COPD: understanding patients' adherence to inhaled medications

Developing and Validating a Nomogram for Non-Adherence to Inhaler Therapy Among Elderly Chronic Obstructive Pulmonary Disease Patients Based on the Social Ecological Model

Purpose

This study aimed to identify the risk predictors of non-adherence to inhaler therapy and construct a nomogram prediction model for use in Chinese elderly patients with chronic obstructive pulmonary disease (COPD).

Patients and Methods

A cross-sectional study was conducted with 305 participants recruited from a tertiary care hospital in Anhui, China. Adherence was analyzed using the Test of Adherence to Inhalers. Potential predictive factors were incorporated based on the social ecological model, and data were collected through a questionnaire method. R version 4.3.3 was utilized to perform the least absolute shrinkage and selection operator regression model and multivariable logistic regression analysis to identify risk factors and establish a nomogram prediction model.

Results

The results of the multivariable analysis revealed that medication beliefs, illness perception, the COPD Assessment Test score, smoking status, and education level were significant risk factors for non-adherence to inhaler therapy in elderly COPD patients (all P < 0.05). The nomogram prediction model for non-adherence to inhaler therapy in elderly COPD patients demonstrated a good discriminative ability, with an area under the receiver operating characteristic curve of 0.912. The C-index was 0.922 (95% CI: 0.879 to 0.965), and the Brier value was 0.070, indicating good consistency and calibration. Decision curve analysis indicated that the use of the nomogram would be more beneficial in clinical practice when the threshold probability of non-adherence exceeds 17%.

Conclusion

This study identified predictive factors regarding non-adherence among elderly patients with COPD and constructed a predictive nomogram. By utilizing the nomogram model healthcare professionals could swiftly calculate and comprehend the non-compliance level of COPD patients, thus guiding the development of personalized interventions in clinical practice.

Contributing to self-care of a person with chronic obstructive pulmonary disease: A qualitative study of the experiences of family caregivers

AIM

To explore family caregivers' experiences of contributing to self-care of patients with chronic obstructive pulmonary disease (COPD).

DESIGN

A qualitative description study.

METHODS

Individual semi-structured interviews were conducted face-to face, by telephone or video calls in a purposive sample of 17 family caregivers of patients with COPD recruited in Italy, and analysed through content analysis. The consolidated criteria for reporting qualitative studies (COREQ) checklist was used for study reporting.

RESULTS

Ten subcategories were derived from 106 codes grouped into three main categories: family caregiver contributions to maintaining disease stable and ensuring a normal life for patients; family caregiver contributions to disease monitoring; and family caregiver contributions to coping with disease exacerbations. Family caregivers provided practical and emotional support, and their contribution was essential to improve treatment adherence, to enable the patient to continue living a normal life, and to have access to the healthcare services. Family caregivers were constantly vigilant and monitored patients daily to detect worsening conditions, and they managed exacerbations especially when patients were unable to do it due to their critical conditions.

CONCLUSION

This study broadens knowledge of family caregivers' contributions to patients' self-care in COPD, describing the different ways family members provide daily care to patients and the many responsibilities they take on.

IMPACT

Family caregivers perform a variety of behaviours when supporting patients with COPD in self-care, especially when patients are more dependent and the disease more severe. Nurses should acknowledge the various contributions provided by family caregivers and develop educational interventions aiming to support them in patient care and improve patient outcomes.

PATIENT OR PUBLIC CONTRIBUTION

Researchers shared the draft study report with participants for validation and feedback. This helped to strengthen the study design and results.

Validation of an Inhaled Therapy Beliefs Questionnaire in Patients with Chronic Obstructive Pulmonary Disease

Background: To carry out a validation questionnaire that assesses beliefs about inhaled treatments in patients with chronic obstructive pulmonary disease (COPD), as knowing patients' beliefs could help to improve medication adherence and health outcomes. Methods: We evaluated data from 260 COPD patients from electronic medical record databases from five primary healthcare centers, in a descriptive, cross-sectional study with a sample size calculated for a 10-item questionnaire, with an estimated Cronbach's alpha of 0.70 and a 95% confidence level. Study participants were selected via systematic random sampling. Variables: Ten-item Inhaled Therapy Beliefs Questionnaire, CCTI-Questionnaire v.2.0, time for completion, age, sex, educational level, spirometry severity (GOLD criteria), exacerbations (previous year), characteristics of inhaled treatment, and smoking habit. A two-year follow-up in a subsample of 77 patients from one health center was utilized. The Morisky-Green test, pharmacy dispensing data, test-retest (kappa coefficient), and an exploratory analysis of the adherence-belief relationship (ji-squared) were measured. Results: The 10-item questionnaire showed good viability (3 min completion time) when performed face-to-face or telephonically; its psychometric properties were acceptable, with an internal consistency (Cronbach's alpha) score of 0.613. Three factors explained 47.58% of the total variance (p < 0.0001): use (factor 1), effects (factor 2), and objectives (factor 3) of inhalers. The two-year follow-up ultimately considered 58 out of the 77 patients (10 deceased, 4 unlocated, 2 mistakes, 2 no inhaled treatment, and 1 withdrawal). Non-adherence was 48.3% in terms of the Morisky-Green test; 31% in terms of pharmacy dispensing data; and 40.4% considering both methods. There was low test-retest reliability, indicated by items 4, 8, and 9 of the CCTI-Questionnaire (Kappa = 0.4, 0.26, and 0.34; p-value < 0.0001, 0.008, and 0.001, respectively). There was mild correlation between beliefs and adherence. Conclusions: The ten-item CCTI-Questionnaire v.2.0 demonstrated acceptable psychometric properties regarding feasibility, reliability, and content validity.

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.

Illness Perceptions, Cognitions, and Beliefs on COPD Patients' Adherence to Treatment - A Systematic Review

Background

Chronic Obstructive Pulmonary Disease (COPD) is a chronic inflammatory lung disease characterized by persistent respiratory symptoms and airflow limitation. Besides its irreversibility, COPD is a treatable condition, and patients would strongly benefit from being adherent to their treatments. However, almost half of them are non-adherent, and, according to several recent studies, the way the patient perceives the disease might influence this variable.

Aim

This systematic review provided a synthesis of studies about the relationships between illness perceptions (IP), cognitions, beliefs, and adherence in COPD.

Methods

English language publications were searched in PubMed, Medline, Scopus, ResearchGate, PsycINFO, and Cochrane Library databases from November 2022 to February 2023, following PRISMA guidelines. The reference lists of eligible studies were also searched. Data extraction and critical appraisal were undertaken by two reviewers working independently.

