Adherence to asthma therapy in the preschool child

GEMA 5.3. Spanish Guideline on the Management of Asthma

The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).

Medication Adherence and Common Barriers for Caregivers of Preschool Children with Pediatric Glaucoma

Purpose. To investigate the medication adherence among caregivers of preschool children with pediatric glaucoma and to elucidate common barriers leading to poor adherence. Methods. A cross-sectional study. Caregivers of preschool children with pediatric glaucoma completed a questionnaire on demographic information of caregivers, demographic and disease characteristics of children, caregivers-reported medication adherence (by an adapted Morisky Adherence Scale), and possible 13 barriers. Results. Overall 132 questionnaires were considered valid. Thirty-six percent of all reported poor medication adherence. Caregivers’ age and self-evaluated knowledge about pediatric glaucoma showed a significant difference between the adherent and nonadherent groups ( $P<0.05$ ). Nineteen percent of all reported only one barrier as important, 65% cited multiple barriers, and 16% cited no barriers. Anxiety and depression were cited as important by most caregivers in both groups. Univariate logistic regression analysis demonstrated that difficulty with the acquisition of medications (OR, 2.5; 95% CI, 1.1–5.7; $P=0.025$ ), difficulty with medication schedule (OR, 2.3; 95% CI, 1.0–5.0; $P=0.043$ ), and high expenses for medications (OR, 4.8; 95% CI, 1.4–15.9; $P=0.011$ ) were significantly associated with higher odds of poor adherence. Conclusions. Over one-third of caregivers of preschool children with pediatric glaucoma were in poor medication adherence. Nearly two-thirds of caregivers cited multiple barriers simultaneously as important hindrances to medication usage. Anxiety and depression, difficulty with the acquisition of medications, difficulty with the medication schedule, and high expenses for medications were prominent barriers. Individualized solutions should be provided according to reported barriers by each caregiver and the other most common barriers.

Risk Factors for Non-Adherence to Inhaled Corticosteroids in Preschool Children with Asthma

Non-adherence to asthma controllers increases morbidity among school-aged children. This study aimed to determine non-adherence risk factors in preschool children with asthma. We investigated 172 children <6 years diagnosed with asthma in 2018 and analyzed baseline characteristics and loss of control events extracted from the medical records for four years following diagnosis. At end of follow-up, 79 children had a prescription of inhaled corticosteroids (ICS) and were included in the analyses. Adherence was assessed in a two-year period through pharmacy claims using percentage of days covered (PDC) analyzed dichotomously with non-adherence defined as PDC < 80% and using adherence ratio (AR) defined as days with medical supply divided by days without. Of the 79 children, 59 (74.7%) were classified as non-adherent. In analyses adjusted for sex, age and exacerbations prior to inclusion, adherence was positively associated with having had a loss of control event requiring a step-up in asthma controller (aAR:2.34 [1.10;4.98], p = 0.03), oral corticosteroids (aAR:2.45 [1.13;5.34], p = 0.026) or redeeming a short-acting b2-agonist prescription (aAR:2.91 [1.26;6.74], p = 0.015). Further, atopic comorbidity was associated with increased adherence (aAR:1.18 [1.01;1.37], p = 0.039), whereas having a first degree relative with asthma was associated with worse adherence (aAR:0.44 [0.23;0.84], p = 0.015). This study found poor adherence to ICS among three quarters of preschool children with asthma. Increasing adherence was associated with atopic comorbidity and loss of control events, whereas lower adherence was associated with atopic predisposition. These findings should be considered to improve adherence in preschool children with asthma.

Are we overcoming our inability to have pediatric patients properly use inhaled corticosteroids by inappropriately escalating their therapy?

OBJECTIVE

To perform a narrative review to describe and discuss potential methods and strategies for effectively assessing and dealing with poor adherence and/or misuse of inhalers in difficult-to-treat pediatric asthmatic patients.

DATA SOURCES

Articles available in electronic databases, published from inception to April 2021.

STUDY SELECTIONS

Relevant articles in the literature that discuss and analyze potential methods and strategies for effectively assessing and dealing with poor adherence and/or misuse of inhalers in difficult-to-treat pediatric asthmatic patients.

RESULTS

Validated self-reported questionnaires, weighing inhaler canisters, and pharmacy records might be the most suitable methods for assessing adherence to inhaled controller therapy in clinical practice. Additionally, validated instruments could be used as an objective measurement of the adequacy of inhaler technique. Finally, empathy and a true and strong physician-parent/patient partnership have a more powerful influence on adherence than almost any other factor, and they are probably the most cost-effective methods not only for detecting poor adherence to controller therapy but also for dealing with and improving it.

CONCLUSIONS

Failure to detect or effectively handle nonadherence and/or inhaler misuse in a patient with uncontrolled asthma can mislead clinicians into thinking that the patient is nonresponsive to the original less-intensive therapy, resulting in unneeded dosage increases and/or escalation of controller therapy to more costly medications, in some cases reaching the level of biologic therapy.

