A and TAI.

CONCLUSIONS

Our results highlighted the need to conduct further high-quality studies to evaluate the reliability, validity and responsiveness of the available PROs.

Impact of asthma on women and men: Comparison with the general population using the EQ-5D-5L questionnaire

BACKGROUND

The aim was to evaluate the impact of asthma on patients' Health-Related Quality of Life (HRQoL) by comparing asthmatic women and men with reference norms, to examine the factors which contributed to an impaired HRQoL, and to identify groups at higher risk.

METHODS

Cross-sectional evaluation of 222 primary care patients with persistent asthma (18-40 years old). HRQoL impact was estimated with the EuroQol-5 Dimensions (EQ-5D), which allows calculating Quality-Adjusted Life-Years (QALYs) by applying society preferences. Participants self-completed the EQ-5D questionnaire online. Telephonic interviews collected information on medication and adherence, and administered the Asthma Control Questionnaire. Severity markers included asthma-related comorbidity, previous oral corticosteroids course prescription, and inhaled corticosteroids daily dose. After bivariate analyses, multiple linear regression models were constructed to examine the relations between HRQoL asthma impact and socio-demographic and clinical variables, using as dependent variable the deviation from general population-based EQ-5D reference norms.

RESULTS

Deviation from the EQ-5D index norms was moderate in most age/gender groups (-0.1, which corresponds to 0.6 standard deviations), while it was large in women aged 18-24 years (-0.18, corresponding to 1.1 standard deviations). In regression models, a poor asthma control was the only factor independently associated to HRQoL impact in both women and men: β -0.18 (p<0.001) and -0.15 (p = 0.01) respectively. Translating these β coefficients to QALYs, they are interpretable as 66 fewer days of full health per year in women with uncontrolled asthma and 55 for men, compared with those with controlled asthma.

CONCLUSION

Persistent asthma has a moderately negative HRQoL impact on patients of both genders, and the youngest women have been identified as a high risk group which merits further research. We identified asthma control as the major contributor to impaired HRQoL in patients, regardless of their gender, suggesting that asthma HRQoL impact could be alleviated by achieving a good control of symptoms.