Medication adherence and the risk of severe asthma exacerbations: a systematic review

Understanding Patient Perspectives on Medication Adherence in Asthma: A Targeted Review of Qualitative Studies

Adherence to asthma medications is generally poor and undermines clinical outcomes. Poor adherence is characterized by underuse of inhaled corticosteroids (ICS), often accompanied by over-reliance on short-acting β₂-agonists for symptom relief. To identify drivers of poor medication adherence, a targeted literature search was performed in MEDLINE and EMBASE for articles presenting qualitative data evaluating medication adherence in asthma patients (≥12 years old), published from January 1, 2012 to February 26, 2018. A thematic analysis of 21 relevant articles revealed several key themes driving poor medication adherence, including asthma-specific drivers and more general drivers common to chronic diseases. Due to the episodic nature of asthma, many patients felt that their daily life was not substantially impacted; consequently, many harbored doubts about the accuracy of their diagnosis or were in denial about the impact of the disease and, in turn, the need for long-term treatment. This was further compounded by poor patient-physician communication, which contributed to suboptimal knowledge about asthma medications, including lack of understanding of the distinction between maintenance and reliever inhalers, suboptimal inhaler technique, and concerns about ICS side effects. Other drivers of poor medication adherence included the high cost of asthma medication, general forgetfulness, and embarrassment over inhaler use in public. Overall, patients' perceived lack of need for asthma medications and medication concerns, in part due to suboptimal knowledge and poor patient-physician communication, emerged as key drivers of poor medication adherence. Optimal asthma care and management should therefore target these barriers through effective patient- and physician-centered strategies.

A Novel, Portable MESH Nebulizer-An Alternative to Metered Dose Inhaler: Efficacy and Usability in Preschool Wheezers

Introduction and Objectives: Wheezing episodes are the first causes of doctor's consultation in preschool age. Treatment is usually administered with a metered dose inhaler (MDI) spacer. At variance, many parents and doctors prefer to use a compressor nebulizer, which cannot be easily carried. The study is aimed at testing whether a pocket mesh nebulizer has similar efficacy and acceptability than a standard MDI device. Materials and Methods: The IPAC study was a randomized, controlled, non-inferiority trial (number: 1616/2018, Ospedale Pediatrico Bambino Gesu'-IRCCS). The study had two arms: cases, using MicroAIR U100, and controls, using MDI+spacer device. Both devices were adopted for long-term treatment and for exacerbations. Follow-up was organized with clinical visits and a daily e-diary connected to an application for mobile phone. Results: One hundred patients were enrolled. The frequency of asthmatic symptoms showed a non-inferiority for MicroAIR U100 group vs. MDI. Accordingly, no significant difference was found in the average % of days with cough, wheezing, breathlessness after exercise, days lost at school, and not-programmed visits. Considering only patients with >1 day with symptoms, no significant sdifferences were found in the number of exacerbations nor in the cumulative days with symptoms. The acceptance and usability of both devices have been favorable. However, the MDI+AeroChamber® device showed better acceptability. Conclusions: Our study shows that MicroAIR U-100, a mesh nebulizer, has similar clinical efficacy but lower acceptance and usability than an MDI plus Aerochamber® in delivering therapy in preschool wheezers. Therefore, MicroAIR U-100 might be a valuable second choice, when the delivery of medication with an MDI plus Aerochamber® is not accepted, or wrongly used by the parents.

Relación entre representación de enfermedad, representación del tratamiento y adherencia en adultos con asma: Una revisión

La adherencia al medicamento de control es el pilar fundamental para el control del asma; sin embargo, se ha identificado que una representación negativa de la enfermedad y el tratamiento impactan de modo negativo en esta. Se hizo una revisión narrativa para identificar los estudios empíricos acerca de representación de enfermedad, representación del tratamiento y adherencia a medicamentos de control en adultos con asma, desde el modelo de sentido común y representación de la enfermedad (MSCRE). Se identificaron 17 estudios divididos en transversales y longitudinales (12), experimentales (3) y de intervención (2), reportando que las principales dimensiones del MSCRE asociadas con la adherencia son la necesidad del tratamiento, preocupación, control de la enfermedad y del tratamiento, temporalidad crónica y consecuencias. Se concluye que el MSCRE es un modelo psicológico que tiene aplicaciones en la investigación y atención clínica para explicar y promover conductas de adherencia a medicamentos de control en adultos con asma.

Revista Digital Internacional de Psicología y Ciencia Social | Volumen 6 | Número 1 | Enero-Junio 2020 | Investigación y acción para el cambio social

El nombre del presente número es “La investigación para la acción y el cambio social”, decidimos titularlo de esa manera porque consideramos de fundamental interés destacar la importancia que ha adquirido el trabajo científico desarrollado por los profesionales de distintas disciplinas para favorecer a la población que atienden respectivamente, pues en los trabajos presentados se muestra una excelente articulación entre la teoría y la práctica, poniendo en evidencia que se parte de una concepción social y científica, holística, pluralista e igualitaria.

Does adherence to inhaled corticosteroids predict asthma-related outcomes over time? A cohort study

Inhaled corticosteroids (ICS) adherence is important for asthma management. Current evidence on the impact of ICS adherence on outcomes is mostly based on correlational analyses of between-person data. Although it is widely acknowledged that asthma outcomes fluctuate over time, evidence on predictors of within-person change is scarce. We aimed to quantify these fluctuations and the longitudinal relationships between ICS adherence and outcomes at both between- and within-person levels.A prospective cohort of persistent asthma patients in France and the UK (n=847, age 6-40 years) provided 3756 reports over up to 2 years via computer-assisted telephone interviews and text messages on ICS adherence, asthma control, reliever medication use and exacerbations. We examined adherence-outcome relationships via longitudinal models, controlling for confounders, including severity.Considerable within-person variability was found for exacerbations (91%), asthma control (59%) and reliever use (52%); 431 (11.5%) reports signalled exacerbations and 2046 (54.5%) poor control. At between-person level, patients with higher average adherence were more likely to report asthma control (OR 1.25, 95% CI 1.06-1.47), but not asthma exacerbations (OR 0.99, 95% CI 0.87-1.12) or lower reliever use (b -0.0004, 95% CI -0.089-0.088). At within-person level, higher-than-usual adherence was associated with higher concomitant reliever use (b 0.092, 95% CI 0.053-0.131) and lower subsequent reliever use (b -0.047, 95% CI -0.005- -0.088); it was unrelated to asthma control (OR 0.93, 95% CI 0.84-1.02) or exacerbations (OR 1.04, 95% CI 0.94-1.16).Patients maintaining high ICS adherence over time have better asthma control. Temporarily increasing ICS adherence tends to be simultaneous to higher reliever use and reduces reliever use later on. Causes of within-person variation in outcomes require more investigation.

Once daily combined inhaled steroid and ultra long-acting bronchodilator prescribing in pediatric asthma: a dual Center retrospective cohort study

OBJECTIVE

A high proportion of children and adolescents who have "difficult" or therapy-resistant asthma, are found to have poor adherence to maintenance therapies. Such individuals are thus difficult asthmatics (for reasons of poor adherence) rather than being young people with true difficult asthma. In our centers, once daily ICS/ULABA (Relvar™) is considered if there is an increase in reported interval symptoms, asthma attacks requiring hospital attendance or rescue oral prednisolone, or persistently low lung function despite reported regular use of a twice daily ICS/LABA preparation. In the majority of these young people, a clinical history of overt non-adherence or a clinical suspicion of covert non-adherence will be noted.

METHODS

The aim of our retrospective cohort study was to assess the clinical effectiveness of Relvar™ in a selected adolescent asthma population.

RESULTS

In a pre-selected group of adolescents with likely poor prior adherence to inhaled therapies, a change to Relvar™ (once daily combined ICS/ULABA) led to improvements in asthma control, as assessed by ED attendances and oral steroid burden.

CONCLUSIONS

A prospective study to verify these findings and also explore the effects on quality of life, asthma control, and adherence is warranted.

Does a tailored intervention to promote adherence in patients with chronic lung disease affect exacerbations? A randomized controlled trial

BACKGROUND

Poor medication-adherence is common in chronic lung patients, resulting in reduced health-outcomes and increased healthcare-costs. This study aimed to investigate the impact of an acoustic reminder and support calls on adherence to inhaled therapy in asthma and COPD patients and to determine their effect on exacerbations.

METHODS

This single-blinded randomized controlled trial investigated asthma and COPD patients during 6 months in an ambulatory setting. The intervention consisted of daily alarm clock and support phone calls, whenever use of rescue medication doubled or inhaled medication was not taken as prescribed. Primary outcome was time to next exacerbation. Frequency of exacerbations, adherence to inhaled medication and quality of life scores were secondary outcomes. Cox and Poisson regression were used to determine intervention effect on time to exacerbation and frequency of exacerbations, respectively.