Understanding the Influences Behind Parents' Asthma Decision-Making: A Qualitative Exploration of the Asthma Network of Parents with Children with Asthma

Introduction

Interventions aimed at optimizing parents’ ability to manage their children’s asthma could be strengthened by better understanding the networks that influence these parents’ choices when managing asthma. This study aimed to explore the asthma networks of parents of children with asthma—specifically to gain insights into whom parents select to be within their networks and why; how individuals within parents’ networks influence the way in which they manage their children’s asthma medications, and factors driving the development of these networks.

Methods

A qualitative research methodology utilizing semi-structured interviews with parents of children with asthma was employed to fulfil the objectives of this study.

Results

Twenty-six face-to-face interviews with parents of children with asthma were conducted, recorded, and transcribed. Transcriptions were independently coded for concepts and themes by the research team. Asthma medications was a dominant theme identified, and revealed that parents actively sought advice and support from a series of complex and multidimensional relationships with people and resources in their health network. These not only included health care professionals (HCPs) but also personal connections, lay individuals, and resources. The composition and development of these asthma networks occurred over time and were determined by several key factors: satisfaction with their HCP provider; need for information; convenience; trust and support; self-confidence in management; and parents’ perceptions of their children’s asthma severity.

Conclusions

By exploring parents’ asthma network, this study uncovers the complex relationship between HCPs, family and friends of parents of children with asthma, and provides new insight into the intimate and parallel influence they have on parent’s decision-making.

They just don't take their medicines: Reframing medication adherence in asthma from frustration to opportunity

Assessing and addressing suboptimal adherence to asthma medications is a key component in the treatment of all children with asthma, particularly those with difficult-to-treat asthma. However, parents often overreport adherence to asthma medications. Increased medication adherence could lead to improved outcomes in the form of better asthma control and decreased asthma exacerbations, as well as decreased healthcare utilization costs. Yet there are many complex factors that affect medication adherence, and barriers are often different in each family. Social determinants of health, complex healthcare relationships, and patient-related factors may all affect medication adherence. Multicomponent patient-centered strategies, as well as strategies that utilize technology and habit formation strategies may be helpful in improving medication adherence. Further study is needed to reliably and sustainably improve medication adherence in children with asthma across the broader population; in some populations, alternate diagnoses, adjusting therapy, and other intervention may be required to improve asthma control and health.

Management of Asthma in the Preschool Child

The management of asthma in the preschool population is challenging because disease phenotypes are heterogeneous and evolving. Available therapies aimed at preventing persistent symptoms and recurrent exacerbations include inhaled corticosteroids and leukotriene receptor antagonists; episodic use of inhaled corticosteroids and azithromycin may result in a decrease in exacerbations among children with intermittent disease. This article reviews an approach using patient characteristics for selecting initial treatment approaches based on disease phenotype, such as symptom patterns or evidence of atopic markers. Evidence for and against the use of oral corticosteroids during acute episodes and barriers to adherence and effective treatment are discussed.

It takes a village - asthma networks utilized by parents when managing childhood asthma medications

Objective: We are yet to understand how widely parents seek asthma medication management information for their children, how they are used for health information, how parents engage with them and their influence on parent's decision-making. This study aimed to gauge the current level of asthma knowledge and skills of parents of children with asthma and gain insight into who and what influences their child's asthma medication management decisions. Method: Social network theory was used to map parents' asthma networks and identify the level of influence of each individual/resource nominated. Parents of children with asthma (aged 4-18 years) were interviewed, completed an asthma network map, questionnaires and an inhaler technique assessment. Results: Twenty-six parents participated and had significant gaps in asthma knowledge and inhaler technique skills. The asthma networks of participants ranged from two to ten individuals/resources, with an average number of five. The most commonly nominated individual/resource was general practitioners followed by family members and the internet. Professional connections represented 44% of individuals/resources in networks, personal connections 42% and impersonal connections 14%. When parents were asked about how influential individuals/resources were, professional connections represented 53% of parents influences, personal connections 36% and impersonal connections 11%. Conclusion: This study highlights the priority and co-influence of non-medical sources of information/support on parent's behaviors and decision-making with regards to their child's asthma medicine taking. In further understanding the complexities surrounding these connections and relationships, HCPs are better positioned to assist parents in addressing their needs and better supporting them in the management of their child's asthma.

Managing problematic severe asthma: beyond the guidelines

This review discusses issues related to managing problematic severe asthma in children and young people. A small minority of children have genuinely severe asthma symptoms which are difficult to control. Children with genuinely severe asthma need investigations and treatments beyond those described within conventional guidelines. However, the majority of children with poor symptom control despite high-intensity treatment achieve improvement in their asthma control once attention has been paid to the basics of asthma management. Basic asthma management requires optimisation of inhaler technique and treatment adherence, avoidance of environmental triggers and self-management education. It is also important that clinicians recognise risk factors that predispose patients to asthma exacerbations and potentially life-threatening attacks. These correctable issues need to be tackled in partnership with children and young people and their families. This requires a coordinated approach between professionals across healthcare settings. Establishing appropriate infrastructure for coordinated asthma care benefits not only those with problematic severe asthma, but also the wider asthma population as similar correctable issues exist for children with asthma of all severities. Investigation and management of genuine severe asthma requires specialist multidisciplinary expertise and a systematic approach to characterising patients' asthma phenotypes and delivering individualised care. While inhaled corticosteroids continue to play a leading role in asthma therapy, new treatments on the horizon might further support phenotype-specific therapy.

