Any advice given and opinions expressed in this article are those of the author and do not necessarily reflect the views of Chiesi Limited. All content in this article is for informational and educational purposes only. |
Poor adherence is a significant issue in respiratory care:
- in asthma, approximately 50% of patients on long-term therapy for asthma fail to take medications as directed at least part of the time1,
- in COPD, more than half of all patients fail to take their medications as prescribed.2,
In this article, we’ll explore how medication adherence can be defined, as well as the roots of nonadherence. Dr Daniel O’Toole, Consultant Clinical Psychologist and Maeve Savage, Highly Specialist Pharmacist in asthma, COPD and integrated respiratory care, will give their thoughts on how healthcare professionals can identify poor adherence and how we might begin to improve adherence in respiratory care.
Defining adherence
Adherence can be defined as the extent to which a person’s behaviour aligns with the agreed recommendations from their healthcare professional.3,
However, adherence is not black-and-white; it is not as simple as an individual following a healthcare professional’s instructions with complete accuracy (adherence) or straying from it in some way (nonadherence).3, Adherence challenges can occur throughout the patient journey, for example late, or non-initiation of the prescribed treatment, sub-optimal implementation of the dosing regimen or early self-discontinuation of the treatment.4,
The importance of adherence
The personal cost of medication nonadherence is well documented across a wide range of medical conditions. Asthma and COPD are no different: poor adherence to inhaled treatments in both asthma and COPD is associated with poorer quality of life, and greater risk of exacerbations and death.5,6, This has significant consequences for the individual, but often forgotten is the impact a lack of improvement, or deterioration in a person’s condition can have on their support network.
Fortunately, patients can expect an improvement in their clinical outcomes with better adherence to inhaled therapy:6,7,
- in asthma, patients with higher adherence to their inhaled corticosteroids are associated with better symptom control, significantly reduced risk of exacerbation, and positive impacts on asthma-related mortality
- in COPD, patients with good adherence to their inhaler treatment presented a longer time before the first exacerbation, a lower susceptibility to exacerbation and lower all-cause mortality.
Nonadherence also carries a significant economic burden. Lack of symptom control, poor quality of life and frequent exacerbations increase demand on healthcare resources, not to mention the added costs of medication wastage. 5,8,9,
The roots of medication nonadherence
There is no such thing as a ‘typical’ nonadherent patient – and perceptions that a nonadherent patient are easy to identify should be challenged. People who do not adhere to their prescribed treatments can fall into two broad categories (although these are not mutually exclusive):10,
- intentional nonadherence: where a person decides not to follow treatment recommendations, due to their beliefs, circumstances, priorities, preferences and experiences, or
- non/unintentional nonadherence: where a person wants to take the medication, but there is a barrier to doing so due to capacity or resource limitations, for example issues with memory, physical ability, service provision or knowledge.
Intentional vs non/unintentional nonadherence
Intentional nonadherence | Non/unintentional nonadherence |
Motivational beliefs and preferences present perceptual barriers to adherence | Capacity and resources present practical barriers to adherence |
Influencing factors include: personal or cultural beliefs, inconvenience, perception of side effects. | Influencing factors include: mental and physical capacity, health literacy, literacy, age, memory, anxiety, depression and use of multiple medicines. |
Adapted from Scullion 2020.11,
A note on sociodemographic factors
There is no clear and consistent relationship between sociodemographic variables (for example gender, ethnicity, socio-economic status or education) and adherence; nonadherence impacts people from across the socioeconomic spectrum.10, Studies have examined this across a variety of chronic medical conditions with sociodemographic factors consistently failing to predict adherence behaviour.12,13,
Engaging with those struggling with adherence
Adherence should not be seen as something a person has to manage on their own. It is a complex issue, where the person and their healthcare professional have to work collaboratively together to get the best outcome. So how can healthcare professionals begin to engage the non-adherent patient? Highly Specialist Pharmacist Maeve Savage recently completed an MSc in the field of adherence to inhaled therapy, and believes the best place to start is with an exploration of the patient’s perspectives of their condition and its treatment:
“Clinicians should adopt an open, non-judgmental approach, and normalise nonadherence. This encourages patients to discuss any concerns regarding their treatment. This encourages patients to discuss any concerns regarding their treatment. It is through this patient-centred approach that clinicians can best support their patients to make informed decisions about their care.”
Consultant Clinical Psychologist Dr Daniel O’Toole has published research on adherence to inhaled therapies and worked with patients in the NHS for 20 years. He agrees: “Ensuring that the patient has a good, common-sense rationale for treatment necessity that takes account of the individual’s perception of the condition is an important part of any consultation connected to adherence.”
Identifying poor adherence in asthma and COPD patients
There are many indicators of a patient’s current ability to adhere to their prescribed medication, but no single method is perfect. Often a combination of approaches is required for a comprehensive assessment of adherence. In addition, each person will need an individualised approach, and one that is empathetic and non-judgemental.
Occasionally, poor adherence may be identified by poor symptom control, although this is not always accurate: “If a patient with either COPD or asthma presents with poor symptom control or excessive SABA use, as a pharmacist, my first thought is adherence,” says Maeve, “but whilst both these things could suggest nonadherence, it should never be considered objective evidence. Further information gathering is required.”
You can explore more in the topic of use (or overuse) of SABA in asthma in this article.
It is good practice to address adherence at every patient contact, not only where you suspect poor adherence. Asking the patient directly is the simplest and most important means of doing this, but it is not without its pitfalls. Patients tend towards over reporting medication use, so another approach is required for corroboration.14, Asking directly but empathically encourages the patient to open up about their medication use.
