Improving adherence in asthma
Poor adherence in asthma is strongly linked to poor outcomes. As healthcare professionals we need to work in partnership with patients to understand their individual needs and motivation in order to improve adherence
Last month’s Advanced Practice discussed the elements of an asthma review that are essential for keeping patients safe, including an assessment of the patient’s adherence to treatment and advice.1 This is important because good asthma control is strongly related to adherence to prescribed medication.2 The National Review of Asthma Deaths (NRAD), found that many of those who died were taking inadequate amounts of inhaled corticosteroids (ICS) and overusing short-acting bronchodilators (SABAs).3 Despite the availability of national and international guidelines on asthma management,4,5 and a multitude of options for inhaled therapies which should mean that most people can manage their asthma effectively, there is still a recognised gap between the theory and practice of effective asthma care.6
WHAT DO WE MEAN BY ADHERENCE?
The World Health Organization (WHO) has described adherence as the extent to which an individual takes medication (or makes lifestyle changes) in line with the agreed recommendations from the clinician.7
There are several recognised factors that may affect someone’s ability to adhere to recommended medication regimes, and these may be broadly described as ‘intentional non-adherence’ or ‘unintentional non-adherence’. WHO lists several categories of non-adherence that should be considered.8
Socioeconomic factors
Adverse social conditions, such as poor housing or homelessness, poverty, or social or psychological stress, can lead to both intentional and unintentional non-adherence.
Asthma patients are not exempt from prescription charges and this has been found to result in intentional non-compliance: more on this later.
Factors associated with the health care team and system
Some individuals have problems accessing care for a variety of reasons. How flexible is your practice about clinic hours/ appointments, for example? Some people may find it impossible to get time off work to attend for an asthma review if this is only offered during their working hours. See Activity 1.
As healthcare professionals (HCPs) we would like to be liked by everyone. This is not possible, however ‘nice’, accommodating and accessible we try to be. Some patients may avoid contact for personal reasons, and some will perceive all HCPs as ‘authority figures’ and will avoid contact or reject advice.
Disease-related factors
If the person with asthma does not believe that it could ever be a serious problem (‘Nobody ever died of asthma!’) then they will be unlikely to take their asthma seriously and take treatment as prescribed.
Therapy-related factors
If an individual believes that the treatment they have been prescribed is harmful or dangerous then they will probably be unwilling to take it: this is intentional non-compliance. If the medication regimen is complicated – e.g. four times daily – then they will be more likely to forget it: this is unintentional non-adherence.
Asthma medication is usually delivered by the inhaled route and therein lies a significant problem. Although there are many different types of inhaler available, failure to use an inhaler correctly is very common,9 and will result in inadequate therapy: this is also unintentional non-adherence.
Patient-related factors
Inability to use an inhaler – for example, because of dexterity problems, or forgetfulness due to memory difficulties, may be a particular problem in older people and will result in unintentional non-adherence.
WHY IS ADHERENCE IMPORTANT?
Research has shown that better adherence to prescribed therapies is associated with improved asthma control and a reduction in exacerbations and mortality.2,10 In the NRAD report, people who died following an asthma attack were often noted to have been using no, or suboptimal amounts of, ICS while overusing their SABA therapy.3 Current guidelines suggest that SABAs should be needed no more than two to three times per week,4,5 but some of the patients in the NRAD report were using hundreds of doses per month.
Knowing how many doses of medication are in the inhaler, along with the prescribed dosing regimen, can help you to ascertain whether someone is overusing their SABA or underusing their ICS inhaler, although this is not foolproof. A patient who regularly orders repeat prescriptions of their ICS may still not be using it regularly and may have a cupboard full of unused inhalers at home. However, it is possible to highlight potential problems by searching the practice record for:
- Patients who have been prescribed six or more SABA inhalers in the previous 12 months
- Patients who have collected less than 75% of their prescribed ICS inhalers.
Such individuals are potentially at risk, and should be offered an early review. Consideration could also be given to removing the repeat prescription for their SABA until such time as they are seen.
NRAD also reported that about one-in-five (22%) of patients who died had missed an asthma review appointment in the 12 months before their death.3 The findings of the NRAD report,3 and the Asthma UK survey,6 indicate that HCPs need to consider improved ways to encourage people to attend their asthma reviews, by making them more meaningful, patient-focused experiences which take into account the range of reasons why people may be more likely not to attend, why they might be less motivated to self-manage and how shared decision-making might encourage people to engage more actively with healthcare providers to improve their own asthma-related health.10,11 See Activity 2.
IMPROVING ADHERENCE
Patient’s understanding
There is a link between how well an individual understands what drives their asthma symptoms (i.e. uncontrolled inflammation) and adherence.12,13 Patient education, as part of the diagnostic process and ongoing review is, therefore, essential. Based on the findings from these studies and others, taking time to explain the inflammatory nature of asthma and how inhaled steroids will help to control this inflammation and therefore reduce symptoms is a key component in improving adherence.
