Enhancing patient adherence to asthma therapy

INTRODUCTION — Patient adherence to medical regimens is a major problem in chronic disease management. Adherence to asthma medication regimens tends to be very poor, with the reported rates of nonadherence ranging from 30 to 70 percent [1-3]. Up to three-quarters of the total costs associated with asthma may be due to poor asthma control.

Improved patient adherence may lead to improvements in asthma control and quality of life [4], and good adherence is associated with lower risk of severe asthma exacerbations [5]. The role of the clinician is to adequately inform the patient about the prescribed regimen, assess adherence at every visit, and discuss the importance of adherence even in the absence of symptoms. In the patient who manifests nonadherence, the clinician should explore with the patient barriers to adherence and methods to overcome these barriers. Failing to address nonadherence can result in persistent poor asthma control and inappropriate escalation of therapy [6].

Strategies to enhance adherence to asthma therapy will be reviewed here. An approach to asthma management, a discussion of what patients need to know about their asthma, and the role of peak flow monitoring are discussed separately. (See "An overview of asthma management" and "Asthma education and self-management" and "Peak expiratory flow monitoring in asthma".)

REASONS FOR NONADHERENCE — A number of factors are associated with nonadherence to asthma therapy [1,2,7,8]. Medication-related factors include difficulties with inhaler devices, dosing frequencies, complex regimens, side effects, cost of medication, dislike of medication, and distant pharmacies. Adherence may vary by asthma medication type: one study found higher adherence to asthma biologics than to inhaled glucocorticoids [9].

Factors unrelated to medications include misunderstanding or lack of instruction, fears about side effects, dissatisfaction with health care professionals, unexpressed/undiscussed fears or concerns, inappropriate expectations, poor supervision/training or follow-up, anger about one's condition or its treatment, underestimation of severity, cultural issues, stigmatization, forgetfulness or complacency, attitudes toward ill health, and religious issues [10]. Social barriers such as complicated work schedules, caring for other family members, or even the perceived safety of the neighborhood can all affect adherence [11]. Finally, stress, depression, and comorbidities can all influence adherence [12-14].

Several other reasons make adherence to asthma treatment recommendations problematic: medication regimens are of long duration and include multiple medicines; dosing may occur on both a fixed schedule and an as needed basis; and patients go through periods of symptom remission [3].

A number of types of nonadherence can interfere with therapy, including underuse, overuse, or erratic use [1,15]. Underuse of asthma medications appears to be more common than overuse [16,17]. In a study comparing self-reported use of inhaled medications recorded in a diary to actual use determined by an electronic monitor of inhaler activation, it was found that subjects were not as compliant as they reported to be in their diaries [18]. Another study found that inhaled beta agonists are no more likely to be overused than anti-inflammatory agents [19]. This observation tends to dispel the concern that patients will overuse inhaled beta agonists because of their fast symptom relief.

It is important to appreciate that nonadherence does not necessarily represent irrational behavior. There are many influences that may make a patient-initiated change in the regimen appropriate, such as a belief that the medication is not needed, intolerable side effects, problems with cost, and the inconvenience of obtaining refills. This problem has been described as "intelligent nonadherence" [20]. Interventions such as shared decision-making or problem-solving that take into account the beliefs and priorities of each patient have had some, but not complete, success, with shared decision-making being most successful [21,22]. With the features of the electronic health record (EHR) becoming more robust, medications can be ordered electronically through patient portals, and integrated speech recognition technology may be feasible for reminding patients to refill medications [23].

IMPROVING ADHERENCE — Health care providers can utilize a series of strategies to help improve their patient’s adherence [2,24]. These strategies include developing a partnership with the patient (or parent/caregiver), seeking to understand the patient’s concerns and barriers to adherence, providing information that is personalized to that patient’s disease or situation, and keeping the patient’s health literacy in mind when talking to the patient and giving written instructions [25].

Establish partnership — One of the first, and most important, steps is to develop a partnership with the patient (and family/caregivers). The provider should work to understand the patient's goals of therapy and, in turn, describe the general goals of asthma therapy to the patient. These steps help to facilitate agreement between the patient and provider on what the goals of therapy should be [22,26].

