Medication compliance and asthma: overlooking the trees because of the forest

A review of the effects of medication delivery systems on treatment adherence in children with asthma

BACKGROUND

A patient's adherence to an appropriate treatment regimen is necessary to minimize morbidity and mortality associated with childhood asthma. Many factors influence the success of treatment adherence.

OBJECTIVE

The goal of this article was to examine the effect of the mode of medication delivery on the success of treatment adherence in children with asthma.

METHODS

Relevant clinical studies were identified through a MEDLINE search of articles published from 1966 to 2002, using the search terms adherence, aerosol, asthma, children, compliance, dry powder inhaler, metered-dose inhaler, nebulizer, and pediatric.

RESULTS

A relationship seems to exist between treatment adherence and the type of medication delivery system used in childhood asthma. The highest rates of adherence appear to be associated with oral medications.

CONCLUSIONS

Clinicians should consider the mode of medication delivery as 1 factor that can influence the success of treatment adherence.

Medication compliance and disease exacerbation in patients with asthma: a retrospective study of managed care data

BACKGROUND

Compliance with asthma medications probably results in improved outcomes, but few studies have examined this relationship.

OBJECTIVE

To examine the association between medication compliance and exacerbation in asthmatic patients.

METHODS

Retrospective analysis of a managed care database. The 97,743 participants (aged 6-99 years; mean age, 32.8 years) had asthma and prescriptions for controller medications. Compliance with the index medication (the first controller medication prescribed) was measured using 2 methods: medication possession ratio (MPR), calculated for 365 days after the index date, and number of prescriptions for each index medication. Exacerbation was defined as 1 or more emergency department visits or hospitalizations within 1 year of the index date. Multivariate models were used to determine the odds of exacerbation based on relative compliance for each definition of compliance.

RESULTS

Based on the median MPR, more-compliant patients were less likely to experience exacerbation than less-compliant patients (odds ratio, 0.94; 95% confidence interval, 0.91-0.97; P < .001). Using the 75th percentile MPR, risk of exacerbation was even smaller (odds ratio, 0.89; 95% confidence interval, 0.86-0.92; P < .001). All the cutoff points for compliance (> or = 2 through > or = 6 prescriptions) demonstrated significantly less exacerbations in more-compliant vs less-compliant patients after adjusting for covariates. As the criteria for compliance became more stringent, more-compliant patients became increasingly less likely to have an exacerbation vs less-compliant patients.

CONCLUSION

More-compliant asthmatic patients were significantly less likely to experience exacerbation than less-compliant asthmatic patients. These findings demonstrate the importance of improving medication compliance among asthmatic patients to impact outcomes.

Development of an expert system knowledge base: a novel approach to promote guideline congruent asthma care

Existing guidelines for the clinical management of asthma provide a good framework for such tasks as diagnosing asthma, determining severity, and prescribing pharmacological treatment. Guidance is less explicit, however, about establishing a patient-provider partnership and overcoming barriers to asthma management by patients in a way that can be easily adopted in clinical practice. We report herein the first developmental phase of the "Stop Asthma" expert system. We describe the establishment of a knowledge base related to both the clinical management of asthma and the enhancement of patient and family self-management (including environmental management). The resultant knowledge base comprises 142 multilayered decision rules that describe clinical and behavioral management in three domains: 1) determination of asthma severity and control; 2) pharmacotherapy, including prescription of medicine for chronic maintenance, acute exacerbation, exercise pretreatment, and rhinitis relief; and 3) patient self-management, including the process of intervening to facilitate the patient's asthma medication management, environmental control, and well-visit scheduling. The knowledge base provides a systematic and accessible approach for intervening with family asthma-related behaviors.

Managing asthma in the real world

Asthma treatment is suboptimal in many patients, with impacts on morbidity and mortality, healthcare resource utilisation and patients' quality of life. The reasons for this include the inherent variability of asthma and the unpredictability of exacerbations, which can range from mild to fatal. In addition, asthma can be difficult to diagnose, particularly in the very young and old. Although treatment guidelines are widely available and well publicised, surveys have identified a significant gap between treatment aims and current levels of asthma control. Patient adherence to inhaled corticosteroids is poor, and many patients rely on short-acting beta2-agonists. The reasons for this are complex but are believed to include poor perception by patients of their asthma severity, concerns about the safety and efficacy of medication and low treatment expectations. Patients appear to be unaware of the extent to which airway inflammation can be controlled and are therefore satisfied with poor asthma control, accepting a high level of symptoms. Increasing patient understanding of asthma and its treatment, allowing patients greater involvement in treatment decisions, increasing the role of asthma nurses and improved communication between physicians and patients may improve outcomes in patients with asthma.

