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      Improving adherence with inhaler therapy in COPD

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          Abstract

          Chronic obstructive pulmonary disease (COPD) is a major public health problem, associated with considerable morbidity and health care costs. The global burden of COPD morbidity is predicted to rise substantially in the coming decade, but could be moderated by better use of existing management strategies. Smoking cessation, medication therapy, and pulmonary rehabilitation have all been shown to diminish morbidity and improve patient outcomes. But each of these strategies requires adherence. Adherence is crucial for optimizing clinical outcomes in COPD, with nonadherence resulting in a significant health and economic burden. Suboptimal medication adherence is common among COPD patients, due to a number of factors that involve the medication, the delivery device, the patient, and the health professionals caring for the patient. Lack of medication adherence needs to be identified and addressed by using simplified treatment regimens, increasing patient knowledge about self-management, and enhancing provider skills in patient education, communication, and adherence counseling. This article reports some of the challenges of medication nonadherence faced by the clinician in the management of COPD, and suggests ways to evaluate and improve adherence effectively in primary care.

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          Most cited references 25

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          Effects of smoking intervention and the use of an inhaled anticholinergic bronchodilator on the rate of decline of FEV1. The Lung Health Study.

          To determine whether a program incorporating smoking intervention and use of an inhaled bronchodilator can slow the rate of decline in forced expiratory volume in 1 second (FEV1) in smokers aged 35 to 60 years who have mild obstructive pulmonary disease. Randomized clinical trial. Participants randomized with equal probability to one of the following groups: (1) smoking intervention plus bronchodilator, (2) smoking intervention plus placebo, or (3) no intervention. Ten clinical centers in the United States and Canada. A total of 5887 male and female smokers, aged 35 to 60 years, with spirometric signs of early chronic obstructive pulmonary disease. Smoking intervention: intensive 12-session smoking cessation program combining behavior modification and use of nicotine gum, with continuing 5-year maintenance program to minimize relapse. Bronchodilator: ipratropium bromide prescribed three times daily (two puffs per time) from a metered-dose inhaler. Rate of change and cumulative change in FEV1 over a 5-year period. Participants in the two smoking intervention groups showed significantly smaller declines in FEV1 than did those in the control group. Most of this difference occurred during the first year following entry into the study and was attributable to smoking cessation, with those who achieved sustained smoking cessation experiencing the largest benefit. The small noncumulative benefit associated with use of the active bronchodilator vanished after the bronchodilator was discontinued at the end of the study. An aggressive smoking intervention program significantly reduces the age-related decline in FEV1 in middle-aged smokers with mild airways obstruction. Use of an inhaled anticholinergic bronchodilator results in a relatively small improvement in FEV1 that appears to be reversed after the drug is discontinued. Use of the bronchodilator did not influence the long-term decline of FEV1.
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            Health beliefs, disease severity, and patient adherence: a meta-analysis.

            A large body of empirical data exists on the prediction of patient adherence from subjective and objective assessments of health status and disease severity. This work can be summarized with meta-analysis. Retrieval and summary analysis of r effect sizes and moderators of the relationship between patient adherence and patients': (1) beliefs in disease threat; (2) rated health status (by physician, self, or parent); and (3) objective disease severity. Comprehensive search of published literature (1948-2005) yielding 116 articles, with 143 separate effect sizes. Calculation of robust, generalizable random effects model statistics, and detailed examination of study diversity with moderator analyses. Adherence is significantly positively correlated with patients' beliefs in the severity of the disease to be prevented or treated ("disease threat"). Better patient adherence is associated with objectively poorer health only for patients experiencing disease conditions lower in seriousness (according to the Seriousness of Illness Rating Scale). Among conditions higher in seriousness, worse adherence is associated with objectively poorer health. Similar patterns exist when health status is rated by patients themselves, and by parents in pediatric samples. Results suggest that the objective severity of patients' disease conditions, and their awareness of this severity, can predict their adherence. Patients who are most severely ill with serious diseases may be at greatest risk for nonadherence to treatment. Findings can contribute to greater provider awareness of the potential for patient nonadherence, and to better targeting of health messages and treatment advice by providers.
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              Medication adherence issues in patients treated for COPD

              Although medical treatment of COPD has advanced, nonadherence to medication regimens poses a significant barrier to optimal management. Underuse, overuse, and improper use continue to be the most common causes of poor adherence to therapy. An average of 40%–60% of patients with COPD adheres to the prescribed regimen and only 1 out of 10 patients with a metered dose inhaler performs all essential steps correctly. Adherence to therapy is multifactorial and involves both the patient and the primary care provider. The effect of patient instruction on inhaler adherence and rescue medication utilization in patients with COPD does not seem to parallel the good results reported in patients with asthma. While use of a combined inhaler may facilitate adherence to medications and improve efficacy, pharmacoeconomic factors may influence patient’s selection of both the device and the regimen. Patient’s health beliefs, experiences, and behaviors play a significant role in adherence to pharmacological therapy. This manuscript reviews important aspects associated with medication adherence in patients with COPD and identifies some predictors of poor adherence.
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                Author and article information

                Journal
                Int J Chron Obstruct Pulmon Dis
                International Journal of COPD
                International Journal of Chronic Obstructive Pulmonary Disease
                Dove Medical Press
                1176-9106
                1178-2005
                2010
                2010
                24 November 2010
                : 5
                : 401-406
                Affiliations
                [1 ]College of Nursing, University of Colorado Denver, Aurora, Colorado;
                [2 ]Department of Research, Olmsted Medical Center, Rochester, Minnesota, USA
                Author notes
                Correspondence: Suzanne C Lareau, College of Nursing, University of Colorado Denver, Education 2 North, 13120 East 19th Ave/Room 4327, PO Box 6511/C288-4, Aurora, CO 80045, USA, Tel +1 303 724 3581, Fax +1 303 724 8560, Email suzanne.lareau@ 123456ucdenver.edu
                Article
                copd-5-401
                10.2147/COPD.S14715
                3008325
                21191434
                © 2010 Lareau and Yawn, publisher and licensee Dove Medical Press Ltd.

                This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited.

                Categories
                Review

                Respiratory medicine

                chronic obstructive pulmonary disease, clinician, adherence

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