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 ß(2)-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 R(2) = 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.

Adherence to asthma therapy in the preschool child.

Preschool children's adherence to asthma therapy is often sub-optimal and can result in decreased quality of life for children and parents, as well as an increased risk for dangerous asthma exacerbations. Asthma management for the preschool child presents some unique challenges to adherence to therapy, including the child's limited ability to communicate, multiple caregivers responsible for medications, and parental concerns about medications. Parent beliefs, characteristics of the regimen, and family functioning have been associated with adherence levels. Understanding and improving adherence to asthma therapy for the preschool child will necessarily require addressing these age-specific concerns.

Reasons for pediatrician nonadherence to asthma guidelines.

BACKGROUND: The 1997 National Heart, Lung, and Blood Institute (NHLBI) asthma guidelines include recommendations on how to improve the quality of care for asthma. OBJECTIVE: To identify barriers to physician adherence to the NHLBI guidelines. DESIGN: Cross-sectional survey. PARTICIPANTS: A national random sample of 829 primary care pediatricians. MAIN OUTCOME MEASURES: Self-reported adherence to 4 components of the NHLBI guidelines (steroid prescription, instructing peak flow meter use, screening and counseling patients with asthma for smoking, and screening and counseling parents for smoking). We also collected information on physician demographics, practice characteristics, and possible barriers to adherence. We defined adherence as following a guideline component more than 90% of the time. RESULTS: The response rate was 55% (456/829). Most of the responding pediatricians were aware of the guidelines (88%) and reported having access to a copy of the guidelines (81%). Self-reported rates of adherence were between 39% and 53% for the guideline components. After controlling for demographics and other barriers, we found that nonadherence was associated with specific barriers for each guideline component: for corticosteroid prescription, lack of agreement (odds ratio [OR], 6.8; 95% confidence interval [CI], 3.2-14.4); for peak flow meter use, lack of self-efficacy (OR, 3.4; 95% CI, 1.9-6.1) and lack of outcome expectancy (OR, 4.7; 95% CI, 2.5-8.9); and for screening and counseling of patients and parents for smoking, lack of self-efficacy (OR, 3.8; 95% CI, 1.7-6.2 and OR, 2.8; 95% CI, 1.3-5.9, respectively). CONCLUSIONS: Although pediatricians in this sample were aware of the NHLBI guidelines, a variety of barriers precluded their successful use. To improve NHLBI guideline adherence, tailored interventions that address the barriers characteristic of a given guideline component need to be implemented.

Rural school nurses' asthma education needs.

School nurses play an important role in identifying children with asthma and providing care during school hours. Educational programs designed to improve nurses' asthma knowledge and practices have concentrated on urban settings. The purpose of this investigation was to determine asthma-related practices and educational needs of rural school nurses. A survey about asthma was mailed to school nurses in all counties of the state of Maryland and in Washington, D.C. Responses were compared between rural Maryland counties and counties from the remainder of Maryland and Washington, D.C. The survey addressed attitudes and beliefs, function and roles, medication administration, and educational needs about asthma. We found that rural nurses used peak flow meters less often to assess and monitor asthma, requested fewer referrals for asthma, had fewer interactions with health room assistants, and had reduced access to asthma educational resources. Also, they provided less asthma education in the schools than other school nurses. These results suggest a need for comprehensive asthma educational programs in rural areas that are based on national guidelines, and that address the unique needs of rural school nurses. These programs should also emphasize the need for open communication between rural school nurses, health room assistants, primary care providers, and parents/caregivers.

Derivation of adherence metrics from electronic dosing records.

Numerous adherence variables have been created from electronic dosing records hindering synthesis of the vast body of adherence research. To elucidate the mathematical foundation for electronic adherence monitoring and to understand how diverse electronic adherence metrics are related to each other and the underlying construct of adherence behavior. Several representative adherence metrics are derived mathematically and their relationship to the underlying consumption (or dosing event) rate analyzed. Data from a 3-month study of 286 individuals on single-drug antihypertensive therapy are then used to empirically study the statistical properties of several of these electronic adherence metrics. As suggested by their common link to the consumption (or dosing event) rate, the analyzed electronic adherence metrics were generally strongly correlated (r <- .6 and > .4). The lowest correlation (r = .15) involved the ratio of the observed number of doses to the recommended number (called average adherence), which tended to emphasize quantity consumed, and the ratio of the observed to maximum mean squared rate deviation (MSRD ratio), which focused more on dose timing. Despite their different formulations, electronic adherence variables are generally closely correlated. Adherence metrics that average the consumption rate over multiple doses (by summing up the number of doses and dividing by the monitored time) may be less sensitive to short-term fluctuations in medication intake. Metrics that are more sensitive to timing variability may thus be preferable when timing as well as quantity of dosing are of interest.

