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Compliance and asthma: a patient-centred approach

Charles Broomhead
MB ChB MRCGP DA DRCOG
GP and GP Trainer
Sutton Coldfield
Honorary Clinical Lecturer
Birmingham Medical School
E:charles.broomhead@lineone.net

As doctors and nurses involved in treating patients with asthma, we have a number of laudable objectives. We are exhorted to help them lead a normal life, free from symptoms, with no limitations on activities.(1) Unfortunately many studies continue to demonstrate that we are failing woefully in achieving these goals.(2-6) There is considerable evidence that compliance with all long-term medication is poor. For a number of reasons that will be discussed later, this represents a particular problem in young people. Although by its nature compliance is extremely difficult to measure with any certainty, it is widely believed that 50%, or perhaps less, of adolescents with chronic conditions fully comply with recommendations about their care.(7-9) In the case of asthma, the range of compliance may vary widely from as little as 17% up to 90%.(10,11) No matter how effective a drug may be in theory, if we fail to persuade patients to take it correctly the outcome of treatment is likely to be less than optimal.
It might be argued that if asthmatic patients are satisfied with the control that they are achieving, and therefore fail to attend for follow-up or to obtain repeat prescriptions for prophylactic medication, then there is no problem and we do not need to worry about compliance. In other words, a "no complaints, no problem" approach. Unfortunately this attitude ignores the low expectations that such patients have about their health and the long-term consequences of inadequate therapy.
Haynes defined compliance as "the extent to which a person's behaviour (in terms of taking medication, following diets or executing lifestyle changes) coincides with the instructions given by healthcare providers".(12) "Noncompliance" is the term that is widely used when patients fail to follow our advice regarding their treatment, a concept that many would regard as outdated. The term implies an unequal relationship between the patient and their doctor or nurse. It suggests that theirs is a lesser role in the consultation process and that their views are less important than those of the healthcare professional. Not to follow the instructions and advice that have been given might be viewed as a sort of deviant behaviour from which the patient must be dissuaded. Not surprisingly, this approach is one that often fails to produce the outcome that the healthcare worker seeks. A more patient-centred approach to management is much more likely to produce the outcomes that we want. A "one size fits all" approach will not work as well as one that is tailored to the needs of the patient, and perhaps their parents.
Depending on the age of the patient, if they or their family see themselves as active participants in the decision-making process, and if they believe that the disease is serious but the treatment effective, then they are much more likely to follow the treatment that is advocated.(13) This method, of both patient and healthcare practitioner agreeing a course of treatment to be followed, is known as concordance.

Improving compliance
The reasons why a young asthmatic patient may fail to take their medication are numerous and complex. They include the belief that their medication is unnecessary,(14) and fears about side-effects.(15)
Parental concern often centres on the use of inhaled steroids, a group of drugs that the majority of doctors and nurses see as fundamental in the treatment of all but the mildest asthmatic patients. All of us, particularly those with children of their own, understand these concerns but nevertheless are often unable to allay them. Demonstrating a rapid improvement to parents when medication is started is likely to persuade them of the benefits of following medical advice. To this end, initiating therapy with a short course of oral steroids may prove persuasive.(16)
But it is not just the selection of drug and dosage that is important. Membership of a peer group is an important part of normal adolescent development, and the ability to conform to the behaviour of the group determines the individual's likelihood of acceptance within it. Not only may a physical disability such as shortness of breath mark someone out as different and ineligible for membership for functional reasons, but if the lifestyle and treatment that is advised is also not acceptable and "cool", it may lead to denial of the disease and subsequent rejection of the treatment. For example, advice to use a short-acting b(2)-agonist before exercise may not be followed simply because of an unwillingness to be seen to do so. Similarly, advice not to smoke cigarettes may be doomed for similar reasons.
Thus apparently simple issues such as the choice of inhaler may radically affect the extent of compliance. Not only must the patient be capable of using the device, but it must also be acceptable to them.(17) An inhaler that does not have "street cred" and that the patient is embarrassed to use in front of their peers is unlikely to achieve high acceptance rates.
Accordingly, prescribing generically may not always be the best thing. While the cost of medication is always an important consideration, this is a situation where simply prescribing the cheapest drug in the cheapest inhaler may not prove to be cost-effective. Quite patently the most expensive medications that we prescribe are likely to be those that the patient fails to take or does not take correctly. The ramifications of such inappropriate prescription may be extensive. Not only will the medication be wasted, but also there are likely to be more attendances at surgery, perhaps leading to further expensive investigation and even more expensive medication prescribed in a vain attempt to discover the cause of the lack of improvement. More expenditure may be incurred if the patient is referred to secondary care or perhaps admitted to hospital because of ineffective treatment.
Other social costs to the patient, their family and to the rest of society are incalculable but likely to be enormous. Prescribing a well-designed device containing an effective drug has been shown to improve compliance and to lead to less overall healthcare costs in terms of hospital admission and clinic attendances.(18)
Although, in the main, healthcare workers regard the inhaled route as preferable in the treatment of asthma, oral medication is more likely to be taken correctly.(19) Perhaps not surprisingly, a drug that is inhaled twice daily or less achieves better compliance than more frequent dosage regimens - indeed, complex treatment regimens are often cited as a significant cause of poor compliance.(19,20) Reducing the number of drugs taken, perhaps by the use of combination products, might be expected to result in better adherence to treatment regimens; however, at least one study has failed to confirm this.(21)
 
Strategies to improve compliance
Three distinct areas need to be addressed if compliance is to be improved:

  • The patient and his immediate family.
  • Education about the illness and its management.
  • The treatment itself.

