Sinthia BosnicAnticevich PhD Principal Research Fellow Sydney Medical School University of Sydney Research Leader and Director of Development Woolcock Institute of Medical Research ID: 799339
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Slide1
Improving inhaler technique and adherence: a complex problem in practice
Sinthia Bosnic-Anticevich, PhDPrincipal Research FellowSydney Medical School, University of SydneyResearch Leader and Director of DevelopmentWoolcock Institute of Medical Research
Slide2Inhaler technique and adherence
The when and how of medication management…
Slide3s
ymptomsp
attern of symptoms
history
spirometry
? alternative diagnosis
a
llergy tests
bronchoprovocation
e
xhaled NO
Empiric treatment
ICS +
prn
SABA
Review/adjustment
s
evere asthma/
u
ncontrolled asthma
Assess
adjustreview response
s
evere asthma/
u
ncontrolled asthma
Slide4Implementing HARP (Helping Asthma in Real Patients):
Improving asthma control through assessment and inhaler educationDavid Price, et al.
Slide577% poorly controlled
90% ‘non-adherent’
72–83% demonstrated device handing errors
Slide6Inhaler technique
Controlled
78% not well controlled
All
patients (n=200) performed
at least 2
errors.
72% of patients performed at least 5 errors
Slide7GINA and medication management principles?
Control-based managementLong term goalAchieve good symptoms controlMinimize future risk of exacerbations, fixed airflow limitation and side effectsEvidence based treatment optionsPatients goals should be identified a partnershipCommunication skills of HCPs patient satisfaction, better health outcomesPatient characteristics and phenotypes, patient preferences and practical issues (inhaler technique, adherence and cost to the patient)but…..
Slide8In practice…….
Patients have flare-upsSevere asthma vs uncontrolled asthma ?Inhaler techniqueMedication adherenceIncorrect diagnosisCo-morbiditites and complicated conditionsOngoing exposure to triggersKnowing what patients should be doing required careful investigation.Getting them to do it is difficult. Why?
Slide9Drilling down to the ‘practical issues’…….
Adherence
Slide10ComplianceThe extent to which a patient’s behaviour
matches the prescriber’s adviceAdherenceThe extent to which the patient’s behaviour matches agreed recommendations from the prescriberConcordanceA complex idea relating to the patient/prescriber relationship and the degree to which the prescription represents shared decision.
Slide11AdherenceUp to 70% of adults with asthma do not take their medication as prescribed.
Why?Do not want to?Are not able to?Can not remember to?It is complex and we need to understand more
Slide12There is no ‘typical’ non-adherer
Slide13Slide14Adherence
Self-management
NEED
Perceived
CONCERNS
Side effects
Attribution of side effects
Illness Perceptions
Symptom experiences, expectations and interpretations
Background Beliefs
Negative orientation to medicine in general
Beliefs about personal sensitivity
Past experiences
Views of others
Cultural influences
Practical difficulties
Self efficacy
Satisfaction
Contextual issues
Slide157 factors associated with poor adherence:
Perceived necessity, safety concerns, acceptance of chronicity and medication effectiveness,advice from family and friends, motivation and routing, ease of use,satisfaction with asthma management.
Slide16Interventions to improve adherenceCochrane review 2008.
Randomised Controlled Trials.Adherence Clinical outcomesMinimum of 6 months78 trials.93 interventions.
Slide17Example of interventions
Increased informationCounselling on specific disease, treatment etcAutomated telephone , CA patient monitoring and counselling
Manual telephone follow-up
Family intervention
Various ways of increasing convenience of care
Simplifying dosing
Involving patients more in care through home monitoring
Reminders e.g. programmed reminders
Special reminder pill sets
Dosing dispensing charts
Appointment and prescription refill reminders
Different medication formulationsCrisis intervention conducted when necessary
Lay health mentoringAugmented pharmacy servicesPsychological therapy (CBT)Mailed communications
Group meetings
Slide18Example of interventions
Increased informationCounselling on specific disease, treatment etcAutomated telephone , CA patient monitoring and counsellingManual telephone follow-upFamily intervention
Various ways of increasing convenience of care
Simplifying dosing
Involving patients more in care through home monitoring
Reminders e.g. programmed reminders
Special reminder pill sets
Dosing dispensing charts
Appointment and prescription refill reminders
Different medication formulations
Crisis intervention conducted when necessary
Lay health mentoringAugmented pharmacy servicesPsychological therapy (CBT)Mailed communicationsGroup meetings
Slide19What works?1/3 were associated with improved adherence
RemindersComplex and in combinationInformationRemindersSelf-monitoringReinforcementCounselingFamily therapyPsychology therapyManual telephone follow upSupportive care
Slide20Drilling down to the other ‘practical issue’…….