Once the person with asthma (or their carer) understands the inflammatory nature of the condition, the role of ICS should be clearer – not just as a means of getting the condition under control but also as a way of maintaining control. Thus, the rationale for continuing to use ICS therapy even when well and symptom-free can be stressed. Linked into this will be greater clarity as to why SABA use should be minimal and why increased or overuse of SABA can be viewed as a warning sign, for both the patient and the HCP, of the need for an early review and a potential change in therapy.3
Ability to use inhaled therapies
Unintentional non-adherence can happen because a person with asthma is unable to use their inhalers correctly. This may be in terms of how often they use them, how they prime the device and how they inhale.
The incorrect use of inhalers may be an ingrained behaviour established through years of poor technique and missed opportunities for checking correct technique during the routine review. This was highlighted as a problem in the NRAD report.3 It was found that less than half of the people reviewed in primary care had had their inhaler technique checked in the year before they died. Secondary care did a little better but was also not exempt from these failings. 17% of people admitted to hospital had no documented evidence that their inhaler technique had been checked during their admission. The importance of investing time into assessing inhaler technique, and correcting it where necessary, cannot be overstated.
There is also evidence that many HCPs are unable to use an inhaler correctly,14 so it is not surprising that many patients cannot either. It is absolutely essential that any HCP responsible for teaching and checking a patient’s technique is able to correctly use and demonstrate the inhaler themselves. There are a number of useful resources for HCPs and patients. (See Resources section at the end of this article and Activity 3).
Patient preference
Patient choice is also important for improving adherence to treatment. They should be helped to choose the inhaler which suits them best and which they are able to use. Using patient preference to guide inhaler choice can improve adherence,15,16 and over-rigid adherence to local prescribing guidelines may be a deterrent. For example, prescribing a large volume spacer and MDI for ICS is recommended good practice to reduce the potential for local side effects and improve lung deposition of ICS. It is also cost effective. However, it may not be acceptable to an adult patient who perceives it to be ‘just for the kids’ unless the rationale for its use is explained. Similarly, insisting on a spacer and MDI for a SABA for a school age child to use pre-exercise at school, when his/her friends all have small, portable dry powder inhalers, is a recipe for intentional non-adherence.
Financial concerns
An Asthma UK survey in conjunction with the Royal College of Nursing, the Association of Respiratory Nurse Specialists and Primary Care Respiratory Society UK in 2019 showed that financial concerns were another reason why people did not collect their asthma inhalers regularly, putting themselves at risk of an asthma attack.17
The key findings from the survey of HCPs revealed that 98% think the current medical exemptions list should be reviewed, 57% have had patients who have had an asthma attack or needed emergency care because they had skipped their medication, and 48% reported patients missing an asthma appointment because they were worried about the cost of the medicines they might be prescribed.17 These findings mirror the responses of asthma patients:
- 76% said that they sometimes (or always) struggled to afford their prescriptions
- 57% reported skipping their asthma medication because of the cost of their prescriptions, 82% of whom said that their symptoms got worse as a result.
Health beliefs
Fears about steroids can negatively impact on asthma care.18 ‘Steroids’ have had a bad press and people may not understand that anabolic steroids and the corticosteroids used in asthma are very different substances. Parents may fear the impact of steroids on their child’s growth, without realising that poorly controlled asthma is far more likely to impact on adult height.19 Some children may avoid using or forget to use inhalers until they are unwell, which risks them having an asthma attack, prompting NHS England to remind parents about the importance of regular treatment.20
The key to all of this is to ensure that people have the time and space to discuss their concerns in a non-judgemental setting so that any false beliefs can be corrected.21
MOTIVATION
Although some people with asthma will be very motivated to look after their health and avoid asthma symptoms, others may find it harder to be motivated, and there are a multitude of sometimes complex reasons for this.
People who may be less motivated might be identified through the presence of:
- A history of poor motivation and adherence
- Adverse socio-economic factors, such as low income or a poor support network
- A history of poor attendance or difficult consultations where trust might be lacking.7
Understanding some of the reasons for poor engagement may help both you and the patient move towards an improved understanding of how best to work together. One method, used in motivational interviewing, is to ask the person with asthma to score, from 0-10, how important it is to them to achieve good asthma control and how confident they are that they can achieve this.21 This can provide a strong foundation on which to base further discussions. See Activity 4.
