The Impact of Adherence and Health Literacy on Difficult-to-Control Asthma

Factors associated with therapeutic non-adherence in asthmatic patients: A multicenter study in Algeria

INTRODUCTION

Effective medication adherence, is a real global challenge that emerges as a pivotal factor influencing asthma control, exacerbation frequency, hospitalization rates and ultimately, mortality, morbidity and health care costs. In light of this, our study aimed to assess therapeutic adherence levels among asthmatic patients and identify factors contributing to non-adherence.

METHODS

We conducted a descriptive, cross-sectional multicenter study, among asthmatic patients receiving outpatient or inpatient care across seven asthma centers located in two Algerian cities: Algiers (University Hospital Center of Benimessous, University Hospital Center of Bab el oued,EPSP of Zeralda, EPSP of Beraki and EPSP of Rouiba) and Constantine (Constantine University Hospital Center (CHU), EPSP of Constantine), between July and December 2023. We evaluated therapeutic adherence using the Morisky 8-item questionnaire, while a 12-item questionnaire assessed patients' knowledge levels. Logistic regression analysis enabled us to identify factors associated with non-adherence.

RESULTS

Our study, involved 390 patients, with a median age of 34 years and a sex ratio of 1.5. Notably, 38.2% of asthmatic patients exhibited poor adherence to treatment. Multivariate analysis revealed several factors potentially linked to non-adherence, including, age, place of residence, employment status, access to social insurance, treatment type and complexity, auto-medication, occurrence of adverse effects, limited level of education and inadequate knowledge about asthma management. Furthermore, there was a significant correlation between non-adherence and a higher rate of asthma exacerbations, with a reported occurrence of 68%.

CONCLUSION

Our findings emphasize concerning levels of therapeutic adherence, given its impact on disease control and the quality of life of asthmatic patients. This underscores the importance of implementing a therapeutic education program aimed at improving treatment adherence by addressing the factors identified as barriers in clinical patient management.

Low health literacy impact on headache diagnosis

Health literacy has a broad range of impacts, including whether and where a person seeks treatment and how well that patient interprets and applies clinical recommendations. Patients with headache may not seek treatment, may fail to disclose even severe pain to their physician, and may not understand or adhere to treatment. Universal precautions can be a helpful initial approach, and information styles can be modified as needed over time. Patients should be asked about headache and explanations about headache causes and treatment should be given in everyday language. The teach-back method can confirm if patients understand instructions. Health literacy can impact how patients perceive their headaches and how well they adhere to treatments. Health literacy is a two-way street; it depends on the patient's ability to understand and act on clinical information and the clinician's ability to give clear information. Language and cultural barriers can adversely impact health literacy, even in patients who otherwise have good understanding of medical advice. While health literacy can impact outcomes, those with low or very high health literacy are most likely to be non-adherent, albeit for different reasons. Clinical action plans can be valuable for those with severe headache.

