Patients' perspective of barriers and facilitators to taking long-term controller medication for asthma: a novel taxonomy

Changing high-risk asthma in Memphis through partnership: Results from the CHAMP program

BACKGROUND

Children in metro Shelby County, Tennessee, have disproportionally high asthma-related health care resource use (HRU) compared with those in other regions in Tennessee.

OBJECTIVE

To describe the goals, logistics, and outcomes of the Changing High-Risk Asthma in Memphis through Partnership (CHAMP) program implemented to improve pediatric asthma care in Shelby County.

METHODS

CHAMP established a multidisciplinary team with dedicated medical staff and community health workers, implemented a 24/7 call line to improve access to care, established a patient data registry to address fragmented care, assigned community health educators to improve asthma education and social needs, and partnered with services to address environmental triggers and social determinants of health. Patients eligible for CHAMP are Shelby County residents aged 2 to 18 years with high-risk asthma enrolled in Tennessee's Medicaid managed care program. Health care resource use outcomes 1-year pre- and post-CHAMP enrollment were analyzed for patients who had completed 1 year of CHAMP between January 2013 and December 2022. The 24/7 call line data between November 2013 and December 2022 were analyzed.

RESULTS

CHAMP has enrolled 1348 children; 945 have completed 1 year (63% male; 90% identified as Black). At 1-year post-CHAMP enrollment, patients had 58%, 68%, 42%, and 53% reductions in emergency department visits, inpatient and observation visits, urgent care visits, and total asthma exacerbations, respectively. The number of asthma exacerbations per patient significantly decreased from 2.97 to 1.40 at 1-year post-CHAMP enrollment. Of the calls made to the 24/7 call line, 58% occurred after hours and 52% led to issue resolution without a medical facility visit.

CONCLUSION

CHAMP successfully decreased asthma HRU in children with high-risk asthma in Shelby County by implementing initiatives that targeted barriers to asthma care.

Impact of a digital web-based asthma platform, a real-life study

BACKGROUND

Digital health technology (DHT) is a growing area in the treatment of chronic diseases. Study results on DHT's effect on asthma control have been mixed, but benefits have been seen for adherence, self-management, symptoms, and quality of life. The aim was to evaluate the impact of an interactive web-based asthma treatment platform on asthma exacerbations and health care visits.

METHODS

In this real-life study, we retrospectively collected data on adult patients registered on a web-based interactive asthma treatment platform between December 2018 and May 2021. Patients who activated their accounts were active users, and patients who did not were inactive users and considered as controls. We compared the number of exacerbations, total number of exacerbation events defined as the sum of oral corticosteroid (OCS) and antimicrobial courses, emergency room visits, hospitalizations, and asthma-related health care visits before and one year after the registration on the platform. Statistical tests used included the t-test, Pearson's chi-square test and Poisson regression models.

RESULTS

Of 147 patients registered on the platform, 106 activated their accounts and 41 did not. The active users had significantly fewer total number of exacerbation events (2.56 per person years, relative decline 0.78, 95% CI 0.6 to 1.0) and asthma-related health care visits (2.38 per person years, relative decline 0.84, 95% CI 0.74 to 0.96) than before registration to the platform, whereas the reductions in health care visits and the total number of exacerbation events were not significant in the inactive users.

CONCLUSIONS

An interactive web-based asthma platform can reduce asthma-related health care visits and exacerbations when used actively.

Influence of parental anxiety and beliefs about medicines on feeding and exercise in children living with asthma

This study's primary objective was to establish differences in beliefs about medicines, levels of asthma-related anxiety and diet and exercise behaviours between parents of children with well controlled and poorly controlled asthma. Secondary objectives were to explore how asthma control might shape relationships between parental cognitions and parenting practices concerning paediatric asthma. Parents of children with asthma aged 10-16 years (N = 310) completed standardised questionnaires measuring beliefs about medicines, parental asthma-related anxiety, parenting attitudes towards child activity, parental feeding and asthma control. Parents of children with poorly controlled asthma reported significantly greater asthma medication necessity and concern, asthma-related anxiety, control of child activity, pressure to exercise and unhealthy feeding practices. Moderation analyses indicated that the relationship between parental concern about asthma medicine and parental control of child activity was strongest in children with poorly controlled asthma. Also, the relationship between parental asthma-related anxiety and use of food to regulate child emotion was only significant when asthma was poorly controlled. Parental beliefs about asthma medicines and asthma-related anxiety may indirectly influence asthma outcomes through unhealthy parenting practices around exercise and diet. Eliciting and understanding parents' perceptions of asthma medications and anxiety may facilitate personalised interventions to improve asthma control.

Global Considerations in Asthma Treatment: Management in Low Resource Settings

Low-resource settings have a disproportionately higher burden of asthma due to factors that include environmental triggers, access to healthcare, availability of medications, and uncoordinated health systems. The application of guideline-based management can vary, which further impacts the treatment delivered. This chapter aims to outline the global landscape of asthma management, including cultural and social factors, with suggestions for interventions.

HIOPP-6 – a pilot study on the evaluation of an electronic tool to assess and reduce the complexity of drug treatment considering patients’ views

Background

A complex drug treatment might pose a barrier to safe and reliable drug administration for patients. Therefore, a novel tool automatically analyzes structured medication data for factors possibly contributing to complexity and subsequently personalizes the results by evaluating the relevance of each identified factor for the patient by means of key questions. Hence, tailor-made optimization measures can be proposed.

Methods

In this controlled, prospective, exploratory trial the tool was evaluated with nine general practitioners (GP) in three study groups: In the two intervention groups the tool was applied in a version with (G_{I_with}) and a version without (G_{I_without}) integrated key questions for the personalization of the analysis, while the control group (G_C) did not use any tools (routine care). Four to eight weeks after application of the tool, the benefits of the optimization measures to reduce or mitigate complexity of drug treatment were evaluated from the patient perspective.

Results

A total of 126 patients regularly using more than five drugs could be included for analysis. GP suggested 117 optimization measures in G_{I_with}, 83 in G_{I_without}, and 2 in G_C. Patients in G_{I_with} were more likely to rate an optimization measure as helpful than patients in G_{I_without} (IRR: 3.5; 95% CI: 1.2—10.3). Thereby, the number of optimization measures recommended by the GP had no significant influence (P = 0.167).

Conclusions

The study suggests that an automated analysis considering patient perspectives results in more helpful optimization measures than an automated analysis alone – a result which should be further assessed in confirmatory studies.

Trial registration

The trial was registered retrospectively at the German Clinical Trials register under DRKS-ID DRKS00025257 (17/05/2021).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12875-022-01757-0.

A multilevel perspective on goals, barriers, and facilitators of school-based asthma management

BACKGROUND

School based asthma care is being increasingly used to combat uncontrolled pediatric asthma.

OBJECTIVE

The purpose of these secondary analyses was to explore multi-level perspectives regarding school-based asthma medical management for inner city, school-aged children with poor asthma control.

METHODS

Sixty-six participants from two large U.S. urban school districts and key stakeholders participated in 1:1 interviews and focus groups. Participants were selected from across the asthma care community (children/caregivers, school personnel, nurses, pharmacists, healthcare providers, and administrators/insurers). Qualitative and descriptive techniques were used to analyze data.

RESULTS

Goals: Children/caregivers prioritized living a normal active life with few asthma worries. Other stakeholders prioritized reducing student's asthma related emergency room visits and lost learning time. Facilitators: Continuity of care, strong relationships between care community members, and incentivizers were commonly suggested facilitators. School-based asthma management was viewed as a strong facilitator, particularly in the presence of a full-time school nurse. Barriers: Four themes were identified. (1) Greater systems and policy support for asthma management is needed in general, and at school in particular. (2) Overburdened families and systems often operate in crisis-mode, and asthma management is often not a priority until crisis is reached. (3) Discordance and distrust between members of the asthma care community can hinder shared asthma management. (4) Better communication is needed at all levels to improve care.

CONCLUSION

Moving away from a crisis-based approach to asthma management for high-risk children will require increased systemic support for proactive asthma care and optimized communication within the asthma care community.

Supplemental data for this article is available online at https://dx.doi.org/10.1080/02770903.2021.2018704.