RESULTS

Seventy-five participants were assigned to the intervention group and 74 to usual follow-up care. During a median follow-up of 6.2 months, 22 and 28% in the intervention and control groups respectively, experienced at least one exacerbation. Intervention had no effect on time to first exacerbation (HR 0.65, 95% CI 0.21 to 2.07, P = .24), but showed a trend toward a 39% decreased frequency of exacerbations (RR = 0.61, 95% CI 0.35 to 1.03, P = .070) for the adjusted models, respectively. The intervention group had significantly more days with 80-100% taking adherence regarding puff inhalers (82 ± 14% vs. 60 ± 30%, P < .001) and dry powder capsules (90 ± .10% vs. 80 ± 21%, P = .01). Timing adherence in participants using puff inhalers was higher in the intervention group (69 ± 25% vs. 51 ± 33%, P < .001). No significant differences in QoL were found between the two groups.

CONCLUSION

Participants assigned to the intervention group had significantly better taking and timing adherence of inhaled medication resulting in a trend towards a decreased frequency of exacerbations. However, no effect on time to next exacerbation was observed.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02386722, Registered 14 February 2014.

Exacerbation-Prone Asthma

Patients who are prone to exacerbations of asthma experience significant costs in terms of missed work and school, acute care visits, and hospitalizations. Exacerbations are largely driven by environmental exposures including pollutants, stress, and viral and bacterial pathogens. These exposures are most likely to induce acute severe "asthma attacks" in high-risk patients. These personal risk factors for exacerbations can vary with the phenotype of asthma and age of the patient. In children, allergic sensitization is a strong risk factor, especially for those children who develop sensitization early in life. Airway inflammation is an important risk factor, and biomarkers are under evaluation for utility in detecting eosinophilic and type 2 inflammation and neutrophilic inflammation as indicators of risk for recurrent exacerbations. Insights into inflammatory mechanisms have led to new approaches to prevent exacerbations using mAb-based biologics that target specific type 2 pathways. Challenges remain in developing an evidence base to support precision interventions with these effective yet expensive therapies, and in determining whether these treatments will be safe and effective in young children. Unfortunately, there has been less progress in developing treatments for acute exacerbations. Hopefully, greater understanding of mechanisms relating airway viruses, bacteria, mucin production, and neutrophilic inflammatory responses will lead to additional treatment options for patients experiencing acute exacerbations.

Effects of medication adherence on healthcare services use among asthma patients

INTRODUCTION AND OBJECTIVES

Medication adherence is an important indicator of quality in healthcare, and non-adherence is associated with increased healthcare costs, hospital admissions, re-admissions, and decline in health outcomes. Despite the availability of medication to control and avoid adverse health outcomes, adherence to medications among asthma patients varies between 40% and 60%. The objective of this study is to evaluate the effects of asthma medication adherence on healthcare services.

MATERIAL AND METHODS

This cross-sectional study is based on insurance claims data for Medicaid patients primarily diagnosed with asthma during 2015-2016. A regression analysis was performed to examine the relationship between control and rescue medication adherence with healthcare use (hospital admissions and re-admissions, clinic visits, and emergency department visits), as well as patient demographics (age, gender, and estimated income).

RESULTS

This study found a control medication adherence of 82%. Patients with high rescue medication adherence had fewer emergency department visits (p=.0004) and inpatient admissions (p=.0303). Patients with more than 4 clinic visits had higher rescue medication adherence. Older and low-income patients had higher 30-day re-admissions. Males and low-income patients had more emergency visits.

CONCLUSIONS

These results provide evidence that certain populations (older, low-income, and male) may benefit from additional education on monitoring and controlling asthma. This may reduce costlier healthcare services use in favor of less expensive physician visits and education programs.

Patient-physician discordance in assessment of adherence to inhaled controller medication: a cross-sectional analysis of two cohorts

OBJECTIVE

We aimed to compare patient's and physician's ratings of inhaled medication adherence and to identify predictors of patient-physician discordance.

DESIGN

Baseline data from two prospective multicentre observational studies.

SETTING

29 allergy, pulmonology and paediatric secondary care outpatient clinics in Portugal.

PARTICIPANTS

395 patients (≥13 years old) with persistent asthma.

MEASURES

Data on demographics, patient-physician relationship, upper airway control, asthma control, asthma treatment, forced expiratory volume in one second (FEV₁) and healthcare use were collected. Patients and physicians independently assessed adherence to inhaled controller medication during the previous week using a 100 mm Visual Analogue Scale (VAS). Discordance was defined as classification in distinct VAS categories (low 0-50; medium 51-80; high 81-100) or as an absolute difference in VAS scores ≥10 mm. Correlation between patients' and physicians' VAS scores/categories was explored. A multinomial logistic regression identified the predictors of physician overestimation and underestimation.

RESULTS

High inhaler adherence was reported both by patients (median (percentile 25 to percentile 75) 85 (65-95) mm; 53% VAS>80) and by physicians (84 (68-95) mm; 53% VAS>80). Correlation between patient and physician VAS scores was moderate (r_s=0.580; p<0.001). Discordance occurred in 56% of cases: in 28% physicians overestimated adherence and in 27% underestimated. Low adherence as assessed by the physician (OR=27.35 (9.85 to 75.95)), FEV₁ ≥80% (OR=2.59 (1.08 to 6.20)) and a first appointment (OR=5.63 (1.24 to 25.56)) were predictors of underestimation. An uncontrolled asthma (OR=2.33 (1.25 to 4.34)), uncontrolled upper airway disease (OR=2.86 (1.35 to 6.04)) and prescription of short-acting beta-agonists alone (OR=3.05 (1.15 to 8.08)) were associated with overestimation. Medium adherence as assessed by the physician was significantly associated with higher risk of discordance, both for overestimation and underestimation of adherence (OR=14.50 (6.04 to 34.81); OR=2.21 (1.07 to 4.58)), while having a written action plan decreased the likelihood of discordance (OR=0.25 (0.12 to 0.52); OR=0.41 (0.22 to 0.78)) (R²=44%).

CONCLUSION

Although both patients and physicians report high inhaler adherence, discordance occurred in half of cases. Implementation of objective adherence measures and effective communication are needed to improve patient-physician agreement.

Medication adherence in patients with asthma using once-daily versus twice-daily ICS/LABAs

OBJECTIVE

This real-world observational study compared medication adherence and persistence among patients with asthma receiving the once-daily inhaled corticosteroid/long-acting β₂-agonist (ICS/LABA) fluticasone furoate/vilanterol (FF/VI) versus the twice-daily ICS/LABAs budesonide/formoterol (B/F) and fluticasone propionate/salmeterol (FP/SAL).

METHODS

This retrospective cohort study conducted using IQVIA^TM Health Plan Claims Data included patients with asthma ≥18 years of age initiating ICS/LABA therapy with FF/VI, B/F, or FP/SAL between January 1, 2014 and June 30, 2016 (index date). Patients had ≥12 months and ≥3 months of continuous eligibility pre- and post-index date, respectively. Patients receiving FF/VI were separately matched 1:1 with patients receiving B/F or FP/SAL using propensity score matching (PSM) and multivariable regression to balance baseline covariates between cohorts. The primary endpoint was medication adherence, measured by proportion of days covered (PDC). Secondary endpoints included proportion of patients achieving PDC ≥ 0.5 and PDC ≥ 0.8 and persistence with index medication, measured by time to discontinuation (>45-day gap in therapy).

RESULTS

After PSM, 3,764 and 3,339 patients receiving FF/VI were matched with patients receiving B/F or FP/SAL, respectively. Mean PDC was significantly higher for FF/VI versus B/F (0.453 vs 0.345; adjusted p < 0.001) and FP/SAL (0.446 vs 0.341; adjusted p < 0.001). The proportion of patients achieving PDC ≥ 0.5 or PDC ≥ 0.8, and treatment persistence were significantly higher for FF/VI versus B/F and FP/SAL (all p < 0.001).

CONCLUSIONS

In this real-world study, patients initiating FF/VI had better adherence and lower risk of discontinuing treatment versus B/F or FP/SAL, suggesting that once-daily ICS/LABA treatment might improve adherence and persistence compared with twice-daily alternatives.

High oral corticosteroid exposure and overuse of short-acting beta-2-agonists were associated with insufficient prescribing of controller medication: a nationwide electronic prescribing and dispensing database analysis

BACKGROUND

Recurrent use of oral corticosteroids (OCS) and over-use of short-acting beta-2-agonists (SABA) are factors associated with adverse side effects and asthma-related death. We aim to quantify high OCS exposure, SABA over-use and its association with prescription and adherence to maintenance treatment for respiratory disease, among patients with prescriptions for respiratory disease, from the Portuguese electronic prescription and dispensing database (BDNP).

