Write a 3 page article review not including a title page abstract and refernce page. Cannot use personal pronouns.
Table 6. Suggested Actions to Improve Patient Adherence With Inhaled Aerosol Medication Therapy
Adequately prepared health-care provider
Knowledge of inhaler function and correct use
Understand concept of partnership with patient
Ability to communicate with patient
Recognition of patient barriers to adherence (language, cognitive,
psychological)
Seek appropriate social service or psychiatric support for
nonadherent patients when needed
Evaluate and review patient inhaler technique at initial and follow-up
visits
Provide written treatment plan, specifying actions and times Simplified aerosol-dosing regimen to extent possible and appropriate
Use of daily or twice-daily medications (eg, long-acting 2 agonists or tiotropium)
Use of combination aerosol formulations (eg, salmeterol plus fluticasone [Advair])
Educate the patient about the effectiveness, use, function, and adverse effects of inhaled medications, especially corticosteroids
Give patients realistic expectations about medication effectiveness Educate the patient about the severity of the disease and the risks of
not using the medication
Use pulmonary function tests to document severity, effectiveness Identify problems with patient’s medication expense
Is there a lower cost alternative?
Seek assistance programs from pharmaceutical companies
(Compiled from References 11, 60, and 61.)
simple remedies. Improving adherence is made more dif-
ficult by the fact that health-care providers do not know if
patients are adherent without the use of monitoring,14 pref-
erably using some type of electronic monitor that can record
the date and time of aerosol use. This would require ad-
ditional clinician and staff time and expense, and is not
practical for office and clinic practices. Table 6 lists rec-
ommended actions, based on the factors cited in this re-
view, that evidence suggests are amenable to interven- tion.7,11,60 – 61
Lewis and Fink pointed out that the preparation of health-care professionals should emphasize the concept of partnership with patients to increase adherence.62 Pa- tient education is a key component in partnering with patients. Health-care providers must be able to help the patient understand the disease and begin to master self- management skills.62 Patient education can also address and attempt to correct patient beliefs that can decrease adherence, such as beliefs about the need for the med- ication and concern over adverse effects and depen- dence. With good communication skills, health-care pro- viders may be better able to identify problems with adherence, identify reasons for nonadherence, and seek appropriate solutions.
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Discussion
Rubin: I think it would be useful if
we could modify those electronic mon- itors to shock patients when they forget to take their medication on time. Ad- herence is better if it involves a conse- quence, if it is easy, and if it is imme- diate. Adherence is much better for medications like oral contraceptives, with which there is a fairly immediate consequence if doses are missed.
Rau: I like the shocking monitor idea. This is a tough nut to crack. It’s true, we don’t have any really positive feedback measures to give patients, particularly in the case of inhaled cor- ticosteroid. If they use it correctly, they probably won’t show up in the emer- gency department as soon, or they don’t end up being hospitalized, but that’s really the stick, not the carrot.
I think the best that we can do is educate patients about the risk of not using the drug, so that they realisti- cally appreciate the risk. A little bit of shock therapy helps if they end up in the emergency department or get ad- mitted, which sometimes scares peo- ple into better adherence. But, short of that, I did not find any perfect an- swer to the lack of patient adherence, which is probably around 50% across all medications and in the various stud- ies. So I think education is the best we can do, and it may be the most costly, because who has time in a busy clin- ical setting to really work with the patient? And yet that is probably what is needed, and perhaps a lot of the lack of adherence is because we don’t work with the patient one-on-one be- cause of the cost.
This is a tough nut to crack. It’s often difficult to get a patient to use a medication. A Diskus inhaler should be used up once a month, but we see refill rates of only 4 or 5 a year, so adherence seems to be less than 50%. Most of the data is not about intervention. I think there has to be an intervention, be it a stick or a carrot.
One of the things GlaxoSmithKline tried in Scandinavia, where a lot of people have cell phones, was a simple reminder using the cell phone text- messaging system. In a text message they simply asked, “Did you take your medication?” As I recall, it appeared to improve compliance by 30 or 40 percent [unpublished data]. Are there other kinds of information or systems that might improve compliance?
Rubin: I know there are questions about this, but currently there is a pen- alty, called a co-pay, if you refill your prescription every month. If they use it less frequently than prescribed, they save money. Is there a way to provide financial benefits for patients to fill their prescription when they should, instead of penalizing them?