Insights from Real-World Evidence on the Use of Inhalers in Clinical Practice

Background: Despite the ongoing innovations and the availability of numerous effective inhaled treatment options, achieving optimal disease control in most patients frequently remains disappointing. Unfortunately, although inhaled therapy is the cornerstone of respiratory disease management, the selection of the most appropriate inhaler is still overlooked or underestimated by some healthcare professionals, and inhaler misuse remains a significant challenge in managing chronic respiratory diseases which directly influences patients' quality of life, clinical outcomes, and risk of disease progression. Materials and Methods: This is a unicentric, observational, cross-sectional study designed to evaluate the inhaled therapy prescribed in hospitalized patients and to analyze device changes after hospitalization, as well as the factors associated with these changes. A single face-to-face visit was performed during the patient's hospitalization, where the inhaled therapy used prior to hospitalization was evaluated: technique (critical errors), compliance (TAI questionnaire), maximum peak inspiratory flow [PIF (L/min)], and level of inhaler handling-related knowledge. A binary logistic regression model was used to explore the association between changing device at discharge and the other independent variables Results: The inhaler most used during hospitalization was the metered-dose inhaler (MDI) with a chamber (51.9% of patients), with the dry powdered inhalers (DPI) being the inhalers used in 43% of maintenance inhaled therapies in the community setting prior to hospitalization. In addition, 90% of patients showed a maximum PIF ≥ 30 L/min, and 35.6% performed critical inhaler errors. These patients had statistically significantly lower maximum PIF values (52.1 L/min in patients with critical inhaler errors vs. 60.8 L/min without critical inhaler errors; p > 0.001) and were more likely to exhibit poor inhaler compliance compared to those without critical errors (50.5% vs. 31.0%, respectively). More than half of the patients who used MDI with spacer chamber made critical inhaler errors; 69.9% showed regular or poor treatment adherence, although 75.6% demonstrated good knowledge about inhaler handling. Only in 27% of the patients did the healthcare professional change the type of inhaler after hospitalization within clinical practice. The medical and nursing staff responsible for the patient's hospitalization were not informed of the assessment carried out in the study. The probability of not performing a device change at discharge was lower in patients with previous at-home treatment with combined inhaled therapy with LABA + ICS (OR 0.3 [0.18-0.83], p = 0.016) and in patients under triple inhaled therapy (OR 0.3 [0.17-0.76], p = 0.007). No significant differences were observed in inhaler changes when considering the frequency of critical inhaler errors, inhaler handling-related knowledge or maximum PIF values. Conclusions: Our study highlights the urgent need for a more personalized inhaler selection and consistent monitoring by healthcare professionals to minimize inhaler misuse, increase treatment compliance and adherence, and improve disease management outcomes. It is essential to provide training and promote the role of nursing in the evaluation and education of inhaled therapy. Additionally, the use of standardized approaches and tools, such as the CHECK DIAL, is crucial to facilitate the adaptation of devices to patients' needs.

Understanding the Determinants and Outcomes of Education in Pulmonary Rehabilitation: Moving Toward Person-Centered Care

TOPIC IMPORTANCE

Education and psychosocial support are essential components of pulmonary rehabilitation (PR). However, the delivery of education often follows a one-size-fits-all approach, with individual factors that influence learning rarely considered. Moreover, education-related outcomes are frequently overlooked in PR assessments, and their inconsistent use has limited our understanding of education's impact on people with chronic respiratory diseases. There is a clear need for practical guidance to identify key learning determinants and to define targeted education outcomes, ultimately optmizing PR and establishing quality standards.

REVIEW FINDINGS

Cognitive function, health literacy, psychological status, and social connection can influence an individual's ability to learn. Without proper consideration and assessment, these factors can otherwise become barriers to education and effective self-management. Education in PR should aim to: (1) improve individuals' knowledge to foster informed and active participants; (2) develop their skills to enable autonomy and competence; and (3) enhance their confidence to apply this knowledge and skills in daily life.

SUMMARY

This review emphasizes the importance of person-centered education in PR, provides a framework for understanding which education-related outcomes to target, and highlights the need for future research to enhance this essential component.

Pediatric asthma knowledge: Insights from a Portuguese central hospital study

BACKGROUND

Asthma is a common chronic condition in children, with parental and child health literacy affecting health outcomes and asthma control. This study examined pediatric asthma knowledge at a Portuguese central hospital and its determinants.

METHODS

We conducted a comparative cross-sectional study, applying the Asthma Knowledge Questionnaire (QCSA), answered by adolescents and/or caregivers. The sample was categorized into two groups based on the presence or absence of respiratory conditions, such as asthma or recurrent wheezing, in children. Those with such conditions (Group A) were further divided into two subgroups: those receiving general pediatric care (Group A2) and those receiving specialized care, followed in pulmonology or allergology consultations (Group A1).

RESULTS

The study involved 154 participants, predominantly female (74%) with an average age of 31.2 years ( ± 13.4). The average QCSA score was 14.8 ( ± 3.2), and Group A exhibited a statistically higher score, 15.5 points ±3.2 versus Group B, 14.2 points ± 3.2, p = .034. Group A1 achieved significantly better scores (16 points: range 4-21) than Group A2 (14 points: range 9-21) (p = .029). Scores were correlated positively with the duration of specialized follow-up (ρ = .326; p = .027). Asthma knowledge was correlated with the level of education (r = .468; p < .001). The number of wheezing episodes (r = -.466; p < .001) within the past year were associated to QCSA scores.