Maternal depressive symptoms and emergency department use among inner-city children with asthma.

CONTEXT: Inner-city minority children with asthma use emergency departments (ED) frequently. OBJECTIVE: To examine whether maternal depressive symptoms are associated with ED use. DESIGN, SETTING, AND PATIENTS: Baseline and 6-month surveys were administered to mothers of children with asthma in inner-city Baltimore, Md, and Washington, DC. MAIN OUTCOME MEASURES: Use of the ED at 6-month follow-up was examined. Independent variables included asthma morbidity, age, depressive symptoms, and other psychosocial data. RESULTS: Among mothers, nearly half reported significant levels of depressive symptoms. There were no demographic or asthma-related differences between the children of mothers with high and low depressive symptoms. However, in bivariate analyses, mothers with high depressive symptoms were 40% (prevalence ratio [PR], 1.4; 95% confidence interval [CI], 1.0-3.6; P =.04) more likely to report taking their child to the ED. Mothers aged 30 to 35 years were more than twice as likely (PR, 2.2; 95% CI, 1.9-9.3; P =.001) to report ED use, as were children with high morbidity (PR, 1.9; 95% CI, 1.4-7.1; P =.006). Child age and family income were not predictive of ED use. After controlling for asthma symptoms and mother's age, mothers with depressive symptoms were still 30% more likely to report ED use. CONCLUSIONS: Depression is common among inner-city mothers of children with asthma. Beyond asthma morbidity, maternal age and depressive symptoms are strong predictors of reports of ED visits. Identifying and addressing poor psychological adjustment in mothers may reduce unnecessary ED visits and optimize asthma management among inner-city children.

Depression in sarcoidosis.

Sarcoidosis, a chronic, multisystem disease, impacts quality of life and may increase depression risk. No previous study has reported the depression prevalence among U.S. sarcoid patients. This cross-sectional study examined sociodemographic and disease morbidity factors associated with depression. Patients diagnosed for > or = 1 yr and treated at one of six centers were eligible (n = 176); 154 completed a questionnaire of demographics, treatment, access to medical care, and a short-form Center for Epidemiologic Studies- Depression Scale (CES-D). The primary outcome variable was a CES-D score of > or = 9, indicating clinical depression. The prevalence of depression was 60%. Gender, income, access to medical care, dyspnea on exertion, and number of systems involved were associated with depression. Female sex, decreased access to medical care, and increased dyspnea predicted depression (odds ratio [OR] = 3.33, 11.64, and 2.78, respectively) after adjusting for race, income, and steroid therapy. Despite tertiary care access, patients reported medical care limitation. Health care providers must be sensitive to multiple barriers faced by chronic sarcoid patients; acknowledging depression risk and improving access to medical care will promote better overall health among sarcoid patients. Future studies of sarcoidosis will need to address depression diagnosis and treatment.

Thinner females and heavier males: who says? A comparison of female to male ideal body sizes across a wide age span.

OBJECTIVE: To examine the possibility of a more restrictive thinness standard for females than males across a wide age span. METHOD: Ratings of ideal male and female body sizes were elicited from 303 children, 427 adolescents, 261 young adults, and 326 middle-age adults. Line drawings of babies, children, young adults, and middle-age and older adults were portrayed, ranging in size from very thin to very obese. RESULTS: Most subjects irrespective of gender selected similar ideal body sizes for males and females in each comparison. Very few consistently selected a thinner female than male ideal size. Young adults were more likely than other groups to prefer thinner females. DISCUSSION: The selection of similar thinness standards for both genders is encouraging from a health perspective. However, in all groups, a small bias existed favoring thinner females. This bias may contribute to body concerns in the female population.

A cohort study of possible risk factors for over-reporting of antihypertensive adherence.

