Factors associated with the appropriate use of asthma drugs

Reductions in inhaler greenhouse gas emissions by addressing care gaps in asthma and chronic obstructive pulmonary disease: an analysis

INTRODUCTION

Climate change from greenhouse gas (GHG) emissions represents one of the greatest public health threats of our time. Inhalers (and particularly metred-dose inhalers (MDIs)) used for asthma and chronic obstructive pulmonary disease (COPD), constitute an important source of GHGs. In this analysis, we aimed to estimate the carbon footprint impact of improving three distinct aspects of respiratory care that drive avoidable inhaler use in Canada.

METHODS

We used published data to estimate the prevalence of misdiagnosed disease, existing inhaler use patterns, medication class distributions, inhaler type distributions and GHGs associated with inhaler actuations, to quantify annual GHG emissions in Canada: (1) attributable to asthma and COPD misdiagnosis; (2) attributable to overuse of rescue inhalers due to suboptimally controlled symptoms; and (3) avoidable by switching 25% of patients with existing asthma and COPD to an otherwise comparable therapeutic option with a lower GHG footprint.

RESULTS

We identified the following avoidable annual GHG emissions: (1) ~49 100 GHG metric tons (MTs) due to misdiagnosed disease; (2) ~143 000 GHG MTs due to suboptimal symptom control; and (3) ~262 100 GHG MTs due to preferential prescription of strategies featuring MDIs over lower-GHG-emitting options (when 25% of patients are switched to lower GHG alternatives). Combined, the GHG emission reductions from bridging these gaps would be the equivalent to taking ~101 100 vehicles off the roads each year.

CONCLUSIONS

Our analysis shows that the carbon savings from addressing misdiagnosis and suboptimal disease control are comparable to those achievable by switching one in four patients to lower GHG-emitting therapeutic strategies. Behaviour change strategies required to achieve and sustain delivery of evidence-based real-world care are complex, but the added identified incentive of carbon footprint reduction may in itself prove to be a powerful motivator for change among providers and patients. This additional benefit can be leveraged in future behaviour change interventions.

Development of a community pharmacy-based intervention for patients with uncontrolled asthma

Background

Objective

Methods

Results

Conclusions

Factors associated with the appropriate use of asthma medications among adult asthmatic patients attending asthma clinic in a teaching hospital

INTRODUCTION

asthma tends to be more severe with worse symptoms in Africa due to late diagnosis and delayed initiation of treatment. To identify patient and treatment-related factors which influence the appropriate use of asthma medications.

METHODS

the study was institution based cross-sectional design. Patients were invited to provide information regarding the use of their asthma medications and factors potentially associated with appropriate use of these medications. A stepwise multivariate logistic regression analysis was used to evaluate the most important factor at a 0.05 level of significance.

RESULTS

respondents with better knowledge of their asthma medications were more likely to use them appropriately (OR 5.82 [CI 95% 2.25-15.04]) as were those with positive attitudes and beliefs towards asthma and asthma medications (OR 3.88 [CI 95% 1.44-10.44]).

CONCLUSION

patients need to understand the importance of adhering to the prescribed regimen for their asthma medications even in the absence of overt symptoms in order to optimize clinical outcome.

Contributing Factors for Underutilization of Inhaled Corticosteroids Among Asthmatic Patients Attending at Adama Hospital Medical College, Adama, Ethiopia

INTRODUCTION

Inhaled corticosteroids (ICSs) are a cornerstone medicine for preventive therapy of persistent severe asthma. Although ICs are very effective for the treatment of severe persistent asthma, the majority of the prescribers worldwide aren't aware of ICs use for the treatment of severe persistent asthma.

OBJECTIVE

To evaluate factors contributing to underutilization of ICS by asthmatic patients.

METHODS

Patient interview was conducted among asthmatic patients using a cross-sectional study design who were attending at the Adama Hospital Medical College from March 1 to July 25, 2017. The total number of patients involved in the study was 94. Semi-structured questionnaire through patient interview was used for data collection and data from physicians who were working at the chest clinic of AHMC were collected by self-administered semi-structured questionnaire focusing their perspectives and experiences on patients' ICS.

RESULTS

Generally 73.5% of underutilization of ICS was reported from the total number of patients involved in the study according to the patient's perception. Monthly income, comorbid disease, and behaviors of ICS use were the main factors contributing to underutilization of ICS. According to patient's report, some of the reasons for underutilization of ICS were unaffordability, using the drugs only when symptoms appear, inaccessibility, side effects and recommendation by physicians. There were also similar reports by the physicians working in the AHMC.

CONCLUSION

In our study setting, prevalence of underutilization of ICS was high and the contributing factors were increased cost of ICS, inaccessibility of ICS, poor knowledge of the patients on asthma disease and ICS, bad attitude toward ICS, and lack of recently reviewed local guideline for asthma treatment. Thus, concerned experts need to take actions that guarantee accessibility of ICS at a reasonable price and increase awareness of patients about asthma disease and use of ICS.