Results

A total of 14 studies were included. Adherence to treatment in COPD is confirmed to be low, using both self-report questionnaires and objective assessment systems. Most studies concluded that COPD is perceived as a moderate threat destined to last forever, even if many participants referred to little disease knowledge. This perception did not change between adherent and non-adherent groups. Those who considered more necessary to take their medicines and had a caregiver were more adherent and less concerned about their future. On the other side, forgetfulness, lack of trust in medications, and difficulties in understanding how to take them were perceived as the main causes of non-adherence. Other predictors of non-adherence, like depression, low self-efficacy, and severity of disease were confirmed.

Conclusion

The systematic review highlights the variability of the relationship between IP, cognitions and beliefs, and COPD treatment adherence. A new level of awareness of the relationship between patients' subjective point of view and treatment adherence may inform future treatment options and promote a more personalized intervention.

Effects of medication adherence on disease activity in chronic obstructive pulmonary disease: a systematic review and meta-analysis

The disease activity of Chronic obstructive pulmonary disease (COPD) patients is often measured, which can could be related to medication adherence. Yet, there is no systematic inventory of studies comparing adherents and non-adherent patients in terms of disease activity. The systematic review and meta-analysis aimed to reveal the effect of medication adherence on disease activity in patients with COPD. For the present meta-analysis, studies comparing medication adherence in adherents and non-adherent patients were screened and included. Results were expressed as mean difference (MD) and 95% CI. A total of eleven identified studies matched the inclusion criteria, reporting on a total of 6,346 COPD patients in the analysis. The number of exacerbations in COPD patients over a year was significantly lower in non-adherent patients than in adherent subjects (MD = 0.69, 95% CI [0.36,1.01], P < 0.0001). Similarly, a significant difference was observed between medication-adherent and non-adherent groups in FEV1 (MD = -166.47, 95% CI [-255.03, -77.92], P= 0.0002). Interestingly, the results of the meta-analysis showed no significant difference between medication-adherent and non-adherent patients in SGRQ (MD = -0.85, 95% CI [-4.98, 3.27], P= 0.68), CAT (MD = -0.83, 95% CI [-1.78, 0.13], P= 0.09), and FEV1% (MD = -3.33, 95% CI [-6.83, 0.17], P= 0.06).The studies performed suggested that clinical medical staff should pay attention to the medication behavior of COPD patients and effectively improve the medication adherence of patients.

Pharmacotherapies in Older Adults with COPD: Challenges and Opportunities

Older adults have a higher prevalence of chronic obstructive pulmonary disease (COPD), which will likely increase substantially in the coming decades owing to aging populations and increased long-term exposure to risk factors for this disease. COPD in older adults is characterized by low-grade chronic systemic inflammation, known as inflamm-aging. It contributes substantially to age-associated pulmonary changes that are clinically expressed by reduced lung function, poor health status, and limitations in activities of daily living. In addition, inflamm-aging has been associated with the onset of many comorbidities commonly encountered in COPD. Furthermore, physiologic changes that are often seen with aging can influence the optimal treatment of older patients with COPD. Therefore, variables such as pharmacokinetics, pharmacodynamics, polypharmacy, comorbidities, adverse drug responses, drug interactions, method of administration, and social and economic issues that impact nutrition and adherence to therapy must be carefully evaluated when prescribing medication to these patients because each of them alone or together may affect the outcome of treatment. Current COPD medications focus mainly on alleviating COPD-related symptoms, so alternative treatment approaches that target the disease progression are being investigated. Considering the importance of inflamm-aging, new anti-inflammatory molecules are being evaluated, focusing on inhibiting the recruitment and activation of inflammatory cells, blocking mediators of inflammation thought to be important in the recruitment or activation of these inflammatory cells or released by these cells. Potential therapies that may slow the aging processes by acting on cellular senescence, blocking the processes that cause it (senostatics), eliminating senescent cells (senolytics), or targeting the ongoing oxidative stress seen with aging need to be evaluated.

"It's a lonely battle": A qualitative study of older adult Canadians' experiences with chronic obstructive pulmonary disease medication adherence and support

Background

Medication adherence is critical for optimal management of chronic obstructive pulmonary disease (COPD) and is influenced by patient, treatment and societal factors. Currently, little is known about the patient perspectives of older adult Canadians with COPD regarding medication adherence. Therefore, the purpose of this study was to explore the lived experiences of older Canadian adults with COPD regarding medication adherence and management.

Methods

Semi-structured interviews were conducted with 20 community-dwelling older adults with COPD, and iterative thematic analysis was performed.

Results

Six themes emerged from these data: (1) continuity of care, (2) importance of pharmacy for information and care, (3) medication self-management, (4) "there needs to be more information," (5) drug costs a concern and (6) "it's a lonely battle."

Conclusion

Findings suggested a need for improved continuity of care, disease-related information provision and means of addressing psychosocial needs. Holistic approaches to patient education and self-management, with consideration for varying health literacy, are needed.

Differences in Pulmonary Function Improvement after Once-Daily LABA/LAMA Fixed-Dose Combinations in Patients with COPD

This real-world study evaluated the efficacy of once-daily long-acting β2-agonist (LABA)/long-acting muscarinic antagonist (LAMA) fixed-dose combinations (FDCs) for improving lung function in patients with chronic obstructive pulmonary disease (COPD). Patients with COPD who were treated with once-daily LABA/LAMA FDCs for 12 months were included. We evaluated their lung function improvement after 12 months of treatment with different LABA/LAMA FDCs. A total of 198 patients with COPD who were treated with once-daily LABA/LAMA FDCs were analyzed. A total of 114 patients were treated with umeclidinium/vilanterol (UMEC/VIL); 34 patients were treated with indacaterol/glycopyrronium (IND/GLY); and 50 patients were treated with tiotropium/olodaterol (TIO/OLO). The forced expiratory volume in 1 s (FEV1) was significantly increased in the patients treated with all three once-daily FDCs (55.2% to 60.9%, p = 0.012 for UMEC/VIL, 58.2% to 63.6%, p = 0.023 for IND/GLY, and 54.1% to 57.7%, p = 0.009 for TIO/OLO). The treatment of COPD patients with TIO/OLO resulted in a significant improvement in both forced vital capacity (FVC%) (71.7% to 77.9%, p = 0.009) and residual volume (RV%) (180.1% to 152.5%, p < 0.01) compared with those treated with UMEC/VIL (FVC%: 75.1% to 81.5%, p < 0.001; RV%:173.8% to 165.2%, p = 0.231) or IND/GLY (FVC%: 73.9% to 79.3%, p = 0.08; RV%:176.8% to 168.3%, p = 0.589). Patients treated with UMEC/VIL or TIO/OLO showed significant improvement in FVC. In addition, those receiving TIO/OLO also showed significant improvement in RV reduction.

