Asthma Medication Adherence
What strategies work best to improve asthma medication adherence and asthma outcomes?
By Dana Wallace, MD
Adherence to chronic disease pharmacotherapy, including those for asthma, is a worldwide problem, with estimated adherence to asthma medications varying between 30 to 70%.(1) More than 35% of patient fill less than half of the prescribed medications (2). Even patients prescribed oral steroids are nonadherent up to 45% of the time (2). Non-adherence to inhaled corticosteroids (ICS) is likely responsible for 24% asthma exacerbations & poor outcomes (3). It is estimated that the cost of respiratory disease nonadherence is $35,000/patient/year. (4)
We first need to be able to accurately assess asthma medication adherence, which is difficult both to define and measure, as all feasible methods are indirect. Subjective patient reporting overestimates adherence 2 to 3-fold, as shown in a subset analysis from the Childhood Asthma Management Program (CAMP) (5). The indirect methods used most frequently in research may not be applicable to the clinical practice, including paper or electronic diary, hidden counters on inhaler devices, and determining drugs remaining by counting pills or weighing inhalers. The clinician should use of a standardized questionnaire at each visit, such as the Asthma Control Test (ACT) or a modification of the Morisky-MMAS-8, a validated measure of adherence used for multiple chronic diseases (6). Review of pharmacy refill records should be considered in difficult to control asthmatics to validate that prescriptions are at least being filled at an appropriate interval. Unfortunately, assessment of adherence by the physician during the course of an unstructured office visit is a very inaccurate way to determine adherence.
It is well established that the patient and family need to receive education about asthma, medications used to control asthma, and the long-term results of uncontrolled asthma. However, education in both adult and childhood asthmatics alone is not sufficient as many studies have not shown improvement in asthma outcomes, e.g., hospitalization/ED visits, quality of life, and improvement in lung function, nor adherence to medication. (7) It has been shown that asthma education is more effective in mild to moderate asthma, as in severe asthma, even adequate education and optimal therapy may not control the disease (8). Using tailored education., psycho-educative interventions, combining education with a peak-flow directed asthma action plan, and having multiple educational sessions with a variety of interactive learning options may improve asthma outcomes and reduce unscheduled office and hospital visits and hospitalizations (9) (10, 11). Four studies in children have found that asthma action plans based on symptoms rather than peak flow are more effective at reducing hospitalizations and ED visits (12).
Using shared-decision making with the patient and extended family as part of the initial discussion of asthma diagnosis and management and continued at each follow-up visit has been shown to improve adherence to taking the prescribed medications (13). The American College of Allergy, Asthma, and Immunology has developed a shared-decision making tool to use with severe asthma patients http://asthmarelief.acaai.org/. Motivational interviewing is also of value in promoting adherence and may actually reduce the professional’s time needed to be spent with the patient over the long run. (14) Phone or SMS reminders to adhere to medication schedules, refills, and office visits, have been shown to be effective in the short term but may be less effective beyond a few weeks of use (15). Telemedicine and internet-based education and personalized adherence plans may be future techniques that can improve medication adherence.
Most research shows that a multi-faceted approach, involving on-going education, a written asthma action plan, reminders, shared decision making and motivational interviewing, frequent office visits, questionnaire monitoring of asthma control, establishing an excellent patient-physician and patient-office team relationship, convenient and efficient phone support and scheduling of office visits, a friendly and supportive office staff, and easy access to refills of controlled medications (more difficult access to short-term reliever medication refills) can improve medication adherence and asthma outcomes.
1. Bender B, Milgrom H, Rand C. Nonadherence in asthmatic patients: is there a solution to the problem? Ann Allergy Asthma Immunol. 1997;79(3):177-85; quiz 85-6.
2. Gamble J, Stevenson M, McClean E, Heaney LG. The prevalence of nonadherence in difficult asthma. Am J Respir Crit Care Med. 2009;180(9):817-22.
3. Williams LK, Joseph CL, Peterson EL, Wells K, Wang M, Chowdhry VK, et al. Patients with asthma who do not fill their inhaled corticosteroids: a study of primary nonadherence. J Allergy Clin Immunol. 2007;120(5):1153-9.
4. Cutler RL, Fernandez-Llimos F, Frommer M, Benrimoj C, Garcia-Cardenas V. Economic impact of medication non-adherence by disease groups: a systematic review. BMJ Open. 2018;8(1):e016982.
5. Krishnan JA, Bender BG, Wamboldt FS, Szefler SJ, Adkinson NF, Jr., Zeiger RS, et al. Adherence to inhaled corticosteroids: an ancillary study of the Childhood Asthma Management Program clinical trial. J Allergy Clin Immunol. 2012;129(1):112-8.
6. Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence. Med Care. 1986;24(1):67-74.
7. Bertolotti G, Carone M, Viaggi S, Moscato G, Neri M, Rampulla C, et al. Reliability of a questionnaire for evaluating the understanding of asthma. Monaldi Arch Chest Dis. 2001;56(1):11-6.
8. Bourdin A, Halimi L, Vachier I, Paganin F, Lamouroux A, Gouitaa M, et al. Adherence in severe asthma. Clin Exp Allergy. 2012;42(11):1566-74.
9. Guevara JP, Wolf FM, Grum CM, Clark NM. Effects of educational interventions for self management of asthma in children and adolescents: systematic review and meta-analysis. BMJ. 2003;326(7402):1308-9.
10. Coffman JM, Cabana MD, Halpin HA, Yelin EH. Effects of asthma education on children's use of acute care services: a meta-analysis. Pediatrics. 2008;121(3):575-86.
11. Smith JR, Mugford M, Holland R, Candy B, Noble MJ, Harrison BD, et al. A systematic review to examine the impact of psycho-educational interventions on health outcomes and costs in adults and children with difficult asthma. Health Technol Assess. 2005;9(23):iii-iv, 1-167.
12. Bhogal S, Zemek R, Ducharme FM. Written action plans for asthma in children. Cochrane Database Syst Rev. 2006(3):Cd005306.
13. Bender BG. Can health care organizations improve health behavior and treatment adherence? Popul Health Manag. 2014;17(2):71-8.
14. Borrelli B, Riekert KA, Weinstein A, Rathier L. Brief motivational interviewing as a clinical strategy to promote asthma medication adherence. J Allergy Clin Immunol. 2007;120(5):1023-30.
15. Strandbygaard U, Thomsen SF, Backer V. A daily SMS reminder increases adherence to asthma treatment: a three-month follow-up study. Respir Med. 2010;104(2):166-71.