The provider should explain the recommended actions and the benefits that come from these actions. If possible, it is best to incorporate the patient's goals or expectations into the list of benefits. At subsequent visits, the provider should offer positive reinforcement of the things the patient has accomplished (eg, keeping appointment, taking medications more regularly, longer time between emergency department visits, improved health). At each visit, the provider should ask about adherence to asthma therapy in a nonjudgmental way, and show empathy if the patient reports nonadherence.

Identify barriers to adherence — Patients may have multiple reasons for not taking their medications regularly, so it is essential to identify the reasons that pertain to each patient.

●The patient may have concerns about adverse effects of a medication or the expense: Be sure to address fears or concerns.

●The patient did not understand the number of inhalations/frequency: Simplify the regimen as much as possible and write it down.

●The patient misunderstood the difference between rescue and controller medications: Explain how each medication works to control or prevent symptoms and write it down.

●Test patients' understanding by having them repeat instructions to you in their own words, or provide a scenario and ask patients how they would respond.

●The patient has too many other stresses to focus on their own health: Encourage the patient to seek support through a family member, caregiver, friend, neighbor, or support group.

●The patient feels isolated or angry about their disease/therapy: Provide opportunities to meet other patients who have had the same or similar experiences.

Provide written instructions — Guidelines recommend that patients/families should be given written instructions about how to use long-term control medications (daily self-management) and how to manage exacerbations (rescue medications, trigger avoidance, seeking help) (form 1) [2,24]. The instructions should include the dose, frequency of administration, guidelines for changing dose or adding medications, adverse effects to report to the clinician, and contact information for securing urgent care, if needed. Electronic reminders may also help improve adherence, although further work is needed to clarify best practices [27]. (See "Patient education: Asthma treatment in adolescents and adults (Beyond the Basics)" and "Patient education: Asthma in children (The Basics)".)

Treatment plans should include:

●How to monitor body signs or symptoms and/or peak expiratory flow (PEF) to detect increasing airflow obstruction as early as possible; early signs of airflow obstruction vary according to the individual and should be identified for each patient. (See "Peak expiratory flow monitoring in asthma" and "Patient education: How to use a peak flow meter (Beyond the Basics)".)

●Clear instructions for initiating or modifying treatment when conditions change, such as new or worsened symptoms, or a drop in PEF.

●A list of steps to take when medicines are ineffective or if an emergency situation arises. The steps may include removing the precipitating trigger, giving medication, avoiding strenuous physical activity, and keeping the patient and family calm. (See "Trigger control to enhance asthma management".)

●Specific criteria for seeking emergency medical care without delay, including a pattern of declining PEF; failure of medications at home to control worsening symptoms; difficulty in walking, talking, or breathing (even if wheeze is absent); intercostal retractions; blue fingernails or lips.

●Observable signs that long-term therapy is less than optimal, such as sleep interruption and/or consistently low or highly variable PEF. Such signs should be discussed with the clinician.

●For patients with severe, poorly-controlled asthma, a home visit by a member of the clinical team may allow the clinician to better understand patients’ barriers to adherence and asthma self-management [28]. For these patients, referral to an asthma specialist may be helpful.

●For a patient who does not respond to medications in whom poor adherence is considered, one should always review the diagnosis of asthma. (See "Asthma in children younger than 12 years: Initial evaluation and diagnosis" and "Asthma in adolescents and adults: Evaluation and diagnosis".)

These general steps should be combined with instructions concerning other specific aspects of asthma care as outlined in separate topic reviews. (See "Asthma education and self-management" and "The use of inhaler devices in adults".)

Other interventions — The prevalence and ubiquity of poor asthma adherence and control has prompted multiple innovative approaches in medical technology and educational spaces.

●Digital interventions – Online platforms, websites, and mobile applications can promote communication between patients and providers, support symptom monitoring, allow real-time feedback of symptom data, and can provide information in an engaging manner. A comprehensive review of digital adherence interventions suggests that they improve adherence, asthma control and exacerbations, as well as quality of life, but this assessment is based on small studies and low-quality evidence [29].

Expanding access to such interventions raises several significant concerns. From an information-technology perspective, use of patient-provided data requires management of data privacy, data ownership, and liability for identification of medical problems. It also remains unclear how to best integrate these data into current provider workflow, and whether these interventions may worsen health disparities due to differences in digital access. Further study will be critical to determine best practices in this area.

