Enhancing patient adherence to asthma therapy
- Andrea J Apter, MD, MSc, MA
Andrea J Apter, MD, MSc, MA
- Professor of Medicine, Chief and Program Director
- Section of Allergy & Immunology, Division of Pulmonary, Allergy, Critical Care Medicine
- Perelman School of Medicine, University of Pennsylvania
Patient adherence to medical regimens is a major problem in chronic disease management. Adherence to asthma medication regimens tends to be very poor, with the reported rates of nonadherence ranging from 30 to 70 percent [1-3]. Up to three-quarters of the total costs associated with asthma may be due to poor asthma control. Improved patient adherence may lead to improvements in asthma control and quality of life . The role of the clinician is to adequately inform the patient about the prescribed regimen, and to discuss the importance of adherence even in the absence of symptoms. In the patient who subsequently manifests nonadherence, the clinician should explore with the patient barriers to adherence and methods to overcome these barriers.
REASONS FOR NONADHERENCE
A number of factors are associated with nonadherence to asthma therapy [1,2,5,6]. Medication-related factors include difficulties with inhaler devices, complex regimens, side effects, cost of medication, dislike of medication, and distant pharmacies.
Factors unrelated to medications include misunderstanding or lack of instruction, fears about side effects, dissatisfaction with health care professionals, unexpressed/undiscussed fears or concerns, inappropriate expectations, poor supervision/training or follow-up, anger about one's condition or its treatment, underestimation of severity, cultural issues, stigmatization, forgetfulness or complacency, attitudes toward ill health, and religious issues . Social barriers such as complicated work schedules, caring for other family members, or even the perceived safety of the neighborhood can all affect adherence . Finally, stress, depression, and comorbidities can all influence adherence [9-11].
Several other reasons make adherence to asthma treatment recommendations problematic: medication regimens are of long duration and include multiple medicines; dosing may occur on both a fixed schedule and an as needed basis; and patients go through periods of symptom remission .
A number of types of nonadherence can interfere with therapy, including underuse, overuse, or erratic use [1,12]. Underuse of asthma medications appears to be more common than overuse [13,14]. In a study comparing self-reported use of inhaled medications recorded in a diary to actual use determined by an electronic monitor of inhaler activation, it was found that subjects were not as compliant as they reported to be in their diaries . Another study found that inhaled beta agonists are no more likely to be overused than anti-inflammatory agents . This observation tends to dispel the concern that patients will overuse inhaled beta agonists because of their fast symptom relief.
- Bender BG, Bender SE. Patient-identified barriers to asthma treatment adherence: responses to interviews, focus groups, and questionnaires. Immunol Allergy Clin North Am 2005; 25:107.
- Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA). Full text available online at: www.ginasthma.org (Accessed on January 30, 2015).
- Rand CS, Wise RA. Measuring adherence to asthma medication regimens. Am J Respir Crit Care Med 1994; 149:S69.
- Thoonen BP, Schermer TR, Van Den Boom G, et al. Self-management of asthma in general practice, asthma control and quality of life: a randomised controlled trial. Thorax 2003; 58:30.
- Williams LK, Joseph CL, Peterson EL, et al. Patients with asthma who do not fill their inhaled corticosteroids: a study of primary nonadherence. J Allergy Clin Immunol 2007; 120:1153.
- Dima AL, Hernandez G, Cunillera O, et al. Asthma inhaler adherence determinants in adults: systematic review of observational data. Eur Respir J 2015; 45:994.
- Wells K, Pladevall M, Peterson EL, et al. Race-ethnic differences in factors associated with inhaled steroid adherence among adults with asthma. Am J Respir Crit Care Med 2008; 178:1194.
- Billimek J, Sorkin DH. Self-reported neighborhood safety and nonadherence to treatment regimens among patients with type 2 diabetes. J Gen Intern Med 2012; 27:292.
- Krauskopf KA, Sofianou A, Goel MS, et al. Depressive symptoms, low adherence, and poor asthma outcomes in the elderly. J Asthma 2013; 50:260.
- Bender B, Milgrom H, Rand C, Ackerson L. Psychological factors associated with medication nonadherence in asthmatic children. J Asthma 1998; 35:347.
- Yonas MA, Marsland AL, Emeremni CA, et al. Depressive symptomatology, quality of life and disease control among individuals with well-characterized severe asthma. J Asthma 2013; 50:884.
- Creer, TL. Understanding and dealing with noncompliance in asthma. J Respir Dis 1991; 12:S43.
- Kohler CL, Davies SL, Bailey WC. Self-management and other behavioral aspects of asthma. Curr Opin Pulm Med 1996; 2:16.
- Tan H, Sarawate C, Singer J, et al. Impact of asthma controller medications on clinical, economic, and patient-reported outcomes. Mayo Clin Proc 2009; 84:675.
- Berg J, Dunbar-Jacob J, Rohay JM. Compliance with inhaled medications: the relationship between diary and electronic monitor. Ann Behav Med 1998; 20:36.
- Bosley CM, Parry DT, Cochrane GM. Patient compliance with inhaled medication: does combining beta-agonists with corticosteroids improve compliance? Eur Respir J 1994; 7:504.
- Hindi-Alexander MC, Throm J, Middleton E Jr. Collaborative asthma self-management. Evaluation designs. Clin Rev Allergy 1987; 5:249.
- Apter AJ, Wang X, Bogen DK, et al. Problem solving to improve adherence and asthma outcomes in urban adults with moderate or severe asthma: a randomized controlled trial. J Allergy Clin Immunol 2011; 128:516.
- Wilson SR, Strub P, Buist AS, et al. Shared treatment decision making improves adherence and outcomes in poorly controlled asthma. Am J Respir Crit Care Med 2010; 181:566.
- Bender BG, Cvietusa PJ, Goodrich GK, et al. Pragmatic trial of health care technologies to improve adherence to pediatric asthma treatment: a randomized clinical trial. JAMA Pediatr 2015; 169:317.
- National Asthma Education and Prevention Program: Expert Panel Report III: Guidelines for the diagnosis and management of asthma. Bethesda, MD. National Heart, Lung, and Blood Institute, 2007. (NIH publication no. 08-4051) www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm (Accessed on March 17, 2016).
- Borrelli B, Riekert KA, Weinstein A, Rathier L. Brief motivational interviewing as a clinical strategy to promote asthma medication adherence. J Allergy Clin Immunol 2007; 120:1023.