Children's, parents' and health professionals' views on the management of childhood asthma: a qualitative study

The management of childhood asthma is often sub-optimal. Parents and other caregivers are primarily responsible for disease management and this responsibility includes communication with health professionals. The aim of this multi-perspective qualitative study was to explore the views of children, parents and health professionals to gain insight into the approach to clinical care in the management of childhood asthma. Interviews were held with nine parent-child (6-8 years) dyads, and 13 health professionals working in primary and secondary care. Interviews were transcribed verbatim and analysed thematically. Three key themes emerged that were common to all data sets; (1) Child and parent awareness of symptoms; (2) Management and child wellbeing; and (3) Professional communication education and consultation with families. Although some children demonstrate good awareness of symptoms and appropriate use of medication, some parents expressed difficulty in identifying triggers and symptoms of asthma. Furthermore, parents lacked awareness regarding appropriate use of medication for preventing and managing symptoms of asthma. Health professionals believed that communication and education was lacking. Data from all participants suggested that consultations could be enhanced with greater emphasis on children's and parents' perceptions of asthma in the development of asthma management plans.

CHILDHOOD ASTHMA

GUIDING FAMILIES THROUGH DISEASE MANAGEMENT: Both parents' and children's perceptions and understanding of childhood asthma should be considered when developing asthma management plans. The management of asthma is challenging and can result in poor disease outcomes if care is not taken. An individual's perception of their (or their child's) asthma can also affect the efficacy of treatment. Aidan Searle at the Bristol Biomedical Research Centre, UK, and co-workers, interviewed nine parent-child groups and thirteen health professionals to determine their perceptions of childhood asthma management in primary care. While some children had a strong awareness of symptoms and appropriate medication use, some parents found it difficult to identify asthma triggers and symptoms. Parents also displayed a lack of understanding of management through medication. Health professionals focused on the need for clearer information for families when guiding management of childhood asthma.

Medication Identification Among Caregivers of Urban Children With Asthma

OBJECTIVE

To determine caregiver ability to name their child's inhaled asthma medications, and examine whether perceived ease of remembering names is associated with accurate naming and asthma outcomes.

METHODS

As part of the School-Based Telemedicine-Enhanced Asthma Management trial in Rochester, New York, we asked caregivers of children with persistent asthma to: 1) name their child's inhaled medications, and 2) indicate agreement with the statement, "it is easy to remember the names of my child's asthma medications." We limited analyses to subjects with 1 inhaled medication. Reported names were compared with canisters available during a home visit; complete matches were considered concordant. We compared ease of remembering names with concordance, asthma symptoms, and adherence using bivariate and multivariate analyses.

RESULTS

Overall, 141 caregivers (87%) had children with 1 inhaled medication (62% black race, 68% Medicaid). Most (74%) perceived it easy to remember medication names, yet only 46% reported names concordant with medications at home. Caregivers who did not easily remember medication names were less likely to concordantly name available medications (23% vs 54%; P = .002), and more likely to report that their child experienced >2 symptom days per week (33% vs 16%; P = .03), >2 symptom nights per month (31% vs 12%; P = .02), and missed >1 dose(s) of preventive medication in the previous 2 weeks (52% vs 28%; P = .03). Findings were consistent in multivariate regression analyses.

CONCLUSIONS

Caregivers of urban children with persistent asthma who considered medication names difficult to remember were less able to accurately name available medications, and reported worse control and medication adherence. Greater attention to medication identification might improve outcomes in this population.

High degree of supervision improves adherence to inhaled corticosteroids in children with asthma

Purpose

Adherence to treatment with inhaled corticosteroids (ICS) is a critical determinant of asthma control. The objective of this study was to assess factors that determine adherence to ICS therapy in children with asthma.

Methods

Fifty-eight children with asthma, aged 5 to 16 years, used ICS with or without a spacer for 3 months. Adherence rates as measured from questionnaires and canisters, asthma symptom scores, and inhalation technique scores were assessed every 30 days. The degree of supervision by caregivers was assessed at day 30.

Results

Adherence rates measured using canisters were lower at day 60 than at day 30 (P=0.044) and did not change thereafter (74.4%±17.4% at day 30, 66.5%±18.4% at day 60, and 67.4%±22.2% at day 90). Adherence rates at days 60 and 90 and during the total study period were significantly different when measured by using questionnaires versus canisters (P<0.001, P=0.022, and P=0.001, respectively). In the comparison of adherence rates repeatedly measured at days 30, 60, and 90 and adherence rates during the total study period among the 3 groups, adherence rates in the high-degree supervision group were significantly higher than those in the low-degree supervision group (82.0±16.0 vs. 66.1±14.5, 75.4±14.4 vs. 56.2±18.4, 75.0±18.3 vs. 55.0±19.7 [P=0.027]; 77.9±12.2 vs. 59.1±11.4 [P=0.021]) after adjustment for sex and age.

