Increasing Compliance with Asthma Treatments
with Asthma Treatments
Partner With Your Patients
For most patients with asthma, the disease is something they’d like to ignore. Unfortunately, that’s what some of them do. They forget to take their prescribed medications or to stay away from allergic triggers. They take too little medication or take it incorrectly. They don’t understand health care recommendations. And so on.
Lack of compliance with recommended therapies is a long recognized phenomenon, and numerous studies have reported non-compliance across a broad spectrum of chronic diseases. This article focuses on compliance with treatment regimens for asthma, a disorder in which non-compliance causes poor control of symptoms and may even result in death. Two excellent reviews of the subject were published recently.1,2
Non-compliance goes beyond under-use of medication. Some patients take too much medication, take it irregularly or with inhaled drugs, or use incorrect inhalation technique. An overlooked kind of non-compliance is called “intelligent noncompliance,” in which the patient deliberately does not take the medication, in some cases wisely because of lack of efficacy or severe adverse effects.
Factors that may predispose a patient to non-compliance with asthma therapy include: a disease state of long duration; episodic symptoms, perhaps with asymptomatic periods; complex medication programs that are expensive; required symptom monitoring by diary or peak flow meter; required injections (allergy shots); a need for environmental control measures in the home; and frequent office visits.
Surprisingly, the severity of disease appears to have no effect on compliance behavior, and more severely affected patients are no more compliant than less symptomatic ones. In fact, sicker patients may be that way because they are not adhering to their medication regimens.
Studies of noncompliance with treatments for chronic diseases suggest that 10 percent to 90 percent of patients don’t follow their providers’ advice, with only 50 percent to 60 percent of patients taking more than 80 percent of the prescribed treatment over the entire treatment period. These trends are similar to those observed in asthma care.3
Several issues have made the true prevalence of non-compliance with asthma treatment (and other diseases) difficult to determine. The most non-compliant patients are unlikely to volunteer to participate in a study of compliance. Factors such as gender, geographic location, educational level, ethnic background, marital status and religion do not appear to predispose to non-compliance, most studies show. Patients older than 50 are more compliant than younger ones, but patients older than 65 may have a significant degree of non-compliance because of limited reading ability, memory problems and difficulty understanding basic health information.
In regard to ethnic background, cultural integration or acculturation appears to be a factor in compliance. Families with a high degree of acculturation are more likely to be compliant than those who retain unicultural lifestyles. The psychological makeup of a family can influence compliance. Members of families with high levels of conflict and behavior disturbances are more likely to be non-compliant than patients in more peaceful households. A number of psychiatric disorders, depression in particular, have been linked to non-compliance. A series of studies using the Minnesota Multiphasic Personality Inventory (MMPI) to measure the personalities of patients showed a positive correlation between certain behavioral characteristics and medication use.4 The researchers found that patients who scored high on a panic-fear scale were overusers of medication, while those who scored low were under-users.
Socioeconomic factors also appear to affect compliance. Higher priorities, such as finding decent housing, food and clothing, tend to supersede efforts to buy medication and implement environmental controls. Lack of transportation and continuity of medical care also contribute to non-compliance among the indigent.
It seems logical that knowledge about asthma would enhance compliance, but education alone does not. Educational efforts focusing on specific problems appear to improve compliance behavior, however. For example, many patients do not understand the difference between reliever and preventer medications, what to use when, and the importance of prophylactic dosing. Worries about the adverse effects of chronic therapy, and, for parents, the idea that a child will become immune to medication or be harmed by steroids, all lead to non-compliant behavior. Because of concern about the adverse effects associated with steroid therapy, caregivers expect compliance with these agents to be significantly worse than compliance with bronchodilators. This is not typically the case, however, and compliance is a patient-dependent rather than drug-dependent issue.
While compliance generally refers to pharmacologic therapy, proper control of asthma includes avoiding factors that cause symptoms. Allergy to dust mites is a major cause of allergic asthma, and most studies show that avoidance measures in the home are effective. Unfortunately, implementation of these measures requires the expenditure of money. Removal of carpets (dust mites live in carpets) is a problem for renters, and cockroach control is difficult in inner cities, as is control of exposure to cigarette smoke.
Assessment of Compliance
The simplest way to assess compliance is to ask about it. This method is unreliable, however, with responses almost always overstated. In several studies, patients overestimated their medication use 50 percent to 90 percent of the time. More striking is the finding that patients’ medication diaries and verbal reporting were erroneous even when the patients knew that their compliance was being monitored by electronic means.5,6 The fact is that patients lie to please their health care providers, or for other reasons. Since patient record-keeping is an integral part of drug clinical trial protocols, non-compliance in this setting is particularly worrisome. For example, if patients in a clinical trial were to underreport adverse reactions to a drug, the results could be disastrous when the drug was marketed.
Biochemical methods have been used to measure compliance. Medications such as theophylline or its metabolites have been measured in blood and urine with or without patients’ knowledge. This methodology is limited, since it provides information only of recent drug intake prior to sample collection. In clinical trials, “pill” counting (the number remaining in the container at a scheduled visit after a given interval) or weighing a metered-dose inhaler (MDI) canister are commonly used to check compliance. But these strategies offer no assurance that the pills were actually taken or the aerosol actually inhaled.
