Factors associated with medication nonadherence in patients with COPD

Cost-related medication nonadherence in adults with COPD in the United States 2013-2020

BACKGROUND

Cost-related medication nonadherence (CRN) is associated with poor prognosis among patients with chronic obstructive pulmonary disease (COPD), a population that requires long-term treatment for secondary prevention. In this study, we aimed to estimate the prevalence and sociodemographic characteristics of CRN in individuals with COPD in the US.

METHODS

In a nationally representative survey of US adults in the National Health Interview Survey (2013-2020), we identified individuals aged ≥18 years with a self-reported history of COPD. Cross-sectional study.

RESULTS

Of the 15,928 surveyed individuals, a weighted 18.56% (2.39 million) reported experiencing CRN, including 12.50% (1.61 million) missing doses, 13.30% (1.72 million) taking lower than prescribed doses, and 15.74% (2.03 million) delaying filling prescriptions to save costs. Factors including age < 65 years, female sex, low family income, lack of health insurance, and multimorbidity were associated with CRN.

CONCLUSIONS

In the US, one in six adults with COPD reported CRN. The influencing factors of CRN are multifaceted and necessitating more rigorous research. Targeted interventions based on the identified influencing factors in this study are recommended to enhance medication adherence among COPD patients.

Medication adherence halves COPD patients' hospitalization risk - evidence from Swiss health insurance data

Medication adherence is vital for patients suffering from Chronic Obstructive Pulmonary Disease (COPD) to mitigate long-term consequences. The impact of poor medication adherence on inferior outcomes like exacerbations leading to hospital admissions is yet to be studied using real-world data. Using Swiss claims data from 2015-2020, we group patients into five categories according to their medication possession ratio. By employing a logistic regression, we quantify each category's average treatment effect of the medication possession ratio on hospitalized exacerbations. 13,557 COPD patients are included in the analysis. Patients with high medication adherence (daily medication reserve of 80% to 100%) are 51% less likely to incur exacerbation following a hospital stay than patients with the lowest medication adherence (daily medication reserve of 0% to 20%). The study shows that medication adherence varies strongly among Swiss COPD patients. Furthermore, high medication adherence immensely decreases the risk of hospitalized exacerbations.

Predictors of Patient-reported and Pharmacy Refill Measures of Maintenance Inhaler Adherence in Veterans with Chronic Obstructive Pulmonary Disease

Rationale: Suboptimal adherence to inhaled medications in patients with chronic obstructive pulmonary disease (COPD) remains a challenge. Objectives: To examine the sociodemographic and clinical characteristics and medication beliefs associated with adherence measured by self-report and pharmacy data. Methods: A cross-sectional analysis of data from a prospective observational cohort study of patients with COPD was completed. Participants underwent spirometry and completed questionnaires regarding sociodemographic data, inhaler use, dyspnea, social support, psychological and medical comorbidities, and medication beliefs (Beliefs about Medicines Questionnaire [BMQ]). Self-reported adherence to inhaled medications was measured with the Adherence to Refills and Medications Scale (ARMS), and pharmacy-based adherence was calculated from administrative data using the ReComp score. Multivariable linear regression was used to examine the sociodemographic, clinical, and medication-belief factors associated with both adherence measures. Results: Among 269 participants with ARMS and ReComp data, adherence was the same for each measure (38.3%), but only 18% of participants were adherent by both measures. In multivariable adjusted analysis, a 10-year increase in age (β = 0.54; 95% confidence interval, 0.14-0.94) and the number of maintenance inhalers used (β = 0.53; 0.04-1.02) were associated with increased adherence by self-report. Improved ReComp adherence was associated with chronic prednisone use (β = 0.18; 0.04-0.31) and the number of maintenance inhalers used (β = 0.11; 0.05-0.17). In adjusted analyses examining patient beliefs about medications, increases in the COPD-specific BMQ concerns score (β = -0.10; -0.17 to -0.02) were associated with reduced self-reported adherence. No significant associations between ReComp adherence and BMQ score were found in adjusted analyses. Conclusions: Adherence to inhaled COPD medications was poor as measured by self-report or pharmacy refill data. There were notable differences in factors associated with adherence based on the method of adherence measurement. Older age, chronic prednisone use, the number of prescribed maintenance inhalers used, and patient beliefs about medication safety were associated with adherence. Overall, fewer variables were associated with adherence as measured based on pharmacy refills. Pharmacy refill-based and self-reported adherence may measure distinct aspects of adherence and may be affected by different factors. These results also underscore the importance of addressing patient beliefs when developing interventions to improve medication adherence.

Effects of Adherence to an mHealth Tool for Self-Management of COPD Exacerbations

Purpose

Poor adherence to COPD mobile health (mHealth) has been reported, but its association with exacerbation-related outcomes is unknown. We explored the effects of mHealth adherence on exacerbation-free weeks and self-management behavior. We also explored differences in self-efficacy and stages of grief between adherent and non-adherent COPD patients.

Patients and Methods

We conducted secondary analyses using data from a recent randomized controlled trial (RCT) that compared the effects of mHealth (intervention) with a paper action plan (comparator) for COPD exacerbation self-management. We used data from the intervention group only to assess differences in exacerbation-free weeks (primary outcome) between patients who were adherent and non-adherent to the mHealth tool. We also assessed differences in the type and timing of self-management actions and scores on self-efficacy and stages of grief (secondary outcomes). We used generalized negative binomial regression analyses with correction for follow-up length to analyze exacerbation-free weeks and multilevel logistic regression analyses with correction for clustering for secondary outcomes.

Results

We included data of 38 patients of whom 13 (34.2%) (mean (SD) age 69.2 (11.2) years) were adherent and 25 (65.8%) (mean (SD) age 68.7 (7.8) years) were non-adherent. Adherent patients did not differ from non-adherent patients in exacerbation-free weeks (mean (SD) 31.5 (14.5) versus 33.5 (10.2); p=0.63). Although statistically not significant, adherent patients increased their bronchodilator use more often and more timely, contacted a healthcare professional and/or initiated prednisolone and/or antibiotics more often, and showed at baseline higher scores of self-efficacy and disease acceptance and lower scores of denial, resistance, and sorrow, compared with non-adherent patients.

Conclusion

Adherence to mHealth may be positively associated with COPD exacerbation self-management behavior, self-efficacy and disease acceptance, but its association with exacerbation-free weeks remains unclear. Our results should be interpreted with caution by this pilot study's explorative nature and small sample size.

Management of COPD and Comorbidities in COPD patients by Dispensing Pharmaceutical Care following Global Initiative for chronic Obstructive Lung Disease-Guidelines (GOLD guidelines 2020): A study protocol for a Prospective Randomized Clinical Trial

COPD (chronic obstructive pulmonary disease) is a medical condition that encompasses several chronic, progressive, and severe respiratory illnesses, such as emphysema and chronic bronchitis. COPD is the 4th most deadly disease in the world and its prevalence is expected to increase. Despite the abundance of information on the disease's etiology, pathophysiology, and treatment possibilities, it has long been underdiagnosed and underreported for a long time, particularly in developing countries. The symptoms of COPD result in significant impairments and significant impact on quality of life. COPD is the third leading cause of death in Pakistan. According to the published literature, COPD has been found to be associated with a serious economic burden, either the direct cost to healthcare systems in the form of frequent hospital admissions or indirect costs to patients suffering from COPD. Despite the availability of excellent medication, COPD treatment goals are frequently not achieved resulting in poor management of COPD. The recent studies revealed that due to the missing role of Pharmacists in most of the public sector hospitals of Pakistan, the COPD disease management protocols are not being properly followed. Pharmacists can help the healthcare system by implementing these management protocols that focus on patient education about the disease, prescribed medications, and proper inhalation techniques. Furthermore, the pharmacists as an effective healthcare's team member properly educate the patients about the ongoing assessments and their willingness to follow treatment recommendations and quit smoking, while referring them to smoking cessation programs as needed, following the GOLD guidelines. This aim of this clinical trial is to evaluate the impact of implementing standard treatment guidelines and the role of pharmacists in implementing GOLD guidelines for COPD management.

Shared decision making and medication adherence in patients with COPD and/or asthma: the ANANAS study

Background: Medication adherence to inhalation medication is suboptimal in patients with COPD and asthma. Shared decision making (SDM) is proposed as an intervention to improve medication adherence. Despite its wide promotion, evidence of SDM's association with greater medication adherence is scarce. Also, it is unknown to what degree patients presently experience SDM and how it is associated with medication adherence. Objective: To (i) assess the level of SDM and (ii) medication adherence, (iii) explore the relation between SDM and medication adherence and iv) investigate possible underlying mechanisms. Methods: Cross-sectional observational study. A survey was distributed among Dutch patients with COPD and/or asthma using inhaled medication. Medication adherence was measured using the Test of Adherence to Inhalers (TAI-10), and SDM by the 9-item Shared Decision-Making questionnaire (SMD-Q-9). Feeling of competence, relatedness and feeling of autonomy from the Self-Determination Theory (SDT) were considered as possible mechanisms. The primary outcome was adherence. Results: A total of 396 patients with complete information on relevant covariates were included. Mean SDM-Q-9 score was 26.7 (SD 12.1, range 0-45) and complete adherence was 41.2%. The odds ratio for the association of SDM with adherence was 1.01 (95% CI: 0.99, 1.02). This only changed minimally when adjusted for mediators (mediating effect <3%). Conclusion: The patient experienced level of SDM in daily practice and medication adherence have room for improvement. No association between SDM and medication adherence was observed. Factors related to feeling of competence, relatedness and feeling of autonomy did not meaningfully explain this finding.

Anxiety and Depression Among US Nursing Home Residents with Chronic Obstructive Pulmonary Disease

Background

Chronic obstructive pulmonary disease (COPD) is highly prevalent among nursing home residents; however, few studies have focused on the psychological impact of this clinically significant condition on nursing home residents.

