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A dherence to Treament: How can it be improved ?

A dherence to Treament: How can it be improved ?. Fernán Caballero Fonseca Caracas, Venezuela December 2011. Potential reasons for not achieving control in asthma patients. Adherence Technique Misdiagnosis Location of inflammation Lack of eosinophilic inflammation Genetics.

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A dherence to Treament: How can it be improved ?

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  1. Adherence to Treament: How can it be improved ? Fernán Caballero Fonseca Caracas, Venezuela December 2011

  2. Potential reasons for not achieving control in asthma patients • Adherence • Technique • Misdiagnosis • Location of inflammation • Lack of eosinophilic inflammation • Genetics

  3. Definitions of adherence / compliance • 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 Effective Disease Management Effective Therapies Patient Adherence Urquhart. Eur Heart J. 1996;17:8

  4. Patient persistence on medication in chronic diseases 100% Multiple Sclerosis (Biologic) 90% 80% High Cholesterol (Statin) 70% Hypertension 60% (CCB) 50% Osteoporosis (SERM) 40% Depression 30% (SSRI) 20% Asthma (Inhaled Steroid) 10% 1 2 3 4 5 6 7 8 9 10 11 Across classes, 20% - 35% loss in patient base after fill of initial prescription Patients Continuing Therapy (%) Months of Therapy CCB = calcium channel blocker; SERM = selective estrogen receptor modulator; SSRI = selective serotonin reuptake inhibitor. Vanelli MR et al. Moving beyond market share. In: In Vivo: The Business and Medicine Report. 2002:1-6.

  5. Most adherence is thoughtful Burden of Illness vs Burden of Therapy Missed Work/School Loss of sleep Chronic Symptoms Impaired QOL Uncertainty/Fear Attacks Having to take Rx Side effects Cost Inconvenience Appointments Communication Access

  6. 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 2003 3Williams LK JACI2004;114:1288-1293

  7. Types of nonadherence to medication • Not filling prescriptions • Not following directions • Premature discontinuation

  8. Adherence also pertains to • 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

  9. 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

  10. Depression Nonadherence Unhealthy Behavior Bender BG AAAAI 2010

  11. 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.

  12. Anxiety and depression in adolescents with asthma Is associated with 1. Increased risk of smoking 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

  13. Patients attitudes towards asthma management Proportion of patients that agree with each statement (n=3,415) Patients (%) Partridge MR et al. BMC Pulmonary Medicine 2006:6:13

  14. 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.)

  15. 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 75 70 65 Adherence (%) 60 55 50 0 1 2 3 4 5 6 Week of Study Apter AJ, et al. Am J Respir Crit Care Med. 1998;157:1810-1817.

  16. 40 35 30 25 20 15 10 5 0 Inhalation technique: At least one critical error Below 30 years From 31 to 64 years 65 years and over % Aeroliz. Autohaler Diskus pMDI Turbuhaler Molinard M., J Aerosol Med 2003;16:249-254

  17. 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) Caballero F, Sánchez-Borges M, J Allergy Clin Immunol 2002; 109:S 242

  18. 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

  19. An adherence intervention • standard asthma care • monitoring by MDI Chronologs • direct clinician-to-patient feedback for treatment group Onyirimba. Ann Allergy ClinImmunol 2003;90:411

  20. Improving adherence • Establish a therapeutic goal with the patient • Assess progress • Maintain a positive relationship • Provide positive feedback • Avoid criticism

  21. Listen to the patient Doctorsinterruptthepatient in lessthan 18 secondsafter he startstotalk Beckman HB and Frankel RM Ann Intern Med 1984

  22. Improving adherence • Simplify therapeutic regimen • Allow flexible dosing • Provide adequate information • Minimize painful tests • Maintain frequent contact • Issue appointment reminders

  23. Patient education • 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 Patient education and self-management. Thorax 2003;58(Suppl I):i1

  24. 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

  25. Knowledge self-efficacy, effective self-treatment and self-management in asthma patients Van Der Palen J, et al. (1997) Patient Education and Counseling, 32:S35-S41

  26. 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 Caballero Patient Education & Counseling, 36 (‘99) 47-55

  27. Effect of self-management on hospitalization for asthma Relative risk (IC 95 % Fijo) 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: 1110-6 Zeiger RS et al JACI 1991;87:1160-8 Total 0.1 0.2 1 5 10 Prefer Treatment Prefer control Gibson PG J Allergy Clin Immunol 2000; 106:17-26

  28. Pediatric adherence is enhanced through the effective use of: • 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

  29. The potencial of asthma adherence management to enhance asthma guidelines Weinstein AG. Ann Allergy Asthma Immunol 2011; 106; (4): 283-291

  30. 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

  31. Golfo de Cariaco Edo Sucre - Youenn Jacquin Plaza Venezuela - Orlando Acosta Isla Blanquilla - Youenn Jacquin Los Nevados Edo Merida - Youenn Jacquin VENEZUELA Isla Las Aves - Youenn Jacquin

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