Improving Medication Adherence in Asthma.

In little over a generation, the ingenuity of scientists and clinician researchers has developed inhaled medications and pathway-specific biological agents that control the inflammation and physiology of asthma. Unfortunately, whether it is because of cost or difficulty understanding why or how to use inhaled medications, patients often do not take these medications. The consequences of poor treatment adherence, loss of control and exacerbations, are the same as if the condition remained untreated. Furthermore, poor adherence is difficult to detect without direct measurement. Together this means that poor treatment adherence is easily overlooked and, instead of addressing the cause of poor adherence, additional medicines may be prescribed. In other words, poor treatment adherence is a risk for the patient and adds cost to healthcare systems. In this article, we discuss the rationale for and the delivery of successful interventions to improve medication adherence in asthma. We contextualize these interventions by describing the causes of poor treatment adherence and how adherence is assessed. Finally, future perspectives on the design of new interventions are described.

The Impact of Biofeedback on Self-Efficacy in Adults with Asthma: A Cross-Sectional Descriptive Survey.

Purpose: Educating patients to self-manage chronic diseases such as asthma is a key role for nurses. The success of this education is often limited by low patient self-efficacy. In this study, we hypothesized that the self-efficacy of patients could be enhanced if their education was based on biofeedback of their own self-management, following a nurse led educational intervention. Patients and Methods: Patients with severe and uncontrolled asthma from one centre who participated in an eight-month, nurse-led asthma education and dose adjustment Randomised Control Trial (RCT) were studied (NCT02307669). Inhaler adherence and technique of use were objectively assessed using a validated digital device. The data recorded on this device was used as the basis for the individualised biofeedback. The Asthma Self-efficacy Questionnaire was used to assess self-efficacy. Results: A total of 88 participants (44 in each group) completed the asthma self-efficacy questionnaire at the end of the study. The mean overall level of self-efficacy was high across both groups; 91 (8.7), with both biofeedback and standard care groups having similarly high levels of self-efficacy, biofeedback group: 89 (10) and standard care group 93 (6). Self-efficacy was not related to objective measures of adherence at either the start of the study, 68 (26), p=0.23, or the end of the study, 58 (32), p=0.62. It was also not related to peak expiratory flow (PEF) at the end of the study in either group (r2= 0.0245, p=0.14). Self-efficacy was related to asthma control test (ACT), 18 (5.5), p=0.0014 and quality-of-life measures; EuroQol (EQ5D3L) 6.4 (1.5) p=0.02. Conclusion: Repeated nurse-delivered education results in high levels of self-efficacy among patients with severe asthma. A high level of perceived self-efficacy should not be assumed to result in higher inhaler adherence.

A novel statistical method for assessing effective adherence to medication and calculating optimal drug dosages.

OBJECTIVE: We derive a novel model-based metric for effective adherence to medication, and validate it using data from the INhaler Compliance Assessment device (INCATM). This technique employs dose timing data to estimate the threshold drug concentration needed to maintain optimal health. METHODS: The parameters of the model are optimised against patient outcome data using maximum likelihood methods. The model is fitted and validated by secondary analysis of two independent datasets from two remote-monitoring studies of adherence, conducted through clinical research centres of 5 Irish hospitals. Training data came from a cohort of asthma patients (~ 47,000 samples from 218 patients). Validation data is from a cohort of 204 patients with COPD recorded between 2014 and 2016. RESULTS: The time above threshold measure is strongly predictive of adverse events (exacerbations) in COPD patients (Odds Ratio of exacerbation = 0.52 per SD increase in adherence, 95% Confidence Interval [0.34-0.79]). This compares well with the best known previous method, the Area Under the dose-time Curve (AUC) (Odds Ratio = 0.69, 95% Confidence Interval [0.48-0.99]). In addition, the fitted value of the dose threshold (0.56 of prescribed dosage) suggests that prescribed doses may be unnecessarily high given good adherence. CONCLUSIONS: The resulting metric accounts for missed doses, dose-timing errors, and errors in inhaler technique, and provides enhanced predictive validity in comparison to previously used measures. In addition, the method allows us to estimate the correct dosage required to achieve the effect of the medication using the patients' own adherence data and outcomes. The adherence score does depend not on sex or other demographic factors suggesting that effective adherence is driven by individual behavioural factors.

A protocol for a randomised clinical trial of the effect of providing feedback on inhaler technique and adherence from an electronic device in patients with poorly controlled severe asthma.

INTRODUCTION: In clinical practice, it is difficult to distinguish between patients with refractory asthma from those with poorly controlled asthma, where symptoms persist due to poor adherence, inadequate inhaler technique or comorbid diseases. We designed an audio recording device which, when attached to an inhaler, objectively identifies the time and technique of inhaler use, thereby assessing both aspects of adherence. This study will test the hypothesis that feedback on these two aspects of adherence when passed on to patients improves adherence and helps clinicians distinguish refractory from difficult-to-control asthma. METHODS: This is a single, blind, prospective, randomised, clinical trial performed at 5 research centres. Patients with partially controlled or uncontrolled severe asthma who have also had at least one severe asthma exacerbation in the prior year are eligible to participate. The effect of two types of nurse-delivered education interventions to promote adherence and inhaler technique will be assessed. The active group will receive feedback on their inhaler technique and adherence from the new device over a 3-month period. The control group will also receive training in inhaler technique and strategies to promote adherence, but no feedback from the device. The primary outcome is the difference in actual adherence, a measure that incorporates time and technique of inhaler use between groups at the end of the third month. Secondary outcomes include the number of patients who remain refractory despite good adherence, and differences in the components of adherence after the intervention. Data will be analysed on an intention-to-treat and a per-protocol basis. The sample size is 220 subjects (110 in each group), and loss to follow-up is estimated at 10% which will allow results to show a 10% difference (0.8 power) in adherence between group means with a type I error probability of 0.05. TRIAL REGISTRATION NUMBER: NCT01529697; Pre-results.

A nurse-led intervention study: Promoting compliance with Diskus Inhaler use in asthma patients.

AIM: To examine the impact of a nurse-led patient assessment and education programme in promoting compliance with inhaler use in asthma patients. DESIGN: A quasi-experimental pre-test and post-test design. METHODS: A sample of asthmatic patients (N = 21) were recruited from the population of patients attending an asthma clinic. An Inhaler Proficiency Schedule (IPS) was developed and validated. At each visit, participants were requested to demonstrate their inhaler technique. The participants were investigated as to their confidence level with self-administration of their inhaler and adherence to prescribed doses. This information was recorded on a Patient-Reported Behaviour (PRB) questionnaire. RESULTS: Technique, compliance and patient confidence levels improved with nurse-led education repeated over three visits; this was sustained on measurement at 6 months following completion of the education programme.