CONCLUSION

In summary, the presence of respiratory condition, the follow-up in specialized appointments and higher levels of education were associated with greater asthma knowledge.

An Overview of Adherence-What It Is and Why It Is Important

Asthma, allergic rhinitis, and food allergy are common allergic diseases, yet adherence to many management options remains poor, leading to worse health outcomes and financial implications for society and health systems. The underlying causes of nonadherence are numerous, ranging from patient-specific factors to broader socioeconomic and systems-based factors. In this review, we aim to discuss the definition of adherence, which can be divided into 3 components: initiation, implementation, and persistence, as well as to review various methods of measuring adherence. Subsequently, we will review the epidemiology of adherence to asthma and allergic rhinitis medications, allergen immunotherapy, and oral immunotherapy. Finally, we will discuss the multifaceted etiology of poor adherence and its subsequent impact on patients and society.

Medication non-adherence and predictor factors among adult asthmatic patients in Ethiopia: a systematic review and meta-analysis

OBJECTIVE

A pronounced burden is evident in individuals with asthma, with approximately half of them not adhering to their prescribed medication. Therefore, this study aimed to assess the pooled prevalence of anti-asthma medications non-adherence in Ethiopia.

DATA SOURCES

A comprehensive search was conducted across multiple electronic databases including PubMed, Africa Index Medicus, Science Direct, Hinari, and a search engine, Google Scholar from October 5 to 20, 2023. In addition, digital research repositories from Addis Ababa and Bahir Dar University were accessed.

DATA SELECTION

The eligibility criteria was employed to screen studies after uploading search results to EndNote software to remove duplicates first. Then, two investigators, CT and BBT, independently assessed titles, abstracts, and the full text of all retrieved references to identify potentially eligible studies.

RESULT

This meta-analysis, which was conducted in Ethiopia, and included 11 full-text articles, revealed a pooled asthma medication non-adherence level of 51.20% (95% CI 35.20%, 67.20%) with substantial heterogeneity (I2 = 99.08%). The review has also identified factors predicting non-adherence among asthmatic patients: free (health service) (AOR: 0.31, 95% CI 0.18-0.54), poor knowledge (AOR: 2.85, 95% CI 1.61-5.05), absence of formal education (AOR: 3.01, 95% CI 1.72-5.25), history of previous ADR (AOR: 8.57, 95% CI 1.12-65.3), and the presence of Co- morbidity(AOR: 3.28, 95% CI 2.014-5.68), had shown association with asthma medication non-adherence.

CONCLUSION

Asthma medication non-adherence is notably high in Ethiopia. Addressing medication non-adherence requires a comprehensive approach, including clear communication between healthcare providers, patient education, and addressing financial barriers to ensure better adherence in asthma patients.

Asthma severity: the patient's point of view

Objective

Initiated by the Severe Asthma Network Italy (SANI), this study aims to explore asthma patients' perceptions of disease severity, differentiating between mild and severe asthma. The objective is to identify factors influencing tailored treatment strategies for varying disease severities and to provide insights into asthma care in Italy.

Methods

Conducted between November 2020 and January 2021, a survey using Computer-Assisted Personal Interviewing (CAPI) collected data from 308 Italian adults, representing the population. A 25 item multiple choice questionnaire covered asthma diagnosis, symptoms, treatment approaches, associated conditions, and quality of life.

Results

Among participants, 83.8% reported having mild asthma, while 16.2% had severe asthma. Severe asthma patients had longer disease durations, more severe symptoms, frequent exacerbations, and higher hospital/ER visits. Although treatment adherence and symptom profiles generally aligned with international guidelines for self reported severe asthma, 22% of self identified mild asthmatics experienced severe respiratory symptoms. Oral corticosteroid (OCS) use was observed in 50% of severe cases and 22% of mild cases. Adherence was higher in severe asthma patients (76%) versus mild asthma patients (28%). Both groups experienced comorbidities, with 96% of severe asthmatics and 72% of mild asthmatics reporting impaired quality of life.