“Asking the patient directly is the basis of therapeutic partnership” Maeve explains. “Everything else follows this, but if you ask the patient directly and this does not corroborate with the objective evidence, you might need to take another approach.”
“Identifying poor adherence in clinical practice can be very difficult” Daniel agrees. “Creating a trusting healthcare provider-patient relationship through effective consultation skills is central to well-known approaches like motivational interviewing. This can foster an environment whereby the patient feels able to share their challenges around adherence to treatment and then be provided with evidence-based support to help.”
Here are some of the other ways poor adherence can be identified:
Tool / technique | Details |
Objective markers | Fractional exhaled nitric oxide (FeNO) testing measures the level of inflammation in the airways. It is used to monitor asthma control, but it can also assist in detecting poor adherence to ICS when a FeNO suppression test is employed.15,,16,,17,
For the most part, FeNO scores are lower in asthma patients who are adherent to ICS compared to those who are poorly adherent. This is because ICS reduce inflammation in the airways. However, there is no absolute cut‐off level differentiating good adherence from poor adherence based on the available data – it is rather the proportionate reduction in FeNO following observed doses that determines suboptimal adherence.18, This guide from the Primary Care Respiratory Society provides workflows for interpreting FeNO results within the context of asthma management. Although not an officially recognised marker of adherence, eosinophil counts can provide insights into the inflammatory status of the airways. This is particularly relevant for asthma patients, but it can also be useful in COPD where there is evidence of airway inflammation. If a patient consistently takes their prescribed inhaled corticosteroids, their eosinophil count should decrease or remain within normal ranges. This approach, therefore, can be used to identify those patients who may need support with their adherence to inhaled treatment.19, |
Questionnaires | The Test of Adherence to Inhalers (TAI)* consists of two complementary questionnaires that may be used separately, depending on care needs: the 10 question TAI, which identifies patients with poor adherence and their degree of adherence, and the 12 question TAI, which helps give an idea of their type or pattern of nonadherence.
There is also a TAI toolkit which identifies the individual barriers to adherence and suggests interventions that can support better adherence.20, *TAI Inhaler Adhesion Test is a joint initiative of the Scientific Committee of the TAI Project and Chiesi. |
Prescribing or dispensing records | Monitoring prescription refill records can be used to quantify adherence rates. “Medication Possession Ratio (MPR) is a simple, validated calculation that uses data from refill records” Maeve explains. “Pharmacists, or other healthcare professionals with access to prescription records are ideally placed to interpret this data.”
MPR is calculated by dividing the number of doses prescribed (or issued) by the number that would be expected in a particular timescale, expressed as a percentage. Adherence has been defined as good (≥75%), suboptimal (50%-74%), and poor (25%-49%).21, |
Emonitoring and digital inhalers | Digital inhalers and emonitoring technology allows healthcare providers to remotely track when and how often patients use their inhalers. Inhalers are digitalised with electromechanical sensor(s) and associated microelectronics to detect the time/date of inhaler actuations.22,
One systemic review found evidence that digital inhalers can enhance medication management and increase medication adherence, however adoption of these approaches is low.22, “The accurate measurement of adherence to some inhaled therapies has improved over the years with the development of microchip technology” Daniel says, however, he adds “more often than not, clinicians still tend to rely on patient self-report, health records and prescription insights as mentioned above.” |
Explore this topic further with this video guide on consultations in a virtual environment, or visit our educational site Together in Respiratory to read more about the key steps of a comprehensive patient assessment.
Improving adherence in respiratory care
Adherence to medicines is complex, with multiple contributing factors at play. Several interventions and strategies exist which may improve a patient’s adherence. “Often multi-component interventions are required” reflects Maeve, where elements of several different strategies are required.
Addressing patient beliefs
“Ascertaining the patient’s beliefs about their condition and its treatment is a good place to start” says Maeve. “This can help inform the appropriate support required for the individual.” Evidence shows that shared decision-making leads to better acceptance of the prescribing decision and has a positive correlation with adherence.23, You can explore the topic of shared decision-making in more detail in this article on Chiesi Air.
Tailoring treatment
A tailored or simplified treatment regime also may benefit patients. Device selection should consider the individual needs, preferences, and capabilities of patients.24,
Prescribing inhaled treatments via multiple inhalers, particularly if the devices require different inhalation techniques, may lead to reduced adherence. Prescribing devices with similar inhalation techniques or combination inhalers can help improve adherence.25,26, One systematic review found asthma patients requiring ICS and long-acting β2-agonists saw improved adherence from the prescription of a fixed-combination therapy.27, Furthermore, once-daily inhalers can bring about a significant improvement in adherence, although this may not be suitable for all patients.28,
Other interventions
There are numerous other interventions that can help support respiratory patients to better adhere to their treatments. Further information can be found in the guidance:
National Institute for Health and Care Excellence (NICE) clinical guidance | Guidance and principles covering patient involvement, supporting adherence and medicine reviews. |
Global Initiative for Asthma (GINA) Global Strategy for Asthma Management and Prevention | Guidance on factors contributing to poor adherence and interventions in asthma patients. |
Global Initiative for Chronic Obstructive Lung Disease (GOLD) Global Strategy for Prevention, Diagnosis and Management of COPD | Guidance on adherence factors and intervention strategies in COPD patients. |
“Behaving in ways that are good for our health can be difficult for all of us” Daniel concludes. “The same is true when it comes to adherence to treatment, so trying to understand and respect the patient’s perspective by making sure that they are at the heart of your consultation can really make a difference.”
Support your patients in managing their condition with our resources, including how to use videos and personalised action plans.