SMART in treatment of asthma exacerbations

OBJECTIVE

The objective of this review is to evaluate the effectiveness and practicality of SMART (single maintenance and reliever therapy) in the treatment of asthma exacerbation.

DATA SOURCES

PubMed, MEDLINE, Cochrane, and Clinical Trial databases using the keywords SMART therapy, maintenance and reliever therapy, and budesonide and formoterol.

STUDY SELECTION

Articles were selected based on their relevance and applicability to this topic.

RESULTS

Multiple studies have evaluated the efficacy of SMART in reducing asthma exacerbations in comparison to standard inhaled corticosteroid (ICS) maintenance and short-acting beta-agonist (SABA) rescue therapy. Most of the randomized trials demonstrated a reduction in asthma exacerbation with open-label studies revealing similar effectiveness in reducing asthma exacerbation. Previously, concerns have been raised regarding the administration of increased doses of long-acting beta-agonist that may potentially mask symptoms and delay appropriate medical attention. However, studies have not demonstrated an increase in morbidity or mortality. The primary concern regarding many of these trials is that they have been sponsored by pharmaceutical companies.

CONCLUSION

Although not all studies demonstrated the effectiveness of SMART, the majority revealed a significant reduction in asthma exacerbation frequency and severity.

Understanding the journeys of patients with an asthma exacerbation requiring urgent therapy at a primary care clinic

BACKGROUND

Asthma is a significant health issue in primary care. We examined the journeys of patients with asthma exacerbations requiring urgent therapy at a primary care clinic in Singapore.

METHODS

Face-to-face semi-structured interviews were conducted with patients who received urgent therapy for asthma exacerbation at a primary care clinic. Data collected was used to construct themes.

RESULTS

Fifteen multi-ethnic adult patients were recruited. Participants cited treatment cost, underuse of preventer medication, difficulties attending routine asthma care due to work, and stigma as barriers to asthma control. Reasons for delay in seeking urgent care for asthma were: inability to access medical care out of hours, competing priorities, perception that an exacerbation was 'not serious enough', difficulty recognizing symptoms of asthma exacerbation, and being tired or despondent. Participants were triggered to seek care due to failure of reliever inhalers, duration of symptoms, sleep disturbance, inability to work, or advice from others. During an exacerbation, participants often initiated other self-management measures besides using reliever medication. This included over-the-counter medications and non-pharmacological interventions (e.g. drinking water). Of the 15 patients interviewed, only one stepped up preventer inhaler adequately, according to their Asthma Action Plan (AAP).

CONCLUSIONS

In caring for patients with asthma, primary care providers should address patients' asthma self-management skills, such as recognizing symptoms of asthma exacerbations and regular preventer use, and provide clear instructions on how to respond to asthma symptoms (AAP). Minimizing direct (medication and consultation fees) and indirect costs (loss of earnings and adverse impact on employment prospects) are also important considerations.

Perceptions towards childhood asthma and barriers to its management among patients, caregivers and healthcare providers: a qualitative study from Ethiopia

Background

The management of asthma, which is one of the major causes of childhood morbidity and mortality has been affected by non-adherence to recommended treatment regimens with severe consequences. The aim of the present study was therefore to explore the perceptions of the children with asthma, their caregivers and their healthcare providers towards asthma and barriers to long term childhood asthma management in an institutional setting in Addis Ababa, Ethiopia.

Methods

A qualitative descriptive design was followed for the present study that used individual interviews as a data collection method. The study participants were 23 pairs of children with asthma that had treatment follow-ups in two tertiary hospitals and their caregivers and eight healthcare providers who cared for these children. The data was analyzed using thematic analysis approach.

Results

The study findings revealed that the children’s reported adherence to the recommended treatment regimens was low and they along with their caregivers were facing physical, emotional and social burdens related to asthma. Some of the influencing factors affecting childhood asthma management were found to be the low-level implementation of the asthma management guidelines by the healthcare providers, limited awareness about asthma and its management by the children and their caregivers, use of traditional home remedies and religious healing on a complementary and alternative basis and inadequate education received from healthcare professionals. Further identified barriers to the adherence of especially inhaled corticosteroids appear to be the low necessity beliefs towards chronic administration of treatment regimens and concerns related with difficulty of administration, fear of side effects and general negative attitude towards it, in addition to their low availability and affordability.

Conclusions

Low awareness of the biomedical treatment regimens and use of traditional home remedies and religious healing by the children with asthma and their caregivers, the low-level implementation of the asthma management guidelines as well as low access to medications may among other things contribute to the low adherence of the children to their recommended regimens. The findings support the need for implementation of asthma management guidelines, institution of strong asthma care and education programs that are sensitive to local and individual patients’ and caregiver perceptions and experiences including emotional distress, the need to institute chronic care approach and ways to address patients’ medication access issues.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-01984-2.

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.

Current unmet needs and potential solutions to uncontrolled asthma

Despite the availability of effective inhaled therapies, many patients with asthma have poor asthma control. Uncontrolled asthma presents a significant burden on the patient and society, and, for many, remains largely preventable. There are numerous reasons why a patient may remain uncontrolled despite access to therapies, including incorrect inhaler technique, poor adherence to treatment, oversight of triggers and suboptimal medical care. Shared decision-making, good patient–clinician communication, supported self-management, multidisciplinary patient education, new technology and risk stratification may all provide solutions to this major unmet need in asthma. Novel treatments such as biologics could benefit patients’ lives, while the investigations into biomarkers, non-Type 2 asthma, treatable traits and disease modification give an exciting glimpse into the future of asthma care.

Despite effective therapies, many patients with asthma have poor asthma control, which is preventable. The benefits of shared decision-making, supported self-management, risk stratification and novel treatments in transforming patient care are reviewed.https://bit.ly/3A386Nm

Home-based treatment of biologics for asthma: who, what, where, when and why

INTRODUCTION

The advent of biologic therapies for severe asthma has profoundly changed the management of this pathology. The introduction of home administration is therefore an important innovation to optimize the patients' management, even if there are many aspects that need to be clarified and pointed out.

AREAS COVERED

This review summarizes the path that led to the possibility of self-administration of biologics, and what the pandemic has changed in the management of these patients.

EXPERT OPINION

The growing understanding of asthma phenotypes and endotypes is enabling the careful selection of patients suitable for biologics. In this context, the availability of reliable and simple self-injection devices is important in implementing self-administration. The transition to self-injection is also possible thanks to the high safety profile of biologics. With attention, most patients may potentially be suitable for self-administration. The transition process from hospital to home administration can therefore be carried out correctly by clinicians with adequate expertise in the field of severe asthma and biologic therapies, with the support of other health professionals, pharmacists, and general practitioners. Home administration is probably the best way to guarantee high adherence and high-level satisfaction of patients, even in the long term.

Impact of Social Determinants on the Burden of Asthma and Eczema: Results from a US Patient Survey

Introduction

Little is known about how patients with asthma and eczema perceive their medical care and burden of disease. A survey was conducted to evaluate the perceptions among the general patient population with asthma and/or eczema regarding disease and treatment burden and barriers to adequate care.

Methods

An online survey was completed by market research panelists in the USA between March 24, 2020 and April 6, 2020. Eligible participants were at least 18 years of age and endorsed a diagnosis of asthma and/or eczema. Survey responses are described for all participants, by designated racial/ethnic groups, and by income level.

Results

In all, 841 participants completed the survey (asthma, n = 554; eczema, n = 398; both, n = 111; White, n = 421; Black, n = 252; Hispanic, n = 95; low income [less than $15,000/year], n = 99; higher income [at least $15,000/year], n = 713). More Black and Hispanic participants than White participants, and more participants with low income than higher income, endorsed health literacy as a barrier (e.g., filling out official documents, understanding written materials). Participants with low income were less likely than participants with higher income to have an asthma action plan (42% vs 53%, respectively) and to discuss asthma control with their healthcare provider (54% vs 69%). Black and Hispanic participants were more likely than White participants to have an emergency department visit (52% and 49% vs 31%, respectively) or hospitalization (31% and 39% vs 16%) for asthma within the last 12 months. Participants reporting low income indicated that they experienced eczema symptoms more frequently than participants with higher income; 35% of low-income participants vs 15% of higher-income participants reported that they had not tried any eczema treatments. Participants in all racial/ethnic and income-level groups reported that their asthma or eczema impacted their lifestyle and daily activities.

