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Concordance in asthma care: pills, puffers and poor adherence

Heather Matthews
RN RM BSc(Hons)
Respiratory Nurse Specialist
James Paget University Hospitals NHS Healthcare Trust Great Yarmouth

How often have you spent time with a patient methodically discussing their asthma management and medication, only to have the very same patient present at a later stage with an exacerbation? Taking a patient-centred approach to asthma management can achieve improvement in asthma control, but the style and content of its delivery is all important. 
It has been suggested that up to 79% of asthma admissions are avoidable.(1) With the advent of "Payment by Results", improved asthma control is in the best interests of not only the patient but also the practice-based commissioning groups that wish to avoid preventable attendances and admissions to secondary care. To achieve improved asthma control it is essential to understand why patients do not always follow our advice about managing this chronic respiratory condition, especially regarding medicines management. Poor adherence to medications has been linked with asthma morbidity and mortality, and despite the good work done by nurses over the past decade approximately 50% of patients are estimated to be nonadherent with their asthma medications.(2,3)
It was recommended over 16 years ago in the 1990 version of the BTS/SIGN guideline that "patients should be trained to manage their own treatment rather than require to consult their doctor before making changes".(4) In today's environment this advice is even more relevant, although we would perhaps change the terminology from "trained" to "enabled"!

Knowledge
The first step to enabling people with asthma to manage their condition appropriately is assessing patient knowledge and building upon this. It is clearly documented that empowering people to self-manage reduces hospital admissions, Accident & Emergency attendances and unscheduled visits to the doctor.(5) The current BTS/SIGN guideline encourages a negotiated agreement between the healthcare professional (HCP) and the patient, termed concordance.(4) To establish a concordant approach between the HCP and the patient it is essential to gain insight into the patient's (or their carer's) fears, beliefs and expectations regarding both their condition and prescribed medicines. In a recent survey by the Department of Health, three-quarters of patients wanted more involvement and over half said that the NHS needed to improve this aspect of the HCP/patient relationship.(6) Therefore, if the patient is nonconcordant with their treatment, the implication is that both parties have not come to an understanding, rather than a failure of the patient to follow instructions.
This partnership approach reflects the theme that is a feature of several national initiatives to empower patients with long-term conditions, such as the Expert Patient Programme and the Ask about Medicines campaign, an independent programme aimed at increasing the individual's involvement in decisions about their medications (see Resources list).

Concordance
Concordance in practice means sharing the power in the HCP/patient relationship and agreeing a treatment programme that best fits the individual. Some HCPs may feel quite uncomfortable with the change in their role and may find it feels simpler to just continue with the paternalistic method of issuing instructions. Unfortunately this has not been effective in the past, and evidence demonstrates that patients are not meeting standards set out in the guidelines.(7)
Therefore we may all have to embark on a new and perhaps challenging role of being a partner with our patients. Communication is the key to being a good partner in any situation. To communicate effectively with our patients we must find a common language, shared goals and a mutual respect for what the patient wishes to achieve. To achieve all this in a 10-minute consultation is impossible. Yet, if we do not find ways of doing this, we will continue to have patients who do not understand their condition or how to prevent deteriorations, which could lead to a disruption in their lives and increased use of healthcare resources. When time is limited, the temptation is to be prescriptive and assume that you, as a healthcare professional, are in the best position to tell the patient what to do. However, if we do not discover the patient's needs and help change behaviour, then this is a potentially wasted consultation for both parties. The BTS/SIGN guideline suggests that every consultation is an opportunity to review, reinforce and extend knowledge and skills.(4) Therefore achieving concordance should be viewed as a process and not an event.(4)
Rollnick states that: "It is the practitioner's role to help people make decisions within their own frame of reference."(8) We may have more expert knowledge than many patients, but we do not have the right to tell them what to do. Our duty as nurses is to help the patient make informed decisions about how to control their asthma in a format that they accept and understand. In this way, we can achieve concordance with our patients.

Communication
Many studies reflect the mismatch of what HCPs believe patients want and what really concerns the patient with asthma. Time and time again it is stated that there is a need for improved communication to find out why patients do not discuss factors in their lives that may be affecting their ability to manage their condition. Moffat et al discuss the implications of this problem in an interesting article looking at patient/physician communication in primary care,(9) and in a recent paper by Caress et al it was clearly shown that "there is a need for professional and patient education regarding partnership working, skilful communication, and innovative approaches to service delivery".(10)
What practical tools can we use to facilitate this? If we are to believe that improved communication skills and partnership working can increase adherence to management protocols, reduce morbidity and improve outcomes then the uptake of personalised asthma action plans (PAAPs) must be improved.(11) PAAPs tailored to suit individual needs are recommended (Grade A) in the BTS/SIGN guidelines - using simple agreed plans with patients is a start to improving concordance and eventually adherence with their medications.(4) If we do not give our patients the right tools, then they cannot be expected to manage their conditions when things start to go wrong.
Asthma UK has produced a range of educational materials, such as "Be in Control", which encourage the HCP and the patient to use a PAAP. In addition, the "Power to the Patient" toolkit has been developed to provide nurses with practical advice about empowering patients and resources to maximise any asthma consultation.