Extent, trends, and determinants of controller/reliever balance in mild asthma: a 14-year population-based study

BACKGROUND

The majority of patients with asthma have the mild form of the disease. Whether mild asthma patients receive appropriate asthma medications has not received much attention in the literature. We examined the trends in indicators of controller/reliever balance.

METHODS

Using administrative health databases of British Columbia, Canada (2000 to 2013), we created a population-based cohort of adolescents/adults with mild asthma using validated case definition algorithms. Each patient-year of follow-up was assessed based on two markers of inappropriate medication prescription: whether the ratio of controller medications (inhaled corticosteroids [ICS] and leukotriene receptor antagonists [LTRA]) to total asthma-related prescriptions was low (cut-off 0.5 according to previous validation studies), and whether short-acting beta agonists (SABA) were prescribed inappropriately according to previously published criteria that considers SABA in relation to ICS prescriptions. Generalized linear models were used to evaluate trends and to examine the association between patient-, disease-, and healthcare-related factors and medication use.

RESULTS

The final cohort consisted of 195,941 mild asthma patients (59.5% female; mean age at entry 29.6 years) contributing 1.83 million patient-years. In 48.8% of patient-years, controller medications were suboptimally prescribed, while in 7.2%, SABAs were inappropriately prescribed. There was a modest year-over-year decline in inappropriate SABA prescription (relative change - 1.3%/year, P < 0.001) and controller-to-total-medications (relative change - 0.5%/year, P < 0.001). Among the studied factors, the indices of type and quality of healthcare (namely respirologist consultation and receiving pulmonary function test) had the strongest associations with improvement in controller/reliever balance.

CONCLUSIONS

Large number of mild asthma patients continue to be exposed to suboptimal combinations of asthma medications, and it appears there are modifiable factors associated with such phenomenon.

Predictors of inappropriate and excessive use of reliever medications in asthma: a 16-year population-based study

BACKGROUND

Understanding factors associated with the inappropriate or excessive use of short-acting beta agonists (SABA) can help develop better policies.

METHODS

We used British Columbian (BC)'s administrative health data (1997-2014) to create a retrospective cohort of asthma patients aged between 14 and 55 years. The primary and secondary outcomes were, respectively, inappropriate and excessive use of SABA based on a previously validated definition. Exposures were categorised into groups comprising socio-demographic variables, indicators of type and quality of asthma care, and burden of comorbid conditions.

RESULTS

343,520 individuals (56.3% female, average age 30.5) satisfied the asthma case definition, contributing 2.6 million person-years. 7.3% of person-years were categorised as inappropriate SABA use and 0.9% as excessive use. Several factors were associated with lower likelihood of inappropriate use, including female sex, higher socio-economic status, higher continuity of care, having received pulmonary function test in the previous year, visited a specialist in the previous year, and the use of inhaled corticosteroids in the previous year. An asthma-related outpatient visit to a general practitioner in the previous year was associated with a higher likelihood of inappropriate SABA use. Similar associations were found for excessive SABA use with the exception that visit to respirologist and the use of systemic corticosteroids were associated with increased likelihood of excessive use.

CONCLUSIONS

Despite proven safety issues, inappropriate SABA use is still prevalent. Several factors belonging to patients' characteristics and type/quality of care were associated with inappropriate use of SABAs and can be used to risk-stratify patients for targeted attempts to reduce this preventable cause of adverse asthma outcomes.

Assessment of inhaled corticosteroids use and associated factors among asthmatic patients attending Tikur Anbessa Specialized Hospital, Ethiopia

Background

Inhaled corticosteroids (ICSs) are cornerstone therapy for persistent asthma. However, underutilization of ICSs is common and little is known about factors contributing toward this undesirable use.

Methods

A cross-sectional study was conducted through interview and chart review among persistent asthmatic patients attending chest clinic of Tikur Anbessa Specialized Hospital from 1 May to 31 September 2014. A total of 131 eligible patients who attended the clinic during study period were included in the study. A multivariate logistic regression was used to examine the association between independent and dependent variables.

Results

Overall, extent of underutilization of ICSs was found to be 68%. Monthly income, comorbidity and types of ICSs products prescribed showed significant association with reported underutilization. Patients’ reported reasons for underutilization includes; unaffordability (44%), using only when symptoms exacerbate (21%), fear of side effects (10%), practitioners’ recommendation (10%) and unavailability of ICSs in the local market (7%). Physicians also stated unaffordability, fear of side effects and dependency, lack of local guideline for asthma management and unavailability of ICSs as the contributing factors.