Conclusion

More effective and culturally informed communication and education strategies to improve health information uptake and shared decision-making are needed to reduce the burdens of disease and treatment in highly impacted populations.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12325-021-02021-0.

Disparities in asthma and eczema outcomes have been described in various populations. However, little is known about how these patient populations perceive their disease management or disease burden. A survey of 841 adults across diverse demographic groups in the USA with asthma and/or eczema was conducted to evaluate overall perceived disease burden and to specifically understand burden experiences by marginalized populations. In general, all participants indicated that asthma and eczema have a negative physical, emotional, and social impact on their lives. Some participants who identified as Black or Hispanic, and those with low income (less than $15,000/year), indicated greater difficulties in filling out paperwork or understanding written materials related to their condition than White participants or those with higher incomes. Black and Hispanic participants tended to receive asthma care in the emergency department or urgent care more than White participants and had more emergency department visits and hospitalizations than White Participants. Participants with low income were less likely to discuss their asthma management with their doctor than those with higher incomes and also indicated potential undertreatment of eczema. These results indicate that Black, Hispanic, or low-income patients may experience barriers to health equity. These barriers include lack of effective communication methods and materials to meet the needs of all patients, as well as the overall lack of quality healthcare access. These challenges must be addressed to overcome social disparities in health.

Impact of adherence to treatment with inhaled corticosteroids/long-acting β-agonists on asthma outcomes in the United States

BACKGROUND

Suboptimal adherence to maintenance medication has been associated with poor outcomes in asthma. This study examined single-inhaler inhaled corticosteroid (ICS)/long-acting β2 agonist (LABA) adherence and asthma-related outcomes.

METHODS

This retrospective observational study of patients with asthma initiating ICS/LABA used data from IQVIA PharMetrics Plus (1 January 2014-31 March 2019). Patients included were ⩾18 years old and had ⩾12 months continuous eligibility before, and ⩾180 days follow-up after, the index date. Adherence was measured as proportion of days covered ([PDC] adherent ⩾ 0.8; non-adherent <0.8) each quarter, with outcomes measured each subsequent quarter. Endpoints were asthma-related overall and severe (inpatient/emergency department [ED] visit) exacerbations, rescue medication use, and asthma-related healthcare resource utilization and costs. Regression models evaluated associations between adherence and outcomes, controlling for repeated measures and differences in baseline characteristics.

RESULTS

Overall, 50,037 patients were included (mean age 45.3 years; mean follow-up 23.3 months). Adherent patients were less likely to experience asthma-related overall (adjusted odds ratio [aOR] 95% confidence interval [CI]: 0.942 [0.890, 0.998]; p = 0.041), or severe exacerbations (aOR [95% CI]: 0.778 [0.691, 0.877]; p < 0.001) per quarter versus non-adherent patients. Adherent patients had lower severe exacerbation rates (adjusted rate ratio [aRR] [95% CI]: 0.792 [0.702, 0.893]; p < 0.001) but similar overall exacerbation rates (aRR [95% CI]: 0.993 [0.945, 1.044]; p = 0.783) versus non-adherent patients. The odds of rescue medication use were lower per 20% PDC increase (aOR [95% CI] short-acting β2 agonist: 0.991 [0.985, 0.996]; p = 0.001; oral corticosteroid: 0.988 [0.982, 0.995]; p < 0.001). Adherent patients were less likely to visit EDs per quarter (aOR [95% CI]: 0.775 [0.680, 0.883]; p < 0.001) and odds of hospitalization were lower per 20% PDC increase (aOR [95% CI]: 0.930 [0.881, 0.982]; p = 0.009). Across most measures, adherent patients incurred lower costs.

CONCLUSION

This real-world study highlights the short-term clinical and economic benefits of ICS/LABA adherence in asthma, particularly in reducing severe exacerbations.

Caregivers' and healthcare professionals' perspective of barriers and facilitators to health service access for asthmatic children: a qualitative study

BACKGROUND

There is a high burden of asthma morbidity and mortality in Latin America. It has been proposed that this relates to limited access to diagnostic tests, asthma medications and specialised doctors. However, little is known of what caregivers of asthmatic children and healthcare professionals (HCPs) perceive as barriers and facilitators to adequate care. We aimed to explore the barriers and facilitators to asthma care access from caregivers' and HCP's perspective in an Ecuadorian low-resource setting.

METHODS

In 2017, we conducted 5 focus group discussions (FGD) with 20 caregivers of asthmatic children and 12 in-depth interviews with 3 paediatricians, 6 general doctors and 3 respiratory therapists in Esmeraldas city, Ecuador. FGDs and interviews were digitally recorded, transcribed, open-coded in QDA Miner, categorised using an interpretative phenomenological approach and analysed thematically. Barriers and facilitators were classified into availability, accessibility, acceptability and contact of healthcare services, based on Tanahashi model of health service access.

RESULTS

Limited resources, use of alternative medicines, fear of medication side-effects and lack of specific training for doctors and knowledge in families were common barriers for both caregivers and HCPs. Caregivers and HCPs proposed the implementation of public health asthma-focused programmes that would include close community-based follow-up of people with asthma, educational sessions for their families and public engagement activities. HCPs also suggested implementing training programmes on asthma management for general doctors.

CONCLUSION

Multiple barriers identified by caregivers and HCPs referred to economic and health service organisational issues, fear of side effects of medication or ineffective self-management. Increasing caregivers and HCPs' asthma knowledge, as well as HCPs' communication skills to establish a patient-centred approach with a shared decision-making process could improve asthma care in this setting.

Designing Dynamic Interventions to Improve Adherence in Pediatric Long-Term Treatment - The Role of Perceived Value of the Physician by Primary Caregivers

Primary Caregivers are the fulcrum in the physician-caregiver-child triad. Existing literature discusses static multi-component interventions in detail. In long-term treatments, dynamic intervention design is needed as the environment and situations of the families are dynamic. The objectives of this study are (a) to identify the components of the primary caregiver's perception of the physician's value with reference to the effectiveness of consultation and relationships with the former and with the child; (b) to establish the role of this perception in designing dynamic interventions, and (c) to describe the perception's potential influence on adherence. A PRISMA, chronological, and morphological analysis of the literature is carried out about caregivers' adherence in the pediatric long-term treatment context. We define communication and consultation as the functional, whereas relationship as the emotional component of the caregiver's perception of the physician. We propose a theoretical model that incorporates intervention as an integral component of care. Adherence happens as a response to changing situations and hence fluctuates. Hence, a dynamic intervention design to benefit the child should be incorporated into care through the caregiver-physician bridge. Future research should explore how intervention needs change and the driving reasons for understanding the static and dynamic components of interventions.

The attitude and prevalence of patient noncompliance toward chronic disease medications in Saudi Arabia

Background

Failure of patients' adherence to medications has been a big issue for both physicians and patients; not only it does affect the patients' health but also it affects the financial status of the hospital and the patient.

Objective

This investigation aims to explore the prevalence and the factors affecting the compliance of patients with chronic conditions to their medications.

Materials and Methods

An online survey was distributed to patients who had chronic conditions and lived in the main cities of Saudi Arabia. The questionnaire included sections about the patients' general characters, type of chronic disease, the pattern of prescribed medications' usage, and factors affecting compliance of patients toward their medications. Data was collected in a predesigned excel sheet, and analysis was executed through SPSS program version 26.

Results

301 patients responded to this questionnaire. The lowest incidence of missing pills was among patients with heart failure, followed by chronic kidney disease, whereas the highest frequency of missing pills was among patients with vitamin D deficiency, followed by hyperlipidemia. 38.5% of the patients used mobile applications as reminders for the administration of their medications. 50% of the patients who use reminders take more than four pills a day. 48.2% of the patients stopped medications without consulting their doctors, where 20.9% stopped one medication for less than a month. 57.5% forgot to take drug doses in a year, with a mean of 8.55 ± 26.3 forgotten doses. Females, patients aging between 31 and 45 years old, obese, married, illiterate, self-employed, those who follow with military hospitals, exercising regularly, and ex-smoker all showed a higher incidence of noncompliance to medications. The main reason for noncompliance was forgetfulness in 60% of patients. 63.2% of the patients did not have a GP to help them with medications compliance.