Adherence
Adherence to treatment is a key area to address when considering concordance. Underusage of inhaled corticosteroids (ICSs) in particular has been linked to poor control of asthma. There are numerous reasons why patients do not use their ICS as prescribed, and it is common for patients to perceive that their ICS is not effective because of slow onset of action compared with a short-acting β-2 agonist (SABA).(12) For patients at step three of the guideline, we have the choice of offering our patients combination therapies (eg, budesonide/formoterol, salmeterol/fluticasone), which in conjunction with education, support, and so on, may aid concordance. For example, the combination of budesonide and formoterol allows the patient to adjust the dose of medication in conjunction with a PAAP and used in this way can help achieve self-management. A recent study has also demonstrated that the budesonide/formoterol combination can be used for both maintenance and reliever therapy, leading to improved control and less overall steroid load compared with traditional treatment regimens using a separate SABA.(13) Using this combination treatment in this way could potentially provide further benefits for adherence.

Conclusion
It is important for nurses to recognise that many patients are putting up with unnecessary symptoms and that improving concordance can dramatically improve the life of the individual with asthma.(7) To achieve this, there is a clear need to improve the provision of patient information and to address patient choice regarding asthma management. The patient's wishes regarding their involvement must be respected - for instance, some may choose to trade a degree of symptom control in favour of a treatment regimen with fewer inhalers and a lower dose of ICS, while others may prefer to avoid self-management altogether.(14) Ultimately, improved concordance may not only enhance patients' quality of life but also serve to use scarce NHS resources in an appropriate fashion, by reducing uncontrolled asthma and possible attendances/admissions to secondary care.

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References

  1. Beekman RP. Death from asthma in two regions of England. BMJ 1982;285 (6354):1570-1.
  2. Harrison BDW, et al. An ongoing confidential enquiry into asthma deaths in the Eastern Region of the UK 2001-2003. Prim Care Respir J 2005;14:303-13.
  3. Krishnan JA, et al. Corticosteroid use after hospital discharge among high risk adults with asthma. Am J Resp Crit Care Med 2004;170:1281-5.
  4. British Thoracic Society. Scottish intercollegiate guidelines network. British guideline on the management of asthma. Available from: http://www.brit-thoracic.org.uk
  5. Gibson PG, et al. Self-management education and regular practitioner review for adults with asthma (Cochrane Review). The Cochrane Library 2004. Issue 2.
  6. DH. National consultation: Building on the best; choice, responsiveness and equity in the NHS. Public Survey 2003. Available from:
    http://www.dh.gov.uk/assetRoot/04/07/52/93/04075293.pdf
  7. Haughney J, et al. The living and breathing study: a study of patients' views of asthma and its treatment. Prim Care Respir J 2004;13:28-35.
  8. Rollnick S, et al. Health behaviour change; a guide for practitioners. London: Churchill Livingstone; 1999.
  9. Moffat M, et al. Sub-optimal patient and physician communication in primary care consultations. Prim Care Respir J 2006;15: 159-65.
  10. Caress AL, et al. Involvement in treatment decisions; what do adults with asthma want and what do they get? Results of a cross sectional study. Thorax 2005;60:199-205.
  11. Bauman AE, et al. Getting it right: why bother with patient-centred care? Med J Aust 2003;179(5):253-6.
  12. Cochrane MG, et al. Inhaled corticosteroids for asthma therapy: patient compliance, devices, and inhalation technique. Chest 2000;117:542-50.
  13. Rabe KF, et al. Reduction in asthma exacerbations with budesonide in combination with formoterol for reliever therapy: a randomised, controlled, double-blind study. Lancet 2006;368:744-53.
  14. Haughney J, et al. Living & breathing II. Features of asthma management: quantifying the patient's perspective using discrete choice modelling. Data presented at the European Respiratory Society, Munich; 2-6 September 2006.


Resources

The Expert Patient Programme
W: www.dh.gov.uk

Ask about Medicines campaign
W: www.askaboutmedicines.org

Be in control
W: www.asthma.org.uk

Power to the Patient Toolkit
E: info@powertothepatient.co.uk

BTS/SIGN Guideline on Asthma Management
W: www.brit-thoracic.org.uk