a SLACK Incorporated newspaper

Patient noncompliance can limit effectiveness of asthma treatment

The factors most frequently associated with compliance in asthma treatment are those related to the medication regimen.

[Patient education] [Treatment options]
[Factors for noncompliance] [Drug delivery]

[Your turn]

February 1998

SAN DIEGO - A major contributing factor of poor outcomes in the treatment of asthma is patient noncompliance.

The recent National Asthma Education and Prevention Program (NAEPP) Report of the Second Expert Panel on the Guidelines for the Diagnosis and Management of Asthma places a heavy emphasis on teaching asthma self-management and prevention to patients.

Goals for the asthma patient should include preventing chronic and troublesome symptoms, maintaining near normal pulmonary functions, maintaining normal activity levels, preventing recurrent exacerbations, optimizing pharmacotherapy with minimal adverse events and meeting expectations and satisfaction with medical care.

Patient education

"The patient will require education and skills to know what the expected outcomes are and what to do when there is a deviation from what's expected," said Allan Luskin, MD, associate professor of medicine and immunology/microbiology at Rush Medical Center in Chicago and director, Respiratory Institute at Dean Medical Center in Madison, Wis.

"Education includes what medications to take, when to contact the physician, how to monitor asthma and how to follow-up. An educated patient will know the goals and be able to monitor the clinical status, control the environment, take the medication and take action if the outcomes are less than optimal," he said.

"Most caregivers are surprised to know that the majority of noncompliance is intentional. Just as caregivers do a value assessment, measuring outcomes and cost to choose optimal therapy, patients do their own cost-benefit analysis to determine what, if any, therapy they should take," said Luskin. "This analysis is based on their own perceptions and their understanding, but is clearly influenced by the relationship with their caregiver."

Ensuring improved outcomes in the treatment of asthma requires an understanding of noncompliance. Patient compliance is affected by communication with the caregiver, access to care, the patient's perception of severity and deviation from expected quality of life.

"If patients view nocturnal awakening, exercise limitation and periodic emergency room visits as normal and expected, then their markedly impaired quality of life is not an impetus to compliance because this is their expected norm," said Luskin. "It is critical that patients appreciate that the goals of therapy for asthma are `normal functioning,' so that deviations from normal imply a significant burden of disease to the patient."

Treatment options

Based on the enhanced understanding of inflammation and its contribution to abnormalities in lung function, the NAEPP report specifies persistent asthma should be controlled with daily anti-inflammatory medications. Medications are categorized into two general classes:

long-term control medications, used to achieve and maintain control of persistent asthma; and
quick-relief medications, used to treat acute symptoms and attacks.

"Preventing asthma flares requires appropriate patient adherence to prophylactic pharmacotherapy and behavioral management strategies," said Cynthia S. Rand, PhD, associate professor, division of pulmonary and critical medicine, Johns Hopkins School of Medicine, Baltimore, Md. "Patients who fail to adhere to therapy are at risk of dangerous asthma exacerbations and present a continuing challenge to heath care providers.

Adherence to inhaled anti-inflammatory medication regimens in asthma is generally poor, where adherence rates of less than 50% are common. Factors which have been consistently associated with adherence rates include psychiatric illness, language barriers and, in children, family variables such as family cohesion and communication, according to Rand.

Factors for noncompliance

Three Types of Noncompliance
Unwitting nonadherers: Patients who misunderstand their prescribed regimen or patients who were never sufficiently educated by their health care provider to adequately adhere.
Unwilling nonadherers: Patients unable to adhere to the prescribed asthma therapy because of economic, physical, environmental or personal barriers to adherence.
Intelligent nonadherers: Patients who make personal choices to alter asthma therapies, often undiscovered by health care providers.

Inappropriate medication compliance is not attributable to the same factors for all patients. Rand describes three types of noncompliance:

Unwitting nonadherers - includes patients who misunderstand their prescribed regimen or patients who were never sufficiently educated by their health care provider to adequately adhere.
Unwilling nonadherers - includes patients unable to adhere to the prescribed asthma therapy because of economic, physical, environmental or personal barriers to adherence. These barriers to adherence may be embarrassing to the patient and will often go undiscovered in routine clinical interviews.
Intelligent nonadherers - includes patients who make personal choices to alter asthma therapies, often undiscovered by health care providers.

"Patients who feel better may decide that they no longer need to take prescribed medications," said Rand. "Fear of side effects or long-term medication use may cause some patients to reduce or discontinue dosing. Patients may abandon a therapy because taste, complexity or interference with daily life may convince them that the disadvantages of therapy outweigh the benefits."

Drug delivery

A major factor influencing compliance is the type of inhaled drug delivery system used for long-term therapy, according to James P. Kemp, MD, clinical professor of pediatrics, division of immunology and allergy at the University of California School of Medicine at Irvine.

"While compliance is generally viewed in terms of factors such as ease of use and convenience, it also must be evaluated in the broader context of drug delivery device capabilities and efficacy in getting the drug to the lungs, as well as dosing regimens and proper inhalation technique," he said.

"Delivering the drug to the lungs with the fewest systemic side effects is a major goal of asthma therapy and an important determinant of compliance. Studies have shown that simplifying the dosing regimen has a considerable impact on adherence," said Kemp.

Rand believes the necessary first step in addressing non-adherence is identifying the problem through effective, open-ended patient-provider communication.

According to Rand, studies which have examined physician prescribing practices and instructions to patients have consistently found that patients are rarely given written instructions, often receive little information about their prescribed regimen, infrequently are queried about medication use problems and almost never have their physician discuss with them the integration of the newly prescribed medications with other existing medication regimens.

"Each patient contact should include written, language-appropriate and reading level-appropriate documentation of the regimen for the patient to take home. Successful, effective medication adherence promotion is a partnership with responsibilities and commitments for both the patient and the physician," said Rand.

For more information:

Luskin AT. The NAEPP newly revised guidelines for diagnosis and management of asthma: what impact on asthma treatment. Presented at the American College of Allergy, Asthma Immunology Annual Meeting. Nov. 7-12. San Diego.

Your turn

You can express your views on this article, or other relevant themes, in the Infectious Diseases in Children Specialty Forums.