Identifying patient-specific beliefs and behaviours for conversations about adherence in asthma

Background: Asthma guidelines advise addressing adherence at every visit, but no simple tools exist to assist clinicians in identifying key adherence‐related beliefs or behaviours for individual patients. Aims: To identify potentially modifiable beliefs and behaviours that predict electronically recorded adherence with controller therapy. Methods: Patients aged ≥14 years with doctor‐diagnosed asthma who were prescribed inhaled corticosteroid/long‐acting β₂‐agonist (ICS/LABA) completed questionnaires on medication beliefs/behaviours, side‐effects, Morisky adherence behaviour score and Asthma Control Test (ACT), and recorded spirometry. Adherence with ICS/LABA was measured electronically over 8 weeks. Predictors of adherence were identified by univariate and multivariate analyses. Results: 99/100 patients completed the study (57 female; forced expiratory volume in 1 s mean ± standard deviation 83 ± 23% predicted; ACT 19.9 ± 3.8). Mean electronically recorded adherence (n= 85) was 75% ± 25, and mean self‐reported adherence was 85% ± 26%. Factor analysis of questionnaire items significantly associated with poor adherence identified seven themes: perceived necessity, safety concerns, acceptance of asthma chronicity/medication effectiveness, advice from friends/family, motivation/routine, ease of use and satisfaction with asthma management. Morisky score was moderately associated with actual adherence (r=?0.45, P < 0.0001). In regression analysis, 10 items independently predicted adherence (adjusted R²= 0.67; P < 0.001). Opinions of friends/family about the patient's medication use were strongly associated with poor adherence. Global concerns about ICS/LABA therapy were more predictive of poor adherence than were specific side‐effects; the one‐third of patients who reported experiencing side‐effects from their steroid inhaler had lower adherence than others (mean 62% vs 81%; P= 0.015). Conclusions: This study identified several specific beliefs and behaviours which clinicians could use for initiating patient‐centred conversations about medication adherence in asthma.     

Trends in asthma self-management skills and inhaled corticosteroid use during pregnancy and postpartum from 2004 to 2017

Objective: Asthma exacerbations and medication non-adherence are significant clinical problems during pregnancy. While asthma self-management education is effective, the number of education sessions required to maximise asthma management knowledge and inhaler technique and whether improvements persist postpartum, are unknown. This paper describes how asthma knowledge, skills, and inhaled corticosteroid (ICS) use have changed over time. Methods: Data were obtained from 3 cohorts of pregnant women with asthma recruited in Newcastle, Australia between 2004 and 2017 (N = 895). Medication use, adherence, knowledge, and inhaler technique were compared between cohorts. Changes in self-management knowledge/skills and women's perception of medication risk to the fetus were assessed in 685 women with 5 assessments during pregnancy, and 95 women who had a postpartum assessment. Results: At study entry, 41%, 29%, and 38% of participants used ICS in the 2004, 2007, and 2013 cohorts, respectively (p = 0.017), with 40% non-adherence in each cohort. Self-management skills of pregnant women with asthma did not improve between 2004 and 2017 and possession of a written action plan remained low. Maximum improvements were reached by 3 sessions for medications knowledge and one session for inhaler technique, and were maintained postpartum. ICS adherence was maximally improved after one session, but not maintained postpartum. Perceived risk of asthma medications on the fetus was highest for corticosteroid-containing medication; and was significantly reduced following education. Conclusions: There was a high prevalence of non-adherence and poor self-management skills in all cohorts. More awareness of the importance of optimal asthma management during pregnancy is warranted, since no improvements were observed over the past decade.     

