Cost-Effectiveness and Impact on Health Care Utilization of Interventions to Improve Medication Adherence and Outcomes in Asthma and Chronic Obstructive Pulmonary Disease: A Systematic Literature Review

BACKGROUND

Poor adherence to asthma and chronic obstructive pulmonary disease maintenance therapies impairs health outcomes. Proven and cost-effective programs to promote adherence and persistence are not yet in regular widespread use. Implementation costs are a potential barrier to uptake of such programs.

OBJECTIVE

We undertook a systematic literature review and narrative synthesis of studies investigating the cost-effectiveness of treatment adherence-promoting programs or that determined their impact on health care budget directly or via health care resource use (HCRU).

METHODS

We identified relevant publications using Medline and PreMEDLINE (PubMed), Embase (Embase.com, Elsevier), and EconLit for publications between January 2000 and July 2021. We also searched clinical trial databases and selected conference proceedings.

RESULTS

Of 1,910 potentially relevant articles, 26 met prespecified inclusion criteria and underwent data extraction. Eleven reported a direct assessment of adherence, 15 included economic evaluations, and 17 described HCRU. None included an analysis of biologic medication use. When they were studied, interventions were often found to be highly cost-effective, with dominant incremental cost-effectiveness ratios in some cases. Reductions in direct costs and HCRU (health care visits, hospital admissions, and/or the use of medications, including add-on/reliever treatment and antibiotics) were frequently reported. Reported use of maintenance treatments improved in some studies. Counseling and/or digitally informed programs were used in all cases in which favorable outcomes were observed.

CONCLUSIONS

Adherence-promoting interventions are mostly cost-effective and often result in reduced HCRU and associated costs. Multidisciplinary care involving one-to-one advice and digitally enhanced communications appear to offer the greatest benefit.

One additional educational session in inhaler use to patients with COPD in primary health care - A controlled clinical trial

OBJECTIVE

To investigate whether one additional educational session about inhaler use, delivered to patients with COPD in primary healthcare, could affect the patients' skills in inhaler use. Specifically, to study the effects on errors related to handling the device, to inhalation technique, and to both.

METHODS

This nonrandomized controlled clinical trial included 64 patients who used devices and made errors. COPD nurses assessed inhaler use using a checklist and educated patients. Intervention group received one additional educational session after two weeks.

RESULTS

At baseline, patients in the IG had more devices (n = 2,1) compared to patients in the CG (n = 1,6) (p = 0.003). No other statistically significant differences were seen at baseline. At follow-up, intervention group showed a lower proportion of patients who made errors related to handling the device (p = 0.006). No differences were seen in the other categories.

CONCLUSION

One additional educational session in inhaler use for patients with COPD was effective in reducing the proportion of patients making errors related to handling of their devices.

PRACTICE IMPLICATIONS

Categorization of errors might help healthcare professionals to assess the suitability of patients' devices, tailor patient education, and thus improve patient health.

The Effect of a Theory of Planned Behavior Education Program on Asthma Control and Medication Adherence: A Randomized Controlled Trial

BACKGROUND

Disease management in individuals with asthma is affected by factors such as avoiding triggers that cause attacks and properly using inhaler devices.

OBJECTIVE

To determine the effect of a theory of planned behavior (TPB) education program on asthma control and medication adherence.

METHODS

A randomized controlled trial enrolled 30 participants in the intervention group and 30 in the control group. The educational approach was employed in participants in the intervention group for five home visits over 3 months according to the TPB program.

RESULTS

Before the education program, all participants in the intervention group and 90% of those in the control group had poorly controlled asthma (P > .05). After the program, all individuals in the intervention group and 20% of the control group had well-controlled asthma (P < .001). There was no statistically significant difference between Morisky Medication Adherence Scale-8 pretest scores in the intervention and control groups in terms of medication adherence (2.37 ± 1.75 and 3.13 ± 1.71, respectively; P > .05). Mean Morisky Medication Adherence Scale-8 scores in the intervention group at posttest (7.50 ± 0.78) were significantly higher than those of the control group (3.93 ± 2.03; P < .001.

CONCLUSIONS

This study revealed that asthma control and medication adherence increased in the intervention group after the TPB education program. The program was effective in asthma control and medication adherence for individuals with asthma.

Validation of the inhaler adherence questionnaire

Background

Although electronic monitoring is the “gold standard” for adherence monitoring, the range of inhaler devices on the market exceeds the availability of appropriate monitoring devices. Simple tools, applicable across a range of inhalers, are needed to assess patients’ adherence to prescribed inhaled medication. This study reports on the validation of an Inhaler Adherence Questionnaire (IAQ).