BACKGROUND: The identification of poor medicinal adherence is difficult because direct observation of medication use is usually impractical. Up to 50% of individuals on chronic therapies may not be taking their medication as prescribed. This study is one of the first to explore possible risk factors for over-reporting of antihypertensive adherence using electronic medication monitoring. METHODS: The adherence of 286 individuals on single-drug antihypertensive therapy in a large managed care organization was electronically monitored for approximately three months. Questionnaires on socioeconomic background, adherence to therapy, health beliefs, and social support before and after adherence monitoring were completed. Over-reporting of antihypertensive adherence was assessed by comparing the self-reported frequency of noncompliance with that determined from electronic dosing records. Risk factors for over-reporting were identified by contingency table analysis and step-wise logistic regression. RESULTS: Although only 21% of participants acknowledged missing doses on one or more days per week, electronic monitoring documented nonadherence at this or a higher level in 42% of participants. The following variables were associated with over-reporting: >1 versus 1 daily dose (OR = 2.58; 95% CI = 1.50-4.41; p =.0006), lower perceived health risk from nonadherence (OR = 1.35; 95% CI = 1.10-1.64; p =.0035), and annual household income of <15,000 dollars versus >30,000 dollars (OR = 2.64; 95% CI = 1.13-6.18; p =.025). CONCLUSIONS: Over-reporting of adherence may be affected by factors related to dosing frequency, health beliefs and socioeconomic status. This topic deserves further investigation in other patient populations to elucidate possible underlying behavioral explanations.

Measuring adherence to behavioral and medical interventions.

Measuring adherence to medical and behavioral interventions is important to clinicians and researchers since inadequate adherence can reduce the effectiveness of an intervention. Unfortunately, there is no gold standard for measuring adherence across health behaviors. Adherence needs to be defined situationally with parameters of acceptable adherence carefully delineated and appropriate to the health behavior being studied. Additionally, measurement methods must be valid, reliable, and sensitive to change; this paper reviews these criteria. Methods used to measure adherence to dietary interventions include 24-hour recalls, food diaries, and food frequency questionnaires. Direct and indirect calorimetry, doubly labeled water, and a variety of self-report methods can be used to measure adherence in physical activity interventions. Adherence to pharmacological interventions is assessed using self-report methods, biochemical measures, medication counts, and the automated pharmacy database review strategy. The strengths and weaknesses of these methods for measuring adherence to dietary, physical activity, and pharmacological interventions are reviewed. Control Clin Trials 2000;21:188S-194S

Ethics in adherence promotion and monitoring.

In evaluating and intervening to increase adherence to medical treatments, clinicians and researchers must address ethical issues pertaining to best interest, autonomy, and privacy. "Best interest" refers to the notion that health-care practitioners act in a manner that produces benefits or good outcomes for the patients in their care. "Autonomy" refers to the patient's right to determine whether or not they will accept medical treatment or participate in a clinical study. "Nonmaleficence" refers to the clinician's or researcher's responsibility to "do no harm." "Privacy" refers to the notion that researchers and clinicians promise not to divulge personal information about the patients in their care. Adherence monitoring and promotion pose ethical challenges to researchers and clinicians, which are the topic of this paper. Control Clin Trials 2000;21:241S-247S

The "good enough" body size as judged by people of varying age and weight.

OBJECTIVE: To examine the concept of the "good enough" body size acceptability across a wide range of ages and weight status. RESEARCH METHODS AND PROCEDURES: Subjects were 303 children, 427 adolescents, 261 young adults, and 326 middle-age adults who selected acceptable body sizes from an array of drawings representing their own age and gender. They also selected body sizes representing their own actual and ideal size. RESULTS: A large majority (87%) of subjects considered their own body size socially acceptable. This finding applied to both genders in all age groups and to underweight, normal weight, and overweight subjects. Even among obese subjects, 48% considered their own body size socially acceptable. For the large percentage of subjects who reported a discrepancy between their actual and ideal body sizes, most considered their own body size acceptable. This finding also applied to both genders in all age groups and to underweight, normal weight, and overweight subjects. DISCUSSION: Most male and female subjects across a wide range of ages and status considered their own body size to be within the range of socially acceptable body sizes even though, for many, it did not match their ideal. The implications of expanding body size research to include the conceptual framework of body size acceptability is discussed in terms of contributing to a paradigm of positive psychology.

Unpredictability of deception in compliance with physician-prescribed bronchodilator inhaler use in a clinical trial.