Conclusion

The level of caregiver supervision is an important factor affecting adherence to ICS therapy in children with asthma. Therefore, a high degree of supervision may be required to increase adherence to ICS therapy in children with asthma.

Validation of the 'Test of the Adherence to Inhalers' (TAI) for Asthma and COPD Patients

Background: To validate the ‘Test of Adherence to Inhalers’ (TAI), a 12-item questionnaire designed to assess the adherence to inhalers in patients with COPD or asthma.

Methods: A total of 1009 patients with asthma or COPD participated in a cross-sectional multicenter study. Patients with electronic adherence ≥80% were defined as adherents. Construct validity, internal validity, and criterion validity were evaluated. Self-reported adherence was compared with the Morisky-Green questionnaire.

Results: Factor analysis study demonstrated two factors, factor 1 was coincident with TAI patient domain (items 1 to 10) and factor 2 with TAI health-care professional domain (items 11 and 12). The Cronbach's alpha was 0.860 and the test-retest reliability 0.883. TAI scores correlated with electronic adherence (ρ=0.293, p=0.01). According to the best cut-off for 10 items (score 50, area under the ROC curve 0.7), 569 (62.5%) patients were classified as non-adherents. The non-adherence behavior pattern was: erratic 527 (57.9%), deliberate 375 (41.2%), and unwitting 242 (26.6%) patients. As compared to Morisky-Green test, TAI showed better psychometric properties.

Conclusions: The TAI is a reliable and homogeneous questionnaire to identify easily non-adherence and to classify from a clinical perspective the barriers related to the use of inhalers in asthma and COPD.

Association of caregiver health beliefs and parenting stress with medication adherence in preschoolers with asthma

OBJECTIVE

This study examined the associations of parenting stress and caregiver negative health beliefs with medication adherence in a sample of preschool-aged children with asthma.

METHODS

Participants included 43 caregivers and their child with asthma, aged 2-5 years, who were prescribed a preventative or controller medication. Assessment included parent report of parenting stress associated with parental characteristics and difficult child behavior, health-related beliefs, and adherence to inhaled corticosteroids (ICS). Pharmacy refill records were reviewed to measure medication adherence objectively. Statistical analyses included paired samples t-test and Pearson's correlation coefficients.

RESULTS

Parent-report and objective measures of adherence to ICS were significantly different, with parents reporting significantly higher rates of medication adherence (p < 0.001). Also, increased caregiver negative health beliefs, but not parenting stress, were significantly and negatively associated with an objective measure of ICS adherence (p < 0.01).

CONCLUSIONS

Because the findings for parenting stress are not consistent with that of the literature on school-aged children with asthma, our results may suggest that preschool children are a unique developmental group. A review of endorsed health beliefs also highlights strengths and concerns for caregivers of these very young children. Overall, our study findings underscore the importance of caregivers' health-related beliefs in promoting adherence to ICS in young children with asthma.

Medication use in Australian children with asthma: user's perspective

BACKGROUND AND OBJECTIVES

Medication use-related issues remain problematic in childhood asthma despite effective treatment strategies and public investment into improved asthma management strategies in industrialized countries. This study aimed to carry out an in-depth exploration of the views of parents/carers and children with asthma on medication use.

METHODS

Semi-structured qualitative interviews were conducted with a purposive convenience sample of children with asthma and their parents recruited from general practices in Sydney. Interviews were tape-recorded, transcribed verbatim, and thematically analyzed.

RESULTS

A total of 52 interviews (26 parents/carers and 26 children with asthma) were conducted. Major themes which emerged from the children's interviews included issues such as self-image, resistance to medication use, and lack of responsibility in medication taking. Parental or carer issues included lack of clear understanding of how medications worked, as well as administration difficulties, cost constraints, and beliefs about medications contrary to quality use.

DISCUSSION

This is one of the few research studies exploring the viewpoint of children with asthma about their medications in Australia. Despite investment in dissemination of professional, targeted evidence-based asthma management strategies in healthcare, there seems to be a lack of depth in terms of what parents understand about their child's asthma. Effective communication about medication usage, especially the inclusion of the child in the consultation to empower them to be involved in their own asthma care, may be the answer.

Lung penetration and patient adherence considerations in the management of asthma: role of extra-fine formulations

The mainstay of management in asthma is inhalation therapy at the target site, with direct delivery of the aerosolized drug into the airways to treat inflammation and relieve obstruction. Abundant evidence is available to support the concept that inflammatory and functional changes at the level of the most peripheral airways strongly contribute to the complexity and heterogeneous manifestations of asthma. It is now largely accepted that there is a wide range of clinical phenotypes of the disease, characterized primarily by small airways involvement. Thus, an appropriate diagnostic algorithm cannot exclude biological and functional assessment of the peripheral airways. Similarly, achievement of optimal control of the disease and appropriate management of specific phenotypes of asthma should be based on drugs (and delivery options) able to distribute uniformly along the bronchial tree and to reach the most peripheral airways. Products developed with the Modulite^® technology platform have been demonstrated to meet these aims. Recent real-life studies have shown clearly that extra-fine fixed-combination inhaled therapy provides better asthma control than non-extra-fine formulations, thus translating the activity of the drugs into greater effectiveness in clinical practice. We suggest that in patients with incomplete asthma control despite good lung function, involvement of the peripheral airways should always be suspected. When this is the case, treatments targeting both the large and small airways should be used to improve asthma control. Above all, it is emphasized that patient adherence with prescribed medications can contribute to clinical success, and clinicians should always be aware of the role played by patients themselves in determining the success or failure of treatment.