Objective

We examine the prevalence of, and factors associated with, anxiety and depression in nursing home residents with COPD.

Methods

Using the US 2018 Minimum Dataset (MDS), we conducted a cross-sectional study among 239,615 residents aged ≥50 years old in US Medicare/Medicaid certified nursing homes with COPD. Anxiety and depression were diagnosed based on clinical diagnoses, physical examination findings, and treatment orders. Multivariable adjusted Poisson models with a generalized estimating equations approach account for the clustering among residents within nursing homes.

Results

The average age of the study population was 79 years (SD: 10.6), 62.0% were women, and 43.7% had five or more comorbid conditions. In this population, 37.2% had anxiety, 57.6% had depression, and 27.5% had both mental health conditions. Women, current tobacco users, persons 50-64 years old, those who reported having moderate or severe pain, and nursing home residents with multimorbidity were more likely to have anxiety or depression than respective comparison groups.

Conclusion

Anxiety and depression are common among US nursing home residents with COPD. Women, medically complex patients, and those who report having moderate-to-severe pain appear to be more likely to have anxiety and depression. Clinical teams should be aware of these findings when managing nursing home residents with COPD and use various nonpharmacological and medical interventions for the effective management of anxiety and depression. Longitudinal studies evaluating how anxiety and depression affect the management of COPD and related outcomes, and how best to improve the quality of life of nursing home residents with COPD, are warranted.

Impact of a pharmacist-led, primary medication nonadherence intervention program on prescription fills in underserved patient populations

BACKGROUND

Poor medication adherence is a critical barrier to improving patient health. Patients who are medically underserved are prone to a chronic disease state diagnosis and experience different social determinants of health.

OBJECTIVE

This study aimed to determine the impact of a primary medication nonadherence (PMN) intervention on prescription fills in underserved patient populations.

METHODS

This randomized control trial included 8 pharmacies that were chosen based on current poverty demographic data for each region in a metropolitan area as reported by the U.S. Census Bureau. Randomization was completed by a random number generator into (1) an intervention group or (2) a control group: (1) initiation of a PMN intervention and (2) no intervention offered on PMN. The intervention consists of a pharmacist addressing and resolving patient-specific barriers. Patients were enrolled in a PMN intervention at day 7 of a newly prescribed medication or a medication that has not been used in the previous 180 days, not being obtained for therapy. Data were collected to determine the number of eligible medications or therapeutic alternatives that were obtained after a PMN intervention was initiated and if that medication was refilled.

RESULTS

The intervention group consisted of 98 patients and the control group had 103. Rate of PMN was higher (P = 0.037) in the control group (71.15%) than the intervention group (47.96%). Cost and forgetfulness encompassed 53% of the barriers experienced by patients in the interventional group. The most commonly prescribed medication classes associated with PMN included statins (32.98%), renin angiotensin system antagonists (26.18%), oral diabetes medications (25.65%), and chronic obstructive pulmonary disease and corticosteroid inhalers (10.47%).

CONCLUSION

The rate of PMN had a statistically significant decrease when a pharmacist-led, evidence-based intervention was conducted with the patient. Although this study depicted a statistically significant decrease in PMN rates, larger studies are needed to strengthen the correlation between the decrease in PMN and a pharmacist-led, PMN intervention program.

Illness perception, health literacy, self-efficacy, adherence and quality of life in patients with intermittent claudication - a longitudinal cohort study

BACKGROUND

Patients with intermittent claudication need lifelong treatment with secondary prevention to prevent cardiovascular events and progression of atherosclerotic disease. Illness perception, health literacy, self-efficacy, adherence to medication treatment, and quality of life are factors influencing patients' self-management. Knowledge of these factors could be important when planning for secondary prevention in patients with intermittent claudication.

AIM

to compare illness perception, health literacy, self-efficacy, adherence to treatment, and quality of life in in patients with intermittent claudication.

METHODS

A longitudinal cohort study was conducted with 128 participants recruited from vascular units in southern Sweden. Data were collected through medical records and questionnaires regarding illness perception, health literacy, self-efficacy, adherence to treatment, and quality of life.

RESULTS

In the subscales in illness perception, patients with sufficient health literacy reported less consequences and lower emotional representations of the intermittent claudication. They also reported higher self-efficacy and higher quality of life than patients with insufficient health literacy. In comparison between men and women in illness perception, women reported higher illness coherence and emotional representations associated with intermittent claudication compared to men. A multiple regression showed that both consequences and adherence were negative predictors of quality of life. When examining changes over time, a significant increase in quality of life was seen between baseline and 12 months, but there were no significant differences in self-efficacy..

CONCLUSION

Illness perception differs in relation to level of health literacy and between men and women. Further, the level of health literacy seems to be of importance for patients' self-efficacy and quality of life. This illuminates the need for new strategies for improving health literacy, illness perception, and self-efficacy over time. For example, more tailored information regarding secondary prevention could be provided to strengthen self-management to further improve quality of life in patients with intermittent claudication.

Medication adherence in patients with cluster headache and migraine: an online survey

To examine factors for adherent and non-adherent behavior in patients with cluster headache and migraine. Adults with cluster headache or migraine were included in this anonymous online survey using a questionnaire accessed via homepages of headache support groups. Medication adherence in preventive treatment was measured with the Medication Adherence Report Scale (MARS-D). Factors for non-adherent behavior were examined (subjective socioeconomic status, psychological comorbidities, self-efficacy, coping, side effects, expectations of treatment, information on medical treatment, and trust in the physician/treatment concept). 200 participants (n = 58 with cluster headache, n = 142 with migraine) were included. The rate of medication adherence in preventive treatment was 32.8% for participants with cluster headache and 20.4% for migraine. The most common reasons for low adherence in participants with cluster headache were altering the prescribed medication dose (34%) or taking less than instructed (14%), which was mostly due to insufficient benefit from the medication or side effects. Positive expectations of medical treatment (p ≤ 0.05) correlated significantly with adherent behavior in cluster headache. Furthermore, the adherence-promoting factors coping and self-efficacy were more pronounced in patients with cluster headache than in those with migraine (p < 0.05). This study is the first to comprehensively investigate medication adherence and factors influencing adherent/non-adherent behavior in patients with cluster headache. Patients with cluster headache had similar adherence levels to patients with migraine, but had higher resources of adherence-promoting factors.

Effectiveness of motivational interviewing among patients with COPD: A systematic review with meta-analysis and trial sequential analysis of randomized controlled trials

OBJECTIVE

To evaluate the effectiveness of motivational interviewing (MI) for COPD in behavioral changes and health outcomes, and also verify the reliability of results in conjunction with trial sequential analysis and the Grading of Recommendations Assessment, Development, and Evaluation tool.

METHODS

Studies that implemented MI interventions for COPD patients were systematically searched by eight databases from inception to December 2021. Study screening, quality assessment, data extraction, and meta-analysis were conducted according to Cochrane standards.

RESULTS

Twenty-one studies involving 2344 patients were included. The results of meta-analyses indicated that MI made significant improvement in self-efficacy, lung function, quality of life, emotion, and COPD-related admission, but not in self-management and exercise capacity. Subgroup analyses found that the intervention duration was inversely associated with effect size for both self-efficacy and negative emotion severity. The trial sequential analysis showed MI improved patients' lung function and reduced COPD-related hospitalization with certainty, but the findings for exercise capacity need to be confirmed by further research.

CONCLUSIONS

This systematic review suggested the positive effects of MI on self-efficacy, lung function, quality of life, emotion and COPD-related hospitalization. To make a firm conclusion, more well-designed clinical trials with bigger sample sizes required.

PRACTICE IMPLICATIONS

Clinical and community nurses can use MI for COPD to increase healthy behaviors.

TRIAL REGISTRATION

CRD42021278674.

Development and Validation of a Multivariable Prediction Model to Identify Acute Exacerbation of COPD and Its Severity for COPD Management in China (DETECT Study): A Multicenter, Observational, Cross-Sectional Study

Purpose

There is an unmet clinical need for an accurate and objective diagnostic tool for early detection of acute exacerbation of chronic obstructive pulmonary disease (AECOPD). DETECT (NCT03556475) was a multicenter, observational, cross-sectional study aiming to develop and validate multivariable prediction models for AECOPD occurrence and severity in patients with chronic obstructive pulmonary disease (COPD) in China.

Patients and Methods

Patients aged ≥40 years with moderate/severe COPD, AECOPD, or no COPD were consecutively enrolled between April 22, 2020, and January 18, 2021, across seven study sites in China. Multivariable prediction models were constructed to identify AECOPD occurrence (primary outcome) and AECOPD severity (secondary outcome). Candidate variables were selected using a stepwise procedure, and the bootstrap method was used for internal model validation.

Results

Among 299 patients enrolled, 246 were included in the final analysis, of whom 30.1%, 40.7%, and 29.3% had COPD, AECOPD, or no COPD, respectively. Mean age was 64.1 years. Variables significantly associated with AECOPD occurrence (P<0.05) and severity (P<0.05) in the final models included COPD disease-related characteristics, as well as signs and symptoms. Based on cut-off values of 0.374 and 0.405 for primary and secondary models, respectively, the performance of the primary model constructed to identify AECOPD occurrence (AUC: 0.86; sensitivity: 0.84; specificity: 0.77), and of the secondary model for AECOPD severity (AUC: 0.81; sensitivity: 0.90; specificity: 0.73) indicated high diagnostic accuracy and clinical applicability.

Conclusion

By leveraging easy-to-collect patient and disease data, we developed identification tools that can be used for timely detection of AECOPD and its severity. These tools may help physicians diagnose AECOPD in a timely manner, before further disease progression and possible hospitalizations.

Self-Reported Overall Adherence and Correct Inhalation Technique Discordance in Chronic Obstructive Pulmonary Disease Population

Background: Adherence to inhaled medication constitutes a major problem in patients with chronic obstructive pulmonary disease (COPD) globally. However, large studies evaluating adherence in its entirety and capturing a large variety of potentially associated factors are still lacking.