Patients who mislead their health care providers are difficult to detect. Several studies have shown physicians to be poor at identifying non-compliant patients. A substantial improvement in compliance monitoring was the introduction of electronic monitoring devices for MDIs and pill containers. For example, the Nebulizer Chronolog is a device with a computer chip that electronically records the date and time the metered dose inhaler is actuated. The canister containing the drug is placed directly into the Nebulizer Chronolog and can be used with all types of canisters. Similarly, the pill container “chip” does the same thing when a pill is removed from the container. If used properly, these devices provide valuable and reliable data. Unfortunately, there is still no assurance that the patient actually received the dose. Research has identified cases in which the Nebulizer Chronolog has been actuated multiple times shortly before a follow-up visit–in one instance, 145 times in 5 minutes. In another clinical trial, 14 percent of subjects actuated their inhalers more than 100 times in the 3 hours immediately before a follow-up visit.7
An excellent way to assess drug compliance is to review pharmacy records to determine whether prescriptions are being filled initially and then refilled at an appropriate interval. Pharmacy record review also alerts you to patients who are overusing medication, especially bronchodilator aerosols, which can be dangerous.
Why Are Patients Non-Compliant?
Patients are noncompliant for many reasons. Sometimes patients simply forget to take a dose, but if it occurs frequently, it may represent denial of the disease.
Other reasons include not understanding the provider’s instructions, poor memory (especially in the elderly), inconvenience, embarrassment about using an MDI in public, lack of faith in the medication, failure to see substantial improvements in a few days (common with steroid inhalers), undesirable adverse effects, the cost of medication, and differing cultural opinions about medication use. Also, lack of money to institute environmental control is a serious problem.
How Can Compliance be Improved?
Since research shows that clinicians aren’t very good at recognizing non-compliant patients, we should assume that all patients might have the tendency to not follow their caregivers’ recommendations.
Because research shows that patients forget half of what they are told within 5 minutes of the end of a consultation, review every patient’s medication schedule and other instructions (MDI and peak flow meter) at each subsequent visit. Patients who have trouble using an MDI correctly should use a spacer. Emphasize the importance of taking the prescribed medication on a regular basis, not just when symptoms occur.
Patients with moderate to severe asthma are frequently treated with too many medications. Continuously review the medication regimen with the goal of simplifying it. For example, a patient receiving optimal treatment with an inhaled steroid is unlikely to receive additional benefit from cromolyn, and it should be discontinued. Since adverse drug effects can cause non-compliance, alert the patient to their possibility beforehand. Have the patient repeat the instructions to you to make sure he comprehends them. While education alone does not assure compliance, the more patients understand, the more likely they are to be compliant.
Most studies show that the frequency of dosing appears to be an important factor in compliance. Drug dosing schedules that require no more than twice-a-day dosing can favorably influence compliance and, with a few exceptions, the key asthma drugs are effective when taken every 12 hours. Strategies such as combining two medications in one inhaler have been tried. In one study, an inhaled corticosteroid-bronchodilator combination was compared to the same two drugs given in separate inhalers.9 Compliance with the combination averaged 60 percent to 70 percent, and only 15 percent of patients took the drugs as prescribed for more than 80 percent of the days. Compliance with the bronchodilator medication was no greater than that with the steroid.
For patients who are simply forgetful, linking dosing to some other regularly scheduled event, such as eating a meal with the medication at the table, is helpful. A wristwatch with an alarm can also be effective. Of greatest importance in improving compliance is the establishment of a good patient-provider partnership in which the responsibility for asthma management is shared.10
1. Rand CS, Wise RA, Mellins RB, Malveaux FJ. The role of the patient in fatal asthma. In: Sheffer AL, ed. Fatal Asthma. Lung Biology in Health and Disease. New York: Marcel Dekker; 1998: 429-456.
2. Mawhinney H, Spector SL. Compliance. In: Barnes PJ, Grunstein MM, Leff AR, Woolcock AJ, eds. Asthma. Philadelphia: Lippincott-Raven Publishers; 1997:2099-2113.
3. Sackett, DL, Snow JC. The magnitude of compliance and noncompliance. In: Haynes RB, Taylor DW, Sackett, DL, eds. Compliance in Health Care. Baltimore: John Hopkins University Press; 1979.
4. Kinsman RA, Dirks JF, Dahlem N. Noncompliance to prescribed as needed (PRN) medication use in asthma: usage pattern and patient characteristics. J Psychosomatic Research. 1998;24:97-107.
5. Jonasson G, Carlson KH, Sodal A, Mowinchkel P. Patient compliance in a clinical trial with inhaled budesonide in children with mild asthma. European Respiratory Journal. 1999;14:150-154.
6. Coutts JAP, Gibson NA, Paton JY. Measuring compliance with inhaled medication in asthma. Archives of Diseases in Childhood. 1992;76:332-334.
7. Rand CS, Wise RA, Nides M, et al. Metered dose inhaler adherence in a clinical trial. Am Rev Respir Dis. 1992;146:1559-1564.
8. Guidelines for the Diagnosis and Management of Asthma. Expert Panel Report 2. NIH Publication No. 97-405, April 1997.
9. Bosley CM, Parry DT, Cochrane GM. Patient compliance with inhaled medication: does combining beta-agonists with corticosteroids improve compliance? Eur Respir J. 1994;7:504-509.
10. Mellins RB, Evans D, Zimmerman B, Clark NM. Patient compliance: are we wasting our time and don’t know it? Am Rev Respir Dis. 1992;146:1365-1377.
Kathleen Conboy-Ellis, a pediatric nurse practitioner, is an asthma educator and consultant based in St. Petersburg, Fla.