[The "Compli'Asthme" therapeutic observation survey on good use of inhaled drugs for asthma: perception by general practitioners]

A cross sectional survey was conducted in 2000 in coordination with the CHIESI medical representatives among 1758 French physicians caring for patients with persistent asthma (80% general practitioners, 20% specialists). This "Compli'Asthme" survey was based on a self-administered questionnaire designed to learn more about the physicians' experience with good use of inhaled drugs and to collect information on therapeutic observance, corticophobia, and use of prescribed inhalers. Poor observance was noted as an important problem by 58-85% of the participants. Most of the problems were related to inability to use the inhaler properly (children, elderly subjects) or to patients forgetting to take their medications (adults, parents). For 58% of the participating physicians, corticophobia is frequent. The patients are worried about the anabolizing effect, secondary effects, and dependence. When there is a potential problem with corticophobia, physicians generally question the patients and provide explanations to achieve good observance. Patient preference is taken into consideration by 86% of the physicians prescribing inhalation devices; 90% demonstrate use of the device at the first prescription and 68% make repeated demonstrations at subsequent consultations. For 56-87% of the physicians, poor therapeutic observance, corticophobia, and poor use of the inhaler can be detected and corrected. Patient education is an important element for 77% of the physicians for improving observance and achieving good use of the inhaler. When poor observance and poor use of the inhaler occur, the physicians responding to this questionnaire applied the currently recommended guidelines.

Relationship of adherence to pediatric asthma morbidity among inner-city children

OBJECTIVES

Morbidity from asthma among children is one of the most important US health concerns. This study examines the relationship of baseline nonadherence to subsequent asthma morbidity among inner-city children.

METHODS

A multisite, prospective, longitudinal panel study was conducted of 1199 children who were aged 4 to 9 years and had asthma and their caregivers, most of whom were parents, in emergency departments and clinics at 8 research centers in 7 US metropolitan inner-city areas. Nine morbidity indicators were collected at 3, 6, and 9 months after baseline, including hospitalizations, unscheduled visits, days of wheeze/cough, and days of reduced activities.

RESULTS

Children whose caregivers scored high on a new measure, Admitted Nonadherence, experienced significantly worse morbidity on 8 of the 9 measures. Children who scored high on a new Risk for Nonadherence measure experienced significantly worse morbidity on all 9 morbidity measures. Multiple and logistic regressions found that the adherence measures had independent significant effects on morbidity. Combining the measures improved estimates of morbidity: children whose caregivers were poor on either adherence measure had worse morbidity than those with good adherence on both, eg, rate of hospitalization was twice as high, they missed more than twice as much school, had poorer overall functioning, and experienced more days of wheezing and more restricted days of activity.

CONCLUSIONS

Risk for Nonadherence and Admitted Nonadherence independently and jointly predicted subsequent asthma morbidity. Targeting risks for nonadherence may be an effective intervention strategy. Most risks can be controlled by physicians through reducing the complexity of asthma regimens, communicating effectively with caregivers about medication use, and correcting family misconceptions about asthma medication side effects.

An intervention programme using the ASE-model aimed at enhancing adherence in adolescents with asthma

A randomised controlled trial, involving 112 adolescents with asthma, and a 2-year follow-up was conducted to assess the impact of an intervention programme aimed at enhancing adherence to asthma medication. This programme had a duration of 1 year and consisted of an experimental group which received usual care from a paediatrician, but additionally attended individual and group sessions with an asthma nurse, and a control group which received usual care only. The programme aimed at enhancing adherence by stimulating a positive attitude, increasing feelings of social support, and enhancing self-efficacy. At baseline, and after 12-month (T1) and 24-month (T2) follow-up, the participants filled in questionnaires which were based on the concepts of the ASE-model. Adherence was assessed by self-report (range: 1-10) at the same points in time. After 12 months, 97 adolescents (87%) were available for follow-up, decreasing to 86 adolescents (77%) after 24 months. No statistically significant differences were found between the control and the experimental group, except for one. At T2, self-reported adherence appeared to be statistically significantly higher in the experimental group. In conclusion, there seems to have been no substantial effect of the intervention programme.

Do pregnant women report use of dispensed medications?