Objective: To study both elementary types of adherence to chronic inhaled COPD medication in “real-life” COPD patients and to assess relationships with a wide-ranging spectrum of clinical parameters.

Methods: Data from the Czech Multicentre Research Database (CMRD) of COPD, an observational prospective study, were used. Overall adherence (OA) was evaluated with Morisky Medication Adherence Scale (©MMAS-4) and adherence to an application technique (A-ApplT) with the Five Steps Assessment. Mann–Whitney U test, Spearman’s correlation, and logistic regression were used to explore relationships between variables.

Results: Data of 546 participants (69.6% of all patients from the CMRD) were analyzed. Two-thirds self-reported optimal OA, but only less than one-third demonstrated A-ApplT without any error. OA did not correlate with A-ApplT. Next, better OA was associated with higher education, a higher number of inhalers, a lower rate of exacerbations, poorer lung function, higher degree of upper respiratory tract symptoms (SNOT-22), absence of depressive symptoms, ex-smoking status, regular mouthwash after inhaled corticosteroids (ICS), and flu vaccination. By contrast, better A-ApplT was associated with a lower number of inhalers, better lung function, and regular mouthwash after ICS. Independent predictors of nonoptimal OA included lower degree of education, absence of flu vaccination, anemia, depression, and peptic ulcer history, whereas independent predictors of lower A-ApplT were lower education, absence of regular mouthwash after ICS, and higher COPD Assessment Test score.

Conclusions: Parameters associated with OA and A-ApplT differ, and those associated with both adherence domains are sometimes associated inversely. Based on this finding, we understand these as two separate constructs with an overlap.

Prediction of treatment nonadherence among older adults with chronic obstructive pulmonary disease using Medicare real-world data

BACKGROUND: Suboptimal maintenance medication (MM) adherence remains a clinical problem among Medicare beneficiaries with chronic obstructive pulmonary disease (COPD). OBJECTIVE: To inform risk-based personalized decision-making, this study sought to develop and validate prediction models of nonadherence to COPD MMs for Medicare beneficiaries. METHODS: This was a retrospective cohort study of beneficiaries aged 65 years and older with COPD and inhaled MMs. Nonadherence (proportion of days covered < 0.8) was measured in 12 months following the first MM fill after COPD diagnosis. Logistic and least absolute shrinkage selector operator regressions were implemented, and area under the receiver operating characteristic curve (AUROC) evaluated model accuracy, as well as positive predictive values and negative predictive values. Our models evaluated different sets of predictors for two cohorts: those with an MM prescription before COPD diagnosis (prevalent users) and those without (new users). RESULTS: Among 16,157 prevalent and 40,279 new users of MMs, 11,271 (69.8%) and 34,009 (84.4%), respectively, were nonadherent. The best-performing logistic models achieved AUROCs of 0.8714 and 0.881, positive predictive values of 0.881 and 0.881, and negative predictive values of 0.559 and 0.578, respectively, for prevalent and new users. The least absolute shrinkage selector operator models had similar accuracy. Models with baseline-only predictors had average performance (AUROC < 0.72). The most important predictors were initial MM adherence, short-acting bronchodilator use, and asthma. CONCLUSIONS: To our knowledge, this study is the first to develop predictive models of nonadherence to COPD MMs. Generated models achieved good discrimination and underlined the importance of early adherence. Well-performed models can be useful for care decision-making and interventions to improve COPD medication adherence after the first critical few months following a treatment episode. DISCLOSURES: All authors declared no conflicts of interest.

Psychometric Properties of the Treatment Satisfaction with Medicines Questionnaire (SATMED-Q) in Patients with Diabetes, Arterial Hypertension and Heart Failure

Background: Satisfaction with medicines is crucial in indicating patient experiences with the treatment which impact medicine adherence and compliance. Aim: The aim of this research was to adopt a general measure of patients’ satisfaction with medicines, the Treatment Satisfaction with Medicines Questionnaire (SATMED-Q), to the Polish language (BMQ-PL). Materials and Methods: A total of 197 patients qualified for the research, with the following diagnoses: type 2 diabetes (n = 42), hypertension (n = 55) and heart failure (n = 100), aged 64.73 (SD = 13.27). The criterion-related validity was determined with the use of a Polish version of the Adherence to Refills and Medications Scale. Confirmatory and exploratory factor analyses were used. Results: The respondents’ mean score was 73.63 (SD = 18.42). Cronbach’s alpha for the entire instrument was 0.847. All items of the questionnaire were found to have a positive item–total correlation. A multifactorial linear regression model showed that a significant (p ˂ 0.05) independent variable increasing the SATMED-Q score for the whole group was educational level (vocational education R = 14.576; secondary education R = 14.055; higher education R = 19.372) and low adherence (R = −1.384) was a decreasing variable. Conclusions: The present findings indicate a high level of reliability and validity of the translated SATMED-Q questionnaire, fully comparable to that of the original. The questionnaire can be used for the assessment of satisfaction with medicines among Polish patients.

Inhaler Non-Adherence, Associated Factors and Asthma Control among Asthma Patients in a Tertiary Level Hospital in Tanzania

BACKGROUND

Inhaled medications including corticosteroids are the most effective long-term controller medicines for asthma-related chronic airway inflammation. Despite this fact, 30% to 70% of the uncontrolled asthma patients report non-adherence to their inhalers. This study investigated factors affecting inhaler non-adherence among outpatient asthma patients in Muhimbili National Hospital, Dar es Salaam Tanzania and related the level of inhaler adherence to the extent of asthma control.

METHODS

A cross-sectional hospital-based study was conducted among patients with bronchial asthma in the pulmonology clinic of Muhimbili National Hospital in Dar-es-salaam, Tanzania. Patients' demographic, clinical and socio-economic factors were collected using a structured questionnaire. Medication adherence was self-reported using a 10-item Test of Adherence to Inhalers (TAI) questionnaire. Adherence was gauged as good when the score was 50, intermediate (score 46-49) or poor (score ≤ 45). Asthma control was assessed using a 5-question Asthma Control Test (ACT). A score of ≥20 meant well controlled asthma while a score of ≤19 meant poorly controlled asthma. Patients' inhaler use technique was assessed using a 10-step checklist. Patient's technique was regarded correct when all the steps were performed correctly. Categorical data were summarised as proportions. Binary logistic regression was performed to identify factors associated with inhaler non-adherence. Significance level was set at p-value less than .05.

RESULTS

A total of 385 asthma patients were enrolled in the study. Females were 206 (53.5%), 232(60.3%) were non-adherent to medications and 283(73.5%) had poorly controlled asthma. Lack of health insurance, fear of medication side effects, being too busy, having alternative medication for asthma and incorrect inhaler technique were significantly associated with non-adherence to inhalers, all p-values <.05.

CONCLUSION

The magnitude of inhaler non-adherence and poorly controlled asthma were very high. Promoting adherence through patients' education on asthma and its management, emphasis on patients' insurance coverage and setting aside time to care for ones' self are fundamental in optimising asthma care and treatment.

Determining factors associated with inhaled therapy adherence on asthma and COPD: A systematic review and meta-analysis of the global literature

BACKGROUND

Adherence to therapy has been reported worldwide as a major problem, and that is particularly relevant on inhaled therapy for Asthma and Chronic Obstructive Pulmonary Disease (COPD), considering its barriers and features. We reviewed the global literature reporting the main determinants for adherence on these patients.

METHODS

Searches were made using the Cochrane Library, MEDLINE, EMBASE and ISI Web of Science databases. Analytical, observational and epidemiological studies (cohort, case-control and cross-sectional studies) were included, reporting association between any type of determinant and the adherence for inhaler therapy on Asthma or COPD. Random-effects meta-analysis were used to summarise the numerical effect estimates.

RESULTS

47 studies were included, including a total of 54.765 participants. In meta-analyses, the significant determinants of adherence to inhaled therapy were: older age [RR = 1.07 (1.03-1.10); I² = 94; p < 0.0001] good disease knowledge/literacy [RR = 1.37 (1.28-1.47); I² = 14; p = 0.33]; obesity [RR = 1.30 (1.12-1.50); I² = 0; p = 0.37]; good cognitive performance [RR = 1.28 (1.17-1.40); I² = 0; p = 0.62]; higher income [RR = 1.63 (1.05-2.56); I² = 0; p = 0.52]; being employed [RR = 0.87 (0.83-0.90); I² = 0; p = 0.76] and using multiple drugs/inhalers [RR = 0.81 (0.79-0.84); I² = 0; p = 0.80]. Overall, the strength of the underlying evidence was only low to moderate.

CONCLUSIONS

Many determinants may be associated to patient's adherence, and personalised interventions should be taken in clinical practice to address it by gaining an understanding of their individual features.

Care processes and structures associated with higher medication adherence in adolescent and young adult transplant recipients

BACKGROUND

We aimed to identify care processes and structures that were independently associated with higher medication adherence among young transplant recipients.

METHODS

We conducted a prospective, observational cohort study of 270 prevalent kidney, liver, and heart transplant recipients 14-25 years old. Patients were ≥3 months post-transplant, ≥2 months post-discharge, and followed in one of 14 pediatric or 14 adult transplant programs in Canada. Patients were enrolled between June 2015 and March 2018 and followed for 6 months. Adherence was assessed at baseline, 3, and 6 months using the BAASIS^© self-report tool. Patients were classified as adherent if no doses were missed in the prior 4 weeks. Transplant program directors and nurses completed questionnaires regarding care organization and processes.

RESULTS

Of the 270 participants, 99 were followed in pediatric programs and 171 in adult programs. Median age was 20.3 years, and median time since transplant was 5 years. At baseline, 71.5% were adherent. Multivariable mixed effects logistic regression models with program as a random effect identified two program-level factors as independently associated with better adherence: minimum number of prescribed blood draws per year for those >3 years post-transplant (per 1 additional) (OR 1.12 [95% CI 1.00, 1.26]; p = .047), and average time nurses spend with patients in clinic (per 5 additional minutes) (OR 1.15 [1.03, 1.29]; p = .017).