Conclusion

In this setting, extent of underutilization of ICSs was found to be high and seems the result of complex interaction of various factors. Financial problem combined with inconsistent availability of ICSs in the local market, patients’ poor knowledge of asthma and ICSs, negative attitude toward ICSs, absence of local guidelines for asthma management are found to be essential elements dictating an extent of ICSs use.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-017-2645-2) contains supplementary material, which is available to authorized users.

Factors associated with adherence to asthma treatment with inhaled corticosteroids: A cross-sectional exploratory study

BACKGROUND

Understanding factors at the patient, provider or organizational level associated with inhaled corticosteroids (ICSs) adherence is important when planning adherence-enhancing interventions.

OBJECTIVE

To explore factors associated with adherence to ICS among patients with asthma aged 12-45 years.

METHODS

A cross-sectional study was conducted among patients with asthma reporting ICS prescription during the baseline interview of an intervention study. Three methods were used to measure ICS adherence: a 4-item self-report questionnaire, a single question (SQ) measuring past 7-day exposure to ICS and a medication possession ratio (MPR, i.e., the sum of ICS days of supply/365). We assessed 46 potential factors of ICS adherence derived from the Predisposing, Reinforcing and Enabling Constructs in Educational Diagnosis and Evaluation (PRECEDE) model. Their association with ICS adherence was measured using multivariate logistic regressions.

RESULTS

Among the 319 participants included, 16.0% were deemed adherent according to the 4-item questionnaire. This proportion was 43.0% and 9.1% for the SQ and the MPR method, respectively. Ten factors were associated with good ICS adherence. Among these factors, four were associated with adherence through one of the measuring methods: a low family income level, a high number of asthma drugs used, a good knowledge of asthma pathophysiology and the perception that following the ICS prescription was easy. Two factors emerged through more than one measure: perceiving asthma severity as moderate to very severe and perceiving a high risk of death if ICSs are not taken as prescribed.

CONCLUSION

ICS adherence was poor in those individuals with asthma. Future adherence-enhancing interventions could target the identified modifiable risk factors.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT02093013.

The burden of nonadherence among adults with asthma: a role for shared decision-making

A shared approach to decision-making framework has been suggested for chronic disease management especially where multiple treatment options exist. Shared decision-making (SDM) requires that both physician and patients are actively engaged in the decision-making process, including information exchange; expressing treatment preferences; as well as agreement over the final treatment decision. Although SDM appears well supported by patients, practitioners and policymakers alike, the current challenge is to determine how best to make SDM a reality in everyday clinical practice. Within the context of asthma, adherence rates are poor and are linked to outcomes such as reduced asthma control, increased symptoms, healthcare expenditures, and lower patient quality of life. It has been suggested that SDM can improve treatment adherence and that ignoring patients' personal goals and preferences may result in reduced rates of adherence. Furthermore, understanding predictors of poor treatment adherence is a necessary step toward developing effective strategies to improve the patient-reported and clinically important outcomes. Here, we describe why a shared approach to treatment decision-making for asthma has the potential to be an effective tool for improving adherence, with associated clinical and patient-related outcomes. In addition, we explore insights into the reasons why SDM has not been implemented into routine clinical practice.

Impact of Adding a Decision Aid to Patient Education in Adults with Asthma: A Randomized Clinical Trial

BACKGROUND

Not providing adequate patient education interventions to asthma patients remains a major care gap. To help asthma patients and caregivers discuss inhaled controller medication use, our team has previously developed a decision aid (DA). We sought to assess whether adding this DA to education interventions improved knowledge, decisional conflict, and asthma control among adults with asthma.

METHODS

A parallel clinical trial (NCT02516449). We recruited adults with asthma, aged 18 to 65 years, prescribed inhaled controller medication to optimize asthma control. Educators randomly allocated participants either to the education + DA or to the education group. At baseline and two-month follow-up, we measured asthma knowledge (primary outcome) with a validated self-administered questionnaire (score -37 to +37). Secondary outcomes included decisional conflict and asthma control. Blinded assessors collected data. Between the two time points, the within- and between-group changes were estimated by generalized linear mixed models.

RESULTS

Fifty-one participants (response rate: 53%; age: 44 ± 13 years; women: n = 32) were randomized either to the education + DA group (n = 26) or to the education group (n = 25), and included in statistical analyses. Between baseline and follow-up, mean [95% CI] knowledge scores increased from 21.5 [19.9-23.2] to 25.1 [23.1-27.0] in the education + DA group (P = 0.0002) and from 24.0 [22.3-25.7] to 26.0 [24.0-28.0] in the education group (P = 0.0298). In both of the groups, decisional conflict and asthma control improved. There were no differences between groups.

CONCLUSIONS

Education improved knowledge, decisional conflict, and asthma control whether the DA was added or not.

