Problem solving to improve adherence and asthma outcomes in urban adults with moderate or severe asthma: A randomized controlled trial

Abstract

Background Improving inhaled corticosteroid (ICS) adherence should improve asthma outcomes. Objective In a randomized controlled trial we tested whether an individualized problem-solving intervention improves ICS adherence and asthma outcomes. Methods Adults with moderate or severe asthma from clinics serving inner-city neighborhoods were randomized to problem-solving (PS) (defining specific barriers to adherence, proposing/ weighing solutions, trying the best, assessing, and revising) or standard asthma education (AE) for 3 months, then observed for 3 months. Adherence was monitored electronically. Outcomes included: asthma control, FEV1, asthma-related quality of life, emergency department (ED) visits, and hospitalizations. In an intention-to-treat-analysis, longitudinal models using random effects and regression were employed. Results 333 adults were randomized: 49±14 years, 72% female, 68% African American, 7% Latino, mean FEV1 66%±19%, 103(31%) with hospitalizations and 172(52%) with ED visits for asthma in the prior year. There was no difference between groups in overall change in any outcome (p>0.20). Mean adherence (61%±27%) declined significantly (p=0.0004) over time by 14% and 10% in the AE and PS groups, respectively. Asthma control improved overall by 15% (p=0.002). In both groups, FEV1 and quality of life improved: 6% (p=0.01) and 18% (p<0.0001), respectively. However, the improvement in FEV1 only occurred during monitoring but not subsequently after randomization. Rates of ED visits and hospitalizations did not significantly decrease over the study period. Conclusion Problem-solving was not better than asthma education in improving adherence or asthma outcomes. However, monitoring ICS use with provision of medications and attention, imposed on both groups, was associated with improvement in FEV1 and asthma control. Clinical Trials registration ClinicalTrials.gov number NCT00115323.

Every parent tells a story: why non-adherence may persist in children receiving guideline-based comprehensive asthma care

“…They reported that appropriate problem-solving was the most difficult skill to teach patients [23,24]. A large trial in asthmatic adults showed no benefits of problem-solving education, and the authors suggested that patients' lack of motivation to achieve high adherence was the main reason for this failure [25]. Similarly, an asthma outreach program in inner-city children with asthma in the USA was of limited benefit when parents lacked the motivation to participate [26].…”

Feasibility, acceptability and preliminary effectiveness of patient advocates for improving asthma outcomes in adults

“…Patients strongly recommended the advocate be like the research coordinators (RC) they had encountered in a previous study: recent college graduates who enjoyed working with patients. 23 The patients perceived these persons as willing to listen to them but also accepted by and comfortable with practice personnel.…”

“…31 An electronic monitor was attached to participants’ ICS-containing inhaler. 32, 33 Participants were informed that the monitor recorded time and date of inhaler actuation and that data would be downloaded at data collection visits. All subjects met with DCs monthly for 4 subsequent sessions (Visits 2–5) of data collection including spirometry, downloading monitor data, and reporting any ED visits or hospitalizations.…”

The burden of nonadherence among adults with asthma: a role for shared decision‐making

“…A recent British Columbian population-based analysis of asthmatics prescribed combination therapy estimated adherence rates of between 16% and 32% over 2 years, as measured by percentage of days covered (23). In addition, a patient's adherence to asthma therapies tends to decrease over time, posing a challenge for long-term management (24).…”

“…Interventions include but are not limited to asthma action plans (a step-by-step strategy to manage symptoms and prevent exacerbations), educational interventions, reminder systems, and multifaceted interventions (24,(28)(29)(30)(31)(32)(33)(34)(35)(36). In response to calls for a more patient-centered approach to decision-making, SDM has also been proposed as a valuable tool to improve patient-reported and clinically important outcomes (4,37).…”