OBJECTIVE: To identify subject characteristics that may be predictive of intentional dumping of metered-dose inhalers (MDIs) during a clinical trial. DESIGN: Nebulizer Chronologs (NCs; Medtrac Technologies; Lakewood, CO), which record the date and time of each MDI actuation, were attached to the MDIs of participants who were given a prescribed medication schedule to follow in a clinical trial. Participants were not informed of the function of the NC or that their medication use was being monitored. SETTING: The Lung Health Study, a 5-year clinical trial to evaluate the effect of intensive smoking cessation counseling and regular use of an inhaled bronchodilator on the progression of COPD. PARTICIPANTS: One hundred one smokers, 35 to 60 years of age, with mild to moderate airways obstruction enrolled in The Lung Health Study. MEASUREMENTS AND RESULTS: Thirty of these 101 participants (30%) actuated their inhalers > 100 times within a 3-h interval on at least one occasion during the first year of this 5-year trial. Only 1 of an additional 135 participants who had full foreknowledge of the MDI monitoring capability of the NC did so. Most of these dumping episodes occurred shortly before a clinic follow-up visit, suggesting an active attempt to hide noncompliance from the clinic staff. Whereas self-reported inhaler usage and canister weights were similar for the "dumpers" and "nondumpers," NC data indicated significantly lower compliance rates for dumpers (chi(2); p < 0.05). When demographic variables, treatment and clinic assignments, smoking status, pulmonary function test results, respiratory symptoms, and disease history of dumpers and nondumpers were analyzed, no predictors of dumping could be found. CONCLUSIONS: Deception among noncompliers occurs frequently in clinical trials, is often not revealed by the usual methods of monitoring, and cannot be predicted by data readily available in clinical trials.

Barriers pediatricians face when using asthma practice guidelines.

OBJECTIVE: To describe barriers to the successful use of the 1997 National Heart, Lung, and Blood Institute (NHLBI) asthma guidelines. METHODS: We conducted 3 focus groups to understand barriers to the use of 4 recommendations within the NHLBI guidelines (prescription of inhaled corticosteroids, recommendation of daily peak flowmeter use, smoking cessation screening and counseling, and allergen exposure counseling). PARTICIPANTS: Twenty-one pediatricians and 1 nurse practitioner, who each followed an average of 47 patients with asthma, participated. Six participants (27%) had a faculty or adjunct appointment at a medical school. Nineteen (90%) of the 21 pediatricians were board certified. RESULTS: We identified 171 comments about barriers to adherence. Type of recommendation and physician year of graduation from medical school were related to which barrier was prominent. For corticosteroid prescription, senior physicians mentioned lack of agreement, whereas younger physicians described lack of confidence in dosing or recognizing contraindications. For peak flow-meter use, senior physicians emphasized lack of training. Only senior physicians described the inertia of previous practice as a barrier. All groups mentioned time limitations. CONCLUSIONS: Efforts to improve adherence to asthma guidelines should consider the range of barriers that pediatricians face, such as lack of awareness, familiarity, or agreement, and external barriers owing to environmental, guideline, or patient factors. In addition, this study documents barriers not previously considered, such as lack of self-efficacy, lack of outcome expectancy, and inertia of previous practice, that prevent adherence. Because type of recommendation and physician demographics are related to which barriers are prominent, interventions to improve NHLBI guideline adherence should be tailored to these factors.

Characteristics of participants who stop smoking and sustain abstinence for 1 and 5 years in the Lung Health Study.

BACKGROUND: This study describes baseline and Year 1 predictors of abstinence from smoking for the 3,523 intervention participants who had complete annual 5-year follow-up data in the Lung Health Study (LHS). METHODS: The LHS enrolled 5,887 smokers, aged 35 to 60 years, of whom 3,923 were offered a cessation intervention. Of these, 22% achieved biochemically verified abstinence for 5 years. Logistic regressions were performed. The first outcome variable was abstinence from smoking at 1 year. Then for those who were quit at 1 year, the outcome variable was 5 years of sustained abstinence. RESULTS: All participants who were not using nicotine gum after 1 year in the study were more likely to sustain cessation over 5 years than were gum users at year 1 (OR ranged from 0.31 to 0.44 for four age- and sex-specific groups). Baseline number of previous quit attempts was negatively associated with 5-year quitting success among younger and older men (OR = 0.82 and 0.83). Older participants who were less likely to associate smoking with emotional coping had higher abstinence rates at 5 years of follow-up (OR = 0.89 and 0.84). CONCLUSIONS: Different mechanisms may be responsible for achieving cessation in age/gender groups. These results have implications for planning successful interventions.

Continuity and change in the evaluation of ideal and acceptable body sizes across a wide age span.