Inhaler Technique
Slide21The considerations
Up to 90% of people make handling errors. Across all devicesSome errors are more likely to be related to poor asthma controlSome devices are more intuitive to useOnce you have learnt how to use one, the next one is easierShould be straightforward…….
Slide22Can we improve inhaler technique?
Yes, with the right type of education
✗
✓
Slide23Can we improve inhaler technique?
Yes, with the right type of educationIf education is repeated over time
Slide24Can we improve inhaler technique?
Yes, with the right type of educationIf education is repeated over timeTH group
0%
20%
40%
60%
80%
100%
3
2
1
0
M
onths
0
1
2
3
6
ACC group
3
2
1
0
20%
40%
60%
80%
100%
0
1
2
3
0%
6
M
onths
Slide25Can we improve inhaler technique?
Yes, with the right type of educationIf education is repeated over timeTH group
0%
20%
40%
60%
80%
100%
3
2
1
0
M
onths
0
1
2
3
6
Slide26Can we improve inhaler technique?
Yes, with the right type of educationIf education is repeated over timeIt can be done in a timely manner
(TH) (ACC)
0
1
2
3
4
5
6
7
Time of inhaler technique education
mean
(95% CI)
0
1
2
3
6
0
1
2
3
4
5
6
7
0
1
2
3
6
Slide27But, it is not so simple…
73% perceive their inhaler technique to be good or excellent86% find their inhalers easy to use
95
%
have not
had
their inhaler technique checked in the last
12
months!
!
Slide28WHY do patients not use their inhalers correctly, even when they are taught how?
Slide29The Inhaler Technique Maintenance Framework
1. Perceived threat of asthma
2. Self-management beliefs
3. Self-management self-efficacy
Slide30The Inhaler Technique Maintenance Framework
Symptom experienceWitnessing asthma in othersComorbiditiesValue of health and asthma control Emotions, e.g. fear versus complacencyFamily impact NECESSITY
1. Perceived threat of asthma
2. Self-management beliefs
3. Self-management self-efficacy
Slide31The Inhaler Technique Maintenance Framework
Overarching attitude to medication Preventer necessity beliefsperceived threat asthmaperceived benefits preventerknowledge of preventer rolePreventer concernsSide effects experiencedCONCERNS
1. Perceived threat of asthma
2. Self-management beliefs
3. Self-management self-efficacy
Slide32The Inhaler Technique Maintenance Framework
General life stresses (e.g. financial struggle)Support from significant others Practical and emotionalEmotions, e.g. despair and hopelessness versus caution and optimism
1. Perceived threat of asthma
2. Self-management beliefs
3. Self-management self-efficacy
Slide33The Inhaler Technique Maintenance Framework
A new paradigmIs a complex processMore than just a physical skillIntrinsically linked with other aspects of asthma managementFixing the problem will not be so
easy…
Slide34Should we be looking at them together?
Adherence and inhaler techniqueThe co-existPreliminary researchIT maintenance = adherence + baseline technique + device type (n=233)We have ways to measure thisINCA (INhaler Compliance Assessment)The common patient factorsNecessityConcernsMotivationOverall management of asthma
Slide35Further considerationsAre some devices
favoured/more intuitive, and more likely to be used properly?Are there special populations that we should be considering?Intellectual disabilityElderly/cognitive impairment/ physical impairmentdisadvantagedWhen do the problems start?Childhood/medication taking autonomyHow can we help each other?
Slide36Solutions
HCP working together.Understanding the patient perspective.Considering special populations……
Slide37HCP working together
Slide38Collaboration in Asthma Management in the Community
CAMCOM
Background
Education on inhaler devices
“Hands-on” training
Protocol presentation
Model 1
Training together.
GPs, practice nurses,
Pharmacists.
Model 2
Web-based
Model 3
Collaborative, IPL
Sociocultural theory of learning
E-patient record
Slide39Understanding the
patient’s networks and their influence
Slide40Understanding the
patient’s networks and their influence
Slide41Individuals with Intellectual Disability
Slide42Impact and implications
It has to be based on the best science, but it needs to be relevant to the patient.One size does not fit all.New Asthma Management Guidelines/reportsTraining of undergraduate Medical, Pharmacy and Nursing studentsContinuing Professional Education coursesWe need to work togetherResources.Novel inhalers and support material for HCP and
patients.
We need to make a discussion about the use of inhalers exciting….
Slide43Impact and implications
It has to be based on the bets science, but it needs to be relevant to the patient.One size does not fit all.New Asthma Management Guidelines/reports.Training of undergraduate Medical, Pharmacy and Nursing students.Continuing Professional Education courses.Resources.Novel inhalers and support material for HCP and patients.We need to make a discussion about the use of inhalers exciting….