METHODS

This was a 1-year (2016) retrospective population-based analysis of a random sample of adult patients from the BDNP, the nationwide compulsory medication prescription system. We assessed high OCS exposure (dispensing ≥ 4 packages containing 20 doses of 20 mg each of prednisolone-equivalent, ≥ 1600 mg/year) on patients on persistent respiratory treatment (PRT-prescription for > 2 packages of any respiratory maintenance medications). Excessive use of SABA was defined as having a ratio of SABA-to-maintenance treatment > 1 or having SABA over-use (dispensing of > 1 × 200 dose canister/month, of 100 μg of salbutamol-equivalent). Factors associated with high OCS exposure were assessed by multinomial logistic regression.

RESULTS

The estimated number of patients on PRT was 4786/100,000 patients. OCS was prescribed to more than 1/5 of the patients on PRT and 101/100,000 were exposed to a high-dose (≥ 1600 mg/year). SABA excessive use was found in 144/100,000 patients and SABA over-use in 24/100,000. About 1/6 of SABA over-users were not prescribed any controller medication and 7% of them had a ratio maintenance-to-total ≥ 70% (high prescription of maintenance treatment). Primary adherence (median%) to controller medication was 66.7% for PRT patients, 59.6% for patients exposed to high OCS dose and 75.0% for SABA over-users. High OCS exposure or SABA over-use were not associated with primary adherence. High OCS exposure was associated with a maintenance-to-total medication ratio < 70% (insufficient prescription of maintenance treatment), age > 45 years old and male sex.

CONCLUSIONS

Exposure to high-dose of OCS (101 per 100,000 patients) and SABA over-use (24 per 100,000) were frequent, and were associated with a low maintenance-to-total prescription ratio but not with primary non-adherence. These results suggest there is a need for initiatives to reduce OCS and SABA inappropriate prescribing.

The Relationship Between Real-World Inhaled Corticosteroid Adherence and Asthma Outcomes: A Multilevel Approach

BACKGROUND

Low inhaled corticosteroid (ICS) adherence is associated with increased asthma burden. This relationship is likely bidirectional, and may vary across adherence stages (initiation, implementation, and persistence). Studies rarely examine reciprocal influences.

OBJECTIVE

To investigate the relationship between ICS implementation and asthma-related outcomes over 2 years, considering bidirectionality and temporal sequence.

METHODS

Primary care records (1987-2012) from the Optimum Patient Care Research Database, United Kingdom, were used. Eligible patients were 6 years or older and had 3 or more years of continuous registration starting 1 year before ICS initiation (index date), physician-diagnosed asthma, 2 or more ICS and/or short-acting β-agonist prescriptions each follow-up year, and no long-acting β-agonists, leukotriene receptor antagonists, or maintenance oral corticosteroids in the preceding year. ICS implementation (percentage of days covered) and risk domain asthma control (RDAC; no asthma-related hospitalizations, emergency visits, or outpatient visits and no oral corticosteroid or antibiotic prescriptions with evidence of respiratory review) were estimated for each prescription interval (period between 2 successive prescriptions). Multilevel analyses modeled bidirectional relationships between ICS implementation and RDAC (and its components), controlling for sociodemographic and clinical characteristics.

RESULTS

In prescription data from 10,472 patients, ICS implementation in the preceding interval did not predict RDAC, but was weakly positively associated with simultaneous RDAC. Being male, non-current smoker, without chronic obstructive pulmonary disease diagnosis, and with fewer than 4 comorbidities significantly increased odds of RDAC. Asthma-related antibiotics and outpatient visits in the same interval and short-acting β-agonist overuse in the preceding and same interval predicted lower ICS implementation.

CONCLUSIONS

Patients may adapt their ICS use to their current needs without this impacting later RDAC.

Asthma, asthma control and risk of acute myocardial infarction: HUNT study

Asthma, a chronic inflammatory airway disease, shares several common pathophysiological mechanisms with acute myocardial infarction (AMI). Our aim was to assess the prospective associations between asthma, levels of asthma control and risk of AMI. We followed 57,104 adults without previous history of AMI at baseline from Nord-Trøndelag health study (HUNT) in Norway. Self-reported asthma was categorised as active asthma (i.e., using asthma medication) and non-active asthma (i.e., not using asthma medication). Levels of asthma control were defined as controlled, partly controlled, and uncontrolled based on the Global Initiative for Asthma guidelines. AMI was ascertained by linking HUNT data with hospital records. A total of 2868 AMI events (5.0%) occurred during a mean (SD) follow-up of 17.2 (5.4) years. Adults with active asthma had an estimated 29% higher risk of developing AMI [adjusted hazard ratio (HR) 1.29, 95% CI 1.08-1.54] compared with adults without asthma. There was a significant dose-response association between asthma control and AMI risk, with highest risk in adults with uncontrolled asthma (adjusted HR 1.73, 95% CI 1.13-2.66) compared to adults with controlled asthma (p for trend < 0.05). The associations were not explained by smoking status, physical activity and C-reactive protein levels. Our study suggests that active asthma and poor asthma control are associated with moderately increased risk of AMI. Further studies are needed to evaluate causal relationship and the underlying mechanisms and to clarify the role of asthma medications in the risk of AMI.

A potential role of triple therapy for asthma patients

Introduction: The use of LAMAs in asthma is now supported by pharmacological and clinical evidence, whereas the effectiveness of therapy with ICS/LABA/LAMA fixed dose combinations in patients with asthma still remains to be determined. Areas covered: The pharmacological rationale that explains why it is possible to use triple therapy in asthma and the results of clinical studies that have explored the effects of this therapy in asthmatics is critically examined. A systematic search was conducted on 10 August 2019, and included six electronic databases: EMBASE, MEDLINE, Scopus, The Cochrane Library, Web of Science, and Google Scholar. Expert opinion: The real role of single inhaler triple therapy in asthma will be demonstrated when the various trials that are currently ongoing or are scheduled will be completed. We believe that it is appropriate to treat with triple therapy asthmatic patients who have smoked and remain symptomatic or suffer from frequent exacerbations despite initial inhaler therapy with ICS/LABA. However, we must establish when to step up or mainly step down triple therapy especially in patients who are well controlled, and what will be the cost of these combinations in the management of asthma.

Inhaler technique errors in Romanian patients with asthma - a multicenter study

BACKGROUND

Non-adherence to treatment is associated with poor asthma control, increased exacerbations, decline in lung function, and decreased quality of life. M-health applications have become increasingly in the last years, but little research regarding the efficiency of the instructional videos for correct inhaler use exist. The aim of this study is to assess and improve the inhalator technique and to establish which types of errors were made more often with the help of a mobile health application.

MATERIALS AND METHODS

Seventy-five patients with partially controlled or uncontrolled asthma, using any of turbuhaler, diskus, pressurized metered dose inhaler (pMDI) or soft mist inhaler (SMI), were included in the study. When they first entered the study, the patient's inhaler technique was assessed by a trained medical professional and the technique errors were categorized in handling, respectively inhalation errors. After the first evaluation, the patients downloaded an application on their Smartphone and were encouraged to use the application as much as needed to remind them the correct inhalation technique. The patients were re-called every three months for evaluation, treatment, and assessment of inhalation technique.

RESULTS

We analyzed both handling and inhalation errors for each of the four considered inhalers. We observed a significantly reduced number of inhalation technique errors after using the mobile phone application. Turbuhaler median errors were 6.00, and after six months we did not observe errors. Diskus median error was 6.00, and after six months we observed a maximum of one error. pMDI median errors were 7.00, and after six months we observed just one error. Similarly, SMI median error was 7.00, and after six months we observed just one error.

CONCLUSION

Although technique inhalation errors are very common among asthma patients, video instructions provided through specific mobile phone applications could improve the inhaler technique in order to achieve a better control of the disease.

What Is the Impact of Innovative Electronic Health Interventions in Improving Treatment Adherence in Asthma? The Pediatric Perspective

Suboptimal adherence to treatment is a significant issue in the management of pediatric asthma and is a major cause of uncontrolled disease, life-threatening attacks, and increased use of health care resources. Electronic health solutions have the potential to positively impact asthma self-management in children and adolescents and their families, thereby improving treatment adherence and asthma outcomes. However, there is a lack of sufficient data to support widespread adoption of electronic health tools in pediatric asthma practice. A critical evaluation of the impact of these new interventions on treatment adherence in childhood asthma must consider unmet needs, heterogeneity of trials, safety and data security issues, long-term effects, and cost-effectiveness. This article explores the most relevant issues facing the role of electronic health and its subcategory-mobile health-in promoting treatment adherence in childhood asthma, focusing on current evidence gaps and limitations, and future research perspectives.

Cost saving of switching to equivalent inhalers and its effect on health outcomes

BACKGROUND

Switching inhalers to cheaper equivalent products is often advocated as a necessary cost saving measure, yet the impact on patient's health and healthcare utilisation has not been measured.

METHODS

We identified asthma and chronic obstructive pulmonary disease (COPD) patients from UK primary care electronic healthcare records between 2000 and 2016. A self-controlled case series was used to estimate incidence rate ratios (IRR); comparing outcome rates during the risk period, 3 months after the exposure (financially motivated switch), and control periods (preswitch and postrisk period). Four outcomes were assessed: disease exacerbation, general practitioner consultation, non-specific respiratory events and adverse-medication events. Medication possession ratio (MPR) was calculated to assess adherence. 2017 National Health Service indicative prices were used to estimate cost differences per equivalent dose.

