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.

Obesity and psychoanalysis: treatment and four-year follow-up.

Psychoanalysts provided information about 84 obese patients and 63 patients of normal weight at the beginning of this study, 18 months later, and 4 years later. Treatment lasted from 3 to more than 7 years. Although obesity was the chief complaint of only 6% of the obese patients, their weight loss and maintenance of it compared favorably with results reported for other psychological treatments for obesity. Severe body image disparagement was present in 39% of the obese patients at the beginning of treatment but in only 18% at the 4-year follow-up. Most patients improved in their chief complaint and presenting symptoms. The study indicates that large-scale collaborative research in psychoanalysis is feasible.

Medications used by children with asthma living in the inner city.

OBJECTIVE: The purpose of the study was to examine medication use reported by families participating in an urban school-based community intervention program and to relate this use to other social and medical variables. DESIGN: The design of the study was a cross-sectional questionnaire survey. SETTING: Patients and their families recruited from elementary schools in a community setting were interviewed between December 1991 and January 1992. PARTICIPANTS: A total of 508 children with asthma were identified by school health records and teacher surveys. Their families confirmed the diagnosis and agreed to enter the study. Questionnaires were completed by 392 families. INTERVENTION: The 392 families participated in a controlled trial of asthma education after providing the data that are the basis of this report. RESULTS: More than half of the children took two or more medications for asthma. Thirty-one percent took theophylline alone or in combination with an adrenergic agent; 11% took some form of daily antiinflammatory medication, either cromolyn (8%) or inhaled steroids (3%). The pattern of medication use related to measures of severity and to regular visits to physicians or nurses. In general, however, children were undermedicated. A total of 78 children (20%) reported no medication or over-the-counter medication use, although 37% reported asthma severe enough to be associated with >/=20 days of school missed per month, and 37% had had an emergency room visit for asthma in the past 6 months. More than half of children >/=9 years old supervised their own medication. CONCLUSIONS: We concluded that undermedication is common in poor children with asthma living in urban areas. Antiinflammatory medications are used less commonly than in the general population, and theophylline is used more often. School children may be likely to supervise their own medication.

Measuring adherence with therapy for chronic diseases: implications for the treatment of heterozygous familial hypercholesterolemia.

The failure of patients to adhere adequately to prescribed medication and behavioral regimens is an important medical problem. Poor adherence is most common when the treatment regimen is preventive rather than curative, when patients are asymptomatic, and when the duration of treatment is long. For these reasons, adherence with dietary therapy for hypercholesterolemia is well recognized to be a significant clinical and research challenge. Medication adherence has been acknowledged to be a problem for those treatments with significant side effects, such as flushing and pruritus or the low palatability of bile acid sequestering agents. The availability of drugs that lack these effects has long been viewed as an important contribution to improving overall patient compliance. However, the literature on patient adherence with life-long treatment regimens that are simple and palatable (e.g., antihypertensives) suggests that while these improved treatments can enhance adherence, the overall rates of patient compliance still average only 50%. The fact that patients with heterozygous familial hypercholesterolemia are at high risk for early coronary artery disease and death if they fail to adhere to therapy is not sufficient to assure high rates of appropriate therapy over long periods of time, as demonstrated by the poor or erratic adherence commonly reported to treatments for other life-threatening diseases, such as advanced renal disease, hemophilia, and type I diabetes. The measurement of patient adherence to hypercholesterolemia therapy is often neglected in clinical practice and inadequate in hypercholesterolemia research.(ABSTRACT TRUNCATED AT 250 WORDS)

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.

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.

Trends in compliance with bronchodilator inhaler use between follow-up visits in a clinical trial.