CONCLUSION

Program-level factors including protocols with a greater frequency of routine blood testing and more nurse time with patients were associated with better medication adherence. This suggests that interventions at the program level may support better adherence.

Impact of adherence goal awareness intervention on PDC in various settings: Does awareness help modify medication-taking behavior?

Background

Interventions to improve medication adherence in chronic conditions have shown limited success or sustainability. Previous data revealed that phone calls to patients regarding adherence goal awareness resulted in significant improvement in proportion of days covered (PDC).

Objectives

The objective of this study was to explore specific pharmacist adherence interventions via phone in various practice settings.

Methods

A prospective, randomized controlled study was conducted with patients who belonged to university-associated health care settings [ambulatory care, chain store, small health plan, and federally qualified health center (FQHC)]. At each site, patients with at least one chronic medication and a calculated PDC < 0.80 were randomized into control (n=115) and intervention (n=126) groups. Control groups (C) received usual pharmacy communication while intervention groups (X) were specifically called by a pharmacist to be informed of PDC goals and their commitment to adherence. PDC values were calculated 3 to 12 months for both groups the time of intervention, then compared with each patient's respective baseline/pre-PDC.

Results

Data from a total of 241 patients were pooled to examine change in PDC. There was no significant difference between groups in baseline criteria or PDC. Comparing within groups, there were significant correlations between Pre- and Post-PDCs for the intervention group (X = 0.32 p < 0.05) alone. There were significant improvements from initial PDC to those calculated at the time of Post-intervention PDC within both groups, (C = 0.18 ± 0.28 p < 0.05) and (X = 0.16 ± 0.24, p < 0.05). Approximately 44% of all sampled patients reached their adherence goals (PDC ≥ 0.80) after 3–9 months.

Conclusions

Results suggested that patient adherence behavior may improve after any call made by pharmacy staff. This communication and attention from the pharmacy may be enough for patients to consider their medication-taking habits without the need for discussing specific goals and importance of adherence.

Patient's awareness on COPD is the strongest predictor of persistence and adherence in treatment-naïve patients in real life: a prospective cohort study

BACKGROUND

There is little evidence about the factors that predict persistence/adherence in treatment-naïve patients with COPD in clinical practice. The aim of this study was to evaluate persistence and adherence levels among treatment-naïve patients diagnosed with COPD who had a prescribed inhaled medication, using data from real-world clinical practice.

METHODS

Multicentric study with a 6 month-followed-up period. Patients were considered persistent if they collected all their inhaler refills. In a random sample of patients, we evaluated adherence using the Test of Adherence to Inhalers (TAI). We assessed Health Related Quality of Life (HRQL) with St George's Respiratory Questionnaire (SGRQ).

RESULTS

Of the 114 patients included, 46 (40.4%) were defined as persistent. Patients who had awareness about COPD (adjusted RR 2.672, 95% CI 1.125-6.349) were more likely to be persistent; patients with multidose DPI were less likely to be persistent that those with single dose DPI (adjusted RR 0.341, 95% CI 0.133-0.877). Higher levels of SGRQ total were associated with a lower probability of persistence (adjusted RR 0.945, 95%CI 0.894-0.998). Patients who had had an appointment with their GP in the previous six months were more likely to be persistent (adjusted RR 3.107, 95% CI 1.022-9.466). Patients who had awareness about COPD and those with lower symptom SGQR score were more likely to be adherent (24/25, 96.0% vs 16/22, 72.7%, p = 0.025, and mean 29.1, sd 19.4 vs mean 41.4, sd 15.9, respectively, p = 0.026, respectively).

CONCLUSIONS

Less than 50% of patients were defined as persistent. Patients' awareness of their disease and levels of HRQL were associated with high rate of persistence and adherence. In addition, frequent visits to general practitioner, increases the rate of persistence to treatment.

Associations of Medication Regimen Complexity with COPD Medication Adherence and Control

Introduction

Medication adherence is often low among people with chronic obstructive pulmonary disease (COPD) and medication regimen complexity may be a contributing factor. In this study, we sought to examine the role of medication regimen complexity in COPD medication adherence among patients with multimorbidity.

Methods

We performed cross-sectional analysis of data on COPD patients in primary care and pulmonary practices in New York City and Chicago (n=400). Regimen complexity was represented by the medication regimen complexity index (MRCI) and simple medication count. Adherence was measured by self-report and inhaler dose counts. Disease control measures included the COPD severity score (COPDSS) and the Medical Research Council (MRC) severity index.

Results

Mean age of study participants was 69 years, 66% had MRC grades 4 or 5, and 45% had low medication adherence. MRCI scores did not differ significantly between those with and without adequate medication adherence. Patients with higher MRCI scores were more likely to have severe COPD (OR 5.00, 95% CI 1.46-17.1, p=0.01) and dyspnea grades 3 or 4 (OR 2.27, 95% CI 1.03-5.03, p=0.04). Significant associations of medication count with COPD severity were also observed.

Discussion

These findings demonstrate that among patients with COPD and comorbid hypertension and diabetes, higher medication regimen complexity is associated with worse COPD control but not with COPD medication adherence.

Development and validation of the scoliosis misconception scale (SMS) for assessing level of misconception of patients with adolescent idiopathic scoliosis

BACKGROUND

Little is known about patients' understanding of adolescent idiopathic scoliosis (AIS). This paper aims to develop and validate the Scoliosis Misconception Scale (SMS) and to explore patients' level of misconception about AIS.

METHODS

A total of 195 patients who were newly referred with newly diagnosed AIS were recruited to assess their levels of misconception and psychological distress before and after their first consultation with a specialist. The 17-item SMS was administered to assess patients' level of misconception about AIS and the Kessler Psychological Distress Scale (K10) was used to measure their level of distress.

RESULTS

According to the Item Response Theory, all items were within the acceptable range from -3.69 to 2.39 for difficulty parameters, which determined the difficulty of the scale, while most of the items were within the acceptable range from 0.11 to 1.54 for the discrimination parameters, which determined the rate at which the probability of endorsing a correct item changes given ability levels. Internal consistency by marginal reliability was 0.66. One-sample t test revealed that participants on average scored 6.79 (SD = 2.12) before the first clinic session and 6.45 (SD = 2.51) after the first clinic session, both significantly higher than 0 [t(75) = 27.86, p < .001; t(75) = 22.43, p < .001].

CONCLUSIONS

Despite a longstanding clinical model that functions well to treat AIS, most patients still have significant misconceptions about the condition. This highlights the necessity to assess patients' knowledge level of a medical condition and potential generalisability of misconception-distress link to the forefront across other illnesses.

Portuguese Version of the Intentional Non-Adherence Scale: Validation in a Population of Chronic Pain Patients

Objective: Despite the effectiveness of pain medicines, nonadherence to prescribed medication remains a major problem faced by healthcare systems. The aim of present study was to perform the translation, cultural adaptation, and validation of the Intentional Non-Adherence Scale (INAS) for the European Portuguese language in a sample of chronic pain patients.

Methods: A Portuguese version of the INAS scale was constructed through a process of translation, back translation, and expert’s panel evaluation. A total of 133 chronic pain patients were selected from two chronic pain clinics from tertiary hospitals in Porto, Portugal. The protocol interview included the assessment of pain beliefs (PBPI), beliefs about medicine (BMQ), medication adherence (MARS-P9), and two direct questions about adherence previously validated.

Results: The internal consistency in all subscales was α = 0.902 for testing treatment; α = 0.930 for mistrust treatment; α = 0.917 for resisting treatment; and α = 0.889 for resisting illness. Exploratory and confirmatory factor analysis revealed a four-factor structure that explained 74% of the variance. The construct validity of the INAS was shown to be adequate, with the majority of the previously defined hypotheses regarding intercorrelations with other measures confirmed.

Conclusion: The Portuguese version of INAS could be a valuable and available instrument for Portuguese researchers and clinicians to assess the intentional nonadherence determinants during the management of chronic pain.

Maximizing Adherence and Gaining New Information For Your Chronic Obstructive Pulmonary Disease (MAGNIFY COPD): Study Protocol for the Pragmatic, Cluster Randomized Trial Evaluating the Impact of Dual Bronchodilator with Add-On Sensor and Electronic Monitoring on Clinical Outcomes

Background

Poor treatment adherence in COPD patients is associated with poor clinical outcomes and increased healthcare burden. Personalized approaches for adherence management, supported with technology-based interventions, may offer benefits to patients and providers but are currently unproven in terms of clinical outcomes as opposed to adherence outcomes.

Methods

Maximizing Adherence and Gaining New Information For Your COPD (MAGNIFY COPD study), a pragmatic cluster randomized trial, aims to evaluate the impact of an adherence technology package (interventional package), comprising an adherence review, ongoing provision of a dual bronchodilator but with an add-on inhaler sensor device and a connected mobile application. This will compare time to treatment failure and other clinical outcomes in patients identified at high risk of exacerbations with historic poor treatment adherence as measured by prescription collection to mono/dual therapy over one year (1312 patients) versus usual care. Treatment failure is defined as the first occurrence of one of the following: (1) moderate/severe COPD exacerbation, (2) prescription of triple therapy (inhaled corticosteroid/long-acting β₂-agonist/long-acting muscarinic antagonist [ICS/LABA/LAMA]), (3) prescription of additional chronic therapy for COPD, or (4) respiratory-related death. Adherence, moderate/severe exacerbations, respiratory-related healthcare resource utilization and costs, and intervention package acceptance rate will also be assessed. Eligible primary care practices (N=176) participating in the Optimum Patient Care Quality Improvement Program will be randomized (1:1) to either adherence support cluster arm (suitable patients already receiving or initiated Ultibro^® Breezhaler^® [indacaterol/glycopyrronium] will be offered interventional package) or the control cluster arm (suitable patients continue to receive usual clinical care). Patients will be identified and outcomes collected from anonymized electronic medical records within the Optimum Patient Care Research Database. On study completion, electronic medical record data will be re-extracted to analyze outcomes in both study groups.