RESULTS

We identified a cohort of 569 901 asthma and 171 231 COPD regular inhaler users, 2% and 6% had been switched, respectively. Inhaler switches between a brand-to-generic inhaler, and all other switches (brand-to-brand, generic-to-generic, generic-to-brand), were associated with reduced exacerbations (brand-to-generic: IRR=0.75, 95% CI 0.64 to 0.88; all other: IRR=0.79, 95% CI 0.71 to 0.88). Gender, age, therapeutic class, inhaler device and inhaler-technique checks did not significantly modify this association (p<0.05). The rate of consultations, respiratory-events and adverse-medication events did not change significantly (consultations: IRR=1.00, 95% CI 0.99 to 1.01; respiratory-events: IRR=0.96, 95% CI 0.95 to 0.97; adverse-medication-events: IRR=1.05, 95% CI 0.96 to 1.15). Adherence significantly increased post-switch (median MPR: pre-switch=54%, post-switch=62%; p<0.001). Switching patients, in the cohort of regular inhaler users, to the cheapest equivalent inhaler, could have saved around £6 million annually.

CONCLUSION

Switching to an equivalent inhaler in patients with asthma or COPD appeared safe and did not negatively affect patient's health or healthcare utilisation.

Prevalence and predictors of adherence to controller therapy in adult patients with severe/difficult-to-treat asthma: a systematic review and meta-analysis

Objective: Nonadherence to prescribed treatment is an important cause for poor asthma control. This systematic review aimed to determine the prevalence and determinants of nonadherence in adult patients with severe asthma.Data sources: Embase and Pubmed were searched for publications in English studying adult patients and containing the keywords "severe asthma", "adherence", and "compliance".Study selection: Only studies utilizing objective methods for monitoring adherence and clear definition of the level of asthma severity were included. Predominantly pediatric studies or studies of less severe asthma were excluded.Results: The search returned 488 reports, of which 14 reports (of 2297 patients) were included. The weighted mean age of patients was 44 years and 64% were females. In studies using a cutoff of acquiring 50% or less of the medication, an overall rate of nonadherence was 42.9%. For studies reporting nonadherence of a continuous scale, the weighted mean nonadherence was 42.9% (95% CI 28.2-49.5). Meta-analysis of adherence predictors showed that male sex was associated with adherence with an odds ratio of 2.25 and higher asthma quality of life questionnaire (AQLQ) scores with a mean difference 0.47 points in adherent patients. Other predictors were reported to have significant association with adherence (e.g. older age, more knowledge about asthma, simpler medication schedules) but these were from single studies.Conclusion: Nonadherence to therapy is a common problem in the management of patients with severe asthma. More robust and objective methods are needed to homogenize and improve the accuracy of assessment methods. More studies are needed from developing countries. Systematic review registration number: CRD42018114669.

Predicting asthma attacks in primary care: protocol for developing a machine learning-based prediction model

INTRODUCTION

Asthma is a long-term condition with rapid onset worsening of symptoms ('attacks') which can be unpredictable and may prove fatal. Models predicting asthma attacks require high sensitivity to minimise mortality risk, and high specificity to avoid unnecessary prescribing of preventative medications that carry an associated risk of adverse events. We aim to create a risk score to predict asthma attacks in primary care using a statistical learning approach trained on routinely collected electronic health record data.

METHODS AND ANALYSIS

We will employ machine-learning classifiers (naïve Bayes, support vector machines, and random forests) to create an asthma attack risk prediction model, using the Asthma Learning Health System (ALHS) study patient registry comprising 500 000 individuals across 75 Scottish general practices, with linked longitudinal primary care prescribing records, primary care Read codes, accident and emergency records, hospital admissions and deaths. Models will be compared on a partition of the dataset reserved for validation, and the final model will be tested in both an unseen partition of the derivation dataset and an external dataset from the Seasonal Influenza Vaccination Effectiveness II (SIVE II) study.

ETHICS AND DISSEMINATION

Permissions for the ALHS project were obtained from the South East Scotland Research Ethics Committee 02 [16/SS/0130] and the Public Benefit and Privacy Panel for Health and Social Care (1516-0489). Permissions for the SIVE II project were obtained from the Privacy Advisory Committee (National Services NHS Scotland) [68/14] and the National Research Ethics Committee West Midlands-Edgbaston [15/WM/0035]. The subsequent research paper will be submitted for publication to a peer-reviewed journal and code scripts used for all components of the data cleaning, compiling, and analysis will be made available in the open source GitHub website (https://github.com/hollytibble).

Severe T2-high asthma in the biologics era: European experts' opinion

The European Respiratory Biologics Forum gathered participants from 21 countries in Madrid, Spain, to discuss the management and treatment of severe asthma in the era of biologics. The current insights on the pathophysiology of severe asthma were discussed, as well as the role of respiratory biologics in clinical practice and strategies for eliminating chronic use of oral corticosteroids. The participants also highlighted the key challenges in identifying patients with severe asthma based on phenotypes, biomarkers and treatable traits, and the existing problems in patient referral to specialist care. The monitoring of treatment was debated and the need for a change towards precision medicine and personalised care was emphasised throughout the meeting. This review provides a summary of the discussions and highlights important concerns identified by the participants regarding the current management of severe asthma.

Determination of Personalized Asthma Triggers From Multimodal Sensing and a Mobile App: Observational Study

BACKGROUND

Asthma is a chronic pulmonary disease with multiple triggers. It can be managed by strict adherence to an asthma care plan and by avoiding these triggers. Clinicians cannot continuously monitor their patients' environment and their adherence to an asthma care plan, which poses a significant challenge for asthma management.

OBJECTIVE

In this study, pediatric patients were continuously monitored using low-cost sensors to collect asthma-relevant information. The objective of this study was to assess whether kHealth kit, which contains low-cost sensors, can identify personalized triggers and provide actionable insights to clinicians for the development of a tailored asthma care plan.

METHODS

The kHealth asthma kit was developed to continuously track the symptoms of asthma in pediatric patients and monitor the patients' environment and adherence to their care plan for either 1 or 3 months. The kit consists of an Android app-based questionnaire to collect information on asthma symptoms and medication intake, Fitbit to track sleep and activity, the Peak Flow meter to monitor lung functions, and Foobot to monitor indoor air quality. The data on the patient's outdoor environment were collected using third-party Web services based on the patient's zip code. To date, 107 patients consented to participate in the study and were recruited from the Dayton Children's Hospital, of which 83 patients completed the study as instructed.

RESULTS

Patient-generated health data from the 83 patients who completed the study were included in the cohort-level analysis. Of the 19% (16/83) of patients deployed in spring, the symptoms of 63% (10/16) and 19% (3/16) of patients suggested pollen and particulate matter (PM2.5), respectively, to be their major asthma triggers. Of the 17% (14/83) of patients deployed in fall, symptoms of 29% (4/17) and 21% (3/17) of patients suggested pollen and PM2.5, respectively, to be their major triggers. Among the 28% (23/83) of patients deployed in winter, PM2.5 was identified as the major trigger for 83% (19/23) of patients. Similar correlations were not observed between asthma symptoms and factors such as ozone level, temperature, and humidity. Furthermore, 1 patient from each season was chosen to explain, in detail, his or her personalized triggers by observing temporal associations between triggers and asthma symptoms gathered using the kHealth asthma kit.

CONCLUSIONS

The continuous monitoring of pediatric asthma patients using the kHealth asthma kit generates insights on the relationship between their asthma symptoms and triggers across different seasons. This can ultimately inform personalized asthma management and intervention plans.