Medication adherence in the asthmatic child and adolescent

Asthma is a common inflammatory condition affecting more than 7 million children in the United States alone, and tens of millions more globally. Despite effective preventive medications, medication nonadherence in children and adolescents is alarmingly high. Nonadherence can result in poor asthma control, which leads to decreased quality of life, lost productivity, increased health care utilization, and even the risk of death. Nonadherence in children and adolescents deserves special attention because they face unique barriers to adherence that change with age. Young children depend on adults for the delivery of asthma care, and their care is strongly influenced by parental motivation and attitudes and the home environment. As these children enter adolescence, they typically assume responsibility for their asthma care at the same time that they are claiming their independence and possibly experimenting with high-risk behaviors. Morbidity and mortality, as well as nonadherence, appear to be greatest among adolescents and minority children. Although no perfect tool for measuring adherence exists, objective methods, such as electronic monitoring, can provide valuable information to health care providers. Beyond asthma self-management and education, no specific resource-heavy adherence interventions have proven consistently helpful. However, large-scale, well-designed studies on this subject are lacking. In light of the fact that nonadherence is a potentially modifiable factor that impacts on morbidity and mortality, it is worth pursuing further research to determine better interventions. It is likely, however, that no one answer exists, and interventions will need to be tailored to specific at-risk populations.

Incentive device improves spacer technique but not clinical outcome in preschool children with asthma

AIM

To investigate the influence of an incentive device, the Funhaler, on spacer technique and symptom control in young children with asthma and recurrent wheeze.

METHODS

Randomised controlled trial where 132 2-6 year old asthmatic children received regular inhaled fluticasone through Aerochamber Plus, or Funhaler. The setting was a research clinic at Princess Margaret Hospital for Children, Perth, Australia. Subjects were followed up for a year. The main outcome measure was asthma symptoms. Proficiency in spacer technique was measured as salbutamol inhaled from spacer onto filter. Quality of life was measured every three months. Groups were compared in terms of spacer technique, symptoms and quality of life. The relationship between spacer technique and clinical outcome was examined.

RESULTS

There was no difference between Funhaler and Aerochamber groups in wheeze free days, cough free days, bronchodilator free days or quality of life (P = 0.90, 0.87, 0.74 and 0.11 respectively). Spacer technique was better in the Funhaler group (P = 0.05), particularly in subjects younger than 4 years of age (P = 0.002). Drug dose on filter (as the mean of five 100 mg doses) ranged from zero to 136 mg.

CONCLUSIONS

Use of Funhaler incentive device does not improve clinical outcome, but improves spacer technique in children younger than 4 years. Variability in drug delivery is large in young children using pressurised metered dose inhalers and spacers.

Adherence rate to beclomethasone dipropionate and the level of asthma control

There are only a few studies assessing the relationship between adherence rate to ICS, as assessed by electronic monitoring, and the level of asthma control in childhood. The present study was carried out to examine the relationship between adherence to beclomethasone diproprionate (BDP) as well as other factors related to poor asthma control. In this prospective cohort study, 102 steroid naïve randomly selected subjects with persistent asthma, aged 5-14 years were prescribed 500-750 μg daily of BDP-CFC and followed during one year. Adherence to BDP was measured electronically in the 4th, 8th and 12th months of study. The level of asthma control was classified as either controlled or uncontrolled instead of the current three categories recommended by the Global Initiative for Asthma (GINA). Mean adherence rate was higher in patients with controlled asthma during follow-up, but went down from 60.4% in the 4th month to 49.8% in the 12th month (p = 0.038). Conversely, among patients with uncontrolled asthma, the mean adherence rate decreased from 43.8% to 31.2% (p = 0.001). Multivariate analysis showed that the level of asthma control was independently associated to the adherence rate in all follow-up visits (p-values equal or lower than 0.005). The level of asthma control was directly proportional to adherence rate. Our results suggest that a BDP daily dose by 300 μg seems to be enough to attain control over mild and moderate persistent asthma, including exercise induced asthma.

Inhaled corticosteroid adherence in paediatric patients: the PACMAN cohort study

AIMS

Poor adherence with inhaled corticosteroids (ICSs) has been reported frequently and may be associated with uncontrolled asthma. A better understanding of factors influencing adherence may help to achieve higher adherence rates for a larger part of the population, which will eventually lead to better asthma control. The aim of this study was to investigate factors associated with adherence in paediatric ICS users.

METHODS

We included 527 children using ICSs who participated in the Pharmacogenetics of Asthma Medication in Children: Medication with Anti-inflammatory Effects (PACMAN) cohort study. The outcome, a parent-reported adherence, was assessed by using the Medication Adherence Report Scale. Four categories of determinants were studied: child characteristics, family characteristics, medication use (parental beliefs towards medication; using Beliefs about Medicines Questionnaire) and environmental factors.