Adolescents’ inhaled corticosteroid adherence: the importance of treatment perceptions and medication knowledge

Background: Studies measuring inhaled corticosteroid (ICS) adherence frequently report adherence rates below 50%. Although asthma is common in adolescents, few studies have explored determinants of ICS adherence in adolescents. The objective of this study was to examine adherence and related factors in adolescent ICS users. Methods: Adolescent ICS users, aged 12–18 years, were randomly recruited from a sample of 94 community pharmacies belonging to the Utrecht Pharmacy Practice Network for Education and Research to complete an online questionnaire. The survey contained questions on asthma control, self-reported adherence, medication beliefs and medication knowledge. Data were collected between April and August 2013. Results: Complete questionnaire data were received from 182 adolescents of which 40% reported to be adherent. Approximately 40% of the participants perceived strong needs, whilst only 10% was highly concerned about adverse effects regarding their ICS use. Good adherence was significantly associated with asthma control (OR: 2.1, 95% CI: 1.1–4.1). Necessity beliefs and sufficient medication knowledge were associated with better adherence (p?<?0.05). Conclusion: Our results suggest that by improving knowledge about asthma treatments and stimulating positive perceptions towards medicines, especially regarding the necessity of medication use, better adherence rates might be achieved.     

Improving pediatric asthma care: A partnership between pediatric primary care clinics and a free-standing Children's Hospital

Background: Asthma is a common chronic disease of childhood. Providers’ adherence to asthma guidelines is still less than optimal. Objectives: To determine if an Asthma Education Program aimed at primary care practices can improve asthma care within practices and if the results vary by duration of the program. Methods: Ten practices were randomly assigned to an Early Asthma Education Intervention (EI) group or a Delayed Asthma Education Intervention (DI) group. The EI group received the intervention for 12 months and was monitored for 6 additional months. The DI group was observed without intervention for 12 months, then received the intervention for 6 months, and was monitored for 6 additional months. The program included training of asthma educators in each practice and then monitoring for improvement in medical record documentation of National Asthma Education and Prevention Program (NAEPP) asthma quality indicators by blinded random review of patient charts. Results: In the EI group, 6-, 12-, and 18-month data revealed significant improvement in documentation of asthma severity, education, action plan, night time symptoms, and symptoms with exercise compared to baseline and compared to DI group at baseline and at the 12-month interval. In the DI group, significant improvement in documentation in all of the above endpoints and also in documentation of NAEPP treatment guidelines was noted at 18 and 24 months. In both groups, documentation levels remained relatively stable at 6 months after the intervention, with no significant differences between groups. While improved, guideline adherence was <80% for half of the indicators. Conclusion: In-office training of non-physician asthma providers improves the quality of asthma care.     

Enhancing guideline‐based asthma care processes through a multi‐state,multi‐center quality improvement program

Objective: This study investigated the effectiveness of Enhancing Care for Patients with Asthma (ECPA)—a collaborative quality improvement program implemented in 65 community health centers that serve asthma patients in four states—on clinic‐based asthma performance measures consistent with national guidelines. Methods: This study utilized a pretest‐posttest quasi‐experimental design. Six clinic‐based performance measures of each center were collected from a retrospective chart review at time points: before the ECPA implementation; at the end of the 12‐month long ECPA program; and 6 months after program completion. The effectiveness of the ECPA was assessed using generalized linear mixed models with a Poisson distribution and log link by evaluating the change in each measure from baseline to program completion, from baseline to 6‐month post‐program completion and from program completion to 6‐month post‐program completion. Results: The ECPA implementation was positively associated with improvement in all measures from baseline to program completion: documentation of asthma severity (rate ratio (RR) 1.314; 95% confidence interval (CI) 1.206, 1.432); Asthma Control Test (RR 3.625; 95% CI 3.185, 4.124); pulmonary function testing (RR 1.771; 95% CI 1.527, 2.054), asthma education (RR 2.246; 95% CI 2.018, 2.501), asthma action plan (RR 2.335; 95% CI 2.070, 2.634) and controller medication (RR 1.961; 95% CI 1.504,2.556). Improvement was sustained for all six measures at the 6‐month post‐program completion time point. Conclusion: This study demonstrated the favorable effect of the ECPA program on evidence‐based asthma quality measures. This program could be considered a model worth replication on a broader scale.     