Longitudinal Patterns of Mexican and Puerto Rican Children's Asthma Controller Medication Adherence and Acute Healthcare Use

Rationale: Researchers tend to study Latinos as a single group, but recent asthma research confirmed differences among Latino subgroups. Variations in controller medication adherence may be a factor in the observed health disparities between Mexican and Puerto Rican children. Adherence is not a stable phenomenon; however, there is a paucity of data on patterns of adherence, sociodemographic predictors of patterns, and variations in asthma-related acute healthcare use by adherence pattern among Latino subgroups. Objectives: To identify patterns of inhaled corticosteroid medication adherence over 12 months among Mexican and Puerto Rican children with persistent asthma, to examine sociodemographic predictors of adherence patterns by ethnicity, and to investigate asthma-related acute healthcare use based on these patterns. Methods: We analyzed controller medication Doser data from Mexican and Puerto Rican children (n = 123; ages 5-12 yr) with persistent asthma who participated with their caregivers in a longitudinal nonintervention study (Phoenix, AZ, and Bronx, NY). Interview and medical record data were collected at enrollment and at 3, 6, 9, and 12 months after enrollment. Results: Forty-seven to fifty-three percent of children had poor adherence (<50%) over each of the follow-up periods (cross-sectional). Children with lowest adherence were Puerto Rican, from nonpoor families, or female. Longitudinal latent class analysis yielded four adherence classes: poor, moderate, decreasing adherence, and increasing adherence. Puerto Rican children had significantly higher odds of "decreasing" (odds ratio [OR], 2.86; 95% confidence interval [CI], 0.40 to 20.50) and "poor" (OR, 5.62; 95% CI, 1.44 to 21.90) adherence than Mexican children. Females had significantly greater odds of "decreasing" (OR, 4.80; 95% CI, 0.73 to 31.74) and "poor" (OR, 5.20; 95% CI, 1.77 to 15.30) adherence group membership than males. The "decreasing" adherence group was comprised of only poor children. Children in the "poor" adherence class had the highest mean number of acute visits and emergency department visits/hospitalizations across all assessment periods. Conclusions: This study demonstrated that unique ethnicity within Latino populations may be associated with different risk levels for suboptimal controller medication adherence, which may be a factor in the observed asthma health disparities between Mexican and Puerto Rican children. Increased understanding of and attention to children's controller medication adherence patterns will provide evidence needed to identify children at highest risk for acute healthcare use and offer more-intensive intervention using less-intensive approaches for those at low risk. Clinical trial registered with www.clinicaltrials.gov (NCT01099800).

Diagnosis of severe asthma

Patients with asthma that is uncontrolled despite high intensity medication can present in both primary and specialist care. An increasing number of novel (and expensive) treatments are available for patients who fail conventional asthma therapy, but these may not be appropriate for all such patients. It is essential that a rigorous evaluation process be undertaken for these patients to identify those with biologically severe asthma who will require novel therapies, and those who may improve with control of contributory factors. In this article, we describe three key steps in the diagnostic evaluation process for severe asthma. The first step is confirmation of asthma diagnosis with objective evidence of variable airflow obstruction. The second involves management of contributory factors such as non-adherence, poor inhaler technique, ongoing asthma triggers, and comorbidities. The third step involves phenotyping and endotyping of patients with severe asthma. We provide a practical approach to implementing these measures in both primary and secondary care.

Potential normalization of an asthma mHealth intervention in community pharmacies: Applying a theory-based framework

BACKGROUND

Effective mobile health (mHealth) interventions have been developed to support patients with their medication use, however to date few are widely used in pharmacy practice. Normalization of an intervention is essential to have a population impact, which is defined as 'the process of getting a new intervention into routine practice'.

OBJECTIVE

The aim of this study was to assess the normalization potential of a complex mHealth intervention for adolescents with asthma (ADolescent Adherence Patient Tool; ADAPT) in community pharmacy practice.

METHODS

The Normalization Process Theory (NPT), a sociological action theory, was retrospectively applied to study the normalization potential of ADAPT. NPT explains factors that promote or hinder implementation, embedding, and integration of new interventions in clinical practice. Evaluation data (structured interviews and questionnaires) of 23 pharmacists who used the ADAPT intervention were used for this study.

RESULTS

Pharmacists understood the purpose of the ADAPT intervention and were prepared to undertake the necessary work of implementation. However changes at different levels are needed to support full normalization, such as changes in the intervention itself and changes in the pharmacist's work flow. The potential for normalization could also be enhanced by the use of product champions and appropriate reimbursement guidelines, to ensure uptake of the intervention by other pharmacists. Support from professional bodies for the use of mHealth could also promote normalization.

CONCLUSIONS

Normalization of mHealth is a complex continuous process. The ADAPT intervention has the potential to be normalized in community pharmacy practice, but full normalization would require changes in both daily pharmacy practice and reimbursement models.

Asthma exacerbation prediction: recent insights

PURPOSE OF REVIEW

Asthma attacks are frequent in children with asthma and can lead to significant adverse outcomes including time off school, hospital admission and death. Identifying children at risk of an asthma attack affords the opportunity to prevent attacks and improve outcomes.

RECENT FINDINGS

Clinical features, patient behaviours and characteristics, physiological factors, environmental data and biomarkers are all associated with asthma attacks and can be used in asthma exacerbation prediction models. Recent studies have better characterized children at risk of an attack: history of a severe exacerbation in the previous 12 months, poor adherence and current poor control are important features which should alert healthcare professionals to the need for remedial action. There is increasing interest in the use of biomarkers. A number of novel biomarkers, including patterns of volatile organic compounds in exhaled breath, show promise. Biomarkers are likely to be of greatest utility if measured frequently and combined with other measures. To date, most prediction models are based on epidemiological data and population-based risk. The use of digital technology affords the opportunity to collect large amounts of real-time data, including clinical and physiological measurements and combine these with environmental data to develop personal risk scores. These developments need to be matched by changes in clinical guidelines away from a focus on current asthma control and stepwise escalation in drug therapy towards inclusion of personal risk scores and tailored management strategies including nonpharmacological approaches.

SUMMARY

There have been significant steps towards personalized prediction models of asthma attacks. The utility of such models needs to be tested in the ability not only to predict attacks but also to reduce them.

Key factors associated with uncontrolled asthma - the Asthma Control in Latin America Study

Objective: This study aimed to estimate asthma control at specialist treatment centers in four Latin American countries and assess factors influencing poor asthma control.Methods: Patients aged ≥12 years with an asthma diagnosis and asthma medication prescription, followed at outpatient specialist centers in Argentina, Chile, Colombia, and Mexico, were included. The study received all applicable ethical approvals. The Asthma Control Test (ACT) was used to classify patients as having controlled (ACT 20-25) or uncontrolled (ACT ≤19) asthma. Frequency and statistical tests were used to assess the association between hospital admissions/exacerbations/emergency department (ED) visits and uncontrolled asthma; multivariate logistic regression was used to assess the association of uncontrolled asthma with clinical/demographic variables.Results: A total of 594 patients were included. Overall controlled-asthma prevalence was 43.4% (95% confidence interval [CI]: 39.0, 47.4). Patients with uncontrolled asthma were more likely to be women (adjusted odds ratio [aOR]: 1.85; p = 0.003), non-white (aOR: 2.14; p < 0.001), obese (aOR: 1.71; p = 0.036), to have a low monthly family income (aOR: 1.75; p = 0.004), to have severe asthma (aOR:1.59; p = 0.26), and, compared with patients with controlled asthma, to have a higher likelihood of asthma exacerbations (34.5% vs. 15.9%; p < 0.001), hospital admissions (6.9% vs. 3.1%; p = 0.042), and ED visits (34.5% vs. 15.9%; p < 0.001) due to asthma.Conclusions: Even in specialist ambulatory services, fewer than half of patients were classified as having controlled asthma. The proportion of uncontrolled patients varied according to clinical and demographic variables.

Advances in the aetiology, management, and prevention of acute asthma attacks in children

Acute attacks of wheeze or asthma are among the most common reasons for paediatric hospital attendance, and the incidence of severe attacks in the UK is among the highest in Europe. Although most attacks are driven by infection, there are important differences in the underlying pathophysiology of asthma and wheeze between preschool and school-aged children. Allergen sensitisation, airway eosinophilia, and type 2 inflammation predominate in older children, whereas phenotypes in preschool children are variable, often including non-atopic episodes driven by neutrophilic infection. Currently, a universal approach is adopted towards management, but there is a need to make objective assessments of airway function, inflammation, and infection, both during the attack and during stable periods, to identify treatable traits and to target therapy if outcomes are to be improved. An assessment of the risk factors that led to the attack and early, focused follow-up are essential to ensure attacks never occur again.

Better understanding the influence and complexity of beliefs on medication adherence in asthma

OBJECTIVE

The aim was to better understand how beliefs influence medication adherence in asthma.

METHODS

All participants were prescribed an inhaled corticosteroid for a diagnosis of asthma. Each participant completed a survey consisting of: Beliefs about Medicines Questionnaire (BMQ), Brief-Illness Perception Questionnaire (B-IPQ) and Multi-dimensional Health Locus of Control Scale (MHLCS). Adherence to inhaled corticosteroids was elicited using the Medication Adherence Report Scale (MARS). Multiple linear regression with interaction effects was used to identify significant predictors of medication adherence and interactions between beliefs.

RESULTS

A total of 198 participants completed the survey. The mean(±SD) MARS score was 19.2(±4.5). A multivariable model (adjusted R² = 0.39) predicted adherence using: age, asthma hospitalisation, timeline (B-IPQ) subscale, necessity and concern (BMQ) subscales, doctor (MHLCS) subscale and the two interaction effects (concerns [BMQ] moderated by chance [MHLCS] and treatment control [B-IPQ] moderated by understanding [B-IPQ]).

CONCLUSION

The findings of this study contribute to a better understanding of the role of beliefs in medication adherence in asthma. Certain beliefs meaningfully interrelate and change the relationship they have with medication adherence.

