According to the Centers for Disease Control and Prevention, chronic disease accounts for approximately 75% of the nation’s aggregate health care spending—an estimated $5,300 per person in the U.S. each year. The annual cost of asthma alone is more than $81.9 billion, including medical costs and loss of work and school days.1 Asthma exacerbations result in approximately 2 million emergency department (ED) visits each year—25% of all annual ED visits in the US—and 500,000 hospitalizations, with an average three-day length of stay. Children are hospitalized for uncontrolled asthma more frequently than for any other childhood disease.
The reason patients have so many acute episodes of asthma that require intensive interventions in the hospital is not due to a lack of effective therapies to manage the disease. The problem is that up to 70% of adults and children with asthma do not adhere to their prescribed treatment regimen, typically inhaled corticosteroids (ICS). 2,3 And the more severe the asthma, which typically requires multiple medications, the more likely a patient is to resist taking ICS as prescribed.
Medication nonadherence in asthma patients leads not only to high rates of hospital, ED, and clinic visits, but also to greater mortality, more frequent use of oral corticosteroids, and decreased pulmonary function and asthma-related quality of life. These patients continue to be symptomatic after discharge, since the true cause of treatment failure goes unrecognized.
Previous strategies—including reminders, supervised self-monitoring, rewards for success, and psychological therapy–to improve adherence have not been very successful. Long-term implementation of such time- and labor-intensive strategies have not been practical. Recent studies, however, have found that by combining technology (web apps and electronic adherence monitors) and patient-centered communication skills, asthma patients are able to improve adherence to inhaled corticosteroids and maintain control of their disease.
We developed the Asthma Adherence Pathway (AAP), an online monitoring tool that helps physicians identify nonadherent behavior in asthma patients, uncover the specific reasons individual patients don’t follow treatment plans, and motivate them to adhere to their inhaled corticosteroid regimen using patient-centered communication techniques. We recently demonstrated in a randomized controlled trial that the AAP improves ICS adherence and asthma control in a study of 40 patients with poorly controlled asthma. After three months of adherence monitoring with Adherium’s SmartInhaler technology alongside visits with physicians trained in strategies to promote adherence, 81% of the intervention group were adherent and had greater asthma control.4
For hospitals transitioning to value-based reimbursement and away from fee-for-service, improving patients’ adherence to treatment for chronic disease has become paramount; it can mean the difference between receiving financial incentives for reducing unnecessary hospital readmissions and improving quality of care, or getting dinged with penalties. By improving adherence to ICS, nearly 25% of severe asthma exacerbations can be prevented, according to one study on the impact of nonadherence in asthma.5 Economic models examining the cost of uncontrolled asthma report that interventions that achieve full adherence are associated with significant return on investment, particularly in patients with severe asthma, where the cost of health care is extremely high.6
Taking a proactive approach
There are two paths to improving medication adherence in patients with chronic disease. The first is the standard disease management approach of initiating medication-use tracking after a patient repeatedly shows up in the ED or is hospitalized. The second approach is a proactive one, which we advocate. We’re suggesting that clinicians identify patients who potentially might be nonadherent to their asthma medications in order to prevent unnecessary ED visits and hospitalizations. Candidates for monitoring might be those asthma patients who have already used emergency or hospital care, have excess use of rescue beta-2agonists indicating poor asthma control, and those who admit they have non-adherent attitudes and behaviors. Length of monitoring can range from one to several months.
Improving adherence begins with clinicians objectively monitoring whether patients are taking inhaled corticosteroids as directed, including proper technique when using their inhalers. Indirect adherence measures are pharmacy prescription refill databases and adherence questionnaires, neither of which measures actual medication use or provides a framework to address a patient’s pattern of medication use. Reviewing medication use with a patient and discussing difficulties over specific time intervals, increases patient accountability, provides insight into the adherence problem, and offers solutions that indirect measures cannot.