Conclusion

This study highlights the disparity between clinical categorization and patient perceptions of asthma severity. The prevalence of self reported severe asthma exceeds literature data. The burden of mild asthma remains significant, with treatment approaches not fully aligned, particularly regarding disproportionate OCS use. Addressing this gap requires enhancing patient education, improving diagnostic practices, and promoting adherence.

Cost-Effectiveness of Fractional Exhaled Nitric Oxide Suppression Testing as an Adherence Screening Tool Among Patients With Difficult-to-Control Asthma

BACKGROUND

Approximately 50% of adults on long-term asthma medication are nonadherent. Current methods to detect nonadherence have had limited effect. Fractional exhaled nitric oxide suppression testing (FeNOSuppT) has demonstrated clinical effectiveness as an adherence screening tool to detect poor adherence to inhaled corticosteroids in difficult-to-control asthma prior to initiation of expensive biologic therapy.

OBJECTIVE

Estimate the cost effectiveness and budget impact of FeNOSuppT as a screen prior to the initiation of biologic therapy among U.S. adults with difficult-to-control asthma and high fractional exhaled nitric oxide (≥45 ppb).

METHODS

A decision tree simulated the progression of a cohort of patients over a 1-year time horizon into 1 of 3 states ([1] discharged from or [2] remain in specialist care; or [3] progress to biologics). Two strategies, with and without FeNOSuppT, were examined and the incremental net monetary benefit estimated using a discount rate of 3% and a willingness-to-pay threshold of $100,000 per quality-adjusted life year (QALY). Sensitivity analysis and a budget impact analysis were also undertaken.

RESULTS

In the baseline scenario, FeNOSuppT prior to the initiation of biologic therapy was associated with lower costs ($4,435/patient) and fewer QALYs (0.0023 QALY/patient) compared with no FeNOSuppT over 1 year and was considered cost effective (incremental net monetary benefit = $4,207). The FeNOSuppT was consistently found to be cost effective across a range of scenarios and in deterministic and probabilistic sensitivity analyses. Assuming differential levels of FeNOSuppT uptake (20%-100%), this was associated with budget savings ranging from USD $5 million to $27 million.

CONCLUSIONS

The FeNOSuppT is likely to be cost effective as a protocol-driven, objective, biomarker-based tool for identifying nonadherence in difficult-to-control asthma. This cost effectiveness is driven by cost savings from patients not progressing to expensive biologic therapy.

Medication use in uncontrolled pediatric asthma: Results from the SysPharmPediA study

BACKGROUND

Uncontrolled pediatric asthma has a large impact on patients and their caregivers. More insight into determinants of uncontrolled asthma is needed. We aim to compare treatment regimens, inhaler techniques, medication adherence and other characteristics of children with controlled and uncontrolled asthma in the: Systems Pharmacology approach to uncontrolled Paediatric Asthma (SysPharmPediA) study.

MATERIAL AND METHODS

145 children with moderate to severe doctor-diagnosed asthma (91 uncontrolled and 54 controlled) aged 6-17 years were enrolled in this multicountry, (Germany, Slovenia, Spain, and the Netherlands) observational, case-control study. The definition of uncontrolled asthma was based on asthma symptoms and/or exacerbations in the past year. Patient-reported adherence and clinician-reported medication use were assessed, as well as lung function and inhalation technique. A logistic regression model was fitted to assess determinants of uncontrolled pediatric asthma.

RESULTS

Children in higher asthma treatment steps had a higher risk of uncontrolled asthma (OR (95%CI): 3.30 (1.56-7.19)). The risk of uncontrolled asthma was associated with a larger change in FEV₁% predicted post and pre-salbutamol (OR (95%CI): 1.08 (1.02-1.15)). Adherence and inhaler techniques were not associated with risk of uncontrolled asthma in this population.