PRACTICE IMPLICATIONS

If these beliefs are causally related to medication adherence and can be intervened upon, the findings are useful for providing targets to personalise adherence support.

Inhaler Review in Older Adults with Asthma or COPD: A Cost-Effectiveness Study and a Perspective in Portugal

OBJECTIVES

Older patients with asthma or chronic obstructive pulmonary disease are particularly susceptible to exacerbations that may be associated with incorrect use of inhalers. Educational programs with inhaler technique review seem to be effective, but no studies have addressed their cost-effectiveness in older adult patients. The objective was to perform a cost-effectiveness analysis of education programs in older patients and estimate the cost benefit of applying such a program in Portugal.

DESIGN

We developed a decision tree analysis from a healthcare perspective, according to intervention costs and the exacerbation rates and costs described in a previous meta-analysis. A sensitivity analysis of worst and best case scenarios was performed to estimate thresholds for intervention affordable limits, as well as cost-saving estimations and incremental cost-effectiveness ratios (ICERs) for a Portuguese scenario.

SETTING AND PARTICIPANTS

We estimated cost-effectiveness thresholds applicable in all settings and performed a sensitivity analysis of a theoretical intervention model in all patients including an inhaler technique review at an annual appointment with a doctor and a nurse.

RESULTS

In the best case scenario, the intervention affordable budget could be up to almost 1800€ (US $1585.24) per patient per year. Mean intervention-associated savings in Portugal would be 311.88€ (US $274.68) per patient per year, representing annual savings up to €131 million (US $150 million) for the whole health system, already including intervention costs. ICERs for Portugal vary between 93.73€ (US $82.55) and 437.43€ (US $385.25) per exacerbation avoided.

CONCLUSION

A model of an intervention program with an inhaler technique review in older adult patients suggests that this intervention is cost-effective and can generate significant savings. J Am Geriatr Soc 1-7, 2019.

Effect of a mHealth intervention on adherence in adolescents with asthma: A randomized controlled trial

BACKGROUND

Adherence rates among asthma patients are generally low and decrease during adolescence, resulting in poorly controlled asthma. The aim of our study was to evaluate the effectiveness of the ADolescent Adherence Patient Tool (ADAPT), an interactive mobile health (mHealth) intervention, in supporting self-management and improving inhaled corticosteroid adherence in adolescents with asthma.

METHODS

We conducted a cluster randomized controlled trial in 66 Dutch community pharmacies. Asthma patients aged 12-18 years were invited to participate, based on pharmacy medication refill records. The main study outcome was self-reported medication adherence, measured with the Medication Adherence Report Scale (MARS). Secondary outcomes were asthma control and quality of life. Outcomes were measured at start (t = 0 months) and at the end of follow-up (t = 6 months). Mixed-effects models were used to analyze the effect.

RESULTS

In total, 234 adolescents (147 in the control group and 87 in the intervention group) completed the study; mean age 15.1 ± 1.9 years and 52.6% females. Adherence rates of patients with low baseline adherence (MARS scores ≤19; n = 76) increased with 1.42 points in the intervention group (n = 26). Adherence rates of patients in the control group (n = 50) decreased with 0.70 points. Thus there was a positive effect of the intervention on medication adherence (MARS +2.12, p = 0.04). This effect was stronger (MARS +2.52, p = 0.02) in poor adherent adolescents with uncontrolled asthma (n = 74). No effect of the intervention was observed on asthma control or quality of life.

CONCLUSIONS

The ADAPT intervention increases medication adherence in adolescents with asthma having poor adherence rates at baseline. Healthcare providers should consider a tailored mHealth approach to improve the asthma treatment.

Impact of eHealth on medication adherence among patients with asthma: A systematic review and meta-analysis

BACKGROUND

Asthma is an important public health issue in the United States. eHealth technology offers a potential solution to asthma treatment adherence, but the relative effect of various types of eHealth interventions has not been systematically studied.

OBJECTIVES

To systematically review the effectiveness of eHealth in improving adherence to inhaled corticosteroids (ICS) among patients with persistent asthma, as well as the satisfaction of patients undergoing eHealth interventions.

METHODS

Literature searches were conducted in five databases in August 2018. Included studies were randomized controlled trials comparing eHealth interventions versus usual care in improving adherence among patients prescribed ICS for persistent asthma. Quantitative synthesis was performed using a random effects model.

RESULTS

Eighty records were identified after removal of duplicates. Fifteen trials were eligible for qualitative synthesis. Included trials utilized: social media (n = 1), electronic health records (n = 1), telehealth (n = 6), and mHealth (n = 7). Twelve trials were eligible for quantitative synthesis. Results show a small but significant overall effect of eHealth interventions on adherence to ICS (Standardized Mean Difference (SMD) = 0.41, 95%CI = 0.02-0.79). Among the different types of eHealth interventions, a significant improvement in adherence was observed for mHealth interventions compared to usual care in a pooled analysis of 4 trials (SMD = 0.96, 95%CI = 0.28-1.64). However, there was considerable heterogeneity among studies. Patient satisfaction was evaluated in 5 trials comparing telehealth (n = 2) and mHealth (n = 3) with usual care. Participants found the interventions to be helpful and satisfactory.

CONCLUSION

eHealth interventions, especially mHealth interventions, are effective and acceptable in improving patient adherence to ICS.

Development and validation of the family management scale for children with asthma (FMSCA)

Objective: This study aims to develop and validate the Family Management Scale for Children with Asthma (FMSCA) in China context. Methods: Based on the Family Management Style Framework (FMSF) model, an original 89 items were generated from literature review and interviews with 15 caregivers of children with asthma. The preliminary scale was refined to 82 items through two rounds of experts' evaluation and a pilot study, then administered to 329 caregivers of children with asthma for testing between April and July 2013. Item analysis and exploratory factor analysis were performed to screen the items, reliability and validity analysis were tested using psychometric techniques (internal consistency, split-half reliability, test-retest reliability, content validity, and construct validity). Confirmatory factor analysis was adopted to further evaluate the construct validity of the scale in an additional 600 children with asthma and their parents from August 2014 to December 2015. Results: A final 57-item FMSCA from 8 subscales (children identity, view of condition, management mindset, parental mutuality, parenting philosophy, management approach, family focus, and future expectation) were generated. The excellent internal consistency (Cronbach's α = 0.918), very good split-half reliability (r = 0.802, p < 0.01) and test-retest reliability (r = 0.857, p < 0.01) indicate a satisfactory reliability of the FMSCA. The Item Content Validity Index (I-CVI) of the scale ranged 0.8 3 ～1.00, Scale Content Validity Index (S-CVI) was 0.807, indicating a good content validity. Construct validity was established by accepted correlation coefficient of item-to-subscale (r range = 0.513-0.865, P < 0.01), intersubscale (r range = 0.195-0.604, p < 0.01), and subscale-to-total (r range = 0.408-0.876, p < 0.01), respectively. Additionally, the factors accounted for 51.586%∼74.063% of the variance in each subscale, confirmatory factor analysis indicated the confirmatory model fitted data well and the scale had adequate construct validity. Conclusions: The study demonstrates FMSCA can serve as a valid and reliable measure of family management level for Chinese children with asthma.

Inhaler technique education in elderly patients with asthma or COPD: impact on disease exacerbations-a protocol for a single-blinded randomised controlled trial

INTRODUCTION

Chronic Obstructive Pulmonary Disease (COPD)and asthma affect more than 10% of the population. Most patients use their inhaler incorrectly, mainly the elderly, thereby becoming more susceptible to poor clinical control and exacerbations. Placebo device training is regarded as one of the best teaching methods, but there is scarce evidence to support it as the most effective one to improve major clinical outcomes. Our objective is to perform a single-blinded RCT to assess the impact of this education tool in these patients.

METHODS AND ANALYSIS

A multicentre single-blinded Randomised Controlled Trial (RCT) will be set up, comparing an inhaler education programme with a teach-to-goal placebo-device training versus usual care, with a 1-year follow-up, in patients above 65 years of age with asthma or COPD. Intervention will be provided at baseline, and after 3 and 6 months, with interim analysis at an intermediate time point. Exacerbation rates were set as primary outcomes, and quality of life, adherence rates, clinical control and respiratory function were chosen as secondary outcomes. A sample size of 146 participants (73 in each arm) was estimated as adequate to detect a 50% reduction in event rates. Two-sample proportions χ² test will be used to study primary outcome and subgroup analysis will be carried out according to major baseline characteristics.

ETHICS AND DISSEMINATION

Every participant will sign a written consent form. A Data Safety Monitoring Board will be set up to evaluate data throughout the study and to monitor early stopping criteria. Identity of all participants will be protected. This protocol was approved on 22 November 2017 by the local Ethics Committee of University of Beira Interior, with the reference number CE-UBI-Pj-2017-025. Results will be presented in scientific meetings and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT03449316; Pre-Results.