RESULTS

Good adherence was observed in 302 children (57%). Increased fractional exhaled nitric oxide values (indication for airway inflammation) were associated with a lower chance of good adherence (OR = 0.25, 95%CI = 0.15-0.41). Parental necessity beliefs about medication were associated with higher adherence (OR = 2.32, 95%CI = 1.59-3.39). Dutch origin was also associated with higher adherence rates (OR = 2.11, 95%CI = 1.09-4.07). Furthermore, younger age (< 6 years) was associated with better adherence (OR = 1.62, 95%CI = 1.02-2.59).

CONCLUSIONS

Increased airway inflammation was associated with lower ICS adherence, which underlines the need of good adherence to reach disease control. Our results suggest that by improving knowledge, especially in ethnic minorities, and by stimulating positive parental perception towards the nature of the disease, the characteristics of the prescribed drugs and the use of medications, better adherence and as a result better asthma control could be reached.

Relationship between maternal demoralization, wheeze, and immunoglobulin E among inner-city children

BACKGROUND

Prior research has linked maternal prenatal and postnatal mental health with the subsequent development of asthma in children. However, this relationship has not been examined in inner-city African Americans and Hispanics, populations at high risk for asthma.

OBJECTIVE

To determine the relationship of maternal demoralization with wheeze, specific wheeze phenotypes, and seroatopy among children living in a low-income, urban community.

METHODS

African American and Dominican women aged 18 to 35 years residing in New York City (the Bronx and Northern Manhattan) were recruited during pregnancy (n = 279). Maternal demoralization (ie, psychological distress) was measured both prenatally and postnatally by validated questionnaire. Outcomes included wheeze, transient (birth to 2.5 years of age), late onset (3-5 years), and persistent (birth to 5 years of age), evaluated via questionnaire and total and indoor allergen specific IgE (at birth and ages 2, 3, and 5 years). Logistic regression with generalized estimating equations assessed the association of demoralization with wheeze and atopy. Multinomial regression explored associations between demoralization and specific wheeze phenotypes.

RESULTS

Prenatal demoralization significantly predicted overall wheeze (adjusted odds ratio OR, 1.66; 95% confidence interval [CI], 1.29-2.14), transient wheeze (OR, 2.25; 95% CI, 1.34-3.76), and persistent wheeze (OR, 2.69; 95% CI, 1.52-4.77). No association was found between demoralization and IgE after adjustment (total IgE: OR, 1.04; 95% CI, 0.74-1.45; any specific IgE: OR, 0.96; 95% CI, 0.57-1.60).

CONCLUSIONS

In this inner-city cohort, prenatal demoralization was associated with transient and persistent wheeze. Understanding how maternal demoralization influences children's respiratory health may be important for developing effective interventions among disadvantaged populations.

Adherence with preventive medication in childhood asthma

Suboptimal adherence with preventive medication is common and often unrecognised as a cause of poor asthma control. A number of risk factors for nonadherence have emerged from well-conducted studies. Unfortunately, patient report a physician's estimation of adherence and knowledge of these risk factors may not assist in determining whether non-adherence is a significant factor. Electronic monitoring devices are likely to be more frequently used to remind patients to take medication, as a strategy to motivate patients to maintain adherence, and a tool to evaluate adherence in subjects with poor disease control. The aim of this paper is to review non-adherence with preventive medication in childhood asthma, its impact on asthma control, methods of evaluating non-adherence, risk factors for suboptimal adherence, and strategies to enhance adherence.

Shared decision-making in pediatrics: a national perspective

OBJECTIVES

To identify patterns of shared decision-making (SDM) among a nationally representative sample of US children with attention-deficit/hyperactivity disorder (ADHD) or asthma and determine if demographics, health status, or access to care are associated with SDM.

PATIENTS AND METHODS

We performed a cross-sectional study of the 2002-2006 Medical Expenditure Panel Survey, which represents 2 million children with ADHD and 4 million children with asthma. The outcome, high SDM, was defined by using latent class models based on 7 Medical Expenditure Panel Survey items addressing aspects of SDM. We entered factors potentially associated with SDM into logistic regression models with high SDM as the outcome. Marginal standardization then described the standardized proportion of children's households with high SDM for each factor.

RESULTS

For both ADHD and asthma, 65% of children's households had high SDM. Those who reported poor general health for their children were 13% less likely to have high SDM for ADHD (64 vs 77%) and 8% less likely for asthma (62 vs 70%) when adjusting for other factors. Results for behavioral impairment were similar. Respondent demographic characteristics were not associated with SDM. Those with difficulty contacting their clinician by telephone were 26% (ADHD: 55 vs 81%) and 29% (asthma: 48 vs 77%) less likely to have high SDM than those without difficulty.

CONCLUSIONS

These findings indicate that households of children who report greater impairment or difficulty contacting their clinician by telephone are less likely to fully participate in SDM. Future research should examine how strategies to foster ongoing communication between families and clinicians affect SDM.