Registration Number

ISRCTN10567920.

Conclusion

MAGNIFY will explore patient benefits of technology-based interventions for electronic adherence monitoring.

The impact of Tai Chi and mind-body breathing in COPD: Insights from a qualitative sub-study of a randomized controlled trial

PURPOSE

Chronic obstructive pulmonary disease (COPD) is associated with multiple psychosocial and behavioral factors. Prior research suggests that mind-body interventions may support the development and maintenance of healthy behaviors and improve health-related quality-of-life in such patients. We sought to qualitatively explore cognitive, psychosocial, and behavioral changes in patients with COPD who participated in two different mind-body interventions compared to an education control.

METHODS

We analyzed semi-structured qualitative exit interviews from a prospective, randomized pilot trial (N = 123) investigating 12-weeks of Tai Chi (TC) vs. mind-body breathing (MBB) vs. education (EDU) control in patients with moderate-severe COPD. TC involved traditional movements, that integrate meditative breathing, while MBB focused mainly on meditative breathing techniques alone. Interviews were audio-recorded and transcribed verbatim. Qualitative analysis of randomly selected transcripts was performed by two independent reviewers using an iterative process to identify emergent themes informed by grounded theory methods until thematic saturation was reached.

RESULTS

A total of 66 transcripts were reviewed (N = 22 TC, N = 22 MBB, N = 22 EDU). Participants were mean age = 68.1 years, GOLD Stage = 2.3, baseline FEV11 percent predicted mean (SD): 58% (13.4), 42.4% female. We identified six frequently mentioned themes: 1) overall awareness and understanding, 2) self-care knowledge, skills and behaviors, 3) behavior-related neurocognitive concepts, 4) physical function, 5) psychological well-being, and 6) social support/social function. Compared to EDU, more participants in TC and MBB noted improvements in awareness of self and the mind-body connection (e.g., body and breath awareness), knowledge of breathing techniques and integration of self-care skills with daily activities, self-efficacy for symptom management (particularly managing anxiety and dyspnea), acceptance of disease, physical function improvements (e.g., endurance, dyspnea, fatigue), and psychological well-being (particularly relaxation, emotion regulation and decreased reactivity). Compared to MBB, those in TC shared more intention to continue with self-care behaviors, physical activity self-efficacy, and improved flexibility. All three groups, including EDU, noted increased social support and knowledge of disease. Those in EDU, however, had fewer mentions of processes related to behavior change, and less concrete changes in neurocognitive, psychological, and physical function domains.

CONCLUSIONS

Mind-body interventions including meditative breathing may impact behavior-related neurocognitive and emotional factors that improve self-care management and support positive behavioral changes in patients with COPD.

TRIAL REGISTRATION

This trial is registered in Clinical Trials.gov, ID number NCT01551953.

Beclomethasone/Formoterol in Extra-Fine Formulation Improves Small Airway Dysfunction in COPD Patients

Introduction

In patients with chronic obstructive pulmonary disease (COPD), small airway dysfunction (SAD) is a key element and a functional consequence of the pathology. The exact role of SAD as a specific ‘pharmacological target’ represents an important research topic. Our objective was to ascertain whether an extra-fine formulation of beclomethasone dipropionate/formoterol fumarate (BDP/FF) NEXThaler^® 100/6 μg b.i.d. could improve SAD and, consequently, the quality of life of COPD patients.

Methods

We enrolled COPD patients with severe airflow obstruction and at least one moderate exacerbation in the previous year, having started treatment with BDP/FF NEXThaler^® for no more than 1 week. Patients underwent three visits: at the start of the treatment (V1), 6 weeks (V2), and 12 weeks later (V3). At each visit, we evaluated the fall in resistance from 5 to 20 Hz (R5–R20) and residual volume/total lung capacity (RV/TLC) ratio by impulse oscillometry, spirometry, and plethysmography. The COPD Assessment Test (CAT) and the modified Medical Research Council (mMRC) questionnaire were also administered to assess the disease’s impact on quality of life.

Results

We enrolled 43 COPD patients (mean age 69 years, FEV₁ 43%). R5–R20 significantly changed from baseline [0.23 ± 0.09 kPa/(l/s)] to V2 [0.16 ± 0.09 kPa/(l/s)] and V3 [0.16 ± 0.08 kPa/(l/s)] (p < 0.05). Clinical status was also significantly improved compared to baseline; in fact, CAT score changed from an average baseline value of 13–6 and 4 (V2 and V3, respectively) (p < 0.05). A correlation was found between CAT percentage change values and the corresponding ones of R5–R20 (r = − 0.329, p = 0.045) and RV/TLC (r = 0.354, p = 0.029).

Conclusions

In COPD patients, treatment with BDP/FF extra-fine formulation improved functional parameters related to small airway disease as well as the disease impact on health status.

Trial Registration

ClinicalTrials.gov identifier, NCT04421742.

Low perceived service quality in community pharmacy is associated with poor medication adherence

OBJECTIVE

Community pharmacists are highly accessible healthcare professionals, whose regular contact with patients provides ongoing opportunities to improve medication safety and promote medication adherence. This study investigates whether patients who experience low service quality in community pharmacies are less adherent to their regular medications.

METHODS

Eight Australian pharmacies were recruited, 5 self-identified as having a price promotion business strategy and 3 with a service-focused business strategy. Patients taking regular prescribed medicines who had previously attended the pharmacy completed e-surveys in-store with measures of perceived service quality (pSQ) and self-reported adherence. Multivariate regression using multilevel modelling with bootstrapping was used to explore the relationships between variables.

RESULTS

Surveys were completed by 319 respondents. Attending pharmacies with a price promotion business strategy was predictive of lower pSQ and poor medication adherence. The between-pharmacy slope of the relationship between pSQ and adherence was 2.25 (with 95 % confidence intervals = 1.50, 2.86) and was highest in pharmacies with lowest pSQ.

CONCLUSION

This study highlights that when patients experience low service quality, in community pharmacies they are more likely to report poor adherence to their regular prescribed medicines.

PRACTICE IMPLICATIONS

Community pharmacies need to be designed and managed to allow pharmacists to provide high levels of patient-centred care.

Chinese Medicine for Chronic Obstructive Pulmonary Disease: A Pilot Study on Patient Preferences

PURPOSE

The patient's preference plays an important role in clinical practice. There currently is no available evidence regarding the perception and attitudes of patients with chronic obstructive pulmonary disease (COPD) towards the use of Chinese medicine (CM) approaches. This study was designed to explore preferences and factors associated with CM among COPD patients.

PATIENTS AND METHODS

A pilot survey was conducted among COPD patients using a structured, pre-tested questionnaire. The perceptions of CM therapies (including herbal medicine, non-pharmacotherapies), and expected clinical outcomes were investigated based on patient preference. Factors associated with preference of treatment scenarios were estimated in order of importance.

RESULTS

Thirty patients were enrolled in the survey, including 27 males and 3 females. Two-thirds of the patients preferred integrative Chinese and Western medicine for the treatment of COPD. Chinese patent medicines and CM decoction therapy were more popular than CM injections. The preferred non-drug therapy was point application, followed by acupuncture, Tai chi, or Qigong. More than 70% of patients reported that important clinical outcomes were improvements in lung function (77%) and dyspnea, cough, and sputum symptoms (73%), followed by exercise endurance (50%). Besides clinical efficacy, costs and side effects were also important factors for treatment selection.

CONCLUSION

This pilot study showed that Chinese patent medicine and CM decoctions were preferred options for complementary medicines to combine with routine pharmacotherapy for COPD treatment according to the patients' preferences. The improvement of dyspnea, cough symptoms, and lung function was the most desired clinical outcomes for patients. Quicker symptom relief, lower costs, and fewer side effects were key attributes for the treatment selection. Further research with a larger sample size is needed to definitively address the comprehensive conclusion.

Treatment Preferences of Patients with Chronic Obstructive Pulmonary Disease: Results from Qualitative Interviews and Focus Groups in the United Kingdom, United States, and Germany

BACKGROUND

A wide range of therapeutic regimens, including single-inhaler triple therapies (SITTs), are now available for the maintenance treatment of chronic obstructive pulmonary disease (COPD). Thus, an improved understanding of patient preferences may be valuable to inform physician prescribing decisions. This study was performed to assess the factors considered by patients when making decisions about their COPD treatments using qualitative techniques.

METHODS

In the United Kingdom, United States and Germany, individual qualitative interviews (n=10 per country) and focus groups (1 per country; [United Kingdom, n=4; United States, n=6; Germany, n=6 participants]) were conducted. Interviews and focus groups were semi‑structured, lasting approximately 60 minutes, and focused on treatment preferences. Data were analyzed according to emerging themes identified from the interviews; qualitative thematic analysis of the data was performed using specialist software.

RESULTS

In interviews and focus groups, efficacy, ease of use, and lower frequency of use were favored attributes for current treatment, while side effects, medication taste, and more complex administration techniques were key dislikes. In interviews, most participants would consider a switch in medication, mainly for improved efficacy, but also to reduce medication frequency or following physician advice. Overall, efficacy and ease of use were the 2 most important attributes reported in interviews in all 3 countries.

CONCLUSION

Patients with COPD have preferences for certain attributes of medication, highlighting the multi-faceted nature of treatment effectiveness and the importance of the delivery device.These results were subsequently used to inform the design of a discrete choice experiment.