STUDY OBJECTIVE: To assess objectively measured, long-term trends in compliance with physician-prescribed metered-dose inhaler (MDI) use during a clinical trial. DESIGN: A prospective study. SETTING: The Lung Health Study, a 5-year clinical trial to determine the effect of special intervention with an intensive smoking cessation program and bronchodilator therapy in cigarette smokers 35 to 60 years of age with minimal to moderate airflow limitation due to COPD. PARTICIPANTS: Two hundred thirty-one participants who were issued an MDI with an attached Nebulizer Chronolog (NC) (Forefront Technologies Inc; Lakewood, Colo) which electronically records the date and time of each MDI actuation. One hundred two participants were not informed of the recording capabilities of the attached NC, while 129 participants were aware of the NC's monitoring function. INTERVENTION: Following an initial 12-week period of counseling, participants returned to the clinic every 4 months. MEASUREMENTS AND RESULTS: Analysis of the data from the NC collected over a period of 2 years indicates that compliance with the prescribed medication regimen was best immediately following each follow-up visit and gradually declined during the interval between follow-up visits. The level of compliance after each visit was lower for each successive follow-up. These trends could not be observed from self-report or weighting the medication canisters at follow-up visits. The participants who were informed of the NC's function and who were provided with detailed feedback about their inhaler use generally showed better compliance.

Improving inhaler adherence in a clinical trial through the use of the nebulizer chronolog.

This study examined whether utilizing an electronic medication monitor (Nebulizer Chronolog) to provide participants with detailed feedback on their metered-dose inhaler (ipratropium bromide or placebo) usage patterns would result in closer adherence to the prescribed regimen of two inhalations three times daily compared to a control group not receiving feedback. Adherence was also measured by canister weighing and self-report. Two-hundred fifty-one consecutive special intervention participants from the University of California, Los Angeles, and Johns Hopkins University centers of a National Heart, Lung, and Blood Institute-sponsored clinical trial were enrolled in this ancillary study. Compared to controls, feedback participants at the 4-month follow-up adhered more closely to the prescribed three sets per day (mean 1.95 vs 1.65) and used the prescribed two actuations in a greater percentage of sets (80 percent vs 60.3 percent). These results indicate that electronic monitoring of metered-dose inhaler use with a Nebulizer Chronolog in a clinical trial not only provides a more accurate assessment of adherence to prescribed inhaler use, but also enhances adherence when participants are given feedback of the monitoring results.

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.

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.

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.

Pregnancy in bulimic women.

Four primiparous bulimic women were interviewed. Pregnancy outcome was not affected adversely by bulimia. Gestational age ranged from 37-41 weeks, and average infant birth weight was 3121 g. Maternal weight gain averaged 40 lb. Bulimic behaviors decreased during pregnancy, but returned to prepregnant levels after delivery in three of the four women.

The effect of an educational intervention on the rate of neonatal circumcision.

Despite the absence of verifiable indications, routine circumcision of the male neonate remains one of the most common surgical procedures in the United States. A sample of obstetric clinic patients in a large urban hospital was tested to determine whether spoken educational intervention would reduce the rate of circumcision. The results showed that the rate was lowered significantly (94.4% circumcised in the control group versus 72% circumcised in the study group). Nevertheless, the majority of the study mothers requested circumcision for their sons despite the educational intervention, suggesting the presence of strong social motives. The authors conclude that many mothers in this population chose circumcision because of inadequate medical information or strong social motives. Both must be addressed if the rate of elective circumcision is to be reduced.

Gastric surgery in morbid obesity. Outcome in patients aged 55 years and older.

OBJECTIVE: To evaluate long-term outcome of gastric restrictive surgery in morbidly obese patients aged 55 years and older. DESIGN: Retrospective review with 3- to 13-year postoperative follow-up. Average follow-up 6 years. SETTING: Private surgical practice with bariatric surgery specialty. STUDY PARTICIPANTS: Eighty-eight morbidity obese patients, 73 women and 15 men, aged 55 years and older. INTERVENTION: Between 1977 and 1989, 77 patients had Roux-en-Y gastric bypass, four had vertical banded gastroplasty, and seven had silicone ring vertical gastroplasty. MAIN OUTCOME MEASURES: Weight loss, change in incidence of comorbidity, and reduction in medication use. RESULTS: Patients had an average of 57% excess body weight loss, lost 31 kg, and decreased their body mass index by 12 kg/m2. There was a 20% to 48% reduction in the number of patients requiring medication for obesity-related disorders (eg, diabetes mellitus and hypertension). Body mass index of less than 30 kg/m2 was achieved and maintained by 42% of patients. CONCLUSION: This form of therapy is appropriate for selected patients in the older age groups.