Communication during counseling sessions about inhaled corticosteroids at the community pharmacy

BACKGROUND

Pharmaceutical care is one of the major tasks of pharmacists, which aims to improve patient outcomes. Counseling patients with asthma or chronic obstructive pulmonary disease about their use of inhaled corticosteroids (ICS) might enhance medication adherence and symptom control. Therefore, effective pharmacist-patient communication is very important. In this regard, both affective communication, for handling emotions, and instrumental communication, for exchanging biomedical and lifestyle information, are relevant. Until now, only few studies have explored pharmacist-patient communication, and further insight is needed in this regard. The aim of this study is to investigate how pharmacists and pharmacy technicians communicate about ICS with patients with asthma and/or chronic obstructive pulmonary disease, what topics are discussed by them, and whether pharmacists and pharmacy technicians differ in their communication during counseling sessions.

METHODS

Patients aged ≥18 years who had used ICS for at least 1 year and filled at least two ICS prescriptions in the preceding year were recruited through 12 pharmacies. Participants had one counseling session with a pharmacist or a pharmacy technician, which was video-recorded. The process and content of the provider-patient communication were analyzed using the Roter interaction analysis system, adapted to the pharmaceutical setting.

RESULTS

A total of 169 sessions were recorded and analyzed. The communication appeared largely instrumental. Lifestyle, psychosocial issues, and ICS adherence were not discussed in detail. The pharmacists had longer conversations and more affective talk than the pharmacy technicians.

CONCLUSION

Pharmacists and pharmacy technicians may need to pay more attention to ICS adherence, lifestyle, and psychosocial topics. They differed in their communication; the pharmacists exhibited more affective behavior and discussed medical and therapeutic issues more extensively compared to the pharmacy technicians. Educational courses for pharmacists and pharmacy technicians could focus more on the discussion of adherence, lifestyle, and psychosocial topics with patients.

Albuterol Overuse: A Marker of Psychological Distress?

BACKGROUND

Albuterol overuse, 3 or more canisters per year, is associated with poor asthma control and frequent exacerbations.

OBJECTIVE

To describe albuterol use on symptom and symptom-free days and identify predictors of albuterol overuse and controller medication underuse.

METHODS

Secondary analyses of data from adults with mild asthma from the Trial of Asthma Patient Education were carried out. Based on albuterol use of 80% or more on symptom days and less than 20% on symptom-free days, participants were characterized as expected users, overusers, or underusers of albuterol. Good controller medication adherence was defined as 80% or more of prescribed doses. Data included demographic characteristics, diary data, spirometry, and scores from standardized questionnaires. Bivariate associations were examined between categorization of medication use and measured characteristics.

RESULTS

Of the 416 participants, 212 (51%) were expected users, 114 (27%) were overusers, and 90 (22%) were underusers of albuterol. No differences were observed among the user groups by demographic characteristics or lung function. Expected users demonstrated the highest asthma-related knowledge, attitudes, and efficacy. Overusers reported the greatest symptom burden, worst asthma control, and highest frequency of symptom days. Overusers also had the highest burden of depression symptoms. More frequent symptom days accounted for 15% of overuse, greater use on symptom days accounted for 31%, and greater use on symptom free days accounted for 54% of overuse. Mean controller adherence was high across all groups, and there were no differences between the groups.

CONCLUSIONS

Although overusers experienced more frequent symptom days and used more albuterol on those days, most overuse was attributable to unexpected use on symptom-free days. High levels of comorbid depression were observed, particularly among overusers and among those nonadherent to controller medication.

Decisional conflict in asthma patients: a cross sectional study

OBJECTIVE

This study aimed at determining the level of decisional conflict in asthmatic individuals facing recommendation-based decisions provided to improve asthma control.

METHODS

This was a cross-sectional study performed on a convenience sample of 50 adults aged between 18 and 65 years with a diagnosis of asthma. They completed a decisional conflict scale (possible range of 0-100%), asthma knowledge and control questionnaires (both 0% and 100%), and a general questionnaire on socio-demographic characteristics. A decisional conflict was considered clinically significant with a score greater than 37.5%. Simple descriptive statistics were used to investigate associations with decisional conflict.

RESULTS

Participants were mainly women (76%) and diagnosed with mild asthma (72%). The median age (1st and 3rd quartile) was 25 years (22 and 42). The median score (1st and 3rd quartile) of decisional conflict was 33% (24 and 44). A clinically significant score (>37.5%) was obtained in 36% of subjects. A statistically significant negative correlation between the knowledge score and the decisional conflict score (r(p) = -0.38; p = 0.006) was observed. The level of knowledge was the only statistically independent variable associated with the decisional conflict score (p = 0.0043).

CONCLUSIONS

A considerable proportion of patients with asthma have a clinically significant level of decisional conflict when facing decisions aimed at improving asthma control. Patients with poor knowledge of asthma are more at risk of clinically significant level of decisional conflict. These findings support the relevance of providing asthmatic patients with relevant information in decision aids.