Two-Year Outcomes for the Double-Blind, Randomized, Sham-Controlled Study of Targeted Lung Denervation in Patients with Moderate to Severe COPD: AIRFLOW-2

Purpose

COPD exacerbations are associated with worsening clinical outcomes and increased healthcare costs, despite use of optimal medical therapy. A novel bronchoscopic therapy, targeted lung denervation (TLD), which disrupts parasympathetic pulmonary innervation of the lung, has been developed to reduce clinical consequences of cholinergic hyperactivity and its impact on COPD exacerbations. The AIRFLOW-2 study assessed the durability of safety and efficacy of TLD additive to optimal drug therapy compared to sham bronchoscopy and optimal drug therapy alone in subjects with moderate-to-severe, symptomatic COPD two years post randomization.

Patients and Methods

TLD was performed in COPD patients (FEV1 30-60% predicted, CAT≥10 or mMRC≥2) in a 1:1 randomized, sham-controlled, double-blinded multicenter study (AIRFLOW-2) using a novel lung denervation system (Nuvaira, Inc., USA). Subjects remained blinded until their 12.5-month follow-up visit when control subjects were offered the opportunity to undergo TLD. A time-to-first-event analysis on moderate and severe and severe exacerbations of COPD was performed.

Results

Eighty-two subjects (FEV1 41.6±7.4% predicted, 50.0% male, age 63.7±6.8 yrs, 24% with prior year respiratory hospitalization) were randomized. Time-to-first severe COPD exacerbation was significantly lengthened in the TLD arm (p=0.04, HR=0.38) at 2 years post-TLD therapy and trended towards similar attenuation for moderate and severe COPD exacerbations (p=0.18, HR=0.71). No significant changes in lung function or SGRQ-C were found 2 years post randomization between groups.

Conclusion

In a randomized trial, TLD demonstrated a durable effect of significantly lower risk of severe AECOPD over 2 years. Further, lung function and quality of life remained stable following TLD.

Clinical Trial Registration

NCT02058459.

Training improves the handling of inhaler devices and reduces the severity of symptoms in geriatric patients suffering from chronic-obstructive pulmonary disease

PURPOSE

Elderly patients with impaired vision, cognitive decline or motor/sensory disturbances of their fingers suffering from chronic-obstructive pulmonary disease (COPD) encounter difficulties in handling inhaler devices used as the cornerstones of treatment of pulmonary obstruction. Many elderly patients make severe mistakes which impede adequate drug delivery to the bronchioles. This multimodal training program was designed to reduce the number of handling mistakes of inhaler devices.

METHODS

From October 1, 2016 to September 30, 2017, a prospective intervention study was conducted in 38 in-patients > 65 years (median age 79 years) with previously diagnosed COPD. The effect of an 8-day intervention comprising daily counselling and video demonstration according to the recommendations of the German Airway League on the frequency of mistakes during handling of inhaler devices, the forced expiratory volume in 1 s (FEV1), the forced vital capacity (FVC) and the perception of symptoms (COPD Assessment Test, CAT) were studied. Measurements on days 1 and 8 were compared by Wilcoxon signed rank test.

RESULTS

The number of handling mistakes per patient decreased as a consequence of the intervention from 3.0 (0-7) to 0.5 (0-6) [median (minimum-maximum; p < 0.0001)]. The CAT Score decreased from 19.5 (14/24) to 14.5 (10.75/21) [median (25./75. percentile; p < 0.0001) indicating a substantial reduction of clinical symptoms. Conversely, FEV1 and FVC only slightly increased (difference statistically not significant). At study entry, the number of handling mistakes was inversely correlated with the Mini Mental Status Test (MMST) score (p = 0.01). The reduction of the number of handling mistakes during the intervention was not correlated with the MMST.

CONCLUSION

In COPD, intensive training for 8 days improved the handling of inhalers and reduced clinical symptoms in geriatric patients. Patients with cognitive abnormalities also benefitted from this intervention.

TRIAL REGISTRATION

German Clinical Trials Registry DRKS00023196 , date of registration September 29, 2020 (retrospectively registered).

Determinants of medication adherence among chronic patients from an urban area: a cross-sectional study

BACKGROUND

Medication adherence is a complex area of behaviour. Little is known about what influences chronic patients to take their medicines. This study has aimed to compare and contrast the health-related beliefs, experiences and types of behaviour typical among patients who have at least one chronic condition and are following a pharmacological treatment in accordance with their level of medication adherence.

METHODS

A questionnaire-based cross-sectional study, consisting of socio-demographic data, the 4-item Morisky-Green scale and 37 statements about health beliefs, perceptions and experiences, was conducted at different levels of healthcare (primary and tertiary settings).

RESULTS

A total of 577 questionnaires were analyzed. Respondents had a mean age of 64 and took an average of 4.6 drugs. Optimal adherence was reported by 58.6% of respondents. Bivariate analysis showed adherent subjects were older, took more medications, were in better spirits and had greater confidence and information regarding their treatment. Multivariate analysis found older age and the statements 'My doctor periodically reviews my treatment' and 'I am motivated to continue with the treatment' to be significantly related to medication adherence, while 'I make variations when taking medication depending on how I feel' was significant for medication non-adherence.

CONCLUSION

Medication non-adherence is common among chronic patients. Patient-centred approaches should be implemented in daily clinical practice as patient health beliefs, experiences and conduct influence medication-taking. Motivational interviewing might improve medication adherence in permitting emotional state managing and increasing educational skills, patient motivation and confidence between patients and healthcare providers.

Prevalence and factors associated with adherence to anti-hypertensives among adults with hypertension in a developed Asian community: A cross-sectional study

Introduction:

Poor adherence to anti-hypertensive medications (AHM) results in hypertension treatment failure. Understanding and addressing the factors associated with adherence to AHM may potentially improve health outcomes. This study aimed to assess the prevalence and factors associated with patients’ adherence to AHM in a developed Asian community.

Methods:

An assistant-administered questionnaire survey was conducted on multi-ethnic Asian adults aged 31–80 years with essential hypertension based on their electronic health records (EHR) at a public primary-care clinic. Data on their demographic characteristics, clinical measurements of blood pressure and body mass index, co-morbidities and prescriptions from the EHR, along with the Medication Adherence Report Scale-5 scores were collated, audited and analysed. A MARS-5 score of <25 indicated poor adherence. Logistic regression was used to identify factors associated with adherence to AHM.

Results:

Data of 395 patients were analysed. Of these, 179 (45.3%) had poor adherence to at least one AHM. Bivariate analysis showed that poor adherence was significantly associated with lower mean age (59 years old vs. 63 years old), higher mean clinic diastolic blood pressure (76 mmHg vs. 73 mmHg) and higher mean weight (70.4 kg vs. 67.4 kg). Logistic regression showed that patients with no co-morbidities (such as diabetes mellitus, dyslipidaemia, stroke and ischaemic heart disease) had better medication adherence (MA; odds ratio=1.98; 95% confidence interval 1.14–3.45; p=0.02). There was no significant MA difference between the classes, dose frequency and number of AHM.

Conclusion:

Almost half of the patients had poor adherence to at least one AHM. Co-morbidity significantly influenced their MA. Attention should be directed to patients with co-morbidities to assess their AHM adherence.

Adherence to COPD free triple inhaled therapy in the real world: a primary care based study

INTRODUCTION

The development of new pharmacological treatments for chronic obstructive pulmonary disease (COPD) has improved health-related quality of life of patients. However, suboptimal adherence may limit its potential.

OBJECTIVE

The aim of the present study was to assess the adherence to free triple inhaled therapy and to investigate poor adherence determinants among primary care patients.

METHODS

Data were derived from a primary care database in Italy. Patients aged 40+ affected by COPD and prescribed with inhaled corticosteroids, long-acting beta agonists and long-acting muscarinic antagonists (N = 3177) were enrolled. Low adherence was defined as a proportion of days covered (PDC) by medications prescription lower than 80%. Predictors of low adherence were tested using logistic regression models.

RESULTS AND CONCLUSIONS

The 85% of enrolled patients showed poor adherence to free triple inhaled therapy. Comorbidities, such as heart failure (OR 1.78, 95%CI 1.19-2.75), depression (OR 1.41, 95%CI 1.06-1.88) and peripheral vascular disease (OR 1.32, 95%CI 1.01-1.74) were associated with poor adherence. Former (OR 0.52, 95%CI 0.34-0.78) or current smokers (OR 0.61, 95%CI 0.41-0.93) and patients with more severe airways obstruction or history of severe exacerbations (OR 0.64, 95%CI 0.52-0.79) were less likely to exhibit poor adherence. Real-world adherence to triple inhaled therapy with different inhalers is generally low. Higher GOLD airways obstruction stage and current or former smoking status are associated with increased adherence to treatment. Reduced perceived benefit on symptoms control is probably linked to poorer adherence to free triple therapy.

Day and Night Control of COPD and Role of Pharmacotherapy: A Review

The topic of 24-hour management of COPD is related to day-to-night symptoms management, specific follow-up and patients’ adherence to therapy. COPD symptoms strongly vary during day and night, being worse in the night and early morning. This variability is not always adequately considered in the trials. Night-time symptoms are predictive of higher mortality and more frequent exacerbations; therefore, they should be a target of therapy. During night-time, in COPD patients the supine position is responsible for a different thoracic physiology; moreover, during some sleep phases the vagal stimulation determines increased bronchial secretions, increased blood flow in the bronchial circulation (enhancing inflammation) and increased airway resistance (broncho-motor tone). Moreover, in COPD patients the circadian rhythm may be impaired. The role of pharmacotherapy in this regard is still poorly investigated. Symptoms can be grossly differentiated according to the different phenotypes of the disease: wheezing recalls asthma, while dyspnea is strongly related to emphysema (dynamic hyperinflation) or obstructive bronchiolitis (secretions). Those symptoms may be different targets of therapy. In this regard, GOLD recommendations for the first time introduced the concept of phenotype distinction suggesting the use of inhaled corticosteroids (ICS) particularly when an asthmatic pattern or eosiophilic inflammations are present, and hypothesized different approaches to target symptoms (ie, dyspnea) or exacerbations. Pharmacotherapy should be evaluated and possibly directed on the basis of circadian variations, for instance, supporting the use of twice-daily rapid-action bronchodilators and evening dose of ICS. Recommendations on day and night symptoms monitoring strategies and choice of the specific drug according to patient’s profile are still not systematically investigated or established. This review is the summary of an advisory board on the topic “24-hour control of COPD and role of pharmacotherapy”, held by five pulmonologists, experts in respiratory pathophysiology, pharmacology and sleep medicine.