"Drugs Don't Work in Patients Who Don't Take Them"

The more recent term "adherence" is now taking the place of the earlier notion of "compliance," as it emphasizes the physician-patient partnership. To date, however, it has not been clearly defined. There are many limitations to measuring adherence, and presently no standard methods have been established. Even in clinical trials throughout medicine, the reported rates for adherence range only between 43 % and 78 %. Particularly medication adherence is highly relevant to the treatment of mentally ill adolescents, as they make up a population especially vulnerable to nonadherence - and high rates thereof have been reported. Factors influencing adherence are poorly understood and researched, especially in adolescents with mental illness. Physicians can currently rely only on concepts from other populations and expert recommendations. Concepts for children or adults should not directly be transferred to adolescent patients. Results from the current "SEMA" study should contribute to guiding future research in the development of interventions to improve medication adherence, in particular for this juvenile population.

[Asthma exacerbations in adults: Preventing and treat]

Exacerbations of asthma are still responsible for 900 deaths per year in France, most of which are considered preventable. They have a major impact on the quality of life of patients and are responsible for a large part of the socio-economic cost of asthma in France. Exacerbations of asthma can be partly prevented by inhaled corticosteroid treatment as controller therapy, at a dose adapted to the level of control of symptoms and the management of aggravating factors. Every patient should benefit from a written action plan that allows them to start oral corticosteroid therapy as soon as possible during an exacerbation. The treatment combines short-acting bronchodilators with systemic corticosteroids. Systemic antibiotic therapy has no place in the treatment of exacerbations. The patient must be seen early in the course of an exacerbation of asthma to review all of his follow-up.

Treatable traits in acute exacerbations of chronic airway diseases

Acute exacerbations of chronic airway disease are common occurrences that cause a major burden of illness. Acute exacerbations are associated with impaired health status, increased lung function decline, hospitalization and increased risk of death. Exacerbation avoidance is a major priority. Despite this goal, exacerbations continue to occur and the need for effective models of care that optimize patient outcomes are urgently needed. 'Treatable Traits' is an approach to personalized medicine that has been proposed for the management of airway diseases. The treatable traits approach allows for the recognition of clinically important, identifiable and treatable disease characteristics, followed by targeted and individualized treatment interventions to address each trait. We review the literature relating to treatable traits in airway diseases; in particular, those traits that can predict exacerbations and approaches to management that aim to prevent exacerbations by using a treatable traits model of care. We propose this approach as a potentially useful model of care to both prevent and manage acute exacerbations.

Patients with Asthma Prescribed Once-Daily Fluticasone Furoate/Vilanterol or Twice-Daily Fluticasone Propionate/Salmeterol as Maintenance Treatment: Analysis from a Claims Database

Introduction

There is a paucity of data describing prescribing patterns and adherence to therapy of inhaled corticosteroids (ICS) in combination with long-acting β₂-agonists (LABA) in the Japanese population in clinical practice.

Methods

This was a non-interventional, retrospective, cohort study of patients who were prescribed medication for asthma, using data from the Japan Medical Data Center Claims Database. Data from patients aged ≥ 15 years with a prescription of asthma drugs between December 2014 and October 2015 (Day 0, the index date when asthma medication was initiated) were analysed in 12-month pre-index and post-index periods. Part 1 focused on baseline characteristics and epidemiological outcomes in the pre- and post-index period in the overall asthma population, whereas comparing medication adherence [number of prescribed days per year and proportion of days covered (PDC)] between ICS/LABA-naïve patients treated with once-daily fluticasone furoate/vilanterol (FF/VI) and twice-daily fluticasone propionate/salmeterol (FP/SAL) was the primary endpoint in Part 2.

Results

Of the available patient data (N = 2,953,652), 28,699 patients were identified as having asthma. ICS/LABA was the main asthma treatment prescribed; 11,167 (38.9%) patients were continuous ICS/LABA users. In ICS/LABA-naïve asthma patients, treatment with once-daily FF/VI was associated with higher medication adherence compared with twice-daily FP/SAL; mean [standard deviation (SD)] number of prescribed days per year was 97.8 (115.9) for FF/VI versus 80.5 (92.7) for FP/SAL (p = 0.04), mean (SD) PDC was 26.7% (31.5) for FF/VI versus 21.9% (24.8) for FP/SAL (p = 0.04). FF/VI was also associated with a lower rate of treatment discontinuation and no difference in use of short-acting beta₂-agonists or oral corticosteroids compared with FP/SAL.

Conclusions

ICS/LABA was the major prescribed asthma treatment in Japan. Medication adherence was greater with FF/VI, which may indicate that patients are more likely to adhere to once-daily FF/VI versus twice-daily FP/SAL.

Funding

This study was funded by GSK (study sponsor).

Study Registration

GSK Study No. 207264, GSK Study Register site: https://www.gsk-clinicalstudyregister.com/search/?search_terms=207264.

Electronic supplementary material

The online version of this article (10.1007/s41030-018-0084-4) contains supplementary material, which is available to authorized users.

A Systematic Review of the Effectiveness of Text Message Reminders on Asthma Medication Adherence

OBJECTIVE

Cell phone text messaging reminders offers the promise of an efficient technology for the management of chronic diseases, such as asthma. This review aims to evaluate the effectiveness of text message reminders in improving medication adherence for asthma compared to usual care.

METHODS

Randomized controlled trials assessing the effect of text message reminders on adherence to asthma medication were identified from PubMed, Medline, Web of Knowledge EBSCOhost, OvidSP, PsycINFO, and Cochrane Central Register of Controlled Trials and Cochran Health Technology Assessment databases. Literature searches were restricted to the English language, and no restrictions were imposed on the year and country of publication.

RESULTS

Five studies that were deemed relevant to the systematic review were identified from the literature search. Findings on whether text message reminders improve medication adherence were mixed. However, the review indicates that text-messaging interventions were effective as a means of addressing forgetfulness by reminding patients to take their medications.

CONCLUSION

This review adds to the body of literature reviewing the effectiveness of emerging technologies in the management of diseases. Despite the fact there is limited evidence across the population of studies to support the effectiveness of text message reminders, such technology represents an important tool to achieve optimal medication adherence among asthmatics.

Does allergy explain why some children have severe asthma?

Asthma is a common disease in childhood with a minority of affected children having severe therapy-resistant asthma (STRA). Children with STRA can be differentiated from those with mild-moderate disease by greater allergic sensitization, increased eosinophilic airway inflammation, increased airway remodelling and reduced corticosteroid responsiveness. The aetiology of STRA in children is multifactorial but allergy seems to play a key role. Many children with asthma have coexisting allergic disease, and severe rhinitis seems to be an important driver of STRA in children. Allergies to foods, moulds, pollen and pets have also been associated with severe asthma exacerbations. Identifying allergens that are driving asthma symptoms in children with STRA may provide additional strategies for improving their disease control. Avoidance strategies may be possible. Additional monoclonal antibody therapy with Omalizumab or Mepolizumab may be helpful in children with clinically important polysensitization.

Inhaler Technique Education and Exacerbation Risk in Older Adults with Asthma or Chronic Obstructive Pulmonary Disease: A Meta-Analysis

OBJECTIVES

To evaluate the effect of inhaler education programs on clinical outcomes and exacerbation rates in older adults with asthma or chronic obstructive pulmonary disease (COPD).

DESIGN

Systematic review and meta-analysis.

SETTING AND PARTICIPANTS

Older adults with asthma or COPD, either in primary or secondary health care and pharmacy setting.

MEASUREMENTS

We searched the Medline, Embase, and Central databases according to the main eligibility criteria for inclusion: systematic reviews, meta-analysis, clinical trials and quasi-experimental studies; participants aged 65 and older; education on inhaler technique and reporting of disease control and exacerbation rates. We used the Grading of Recommendations, Assessment, Development and Evaluations scale for quality assessment and used a random-effect model with Mantel-Haenszel adjustment to perform a meta-analysis.

RESULTS

We included 8 studies (4 randomized, 4 quasi-experimental) with a total of 1,812 participants. The most frequent type of intervention was physical demonstration of inhaler technique, training with placebo devices. Five studies showed significant reduction in exacerbation rates (pooled risk ratio=0.71, 95% confidence interval=0.59-0.86; p < .001), although effect on disease control and quality of life showed high discrepancy in the reported results, and all randomized studies revealed uncertainty in their risk of bias assessment.

CONCLUSION

All interventions seemed to improve inhaler performance and clinically relevant outcomes, but a placebo device could be the most effective. There is evidence that interventions reduce exacerbation risk in older adults, although to an overall moderate degree. J Am Geriatr Soc 67:57-66, 2019.

Consistency and replicability of a pharmacist-led intervention for asthma patients: Italian Medicines Use Review (I-MUR)

AimThis study aimed to assess the consistency and replicability of these process measures during provision of the Italian Medicines Use Review (I-MUR).

BACKGROUND

Medication review is a common intervention provided by community pharmacists in many countries, but with little evidence of consistency and replicability. The I-MUR utilised a standardised question template in two separate large-scale studies. The template facilitated pharmacists in recording medicines and problems reported by patients, the pharmaceutical care issues (PCIs) they found and actions they took to improve medicines use.

