adherence to treament: how can it be improved ? fernán caballero fonseca caracas, venezuela...
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Adherence to Treament: How can it be improved ?
Fernán Caballero FonsecaCaracas, Venezuela
December 2011
• Adherence• Technique • Misdiagnosis• Location of inflammation• Lack of eosinophilic inflammation• Genetics
Potential reasons for not achieving control in asthma patients
Definitions of adherence / compliance
EffectiveEffectiveTherapiesTherapies
PatientPatientAdherenceAdherence
EffectiveEffectiveDiseaseDiseaseManagementManagement
• The extent to which the patient's actual practice corresponds to the prescribed regimen • For ambulatory patients ... the link between
medical process and treatment outcome
Urquhart. Eur Heart J. 1996;17:8
Months of Therapy
Vanelli MR et al. Moving beyond market share. In: In Vivo: The Business and Medicine Report. 2002:1-6.
Pat
ien
ts C
on
tin
uin
g T
her
apy
(%)
Patient persistence on medication in chronic diseases
CCB = calcium channel blocker; SERM = selective estrogen receptor modulator; SSRI = selective serotonin reuptake inhibitor.
Across classes, 20% - 35% loss in patient base after fill of initial prescription
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1 2 3 4 5 6 7 8 9 10 11
Multiple Sclerosis(Biologic)
High Cholesterol(Statin)
Hypertension(CCB)
Osteoporosis(SERM)
Depression(SSRI)
Asthma (InhaledSteroid)
Most adherence is thoughtful
Missed Work/SchoolLoss of sleep
Chronic SymptomsImpaired QOL
Uncertainty/FearAttacks
Having to take RxSide effects
CostInconvenienceAppointments
CommunicationAccess
Burden of Illness vs Burden of Therapy
Adherence and outcomes
• Adherence/persistence rates range from 5-50%1
• Use patterns tend to be sporadic2
• Non-adherence likely accounts for ~60%of hospitalizations3
1Luskin AT Bukstein DA. Ann Allergy 1999, 2001 2Bender B JACI 20033Williams LK JACI 2004;114:1288-1293
Types of nonadherence to medication
•Not filling prescriptions
• Not following directions
• Premature discontinuation
• Keeping the clinic visit schedule
• Contacting the clinic as directed
• Bringing medicines, diaries, or biological samples to clinic appointments
• Completing diaries
• Maintaining a diet, allergen avoidance, exercise program, or other aspects of the clinical regimen
Adherence also pertains to
Patient-related barriers
• Patient/family demonstrate psychological problems
• Patient doesn’t understand the treatment
• Condition is either mild or severe
• Patient has insufficient faith in physician or treatment
• Patient just isn’t motivated
Depression
Nonadherence Unhealthy Behavior
Bender BG AAAAI 2010
Depression is a risk factor for nonadherence
Depressed patients are 3 times more likely to be nonadherent with medical treatment recommendations than nondepressed patients.
DiMatteo MR. Arch Intern Med. 2000;160:2101-2107.
Anxiety and depression in adolescents with asthma
Is associated with
1. Increased risk of smoking
2. Decreased use of controller medication
Adolescents who smoked were 2.58 times more likely to demonstrate evidence of depression or anxiety
Bush T. J Adolescent Health 2007;40:425
0 10 20 30 40 50 60 70 80 90 100
I want immediate relief
I am confident to intervene early
I use my medication as and when necessary
I manage my asthma myself
I prefer to adjust ICS to changes of my asthma
Concern side effects of higher doses
Concern too much medication when well
Fear of having a serious asthma attack
No need to take my asthma medications every day
Prefer to take high dose of [ICS/combination]
Agree strongly Agree somewhat(n=3,415)
Patients attitudes towards asthma management
Patients (%)
Proportion of patients that agree with each statement
Partridge MR et al. BMC Pulmonary Medicine 2006:6:13
Treatment-related barriers
• Treatment is prolonged and/or prophylactic
• Consequences of therapy are delayed
• Medication is associated with adverse side effects
• Medication is expensive
• Therapeutic regimen is complex and difficult to administer ( multiples devices etc.)
Adherence to inhaled asthma therapy decreases over time
• Adults with moderate-to-severe asthma (N=50)• Treated with ICS twice daily• Actuation of inhaler monitored electronically
Apter AJ, et al. Am J Respir Crit Care Med. 1998;157:1810-1817.