Methods

Seventy-four adults who self-reported doctor diagnosed asthma and who were prescribed daily inhaled corticosteroids (ICS) for asthma contributed data for these analyses. These participants were part of a larger study, investigating factors associated with non-adherence to prescribed daily inhaled corticosteroid medication. Participants were informed the research was investigating asthma management without explicit mention that medication adherence was being monitored. Inhaled corticosteroid medication adherence was measured in two ways. Firstly, participants completed the 6-item IAQ at enrolment. Secondly, ICS via pressurised Metered Dose Inhaler (pMDI) use was monitored electronically using the DoserCT which recorded daily use over 6 weeks. During the 6 weeks of prospective medication monitoring via the DoserCT we did not have contact with participants so that the adherence measure would reflect usual self-management behaviour.

Results

Two of the six questions in the IAQ had poor face validity and their exclusion from the questionnaire resulted in improved internal consistency. Mean days adherent were 37.1, 29.2 and 33.2% for subjects with IAQ scores of 0, 1 and 2 respectively. Higher IAQ scores of 3 and 4 were associated with greater mean days adherent of 73.7 and 67.4% respectively. A cut-point of 2 or less had a sensitivity of 73% and a specificity of 80% for detecting non-adherence. The area under the ROC curve was 0.764 (p < 0.001).

Conclusions

The modified 4-item IAQ is simple, quick to complete and useful for measuring adherence with prescribed daily inhaled medication. This validation of the IAQ provides evidence for its utility in research and it will be important to validate this simple, inexpensive tool for use in clinical practice.

WEARCON: wearable home monitoring in children with asthma reveals a strong association with hospital based assessment of asthma control

Background

Asthma is one of the most common chronic diseases in childhood. Regular follow-up of physiological parameters in the home setting, in relation to asthma symptoms, can provide complementary quantitative insights into the dynamics of the asthma status. Despite considerable interest in asthma home-monitoring in children, there is a paucity of scientific evidence, especially on multi-parameter monitoring approaches. Therefore, the aim of this study is to investigate whether asthma control can be accurately assessed in the home situation by combining parameters from respiratory physiology sensors.

Methods

Sixty asthmatic and thirty non-asthmatic children were enrolled in the observational WEARCON-study. Asthma control was assessed according to GINA guidelines by the paediatrician. All children were also evaluated during a 2-week home-monitoring period with wearable devices; a physical activity tracker, a handheld spirometer, smart inhalers, and an ambulatory electrocardiography device to monitor heart and respiratory rate. Multiple logistic regression analysis was used to determine which diagnostic measures were associated with asthma control.

Results

24 of the 27 uncontrolled asthmatic children and 29 of the 32 controlled asthmatic children could be accurately identified with this model. The final model showed that a larger variation in pre-exercise lung function (OR = 1.34 95%-CI 1.07–1.68), an earlier wake-up-time (OR = 1.05 95%-CI 1.01–1.10), more reliever use (OR = 1.11 95%-CI 1.03–1.19) and a longer respiratory rate recovery time (OR = 1.12 95%-CI 1.05–1.20) were significant contributors to the probability of having uncontrolled asthma.

Conclusions

Home-monitoring of physiological parameters correlates with paediatrician assessed asthma control. The constructed multivariate model identifies 88.9% of all uncontrolled asthmatic children, indicating a high potential for monitoring of asthma control. This may allow healthcare professionals to assess asthma control at home.

Trial registration

Netherlands Trail Register, NL6087. Registered 14 February 2017.

Optimizing inhaler use by pharmacist-provided education to community-dwelling elderly

OBJECTIVE

To assess, using a standard observational tool, the ability of patients to demonstrate and maintain proper inhaled medication administration techniques following pharmacist education.

DESIGN

Six-month observational study.

SETTING

Patients' homes or adult day health center.

PARTICIPANTS

Patients in a Program for All-inclusive Care for the Elderly (PACE) prescribed one or more inhaled medications used at least once daily.

INTERVENTION

Instruction by on-site clinical pharmacist.

MEASUREMENTS

Hickey's Pharmacies Inhaler Technique assessment (score range: 0-20, higher better).

RESULTS

Forty-two patients were evaluated at baseline, taught proper techniques for using inhaled medications, assessed immediately following the education, and re-assessed 4-6 weeks later. The mean pre-assessment score was 14 (SD 4.5, range 0-20), the initial post-assessment score increased to 18 (SD 3, range 10-20). The second post-assessment (4-6 weeks later) score mean was 17.7 (SD 3, range 10-20). Both follow-up scores were significantly improved from baseline (p < 0.05). Multivariable analysis indicated the strongest predictors of second post-training score were: score after initial pharmacist training and being subscribed to auto-refill. These characteristics predicted ∼70% of the variance in the second score (p < 0.001).

CONCLUSIONS

These results indicate that education by a pharmacist combined with an auto-refill program can improve and sustain appropriate inhaler use by community-dwelling elders in a PACE program. The improved score was maintained 4-6 weeks later indicating a sustained benefit of medication administration education. Optimal inhaler use ensures optimal dosing and supports appropriate inhaler treatment in lieu of oral agents.