SHARED DECISION-MAKING
Shared decision-making in asthma management is the natural next step to achieving a joint view as to how best to manage an individual’s asthma. The first stage of shared decision-making is to hear the individual’s ideas, concerns and expectations of their asthma and asthma treatment; this is known as the ICE consultation model.22
NICE guidance on shared decision making states that this should be a collaborative process between the HCP and the service user which enables that individual to reach a decision about any tests or treatment options, based on both clinical evidence and the individual’s personal preferences, health beliefs, and values.11 NICE states that the options discussed should include the potential risks, benefits and consequences of different treatment options, along with consideration of the pros and cons of doing nothing.11
Some people, however, will prefer to have a more passive approach to healthcare, taking the view that the clinician knows best, and NICE recognises this. However, NICE also states that everyone should be given the opportunity to choose the level of involvement that suits them and that this can only be known through a two-way conversation where the patient’s views are listened to and respected.11
SUMMARY
Non-adherence in asthma, and other conditions, is a complex issue with many causes. In asthma, non-adherence is associated with poor outcomes. It is therefore important, if we are to have an impact in reducing the unacceptable levels of asthma morbidity and mortality that still exist, that we make every effort to discover and address the reasons why an individual is not adhering to their treatment. To achieve this we will need to ensure that care is accessible and acceptable and will need to put the patient’s agenda at the forefront of our consultations.
REFERENCES
1. Levy M. Asthma reviews: a new look. Practice Nurse 2020;50(1):30–36
2. Makela MJ, Backer V, Hedeaard M, Larsson K. Adherence to inhaled therapies, health outcomes and costs in patients with asthma and COPD. Respir Med 2013;107(10:1481-90
3. Royal College of Physicians. Why asthma still kills: The National Review of Asthma Deaths (NRAD); 2014 https://www.rcplondon.ac.uk/projects/national-review-asthma-deaths
4. Scottish Intercollegiate Guideline Network (SIGN)/British Thoracic society (BTS). British guideline on the management of asthma 2019 https://www.sign.ac.uk/sign-158-british-guideline-on-the-management-of-asthma.html.
5. Global Initiative for Asthma (GINA). Global Strategy for Asthma Management and Prevention; 2019. http://www.ginasthma.org.
6. Asthma UK. The reality of asthma care in the UK; 2019 https://www.asthma.org.uk/578f5bcf/globalassets/get-involved/external-affairs-campaigns/publications/annual-asthma-care-survey/annual-asthma-survey-2018/asthmauk-annual-asthma-survey-2018-v7.pdf
7. World Health Organization. Adherence;2003 https://www.who.int/chp/knowledge/publications/adherence_Section1.pdf
8. Sabate E (ed). Adherence to long-term therapies: evidence for action. World Health Organization, Geneva; 2003 https://www.who.int/chp/knowledge/publications/adherence_report/en/
9. Sanchis J, Gich I, Pedersen S. Systematic review of errors in inhaler use: has patient technique improved over time? Chest 2016;150(2):394-406.
10. Simpson SH, Eurich DT, Majumdar SR, et al. A meta-analysis of the association between adherence to drug therapy and mortality. BMJ 2006;333(7557):15. doi:10.1136/bmj.38875.675486.55
11. NICE. Shared Decision Making. Key Therapeutic Topic (KTT) 23; 2019 https://www.nice.org.uk/advice/ktt23/chapter/Evidence-context
12. Schaffer SD, Tian L. Promoting adherence: effects of theory-based asthma education Clin Nurs Res 2004;13(1):69-89.
13. Al-Muhsen S, Horanieh N, Dulgom S, et al. Poor asthma education and medication compliance are associated with increased emergency department visits by asthmatic children. Ann Thorac Med 2015;10(2):123–131. doi:10.4103/1817-1737.150735
14. Plaza V, Giner J, Rodrigo GJ, et al. Errors in the use of inhalers by health care professionals: a systematic review. J Allergy Clin Immunol Pract 2018;6(3):987-95.
15. George M, Bender B. New insights to improve treatment adherence in asthma and COPD. Patient Prefer Adher 2019;13: 1325–1334. doi:10.2147/PPA.S209532
16. Plaza V, Giner J, Calle M, et al. Impact of patient satisfaction with his or her inhaler on adherence and asthma control. Allergy Asthma Proc 2018;39(6):437-44.
17. Asthma UK. Stop unfair asthma prescription charges; 2019 https://www.asthma.org.uk/support-us/campaigns/our-policy-work/prescription-charges/
18. Normansell R, Kew KM, Stovold E. Interventions to improve adherence to inhaled steroids for asthma. Cochrane Database Syst Rev 2017; 4:CD012226.
19. Boutopoulou B, Koumpagioti D, Matziou V, et al. Interventions on adherence to treatment in children with severe asthma: a systematic review. Front Pediatr 2018;6:232. doi:10.3389/fped.2018.00232
20. NHS England. NHS warning to parents as ‘asthma season’ hits. 2019 https://www.england.nhs.uk/2019/09/nhs-warning-to-parents-as-asthma-season-hits/
21. Tsay AJ. The Internet, ethics, and false beliefs in health care. Am Med Assoc J Ethics 2018;20(11):E1003-1006.
22. Matthys J, Elwyn G, Van Nuland M, et al. Patients' ideas, concerns, and expectations (ICE) in general practice: impact on prescribing. Br J Gen Pract 2009;59(558):29–36. doi:10.3399/bjgp09X394833
