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      Patient-physician discordance in assessment of adherence to inhaled controller medication: a cross-sectional analysis of two cohorts

      1 , 1 , 2 , 1 , 1 , 3 , 2 , 2 , 4 , 2 , 5 , 5 , 5 , 5 , 5 , 6 , 7 , 8 , 9 , 9 , 9 , 9 , 9 , 10 , 10 , 10 , 11 , 11 , 11 , 11 , 12 , 12 , 13 , 12 , 12 , 12 , 12 , 13 , 14 , 14 , 15 , 15 , 15 , 16 , 17 , 18 , 18 , 19 , 20 , 20 , 3 , 21 , 21 , 22 , 23 , 24 , 24 , 24 , 25 , 26 , 27 , 26 , 28 , 28 , 29 , 29 , 30 , 31 , 30 , 30 , 32 , 33 , 34 , 34 , 35 , 36 , , 1 , 2 , 4 , 36 , Inspirers group

      BMJ Open

      BMJ Publishing Group

      asthma, medication adherence, discordance, logistic models

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          Abstract

          Objective

          We aimed to compare patient’s and physician’s ratings of inhaled medication adherence and to identify predictors of patient-physician discordance.

          Design

          Baseline data from two prospective multicentre observational studies.

          Setting

          29 allergy, pulmonology and paediatric secondary care outpatient clinics in Portugal.

          Participants

          395 patients (≥13 years old) with persistent asthma.

          Measures

          Data on demographics, patient-physician relationship, upper airway control, asthma control, asthma treatment, forced expiratory volume in one second (FEV 1) and healthcare use were collected. Patients and physicians independently assessed adherence to inhaled controller medication during the previous week using a 100 mm Visual Analogue Scale (VAS). Discordance was defined as classification in distinct VAS categories (low 0–50; medium 51–80; high 81–100) or as an absolute difference in VAS scores ≥10 mm. Correlation between patients’ and physicians’ VAS scores/categories was explored. A multinomial logistic regression identified the predictors of physician overestimation and underestimation.

          Results

          High inhaler adherence was reported both by patients (median (percentile 25 to percentile 75) 85 (65–95) mm; 53% VAS>80) and by physicians (84 (68–95) mm; 53% VAS>80). Correlation between patient and physician VAS scores was moderate (r s=0.580; p<0.001). Discordance occurred in 56% of cases: in 28% physicians overestimated adherence and in 27% underestimated. Low adherence as assessed by the physician (OR=27.35 (9.85 to 75.95)), FEV 1 ≥80% (OR=2.59 (1.08 to 6.20)) and a first appointment (OR=5.63 (1.24 to 25.56)) were predictors of underestimation. An uncontrolled asthma (OR=2.33 (1.25 to 4.34)), uncontrolled upper airway disease (OR=2.86 (1.35 to 6.04)) and prescription of short-acting beta-agonists alone (OR=3.05 (1.15 to 8.08)) were associated with overestimation. Medium adherence as assessed by the physician was significantly associated with higher risk of discordance, both for overestimation and underestimation of adherence (OR=14.50 (6.04 to 34.81); OR=2.21 (1.07 to 4.58)), while having a written action plan decreased the likelihood of discordance (OR=0.25 (0.12 to 0.52); OR=0.41 (0.22 to 0.78)) (R 2=44%).

          Conclusion

          Although both patients and physicians report high inhaler adherence, discordance occurred in half of cases. Implementation of objective adherence measures and effective communication are needed to improve patient-physician agreement.

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          Most cited references 43

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          A comparison study of multiple measures of adherence to HIV protease inhibitors.

          Poor adherence to HIV protease inhibitors may compromise the effectiveness of treatment. Few studies have compared methods for measuring adherence or have related adherence measures to a clinical outcome. To examine the relationship among a composite score of adherence, the three primary measures of adherence, and HIV virologic response. Longitudinal cohort study. Public HIV clinic. 108 HIV-infected adults receiving protease inhibitors or non-nucleoside reverse transcriptase inhibitors who were monitored for 666 monthly intervals. Medication Event Monitoring System (MEMS), pill count, and interview combined into a composite adherence score (CAS), and HIV viral load. Mean antiretroviral adherence differed by adherence measure (MEMS, 0.63; pill count, 0.83; interview, 0.93; and CAS, 0.76). Composite adherence score decreased significantly over time. Composite adherence score, MEMS values, pill values, and interview values were statistically significantly associated with achievement of an undetectable viral load within 6 months of initiating therapy. Composite adherence score showed the strongest predictive relationship (odds ratios for a 10% increase in adherence for CAS, MEMS, pill count, and interview, respectively, were 1.26 [95% CI, 1.16 to 1.37], 1.13 [CI, 1.06 to 1.21], 1.10 [CI, 1.02 to 1.19], and 1.35 [CI, 0.94 to 1.94]). Different measures applied to the same patient suggest different levels of adherence. Adherence may be underestimated by MEMS and overestimated by pill count and interview. A summary measure combining several measures is more strongly related to a clinical response, but more practical measurement methods are needed for clinical use.
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            Early intervention with budesonide in mild persistent asthma: a randomised, double-blind trial.