Conclusion

The compliance of Saudi patients toward their chronic medications requires improvement. Similar studies in other areas in Saudi Arabia are recommended.

Non-adherence and sub-optimal treatment with asthma medications in young adults: a population-based cohort study

OBJECTIVE

Pharmacological treatment plays a key role in the management of asthma, but medication adherence is generally low. Our aim was to assess factors associated with dispensing patterns of, and adherence to, asthma medication in young adults with asthma.

METHODS

The study included young adults (age 22-24 years) from the Swedish population-based birth cohort BAMSE (n = 3,064) with linkage to register data on dispensed asthma medications and recorded diagnosis. Dispensing information was collected in January 2014-June 2019 (the study period) to cover the period of questionnaire data. Adherence to asthma medication was defined as refilling a prescription within 18 months.

RESULTS

In total, 234 individuals (7.6%) had asthma (doctor's diagnosis of asthma in combination with respiratory symptoms) and had been dispensed at least one prescription of asthma medication during the study period. Among them, 77% were dispensed a controller medication. The mean number of prescriptions dispensed per individual was higher in males than females (11.0 vs. 7.2; p < 0.01). The proportion of asthmatics with only a short-acting β₂-agonist (SABA) dispensed was 22%, of which 33% were classified as having uncontrolled asthma. Adherence to controller medication was 60% and higher among those with an asthma diagnosis from specialized care than those diagnosed in primary care (RR 1.32 95% CI 1.03-1.69). Sex, socioeconomic status, and non-allergic comorbidity did not affect adherence.

CONCLUSION

Young adults with asthma had few prescriptions of asthma medication dispensed, indicating sub-optimal treatment. A considerable proportion was dispensed only SABA. Furthermore, adherence to controller medication was relatively low.

Barriers to implementing asthma self-management in Malaysian primary care: qualitative study exploring the perspectives of healthcare professionals

Asthma self-management is a crucial component of asthma management. We sought to explore healthcare professionals' (HCPs') perceptions on barriers to asthma self-management implementation in primary care. We recruited 26 HCPs from six public primary care clinics in a semi-urban district of Malaysia in 2019. The analysis was done inductively. HCPs described barriers that resonated with the "COM-B" behaviour change framework. Capability-related issues stemmed from a need for specific self-management skills training. Opportunity-related barriers included the need to balance competing tasks and limited, poorly tailored resources. Motivation-related barriers included lack of awareness about self-management benefits, which was not prioritised in consultations with perceived lack of receptiveness from patients. These were compounded by contextual barriers of the healthcare organisation and multilingual society. The approach to implementation of asthma self-management needs to be comprehensive, addressing systemic, professional, and patient barriers and tailored to the local language, health literacy, and societal context.

Mixed methods process evaluation of my breathing matters, a digital intervention to support self-management of asthma

This study aimed to explore user engagement with 'My Breathing Matters', a digital self-management intervention for asthma, and identify factors that may influence engagement. In a mixed methods design, adults with asthma allocated to the intervention arm of a feasibility trial (n = 44) participated in semi-structured interviews (n = 18) and a satisfaction questionnaire (n = 36) to explore their views and experiences of the intervention. Usage data highlighted that key intervention content was delivered to most users. The majority of questionnaire respondents (78%; n = 28) reported they would recommend the intervention to friends and family. Interviewees expressed positive views of the intervention and experienced several benefits, mainly improved asthma control, medication use, and breathing technique. Factors that may influence user engagement were identified, including perceptions of asthma control, current self-management practices, and appeal of the target behaviours and behaviour change techniques. Findings suggested My Breathing Matters was acceptable and engaging to participants, and it was used as intended.

[Patient expectations in asthma care]

Asthma, a common chronic disease characterized by variable levels of severity, requires patient-centered management to achieve the best health outcomes. Studies have highlighted the gap between consensus management recommendations and patient goals, which represent a potential source of therapeutic wandering and of poor compliance. Patient expectations are continually evolving and are dependent on knowledge, feelings and individual experience. From this perspective, listening carefully to patients and caregivers makes it easier to exchange views and define common goals. The active participation of patients at all levels of decision-making and transmission of information may improve asthma control and other quality of life parameters.

Physician's perspective regarding asthma guided self-management: directives or guidance?

INTRODUCTION

Asthma guided self-management enhances patients' control of their condition under the guidance of the treating physician. The aim of the present study was to understand how physicians perceive, endorse, uptake, and support asthma guided self-management.

METHODS

We conducted a secondary supplementary analysis of data originally collected as part of a multicenter collective case study in which physicians treating patients with asthma were interviewed. Using reflective thematic analysis, we aimed to explore physicians' understanding of guided asthma self-management as related to four ideas, namely: (a) understanding of the disease management and treatment goals; (b) defining medical frame and guidance; (c) describing the importance of patient-physician relationship; and (d) implementing asthma guided self-management.

RESULTS

Evidence indicates that physicians perceived optimal guided self-management as related to patients' adherence to physician's instructions and recommendations, supported by the adjustment of prescribed pharmaceutical therapy contingent upon patient's symptoms. Some physicians also perceived behavior change and environmental control along with the medical recommendations. While physicians' perception of asthma and its treatment were aligned with the recommended guidelines-i.e., patient-centered care approach based on guided self-management, the actual guidance offered to patients remained primarily directive and paternalistic. Non-pharmacological approaches, such as exercise, smoking cessation, patient self-monitoring, and self-management supported by education and written self-management plans, were given little consideration in the context of the recommended treatment plan.

Theoretical asthma self-management program for Taiwanese adolescents with self-efficacy, outcome-expectancy, health behaviour, and asthma symptoms: A randomized controlled trial

Background

The asthma prevalence of Taiwanese adolescents continued to rise. With physical and psychological changes in adolescents, managing asthma can be quite challenges and affect social, emotional and physical wellbeing. Adolescents with high self-efficacy levels are more likely to be involved in prevention and management activities. The aim of this study was to develop an effective asthma self-management program taking account for adolescents' developmental stages and based on Bandura's self-efficacy model.

Methods

A two-arm, parallel group, randomized controlled trial was used. The outcomes were self-efficacy, outcome-expectancy, asthma prevention and self-management behaviour, and controlling asthma symptoms. Translation and back-translation process were used for original tools in English. Good consistent reliabilities of Chinese versions tools were identified. A t-test or Mann-Whiney U test was employed to determine any mean differences of outcome variables between groups overtime.

Results

A sample of 83 patients completed the study. The mean age was 14.2 years (SD = 1.8). Approximately 56.6% of the participants were males. 73% of participants (n = 61) had a mild to intermittent level of asthma severity. Significant improvements were found on self-efficacy, t = −2.8; outcome-expectancy, U = 646, prevention behaviours, t = −3.5, and management behaviours, t = −3.2, but non-significant results for the outcome of asthma control, U = 716.

Conclusions

The results provided evidence to support the efficacy of the asthma self-management program. The findings indicated the program improved adolescents’ self-confidence in managing their asthma symptoms. Future clinical practice should consider delivering an educational program using multifaceted and interactive learning strategies.

Barriers to and competency with the use of metered dose inhaler and its impact on disease control among adult asthmatic patients in Ethiopia

Background

Asthma is one of the chronic diseases which affects the airway, and inhalers are the preferred medications to treat this problem. Improper inhalational technique leads to decreased efficacy of the medication by reducing its deposition in the lungs. The aim of this study was to assess the barriers to and competency with the use of Metered Dose Inhaler (MDI) and its impact on disease control among adult asthmatic patients.

Methods

A prospective cross-sectional study was conducted in University of Gondar comprehensive specialized hospital outpatient department (OPD) chronic follow up from 12-March-2018 to 15-May- 2018. Patients were interviewed face to face with questions which determined their competency, asthma control level and barriers for inhaler use.

Result

Overall, 307 asthmatic patients were included in the study. More than half of participants were females, 170 (55.4%) and lived in urban area 185 (60.3%). The mean age of the respondents was 51.77 years with a standard deviation of ±15.40. The cost of medication, 282 (91.9%) and the perception that medication should be used in response to symptoms but not on a regular basis 277 (90.2%) were the most identified barriers. Only 56 (18.2%) were competent for Metered Dose Inhaler use (MDIU) and 17 (5.5%) patients had well controlled asthma. Being not competent AOR 0.168[0.41–0.687] was one of the factors decreasing asthma control.