Treatment Adherence in Patients with Obstructive Pulmonary Diseases

COPD is the third most common cause of death globally. Adherence rates in patients with obstructive pulmonary diseases usually range between 10% and 40%. The aim of the study was to evaluate the level of treatment adherence to inhaled therapy in patients with obstructive pulmonary diseases. A total of 325 patients, of mean age 63.04 ± 11.29, with COPD or asthma, were included into the study between 2020 and 2021. The following questionnaires were used: Beliefs about Medicines Questionnaire, Test of Adherence to Inhalers and Adherence to Refills and Medications Scale. The respondents tended to be convinced of the necessity of their medication (3.87 points per question). The patients reported moderate levels of overall adherence (21.15 ± 6.23). A total of 74% of patients demonstrated sporadic non-compliance. We conclude that patients with obstructive pulmonary diseases are moderately adherent to their medication. Beliefs about medicines have a significant impact on adherence to medications. Being unemployed, being a non-smoker and belief in the necessity of medication are independent determinants of better medication adherence. The number of hospital admissions due to exacerbations of the disease over the last year and belief that medicines are harmful are independent determinants of poorer medication adherence.

Medication availability and economic barriers to adherence in asthma and COPD patients in low-resource settings

Inhaled medication is essential to control asthma and COPD, but availability and proper adherence are challenges in low-middle income countries (LMIC). Data on medication availability and adherence in Central Asia are lacking. We aimed to investigate the availability of respiratory medication and the extent of financially driven non-adherence in patients with COPD and asthma in Kyrgyzstan. A cross-sectional study was conducted in two regions of Kyrgyzstan. Patients with a physician- and spirometry confirmed diagnosis of asthma and/or COPD were included. The main outcomes were (1) availability of respiratory medication in hospitals and pharmacies, assessed by a survey, and (2) medication adherence, assessed by the Test of Adherence to Inhalers (TAI). Logistic regression analyses were used to identify predictors for adherence. Of the 300 participants (COPD: 264; asthma: 36), 68.9% were buying respiratory medication out-of-pocket. Of all patients visiting the hospital, almost half reported medication not being available. In pharmacies, this was 8%. Poor adherence prevailed over intermediate and good adherence (80.7% vs. 12.0% and 7.3%, respectively). Deliberate and erratic non-adherence behavior patterns were the most frequent (89.7% and 88.0%), followed by an unconscious non-adherent behavioral pattern (31.3%). In total, 68.3% reported a financial reason as a barrier to proper adherence. Low BMI was the only factor significantly associated with good adherence. In this LMIC population, poor medication availability was common and 80% were poorly adherent. Erratic and deliberate non-adherent behaviors were the most common pattern and financial barriers play a role in over two-thirds of the population.

Factors associated with health status and exacerbations in COPD maintenance therapy with dry powder inhalers

The study aimed to determine the associations of Peak Inspiratory Flow (PIF), inhalation technique and adherence with health status and exacerbations in participants with COPD using DPI maintenance therapy. This cross-sectional multi-country observational real-world study included COPD participants aged ≥40 years using a DPI for maintenance therapy. PIF was measured three times with the In-Check DIAL G16: (1) typical PIF at resistance of participant’s inhaler, (2) maximal PIF at resistance of participant’s inhaler, (3) maximal PIF at low resistance. Suboptimal PIF (sPIF) was defined as PIF lower than required for the device. Participants completed questionnaires on health status (Clinical COPD Questionnaire (CCQ)), adherence (Test of Adherence to Inhalers (TAI)) and exacerbations. Inhalation technique was assessed by standardised evaluation of video recordings. Complete data were available from 1434 participants (50.1% female, mean age 69.2 years). GOLD stage was available for 801 participants: GOLD stage I (23.6%), II (54.9%), III (17.4%) and IV (4.1%)). Of all participants, 29% had a sPIF, and 16% were shown able to generate an optimal PIF but failed to do so. sPIF was significantly associated with worse health status (0.226 (95% CI 0.107–0.346), worse units on CCQ; p = 0.001). The errors ‘teeth and lips sealed around mouthpiece’, ‘breathe in’, and ‘breathe out calmly after inhalation’ were related to health status. Adherence was not associated with health status. After correcting for multiple testing, no significant association was found with moderate or severe exacerbations in the last 12 months. To conclude, sPIF is associated with poorer health status. This study demonstrates the importance of PIF assessment in DPI inhalation therapy. Healthcare professionals should consider selecting appropriate inhalers in cases of sPIF.

Understanding barriers to and strategies for medication adherence in COPD: a qualitative study

Background

Medication adherence in chronic obstructive pulmonary disease (COPD) is low, though not enough is known about the factors that affect adherence in COPD. This study uses qualitative methods to understand the patient perspective on facilitators and barriers to medication adherence in COPD as well as patient-reported strategies for self-management of disease.

Methods

Semi-structured interviews were conducted with 30 individuals (n = 30). Transcripts were analyzed using iterative qualitative coding by 2 independent coders, and codes were categorized using thematic analysis.

Results

Challenges with adherence reported were gaps in understanding, forgetfulness of the patient, physician availability, cost navigation, and overcoming substance use. Most commonly, the financial burden of COPD medications caused patients to source other countries to obtain medications, rely on sample medications collected during doctors’ visits, and to alter medication dosage and frequency to extend the length of a prescription. Tools and resources reported by patients to support self-management of COPD included pharmacist assistance, physician office information, and community resources. Individuals further reported that the use of logs or diaries to track medication usage, visual or temporal cues to take medications, and support from family members were helpful in promoting adherence to their COPD medication regimen.

Conclusions

Medication adherence in individuals with COPD is affected by challenges with self-management of disease and financial burden of medications. However, patients reported multiple tools and resources to support adherence. Physician recognition of these factors impacting self-management, as well as awareness of strategies to promote adherence and manage disease, may improve patient outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-01892-5.

