Transcript WAC_Asthma Care and Education_FINAL_POSTING

Asthma Care:
Education and Adherence
Maureen George PhD RN AE-C FAAN
University of Pennsylvania
Philadelphia
Adherence: A process and an outcome
• DEFINITION:
– Willingness to start, and how closely one follows, the
treatment regimen
• Adherence is not a dichotomy
– Chronic underuse
– Erratic patterns of use
– Mixed
– Administration technique
– Primary vs. secondary
– Unwitting (unintentional) vs. deliberate (intentional)
• No factors reliably predict adherence
Rates of non-adherence in asthma
• 44-72% adherence to ICS
– Apter, Boston, George, et al., JACI 2003
• 8-13% continue to refill ICS after 12 months
– Bender, Pedan and Varasteh. JACI 2006
– Marceau, Lemiere, Berbiche, Perreault and Blais. JACI 2006
• 64-91% adhere to PFM in clinical trials
– Reddel,Toelle,Marks,Ware,Jenkins& Woolcock. Thorax
2007
• 27% perform environmental remediation
– Huss, Squire , Carpenter et al., JACI 1992
Adherence in children and adolescents
• Adherence to treatment ranges from 43% to 100%,with an
average of 58% in developed countries.
– Burkhart & Dunbar-Jacob In: Hayman, Mahom & Turner, eds. Chronic
illness in children: An evidence-based approach. 2002:199-229.
• The adherence of infants and toddlers to recommended
treatment regimens is largely determined by the ability of the
parent to understand the recommended management.
• As age increases, children have the cognitive ability to carry out
treatment tasks, but continue to need parental supervision.
• Greater parental perception of their child’s vulnerability is
directly correlated with sustained adherence
– Spurrier et al. Pediatric Pulmonology, 2000, 29:88–93.
Adherence in children and adolescents
• Behavioral techniques designed to help children, such as goalsetting, cueing, and rewards or tokens, have been found to
improve adherence in the school-aged population.
– Rapoff M. Adherence to pediatric medical regimens. New York, Plenum,
1999
• Increasing numbers of single and working parents have shifted
more of the responsibility for disease management to the child.
• Children and adolescents who assume early sole responsibility
for their treatment regimen are less adherent and in poorer
control of their disease.
• The more conflict in the home or between the parent and the
child, the worse the adherence.
Ways to measure adherence
•
•
•
•
•
Self-report
Electronic monitoring
Provider estimate
Biologic assay
Electronic records
– Prescription utilization
– Appointment keeping
Adherence to TID Inhaled Bronchodilator
70
% Reported or Recorded
Adherence
60
50
40
Self-Report
30
Monitor
20
10
< 1 x day
1 x day
2 x day
3 x day
0
Rand, et al (1992). AJRCCM, 146, 1559-1564
Asthma controllers
Telephoning the patient's pharmacy to assess adherence with
asthma medications by measuring refill rate for prescriptions
Sherman, James MD; Hutson, Alan PhD; Baumstein, Sandra PharmD; Hendeles, Leslie PharmD
Journal of Pediatrics. 136(4):532-6, 2000 Apr
Adherence and Asthma Controller MedicationsAdutls and Adolescents
*
ICS = Inhaled corticosteroid; LTRA = Leukotriene Receptor Antagonist; LABA=Long Action Beta 2 Agonist
* P<.0001 versus ICS+LABA, ICS Alone, ICS+LTRA
Stempel DA. Respir Med. 2005;99:1263-1267.
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Non-adherence in asthma
• Is associated with
– Greater morbidity
• More symptoms
• More ED visits and hospitalizations
• More OCS use
Costs of non-adherence
Direct
Indirect
Berg, Dischler, Wagner, Raia & Palmer-Shevlin, 1993
Patient education is necessary but not sufficient
• Interventions that encourage symptom or peak flow monitoring
have shown significant but small effects on asthma morbidity
– Guevara, Wolf, Grum and Clark. Effects of educational interventions
for self-management of asthma in children and adolescents:
systematic review and meta-analysis, BMJ 326 (2003), pp. 1308–1309.
• Interdisciplinary pediatric program decreased urgent care
– Walders et al., Chest (2006)
• Nurse led interdisciplinary adult inpatient program decreased
urgent care
– George et al., Arch Int Med (1999)
• Nurse led education resulted in short term increases in adherence
and reduction in symptoms
– Smith, et al., Thorax (2005)
Interface
Good
therapies
Human
behavior
Treatment
outcomes
Asthma Control
• Approximately 55% of adults with asthma
have uncontrolled disease
– Peters, 2007
• Even those with mild asthma may experience
a severe attack
– Akinbami, 2011
Asthma Self Management
Education
• Attacks can be prevented with ASM
– a personalized asthma action plan guides use of short-term
relief and daily controller therapies
– a plan for monitoring and responding appropriately to
symptoms
– a plan to reduce/avoid trigger exposure and mitigate risks
– continuity of care
• ASM training requires ~5.5 hours of patient contact
– Cabana and Le. JACI(2005)
• Together, these ASM “best practices” are strongly linked to
enhanced asthma control and reduced exacerbations
– EPR-3, 2007; Powell, 2003; Steuten, 2007; Toelle, 2004
Asthma Self Management
Education
• Healthy People 2010 Objective 24-6 sought to
increase the proportion of individuals receiving
formal ASM education from 8% to 30%
– US Department of Health and Human Services, 2000
• In 2007, only 12% of adults reported having
received ASM education
– CDC, 2007
• Only 55% of adults with asthma can recognize
the early signs of an attack; 65% know the
appropriate response
– CDC, 2007
Why should we try to improve adherence?
• To achieve control
– Reduce impairment
– Reduce risk
• To enhance patient safety
– Fewer relapses
– Less risk of unneeded intensification
• “Increasing the effectiveness of adherence
interventions may have a far greater impact on the
health of the population than any improvement in
specific medical treatments”
– Haynes et al. Cochrane Database of Systematic Reviews 2001
How do we improve adherence in challenging families?
• Patients need to be supported, not blamed
• Patient-tailored interventions are required
• Health professionals need to be trained in
adherence
• A multidisciplinary and multidimensional
approach is needed
– ADHERENCE TO LONG-TERM THERAPIES: Evidence
for action. WHO, 2003
Interventions to improve adherence
• Most effective
– Complex, multi-faceted interventions that combine self
management training with counseling, simplified
regimens, reinforcement, reminders and supervision
– Provide feedback
– Reach agreement on overt monitoring
– Tailor regimen and allow for incomplete adherence
– Contract
– Increase frequency and length of appointments
Multiple Factors Affect Adherence to Preventive Asthma Therapy
Beliefs
Intentional
Nonadherence
Skills
Ability
Motivation
Patient–Provider
Communication
Regimen
• Convenience
• Understanding
• Simplicity
Unintentional
Nonadherence
Patient
• Psychological
• Social
• Cultural
• Economic
Adapted from Respiratory Medicine, v. 93, Clark N, et al. Patient factors and compliance with asthma therapy, pp. 856862,©1999, with permission from Elsevier.
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