CONCLUSION

This study showed that children with uncontrolled moderate-to-severe asthma were treated in higher treatment steps compared to their controlled peers, but still showed a higher reversibility response to salbutamol. Self-reported adherence and inhaler technique scores did not differ between controlled and uncontrolled asthmatic children. Other determinants, such as environmental factors and differences in biological profiles, may influence the risk of uncontrolled asthma in this moderate to severe asthmatic population.

Implementation of standardized asthma management programs in outpatient settings

PURPOSE OF REVIEW

This article reviews new approaches, facilitators, barriers, and opportunities to increasing adoption of standardized asthma management programs in the outpatient care setting.

RECENT FINDINGS

Primary care clinicians providing asthma care in the outpatient setting are challenged by the complexity of guidelines and want standardization of tools that are easy to use and that can be integrated within their practice's workflow. Programs that integrate clinical decision support tools within a practice's electronic health record and provide support from specialists may enhance uptake of asthma management programs in the outpatient setting and reduce asthma morbidity. Lack of an implementation science framework, consideration for organizational context, and clinician buy-in are recently recognized barriers to adoption of asthma programs and improved asthma outcomes. In addition, many of these interventions are labor intensive, costly, and may not be capable of wide dissemination because of the EHR interoperability problem.

CONCLUSION

Programs that simplify the guidelines, integrate clinical decision support within the EHR, and ground their approach with an implementation science framework may improve the quality of asthma care provided in the outpatient setting.

Effect of an Asthma Exacerbation on Medication Adherence

BACKGROUND

Few studies have looked at the effect of an asthma exacerbation on asthma medication adherence.

OBJECTIVE

To measure asthma medication adherence in the 12 months after an asthma exacerbation and the influence of care type (specialist vs primary care provider) as well as social economic status on adherence.

METHODS

We measured portion of days covered (PDC) during the 12 months before and after an exacerbation in a cohort of patients with asthma who were aged 18 years and older. Subanalyses looked at PDC in those who had more than one exacerbation after the sentinel exacerbation, by type of care received (primary care, allergist or pulmonologist, or no care) during both periods and by socioeconomic status (SES), defined as the lower quartile of annual income for the group.

RESULTS

In a cohort of 1,697 patients, PDC improved significantly (from 0.44 to 0.53; P < .001) after an asthma exacerbation. Improvement in PDC was even greater (from 0.45 to 0.57; P < .001) if they had more than one exacerbation after the sentinel exacerbation. Being seen by a specialist after the exacerbation but not before it, resulted in the greatest improvement in PDC (0.17 mean change). Patients not seen by a specialist either before the exacerbation or after had a mean change of just 0.07. Those with a lower SES had an overall lower PDC before the exacerbation (0.37 vs 0.43) but saw a similar improvement in the PDC compared with those in a higher SES (0.09 vs 0.10).

CONCLUSIONS

An asthma exacerbation is associated with a significant and sustained effect on medication adherence.

Asthma Management in Children

Asthma is a common, complex heterogeneous disease often beginning in early life and is characterized by reversible airflow obstruction. The phenotypic differences that exist in children with asthma may impact underlying comorbid conditions and pharmacologic treatment choices. Prenatal factors for increased risk of asthma could include maternal diet and the maternal microbiome. Evidence also suggests that postnatal microbial exposures and colonization contribute to the risk of allergic diseases and asthma. After confirming the diagnosis, asthma management in children centers on 3 broad areas: pharmacologic treatment, treatment of underlying comorbidities, and education of the patient and caregivers on the importance of adherence and device technique. Moreover, social determinants of health significantly impact on symptom burden and treatment response.

Improving Adherence in Urban Youth With Asthma: Role of Community Health Workers

BACKGROUND

The Asthma Action at Erie Trial is a comparative effectiveness trial comparing a community health worker (CHW) versus certified asthma educator (AE-C) intervention in low-income minority children.

OBJECTIVES

Determine whether asthma medication possession, adherence, technique, and triggers differ in children receiving an asthma CHW compared with an AE-C intervention.