Ad
her
ence
(%
)
Week of Study
50
55
60
65
70
75
0 1 2 3 4 5 6
Inhalation technique: At least one critical error
40
35
0
30252015
10
5
%
Molinard M., J Aerosol Med 2003;16:249-254
Aeroliz. Autohaler Diskus pMDI Turbuhaler
Below 30 years
From 31 to 64 years65 years and over
Caballero F, Sánchez-Borges M, J Allergy Clin Immunol 2002; 109:S 242
Number (%) of patients performing the different inhalations maneuvers correctly
MDI TH CI
Remove the cap 73 (100) NA NA
Shake the inhaler 47 (64.3) NA NA
Keeping the inhaler upright 64 (87.7) NA NA
Exhale to residual volumen 30 (41.1) 16 (57.1) 11 (57.8)
Keeping head upright 71 (97.3) NA NA
Place mouthpiece correctely 65 (89.0) 26 (92.9) 18 (94.7)
Inhaling slowly presing the inhaler 39 (53.4) NA NA
Deep and powerful inspiration 50 (68.5) 25 (89.3) 18 (94.7)
Breath holding for 5 sec. 47 (64.4) 22 (78.6) 14 (73.7)
Exhale away from mouthpiece 55 (75.3) NA NA IDM: Inhalador de dosis medida; TH: Turbohaler(R); CI: Aerolizer (R)
Improved adherence through monitoring and feedback
• Nides Chest. 1993;104:501
• Yeung Respir Med. 1994;88:31
• Matsuymara Ann Pharmacother. 1993;27:851
• Onyirimba Ann Allergy. 2003;90:411
Weinstein. Ann Allergy Asthma Immunol, 2005;94:251
An adherence intervention
• standard asthma care•monitoring by MDI Chronologs• direct clinician-to-patient feedback for treatment group
Week of study
1 2 3 4 5 6 7 8 9 10
Mea
n D
aily
Adh
eren
ce
20
30
40
50
60
70
80
90
Treatment Control
Onyirimba. Ann Allergy Clin Immunol 2003;90:411
• Establish a therapeutic goal with the patient
• Assess progress
• Maintain a positive relationship
• Provide positive feedback
• Avoid criticism
Improving adherence
Listen to the patient
Doctors interrupt the patient in less than 18 seconds after he starts to talk
Beckman HB and Frankel RM Ann Intern Med 1984
Improving adherence
• Simplify therapeutic regimen
• Allow flexible dosing
• Provide adequate information
• Minimize painful tests
• Maintain frequent contact
• Issue appointment reminders
Patient education
Patient education and self-management. Thorax 2003;58(Suppl I):i1
• Every office visit is an opportunity to reinforce self-management skills
• Use hospital admission to review self-management skills
• No patient should leave hospital without a written asthma action plan
• At routine visits review self-management in case asthma deteriorates
• Brief simple education linked to patient goals is most likely to be acceptable to patients
Components of an asthma management plan
• Triggers• Personal best peak flow• Routine medications• Signs and symptoms of worsening
asthma• Medications required for emergencies
and how to monitor response to them• Emergency contacts
Knowledge self-efficacy, effective self-treatment andself-management in asthma patients
Van Der Palen J, et al. (1997) Patient Education and Counseling, 32:S35-S41
Effects of a self-management educational program for the control of childhood asthma.
• Objetive:Evaluation of the effect of a self-management educational program in 29 children 6 to 14 y/o and their parents
• Randomized, prospective and single blind.• Results : The experimenltal group experienced a
estadistical significant effect on children´s asthma knowledge ( P < 0.001), self-management abilities
( P < 0.0001) and in parents knowlege ( P < 0.008)• A significant impact on the Morbility Index of the
study group at post-test ( P < 0.05) • Younger children benefited more than older ones ( P < 0.009)
MA Gabriela Pérez, Lya Felman, Fernán CaballeroPatient Education & Counseling, 36 (‘99) 47-55
Effect of self-management on hospitalization for asthma
Action plan + self-managemant
Cote J et al AJRCCM, 1997;155: 1509-14
Crowie L. et al Chest 1997; 112:1134-8
Ignacio-García JM et al AJRCCM 1995;151:353-9 Lahdensuo A et al
BMJ 1990;312:748-52 Yoon R et al
Thorax 1993;48: 1110-6Zeiger RS et al
JACI 1991;87:1160-8 Total
0.1 0.2 1 5 10Prefer Treatment Prefer control
Relative risk(IC 95 % Fijo)
Gibson PG J Allergy Clin Immunol 2000; 106:17-26
• Doctor-patient communication
• Parent/child education about therapies and disease management
• Identifying relevant patient goals for therapy and directly linking them to adherence
• Tailoring of therapies and management regimens to match patients’ preferences, lifestyles and abilities
Pediatric adherence is enhanced through the effective use of:
Weinstein AG. Ann Allergy Asthma Immunol 2011; 106; (4): 283-291
The potencial of asthma adherence management to enhance asthma guidelines
Final coments :
• It is easier to change patient therapy than to change patient behavior
• Patient reports of non-adherence are virtually always accurate, while patient report of good adherence are frequently exaggerated
• Non-adherence with therapy has different causes: adherence promotion strategies should be tailored to the cause
Henry Milgrom and Fernan Caballero
VENEZUELA
Golfo de Cariaco Edo Sucre - Youenn Jacquin
Isla Blanquilla - Youenn Jacquin
Isla Las Aves - Youenn Jacquin
Plaza Venezuela - Orlando Acosta
Los Nevados Edo Merida - Youenn Jacquin