Surveillance of drug safety in pregnancy often draws on administrative prescription registries. Noncompliance in the use of prescribed medication may be frequent among pregnant women owing to their fear of fetotoxic side effects. To estimate compliance in the use of prescription drugs dispensed during pregnancy, we compared prescription data from the North Jutland Prescription Database with information on drug use provided by pregnant women to the Danish National Birth Cohort (DNBC), which is a health interview survey. We used the North Jutland Prescription Database to identify all prescription drugs dispensed during pregnancy for the 2,041 women who were enrolled in the DNBC in the County of North Jutland, Denmark. Compliance was defined as the probability of reporting drug use in DNBC after purchasing a dispensed prescription drug. The overall compliance to drugs purchased within 120 days before the interview was 43% (95% confidence interval = 40-46). Drugs used for treating chronic diseases, for example, beta-blockers, insulin, thyroid hormones, and diuretic and antiepileptic drugs, were always reported to be used, but compliance was low for drugs used for local or short-term treatment such as antihistamines, antibiotics, antacids, nonsteroid anti-inflammatory drugs, and gynecologic drugs. Thus, for the latter drug groups the prescription database may provide an incomplete identification of exposure. Neither data source is unbiased regarding actual drug intake. Nevertheless, our results indicate that for some drug groups risk assessment studies based on prescription data may produce false negative results as a result of noncompliance.

Beliefs that support the behavior of people with asthma: a qualitative investigation

Differences between patients' knowledge and behavior in relation to asthma may account for continuing morbidity in theface of professional and public asthma education campaigns. We conducted a qualitative study of beliefs that support asthma-related behavior, obtaining data from interviews with 70 adult patients. Analysis identified four clear subgroups, or "streams," of adults with asthma: an "anonymous" stream, who doubt that they have asthma and manage symptoms outside the organized health system; an "isolated" stream, who feel dependent on bronchodilators and do not understand the potential of preventive therapy; a "suboptimal" stream, who are confident that they are managing their asthma effectively but who are excessively reliant on bronchodilators; and an "optimal stream," who have high expectations of outcomes and participate actively in a partnership with a doctor. Characteristics of the doctor and the doctor-patient relationship are important elements in altering asthma-related behavior in ways that may facilitate the best health outcomes.

Adherence to asthma therapy

OBJECTIVE

This article presents information on the important impact the lack of adherence to prescribed treatments has on the morbidity and mortality of asthma. After reading this article, readers should have an understanding of the significant role clinicians, as well as patients and their families, play in promoting adherence.

DATA SOURCES

A detailed literature search was conducted. Relevant studies were used. Only literature in the English language was reviewed.

STUDY SELECTION

Material was taken from academic/scholarly publications, appropriate reviews, and published abstracts.

RESULTS

Over the last decade, many researchers have examined ways to improve adherence to asthma therapy, including improving clinician-patient communication, educating the patient, and simplifying the treatment regimen. Nonadherence is a problem in pediatric and adolescent patients, whose needs are different from those of adult patients. Because proper technique is essential with metered-dose inhalers and peak flow meters, special efforts are required by clinicians to promote adherence to these devices.

CONCLUSIONS

Promoting adherence involves a good clinician-patient relationship, as well as provision of personalized, practical, and repeated education.

Asthma education: creating a partnership

This article advances the theory that the key to creating an effective partnership is teaching asthma patients what to self-treat, how to self-treat, and when to consult a clinician. The five comanaging rules that the health educator is encouraged to emphasize with the adult asthma patient are: know your own unique asthma symptoms and triggers; keep written records; see appropriate specialists; know your medicines and follow your action plan; and accept no treatment you do not understand. Current research shows asthma to be a chronic inflammatory disorder of the airways. In susceptible individuals, this inflammation causes recurrent episodes of wheezing, breathlessness, chest tightness, and cough, particularly at night and in the early morning. The stepwise approach to asthma therapy divides asthma into several levels of severity. However, patients at any level of severity can have mild, moderate, or severe exacerbations. Asthma triggers; how to use a metered dose inhaler (MDI), a dry powder inhaler (DPI), and a peak flow meter; and how to follow an asthma action plan are thoroughly covered. The last section of the article deals at length with the indications for and actions of long-term-control medications, used to achieve and maintain control of persistent asthma, and quick-relief medications, used to treat symptoms and exacerbations.

Effect of salmeterol on patients' adherence to their prescribed refills for inhaled corticosteroids

BACKGROUND

Optimal treatment for persistent asthma requires multiple classes of medication, including antiinflammatory agents and bronchodilators. Inhaled corticosteroids are the most effective antiinflammatory agents available and are recommended by recent guidelines as first-line treatment. Salmeterol, a long-acting inhaled bronchodilator, is recommended as adjunctive therapy to inhaled corticosteroids. Non-adherence to prescribed medication is prevalent and has been implicated in asthma exacerbations. Salmeterol's benefits in terms of asthma control are readily perceived by patients whereas the benefits of inhaled corticosteroid therapy may be less apparent.

OBJECTIVE

To evaluate whether the addition of salmeterol to a medication regimen affects patient adherence to prescription refills for inhaled corticosteroids.

METHODS

A retrospective medical chart and pharmacy claims record review before and after the addition of salmeterol was used. Medication adherence rates were calculated for 67 patients requiring inhaled corticosteroids for at least 8 months before and after the addition of salmeterol.