Obesity and post-operative pain.

Patients underwent elective abdominal surgery for morbid obesity (mean = 154 kgs, n = 55) or cholecystectomy (mean = 71 kgs, n = 54). Post-operative narcotics were transformed into morphine equivalent units (ME). Morbidly obese patients received significantly fewer total doses than cholecystectomy patients and less total mg ME/kg over a five-day period. Sedative use for both groups was comparable. In the morbidly obese patients, preoperative psychiatric and drug usage data predicted 67% of the variance in number of doses and 69% of the variance in total mg ME/kg.

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.

Parental behavior after perinatal death: twelve years of observations.

Perinatal death is a tragic occurrence, and parents vary in their needs and how they express grief. This prospective study describes choices parents made regarding contact with their baby following stillbirth or immediate neonatal death. Between 1 January 1979 and 1 March 1991, 808 consecutive families were enrolled in the Perinatal Mortality Counseling Program at the University of Florida. Following perinatal death, most parents wanted contact with their baby to personalize the event, information about the death and follow-up from their health care providers. However, no option was chosen by all parents. This large study strongly supports offering choices to all parents. Providers should neither bias parents nor make presumptions that would limit parental choices.

The effects of contingent payment and frequent workplace monitoring on smoking abstinence.

This study examined the relative contribution of contingent payment and worksite CO monitoring to the long-term maintenance of smoking abstinence. Forty-seven hospital employees who had abstained from smoking for five days (confirmed by CO analysis) were randomly assigned to one of three follow-up groups: (a) contingent payment/frequent monitoring (n = 17); (b) noncontingent payment/frequent monitoring (n = 16); or (c) non-contingent payment/infrequent monitoring (n = 14). Contingent payment combined with frequent CO monitoring delayed but did not ultimately prevent subjects relapse to smoking by the end of the six month follow-up. Contingent subjects maintained CO values less than or equal to 11 ppm significantly longer than did either the Non-contingent or the Control subjects (p = .03). CO monitoring alone had no effect on abstinence outcomes; both Noncontingent and Control subjects showed high rates of early relapse.

Use of community health workers with inner-city children who have asthma.

Use of community health workers (CHWs) to obtain health, social, and environmental information from African-American inner-city children with asthma was one component of a larger intervention study designed to reduce morbidity in African-American children with asthma. A subset of 140 school-aged children with asthma was recruited and enrolled in a program to receive home visits by CHWs for the purposes of obtaining medical information and teaching basic asthma education to the families. Data obtained by the CHWs revealed low inhaled steroid use, high beta 2 agonist use, frequent emergency-room visits, decreased primary-care visits, and increased allergen and irritant exposure. Appropriately recruited and trained CHWs are effective in obtaining useful medical information from inner-city families with children with asthma and providing basic asthma education in the home.

Social factors associated with behavioral problems in children with asthma.

The objective of this study was to describe the proportion of children with a behavior problem and examine which independent variables are associated with the presence of a behavior problem in a group of 392 inner-city children with asthma. Data on child asthma symptoms, medication use, health-care utilization, and school absences were obtained from the parent during a structured telephone interview. Included in the interview was a measure of behavior problems and social support questions. Children classified with a high level of asthma symptoms were more than twice as likely to experience a behavior problem than children classified with a low level of asthma symptoms (P = 0.002). Use of theophylline medication was not correlated with behavior problems (P = 0.45). Significant variables were low level of social support and high or moderate level of asthma symptoms. We have identified a group of children at risk for behavior problems, specifically in families that lack adequate social and financial resources.