Conclusion

Generally from this study, cost of the medication and the perception that medication should be used only for symptoms were the major identified barriers that affect the MDI use among asthmatic patients. Patients show very poor competence to their MDI which in turn led to poor asthma control. So, patients need to be taught the correct inhaler technique in the hospital and pharmacy while they came for follow up every time.

Understanding Patient Perspectives on Medication Adherence in Asthma: A Targeted Review of Qualitative Studies

Adherence to asthma medications is generally poor and undermines clinical outcomes. Poor adherence is characterized by underuse of inhaled corticosteroids (ICS), often accompanied by over-reliance on short-acting β₂-agonists for symptom relief. To identify drivers of poor medication adherence, a targeted literature search was performed in MEDLINE and EMBASE for articles presenting qualitative data evaluating medication adherence in asthma patients (≥12 years old), published from January 1, 2012 to February 26, 2018. A thematic analysis of 21 relevant articles revealed several key themes driving poor medication adherence, including asthma-specific drivers and more general drivers common to chronic diseases. Due to the episodic nature of asthma, many patients felt that their daily life was not substantially impacted; consequently, many harbored doubts about the accuracy of their diagnosis or were in denial about the impact of the disease and, in turn, the need for long-term treatment. This was further compounded by poor patient-physician communication, which contributed to suboptimal knowledge about asthma medications, including lack of understanding of the distinction between maintenance and reliever inhalers, suboptimal inhaler technique, and concerns about ICS side effects. Other drivers of poor medication adherence included the high cost of asthma medication, general forgetfulness, and embarrassment over inhaler use in public. Overall, patients' perceived lack of need for asthma medications and medication concerns, in part due to suboptimal knowledge and poor patient-physician communication, emerged as key drivers of poor medication adherence. Optimal asthma care and management should therefore target these barriers through effective patient- and physician-centered strategies.

Evaluation of a shared decision-making communication skills training for physicians treating patients with asthma: a mixed methods study using simulated patients

Background

Shared decision-making (SDM) is a key principle in asthma management, but continues to be poorly implemented in routine care. This study aimed to evaluate the impact of a SDM communication skills training for physicians treating patients with asthma on the SDM behaviors of physicians, and to analyze physician views on the training.

Methods

A mixed methods study with a partially mixed sequential equal status design was conducted to evaluate a 12 h SDM communication skills training for physicians treating patients with asthma. It included a short introductory talk, videotaped consultations with simulated asthma patients, video analysis in small group sessions, individual feedback, short presentations, group discussions, and practical exercises. The quantitative evaluation phase consisted of a before (t0) after (t1) comparison of SDM performance using the observer-rated OPTION⁵, the physician questionnaire SDM-Q-Doc, and the patient questionnaire SDM-Q-9, using dependent t-tests. The qualitative evaluation phase (t2) consisted of a content analysis of audiotaped and transcribed interviews.

Results

Initially, 29 physicians participated in the study, 27 physicians provided quantitative data, and 22 physicians provided qualitative data for analysis. Quantitative results showed significantly improved performance in SDM following the training (t1) when compared with performance in SDM before the training (t0) (OPTION⁵: t (26) = − 5.16; p < 0.001) (SDM-Q-Doc: t (26) = − 4.39; p < 0.001) (SDM-Q-9: t (26) = − 5.86; p < 0.001). The qualitative evaluation showed that most physicians experienced a change in attitude and behavior after the training, and positively appraised the training program. Physicians considered simulated patient consultations, including feedback and video analysis, beneficial and suggested the future use of real patient consultations.

Conclusion

The SDM communication skills training for physicians treating patients with asthma has potential to improve SDM performance, but would benefit from using real patient consultations.

Drug discount cards in an era of higher prescription drug prices: A retrospective population-based study

OBJECTIVES

Drug discount programs have emerged as a potential option for patients seeking greater accessibility and affordability. However, there is limited knowledge regarding program utilization and cost savings. The objective of this study was to evaluate medication prescriptions with drug discount card usage and estimate cost savings.

DESIGN

Retrospective study.

SETTING AND PARTICIPANTS

Using population-based prescription data, the study included patients who filled prescriptions from January 2009 to December 2016 nationwide using NeedyMeds.org drug discount cards.

OUTCOME MEASURES

We determined the frequency of drug discount card prescriptions (across pharmacy types, pharmacy location, and prescriber specialty), estimated cost savings using the drug discount card (average per drug discount card and total program dollars saved) and evaluated the top prescription drugs by frequency.

RESULTS

A total of 4,638,581 prescriptions with discount cards were identified (79.8% at national, 6.3% at regional, and 12.9% at local pharmacies). Most were filled at urban locations (urban clusters, 88.6%; urbanized areas, 8.4%) and in ZIP codes with lower median household incomes (62.7%). Overall, 3.62 million prescriptions (78.0% of the total) were associated with discounts, resulting in a total savings of $199,183,112 (median cost savings, $17.80 [47.8%] per prescription). Opiates were the most common class of drugs for which discount cards were used.

CONCLUSION

The use of a drug discount program over 8 years resulted in total savings of nearly $200 million (approximately $18 per prescription) compared with the original cost. However, although patients might accrue financial benefit, there is still a lack of price transparency. Additional research is needed to better understand the impact of these programs and to evaluate ways to improve medication access at a reasonable cost to patients.

Asthma patients' perception on their care pathway: a qualitative study

Because of insufficient asthma control in many patients, the collaboration between stakeholders is regarded as a promising strategy to improve asthma outcomes. This study explored the perceptions of French adult asthma patients on their care pathway. We conducted a qualitative study based on the interviews of 30 asthma patients aged 18–40 years, recruited in French primary care. We performed a thematic analysis of the data collected, using the NVivo software. According to the patients, the stakeholders involved in asthma management included those visible to healthcare professionals (patient, general practitioner, specialist(s), pharmacist, physiotherapist, family and friends) and those concealed by the patients (complementary and alternative practitioners); other stakeholders, such as nurses and occupational physicians, were not involved. Asthma management at diagnosis and follow-up phases proved to be unstructured, and were associated with poor patient education. This was supported by patients’ ambivalence (in relation to illness and treatments), poor communication between patients and healthcare professionals (lack of listening and use of inappropriate vocabulary by physicians, underreporting of alternative medicine use by patients) and weak cooperation between professionals (limited to interaction between the general practitioner and the specialist, either pulmonologist or allergist). Asthma management would probably benefit from a more coordinated care pathway at each phase of the disease that is consistent with the expectations and goals of the patients. It should be based on improved organization (involvement of other healthcare professionals and the patient as partners) and processes (regular follow-up, specific tools such as peak flow meter or action plan).

Perceptions of complementary/alternative medicine use and influence on evidence-based asthma medicine adherence in Malaysian children

Complementary and alternative medicine (CAM) is widely used especially in Asia including for childhood asthma. The use of CAM could influence adherence to evidence-based (E-B) medicine. We explored the views of carers of Malaysian children with asthma regarding the use of CAM for childhood asthma, and its relationship with self-reported adherence to E-B medicine. We used a screening questionnaire to identify children diagnosed with asthma from seven suburban primary schools in Malaysia. Informed consent was obtained prior to the interviews. We conducted the interviews using a semi-structured topic guide in participants' preferred language (Malay, Mandarin, or Tamil). All interviews were audio-recorded, transcribed verbatim and coded using Nvivo. Analysis was performed thematically, informed by the Necessity-Concerns Framework. A total of 46 carers (16 Malays, 21 Indians, 9 Chinese) contributed to 12 focus groups and one individual interview. We categorised participants' as 'Non-CAM'; 'CAM'; or 'combination' user. Cultural practices and beliefs in the efficacy of CAM resulted in widespread use of CAM. Most carers used CAM as 'complementary' to E-B medicine. Concerns about dependence on or side effects of E-B treatment influenced carers' decisions to rely on CAM as an 'alternative', with an important minority of accounts describing potentially harmful CAM-use. Healthcare professionals should discuss beliefs about the necessity for and concerns about use of both E-B medicine and CAM, and provide balanced information about effectiveness and safety. The aim is to improve adherence to regular E-B preventer medication and prevent delays in seeking medical advice and harmful practices associated with CAM.