METHODS

Community pharmacists from four cities and across 15 regions were involved in the two studies. Patients included were adults with asthma. Medicines use, adherence, asthma problems, PCIs and actions taken by pharmacists were compared across studies to assess consistency and replicability of I-MUR.FindingsThe total number of pharmacists and patients completing the studies was 275 and 1711, respectively. No statistically significant differences were found between the studies in the following domains: patients' demographic, patients' perceived problems, adherence, asthma medicines used and healthy living advice provided by pharmacists. The proportion of patients in which pharmacists identified PCIs was similar across both studies. There were differences only in the incidence of non-steroidal anti-inflammatory drug use, the frequency of potential drug-disease interactions and in the types of advice given to patients and GPs.

CONCLUSIONS

The use of a standardised template for the I-MUR may have contributed to a degree of consistency in the issues found, which suggests this intervention could have good replicability.

Implementing Health Care Technology Research into Practice to Improve Adult Asthma Management

BACKGROUND

Use of health technology has shown potential to improve asthma adherence and outcomes. Few studies have looked at the implementation of such research within larger asthma populations.

OBJECTIVE

This report examines the process of translating results from a pragmatic trial using speech recognition (SR) in children with persistent asthma into the standard operating procedure within a large health maintenance organization. Medication adherence and outcomes in adults with asthma were examined.

METHODS

The SR protocol was implemented for the total Kaiser Permanente Colorado (KPCO) patient population of 480,142, of whom 36,356 had asthma. Patients had persistent asthma, filled 1 or more inhaled corticosteroid prescriptions in the prior 6 months, and remained continuously enrolled with KPCO for 2 years. Documented exacerbations included the presence of a hospitalization, emergency department visit, or course of oral corticosteroid where asthma was the principal diagnosis. Adherence and exacerbation events were compared 1 year before and 1 year after intervention for 4,510 adults aged 19 to 64.

RESULTS

Patient adherence demonstrated a small but significant improvement from 39.5% to 41.7% (P < .0001). Although not significant, data trends suggested greater improvement for patients with lower socioeconomic status. When an outlier month was removed from both the pre- and postintervention time periods, courses of oral corticosteroids decreased. Emergency department visits and hospitalizations were infrequent in both time periods and did not decrease over time.

CONCLUSIONS

A low-cost SR intervention reminding patients to fill and take their daily controller asthma medication can improve treatment adherence and decrease the need for oral corticosteroids due to asthma exacerbations, but not decrease emergency department visits or hospitalizations.

Novel methods for device and adherence monitoring in asthma

PURPOSE OF REVIEW

The article aims to provide an updated and evidence-based review of the innovative electronic health interventions to monitor and improve inhaler technique and adherence to recommended therapy in asthma.

RECENT FINDINGS

Out of the 290 articles identified by the search strategy, 23 manuscripts fulfilled the review inclusion criteria. Included studies mainly addressed m-health, electronic reminders, telemedicine, and inhaler tracker interventions. Investigations were performed both in adults and children. Remarkably, the majority of studies were performed in the most recent years, showing a progressively increasing interest for this field. Existing findings appear to be of moderate-high quality. A significant number of papers, however, were published in scientific journals with a low impact factor (<2). Furthermore, extremely high heterogeneity was found in the considered study endpoints. Collected evidence supports a relevant role for e-health in monitoring and improving inhaler use and treatment adherence in asthma. The patients' acceptance and satisfaction towards assessed interventions were also found to be positive.

SUMMARY

E-health represents a highly valuable tool for achieving optimal and personalized asthma management. Unanimously agreed and adopted standards for conducting trials and reporting results on e-health in asthma are however needed to fully understand its real added value.

Interventions on Adherence to Treatment in Children With Severe Asthma: A Systematic Review

Introduction: Poor adherence to inhaled medication is a commonly encountered problem among children with asthma. However, there is a relatively paucity of data regarding the adherence of children with severe asthma, as well as the merit of any interventions to improve this adherence. Objectives: The aim of this systematic review was to identify the available literature on the rate of adherence and the influence of interventions in improving adherence to controller inhaled medication, in children with severe asthma. Methods: A systematic literature search was performed in MEDLINE/PubMed, Cochrane Library, and Scopus databases. Studies were included in the present review if their target population were children and/or adolescents with severe asthma and presented data on medication adherence before and after a given intervention. Results: A total of seven studies, conducted in USA, Canada, and UK, and published between 2012 and 2018, met the inclusion criteria. Adherence to controller medication was assessed via either objective or subjective measures (questionnaires), or a combination of them. Interventions included communication during pediatric visits and audio-taped medical visits, individualized care programs, electronic monitoring devices, interactive website and peak-flow prediction with feedback. Adherence rates for the baseline (before intervention) or for the control groups ranged from 28 to 67%. In general, there was a significant improvement of adherence after intervention with rates increasing to 49-81%. Conclusion: Adherence rate in children with severe asthma is not satisfactory but it can be improved after proper interventions. Nevertheless, the heterogeneity among adherence assessment tools, and the variety of interventions, in combination with the lack of studies focusing on severe asthma, highlight the need for further research in this field.

School-supervised use of a once-daily inhaled corticosteroid regimen: A cluster randomized trial

BACKGROUND

School-supervised use of a once-daily inhaled corticosteroid regimen (supervised therapy) can improve medication adherence and asthma control.

OBJECTIVE

We sought to evaluate the effectiveness of supervised therapy in a unique setting and population.

METHODS

We conducted a cluster randomized trial of supervised therapy in 20 elementary schools with a disproportionate enrollment of low-income Latino students. Schools were purposively selected, matched, and randomized to receive 9 months of supervised therapy with mometasone furoate or usual care. All English- or Spanish-speaking students with self-reported asthma were eligible. The Asthma Control Questionnaire (ACQ) was interviewer administered quarterly at school. Students in supervised therapy schools were hypothesized to have lower ACQ scores than students in usual-care schools.

RESULTS

Of 393 enrolled students, 189 students receiving immediate intervention and 143 students receiving delayed intervention provided 1 or more ACQ data points, were between 6 and 10 years of age, and were included in the primary analysis. At baseline, 39% of students reported taking a controller medication, and 24% had well-controlled asthma. Eighty percent of students receiving immediate intervention were prescribed mometasone. Schools administered 98% of prescribed doses when students attended school. Absences, weekends, and holidays reduced calendar adherence to 53%. During the first year, the mean ACQ score for students receiving immediate and delayed intervention was 1.55 (95% CI, 1.41-1.70) and 1.64 (95% CI, 1.47-1.80), respectively. The estimated treatment effect was -0.08 (95% CI, -0.31 to 0.14).

DISCUSSION

Compared with usual care, supervised therapy did not improve asthma control among this population of Latino students. Additional research is warranted to confirm these results.

Applying UK real-world primary care data to predict asthma attacks in 3776 well-characterised children: a retrospective cohort study

Current understanding of risk factors for asthma attacks in children is based on studies of small but well-characterised populations or pharmaco-epidemiology studies of large but poorly characterised populations. We describe an observational study of factors linked to future asthma attacks in large number of well-characterised children. From two UK primary care databases (Clinical Practice Research Datalink and Optimum Patient Care research Database), a cohort of children was identified with asthma aged 5–12 years and where data were available for ≥2 consecutive years. In the “baseline” year, predictors included treatment step, number of attacks, blood eosinophil count, peak flow and obesity. In the “outcome” year the number of attacks was determined and related to predictors. There were 3776 children, of whom 525 (14%) had ≥1 attack in the outcome year. The odds ratio (OR) for one attack was 3.7 (95% Confidence Interval (CI) 2.9, 4.8) for children with 1 attack in the baseline year and increased to 7.7 (95% CI 5.6, 10.7) for those with ≥2 attacks, relative to no attacks. Higher treatment step, younger age, lower respiratory tract infections, reduced peak flow and eosinophil count >400/μL were also associated with small increases in OR for an asthma attack during the outcome year. In this large population, several factors were associated with a future asthma attack, but a past history of attacks was most strongly associated with future attacks. Interventions aimed at reducing the risk for asthma attacks could use primary care records to identify children at risk for asthma attacks.

A past history of asthma attacks in young children is a strong predictor for future attacks and should be factored into treatment regimes. Childhood asthma attacks take considerable toll on sufferers and their carers, yet risk factors for future attacks are unclear. David Price at the Observational and Pragmatic Research Institute in Singapore and co-workers searched UK primary care databases to find at least two years’ worth of consecutive data on children with asthma aged 5 to 12. The team analyzed data from 3,776 children. Their results showed that past attacks are the strongest predictor for future attacks; of 638 patients who experienced more than one asthma attack during the first year, 240 (38%) had attacks in the second year. Other risk factors included reduced peak flow, lower respiratory tract infections and younger age.