Preschoolers with asthma: narratives of family functioning predict behavior problems

This study tested a model predicting behavior symptoms in preschoolers with asthma. Specifically, it examined the role that asthma severity and children's representations of family functioning may play in the development of child behavior problems in a sample of 53 low-income preschoolers. The study included parent report of asthma severity and a narrative story-stem method to assess children's representations of both general and disease-specific family processes. A regression model tested the inclusion of both types of family processes in predicting child internalizing and externalizing behavior. Disease severity and children's family narratives independently predicted children's behavior over and above the combined effects of demographic variables including child age, socioeconomic status, and family structure. Although children's narratives about general family functioning predicted children's behavior, narratives about family response to asthma symptoms did not. Findings support that both disease severity and family functioning are important considerations in understanding children's behavior problems in the context of asthma. Clinical applications of findings may include: (1) Informing family based-assessments to incorporate children's narratives, and (2) A focus on reducing asthma symptoms and strengthening family functioning to prevent or address child behavior problems.

Cultural-related, contextual, and asthma-specific risks associated with asthma morbidity in urban children

The objective of this study was to examine associations between specific dimensions of the multi-dimensional cumulative risk index (CRI) and asthma morbidity in urban, school-aged children from African American, Latino and Non-Latino White backgrounds. An additional goal of the study was to identify the proportion of families that qualify for high-risk status on each dimension of the CRI by ethnic group. A total of 264 children with asthma, ages 7-15 (40% female; 76% ethnic minority) and their primary caregivers completed interview-based questionnaires assessing cultural, contextual, and asthma-specific risks that can impact asthma morbidity. Higher levels of asthma-related risks were associated with more functional morbidity for all groups of children, despite ethnic group background. Contextual and cultural risk dimensions contributed to more morbidity for African-American and Latino children. Analyses by Latino ethnic subgroup revealed that contextual and cultural risks are significantly related to more functional morbidity for Puerto Rican children compared to Dominican children. Findings suggest which type of risks may more meaningfully contribute to variations in asthma morbidity for children from specific ethnic groups. These results can inform culturally sensitive clinical interventions for urban children with asthma whose health outcomes lag far behind their non-Latino White counterparts.

Monitoring adherence to beclomethasone in asthmatic children and adolescents through four different methods

BACKGROUND

Suboptimal adherence to inhaled steroids is a known problem in children and adolescents, even when medications are administered under parental supervision. This study aimed to verify the adherence rate to beclomethasone dipropionate (BDP) by four currently available methods.

METHODS

In this concurrent cohort study, 102 randomly selected asthmatic children and adolescents aged 3-14 years were followed for 12 months. Adherence rate was assessed every 2 months by self and/or parent report, pharmacy dispensing data, electronic device (Doser); Meditrack Products, Hudson, MA, USA) monitor, and canister weight.

RESULTS

Mean adherence rates to BDP by self and/or parent report, pharmacy records, Doser, and canister weight were 97.9% (95% CI 88.0-98.6), 70.0% (95% CI 67.6-72.4), 51.5% (95% CI 48.3-54.6), and 46.3% (95% CI 44.1-48.4), respectively. Agreement analysis between (Doser) and canister weight revealed a weighted kappa equal to 0.76 (95% CI 0.65-0.87).

CONCLUSIONS

Adherence was a dynamic event and rates decreased progressively for all methods over the 12-month follow-up. Canister weight and electronic monitoring measures were more accurate than self/parent reports and pharmacy records. Rates obtained by these two methods were very close and statistical analysis also showed a substantial agreement between them. As measurements by canister weight are less costly compared with currently available electronic devices, it should be considered as an alternative method to assess adherence in both clinical research and practice.

Methods of assessing adherence to inhaled corticosteroid therapy in children and adolescents: adherence rates and their implications for clinical practice

Nonadherence to inhaled corticosteroid therapy is common and has a negative effect on clinical control, as well as increasing morbidity rates, mortality rates and health care costs. This review was conducted using direct searches, together with the following sources: Medline; HighWire; and the Latin American and Caribbean Health Sciences Literature database. Searches included articles published between 1992 and 2008. The following methods of assessing adherence, listed in ascending order by degree of objectivity, were identified: patient or family reports; clinical judgment; weighing/dispensing of medication, electronic medication monitoring; and (rarely) biochemical analysis. Adherence rates ranged from 30 to 70%. It is recognized that the degree of adherence determined by patient/family reports or by clinical judgment is exaggerated in comparison with that obtained using electronic medication monitors. Physicians should bear in mind that true adherence rates are lower than those reported by patients, and this should be considered in cases of poor clinical control. Weighing the spray quantifies the medication and infers adherence. However, there can be deliberate emptying of inhalers and medication sharing. Pharmacies provide the dates on which the medication was dispensed and refilled. This strategy is valid and should be used in Brazil. The use of electronic medication monitors, which provide the date and time of each triggering of the medication device, although costly, is the most accurate method of assessing adherence. The results obtained with such monitors demonstrate that adherence was lower than expected. Physicians should improve their knowledge on patient adherence and use accurate methods of assessing such adherence.