METHODS

Children with uncontrolled asthma were randomized to receive 10 CHW home visits or 2 AE-C sessions in a clinic over 1 year. Asthma medication possession and inhaler technique were observed; adherence was measured using self-report, dose counters, and electronic monitors. Environmental triggers were captured by self-report, observation, and objective measurement. Mixed effects linear and logistic regression models were estimated for continuous and binary outcomes.

RESULTS

Children (n = 223) were mainly Hispanic (85%) and ages 5 to 16 years. Quick-relievers (82%), spacers (72%), and inhaled corticosteroid (ICS)-containing medications (44%) were tracked. Of those with uncontrolled asthma, 35% lacked an ICS prescription (n = 201). Children in the CHW arm were more likely to have an ICS prescription at 12 months (odds ratio 2.39; 95% CI 0.99-5.79). Inhaler technique improved 9.8% in the CHW arm at 6 months (95% CI 4.20-15.32). The ICS adherence improved in the CHW arm at 12 months, with a 16.0% (95% CI 2.3-29.7; P = .02) difference between arms. Differences in trigger exposure over time were not observed between arms.

CONCLUSIONS

The CHW services were associated with improved ICS adherence and inhaler technique, compared with AE-C services. More information is needed to determine the necessary dosage of intervention to sustain adherence.

Assessment of Real-World Escalation to Biologics in US Patients With Asthma

BACKGROUND

Previous studies indicate that suboptimal medication adherence may contribute to uncontrolled asthma. Global Initiative for Asthma (GINA) guidelines recommend treatment escalation to biologics for patients with uncontrolled asthma despite adherence to high-dose maintenance medication and who have eosinophilic/allergic biomarkers or require maintenance oral corticosteroids.

OBJECTIVE

This study aimed to describe the clinical status of patients with asthma escalated to biologic therapy.

METHODS

This retrospective claims database analysis enrolled US patients with asthma who were escalated to biologics between January 2016 and June 2020. Exacerbations, control status, GINA step, and maintenance medication adherence during the 12 months before biologic therapy initiation were analyzed. Asthma control was assessed using both the European Respiratory Society/American Thoracic Society (ERS/ATS) and Stempel criteria. Adherence was defined as the proportion of days covered (PDC) by maintenance medication claims.

RESULTS

Of 1786 patients escalated to biologics, 506 were included for analysis. During the 12 months before escalation, 346 patients had confirmed exacerbations. Uncontrolled asthma status was estimated in 55% and 70% of patients (ERS/ATS and Stempel criteria, respectively). GINA step was inferred for 395 patients: 154 were at step 2, 11 at step 3, 104 at step 4, and 126 at step 5. Of 403 patients with maintenance medication claims, 63% had suboptimal maintenance medication adherence (PDC <80%).

CONCLUSION

In this study, most patients initiating biologic therapy had mild-to-moderate asthma or suboptimal maintenance medication adherence, possibly indicating inappropriate escalation. Incorporating objective medication adherence monitoring into existing guidelines may reduce inappropriate escalation to biologics.

Difficult-to-Control Asthma Management in Adults

The management of difficult-to-control asthma remains a significant challenge, which frequently requires the input of the wider multidisciplinary team. This review covers the importance of systematic assessment, phenotyping, treatment options at step 4, an overview of biologics and novel therapies for type 2 (T2) inflammation, and nonpharmacological interventions. Once people have been identified as suffering from difficult-to-control asthma, it is important to use the systematic assessment process to allow accurate diagnosis and optimization of adherence as well as identification and treatment of any relevant comorbidities. Before initiating a biologic, it is important to optimize inhaled therapies and sufficiently phenotype individual patients to allow for the logical use of biologic agents targeting T2 inflammation. For patients who either do not have evidence of T2 inflammation or remain symptomatic despite biologics, attention should be paid to the available nonpharmacological interventions. Difficult-to-treat asthma remains an area of significant unmet need, but improvements in models of service delivery and the ongoing pharmacological pipeline are causes for significant optimism that sooner rather than later there will no longer be asthmatic patients who are difficult to treat.