OBJECTIVE: Continuity and change in the evaluation of ideal and acceptable body sizes across a wide subject age span were examined. METHOD: Ratings of ideal and socially acceptable body sizes were elicited from 303 children, 427 adolescents, 261 young adults, and 326 middle-age adults. Line drawing arrays of babies, children, young adults, middle-age, and older adults were portrayed, ranging in size from very thin to very obese. RESULTS: All subject groups selected, in all arrays, similar ideal body sizes, rated sizes in the midrange of fatness as socially acceptable, and were least accepting of very thin and obese body sizes. Tolerance for body size variations increased with subject age. DISCUSSION: Continuity throughout a wide subject age span was observed in evaluations of body sizes. However, adults were more accepting of body size variations than younger subjects, especially children. Implications of endorsing midrange body sizes for the fashion industry are discussed.

Assessing pediatric clinical asthma practices and perceptions: a new instrument.

Over the past 20 years, the most substantial increases in prevalence, morbidity, and mortality of asthma have been observed among children aged 5-14 years. A survey instrument designed to measure clinical asthma management practices of primary care physicians was developed and evaluated. Study participants included 127 practitioners providing pediatric asthma care in inner-city communities in Baltimore, MD and Washington, DC. Study results found that the instrument assessed four separate dimensions of clinical assessments and five dimensions of physician perceptions. These dimensions should be considered in future research protocols and may be used to design tailored interventions to improve asthma care.

Emergency department visits by urban African American children with asthma.

BACKGROUND: Asthma morbidity among African American children has been identified as a significant national health concern. High emergency department use is one index of this morbidity and may reflect disease severity, disease management, and social factors. OBJECTIVE: This study examined the prevalence and correlates of emergency department use and other indices of asthma morbidity among a sample of urban, low-income, African American children. METHODS: Parents of 392 elementary school children with asthma who had consented to participate in an asthma education program were interviewed by phone according to a standardized protocol. RESULTS: Children had a mean of 6.2 days of restricted activity (SD 8.1) and 7.9 symptomatic nights (SD 8.1). The mean number of school days missed because of asthma was 9.7 (SD 13.5). Among children with asthma symptoms in the past 12 months, 73.2% could identify a specific physician or nurse who provided asthma care. For those families without an identified asthma primary care provider, 39.3% received their usual asthma care from the emergency department. A total of 43.6% of the children had been to the emergency department for asthma care without hospitalization in the previous 6 months. Close to 80% of children reported using one or more prescribed asthma medication, and of these only 12% reported using inhaled anti-inflammatory medications. Families of children who had used the emergency department in the prior 6 months reported more asthma symptoms, lower social support, problems paying for health care, and the absence of a hypoallergenic mattress cover and that they had seen a physician for regular asthma care in the past 6 months. CONCLUSIONS: We conclude that asthma management for children in the inner city relies on episodic care and emergency care, that asthma medication management does not conform to current guidelines, and that asthma symptoms resulting in school absences and workdays lost are prevalent.

A pharmacodynamic assessment of the impact of antihypertensive non-adherence on blood pressure control.

OBJECTIVES: To evaluate if antihypertensive regimens that conform to present FDA guidelines by maintaining > or = 50% of their peak effect at the end of the dosing interval protect patients during sporadic lapses in adherence. METHODS: 169 patients on monotherapy for high blood pressure underwent electronic adherence monitoring for 3 months. Blood pressures were measured during non-study office visits and were retrieved from automated medical records. Questionnaires were used to obtain other covariate information. The ratio of the dosing interval to the half-life of drug activity (I') was used to capture conformity with FDA guidelines. Data analysis focused on the interaction between I' and the impact on blood pressure of delayed dosing. RESULTS: The average (+/- standard deviation) blood pressure during the study was 139.0(+/- 12.0)/85.0(+/- 6.9) mm Hg. Lisinopril followed by sustained-release verapamil, atenolol, and hydrochlorothiazide were the most frequently prescribed agents. The majority of regimens (99%) conformed to FDA dosing guidelines. Of the patients 23% missed a dose before their blood pressure check. Non-adherence, however, did not have a direct impact on blood pressure, and no interaction with I' of was detected. CONCLUSIONS: Among patients with relatively mild hypertension on single-drug therapy, regimens that conform to current FDA dosing guidelines may prevent losses of blood pressure control during episodic lapses of adherence. These findings should be replicated in other patient populations with standardized blood pressure measurement to confirm their validity.