Asthma control in adolescents: the importance of assessing adherence

Background Asthma control is the goal of the management, but some patients do not achieve adequate control. Adherence to prescriptions is a relevant factor in this issue. As very few studies addressed this problem in adolescents, we investigated this aspect in this setting. Methods This cross-sectional study consecutively enrolled 87 adolescents (60 males, 27 females, median age 14.2 years) with asthma visited at a third-level pediatric clinic. We used two questionnaires: Morisky Medication Adherence Scale (MMAS-8) and TAI. Results As regards MMAS-8, 23 (26.6%) adolescents had low adherence, 34 (39%) medium, and 30 (34.4%) high. Concerning TAI, 34 (39%) had low adherence, 43 (49.5%) medium, and 10 (11.5%) high. After stratification per asthma control grade, adolescents with partly-controlled asthma had the highest scores for medium adherence (p=0.0017 and 0.049, respectively for MMAS-8 and TAI). Conclusions Adolescents with asthma have poor adherence independently to the asthma control grade. This failure implicates that more attention should be paid to this issue in clinical practice.

Impact of PIF, Inhalation Technique and Medication Adherence on Health Status and Exacerbations in COPD: Protocol of a Real-World Observational Study (PIFotal COPD Study)

INTRODUCTION

Dry powder inhalers (DPIs), a commonly prescribed inhaler type for respiratory diseases, require patients to generate sufficient peak inspiratory flow (PIF) to ensure optimal drug delivery to the airways. Effectiveness of therapy also requires a good inhalation technique and adequate medication adherence. For patients with chronic obstructive pulmonary disease (COPD), recent studies conducted in tertiary care suggest that DPI users with suboptimal PIF have poorer COPD-related health status and increased exacerbation risk versus those with optimal PIF. The PIFotal study will investigate the impact of PIF, inhalation technique and medication adherence on patient-reported outcomes in patients with COPD in primary care using a DPI for their maintenance therapy.

METHODS AND ANALYSIS

This cross-sectional observational study will assess 1200 patients (aged ≥ 40 years, diagnosed with COPD and using a DPI for COPD maintenance therapy for ≥ 3 months) from the Netherlands, Spain, Portugal, Poland, Greece and Australia. Assessments will consist of (1) PIF measurements (usual patient inhalation manoeuvre, maximal PIF against resistance of own inhaler, and maximal PIF against low resistance); (2) Clinical COPD Questionnaire (CCQ), COPD Assessment Test and Test of Adherence to Inhalers scores; and (3) video recordings of patient inhalation technique. Dependent variables include health status (CCQ score), number of self-reported exacerbations in previous 12 months, and healthcare resource utilisation in previous 6 months. Independent variables include PIF values, inhalation technique errors, medication adherence, and demographic and clinical characteristics. In the primary analysis, the mean difference in CCQ score between patients (1) with optimal/suboptimal PIF, (2) exhibiting/not exhibiting inhalation technique errors, and (3) adhering/not adhering to medication will be examined in a multivariable linear mixed model.

ETHICS

The study protocol was approved by ethics committees/institutional review boards of all participating sites prior to enrolment; written informed consent was obtained from all study participants.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov: NCT04532853.

Association between medication adherence and health-related quality of life in patients with chronic obstructive pulmonary disease

Background

Chronic Obstructive Pulmonary Disease (COPD) is one of the prominent cause of mortality worldwide. Nowadays, the level of medication adherence in COPD patients is very low, which reduces the clinical therapeutic effects. The purpose of the present study is to investigate the relationship between medication adherence and Health-Related Quality of Life (HRQoL) in COPD patients referred to the pulmonologist’s office.

Methods

This observational study was performed on 100 COPD outpatient cases. Each patient was interviewed to answer questionnaires regarding demographic and clinical information. To assess quality of life, health status, and severity of dyspnea, the St George’s Respiratory Questionnaire - COPD-Specific Version (SGRQ-C), COPD Assessment Test (CAT), and Modified British Medical Research Council (mMRC) questionnaires were used, respectively. Persian version of the Morisky Medication Adherence Scale (MMAS-8-Item) was used to measure medication adherence. To determine the adherence predictors, an ordinal logistic regression analysis was performed.

Results

Out of 100 patients with mean (±SD) age of 61.35 (±10.79) years, 74% had medium and high medication adherence. In the final ordinal logistic model, quality of life, health status, and education level found to have positive effect on medication adherence while polypharmacy had negative effect. We did not find any significant association between age, gender, Body Mass Index (BMI), and other variables with medication adherence.

Conclusions

Patients with high quality of life are more adherent to their medications. Furthermore, patients who have polypharmacy, tend to have less adherence to their medications.

Adherence to Inhaled Therapy in Patients with COPD Associated to Pneumoconiosis

Background

Pneumoconiosis has high prevalence of chronic obstructive pulmonary disease (COPD), respiratory morbidity, and mortality.

Objective

The aim of the present study was to examine patient characteristics and adherence to inhaled therapy among pneumoconiosis with COPD in a real-world clinical setting.

Methods

A cohort of pneumoconiosis patients with COPD prescript with at least one type of long-acting inhaled drug was followed for adherence for 2 years. Demographic and COPD-related characteristics were collected in baseline.

Results

In baseline, after adjusting for age, dust exposure duration positively correlated with number of acute exacerbation (AE) frequency in the last year. There were close associations among COPD Assessment Tool (CAT) score, modified Medical Research Council Dyspnea Scale (mMRC) grade, number of AE, and pre-FEV₁ value. Of 296 participants originally recruited, 213 participants finished the 2-year follow-up for adherence. 122 (57.28%) were non-adherent to inhaled therapy. The most common reason for non-adherence was “relief of symptoms after short-term controller medication use” (53.28%). Patients who were non-adherent reported higher body mass index (BMI), less AE events in the last year, higher pre-FEV₁ value, higher post-FEV₁ value and low CAT, mMRC scores compared to adherent in baseline. High pre-FEV₁ value (OR = 1.04, CI = 1.018–1.064) and low mMRC scores (OR = 0.406, CI = 0.214–0.771) were risk factors found associated with non-adherence.

Conclusion

A majority of pneumoconiosis patients complicated with COPD have suboptimal inhaled therapy adherence. Evidence-based, adherence-enhancing interventions should be targeted on less severe subjects.

Factors associated with medication adherence among people living with COPD: Pharmacists' perspectives

Background

While medication is an integral part of the effective management of COPD, more than 50% of people living with COPD do not adhere to their prescribed medications. The drivers underpinning this observed behaviour are poorly understood. As pharmacists generally have the final interaction with patients prior to their use of medications, their perspectives may offer insights about patients' medication use that may improve our understanding of this complex issue.

Objective

This study explored pharmacists' experiences of providing care for patients living with COPD to gain insight about factors that impact their medication-taking behaviour.

Methods

Fourteen pharmacists who worked in practice settings across the South-East Queensland region of Australia participated in interviews between March 2019 and January 2020. Interviews were audio-recorded, transcribed verbatim, and thematically analysed.