            Although inhaled glucocorticosteroids are recommended for persistent asthma, their long-term effect on recent onset, mild, persistent asthma has yet to be established. We did a randomised, double-blind clinical trial in 7241 patients in 32 countries to assess the effects of budesonide in patients who had had mild persistent asthma for less than 2 years and who had not had previous regular treatment with glucocorticosteroids. Patients aged 5-66 years received either budesonide or placebo once daily for 3 years in addition to their usual asthma medications. The daily budesonide dose was 400 microg, or 200 microg for children younger than 11 years. The primary outcome was time to first severe asthma-related event, and analysis was by intention to treat. 198 of 3568 patients on placebo and 117 of 3597 on budesonide had at least one severe asthma exacerbation; hazard ratio 0.56 (95% CI 0.45-0.71, p<0.0001). Patients on budesonide had fewer courses of systemic corticosteroids and more symptom-free days than did those on placebo. Compared with placebo, budesonide increased postbronchodilator forced expiratory volume in 1 s (FEV1) from baseline by 1.48% (p<0.0001) after 1 year and by 0.88% (p=0.0005) after 3 years (expressed as percent of the predicted value). The corresponding increase in prebronchodilator FEV1 was 2.24% after 1 year and 1.71% after 3 years (p<0.0001 at both timepoints). The effect of treatment on all outcome variables was independent of the baseline lung function (prebronchodilator or postbronchodilator) or baseline medication. In children younger than 11 years, 3-year growth was reduced in the budesonide group by 1.34 cm. The reduction was greatest in the first year of treatment (0.58 cm) than years 2 and 3 (0.43 cm and 0.33 cm, respectively). Long-term, once-daily treatment with low-dose budesonide decreases the risk of severe exacerbations and improves asthma control in patients with mild persistent asthma of recent onset.
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              Low dose inhaled budesonide and formoterol in mild persistent asthma: the OPTIMA randomized trial.

              The optimal treatment for mild asthma is uncertain. We assessed the effects of adding a long-acting inhaled beta-agonist, formoterol, to low doses of an inhaled corticosteroid, budesonide, for 1 yr in subjects with mild asthma, receiving no or only a small dose of inhaled corticosteroid. The 698 corticosteroid free patients (Group A) were assigned to twice daily treatment with 100 microg budesonide, 100 microg budesonide plus 4.5 microg formoterol, or placebo. The 1,272 corticosteroid-treated patients (Group B) were assigned to twice daily treatment with 100 microg budesonide, 100 microg budesonide plus 4.5 microg formoterol, 200 microg budesonide, or 200 microg budesonide plus 4.5 microg formoterol. The main outcome variables were time to the first severe asthma exacerbation and poorly controlled asthma days. In Group A, budesonide alone reduced the risk for severe exacerbations by 60% and poorly controlled days by 48%; adding formoterol increased lung function with no change in other end points. By contrast, in Group B, adding formoterol reduced the risk for the first severe exacerbation and for poorly controlled days by 43 and 30%, respectively. Thus, in corticosteroid-free patients, low dose inhaled budesonide alone reduced severe exacerbations and improved asthma control, and in patients already receiving inhaled corticosteroid, adding formoterol was more effective than doubling the corticosteroid dose.
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                Author and article information