Guided asthma self-management or patient self-adjustment? Using patients' narratives to better understand adherence to asthma treatment

PURPOSE

The purpose of this study was to better understand patients' perspective of asthma self-management by focusing on the sociocultural and medical context shaping patients' illness representations and individual decisions.

PATIENTS AND METHODS

We conducted a secondary analysis of semi-structured interviews carried out as part of a multicentered collective qualitative case study. In total, 24 patients, aged 2-76 years with a confirmed diagnosis of asthma (or were parents of a child), who renewed the prescription for inhaled corticosteroids in the past year, participated in this study. The thematic analysis focused on asthma-related events and experiences reported by the patients. Consistent with narrative inquiry, similar patterns were grouped together, and three vignettes representing the different realities experienced by the patients were created.

RESULTS

The comparison of experiences and events reported by the patients suggested that patients' perceptions and beliefs regarding asthma and treatment goals influenced their self-management-related behaviors. More specifically, the medical context in which the patients were followed (ie, frame in which the medical encounter takes place, medical recommendations provided) contributed to shape their understanding of the disease and the associated treatment goals. In turn, a patient's perception of the disease and the treatment goals influenced asthma self-management behaviors related to environmental control, lifestyle habits, and medication intake.

CONCLUSION

Current medical recommendations regarding asthma self-management highlight the importance of the physicians' guidance through the provision of a detailed written action plan and asthma education. These data suggest that while physicians contribute to shaping patients' beliefs and perceptions about the disease and treatment goals, patients tend to listen to their own experience and manage the disease accordingly. Thus, a medical encounter between the patient and the physician, aiming at enhancing a meaningful conversation about the disease, may lead the patient to approach the disease in a more effective manner, which goes beyond taking preventative paths to avoid symptoms.

Impact of a digital health intervention on asthma resource utilization

Digital health interventions have been associated with reduced rescue inhaler use and improved controller medication adherence. This quality improvement project assessed the benefit of these interventions on asthma-related healthcare utilizations, including hospitalizations, emergency department (ED) utilization and outpatient visits. The intervention consisted of electronic medication monitors (EMMs) that tracked rescue and controller inhaler medication use, and a digital health platform that presented medication use information and asthma control status to patients and providers. In 224 study patients, the number of asthma-related ED visits and combined ED and hospitalization events 365 days pre- to 365 days post-enrollment to the intervention significantly decreased from 11.6 to 5.4 visits (p < 0.05) and 13.4 to 5.8 events (p < 0.05) per 100 patient-years, respectively. This digital health intervention was successfully incorporated into routine clinical practice and was associated with lower rates of asthma-related hospitalizations and ED visits.

[Simplifying complex drug therapies : Challenges and solutions]

The difficulties of managing a complex medication regimen are often underestimated in outpatient care. A large number of drugs (polypharmacy) and complicated dosage schemes or dosage forms may overstrain patients. Indeed, wrong drug administration can impair treatment success or cause adverse drug events.Patients are often unaware of the medication administration errors. Furthermore they do not voice administration problems, often because they are not aware of the potential to optimize their drug therapy. Medication regimen complexity can often be reduced by simple measures. However, feasible concepts for reducing medication regimen complexity in a structured way have been lacking in routine care so far.Electronic decision support facilitates systematic and efficient identification of factors that increase the complexity of a medication regimen. Furthermore, electronic decision aids may enable physicians and pharmacists to take appropriate measures in order to reduce medication regimen complexity. Personalizing the analysis and resulting measures to reduce medication regimen complexity might increase readiness of patients to implement changes in treatment and, thus, probably increase adherence. The first results of a prospective trial that is supported by the Federal Joint Committee (G-BA) Innovationsfonds (HIOPP-6, Komplexitätsreduktion in der Polypharmazie unter Beachtung von Patientenpräferenzen) will be available in autumn 2018 and answer these questions.

Treatment perceptions in patients with asthma: Synthesis of factors influencing adherence

BACKGROUND

Non-adherence to asthma treatment is a contributing factor for poorly controlled asthma.

AIM

The aim of this systematic review is to explore patients' perceptions of their inhaled asthma treatment, and how these relate to adherence, using both qualitative and quantitative data.

METHODS

Pre-determined search terms and inclusion criteria were used to search electronic databases (The Cochrane Library, MEDLINE, EMBASE and PsycINFO). Two researchers screened titles and abstracts using the Rayyan web app and data were extracted in relation to psychological components (beliefs about, and attitudes towards, medicines) and adherence.

RESULTS

Of 1638 papers, 36 met the inclusion criteria. Key themes were: Perceived need for treatment - all 12 studies using the BMQ to measure patients' perceived need for treatment found that patients' beliefs about their necessity for treatment were associated with adherence-; Concerns about treatment - immediate and long-term side effects (58%), worries about safety (19%), and potential addiction to asthma medication (31%)-; and Perceived social stigma - 22% of studies reported that embarrassment contributed to poor adherence.

CONCLUSIONS

Acknowledging and addressing patient treatment beliefs and perceptual barriers to adherence is integral to designing adherence interventions for asthma patients. Further research is needed to better our understanding of the relationship between treatment perceptions and adherence.

Improving adherence to asthma medications: current knowledge and future perspectives

PURPOSE OF REVIEW

Poor adherence to asthma controller medications, particularly inhaled corticosteroids, has been well known for decades and is a major cause of uncontrolled asthma and increased healthcare utilization. This review presents recent evidence on factors leading to nonadherence in specific age groups, parents of young children, adolescents and young adults, adults, and the elderly. Novel management strategies including electronic sensors with associated smart phone applications for adherence improvement are discussed.

RECENT FINDINGS

Interventions to promote adherence must include a focus on issues important to the patient. Parents are concerned about adverse effects and the difficulty of medication administration in their child; adolescents and young adults need help with organizational skills and social barriers; adults may be more receptive to the need for daily medication after an acute exacerbation and acceptance of their disease; the elderly may have medication misuse issues associated with cognitive decline and other comorbidities related to aging. In all age groups, a trusting relationship with the provider is the key. New digital devices to track adherence may provide feedback to the patient and provider to evaluate and to promote adherence.

SUMMARY

Personalized approaches are required to address adherence barriers in target populations. Research on specific needs and barriers in target populations and development of appropriate strategies for use of new digital technology for adherence monitoring is needed.

Barriers to medication adherence in asthma: The importance of culture and context

OBJECTIVE

Significant disparities exist in asthma outcomes. Racial and ethnic minorities have lower controller medication adherence, which may contribute to differences in asthma morbidity between minority and non-minority groups. The objective of this review is to identify individual, patient-provider communication, and systems issues that contribute to this pattern of medication underuse and to discuss potential strategies for intervention.

DATA SOURCES

Data were gathered from numerous sources, including reports of pharmacy and medical records, observational studies, and trials.

STUDY SELECTIONS

Studies analyzed factors contributing to patterns of asthma medication adherence that differ by race and ethnicity.

RESULTS

There is clear evidence of underuse of asthma controller medications among racial and ethnic minorities in prescription receipt, prescription initiation, and medication use once obtained. Individual factors such as medication beliefs and depressive symptoms play a role. Provider communication is also relevant, including limited discussion of complementary and alternative medicine use, difficulties communicating with patients and caregivers with limited English proficiency, and implicit biases regarding cultural differences. Systems issues (eg, insurance status, cost) and social context factors (eg, exposure to violence) also present challenges. Culturally informed strategies that capitalize on patient strengths and training providers in culturally informed communication strategies hold promise as intervention approaches.

CONCLUSION

Disparities in controller medication use are pervasive. Identifying the sources of these disparities is a critical step toward generating intervention approaches to enhance disease management among the groups that bear the greatest asthma burden.

Concordance among children, caregivers, and clinicians on barriers to controller medication use

OBJECTIVE

While much research has addressed asthma medication adherence, few have combined quantitative and qualitative data, and none has addressed the triad of child, caregiver, and clinician simultaneously. This study assessed, with mixed methods, barriers to medication adherence within this triad.