A better approach is to use electronic monitors for metered-dose inhalers, which allow clinicians to assess patients’ patterns of medication use for at least a month. SmartInhaler technology provides a read-out of when a patient uses an inhaler and lights up and vibrates if the patient forgets to use the inhaler at the prescribed time. In a randomized trial of school children with asthma, those who used a SmartInhaler device with audiovisual reminders had an 84% rate of adherence to inhaled corticosteroids compared with 30% in the control group.7
Fitting the strategy to the barrier
There are many reasons patients don’t take their asthma medications as prescribed. But it’s important for clinicians to pinpoint the exact cause for nonadherence for each patient to successfully overcome those barriers. The Asthma Adherence Pathway permits a detailed assessment of the reasons for non-adherence and strategies to promote adherence.
Some patients don’t understand their treatment regimen or forget instructions due to cognitive decline related to aging, or health literacy or language issues. Here the clinician should provide clear instruction and verify the patient’s comprehension and inhaler technique. Other patients may forget to use their inhalers and frequently run out of medication because their lives are chaotic, or they are elderly and have memory problems. The right intervention for these patients includes simplification of the regimen, tailoring treatment to a specific daily activity such as tooth brushing and memory aids. Patients may be nonadherent because they underestimate the severity of their disease and don’t believe they need continuous medication—until they have an exacerbation and must use a rescue inhaler. There, the physician may consider peak flow monitoring or an exercise challenge to convince the patient that maintenance treatment is necessary. Another subset of patients may take medication intermittently because they are worried about side effects or don’t like taking steroids. The clinician would then address the pros and cons of treatment and counsel patients to reduce their exposure to allergens or irritants to possibly decrease medication.
Identifying the best strategy to overcome a patient’s resistance to taking medication is only step one of the solution, however. Clinicians also must motivate a patient to follow the strategy, even though the patient is ambivalent about accepting the recommendation. AAP teaches clinicians to use motivational interviewing and shared decision-making techniques, which can be briefly integrated into patient 15 minute visits and alleviate ambivalence by making patients active participants in the management of their care. These patient-centered counseling approaches provide a non-judgmental atmosphere for patients to discuss their true conflicts about taking their medications. Patients have an opportunity to express their values and preferences for treatment, and physicians can then explain the benefits and risks of treatment options. Together, clinician and patient negotiate a treatment regimen that accommodates patient goals and preferences, greatly increasing the likelihood that the patient will follow it.
The Asthma Adherence Pathway can be modified to fit other chronic diseases, such as chronic obstructive pulmonary disease, diabetes, or cardiovascular disease, all of which are associated with high rates of medication nonadherence. By partnering with our patients to assist them in following treatment plans, we can help them achieve greater control of their chronic disease with superior outcomes and quality of life, while preventing unnecessary hospitalizations, ED and physician visits, and mortality.
Andrew G. Weinstein, MD, is an Associate Clinical Professor of Pediatrics at the Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia and President of Asthma Management Systems, LLC.
1 Nurmagambetov T, Kuwahara R, Garbe P. The Economic Burden of Asthma in the United States, 2008 – 2013. Ann Am Thorac Soc 2018; 15: 348-356.
2 Gamble J, Stevenson M, McClean E at al. The Prevalence of Nonadherence in Difficult Asthma. Am J Respir Crit Care Med 2009; 180: 817-822.
3 Milgrom H, Bender B, Ackerson L et al. Noncompliance and Treatment Failure in Children with Asthma. J Allergy Clin Immunol 1996; 98: 1051-1057.
4 Weinstein AG, Gentile DA, Singh A et al. Validation of the Asthma Adherence Management Model (AAMM). J Allergy Clin Immunol 2018; 141: Supplement, AB60.
5 Williams LK, Peterson EL, Wells K et al. Quantifying the Proportion of Severe Asthma Exacerbations Attributable to Inhaled Corticosteroid Nonadherence. J Allergy Clin Immunol 2011; 128: 1185–1191.
6 Zafari Z, Lynd LD, FitzGerald JM et al. Economic and Health Effect of Full Adherence to Controller Therapy in Adults with Uncontrolled Asthma: A Simulation Study. J Allergy Clin Immunol 2014; 134: 908-15.
7 Chan AH, Stewart AW, Harrison J et al. The Effect of an Electronic Monitoring Device with Audiovisual Reminder Function on Adherence to Inhaled Corticosteroids and School Attendance in Children with Asthma: A Randomized Controlled trial. Lancet Respir Med 2015; 3: 210-219.