Results

Two overarching themes were identified which modulated medication-taking behaviour. Barriers comprised patient-related factors including, financial constraints, poor inhaler technique, and inaccurate beliefs; alongside pharmacist-related factors such as a lack of COPD-specific training and time constraints. Factors that promote adherence included patient education and monitoring and collaborative relationships between key stakeholders.

Conclusions

Medication non-adherence is common. While pharmacists expressed a desire to better support their patients, practical strategies to overcome the challenges that they face in clinical settings are lacking. Future research should focus on exploring ways to engage patients at the pharmacy level thereby enhancing the provision of services that would optimise medication adherence.

Time-to-first exacerbation, adherence, and medical costs among US patients receiving umeclidinium/vilanterol or tiotropium as initial maintenance therapy for chronic obstructive pulmonary disease: a retrospective cohort study

BACKGROUND

Adherence to chronic obstructive pulmonary disease (COPD) maintenance medication is important for managing symptoms and exacerbation risk, and is associated with reduced mortality, hospitalizations, and costs. This study compared on-treatment exacerbations, medical costs, and medication adherence in patients with COPD initiating treatment with umeclidinium/vilanterol (UMEC/VI) or tiotropium (TIO).

METHODS

This retrospective matched cohort study selected patients from Optum's de-identified Clinformatics Data Mart database who initiated maintenance treatment with UMEC/VI or TIO between 01/01/2014 and 12/31/2017 (index date defined as the first dispensing). Eligible patients were ≥ 40 years of age and had ≥ 12 months continuous health plan coverage pre- and post-index; ≥ 1 medical claim for COPD pre-index or on the index date; no moderate/severe COPD-related exacerbations on the index date; no asthma diagnosis pre- or post-index; no maintenance medication fills containing inhaled corticosteroids, long-acting β2-agonists, or long-acting muscarinic antagonists pre-index or on the index date; and no fills for both UMEC/VI and TIO on the index date. Outcomes included time-to-first (Kaplan-Meier analysis) and rates of on-treatment COPD-related moderate/severe exacerbations, medication adherence (proportion of days covered [PDC] and proportion of adherent patients [PDC ≥ 0.8]), and COPD-related medical costs per patient per month (PPPM). Propensity score matching was used to adjust for potential confounders.

RESULTS

Each cohort included 3929 matched patients. Kaplan-Meier rates of on-treatment COPD-related exacerbations were similar between cohorts (hazard ratio at 12 months; overall: 0.93, moderate: 0.92, severe: 1.07; all p > 0.05). UMEC/VI versus TIO initiators had significantly higher adherence (mean PDC: 0.44 vs 0.37; p < 0.001; proportion with PDC ≥ 0.8: 22.0% vs 16.4%; p< 0.001) and significantly lower mean on-treatment COPD-related total medical costs ($867 vs $1095 PPPM; p = 0.028), driven by lower outpatient visit costs.

CONCLUSIONS

These findings provide valuable information for physicians considering UMEC/VI or TIO as initial maintenance therapy options for patients with COPD.

Multidimensional factors affecting medication adherence among patients with chronic obstructive pulmonary disease

AIMS AND OBJECTIVES

This study aimed to investigate the effects of socioeconomic-, patient-, treatment-, condition- and health system-related factors on medication adherence in patients with chronic obstructive pulmonary disease (COPD).

BACKGROUND

Medication adherence is essential for the management of chronic diseases. The World Health Organization created a Multidimensional Adherence Model (MAM) and showed that medication adherence is affected by a combination of numerous factors.

DESIGN

A descriptive correlational study was conducted.

METHODS

A total of 114 patients with COPD were included. Data were collected on five dimensions based on the MAM framework. Medication adherence, self-efficacy and symptoms were evaluated using the Adherence to Refills and Medications Scale-7 (ARMS-7), COPD Self-Efficacy Scale (CSES) and COPD Assessment Test (CAT), respectively. The data were analysed using descriptive statistics, correlational statistics and structural equation modelling. The STROBE checklist was used.

RESULTS

The ARMS-7 scores were associated with the body mass index of patients (F = 4.245, p = .017), smoke pack-years (r = .277, p = .004) and the CSES total score (β = -0.249, p = .002) in patient-related factors. The ARMS-7 score was not associated with socio-economic and health system-related factors. The ARMS-7 score showed a significant correlation between COPD diagnosis duration (r = -.276, p = .003) and the total number of drugs (r = -.215, p = .022) in treatment-related factors. The ARMS-7 scores were associated with the number of comorbid illnesses of patients with COPD in condition-related factors (F = 3.533, p = .033).

CONCLUSION

This study showed that medication adherence in COPD was mostly affected by patient-, treatment- and condition-related factors.

RELEVANCE TO CLINICAL PRACTICE

Healthcare professionals should establish training and counselling programs to increase the medication adherence level of patients, particularly for patients who are newly diagnosed, require multiple drugs and have comorbid diseases or low self-efficacy.

Factors Associated with Medication Non-Adherence in Patients with Dyslipidemia

Lack of medication adherence among patients with dyslipidemia negatively affects health-related outcomes. This study aims to evaluate medication adherence; we also aim to investigate the predictors of non-adherence among patients with dyslipidemia in Jordan. Medication adherence was evaluated in a total of 228 dyslipidemia patients. The Beliefs about Medicines Questionnaire was also used to assess patients' beliefs about medications. The majority of the current study participants (73.2%) reported non-adherence to the prescribed medications. There were significant negative associations between medication adherence and concerns of prescription drug use (B = -0.41, p-value < 0.01), duration of dyslipidemia (B = -0.22, p-value < 0.01), and the number of medications (B = -0.64, p-value < 0.01). Positive associations were found between medication adherence and the necessity of prescription drug use (B = 0.43, p-value < 0.01), taking statin and fibrate (B = 2.04, p-value < 0.01), and moderate-intensity statin (B = 2.34, p-value < 0.01). As for patients' beliefs about medications, the item "My medicine to lower my cholesterol disrupted my life" had the highest mean (3.50 ± 0.99). This study revealed a low adherence rate to medication among patients with dyslipidemia. It also demonstrates modifiable factors such as beliefs regarding perceived risk, medication harms, treatment duration, and the number of medications associated with poor adherence in patients with dyslipidemia.

A structural equation model of relationships of health literacy, illness and medication beliefs with medication adherence among patients with chronic obstructive pulmonary disease

OBJECTIVE

To determine the relative contributions of health literacy (HL) and illness and medication beliefs to medication adherence among older COPD patients and determine the pathways through which they operate.