METHODS

We conducted interviews with publicly-insured children with asthma, their caregivers, and their primary-care clinicians. Children (7-17 years) had been prescribed daily inhaled corticosteroids and visited the ED for asthma (past year). Participants answered open-ended and survey questions, rating suggested barriers to medication use (never vs. ever a barrier). McNemar's tests compared report of barriers by each group (children, caregivers, clinicians), and assessed concordance within triads.

RESULTS

Fifty child-caregiver dyads participated (34 clinicians). Children (40% female; median age 10 years) had mostly non-Hispanic black (90%) caregivers with less than or equal to high-school education (68%). For barriers, children and clinicians were more likely than caregivers to report medications running out. Clinicians were also more likely to cite controllers being a "pain to take" (vs. children) and forgetfulness (vs. caregivers) (all p < .05). There was a lack of within-triad concordance regarding barriers to adherence, especially regarding medication running out, worrying about taking a daily medication, and medication being a pain to take. Qualitative data revealed themes of competing priorities, home routines, and division of responsibility as prominent contributors to medication adherence.

CONCLUSIONS

There was significant disagreement among children, caregivers, and clinicians regarding barriers to daily use of asthma medications. To tailor asthma management conversations, clinicians should understand family-specific barriers and child-caregiver disagreements.

Cognitive factors predict medication adherence and asthma control in urban adolescents with asthma

PURPOSE

Adolescents with asthma often report poor medication adherence and asthma control. Cognitive factors embedded in the social cognitive theory including self-efficacy, outcome expectations, and barrier perceptions may explain poor asthma outcomes in this population. This study was performed to examine the extent to which these cognitive factors are intercorrelated and explain medication adherence and asthma control in urban adolescents.

PATIENTS AND METHODS

A total of 373 urban adolescents (12-20 years) with asthma completed questionnaires measuring asthma-related self-efficacy, outcome expectations, barrier perceptions, medication adherence, and asthma control. Multiple linear regression was conducted to examine the extent to which the three cognitive factors predicted medication adherence and asthma control after controlling for covariates including age, sex, household income, and age at diagnosis.

RESULTS

Participants' ages were on average 14.68 (±1.94) years; 50% were female, and most (78.6%) were African American. Higher self-efficacy associated with lower barrier perceptions and higher outcome expectations (r=0.50, p<0.001; r=-0.26, p<0.001, respectively). Self-efficacy predicted better asthma control (B=-0.098, p=0.004) and adherence (B=0.426, p=0.011), whereas barrier perceptions predicted poorer asthma control (B=0.13, p<0.001) and adherence (B=-0.568, p<0.001). Self-efficacy independently predicted fewer missed doses (B=-0.621, p=0.006), and barrier perception independently predicted asthma control (B=0.12, p<0.001) and adherence (B=-0.519, p<0.001).

CONCLUSION

Improving medication adherence and asthma control among adolescents may require a multifaceted approach. Interventions focused on increasing self-efficacy and addressing barriers, actual or potential, to medication adherence could ameliorate asthma disparities in urban adolescents.

Using the theoretical domains framework to identify barriers and enablers to pediatric asthma management in primary care settings

OBJECTIVES

This study aimed to apply a theory-based approach to identify barriers and enablers to implementing the Alberta Primary Care Asthma Pediatric Pathway (PCAPP) into clinical practice. Phase 1 included an assessment of assumptions underlying the intervention from the perspectives of the developers. Phase 2 determined the perceived barriers and enablers for: 1) primary care physicians' prescribing practices, 2) allied health care professionals' provision of asthma education to parents, and 3) children and parents' adherence to their treatment plans.

METHODS

Interviews were conducted with 35 individuals who reside in Alberta, Canada. Phase 1 included three developers. Phase 2 included 11 primary care physicians, 10 allied health care professionals, and 11 parents of children with asthma. Phase 2 interviews were based on the 14 domains of the Theoretical Domains Framework (TDF). Transcribed interviews were analyzed using a directed content analysis. Key assumptions by the developers about the intervention, and beliefs by others about the barriers and enablers of the targeted behaviors were identified.

RESULTS

Eight TDF domains mapped onto the assumptions of the pathway as described by the intervention developers. Interviews with health care professionals and parents identified nine TDF domains that influenced the targeted behaviors: knowledge, skills, beliefs about capabilities, social/professional role and identity, beliefs about consequences, environmental context and resources, behavioral regulation, social influences, and emotions.

CONCLUSIONS

Barriers and enablers perceived by health care professionals and parents that influenced asthma management will inform the optimization of the PCAPP prior to its evaluation.

Barriers and facilitators of effective self-management in asthma: systematic review and thematic synthesis of patient and healthcare professional views

Self-management is an established, effective approach to controlling asthma, recommended in guidelines. However, promotion, uptake and use among patients and health-care professionals remain low. Many barriers and facilitators to effective self-management have been reported, and views and beliefs of patients and health care professionals have been explored in qualitative studies. We conducted a systematic review and thematic synthesis of qualitative research into self-management in patients, carers and health care professionals regarding self-management of asthma, to identify perceived barriers and facilitators associated with reduced effectiveness of asthma self-management interventions. Electronic databases and guidelines were searched systematically for qualitative literature that explored factors relevant to facilitators and barriers to uptake, adherence, or outcomes of self-management in patients with asthma. Thematic synthesis of the 56 included studies identified 11 themes: (1) partnership between patient and health care professional; (2) issues around medication; (3) education about asthma and its management; (4) health beliefs; (5) self-management interventions; (6) co-morbidities (7) mood disorders and anxiety; (8) social support; (9) non-pharmacological methods; (10) access to healthcare; (11) professional factors. From this, perceived barriers and facilitators were identified at the level of individuals with asthma (and carers), and health-care professionals. Future work addressing the concerns and beliefs of adults, adolescents and children (and carers) with asthma, effective communication and partnership, tailored support and education (including for ethnic minorities and at risk groups), and telehealthcare may improve how self-management is recommended by professionals and used by patients. Ultimately, this may achieve better outcomes for people with asthma.

Barriers and facilitators of adherence to antidepressants among outpatients with major depressive disorder: A qualitative study

BACKGROUND

One of the major challenges in treating major depressive disorder (MDD) is patients' non-adherence to medication. This study aimed to explore the barriers and facilitators of patients' adherence to antidepressants among outpatients with MDD.

METHODS

Semi-structured and individual in-depth interviews were conducted among patients with MDD who were taking antidepressants, in the psychiatric clinic of a government-run hospital in Malaysia. Participants were purposively sampled from different genders and ethnicities. Interviews were conducted using a validated topic guide, and responses were audio-recorded, transcribed verbatim, checked, and analyzed using the grounded theory approach.

RESULTS

A total of 30 patients were interviewed. Forty different themes and sub-themes were identified which were conceptually divided into two distinct categories related to barriers and facilitators to adherence. The barriers were: patient-specific, medication-specific, healthcare provision and system, social-cultural, and logistics. The facilitators were: having insight, perceived health benefits, regular activities, patient-provider relationship, reminders, and social support networks.

CONCLUSIONS

Patient-specific barriers and medication side effects were the major challenges for adhering to treatment. Perceived health benefits and having insight on the need for treatment were the most frequently cited facilitators. Targeted interventions should be developed to address the key barriers, and promote measures to facilitate adherence in this group of patients.

Poor Adherence With Medication Refill and Medical Supplies Maintenance as Risk Factors for Inpatient Asthma Admission in Children

Background. Asthma results in significant pediatric hospitalizations in the inner city. Many asthmatic children were admitted to our hospital as a result of lack of medications or medical supplies that had been previously prescribed ("ran out," "broken," or "lost"). Objective. To identify the incidence of children admitted for asthma because of lack of prescribed medications/supplies and to assess risk factors for poor adherence between groups. Methods. This was a prospective chart review of 200 asthmatic children admitted to Children's Hospital of Michigan, Detroit. The data included asthma severity, lack of prescribed medications/medical supplies, and outpatient management. Results. In all, 35.5% or 71/200 of asthmatic children admitted had lack of prescribed medication/supplies (9% lacked both). The most common deficiency was β2-agonist (20.5%; 41/200). Teenagers had the highest lack of medications/medical supplies (55.6%; 5/9) compared with toddlers (17.2%; 16/93) and preschoolers (17.9%; 5/28). Patients with severe persistent asthma had a higher incidence of lacking medicine (31.8%; 7/22) compared with 25% (14/56) with moderate persistent asthma and 23.4% (15/64) of mild asthmatics. We found the lack of asthma medical supplies, including nonfunctioning or lost nebulizers/spacers, in 44.4% (4/9) of teenagers, 17.2% (16/93) of toddlers, and 21.4% (6/28) of preschool-aged children. We found no significant difference in these deficiencies whether patients were managed by asthma specialists or primary care providers. Conclusions. Significant numbers of asthmatic children admitted reported lack of prescribed medications/medical supplies. The most severe asthmatics were most likely to run out of medications. Interventions targeted at these deficiencies may avoid hospitalizations.