Results from a community-based trial testing a community health worker asthma intervention in Puerto Rican youth in Chicago

Abstract

Objective: Puerto Rican children suffer disproportionately from asthma. Project CURA tested the efficacy of a community health worker (CHW) intervention to improve use of inhaled corticosteroids (ICS) and reduce home asthma triggers in Puerto Rican youth in Chicago. Methods: This study employed a behavioral randomized controlled trial design with a community-based participatory research approach. Medications and technique were visually assessed; adherence was determined using dose counters. Home triggers were assessed via self-report, visual inspection and salivary cotinine. All participants received education on core asthma topics and self-management skills. Participants in the CHW arm were offered home education by the CHW in four visits over four months. The attention control arm received four newsletters covering the same topics. Results: While most of the participants had uncontrolled persistent asthma,?<?50% had ICS at baseline. In the CHW arms, 67% of participants received the full four-visit intervention. In the Elementary school cohort (n?=?51), the CHW arm had lower odds of having an ICS (OR?=?0.2; p?=?0.02) at 12-months; no differences were seen in other outcomes between arms at any time point. The only significant treatment arm difference in the high school cohort (n?=?50) was in inhaler technique where the CHW arm performed 18.0% more steps correct at five months (p?<?0.01) and 14.2% more steps correct at 12 months (p?<?0.01). Conclusions: While this CHW intervention did not increase the number of participants with ICS or reduce home asthma triggers, important lessons were learned including challenges to CHW intervention fidelity and the need for CHWs to partner with clinical providers.     

Burden of asthma among patients adherent to ICS/LABA: A real-world study

Objectives: Asthma is a chronic respiratory condition with a U.S. prevalence of 7.4%. Despite numerous treatment options, asthma remains poorly controlled in some patients. Uncontrolled asthma is associated with high healthcare resource utilization (HCRU) and reduced productivity. This study assessed symptoms, productivity, and HCRU of patients adherent to medium/high-dosage inhaled corticosteroid/long-acting beta2-agonist (ICS/LABA) treatment, and the relationship of asthma control with these parameters. Methods: Data were collected in the U.S. in 2013–2016 in the Adelphi Respiratory Disease Specific Programme, a cross-sectional survey. Participating physicians (n = 258) each completed a record form for eligible patients, who were receiving medium/high-dosage ICS/LABA treatment with self-reported moderate/high adherence, completed the Asthma Control Test (ACT) and the Work Productivity and Activity Impairment (WPAI) questionnaire, and were included in the analyses. Results: Patients (n = 428) had a mean of 59% symptom-free days in the past month. Wheezing was the most troublesome symptom for 25% of patients. In the previous 12 months, the mean number of exacerbations was 1.3; 15% of exacerbations required emergency room treatment and/or hospitalization. Mean physician visits for asthma was 5.7. Asthma impacted leisure/personal time frequently/constantly for 11% of patients, with 20% overall work impairment. Asthma was poorly controlled (ACT score ≤15) in 18% of patients; poorer asthma control was associated with higher rates of exacerbations, work impairment, and HCRU. Conclusion: Given the substantial burden described, greater attention to asthma monitoring and management is necessary. Identification of novel treatments may be important for patients not responding to medium/high-dosage ICS/LABA treatment.     

Combining pharmacy expertise with asthma educator certification: assessing the impact on inner-city asthma patients

Objective: Asthma is one of the major causes of hospital readmissions in the South Bronx. The goal of this study was to assess the impact of asthma education provided by registered pharmacists with asthma educator certification (AE-C), on medication adherence and hospitalizations/Emergency Department (ED) visits. Methods: This was a retrospective chart review of patients seen in the pulmonary clinic from October 2014 to August 2015 for asthma education by AE-C pharmacists. Medical records were reviewed over an 18-month period – 9?months before and after the initial asthma education session. Data obtained included adherence to asthma controller inhalers based on pharmacy refill claims, asthma control using asthma control test (ACT) scores and asthma-related hospitalizations or ED visits within 30?days of asthma education. Pre-education data served as the pre-intervention group data and post-education data served as the post-intervention group data, allowing each patient to serve as their own control. Results: We found a statistically significant improvement in average medication adherence, i.e. asthma controller inhaler fills at pharmacy (46.3% vs 67.9%, p-value <0.001) and asthma control (15.71% vs 56.38%, p-value <0.001) between the pre-intervention and the post-intervention groups. Additionally, a lower hospitalization/ED utilization rate (31.2% vs 6.38%, p-value <0.001) was observed in the post-intervention group within 30?days of education. Conclusions: Asthma education provided by AE-C pharmacists had a positive impact on asthma care in our inner-city community. Improving medication adherence and asthma control as well as decreasing hospital utilization could potentially decrease health care costs in addition to improving quality of life.     