                Journal
                BMJ Open
                BMJ Open
                bmjopen
                bmjopen
                BMJ Open
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2044-6055
                2019
                7 November 2019
                : 9
                : 11
                Affiliations
                [1 ] departmentCenter for Health Technology and Services Research (CINTESIS), Faculty of Medicine , University of Porto (FMUP) , Porto, Portugal
                [2 ] departmentImmunoalergology , CUF-Porto Hospital and Institute , Porto, Portugal
                [3 ] departmentServiço de Pediatria, Centro Materno Infantil do Norte , Centro Hospitalar Universitário do Porto , Porto, Portugal
                [4 ] MEDIDA – Medicina, Educação, Investigação, Desenvolvimento e Avaliação , Porto, Portugal
                [5 ] departmentServiço de Pneumologia A, Hospital Universitário de Coimbra , Centro Hospitalar e Universitário de Coimbra EPE , Coimbra, Portugal
                [6 ] departmentUnidade de Imunoalergologia , Unidade Local de Saúde de Matosinhos EPE , Senhora da Hora, Portugal
                [7 ] departmentImunologia Básica e Clínica, Faculdade de Medicina , Universidade do Porto , Porto, Portugal
                [8 ] departmentServiço de Imunoalergologia, Hospital de Santa Maria , Centro Hospitalar Lisboa Norte EPE , Lisboa, Portugal
                [9 ] departmentServiço de Pediatria , Unidade Local de Saúde de Matosinhos EPE , Senhora da Hora, Portugal
                [10 ] departmentServiço de Pneumologia B, Hospital Geral , Centro Hospitalar e Universitário de Coimbra EPE , Coimbra, Portugal
                [11 ] departmentServiço de Imunoalergologia, Hospital Universitário de Coimbra , Centro Hospitalar e Universitário de Coimbra EPE , Coimbra, Portugal
                [12 ] departmentServiço de Imunoalergologia, Hospital de Dona Estefânia , Centro Hospitalar de Lisboa Central EPE , Lisboa, Portugal
                [13 ] departmentPathophysiology, CEDOC, Integrated Pathophysiological Mechanisms Research Group , Nova Medical School , Lisboa, Portugal
                [14 ] departmentServiço de Pneumologia , Hospital Beatriz Ângelo , Loures, Portugal
                [15 ] departmentServiço de Pediatria , Hospital da Senhora da Oliveira , Guimaraes, Portugal
                [16 ] departmentServiço de Imunoalergologia , Hospital Amato Lusitano , Castelo Branco, Portugal
                [17 ] departmentServiço de Imunoalergologia , Centro Hospitalar do Algarve EPE , Faro, Portugal
                [18 ] departmentServiço de Imunoalergologia , Hospital São João , Porto, Portugal
                [19 ] departmentUniversity of Beira Interior , CICS - Health Sciences Research Centre; NuESA – Environment & Health Study Group, Faculty of Health Sciences , Covilha, Portugal
                [20 ] departmentCova da Beira University Hospital Centre , Department of Allergy & Clinical Immunology , Covilhã, Portugal
                [21 ] departmentUnidade de Imunoalergologia , Hospital do Divino Espirito Santo de Ponta Delgada EPE , Ponta Delgada, Portugal
                [22 ] departmentServiço de Pneumologia , Centro Hospitalar de Trás-os-montes e Alto Douro EPE , Vila Real, Portugal
                [23 ] departmentImunoalergologia , Grupo HPA Saúde , Portimao, Portugal
                [24 ] departmentServiço de Pneumologia , Centro Hospitalar Barreiro Montijo EPE , Barreiro, Portugal
                [25 ] departmentServiço de Pediatria , Centro Hospitalar do Médio Ave EPE , Santo Tirso, Portugal
                [26 ] departmentPediatrics , Hospital de Santa Maria , Lisbon, Portugal
                [27 ] departmentLaboratory of Clinical Pharmacology and Therapeutics , University of Lisbon Medical Faculty , Lisboa, Portugal
                [28 ] departmentServiço de Pneumologia , Hospital Garcia de Orta EPE , Almada, Portugal
                [29 ] departmentServiço de Pediatria , Centro Hospitalar Tondela Viseu EPE , Viseu, Portugal
                [30 ] departmentPneumology , Centro Hospitalar de Lisboa Central , Lisbon, Portugal
                [31 ] NOVA Medical School , Lisbon, Portugal
                [32 ] departmentImunoalergologia , Centro de Imunoalergologia do Algarve , Portimão, Portugal
                [33 ] departmentServiço de Imunoalergologia , Serviço de Saúde da Região Autónoma da Madeira , Funchal, Portugal
                [34 ] departmentServiço de Imunoalergologia , Centro Hospitalar Vila Nova de Gaia/Espinho , Vila Nova de Gaia, Portugal
                [35 ] departmentBloco operatório , Centro Hospitalar Vila Nova de Gaia/Espinho , Vila Nova de Gaia, Portugal
                [36 ] departmentDepartment of Community Medicine, Information and Health Decision Sciences (MEDCIDS) , University of Porto Faculty of Medicine , Porto, Portugal
                Author notes
                [Correspondence to ] Dr Joao A Fonseca; fonseca.ja@ 123456gmail.com
                Article
                bmjopen-2019-031732
                10.1136/bmjopen-2019-031732
                6858182
                31699737
                © Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

                Product
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100001871, Fundação para a Ciência e a Tecnologia;
                Award ID: POCI-01-0145-FEDER-029130
                Award ID: SFRH/BPD/115169/2016
                Categories
                Health Services Research
                Original Research
                1506
                1704
                Custom metadata
                unlocked

                Medicine

                medication adherence, asthma, discordance, logistic models

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