Point your SmartPhone at the code above. If you have a QR code reader the video abstract will appear. Or use:

https://youtu.be/RlA6NHUbnFY

Bedside medication delivery programs: suggestions for systematic evaluation and reporting

PURPOSE

Several factors lead to medication non-adherence after hospital discharge. Hospitals and pharmacies have implemented bedside medication delivery (BMD) programs for patients, in an attempt to reduce barriers and improve medication adherence. Here, we provide a critical review of the literature on these programs.

DATA SOURCES

We conducted a literature search on BMD programs in PubMed, Google Scholar, Scopus and a general Google search using these keywords: 'medication delivery bedside', 'discharge medication delivery', 'meds to bedside' and 'meds to beds'.

STUDY SELECTION

We identified 10 reports and include data from all reports.

DATA EXTRACTION

Data on study characteristics and settings were extracted along with four outcomes: medication error, patient satisfaction, 30-day hospital readmission and visits to the emergency department.

RESULTS OF DATA SYNTHESIS

Of the 10 reports, only 4 were peer-reviewed publications; others were reported in the lay press. Outcomes were reported in both qualitative and quantitative terms. Less than half of reports provided quantitative data on 30-day readmission and patient satisfaction. Others suggested qualitative improvement in these outcomes but did not provide data or specific details. None reported outcomes of their programs beyond 30 days.

CONCLUSION

We highlight the need for increased use of optimal program design and more rigorous evaluations of the impact of BMD programs. We also provide guidelines on the types of evaluations that are likely needed and encourage improved reporting.

Determinants of self-reported adherence to inhaler therapy in patients with chronic obstructive pulmonary disease

Background

Adherence to therapy is crucial for COPD patients, since non-adherence leads to worse quality of life, increased health-care expenditure and poor clinical outcome. The aim of this study was to identify the main determinants of suboptimal adherence to therapy in a cohort of COPD patients.

Methods

General information (age, BMI, smoking, comorbidities, education, life style), lung function, exacerbations, symptoms and COPD treatment were collected. Adherence to therapy was assessed by self-reported 4-item Morisky Medication Adherence Scale (MMAS-4), and was related to anthropometric, socio/economic and health status data, obtained by questionnaires (COPD Assessment Test, CAT; Treatment Satisfaction Questionnaire, HRQoL; Katz Index of Independence of Daily Living Activities, Lawton Instrumental Activities of Daily Living Scale).

Results

136 COPD patients were studied (age 72±8 yrs; 73.5% men; BMI 28.5±7.4 kg/m²; FEV¹ 53.5±19.0 % predicted). Nearly half of the patients (46.3%) had suboptimal adherence to therapy (score >0) and, as compared to those with optimal adherence, had higher prevalence of women and coronary artery disease, heavier smoking history and worse CCQ overall score. The results of multivariate analysis showed that the determinants of suboptimal adherence were female sex (OR 4.339, 95%CI 1.509-12.474, p=0.006), amount of pack/years smoked (OR 1.947, 95%CI 1.141-3.323, p=0.015), higher CCQ overall score (OR 3.318, 95%CI 1.050-9.892, p=0.049) and higher education (OR 2.758, 95%CI 1.083-7.022, p=0.033). Adherence was better in patients assuming triple inhaler therapy.

Conclusions

Suboptimal adherence is frequent among COPD patients, particularly in women, heavy smokers and subjects with high educational level. Interventions to improve adherence should be especially addressed to patients with these characteristics.

Relationship between symptom burden, medication adherence and spiritual well-being in patients with chronic obstructive pulmonary disease

AIMS AND OBJECTIVES

To investigate the relationship between symptom burden, medication adherence and spiritual well-being in patients with chronic obstructive pulmonary disease (COPD).

BACKGROUND

The relationship between spirituality and medication adherence has been investigated in different chronic conditions. However, the relationship between symptom burden, medication adherence and spiritual well-being in patients with COPD has not been explored.

DESIGN

A descriptive correlational study design was adopted.

METHODS

A total of 112 patients with COPD were included in the study. Data were collected using the COPD Assessment Test (CAT), the Adherence to Refills and Medications Scale-7 (ARMS-7) and the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being Scale (FACIT-Sp). The data were analysed using descriptive and correlational statistics. The Strengthening the Reporting of Observational studies in Epidemiology (STROBE) Checklist was used.

RESULTS

The CAT score was significantly higher in patients on long-term oxygen therapy and those who had more than three comorbid conditions (p < .05). The mean score of ARMS-7 was significantly associated with age (p < .05). Current smokers had higher ARMS-7 and lower FACIT-Sp scores (p < .001). The FACIT-Sp score was negatively and moderately associated with the CAT and ARMS-7 scores (p < .001).

CONCLUSION

This study concluded that individuals with higher spiritual well-being had lower symptom burden and higher medication adherence. The need for long-term oxygen therapy and a high number of comorbid conditions were associated with increased symptom burden. Current smokers had lower spiritual well-being and medication adherence.

RELEVANCE TO CLINICAL PRACTICE

Spiritual well-being should be evaluated when assessing symptom burden and medication adherence in clinical practice. In addition, further studies examining the causal relationship between symptom burden, spiritual well-being and medication adherence in different populations are warranted.

The use of discrete choice experiments in adherence research: A new solution to an old problem

Theory can play an important role in providing the framework, and underpinning the design and implementation of interventions to improve medication adherence. Interventions that are grounded in a theory are relatively more effective in improving medication adherence than interventions which do not have a theoretical support. However, a large body of adherence research does not appear to be linked to any theory or model, which therefore may have resulted in interventions that are either ineffective or not sustainable. Interventions that are based on theory have mainly employed socio-behavioural models to explain, and design interventions to address, the complex phenomenon of adherence. Yet, the effectiveness of these interventions is inconclusive, supporting the argument that socio-behavioural models alone have limited applicability in explaining behaviour associated with medication-taking. An important reason for this limitation may be the complex and dynamic nature of adherence. There is a need to include a wide variety of factors in a model and examine adherence in the context of its three phases (initiation, implementation, and discontinuation). One possible way forward is to also examine medication-taking behaviour from an economic perspective, for example, by using a discrete choice experiment (DCE), which provides a different approach to understanding human behaviour about medication-taking and the complexities of decision-making in adhering to medication. DCEs can help in understanding how patients decide to initiate, continue or discontinue taking medication, factors that influence their decision, and the relative importance of those factors, which can assist researchers to prioritise interventions to improve medication adherence. Integration of multiple theories is needed to examine adherence from multiple perspectives and design interventions that are effective and sustainable. This commentary focusses on the pros and cons of some of the commonly used socio-behavioural models in adherence research and suggests a way forward by incorporating DCEs in adherence research.

Validity of the Medication Adherence Rating Scale for Adherence to Inhaled Corticosteroids among Older Adults with Asthma or Chronic Obstructive Pulmonary Disease

Regular use of inhaled corticosteroids (ICS) is the standard of care for patients with persistent asthma and chronic obstructive pulmonary disease (COPD). Adherence to ICS is measured using the 10-item Medication Adherence Report Scale (MARS), a self-reported medication adherence assessment. However, data on the validity of this measure are limited. Data were obtained from two cohort studies that examined the association of health literacy with self-management behaviors among adults ages 65 and older with asthma and adults ages 40 and older with COPD. ICS adherence was objectively measured over a 4-week period using electronic monitoring devices. Adequate adherence by MARS assessment was defined as a score ≥4.5, and by electronic monitoring as ≥80% of doses prescribed. We assessed the criterion validity using correlations between self-reported adherence and electronic adherence. Receiver Operating Characteristic (ROC) curve analysis was performed between the two measures. Among patients with asthma, the continuous values for adherence measured by self-report and electronically were weakly correlated (r = 0.33, p < 0.001); similarly, the agreement between the dichotomized measures was weak (kappa 0.30, p=.49). Findings were similar for COPD patients: r = 0.26, p = 0.003; kappa 0.19, p = .60. Area under curve (AUC) values generated from ROC analysis was 0.69 and 0.61, for asthma and COPD patients, respectively. Commonly used measure for adherence performed weakly compared to electronic monitoring in separate populations of patients with asthma and COPD. Investigators measuring self-reported medication adherence among patients with these pulmonary diseases should consider using alternative instruments or using objective measures exclusively.

Adherence to Therapy in Chronic Obstructive Pulmonary Disease: A Systematic Review

Adherence to therapy plays a key role in treatment optimization and clinical outcome in patients with chronic obstructive pulmonary disease (COPD). The adherence to inhaled medications is poor, ranging from 20% to 60%. In this study we searched Medline and PubMed literature regarding factors that could have an impact on therapy adherence in COPD patients, using the key words "COPD" or "chronic obstructive pulmonary disease" and "adherence". The search was limited to the English language article published between January 2013 and December 2019. Review papers, study protocols, and meta-analyses were excluded. The final material included 25 articles. The evaluation was performed using the Cochrane Review Manager guidelines. The 25 articles represented 29 countries from 5 continents. We assessed adherence to therapy and the impact of selected factors on the adherence in 27,660 COPD patients (60.9% of whom were male, mean age 64 years). The factors affecting adherence were broken down into three categories: sociodemographic, clinical, and psychological. There were two standardized instruments used in the analyzed studies: Test of Adherence to Inhalers (TAI) and self-reported Morisky Medication Adherence Scale (MMAS-8). We found that 46.3% of patients had a moderately good level of adherence to inhaled therapy (TAI range around 50 points), while 41.6% of patients had a high level of adherence to oral therapy. The nature of non-adherence was in most cases inadvertent rather than an erratic or deliberate demeanor (48.5% vs. 38.9% vs. 42.4%, respectively). We conclude that standardized instruments enable the prediction of adherence to therapy and should be used in clinical practice. The assessment of adherence is essential for undertaking interventions to counteract plausible non-adherence. Collaboration between an educator and a psychologist is required to evaluate the patient's motivation and to ensure his comprehension of treatment prescribed.