RESULTS

Adherence with inhaled corticosteroid therapy before (49.7% +/- 29.3%) and after (56.5% +/- 28.6%) the introduction of salmeterol was not significantly different (P = .0785, pre versus post). Adherence with salmeterol was significantly higher (58.7% +/- 28.3%) than inhaled corticosteroids at baseline (P = .0202), but not with concurrent use. Dosing frequency of inhaled corticosteroid administration was not a significant factor in adherence, but increasing age was (r = 0.41788, P = .0048).

CONCLUSIONS

The addition of salmeterol does not adversely affect the adherence rates to prescription refills for prescribed inhaled corticosteroid therapy. On average, important antiinflammatory treatment should not be supplanted with salmeterol if prescribed in combination.

Inhaled corticosteroids for asthma therapy: patient compliance, devices, and inhalation technique

BACKGROUND

Patient compliance, inhalation devices, and inhalation techniques influence the effectiveness of inhaled medications.

METHODS

This article presents the results of a systematic literature review of studies measuring compliance with inhaled corticosteroids, measuring inhalation technique with different inhalation devices, and estimating the proportion of inhaled drug that is deposited in the lung.

RESULTS

Overall, patients took the recommended doses of inhaled medication on 20 to 73% of days. Frequency of efficient inhalation technique ranged from 46 to 59% of patients. Education programs have been shown to improve compliance and inhalation techniques. The lung deposition achieved with different inhalers depends on particle size as well as inhaler technique.

CONCLUSION

This review demonstrates that multiple factors may come between a prescription of an inhaled corticosteroid and the arrival of that medicine at its target organ, the lung.

Improving patient compliance with asthma therapy

Patients fail to comply with asthma medication for a variety of reasons. These range from physical inability to use an inhaler, through simple forgetfulness, to a conscious decision not to use medication as prescribed due to internal or cultural health beliefs or socioeconomic factors. In some patients, poor self-care because of deep-rooted psychological factors (i.e. factors of which patients have only limited awareness) can affect compliance. Poor doctor-patient communication can be the cause in many other individuals. Thus, there is no single solution that will improve compliance in all patients. Simplifying the regimen or providing memory aids will be sufficient for some patients, while education or psychological counselling will be more appropriate for others. Doctors can also use a range of communication skills to improve the way in which they present information, motivate patients and reinforce progress. These approaches, plus respect for patients' health beliefs and involving them in treatment decisions, can help foster an atmosphere of mutual responsibility and concordance over medicine taking.

Preventive pharmacologic therapy among asthmatics: five years after publication of guidelines

BACKGROUND

Guidelines from the National Heart, Lung, and Blood Institute first published in 1991 have recommended anti-inflammatory (AI) agents as a first-line therapy and the bronchodilator as an acute reliever of symptoms.

OBJECTIVE

To examine the current usage of anti-inflammatory steroids (inhaled corticosteroids, Cromolyn, systemic steroids) and bronchodilators and compare them with the national guidelines. The relationship between preventive AI usage and the characteristics of the asthma patients and their providers was also examined.

METHODS

Cross-sectional survey data linked with 6-month pharmacy claims of asthmatic members at an HMO in California.

RESULTS

AI usage increased with current severity (mild, 36.9%; moderate, 47.3%; and severe, 56.8%), though a large percentage are not receiving this emphasized treatment. Bronchodilators were used at a higher rate and 24% of asthmatics relied solely on bronchodilators. Use of bronchodilators without AI (BWAI) was present at all severity levels (mild, 19.5%; moderate, 24.6%; and severe, 24.7%). Advancing age, increasing severity, care by an asthma specialist, and not smoking increased the likelihood of using AIs. Increasing severity, longer duration of asthma, smoking, younger age group, care by a generalist, and no chronic bronchitis increased the likelihood of BWAI.

CONCLUSIONS

These results suggest that there is a low level of AI usage despite emphasis in guidelines. Current asthma management in a community-based setting depicts a significant underutilization of long-term control agents and, conversely, an overutilization of symptom relief agents compared with guidelines published 5 years ago. Actively involving patients in the guideline dissemination process, rather than just the medical community, may increase preventive medication usage.

Meeting Patient Needs in Asthma Education

Preventable drug-related morbidity and mortality in asthma patients is related to inappropriate behavior by both patients (noncompliance) and health care professionals (prescribing and monitoring). Compliance is the crucial factor for success of a therapeutic regimen. Impacting factors have been identified as skills in administration techniques, interactions between patients and providers, and patient expectations. Beneficial effects on the cost of care and quality of life are gained from increasing level of care available to patients. Intensive education including development of self-monitoring skills, early treatment of exacerbations, and access to regular outpatient and Emergency Room care have been shown to be effective.