●Telemedicine – Increasing familiarity with and use of telemedicine since the start of the COVID-19 (coronavirus disease 2019) pandemic may allow expanded use of this modality for directly observed therapy, peak expiratory flow monitoring, and asthma follow-up visits. These telemedicine interventions have been shown to be effective at improving adherence to asthma therapy in some populations [30-32]. (See "Telemedicine for adults".)

●School-based treatment interventions – School-based programs have shown some promise for improving childhood asthma outcomes. The School-based Asthma Management Plan aims to coordinate asthma management between family, clinicians, and school personnel. It includes action plans designed to achieve maximum coordination [33]. Other school-based interventions have proposed incorporating directly observed therapy and telemedicine visits [30].

Schools serving low-income children tend to have the fewest resources, students with the most prevalent and severe disease, and the greatest need for providing school-based interventions. School systems with marginal resources may not have a full or even part-time nurse, an essential advocate for asthmatic children. New solutions are needed to resolve inequities of funding schools, particularly those in poorer communities.

PATIENT ACTIVITIES TO ENHANCE ADHERENCE — Patient self-management of asthma or any chronic disease must be learned. Patients can be taught coping skills and problem-solving skills to use in increasing their compliance. The following approaches from a workbook developed for pulmonary patients at the University of Alabama at Birmingham are suggested; the figures can be printed and given to appropriate patients:

●Activity 1 – Identify problems in taking medications (table 1A-B)

●Activity 2 – Take steps to solve medicine-taking problems (table 2)

●Activity 3 – Learn solutions to common problems (table 3)

LIMITATIONS OF RESEARCH ON ADHERENCE — Research on adherence is difficult and can be limited by risk of bias, particularly biases associated with blinding. One example is that observation changes behavior, that is, that inhaled glucocorticoid use measured by a monitor may yield a different result from unobserved glucocorticoid inhaler use (Hawthorne effect). Studies must account for whether adherence is associated with changes in asthma outcomes. Research also must account for dropout, adverse events, and other threats to methodology [34]. More research is needed to find better ways to measure adherence, to intervene to improve it, and to establish an association between adherence and important clinical outcomes. Finally, more research is needed to understand patient barriers to adherence and preferences.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Asthma in adolescents and adults" and "Society guideline links: Severe asthma in adolescents and adults".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)

●Basics topic (see "Patient education: Coping with high drug prices (The Basics)" and "Patient education: Asthma in adults (The Basics)" and "Patient education: Medicines for asthma (The Basics)" and "Patient education: Asthma in children (The Basics)")

●Beyond the Basics topics (see "Patient education: Asthma treatment in adolescents and adults (Beyond the Basics)" and "Patient education: Trigger avoidance in asthma (Beyond the Basics)" and "Patient education: How to use a peak flow meter (Beyond the Basics)" and "Patient education: Inhaler techniques in adults (Beyond the Basics)" and "Patient education: Asthma inhaler techniques in children (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Adherence to asthma medication regimens tends to be very poor, with the reported rates of nonadherence ranging from 30 to 70 percent. (See 'Introduction' above.)

●Medication-related factors that contribute to poor adherence include difficulties with inhaler devices, complex regimens, side effects, cost of medication, dislike of medication, and distant pharmacies (table 1A and table 1B). (See 'Reasons for nonadherence' above.)

●Factors unrelated to medications that contribute to poor adherence include misunderstanding or lack of instruction about the medications, which may be exacerbated by low literacy, fears about side effects, dissatisfaction with health care professionals, anger about one's condition or its treatment, underestimation of severity, cultural and social issues, stigmatization, and forgetfulness or complacency. (See 'Reasons for nonadherence' above.)

●One of the first, and most important, steps to improving adherence is to establish the goals of therapy in a collaborative fashion with the patient (table 2). (See 'Improving adherence' above.)

●Additional steps towards improving adherence include identifying and addressing reasons for nonadherence, clarifying the patient's expectations for treatment and addressing fears and concerns, simplifying the medical regimen, explaining how each medication works to control or prevent symptoms, and providing written instructions about long-term control and rescue medications (table 3 and form 1). (See 'Improving adherence' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges William Bailey, MD, who contributed to earlier versions of this topic review.