METHODS

The study was conducted using data from a prospective cohort of COPD patients in New York City and Chicago. We used structural equation modeling to examine the pathways linking HL, through medications and illness beliefs, with COPD medication adherence.

RESULTS

Out of 393 older adults with COPD, 123 (31%) had limited HL and 208 (53%) reported low adherence to daily COPD medications. Those with limited HL were more likely to have low medication adherence (p < 0.0001). Medications concerns (p = 0.001) and medication necessity (p = 0.003) demonstrated a mediational role between HL and adherence. However, in the final multivariate model, HL did not have direct effect on medication adherence (p = 0.12) and illness beliefs (p = 0.16) did not demonstrate a mediational role between HL and adherence.

CONCLUSION

Our findings suggest that low HL is not a direct predictor of poor medication adherence among COPD patients.

PRACTICE IMPLICATIONS

Addressing medication concerns and reinforcing the need for daily COPD medications may be a more effective strategy for increasing adherence in this population.

What is the Impact of Outreach Services on Medication Adherence for COPD Patients? A Systematic Review

Chronic obstructive pulmonary disease (COPD) patients have been known to have poor medication adherence rates. The purpose of this systematic review was to assess if outreach services could impact on medication compliance rates. CINAHL, Medline, Clinical Key and Cochrane library were all searched electronically along with grey literature for all eligible studies conducted on COPD patients in a non-acute hospital setting. Systematic review methodology was followed for data selection, extraction and risk of bias, validity testing and data analysis. Eight studies met all inclusion criteria. 4 randomised control trials and 4 quantitative intention-to-treat studies. 2 of the studies failed validity testing but due to a lack of articles, were included in the synthesis. Given the heterogeneity of data, a narrative synthesis was adopted. All 8 studies demonstrated the ability for an outreach service to improve medication adherence in the community setting. Secondary to this result, this systematic review showed the ability to reduce hospital admissions of exacerbations of COPD due to increased medication adherence. Quality of life was assessed but did not improve but importantly did not decrease. Medication adherence has the potential to be improved from an outreach programme but requires more high-quality research in the area to develop a standardised plan of care to identify the most effective way of educating patients on medication adherence. Medication adherence education should not be a once-off assessment, this systematic review has shown it must be continuous, re-checked and re-educated regularly.

Risk Factors for Acute Exacerbation of Chronic Obstructive Pulmonary Disease in Industrial Regions of China: A Multicenter Cross-Sectional Study

Background

The exacerbation of chronic obstructive pulmonary disease (COPD) seriously affects the patient’s quality of life and prognosis. This multicenter cross-sectional study investigated the characteristics of stable COPD and risk factors for acute exacerbation of COPD (AECOPD) in patients in Changchun, Jilin Province, China.

Methods

The study included 400 outpatients admitted to four secondary hospitals and four tertiary hospitals in Jilin Province from March 2018 to March 2019. Data on the general condition of stable COPD patients, patient self-management, COPD Assessment Test (CAT) scores, number of acute exacerbations in the past 12 months, and medications received during the study period were collected using a questionnaire.

Results

Sociodemographic characteristics and clinical data were obtained from 306 patients, and drug prescription data were obtained from 329 patients. Pearson correlation analysis revealed that CAT scores were positively correlated with the number of acute exacerbations. Age, education level, smoking history, disease duration, number of comorbidities, and the presence of ischemic heart disease (IHD) were associated with AECOPD. Moreover, the level of education, disease duration, and the presence of IHD were independent risk factors for AECOPD. Poor compliance due to the lack of understanding of the disease and the high cost of treatment is a risk factor for AECOPD. In addition, increased air pollution in industrial cities and vitamin D deficiency are closely related to AECOPD.

Conclusion

Low education level, long disease duration, and the presence of IHD may promote the exacerbation and poor control of COPD in patients in Jilin Province.

Adherence to inhalers and comorbidities in COPD patients. A cross-sectional primary care study from Greece

Background

Comorbidities and adherence to inhaled therapy appears to have a major impact on treatment goals, health status and disease control in chronic obstructive pulmonary disease (COPD). Aim of the study was to assess levels of adherence to inhalers, comorbidities and associations with COPD outcomes in patients residing in rural and semi-urban areas of Greece.

Methods

Two hundred fifty-seven COPD patients were enrolled from primary health care in 2015–2016. Physicians used structured interviews and questionnaires to assess quality of life and disease status. Patients were classified into groups according to GOLD 2019 guidelines (based on CAT and mMRC). Adherence to inhalers was measured with the Test of Adherence to Inhalers (TAI). Multivariate linear and logistics regression models were used to assess associations between comorbidities and adherence to inhalers with COPD outcomes, including CAT and mMRC scores, exacerbations and GOLD A-D status.

Results

74.1% of COPD patients reported poor adherence, while most of them were characterized as deliberate non-compliers (69.5%). 77.1% had ≥2 comorbidities, with overweight/obese (82.2%), hypertension (72.9%) and diabetes mellitus (58%) being the most prevalent. In multivariate analysis, COPD outcomes having significant associations with poor adherence included worse health status [OR (95% CI) 4.86 (1.61–14.69) and 2.93 (1.51–5.71) based on CAT and mMRC, respectively], having ≥2 exacerbations in the past year [4.68 (1.51–4.44)], and disease status e.g., be in groups C or D [3.13 (1.49–8.53) and 3.35 (1.24–9.09) based on CAT and mMRC, respectively). Subjects with gastroesophageal reflux showed better inhaler adherence [OR (95% CI) 0.17 (0.6–0.45)], but none of the comorbid conditions was associated with COPD outcomes after adjustments.

Conclusions

Poor adherence to inhalers and comorbidities are both prevalent in COPD patients of primary care residing in rural/semi-urban areas of Greece, with adherence influencing COPD outcomes. Raising awareness of patients and physicians on the importance of comorbidities control and inhaler adherence may lead to interventions and improve outcomes.

Medication adherence among patients with chronic obstructive pulmonary disease treated in a primary general hospital during the COVID-19 pandemic

Background

The objective of this study was to investigate medication adherence and the associated influencing factors in patients with chronic obstructive pulmonary disease (COPD) who were treated in a primary general hospital in Shanghai China during the 2019 novel coronavirus (COVID-19) pandemic.

Methods

From March to April 2020, all of the COPD patients treated in our department in the last 7 years were interviewed by telephone. The basic patient data and each questionnaire item were collected, and influencing factors were analyzed by the Chi-square test, U test, and univariate and multivariate logistic regression analyses.