Exploring the intersection of executive function and medication adherence in school-age children with asthma

Asthma is one of the most common chronic diseases of childhood. For children with persistent asthma, asthma control is largely related to controller medication adherence. With increasing calls for children to be involved in their own asthma management, there is a gap in our knowledge about the executive functioning of children with asthma. Objective: The purpose of this study was to explore the relationship between executive function, asthma, and medication adherence among school-age children with asthma. Methods: Thirty-one children ages 7 to 11 years (M = 8.9 ± 1.51) and one of their parents were enrolled in this study. Parents reported on asthma control while children reported on asthma control, medication beliefs, medication adherence, and completed an executive function battery that assessed inhibition, updating, shifting and planning. Results: Compared to the reference sample, children in this study had significantly lower composite scores in inhibition, t (31) = ?3.84, p =. 001, and shifting, t (30) = ?3.73, p =. 001. Controlling for age and asthma control, hierarchical regression analyses revealed that shifting accounted for 16% of the variance in child-reported medication adherence. Conclusions: This study revealed lowered executive functioning scores among school-age children with persistent asthma. Furthermore, it appears executive functioning and controller medication adherence are intertwined and warrant future exploration.     

Association of caregiver health beliefs and parenting stress with medication adherence in preschoolers with asthma

Objective: This study examined the associations of parenting stress and caregiver negative health beliefs with medication adherence in a sample of preschool-aged children with asthma.

Methods: Participants included 43 caregivers and their child with asthma, aged 2–5?years, who were prescribed a preventative or controller medication. Assessment included parent report of parenting stress associated with parental characteristics and difficult child behavior, health-related beliefs, and adherence to inhaled corticosteroids (ICS). Pharmacy refill records were reviewed to measure medication adherence objectively. Statistical analyses included paired samples t-test and Pearson’s correlation coefficients.

Results: Parent-report and objective measures of adherence to ICS were significantly different, with parents reporting significantly higher rates of medication adherence (p?p?Conclusions: Because the findings for parenting stress are not consistent with that of the literature on school-aged children with asthma, our results may suggest that preschool children are a unique developmental group. A review of endorsed health beliefs also highlights strengths and concerns for caregivers of these very young children. Overall, our study findings underscore the importance of caregivers’ health-related beliefs in promoting adherence to ICS in young children with asthma.     

Controller adherence following hospital discharge in high risk children: A pilot randomized trial of text message reminders

Objective: To assess the feasibility of a mobile health, inhaled corticosteroid (ICS) adherence reminder intervention and to characterize adherence trajectories immediately following severe asthma exacerbation in high-risk urban children with persistent asthma. Methods: Children aged 2–13 with persistent asthma were enrolled in this pilot randomized controlled trial during an asthma emergency department (ED) visit or hospitalization. Intervention arm participants received daily text message reminders for 30 days, and both arms received electronic sensors to measure ICS use. Primary outcomes were feasibility of sensor use and text message acceptability. Secondary outcomes included adherence to prescribed ICS regimen and 30-day adherence trajectories. Group-based trajectory modeling was used to examine adherence trajectories. Results: Forty-one participants (mean age 5.9) were randomized to intervention (n = 21) or control (n = 20). Overall, 85% were Black, 88% had public insurance, and 51% of the caregivers had a high school education or less. Thirty-two participant families (78%) transmitted medication adherence data; of caregivers who completed the acceptability survey, 25 (96%) chose to receive daily reminders beyond that study interval. Secondary outcome analyses demonstrated similar average daily adherence between groups (intervention = 36%; control = 32%, P = 0.73). Three adherence trajectories were identified with none ever exceeding 80% adherence. Conclusions: Within a high-risk pediatric cohort, electronic monitoring of ICS use and adherence reminders delivered via text message were feasible for most participants, but there was no signal of effect. Adherence trajectories following severe exacerbation were suboptimal, demonstrating an important opportunity for asthma care improvement.     

