A Pilot Study of the Effect of an Educational Web Application on Asthma Control and Medication Adherence.

BACKGROUND: An Asthma Adherence Pathway (AAP) application, which is an Internet application that combines patient and clinician education strategies to promote adherence to asthma therapy, has been developed. OBJECTIVE: The primary objective of this pilot study was to evaluate the effectiveness of the AAP application with electronic adherence monitors on asthma control. Secondary objectives evaluated the effect of AAP and monitors on medication adherence, asthma symptoms, quality of life, psychosocial factors, and barriers to treatment. METHODS: Adult patients with asthma were randomly assigned either to intervention (n = 19) or control (n = 20) groups in this 3-month prospective study, and they completed the Asthma Control Questionnaire (ACQ). Intervention patients completed the AAP software and were given barrier-specific motivational interviewing adherence strategies and a SmartTrack device to monitor mometasone furoate/formoterol (MF/F) use. Clinicians in the interventional group received adherence management training. Interventional patients were given feedback regarding adherence findings at each visit. Treatment adherence was determined by the mean of 4 measures of doses taken over 3 months. Control patients were not monitored for MF/F adherence. RESULTS: The mean MF/F adherence in the intervention group was 81%. The intervention and control groups did not differ on the mean baseline ACQ. Thirteen intervention patients achieved the minimal important difference (defined as an improvement ≥0.5 units on the ACQ) compared with 6 control patients (P = .016). The intervention group showed greater improvement in the ACQ (0.75) than the control group (0.19) representing a moderate-to-large effect size of d = 0.638. CONCLUSIONS: The AAP was effective in promoting adherence and helped to improve asthma control. These findings provide preliminary validation of the AAP model.

Improving adherence to asthma therapies.

PURPOSE OF REVIEW: Adherence to asthma therapies is poor leading to unnecessary morbidity and increased use of emergency and hospital resources. Strategies to improve adherence have not been successful. RECENT FINDINGS: Asthma adherence disease management is a clinical method to improve adherence for asthma patients. The method includes: diagnosing adherence status; identifying patient barriers leading to nonadherence; selecting specific strategies for the clinician for each barrier identified; use of patient-centered communication skills to enhance the effectiveness of the strategies employed. This approach is now being tested in multiple controlled trials. SUMMARY: Clinicians may want to consider these strategies, in whole or in part, to improve asthma patient adherence.

Asthma adherence management for the clinician.

BACKGROUND: Nonadherence to asthma treatment has been related to increased hospital and emergency care, morbidity, and unnecessary costs. Improving patient adherence is a key component to achieving optimal outcomes. OBJECTIVE: Review barriers, interventions, and communication skills shown to be effective in promoting asthma adherence. METHODS: Asthma adherence literature was reviewed. RESULTS: Sequential management principles to achieve adherence include the following: (1) measuring adherence, (2) identifying barriers that result in nonadherence, (3) using specific strategies to overcome barriers; and (4) using communication skills to enhance the delivery of selected strategies. CONCLUSION: Careful attention to adherence management principles may increase adherence, enhance outcomes, and reduce unnecessary morbidity and cost. The case described applies these principles and gives the reader a framework to review.

Development and preliminary validation of the Adult Asthma Adherence Questionnaire™.

BACKGROUND: Asthma medication adherence is related to better asthma outcomes, but identification of suboptimal patient adherence behavior is not standardized in clinical settings. OBJECTIVE: [corrected] The purpose of this study was to develop a practical questionnaire that reflects nonadherence risk and identifies potential adherence barriers. METHODS: A questionnaire that included 20 potential adherence questions was completed by 420 adult patients with asthma who filled a prescription for an inhaled corticosteroid (ICS) and a short-acting beta agonist (SABA) in the previous 6 months. Questions without substantial floor or ceiling effects that were significantly related to self-reported low adherence or previous ICS canister dispensings were identified. Internal consistency reliability was tested by Cronbach α. Relationships of these questions to Asthma Control Test scores, future percent of days covered for ICS dispensings, and future asthma exacerbations and SABA dispensings were determined. RESULTS: Five final questions were identified: following "my medication plan," forgetting, not "needing" the medications, side effects, and cost. Low internal consistency reliability (<0.50) suggested items should not be summarized by a single score. All five questions were related to Asthma Control Test scores. Following the medication plan, forgetting, and not needing medication were significantly related to prospective percent of days covered. Side effects were related to subsequent SABA and oral corticosteroid dispensings, and cost was significantly related to oral corticosteroid dispensings. CONCLUSIONS: We identified five questions related to other measures of adherence and to asthma control that can be used clinically to identify patients at risk of nonadherence and the specific adherence barriers involved.

The potential of asthma adherence management to enhance asthma guidelines.

OBJECTIVE: Expert Panel Report 3 Guidelines recommend that physicians use adherence management strategies; however, the evidence for these interventions is weak. Clinicians need effective proven adherence interventions, because approximately 50% of patients with asthma do not follow physician medication recommendations, resulting in unnecessary morbidity. This review examines components of an organized adherence management program that has been successful in uncontrolled trials promoting adherence and reducing morbidity and cost. DATA SOURCES: Literature review was undertaken in the following areas of asthma management: guidelines, cost; morbidity; adherence, monitoring; and communication skills. STUDY SELECTIONS: Studies that examined outcomes from psychoeducational, behavioral, monitoring, and communication interventions. RESULTS: Studies using individual interventions by themselves were modestly effective in promoting adherence. Two uncontrolled studies of children with severe asthma, treated in both inpatient and outpatient rehabilitation settings, used 4 intervention strategies to achieve marked reduction in morbidity and cost. These strategies included: (1) objective adherence monitoring; (2) identification of the cause(s) of nonadherence; (3) delivery of specific strategies for each cause; and (4) use of motivational interviewing communication skills to enhance the delivery of the strategy. CONCLUSION: Nonadherence continues to be a significant problem. Physicians need a proven organized approach to improve adherence and reduce morbidity and cost. Evaluation of effective methods in a controlled fashion is warranted to increase adherence management evidence for future asthma guidelines.

Should patients with persistent severe asthma be monitored for medication adherence?

BACKGROUND: Poor asthma outcomes often result from patients not following physician medication recommendations (ie, nonadherence). Estimates suggest that 50% of patients with asthma do not follow physician medication recommendations. OBJECTIVE: To examine the rationale for making available objective medication adherence monitors for physicians to improve the quality of care for patients with severe persistent asthma. METHODS: Review of the literature was undertaken in the following areas related to asthma: cost, morbidity, adherence, adherence monitoring, outcomes, and guidelines. RESULTS: Patients with severe asthma are at risk for nonadherence because of (1) the use of multiple medications to control symptoms, (2) coexisting disease states, (3) the occurrence of depression and anxiety, and (4) the high cost of care. Research studies have demonstrated the effectiveness of objective monitoring as part of multiple clinical strategies to improve adherence and reduce morbidity and the cost of asthma care. Without objective adherence monitoring, physicians may not accurately assess nonadherence as the cause of treatment failure. This may lead to inappropriate increases in therapy, diagnostic studies, and consultations and may leave the patient at risk for persistent symptoms, morbidity, and death. CONCLUSION: By correctly assessing nonadherence as the cause of treatment failure in patients with not only severe asthma but mild and moderate disease as well, practicing physicians may improve the quality of care provided.