Status of childhood asthma in the United States, 1980-2007

Centers for Disease Control and Prevention data were used to describe 1980-2007 trends among children 0 to 17 years of age and recent patterns according to gender, race, and age. Asthma period prevalence increased by 4.6% per year from 1980 to 1996. New measures introduced in 1997 show a plateau at historically high levels; 9.1% of US children (6.7 million) currently had asthma in 2007. Ambulatory care visit rates fluctuated during the 1990 s, whereas emergency department visits and hospitalization rates decreased slightly. Asthma-related death rates increased through the middle 1990 s but decreased after 1999. Recent data showed higher prevalence among older children (11-17 years), but the highest rates of asthma-related health care use were among the youngest children (0-4 years). After controlling for racial differences in prevalence, disparities in adverse outcomes remained; among children with asthma, non-Hispanic black children had greater risks for emergency department visits and death, compared with non-Hispanic white children. For hospitalizations, for which Hispanic ethnicity data were not available, black children had greater risk than white children. However, nonemergency ambulatory care use was lower for non-Hispanic black children. Although the large increases in childhood asthma prevalence have abated, the burden remains large. Potentially avoidable adverse outcomes and racial disparities continue to present challenges. These findings suggest the need for sustained asthma prevention and control efforts for children.

Steroid Phobia and Adherence—Problems, Solutions, Impact on Benefit/Risk Profile

Adherence is important with all medications. It can be more difficult with inhaled steroids in light of concern about adverse effects. Although the degree of fear regarding inhaled steroids is difficult to quantify, it appears to be an important factor in adherence. These fears exist for several reasons, including misinformation obtained from such sources as the Internet. To improve adherence and decrease morbidity and mortality, it is vital that health care providers are aware of potential barriers to adherence. Measures such as simplifying and properly explaining medication regimens are helpful. Just as important is the establishment of a strong patient-provider relationship. This makes it easier to convince patients of the need for recommended medications. If the provider is able to effectively communicate and convince the patient of the benefit/risk ratio of steroids, improved patient outcomes can be achieved.

Monitoring nebulizer use in children: comparison of electronic and asthma diary data

BACKGROUND

Measurement of nebulizer medication adherence that relies on self-report of medication use is subject to recall bias and increased patient burden. Electronic monitoring of nebulizer medication use is relatively new technology and provides an objective measure of nebulizer use.

OBJECTIVE

To examine levels of agreement for nebulizer use between self-report on diary cards and electronic monitor data in young inner-city children with asthma.

METHODS

Of 221 enrolled children with persistent asthma, 157 (71%) provided 12 weeks of diary card and nebulizer monitor recordings that were matched by date across days and by patient. Concordance, sensitivity, specificity, and kappa coefficients were calculated between self-report and electronic data.

RESULTS

The children were predominantly African American (89%) and male (66%), with a mean age of 4.6 years. Their persistent asthma was categorized as mild (61%) or moderate to severe (35%). Concordance between diary and electronic data was 85%, with overreporting on diary cards noted on 15% of the total days. Sensitivity of the diary data relative to the electronic data ranged from 0.80 to 0.91 during the 12-week study. Diary return rates decreased from 75% during the initial 3 weeks to 44% at 12 weeks.

CONCLUSIONS

Electronic monitoring of nebulizer use provides a more precise measure of long-term medication use than does self-report on diary cards, and it is feasible for use in high-risk populations. However, diary cards seem to be a valid alternative for short-term monitoring of nebulizer use, resulting in only a slight overestimation of medication use.

AIP: a proposed mechanism for evaluating adherence improvement initiatives

Pharmacy prescription databases are useful for determining rates of adherence to long-term medication therapy. Thus far, however, analyses based on such databases have provided only snapshots of adherence rates over discrete time intervals and have been of limited usefulness for the timely measurement of adherence trends when adherence improvement strategies change over time. The Adherence Index of Performance is new mechanism that can be used to monitor pharmacy prescription databases over time to detect changes that occur when adherence improvement strategies are changed during a therapeutic period.

Poor adherence to self-medication instructions in children with asthma and their parents

This study describes a self-treatment program for parents of children with asthma. The aim was to prevent asthma exacerbations by learning to recognise prodromal signs and acting upon them by increasing inhaled corticosteroids (ICS). The study questions were: (1) can we teach parents and children to recognise prodromal signs? (2) are instructions to increase inhalation medication followed? (3) will frequency and severity of asthma attacks diminish subsequently? Due to physicians' changed attitude towards prescription of ICS, fewer children could be recruited who were "ICS-naive" than expected. Twenty-nine children of the age of 4-11 years with moderate asthma, participated in a one year prospective randomised study. Structured information was given to all patients on asthma, symptoms and medication. The experimental group received additional information on recognising prodromal signs and doubling ICS during one week. Only in 25% of the patients who recognised prodromal signs the dose of ICS was doubled (as prescribed), in 75% inadequately or not at all. Recognition of prodromal signs was poor as well as compliance to increase as-needed medication. No significant decrease of asthma symptoms occurred in the experimental group. Clinical implications are important for self-treatment instructions: an individually tailored and multi-component program should be offered by health care providers in order to help the patient to recognise early alarm symptoms, comply to self-treatment instructions and to make adaptations for continuous self-regulation.