Results

A total of 191 patients with COPD were queried, and 84 (44.0%) valid questionnaires were obtained. Among them, individuals with group B symptoms were most represented (45.2%); 53.6% had Medical Research Council (MRC) dyspnea levels of 2 or above. Chronic obstructive pulmonary disease assessment test (CAT) had an average of 9 [3, 13], and 52.4% of patients used two-drug combination therapy. Medication adherence was both good in ordinary times and over the past 2 months of the pandemic, and 88.8% of patients had no acute exacerbation during the pandemic. The CAT scores of male patients <70 years old, and patients with general outpatient follow-up and regular gargling were reduced (P<0.05). Drug combination and doctor’s supervision were favorable factors affecting medication adherence during the 2 months of the pandemic, while possible depression was an unfavorable factor (P<0.05).

Conclusions

During the pandemic, medication adherence in patients with COPD was similar to that in regular times, and was significantly related to drug combination, doctor’s supervision, and accompanying mood disorders. An effective way to improve patient adherence and disease control could be strengthening follow-up education and diagnosing and treating depression and other complications.

A cohort study of medication adherence among patients with chronic obstructive pulmonary disease in Egypt

Chronic obstructive pulmonary disease (COPD), the most common chronic respiratory disease, is expected to become the third leading cause of death worldwide in 2020. A prospective cohort study conducted in 2017 and 2018 aimed to identify factors associated with inhaler treatment adherence in patients with COPD in Cairo (Egypt). Physicians collected data regarding patient deaths, treatment-related adverse events, and patients’ social support (no support, patient, support by spouse, children, and siblings) from their patients with COPD. The reason for treatment discontinuation was categorized as per patient decision or per physician decision. Adherence was categorized as treatment continued or treatment stopped. Patients who decided to stop treatment were considered non-adherent to COPD therapy. A total of 1311 patients as well as 98 physicians and 205 pharmacists were included. Pharmacists and social support (spouse, children/siblings) were identified as key positive factors in patients’ decisions to adhere to their prescribed COPD treatment regimens. A total of 631 patients (48.1%) stopped the treatment, including 170 (27.0%) due to patient decision and 55 (8.7%) deceased. After Cox model analysis, a low number of patients (6–19) attended by the pharmacist was a significant predictive factor (hazard ratio [HR] = 1.40, 95% confidence interval [CI] = 1.03–1.91, p = 0.03) for deciding to stop treatment. A wife or husband (HR = 0.85, 95% CI = 0.72–1.02, p = 0.07) as well as children or brother/sister (HR = 0.77, 95% CI = 0.57–1.04, p = 0.08) provided a positive effect for continued treatment. Pharmacists are well positioned to play a role as an essential public health resource that can help improve adherence as well as social support that should be considered as an important component to improve adherence to long-term therapy in COPD as well as other chronic non-communicable diseases in low- and middle-income countries.

Inhaler device feature preferences among patients with obstructive lung diseases: A systematic review and meta-analysis

BACKGROUND

Bronchodilators administered through inhalation devices are the mainstay treatment for patients with obstructive lung diseases. Patients do not view devices as interchangeable. This systematic review and meta-analysis examined device feature preferences among patients with obstructive lung diseases treated with handheld inhalers.

STUDY APPRAISAL AND SYNTHESIS METHODS

PubMed, EMBASE, PsycINFO, Cochrane, and Google Scholar were searched to identify publications between 2010 and 2019 that met the following criteria:A manual search extended the study period from 2001 to 2019. Random-effects models were used to generate pooled mean effect sizes and 95% confidence intervals (CIs) for preferred device features. Heterogeneity was measured by the I statistic.

RESULTS

Nineteen studies (n = 11,256) were included in this meta-analysis. Average age ranged from 50.4 to 74.3 years. The majority of patients were male (57%) and had chronic obstructive pulmonary disease (92%).Patients preferred the following device features: CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS:: Adults with obstructive lung diseases preferred small inhaler devices that were portable, durable, perceived as easy to use, and fast in medication administration. Healthcare providers should give due consideration to the patient's device feature preferences when developing a treatment plan that prescribes an inhalation device.

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.

The Association Between Beliefs and Adherence to Inhaled Controller Medication Among Older Adults with Asthma: A Cross-Sectional Study in Primary Care

BACKGROUND

While illness perceptions and medication beliefs have been shown to be associated with inhaled corticosteroid (ICS) adherence in younger adults with asthma, their impact on older adults is less understood. This study aimed to determine the prevalence of ICS adherence among older Asian adults and to assess the association between ICS adherence, illness perceptions and medication beliefs.

METHODS

A questionnaire survey on older multi-ethnic Asian patients, aged ≥60 years, with physician-diagnosed asthma, was conducted in two Singapore public primary care clinics. The scores of the Medication Adherence Report Scale for asthma (MARS) were computed to determine the adherence to ICS alone or in combination with LABA. Illness perceptions and medication beliefs were assessed by the scores from the Brief-Illness Perception Questionnaire (B-IPQ) and Beliefs about Medications Questionnaire (BMQ), respectively. Logistic regression analyses were used to identify factors associated with ICS adherence.

RESULTS

Analyses of 323 participants (57% males; Chinese 73.7%, Malay 12.7%, Indian 12.4%; mean age 71.5 years) showed that 40.9% of them had good adherence to ICS (mean MARS score≥4.5). Good adherence to ICS was associated with perception of asthma as a chronic illness (OR=1.22; 95% CI=1.10-1.35; p<0.001), belief of ICS as an essential medication (2.67; 1.76-4.06; p<0.001) and fewer concerns about its use (0.39; 0.26-0.60; p<0.001). Patients on combined ICS-LABA therapy had higher adherence (2.50; 1.41-4.44; p=0.02) than those on ICS monotherapy.

CONCLUSION

Four in ten older patients with asthma were adherent to ICS. Perception of medication necessity, chronicity of illness, concerns and use of ICS-LABA medication were associated with adherence.