Atkins: That relates to a comment you made earlier about fluticasone. I suspect another point was the fact that a lot of people were getting a higher- dose prescription of fluticasone and then probably only using one MDI puff, because that makes it so they only have to fill the prescription every 2 months.
Rau: That is a very good comment. The data from Nides and colleagues1 clearly showed better adherence among patients who knew they were being monitored and received feed- back.
Atkins:
DETERMINANTS OF PATIENT ADHERENCE TO AN AEROSOL REGIMEN
We have a prototype Adaptive Aerosol Delivery nebulizer system that monitors adherence and whether the parents used the device as instructed (ie, compliance with device instructions). We called the combined function of adherence and compliance “true adherence.” Feedback on how to use the device seemed to be important
Newman: You stressed the impor- tance of involving patients in treat- ment plans. What about choice of in- haler device? Do patients adhere better if they’re using devices they prefer and helped choose?
Rau: That’s an extremely relevant question. I did not show any data on the effect of patient preference on ad- herence, and perhaps I missed some things in my literature search, but I didn’t see a lot of data on that. I think we tend to forget about patient pref- erence, particularly in the American clinical setting. We instead look at the disease. What device/drug combina- tion is available to treat that disease? And then we make the choice from that “Chinese menu,” to use Dick Ah- rens’ analogy. We never asked the pa- tient if they liked the device, though we don’t always have much choice about the device, particularly now. But I suspect that has something to do with it.
Nikander:*
to the parents.1
REFERENCE
1. Nikander K, Arheden L, Denyer J, Cobos N. Parents’ adherence with nebulizer treat- ment of their children when using an adap- tive aerosol delivery (AAD) system. J Aero- sol Med 2003;16(3):273–281.
* Kurt Nikander, Respironics, Cedar Grove, New Jersey.
Pierson:†
1.
REFERENCE
Nides MA, Tashkin DP, Simmons MS, Wise RA, Li VC, Rand CS. Improving in- haler adherence in a clinical trial through the use of the nebulizer chronolog. Chest 1993;104(2):501–507.
I want to make a com- ment as someone who manages pa- tients with COPD, most of whom are elderly and many of whom have co- morbidities that interfere further with the adherence that you’ve discussed. If I have a patient with severe COPD, according to the current GOLD guide-
† David J Pierson MD FAARC, Division of Pulmonary and Critical Care Medicine, Har- borview Medical Center, University of Wash- ington, Seattle, Washington.
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lines,1 and most of the others, that per- son should be on a short-acting ag- onist for rescue, perhaps a long-acting agonist for control, perhaps a long- acting anticholinergic for control, and perhaps an inhaled corticosteroid. With the current way of the world, with devices being married to drugs in a proprietary fashion, and not every company offering every drug or de- vice, that means that this patient with severe COPD is going to have to be using, daily, a minimum of 3, and per- haps 4, different inhaler systems, all of which operate differently, with dif- ferent instructions. We’ve seen, as yes- terday in the presentation, some ex- amples of how horrendously difficult that can be.
It seems to me that just continuing to work on patient adherence and ed- ucation is not the whole story, and somehow in some future time it’s got to be easier for patients to get the drugs they need to take, according to the best evidence we have, in a more sim- ple way. I think that perhaps would mean fewer different kinds of inhal- ers. That would require a different sys- tem than what we have currently, with each drug being married proprietarily to a patented device that doesn’t ap- ply to the other drugs.
REFERENCE
1. Pauwels RA, Buist AS, Calverley PM, Jen- kins CR, Hurd SS; GOLD Scientific Com- mittee. Global strategy for the diagnosis, management, and prevention of chronic ob- structive pulmonary disease. NHLBI/WHO Global Initiative for Chronic Obstructive Lung Disease (GOLD) Workshop sum- mary. Am J Respir Crit Care Med 2001; 163(5):1256–1276; Respir Care 2001; 46(8):798–825.