Lay Health Coaching to Increase Appropriate Inhaler Use in COPD: A Randomized Controlled Trial

PURPOSE

Poor adherence to medications is more prevalent for chronic obstructive pulmonary disease (COPD) than for other chronic conditions and is associated with unfavorable health outcomes. Few interventions have successfully improved adherence for COPD medications; none of these use unlicensed health care personnel. We explored the efficacy of lay health coaches to improve inhaler adherence and technique.

METHODS

Within a randomized controlled trial, we recruited English- and Spanish-speaking patients with moderate to severe COPD from urban, public primary care clinics serving a low-income, predominantly African American population. Participants were randomized to receive 9 months of health coaching or usual care. Outcome measures included self-reported adherence to inhaled controller medications in the past 7 days and observed technique for all inhalers. We used generalized linear models, controlling for baseline values and clustering by site.

RESULTS

Baseline adherence and inhaler technique were uniformly poor and did not differ by study arm. At 9 months, health-coached patients reported a greater number of days of adherence compared with usual care patients (6.4 vs 5.5 days; adjusted P = .02) and were more likely to have used their controller inhalers as prescribed for 5 of the last 7 days (90% vs 69%; adjusted P = .008). They were more than 3 times as likely to demonstrate perfect technique for all inhaler devices (24% vs 7%; adjusted P = .01) and mastery of essential steps (40% vs 11%; adjusted P <.001).

CONCLUSIONS

Health coaching may provide a scalable model that can improve care for people living with COPD.

Device use errors with soft mist inhalers: A global systematic literature review and meta-analysis

Inhaled bronchodilators are the cornerstone of treatment for chronic obstructive pulmonary disease (COPD). Soft mist inhalers (SMIs) are devices that deliver bronchodilators. Although correct device use is paramount to successful medication delivery, patient errors are common. This global systematic literature review and meta-analysis examined device use errors with SMIs among patients with obstructive lung diseases. PubMed, EMBASE, PsycINFO, Cochrane, and Google Scholar were searched to identify studies published between 2010 and 2019 that met the following inclusion criteria: (a) English language; (b) a diagnosis of COPD, bronchitis, or emphysema; and (c) reported device use errors among adults receiving long-acting bronchodilator treatment with Respimat® SMI (i.e. Spiriva®, Stiolto®, Spiolto®, and Striverdi®). Descriptive statistics examined sociodemographics, clinical characteristics, and device use errors. Meta-analysis techniques were employed with random-effects models to generate pooled mean effect sizes and 95% confidence intervals (CIs) for overall and step-by-step errors. The I2 statistic measured heterogeneity. Twelve studies (n = 1288 patients) were included in this meta-analysis. Eighty-eight percent of patients had COPD, and most had moderate/very severe airflow limitation (Global Initiative for Chronic Obstructive Lung Disease spirometric stages II to IV). Aggregate results revealed that 58.9% (95% CI: 42.4-75.5; I2 = 92.8%) of patients made ≥1 device use errors. Among 11 studies with step-by-step data, the most common errors were failure to (1) exhale completely and away from the device (47.8% (95% CI: 33.6-62.0)); (2) hold breath for up to 10 seconds (30.6% (95% CI: 17.5-43.7)); (3) take a slow, deep breath while pressing the dose release button (27.9% (95% CI: 14.5-41.2)); (4) hold the inhaler upright (22.6% (95% CI: 6.2-39.0)); and (5) turn the base toward the arrows until it clicked (17.6% (95% CI: 3.0-32.2)). Device use errors occurred in about 6 of 10 patients who used SMIs. An individualized approach to inhalation device selection and ongoing training and monitoring of device use are important in optimizing bronchodilator treatment.

Living environment, social support, and informal caregiving are associated with healthcare seeking behaviour and adherence to medication treatment: A cross-sectional population study

Despite the well-known associations between local environment and health, few studies have focused on environment and healthcare utilisation, for instance healthcare seeking behaviour or adherence. This study was aimed at analysing housing type, behaviour based on perceived local outdoor safety, social support, informal caregiving, demographics, socioeconomics, and long-term illness, and associations with health-seeking and adherence behaviours at a population level. This study used data from the Swedish National Public Health Survey 2004-2014, an annually repeated, large sample, cross-sectional, population-based survey study. In all, questionnaires from 100,433 individuals were returned by post, making the response rate 52.9% (100,433/190,000). Descriptive statistics and multiple logistic regressions were used to investigate associations between explanatory variables and the outcomes of refraining from seeking care and non-adherence behaviour. Living in rented apartment, lodger, a dorm or other was associated with reporting refraining from seeking care (adjusted OR 1.16, 95% CI 1.00-1.22), and non-adherence (adjusted OR 1.22; 95% CI 1.13-1.31). Refraining from going out due to a perceived unsafe neighbourhood was associated with refraining from seeking care (adjusted OR 1.59, 95% CI 1.51-1.67) and non-adherence (adjusted OR 1.26, 95% CI 1.17-1.36). Social support and status as an informal caregiver was associated with higher odds of refraining from seeking medical care and non-adherence. This study suggests that living in rental housing, refraining from going out due to neighbourhood safety concerns, lack of social support or informal caregiver status are associated with lower health-seeking behaviour and non-adherence to prescribed medication.

Status of and strategies for improving adherence to COPD treatment

Despite the wide application of adherence as a concept, the definition, evaluation and improvement of the adherence to treatment by patients with chronic obstructive pulmonary disease (COPD) still present some challenges. First, it is necessary to clearly define the concepts of treatment adherence, compliance and persistence. Second, it is critical to consider the various methods of evaluating and quantifying adherence when interpreting adherence studies. In addition, the advantages and disadvantages of the different ways of measuring treatment adherence should be taken into account. Another subject of some debate is the number of variables associated with COPD treatment adherence. Adherence is a complex concept that goes beyond the dosage or the use of inhalation devices, and a number of variables are involved in determining adherence, from the clinical aspects of the disease to the patient's confidence in the doctor's expertise and the level of social support experienced by the patient. Notably, despite these challenges, the importance of adherence has been well established by clinical trials and routine clinical practice. The available evidence consistently shows the substantial impact that a lack of adherence has on the control of the disease and its long-term prognosis. For these reasons, the correct evaluation of therapeutic adherence should be a key objective in clinical interviews of patients. In recent years, various initiatives for improving adherence have been explored. All these initiatives have been based on patient education. Therefore, health care professionals should be aware of the issues pertaining to adherence and take the opportunity to educate patients each time they contact the health care system.

Device-handling study of a novel breath-actuated inhaler, Synchrobreathe®, versus a pMDI

INTRODUCTION

Synchrobreathe®, a new-generation, novel breath-actuated inhaler (BAI) can address the key issues arising during the use of both pressurised metered dose inhalers ([pMDIs]; hand-breath coordination) and dry powder inhalers ([DPIs]; high inspiratory flow required) with respect to optimal drug deposition.

MATERIALS AND METHODS

This was an open-label, prospective, 2-week, multicentre study that assessed device handling, ease of use, errors and participant perception regarding the use of Synchrobreathe® versus a pMDI in patients with chronic obstructive pulmonary disease (COPD) (n = 162) or asthma (n = 239) and inhaler-naïve healthy volunteers (n = 59). Ability to use the device without errors at the first attempt, total number of errors before and after training, time taken to use the device correctly and total number of training sessions, and number of attempts to perform the correct technique on Day 1 and Day 14 were evaluated. Device handling and preference questionnaires were also administered on Day 14.

RESULTS

Of 460 participants, 421 completed the study. The number of participants using Synchrobreathe without any error after reading the patient information leaflet (PIL) was significantly low (p < 0.05) on Day 1. On Day 14, significantly more number of participants used Synchrobreathe without any error (p < 0.001). The total number of errors before and after training with Synchrobreathe was significantly less (p < 0.001). The average time required to perform the inhalation technique correctly (p < 0.01) and the total number of attempts (P < 0.001) with Synchrobreathe were significantly lower. The average number of attempts to inhale correctly was significantly (p < 0.001) less with Synchrobreathe on Day1 and Day 14. Most participants rated Synchrobreathe as their choice of inhaler.

CONCLUSION

Synchrobreathe is an easy-to-use and easy-to-handle device with significantly less number of errors, which may have positive implications for disease control in asthma and COPD.

Translation and initial validation of the Medication Adherence Report Scale (MARS) in Italian patients with Crohn's Disease

The MARS-5 (Medication Adherence Report Scale) was developed in English. The aim of this project was to analyse the MARS-5I (© Prof Rob Horne) psychometric properties and to identify whether its Italian translation is suitable for assessing medication adherence in Crohn Disease (CD) Italian patients. The MARS was translated and linguistically validated in Italian. The MARS-5I was used for evaluating medication adherence in the SOLE study, conducted in Italy on 552 subjects with CD. In order to un-bias the questionnaire results from the effects of treatment change and/or effectiveness, the analyses were performed on the 277 patients whose disease activity remained stable, selected among the 371 patients who maintained the same treatment between two consecutive visits. Internal consistency was high (Cronbach's alpha of 0.86). Pearson's correlation coefficient was 0.50 (p<0.001) and 0.86 (p<0.001- outliers removed), indicating satisfactory test-retest. MARS 5I scores were not correlated with Treatment Satisfaction Questionnaire for Medication but a small and statistically significant correlation was shown with physician-evaluated medication adherence, indicating convergent validity. MARS-5I, the Italian translation of the English MARS, showed satisfactory internal consistency and test-retest, and a low but statistically significant convergent validity. We confirmed the utility of this tool in patients with CD.