The patient's perspective: adherence or non-adherence to asthma controller therapy?

STUDY OBJECTIVE: Adherence with controller therapy poses a major challenge to the effective management of persistent asthma. The aim of this study was to explore the patient-related aspects of adherence among adult asthmatics. DESIGN AND PARTICIPANTS: The participants (n = 509 adult asthmatics), recruited from all parts of Denmark, answered the questionnaire concerning asthma knowledge, attitudes, adherence, and treatment through the Internet. RESULTS: A total of 67% of the patients were prescribed inhaled corticosteroids (ICS). However, according to Global Initiative for Asthma (GINA)-guidelines' symptom severity classification, 85% should have been on ICS. Accidental and intentional non-adherence with ICS at least twice a week was reported by 27% and 24%, respectively. In case of deterioration, 60% of the patients preferred to take more reliever medication, instead of increasing the ICS dose. Having a fixed daily routine with regard to medication and following the advice given by their doctor were the main reasons for adherence, whereas lack of perceived symptoms was the main reason for non-adherence. Non-adherence was associated with increasing disagreement with the statements that controller therapy is effective (p < 0.04), as well as an essential part of asthma therapy (p < 0.002). CONCLUSIONS: Both accidental and intentional non-adherence with controller therapy is common among adult asthmatics. The reasons for suboptimal adherence seem to be accessible through education of both patients and caregivers.     

Effectiveness of drug treatment strategies to prevent asthma exacerbations and increase symptom-free days in asthmatic children: a network meta-analysis

Objective: To determine the effectiveness and safety of current maintenance therapies that include inhaled corticosteroids (ICS), long-acting β-agonists (LABA) and/or leukotriene receptor antagonists (LTRAs) in preventing exacerbations and improving symptoms in pediatric asthma. Methods: A systematic review with network meta-analysis was conducted after a comprehensive search for relevant studies in the PubMed, Cochrane Library, Embase and Clinical Trials databases, up to July 2014. Randomized clinical trials were selected comparing treatment strategies of the Global Initiative for Asthma guidelines. The full-text randomized clinical trials compared maintenance treatments for asthma in children (≤18 years) of ≥4 weeks duration, reporting exacerbations or symptom-free days. The primary and secondary effectiveness outcomes were the rates of moderate/severe exacerbations and symptom-free days from baseline, respectively. Withdrawal rates were taken as the safety outcome. Results: Included in the network meta-analysis was 35 trials, comprising 12?010 patients. For both primary and secondary outcomes, combined ICS and LABA was ranked first in effectiveness (OR 0.70, 95% CI: 0.52–0.97 and OR 1.23, 95% CI: 0.94–1.61, respectively, compared with low-dose ICS), but the result of secondary outcomes was statistically insignificant. Low-dose ICS, medium- or high-dose ICS and combined ICS and LTRA strategies were comparable in effectiveness. ICS monotherapies, and ICS?+?LABA and ICS?+?LTRA strategies were similarly safe. High-dose ICS had the highest rate of total withdrawals, but the difference was not significant. Conclusions: Combined ICS and LABA treatments were most effective in preventing exacerbations among pediatric asthma patients. Medium- or high-dose ICS, combined ICS and LTRAs, and low-dose ICS treatments seem to be equally effective.     

The Patient's Perspective: Adherence or Non-adherence to Asthma Controller Therapy?