Medication Compliance in COPD Patients

Chronic obstructive pulmonary disease (COPD) is one of the most severe public health problems and a leading cause of death worldwide. One of the main reasons for poor control of the disease is low patient compliance with treatment plan. The aim of the study was to investigate sociodemographic and health status factors that may have an influence on adherence to treatment. There were 106 inpatients (F/M, 42/64; mean age 70 ± 6 years) with COPD enrolled into this retrospective study. Patients completed the Adherence to Refills and Medications Scale (ARMS) to assess adherence to therapy. We found that the mean ARMS score was 23.1 ± 6.8. About 86% of patients had low adherence, and 14% had good adherence (mean score 3.2 ± 2.4). The low-adherence patients were more likely to be older (p = 0.020), female (p = 0.011), single (p = 0.019), not professionally active (p = 0.049), hospitalized more often (p = 0.005) and for a longer time (p = 0.046), feel worse (p = 0.023), experience a greater impact of the disease on sleep quality (p = 0.008) and daily activities (p = 0.001), and had a higher GOLD stage of COPD when compared to patients with good adherence patients (p = 0.012). Multiple factor analysis demonstrates that independent adverse predictors of the ARMS score included the following: being single (OR = 3.18), having had more than eight hospitalizations (OR = 1.18), and experiencing dysfunction in daily activities (OR = 1.79). Male gender (OR = 0.77) and longer than 21-day hospitalizations (OR = 0.93) were independent positive predictors of adherence. In conclusion, COPD patients demonstrate a low level of adherence to pharmacotherapy. Adherence is adversely affected by sociodemographic (older age, female gender, being single, and professionally inactive) and clinical factors (more frequent hospitalizations, perception of poor well-being, disordered sleep and daily functioning, and a higher GOLD stage).

Evaluation of rescue medication use and medication adherence receiving umeclidinium/vilanterol versus tiotropium bromide/olodaterol

Background

This was the first real-world head-to-head study comparing inhaled long-acting muscarinic antagonist/long-acting β2-agonist fixed-dose combination treatments as maintenance therapy.

Methods

Retrospective observational study including commercial, Medicare Advantage with Part D or Part D-only enrollees aged ≥40 years from the Optum Research Database. Patients initiated umeclidinium/vilanterol (UMEC/VI) or tiotropium bromide/olodaterol (TIO/OLO) between June 1, 2015 and November 30, 2016 (index date) with 12 months of pre- and post-index continuous enrollment. Outcomes were modeled following the inverse probability of treatment weighting. The primary endpoint, rescue medication use, was modeled using weighted ordinary least squares regression with bootstrapped variance estimation. Intent-to-treat analysis evaluated non-inferiority and superiority of UMEC/VI to TIO/OLO with thresholds of 0.30 and 0 units, respectively. On-treatment sensitivity analysis evaluated the superiority of UMEC/VI to TIO/OLO for rescue medication use. The secondary endpoint, medication adherence (proportion of days covered [PDC]≥80%), was evaluated using weighted logistic regression. Post hoc weighted Cox proportional hazards regression analysis evaluated escalation to multiple inhaler triple therapy (MITT).

Results

The study population included 14,324 patients; 9549 initiated UMEC/VI and 4775 initiated TIO/OLO. During the 12-month post-index period, UMEC/VI initiators used 0.16 fewer adjusted mean units of rescue medication than TIO/OLO initiators (95% CI: -0.28, -0.04), meeting pre-specified non-inferiority (P<0.001) and superiority (P=0.005) criteria; the on-treatment sensitivity analysis for superiority was not statistically significant. Significantly more UMEC/VI than TIO/OLO initiators (28.6% vs 22.7%; P<0.001) achieved a clinically meaningful level (PDC≥80%) of medication adherence. The adjusted risk of escalation to MITT was similar between treatment groups (HR=0.93; 95% CI: 0.81, 1.06; P=0.268).

Conclusion

UMEC/VI was superior to TIO/OLO for rescue medication use and UMEC/VI initiators had better medication adherence than TIO/OLO initiators. This study supports findings from a head-to-head trial that demonstrated significant, clinically meaningful improvements in lung function with UMEC/VI versus TIO/OLO.

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.

Electronic inhaler monitoring and healthcare utilization in chronic obstructive pulmonary disease

INTRODUCTION

The effect of electronic inhaler monitoring (EIM) on healthcare utilization in chronic obstructive pulmonary disease (COPD) has not been studied. We hypothesized that the use of EIM in conjunction with a disease management program reduces healthcare utilization in patients with COPD.

METHODS

This is a retrospective pre- and post-analysis of a quality improvement project. Patients with COPD and high healthcare utilization (≥one hospitalization or emergency room visit during the year prior to enrolment) were provided with electronic monitoring devices for monitoring controller and rescue inhaler utilization for one year. Patients were contacted when alerts were triggered, indicating suboptimal adherence to controller inhaler or increased use of rescue inhalers, potentially signalling an impending exacerbation. Healthcare utilization was assessed pre- and post-monitoring, with each subject serving as his/her own control.

RESULTS

Patients with COPD and high healthcare utilization (n = 39) were recruited. Mean EIM duration was 280.5 (±120.6) days. The mean age was 68.6 (±9.9) years, FEV1 (mean forced expiratory volume in one second) was 1.1 (±0.4) L, and mean Charlson Comorbidity index was 5.6 (±2.7). Average adherence was 44.4% (28.4%). Compared with the year prior to enrolment, EIM was associated with a reduction in COPD-related healthcare utilization per year (2.2 (±2.3) versus 3.4 (±3.2), p = 0.01). Although there was a reduction in all-cause healthcare utilization, this was not statistically significant (3.4 (±2.6) versus 4.7 (±4.1), p = 0.06).

DISCUSSION

EIM in conjunction with a disease management program may play a role in reducing healthcare utilization in COPD patients with a history of high healthcare utilization.

Cross-Cultural Adaptation Of The Persian Version Of Test Of The Adherence To Inhalers (TAI)

PURPOSE

Despite the importance of using inhalers concerning chronic obstructive pulmonary disease (COPD), patients generally have problems regarding adherence to medication regimen. The first step in understanding medication adherence is its assessment which requires a reliable tool. The aim of this study was to translate and perform the psychometric assessment of Test of Adherence to Inhalers (TAI).

PATIENTS AND METHODS

In this cross-sectional study, the 10-item TAI was utilized. Patients with COPD referring to Amir-al-Momenin and Vali-Asr hospitals in Arak, Iran, were the study population. The tool was translated using forward-backward translation, and its validity was evaluated via face validity, content validity, and concurrent validity. The reliability of the tool was assessed using test-retest and Cronbach's alpha.

RESULTS

A total of 100 patients with COPD participated in the study, where the results showed that the tool has a good face validity. The CVR was 0.83, the CVI was 0.95, and the concurrent validity with General Medication Adherence Scale (GMAS) was moderate which was not significant (r = 0.613, p = 0.06). The results of the reliability test further showed that in the test-retest, Pearson correlation coefficient was 0.986, ICC was 0.972, and Cronbach's alpha was 0.986.

CONCLUSION

The tool was translated to Farsi language, with the results indicating that Farsi TAI is a valid and reliable tool for measuring inhaler adherence in patients with chronic pulmonary disease.