Perhaps the most important component of any strategy to improve compliance is the development of a trusting relationship between the healthcare practitioner and their patient.(22) Time spent exploring the patient's and their parents' beliefs, concerns and expectations about the illness and its management will pay huge dividends. The overall aim should be to develop a "partnership for care" that accepts the patient and their family as equal participants in management decisions. This may mean that, at least initially, treatment targets are set lower than the healthcare professional would prefer. It is important to remember that "having asthma" represents only a small facet of that individual's life, particularly when dealing with adolescents. No matter what we may think, the patient's "illness" cannot and should not entirely define who and what they are.
Education is essential, the informed patient being the one who is most likely to participate effectively in their own treatment. There is, of course, no single best way of teaching patients about their asthma and its management. A variety of educational techniques will need to be explored and appropriately tailored to the needs of the individual patient. Different methods will need to be adopted as the patient's understanding, knowledge and confidence develops. Providing material that can be taken away and reviewed at home is an important component in this, as is the provision of a written treatment plan.(23) Education will often be a slow process but is one that can only proceed effectively at the rate dictated by the patient. Although this may sometimes appear frustrating and is certainly time-consuming, it is something that cannot and does not usually need to be rushed. What is necessary is the repetition of the same consistent message, reinforced by regular review. By inference this means that the best results will be obtained when patients remain under the care of a single clinician, and when they are encouraged to return for regular reassessment, whether or not they perceive themselves as having a problem with their condition.
Medication that is prescribed must of a type that is acceptable to the patient and their parents, and part of this process is dependent upon good education and an understanding of the rationale for its provision. Choice of drug and inhaler will revolve around their wishes and ability to use a particular device and must not simply be driven by cost. Treatment regimens must similarly be acceptable and manageable.

References

  1. National Institute of Health, National Heart, Lung and Blood Institute. Global initiative for asthma (GINA). Global strategy for asthma management and prevention. London: GINA; Revised 2002.
  2. Smith NM. The "Needs of People with Asthma" survey and initial presentation of the data. Asthma J 2000;5:133-7.
  3. National Asthma Campaign. The impact of asthma survey. London: Allen & Hanburys; 1996.
  4. Price D, Ryan D, Pearce L, Bride F. The AIR study: asthma in real life. Asthma J 1999;4:74-8.
  5. King JL, Browning DC, Martin AA, Shrewsbury SB. Is asthma well controlled in primary care clinics? Baseline results from the Patient Outcomes Measurement Study (POMS). Eur Respir J 2000;16(Suppl 31):33.
  6. Rabe KF, Vermeire PA, Soriano JB, Maier WC. Clinical management of asthma in 1999: the Asthma Insights and Reality in Europe (AIRE) study. Eur Respir J 2000;16:802-7.
  7. LaGreca AM. Issues in adherence with pediatric regimens. J Pediatr Psychol 1990;15:423-36.
  8. Bosley CM, Fosbury JA, Cochrane GM. The psychological factors associated with poor compliance with treatment in asthma. Eur Respir J 1995;8:899-904.
  9. Adams S, Pill R, Jones A. Medication, chronic illness and identity; the perspective of people with asthma. Soc Sci Med 1997;45:189-201.
  10. Lemanek K. Adherence issues in the medical management of asthma. J Pediatr Psychol 1990;15:437-58.
  11. Dekker FW, Dielman FE, Kaptein AA. Compliance with pulmonary medication in general practice. Eur Respir J 1993;6:886-90.
  12. Haynes RB. Compliance in health care. Baltimore (MD): Johns Hopkins University Press; 1979.
  13. Chambers C, Markson L, Diamond J, Lasch L, Berger M. Health beliefs and compliance with inhaled orticosteroids by asthmatic patients in primary care paediatrics. Respir Med 1999;93(2):88-94.
  14. Tettersell MJ. Asthma patient's knowledge in relation to compliance with drug therapy. J Adv Nurs 1993;18:103-13.
  15. Price JE. Issues in adolescents, asthma: what are the needs? Thorax 1996;51(Suppl 1):S13-7.
  16. Pedersen S. Ensuring compliance in children. Eur Respir J 1996;5:143-5.
  17. National Institute for Clinical Excellence. Inhaler devices for routine treatment of chronic asthma in older children (aged 5-15 years). London: NHS; 2002.
  18. Price D. Appleby. Fluticasone propionate: an audit of outcomes and cost-effectiveness in primary care. Respir Med 1998;92:351-3.
  19. Sherman J, Hendeles L. Improving adherence to asthma medications. Contemp Paediatr 1999;16(1):58.
  20. Blackwell B. Drug therapy: patient compliance. N Engl J Med 1973;289:249-52.
  21. Tashkin D. Multiple dose regimens: impact on compliance. Chest 1995;107(5):176s-82.
  22. Kelly WH, Murphy S. Helping children adhere to asthma treatment regimens. Pediatr Allergy Immunol 2001;15(1):25-30.
  23. NHLBI. National asthma education and prevention program. Expert panel report 2. Guidelines for the diagnosis and management of asthma. NIH Publications No. 97-4051. Bethesda (MD): US Department of Health and Human Services; 1997.

Resources
Global Initiative for Asthma
W:www.ginasthma.com
National Heart Lung and Blood Institute (US?site)
W:www.nhlbi.nih.gov/index.htm

Event
World Asthma Day
6 May 2003