Asthma control in primary care: the results of an observational cross-sectional study in Italy and Spain

Background

Poor asthma control observed in several surveys may be related to a lack of systematic assessment by physicians and/or to patient underestimation of symptoms. Along this line, the purpose of this study was to investigate the level of asthma control in patients attending the GP office for different reasons, either for renewal of drug prescription or for worsening of asthma symptoms.

Methods

Each of the 145 General Practitioners (GP) in Italy and Spain selected at least eight asthmatic patients attending their office for a renewal of drug prescription (Group A) or for worsening of asthma symptoms (Group B), between May and December 2009. Asthma Control Test (ACT) and other clinical information (including SF-12 questionnaire) were collected.

Results

Data from 1375 patients with moderate-severe asthma were analysed (mean age: 47.2 years; female: 59%; smokers or ex-smokers: 35.4%); 57% were on treatment with ICS-LABA combination. ACT score < 20 (uncontrolled asthma) was observed in 77.8% Group B patients, as expected, but also in 28.6% Group A patients. Uncontrolled patients reported their asthma being well or fairly well controlled in 68.4% of cases. Risk factors for uncontrolled asthma were older age, asthma severity, and smoking habit. In uncontrolled patients, GPs changed or increased the level of therapy in 75.8% and initiated asthma treatment in 61.3% of cases, in association with educational intervention, closer monitoring or pulmonologist consultations.

Discussion

The systematic use of ACT in asthmatics attending GP’s clinic may detect high rates of uncontrolled patients who underestimate their clinical conditions, particularly those asking solely for asthma medication renewal. Poor adherence to daily drug therapy was reported in more than 40% of patients and could be an important contributor of uncontrolled asthma.

Conclusions

The results highlight the importance of routine longitudinal assessment of asthma patients in primary care and point to the need for an increased attention to asthma management by GPs.

Pathways linking health literacy, health beliefs, and cognition to medication adherence in older adults with asthma

BACKGROUND

Limited health literacy is associated with low adherence to asthma controller medications among older adults.

OBJECTIVE

We sought to describe the causal pathway linking health literacy to medication adherence by modeling asthma illness and medication beliefs as mediators.

METHODS

We recruited adults aged 60 years and older with asthma from hospital and community practices in New York, New York, and Chicago, Illinois. We measured health literacy and medication adherence using the Short Test of Functional Health Literacy in Adults and the Medication Adherence Rating Scale, respectively. We used validated instruments to assess asthma illness and medication beliefs. We assessed cognition using a cognitive battery. Using structural equation modeling, we modeled illness and medication beliefs as mediators of the relationship between health literacy and adherence while controlling for cognition.

RESULTS

Our study included 433 patients with a mean age of 67 ± 6.8 years. The sample had 84% women, 31% non-Hispanic blacks, and 39% Hispanics. The 36% of patients with limited health literacy were more likely to have misconceptions about asthma (P < .001) and asthma medications (P < .001). Health literacy had a direct effect (β = 0.089; P < .001) as well as an indirect effect on adherence mediated by medications concerns (β = 0.033; P = .002). Neither medication necessity (β = 0.044; P = .138) nor illness beliefs (β = 0.007; P = .143) demonstrated a mediational role between health literacy and adherence.

CONCLUSIONS

Interventions designed to improve asthma controller medication adherence in older adults may be enhanced by addressing concerns about medications in addition to using communication strategies appropriate for populations with limited health literacy and cognitive impairments.

What patients really think about asthma guidelines: barriers to guideline implementation from the patients' perspective

BACKGROUND

Treatment of asthma does not always comply with asthma guidelines (AG). This may be rooted in direct or indirect resistance on the doctors' and/or patients' side or be caused by the healthcare system. To assess whether patients' concepts and attitudes are really an implementation barrier for AG, we analysed the patients' perspective of a "good asthma therapy" and contrasted their wishes with current recommendations.

METHODS

Using a qualitative exploratory design, topic centred focus group (FG) discussions were performed until theoretical saturation was reached. Inclusion criteria were an asthma diagnosis and age above 18. FG sessions were recorded audio-visually and analysed via a mapping technique and content analysis performed according to Mayring (supported by MAXQDA®). Participants' speech times and the proportion of time devoted to different themes were calculated using the Videograph System® and related to the content analysis.

RESULTS

Thirteen men and 24 women aged between 20 and 77 from rural and urban areas attended five FG. Some patients had been recently diagnosed with asthma, others years previously or in childhood. The following topics were addressed: (a) concern about or rejection of therapy components, particularly corticosteroids, which sometimes resulted in autonomous uncommunicated medication changes, (b) lack of time or money for optimal treatment, (c) insufficient involvement in therapy choices and (d) a desire for greater empowerment, (e) suboptimal communication between healthcare professionals and (f) difficulties with recommendations conflicting with daily life. Primarily, (g) participants wanted more time with doctors to discuss difficulties and (h) all aspects of living with an impairing condition.

CONCLUSIONS

We identified some important patient driven barriers to implementing AG recommendations. In order to advance AG implementation and improve asthma treatment, the patients' perspective needs to be considered before drafting new versions of AG. These issues should be addressed at the planning stage.

TRIAL REGISTRATION

DRKS00000562 (German Clinical Trials Registry).

Family Engagement in Pediatric Sickle Cell Disease Visits

Adults with sickle cell disease (SCD) report problems in relationship building and information exchange during clinic visits. To explore the origin of these communication challenges, we compare communication in pediatric SCD, diabetes, and asthma visits. We collected visit videos and parent surveys from 78 children ages 9-16 years with SCD, asthma, or diabetes. Coders assessed child, parent, and physician utterances reflecting relationship building, information giving, and information gathering. Associations of engagement with type of chronic disease visit were performed with negative binomial regression. Compared to SCD visits, children in diabetes visits spoke 53% more relationship-building utterances (p < .05) and physicians in asthma visits spoke 48% fewer relationship building utterances to the child (p < .01). In diabetes visits, physicians gave almost twice as much information to children and gave 48% less information to parents (both p < .01) compared to SCD visits. Compared to SCD visits, physicians spoke fewer information-gathering utterances to parents in diabetes and asthma visits (85% and 72% respectively, both p < .001). SCD visits reflect less engagement of the children and greater physician effort to gather information from parents. These differences highlight opportunities to enhance engagement as a mechanism for ultimately improving SCD care.

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 can adherence to asthma medication be enhanced? Triangulation of key asthma stakeholders' perspectives

BACKGROUND AND OBJECTIVES

Adherence to daily asthma controller medication has been shown to be the most effective component of asthma self-management; however, patient's adherence to asthma medication remains poor. This study aimed to understand how patients' long-term asthma controller medication adherence may be improved and facilitated by comparing key asthma stakeholders' perspectives.

METHOD

Six focus group interviews including 38 asthma stakeholders (n = 13 patients, n = 13 pulmonologist physicians, and n = 12 allied healthcare professionals) were conducted. Interviews were qualitatively analysed.

RESULTS

Although similar themes were brought up across different asthma stakeholders, the way in which they were framed differed across stakeholders. The most salient discussion revolved around the content and the moment in which asthma education should be approached to facilitate patients' adherence to asthma medication.

CONCLUSION

Asthma medication adherence is a complex process and successful interventions aimed at its improvement would benefit from: (a) making an effort to understand patients' experiences and negotiate the treatment regimen, rather than imposing recommendations; (b) considering treatment as a shared responsibility involving the patient, the healthcare professional(s), and the patients' social networks; and,