Nonadherence Undermines Treatment

Patient adherence with asthma self-management plans, as with all chronic medical conditions, is often poor. Adherence to daily medication regimens averages about 50% or less for chronic conditions in general, including patients with asthma. Adherence as defined in these studies means that about half of the prescribed medication was taken, although it does not necessarily signify that it was taken in the appropriate manner. In addition, the report of 50% medication adherence reflects the average of groups of patients studied but does not translate into a uniform pattern of taking every other dose of medication. Individual adherence patterns include widely varying behaviors, with some patients taking close to all their medications at the appropriate time and others taking almost no medication. Individual adherence fluctuates greatly over time, often with periods of time during which patients take no medication for varying periods, often for days or weeks at a time. Further, asthma medication adherence may be on the decline. A 1993 review of ten published studies found that adherence had averaged 48%. Recently published studies have reported mean inhaled corticosteroids (ICS) adherence at 34% in adults and 40% in children. Other studies have shown alarmingly high rates of medication abandonment, reflected in refill nonpersistence, a problem not unique to asthma. For example, large administrative and pharmacy database studies have revealed that 59% of patients with asthma, 39% of patients with hypertension and 86% of patients with chronic obstructive pulmonary disease (COPD) ceased refilling their medication and did not return to fill again within a year. Decreasing ICS adherence is followed by worsening asthma symptoms in children. Because most adherence research is conducted on patients who volunteer to participate in studies and know that their adherence is being monitored, these numbers may be inflated. One medication refill study, reflecting the behavior of 5,500 adult and pediatric patients using a national pharmacy chain, found mean ICS adherence of 22.2% over 12 months.

Impact of Nonadherence

Depending on the duration of action and the drug side-effects profile, periods of nonadherence may have several potential consequences, including waning drug action, hazardous rebound effects when administration stops abruptly, and overdose effects when administration of full-strength drugs suddenly resumes. In studies of metered-dose inhaler (MDI) use among children with asthma, inhalers were not used on 48% of study days and abandonment of medication typically occurred for several consecutive days. The consequences of such start-and-stop adherence patterns are unknown. Time to onset of the effectiveness of ICS in the treatment of mild-to-moderate asthma is about 3 weeks, with faster impact (3 days) reflected on morning peak expiratory flow values in patients with severe asthma. It remains to be determined how varying patterns of adherence translate into asthma control and whether, for example, control in patients with relatively high adherence who fail to use their medication for 1 week or longer is poorer than in patients who use less total medication but with better regularity.

While the assumption that underuse of asthma controller medication can result in less control over the disorder is accurate, conclusions about the amount of medication required by any individual child are difficult to establish largely because of individual variations in disease characteristics, medication requirements and drug metabolism rates. The prevailing standard, as reflected by the US National Asthma Education and Prevention Program (NAEPP) guidelines for the diagnosis and management of asthma, is that increased medication administration is the correct response to inadequate symptom control. The potential benefit of medication escalation on the part of the physician is realized only if the patient responds by adhering to the new regimen. Although some studies have defined nonadherence as less than 75% of medication taken, it is impossible to establish a minimum level of adherence that is sufficient for all patients. Evidence exists that ICS are highly effective in controlling asthma, that some benefit persists even at relatively low dosing frequency, and that a dose-response relationship exists between degree of adherence and degree of benefit. Suissa et al, for example, conducted a nested case-control study of patients with severe asthma and found that decreasing number of ICS pharmacy refills was associated with increasing risk of death from asthma. As few as three ICS canisters per year reduced risk by one half, with increasing protection gained as refills increased up to a full adherence level of 12 canisters per year. Clearly, as adherence levels drop, asthma becomes less controlled. For example, in a 3-month study, children with a median ICS adherence of 14% had asthma exacerbations requiring urgent office visits and oral steroid bursts, whereas those with adherence levels of 68% remained medically stable. Even children with relatively mild asthma demonstrated increased asthma symptoms as adherence declined. Nonadherent adults with asthma had more airway obstruction than adherent patients. In large studies of managed care populations, decreasing use of ICS has been linked to increased risk of hospitalization. Children who did not adhere to their asthma treatment regimen had poorer asthma control and required more urgent-care visits, steroid bursts and hospitalizations. In a recent study of 18,456 Medicaid children with asthma, increasing adherence to controller medication was associated with higher cost but also decreasing odds of an ED visit. Tragically, nonadherence has been associated with asthma-related deaths in children, particularly where psychologic dysfunction was observed in the patient or the patient’s family.

Strategies to Change Patient Behavior

Numerous strategies to improve patient adherence have been tested, many in carefully conducted randomized clinical trials. While most of these interventions have been able to change patient or parent behavior, changes are often small and difficult to sustain. Further, effective interventions are often costly and require large amounts of healthcare provider time or supplementary staff. A Cochrane Collection meta-analysis of 69 randomized trials of adherence interventions, covering a large range of ages and diseases, reported that 40% produced an effect on both adherence and at least one clinical outcome. All involved complex interventions combining components such as information giving, reminders, self-monitoring, reinforcement, counseling, psychological therapy, crisis intervention and telephone follow-up. A meta-analysis of 70 controlled studies of interventions to improve adherence across various chronic pediatric conditions, including asthma, diabetes, cystic fibrosis, cancer, sickle cell disease and gastrointestinal disorders, revealed moderate effect size in multicomponent behavioral interventions and small effect size from interventions limited to education and instruction. Multicomponent behavioral programs again included a variety of interventions such as behavioral reinforcement, social support, computer and technology-based components, homework assignments and family and individual psychological counseling. Other promising strategies include the use of patient advocates or navigators and introduction of innovative web-based technology into school-based clinics to improve care coordination and adherence.

A recent consensus report from a group of 20 internationally recognized experts on adherence emphasized the essential importance of identifying simple, brief interventions that could be delivered by healthcare providers during the course of routine office care. The challenge, then, becomes one of identifying interventions that are not costly, do not require a large amount of healthcare provider time and can be implemented during routine office visits. Do such interventions exist, and are they evidence based? A considerable amount of evidence indicates that key communication strategies exist that can change parent and patient behavior and are evidence-based, time-efficient and teachable to busy healthcare providers.

Five Communication Strategies for Changing Patient Behavior

Behavioral scientists have long adopted a translational research approach to understanding and changing health behaviors. Much like ‘bench’ research, the process begins with studies that document frequencies, predictors and moderators of health behaviors. This information is used to build models, or theories, that explain health behaviors. Such models of behavior change are used, in turn, to translate theory to the ‘bedside’ by allowing behavioral scientists to develop and test interventions that change people’s health behavior. Strategies to change patient behavior have been rooted in a number of health behavior change frameworks. These include patient-centered care , motivational interviewing , readiness to change and shared decision-making . Each has produced evidence of the effectiveness of very specific communication strategies. These strategies are discussed below, along with evidence from each model that supports its use. The collective group of five strategies are presented here as an integrated program that can guide provider behavior during patient visits to increase treatment effectiveness and outcomes. Further, these strategies can enhance satisfaction from the encounter for both the family and the healthcare provider.