Study objective. Adherence with controller therapy poses a major challenge to the effective management of persistent asthma. The aim of this study was to explore the patient-related aspects of adherence among adult asthmatics. Design and participants. The participants (n = 509 adult asthmatics), recruited from all parts of Denmark, answered the questionnaire concerning asthma knowledge, attitudes, adherence, and treatment through the Internet. Results. A total of 67% of the patients were prescribed inhaled corticosteroids (ICS). However, according to Global Initiative for Asthma (GINA)-guidelines' symptom severity classification, 85% should have been on ICS. Accidental and intentional non-adherence with ICS at least twice a week was reported by 27% and 24%, respectively. In case of deterioration, 60% of the patients preferred to take more reliever medication, instead of increasing the ICS dose. Having a fixed daily routine with regard to medication and following the advice given by their doctor were the main reasons for adherence, whereas lack of perceived symptoms was the main reason for non-adherence. Non-adherence was associated with increasing disagreement with the statements that controller therapy is effective (p < 0.04), as well as an essential part of asthma therapy (p < 0.002). Conclusions. Both accidental and intentional non-adherence with controller therapy is common among adult asthmatics. The reasons for suboptimal adherence seem to be accessible through education of both patients and caregivers.     

Outcomes of the Montana Asthma Home Visiting Program: A home-based asthma education program

Objective: Asthma is a common disease in children. Home-based, multi-trigger, multi-component interventions with an environmental focus have been shown to be effective to address asthma in children. The objective of this study was to assess the outcomes and feasibility of implementing a specific asthma home visiting (HV) program in a rural area. Methods: Children aged 0–17 years with uncontrolled asthma were enrolled in an asthma HV program that included six contacts over a 12-month period delivered by a registered nurse specifically trained in asthma education and trigger removal in eleven counties in the rural state of Montana. Between June 2010 and December 2016, data on asthma symptoms and asthma self-management skills were collected at baseline and throughout the program. In June 2017, they were analyzed to assess changes in asthma control and quality of life over time among participants completing all six contacts. Results: Since June 2010, 152 of 338 enrolled children completed all six contacts outlined in the program (45%). Participants who completed the program reported significant improvements in asthma control test scores, self-management skills, and self-efficacy related to asthma management. These results improved the longer participants remained in the program. Conclusions: These findings suggest that it is feasible to implement a 12-month HV program using local public health resources in a rural area as outcomes improved over this time period.     

Impact of an Adherence Intervention Program on Medication Adherence Barriers,Asthma Control,and Productivity/Daily Activities in Patients With Asthma

Objective. This study evaluated the impact of an asthma patient intervention program, with a focus on medication adherence on adherence barriers, asthma control, and productivity/daily activities. Methods. Patients ≥18 years old who were employed by a large Southeastern public school system, had ≥1 medical claim for asthma, and were taking ≥1 asthma medication were invited to participate in the study. The ASK-20, the Asthma Control Test (ACT), and a productivity questionnaire were administered before and after a 6-month period of intervention that involved the use of baseline ASK-20 results to create patient-specific reports on adherence barriers and talking points for care managers to use during the two outbound telephone calls addressing barriers identified. Patients also received three educational mailings. The ASK-20 is a brief, self-reported instrument developed to identify patient-specific barriers to medication adherence and to improve provider/patient communication about adherence. Results. Of 112 individuals who enrolled, 87 completed the program (77.7%). Participants' mean age was 48.2 years (SD = 10.5), and most were female (86.2%) and white (64.4%). The mean number of years with asthma was 17.5 (SD = 14.7); approximately one third (36.8%) of participants had had asthma for >20 years. The intervention was associated with a significant reduction in the number of adherence barriers (3.8 to 2.8; p = .0021) as well as improvement in asthma control as reflected in an increase in the percentage of participants with controlled asthma defined as having an ACT score > 19 (50.0% to 64.6%; p = .0285). Significant reductions in the mean number of days that housework or schoolwork was limited by asthma (p = .0059) and the mean number of days that family, social, or recreational activities were missed or limited because of asthma (p = .0185) were also observed. The majority of the participants (95%) rated the program as being good, very good, or excellent. Conclusion. Programs incorporating a clinical assessment tool such as the ASK-20 for identifying a broad range of risk factors for nonadherence and for developing patient-specific intervention may reduce adherence barriers and improved disease control and ability to perform daily activities in patients with asthma.