Rau: I’m going to get on my “soap box” for a moment. Though I don’t have any quantitative data to support this, I think that an undesirable effect of the numerous new and improved aerosol technologies is that we’ve now got far too many choices of devices and too many differences among the device categories. It’s akin to the early
days of the railroad industry, before they had a standard railway gauge, and a train from one railroad system couldn’t go on the tracks of another railroad system. That didn’t help the traveler who needed to get from New York to Chicago.
It’s a complicated issue, but I think it would be good if, instead of 3 dif- ferent breathing patterns for MDI, neb- ulizer, and DPI, and all the sub-dif- ferences, we had one standard breathing pattern and at least some type of standardization among the aerosol devices, so that patients heard similar instructions for MDI and DPI. Cur- rently, we have to instruct the patient to breathe in totally opposite ways, which is very confusing.
Pierson: Or at least if they were using 2 different forms of dry powder drug, they could get both drugs from the same inhaler, or at least the same kind of inhaler that operates the same way.
Leach: In the early 1990s the Food and Drug Administration asked us for a dose-response study on QVAR. We decided that the only way to do it was to have patients come in 5 days a week for observation and training. And, as cited in the Busse et al study,1 we found a very significant dose-response relationship. Our assumption was that in past studies no one had forced pa- tients to be that compliant. With some new drugs that are not quite as safe but are very effective, we have to find ways to make sure people are compli- ant in the clinical trials.
REFERENCE
1. Busse WW, Brazinsky S, Jacobson K, Stricker W, Schmitt K, Vanden Burgt J, et al. Efficacy response of inhaled beclometha- sone dipropionate in asthma is proportional to dose and is improved by formulation with a new propellant. J Allergy Clin Im- munol 1999;104(6):1215–1222.
Smaldone: I was amazed that the study by Rand et al1 showed that pa- tient diaries were not as accurate as
the counters. Patients often bring me their diaries, particularly when they take oral prednisone, and tell me I took it here, I took it there. There’s no rea- son, a priori, for me to believe or to disbelieve them. Maybe it’s because they are bringing me their data rather than me saying to keep a diary. In that study did they ask patients to keep a diary? Maybe it was onerous for some patients and they faked it. I’m curious what they said about why diaries were so unreliable?
REFERENCE
1. Rand CS, Wise RA, Nides M, Simmons MS, Bleecker ER, Kusek JW, et al. Me- tered-dose inhaler adherence in a clinical trial. Am Rev Respir Dis 1992;146(6): 1559–1564.
Rau: They did speculate on that. They speculated that—and I think this is a big factor—patients want to please their physicians, so if they didn’t take their 4 puffs or whatever they’re still going to put a few hatch marks in the diary, because that’s what you asked them to do. But it can also go the other way. The other reason may be they don’t like you at all; you’ve got lousy patient/physician communica- tion, so they’re just going to lie to you. They say, “I don’t care what he thinks, I will just say I used it and thenIwilldoitthewayIwanttoand see what happens.” Those were the speculations. I don’t think anybody knows.
There was a survey, con- ducted by Chapman, that examined pa- tients’ preferences for the Diskus ver- sus the Turbuhaler.1 Patients reported they preferred the Diskus over the Tur- buhaler, because with the Diskus they could taste the drug and therefore felt that they were getting their treatment. With Turbuhaler they didn’t taste the drug and therefore didn’t feel like they were actually being treated. Of course, the fact that they were tasting it meant that a lot was depositing in the mouth
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DETERMINANTS OF PATIENT ADHERENCE TO AN AEROSOL REGIMEN
Laube:
and not reaching the lungs. I don’t know if that preference translated into the patients using their device more correctly or more often.
REFERENCE
1. Chapman KR. Effect of inhaled route of administration on compliance in asthma. Eur Respir Rev 1998;8:275–279.
Rau: Apter and colleagues1 studied patients’ knowledge and beliefs about the effectiveness of the drug, and that certainly links to whether they think they are getting the medication or not. If they don’t think they are—and this has happened with the Proventil HFA inhaler, because of its softer, gentler aerosol plume—then patients worry that they’re not getting the medica-
tion. Who knows what that might lead to?
REFERENCE
1. Apter AJ, Reisine ST, Affleck G, Barrows E, ZuWallack RL. Adherence with twice- daily dosing of inhaled steroids: socioeco- nomic and health-belief differences. Am J Respir Crit Care Med 1998;157(6 Pt 1):
